medical essays-第43章

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dies。　　Let　me　shorten　one　of　Ambroise　Pare's　stories　for　you。　　There　had　been　a　great　victory　at　the　pass　of　Susa；　and　they　were　riding　into　the　city。　　The　wounded　cried　out　as　the　horses　trampled　them　under　their　hoofs；　which　caused　good　Ambroise　great　pity；　and　made　him　wish　himself　back　in　Paris。　　Going　into　a　stable　he　saw　four　dead　soldiers；　and　three　desperately　wounded；　placed　with　their　backs　against　the　wall。　　An　old　campaigner　came　up。　〃Can　these　fellows　get　well？〃　he　said。　　〃No！〃　answered　the　surgeon。　　Thereupon；　the　old　soldier　walked　up　to　them　and　cut　all　their　throats；　sweetly；　and　without　wrath　（doulcement　et　sans　cholere）。　　Ambroise　told　him　he　was　a　bad　man　to　do　such　a　thing。　〃I　hope　to　God；〃　he　said；　〃somebody　will　do　as　much　for　me　if　I　ever　get　into　such　a　scrape〃　（accoustre　de　telle　facon）。　　〃I　was　not　much　salted　in　those　days〃　（bien　doux　de　sel）；　says　Ambroise；　〃and　little　acquainted　with　the　treatment　of　wounds。〃　　However；　as　he　tells　us；　he　proceeded　to　apply　boiling　oil　of　Sambuc　（elder）　after　the　approved　fashion　of　the　time；with　what　torture　to　the　patient　may　be　guessed。　　At　last　his　precious　oil　gave　out；　and　he　used　instead　an　insignificant　mixture　of　his　own　contrivance。　　He　could　not　sleep　that　night　for　fear　his　patients　who　had　not　been　scalded　with　the　boiling　oil　would　be　poisoned　by　the　gunpowder　conveyed　into　their　wounds　by　the　balls。　　To　his　surprise；　he　found　them　much　better　than　the　others　the　next　morning；　and　resolved　never　again　to　burn　his　patients　with　hot　oil　for　gun…shot　wounds。

This　was　the　beginning；　as　nearly　as　we　can　fix　it；　of　that　reform　which　has　introduced　plain　water…dressings　in　the　place　of　the　farrago　of　external　applications　which　had　been　a　source　of　profit　to　apothecaries　and　disgrace　to　art　from；　and　before；　the　time　when　Pliny　complained　of　them。　　A　young　surgeon　who　was　at　Sudley　Church；　laboring　among　the　wounded　of　Bull　Run；　tells　me　they　had　nothing　but　water　for　dressing；　and　he　（being　also　doux　de　sel）　was　astonished　to　see　how　well　the　wounds　did　under　that　simple　treatment。

Let　me　here　mention　a　fact　or　two　which　may　be　of　use　to　some　of　you　who　mean　to　enter　the　public　service。　　You　will；　as　it　seems；　have　gun…shot　wounds　almost　exclusively　to　deal　with。　　Three　different　surgeons；　the　one　just　mentioned　and　two　who　saw　the　wounded　of　Big　Bethel；　assured　me　that　they　found　no　sabre…cuts　or　bayonet　wounds。　It　is　the　rifle…bullet　from　a　safe　distance　which　pierces　the　breasts　of　our　soldiers；　and　not　the　gallant　charge　of　broad　platoons　and　sweeping　squadrons；　such　as　we　have　been　in　the　habit　of　considering　the　chosen　mode　of　warfare　of　ancient　and　modern　chivalry。　＇Sir　Charles　James　Napier　had　the　same　experience　in　Virginia　in　1813。　〃Potomac。　　We　have　nasty　sort　of　fighting　here；　amongst　creeks　and　bushes；　and　lose　men　without　show。〃　　〃Yankee　never　shows　himself；　he　keeps　in　the　thickest　wood；　fires　and　runs　off。〃　These　five　thousand　in　the　open　field　might　be　attacked；　but　behind　works　it　would　be　throwing　away　lives。〃　　He　calls　it　〃an　inglorious　warfare；〃　says　one　of　the　leaders　is　〃a　little　deficient　in　gumption；〃but　still　my　opinion　is；　that　if　we　tuck　up　our　sleeves　and　lay　our　ears　back　we　might　thrash　them；　that　is；　if　we　caught　them　out　of　their　trees；　so　as　to　slap　at　them　with　the　bayonet。〃　Life；　etc。　vol。　　i。　　p。　　218　et　seq。＇

Another　fact　parallels　the　story　of　the　old　campaigner；　and　may　teach　some　of　you　caution　in　selecting　your　assistants。　　A　chaplain　told　it　to　two　of　our　officers　personally　known　to　myself。　　He　overheard　the　examination　of　a　man　who　wished　to　drive　one　of　the　〃avalanche〃　wagons；　as　they　call　them。　　The　man　was　asked　if　he　knew　how　to　deal　with　wounded　men。　　〃Oh　yes；〃　he　answered；　〃if　they're　hit　here；〃　pointing　to　the　abdomen；　〃knock　'em　on　the　head；they　can't　get　well。〃

In　art　and　outside　of　it　you　will　meet　the　same　barbarisms　that　Ambroise　Pare　met　with；for　men　differ　less　from　century　to　century　than　we　are　apt　to　suppose；　you　will　encounter　the　same　opposition；　if　you　attack　any　prevailing　opinion；　that　Sydenham　complained　of。　So　far　as　possible；　let　not　such　experiences　breed　in　you　a　contempt　for　those　who　are　the　subjects　of　folly　or　prejudice；　or　foster　any　love　of　dispute　for　its　own　sake。　　Should　you　become　authors；　express　your　opinions　freely；　defend　them　rarely。　　It　is　not　often　that　an　opinion　is　worth　expressing；　which　cannot　take　care　of　itself。　Opposition　is　the　best　mordant　to　fix　the　color　of　your　thought　in　the　general　belief。

It　is　time　to　bring　these　crowded　remarks　to　a　close。　　The　day　has　been　when　at　the　beginning　of　a　course　of　Lectures　I　should　have　thought　it　fitting　to　exhort　you　to　diligence　and　entire　devotion　to　your　tasks　as　students。　　It　is　not　so　now。　　The　young　man　who　has　not　heard　the　clarion…voices　of　honor　and　of　duty　now　sounding　throughout　the　land；　will　heed　no　word　of　mine。　　In　the　camp　or　the　city；　in　the　field　or　the　hospital；　under　sheltering　roof；　or　half…protecting　canvas；　or　open　sky；　shedding　our　own　blood　or　stanching　that　of　our　wounded　defenders；　students　or　teachers；　whatever　our　calling　and　our　ability；　we　belong；　not　to　ourselves；　but　to　our　imperilled　country；　whose　danger　is　our　calamity；　whose　ruin　would　be　our　enslavement；　whose　rescue　shall　be　our　earthly　salvation！






SCHOLASTIC　AND　BEDSIDE　TEACHING。

An　Introductory　Lecture　delivered　before　the　Medical　Class　of　Harvard　University；　November　6；　1867。

The　idea　is　entertained　by　some　of　our　most　sincere　professional　brethren；　that　to　lengthen　and　multiply　our　Winter　Lectures　will　be　of　necessity　to　advance　the　cause　of　medical　education。　　It　is　a　fair　subject　for　consideration　whether　they　do　not　overrate　the　relative　importance　of　that　particular　mode　of　instruction　which　forms　the　larger　part　of　these　courses。

As　this　School　could　only　lengthen　its　lecture　term　at　the　expense　of　its　〃Summer　Session；〃　in　which　more　direct；　personal；　and　familiar　teaching　takes　the　place　of　our　academic　discourses；　and　in　which　more　time　can　be　given　to　hospitals；　infirmaries；　and　practical　instruction　in　various　important　specialties；　whatever　might　be　gained；　a　good　deal　would　certainly　be　lost　in　our　case　by　the　exchange。

The　most　essential　part　of　a　student's　instruction　is　obtained；　as　I　believe；　not　in　the　lecture…room；　but　at　the　bedside。　　Nothing　seen　there　is　lost；　the　rhythms　of　disease　are　learned　by　frequent　repetition；　its　unforeseen　occurrences　stamp　themselves　indelibly　in　the　memory。　　Before　the　student　is　aware　of　what　he　has　acquired；　he　has　learned　the　aspects　and　course　and　probable　issue　of　the　diseases　he　has　seen　with　his　teacher；　and　the　proper　mode　of　dealing　with　them；　so　far　as　his　master　knows　it。　　On　the　other　hand；　our　ex　cathedra　prelections　have　a　strong　tendency　to　run　into　details　which；　however　interesting　they　may　be　to　ourselves　and　a　few　of　our　more　curious　listeners；　have　nothing　in　them　which　will　ever　be　of　use　to　the　student　as　a　practitioner。　　It　is　a　perfectly　fair　question　whether　I　and　some　other　American　Professors　do　not　teach　quite　enough　that　is　useless　already。　　Is　it　not　well　to　remind　the　student　from　time　to　time　that　a　physician's　business　is　to　avert　disease；　to　heal　the　sick；　to　prolong　life；　and　to　diminish　suffering？　　Is　it　not　true　that　the　young　man　of　average　ability　will　find　it　as　much　as　he　can　do　to　fit　himself　for　these　simple　duties？　Is　it　not　best　to　begin；　at　any　rate；　by　making　sure　of　such　knowledge　as　he　will　require　in　his　daily　walk；　by　no　means　discouraging　him　from　any　study　for　which　his　genius　fits　him　when　he　once　feels　that　he　has　become　master　of　his　chosen　art。

I　know　that　many　branches　of　science　are　of　the　greatest　value　as　feeders　of　our　medical　reservoirs。　　But　the　practising　physician's　office　is　to　draw　the　healing　waters；　and　while　he　gives　his　time　to　this　labor　he　can　hardly　be　expected　to　explore　all　the　sources　that　spread　themselves　over　the　wide　domain　of　science。　　The　traveller　who　would　not　drink　of　the　Nile　until　he　had　tracked　it　to　its　parent　lakes；　would　be　like　to　die　of　thirst；　and　the　medical　practitioner　who　would　not　use　the　results　of　many　laborers　in　other　departments　without　sharing　their　special　toils；　would　find　life　far　too　short　and　art　immeasurably　too　long。

We　owe　much　to　Chemistry；　one　of　the　most　captivating　as　well　as　important　of　studies；　but　the　medical　man　must　as　a　general　rule　content　himself　with　a　clear　view　of　its　principles　and　a　limited　acquaintance　with　its　facts；　such　especially　as　are　pertinent　to　his　pursuits。　　I　am　in　little　danger　of　underrating　Anatomy　or　Physiology；　but　as　each　of　these　branches　splits　up　into　specialties；　any　one　of　which　may　take　up　a　scientific　life…time；　I　would　have　them　taught　with　a　certain　judgment　and　reserve；　so　that　they　shall　not　crowd　the　more　immediately　practical　branches。　　So　of　all　the　other　ancillary　and　auxiliary　kinds　of　knowledge；　I　would　have　them　strictly　subordinated　to　that　particular　kind　of　knowledge　for　which　the　community　looks　to　its　medical　advisers。

A　medical　school　is　not　a　scientific　school；　except　just　so　far　as　medicine　itself　is　a　science。　　On　the　natural　history　side；　medicine　is　a　science；　on　the　curative　side；　chiefly　an　art。　　This　is　implied　in　Hufeland's　aphorism：　〃The　physician　must　generalize　the　disease　and　individualize　the　patient。〃

The　coordinated　and　classified　results　of　empirical　observation；　in　distinction　from　scientific　experiment；　have　furnished　almost　all　we　know　about　food；　the　medicine　of　health；　and　medicine；　the　food　of　sickness。　　We　eat　the　root　of　the　Solanum　tuberosum　and　throw　away　its　fruit；　we　eat　the　fruit　of　the　Solanum　Lycopersicum　and　throw　away　its　root。　　Nothing　but　vulgar　experience　has　taught　us　to　reject　the　potato　ball　and　cook　the　tomato。　　So　of　most　of　our　remedies。　The　subchloride　of　mercury；　calomel；　is　the　great　British　specific；　the　protochloride　of　mercury；　corrosive　sublimate；　kills　like　arsenic；　but　no　chemist　could　have　told　us　it　would　be　so。

》From　observations　like　these　we　can　obtain　certain　principles　from　which　we　can　argue　deductively　to　facts　of　a　like　nature；　but　the　process　is　limited；　and　we　are　suspicious　of　all　reasoning　in　that　direction　applied　to　the　processes　of　healthy　and　diseased　life。　　We　are　continually　appealing　to　special　facts。　　We　are　willing　to　give　Liebig's　artificial　milk　when　we　cannot　do　better；　but　we　watch　the　child　anxiously　whose　wet…nurse　is　a　chemist's　pipkin。　　A　pair　of　substantial　mammary　glands　has　the　advantage　over　the　two　hemispheres　of　the　most　learned　Professor's　brain；　in　the　art　of　compounding　a　nutritious　fluid　for　infants。

The　bedside　is　always　the　true　centre　of　medical　teaching。　　Certain　branches　must　be　taught　in　the　lecture…room；　and　will　necessarily　involve　a　good　deal　that　is　not　directly　useful　to　the　future　practitioner。　　But　the　over　ambitious　and　active　student　must　not　be　led　away　by　the　seduction　of　knowledge　for　its　own　sake　from　his　principal　pursuit。　　The　humble　beginner；　who　is　alarmed　at　the　vast　fields　of　knowledge　opened　to　him；　may　be　encouraged　by　the　assurance　that　with　a　very　slender　provision　of　science；　in　distinction　from　practical　skill；　he　may　be　a　useful　and　acceptable　member