The Country Doctor — His Place in the Profession

Annual Oration 1876

By Pierre LeBreton Stickney, M.D.

Mr. President and Fellows of the Massachusetts Medical Society:—

It is upon such occasions as this, the Anniversary of our ancient Society, that the larger number of the profession here assemble from the smaller cities, the country towns, and the villages of the State, to revive the ties of fellowship and to enjoy the pleasures of an annual reunion. They come hither to strengthen old friendships and refresh old associations. They come hoping to have new and better thoughts awakened within them, so that reanimated by the inspirations of the day, they may return encouraged and sustained for the laborious routine of their ordinary professional life.

It may not be inappropriate, therefore, to wander a little from the ordinary track of philosophic or scientific discussion, and to offer you a few random thoughts on the life and habits of the so called “country doctor;” his needs and the place he occupies in the field of medical culture. I am the more inclined to this, since the majority, perhaps, of those who now listen to me are men occupying the out-posts—in the valleys, on the hilltops, or along the mountain ranges—men who are called upon to perform the varied and responsible duties of active citizenship, as well as to be ever diligent workers in their own special calling.

These men, comparatively isolated from their professional brethren, go through their yearly round of labor, day and night, over hill and valley, obliged to depend almost solely upon their own thoughts for companionship, and upon their books for counsel; contentedly working on, through a long life it may be, and rarely “known beyond their own country ride—sturdy, warm hearted, useful class of men, under whose rough coat and blunt exterior,” says Dr. John Brown of Edinburgh, “you find professional skill, enthusiasm, intelligence, humanity, courage and science.” Many of them are master workmen, “who need not to be ashamed,” learned in literary, medical, and even classic lore, and capable of ranking alongside of the leaders in our profession.

It is an old saying that success in the business of life depends mainly on our location—that its surroundings and influences impress us, and stamp the peculiarities of its prevailing characteristics upon our feelings, habits of thought, and modes of life. Every community also aggregates a similar power in its social, moral and mental forces, in the variety of its labor and employments—a power that is subtle, working silently, not easily analyzed, but which controls individual thought and action in no small degree.

Notwithstanding, however, the influence of location and of this social power, there is much to be affirmed of the man himself. Circumstances are not the sum of force of every thing, while the man is nothing; for we recognize under every condition of life, that the true, brave man will attempt to rise above and control its varying accidents, and to do worthily all that comes within the range of human possibilities. Conscious of this predetermined purpose, he regards all around him with a searching gaze, detects “all disguises and pretensions, looks straight into the heart of things, measures all by absolute standards,” and strives to live and act nobly in the environments and actualities of life, whatever they may be. This is true of every brave soul, but no better or truer examples can be found than among our country doctors, many of whom, guided by generous motives, and governed by fixed principles of right, devote themselves with active benevolence and rare fidelity to the practice of their art among the rural population in these secluded country villages.

The contrasts and differences between a country and a city practice lie principally in the sodality of the one and the isolation of the other. Each position, however, has its advantages and disadvantages; and in its own way fashions and developes those special influences which have so much to do in adapting the practitioner for his work.

In the city are found large opportunities for every kind of advancement. The social conditions, the literary associations, the public libraries, and other sources of improvement, furnish in cities a scope and variety of means which are not to be had elsewhere. So also the immediate opportunities of daily professional intercourse, out of which grow mutual reliance and assistance; the ready communication of newly-acquired knowledge and fresh experiences; and the benefits of professional observations possible only in the public charities of a city;—all these contribute greatly to the common advantage and success of medical men in populous places.

On the other hand, the “country doctor” has comparatively few such advantages; for while his practice embraces the whole range of medical and surgical service, his opportunities for outside aid and improvement are meagre and limited. His resources are his self-reliant skill and faculty, his native good sense and good judgment, and what there is in him of heroic worth and virtue. With no ready chance for mutual counsel, he stands alone; and he must of necessity be plucky, sharp of observation, cautious, yet with quick sense of apprehension. He must be capable of acting at once, of doing the right thing at the right time, and of doing it as perfectly as possible. A human life hangs in the balance, and with what of courage, insight and ability there is in him, he must wrestle alone with the danger. Circumstances and exigencies like these ripen his native qualities, and bring him occasions which test the temper of his mental fibre as well as his firmness and force of character.

Then again, this work, with all its demands and difficulties, comes under the immediate notice of every one. The country practitioner goes at once to the front, to be seen and known of all. His qualities as a man, his capability to perform successfully the duties of his calling, will be sharply criticized by all. The people among whom he dwells belong mostly to that great middle class which holds together the extremes of society; intelligent people, capable of forming correct judgments. Before such judges stands the “country doctor,” and there is no chance for hiding behind subterfuges, or for shirking responsibilities. No petty artifices will excuse blunders or stupidity; sharp eyes follow him every where, constantly observing, and discerning “what manner of man he is.”

Dr. Samuel Johnson, in his criticism on Dr. Akenside, the poet, says: “A physician in a great city seems to be the mere plaything of fortune, his degree of reputation is for the most part totally casual. They that employ him know not his excellence, they that reject him know not his deficiencies.” In the country the case is far different. There the analysis of character and ability is more complete; for there that distinction is less which comes from position and wealth; and every one, rich or poor, man or woman, counts at a full rate in the expression of opinions.

But an attractive feature of country practice grows out of the free yet respectful intercourse, which constitutes one of the main sources of pleasure and help of country life. Known by every one, if intelligent and educated, possessing a warm heart and generous sympathies, “the country doctor” gains respect, esteem and love. He in turn learns to know his people—even better than they know themselves. He knows them from birth; “knows what stock they are made of;” knows their constitution, their habits of life, their social and moral qualities, and their secrets too; and, “king of health in his own regions,” thus under stands full well how to manage their physical ills deftly and safely. To them he is the friend, the comforter and the adviser; and he becomes, what is growing rare in cities, the family doctor, in whom all confidences meet and rest, and in whom all hopes of human aid are centred in times of trial, sorrow and impending dissolution.

In every sense, too, he becomes a public man, and has a work outside his profession, and an influence to be exerted in all the various ways by which the interests of society may be advanced. In this way, also, a mutual esteem, full of tender sensibility and strong attachment, grows up between him and his fellow-citizens, which continues firm and lasting to the very end.

Living and trained amid such scenes and such varied duties, “the country doctor” gains “self-reliance, presence of mind, simplicity, readiness of resource and sagacity; and thus becomes an independent, self-contained man, capable, skillful and safe.”

A long list of examples conspicuous for these qualities could easily be gathered from among our country practitioners—men of vigorous intellects and solid attainments, of good practical sense, of fervid enthusiasm and of patient endurance. Foremost among these in our New-England history was Dr. Nathan Smith. He truly was a rare man. From almost abject poverty he carried himself by his own efforts through a course of medical study at home, and then abroad at Edinburgh. Returning, he settled in a country town among the hills of New-Hampshire, where he spent a few years in the arduous duties of a “country doctor;” and soon became a wise and skilful practitioner, especially in the department of surgery. He was a close, sagacious observer; ingenious, full of resources, and well-informed in the best and latest knowledge of his time. The whole tone and character of his mind was self-reliant and independent. Genial and generous hearted, earnest in acquiring knowledge from all sources, and possessing a large share of what is of more avail than genius, that rare common sense which controls the practical affairs of life, his knowledge was always at hand and ready to be applied in all emergencies. Removing to Hanover, he established the medical department of Dartmouth College. There for a dozen years he gave lectures, with occasional limited assistance in chemistry, in all the branches of medicine and surgery, while his reputation attracted students from all parts of the country. Besides his other labors, he published several important essays—and among them was that notable one, which at the time created much discussion, not to say opposition, on the “Treatment of Typhous Fever.” In this short essay he promulgated, and insisted upon, a more rational method of treatment, a method which with some modifications is now, after the lapse of more than half a century, recognized as proper in the management of that disease. Thus constantly engaged, a man of thought and action, he became one of the foremost practitioners and surgeons of his time.

The names of other men will readily occur to you as representatives of the type of country practitioners which I have described. I might call over the Crosbys and Musseys, the Deans, Childs and Tullys, and scores of others, who as eminent physicians, teachers and devoted students in science, are illustrations of the fact that a doctor need not occupy a second place in his profession, though, as our poet has said, “reduced to practice in a country town.”

The truth is, all things considered, no practitioner of medicine should be so thoroughly educated, clear headed, and quick witted, as the country physician. Thrown so much upon his own resources, he requires above all others a broad and comprehensive education which shall fit him for all emergencies. Nor should this education consist merely in the acquisition of a certain amount of knowledge accumulated by others, but it should be such as to enable him to make for himself exact observations and original investigations.

Most assuredly a country practice affords no hiding place for a poorly educated or incapable doctor. That there are such to be found in the country, as elsewhere, is of course true; but it is none the less true, we apprehend, that in a just estimate of the nature of disease and its remedies, and in the proper management and care of the sick for their restoration to health, the average country physician is, to speak within bounds, quite the peer of the average city practitioner.

The position which “the country doctor” holds in the profession has in it another element of importance. Through loss of time upon the road, and the want of frequent opportunity to make the more strictly scientific investigations for himself, he is too apt to take a large share of his scientific knowledge at second hand. Most of the chemical analyses required in his practice must be of a simple character if he alone is to make them, and for nice questions of pathology he must of necessity in a great measure depend upon the researches of others. But, aside from the work which belongs to the professional chemist and pathologist, he has his share in a kind of labor which is none the less important, either in its scientific aspects or in its practical value. As his practice is for the most part with a class of patients whose mode of life developes inherited vigor and robustness, he possesses under favorable conditions excellent opportunities, not only for observing the natural course of disease, but also of obtaining the best results from the remedies employed for its removal. It is therefore more especially his province to weigh carefully medical theories and scientific suggestions with the entire circle of comprehended and admitted facts—“the phenomena of the diseases themselves”—and to test fairly the claim of everything that is regarded useful for their treatment; so that in this regard the “many things of which we are in doubt can be demonstrated, or at least rendered more probable.”

The discoveries which have been made in both normal and morbid anatomy, the researches of chemistry, and the exact experiments of physiology have all contributed to the recent solid progress in medical science. Every organ, tissue, and fluid of the body has been made the subject of the most subtle experiment and research; while the functions of these organs have each in turn been subjected to the most careful study, and their characteristics explained. With instruments of precision and accuracy, modes of examination have been multiplied—resulting in clearer and more accurate methods of diagnosis, and affording standards of absolute comparison. All this increased knowledge has added immensely to a more complete understanding of the various processes of respiration, secretion, circulation, and nutrition, and of that intricate and complex nervous system which performs so important a part in the mysterious functions of life. In addition, this knowledge has defined within rational limits the methods of investigation of the organs and functions of living beings, and established principles which naturally lead to the further discovery of truth, and has “lifted the science of disease out of the plane of conjecture and placed it upon the basis of observed and undeniable facts.”

Notwithstanding, however, this increased and more perfect science by which disease may be more clearly comprehended, the knowledge of the exact value of remedial agents, by which it is to be mitigated or removed, is still exceedingly imperfect and limited. Those medicinal measures by which this science and philosophy are to be reduced to therapeutic success are still singularly involved in perplexing doubts and uncertainties.

By chemical research many of these agents have been demonstrated to possess powers capable of modifying vital action, and thus to directly modify diseased conditions. By this research much has been done in rendering drugs more available in their essential qualities and ease of administration, yet with all this there still remains a much larger number of agents whose physiological action and whose therapeutical value and application are by no means determined. This statement is applicable to old as well as new remedies; and they both require a more thorough investigation based on intelligently observed clinical facts. Tested by the present modes of chemical and physiological analysis, their practical uses being better defined and understood, much of the uncertainty and skepticism which now cumber and retard the progress of medicine may be more readily removed. There are no problems within the whole range of medical inquiry more difficult of solution than those involved in ascertaining the modes of action of drugs and their true therapeutic value.

It is only by a vigorous method of clinical demonstration that the difficulties and doubts which cluster around the “path in therapeutics” can be removed and substantial truths in this regard determined; and if there is ever to be a rational and philosophical method of treatment of disease, this can only be accomplished by applying to the department of materia medica a mode of observation and experiment similar to that by which the other branches of medicine have been brought to their present degree of perfection.

In such researches, so complex and obscure, progress can only be made by slow and laborious approximations. It requires far more of that subtle and dextrous keenness of mind to make a series of trusty observations in clinical medicine than in forming any number of hypotheses, however plausible. In dealing with such problems, “dashing speculations and vague theories are of no avail, for these are neither philosophy nor science.” It is only by cautious, laborious and steady observation and investigation that they can be apprehended and demonstrated. Any satisfactory solution of these difficult problems can only be accomplished by confining the inquiry within narrow limits, and subjecting it to frequent careful examinations in accordance with strict scientific methods.

It is in these more practical aspects that “the country doctor,” as a general practitioner, comes into close relation with these researches, and it is by clinical observations and demonstrations, which he can the better make, in rigidly testing cases, that the essential or comparative value of the results aimed at can be attained; for of all those thus engaged in watching and estimating the practical effects of medicines, none have superior advantages, a better class of subjects, or patients under better conditions for the purpose. With such opportunities it comes most emphatically within the range of his labors to gather up and record the facts, in order that practical inferences and correct conclusions relating to these agents may be reached—as a worthy contribution on his part towards perfecting the science and art of his profession. This is indeed a work which pertinently belongs to “the country doctor.” In no other way can he better subserve the interests of the profession than by collecting this great mass of observations and results which shall especially serve to determine right modes of treatment and out of which definite rules of practice may naturally grow; so that “the art may indeed keep pace with and take the maximum of good out of science.”

Within the limits of the membership of this society there are hundreds of active, working “country doctors,” having under daily observation a multitude of cases undergoing medical treatment. The large proportion of these cases are probably similar in kind, and in manner of development; and the treatment to which they are subjected is probably of a tolerably uniform character. Yet in the treatment of this large number of cases how many careful observations and trials are there made for testing the utility of even a single drug, old or new, or in demonstrating any original or better method for their special or general exhibition? There can be no question that if a trustworthy and discriminative series of observations and results, respecting the properties, action and effects of remedial agents could be accurately and honestly gathered up—a matter which could be in a great measure accomplished through the combined labors of so large a number of “country doctors”—a great advance in therapeutical knowledge would soon be realized. Nor would it be long before there would grow out of this gathered material not only this more complete understanding of “the immediate and conjunct causes” and natural processes of disease, but also a philosophic system of therapeutics which would be in rational accordance with the facts of pathology. Moreover, out of it would also grow a more perfect “union of the physiologist with the physician;” a union by which the affirmations and conclusions of science could be the better verified through the test of actual experience.

It is to this end that our efforts, and especially those of the “country doctor,” should tend, not as naturalists only, but as physicians. For, however much one may have of that inward gift, that special sagacity and that force of practicality, the quickness of eye, tact and invention, previously alluded to, it is the well-stored mind, rich in acquired knowledge, which utilizes science and gives that “power of perceiving the minute differences and fine analogies which discriminate or unite” the various elements of the difficult problems requiring the physician’s solution.

Certainly there can be no better or sharper incitements to labor, and to keep alive the fire of enthusiasm, Dr. Brown speaks of, than the being employed in noting and watching, with constantly accruing acquisitions, the discoveries of new truths or the confirmation of old ones.

But frequent reviews of our labors are also necessary and profitable. Says the Editor of The Lancet, with pertinent emphasis, “We all fall more or less into routine treatment, and no exercise is more beneficial to us as physicians than that we should be our own critics to test in all lights and ways the soundness of the conclusions we have arrived at, and of the details of the treatment which we practise. Not the least advantage of such an attitude towards our own practice is, that it makes practice so much more interesting. The most ordinary case of illness methodically studied—which by the way can be done with very little fuss and loss of time–becomes a lesson to us more instructive than mere books.”

What opportunity there is for the wholesome exercise of learning and applying such lessons during the long rides and tedious waitings of a country practice! On account of his isolation, “the country doctor” is especially liable to fall into this alleged routine mode of practice. It is one of the evil habits which grows out of his situation; and there is no better prevention for a slothful round of service, no better stimulation for inciting an increased interest in his work, than this self-criticism of his own practice, The Lancet speaks of.

There is another habit which attaches to “the country doctor,” and which not only detracts from his own professional and intellectual improvement, but involves a serious loss to the whole profession, and this is his apparent indifference in permitting the results of his experience, his acquired knowledge from years of practice, to run to waste. Many an intelligent and educated country physician lives a long life accumulating a deal of useful practical knowledge, and dies leaving no substantial record of it; while no one has more time otherwise unoccupied, or better opportunity for the study of cases, for carefully noting their peculiarities, for thoughtfully developing the conclusions they lead to, and for earnestly keeping up those “strivings for truth which shall help the brethren.” The old excuses, of “want of leisure, or inability to write,” are but stale subterfuges unworthy educated men. Because one practises in a country town, it is no excuse for him to grow idle or selfish, and to do nothing for science, or not to add any thing to the common stock of knowledge. There is need enough for all to work in this wide field of medical culture, which is broad enough to occupy the attention of the keenest and best cultured minds, or to gratify the highest scientific ambition.

Imperfection belongs to all human efforts, and our work is no exception. There is no cause, however, for being dismayed in the expression of our thoughts, even if the balance of excellence in scientific or literary attainments be somewhat against one. It is well to remember that our labors and experiences, in city and in country, are not dissimilar, and that such doubts and fears and anticipated failures are common to all. The more we know of the scientific ventures and mistakes of others, the sooner we shall discover that our real differences in such matters are of small account. It is some satisfaction, as well as comfort, to find out how much the greater gods shrink on close inspection.

It is of right then that we work steadily and independently, with stubborn perseverance in our own circle, even if it is a narrow one, examining and thinking for ourselves, and plucky enough to express our convictions though in never so homely a garb. The domain of our art lies all around us, and is patiently waiting for discoverers of its mysteries. Beneath its surface are hidden truths of precious worth, and we are but to search with earnest and diligent purpose to gather therefrom a rich return for our labors. As interpreters of the laws of physical life, and as “ministers and helps” in this divine art of healing, there rests upon every one, in the country as well as the city, the burden of his own share of the work; and he should constantly bear in mind the significant words of the great and good Sydenham:— “whatever others shall have done, I should always consider that my life had been given to me in vain while being employed in this work, unless I had myself contributed something, however small, into the common treasury of medicine.”

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