No. 3755.

AUGUST 17, 1895.

ABSTRACT OF

An AddressTO

GRADUATES IN MEDICINE IN THEUNIVERSITY OF EDINBURGH.

Delivered on August 1st, 1895,

BY W. S. GREENFIELD, M.D. LOND.,F.R.C.P LOND. AND EDIN.,

PROFESSOR OF PATHOLOGY AND CLINICAL MEDICINE IN THEUNIVERSITY.

GENTLEMEN,—It is my pleasant duty and privilege to

convey to you the congratulations of my colleagues and ofthe University on the attainment of your degrees and uponthe varied honours and distinctions bestowed to-day. To

those of you who have attained the degree of M.D. weoffer our sincere congratulations, not only in that

yon have elected to reach the fullest medical standard ofour University, but that so many of you have contributedTheses of high value to medical science. It is no small

thing to be graduates of this University, to share the inherit-ance of so many noble traditions, and to belong to the schoolof so many eminent men of the past and present. You arc

no mere licentiates of a medical corporation, but members ofa University which in the past has been, as we trust it will

continue to be in the future, distinguished in all branches ofiearning. During long years the combined influence andmutual interaction of the various Faculties have moulded andelevated the teaching of the whole. Many of you have directlyprofited by the teaching of professors in other Faculties thanthat of medicine, but even those who have not done so musthave felt their influence. Remarkable as is this Universityin the long combination of distinction in medicine with thatin divinity, law, philosophy, and science, it is hardly lessunique in its relations to the citizens of this noble andbeautiful city. For long years, in place of antagonismbetween town and gown, the University has been amongstthe chief glories and most dearly cherished objects ofsolicitude of the inhabitants. The fathers of the city,its eminent citizens, its wealthy men, have viedwith one another to foster and develop it. Apartfrom higher interests, the results of their munificenceand care are seen to-day in the noble buildings, bothof the University and the Royal Infirmary, in which youhave received your training. You owe, then, a debt to thiscity as well as to the University, which should be an incentive*’L-o each one of you to see to it that by your life and influenceyou do nothing to tarnish the fair fame of either. Nay, Iwould go further, and say that by all means in your poweryou should aim to promote the renown and success of theUniversity, and to increase its material prosperity.You have chosen a profession higher, perhaps, than any

other, hardly excepting Divinity. It is full of noble tradi-tions and memories, of possibilities of good to your fellowmen, and of self-culture in all the highest qualities of man.You are rightly proud of your choice, and you will do well to,retain your high ideal of your position and duty. All themore will you find this essential, since you will meet withmany temptations to a lower standard in your own life.Still more will you find that your view is not shared by themajority of those aronnd you. If you imagine that the’public entertain a like view of the portion and objects ofyour profession, you will soon be undeceived. In theorythey may, and here and there some noble souls may recogniseit, but for the most part your views and aims will be mis-understood. If, for example, you try to introduce sanitaryimprovements, you will probably be charged with a desirefor notoriety, with ignorance of the common facts of life, and,above all, with a desire to raise the rates. Obloquy andsuspicion will often be your meed, instead of gratitude andregard. Your monetary compensation, if any, will begrudged, and possibly be cut down below that of a commonscavenger. The picture in Charles liingaley’s ’’Two Years

Ago " is true to the life to this day. 1 speak from intimateknowledge in many instances. "A meddlesome conceitedfello-.v," they will say, "fresh from college, full of new-fangledideas." " As if we did not know what water we should drink,what a.ir we should breathe ; what wc should do with oursewage, how we should feed and clothe our children,"and so on. "Our fathers lived to a good old age withoutany of your new noiion,. What did for Them will do for us."In such matters and a multitude of others you will find thatthe public, in spite of modern education and enlightenment,will oppose or thwart you. Even the diffusion of knowledge,the abundance of popular medical literature (so called), theready access to medical works, due partly to their wideadvertisement, will often act prejudicially to your treatmentof patients, especially amongst the better educated classes.Indeed, it is often with them that the dangerous "littleknowledge " is a serious barrier to successful treatment. Toface such difficulties will often tax all your endurance and

courage. Only by patience, tact, and forbearance can yousucceed, whether in dealing with individual cases or withmatters of wider interest. But, beyond this, there is one

prevalent opinion which will come in to mar your influence.Money is, for the vast number of men, the first object inlife ; this, and not character or ability, is the standardof success. Do not be aurprised if you are believed tohave this as your first object. If it is really so I pityyou. Not only may you fail utterly in your object, but

you will be led into ways which must bring you loss ofcharacter, I mean real, not reputed character, and whichmay mar your success in the alleviation and cure of disease.It will lead to much bitterness and sorrow, to misunderstand-

ings and quarrels with your medical brethren, to a loweringof the dignity of your profession.

[Professor Greenfield here emphatically cautioned hisaudience against making pecuniary success their main

object in life. He urged on them the advantages of literaryculture, and continued :]

In the practice of your profession you will necessarily beexposed to many temptations and meet with many difficulties.Time forbids any full reference to these, but there are oneor two on which I would, before we part, say a, few words ofcounsel. Every medical man is in a relation of peculiarconfidence to his patients and their friends. There are somefacts which he must know, both as to patient and family,which are sacred confidences. There are others with regardto which he must exercise a wise reticence, even to the

patient himself or to his nearest friends. And no task ismore difficult sometimes than to know when to speak andwhen to be silent. But beyond this there is one rule, too oftenforgotten, that a practitioner should never talk about his

patients or their diseases to others. There are some obvious

exceptions-where you may silence false rumours, forinstance. But, as a rule, it is only at the request, or with thesanction, of the patient or his friends that you should speakat all. I cannot too strongly urge yon to cultivate this ruleof silence. Once break through it and you will find it hardto stop, but let it be known that it is your rule, and you willretain the confidence of your patients and the credit of yourprofession. You will often be tempted to speak so long asmorbid curiosity and gossip, those two most inherent anddevilish of common vices, exist; the guise of sympathy, thobad example of some prominent men, the prying eyes of theworld, to whom no details of inner life are sacred nowadays,will tempt you; and you will be blamed if you will not

divulge in private life what all the world considers itselfentitled to know about public men. If you knew what onecould tell of the mischief wrought by gossip, and especiallyby gossip founded on the sayings of men who shouldknow the facts, you would shrink from all possible chanceof doing such harm. Let your sense of honour guardyour lips, and even keep the doors of thy mouth from thewife of thy bosom. When pressed for information it, is a

good rule to say, ‘‘ It might do no harm for you to be.told, but I am the last person to give you any information."I will not insult you by supposing that yon will talkabout your patients, with the idea that it will benefit yourpractice, by saying, for instance, that Lord So and So is.under your care. It is not my business to, teaclx yon thearts of quackery. There are plenty of teachers. Not lessdifficult is it to know how to convey truth to your patients andtheir friends. Medical men are often blamed for concealingthe truth from patients, even when asked directly. Muchof this popular error arises from the fact that the presenta-tion of truth is amoungst the most dillicult of acquirements.

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The most perfect portrait is not that which presents everydetail so that it can be studied with a microscope, butthat which conveys the living likeness to the casual beholder.How few artists, how few writers, can succeed in this. It isno sophistry, but practical truth, that you must endeavour toconvey the right impression as seen from the standpoint ofyour hearer. And in doing so you must keep in view thepractical object for which you are consulted. To tell a manthat he has heart disease may torture him with fears ofsudden death, may lead him to give up his work and to live alife of misery and apprehension, when you know that he maylive a long life and do active work, if due precautions aretaken. It is your duty, and must be your anxious study,so to convey the truth that it may enter his mind in a waywhich shall give him hope and courage, and lead him to takesuch precautions and live such a life as will conduce to bothhealth and happiness; otherwise, as one has often seen, hemay, after long years of misery, discover that you in youreager desire to be truthful, and, perhaps, from over-

confidence in your diagnostic powers, have done him moreinjury than his disease. How many cases of this kind onecould relate did time permit. But I pass on to mentionanother closely related point. Bear always in mind thatnot only cannot the subjective and objective coincide, butthat, from many points of view, a patient must always beregarded as aberrant. His mental condition cannot be yours.You see matters in that dry light of truth which Aristotlecommends. The patient’s fears, anxieties, wrong ideas, andspeculations cannot be yours. He watches your every phaseof expression; a puzzled or anxious look on your face mayconvey to him a sentence of death. Medical men, when ill,are the worst patients in this respect. One look may effaceall that you can say. Hence no endowment is better in adoctor than a calm, cheerful, sympathetic manner, especiallyif combined with clearness, decision, and thoroughness indirections and candour in speech. "A merry heart doeth goodlike medicine," and is often a better sedative than all yourdrugs. Be anxious if you must, but let it be as a stimulus tomore careful investigation, more watchful care in yourself.Beyond this, remember that sickness makes a man not him-self. The higher his intelligence, the greater his activity, thewider his responsibilities, the more intolerable is sickness.It is not the physical but the mental pain which is hardestto bear, the risks of suffering to others, the apprehension ofimagined or real woes. More than this, the mental andmoral condition, like the pathological processes of disease,often revert to the type of early life. A child’s ailments areoften revealed by peevishness, a baby cries from hunger orpain oftener than from innate depravity. And a good, wise,and high-souled man, or a loving, patient, considerate womanmay suffer tortures from the most trivial causes in sickness-e.g., a picture hung askew, or a spot on the wall. "We, then,that are strong ought to bear the infirmities of the weak."A medical man must exercise the fullest patience, considera-tion, sympathy, and control of temper. I have known in-stances where, forgetting this, perhaps himself wearied andoverwrought in mind and body, a medical man has spokenharshly, or even has left a patient in advanced stages ofdisease, because of some imaginary slight. If you wouldavoid life-long remorse, apart from the discredit of such

things to yourself and your profession, I beseech you to re-member that" Better is he that ruleth his spirit than he thattaketh a city," or distinguishes himself in diagnosis. In yourrelations to your medical brethren you may also meet withdifficulties. One should perhaps pass these in silence, or speakwith bated breath, in the presence of the public. But the factthat there are sometimes dissensions amongst medical men isbut too well known, and the public judgment is warped byknowledge of the exceptions, and ignorance of the rule ofbrotherly feeling and action. That we are not onlyno better, but rather worse, than other men in this

respect is a common belief. It is no answer to saythat amongst those whose profession is higher, and whosecreed is one of universal charity, the odium theologicum is acommon and flagrant fact. Whatever may be our theory,however stringent our codes of medical ethics, it is

unquestionable that ill-feelings and misunderstandingsdo too often mar our charactor, and will, I suppose,so long as we are human. Amongst the most frequentcauses are those which relate to the distribution of patients,or rather clients. Medical practitioners, especially earlyin life, are charged with seeking to get the patients ofothers. The general idea that people are divided into theclients of Dr. A. and Dr. B. : that if Dr. A. is asked to see,

y and does see, anyone in a family which Dr. B. usuallyt attends, he is a supplanter, to be scorned and avoided by... Dr. B., and that Dr. H. may justly refuse to see anyone in thats family again, even in an emergency, are rules sometimeso supposed to govern practice. I do not say whether this is,f right or no, I record the fact. And there are too manye thorny questions, too many intricate problems, which arisen in connexion with such matters for me to attempt to dealf with them. But this I will say, that I know of no rule ofa law, common or statutory, which empowers a medical man toy claim an exclusive right to attend any man or his family,e and that the public in general does not understand the high

ground of privilege which is sometimes claimed. Believe’

y me, gentlemen, the only real, sure, and lasting bond of unione between medical man and patient is that of mutual confi-

dence and respect. The exhibition of jealousy and distrust.e of the character and motives of one’s fellow-practitioner is.r more likely to lead to loss of confidence than to its increase.- Readiness to consult with others when desired is not likely to-e lose a patient. A man will not readily part with the services.e of one who has been in his confidence and has helped him ora his family in times of trouble. Exclusiveness, suspicion,t jealousy, evil report of one’s neighbours, will only destroyt confidence where it might otherwise be retained, and ae patient may long to be released from a bondage which he’. did not seek. In such cases some people will go long dis-e tances to consult others, concealing or denying the fact thati they have been under treatment, and often they do this to>e their own detriment, as well as to that of their medical man.

I have often been astonished that patients have not enjoyed, the advantage of consultation with medical men in theire own neighbourhood, who could far better advise with their1 own medical attendant, and have found the explanation in

the fact of mutual distrust and the idea that such a stepi would be resented. I have dwelt upon this point because II judge it to be one of the most urgent practical importance.r But pray do not misunderstand me. It is one of the most) stringent and primary rules that no medical man should. under any guise, directly or indirectly, interfere with the- conduct of a case which is under the care of another, ’.a unless consulted by him. Moreover, you will remember that . I say this to guide ’your own conduct, not to influence’b your opinion of the conduct of others. There are salutaryf rules, established by long experience and concurred in by1 the wisest and best of our profession, which should regulate, your conduct to your fellows, even if you cannot as yet see) their justice or wisdom. Need I add that to comment upon

the treatment or diagnosis of others, a habit we are all prone, to, is not only a crime but a blunder. No man can judge ofi a case which he has not seen, and reports or rumours should- never be trusted or be the ground of comment. Leave such, criticisms to those who cannot know how deep is the anxiety,’ how great the difficulty, of the actual diagnosis and treatment. of disease. You may think that in what I have said I have. given a counsel of perfection unattainable by mortal man.l But if you do not aim high now, you probably never will.i And finally, gentlemen, let me commend to you the quality

of thoroughness. Far more mistakes are made in diagnosis,l and consequently in treatment, by want of thoroughness,i than from ignorance. It has been our effort to ensure. that as you have received a complete scientific training,j so you should be thorough and methodical in all your. clinical work. You cannot be too rigorous with your-

selves in this. Cultivate the habit of thorough investiga-: tion in your earlier years, and you will gain a power ofperception which will stay with you in the busier years of; practice. There is genius in medicine as in other spheres,r but the highest genius is in the power of careful and

thorough attention. It is thus that the great men in allscience have gained their renown. Every patient is a new

; and complex problem-not a mere "case"—with his ownr heritage of tendencies, his own habits, his temperament, his

past life. Study all these with care, and you will developpowers which will make your success as medical men. It is, not always the brilliant students who become successful and; distinguished, but those who with good ability, assiduous care,; and perseverance train what powers they have. Let those-

, who have been depressed and daunted by their failures atexaminations remember that the race is not always to the

, swift or the battle to the strong. Their difficulty inr grasping facts or unravelling problems may have been dueE only to slow development, and they may discover new; powers and attain high qualities by steady and persevering, work.