Medicine - Teacher and Student Part 3
( Originally Published 1905 )
Students of Medicine, Apprentices of the Guild, with whom are the promises, and in whom centre our hopes—let me congratulate you on the choice of calling which offers a combination of intellectual and moral interests found in no other profession, and not met with at all in the common pursuits of life—a combination which, in the words of Sir James Paget, "offers the most complete and constant union of those three qualities which have the greatest charm for pure and active minds—novelty, utility, and charity." But I am not here to laud our profession; your presence here on these benches is a guarantee that such praise is superfluous. Rather allow me, in the time remaining at my disposal, to talk of the influences which may make you good students-now in the days of your pupilage, and hereafter when you enter upon the more serious duties of life.
In the first place, acquire early the Art of Detachment, by which I mean the faculty of isolating yourselves from the pursuits and pleasures incident to youth. By nature man is the incarnation of idleness, which quality alone, amid the ruined remnants of Edenic characters, remains in all its primitive intensity. Occasionally we do find an individual who takes to toil as others to pleasure, but the majority of us have to wrestle hard with the original Adam, and find it no easy matter to scorn delights and live laborious days. Of special importance is this gift to those of you who reside for the first time in a large city, the many attractions of which offer a serious obstacle to its acquisition. The discipline necessary to secure this art brings in its train habits of self-control and forms a valuable introduction to the sterner realities of life.
I need scarcely warn you against too close attention to your studies. I have yet to meet a medical student, the hey-day in whose blood had been quite tamed in his college days; but if you think I have placed too much stress upon isolation in putting the Art of Detachment first in order amongst the desiderata let me temper the hard saying by telling you how with "labors assiduous due pleasures to mix." Ask of any active business man or a leader in a profession the secret which enables him to accomplish much work, and he will reply in one word, system; or as I shall term it, the Virtue of Method, the harness without which only the horses of genius travel. There are two aspects of this subject; the first relates to the orderly arrangement of your work, which is to some extent enforced by the roster of demonstrations and lectures, but this you would do well to supplement in private study by a schedule in which each hour finds its allotted duty. Thus faithfully followed day by day system may become at last engrained in the most shiftless nature, and at the end of a semester a youth of moderate ability may find himself far in advance of the student who works spasmodically, and trusts to cramming. Priceless as this virtue is now in the time of your probation, it becomes in the practising physician an incalculable blessing. The incessant and irregular demands upon a busy doctor make it very difficult to retain, but the public in this matter can be educated, and the men who practise with system, allotting a definite time of the day to certain work, accomplish much more and have at any rate a little leisure; while those who are unmethodical never catch up with the day's duties and worry themselves, their confreres, and their patients.
The other aspect of method has a deeper significance, hard for you to reach, not consoling when attained, since it lays bare our weaknesses. The practice of medicine is an art, based on science. Working with science, in science, for science, it has not reached, perhaps never will, the dignity of a complete science, with exact laws, like astronomy or engineering. Is there then no science of medicine? Yes, but in parts only, such as anatomy and physiology, and the extraordinary development of these branches during the present century has been due to the cultivation of method, by which we have reached some degree of exactness, some certainty of truth. Thus we can weigh the secretions in the balance and measure the work of the heart in foot-pounds. The deep secrets of generation have been revealed and the sesame of evolution has given us fairy tales of science more enchanting than the Arabian Nights' entertainment. With this great increase in our knowledge of the laws governing the processes of life, has been a corresponding, not less remarkable, advance in all that relates to life in disorder, that is, disease. The mysteries of heredity are less mysterious, the operating room has been twice over robbed of its terrors; the laws of epidemics are known, and the miracle of the threshing floor of Araunah the Jebusite, may be repeated in any town out of Bumbledom. All this change has come about by the observation of facts, by their classification, and by the founding upon them of general laws. Emulating the persistence and care of Darwin, we must collect facts with open-minded watchfulness, unbiased by crotchets or notions; fact on fact, instance on instance, experiment on experiment, facts which fitly joined together by some master who grasps the idea of their relationship may establish a general principle. But in the practice of medicine, where our strength should be lies our great weakness. Our study is man, as the subject of accidents or diseases. Were he always, inside and outside, cast in the same mould, instead of differing from his fellow man as much in constitution and in his reaction to stimulus as in feature, we should ere this have reached some settled principles in our art. And not only are the reactions themselves variable, but we, the doctors, are so fallible, ever beset with the common and fatal facility of reaching conclusions from superficial observations, and constantly misled by the ease with which our minds fall into the ruts of one or two experiences.
And thirdly add to the Virtue of Method, the Quality of Thoroughness, an element of such importance that I had thought of making it the only subject of my remarks. Unfortunately, in the present arrangement of the curriculum, few of you as students can hope to obtain more than a measure of it, but all can learn its value now, and ultimately with patience become living examples of its benefit. Let me tell you briefly what it means. A knowledge of the fundamental sciences upon which our art is based—chemistry, anatomy, and physiology—not a smattering, but a full and deep acquaintance, not with all the facts, that is impossible, but with the great principles based upon them. You should, as students, become familiar with the methods by which advances in knowledge are made, and in the laboratory see clearly the paths the great masters have trodden, though you yourselves cannot walk therein. With a good preliminary training and a due apportioning of time you can reach in these three essential studies a degree of accuracy which is the true preparation for your life duties. It means such a knowledge of diseases and of the emergencies of life and of the means for their alleviation, that you are safe and trustworthy guides for your fellowmen. You cannot of course in the brief years of pupilage so grasp the details of the various branches that you can surely recognize and successfully treat all cases. But here if you have mastered certain principles is at any rate one benefit of thoroughness —you will avoid the sloughs of charlatanism. Napoleon, according to Sainte Beuve, one day said when somebody was spoken of in his presence as a charlatan, "Charlatan as much as you please, but where is there not charlatanism?"
Now, thoroughness is the sole preventive of this widespread malady, which in medicine is not met with only outside of the profession. Matthew Arnold, who quotes the above from Sainte Beuve, defines charlatanism as the "confusing or obliterating the distinctions between excellent and inferior, sound and unsound, or only half sound, true and untrue or half true." The higher the standard of education in a profession the less marked will be the charlatanism, whereas no greater incentive to its development can be found than in sending out from our colleges men who have not had mental training sufficient to enable them to judge between the excellent and the inferior, the sound and the unsound, the true and the half true. And if we of the household are not free from the seductions of this vice, what of the people among whom we work? From the days of the sage of Endor, even the rulers have loved to dabble in it, while the public of all ages have ever revelled in its methods—today, as in the time of the Father of Medicine, one of whose contemporaries (Plato) thus sketches the world old trait: "And what a delightful life they lead! they are always doctoring and increasing and complicating their disorders and always fancying they will be cured by any nostrum which anybody advises them to try."
The Art of Detachment, the Virtue of Method, and the Quality of Thoroughness may make you students, in the true sense of the word, successful practitioners, or even great investigators; but your characters may still lack that which can alone give permanence to powers—the Grace of Humility. As the divine Italian at the very entrance to Purgatory was led by his gentle Master to the banks of the island and girt with a rush, indicating thereby that he had cast off all pride and self-conceit, and was prepared for his perilous ascent to the realms above, so should you, now at the outset of your journey take the reed of humility in your hands, in token that you appreciate the length of the way, the difficulties to be overcome, and the fallibility of the faculties upon which you depend.
In these days of aggressive self-assertion, when the stress of competition is so keen and the desire to make the most of oneself so universal, it may seem a little old-fashioned to preach the necessity of this virtue, but I insist for its own sake, and for the sake of what it brings, that a due humility should take the place of honour on the list. For its own sake, since with it comes not only a reverence for truth, but also a proper estimation of the difficulties encountered in our search for it. More perhaps than any other professional man, the doctor has a curious—shall I say morbid?—sensitiveness to (what he regards) personal error. In a way this is right; but it is too often accompanied by a cocksureness of opinion which, if encouraged, leads him to so lively a conceit that the mere suggestion of mistake under any circumstances is regarded as a reflection on his honour, a reflection equally resented whether of Iay or of professional origin. Start out with the conviction that absolute truth is hard to reach in matters relating to our fellow creatures, healthy or diseased, that slips in observation are inevitable even with the best trained faculties, that errors in judgment must occur in the practice of an art which consists largely of balancing probabilities;—start, I say, with this attitude in mind, and mistakes will be acknowledged and regretted; but instead of a slow process of self-deception, with ever increasing inability to recognize truth, you will draw from your errors the very lessons which may enable you to avoid their repetition.
And, for the sake of what it brings, this grace of humility is a precious gift. When to the sessions of sweet silent thought you summon up the remembrance of your own imperfections, the faults of your brothers will seem less grievous, and, in the quaint language of Sir Thomas Browne, you will "allow one eye for what is laudable in them." The wrangling and unseemly disputes which have too often disgraced our profession arise, in a great majority of cases, on the one hand, from this morbid sensitiveness to the confession of error, and, on the other, from a lack of brotherly consideration, and a convenient forgetfulness of our own failings. Take to heart the words of the son of Sirach, winged words to the sensitive souls of the sons of Esculapius: "Admonish a friend, it may be he has not done it; and if he have done it, that be do it no more. Admonish thy friend, it may be he hath not said it; and if he have, that he speak it not again. Admonish a friend, for many times it is a slander, and believe not every tale." Yes, many times it is a slander, and believe not every tale.
The truth that lowliness is young ambition's ladder is hard to grasp, and when accepted harder to maintain. It is so difficult to be still amidst bustle, to be quiet amidst noise; yet, "es bildet ein Talent sich in der Stille" alone, in the calm life necessary to continuous work for a high purpose. The spirit abroad at present in this country is not favourable to this Teutonic view, which galls the quick apprehension and dampens the enthusiasm of the young American. All the same, it is true, and irksome at first though the discipline may be, there will come a time when the very fetters in which you chafed shall be a strong defence, and your chains a robe of glory.
Sitting in Lincoln Cathedral and gazing at one of the loveliest of human works—for such the angel Choir has been said to be—there arose within me, obliterating for the moment the thousand heraldries and twilight saints and dim emblazonings, a strong sense of reverence for the minds which had conceived and the hands which had executed such things of beauty. What manner of men were they who could, in those (to us) dark days, build such transcendent monuments? What was the secret of their art? By what spirit were they moved? Absorbed in thought, I did not hear the beginning of the music, and then, as a response to my reverie and arousing me from it, rang out the clear voice of the boy leading the antiphon, "That thy power, thy glory and the mightiness of thy kingdom might be known unto men." Here was the answer. Moving in a world not realized, these men sought, however feebly, to express in glorious structures their conceptions of the beauty of holiness, and these works, our wonder, are but the outward and visible signs of the ideals which animated them.
To us in very different days life offers nearly the same problems, but the conditions have changed, and, as has happened before in the world's history, great material prosperity has weakened the influence of ideals, and blurred the eternal difference between means and end. Still, the ideal State, the ideal Life, the ideal Church—what they are and how best to realize them—such dreams continue to haunt the minds of men, and who can doubt that their contemplation greatly assists the upward progress of our race? We, too, as a profession, have cherished standards, some of which, in words sadly disproportionate to my subject, I have attempted to portray.
My message is chiefly to you, Students of Medicine, since with the ideals entertained now your future is indissolubly bound. The choice lies open, the paths are plain before you. Always seek your own interests, make of a high and sacred calling a sordid business, regard your fellow creatures as so many tools of trade, and, if your heart's desire is for riches, they may be yours; but you will have bartered away the birthright of a noble heritage, traduced the physician's well-deserved title of the Friend of Man, and falsified the best traditions of an ancient and honourable Guild. On the other hand, I have tried to indicate some of the ideals which you may reasonably cherish. No matter though they are paradoxical in comparison with the ordinary conditions in which you work, they will have, if encouraged, an ennobling influence, even if it be for you only to say with Rabbi Ben Ezra, "what I aspired to be and was not, comforts me." And though this course does not necessarily bring position or renown, consistently followed it will at any rate give to your youth an exhilarating zeal and a cheerfulness which will enable you to surmount all obstacles—to your maturity a serene judgment of men and things, and that broad charity without which all else is nought—to your old age that greatest of blessings, peace of mind, a realization, maybe, of the prayer of Socrates for the beauty in the inward soul and for unity of the outer and the inner man; perhaps, of the promise of St. Bernard, "pax sine crimine, pax sine turbine, pax sine rixa."