Introductory lecture, delivered at the Middlesex Hospital, Oct. 1, 1847
DELIVERED AT THE MIDDLESEX HOSPITAL,
October 1, 1847,
R. G. LATHAM, M.D.
LECTURER ON FORENSIC MEDICINE, ETC.
(From the London Medical Gazette, October 15, 1847.)
There are certain facts of such paramount importance, that they not only bear, but require, repetition. The common duties of every-day life, and the common rules of social policy, are matters which no moralist states once for all: on the contrary, they are reiterated as often as occasion requires—and occasion requires them very often. Now it is from the fact of certain medical duties, both on the part of those who teach and those who learn, being of this nature, that, with the great schools of this metropolis, every year brings along with it the necessity of an address similar to the one which I have, on this day, the honour of laying before you.
You that come here to learn, come under the pressure of a cogent responsibility—in some cases of a material, in others of a moral nature—in all, however, most urgent and most imperative.
To the public at large—to the vast mass of your fellow-creatures around you—to the multitudinous body of human beings that sink under illness, or suffer from pain—to the whole of that infinite family which has bodily, not unmixed with mental affliction, for its heritage upon earth—to all who live, and breathe, and feel, and share with yourselves the common lot of suffering—here, in their wholeand depth, and length and breadth, are your responsibilities of one kind. You promise the palliation of human ailment; but you break that high promise if you act unskilfully. You call to you all those that are oppressed; but you may aggravate the misery that you should comfort and relieve. You bear with you the outward and visible signs, if not of the high wisdom that heals, at least of the sagacious care that alleviates. Less than this is a stone in the place of bread; and less than this is poison to the fountain-springs of hope.
Not at present, indeed, but within a few brief years it will be so. Short as is human life, the period for the learning of your profession is but a fraction of the time that must be spent in the practice of it. A little while, and you may teach where you now learn. Within a less period still, you will practise what you are now taught.
And practice must not be begun before you have the fitness that is sufficient for it. Guard against some of the current commonplaces of carelessness, and procrastination. Lawyers sometimes say "that no man knows his profession when he begins it." And what lawyers say of law, medical men repeat about physic. Men of that sort of standing in medicine which, like the respectability of an old error, is measured by time alone, are fondest of talking thus; and men of no standing of any sort are fondest of being their echoes. It is the currentof your practical men, i. e. of men who can be taught by practice alone. Clear your heads of this nonsense. It will make you egotists, and it will make you empirics: it will make you men of one idea: it will make you, even when you fancy it would do you just the contrary, the wildest of speculators. The practice of practical men, in the way I now use the words, is a capital plan for making anything in the world, save and except practitioners.
Well! this has seemed excursive, but it is not so: it is a reason against the putting off of your learning-time. When your first case comes, you must be as fit for it as you are ready for it.
A difference between old practitioners and beginners there always will be—so long at least as there is value in experience, and a difference between age and youth; but this difference, which is necessary, must be limited as much as possible, must be cut down to its proper dimensions, and must by no means whatever be permitted to exaggerate itself into an artificial magnitude. If it do so, it is worse than a simple speculative error,—it is a mischievous delusion: it engenders a pernicious procrastination, justifies supineness, and creates an excuse for the neglect of opportunities: it wastes time, which is bad, and encourages self-deception, which is worse.
A difference between old practitioners and beginners there always will be: but it should consist not so much in the quality of their work as in the ease with which it is done. It should he the gain of the practitioner, not the loss of the patient.
Now, if I did those whom I have the honour to address the injustice of supposing that the moral reasons for disciplinal preparation, during the course of study now about to he entered into, were thrown away upon their minds and consciences, I should be at liberty to make short work of this part of my argument, and to dispose of much in a most brief and summary manner. I should be at liberty to say, in language more plain and complimentary, and more cogent than persuasive, that you must be up to your work when you begin it. If you stumble at the threshold, you have broken down for after-life. A blunder at the commencement is failure for the time to come. Furthermore; malapraxis is a misdemeanor in the eyes of the law, for which you may first be mulcted by a jury, and afterwards be gibbeted by the press. This fact, which there is no deny ing, ought to be conclusive against the preposterous doctrine which I have exposed: conclusive, however, as it is, it is one which I have not chosen to put prominent. Let a better feeling stand instead of it. Honesty is the best policy; but he is not honest who acts upon that policy only.
All this may be true; yet it may be said that the responsibility is prospective. "'Sufficient for the day is the evil thereof.' We'll think about this when we have got through the Halls and Colleges. You must give us better reasons for sacrificing our inclinations to our duty than those of a paulo-post-futurum responsibility." Be it so: you have still a duty, urgent and absolute—not prospective, but immediate—not in the distance, with contingent patients, but close at hand, with the realities of friend and family—not abroad with the public, but at home with your private circle of parents, relatives, and guardians. By them you are entrusted here with the special, definite, unequivocal, undoubted object—an object which no ingenuity can refine away, and no subtlety can demur to—of instruction, discipline, preparation. You not only come up here to learn, but you are sent up to do so: and anxious wishes and reasonable hopes accompany you. You are commissioned to avail yourself of a time which experience has shewn to be sufficient, and of opportunities which are considered necessary: and there is no excuse for neglect.
Great as are the opportunities, they are not numerous enough to be wasted and limited as is the time in the eves of those who only know it in its misapplication, is the period that a considerable amount of experience has sanctioned as a fair and average time for fair and average abilities, and for fair and average industry:—not a minimum period made for iron assiduity on the one hand, or for fiery talent on the other, but a period adapted to the common capacities of the common mass of mankind—a common-sense time,—a time too long or too short only for the extremes of intellect—too short for the slowness of confirmed dulness, too long for the rapid progress of extraordinary and rarely-occurring genius.
Of this time you are bound to make the most. It is your interest to do so for your own sakes; it is your duty to do so for the sake of your friends.
You come to the hospital to learn—you come to the hospital to learn in the strictest sense of the word. You come to learn medicine, as you would go—if instead of physic your profession were the law—to the chambers of a special pleader, a common lawyer, or an equity draughtsman. In this strict sense does your presence here imply study—study exclusive, and study without any loss of time, and without any division of attention. You do not come here as a clergyman goes to the University; but as artists go to Rome—not to keep terms, but to do work.
I must here guard against the misinterpretation of an expression used a few sentences back. I wish to let nothing drop that may encourage the germs of an undue presumption. I expressed an opinion—which I meant to be a decided one—that the time allowed for your medical studies was full, fair, and sufficient,—so much so that if it prove insufficient the fault must lie in the neglect of it. Sufficient, however, as it is, it gives no opportunity for any superfluous leisure. It must not be presumed on. You have no odd months, or weeks, or days, or even hours, to play with. It is a sufficient space for you to lay in that knowledge of your profession which the experience and opinion of your examining boards have thought proper to require. I believe the amount thus required, to be, like the time granted for the acquisition of it, a fair amount. But it is not a high one, and it is not right that it should be so. Standards of fitness that are set up for the measure of a body of students so numerous as those in medicine, rarely err on the side of severity. They favour mediocrity; and they ought to favour it. It is safe: and that is all they have a right to look to. What they profess is never very formidable and what they require is generally less than what is professed. But the time that is sufficient for this modicum (or minimum) of professional learning is not the time sufficient for the formation of a practitioner of that degree of excellence which the competition of an open profession, like that of medicine, requires as the guarantee of success. An examining board has but one point to look to—it must see that you can practise with safety to the public. It never ensures, or professes to ensure, that you shall practise with success to yourself, or even that you shall practise at all. In the eyes of an Examiner, as in those of a Commissioner of Lunacy, there are but two sorts of individuals; those that can be let loose upon the public, and those that cannot. In the eyes of the public there is every degree of excellence, and every variety of comparative merit or demerit.
Now as to the way of attaining these higher degrees of merit, and the rewards, moral or material, which they ensure; which follow them as truly as satisfaction follows right actions, and as penalties follow wrong ones. The opportunity we have spoken of. It consists in the whole range of means and appliances by which we here, and others elsewhere, avail ourselves of those diseases that humanity has suffered, and is suffering, for the sake of alleviating the misery that they seem to ensure for the future. Disease with us is not only an object of direct and immediate relief to the patient who endures it, but it is an indirect means of relief to sufferers yet untouched. Out of evil comes good. We make the sick helpful to the sound; the dead available to the living. Out of pestilence comes healing, and out of the corruption of death the laws and rule of life. Suffering we have, and teaching we have, and neither must be lost upon you. It is too late to find that these objects, and objects like them, are repugnant and revolting. These things should have been thought of before. Your choice is now taken, and it must be held to. The discovery that learning is unpleasant is the discovery of a mistake in the choice of your profession; and the sooner you remedy such a mistake the better—the better for yourselves, the better for your friends, the better for the public, and the better for the profession itself.
Steady work, with fair opportunities—this is what makes practitioners. The one without the other is insufficient. There is an expenditure of exertion where your industry outruns your materials, and there is a loss of useful facts when occasions for observation are neglected.
See all you can, and hear all you can. It is not likely that cases will multiply themselves for your special observations, and it is neither the policy nor the practice of those who are commissioned with your instruction to open their mouths at random.
See all you can. If the case be a common one, you get so much familiarity with a phenomenon that it will be continually presenting itself. If a rare one, you have seen what you may seldom see again. There is every reason for taking the practice of the hospital exactly as you find it. It represents the diseases of the largest class of mankind—the poor; and, although in some of the details there may be a difference, upon the whole the forms of disease that are the commonest in hospitals are the commonest in the world at large; and vice versa. Hence, what you see here is the rule rather than the exception for what you will see hereafter. The diseases are not only essentially the same, but the proportion which they bear to one another is nearly so, I mention this, because there is often a tendency to run after rare cases to the neglect of common ones; whilst, on the other hand, remarkable and instructive forms of disease are overlooked, simply because they are thought the curiosities rather than the elements of practice. You may carry your neglect of common cases, on the strength of their being common, too far. You may know all about catalepsy and hydrophobia, and nothing about itch or measles. You may find that, of the two parties concerned, the patient and yourself, it is the former that knows the most about his complaint. You may live to have your diagnosis corrected by the porter, your prognosis criticised by the nurse. On the other hand, by missing single instances of rare disease, you may miss the opportunity of being able to refer to your memory rather than to your library.
I have given you reasons against being afraid of over-observation, and against the pernicious habit of neglecting the case because it is common, and that because it is rare—a common excuse for neglecting all diseases, and a popular reason for doing so. Medicus sum, nihil in re medicâ a me alienum puto, &c. Some minds, indeed, are so constituted that they can make much, very much, out of single cases, out of solitary specimens of diseases. The power of minute analysis is the characteristic of this sort of observation. It is just possible so to seize upon the true conditions of a disease, as to satisfy yourself, once for all, of its real permanent attribute—of its essence, if I may so express myself. And this being seen, you may, for certain purposes, have seen enough; seen it at one glance; seen it at a single view as well as others see it at a hundred. I say that certain minds are thus constituted; but they are rarely the minds of many men in a single generation, and never the minds of beginners. Before this power is attained your observation must be disciplined into the accuracy and the rapidity of an instinct; and to this power of observation—attainable only by long practice, and after long practice—a high power of reflection must be superadded.
No such power must be presumed on. If the student delude himself, the disease will undeceive him. The best practitioners, in the long run, are those whose memory is stored with the greatest number of individual cases—individual cases well observed, and decently classified. It is currently stated that the peculiar power of the late Sir Astley Cooper was a power of memory of this sort, and I presume that no better instance of its value need be adduced. Now the memory for cases implies the existence of cases to remember; and before you arrange them in the storehouse of your thoughts you must have seen and considered; must have used both your senses and your understanding; must have seen, touched, and handled with the one, and must have understood and reflected with the other.
I am talking of these things as they exist in disciplined intellects, and in retentive memories; and, perhaps, it may be objected that I am talking of things that form the exception rather than the rule; that I am measuring the power of common men by those of extraordinary instances. I weigh my words, when I deliberately assert, that such, although partially the case, is not so altogether; and that it is far less the case than is commonly imagined. In most of those instances where we lose the advantage of prior experience, by omitting the application of our knowledge of a previous similar case, the fault is less in the laxity of memory than in the original incompleteness of the observation. Observe closely, and ponder well, and the memory may take care of itself. Like a well-applied nick-name, a well-made observation will stick to you—whether you look after it or neglect it. The best way to learn to swim is to try to sink, and it is so because floatation, like memory, is natural if you set about it rightly. Let those who distrust their remembrance once observe closely, and then forget if they can.
There are good reasons for cultivating this habit at all times, but there are especial reasons why those who are on the threshold of their profession should more particularly cultivate it. Not because you have much to learn—we have all that—nor yet because you have the privilege of great opportunities—we have all that also—must you watch, and reflect, and arrange, and remember. Your time of life gives you an advantage. The age of the generality of you is an age when fresh facts are best seized; and best seized because they are fresh. Whether you are prepared to understand their whole import, as you may do at some future period, is doubtful. It is certain that the effect of their novelty is to impress them more cogently on your recollection.
And this is practice—practice in the good sense of the term, and in a sense which induces me to guard against the misconstruction of a previous application of it. A few sentences back I used the phrases practical men, adding that those so called were men who could be taught by practice only. I confess that this mode of expression was disparaging: for the purpose to which it was applied it was meant to be so. It is a term you must be on your guard against. Practice is so good a thing of itself that its name and appellation are applied to many bad things. Slovenliness is practice, if it suits the purpose of any one to call it so; contempt for reading is practice; and bleeding on all occasions when you omit to
purge is practice;—and bad practice too. Be on your guard against this: but do not be on your guard against another sort of practice: the practice of men who first observe, and then reflect, and then generalise, and then reduce to a habit their results. This is the true light for you to follow, and in this sense practice is not only a safe guide but the safe guide. It is experience, or, if you choose a more philosophic term, induction. Theoretical men can be taught by this, and the wisest theorists are taught by it. When I said that practical men were taught by practice only, I never implied that they were the only men that practice could teach. Experience makes fools wise; but fools are not the only persons who can profit by experience.
See and hear—the senses must administer to the understanding. Eye, and ear, and finger—exercise these that they may bring in learning.
See and hear—the senses must administer to their own improvement. Eye, and ear, and finger—exercise these, that they may better themselves as instruments. The knowledge is much, but the discipline is more. The knowledge is the fruit that is stored, but the discipline is the tree that yields. The one is the care that keeps, the other the cultivation that supplies.
The habit of accurate observation is by no means so difficult as is darkly signified by logicians, nor yet so easy as is vainly fancied by empirics. It is the duty of those who teach you to indicate the medium.
The tenor of some of my observations runs a risk of misrepresentation. It has been limited. It has spoken of cases, as if there was nothing in the whole range of medical study but cases; and of observation, as if the faculties of a medical man were to take a monomaniac form, and to run upon observation only; of hospitals, as if they consisted of beds and patients alone; and of clinical medicine and of clinical surgery, as if there was no such a paramount subject as physiology, and no such important subsidiary studies as chemistry and botany. It is all hospital and no school—all wards and no museum—all sickness and no health. This has been the line that I have run on; and I feel that it may be imputed to me that I have run on it too long and too exclusively. Whether I undervalue the acquisition of those branches of knowledge which are collateral and subordinate to medicine, rather than the elements of medicine itself—which are the approaches to the temple rather than the innermost shrine—will be seen in the sequel. At present I only vindicate the prominence which has been given to clinical observation, by insisting upon the subordinate character of everything that is taught away from the bed, and beyond the sensible limits of disease. No single subject thus taught is the direct and primary object of your learning. The art of healing is so. You learn other things that you may understand this; and in hospitals at least you learn them with that view exclusively. If you wish to be a physiologist, chemist, or botanist, irrespectively of the medical application of the sciences of physiology, chemistry, and botany, there are better schools than the Middlesex Hospital, or, indeed, than any hospital whatever. There they may be studied as mathematics are studied at Cambridge, or as classics at Eton—simply for their own great and inherent values. But here you study them differently, that is, as mathematics are taught at a military college, or as classics are taught at the College of Preceptors, for a specific purpose, and with a limited view—with a view limited to the illustration of disease, and with the specific purpose of rendering them indirect agents in therapeutics. If you could contrive the cure of disease without a knowledge of morbid processes, it would be a waste of time to trouble yourself with pathology; or if you could bottom the phenomena of diseased action without a knowledge of the actions of health, physiology would be but a noble science for philosophers; or if you could build up a system of physiology, determining the functions of organs, and the susceptibilities of tissues, independent of the anatomy of those organs and those tissues, scalpels would be as irrelevant to you as telescopes; and if these three sciences received no elucidation from chemistry, and botany, and physics, then would chemistry, and botany, and physics, have the value—neither more nor less—of the art of criticism or of the binomial theorem. What you are taught in the schools is taught to you, not because it is worth knowing—for Latin, and Greek, and Mathematics, are worth knowing—but because, before patients can be cured, they are necessary to be learned.
And, in order to be taught at all, they must be taught systematically. It is an easy matter to ask for a certain amount of these two collateral sciences—to pick and choose just the part wanted for use, to require just that modicum of botany which illustrates the Pharmacopoeia, and just those fragments of chemistry that make prescriptions safe, and urine intelligible. It is easy, I say, to ask for all this; but the art of thus teaching per saltum has yet to be discovered. The whole is more manageable than the half. What it may be with others is more than I can tell; but, for my own particular teaching, I would sooner take the dullest boy from the worst school, and start him in a subject at the right end, than begin at the wrong end with the cleverest prizeman that ever flattered parent or gratified instructor. Bits of botany and crumbs of chemistry are less digestible than whole courses.
Thus much for those studies that make your therapeutics rational. Some few have spoken slightly of them—as Sydenham, in the fulness of his knowledge of symptoms, spoke slightingly of anatomy, or as a Greek sculptor, familiar with the naked figure, might dispense with dissection. They are necessary, nevertheless, for the groundwork of your practice. They must serve to underpin your observations.
And now we may ask, whether, when a medical education has been gone through, you have collected from it, over and above your professional sufficiency, any secondary advantages of that kind which are attributed to education itself taken in the abstract? Whether your knowledge is of the sort that elevates, and whether your training is of the kind that strengthens?
Upon the whole, you maybe satisfied with the reflex action of your professional on your general education—that is, if you take a practical and not an ideal standard. It will do for you, in this way, as much as legal studies do for the barrister, and as much as theological reading does for the clergyman; and perhaps in those points not common to the three professions medicine has the advantage. Its chemistry, which I would willingly see more mixed with physics, carries you to the threshold of the exact sciences. Its botany is pre-eminently disciplinal to the faculty of classification; indeed, for the natural-history sciences altogether, a medical education is almost necessary. Clear ideas in physiology are got at only through an exercised power of abstraction and generalization. The phenomena of insanity can be appreciated only when the general phenomena of healthy mental function are understood, and when the normal actions of the mind are logically analyzed. Such is medical education as an instrument of self-culture: and as education stands at present, a man who has made the most of them may walk among the learned men of the world with a bold and confiding front.
I insist upon thus much justice being done to the intellectual character of my profession—viz. that it be measured by a practical, and not an ideal, standard. Too much of the spirit of exaggeration is abroad—of that sort of exaggeration which makes men see in the requisites for their own profession the requisites for half-a-dozen others—of that sort of exaggeration which made Vitruvius, himself an architect, prove elaborately that before a man could take a trowel in his hand he must have a knowledge of all the sciences, and a habit of all the virtues. Undoubtedly it would elevate medicine for every member in the profession to know much more than is required of him—yet this is no reason for our requiring much more than we do. Such a notion can be entertained only through a confusion of duty on the part of those who direct medicine. Their business is the public safety; and the position of their profession is so only so far as it affects this. Trusts are intended for the benefit of any one but the trustee.
Two objections lie against the recommendation of extraneous branches of learning in medicine: in the first place, by insisting upon them as elements of a special course of instruction, they are, by implication, excluded from a general one; in the second place, they are no part of a three years’ training.
Concentrate your attention on the essentials. I am quite satisfied that as far as the merits or demerits of an education contribute to the position of a profession, we may take ours as we find it, and yet hold our own. Nevertheless, lest the position given to medicine by its pre-eminent prominence, in conjunction with the church and bar, as one of the so-called learned professions, should encourage the idea that a multiplicity of accomplishments should be the character of a full and perfect medical practitioner, one or two important realities in respect to our position should be indicated. We are at a disadvantage as compared with both the church and the bar. We have nothing to set against such great political prizes as chancellorships and archbishoprics. We are at this disadvantage; and, in a country like England, it is a great one: so that what we gain by the connection, in the eyes of the public, is more than what we give; and the connection is itself artificial, and, as such, dissoluble. It is best to look the truth in the face—we must stand or fall by our own utility.
Proud to be useful—scorning to be more—must be the motto of him whose integrity should be on a level with his skill, who should win a double confidence, and who, if he do his duty well, is as sure of his proper influence in society, and on society—and that influence a noble one—as if he were the member of a profession ensured to respectability by all the favours that influence can extort, and all the prerogatives that time can accumulate. As compared with that of the church and bar, our hold upon the public is by a thread—but it is the thread of life. Such are the responsibilities, the opportunities, and the prospects, of those who are now about to prepare themselves for their future career. We who teach have our responsibilities also; we know them; we are teaching where Bell taught before us; we are teaching where ground has been lost; yet we are also teaching with good hopes, founded upon improved auguries.