Physicians, subsequence and consequence.

The title of my lecture derives from a statement by the great lexicographer Dr Samuel Johnson in the course of a review of the Essay on Waters, by Dr Charles Lucas. Lucas extolled the healing powers of the waters at Bath (where he was physician) and elsewhere during an enforced hiatus in his political life in Dublin. Dr Johnson was evidently not persuaded: “It is incident to physicians, I am afraid, beyond all other men, to mistake subsequence for consequence.” Like most Johnsonian aphorisms this one is at once arresting and amusing. One has an immediate sense that he is right — and as a physician, rightly, one is uncomfortable. But again typically, as one reflects on it, there are depths and complexities. Its force derives from the tension created between the perception that there is an important truth here, and the perception that it is not universal. In this lecture in which we celebrate the memory and contribution of a truly great physician, I want to explore some of these complexities, using Swithin Meadows as the exemplar — firstly, because he did not fall into the Johnsonian trap as Dr Lucas did; and secondly because these issues are deeply relevant to us and our patients today. I first met Dr. Meadows in 1962 in Dunedin when he and Mr Douglas Northfield (the neurosurgeon) toured the main medical centres in New Zealand, and finally led a 2 day course on neurology in Auckland. His physical presence, his wisdom, his warmth and geniality, and his integrity made a profound impression, which was consolidated when, the following year, I came to Queen Square. To see him examine a patient conveyed a sense of a master craftsman at work. And to hear him lecture created a sense of inevitability of the soundness of his conclusions, based as they were on his perspicacious observation, deep knowledge, and long experience. Nowhere was this better shown than in his lecture — which I first heard in Dunedin — on the neurology of visual failure. As Ralph Ross Russell, his successor at the Moorfields Eye Hospital, observed, to hear Meadows talk about the neurology of visual failure was like hearing a successful farmer talk about the rotation of crops. If you did it his way, all would be well. And it was. The love of the land implied in this comment was a reality. In retirement he and his wife Anne spent much time in a remote cottage in the West Country, accessible by a dirt track, and then only in fine weather. His earlier career was marked by his outstanding ability, conspicuously shown when, against all expectations (including his own) he was appointed to a post as Medical Registrar at St Thomas’s Hospital over the heads of that august institution’s own graduates: a considerable feat in the early 1930s. He soon moved to Queen Square, where his mentors included many whose names are familiar in neuro-ophthalmology: Holmes, Adie, Collier, and Symonds. The residents at that time often discussed to whom they would go if they were neurologically ill themselves. The consensus was that they would get Symonds to take the history, Holmes to perform the physical examination, and Adie to interview the relatives because he was such a nice man. Meadows was appointed Physician to the Westminster Hospital in 1938, and in 1939 to the Maida Vale Hospital. He moved to Queen Square in 1946 and was appointed to the Moorfields Eye Hospital in 1955. This latter post shaped his interests and determined the contribution for which he is best remembered. He would be gratified that this lecture which he endowed and is given biennially and related alternately to Moorfields and Queen Square, is being given this year in association with the European Neuro-ophthalmology Society’s meeting. Though one of the outstanding general neurologists of his day, whose opinion was widely sought, his special aVection was for the disorders of the visual system. He had, however, a personal aversion to the name “neuro-ophthalmology”, observing that one might as well define a subject of “neuro-foot” to deal with the neurological disorders of that structure. But we must not take oVence: his commitment to our subject — whatever we call it — was real. Let us come back to Dr. Johnson’s aphorism and consider it in a little more detail. First, subsequence. Though Johnson rightly — as I shall illustrate later — viewed as harmful the use to which doctors often put the principle when assessing treatment, it is nevertheless at the heart of the diagnostic and prognostic process. Let me illustrate with Meadows’s own work. His first major paper was with Sir J Neurol Neurosurg Psychiatry 1999;67:282–289 282