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[SEPT. 5, 1953

TO THE NEWLY GRADUATEDA VALEDICTORY ADDRESS *

Sir SYDNEY SMITHC.B.E., M.D. Edin., F.R.C.P.E.

REGIUS PROFESSOR OF FORENSIC MEDICINE AND DEAN OF THE

FACULTY OF MEDICINE, UNIVERSITY OF EDINBURGH

* Based on the Promotor’s Address delivered at the graduationceremony in the McEwan Hall, Edinburgh, on July 15,1953. The full text of the address will presently appearin the University of Edinburgh Journal.

You have been brought up in a world of reason. You

have been taught to examine all things in the light ofscience, and this may have led you to believe that sciencefalnis all your requirements, and that it can itself

provide a philosophy of life or, at least, the material fromwhich such a philosophy can be fashioned. Possibly itcan, but a university education, though it must bedirected to the production of individuals skilled in thefundamentals of a particular profession, must also fostertastes and stimulate interest in many things which leadto a fuller life both intellectually and emotionally. Donot be led away, however, by the oft-repeated assertionthat only by the study of a particular department ofknowledge can this be achieved. You no doubt havebeen told and will be told again that the study of Lawor of Medicine is purely vocational and devoid of culturalvalue. Such assertions are ordinarily made by thoseversed in neither, but they merit discussion for all that.I have heard it said that it is only by the study ofliterature written in the Greek and Latin tongues thattrue culture can be acquired and that no other study canhave that ennobling and beautifying effect on the mind.It may well be so, but if such studies have had thateffect on my classical colleagues it has completelyescaped my notice. But if any subject is studied for theprofessional benefits which one may acquire from it andnot for the pleasure and satisfaction which it gives, it isnot likely to have much cultural value : if the mind isconcentrated on any one department of learning to theexclusion of all others, it will clearly be narrower inoutlook.

LivingIt may well be true that we have from necessity directed

most of your time to vocational training and that wehave not paid much attention to training you how tolive. The graciousness of life has perhaps been blurredby the overriding necessity of acquiring efficiency andof keeping abreast of scientific progress. W’e may thushave given you too little time to cultivate a sense ofbeauty, to quicken your appreciation, and to improveyour discrimination between things which are good andthose which are not. That is not necessarily the case,but even if it were, it is fortunately not too late to

remedy it. You must not only keep in touch with theliterature in your own and related subjects, but youwould also be wise to take such interest as you can inliterature in general, in music, and in art. History is thegreat opener of doors and you will find that the historyof your own subject will give you an insight into thedevelopment of man and his problems, and add interestand colour to your life. Getting a wider knowledge ofman and the world he lives in, of his arts and crafts, ofhis philosophy and religions, and obtaining some acquaint-ance with the thoughts and ideas of the great scholarsand scientists of the past will provide you with a well-furnished mind which, when the emotional side of yourlife becomes of lessening importance and your work isnot the all-in-all that you think it is now, will be a sourceof comfort and delight.Do not think that I am talking unrealistically. I

know how little time you will have to spare, but I know

that if you follow my advice you will soon find that thetime so used is well used, and, far from interfering withyour general way of life, will embellish it. Remember

always that although wide reading may rescue you fromliving in an intellectual slum, it is quite possible to behighly educated and still lead a life of aesthetic squalor ;so do try to interest yourselves in things which have thatintangible quality which we call beauty and from whichyou will obtain quite a special satisfaction.None of these things, however, can give you what you

may find increasingly desirable—namely, to discoversome meaning and purpose in life. In your youth youwill find many opiates to prevent you from thinking ofthese matters--your work, your play, and such aestheticoutlets as appeal to you-but the time must come whenthese ancient unsolved problems will occupy yourattention and I am afraid that there is no ready answer.The simple faiths of our fathers would suffice, but oureducation, especially in Science, has tended to destroythat faith and there does not seem to be any method bywhich it may he regained. No doubt, as Hippocratessaid, it is the duty of a physician to heal his patients andnot to philosophise, but though that may suffice in themeantime, we must appreciate that the wide under-

standing and sympathy which we associate with goodmedical practice will be reinforced and supported if thedoctor himself sees life whole and sees it clearly throughan upholding faith.

Progress and Morality

Although the history of medicine goes back to the

beginning of written speech, there is no part of thatfive-thousand-year story which is so exciting anddramatic as that of the past century. Into this periodhave been crowded more advances in medical sciencethan in all previous recorded history, and as the yearsunfold, the pace of progress increases, almost ingeometrical progression.

In view of the formidable salients that we haveestablished, we might reasonably expect to find com-parable progress in our moral outlook and in our socialsense, which would naturally be shown in betterbehaviour ; we might, in fact, hope to be on the roadto a relatively crime-free state in which knowledge ofright and wrong, of good and evil, would in itselfbe sufficient deterrent to crime. Here again we areunfortunately in error, for we find that all our advancesin medical knowledge, all our improved conditions ofliving, all our social improvements have been accom-panied by a rapid rise in all forms of crime, and todaythere is roughly five times as much serious crime as therewas before 1930. Unfortunately the incidence of crimeis highest amongst quite young people. The fact thatcrime does not appear to have been curbed by ourvarious efforts at reform and reablement must raise thequestion whether our methods of dealing with mis-behaviour in general require re-examination. This is a,

matter which affects both Law and Medicine, for crimeis a social disease and Medicine and Law are socialsciences.A thing which we are apt to forget is that there does

not appear to have been any inheritable development ofthe moral or ethical sense in the whole of human history.A child comes into the world now, as always, with but afew primitive instincts such as those connected with

self-preservation and procreation. He is normallyaggressive and acquisitive and in all respects a potentialcriminal. What we call criminal tendencies, however,are merely normal primitive urges which are not sociallyacceptable, and unless they are diverted into channelswhich conform to the rules of the society in which helives, the child will be classified as a delinquent. Traininghas thus to be repeated with each new generation, for,

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as I have said, one does not inherit morals. A great dealof responsibility, therefore, lies on the shoulders of thosewho deal with the training of young people from birthonwards, and the family doctor is one of these. If dis-

orderly conduct in man cannot be controlled, how muchless can disorderly conduct in groups or in nations ;and without such control what does the future hold ’?We have had the frightening experience of glimpsing,during the war which we are now recovering from, theprimitive savagery of the human mind when the controlselaborated by training went down in the stress of nationalconflict. That glimpse into the primitive Hell of themind of uninhibited man tells us that unless we cancontrol ourselves, there must always be a danger of acomplete eclipse of the civilisation of which we are soproud. It seems to me to be inevitable that such a

catastrophe will occur if we continue to put more andmore dangerous instruments into the hands of thehuman race which is unable to control itself, and inwhich, I fear, control cannot be established in the timeavailable.

The Harmony of Mind and BodyThe insistence on the scientific approach to the study

of disease has not, I hope, left you with the feeling thatman is but a bag of organs each of which is liable tocertain disease processes for which appropriate treatmentsmay be available. This would be to give you an entirelywrong conception of the place of the doctor. There isno such thing as a diseased organ in isolation, there areno diseases to treat-but only diseased men. Do not

forget that you are dealing with the whole man-notonly the body, not only the mind-but the man himself.You must take into consideration not only his physicalcondition but his general environment, including hiswork and his domestic affairs in so far as they may havesome relation to his physical and mental state. Youmust remember that many patients come to you notonly suffering from damaged bodies, but with bruisedminds, lacerated consciences, and broken hearts. Youhave not seen examples of these in your museums, butthey are real enough, and much of your success as doctorswill depend on the care and understanding with whichyou treat such matters.From the earliest days of recorded history, physicians

have been aware of the importance of the harmony ofmind and body in relation to physical ailments. Empe-docles, Hippocrates, Plato, and Galen have all spokenof these matters. John Goodsir, who gave the Pro-motor’s Address in Edinburgh in 1859, declared : " Inthe treatment of disease the adjustment may require tobe directed as much to the psychical as to the physicalconditions of the case." Now listen to Shakespearespeaking three-and-a-half centuries ago :Macbeth How does your patient, Doctor ?Doctor : Not so sick, my lord,

As she is troubled with thick-coming fanciesThat keep her from her rest.

Macbeth Cure her of that :Canst thou not minister to a mind diseas’d,Pluck from the memory a rooted sorrow,Raze out the written troubles of the brain,And with some sweet oblivious antidoteCleanse the stuff’d bosom of that perilous stuffWhich weighs upon the heart ?

Doctor : Therein the patient must minister to himself.Macbeth Throw physic to the dogs ; I’ll none of it.

An excellent description of the clinical effects producedby a guilty conscience. The doctor appears, at first

sight, to have adopted a negative attitude, but youwill remember that after seeing Lady Macbeth sleep-walking, he said to her waiting gentlewoman, " Moreneeds she the divine than the physician," indicating thathe had diagnosed her condition as being due to a guilty

conscience but, in the awful presence of the tempestuousMacbeth, he apparently judged it prudent to keep hisdiagnosis to himself.

Thus, scientists and philosophers have long noted theimportance of balanced action (and interaction) betweenbody and mind ; the question of the relationship betweenthe two has indeed already intruded violently upon oiiinotice in medical practice. The duty now falls on us tcexamine the character and implications of this relation.ship, however formidable an enterprise that may appealtoday. As this knowledge is gained, preventive medicineof the future will have increasingly at its command botta fuller understanding of the means by which balance i,maintained between the various systems of the body andbetween body and mind, and an accepted means oj

diagnosing imbalance. I have no doubt that when allthis has been achieved, entirely new vistas in the main.tenance of health will be opened up. Meanwhile, we mus1do our best to apply our present skill in investigation tcthe early diagnosis of imbalance, which probably occun

long before disease makes itself manifest, and to thE

problem how such early imbalance can be adjusted.You may consider that these matters and many othet

growing points in medical science, such as the intensivEresearch into fundamental knowledge of the cell, of thEgrowing importance of physical biology, of balancedaction between mind and matter and the physicaeffects of emotional states thereon, do not closely concerryou and that they are matters of interest only to thosewhom you consider great scientists. Nothing could befarther from the truth. You in your walk of life, bJcareful observation and careful recording, can all takE

part in the advance. Many of the great steps forwardhave been the result of observations, not of geniusefbut of quite ordinary people like you and me. If youare honest and sincere in all your observations, in aLyour deductions, and in all things relating to your workyou will play your part in scientific progress, whateveiyour position in life may be. You cannot all be clever,but you can all be honest, and that attribute alone willplace you amongst those who will undoubtedly meritrespect from their fellows.

The Wider Scene

It is not fitting for us complacently to point to theadvances that we have made in maintaining health, inpreventing disease, in increasing the duration and

improving the standard of life, when in the world aboutus disease is still rampant. We cannot view with

equanimity the fact that, although the expectation oflife of a newly born baby in Britain is about 65 years, a,

baby in India can expect to live for only 27. Nor is the

length of life the only story ; think of the niisery andill health which precede these early deaths. ilore-

over, not only are more than a third of the world’s peopletoday living on a subnormal diet with all its dangers.but there are annually about 20 million more mouths tofeed. It is essential that there should be either a coil-siderable increase in the world production of food or

that steps be taken to limit the birth-rate. This dilemmais inescapable.

Health, though universally esteemed, has no vestedinterests, and to the profession of medicine there are nofrontiers either national or ideological. Interested as weare only in the health and wellbeing of the people inevery land, it may well be that a combination of doctorsthroughout the world in a drive for health may prove tobe the first real step towards world peace.

Envoi

This, then, is our heritage, and these some of our

responsibilities. Conscious of the many problems whichbeset us, let us not only devote ourselves to those thingswhich lie clearly to our hand, but look towards the misty

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horizon of the future in the knowledge that much will berevealed to us which is now but formless dreams. In

this world of falling ideals, of shifting standards andabandonment of faith, let us remember that the pro-fessions of Law and Medicine have stood with rock-likefirmness against all subversive tides. Let us then hold

fast to those principles of conduct enunciated by ourforefathers, which were their stay and staff throughoutthe centuries, and pass on undimmed to our successorsthe torch of knowledge and the ideals that have beenbequeathed to us.

BASIC SCIENCE

SOME OBSERVATIONS IN THE UNITED STATES

D. C. SINCLAIRM.A. Oxfd, M.D. St. And.

UNIVERSITY DEMONSTRATOR IN HUMAN ANATOMY, OXFORDUNIVERSITY

THANKS to the generosity of the Rockefeller Founda-tion, I have just spent three months visiting medicalschools in the United States of America, and seen some-thing of medical education in the preclinical or " basic "sciences.

I can do no more than record one man’s impressions ofa restricted number of places ; for there are 81 medicalschools in the U.S.A. and I visited only 12. * The presentadventurous tendencies of American medical educationmake it inevitable that so small a sample should havemissed much of importance ; nevertheless, the tourwas planned to cover as wide a range of conditions as

possible.At the moment a wave of educational unrest is rolling

ever the medical schools of the U.S.A. Curriculum com-mittees are in session throughout the land, teaching"shop" has replaced clinical " shop " in the internes’dining-room, and the questionnaire has come into itsown (one head of a department recently received in asingle year 82 questionnaires, dealing for the most partwith methods of teaching). In an attempt to turn allthis energy to good account, the Association of AmericanMedical Colleges has undertaken a series of " teachinginstitutes " (Berry 1953), at which the teaching ofdifferent subjects will be discussed. The first of these

institutes, dealing with physiology, biochemistry, andpharmacology, is to be held in October, and subsequentsessions will be held annually. Meanwhile, discussion isuniversal, and this in itself is educating teachers to anappreciation of what goes on, not only in other medicalschools, but also on other floors of their own building.Arguments will, of course, persist indefinitely, since noadequate objective techniques as yet exist for theassessment of new procedures in medical education.It is, perhaps, a major criticism of some of the currenteducational experiments that little attempt is beingmade to find out the effects produced on the students.Western Reserve University School of Medicine is at themoment acting as an enormous pilot plant for variouseducational techniques, which are being pursued withgreat energy and determination. This carries with it acertain risk, and not for many years will it be knownwhether the risk has been justified. By the deeds of the

’Albany Medical College ; University of Cincinnati College ofMedicine; University of Colorado School of Medicine ;Columbia University College of Physicians and Surgeons ;Cornell University Medical College ; Harvard UniversityMedical School; State University of Iowa College ofMedicine; Johns Hopkins University School of Medicine ;University of Rochester School of Medicine ; Universityof Vermont College of Medicine ; Western Reserve

University School of Medicine ; Yale University Schoolof Medicine.

Reserve graduates we shall know them. But what arethese experimental techniques, and why are they beingadopted ? To answer these questions we must examinethe background of standard teaching against which theystand out.

Students

In the last few years there has been intense com-petition for places in American medical schools, thoughby 1951 the peak had been passed (Stalnaker 1951).

In 1953 the Admission Requirements of American MedicalColleges shows estimated figures varying from 150 applicantsfor 120 places at the State University of Iowa to 1400 appli-cants for 50 places at Albany. Almost all schools insist on threeyears of college work, and in practice most accepted candidateshave completed four. Admission procedure is remarkablyuniform ; the candidate sends evidence of his college gradesand his physical and financial stability, and if he appearssuitable he then has an interview, lasting perhaps half an hour,with each of several faculty members. Likely men who donot live within range of the school may be interviewed byproxy.The medical college admission test-" a mixed test of

general scholastic ability, understanding of modern societyand achievement in science " which is administered by theEducational Testing Service (1953) in Princeton-is eitherinsisted on or " recommended " by 79 out of the 81 medicalschools. The details of the admission process are complex, andit must suffice to say that the main obstacle in the path of themedical student is the business of becoming one. Onceadmitted, he runs little risk of being thrown out, for in thebigger private schools a wastage of more than one or twostudents each year is unusual. Indeed, any scholastic failureis regarded as a failure of the selection committee, and thecauses are very carefully investigated before the student isrefused permission to continue. In State schools the wastageis often greater, for they are bound to give preference toapplicants from their own State, and these may not alwaysbe of the quality obtainable by a school with no restrictionson its catchment area.

The average successful student arrives with a goodgrounding in physics and chemistry and a fair knowledgeof elementary biology ; he is often inadequately informedon other subjects, such as mathematics and English(Dorst 1947). Courses such as genetics, psychology, orcomparative anatomy sound well on paper, but are con-sidered by medical schools as of little value. TheAssociation of American Medical Colleges has said that awider and less specialised premedical education isdesirable, but so far this opinion has had little effect(Whitehorn 1952).

College training is a time of intense and often almostmorbid competition for grades, and the attitude thatexamination marks are an end in themselves maypersist into medical school. American students are morearticulate in conversation and in public speaking thantheir British colleagues, but even less able to expressthemselves on paper ; this failing may in part beattributed to the examination system in many parts ofthe country, which makes it possible for a student to beadmitted to medical school without ever having beenasked to write down his ideas on any subject.The average American student is some two years older

than the British student, more serious-minded, and moreaggressive. Something like one-third of the students

may be married, and many have part-time jobs.

Curriculum

The greater part of the first two years of medical

training is devoted to six major subjects : anatomy,physiology, biochemistry, microbiology, pathology, andpharmacology. These are commonly referred to as the" basic sciences," and are compulsory in all schools. An

analysis was made of the allocation of time to these sixsubjects in 10 out of the 12 schools I visited, the 2 schoolswith unusual curricula (Western Reserve and Colorado)being omitted. The mean number of hours allotted to