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nasal, vaginal, rectal; many beautiful and useful refinements in chemical reactions and in pathological appearances, all useful as means of diagnosis. You must master them all. They are the tools of your profession. If you miss learning their use now you may never again have the chance. In the remote West, in a small country village in the East, or elsewhere, you will sometimes sorely need them, when you will have no willing professor or quiz master to whom you may appeal. They will help you in a multitude of cases, and often are simply indispensable.
But I want to urge you to do one thing more: to combine with all of our nineteenth-century inventions eighteenthcentury shrewdness of observation and acute cultivation of the normal, unassisted senses, in order to make up the more perfect doctors of the twentieth century. If you have not read "Spare Hours," by the lovable and accomplished Dr. John Brown, of Edinburgh, the author of "Rab and His Friends," that most charming medical story, you have a treat before you. Some pages are more succulent than others, but there is not a sterile patch among them. In the third series you will find most of the medical papers, and they are bracing reading for a doctor. I know nowhere a stronger plea for this very education of the senses which I wish to urge upon you. As there were heroes before Agamemnon, so eyes and ears existed before oxygen was known or Laënnec lived, and our forefathers had sharp eyes, shrewdly hearing ears, and delicate fingers that had to take the place of the specula and the scopes of our day. "Every fellow," says the blind but knowing master of wood-craft, in Dr. S. Weir Mitchell's last story, "every fellow ought to be blind ten years, and deaf ten more, and then get his eyes and ears. He'd know a heap, I tell you he would."
Medicine is not a deductive science. We do not start from a priori principles and reason to conclusions. It is intensely inductive. We collect our facts, the more the
better, as increasing numbers diminish the ever-possible chances of error; we collate them in orderly sequence, and gradually rise from facts to principles. Hence if our facts are badly observed, our principles are sure to be erroneous.
I am persuaded that the chief source of errors in diagnosis is not want of knowledge, but careless or insufficient examination into the facts of the disease. I have seen a diagnosis of rheumatism of the knee-joint in a case in which lifting the knee two inches from the bed instantly showed the crepitus from a spontaneous fracture following long-existing osteomyelitis. I have been called to a case of hæmorrhoids which a glance and a touch resolved into an ischio-rectal abscess; and I have seen days of uncertainty and groping for a diagnosis cut short by a few taps over the back of the lungs that revealed an unsuspected pneumonia. Had the leg been once lifted, the perineum inspected and touched, the posterior chest examined-two minutes only, but two minutes of exactness-no such errors would have occurred.
The eye must be taught to take in much for which no speculum is needful. The physiognomy of the patient, the modes of expression, whether facial or vocal, spontaneously assumed postures of the body, tremulous or steady movements, the color, the breathing both as to frequency and character; the outlines of the body, normal or abnormal; the exact relations of parts; all these, and a hundred more, all stand with their cup of information filled to the brim for him who will drink. The ear may be aided by the stethoscope, but it must not be trammeled by it. It must be trained to abnormal alertness, and hear every sound, from the normal loud gurgling of the intestines to the faintest suggestion of it while using taxis in a hernia; from the loud tubular breathing of a widespread pneumonia, to the judicious discrimination of the relative respiratory murmur in the apices. The touch, though it can scarcely be educated up to the standard of Laura Bridgman, can give you the
needful facts as to hardness, softness, elasticity, resistance, contour, crepitus, and the like, if you will but use it. No instrument can replace it. Let your fingers therefore itch till you have touched and felt every case that by hook or crook you can lay your hands on. Smell and taste are not seldom called into play, and here at least we can use no artificial helps. Yet they are sorely neglected with all the other senses. The epicure in Juvenal's day could distinguish between an oyster from the Lucrine Lake or from Britain. We could do as much were we to cultivate our natural powers as well. Cultivate these senses largely by a study of your own body. Haud inexpertus loquor. The hours I have spent in such study have been among the most remunerative, not only in the facts learned, but in the exact methods acquired, and the fine filing of the senses to a cultivated acuteness.
In all this I would not decry the use of the modern instruments of precision. Their introduction marks the beginning of modern science, when the balance, the yardstick, and the pendulum took the place of vague guessing at weight, length, and time. But, back of all our medical instruments, without which they are almost worthless, are our natural senses. Fifty instruments, though they can aid the five senses, can never replace them. In mountaineering, the Alpenstock is invaluable as an aid; but it can never take the place of a stout pair of legs.
This careful development of the senses should foster a spirit of exactness in all your work; in the use of instruments of precision as well as of the senses themselves. Science is always hostile to the word "about"-"about three inches long," "about one hundred and one degrees," "about ten days." When it is so easy to use the measure, the thermometer, the calendar, why say "about"? In the history of a case as derived from the patient, it may do very well; but in your own later notes it should never appear. One
of the surprising and characteristic differences between most of the laity even very intelligent men and women-and ourselves is their inaccurate observation or non-observation of plain facts. This is due solely to the want of training of their natural senses, and is the best argument I can give you for the schooling of the senses.
I am well aware that during your collegiate course you will have only moderate opportunities to use Nature's gifts— in my day we had none at all-and that most that I have said will apply rather to your post-collegiate course. But the accurate scientific habit or the shiftless unscientific habit will be begun and largely formed here, and it is generally true that what your habits are when you graduate, such they will be until Time shall administer his last anodyne and you pass into your long sleep.
Given the facts, accurately observed and carefully noted, what then? Then comes the highest art of the physician: the reasoning process by which is evolved his diagnosis, upon which depends his treatment. He must take one plus one and make them into two, a tertium quid wholly distinct from either of its constituent factors. And in medicine the two ones often lie far apart. They must be correlated not only in any individual case, but in cases years asunder, by a mental stereoscopic vision, the possession of the few, the envy of the many.
This logical faculty is partly inborn, it is true, and varies in natural strength as much as the natural acuity of vision; but it is also amenable in an immense degree to cultivation. The wider your knowledge, the better your reasoning will be. You must at first laboriously toil over the process, as does the tyro in Euclid over every equation in each successive problem, over and over again. But when these steps have become as A, B, C to him, then he begins to leap, and finally, when a master geometer, his "therefore" clears a whole book at a bound. So with you, the halting method of your early
days, if carefully purified from its faults and strengthened by constant and watchful repetition, will at length give way to quick perception; the correlated facts soon become as familiar to you as his old friends, X, Y, and Z, are to the geometer, and with a mental "therefore" you, as quickly and as accurately, leap to your diagnosis, and thence to your treatment. Painstaking and habitual induction slowly give place to intuition. To the laity it often seems so easy and takes so little time that it is hardly worth paying much for. They should learn that it is like the ease of the accomplished athlete, the swordsman, the equestrian. As in a plant, the long roots are hidden; only the brilliant flower is seen.
Of treatment, the last and most important point of allthe "final cause" of there being any doctors at all-you will hear and see so much that I will only quote Broussais: "The real physician is the one who cures; the observation that does not teach the art of healing is not that of a physician; it is that of a 'naturalist.'" And I add my commentary: "The observation of the naturalist must precede, as it ought to lead up to, the art of the physician."
You will be much tempted to devote yourself to one or two favorite branches, to which you perhaps think you will devote yourself later as specialists, and to neglect others. No greater mistake could be made. Few men follow their early selection of a career. Circumstances compel a change. This collegiate part of your course stands in the same relation to your later professional life that a common school education does to your general education.
Everyone must know the three R's whatever he may be, "farmer, lawyer, doctor, chief." So every doctor must know chemistry, though he become a surgeon; the eye, though he practice medicine; the microscope, though he become an obstetrician; obstetrics, though he turn out a pathologist. Each is a strand in the stout medical rope, and without it the rest would be weak and worthless. You must "know