Introductory lecture delivered in the Adelaide Hospital, Dublin, at the commencement of the clinical course, October 31, 1864
DELIVERED IN THE
COMMENCEMENT OF THE CLINICAL COURSE,
OCTOBER 31, 1864.
JAMES F. DUNCAN, A.M., M.D., T.C.D.
Fellow of the King and Queen's College of Physicians in Ireland, Physician to the Adelaide
and to Simpson's Hospital
PRINTED BY ALEXANDER THOM, 87, ABBEY-STREET.
Gentlemen,—I appear before you to-day, taking my regular turn for the second time as one of the medical staff of this hospital, for the purpose of delivering the usual Introductory Lecture to the Course of Clinical Instruction now about to commence. Six years have elapsed since this institution first opened its doors for the reception of patients, undertaking at the same time the arduous duty of receiving a class of medical students for the purposes of professional instruction and entering into competition with the other hospitals of this city, which had long been engaged in the same honourable pursuit, and which had earned for the medical school of Dublin a reputation second to none throughout the world. What was at that time a doubtful experiment is now, we are happy to say, an established success. The feelings of anxiety with which we looked forward to the contingencies of the future have given place to an assured conviction on our part of permanent stability and increasing usefulness. We can appeal to the Report of the Government Inspector of the Board of Health for the year 1863, which has just been published, a copy of which I hold in my hands, to show that in all material respects;—sanitary condition; appliances for the relief of the sick; class of diseases admitted; number of patients and results of treatment—our hospital will bear to be compared with any other of its size in the United Kingdom. This is the more gratifying when we remember that it is supported solely by the contributions of its friends—a fluctuating source of income, it is true, but the value of which is attested by the fact that upwards of,£18,000 had been raised within the first six years of its existence, terminating on the 31st of last December. It is a matter of congratulation to the supporters of the institution, that this year, notwithstanding the depressed state of the country, the ordinary income has been more than maintained, while considerable additions have been made to the Endowment Fund from unexpected quarters; giving the promise in a few years, when it becomes better known, of such a foundation to rest on as will secure it against the casualties to which it is at present exposed.
As to our pupils, we already count them by scores; and we can point with some degree of pardonable pride, not only to the numbers who have passed the usual Collegiate Examinations to qualify them for practice, but still more to the high places that many of them have taken at the Competitive Examinations, where rival institutions, represented in the persons of their alumni, are brought into collision, and the merits of each, as a school of medicine, put to the only test appreciated by the public. Of the hospital staff I will only say this, that we are ready to the utmost of our power to discharge the duties we have undertaken. The success of the past will make us exert ourselves the more strenuously for the future; and now that the difficulties inherent in the early history of all such undertakings have been overcome, we hope that the time has arrived when we may fairly calculate on freedom from future anxieties.
The first topic I shall allude to is the change which has taken place in the constitution of the hospital staff" since we last met here by the untimely death of our esteemed colleague, the late Dr. Mayne. I think it would be a culpable omission, if in this place, the scene of his labours and his usefulness, and if on this occasion, the first that has occurred since his removal, no notice were to be taken of the sad event which has deprived this institution of his services, and society at large of one of its most useful members. Dr. Mayne was no ordinary man. The extent of his practice, his reputation as a man of science, and the confidence reposed in him by his professional brethren, all establish this point beyond the possibility of contradiction. But if the question be asked, to what special cause was he indebted for his success? I think it may fairly be said that it was not so much to the eminent abilities he possessed as to the energy with which he cultivated his profession, and applied himself to the pursuit of everything having even an indirect bearing on the one great object of his life. It would be easy to point to other names in the catalogue of eminent men, alas! too numerous, recently removed from the profession in this city, more distinguished for brilliancy of genius, for originality of conception, for fertility of resource; but it would be impossible to name any one more distinguished for practical sagacity unci sound judgment, as well as for all those sterling qualities of mind which combine to form the safe and successful practitioner. It is no disparagement to Dr. Mayne to say that his abilities, great as they were, were not of that pre-eminent kind occasionally met with, which seem to grasp by a sort of ready intuition at the results of learning without the labour of acquiring them; whatever he learned, he learned in the ordinary way, with all the toil and self-denial and perseverance that other men have to use in doing so. It is this that makes him so peculiarly a model for young men to study. Had his success in life been due to his great talents mainly, it could have furnished no encouragement to others not similarly endowed. But owing it to what is equally within the reach of all, it becomes a matter of some moment to dwell upon those features of his character which led to such results, that you may the better profit by his example. In the first place, then, I would say he was distinguished pre-eminently for the earnestness of his character. He did nothing by halves. Whatever he thought worthy of being done at all, he thought worthy of being done well. This led him, in the investigation of disease, to take the greatest pains to find out its true nature. He took nothing for granted, he jumped to no hasty conclusion, he was never in a hurry. Not that he spent much time in the process, or fell into tediousness. He had too just a sense of the value of time to waste it unnecessarily. He could reason quickly, and he had sharp discernment; but he acted on the principle that a little extra exertion in the first investigation of a case will often save a great deal of trouble afterwards. By long-continued practice he was able at a glance to estimate properly the precise value of particular symptoms. It not unfrequently happens that some obscure symptom, scarcely to be detected by an ordinary observer, will throw more light upon the nature of the case than other phenomena that attract greater attention. Habits of close and careful attention, such as these, are clearly within the reach of everyone who now hears me, and demand no special ability on the part of the observer beyond patience, attention, and practice.
In the second place, he had all his senses, not only well adapted for the observation of disease, but carefully educated for the purpose. There are, undoubtedly, great natural differences among men as to the perfection of the several senses, and their power of discriminating minute shades of differences in the condition of surrounding objects. A medical man, above all others, requires to have them all—sight, hearing, touch, taste, and smell—highly developed, and in a condition of perfect health. If he has not, so far as the imperfection extends, he is unfitted for his office; and it ought to be a matter of serious consideration for a young man labouring under any physical defect, whether he ought to think of entering a profession in which the want of any faculty is a serious hindrance to his success. But whatever may be the degree of natural development in which the senses exist in any particular instance, we all know that they are susceptible of great improvement by diligent cultivation. Many instances might be given in proof of this. A physician has been known to tell the nature of a case of illness to which he was called by the mere smell he got entering the house; others can anticipate the description of a patient's feelings or symptoms by merely reading the expression of his countenance; the evidence of some latent and unsuspected ailment betraying itself in his aspect or appearance.
In the third place, he was a man of system. Without this, which he carried almost to the precision of a Martinet, he never could have got through the amazing amount of work he was accustomed to perform. I regret to say that this is one of many things in which medical students are usually deficient. Perhaps they are not altogether to blame for this, the extremely defective arrangements connected with the existing plan of medical education helping to produce it; but whatever the cause, the evil is greatly to be deplored. The want of habits of order tends to make their knowledge confused and inaccurate, entails upon them additional labour in acquiring it, and renders the retention of it in the memory a matter of greater difficulty.
Dr. Mayne was singularly felicitous in his descriptions of disease. He possessed the admirable tact of selecting the salient points of his cases, as well as of setting them before his readers, with a perspicuity and force of language that could not fail to represent the precise ideas he intended to convey. He did not exhaust attention by enumerating unimportant symptoms which had little bearing on the real nature of the affection; yet he omitted nothing that ought to be noticed. He was minute without being prolix; he was concise without being obscure. When he used technical terms it was not from pedantry, but because he felt that no other words would answer his purpose as well. Well, do I remember the brief but telling notes recorded in the prescription-books of the Whitworth Hospital, where he acted as clinical clerk to the late Dr. John Crumpton, when he handed them over to me as his successor, now nearly thirty years ago, which only required the outline to be filled up from his retentive memory to form a perfect history of each case, whenever subsequent circumstances should render such a course necessary.
It is scarcely requisite that I should add that he was enthusiastically devoted to his profession. He loved it for its own sake; and you may depend upon it, that without a natural taste for the pursuit, none of you will ever arrive at any real eminence in it. There is a wide difference between entering upon it as a mere matter of business, and cultivating it as a profession. In the one case all your efforts will be directed to the sordid object of earning a livelihood; in the other you will be animated by the desire of securing a suitable scope for the exercise of your higher faculties, and of fulfilling the duties devolving upon you as a member of the social circle.
The points in Dr. Mayne's character to which I have alluded, have especial reference to such an audience as I now address; but there were others which rendered him a fitting model to men of all professions. He was singularly destitute of affectation; his manner was plain in the extreme; there was nothing put on or assumed about him; you saw him as he was; he took no pains to set himself off to better advantage than was his usual character; he shrunk from everything that had the least shadow of falsehood or dishonesty. "While he wished never to appear worse than he really was, he seemed scrupulously to avoid everything that would represent himself to be better. Then, again, he was remarkably humble; he never gave you the idea of a man who thought of himself more highly than he ought to think; he was ever ready to recognise merit wherever discovered, and he was always more anxious to give to others the meed of praise for any professional discoveries to which they were entitled than to secure his own. When I add to this, that, without being particularly demonstrative in his manner, he was a warm and steady friend, conscientious in the discharge of duty, inflexible in his principles, and animated by a delicate sense of honour in all the relations of life, I think I have said enough to convince all who now hear me, that the loss which we have sustained is no ordinary one, and that the best use we can make of his example is to follow it as closely as we can.
I presume I may take it for granted that all of you who purpose attending this hospital, intend to make the healing art, in some one of its departments, the great business of your lives. There are no amateur students among you. The time has not yet arrived in the history of the world when, either as a part of general education, or as an avenue to social rank and distinction, men will think it worth their while to spend time in hospital attendance. In other professions such an event not unfrequently occurs. Multitudes enter the army who never dream of buckling on their armour in actual war; and others eat their dinners in the Inns of Court, who are never subsequently seen with a bag of briefs in the hall of justice. The subsidiary advantages presented by these professions to those embracing them, accounts for the difference; but the votaries of Esculapius have nothing to attract them to his shrine but what springs from the service itself. Yet I cannot help thinking, in opposition to the opinions generally entertained by the public and the profession, that a more general diffusion among the community of a knowledge of the true principles of medical treatment would be attended with beneficial results. Not to mention emergencies that are liable to happen in remote quarters of the globe, how often do occasions arise at home of sudden and severe illness, when no skilled assistance is within reach, when the bystanders, in their anxiety to do something that may be useful, unfortunately fall into the mistake of doing the very opposite of what they ought to have done; so that when the expected aid arrives, he finds the patient actually injured by their well-meant but injudicious interference? To me it appears that this is the only effective way of putting down quackery. Legislative enactments cannot do it, neither can exclusion from medical corporations. So far as legitimate medicine has yet triumphed over the boasted presumptions of irregular practitioners, the victory has been due to the increasing intelligence of the community. The credulity of the multitude springs from their ignorance—remove this, and the field in which quackery flourishes, as weeds do in a neglected farm, will cease to yield its accustomed harvest.
I am not in the least afraid that a more general diffusion of a knowledge of medicine among the people would be of the least disadvantage to the profession. At present we have often to complain of the injury done to our patients, either by their attempts to cure themselves, or by the mischievous suggestions made to them by well-meaning but mistaken friends. The evil is that most persons think that they know more of practical medicine than they really do. If they were further enlightened they would have a juster conception of their own ignorance, and be less willing to interfere. No men have a greater unwillingness to meddle in the treatment of disease than those who, having practised it honourably in some department of the public service during the greater part of their lives, have retired from the field of labour. Knowing the progressive character of medicine as a practical art, they feel that it should be transferred to the hands of younger men than themselves, more conversant with the existing state of scientific knowledge than they can possibly be.
Assuming then that the object which students have in coming here is to acquire a practical acquaintance with pathology and therapeutics, let me call your attention very briefly to the different modes of studying these subjects, that you may have a better idea of the value and importance of each. These may be arranged under four different heads,—books, attendance upon lectures, clinical instruction, and grinding. Each of these methods has advantages and disadvantages of its own, and all must be combined if the student would be "in omni teres atque rotundus."
The scientific works of medical men, whether systematic treatises upon general medicine, or monograms upon special branches of the subject, may be compared to the maps or charts employed in navigation. Therein are laid down the results of a past experience for the guidance of younger and less experienced men following in their track. As well might the mariner think of starting on a long and dangerous voyage without the appliances of his art, as the medical man enter on the practice of his profession without a knowledge of the views entertained by his predecessors of the treatment of disease. This knowledge may, indeed, be acquired in various ways, but in none so fairly to the authors or so useful to yourselves as by the actual perusal of the original works in which they have appeared. If practical medicine is to maintain its proper place among the kindred professions, it can only be done by the body at large possessing: some claim to the title of a learned and an educated class; and a man who has no taste for reading, and no personal acquaintance with books, especially those bearing on his own department of general science, can scarcely be looked upon as having any pretension to be regarded in this light. For this reason, then, if there were no other, it is essential that you should become as extensively acquainted as possible with the writings of the most esteemed authors upon the various departments of medicine.
But it would be a mistake to suppose that any one could prepare himself for actual conflict with the realities of the sick room by merely making himself master of all that had been written on the subject. In the first place, if he has never seen any plan of treatment put into practice, how is he to decide between the merits of different, and it may be, opposite plans recommended by different authors? These differences, in many cases, may be satisfactorily explained and reconciled; but to the student, brought into contact with disease for the first time, they must prove hopelessly embarrassing. In the second place, medicine is a progressive science. The history of the last half century establishes this point beyond the possibility of contradiction. The effect of this continual progression is to render works of undoubted merit at the date of their publication, comparatively valueless after the lapse of a few years.
But the great objection is, that books, however well adapted to explain the theory of medicine, are of little practical use in making us acquainted with disease as it occurs in nature. The ordinary symptoms of any morbid state, as described in books, are rarely if ever met with in any individual. They are either modified by special influences originating in the constitution of the patient, or they are combined with other morbid states, which complicate and alter the complexion of the case. It has not unfrequently happened that a student familiar with the name of a disease, and capable of telling by rote all that had been written about it, has failed to recognise a case of it when presented to his notice, simply because he never had enjoyed the opportunity of making himself acquainted with its general features. You all know how difficult it is to picture to yourself the appearance of a friend whom you have often heard of but have never seen. Let his photograph be sent home, and your ideas will become more definite; yet even then you may, perhaps, pass him in the street, because you have not yet caught the true expression of his features as they are displayed under the varying emotions of actual life. But as soon as you have been introduced to him, and have become familiar with his aspect and appearance, every thing is changed. You recognise him at a glance, and even at a distance, when his features are too far off to be distinctly seen, his very gait and manner and dress will be sufficient to identify him. The same thing is true of disease. Verbal descriptions are all very well in their way, but they fail to make the vivid immediate impression on the senses that the constant habit of observing living examples is sure to do. Here, then, is the grand defect in books as a method of studying medicine—and I mention it to warn you of the mistake of thinking you can safely neglect the opportunities afforded by the wards of the hospital, in the hope that you can make up for them afterwards by reading in your closet—they give no room for the proper training of your various senses in the observation of disease. It is only by actual and repeated use at the bedside of the patient, that these essential instruments for the detection of morbid phenomena can be educated to their peculiar function. What verbal description, for example, will give you such a clear conception of the peculiar aspect presented by a patient labouring under fever or pneumonia as a single glance at a characteristic specimen will do? These are all what Locke calls simple ideas, and are only to be acquired by the actual perception of each by its appropriate sense.
The only other defect that I shall notice under this head is, that the statements contained in books as to the efficacy of particular modes of treatment must be all taken on credit. They may or may not be true; but the reader has no means of testing their accuracy except seeing them applied to practice. Without impugning the truthfulness of the writers, there may yet be grounds for questioning the accuracy of their conclusions. What proof is there that they have not fallen into a mistake in forming an estimate of causes and their effects? Several medical men will watch simultaneously the progress of a case of illness, enjoying equal opportunities of studying its phenomena; yet if you come to ask them afterwards their opinion of the effects produced by any particular remedy employed in the treatment, the probability is that the estimate formed by each will be very different. One will consider it beneficial, another inefficient, a third positively injurious. How is this to be accounted for? Simply by the differences existing among them as to intelligence, closeness of observation, and accuracy in drawing deductions. I have often been struck at the various opinions expressed by the members of the class, when making a physical examination of a patient, as to so simple a thing as the comparative resonance of the percussion sound in two sides of the chest. Here is a matter upon which it might be thought that the merest tyro in the profession could scarcely fall into a mistake, and yet the contrary is the fact. Differences in the mode of percussion, in the degree of force employed, in the attitude of the patient, and in the tension of the Thoracic parieties will sensibly alter the result, and lead to innumerable errors. And if this be true when the point to be determined is merely the physical condition of a part, can it be a matter of surprise that mistakes should occur when the question for consideration relates to some vital phenomenon of an obscure character, and involves a comparison of the patient's state at two different periods of time?
Systematic courses of lectures, as given in connexion with schools of anatomy, have this advantage over text-books, that being given vivâ voce, the teacher is able to introduce into his lectures every new discovery as it comes out, and so to keep his pupils up to the standard of medical knowledge existing at the time. They are also usually illustrated by morbid preparations and drawings, which are rarely accessible to the mere reader of books. But they labour under the same defects as books, of not bringing the student into direct intercourse with the sick. They have this additional drawback, that the lecturer is apt unduly to impregnate his hearers with his own opinions, to the exclusion of those entertained by other teachers on the same subject. This is more likely to occur with oral instruction than with books, because the living man seen and heard is more apt to bulk in the eye and to influence the judgment of the student than the author of a treatise whom he has never met. When a man learns all by reading, all his instructors are placed on the same level, and no one takes undue precedence over the rest.
Clinical instruction differs from both the methods of study just mentioned in this, that it deals with cases of real disease present in the hospital, and subjected to all the details of actual treatment. It has this great advantage, therefore, that it affords the student opportunities of seeing living examples of what he wishes to study, and of exercising his faculties in investigating them. He no longer trusts to the ipse dixit of his teacher, or to the dogmatic statements of any author, however learned. He tests every assertion for himself, and withholds or accords his assent as his judgment is convinced. And although in nine cases out of ten, where a difference of opinion exists between him and his teacher, it will be found that his teacher is right, and he is in error; yet scepticism has this great advantage in this instance, that it leads him but the more carefully to put everything to the proof, and to be satisfied with nothing short of absolute conviction.
If you trust to what you read in text-books, there ought to be no difficulty, for example, in distinguishing between an endocardial and an exocardial murmur, or between the friction sound of pleuritis and the crepitus of pulmonary inflammation, yet it often happens that these various sounds, essentially distinct, when fully developed, approximate so closely to one another in their embryo conditions, that it requires considerable practice, and long-continued attention to distinguish them. This is but a familiar instance of what we are perpetually meeting with, and which establish, beyond question, the necessity of some further instruction than that afforded by books, if we would be masters of the art upon which we intend to enter. The necessity of practical teaching may be further illustrated in this way:—A skilful nurse will be able to tell by the cry of an infant whether it proceeds from pain, from hunger, or from irritability. The sound alone is sufficient in her ear to determine the point. In the same way, the mere act of coughing, if attentively listened to, will be sufficient, in many instances, to determine the nature of the affection upon which it depends.
Clinical instruction consists of two parts, that given in the class-room and that at the bedside. The former is necessary, as embracing many topics connected with the cases which cannot be conveniently given before patients. Illustrative diagrams often require to be used, which would be out of place in the wards; and statements have to be made by the teacher which would be injurious or distressing to the patient if made in his hearing. The method I have been in the habit of pursuing in this hospital is, I believe, not practised elsewhere. It consists in reducing the principal points of the case, forming the subject of lecture, to a sort of skeleton sketch, writing them in large characters on paper, and then pointing them out to the attention of the class, as they become the text for the requisite remarks. In this way mistakes are guarded against, the attention is fixed, and an interest kept up, which is hard to be maintained when the pupils have only their ears to exercise.
The other part—namely, that given at the bedside, is a sort of practical demonstration; the teacher pointing out the prominent symptoms of disease as exhibited by the patient under examination, and drawing attention to the special peculiarities of each case, as they correspond with or differ from what is ordinarily observed in similar instances. Here we are accustomed not only to tell the students that they will find certain signs and symptoms in the patient, if they will take the trouble of looking for them, but we place the stethoscope ourselves on the spot indicated, and by personal efforts endeavour to make the student realize exactly what he is in search of. It is astonishing how often mistakes will occur when least to be expected; and a pupil will sometimes say he hears a particular sound, and in reality thinks he hears it, when all the while his attention is directed to a different direction. Very recently we had a case illustrating this. A young woman labouring under anæmia was admitted into No. 8. She had a well-marked bruit on the side of her neck. I pointed it out to the students in attendance, and they all recognised it. I then asked them what was the name of the bruit; almost all of them declared it was a Bruit de Diable—a sound produced in the jugular veins, and owing its origin to the peculiar thin condition of the blood. But in this they were mistaken. It was a bellows' sound. No one familiar with these sounds could have the least difficulty in distinguishing them. The one is a continuous whir like the noise produced by a conch shell applied to the ear; the other resembles that produced by the use of the domestic instrument from which it derives its name. How was the mistake to be accounted for? Simply thus:—They knew the situation where the morbid sound existed was the precise spot where Bruit de Diable is commonly met with, and they also knew that the patient was suffering from that kind of disease in which it is most frequently observed. In addition to the evidence afforded by the peculiarity of the sound, the diagnosis was confirmed by the effect produced by change of posture. When the patient assumed the horizontal position the bruit was increased, which is what might be expected in a bellows' murmur, but the reverse of what ought to occur in Bruit de Diable.
Clinical instruction, in addition to affording an opportunity for the exercise of the several senses in their approximate functions, trains the student to habits of accurate observation. This he does when he watches closely the several changes that occur from one day to another in the patient's condition. Regular attendance is, of course, essential to this; otherwise he may miss the opportunity of noticing some of the most important phenomena that present themselves; above all, he will fail to trace the connexion that subsists between the treatment employed and the results to which it leads. Recently we discovered the friction sound of pericarditis newly developed in a boy convalescent from scarlatina. The students in attendance—some of our most intelligent and expert pupils—all satisfied themselves of the accuracy of the observation. Prompt and active treatment was employed, and the next day every trace of the affection had disappeared. The gentlemen who were present when the morbid sound was discovered, and who saw the success of the remedies employed, required no argument to convince them of what their own senses had witnessed; but the others who attended on the next day after the removal of the physical condition, had to take the statement entirely on trust.
It may be thought, after what has been said, that clinical teaching alone is sufficient of itself to educate medical pupils for the practical part of their profession, and to fit them for entering upon the duties of their office. But this is obviously a mistake. It only reaches to a small portion of the catalogue of ills that flesh is heir to. It is evident that students only meet with instances of those forms of disease that happen to be admitted to hospital during the period of their attendance. Of the rest they can know nothing, except as they become acquainted with them in some other way. Some diseases are never to be seen within the walls of an hospital. Others appear there occasionally, at uncertain and distant intervals. Variations in the intensity of epidemic influences account for many of these irregularities; others can be traced to no definite cause. This, then, is the defect of this method of instruction—a defect incapable of being got rid of, and requiring to be supplemented by one or other of the modes already specified. There is also another defect inherent in the system, and traceable to the same cause—namely, that the teaching must be more or less of a desultory character. Depending, as it does, upon the particular instances of disease present in the hospital at any given time, it cannot be taken up in regular order, so as to exhibit it in its natural connexion to kindred affections, and in its proper position in systematic nosology. This may be thought a matter of little moment, but it really is not so. Studying any subject in its analogies and contrasts tends materially to enlarge the mind of the student. It prevents misapprehensions, suggests useful hints, and prepares the way for enlightened and skilful practice.
The last method of instruction—"grinding"—is, as you are all aware, a system of catechetical instruction earned on in classes by private tutors, principally with a view of enabling the pupil to pass his examination for his licence to practice. It exercises the attention and memory of the student, and supplies him with much useful information; but as it is conducted at a distance from the sick, it can do nothing directly to exercise his senses and improve his powers of observation. Against this system there exists among many persons a very decided objection. This is because it has to a great extent degenerated into a mere process of cramming. Pupils are taught a certain number of answers to appropriate questions, which they afterwards repeat with little more intelligence than a parrot. The "cruxes" of crusty examiners are carefully registered, to meet their peculiar views; while comparatively little care is taken to give the student a true insight into the real nature of disease. But all these objections spring from the abuses which have crept into the system. In its proper place, where rightly used, it is a most valuable auxiliary to other modes of study. In this hospital much of the bedside teaching is made to assume this character; and when practised with the living illustration before the eyes of the observer, it appears to me to be one of the very best as well as one of the most popular forms of clinical instruction we possess.
Gentlemen, you are all aware, I presume, that this hospital was originally founded for a special purpose, unconnected with the science of medicine. At the time of its foundation it was a moot question among the promoters whether the existence of a medical class in conjunction with it was compatible with the great object aimed at in its institution. If I mistake not, some of its supporters still think that it would be much better for the original design, if the clinical department were separated from the charity. One reason I believe for their holding this opinion is, that they would not then be constrained to maintain any fixed number of beds, but would be at liberty to adjust the accommodation to the amount of support they receive. They would thus be freed from the disagreeable necessity of bringing the wants of the institution before the public, in the urgent manner they are now obliged to do, in order to keep pace with the exigencies of the medical class. I am not aware whether there is any other feeling influencing these persons or not, but I can well conceive that they may imagine that the sick poor would be more willing to enter an hospital where there is no instruction given than where there is. This latter idea, if it exists, I am firmly convinced is exactly the reverse of the truth. The confidence which the poor feel in the skill of a physician, explaining to a class of students the peculiarities of their ailments, is much greater than in that of one who having no occasion to express his opinions, makes his examination, and directs his treatment in silence. Upon this point I think I am better able to express an opinion than most persons, having been for many years physician to the non-clinical wards in Sir P. Dun's Hospital, before I accepted my present office. In it I had no class to instruct, and if I am not greatly mistaken, judging merely from the patients' manner and looks in both institutions, the feelings entertained towards me here, as regards my skill and ability to treat their diseases skilfully, are much more satisfactory than they were in the former. As to the other objection I cannot help thinking, that if the principle were once admitted that the public were to be left to themselves to supply, without solicitation, the requisite funds to support the charity, the resources at the disposal of the committee would get smaller and smaller, until they dwindled down to nothing. The great advantage of charity sermons in support of such an institution as this is, not so much the amount of money they bring in, as their keeping the existence of the necessities of the hospital prominently before the public. A careful consideration of this whole subject has produced, in my mind, a decided conviction that the abolition of the medical class would be detrimental to the best interests of the charity. Not to speak of the services rendered to the hospital by the pupils as clinical clerks and dressers—services at present rendered gratuitously, but which would then have to be paid for—think of what an advantage it has been to have had the merits of the hospital brought under the notice of hundreds of families who have had their sons or their nephews in attendance, who would otherwise have known little of its merits, if they had even heard of its existence. The medical school has been a cheap standing advertisement. The great stimulus to sustained interest and activity in the service of the hospital, presented to the staff of medical attendants, is the class of students. Take this away, and you will soon find it necessary to provide salaries for the performance of duties, which will cease to be attractive. At present the office of physician and surgeon is an object of ambition to the most promising members of the profession, whenever a vacancy occurs. Do you think it would continue to be so if this inducement to seek for the appointment were removed? Further, I consider the existence of the clinical arrangements to be necessary, in order to uphold the original design of the institution. That design was to provide an efficient hospital for the treatment of cases requiring professional assistance. It was not to be a shelter for chronic cases lasting for years, but presenting no hope of ultimate amendment. However important such an institution may be, it is not what was contemplated in the establishment of the present charity. Take away then the active surveillance of the medical officers, stimulated by the perpetually recurring necessity of maintaining its true character, and there can be but little doubt that it will soon degenerate into an ordinary alms-house. Besides, if it is to remain an hospital, where the sick are to come for health, it must be obvious to everyone that the poor, for whose benefit it is intended, have a right to be assured that they will receive within its walls the best and most skilful treatment, otherwise they will naturally prefer admission to some other institution, even though it does not present to them the same religious advantages. This undoubtedly requires that eveiy reasonable effort should be made to create for it a scientific character, and to maintain it when it has been created.
Most of you, I dare say, are aware that a rule has been introduced within the last year, restricting the admission to Protestants only. With the religious question involved in this rule, the medical staff, as such, have nothing to do. Our business is to administer the rules as we find them; but the rule is important in its bearing upon the subject just touched on. At first it was feared that it would empty our beds, and deprive us of the materials necessary to an interesting and instructive clinique. The experience of the past nine months has dissipated such an apprehension. The accommodation at our disposal has never been equal to the number of applicants for admission. Again and again have we been obliged to refuse urgent and interesting cases for want of room. The restricted character of the admissions has only made the Protestant poor doubly anxious to come here. Then again, our wards are largely supplied by patients from remote parts of Ireland. Within the twelve months ending September 1, we have had 127 of this class alone, and these are always interesting and important cases, being sent up to town from the greater severity of their ailments, or their unusual character; and when to all this we add that the Protestant population of this city and neighbourhood is 80,000 or 90,000, there is plainly no reason why we ought not to be able to supply even a larger hospital than this with a constant succession of suitable cases. But while we of the medical staff have nothing to do with the making of the rule in question, I cannot help expressing my conviction of its propriety under existing circumstances. Deeply as I regret the exclusion of any class of persons from the benefits of the hospital who may be willing to accept them on the terms imposed, I feel that the repetition of the painful controversies to which the fundamental rule gave rise, must, if continued, have proved detrimental, if not destructive to the institution. Toleration even of error lies at the very base of Protestantism. No man can claim for himself the right of forming his own opinions and acting upon them, without conceding the same privilege to everyone else; and while it is perfectly true that no man could say that his liberty was interfered with by any rule of the hospital, because nothing could force him to enter it against his will, and after he was admitted there was nothing to prevent his leaving it the moment he felt disposed to do so; yet, certainly, as long as patients of this class were indiscriminately admitted, questions of a very painful nature would continue to arise, not always admitting of a solution free from blame to the hospital or its officials.
And now, gentlemen, in conclusion, permit me to say how heartily I approve of the distinctive feature of the hospital—namely, its religious character. Other hospitals in this city have made ample provision for the bodily ailments of the inmates, supplying them freely with the most skilful medical and surgical treatment, while they have left the higher interests of their spiritual nature unattended to. They do not, indeed, prevent benevolent efforts for their welfare being made by other persons willing to undertake the task; but these, originating beyond the limits of the hospital arrangements, are necessarily subjected to regulations which restrict their freedom of action, and interfere with their efficiency. A large portion, besides, of the persons entering such institutions are friendless and unknown; and from long neglect of religious ordinances, are little disposed to seek for them unless offered by others. Those, who most need the visits of a kind and faithful pastor, are the very persons least likely to obtain them. The case is different here. The religious oversight of the inmates is not left to the chance visit of some unknown teacher, but a faithful minister of the Gospel has been appointed, whose especial duty it is to visit the wards daily, and going from bed to bed, to administer instruction, comfort, and sympathy to each of the sufferers as he sees their necessity requires. Standing as I do here on this public occasion, I would be guilty of a gross omission, if I did not bear witness to the faithfulness and diligence with which these duties have been performed by the present most excellent Chaplain, and to the good that he has been the means of doing to all classes of the patients.
Every attack of illness, when regarded in its true light, must be looked upon as a personal call to repentance; yet too often the lighter forms of it especially are not traced to their proper source. Samuel in the temple heard the voice of Jehovah calling to him in the dead of night, but it was not until Eli instructed him that he was led to say—"Speak, Lord, for thy servant heareth." So it often happens with the sick. The providence of God comes to them again and again, it may be with calls of increasing severity; but they do not understand the purpose of the visitation, nor do they meekly bend to receive it. How important then is it that there should be some friendly monitor at hand in such a place as this to interpret the visitation, and teach them how to apply it.
Next to a church, there is not a more sacred spot on earth than an hospital. The feelings with which we enter the wards ought to bear some affinity to that holy reverence with which we go up to worship. God is there in an especial manner, accomplishing his own purposes of mercy, and working really but invisibly in the hearts of His people. How appropriate to such a scene is the language of the patriarch, as he rose from his solitary couch on the plains of Syria, and exclaimed—"Surely the Lord is in this place, and I knew it not." The great Father of the human family takes his erring children aside, each one separately, that he may talk to them in private, chiding them for their faults, and administering correction. With what subdued feelings, with what bated breath, ought the other members of the household to stand by, and pause till the chastisement is over, and the offender restored to favour. There is, to my mind, great beauty in that passage of St. Paul, where, speaking of an erring brother, he says—"Ye which are spiritual restore such an one in the spirit of meekness, considering thyself lest thou also be tempted." Considering thyself. Do we think enough, as we pass from bed to bed, that we are ourselves partakers of the same mortality, and that in due time we shall be called to take our places in the sick room, and on the bed of death? My young friends, let this thought lead you to avoid all levity of conduct in your intercourse with the sick; let it produce in you greater tenderness of manner, greater sympathy for their sufferings, and greater forbearance towards their infirmities. The time cannot be far off when you will need all these things yourselves. My friends, the service you have entered on is like the forlorn hope of a besieging army. It exposes you to greater dangers than fills to the lot of other young men of your own age. You are more liable to sickness—more liable to death. Have you considered the consequences? Are you prepared for the risk? Nothing but true religion can make you so. But this, whatever opinion you may have hitherto formed regarding it, will not only enable you to look forward to the last great conflict without apprehension, but will greatly enhance your happiness during life. It will make yon more devoted to your profession, will inspire you with fresh motives for its cultivation, supply you with encouragement under difficulties, and will recompense you in the end with a better reward than you can possibly have without it.
- The correctness of this opinion was confirmed on the day of lecture by the Veil, the Archdeacon of Meath, who stated to me, that a patient recommended by him told him, on his return home, the confidence inspired in his mind by hearing me explain the features of his complaint to the class.
- Some few hospitals in town are not open to this remark; but the religious care of the sick was the primary object for which the Adelaide was established.