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Gilman, Please accept the dedication of this volume of addressee, in memory of those happy days in 1889 when, under your guidance, the Johns Hopkins Hospital was organized and opened; and in grateful recognition of your active and intelUgent interest in medical education. Youra sincerely, William OsLEB. \-\'&' CONTENTS (xur. fkom L AsqiTAinHiTAS 1 n DOCTOB AND XxrBSX 13 ni Teacher and Sttobnt 21 IV Physic and Physicians as Depicted in Plato . . 45 V The Leaven of SaENCE 77 VI The Abhy Surgeon 103 VII Teaching and Thinkino 121 VIII Internal Medicine as a Vocation .... 137 IX NuESE AND Patient 153 X Beitish Medicine in Greater BanAiN . . .167 XI Afier Twenty-Five Years 197 Xn Books and Men 217 XIII Medicine in the Nineteenth Centcey . . . 227 XIV Chauvinism in Medicine 277 XV Some Aspects of A3iEEici.v Medical Bibliogbafhy . 307 XVI The Hospital as a College 327 XVII On the Educational Value of the Medical Society 343 XVJLu The I^Iastib-Wobd in Medicine . . . .363 vii iHHMa AEQUANIMITAS AB. Thou must be Uke a promontory of the sea, agamst which, though the waves beat continuaUy. yet it both itself stands, and about it are thoee awelling waves stilled and quieted. Mabcus Aubeltos. I say : Fear not ! Life still lieaves human effort scope. But, since life teems with ill. Nurse no extravagant hope ; Because thou must not dream, thou need'st not then despair! Matthew Abnold, Empedoclea on Etna. \ i AEQUANIMITAS' TO many the frost of custom has made even these im- posing annual ceremonies cold and lifeless. To you, at least oi those present, they should have the solemnity of an ordinance — called as you are this day to a high dignity and to so weighty an oflSce and charge. You have chosen your Geniufi, have passed beneath the Throne of Necessity, and with the voices ^f the fatal sisteris still in your ears, will soon en!;er the plain of Forgetfulness and drink of the waters of its river. Ere you are driven all manner of ways, like the souls in the tale of Er the Pamphylian,* it is my duty to say a few words of encouragement and to bid you, in the name of the Faculty, God-speed on your jourrc^y. I could have the heart to spare you, poor, careworn survivors of a hard struggle, so " lean and pale and leaden- eye " with study ; " and my tender mercy constrains me to consider but two of the score of elements which may make or mar your lives — which may contri te to your luxess, or help you in the days of failure. In the first p'aoe, in the physician or surgeon no quality takes rank with imperturbability, and I propose for a few minutes to direct your attention to this essential bodily virtue. Perhaps I may be able to give those of you, in 1 Valedictory Address, University of Pennsylvania, May 1, 1880 * The Bepublic, Book X. 8 AEQUANIMITAS whom it has not developed during the ciiticftl scene:; oi the put moiith, a hint or two of its importance, possibly a suggestion for its attainment. Imperturbability aieans coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility, impassiveness, or, to use an old and expressive word, phlegm. It is the quaUty which is most appreciated by the laity though often misunderstood by tnem ; and the physician who has the misfortune to be without it, who betrays indecision and worry, and who shows that he is flustered and flurried in ordinary emer- gencies, loses rapidly the confidence of his patients. In full levelopment, as we see it in some of our older colleagues, it has the nature of a divine gift, a blessing to the possessor, a comfort to all who come in contact with him. You should know it well, for there have been before you for years several striking illustrations, whose example has, I trust, made a deep impression. As imperturbability is largely a bodily endowment, I regret to say that there are those amongst you, who, owing to congenital defects, may never be able to acquire it. Education, however, wUldo much; and with practice and experience the majority of you may expect to attain to a fair measure. The first essential is to have your nerves well in hand. Even under the most serious circumstances, the physician or surgeon who allows " his outward action to demon- strate the native act and figure of his heart in complement extern," who shows in his fac3 the slightest alteration, expressive of anxiety or fear, has not his medullary centres under the highest control, and is liable to disaster at any moment. I have spoken of this to you on many occasions, 4 AEQUANIMITAS and have urged you to educav^e your nerve centres so that not the slightest dilator or contractor influence shall pass to the vesseb of your face under any professional trial. Far be it from me to urge you, ere Time has carved with his hours those fair brows, to quench on all occasions the blushes of ingenuous shame, but in dealing with your patients emergencies demanding these should certainly not arise, and at other times an inscrutable face may prove a fortune. In a true and perfect form, imperturbability is indissolubiy associated with wide experience and an intimate knowledge of the varied aspects of disease. With such advantages he is so equipped that no eventuality can disturb the mental equilibrium of the physician ; the possibilities are always manifest, and the course of action clear. From its very nature this precious quality is liable to be misinterpreted, and the general accusation of hardness, so often brought against the pioiession, has here its founda- tion. Now a certain measure of insensibility is not only an advantage, but a positive necessity in the exercise of a calm judgment, and in carrying out delicate operations. Keen sensibility is doubtless a virtue of high order, when it does not interfere with steadiness of hand or coolness of nerve ; but for the practitioner in his woiking-day world, a callousness which thinks only of the good to be effected, and goes ahead regardless of smaller considerations, is the preferable quality. Cultivate, then, gentlemen, such a judicious measure of obtuseness as will enable you to meet the exigencies of practice with firmness and courage, without, at the same time, hardening " the human heart by which we live." In the second place, there is a mental equivalent to this 5 i'i AEQUANIMITAS bodUy endo'nxient, which is as important in our pUgrimage as imperturbabiUty. Let me recall to your minds an incident related of that best of men and wisest of rulers, Antoninus Pius, who, as he lay dying, in his home at Lonum in Etruria, summed up the philosophy of life in the watch- word, AeqmnimUas. As for him, about to pass flammaraia moenia mundi (the flaming rampart of the world), so for you, fresh from Qotho's spindle, a calm equanmuty is the desiable attitude. How difficult to attain, yet how necessary, in success as in faUure! Natural tempera- ment has much to do with its development, but a clear knowledge of our relation to our fellow-creatures and to the work of Ufe is also indispensable. One of the first essentials in securing a good-natured equanimity is not to expect too much of the people amongst whom you dwell. " Knowledge comes, but wisdom lingers," and m matters medical the ordinary citizen of to-day has not one whit more sense than the old Romans, whom Lucian scourged for a credulity which made them fall easy victims to the quacks of the time, such as the notorious Alexander, whose exploits make one wish that his advent bar! been delayed some eighteen centuries. Deal gently then with this de- liciously credulous old human nature in which we work, and restrain your indignation, when you find your pet parson has triturates of the 1000th potentiality in his waistcoat pocket, or you discover accidentally a case of Warner's Safe Cure in the bedroom of your best patient. It must needs be that offences of this kind come ; expect them, and do not be vexed. Curious, odd compounds are these fellow-creatures, at whose mercy you will be ; full of fads and eccentricities, 6 AEQUAN1M1TA8 of whims and fancies ; but the moro closely we study their little foibles of one sort and another in the inner life which we see, the more surely is the conviction borne in upon us of the likeness of their weaknesses to our own. The simi- larity would be intolerable, if a happy egotism did not often render us forgetful of it. Hence the need of an infinite patience and of an ever-tender charity toward these fellow- creatur«)8 ; have they not to exercise the same toward us ? A distressing feature in the life which you are about to enter, a feature which will press hardly upon the finer spirits among you and ruffle their equanimity, is the un- certainty which pertains not alone to our science and art, but to the very hopes and fears which make us men. In seeking absolute truth we aim at the imattainable, and must be content with finding broken portions. You re- member in the Egyptian story, how Typhon with his con- spirators dealt with good Osiris ; how they took the virgin Truth, hewed her lovely form into a thousand pieces, ard scattered them to the four winds; and, as Milton says, " from that time ever since, the sad friends of truth, such as durst appear, imitating the careful search that Isis made for the mangled body of Osiris, went up and down gathering up limb by limb still as they could find them. We have not yet found them all," ' but each one of us may pick up a fragment, perhaps two, and in moments when mortality weighs less heavily upon the spirit, we can, as in a vision, see the form divine, just as a great Naturalist, an Owen or a Leidy, can reconstruct an ideal creature from a fossil fragment. > Areopagitica. 7 AEQUANIMITAS It hM been said that in prosperity onr equanimity is chiefly exercised m enabling us to bear with composure the misfortunes of our neighbours. Now, while nothing disturbs our mental placidity more sadly than straightened means, and the lack of those things after which the Gentiles seek, I would warn you againsv the trials of the day soon to come to some of you— the di>y of large and successful practice. Engrossed late and soon in professional cares, getting and spending, you may so lay waste your powers that you may find, too late, with hearts given away, that there is no place in your habit-stricken souls for those gentler influences which make life worth living. It is sad to think that, for some of you, there is in store disappointment, perhaps failure. You cannot hope, of course, to escape from the cares and anxieties incident to professional life. Stand up bravely, even against the worst. Your very hopes may have passed on out of sight, as did all that was near and dear to the Patriarch at the Jabbok ford, and, like him, you may be left to struggle in the night alone. Well for you, if you wrestle on, for in persistency lies victory, and with the morning may come the wished-for blessing. But not always ; there is a struggle with defeat which some of you will have to bear, and it will be well for you in that day to have cultivated a cheer- ful equanimity. Remember, too, that sometimes " from our desolation only does the better life begin." Even with disaster ahead and ruin imminent, it is better to face them with a smile, and with the head erect, than to crouch at their approach. And, if the fi-^ht is for principle and justice, even when failure seems certain, where many have failed before, cling to your ideal, and, like Childe Roland 8 AEQUANIMITA8 beioie the dark tower, set the slug-horn to yonr lips, blow the ohftllenge, and calmly await the conflict. It has been said that " in patience ye shall win your souk," and what is this patience but an equanimity which enables you to rise superior to the trials of life ? Sowing as you shall do beside all waters, I can but wish that you may reap the promised blessing of quietness and of assur- ance forever, until Within this life, Though lifted o'er ita strifej you may, in the growing winters, glean a little of that wisdom which is pure, peaceable, gentle, full of mercy and good *niits, without partiality and without hypocrisy. The past is always with us, never to be escaped; it alone is enduring ; but, amidst the changes and chances which succeed one another so rapidly in this life, we are apt to live too much for the present and too much in the future. On such an occasion as the present, when the Alma Mater b in festal array, when we joy in her growing prosperity, it is good to hark back to the olden days and gratefully to recall the men whose labours in the past have made the present possible The great possession of any Uni\ is lz its great names. It is not the " pride, pomp and circumstance " of an insti- tution which bring honour, not its wealth, nor the number of its schools, not the students who throng its halls, bus the men who have trodden in its service the thorny road through toil, even through hate, to the serene abode of Fame, climbing "like stars to their appointed height." These bring glory, and it should thrill the heart of every alumnus of this school, of every teacher in its faculty, 9 \{ 1 AEQUANIMITAS M it does mine this d«y, reverently and thankfully to recall such names amongst its founders as Morgan, Shippen, and Rv.h, and such men amongst their successors as Wistar, Physick, Barton, and Wood. Gentlemen of the Faculty— ^oWe*«e oblige. And the sad reality of the past teaches us to-day in the freshness of sorrow at the loss of friends and colleagues, '• hid in death's dateless night." We miss from our midst one of your best known instructors, by whose lessons you have profited, and whose example has stimulated many. An earnest teacher, a faithful worker, a loyal son of this University, a good and kindly friend, Edward Bruen has left behind him, amid regrets at a career untimely closed, the memory of a well-spent life. We mourn to-day, abo, with our sister college, the grievous loss which she has sustained in the death of one of her most distinguished teachers, a man who bore with honour an honoured name, and who added lustre t^ the profession of this city. Such men as Samuel W. Gross can ill be spared. Let us be thankful for the example of a courage which could fight and win ; and let us emulate the zeal, energy, and industry which characterized his career. Personally I mourn the loss of a preceptor, dear to me as a father, the man from whom more than any other I received inspiration, and to whose example and precept I owe the position which enables me to address you to- day. There are those present who will feel it no exag- geration when I say that to have known Palmer Howard was, in the deepest and truest sense of the phrase, a Uberal education — 10 AEQUANIMITAS Whftterer w»y my dayt decline. I felt and feel, tho' left alone, HU being working in mine own^ The footstep* of hia life in mine. While preaching to you a doctrine of equanimity, I am, myself; a castaway. Recking not my own rede, I illustrate the inconsistency which so readily besets u . One might have thought that in the premier school of America, in this Civitas Hippocratica, with associations so dear to a lover of his profession, with colleagues so distincuished, and with students so considerate, one might have '.lought, I say, that the Hercules Pillars of a man's ambition had here been reached. But it has not been so ordained, and to-day I sever my connexion with this University. More than once, gentlemen, in a life lich in the priceless blessings of friends, I have been placed in positions in which no word-, could express the feelings of my heart, and so it is with me now. The keenest sentiments of gratitude well up from my innermost being at the thought of the kind- liness and goodness which have fohowed me at every step during the past five years. A stranger— I cannot say an alien— among you, I have been made to feel at home- more you could not have done. Could I say more 1 Whatever the future may have in store of success or of trials, nothing can blot the memory of the happy days I have spent in this city, and nothing can quench the pride I shall always feel at having been associated, even for a time, with a Faculty so notable in the past, so distinguished in the preser i, as that from which I now part. Gentlemen,— Farewell, and take with you into the struggle the watchword of the good old Roman— Aequanimitas. 11 I'l ) ■- — -t II DOCTOR AND NURSE 18 ^?ile. He is the flower (such ^l^^f ^^^ ^ y^ n^arveUed ^hen that stage of man jfl ^°« ^'^^;^ .tared as little as any m It m history, he wiU ^^^^^f ^*^t notebly exhibited the virtues 1 defects of the P«'f ' f ^ J^eJt is possible to thosejho of the raoe. Generosity be h^j^«"^h^^ ^ ,^^, ^ ^J'''°'''^^. practise an art. never *« *h^«Ji\°i^ ^ thousand embarrassments . Z a hundred secrets ; t^^*' f ^^^^i*^ cheerfulness and courage. 2d what are more im^^ut H^r^lean ^ ^^^^ ^^^ ^^^^^ ^^^^^^ So that he brings a^ and chee^"' ^^^^^^^ "^"^ -^^ ;:::::J^s s..v..so.. p.iace t. r«..«^. ^^ not Silence the wisdom 0^^^^^,'^^:;::^^. S^^^ tbl^^our of wise Men. f « ^-^'Stt abtdanl. but the weU- of Taciturnity. ^^^.^ > Hear^ Such Silence may be Eloquence. weighed thoughts of their Hearts- bu and speak thy worth above the power o ^^^^ ^^^^^^ t ^' t 14 II DOCTOR AND NURSE* THERE are individuals— doctors and nurses, for ex- ample — ^whose very existence is a constant reminder of our frailties ; and considering the notoriously irritating character of such people, I often wonder that the world deals so gently with them. The presence of the parson suggests dim possibilities, not the grim realities conjured up by the names of the persons just mentioned ; tue lawyer never worries us — in this way, and we can imagine in the future a social condition in which neither divinity nor law shall have a place — when all shall be friends and each one a priest, when the meek shall possess the earth ; but we cannot picture a time when Birth and Life and Death shall be separated from that " grizzly troop " which we dread so much and which is ever associated in our minds with " physician and nurse." Dread ! Yes, but mercifully for us in a vague and misty way. Like schoolboys we play among the shadows cast by the turrets of the temple of oblivion, towards which we travel, regardless of what awaits us in the vale of years beneath. Suffering and disease are ever before us, but life is very pleasant ; and the motto of the world, when well, is " forward with the dance." Fondly imagin* > Johns Hopkins Hospital, 1891. 16 •I, DOCTOR AND NURSF. ^ , M^ioiMy. the tragedy ^1^*^ « .^ proportion.. A.«l better » ; fo^ ^«« ^^^ U " a « had a l*-'--^-^ ^^ po,. or the hamM. Ufe, it woald be lAe heamg 8 » ^^^^ sqwrrel'. heart beat, and «e Aould die Ues on the other side of «le«oe. ^^^^ ^ ^^ ^, With many, however, it »'' ™™ . j t„t by the '-'•' ^"^.r nl r-S;. o. human Btem exigencies of Uie, wn ^^^^ ^ ^^ ^^"^r rTr:"-:tely conscious ol r;^r^'or-su«e.ng.andoithoseine.tab^^ Btege accessories-doctor "^^ n^^^ ^^^ ^^aical pro- H Menibers ^'^/^^.f/;^^^^^^^^ a larger fession. composed chiefly o^JJ^^' ^^ i^ast. the share of attention and regard, you have satisfaction of ^^^^^^'^^^^^^iZ^^^^^^ books the more honourable calling J^ °^^ ^* j,^ ,ten an o, Solonion^^-^tXg" e^r^^^^^^ E^och. and early grandmother, bending ^ ^^ ^^^^ Bhowir.g Mahala how to soothe his ^^''^ , ^^ ^ I- -la Woman " the link among the days, »u his pains. Woman, successive generations, trained in a bitter school, has m ^^^^^^ ^^^^^ played the part of Mahala to the little Enoc^' '^^ ^ , A,.A Tanoplot It SCCmS a lar cry uui^a to the wounded I^^^^*' \ ^j ^amelot to the Johns plain of Mesopotamia and the l^^^^j V' ^j^ ^^^^ Hopkins Hospital, but the spirit which makes DOCTOR AND NURSE posttble is the same, tempered through the ages, by the benign influence of Christianity. Among the ancients, many had riaen to the idea of forgiveness of enemies, of patience mider wrong doing, and even of the brotherhood of man ; but the spirit of Love only received its mcama- tion with the ever memorable reply to the ever memor- able question, Who is my neighbour 1-a reply which has changed the attitude of the world. Nowhere in ancient history, sacred or profane, do we find pictures of devoted heroism in women such as dot the annals of the CathoUc Church, or such as can be paralleled in our own century. Tender maternal affection, touching filial piety were there; but the spirit abroad wf at of Deborah not Rizpah, of Jael not Dorcas. In the gradual division of labour, by which civihxation has emerged from barbarism, the doctor and the nurse have beeu evolved, as useful accessories in the mcesfant warfare in which man is engaged. The history of the race is a grim record of passions and ambitions, of weak- nesses and vanities, a record, too often, of barbaric in- humanity, and even to-day, when philosophers would hav ' believe his thoughts had widened, he is ready as of ) chut the ga^os of mercy, and to let loose the dogs of vs -i. It was in o^e of these attacks of race-mania that your profession, until then unsettled and ill-defined, took, under Florence Nightingale-«ver blessed be her name— its modern position. IndividuaUy. man, the unit, the microcosm, is fast bound in chains of atavism, inheriting legacies of feeble wiU and strong desires, taints of blood and brain. What wonder, then, that many, sore let and hindered in running the 17 I \ DOCTOR AND NURSE race. faU by the way. and need a shelter in which to recruit or to die. a hospital, in which there shall be no harsh comments on conduct, but only, so far as « possible, love and peace and rest ? Here, we learn to scan gently our brother man, judging not, asking no questions, but meting out to aU alike a hospitality worthy oi th^ Hotd Dieu, and deeming ourselves honoured in being allowed to act as its dispensers. Here, too, are daUy before our eyes the problems which have ever perplexed the human mind ; problems not presented in the dead abstract of books, but in the living concrete of some poor fellow in his last round, fighting a brave fight, but sadly weighted, and going to his account "unhouseU'd. disappointed, unanel'd. no reckoning made." As we whisper to each other over his bed that the battle is decided and Euthanasia alone remains, have I not heard in reply to that muttered proverb, so often on the lips of the physician. " the fathers have eaten sour grapes," your answer, in clear accents- the comforting words of the prayer of Step n1 But our work would be much restricted were it not for man's outside adversary-Nature, the great Moloch, which exacts a frightful tax of human blood, spar- ing neither young nor old ; taking the chUd from the cradle, the mother from her babe, and the father from the fanuly. Is it strange that man, unable to dis- sociate a personal element from such work, has incarnated an evU principle - the devil? If we have now so far outgrown this idea as to hesitate to suggest, in seasons of epidemic peril, that " it is for our sins we suffer "—when we know the drainage is bad ; if we no longer mock the heart prostrate m the grief of loss with the words " whom 18 I i 1 I DOCTOR AND NURSE the Lord loveth He chastencth "—when we know the mUk should have been sterilized— if , I say, we have, in a measure, become emancipated from such teachings, we have not yet risen to a true conception of Nature. Cruel, in the sense of being inexorable, she may be called, but we can no more upbraid her great laws than we can the lesser laws of the state, which are a terror only to evildoers. The pity is that we do not know them all ; in our ignor- ance we err daily, and pay a blood penalty. Fortunately it is now a great and growing function of the medical pro- fession to search out the laws about epidemics, and these outside enemies of man, and to teach *o you, the pubUc— dull, stupid pupils you are, too, as i. rule— the ways of Nature, that you may walk therein and prosper. It would be interesting. Members of the Graduatmg aass, to cast your horoscopes. To do so coUectively you would lot like ; to do so individually— I dare not ; but it is safe to predict certain things of you, as a whole. You wiU be better women for the life which you have led here. But what I mean by " better women " is that the eyes of your souls have been opened, the range of your sympathies has been widened, and your characters have been moulded by the events in which you have been participators during the past two years. Practically there should be for each of you a busy, useful, and happy life ; more you cannot expect ; a greater bles- sing the world cannot bestow. Busy you will certainly be, as the demand is great, both in private and public, for women with your training. Useful your lives must be, as you will care for those who cannot care for themselves, and who need about ^^^liem, in the day of tribulation, gentle 19 »■ \ DOC?rOE AND NUB8B hftncU end tender hearts. And happy lives shall be yours, because busy and useful ; having been initiated into the great secret— that happiness lies in the absorption in some vocation which satisfies the soul ; that we have here to add what we can to, not to get what we can from, life. And, finally, remember what we are— useful super- numeraries in the battle, simply stage accessories in the drama, playing minor, but essential, parts at the exits and entrances, or picking up, here and there, a strutter, who may have tripped upon the stage. You have been much by the dark river — so near to us all — and have seen so many embark, that the dread of the old boatman has almost disappeared, and When tha Angel of the darker Drink At last shall find you by the river brink, And offering his cup, invite your soul Forth to your lips to quaff —you shall not shrink : your passport shall be the blessing of Him in whose foot- steps you have trodden, unto whose sick you have minis- tered, and for whose children you have cared. V t'" M 20 Ill TEACHER AND STUDENT 21 mmmmt A University consists, and has ever consisted, in demand and supply, in wants wWch it alone can satisfy and which it does satisfy, in the communication of knowledge, and the relation and bond which exists between the teacher and the taught. Ito constituting, animating principle is this moral attraction of one class of persons to another ; which is prior in its nature, nay commonly m its hiHtory. to any other tie whatever ; so that, where this is wanting, a Um- versity is alive only in name, and has lost its true essence, whatever be the advantages, whether of position or of affluence, with which the civU power or private benefactors contrive to encircle it. John Henby Newman. It would seem, Adeimantus, that the direction in which education starts a man will determine his future life. Plato. Republic, iv.— Jowett's TranslaUon. 22 L III TEACHER AND STUDENT* I TRULY it may be said to-day that in the method* of teaching medicine the old order changeth, giving place to new, and to this revolution let me briefly refer, since it has an immediate bearing on the main point I wish to make in the first portion of my address. The medical schools of the country have been either independent. Uni- versity, or State Institutions. The first class, by far the mc3v numerous, have in title University affiliations, but are actually devoid of organic imion with seats of learning. Necessary as these bodies have been in the past, it is a cause for sincere congratulation that the number is steadily diminishing. Admirable in certain respects— adorned too in many instances by the names of men who bore the bur- den and heat of the day of small thii. •?», and have passed to their r« > amid our honoured dead — the truth must be acknowledged that the lamentable state of medical education in this coimtry twenty years ago was the direct result of the inherent viciouaness of a system they fostered. Something in the scheme gradually deadened in the pro- fessors all Sense of the responsibility until they professed to teach (mark the word), in less than two years, one of ^ Unirenity of Minnesota, 1892. 23 I TEACHER AND STUDENT the most difficult arta in the world to acquire. Fellow teachers in medicine, believe me that when fifty or sixty years hence some historian traces the development of the profession in this country, he will dwell on the notable achievements, on the great discoveries, and on the un- wearied devotion of its members, but he will pass judg- ment— yes, severe judgment — on the absence of the sense of responsibility which permitted a criminal h.at; m medical education unknown before in our annals. But an awakening has come, and there is sounding the knell of doom for the medical college, responsible neither to the public nor the profession. T 'a with close university connexions have been the m> isive and thorough in this country. The revolutiou d to began some twenty years ago with the appearance of the President of a well-known University at a meeting of its medical faculty with a peremptory com- mand to set their house in order.* Universities which teach only the Liberal Arts remain to-day, as in the middle ages, Scholse minores, lacking the technical faculties which make the Scholee majores. The advantages of this most natural vmion are manifold and reciprocal. The profes- sors in a University medical school have not that inde- pendence of which I have spoken, but are under an influence which tends constantly to keep them at a high level ; they are urged by emulation with the other faculties to improve the standard of work, and so are given a strong stimulus to further development. To anyone who has watched the growth of the new 1 Seo Holmes on President Eliot in Life aiid Letters of 0. W. Holme*, 1S06. u. 187, 188, 190. 24 TEACHER AND STITDENT ideas in education it is evident that the most solid advances in methods of teaching, the improved equipment, clinical and laboratory, and the kindlier spirit of generous rivalry— which has replaced the former debased method of counting heads as a test of merit — all these advantages have come from a tightening of the bonds between the medical school and the University. And lastly there are the State schools, of which tnis college is one of the few examples. It has been a char- acteristic of American Institutions to foster private industries and to permit private corporations to meet any demands on the part of the public. This idea carried to extreme allowed the unrestricted manufacture — note the term— of doctors, quite regardless of the qualifications usually thought necessary in civilized communities — of physicians who may never have been inside a hospital ward, and who had, after graduation, to Isarn medicine somewhat in the fashion of the Chinese doctors who re- cognized the course of the arteries of the body, by noting just where the blood spurted when the acupuncture needle was inserted. So far as I know, State authorities have never interfered with any legally instituted medical school, however poorly equipped for its work, however lax the qualifications for licen'ie. Not only has this policy of non-intervention boeri carried to excess, but in many States a few physiciais in any town could get a charter for a school withe it giving guarantees that laboratory or clinical facilities would be available. This anomalous condition is rapidly changing, owing partly to a revival of loyalty to higher ideals within the medical profession, and partly to a growing appreciation in the public of the 25 1 TEACHER AND STUDENT I IP value of physicians thoroughly educated in modern methods. A practical acknowledgment of this is found in the recognition in three States at least of medicine as one of the technical branches to be taught in the University supported by the people at large. But it is a secondary matter, after all, whether a school is under State or University control, whether the endow- ments are great or small, the equipments palatial or humble ; the fate of an institution rests not on these ; the inherent, vital element, which transcends all material interests, which may give to a school glory and renown in their absence, and lacking which, all the " pride, pomp and circumstance " are vain — this vitalizing element, I say, lies in the men who work in its halls, and in the ideals which they cherish and teach. There is a passage in one of John Henry Newman's Historical Sketches which ex- presses this feeling in terse and beautiful language : " I say then, that the personal influence of the teacher is able in some sort to dispense with an academical system, but that system cannot in any way dispense with personal influence. With influence there is life, without it there is none ; if influence is deprived of its due position, it will not by those means be got rid of, it will only break out irregxilarly, dangerously. An academical system without the personal influence of teachers upon pupils, is an Arctic winter ; it will create an ice-bound, petrified, cast-iron University, and nothing else." Naturally from this standpoint the selection of teachers is the function of highest importance in the Regents of a University. Owing to local conditions the choice of men for certain of the chairs is restricted to residents in the 26 i TEACHER AND STUDENT University town, as the salaries in most schools of this country have to be supplemented by outside work. But in all departments this principle should be acknowledged and acted upon by trustees and faculties, and supported by public opinion — that the very best men available should receive appointments. It is gratifying to note the broad liberality displayed by American colleges in welcom- ing from all parts teachers who may have shown any special fitness, emulating in this respect the liberality of the Athenians, in whose porticoes and lecture halls the stranger was greeted as a citizen and judged by his mental gifts alone. Not the least by any means of the object lessons taught by a great University is that literature and science know no country, and, as has been well said, acknowledge " no sovereignty but that of the mind, and no nobility but that of genius.' But it is difficult in this matter to guide public opinion, and the Regents have often to combat a provincialism which is as fatal to the highest development of a University as is the shibboleth of a sectarian institution. II To paraphrase the words of Matthew Arnold, the function of the teacher is to teach and to propagate the best that is known and taught in the world. To teach the current knowledge of the subject he professes— sifting, analyzing, assorting, laying down principles. To pro- pagate ; i.e., to multiply, facts on which to base principles —experimenting, searching, testing. The best that is known and taught in the world— nothing less can satisfy a teacher worthy of the name, and upon us of the medical 27 TEACHER AND STUDENT faculties lies a bounden duty in this respect, since onr Art, co-ordinate with human suffering, is cosmopolitan. There are two aspects in which we may view the teacher —as a worker and instructor in science, and as practitioner and professor of the art ; and these correspond to the natural division .f the faculty into the medical school proper and the hospital. In this emir nvy practical country the teacher of science has not yet received full recognition, owing in part to the great expense connected with his work, and in part to carelessness or ignorance in the public as to the real strength of a nation. To equip and mam- tain separate Laboratories in Anatomy, Physiology, Chemistry (physiological and pharmacological), Patho- logy and Hygiene, and to employ skilled teachers, who shall spend all their time in study and instruction, require a capital not to-day at the command of any medical school in the land. There are fortunate ones with two or three departments well organized, not one with all. In contrast, Bavaria, a kingdom of the German Empire, with an area leas than this State, and a population of five and a half millions, supports in its three University towns flourishing medical schools with extensive laboratories, many of which are presided over by men of world-wide reputation, the steps of whose doors are worn in many cases by students who have crossed the Atlantic ; seeking the wisdom of methods and the virtue of inspiration not easily accessible at home. But there were professors in Bavarian medical schools before Marquette and Joliet had launched their canoes on the great stream which the intrepid La Salle had discovered, before Du Lhut met 28 TEACHER AND STUDENT Father Hennepin below the falls of St. Anthony ; and justioe compels us to acknowledge that while winning an empire from the back-woods the people of this land had more urgent needs than laboratories of research. All has now changed. In this State, for example, the phe- nomenal growth of which has repeated the growth of the nation, the wilderness has been made to blossom as the rose, and the evidences of wealth and prosperity on every aide almos. 'rain one to break out into the now old song, " Happ^ lat people that is m such a case." But in the enormous development of material mterests there is danger lest we miss altogether the secret of a nation's life, the true test of which is to be found in its intellectual and moral standards. There is no more potent antidote to the corroding influence of mammon than the presence in a community of a body of men devoted to science, living for investigation and caring nothing for the lust of the eyes and the pride of life. We forget that the measure of the value of a nation to the world is neither the bushel nor the barrel, but mind ; and that wheat and pork, though useful and necessary, are but dross in com- parison with those intellectual products which alone are impershable. The kindly fruits of the earth are easily grown ; the finer fruits of the mind are of slower develop- ment and require prolonged culture. Each onft of the scientific branches to which I have referred has been so specialized that even to teach it takes more time than can be given by a single Professor, while the laboratory classes also demand skilled assistance. The aim of a school should be to have these depart- ments in the charge of men who have, first, enihutiaam 29 IMaJi^^^aUUa i\ \i i i I TEACHER AND STUDENT that deep love of a subject, that desire to teach and e^rtend it without which all instruction becomes cold and lifeless ; secondlv a jM versonal knowledge of the hratwh tau^M ; ^ot u second-hand information derived from books, but the Uving experience derived from expenmental and practical work in the best laboratories. This type of instructor ^s fortmiately not rare in American schools. Th3 well-grounded students who have pursued thenc studies in England and on the Continent have added depth and breadth to our professional scholarship, and theu: critical faculties have been sharpened to discern what is best in the world of medicine. It is particularly m these branches that we need teachers of wide learning, whose standards of work are the highest known, and whose methods are those of the masters in Israel. Thirdly men are required who have a sense of obligation, that feeling which impels a teacher to be also a contributor, and to add to the stores from which he so freely draws. And precisely here is the necessity to know the best that is taught m this branch, the world over. The investigator, to be sue cessful, must start abreast of the knowledge of the day. and he differs from the teacher, who, living m the present, expounds only what is current, in that his thorghts must be in the future, ar.d his ways and work in advance of the day in which he lives. Thus, unless a bacteriologist uas studied methods thoroughly, and is famUiar with the ex- traordinarily complex flora associated with healthy and diseased conditions, and keeps in touch with every labor- atory of research at home and abroad, he wiU in attempting original work, find himself exploring ground already weU- known, and will probably burden an already over-laden 80 TEACHER AND STUDENT literature with faulty and crude observations. To avoid mistakes, he must know what is going on in the laboratories of England, France and Germany, as well as in those of his own country, and he must receive and read x or ten journals devoted to the subject. The same need for wide and accurate study holds good in all branches. Thoroughly equipped laboratories, in charge of men, thoroughly equipped as teachers and investigators, is the most pressing want to-day in the medial schools of this country. The teacher as a professor and practitioner of his art is more favoured than his brother, of whom I have been speaking ; he is more common, too, and less interesting ; though in the eyes of " the fool multitude who choose by show" more important. And from the standpoint of medicine as an art for the prevention and cure of disease, the man who translates the hieroglyphics of science into the plain language of healing is certainly the more useful. He is more favoured inasmuch as the laboratory in which he works, the hospital, is a necessity in every centre of population. The same obligation rests on him to know and to teach the best that is known and taught in the world— on the surgeon the obligation to know thoroughly the scientific principles on which his art is based, to be a maste)- in the technique of his handicraft, ever studying, modifying, improving -.—on the physician, the obligation to study the natural history of diseases and the means for their prevention, to know the true value of regimen, diet and drugs in their treatment, ever testing, devising, thinking ;— and upon both, to teach to their students habits of reliance, and to be tr them 31 Uj ft'* "hi !i : i i> I TEACHER AND STUDENT examples of gentleness, forbearance and courtesy in dealing with their suffering brethren. . ^ • xu« ,^1.. I would fain dweU upon many other pomts m the rela tion of the hospital to the medical school-on the necessx^ of ample, full and prolonged clinical mstruction, and on L importance of bringing the ^tude^* f^^ *^^ ^^^^ into close contact, not through the cloudy knowledge o the amphitheatre, but by means of the accurate, cntjcal knowle^e of the wards ; on the propnety of encoj^apng the younger men as instructors and helpers m ward work and on the duty of hospital physicians and surgeons to :Lbute to the advance of their art-but pass on w. b an aUusion to a very delicato matter m college ^^^^^^ From one who. like themselves, has passed la erne efe .uarante ans, the seniors present will P^^oy Jewplam reinarks upon the disadvanteges to a school of havmg t^ many men of mature, not to say riper, years. InsensiWy, in the fifth and sixth decades, there begms to (^ep over most of us a change, noted physically among other ways the silvering of the hair and that le^emng of ehshcity. which impels a man to open rather than to vault a five- barred gate. It comes to all sooner or later ; to some it is only too painfully evident, to others it comes unconsciously. Ih no pace perceived. And with most of us this physical change has its mentel equivalent, not necessarily accom. panied by loss of the powers of appUcation or of judg- ment; on the contrary, often the mind grows clearer and the memory more retentive, but the change is seen in a weakened receptivity and in an mability to adapt oneself to an altered intellectual enviromnent. It « this loss of mental elasticity which makes men over forty so 82 I I TEACHER AND STUDENT slow to receive new truths. Harvey complained in his day that few men above this critical age seemed able to accept the doctrine of the circulation of the blood, and in our own time it is interesting to note how the theory of the bacterial origin of certain diseases has had, as other truths, to grow to acceptance with the generation in which it was announced. The only safeguard in the teacher against this lamentable condition is to live in, and with the third decade, in company with the younger, more receptive and progressive minds. There is no sadder picture than the Professor who has outgrown his usefulness, and, the only one unconscious of the fact, insists, with a praiseworthy zeal, upon the performance of duties for which the circumstances of the time have rendered him unfit. When a man nor wax nor honey can bring home, he should, in the interests of an institution, be dissolved from the hive to give more labourers room ; though it is not every teacher who will echo the sentiment — Let me not live ... After my flame lacks oil, to be the snuff Of younger spirits whose apprehensive senses All but new things disdain. As we travel farther from the East, our salvation lies in keeping our faces toward the rising sun, and in letting the fates drag us, like Cacus his oxcu, backward into the cave of oblivion; n L r s III Students of Medicine, Apprentices of the Guild, with whom are the promises, and in whom centre our hopes AE. 88 D !t fi * II i TEACHER AND STUDENT —let me congratulate you on the choice of calling which ofiers a combination of intellectual and moral interests found in no other profession, and not met with at all in the common pursuits of life— a combination which, b the words of Sir James Paget, " offers the most com- plete and constant union of those three qualities which have the greatest charm for pure and active minds— novelty, utility, and charity," But I am not he.e to laud our profession; your presence here on these benches is a guarantee that such praise is superfluous. Rather allow me, in the time remaining at my disposal, to talk of the influences which may make you good students— now in the days of your pupilage, and hereafter when you enter upon the more serious duties of life. In the first place, acquire early the A t of Detachment, by which I mean the faculty of isolating yourselves from the pursuits and pleasures incident to youth. By nature man is the incarnation of idleness, which quality alone, amid the ruined remnants of Edenic characters, remains in all its primitive intensity. Occasionally we do find an individual who takes to toil as others to pleasure, but the majority of us have to wrestle hard with the original Adam, and find it no easy matter to scorn delights and live laborious days. Of special importance is this gift to those of you who reside for the first time in a large city, the many attractions ^f which offer a serious obstacle to its acquisition. The discipline necessary to secure this art brings in its train habits of self-control and forms a valu- able introduction to the sterner realities of life. I need scarcely warn you against too close attention to your studies. I have yet to meet a medical student, 34 MMI TEACHER AND STUDENT the hey-day in whose blood had been quite tamed in his college days ; but if you think I have placed too much stress upon isolation in putting the Art of Detachment first in order amongst the desiderata let me temper the hard sajong by telling you how with "labors assiduous due pleasures to mix." Ask of any active business man or a leader in a profession the secret which enables him to accomplish much work, and he will reply in one word, system ; or as I shall term it, the Virttie of Method, the harness without which only the horses of genius travel. There are two aspects of this subject ; the first relates to the orderly arrange nent of your work, which is to some extent enforced by the roster of demonstrations and lectures, but this you wc"ld do well to supplement in private study by a schedule in which each hour finds its allotted duty. Thus faithfully followed day by day system may become at last engramed in the most shiftless nature, and at the end of a semester a youth of moderate ability may find himself far in advance of the student who works spasmodically, and trusts to cramming. Priceless as this virtue is now in the time of your probation, it becomes in the practising physician an incalculable blessing. The incessant and irregular demands upon a busy doctor make it very difficult to retain, but the public in this matter can be educated, and the men who practise with system, allotting a definite time of the day to certain work, accom- plish much more and have at any rate a little leisure ; while those who are unmethodical never catch up with the day's duties and worry themselves, their confreres, and their patients. The other aspect of method has a deeper significance, 86 n li. TEACHER AND STUDENT hard for you to reach, not consoling when attained, since it lays bare our weaknesses. The practice of medicine is an art, based on science. Working with science, in science, for science, it has not reached, perhaps never will, the dignity of a comp'<^te science, with exact laws, like astron- omy or "ngineein." Is there then no science of medicine ? Yes, but in parts only, such as anatomy and physiology, and the extraordinary development of these branches during the present century has been due to the culti- vation of method, by which we have reached some degree of exactness, some certainty of truth. Thus we can weigh the secretions in the balance and measiire the work of the heart in foot-pounds. The deep secrets of generation have been revealed and the sesame of evolution has given us fairy tales of science more enchanting than the Arabian Nights' entertainment. With this great increase in our knowledge of the laws governing the processes of life, ha& been a corresponding, not less remarkable, advance in all that relates to life in disorder, that is, disease. The mysteries of heredity are less mysterious, the operating- room has been twice over robbed of its terrors ; the laws of epidemics are known, and the miracle of the threshing floor of Araunah the Jebusite, may be repeated in any town out of Bumbledom. All this change has come about by the observation of facts, by their classification, and by the founding upon them of general laws. Emulating the persistence and care of Darwin, we must collect facts with open-minded watchfulness, unbiased by crotchets or notions ; fact on fact, instance on instance, experiment on experiment, facts which fitly joined together by some master who grasps the idea of their relationship may estab- 86 ■ii TEACHER AND STUDENT lish a general principle. But in the practice of medicine, where our strength should be lies our great weakntas. Our study is man, as the subject of accidents or diseases. Were he always, inside and outside, cast in the same mould, instead of differing from his fellow man as much in consti- tution and '.i\ his reaction to stimulus as in feature, we should ere this have reached some settled principles in our art. And not only arc the reactions themselves variable, but ne, the doctors, are so fallible, ever beset with the common and fatal facility of reaching concliisions from superficial observations, and constantly misled by the ease with which our minds fall into the nist of one or two experiences. And thirdly add to the Virtue of Method, the Quality of TJiorougJniess, an element of such importance that I had thought of making it the only subject of my remarks. Unfortunately, in th«» present arrangement of the curri- culum, few of you as student: can hope to obtain more than a measure of it, but all can learn its value now, and ultimately with patience be jome living examples of its benefit. Let me tell you briefly what it means. A knowledge of the fundamental sciences upon which our art is based — chemistry, anatomy, and physiology — not a smattering, but a full and deep acquaintance, not with all the facts, that is impossible, but with the great principles based upon them. You should, as students, become familiar with the methods by which advances in knowledge are made, and in the laboratory b?e clearly the paths the great masters have trodden, though you yourselves cannot walk therein. With a good preliminary training and a due apportion'Jig of time you can reach in these three essen- 37 ) " TEACHER AND STUDENT il., tial studies a degree of accuracy which is the true prepara* tion for your life duties. It means such a knowledge of diseases and of the emergencies of life and of the means for their alleviation, that you are safe and trustworthy guides for your fellowmen. You cannot of course in the brief years of pupilage so grasp the details of the various branches that you can surely recognize and successfully treat all cases. But uere if you have mastered certain principles is at any rate one benefit of thoroughness — you will avoid the sloughs of charlatanism. Napoleon, according to Sainte Beuve, one day said when somebody was spoken of in his presence as a charlatan, " Charlatan as much as you please, but where is there not charlatan- ism ' " Now, thoroughness is the sole preventive of this widespread malady, which in medicine is not met with only outside of the profession. Matthew Arnold, who quotes the above from Sainte Benve, defines charlatanism as the " confusing or obliterating the distinctions between excellent and inferior, sound and unsound, or only half sound, true and untnie or half true." The higher the standard of education in a profession the less marked will be the charlatanism, whereas no greater incentive to its development can be found than in sending out from our colleges men who have not had mental training sufficient to enable them to judge between the excellent and the inferior, the sound and the unsound, the true and the half true. And if we of the household are not free from *he seductions of this vice, what of the people among whom we work ? From the days of the sage of Endor, even the rulers have loved to dabble in it, while the public of all ages have ever revelled in its methods — to-day, as in the 88 TEACHER AND STUDENT time of the Father of M e, one of whose contempor- aries (Plato) thir 'etcti B the world old trait: "And what a delightful liie they lead ! they are always doctoring and increasing and complicating their disorders and always fancying they will be cured by any nostrum which anybody advises them to try." The Art of Detachment, the Virtue of Method, and the Quality of Thoroughness may make you students, in the true sense of the word, successful practitioners, or even great investigators ; but your characters may still lack that which can alone give permanence to powers — the Grace of HumUity. As the divine Italian at the very entrance to Purgatory was led by his gentle Master to the banks of the island and girt with a rush, indicating thereby that he had cast off all pride and self-conceit, and was prepared for his perilous ascent to the realms above, so should you, now at the outset of your journey take the reed of humility in your hands, in token that you appreciate the length of the way, the difficulties to be overcome, and the fallibility of the faculties upon which you depend. In these days of aggressive self-assertion, when the stress of competition is so keen and the desire to make the most of oneself so universal, it may seem a little old- fashioned to preach the necessity of this virtue, but I insist for its own sake, and for the sake of what it brings, that a due humility should take the place of honour on the list. For its own sake, since with it comes not only a reverence for truth, but also a proper estimation of the difficulties encountered in our search for it. More perhaps than any other professional man, the doctor has a curious — shall I say morbid ?— sensitiveness to (what he regards) per- il TEACHER AND STUDENT sonal error. In a way this is right ; but it is too often accompanied by a cocksureneas of opinion which, if en- couraged, leads him to so lively a conceit that the mere suggestion of mistake under any circumstances is regarded as a reflection on his honour, a reflection equally resented whether of lay or of professional origin. Start out with the conviction that absolute truth is hard to reach in matters relating to our fellow creatures, healthy or diseased, that slips in observation are inevitable even with the best trained faculties, that errors in judgment must occur in the practice of an art which consists largely in balancing probabilities ;— start, I say, with this attitude of mind, and mistakes will be acknowledged and regretted; but instead of a slow process of self-deception, with ever in- creasing inability to recognize truth, you will draw from your errors the very lessons which may enable you to avoid theur repetition. And, for the sake of what it brings, this grace of humility is a precious gift. When to the sessions of sweet silent thought you summon up the remembrance of your own imperfections, the faults of your brothers will seem less grievous, and, in the quaint language of Sir Thomas Browne, you wiU " allow one eye for what is laudable in them." The wrangling and unseemly disputes which have too often disgraced our profession arise, in a great majority of cases, on the one hand, from this morbid sen- sitiveness to the confession of error, and, on che other, from a lack of brotherly consideration, and a convenient forgetfdness of our own faUings. Take to heart the words of the son of Sirach, winged words to the sensitive souls of the sons of Esculapius : " Admonish a friend, it may 40 TEACHER AND STUDENT be he has not done it ; and if he have done it, that he do it no more. Admonish thy friend, it may be he hath not said it ; and if he have, that he speak it not again. Ad- monish a friend, for many times it is a slander, and believe not every tale." Yes, many times it is a slander, and be- lieve not every tale. The truth that lowliness is young ambition's ladder is hard to grasp, and when accepted harder to maintain. It is so difficult to be still amidst bustle, to be quiet amidst noise ; yet, " es hUdet ein Talent sick in der Stille " alone, in the calm life necessary to continuoiis work for a high purpose. The spirit abroad at present in this country is not favourable to this Teutonic view, which galls the quick apprehension and dampens the enthusiasm of the young American. All the same, it is true, and irksome at first though the discipline may be, there will come a time when the very fetters in which you chafed shall be a strong defence, and your chains a robe of glory. Sitting in Lincoln Cathedral and gazing at one of the loveliest of human works — for such the angel Choir has been said to be — there arose within me, obliterating for the moment the thousand heraldries and twilight saints and dim emblazonings, a strong sense of reverence for the minds which had conceived and the hands which had executed such things of beauty. What manner of men were they who could, in those (to us) dark days, build such trans- cendent monuments ? What was the secret of then- art ? By what spint were they moved ? Absorbed in thought, I did not hear the beginning of the music, and then, as a response to my reverie and arousing me from it, rang out the clear voice of the boy leading the antiphon, " That thy 41 ■# ■^ o i I TEACHER AND STUDENT power, thy glory and mightiness of thy kingdom might be known unto men." Here was the answer. Moving in a world not realized, these men sought, however feebly, to express in glorious structures their conceptions of the beauty of holiness, and these works, our wonder, are but the outward and visible signs of the ideals which animated them. To us in very different days life offers nearly the same problems, but the conditions have changed, and, as has happened before in the world's history, great material prosperity has weakened the influence of ideals, and blurred the eternal difference between means and end. Still, the ideal State, the ideal Life, the ideal Church — what they are and how best to realize them — such dreams continue to haunt the minds of men, and who can doubt that their con- templation greatly assists the upward progress of our race ? We, too, as a profession, have cherished standards, some of which, in words sadly disproportionate to my subject, I have attempted to portray. My message is chiefly to you, Students of Medicine, since with the ideals entertained now your future is indissolubly bound. The choice lies open, the paths are plain before you. Always seek your own interests, make of a high and sacred calling a sordid business, regard your fellow creatures as so many tools of trade, and, if your heart's desire is for riches, they may be yours ; but you will have bartered away the birthright of a noble heritage, traduced the physician's well-deserved title of the Friend of Man, and falsified the best traditions of an ancient and honourable Guild. On the other hand, I have tried to indicate some of the ideals which you may reasonably cherish. No matter 42 TEACHER AND STUDENT though they are paradoxical in comparLv>n with the ordinary conditions in which you work, they will have, if encouraged, an ennobling influence, even if it be for you only to say with Rabbi Ben Ezra, " what I aspired to be and was not, comforts me." And though tuis course does not necessarily bring position or renown, consistently followed it will at any rate give to your youth an exhilarating zeal and a cheerfulness which will enable you to surmount all obstacles — to your maturity a serene judgment of men and things, and that broad charity without which all else is nought — ^to your old age that greatest of blessings, peace of mind, a realization, ma;*be, of the prayer of Socrates for the beauty in the inward soul and for unity '' the outer and the inner man ; perhaps, of the promise of Bernard, " pax sine crimine, pax sine turbine, pax sine -a." 48 IV PHYSIC AND PHYSICIANS AS DEPICTED IN PLATO 4b Ml " To one amall people ... it ww given to create the principle of Progress. That people was the Greek. Except the Uind forces of Nature, nothing moves in this world which is not Greek in its origin." Mains. Quoted in Greek Thinkera by Gomperz. From the lifeless background of an unprogressive world — Egypt Syria, frozen Scythia — a world in which the unconscious social aggr^ate had been everjrthing, the conscious individual, his capacity and rights, almost nothing, the Greek had stepped forth, like the young prince in the fable, to set things going. Waltkb Pateb, Plato and PUUonism. These (years of vague, restless speculation) had now lasted long enough, and it was time for the Mei^erjahre of quiet, methodiral research to succeed if science was to acquire steady and sedentary habits instead of losing itself in a maze of phantasies, revolving in idle circles. It is the undying glory of the medical school of Cos that it introduced this innovation in the domain of its art, and thus exercised the mo t beneficial influence on the whole intellectual life of mankind. " Fiction to the right ! Reality to the left ! " was the battle-cry of this school in the war they were the first to wage against the excesses and defects of the nature-philosophy. Nor could it have found any more suitable champions, for the serious and noble calling of the physician, which brings him every day and every hour in close communion with nature, in the exer- cise of which mistakes in theory engender the most fatal practical consequences, has served in all ages as a nursery of the most genuine and incorruptible sense of truth. The best physicians must be the best observers, but the man who sees keenly, who hears clearly, and whose senses, powerful at the start, are sharpened and refined by constant exercise, will only in exceptional instances be a visionary or a dreamer. GoMFBBZ, Oruk Thinkers, vol i. 46 mam IV PHYSIC AND PHYSICIANS AS DEPICTED IN PLATO ' OUR Historical Club had under consideration last winter the subject of Greek Medicine. After in- troductory remarks and a description of the iEscuIapian temples and worship by Dr. Welch, we proceeded to a systematic study of the Hippocratic writings, taking up in order, as found in them, medicine, hygiene, surgery, and gynaecology. Among much of interest which we gleaned, not the least important was the knowledge that as an art, medicine had made, even before Hippocrates, great progress, as much almost as was possible without a basis in the sciences of anatomy and physiology. Minds inquisitive, acute, and independent had been studying the problems of nature and of man ; and several among the pre-Socratic philosophers had been distinguished physi- cians, notably, Pythagoras, Empedocles, and Democritus. Unfortunately we know but little of their views, or even of the subjects in medicine on which they wrote. In the case of Democritus, however, Diogenes Laertius has pre- served a list of his medical writings, which intensifies the 1 Johns Hopkins Hospital Historical Club, 1893. 47 PHYSIC AND PHYSiaANS regret at the loss of the works of this great man, the title of one of whose essays, " On Those who are Attacked with Cough after Illness" indicates a critical observation of disease, which Daremberg seems unwilling to allow to the pre-Hippocratic philosopher-physicians. We gathered also that in the golden age of Greece, medicine had, as to-day, a triple relationship, with science, with gymnastics, and with theology. We can imagine an Athenian father of the early fourth centurv worried about the enfeebled health of one of his growing lads, asking the advice of Hippocrates about a suspicious cough, or sending him to the palaestra of Taureas for a systematic course in gymnastics ; or, as Socrates advised, " when human skill was exhausted," asking the assistance of the divine Apollo, through his son, the " hero-physician," .^Isculapius, at his temple in Epidaurus or at Athens itself. Could the Greek live over his parental troubles at the end of the nineteenth century, he would get a more exact diagnosis and a more rational treatment; but he might travel far to find so eminent a " professor " of gynmastic as Miccus for his boy, and in Christian science or faith-healing he would find our bastard substitute for the stately and gracious worship of the iEsculapian temple.' From the Hippocratic writings alone we have a very ^ For an account of " ^sculapius at Epidauros and Athena," chapter vi. of Dyer's Qoda of Oreece (Maomillan, 1891), a chapter which contains also aa. excellent discussion on the relation of secular to priestly medicine. In Chapter III cf Pater's delightful story Mariua (he Epicurean, is a description of one of the RomaniEsculapiat and an account of the method of procedure in the "cure," the ridiculous aspects of which are so graphically described in the " Plutus " of Aristophanes. 48 AS DEPICTED IN PLATO imperfect knowledge of the state of "ledicine in the most brilliant period of Grecian history ; and many details re* lating to the character and to the life of physicians are gleaned only from secular authors. So much of the daily life of a civilized community relates to problems of health and disease that the great writers of every age of necessity throw an important side-light, not only on the opinions of the people on these questions, but often on the condition of special knowledge in various branches. Thus a consider* able literature already illustrates the medical knowledge of Shakespeare, from whose doctors, apothecaries, and mad*folk much may be gathered as to the state of the pro- fession in the latter part of the sixteenth century. So also the satire of Molidre, malicious though it be, has preserved for us phases of medical life in the seventeenth century, for which we scan in vain the strictly medical writings of that period ; and writers of our times, like George Eliot, have told for future generations in a character such as Lydgate, the little every-day details of the struggles and aspirations of the profession of the nineteenth century, of which we find no account whatever in the files of the Lancet. We are fortunate in having had preserved the writings of the two most famous of the Grr-^k philosophers — the great idealist, Plato, whose " contemplation of all time and all existence " was more searching than that of his pre- decessors, fuller than that of any of his disciples, and the great realist, Aristotle, to whose memory every department of knowledge still pays homage, and who has swayed the master-minds of twenty-two centuries. From the writings of both much may be gathered about Greek physic and physicians ; but I propose in this essay to restrict myself AE. 49 E It;! V PHYSIC AND PHYSICIANS to what I have culled from the Dialogw* of Plato. I shall first speak of his physiological and pathological specu- lations ; then I shall refer to the many interesting allusions to, and analogies drawn from, medicine and physicians ; and, lastly, I shall try to estimate from the Dialogues the social standing of the Greek doctor, and shall speak on other points which bear upon the general condition of the profession. The quotations are made in every instance from Professor Jowett's translation, the third edition, 1892.' ■' To our enlightened minds the anatomy and physiol ,y of Plato are crude and imperfect ; as much or even more so than those of Hippocrates. In the Timaua he con- ceived the elements to be made up of bodies in the form of triangles, the di£[erent varieties and combinations of which accounted for the existence of the four elementary bodies of Empedocles— fire, t th, water, and air. The differences in the elementary bodies are due to differences in the size and arrangement of the elementary triangles, which, like the atoms of the atomist, are too small to be visible. Mar- row had the most perfect of the elementary triangles, and from it bone, flesh, and the other structures of the body were made. " God took such of the primary triangles as were straight and smooth, and were adapted by their perfection to produce fire and water, and air and earth ; these, I say, he separated from their kinds, and mingling them in due proportions with one another, made the mar- ^ The Dialoguea of Plato, translated into English by B. Jowett, M.A., Master of Balliol College, Oxford. At the Clarendon Press, fint edition, 1871 ; third edition, 1892. 50 ? AS DEPICTED IN PLATO row out of them to be a universal seed of the whole race of mankind ; and m this seed he then phmted and encloaed the souls, and in the original distribution gave to the mar- row as many and various forms as the different kinds of souls were hereafter to receive. That which, like a t-sld, was to receive the divine seed, he made round every way,* and called that portion of the marrow brain, intending that, when an animal was perfected, the vessel containing this substance should be the head ; but that which was intended to contain the remaining and mortal part of the soul he distributed into figures at once round and elon- gated, and he called them all by the name ' marrow ' ; and to these, as to anchors, fastening the bonds of the whole soul, he proceeded to fashion around them the entire frame- work of our body, constructing for the marrow, first of aH, a complete covering of bone." ' The account of the structure of bone and flesh, and of functions of respiration, digestion, and circulation is un- intelligible to our modem notions. Plato knew that the blood was in constant motion ; in speaking of inspiration and expiration, and the network of fire which interpenetrates the body, he says : " For when the respiration is going in and out, and the fire, which is fast bound within, follows it, and ever and anon moving to and fro, enters the belly and reaches the meat and drink, it dissolves them, and dividing them into small portions, and guiding them through the passages where it goes, pumps them as from a fountain into the channels of the veins, and makes the stream of the veins flow through the body as through a con- duU.*^ ' A complete circulation was unknown ; but Plato > DialoQuu, iii. 493. 51 * Ibid. iii. 601. liiiTM PHYSl. AN'D f^HVaiHANS understood fully that tlie blooi v^as the source of nourish- naeut,— " the liquid itself wc -aU blood, which nourishes the flesh and the whole body, whence all parts are watered and empty spaces fill«J." * In the young, the triangles, or in modem parlance we would say the atoms, are new, and are compared tc the keel of a vessel just off the stocks. Thoy are locked firnily together, but form a soft and deli- cate mass freshly made of marrow and nourished on milk. The process of digestion is described as a struggle between the triangles out of which the meats and drinks are com- pobed, and those of the bodily frame ; and as the former are older and weaker the newer triangles of the body cut them up, and in this way the animal grows great, being nourished by a multitude of similar particles. The triangles are in constant fluctuation and change, and in the " Sym- posium " Socrates makes Diotima say, " A man is called the same, and yet in the short interval which elapses be- tween vouth and age, and in which every animal is said to have life and identity, he is undergoing a perpetual pro- cess of loss and reparation — hair, flesh, bones, and the whole body are always changing." ' The description of senility, euthanasia, and death is worth quoting : " But uhen the roots of the iriangks are loosened by having unaergone many conflicts with many thinnfs in the course of time, they are no longer able to cut or assimilate the food w lich enters, but are themselves easily divided by the bodies which come in from ^vithout. In this way every animal is overcome and tiecays, and tLis affection is called old age. And at last, whe- the bonds by which the triangles of the marrow are uniied no long^^ ' Dialogua, iii. 503. > Ibid. i. 578. 52 AS DEPICTED IN PLATO hdd, and are parted by r^ie Btxai of eziitenoe, they in torn loosen the bonds of "^e aor and sh , obtaining tt. natural release, flies away with joy For t at which taker place accorduig to uulure b pleasant, but hat which is contrciry to t^^ture is ji^inful. 4nd thus deuth, if caused by disease or ^ produced by wounds, is painful and violent ; but that sort of death which comes with old age and fulfill the debt of natur^> is the easiest of deaths, and is accom- pani^^ 1 with pleasure rather than with pain." ' The mode of origin and th*- nature of iseaa**. aa d^ scribed in the TitncBug, are in Keeping with this irimitive and imperfect science The diseases of the bt ly ^rise when anyone of the four -ilement » is out of place, i i»en the blood, sinews and flean axe produced m a w-" ^ ord^ \ Much influence is attributed to the various kii.u ' f bud. The worst of all diseases, he thinks, are shr « ' the spinal marrow, in whi h the ^iiole course of the I d' is reversed. Other disease are produced bv diso-ders of respiration; as by phleg'- when detained within hy rea >n of the air bubbles." This, if mingled with bb k aile and is ersed about th-' cou^'ses of the head prouuce* ep pay, attacks of which ng sleep, hr- says, are not s m\ -t at when it assails those who are iwake it is ha^ ^ got rid of, and "bei'ig a i u Section of a sarrcd par iio.-tt justly called sacred" morhus SQeminenetly bad. Do not great crimes and the spirit of pure evil spring out of a fulness of nature ruined by education rather 'han from any inferiority, whereas weak natures are scarcel; capable of any very great good or very great evil." * In the PhcBdnu there is recognized a form of madness " which is a divine gift and a source of the chiefest blessings granted to man." Of this there are four kinds— prophecy, inspiration, poetry and love. That indefinable something which makes the poet as contrasted with th rhymster and which is above and beyond all art, is well characterized in the following sentence : " But he who, having no touch of the LIuse's madness in his soul, comes to the door and thinks that he will get into the temple by the help of art- he, I say, and his poetry are not admitted. The sane man disappears and is nowhere when he enters into rivalry with a madman." ' Certain crimes, too, are definitely recog- nized as manifestations of insanity ; in the Laws the in- curable criminal is thus ac'.lressed : " Oh, sir, the 'mpulse which moves you to rob temples is not an ordinary human malady, nor yet a visitation of heaven, but a madness > Dialogutt, iii. 189. ' Ibid. i. 450-1 ; " Not by wisdom do poets write poetry, but by a sort of insplraticm and gemm."— Apology. 66 AS DEPICTED IN PLATO which is begotten in man from ancient and unezpiated crimes of his race." In the Laws, too, it is stated that there are many sorts of madness, some arising out of disease, and others originating in an evil and passionate temperament, and are increased by bad education. Re- specting the care of the insane, it is stated that a madman shall not be at large in the city, but his relations shall keep him at home in any way they can, or if not, certain fines are irsntioned.^ The greatest aid in the prevention of disease is to pre- serve the due proportion of mind and body, " for there is no proportion or disproportion more productive of health and disease, and virtue and vice, than that between soul and body." In the double nature of the living being if there is in this compound an impassioned soul more power- ful than the body, "that soul, I say, convulses and fills with disorders tho whole inner nature of man ; and when eager in the pursuit of some sort of learning or study, causes wasting ; or again, when teaching or disputing in private or in public, and con»iderations and controversies arise, inflames and dissolve? the composite form of man and introduces rheums ; and the nature of this pheno- menon is not understood by most professors of medicine, who ascribe it to the opposite of the real cause." . . . Body and mind should both be equally exercised to pro- tect against this disproportion, and " we should not move the body without the soul or the soul without the body. In this way they will be on their guard against each other, and be healthy and well balanced." He urges the mathe- > Dtofa^nM, ▼. 236, 323. 394. 67 i PHYSIC AND PHYSiaANS matician to practise gymnastic, and the gymnast to culti- vate music and philosophy/ The modes of treatment advised are simple, and it is evident that Plato had not much faith in medicines. Pro- fessor Jowett's commentary is here worth quoting : " Plato is stm the enemy of the purgative treatment of physicians, which, except in extreme cases, no man of sense will ever adopt. For, as he adds, with an insight into the truth, ' every disf>a8e is akin to the nature of the living being and is only irritated by stimulants.' He is of opinion that nature should be left to herself, and is inclined to think tiiat physicians are in vain (cp. Laws, VI. 761 C, where he says that warm baths would be more beneficial to the limbs of the aged rustic than the prescriptions of a not overwise doctor). If he seems to be extreme in his con- demnation of medicine and to rely too much on diet and exercise, he might appeal to nearly all the best physicians of our own age in support of his opinions, who often &peak to their patients of the worthlessness of drugs. For we ourselves are sceptical about medicine, and very unwilling to submit to the purgative treatment of physicians. May we not claim for Plato an anticipation of modem ideas as about some questions of astronomy and ph3rsics, so also about medicine ? As in the Charmides (156, 7) he tells us thbt the body cannot be cured without the soul, so in the TimcBiu he strongly asserts the sympathy of soul and body ; any defect of either is the occasion of the greatest discord and disproportion in the other. Here too may be a presentiment that in the medicine of the future the in- terdependence of mind and body will be more fully recog- * Ditdoguea, iii. 010-1. 68 AS DEPICTED IN PLATO nized, and that the influence of the one over the other may be exerted in a manner which is not now thought possible." * The effect of the purgative method to which Plato was so opposed is probably referred to in the following passage. " When a man goes of his own accord to a doctor's shop and takes medicine, is lie not quite aware that soon and for many days afterwards, he will be in a state of body which he would rather die than accept as a permanent condition of his life 1 " It is somewhat remarkable that nowhere in the Dialogue$ is any reference made to the method of healing at the .^Bsculapian temples. The comments upon physic and physicians are made without allusion to these institutions. Hippocrates and other practitioners at Athens were pro* bably secilar Asclepiads, but as Dyer remarks, " in spite of the severance the doctors kept in touch with the wor- ship of iEsculapius, and the priests in his temples did not scorn such secular knowledge aa they could gain from lay practitioners.* II So much for the general conception of the structure and functions of the body, in order and disorder, as conceived by Plato. Were nothing more to be gleaned, the thoughts on these questions of one of the greatest minds of what was intellectually the most brilliant period of the race, would be of interest, but scattered throughout his writings are innumerably little chUer dicta, which indicate a pro* foimd knowledge of that side of human nature which turns > Dialogues, Ui. 413. * The Gods of Greece. 59 ! I PKYSIC AND PHYSICIANS nppennoBt when the machinery is oat of gear. There are, in addition, many charming analogies drawn from medicine, and many acute suggestions, some of which have a modem flavour. The noble pilot and the wise phjrsician who, as Nestor remarks, "is worth many another man," furnish some of the most striking illustrations of the Dialogves. One oi the most admirable definitions of the Art of Medicine I selected as a rubric with which to grace my text-book, " And I said of medicme, that this is an Art which considers the constitution of the patient, and has principles of action and reasons in each case." Or, again, the comprehensive view taken in the statement, "There is one science of medicine which is concerned with the inspection of health equally in all times, present, past and future." Plato gives a delicious account of the origin of the modem medicine, as contrasted with the art of the guild of Asclepius. ^ Well, I said, and to require the help of medicme, not when a vround has to be cored, or on occasion of an epidemic, but just because by indolence and a habit of life such as we have bem describing, men fill themselves with waters and winds, as if their bodies were a marsh, compelling the ingenious sons of Asclepius to find more names for diseases, such as flatulence and catarrh ; is not this, too, a di^;race ? Yea, he said, they do certainly give very strange and new-fangled names to diseases. Yes, I said, and I do not believe there were any such diseases in the days of Asclepius ; and this I infer from the circumstance that the hero Eurypylus, after he has been wounded in Homer, drinks a posset of Pramnian wine well besprinkled with barley-meal and grated cheese, which are certainly inflammatory, and yet the sons of Asclepius who were at the Trojan war do not blame the damsel * Dialogues, iii. 93. 60 AS DEnCTED IN PLATO who givM him the drink, or raboke Pfttrooloi, who is treating his Well, he Mkid, that was surely an extraordinary drink to be given to a person in his condition. Not 80 extraordinary, I replied, if you bear in mind that in former days, as u commonly said, before thetimeof Herodicu8,th€V£uildof Asclepius did not practise our present system of medicine, which may be said to educate diseases. But Herodicus, being a trainer, and himself of a sickly constitution, by a combination of training and doctoring found out a way of torturing first and chiefly iximself, and secondly the rest of the world. How was that ? he said. By the invention of lingering death ; for he had a mortal disease which he perpetually tended, and as recovery was out of the ques- tion, he passed his entire life as a valetudinarian ; he could do nothing but attend upon himself, and he was in constant torment whenever he departed in anything from his usual regimen, and so djnng hard, by the help of science he struggled on to old age. A rare rewaxd of his skill 1 He goes on to say that Asclepius did not instruct his descendants in valetudinarian arts because he knew that in well-ordered states individuals with occupations had no time to be ill. If a carpenter falls sick, he asks the doctor for a "rough and ready cure — ^an emetic, or a purge, or a cautery, or the knife — ^these are his remedies." Should any one prescribe for him a course of dietetics and tell him to swathe and swaddle his head, and all that sort of thing, he says, ** he sees no good in a life spent in nursing his disease to the neglect of his customary employ- ment ; and therefore bidding good-bye to this sort of physician, he resumes his ordinary habits, and either gets well and lives and does his business, or, if his constitution fails, he dies and has no more trouble." ^ He is more in unest in another place (Oorgiaa) in an *■ Dialoguu, iii. 93-4. 61 j; ) PHYSIC AND PHYSICIANS •ocoont of the reUtionB of the arte of medicine and gym> nasties: "The soul and the body being two, have two arte corresponding to them : there is the art of politics attending on the soul ; and another art attending on the body, of which I know no specific name, but which may be described as having two divisions, one of them gym- nastic, and the other medicine. And in politics there is a legislative part, which answers to gymnastic, as justice does to medicine ; and the two parts run into one another, justice having to do with the same subject as legislation, and medicine with the same subject as g3rmnastic, but with a difference. . . . Cookery simulates the disguise of medicine, and pretends to know what food is the best for the body ; and if the ph3rsician and the cook had to enter into a competition in which children were the judges, or men who had no more sense than chTdren, as to which of them best understands the goodness or badness of food, the physician would be starved to death." ^ And later in the same dialogue Socrates claims to be the only true politician of his time who speaks, not with any view of pleasing, but for the good of the State, and is un- willing to practise the graces of rhetoric — ^and so would make a bad figure in a court of justice. He says : " I shall be tried just as a physician would be tried in a court of little boys at the indictment of the cook. What would he reply under such circumstances, if some one were to accuse him, sayiug, ' my boys, many evil things has this man done to you ; he is the death of you, especially of the younger ones among you, cutting and burning and starving and suffocating you, until you know not what to *■ Dialogues, ii. 345-6. 62 AS DEPICTED IN PLATO do; he gives 70a the bitterest potions, and compels you to hunger and fast ? How unlike the variety of meats and sweets on which I feasted for you.* What do you suppose that the phjrsician would be able to reply when he found himself in such a predicament? If he told the truth he could only say : ' All these evil things, my bojrs I did for your health,' and then would there not just be a clamour among a jury like that 1 Hew they would cry out ! " * The principle of continuity, of uniformity, so striking in ancient physics was transferred to the body, which, like the world, was conceived as a whole. Several striking passages illustrative of this are to be found. Thus to the question of Socrates, " Do you think that you can know the nature of the soul intelligently without knowing the nature 0! the whole ? " Phaedrus replies, " Hippocrates, the Aflclepiad, says that the nature even of the body can only be understood as a whole." * The importance of treating the whole and not the part is insisted upon. In the case of a patient who comes to them with bad eyes the saying is " that they cannot cure his eyes by them- selves, but that if his eyes are to be cured his head must be treated " : and then again they say " that to think of curing the head alone and not the rest of the body also is the height of folly." Charmides had been complaining of a headache, and Critiaii had asked Socrates to make believe that he could cure him of it. He said that he had a charm, which he had learnt, when serving with the army, of one of the physicians of the Thracian king, Zamobds. This physi- ^ Dialoguea, ii. 415. * Ibid. i. 479. 68 . ( t W': PHYSIC AND PHYSICIANS cun had told Soontet that the cuie of the part shotdd not be attempted without treatment of the whole, and aUo that no attempt should be made to cure the body without the soul, " and, therefore, if the head and body are to be well you must begin by curing the soul ; that is the first thing. . . . And he who taught me the cure and the charm added a special direction, ' Let no one,' he said, ' persuade you to cure the head until he has first given you his soul to be cured. For this,' he said, ' is the great enor of our day in the treatment of the human body, that physicians sepa- rate the soul from the body.' " The charms to which he referred were fair words by which temperance was im- planted in the soul.' Though a contemporary, Hippocrates is only once again referred to in the Dialogues— wlieie the young Hippocrates, son of Apollodorus, who has come to Protagoras, " that almighty wise man," as Socrates terms him in another place, to learn the science and knowledge of human life, is asked by Socrates, " If you were going to Hippocrates of Cos, the Asdepiad, and were about to give him your money, and some one had said to you, ' You are paying money to your namesake, Hippocrates, Hippocrates; U\\ me, what is he that you give him money?' how would you have answered ? " "I should say," he replied, " that I gave money to him as a physician." " And what will he make of you?" "A physician,' he said'— a paragraph which would indicate that Hippocrates was in the habit of taking pupils and teaching them the art of medicine ; and m the Euthydemus, with reference to the education ol physicians, Socrates sap, "that he would » Dialogues, L 11-13. ' Ibid. I 131-2. G4 AS DEPICTED IN PLATO send such to those who profess the art, and to those who demand payment for teaching the art, and profess to teach it to any c a who will come and learn." We get a glimpse of the method of diagnosis, derived doubtless from personal observation, possibly of the great Hippocrates himself, whose critical knowledge of pdmo* nary complaints we doily recognize in the use of his name in association with the clubbed fingers of phthisis, and with the succuBsion splash of pneumo-thorax. " Suppose some one, who is inquiring into the health or some other bodily quality of another : he looks at his face and at the tips of his fingers, and then he says, ' Uncover your chest and back to me that I may have a better view.' " And then Socrates says to Protagoras, " Uncover your mind to me ; reveal your opinion, etc." * One of the most celebrated medical passages is that in which Socrates professes the art of a midwife practising on the souls of men when they are iii labour, and diagnosing their condition, whether pregnant with the truth or with with some " darling folly." The entire section, though long, must be quoted, Socrates is in one of his "littie difficulties " and wishes to know of the young The»tetus, who has been presented to him as a paragon of learning, and whose progress in the path of knowledge has been sure and smooth—" flowing on silently like a river of oil " — what is knowledge ? Thesetetus is soon entangled and cannot shake off a feeling of anxiety. Theat. I can assure you, Socrates, that I have tried very often, when the report of questions asked by you was brought to me ; but I can neither persuade mymU that I have any answer to give. AK. * Dialogues, i. 176. 65 PHYSIC AND PHYSICIANS nor hMT of any one who tat^mn ai you would h»v» turn ; Mtd I eMiDOt abake off » feoliog of uudety. Soe. TheM u« the puige of Ubour. my dear Tbeatetoe ; yoa hare loiDethiiig within yoa which you are bringing to the birth. JlUot. I do not know, Sooratet ; I only eay what I fecL Soe. And did you never hear, simpleton, that I am the eon of • midwife, brave and burly, whoee name waa Phanarete T Themt. Yea, I have. Soc. And that I myaelf praotiae midwifery T Themt. No, never. ._, j ,_. Soc Let me tell you that I do though, my friend ; bat you muat not reveal the aecret, aa the world in general have not found me out ; and therefore they only aay of me. that I am the atrangeat of morula, and drive men to their wits' end. Did you ever hear that too? ThtcBt. Yea. Soe. Shall I tell you the reaaon ? Theat. Byallmeana. Soc. Bear in mind the whole busineea of the midwivea. and then you will aee my meaning better. No woman, aa you an? probably aware, who ia atill able to conceive and bear, attends other women, but only those who are past bearing. Theat. Yes, I know. Soe. The reason of this is said to be that Artemis— the goddess of chUdbirth— is not a mother, and she honours those who are like herself ; but she could not allow the barren to be midwivne, because human nature cannot know the mystery of an art without ex- penence ; and therefore she asugned this oflSce to those who are too old to hear. Theat. I dare say. Soc. And I dare aay, too, or rather I am absolutely certam. that the midwivea know better than others who ia pregnant and who is not T Theat. Very true. Soe. And by the use of potions and incantations they are able to arouse the pangs and to soothe them at will ; they can make tnoee bear who have a difficulty in bearing, and if they think fit, they can smother the embryo in the womb. Thecel. They can. Soc. Did you ever remark that they are also most c unnin g matchmakers, and have a thorough knowledge of what unions are likely to produce a brave brood T 66 AS DEPICTED IN PLATO TJkMif. No, DOTMr. Soe. Then l«t me toll you tb*t thi# in tbeir gr<«l> st pride, mon than outtiog the umbilical cord. Aiid f you iwtlect, jroa wiU see th»l the Mune art whica cultivates md gat hen in tb< f.*t the true midwife is also the true and only matchmaker. Theat. Clearly. Soe. Such are the midwivoH. whoso task it* a very important one, but not so important as mine ; for wooion do not bring into the world at one time real children, and at another time counter- feits which are with difficulty distinguished from them ; if they did, then the discernment of the true and false birth would be the crowning achievement of the art of midwifery — you would think so? Theat. Indeed I should. Soe. WeH. my art of midwifery is in most respects like theirs ; but differs in that I attend men and not women, and I look after their souls when they are in labour, and not after their bodies; and the triumph of i ny art is in thoroughly examining whether the thought which the mind of the young man is bringing to the birth, is a false idol or a noble and true birth. And like the midwives, I am barren, and the reproach which is often made against me, that I ask questions of others and have not the wit to answer them myself, is very just ; the reason '«, that the god compels me to bo a midwife, but forbids me to brit:g forth. And therefore I am not mjTself at all wise, nor have I anything to show which is the inven- timi or birth of my own soul, but those who converse with me profit. Some of them appear dull enough at first, but afterwards, as our acquaintance ripens, if the god is gracious to them, they all make astonishing progress ; and this in the opinion of othe.fi as well as their own. It .d quite clear that they had never learned anything from me ; the many fine discoveries to which they cUng are of thdr own making. But to me and the god thay owe their 67 PHYSIC AND PHYSICIANS 1 delivery. And the proof of my words is, that many of them in their ignorance, either in their self-oonoeit despising me, or falling under the influence of others, have gone away too soon ; and have not only loat the children of whom I had previously delivered them by an ill bringing up, but have stifled whatever else they had in them by evil oommunicatioiiis, being fonder of lies and shams than of the truth ; and they have at last ended by seeing themselves, as others see them, to be great fools. Aristeidee, the son of Lysi- maohus, is one of them, and there are many others. The truants often return to me, and beg that I would ronsort with them again —they are ready to go to mo on their knees — and then, if my familiar allows, which is not always the case, I receive them and they begin to grow again. Dire are the pangs which my art is able to arouse and to allay in those who consort with me, just like the pangs of women in childbirth ; night and day they are full of perplexity and travail which is even worse than that of the women. So much for them. And there are others. Thesetetus, who come to me apparently having nothing in them ; and as I know that they have no need of my art. I coax them into marrying some one, and by the grace of God I can generally tcU who is likely to do them good. Many of them I have given away to Prodicus, and many to other inspired sages. I tell you this long story, friend Theetetns, because I suspect, as indeed yuu seem to think yourself, that you are in labour— great with some conception. Come then to me, w'.o am a midwife's son and myself a midwife, and try to answer the questions which I will ask you. And if I abstract and expose your tirst-bom, i;ecau8e I discover upon inspection that the con eption which you have formed is a vain shadow, do not quarrel with me on that account, as the manner of women is when their first children are taken from them. For I have actually known some who were ready to bite me when I deprived them of a darling folly ; they did not perceive that I acted from good will, not knowing that no god is the enemy of man— that was not within the range of their ideas ; neither am I their enemy in all this, but it would be wrong in me to admit falsehood, or to stifle the truth. Once more, then, Thetetetus, I repeat my old question, " What ia knowledge T " and do not say that you cannot tell ; but quit your- self like a man, and by the help of God you will be able to telL* Socrates proceeds to determine whether the intellectual ^ Dialoguu, iv. 201-4. 68 AS DEPICTED IN PLATO babe brought forth by TheatetuB is a wind-egg or a real and genuine birth. " This then is the child, however he may turn out, which you and I have with difficulty brought into the world, and now that he is bom we must run round the hearth with him and see whether he is worth rearing or only a wind-egg and a sham. Is he to be reared m any case and not exposed ? or will you bear to see him rejected and not get into a passion if I take away your firs^bom ? " The conclusion is " that you have brought forth wind, and that the offspring of your brain are not worth bringing up." And the dialogue ends as it began with a reference to the midwife : " The office of a midwife I, like my mother, have received from God ; she delivered women, and I deliver men ; but they must be young and noble and fair." Ill From the writings of Plato we may gather many details about the status of physicians in his time. It is very evident that the profession was far advanced and had been progressively developing for a long period before Hippo- crates, whom we erroneously, yet with a certain propriety, call the Father of Medicine. The Little by-play between Socrates and Euthydemus suggests an advanced condition of medical literature : " Of course, you who have so many books are going in for being a doctor," says Socrates, and then he adds, " there are so many books on medicine, you know." As Dyer remarks, whatever the quality of these books may have been, their number must have been great to give point to this chaff. It may be cleany gathered from the writings of Plato that two sorts of physicians (apart altogether from quacks 69 'H' Ml U PHYSIC AND PHYSICIANS and the iEBCukpian guild) existed in Athens, the private practitioner, and the State-physician. The latter, though the smaller numerically, representing apparently the moat distinguished class. From a reference in one of the dia- logues {Gorgias) they evidently were elected by public aggembly,— " when the assembly meets to elect a physi- cian."* The office was apparently yearly, for in the SUxteman is the remark, "when the year of office has expired, the pilot or physician has to come before a court of review " to answer any charges that may be made against him. In the same dialogue occurs the remark, " and if anyone who is in a private station has the art to advise one of the public physicians, must he not be called a physi- cian ? " ' Apparently a physician must have been in practice for some time and attained great eminence before he was deemed worthy of the post of State-physician. " If you and I were physicians, and were advising one another that we were competent to practise as state-physi- cians, should I not ask you, and would you not ask me, Well, but how about Socrates himself, has he good health ? And was any one else ever known to be cured by him whether slave or freeman ? " ' A reference to the two sorts of doctors is also found in the Republic : " Now you know that when patients do not require medicine, but have only to be put under a regimen, the inferior sort of practitioner is deemed to be good enough ; but when medicine has to be given, then the doctor should be more of a man." * The office of State-physician was in existence fully two » Dialogues, il. 335. Ibid. iv. 453. 502. » Ibid. ii. 407. « !b ii. Hi. 153. 70 AS DEPICTED IN PLATO generations before this time, for Democedes held this post at Athens in the second half of the sixth century at a salary of £406, and, very much as a modem professor might be, he Tfas seduced away by the offer of a great increase in "lalary by Polycrates, the tyrant of Samos. It is evident, too, from the Laws, that the doctors had assistants, often among the slaves. For of doctors, as I may remind you, some have a gentler, other* a ruder method of euro ; and as children ask the doctor to be gentle with them, so we will ask the legislator to cure our disorders with the gentlest remedies. Wliat I mean to say is, that besides doctors there are doctors' servants, who are also styled doctors. Cle. Very true. (Eth. And whether they are slaves or freemen makes no differ- ence ; they acquire their knowledge of medicine by obeying and observing their masters ; empirically and not according to the natural way of learning, as the manner of freemen •is, who have learned scientifically themselves the art which they impart scien- tifically to their pupils. You are aware that there are these two classes of doctors ? Cle. To bo sure. (Eth. And did you ever observe that thei« are two classes of patients in states, slaves and freemen ; and the slave di)ctore run about and cure the slaves, or wait for them in the dispensaiies — practitioners of this sort never talk to their patients individually, or let them talk about their own individual complaints ? The slave-doctor prescribes what mere experience suggests, as if he had oxact knowledge ; and when he has given his orders, like a tyrant, he rushes off with equal assurance to some other servant who is ill ; and so he relieves the master of the hotise of the care of his invalid slaves. But the other doctor, who is a frecirar., attends and practises upon freemen ; and he carries his inquinvH far back, and goes into the nature of the disorder ; he enters into liscourso with the patient and with his friends, and is at once getting information from the sick man, and also instructing him as far as he is able, and he will not prescribe for him until ho has first convinced him ; at h-M, when he has hmuKlit tin- patient more and more under his IMrsuasive inllucaces ami sot tiini on the mad to health, he attempts 71 \l ii If Ji PHYSIC AND PHYSICIANS to effect a onre. Now which is the better way of proceeding in • physician and in a trainer ? Is he the better who aocompUshea his ends in a double way, or he who works in one way, and that the ruder and inferior ? ^ This idea of first convincing a patient by argument is also mentioned in the Oorgitu, and would appear indeed to have furnished occupation for some of the numerous sophists of that period. Gorgias, lauding the virtues of rhetoric and claiming that she holds imder her sway all the inferior art, says : " Let me offer you a striking ex- ample of this. On several occasions I have been with my brother Herodicus, or some other physician, to see one of his patients, who would not allow the physician to give him medicine or apply the knife or hot iron to him ; and I have persuaded him to do for me what he would not do for the physician just by the use of rhetoric. And I say that if a rhetorician and a physician were to go to any city, and had there to argue in the Ecclesia or any other assembly as to which of them should be elected state-physician, the physician would have no chance ; but he who could speak would be chosen if he wished." ' In another place {Laws) Plato satirizes this custom : " For of this you may be very sure, that if one of those empirical physicians, who practise medicine without science, were to come upon the gentle- man physician talking to his gentleman patient, and using the language almost of philosophy — beginning at the beginning of the disease, and discoursing about the whole nature of the body, he would burst into a hearty laugh — he would say what most of those who are called doctors always have at their tongue's end : foolish fellow, he would ' Diaioffuu, V. 103-4. ' Ibid. ii. 336. 78 dk AS DEPICTED IN PLATO wy, you are not healing the sick man, but you are educa- ting him ; and he does not want to be made a doctor, but to get weU." » Of the personal qualifications of the phjrsician not much is said ; but in the Republic (III. 408) there is an original, and to us not very agreeable, idea : " Now the most skilful physicians are those who, from their youth upwards, have combined with a knowledge of their art, the greatest ex- perience of disease ; they had better not be in robust health, and should have had all manner of diseases m their own person. For the body, as I conceive, is not the in- strument with which they cure the body ; in that case we could not allow them ever to be or to have been sickly ; but they cure the body with the mind, and the mind which has become and is sick can cure nothing." ' Some idea of the estimate which Plato put on the phjrsi- cian may be gathered from the mystical account in the Phcedrua of the natiire of the soul and of life in the upper world. We are but animated failures — the residua of the souls above, which have attained a vision of truth, but have fallen " hence beneath the double load of forgetful- ness and vice." There are nine grades of human existence into which these souls may pass, from that of a philosopher or artist to that of a tjrrant. The phjrsician or lover of gymnastic toils comes in the fourth class.' But if Plato assigns the physician a place in the middle tier in his mystery, he welcomes him socially into the most select and aristocratic circle of Athens. In that most festive of all festal occasions, at the house of Agathon, described in the Symposium, Eryximachus, a physician ' Dialogmit v. 240. ' Ibid. ui. (M. 3 ibid. i. 404. 78 i I PHYSIC AND PHYSICIANS and the son of one, is a chief speaker, and in his praise ol love says, " from medicine I will begin that I may do honour to my art." We find him, too, on the side of tem- perance and sobriety: "The weak heads like myself, Aristodemus, Phsedros, and others who never can drink, are fortunate in finding that the stronger ones are not in a drinking mood. (I do not include Socrates, who is able either to driiUc or to abstain, and will not mind, which- ever we do.) Well, as none of the company seem disposed to drink much, I may be forgiven for saying, as a physician, that drinking deep is a bad practice, which I never follow, if I can help, and certainly do not recommend to another, least of all to any one who still feels the effect of yester- day's carouse." The prescriptions for hiccough, given by Eryximachua, give verisimilitude to the dialogue. When the turn of Aristophanes came he had eaten too much and had the hiccough, and he said to Eryximachus, " You ought either to stop my hiccough or speak in my turn." Eryximachus recommended him to hold bis breath, or if that failed to gargle with a little water, and if the hic- cough still continued, to tickle his nose with something and sneeze, adding, " if you sneeze once or twice even the most violent hiccough is sure to go." ' Upon the medical s3nnptonxs narrated in that memo- rable scene, unparalleled in literature, after Socrates had drank the poison in prison, it is unnecessary to dwell ; but I may refer to on<> aspect as indicating the reverence felt for the representative of the great Healer. Denied hia wish (by the warning of the jailor, who says that there is only sufficient poison) to offer a libation to a god, Socrates' * DicUoguts, i. 546. &o6, S56. 74 AS DEPICTED IN PLATO dying words were, " Crito, we owe a cock to Aaoulapius." " The meaning of this solemnly smiling farewell of Socrates would seem to be," according to Dyer, " that to .^scula- pitts, a god who always is prescribing potions and whose power is manifest in their effects, was due that most wel> come and sovereign remedy wliich cured all the pains and ended all the woes of Socrates — ^the hemlock, which cured him of life which is death, and gave him the glorious reali- ties of hereafter. For this great boon of awakening into real life Socrates owed ^Esculapius a thankoffering. This offering of a cock to ^culapius was plainly intended for him as the awakener of the dead to life everlasting." And permit me to conclude this abready too long account with the eulogium of Professor Jowett — words worthy of the master, worthy of his great interpreter to this genera- tion: "More than two thousand two hundred years have passed away since he returned to the place of Apollo and the Muses. Yet the echo of his words continues to be heard among men, because of all philosophers he has the most melodious voice. He is the inspired prophet or teacher who can never die, the only one in whom the out- ward form adequately represents the fair soul within ; in whom the thoughts of all who went before him are reflected and of all who come after him are partly anticipated. Other teachers of philosophy are dried up and withered — after a few centuries they have become dust ; but he ia fresh and blooming, and is always begetting new ideas in the minds of men. They are one-sided and abstract ; but he has many sides of wisdom. Nor is he alwa3rs con- sistent with himself, because he is always moving onward, 76 •»h PHYSIC AND PHYSICIANS and knows that there are many more things in philosophy than can be expressed in words, and that truth is greater than consistency. He who approaches him in the most reverent spirit shall reap most of the fruits of his wisdom ; he who reads him by the light of ancient commentators will have the least understanding of him. " We may see him with the eye of the mind in the groves of the Academy, or on the banks of the Ilissus, or in the streets of Athens, alone or walking with Socrates, full of these thoughts which have since become the common possession of mankind. Or we may compare him to a statue hid away in some temple of Zeus or ApoUo, no longer existing on earth, a statue which has a look as of the God himself. Or we may once more imagine him foUowing in another state of being the great company of heaven which he beheld of old in a vision {Phcddnu, 248). So, ' partly trifling but with a degree of seriousness ' '{Sym- posium, 197, E), we linger around the memory of a world which has passed away {Phcedrut, S280, C)." If ■ w 76 THE LEAVEN OF SCIENCE 77 ,BSSL IK.Mi '^ KnowMge oomes, bat wiidom lingen. Loektley Hall, TKTinrsoH. Who bres not knowledge t Who shall rail Against her beauty T May sho mix With men and proaper ! Who shall fix Her piUan T Let hw work prevuL In Mtmoriam, CXIV, Tmsvyws 78 THE LEAVEN OF SCIENCE' I IN the continual remembrance of a glorious pait indi- viduals and nations find their noblest inspiration, and if to-uivy this inspiration, so valuable for its own sake, so important in its associations, is weakened, is it not because in the strong dominance of the individual, so charaoteristio of a democracy, we have lost the sense of continuity 1 As we read in Roman history of the ceremonies commemorative of the departed, and of the scrupulous care with which, even at such private festivals as the Ambarvalia, the dead were invoked and remembered, we appreciate, though feebly, the part which this sense of continuity played in the lives of their successors— an ennobling, influence, through which the cold routine of the present received a glow of energy from " the touch divine of noble natures tone." In our modem lives no equivalent to this feeling exists, and the sweet and gracious sense of an ever>present immortality, recognized so keenly and so closely in the religion of Numa, has lost all value to us. We are even impatient of those who would recall the past, and who > WiatM- lutitate of Anatomy and Biology of the UoiTenHy of Fannqrlvaaia, 1894. 79 mtM Hi Hi Hi, lb 28 |3j2 |40 1^ 1 2.2 12.0 1.8 MICROCOPY RESOLUTION TEST CHART NATIONAL BUREAU OF STANDARDS STANDARD REFERENCE MATERIAL 1010a (ANSI and ISO TEST CHART No. 2) 11 THE LEAVEN OF SCIENCE would insist upon the importance of its recognition as a factor in our lives, impatient as we are of everything save the present with its prospects, the future with its possi- bilities. Year by year the memory of the men who made this institution fades from ont the circle of the hills, and the shadow of oblivion falls deeper and deeper over their forms, until a portrait, or perhaps a name alone, remains to link the dead with the quick. To be forgotten seems inevitable, but not without a sense of melancholy do we recognize that the daily life of three thousand students and teachers is passed heedless of the fame, careless of the renown of these men ; and in the second state sublime it must sadden the " circle of the wise," as they cast their eyes below, to look down on festivals in which they play no part, on gatherings in which their names are neither invoked nor blessed. But ours the loss, since to us, distant in humanity, the need is ever present to cherish the me- mories of the men who in days of trial and hardship laid on broad lines the foundations of the old colonial colleges. To-day, through the liberality of General Wistar, we dedicate a fitting monument to one of the mighty dead of the University— Caspar Wistar. The tribute of deeds has already been paid to him in this splendid structure, to all m the stately group of academic buildings which you now see adorning the campus— the tribute of words remains, to be able to offer which I regard a very special honour. But as this is an Institute of Anatomy, our tribute to- day may be justly restricted, in its details at least, to a eulogy upon the men who have taught the subject in this University. About the profes£,or8hip of anatomy cluster memories which give it precedence of all others, and in the 80 THE LEAVEN OF SCIENCE septemviri of the old school the chairs were arranged, with that of anatomy in the centre, with those of physiology, chemistry, and materia medica on the left, and with those of practice, surgery, and obstetrics on the right. With the revival of learning anatomy brought life and liberty to the healing art, and throughout the sixteenth, seventeenth, and eighteenth centuries the great ' ames of the profession, with but one or two exceptions, are those of the great anat- omists. The University of Pennsylvania has had an extra- ordinary experience in the occupancy of this important chair. In the century and a quarter which ended with the death of Leidy, six names appear on the faculty roll as professors of this branch. Dorsey, however, only delivered the introductory lecture to the course, and was seized the same evening with his fatal illness ; and in the next year Physick was transferred from the chair of surgery, with Homer as his adjunct. In reality, therefore, only four men have taught anatomy in this school since its foundation. Physick's name must ever be associated with the chair of surgery. We do not know the faculty exigencies which led to the transfer, but we can readily surmise that the youthfulness of Horner, who was only twenty-six, and the opportunity of filching for surgery so strong a man as Gibson from the Faculty of the University of Maryland, then a stout rival, must have been among the most weighty con- siderations. If in the average length of the period of each incumbency the chair of anatomy in the University is remarkable, much more so is it for the quality of the men who followed each other at such long intervals. It is easy to praise the Athenians among the Athenians, but where is the school ▲E. 81 o THE LEAVEN OF SCIENCE I:) in this country which can show such a succession of names in this branch : Shippen, the first teacher of anatomy ; Wistar, the author of the first text-book of anatomy ; Homer, the first contributor to human anatomy in this country ; and Leidy, one of the greatest comparative anatomists of his generation ? Of European schools, Edinburgh alone presents a parallel picture, as during the same period only four men have held the chair. The long- evity and tenacity of the three Monros have become pro- verbial ; in succession they held the chair of anatomy for 126 years. Shortly before the foundation of this school Monro secundus had succeeded his father, and taught un- interruptedly for fifty years. His son, Monro tertixis, held the chair for nearly the same length of time, and the re- mainder of the period has been covered by the occupancy of John Goodsir, and his successor. Sir William Turner, the present incumbent. To one feature in the history of anatomy in this school I must refer in passing. Shippen was a warm personal friend and house-pupil of John Hunter. Physick not only had the same advantages, but became in addition his house- surgeon at St. George's Hospital. Both had enjoyed the intimate companionship of the most remarkable observer of nature since ArLstotle, of a man with wider and more scientific conceptions and sympathies than had ever before been united in a member of our profession, and whose funda- mental notions of disease are only now becoming prevalent. Can we doubt that from this source was derived the power- ful inspiration which sustained these young men. One of them, on his return from England, at once began the first anatomical classes which were held in the colonies ; 82 THE LEAVEN OF SCIENCE the other entered upon that career so notable and so honour- able, which led to the just title of the Father of American Surgery. It is pleasant to think that direct from John Hunter came the influence which made anatomy so strong in this school, and that zeal in the acquisition of specimens which ultimately led to the splendid conections of the Wistar-Homer Museum. William Shippen the younger shares with John Morgan the honour of establishing medical instruction in this city. When students in England they had discussed plans, but it was Morgan who seems to have had the ear of the trustees, and who broached a definite scheme in his celebrated "Discourse," delivered in May, 1765. It was not until the autumn of the year that Shippen signified to the board his willingness to accept a professorship of anatomy and surgery. He had enjoyed, as I have mentioned, the friend- ship of John Hunter, and had studied also with his cele- brated brother, William. Associated v/ith him as fellow - pupil was William Hewson, who subsequently became so famous as an anatomist and physiologist, and as the dis- coverer of the leucocytes of the blood, and whose descend- dants have been so prominent in the profession of this city. No wonder, then, with such an education, that Shippen, on his return in 1762, in his twenty-sixth year, should have begun a course of lectures in anatomy, the introductory to which was delivered in the State House on November 16. To him belongs the great merit of having made a beginning, and of having brought from the Hunters methods and traditions which long held sway in this school. VVistar in his eulogium pays a warm tribute to his skill as a lecturer and as a demonstrator, and to the faithfulness with which 88 If Mi! fi. i u THE LEAVEN OF SCIENCE he taught the subject for more than forty years. Apart from his comiection with this institution he served as Director-General of the Military Hospitals from 1777 to 1781, and was the second president of the College of Phy- sicians. In the history of the profession o'' this country Caspar Wistar holds an unique position. He is its Avicenna, its Mead, its Fothergill, the very embodiment of the physician who, to paraphrape the words of Armstrong, used by Wistar in his Edinburgh Graduation Thesis, " Sought the cheerful haunts of men, and minglei with the bustling crowd." He taught anatomy in this school as adjunct and professor for twenty-six years. From the records of his contem- poraries we learn that he was a brilliant teacher, " the idol of his class," as one of his eulogists says. As an anat- omist he will be remembered as the author of the first American Text-Book on Anatomy, a work which was exceedingly pop\ilar, and ran through several editions. His interest in the subject was not, however, of the " knife and fork " kind, for he was an early student of mammalian palaeontology, in the development of which one of his successors was to be a chief promotor. But Wistar's claim to remembrance rests less upon his writings than upon the impress which remains to this day of his methods of teaching anatomy. Speaking of these, Horner, who was his adjunct and intimate associate, in a letter dated February 1, 1818, says, " In reviewing the several parti- culars of his course of instruction, it is difl&cult to say in what part his chief merit consisted ; he undertook every- thing with so much zeal, and such a conscientious desire to benefit those who came to be instructed by him, that 84 A THE LEAVEN OF SHENCE he seldom failed of giving the most complete satisfaction. There ware, however, some parts of his course peciiliar to himself. These were the addition of models on a very large scale to illustrate small parts of the human structure ; and the division of the general class into a number of sub- classes, each of which he supplied with a box of bones, in order that they might become thoroughly acquainted with the human skeleton, a subject which is acknow- ledged by all to be at the very foundation of anatomical knowledge. The idea of the former mode of instruction was acted on for the first time about fifteen years ago." We have no knowledge of a collection of speciniens by Shippen, thougn it is hard to believe that he could have dwelt in John Hunter's house and remained free from the insatiable hunger for specimens which characterized his master. But the establishment of a museum as an impor- tant adjunct to the medical school was due to Wistar, whose collections formed the nucleus of the splended array wbich you will inspect to-day. The trustees, in acceT>*,ing the jnft on the death of Dr. Wistar, agreed that it should be styled the Wistar Museum, and now, after the lapse of seventy-six years, the collection has found an appro- priate home in an Institute of Anatomy which bears his honoured name. But Wistar has established a wider claim to remem- brance. Genial and hospitable, he reigned supreme in society by virtue of exceptional qualities of heart and head, and became, in the language of Charles Caldwell, " the i,en8ori'''n commune of i large circle of friends." About no other name in our ranks cluster such memories of good fellowship and good cheer, and it stands to-day in 85 1 'I 1 I ( THE LEAVEN OF SCIENCE this city a synonyva for esprit and social intercourse. Year by year his face, printed on the invitations to the " Wistar Parties " (still an important function of winter life in Philadelphia) perpetuates the message of his life, " Go seek the cheerful haunts of men." How different was the young prosector and adjunct who next taught the subject ! Horner was naturally reserved and diffident, and throughout his life those obstinate ques- tionings which in doubt and suffering have so often wrung the heart of man were ever pre&ent. Fightings within and fears without harassed his gentle and sensitive soul, on which mortality weighed heavily, and to which the four last things were more real than the materials in which he worked. He has left us a journal intime, in which he found, as did Amiel, of whom he was a sort of medical prototype, " a safe shelter wherein his questionings of fate and the future, the voice of grief, of self-examination and confession, the soul's cry for inward peace, might make themselves freely heard." Listen to him : " I have risen early in the morning, ere yet the watchman had cried the last hour of his vigil, and in undisturbed solitude giving my whole heart and understanding to my Maker, prayed fervently that I might be enlightened on this momentous subject, that I might be freed from the errors of an excited imacina- tion, from the allurements of personal friendship, from the prejudices of education, and that I might, under the influence of Divine grace, be permitted to settle this ques- tion in its true merits." How familiar is the cry, the great and exceeding bitter cry of the strong soul in the toils and doubtful of the victory ! Horner, however, was ont of those on whom both blessings rested. Facing the spectres 86 % % THE LEAVEN OF SCIENCE of the mind, he laid them, and reached the desired haven. Ill spite of feeble bodily health and fits of depression, he carried on his anatomical studies with zeal, and as an ori- ginal worker and author brought much reputation to the University. Particularly he enriched the museum with many valuable preparations, and his name will ever be associated with that of Wistar in the anatomical collection which bears their names. But whut shall I say of Leidy, the man in whom the leaven of 'jcience wrought with labour and travail for so many The written record survives, scarcely equah '-ety and extent by any naturalist, but how meagre. . pict" e of the man as known to his friends. The traits which luade his life of such value— the patient spirit, the kindly disposition, the sustained zeal— we shall not see again incarnate. The memory of them alone re- mains. As the echoes of the eulogies upon his life have scarcely died away, I need not recount to this audience his ways and work, but upon one aspect of his character I may dwell for a moment, as illustrating an influence of science which has attracted much attention and aroused discussion. So far as the facts of sense were concerned, there was not a trace of Pyrrhonism in his composition, but in all that relates to the ultra-rational no more consistent disciple of the great sceptic ever lived. There was in him, too, that delightful " ataraxia," that imperturbability which is the distinguishing feature of the Pyrrhonist, in the truest sense of the word. A striking parallel exists between Leidy and Darwin in this respect, and it is an interesting fact that the two men ot this century who have lived in closest intercourse >vith nature should have found full satisfaction 87 I*'' THE LEAVEN OF SCIENCE in their studies and in their domestic affections. In the autobiographical section of the life of Charles Darwin, edited by his son Francis, in • Mch are laid bare with such charming frankness the inner thoughts of the great natura- list, we find that he, too, had reached in suprasensuous affairs that state of mental imperturbability in which, to borrow the quaint expression of Sir Thomas Browne, they stretched not his pia mater. But while acknowledging that in science scepticism is advisable, Darwin says that he was not himself very sceptical. Of these two men, aUke in this pomt, and with minds distinctly of the Aristotelian type, Darwin yet retained amid an overwhelming accumula- tion of facts— and here was his great superiority— an extra- ordinary power of generalizing principles from them. Defi- cient as was this quality in Leidy, he did not, on the other hand, experience " the curious and lamentable loss of the higher aesthetic taste " which Darwin mourned, and which may have been due in part to protracted ill health, and to an absolute necessity of devoting all his powers to collecting facts in support of his great theory. When I think of Leidy's simple life, of his devotion to the study of nature, of the closeness of his communion with her for so many years, there recur to my mind time and again the lines, — imi He is made one with nature : there is heard His voice in all her music, from the moan Of thunder, to the song of night's sweet bird ; He is a presence to be felt and known In darkness and in light, from herb and stone. Spreading itself where'er that Power may move Which has withdrawn bia being to its own, 88 i!i 1 I -M THE LEAVEN OF SCIENCE II Turning from the men to the subject in which they worked, from the past to the present, let us take a hasty glance at some of the developments of human anatomy and biology. Truth has been well called the daughter of Time, and even in anatomy, which is a science in a state of fact, the point of view changes with successive generations. The following story, told by Sir Robert Christison, of Barclay, one of the leading anatomists of the early part of this century, illus- trates the old a. Ae of mind still met with among " bread and butter " teaches of the subject. Barclay spoke to his class as follows : " Gentlemen, while canying on your work in the dissecting-room, beware of making anatomical discoveries ; and above all beware of rushing with them into print. Our precursors have left us little to discover. You may, perhaps, fall in with a supernumerary muscle or tendon, a slight deviation oi extra branchlet of an artery, or, perhaps, a minute stra<' twig of a nerve — that will be all. But beware ! Publish :hc fact, and ten chances to one you will have it shown that yo' have been forestalled long ago. Anatomy may be likened to a harvest-field. First come the reapers, who, entering upon untrodden ground, cut down great store of com from all sides of them. These are the early anatomists of modem Europe, such as Vesalius, Fallopius, Malpighi, and Harvey. Then come the gleaners, who gather up ears enough from the bare ridges to make a few loaves of bread. Such were the anatomists of last century — Valsalva, Cotunnius, Haller, Winslow, Vicq d'Azyr, Camper, Hunter, and the two Monros. Last of all come the geese, who still contrive to pick up a few grains scattered here and there among the 89 II H 'hi M 1 THE LEAVEN OF SCIENCE stubble, and waddle borne in the evening, poor things, cackling with joy because of thoir succecss. Gentlemen, we are tht ^^cse." Yes, geese they were, gleaning amid the stubble of a restricted field, when the broad acres of biology were open before them. Those were the days when anatomy meant a knowledge of the human frame alone ; and yet the way had been opened to the larger view by the work of John Hunter, whose comprehensive mind grasped as proper subjects of study for the anatomist all the manifestations of life in order and disor_er. The determination of structure with a view to the dis- covery of function has been the foundation of progress. The meaning may not always have been for " him who runs to read ; " often, indeed, it has been at the time far from clear ; and yet a knowledge in full detail of the form and relations must precede ; correct physiology. The extraordinary development oi ^u the physical sciences, and the corresponding refinement of means of research, have contributed most largely to the enlightenment of the " geese " of Barclay's witticism. Take the progress in any one department which has a practical aspect, such as, in the anatomy and physiology of the nervous system. Read, for example, in the third edition of Wistar's Anatomy. edited by Horner in 1825, the description of the convolu- tions of the brain, on which to-day a whole army of special students are at work, medical, surgical, and anthropological, and the functions of which are the objective poirt of physio- logical and psychological research— the whole subject is thus disposed of : " The surface of the brain resembles that of the mass of the small intestine, or of a convoluted, cylin- drical tube ; it is, ' .efore, said to be convoluted. Tlie 90 1 THE LEAVEN OF SCIENCE fissures between these convolu^'ons do not extend very deep into the substance of the t.; ain." The knowledge of fimction rnrrelated with this meagre picture of structure is best expressed, perhaps, in Shakesp'^arian diction, " that when the brains were out, the man would die." The laborious, careful establishment of structure by the first two generations in this century led to those brilliant dis- coveries in the functions of the nervous system which have not only revolutionized medicine, but have almost enabled psychologists to dispense with metaphysics ^'together. It is pa-ticularly int<'resting to note the widespread depend- ence of many departments on accurate anatomijal know- ledge. The new cerebral anatomy, partir'- 'arly the Uidy of the surface of the brain, so summaril .Ismissed »n a few lines by Wistar, made plain the path for Hitzig and Fritsch, the careful dis.section of cases of disease of the brain prepared the way for Hughlings Jackson ; and gra- dually a new phrenology on a scientific basis has replaced the crude notions of Gall and Spurzheim ; so that with the present generation, little by little, there has been established on a solid structure of anatomy, the localization of many of the functions of the brain. Excite with a rougV touch, from within or from without, a small region of that mysteri- ous surface, and my lips may move, but not in the articu- lote expression of thought, and I may see, but I cannot read the page before me ; touch here and sight is gone, and there again and hearing fails. One by one the centres may be touched which preside over the muscles, and they may, singly or together, lose their power. All these func- tions may go without the loss of consciousness. Touch with the slow finger of Time the nutrition of that thiu 91 :'.* i ! THE LEAVEN OF SCIENCE layer, and backward by slow degrees creep the intellectual faculties, back to childish simplicity, back to infantile silliness, back to the oblivion of the womb. To this new cerebral physiology, which has thus grad- ually developed with increasing knowledge of structure, the study of cases of disease has contributed enormously, and to-day the diagnosis of affections of the nervous system has reached an astonishing degree of accuracy. The inter- dependence and sequence of knowledge in various branches of science is nowhere better shown than in this very subject. The facts obtained by precise anatomical investigation, from experiments on animals in the laboratory, from the study of nature's experiments upon us m disease, slowly and painfully acquired by many minds in many lands, have brought order out of the chaos of fifty years ago. In a practical age this vast change has wrought a corresponding alteration in our ideas of what may or may not be done in the condition of perverted health which we call disease, and we not only know better what to do, but also what to leave undone. The localization of centres in the surface of the brain has rendered it possible to make, with a considerable degree of certainty, the diagnosis of focal disease, and Macewen and Horsley have supplemented the new cerebral physiology and pathology by a new cerebro-spinal surgery, the achievements of which are scarcely credible. But this is not all ; in addition to the determination of the centres of sight, hearing, speech, and motor activities, we are gradually reaching a knowledge of the physical basis of mental phenomena. The correlation of intelli- gence and brain weight, of mental endowment and in- creased convolution of the brain surface, was recognized 92 L^ THE LEAVEN OF SCIENCE even by the gleaners of Barclay's story ; but within the past twenty-five years the minute anatomy of the organ has been subjected to extensive study by methods of ever- increasing delicacy, which have laid bare its complex mechanism. The pyramidal cells of the cerebral grey matter constitute the anatomical basis of thought, and with the development, association, and complex connection of these psychical cells, as they have been termed, the psychical functions are correlated. How far these mechan- ical conceptions have been carried, may be gathered from the recent Croonian Lecture before the Royal Society, in which Ram6n y Cajal based the action and the degree, and the development of intelligence upon the complexity of the cell mechanism and its associations. Even the physical basis of moody madness has not evaded demonstration. Researches upon the finer structure of the cerebral cortex lead to the conclusion that imbecility, mental derange- ment, and the various forms of insanity are but symptoms of diseased conditions of the pyramidal cells, and not separ- ate affections of an indefinable entity, the mind. Still further ; there is a school of anthropologists which strives to associate moral derangement with physical abnormali- ties, particularly of the brain, and urges a belief in a cri- minal psychosis, in which men are " villains by necessity, fools by heavenly compulsion, knaves, thieves, and treachers by spherical predominance." This remarkable revolution in our knowledge of brain functions has resulted directly from the careful and accurate study by Barclay's " geese," of the anatomy of the nervous system. Truly the gleaming of the grapes of Ephraim has been better than the vintage of Abi-ezer. 93 1 1 \ ' THE LEAVEN OF SCIENCE The study of structure, however, as the basis of vital phenomena, the strict province of anatomy, forms but a small part of the wide subject of biology, which deals with the multiform manifestations of life, and seeks to know the laws governing the growth, development, and actions of living things. John Hunter, the master of Shippen and Physick, was the first great biologist of the moderns, not alone because of his extraordinary powers of observa- tion and the comprehensive sweep of his intellect, but chiefly because he first looked at life as a whole, and studied all of its manifestations, in order and disorder, in health and in disease. He first, in the words of Buckle, " deter- mined to contemplate nature as a vast and united whole, exhibiting, indeed, at different times, different appearances, but preserving amidst every change, a principle of uniform and uninterrupted order, admitting of no division, under- going no disturbance, and presenting no real irregularity, albeit to the common eye irregularities abound on every side." We of the medical profession may take no little pride in the thought that there have never been wanting men in our ranks who have trodden in the footsteps of this great man ; not only such giants as Owen, Huxley, and Leidy, but in a more humble way many of the most diligent students of biology have been physicians. From John Hunter to Charles Darwin enormous progress was made in every department of zoology and botany, and not only in the accumulation of facts relating to structure, but in the knowledge of function, so that the conception of the phe- nomena of living matter was progressively widened. Then with the Origin of Species came the awakening, and the theory of evolution has not only changed the entire aspect 94 THE LEAVEN OF SCIENCE it of biology, but has revolutionized every department of human thought. Even the theory itself has come within the law ; and to those of us whose biology is ten years old, the new concep- tions are, perhaps, a little bewildering. The recent litera- ture shows, however, a remarkable fertility and strength. Around the nature of cell-organization the battle wages most fiercely, and here again the knowledge of structure is sought eagerly as the basis of explanation of the vital phenomena. So radical have been the changes in this direction that a new and complicated terminology has sprung up, and the simple, undifferentiated bit of proto- plasm has now its cytosome, cytolymph, caryosome, chro- mosome, with their somacules and biophores. These accurate studies in the vital units have led to material modifications in the theory of descent. Weismann's views, particularly on the immortality of the unicellular organisms, and of the reproductive cells of the higher forms, and on the transmission or non-transmission of acquired characters, have been based directly upon studies of cell-structure and cell-fission. In no way has biological science so widened the thoughts of men as in its application to social problems. That throughout the ages, in the gradual evolution of life, one unceasing purpose runs ; that progress comes through unceasing competition, through unceasing selection and rejection ; in a word, that evolution is the one great law controlling all living things, " the one divine event to which the whole creation moves," this conception has been the great gift of biology to the nineteenth century. In his work on Social Evolution, Kidd thus states the problem in 95 , , '/ ^; u THE LEAVEN OF SaENCE clear tenns : " Nothing tends to exhibit more strikingly the extent to which the study of our social phenomena must in future be based on the biological sciences, than the fact that the technical controversy now being waged by biologists as to the transmission or non-transmission to offspring of qualities acquired during the lifetime of the parent, is one which, if decided in the latter sense, must produce the most revolutionary effect throughout the whole domain of social and political philosophy. If the old view is correct, and the effects of use and education are transmitted by inheritance, then the Utopian dreams of philosophy in the past are undoubtedly possible of realiza- tion. If we tend to inherit in our own persons the result of the education and mental and moral culture of past generations, then we may venture to anticipate a future society which will not deteriorate, but which may continue to make progress, even though the struggle for existence be suspended, the population regulated exactly to the means of subsistence, and the antagonism between the individual and the social organism extinguished. But if the views of the Weismami party are in the main correct ; if there can be no progress except by the accumulation of congenital variations above the average to the exclusion of others below ; if, without the constant stress of selection which this involves, the tendency of every higher form of life is actually retrograde; then is the whole human race caught in the toils of that struggle and rivahy of life which has been in progress from the beginning. Then must the rivalry of existence continue, humanized as ^o conditions it may be, but immutable and inevitable to tne end. Then also must all the phenomena of human life^ individual, 90 THE LEAVEN OF SHENCE political, social, and religious, be couidered as aspects of this cosmic process, capable o' ' ^ing studied and ' der- stood by science only in theii relations thereto." * Biology touches the problems of life at every point, and may claim, as no other science, completeness of view and a comprehensiveness which pertains to it alone. To all whose daily work lies in her manifestations the value of a deep insight into her relations cannot be overestimated. The study of biology trains the mind in accurate methods of observation and correct methods of reasoning, and gives to a man clearer points of view, and an attitude of mind more serviceable in the working-day-world than that given by other sciences, or even by the humanit'es. Year by year it is to be hoped that young men will obtain in this Institute a fundamental knowledge of the laws of life. To the physician particularly a scioatific discipline is an incalculable gift, which leavens his whole life, giving exact- ness to habits of thought and tempering the mind with that judicious faculty o' distrust which can alone, amid the uncertainties of piactice, make him wise unto salvation. For perdition inevitably awaits the mind of the practi- tioner who has never had the full inoculation with the leaven, wh'^ has never grasped clearly the relations of science to his art, and who knows nothing, and perhaps cares less, for the limitations of either. And I may be permitted on higher grounds to congratu- late the University of Pennsylvania on the acquisition of this Institute. There is greac need in the colleges of this councry of men who are thinkers as well as workers — men with ideas, men who have drunk deep of the Astral wine, 1 Social Evolution. .>y Benjamin Kidd. London. 1894. AE. C7 H 'nmm THE LEAVEN OP SCIENCE li:! m and whose energies are not sapped in the tread-mill of the class-room. In these laboratories will be given opportuni- ties for this higher sort of university work. The conditions about us are changing rapidly : in the older states utility is no longer regarded as the test of fitness, and the value of the intellectual life has risen enormously in every depart- ment. Germany must be our model in this respect. She is great because she has a large group of men pursuing pure science with unflagging industry, with self-denying zeal, and with high ideals. No secondary motives sway their minds, no cry reaches them in the recesses of their laboratories, " of what practical utility is your work ? " but, unhampered by social or theological prejudices, they have been enabled to cherish " the truth which haf never been deceived — that 'complete trith which carries with it the antidote against the bane and danger which follow in the train of half -knowledge." (Heknholtz.) The leaven of science gives to men habits of mental accuracy, modes of thought which enlarge the mental vision, and strengthens — to use an expression of Epichar- mus — " the sinews of the understandmg." But is there nothing further ? Has science, the last gift of the gods, no message of hope for the race as a whole ; can it do no more than impart to the individual imperturbability amid the storms of life, judgment in times of perplexity ? Where are the bright promises of the days when "the kindly earth should slumber rapt in universal law " ? Are these, then, futile hopes, vain imaginings of the dreamers, who from Plato to Comte have sought for law, for order, for the civiias Dei in the regnum hominis ? Science has done much, and will do more, to alleviate 98 THE LEAVEN OF SCIENCE the unhappy condition in /hich so many millions of our fellow-creatiires live, and in no way more thau in mitigating some of the horrcrs of disease ; but we are too apt to forget that apart from and beyond her domain lie those irresistible forces which alone sway the hearts of men. V.'itn reason science never parts company, but with feeling, emotion, passion, what has she to do ? They are not of her ; they owe her no allegiance. She may study, analyze, and define, she can never control them, and by no possibilty can their ways be justified to her. The great philosopher who took such a deep interest in the foundation of this University, chained the lightnings, but who has chained the wayward spirit of man? Strange compound, now wrapt in the ecstasy of the beatific vision, now wallowing in the sloughs of iniquity, no leaven, earthly or divine, aas worked any permanent change m him. Listen to the words of a student of the heart of man, a depictor of his emotions : " In all ages the reason of the world has been at the ii.«5rcy of brute force. The reign of law has never had more than a passing reaUty, and never can have more than that so long as man is human. The individual intellect, and the aggregate intelligence of nations and races, have alike perished in the struggle of mankind, to revive again, indeed, but as surely to be again put to the edge of the sword. Look where you will throughout the length and breadth of all that was the world, 5000 or 500 years ago ; everywhere passion has swept thought before it, and belief, reason. Passion rules the world, and rules alone. And passion is neither of the head nor of the hand, but of the heart. Love, hate, ambi- tion, anger, avarice, either make a slave of intelligence to serve their impulses, or break down its impotent opposition 99 Mdb MUflHfa THE LEAVEN OF SCIENCE with the unanswerable argument of brute force, and tear it to pieces with iron hands." (Marion Crawford.) Who runs may read the scroll which reason has placed as a warning over the human menageries : " chained, not tamed." And yet who can doubt that the leaven of science, working in the individual, leavens in some slight degree the whole social fabric. Reason is at least free, or nearly so ; the shackles of dogma have been removed, and faith herself, freed from a morganatic alliance, finds in the release great gain. H' 1 il One of the many fertile fancies of the " laughing phil- osopher," a happy anticipation again of an idea peculiarly modern, was that of the influence upon us for weal or woe of Externals, of the idola, images, and effluences which encompass us — of Externals upon which so much of our happiness, yes, so much of our every character depends. The trend of scientific thought in this, as in the atomic theory, has reverted to the Sage of Abdera ; and if environment really means so much, how all-important a feature in educa- tion must be the nature of these encompassing effluences. This magnificent structure, so admirably adapted to rhe prosecution of that science from which modern thought has drawn its most fruitful inspirations, gives completeness to the already exhilarating milieu of this University. Here at last, and largely owing to your indomitable energy, Mr. Provost, are gathered all the externals which make up a Schda major worthy of this great Commonwealth. What, after all, is education but a subtle, slowly-afEected change, due to the action upon us of the Externals ; of the written record of the great minds of all ages, of the beautiful and 100 THE LEAVEN OF SCIENCE harmonious surroundings of nature and of art, and of the lives, good or ill, of our fellows— these alone edu'^ate us, these alone mould the developing minds. Within the bounds of this campus these influences will lead successive generations of youth from matriculation in the college to graduation in the special school, the complex, varied in- fluences of Art, of Science, and of Charity ; of Art, the highest development of which can only come with that sustaining love for ideals which, " burns bright or dim as each are mirrors of the fire for which all thirst ; " of Science, the cold logic of which keeps the mind independent and Iree from the toils of self-deception and half-knowledge ; of Charity, in which we of the medical profession, to walk worthily, must live and move and have our being. 101 \\fi ] I VI THE ARMY SURGEON loa I! < Nor Mare his sword nor war's quick fire shall bum The living record of your memory. 'Gainst death and all-obliTious enmity ShaU you pace forth ; your praise shall stiU 6nd room Kven in the eyes of all posterity. Shakispiabe. SonneU, LV. 104 VI THE ARMY SURGEON' AT the outset I am sure you will permit mt, on >w>half of the profession, to offer to the Army Medical Department hearty congratulations on the completion of the arrangements which have made possible this gathering. With capacities strained to the utmost in furnishing to students an ordinary medical education, the schoob at large cannot be expected to equip aiaiy surgeons wilh the full details of special training. A glance at the curriculum just comp'^ted brings into sharp relief the dipabilities under which previous classes must have proceeded to their labours, the members of which have had to pick up at random — in many cases have probably never acquired — the valuable know- ledge traversed in the lectures and laboratory exercises of the session. But greatest of all the advantages of an army medical school must be counted the contact of the young officers with their seniors, with the men under whose directions they subsequently have to work. In comparison with their predecessors, with what different feelings and ideas will the men before us enter upon their duties in the various posts to which they have been assigned. In8+«ad of hazy notions — perhaps to one fresh from the Examining Board not ' leasant ones— of a central authority at Washington, of a Yama enthroned as Secretary of » Army Medical School, Washington, February 28, 1894. 105 \0': mil i r ' il t f I THE ARMY SURGEON War, and of an exacting Surgeon'Greneral, the young officer who has enjoyed the delightful opportunities of four months' study amid these inspiring surroundings, which teem with reminders of the glories of the corps and of the greatness of his profession, the young officer, I say, must be indeed a muddy-mettled fellow who does not carry away, not alone rich stores of information, but, most precious of all educational gifts, a true ideal of what his life-work should be. Members of the Graduating Class: Though to you it may not, to me it seems peculiarly appropriate that the Surgeon-General should have asked a civilian to make an address on this occasion. With the strictly military aspects of your future life you Lave made yourselves familiar; of the merits and demerits of the army as a career for a physician you have in the past four months heard very much ; but about all subjects there are some questions which are more freely handled by one who is unhampered by too particular knowledge, and this is my position, I may say my advantage, to-day. For me the Army Medical Department, so far as particulars are concerned, means a library with unsurpassed facilities, the worth of which is doubled by the liberality of its management ; a museum in which I have spent some delightful hours ; an index-catalogue, which is at my elbow like a dictionary ; and the medical history of the late V particularly the volumes by Woodward and Smart. Further, in my general reading in the history of the profession of this country, I have here and there gleaned facts about the corps and its members. I have lead the spir.ted vindication of John Morgan, who may 106 THE ARMY SURGEON be called the first Surgeon-General, and I am faailiar with the names and works of many of your distinguished predecessors who have left their mark in our literature. But as I write an aspiration of the past occurs, bringing me, it seems, closer to you than any of the points just mentioned, a recollection of the days when the desire of my life was to enter the India Medical Service, a dream of youth, dim now and almost forgotten— a dream of " Vishnu land, what Avatar ! " Speaking, then, from the vantage ground of my ignor- ance, let me tell you briefly of the opportunities of the life you have chosen. First among your privileges I shall place a feature often spoken of as a hardship, viz., the frequent change from station to station. Permanence of residence, good undoubtedly for the pocket, is not always best for wide mental vision in the physician. You are modern representatives of a professional age long past, of a day when physicians of distinction had no settled homes. You are Cyprid larvae, unattached, free-swimming, seeing much in many places ; not fixed, as we barnacles of civil life, head downward, degenerate descendants of the old professional Cirripeds, who laid under contribution not one, but a score of cities. Without local ties, independent of the public, in, while not exactly of, our ranks, you will escape many of the anxieties which fret the young physician— the pangs of disprized worth, the years of weary waiting, the uncer- tainty of the effort; and perhaps those sorer trials in- evitable in an art engaging equally heart and head, in which, from the very nature of the occupation, the former is apt— in finer spirits— to be touched with a grievoua 107 .' ' ■ I \0' I' 1= r n THE ARMY SUPGEON sensibility. In change, that leaven of life denied to so many, you will find a strong corrective to some of the most unpleasant of the foibles which beset us. Self- satisfaction, a frame of mind widely diffused, is manifest often in greatest intensity where it should be least en- couraged, and in individuals and communities is some- times so active on such slender grounds that the condi- tion is comparable to the delusions of grandeur in the insane. In a nomad life this common infirmity, to the entertainment of which the twin sisters. Use and Wont, lend their ever-ready aid, will scarcely touch you, and for this mercy give thanks ; and while you must, as men, entertain many idols of the tribe, you may at least escape this idol of the cave. Enjoying the privilege of wide acquaintance with men of very varied capabilities and traming, you can, as spectators of their many crotchets and of their little weaknesses, avoid placing an undue estimate on your own individual powers and position. As Sir Thomas Browne says, it is the " nimbler and con- ceited heads that never looked a degree beyond their nests that tower and plume themselves on light attain- ments," but " heads of capacity and such as are not full with a handful or easy measure of knowledge think they know nothing till they know all ! " Per contra, in thus attaining a broader mental platform, you may miss one of the great prizes of the profession —a position m a community reached in length of days by one or two, who, having added to learning, culture, to wisdom, charity, pass the evening of their lives in the hearts of their colleagues and of their kind. No gift of Apollc.not the Surgeon-Generalship, not distinguished 108 THE ARMY SURGEON position in science, no professorship, however honoured, can equal this, this which, as wandering Army Surgeons, you must furego. Fortunate is it for you that the service in one place is never long enough to let the roots strike so deeply as to make the process of transplantation too painful. Myself a peripatetic, I know what it is to bear the scars of partings from comrades and friends, scars which sometimes ache as the memories recur of the days which have flown and of the old familiar faces which have gone. Another aspect of the life of the Army Surgeon, isolation in some degree from professional colleagues, will influence you in different ways— hurtfully in the more dependent natures, helpfully in those who may have learned tkat "not from without us, only from within comes, or can ever come, upon us light "—and to such the early years of separation from medical societies and gatherings will prove a useful seed-time for habits of study, and for the cultivation of the self-reliance that forms so important an element in the outfit of the practitioner. And, after all, the isolation is neither so enduring nor so corroding as might have fallen to your lot in the routine of country practice. In it may be retained, too, some measure of individuality, lost with astonishing rapidity in the city mills that rub our angles down and soon stamp us all alike. In the history of the profession there are grounds for the statement that isolation promotes originality. Some of the most brilliant work has been done by men in extremely lim' .d spheres of action, and during the past hundred ye£ i-s it is surprising how many of the notable achievements have been made by physicians dwelling far from educational centres — Jenner worked out his discovery in a village ; 109 N i THE ARMY SURGEON McDowell, Long, and Sims were country doctors ; Koch was a district physician. So much depends upon the sort of start that a man makes in his profession that I cannot refrain from con- gratulating you again on the opportunities enjoyed durmg the past four months, which have not only added enor- mously to your capabilities for work, but have familiarized vnu with Ufe at the heart of the organization of which uereafter you wiU form part, and doubtless have given you fruitful ideas on the possibilities of your individual development. NaturaUy each one of you will desire to make the best use^of his talents and education, and let me sketch briefly what I think should be your plan of action. Throw away, in the first place, all ambition beyond that of doing the day's work weU. The traveUers on the road to success live in the present, heedless of taking thought for the morrow, having been able at some time, and in some form or other, to receive into their heart of hearts this maxim of the Sage of Chelsea : Your business is " not to see what Ues dimly at a distance, but to da what lies clearly at hand." Fevered haste is not en- couraged m mUitary circles, and if you can adapt your inteUectual progress to army rules, making each step in your mental promotion the lawful successor of some other, you wiU acquire little by little those staying powers without which no man is of much value in the ranks. Your opportunities for study will cover at first a wide field in medicine and surgery, and this diffuseness in your work may be your salvation. In the next five or ten years note with accuracy and care everything that comes within your profpsaional ken. There are, in truth, 110 I t THE AlvMY SURGEON no specialties in medicine, since to know fully many of the most important diseases a man must be familiar with their manifestations in many organs. Let nothing slip by you ; the ordinary humdnmi cases of the morning routine may have been accurately described and pictured, but study each one separately as though it were new— 80 it is so far as your special experience goes ; and if the spirit of the student is in you the lesson will be there. Look at the cases not from the standpoint of text-books and monographs, but as so many stepping-stones in the progress of your individual development in the art. This will save you from the pitiable mental attitude of the men who travel the road of practice from Dan to Beersheba, and at every step cry out upon its desolation, it dreariness, and its monotony. With Laurence Sterne, in afford to pity such, since they know not that t.. barrenness of which they complam is within themselves, a result of a lack of appreciation of the meaning and method of work. In the early years of service your advantages will be fuDy as great as if you had remained in civil life. Faith- fulness in the day oi small things will insensibly widen your powers, correct your faculties, and, in moments of despondency, comfort may be derived from a knowledge that some of f it work of the profession has come from men whose ci . field wm I'r ited but well-tilled. The important thing is to make the lesson of each case tell on your education. The value of experience is not in seemg much, but in seeing wisely. Experience in the true sense of the term does not come to all with years, or with increasing opportunities. Growth in the acquisi- tion of facts is not necessarily associated with develop- Ill '•. 1 I R ./•• !! I: \ i IBE ARMY SURGEON ment. Many grow through life mentally as the crystal, by simple accretion, and at fifty possess, to vary the figure, the unicellular mental blastoderm with which they started. The gro%/th which is organic and enduring, is totally different, marked by changes of an unmistakable character. The observations are made with accuracy and care, no pains are spared, nothing is thought a trouble in the investigation of a problem. The facts are looked at in connexion with similar ones, their relation to others is studied, and the experience of the recorder is compared with that of others who have worked upon the question. Insensibly, year by year, a man finds that there has been in his mental protoplasm not only growth by assimilation but an actual development, brmging fuller powers of observation, additional capabilities of mental nutrition, and that mcreased breadth of view which is of the very essence of wisdom. As clinical observers, we study the experiments which Nature makes upon our fellow-creatures. These experi- ments, however, in striking contrast to those of the laboratory, lack exactness, possessing as thc^ do a vari- bility at once a despair and a delight— the despair of those who look for nothing but fixed laws in an art which is still deep in the sloughs of Empiricism ; the delight of those who find in it an expression of a universal law transcending, even scorning, the petty accuracy of test- tube and balance, the law that in man " the measure of all things," mutability, variability, mobility, are the very marrow of his being. The dientele in which you work has. however, more stability, a less extended range of variation than that with which we deal in civil life. In 112 4 THE ARMY SUROEON a body of carefully selected active young men, you have a material for study in which the oscillations are less striking, and in which the results of the experiments, i.e., the diseases, have a greater uniformity than in infancy and old age, in the enfeebled and debauched. This adds a value to the studies of army medical officers, who often have made investigations in hygiene, dietetics, and medicine, so trustworthy and thorough that they serve us as a standard of comparison, as a sort of abscissa or base-line. Thus you have demonstrated to us, and to the community at large, the possibilities of stamping out BtQallpox by systematic revaccinat'on ; in civil practice we strive to reach the low rate of mortality of army hospitals in the treatment of typhoid fever and of f :eumonia. Many of the most important facts relating to etiology and symptomatology have come from camp or barrack. I often think that army surgeons scarcely appreciate that in their work they may follow the natural history of a disease under the most favourable circumstances ; the experiments are more ideal, the conditions less disturbing than those which prevail either in family practice or in the routine of the general hospital. Many of the common disorders can be tracked from inception to close, as can be done in no other line of medical work, and the facilities for the continuous study of certain affections are un- equalled. This, which is a point to be appreciated in the intrinsic education of which I spoke, gives you a decided advantage over your less favoured brethren. Your extraordinary range of observation, from the Florida Keys to Montana, from Maine to Southern Cali- fornia, affords unequalled facilities for the study of many AE. lis I ill if 'il i ^^ II !' i I ; THE ARMY SURGEON oi the vexed problems in medicine— facilities, indeed, which in the diversity of morbid conditions to be studied are equalled in no position in civil Ufe. Let me here mention a few of the subjects that may profitably engage your attention. No question is of more importance at present than the settlement, definitely, of the varieties of fever in the West and South. The studies of Baumgarten in St. Louis, and of Guiteras and others in the Southern States, suggest the possibility that in addition to typhoid fever and malaria— the common affections— there are other fevers the symptomatology and morbid anatomy of which still require careful elucidation. In this you will be walking in the footsteps of notable predecessors in the corps, and in the exhaustive works of Woodward and Smart, to which I have already alluded, and which are always available, you will find a basis from which you may start your personal observations. More par- ticularly in this direction do we need careful anatomical investigation, since the symptomatology of certain of the affections in question has much in common with that of the ordinary continued fevers of the North. I may call your attention to the satisfactory settlement of the nature of mountam fever by army surgeons, and need hardly add that the specimens contributed by Hofi and by Girard to this museum demonstrate conclusively that it is in reality typhoid fevc . In the Southern posts malaria with its protean mani- festations presents still many interesting problems for solution, and you will leave this school better equipped than any of your predecessors for the study and difieren- tiation of its less known varieties. With positive know- 114 Miiill ■M THE ARMY SXJRGEON ledge as to the etiology, and a practical familiarity with methods of blood-examination, you can do much in many localities to give to malaria a more definite position than it at present occupies in the profession, and can o£Eer in doubtful cases the positive and satisfactory test of the microscope. The hsematuria of the South requires to be studied anew — ^^ e filarial cases separated from the malarial, and, most important of all, the relation of quinine to hematuria positively set+led. In the more (distant posts, where, so far as the soldier is concerned, your opportunities for study may be limited,- you n\ay add greatly to our knowledge of the disorders prevalent among the Indians. More particularly do we need additional information as to the frequency of tubercu- losis among them, and its clinical history. One of your number, Dr. Edwards, has already furnished admirable statistics upon this point, but the field is still open, and much remains to be done. In this connexion, too, you may be able to carry saving knowledge upon the etiology of the disease, and enforce regulations for its prevention. You have only to turn to the Index-catalogue to see how scanty in reality are the facts in the nosology of the North American Indian. At many posts there will be presented to you the interesting effects of altitude, with problems of the greatest physiological importance. An excellent piece of work may be done upon its influences upon the red blood-corpuscles, in determining whether, as has been maintained, there is an increase numerically per cubic millimetre, so long as the individual remains in the more rarefied atmosphere. Points remain to be settled also upon the effects of altitude 115 ^ THE ARMY SURGEON upon the chest-capacity, the chest-measurement. and the heart, and our knowledge is stUl lacking on questions reUting to the influence of high altitudes upon many of the ordinary diseases. To one of you, perhaps, another peculiarly American disease— milk-sickness— may reveal its secret. Our know- ledge of its etiology has not been materially increased since the early papers on the subject, which so weU described its symptomatology. These are but a few of the questions suggesting them- selves to my mind, to which, as chance affords, you could direct your attention. In a ten or fifteen years' service, traveUing with seemg eyes and hearmg ears, and carefuUy- kept note-books, just think what a store house of climcal material may be at the command of any one of you- material not only valuable in itself to the profession, but of infinite value to you personally in its acquisition, render- ing you painstaking and accurate, and giving you, year by year, an increasing experience of the sort to which I have already more than once referred. In what I have said hitherto I have dwelt chiefly on your personal development, and on the direction in which your activities might be engaged, but while you are thus laying the foundation of an education in all that relates to the technical side of ;-e profession, there are other duties which caU for a word or two. In the commumties to which you may be sent do not forget that, though army officers, you owe allegiance to an honourable pro- fession, to the members of which you are linked by ties of a most binding character. In situations in which the advantages of a more critical training give you a measure 116 i THE ARMY SURGEON of superiority over your confrires in civil life, let it not be apparent in your demeanour, but so order yourselves that in all things you may appear to receive, not to grant favours. There are regions, in partihus infiddium, to which you will go as missionaries, carrying the gospel of loyalty to truth in the science and in the art of medicine, and your lives of devotion may prove to many a stimu- lating example. You cannot afford to stand aloof from your professional colleagues in any place. Join their associations, mingle in their meetings, giving of the best of your talents, gathering here, scattering there; but everywhere showing that you are at all times faithful students, as willing to teach as to be taught. Shun as most pernicious that frame of mind, too often, I fear, seen in physicians, which assumes an air of superiority and limits as worthy of your communion only those with satisfactory collegiate or sartorial credentials. The pass- ports to ycuT fellowship should be honesty of purpose and a devotion to the highest interests of our profession, and these you will find widely diffused, sometimes appa-ent only when you get beneath the crust of a rough exterior. If I have laid stress upon the more strictly professional aspects of your career it has been with a purpose. I believe tho arrangements in the departm-^nt are such that, witft habit jf ordinary diligence, each one of you may attain not only a high grade of personal development, but may become an important contributor in the advance- ment of OUT art. I have said nothing of the pursuit of the sciences cognate to medicine, of botany, zoology, geology, ethnology nnd archaeology. In every one of these, so fascinating in themselves, it is true that army 117 I >f I' i M I ' THE ARMY SURGEON medical offioen have risen to distinction, bat I claim that your first duty is to medicine, which should have your best services and your loyal devotion. Not, too, in the perfunctory discharge of the daily routine, but in zealous endeavour to keep pace with, and to aid in, the progress of knowledge. In this way you will best serve the depart- ment, the profession, and the public. Generalities, of the kind in which I have been indulging, though appropriate to the occasion, are close kin, I ^eP", to the fancies fond, that vanish like the gay motes which float for a moment in the sunbeams of our mind. But I would fain leave with you, in closing, something of a more enduring kind— a picture that for me has always had a attraction, the picture of a man who, amid cu. ^s the most unfavourable, saw his opportunity u i quick to " grasp the skirts of happy chance." Far away in the northern wilds, where the waters of Lake Michigan and Lake Huron unite, stands the fort of Michilimackinac, rich in memories of Indian and voyageur, one of the four important posts on the upper lakes in the days when the Rose and the Fleur-de-lis strove for the mastery of the Western worid. Here was the scene of Marquette's mission, and here beneath the chapel of St. Ignace they laid his bones to rest. Here the intrepid La Salle, the brave Tonty, and the resolute Du Lhut had halted in their wild wanderings. Its palisades and bastions had echoed the war-whoops of Ojibwas and Ottawas, of Hurons and Iroquois, and had been the scene of bloody massacres and of hard-fought fights. At the conplusion of the war of 1812, after two centuries of struggle, peace settled at last upon the old fort, and 118 m^t THE ARMY SURGEON early in her reign celebrated one of the most famous of her minor victories, one which carried the high-sounding name of Michilimackinac far and wide, and into circles where Marquette, Du Lliut and La Salle were unknown. Here, in 1820, was assigned to duty at the fort, which had been continued in use to keep the Indians in check. Surgeon William Beaumont, then a young man in the prime of life. On June 22, 1822, the accidental discharge of a musket made St. Martin, a voyageur, one of the most famous subjects in the history of physiology, for the wound laid open his stomach, and he recovered with a permanent gastric fistula of an exceptionally favourable kind. Beau- mont was not slow to see the extraordinary possibilities that \7ere before him. Early in the second decade of the century the process of gastric digestion was believed to be due to direct mechanical maceration or to the action of a vital principle, and though the idea of a solvent juice had long been entertained, the whole question was sub judice. The series of studies made by Beaumont on St. Martin settled for ever the existence of a solvent fluid capable of acting on food outside as well as within the body, and in addition enriched our knowledge of the processes of digestion by new observations on the move- ments of the stomach, the temperature of the interior of the body, and the digestibility of the various articles of food. The results of his work were published in 1833, in an octavo volume of ^ss than 300 pages.' In looking through it one cannot but recognize that it is the source » Experimenta and Observations on the Oaatrie Juice and the Physiology of Digestion. By William Beaumont. M.D., Surgeon in the United Statea Armv- Plattsburg. 1833. 119 1 !' U w i r" THE ARMY SURGEON of a very large part of the current statements about digestion ; but apart altogether from the value of the facts, there are qualities about the work which make it a model of its kind, and on every page is revealed the character of the man. From the first experiment, dated August 1, 1825, to the last, dated November 1, 1833, the observa- tions are made with accuracy and care, and noted in plain, terse language. A remarkable feature was the persistence with which for eight years Beaumont pursued the subject, except during two intervals when St. Martin escaped to his relatives in Lower Canada. On one occasion Beaumont brought him a distance of two thousand miles to Fort Crawford, on the upper Mississippi, where, in 1829, the second series of experiments was made. The third series was conducted in Washington, in 1832 ; and the fourth at Plattsburg in 1833. The determination to sift the question thoroughly, to keep at it persistently until the truth was reached, is shown in every one of the 238 experiments which he has recorded. The opportunity presented itself, the observer had the necessary mental equipment and the needed store of endurance to carry to a successful termination a long and laborious research. William Beaumont is indeed a bright example in the annab of the Army Medical Department, and there is no name on its roll more deserving to live in the memory of the profession of this country. And in closing let me express the wish that each one of you, in all your works begun, continued and ended, may be able to say with him: "Truth, like beauty, ' when unadorned is adorned the most,' and in prosecuting experiments and inquiries I believe I have been guided by its light." 120 f 1! vn TEACHING AND THINKING I I 131 L«t us then blush, in this so ample and so wonderful field of L«t UB men uiuoi , „xop«wia what is promised), to 'leaner liiigs to higher, we shall at length 1. rooe.ved mto her Ooset-^r^te^ to Anatomical ExmiMions concerning the Generation of Lirnng Creatures. 1653. ^^^^ ^^^^ 122 '•i: vn TEACHING AND THINKING ' The Two Func OF A Medical School \ i MANY things have been urged against our nineteenth century civilization — that political enfranchise! ment only ends in anarchy, that the widespread unrest in spiritual matters leads only to unbelief, and that the best commentary on our boasted enlightenment is the picture of Europe in arms and the nations everywhere gnarring at each other's heels. Of practical progress in one direction, however, there can be no doubt ; no one can dispute the enormous increase in the comfort of each individual life. Collectively the human race, or portions of it at any rate, may in the past have enjoyed periods of greater repose, and longer intervals of freedom from strife and anxiety ; but the day has never been when the unit has been of such value, when the man, and the ^an alone, has been so much the measure, when the individual as a living organism has seemed so sacred, when the obligations to regard his rights have seemed so imperative. But even these changes are » McGill Medical School, October 1, 1894. 123 I J TEACHING AND THINKING as nothing in comparison with the ^^^^ff^^^'^^^.^ his physical weU-being. The bitter cry of Isaiah that with the multiplication of the nations their joys had not been increased. stiU echoes in our ears. The sorro^ and troubks of men. it i. - .. may not have been ^-^^^^^ ^"^"^^^ but bodUy pain and sufiering. though not abolished, have been assuaged as never before, and the share of each m the Wdtschmerz has been enormously lessened. Sorrows and griefs are companions sure sooner or later to join us on our pilgrimage, and we have become perhaps more sensitive to them, and perhaps less amenable to he old time remedies of tte physicians of the soul : but the pains and woes of the body, to which we doctors mimster L decreasing at an extraordinary rate, and m a way that makes one fairly gasp in hopeful anticipation. In his Gramtmr of AsserU, in a notable passage on suffering, John Henry Newman asks. " Who can weigh and measure the aggregate of pain which this one generation has endured, and will endure, irom birth to dea h ? Then add to this aU the pain which has fallen and will fall upon our race through centuries past and to come But take the other view of it-think of the Nemesis which has over- taken pain during the past fifty years ! Anesthetics and antiseptic surgery have almost manacled the demon and since their introduction the aggregate of pam which _ as been prevented far outweighs in civUized commumties that which has been suffered. Even the curse of travail has been lifted from the soul of women. The greatest art is in the concealment of art, and 1 may say that we of the medical profession excel in this respect. You of the pubUc who hear me. go about the duties of the 124 TEACHING AND THINKING day profoundly indifEerent to the facts I have just men- tioned. You do not know, many of you do not care, that for the cross-legged Juno who presided over the arrival of your grandparents, there now nits a benign and straight- legged goddess. You take it for granted that if a shoulder is dislocated there is chloroform and a delicious Ne^ onthe instead of the agony of the pulleys and paraphernalia of fifty years ago. You accept with a selfish complacency, as if you were yourselves to be thanked for it, that the arrows of destruction fly not so thickly, and that the pestilence now rarely valketh in the darkness; stiix less do ycu realize that you may now pray the prayer of Hezekiah with a reasonable prc.pect of its fulfilment, since modern science has made to almost everyone of you the present of a few years. I say you do not know these things. You hear of them, and the more intelligent among you perhaps ponder them in your hearts, but they are among the things which you take for granted, like the sunshine, and the flowers and the glorious heavens. 'Tis no idle challenge which we physicians throw out to the world when we claim that our mission is of the highest and of the noblest kind, not alone in curing disease but in educating the people in the laws of health, and in preventing the spread of plagues and pestilences ; nor can it be gain- said that of late years ov.r record as a body has been more encouraging in its practical results than those of the other learned professions. Not that we all live up to the highest ideals, far from it — we are only men. But we have ideals, which mean much, and they are realizable, which means more. Of course there are Gehazis among us who 125 N TEACHING AND THINKING serve for shekels, whose ears hear only the lowing of the oxen and the jingling of the guineas, but these are excep- tions. The rank and file labour earnestly for your good, and self-sacrificing devotion to your interests animates our best work. The exercises in which we are to-day engaged form an incident in this beneficent work which is in progress everywhere; an incident which will enable me to dwell upon certain aspects of the university as a factor in the promotion of the physical veil-being of the race. II A great university has a dual function, to teach and to think. The educational aspects at first absorb all its energies, and in equippmg various departments and pro- viding salaries, it finds itself hard pressed to fulfil even the first of these duties. The story of the progress of the medical school of this institution illustrates the struggles and difficulties, the worries and vexations attendant upon the effort to place it in the first rank as a teaching body. I know them well, since I was in the thick of them for ten years, and see to-day, the realization of many of my day- dreams. Indeed in my wildest flights I never thought to s»e such a splendid group of buUdings as I have just inspected. We were modest in those days, and I remember when Dr. Howard showed me in great confidence the letter of the Chancellor, in which he conveyed his first generous bequest to the Faculty, it seemed so great that in my joy I was almost ready to sing my Num dimUtis. The great advances here, at the Montreal General Hospital, and at the Royal Victoria (both of which institutions form most 126 TEACHING AND THINKING easential parts of the medical schools of this city) mean increased teaching facilities, and of necessity better equipped graduates, better equipped doctors! Here is the kernel of the whole matter, and it is for this that we ask the aid necessary to build large laboratories and large hospitals in which the student may learn the science and art of medicine. Chemistry, anatomy and physiology give that perspective which enables him to place man and his diseases in their proper position in the scheme of life, and afford at the same time that essential basis upon which alone a trustworthy experience may be built. Each one of these is a science in itself, complicated and difficult, demanding much time and labour for its acquisition, so that in the few years which are given to their study the student can only master the principles and certain of the facts upon which they are founded. Only so far as they bear upon a due understanding of the phenomena of disease do these subjects form part of the medical curriculum, and for us they are but means — essential means it is true — to this end. A man cannot become a competent surgeon without a full knowledge of human anatomy and physiology, and the physician without physiology and chemistry flounders along in an aimless fashion, never able to gain any accurate conception of disease, practising a sort of pop- gun pharmacy, hitting now the malady and again the patient, he himself not knowing which. The primary function of this department of the univer- sity is to instruct men about disease, what it is, what are its manifestations, how it may be prevented, and how it may be cured ; and to learn these things the four hundred young men who sit on these benches have come from all parts of 127 TEACHING AND THINKING the land. But it iB no light r-ponribiUty "If ^ » f"d^ tl« in thi. matter. The t«k is be»t w>th d.fflo«H «. rlinherent in the object ^^^^l^^Z^ Mlve. while not a lew are oaneed by the laoK oi ™'™' «^in medioal matte™ of the people among whom we '^C;:L. 0. ai«.« are eo complex that it i. e^- rively Leult to .».teh out the law, which control them r^ aSugh we have eeen a complete evolution m our Z. wha^has been accomplished by the new school of Se is only an earnest o. what the titure h» .n^«. The three jreat advances of the century has been a know Xrhe'LodeofcontroUingepidemicdise.ses.them^ dSon of anit helpful ; there is much to stimulate the mind at the old Pemisylvania Hospital and at the University, and he would be none the wor^ for a few weeks spent still farther south on the banks of the Chesapeake. The aU-important matter is to ge breadth of view as early as possible, and this is difficult without travel. Poll the successful consulting physicians of this country to-day, and you will find they have been evolved either from general practice or from laboratory and clinical work : many of the most prominent having risen from the ranks of general practitioners. I once heard an eminent con- sultant rise in wrath because some one had made a remark reflecting upon this class. He declared that no single part of his professional experience had been of such value. But I wish to speak here of the training of men who start with the object of becoming pure physicians. From the vantage ground of more than forty years of hard work. Sir Andrew Clark told me that he had striven ten years for bread, ten years for bread and butter, and twenty years for cakes and ale ; and this is really a very good partition of the life of the student of internal medicine, of some at least, since all do not reach the last stage. 142 ■■A INTERNAL MEDICINE AS A VOCATION It is high time we had our young Lydgatc started.' If he has shown any signs of nous during hlo student and hospital days a dispensary assistantship should be avail- able ; anything should be acceptable which brings him into contact with patients. By all means, if possible, let him be a pluralist, and — as he values his future life — let him not get early entangled in the meshes of specialism. Once established as a clinical assistant he can begin his education, and nowadays this is a very complicated matter. There are three lines of work which he may follow, all of the most intense interest, all of the greatest value to him — chemistry, physiology, and morbid anatomy. Professional chemists look askance at physiological chemistry, and physiological chemists criticize pretty sharply the work of some clinical chemists, but there can be no doubt of the value to the physician of a very thorough training in methods and ways of organic chemistry. We sorely want, in this coimtry, men of this line of training, and the outlook for them has never before been so bright. If at the start he has not had a good chemical training, the other lines should be more closely followed. Physiology, which for him will mean very largely ex- perimental therapeutics and experimental pathology, will open a wider view and render possible -•, deeper grasp of the problems of disease. To Traube and men of his stamp, the physiological clinicians, this generation owes much more than to the chemical or post-mortem'ioom group. The training is more difficult to get, and now- i This well-drawn character in George Eliot's Middlemarch may be studied with advantage by the physician ; one of the most imponant lessons to be gathered from it ia — marry the right woman ! 143 1^^ v\ m It. M i i. INTERNAL MEDICINE AS A VOCATION ^y,. ,h.a phyriology i. o«ltiv.t,d « » -ri^^u! Lm the labo^tory. On the otto hand, *« «»« Zutie. lot work are now mo« num«ou., and the tram r:t:ch° a .onn« . -k"" "^ U»ch practical medicine to the l«ge cl.»e, •, how t„ g.ve Zl protracted and .y.tematie ward .n.truct.on ? I ^. li no teacher in the country who control, eno^ eUnical material tor the instruction of ela^. «y o. 200 rr„ during the third and fourth year.. It «em. ■• me that there are two plan, open to the -1>°* ."J I to utai« di.pen.arie, for clinical m..ruct,on much 1^ than i. at pre^nt the rule. For ■.,„ purpo.c a Chil^room for 'a c! .. of twenty-ave or '^^^^ immediately adjoining the di.pen.ary .. e.«;nt>al. For r^L'n pLy.lc^ aiagno.i., for the obicet.^ trac- ing of diMa.e, and for he in.truct,on of .tudent. .n the Z of their sen.., .uch an arrangement .. .nv^u^ble^ There are hundred, of di.pcn.ane. m '"■* ^^ ;. U fea.ible, and in which the matenal no. >s not pro rl,^ •orkcd up beoauM of the lack oi this vs;; 5..un.!.tt.. 146 i 1 I INTERNAL MEDICTNF A.< A VOCATION the second place. I feel sure tha+ ultima ♦'ly we shall d*"- velop a system • f extra-mural 'oachin similar t^o that which has been ^o successful Ed. urgh ; md thi« will give employment to n large number of thi 'ounger men. M any large university si ■ ool of medicii ^ there might be four or *ive extra-mural teachers of medicine, selected from men who could show that they were fully qualified to teach and that they had a sufficient number of beds at their commarid with proper equipment for clinical work. At Rdinbursh there are eight extra-mura teachers of internal medicine whose courses jualify the studen* to present himself for examination either before the R* val Colleges or the University. If we e er are to give amr third and fourth year studei i pro'^ -acted and comple' courses in physical diagnosis and clinical nx dicin> ax- tendinc throughout the session, and not in cL^asep >i a brief period of six v^ceks' dnjation, I am con; ler ths^ the number of men engaged in teaching must greatly increased. IT Ten years' * ard -^ork tells with colleagut an fn^r-is in the professi' and with <"nlarged clinical ae ].hy8ician ent< rs upon the cond, or bre -butter period. This, o most m*»n, is the jn-eat tnai 51 e the risks are greater, and many uow (iro[. out of th* race, wearied at the length of the way and drift into specialism or general practice. The physician develops more slowly than the surgeor- and success comes later There are surgeons at forty year in full practice auu it the very top of the wave, a ti: 3 at which the phj^ician is only 147 INTERNAL MBDICTNE AS A VOCATION „«™ring to reap the harvest of year, ol patient tod Thfrton mJ have hancU, and better, young hands. He , Shave a head, too, hut this doe. not e«m « fln« to .ueoe«, and he cannot have an old head wrth vtlhanda. At the end oltwenty years, when about orty Cour Lydgateshould have a first-class reputahon m the pXon.'a^d a large circle o. friends and s^e^- He L „fobably have precious little capital m the bank, but T.^Tl accuiuation of inter.st.be«ing funds «. his tain.pfn. He has gathered a stock of "P^-l ^■'°- lie which his friends in the profession apprec-ate, and ty begin to seek his counsel - doubtfal case, and griually learn to lean upon hm » "»» °' '"^ ^ may awake some day. perhaps, quite suddenly, to tod It twenty years of quiet work, done for the love of it, has a very solid value ^^^ ^ ^^^ The environment of a large ciiy w "" Jwth of a good clinical physician. Even m small towns iTln can if he has it in him, become weU versed m len o" work, and with the assistance of an o^™« visit to some medical centre he can become an expert H6«l Dieu, ha. just gone. He wroU askmg me for 148 INTERNAL MEDICINE AS A VOCAT ^ letter of advice, from which I take the liberty of extract- ing one or two paragraphs : — "Your training warrants a high aim. To those who ask, say that you intend to practise medicine only, and will not take surgical or midwifery cases. X. has promised that you may help in the dispensary, ana as you can count blood and percuss a cheat you will be useful to him in the wards, which, by the way, he now rarely visits. Be careful with the house physicians, and if you teach them anything do it gently, and never crow when you are right. The crow of the young rooster before his spurs are on always jars and antagonizes. Get your own little clinical laboratory in order. Old Dr. Rolando will be sure to visit you, and bear with him as he tells you how he can tell casts from the ascending limb of the loop of Henle. Once he was as you are now, a modern, twenty years ago ; but he crawled up the bank, and the stream has left him there, Ijut he does not know it. He means to impress you ; be civil and show him the new Nissl- stain preparations, and you will have him as a warm friend. His good heart has kept him with a large general practice, and he can put post-mortetns in your way, and may send for you to sit up o' nights with his rich patients. If Y. asks you to help in the teaching, jump at the chance. The school is not what you might wish, but the men are in earnest, and a clinical microscopy-class or a voluntary ward-class, with Y.'s cases, will put you on the first rung of the ladder. Yes, join both the city and the county society, and never miss a meeting. Keep your mouth shut too, for a few years, paHicularly in discussions. Let the old men read new books ; you read the journals 149 INTERNAL BIEDTCINE AS A VOCATION and the old books. Study LaSrmec this winter ; ForWa Translation can be cheaply obtained, but it wiU help to keep up your French to read it in the original. The old Sydenham Society editions of the Greek writers and of Sydenham are easUy got and are reaUy very helpful. Aa a teacher you can never get orieniirt without a knowledge of the Fathers, ancient and modem. And do not forget, above aU things, the famous advice to Blackmore, to whom, when he first began the study of physic, and asked what books he should reul, Sydenham replied, Don QutxoU meaning thereby, as I take it. that the only book o physic suitable for permanent reading is the book ol Nature." A young fellow with staying powers who avoids entangle- ments, may look forward in twenty yearn to a good con- sultation practice in any town of 40.000 to 50,000 m- habitants. Some such man. perhaps, in a town far distant, taking care of his education, and not of his bank book, may be .he Austin Flint of New York in 1930. " Many are called, but few are chosen," and of the many who start out with high aims, few see tha goal. Even when reached the final period of " cakes and ale " has serious drawbacks. There are two groups of consultants, the intra- and the extra-professional ; the one gets work through his colleagues, the other, having outgrown the narrow limits of professional reputation, is at the mercy of the profanum vul^us. Then for him " farewell the tranquil mind, fareweU content." His life becomes an incessant struggle, and between the attempt to carry on an exhausting and irksome practice, and to keep abreast with young fellows still in the bread-and-butter stage, 150 ■MiMiili X '■ i '^i INTERNAL MEDICINE AS A VOCATION the consultant at this period is worthy of our sincerest sympathy. One thing may save him. It was the wish of Walter Savage Landor always to walk with Epicurus on the right hand and Epictetus on the left, and I would urge the clinical physician, as he traveb farther from the East, to look well to his companions— to see that they are not of his own age and generation. He must walk with the " boys," else he is lost, irrevocably lost ; not all at once, but by easy grades, and every one perceives his ruin before he, " good, easy man," is aware of it. I would not have hint a basil plant, to feed on the brains of the bright young fellows who follow the great wheel uphill, but to keep his mind receptive, plastic, and impressionable he must travel with the men who are doing the work of the world, the men between the ages of twenty-five and forty. In the life of every successful physician there comes the temptation to toy with the Delilah of the press— daily and otherwise. There are times when she may be courted with satisfaction, but beware ! sooner or later she La sure to play the harlot, and has left many a man shorn of his strength, viz., the confidence oi his professional brethren. Not altogether with justice have some notable members of our profession laboured under the accusation of pan- dering too much to the public. When a man reaches the climacteric, and has long passed beyond the professional stage of his reputation, we who are still " in the ring " must exercise a good deal of charity, and discount largely the on dits which indiscreet friends circulate. It cannot be denied that in dealings with the public just a little touch of humbug is immensely effective, but it is not 151 INTERNAL MEDICINE AS A VOCATION aecc«»ry. In a large city there were three eminent consultants of world-wide reputation; one was said to be a good physician but no humbug, the second was no physician but a great humbug, the third was a great physician and a great humbug. The first achieved the greatest success, professional and social, possibly not financial. While living laborious days, happy in his work, happy in the growing recognition which he is receiving from his coUeagues, no shadow of doubt haunts the mind of the young phvsician, other than the fear of failure ; but I warn him to cherish the days of his freedom, the days when he can follow his bent, untrammeled, undisturbed, and not as yet in the coils of the octopus. In a play of Oscar Wilde's one of the characters remarks, " there are only two great tragedies in life, not getting what you want- and getting it ! " and I have known consultants vihose treadmill life illustrated the bitterness of this mot, and whose great success at sixty did not bring the comfort they had anticipated at forty. The mournful echo of the words of the preacher rings in their ears, words which I not long ago heard quoted with deep feeling by a dis- tinguished physician, " Better is an handful with quietness, than both the hands full Nvith travail and vexation of spirit." \ 162 IX 'I I NURSE AND PATIENT iw i l«ud.IwiUtakeheedtomywayB. that I offend not in my ^nJSi keep my mouth a8 it were with a bridle^^ ^^ ^^ ^ If thou hast heard a word, let it die with thee ; and be bold. it wiU not burst thee. ecclksusticxts xix. 10. Lo, in the vale of years beneath A grisly troop are seen. The painful family of death. More hideous than their queen : This racks the joints, this fires the vems. That every labouring sinew strains. Those in the deeper vitala rage : ^^^^^ ^^^^ H .1 154 IX If NURSE AND PATIENT ' THE trained nurse as a factor in life may be regarded from many points of view— philanthropic, social, personal, professional and domestic. To her virtues we have been exceeding kind— tongues have dropped manna in their description. To her faults— well let us be blind, since this is neither the place nor the time to expose them. I would rather call your attention to a few problems connected with her of interest to us collectively,— and individually, too, since who can tell the day of her coming. la she an added blessing or an added horror in our be- ginning civilization? Speaking from the point of view of a sick man, I take my stand firmly on the latter view, for several reasons. No man with any self-respect cares to be taken off guard, in mufti, so to speak. Sickness dims the eye, pales the cheek, roughens the chin, and makes a man a scarecrow, not fit to be seen by his wife, to say nothing of a strange woman all in white or blue or gray. Moreover she will take such unwarrantable liberties with a fellow, particularly if she catches him with fever ; then her special virtues could be depicted by King Lemuel alone. So far as she is concerned you are again in swathing bands, > Johns Hopkins Hospital, 1897. 165 NURSE AND PATIENT and in her hands you are, as of yore, a helpless lump of human clay. She will stop at nothing, and between baths and spongings and feeding and temperature-taking you are ready to cry with Job the cry of every sick man — " Cease then, and let me alone." For generations has not this been his immemorial pri^nlege, a privilege with vested rights as a deep-seated animal instinct — to turn his face toward the wall, to sicken in peace, and, if he so wishes, to die undisturbed ? All this the trained nurse has, alas ! made impossible. And more, too. The tender mother, the loving wife, the devoted sister, the faithful friend, and the old servant who ministered to his wants and carried out the doctor's instructions so far as were consistent with the sick man's wishes— all, all are gone, these old familiar faces ; and now you reign supreme, and have added to every illness a domestic complica^^icn of which our fathers knew nothing. You have upturned an inalienable right in displacing those whom I have just mentioned. You are intruders, innovators, and usurpers, dislocating, as you do, frcn theur tcnderest and most loving duties these mothers, wives and sisters. Seriously, you but lightly reck the pangs which your advent may cause. The handing over to a stranger the care of a life precious beyond all computation may be one of the greatest earthly trials. Not a little of all that is most sacred is sacrificed to your greater skill and methodical ways. In the com- plicated fabric of modern society both our nursing and our charity appear to be better done second-hand, though at the cost in the one case as in the other of many Beatitudes, links of that golden chain, of which the poet sings, let down from heaven to earth. 15G H NURSE AND PATIENT Except in the warped judgment of the sick man, for which I have the wannest sympathy, but no respect, you are regarded as an added blessing, with, of course, certain limitatioi.^. Certainly you have made the practice of medicine easier to the physician ; you arc more than the equivalent of the old two hourly doses to a fever patient ; and as the public grows in intelligence you should save in many instances the entire apothecary's bill. In his chapter on Instinct, in the Origin of the Species, Dar- win gives a graphic account of the marvellous care-takmg capacity of the little Formica fusca-a slave ant. One of these " introduced into a company of her masters who were helpless and actually dying for lack of assistance, instantly set to work, fed and saved the survivors, made some cells, and tended the larvae and put all to rights. Vta aU to riqUs ! How often have I thought of this ex- pression and of this incident when at your word I have seen order and quiet replace chaos and confusion, not alone in the sick-room, but in the household. As a rule, a messenger of joy and happiness, the trained nurse may become an incarnate tragedy. A protracted illness, an attractive and weak Mrs. Ebb-Smith as nurse, and a weak husband— and all husbands are weak— make fit elements for a domestic tragedy which would be far more common were your principles less fixed. WhUe thus a source of real terror to a wife, you may become a more enduring misery to a husband. In our huni.-d progress the weak-nerved sisters have suffered surely, and that deep mysterious undercurrent of the emotions, which flows along silently in each one of us, is apt to break out in the rapids, eddies and whirls of hysteria 157 K- NURSE AND PATIENT or neurasthema. By • finely measured sympathy and . wiw combination of affection with firmness, you gam the fuU confidence of one of these unfortunates, and b«rome to her a rock of defence, to which she clings, and without which she feels again adrift. You become e«^ntml m her life, a fixture in the family, and at times a dark shadow between husband and wife. As one poor victun expressed it. " She owns my wife body and soul, and. so far as I am concerned, she has become the equivalent of her disease. Sometimes there develops that occult attraction between women, only to be explamed by the theory of Aristophanes as to the origin of the race ; but usuaUy it grows out of the natural leaning of the weak upon the strong, and m the nurse the wife may find that " stern strength and pro- mise of control " for which in the husband she looked m vain. , ., To measure finely and nicely your sympathy m these cases is a very deUcate operation. The individual tempera- ment controls the situation, and the more mobile of you wiU have a hard lesson to learn in subduing your emotions. It is essci tial, however, and never let your outward action demonstrate the native act and figure of your heart. You are lost irrevocably, should you so far give the rems to your feelings as to " ope the sacred source of sympathetic tears " Do enter upon your duties with a becoming sense of your frailties. Women can fool men always, women only sometimes, and it may be the lot of any one of you to be such a castaway as the nurse of whom I was told a few weeks ago. The patient was one of those Alphonsine Plessis-'Ae creatures whom everybody had to love, and for whom the primrose path of dalliance had 168 NURSE AND PATIENT ended in a rigid rett cure. After three weary months she was sent to a quiet place in the mountains with the more sedate of the two nurses who had been with her. ^Lm Blank had had a good training and a large experience, and was a New England urom&n of the very best type. Alas ! hers the greater fall ! An accomplishment of this siren, which had produced serious symptoms, was excessive cigarette smoking, and Dr. had strictly forbidden tobacco. Three weeks later, my informant paid a visit to the secluded resort, and to his dismay found patient and nurse on the verandah enjoying the choicest brand of Egyptian cigarette ! While not the recipient of all the wretched secrets of life, as are the parson and the doctor, you will frequently be in households the miseries of which cannot be hid, all the cupboards of whicj are open to you, and you become the involuntary possessor of 'he most sacred confidences, known perhaps to no other soul. Nowadays that part of the Hippocratic oath which enjoins secrecy as to the things seen and heard among the sick, should be administered to you at graduation. Printed in your remembrance, written as headlines on the tablets of your chatelames, I would have two maxims : " I will keep my mouth as it were with a bridle," and " If thou hast heard a word let it die with thee." Taciturnity, a discreet silence, is a virtue little cultivated in these garru- lous days when the chatter of the bander-log is every- where about us, when, as some one has remarked, speech has taken the place of thought. As an inherited trait it is perhaps an infirmity, but the kind to which I refer is an acquired faculty of infinite value. Sir Thomas 159 i ii ( if 4 m N NDE8E AND PATIENT b™-„. d«w th. dutinction nicly when kt^ "i*. " '^^"^ T^^ZTt^ ™dom ol looU, but, ii rightly ..m«J, :::^rJ.:rten, Who have not the «b„t the virtue of taeitumity."-th. talent for «lence Crlyl. "Itog. medical .nd grue^me have a ,ingul,.r attraction lor rn^fy people, and in the oy day. °' -"— i; boUe-tongued nur« may be W on to tell of movrng • J ,." in ward or theatre, and once untied, that Ta™ Jn o! event.. To Ulk of di«.«. U a «.rt of Arab^n Ni^f entertainment to which no d.»r.et nur« v,^, Ipnd her talents. . Wil the growth of one abominabk pracfce m recent dl I am nTt certain you have anything to do, thou h I Le heard your name mentioned i"."-""-™'"* 't I refer to the habit of openly di«u»mg adment. which h^u^ never be mentioned. Doubtle.. it Una mea.ure t reedt of the di.gu.ting publicity in wbch we l.ve, andrthepemiciouehabHofaUowingthefilthoftheguter. , a. preyed in the newpaper. to pollute the stream of our ^y live.. ThUopen talk about per«>m>l mdadje. u an ^i„„. breach of good manner.. Not a month ago, I h~o women, both taUor-made, who .at oppo..te ^ mTin a .treet-car, compare note, on ' » —« in Fulvian accent, audible to everyone. I have heard a "ung woman at a dinner-table relate expenencc. which ler Ither would have bluebcd to have told to the fanuly plyli^.. Everything nowaday, i. proclaimed from the t^!top., among them our Uttle bodily woe. and worr,«. Z i. a^ lap« from the go»J old pracfce ol our grand- 160 NURSE AND PATIENT ffttken, of which Oco^e Sand write*, " People knew how to live and die in thoae days, and k^'pt their iixfinnitiea out of sight. You might have the goitt, but you mu«t walk about all the same without making grimace? It was a point of good breeding to hido one sufiermg." We doctors are great sinners in this manner, and among ourselves and with the laity are much too fond oi " Ulkuig shop." To anotuer danger I may refer, now that I have waxed bold. With the fullest kind of training you cannot escape from the perib of half-knowledge, of pseu.io science, that most fatal and common of mental states. In your daily work you involuntarily catch the accents and learn the language of science, often without a clear conception of its meaning. I turned mcidentally one day to a very fine example of the nurse learned and asked in a humble tone what the surgeon, whom I had failed to meet, had thought of the case, and she promptly replied that " he thought there were features suggestive of an intra- canalicular myxoma ; " and when I looked anxious and queried, " had she happened to hear if he thought it had an epiblastic or mesoblastic origin ? " this daughter of Eve never flinched ; " mesoblastic, I believe," was her answer. She would have handed sponges— I mean gauze — with the same sang froid at a Waterloo It must be very difficult to ie.iit the fascination of a desire to know more, much more, of the deeper depths of the things you see and hear, and often this ignorance must be very tantalizing, but it is more wholesome than an assurance which rests on t thin veneer of knowledge. A friend, a distinguished surgeon, has written, in the AS. 161 M NURSE AND PATIENT Lady Priestley vein, an essay on " The Fall of the Trained Nurse," which, so far, he has very wisely refrained from publishing, but he has permitted me to make one extract for your delectation. " A fifth common decleniion is into the bonds of marriage. The facility with which these modem Vestals fall into this commonplace condition is a commentary, shall I not say rather an illustration, of the inconsistency so notorious in the sex. The Association of Superintendents has in hand, I believe, a Collective Inves- tigation dealing with this question, and we shall shortly have accurate figures as to the percentage of lady super- intendents, of head-nurses, of graduates and of pupils who have bartered away their heritage for a hoop of gold." I am almost ashamed to quote this rude paragraph, but I am glad to do so to be able to enter a warm protest against such sentiments. Marriage is the natural end of the trained nurse. So truly as a young man married is a young man rcarred, is a woman unmarried, in a certam sense, a woman undone. Ideals, a career, ambition, touched though they be with the zeal of St. Theresa, all vanish before " the blind bow-boy's butt shaft." Arc you to be blamed and scoffed at for so doing ? Contrari- wist', you are to be praised, with but this caution— which I insert a* the special request of Miss Nutting— that you abstain from piiilandering during your period of training, and, as much as in you lies, spare your fellow-workers, the physicians and surgeons of the staff. The trained nurse is a modern representative, not of the Roman Vestal, but of the female guardian in Pluto's republic— a choice selection fiom the very best women of the community, who know the laws of health, and whose sympathies have 1G2 n NURSE AND PATIENT 3 been deepened by contact with tue best and worst of men. The experiences of hospital and private work, while they may not make her a Martha, enhance her value in many way? as a life-companion, and it is a cause, not for re- proach, but for congratulation, that she has not acquired immunity from that most ancient of all diseases — that malady of which the Rose of Sharon sang so plaintively, that sickness '* to be stayed not with flagons nor comforted .rith apples." A luxury, let us say, in her private capacity, in public the trained nurse has become cue of the great blessings of humanity, taking a place beside the physician and the priest, and not inferior to cither in her mission. Not that lier calling here is in any way new. Time out of mind she lias made one of a trinity. Kindly lioada have always been ready to devise means for allaying suffering ; tender hearts, surcharged with the miseries of this " battered caravanserai," hav<; ever been ready to speak to the sufferer of a way of peace, and loving hands have ever ministered to those in sorrow, need and sickness. Nursing as an art to be cultivated, as a profession to be followed, is mcxlern ; nursing as a practice originated in the dini past, when somo mother among the cave-dwellers cooled the forehead of her sick child with water from the brook, or first yielded to the prompting to leave a well-covered bone and a handful of meal by the side of a wounded man left in the hurried flight before an enemy. As a profession, a vocation, nursing has already reached in this country a high develop- ment. Graduates arj numcro'is, the directories are full, and in many places there is over-crowding, and a serious complaint that even very capable v.'omen find it hard to 103 I I '! NURSE AND PATIENT get employment. This wiU correct iteelf in time, m the eziBting conditions adjust the supply and demand. A majority oi the appUcants to our schools are women who seek in nursmg a vocation in which they can gam a UveUhood in a womanly way ; but there is another aspect of the question which may now be seriously taken up m this country. There is a graduaUy accumulating surplus of women who will not or who cannot fulfil the highest duties for which Nature has designed them. I do not know at what age one dare caU a woman a spinster. I will put it. perhaps rashly, at twenty-five. Now. at that cntical period a woman who has not to work for her Uving. who is without urgent domestic ties, is very apt to become a dangerous element unless her energies and emotions are diverted in a proper channel. One skilled in hearts can perhaps read in her face the old. old story ; or she caUs to mind that tender verse of Sappho— Ab the sweet-applo bluBhoe on the end of th« bough, the very end of the bough, which the gatherer* overlooked, nay overlooked not but couW not reach. But left alone, with splendid capacities for good, she is apt to fritter away a precious life in an aimless round of social duties, or in spasmodic efforts at Church work. Such a woman needK a vocation, a calling which wiU satisfy her heart, and she should be able to find it in nursmg without entering a regular school or working in ecclesiastical harness. An organized nursing guUd. simUar to the German Deaconesses, could undertake the care of large or small institutions, without the establishment of training schooU 164 NURSE AND PATIENT m the ordinary sense of the term. Such a guild might be entirely secular, with St. James, the Apostle of practical i-eligion, as the patron. It would be of special advantage to smaller hospitals, particularly to those un- attacaed to Medical Schoob, and it would obviate the existmg anomaly of scores of training schools, in which the pupils cannot get an education in any way com- mensurate with the importance of the profession. In the period of their training, the members of the Nursing Guild could be transferred from one institution to another until their education was complete. Such an organization would be of inestimable service in connexion with District Nursing. The noble work of Theodore Fliedner should be repeated at an early day in this country. The Kaisers- werth Deaconesses have shown the world the way. I doubt if we have progressed in secularism far enough successfully to establish such guilds apart from church organizations. The Religion of Humanity is thin stuff for women, whose souls ask for somethii^ more substantial upon which to feed. There ia no higher mission in this life than nursing God's poor. In so doing a woman may not reach the ideals of her soul ; she may fall far short of the ideals of her head, but she will go far to satiate those longings of the heart from which no woman can escape. Romola, the student, helping her blind father, and full of the pride ol learning. we admire ; Romola, the devotee, carrying in her withered heart woman's heaviest disappointment, we pity ; Romola, the nurse, doing noble deeds amid the pestilence, rescuing those who were ready to perish, we love. On the stepping-stones of our dead selvea we rise to 166 1 1 •II i • NURSE AND PATIENT higher things, and in the inner life the serene heights are reached only when we die unto those selfish habits and feelings which absorb so much of our lives. To each one of us at some time, I suppose, has come the blessed impulse to break away from all such ties and follow cherished ideals. Too often it is but a flash of youth, which darkens down with the growing years. Though the dream may never be realized, the impulse will not have been wholly in vain if it enables us to look with sympathy upon the more successful efforts of others. In Institutions tlie corroding effect of routine can be withstood only by main- taining high ideals of work ; but these become the sound- ing brass and tinkling cymbals without corresponding sound practice. In some of us the ceaseless panorama of suffering tends to dull that fine edge of sympathy with which we started. A great corporation cannot have a very fervent charity ; the very conditions of its existence limit the exercise. Against this benumbing influence, we physicians and nurses, the immediate agents of the Trust, have but one enduring corrective — the practice towards patients of the Golden Rule of Humanity as announced by Confucius : " What you do not like when done to yourself, do not do to others," — so familiar to us in its positive form as the great Christian counsel of per- fection, in which alone are embraced both the law and the prophets. u 166 BRITISH MEDICINE IN GREATER BRITAIN M i 'l i .(' i til I , H 9 I 107 'i Cranmer. Nor shall this peace sleep with her; but as when The bird of wonder dies, the maiden phoenix. Her ashes new-create another heir As great in admiration as herself. So shall she leave her blessedness to one — When heaven shuU call her from this clotid of darkness — Who from the sacred ashes of her honour Shall star-like rise, as great in fame as she was. And so stand fix'd. Peace, plenty, love, truth, terror, That were the servants to this chosen infant, Shall then be his, and like a vine grow to him : Wherever the bright sun of heaven shall shine. His honour and the greatness of his name Shall be, and make new nations : he shall flourish. And, Uke a mountain cedar, reach his branches To all the plains about him. Our children's children Shall sec this, and bless heaven. Kiy^g. Thou speakest wonders. Shakespeabi, King Henry VIII, Act V. 166 % BRITISH MEDICINE IN GREATER BRITAIN ' I TO trace successfully the evolution of any one of the learned professions would require the hand of a master — of one who, like Darwin, combined a capacity for patient observation i;vith philosophic vision. In the case of medi- cine the difficulties are enormously increased by the extra- ordinary development which has taken place during the nineteenth century. The rate of progress has been too rapid for us to appreciate, and we stand bewildered and, as it were, in a state of intellectual giddiness, when we attempt to obtain a broad, comprehensive view of the subject. In a safer " middle flight " I propose to dwell on certain of the factors which have moulded the pro- fession in English-speaking lands beyond the narrow seas — of British medicine in Greater Britain Even for this lesser task (though my affiliations are wide and my aym- pathies deep) I recognize the limitations of my fitness, and am not unaware that in my ignorance I shall overlook much which might have rendered less sketchy a sketch necessarily imperfect. Evolution advances by such slow and imperceptible degrees that to those who are part of it the finger of time scarcely seems to move. Even the great epochs are seldom ' British Medioal AMOciatloo, Montreal, 1897. 169 ' Jl ^ yii ^m BRITISH MEDICINE IN GREATER BRITAIN apparent to the participators. During the last century neither the colonists nor the mother country appreciated the thrilling interest of the long-fought duel for the pos- session of this continent. The acts and scenes of the drama, to them detached, isolated and independent, now glide like dissolving views into each other, and in the vitascope of history we can see the true sequence of events. That we can meet here to-day, Britoi.. -n British soil, in a French province, is one of the far-ofi results of that struggle. This was bat a prelude to the other great event of the eighteenth century : the revolt of tiie colonies and the founding of a second great English-speaking iiatK)n— in the words of Bishop Berkeley's prophecy, " Time's noblest offspring." It is surely a unique spectacle that a century later descendants of the actors of these two great dramas should meet in en English city in New France. Her'', the Ameri- can may forget Yorktown in Louisbourg, the Englishman Bunker Hill in Quebec, and the Frenchman both Louis- bourg and Qu.'bec in r^hateauguay ; wlile we Canadians, English and French, remembering former friendships and forgetting past enmities can welcome you to our country— the land in which and for which you have so often fought. Once, and only «»nce, before in tho history of the worid could such a gathering as this hav." taken place. Divided though the Greeks were, a Hellenic sentiment of extra- ordinary strength united them in certain assemblies and festivals. No great flight of imagination is required to picture a notable representation of our profession in the fifth century b.c. meeting in such a colonial town as Apri- gentum, under the presidency of Empedocles. Delegates 170 s 4 BRITISH MEDICINE IN GREATER BRITAIN from the mother cities, brilliant predecessors of Hippo- crates of the stamp of Democedes and Herodicus, delegates from the sister colonies of Syracuse and other Sicilian towns, from neighbouring Italy, from far distant Massilia. and from still more distant Panticapacum and Istria. And in such an assemblage there would have been men capable of discussing problems of life and mind more brilliantly than in many subsequent periods, in proportion as the pre- Hippocratic philosophers in things medical had thought more deeply than many of those who came after them. Wo Eujilish aro the modern CJreeks, and wo alone have colonised as tlicy did, as free peoples. There have been otlier great colcmial empires, Phamician, Roman, Spanish. Dutch and French, but in civil liberty and intellectual freedom Matjna Ora>cia and (Jreater Britain stand alone. The parallel so often drawn between them is of particular interest with reference to the similarity between the (treek settlements in Sicily and the Engli.>;h plantations on the Atlantic coast. Indeed, Freeman says : " I can never think »>f America without something suggesting Sicily, or of Sicii} witliout sonu'tliing suggesting America." I wish to use the jjarallel only to emphasise two points, one of difference and one of resemblance. The Greek colonist took Greece with him. Hellas had no geograplxical bounds, " Massilia and Olbia were cities of Hellas in as fiJl sense as .\thens or Sparta." While the emigrant Britons changed their sky, not their character, in crossing the great sea, yet the home -stayers had never the same feeling toward the plantations as the Greeks had towards the colonial cities of Magna Grajcia. If, as has been shrewdly sumiised; Professor Seely was lleroilotus reincarnate, how grievoj 171 I>1t! BRITISH MEDICINE IN GREATER BRITAIN the Bpirit of the father of history murt h*ve been to lay of EngUahmen, " nor have we even now ceased to think of ourselves as simply a race inhabiting an island off the northern coast of the Continent of Europe." The assump- tion of gracious superiority which, unless carefully cloaked, smacks just a little of our national arrogance, is apt to jar on sensitive colonial nerves. With the expansion of the Empire, and the supplanting of a national by an imperial spirit this will become impossible. That this sentiment never prevailed in Hellas, as it did later in the Roman Empire, was due largely to the fact that in literature, m science and in art, the colonial cities of Greece early over- shadowed the mother cities. It may be because the settle- ments of greater Britain were of slower growth that it rook several generations and several bitter trials to teach a lesson the Greeks never had to learn. The Greek spirit was the leaven of the old world, the workings of which no nationality could resist ; thrice it saved western civilisation, for it had the magic power of leading captivity captive and making even, captive con- querors the missionaries of her culture. What modern medicine owes to it wiU appear later. " The love of science the love of art, the love of freedom— vitally correlat.:d tc each other, and brought into organic union," were the essen- tial attributes of the Greek genius (Butcher). While we cannot chiira for the Anglo-Saxon race all of these distinc- tions it has in a high degree that one which in pracxical life is the most valuable, and which has been the most precious gift of the race to the world— the love of freedom, Of {i«edom in her regal seat Of EngUnd. 173 BRITISH MEDICINE IN GREATER BRITAIN It ^ould carry me too far afield to discuas the differences between the native Briton and his chUdren scattered so widely up and down the earth. In Canada, South Africa, Australia, and New Zealand, types of the Anglo-Saxon race are developing which will differ as much from each other, and from the English, as the American does to-day from the original stock ; but amid these differences can everywhere be seen those race-qualities which have made us what we are—" courage, national integrity, steady good sense, and energy in work." At a future meeting of the Association, perhaps in Australia, a professional Sir Charles Dilke with a firm grasp of the subject may deal with the medical problems of Greater Britain in a manner worthy of the ad(ii'iS8 in medicine. My task, as I meationed at the cuiflet, is much less ambitious. Could some one with full knowledge patiently analyse the characteristics of British medicine, he would find certain national traits sufficiently distinct for recognition. Three centuries cannot accomplish very much (and that period has only just passed since the revival of medicine in Eng- land), but the local conditions of isolation, which have been singulariy favourable to the development of special pecuUarities 'n the national character, have not been with- out effect in the medical profession. I cannot do more than touch upon a few features, which may be useful as indicating the sources of influence upon Great Britain in the past, and which may perhaps be suggestive as to lines of progress in the future. Above the fireplace in Sir Henry Acland's library are three panelled portraits of Linacre, Sydenham, and Harvey ; the scroll upon them reads LiUercs, Praxis, ScierUia. To 178 li I i 1.0 I.I 2.8 b <- u 2.5 2.2 2.0 1.8 MICROCOPY RESOLUTION TEST CHART NATIONAL BUREAU OF STANDARDS STANDARD REFERENCE MATERIAL 1010a (ANSI and ISO TEST CHART No. 2) I I BRITISH MEDICINE IN GREATER BRITAIN this great triumvirate, as to the fountain heads, we may trace the streams of inspiration which have made British medicine what it is to-day. Linacre, the type of the literary physician, must ever hold a unique place in the annals of our profession. To him was due in great measure the revival of Greek thought in the sixteenth century in Englo A ; and in the last Har- veian oration Dr. Payne has pointed out his importance as a forerunner of Harvey. He made Greek methods avail- able ; through him the art of Hippocrates and the science of Galen became once more the subject of careful, first- hand study. Linacre, as Dr. Payne remarks, " was pos- sessed from his youth till his death by the enthusiasm of learning. He was an idealist devoted to objects whicli the world thought of little use." Painstaking, accurate^ critical, hypercritical perhaps, he remains to-day the chief literary representative of British medicine. Neither in Britain nor in Greater Britain have we maintained the place in the world of letters created for us by Linacre's noble start. It is true that in no generation since has the profession lacked a man who might stand unabashed in the temple at Delos ; but, judged by the fruits of learning, scholars of his type have been more common in France and Germany. Nor is it to our credit that so little provision is made for the encouragement of these studies. For years the reputation of (treat Britain in this matter was sustained almost alone by the great Dee-side scholar, the surgeon of Banchory, Francis Adams— the interpreter of Hippocrates to English students. In the nineteenth century he and Greenhill well maintained the traditions of Linacre. Their work, and that of a few of our contemporaries, among 174 BRITISH MEDICINE IN GREATER BRITAIN 1 I whom Ogle must be specially mentioned, has kept ns in touch with the ancients. But by the neglect of the study of the humanities, which has been far too general, the profession loses a very precious quality. While iti critical scholarship and in accurate historical studies, British medicine must take a second place, the influence of Linacrc exerted through the Royal College of Physicians and the old Universities, has given to the hiunanities an important part in education, so that they have moulded a larger section of the profession than in any other country. A physician may possess the science of Harvey and the art of Sydenham, and yet there may be lacking in him those finer qualities of heart and head which count for so much in life. Pasture is not everything and that indefinable, though well understood, something which wc know as breeding, is not always an accompaniment of great professional skill. Medicine is scon at its best in men whose faculties have had the highest and most harmonious culture. Tlie Lathams, the Watsons, the Pagets, the Jenners, and the Gairdners have influenced the profession less by their special work than by exem]>lifying those graces of life and refmements of heart which make up character. And the men of this stamp in Greater Britain have left the most enduring mark,— Beaumont, Bovell and Hodder in Toronto ; Holmes, Campbell and Howard in this city ; the Warrens, the Jacksons, the Bigelows, the Bowditches, and the Shattucks in Boston ; Bard, Hossack, Francis, Clark, and Flint of New York ; Morgan, Shippen, Redman, Rusli, Coxe, the elder Wood, the elder Pepper, and the elder Mitchell of Philadelphia— Brahmins all, in the lan- guage of the greatest Brahmin among them, Oliver Wendell 175 i R1 m. BRITISH MEDICINE IN GREATER BRITAIN Holme8.-these and men like unto them have been the leaven which has raised our profession above the dead level of a business. . , The liUercB hurmniores, represented by Linacrc. revived Greek methods ; but the Faculty during the sixteenth and at the beginning of the seventeenth centuries was m a slough of ignorunce and self-conceit, and not to be aroused even by Moses and the prophets in the form of Hippocraces and the fathers of medicine. In the pictures referred to Sydenham is placed between Linacre and Harvey ; but science preceded practice, and Harvey's great Lumleian lectures were delivered before Sydenham was born. Lmacre has been weU caUed. by Payne. Harvey's mtellectual grand- father "The discovery of the circulation of the blood was the climax of that movement which began a century and a half before with the revival of Greek medical classics and especiaUy of Galen." (Payne.) Harvey refomed to Greek methods and became the founder of modern ex- perimental physiology and the great glory of British scientific medicine. The demonstration of the circulation of the blood remains in every detail a model research. 1 shaU not repeat the oft-told tale of Harvej-'s great and enduring influence, but I must refer to one feature which, until lately, has been also a special characteristic of his direct successors in Great Britain. Harvey was a practi- tioner and a hospital physician. There -« gossipmg statements by Aubrey to the effect that he fell mightily in his practice " after the publication of the De mtu cord«. and that his " therapeutic way '" was not admued ; but to these his practical success is the best answer. It is rema.K- able that a large proportion of all the physiological work 176 "& BRITISH MEDICINE IN GREATER BRITAIN of Great Britain has been done by men who have become successful hospital physicians or surgeons. I was much impressed by a conversation with Professor Ludwig in 1884. Speaking of the state of English physiology, he lamented the lapse of a favourite English pupil from science to prac- tice ; but, he added, " while sorry for him, I am glad for the profession in England." He held that the clinical physicians of that country had received a very positive impress from the work of their early years in physiology and the natural sciences. I was surprised at the list of names which he cited ; among them I remember Bowman, Paget, Savory and Lister. Ludwig attributed this feature in part to the independent character of the schools in Eng- land, to the absence of the University element so important in medical life in Germany, but, above all, to the nractical character of the English mind, the better men preferring an active life in practice to a secluded laboratory career. Thucydidea it was who said of the Greeks* that they possessed " the power of thinking before they acted, and of acting, too." The same is true in a high degree of the EngUsb race. To know just what has to be done, then to do it, comprises the whole philosophy of practical life. Sydenh&m—AnglicB lumen, as he has been well called— is the model practical physician of modern times. Linacre led Harvey back to Galen, Sydenham to Hippocrates. The one took Greek science, the other not so much Greek medi- cine as Greek methods, particularly intellectual fearlessness, and a certain knack of looking at things. Sydenham broke with authority and went to natm-e. It is an extra- ordinary fact that he could have been so emancipated from dogmas and theories of all sorts. He laid down the Aau 177 K I inu r= i I 'ih k : .1 m m ilBS !^M WM'i ^m\\ !' ! BRITISH MEDICINE IN GREATER BRITAIN tatomenUl proporition. and .etod upon it, th.t-'ril ai.e«e, should be d«oribed » objert. ol » »^^^J^ To do him jostioe we mmt remember, as Dr. John Brown „y.," in tie mid.tolwhatam«soI errors and pre)«d.e». of fteories actively mischievous, he was ph>.*d, at a tune when the mania ol hypothec was at its height and when the practical part of his art was overrm. and stultified by ^lU'X nostrums." Sydenham led us back to H^- I^tes I wo«ld that we could be led oltener to Sydenham ! I^r^Lessary to bear in mind what h. says abou. the ZJ.I the study of medicine. " In writing therefore, ^th a natural history of diseases, every merel, phJoso_ IL hypothesU should be set aside, and the mamf est and S^-omena, however minute, should be noted with Z utnfost exactness. The usefulne. of t^» P-^^ cnnot be easily overrated, as compared with the subtle b^es and tkg notions of modem writers, for can S« be a shorter, or indeed any other way oi coming a "bific causes, or discovering the curative icd-.tion^ thi by a certain perception of the pecdiar syrnptoms 1 B^fteL steps and helps it was that the father of physic, fr^tt Bppoc^tes, came to excel, his th-y ^eing no * Lthan an exact description nr view -A Natuie. He Cd that Nature alone ot«.a termmates d»eases. and ZL a core with a few simple medicines, and often enough r^n m^cines at all." WeU indeed has a recent ™ter larked, " Sydenham is -^"e every previous ^ach«o. th, principles and prartice of medicme m *« ^^r^^ world" He, not linacre or Harvey, is the model British ^H^ian in'whom were -centrated aU those J.a<.^> Lcincts upon which we lay such stress m the Anglo-Saxon character. ^^ BRITISH MEDICINE IN GREATER BRITAIN The Greek faculty which we possess of ttinking and acting has enabled us, in spite of manjr disadvpntages, to take the lion's share in the great practical advances in medicine. Three among the greatest scientific movements of the century have come from Germany and France. Bichat, Laennec and Louis laid the foundation of modern clinical medicine ; Virchow and his pupils of scientific pathology ; wLUe Pasteur and Koch have revolutionized the study of the causes of disease ; and yet, ihe modem history of the art of medicine could almost be writtri in its fulness from the records of the Anglo-Saxon race. We can claim every practical advance of the very first rank — vaccination, anaesthesia, p 'eventive medicine and antiseptic surgery, the '* captain jewels in the carcanet" of the pro- fession, beside which can be placed no others of equal lustre. One other lesson of Sydenham's life needs careful con- ninj. The English Hippocrates, as I said, broke with authority. His motto was Thcu Nature art my Goddess ; to thy law My serri Ecclesiastical Polity. Book ii.. vii. 2. 181 ] ' ' S I I!) 11 i t ill; BRITISH MEDICINE IN GREATER BRITAIN ♦ p^mhridM miKht have BaUed in the Mayflower ^Il^t^.^« -"^y punned exp^tioM „d the early "^^^^^^^g „fe«nee, to th.« ^lonie. conum many «^'^8 ^ ^^^ Zttd wK 'co^n Mather ealled an " angeUea. con- Uuettatea w ^._^^ ^^ ^^ ^, ^^^ »,, r °L sWUn P%«o4 ha. been taqnently profe«ed and practised "y " „ _ ^i^it, finding physic „., the study of Dmnity^ F'™- ^^y. ".'"^'irrNefEng^nd Inie. .ere »=hoUriy »ble sicians in *« «»" '^ ;„ Ha«thon.e's .■Jcorto lelW, ■"". ''T; t^efTa s' -t,^^ o" his own l«e : " Made up n;r.:s::bUbt..,,uietyeji.^to«d 1 1:^ carhig Uttie .r theniseiv., ^^a^^J --^, of constant if not warm affections.- asingui y n:;l"««—5tSschooU (University /^i:y;snia,ne..Ki.-sCoUege(^^^^^^^ l%en trained und.t.^^^^-tr.:: :rr:c:rcirsu:.onphada.o,. BR1TT«»H MEDICINE IN GREATER BRITAIN powerful effect in moulding profewional life in the pre- revolutionary period. They were men who had enjoyed not alone the instruction but often the intimate friendship of tho great English and European physicians. Morgan, Rush, Shippen, Bard, Wistar, Hossack and others had received an education comprising all that was best in the period, and had acquired the added culture which can only come from trtvel and wide acquaintance with the world. Morgan, the founder of the medical school of the University of Pennsylvania, was u way seven years, and before return- ing had taken his seat as .t corresponding meriiber of the French Acader y of Sur rr. h( 'des having been elected a Fellow of the Royal H«)ciety I'he War of Independence interrupted temporarily the stivam of students, but not the friendship which existed b^''*«*'n Cull»>n ar.d Fothergill and their old pu^iilH in Arae; ^^ correspondence of these two warm friends of the ^ estifies to the strong professional intimacy whicli ex i at the time between the loaders of the profession in i old and new worlds. But neither Boerhaave, Cullcs colonial medicine as did the great Long, weary centuries separated Ha troui Uabii ; not a century elapsed from the death grent physi- ologist to the advent of the man i personality may be seen all the distinct medicine, and the range of whose mighty iit^ few, ii any, equals since Aristotle. Hun''='r" the profession of this continent, so deep : d e exerted in three ways. In the first plai his army surgeon, and his writings on su ct interest to military men, carried his wurk ana ^vays intt 183 r Fnthergill stamped , the organization on a large scale in Vienna of a systtim of graduate teaching designed especially for f r reigners and the remarkable expansion of the German laboratories combined to divert the stream of students from France. The change of allegiance was a deserved tm ute to the splendid organization of the German universities, to the untiring zeal and energy of their professors and to their single-minded devotion to science for its own sake. In certain aspects the Australasian Settlements present the most interesting problems of Greater Britain. More homogeneous, thoroughly British, isolated, distant, they must work out their destiny with a less stringent environ- ment, than, for example, surrounds the English in Canada. The traditions are more uniform and of whatever character 191 H i: !■ i' 1 BRITISH MEDICINE IN GREATER BRITAIN have filtered through British channels. The professional population of native-trained men is as yet small, and the proportion of graduates and Ucentiates from the English, Scotch and Irish colleges and boards guarantees a domi- nance of Old Country ideas. What the maturity wiU show cannot be predicted^ but the vigorous infancy is full of crescent promise. On looking over the fUes of Australian and New Zealand journals, one is anpressed with the mono- tonous simUarity of the diseases in the antipodes to those of Great Britain and of this continent. Except in the matter of parasitic afEections and snake-bites, the nosology presents few distinctive quaUties. The proceedings of the four Intercolonial Congresses indicate a high level of pro- fessional thought. In two points Australia has not pro- gressed as other parts of Greater Britain. The satisfactory regulation of practice, so early settled in Canada, has been beset with many difficulties. Both in the United States and in AustraUa the absence of the military element, which was so strong in Canada, may in part at least account for the great difference which has prevailed in this matter of the state licence. The other relates to the question of ethics, to which one really does not care to refer, were it not absolutely forced upon the attention in reading the journals. Elsewhere professional squabbles, always so unseemly and distressing, are happily becoming very rare, and in Great Britain, and on this side of the water, we try at any rate " to wash our dirty linen at home." In the large Australian cities, differences and dissensions seem lamentably common. Surely they must be fomented by the atrocious system of elections to the hospitals, which plunges the entire profession every third or fourth year ^ 192 BRITISH MEDICINE IN GREATER BRITAIN into the throes of a contest, in which the candidates have to eolicit the sufbrages of from 2,000 to 4,000 voters ! Well, indeed, might Dr. Batchelor, say, in his address at the fourth Intercolonial Congress : " It is a scandal that in any British community, much less in a community which takes pride in a progressive spirit, such a pernicious system should survive for an hour." Of India, of " Vishnu-land," what can one say in a few minutes ? Three thoughts at once claim recogniticn. Here in the dim dawn of history, with the great Aryan people, was the intellectual cradle of the world. To the Hindoos we owe a debt which we can at any rate acknow- ledge ; and even in medicina, many of our traditions and practices may be traced to them, as may be gathered from that most interesting History of Aryan Medical Science, by the Thakore Saheb of Gondal. Quickly there arises the memory of the men who have done so much for British medicine in that great empire. Far from their homes, far from congenial surroundings, and far from the stimulus of scientific influences, Annesley, Ballingall, Twining, Morehead, Waring, Parkes, Cunning- ham, Lewis, Vandyke Carter, and many others, have up- held the traditions of Harvey and of Sydenham. On the great epidemic diseases how impoverished would our litera- ture be in the absence of their contributions ! But then there comes the thought of " the petty done, the undone vast," when one considers the remarkable opportunities for study which India has presented. W'lere else in the world is there such a field for observation in cholera, leprosy, dysentery, the plague, typhoid fever, malaria, ind in a host of other less important maladies. And what has the AE. 193 o li BRITISH MEDICINE IN GREATER BRITAIN Britiri. Gov«nment done tow«d. the «»nti8o b«»tig.- tio. .f the ourge of India and that the incidence of the disease should remam so high among the troops point to serious sanitary defects as y^^'^'^^^^ A. U, the prevalence of venereal disease among the soldiers _n admission of nearly 600 per mille tells its o«n tale On reading the journals and discussions one ge« the impression that matters «e not as they should be m Inia. Thereseems to bean absence ofproper standards o autho- rity Had there been in each presidency duimg the past twenty years thoroughly equipped govermnent laborator^s n ch^g' of able men, well trained in modem methods, the contributions U> our knowledge of epidemic '^-^l have been epoch-making, and at any rate we shodd ha^e been spared the crudeness which is evident m the work (partic^arly in that upon malaria) of some zealous but badly trained men. „+,:oa In estimating the progress of medicine m the countries comprising Greater Britain, the future rather than the 194 BRITISH MEDICINE IN GREATER BRITAIN present should be in our minds. The strides which have been taken during the past twenty years are a strong warrant that we have entered upon a period of excep- tional development. When I see v. hat has been accom- plished in this city in the short space of time since I left, I can scarcely credit my eyes : the reality exceeds the ut- most desire of my dreams. The awakening of the pro- fession in the United States to a consciousness of its respon- sibilities and opportunities has caused unparalleled changes, which have given an impetus to medical education and to higher lines of medical work which has already borne a rich harvest. Within two hundred years who can say where the intellectual centre of the Anglo-Saxon race will be ? The Mother Country herself has only become an intellectual nation of the first rank within a period alto- gether too short to justify a prediction that she has reached the zenith. She will probably reverse the history of Hellas, in which the mental superiority was at first with the colonies. At the end of the twentieth century, ardent old-world students may come to this side " as o'er a brook," seeking inspiration from great masters, perhaps in this very city ; or the current may turn towards the schools of the great nations of the south. Under new and previously unknown conditions, the Africander, the Australian, or the New Zealander may reach a development before which even " the glory that was Greece " may pale. Visionary as this may appear, it is not one whit more improbable to-day than would have been a prophecy made in 1797 that such a gathering as the present would be possible within a century on the banks of the St. Lawrence. Meanwliile, to the throbbing vitality of modern medicine 195 II ii I > ' « ' (, BBITISH MEDICINE IN OBEATBE BRITAIN the t-o «.t m«ti««. 1»M 'W «">»*• '" ""^ " "^^ , i^ prid. in . P""-"" "^lit K-tmctil of „«Ud„.. obUterating the rtrong«t '•"«»' ^™'°"'^'^"7, :Ltl »l^:Ube'x»ohed1 Whoc.„»yt^t «. o« TUn. win weld n. link, "e'""" -"^^t !rt;:dCi:^:^:r;:--?^Ht o, hope at least that the ^-'-';— ^.^t earth ^^^^^ ^^IZ^o^^rLr^^- »< 'hat gUmmot perhaps oi the larger Bop day when " the common sense of most shaU . ,M ■ in awe " There remains for us. Grea - awns oi ZlZZi. the ho«>den duty to cherish the best r^dSrof our fathe.,and particularly of the men who "ttBritish medicine its most distinctive fea^res. o '"^-^-rrHry^x^itio:: Literature. Science and Practice. 196 I XI AFTER TWENTY-FIVE YEARS 197 ;> I :->^^:' For iome we loved, the loveliest and tae best That from his Vintage rolling Time has prett. Have drunk their Cup a Round or two before, And one oy one crept ailently to rest. Omab Khayyam. 196 tfta^MMiiaHife XI AFTER TWENTY-FIVE YEARS FROM two points of view alone have we a wide and satisfactory view of life-one. as, amid the glorious tints of the early mom. ere the dew of youth ha^ been brushed off. we stand at the foot of the hill, ea^^er for the journey ; the other, wider, perhaps less satisfactory, as we gaze from the summit, at the lengthening shadows cast the setting sun. From no point in the ascent have we the same broad outlook, for f.e steep and broken pathway af- fords few halting places with an unobscured viewi You remember in the ascent of the Mountain of Purgatory. Dante, after a difficult climb, reached a high terrace en- circUng the hill, and sitting down turned to the East re- marking to his conductor-" all men are dehghted to look back " So on this occasion, from the terrace of a quarter of a century. I am delighted to look back, and to be able to tell you of the prospect. Twenty.five years ago this Faculty, with some hardi- hood, selected a young and untried man to deliver the lee » McOill allege. Montreal, 1899. 19C I AFTER TWENTY-FIVE YEABS tures on the Institutes of Medicine. With characteristic generosity the men who had claims on the position in virtue of service in the school, recognizing that the times were changing, stepped aside m favour of one who had had the advantage of post-graduate traming in the subjects to be taught. The experiment of the Faculty, supplemented on my part by enthusiasm, constitutional energy, and a fond- ness for the day's work, led to a certain measure of success. I have tried to live over again in memory those happy early days, but by no possible effort can I recall much that I would fainremember. The dust of passing years has blurred the details, even in part the general outlines of the picture. The blessed faculty of forgetting is variously displayed in us. In some, as in our distinguished countryman, John Beattie Crozier, it is absent altogether, and he fills chapter after chapter with delightful reminiscences and descriptions of his experiences and mental states.' At corresponding periods— we are about the same age— my memory hovers like a shade about the magic circle which Ulysses drew in Hades, but finds no Tiresias to lift the veil with which obli- vion has covered the past. Shadowy as are these recollec- tions, which, be they what they may Are yet the fountain light of all our day, Are yet a master light of all our seeing, they are doubly precious from their association with men who welcomed me into the Faculty, now, alas, a sadly re- duced remnant. To them— to their influence, to their ex- ample, to the kindly encouragement I received at their hands— I can never be sufficiently grateful. Faithfulness * My Inner Life, Longmans, 1898. 200 AFTER TWENTY-FIVE YEARS in the day of small things may be said to have been the distinguishing feature of the work of the Faculty in those days. The lives of the senior members taught us youngsters the lesson of professional responsibility, and the whole tone of the place was stimulating and refreshmg. It was an education in itself, particularly in the amenities of faculty and professional life, to come under the supervision of two such Deans as Dr. George Campbell and Dr. Palmer Howard. How delightful it would be to see the chairs which they adorned in the school endowed in their memories and called by their names ! One recollection is not at aU shadowy— the contrast in my feelings to-day only serves to sharpen the outlines. My first appearance before the class filled me with a tremulous mieasiness and an overwhelming sense of embarrassment. I had never lectured, and the only paper I had read before a society was with all the possible vaso-motor accompani- ment. With a nice consideration my colleagues did not add to my distress by their presence, and once inside the lecture room the friendly greeting of the boys calmed my fluttering heart, and, as so often happens, the ordeal was most severe in anticipation. One permanent impression of the session abides— the awful task of the preparation of about one hundred lectures. After the ten or twelve with which I started were exhausted I was on the treadmill for the remainder of the session. False pride forbade the reading of the excellent lectures of my predecessor, Dr< Drake, which, with his wonted goodness of heart, he had offered. I reached January in an exhausted condition, but relief was at hand. One day the post brought a brand-new work on physiology by a well-known German professor 201 1 i 1 1 i AFTER TWENTY-FIVE YEARS and it was remarkable with what rapidity my labours oi the last hall of the session were lightened. An extraordin- ary improvement in the lectures was noticed ; the students benefited, and I gained rapidly in the facility with which I could translate from the German. Long before the session was over I had learned to appre- ciate the value of the position entrusted to me, and sought the means to improve the methods of teaching. I had had the advantage of one of the first systematic courses on practical physiology given at University College, London, a good part of which consisted of lessons and demonstra- tions in histology. In the first session, with but a single microscope, I was only able to give the stock display of the circulation of the blood, ciliary action, etc., but a fortunate appointment as physician to the smallpox department of the General Hospital carried with it a salary which enabled me to order a dozen Hartnack microscopes and a few bits of simple apparatus. This is not the only benefit I received from the old smallpox wards, which I remember with grati- tude, as from them I wrote my first clinical papers. Dur- ing the next session I had a series of Saturday demonstra- tions, and gave a private course in practical histology. One grateful impression remains — the appreciation by the students of these optional and extra hours; For several years I had to work with very scanty accommodation, tres- passing in the chemical laboratory in winter, and in SUE iier using the old cloak room downstairs for the histolo- gy. In 1880 1 felt very proud when the faculty converted one of the lecture rooms into a physiological laboratory and raised a fund to furnish and equip it. MeanwhUe I had found time to take my bearings. From the chair of the 202 I 1 AFTER TWENTY-FIVE YEARS Institutes of Medicine both physiology and pathology were taught. It has been a time-honoured custom to devote twenty lectures of the course to the latter, and as my collea- gues at the Montreal General Hospital had placed the post- mortem room at my disposal I soon found that my chief interest was in the pathological part of the work. In truth, I lacked the proper technique for practical physiology. For me the apparatus never would go right, and I had not a Diener who could prepare even the simplest experiments. Alas ! there was money expended (my own usuaUy, I am happy to say, but sometimes my friends', as I was a shock- ing beggar !) in apparatus that I never could set up, but over which the freshmen firmly beUeved that I spent sleep- less nights in elaborate researches. StiU one could always get the blood to circulate, cUiato wave and the fibrin to digest. I do not think that any member of the ten suc- cessive classes to which I lectured understood the structure of a lymphatic gland, or of the spleen, or of the placental circulation. To those structures I have to-day an ingrained hatred, and I am always delighted when a new research demonstrates the folly of all preceding views of their forma- tion. Upon no subjects had I harder work to conceal my ignorance. I have learned since to be a better student, and to be ready to say to my fellow students " I do not know." Four years after my college appointment the Governors of the Montreal General Hospital elected me on the visiting staff. What better fortune could a young man desire ! I left the same day for London with my dear friend, George Ross, and the happy days we had together working at clinical medicine did much to weau me from my first lovei From that date I paid more and more attention to patho- 203 it I •f I AFTER TWENTY-FIVE YEARS logy and practical medicine, and added to my courses one in morbid anatomy, another in pathological histology, and a summer class in clinical medicinei I had become a plura- list of the most abandoned sort, and at the end of ten years it was difficult to say what I did profess : I felt like the man in Alcibiades II. to whom are applied the words of the poet: — Full many a thing he knew ; But knew them all badly. Weakened in this way, I could not resist when temptation came to pastures new in the fresh and narrower field of clinical medicine. After ten years of hard work I left this ( rich man not in this world's goods, for such I have th-. ^fortune — or the good fortune — lightly to esteem, but rich in the goods which neither rust nor moth have been able to corrupt, — in treasures of friendship and good fellowship, and in those treasures of widened experience and a fuller knowledge of men and manners which contact with the bright minds in the profession ensures. My heart, or a good bit of it at least, has stayed with those who bestowed on me these trea- sures. Many y I have felt it turn tov'T,rds this city to the dear frit . left there, -v college companions, my teachers, my old chums, the men with whom I lived in closest intimacy, and in parting from whom I felt the chordse tendinese grow tense. II Twenty-five years ago the staff of this school consisted of the historic septenary, with one demonstrator. To-day I find on the roll of the Faculty 52 teachers. Nothing em- 204 AFTER i'WENTY-FIVE YEARS phasizcs 80 sharply the character of the revolution wliich has graduaUy and sUently replaced in great part for the theoretical, practical teaching, for the distant, cold lecture of the amphitheatre the elbow to elbow personal contact 0* the laboratory. The school, as an organization, the teacher and the student have been profoundly influenced by this change. When I joined the faculty its finances were in a condition of deUghtful simplicity, so simple indeed that a few years later they were intrusted to my care. The current ex- penses were met ly the matriculation and graduation fees and the government grant, and each professor collected the fees and paid the expenses in his department. To-day the support of the laboratories absorbs a much larger sum than the entire income of the school in 1874. The greatly in- creased accommodation required for the practical teaching has made endowment a vital necessity. How nobly, by spontaneous gifts and in generous response to appeals the citizens have aided the efforts of this faculty I need not remind you. Without it McGill could not have kept pace with the growing demands of modern methods. Upon one feature in the organization of a first-class school permit me to dwell for a moment or two. The specialization of to-day means a group of highly trained experts in the scientific branches, men whose entire energies are devoted to a single subject To attain proficiency of this sort much time and money are required. More than this, these men are usually drawn from our very best students, with minds above the average. For a majoi Ay of them the life devoted to science is a sacrifice ; not, of course, that it is so felt by them, smce the very essence of success demands that in their work 205 [?;:ii i ■: AFTER TWENTY-FIVE YEARS should lie their happiness. I wish that the situation could be duly appreciated by the profession at large, and by the trustees, governors and the members of the faculties throughout the country. Owing these men an enormous debt, since we reap where they have sown, and gamer the fruits of their husbandry, what do we give them in return ? Too often beggarly salaries and an exacting routine of teaching which saps all initiative. Both in the United States and Canada the professoriate as a class, the men who live by college teaching, is wretchedly underpaid. Only a few of the medical schools have reached a financial position which has warranted the establishment of Horoughly equipped laboratories, and fewer still pay salanes in any way commensurate with the services rendered. I am fully aware that with cobwebs in the purse not what a faculty would desire has only too often to be done, but I have not referred to the matter without full knowledge, as there are schools with large incomes in which there has been of late a tendency to cut down salaries and to fill vacancies too much on Wall Street principles. And not for relief of the pocke^ alone would I plead. The men in charge of our Canadian laboratories are overworked in teaching. A well organized staff of assistants is very difficult to get, and still more diffi- cult to get paid. The salary of the professor should be in many cases that of the first assistant. When the entire energy of a laboratory is expended on instruction, research, a function of equal importance, necessarily suffers. Special endowments are needed to meet the incessant and urgent calls of the scientific staff. It is gratifying to know that certam of the bequests to this school have of late been of this kind, but I can safely say that no department is as yet 206 AFTER TWENTY-FIVE YEARS fully endowed. Owing to faulty conditions of preliminrry education the medical school has to meet certain illegiti- mate expenses. No one should be permitted to register as a medical student who ha-l not a good preliminary training in chemistry. lu is an anomaly that our schools should continue to teach general chemistry, to the great detriment of the subject of medical chemistry, which alone belongs in the curriculum. Botany occupies a similar position. But the laboratories of this medical school are not those directly under its managemt nt. McGill College turned out good doctors when it b d no scientific laboratories, when the Montreal General Hospital and the University Mater- nity were its only practical departments. Ample clinical material and gO(-al Victoria Hospital by our large-hearted Canadian Peers has doubled the cUnical fa- culties of this school, and by the stimulus of a healthy rivalry has put the Montreal General Hospital into a con- dition of splendid efficiency. Among the many changes which have occurred within the past twenty-five years, I would place these first in order of importance, since they assure the continued success of McGiU as a school of practi- cal medicine. Equally with the school as an organization, the teacher has felt deeply the changed conditions in m al education, and many of us are much embarrassed know what and how to teach. In a t- :^riod of transition it is not easy to get orientirt. In some subjects fortunately there is but the 207 AFTER TWENTY-FIVE YEARS single difficulty-what to teach. The phenomenal stridea in every branch of scientific medicine have tended to over- load it with detaU. To winnow the wheat from the chaff and to prepare it in an easUy digested shape for the tender stomachs of first and second year students taxes the re- sources of the .aost capable teacher. The devotion to a subject, and the enthusiasm and energy which enables a man to keep abreast wi*1. its progress, are the very qualities which often lead him into pedagogic excesses. To reach a right judgment m these matters is not easy, and after all it may be said of teaching as Izaak Walton says of angling, " Men are to be born so, I mean with inclinations to it." For many it is very hard to teach down to the level of be- ginners. The Rev. John Ward, Vicar of Stratford-on-Avon, shortly after Shakespeare's day made an uncomplimentary classification of doctors which has since become well- known :— " first, those that can talk but doe nothing ; secondly, some that can doe but not talk ; third, some that can both doe and talk ; fourthly, some that can neither doe nor talk— and these get most monie." ' Professors similarly may be divided into four classes. There is, first, the man who can think but who has neither tongue nor technique. Though useless for the ordinary student, he may be the leaven of a faculty and the chief glory of his university. A second variety is the phonographic professor, who can talk but who can neither think nor work. Under the old regime he repeated year by year the same lecture. A third is the man who has technique but who can neither talk nor think ; and a fourth is the rare professor who can do all » Diary of the Rev. John Ward, ed. Dr. Charles Severn, Lond.; 1839. 208 I AFTER TWENTY-FIVE YEARS three— think, talk and work. With these types fairly re- presented in a faculty, the diversities of gifts only serving to illustrate the wide spirit of the teacher, the Dean at least should feel happy. But the problem of all others which is perplexing the teacher to-day is not so much what to teach, but how to teach it, more especially how far and in what subjects the practical shall take the place of didactic teaching. All wil' agree that a large proportion of the work of a medical stu- dent should be in the laboratory and in the hospital. The dispute is over the old-fashioned lecture, which has been railed against in good set terms, and which many would like to see abolished altogether. It is impossible, I think to make a fixed rule, and teachers should be allowed a wide discretion. With the large classes of many schools the abolition of the didactic lecture would require a total recon- struction of the curriculum and indeed of the faculty. Slowly but surely practical methods are everywhere taking the place of theoretical teaching, but there will, I think, always be room in a school for the di<^ tic lecture. It is destined within the next ten years to be much curtailed, and we shall probably, as is usual, go to extremes, but there will always be men who can present a subject in a more lucid and attractive manner than it can be given in a book. Sir William Gairdner once remarked that the reason why the face and voice of the teacher had so much more power than a book is that one has a more ! ving faith in him. Years ago Murchison (than whom Gi^at Britain certainly never had a more successful teacher of medicine) limited the lecture in medicine to the consideration of rare cases, and the prominent features of a group of cases, and to ques- AE. 209 P I VFTER TWENTY-FIVE YEARS tioM of prognosi> which cannot be di«cu«ed at the bedside. For the past four years m the subject of medicme I have been making an experiment in teaching only by a weekly examination on a set topic, by practical work in the wards, in the out-patient room and the clinical laboratory, and by a weekly consideration in the amphitheatre of the acute diseases of the season. With a smaU class I have been satisfied with the results, but the plan would be difficult to carry out with a I'.rge body of students. The student lives a happy life in comparison with that which feU to our lot thirty years ago. Envy, not sym- pathy, is my feeling towards him. Not only is the rrnnu more attractive, but it is more diversified and the viands are better prepared and presented. The present tendency to stuffing and cramming wUl be checked in part when you cease to mb, ^he milk of general chemistry and botany with the proper dietary of the medical school. Undoubtedly the student tries to learn too much, and we teachers try to teach him too much-neither, perhaps, with great success. The existing evils result from neglect on the part of the teacher, student and examiner of the great fundamental principle laid down by Plato-that education is a life-long process, In which the student can only makt. a beginning during 'his college course. The system under which we work asks too much of the student in a limited time. To cover the vast field of medicine in four years is an impos- sible task. We can only instil principles, put the student in the right path, give him methods, teach him how to study, and early to discern between essentials and non- essentials. Perfect happiness for student and teacher will come with the abolition of examinations, which are stum- 210 1 AFTER TWENTYFIVE YEARS bling blocks and rocks of offence in the pathway of the true student. And it is not so Utopian as may appear at first bl-ah. Ask any demonstrator of anatomy ten days before the examinations, and he should be able to give you a list of the men fit to pass. Extend the personal intimate know- ledge such as is possessed by a competent demonstrator of anatomy into all the other departments, and the degree could be safely conferred upon certificates of competency, which would really mean a more thorough knowledge of a man's fitness than can possibly be got by our present sys- tem of examination. I see no way of avoiding the neces- sary tests for the license to practise before the provincial or state boards, but these should be of practical fitness only, and not, as is now so often the case, of a man's knowledge of the entire circle of the medical sciences. Ill But what is most important in an introductory lecture remains to be spoken, for dead indeed would I be to the true spirit of this day, were I to deal only with the questions of the curriculum and say nothing to the young men who now begin the serious work of life. Personally, I ha^e never had any sympathy with the oft-repeated sentiment ex- pressed originally by Abernethy, I believe, who, seeing a large class of medical students, exclaimed, " Good God, gentlemen ! whatever will become of you 1 " The profes- sion into which you enter to-day guarantees to each and every one of you a happy, contented, and useful life. I do not know of any other of which this can be said with greater assurance. Many of you have been influenced in your choice by the example and friendship of the doctor iu your 211 Ihi .^! I b^£^ AFTER TWENTY-nVE YEARS Umily, or of some country practitioner in whom you have recognized the highest type o! manhood and whose unique position in the community has fiUed you with a laudable ambition. You wiU do weU to make such an one your ex- cmplar, and I would urge you to start with no higher am- bition than to join the noble band of general practitioners. They form the very sinews of the profession— generous- hearted men, with weU-balanced, cool heads, not scientific always, but learned in the wisdom not of the laboratories but of the sick room. This school can take a greater pride in her graduates scattered throughout the length and breadth of the contment than in her present splendid equipment ; they explain in great part the secret of her strength. I was much interested the other day in reading a letter of John Locke to the Earl of Peterborough who had con- sulted him about the education of his son. Locke Insisted that the main point in education is to get " a relish of know- ledge." " This is putting life into a pupil." Get early this relish, this clear, keen joyance in work, with which languor disappears and aU shadows of annoyance flee away. But do not get too deeply absorbed to the exclusion of aU outside interests. Success in life depends as much upon the man as on the physician. Mix with your fellow students, mingle with their sports <^nd their pleasures. You may think the latter rash advice, but now-a-days even the plea- sures of a medical stude t have become respectable, and I have no doubt that the " footing supper," which in old Cot^ street days was a Bacchanalian orgie, has become a love feast in which even the Principal and the Dean might participate. You are to be members of a poUte as weU as 212 mmmmmsS' AFTER TWENTY-FIVE YEARS of a liberal profewion and the more you see of life outside the narrow circle of your work the better equipped wiU you be for the strugglo. I often wish that the citizens in our large educational centres would take a little more mterest in the social life of the students, many of whom catch but few glimpses of home life during their course. As to your method of work. I have a single bit of advice, which I give with the earnest conviction of its paramount influence in any success which may have attended my efforte in Ufe-TaJte no thought for the morrm. Live neither in the past nor in the future, but let each day's work absorb your entire energies, and satisfy your widei,^. ambition That was a singular but very wise answer which Cron.v- '» gave to BeUevire— " No one rises so high as he who kiio i not vhither he is going," and there is much truth in it. The student who is worrying about his future, anxious over tlie examinations, doubting his fitness for the profession, is certain not to do so well as the man who cares for nothing but the matter in hand, and who knows not whither he is going ! While medicine is to be your vocation, or calling, see to it that you have also an avocation— some intellectual pas- time which may serve to keep you in touch with the world of art, of science, or of letters. Begin at once the cultiva- tion of some interest other than the purely professional. The difficulty is in a selection and the choice will be differ- ent according to your tastes and training. No matter what it is— but have an outside hobby. For the hard working medical student it is perhaps easiest to keep up an interest in literature. Let each subject in your year's work have a corresponding outside author. When tired of anatomy 219 i V AFTER TWENTY-FIVE YEARS refresh your mind with Oliver Wendell Hohnes ; after a worrying subject in physiology, turn to the great idealists, to Shelley or Keats for consolation ; when chemistry dis- tresses your soul, seek peace in the great pacifier, Shake- speare; and when the complications of pharmacology are unbearable, ten minutes with Montaigne will lighten the burden. To the writings of one old physician I can urge your closest attention. There have been, and, happily, there are still in our ranks notable illustrations of the inti- mate relations between medicine and literature, but in the group of literary physicians Sir Thomas Browne stands preeminent. The Religio Medici, one of the great English classics, should be in the hands— in the hearts too— of every medical student. As I am on the confessional to-day, I may tell you that no book has had so enduring an influence on my life. I was introduced to it by my first teacher, the Rev. W. A. Johnsou, Warden and Founder of the Trinity College School, and I can recall the delight with which I first read its quaint and charming pages. It was one of the strong influences which turned ray thoughts towards medi- cine as a profession, and my most treasured copy— the second book I ever bought— has been a constant companion for thirty-one years,— comes viae vitseque. Trite but true, is the comment of Seneca—" If you are fond of books you will escape the ennui of life, you will neither sigh for even- ing, disgusted with the occupations of the day— nor will you live dissatisfied with yourself or unprofitable to others." And, finally, every medical student should remember that his end is not to be made a chemist or physiologist or anatomist, but to learn how to recognize and treat disease, how to become a practical physician. Twenty years ago. 214 AFTER TWENTY-FIVE YEARS during the summer session. I held my first class in clinical medicine at the Montreal General Hospital, and on the title page of a note book I had printed for the students I placed the foUowing sentence, which you will find the alpha and omega of practical medicine, not that it by any means covers the whole field of his education :— " The knowledge which a man can use is the only real knowledge, the only knowledge which has life and growth in it and converts itself into practical power. The rest hangs like dust about the brain or dries like rain drops off the stones." (Froude.) Hi \'n\ 216 b How easily, how secretly, how safely in books do we make bare without shame the poverty of human ignorance ! These are the masters that instruct us without rod and ferrule, without words of auger, without payment of money or clotuing. Should ye approach them, they are not asleep ; if ye seek to question them, they do not hide themselves ; should ye err, they do not chide ; and should ye show ignorance, they know not how to laugh. O Books ! ye alone are free and Uberal. Ye give to all that seek, and set free all that servo you zealously. RiCHABD DE BuEY, PMhMUon, Crolier Oub Edition, vol. ii. p. 22 Books delight us when prosperity sweetly smiles ; they stay to comfort us when cloudy fortune frowns. They lend strength to human compacts, and without them grave judgments may not be P'°P°^°^^- Ibid. p. 113. For Books are not absolutely dead things, but do contain a potency of Ufe In them to be as active as that soul was whose progeny they are ; nay, they do preserve as in a vial the purest efficacy and extraction of that living intellect that bred them. JoHS Milton, Areopagitica. 218 ^v XII BOOKS AND MEN' THOSE of us from other citb" \/ho bring congratu- lations ^Ms evening can hardly escape thetinglings of envy when we see this noble treasure house ; but in my own case the bitter waters of jealousy which rise in my soul are at once diverted by two strong sensations. In the f rst place I have a feeling of lively gratitude towards this library. In 1870 as a youngster interested in certain clinical subjects to which I could find no reference in our library at McGiU, I came to Boston, and I here found what I wanted, and I found moreover a cordial welcome and many friends. It was a small matter I had in hand but I wished to make it as complete as possible, and I have al- ways felt that this library helped me to a good start. It has been such a pleasure in recurring visits to the library to find Dr. Brigham in charge, with the same kindly interest in visitors that he showed a quarter of a century ago. But the feeling which absorbs all others is one of deep satisfaction that our friend, Dr. Chadwick, has at last seen fulfilled the desire of his eyes. To few is given the tenacity of will which enables a man to pursue a cherished purpose through a quarter of a century—" Ohne Hast, aher ohne Raet " ('tis his favourite quotation) ; to fewer still is the I Boeton Medical Library. 1901. 219 BOOKS AND MEN fruition granted. Too often the reaper is not the sower. Too often the fate of those who labour at some object for the public good is to see their work pass into other hands, and to have others get the credit for enterprises which they have initiated and made possible. It has not been so with our Liend, and it intensifies a thousandfold the plea- sure of this occasion to feel the fitness, in every way, of the felicitations which have been offered to him. It is hard for me to speak of the value of libraries in terms which would not seem exaggerated. Books have been my delight these thirty years, and from them I have received incalculable benefits. To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all. Only a maker of books can appreciate the labours of others at their true value. Those of us who have brought forth fat volumes should offer hecatombs at these shrines of Minerva Medica. What exsuccous, attenuated offspring they would have been but for the pabulum furnished through the placental circulation of a library. How often can it be said of us with truth, " Das heste was er ist verdankt er Andern ! " For the teacher and the worker a great library such as this is indispensable. They must know the world's best work and know it at once. They mint and make current coin the ore so widely scattered in journals, transactions and monographs. The splendid collections which now exist in five or six of our cities and the unique opportunities of the Surgeon-General's Library have done much to give to American medicine a thoroughly eclectic character. But v'hen one considers the unending making of books, 220 \ ■ 1 H t; BOOKS AND MEN who does not sigh for the happy days of that thrice happy Sir WiUiam Browne' whose pocket library sufficed for his Ufe's needs ; drawing from a Greek testament his di- vinity, from the aphorisms of Hippocrates his medicme, and from an Elzevir Horace his good sense and vivacity. There should be in connection with every library a corps of instructors in the art of reading, who would, as a labour of love, teach the young idea how to read. An old writer says that there are four sorts of readers : " Sponges which attract all without distinguishing ; Howre-glasses which receive and powre out as fast ; Bagges which only retam the dregges of the spices and let the wine escape, and Sives which retaine the best onely." A man wastes a great many years before he reaches the " sive " stage. For the general practitioner a weU-used library is one of the few correctives of the premature seniUty which is so apt to overtake him. Self-centred, self-taught, he leads a soUtary life, and unless his every-day experience is con- trolled by careful reading or by the attrition of a medical society it soon ceases to be of the slightest value and be- comes a mere accretion of isolated facts, without corre- lation. It is astonishing with how little reading a doctor can practise medicine, but it is nc. astonishing how badly he may do it. Not three months ago a physician living within an hour's ride of the Surgeon-General's Library brought to me his little girl, aged twelve. The diagnosis of infantUe myxoedema required only a half glance. In i In one of the Annual Orations at the Royal CoUege of Physicians he said : " Behold an instaace of human ambition ! not to be rati- fied but by the conquest, as it were, of three worlds, lucre m the country, honour in the coUege, pleaaure in the medicinal sprmgs. 221 i-' n I II 1 , 1 BOOKS AND MEN placid contentment he had been practising twenty years in " Sleepy Hollow " and not even when his own flesh and blood was touched did he rouse from an apathy deep as Rip Van Winkle's sleep. In reply to questions : No, he had never seen an3rthing in the journals about the thyroid gland ; he had seen no pictures of cretinism or myxosdema ; in fact his mind was a blank on the whole subject. He had not been a reader, he said, but he was a practical man with very little time. I could not help thinking of John Bunyan's remarks on the elements of success in the prac- tice of medicine. " Physicians," he says, " get neither name nor fame by the piicking of wheals or the picking out thistles, or by laying ■^f plaisters to the scratch of a pin ; every old woman can uo this. But if they would have a name and a fame, if they will have it quickly, they must do some great and desperate cures. Let them fetch one to life that was dead, let them recover one to his wits that was mad, let them make one that was born blind to see, or let them give ripe wits to a fool— these are notable cures, and he that can do thus, if he dost thus first, he shall have the name and fame he deserves ; he may lie abed till noon." Had my doctor friend been a reader he might have done a great and notable cure and even have given ripe wits to a tool ! It is in utilizing the fresh know- ledge of the journals that the young physician may attain quickly to the name and fame he desires. There is a third class of men in the profession to whom books are dearer than to teachers or practitioners — a small, a silent band, but in reality the leaven of the whole lump. The profane call them bibliomaniacs, and in truth they are at times irresponsible and do not always know the 222 BOOKS AND MEN difference between meum and tuum. In the presence of Dr. Billings or of Dr. Chadwick I dar-; not further charac- terize them. Loving books partly for their contents, partly for the sake of the authors, they not alone keep alive the sentiment of historical continuity in the pro- fession, but they are the men who make possible such gatherings as the one we are enjoying this evening. We need more men of their class, particulariy in this country, where every one carries in his pocket the tape-measure of utility. Along two lines their work is valuable. By the historical method alone can many problems in medicine be approached profitably. For example, the student who dates his knowledge of tuberculosis from Koch may have a very correct, but he has a very incomplete, appreciation of the subject. Within a quarter of a century our libraries will have certain alcoves devoted to the historical con- sideration of the great diseases, which will give to the student that mental perspective which is so valuable an equipment in life. The past is a good nurse, as Lowell remarks, particularly for the weanlings of the fold. 'Tis man's worst deod To let the things that have been, run to wast© And in the unmeaning Present sink the Past. But in a more excellent way these laudatores temporis acti render a royal se-vice. For each one of U3 to-day, as in Plato's time, there is a higher as well as a lower edu- cation. The very marrow and fitness of books may not suffice to save a man from becoming a poor, mean-spirited devil, without a spark of fine professional feelmg, and without a thought above the sordid issues of the day. The men I speak of keep alive in us an interest in the great 223 ) i BOOKS AND MEN men of the past and not alone in their works, which they cherish, but in their lives, which they emulate. They would remind us continually that in the records of no other profession is there to be found so large a number of men who have combined intellectual pre-eminence with nobility of cha-acter. This higher education so much needed to-day is not given in the school, is not to be bought in the market place, but it has to be wrought out in each one of us for himself ; it is the silent influence of character on character and in no way more potently than in the contemplationof the lives of the great and good of the past, in no way more than in " the touch divine of noble natures gone." I should like to see in each library a select company of the Immortals set apart for special adoration. Each country might have its representatives in a sort of alcove of Fame, in which the great medical classics were gathered Not necessarily books, .^cre often the epoch-making con- tributions to be found in ephemeral journals. It is too early, perhaps, to make a selection of American medical classics, but it might be worth while to gather suffrages in regard to the contributions which ought to be placed upon our Roll of Honour. A few years ago I made out a list of those I thought the most worthy which I carried down to 1850, and it has a certain interest for us this evening. The native modesty of the Boston physician is well known, but in certain circles there has been associated with it a curious psychical phenomenon, a conviction of the utter worthlessness of the statw prmens ^. New England, as compared with conditions existing elsewhere. There is a variety to-day of the Back Bay Brahmin who delights 224 BOOKS AND MEN in cherishing the belief that medically things are every- where better than in Boston, and who is aiways ready to predict "an Asiatic removal of candlesticks," to borrow a phrase from Cotton Mather. Strange indeed would it have been had not such a plastic profession as ours felt the influences which moulded New England mto the in- tellectual centre of the New World. In reality, nowhere in the country has the profession been adorned more plen- tifully with men of culture and of character— not volu- minous writers or exploiters of the prouucts of other men's brains— and they manage to get a full share on the Roll of Fame which I have suggested. To 1850, I have counted some twenty contributions of the first rank, con- tributions which for one reason or another deserve to be called American medical classics. New England takes ten. But ill medicine the men she has given to the other parts of the country have bf m better than books. Men like Nathan R. Smith, Austin Flint, Willard Parker, Alon- zo Clark, Elisha Bartlett, John C. Dalton, and others carried away from their New England homes a love of truth, a love of lca.rrjnji and above all a proper estimate of the personal character of the physician. Dr. Johnson shrewdly remarked that ambition was usuaUy proportionate to capacity, which is as true of a profession as it is of a man. What we have seen to-night reflects credit not less on your ambition than on your capacity. A library after all is a great catalyser, accelera- ting the nutrition and rate of progress in a profession, and I am sure you will find yourselves the better for the sacri- fice you have made in securing this home for your books, this workshop for your members. AE. 225 Q I XIII MEDICINE IN THE NINETEENTH CENTURY I 227 I I il"' ^' I Even where the milder zone afforded man A seeming shelter, yet contagion there. Blighting his being with unnumbered ills, Spread hke a quenchless fire ; nor truth availed Till late to arrest its progress, or create That peace which first in bloodless victory waved Her snowy standard o'er this favoured clime. Happiness And Science dawn though late upon the earth ; Peace cheers the mind, health renovates the frame ; Dibease and pleasure cease to mingle here. Reason and passion cease to combat there ; Whilst mind unfettered o'er the earth extends Its all-Bubduiug energies, and wields The sceptre of a vast dominion there. Shelley, The Daemon of the Wcrld, nb xm MEDICINE IN THE NINETEENTH CENTURY ' FOR countless generations the prophets and kings of humanity have desired to see the things which men have seen, and to hear the things which men have heard in the course of the wonderful nineteenth century. To the call of the watchers on the towers of progress there had been the one sad answer— the people sit in darkness and in the shadow of death. Politically, socially, and morally the race had improved, but for the unit, for the individual, there was little hope. Cold philosophy shed a glimmer of light on his path, religion in its various guises illumined hia sad heart, but neither availed to lift the curse of suffering from the sin-begotten son of Adam. In the fulness of time, long expected, long delayed, at last Science emptied upon him from the horn of Amalthea blessings which cannot be enumerated, blessings which have made the century forever memorable ; and which have followed each other with a rapidity so bewildering that we know not what next to expect. To us in the medical profession, who deal with this unit, and measure * Johns Hopkins Historical Club, January, 1901 ; and pub- lished in the New York Sun 229 i'i MEDICINE IN THE NINETEENTH CENTURY progress by the law of the greatest happiness to the greatest number, to us whose work is with the sick and .'ifiering, the great boon of this wonderful century, with which no other can be compared, is the fact that the leaves of the tree of Science have been for the healing of the n lions. Measure as we may the progress of the world — materially, in the advantages of steam, electricity, and other mechani- cal appliances ; sociologically, in the great improvement in the conditions of life ; intellectually, in the diffusion of education ; morally, in a possibly higher standard of ethics — there ia no one measure which can compare with the decrease of physical suffering in man, woman, and child when stricken by disease or accident. This is the one hct of supreme personal import to every one of U3. f a. ' the Promethean gift of the century to man. THE GROWTH OF SCIENTIFIC MEDICINE The century opened auspiciously, and those who were awake saw signs of the dawn. The spirit of Science was brooding on the waters. In England the influence of John Hunter stimulated the younger men to the study of the problems of anatomy and pathology. On the Con- tinent the great Boerhaave— the Batavian Hippocrates — had taught correct ways in the study of the clinical aspects of disease, and the work of Haller had given a great impetus to physiology. The researches of Morgagni had, as Virchow has remarked, introduced anatomical thinking into medicine. But theories still controlled practice. Under the teaching of CuUen, the old idea that humours were the seat of disease had given place to a neuro- 230 MEDICINE IN THE NINETEENTH CENTURY pathology which recognized the paramount influence of the nervous system in disease. His coUeague at Edin- burgh, Brown, brought forward the attractive tlieory that aU diseases could be divided into two groups, the one caused by excess of excitement— the sthenic— the other by deficiency-the asthenic-«ach having its appropriate treatment, the one by depletion, the other by stimulation. In a certain measure Hahnemann's theory of homoeo- pathy was a reaction against the prevalent theories of the day, and has survived through the century, though in a much modified form. Some of his views were as follows : " The only vocation of the physician is to heal ; theo- retical knowledge is of no use. In a case of sickness he should only know what is curable and the remedies. Of the diseases he cannot know anything except the symp- toms. There are internal changes, but it is impossible to learn what they are ; symptoms alone are accessibic ; with their removal by remedies the disease is removed. Their effects can be studied in the healthy only. They act on the sick by causing a disease simUar to that which is to be combated, and which dissolves itself into this simUar affection. The full doses required to cause symp- toms in the well are too large to be employed as remedies for the sick. The healing power of a drug grows in an inverse proportion to its substance. He says, literally : ' Only potencies are homoeopathic medicines.' ' I recog- nize nobody as my follower but him who gives medicine in so small doses as to preclude the perception of anything medicinal in them by means either of the senses or of chemistry.' 'The pellets may be held near the young infant when asleep.' ' Gliding the hand over the patient 231 i |1^ ) 1 MEDICINE IN THE NINETEENTH CENTURY will cure him, provided the manipulation is done with firm intention to render as much good with it as possible, for its power is in the benevolent will of the manipulator.' Such is the homoepathy of Hahnemann, which is no longer recognized in what they call homoeopathy to-day."— (A. Jacobi.) The awakening came in France. In 1801 Bichat, a young man, published a work on general anatomy, in which he placed the seat of disease, not in the organs, but in the tissues or fabrics of which ':hey were composed, which gave an ejctraordinary impetus to the investigation of pathological changes. Meanwhile, the study of the appearances of organs and bodies when diseased (morbid anatomy), which had been prosecuted with vigor by Mor- gagni in the eighteenth century, had been carried on actively in Great Britain and on the Continent, and the work of Broussais stimulated a more accurate investiga- tion of local disorders. The discovery by Laennec of the art of auscultation, by which, through changes in the normal sounds within the chest, various diseases of the heart and limgs could be recognized, gave an immense impetus to clinical research. The art of percussion, dis- covered by Auenbrugger in the eighteenth century, and reintroduced by Corvisart, contributed not a little to the same. Laennec's contributions to the study of diseases of the lungs, of the heart, and of the ab-^ominal organs really laid the foundation of modern clinical medicine. A little later Bright published his researches on diseases of the kidneys, from which we date our knowledge of this important subject. One of the most complicated problems of the first half of the century related to the differentiation 282 MEDICINE IN THE NINETEENTH CENTURY of the fevers. The eruptive fevers, measles, scarlet fever, and small-pox were easily recognized, and the great group of malarial fevers was well known ; but there remained the large class of contmued fevers, which had been a source of worry and dispute for many generations. Louis clearly differentiated typhoid fever, and by the work of his Ameri- can pupils, W. W. Gerhard and Alfred Still6, of Phila- delphia, and George B. Shattuck, of Boston, typhus and typhoid fevers were defined as separate and independent affections. Relapsing fever, yellow fever, dengue, etc., were also distinguished. The work of Graves and Stokes, of Dublin ; of Jenner and Budd, in England ; of Drake, Dickson, and Flint, in America, supplemented the labours of the French physicians, and by the year 1860 the pro- fession had reached a sure and safe position on the question of the clinical aspects of fevers. The most distinguishing feature c ■ ':he scientific medicine of the century has been the phenomenal results which have followed experimental investigations. While this method of research is not new, since it was introduced by Galen, perfected by Harvey, and carried on by Hunter, it was not until well into the middle of the century that, by the growth of research laboratories, the method exer- cised a deep influence on progress. The lines of experi- mental research have sought to determine the functions of the organs in health, the conditions under which per- version ol these functions occurs in diseases, and the possi- bility of exercising protective and curative influences on *;he processes of disease. The researches of the physiological laboratories have enlarged in every direction our knowledge of the great 233 PI' ! i ^ :n- i. it f i MEDICINE IN THE NINETEENTH CENTUR'' functions of life — digestion, assimilation, circulation, respiration, and excretion. Perhaps in no department have the results been more surprising than in the growth of our knowledge of the frmctions of the brain and nerves. Not only has experimental science given us clear and accurate data upon the localization of certain functions of the brain and of the pa'.i s of sensatory and of motor impulses, but it has opened an entirely new field in the diagnosis and treatment of the diseases of these organs, in certain directions of a most practical nature, enabling us to resort to measures of relief undreamed of even thirty years ago. The study of physiology and pathology withm the past half-century has done more to emancipate medicine from routine and the thraldom of authority than all the work of all the physicians from the days of Hippocrates to Jenner, and we are as yet but on the threshold. THE GROWTH OF SPECIALISM The restriction of the energies of trained students to narrow fields in science, while not without its faults, has been the most important single factor in the remarkable expansion of our knowledge. Against the disadvantages in a loss of breadth and harmony there is the compensatory benefit of a greater accuracy in the application of know- ledge in specialism, as is well illustrated in the cultivation of special branches of practice. Diseases of the skin, of the eye, of the ear, of the throat, of the teeth, diseases of women, and of children are now studied and practised by men who devote all their time to one limited field of 234 MEDICINE IN THE NINETEENTH CENTURY work. While not without minor evils, this custom has yielded some of the great triumphs of the profession. Dentistry, ophthalmology, and gynaecology are branches which have been brought to a state of comparative per- fection, and very largely by the labours of American physi- cians. In the last-named branch the blessings which have been brought to suffering women are incalculable, not only as regards the minor ailmeuta oi life, but in the graver and more critical accidents to which the sex m liable. One of the most remarkable and beneficial reforms of the nineteenth century has been in the attitudt of the pro- fession and the public to the subject of insanity, and the gradual formation of a body of men in the profession who labour to find out the cause and means of relief of this most distressing of all human maladies. The reform movement inaugurated by Tuke in England, by Rush in the United States, by Pinel and Eaquirol in France, and by Jacobi and Hasse in Germany, has spread to all civilized countries, and has led not only to an amelioration and improveiuent in the care of the insane, but to a scientific study of the subject which has already been productive of much goodi In this country, while the treatment of the insane is careful and humanitarian, the unfortunate affiliation of insanity with politics is still in many States a serious hindrance to progress. It may be interesting to take a glance at the state of medicine in this country at the opening of the century. There were only three schools of medicine, the most im- partant of which were the University of Pennsylvania and the Harvard. There were only two general hospitals. The medical education was chiefly in the hands of the 235 ^M !' I' : a stealthy entrince into jur bodies, whvre they wreak harm and death. Scientif cally considered, however, they are the smallest of living thiiigs yet known. They are not animals, but are members of the vegetable kingdom, and are pos- sessed of definite v^^t varying shapes. They consist of a jelly-lik<^ substance called protoplasm, which is covereu in and held in place by a well-fo med membrane of i rela tively hard aid dense character, exactly similar i com- position to the woody fibre of tret According to their siiUi th'> ' Acteria are divide< .to three chief groups, called respectively co. -i, be i, an< spirilla. The cocci are spherical bodies aad r.^y exist singly o" in pair=!. in fours, in dusterf. or i c jnp in this group we find the smallest bacteria kn v . many of them not over -150,000 of an inch diaineter. The bacilli are rod iike bodi s, varymg miKh ii -n?'- in « afferent species and in members uf the sam* sp^ie?. Iney are larger than the cocci, measiiring in length fe » 1 25,000 of an inch to 1-4,000, a; I in breadth ir m i-i 26,000 to 1-16,000 of an inch, iiany varieties ^^ssed of organs of I comotion < alleut it. A supp >' of air is by no means easential to a germs. To ome it ia absolutely necessary, and suck geiiiis are called aerobes. AE. 241 B ■aces of in MEDICINE IN THE NINETEENTH CENTURY To others air is whoUy detrimental, and they constitute the anaerobes, while to the majority of bacteria air supply is a matter of indifierence, and in consequence they are grouped under the term facultative anaerobes. The food supply of mi:uy consists of dead animal and vegetable materials, a few require Uving tissues, whUe a smaU number can exist whoUy upon n.lneral salts, or even the nitrogen of the air. The lowest temperature at which some bacteria can multiply is the freezing-point of water, and the highest 170 degrees Fahrenheit. However, the average range of temperature suitable to the majority Ues between 60 and 104 degrees Fahrenheit, 98 2-5 degrees Fahrenheit being the mo^it suitable for the growth of disease-producing germs. Light, ordinarUy diffused day- light, or its absence, is a matter of no moment to most germs, but direct sunUght is a destroyer of all bacteria. The study of the life histories of these diminutive plants excites the wonder of those who make observations upon them. It is truly marvellous to know that these bacteria can accomplish in their short lives of possibly a few hours or days feats which would baffle the cleverest of chemists if given years of a lifetime to work upon. They give to the farmer the good quality of his crops, to the dairyman superior butter and cheese ; they assist in large measure in freeing our rivers and lakes from harmful poUutions. Here it should be strongly emphasized that those bacteria which cause disease are only of a few species, all others con- tributing to our welfare in countless ways. Quite as astonishing b the discovery that within the root-knobs of pease and beans Uve bacteria which by splitting up mineral salts containing nitrogen, and by 242 MEDICINE IN THE NINETEENTH CENTURY absorbing nitrogen from the air, give it over to the plant 80 that it b ei-Abled to grow luxuriantly, whereas, with- out theb presence, the tiller of the soU might fertilize the ground in vain. It is quite possible that not alone pease and beans, but all grasses and plants and trees depend upon the presence of such germs for their very existence, which in turn supply man and animals with their means of existence. Hence we see that these nitrifying bacteria, as they are called, if swept out of existence., would be the cause of cessation of all life upon the globe. And arguing backward, one prominent authority states it as his belief that the first of aU life on this earth were those lowly forms of plants which only required the nitrogen of air or salts to enable them to multiply. Limiting observation now to the sphere of medicine, it will be readily perceived that the presence of bacterial life in a causative relation to disease b an object of para- mount regard. The following paragraphs will briefly treat of the diseases associated with micro-crganisms and the common modes of infection in each, the chain of eventi subsequent to an infection, and the possibilities of protec- tion or cure by means of substances elaborated in the body of an invidiual or animal recently recovered from an in- fectious disease : Anthrax.— A. disease chiefly of cattle and sheep, occa- sionally of man, is caused by the Bacillus arUhracis, dis- covered m 1849-50 by Pollender and Davaine. It enters the body through abrasions of the skin, by inhalation of the spores, or seeds, into the lungs, or by swallowing in- fected material. Leprosy.— TUa disease is caused by a bacillus Known ! .' i MEDICINE IN THE NINETEENTH CENTURY as BacShu leprae, which was discovered by Hansen in 1879. It is doubtful if it has been grown outside the body. It is supposed to enter by abrasions of the skin, but it is very feebly contagious, notwithstanding popular ideas as to its supposedly highly contagious nature. Tuberculosis.— AXi forms of this disease, among which is ordinary consumption, are caused by a baciUus closely resembling that of leprosy. It was discovered by Koch m 1880-82, and named BadUus tuberculosis. The ways of infection are by inhalmg the dried sputum of consumptives, drinking infected cow's milk, or eating infected meat. Typhoid Fever.— A. disease of human beings only. Eberth in 1880 discovered the germ causing it and called it BaciUus typhosus. It gains entrance to our bodies chiefly in the milk and water we drink, which comes from infected sources ; a rarer method is by inhalation of infected air. Diphtheria.— X disease of human beings chiefly. It is caused by a bacUlus which was described in 1883-84 by Klebs and Loeffler, and is known ac BaciUus dipJUheriae, or Klebs-Loeffler bacillus. Its moc^.c of entry b by inhaUng infected air, or by drinking or eating infected mUk or food. C/iofero.— This disease is peculiar to human beings. Its native home is on the banks of the river Ganges in India, where Koch in 1884 was able to isolate its causative spi- rillum. Man is infected by drinking contaminated water or by contact. Lockjaw, or TefantM.— Afflicts men, horses, and dogs. The BaciUus tetani is the most deadly of all known bacteria. It enters the body by wounds. It was discovered in 1884 by Nicolaier. Influenza, or the GWp.-Caused by one of the smaUest- 244 Jk MEDICINE IN THE NINETEENTH CENTURY known baciUi ; discovered in im by Canon and Pieiffer. Infection spreads by the scattering about by a^-currents of the dried nasal and bronchial secretion of those suffer- ing from the disease, and its portal of entry is by the nc. and bronchial tubes. . Pneumoma.-Caused by a coccus which grows m pa« and smaU chains. It enters the body by means of the respiratory tract. It is present in the saliva of twenty per Tenrofhlalthy persons. Proved by Frankel in 1886 to be the cause of this disease. . , .„j Bubonk Plague.-ln 1894 Kitasato and Yersm isolated a smaU bacillus in a large number of cases and proved it to be the cause. It enters the body by means of womids of the skin, and through bites of fleas from infected rats, which are ..id to be one of the chief factors m spreadmg this dread malady. . YeUow Fever.-The cause of this disease is still under discussion. ^ „.« Such are a few of the infectious diseases which we can readily attribute to the presence of definite micro-organ- isms in respective cases. But strange as it may seem, the most typical of all infectious dUeases. small-pox. scarlet fever, measles, and hydrophobia, have as yet not yielded up their secrets. This is possibly due to the minute size of the micro-organisms concerned, which make it beyond the power of the best microscope to demonstrate them. In this coMiexion it has recently been shown by Roux and Nocard that in the case of the disease known as pleuro- pneumonia of cattle the causative agent is so vc^ sro..! as just to be barelv visible. Agam. it is qnite po.'ubi^ that these diseases may be caused by living things wc know 246 MEDICINE IN THE NINETEENTH CENTURY nothing about, which may be quite dissimilar from the bacteria. INFECTION-ITS PROCESSES AND RESULTS In the foregoing list of diseases associated with specific bacteria, attention has been arawn to the common modes of infection, or, as they are technically called, " portals of entry," and it now remains to touch upon the main factors, processes, and results following upon the entry into the body of such disease-producing microbes. It is a well-known fact that the normal blood has of itself to a considerable extent the power of killing germs which may wander into it through various channels. Likewise the tissue cells of the body m general show similar action depending upon the different cell groups, state of health, general robustness, and period of life. The germ- killing power varies in different individuals, though each may be quite healthy. Considered as a whole, this power possessed by the body against germs is known as " general resistance." And when by any means this power of resistance is lost or diminished, we run grave risks of incurring disease. Granted a case of infection, let us now trace up briefly what occm*s. Between the period when the bacteria gain a lodgment and that in which the disease assumes a notice- able form, the patient simply feek out of sorts. It is during this stage that the blood and tissues are deeply engaged in the attempt to repel the attacks of the invading microbes. With varjring speed the germs multiply throughout the 846 S' MEDICINE IN THE NINETEENTH CENTTOT , body neneiaUy, or may be .t fart locriiMd, oi even m in Mdtiplying in the tiMuee, they generate m me «»mg lo^ito fteir nonons poison., which soon c»u« prolo,md eh««». throughout the body, the patient b«om«i de- Doi the body now give up the fight enti«ly ? No , on the eontrary, the white blood^ella, the wandermg cdK °^d the eells o! the tissues mos* aflected shB eay on an *neq«I figbt. From the lymphatic glands and spleen °^roI white cells rush to the fray and .tten.pt U, eat rind dertroy the toe, but possibly in vain •, the d^ease ™ns its course, to end either in death or recove^ How, then, in cases ol recovery, are the microbes finaUy overcome ? i.j_v. This quertion involves many complex processes wUch at present are by no mean, thoroughly understood, but we win concern ourselves with the simple prmciple. It has been previously mentioned that once the bacteria get a good foothold the body is subjected to *» «" »" ° 'generated PO*"™' """" '" "^"^ " ''T, le fevlr L to such symptoms as loss of appehte, headache, feve , ^ins and ach^ and even a state of stupor or uncon^m^- „eM In addition to the active warfare of the white blood- Za> groups of celU throughout the body, after recovenng torn fhe Lt rude shock of the to«ns, begm to toeraU S prepuce, then efiect a change in the chem.c.^ con- Lion of the toxins, and finaUy elaborate suWUno» which antagonize the toxin, and destroy h«r «t.on dto- gether, thus lending aid to the wamor cells, which at last rvercome the invading microbes. Recovery » brought 247 M , MEDICINE. IN THE NINETEENTH CENTURY about, and a more or leas permanent degree of immunity against the special form of disease ensues. Now if we could use these antagonizing substances, or, as they are called, antitoxins, upon other men or animals sick with a similar disease, would their bodies be at once strengthened to resist and finally overcome the disease 1 Yes, in a certain majority of cases they would, and this b exactly what scientific observers have noted, worked out, and have successfully applied. A new art in the healing of disease, which is spoken of broadly as serum-therapy, or medication by curative or protective serums, has thus been discovered. The first observers in this new field were Pasteur and Raynaud in France in 1877-78, and Salmon and Smith in this country in 1886. Raynaud, by injecting serum from a calf which had had an attack of cow-pox, prevented the appearance of the disease in a calf freshly inoculated with the virulent material of the disease. Pasteur, by using feebly infective germs of fowl cholera, conferred immunity upon healthy fowls against the disease, and was able to cure those which were ill. Salmon and Smith injected small and repeated amounts of the elaborated toxins or poisons of the bacillus of hog cholera into healthy swine, and were able to confer immunity upon them. However, it was not until Behring in 1892 announced his discovery of an antitoxin serum for diphtheria, along with an undisputed proof of its value in treatment, that the attention of the scientific world was finally aroused and stimulated to the appreciation of the great possibilities of serum-therapy. Strange as it may seem, much opposition arose to this 248 BIEDICINE IN THE NINETEENTH CENTURY new method of treatment, not alone from the lay portions of the community, but even from the ranks of the medical profession itself. This opposition was due in part to mis- conceptions of the principles involved in the new doctrine, and in part to the falsely philanthropic prejudices of the pseudo-scientific sections of both parties. But by the persevering work of the enthusiastic believers in serum- therapy, positive conviction has now replaced misconcep- tion and prejudice in the minds of the majority of its former opponents. The accumulation of statistical evidence, even where all allowance is made for doubtful methods of compilation, shows that the aggregate mortality of diphtheria has been reduced fully fifty per cent, since the introduction of anti- toxic treatment by Behring in 1892. Since the method of preparation of the commercial diphtheria antitoxin illustrates the general principles involved in the search for the production of curative or protective serums for infectious diseases in general, a sum- mary of the steps in its manufacture will now be given. A race of diphtheria bacilli, which has been found to yield a poison of great virulence in alkaline beef broth, is grown for a week or ten days in this medium. The toxin is then separated and its virulence exactly determined. It is preserved in sterile receptacles for immediate or future use. The next step is the inoculation of a suitable animal with the toxin. Of all animak the horse has been found to meet nearly every requirement. Such an animal, in a state of perfect health, receives an injection of twenty cubic centimetres of toxin, along with ten or fifteen of standard antitoxin, beneath the skin of the neck or fore- 249 i m u- Ui :/ 1 i? MEDICINE IN THE NINETEENTH CENTURY quarters, upon three separate occasions at intervals of five days. After this it receives increasing doses of toxin, alone, at intervals of six to eight days, until, at the end of two months, it is able to stand with Uttle discomfort doses of such strength that if given in the first stage these doses would have quickly caused death. At this period the horse is bled to a small extent, and its serum tested to ascertain if prospects are good for the production by the animal of a high grade of antitoxin. If satisfactory progress has been made, the injections are continued for another month, when, as a rule, the maximal degree of antitoxic power in the serum will have been attained. The horse is now bled to the proper extent, the blood being received in a sterile jar and placed in an ice-box. Here it coagulates, and the serum separates from it. When the separation of clot and serum is complete, the latter is drawn off, taken to the laboratory, and standardized. This being finished, an antiseptic fluid is added to pre- serve the serum from decomposition. It is then bottled, labelled, and sent out for use. In similar fashion tetanus antitoxin is prepared ; and quite recently Calmette has produced an antitoxic serum for use in snake bite, by injecting horses with minute in- creasing doses of snake venom. His experiments have givf^n some remarkable results, not only in laboratory work, but also in cases of actual snake bite occurring in man. Thus bacteriological scientists, after years of labori- ous work, in the face of much criticism and severe denun- ciation, may confidently announce that they have in their possession a magic key to one of nature's secret doors, 260 MEDICINE IN THE NINETEENTH CENTURY The lock lias been turned. The door stands partly open, and we are permitted a glimpse of the future poasibiUtiea to be attained in the great fight against disease. PREVENTIVE MEDICINE The following are some of the diseases which have been remarkably controlled through preventive medicine : Smofl-pox.— WhUe not a scourge of the first rank, like the plague or cholera, at the outset of the nineteenth cen- tury variola was one of the most prevalent and dreaded of all diseases. Few reached adult life without an attack. To-day, though outbreaks still occur, it is a disease tho- roughly controlled by vaccination. The protective power of the inoculated cow-pox is not a fixed and constant quantity. The protection may be for life, or it may last only for a year or two. The all-important fact is this : That efficiently vaccinated persons may be exposed with impunity, and among large bodies of men (e.g., the Ger- man army), in which revaccination is practised, small-pox is unknown. Of one hundred vaccinated persons exposed to small-pox, possibly one might take the disease in a mild form; of one hundred unvaccinated persons so exposed one alone might escape-from twenty-five to thirty would die To be efficient, vaccination must be earned out systematically, and if all the inhabitants of this country were revaccinated at intervals small-pox would disappear (as it has from the German army), and the necessity for vaccination would cease. The difficulty arises from the constant presence of an unvaccinated remnant, by which the disease is kept alive. The Montreal experience m 1885 is an object-lesson never to be forgotten. 251 ii: ( \ 'ir 1m j < MEDICINE IN THE NINETEENTH CENTURY For eight or ten yean vaccination had been neglected, particularly among th*- French-Canadians. On February 28, 1886, a Pullman cai conductor, who came from Chicago, where the disease had been slightly prevalent, was ad- mitted into the H6tel Dieu. Isolation was not carried out, and on the 1st of April a servant in the hospital died of small-pox. FoUowing her death the authorities of the hospital sent to their homes all patients who presented no symptoms of the disease. Like fire in dry grass, the con- tagion spread, and within nine months there died of small- pox three thousand one hundred and sixty-four persons. It ruined the trade of the city for the winter, and cost miUions of dollars. There are no reasonable objections to vaccination, which is a simple process, by which a mild and harmless disease is introduced. The use of the animal vaccme does away with the possibUity of introduction of other disorders, such as syphilis. Typhus fever.— Until the middle of the nineteenth cen- tury this disease prevailed widely in most of the large cities, particularly in Europe, and also in jails, ships, hospitals and camps. It was more widely spread than typhoid fever and much more fatal. Murchison remarks of it that a complete history of its ravages would be the history of Europe during the past three centuries and a half. Not one of the acute infections seems to have been more dependent upon fUth and unsanitary conditions. With the gradual introduction of drainage and a good water supply, and the reUef of overcrowding, the disease has almost entirely disappeared, and is rarely mentioned now in the bills of mortality, except in a few of the larger and more unsanitary cities. The foUowing figures iUus- 252 ' u ^ MEDiaNE IN THE NINETEENTH CENTURY trate what has been done in England within sixty yean : In 1838 in England twelve hundred and twenty-eight per- sons died of fever (typhus and typhoid) per milUon of living. Twenty years Uter the Bgures were reduced to nine hundred and eighteen ; in 1878 to three hundred and six of typhoid and to thLHy-six of typhus fever. In 1892 only one hundred and thirty-seven died of typhoid fever and only three of typhus per miUion living '. Typhoid Fet-cr.— While preventive medicine can claim a great victory in this disease also, it is less brilliant, since the conditions which favour its prevalence are not those speciaUy relating to overcrowding as much as to imperfect water supply and the contamination of certam essential foods, as milk. It has been repeatedly demonstrated that, with a pure water supply and perfect drainage, typhoid fever almost disappears from a city. In Vienna, after the introduction of good water, the rate of mortality from typhoid fever fell from twelve per ten thousand of the inhabitants to about one. In Munich the faU was stUl more remarkable ; from above twentynine per ten thou- sand inhabitants in 1857 it feU to about one per ten thou- sand in 1887. That typhoid fever in this country is still a very prevalent disease depends mainly upon two facts : First, not onlvis the typhoid baciUus very resistant, but it may remain for a long time in the body of a person after recovery from typhoid fever, and such persons, m apparent good health, may be a source of contamination. With manyof theconditions favouring the persistence and growth of the bacillus outside the body we ate not yet familiar. The experience in the Spanish-American War illustrates how dangerous is the concentration together of large 263 ■ 1 ) ! L^'lt MEDICINE IN IHE NINETEENTH CENTURY numbew of individuals. But, irhoid fever iu the United States, particularly in countr- dbin la, ia the absence of anything like efiBcient nir.i sanitation. Many countries have yet to lej^rn the alpha l)ft of Siuuta- tion. The chief danger results from the impure water supplies of the smaller towns, while the local house epi- demics are due to infected wells, and the mUk outbreaks due to the infection of dairy farms. The importance of scrupulously guardi.g the sources of supply was never better illustrated than in the well-known and oft-quoted epidemic in Plymouth, Pennsylvania. The town, with a population of eight thouaan i, was in part supplied with drinking-water from a reservoir fed by a mountain-stream. During January, February, and March, in a cottage by the side of and at a distance of from sixty to eighty feet from this stream, a man was ill with typhoid fever. The a.^tendant8 were in the habit at night of throw- ing out the evacuations on the ground towards the stream. During these month the ground was frozen and covered with snow. In the latter part of March and early in April there was con:iderable rainfall and a thaw, in which a large part of the three months' accumulation of discharges was washed into the brook no^ Ixty feet distant. At the very time of this thaw the patient had numerous and copious discharges. About the 10th of April cases of typhoid fever broke out in the town, appearing for a time at the rate of fifty a day. In all about twelve hundred were attacked. An imiuense majority of the cases were m the part of the town which received water from the infected reservoir. 254 MEDICINE IN THE NINETEENTH Ji^TUBY The use oi boiled water and o( ice made fr- n distilled wat'-r, the syatematic inspection oi dairiea, - scr i>ulous supervimoii of the sources from which the ater is obtained, an efficient system of sewage removal, and, above all. the most scrupulous care m tho part of physicians and ot nurses in the disinfection of the discharges of typhoid fever patients— these are the factors necessary to redufle to a minimum the incidence of typhoid fever. Choltrn— One of the great scourgea of the nineteenth CO.- V ^adc inroads into Europe and America from Inci .*. its native home. We have, however, found out the germ, found out the conditions under which it lives, and it is not likely that it will ever again gain a foothold in this country or Great Britain. Since the last epidemic, 1873, the disease, though brought to this country on several occasions, has always been held in check at the port of entry. It is communicated almost entirely through in- fected water, and the virulence of an epidemic in any city is in direct proportion to the imperfection of the water supply. This was shown in a remarkable way in the Hamburg epideiric of 1892. In Altona, which had a filtra- tion plant, there were only five hundred and sixteen cases, many of them refuge' trom Hamburg. Hamburg, where the unfiltered water o. tlic Elbe was used, had some eighteen thousand cases, with nearly eight thousand deaths. Yellow Fi-ver.—Thc cause of this disease is still under discussion. It has an interest to us in this country from its continued prevalence in Cuba, and from th? fact that at intervals it makes inroads into the Southern States, causing serious commercial loss. The history of the disease in the other West India islands, particularly Jamaica, indicates 256 1 1 t MEDICINE IN THE NINETEENTH CENTURY the steps which must be taken ior ito prevention. For- merly yeUow fever was as fatal a scourge in them as it is to-day in Cuba. By an efficient system of sanitation it has been aboUshed. The same can be done (and wiU be done) m Cuba within a few years. General Wood has already pointed out the way in the cleansing of Santiago. The Plagm.-One of the most remarkable facts in connexion with modern epidemics has been the revival of the bubonic plague, the most dreaded of all the great infections. During the nineteenth century the disease m Europe has been confined almost exclusively to Turkey and Southern Europe. Since 1894. when it appeared at Hong Kong, it has gradually spread, and there have been outbreaks of terrible severity in India. It has ex- tended to certain of the Mediterranean ports, and during the past summer it reached Glasgow, where there has been a smaU outbreak. On this hemisphere there have been small outbreaks in certain of the South American ports, cases have been brought to New York, and there have been to November 1 twenty-one cases among the Chmese in San Francisco; Judging from the readmess with which it has been checked and limited in Australia, and ui particular the facility with which the recent out- break in Glasgow has been stamped out. there is very little risk that plague will ever assume the proportions which gave to it its terrible reputation as the " black death" of the Middle Ages. As I have already men- tioned, the germ is known, and prophylactic inoculations have been made o.i a large scale in India, with a certam measure of success. Tuberculosis.— In all communities the white plague, 25G MEDiaNE IN THE NINETEENTH CENTURY as Oliver WendeU Holmes calls it, takes the first i-ank as a killing disease. It has been estimated that of it one hundred and twenty thousand people die yearly in this country. In all mortaUty biUs tuberculosis of the lungs, or consumption, heads the list, and when to this ifl added tuberculosis of the other organs, the number swells to such an extent that this disease equals in fatality all the other acute infective diseases combined, if we leave ou^. pneumonia. Less than twenty years ago we knew little or nothing of the cause of the disease. It was believed to be largely hereditary. Koch discovered the germ, and wiih this have come the possibiUties of limiting its ravages. The foUowing points with reference to it may be stated : In a few very rare instances the disease is transmitted from parent to chUd. In a large proportion of aU cases the disease Ls "caught." The germs are widely dis- tributed through the sputum, which, when dry, becomes dust, and is blown about in aU directions. Tubercle baciUi have been found in the dust of streets, houses, hospital wards, and much-frequented places. A single individual may discharge from the lungs countless myriads of germs in the twenty-four hours. Dr. NuttaU esti- muted from a patient in the Johns Hopkins Hospital, who had only moderately advanced consumption, that from one and a half to four and a third bUlions of germs were thrown off in the twenty-four hours. The con- sumptive, as has been well stated, is almost harmless, and only becomes harmful through bad habits. The germs are contained in the sputum, which, when dry, is widely scattered in the form of dust, and constitutes AB. 267 8 1 'I V l\ BiEDICINE IN THE NINETEENTH CENTURY the great medium for the tranBmission oi the difleasc. If expectorated into a handkerchief, the sputum dnes quickly, particularly if it is put into the pocket or under the pi ow. The beard or moustache of a consumptive is smeared with the germs. Even in the most careful the hands are apt to be soUed with the germs, and m those who are dirty and careless the furniture and matenals which they handle readUy become infected. Where the dirty habit prevails of spitting on the floor, a room or the entire house, may contain numbers of germ^ In the majority of all cases the infection m tuberculosis is by inhalation. This is shown by the frcquencv with which the disease is met in the lungs, and the' great prevalence of tuberculosis in institutions in which the residents are restricted in the matter of fresh air and a free, open life. The disease prevails speciaUy in cloUters. in jails and in asylums. Infection through mUk is also possible ; it is doubtful whether the disease is transmitted through meat. So widespread are the germs that post-mortem examination has shown that a very large number of persons show slight signs of the disease who have never during life presented any symptoms; in fact, some recent investigations would indicate that a very large proportion of all persons at the age of forty have somewhere in their belies slight tuberculous lesions. This shows the iraportanct of the individual predisposition, upon which the older writers laid so much stress, and the importance of maintaimng the nutrition at its maximum. One of the most remarkable features of modern pro- tective medicine is the widespread interest that has been 268 MEDICINE IN THE NINETEENTH CENTURY aroused in the crusade against tuberculosis. What has already been accomplished wanants the belief that the hopes of even the most enthusiastic may be realized. A positive decline in the prevalence of the disease has been shown in many of the larger cities during the past ten years. In Massachusetts, which has been a hot-bed of tuberculosis for many years, the death-rate has fallen from forty- two per ten thousand inhabitants in 1863 to twenty-one and eight-tenths per ten thousand inhabitants m 1895. In the city of Glasgow, in which the records have been very carefully kept, there has been an extra- ordinary fall in the death-rate from tuberculosis, and the recent statistics of New York City show, too, a similar remarkable diminution. In fighting the disease our chief weapons are : First, education of the public, particularly of the poorer classes, who do not fully appreciate the chief danger in tlie disease. Secondly, the compulsory notification and registration of all cases of tuberculosis. The importance of this relates chiefly to the very poor and improvident, from whom after all, comes the greatest danger, and who should be under constant surveillance in order that these dangers may be reduced to a minimum. Thirdly, the foundation in suitable localities by the city and by the State of sanatoria for the treatment of early cases of the disease. Fourthly, provision for the chronic, incurable cases in special hospitals. Diphtheria.— Since the discovery of the germ of this disease and our knowledge of the conditions of its trans- mission, and the discovery of the antitoxin, there has been a great reduction in its prevalence and an equally 259 i m In ,1! ;il I ill li* MEDICINE LN THE NINETEENTH CENTURY remarkable reduction in the mortality. The more careful isoUtion of the sick, the thorough disinfection of the clothing, the rigid scrutiny of the nulder cases of throat disorder, a more stringent surveillance in the period of convalescence, and the routine examination of the throats of school-children-these are the essential measures by which the prevalence of the disease has been very markedly diminished. The great danger is in the mild cases, in which the disease has perhaps not been suspected, and in which the chUd may be walking about and even going to school. Such patients are often a source of widespread infection. The careful attention given by mothers to teeth and mouth of children is also an important factor. In children with recurring attacks of tonsilUtis, in whom the tonsils are enlarged, the organs should be removed. Through these measures the incidence of the disease has been very greatly reduced. Pw«imonto.-WhUe there has been a remarkable diminution in the prevalence of a large number of aU the acute infections, one disease not only holds its own, but seems even to have increased in its virulence. In the mortality bills, pneumonia is an easy second, to tuber- culosis; indeed, in many cities the death-rate is now higher and it has become, to use the phrase of Bunyan, "the Captain of the men of doath." It attacks particularly the intemperate, the feeble, and the old, though every year a large number of robust, bealthy individuals succumb. So frequent is pneumonia at advanced periods of life that to die of it has been said to be the natural end of old men in thi6 country. In many ways, too, it is a satisfactory disease, if one may use such an expression. It is not 260 ■■■ MEDICINE IN THE NINETEENTH CENTURY associated with much pain, except at the onset, the battle is brief and short, and a great many old persons succumb to it easily and peacefully. We know the cause of the disease ; we know only too well its symptoms, but the enormous fatality (from twenty to twenty.five per cent.) speaks only too plainly of the futility of our means of cure, and yet in no disease has there been so great a revolution in treatment. The patient is no longer drenched to death with drugs, or bled to a point where the resisting powers of nature are exhausted. We are not without hope, too, that ux the future an antidote maybe found to the toxins of thedisease, and of late there have been introduced several measures of great value in supporting the weakness of the heart, a special danger in the old and debilitated. ffj/dropfto5io.— Rabies, a remarkable, and in certain countries a widespread, disease of animab, when trans- mitted to a man by the bite of rabid dogs, wolves, etc.; is known as hydrophobia. The specific germ is unknown, but by a series of brilliant observations Pasteur showed (1) that the poison has certain fixed and peculiar properties in connexion with the nervous system ; (2) that susceptible animals could be rendered refractory to the disea^, or incapable of taking it, by a certain method of inoculation ; and (3) that an animal unprotected and inoculated with a dose of the virus sufficient to cause the disease may, by the injection of proper anti-rabic treatment escape. Supported by these facts, Pasteur began a system of treat- ment of hydrophobia in man, and a special institute was founded in Paris for the purpose. When carried out promptly the treatment ia successful in an immense 261 If, iw i ^ 1/ < M 11 li' Ml MEDICINE IN THE NINETEENTH CENTURY majority of aU cases, and the mortaUty in persons bitten by animals proved to be rabid, who have subsequently had the anti-rabic treatment, has been reduced to less than one-half per cent. The disease may be stamped out in dogs by careful quarantine of suspected animals and by a thoroughly carried out muzzling order. Afa/arta.-Among the most remarkable of modem discoveries is the cause of malarial fever, one of the great mahidies of the world, and a prime obstacle to the settle- ment of Europeans in tropical regions. UntU 1880 the cause was quite obscure. It was known that the disease prevailed chiefly in marshy districts, in the autumn, and that the danger of infection was greatest in the evenmg and at night, and that it was not directly contagious. In 1880 a French army surgeon. Laveran. discovered m the red blood-corpuscles small bodies which have proved to be the specific germ of the disease. They are not bacteria, but little animal bodies resembling the amoeba -tiny Uttle portions of protoplasm. The parasite m its earUest form is a small, clear, ring-shaped body inside the red blood-corpuscle, upon which it feeds, gradually increasing in size and forming within itself blackish grains out of the colouring matter of the corpuscle. When the little parasite reaches a certain size it begins to divide or multiply, and an enormous number of these breaku.g up at the same time .nve of! poison in the blood, which causes the paroxysms of fever. Duirng what is known as the chill, in the intermittent fever, for example, one can always find these dividing parasites. Several different forms o! the parasites have been found, corresponding to different varieties of malaria. Parasites of a very simUar 262 MEDICINE IN THE NINETEENTH CENTURY nature exist abundantly in birds. Ross, an army surgeon in India, found that the spread of this parasite from bird to bird was effected through the intervention of the mosquito. The parasites reach maturity in certam cells of the coats of the stomach of these, insects, and develop into peculiar thread-like bodies, many of which ultimately reach the salivary gknds, from which, as the insect bites, they pass with the secretion of the glands into the wound From this as a basis, numerous observers have worked out the relation of the mosquito to malaria m the human subject. , Briefly stated, the disease b transmitted chiefly by certain varieties of the mosquito, particularly the Am- phdes. The ordinary Culex, which is present chiefly in the Northern States, does not convey the disease. The Anovhdes sucks the blood from a person infected with malaria, takes in a certain number of parasites, which undergo development in the body of the insect, the final outcome of which is numerous small, thread-like struc- tures, which are fomid in numbers in the salivary glands. From this point, when the mosquito bites another m- dividual. they pass into his bloo ( : 1 ' \ if li MEDICINE IN THE NINETEENTH CENTURY frequent cause of ruined digestion in business men is the hurried meal at the lunch-counter. And a third factor, most important of all, illustrates the old maxim, that more people are killed by over eating and diinkmg than by the sword. Sensible people have begun to realize that alcoholic excesses lead inevitably to impaired health. A man may take four or five drinks of whiskey a day, or even more, and think perhaps that he transacts his business better with that amount of stimulant; but it only too frequently happens that early in the fifth decade, just as business or political success is assured, Bacchus hands in heavy bills for payment, in the form of serious disease of the arteries or of the liver, or there is a general breakdown. With the introduction of light beer there has been not only less intemperance, but a reduction in the number of cases of organic disease of the heart, liver and stomach caused by alcohol. WTiile temperance in the matter of alcoholic drinks is becoming a characteristic of Americans, intemperance in the quantity of food taken is almost the rule. Adults eat far too much, and physicians are beginning to recognize that the early degenerations, particularly of the arteries and of the kidneys, leading to Bright's disease, which were formerly attributed to alcohol are due in large part to too much food. 2Vwr«tn<7.— Perhaps in no particular does nineteenth- century practice differ from that of the preceding centuries more than in the greater attention which is given to the personal comfort of the patient and to all the accessories comprised in the art of nursing. The physician has in the trained nurse an assistant who carries out his directions with a watchful care, is on the lookout for danger-signals 270 MEDICINE IN THE NINETEENTH CENTURY and with accurate notes enables him to estimate the progress of a critical case from hour to hour. The intelligent, devoted women who have adopted the profession of nursing, are not only in their mmistrations a public benefaction, but they lighten the anxieties which form so large a part of the load of the busy doctor. Massage and Hydrotherapy have taken their places as most impo'i;ant measures of relief in many chronic conditions, and the latter has been almost universally adopted as the only safe means of combating the high temperatures of the acute fevers. Within the past quarter of a century the value of exercise in the education of the young has become recognized. The increase in the means of taking wholesome out-of-door exercise is remarkable, and should show in a few years an influence in the reduction of the nervous troubles in young persons. The prophylactic benefit of systematic exercise, taken in moderation by persons of middle ag?, is very great. Golf ana the bicycle have in the past few years materially lowered the average mcomes which doctors in this country derive from persons under forty. From the senile contingent — those above this age— the average income has for a time been raised by these exercises, as a large number of persoi^ have been injured by taking up sports which may be vigorously pursued with safety only by those with young arteries. Of three departures in the art cf healing, brief mention may be made. The use of the extracts of certain organs (or of the organs themselves) in disease is as eld as the days of the Romans, but an extraordinary impetus has been given to the subject by the discovery of the curative 271 ''I 'it ■w. .is M % - Ill MEDiaNE IN THE NINETEENTH CENTURY powers of the extract of the thyroid gland in the diseases Lwn as cretinism and myxcBdema. The brahancy of the results in these diseases has had no P«^«l "^ *^« history of modem medicine, but it camiot be said that in the use of the extracts of other organs for disease the results have fulfiUed the sanguine expectations of many. There was not, in the first place, the same pbysio bgical basis, a.d practitioners have used these extracts too mdis;riminately and without sufficient knowledge of the '""^ndlv. as I have abready mentioned, we possess a sure and certain hope that for many of the acute infec- tions antitoxins wiU be found. A third noteworthy feature in modem treatment ha^ been a return to psychical methods of cure, m which faUh in somiUng u suggested to the patient. After aU, faith b the great lever of life. Without it. man can do nothing; with it. even with a fragment as a grain oj mustard-seed, all things are possible to him. Faith m us, faith in our dmgs and methods, is the great stock m trade of the profession. In one pan of the balance, put the uharmacopcBias of the world, all the editions from Lcorides to'the last issue of the Uni^d States Dispei. satorv • heap them on the scales as did Eunpides his S Li the'celebrated contest in the " Frogs '' •, m the other put the simple faith with which from the days of the Pharaohs untU now the children of men have swahowed the mixtures these works describe, and the bu^ky ^mes will kick the beam. It is the aurum potaMe, the touch- stone of success in medicine. As Galen says, confidence ltd hope do more good than physic-" he cures most 272 MEDICINE IN THE NINETEENTH CENTURY i in whom most are confident."' That strange compound of charlatan and philosopher, Paracelsus, encouraged his patients " to have a good faith, a strong imagination, and they shall find the effects" (Burton). While we doctors often overlook or are ignorant of our own faith- cures, we are just a wee bit too sensitive about those per- formed outside our ranks. We have never had, and cannot expect to have, a monopoly in this panacea, which is open to all, free as the sim, and which may make of every one in certain cases, as was the Lacedemonia i of Homer's day, " a good physician out of Nature's grace." Faith in the gods or in the saints cures one, fa'th in little pills another, hypnotic suggestion a third, faith in a plain common doctor a fourth. In all ag'^s the prayer of faith has healed the sick, and the mental attitude of the suppliant seems to be of more consequence than the powers to which the prayer is addressed. The cures in the temples of iEsculapius, the miracles of the saints, the remarkable cures of those noble men, the Jesuit .nission- aries, in this country, the modern miracles at Lourdes and at St. Aime de Beaupre in Quebec, and the wonder- workings of the so-called Christian Scientists, are often genoine, and must be considered in discussing the founda- tions of therapeutics. We pli/sicians use the same power every day. If a poor lass, paralyzed apparently, helpless, bed-ridden for years, comes to me, having worn out in mind, body and estate a devoted family ; if she in a few weeks or less by faith in me, and faith alone, takes up her lod and walks, the saints of old could not have done more, St. Anne and many others can scarcely to-day do less. We enjoy, I say, no monopoly in the faith AE. 273 T if. M ,1 ' • !« fill. \ MEDICINE IN THE NINETEENTH CENTURY buBinew. The faith with which we work, the faith, indeed, which is available to-day in everyday Ufe has its limitations. It will not raise the dead ; it will not put in a new eye in place of a bad one (as it did to an Iroquois Indian boy for one of the Jesuit fathers), nor will it cure cancer or pneumonia, or knit a bone ; but. in spite of these nmeteenth-oentury restrictions, such as we find it. faitn iB a most precious commodity, without which we should be very badly off. . , Hypnotism, introduced by Mesmer m the eighteenth cent!^. has had several revivals as a method of treatment during the nineteenth century. The first careful study of it was made by Braid, a Manchester surgeon, who introduced the terms hypnotism, hypnotic, and nervous sleep ; but at this time no very great measure of success followed its use in practice, except perhaps in the case of an Anglo-Indian surgeon. James Esdaile, who. pnor to the introduction of anesthesia, had performed two hundred and sixty-one surgical operations upon patients m a state of hypnotic unconsciousness. About 1880 the French physicians, particularly Charcot and Bernheim. took up the study, and since that time 'aypnotism has been extensively practised. It may be defined as a subjective psychical condition, which Braid called nervous sleep, resembUng somnambulism, in which, as Shakespeare says, in the description of Lady Macbeth, the person receives at once the benefit of sleep and does the effects or acts of watching or waking. Therapeutically, the important fact is that the individual's natural sut eptibilit> to suggestion is increased, and this may hold aftc- the condi- tion of hypnosis has passed away . The condition of hypnosis 274 \ MEDiaNE IN THE NINETEENTH CENTURY is usually itself induced by suggestion, requesting the subject to close the eyes, to think of sleep, and the operator then repeats two or three times sentences suggesting sleep, and suggesting that the limbs are getting heavy and that he is feeling drowsy. During this state it has been found that the subjects are very susceptible to sugges- tion. Too much must not be expected of hypnotism, and the claims which have been m^'\e for it have been too oiten groRsly exaggerated. It seems, as it has been reo'- '' jqV put, that hypnotism "at best permits of nu . gestions more effective for good or bad than c»> '■ -i upon one in his waking state." It is found to ... ^^ very ittle use in organic disease. It has been helpful in some cases of hysteria, in certain functional spasmodic affections of the nervous system, in the vicious habits of childhood, and m suggesting to the victims of alcohol and drugs that they should get rid of their inordi- nate desires. It has been used successfully in certain cases for the relief of labour pains, and in surgical opera- tions ; but on the whole, while a valuable agent in a few cases, it has scarcely fulfilled the expectations of its advocates. It is a practice not without serious dangers, and should never be performed except in the presence of a third person, while its indiscriminate employment by ignorant persons should be prevented by law. One mode of faith-healing in modern days, which passes under the remarkable name of Christian Science, is probablv nothing more than mental suggestion under another name. " The atient is told to be calm, and is assured that all will go well ; that he must try to aid the healer by believing that what is told him is true. The healer 276 'V, I f 1 i I MEDICINE IN THE NINETEENTH CENTURY then, quietly but finnly. asserts and reiterates that there is no pain, no suffering, that it U disappearing, that relief wiU come, that the patient is getting well. This « precisely the method which Bernheim used to use with such success with his hypno€tic patients at Nancy itera: mg and reiterating, in a most wearUome way, that the disease would disapFar and the patient would feel better. As has been pointed out by a recent writer (Dr. Harry Mar- shall) the chief basis for the growth of Christian Science is that which underlies every popular fallacy: "Oliver WendeU Holmes outlined very clearly the factors concerned showing (a) how easUy abundant facts can be coUected to prove anything whatsoever; (b) how insufficient • exalted wisdom, immaculate honesty, and vast general acquirements' are to prevent an individual from having the most primitive ideas upon subjects out of his line of thought; and. finally, demonstrating 'the boundless credulity and excitability of mankind upon subjects con- nected with medicine.' " 276 XIV CHAUVINISM IN MEDICINE i 277 1 1 1, ■'• < ' I (eel not in my«elf thow common antipat .es th»t I can Ab cover in other. : tboae national repugnances do not touch me. nor do I behold with preiudicetheFrench.ItaUan Spamard orDutJ. but where I find their actions in balance with my countrymen -. I honour, love, and embrace them in the same degree. I was born n the eighth climate, but seem for to be framed and con-teUated ^nto aU : I am no plant that wiU not prosper out of a.garden ; all place.. aU airs, make unto me one country ; I am m England. everywhere, and under any taer' '«*n. m.a« All's not offence that indiscretion finds And dotage terms so. ».• „ r.«. Art TI Shakispkaei, King Lear, Act ii. Still in thy right hand carry gentle peace. To sUence envious tongues. vniXctlll Shamspeabe, King Henry VIII, Act III. LtJd i.--.^L, 278 XIV CHAUVINISM' IN MEDICINE* A RARE and precious gift is the Art of Detach nt, by which a man may so separate himself from a life-long environment as to take a panoramv. view of the conditions under which he has liv. 1 ^nd movei: it frees him from Plato's den long enough to see the realities as they are, the shadows as they ap^ar. Could a physi- cian attain to such an art he would find in the state of his profession a theme calling as well for the exercise c^ the highest faculties of description and imagination as for the deepest phUosophic insight. With wisdom of the den only and of my fellow-prisoners, such a task is beyond my ambition and my powers, but to emphasizr duly the sub- ject that I wish to bring home to your hearts I must first refer to certain distinctive features of our profession : I. FOUR GREAT FEATURES OF THE GUILD Its mUe ancarfrt/.-Like everything else that is good and durable in this world, modern medicine is a product of the Greek intellect, and had its origin when that won- 1 Definition: A narrow. ilUberal spirit in matters national* provincial, collegiate, or personal. a Canadian Medital Association, Montreal, 1902. 279 •i!. : u II ( 4 I I! i \ CHAUVINISM IN MEDICINE derful people created positive or rational science, and no small credit is due to the physicians who, a& Professor Gomperz remarks (in his brilliant chapter " On the Age of Enlightenment," Greek Thinkers, Vol. 1), very early brought to bear the spirit of criticism on the arbitrary and superstitious views of the phenomena of life. If science was ever to acquire " steady and accurate habits instead of losing itself in a maze of phantasies, it must be by quiet methodical research." " It is the undying glory of the school of Cos that it introduced this innovation into the domain of its Art, and thus exercised the most bene- ficial influence on the whole intellectual life of mankind! Fiction to the right ! Reality to the left ! was the battle cry of this school in the war it was the first to wage against the excesses and defects of the nature philosophy " (Gom- perz). The critical sense and sceptical attitude of the Hippocratic school laid the foundations of modem medi- cine on broad lines, and we owe to it : first, the emanci- pation of medicine from the shackles of priestcraft and of caste ; secondly, the conception of medicine as an art based on accurate observation, and as a science, an integral part of the science of man and of nature ; thirdly, the high moral ideals, expressed in that most "memorable of human documents" (Gomperz), the Hippocratic oath; and fourthly, the conception and realization of medicine as the profession of a cultivated gentleman.* No other profes- t Nowhere in literature do we have such a charming picture illustrating the position of a cultivated physician in society as that given in Plato's Dialogues of Eryximachus, himself the son of a physician, Acumenus. In that most briUiant age the physician was the companion and friend, and in intellectual intercourse the peer of its choicest spirits, 280 ^ CHAUVINISM IN MEDICINE 9ion can boast of the same unbroken continuity of methods and of ideals. We may indeed be justly proud of our apostolic succession. Schools and systems have flou- rished and gone, schools which have swayed for genera- tions the thought of our guild, and systems that have died before their founders ; the philosophies of one age have become the absurdities of the next, and the foolish- ness of yesterday has become the wisdom of to-morrow ; through long ages which were slowly learning what we are hurrying to forget— amid all the changes and chances of twenty-five centuries, the profession has never lacke«l men who have lived up to these Greek ideals. They were those of (Jalen and of Aretseus, of the men of the Alexandrian and Byzantine schools, of the beat of the Arabians, of the men of the Renaissance, and they are ours to-day. A second distinctive feature is the remarkable solidarity. Of no other profession is the word universal applicable in the same sense. The celebrated phrase used of the Catholic Church is in truth much more appropriate when applied to medicine. It is not the prevalence of disease or the existence ever3rwhere of special groups of men to treat it that betokens this solidarity, but it is the identity throughout the civilized world of our ambitions, our methods and our work. To wrest from nature the secrets which have perplexed philosophers in all ages, to track to theur sources the causes of disease, to correlate the vast stores of knowledge, that they may be quickly available for the prevention and cure of disease— these are our am- bitions. To carefully observe the phenomena of life in all its phases, normal and perverted, to make perfect that 281 ( i \i\\. • •U h , J H I CHAUVINISM IN MEDICINE most difficult of aU arts, the art oi observation, to caU to aid the science of experimentation, to cultivate the reason- ing faculty, so as to be able to know the true from the false-these are our methods. To prevent disease, to re- Ueve suffering and to heal the sick-this is o;^ work. The profession in truth is a sort of guild or brotherhood, any member of which can take up his calling m any part of the world and find brethren whose language and methods and whose aims and ways are identical with his own. Thirdlv its progressive char octet. -Based on science, medicine has followed and partaken of its fortunes, so that in the great awakening which has made the nme- teenth memorable among centuries, the profession re- ceived a quickening impulse more powerful than at any period in its history. With the sole exception of the mechanical sciences, no other department of hmnan know- ledge has undergone so profound a change-a change 30 profound that we who have grown up in it have but slight appreciation of its momentous character. And not only in what lias been actually accomplished in unravelUng the causes of disease, in perfecting methods of prevention, and in wholesale relief of suffering, but also m the un- loading of old formulae and in the substitution of the scientific spirit of free inquiry for cast-iron dogmas we see a promise of still greater achievement and of a more glorious future. And lastly, the profession cf medicine is distinguished from aU others by its singular beneficence. It alone does the work of charity in a Jovian and God-like way, dis- pensing with free hand truly Promethean gifts. There are those who listen to me who have seen three of the most 282 A CHAUVINISM IN MEDICINE benign endowments granted to the race since the great Titan stole fire from the heavens. Search the scriptures of human achievement and you cannot find any to equal in beneficence the introduction of Anesthesia, Sanitation, with all that it includes, and Asepsis— a short half-century's contribution towards the practical solution of the pro- blems of human suffering, regarded as eternal and insolu- ble. We form almost a monopoly or trust in. this busi- ness. Nobody else comes into active competition with us, certainly not the other learned professions which con- tinue along the old lines. Every few years sees some new conquest, so that we have ceased to wonder. The work of half a dozen men, headed byLaveran, has made waste places of the earth habitable and the wilderness to blossom as the rose. The work of Walter Reed and his associates will probably make yellow fever as scarce in the Spanish Main as is typhus fever with us. There seems to be no limit to the possibilities of scientific medicine, and while philanthropists are turning to it as to the hope of hiaman- ity, philosophers see, as in some far-off vision, a science from which may come in the prophetic words of the Son of Sirach, " Peace over all the earth." Never has the outlook for the profession been brighter. Everywhere the physician is better trained and better equipped than he was twenty-five years ago. Disease is understood more thoroughly, studied more carefully and treated more skilfully. The average sum of human suf- fering has been reduced in a way to make the angels re- joice. Diseases familiar to our fathers and grandfathers have disappeared, the death rate from others is falling to the vanishing point, and public health measures hav 288 [ * Hi I 1/^ h i! CHAUVINISM IN BIEDICINE lessened me sorrows and brightened the lives of millions. The vagaries and whims, lay and medical, may neither have diminished in number nor lessened in their capacity to distress the faint-hearted who do not appreciate that to the end of time people must imagine vain things, but they are dwarfed by comparison with the colossal advance of the past fifty years. So vast, however, and composite has the profession become, that the physiological separation, in which de- pendent parts are fitly joined together, tendi to become pathological, and while some parts suffer necrosis and degeneration, others, passing the normal limits, become disfiguring and dangerous outgrowths on the body medical. The dangers and evils which threaten harmony among the units, are internal, not external. And yet, in it more than in any other profession, owing to the circumstances of which I have spoken, is complete organic unity poswble. Of the many hindrances in the way time would fail me to speak, but there is one aspect of the question to which I would direct your attention in the hope that 1 may speak a word in season. Perhaps no sin so easily besets us as a sense of self- satisfied superiority to others. It cannot always be called pride, that master sin, but more often it is an attitude of mind which either leads to bigotry and prejudice or to such a vaunting conceit in the truth of one's own be- liefs and positions, that there is no room for tolerance of ways and thoughts which are not as ours are. To avoid some smirch of this vice is beyond h.man power ; we ...e all dipped in it, some Ughtly, others deeply grained. Par- taking of the nature of uncharitableness, it has not the 284 CHAUVINISM IN MEDICINE intenBity of envy, hatred and malice, but it "hades off in fine degrees from thf .. It may be a perk tly harm- less, even an amusing trait in both nations and indi- viduals, and so well was it depicted by Charlet, Horace Vemet, and others, under the character of an enthusiastic recruit named Chauvin, that the name Chauvinism has become a by-word, expressing a bigoted, intolerant spirit. The significance of the word has been widened, and it may b«> used as a synonym for a certam type of nationalism, for a narrow provincialism, or for a petty parochialism. It does not express the blatant loudness of Jingoism, which is of the tongue, while Chauvinism is a condition of the mind, an aspect of character much more subtle and dan- gerous. The one is more apt to be found m the educated classes, while the other is pandemic in the fool multitude— " that numerous piece of monstrosity which, taken asunder, seem men and reasonable creatures of God, but confused together, make but one great beast, and a monstrosity more prodigicius than Hydra " {Rdigio Medici). Wher- ever found, and iu whatever form. Chauvinism is a great enemy of progress and of peace and concord among the units. I have not the time, nor if I had, have I the ability to portray this failing in all its varieties ; I can but touch upon some of its aspects, national, provincial and paro- chial. II. NATIONALISM IN MEDICINE Nationalism has been the great curse of humanity. In no other shape has the Demon of Ignorance assumed more hideous propor* >n3 ; to no other obsession do we yield ourselves more readily. For whom do the hosannas ring 285 Kii H % : \ M 1 i hi CHAUVINISM IN MEDICINE higher than for the succesaful butcher of tens of thousands of poor feUows who have been made to pasd through the fire to this Moloch of nationalism ? A vice of the blood, of the plasm rather, it runs riot in the race, and rages to- day as of yore in spite of the precepts of reUgion and the practice of democracy. Nor is there any hope of change ; the pulpit is dumb, the press fans the flames, Uterature panders to it and the people love to have it so. Not that aU aspects of nationalism are bad. Breathes there a man with soul so dead that it does not glow at the thought of what the men of his blood have done and suffered to make his country what it is ? There is room, plenty of room, for proper pride of land and birth What I inveigh against is a cu-sed spirit of intolerance, conceived in distrust and bred m ignorance, that makes the mental attitude perenniaUy antagonistic, even bitterly antagonistic to everything foreign, that subordinates everywhere the race to the nation, forgetting the higher claims of human brotherhood. . While medicine is everywhere tinctured with national characteristics, the wider aspects of the proiession, to which I have alluded-our common lineage and the com- munity of interests-should always save us from the more vicious aspects of this sin, if it cannot prevent it altogether. And yet I cannot say, as I wish I could, that we are whoUy free from this form of Chauvinism. Can we say, as Eng- lish, French, German or American physicians, that our culture is always cosmopoUtan, not national, that our attitude of mind is always as frankly open and friendly to the French as to the English, to the American as to the German, and that we are free at aU times and in aU places 286 CHAUVINISM IN MEDICINE from prejudice, et all oimes free from a self-satisfied feeling of superiority the ono over the othe;* ? There has been of late year J a closer union of the profession of the different countries through the International Congress and through the international meetings of the special societies; but this is not enough, aud the hostile attitude has by no means disappeared. Ignorance is at the root. When a man talks slightingly of t;he position and work of his profession in any country, or when a teacher tells you that he fails to find inspiration in the work of his foreign colleagues, in the woids of the Arabian proverb — he is a fool, shun him ! Full knowledge, which alone disperses the mists of ignorance, can only be obtained by travel or by a thorough acquaintance with the literature of the different coimtries. Personal, first-hand intercourse with men of different lands, when the mind is young and plastic, is the best vaccination against the disease. The man who has sat at the feet of Virchow, or has listened to Traube, or Hehnholtz, or Cohnheim, can never look with unfriendly eyes at German medicine or German methods Who ever met with an English or American pupil of Louis or of CTiarcot, who did not love French medicine, if not for its own sake, at least for the reverence he bore his great master ? Let our young men, particularly those who aspire to teaching positions, go abroad. They can find at home laboratories and hospitals as well equipped as any in the world, but they may find abroad more than they knew they sought — widened sympathies, heightened ideab and something perhaps of a Wdt-cultur which will remain through life as the best protection against the vice of nationalism. 287 I H, : f -■ / I ! i ll I;! CHAUVINISM IN MEDICINE Next to a personal knowledge oi men, a knowledge of the Uterature of" the profession of difierent countries wiU do much to counteract intolerance and Chauvinism. The oreat works in the department of medicine m which a man is interested, are not so many that he camiot know their contents, though they be in three or four languages. Thuik of the impetus French medicine gave to the pro- fession in the first half of the last century, of the debt we aU owe to German science in the latter half, and of the lesson of the practical application by the English of sani- tation and asepsis ! It is one of our chief glories and one of the unique features of the profession that, no matter where the work b done in the world, if of any value, it is quickly utilized. Nothing has contributed more to the denationalization of the profession of this contment than, on the one hand, the ready reception of the good men from the old countries who have cast in their lot with us. and. on the other, the influence of our young men who have returned from Europe with sympathies as wide as the profession itself. There is abroad among us a proper spirit of eclecticism, a willingness to take the grK)d where- ever found, that augurs well for the future. It helps a man immensely to be a bit of a hero-worshipper. and the stories of the Uves of the wasters of medicine do much to stimulate our ambition and rouse our sympathies. 1 the Ufe and work of such men as Bichat and Laennec wiU not stir the blood of a yomig man and make bim feel proud of France and of Frenchmen, he must be a dull and muddy mettled rascal. In reading the Ufe of Hunter, of Jenner. who thinks of the nationaUty which is merged and lost m our interest in the man and in his work ? In the halcyon 288 v< CHAUVINISM IN MEDICINE days of the Reiuussance there wu nc nationalism in medicine, but a fine catholic spirit made great leaders like Veealius, Eustachius, Stensen and others at home in every comitry in Europe. While this is impossible tO'day, a great teacher of any country may have a world-wide audience in our journal literature, which has done so much to make medicine cosmopolitan. III. PROVINCIALISM IN MEDICINE While we may congratulate ourselves that the worst aspects of nationalism in medicine are disappearing be- fore the broader culture and the more intimate know- ledge brought by ever-increasing intercourse, yet in Eng- lish-speaking coimtries conditions have favoured the growth of a very unpleasant subvariety, which may be called provincialism or sectionalism. In one sense the profession of this continent is singularly homogeneous; A young man may be prepared for his medical course in Louisiana and enter McGUl College, or he may enter Dal- housie College, Halifax, from the State of Oregon, and in either case he will not feel strange or among strangers so soon as he has got accustomed to his environment. In collegiate life there is a frequent interchange of teachers and professors between all parts of the country. To better his brains the scholar goes freely where he wishes — to Harvard, McGill, Yale, or Johns Hopkins ; there are no restrictions. The various medical societies of the two countries are, without exception, open to the members of the profession at large. The President of the Asso- ciation of American Physicians this year (Dr. James Stewart), is a resident of this city, which gave also last year AE. 289 U '.>. h CHAXmNISM IM MEDICINE ohirf ioJiu «. «PP«t«l by ».n ol .U «*»». T^ text-book. Md oMHuJi U6 tyoywUn a ownmon . thwe i, m l«t, . «m«k.bl. homogenrity to the E.#«l'-I** *g profe^.. not only on thi. conttoent tat tbroo^™^ r. w«ld. N.t«i.Uy. to widdy «»tt»rf «»»»'^'»' ^ the whole-*-, exiet, but it i. dto„«»hu* ^ ™.t hmrtion ol the netioMl ««c..t.on. » to lo^ ^t J hannony «.d brotherhood .mong the «.t^ Ite ol these broad tond.. But we .ufier «dly torn a ^vtoeirito which ha. paduJly e«th.aU«i «. a-d '^.^ origir^y from au attempt to rehev. cou- Ition. taeupportable to themaelve.. I have prawd the ^Lar^ble.aud^ttoa^t^rr^pect^-J'em^^ ::r"^;:irrMnrSe. the greate-t p^toer.l Uberty may become iu greateet eng^ Telaver.;. The tyram.y ol Ubour umone, ol truet^ *Id ol an irreeponrible pre- may b«r a. h«»^y 2«- Lple a. autocraey to its worrt lorm. tod, .t«uge Cw «I fate! «" ^'""^^ "' ^"™""^ " • ZLha. to>p«ed to a few years a TO^e -- ^^^^ than that which atSicte our brethren m Great Bntam, which t»olc generations to forge. ThedeUghtlul freedom ol toteroooise ol which I spoUe, ,^ wSe and generous, is Itouted to touUectual and ^ m. «id on the pr«>tical side, not only are gemd Scour^ous lacilities lacktog, but the ba» d a ng.d provincialism are pat up, tomg each State a. wrth a i 3^; CHAUVINISM IN MEDICINE Chinese wall. In the Dominion of Canada there are eight portals of entry to the profession, m the United States ahnost as many as there are States, in the United King- dom nineteen, I believe, but in the latter the license of any one of these bodies entitled a man to registration any- where in the kingdom. Democracy m full circle has reached on this hemisphere a much worse condition than that in which the conservatism of many generations has entangled the profession of Qreat Britain. Upon the origin and growth of the Provincial and State Boards I do not propose to touch. The ideal has been reached so far as organization is concerned, when the profession elects its own Parliament, to which is committed the con- trol of all n tters relating to the license. The recognition, in some form, of this democratic principle, has been one great means of elevating the standard of medical edu- cation, and in a majority of the States of the Union it has secured a minimum period of four years of study, and a State Examination for License to Practice. All this is as it should be. But it is high time that the profession real- ized the anomaly of eight boards in the Dominion and some scores in the United States. One can condone the iniquity in the latter country more read' - in Canada, in which the boards have existed for a k ^or penod, and where there has been a greater uniformity in the medical curriculum. After all these years that a young man, a graduate of Toronto and a registered practitioner m Ontario, cannot practise in the Province of Quebec, his own country, without submitting to vexatious penalties of mind and pocket, or that a graduate from Montreal and a registered practitioner of this province cannot go to 291 .11 ■ f[ 1 I; CHAUVINISM IN MEDICINE M*nitoU, hi» own country •gain, and take up hU Ule'fc work without additional paymento and penalties, i», I maintain, an outrage ; it is provincUlism run riot. That this pestiferous condition should exist throughout the various provinces of this Dominion and so many States of tVe Union, illustrates what I have said of the tyranny of democracy and how gr-^at enslavers of liberty its chief proclaimers may be. That the cure of this vicious state has to be sought in Dominion biUs and National examining boards, indicates into what debasing depths of narrow provincialism we have sunk. The solution seems to be so simple, particularly in this country, with its uniformity of methods of teaching and length of curriculum. A generous spirit that wUl give to local laws a Uberal interpretation, that limits its hostility to ignorance and viciousness, that has regard as much or more for the good of the guUd aa a whole as for the profession of any province— could such a spirit brood over the waters, the raging waves of discord would soon be stilled. With the attitude of mind of the general prac- titioner in each province rests the solution of the problem. Approach it in a ' lindly and gracious spirit and the diffi- culties which seem so hard will melt away. Approach it in a Chauvinistic mood, fuUy convinced that the superior and unparalleled conditions of your province will be jeo- pardized by reciprocity or by Federal legislation, and the present antiquated and disgraceful system must await for its removal the awakening of a younger and more in- telligent generation. It would ill become me to pass from this subject- familiar to me from my student days from the mterest 292 iirfi CHAUVINISM IN MEDICINE taken in it by that lar-wghted and noble-minded man, Dr Palmer Howard— it would ill become me, I say, not to pay a tribute ol words to Dr. Roddick for the leal and pewirtence with which he has laboured to promote umon in the compound, comminuted fracture of the profession of this Dominion. My feeling on the subject of mter- national, intercolonial, and interprovincial registration is this-a man who presents evidence of proper traming, who U a registered practitioner in his own councry and who brings credentials of good stonding at the t" ■>« of departure, should be welcomed as a brother, treated as such in any country, and registered upon payment of the usual fee. The ungenerous treatment of English physi- cians in Switzerland, France, ard Italy, uid the chaotic state of internecine warfare existmg on this contment, indicatfl how far a miserable Chauvinism can corrupt the great and gracious ways which should characterize a liberal profession. , n j Though not germane to the subje-t, may I be aUowed to refer to one other point in connexion with the State Boards-a misunderstanding, I believe, of their func- tions. The profession asks that the man applying for admission to its ranks shaU be of good character and fit to practise the science and art of medicine. The latter is easily ascertained if practical men have the place and the equipment for practical examinations. Many of the boards have not kept pace with the times, and the ques- tions set too cten show a lack of appreciation of modem methods. This has, perhaps, been unavoidable since, m the appointment of examiners, it has not always been possible to select experts. The truth is, that however 29S i Ni V "^1 !, 111 III CHAUVINISM IN MEDICINE well organized and equipped, the State Boards cannot examine properly in the scientific branches, nor is there need to burden the students with additional examinations in anatomy, physiology and chemistry. The Provincial and State Boards have done a great work for medical education on this continent, which they would crown and extend by doing away at once with all theoretical examinations and limiting the tests for the license to a rigid practical examination in medicine, surgery, and midwifery, in which all minor subjects could be included. IV. PAROCHIALISM IN MEDICINE Of the parochial and more personal aspects of Chau- vinism I hesitate to speak ; all of us, unwittingly as a rule, illustrate its varieties. The conditions of life which round us and bound us, whether in town or country, in college or institution, give to the most liberal a smack of parochial- ism, just as surely as we catch the tic of tongue of the land in which we live. The dictum put into the mouth of Ulysses, " I am a part of all that I have met ," expresses the truth of the influence upon us of the social environment, but it is not the whole truth, since the size of the parish, representing the number of points of contact, is of less moment than the mental fibre of the man. Who has not known lives of the greatest freshness and nobility ham^ -i'ed at every turn and bo\md in chains the most commonplace and sordid, lives which illustrate the liberty and freedom enjoyed by minds innocent and quiet, in spite of stone walls and iron bars. On the other hand, scan the history of progress in the profession, and men the most illiberal and narrow, reeking of the most perni- 294 .XL. CHAUVINISM IN MEDICINE cioTifl type of Chauvinism, have been among the teachers and practitioners in the large cities and great medical centres ; so true is it, that the mind is its own place and in itself can make a man independent of his environment. There are shades and varieties which are by no means offensive. Many excellent features in a man's character may partake of its nature. What, for example, is more proper than the pride which we feel in our teachers, m the university from which we have graduated, in the hospital at which we have been tramed ? He is a " poor sort " who is free from such feelings, which only manifest a proper loyalty. But it easUy degenerates into a base intolerance which looks with disdain on men of other schools and other ways. The pride, too, may be in in- verse proportion to the justness of the claims. There is plenty of room for honest and friendly rivaby between schools and hospitals, only a bUnd Chauvinism puts a man into a hostile and intolerant attitude of mind at the mention of a name. Alumni and friends should remember that indiscriminate praise of institutions or men is apt to rouse the frame of mmd iUustrated by the ignore nt Athenian who, so weary of hearing Aristides always called the Just, very gladly took up the oyster shell for his os- tracism, and even asked Aristides himself, whom he did not know, to mark it. A common type of collegiate Chauvinism is manifest in the narrow spirit too often displayed in filling appoint- ments. The professoriate of the profession, the most mobUe column of its great army, should be recruited with the most zealous regard to fitness, irrespective of local conditions that are apt to influence the selection. In- 295 ili \v H \. I 1 H '< H J < h i i '•I, 1 ^ % i CHAUVINISM IN MEDICINE breeding is as hurtful to colleges as to cattle. The inter- change of men, particularly of young men, is most stim- ulating, and the complete emancipation of the chairs which has taken place in most of our universities should extend to the medical schools. Nothing, nerhaps, has done more to place German medicine in the lorefront to-day than a peripatetic professoriate, owing allegiance only to the profession at large, regardless of civic, sometimes, indeed, of national limitations and restrictions. We acknowledge the principle in the case of the scientific chairs, and with increasing frequency act upon it, but an attempt to ex- pand it to other chairs may be the signal for the display of rank parochialism. Another unpleasant manifestation of collegiate Chau- vinism is the outcome, perhaps, of the very keen com- petition which at present exists in scientific circles. In- stead of a generous appreciation of the work done in other places, there is a settled hostility and a narrowness of judgment but little in keeping with the true spirit of science. Worse still is the " lock and key " laboratory in which suspicion and distrust reign, and everyone is jealous and fearfiil lest the other should know of or find out about his work. Thank God ! this base and bastard spirit is not much seen, but it is about, and I would earnestly entreat any young man who unwittingly finds himself in a laboratory pervaded with this atmosphere, to get out ere the contagion sinks into his soul. Chauvinism in the unit, in the general practitioner, is of much more interest and importance. It is amusing to read and hear of the passing of the family physician. There never was a time in our history in which he was so 296 CHAUVINISM IN MEDICINE much in evidence, in which he was so prosperous, in which his prospects were so good or his power in the community 80 potent. The public has even begun to get aentmiental over him ! He stiU does the work ; the consultants and the specialists do the talking and the writing ; and take the fees ! By the work, I mean that great mass of routme practice which brings the doctor into every household in the land and makes him, not alone the adviser, but the valued friend. He is the standard by which we are mea- sured. What he is, we are ; and the estimate of the pro- fession in the eyes of the public is their estimat«. of him. A weU-trained. sensible doctor is one of the most valuable assets of a community, worth to-day, as in Homer's time, many another man. To make him efficient is our highest ambition as teachers, to save him from evil should be oux- constant care as a guild. I can only refer here to certam aspects in which he is apt to show a narrow Chauvinism hurtful to himself and to us. In no single relation of life does the general practitioner Bhow a more Uliberal spirit than in the treatment of him- self I do not refer so much to careless habits of Uvmg, to lack of routine in work, or to faUure to pay due atten- tion to the business side of the profession-sins which so easUy beset him-but I would speak of his failure to realize first, the need of a Ufelong progressive personal traimng, and secondly, the danger lest in the stress of practice he sacrifice that most precious of all possessions, his mental independence. Medicine is a most difficult art to ac- quire. AU the college can do is to teach the student principles, based on facts in science, and give him good methods of work. These simply start him in the right direc- 297 14 1^^ CHADVnnSM IN MEDICINE *: I li 'lf of it, and failing to do so he acts in a most illiberal and unjust w^v to himself and to the profession at large. Not only may the older man, if he has soft arteries in his grey cortex, pick up many points 298 1^.1. CHAUVINISM IN MEDICINE from the young feUow, but there ia much clinical wisdom afloat in each parish which is now wasted or dies with the old doctor, because he and the young men have never been on friendly terms. In the fight which we have to wage incessantly against ignorance and quackery among the masses and foUies of all sorts among the classes, diagnosia, not drugging, is our chief weapon of offence. Lack of systematic personal training in the methods of the recognition of disease leads to the misapplication of remedies, to long courses of treat- ment when treatment is useless, and so direcUy to that lack of confidence in our methods which is apt to place us in the eyes of the public on a levd with empirics < d quacks. Few men live lives of more devot If-sacrifice than the famUy physician, but he may bee .le so completely absorbed in work that leisure is unknown ; he has scarce time to eat or to sleep, and, as Dr. Drummond remarks in one of his poems, " He's the only man, I know me, don't get no holiday." There is danger in this treadmill life lest he lose more than health and time and rest— his in- teUectual independence. More than most men he feels the trapp'^y of isolation— that inner isolation so well ex- presse' Alatthew Arnold's Ime "We mortal miUions live oL Even in ■ pulous districts the practice of medicine is a lonely road which wincls up-hiU aU the way and a man may easUy go astray and never reach the De- lectable Mountains unless he early finds those shepherd guides of whom Bunyan tells, Knowledge, Experience, Watchful, and Sincere. The circumstances of life mould him into a masterful, self-confident, self-centered man, whose worst faults often partake of his best qualities. The 299 ^h m ih i' H \l \\ \\ 1.1. I CHAUVINISM IN MEDICINE peril is that should he cease to think for himself he becomes a mere automaton, doing a penny-in'the-slot business which places him on a level with the chemist's clerk who can hand out specifics for every Ul, from the " pip " to the pox. The salt of life in him is a judicious scepticism, not the coarse, crude form, but the sober sense of honest doubt eicpressed in the maxim of the sly old Sicilian Epi- charmus, " Be sober and distrustful ; these are the sinews of the understanding." A great advantage, too, of a sceptical attitude of mind is, as Green the historian re- marks, " One is never very surprised or angry to find that one's opponents are in the right." It may keep him from self-deception and from falling into that medical slumber into which so many drop, deep as the theological slumber so lashed by Erasmus, in which a man may write letters, debauch himself, get drunk, and even make money — a slumber so deep at times that no torpedo-touch can waken him. It may keep the practitioner out of the clutches of the arch enemy of his professional independence — the perni- cious literature of our camp-followers, a literature in- creasing in bulk, in meretricious attractiveness, and in impudent audacity. To modern pharmacy we owe much, and to pharmaceutical methods we shall owe much more in the future, but the profession has no more insidious foe than the large borderland pharmaceutical houses. No longer an honoured messmate, pharmacy in this form threatens to become a huge parasite, eating the vitals of the body medical. We all know only too well the bastard literature which floods the mail, every page of which illus- trate» the truth of the axiom, the greater the ignorance 800 -^-' * CHAUVINISM IN MEDICINE the greater the dogmatism. Much of it U advertisements of nostrums foisted on the profession by men who trade on the innocent credulity of the regular physician, quite as much as any quack preys on the gullible public. Even the most respectable houses are not free from this sm of arrogance and of ignorant dogmatism m their literature. A still more dangerous enemy to the mental virility of the general practitioner, is the " drummer " of the drug house. While many of them are good, sensible feUows, there are others, voluble as Cassio, impudent as Autolycus, and sense- less as Caliban, who wUl tell you glibly of the virtues of extract of the coccygeal gland in promoting pmeal meta- boUsm, and are ready to express the mo^ emphatic opm- ions on questions about which the greatest masters of our art are doubtful. No class of men with which we have to deal illustrates more fuUy that greatest of ignorance- the ignorance vhich is the conceit that a man knows what he does not know ; but the enthralment of the practitioner by the manufacturing chemist and the revival of a pseudo- scientific polypharmacy are too large questions to be dealt with at the end of an address. But there is a still greater sacrifice which many of us make, heedlessly and thoughtlessly forgetting that " Man does not live by bread alone. One cannot practise medi- cine alone and practise it early and late, as so many of us have to do, and hope to escape the maUgn influences of a routine life. The incessant concentration of thought upon one subject, however interesting, tethers a man's mmd in a narrow field. The practitioner needs culture as weU as learning. The earliest picture we have m lite- rature of a scientific physician, in our sense of the term, 801 h i:\ > il ", ..' i ! CHAUVINISM IN MEDICINE IB as a otdtared Qreek gentleman ; and I care not whether the young man labours among the beautiful homes on Sherbrooke Street, or in the slums of Caughnawauga, or in some sparsely settled country district, he cannot afford to have learning only. In no profession does culture count for so much as in medicine, and no man needs it more than the general practitioner, working among all sorts and conditions of men, many of whom are influenced quite as much by his general ability, which thty can appreciate, as by his learning of which they have no measure. The day has passed for the " practiser of physic " to be like Mr. Robert Levet, Dr. Johnson's friend, " Obscurely wise and coarsely kind." The wider and freer a man's general education the better practitioner is he likely to be, parti- cularly among the higher classes to whom the reassurance and sympathy of a cultivated gentleman of the tj^je of Eryzimachus, may mean much more than pills and po- tions. But what of the men of the type of Mr. Robert Levet, or "Ole Docteur Fiset," whose virtues walk a narrow round, the men who do the hard general practices in the poorer districts of the large cities, in the factory towns and in the widely scattered rough agricultural re- gionc —what, I hear you say. has culture to do with them ? Everything ! It is the bichloride which may prevent the mfection and may keep a man sweet and whole amid the most debasing surroundings. Of very little direct value to him in his practice — though the poor have a pretty keen appreciation of a gentleman — it may serve to pre- vent the degeneration so apt to overtake the overworked practitioner, whose nature is only too prone to be subdued like the dyer's hand to what it works in. If a man does 802 CHAUVINISM IN MEDICINE not sell his soul, if he does not part with his birthright of independence for a mess of pottage to the Ishmaelites who harass our borders with their clubs and oppress us with their exactions, if he can only keep free, the conditions of practice are nowhere incompatible with St. Paul's noble Christian or Aristotle's true gentleman (Sir Thomas Browne). Whether a man will treat his professional brethren in a gentlemanly way c. in a narrow illiberal spirit is partly a matter oi temperament, partly a matter of traming. If we had only to deal with one another the difficulties would be slight, but it must be confessed that the practice of medicine among our fellow creatures is often a testy and choleric business. When one has done his best or when a mistake has arisen through lack of special know- ledge, but more particularly when, as so often happens, our heart's best sympathies have been engaged, to be mis- understood by the patient and his friends, to have evil motives imputed and to be maligned, is too much for human endurance and justifies a righteous indignation. Women, our greatest friends and our greatest enemies, are the chief sinners, and while one will exhaust the re- sources of the language in describing our mistakes and weaknesses, another will laud her pet doctor so indiscrimin- ately that all others come under a sort of oblique con- demnation. " Foeminae simt medicorum tubse " is an old and true saying. It is hard to say whether as a whole we do not suffer just as much from the indiscriminate praise. But against this evil we are helpless. Fai ther- wise, when we do not let the heard word die ; not to listen is best, though that is ncft always possible, but silence 303 'i ir ; f 1 fr '\\ CHAUVINISM IN BIEDICINB is always poasible, than which we have no better weapon in otir armoury against evil-speaking, lying, and slander- mg. The bitterness is when the tale is believed and a brother's good name is involved. Then begins the worst form of ill-treatment that the practitioner receives— and at his own hands ! He allows the demon of resentment to take possession of his soul, when five minutes' frank conversation might have gained a brother. In a small or a large community what more io3rful than to see the brethren dwelling together in unity. The bitterness, the rancour, the personal hostility which many of us remember in our younger days has been largely replaced by a better feeling and while the golden rule is not always, as it should be, our code of ethics, we have certainly become more charitable the one towards the other. To the senior man in our ranks we look for an example, and m the smaller towns and country districts if he would remember that it is his duty to receive and welcome the young fellow who settles near him, that he should be willing to act as his adviser and refuse to regard him as a ri al, he may make a good friend and perhaps gain a brother. In speaking of professional harmony, it is hard to avoid the trite and commonplace, but neglecting the stale old chaps whose ways ire set and addressing the young, to whom sympathy and encouragement are so dear, and whose way of life means so much to the profession we love, upon them I would urge the practice of St. Augus- tine, of whom it is told in the Golden Legend that " he had these verses written at his table : Quisquis amat dictis abcsentum rodere vitam, Hanc mensam indignam noverit esse sibi * 304 CHAUVINISM IN MEDiaNE That is to My : Whosoever 'oves to missay any creature that is absent, 't may be said that this teble is deniad to him at all." With our History, Traditions, Achievements, and Hopes, there is little room for Chauvinism in medicine. The open mind, the free spirit of science, the ready accept- ance of the best from any and every source, the attitude of rational receptiveness rather than of antagonism to new ideas, the liberal and friendly relationship between dif- ferent nations and different sections of the same nation, the brotherly feeling which should characterize members of the oldest, most beneficent and universal guild that the race has evolved in its upward progress— these should neutralize the tendencies upon which I have so lightly touched. I hegan by speaking of the art of detachment as that rare i.id precious quality demanded of one who wished to take a philosophical view of the profession as a whole. In another way and in another sense this art may be still more precious. There is possible to each one of us a higher type of intellectual detachment, a sort of separation from the vegetative Ufe of the work-a-day world— always too much with us— which may enable a man to gain a true knowledg oi himself and of his relations to his fellows. Once attained, self-deception is impossible, and he may see himself even as he is seen— not always as he would like to be seen— and his own deeds and the deeds of others stand out in their true light. In such an atmosphere pity for himself h so commingled with sympathy and love for others that thexe is no place left for criticism or for a harsh judgment of his brother. But as Sir Thomas Browne 'I M ' AK. 305 11 ' M '■I i»'P 'i CHAUVINISM IN IfEDICINE — mott liberal of men and most dutinguished oi general praotitionen— «o beaatiially remarks : " These are Thonghte of things which Thoughts but tenderly touch,'* and it may be sufficient to remind this audience, made up of practical men. that the word of aoUon w itronger than the vnrd of $feeoh. 30e XV SOME ASPECTS OF AMERICAN MEDICAL BIBLIOGRAPHY 307 'I \ I i I. i. i J i ^PJ h Li Without History a man's soul is purblind, seeing only the things which almost touch his eyes. Fuller, Holy and Profane State, 1642. Every physician will make, and ought to make, observations from his own experience ; but he will be able to make a better judgment and juster observations by comparing what he reads and what he sees together. It is neither an affront to any man's understanding, nor a cramp to his genius, to say that both the one and the other may be usefully employed, and happily improved in searching and examining into the opinions and methods of those who lived before him, especially considering that no one is tied up from judging for himself, or obliged to give into the notions of any author, any further than he finds them agreeable to reason, and reducible to practice. No one therefore need fear that his natural sagacity, whatever it is, should be perplexed or misled by reading. For there is as large and fruitful a field for sagawity and good judgment to display themselves in, by dis- tinguishing between one author and another, and sometimes be- tween the several parts and passages in the same author, as is to be found in the greatest extent and variety of practice. ... It has not usually been looked upon as an extraordinary mark of wisdom for a man to think himself too wise to be taught; and yet this seems to be the case of those who rely wholly upon their own experience, and despise all teachers but themselves. FwENO, Hittory of Physic, Volume I. 1^ 808 K,' 5 XV SOME ASPECTS OF AMERICAN MEDICAL BIBLIOGRAPHY' I IN conferring upon me the presidency of this Association, I felt that you wished to pay a compliment to a man who had been much helped by libraries and who knew their value, and I hoped that it was, perhaps, in recogni- tion of the fact that a practical and busy physician may be at the same time a book lover, even a book worm. You are familiar, of course, with the objects of this Association, but as there are present with us also those who are not members, this is an occasion in which a little missionary work is timely, and I may briefly refer to some of them. An association of the medical libraries of the country, our membership includes both the great libraries^ with 50,000-100,000 volumes, and the small collections just started of a few hundred books. The former gain nothing directly from an affiliation with us— they give more than they get, but the blessing that goes with this attitude is not to be despised, and from their representa- tives we look for guidance and advice. Please understand 1 Asaociation of Medical Librarians, 1902. 309 ill' i [■I ni,;. i i« I . r. i..'l r, ; , i ; V H ! iM. SOME ASPECTS OF AMERICAN that in this address I am not talking to the men in charge of them who are familiar with what I shall say, and who are experts where I am only a dabbler ; but I wish to catch the inexperienced, those in charge of the small but growing libraries, upon whom I wish to impress some wider aspects o* the work. In the recent history of the profession ther<' is nothii^ more encouraging than the increase in the nnnber of medical libraries. The organi- zation of a library means effort, it means union, it means progress. It does good to men who start it, who help with money, with time and with the gifts of books. It does good to the young men, with whom our hopes rest, and a library gradually and insensibly moulds the profession of a town to a better and higher status. We trust that this Association may be a medium through which men interested in the promotion of the welfare of the profession may do much good in a quiet way. We have to thank some twenty physicians who have kindly joined us in this work and whose subscriptions help to pay the expenses of our exchange ; but their names on our list do more— it is an encouragement to know that they are with us, and as they get nothing in return (except the Bulletin) they should know how much we appreciate their fellowship. We have to thank, in particular, many editors who send us their journals for distribution, and the editors of many Transactions. The liberality with which the work of our Exchange has been aided by the large libraries is beyond all praise. Time and again the Library of the Surgeon-General's Office, the Academy of Medicine of New York, the Boston Medical Library Association, and the College of Physicians' Library of Philadelphia have 810 MEDICAL BIBLIOGRAPHY fiUed long lists of wants for smaUer libraries. The pro- fession is deeply indebted to Drs. Merrill, Chadwick. and Brigham. to Mr. Browne and to Mr. C. P. Fisher for their disinterested labours. In some details our machmery could be better adjusted, but we have had to work with very little money, which means sUght clerical help where much is needed, but with an increasing membership we can look forward confidently to a much more complete organization ar • a wider field of usefulness. But this Ah Jn may have other ambitions and hopes. We des^e to foster among our members and in the profession at large a proper love of books. For its own sake and for the sake of what it brings, medical biblio- graphy is worthy of a closer study than it has received heretofore in this country. The subject presents three aspects, the book itself, the book as a literary record, i e its contents, and the book in relation to the author Strictly speaking, bibliography means the science of everythmg relating to the book itself, and has nothing to do with its contents. In the words of a recent writer, the bibliographer " has to do with editions and their pecu- liarities, with places, printers, and dates, with types and Ulustrations, with sizes and collations, with bindings and owners, with classifications, collections, and catalogues. It is the book as . -naterUl object in the world that is his care, not the instruction of which it may be. or may faU to be. the vehicle. BibUography is the science or the art. or both, of book description." * But there is a larger sense of the word, and I shall discuss Professor Ferguson. Some Aspects of BiUiography, Edinburgh, 1 a 1900. 811 V I u i< < r f 11 i V ■ ; SOME ASPECTS OF AMERICAN some aspects of Amercan medical bibliography in the three- fold relationship to which I have referred. II .ae typographical considerations may be passed over with a few words. We have no Aldus or Froben or Stephanus or Ekevir, whose books are sought and prized for them.^elves, irrespective of their contents. With few exceptions the medical works published here at the end of the eighteenth and the beginning of the nineteenth cen- turies were poor specimens of the printer's art. Compare a Sydenham lirst edition of 1682 with Caldwell's Cullen, issued in Philadelphia more than 100 years later, and the comparison is in favour of the former ; and yet there is much of bibliographical interest in early American publica- tions. It would make an instructive exhibit to take a series of surgical books issued in this country from Jones' Manual in 1776 to KMy's Operative Gynecology ; it would illustrate the progress in the art of book making, and while there would be nothing striking or original, such volumes as Dorsey'd Elements of Surgery (1813), particularly in the matter of illustrations, would show that there were good book makers at that date. At one of the meetings of the American Medical Association i, selection of the works issued during the 117 years of the existence of the house of Lea Brothers would form an instructive exhibition. There are few medical works in this country the genealogy of which requires any long search. Other than the " Code of Ethics " of the American Medical Associa- tion and the " American Pharmacopeia," both of which, by the way, have histories worth tracking, and the " Dis- 812 MEDICAL BIBLIOGRAPHY pensatory" of Wood and Bache, I know of no wor^s fifty years old which continue to be reprinted. Compared with the text-books, etc., the journals of the early days were more presentable, and the general appearance of such publications as the Medical Repository, of New York, the Medical Museum, of Philadelphia, and later the Medical and Physical Journal, the North American Medical and Surgical Journal and the Medical Recorder, not only contrasts favourably with that of European journals of the period, but one gets an impression of capable and scholarly editorial control and a high grade of origmal contribwion. The Medical and Physical Journal, founded in 1820, has a special mterest and should be put on the shelves just before the American Journal of the Medical Sciences, into which it merged, one of the few great journals of the world, and the one from which one can almost write the progress of American medicine during the past century. While there is not in American medicine much of pure typographical interest, a compensation is offered in one of the most stupendous bibliographical works ever under- taken. The Index-Catalogue of the Library of the Surgeon-General's Office atones for all shortcomings, as in it is furnished to the world a universal medical biblio- graphy from the earliest times. It will ever remain a monument to the Army Medical Department, to the enterprise, energy and care of Dr. Billings, and to the scholarship of his associate, Dr. Robert Fletcher. Ambi- tious men before Dr. Billings had dreamt of a comprehen- sive medical bibliography. Conrad Gesner, the learned Swiss naturalist and physician, published his BiUiotheca Universalis as early as 1545 and followed it in 1548-9 313 Ijtt ! i ' i SOME ASPECTS OF AMERICAN by a supplement entitled Pandectarum sive Partitionum universalium Conradi Gesneri, libri xxi. Book xx, which was to represent the quintessence o! the labours oi his life and which was to include the medical bibliography, never appeared, owing to his untimely yet happy death — fdix mors Gesneri, as Caius says, in the touching tribute to his friend.* Merklin, von Haller, Ploucquet, Haeser, Young, Forbes, Atkinson and others have dipped into the vast subject, but their efforts are Lilliputian beside the Gar- gantuan undertaking of the Surgeon-General's Office. One work I cannot pass without a regret and a reference— the unfinished medical bibliography of James Atkinson, London, 1834. If not on your shelves, keep your eyes on the London catalogues for it. It only includes the letters A and B, but it is a unique work by a Thelemite, a true disciple of Rabelais. I need not refer in this audi- ence to the use of the Index-Catalogue in library work ; it is also of incalculable value to any one interested in books. Let me give an everyday illustration. From the library of my friend, the late Dr. Rush Huidekoper, was sent to me a set of very choice old tomes, among which was a handsome folio of the works of du Laurens, a sixteenth century anatomist and physician. I had never heard of him, but was very much interested in some of his medical dissertations. In a few moments from the Index-Catalogue the whole bibliography of the man was before me, the dates of his birth and death, the source of his biography, and where to look for his portrait. It b impossible to overestimate the boon which this work is to book lovers. » <7ai» Opara, Jebb's edition. 814 ■aa MEDICAL BIBLIOGRAPHY One other point— the Index is not used enough by students. Take under the subject of diseases of the heart. Only the other day I referred to a journal article which had a very full bibUography. and I turned to Volume V in the old series, and to the just issued Volume VI of the new series, and there was the literature in full on this subject and in it many articles which the author had overlooked. The entire bibliography might have been omitted with advantage from the paper and simply a reference made to the Index- Catalogue. It would be well in future if writers would bear in mmd that on many subjects, particularly those covered by the second series of the Catalogue, the biblio- graphy is very complete, and only supplementary refer- ences should be made to the articles which have appeared since the volume of the new series dealing with the subject was printed. t III The second aspect of a book relates to its contents, which may have an enduring value or which may be of interest only as illustrating a phase in the piogress of knowledge, or the importance may relate to the conditions under which the book appeared. It IS sad to think how useless are a majority of the works on our shelves— the old cyclopedias and dictionaries, the files of defunct journals, the endless editions of text-books as dead as the authors. Only a few epoch-making works survive. Editions of the Hippocratic writings appear from time to time, and in the revival of the study of the history of medicine the writings of such masters as Galen and Aretjeus reappear, but the interest is scholastic, and amid 815 :^l'lt ^r^ I:- i\i H ,! 'n I l 1 ,4 \ SOME ASPECrrS OF AMERICAN the multiplicity of studies how can we ask the student to make himself familiar with the ancients? We can, however, approach the consideration of most subjects from an historical standpoint, and the young doctor who thinks that pathology began with Virchow gets about the same erroneous notion as the student who begins the study of American history with the Declaration of Inde- pendence. Now among the colossal mass of rubbish on the shelves there are precious gems which should be polished and well set and in every library put out on view. But let me first mollify the harshness of the expression just used. The other day, thinking in this way, I took from a shelf of old books the first one I touched. It was Currie's Historical Account of the Climalis and Diseases of the VnUed States of America, published in Philadelphia in 1792, I had possessed it for years, but had never before looked into it. I found the first comprehensive study on climatology and epidemiology made in this country, one which antedates by several years Noah Webster's work on epidemics. With remarkable industry Dr. Currie collected from correspondents in all parts of the country informa- tion about the prevalent diseases, and I know of no other work from which we can get a first-hand sketch from the practitioners ' emselves of the maladies prevalent in the different States. Then T had to look up his possible relationship with James Currie, of Liverpool, the strong advocate of hydrotherapy, the friend and editor of Bums, who had had, I remember, interesting affiliations with Virginia. At the outbreak of the Revolutionary War he was employed as a clerk at one of the landings on 316 MEDICAL BIBLIOGRAPHY the James River, and suffered not a little for the Tory cause. His letters, given in his Life, which are well worth reading, give a valuable picture of the period. The American Currie's book at least was not rubbish in 1792, but who will read it now ? And yet it is on our shelves for a purpose. It may not be called for once in five years ; it did a good work in its day, and the author lived a life of unselfish devotion to the profession. As a maker of much which in a few years will be rubbish of this kind, let me take back the harsh expression. But I wish to refer particularly to certain treasures in American bibliography which you should all have on your shelves. Of course the great libraries have most of them, and yet not all have all of them, but with a little effort they can be picked up. Take that notable Discourse upon the Institution of Medical Schools in America, by John Morgan, M.D., 1765. From it dates the organiza- tion of medical colleges in this country, but there is much more in this scholarly address. The introduction contains a picture of the state of practice in Philadelphia which is in its way unique, and for the first time in the history of the profession in this country Morgan tried to introduce what he calls the regular mode of practismg physic, as apart from the work of the surgeon and apothe- cary. What interests us, too, is his plea for the estab- lishment of a medical library. Listen to his appeal : "Perhaps the physicians of Philadelphia, touched with generous sentiments of regard for the rising generation and the manifest advantages accruing to the College thereby, would spare some useful books or contribute somewhat as a foundation on which we might begin." The 317 1 SOME ASPECTS OF AMERICAN biographical fragment* in the introduction show the remarkable care with which eome of the young colonial physicians sought the best available education. Few to-day, after a protracted apprenticeship, do as did Morgan, epend five -^-ars m Europe under the most celebrated miSters, bv .e returned a distinguished Fellow of the Royal Society of London, and a Correspondent of the Royal Academy of Surgery in Paris. John Jones's Plain, Practical, Concise, Remarlu on the Treatment of Wounds and Fractures, Designed for the Use of Young Military and Naval Surgeons in North America, 1776, was the vade mecum of the young surgeons in the Revolutionary War. As the first separate surgical treatise published in this country it has a distinct biblio- graphical value, and, when, possible, you should put the three editions together. Samuel Bard's study on Angina Suffocativa (17.1), or diphtheria, as it would be now termed, is an American classic of the first rank. It is difficult to get, but it is worth looking for. Get, too, his work on Midwifery, 1807, the first published m this country. An enterprising librarian wUl have all the editions of such a work. Thomas Bond's Lecture Introductory to the Study of Clinical Medicine at the Pennsylvania Hospital, 1766, remamed m manuscript until printed in Vol. IV of the North Anaerican Medical Journal, 1827, a copy of which is not difficult to obtain. It is abo republished in Morton's History of the Pennsylvania Hospital, and I republished it in the University Medical Magazine in 1897. The works of Rush should be fully represented even in the smaller libraries. His collected writings passed 818 or i MEDICAL BIBLIOGRAPHY through five editions and are easj to get. Ru«h " is the father not only of American medicine, but of American medical literature, the type of a great man, many-sided, far-seeing, full of intellect, and genius ; abused and vili- fied, as man hardly ever was before, by his contemporaries, professional and non-professional ; misunderstood by his immediate successors, and unappreciated by the present generation, few of whom know an3rthing of his real character." I gladly quote this estimate of Rush by S. D. Gross. Owing to the impression that he was disloyal to Washington, there has arisen of late a certain feeling of antagonism to his name. The truth is he was a strong hater, and, as was common at that period, a bitter partisan. I wish some one would give us the account from contemporary letters, and from the side of Rush. There is an astonishing amount of bibliographical interest in the writings of Rush, and a good story awaits the leisure hours of some capa'^i young physician. His letters are innumerable and scattered m many libraries. I came across one the other day {Bulletin of the New York Library, vol. I, No. 8), dated July 27, 1803, in which, replying to an invitation from Horatio Gates, he says pathetically, " A large and expensive family chain me to the pestle and mortar," and in a postscript he adds that as he now con- fines his labours to his patients, without trying to combat ignorance and error, he is kindly tolerated by his fellow- citizens. Many early works of great importance are difficult to find, such as Elisha North on spotted Typhus or cere- brospinal fever, 1811. Noah Webster's History of Epi- demics has a special value, apart from its interest as the 319 i-\ 1- ■ ' i N 1 .; cl- i r I i. ' I' SOME ASPECTS OF AMERICAN mott imporUnt medical work written in this country by a layman. The tracts on vaccination by Waterhouae— the American Jcnner-should be sought for carefully. Try to have a copy of Nathan Smith's A Practical Euay on Typhous Fever (1824) to hand to any young physician who asks for something good and fresh on typhoid fever. There is a long list of important essays which you should have. I cannot begin to name them all, but I may mention, as an example, Jacob Bigelow on Sdf-lmitcd Diseates, 1836, which is a tract every senior student should read, mark, learn and inwardly digest. If not obtainable, his Nature in Disease, 1859, contains it and many other essays of value. James Jackson's Letters to a Youn^ Physician, 1856, are still worth reading -and worth re- publishing. The stories of the great epidemics offer material for care- ful bibliographical research. Matthew Carey's graphic description of the great epidemic of yellow fever in Phila- delphia, whUe not so lifelike and briUiant as De Foe's great story of the plague in London, has the advantage of the tale of an eye-witness and of a brave man, one of the smaU band who rose above the panic of those awful days. It is a classic of the first rank. The Uttle book, by the way, had a remarkable sale. The first edition is dated November 13, 1793, the second, November 23, the third, November 30, and the fourth, January 16, 1794. Brockden Brown's Arthur Mervyn, whUe it gives in places a vivid description of this epidemic, is, in comparison, disappointing and lame, not worthy to be placed on the same shelf with Carey's remarkable account. 320 MEDICAL BIBLIOGRAPHT Eyen the smaller libn hould have the works of this tjjpe. They are nc*^ ha. ^ get, if looked for in the right way. Early Aax.-. jan works on special subjects shookl be sought for. The collection of works exhibited in the section on ophthalmology at the meeting of the American Medical Association shows in the most instructive manner the early publications on the subject in this country. IV The third aspect of medical bibliography relates to writings which have a value to us from our interest in the author. After all, the true bibliophile cares not so much for the book as for the man whose life and mind are illustrated in it. There are men of noble life and high character, every scrap of whose writings should be precious to us, and such men are not rare. The works are not always of any special value to-day, or even of any intrinsic interest, but they appeal to us through the sympathy and even the afiection, stirred in us by the story of the man's life. It is, I know, a not uncommon feeling — a feeling which pervades No. XXXII of Shakespeare's Sonnet8 and is so beautifully expressed in the concluding line, " Theirs for their style I'ii read, his for his love." Such an attitude I feel personally toward the literary remains of John Morgan, David Ramsay, Daniel Drake, John D. Godman, James Jackson, junr., Elisha Bartlett and others In our libraries under John Morgan, to whose remark- able essay I have already referred, there should be also his Vindication, which gives the story of the Army Medical Department in the early days of the Revolution. One AE. 821 T . ! ;1 SOME ASPECTS OF AMERICAN of the most famous names in American medicine is David Ramsay, perhaps the most distinguished pupil of Ben- jamin Rush, a man of high character. fuU of zeal and ambition and devoted to his profession, yet what he has left in general Uterature far excels in importance his medical writmgs. The larger libraries should have his famous Htttory of the American Revolution, 1789 his Life of Washif^n, and the History of South Carolina 1809 The memory of such a man shoi^d be cherished among us. and one way-and the best-is to put a com- plete set of his writings on our shelves. Another noble soul of the same stamp was John D. Godman. the tragedy of whose life and early death has a pathos unequalled in the annalsof the professionof America. Besides his anatomical works, his Museum of Ammcan Natural History and The Rambles of a Naturalist should be among your treasured Americana. There is a large literature in this group illustrating the excursions of medical men into pure literature. A com- plete set of the writings of Oliver Wendell Holmes should be in every medical library. His Boylston prize essays on Neuralgia, on Malanal Fever, and on Direct Exipkra- tions can be had bound m one volume. One of his writings is inestimable, and wul be remembered in the profession as long. I believe, as posterity will cherish his Chambered Nautilus or the Last Leaf. If you can find the ongmal pamphlet on the Contagi(mn^s of Puerperal Fever, a reprint from the New England Journal of Medicine and Surgery, 1843. have it bound in crushed levant- tis worthy of it. The reprint of 1855 is more accessible^ FaUing either of these, get the journal and cut out and 322 3? MEDICAL BIBLIOGRAPHY bind the article. Semmelweisa, who gets the credit for introducing asepsis in midwifery, came some years later. Occasionally, a well-known medical writer will dabble in pure literature, and will sometimes, as in the case of Dr. Wier Mitchell, attain a success as remarkable as that which he has had in his profession. Put his writings on the shelves— they illustrate his breadth and his strength. A volume of poems may illustrate some strong man's foible. George B. Wood's epic poem, " First and Last," and the "Eolopoesis" of Jacob Bigelow illustrate the dangers which beset physicians who write poetry. Biography is a department which you will find a very attractive and a most profitable field to cultivate for your readers. The foreign literature includes several compen- hensive encyclopedias, but it is not a department very well represented in this country. It is true that an enor- mous literature exists, chiefly m periodicals, but the sort of biography to which I refer has a threefold distinction. The subject is a worthy one, he is dead, and the writer has the necessaiy qualifications for the task. We possess three notable works on American medical biography: James Thacher, 1828 ; Stephen W. Williams, 1846, and Samuel D. Gross, 1861, which remain to-day the chief works of reference to the latter date. Thacher's is a remarkable production and for the period a most ambitious work. It has been a common tap to which writers have gone for information on the history of medicine in this country, and the lives of the prominent physicians to about 1825. It is a rare volume now, but worth its price, and I know of no more fascinating book, or one more difficult to put down, Even the printed list of subscribers 823 i' I SOME ASPECTS OF AMERICAN -alongone,too-iBmo8tmtere8ting. Many of Thacher's best known books come in the third category, and are of value in a medical library only so far as they illustrate the remarkable versatiUty of the man. His Practice, the first American one, you will, of course, try to get, and you should also U/e one of the editions of his Jmrnal of the Reooluiumary War, through which he served with pencil, as well as scalpel, m hand. It is a most graphic account, and of interest to us here smce he describes very fully the campaign in this region, which led to the sur- render of Burgoyne, the treachery of Arnold, and he was an eye-witness of the tragic end of poor Major Andr6. You wiU not find it easy to get a complete set of his writmgs. There are many smgle volumes for which you will be on the look out. Caldwell's AvkHnography is a storehouse of facts (and fancies !) relating to the University of Pennsyl- vania, to Rush and to the early days of the Transylvania University and the Cincinnati schools. Pickled, as it is, in vmegar, the work is sure to survive. Have carefully rebound James Jackson's memoir of his son (1836), and put it in the way of the young men among your readers. Few biographies will do them more good. For the curious pick up the literature on the Chapman- Pattison quarrel, and anything, in fact, relating to that vivacious and pugnacious Scot, Granville Sharpe Pattison. There are a few fuU-blown medical biographies of special interest to us : The life and writings of that remarkable phUosopher and physician. Wells, of Charleston. The Ufe of John C. Warren (1860) is full of interest, and m the Essays of David Hossack you will get the inner history of the profesfton in New York during the early years of the 824 MEDICAL BIBLI0GR>:PHY last century. In many ways Daniel Trake is the most unique figure in the history of American medicine. Get his Life, by Mansfield, and his Pioneer Life in Kentucky. He literally made Cincinnati, having " booned " it in the early days in his celebrated Picture of Cincinnati, 1815. He founded nearly everything that is old and good in that city. His monumental work on The Diseases of the Mississippi VaUey is in every library ; pick out from the catalogues every scrap of his wilbings. I must bring these " splintery," rambling remarks tr a close, but I hope that I may have stirred in you an interest in some of the wider aspects oi American medical bioblio- graphy — I mean aspects other than the daily demand upon you for new books, new editions and new joumab. Keep ever in view, each one in this circle, the important fact that a library should be a storehouse of everything relating to his history of the profession of the locality. Refuse nothing, especially if it is old ; letters, manuscripts of all kinds, pictures, everjrthing illustrating the growth as well as the past condition, should be preserved and tabulated. There is usually in each community a man who is fond of work of this sort. Encourage him in every possible way. Think of the legacy left by Dr. Toner, of Washington, rich in materials for the history of the profession during the Revolutionary War ! There should be a local pride in collecting the writings and manuscripts of the men who have made a school or a city famous. It is astonishing how much manuscript material is stowed away in old chests and desks. Take, for example, the recent " find " of Dr. Cordell of the letters of the younger Wieaenthal, of Baltimore, describing student life in London about the middle of the eighteenth century. 826 Mi 1 • 1 AMERICAN MEDICAL BIBLIOGRAPHY Think of the precious letters of that noble old man, Nathan Smith, full of details about the foundations of the Dart- mouth and the Yale Schools of Medicine ! Valuable now (too valuable to be in private hands), what will they be 100 or 200 years hence ! What ohould attract us aU is a study of the growth of the American mind in medicine since the starting of the colonies. As m a mirror this story is reflected in the literature of which you are the guardians and collectors— in letters, in manuscrpts, in pamphlets, in books, and in journals. In the eight generations which have passed, the men who have striven and struggled— men whose lives are best described in the words of St. Paul, in joumeyings often, in perils of water, in perils in the city, m perils in the wilderness, in perils in the sea, in weariness and pain- fulness, in watchings often, in hunger and thirst, and in fastings— these men, of some of whom I have told you somewhat, have made us what we are. With the irre- vocable past into which they have gone lies our future, since our condition is the resultant of forces which, in these generations, have moulded the profession of a new and mighty empire. From the vantage ground of a young century we can trace in the literature how three gi^at streams of influence— English, French and German- have blended into the broad current of American medicine on which we are afloat. Adaptiveness, lucidity and thoroughness may be said to be the characteristics of these AngUcan, GaUic and Teutonic influences, and it is no smaU part of your duty to see that these influences, the combination of which gives to medicine on this continent its distinctively eclectic quality, are maintained and extended; 32fi XVI THE HOSPITAL AS A COLLEGE l« 327 Hw Hospital is thft only proper College in trfaich to rear a tme disciple of Aesculapius. ABntraiBT. Tlie most essential part of a student's instruction is obtained, aa 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 on the memory. Before the studoit is aware of what he has acquired he has learned the aspects and causes 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. OuviB WxNDXLL Houiis, Introductory Lecture, 1867. *l XVI THE HOSPITAL AS A COLLEGE THE last quarter of the last century saw many remark- able changes and reformations, among which in far-reaching general importance not one is to be compared with the reform, or rather revolution, in the teaching of the science and art of medicine. Whether the conscience of the professors at last awoke, and felt the pricking of remorse, or whether the change, as is more likely, was only part of that larger movement toward larger events in the midst of which we are to-day, need not be here discussed. The improvement has been in three directions : in demand- ing of the student a better general education ; in lengthening the period of professional study ; and in substituting laboratories for lecture rooms — ^that is to say, in the replace- ment of theoretical by practical teaching. The problem before us as teachers may be very briefly stated : to give to our students an education of such a character that they can become sensible practitioners— the destiny of seven-eighths of them. Toward this end are all our endowments, our multiplying laboratories, our complicated curricula, our palatial buildings. In the four years' course * Academy of Medicine, New York, 1903. 829 i; hi) ilA THE HOSPITAL AS A COLLEGE « division is very properly made between the preparatory or scientific branches and the practical ; the former are taught in the school or college, the latter in the hospital. Not that there is any essential difference ; there may be as much science taught in a course of surgery as in a course of embryology. The special growth of the medical school m the past 25 years has been in the direction of the practical teaching of science. Everywhere the lectures have been supplemented or replaced by pro „ I practical courses, and instead of a single laboratory devoted to anatomy, there are now laboratories of physiology, of physiological chemistry, of pathology, of pharmacology, and of hygiene. Apart from the more attractive mode of presentation and the more useful character of the knowledge obtained m this way, the student learns to use the instruments of precision, gets a mental training of incalculable value, and perhaps catches some measure of the scientific spirit. The main point is that he has no longer merely theoretical knowledge acquired in a lecture room, but a first-hand practical acquaintance with the things themselves. He not only has dissected the sympathetic system, but he has set up a kymograph and can take a blood pressure observation, he has personally studied the action of digitalis, of chloro- form and of ether, be has made his own culture media and he has " plated " organisms. The young fellow who is Bent on to us in his third year is nowadays a fairly well- trained man and in a position to begin his life's work in those larger laboratories, private and public, which nature fills with her mistakes and experiments. How can we make the work of the student in the third and fourth year as practical as it k in his first and second ? 330 i.-TniiiT-T.rT-iif THE HOSPITAL AS A COLLEGE I take it for granted we all feel that it should be. The answer it, take him from the lecture-room, take him from the amphitheatre— put him m the out-patient department —put him m the wards. It is not the systematic lecture, not the amphitheatre clinic, not even the ward class— all of which have their value— in which the reformation is needed, but m the whole relationship of the senior student to the hospital. During the first two years, he is thoroughly at home m the laboratories, domiciled, we may say, with his place in each one, to which he can go and work quietly under a tutor's direction and guidance. To parallel this condition in the third and fourth years certain reforms are necessary. First, in the conception of how the art of medicine and surgery can be taught. My firm conviction is that we should start the third year student at once en his road of life. Ask any physician of twenty years' standing how he has become proficient in his art, and he will reply, by constant contact with disease ; and he will add that the medicine he learned in the schools was totally different from the medicine he learned at the bedside. The graduate of a quarter of a century ago went out with little practical knowledge, which increased only as his practice increased. In what may be called the natural method of teaching the student begins with the patient, contmues with the patient, and ends hia studies with the patient, using books and lec- tures as tools, as means to an end. The student starts, in fact, as a practitioner, as an observer of disordered machines, with the structure and orderly functions of which he is perfectly familiar. Teach him how to observe, give him plenty of facts to observe, and the lessons will come out of the facts themselves. For the junior student in medicine 881 ii THE HOSPITAL AS A CX>LLEaE and luigerj it is a safe role to have no teaching without a patient (or a text, and the best teaching is that taught by the patient himself. The whole art of medicine is in observation, as the old motto goes, but to educate the eye to see, the ear to hear and the finger to feel takes time, and to make a beginning, to start a man on the right path, is all that we can do. We expect too much of the student and we try to teach him too much. Give him good methods and a proper point of view, and all other things will be added, as his experience grows. The second, and what is the most important ' >. jzm, is in the hospital itself. In the interests of tl medical student, of the profession, and of the public at large we must ask from the hospital authorities much greater facili- ties than are at present enjojred, at least by the students of a majority of the medical schools of this country. The work of the third and fourth year should be taken out of the medical school entire^^ and transferred to the hospital, which, as Abemethy rtuarks, is the proper college for the medical student, in his last years at least. An extraordinary difficulty here presents itself. While there are institutions in which the students have all the privileges to be desired, there are others in which they are admitted by side entrances to the amphitheatre of the hospital, while from too many the students are barred as hurtful to the best interests of the patients. The work of an institution in which there is no teaching is rarely first class. There is not that keen interest, nor the thorough study of the cases, nor amid the exigencies of the busy life is the hospital physician able to escape clinical slovenliness unless he teaches and in turn is taught by assistants and students. It is, I think, safe to say that 882 THE HOSPITAL AS A COLLEGE in » hospital with students in the wards the patients are more carefully looked after, their diseases are more fully studied and fewer mistakes made. The larger question, of the extended usefulness of the hospital in promoting the diffusion of medical and surgical knowledge, I cannot here consider. I envy for our medical students the advantages enjoyed by the nurses, who live in daily contact with the sick, and who have, in this country at least, supplanted the former in the affections of the hospital trustees. The objection often raised that patients do not like to have students in the wards is entirely fanciful. In my experience it is just the reverse. On this point I can claim to speak with some authority, having served as a hospital physician for more than 26 years, and having taught chiefly m the wards. With the exercise of ordinary dis- cretion, and if one is actuated by kindly feelings towards the patients, there is rarely any difficulty. In the present state of medicine it is very difficult to carry on the work of a first-rlass hospital without the help of students. We ask far too much of the resident physicians, whose number has not increased in proportion to the enormous increase in the amount of work thrust upon them, and much of the routine work can be perfectly well done by senior students. II How, practically, can this be carried into effect ? Let us take the third year students first. A class of 100 students maybe divided into ten sections, each of which maybe called a clinical unit, which should be in charge of one instructor. Let us follow the course of such a unit through the day. sas i r t u I :i TBI': H08i'.^Ti»L AS A COLLEGE On Mondays, ^Vedne^Kyj, and Fridays at a.m. element- ary instruction in phyt»i(.al diagnosis. From 10 to 12 a.m. practical instruction in the out-patient department. This may consist hi part in seeing the cases in a routine way, in receiving instruction how to take histories, and in becoming familiar with the ordinary aspect of disease as seen in a medical outcl inic . At 12 o'clock a senior teacher could meet four, or even five, of the units, dealing more systematically with special cases. The entire morning, or, where it is customary to have the hospital practice in the afternoon, a large part of the afternoon, two or three hours at least, should be spent in the out-patient department. No short six weeks* course, but each clinical unit throughout the sessi) ^n should as a routine see out-patient practice under skilled direction. Very soon these students are able to take histories, have learned how to examine the cases, and the out-patient records gradually become of some value. Of course all of this means abundance of clinical material, proper space in the out-patient department for teaching, sufficient apparatus and young men who are able and willing to undertake the work. On the alternate days, Tuesdays, Thursdays and Satur days, the clinical unit (which we are following) is m t\ surgical out-patient department, seeing minor surger} learning how to bandage, to give, ether, and helping in ad the interesting w( rk of a surgical dispensary Groups of three or four units should be in charge of a 'emoiistrator of morbid anatomy, who would take hem to post nortems, the individual men doing the work, and one day li *^hc w( ek Ml the units could sHend the morisiH anatorr ^'pnmn. stration of the professor of pathology. 334 I take it foe t^ranted 1 THE HOSPIIAL A8 A COLLEGE that the 4udent has go »o lar :hat he haa fiiushed hi* pathological hiatology in s sec 1 year vhich is the case in the more advanced schools. Other hours of the day or the third y ar could be de- voted to the teaching of obstetrics, materi* medica, thera- peutics, hygiene and clinical microscopy. At the end of the session in a well-conducted school the third-year student is rcallv a very well-informed fellow. He knows tht difference between Pott's disease and Pott's fn ire ; he can readily feel an enlarged spleen, t id hf' know le difference between Charcot's crystals and Char ot's joint In the fourth year 1 would .nil maintain the mni'^al un^ of ten men, whose wr k would be transferred frc aeot patient department to the wards. Fach ma ihoul ' bt^ allowed to serve in the medical, and, for a k period af^ possible, in the sunrical wards. He .«?* oul be assigned four or five . .eds. He has bad experi n. enough in his third year r ^ enable liim to take e hi.'*tory of the new cases, whu ;i would need, of course sup'^Tvi ..m )r correction by the senior house officer or atte iirig physic^n Under the siipervioion of the house physician ' '1oe« all of the work ' iijected with ' la own patients n v « A the urine, etc., and take? the da y rerord as dk v the attending physics in. One >r two of t' ■> dim *. utti are taken round the wards three or four times m tl week by one of the teachers for a couple of hours, the cases commented upon, the students asked questions and the groups made familiar 'nth tKo progress of tli. ca«es. In this way the student gets a tamiliarity with diaeasie, a practical know- ledge of clinic, method, and a practical knowledge of how to treat disease. With equal advantage the same plan 835 I"' fi K { : \s\^ u I I I ■^ THE HOSPITAL AS A COLLEGE can be followed in the suxgicsl wards and in the obstetrical and gynecological departments. An old method, it is the only method by which medicine and surgery can be taught properly, as it is the identical manner in which the physician is himself taught when he gets into practice. The radical refor-: needed is in the introduction into this country of the system of clinical clerks and surgical dressers, who should be just as much a part of the machinery of the wards as the nurses or the house physicians. There is no scarcity of material; on the contrary, thero is abundance. Thmk of the plethora of patients in this city, the large majority of whom are never seen, not to say touched, by a medical student ! Think of the hundreds of typhoid fever patients, the daily course of whose disease is never watched or studied by our pupils ! Think how few of the hundreds of cases of pneumonia which will enter the hospitals during the next three months, will be seen daily, hourly, in the wards by the fourth year men ! And yet it is for this they are in the medical school, just as much as, more indeed, than they are in it to learn the physiology of the liver or the anatomy of the hip- joint. But, you may ask, how does such a plan work m prac- tice ? From a long experience I can answer, admirably ! It has been adopted in the Johns Hopkins Medical School, of which the hospital, by the terms of the founder's will, is an essential part. There is nothing special in our material, our wards are not any better than those in other first-class hospitals, but a distinctive feature is that greater provision is made for teaching students and perhaps for the study of disease. Let me tell you in a few words just how the 836 ( THE HOSPITAIi AS A ( i ^EGE work is conducted. The third year students are taught medicine : First, in a systematic course of physical diagnosis con- ducted by Drs. Thayer and Futcher, the Associate Professors of Medicine, in the rooms adjacent to the out-patient department In the second half of the year, after receiving instruction in history-taking, the students take notes and examine out-patients. Seooruay, three days in the week at the conclusion of the out-patient hours, the entire class meets the teacher in an adjacent room, and the students are taught how to examine and study patients. It is remarkable how many interesting cases can be shown in the course of a year in this way. Each ctudent who takes a case is expected to report upon and " keep track " of it, and is questioned with refer- ence to its progress. The opportunity is taken to teach the student how to look up questions in the literature by setting subjects upon which to report in connexion with the case-j they have seen. A class of fifty can be dealt with very conveniently in this manner. Thirdly, the clinical microscopy class. The clinical laboratory is part of the hospital equipment. It is in charge of a senior assistant, who is one of the resident officers of the hospital. There is room in it for about one hundred students on two floors, each man having his own work-table and locker and a place in which he can have his own speci- mensandworkat odd hours. The course is a systematic one, giventhroughout the session, from two hours to twohours and a half twice a week, and consists of routine instruction in the methods of examining the blood and secretions, the gastric contents, urine, etc. This can be made a most invaluable AR 837 z il : ■ *: ■ THE HOSPITAL AS A CX)LLEGE course, enabling the student to continue the microscopic work which he has had in his first and second years, and he {amiliarizes himself with the use of a valuable instrument, which becomes in this way a clinical tool and not a mere toy. The clinical laboratory in the medical school, should be connected with the hospital, of which it is an essential part. Nowadays the microscopical, bacteriological and chemical work of the wards demands skilled labour, and the house physicians as well as the students need the help and super- vision o' experts in clinical chemistry and bacteriology, who shoxJd form part of the resident staff of the institution. Fourthly, the general medical clinic. One day m the week, in the amphitheatre, a clinic is held for the third and fourth year students and the more interesting cases in the wards are brought before them. As far as possible we present the diseases of the reasons, and in the autumn special attention is given to malarial and typhoid fever, and later in the winter to pnevimonia. Committees are appointed to report on every case of pneumonia and the complications of typhoid fever. There are no systematic lectures, but in the physical diagnosis classes there are set recitations, and in what I call the observation class in the dispensary held three times a week, general statements are often made concerning the diseases imder consideration. Fourth Year Ward Work. — The class is divided into three groups (one in rr .odicine, one insurgery, a .d one in obstetrics and gysenology) which serve as clinical clerks and surgical dressers. In medicine each student has five or six beds. He takes notes of the new cases as they come in, does the urine and blood work and helps the house physician in the general care of the patients. From nine to eleven the visit is made 338 %. i THE HOSPITAL AS A COLLEGE with the clinical clerks, and systematic instruction is given. The interesting cases are seen and new cases are studied, and the students questioned with reference to the symptoms and nature of the disease and the course of treatment. What I wish to emphasize is that this method of teaching is not a ward-ckss in which a group of students is taken mto the ward and a case or two demonstrated ; it is ward-work, the students themselves taking their share in the work of the hospital, just as much as the attending physician, the interne, or the nurse. Moreover, it is not an occasional thing. His work in medicine for the three months is his major subject and the clinical clerks have from nine to twelve for their ward-work, and an hour in the afternoon in which some special questions are dealt with by the senior assistant or by the house physicians. The Recitation Class.—ks there are no regular lectures, to be certain that all of the subjects in medicine are brought before the students in a systematic manner, a recitation class is held once a week upon subjects set beforehand. The WeeUy Clinic in the amphitheatre, in which the clinical clerks take Xea^tng parts, as they report upon their cases and read the notes of their cases brought before th? class for consideration. Certain important aspects of medicine are constantly kept before this class. Week after week the condition of the typhoid fever cases is discussed, the more interesting cases shown, the complications systematically placed upon the board. A pneumonU com- mittee deals with all the clinical features of this common disease, and a list of the cases is kept on the blackboard, »nd during a session the students have reports upon fifty or sixty cases, a large majority of which are seen in the 889 •"I li f , THE HOSPITAL AS A COLLEGE clinic by all of them, while the clinical clerks have in the wards an opportunity of studying them daily. The general impression amung the students and the junior teachers is that the system has worked well. There are faults, perhaps more than we see, but I am sure they are not in the system. Many of the students are doubtless not well informed theoretically on some subjects, as personally I have always been opposed to that base and moi^t pernicious system of educating them with a view to examinations, but even the dullest learn how to examine patients, and get familiar with the changing aspects of the important acute diseases. The pupil handles a sufficient number of cases to get a certain measure of technical skill, and there is ever kept before him the idea that he is not in the hospital to learn everything that is known but to learn how to study disease and how to treat it, or rather, how to treat patients. Ill A third change is in reorganization of the medical school. This has been accomplished in the first two years by an extraordinary increase in the laboratory work, which has necessitated an increase in the teaching force, and indeed an entirely new conception of how such subjects as physiology, pharmacology and pathology should be taught. A corres- ponding reformation is needed in the third and fourth years. Control of ample clinical facilities is as essential to-day as large, well-endowed laboratories, and the absence of this causes the clinical to lag behind the scientific edu- cation. Speaking for the Department of Medicine, I should say that three or four well-equipped medical clinics of fifty 840 THE HOSPITAL AS A CiOLLEQE to seventy-five beds each, with out-patient departments under the control of the directors, are required for a school of maximum size, say 800 students. Within the next quarter of a century the larger universities of this country will have their own hospitals in which the problems of nature known as disease will be studied as thoroughly as are those of geology or Sarscrit. But even with present conditions much may be done. There are hundreds of earnest students, thousands of patients, and scores of weU-equipped young men willing and anxious to do practical teaching. Too often, as you know full well, " the hungry sheep look up and are not fed ; " for the bread of the wards they are given the stones of the lecture-room and amphitheatre. The dissociation of student and patient is a legacy of the per- nicious system of theoretical teaching from which we have escaped in the first and second years. For the third and fourth year students, the hospital b the coUege ; for the juniors, the out-patient depart- ment and the clinics ; for the seniors, the wards. They should be in the hospital as part of its equipment, as an essential part, without which the work cannot be of the best. They should be in it as the place in which alone they can learn the elements of tho'' art and the lessons which will be of service to them when in practice for themselves. The hospital with students in its dispensaries and wards doubles its usefulness m a community. The stimulus of their presence neutralizes that clinical apathy certain, sooner or later, to beset the man who makes lonely " rounds " with his house-physician. Better work is done for the pro- fession and for the public ; the practical education of young men, who carry with them to all parts of the country good 841 THE HOSPITAL AS A COLLEGE ^. methods, extends enormously the work of an institution, and the profession is recruited by men who have been tau(^t to think and to observe for themselves, and who become independent practitioners of the new school of scientific medicine — ^men whose faith in the possibilities of their art has been strengthened, not weakened, by a knoviiedge of its limitations. It is no new method which I advocate, but the old method of Boerhaave, of the elder Rutherford of the Edinburgh school, of the older men of this city, and of Boston and of Philadelphia — the men who had been pupils of John Hunter and of Rutherford and of Saunders. It makes of the hospital a college in which, as clinical clerks and surgical dressers, the students slowly learn for themselves, under skilled direction, the phenomena of disease. It is the true method, because it is the natural one, the only one by which a physician grows in clinical wisdom after he begins practice for himself — all others are bastard substitutes. Ill H = ?%-l:^^i^ 848 xvn ON THE EDUCATIONAL VALUE OF THE MEDICAL SOCIETY. 848 u i( 'A ! I. '< ; Let tu hold faat the profeaaion of our faith without wavering. . . . and let us consider one another, to provolce unto love and to good works : not forsaking the assembling of ourselves together, as the D&anner of some is. Efistlx to thi Hibbxws, Chapter z. The want of energy is one of the main reasons why so few persons continue to improve in later years. They have noc the will, and do not know the way. They " never try an experiment " or look up a point of interest for themselves ; they make no sacrifices for the saJce of knowledge ; their minds, like their bodies, at a certain age become fixed. Genius has br>n defined as "the power of taking pains " ; but hardly any one keeps up his interest in know- ledge throughout a whole life. The troubles of a familv, the business of making money, the demands of a profession i troy the elasticity of the mind. The waxen tablet of the m< -nory, which was ; vice capable of receiving "true thoughts and olear impreesionB," becomes hard and crowded ; there is no room for the accumulations of a long life {Thecet, 194 if.). The student, as years advance, rather makes an exchange of knowledge than adds to his stores. Jowett's Introductions to Plato. 844 XVII ON THE EDUCATIONAL VALUE OF THE MEDICAL SOCIETY' A S the Autocrat remarks : Little of all we value here Wake* on the mom of its hundredth year. All the more reason to honour such occasions as the present in an appropriate manner. The tribute of words that I gladly bring— and that you may take as expressing the sentiments of your brethren at large— necessarily begins with congratulations that your society has passed into the select group of those that have reached a century of existence. But congratulations must be mingled with praise of the band of noble men who, in 1803, made this gathering possible. It is true they did but follow the lead of their colleagues of Litchfield County and their own example when, in 1784, the physicians of this county organized what is now one of the oldest medical societies in the land. In the introduction to the volume of Transac- tiona of this Society, published m 1788, the following brief statements are made as to the objects of the organization, i Centennial celebration of the New Haven Medical Association New Haven. January 6. 10OS. 845 i{-. <■ ON THE EDUCATIONAL VALUE which may be tniuposed from the parent to the child, and which I quote in Ulustration of the character of the men and as giving in brief the chief uses of a medical society : " This society was formed on the most liberal and generous principles, and was designed, first, to lay a foundation for that unanimity and friendship which u essential to the dignity and usefulness of the profession ; to accomplish which, they resolved, secondly, to meet once in three months ; thirdly, that in all cases where counsel is requisite they will assist each other without reserve; fourthly, that all reputable practitioners in the country, who have been in the practice for one year or more, may be admitted members ; fifthly, that they will communicate their observations on the air, seasons and climate, with such discoveries as they may make m physic, surgery, botany or chemistry, and deliver faithful histories of the various diseases incident to the inhabitants of this country, with the mode of treatment and event in singular cases ; sixthly, to open a correspondence with the medical societies in the neighbouring states and in Europe, for which purpose they have a standing committee of correspondence ; seventhly, to appoint a committee for the purpose of examining candidates for the profession, and to give certificates to the deserving." Changed conditions have changed some of these objects, but m the main they hold good to-day. Some of the paragraphs have suggested to me the subject of my address — the educational value of the medical society. There are many problems and difficulties in the education of a medical student, but they are not more difficult than the question of the continuous education of 846 T^» OF THE MEDICAL SOCIETY the general practvtiowr. Over the one we have some control, over the other, none. The university and the state board m»' e it certain that the one has a mmunum, at least, of proi J«ional knowledge, but who can be cerUin of the state of that knowledge of the other in five or ten years from the date of his graduation ? The specialist may be trusted to take care of himself-the conditions of his existence demand that he shaU be abreast of the times ; but the family doctor, the private m our peat army, the essential factor in the battle, should be carefully nurtured by the schools and carefully guarded by the public. Humanly speaking, with him are the issues of life and death, since upon him falls the grevious responsi- bUity in those terrible emergencies which bring darkness and despair to so many households. No ckss of men needs to call to mind more often the wise comment of Plato that education is a life-long business. The difficulties are partly adherent to the subject, partly have to do with the individual and his weakness. The problems of disease are more complicated and difficult than any others with which the trained mind has to grapple ; the conditions in any given case may be unlike those in any other ; each case, indeed, may have its own problem. Law, constantly looking back, has its forms and procedures, its precedents and practices. Once grasped, the certainties of divinity make its study a delight and its practice a pastmie ; but who can tell of the uncertainties of medicine as an art 1 The science on which it is based b accurate and definite enough ; the physics of a man's circulation are the physics of the waterworks of the town in which he Uves. but once out of gear, you cannot apply the same rules for the repair 347 \n ON THE EDUCATIONAL VAI.UE T ^ { of the one M of the other. Vftmbility ie the Uw of life, •nd M no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease. This is the fundamental di£Bculty in the education of the physician, and one which he may never grasp, or he takes it so tenderly that it hurts instead of boldly accepting the axiom of Bishop Butler, more true of medicine than of any other profession : " Probability is the guide of life." Surrounded by people who demand certainty, and not philosopher enough to agree with Locke that ** FrchiAUity $upjilies the defect of our knowledge and gwden u» when that faUa and ia always canvertant about things of which toe have no certainty," the practitioner too often gets into a habit of mind which resents the thought that opinion, not full knowledge, must be his stay and prop. There is no dis- credit, though there is at times much discomfort, in this everlasting perhaps with which we have to preface so much connected with the practice of our art. It is, as I said, inherent in the subject. Take in illustration an experience of last week. I saw a patient with Dr. Bolgiano who presented marked pulsation to the left of the sternum in the second, third and fourth interspaces, visible even before the night-dress was removed, a palpable impulse over the area of pulsation, flatness on percussion, accentuated heart sounds and a soft systolic bruit. When to this were added paralysb of the left recurrent laryngeal nerve, smallness of the radial pulse on the left side, and tracheal tugging, there is not one of you who would not make, under such circumstances, the diagnosis of aneurism of the aorta. Few of us, indeed, would p'lt in the perhaps, or 848 '!. m OF THE MEDICAL SOCIETY think o! it M ft probftbility with such a combination of phywcftl •igns, and yet the ;v^sociate contutions wiiich had been present-a smaU priiuu tun. our of the left lobe of the thyroid, with secondary iiodul^ in ih iytnpU g'.ands of the neck and involvement of tho raediasrinum and metastases in the brain with optic neurtifl-leit no question that the tumour causing the remarkable intrathoracic com- bination was not aneurismal but malignant. Listen to the appropriatecommentof the Fatherof Medicine, who twenty- five centuries ago had not only grasped the fundamental conception of our art as one based on observation, but had laboured aUo through a long life to give to the profession which he loved the saving health of science— listen, I say, to the words of his famous aphorism : " Exj>erience is faUacunu and judgmerU difficult ! " But the more serious problem relates to the education of the practitioner after he has left the schools. The founda- tion may not have been laid upon which to erect an intel- lectual structure, and too often the man starts with a total misconception of the prolonged struggle necessary to keep the educatiuu he has, to say nothing of bettering the instruction of the schools. As the practice of medicine is not a business and can never be one,' the education of » In every age there have \yt^n EUjaha ready to give up in deepair at the progresa of comiu. cialism in the profeeaion. Garth says in 1699 (Diaptntary)— . ,. j How aickening Physick hangs her pensive head And what was once a Science, now's a Trade. Of medicine, many are of the opinion expressed by one of Aken- side's disputants at Tom's Coffee House, that the <^aciente en- deavoured to nLke it a science and faUed, and the moderns to make it a trade and have succeeded. To-day the cry » louder than ever, and in truth there are groundn for alarm ; but, on the 849 i n ■ ' • « t *-r 1 ■«-i A t; 1 •t ON THE EDUCATIONAL VALUE the heart— the moral side of the man— must keep pace with the education of the head. Our fellow creatures cannot be dealt with as man deals in com and coal ; " the human heart by which we live" must control our professional relations. Aftcjr all, the personal equation has most to do with success or failure in medicine, and in the trials of life the fire which strengthens and tempers the metal of one may soften and ruin another. In his philosophy of life the young doctor will find Rabbi Ben Ezra ' a better guide, with his stimulating Then, welcome each rebuff That turns earth's smoothness rough, Each sting that bids nor sit nor stand but go I than Omar, whose fatalism, so seductive in Fitzgerald's verses, leaves little scope for human effort. For better or worse, there are few occupations of a more satisfying character than the practice of medicine, if a man can but once get orientirt and bring to it the philosophy of honest work, the philosophy which insists that we are here, not to get all we can out of the life about us, but to see how much we can add to it. The discontent and grumblings which one hears have their source in the man more often than in his environment. In the nature of the material in which we labour and of which, by other han<^. we can say to these Elijahs that there are many more than 7,000 left who have not bowed the knee to this Baal, but who practise caiUe ctute tt probe. » See Browning's poem. A good Uttle edition has just been issued (with an introduction by William Adams Slade), which I oommead tc young graduates. 850 .'lU, OF THE MEDICAL SOCIETY the way, we are partakers, there ia much that could be improved, but, as Mrs. Poyser remarks, we must accept men as the Lord made them, and not expect too mudi. But let me say this of the public : it is rarely responsible for the failures in the profession. Occasionally a man of superlative merit is neglected, but it is because he lacks that most essential gift, the knowledge how to use his gifts. The failure in 99 per cent, of the cases is m the man hinielf ; he has not started right, the poor chap has not had the choice of his parents, or his education has been faulty, or he has fallen away to the worship of strange gods, Baal or Ashtoreth, or worse still, Bacchus. But after all the kilUng vice of the young doctor is intellectual laziness. He may have worked hard at college, but the years of probation have been his rum. Without specific subjects upon which to work, he gets the newspaper or the novel habit, and fritters his energies upon useless literature. There is no greater test of a man's strength than to make him mark time in the " stand and wait " years. Habits of systematic reading are rare, and are becoming more rare, and five or ten years from his license, as practice begins to grow, may find the young doctor knowing less than he did when he started and without fixed educational purpose in life. Now here is where the medical society may step in and prove his salvation. The doctor's post-graduate education comes from patients, from books and journals, and from societies, which should be supplemented every five or six years by a return to a post-graduate school to get rid of an almoft inevitable slovenliness in methods of work. 0! his chief teachers, his patients, I cannot here speak. 861 i'i ON THE EDUCATIONAL VALUE Each case has ito lesson-a lesson that may be, but is not always, learnt, for clinical wisdom U not the eqmvalent of experience. A man who has seen 600 cases oi pneumoma may not have the understanding of the disease which comes with an intelligent study of a score of cases, so different are knowledge and wisdom, which, as the poet truly sa^, " far from being one have ofttimes no connexion." Nor can I speak of his books and journals, but on such an occa- sion as the present it seems appropriate to say a few words on the educational value of the medical society. The first, and in some respects the most miportant, function is that mentioned by the wise founders of your parent society-to Uy a foundation for that um^ and friendship which is essential to the dignity and usefutoess of the profession. Unity and friendship ! How we aU long for them, but how difficult to attain ! Strife seems rather to be the verv Ufe of the practitioner, whose warfare is incessant against disease and agamst ignorance and prejudice, and. sad to have to admit, he too often lets his angry passions rise against his professional brother. The quarrels o! doctors make a pretty chapter in the history of medicine. Each generation seems to have had its own. The Coans and the Cnidians. the Arabians and the Galenists. the humoraUsts and the soUdists. the Brunonians and the Broussaisians. the homcepaths and the regulars, have m different centuries, rent the robe of .Esculapius. But these larger quarrels are becoming less and less intense, and m the last century no new one of moment sprang up, whUe it is easy to predict that in the present century, when science has fully leavened the dough of homoepathy, the areat breach oi our day wiU be healed. But in too many * 862 :i\ OF THE MEDICAL SOCIETY towns and smaller communities miserable factions prevails, and bickerings and jealousies mar the dignity and useful- ness of the profession. So far as my observation goes, the fault lies with the older men. The young fellow, if handled aright and made to feel that he is welcomed and not regarded as an intruder to be shunned, is only too ready to hold out the hand of fellowship. The societj comes in here as professional cement. The meetings in a friendly social way lead to a free and open discussion of differences in a spirit that refuses to recognize differences of opinion on the non-essentials of life as a cause of per- sonal animosity or ill-feeling. An attitude of mind habi- tually friendly, more particularly to the young man, even though you feel him to be the David to whom your king- dom may fall, a little of the old-fashioned courtesy which makes a man shrink from wounding the feelings of a brother practitioner— m honour preferring one another ; with such a spirit abroad in the society and among its older men, there is no room for envy, hatred, malice or any uncharitableness. It is the confounded tales of patients that so often set us by the ears, but if a man makes it a rule never under any circumstances to believe a story told by a patient to the detriment of a fellow-practitioner —even if he knows it to be true !— though the measure he metes may not be measured to him again, he will have the satisfaction of knowing ihat he has clo.-ed the ears of his soul to ninety-nine lies, and to have misse i the hundredth truth will not hurt him. Most of the quarrels of doctors are about non-essential, miserable trifles and annoyances —the pin pricks of practice — which would sometimes try the patience of Job, but the good-fellowship and friendly % AE. 353 ▲ ▲ I I 1 I I it ' ' ( ON THE EDUCATIONAL VALUE intercourse of the medical society should reduce these to a minimum . The well-conducted medical society should represent a clearing house, in which every physician of the district would receive his inteUectual rating, and in which he could find out his professional assets and liabilities. We doctors do not " take stock " often enough, and are very apt to carry on our shelves stale, out-of-date goods. The society helps to keep a man " up to the times," and enables him to refurnish his mental shop with the latest wares. Rightly used, it may be a touchstone to which he can bring his experiences to the test and save him from falling into the rut of a few sequences. It keeps his mind open and recep- tive, and counteracts that tendency to premature senility which is apt to overtake a man who lives in a routine. Upon one or two speciaUy valuable features of the society I may dwell for a moment or two. In a city association the demonstration of instructive specimens in morbid anatomy should form a special feature of the work. After aU has been done, many cases of great obscurity in our daily rounds remain obscure, and as post- mortems are few and far between, the pnvate practitioner is at a great disadvantage, since his mistakes in diagnosis are less often corrected than are those of hospital physicians. No more instructive work U possible than carefully demon- strated specimens illustrating disturbance of function and explanatory of the clinical symptoms. It is hard in this country to have the student see enough morbid anatomy, the aspects of which have such an important bearing upon the mental attitude of the growing doctor. For the crass therapeutic credulity, so widespread to-day, and upon which 364 1 OF THE MEDICAL SOCIETY our manttfactaring chemists wax fat, there is no more potent antidote than the healthy scepticism bred of long study in the post-mortem room. The new pathology, so fascinating and so time-absorbing, tends, I fear, to grow away from the old morbid anatomy, a training in which is of such incalculable advantage to the physician. It is a subject which one must learn in the medical school, but the time assigned is rarely suflScient to give the student a proper grasp of the subject. The younger men should be encouraged to make the exhibition of specimens part of the routine work of each meeting. Something may be learned from the most ordinary case if it is presented with the special object of illustrating the relation of disturbed function to altered structure. Of still greater educational value is the clinical side of the society. No meeting should be arranged without the presentation of patients, par- ticularly those illustrating rare and unusual forms of disease. Many diseases of the skin and of the joints, a host of nervous affections, and many of the more remark- able of general maladies, as myxcedema, cretinism, achon- droplasia, etc., are seen so rarely and yet are so distinctive, requiring only to be seen to be recognized, that it is in- cumbent upon members to use the society to show such cases. A clinical evening devoted to these rarer affections is of very great help in diffusing valuable knowledge. The importance of a clinical demonstration was never better illustrated than at the International Congress in London in 1881, when Dr. OrA and others presented one morning at the Clinical Museum a group of cases of myxcedema. There were men from all parts of the world, and the general recognition of the disease outside of England datca 856 J If I I if 'A • I ON THE EDUCATIONAL VALUE from that meeting. The phyBiognomy of disease is learned slowly, and yet there are a great many affections which can be recognized, sometimes at a glance, more often by careful inspection, without any history. The society should be a school in which the scholars teach each other, and there is no better way than by the demonstration of the more unusual cases that happen to fall in your way. I have gone over my history cards of private patients brought or sent to me by last-year physicians, in which the disease was not diagnosed though recognizable de mm. Gout, pseudo-hypertrophic muscular paralysis, hysterical lordosis, spondylitis deformans, preataxic tabes (myosis, ptosis, etc). Graves' disease. Parkinson's disease, anorexia nerv'osa. Raynaud's disease, pernicious ansemia, spastic diplegia, spastic hemiplegia and cyanosis of chrome empny- sema were on the list. Some of these are rare diseases, but at an active society in the course of a few years every one of them could be demonstrated. The presentation of the histories of cases may be made very instructive, but this is often a cause of much weariness and dissatisfaction. A brief oral statement of the special features of a case is much to be preferred to a long, written account. The protocol or daily record of a long case shouW never be given in full. The salient points should be brought out particularly the relation the case bears to the known features of the disease and to diagnosis and treatment. The volume of the Transactions of the New Haven County Medical Society, 1788. contains many admirably reported cases I select one for special comment, as it is, so far as 1 know, the first case on record of a most remarkable disease to which much attention has been paid of late— 866 OF THE MEDICAL SOCTETY the hypertrophic stenosis of the pylorus in chUdren (see fuU discussion in the Lancet ol December 20, 1902). Dr; Hezekiah Beardsley reports a Cote of Schirrhus of the Pylonu of an Infant. Every feature of the disease as we know it now is noted— the constant puking, the leanness, the wizened, old look of the child are weU described, and the diagnosis was made four months before death ! The post-mortem showed a dilated and hypertrophied stomach and "the pylorus was invested with a hard, compact substance or schirrosity which so completely obstructed the passage into the duodenum, as to admit with the greatest difficulty the finest fluid." If other men had been as accurate and careful as Dr. Beardsley, and if other societies had foUowed the good example set so early by the New Haven County Medical Association, not only would this rare disease have been recognized, but by the accumulation of accurate observations many another disease would have yielded its secret. But it illustrates the old story— there is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language. In no way can a society better help in the education of its members than in maintaining for them a good library, and I am glad to know that this is one of your functions. It is most gratifying to note the growing interest in this work in all parts of the country. In the last number of the Bulletin of the Association of Medical Librarians there is a list of twenty-five societies with medical libraries. An attractive reading-room, with the important weekly journals, and with shelves stocked with the new books in different departments, becomes an educational centre 857 I, .1 ii Vi )i t. f i r ON THE EDUCATIONAL VALUE in which the young man can keep up his training and to which the older practitioner can go for advice when he is in despair and for reassurance when he is in doubt. The self-sacrifice necessary to establish and maintain such a Ubrary does good to the men who take part in it ; harmony is promoted, and, in the words of your fathers, the dignity and usefulness of the profession are maintained. Why is it that 'arge majority of all practitioners are not members of a medical society 1 Dr. Simmons estimates that there are 77,000 physicians in the United States who do not belong to any medical aociety whatever ! In part this is due to apathy of the officers and faUure to present an attractive programme, but more often the fault is in the men. Perhaps given over wholly to commercialiam a doctor feels it a waste of time to job a society, and ao it is if he is in the profession only for the money he can get out of patients without regard to the sacred obligation to put himself In the best possible position to do the best that is known for them. More frequently, 1 fear, the " doUar-doctor " is a regular frequenter of the society, knowing full well how suicidal in the long run is isolation from tho general body of the profession. The man who knows it all and gets nothing from the society reminds one of that little dried-up miniature of humanity, the pre- macurely senile infant, whose tabetic marasmus has added old age to infancy. Why should he go to the society and hear Dr. Jones on the gastric relations of neurasthenia when he can get it all so much better in the works of Einhorn or Ewald ? He is weary of seeing appendices, and there are no new pelvic viscera for demonstration. It is a waste of time, he says, and he feels better at hcv-ie, 058 OF THE MEDICAL SOCIETY and perh»p« that is the beat place for a man who has reached this stage of intellectual stagnation. Greater sympathy must be felt for the man who has started aU right and has worked hard at the societies, but as the rolling years have brought ever-mcreasing demands on his time, the evening hours fiiid hmi worn out yet not able to rest, much less to snatch a little diver- sion or instruction in the company of his feUovi-s whom he loves so weU. Of all men. in the profession *.he forty- visit-a-day man is the most to be pitied. Not always an automaton, he may sometimes by economy of words and ertraordinarv energy do his work well, but too often he is the one above all others who needs the refreshment of mind and recreation that is to be had in a well-conducted society Too often he is lost beyond aU recall, o^d, Uke Ephraim joined to his idoU, we may leave him alone^ Many good men are ruined by success in practice, and need to pray the prayer of the Litany against the evib of prosperity. It is only too true, as you know well, that a most successful-as the term goes-doctor may practise with a clinical slovenliness that makes it impossible for that kind old friend, Dame Nature, to cover his mistakes. A well-conducted society may be of the greatest help in stimulating the practitioner to keep up habits of scientific study. It seems a shocking thing to say, but you all know it to be a fact that many, very many men in large practice never use a stethoscope, and as for a microscope, they have long forgotten what a leucocyte or a tube cast looks like. This in some cases may be fortunate, as imperfect or half knowledge might only lead to mistakes, but the secret of this neglect of means of incalculable holp is the fact that 869 ON THE EDUCATIONAL VALUE he hM not atUined the full and enduring knowledge which should h»ve been given to him in the medical school. It is astonishing with how little outside aid a large practice may be conducted, but it is not astonishing that in it cruel and unpardonable mistakes are made. At whose door so often Ues the responsibility for death in cases of empyema but at that of the busy doctor, who has not time to make routine examinations, or who is " so driven " that the urine of his scarlet fever or puerperal patients is not examined until the storm has broken ? But I hear it sometimes said you cannot expect the general practitioner, particularly in country districts, to use the microscope and stethoscope— these are refinements of diagnosis. They are not ! They are the essential means which can be used and should be used by every intelligent practitioner. In our miserable, antiquated system ot teaching we send our graduates out wholly unprepared to make a rational diagnosis, but a man who is in earnest —and, thank heaven! most of the young men to-day in the profession are in earnest— can supply the defects in his education by careful study of his cases, and can supplement the deficiency by a post-gra-liiate course. A room fitted as a small laboratory, \^ aii .he necessary chemicals and a microscope, will prove a better investment in the long run than a static machine or a new-fangled air-pressure spray apparatus. It is not in the local society only th.\t a man can get encouragement in his day's work and a betterment of mind and methods. Every practitioner should feel a pride in belonging to his stete society, and should attend the meetings whenever possible, and gradually learn to 360 OF THE BiEDICAL SOCIETY know biB coUe«gue«. and here let me direct your attention to an important movement on the pMt of the Amencan Medical Association, which has for its object the organua- tion of the profession throughout the entire country. This can be accomplished only by a uniformity in the organization of the state societies, and by making the county society the unit through which members are ad- mitted to the state and natiomd bodies. Those of you interested will find very instructive information on this subject in the Jwmd of the association in a series of papers by Dr. Simmons, the editor, which have been repnnted in pamphlet form. As now managed, with active sections conducted by good men from all parts of the country, the meeting of the National Association is in itself a sort of brief post-graduate course. Those of you at the receptive age who attended the Saratoga meeting last June must have been impressed with the educational value of such a gathering. The Annual Museum was itself an important education in certain lines, and the papers and discussions in the various sections were of the greatest possible value. But I need say no more to this audience on the subject of medical societies ; you of New England have not " for- saken the gath-ring of yourselves together as the manner ot some is," but have been an example to the whole country. In the dedication of his Hdy War, fhomas Fuller has some very happy and characteristic remarks on the bounden duty of a man to better his heritage of birth or fortune, and what the father found glass and made crystal, he urges the son to find crystal and make peari. Your heritage has been most exceptional, and. I believe, from all that I know of the profession in this city and State, that could 961 1.0 I.I 1.25 JUS 1^ l£& 11^ 1^ ■ 3.2 1^ |3^ Ui u Ih 11^ 1.8 1.6 MICROCOPY RESOLUTION TEST CHART NATIONAL BUREAU OF STANDARDS STANDARD REFERENCE MATERIAL 1010a (ANSI and ISO TEST CHART No. 2) EDUCATIONAL VALUE OF MEDICAL SOCIETY your fathers return they would say that of their crystal you had made pearl. One cannot read their history as told by Bronson, or as sketched by your distinguished citizen, my colleague, Dr. Welch, without a glow of admiration for their lofty ideals, their steadfastness and devotion, and for their faith in the profession which they loved- The times have changed, scondition of practice have altered and are altering rapidly, but when such a celebration takes us back to your origin in simpler days and ways, we find that the ideals which inspired them are ours to-day- ideals which are ever old, yet always fresh and new, and we can truly say in Kipling's words : The men bulk big on the old trail, our own trail, the out trail. They're God's own guides on the Long Trail, the trail that is always new. 862 XVIIl THE MASTER-WORD IN MEDICINE 363 If any oi.e is desiroua of carrying cut in detail the Platonic education of after-life, some such counsols as the foUowing may be offered to him : That he shaU chooee the branch of knowledge to which hia own mind moBt distinctly inclines, and in which he takes the greatest deUght, either one which seems to connect with hip own daily employment, or, perhaps, furnishes the greatest contrast to it. He may study from the speculative side the pro- fession or business in which he is practically engaged. He may make Homer, Dante, Shakespeare< Plato, Bacon the friends and companions of his Ufe. He may find opportunities of hearing the living voice of a great teacher. He may select for mquiry some point of history, or some unexplained phenomenon of nature. An hour a day passed in such scientific or Uterary pursmta will furnish as many facts as the memory can retain, and will give him "a pleasure not to be repented of" (Timaus, 59 D). Only let him beware of being the slave of crotchets, or of running after a Will o' the Wisp in his ignorance, or in 1 is vanity of attnbutii.g to himself the gifts of a poet, or assuming the air of a philosopher. He should know the limits of his own powers. Better to build up the mind by slow additions, to creep on quietly from one thmg to another, to gain insensibly new powers and new mterests in knowledge, than to form vast schemes which are never destined to be realized. . . „, . JoWKTT, Introductions to Flato. Contend, my soul, for moments and for hours ; Each is with service pregnant, each reclaimed Is Uke a Kingdom conquered, where to reign. Robert Louis Stevenson. In the case of our habits we are only masters of the beginning, their growth by gradual stages being imperceptible, like the growth of disease. , _^, . Abistotle, Ethics. 864 XVIII THE MASTER-WORD IN MEDICINE I BEFORE proceeding to the plewmg duty of addressing the „ndergraduat»». as a native of this P^vmce and as an old student ol this sehool. I must say a few words on he momentous changes inaugurated with th« « he r^t important, perhaps, which have token pl«:e n the Ltory of the profession in OnUrio. The splendid labora- rihich we saw opened this afternoon, a witness to the ^^reciation by the authorities of the needs of science m icme, makes possible the highest standards of edu^a tion in the subjects upon which our Art - has j. They may do more. A Uberal policy, with a due regard to the truth that the greatness of a school Ue, m l"f^- " ""^^ should build up a great scientiic centre which wdl brmg r^ L to thU city and to our country The men in charge of the departments are of the right stamp. See to it that ;;« treat'them ^n the right way by givmg skiUed assi ,.a„ce Lough to ensure that the vitality of men who could work Z tt world is not »pped ty the routine of t^achmg.^' "gret wiU, I know, be m the mmds of nany of my younger Xrs. The removal of the department of anatomy and 1 University of Toronto, 1903. 365 % mA . THE MASTER-WORD IN MEDICINE physiology from the biological laboratory of the university breaks a connexion which has had an important influence on medicine in this city. To Professor Ramsay Wright is due much of the inspiration which has made possible these fine new laboratories. For years he has encouraged iii every way the cultivation of the scientific branches of medi- cine and has unselfishly devoted much time to projioting the best interests of the Medical Faculty. And in passing let me pay a tribute to the ability and zeal with which Dr. A. B. Macallum has won for himself a world-wide reputation by mtricate studies which have carried the name of this University to every nook and corner of the globe where the science of physiology is cultivated. How much you owe to him in connexion with the new buildings I need scarcely mention in this audience. But the other event which we celebrate is of much greater importance. When the money is forthcoming it is an easy matter to join stone to stone in a stately edifice, but it is hard to find the market in which to buy the precious cement which can unite into an harmonious body the professors of medicine of two rivpl medical schools in the same city. That this has been accomplished so satisfactorily is a tribute to the good sense of the leaders of the two faculties, and tells of their recognition of the needs of the profession in the pro- vince. Is it too much to look forward to the absorption or afl&liation of the Kingston and London schools into the Provincial University 1 The day has passed in which the small school without full endowment can live a life bene- ficial to the students, to the profession or to the public. I know well of the sacrifice of time and money which is freely made by the teachers of those schools ; and they will not 866 THE MASTER-WORD IN MEDICINE misunderstand my motives when I urge them to commit suicide, at least so far as to change their organizations mto clinical schools in affiliation with the central university, a* part, perhaps, of a widespread affiliation of the hospitals of the province. A school of the first rank in the world, such as this must become, should have ample clinical faculties under its own control. It U as much a necessity that ae professors of medicine and surgery, etc., should ha ,J hospital services under their control throughout the year, as it is that professors of pathology auc' physiology should have laboratories such as those in which we here meet. It should be an easy matter to arrange between the provmcial authorities and the vrustee. of the Toronto General Hospita to replace the present antiquated system of multiple small services by modern well-equipped dlnics-three in medicmo and three in surgery to begin with. The increased effi- ciency of the service would be a substantial quid pro qw>, but there would have to be a self-de.nying ordinance on the part of many of the attending physicia- - With the large num- ber of students in the combined school no one hospital can furnish in practical medicine, surgery and the specialties a training in the art an equivalent of that which the student will have in the science in the new laboratories. An affilia- tion should be sought with every other hospital in the city and province of fifty beds and over, in each of which two or three extra-mural teachers could be recognized, who would receive for three or more months a number of stu- dents proportionate to the beds in the hospital. I need not mention names. We all know men in Ottawa, Ki'g- gton, London, Hamilton, Cuelph and Chatham, who could take charge of small groups of the senior students and make 867 i THE MASTER-WORD IN MEDICINE of them good practical doctors. I merely throw out the suggestion. There are difficulties m the way ; but is there anything worth struggling for in this life which does not bristle with them ? Students of Medicine : May this day to be each of youj as it was to me when I entered this school thirty-five years ago, the beginning of a happy life in a happy calling. Not one of you has come here with such a feeling of relief as that which I experienced at an escape from conic sections and logarithms and from Hooker and Pearson. The dry bones became clothed with interest, and I felt that I had at last got to work. Of the greater advantages with which you start I shall not speak. Why waste my words on what you cannot understand. To those of us only who taught and studied m the dingy old building which stood near here is it given to feel the full change which the years have wrought, a change which my old teachers, whom I see here to-day— Dr. Richardson, Dr. Ogden, Dr. Thorburn and Dr. Oldright— must find hard to realize. One looks about in vain for some accustomed object on which to rest the eye m its backward glance— all, all are gone, the old familiar places. Even the landscape has altered, and the sense of loneliness and regret, the sort of homesickness one experi- ences on such occasions, is relieved by a feeling of thankful- ness that at least some of the old familiar faces have been spared to see this day. To me at least the memory of those happy days is a perpetual benediction, and I look back upon the two years I spent at thi school with the greatest de- light. There were many chux^s that might have been im- proved—and we can say the same of every medical school of that period— but I seem to have got much more out of it 368 .\. THE MASTER-WOBD IN MEDICINE ,k„«, picture o. the period .eem. ^7 i8 is a very special occasion, with special addresses. I consider -myself most happy to have been selected for this part of th.^ programme. To the audi- ence at large I fear that what I have to say wiU appear trite and commonplace, but bear with me. since, indeed, to most of you how good soever the word, the season is long past m which it CMidd be spoken to your edification. As I glance fron L. -o face the most striking smgle peculiarity is the extraordmary diversity that exists among you. Alike in that you are men and white, you are unlike in your fea- tures. very unlike in your minds and in your mental tram- ing and your teachers wUl mourn the singular mequalities m your capacities. And so it is sad to think will be your, careers ; for one success, for another failure ; one will tread the primrose path to the great bonfire, another the straight and narrow way to renown ; some of the best of you will be stricken early on the road, and will join that noble band of youthful martyrs who loved not their lives to the death ; others, perhaps the most briUiant among you, like my old friend and comrade, Dick Zimmerman (how he would have rejoiced to see this day !). the Fates will overtake and wlml to destruction just as success seems assured. When the iniquity of obUvion has blindly scattered her poppy over us. some of you wiU be the trusted counseUors of this com- 872 i'.il'v' THE MASTER-WORD IN MEDICTNE munity, ; ad the heads of departments of this Faculty ; while for the large majority of you, let us hope, is reserved the happiest and most useful lot given to man -to become vigorous, whole-souled, inteUigent, general practitioners. It seems a bounden duty on such an occasion to be honest and frank, so I propose to teU you the secret of Ufe as I liave seen the game played, and as I nave tried to play it myself. You remember in ou. ^f the Jur ^ «»tories that when Mowgli wished to be avenged on tht ilagers he could only get the help of Hathi and his r ons by sending them the master-word. Thi- I propc'.^ to give you in the hope, yes, in the full assuran that sour of you at least wUl lay hold upon it to your profit. Though a Uttle one, the master- word looms large in meaning. It is the open sesame to every portal, the great equalizer m the world, the true phUo- sopher's stone, which transmutes aU the bat»e metal of hu- manity into gold. The stupid man among you it wUl make bright, the bright man brilliant, and the brilliant student steady. With the magic word in your heart all things are possible, and without it a" study is vanity and vexation. The miracles of Ufe are with it ; the blind see by touch, the deaf hear with eyes, the dumb speak with fingers. To the youth it brings hope, to the middle-aged confidence, to the aged repose. True balm of hurt minds, in its presence the heart of the sorrowful is lightened and consoled. It is di- rectly responsible for all advances in medicine durmg the past twenty-five centuries. Laying hold upon it Hippo- crates made observation ana science the warp and woof of our art. Galen so read its meaning that fifteen centuries stopped thinking, end slept until awakened by the De Pa- s.d THE MASTER-WORD IN MEDICINE hrica of VesaUus, which is the very incarnation of the master-word. With its inspiration Harvey gave an im- Ddse to a larger circulation than he wot of. an unpulse which we feel to-day. Hunter sounded all its heights and depths, and stands out in our history as one of the great exemplars of its virtue. With it Virchow smote the rock, and the waters of progress gushed out ; whUe in the hands of Pasteur it proved a very talisman to open to us a new heaven in medicine and a ne^arth in surgery. Not only has it been the touchstone of progress, but it is the measure of success in every-day Ufe. Not a man before you but is beholden to it for his position here, while he who addresses you has that honour directly in consequence of havmg had it graven on his heart when he was as you are to-day. i^d the master-word is Work, a Uttle one, as I have said, but fraught with momentous sequences if you can but write it on the tablets of your hearts, and bind it upon your fore- heads. But there is a serious difficulty in getting you to understand the paramount importance of the work-habit as part of your organization. You are not far from the Tom Sawyer stage with its phUosophy " that work consists of whatever a body is obliged to do." and that play con- sists of whatever a body is not obliged to do." A great many hard things may be said of the work-habit: For most of us it means a hard battle ; the few take to it naturaUy ; the many prefer idleness and never learn to love labour. Listen to this : " Look at one of your industrious fellows for a moment, I beseech you," says Robert Loms Stevenson. " He sows hurry and reaps indigestion ; he puts a vast deal of activity out to interest, and receives a larae measure of nervous derangement -iu return; Either * 874 i THE MASTERWORD IN MEDICINB he absentB himself entirely from aU feUowship, "^d Uve. a recluse in a garret, with carpet sUppen and a leaden mkpot. or he comes among people swiftly and bitterly m a ^n- traction of hb whole nervous system, to discharge some temper before he returns to work. I do not care how much or how weU he works, this feUow is an evil feature m other people's Uves." ITiese are the sentiments of an over- ^rked. dejected man ; let me quote the motto of his saner moments : " To travel hopefully is better than to arrive and the teue success is in labour." If you wish to learn of the miseries of scholars in order to avoid them read Part I. Section 2. Member 3. Subsection XV. of that immortal work, the AnMomy of MdancMy ; but I am here to warn you against these evils, and to entreat you to form good habits in your student days. , ,. * At the outset appreciate clearly the amis and obj^ts each one of you should have in view-a know edge of dis- ease and its cure, and a knowledge of yourself. The one, special education, will make you a practitioner of m*di. cine ; the other, an imier education, may make you a truly good man, four square and without a flaw. The one is ex- Lsic and is largely accomplished by teacher and tutor, by text and by tongue ; the other is intnnsic and is the mental salvation to be wrought out by each one for himself. The first may be had without the second ; any one of you may become an active practitioner, without ever havmg had sense enough to realize that through Ufe you ^ve been a fool ; or you may have the second without the first and, without knowing much of the art. you may have the en- dowments of head and heart that "^^ke the^^^f /^^ ^ possess go very far in the community. With what I hop. *^ 876 «1 THE MASTER-WORD IN MEDICINE to infect yoa is a desire to have a due proportion of each. So far as your professional education is concerned, what I shall say may make for each one of you an easy path easier. The multiplicity of the subjects to be studied is a difficulty, and it is hard for teacher and student to get a due sense of proportion in the work. We are in a transition stage in our methods of teachings, and have not everywhere got away from the idea of the examination as the " be-all and end-all ; " so that the student has constantly before his eyes the magical letters of the^ degree he seeks. And this is well, perhaps, if you will remember that having, m the old phrase, commenced Bachelor of Medicine, you have only reached a point from which you can begin a Ufe-long process of education. So many and varied are the aspects presented by this theme that I can only lay stress upon . few of the more es- sential. The very first step towards success in any occupa- tion is to become interested in it. Locke put this in a very happy way when he said, give a pupU " a relish of know- ledge " and you put life into his work. And there is no- thing more certain than that you cannot study well if you are not interested in your profession. Your presence here b a warrant that in some way you have become attracted to the study of medicine, but the speculative possibilities so warmly cherished at the outset are apt to cool when in contact with the stem realities of the class-room. Most of you have already experienced the all-absorbing attraction of the scientific branches, and nowadays the practical method of presentation has given a zest which was usuaUy lacking in the old theoretical teaching. The Ufe has be- come more serious in consequence, and medica. students 3Tu THE MASTER-WORD IN MEDICINE have put away many of the chUdish tricks with which we used to keep up their bad name. Compare the picture of the " sawbones " of 1842. as given in the recent biography of Sir Henry Acland, with the representatives to-day, and it is evident a great revolution has been effected, and very largely by the salutary influences of improved methods ol education. It is possible now to fill out a day with prac- tical work, varied enough to prevent monotony, and so arranged that the knowledge b picked out by the student himsdf , and not thrust into him, willy-nilly, at the pomt of the tongue. He exercises his wits and is no longer a pas- sive Strasbourg goose, tied up and stuffed to repletion. How can you take the greatest possible aovantage of your capacities with the least possible strain? By culti- vating system. I say cultivating advisedly, smce some of vou will find the acquisition of systematic habits very hard. There are minds congenitally systematic ; others have a Ufe-long fight against an inherited tendency to diffuseness and carelessness in work. A few brilliant feUows try to dispense with it altogether, but they are a burden to their brethren and a sore trial to their intimates. I have heard it remarked that order is the badge of an ordinary mmd. So it may be. but as practitioners of medicine we have to be thankful to get into that useful class. Let me entreat those of you who are here for the first time to lay to heart what I say on this matter. Forget all else, but take away this comisel of a man who has had to fight a hard battle, and not always a successful one, for the Uttle order he has had in his life ; take away with you a profound conviction of the value of system in your work. 1 appeal to the fresh- men especiaUy, because you to-day make a begimung. and 377 [ THE MASTER WORD IN MEDICINE your future career depends very mucli upon the habits you wiU form during this session. To foUow the routine of the classes is easy enough, but to take routme ^n^ eve^ 1*^ of your daily Ufe is a hard task. Some of you wiU start out io4illy as did Christian and Hopeful, and for many days wmToarney safely towards the Delectable Mountams. dreaming of them and not thinking of disaster untU you find yo^lves m the strong captivity of Doubt and under the grinding tyram^y of Despair. You ^^^ ^^^« confident. Begm again and more cautiously. No student escapes whoUy from these perils and trials; be not dis- riSIned.e^ctthem. Let each hour of the dayj^ve its allotted duty, and cultivate that power of concentratu,n which grows with its exercise, so that the attention neither flags nor wavers, but settles with a bull-dog tenacity on Z subject before you. Constant repetition makes a good habit fil easUy in yo.ir mind, and by the end of the^^ you may have gained that most precious of all ^^o^^^- the power to work. Do not underestimate the <^fficu^^ you will have in wringing from your reluctant selves the stem determination to exact the uttermost mmute on your schedule. Do not get too interested in one ^^dy at the expense of another, but so map out your day that due al- lowance is given to each. Only in this way can the average student get the best that he can out of his capacities And it is worth aU the pains and trouble he can possib^ take for the ultimate gain-if he can reach his doctorate with system so ingrained ohat it has becorr an mtegral part of lis being. The artistic sense of perfection mj°^k^ another much-to-be-desired quaUty to be cultivated. No matter how trifling the matter on hand, do it with a feelmg 878 THE MASTER-WORD IN MEDICINB that it ''- -lands the best that '^ in you, and when done look it ovex vnth a critical eye, no- sparing a strict judgment of vouraelf This it is that makes anatomy a student b touch- stone Take the man who does his " part " to perfection, who has got out aU there is in it, who labours over the oags of connective tissue and who demonstrates Meckel s gan- bUou in his part-this is the feUow in after years who is apt in emergencies, who saves a leg badly smashed in a railway accident, or fights out to the finish, never knowing when he is beaten, in a case of typhoid fever. Learn to love the freedom of the student hfe. only too quickly to pass awav ; the absence o! the coarser cart, of after days, the joy in comradeship, the deUght in new work, the happmess in knowing that you are makmg progress. Once o\dy can you enjoy these pleasures. The seclusion of the student Ufe is not always good for a man, particularly for those of you who will afterwards engage in general } • tice, since you will miss that faciUty of intercourse x. a which often the doctor's success depends. On t^'^e ^^her hand sequestration is essential for those of you with high ambitions proportionate to your capacity. It was for such that St. Chrysostom gave his famous couniel. Depart from the highways and transplant thyself into some en- closed gromid. for it is hard for a tree that stends by the wav8id3 to keep its frait till it be rve." H^s work no dangers comiected with it? What of this bogie of overwork of which we hear so much ? There a« dangers, but they may readily be avoided with a litt e care^ I can only mention two, one physical, one mental The very best students are often not the strongest. Ill-health the bridle of Theages, as Plato called it in the case of one of 379 THE MASTER-WORD IN MEDICINE hiB friendfl whose mind ha 1 thriven at the expend oi his body may have been the diverting influence towards booto or the profession. Among the good men who have studied with me there stands out in my remembrance many a yomig Lycidas. " dead ere his prime." sacrificed to carelessness m habits of Uvmg and neglect of ordinary sanitary ^ws. M^ dical students are much exposed to infection of all sorts to combat which the body must be kept in first-class cona- tion. Grossteste. the great bishop of Lincob, remarked that there were three things necessary for temporal salva- tion-food, sleep and a cheerful disposition. AddtothMe suitable exercise and you have the means by which good health may be maintained. Not that health is to be a matter of perpetual soUcitation, but habits which favour the corpus sanum foster the mma sana, in which the joy ot Uving and the joy of working are blended in one harmony Let me read you a quotation from old Burton, the great authority on morbi ervdUorum. There are " many reasons why students dote more often than others. The first la their negligence ; other men look to their tools, a pamter will wash his pencils, a smith will look to his hammer, anvil, forge ; a husbandman will mend his plough-irons, and orind his hatchet, if it be dull ; a falconer or huntsman will have an especial care of his hawks, hounds, hrrses. do^. etc • a musician will string and unstring his lute. ete. ; only scholars neglect that instrument, their brain and spirits (1 mean) which they daUy use." ' . * ^i. Much study is not only beUeved to be a weariness of the flesh, but also an active cause of Ul-health of mmd, m aU grades and phases. I deny that work, legitimate work, » Quotation msonly from Marailiua Ficinua. 380 THE MASTER-WORD IN MEDICINE has anything to do with this. It is that foul fiend Worry who is responsible for a large majority of the cases. The more carefully one looks into the causes of nervous break- down m studento, the less important is work P^- '« » » factor. There are a few cases of genuine overwork, but they are not common. Of the causes of worry in the stu- dent life there are three of prime importance to which 1 may briefly refer. An anticipatory attitude of mind, a perpetual forecast- b- disturbs the even tenor of his way and leads to disaster. Years ago a sentence m one of Carlyle's essays made a last- ing impression on me : " Our duty is not to see what lies dimly at a distance, but to do what lies clearly at baud. I have long mainteaied that the best motto for a student is. " Take no thought for the monow." Let the uay s work suffice ; live for it. regardless of what the future has m store. beUeving tha. to-morrow should take thought for the things of itself. There is no such safeguard against the morbid apprehensions about the futme. the dread of ex- aminations and the doubt of the ultimate, success. Nor is there any risk that such an attitude may breed careless- ness On the contrary, the absorption m the duty of the hour is in itself the best guarantee of ultimate success. " He that observeth the wind shaH not sow. and he that regard- eth the clouds shaU not reap," which means you camiot work profitably with your mind set upon the future. Another potent cause of worry is an idolatry by which many of you will be sore let and hindered. The mistress of your studies should be the heavenly Aphrodite, the mother- less daughter of Uranus. Give her your whole heait, and she will be your protectress and friend. A jealous creature, 881 i THE MASTER-WORD IN MEDICINE brooking no second. U sle finds you trifling and coquetting with her rival, the younger, earthly Aphrodite, daughter of Zeus and Dione. she will whistle you off and let you down the wind to be a prey, perhaps to the examiners, certainly to the worm regret. In plainer language, nut youi affec- tions in cold storage for a few years, and you wiU take them out ripened, perhaps a bit meUow, but certamly less subject to tho^ frequent changes which perplex so many young men. Only a grand pas8ion,-an ill-absorbing devotion to the elder goddess can save the man with a congemtal ten- dency to philandering, the flighty Lydgate whospoi^ with Celia and Dorothea, and upon whom the judgment ulti- mately falls in a basU-plant of a wife like Rosamond. And thirdly, one and all of you will have to face the or- deal of every student in this generation who sooner or later tries to mix the waters of science with the oU of faith. You can have a great deal of both if you only keep them se- parate. The worry comes from the attempt at mixture. As general practitioners you will need aU the faith you can carry, and while it may not a! vays be of the c nventional pattern, when expressed in your lives rather than on yoi^ lips, the variety is not a bad one from the standpomt of St James ; and may help to counteract the common scandal aUuded to in the celebrated diary of that gossipy old pastor- doctor, the Rev. John Ward : " One told the Bishop of Gloucester that he imagined physitians of all other men the most competent judges of all other affairs of religion-and his reason was because they were wholly unconcerned with it." ni Professional woriL of any sort tends to narrow the mmd, THE MASTER-WORD IN MEDICTNE to limit the point of vie^ and to put a hall-mark on a man of a moat unmistakable kind. On the one hand are the intense, ardent natures, absorbed in their studies and quickly losing interest m everything but their profession, while other faculties and interests " fust " unsued. On the other hand are the bovine brethren, who think of no- thing but the treadmill and the com. From very different causes, the one from concentration, the other from apathy, both are apt to neglect those outside studies that widen the sympathies and help a man to get the best there is out of life. Like art, medicine is an exacting mistress, and m the pursui'; oi one of the scientific branches, sometimes, too, in practice, not a portion of a man's spirit may be left free for other distractions, but this does not often happen. On account of the intimate personal nature of hia work, the medical man, perhaps more than any other man, needs that higher education of which Plato speaks,—" that education m virtue from youth upwards, which enables a. man eagerly to pursue the ideal perfection." It is not for all, nor can all attain to it, but there is comfort and help in the pursuit, even though the end is never reached. For a large ma- jority th3 daily round and the common task furnish more than enough to satisfy their heart's desire, and there seems no room left for anything else. Like the good, easy man whom MUton scores in the AreopagUica, whose reUgion was a " traffic so entangled that of aU mysteries he could not skill to keep a stock going upon that trade " and handed it over with all the locks and keys to " a divine of note and estimation," so it is with many of us in the matter of this higher education. No longer intrinsic, wrought in us and ingrained, it has become, in Milton phrase, a " dividual 383 THE MASTER-WORD IN BfEDICINE „,ovable." h^ded over now^Uy to the djuly pre- or to the haphiuard inBtruction oi the pulpit, the pUt onn ^ the miiaanes. Like a good many other things, it oom^ b a^r and more enduring fom H not too c^nsciotu^y sought. The aU-important thing is to get a rebsh for the aZ company of the race m a daUy intercourse with some Jmegr^ minds of aU ages. Now. in the spnng-timeof life pick your intimates among them, and begm a systema- liie, picK yo will need a tic cultivation of their worifs. «»"7 / strong leaven to raise you above the dough m which itjnU be y7ur lot to labour. Uncongenial sunoundmgs. an evw- pr^ent dissonance between the aspirations within and the actuaries without, the oppressive discords of hui^n so- ciety, the bitter tragedies of Ufe, the lacrym