Alfred Stillé

“ So mortifying an experience I had never before endured, and I think it could hardly befall one now, so largely has the vain dream been dispelled which long was cherished that America was competent to create an exclusively American science and art of medicine, and which tended to hold back the wheels of medical progress. No one doubts at present that medicine had its roots in the very dawn of humanity, and has never ceased to grow in stature and strength, and by its very nature must continue to grow while mankind survives and disease and injuries occur. ”

“ A house cannot be built in the air, nor can we create a science or an art unless it rests upon foundations consolidated by time and approved by experience. In vain do we try to detach it from its origin and its history. As well might we expect a tree to bring forth fruit if we uproot it from the ground out of which it sprang. Attempts have never ceased to claim for it an independent existence. ”

“ It never deserved to be pondered more carefully than at the present day, when every fledgling in science or literature feels impelled to spread his wings for a flight toward the stars, too often forgetful of the melancholy fate of Icarus. But not only does immaturity of intellect produce abortions in science and art, but it also generates many that are feeble and incoherent rather than incomplete. ”

“ Upon the one the true physician looks with disgust, upon the other with contempt, striving meanwhile to keep his own skirts clear from the stains of similar coarseness or folly. He knows how great a heritage of knowledge and wisdom has come down to him through the ages, and strives to preserve it for his successors untainted by the defects and errors which it is impossible for any branch of knoweldge or any department of art to escape. ”

“ We may try to suspend medicine by the balloons of theory, and the vulgar may applaud our ingenious inventions, but sooner or later the gas escapes from them, and the baseless fabric rushes to the ground.
It has been said that every nation in the long run possesses the best government it is fitted for. And it is at least equally true that the social and intellectual condition of a nation represents the best it is at the time fitted to enjoy. ”

“ It is this faculty which essentially distinguishes the philosopher from the poet, and enables one to follow a straight path on the firm earth, while the poet on the wings of his imagination soars beyond the verge of human reason. ”

“ We hear a great deal of "the advance of medicine," and are often reminded of discoveries made in human and comparative anatomy and physiology through vivisection, experimental phyisiology, and chemistry, and are apt to believe that before us all the world was in darkness. But if the light of the present day does not dazzle us so much as to prevent our reading the history of medicine aright, we shall be surprised at the uniformity of the pictures of disease bequeathed to us by ancient writers, and of their identity with those that nature furnishes us to-day. ”

“ There was a time, and that quite within the memory of the elders of our profession, when physicians of reputation, and who even filled official positions as teachers in medical schools, were not ashamed to promulgate such doctrines, and actively and even zealously oppose every hint and resent every declaration which implied that the teaching of medicine in this country was disgracefully crude and narrow. They stigmatized those who clamored for a nearer assimilation of our schools and of the profession to the best models of the old world as unpatriotic, if not disloyal. ”

“ Have we no reason to apply this judgment to ourselves? Have we not, in our eagerness to cultivate the science of medicine been guilty of decrying and neglecting medical art? There was a time when either medical schools did not exist or were held to be secondary to personal and practical instruction. There was also a time which, indeed, continued almost to the present day, when the medical student was an apprenticed pupil for a term of years, during which he performed such almost menial services as his preceptor required. ”

“ The treatment of every case of sickness must be determined ultimately for and by itself, tentatively by skilled men, and as their practical sagacity may determine, while they bear in mind that the virtues of a medicine depend less upon its intrinsic properties and powers than on the sagacity of the physician who administers it; just as the efficiency of firearms depends less upon the explosives and the missile they contain than on the judgment and accuracy of aim of the man who discharges them. ”

“ If there is any branch of knowledge in which modesty and humility are becoming it is that which concerns the action of medicines and their curative powers, for in them the elements are infinite in number and constant in their inconstancy. How cautious should we be in formulating laws in this branch of medicine when we remember that the strictest rules of interpretation have been applied only in the most exact of all natural sciences—astronomy. Yet it is related that Newton was asked one day what enabled him to walk as he willed, and he boldly answered, "I do not know." ”

“ For him it is eminently true that "the aim of university teaching is not to perfect the student in knowledge, but to prepare him to learn." It is not absolute truth which men in general are competent to understand, nor is anyone competent to teach them; neither are they able duly to estimate those partial and approximate truths which even philosophers discern but dimly. Out of the multitude of devotees a few only are qualified to approach the sacred shrine. Even the most learned and gifted hardly do more than see it through a glass darkly. ”

“ But this rapid and intuitive faculty is always inborn, one of those mental operations that we attribute to genius, and which is unknown to the average mind. It is like the power to declare the result of arithmetical calculations more rapidly than they can be worked out by the most expert accountant. No calculating prodigy has ever been able to describe the process by which such astonishing results are reached; and, strange to say, these natural arithmeticians have generally been otherwise quite undistinguished either as mathematicians or in the common business of life. ”

“ Every age, every generation, almost every period of a few years has witnessed greater or less changes in the doctrines, the principles, and the practice of medicine. If they are less ostensible and radical now than during the ages of inflexible theory and blind faith, if they come into view more gradually and gently, and grow distinct only through the lapse of time, it is because practical medicine is no longer so exclusively as it was the outcome of conjecture and speculation which reached their conclusions with a bound, but is rather a slow and vital growth of positive knowledge. ”

“ This faculty, which has been called the scientific imagination, is not the faculty of the poet, by which he sees things that do not really exist, but the power of mentally conceiving or realizing the whole of a picture of which a part only is presented to the senses. It is this scientific imagination which derives its value from the uniformity of nature, and enables one not to speculate at random under the spur of the imagination, but by obeying the laws of cause and effect, and the associations which nature infallibly creates, to become a faithful intepreter of nature's laws. ”

“ There is a science, and there is an art, of medicine, but the boundary line between them is not always clearly defined: for although we may arbitrarily separate the one from the other, it is evident that while both are independent in their nature, each tends to throw light upon the other—the science upon the art, by enabling us to group together empirical facts in an order and arrangement which makes both the science and the art more intelligible ”

“ In medicine they dispense physicians from that laborious research without which no substantial and lasting results can be reached. And when they are set forth with the fascinating art of speculative genius they draw around them a crowd of disciples who shrink from the slow and toilsome pursuit of the highest truth. ”

“ Little they recked of the student's thirst for knowledge, and as little seemed conscious that medicine was perpetually changing as a science and as an art. If the professor slumbers the student cannot remain awake, unless it be to resent as dishonest that he should be given a stone instead of the bread that he asked for and paid for. ”

“ In addition to all these hindrances to a search for medical and for other truths is the notorious fact that medical literature is full of the products of ignorance, unskilfulness, and even deceit, and hence that the simple truth seldom stands out clearly. The half-educated and the inexperienced observer or commentator is very apt to deceive others while he deceives himself. What he does not discern clearly he cannot make clear to others. ”

“ Our art is personal and individual in its application; and, however wide the field from which we may derive our knowledge and our skill in exercising it, we can never employ aright its vast resources unless we are able to gather them all together and apply them not only to a particular form of fever, inflammation, or degeneration, but also, and above all, adapt them to the individual man, woman, or child for whom we exercise the office of a physician.
Let me further illustrate the relations between the science and the art of medicine. ”

“ They make but little account of that quintessence of wisdom which Hippocrates at the first distilled, and which has come down to us through the ages unimpaired, and is as true to-day as when it was uttered twenty-four centuries ago: "Life is short but Art is long, and the opportunities of learning it are fleeting; for things are often not what they seem, and to judge them is difficult." ”

“ Sometimes, indeed, they have ceased to possess their phenomenal faculty on attaining adult age. In practical affairs, and conspicuously in practical medicine, this instinctive faculty is apt to be designated as common sense, and, when habitually exercised upon concrete facts, and not upon abstract numbers, is rendered stronger and more manageable by time and exercise, and those who possess it are looked up to as wise men in their several spheres, and are appealed to in doubtful cases. They possess an authority which they have derived not from science alone, nor from experience alone. ”

“ As in Newton's case, so in our own, it will often be a mark of wisdom to confess ignorance, just as it is too often the sign of an ignorant, pretentious man to profess a knowledge of things he does not understand. Judged by this test, how few scientific physicians could justify their claim to wisdom; for they are addicted to explaining everything, and, unlike Newton, feel so humiliated by admitting their ignorance, that they are apt to offer vague or even impossible or unintelligible explanations rather than confess that they do not know. ”

“ In the remarks that are to follow I shall endeavor to illustrate the uncertainty of therapeutical laws, and show that it depends neither upon themselves, nor solely upon the fallibility of human judgment, but chiefly upon the extreme complexity and obscurity of the problems that occur in practical medicine. In that department of knowledge there is no constant quantity whatever, neither the physician, nor the patient, nor the remedy. The very complexity and uncertainty of clinical problems render the practice of medicine at once the most difficult and one of the most interesting of arts ”

“ The ridicule, discredit, and oppression that dogged the careers of Galileo, of Savonarola, of Harvey, of Jenner, and so many others whose names stand in the long martyrology of science, are hardly intelligible to the present generation, which has at least some reason to boast of its love of truth for truth's sake, and its freedom from prejudice. ”

“ It should never be forgotten that the patient has no direct concern with the learning and science of his physician, and is incapable of estimating their value. They are of interest to him in so far only as they are reinforced by the physician's tact in seizing the essential elements of his patient's disease, and his dexterity in adapting his remedies, not so much to the nominal affection, as to the actual, living, suffering, endangered patient before him. ”

“ He can hardly fail of being surprised at the complacency of medical writers to whom their science seems to present no mysteries, and their art no difficulties, so glibly do they expound riddles that have perplexed the wise in preceding ages, and so jauntily do they make light of the nature and cure of diseases which have always defied the maturest skill and which continue to resist the most consummate art, notwithstanding the loud promises and positive assertions of physicians who are too often ignorant of medical history and of the conditions of cure taught by personal experience. ”

“ The mighty men of valor and the puny dwarfs, the philosophers and the fools, the law-givers and the men of renown for all that makes illustrious figures in history—they all shrink down to a common level in the earth from which they sprang, and to which they must sooner or later return again.
Properly considered, medical education is a branch of general education. Its true foundations are in general science, philosophy, and literature. It must, like other edifices, be built up by adding stone to stone, course to course, story to story. ”

“ In medicine, as in every other department of knowledge that is founded upon a study and correlation of natural phenomena, this double quality exists—a substratum of positive, demonstrable, and imperishable truth, and a superstructure of more artificial and transient materials imposed by the instinctive longing of the mind for explanations and laws, and, in default of substantial principles, for theories however crude and hypotheses however wild. Theories in the natural sciences are no more essential to them than the clothing we wear is essential to our structure and functions ”