Medicine - On the Educational Value of the Medical Society
( Originally Published 1905 )
As the Autocrat remarks:
Little of all we value here
All the more reason to honour such occasions as the present in an appropriate manner. The tribute of words that I gladly bring—and that you may take as expressing the sentiments of your brethren at large—necessarily begins with congratulations that your society has passed into the select group of those that have reached a century of existence. But congratulations must be mingled with praise of the band of noble men who, in 1803, made this gathering possible. It is true they did but follow the lead of their colleagues of Litchfield County and their own example when, in 1784, the physicians of this county organized what is now one of the oldest medical societies in the land. In the introduction to the volume of Transactions of this Society, published in 1788, the following brief statements are made as to the objects of the organization, which may be transposed from the parent to the child, and which I quote in illustration of the character of the men and as giving in brief the chief uses of a medical society: "This society was formed on the most liberal and generous principles, and was designed, first, to lay a foundation for that unanimity and friendship which is essential to the dignity and usefulness of the profession; to accomplish which, they resolved, secondly, to meet once in three months; thirdly, that in all cases where counsel is requisite they will assist each other without reserve; fourthly, that all reputable practitioners in the country, who have been in the practice for one year or more, may be admitted members; fifthly, that they will communicate their observations on the air, seasons and climate, with such discoveries as they may make in physic, surgery, botany or chemistry, and deliver faithful histories of the various diseases incident to the inhabitants of this country, with the mode of treatment and event in singular cases; sixthly, to open a correspondence with the medical societies in the neighbouring states and in Europe, for which purpose they have a standing committee of correspondence; seventhly, to appoint a committee for the purpose of examining candidates for the profession, and to give certificates to the deserving." Changed conditions have changed some of these objects, but in the main they hold good today.
Some of the paragraphs have suggested to me the subject of my address—the educational value of the medical society. There are many problems and difficulties in the education of a medical student, but they are not more difficult than the question of the continuous education of the general practitioner. Over the one we have some control, over the other, none. The university and the state board make it certain that the one has a minimum, at least, of professional knowledge, but who can be certain of the state of that knowledge of the other in five or ten years from the date of his graduation? The specialist may be trusted to take care of himself—the conditions of his existence demand that he shall be abreast of the times; but the family doctor, the private in our great army, the essential factor in the battle, should be carefully nurtured by the schools and carefully guarded by the public. Humanly speaking, with him are the issues of life and death, since upon him falls the grievious responsibility in those terrible emergencies which bring darkness and despair to so many households. No class of men needs to call to mind more often the wise comment of Plato that education is a life-long business. The difficulties are partly adherent to the subject, partly have to do with the individual and his weakness. The problems of disease are more complicated and difficult than any others with which the trained mind has to grapple; the conditions in any given case may be unlike those in any other; each case, indeed, may have its own problem. Law, constantly looking back, has its forms and procedures, its precedents and practices. Once grasped, the certainties of divinity make its study a delight and its practice a pastime; but who can tell of the uncertainties of medicine as an art? The science on which it is based is accurate and definite enough; the physics of a man's circulation are the physics of the waterworks of the town in which he lives, but once out of gear, you cannot apply the same rules for the repair of the one as of the other. Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease. This is the fundamental difficulty in the education of the physician, and one which he may never grasp, or he takes it so tenderly that it hurts instead of boldly accepting the axiom of Bishop Butler, more true of medicine than of any other profession: "Probability is the guide of life." Surrounded by people who demand certainty, and not philosopher enough to agree with Locke that "Probability supplies the defect of our knowledge and guides us when that fails and is always conversant about things of which we have no certainty," the practitioner too often gets into a habit of mind which resents the thought that opinion, not full knowledge, must be his stay and prop. There is no discredit, though there is at times much discomfort, in this everlasting perhaps with which we have to preface so much connected with the practice of our art. It is, as I said, inherent in the subject. Take in illustration an experience of last week. I saw a patient with Dr. Bolgiano who presented marked pulsation to the left of the sternum in the second, third and fourth interspaces, visible even before the night-dress was removed, a palpable impulse over the area of pulsation, flatness on percussion, accentuated heart sounds and a soft systolic bruit. When to this were added paralysis of the left recurrent laryngeal nerve, smallness of the radial pulse on the left side, and tracheal tugging, there is not one of you who would not make, under such circumstances, the diagnosis of aneurism of the aorta. Few of us, indeed, would put in the perhaps, or think of it as a probability with such a combination of physical signs, and yet the associate conditions which had been present—a small primary tumour of the left lobe of the thyroid, with secondary nodules in the lymph glands of the neck and involvement of the mediastinum and metastases in the brain with optic neuritis—left no question that the tumour causing the remarkable intrathoracic combination was not aneurismal but malignant. Listen to the appropriate comment of the Father of Medicine, who twenty-five centuries ago had not only grasped the fundamental conception of our art as one based on observation, but had laboured also through a long life to give to the profession which he loved the saving health of science—listen, I say, to the words of his famous aphorism: "Experience is fallacious and judgment difficult!"
But the more serious problem relates to the education of the practitioner after he has left the schools. The foundation may not have been laid upon which to erect an intellectual structure, and too often the man starts with a total misconception of the prolonged struggle necessary to keep the education he has, to say nothing of bettering the instruction of the schools. As the practice of medicine is not a business and can never be one,' the education of the heart—the moral side of the man—must keep pace with the education of the head. Our fellow creatures cannot be dealt with as man deals in corn and coal; "the human heart by which we live" must control our professional relations. After all, the personal equation has most to do with success or failure in medicine, and in the trials of life the fire which strengthens and tempers the metal of one may soften and ruin another. In his philosophy of life the young doctor will find Rabbi Ben Ezra a better guide, with his stimulating
Then, welcome each rebuff
than Omar, whose fatalism, so seductive in Fitzgerald's verses, leaves little scope for human effort.
For better or worse, there are few occupations of a more satisfying character than the practice of medicine, if a man can but once get orientirt and bring to it the philosophy of honest work, the philosophy which insists that we are here, not to get all we can out of the life about us, but to see how much we can add to it. The discontent and grumblings which one hears have their source in the man more often than in his environment. In the nature of the material in which we labour and of which, by the way, we are partakers, there is much that could be improved, but, as Mrs. Poyser remarks, we must accept men as the Lord made them, and not expect too much. But let me say this of the public: it is rarely responsible for the failures in the profession. Occasionally a man of superlative merit is neglected, but it is because he lacks that most essential gift, the knowledge how to use his gifts. The failure in 99 per cent. of the cases is in the man himself; he has not started right, the poor chap has not had the choice of his parents, or his education has been faulty, or he has fallen away to the worship of strange gods, Baal or Ashtoreth, or worse still, Bacchus. But after all the killing vice of the young doctor is intellectual laziness. He may have worked hard at college, but the years of probation have been his ruin. Without specific subjects upon which to work, he gets the newspaper or the novel habit, and fritters his energies upon useless literature. There is no greater test of a man's strength than to make him mark time in the "stand and wait" years. Habits of systematic reading are rare, and are becoming more rare, and five or ten years from his license, as practice begins to grow, may find the young doctor knowing less than he did when he started and without fixed educational purpose in life.
Now here is where the medical society may step in and prove his salvation. The doctor's post-graduate education comes from patients, from books and journals, and from societies, which should be supplemented every five or six years by a return to a post-graduate school to get rid of an almost inevitable slovenliness in methods of work. Of his chief teachers, his patients, I cannot here speak. Each case has its lesson—a lesson that may be, but is not always, learnt, for clinical wisdom is not the equivalent of experience. A man who has seen 500 cases of pneumonia may not have the understanding of the disease which comes with an intelligent study of a score of cases, so different are knowledge and wisdom, which, as the poet truly says, "far from being one have ofttimes no connexion." Nor can I speak of his books and journals, but on such an occasion as the present it seems appropriate to say a few words on the educational value of the medical society.
The first, and in some respects the most important, function is that mentioned by the wise founders of your parent society—to lay a foundation for that unity and friendship which is essential to the dignity and usefulness of the profession. Unity and friendship! How we all long for them, but how difficult to attain! Strife seems rather to be the very life of the practitioner, whose warfare is incessant against disease and against ignorance and prejudice, and, sad to have to admit, he too often lets his angry passions rise against his professional brother. The quarrels of doctors make a pretty chapter in the history of medicine. Each generation seems to have had its own. The Coans and the Cnidians, the Arabians and the Galenists, the humoralists and the solidists, the Brunonians and the Broussaisians, the homoepaths and the regulars, have, in different centuries, rent the robe of .Esculapius. But these larger quarrels are becoming less and less intense, and in the last century no new one of moment sprang up, while it is easy to predict that in the present century, when science has fully leavened the dough of homoepathy, the great breach of our day will be healed. But in too many towns and smaller communities miserable frictions prevail, and bickerings and jealousies mar the dignity and usefulness of the profession. So far as my observation goes, the fault lies with the older men. The young fellow, if handled aright and made to feel that he is welcomed and not regarded as an intruder to be shunned, is only too ready to hold out the hand of fellowship. The society comes in here as professional cement. The meetings in a friendly social way lead to a free and open discussion of differences in a spirit that refuses to recognize differences of opinion on the non-essentials of life as a cause of personal animosity or ill-feeling. An attitude of mind habitually friendly, more particularly to the young man, even though you feel him to be the David to whom your kingdom may fall, a little of the old-fashioned courtesy which makes a man shrink from wounding the feelings of a brother practitioner—in honour preferring one another; with such a spirit abroad in the society and among its older men, there is no room for envy, hatred, malice or any uncharitableness. It is the confounded tales of patients that so often set us by the ears, but if a man makes it a rule never under any circumstances to believe a story told by a patient to the detriment of a fellow-practitioner--even if he knows it to be true!—though the measure he metes may not be measured to him again, he will have the satisfaction of knowing that he has closed the ears of his soul to ninety-nine lies, and to have missed the hundredth truth will not hurt him. Most of the quarrels of doctors are about non-essential, miserable trifles and annoyances—the pin pricks of practice—which would sometimes try the patience of Job, but the good-fellowship and friendly intercourse of the medical society should reduce these to a minimum.
The well-conducted medical society should represent a clearing house, in which every physician of the district would receive his intellectual rating, and in which he could find out his professional assets and liabilities. We doctors do not "take stock" often enough, and are very apt to carry on our shelves stale, out-of-date goods. The society helps to keep a man "up to the times," and enables him to refurnish his mental shop with the latest wares. Rightly used, it may be a touchstone to which he can bring his experiences to the test and save him from falling into the rut of a few sequences. It keeps his mind open and receptive, and counteracts that tendency to premature senility which is apt to overtake a man who lives in a routine. Upon one or two specially valuable features of the society I may dwell for a moment or two.
In a city association the demonstration of instructive specimens in morbid anatomy should form a special feature of the work. After all has been done, many cases of great obscurity in our daily rounds remain obscure, and as post-mortems are few and far between, the private practitioner is at a great disadvantage, since his mistakes in diagnosis are less often corrected than are those of hospital physicians. No more instructive work is possible than carefully demonstrated specimens illustrating disturbance of function and explanatory of the clinical symptoms. It is hard in this country to have the student see enough morbid anatomy, the aspects of which have such an important bearing upon the mental attitude of the growing doctor. For the crass therapeutic credulity, so widespread to-day, and upon which our manufacturing chemists wax fat, there is no more potent antidote than the healthy scepticism bred of long study in the post-mortem room. The new pathology, so fascinating and so time-absorbing, tends, I fear, to grow away from the old morbid anatomy, a training in which is of such incalculable advantage to the physician. It is a subject which one must learn in the medical school, but the time assigned is rarely sufficient to give the student a proper grasp of the subject. The younger men should be encouraged to make the exhibition of specimens part of the routine work of each meeting. Something may be learned from the most ordinary case if it is presented with the special object of illustrating the relation of disturbed function to altered structure. Of still greater educational value is the clinical side of the society. No meeting should be arranged without the presentation of patients, particularly those illustrating rare and unusual forms of disease. Many diseases of the skin and of the joints, a host of nervous affections, and many of the more remarkable of general maladies, as myxoedema, cretinism, achondroplasia, etc., are seen so rarely and yet are so distinctive, requiring only to be seen to be recognized, that it is incumbent upon members to use the society to show such cases. A clinical evening devoted to these rarer affections is of very great help in diffusing valuable knowledge. The importance of a clinical demonstration was never better illustrated than at the International Congress in London in 1881, when Dr. Ord and others presented one morning at the Clinical Museum a group of cases of myxoedema. There were men from all parts of the world, and the general recognition of the disease outside of England dates from that meeting. The physiognomy of disease is learned slowly, and yet there are a great many affections which can be recognized, sometimes at a glance, more often by careful inspection, without any history. The society should be a school in which the scholars teach each other, and there is no better way than by the demonstration of the more unusual cases that happen to fall in your way. I have gone over my history cards of private patients brought or sent to me by last-year physicians, in which the disease was not diagnosed though recognizable de visu. Gout, pseudo-hypertrophic muscular paralysis, hysterical lordosis, spondylitis deformans, preataxic tabes (myosis, ptosis, etc.), Graves' disease, Parkinson's disease, anorexia nervosa, Raynaud's disease, pernicious anaemia, spastic diplegia, spastic hemiplegia and cyanosis of chronic emphysema were on the list. Some of these are rare diseases, but at an active society in the course of a few years every one of them could be demonstrated.
The presentation of the histories of cases may be made very instructive, but this is often a cause of much weariness and dissatisfaction. A brief oral statement of the special features of a case is much to be preferred to a long, written account. The protocol or daily record of a long case should never be given in full. The salient points should be brought out, particularly the relation the case bears to the known features of the disease and to diagnosis and treatment. The volume of the Transactions of the New Haven County Medical Society, 1788, contains many admirably reported cases. I select one for special comment, as it is, so far as I know, the first case on record of a most remark-able disease, to which much attention has been paid of late—the hypertrophic stenosis of the pylorus in children (see full discussion in the Lancet of December 20, 1902). Dr. Hezekiah Beardsley reports a Case of Schirrhus of the Pylorus of an Infant. Every feature of the disease as we know it now is noted—the constant puking, the leanness, the wizened, old look of the child are well described, and the diagnosis was made four months before death! The post-mortem showed a dilated and hypertrophied stomach and "the pylorus was invested with a hard, compact substance or schirrosity which so completely obstructed the passage into the duodenum, as to admit with the greatest difficulty the finest fluid." If other men had been as accurate and careful as Dr. Beardsley, and if other societies had followed the good example set so early by the New Haven County Medical Association, not only would this rare disease have been recognized, but by the accumulation of accurate observations many another disease would have yielded its secret. But it illustrates the old story—there is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.
In no way can a society better help in the education of its members than in maintaining for them a good library, and I am glad to know that this is one of your functions. It is most gratifying to note the growing interest in this work in all parts of the country. In the last number of the Bulletin of the Association of Medical Librarians there is a list of twenty-five societies with medical libraries.
An attractive reading-room, with the important weekly journals, and with shelves stocked with the new books in different departments, becomes an educational centre in which the young man can keep up his training and to which the older practitioner can go for advice when he is in despair and for reassurance when he is in doubt. The self-sacrifice necessary to establish and maintain such a library does good to the men who take part in it; harmony is promoted, and, in the words of your fathers, the dignity and usefulness of the profession are maintained.
Why is it that a large majority of all practitioners are not members of a medical society? Dr. Simmons estimates that there are 77,000 physicians in the United States who do not belong to any medical society whatever! In part this is due to apathy of the officers and failure to present an attractive programme, but more often the fault is in the men. Perhaps given over wholly to commercialism a doctor feels it a waste of time to join a society, and so it is if he is in the profession only for the money he can get out of patients without regard to the sacred obligation to put himself in the best possible position to do the best that is known for them. More frequently, I fear, the "dollar-doctor" is a regular frequenter of the society, knowing full well how suicidal in the long run is isolation from the general body of the profession. The man who knows it all and gets nothing from the society reminds one of that little dried-up miniature of humanity, the pre-maturely senile infant, whose tabetic marasmus has added old age to infancy. Why should he go to the society and hear Dr. Jones on the gastric relations of neurasthenia when he can get it all so much better in the works of Einhorn or Ewald? He is weary of seeing appendices, and there are no new pelvic viscera for demonstration. It is a waste of time, he says, and he feels better at home, and perhaps that is the best place for a man who has reached this stage of intellectual stagnation.
Greater sympathy must be felt for the man who has started all right and has worked hard at the societies, but as the rolling years have brought ever-increasing demands on his time, the evening hours find him worn out yet not able to rest, much less to snatch a little diversion or instruction in the company of his fellows whom he loves so well. Of all men in the profession the forty-visit-a-day¬ man is the most to be pitied. Not always an automaton, he may sometimes by economy of words and extraordinary energy do his work well, but too often he is the one above all others who needs the refreshment of mind and recreation that is to be had in a well-conducted society. Too often he is lost beyond all recall, and, like Ephraim joined to his idols, we may leave him alone. Many good men are ruined by success in practice, and need to pray the prayer of the Litany against the evils of prosperity. It is only too true, as you know well, that a most successful—as the term goes—doctor may practise with a clinical slovenliness that makes it impossible for that kind old friend, Dame Nature, to cover his mistakes. A well-conducted society may be of the greatest help in stimulating the practitioner to keep up habits of scientific study. It seems a shocking thing to say, but you all know it to be a fact that many, very many men in large practice never use a stethoscope, and as for a microscope, they have long forgotten what a leucocyte or a tube cast looks like. This in some cases may be fortunate, as imperfect or half knowledge might only lead to mistakes, but the secret of this neglect of means of incalculable help is the fact that he has not attained the full and enduring knowledge which should have been given to him in the medical school. It is astonishing with how little outside aid a large practice may be conducted, but it is not astonishing that in it cruel and unpardonable mistakes are made. At whose door so often lies the responsibility for death in cases of empyema but at that of the busy doctor, who has not time to make routine examinations, or who is "so driven" that the urine of his scarlet fever or puerperal patients is not examined until the storm has broken?
But I hear it sometimes said you cannot expect the general practitioner, particularly in country districts, to use the microscope and stethoscope—these are refinements of diagnosis. They are not! They are the essential means which can be used and should be used by every intelligent practitioner. In our miserable, antiquated system of teaching we send our graduates out wholly unprepared to make a rational diagnosis, but a man who is in earnest —and, thank heaven! most of the young men to-day in the profession are in earnest—can supply the defects in his education by careful study of his cases, and can supplement the deficiency by a post-graduate course. A room fitted as a small laboratory, with the necessary chemicals and a microscope, will prove a better investment in the long run than a static machine or a new-fangled air-pressure spray apparatus.
It is not in the local society only that a man can get encouragement in his day's work and a betterment of mind and methods. Every practitioner should feel a pride in belonging to his state society, and should attend the meetings whenever possible, and gradually learn to know his colleagues, and here let me direct your attention to an important movement on the part of the American Medical Association, which has for its object the organzation of the profession throughout the entire country. This can be accomplished only by a uniformity in the organization of the state societies, and by making the county society the unit through which members are admitted to the state and national bodies. Those of you interested will find very instructive information on this subject in the Journal of the association in a series of papers by Dr. Simmons, the editor, which have been reprinted in pamphlet form. As now managed, with active sections conducted by good men from all parts of the country, the meeting of the National Association is in itself a sort of brief post-graduate course. Those of you at the receptive age who attended the Saratoga meeting last June must have been impressed with the educational value of such a gathering. The Annual Museum was itself an important education in certain lines, and the papers and discussions in the various sections were of the greatest possible, value, But I need say no more to this audience on the subject of medical societies; you of New England have not "forsaken the gathering of yourselves together as the manner of some is," but have been an example to the whole country.
In the dedication of his Holy War, Thomas Fuller has some very happy and characteristic remarks on the bounden duty of a man to better his heritage of birth or fortune, and what the father found glass and made crystal, he urges the son to find crystal and make pearl. Your heritage has been most exceptional, and, I believe, from all that I know of the profession in this city and State, that could your fathers return they would say that of their crystal you had made pearl. One cannot read their history as told by Bronson, or as sketched by your distinguished citizen, my colleague, Dr. Welch, without a glow of admiration for their lofty ideals, their steadfastness and devotion, and for their faith in the profession which they loved. The times have changed, conditions of practice have altered and are altering rapidly, but when such a celebration takes us back to your origin in simpler days and ways, we find that the ideals which inspired them are ours today ideals¬ which are ever old, yet always fresh and new, and we can truly say in Kipling's words:
The men bulk big on the old trail, our own trail, the out trail,