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A Lecture INTRODUCTORY TO A COURSE ON CLINICAL MEDICINE.
770 succeeded in dilating the urethra up to a fair size, the nar- and plain. And here let me say, avoid hastily jumping t rowing rapidly returns in spite of periodically passed instru- conclusions, and thus possibly arriving at a wrong resull ments ; or that diffioult micturition still exists; or that re- It is better to know nothing than to be misinformed; anc tention of urine often occurs: is it not clear that something bearing this in mind, I shall often have to tell you (not ii further is necessary? In other words, if dilatation provesthe hearing of the patient perhaps), that I do not kn01 insufficient, what then ? This question I propose for the what is the matter. You may recollect Artemus Ward’ ,next part of my subject. caution, 11 Don’t you prophesy onless you know"; word which really contain a good deal of wisdom. Even when presuming on a certain amount of knowledge, I do prophesy -
-
.
’
’
A Lecture INTRODUCTORY TO A COURSE ON
MEDICINE.
CLINICAL Delivered at
BY
JULIUS
Charing-cross Hospital,
POLLOCK, M.D.,
PHYSICIAN TO THE HOSPITAL.
GENTLEMEN,-It will be my pleasing duty during th
.ensuing
twelve months to instruct you
specially in clinic! employ this our nrs the aim an briefly by considering
medicine, and I do not think
meeting better than object of our labours.
we can
Clinical lectures are supposed to be given, as the wor clinical" implies, at the bedside ; but for many reasons i is found to be most convenient, as a rule, to deliver the lec ture in the theatre, illustrating it subsequently by the exa mination of the patients in the wards. Whilst using th cases under our care for purposes of instruction, we mus not forget the interests of the patients themselves, and it i .not always desirable to say all we would wish to say of ; case in the hearing of the patient; nor must we forget tha in many cases a prolonged and tedious examination may be very prejudicial, and our curiosity must give way to thj welfare of the patient. And here let me impress upon yoi ’the duty of treating the sick in the hospital with the greates -61
kindness and consideration, never forgetting, in your laud able anxiety to obtain knowledge, that the chief objectt patient has in entering a hospital is to get well. The very essence of clinical teaching is that it should bE practical; that you should see, and hear, and feel those morbid states which are described to you in lectures and books. But before you are able to detect disease you must become familiar with health. Your eyes must become learned in the natural appearance of the various parts of the human frame, and your ears accustomed to the natural sounds made by the heart and lungs, or you may fall into the error of mistaking that which is quite normal for disease, and, on the other hand, overlook serious mischief. Let me, then, recommend you carefully to study the natural sounds of the heart and lungs, so that your ears may be able to detect at once any departure from health. In your visits to the wards you must not expect to find the various diseases exactly like the descriptions given in lectures and books. The cases they describe are typical ones, in which the symptoms are what they should be; but real disease exhibits great variety, and those who only know it from books would be often sorely puzzled at the bedside; and were it not for this, anyone with a text-book of medicine in his hand would be of the same value as the most experienced physician. Many diseases are quite Protean in their character, and to be understood must be carefully and practically studied : hence the value of clinical teach-
ing.
you must not be content to take my word for any matter you must confirm or correct what I say by your own ob. servation; and let me tell you that the observations of at intelligent student are often of much value to the teacher In studying our cases in the wards you will encounter many that are especially interesting from their comparative rarity, but I must warn you against any neglect of the more ordinary diseases, for after all it is doubtful whether the investigations of what I may call the curiosities of disease repay us so well as the careful study of its more usual forms. Clinical teaching is of especial use in enabling you to recognise disease in its varied phases-in other words, to form a correct diagnosis ; but it has a further value in teaching you the use of drugs-in other words, the art of prescribing. The object and mode of action of some medicines are simple enough - as when we administer an aperient to open the bowels, an alkali to counteract acidity, or an astringent to combat relaxation; but there is a large number of drugs of whose modus operandi we are ignorant-such as quinine, mercury, iodide of potassium, and many others. When we prescribe these we do so empirically, as it is termed; their value having been learnt from experience of their use. Thus we know that quinine is of the greatest value in ague, mercury in syphilis, and iodide of potassium in various glandular diseases; but we do not know how they act, nor why they In following the course of diseases in are of any service. the wards, you will have opportunities of seeing these drugs in use, of watching their action, and of judging of their value. You may also observe how certain drugs are combined with others, and that a judicious combination is often I know that in saymore efficacious than any single drug. ing this I shall invite criticism from a certain school of practitioners who hate 11 mixtures"; but I only give you my experience, gentlemen, valeat quantum, and ask you to come and see for yourselves. There are many cases in which the tendency to recovery is strong, cases which require little or no medicine, and in which our chief care perhaps is not to impede what has been termed the vis medicatrix naturm. These are the cases that do such credit to homoeopathy. There is another class of ailments in which active treatment is absolutely necessary, and without which such diseases would go on from bad to worse. And you will also see many of those sad disorders over which we have little or no control, cases in which our chief aim is to alleviate suffering and to smooth the path to the grave. Gentlemen, I have been very brief, almost trite, in my remarks, and I am painfully conscious that they contain nothing new or original; but I trust I have said enough to convince you that clinical work is full of interest, and its
study
of the
highest importance. ON A
CASE
OF PARALYSIS OF THE TONGUE FROM HÆMORRHAGE IN THE MEDULLA OBLONGATA.
BY J. HUGHLINGS
JACKSON, M.D., F.R.C.P.,
AND TO THE HOSPITAL FOR THE PARALYSED AND EPILEPTIC.
PHYSICIAN TO THE LONDON
HOSPITAL,
You must not suppose, however, that we can always give to the complaint from which a patient is suffering, a rare one, but also one of great THis case is not or always be certain of what ’is the matter. Many cases value. It derives itsonly value from the careful examination In the diffiare obscure, even to the most experienced. culties that surround you in the study of your profession, Dr. Lockhart Clarke has made of the medulla oblongata; it may be a melancholy satisfaction to you to find that even an examination revealing a very limited lesion, correspondthose who have laboured at it for years do not know every- ing to the most striking symptom-paralysis of the tonguething ; for I well remember the relief it was to my mind during life. in early school days when the master had to look out some The , greater part of the life-history of the case was pubGreek or Latin word in the Dictionary. You will find, lished me eight years ago (Lond. Hosp. Rep., 1864, vol. i., in that a case at instances first difficult and by however, many obscure, by careful watching and waiting will become easy p. 368). A brief note of the morbid appearances is given in a name
observed
-
.
’
’
A Lecture INTRODUCTORY TO A COURSE ON
MEDICINE.
CLINICAL Delivered at
BY
JULIUS
Charing-cross Hospital,
POLLOCK, M.D.,
PHYSICIAN TO THE HOSPITAL.
GENTLEMEN,-It will be my pleasing duty during th
.ensuing
twelve months to instruct you
specially in clinic! employ this our nrs the aim an briefly by considering
medicine, and I do not think
meeting better than object of our labours.
we can
Clinical lectures are supposed to be given, as the wor clinical" implies, at the bedside ; but for many reasons i is found to be most convenient, as a rule, to deliver the lec ture in the theatre, illustrating it subsequently by the exa mination of the patients in the wards. Whilst using th cases under our care for purposes of instruction, we mus not forget the interests of the patients themselves, and it i .not always desirable to say all we would wish to say of ; case in the hearing of the patient; nor must we forget tha in many cases a prolonged and tedious examination may be very prejudicial, and our curiosity must give way to thj welfare of the patient. And here let me impress upon yoi ’the duty of treating the sick in the hospital with the greates -61
kindness and consideration, never forgetting, in your laud able anxiety to obtain knowledge, that the chief objectt patient has in entering a hospital is to get well. The very essence of clinical teaching is that it should bE practical; that you should see, and hear, and feel those morbid states which are described to you in lectures and books. But before you are able to detect disease you must become familiar with health. Your eyes must become learned in the natural appearance of the various parts of the human frame, and your ears accustomed to the natural sounds made by the heart and lungs, or you may fall into the error of mistaking that which is quite normal for disease, and, on the other hand, overlook serious mischief. Let me, then, recommend you carefully to study the natural sounds of the heart and lungs, so that your ears may be able to detect at once any departure from health. In your visits to the wards you must not expect to find the various diseases exactly like the descriptions given in lectures and books. The cases they describe are typical ones, in which the symptoms are what they should be; but real disease exhibits great variety, and those who only know it from books would be often sorely puzzled at the bedside; and were it not for this, anyone with a text-book of medicine in his hand would be of the same value as the most experienced physician. Many diseases are quite Protean in their character, and to be understood must be carefully and practically studied : hence the value of clinical teach-
ing.
you must not be content to take my word for any matter you must confirm or correct what I say by your own ob. servation; and let me tell you that the observations of at intelligent student are often of much value to the teacher In studying our cases in the wards you will encounter many that are especially interesting from their comparative rarity, but I must warn you against any neglect of the more ordinary diseases, for after all it is doubtful whether the investigations of what I may call the curiosities of disease repay us so well as the careful study of its more usual forms. Clinical teaching is of especial use in enabling you to recognise disease in its varied phases-in other words, to form a correct diagnosis ; but it has a further value in teaching you the use of drugs-in other words, the art of prescribing. The object and mode of action of some medicines are simple enough - as when we administer an aperient to open the bowels, an alkali to counteract acidity, or an astringent to combat relaxation; but there is a large number of drugs of whose modus operandi we are ignorant-such as quinine, mercury, iodide of potassium, and many others. When we prescribe these we do so empirically, as it is termed; their value having been learnt from experience of their use. Thus we know that quinine is of the greatest value in ague, mercury in syphilis, and iodide of potassium in various glandular diseases; but we do not know how they act, nor why they In following the course of diseases in are of any service. the wards, you will have opportunities of seeing these drugs in use, of watching their action, and of judging of their value. You may also observe how certain drugs are combined with others, and that a judicious combination is often I know that in saymore efficacious than any single drug. ing this I shall invite criticism from a certain school of practitioners who hate 11 mixtures"; but I only give you my experience, gentlemen, valeat quantum, and ask you to come and see for yourselves. There are many cases in which the tendency to recovery is strong, cases which require little or no medicine, and in which our chief care perhaps is not to impede what has been termed the vis medicatrix naturm. These are the cases that do such credit to homoeopathy. There is another class of ailments in which active treatment is absolutely necessary, and without which such diseases would go on from bad to worse. And you will also see many of those sad disorders over which we have little or no control, cases in which our chief aim is to alleviate suffering and to smooth the path to the grave. Gentlemen, I have been very brief, almost trite, in my remarks, and I am painfully conscious that they contain nothing new or original; but I trust I have said enough to convince you that clinical work is full of interest, and its
study
of the
highest importance. ON A
CASE
OF PARALYSIS OF THE TONGUE FROM HÆMORRHAGE IN THE MEDULLA OBLONGATA.
BY J. HUGHLINGS
JACKSON, M.D., F.R.C.P.,
AND TO THE HOSPITAL FOR THE PARALYSED AND EPILEPTIC.
PHYSICIAN TO THE LONDON
HOSPITAL,
You must not suppose, however, that we can always give to the complaint from which a patient is suffering, a rare one, but also one of great THis case is not or always be certain of what ’is the matter. Many cases value. It derives itsonly value from the careful examination In the diffiare obscure, even to the most experienced. culties that surround you in the study of your profession, Dr. Lockhart Clarke has made of the medulla oblongata; it may be a melancholy satisfaction to you to find that even an examination revealing a very limited lesion, correspondthose who have laboured at it for years do not know every- ing to the most striking symptom-paralysis of the tonguething ; for I well remember the relief it was to my mind during life. in early school days when the master had to look out some The , greater part of the life-history of the case was pubGreek or Latin word in the Dictionary. You will find, lished me eight years ago (Lond. Hosp. Rep., 1864, vol. i., in that a case at instances first difficult and by however, many obscure, by careful watching and waiting will become easy p. 368). A brief note of the morbid appearances is given in a name
observed