Popular Science Monthly/Volume 45/August 1894/On Accuracy in Observation
By H. LITTLEWOOD, F. R. C, S.
THERE are many theories afloat to solve the great question of medical education—what subjects should be taught in the early part of the curriculum, and what left out. I do not think it is quite such a great matter what is taught: how it is taught is of far more importance. For I take it that there is no training which can turn out a medical man who is up to date in every branch of his profession, and very thankful I am that there is no place in the world for such a prodigy. He would be very like a historical character described in one of George Eliot's novels: "The simplest account of him one sees reads like a laudatory epitaph, at the end of which the Greek and Ausonian Muses might be confidently requested to tear their hair, and Nature to desist from any second attempt to combine so many virtues with one set of viscera." To hear some men, and even medical men, talking, one might almost suspect that we had found the realization of such a description. The great aim and object of medical education, and, in fact, of all education, is that it should make you accurate observers; and any plan or scheme of education that has not succeeded in this has been a failure, even if, after years of study, you can write the whole of the letters of the alphabet after your name. You hear people talk of education, and of So-and-so going to this or that school or university, either at home or abroad, to finish his education. Never was there a more mistaken notion. The word "education" should almost be used like the word "eternity." It must go on as long as humanity exists. What you should be doing at your school and university is to train yourselves to observe things accurately, so that you may rightly interpret their meaning. Let me tell you it is a very difficult thing to be accurate. You will, I am sure, forgive me for again quoting from George Eliot, but she has so well expressed what I want to say: "Examine your words well, and you will find that, even when you have no motive to be false, it is a very hard thing to say the exact truth even about your own feelings: much harder than saying something fine about them which is not the exact truth." If such is the case, we can not be too laborious and painstaking in order to eliminate error. If your early studies in chemistry, biology, anatomy, physiology, etc., have been rightly conducted, you should have learned to note facts and to make careful observations; and you will find this training invaluable when you begin your hospital work, as also during the remainder of your medical lives; for the whole art and science of medicine must be founded on accurate observation. All careful students of medicine should be good and accurate note-takers; the practice of sketching and making diagrams of the things you are observing is a very valuable one to cultivate. In taking notes on your cases acquire the habit of putting your observations on paper while you have the patient before you; compare the diseased or injured part with the corresponding healthy part; and if both similar parts are affected, you must compare the)m with what you have learned to consider as a healthy ideal. If records are not made at the time they lose somewhat of their value, even if they are made within a few hours after the appearances observed have been described; but if left days or weeks and I know this is sometimes the case the imagination is left to fill in the details; and should they be left for a much longer period, it is perfectly astonishing what may not be described as facts, especially if the writer is anxious to make the accounts read well. I believe this is the reason why there is so much doubt about so-called facts; a good many of them are not facts at all, but merely expressions of a very fertile imagination. There is more truth in some of the stories of the Arabian Nights. A certain part of what has been called the new criticism of some ancient writings and records consists in trying to ascertain how soon after seeing these events did the eyewitness write the records. Of course a good deal of the value of these records depends upon the decision of such a point how much and how little has the imagination taken part in the evolution of these so-called records of well-authenticated facts? Then, in describing your cases, do not use language that lends itself to exaggeration. Whenever you can put down actual measurements and actual figures it is much better to do so.
According to the statistical tables of some operations and new methods of treatment one finds all the cases, or a large majority of them, classed under the heading of "cured." This is a very unfortunate word, for it appears to have a variety of meanings; and what one person understands as a cure certainly would not come up to the standard of another. I often wonder if the notes of some of the failures have not been lost or if the cases of failure have not been removed, because, for some reason or other, they do not quite come within the category of the title-heading selected for these tables. We do not find many statistical tables of failures. When one reads these accounts one wonders if they were written for the purpose of finding out the truth, or was there some other motive? Macaulay, in his essay on Gladstone on Church and State, has a passage which I think I may aptly quote here: "It seems quite clear that an inquirer who has no wish except to know the truth is more likely to arrive at the truth than an inquirer who knows that if he decides one way he shall be rewarded, and if he decides another he shall be punished." But as students your first object must be to be accurate. I will give you one or two examples of curious notes that I have seen lately made by some students. I was reading an account of an operation I had performed the day before, and, finding not a single statement in the note was quite accurate, I asked how it was that such an account had been written. The student excused himself by saying that he had not seen the case, but had gathered from another that I had done exactly what he described. In another example, from some notes on two cases of suprapubic lithotomy undertaken on the same day and these were written by an eyewitness, I was startled to read in both the accounts this passage: "The peritonæum was then opened." I need hardly say that this statement was pure fiction. I quote these examples to show you that I am not exaggerating; I am sorry to say I could multiply them. Of course you will all agree with me that notes of this kind are infinitely worse than no notes. Now, how is it that it is so difficult to be accurate? I think accuracy means a careful training of all one's faculties, and this is so often neglected. It is so much easier to let other people think for us than it is to think for ourselves. A medical man who has not acquired the faculty of thinking and interpreting for himself has missed his vocation. I have sometimes heard students remarking on the physical signs of a chest, that such and such parts are dull on percussion, or that there was a cardiac murmur heard at a certain part of the chest because Dr. B. had said so, and not because the speaker had appreciated the differences of sound. You must learn to appreciate these things for yourselves by trying to test them by your ideal normal standard; and until you have actually heard, seen, or felt them, these things can not be said to exist as far as you are concerned. The eye only can see what it brings with it the power of seeing. When you first look down a microscope everything looks indistinct, a mass of pretty coloring; then, after training, certain details are observed—nuclei, nucleoli, fibers, cells, etc. After carefully studying the detailed structure of an organ you can recognize it the next time you see it; then, knowing the different elements of which it is composed, you can recognize if it is a specimen of a healthy organ or if the organ is in any way diseased. The trained eye is able to see endless minute differences where the untrained eye discerns nothing. Things look very hazy and indistinct in the first gray of the early morning; every day of your lives adds some new facts, some new observations, and each day brings you nearer the brightening sunshine of a more extended knowledge, until some of you may be fortunate enough to realize the lofty ideal of Prof. Huxley: "Education promotes morality and refinement by teaching men to discipline themselves, and by leading them to see that the highest, as it is the only permanent, content is to be attained, not by groveling in the rank and steaming valleys of sense, but by continually striving to those high peaks where, resting in eternal calm, reason discovers the undefined bright ideal of the highest good—a cloud by day, a pillar of fire by night." We do not all see the same differentiations of color or appreciate the varieties of taste, smell, or touch, or hear to the same extent the infinite variety of musical expression; and it is only by cultivating our senses that they can be improved. About a year ago, at the Ida Hospital there were some very offensive smells. Everybody thought there must be something wrong with the drains, until the resident, Mr. Wilks, discovered a horribly offensive fungus. I requested him to bring some specimens to the infirmary weekly board meeting, and I was very much interested to hear what the different members would say. The first to examine it said that "it did not smell at all"; the second that "it was not so bad"; but all the other members agreed with me that it was horribly offensive and quite accounted for the bad smells. I mention this as an example of differences of opinion about a fact as to whether something was or was not offensive, and to illustrate that we do not all appreciate sensations to the same extent. You are all of you familiar with the curious phenomenon of color-blindness; but there is a much more common and not so easily detected form of blindness which has received the name of "intellectual blindness." We all suffer from it more or less; some to such an extent as to be almost like unto an ancient description of some heathen gods, "who have eyes and see not, ears and hear not, noses have they and they smell not." You have all of you been struck with the fact that there are certain things we see every day, yet all at once we discover something in them we have never noticed before. I venture to predict that, if I gave all of you a piece of paper and asked you to write down the exact figures as they appear on the face of your watches, not one tenth of you would put them down accurately—i. e., of course if you have not already tried the experiment—and yet all of you have seen your watch faces several hundreds of times. Or, if you like to make the experiment of getting half a dozen eyewitnesses to describe something they have seen, it is more than probable we should find very marked differences in their descriptions. I think you will agree with me that some of the descriptions in the daily papers bear out this contention. You often have your mistakes pointed out to you before you are conscious of their existence. You must have very clear ideas of the anatomy and physiology of a human being in a healthy condition before you can become accurate observers of disease. This knowledge can only be obtained by diligent work in your dissecting rooms and laboratories; there is no royal road to it. Do not forget that you are all disciples of William Harvey, John Hunter, and Charles Darwin.
To sum up in one short sentence. Your observations will consist in comparing your ideal standard of the normal with any conditions you consider to be aberrations from that type. Then, having made your observations, the next thing you have to learn is to arrange them in their proper proportional perspective and to rightly interpret their true significance. Given certain altered conditions, how have they been produced? What have been their antecedents? Prof. Huxley has called the interpretation of these facts "retrospective prophecy." In his book called Science and Culture there is an interesting address entitled After the Method of Zadig: Retrospective Prophecy as a Function of Science; and as this method is one which you as students will largely adopt I will venture to read to you the story of Zadig. It is very doubtful where this philosopher lived. Babylon claims him; but he appears to have forsaken this city to live on the banks of the Euphrates, where he could be alone with Nature to investigate and unravel her mysteries.
The story is briefly this: The chief eunuch having been sent in search of the queen's dog, which had been lost, met Zadig, who had seen the markings on the sand left by the straying animal, and from this was able to give almost an exact description of its appearance. Later on the grand huntsman came the same way looking for one of the king's horses which had been lost, and Zadig, having noticed the marks on the sand and the disturbances among some trees through which the animal had passed, was able in like manner to describe it. As neither of the animals could be found, Zadig was accused of having stolen them; he was taken prisoner and brought before the court, and sentenced to transportation. No sooner was the sentence passed than the missing animals were found, so the judges had to reverse their sentence, but fined him four hundred ounces of gold for saying he had seen that which he had not seen. After paying the fine he explained to the court how he had been able so exactly to describe the animals; from this his fame spread widely. The king commanded that the gold should be returned to him; this was done, but three hundred and ninety-eight ounces were retained by the court for legal expenses, etc.
You will be saying. But, after all, this method is only applied common sense; but let me tell you that it is a very great advance on certain other methods which have been adopted by the so-called wise men through the ages. It is not so long ago that witches were burned because the death of some pigs was thought to be due to witchcraft. Nowadays, probably, the cause of death would appear in the death certificate of those pigs as swine fever; and many of the so-called haunted houses, by the method of Zadig, have been proved to be haunted, not by the ghosts of the departed, but by bad drains. Children often adopt, quite unconsciously, the method of Zadig. I had a good illustration of this last Sunday, and I must tell you about it. Talking to a blind child in the children's ward, I asked her if she knew who I was. She said at once, "Yes, the doctor." I asked her how she knew that. She answered again, "Oh, nurse always says 'Hush' when the doctors come into the wards."
Xow, gentlemen, if you really enter into the true spirit of medical work, you will very soon train yourselves to be accurate observers, and from observing human beings you will soon be tempted to investigate and delight in other natural phenomena, to find out your own proper place in this great cosmic system, of which you are only a unit or microcosm. There is no doubt that a true student of Nature has provided himself with endless sources of amusement and happiness. Some of you may remember the lines of Longfellow on the fiftieth birthday of the great naturalist Agrassiz:
"And nature, the old nurse, took
And this is the heritage of all honest students of medicine who have built up their life's work on accurate observation.
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