THE YOUNG PRACTITIONER

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THE YOUNG PRACTITIONER

[A Valedictory Address delivered to the Graduating Class of the Bellevue Hospital College, March 2, 1871.]

The occasion which calls us together reminds us not a little of that other ceremony which unites a man and woman for life. The banns have already been pronounced which have wedded our young friends to the profession of their choice. It remains only to address to them some friendly words of cheering counsel, and to bestow upon them the parting benediction.

This is not the time for rhetorical display or ambitious eloquence. We must forget ourselves, and think only of them. To us it is an occasion; to them it is an epoch. The spectators at the wedding look curiously at the bride and bridegroom; at the bridal veil, the orange-flower garland, the giving and receiving of the ring; they listen for the tremulous "I will," and wonder what are the mysterious syllables the clergyman whispers in the ear of the married maiden. But to the newly-wedded pair what meaning in those words, "for better, for worse," "in sickness and in health," "till death us do part!" To the father, to the mother, who know too well how often the deadly nightshade is interwoven with the wreath of orange-blossoms, how empty the pageant, how momentous the reality!

You will not wonder that I address myself chiefly to those who are just leaving academic life for the sterner struggle and the larger tasks of matured and instructed manhood. The hour belongs to them; if others find patience to listen, they will kindly remember that, after all, they are but as the spectators at the wedding, and that the priest is thinking less of them than of their friends who are kneeling at the altar.

I speak more directly to you, then, gentlemen of the graduating class. The days of your education, as pupils of trained instructors, are over. Your first harvest is all garnered. Henceforth you are to be sowers as well as reapers, and your field is the world. How does your knowledge stand to-day? What have you gained as a permanent possession? What must you expect to forget? What remains for you yet to learn? These are questions which it may interest you to consider.

There is another question which must force itself on the thoughts of many among you: "How am I to obtain patients and to keep their confidence?" You have chosen a laborious calling, and made many sacrifices to fit yourselves for its successful pursuit. You wish to be employed that you may be useful, and that you may receive the reward of your industry. I would take advantage of these most receptive moments to give you some hints which may help you to realize your hopes and expectations. Such is the outline of the familiar talk I shall offer you.

Your acquaintance with some of the accessory branches is probably greater now than it will be in a year from now,--much greater than it will by ten years from now. The progress of knowledge, it may be feared, or hoped, will have outrun the text-books in which you studied these branches. Chemistry, for instance, is very apt to spoil on one's hands. "Nous avons change tout cela" might serve as the standing motto of many of our manuals. Science is a great traveller, and wears her shoes out pretty fast, as might be expected.

You are now fresh from the lecture-room and the laboratory. You can pass an examination in anatomy, physiology, chemistry, materia medica, which the men in large practice all around you would find a more potent sudorific than any in the Pharmacopceia. These masters of the art of healing were once as ready with their answers as you are now, but they have got rid of a great deal of the less immediately practical part of their acquisitions, and you must undergo the same depleting process. Hard work will train it off, as sharp exercise trains off the fat of a prize-fighter.

Yet, pause a moment before you infer that your teachers must have been in fault when they furnished you with mental stores not directly convertible to practical purposes, and likely in a few years to lose their place in your memory. All systematic knowledge involves much that is not practical, yet it is the only kind of knowledge which satisfies the mind, and systematic study proves, in the long-run, the easiest way of acquiring and retaining facts which are practical. There are many things which we can afford to forget, which yet it was well to learn. Your mental condition is not the same as if you had never known what you now try in vain to recall. There is a perpetual metempsychosis of thought, and the knowledge of to-day finds a soil in the forgotten facts of yesterday. You cannot see anything in the new season of the guano you placed last year about the roots of your climbing plants, but it is blushing and breathing fragrance in your trellised roses; it has scaled your porch in the bee-haunted honey-suckle; it has found its way where the ivy is green; it is gone where the woodbine expands its luxuriant foliage.

Your diploma seems very broad to-day with your list of accomplishments, but it begins to shrink from this hour like the Peau de Chagrin of Balzac's story. Do not worry about it, for all the while there will be making out for you an ampler and fairer parchment, signed by old Father Time himself as President of that great University in which experience is the one perpetual and all-sufficient professor.

Your present plethora of acquirements will soon cure itself. Knowledge that is not wanted dies out like the eyes of the fishes of the Mammoth Cave. When you come to handle life and death as your daily business, your memory will of itself bid good-by to such inmates as the well-known foramina of the sphenoid bone and the familiar oxides of methyl-ethylamyl-phenyl-ammonium. Be thankful that you have once known them, and remember that even the learned ignorance of a nomenclature is something to have mastered, and may furnish pegs to hang facts upon which would otherwise have strewed the floor of memory in loose disorder.

But your education has, after all, been very largely practical. You have studied medicine and surgery, not chiefly in books, but at the bedside and in the operating amphitheatre. It is the special advantage of large cities that they afford the opportunity of seeing a great deal of disease in a short space of time, and of seeing many cases of the same kind of disease brought together. Let us not be unjust to the claims of the schools remote from the larger centres of population. Who among us has taught better than Nathan Smith, better than Elisha Bartlett? who teaches better than some of our living contemporaries who divide their time between city and country schools? I am afraid we do not always do justice to our country brethren, whose merits are less conspicuously exhibited than those of the great city physicians and surgeons, such especially as have charge of large hospitals. There are modest practitioners living in remote rural districts who are gifted by nature with such sagacity and wisdom, trained so well in what is most essential to the practice of their art, taught so thoroughly by varied experience, forced to such manly self-reliance by their comparative isolation, that, from converse with them alone, from riding with them on their long rounds as they pass from village to village, from talking over cases with them, putting up their prescriptions, watching their expedients, listening to their cautions, marking the event of their predictions, hearing them tell of their mistakes, and now and then glory a little in the detection of another's blunder, a young man would find himself better fitted for his real work than many who have followed long courses of lectures and passed a showy examination. But the young man is exceptionally fortunate who enjoys the intimacy of such a teacher. And it must be confessed that the great hospitals, infirmaries, and dispensaries of large cities, where men of well-sifted reputations are in constant attendance, are the true centres of medical education. No students, I believe, are more thoroughly aware of this than those who have graduated at this institution. Here, as in all our larger city schools, the greatest pains are taken to teach things as well as names. You have entered into the inheritance of a vast amount of transmitted skill and wisdom, which you have taken, warm, as it were, with the life of your well-schooled instructors. You have not learned all that art has to teach you, but you are safer practitioners to-day than were many of those whose names we hardly mention without a genuflection. I had rather be cared for in a fever by the best-taught among you than by the renowned Fernelius or the illustrious Boerhaave, could they come back to us from that better world where there are no physicians needed, and, if the old adage can be trusted, not many within call. I had rather have one of you exercise his surgical skill upon me than find myself in the hands of a resuscitated Fabricius Hildanus, or even of a wise Ambroise Pare, revisiting earth in the light of the nineteenth century.

You will not accuse me of underrating your accomplishments. You know what to do for a child in a fit, for an alderman in an apoplexy, for a girl that has fainted, for a woman in hysterics, for a leg that is broken, for an arm that is out of joint, for fevers of every color, for the sailor's rheumatism, and the tailor's cachexy. In fact you do really know so much at this very hour, that nothing but the searching test of time can fully teach you the limitations of your knowledge.

Of some of these you will permit me to remind you. You will never have outgrown the possibility of new acquisitions, for Nature is endless in her variety. But even the knowledge which you may be said to possess will be a different thing after long habit has made it a part of your existence. The tactus eruditus extends to the mind as well as to the finger-ends. Experience means the knowledge gained by habitual trial, and an expert is one who has been in the habit of trying. This is the kind of knowledge that made Ulysses wise in the ways of men. Many cities had he seen, and known the minds of those who dwelt in them. This knowledge it was that Chaucer's Shipman brought home with him from the sea--

"In many a tempest had his berd be shake."

This is the knowledge we place most confidence in, in the practical affairs of life.

Our training has two stages. The first stage deals with our intelligence, which takes the idea of what is to be done with the most charming ease and readiness. Let it be a game of billiards, for instance, which the marker is going to teach us. We have nothing to do but to make this ball glance from that ball and hit that other ball, and to knock that ball with this ball into a certain caecal sacculus or diverticulum which our professional friend calls a pocket. Nothing can be clearer; it is as easy as "playing upon this pipe," for which Hamlet gives Guildenstern such lucid directions. But this intelligent Me, who steps forward as the senior partner in our dual personality, turns out to be a terrible bungler. He misses those glancing hits which the hard-featured young professional person calls "carroms," and insists on pocketing his own ball instead of the other one.

It is the unintelligent Me, stupid as an idiot, that has to try a thing a thousand times before he can do it, and then never knows how he does it, that at last does it well. We have to educate ourselves through the pretentious claims of intellect, into the humble accuracy of instinct, and we end at last by acquiring the dexterity, the perfection, the certainty, which those masters of arts, the bee and the spider, inherit from Nature.

Book-knowledge, lecture-knowledge, examination-knowledge, are all in the brain. But work-knowledge is not only in the brain, it is in the senses, in the muscles, in the ganglia of the sympathetic nerves,--all over the man, as one may say, as instinct seems diffused through every part of those lower animals that have no such distinct organ as a brain. See a skilful surgeon handle a broken limb; see a wise old physician smile away a case that looks to a novice as if the sexton would soon be sent for; mark what a large experience has done for those who were fitted to profit by it, and you will feel convinced that, much as you know, something is still left for you to learn.

May I venture to contrast youth and experience in medical practice, something in the way the man painted the lion, that is, the lion under?

The young man knows the rules, but the old man knows-the exceptions. The young man knows his patient, but the old man knows also his patient's family, dead and alive, up and down for generations. He can tell beforehand what diseases their unborn children will be subject to, what they will die of if they live long enough, and whether they had better live at all, or remain unrealized possibilities, as belonging to a stock not worth being perpetuated. The young man feels uneasy if he is not continually doing something to stir up his patient's internal arrangements. The old man takes things more quietly, and is much more willing to let well enough alone: All these superiorities, if such they are,'you must wait for time to bring you. In the meanwhile (if we will let the lion be uppermost for a moment), the young man's senses are quicker than those of his older rival. His education in all the accessory branches is more recent, and therefore nearer the existing condition of knowledge. He finds it easier than his seniors to accept the improvements which every year is bringing forward. New ideas build their nests in young men's brains. "Revolutions are not made by men in spectacles," as I once heard it remarked, and the first whispers of a new truth are not caught by those who begin to feel the need of an ear-trumpet. Granting all these advantages to the young man, he ought, nevertheless, to go on improving, on the whole, as a medical practitioner, with every year, until he has ripened into a well-mellowed maturity. But, to improve, he must be good for something at the start. If you ship a poor cask of wine to India and back, if you keep it a half a century, it only grows thinner and sharper.

You are soon to enter into relations with the public, to expend your skill and knowledge for its benefit, and find your support in the rewards of your labor. What kind of a constituency is this which is to look to you as its authorized champions in the struggle of life against its numerous enemies?

In the first place, the persons who seek the aid of the physician are very honest and sincere in their wish to get rid of their complaints, and, generally speaking, to live as long as they can. However attractively the future is painted to them, they are attached to the planet with which they are already acquainted. They are addicted to the daily use of this empirical and unchemical mixture which we call air; and would hold on to it as a tippler does to his alcoholic drinks. There is nothing men will not do, there is nothing they have not done, to recover their health and save their lives. They have submitted to be half-drowned in water, and half-choked with gases, to be buried up to their chins in earth, to be seared with hot irons like galley-slaves, to be crimped with knives, like cod-fish, to have needles thrust into their flesh, and bonfires kindled on their skin, to swallow all sorts of abominations, and to pay for all this, as if to be singed and scalded were a costly privilege, as if blisters were a blessing, and leeches were a luxury. What more can be asked to prove their honesty and sincerity?

This same community is very intelligent with respect to a great many subjects-commerce, mechanics, manufactures, politics. But with regard to medicine it is hopelessly ignorant and never finds it out. I do not know that it is any worse in this country than in Great Britain, where Mr. Huxley speaks very freely of "the utter ignorance of the simplest laws of their own animal life, which prevails among even the most highly educated persons." And Cullen said before him "Neither the acutest genius nor the soundest judgment will avail in judging of a particular science, in regard to which they have not been exercised. I have been obliged to please my patients sometimes with reasons, and I have found that any will pass, even with able divines and acute lawyers; the same will pass with the husbands as with the wives." If the community could only be made aware of its own utter ignorance, and incompetence to form opinions on medical subjects, difficult enough to those who give their lives to the study of them, the practitioner would have an easier task. But it will form opinions of its own, it cannot help it, and we cannot blame it, even though we know how slight and deceptive are their foundations.

This is the way it happens: Every grown-up person has either been ill himself or had a friend suffer from illness, from which he has recovered. Every sick person has done something or other by somebody's advice, or of his own accord, a little before getting better. There is an irresistible tendency to associate the thing done, and the improvement which followed it, as cause and effect. This is the great source of fallacy in medical practice. But the physician has some chance of correcting his hasty inference. He thinks his prescription cured a single case of a particular complaint; he tries it in twenty similar cases without effect, and sets down the first as probably nothing more than a coincidence. The unprofessional experimenter or observer has no large experience to correct his hasty generalization. He wants to believe that the means he employed effected his cure. He feels grateful to the person who advised it, he loves to praise the pill or potion which helped him, and he has a kind of monumental pride in himself as a living testimony to its efficacy. So it is that you will find the community in which you live, be it in town or country, full of brands plucked from the burning, as they believe, by some agency which, with your better training, you feel reasonably confident had nothing to do with it. Their disease went out of itself, and the stream from the medical fire-annihilator had never even touched it.

You cannot and need not expect to disturb the public in the possession of its medical superstitions. A man's ignorance is as much his private property, and as precious in his own eyes, as his family Bible. You have only to open your own Bible at the ninth chapter of St. John's Gospel, and you will find that the logic of a restored patient was very simple then, as it is now, and very hard to deal with. My clerical friends will forgive me for poaching on their sacred territory, in return for an occasional raid upon the medical domain of which they have now and then been accused.

A blind man was said to have been restored to sight by a young person whom the learned doctors of the Jewish law considered a sinner, and, as such, very unlikely to have been endowed with a divine gift of healing. They visited the patient repeatedly, and evidently teased him with their questions about the treatment, and their insinuations about the young man, until he lost his temper. At last he turned sharply upon them: "Whether he be a sinner or no, I know not: one thing I know, that, whereas I was blind, now I see."

This is the answer that always has been and always will be given by most persons when they find themselves getting well after doing anything, no matter what,--recommended by anybody, no matter whom. Lord Bacon, Robert Boyle, Bishop Berkeley, all put their faith in panaceas which we should laugh to scorn. They had seen people get well after using them. Are we any wiser than those great men? Two years ago, in a lecture before the Massachusetts Historical Society, I mentioned this recipe of Sir Kenelm Digby for fever and ague: Pare the patient's nails; put the parings in a little bag, and hang the bag round the neck of a live eel, and place him in a tub of water. The eel will die, and the patient will recover.

Referring to this prescription in the course of the same lecture, I said: "You smiled when I related Sir Kenehn Digby's prescription, with the live eel in it; but if each of you were to empty his or her pockets, would there not roll out, from more than one of them, a horse-chestnut, carried about as a cure for rheumatism?" Nobody saw fit to empty his or her pockets, and my question brought no response. But two months ago I was in a company of educated persons, college graduates every one of them, when a gentleman, well known in our community, a man of superior ability and strong common-sense, on the occasion of some talk arising about rheumatism, took a couple of very shiny horse-chestnuts from his breeches-pocket, and laid them on the table, telling us how, having suffered from the complaint in question, he had, by the advice of a friend, procured these two horse-chestnuts on a certain time a year or more ago, and carried them about him ever since; from which very day he had been entirely free from rheumatism.

This argument, from what looks like cause and effect, whether it be so or not, is what you will have to meet wherever you go, and you need not think you can answer it. In the natural course of things some thousands of persons must be getting well or better of slight attacks of colds, of rheumatic pains, every week, in this city alone. Hundreds of them do something or other in the way of remedy, by medical or other advice, or of their own motion, and the last thing they do gets the credit of the recovery. Think what a crop of remedies this must furnish, if it were all harvested!

Experience has taught, or will teach you, that most of the wonderful stories patients and others tell of sudden and signal cures are like Owen Glendower's story of the portents that announced his birth. The earth shook at your nativity, did it? Very likely, and

"So it would have done,
At the same season, if your mother's cat
Had kittened, though yourself had ne'er been born."

You must listen more meekly than Hotspur did to the babbling Welshman, for ignorance is a solemn and sacred fact, and, like infancy, which it resembles, should be respected. Once in a while you will have a patient of sense, born with the gift of observation, from whom you may learn something. When you find yourself in the presence of one who is fertile of medical opinions, and affluent in stories of marvellous cures,--of a member of Congress whose name figures in certificates to the value of patent medicines, of a voluble dame who discourses on the miracles she has wrought or seen wrought with the little jokers of the sugar-of-milk globule-box, take out your watch and count the pulse; also note the time of day, and charge the price of a visit for every extra fifteen, or, if you are not very busy, every twenty minutes. In this way you will turn what seems a serious dispensation into a double blessing, for this class of patients loves dearly to talk, and it does them a deal of good, and you feel as if you had earned your money by the dose you have taken, quite as honestly as by any dose you may have ordered.

You must take the community just as it is, and make the best of it. You wish to obtain its confidence; there is a short rule for doing this which you will find useful,--deserve it. But, to deserve it in full measure, you must unite many excellences, natural and acquired.

As the basis of all the rest, you must have all those traits of character which fit you to enter into the most intimate and confidential relations with the families of which you are the privileged friend and counsellor. Medical Christianity, if I may use such a term, is of very early date. By the oath of Hippocrates, the practitioner of ancient times bound himself to enter his patient's house with the sole purpose of doing him good, and so to conduct himself as to avoid the very appearance of evil. Let the physician of to-day begin by coming up to this standard, and add to it all the more recently discovered virtues and graces.

A certain amount of natural ability is requisite to make you a good physician, but by no means that disproportionate development of some special faculty which goes by the name of genius. A just balance of the mental powers is a great deal more likely to be useful than any single talent, even were it the power of observation; in excess. For a mere observer is liable to be too fond of facts for their own sake, so that, if he told the real truth, he would confess that he takes more pleasure in a post-mortem examination which shows him what was the matter with a patient, than in a case which insists on getting well and leaving him in the dark as to its nature. Far more likely to interfere with the sound practical balance of the mind is that speculative, theoretical tendency which has made so many men noted in their day, whose fame has passed away with their dissolving theories. Read Dr. Bartlett's comparison of the famous Benjamin Rush with his modest fellow-townsman Dr. William Currie, and see the dangers into which a passion for grandiose generalizations betrayed a man of many admirable qualities.

I warn you against all ambitious aspirations outside of your profession. Medicine is the most difficult of sciences and the most laborious of arts. It will task all your powers of body and mind if you are faithful to it. Do not dabble in the muddy sewer of politics, nor linger by the enchanted streams of literature, nor dig in far-off fields for the hidden waters of alien sciences. The great practitioners are generally those who concentrate all their powers on their business. If there are here and there brilliant exceptions, it is only in virtue of extraordinary gifts, and industry to which very few are equal.

To get business a man mast really want it; and do you suppose that when you are in the middle of a heated caucus, or half-way through a delicate analysis, or in the spasm of an unfinished ode, your eyes rolling in the fine frenzy of poetical composition, you want to be called to a teething infant, or an ancient person groaning under the griefs of a lumbago? I think I have known more than one young man whose doctor's sign proclaimed his readiness to serve mankind in that capacity, but who hated the sound of a patient's knock, and as he sat with his book or his microscope, felt exactly as the old party expressed himself in my friend Mr. Brownell's poem--

"All I axes is, let me alone."

The community soon finds out whether you are in earnest, and really mean business, or whether you are one of those diplomaed dilettanti who like the amusement of quasi medical studies, but have no idea of wasting their precious time in putting their knowledge in practice for the benefit of their suffering fellow-creatures.

The public is a very incompetent judge of your skill and knowledge, but it gives its confidence most readily to those who stand well with their professional brethren, whom they call upon when they themselves or their families are sick, whom they choose to honorable offices, whose writings and teachings they hold in esteem. A man may be much valued by the profession and yet have defects which prevent his becoming a favorite practitioner, but no popularity can be depended upon as permanent which is not sanctioned by the judgment of professional experts, and with these you will always stand on your substantial merits.

What shall I say of the personal habits you must form if you wish for success? Temperance is first upon the list. Intemperance in a physician partakes of the guilt of homicide, for the muddled brain may easily make a fatal blunder in a prescription and the unsteady hand transfix an artery in an operation. Tippling doctors have been too common in the history of medicine. Paracelsus was a sot, Radcliffe was much too fond of his glass, and Dr. James Hurlbut of Wethersfield, Connecticut, a famous man in his time, used to drink a square bottle of rum a day, with a corresponding allowance of opium to help steady his nerves. We commonly speak of a man as being the worse for liquor, but I was asking an Irish laborer one day about his doctor, who, as he said, was somewhat given to drink. "I like him best when he's a little that way," he said; "then I can spake to him." I pitied the poor patient who could not venture to allude to his colic or his pleurisy until his physician was tipsy.

There are personal habits of less gravity than the one I have mentioned which it is well to guard against, or, if they are formed, to relinquish. A man who may be called at a moment's warning into the fragrant boudoir of suffering loveliness should not unsweeten its atmosphere with reminiscences of extinguished meerschaums. He should remember that the sick are sensitive and fastidious, that they love the sweet odors and the pure tints of flowers, and if his presence is not like the breath of the rose, if his hands are not like the leaf of the lily, his visit may be unwelcome, and if he looks behind him he may see a window thrown open after he has left the sick-chamber. I remember too well the old doctor who sometimes came to help me through those inward griefs to which childhood is liable. "Far off his coming "--shall I say "shone," and finish the Miltonic phrase, or leave the verb to the happy conjectures of my audience? Before him came a soul-subduing whiff of ipecacuanha, and after him lingered a shuddering consciousness of rhubarb. He had lived so much among his medicaments that he had at last become himself a drug, and to have him pass through a sick-chamber was a stronger dose than a conscientious disciple of Hahnemann would think it safe to administer.

Need I remind you of the importance of punctuality in your engagements, and of the worry and distress to patients and their friends which the want of it occasions? One of my old teachers always carried two watches, to make quite sure of being exact, and not only kept his appointments with the regularity of a chronometer, but took great pains to be at his patient's house at the time when he had reason to believe he was expected, even if no express appointment was made. It is a good rule; if you call too early, my lady's hair may not be so smooth as could be wished, and, if you keep her waiting too long, her hair may be smooth, but her temper otherwise.

You will remember, of course, always to get the weather-gage of your patient. I mean, to place him so that the light falls on his face and not on yours. It is a kind of, ocular duel that is about to take place between you; you are going to look through his features into his pulmonary and hepatic and other internal machinery, and he is going to look into yours quite as sharply to see what you think about his probabilities for time or eternity.

No matter how hard he stares at your countenance, he should never be able to read his fate in it. It should be cheerful as long as there is hope, and serene in its gravity when nothing is left but resignation. The face of a physician, like that of a diplomatist, should be impenetrable. Nature is a benevolent old hypocrite; she cheats the sick and the dying with illusions better than any anodynes. If there are cogent reasons why a patient should be undeceived, do it deliberately and advisedly, but do not betray your apprehensions through your tell-tale features.

We had a physician in our city whose smile was commonly reckoned as being worth five thousand dollars a year to him, in the days, too, of moderate incomes. You cannot put on such a smile as that any more than you can get sunshine without sun; there was a tranquil and kindly nature under it that irradiated the pleasant face it made one happier to meet on his daily rounds. But you can cultivate the disposition, and it will work its way through to the surface, nay, more,--you can try to wear a quiet and encouraging look, and it will react on your disposition and make you like what you seem to be, or at least bring you nearer to its own likeness.

Your patient has no more right to all the truth you know than he has to all the medicine in your saddlebags, if you carry that kind of cartridge-box for the ammunition that slays disease. He should get only just so much as is good for him. I have seen a physician examining a patient's chest stop all at once, as he brought out a particular sound with a tap on the collarbone, in the attitude of a pointer who has just come on the scent or sight of a woodcock. You remember the Spartan boy, who, with unmoved countenance, hid the fox that was tearing his vitals beneath his mantle. What he could do in his own suffering you must learn to do for others on whose vital organs disease has fastened its devouring teeth. It is a terrible thing to take away hope, even earthly hope, from a fellow-creature. Be very careful what names you let fall before your patient. He knows what it means when you tell him he has tubercles or Bright's disease, and, if he hears the word carcinoma, he will certainly look it out in a medical dictionary, if he does not interpret its dread significance on the instant. Tell him he has asthmatic symptoms, or a tendency to the gouty diathesis, and he will at once think of all the asthmatic and gouty old patriarchs he has ever heard of, and be comforted. You need not be so cautious in speaking of the health of rich and remote relatives, if he is in the line of succession.

Some shrewd old doctors have a few phrases always on hand for patients that will insist on knowing the pathology of their complaints without the slightest capacity of understanding the scientific explanation. I have known the term "spinal irritation" serve well on such occasions, but I think nothing on the whole has covered so much ground, and meant so little, and given such profound satisfaction to all parties, as the magnificent phrase "congestion of the portal system."

Once more, let me recommend you, as far as possible, to keep your doubts to yourself, and give the patient the benefit of your decision. Firmness, gentle firmness, is absolutely necessary in this and certain other relations. Mr. Rarey with Cruiser, Richard with Lady Ann, Pinel with his crazy people, show what steady nerves can do with the most intractable of animals, the most irresistible of despots, and the most unmanageable of invalids.

If you cannot acquire and keep the confidence of your patient, it is time for you to give place to some other practitioner who can. If you are wise and diligent, you can establish relations with the best of them which they will find it very hard to break. But, if they wish to employ another person, who, as they think, knows more than you do, do not take it as a personal wrong. A patient believes another man can save his life, can restore him to health, which, as he thinks, you have not the skill to do. No matter whether the patient is right or wrong, it is a great impertinence to think you have any property in him. Your estimate of your own ability is not the question, it is what the patient thinks of it. All your wisdom is to him like the lady's virtue in Raleigh's song:

"If she seem not chaste to me,
What care I how chaste she be?"

What I call a good patient is one who, having found a good physician, sticks to him till he dies. But there are many very good people who are not what I call good patients. I was once requested to call on a lady suffering from nervous and other symptoms. It came out in the preliminary conversational skirmish, half medical, half social, that I was the twenty-sixth member of the faculty into whose arms, professionally speaking, she had successively thrown herself. Not being a believer in such a rapid rotation of scientific crops, I gently deposited the burden, commending it to the care of number twenty-seven, and, him, whoever he might be, to the care of Heaven.

If there happened to be among my audience any person who wished to know on what principles the patient should choose his physician, I should give him these few precepts to think over:

Choose a man who is personally agreeable, for a daily visit from an intelligent, amiable, pleasant, sympathetic person will cost you no more than one from a sloven or a boor, and his presence will do more for you than any prescription the other will order.

Let him be a man of recognized good sense in other matters, and the chance is that he will be sensible as a practitioner.

Let him be a man who stands well with his professional brethren, whom they approve as honest, able, courteous.

Let him be one whose patients are willing to die in his hands, not one whom they go to for trifles, and leave as soon as they are in danger, and who can say, therefore, that he never loses a patient.

Do not leave the ranks of what is called the regular profession, unless you wish to go farther and fare worse, for you may be assured that its members recognize no principle which hinders their accepting any remedial agent proved to be useful, no matter from what quarter it comes. The difficulty is that the stragglers, organized under fantastic names in pretentious associations, or lurking in solitary dens behind doors left ajar, make no real contributions to the art of healing. When they bring forward a remedial agent like chloral, like the bromide of potassium, like ether, used as an anesthetic, they will find no difficulty in procuring its recognition.

Some of you will probably be more or less troubled by the pretensions of that parody of mediaeval theology which finds its dogma of hereditary depravity in the doctrine of psora, its miracle of transubstantiation in the mystery of its triturations and dilutions, its church in the people who have mistaken their century, and its priests in those who have mistaken their calling. You can do little with persons who are disposed to accept these curious medical superstitions. The saturation-point of individual minds with reference to evidence, and especially medical evidence, differs, and must always continue to differ, very widely. There are those whose minds are satisfied with the decillionth dilution of a scientific proof. No wonder they believe in the efficacy of a similar attenuation of bryony or pulsatilla. You have no fulcrum you can rest upon to lift an error out of such minds as these, often highly endowed with knowledge and talent, sometimes with genius, but commonly richer in the imaginative than the observing and reasoning faculties.

Let me return once more to the young graduate. Your relations to your professional brethren may be a source of lifelong happiness and growth in knowledge and character, or they may make you wretched and end by leaving you isolated from those who should be your friends and counsellors. The life of a physician becomes ignoble when he suffers himself to feed on petty jealousies and sours his temper in perpetual quarrels. You will be liable to meet an uncomfortable man here and there in the profession,--one who is so fond of being in hot water that it is a wonder all the albumen in his body is not coagulated. There are common barrators among doctors as there are among lawyers,--stirrers up of strife under one pretext and another, but in reality because they like it. They are their own worst enemies, and do themselves a mischief each time they assail their neighbors. In my student days I remember a good deal of this Donnybrook-Fair style of quarrelling, more especially in Paris, where some of the noted surgeons were always at loggerheads, and in one of our lively Western cities. Soon after I had set up an office, I had a trifling experience which may serve to point a moral in this direction. I had placed a lamp behind the glass in the entry to indicate to the passer-by where relief from all curable infirmities was to be sought and found. Its brilliancy attracted the attention of a devious youth, who dashed his fist through the glass and upset my modest luminary. All he got by his vivacious assault was that he left portions of integument from his knuckles upon the glass, had a lame hand, was very easily identified, and had to pay the glazier's bill. The moral is that, if the brilliancy of another's reputation excites your belligerent instincts, it is not worth your while to strike at it, without calculating which of you is likely to suffer most, if you do.

You may be assured that when an ill-conditioned neighbor is always complaining of a bad taste in his mouth and an evil atmosphere about him, there is something wrong about his own secretions. In such cases there is an alterative regimen of remarkable efficacy: it is a starvation-diet of letting alone. The great majority of the profession are peacefully inclined. Their pursuits are eminently humanizing, and they look with disgust on the personalities which intrude themselves into the placid domain of an art whose province it is to heal and not to wound.

The intercourse of teacher and student in a large school is necessarily limited, but it should be, and, so far as my experience goes, it is, eminently cordial and kindly. You will leave with regret, and hold in tender remembrance, those who have taken you by the hand at your entrance on your chosen path, and led you patiently and faithfully, until the great gates at its end have swung upon their hinges, and the world lies open before you. That venerable oath to which I have before referred bound the student to regard his instructor in the light of a parent, to treat his children like brothers, to succor him in his day of need. I trust the spirit of the oath of Hippocrates is not dead in the hearts of the students of to-day. They will remember with gratitude every earnest effort, every encouraging word, which has helped them in their difficult and laborious career of study. The names they read on their diplomas will recall faces that are like family-portraits in their memory, and the echo of voices they have listened to so long will linger in their memories far into the still evening of their lives.

One voice will be heard no more which has been familiar to many among you. It is not for me, a stranger to these scenes, to speak his eulogy. I have no right to sadden this hour by dwelling on the deep regrets of friendship, or to bid the bitter tears of sorrow flow afresh. Yet I cannot help remembering what a void the death of such a practitioner as your late instructor must leave in the wide circle of those who leaned upon his counsel and assistance in their hour of need, in a community where he was so widely known and esteemed, in a school where he bore so important a part. There is no exemption from the common doom for him who holds the shield to protect others. The student is called from his bench, the professor from his chair, the practitioner in his busiest period hears a knock more peremptory than any patient's midnight summons, and goes on that unreturning visit which admits of no excuse, and suffers no delay. The call of such a man away from us is the bereavement of a great family. Nor can we help regretting the loss for him of a bright and cheerful earthly future; for the old age of a physician is one of the happiest periods of his life. He is loved and cherished for what he has been, and even in the decline of his faculties there are occasions when his experience is still appealed to, and his trembling hands are looked to with renewing hope and trust, as being yet able to stay the arm of the destroyer.

But if there is so much left for age, how beautiful, how inspiring is the hope of youth! I see among those whom I count as listeners one by whose side I have sat as a fellow-teacher, and by whose instructions I have felt myself not too old to profit. As we borrowed him from your city, I must take this opportunity of telling you that his zeal, intelligence, and admirable faculty as an instructor were heartily and universally recognized among us. We return him, as we trust, uninjured, to the fellow-citizens who have the privilege of claiming him as their own.

And now, gentlemen of the graduating class, nothing remains but for me to bid you, in the name of those for whom I am commissioned and privileged to speak, farewell as students, and welcome as practitioners. I pronounce the two benedictions in the same breath, as the late king's demise and the new king's accession are proclaimed by the same voice at the same moment. You would hardly excuse me if I stooped to any meaner dialect than the classical and familiar language of your prescriptions, the same in which your title to the name of physician is, if, like our own institution, you follow the ancient usage, engraved upon your diplomas.

Valete, JUVENES, artis medicae studiosi; valete, discipuli, valete, filii!

Salvete, VIRI, artis medicae magister; Salvete amici; salvete fratres! _

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