No. 2262.

JANUARY 5, 1867.

LectureINTRODUCTORY TO

CLINICAL MEDICINE,Delivered on the 8th of October, 1866.

BY JAMES ALDERSON, M.D., F.R.S.,SENIOR PHYSICIAN TO, AND CLINICAL LECTURER AT THE SCHOOL OF,

ST. MARY’S HOSPITAL.

GENTLEMEN,-I am always glad to use the opening lectureof the session by inviting the attention of the students to someuseful rules for their guidance in the course of the studieswhich we commence to-day. St. Mary’s School is now grow-ing into a large institution, which may be expected to bear-if it does not already do so-a sensible influence on the cha-racter of the rising generation of the profession.The first great lesson which I should desire to be deeply

read by all of you is to cultivate a sense of the immense re-sponsibility of the work you undertake. I rejoice to believethat St. Mary’s School has already been prominent in reformingthe frivolous and larky habits which have been too often attri-buted to the character of medical students; and whilst so manyefforts have been made to improve the education, and therebythe efficiency and social status of the great class of general practi-tioners, it is gratifying to think that those who are taking theirfirst step towards that career are doing it with a serious convic-tion of their obligations. There is something beyond your ownadvancement or the honour of your profession for you to keepin mind : there is, beyond even a general sense of duty, thesolemn fact that you will have the lives of individuals and the

happiness of families under your guardianship. Each one of

you will bring his different amount of natural talent to devoteto the great object which you have chosen for your futurework in life. The most gifted among you cannot succeed init without industry; and the least endowed may by that in-dustry, under good direction, be able to cultivate his naturalcapabilities to efficient purpose.

In the work of self-improvement the first point to be aimedat is to establish a habit of concentrated observation. A halfattention and a divided mind will help no one to seize the in-numerable and minute particulars which together make up adue knowledge of those most difficult of all sciences-Patho-logy and Therapeutics. They are difficult, because the massof evidence on which they are founded is almost unlimited,because no exact general rules can be laid down for the adap-tation of all those minute particulars, and because cool judg-ment and highly cultivated memory must be applied to thatadaptation in every single instance. Your first object there-fore will be to teach yourselves to observe closely, and to de-vote every possible effort towards the improvement of thememory. Acute observation is, in fact, the very foundationof memory. I have often quoted the well-known instance ofthe manner in which conjurors educate themselves for theirbusiness. By degrees they learn to fix in their minds at arapid glance as many objects which are placed before them asthey possibly can. It is done by a highly concentrated atten-tion, and the power they arrive at is so far beyond what theuneducated eye believes to be possible, that at last that powerappears to be a marvel which is merely the result of educatedfaculties. This education is pursued by artists, who learn notonly to see form and colour which common observers are not ableto perceive, but they can take in at a glance all minute details ofscenes and pictures, which remain with them for their profes-sional use. The mere hieroglyphics which Turner jotted down,reproduced to his mind not only the grand effect of a mag-nificent scene, but a thousand minutia3 which to others it wasa wonder that he could ever have perceived in his transientgaze. We might instance in almost every art and calling theuse of cultivating this faculty of close and rapid observation,and here, in the wards of this hospital, you will all have theopportunity of beginning such a course of self-improvement.After the brief visits to each patient in the wards, and afterlistening to the observations of the clinical teacher, every one

of you can try to recall how many symptoms of each case andhow many observations on them remain fixed distinctly in thememory, and we cannot doubt that whoever has the largestamount of these acts of memory in his possession at the end ofthe session will be the most advanced towards becoming a goodpractitioner. Genius is a great gift, but honest industry is amore valuable quality. There are innumerable ways in whichthe art of memory has been cultivated, different professorsgiving each their system of mnemonics; but I believe that oneof the best plans that can be adopted is, after having had sub-jects presented to the mind, to interrogate the memory as soonas possible, to see how much has been retained, and how muchhas been merely vaguely seized, and therefore sure to passaway unprofitably.Notwithstanding the idle innovation which tends to excuse

the youth of our time from all classical attainments, I cannothelp believing that there are some Ciceronian readers amongstyou. Those who have not that advantage may like to hearthe incident about Simonides to which the origin of artificialmemory is referred. The story goes, that whilst Simonideswas at Crannon, in Thessaly, with one Scopas, he was suddenlycalled out; returning quickly to the room he found the roofhad fallen in and all the guests were buried in the ruins. Thebodies were so mutilated that they were not to be distinguishedfrom each other. In the eagerness to afford rights of sepultureto each there was great rejoicing that Simonides was able topicture in his memory the exact scene which he had left,realising in his mind tne order in which the guests had sat,thus indicating where each body would be found. This issaid to be the origin of artificial memory by means of impres-sions on the sight. Fifty years ago Von Feneigle’s plan, whichcaused great excitement, was based on the same principle.But the fact is that all our senses ought to be engaged in onegreat act of attention when we wish the cultivation of ourmemory. You will not only have to make a vast collection ofsymptoms, and of inferences deduced from those symptoms,but you will in this hospital be furnished with the mostvaluable of all opportunities-viz., the dead-house, whichaffords the solution of so many mysteries. It will require theexertion of a great act of memory to reproduce all that hasgone before in the way of symptoms and reasoning, in orderto turn this final revelation to its full account. Post-mortemexaminations are, in fact, your greatest, most invaluable op-portunities,-unless you should become hospital surgeons orphysicians, they are opportunities which you will never haveagain ; and every case that you examine ought to be fixed inyour memory, clearly reflected there, in order to explain andillustrate a hundred difficulties which will continually arisein practice on to the end of your lives. No one had a morevivid sense of the value of the mortuary than one whom I con-sider to have been one of the greatest, if not the greatest, ofmodern pathologists. Dr. Bright felt that, towards the endof his life, his practice required to be guided and enlightenedby continual revelations of results of disease. After giving uphis hospital, he once said to me, whilst considering an obscurecase,

" I envy you, who have still the advantage of the dead-house ; if anybody would give me my income I would gladlygo back to it." And we may observe from this exclamation,not only the value of that line of study, but the indomitableindustry with which this successful physician had used it. I con-ceive that it was industry and a clear unprejudiced intelligence,rather than any particular genius, which made him what hewas. Before leaving the subject of the mortuary I should liketo notice that your work in learning practical anatomy has atendency to detract from the sacred respect which ought to befelt by human beings towards the remains of fellow-men. Itis our especial duty, who belong to the medical profession, torespect the human frame-as well our own as that of otherpersons : a respect not to be neglected even when the spirithas been withdrawn from it. We should remember that theCreator has made it in his image, and that its future destinyis still a mystery.

I am now going for a few minutes to pass from the subjectof intellectual training to that of conduct and manners. The

general bearing towards authorities and mutual intercourseamongst yourselves are, perhaps, beyond my legitimate topics.These, however, are most valuable themes of exhortation onthe opening of a school, commended by considerations of thedeepest interest to yourselves and to the profession. I rejoiceto know that the students of St. Mary’s have hitherto pre-sented a good example of gentlemanly manners, and that uni-form good conduct, prompted, as I believe, by good feeling,has marked their time of pupilage; and I equally rt-joice toknow that the career of after-life has opened with a promise

2

of success which may well be attributed to beginnings soauspicious.

That, however, which most concerns me now to dilate uponis proper conduct to the sick, especially of those who are nowentering on their studies in the wards. 1 should like to insiston the almost solemn obligation which young men, with youthand health qnd high spirits, are under, to adopt manners covr-tAoit-9, I might almost say 7-everential, towards the suffering in-mates ; especially to cultivate the great virtue of modest treat-ment in all personal examinations. Many of you will hardlyconceive to what extent the sense of delicacy is keen amongstpersons who might be called, comparatively, of the lowerorders. There are a hundred little ways in which this deli-cacy may be considered, and many rough, incautious acts mayde avoided without the least approach to anything like effemi-nate prudery: which last fault is, perhaps, as oppressive to apatient as a want of proper delicacy. True feeling and ac-quired tact will point out the proper medium ; and the valueof perfect manners towards the sick, which may be obtained int-he wards of an hospital, will be felt by you continually inafter-life, contributing in no small degree to your success inpractice. Not only in the mode of examining, but the verylanguage used, especially in the female wards, ought to bestudied and nicely adapted to each particular case. To learnin your time of pupilage the nice distinction between coarse-and affectation will be well worthy of your serious atten-tion. It is due to your character as gentlemen, and to yourprinciples of humanity. It will also be of great consequenceto you as to your future popularity. I remember long ago aninstance in which a most worthy practitioner lost the attend-ance for ever of one of the most important families in hisnehbourhooJ. by a single vulgar and abrupt expression.may mention, as a minor inducement to you to adopt that

’Clir:-,,’3t, and pure line of conduct, joined with that polishedlll,’,;,’B"1’ which ought to distinguish the medical above all otherprofession.--, that these are the qualities that will first bearfruit in your future course of life. A reputation for scientific.knowledge and for successful practice must be gained by de-grees whilst you are actually at work-its acquisition must bea work of time ; whilst your first acceptance by the publicP2-c,E,t depend chiefly on personal qualifications of which all canwl.1-1=;e alverted only, so far, to your conduct towards the

patients. There is another class towards whom a very strictand well-re6ulated tone of manners is imperatively necessary.It is a, difficulty peculiar to the wards of an hospital, and onethat is altogether unavoidable, that young men have to workin conjunction with young persons of the other sex; and itrather increases the difficulty that the young men are, in mostca.sF, ia a superior social position to the nurses, so that a cer-tain í’.,’1Y"lTt of respect and reticence is gracefully appropriateto regulate the conduct of the superior towards the inferiorclass. Tt Is impassible to lay down minute rules for the com-mllnÎcdion between pupil and nurse, but I trust the hint maynot bo unavailing to you, and that a habit of gentlemanly self-restra,ir..t will be cultivated by all of you, especially by thosewho are us yet strangers to the customs and manners of a great1-,it..:l. 1 am. not myself by any means the advocate oftaki&bgr;g the great and useful work of nursing out of the handso-f CLBS of women by whom it has always been supplied.’Employ !it0ut is washed by that class; they can sympathisemore, they can understand better the wants and feelings ofthe sick, who belong more nearly to their own condition ; andit is my opinion that we are doing better in educating thesepeople to a more complete knowledge of their duty, than inencouraging members of a higher class to accept work whichdoes not naturally belong to them. In the wards of St. Mary’syou meet chiefly the genuine hired nurse ; and you will con-sult not only the formation of your own manners, but theimprovement of the nurse, by avoiding any possible approachto levity or familiarity.The observations with which I began this lecture, as to the

vahe of intensely concentrated observation, cannot find moreimportant topic than that which the unhappy epidemic nowpresent immediately affords. You are called at the very out-39t to’the study of the gravest and most difficult of all diseases,a disease which is still the humiliation of medical science, themost earnest study of which has as yet been baffled in trving todiscover the cause and in applying remedies. One thing iscertain, thab mere tentative remedies have all failed equally.It is also certain that we have arrived at a few facts in regardto the morbid change, and to a knowledge of many of theelements which favour the development of the disease; whilstspeculations as to the exciting cause in each locality have

proved, in their turns, to be signal failures. All that can bemade out is, that that which depresses the system, whichinduces a low state of vitality, affords liability to attack,and even this, when we come closely to investigate it, re-

quires some modification. I think we are in a position, inregard to this difficult subject, to attempt some further plansof treatment, based, not as heretofore on the poor system of"trying plans," but upon reasoning drawn from the few factswhich we have been able to realise. I shall continue this sub-

ject at my next lecture. In the meantime we have only, bothstudents and teachers, to go on in the course of investigation.There has been a painful uniformity in the symptoms, butstill some new lights may be afforded by very keen observa.tion. So far as to the morbid changes as seen after deaththere has been a similar uniformity in all cases, as I shall hopeto prove to you on the next occasion. It is into this source ofinformation that we must be especially anxious to inquire.The two inspections which I have already had with you havebeen full of interest, and before we meet again possibly somefurther evidence may be afforded to us, which we may hope toturn to good account.

ON

COMPENSATION FOR RAILWAY INJURIES.

BY JAMES SYME, ESQ., F.R.S.E.,PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF EDINBURGH.

SINCE the passing of Lord Campbell’s Act-a most unjustpiece of legislation as it has always seemed to me, whichestablished the principle of regulating the amount of damagesfor personal injuries in accordance with the value of individualsto society and to their families, -claims of this kind have be-come very frequent, under circumstances which seriously callfor consideration. For instance, at this time last year a trialtook place at Guildhall in the Court of Common Pleas, on thepart of a commercial traveller, who prosecuted the GreatNorthern Railway Company for compensation on account ofan injury alleged to have been sustained from a collision ontheir line. In this case Sir Wm. Fergusson, Mr. Erichsen,and Dr. Russell Reynolds declared that there was organicdisease of the spine, which in all probability would soon provefatal; while, on the other hand, Mr. Borlase Childs, Mr.Pollock, of St. George’s Hospital, Mr. Cock, of Guy’s Hos-pital, Dr. Risdon Bennett, of St. Thomas’s Hospital, Dr.

Dunsmure, President of the Edinburgh College of Surgeons,and myself, no less confidently expressed the conviction thatthere was no organic disease whatever, and no reason why theclaimant should not enjoy good health. The jury, instead ofthe j612,000 asked, gave .E4700 of damages; and before theend of many months, the plaintiff, who had been rapidly re-covering, admitted that he was quite well, as he still con-tinues to be.The truth is, that when juries find the medical evidence so

conflicting, not being able to judge for themselves as to themerits of the case, they almost always decide in favour of theclaimant, so that there is thus great encouragement affordedto unfounded or exaggerated demands for redress. Indeed anyman who travels by railway may easily obtain a competencyby stumbling on the platform after the door of his carriage hasbeen opened by a servant of the company, but before the trainhas ceased to move. He has then merely to go to bed, call ina couple of sympathizing doctors, diligently peruse Mr.Erichsen’s lately published work on Railway Iujuries, go intocourt on crutches, and give a doleful account of the distressexperienced by his wife and children through his personal suf-ferings, which have resulted from the culpable negligence thatallowed him to leave his seat prematurely. Who can doubtthat in such circumstances the jury would give large damages.

This system ought certainly to be put down, and as onemeans of doing so, I beg to suggest the publication of casesexhibiting an entire discrepancy between tb medical evidence,in order that regard for professional character may tend tocheck the reckless advocacy of one-sided views. The resultsof such cases in regard to the claimant’s speedy recovery ofhealth would also be worthy of attention for the same purpose;