It is often a distinguishing mark of those who have achieved most that they are deeply concerned about the incompleteness of their work. Sir James Mackenzie was no exception to this rule. Indeed, his work, in the sense in which lie himself understood it, was but beginning; the foundation had scarcely been laid. It was this knowledge which drove him, at the zenith of a remarkably successful career as a consulting physician, to abandon his practice in Harley Street, and to return (literally) to general practice. At a moment when
"specialisation" had reached, perhaps, its most extreme form, such an action left his professional brethren in amazement. It was even suggested that the only possible explanation was a. breakdown in health. But at that time Mackenzie's health was excellent ; his concern was rather the health of his profession. He who had, as a general practitioner, originated one of the most intensively specialised branches of medical study—namely, modern cardiology, with its elaborate instruments and exquisite methods—left that study behind at the very moment when academic bodies all over the world were offering him their con-
THE SPECULUM. 35 gratulations and honours. He left it because he had discovered its limitations.
From research in the heart he had already passed to contemplation of the whole living creature. That is to say, he had rediscovered himself as a general prac- titioner, a man primarily concerned, not with the processes of disease, but with the human reactions to those processes. In this dim field his genius flashed for the last time. There was given to him a vision of life as an unsuspected, mys- terious force, different in its essence from the "electrical stimulations" used by physiologists to replace it. Face to face with death, he wrote to a friend that
"the whole of the physiological interpretation of the functional activities of organs will have to be scrapped." These ideas are now leavening medical thought in many lands. Like all simple ideas, they are revolutionary, and can only very slowly find a place in conscious intellectual activity. Thus Mackenzie passes, separated from many of his own disciples who were unable to follow him on his last and greatest adventure. His immortality, indeed, is not in the great text- books of his earlier years, but in the minds of the family doctors of this and other countries, in which the seed he has sown will assuredly come in time to a rich harvest.
--Times, 27/1/25.
( . ) V ir, In (ar
inaugural AbOrese to lboepttat %tubente, 1925.
By MR. B. T. ZWAR.
An official opening of the Clinical School is a practice which has long been honoured in various clinical schools of Great Britain. It is one that used to be carried out at this school by an address from the chairman of the medical staff, but somehow the practice fell into disuse.
When during the last year a committee of the medical staff had reviewed its standing orders this committee forwarded a report, which contained the recom- mendation, "That there should be again an annual address relating to the open- ing of the Clinical School, and the clinical work of the medical course." This recommendation was duly adopted by the medical staff, and embodied in its standing orders.
To-day, then, it is my duty and privilege to renew a time-honoured custom.
I have selected for my address certain questions and problems associated with the medical curriculum, questions and problems which confront you now, or will confront you at various stages of your career.
In order fully to appreciate some of the problems associated with the system of medical training, and particularly with the clinical part of the same, it is de- sirable very briefly to trace the evolution of medical education.
Modern medical teaching has as its earliest foundation the work of the great Greek. physician Hippocrates (460 to 357 B.C.), a careful and observant physician, who, even at that remote period, was a strong believer in surgical measures. The great feature of his work was the recognition of disease as a result of natural causes. He and his followers bequeathed to the medical world the principles of minute observation of symptoms.
Previous to Hippocrates the practice of the medical art had relied more
upon the influence of some deity than upon any intrinsic efficacy in the methods adopted, e.g. : The priests of ./Esculapius—Greek god of healing--relied upon purely religious exercises to effect a cure of disease.
There are some points in the early history of surgery that are of special in- terest in studying its evolution. Although medicine and surgery now dove-tail into one another, and have inter-connecting features, the two arts have a separate history, and at some periods there has been a hostile relationship be- tween the practitioners of these kindred arts.
In surgery, you are still reminded of the early association of the callings of the barber and the surgeon by the fillet round the barber's pole ; this signified the ribbon which was bound round the patient's arm before bleeding. Up to 1540 the two callings—that of the barber and the surgeon—were practised by the same individuals. It was in 1745 that the surgeons seceded from the Barber- Surgeons' Company, and formed the Royal College of Surgeons.
It will be readily understood that the position in public esteem of medicine and surgery in those days was in marked contrast with that of to-day. The change is the result of fruitful and epoch-making labours of many research workers in the fields of medicine and surgery and their kindred sciences, to- gether with the evolutionary changes in the teaching and training of medical men and women.
The history of the evolutionary period is full of interest, and well worthy of your study. The historical steps of the development of medical education in modern times are thus summarised by Sir George Newman :
After the Rennaissance, medical teaching consisted of courses of anatomy, botany, with a little bedside lecturing,. and an occasional autopsy. In the 17th Century, Mayerne developed bedside study in England, and lecturing increased.
In the 18th Century came dissecting as a routine, and under the inspiration of Bwrhaave were established chairs of clinical medicine and surgery, and an appren- ticeship system, combined with hospital instruction. Private coaching or medical schools were undertaken by Smellie in obstetrics, Cullen in medicine, Black in chemistry, and the Hunters in anatomy and surgery. Hospital pupilage, how- ever, was unorganised, and mainly self-determined by the student. The General Medical Council of Medical Education and Registration of the United Kingdom was constituted by the Medical Act of 1858. The present medical curriculum has evolved as a result of the activities and influence of this body.
With the steady advance in knowledge of medicine and surgery, and the kindred sciences, the curriculum must constantly undergo evolutionary changes.
As at present constituted, it consists of two clearly defined parts. The first part
—the first three years—includes the training and practice in the basic sciences of medicine, chemistry, physics and biology, and their application to medicine.
It includes those fundamental subjects of anatomy and physiology.
The second half of the curriculum is devoted to the clinical study of medicine, surgery and allied subjects, together with instructions in pharmacology, therapeutics, pathology and bacteriology. But just as no progress can be made in basic medical sciences without a foundation of biology, physics and chemistry, and a knowledge of the scientific methods, so no real understanding of the clinical sciences is possible without an effective integration of anatomy, physiology and pathology into them. You should never lose sight of the importance of the inter- relationship of these subjects.
"A man cannot become a competent surgeon without a full knowledge of human anatomy and physiology, and the physician without physiology and
THE SPECULUM. 37 chemistry flounders along in an aimless fashion, never able to gain an accurate conception of disease, practising a sort of pop-gun pharmacy, hitting now the malady and again the patient, he himself not knowing which."—Sir Wm. Osler, Montreal Med. Journal, 1895.
Regarding pathology :—"Successful knowledge of the infinite variations of disease can only be obtained by a prolonged study of morbid anatomy. While of special value in training the physician in diagnosis, it also enables him to correct his mistakes."—Sir Wm. Osier, Internal Medicine as a Vocation," ivied.
News (N.Y.), 1897.
It is the object of the first part of the curriculum to prepare you for the second, the real and crucial business of your trainin ,—"the crown of the whole system" (of medical education). The object of the second part—the clinical work—is so to direct and guide you in the application of your knowledge and in the gaining of such experience as will prepare you for your life's work.
With the growth of knowledge and the expansion of the various subjects, it is difficult to cover in detail the whole of the different subjects for clinical study. The key of practically all the English systems is to bring the student directly into contact with the patient. After a preparatory tutorial course he commences his attendances at the hospital. Some authorities recommend that the clinical work should be commenced in the O.P. department, but there is much to be said for commencing in the wards, and the new regulations of the General Medical Council recommend this. It is, as you know, the practice followed at this school.
It is the object of the second period that the student should acquire skill and efficiency in clinical methods, and in the examination and treatment of patients, and, to quote Sir Clifford Albutt, a well-known authority on medical education : "Instruments of precision, apparatus and the laboratory should be supplementary to the use of eyes, ears and hands in elucidating the patient's condition."
All authorities on medical education recognise that the most important part of- clinical work is for the student to learn how to observe, to recognise the im- portance of careful, thorough and repeated personal examination of the patient
—the history, signs, subjective symptoms, their progress, and the meaning of the same.
The proper relationship of clinical methods to laboratory methods and tests must also be appreciated. Their proper function is to confirm the interpretation and enhance the meaning of the signs and symptoms which have been estab- lished by clinical investigation.
It is the experience gained by thorough clinical investigations which will prove most helpful to you in the future practice of your profession, and which will give you confidence in your work.
It cannot be too strongly impressed upon you that you should make full use of your opportunities in the wards, and of other clinical work in the hospital.
Before closing, I would like to refer to one or two factors connected with the study and practice of medicine. It is most desirable that medical students and medical men and women should foster interests (literary and others) out- side those purely connected with the medical profession, for it is an undoubted fact that "professional work of any sort tends to narrow the mind, to limit the point of view" (Osler). Of books which will prove both entertaining and helpful to medical students, and which are well worthy of careful study, I have put down the following list
Aequanimitas, With Other Addresses (Sir William Osler).
Counsels and Ideals From the Writings of William Osler (Camas).
The Memoirs and Letters of Sir James Paget (Stephen Paget).
The Life of Pasteur.
The Masters of Medicine Series.
The Life of Lord Lister (Godlee).
Oliver Wendell Holmes—Breakfast Table Series.
Then again it must be borne in mind that the work of the medical profession is the most exacting of all the professions. It frequently carries with it the most severe mental and physical strain; yet in no other profession is the ques- tion of physical and mental fitness of such vital importance. Medical students, medical men and women owe it to themselves, and to the duties which are and will be imposed upon them by their profession, to keep themselves physically and mentally fit.
It should be one of your duties not to neglect your out-of-door sports, and quite early prepare yourself for the days when such games as cricket, football, lacrosse and tennis will be too strenuous, but when golf and other out-of-door interests will still prove both restful and invigorating.
It is well that early in your career you should appreciate clearly the relation- ship which, as members of the medical profession, you will occupy to those of your fellow members of the community who will seek your aid - and advice. The absolute trust and confidence which it is desirable should be placed by the patient in his or her medical attendant carries with it a great responsibility in return. The need for secrecy in regard to all knowledge regarding a patient's health derived in the course of your professional association with the same is so generally recognised that I need hardly refer to it. The following extract from the Hippocratic oath which bears on it is, however, of interest : "I will keep silence on that which I hear or see in the course of treatment or in everyday life, which should not be repeated, holding such to he a secret."
In dealing with your patients, both in your work as students and after, you will do well to follow the golden rule : "To do unto others, etc."
In your work in the hospital you must be guided by the fact that you are working amongst sick people, some of whom are actually fighting for their lives.
The big responsibility of medical work and the stress and strain, both mental and physical, associated therewith, emphasises the importance of another question, viz., the use of alcohol either as stimulant or a sedative.
I only desire to submit this to your consideration by bringing to your notice the following two extracts from addresses by the late Sir William Osler.
In an address to students at the Yale University in 1913 he spoke as fol- lows : "To drink, nowadays, but few students become addicted, but in every large body of men a few are to be found whose incapacity for the day results from the morning clogging of nocturnally-flushed tissues. As moderation is very hard to reach, and as it has been abundantly shown that the best of mental and physical work may be done without alcohol in any form, the safest rule for the young man is that which, I am sure, most of you follow—abstinence."
And in 1903 he expressed himself thus :—
" (1) Unanimity of opinion has not been reached on the question of alcohol as a food ; the balance of evidence is in favour of the view that it does so act.
THE SPECULUM. 39
"(2) A healthy man does not require alcoholic stimulants of any kind.
"(3) So far as actual damage to the machine, a moderate quantity of beer or spirits, taken at luncheon or dinner, seems to have no special in- fluence one way or another.
"(4) The danger lies in excess, but this is not easy to define. A man who takes three or four glasses of spirits 'daily is certainly drinking to excess. He may feel no ill-effects at the time, but, continued for years, the practice may damage seriously his constitution. To get the necessary satisfaction he must invariably increase the daily amount, and such a man is always confronted by the terrible danger of permanent enslavement."
The extracts which I have given you contain the considered opinion of a man who has left an enduring impression on medical education, and who rose to the highest position in the councils of the profession.
To emphasise the importance of his opinion, I will only ask you to remember that a member of the medical profession may at any time be called to decide issues which may mean life or death to his patient.
I trust, ladies and gentlemen, that some of the points raised in the course of this address, and the reflections thereon, may be of some use to you. To each one of you the clinical study of medicine and of surgery will be much what you make it ; to me, a subject fascinating in its interests ; to another, a care and con- stant source of worry. To each one of you I would say that it is a subject well worthy of the closest attention and study.
cd
1Renaissance.
You are to picture Messer Andrea Giorgione, Court Physician to his Puis- sance the Duke of Ferrara, as he ascends the steps of the Ducal Palace one pleasant spring morning in the year 1522. A portly gentleman is Messer Andrea, who wears his professional suit of black velours and silver-hilted sword with the air of one knowing his own worth. And no small worth, for Messer Giorgione is skilled in all knowledge that is to be learnt at the University of Pisa, the ne plus ultra of 16th Century medical learning.
It is needless for us of to-day to ridicule this doctor's little skill. To us, the medicine of the time appears compact of age-old dicta of Hippocrates or Galen, as yet unin fused by the modern spirit of observation and inquiry. Such know- ledge as was, assuredly Giorgione possessed it ; and in his generation he was esteemed gentleman and highly. learned man.
Our doctor, then ascends the steps, and enters the palace, and in due time is ushered into the presence of his august patient. Here the matter is tersely explained : his Puissance, it appears, is assailed by a conflux of low humours, which have quite incapacitated him from duties of State, and it is the task of Doctor Giorgione to restore the potentate to immediate efficiency. The leech clearly has no love for his responsibilities, for the Duke sick is still the Duke, quick to conceive and most unpleasantly quick to act. So it is with sincere relief that he makes his diagnosis and prescription, and, pocketing a snug bag of ducats on account ( for good payers in high places were rare at that time), returns to his lodging. Observe now the consequence
In a few days, it is rumoured about the city that the Duke has taken a turn for the worse. He is unhappy, languid, incessantly thirsty, but oddly restless
• withal, so that not even the next solemn audience could pass without his re- peatedly quitting the chamber. Popular speculation was rife as to the cause of this decline. Some, in view of the strained relations with Milan, were of opinion that poison entered somehow into the matter ; others, who had known the Duke in his younger days, held other views. But the general verdict was.
that his Highness was not long for this world, wherein everyone was hugely puzzled, and Messer Andrea about as much as any.
Ere long, it is reported that the ducal state is progressively worse, and hooks were freely opened in Ferrara against the possibility of his living beyond Midsummer's Day. Hearing this, the Cardinal di Como, the Duke's half- brother, decreed a day of prayer ; yet the whole bench of ecclesiastics were unable to obtain the desired cure. Whereupon, the matter was turned over in- continent to the secular arm, in the light of Milanese intrigue.
When this news was conveyed to Messer Giorgione, he decided that he is most innocent who is not there to be tried, and that the air of Florence was more to his health than that of Ferrara. Hastily collecting his lighter goods, includ- ing the Duke's bag of ducats, he galloped out upon the Florence road one hour ahead of an order for his apprehension.
Foiled in this direction, the authorities did not delay in effecting the arrest of the apothecary who was known to be in the habit of dispensing the doctor's prescriptions. Professional secrecy as between doctor and chemist was less rigidly observed in those days than it is to-day, so it was after only a dozen turns of the rack that the apothecary confessed to the whereabouts of Doctor Giorgione's prescription for the Duke. It was observed that his Highness was present during the examination : he appeared vindictive, but apparently had suffered.
The hellish document in question was opened by the Cardinal di Como in the presence of the Duke, the prisoner and a full tribunal. In clear accents, the worthy cleric read the full contents of the scroll. He then caused the phial wherefrom his Puissance was wont to take his draught to be brought, and care- fully studied the label. The prescription contained as one of its ingredients podophyllum root, and the direction was that it should be taken at nightime.
"Nora Somni," said the Cardinal, and pointed to the apothecary's writing on the phial. It read : "HORAS OMNI."
—G.A.K.
FI fiDobern lullaby.
Rock-a-bye baby, upon the bough, You get your milk from a certified cow ! Before your eugenic young parents were wed, They had decided how you should be fed.
Hush-a-bye, baby, on the tree top,
If grandmother trots you, you tell her to stop.
Shun the trot-horse that your grandmother rides—
It will work harm to your little insides.
Mamma's scientific—she knows all the laws—
She kisses her darling through carbolised gauze.
Rock-a-bye baby, don't wriggle and squirm, Nothing is near you that looks like a germ.
—Western Druggist.