consist of assimilable elements, such as are found making a part
of healthy tissues. These are divisible into three classes,--foods,
poisons, and inert, mostly because insoluble, substances. The food of
one animal or of one human being is sometimes poison to another, and
vice versa; inert substances may act mechanically, so as to produce
the effect of poisons; but this division holds exactly enough for our
purpose.
Strictly speaking, every poison consisting of assimilable elements may
be considered as unwholesome food. It is rejected by the stomach, or it
produces diarrhoea, or it causes vertigo or disturbance of the heart's
action, or some other symptom for which the subject of it would consult
the physician, if it came on from any other cause than taking it under
the name of medicine. Yet portions of this unwholesome food which
we call medicine, we have reason to believe, are assimilated; thus,
castor-oil appears to be partially digested by infants, so that they
require large doses to affect them medicinally. Even that deadliest of
poisons, hydrocyanic acid, is probably assimilated, and helps to make
living tissue, if it do not kill the patient, for the assimilable
elements which it contains, given in the separate forms of amygdalin and
emulsin, produce no disturbance, unless, as in Bernard's experiments,
they are suffered to meet in the digestive organs. A medicine consisting
of assimilable substances being then simply unwholesome food, we
understand what is meant by those cumulative effects of such remedies
often observed, as in the case of digitalis and strychnia. They are
precisely similar to the cumulative effects of a salt diet in producing
scurvy, or of spurred rye in producing dry gangrene. As the effects of
such substances are a violence to the organs, we should exercise the
same caution with regard to their use that we would exercise about
any other kind of poisonous food,--partridges at certain seasons, for
instance. Even where these poisonous kinds of food seem to be useful, we
should still regard them with great jealousy. Digitalis lowers the pulse
in febrile conditions. Veratrum viride does the same thing. How do we
know that a rapid pulse is not a normal adjustment of nature to the
condition it accompanies? Digitalis has gone out of favor; how sure are
we that Veratrum viride will not be found to do more harm than good in
a case of internal inflammation, taking the whole course of the disease
into consideration? Think of the change of opinion with regard to the
use of opium in delirium tremens (which you remember is sometimes called
delirium vigilans), where it seemed so obviously indicated, since the
publication of Dr. Ware's admirable essay. I respect the evidence of
my contemporaries, but I cannot forget the sayings of the Father of
medicine,--Ars longa, judicium difficile.
I am not presuming to express an opinion concerning Veratrum viride,
which was little heard of when I was still practising medicine. I am
only appealing to that higher court of experience which sits in judgment
on all decisions of the lower medical tribunals, and which requires more
than one generation for its final verdict.
Once change the habit of mind so long prevalent among practitioners of
medicine; once let it be everywhere understood that the presumption is
in favor of food, and not of alien substances, of innocuous, and not
of unwholesome food, for the sick; that this presumption requires very
strong evidence in each particular case to overcome it; but that, when
such evidence is afforded, the alien substance or the unwholesome food
should be given boldly, in sufficient quantities, in the same spirit as
that with which the surgeon lifts his knife against a patient,--that
is, with the same reluctance and the same determination,--and I think
we shall have and hear much less of charlatanism in and out of the
profession. The disgrace of medicine has been that colossal system of
self-deception, in obedience to which mines have been emptied of their
cankering minerals, the vegetable kingdom robbed of all its noxious
growths, the entrails of animals taxed for their impurities,
the poison-bags of reptiles drained of their venom, and all the
inconceivable abominations thus obtained thrust down the throats of
human beings suffering from some fault of organization, nourishment, or
vital stimulation.
Much as we have gained, we have not yet thoroughly shaken off the notion
that poison is the natural food of disease, as wholesome aliment is
the support of health. Cowper's lines, in “The Task,” show the
matter-of-course practice of his time:
“He does not scorn it, who has long endured
A fever's agonies, and fed on drugs.”
Dr. Kimball of Lowell, who has been in the habit of seeing a great
deal more of typhoid fever than most practitioners, and whose surgical
exploits show him not to be wanting in boldness or enterprise, can tell
you whether he finds it necessary to feed his patients on drugs or not.
His experience is, I believe, that of the most enlightened and advanced
portion of the profession; yet I think that even in typhoid fever, and
certainly in many other complaints, the effects of ancient habits
and prejudices may still be seen in the practice of some educated
physicians.
To you, young men, it belongs to judge all that has gone before you.
You come nearer to the great fathers of modern medicine than some of you
imagine. Three of my own instructors attended Dr. Rush's Lectures. The
illustrious Haller mentions Rush's inaugural thesis in his “Bibliotheca
Anatomica;” and this same Haller, brought so close to us, tells us he
remembers Ruysch, then an old man, and used to carry letters between him
and Boerhaave. Look through the history of medicine from Boerhaave
to this present day. You will see at once that medical doctrine and
practice have undergone a long series of changes. You will see that
the doctrine and practice of our own time must probably change in their
turn, and that, if we can trust at all to the indications of their
course, it will be in the direction of an improved hygiene and a
simplified treatment. Especially will the old habit of violating the
instincts of the sick give place to a judicious study of these same
instincts. It will be found that bodily, like mental insanity, is best
managed, for the most part, by natural soothing agencies. Two centuries
ago there was a prescription for scurvy containing “stercoris taurini
et anserini par, quantitas trium magnarum nucum,” of the hell-broth
containing which “guoties-cumque sitit oeger, large bibit.” When I
have recalled the humane common-sense of Captain Cook in the matter
of preventing this disease; when I have heard my friend, Mr. Dana,
describing the avidity with which the scurvy-stricken sailors snuffed up
the earthy fragrance of fresh raw potatoes, the food which was to supply
the elements wanting to their spongy tissues, I have recognized that the
perfection of art is often a return to nature, and seen in this single
instance the germ of innumerable beneficent future medical reforms.
I cannot help believing that medical curative treatment will by and
by resolve itself in great measure into modifications of the food,
swallowed and breathed, and of the natural stimuli, and that less will
be expected from specifics and noxious disturbing agents, either alien
or assimilable. The noted mineral-waters containing iron, sulphur,
carbonic acid, supply nutritious or stimulating materials to the body
as much as phosphate of lime and ammoniacal compounds do to the cereal
plants. The effects of a milk and vegetable diet, of gluten bread
in diabetes, of cod-liver oil in phthisis, even of such audacious
innovations as the water-cure and the grape-cure, are only hints of
what will be accomplished when we have learned to discover what organic
elements are deficient or in excess in a case of chronic disease,
and the best way of correcting the abnormal condition, just as an
agriculturist ascertains the wants of his crops and modifies the
composition of his soil. In acute febrile diseases we have long ago
discovered that far above all drug-medication is the use of mild liquid
diet in the period of excitement, and of stimulant and nutritious food
in that of exhaustion. Hippocrates himself was as particular about his
barley-ptisan as any Florence Nightingale of our time could be.
The generation to which you, who are just entering the profession,
belong, will make a vast stride forward, as I believe, in the direction
of treatment by natural rather than violent agencies. What is it that
makes the reputation of Sydenham, as the chief of English physicians?
His prescriptions consisted principally of simples. An aperient or an
opiate, a “cardiac” or a tonic, may be commonly found in the midst of
a somewhat fantastic miscellany of garden herbs. It was not by his
pharmaceutic prescriptions that he gained his great name. It was
by daring to order fresh air for small-pox patients, and riding on
horseback for consumptives, in place of the smothering system, and
the noxious and often loathsome rubbish of the established schools. Of
course Sydenham was much abused by his contemporaries, as he frequently
takes occasion to remind his reader. “I must needs conclude,” he says,
“either that I am void of merit, or that the candid and ingenuous part
of mankind, who are formed with so excellent a temper of mind as to be
no strangers to gratitude, make a very small part of the whole.” If in
the fearless pursuit of truth you should find the world as ungracious in
the nineteenth century as he found it in the seventeenth, you may learn
a lesson of self-reliance from another utterance of the same illustrious
physician: “'T is none of my business to inquire what other persons
think, but to establish my own observations; in order to which, I ask no
favor of the reader but to peruse my writings with temper.”
The physician has learned a great deal from the surgeon, who is
naturally in advance of him, because he has a better opportunity of
seeing the effects of his remedies. Let me shorten one of Ambroise
Pare's stories for you. There had been a great victory at the pass of
Susa, and they were riding into the city. The wounded cried out as the
horses trampled them under their hoofs, which caused good Ambroise great
pity, and made him wish himself back in Paris. Going into a stable he
saw four dead soldiers, and three desperately wounded, placed with their
backs against the wall. An old campaigner came up.--“Can these fellows
get well?” he said. “No!” answered the surgeon. Thereupon, the old
soldier walked up to them and cut all their throats, sweetly, and
without wrath (doulcement et sans cholere). Ambroise told him he was a
bad man to do such a thing. “I hope to God;” he said, “somebody will
do as much for me if I ever get into such a scrape” (accoustre de telle
facon). “I was not much salted in those days” (bien doux de sel), says
Ambroise, “and little acquainted with the treatment of wounds.” However,
as he tells us, he proceeded to apply boiling oil of Sambuc (elder)
after the approved fashion of the time,--with what torture to the
patient may be guessed. At last his precious oil gave out, and he used
instead an insignificant mixture of his own contrivance. He could not
sleep that night for fear his patients who had not been scalded with
the boiling oil would be poisoned by the gunpowder conveyed into their
wounds by the balls. To his surprise, he found them much better than the
others the next morning, and resolved never again to burn his patients
with hot oil for gun-shot wounds.
This was the beginning, as nearly as we can fix it, of that reform which
has introduced plain water-dressings in the place of the farrago of
external applications which had been a source of profit to apothecaries
and disgrace to art from, and before, the time when Pliny complained
of them. A young surgeon who was at Sudley Church, laboring among the
wounded of Bull Run, tells me they had nothing but water for dressing,
and he (being also doux de sel) was astonished to see how well the
wounds did under that simple treatment.
Let me here mention a fact or two which may be of use to some of you who
mean to enter the public service. You will, as it seems, have gun-shot
wounds almost exclusively to deal with. Three different surgeons, the
one just mentioned and two who saw the wounded of Big Bethel, assured me
that they found no sabre-cuts or bayonet wounds. It is the rifle-bullet
from a safe distance which pierces the breasts of our soldiers, and not
the gallant charge of broad platoons and sweeping squadrons, such as
we have been in the habit of considering the chosen mode of warfare
of ancient and modern chivalry. [Sir Charles James Napier had the same
experience in Virginia in 1813. “Potomac. We have nasty sort of fighting
here, amongst creeks and bushes, and lose men without show.” “Yankee
never shows himself, he keeps in the thickest wood, fires and runs
off.”--“These five thousand in the open field might be attacked,
but behind works it would be throwing away lives.” He calls it “an
inglorious warfare,”--says one of the leaders is “a little deficient in
gumption,--but--still my opinion is, that if we tuck up our sleeves and
lay our ears back we might thrash them; that is, if we caught them out
of their trees, so as to slap at them with the bayonet.”--Life, etc.
vol. i. p. 218 et seq.]
Another fact parallels the story of the old campaigner, and may teach
some of you caution in selecting your assistants. A chaplain told it
to two of our officers personally known to myself. He overheard the
examination of a man who wished to drive one of the “avalanche” wagons,
as they call them. The man was asked if he knew how to deal with wounded
men. “Oh yes,” he answered; “if they're hit here,” pointing to the
abdomen, “knock 'em on the head,--they can't get well.”
In art and outside of it you will meet the same barbarisms that Ambroise
Pare met with,--for men differ less from century to century than we are
apt to suppose; you will encounter the same opposition, if you attack
any prevailing opinion, that Sydenham complained of. So far as possible,
let not such experiences breed in you a contempt for those who are the
subjects of folly or prejudice, or foster any love of dispute for its
own sake. Should you become authors, express your opinions freely;
defend them rarely. It is not often that an opinion is worth expressing,
which cannot take care of itself. Opposition is the best mordant to fix
the color of your thought in the general belief.
It is time to bring these crowded remarks to a close. The day has been
when at the beginning of a course of Lectures I should have thought it
fitting to exhort you to diligence and entire devotion to your tasks
as students. It is not so now. The young man who has not heard the
clarion-voices of honor and of duty now sounding throughout the land,
will heed no word of mine. In the camp or the city, in the field or the
hospital, under sheltering roof, or half-protecting canvas, or open
sky, shedding our own blood or stanching that of our wounded defenders,
students or teachers, whatever our calling and our ability, we belong,
not to ourselves, but to our imperilled country, whose danger is our
calamity, whose ruin would be our enslavement, whose rescue shall be our
earthly salvation!
SCHOLASTIC AND BEDSIDE TEACHING.
An Introductory Lecture delivered before the Medical Class of Harvard
University, November 6, 1867.
The idea is entertained by some of our most sincere professional
brethren, that to lengthen and multiply our Winter Lectures will be
of necessity to advance the cause of medical education. It is a fair
subject for consideration whether they do not overrate the relative
importance of that particular mode of instruction which forms the larger
part of these courses.
As this School could only lengthen its lecture term at the expense
of its “Summer Session,” in which more direct, personal, and familiar
teaching takes the place of our academic discourses, and in which more
time can be given to hospitals, infirmaries, and practical instruction
in various important specialties, whatever might be gained, a good deal
would certainly be lost in our case by the exchange.
The most essential part of a student's instruction is obtained, as I
believe, not in the lecture-room, but at the bedside. Nothing seen there
is lost; the rhythms of disease are learned by frequent repetition; its
unforeseen occurrences stamp themselves indelibly in the memory. Before
the student is aware of what he has acquired, he has learned the aspects
and course and probable issue of the diseases he has seen with his
teacher, and the proper mode of dealing with them, so far as his master
knows it. On the other hand, our ex cathedra prelections have a strong
tendency to run into details which, however interesting they may be to
ourselves and a few of our more curious listeners, have nothing in them
which will ever be of use to the student as a practitioner. It is a
perfectly fair question whether I and some other American Professors do
not teach quite enough that is useless already. Is it not well to remind
the student from time to time that a physician's business is to avert
disease, to heal the sick, to prolong life, and to diminish suffering?
Is it not true that the young man of average ability will find it as
much as he can do to fit himself for these simple duties? Is it not
best to begin, at any rate, by making sure of such knowledge as he will
require in his daily walk, by no means discouraging him from any study
for which his genius fits him when he once feels that he has become
master of his chosen art.
I know that many branches of science are of the greatest value as
feeders of our medical reservoirs. But the practising physician's office
is to draw the healing waters, and while he gives his time to this
labor he can hardly be expected to explore all the sources that spread
themselves over the wide domain of science. The traveller who would not
drink of the Nile until he had tracked it to its parent lakes, would be
like to die of thirst; and the medical practitioner who would not use
the results of many laborers in other departments without sharing their
special toils, would find life far too short and art immeasurably too
long.
We owe much to Chemistry, one of the most captivating as well as
important of studies; but the medical man must as a general rule content
himself with a clear view of its principles and a limited acquaintance
with its facts; such especially as are pertinent to his pursuits. I am
in little danger of underrating Anatomy or Physiology; but as each of
these branches splits up into specialties, any one of which may take up
a scientific life-time, I would have them taught with a certain judgment
and reserve, so that they shall not crowd the more immediately
practical branches. So of all the other ancillary and auxiliary kinds
of knowledge, I would have them strictly subordinated to that particular
kind of knowledge for which the community looks to its medical advisers.
A medical school is not a scientific school, except just so far as
medicine itself is a science. On the natural history side, medicine is
a science; on the curative side, chiefly an art. This is implied in
Hufeland's aphorism: “The physician must generalize the disease and
individualize the patient.”
The coordinated and classified results of empirical observation, in
distinction from scientific experiment, have furnished almost all we
know about food, the medicine of health, and medicine, the food of
sickness. We eat the root of the Solanum tuberosum and throw away its
fruit; we eat the fruit of the Solanum Lycopersicum and throw away its
root. Nothing but vulgar experience has taught us to reject the potato
ball and cook the tomato. So of most of our remedies. The subchloride
of mercury, calomel, is the great British specific; the protochloride of
mercury, corrosive sublimate, kills like arsenic, but no chemist could
have told us it would be so.
From observations like these we can obtain certain principles from which
we can argue deductively to facts of a like nature, but the process
is limited, and we are suspicious of all reasoning in that direction
applied to the processes of healthy and diseased life. We are
continually appealing to special facts. We are willing to give Liebig's
artificial milk when we cannot do better, but we watch the child
anxiously whose wet-nurse is a chemist's pipkin. A pair of substantial
mammary glands has the advantage over the two hemispheres of the most
learned Professor's brain, in the art of compounding a nutritious fluid
for infants.
The bedside is always the true centre of medical teaching. Certain
branches must be taught in the lecture-room, and will necessarily
involve a good deal that is not directly useful to the future
practitioner. But the over ambitious and active student must not be led
away by the seduction of knowledge for its own sake from his principal
pursuit. The humble beginner, who is alarmed at the vast fields of
knowledge opened to him, may be encouraged by the assurance that with a
very slender provision of science, in distinction from practical skill,
he may be a useful and acceptable member of the profession to which the
health of the community is intrusted.
To those who are not to engage in practice, the various pursuits
of science hardly require to be commended. Only they must not be
disappointed if they find many subjects treated in our courses as a
medical class requires, rather than as a scientific class would expect,
that is, with special limitations and constant reference to practical
ends. Fortunately they are within easy reach of the highest scientific
instruction. The business of a school like this is to make useful
working physicians, and to succeed in this it is almost as important not
to overcrowd the mind of the pupil with merely curious knowledge as it
is to store it with useful information.
In this direction I have written my lecture, not to undervalue any form
of scientific labor in its place, an unworthy thought from which I hope
I need not defend myself,--but to discourage any undue inflation of the
scholastic programme, which even now asks more of the student than the
teacher is able to obtain from the great majority of those who present
themselves for examination. I wish to take a hint in education from the
Secretary of the Massachusetts Board of Agriculture, who regards the
cultivation of too much land as a great defect in our New England
farming. I hope that our Medical Institutions may never lay themselves
open to the kind of accusation Mr. Lowe brings against the English
Universities, when he says that their education is made up “of words
that few understand and most will shortly forget; of arts that can never
be used, if indeed they can even be learnt; of histories inapplicable to
our times; of languages dead and even mouldy; of grammatical rules
that never had living use and are only post mortem examinations; and of
statements fagoted with utter disregard of their comparative value.”
This general thought will be kept in view throughout my somewhat
discursive address, which will begin with an imaginary clinical lesson
from the lips of an historical personage, and close with the portrait
from real life of one who, both as teacher and practitioner, was long
loved and honored among us. If I somewhat overrun my hour, you must
pardon me, for I can say with Pascal that I have not had the time to
make my lecture shorter.
In the year 1647, that good man John Eliot, commonly called the Apostle
Eliot, writing to Mr. Thomas Shepherd, the pious minister of Cambridge,
referring to the great need of medical instruction for the Indians, used
these words:
“I have thought in my heart that it were a singular good work, if
the Lord would stirre up the hearts of some or other of his people
in England to give some maintenance toward some Schoole or Collegiate
exercise this way, wherein there should be Anatomies and other
instructions that way, and where there might be some recompence given to
any that should bring in any vegetable or other thing that is vertuous
in the way of Physick.