No. 2715

SEPTEMBER 11, 1875.

THE LANCET.

LONDON: SATURDAY, SEPTEMBER 11, 1875.

ADDRESS TO STUDENTS.

ONCE more the rolling year brings us near to the com.mencement of another session at our medical schools, andonce more in our Students’ Number" we collect the in-

formation relating to the various universities, colleges, hos.

pitals, and schools of medicine which is of interest to thoseabout to commence or to renew their medical studies. Tc

all such we would offer, as is our custom, a word of welcomeand advice.

The change of life from the rest or preparation of themonths that are past to the busy work of those that artcoming will probably be unwelcome to none-will be plea.sant to most. The vast possibilities of the future are broughtinto more tangible reality by a sudden change to contrastedoccupations, such as to many the 1st of October will imply j ’:and the present is an earnest of the future. They have alreadysome idea of what the words 11 study " and " examination

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mean, and the consciousness of achievement which is pro-duced by the successful passage of a preliminary ordeal

gives a more vivid tint to the anticipation of future progress.Successive steps upwards seem less hard to climb when oneis felt to be already firm beneath the feet.We would suggest no discouraging reflection when we say

that the task before you will need all the ardour, all the

effort, you can bring to bear upon it. Its difficulties are not

perhaps those most apparent to you. That 11 things are notwhat they seem" is true in many applications. Thedifficultiesof life are rarely those which loom vast, with shadowy outline,in the early morning light. It is not the amount which isto be learned or obtained that is the real difficulty in thestudent’s career. It is in the path by which you are to gainthe end that the chief dangers lie. We purpose to devote

our space to-day to some indication of the manner in whichthe path, with its slippery and uneven surface, its insidiouspitfalls and enticing by-ways, may best be traversed.To the work itself there is no need you should be urged.

There are perhaps none who take the trouble to read the

suggestions we have to offer, who are not earnest in theirresolution to tread with unhesitating step and straight-forward course the student’s road. It is concerning theway to direct your good-intentioned will into effectual ope-ration that you really need advice : what to do and what toavoid in your daily occupation; how so to economise yourtime and spend your effort as to obtain in the short periodof your curriculum the best possible education for yourfuture work.

The suggestions we have to offer you, the advice you need,relate to a twofold subject-how to work and how to rest.Work is to be the subject of your chief thought. That

which is before you, could you have its details at once

visible to you, would indeed appear colossal in its propor- Itions. Abuut twelve distinct regions of knowledge have to I

be traversed, comprehended in many separate courses 0:

instruction. Each of these has to be mastered in more 0]

less completeness, some in theory only, others by practicalstudy as well. Happily the positions of difficulty have no1to be at once encountered, and by successive conquest majall be won by ordinary ability and well-directed energy.To speak first, therefore, of your work. The points on whiel

you need suggestions refer less to what you should do thaIhow you should do it. There are perhaps few students whoat the end of their hospital career, do not look back on timeeffort, and labour wasted, because at first they did not kno"B’lhow to work. The whole system of instruction to which thtstudent comes is to the large majority a strange one. Th(

transition from book study to oral teaching is one to whic1the mental habits are not easily accommodated. The sub.

jects of study are strange and unfamiliar. The method oi

inductive reasoning, on which the scientific elaborations pre.sented to him are founded, is itself foreign, often, to his madeof conscious thought. Happily a certain proportion of stu.dents now come up well prepared, well grounded in prelimi.naries, not only classical, but physical and biological. It is

perhaps impossible to exaggerate the advantage which isafforded by such a knowledge of the methods of reasoningemployed in the natural sciences. We are glad to believethat a constantly increasing proportion of those who begiathe more stern curriculum have been thus trained.

Let your work be uniformly steady. Prevent the need

for "spurts." Do not attempt too much at first. Begin asyou mean to go on, and go on as you begin. How longshould you work a day P This will be in some measure de-

cided for you. You should aim at reading three hours a

day, apart from the lectures you attend and the practicalwork you are engaged in. If you do this and persevere in

it, you will, if your work is rightly directed, be not far atthe end of the session from the position at which you aimed.There are two styles of work. Some men will work un-

remittingly at one subject at a time, mastering it, and thenpassing-to another. Others work uniformly at all the sub-

jects they are studying, devoting daily such a time to eachas shall enable them to make sure of the portion they havethat day received. There can be no question that this

latter method is that which yields the best results. It maynot be so successful in obtaining prizes, but it will leave

you with much more satisfactory knowledge and a muchmore honourable position at the end.The ultimate end of your study is to obtain a well-

grounded knowledge of the three great divisions of medicalscience and art-medicine, surgery, and midwifery. Theyconstitute the triple structure which you are to build, andit is to be erected on a triple foundation. Anatomy, physio-logy, and chemistry are the three corner stones on whichthe erection is to be based. Ancillary, and important insubordinate positions, are the collateral sciences of botany,comparative anatomy, and zoology. Materia medica, medi-

cal jurisprudence, and hygiene are, in effect, based on andcompounded of other sciences.

All these studies differ from those which will probablyhave occupied your preceding attention in the circum-

stance that their facts are iolcZtFi in thuir presentation,in varying degree it is true, but more or less in all. In

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many other branches of study the facts are so linked

together that they are repeatedly brought before the

student’s attention. The demonstrations of mathematicsare involved in the discussion of subsequent problems,in substance and in method, to an extent which renderstheir retention in the memory easy. The facts of classical

studies, the meaning of words, the construction of sen-

tences are constantly recurring in fresh association but

repeated similarity, so that they are indelibly imprinted onthe memory and can be retained with little conscious effort

on the part of the learner beyond that involved in their

acquirement. With the physical, and especially with themedical, sciences it is very different. Few facts in anatomyinvolve any which have gone before. The result is that

the student, in acquiring new facts, is constantly liable to

forget the old, however well he may have learned them.Hence it is necessary to ensure, by constant, diligent, forced

repetition, the retention of that which has been alreadyacquired. There is no subject of study in which this ?not necessary; but the need for it is much greater in somethan in others. The disjunction of fact in some medicalsciences is painfully complete, extending down to the mi-nutest details. In others it is less so. But with respect toall it is true that, for any effectual retention of the

facts acquired, frequent repetition is necessary. The

student should aim at keeping fresh in his memory thatwhich he has before learned, so that at any moment his

past acquirements may be as accessible and as accurate asthose of the most recent date. This is difficult, needs much

perseverance, but is indispensable for successful study. It

is the only system which will rob coming examinations oftheir terror and enable you to dispense with the help of the"grinder."A large proportion of the knowledge you acquire has to

be conveyed to you by the use of symbols. A proportion,also large and happily every day increasing, is learnt byactual observation, by obtaining evidence with the varioussenses of the facts in question. Different minds will ap-

preciate in different degrees the respective methods. To all

the method of actual observation is of incalculable value,

impressing the facts upon the mind, and training thestudent to look beyond occurrence for cause, to search forthe operation of the law of sequence, which is the greatproblem of medical practice, and which is indispensable toany efficient exercise of medical skill. In recording facts,observations, and statements made to you, vary the symbolicmethod you employ. Wherever you can, let a diagrammaticrepresentation aid the written note. The roughest sketchor diagram, wholly inartistic, will prove of the greatestvalue in fixing on the mind a relation which no descriptioncould accurately convey.

This leads to the question how far you should take notesof the lectures you have to attend. On this no general rulecan be given. l4Zost men find that they can attend better,can carry away even in memory more of what is said tc

them, when they take notes than when they do not. Witb

others it is not so; the attention, unembarrassed by anjmechanical occupation, can receive, and the mind retain.far more when the hands and mind are at rest. It wil

vary, too, with different lecturers. The care in the col.

lection, in the classification, in the presentation of factswhich some lecturers take, renders their lectures of so

much value that it is well to secure as much of them

as possible. When you do take notes, endeavour to

take at the time such notes as you can keep per-

manently. The time spent in writing out notes is often

time absolutely wasted. Moreover, it is a dangerous wasteof time. The student is apt to fancy, when he has writtenout his notes, that he has learned them. The facts have

become familiar; he can, perhaps, recall the chief in detail;but as a rule, under the circumstances, they are not learned.The facts speedily vanish from the mind. Therefore, if you dowrite out notes a second time, take care that you learn them

thoroughly as well; and do not mistake the act of writingout for the operation of learning them, similar as they mayat the moment seem.

Some of the subjects of your study are to be learned in

practice as well as in theory. This is the case, to the greatestextent, with anatomy. There are very few facts of anatomywhich you have to learn which you cannot vedfy for your-selves. With physiology and chemistry it is so to a less

degree. In medicine and surgery the facts are capable ofverification to a great extent, but not with such complete-ness as in anatomy. It is one of the greatest improvementsin the medical schools of the present day that practical in-struction is carried to almost the highest point to which itcan be brought. Many subjects which before were taughtin theory only are now taught, and very thoroughly taught,in practice also. It is so in histology, normal and morbid;it is so in chemistry; and it is so in many parts of phy-siology. Make, therefore, the utmost possible use of youropportunities of acquiring the practical knowledge, whichis so much more easily retained and so much more usefullyreproduced when needed, than any mere theoretical know-

ledge ; but be careful not to content yourself with practicalwork. You must study and think as well as observe. There

is great danger in allowing the mechanical to take the placeof the intellectual. It is so especially in anatomy. The

student dissects carefully, and imagines that by careful dis-section, by careful " cleaning" of his parts, he is learningtheir anatomy. He may be, but is not necessarily doing so.He must supplement his practical work with careful readingand thoughtful observation. He may economise much pre-cious time by accurately observing the position and relationof that which he has dissected. But in any case dissections

must be thoroughly learned. Note carefully the connexionsbetween the different objects in the region you are dissect.

ing. Endeavour, as far as you can, by careful systema-tising, to reduce everything to well arranged and orderedform. The increased power and knowledge will be muchmore than recompense for the additional trouble which the

method gives you.The arrangements of the curriculum will probably seem

to you in many respects unreasonable. They are not per-fect ; but bear in mind that the parts which seem to you tobe faulty have objects which you may not now perceive.Patiently endeavour, then, to make the most of what

appear to you its useless provisions. Your patience willoften be tried by having to listen to what seem out of placeaccounts of departments of knowledge as yet Quite un-

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familiar. Do not H cut" lectures because you do not see

their value. Endeavour to attend them regularly, and to

carry away as much as you can, and you will find your

subsequent work in other subjects, as well as in that depart-ment, rendered easier.With reference to the later studies of medicine and sur-

gery we would repeat what we said of the earlier ones-embrace every opportunity of acquiring knowledge prac-tically by direct observation. Examine patients for your-selves-touch, feel, handle, listen wherever you can. You

cannot educate too carefully your senses to appreciate the

signs of disease. In the majority of cases those signs may beindubitable and obvious; but in others, frequent enough,they are so obscure as to need all your knowledge, all yourtact, all your practice to recognise and weigh them. These re-marks, generally applicable as they are, apply with much forceto the post-mortem appearances of disease. Lose no oppor-

tunity of witnessing post-mortem examinations. If you haveseen the cases during life so much the better; but whetheryou have or not, attend the examination after death. Make

yourselves thoroughly familiar with the normal appearance oforgans and with the variations from the normal which maybe met with apart from actual disease. It is impossible toexaggerate the importance of your present careful study inthe deadhouse. You will have opportunities throughoutlife of keeping up and improving your clinical knowledge.Every day’s work is a day of clinical practice. But when

you are engaged in actual practice, opportunities for patho-logical observation will come rarely; but when they docome, on your knowledge and experience important issueswill often depend. If the knowledge which might havebeen acquired during student-life is not gained, the oppor-tunities of obtaining it will probably not recur, and the losswill be life-long.In the wards, do not let your desire to observe for your-

selves carry you, as it does with a large number, chieflywhere observation is easiest. The eye is the organ most

easily educated; do not give it, therefore, an exclusive shareof attention. Exercise your other senses. Do not be alwaysrunning after sensational cases, or hanging over the railsof the operating theatre. If you are working at surgery ormedicine, examine the patients when the dressers or clerksare working, and then, having learned the signs and sym-ptoms of the cases, attend the surgeons’ and physicians’visit, to hear their remarks and note what you have failedto observe.

It follows from what we have said that you should make

it one of your first objects to hold practical posts in thehospital. Despise nothing, however low, that gives youscope for the exercise and improvement of your knowledge.When you have the actual treatment of patients entrustedto you, note carefully the results of the remedies you em-ploy. Do not prescribe and take no notice of the effectof your treatment, but look diligently for, and note theabsence as well as the presence of the results you expectedto follow. Above all, you should study and think over thecases you see. Read up every important case you meet with,and endeavour to fix its salient points in the memory, so as tobecome familiar with those that are typical of the disease.To turn now from your work to the other object to which

your time must be devoted-rest. How to rest is in import-ance second only to how to work. The opposition of termsis not, perhaps, that which seems most natural to the juniorstudent. To those who are ending their work it may havea more obvious significance. " Work and play" is the

usual time-worn antithesis. "Play," however, is a term

which accords better with the amusements of the

schoolboy than of the student. It implies an elevatiou ofa pastime, a relaxation, into an object of primary import-ance. If you wish to be successful, to acquire fairly theknowledge needful and for which you are sent to a medicalschool-if you wish to fit yourselves for future work in life,you must first of all learn to subordinate, in thought andaction, your recreation to your work. The recreation youtake should be of such a kind as will best fulfil its end-to

re-create and strengthen your powers. It is on this account,and no other, that you should choose it. What it, then,should be you must allow your strength and opportunitiesto decide. It should be one which provides effectual changeof thought and occupation. It should give a sufficientamount of exercise, and exercise in the open air is essentialfor its due beneficial effect. It should leave no unpleasantafter-taste, physical cr moral. It should not be one which

has for you any special seductive attraction, which maynow or at some future time prove too powerful to be effectu-

ally repressed. You may be fonder of one amusement than

of another; you may have more natural aptitude for onethan for another. Beware how you allow your inclination

or your aptitude to be your guide in electing your habitualrecreation. In so far as you allow these, rather than its

effect, to guide you, you raise recreation from its subordinateposition and make it an end instead of a means.Bear in mind at all times the responsibilities of your

profession. You will hear much of them in the openingaddresses, and we will not dwell upon them now. We will

only urge you, above all, to cultivate tenderness to the

sick under your charge, not only in action, but in word andeven in thought. You will often have to inflict physicalpain, sometimes to cause mental suffering; but let the

latter as well as the former be as little as possible. How

much pain is caused to sick persons by thoughtless, incon-siderate modes of expression is incalculable. Remember

that you come in contact with the tenderest points of theirnature. The expression or the gesture or the slight neglectwhich has in it nothing in itself blameworthy, which wouldcause no annoyance to a healthy person, may to them be asource of much distress, of pain as real as any you inflictupon them physically. Pain, disease, and death are hardlymore than names to your subjective life; to those to whomthey are the realities of the present or the nearer future theychange the whole course of thought and feeling. Beware,then, how you judge the sick by the standard of the healthy.Endeavour to enter into their feelings. Bear with the irri-

tability which may be annoying to you, the obstinacy whichmay vex you and render your own task needlessly difficult.Invest suffering in another with that reverence which isdue to its sad mystery. It has its roots deep down beneaththe surface of our life, and reaches, in each, the inner depthsof calm or storm, in a region into which you cannot pass,except by tender sympathy and thoughtful care.