[Current students should, in particular, note Mr. Hetling's tips on taking notes in lecture: "The practice of taking notes from lectures is of clear and decided utility; and every student ought to make it a point to keep correct and complete notes of one course of lectures, on each department of medical science. But it will be seldom advisable to take notes of a first course, where two or more of the same kind are to be attended, in order that the mind may, in the first instance, be wholly devoted to following and comprehending the lecturer. The use of short-hand I consider as every way to be reprobated j it converts the writer into a mere mechanic; it employs him in copying words, instead of digesting and compressing thoughts; and unless he has three or four hours to bestow on the same subject after the lecture, his manuscript remains in a form almost as inconvenient for reference as if it were written in an unknown language."]
MR. HETLING'S SURGICAL LECTURES AT THE BRISTOL INFIRMARY.
I Shall now proceed to make a few more observations on the duties and attendance of hospital practice.
I conceive that the principal obligations and duties of a hospital surgeon are reducible to two objects.
1st. The benefit of the poor who are confided to his care.
2nd. The instruction of pupils.
With respect to the first of these duties, I have endeavoured, to the best of my ability, unremittingly to discharge it ever since I entered upon my office. In the course of the regular performance of this duty, you have had frequent opportunities of obtaining surgical information during your daily attendance in this hospital; but it must be obvious to you, as well as to myself, that it has not been to that extent the subject is capable of. It must be evident that the bedside of a patient is not a fit place to convey instruction: and our perambulations through the wards will not admit of anything approaching towards a regular education.
Public hospitals in themselves cannot, it is obvious, create knowledge; they can only afford desirable opportunities for study and practice to those who are disposed to attend them; and it must still be from individual exertion that improvement will spring. The experience afforded in a hospital tends to keep down that luxuriance of plausible theories, which so very much disfigures the pages of several surgical works even of the present day. Many such have been received at first with great approbation; but the man of experience, who has the opportunity of comparing them with what nature exhibits in a hospital, has detected the visionary and oftentimes the pernicious doctrines they attempt to inculcate.
It will be an object with me to make the practice of surgery interesting to you; and that you may not be left to learn the principles of your art in the hurried and rapid manner which the daily attendance on every hospital can only afford, I wish you to reason on the cases that may offer themselves to your notice, and to deduce from the result of them those principles which shall guide your future conduct and give you confidence, that your practice may not be confused and unmeaning.
My purpose is to excite you to diligence; to represent your profession as requiring and deserving by its importance your continued study ; to remind you how much is still due to the improvement of your mind and talents during the preliminary education you are receiving.
I will endeavour to instruct you in all the daily duties of an hospital, and those are always the most essential. If the directions which I shall lay down should enable you to go your rounds in the hospital with a quicker eye and clearer understanding of the cases that are committed to your care, and a more perfect command of the ordinary remedies, I shall be very highly gratified with this discharge of my duty.
In hospital practice you will every day see some point illustrated, some doctrine confirmed, or some rule of practice established; at the same time almost every occurrence will serve to deepen the impression of those ideas, it will be my constant endeavour to imprint on your minds.
In hospital, and even in private practice, you will seldom have the opportunity of noticing diseases in their first stages; to repair the defect that may hence arise, it will be very necessary to form in your mind a correct knowledge of the earliest characteristic symptoms of every disease.
In your attendance on an hospital, avoid the too common practice of merely walking through the wards to glance at the most prominent cases; rather go to the bedside and enquire diligently into the history, symptoms, progress and circumstances of the complaints, and into the effects of the remedies employed for their relief. Of all the more important particulars take regular and accurate notes. Do not trust too much to memory—memory is a good faculty, but it will be nothing the better for being too much confided in. Sensible impressions fade if they are not often repeated, or revived by proper memoranda. Amongst the extensive range of patients, select the most interesting for your own observation. A few such cases strictly attended to will advance your knowledge in a far greater degree than a hasty gleaning from the wide field which every hospital affords. Thus you will acquire the habit of accurate information, without which opportunities will avail but little. A man may know very little of the nature of a disease, though he has repeatedly seen it; for seeing is not observing, although it is essential to it.
Among the thousands who see the flowers of the field, how few know the parts of which any one is composed, or could give an intelligible description of them? Not from any difficulty in the object, or want of capacity in themselves, but merely for want of observation. So it is with diseases. Their phenomena will not enter the mind by mere intuition; they must be marked, distinguished, and compared. To some this task will be easier than to others, but it is nevertheless essential to all.
I would also recommend you to accustom yourselves, as far as a proper consideration for a suffering patient will permit, to pay particular attention to the feel of parts under various circumstances of disease, that you may acquire what has been called the tactus eruditus, and thus be able to discriminate one species of tumour from another; for instance, an abscess, or an enlarged gland in the groin, from hernia, and other diseases of that part.
The science of surgery, it has been well observed by the late Mr. John Pearson, " like any other branch of natural knowledge, is not the production of a vigorous imagination, nor a lively invention, but it is the offspring of a long and diligent experience; and if a man attempts to learn it in any other way, than by going from his study to the bedside of his patient, and returning from thence to his study again, he will find himself mistaken. The human mind may be dazzled by the boldness of her flights, or wounded by the keenness of her speculations, but the subtlety of nature can only be penetrated by those who submit to become her patient and vigilant servants."
I design occasionally to introduce clinical observations on those surgical patients that may be admitted under my care, whose cases are either intricate or particularly interesting. This will afford you solid instruction, as you will see the effects of the method of treatment that is adopted in the course of the disease; you will also thence contract a habit of observing facts, and consequently feel an aversion to all reasoning that is not conformable to them. Another advantage will be, that complete collections of observations on the cases treated will be kept, and from their comparison the most certain rules for the treatment of similar complaints may be drawn.
Clinical lectures are to the practice of surgery what dissection is to anatomy; it is demonstration. He who engages in practice without this species of instruction, must be supposed to know diseases only by description; and when the fallacious appearances and changeful forms which diseases assume are considered, it is really to be apprehended that consequences too unpleasant to dwell on must then succeed. He, on the contrary, who has thus had diseases 'placed before him, their various shades of difference pointed out, and their peculiar cast and character rendered familiar to him, will approach his patient with satisfaction and success.
The clinical lecturer ought to possess many requisites both of tact and discrimination, which can only be acquired by a long and regular attendance on clinical practice. For some years past the impulse to deliver clinical lectures at our great hospitals has been gradually increasing; and the great wonder is, that the example of the royal infirmary of Edinburgh did not long ago render the measure universal. Most of you, no doubt, have lately read the interesting and attracting clinical lectures now so ably delivered in London by Dr. Elliotson at St. Thomas's Hospital, on medical, and by Mr. Henry Earle at St. Bartholomew's, on surgical cases. I recommend the perusal of them to your particular attention.
The practice of taking notes from lectures is of clear and decided utility; and every student ought to make it a point to keep correct and complete notes of one course of lectures, on each department of medical science. But it will be seldom advisable to take notes of a first course, where two or more of the same kind are to be attended, in order that the mind may, in the first instance, be wholly devoted to following and comprehending the lecturer. The use of short-hand I consider as every way to be reprobated j it converts the writer into a mere mechanic; it employs him in copying words, instead of digesting and compressing thoughts; and unless he has three or four hours to bestow on the same subject after the lecture, his manuscript remains in a form almost as inconvenient for reference as if it were written in an unknown language.
The taking of notes is exceedingly proper, such as those which are proposed to mark any observations particularly deserving of future attention; or such as, not being understood at the moment, may require revision and comparison with the accounts respecting it given by some respectable author. But perhaps the greatest advantage they afford is the unremitting attention which they necessarily excite, acting as a constant monitor, and preserving the mind from straying, so that nothing material can escape unrecorded. Whilst addressing you on this subject, I cannot refrain from giving you a word or two on a practice that leads a student very soon into habits of negligence and inattention; I allude to the copying of lectures taken by others. This I have reason to suspect is much too frequently adopted. The consideration that the assistance of another's notes can be obtained, will frequently turn the balance wavering between duty and indulgence.
On this subject the late Dr. Mason Good observes—" In your attendance on lectures, I would rather advise you to carry the substance of them away in your head than in your note book; many trust too much to their notes. You will do well to remember, that you cannot consult these memoranda at the bedside of your patient. I would not be understood as entirely discouraging the system of taking notes, but I consider that most students, who attend a course of lectures for the first time, will derive more solid advantage from attention without writing, than writing, as may be done without mental application. The most useful method is to take down the heads of the lecture only, and to fill them up at home, so as to preserve an authentic record of the most important facts, and to form a general analysis of what he has heard. This has the advantage of keeping up the attention, of giving to the mind a habit of digesting what is presented to it; and lastly, of enabling the student to acquire a facility of expressing his thoughts in writing."
Permit me, additionally, to suggest one hint or two. Never read without your pen or pencil in your hand, and your commonplace book beside you, in which you will enter such passages as strike your mind by their novelty or importance. You are not aware of the great advantage you will derive from constantly committing your observations and thoughts to writing. A person can never ascertain how much he has acquired till he records and arranges his knowledge.
Human, comparative, and morbid anatomy, pathology, physiology, with the other collateral branches of our science, will occupy an accessory place in these lectures, but I shall occasionally introduce them when necessary to illustrate the different action of parts both in health and disease. I shall thus select and transfer from those subjects what may prove useful and explanatory of that science which we have principally in view. I shall also avail myself of every opportunity of exposing to your notice such of those specimens of morbid anatomy, that I may obtain either in my private or public practice, as may tend to elucidate the subject we are discoursing upon. The examination of the dead body, in every doubtful or difficult case, is in general an appeal to truth; it establishes the fact we are searching after, and corrects conjecture and theory. Much may be learned in the examination of the dead body, without delicate skill or profound knowledge. A student only possessed of a slight knowledge of anatomy, might soon be qualified to perform many useful inspections of the diseased subject. He would soon be enabled to distinguish between changes which may have some considerable resemblance to each other, and which have been generally confounded. This will ultimately lead to a more attentive observation of symptoms while diseased actions are taking place, and be the means of detecting and distinguishing diseases more accurately. When this has been done, it will be more likely to produce a successful inquiry after a proper method of treatment. The examination of dead bodies, whose cases you may have attended, will afford you solid instruction. For eases having a fatal issue are often not less instructive than such as terminate favourably. They frequently tend to point out more accurately the plan to be pursued in the treatment of similar complaints; they afford valuable information relative to the probable causes of failure, and when an examination is permitted, they throw light on the more intimate nature and modifications of the disease.
In addition to this mode of acquiring a knowledge of disease, I must on no account forget to mention the advantage of embracing every opportunity to examine morbid parts, after they are removed by operation. For many diseases consist in a real alteration of the structure, the nature of which can only be fully detected by anatomical investigation.
I shall likewise introduce morbid parts preserved in spirits; others in a dried state, with casts of any rare or curious disease I may obtain ; additionally I shall illustrate the subjects treated on by plans and drawings, a mode of teaching sometimes exceedingly useful in connecting the two departments of surgery and anatomy, by demonstrating what otherwise could not be obtained, and which, by reviving the recollection of our past studies, will enable us to understand the subject immediately under review.
London Medical and Surgical Journal, Volume 1, 1832, pp. 553-556