No. 3237

SEPTEMBER 12, 1885

THE LANCET.

LONDON: SATURDAY, SEPTEMBER 12, 1885.

ADDRESS TO STUDENTS.

IT is probable that the great majority of those who willread these observations have either decided to enter uponthe study of Medicine with a view to practise it, or havealready advanced some length along the path to a medicalqualification. We must, however, preface any advice tosuch readers by a few words to those who are only consider-ing the choice of a profession, for it is the sad lot of all

teachers and practitioners to see men attempting to

enter the profession of medicine who are manifestlyunfitted for it. It might seem needless to caution the blind,the halt, the maimed, and the lame against such a line of lifeas that of the medical practitioner; but having seen studentsso short-sighted that all study was a difficulty, and someforms of practical work an impossibility, or stammering tosuch an extent that conversation was well-nigh imprac-ticable and always embarrassing, or so deaf that ausculta-tion revealed nothing to them, or so lame that in more sensesthan one they were greatly out-distanced by their fellowsm the race of life; having as we say, actually seen all these,we are compelled to speak strongly against the folly and thecruelty of parents and guardians permitting a youth with anyobvious physical deformity or inability attempting the studyand the practice of medicine. The point does not admit ofargument, and the mistake can only be made when it is

supposed that some special ability or some particularlyfavourable opening for practice will counterbalance any dis-advantage arising from such an infirmity. We can onlyrepeat that such a hope is but a delusion which is fraughtwith very painful consequences to those who are the

subjects of it. But not only should the medical

practitioner be fully possessed of his five senses, he

should have also a good constitution and sound health.It is true that there are many different walks in the broad

field of medicine, and that in some " the wind is temperedto the shorn lamb"; but even there the possessor of

sound health has an enormous advantage, and in the com-mon lines of practice he has the field altogether to himself.Year after year we have to chronicle the untimely death ofsome youth who has been worsted quite early in the fight, orof some young and able practitioner who has fallen a victim tothe exigencies of practice or of his science, just at the timewhen he and others are reaping the chief fruits of his earlierlabours. And who can estimate the weariness and heart-

ache of many more who day by day feel the pressure of theirwork too great for their feeble strength. But if the physicalpowers of a youth are to be carefully considered, the mentaland moral character are of equal importance. It is both

vain and wrong to ask that only boys of the highest orderof mental calibre should be allowed or incited to studymedicine. Such will find in it ample scope for all their powers,but the youth of average capacity will be able to master theprinciples of the various sciences on which the successful prac-tice of medicine rests, and will be able to fill worthily and well

many of the posts in the broad field of medicine. But, onthe other hand, the dullard and the dolt should not beallowed to choose medicine as their profession; averagemental powers are a sine qud non. And not only so, but theintending medical student should be in deed and in truth astudent, one to whom patient study is a pleasure, and whohas to some extent formed the regular habits of a student.For it should be well understood from the outset that the

study of medicine requires patient, regular, diligent workall through the usual curriculum, if at the end of it thelicentiate to practise is to be really fitted for his position.The practice of medicine is no longer empirical, by rule ofthumb-to be learnt by seeing what others do; but year byyear it is becoming more and more scientific, demandingincreasing intellectual effort for its comprehension and

execution. On the necessity for good morals, in the coarseracceptance of that term, we need not insist; but it is wellfor the advisers of a youth to remember that the callingof a medical man is one that demands a high standardof moral excellence. Above all, a love of truth should be a

distinguishing feature, for in no other profession are thereso many pitfalls for those in whom this virtue is not con-spicuous. A cheerful, kindly disposition, an outspokenmanly frankness, a power of evincing sympathy apart fromall forms of mawkish sentimentality, the ense so rare, butyet called "common sense," and that which we all recogniseas strength of character, are the other features which shouldnot be sought in vain in the youths who, in a few weeks,will be entering at our medical schools. For success in

medical practice, neither wealth, nor friends, nor mere

intellectual endowments count for so much as character,which may be alike the birthright of the poor and the rich.To those who,,in any fair way, fulfil the conditions we

have named we can promise in the study and practice ofmedicine full scope for all their powers, honourable success

in life, and the truest education ennobled by a life-longbeneficence.

QUALIFICATIONS AND DEGREES.

Having decided upon a medical career, the first point forthe student to determine is what qualifications to practiseand what honourable medical degress he should seek toacquire. We would urge upon all to consider this matter

carefully at the outset, for when, as not rarely happens, astudent sees reason to change his course midway, it usuallyentails considerable loss of time, both directly and indirectly.The decision must mainly depend upon two factors, the oneintellectual the other pecuniary. Every lad of good intel-lectual powers and studious habits, coupled with goodhealth, should unquestionably acquire more than a merelicence to practise-either a degree in medicine at a uni-versity, or the Fellowship of the Royal College of Surgeonsof England, or both. As the course of study for eachof these higher degrees is practically the same, the

student need not at once determine which of them he shall

take. With the increased facilities for obtaining a medicaldoctorate, the holders of this title are becoming muchmore numerous, and its advantages are such as will wellrepay the extra time and money its acquirement costs.Teachers frequently have to listen to the regrets of seniorstudents, who complain that when they commenced theirstudies they and their advisers were alike unaware of the

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importance and of the means of obtaining a degree inmedicine. We trust that none of our readers will allow

themselves to experience the disappointment which it hasoften been our lot to witness. Where, however, a studentfinds study a labour and a weariness to the flesh, or hisintellectual powers are not well up to the average, or wherehis early education has been deficient, it is far wiser not toattempt to obtain the higher qualifications, for not only willthe failure to do so entail disappointment, with its attendantevils, but it will probably involve waste of time, disarrange-ment of the curriculum, and the distraction of the student’sattention from those parts of his work upon which he willhave chiefly to rely for success in his after-life. The extra Icost of such qualifications, both in themselves and in theadditional time required in preparation for them, should befaced at first ; and where the means at the student’s disposalare such as only to allow of his obtaining the usual licencesto practise, he may solace himself with the reflection thattrue merit is sure of due recognition and reward, and thatin the future, as in the past, both success and honour maybe obtained in the practice of medicine, even without theadornment of the coveted initials.

THE CHOICE OF A SCHOOL.

The choice of a school should next engage attention.Matters of secondary importance are often allowed to deter-mine this choice, such as the connexion of a relative orfriend with a particular school, or acquaintance with oneof the staff of the hospital. This last is no doubt of

distinct advantage, and, wherever possible, an intendingstudent should secure an introduction to at least some one

of his teachers. But, after all, the primary factors in theselection of a school are other than these. Where a specialcourse of study is to be pursued, it is unquestionablydesirable to enter at a school where there are several other

men taking the same course. But, other things being equal,th most important point is to choose between a large anda small school. Where a lad is well able to fight his way inthe world, has a certain independence of character, or hasunusual ability, he should, without doubt, enter at one ofthe larger medical schools, where he will derive greatadvantage from contact with many minds, and will not bein danger of falling out of the race; but for youths ofless independence of character or vigour of intellect, whoneed more individual oversight from their teachers, or forthe timid and retiring, who cannot maintain their ownamong a large number, the smaller schools are best adapted.The schools of intermediate size are very valuable, as com-

bining to a large extent the distinctive advantages of eitherextreme. Without in any way particularising schools,we wouldfurther point out two or three things that should be kept inview before a final choice is made. And, first of all, thechoice should not rest upon the reputation the school mayhave had in the past. From many causes schools fluctuate

very much from decade to decade, and therefore some painsshould be taken to inquire into the present condition of theschool-the honoured alma mater of the father not alwaysbeing the best place for the son. Such an inquiry shouldinclude four points at least. The first is as to the provisionof proper means of teaching the various sciences upon whichthe practice of medicine rests, and especially the practicalbranches of these sciences. The second is the existence 01

sufficient clinical material in proportion to the number ofstudents "walking" the hospital. The third is the care

taken in utilising this material in systematic clinical instruc-tion. And the fourth is the number of resident appoint-ments open to the senior students as a reward of merit, andnot dependent upon the favour of the staff or the opulenceof the student. The value of such appointments cannot beoverstated, and every student should make it his ambitionto hold at least one of them; they should not, therefore, b,bestowed by favour or be purchasable by money.With this we must bring to a close our remarks on this.

part of our subject. There is much more that might besaid with advantage, but we have said enough if we havesucceeded in showing that great care should be taken,not only in arriving at the choice of the profession ofmedicine, but also in marking out the chart of the student’sprojected voyage, and in the selection of the ship to bear

him safely and well to his journey’s end.THE CURRICULUM.

It is unnecessary for us to give any counsel as to thecurriculum the student should follow, for at each school thisis carefully arranged so as to meet in the best way the wantsof those preparing for the various medical qualifications,and the student should seek and be careful to follow the

advice of his Dean on this matter. We may, however,impress upon our readers the great importance of passingthe qualifying examinations at the specified time. The

curriculum is always arranged with this view, and if

one or more of the examinations be postponed, the student’swork is disarranged, for he has to study the subjects-taught in his earlier lectures while he is attending the latercourses, from which he is therefore unable to derive full

benefit. Of course this applies most to the earlier exami-nations ; and here let us notice the great importance ofthe student’s first session. It used to be a common

notion among certain medical students that the first

year at the school was of small moment, and mightwithout serious harm be wasted in various amusements.

Lately the Colleges of Physicians and Surgeons have so

rearranged their examinations that students have to passone at the end of their first year, and hence from what we

have already said it is evident that this year cannot be

misspent with impunity. But, apart from that, the studentsfirst year at his medical school is the most valuable to him

of all, for in it he forms habits which will influence hiswhole future course, and starts out either on the right or thewrong path. In it worthy friendships are most easilyformed, and habits of regularity, punctuality, and of pains-taking industry are most easily acquired, and when thusacquired become almost a second nature. On a well-chosen

friendship great store is to be set. A man’s best friends, orhis worst, are those of his youth ; and few things, if

any, add more to the true happiness of a life than

a close and life-long friendship. But student-friendsare of great help to each other in their work. In free

informal chat the best qualities of heart may be culti-

vated ; while in friendly discussion, as distinct from

polemical wrangling, the intellectual powers are exercisedand quickened. When possible, it is best for the student toseek his friends among the men of his own year, so that their

work will bring them together and give them common in-

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terests. And if, in addition to the work of the schools,friends can together make the pursuit of some branch ofnatural science their pastime, they will enrich their after-life in a degree little imagined by those unable to do so. It

matters little whether it be zoology, botany, geology, or anyother of the " ologies"; in the pursuit of any one of themthere is great delight, which to the medical man is enhanced

by the side lights they throw upon the subjects of his dailywork. And, further, it is most important that those whoare so busily occupied as the practitioners of medicine

usually are should have some pastime always ready at handto which they can turn for refreshment and true rest.One of the peculiarities of the medical curriculum which

will early arrest the attention of the intelligent student isthe compulsory attendance upon the same course of certainlectures on two successive years. Of late the tendency hasbeen to modify this arrangement, and to lessen the numberof lectures that the student is compelled to attend. Weare not ourselves satisfied of the wisdom of this modifica-

tion, and believe that it is but a preliminary step to a still- further rearrangement of the curriculum. The argumentsfor and against enforcing attendance upon lectures are toofamiliar to need repetition here, and we can only state ourconviction that lectures are of immense value to the students,provided only that they are good lectures. When rightlyfollowed, double courses of lectures are not a mere wearyrepetition for the student. They are planned with a i

view to letting the junior man acquire in his first

year an acquaintance with the principles of the sciencetaught, and a general outline of the subject; then, inhis second year, coming to the lectures with a carefullylaid foundation, he is able without difficulty to acquiredetails and build upon it the desired superstructure. And

this is the plan upon which the student should pursue allhis studies. His first and chief aim should be to acquire a

knowledge of the scientific method, coupled with an appre-ciation of the value of scientific precision. He is then

prepared to grasp the principles of the sciences upon whichthe intelligent and successful practice of medicine and

surgery rests, and only after that should he seek to add tohis stock of knowledge a mass of details. Too often an in-

dustrious student is so intent upon acquiring details that hefails to become a thorough master of principles, and whentime has obliterated his clear recollection of the mass of more

or less disconnected facts with which he had burdened his

memory, he is distressed to find that his labour has been

wholly lost. When principles are mastered, details are easilyacquired and more readily retained in the memory, for theprinciples form, as it were, a framework upon which thefacts hang. A scientific principle, too, when once appre-ciated, is rarely, if ever, again lost; but it is only when aman is still at his college or hospital that he is in a reallyfavourable position for becoming imbued with scientific

modes of thought or of comprehending scientific theoriesand principles. Unless he be a scientific man in thoughtand purpose when he enters upon his life’s work, there issmall prospect of his ever becoming one. But every day of anobservant man’s life adds to his stock of knowledge and hismass of details, while the possession of the scientific instinctquickens the perception of the true and endows with acharm what would otherwise be simply laborious. In

saying this we would not be understood to undervaluethe importance to the student of his having a well fur-nished mind thoroughly stocked with accurate knowledge;we are only striving to point out that such knowledgeshould be held second both in importance and time to truescientific education and to the mastery of the principles andlaws of science. Lest we should be misunderstood, we hastento add that next in importance to this is the acquirement bythe student of medicine of accuracy of manipulation andof observation. It is for this reason, as well as others of

equal and obvious importance, that the pursuit of practicalanatomy is of such supreme value. We can assure our

readers that too much time or care cannot be devoted to dis-

section ; and above all, we would impress upon them thathurried, careless dissection is quite valueless and a merewaste of time, for the study of anatomical models or draw-

ings is capable of teaching as much with the expendi-ture of far less time. The beginner may naturallybe at a loss to understand why so much stress should

be laid upon each individual student laboriously’ dis-secting all parts of the human body, when so much

ingenuity has been shown in designing excellent ana-tomical plates and models, or when the results of one

man’s dissection can be studied by an entire class. But

his first careful dissection will convince such a one

that it is while he is working and is cleaning the variousstructures, and not when all this is done and the dis-

section completed, that he learns the anatomy of the

part. When the student has completed a dissection its

educational value for him is at an end; and so it is

that nothing can ever form a substitute for patient, carefuldissection, and the student should, at the outset of his

course, steadfastly resist the temptation which " demonstra-tions" and so on offer to the neglect of his own personalwork. If care be taken to acquire accuracy and skilful

manipulation in the dissecting-room and in the histologicallaboratory, there will be no difficulty in studying medicine andsurgery in the same careful way or in carrying out the variousmanipulations their practice demands. And here we would

pause to urge students to lose no opportunity of becomingpersonally familiar with all the manipulations and detailsof practice they will see in the medical and surgical wardsof their hospital. The student should himself take tempera-tures, pad splints, hold stumps, prepare dressings, and applyevery kind of bandage. Experienced nurses become so

skilful in one and all of these that students are prone to

stand by and watch them, partly from a vis inertiae, andpartly from a fear of showing themselves less skilled. But

if they do, they will not be long in practice before boththey and their patients will have cause to regret their

neglected opportunities. Even the simplest manipula-tions require practice before they can be performed easily,quickly, confidently, and well. Nothing looks easier thanto take the temperature of a patient accurately, and yetnothing but practice can render anyone familiar with

the many little details which are essential to accuracy or

enable him to register his results with justifiable confidence *Of course this advice applies with equal force to thepractical use of the various special instruments used forpurposes of diagnosis and treatment, such as the stethoscope,laryngoscope, ophthalmoscope, apparatus for quantitative

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analysis of urine, tourniquets, specula, &c. In these matters

as in so much else, the practical knowledge and handinessof the student when he leaves his hospital are his stock-in-trade throughout life, to which he will be able to add butlittle in after-years, although he can turn them to increasingadvantage as his experience grows.

CLINICAL LECTURES.

In reference to the later parts of a student’s career wewould add a word as to the value of clinical lectures, andthe more advanced the student the greater the advantage hewill obtain from a regular attendance at these lectures. Wehave sometimes heard such lectures spoken of as painfulnecessities for the student, attendance upon which is a stern

duty devoid of benefit. But unless the lecturer be unfitted for

his task or careless in his preparation, or the student attendthe class before he is able to appreciate the instruction given,this is an entirely mistaken view. In connexion with these

classes particularly, and in the regular visits paid to thewards, much advantage is to be gained from the habit of note-taking. We cannot now enlarge on this point, nor is it

needful, for we are content to apply to this as to the otheritems of advice we have ventured to give to the student,the injunction: "Prove all things; hold fast that which

is good." This may well be taken as the motto of the student ’,all through his career. At every step in his course he willbe placed in a position personally to verify the accuracy ofthe statements of his teachers, and if only he learn how toquestion Nature and elicit from her accurate answers, hewill enter upon the practice of his profession with a mineof the truest wealth at his feet.

CONCLUSION.

Of very many questions of importance to medical studentswe have been unable to say a word in the space at our

disposal. We have not discussed the relative value of aclassical or of a scientific preliminary education, believingthat to all or very nearly all our readers any advice on thispoint would be offered too late, and well knowing that inthis matter the schoolmasters have almost entire control.

Nor have we discussed the best directions for the licensed

practitioners to turn their attention to when leaving theirhospitals. The factors which enter into the question areso varied and so personal that it is unprofitable to I

discuss it in any general way. At the close of his course

the student should seek the counsel of those who have

watched his career, and who can judge of his capabilitiesand his special fitness for any particular department of

practice. Nor have we alluded to the question of medical

specialism. Whatever may be thought on this subject as itaffects practitioners and the public, to the student, at any rate,there should be no specialism. Not only should he avoid

pending an undue share of his all too short curriculum onlone department of m ’dicine or surgery at the expense ofothers, but he should be very careful to avail himself of allthe opportunities afforded him of becoming acquainted withthe teaching and practice of those who have charge of thevarious special departments of his hospital. Unfortunately,there is a great tendency for students to neglect thesedepartments, and if only they would follow the advice heregiven, the evil of medical specialism would quickly be ingreat part remedied.

Nor have we said a word upon the sports and pastimesbest adapted for medical students. Individual tastes differ

and must be allowed fair play. We wouldonlyurgeour readersto remember that, if true students, they must hold all thingssubsidiary tu the proper pursuit of their studies. All that 6t$

them for their work is to be cultivated ; all that interfereswith the due punctual and regular attendance upon classes orother parts of their work, or that tends to rival in interest

the work they have taken in hand, must be resolutely fore-sworn. Within these limits, the wider the scope of a

student’s activities, and the more completely he can eerci:eand train all his powers, whether of mind or body, ttebetter; and, above all, let him take counsel from that oldbut not obsolete Authority which says " Whatsoever tt)Thand findeth to do, do it with thy might." "

THE CHOICE OF A TEXT-BOOK.

THE question which the student is always asking, andnaturally, is what book will best serve his purpose in pre-paring for certain examinations. The answer to this

question is one which becomes every year more difficult.The number of medical text-books of a high class is nowvery great; therefore to select a few from amongst themmay seem invidious. At the same time a list, which by nomeans pretends to be exhaustive, can be drawn up thatmay prove of value as a guide to the student in his choice.As representing all the various examining bodies, we maytake for this purpose the Examining Board for England(Royal College of Physicians and Royal College of Surgeons)and the University of London.

THE EXAMINING BOARD FOR ENGLAND.

For the First Examination of this Board the student will

be required to have gained a fair knowledge of ElementaryAnatomy and Physiology, of Botany, Chemistry, MatersMedica, and Pharmacy ; and if he be diligent he should beable to pass both parts of the examination by the close ofhis first year. In Anatomy, he may have recourse to GRAÙ sText-book, and to the works on Osteology by WARD, HOLDEN,and NORTON. In Physiology, the Elementary Text-book ofHUXLEY might well be mastered first. In C3cenisty,RoscoE’s Elementary book and ATTFIELD’S work. In

Chemical Physics, FowNES’ Inorganic Chemistry, edited byWATTS, or BALFOUR STEWART’S Elementary Physics.Botany: OLmER’s Elementary Botany; BALFOUR’S, or

BENTLEY’s, or THOMB’s book. Materia Medica: The work,of MITCHELL BRUCE, ROBERTS, GARROD, and BRUNTOX’9or OwEN’s Elements.

For the Second Examination (corresponding to the PrimaryMembership at the College of Surgeons), the subject of

Anatomy may be well studied in GRAY’S Anatomy, ELm’, sDemonstrations, or HEATH’S Practical Anatomy. The

anatomical plates of ELLis and those of GODLEE are very zuseful in supplementing practical work, or the handier

volume of MASSE. In Physiology, the books most to berecommended are RxRxES’ Handbook, G. YEo’s Text-book.and H. PowER’s Elements; and Histology, apart from thesections devoted to it in the works of GRAY and EiREE..

may be read in KLEIN’S Elements.

For the Third or Final Examination in the subjects :

Surgery and Surgical Anatomy there are the text-books o: