Medical Graduate 
And His Needs THE 
MEDICAL GRADUATE 
AND 
HIS NEEDS. 
GEORGE C. WELLNER, M. D. 
BY 
DETROIT, MICH. ; 
GEORGE S. DAVIS. 
1884, Copyright, 1884, by Georg® S. Davis, 
Detroit, Mich, TO 
PROF. CHARLES W HEWITT, A. M., M. D., 
THE UNTIRING SECRETARY AND ENERGETIC AND EFFICIENT EXECUTIVE 
OFFICER OF THE MINNESOTA STATE BOARD OF HEALTH, AS A 
TRIBUTE OF PROFESSIONAL RESPECT AND PRIVATE ESTEEM, 
THIS LITTLE VOLUME IS SINCERELY INSCRIBED BY 
THE AUTHOR. CONTENTS. 
On the Study of Medicine 5 
Methodic Clinical Inquiry 12 
On the Physician , 21 
On Diagnosis .. 36 
On Prognosis 54 
On Treatment 59 
From Graduation to Practice 69 
The Material Outfit 79 
The Hospital Course 84 
Post-Graduate Study in New York 87 
Post-Graduate Study in Europe. 93 PREFACE. 
The following production, although small in compass, is 
the result of a good deal of observation and reflection. 
It is now years ago that the author first observed that, in 
common with all young physicians on their entrance into prac 
tice, he constantly encountered certain difficulties respecting 
which neither his Alma Mater nor the books had taught him 
anything. However, these difficulties were not owing to a 
positive want of professional acquirements, but wholly to an 
unqualifiedness to use them to the best advantage. With a 
view to self-improvement he began to note down, as occasion 
in his own practice and that of others suggested, specifically 
all such of the more important and elementary difficulties as 
appeared to him not to have sufficiently attracted attention, 
adding, at the same time, such hints, cautions, and specific 
directions as his judgment suggested. The fruit of this labor is 
this little volume. Its being the only one of the kind, may 
serve as its raison d'etre. The customary challenge, “Why 
do ye spend money and time for that which is not bread?' 
does not apply to it. 
Although designed chiefly for students and young prac- 
titioners, it can be read with profit by “children of a larger 
growth.’ 4 ON THE STUDY OF MEDICINE. 
• If it is a truth of study in general that inborn apti- 
tude is a fundamental prerequisite to success, it is a 
truth of the study of medicine in particular. He who 
presumes to tread the tedious and distant path leading 
to the temple of Esculapius without this aptitude, 
without a decided natural bent for it, will succumb too 
soon to the burden of his task. The elasticity of the 
mind, so essential to the attainment of the goal, will 
give way, impatience, discontent and fatigue will set 
in, and the career entered upon with no special calling 
for it, is abandoned, or the study will at best be con- 
tinued with indifference and irksomeness, without aP 
prospect of success or reward whatever. But not only 
the mental, the physical powers as well must be ade- 
quate to the exertions required by the study of medi- 
cine. How many a young man whose health does not 
possess the requisite ruggedness to bear the strain 
without detriment, has snatched away from him 
through premature disease or death the reward of 
years of successful labor, before the aim of which has 
been reached, or soon after when the already shattered 
health is altogether undermined by the hardships of 
active professional life ! Really, how often do the 
best founded hopes and the most justified expectations 6 
ON THE STUD Y OF MEDICINE. 
come to premature disappointment and sad grief! 
And how urgent is it to address the voice of warn- 
ing to those who are about to engage in the study of 
medicine without this important coadjuvant, good 
health ! On the other hand, he who does not command 
the means to prosecute extensively, or with at least 
approximate thoroughness, so spacious, so import- 
ant a subject in its results, as medicine, ought, as in 
bounden duty, to abstain from its study. For he 
would fail to acquire that degree of scientific educa- 
tion and professional drill which is so immediately es- 
sential to establish the success of practice, to secure 
the respect of the public, and to beget that self-con- 
fidence which is so indispensable to the physician. 
Only he who has by means of a liberal education and 
extended medical and other studies laid a secure 
foundation, can with any certainty hope to attain to 
success, maintain his independence, and consider the 
future as secured. How painfully frequent is it to 
see physicians, who, having lacked the pecuniary 
means of thoroughly studying their profession, never 
succeed in issuing from the sphere of indigence, re- 
maining ever in a subordinate position, engaged in a 
continuous struggle for existence, vexed by cares for 
the future ! And is there possibly a sadder lot than 
that of a conscientious medical man, who, in a calling 
full of privations and hardships, can not earn even the 
means of satisfying the demands of a modest liveli- 
hood, and when adverse circumstances encroach ON THE STUD Y OF MEDICINE. 
7 
upon him cannot dispense with even the charity of 
others? 
His extremely arduous studies over, the young 
physician enters upon practice. Now can it be said 
that practice affords him any recreation or respite 
from the exertions he has just escaped? By no means. 
For to the ordinary fatigues of practice, there are 
added the irregularities of living and the emotional 
perturbations which no conscientious, no true physi- 
cian can shun, can shake off. So far as bodily exertion, 
wear and tear of body, is concerned, it may con- 
fidently be asserted that that involved in the 
practice of medicine exceeds that of any other 
profession. There do indeed obtain in the 
profession diverse degrees of exertion according 
to the position of the practitioner; thus, while the 
exertions required of the physician in the larger 
towns are generally fairly tolerable, those peculiar 
to country practice amount to actual toil, and are fre- 
quently insufferable. Take medical practice at its 
best. The eminent practitioner of the metropolis, 
as well as he of a more comfortable practice, whose 
patients in point of intelligence, influence, and pay, 
leave little or nothing to be desired, who makes his 
professional rounds by carriage, aided by numberless 
other advantages, even he finds practice fatiguing 
enough at all times. How much more downright 
toilsome and exhausting, then, must be the practice 
of that large class of physicians in cities and the 8 
ON THE STUD V OF MEDICINE. 
larger towns, who, as beginners, or what is still worse, 
practitioners of advanced age—but too often the case 
—are compelled to walk their visits which many 
times extend to distant parts of the town, and up 
many a stairway in lofty tenements 0 If to this are 
added the heat of summer, the rigor of winter, the 
other inclemencies of weather, the frequent necessity 
of visiting patients late in the evening, the disturb- 
ance of sleep, the irregular hours for food and sleep, 
and other necessities, the deprivation of many other 
comforts of life, the numerous occasions for agita- 
tion, the numberless exquisite vexations, it must 
unqualifiedly be conceded that the practice of medi- 
cine is harder, more burdensome, more exhausting, 
than that of any other profession. And yet these 
hardships and privations appear well-nigh insignifi- 
cant compared with those of the country practi- 
tioner, he of that heroic class, “ the toiling many, and 
the resting few.” In all seasons, in all states of 
weather, day or night, afoot or in a lumber wagon, 
over bad roads, and through deep sloughs, he is in 
fact the unique of professional men. Let him who 
has no experience of the hardships of such practice, 
make an effort at a conception of them. Let him 
conceive the physician as being roused at midnight 
from a sound sleep and a warm bed, to go into the 
country a dozen or more miles. The roads are bad, 
the night is dark, and, as a consequence, following 
the right road difficult, to say the least. After sev- ON THE STUD V OF MEDICINE. 
9 
eral hours’ ride of much discomfort, due to broken 
sleep, the raw air or rain, the uncertainties as to the 
right road or direction, the apprehensions of upset- 
ting the vehicle, jf not to the more serious possibili- 
ties of winter, he arrives at the house of his patient. 
As a rule no comforts await him here, and if, having 
rendered his services, the condition of the roads, 
darkness, or the nature of the patient’s case is such 
as not to compel him to tarry all night, he has a right 
to improve the opportunity for self-congratulation. 
But if detention should be his lot, perhaps as often the 
case as not, his time will then for the remainder of 
the night belong in a large measure to the patient, 
sleep will probably not visit him, and one thing or 
another will yet have to be suggested capable of 
whiling away the tedium and bore of those hours. 
To these multiplied exertions are added the dis- 
advantages to health accruing from changes of tem- 
perature and inclemencies of weather, unavoidable 
influences made operative in the highest degree by the 
increased susceptibility of the body to them in the 
night and early morning hours. Taken all in all, the 
daily and nightly hardships of practice cannot fail to 
impress themselves upon the health of the physician 
however hardy he may be. The young practitioner 
whose health is all but fortified by a strong constitu- 
tion, whose body is in nowise inured to the severe 
privations of practice, will find but too soon that these 
exposures of the very opposite kind are most prolific ON THE STUDY OF MEDICINE. 
of various constitutional disorders, more especially of 
nervous prostration and catarrhal and other inflam- 
matory affections of the air-passages, etc. His health 
once permanently impaired, his fondest hopes and 
best aspirations together with years *of conscientious 
and successful labor are blasted. He can no longer 
hope to attain anything like success in his profession; 
and, what is perhaps more serious and afflictive, his 
years, the exhaustion of his means, and above all his 
impaired health, render success even outside of the 
profession highly improbable. On the other hand, the 
veteran practitioner whose constitution has more suc- 
cessfully withstood the buffets of practice, at last falls 
a prey to rheumatism or “poor health,” and he must 
remain content if he is only occasionally vexed, his 
body only incommoded at intervals; if practice is not 
made difficult or altogether impossible, and some grave 
form of heart- or other disease does not set in to 
burden and embitter the last years of life. 
These are some of the considerations which the 
candidate of medicine ought well to weigh in mind at 
the very outset of his medical studies. Good 
health, inborn aptitude, and, as a rule, ample 
pecuniary means, these are the conditions of success. 
With them, all the added and superadded obstacles 
and difficulties of medical practice will prove to be 
comparatively trivial, or so many “ sufferings devinely 
appointed as joys;” without them the result will at best 
be average professional ability, that is, a wretched ON THE STUD Y OF MEDICINE. 
mediocrity which is everywhere at a notorious dis- 
count. Average ability in the physician in the present 
overcrowding of the ranks of the profession means 
mediocrity of success,and mediocrity of success means 
humiliation, debt, poverty—poverty that will ride him 
more oppressively,more persistently, than did the Old 
Man of the Sea bestride Sinbad: 
“ Misplaced in life, 
I know not what I could have been, but feel 
I am not what I should be.” METHODIC CLINICAL INQUIRY. 
Method is defined by Coleridge, in his admirable 
essay, to be “ a progressive transition from one step to 
another.” “Without method,” says this great thinker, 
“ all things in us and about us are a chaos, and so long 
as the mind is entirely passive—so long as there is 
an habitual submission of the understanding to mere 
events and images as such, without any attempt to 
classify and arrange them, so long the chaos must con- 
tinue. There may be transition, but there can not be 
progress; there may be sensation, but there can not be 
thought; for the total absence of method renders 
thinking impracticable, as we find that partial defects 
of method render thinking a trouble and fatigue; but 
as soon as the mind becomes accustomed to contem- 
plate not things only, but likewise relations of things, 
there is immediate need of some path or way of transit 
from one to the other of the things related—there 
must be some law of agreement, of contrast, between 
them—there must be some mode of comparison; in 
short, there must be method. We may, therefore, 
assert that the relations of things form the prime 
objects, or, so to speak, the materials of method; 
and that the contemplation of these relations is the 
indispensable condition of thinking methodically. METHODIC CLINICAL INQUIRY. 
13 
Of these relations of things we distinguish two prin- 
cipal kinds. One of them is the relation by which 
we understand that a thing must be; the other, that 
by which we merely perceive that it is. The one we 
call the relation of law, using that word in its high- 
est and original sense—namely, that of laying down a 
rule to which the subjects of the law must necessarily 
conform; the other we call the relation of theory.” 
To a successful examination, method is indispen- 
sable. It gives perspective to the beginner, and com- 
prehensiveness to indifferent and mediocre talents; it 
leads the sanguine to sobriety, and it is the measure 
which guides the judicious and experienced. To 
discard all methodical procedure would entail cir- 
cumlocutions, iterations, and omissions; but more 
especially does an examination, devoid of method, 
lack the band which unites the symptoms and groups 
of symptoms, the examiner having in the most favor- 
able case an aggregate of phenomena with which he 
is unable to cope otherwise than by wasting his 
strength and time upon them individually. Though 
it is not always practicable to adhere to a stereotyped 
order of examination, and one must often occupy 
himself with what the patient chooses to bring for- 
ward, yet in the mind, at least, one must hold to some 
order, and, when there obtains no longer any contra- 
indicating circumstance, return practically to it. 
There are, it is true, highly-gifted diagnosticians, 
whose perspicuity and great comprehensive grasp of 14 
METHODIC CLINICAL INQUIRY. 
mind may dispense with much that is superfluous; 
but the only test of the correctness of their diagno- 
ses is a mental review of a methodic examination. 
Nothing in lieu of experience is, therefore, of 
more importance to the success of the young clini- 
cian than method. No other means will so well ena- 
ble him to turn to profitable account his attainments, 
skill, and mental acumen; certainly, the want of no 
other means is capable of causing him so much dis- 
appointment and abatement of professional dignity. 
The failures of the young physician, let it be remem- 
bered, are owing less to a want of positive acquire- 
ments and experience, than to inexpertness, unquali- 
fiedness to use them. It is not so much in point of 
fact, the presence of the medical attributes—the 
open eye, the quick ear, the lively touch, the keen 
smell, etc.,—as the ability to use them well, that 
conditions success. If the young physician will but 
consider the source of all his embarrassments, uncer- 
tainties, and disconcertions at the bedside; his doubt 
and vacillation in diagnosis; his irresolution, impatient 
expectation, and shifting in treatment,—he will find, 
upon mental introspection, not a want of thought or 
matter for thought, but a want of order; he will find 
that there is transition, but no progress; that there is 
sensation, but no relativity of thought. 
There are two methods essentially adapted to the 
needs of the clinical beginner, namely, the Synthetic 
and the Analytic. There are still other methods, but METHODIC CLINICAL INQUIRY. 
15 
each and all of them are too complex or difficult to be 
practical, and the junior diagnostician cannot hope to 
use them with any, degree of facility whatever. 
Neither is any one, nor all of them together, more 
scientific, more comprehensive or more reliable than 
the synthetic or the analytic—the synthetic reversed. 
It is true, expert diagnosticians', men of great experi- 
ence and close observation, gradually acquire what 
has been defined as non-communicable intuition and 
tact; a kind of natural method which permits them to 
dispense in a measure with a more rigorous applica- 
tion of the synthetic or analytic. But, on the other 
hand, the great bulk of practitioners of nearly every 
denomination, and, with a few exceptions, of nearly 
all grades of ability, those who carp at the study of 
method, as well as those who appear only practically 
indifferent to it, all, observe in a manner and measure, 
though perhaps unconsciously and instinctively, the 
one or the other, as the case may be, of these two 
methods. 
The Synthetic, Genetic, or Historic Method, is 
divisible into four serial parts: 1. Medical Genealogy; 
2. Medical Biography; 3. History of the Existing 
Affection; 4. Present Condition: of the Patient. 
1. Medical Genealogy investigates the health 
and the diseases of lineal and collateral antecedents, 
and relatives of several generations. It sets out with 
the parents, adverts, if necessary, to brothers and sis- 
ters, grandparents, etc. Rigorously employed, medi- METHODIC CLINICAL INQUIRY. 
cal genealogy must not omit or slight age, habits, 
occupation, standing, inclination, idiosyncrasy, etc. 
2. Medical Biography begins with the birth of 
the individual, passes in detailed review the epochs, 
affections -and phases of evolution of early life, and 
arrives through the histories respective of health and 
disease, at the present constitution, diathesis, cachexia, 
and existing affection and its remote and its more 
proximate causes. 
3. History of the Existing Affection opens with 
the investigation of the circumstances under which 
the disease originated, elicits its etiological or causal 
moments, acquaints itself with its inception, its course, 
and the treatment hitherto pursued. It must segre- 
gate every important fact relative to social position, 
occupation, predisposition, habits, idiosyncrasy, etc. 
Like the preceding parts, it must give its result histori- 
cally serial, 
4. Present Condition of the Patient follows the 
same order, inasmuch, as the present morbid phenom- 
ena taken collectively precede in the order of ex- 
amination the individual synergies, etc. 
In its most comprehensive and rigorous application, 
this method must not pass over any organ or function, 
and from the sum total of the product, differential 
diagnostics separates the pathological from the spu- 
rious phenomena, and combines them with the medi- 
cal genealogy, medical biography, and history of 
the existing affection; then comparing, relating, and METHODIC CLINICAL INQUIRY, 
17 
arranging them, sets them to a pathological likeness 
to which comparative diagnostics assigns its proper 
nosological position. 
The synthetic is the more accurate and compre - 
hensive method. It is true it leads with difficulty, 
but then with certainty to a knowledge of complicated 
and wearisome maladies, which from modification and 
change by time and therapeutic interference have lost 
their marked character and the order of their ex- 
pression. kis admirably adapted to the making of 
case-records, and as a corrigent and sheet-anchor 
when the physician finds himself misled through other 
methods, or is unable to arrive at any satisfactory 
issue. 
Against this method may be urged that it occupies 
much time, implies great labor, sweeps up much use- 
less material, and that the examination of the present 
condition in physiological order is fatiguing to the 
patient. 
The synthetic method is purely interdicted when 
the disease is of a very painful nature, where the pa- 
tient is much exhausted, and when there is otherwise 
danger in protracting the examination. It is partly 
inadmissable in young children, deaf-mutes, disorders 
of the mind, or where the statements are for any 
reason unreliable. 
The Analytic, or Retrospective Method, is the 
opposite of the synthetic. It commences with the in- 
quiry into the present condition of the patient, and METHODIC CLINICAL INQUIRY. 
endeavors to ascertain the prominent changes of 
structure and the phenomena subordinate thereto. 
• The result of this inquiry is taken as a starting point 
for conducting either the history of the existing affec- 
tion or the medical biography, and, if need be, the 
medical genealogy. The synthetic method views the 
disease as developing, and genetically unfolds the 
case with the aid of the phenomena it historically 
elicits. The analytic, on the other hand, regards at 
outset the disease as already a collective whole, as 
already developed, at least for diagnostic and thera- 
peutic purposes. It begins with the present condition 
of the patient, by seizing upon the principal or most 
proximate phenomenon, resolves it into its component 
parts, assigns it its diagnostic relation, and, passing 
on to other single and aggregate phenomena, it ex- 
tends retrogressively, not necessarily over the entire 
present condition of the patient, history of the exist- 
ing affection, medical biography, and medical genea- 
logy, but only to those moments which directly or in- 
directly relate to the disease. This method, unlike 
the synthetic, need not in the end, owing to the 
greater objectivity of its moments, make a compara- 
tive estimate of the value of the respective symptoms, 
but directly betakes itself to the general principles of 
diagnostics to determine their character by com- 
paring them with similar or identical pathological 
likenesses. 
The analytic method is chosen where there is METHODIC CLINICAL INQUIRY. 
19 
danger in a protracted examination; where a simple 
ailment obtains, and where the patient must be spared. 
Though these circumstances afford a pretext and 
opportunity for slighting and ignoring the less proxi- 
mate but, therefore, not any the less important phe- 
nomena, and for giving the simple manifestation of the 
disease a favorite interpretation. This method, though 
far shorter and more convenient than, the synthetic, 
presupposes greater praxis and critical judgment in 
the physician which enable him to make a diagnosis 
from the few given data only. 
Though one can indicate the idea that should 
determine the direction and course of an orderly and 
well-connected examination; and, moreover, approxi- 
matively indicate how to ask, or examine, hntwhat tht 
physician shall ask,his experience,education and genius 
can only suggest. For this reason all quiz-formulae 
or tables are useless, and even objectionable, for the 
physician of mediocre ability will but too much in- 
cline to admeasure every disease to his limited for- 
mula, and to omit necessary questions not contained 
in it. 
The tact, the nice perception, the ready power of 
appreciating and doing what is required by circum- 
stances, with which the physician conducts himself at 
the bedside; the order and precision of his questions; 
the exhaustive catechisation and the skillfully con- 
ducted exploration; the observance of a proper firm- 
ness as well as a ready forbearance at the right time 20 
METHODIC CLINICAL INQUIRY. 
and place; the avoidance of unessential, time-con- 
suming examinations; the elicitation and development 
of every essential moment; and the arrangement of 
the result to form a just adaptation of parts to each 
other, a connected whole, of which the probability and 
necessity of the connection can be proved, according 
to anatomical and physiological laws, these are the 
criteria of a methodic examination and of a capable 
diagnostician. ON THE PHYSICIAN. 
“ i. Medicine is, of all the arts, the most noble, but 
owing to the ignorance of those who practice it, and 
■% 
of those who inconsiderately form a judgment of 
them, it is at present far behind all the other arts. 
Their mistake appears to me to arise principally from 
this, that in the cities there is no punishment con- 
nected with the practice of medicine (and with it 
alone), except disgrace, and that does not hurt those 
who are familiar with it. Such persons are like the 
figures which are introduced in tragedies, for as they 
have the shape and dress and personal appearance of 
an actor, but are not actors, so also physicians are 
many in title, but few in reality. 
“ 2. Whoever is to acquire a competent knowledge 
of medicine, ought to be possessed of the following 
advantages; Natural disposition, instruction, a fav- 
orable position for the study, early tuition, love of 
labor, leisure. First of all, a natural talent is re- 
quired, for where Nature opposes, everything else is 
vain; but when Nature leads the way to what is 
most excellent, instruction in the art takes place, 
which the student must try to appropriate to himself 
by reflection, becoming an early pupil in a place 
well adapted for instruction. He must also bring to 22 
ON THE PHYSICIAN. 
the task a love of labor and perseverance, so that the 
instruction taking root, may bring forth proper and 
abundant fruits. 
“3. Instruction in medicine is like the culture of 
the products of the earth. For a natural disposition, 
is, as it were, the soil; the tenets of pur teacher are, 
as it were, the seed; instruction in youth is like the 
planting of the seed in the ground at the proper 
season; the place where the instruction is communi- 
cated is like the food imparted to vegetables by the 
atmosphere; diligent study is like the cultivation of 
the fields, and it is time which imparts strength to all 
things, and brings them to maturity. 
“4. Having brought all these requisites to the study 
of medicine, and having acquired a true knowledge of 
it, we shall thus, in traveling through the cities, be 
esteemed physicians, not only in name, but in reality. 
But inexperience is a bad treasure, and a bad fund to 
those who possess it, whether in opinion or reality, 
being devoid of self-reliance and contentedness, and 
nurse both of timidity and audacity: for timidity be- 
trays a want of power, and audacity a want of skill. 
There are, indeed, two things, knowledge and opinion, 
of which the one makes its possessor really to know; 
the other to be ignorant. >T 
“5. Those things which are sacred are to be impart- 
ed only to sacred persons, and it is not lawful to 
impart them to the profane until they have been initiat- 
ed in the mysteries of the science.”—Hippocratic Law. ON THE PHYSICIAN. 
23 
In addition to the Hippocratic requisites for a 
physician, there are others no less important. Of 
importance to the success of the physician, is his own 
good health, physical and mental. The physician 
ought not to be ailing, at least not in a degree dero- 
gating on the one hand from his critical acumen, and 
on the other from his bodily endurance. He should 
not be splenetic nor petulant, least of all himself 
plaintive; for the solicitude for his own condition will 
absorb that for his patient, and thus disappoint his 
expectations. He should neither be indolent nor ab- 
stracted,lest many seeming insignificancies escape him. 
The junior practitioner should not let a want of 
confidence paralyze his beginning; nor too great a 
presumption of knowledge dispel insurmountable 
difficulties. He should not be possessed of enthusiasm 
or trepidation for anything. In the exercise of his 
calling, he should be serene and earnest, firm and 
benign, but in every instance sympathizing. In short, 
he ought to appear at the bedside, in the character of 
the calm, deliberate diagnostician. It is no very easy 
matter to cast off love and hate, joy and sorrow, en- 
thusiasm and despondency, as though they were but 
the mere vestures which screen our humanity; but let 
him not approach the bedside until he is in the clear 
with himself. 
At the bedside the physician should avoid too cheer- 
ful a frame of mind which views everything on the 
sunny side; likewise too disconsolate a mood which 24 
ON THE PHYSICIAN. 
pictures everything as inevitable and calamatous. The 
diagnostician ought so to discipline his mental and 
physical infirmities, that he may at the decisive mom- 
ent .subjugate them, and leave unhampered all his 
powers. The defects and faults of the patient can in 
a measure be amended by the examiner, but those of 
the latter can hardly be remedied. 
The young physician should not repose his merits 
or demerits, as is too often done, either in the estima- 
tion of the patient or in the judgment of the public. 
And, to escape the numerous and exquisite humilia- 
tions by which the first years of his professional life 
will be checkered, he should neither allow his ambition 
to be cried up by fashion and a momentary success, 
nor to be cried down by unmerited censure. The 
public, the mass as such, is ever disposed to reason 
about physicians like a reasonless animal; and 
one can daily make the observation that the greatest 
ignoramuses, whom even luck does not favor, can 
maintain themselves for decades as celebrated prac- 
titioners. 
Of importance to success is his deportment in the 
presence of the patient. For example, to enter the 
sickroom precipitately, cast aside hat and cane, bustle 
into a chair, and question hastily, is by no means 
adapted to lead the patient to repose entire confidence 
in the physician. Believing to see in the hurried ex- 
amination, the discharge of an onerous duty, the 
patient regards his case as slighted or as already given ON THE PHYSICIAN. 
25 
up; to proceed in the opposite extreme, would no less 
defeat expectation. He who indeterminedly ap- 
proaches the bedside, questions in an unsteady manner, 
pondering for minutes at a time after each answer, 
provokes impatience and awakens distrust. 
The look with which one meets that of the patient 
is of consequence. The severe, penetrating look of 
the critical diagnostician overawes the timid and 
susceptible, and is shunned by them; while the know- 
ing and intelligent mistrust the inordinately lax mien 
of the phlegmatic dullard or that of the obsequious 
simperer. Though the physician will endeavor, as in 
a measure he must, to suit his individuality to that of 
his patient, yet he should not place himself on a level 
with him. The physician, in his relation to the 
patient, is emphatically above alike the high and the 
low; he ought not to be trivial with the one, nor make 
concessions sacrificial of professional stability to the 
other. He that allows those of “quality” to make 
difficult his duty for him, is served right if their treat- 
ment of him is that of body-servant instead of medical 
advisor. 
Though the physician should ever be impressive of 
the dignity of his calling, and, therefor, conservative 
of his deportment before his patient, as well as of his 
address to him, yet he must suit them to the exacting 
wants of the case. Patients are dull, dejected, sulky, 
fretful and querulous, and, as a matter of course, the 
manner of approaching them successfully must be 26 
ON THE PHYSICIAN. 
varied with the prevailing exigency. But he should 
forbear to act the medical histrion, who, trespassing 
all bounds, sobs with the sentimental, jests with the 
sportive, and sighs with the weary. Lastly, he should 
advisedly refrain from ever introducing himself to the 
patient by that derisive duad popularily considered so 
significant and exhaustive of medical diagnostics: a 
look at the tongue and a feel of the pulse; or by that 
absurd and hackneyed phrase: “Are yon sick?” or 
“What ails you ?” etc., than which there is nothing 
better adapted to fret the patient and dispossess him 
of confidence in the physician. 
Among the many trying situations in the early 
practice of the young physician, there are perhaps few- 
more embarrassing, certainly none more frequent, than 
that of excessive self-consciousness at the bedside. 
Alive to the correctness of his every action, anxious 
to conduct the examination aright, and more than ap- 
prehensive of making a bad impression, he not infre- 
quently believes himself, or rather his professional com- 
petence, to be the subject of critical observation, if not 
of suspicion, by the intelligent patient and his attend- 
ants. Fearful of prejudices and their consequences, 
and as yet unfamiliar with so anxious a scene as that of 
the sickroom, his mind is frequently overstimulated, a 
condition of want of confidence, or better, of exces- 
sive self-consciousness, in which he can no longer 
with reliable precision follow system or purpose 
hatever, and where the result will at best be a par- ON THE PHYSICIAN, 
27 
tial diagnosis. The anxious look and distressed coun- 
tenance of the patient watchfully turned upon him; 
the;, expectant attitude of friends and attendants 
throughout the entire examination; their critical atten- 
tion, whispers, and probable distrust of him, abash 
him—strike him with a humbling sense of inferiority, 
and he is no longer capable of examining relevantly 
to the issue; he is entirely preoccupied by how he 
questions and how he examines. Questions no longer 
suggest themselves in orderly relation, and he asks 
them as they happen to occur to him: now he queries 
of bowels, now of antecedents, and now of diet, age, 
etd.; questions not readily enough presenting them- 
selves, he makes a confused pause, and next, under 
the impulse of keeping busy, he abstractedly feels of 
the pulse, looks at the tongue, and gives directions, to 
recur again to bowels, antecedents, etc. His voice, 
too, becomes indetermined, his very eye and cheek 
becoming accessories, as signs, to his extreme dis- 
comfiture. To escape so disagreeable an ordeal, the 
clinical beginner should, before entering upon his 
duty, first of all somewhat disedge his diffidence and 
the novehy of the situation, by a little unreserved 
converse with the attendants. But if his want of self- 
possession does not with safety permit this, nor even 
distinctness or coherency of speech—by no means in- 
frequent when the clinical novice is 
suddenly honored with a professional call to a patient 
of “ quality ”—then let him, the first flutter attendant 28 
ON THE PHYSICIAN. 
on entering the house having subsided, immediately 
seize the only opportunity to compose himself for the 
examination. Nothing is so well calculated to do this 
than the statement of the attendants which leaves him 
merely a listener. Unless his presence of mind have 
returned, he should from time to time interrupt the 
examination to communicate the result. He will find 
this much more practicable than to reserve the entire 
communication for the last, when the burden of speech 
has become great, and the anxiety of friends and at- 
tendants painfully inquisitive. 
The young practitioner needs especially to be plied 
with motives for circumspection on the subject of 
misdiagnosis. To misdiagnosticate a disease well- 
known to the laity, is to hazard an ultimate exposure 
of the mistake, the result of either ignorance or in- 
advertance, and its consequent odium which, not un- 
like that celebrated ghost, will not down, except at the 
price of his professional reputation. Though this is 
in a measure unavoidable, yet it may be so minimized 
in the catalogue of clinical embarrassments as to be 
scarcely appreciable. The young clinician coming in 
charge of a case that he is unable to diagnosticate can 
not too forcibly nor too often be preadmonished 
not to be precipitate in either christening the disease 
or in shaping its treatment. There is, except in 
certain exigent cases, no occasion or press for haste 
whatever, and if the physician will but reserve his first- 
born opinion, and consider that the writing of a ON THE PHYSICIAN. 
29 
prescription then and there is not, as is so generally 
practiced, the grand prerequisite for the case; and 
that while still fresh in the confidence of his patrons, 
a little special preoccupation with the case, an hour or 
so spent in most thoroughly quizzing patient and 
attendants,—he will come to no other conclusion more 
often than that second thoughts are as a rule more 
reliable than first thoughts. Whatever mode of pro- 
cedure he may, however, elect, let him in no instance, 
drift so far astern of duty and medical common sense, 
as to prescribe from mere force of habit. This abomi- 
nable practice has already made the profession the 
butt of numberless dirisive and sarcastic reflections. 
There is in all medicine no aid to practice, the 
acquisition of which is so ardently coveted by the 
young graduate as a short cut to diagnosis. To 
scrimp the science and the art of diagnosis to a mere 
effort at taw and pushpin, and to clutter his memory 
with the signs and symptoms of disease, appears to be 
the only engrossing and foodful task of the average 
medical beginner. And thus it is that in the first 
years of his practice he can neither diagnosticate nor 
differentiate a large number of diseases. Let him, for 
illustration, give on the spur of the moment the differ- 
ential diagnosis of waxy-liver and cancer of the liver, 
parenchymatous nephritis and interstitial nephritis* 
mitral direct murmur and mitral systolic murmur, 
meningitis and myelitis, spinal congestion and spinal 
irritation, simple meningitis and tubercular meningitis, 30 
ON THE PHYSICIAN. 
and of numerous others, and he will at once discover 
the result of his most exertive efforts to be at best but 
so many macaronic compounds, and that there is no 
compendious method whatever to diagnosis. Let him 
confront a case taken at random, say a true congestion 
of the liver, and his sciolous semeiology will instantly 
discover itself. He will indeed hit upon a few of its 
signs and symptoms, such, perchance, as enlargement 
of the organ, pain, jaundice, indigestion, obstructed 
circulation, but, then, these are common to many 
other diseases of the liver, and fancy, not facts, will 
finally have to complete the diagnosis. Such diagnos- 
ticating is, to use an apt figure, like attempting to spell 
a word without knowing for certain its orthography. 
The medical abecedarian is, indeed, most frequently 
in the predicament of the poor speller who, though 
perfectly cognizant of the identity of some of the let- 
ters of two or more similarly spelled words, cannot at 
the price of his salvation, spell or point out certain 
differences between them. In such plight, the diag- 
nostician need not give himself up to any soothing 
hopes of bridging over his diagnostic deficits by trick, 
knack, juggle, or any facile legerdemain. Sciolism in 
medicine, as in other domains of knowledge, is super- 
able only by effort, hard continuous effort, effort, 
moreover, in the right direction. Let the candidate 
for the degree of Doctor of Medicine relinquish his 
nutshell literature of “Essentials,” “Synopses,” “Epi- 
tomies,” “Vade Mecums,” “Compends,” etc., let him ON THE PHYSICIAN. 
apply himself to the great text-books of practical 
medicine, pathology, hygiene, microscopy, etc., in 
short, let him understand, as he ought, his business, 
and he will unconsciously have relegated his diag- 
nostic wool-gathering and clinical geeing and hawing 
and possessed himself of the coveted and only true 
short cut to diagnosis. 
There is one branch of the medical art the prac- 
tice of which is, in view of its necessity and conse- 
quence, far too neglected by the medical beginner, 
namely, the art of writing prescriptions. Hence the 
inability of many a young practitioner to write his 
prescriptions with indifference as to the presence of 
others. It matters little however capable he may be, 
a certain amount of embarrassment peculiar to most 
persons unaccustomed to show their penmanship be- 
fore others, will surely possess him. This, moreover, 
is not a little hightened by his consciousness of the 
popular vulgar fancy, inborn, as it were, with most 
persons, especially the ignorant and half-educated, 
which admires nothing so much, not even orthogra- 
phy and grammar, as high-flourished, cursive pen- 
manship, than which nothing is so generally regarded 
a more respectable mark of ripe scholarship. Pain- 
fully conscious of this before lookers on, and therefor 
necessarily unsteady and inattentive to the substance 
of his prescription, the young doctor allows himself 
to be hurried into writing fast, being entirely preoc- 
cupied with how he writes. As a result of these off- 32 
ON THE PHYSICIAN. 
hand exertions it not infrequently follows that after 
leaving his patient he mentally comes to himself, and 
then will have nothing of more pressing moment to 
do than to speed after the prescription-bearer to the 
apothecary’s to correct some “irregularity” of dose, 
etc. To avoid such unprofitable and vexatious 
experience he has one more reason for hold- 
ing attendants to their business, and for 
not tolerating curious folk in the sickroom. 
The subject may appear trifling, but it is anything but 
that. When it is reflected upon that a prescription 
must first be reasoned out, then correctly, carefully 
written down; that the beginner is in need at the bed- 
side of nothing so much as self-possession; that he 
would by all means avoid being seen to dwell with 
long and anxious attention upon the prescription, 
to write it out, as it were, by laborious installments, 
advice can assuredly not be thought superfluous or 
overcarking. If prescriptions were, as they ought to 
be, indited, composed,—and not dashed off in a mo- 
ment’s time with merely an off-hand mental effort, those 
abominable, execrable specimens of to-day would have 
an end, and accidents without number, from this source, 
as well. Let the young prescriber hearken to counsel, 
and take sufficient time clearly to think out, and 
correctly and legibly to write out his prescriptions. 
One more point concerning tact. The young 
physician should accustom himself to the use of the 
stethoscope, as there remains no longer an excuse for ON THE PHYSICIAN. 
33 
burrowing the side of one’s face in the chest of the 
patient and thus, auscultation, circumscribe it. Multi- 
plied as have been the arguments trumped up for 
immediate auscultation, enough have not yet been ad- 
duced for proof sufficient to give it warrant. It is ob- 
jectionable alike from considerations of convenience, 
cleanliness and propriety. In auscultation of the 
female chest, common decency, if nothing more, de- 
mands the employment of mediate or stethoscopic 
auscultation. 
Though the physician should keep abreast of the 
age in which he lives, which, for one thing, means 
that he ought to have at hand all the more necessary 
and practical appliances and instruments required for 
the successful prosecution of his profession, yet it 
does not follow from this that he should keep a very 
mechanic’s shop. We are living in an age 
of instruments and appliances, where every phy- 
sician is also an inventor, and where there are 
twenty and more instruments of a kind; and it 
behooves the medical beginner to be wary. Let 
him beware of buying instruments that will be- 
come antiquated in his possession and rusty 
from the wear of time before he has occasion to use 
them. Though his means allow him to purchase 
whatever of instruments and appliances he may wish, 
let him not have a different instrument for every 
other case, which is the counterpart of having a dif- 
ferent medicine for every other disease, and prognos- 34 
ON THE PHYSICIAN. 
tic of quackery and medical dandyism. Let him 
wisely imitate the skillful artisan who makes one in- 
strument serve many purposes. Thus a small num- 
ber of judiciously selected instruments may be put to 
the greatest variety of uses, and the want of a special 
instrument not be felt. 
It has come from a thoughtful source that we are 
fast getting to be a profession of mere mechanics, ar- 
tificers; that we are dealing with our patients through 
media; that we are losing certain natural powers pos- 
sessed in a higher degree by our ancestors; that our 
senses are becoming obtunded from want of training; 
that we are neglecting the study of a most impor- 
tant factor in our art, viz., human nature; that it is 
the cultivation of the study of human nature, more 
than anything else that gives medical chicanery and 
charlatanry its success and peculiar prestige. 
These charges are not without suggestiveness. 
For example, despite of every mark of appreciation 
of the importance of the sense aids, the beginner is 
to be cautioned not to neglect his sense of touch be- 
cause of the employment of the thermometer. The 
same may be predicated of the other senses. As to 
the study of human nature, the beginner may have 
learned something of temperament, but of faith as a 
therapeutic coadjuvant he has learned nothing appre- 
hensible. Faith is the assent of the mind to anything, 
but in medicine it is practically assent to whatever 
the physician does or says, whether right or wrong, ON THE PHYSICIAN. 
35 
true or untrue. But it is more the manner than the 
matter that creates faith. Thus the physician may 
successfully treat a case, yet not possess the patient’s 
faith; or he may fail time and again in the same fam- 
ily, yet be still the idol, the incomparable. These are 
pointed facts too little heeded and not at all studied. 
If it were more the matter, the purely scientific phy- 
sician would incomparably be the most popular. The 
secret of begetting faith is, the utmost self-assurance 
in every act and word, of which the con- 
scious power of ability, the halo of al- 
mightiness surrounding the presence of the master-* 
minds of the profession, is the best illustration. ON DIAGNOSIS. 
“ When a patient presents himself for examina- 
tion or for treatment, he tells us of certain things 
that he feels or sees, which are wrong, and 
which we call ‘symptoms;’ we ask him ques- 
tions, and learn additional facts of a similar class; we 
observe him, and notice other facts which he can neither 
feel nor know by independent means, and these we 
call ‘signs,’ or ‘objective symptoms.5 From what 
we are informed, and from what we observe, we pass 
on to the inference of other facts: we believe, when 
some three, or four, or more changes from the healthy 
state are present, that other alterations exist; and this 
belief is more or less strong, and its character more 
or less definite, according to the state of medical 
science, and our knowledge of it, at the time 
the patient presents himself. We infer certain things, 
certain conditions which we cannot see, but which 
we may, in some measure classify, and, therefore, call 
by distinctive names. Thus heat of the skin is a 
symptom from which we infer a number of ulterior 
conditions. This is what we call ‘diagnosis’ in its 
practical sense.” 
The diagnosis begins with the inspection of the 
patient, and his physiognomy will first engage the ON DIAGNOSIS. 
attention of the physician. It is an invaluable gauge 
of his condition; an unfailing record of every pain as 
well as of every ease. Indeed, its daily and hourly 
suggestiveness is so marked that it is distinctively 
stamped even upon the faces of the attendants, and 
reflected from them, and that in a degree enabh’ngthe 
observing physician unerringly to read the counte- 
nance of his patient by proxy ere he has yet entered 
the room. The first impression from the patient will 
serve to limit the inquiries of the physician to a class of 
diseases. Thus he will necessarily know whether the 
disease in hand is of childhood, old age or the partu- 
rient state; and, most often, whether of the vascular 
or nervous system, acute or chronic, etc. Next, the 
physician should assure himself of the favorableness 
of the surroundings for his purposes. Not infre- 
quently it happens that on the entrance of the physi- 
cian the entire household, filled with curiosity and 
expectation of the things to come, crowd into the 
sick-room; and, each eager to add his mite to the 
general fund of information, they wax 
and sorely distress the patient The physician will do 
well to insist on these folk retiring ere they have yet 
involved the patient in a wrangle of crimination and 
recrimination. 
The physician should on entering the sickroom 
note, though as unobserved as possible, everything 
that might be of aid to his diagnosis. A number of 
objects may present themselves for this purpose; ob‘ 38 
ON DIAGNOSIS. 
jects indicative of occupation, pastime, habits, etc. 
He will at a glance survey the location and condition 
of the room and its contents; know whether it is 
cleanly or uncleanly; whether the surroundings, per- 
sons and objects, are pleasant or unpleasant. He 
will remark with especial heed the presence or ab- 
sence of medical apparatus, remnants of medicines, 
etc., which have been put aside or hidden, but not 
sufficiently to conceal them from the discerning eye of 
the sagacious diagnostician. 
With many persons a scene of hurried activity and 
confusion, to produce orderly arrangement, ensues on 
the entrance of the physician. Let him well observe 
everything transpiring in the stir around him. If he 
have his senses on the alert, he will often gather many 
a diagnostic datum from this, for more reasons objec- 
tionable than desirable, state of things. Thus from 
misplaced and ill-timed propriety, his nose will often 
be greeted by a deft attendant hurrying by him with 
what is not infrequently his most valuable diagnostic 
material, namely, the excrements of the patient. 
It does not always happen that the patient is found 
in a posture or light favorable for one’s purpose, but 
the physician should in no instance, unless the case 
demands it, permit so vexatious a circumstance as a 
dark room or any other disadvantageous state of 
things to lessen the integrity of his examination or 
diagnosis. 
Having inspected his patient, and exchanged such ON DIAGNOSIS. 
39 
civilities as are proper and practicable with him, the 
physician will request him to deliver himself of every- 
thing pertaining to his illness. The physician should 
listen attentively, for nothing gratifies the patient 
more, unless it be talk to no purpose, in which case 
he will cleverly lead him back and limit him to 
the narration of facts. During the statement, the 
physician has leisure to acquaint himself with 
the patient’s individuality, culture, manner of 
speech, and to remark every important suggestion 
offered by his case: condition of the sensorium, 
rationality, voice, position of body and limbs, design or 
anxiety to ignore or slight certain circumstances or 
constantly to recur to them; repeated feeling of parts, 
laying on of hands, etc. 
Having given a careful hearing to the patient’s 
detail, the physician enters upon cross-examination. 
His questions to the patient should be admeasured to 
his understanding, yet accurate, positive and to the 
point; and, if the answers are pertinent, should be 
followed by such as arise directly or such as are taken 
from method. Where, owing to limited intelligence 
or suffering, the patient is unable to say more than 
“ yes ” or “ no,” the answer should be contained in the 
question. However, all suggestive questions should be 
avoided as much as possible, as many patients incline 
to affirm every presumption. 
Such questions only as are relative tb the issue 
should be put. A departure from this rule is admis- 40 
ON DIA GNOSIS. 
sable only where the state of the mind or the dis- 
position of the patient is such as demands advertant 
circumlocution. In purely subjective symptoms, of 
the actual existence of which there is a doubt, the 
question should again be put, but in a different order, 
with the design of circumventing either the misrepre- 
sentations or answers indifferently made with the 
intention of ridding himself of what is to him a 
bother. 
Suspension or intermission in the examination is to 
be made only when the condition of the patient de- 
mands it, otherwise it would lead the physician from 
his adopted course, and, moreover, give the patient 
leisure to introduce matter foreign to the issue. In 
violent paroxysms, the examinations should be staid, 
to be resumed at the next intermission. 
Every utterance of the patient is not to be credited 
with veracity, though he may often underrate his ail- 
ment; in both cases, exploration should be the medium. 
If any of the answers have escaped his memory, the 
physician should repeat the question, though in a 
manner that seems to aim at double assurance; for ab- 
straction and absentmindedness in the physician, the 
sick never excuse. 
Those who, from a paucity of ideas and words, are 
unable to express themselves, must be encouraged and 
assisted. Such patients are, for instance, incapable of 
saying anything more specific than “I feel sick” or 
“I feel sick here,” indicating the affected part by lay- ON DIAGNOSIS. 
41 
ing on the hand, and utterly fail to convey more 
definite ideas without the cooperation of the physi- 
cian. But let him, if the absolute correctness of the 
diagnosis is of moment, beware of anticipation. 
Until the patient is prepared for it, the physician 
should sedulously forbear to intimate or broach things 
that may £ive his patient unrest, embarrassment or 
may violate his sense of decency. To many patients 
there is nothing more odious than the snatching away 
of covers, and the laying on of hands; it makes them 
stubborn and sulky, whereas, to patience and persever- 
ance every necessary concession would be made. If 
a physician have an unusually delicate task to per- 
form, let him in neither speech nor manner discover 
its extraordinariness, lest the patient, from the stress 
given the occasion, construe the necessary compliance 
into positive indecency. Bashful women—for the 
question can only be of women—would escape or 
refuse answer if time were given them to consider the 
magnitude of the seeming indecency. An uncondi- 
tional, decisive question, put in a manner showing at 
once the necessity and the naturalness of the commu- 
nication, will generally if not always evoke the desired 
answer. 
To the patient’s sense of shame, concession is to 
be made in so far only, as it is unprejudicial to’a com- 
plete diagnosis. Everything that might make him 
fretful should scrupulously be obviated. The physi- 
cian should spare his patient as much as is consistent 42 
ON DIAGNOSIS. 
with his duty; delicate and painful parts, for example, 
should neither be exposed nor handled too often. 
Heedless of this caution, the physician but too often 
gives the patient opportunity to interpret that lofty 
axiom that medicine knows not shame, in a most 
equivocal sense. 
The physician should not content himself with 
an incomplete examination; neither should he ex- 
tend it beyond all the bounds of propriety. In 
critical cases, the greatest acumen is called forth 
to perceive the indications from the several 
symptoms. In simulative and dissimulative cases, 
presenting an illusive and unfavorable prognosis, one 
may justifiably have recourse to innocent means 
to help make a diagnosis. Cases of doubtful diag- 
nosis, the examination of which may be deferred, 
should be examined from time to time. Some cases 
admit but gradually of a diagnosis. Concessions may 
be made to the innocent humors of the patient, espe- 
cially if admissions of value to the diagnosis are there- 
by made. 
In his early practice the physician will often fail to 
make a diagnosis. Though he will almost always dis- 
cover the symptoms of the disease and interpret them 
severally, yet he will often be unable to constitute 
them a diagnostic whole. This inability is directly 
due to inexpertness in diagnosticating; in part to an 
absence of typicalness in the disease; to symptoms in- 
sufficiently pronounced; and to the presence of inci- ON DIAGNOSIS. 
43 
dental phenomena. The physician should never be 
precipitate in naming the disease; but rather aim to 
complete his diagnosis by repeated examinations. It 
is an error of the grossest kind, to hold that a diag- 
nosis can be made by a mere sally of genius, or by 
resoluteness, venturesomeness, or guess-work of any 
description whatever. Hard study and close observa- 
tion only will suffice to make a correct, a reliable 
diagnosis. 
A fruitful source of defective, meagre and erron- 
eous diagnosis, peculiar to the first years of practice, 
is forgetfulness to note all the signs and symptoms of 
the case, or to search for all evidences of disease. 
What young practitioner has not had his judgment 
misgive him, even after his best endeavors, that the 
diagnosis was still anything but certain;—has not in 
almost every case of his virgin practice remembered 
the omission of important points in the examination 
after having left his patient! To instance this 
thoroughly, let him, when next he has visited a 
patient, compare the symptoms as he has elicited 
them with the number necessarily or usually present 
in the disease, and he will find that his examination 
has been too limited, that he has forgotten to make 
some of the most necessary observations—not that he 
was unacquainted with them, but because the number 
of observations serially to be made was too large 
either to make or compare without introducing sys- 
tem. This seeming improvidence of memory is 44 
ON DIAGNOSIS. 
clearly altogether due to a want of discipline 
in examining. Here as in all other processes of 
investigation, system only is reliable, and no amount 
of finger-filleting or memory-assisting legerdemain 
promises credible results. It must be evident that to 
search for all signs and symptoms, diagnostic and sup- 
plementary, of a given disease; to elicit a score or two 
of evidences, some method or rule must needs be 
adhered to, if more or less that is important shall not 
be forgotten or at the least risked of being forgotten. 
Patients are often irritable, sullen, and headstrong, 
owing to either natural disposition or disease. A 
patient may be refractory owing, respectively, to 
having already been subjected to unsuccessful treat- 
ment; having a physician not possessed of his confidence 
forced upon him by importunate but well-meaning 
friends; or he may be at variance with those about 
him; finally, his forbearance from communication may 
be attributable to reasons of a more delicate descrip- 
tion. It will not be difficult to determine whether the 
cause of this is to be looked for without or within the 
patient; if without, itwill often require much ingenuity 
and tact to induce him to unveil a circumstance to the 
hiding of which he is not altogether disinclined 
to sacrifice the impending result of the disease. The 
physician should prevail upon him by gentle and sin- 
cere means; by creating hope; by removing every- 
thing that might give offense; by assurance of readdy 
desisting, on demand, from further treatment. This ON DIAGNOSIS. 
is not, as it may seem on first view, a matter of little 
moment; for there is without question, nothing that 
renders the diagnosis more difficult and vexatious than 
a persistently stubborn behavior of the patient. And 
unless this peculiar antagonism can be reconciled to 
his purpose, the physician will do well to resign the 
case. Such a course will certainly be most justifiable, 
and no less in the interest of the patient than the 
physician. 
The physician will, as a rule, if the disease is not 
of an immodest nature, communicate the result of his 
examination to the relatives or attendants of the 
patient; if, on the other hand, the disease is of an 
immodest or delicate description, he will confide it to 
the patient as subject to his discretion. Again, the 
nature of many diseases is not to be revealed to the pa- 
tient of a sudden, but gradually; the nonsuspecting 
victim of incipient consumption should not be start- 
lingly confronted with what is at best an almost inev- 
itable death-warrant; and the highly nervous patient 
should not always be informed of the extent and 
gravity of his malady, at least not more than is neces- 
sary to secure compliance and co-operation. Other 
patients, again, are so torpid, so indifferent regarding 
the importance of their ailments, that they must 
needs be magnified to create the concern and solici- 
tude necessary to successful treatment. 
In the course of the treatment of tardy eases, the 
physician will often covertly be cross-examined by 46 
ON DIA GNOSIS, 
certain patients with reference to their complaint, its 
prognosis, etc. But he should, before unwittingly 
answering, give a rational interpretation to such ques- 
tions, as “ Doctor, What is your opinion of my case?” 
“You know that I cannot recover?” etc. The physi- 
cian may, with few exceptions, take it as axiomatic 
that an unfavorable prognosis is never welcome; that 
such questions are almost always prompted by in- 
quisitiveness, disinclination for further treatment, re- 
luctance to incur further expense; or by the desire to 
evoke a bad prognosis, and thus have a pretext for 
changing doctors. Hence, the physician will regard 
most of these queries as so many disturbing incidents, 
which he must dispel or conciliate as best he can. It 
will often be found that the best interests of the pa- 
tient demand expedients, not only to questions, that, 
nicely speaking, irreconcilably clash with the truth. 
In such straits, the physician should ever be mindful 
of the fact that the restoration of the patient to 
health is ever his chief aim, and that all his endeav- 
ors ought to be desiderative of this object. Again, 
whereas, every impression received by the patient, 
results, philosophically speaking, in either good or 
bad, therefor, every impression should be calculated 
with reference to its effect. 
There is one adverse circumstance attendant on 
every sick person, against which the physician can not 
guard too closely, and which is more liable to rob 
him of his patient than death itself—namely, outside ON DIAGNOSIS. 
47 
influences, or as it has aptly been termed, “ Chatter- 
ing Hopes and Advices.” Perhaps nothing in all 
medical practice, not even the death of the patient, is 
capable of giving the young practitioner such exquisite 
mortification, disappointment and thorough disgust 
for his profession, as the request to surrender his 
patient into more skillful hands, or what is, if possi- 
ble, still more keen, his unceremonious dismissal. 
The young practitioner should well secure his pa- 
tient’s interests, as well as his own, against such un- 
necessary pesterment, by determinedly interdicting 
daily and hourly, if not all, communication of neigh- 
boring gossips with his patient, no matter what his 
disease! This is a point not at all, or at least not 
sufficiently, enforced in private practice. What pa- 
tient seriously ill that has not a constant stream of 
visitors, and at all hours of the day! And how 
many such patients that are not literally visited to 
death! 
The physician is almost daily consulted by pa- 
tients whose cases do not so much demand medica- 
tion as hygienic regulation. But, however simple, 
however little in need of any actual drug the case 
may be, the physician should never simply send the 
patient about his business with the jejune advice so 
much regarded as a mark of medical, common sense: 
“That’s nothing,” “That will of itself disappear,” 
“Your case requires no treatment,” etc. Where the 
patient is intelligent and the case unmistakably simple, 48 
ON DIA GNOSIS. 
a few words of explanation and advice may indeed 
answer every purpose; but in the great majority of 
cases the patient wants to be “examined”, and then 
nothing short of a ransacking of the whole person, 
and a complete detailing of the result will give satis- 
faction. Such a task will often require hours of time, 
but the young physician, in view of his abundant 
leisure, can well afford to undertake it, for besides 
acquiring facility and skill in physical and cateche- 
tical examination, the habit of laboriously and con- 
scientiously examining will of itself beget a reputa- 
tion for professional thoroughness and acquirements. 
But as it is at present, there is altogether too much 
sinecurism in the profession to secure the average 
patient a more painstaking interest than a look at the 
tongue and a feel of the pulse, in addition to the 
traditional quiz about sleep, appetite, and the bowels. 
The physician should let no regards for pleasant- 
ness or convenience, deter him in any instance from 
performing those offensive but positive duties, though 
which in point of pleasantness do not rank above 
common scavenging. It is here where the young and 
the routine practitioner sin most; in shirking digital 
examinations of privities, and ocular inspection of 
excrements; in neglecting to make analyses, and in 
shunning all those disagreeables peculiar to the con- 
scientious practice of medicine. The fastidiously 
genteel beginner is not altogether disinclined to em- 
ploy another’s finger, or to glove his own, for certain ON DIAGNOSIS. 
49 
duties, fancied menial, and to make a large item 
in his bill for every violence done to his imagina- 
tion. 
' But let the physiqian beware of carrying his use- 
fulness in the service of the patient too far. He 
should not permit himself, unless specially indicated, 
to be carried to such officiousness as to assist, in the 
presence of other help, in undressing the patienffor 
the purpose of examination; in dressing him, moving 
him out of bed and back into bed; in arranging his 
bedding, and in making himself “generally useful.” 
The profession, or at least many of its members, has, 
aside from this, suffered largely in public esteem from 
the assumption of offices, formerly exercised exclu- 
sively by a sort of professional menial. There is 
a practical as well as a metaphysical reason for avoid- 
ing such forward interposition of services. There is, 
namely, a certain conduct, confined to no caste, a 
certain letting one’s self down, more easily felt than 
defined, which is inevitably sacrificial of dignity of 
character. In our profession we have but too many 
sorry and abiding illustrations of this fact. 
It requires a peculiar talent to make passive a ca- 
pricious, obstinate, struggling child. When the usual 
means do not suffice, recourse must be had to others. 
Though the physician will in unexceptional cases not 
allow the cries and struggles of the little patient to 
deter him from his purpose, yet in certain cases he 
will do well rather to conciliate this peculiar opposi- 50 
ON DIAGNOSIS. 
tion than to provoke a fit of fright. The physician, 
in such circumstances, has the choice of making his 
diagnosis without the aid of the exploration; to wait 
until the paroxysm has subsided, or to depart and 
return some other time, with the hope of better suc- 
cess. Perhaps one of the most successful ways of 
dealing with these little unmanageables for the pur- 
pose of examining them, is to approach them in a 
well-darkened room, where they cannot distinguish 
the presence and manipulations of the physician from 
those of the attendants. 
But, as has been said by a close observer of sick 
children, “There is a certain tact necessary for suc- 
cessfully investigating the diseases of children. If, 
when summoned to a sick child, you enter the room 
abruptly, and going at once to your patient, }?ou be- 
gin to look closely at it, while at the same time you 
question the mother or nurse about its ailment in 
your ordinary pitch of voice, the child, to whom you 
are a perfect stranger, will be frightened, and will 
begin to cry; its pulse and respiration will be hurried, 
its face will grow flushed, and you will thus have lost 
the opportunity of acquainting yourself with its real 
condition in many respects. Besides this, the child 
once excited, will not subside so long as you are pres- 
ent. If you want to see its tongue, or auscultate its 
chest, its terrors will be renewed, and it will scream 
violently; you will leave the room little wiser than 
you entered it, and very likely fully convinced that it ON DIAGNOSIS. 
51 
is impossible to make out children’s diseases.” * * 
* * “Your first object must be not to alarm it; if 
you succeed in avoiding this danger, it will not belong 
before you acquire its confidence. Do not, therefore, 
on entering the room, go at once close up to the 
child; but, sitting down sufficiently near to watch it, 
and yet so far off as not to attract its attention, put a 
few questions to its attendant. All your observations 
must be made without staring the child in the face.” 
Children of one and a half to two years old will 
already bear some rigor, but a doctor with the face of 
an inquisitor will, as a rule, attain just the opposite of 
his expectations. Children that have not yet the 
power of speech, must first be made passive by tender, 
affectionate treatment. If they indicate a part as 
painful, the physician should assure himself that it is 
actually the seat of pain; they often locate pain where 
it is not. Half-grown girls should not be questioned 
things they can not or ought not to know. For 
information apply to the relatives. Girls, youths and 
boys can often not be made to speak until those under 
whose surveillance they are, absent themselves. One 
should well mark their actions as well as their manner 
of speech. 
To become an eminently successful, or rather, 
popular children’s doctor, the physician must, at least, 
be a putative if not a genuine lover of children. Not 
that it is here contended for that a love for children 
is, generally speaking, in itself absolutely requisite to 52 
ON DIAGNOSIS. 
the proper management of their ailments, though in fine 
it is, indeed, not unessential, but the doctor that is bar- 
ren of all natural affection for children, and even too 
remits to hide his defect before the very eyes of the 
fond parent, may be assured of being retired early 
from this branch of practice. The doctor that comes 
to the little patient with nothing in his countenance 
that it may understand, that will question tartly in its 
presence, that will summarily proceed to subject it to 
an examination as unsparing of alarm to it, as it is 
thorough; that will concede nothing in point of 
omitting treatment and measures highly obnoxious to 
it, will—no matter what his other professional abilities 
—never be a favorite with the little ones, nor, as a 
matter of course, with parents. It is an extensive fact 
that popularity with the little patient almost always 
outweighs medical competence in the estimation of 
many parents. Thus the child insists on having the 
sugar-plum doctor, and the indulgent parent, more than 
gratified for an opportunity to do something accepta- 
ble for the little darling, gladly consents. The sugar- 
plum doctor comes, he speaks very softly, he smiles 
sweetly, he is all obligation, he has his pockets filled 
with good things, he is very indulgent, he never in- 
sists on wearying examinations or the examination of 
parts not easily accessible, and, hence, never makes 
his little patient fret or cry, nor does he prescribe 
“nasty ” medicines. And the sugar-plum doctor is 
popular, or, what means the same thing in these pro- ON DIAGNOSIS. 
53 
sale times, he is successful. Without commending 
this for his imitation, let the young practitioner be 
advised so to conduct his management of this peculiar 
practice, that he may be of the most competent service 
to his little patients. But it is obvious that to be en- 
abled to do so he must first possess himself of their 
patronage. Let him avoid extremes ; let him not 
despise policy, but let his policy consist in honorable 
expedients. cm PROGNOSIS. 
“ The practical test of a true science is the power 
which it confers of ‘ prevision,’ or of knowing now 
what will follow hereafter. Some sciences have at- 
tained to this point, as we see daily illustrated by 
physics and chemistry; but as yet medical science has 
arrived at only very partial security of forecast. And 
yet the fore-knowledge of the consequences of a pres- 
ent disease, is that for which patients and their friends 
often seek from the physician with the greatest eager- 
ness. When we can prognosticate with certainty, 
medicine will have become a ‘science.’ At present 
we only, with different degrees of nearness, approach 
this end. We may describe the ‘ probabilities ’ of a 
given disease; we may even measure them; we may 
accept or reject lives at insurance offices; or we may 
affix a numerical value to their duration; but we 
deal with doubts and not with certainties. Life is too 
subtle for us to know or measure all its possible con- 
tingencies; and our information is too scanty to render 
us thoroughly satisfactory interpreters of the outcome 
of any malady. But, with all this doubt, much may 
be accomplished for the safety of society, and the 
relief of individual anxiety or care.” 
The young physician should well mark that it is not ON PROGNOSIS. 
55 
as is commonly believed and practiced, the province of 
the physician to predict the results, but only to esti- 
mate the tendencies of the disease. He should be 
mindful of the axiom that: “ Inasmuch, as it is im- 
possible to predict anything with certainty so long as 
we remain unacquainted with any one of the con- 
ditions of a given event, and ignorant how they may 
act in a particular instance; and, as in the living body, 
no occurrence or effect ever does take place constantly 
in the same manner at all times, we can never with 
perfect certainty predict any occurrence or effect 
whatever.” 
The physician should, as a rule, not state his opin- 
ion of the duration and termination of a disease, unless 
requested to do so, and then in a manner rather 
suggestive of the tendencies than the results of the 
disease. To attempt more than this, is to impose upon 
himself a task as hazardous to his reputation as it is 
unnecessary and foreign to his purpose, and the non- 
fulfillment of which is daily and hourly witnessed, in 
convalescence and decease, in change for the better 
and for the worse, notwithstanding all the prognosti- 
cations to the contrary. Although the prognosis be 
correct, as in many cases it may, it is not always 
proper or advisable to make it known. For example, 
by a precipitate disclosure that the disease is lethal, 
and its course, therefore, inevitable, the physician will, 
at most, for his pains, procure his discharge, and an 
obnoxious course of treatment for his patient. In most 56 
ON PROGNOSIS. 
cases, indeed, the physician may earn credit for him- 
self and his profession by anticipating the course of 
events and communicating it. 
Until the junior practitioner has acquired the fore- 
casting skill of experience, his opinion of the tendency, 
duration and result of the disease should be based upon 
certain prognostic data, such as the deviation of the or- 
ganism from health; the resistence of the constitution; 
the vitality of the diseased organ; and the degree of 
its involvement; the deviation of the disease from its 
acme; the suppression of the crises; the intensity of 
the disease; the amount of complication; the rapidity 
of the elimination of the diseased products; etc. 
The principles that have been enjoined on the 
physician respecting the prognosis as a whole, should 
also be observed with reference to the particular dis- 
ease and its various stages. The educated physician 
will not prognosticate a definite number of days for 
the accession, culmination and resolution of a fever; 
nor will he on diagnosticating an incipient pneumonia, 
acquaint and terrify his patient with an inevitable 
stage of red and gray hepatization, or with possible 
cheesy degeneration. The same may be urged for the 
measures probably to be employed. Let him never be 
communicative about the remedies to which he may 
be obliged to have recourse; for every such confession 
surrenders up a certain amount of decisiveness, pur- 
pose and professional stability. ON TREATMENT. 
“ In the prevention or treatment of disease our 
science culminates and becomes an art. Unless it can 
accomplish one or the other of these ends, the world 
would do as well without as with our aid. It is of some 
value to know the probabilities of our stale, but it is 
of comparatively small value to have this knowledge 
if we can do nothing either to ward off, alleviate, or 
cure disease. We may prepare some people for the 
worst, we may dispel some groundless fears; but our 
mission is to do more than this: we have to try to 
‘cure the curable, and comfort the incurable.’ ” 
In conducting his plan of treatment, the physician 
should not be too ready to condemn a remedy or 
measure if its efficacy is not immediately manifested. 
It is a fact of no inconsiderable moment, that the 
proper treatment is often sacrificed to impatient ex- 
pectation. It is a very common and grave error to 
assume that the medicine has been administered or 
the treatment carried out for the reason that it was 
prescribed. The remedy may not have been taken, 
or, if taken, rejected by vomiting or otherwise 
eliminated from the system; it may have been insuffi- 
cient or rendered inert; it may have been adulterated 
or inert. The prescriber or dispenser may have been 58 
ON TREATMENT. 
in fault, owing, respectively, to the prescribing of 
chemical incompatibles, the mistaking of symbols, 
carelessness, ignorance, dishonesty, oversight in com- 
pounding, misreading and miscopying of directions, 
etc. 
Patients often have or develop an extreme aver- 
sion for a medicine, owing to its continued exhibition, 
its peculiarity, or to an idiosyncrasy of the patient. 
Though the possible correction of this objectionable 
particular is an old maxim of good practice, and 
though the physician is by no means remiss in correct- 
ing it when perceived, yet this species of surfeit is far 
too often due to ignorance of elegant pharmacy in the 
physician; and the patient’s expressive: “I will not,” or 
“I cannot take that horrid stuff!” is but too often justi- 
fied. The young prescriber should, when inditing his 
prescriptions, never be forgetful of what palatability 
or rather, though it amounts to the same, insipidity, 
has done for homeopathy. 
Where the same medicine is to be exhibited for a 
long time, some advertance should be had to tasteful- 
ness. Where the taste is necessarily (?) surprising, 
extraordinary or very objectionable, the patient should 
profidently be made acquainted with the reason for 
the same. As to idiosyncrasy, the pecularities of the 
Individual irrespective of temperament, it is a subject 
altogether too much slighted in modern practice; the 
physician seldom, if ever, adverting to it in his daily 
routine. Though experience is the only sure guide in ON TREATMENT. 
59 
these cases, the physician should, where hazardous 
drugs and doses are to be employed, always question 
as to the presence of such constitutional peculiarities 
for either drug or dose. This will spare him much 
disagreeable experience and the frequent facing of the 
problem, why this person was not affected by more 
than a maximum dose, and that person almost 
poisoned by a dose less than minimum. 
Where the right treatment for a given disease 
proves inefficacious after a reasonable trial, the integ- 
rity of the diagnosis, unless certain, should be ques- 
tion and redetermined. Where the diagnosis is cer- 
tain and the treatment classic, yet inefficacious, 
the physician must individualize or the next most 
reputable remedy should be tried; if still without suc- 
cess, the association of counsel in the case, before 
entirely losing the confidence of patient and attend- 
ants, will be the most politic measure for the beginner 
whose reputation is still in the making. Where the 
diagnosis is quite certain, but the indication is not 
met by the treatment after a reasonable trial, the 
young doctor should for obvious reasons not follow 
the lax practice of the day—permit the repeated com- 
pounding of the same ineffectual remedy. 
The physician should never, unless circumstances 
expressly call for it, familiarize the patient with the 
drugs employed by him. Neither should he ever en- 
ter into a parley with him respecting the merits of 
remedies, etc. To inform certain patients that it is ON ERE A TMENT. 
quinine, potash, or calomel which is to save them, 
is to divest the remedy of its most potent charm— 
faith, and to surrender it to its repute with the patient 
or, what is the same, to his prejudices. Others, again, 
it is no less an error to leave altogether in ignorance 
as to the object of the remedy to be admin- 
istered. Thus, for instance, the well-known feeling 
of indefinite expectation, or “moral effect,” resulting 
in most persons on taking a dose of medicine, is, es- 
pecially where the patient lacks confidence in the phy- 
sician, almost always shaped by their preconceived 
notions of the medicine. This circumstance, this 
“moral effect” which is so frequently the only proper, 
the only curative measure available, is not sufficiently 
appreciated in routine practice, though in his diag- 
nostic and therapeutic perplexities, the physician gladly- 
enough avails himself of it. What a subject for 
regret, that many daily cures, confidently attributed 
to some favorite remedy, cannot be shown to be due 
and due alone, as they are in fact, to this power! 
The beginner in the practice of medicine cannot 
too forcibly be enjoined to adhere to the established 
canons of therapeutics, and not go in quest of new 
remedies. Here, as elsewhere in science, he should 
remember that no amount of vaunting and recom- 
mendation nor a score of isolated trials and favorable 
reports, suffice to give the stamp of proof to a re- 
puted remedy. It will be a safe rule in this era of 
advertisement and multiplicative medicine, for the ON TREATMENT. 
61 
beginner to discard every new reputed remedy, and 
faithfully to follow the medical classics. He will 
have neither the leisure nor the sanction of the pa- 
tient’s interests to discriminate the good from the bad* 
in an infinitude of annual new-fanglednesses, nor to 
venture experiments before having mastered the sci- 
ence of his profession as it is. 
The physician should on coming in charge of a 
case, in every instance inform himself of the reme- 
dial means hitherto employed, domestic and other 
remedies not excepted. This will, besides often spar- 
ing him much useless drugging and valuable time, 
better enable him to appreciate the present face of 
the disease, where this has been more or less distorted 
by therapeutic interference. The physician ought 
always to acquaint himself with the diagnosis and 
treatment of a brother practitioner, where he succeeds 
him', by regardfully questioning the patient or attend- 
ants thereto; by liberally dealing with his measures; 
and, where the case is peculiarly perplexing or where 
it is otherwise demanded, by conscientiously review- 
ing his very prescriptions. Though the physician 
can not respect the professional creed or competence 
of a brother physician, and, therefore, not forego the 
traditional smile and shrug of deprecation, etc., he 
should at least regard the treatment, or interference 
of his predecessor, as a fact, as an actual circum- 
stance in the history of the case; and hence, though 
not always essential to the diagnosis, almost invaria- 62 
ON TREATMENT. 
bly essential to a correct understanding of the case 
in its entirety. 
Much of the success of treatment, no less than 
*he frequent occurrence of vexing casualties in 
course of treatment, depends directly on the manner 
of giving directions to patients and attendants. The 
physician should make it a point in practice to give 
all of his directions at one time, and not scatter them 
over a half-hour’s or an hour’s conversation, or inter- 
sperse them with anecdotes and hon mot, which prac- 
tice is quite sure to result in a family debate after his 
going, for the purpose of discussing and determining 
what all he has said and meant. The directions 
should be, it is at once needless and needful to say, 
exhaustive of the necessary nursing and other details, 
and leave nothing to be wished for in point of being 
explicit and expressive. Where the attendant 
does not seem to understand or is otherwise inapt— 
but too frequently the case—he should, as a matter of 
course, be instructed. Nothing gratifies an attendant 
or nurse more, especially an intelligent and experi- 
enced one, than precise and complete instructions, 
and nothing is as capable of so much prepossessing 
him in favor of the physician. There are many 
patients and attendants, chiefly young persons and the 
unsophisticated of the lower classes, who are so diffi- 
dent or stand so much in awe of “the doctor” as to 
be afraid of asking the necessary information. Such 
self-insufficients should, provided the carrying out of ON TREATMENT. 
63 
the treatment is of any consequence at all, be made to 
repeat the directions after being plainly communicated 
to them. For it can not be gainsaid that the annoying 
mistakes and untoward accidents are altogether of too 
frequent occurrence, and prolific only from the sources 
animadverted on. 
The physician should prescribe with a definite 
purpose and where there is a clear indication. This 
imports something more than is generally and usually 
apprehended under it: Making a correct diagnosis 
and finding the right remedy, which is by no means 
synonymous with good practice. The physician 
having made out the character of the disease, too often 
contents himself with being guided by the subsequent 
course of the “symptoms” and the product of the 
perfunctory quiz as to appetite, sleep, and bowels; 
whereas,nothing short of known pathological conditions, 
their extent and degree,together with their therapeutic 
correlatives, appropriate remedy and dose throughout 
the course of the disease, ought to satisfy him. On 
the whole, patients are not sufficiently often examined, 
and, therefore, the treatment not varied—adapted to 
the varying phases of the disease; they are too often 
misdrugged, too often under-dosed, and still more 
often over-dosed; the medicines too long and not long 
enough continued. 
A source of much vexation and chagrin to the 
young physician, is to experience repeated prescrip- 
tions for the same ailment fail of making the slightest 64 
ON TREATMENT. 
impression upon it. Such inefficacy of treatment is 
always tentative of shaking the correctness of the 
diagnosis and treatment, and, as a result, the con- 
fidence of the patient and his friends in the physician. 
On such occasions, having been disappointed after 
doing his best, and feeling the criticalness of his posi- 
tion, he anxiously casts about in mind for new and 
untried indicants and measures; not arriving at a 
definite result, and becoming more and more uncer- 
tain, believing, furthermore, that the patient or attend- 
ants are not altogether ignorant of his predicament, 
he instinctively begins to feel the necessity of making 
a more exhaustive examination, of finding a more 
appreciable idea of “ what’s the matter.” But con- 
scious of his short-coming, and earful of exposing 
himself to reprehension or of losing his patient’s con- 
fidence, he only partially re-examines and re interro- 
gates. The result of some mechanical fumbling and 
desultory quizzing, not proving satisfactory, as might 
have been expected, he instinctively quits the subject 
of diagnosis for that of treatment. His mind now 
wanders, with much uncertainty and no definiteness of 
purpose, in quest of new remedies. Mentally rapidly 
reviewing the catalogue of materia medica, reverting 
to similar cases and their successful treatment, he 
finally seizes upon a remedy, though the plan of treat- 
ment is first shaped and matured after the books have 
been consulted. These brown-studies at the bedside 
are as needless as they are undesirable and profitless. ON TREATMENT. 
65 
The result of every examination must invariably be a 
positive product, however insufficient for a complete 
diagnosis. Hence, the physician should at least know 
the present totality of the disease and be able to deter- 
mine its present therapeutic affinity. However intracti- 
cable the disease,however incomplete the diagnosis,the 
present facts can be the only measure for therapeutic 
effort. The corrective for an incomplete diagnosis 
and a persistent inefficacy of treatment must bg looked 
for in supplementary examinations. 
One of the most fatal quicksands to the profes- 
sional success of the beginner, is, beyond question, the 
well-known class of incurables, whose purpose of ex- 
istence would seem best explained by their predilec- 
tion for young, because painstaking practitioners, and 
by their peculiar fitness for damaging reputation. 
There is hardly another source of more frequent dis- 
paragement to the profession and of humiliation and 
chagrin to the physician than those chronic wrecks,who, 
Banquo-like, haunt the profession, who have done all 
but died and been buried, and who, having made the 
rounds of all materia medica and therapeutics or the 
entire surgical armamentary, finally issue from the 
gantlet of the profession as, in public estimation, 
martyrs to medical bungling. In view of the fact 
that it is quite impossible to cure most, or at least 
many, of these cases, the young physician should, 
whatever difficulties and tasks he may be willing to 
encounter in the consciousness of his ability, advisedly 66 
ON TREATMENT. 
avoid by all manner of means this class of cases to 
whom disease has, as it were, become a normal con- 
dition, and who have successfully defied the best 
efforts of a score of good practitioners. Let him not 
begin his practice by staking his reputation, though 
yet a blank, against what is at best a mere possibility 
of a prize. Let him ween himself fortunate if the 
halcyon days of his sinecurism remain undisturbed by 
these forlorn hopes. But if he can not well avoid 
taking such a case, then let him be careful to impress 
the mind of his patient with the necessity for the 
requisite time to effect a cure. Let him verbally 
stipulate a term that will suffice for thoroughly master- 
ing the case and employing the various resources for 
it. Let him, furthermore, if the case promise to prove 
incurable' and he has endeavored his best, associate 
reputable counsel with himself, that the brunt of the 
unreasonable blame inevitably following may fall upon 
one who is better able than himself to carry it. 
Another fact, that the young prescriber doubtlessly 
knows but does not appreciatively enough act upon, is 
that, to the successful treatment of children’s diseases, 
the palatability of his medicines and the unobjection- 
ableness of his measures to the patient, are at least as 
important as the correctness of the diagnosis itself. 
For what does it avail him to have made a correct 
diagnosis, if his medicines are not administered or his 
measures carried out! And that the fond mother re- 
fuses, again and again, to provoke a struggle with her ON TREATMENT. 
67 
darling to administer what she herself admits to be at 
best but a disgusting potion, is a matter of daily 
observation. The physician’s dismissal from the 
charge of a case is to be attributed at least as often to 
the prescription of measures and medicines repugnant 
to the child, and therefore to the parent, as to mis- 
diagnosis and positive mistreatment. What more 
suggestive hint of the proof of this fact does the phy- 
sician need than the old, old story that the child 
refuses to take its medicine! And, else why is it that 
homeopathy is so popular, so “ successful,” with cer- 
tain classes, especially in children’s diseases, if it is not 
by reason of the absence of taste in medicine that is 
supposed to be present! Let the young practitioner 
canvass the merits of homeopathy in the estimation of 
its patrons, and he will find that all assertion and com- 
mendation of its “ superiority over allopathy and other 
systems ” resolves itself, besides its shibboleth “ suc- 
cess,” into the one great prestige “ the medicines (!) 
are so nice to take.” Or is the popularity of homeo- 
pathy with its patrons perhaps due to their being so 
very familiar with the philosophy of the doctrine of 
S. S. C., that they are in fine convinced of its truth! 
Though homeopathy, judged from a psychological 
point of view, is but a species of system in insanity, yet, 
like many other errors of the mind, it has been of in- 
calculable benefit to the healing art, as revealing what 
nature, aided by judicious nursing only, can effect. 
Let the young therapeutist never be forgetful of this 
fact. 68 
ON TREATMENT. 
There is one branch of his art in which the gradu- 
ate is so lamentably deficient, and about which he is 
as ignorant when he leaves college as when he entered 
it. This is dietetics—not with reference to his own 
needs, but to those of his patients. No educated phy- 
sician will now question the great import of dietetics 
in the treatment of disease, and yet the young phy- 
sician knows almost next to nothing about it. It is 
not necessary that he should be able to boil, roast, 
bake and broil to know something of dietary, but he 
ought at least to have a knowledge of its principles. 
Perhaps the largest field for successful treatment is 
offered in diseases of the stomach. But so long as 
there prevails the astounding spectacle of the same 
dyspeptic patient making the rounds of a dozen doc- 
tors, and being informed by them successively to eat 
everything; to eat nothing; to take solids only; to 
take fluids only; to eat much; to eat little, etc., so long 
specialists only will work this field successfully. FROM GRADUATION TO PRAC- 
TICE.* 
The graduate in medicine beginning the practice 
of his profession directly after receiving his diploma 
finds himself in a position not unlike that of many a 
newly arrived traveler in foreign parts at his first 
essays to speak and understand the language of the 
country. The chances are that the traveler’s sole 
knowledge of the tongue has been acquired in a 
limited series of “ lessons ” at home. With his own 
master he thought himself tolerably proficient, but 
abroad the inhabitants seem to talk the language in a 
different way, they have other voices; their expressions 
are peculiar; they make strange gestures; and utter 
their words so rapidly. The result is that, while the 
bewildered stranger catches here and there a familiar 
word or simple phrase, his diagnosis of the general 
meaning of what is said is apt to be very vague and 
confused. 
The plight of the embryo practitioner is not much 
better. His mind is stored with excellent medical pre- 
cepts, together with a fine assortment of correct pre- 
scriptions. He can discourse to his patient right learn- 
edly, but, alas! like our traveler he can talk better 
than he can understand. In his mental outfit are the 70 
FROM GRADUATION TO PRACTICE. 
keys to diagnoses of numberless diseases, but for the 
particular case in hand none of them ever seem to fit. 
The cases which the young practitioner meets all 
appear to be anomalous ones. He recognizes as 
familiar certain features, certain symptoms, but then 
there are other symptoms that are certainly out of 
place and incongruous. The art of medical observa- 
tion, the art of appreciating symptoms at their proper 
value, has not yet been acquired. The tyro is unduly 
concerned about “ pathognomonic ” symptoms, and is 
very prone to hasty generalizations— in a word, lacks 
practical experience. His three years’ “curriculum ” 
has afforded him more instruction than training, and 
it is only the combination of these two demerits that 
makes a complete education. The training of practi- 
cal observation and experience is necessary before his 
knowledge can profit him. Knowledge is power only 
when conjoined with wisdom. The studies of the 
medical student are so crowded with matters new and 
strange to him, they embrace subjects of such a varied 
character and so infinite in number, that the mind can 
afford but little activity to any faculty save that of 
memory. He emerges from the course with a vast 
collection of facts, but with very little individual 
judgment. His judgments are those of his professors; 
he scarcely dare make his prescriptions original, and 
his diagnoses are sure only when he meets the counter- 
parts of cases he has been shown at the clinics. Alma 
Mater sets her young brood adrift to complete its evo- FROM GRADUATION TO PRACTICE. 
lution alone. She dubs the graduate “teacher of 
medicine,” when yet he has the most to learn. Is it 
safe to trust this fledgling alone? He has his feathers, 
and much he may plume himself on them, but little he 
knows how they are to be used; he has yet to be 
taught to fly. The element of training is still lacking 
in his education. How is this to be obtained? 
Without further instruction, the young graduate 
may adopt the independent course of beginning prac- 
tice at once, trusting to time to remedy his defects. 
The objections to this course are that the experience, 
besides being acquired very slowly, is often warped by 
early prejudices that resultfrom too partial observation, 
and impaired by careless methods of practice that are 
liable to become confirmed habits. The paucity of 
the material observed leads often to conclusions that 
a wider field and more friction with other observers 
would have shown plainly to be erroneous. Many 
succeed well in spite of these drawbacks; and, though 
it may be said of these practitioners, as of other self- 
made men, “It is better to be self-made than not 
made at all,” it is none the less the duty of the phy- 
sician to avail himself of every facility at his command 
to make his equipment for the intelligent practice of 
his art as thorough and complete as possible. 
When the recent graduate has the opportunity of 
forming an association with an established physician 
of large practice, where his work is under the con- 
trolling influence of an older and more experienced 72 
FROM GRADUATION TO PRACTICE. 
head, his advantages are increased, but such an ar- 
rangement has also its disadvantages. The control, 
which at first serves as a valuable check and guidance 
becomes in time a great hindrance to independence 
of opinion. The habit of referring every question to his 
superior checks the evolution of his own judgment, 
and tends to render him a mere reflection of the 
opinions of one man. Moreover, these opinions are 
not likely to be uniformly enlightened on all subjects. 
Every physician of position and experience has his 
strong points, but upon others his authority is less re- 
liable. Indeed, few are free from more or less faulty 
prejudices. It is, perhaps, especially important that 
the young physician who assumes the relation of 
assistant or junior partner to an older practitioner 
should already have formed a broad mental ground- 
work of sound, catholic opinions. 
With regard to the uses of the dispensary system 
in our large cities, there is much to criticize. The 
material afforded for study is vast and of incalculable 
value, but, unfortunately, the manner in which it is 
generally used is most wasteful, and in too large a 
degree profitless. A young physician, often entirely 
inexperienced, is placed in charge of a class, averaging 
from, say, ten to fifty or more new patients a day. 
There is a certain consciousness of official dignity in 
disposing of so many cases within the allotted hour. 
His patients are from an inferior class, that he looks 
upon with unavoidable disdain, and regards as simply FROM GRADUATION TO TRAC TICE. 
73 
so much food for science—and, were this food digested 
as it should be, more good would result both to science 
and to the patient. As it is, the material is bolted as 
rapidly as possible, occasionally pausing for a “snap ” 
diagnosis of an “interesting case,” but with little 
appreciation of the advantages that are being squan- 
dered. While the conscience of the attending physician 
can ordinarily be trusted to deal in tolerably good 
faith with the patients he sees, he has neither time nor 
usually sufficient incentive to make such careful in- 
vestigations as should be made. The physician is too 
isolated, too irresponsible, and slip-shod work is too 
much the rule. The average dispensary class by no 
means affords that sort of training to the young 
graduate which he especially needs. 
In a large hospital the system is vastly better. 
The “ House” acts as the teacher of his assistants, 
and his work in turn is under the supervision of the 
attending physician. The members of the staff are in 
intimate association with one another, and their inter- 
course affords friction which keeps up enthusiasm in 
the work and tends to raise its standard. The experi- 
ence gained by the interne of such a hospital is unex- 
celled by any method of medical training. But it has 
its limits. The term of service is a short one, and, 
though the cases observed embrace a wide range of 
diseases, there are many classes of affections which 
are rarely met with except in certain special institu- 
tions. Moreover, the conditions of the service often 74 
FROM GRADUATION TO PRACTICE 
confine the interne to a certain department of the 
hospital, where he is exclusively concerned with a 
particular set of diseases. The arrangement is doubt- 
less a wise one, and is attended with good results, so 
far as thoroughness in the work is concerned, but it 
nevertheless leaves the young physician at the end of 
his term of service still but partially prepared for all 
the exigencies of a general practice. The training he 
has received enables him to acquire what remains with 
comparative ease. In a good measure he has acquired 
the scientific habit, the art of weighing evidence as 
evinced by symptoms, the habit of recording observa- 
tions, and, moreover, considerable expertness in making 
a diagnosis. His mental receptivity is also greatly 
increased He can better digest new facts and esti- 
mate the value of new methods and theories. It is at 
this period that the medical novitiate has generally, 
where practicable, sought the advantages of foreign 
instruction. 
Until recently there has been little or no provision 
in this country for the pursuit of such studies as are 
demanded at this period of the medical education. 
Abroad, at hospitals and polyclinics were courses 
especially designed for the practitioner—courses of 
short duration, several of which could be pursued 
together, and in which the matriculant was brought in 
contact with an abundance of classified material which 
he was enabled to study under the guidance of experi- 
enced specialists. The necessity of seeking these FROM GRADUATION TO PRACTICE. 
75 
advantages abroad is, fortunately for the great major- 
ity of young physicians, becoming every year less. In 
the past few years much has been done to supply the 
requirements of practical clinical instruction which 
recent graduates demand. A number of classes in 
various special departments have been established in 
different institutions, and have uniformly been well 
attended. The two schools which have been opened 
in this city within the last few months, with the especial 
object of supplying the demand referred to, demon- 
strated the fact at once that such a demand was 
urgent. There is reason to believe that, in the future, 
schools of this character will form an important acces- 
sory of medical education. The plan of instruction 
that before had been followed in special institutions 
has in these schools been systematized and made more 
comprehensive. Many who seek instruction have 
already seen something of practice, and what they re- 
quire is not didactic teaching, but practical demonstra- 
tion. They wish to see exemplified upon patients the 
proper methods of diagnosis and treatment by those 
whom long and special study has qualified to speak 
with a degree of authority. 
Such are the facilities afforded the medical gradu- 
ate to perfect his training for the practice of his pro- 
fession. A word with regard to his animus—to the 
motives which should actuate him in this preparatory 
work. Unfortunately, in the pursuit of our profession, 
there are two important motives which are liable to 76 
FROM GRADUATION TO PRACTICE. 
conflict. One is scientific, the other commercial. But 
there need be no conflict; the two motives should be 
made coincident. For the practitioner an undue 
prominence of either is a loss. The physician wholly 
engrossed in the scientific aspects of his profession 
will have indifferent success as a practitioner. He 
may gain kvdoS, but few shekels. The doctor who 
practices with an eye single to his fee is false to his 
oath and false to his patients. In the early studies of 
the young physician, the commercial spirit is especi- 
ally noxious. It belittles his professional aims and 
lowers the standard of his preparatory work. The 
desire for prosperity is a legitimate incentive, so long 
as it does not predominate. The greater the interest 
in his work, the more likely that it will be effective 
and fruitful. But the prevailing motive should be the 
desire to acquire competence in his art; all else should 
be subordinate. A competence in his pocket will fol- 
low, and it will be seen how commercial aims may 
coincide with the legitimate requirements of science. 
But interest of some kind he must have that is live 
and active. The spirit that actuates him must be a 
thoroughly earnest one, or little will be accomplished. 
The most productive work is always that which is 
directed to ends in which the mind takes an absorbing 
interest. This interest in the medical man may be 
greatly augmented by judicious attention to his natural 
predilections in the choice of particular departments 
of study. FROM GRADUATION TO PRACTICE. 
77 
After the elementary or fundamental part of his 
medical education is completed, the physician soon 
finds his natural tastes and aptitudes tending spon- 
taneously toward certain special lines of medical in- 
vestigation. By properly heeding these intimations 
he will not only add a spark of enthusiasm to his study, 
but, by giving his work a more definite direction, he 
will improve its quality. The attempt to cover the 
whole field of medicine uniformly will only result in 
superficiality. The aim should be, while striving to 
to acquire proficiency in all departments, to attain 
excellence in one. The best work in medicine, with- 
out doubt, is being done in the “specialties.” The 
specialist has a peculiar enthusiam in his adopted 
department of study, and, moreover, the minuter his 
study the wider the field that expands before him, and 
the more it impels him onward. The farther he goes 
the better he appreciates the fact that the consensus of 
all the medical sciences is such that to excel in one 
branch of medicine he must also be proficient in all its 
sister branches. There are artisans in special medi- 
cine to whom the term “mere specialists” justly 
applies, but the specialist has no true title to the name 
who is not also a good physician. 
It is not, however, the writer’s intention to advise 
every young doctor to become a specialist. What he 
would urge is that each choose, sooner or later, some 
particular line of study in which he shall aim at an 
especially high standard of excellence, and from 78 
FROM GRADUATION TO TRAC TICE. 
which, as a good point of departure, he can better 
attack the whole field. A wall intervenes between 
him and success. It is wiser first to effect a 
breach at some one point than to attempt to batter it 
all down at once. The fowler who singles out a par- 
ticular bird in a flock will be surer of his game than 
he who makes a random shot at all. It is not designed 
that other departments of study shall be neglected, 
but that at some point there shall be a glow in his 
work; and the fire of enthusiasm once kindled will soon 
inflame the whole. THE MATERIAL OUTFIT.* 
With all the natural acumen a man may possess, 
and with all the education he may have fortified him- 
self with, there are certain material appliances without 
which it is vain to attempt the practice of medicine at 
the present day. No one man needs them all; some 
need more of them, some fewer. In general terms, 
these appliances may be divided into instruments, 
materials for dressings, and more or less of a stock of 
medicines. 
Of all of them, he whose lot is cast in the country 
will require more at the outset than his city confrere, 
for the latter, being near the sources of supply, may 
forego the acquisition of the greater number until he 
actually has occasion to employ them, whereas the 
country practitioner must be nunquam 7ion paratus. 
There can be no question, however, but that both are 
apt to imagine at the start that it is well to provide 
themselves with an array of instruments, and the 
like, most of which will never be of any more use 
to them than the show-bottles in an apothecary’s 
window. 
Discretion comes into play very decidedly in the 
selection of such appliances as the physician needs to 
have in his possession. There are certain articles of THE MATERIAL OUTFIT. 
every-day use that cannot be omitted, of course—the 
thermometer, the hypodermic syringe, the pocket-case 
of minor instruments, a spirit-lamp, a specific-gravity 
bulb, a few test-tubes, and the more ordinary reagents 
for testing urine. These must be had; the question 
is, how to select them. The first piece of advice we 
have to give is, do not buy articles that are cheap. 
Nothing is sold much below the ordinary price unless 
there is some factor in the case that will afterward 
account for the low price, to the disgust of the pur- 
chaser. It would be well for the graduate to buy the 
necessary outfit before leaving the city in which he 
has pursued his college course, and it will be of ad- 
vantage if he can get some older practitioner’s advice 
in its selection. If he happens to have taken his de- 
gree at a country college, it would be better to write 
to some acquaintance in the city, rather than corre- 
spond directly with the dealer, for the latter, with the 
best intentions possible, is quite likely to misunder- 
stand his customer’s wishes. Much disappointment 
would often be saved by paying a physician for the 
trouble of making the selection. 
As a general thing, it is not well to invest in nov- 
elties. Often an instrument that seems extremely 
well adapted for the purpose it is intended to serve 
will turn out to be of little or no practical use. Ap- 
pliances made of soft rubber had better not be 
obtained until they are really wanted for use, as that 
material is apt to deteriorate rapidly. THE MATERIAL OUTFIT. 
81 
In regard to medicines, it is mostly the country 
practitioner that needs to keep them on hand, but 
even him we should advise not to invest heavily in 
them, unless the field of his practice is quite remote 
from an apothecary’s. 
In the matter of drugs, too, it is well to avoid 
novelties, except under unusual circumstances. We 
would repeat, also, what we took occasion to remark 
in regard to instruments, that it is poor economy to 
buy cheap articles. They are always dear at any 
price. THE HOSPITAL COURSE.* 
No man can be said t,o have prepared himself 
properly for a creditable career in medicine unless he 
adds some practical training, under competent super- 
vision, to the learning he has acquired in the college 
course. Rarely will any other form of such training 
be found fully to take the place of a term of service 
on the house staff of a general hospital. We would, 
therefore, beyond all things else, urge the young 
graduate to leave no stone unturned to secure such a 
service. Even an opportunity to form a business 
connection with an established practitioner should not 
be allowed to stand in the way, for any man who is 
judged worthy of such an association at a time when 
he has barely emerged from the medical college, is 
most assuredly the very one whom a hospital course 
will most develop, and to a certainty he is the very 
one who can afford to give up the glittering bauble of 
the present, and rely with well-grounded confidence 
on the incomparable advantage that such a training 
will bring him in the course of a few months. Too 
many men suffer all other considerations to be over- 
shadowed by the reflection that they have spent a 
good deal of time and money in acquiring the right 
to practice, and by the consequent conviction that THE HOSPITAL COURSE. 
they ought to begin earning a living as soon as possi- 
ble. This is a grave error. In the long run, nothing 
is gained by beginning to practice at an early age; 
one will achieve competence quite as soon by starting 
upon his actual work at the age of thirty as by setting 
out at the age of twenty-five. Time is not lost, 
therefore, but put out at interest, so to speak, by de- 
voting it to the completion of one’s education. We 
do not mean to say by any means that the hospital 
course is absolutely essential to success in practice, 
for we are quite aware that our profession includes 
many men of deserved eminence who in their early 
years were compelled to forego the great advantage it 
confers; but we do say, and that without the slightest 
hesitation, that, of two men equally well prepared in 
other respects, he who has seen hospital service will 
tread a path comparatively smooth, while the other 
will have to wage a wearying warfare with the de- 
ficiencies that it is the precise result of such service 
to do away with. 
What is the charm by virtue of which the hospital 
course does all this for a man? The fact that it gives 
him the best “graded course” possible, under the 
guidance of the best practitioners with whom he could 
by any means be thrown. We will state, in general 
terms, what it is. Having passed his hospital exami- 
nation, the young man enters upon the duties of a 
Junior Assistant, Junior “Walker.” If his service is 
on the medical side of the house, but little is generally 84 
THE HOSPITAL COURSE. 
required of him in this grade; he makes the daily 
rounds with the House Physician, and again with the 
Attending Physician; drinking in savoir faire from 
both; when not thus engaged, he superintends the 
details of medication,especially of external applications, 
applies cups, leeches, and the like, passes the catheter, 
and does such other minor manipulations as may be 
thought a little too much for the nurse and rather be- 
neath the dignity of the Senior; he also copies the 
latter’s histories of cases into the record books.' For 
the time being, he is a “general utility man;” but the 
familiarity with details he thus picks up is wonderful, 
and he really comes to be very “knowing.” Become 
a Senior, his leading duty is to elicit and note 
down the patients’ histories,and on occasions he figures 
as “House” pro tern. When he actually becomes 
“House,” he bears the immediate responsibility in the 
management of the cases; aided only by the Attend- 
ing Physician’s daily visit,he has the entire direction of 
the treatment. He thus .acquires confidence that 
never deserts him. On the surgical side the grada- 
tion is much the same, mutatis mutandis. 
It will be seen that by degrees the young man 
advances from a position of no responsibility to speak 
of, to one demanding and begetting the utmost self- 
reliance, In most, if not all, of our hospitals in New 
York, the candidate for a position on the house staff 
of a hospital must first have passed his examination 
for the doctorate; in some cities, as we understand, THE HOSPITAL COURSE. 
85 
this is not the case. It seems to us that the former 
system is by all odds the better one; it insures that all 
the medical officers of the hospital shall be “qualified” 
practitioners, and it allows the young men to devote all 
their energy to the actual work before them,unhampered 
by the perfunctory systematic study of books that an 
impending examination really obliges them to under- 
take. 
Something is to be said in regard to the choice 
between various hospitals. In the first place, we 
would advise a general rather than a special hospital. 
It need not be a large one, for too large a service re- 
quires so much sheer work in its performance that thor- 
oughness of observation is apt to be neglected. The 
field afforded by a special hospital is of great value, 
no doubt, but, if possible, a course should be taken in 
an institution where the practice includes the whole 
range of medicine and surgery. Least of all would 
we advise the young graduate to take a position in a 
lunatic asylum, but, for that matter, there is not much 
likelihood of his being able to get one. Psychiatrics 
is so very special in its scope that it does little toward 
preparing a man for general practice; and, on the 
other hand, good service can scarcely be rendered in 
a lunatic asylum by those who have not had consider- 
able training in a wider field. 
We can not close without a word to those modest 
men, who hastily conclude that a hospital career is 
beyond their reach. They cannot all attain to it, to be 86 
THE HOSPITAL COURSE. 
sure, for hospitals are few; but any man who is fit for 
such an appointment can usually secure it in the end. 
Some of our best men have failed at the first trial, and 
afterward been rewarded with success. Above all, let 
our readers free themselves from the fear of favorit- 
ism. With very few exceptions, our hospitals are 
open to the best men, no matter whence they come or 
where they got their degree. At any rate, it is no 
disgrace to fail in the attempt, and they often succeed 
who enter the contest with but faint hope. THE OPPORTUNITIES FOR THE 
STUDY OF MEDICINE IN NE¥. 
YORK CITY AFTER 
GRADUATION.* 
In my opinion, the best opportunities for the con- 
tinuation of the study of medicine, after graduation, 
are to be found in hospitals. A large hospital is 
better than a small one, for the young practitioner 
should, if possible, see a large number of cases, and 
become rapidly saturated, as it were, with experience. 
When private practice is entered upon, there will 
usually be ample time for the careful and deliberate 
study of a few cases. The number of large hospitals 
is, however, limited, even in New York. Besides, to 
enter one, the graduate must pass an examination, 
one that is competitive and usually much severer than 
that which gave him his degree. 
But a few months as a resident in a small hospital 
afford a larger experience, and give more opportuni- 
ties for practical work, than does time spent in any 
other way Making a rude estimate, it may be said 
that there are from one hundred to one hundred and 
fifty places of all kinds, in hospitals large and small, 
general and special, that are to be filled annually 
in New York. When we remember that from four to 88 
POST-GRADUATE STUDY IN NEW YORK. 
five hundred men are graduated every spring in our 
city, we see that, at best, only about one man in four 
can get a place. I fear, however, that some of these 
places go a begging in our city, although those in 
Bellevue, New-York, Roosevelt, Charity, St. Luke’s, 
and a few others, are eagerly sought after. Indeed, 
great and special preparation is made for passing the 
difficult examinations that are a prerequisite to get- 
ting one of these places. The young men who 
cannot get these desirable places should by no 
means abandon the idea of securing a hospital posi- 
tion. The position of a clinical assistant or dresser, 
and finally of a House Physician or House Surgeon, 
in orfh of the smallest hospitals in New-York, is, in 
my opinion, better able to prepare a man for active 
general practice than * even a lucrative place as an 
assistant or junior partner to a very busy medical 
man. 
Senior partners are usually too busy to give much 
attention to instructing their associates, and it is just 
where the senior has become rusty that the young doc- 
tor, fresh from a college, needs to fix and assimilate 
his knowledge. The attending surgeons and physi- 
cians of hospitals are usually on frank and cordial 
terms with the house staff. They have none of the 
stiffness that they may assume as college professors, 
and he must be a very dull scholar who does not get 
very valuable notes on the cases in the wards from 
these gentlemen. POST-GRADUATE STUDY IN NEW YORK. 
89 
When the young doctor has assimilated the knowl- 
edge he has obtained in a college by a hospital 
course, he then appreciates the intuitive skill of a 
busy practitioner. He can then learn, by looking on, 
while in turn his own resources add something to the 
joint stock of knowledge and experience. But if the 
recent graduate has already been in a hospital, or if, 
from one circumstance or another, he cannot enter 
one as a member of the house staff, what can he do? 
Still I say, come to New York, or stay in New York. 
If you have a decent stock of preparatory knowl- 
edge, a great deal of industry, good health, indom- 
itable will, and about four hundred dollars in cash, or 
available funds, you will be a much better prepared 
general practitioner in six months than the average of 
those whom I have known after they have been five 
years in the profession without post-graduate train- 
ing. A list of all the medical facilities of New York 
—-one comprising the colleges, undergraduate and 
post-graduate, dispensaries, hospitals, general and 
special—should first be made. You will find all this 
in the New York “Medical Register,” although not 
compactly arranged. Then, at the most, three or 
four subjects should be selected, to which three or 
six months may be devoted. Suppose, for example, 
general medicine, diseases of the skin, and gynaecol- 
ogy are selected. In these departments you may 
have a weekly clinical lecture by such men as Flint, 
Delafield, Loomis, and Learning, by paying the ma- POST-GRADUA TE SPUD Y IN NE W YORK. 
triculation fee at their colleges. Then, for twenty 
dollars, you may have private instruction at the Poly- 
clinic or Post-Graduate School, with visits to the hos- 
pital or dispensary with your private instructor. In 
skin diseases you may get Socratic, practical instruc- 
tion by Sturgis, Bulkley, Fox, and others. ,In gynae- 
cology, Dawson and Munde will give you instruction 
in private classes, as a part of their post-graduate 
courses, while you may go to the weekly clinics at the 
undergraduate colleges, held by Thomas, Polk and 
Lusk. 
From Addis Emmet may be had an occasional 
opportunity to see operations at the Woman’s Hos- 
pital, on presentation of your card. Thus I might 
go on. Diseases of the throat and nose, of the eye 
and ear—all have their hospitals, to which the recent 
graduate is welcome, if he will hang up his hat and 
sit down, and not saunter about as if he were some 
distinguished visitor who has just dropped in for a 
half-hour. Private courses in the ophthalmoscope, 
the laryngoscope, otoscope, and microscope, are 
given in connection with the post-graduate and 
under-graduate schools and at the hospitals, at 
hours and times that can be readily ascer- 
tained, and for fees that are very small. At 
many of the dispensaries and hospitals the attend- 
ing surgeons are always short-handed for clinical 
clerks and assistants. A man who will attend regu- 
larly for some two or three weeks, so as to get ac- POST-GRADUA TE STUD Y TV NE IV YOR K, 
91 
quainted with the staff, and who will attach himself 
to one physician or surgeon, will soon find himself 
well appreciated, and actually installed as an assistant, 
without examination, with unlimited opportunities for 
studying and observing the effect of treatment upon 
diseases. If post mortem examinations be what is 
desired, at Bellevue rare opportunities are given, 
while Satterthwaite, Peabody, and others, give pri- 
vate instruction in normal and pathological anatomy. 
The dissecting rooms of the colleges are also open to 
graduates, during the winter and spring, on payment 
of the fees. In a month or so of regular visiting to 
the hospitals, a hard-working and modest man will 
make acquaintances in his particular department of 
study, who will give him an occasional opportunity 
to see private operations, and to go to the various so- 
cieties, public and private, and to hear the discus- 
sions. If the recent graduate has but a few weeks, 
the post-graduate school and polyclinic will furnish 
all the opportunities he can use. If, however, he has 
months, these will not furnish all he can enjoy and 
profit by. The time has come, in our country, when 
even country villages and hamlets are critical as to 
the quality of their medical advice. A young man 
who has lounged about a physician’s office for two or 
three summers, and spent but two short winter ses- 
sions at a medical college in a large city, will stand 
no chance by the side of one who has given three 
solid years to the earnest study of his profession in 92 
POST-GRADUATE STUDY IN NEW YORK. 
the college, and then added to that a number of 
months of practical work, where his responsibility is 
shared by an older head. The mere degree of M. 
D. has, fortunately, come to have slight significance. 
The medical schools of New York are becoming 
more and more accessible. When I say schools, I 
mean not only those strictly so called, but the hos- 
pitals and dispensaries, as well as the colleges. Di- 
rectors and governors realize their responsibilities in 
the direction of opening them to students. Every 
year it becomes easier to get instruction. I would 
earnestly advise any recent graduate, no matter what 
branches of our science and art he wishes particu- 
larly to cultivate, to stop in New York before he goes 
to London, Paris, Berlin, or Vienna. .From some ex- 
perience in all these cities, I think New York now 
offers to the English-speaking student advantages 
quite equal to those to be obtained in the old world. 
If, after graduation, a man can stay a year or two in 
hard work in New York, and then go abroad for a 
few additional months, he will, to my mind, have ideal 
opportunities. But better is it to stay here after 
graduation, if the two kinds of post-graduate instruc- 
tion, that at home and that abroad, can not be obtained. 
There are master minds here as well as in the old 
world. POST-GRADUATE STUDY IN 
EUROPE.* 
In advising a person who has just graduated at a 
school of medicine as to what would be the best course 
for him to pursue in a trip to Europe for the purpose 
of continuing his studies, what we have to say depends 
entirely upon the length of time which he intends to 
remain abroad. If there is no hurry, and two or 
three years can be taken for it, there are points which 
would be of the greatest value to know. 
First of all, as to the expense. Germany is a cheap 
country to live in, and is also, I think, by far the best 
one to learn medicine in. It ought not to cost more 
than from forty to fifty dollars a month, with every- 
thing included. I know of a young man who lived in 
quite an expensive place in Germany, viz., Heidelberg, 
for twenty-five dollars a month for three years. 
But before getting to Germany, and, in fact, before 
leaving this side, it is decidedly advisable to go to 
some respectable broker, and have all the money you 
carry changed into English money, since this is at a 
premium all over Europe, and anyone is glad to 
take it, whereas it is often not the case with other 
money. 
Now as to the method of getting there. We all 94 
POST-GRADUATE STUDY IN EUROPE. 
have our own ideas about transatlantic travel; but, 
after we have landed, one thing is well worth con- 
sideration. In England and on the Continent never 
take a first-class railroad ticket, for the second-class 
one gives you just as much comfort in traveling, and 
costs just two-thirds as much as the first. It is an old 
saying in Germany that no one ever travels first-class 
except princes, green Americans and fools. 
Of course, in order to get as much out of a trip to 
the old country as possible, it is necessary that we 
should know the language of the people among whom 
we expect to reside. And, since Germany is by far 
the best place to study medicine in, we must either be 
already acquinted with the German language, or we 
must acquire a certain familiarity with it as soon as 
possible, and, in order to acquire this, there are many 
things to be observed. First of all, it must be firmly 
resolved not to speak any more English than is abso- 
lutely necessary; therefore, when once in Germany, 
avoid all American and English people, as they will 
certainly keep you from learning German. 
Again, it is desirable to take lessons in German; 
but be particular to select a teacher who does not 
speak English; and on all occasions speak German, 
whether you make mistakes or not. It is really remarkable 
the facility with which the inhabitants learn to under- 
stand a foreigner when he tries to tell them something 
in their own language, even if he does not use a single 
word correctly. The theatre is also a fine place to get POST-GRADUATE STUDY IN EUROPE. 
95 
the ear accustomed to the sounds of the words, and 
especially since on the stage they speak the best Ger- 
man, and pronounce it most distinctly. 
If one has some time to spend abroad, by all 
means he should go to some small university town 
like Heidelberg or Wurzburg, Jena or Giessen, and 
start with histology and pathology, since in these 
places there are not so many novel things to distract, 
and also the professors and their assistants will de- 
vote more time to a single person; they are all more 
or less fond of Americans, especially if they find them 
to be diligent. As soon as they see that you wish to 
learn, they will go to any length to teach you. I re- 
member that, when in Heidelberg, I had looked but a 
few times through a microscope, and could hardly 
tell an air-bubble from a red blood corpuscle. Pro- 
fessor Arnold, the pathologist, was quite amused at 
first, but would sometimes sit for two hours by my 
side, and pour pathology into me as if with a spoon. 
Spend the whole morning in the laboratory of pa- 
thology, for there you can also learn histology; after 
dinner, in the laboratory of physiology, and you will 
certainly be surprised at the amount of science you 
will absorb and the rapidity with which you will learn 
the language. 
I had a friend who went to Jena and avoided all 
Americans for one year, then came to Heidelberg and 
passed his examination, obtaining the first degree in 
his Ph. D. in one year and a half. This I remark POST-GRADUATE STUDY IN EUROPE. 
only to show how the language can be learned by 
avoiding all English-speaking people, throwing off 
false modesty, and speaking German continually, 
whether you make mistakes or not, as before observed. 
It would be well after the first semester (term) to 
attend the lectures and some of the clinics, but never 
miss a post mortem when it can be helped, for they 
make them in a different way from what we do gen- 
erally. 
After a year and a half or two years, you may go 
to a larger town, and the selection will depend upon 
the special branch which you are desirous of paying 
attention to. Vienna is the best for obstetrics, dis- 
eases of women and children, and skin diseases, and 
also possibly for ophthalmology and otology, but for 
the latter branches Heidelberg is very fine. Moos, 
for the ear, is the very best man, since he does not 
have many students, and will devote the whole time 
to one man if necessary. Becker has the finest eye 
clinic in Europe, and is also very kind to students. 
For surgery, Berlin, Vienna, or Munich is the 
best, but the last not so good as the others. 
For pathology, no one is so renowned as Virchow 
in Berlin, but for this branch all of the universities 
are good. For microscopical pathology, the same 
may be said about the universities, but the preference 
might be given to Wurzburg, Heidelberg, and Strass- 
burg. 
It is far more difficult to advise anyone who only POST-GRAD UA TE STUD V IN EUROPE. 
97 
intends to spend six months or one year in Eurbpe, 
but, nevertheless, as a general rule, what has been 
said about a longer period may be applied here also, 
with the exception that it will be almost impossible, in 
so short a time, to acquire enough of the language to 
understand a lecture or appreciate the fine points that 
any teacher may make. In this case I would spend 
at least half of the time, say six months (if one year 
is at disposal), in the laboratories of pathology above 
all, and then in those of physiology. 
About these there can also be said a good deal 
which may be useful. For instance, if a person 
understands the language he has a great advantage, 
but if he does not, then I think he should select 
some place where he can use English, as in Heidel- 
berg. 
Professor J. Arnold, who directs the laboratory of 
pathology, speaks English quite well, and is perfectly 
willing to speak it. His assistant, also, Professor 
Thoma, speaks English very fluently, and is fond of 
speaking it. So here is a rare chance. 
Also in the laboratory of physiology is Professor 
Kuhne, who speaks English, French and German 
almost with the same fluency. Again, his assistant, 
Professor Ewald, has as good a command of our 
language as we ever find in a foreigner. Therefore, 
when there is only a year, Heidelberg is certainly the 
place in which to spend six months of it. There is 
another point to be considered, viz.: if it be possible, 98 
POST-GRADUA IE STUDY IN EUROPE. 
let this be in the spring and summer, for during those 
seasons it is one of the most beautiful places on earth, 
but the winter makes it very disagreeable. 
After a time has been spent with the microscope in 
a smaller town, of course it is then advisable to go to 
the largest clinics to be had, where as much as possi- 
ble can be seen. For this Berlin and Vienna are the 
places, but the latter has the preference over the 
former for many reasons. Then, also, it will be 
winter, and that part of Europe is then much pleas- 
anter than the latitude of Berlin. If you intend to 
spend the winter in Vienna, you may go directly from 
Heidelberg to Switzerland for the midsummer, when 
the universities are closed, and be near your winter 
home without loss of time or money. 
If anyone is already more familiar with French 
than he is with German, and desires to acquaint him- 
self with the French school of medicine rather than 
the German, he may go to France. In this case it 
would also be best to spend the first part of his time 
in one of the smaller towns. France, however, is not 
like Germany in having such a multitude of smaller 
places of learning; but as for the larger cities, we all 
know there is but one—Paris. In that city the hospi- 
tal advantages are the finest, and much time could be 
advantageously spent there. I am, however, inclined 
to think that the teaching in France is not quite so 
systematic and thorough as in Germany, since they POST- GRAD UA TE STUD V IN EUR OPE. 
99 
are more apt to indulge in “glittering generalities,” 
than to confine themselves to pure and absolute 
science. However, as a happy mean, where we find 
all the plodding perseverance of the German system, 
and the fascinations of the French character, we may 
select Strassburg; where we find both a French and a 
German population, and may learn both the languages 
at the same time. But neither Strassburg German 
nor Strassburg French is of the purest. A word 
about Great Britain. As to hospital advantages, there 
is no city in the world where they are greater than in 
London, but the same objections hold good for the 
teaching in England that we have found in the case 
of France. Pathology, however, can be studied to" 
the greatest advantage in Edinburgh, whereas, for 
physiology, no place can be better than the laboratory 
of Professor Foster in Cambridge. The English sur- 
geons are very brilliant, as we all know, and we may 
devote much time, if we wish, in England to the 
branches of surgery and physiology, and also much to 
pathology in Scotland. 
The particular advantages of the larger cities we 
may say are: Vienna, obstetrics, diseases of women 
and children, surgery, skin diseases, ophthalmology, 
otology, and hospital practice; Berlin, pathology, sur- 
gery, chemistry, physiology, ophthalmology, and hospi- 
tal practice; Paris, surgery, physiology, ophthalmology, 
and hospital practice; London, surgery and hospital POST-GRADUA TE STUD V IN EUROPE. 
practice; Cambridge, physiology; and Edinburgh., sur- 
gery and pathology. 
*The articles marked with an aste isk (*) are taken from the New York 
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