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OSLER LIBRAaV, 
 
 IdCGILL UNIVERSITY. 
 
 lilONTftEAL, Canada 
 
 ?'>^ 
 
 INTERNAL MEDICINE AS 
 A VOCATION 
 
INTERNAL MEDICINE AS 
 A VOCATION 
 
 AN ADDRESS 
 
 .« r,.KERAL MEDICINE AT THE NeW YoRK 
 3_E - --;;:;rr: OCTOBER 1..H. 18. 
 
 BY 
 
 WILLIAM OSLER, M. D. 
 
 ,. ■ • *;., Tnhna Hcypkim University 
 Professor of Medinne m the Johns n<yp 
 
 BBPBINTED FROM 
 
 THE MEDICAL NEWS 
 
 NKW YOBK. NOVBMBKB 20TH, 1897 
 
 h-<.]l 
 
 coO 
 
 ^^ 
 
 rwflW!«»***fc'**^"*'^ 
 
JOHN MUBPHY & CO., PRINTERS, 
 BALTIMORE. 
 
ADDRESS. 
 
 IT was with the greatest pleasure that I accepted an invi- 
 * tation to say a few words before this section of the 
 Academy on the importance of internal medicine as a voca- 
 tion, I wish there were another term to designate the wide 
 field of medical practice which remains after the separation 
 of surgery, midwifery, and gynecology. In itself it is not 
 a specialty, but embraces at least half a dozen, and so its 
 cultivators cannot be called specialists, but bear without 
 reproach the good old name physician, in contradistinction 
 to general practitioners, surgeons, obstetricians, and gyne- 
 cologists. I have heard the fear expressed that in this 
 country the sphere of the physician proper is becoming more 
 and more restricted, and perhaps this is true; but I maintain 
 (and I hope to convince you) that the opportunities are still 
 great, and that the harvest is truly plenteous, while the 
 laborers, though not few, are scarcely sufficient to meet the 
 demand. 
 
 At the outset I would like to emphasize the fact that 
 the student of internal medicine cannot be a specialist. The 
 manifestations of almost any one of the important diseases 
 in the course of a few years will " box the compass" of the 
 specialties. Typhoid fever, for example, will not only go 
 the rounds of those embraced in medicine proper, but will 
 carry its student far afield in morbid psychology, and some- 
 times teach him, perhaps at the cost of the patient, a little 
 surgery. So, too, with syphilis, which after the first few 
 
 3 
 
 
Internal Medicine as a Vocation. 
 
 weeks I claim us a medical affection. I often tell my 
 students that it is the oidy disease which they require to 
 study thoroughly. Know syphilis in all its manifestations 
 and relations, and what remains to be learned will not stretch 
 the ])ia mater of a mogalocephalic senior student. 
 
 Ea(;h generation has to grow its own consultants, Hos- 
 sack, Samuel Mitchell, Swett, Alonzo Clark, Austin Flint, 
 Fordyce Barker, and Alfred Loom is, served their day in 
 this city, and then passed on into silence. Their works 
 remain ; but enough of a great physician's experience dies 
 with him to justify the saying " there is no wisdom in the 
 grave." The author of " Rab and His Friends " has a 
 couple of i)aragraphs on this point which are worth quoting : 
 "Much that made such a man what the community, to their 
 highest |)rofit, found him to be, dies with him. His inborn 
 gifts, and much of what was most valuable in his experience, 
 were necessarily incommunicable to others ; this depending 
 much on his forgetting the process by which, in particular 
 cases, he made uj) his mind, and its minute successive 
 steps . . . , but mainly, we believe, because no man can 
 explain directly to another man hoio he does any one prac- 
 tical thing, the doing of which he himself has accomplished 
 not at once or by imitation, or by teaching, but by repeated 
 personal trials, by missing much before ultimately hitting." 
 
 Wherewithal shall a young man prepare himself, should 
 the ambition arise in him to follow in the footsteps of such 
 a teacher as, let us say, the late Austin Flint — the young 
 man just starting, and who will from 1915 to 1940 stand 
 in relation to the profession of this city and this country 
 as did Dr. Flint between 1861 and the time of his death. 
 We will assume that he starts with equivalent advantages, 
 though this is taking a great deal for granted, since Austin 
 Flint had a strong hereditary bias toward medicine, and 
 early in life fell under the influence of remarkable men 
 whose teachings moldetl his thought to the very end. We 
 must not forget that Dr. Flint was a New Englander, and 
 
Internal Medicine an a VociiHon. 
 
 of the same type of mind as his great teachers — Jatues 
 Jackson and Jacob Bigelow. 
 
 Our future consultant has just left the hospital, where, 
 for the first time rcalizinj^ the possibilities of his profession, 
 he has had his ambition fired. Shall he j;o abroad? It is 
 not necessary. The man whom we have (iliosen as his 
 exemplar did not, but fbimd his opportunities in country 
 practice, and in Buifalo and liouisville, then frontier towns, 
 and had a national reputation before he reached New York. 
 But would it be useful to him? Undoubtedly. He will 
 have a broader foundation on which to build, and a year 
 or two in the laboratories and clinics of the great European 
 cities will be most helpful. To walk the wards of Guy's 
 or St. Bartholomew's, to see the work at the St. Louis and 
 at the Salp6tri6re, to have put in a few (piiet months of 
 study at one of the German university towns will store the 
 young man's mind with priceless treasures. I assume that 
 he has a mind. I am not heedless of the truth of Shake- 
 speare's sharp taunt, 
 
 How much the fool that hath been sent to Rome, 
 Exceeds the fool that hath been kept at home. 
 
 At any rate, whether he goes abroad or not, let him early 
 escape from the besetting sin of the young physician. 
 Chauvinism^ that intolerant attitude of mind which brooks 
 no regard for anything outside his own circle and his own 
 school. If he cannot go abroad let him spend part of his 
 short vacations in seeing how it fares with the brethren in 
 his own country. Even a New Yorker could learn some- 
 thing in the Massachusetts General and the Boston City 
 Hospitals. A trip to Philadelphia would be most helpful ; 
 there is much to stimulate the mind at the old Pennsylvania 
 Hospital and at the University, and he would be none the 
 worse for a few weeks spent still farther south on the banks 
 of the Chesapeake. The all-important matter is to get breadth 
 of view as early as possible, and this is difficult without travel. 
 
6 
 
 Internal Medicine as a Vocation, 
 
 I'oll the Huowasfiil cotisniting pliysiciuns of this country 
 to-day, and you will find they have been evolved either 
 from j^eneral practice or from laboratory and clinical work ; 
 many of the most prominent having risen from the ranks of 
 general prac^titioner.s. ! once hoard an eminent consultant 
 rise in wrath because some one had made a remark rcHecting 
 upon this class. He declared that no single part of his 
 professional experience had l)een of such value. But I wish 
 to speak here of the training of men who start with the 
 object of becoming pure physicians. From the vantage 
 ground of more than forty years of hard work, Sir Andrew 
 Clark told me that he had striven ten years for bread, ten 
 years for bread and butter, and twenty years for cakes and 
 ale; and this is really a very good partition of the life of 
 the student of internal medicine, of some at least, since all 
 do not reach the last stage. 
 
 It is high time we had our young Lydgate started.' If 
 he has shown any signs of nous during his student and 
 hospital days a dispensary assistantship should be available ; 
 anything should be acceptable which brings him into con- 
 tact with patients. By all means, if possible, let him be 
 a pluralist, and — as he values his future life — let him not 
 get early entangled in the meshes of specialism. Once 
 established as a clinical assistant he can begin his education, 
 and nowadays this is a very cora})licated matter. There are 
 three lines of work which he may follow, all of the most 
 intense interest, all of the greatest value to him — chemistry, 
 physiology, and morbid anatomy. Professional chemists 
 look askance at physiological chemistry, and physiological 
 chemists criticize pretty sharply the work of some clinical 
 chemists, but there can be no doubt of the value to the 
 physician of a very thorough training in methods and ways 
 
 •This well-drawn character in George Eliot's " Middlemarch " may be 
 studied with advantage by the physician ; one of the most important 
 lessons to be gathered from it is — marry the right woman I 
 
Inieiiial Medicine as a Vocation. 
 
 of organic (ilieraiHtry. We sorely want, in this country, 
 men of this line cf training, and the outlook for them has 
 never before been so bright. If at the start he has not 
 had a good chemical training, the other lines should be 
 more closely followed. 
 
 Physiology, which for him will mean very largely experi- 
 mental therapeutics and experimental pathology, will open 
 a wider view and render possible a deeper grasp of the 
 problems of disease. To Traube and men of his stamp, the 
 physiological clinicians, this generation owes much more than 
 to the chemical or poat-morteni-voom group. The training 
 is more difficult to get, and nowadays when physiology is 
 cultivated as a specialty few physicians will graduate into 
 clinical medicine directly from the laboratory. On the other 
 hand, the opportunities for work are now more numerous, 
 and the training which a young fellow gets in a laboratory 
 controlled by a pure physiologist will help to give that scien- 
 tific impress, which is only enduring when early received. 
 A thorough chemical training and a complete equipment in 
 methods of experimental research are less often met with 
 in the clinical physician than a good practical knowledge 
 of morbid anatomy ; and, if our prospective consultant has 
 to limit his work, chemistry and physiology should yield to 
 the claims of the dead-house. In this dry-bread period he 
 should see autopsies daily, if possible. Successful knowledge 
 of the infinite variations of disease can only be obtained by 
 a prolonged study of morbid anatomy. Of special value in 
 training the physician in diagnosis, it also enables him to 
 correct his mistakes, and, if he reads its lessons aright, it 
 may serve to keep him humble. 
 
 This is, of course, a very full programme, but in ten years 
 a bright man with what Sydenham calls "the ancient and 
 serious diligence of Hippocrates " will pick up a very fair 
 education, and will be fit to pass from the dispensary to 
 the wards. If he cannot go abroad after his hospital term, 
 let it be an incentive to save money, and with the first 
 
8 
 
 Internal Medidne as a Vocation. 
 
 1600 let him take a summer semester in Germany, working 
 quietly at one of the smaller places. Another year spend 
 three months or longer in Paris. Lay schemes in advance, 
 and it is surprising how often the circumstances fit in with 
 them. How shall he live meanwhile? On crumbs— on 
 pickings obtained from men in the cakes-and-ale stage (who 
 always can put paying work into the hands of young men), 
 and on fees from classes, journal work, private instruction, 
 and from work in the schools. Any sort of medical ])ractice 
 should be taken, but with caution — too much of it early may 
 prove a good man's ruin. He cannot expect to do more 
 than just eke out a living. He must put his emotions on 
 ice : there must be no " Amaryllis in the shade," and he 
 must beware the tangles of " Nesera's hair." Success during 
 the firsi: ten years means endurance and perseverance ; all 
 things come to him who has learned to labor and wait, who 
 hides his time " ohne hast, aber ohne rast," whose talent 
 develops "in der Stille," in the quiet fruitful years of 
 urselfish devoted work. A few words in addition about this 
 ury-bvpad decade. He should stick closely to the dispen- 
 saries. A first-class reputation may be built up in them. 
 Bryom Pramwell's "Atlas of Medicine" largely represents 
 his work while an assistant physician to the Royal Infirm- 
 a'-y, Edinburgh. Many of the best-known men in London 
 serve ten, fifteen, or even twenty years in the out-patient 
 departments before getting Vv-ards. Lauder Bruuton has only 
 recently obtained his full physicianship at St. Bartholomew's 
 after a service of more than twenty years in the out-patient 
 department. During this period let him not lose the sub- 
 stance of ultimate success in grasping at the shadow of 
 prfccJf at oppi. rtunity. Time is now his money, and he must 
 not barter a\/ay too much of it in profitless work — profitless 
 so far as his education is conr^erned, though it may mean 
 ready cash. Too many quiz classes or too much journal work 
 has ruined many a promising clinical physician. While the 
 Pythagorean silence of neaily seven years, which the great 
 
 •' . % 
 
Internal Medicine as a Vocation. 
 
 Louis followed (and broke to hurst into a full-blown repu- 
 tation) cannot be enjoined, the young physician should be 
 careful what and how he writes. Let him take heed to his 
 education, and hi? reputation will take care of itself, and in 
 a development under the guidance of seniors he will find 
 plenty of material ^or papers before medical societies and 
 for publication in scientific journals. 
 
 I would like to add here a few words on the question of 
 clinical instruction, as with the great prospective increase of 
 it in our schools there will be many chances of employment 
 for young physicians who wish to follow medicine proper 
 as a vocation. To-day this serious problem confronts the 
 professors in many of our schools — how to teach practical 
 medicine to the large classes; how to give them protracted 
 and systematic ward instruction? I know of no teacher in 
 the country who controls enough clinical material for the 
 instruction of classes of say 200 men during the third and 
 fourth years. It seems to me there are two plans open to 
 the schools : The first is to utilize dispensaries for clinical 
 instruction much more than is at present the rule. For this 
 purpose a teaching-room for a class of twenty-five or thirty 
 students immediately adjoining the dispensary is essential. 
 For instruction in physical diagnosis, for the objective teach- 
 ing of disease, and for the instruction of students in the use 
 of their senses, such an arrangement is invaluable. There 
 are hundreds of dispensaries in which this plan is feasible, 
 and in which the material now is not properly worked up 
 because of the lack of this very stimulus. In the second 
 place, I feel sure that ultimately, we shall develop a system 
 of extra-mural teaching similar to that which has been so 
 success 1 in Edinburgh ; and this will give employment to 
 a large number of the younger men. At any large university 
 school of r juicine there might be four or five extra-mural 
 teachers of medicine, selected from men who could show 
 that they were fully qualified to teach, and that they had 
 a sufficient number of beds at their command, with proper 
 
10 
 
 Internal Medicine as a Vocation. 
 
 equipment for clinical work. At Edinburgh there are eight 
 extra-mural teachers of medicine whose courses qualify the 
 student to present himself for examination either before the 
 Royal Colleges or the University. If we ever are to give 
 our third and fourth year students protracted and complete 
 courses in physical diagnosis and clinical medicine, extending 
 throughout the session, and not in classes of a brief period of 
 six weeks' duration, I am confident that the number of men 
 engaged in teaching must be greatly increased. 
 
 Ten years' hard work tells with colleagues and friends 
 in the profession, and with enlarged clinical facilities the 
 physician enters upon the second, or bread-and-butter period. 
 This, to most men, is the great trial, since the risks are 
 greater, and many now drop out of the race, wearied at the 
 length of the way and drift into specialism or general prac- 
 tice. The physician develops more slowly than the surgeon, 
 and success comes later. There are surgeons at forty years 
 in full practice and at the very top of the wave, a time at 
 which the physician is only preparing to reap the harvest 
 of years of patient toil. The surgeon must have hands, and 
 better, young hands. He should have a head, too, but this 
 does not seem so essential to success, and he cannot have an 
 old head with young hands. At the end of twenty years, 
 when about forty-five, our Lydgate should have a first-class 
 reputation in the profession, and a large circle of friends and 
 students. He will probably have precious little capital in 
 the bank, but a very large accumulation of interest-bearing 
 funds in his brain-pan. He has gathered a stock of special 
 knowledge which his friends in the profession appreciate, 
 and they begin to seek his counsel in doubtful cases, and 
 gradually le;u-n to lean upon hira in times of trial. He 
 may awake some day, perhaps, quite suddenly, to find that 
 twenty years of quiet work, done for the love of it, has a 
 very solid value. 
 
 The environment of a large city is not necessary to the 
 growth of a good clinical physician. Even in small towns 
 
Internal Medicine as a Vocation. 
 
 11 
 
 m 
 
 a man can, if he has it in him, become well versed in 
 methods of work, and with the assistance of an occasional 
 visit to some medical centre he can become an expert diag- 
 nostician and reach a position of dignity and worth in the 
 community in which he lives. I wish to plead particularly 
 for the wasted opportunities in the smaller hospitals of oui- 
 large cities, and in those of more moderate size. There are 
 in this State a score or more of hospitals with from thirty 
 to fifty medical beds, offering splendid material for good men 
 on which to build reputations. Take, for example, the town 
 of Thelma, which I know well, to which young Rondibilis 
 a recent resident at the Hotel Dieu, has just gone. He wrote 
 asking me for a letter of advice, from which I take the 
 liberty of extracting one or two paragraphs : 
 
 "Your training warrants a high aim. Say to those who 
 ask, that you intend to practice medicine only, and will not 
 take surgical or midwifery cases. X. has promised that you 
 may help in the disjiensary, and as you can count blood and 
 percuss a chest you will be useful to him in the wards, 
 which, by the way, he now rarely visits. Be careful with' 
 the house physicians, and if you teach them anything do it 
 gently, and never crow when you are right. The crow of 
 the young rooster before his spurs are on always jars and 
 antagonizes. Get your own little clinical laboratory in order. 
 Old Dr. Rolando will be sure to visit you, and bear with 
 him as he tells you how he can tell casts from the ascending 
 limb of the loop of Henle. He was once as you are now, 
 a modern, but he crawled up the bank twenty years ago • 
 the stream has left him there, but he does not know it! 
 He means to impress you ; be civil and show him the new 
 Nissl-stain preparations, and you will have him as a warm 
 friend. His good heart has kept him with a large general 
 practice, and he can throw post-mortevis in your way, and 
 may send for you to sit up with his rich patients. If Y. 
 asks you to help in the teaching, jump at the chance. The 
 school is not what you might wish, but the men are in 
 
12 
 
 Internal Medicine as a Vocation. 
 
 earnest, and a clinical microscopy-class or a voluntary ward- 
 class, with Y's. cases, will put you on the first rung of the 
 ladder. Yes, join both the city and the county society, and 
 never miss a meeting. Keep your mouth shut, too, for a 
 few years, particularly in discussions. 
 
 " Foote's (Philadelphia) is the catalogue to which I 
 referred. Let the old men read new books ; you read the 
 journals and the old books. Study Laennec this winter; 
 Forbes' * Translation ' can be cheaply obtained, but it will 
 help to keep up your French to read it in the original. 
 The old Sydenham Society editions of the Greek writers and 
 of Sydenham are easily got and are really very helpful. As 
 a teacher you can never get orientirt without a knowledge 
 of the Fathers, ancient and modern. And do not forget, 
 above all things, the famous advice to Backraore, to whom, 
 when he first began the study of physic, and asked what 
 books he should read, Sydenham replied, ' Don Quixote,* 
 meaning thereby, as I take it, that the only book of physic 
 suitable for permanent reading is the book of Nature." 
 
 A young fellow with staying powers who avoids entangle- 
 ments, may look forward in twenty years to a good consulta- 
 tion practice in any town of 40,000 to 50,000 inhabitants. 
 Some such man, perhaps, in a town far distant, taking care 
 of his education, and not of his bank book, may be the Austin 
 Flint of New York in 1930. 
 
 '' Many are called, but few are chosen," and of the many 
 who start out with high aims, few see the goal. Even when 
 reached the final period of "cakes and ale" has serious 
 drawbacks. There are two groups of consultants, the intra- 
 and the extra-professional ; the one gets work through his 
 colleagues, the other, having outgrown the narrow limits of 
 professional reputation, is at the mercy of the profanum 
 vulgus. Then for him "farewell the tranquil mind, fare- 
 well content." His life becomes an incessant struggle, and 
 between the attempt to carry on an exhausting and irk- 
 some practice, and to keep abreast with young fellows still 
 
Internal Medicine as a Vocation. 
 
 13 
 
 ! 
 
 in the bread-and-butter stage, the consultant at this period 
 is worthy of our sincerest sympathy. 
 
 One thing raay save him. It was the wish of Walter 
 •Savage Landor always to walk with Epicurus on the right 
 hand and Epictetus on the left, and I would urge the clinical 
 physician, as he travels farther from the East, to look well 
 to his companions — to see that they are not of his own age 
 and generation. He must walk with the "boys," else he is 
 lost, irrevocably lost ; not all at once, but by easy grades, 
 and every one perceives his ruin before he, "good, easy man," 
 is aware of it. I would not have him a basil plant, to feed 
 on the brains of the bright young fellows who follow the 
 great wheel uphill, but to keep his mind receptive, plastic, 
 and impressionable he must travel with the men who are 
 doing the work of the world, the men between the ages of 
 twenty-five and forty. 
 
 In the life of every successful physician there comes the 
 temptation to toy with the Delilah of the press — daily and 
 otherwise. There are times when she may be courted with 
 satisfaction, but beware ! sooner or later she is sure to play 
 the harlot, and has left many a man shorn of his strength, 
 viz., the confidence of his professional brethren. Not alto- 
 gether with justice have some notable members of our pro- 
 fession labored under the accusation of pandering too much 
 to the public. When a man reaches the climacteric, and has 
 long passed beyond the professional stage of his reputation, 
 we who are still " in the ring " must exercise a good deal 
 of charity, and discount largely the on dits which indiscreet 
 friends circulate. It cannot be denied that in dealings with 
 the public just a little touch of humbug is immensely 
 effective, but it is not necessary. In a large city there were 
 three eminent consultants of world-wide reputation ; one was 
 said to be a good physician but no humbug, the second was no 
 physician but a great luimbug, the third was a great physician 
 and a great humbug. The first achieved the greatest success, 
 professional and socia,., possibly not financial. 
 
14 
 
 Internal Medicine as a Vocation. 
 
 While living laborious days, happy in his work, happy 
 in the growing recognition which he is receiving from his 
 colleagues, no shadow of doubt haunts the mind of the 
 young physician, other than the fear of failure ; but I warn 
 him to cherish the days of his freedom, the days when he 
 can follow his bent, untrammeled, undisturbed, and not as 
 yet in the coils of the octopus. In a play of Oscar Wilde's 
 one of the characters remarks, "there are only two great 
 tragedies in life, not getting what you want — and getting 
 it ! " and I have known consultants whose treadmill life 
 illustrated the bitterness of this mot, and whose great success 
 at sixty did not bring the comfort they had anticipated at 
 forty. The mournful echo of the words of the preacher 
 rings in their ears, words which I not long ago heard quoted 
 with deep feeling by a distinguished physician, " Better is 
 a handful with quietness than both hands full with travail 
 and vexation of spirit." 
 
 I