namely that our young students in Physick may be trained up better then
they yet bee, who have onely theoreticall knowledge, and are forced to
fall to practise before ever they saw an Anatomy made, or duely trained
up in making experiments, for we never had but one Anatomy in the
countrey, which Mr. Giles Firman [Firmin] now in England, did make and
read upon very well, but no more of that now.”
Since the time of the Apostle Eliot the Lord has stirred up the hearts
of our people to the building of many Schools and Colleges where
medicine is taught in all its branches. Mr. Giles Firmin's “Anatomy” may
be considered the first ancestor of a long line of skeletons which have
been dangling and rattling in our lecture-rooms for more than a century.
Teaching in New England in 1647 was a grave but simple matter. A single
person, combining in many cases, as in that of Mr. Giles Firmin,
the offices of physician and preacher, taught what he knew to a few
disciples whom he gathered about him. Of the making of that “Anatomy” on
which my first predecessor in the branch I teach “did read very well”
we can know nothing. The body of some poor wretch who had swung upon the
gallows, was probably conveyed by night to some lonely dwelling at the
outskirts of the village, and there by the light of flaring torches
hastily dissected by hands that trembled over the unwonted task.
And ever and anon the master turned to his book, as he laid bare the
mysteries of the hidden organs; to his precious Vesalius, it might be,
or his figures repeated in the multifarious volume of Ambroise Pare; to
the Aldine octavo in which Fallopius recorded his fresh observations; or
that giant folio of Spigelius just issued from the press of Amsterdam,
in which lovely ladies display their viscera with a coquettish grace
implying that it is rather a pleasure than otherwise to show the
lace-like omentum, and hold up their appendices epiploicae as if they
were saying “these are our jewels.”
His teaching of medicine was no doubt chiefly clinical, and received
with the same kind of faith as that which accepted his words from the
pulpit. His notions of disease were based on what he had observed, seen
always in the light of the traditional doctrines in which he was bred.
His discourse savored of the weighty doctrines of Hippocrates, diluted
by the subtle speculations of Galen, reinforced by the curious comments
of the Arabian schoolmen as they were conveyed in the mellifluous
language of Fernelius, blended, it may be, with something of the lofty
mysticism of Van Helmont, and perhaps stealing a flavor of that earlier
form of Homoeopathy which had lately come to light in Sir Kenelm Digby's
“Discourse concerning the Cure of Wounds by the Sympathetic Powder.”
His Pathology was mythology. A malformed foetus, as the readers of
Winthrop's Journal may remember, was enough to scare the colonists from
their propriety, and suggest the gravest fears of portended disaster.
The student of the seventeenth century opened his Licetus and saw
figures of a lion with the head of a woman, and a man with the head of
an elephant. He had offered to his gaze, as born of a human mother,
the effigy of a winged cherub, a pterocephalous specimen, which our
Professor of Pathological Anatomy would hardly know whether to treat
with the reverence due to its celestial aspect, or to imprison in one of
his immortalizing jars of alcohol.
His pharmacopoeia consisted mainly of simples, such as the venerable
“Herball” of Gerard describes and figures in abounding affluence. St.
John's wort and Clown's All-heal, with Spurge and Fennel, Saffron and
Parsley, Elder and Snake-root, with opium in some form, and roasted
rhubarb and the Four Great Cold Seeds, and the two Resins, of which it
used to be said that whatever the Tacamahaca has not cured, the Caranna
will, with the more familiar Scammony and Jalap and Black Hellebore,
made up a good part of his probable list of remedies. He would have
ordered Iron now and then, and possibly an occasional dose of Antimony.
He would perhaps have had a rheumatic patient wrapped in the skin of a
wolf or a wild cat, and in case of a malignant fever with “purples” or
petechiae, or of an obstinate king's evil, he might have prescribed
a certain black powder, which had been made by calcining toads in
an earthen pot; a choice remedy, taken internally, or applied to any
outward grief.
Except for the toad-powder and the peremptory drastics, one might have
borne up against this herb doctoring as well as against some more modern
styles of medication. Barbeyrac and his scholar Sydenham had not yet
cleansed the Pharmacopoeia of its perilous stuff, but there is no doubt
that the more sensible physicians of that day knew well enough that a
good honest herb-tea which amused the patient and his nurses was all
that was required to carry him through all common disorders.
The student soon learned the physiognomy of disease by going about with
his master; fevers, pleurisies, asthmas, dropsies, fluxes, small-pox,
sore-throats, measles, consumptions. He saw what was done for them. He
put up the medicines, gathered the herbs, and so learned something of
materia medico and botany. He learned these few things easily and well,
for he could give his whole attention to them. Chirurgery was a separate
specialty. Women in child-birth were cared for by midwives. There was
no chemistry deserving the name to require his study. He did not learn a
great deal, perhaps, but what he did learn was his business, namely, how
to take care of sick people.
Let me give you a picture of the old-fashioned way of instruction, by
carrying you with me in imagination in the company of worthy Master
Giles Firmin as he makes his round of visits among the good folk of
Ipswich, followed by his one student, who shall answer to the scriptural
name of Luke. It will not be for entertainment chiefly, but to
illustrate the one mode of teaching which can never be superseded,
and which, I venture to say, is more important than all the rest put
together. The student is a green hand, as you will perceive.
In the first dwelling they come to, a stout fellow is bellowing with
colic.
“He will die, Master, of a surety, methinks,” says the timid youth in a
whisper.
“Nay, Luke,” the Master answers, “'t is but a dry belly-ache. Didst
thou not mark that he stayed his roaring when I did press hard over the
lesser bowels? Note that he hath not the pulse of them with fevers, and
by what Dorcas telleth me there hath been no long shutting up of the
vice naturales. We will steep certain comforting herbs which I will shew
thee, and put them in a bag and lay them on his belly. Likewise he shall
have my cordial julep with a portion of this confection which we do call
Theriaca Andromachi, which hath juice of poppy in it, and is a great
stayer of anguish. This fellow is at his prayers to-day, but I warrant
thee he shall be swearing with the best of them to-morrow.”
They jog along the bridle-path on their horses until they come to
another lowly dwelling. They sit a while with a delicate looking girl
in whom the ingenuous youth naturally takes a special interest. The good
physician talks cheerfully with her, asks her a few questions. Then to
her mother: “Good-wife, Margaret hath somewhat profited, as she telleth,
by the goat's milk she hath taken night and morning. Do thou pluck a
maniple--that is an handful--of the plant called Maidenhair, and make
a syrup therewith as I have shewed thee. Let her take a cup full of
the same, fasting, before she sleepeth, also before she riseth from her
bed.” And so they leave the house.
“What thinkest thou, Luke, of the maid we have been visiting?” “She
seemeth not much ailing, Master, according to my poor judgment. For she
did say she was better. And she had a red cheek and a bright eye, and
she spake of being soon able to walk unto the meeting, and did seem
greatly hopeful, but spare of flesh, methought, and her voice something
hoarse, as of one that hath a defluxion, with some small coughing from
a cold, as she did say. Speak I not truly, Master, that she will be well
speedily?”
“Yea, Luke, I do think she shall be well, and mayhap speedily. But it is
not here with us she shall be well. For that redness of the cheek is
but the sign of the fever which, after the Grecians, we do call the
hectical; and that shining of the eyes is but a sickly glazing, and they
which do every day get better and likewise thinner and weaker shall find
that way leadeth to the church-yard gate. This is the malady which the
ancients did call tubes, or the wasting disease, and some do name the
consumption. A disease whereof most that fall ailing do perish. This
Margaret is not long for earth--but she knoweth it not, and still
hopeth.”
“Why, then, Master, didst thou give her of thy medicine, seeing that her
ail is unto death?”
“Thou shalt learn, boy, that they which are sick must have somewhat
wherewith to busy their thoughts. There be some who do give these tabid
or consumptives a certain posset made with lime-water and anise and
liquorice and raisins of the sun, and there be other some who do give
the juice of craw-fishes boiled in barley-water with chicken-broth,
but these be toys, as I do think, and ye shall find as good virtue, nay
better, in this syrup of the simple called Maidenhair.”
Something after this manner might Master Giles Firmin have delivered his
clinical instructions. Somewhat in this way, a century and a half later,
another New England physician, Dr. Edward Augustus Holyoke, taught a
young man who came to study with him, a very diligent and intelligent
youth, James Jackson by name, the same whose portrait in his advanced
years hangs upon this wall, long the honored Professor of Theory and
Practice in this Institution, of whom I shall say something in this
Lecture. Our venerated Teacher studied assiduously afterwards in the
great London Hospitals, but I think he used to quote his “old Master”
ten times where he quoted Mr. Cline or Dr. Woodville once.
When I compare this direct transfer of the practical experience of a
wise man into the mind of a student,--every fact one that he can use
in the battle of life and death,--with the far off, unserviceable
“scientific” truths that I and some others are in the habit of teaching,
I cannot help asking myself whether, if we concede that our forefathers
taught too little, there is not--a possibility that we may sometimes
attempt to teach too much. I almost blush when I think of myself as
describing the eight several facets on two slender processes of the
palate bone, or the seven little twigs that branch off from the minute
tympanic nerve, and I wonder whether my excellent colleague feels in the
same way when he pictures himself as giving the constitution of
neurin, which as he and I know very well is that of the hydrate of
trimethyle-oxethyle-ammonium, or the formula for the production of
alloxan, which, though none but the Professors and older students can
be expected to remember it, is C10 H4 N4 O6+ 2HO, NO5=C8 H4 N2
O10+2CO2+N2+NH4 O, NO5.
I can bear the voice of some rough iconoclast addressing the Anatomist
and the Chemist in tones of contemptuous indignation: “What is this
stuff with which you are cramming the brains of young men who are to
hold the lives of the community in their hands? Here is a man fallen in
a fit; you can tell me all about the eight surfaces of the two processes
of the palate bone, but you have not had the sense to loosen that man's
neck-cloth, and the old women are all calling you a fool? Here is a
fellow that has just swallowed poison. I want something to turn his
stomach inside out at the shortest notice. Oh, you have forgotten the
dose of the sulphate of zinc, but you remember the formula for the
production of alloxan!”
“Look you, Master Doctor,--if I go to a carpenter to come and stop
a leak in my roof that is flooding the house, do you suppose I care
whether he is a botanist or not? Cannot a man work in wood without
knowing all about endogens and exogens, or must he attend Professor
Gray's Lectures before he can be trusted to make a box-trap? If my horse
casts a shoe, do you think I will not trust a blacksmith to shoe him
until I have made sure that he is sound on the distinction between the
sesquioxide and the protosesquioxide of iron?”
--But my scientific labor is to lead to useful results by and by, in the
next generation, or in some possible remote future.--
“Diavolo!” as your Dr. Rabelais has it,--answers the iconoclast,--“what
is that to me and my colic, to me and my strangury? I pay the Captain of
the Cunard steamship to carry me quickly and safely to Liverpool, not
to make a chart of the Atlantic for after voyagers! If Professor Peirce
undertakes to pilot me into Boston Harbor and runs me on Cohasset rocks,
what answer is it to tell me that he is Superintendent of the Coast
Survey? No, Sir! I want a plain man in a pea-jacket and a sou'wester,
who knows the channel of Boston Harbor, and the rocks of Boston Harbor,
and the distinguished Professor is quite of my mind as to the matter,
for I took the pains to ask him before I ventured to use his name in the
way of illustration.”
I do not know how the remarks of the image-breaker may strike others,
but I feel that they put me on my defence with regard to much of my
teaching. Some years ago I ventured to show in an introductory Lecture
how very small a proportion of the anatomical facts taught in a regular
course, as delivered by myself and others, had any practical bearing
whatever on the treatment of disease. How can I, how can any medical
teacher justify himself in teaching anything that is not like to be of
practical use to a class of young men who are to hold in their hands
the balance in which life and death, ease and anguish, happiness and
wretchedness are to be daily weighed?
I hope we are not all wrong. Oftentimes in finding how sadly ignorant
of really essential and vital facts and rules were some of those whom
we had been larding with the choicest scraps of science, I have doubted
whether the old one-man system of teaching, when the one man was of the
right sort, did not turn out better working physicians than our more
elaborate method. The best practitioner I ever knew was mainly shaped
to excellence in that way. I can understand perfectly the regrets of my
friend Dr. John Brown of Edinburgh, for the good that was lost with the
old apprenticeship system. I understand as well Dr. Latham's fear “that
many men of the best abilities and good education will be deterred from
prosecuting physic as a profession, in consequence of the necessity
indiscriminately laid upon all for impossible attainments.”
I feel therefore impelled to say a very few words in defence of
that system of teaching adopted in our Colleges, by which we wish to
supplement and complete the instruction given by private individuals or
by what are often called Summer Schools.
The reason why we teach so much that is not practical and in itself
useful, is because we find that the easiest way of teaching what is
practical and useful. If we could in any way eliminate all that would
help a man to deal successfully with disease, and teach it by itself
so that it should be as tenaciously rooted in the memory, as easily
summoned when wanted, as fertile in suggestion of related facts, as
satisfactory to the peremptory demands of the intelligence as if taught
in its scientific connections, I think it would be our duty so to teach
the momentous truths of medicine, and to regard all useless additions as
an intrusion on the time which should be otherwise occupied.
But we cannot successfully eliminate and teach by itself that which is
purely practical. The easiest and surest way of acquiring facts is to
learn them in groups, in systems, and systematized knowledge is science.
You can very often carry two facts fastened together more easily than
one by itself, as a housemaid can carry two pails of water with a hoop
more easily than one without it. You can remember a man's face, made
up of many features, better than you can his nose or his mouth or his
eye-brow. Scores of proverbs show you that you can remember two lines
that rhyme better than one without the jingle. The ancients, who knew
the laws of memory, grouped the seven cities that contended for the
honor of being Homer's birthplace in a line thus given by Aulus Gellius:
Smurna, Rodos, Colophon, Salamin, Ios, Argos, Athenai.
I remember, in the earlier political days of Martin Van Buren,
that Colonel Stone, of the “New York Commercial,” or one of his
correspondents, said that six towns of New York would claim in the same
way to have been the birth-place of the “Little Magician,” as he was
then called; and thus he gave their names, any one of which I should
long ago have forgotten, but which as a group have stuck tight in my
memory from that day to this;
Catskill, Saugerties, Redhook, Kinderhook, Scaghticoke, Schodac.
If the memory gains so much by mere rhythmical association, how much
more will it gain when isolated facts are brought together under laws
and principles, when organs are examined in their natural connections,
when structure is coupled with function, and healthy and diseased action
are studied as they pass one into the other! Systematic, or scientific
study is invaluable as supplying a natural kind of mnemonics, if for
nothing else. You cannot properly learn the facts you want from Anatomy
and Chemistry in any way so easily as by taking them in their regular
order, with other allied facts, only there must be common sense
exercised in leaving out a great deal which belongs to each of the two
branches as pure science. The dullest of teachers is the one who does
not know what to omit.
The larger aim of scientific training is to furnish you with principles
to which you will be able to refer isolated facts, and so bring these
within the range of recorded experience. See what the “London Times”
said about the three Germans who cracked open John Bull Chatwood's
strong-box at the Fair the other day, while the three Englishmen
hammered away in vain at Brother Jonathan Herring's. The Englishmen
represented brute force. The Germans had been trained to appreciate
principle. The Englishman “knows his business by rote and rule of
thumb”--science, which would “teach him to do in an hour what has
hitherto occupied him two hours,” “is in a manner forbidden to him.” To
this cause the “Times” attributes the falling off of English workmen in
comparison with those of the Continent.
Granting all this, we must not expect too much from “science”
as distinguished from common experience. There are ten thousand
experimenters without special apparatus for every one in the laboratory.
Accident is the great chemist and toxicologist. Battle is the great
vivisector. Hunger has instituted researches on food such as no Liebig,
no Academic Commission has ever recorded.
Medicine, sometimes impertinently, often ignorantly, often carelessly
called “allopathy,” appropriates everything from every source that can
be of the slightest use to anybody who is ailing in any way, or like to
be ailing from any cause. It learned from a monk how to use antimony,
from a Jesuit how to cure agues, from a friar how to cut for stone, from
a soldier how to treat gout, from a sailor how to keep off scurvy, from
a postmaster how to sound the Eustachian tube, from a dairy-maid how
to prevent small-pox, and from an old market-woman how to catch the
itch-insect. It borrowed acupuncture and the moxa from the Japanese
heathen, and was taught the use of lobelia by the American savage.
It stands ready to-day to accept anything from any theorist, from any
empiric who can make out a good case for his discovery or his remedy.
“Science” is one of its benefactors, but only one, out of many. Ask the
wisest practising physician you know, what branches of science help
him habitually, and what amount of knowledge relating to each branch he
requires for his professional duties. He will tell you that scientific
training has a value independent of all the special knowledge acquired.
He will tell you that many facts are explained by studying them in the
wider range of related facts to which they belong. He will gratefully
recognize that the anatomist has furnished him with indispensable data,
that the physiologist has sometimes put him on the track of new modes
of treatment, that the chemist has isolated the active principles of
his medicines, has taught him how to combine them, has from time to time
offered him new remedial agencies, and so of others of his allies. But
he will also tell you, if I am not mistaken, that his own branch of
knowledge is so extensive and so perplexing that he must accept most
of his facts ready made at their hands. He will own to you that in the
struggle for life which goes on day and night in our thoughts as in the
outside world of nature, much that he learned under the name of science
has died out, and that simple homely experience has largely taken the
place of that scholastic knowledge to which he and perhaps some of his
instructors once attached a paramount importance.
This, then, is my view of scientific training as conducted in courses
such as you are entering on. Up to a certain point I believe in set
Lectures as excellent adjuncts to what is far more important, practical
instruction at the bedside, in the operating room, and under the eye of
the Demonstrator. But I am so far from wishing these courses extended,
that I think some of them--suppose I say my own--would almost bear
curtailing. Do you want me to describe more branches of the sciatic and
crural nerves? I can take Fischer's plates, and lecturing on that scale
fill up my whole course and not finish the nerves alone. We must stop
somewhere, and for my own part I think the scholastic exercises of our
colleges have already claimed their full share of the student's time
without our seeking to extend them.
I trust I have vindicated the apparent inconsequence of teaching young
students a good deal that seems at first sight profitless, but which
helps them to learn and retain what is profitable. But this is an
inquisitive age, and if we insist on piling up beyond a certain height
knowledge which is in itself mere trash and lumber to a man whose life
is to be one long fight with death and disease, there will be some sharp
questions asked by and by, and our quick-witted people will perhaps find
they can get along as well without the professor's cap as without the
bishop's mitre and the monarch's crown.
I myself have nothing to do with clinical teaching. Yet I do not
hesitate to say it is more essential than all the rest put together, so
far as the ordinary practice of medicine is concerned; and this is by
far the most important thing to be learned, because it deals with so
many more lives than any other branch of the profession. So of personal
instruction, such as we give and others give in the interval of
lectures, much of it at the bedside, some of it in the laboratory, some
in the microscope-room, some in the recitation-room, I think it has many
advantages of its own over the winter course, and I do not wish to see
it shortened for the sake of prolonging what seems to me long enough
already.
If I am jealous of the tendency to expand the time given to the
acquisition of curious knowledge, at the expense of the plain
old-fashioned bedside teachings, I only share the feeling which Sydenham
expressed two hundred years ago, using an image I have already borrowed.
“He would be no honest and successful pilot who was to apply himself
with less industry to avoid rocks and sands and bring his vessel safely
home, than to search into the causes of the ebbing and flowing of the
sea, which, though very well for a philosopher, is foreign to him whose
business it is to secure the ship. So neither will a physician, whose
province it is to cure diseases, be able to do so, though he be a person
of great genius, who bestows less time on the hidden and intricate
method of nature, and adapting his means thereto, than on curious and
subtle speculation.”