Medicine - Parochialism in Medicine
( Originally Published 1905 )
Of the parochial and more personal aspects of Chauvinism I hesitate to speak; all of us, unwittingly as a rule, illustrate its varieties. The conditions of life which round us and bound us, whether in town or country, in college or institution, give to the most liberal a smack of parochialism, just as surely as we catch the tic of tongue of the land in which we live. The dictum put into the mouth of Ulysses, "I am a part of all that I have met," expresses the truth of the influence upon us of the social environment, but it is not the whole truth, since the size of the parish, representing the number of points of contact, is of less moment than the mental fibre of the man. Who has not known lives of the greatest freshness and nobility hampered at every turn and, bound in chains the most commonplace and sordid, lives which illustrate the liberty and freedom enjoyed by minds innocent and quiet, in spite of stone walls and iron bars. On the other hand, scan the history of progress in the profession, and men the most illiberal and narrow, reeking of the most pernicious type of Chauvinism, have been among the teachers and practitioners in the large cities and great medical centres; so true is it, that the mind is its own place and in itself can make a man independent of his environment.
There are shades and varieties which are by no means offensive. Many excellent features in a man's character may partake of its nature. What, for example, is more proper than the pride which we feel in our teachers, in the university from which we have graduated, in the hospital at which we have been trained? He is a "poor sort" who is free from such feelings, which only manifest a proper loyalty. But it easily degenerates into a base intolerance which looks with disdain on men of other schools and other ways. The pride, too, may be in inverse proportion to the justness of the claims. There is plenty of room for honest and friendly rivalry between schools and hospitals, only a blind Chauvin-ism puts a man into, a hostile and intolerant attitude of mind at the mention of a name. Alumni and friends should remember that indiscriminate praise of institutions or men is apt to rouse the frame of mind illustrated by the ignorant Athenian who, so weary of hearing Aristides always called the Just, very gladly took up the oyster shell for his ostracism, and even asked Aristides himself, whom he did not know, to mark it.
A common type of collegiate Chauvinism is manifest in the narrow spirit too often displayed in filling appointments. The professoriate of the profession, the most mobile column of its great army, should be recruited with the most zealous regard to fitness, irrespective of local conditions that are apt to influence the selection. Inbreeding is as hurtful to colleges as to cattle. The interchange of men, particularly of young men, is most stimulating, and the complete emancipation of the chairs which has taken place in most of our universities should extend to the medical schools. Nothing, perhaps, has done more to place German medicine. in the forefront to-day than a peripatetic professoriate, owing allegiance only to the profession at large, regardless of civic, sometimes, indeed, of national limitations and restrictions. We acknowledge the principle in the case of the scientific chairs, and with increasing frequency act upon it, but an attempt to expand it to other chairs may be the signal for the display of rank parochialism.
Another unpleasant manifestation of collegiate Chauvinism is the outcome, perhaps, of the very keen competition which at present exists in scientific circles. Instead of a generous appreciation of the work done in other places, there is a settled hostility and a narrowness of judgment but little in keeping with the true spirit of science. Worse still is the "lock and key" laboratory in which suspicion and distrust reign, and everyone is jealous and fearful lest the other should know of or find out about his work. Thank God! this base and bastard spirit is not much seen, but it is about, and I would earnestly entreat any young man who unwittingly finds himself in a laboratory pervaded with this atmosphere, to get out ere the contagion sinks into his soul.
Chauvinism in the unit, in the general practitioner, is of much more interest and importance. It is amusing to read and hear of the passing of the family physician. There never was a time in our history in which he was so much in evidence, in which he was so prosperous, in which his prospects were so good or his power in the community so potent. The public has even begun to get sentimental over him! He still does the work; the consultants and the specialists do the talking and the writing; and take the fees! By the work, I mean that great mass of routine practice which brings the doctor into every household in the land and makes him, not alone the adviser, but the valued friend. He is the standard by which we are measured. What he is, we are; and the estimate of the profession in the eyes of the public is their estimate of him. A well-trained, sensible doctor is one of the most valuable assets of a community, worth to-day, as in Homer's time, many another man. To make him efficient is our highest ambition as teachers, to save him from evil should be our constant care as a guild. I can only refer here to certain aspects in which he is apt to show a narrow Chauvinism hurtful to himself and to us.
In no single relation of life does the general practitioner show a more illiberal spirit than in the treatment of himself. I do not refer so much to careless habits of living, to lack of routine in work, or to failure to pay due attention to the business side of the profession—sins which so easily beset him—but I would speak of his failure to realize first, the need of a lifelong progressive personal training, and secondly, the danger lest in the stress of practice he sacrifice that most precious of all possessions, his mental independence. Medicine is a most difficult art to acquire. All the college can do is to teach the student principles, based on facts in science, and give him good methods of work. These simply start him in the right direction, they do not make him a good practitioner—that is his own affair. To master the art requires sustained effort, like the bird's flight which depends on the incessant action of the wings, but this sustained effort is so hard that many give up the struggle in despair. And yet it is only by persistent intelligent study of disease upon a methodical plan of examination that a man gradually learns to correlate his daily lessons with the facts of his previous experience and of that of his fellows, and so acquires clinical wisdom. Nowadays it is really not a hard matter for a well-trained man to keep abreast of the best work of the day. He need not be very scientific so long as he has a true appreciation of the dependence of his art on science, for, in a way, it is true that a good doctor may have practice and no theory, art and no science. To keep up a familiarity with the use of instruments of precision is an all-important help in his art, and I am profoundly convinced that as much space should be given to the clinical laboratory as to the dispensary. One great difficulty is that while waiting for the years to bring the inevitable yoke, a young fellow gets stale and loses that practised familiarity with technique which gives confidence. I wish the older practitioners would remember how important it is to encourage and utilize the young men who settle near them. In every large practice there are a dozen or more cases requiring skilled aid in the diagnosis, and this the general practitioner can have at hand. It is his duty to avail him-self of it, and failing to do so he acts in a most illiberal and unjust way to himself and to the profession at large. Not only may the older man, if he has soft arteries in his grey cortex, pick up many points from the young fellow, but there is much clinical wisdom afloat in each parish which is now wasted or dies with the old doctor, because he and the young men have never been on friendly terms.
In the fight which we have to wage incessantly against ignorance and quackery among the masses and follies of all sorts among the classes, diagnosis, not drugging, is our chief weapon of offence. Lack of systematic personal training in the methods of the recognition of disease leads to the misapplication of remedies, to long courses of treatment when treatment is useless, and so directly to that lack of confidence in our methods which is apt to place us in the eyes of the public on a level with empirics and quacks.
Few men live lives of more devoted self-sacrifice than the family physician, but he may become so completely absorbed in work that leisure is unknown; he has scarce time to eat or to sleep, and, as Dr. Drummond remarks in one of his poems, "He's the only man, I know me, don't get no holiday." There is danger in this treadmill life lest he lose more than health and time and rest—his intellectual independence. More than most men he feels the. tragedy of isolation—that inner isolation so well expressed in Matthew Arnold's line "We mortal millions live alone." Even in populous districts the practice of medicine is a lonely road which winds up-hill all the way and a man may easily go astray and never reach the Delectable Mountains unless he early finds those shepherd guides of whom Bunyan tells, Knowledge, Experience, Watchful, and Sincere. The circumstances of life mould him into a masterful, self-confident, self-centered man, whose worst faults often par-take of his best qualities. The peril is that should he cease to think for himself he becomes a mere automaton, doing a penny-in-the-slot business which places him on a level with the chemist's clerk who can hand out specifics for every ill, from the "pip" to the pox. The salt of life for him is a judicious scepticism, not the coarse, crude form, but the sober sense of honest doubt expressed in the maxim of the sly old Sicilian Epicharmus, "Be sober and distrustful; these are the sinews of the understanding." A great advantage, too, of a sceptical attitude of mind is, as Green the historian remarks, "One is never very surprised or angry to find that one's opponents are in the right." It may keep him from self-deception and from falling into that medical slumber into which so many drop, deep as the theological slumber so lashed by Erasmus, in which a man may write letters, debauch himself, get drunk, and even make money—a slumber so deep at times that no torpedo-touch can waken him.
It may keep the practitioner out of the clutches of the arch enemy of his professional independence—the pernicious literature of our camp-followers, a literature increasing in bulk, in meretricious attractiveness, and in impudent audacity. To modern pharmacy we owe much, and to pharmaceutical methods we shall owe much more in the future, but the profession has no more insidious foe than the large borderland pharmaceutical houses. No longer an honoured messmate, pharmacy in this form threatens to become a huge parasite, eating the vitals of the body medical. We all know only too well the bastard literature which floods the mail, every page of which illustrates the truth of the axiom, the greater the ignorance the greater the dogmatism. Much of it is advertisements of nostrums foisted on the profession by men who trade on the innocent credulity of the regular physician, quite as much as any quack preys on the gullible public. Even the most respect-able houses are not free from this sin of arrogance and of ignorant dogmatism in their literature. A still more dangerous enemy to the mental virility of the general practitioner, is the "drummer" of the drug house. While many of them are good, sensible fellows, there are others, voluble as Cassio, impudent as Autolycus, and senseless as Caliban, who will tell you glibly of the virtues of extract of the coccygeal gland in promoting pineal metabolism, and are ready to express the most emphatic opinions on questions about which the greatest masters of our art are doubtful. No class of men with which we have to deal illustrates more fully that greatest of ignorance—the ignorance which is the conceit that a man knows what he does not know; but the enthralment of the practitioner by the manufacturing chemist and the revival of a pseudoscientific polypharmacy are too large questions to be dealt with at the end of an address.
But there is a still greater sacrifice which many of us make, heedlessly and thoughtlessly forgetting that "Man does not live by bread alone." One cannot practise medicine alone and practise it early and late, as so many of us have to do, and hope to escape the malign influences of a routine life. The incessant concentration of thought upon one subject, however interesting, tethers a man's mind in a narrow field. The practitioner needs culture as well as learning. The earliest picture we have in literature of a scientific physician, in our sense of the term, is as a cultured Greek gentleman; and I care not whether the young man labours among the beautiful homes on Sherbrooke Street, or in the slums of Caughnawauga, or in some sparsely settled country district, he cannot afford to have learning only. In no profession does culture count for so much as in medicine, and no man needs it more than the general practitioner, working among all sorts and conditions of men, many of whom are influenced quite as much by his general ability, which they can appreciate, as by his learning of which they have no measure. The day has passed for the "practiser of physic" to be like Mr. Robert Levet, Dr. Johnson's friend, "Obscurely wise and coarsely kind." The wider and freer a men's general education the better practitioner is he likely to be, particularly among the higher classes to whom the reassurance and sympathy of a cultivated gentle-man of the type of Eryximachus, may mean much more than pills and potions. But what of the men of the type of Mr. Robert Levet, or "Ole Docteur Fiset," whose virtues walk a narrow round, the men who do the hard general practices in the poorer districts of the large cities, in the factory towns and in the widely scattered rough agricultural regions—what, I hear you say, has culture to do with them? Everything! It is the bichloride which may prevent the infection and may keep a man sweet and whole amid the most debasing surroundings. Of very little direct value to him in his practice—though the poor have a pretty keen appreciation of a gentleman—it may serve to prevent the degeneration so apt to overtake the overworked practitioner, whose nature is only too prone to be subdued like the dyer's hand to what it works in. If a man does not sell his soul, if he does not part with his birthright of independence for a mess of pottage to the Ishmaelites who harass our borders with their clubs and oppress us with their exactions, if he can only keep free, the conditions of practice are nowhere incompatible with St. Paul's noble Christian or Aristotle's true gentleman (Sir Thomas Browne).
Whether a man will treat his professional brethren in a gentlemanly way or in a narrow illiberal spirit is partly a matter of temperament, partly a matter of training. If we had only to deal with one another the difficulties would be slight, but it must be confessed that the practice of medicine among our fellow creatures is often a testy and choleric business. When one has done his best or when a mistake has arisen through lack of special knowledge, but more particularly when, as so often happens, our heart's best sympathies have been engaged, to be misunderstood by the patient and his friends, to have evil motives imputed and to be maligned, is too much for human endurance and justifies a righteous indignation. Women, our greatest friends and our greatest enemies, are the chief sinners, and while one will exhaust the resources of the language in describing our mistakes and weaknesses, another will laud her pet doctor so indiscriminately that all others come under a sort of oblique condemnation. "Feminae sunt medicorum tubae" is an old and true saying. It is hard to say whether as a whole we do not suffer just as much from the indiscriminate praise. But against this evil we are helpless. Far otherwise, when we do not let the heard word die; not to listen is best, though that is not always possible, but silence is always possible, than which we have no better weapon in our armoury against evil-speaking, lying, and slandering. The bitterness is when the tale is believed and a brother's good name is involved. Then begins the worst form of ill-treatment that the practitioner receives—and at his own hands! He allows the demon of resentment to take possession of his soul, when five minutes' frank conversation might have gained a brother. In a small or a large community what more joyful than to see the brethren dwelling together in unity. The bitterness, the rancour, the personal hostility which many of us remember in our younger days has been largely replaced by a better feeling and while the golden rule is not always, as it should be, our code of ethics, we have certainly become more charitable the one towards the other.
To the senior man in our ranks we look for an example, and in the smaller towns and country districts if he would remember that it is his duty to receive and welcome the young fellow who settles near him, that he should be willing to act as his adviser and refuse to regard him as a rival, he may make a good friend and perhaps gain a brother. In speaking of professional harmony, it is hard to avoid the trite and commonplace, but neglecting the stale old chaps whose ways are set and addressing the young, to whom sympathy and encouragement are so dear, and whose way of life means so much to the profession we love, upon them I would urge the practice of St. Augustine, of whom it is told in the Golden Legend that "he had these verses written at his table:
Quisquis amat dictis absentum rodere vitam, Hanc mensam indignam noverit esse sibi:
That is to say: Whosoever loves to missay any creature that is absent, it may be said that this table is denied to him at all."
With our History, Traditions, Achievements, and Hopes, there is little room for Chauvinism in medicine. The open mind, the free spirit of science, the ready acceptance of the best from any and every source, the attitude of rational receptiveness¬ rather than of antagonism to new ideas, the liberal and friendly relationship between different nations and different sections of the same nation, the brotherly feeling which should characterize members of the oldest, most beneficent and universal guild that the race has evolved in its upward progress—these should neutralize the tendencies upon which I have so lightly touched.
I began by speaking of the art of detachment as that rare and precious quality demanded of one who wished to take a philosophical view of the profession as a whole.
In another way and in another sense this art may be still more precious. There is possible to each one of us a higher type of intellectual detachment, a sort of separation from the vegetative life of the work-a-day world—always too much with us—which may enable a man to gain a true knowledge of himself and of his relations to his fellows. Once attained, self-deception is impossible, and he may see himself even as he is seen—not always as he would like to be seen—and his own deeds and the deeds of others stand out in their true light. In such an atmosphere pity for himself is so commingled with sympathy and love for others that there is no place left for criticism or for a harsh judgment of his brother. But as Sir Thomas Browne—most liberal of men and-most distinguished of general practitioners—so beautifully remarks: "These are Thoughts of things which Thoughts but tenderly touch," and it may be sufficient to remind this audience, made up of practical men, that the word of action is stronger than the word of speech.