Introductory Lecture TO THE COURSE OF CLINICAL INSTRUCTION BY THE ORDINARY PHYSICIANS OF THE ROYAL INFIRMARY, EDINBURGH.

NOVEMBER 22, 1862. in their own houses. The very dependence of the sufferers in the former position, the usual absence of relatives or friends who in the time of sickness would gladly minister to their comTO THE fort, make the hospital patients, in the majority of instances, peculiarly the physician’s care. But not only is this the view which the common principles of humanity would lead us to adopt ; there are other reasons, and these-if in one aspect BY THE more selfish in their nature-bear very closely on the subORDINARY PHYSICIANS OF THE ROYAL ject which now engages our attention; for there is no doubt that, if we succeed in gaining the confidence and good opinion INFIRMARY, EDINBURGH. of our patients in hospital, by manifesting at all times a kindly interest in them, weare placed in a still better position for Delivered Nov. 7th, 1862. obtaining a thorough knowledge of the diseases under which they labour, and so of benefiting and relieving them. I have BY J. WARBURTON BEGBIE, M.D., more than once known a most important fact in the history of PHYSICIAN TO THE ROYAL INFIRMARY, EDINBURGH. an hospital patient to remain unrevealed, because the manner of the physician, and his mode of conducting the inquiry, failed GENTLEMEN,—There are probably no courses of lectures on to assure the patient of his real ’interest in her, however conmedical subjects which less require the form of ordinary intro- cerned he might be in her cage. It is thus that many patients keeping secrets, as they ductory remarks than those which are styled clinical. Their hesitate to commit to some physicians’ which through the kinder and more sympathizing them, regard are so that and any explanation importance apparent object of others are readily enough divulged. regarding these might, indeed, rather tend to perplex the inquiries I feel that I need scarcely say to you, gentlemen, that on student, who almost intuitively discerns the benefit to be de- entering the wards of an hospital, in which there may be the rived from clinical instruction. Still, as we now meet many of dying,-there certainly are the seriously and dangerously ill,you for the first time, I shall avail myself of the opportunity all levity should cease, and that a manner and demeanour the afforded me to make a few observations relating to your several most serious, and at the same time interested, which we are able to assume, should be put on. I am well aware that it is duties, privileges, and responsibilities as clinical students; my only forgetfulness which, in most instances, is the cause of a desire being so to influence your conduct, while those all- different conduct; but did we always endeavour to realize the important studies which have brought us here together last, as position in which our patients are placed, even the likelihood to enable you to feel while they continue that you are enjoying, of error arising from that source would be removed. Do not, and when they shall have terminated that you have received, however, suppose that, while I am speaking in favour of the constant and continued maintenance of a serious and grave dethe greatest degree of benefit from them. And in the outset meanour, I consider that there are no occasions upon which, for of your attendance on the wards of an hospital, and partici- a time at least, that may be laid aside ; and let me further pation in the business of a clinical class, it cannot be too guard you against concluding that a hopeful and even joyful urgently or too frequently impressed upon you that the infor- spirit in the physician-which frequently is the means of doing mation you are to receive, the knowledge of diseases and their his patient substantial good-is inconsistent with the gravity of manner and thought which becomes the professional as well treatment you are to acquire, will depend in a comparatively as every other visitor to the wards of an hospital. Of very small degree upon your instructors; in very great measure, if serious character is a large proportion of our cases; and even not entirely, it will result from the use you yourselves make of those best acquainted with their nature and circumstances canthe opportunities afforded you. There is, gentlemen, nothing not always with accuracy reckon in these upon the time and inconsistent in even a regular attendance at the hospital visit manner of the event. Some of you, no doubt, are already and at the clinical lecture during a whole session, and the pos- familiar with hospital experience, and if so, you can probably recall the sudden death of patients in whom you took much session at its close of only a scanty stock- of knowledge. This interest; seriously ill you knew them to be, but for days, it result was, I am happy to think, more common formerly than may have been even hours or minutes, before the fatal catasit is now, or is at all likely again to become. And chiefly because trophe, there had occurred no marked evidence of its dread in the present system of clinical study you are one and all in- approach. This is oftentimes the case in aneurisms, in cardiac vited and encouraged to take a part, not only in acquiring and cerebral affections, and even in pulmonary phthisis; and, bearing it in remembrance, should we not constantly act as if information each for himself individually, but you are enlisted our experience might, on any day or hour, be that of the poet ?

Introductory Lecture

COURSE OF CLINICAL INSTRUCTION

in the

cause of collecting that particular information a of which is to prove useful to the patients under knowledge our care-the greatest object we can have in view; and, further, of importance to all who take an active and interested part in the business of clinical study. In fact, the great aim to be kept in view is this-that the object of clinical study is as little as possible selfish. We are all working for the common good, and that good is-subservient only to the interests of our patients. The great and primary object of hospitals-to which even the clinical study conducted in them stands in a relation of secondary importance-is the benefit of the patients committed to our care. This is a view which must never be absent from our minds, and must to a certain extent be permitted to our actions. Did the objects of clinical regulate and control improvement run counter to the interests of the patientswhich, except in very limited degrees, and under rare and

good

Tread softly; bow the headIn reverent silence bow. No parting bell doth toll; Yet an immortal soul Is passing now."

Such, gentlemen, is a brief allusion to our duty towards the fellow-creatures who here become the objects of our care, and from whose pains and sufferings we have to learn. I know that there is no occasion to enlarge on this subject, for we count upon your hearty co-operation with us in carrying out the views which have been now expressed ; and we feel satisfied that you will always endeavour to assure the patients, by every means in your power, that however anxious you may be to avail yourselves ot the opportunities for instruction afforded you, you will never lose sight of the higher consideration to which I have adverted-namely, their interest and advantage. I turn now to make a few observations which may perhaps assist you in your clinical studies. And firstly, let me counsel peculiar circumstances, they are not even apt to do,--then, you not to devote too much attention to the observation and notwithstanding the loss we should thereby sustain, the latter consideration of what may be called rare cases of disease. In must always be considered paramount, and action be taken the wards of an hospital, during your career as students, it will accordingly. But, as must be well known to those of you, be your fortune-it has generally been that of those who have who have already had any experience of hospital practice, it preceded you-to see certain cases, it may be, of rare and foronly requires the patient to feel satisfied that his interests are midable interest; perhaps interesting also on account of the those chiefly consulted to secure his co-operation to the fullest obscurity attending their diagnosis. I do not say that you extent in the work we have to do. We, on our part, will do should not attend to such cases, but I would impress upon you well always to hold in remembrance that the feelings of the the propriety of not allowing them to interest you so much as sick in hospitals are in every point of view entitled to as much to preclude you from bestowing your best attention upon the consideration from the physician as those of invalids among other and vastly more common cases in the wards. The former, the be’tpr classes of society who are-able to receive his visits perhaps, indeed very likely, (unless you become the physicians No. 2047.

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556 surgeons to a large hospital, or are placed in circumstances and in what manner; if an acute disease, when the crisis may of similar opportunity,) you will never see again ; whereas be expected ; if chronic, whether other maladies or a fresh the latter will be included in the category of cases which, train of symptoms, what the old writers termed superwhen you shortly enter upon the more active duties of your venientia," are likely to appear in its course; how, likewise, profession, you will be daily called upon to recognize and to the administration of remedies is likely to affect it. These treat. You will not therefore question the relative importance and many other questions equally important all present them. of the two classes of cases, in so far as you are concerned. In selves to our notice when ap>lyinn "prognosis" in its extended a large hospital, gathering-as our infirmary, for example, does and proper sense. Intimately related to diagnosis, we can in- its patients from distant quarters, no inconsidemble portion deed only form a correct prognosis when our best attention has of the cases which enter may be classed under the head of been given to the nature and seat of disease. I would beg to comparatively rare diseases. And if we exclude phthisis and direct your attention, in connexion with this important subject, the acute thoracic inflammations-pleurisy, pneumonia, and to one of the genuine writings of the Father of Medicine, enbronchitis, -together with rheumatic fever, those which are titled r.pO"(Vú)(TTLK6v,"(prmnotiones, prognostics.) In it you met with every day in the ordinary run of private practice you will find an admirable and lucid exposition of what was forseldom see in an hospital. Thus among acute ailments, cynanche merly understood by the term " prognosis."" In most diseases, tonsillaris, croup, mumps, measles, whooping-cough, diarrhoea, but more especially in febrile complaints, it was the custom of and many others, are really quite unfrequent in such hospitals. the ancient physicians, particularly of Hippocrates, to pay the This, in so far as the clinical study of disease is concerned, is most minute attention to the appearance presented by the undoubtedly a serious disadvantage, but it is one inseparable patient. He noted invariably the countenance, what expresmovements of the invalid. from the character of a metropolitan infirmary not blest with sion it wore ; the eyes, voice, the amplest means ; and your best plan to counteract the dis- In addition, he inspected the excretions-stools and urine; advantage is to make yourselves familiar with those diseases to paid attention to the perspiration ; and, if vomiting had ocwhich I have referred in dispensary practice. But reverting to curred, to the matters vomited. The sputa, either crude or my former observation, you will find in the hospital wards abun- concocted, were his constant care in diseases of the chest, and dant opportunity for judging as to the duty which lies upon even the salivary secretion in febrile complaints, as respects its you to make yourselves thoroughly acquainted with those dis- quantity and the relation its diminution had to the thirst ex. eases and their treatment with which you are likely to be perienced by the patient, was not lost sight of. The respiraearliest and most frequently brought in contact when you shall tion, sleep and wakefulness, appetite and thirst, weakness or have entered upon your own practice. In so doing you may strength, and frame of mind of the invalid he regarded; also haveat times to exercise some degree of self-denial. The dia- the decubitus ; and finally, to which he attributed very congno&is of thoracic aneurism may present to your minds many siderable importance, days of crisis-critical days. Carefully more attractive features than that of continued fever; and for weighing the indications suggested by a consideration of all the treatment of an empyema or hydro-pericardium by opera- these signs, comparing them, and seldom interrupting the tion, you will be disposed to leave the case of rheumatism or process of nature in febrile diseases by the administration of neuralgia. Now, mark, I do not say that you should not act internal, and specially of any strong, remedies, Hippocrates in tlMt way; but I would urge upon you, just for the consi- was enabled to predict, with a degree of certainty which to derations already adverted to, thoroughly to master the details the minds of his countrymen appeared prophetic, the duration, of knowledge connected with the latter diseases. You know crisis, and very generally the particular manner of termination, that when you are ushered into practice you are sure to meet in various diseases. This was prognosis; and of what imwith them : you may not for a long time, perhaps you may portance he considered it, the first few sentences of the work, referred to will satisfy you never, meet with the former. " It appears to me a most excellent thing for the physician Again, do not allow your whole interest in any given case to be attached merely to its diagnosis. Perhaps you feel some to apply himself to prognosis; for by comprehending the past surprise at my giving you this caution ; but let me assure you and the present, and foretelling, in the presence of the sick, the that my experience of hospital practice leads me to regard it as future, he will be the more readily believed to be acquainted a by no means unnecessary one. Endeavour in every instance, with the circumstances of the sick, so that men will have conwhere possible, to determine the prognosis, or eventualities of fidence to entrust themselves to such a physician. And he will the disease in the particular case under your observation. This manage the treatment best who has foreseen what is to happen is a most important and interesting part of the physician’s from the earlier state of matters. For it is impossible to make duty. In respect to it we may profitably learn a lesson from all the sick well; that, indeed, would be still better than to be the book of Ancient Medicine. The term Prognosis, and its able to foretell what is going to happen ; but since some men actual practical application, are now much more limited than die, some even before calling the physician, from the very It is presently violence of the disease; and as some die immediately after calling when employed by Hippocrates and Galen. understood to mean little, if anything, more than the phy- him, having lived perhaps only one day or a very little longer, sician’s opinion as to the nature of the probable ultimate event, and before the physician can bring his art to counteract the disas to whether the disease is likely to gain the mastery or notease, it therefore becomes necessary to know the nature of such whether the patient is to live or to die. The former would be affections-how far they are above the powers of the constitucalled a good or favourable, the latter a bad or unfavourable, tion."" Thus, he concludes, " A man will be the more esteemed prognosis. Of course, within the limits of death, on the one to be a good physician ; for he will be able to treat those aright hand, and recovery on the other, there will be many shades of who can be saved, from having long anticipated everything; good and bad to apply to the prognosis formed; but there vir- and by foreseeing and announcing beforehand those who will tually the employment of this really important function of the liveand those who will die, he will thus escape blame." Do not for a moment suppose that there was anything like physician may be said to cease. A little reflection, too, will satisfy you that even to this limited extent "prognosis"is an attempt at "divination" in the exercise of prognosis, as more cultivated in private than in hospital practice. I do not practised by the ancient physicians. Hippocrates, at all events, say that such is always the case, but most undoubtedly the is free from any such charge; for apart from the circumstance more attractive features of diagnosis are not unapt to sink the that such pretension was utterly foreign to his character, and importance of prognosis in your estimation ; while, in the in. that with singular ability he laboured throughout his long life stance of the physician visiting in private, his opinion as to to disabuse his countrymen of the notion that there was a the probable issue of the patient’s malady is required by rela- specially divine nature or essence in many diseases, epilepsy, tives and friends, in whose estimation, indeed, the nature of for example,-the "r.p6voLa,"or prescience,-which he fosthe disease is only of secondary importance when compared tered was one purely human ; it was based, indeed, on a truly with the momentous question, is the patient to live or to die ? scientific calculation, which in its turn reposed on the knowIt is not, however, in its limited or restricted sense that I think ledge of some phenomena past, and of others still existing. I we should practise prognosis. Both from its intrinsic import- offer no further comment on the remarkable passage just ance, and as a means of cultivating our best faculties as phy. quoted: the truth and great importance of the view Hippocrates sicians, I conceive it to have very special claims upon our inculcates must be apparent to all, and that physician can have attention. In its more extended signification, we are called seen little of disease and its treatment who is prepared to deny r.pon to determine, not merely what the probable issue of the that a careful prognosis, in so far as both patient and patient’s case may be-good or bad, favourable or unfavourable, life or friends are concerned, is of the utmost consequence; while the (.-ep.b, but as far as is in our power, to consider what has already merit that is likely to accrue in the event of a correct prognosis and the present condition, together with what all the is calculated, as, indeed, it ought to be, to reflect honour and eventualities or prospective occurrences are likely to be. How credit on the physician. and when the disease may resolve itself ; if it prove fatal, when (To be eM!cM<’(!.) or

gesture,

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