Medicine - The Two Functions of a Medical School Part 2
( Originally Published 1905 )
A great university has a dual function, to teach and to think. The educational aspects at first absorb all its energies, and in equipping various departments and providing salaries, it finds itself hard pressed to fulfil even the first of the duties. The story of the progress of the medical school of this institution illustrates the struggles and difficulties, the worries and vexations attendant upon the effort to place it in the first rank as a teaching body. I know them well, since I was in the thick of them for ten years, and see to-day the realization of many of my day-dreams. Indeed in my wildest flights I never thought to see such a splendid group of buildings as I have just inspected. We were modest in those days, and I remember when Dr. Howard showed me in great confidence the letter of the Chancellor, in which he conveyed his first generous bequest to the Faculty, it seemed so great that in my joy I was almost ready to sing my Nunc dimittis. The great advances here, at the Montreal General Hospital, and at the Royal Victoria (both of which institutions form most essential parts of the medical schools of this city) mean increased teaching facilities, and of necessity better equipped graduates, better equipped doctors! Here is the kernel of the whole matter, and it is for this that we ask the aid necessary to build large laboratories and large hospitals in which the student may learn the science and art of medicine. Chemistry, anatomy and physiology give that perspective which enables him to place man and his diseases in their proper position in the scheme of life, and afford at the same time that essential basis upon which alone a trustworthy experience may be built. Each one of these is a science in itself, complicated and difficult, demanding much time and labour for its acquisition, so that in the few years which are given to their study the student can only master the principles and certain of the facts upon which they are founded. Only so far as they bear upon a due understanding of the phenomena of disease do these subjects form part of the medical curriculum, and for us they are but means—essential means it is true-to this end. A man cannot become a competent surgeon without a full knowledge of human anatomy and physiology, and the physician without physiology and chemistry flounders along in an aimless fashion, never able to gain any accurate conception of disease, practising a sort of popgun pharmacy, hitting now the malady and again the patient, he himself not knowing which.
The primary function of this department of the university is to instruct men about disease, what it is, what are its manifestations, how it may be prevented, and how it may be cured; and to learn these things the four hundred young men who sit on these benches have come from all parts of the land. But it is no light responsibility which a faculty assumes in this matter. The task is beset with difficulties, some inherent in the subject and others in the men them-selves, while not a few are caused by the lack of common sense in medical matters of the people among whom we doctors work.
The processes of disease are so complex that it is excessively difficult to search out the laws which control them, and, although we have seen a complete revolution in our ideas, what has been accomplished by the new school of medicine is only an earnest of what the future has in store. The three great advances of the century have been a know-ledge of the mode of controlling epidemic diseases, the introduction of anaesthetics, and the adoption of antiseptic methods in surgery. Beside them all others sink into insignificance, as these three contribute so enormously to the personal comfort of the individual. The study of the causes of so-called infectious disorders has led directly to the discovery of the methods for their control, for example, such a scourge as typhoid fever becomes almost unknown in the presence of perfect drainage and an uncontaminated water supply. The outlook, too, for specific methods of treatment in these affections is most hopeful. The public must not be discouraged by a few, or even by many failures. The thinkers who are doing the work for you are on the right path, and it is no vain fancy that before the twentieth century is very old there may be effective vaccines against many of the contagious diseases.
But a shrewd old fellow remarked to me the other day, "Yes, many diseases are less frequent, others have disappeared, but new ones are always cropping up, and I notice that with it all there is not only no decrease, but a very great increase in the number of doctors."
The total abolition of the infectious group we cannot expect, and for many years to come there will remain hosts of bodily ills, even among preventable maladies, to occupy our labours; but there are two reasons which explain the relative numerical increase in the profession in spite of the great decrease in the number of certain diseases. The development of specialties has given employment to many extra men who now do much of the work of the old family practitioner, and again people employ doctors more frequently and so give occupation to many more than formerly.
It cannot be denied that we have learned more rapidly how to prevent than how to cure diseases, but with a definite outline of our ignorance we no longer live now in a fool's Paradise, and fondly imagine that in all cases we control the issues of life and death with our pills and potions. It took the profession many generations to learn that fevers ran their course, influenced very little, if at all, by drugs, and the £60 which old Dover complained were spent in drugs in a case of ordinary fever about the middle of the last century is now better expended on a trained nurse, with infinitely less risk, and with infinitely greater comfort to the patient. Of the difficulties inherent in the art not one is so serious as this which relates to the cure of disease by drugs. There is so much uncertainty and discord even among the best authorities (upon non-essentials it is true) that I always feel the force of a well-known stanza in Rabbi Ben Ezra
Now, who shall arbitrate? Ten men love what I hate,
One of the chief reasons for this uncertainty is the increasing variability in the manifestations of any one disease. As no two faces, so no two cases are alike in all respects, and unfortunately it is not only the disease itself which is so varied, but the subjects themselves have peculiarities which modify its action.
With the diminished reliance upon drugs, there has been a return with profit to the older measures of diet, exercise, baths, and frictions, the remedies with which the Bithynian Asclepiades doctored the Romans so successfully in the first century. Though used less frequently, medicines are now given with infinitely greater skill; we know better their indications and contradictions, and we may safely say (reversing the proportion of fifty years ago) that for one damaged by dosing, one hundred are saved.
Many of the difficulties which surround the subject relate to the men who practise the art. The commonest as well as the saddest mistake is to mistake one's profession, and this we doctors do often enough, some of us, without knowing it. There are men who have never had the preliminary education which would enable them to grasp the fundamental truths of the science on which medicine is based. Others have poor teachers, and never receive that bent of mind which is the all important factor in education; others again fall early into the error of thinking that they know it all, and benefiting neither by their mistakes or their successes, miss the very essence of all experience, and die bigger fools, if possible, than when they started. There are only two sorts of doctors; those who practise with their brains, and those who practise with their tongues. The studious, hard-working man who wishes to know his profession thoroughly, who lives in the hospitals and dispensaries, and who strives to obtain a wide and philosophical conception of disease and its processes, often has a hard struggle, and it may take years of waiting before he becomes successful; but such form the bulwarks of our ranks, and outweigh scores of the voluble Cassios who talk themselves into, and often out of, practice.
Now of the difficulties bound up with the public in which we doctors work, I hesitate to speak in a mixed audience. Common sense in matters medical is rare, and is usually in inverse ratio to the degree of education. I suppose as a body, clergymen are better educated than any other, yet they are notorious supporters of all the nostrums and hum-buggery with which the daily and religious papers abound, and I find that the further away they have wandered from the decrees of the Council of Trent, the more apt are they to be steeped in thaumaturgic and Galenical superstition. But know also, man has an inborn craving for medicine. Heroic dosing for several generations has given his tissues a thirst for drugs. As I once before remarked, the desire to take medicine is one feature which distinguishes man, the animal, from his fellow creatures. It is really one of the most serious difficulties with which we have to contend. Even in minor ailments, which would yield to dieting or to simple home remedies, the doctor's visit is not thought to be complete without the prescription. And now that the pharmacists have cloaked even the most nauseous remedies, the temptation is to use medicine on every occasion, and I fear we may return to that state of polypharmacy, the emancipation from which has been the sole gift of Hahnemann and his followers to the race. As the public becomes more enlightened, and as we get more sense, dosing will be recognized as a very minor function in the practice of medicine in comparison with the old measures of Asclepiades.
After all, these difficulties—in the subject itself, in us, and in you—are lessening gradually, and we have the consolation of knowing that year by year the total amount of unnecessary suffering is decreasing at a rapid rate.
In teaching men what disease is, how it may be prevented, and how it may be cured, a University is fulfilling one of its very noblest functions. The wise instruction and the splendid example of such men as Holmes, Sutherland, Campbell, Howard, Ross, Macdonnell, and others have carried comfort into thousands of homes throughout this land. The benefits derived from the increased facilities for the teaching of medicine which have come with the great changes made here and at the hospitals during the past few years, will not be confined to the citizens of this town, but will be widely diffused and felt in every locality to which the graduates of this school may go; and every gift which promotes higher medical education, and which enables the medical faculties throughout the country to turn out better doctors, means fewer mistakes in diagnosis, greater skill in dealing with emergencies, and the saving of pain and anxiety to countless sufferers and their friends.
The physician needs a clear head and a kind heart; his work is arduous and complex, requiring the exercise of the very highest faculties of the mind, while constantly appealing to the emotions and finer feelings. At no time has his influence been more potent than at present, at no time has he been so powerful a factor for good, and as it is one of the highest possible duties of a great University to fit men for this calling, so it will be your highest mission, students of medicine, to carry on the never-ending warfare against disease and death, better equipped, abler men than your predecessors, but animated with their spirit and sustained by their hopes, "for the hope of every creature is the banner that we bear."