Medicine - The Army Surgeon
( Originally Published 1905 )
At the outset I am sure you will permit me, on behalf 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 schools at large cannot be expected to equip army surgeons with the full details of special training. A glance at the curriculum just completed brings into sharp relief the disabilities 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 knowledge 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. Instead of hazy notions—perhaps to one fresh from the Examining Board not pleasant ones—of a central authority at Washington, of a Yama enthroned as Secretary of War, and of an exacting Surgeon-General, 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 have 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, today. 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 war, 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 read the spirited vindication of John Morgan, who may be called the first Surgeon-General, and I am familiar 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 ignorance, 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 uncertainty of the effort; and perhaps those sorer trials inevitable 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 grievous 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 encouraged, and in individuals and communities is sometimes so active on such slender grounds that the condition 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 training, 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 conceited heads that never looked a degree beyond their nests that tower and plume themselves on light attainments," 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 in 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 Apollo, not the Surgeon-Generalship, not distinguished position in science, no professorship, however honoured, can equal this, this which, as wandering Army Surgeons, you must forego. 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 that "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 limited spheres of action, and during the past hundred years it is surprising how many of the notable achievements have been made by physicans dwelling far from educational centres—Jenner worked out his discovery in a village; 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 congratulating you again on the opportunities enjoyed during the past four months, which have not only added enormously to your capabilities for work, but have familiarized you with life at the heart of the organization of which hereafter you will form part, and doubtless have given you fruitful ideas on the possibilities of your individual development. Naturally 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 well. The travellers 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 lies dimly at a distance, but to do what lies clearly at hand." Fevered haste is not encouraged in military circles, and if you can adapt your intellectual progress to army rules, making each step in your mental promotion the lawful successor of some other, you will 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 professional ken. There are, in truth, 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 humdrum cases of the morning routine may have been accurately described and pictured, but study each one separately as though it were new— so 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, its dreariness, and its monotony. With Laurence Sterne, we can afford to pity such, since they know not that the barrenness of which they complain 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 fully as great as if you had remained in civil life. Faith-fulness in the day of 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 the best work of the profession has come from men whose clinical field was limited 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 seeing 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 acquisition of facts is not necessarily associated with development. 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 growth 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, bringing fuller powers of observation, additional capabilities of mental nutrition, and that increased 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 experiments, however, in striking contrast to those of the laboratory, lack exactness, possessing as they do a variability 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 clientele in which you work has, however, more stability, a less extended range of variation than that with which we deal in civil life. In 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 small-pox by systematic revaccination; in civil practice we strive to reach the low rate of mortality of army hospitals in the treatment of typhoid fever and of pneumonia. 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 unequalled. 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 California, affords unequalled facilities for the study of many of the vexed problems in medicine—facilities, indeed, which in the diversity of morbid conditions to be studied are equalled in no position in civil life. 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 particularly 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 mountain fever by army surgeons, and need hardly add that the specimens contributed by Hoff and by Girard to this museum demonstrate conclusively that it is in reality typhoid fever.
In the Southern posts malaria with its protean manifestations presents still many interesting problems for solution, and you will leave this school better equipped than any of your predecessors for the study and differentiation of its less known varieties. With positive know-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 offer in doubtful cases the positive and satisfactory test of the microscope. The haematuria of the South requires to be studied anew—the filarial cases separated from the malarial, and, most important of all, the relation of quinine to haematuria positively settled.
In the more distant posts, where, so far as the soldier is concerned, your opportunities for study may be limited, you may add greatly to our knowledge of the disorders prevalent among the Indians. More particularly do we need additional information as to the frequency of tuberculosis 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 upon the chest-capacity, the chest-measurement, and the heart, and our knowledge is still lacking on questions relating 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 well 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, travelling with seeing eyes and hearing ears, and carefully-kept note-books, just think what a store-house of clinical 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, rendering 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 the profession, there are other duties which call for a word or two. In the communities to which you may be sent do not forget that, though army officers, you owe allegiance to an honourable profession, 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 of superiority over your confreres 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 partibus infidelium, 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 stimulating example. You cannot afford to stand aloof from your professional col-leagues 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 passports of your fellowship should be honesty of purpose, and a devotion to the highest interests of our profession, and these you will find widely diffused, sometimes apparent 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 the arrangements in the department are such that, with habits of ordinary diligence, each one of you may attain not only a high grade of personal development, but may become an important contributor in the advancement of our art. I have said nothing of the pursuit of the sciences cognate to medicine, of botany, zoology, geology, ethnology and archaeology. In every one of these, so fascinating in themselves, it is true that army medical officers have risen to distinction, but 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 department, the profession, and the public.
Generalities, of the kind in which I have been indulging, though appropriate to the occasion, are close kin, I fear, 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 singular attraction, the picture of a man who, amid circumstances the most unfavourable, saw his opportunity and was 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 world. 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 conclusion of the war of 1812, after two centuries of struggle, peace settled at last upon the old fort, and 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 Lhut 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. Beaumont was not slow to see the extraordinary possibilities that were 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 movements 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 less than 300 pages.' In looking through it one cannot but recognize that it is the source 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 observations 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 annals 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."