CHAPTER XXIII

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_GRAVES, HUGHES BENNETT, AND CLINICAL TEACHING._

The subjects of this chapter, both men of great influence, left a decisive mark on the systems of clinical teaching in their respective schools of medicine, besides rendering great services to physiology and to medicine.

In Dublin University a Regius Professorship of Physic dates from the time of the Restoration, and other chairs were subsequently founded. The Irish College of Surgeons was established as late as 1784, but nothing great came of it for many years. A Scotchman, Cheyne, settled in Dublin, published in 1817 the first volume of the Dublin Hospital Reports, and by the excellence of his own clinical reports on cases of fever, gave a good tone to the work of the Irish school. But the elevation of the Dublin Medical School to the high rank which it has ever since maintained was the work emphatically of Robert Graves and of William Stokes.

The Graves family, descended from a colonel in Cromwell’s cavalry, who had acquired considerable estates in Limerick county after Cromwell’s subjugation of the country, was represented at the close of the last century by the Regius Professor of Divinity in Dublin University, and one of the senior Fellows of Trinity College, Richard Graves, D.D. His three sons, Richard, Hercules, and Robert obtained at the degree examinations of three successive years the gold medal in science and in classics.

ROBERT JAMES GRAVES, born in 1795 or 1796, after going through a complete arts course, and such medical study as Dublin then afforded, graduated M.B. at Dublin in 1818. He then betook himself to other schools, and successively studied in London, in the most celebrated Continental schools, and in Edinburgh, being away from Dublin more than three years. He had an excellent language-faculty, and once, having forgotten his passport, was imprisoned for ten days in Austria as a German spy, the authorities insisting that no Englishman could possibly speak German as he did. During his stay in Italy, Graves, who had considerable artistic capacity, accidentally made the acquaintance of Turner, the celebrated painter, and became his companion on many journeys. An interesting notice of Graves’ intercourse with Turner has been given by Professor Stokes.[14] It appears that the two lived and travelled together for months without either of them inquiring the name of his companion.

On a voyage from Genoa to Sicily Graves’ courage and decision were strikingly put to the test when the captain and crew, in a terrific gale, were about to quit the ship in the only boat, leaving the two passengers to their fate. Graves, though ill, seized an axe, and stove in the boat, took command, repaired the pumps from the leather of his own boots, and saved the ship.

In 1821 Graves returned to Dublin, and at once took a leading position. Dr. Stokes, for a short time his pupil, and his lifelong friend, says of him at this time: “Nature had been bountiful to him: he was tall in stature, of dark complexion, and with noble and expressive features. In conversation he possessed a power rarely met with; for while he had the faculty of displaying an accurate and singularly varied knowledge without a shade of egotism, he was able to correct error without an approach to offence. He had at once a warm and a sensitive heart, and ever showed lasting and therefore genuine gratitude for the smallest kindness. Loving truth for its own sake, he held in unconcealed abhorrence all attempts to sully or distort it; and he never withheld or withdrew his friendship from any, even those below him in education and social rank, if he found in them the qualities which he loved, and which he never omitted to honour.”

“It is to be observed that as his mind was open and unsuspicious, he occasionally fell into the error of thinking aloud without considering the nature of his audience, and of letting his wit play more freely, and his sarcasm, when defending the right, cut more deeply than caution might dictate.”

During the year 1821 Graves was elected physician to the Meath Hospital, and also became one of the founders of the Park Street School of Medicine. At this time clinical investigation and clinical teaching could scarcely be said to exist, and the pathological studies of other schools were rather held in contempt. The methods in vogue in Edinburgh had not impressed Graves favourably. Students were not then regularly called upon to investigate cases for themselves, nor trained in so doing: they might obtain their degree without having ever practised diagnosis or co-operated in curing disease even to the extent of writing a prescription. “Often have I regretted,” said Graves in his introductory lecture at the Meath Hospital in 1821, “that, under the present system, experience is only to be acquired at a considerable expense of human life. There is, indeed, no concealing the truth—the melancholy truth, that numbers of lives are annually lost in consequence of maltreatment. The victims selected for this sacrifice at the shrine of experience, generally belong to the poorer classes of society, and their immolation is never long delayed when a successful candidate for a dispensary commences the discharge of his duty. The rich, however, do not always escape; nor is the possession of wealth in every instance a safeguard against the blunders of inexperience.”

After commenting on the evil effects of ignorant dogmatism in those of riper years, Dr. Graves went on to expound the plan of Continental clinical instruction. He then alluded to the coarse, harsh, and even vulgar expressions made use of towards hospital patients by Irish medical men of the day, insisting on the necessity of reform in this respect.

The plan that Graves adopted and worked so successfully, essentially consisted in giving to the advanced students charge over particular patients, requiring them to report upon the origin, progress, and present state of their diseases. At the bedside these particulars were verified or challenged by the physician; and then in the lecture-room he discussed with the class the diagnosis, prognosis, and treatment of the cases. The pupil in charge prescribed for the patient, and his prescription was revised and corrected by the physician. The advantages of this system were obvious; students being obliged to give reasons for every plan of cure, became accustomed to a rational and careful investigation of disease, and enjoyed the great benefit of the early correction of their errors.

Nevertheless the system met with much opposition, and even ridicule. As Stokes says, the student was then kept at a distance; no one cared to show him how to teach himself, to familiarise him with “the ways of the sick,” to train his mind to reason, and to inculcate the duty as well as the pleasure of original work.

Graves had both knowledge and eloquence; his style was massive, nervous, and forcible; he could command the minds of his hearers, and he showed himself thoroughly in earnest. “His active mind was ever on the search for analogies, and thus he was led to the discrimination of things apparently similar, and to the assimilation of things at the first view dissimilar, in a degree hardly surpassed by any teacher of medicine.”

Having been elected a Fellow of the King’s and Queen’s College of Physicians, Graves was subsequently appointed Professor of the Institutes of Medicine. In this capacity he gave lectures in which physiology was ably applied to the wants of medical students. In the years 1828-36 he contributed many physiological essays, chiefly to the _Dublin Journal of Medical Science_, of which he was one of the editors till his death, on such subjects as “The Distinctive Characters of Man,” “The Chances of Life,” “Temperament and Appetite,” “The Sense of Touch,” &c., all interesting. But it was not till 1843 that he published the work on which his reputation as an author chiefly rests, his “Clinical Lectures on the Practice of Medicine.” In relation to this one needs no higher authority in its favour than that of Trousseau, who addressed to the translator of the French edition a letter from which we make the following extracts.

“I have constantly read and re-read the work of Graves; I have become inspired with it in my teaching.... The lectures on scarlatina, paralysis, pulmonary affections, cough, headache, have acquired an European reputation.... When he inculcated the necessity of giving nourishment in long-continued pyrexias, the Dublin physician, single-handed, assailed an opinion which appeared to be justified by the practice of all ages, for low diet was then regarded as an indispensable condition in the treatment of fevers. Had he rendered no other service than that of completely reversing medical practice upon this point, Graves would by that act alone have acquired an indefeasible claim to our gratitude.”

“On the other hand, I cannot sufficiently recommend the perusal of the lectures which treat of paralysis; they contain a complete doctrine, and this doctrine has decisively triumphed. The sympathetic paralyses of Whytt and Prochaska have now their place assigned in science, under the much more physiological name of reflex paralyses.”

“Graves is a therapeutist full of resources.... There is not a day that I do not in my practice employ some of the modes of treatment which Graves excels in describing with the minuteness of the true practitioner, and not a day that I do not, from the bottom of my heart, thank the Dublin physician for the information he has given me.”

“Graves is in my acceptation of the term a perfect clinical teacher. An attentive observer, a profound philosopher, an ingenious artist, an able therapeutist, he commends to our admiration the art whose domain he enlarges, and the practice of which he renders more useful and more fertile.”

In 1843 and 1844 Graves was President of the Irish College of Physicians, and was elected a Fellow of the Royal Society in 1849. He was led by his experience to hold strongly the belief that typhus and typhoid were not distinct fevers. His great service to the treatment of fevers is however independent of this. He recognised the ill effects of a lowering system upon fever patients, and steadily set himself to maintain the patient’s strength by food and stimulants. One day he was going round the hospital, when on entering the convalescent ward he began to expatiate on the healthy appearance of some who had recovered from severe typhus. “This is all the effect of our good feeding,” he exclaimed; “and lest, when I am gone, you may be at a loss for an epitaph for me, let me give you one, in three words:—

“HE FED FEVERS.”

Graves’s papers on Cholera embodied in his Clinical Lectures give an able history of the progress of that disease, and his researches led him to urge the foundation of a complete network of medical observatories to record especially the rise, progress, and character of disease, whether endemic or epidemic. Had he lived he might have done much to promote this object, only now and partially being attempted in the collective scheme for the investigation of disease under the auspices of the International Scientific Congress. But his labours shortened his life. He constantly corresponded with pupils all over the world; wrote much for periodical literature on subjects outside medicine, even doing the literary work of a patient whose family were in straitened circumstances. A disease of the liver finally cut him off, after a protracted illness borne with Christian fortitude and faith, on March 20, 1853.

* * * * *

Having been a leading teacher at Edinburgh for many years, JOHN HUGHES BENNETT impressed his individuality upon a larger number of students, and has been more generally recognised than Graves as a man of conspicuous merit. As a clinical teacher, as a physiologist, as a pathologist, as a therapeutist, he had high claims. He reformed the treatment both of pneumonia and of phthisis, and identified a disease, leucocythæmia, whose characters have proved the starting-point for most fruitful investigations.

Bennett was born in London on August 31, 1812, and educated at the Grammar and Mount Radford Schools, Exeter. He was fortunate in having a cultivated mother, a lady of independent thought and spirit, and to her he owed the development of his marked literary and artistic tastes. As a boy she trained him in elocution, in which he afterwards excelled, and widened his thoughts by taking him again and again to the Continent.

Deciding to study medicine, young Bennett was apprenticed to a Mr. Sedgwick of Maidstone, and for a short time attended St. Bartholomew’s Hospital. A little later, however, he decided to enter at Edinburgh University, and soon showed himself an assiduous student. He made the acquaintance of Edward Forbes, J. H. Balfour, John Reid, and others, who afterwards distinguished themselves, and became one of the Presidents of the Royal Medical Society. In 1837 he took the M.D. degree, being awarded a gold medal, on Syme’s recommendation, for the best surgical report, and being mentioned as worthy of a second medal by Sir Charles Bell.

Bennett next studied for two years in Paris, founding the Parisian Medical Society, of which he was the first president. Other two years he devoted to study in German medical schools. The microscope and the stethoscope became in his hands familiar implements of research, and he already began to give forth the results of his study, contributing to Tweedie’s “Library of Medicine” a large proportion of the second volume dealing with diseases of the nervous system.

Bennett returned to Edinburgh in 1841, and on the 1st October published “Treatise on the Oleum Jecoris Aselli, or Cod-liver Oil, as a Therapeutic Agent in certain Forms of Gout, Rheumatism, and Scrofula, with Cases.” His knowledge of this remedy had been acquired in Germany, where cod-liver oil was being used in the treatment of these diseases. Its use had however long been known among the Scotch fishing folk, and Drs. Kay and Bardsley had many years before prescribed it in the Manchester Infirmary. The publication, however, stagnated, and there was added in 1847 to the remaining copies an appendix of cases benefited by cod-liver oil. By this time its administration was decidedly on the increase, and one firm of druggists in Edinburgh had sold six hundred gallons in the preceding year, as compared with one gallon in 1841. At the same time Dr. C. J. B. Williams was introducing purer forms of the oil in London, as we have already related, and by his writings and practice and study of cases of pulmonary consumption did very much to promote its general use.

In November 1841 Bennett started a course of lectures on histology at Edinburgh, in which he illustrated physiology and pathology by microscopical preparations: he also formed classes for private instruction in microscopical manipulation. At that time minute changes in structure were generally overlooked, and to Bennett belongs the credit of first giving such instruction in a systematic form. He strongly desired to gain the chair of General Pathology at Edinburgh, which was vacant in 1842, but he was unsuccessful.

When he was soon afterwards appointed physician to the Royal Dispensary, Bennett had an opportunity of putting into practice what he had learnt in Germany, by establishing what he called a polyclinical course, his students being taught practically, under the eye of the teacher, to examine and prescribe for patients. It must not be forgotten, however, that Syme had previously introduced a somewhat similar procedure at his Minto House (Surgical) Hospital. As Pathologist to the Royal Infirmary, Bennett had great opportunities of studying morbid specimens, and he got together a large pathological collection. He further gave courses of lectures on pathology.

For many years Bennett took a large part in maintaining the literary

## activity of the Edinburgh School. Many papers by him appeared in the

_London and Edinburgh Monthly Journal of Medical Science_, of which he subsequently was part and sole proprietor two or three times, being so lucky as to make a profit on each of his transactions.

In 1848 Dr. Bennett was unanimously elected Professor of the Institutes of Medicine (_i.e._, Physiology) at Edinburgh. In this new work he was soon conspicuous for the practicality of his teaching, and for his continual introduction of matters bearing on pathology and medicine. He made every lecture a complete study, enriching it with all the appliances, material and artistic, that he could command, and embellishing it by finished elocution. He would now and again lay aside his manuscript to comment upon, and frequently to denounce, the opinions of others, by which course he made enemies, for he was not sufficiently measured in his treatment of opponents. Yet it might safely be said that he was not actuated by personal hostility, but only by antagonism of view. Still he was too favourable to his own work, and did not adequately appreciate other men. The general student enjoyed those peculiarities of Dr. Bennett of which he did not himself feel the brunt, but in the clinical class or in the examination hall his unsparing logical acumen tasked the student mind somewhat severely, and he was a generally dreaded examiner.

From the peculiar organisation of Edinburgh work Bennett was expected to be a clinical teacher of medicine as well as a professor of physiology; thus the importance of his work in the infirmary was as great as that in the lecture-room. He was a clinical teacher of the highest order—nothing was suffered to pass unnoticed. All methods of inquiry into the patient’s case were diligently taught to the students, who were led to observe precisely and methodically for themselves. He would test and stimulate his pupils[15] most acutely by disputation, questioning, and argument; and he thus trained a body of men who carry his impress into all their work.

In 1845 Dr. Bennett published a case of “Hypertrophy of the Spleen and Liver,” which is the first recorded case of a disease characterised by a great abundance of white corpuscles in the blood, now known as leucocythæmia. Although Bennett did not at first recognise its true nature, his description and subsequent labours did much to elucidate the disease, and his name must be honourably associated with the subject.

Perhaps, however, the greatest service Bennett rendered to medicine, independently of his promotion of the use of cod-liver oil in phthisis, is his strong protest against the lowering treatment in pneumonia and other inflammatory diseases. On this point the _Lancet_ (October 9, 1875) says: “He reduced the mortality of uncomplicated pneumonia to _nil_. He demonstrated, not only the dispensableness, but the injuriousness, of the antiphlogistic treatment which had ruled the best minds of the civilised world for ages. Doubtless other physicians were working in the same direction even before Bennett, but he devised a treatment of his own which has given most brilliant results, and he adhered to it and to the pathological views on which it was based so steadily and over so long a series of years as to establish its truth, and so largely revolutionise the practice of medicine in acute diseases.” Dr. Bennett’s later attacks on the mercurial treatment of liver diseases were almost equally strong with that on bleeding and the antiphlogistic methods, but being undertaken late in life did not leave such an impression.

Dr. M’Kendrick gives in the _British Medical Journal_, October 9, 1875, a list of no fewer than 105 papers and memoirs by Bennett. Among his larger works were “An Introduction to Clinical Medicine;” “Lectures on Clinical Medicine,” 1850-6, which were entitled in later editions “Clinical Lectures on the Principles and Practice of Medicine.” Of this his principal work, six editions were published during his lifetime in the United States, and the book has been translated into French, Russian, and Hindoo. “Outlines of Physiology” appeared in 1858, and a Text-book of Physiology in 1871-2. His works on Cancerous and Cancroid Growths, on the Pathology and Treatment of Pulmonary Tuberculosis, and on the Restorative Treatment of Pneumonia, will of course be consulted as containing authoritative statements of his views on these important subjects. He wrote the article on Phthisis in Reynolds’ “System of Medicine,” Reports on the Action of Mercury on the Liver, and Researches on the Antagonism of Medicines, as reports to the British Medical Association, 1867-1875.

Dr. M’Kendrick, some time Bennett’s assistant and deputy, says of him:[16] “Professor Bennett was a man of clear and logical intellect. What he wanted in breadth of view he gained in penetrative power. Few could grasp more quickly the essentials of a subject, or perceive sooner or more accurately the real point at issue. _Method_ was the prevailing quality of his mind which guided him as a teacher.... He wanted patience with details, the power of positive scientific expression, and the faculty of taking a wide view of all the facts bearing on what was immediately under discussion. He assumed an attitude of scepticism to all questions until fairly convinced.”

“His tendency to indulge freely in critical and sarcastic remarks upon the works of others did not make him a general favourite with some of his professional brethren, consequently he never attained a large practice as a consulting physician, which was from other considerations his due. He was too much a reformer, too pronounced and outspoken in his opinions; he had too much identified himself with certain lines of thought; and it must be confessed that he did not possess that indefinable manner which inspires confidence both in patient and in practitioner alike.”

“By those who knew him best Dr. Bennett was much beloved. He shone in the social circle, where his love of music and power of brilliant conversation cast a radiance through the room.”

In 1855 Bennett unsuccessfully competed for the chair of the Practice of Physic at Edinburgh, and he felt his non-success very much. For the next ten years he continued in active work, but in 1865 began to suffer severely from a bronchial and throat affection. Later he was attacked by diabetes, and had to spend several winters on the Continent. In 1874 he resigned his professorship. In August 1875 he was gratified by receiving from Edinburgh the LL.D. degree, his bust by Brodie being presented to the University by former pupils. He was operated on for stone in September following at Norwich, by Mr. Cadge, and died on September 25th, being buried at Dean Cemetery, Edinburgh, by the side of his friends, Goodsir and Edward Forbes. His wife, son, and four daughters survived him.

FOOTNOTES:

[14] Biographical Notice, prefixed to Graves’ “Studies in Physiology and Medicine,” 1863.

[15] _Edinburgh Medical Journal_, October 1, 1845.

[16] _Edinburgh Medical Journal_, November 1875, p. 473. See also _British Medical Journal_, October 9th, 1875.

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