I have given you reasons against being afraid of over-observation, and against the pernicious habit of neglecting this case because it is common, and that because it is rare—a common excuse for neglecting all diseases, and a popular reason for doing so. Medicus sum, nihil in re medicâ a me alienum puto, &c. Some minds, indeed, are so constituted that they can make much, very much, out of single cases, out of solitary specimens of diseases. The power of minute analysis is the characteristic of this sort of observation. It is just possible so to seize upon the true conditions of a disease, as to satisfy yourself, once for all, of its real permanent attribute—of its essence, if I may so express myself. And this being seen, you may, for certain purposes, have seen enough; seen it at one glance; seen it at a single view as well as others see it at a hundred. I say that certain minds are thus constituted; but they are rarely the minds of many men in a single generation, and never the minds of beginners. Before this power is attained your observation must be disciplined into the accuracy and the rapidity of an instinct; and to this power of observation—attainable only by long practice, and after long practice—a high power of reflection must be superadded.
No such power must be presumed on. If the student delude himself, the disease will undeceive him. The best practitioners, in the long run, are those whose memory is stored with the greatest number of individual cases—individual cases well observed, and decently classified. It is currently stated that the peculiar power of the late Sir Astley Cooper was a power of memory of this sort, and I presume that no better instance of its value need be adduced. Now the memory for cases implies the existence of cases to remember; and before you arrange them in the storehouse of your thoughts you must have seen and considered; must have used both your senses and your understanding; must have seen, touched, and handled with the one, and must have understood and reflected with the other.
I am talking of these things as they exist in disciplined intellects, and in retentive memories; and, perhaps, it may be objected that I am talking of things that form the exception rather than the rule; that I am measuring the power of common men by those of extraordinary instances. I weigh my words, when I deliberately assert, that such, although partially the case, is not so altogether; and that it is far less the case than is commonly imagined. In most of those instances where we lose the advantage of prior experience, by omitting the application of our knowledge of a previous similar case, the fault is less in the laxity of memory than in the original incompleteness of the observation. Observe closely, and ponder well, and the memory may take care of itself. Like a well-applied nick-name, a well-made observation will stick to you—whether you look after it or neglect it. The best way to learn to swim is to try to sink, and it is so because floatation, like memory, is natural if you set about it rightly. Let those who distrust their remembrance once observe closely, and then forget if they can.
There are good reasons for cultivating this habit at all times, but there are especial reasons why those who are on the threshold of their profession should more particularly cultivate it. Not because you have much to learn—we have all that—nor yet because you have the privilege of great opportunities—we have all that also—must you watch, and reflect, and arrange, and remember. Your time of life gives you an advantage. The age of the generality of you is an age when fresh facts are best seized: and best seized because they are fresh. Whether you are prepared to understand their whole import, as you may do at some future period, is doubtful. It is certain that the effect of their novelty is to impress them more cogently on your recollection.
And this is practice—practice in the good sense of the term, and in a sense which induces me to guard against the misconstruction of a previous application of it. A few sentences back I used the phrases practical men, adding that those so called were men who could be taught by practice only. I confess that this mode of expression was disparaging. For the purpose to which it was applied it was meant to be so. It is a term you must be on your guard against. Practice is so good a thing of itself that its name and appellation are applied to many bad things. Slovenliness is practice; if it suits the purpose of any one to call it so; contempt for reading is practice; and bleeding on all occasions when you omit to purge is practice;—and bad practice too. Be on your guard against this: but do not be on your guard against another sort of practice: the practice of men who first observe, and then reflect, and then generalise, and then reduce to a habit their results. This is the true light for you to follow, and in this sense practice is not only a safe guide but the safe guide. It is experience, or, if you choose a more philosophic term, induction. Theoretical men can be taught by this, and the wisest theories are taught by it. When I said that practical men were taught by practice only, I never implied that they were the only men that practice could teach. Experience makes fools wise; but fools are not the only persons who can profit by experience.
See and hear—the senses must administer to the understanding. Eye, and ear, and finger—exercise these that they may bring in learning.
See and hear—the senses must administer to their own improvement. Eye, and ear, and finger—exercise these, that they may better themselves as instruments. The knowledge is much, but the discipline is more. The knowledge is the fruit that is stored, but the discipline is the tree that yields. The one is the care that keeps, the other the cultivation that supplies.
The habit of accurate observation is by no means so difficult as is darkly signified by logicians, nor yet so easy as is vainly fancied by empirics. It is the duty of those who teach you to indicate the medium.
The tenor of some of my observations runs a risk of misrepresentation. It has been limited. It has spoken of cases, as if there was nothing in the whole range of medical study but cases; and of observation, as if the faculties of a medical man were to take a monomaniac form, and to run upon observation only; of hospitals, as if they consisted of beds and patients alone; and of clinical medicine and of clinical surgery, as if there was no such a paramount subject as physiology, and no such important subsidiary studies as chemistry and botany. It is all hospital and no school—all wards and no museum—all sickness and no health. This has been the line that I have run on; and I feel that it may be imputed to me that I have run on it too long and too exclusively. Whether I undervalue the acquisition of those branches of knowledge which are collateral and subordinate to medicine, rather than the elements of medicine itself—which are the approaches to the temple rather than the innermost shrine—will be seen in the sequel. At present I only vindicate the prominence which has been given to clinical observation, by insisting upon the subordinate character of everything that is taught away from the bed, and beyond the sensible limits of disease. No single subject thus taught is the direct and primary object of your learning. The art of healing is so. You learn other things that you may understand this; and in hospitals at least you learn them with that view exclusively. If you wish to be a physiologist, chemist, or botanist, irrespectively of the medical application of the sciences of physiology, chemistry, and botany, there are better schools than the Middlesex Hospital, or, indeed, than any hospital whatever. There they may be studied as mathematics are studied at Cambridge, or as classics at Eton—simply for their own great and inherent values. But here you study them differently, that is, as mathematics are taught at a military college, or as classics are taught at the College of Preceptors, for a specific purpose, and with a limited view—with a view limited to the illustration of disease, and with the specific purpose of rendering them indirect agents in therapeutics. If you could contrive the cure of disease without a knowledge of morbid processes, it would be a waste of time to trouble yourself with pathology; or if you could bottom the phenomena of diseased action without a knowledge of the actions of health, physiology would be but a noble science for philosophers; or if you could build up a system of physiology, determining the functions of organs and the susceptibilities of tissues, independent of the anatomy of those organs and those tissues, scalpels would be as irrelevant to you as telescopes; and if these three sciences received no elucidation from chemistry, and botany, and physics, then would chemistry, and botany and physics, have the value—neither more nor less—of the art of criticism or of the binomial theorem. What you are taught in the schools is taught to you, not because it is worth knowing—for Latin, and Greek, and Mathematics are worth knowing—but because, before patients can be cured, they are necessary to be learned.
And, in order to be taught at all, they must be taught systematically. It is an easy matter to ask for a certain amount of these two collateral sciences—to pick and choose just the parts wanted for use, to require just that modicum of botany which illustrates the Pharmacopœia, and just those fragments of chemistry that make prescriptions safe, and urine intelligible. It is easy, I say, to ask for all this; but the art of thus teaching per saltum has yet to be discovered. The whole is more manageable than the half. What it may be with others is more than I can tell; but, for my own particular teaching, I would sooner take the dullest boy from the worst school, and start him in a subject at the right end, than begin at the wrong end with the cleverest prizeman that ever flattered parent or gratified instructor. Bits of botany and crumbs of chemistry are less digestible than whole courses.