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A Journal of British and Foreign Medicine, Physiology, Surgery, Chemistry,
Public Health, Criticism, and News.
PUBLISHED BY JOHN JAMES CROFT, AT THE OFFICE OF "THE LANCET,” 423, STRAND.
PHYSICIAN TO THE IXFIRMARY.
rected or confirmed by his more matured judgment. Moreover, if you are in doubt as to any particular symptoms he will be quite ready to assist you in reference to them. It is not to be expected that, during the early period of your
attendance on hospital practice, you should give an undi. CLINICAL STUDY.
vided attention to your clinical work, or be able to appre
ciate, as you will after you have been well grounded in your Delivered at the Liverpool Royal Infirmary,
anatomical, physiological, and other studies, the features of
disease or the nature of surgical lesions. But let not these By A. T. H. WATERS, M.D., F.R.C.P., circumstances prevent you from regularly attending, from
the very commencement of your hospital career, the clinical lectures and the clinical instruction in the wards. And
with reference to the latter part of your time here, when GENTLEMEN,—I wish to call your attention to-day, not you have passed your preliminary examination, a very large specially to any of the cases in the hospital, but to the sub- share of your attention should be given to clinical work. ject of clinical study. It will be my duty, during the next It is then that you should take the office of clinical clerk, few months, to give you a course of clinical lectures inde- and devote yourselves assiduously to the duties which it pendently of clinical instruction in the wards. I am anxious involves. The appointment of clinical clerk is one of great therefore that this, the first occasion of our meeting, should it. Some, if not all, of the examining boards require that
value, but it depends upon yourselves how far you profit by be devoted to an endeavour on my part to enlist your in. a student shall have filled this office before he can be adterest in this portion of your work, and to point out to you mitted to examination for a diploma. This is a wise regulaits paramount importance. All the other studies in which tion. But before you undertake the duties of a clinical you are or have been engaged are but introductory to that clerk you should bave prepared yourselves for the work by of disease at the bedside, and inust be made subservient to taking your own notes of cases; you will thus not only
render yourselves much more useful to your physician, but it. It is in the wards and in the clinical lecture room that you will derive far more benefit from your clerkship than you will see the living examples of the various affections ! you otherwise could. which are treated of in your theoretical discourses on medi. One word with reference to the attendance on post-mortem cine and surgery, that you will learn the practical applica- examinations. You should never fail to be present at these tion of the principles of diagnosis, and that you will be able examinations. If you have watched the progress of a patient to observe the manner in which disease or accident becomes kind from a study of the appearances which the autopsy
during life you will gain information of tbe most valuable amenable to treatment or baffles the skill of the physician reveals. But of what avail will these be to you if you see or surgeon. And let me tell you that if you wish to become the case for the first time in the dead-house, or if you do successful practitioners of medicine you must begin early not carry there with you a well-grounded knowledge of to observe the phenomena of disease, to familiarise your
healthy structure. selves with its various aspects, and to learn the manner in portant part of your clinical work. It is that which, after
And with regard to cage-taking. This is the most imwhich the examination of a patient should be conducted.
the primary difficulties are overcome, will be the most inI do not think that the student of the present day is teresting to you. It is impossible for you to estimate the overtasked as regards attendance on theoretical lectures, nature or progress of cases without carefully placing them nor are the requirements in this direction such as to pre- on record in language of your own. The cases of which vent his daily visit to the wards. There has been, in fact, you preserve notes will dwell in your memory in after-years, a tendency of late to curtail very largely the more formal and will serve as references in the treatment of cases of a lectures, and to give a practical character to our teaching similar character. Many of you, when you have once passed Indeed, the examinations of our licensing boards are now from your school and obtained your qualification to practise, of a nature to test, much more than was formerly the case, will have no opportunities of clinical study except such as the practical knowledge which a man possesses; and if the your private practice may afford, and you will then find system of making candidates for a diploma examine cases the value of the accurate knowledge of clinical facts which of disease, and perform some of the manipulations of sur- you have acquired by systematic case-taking. But casegery, become more general, it cannot fail to have a beneficial taking is not only important in impressing on the mind the influence on the education in our schools of medicine. A features of disease; it is also a most valuable training. It step in the right direction has recently been taken by the leads to clearness of thought, exactitude of language, and College of Surgeons, for which it deserves all credit, in re- habits of regularity-all of the utmost value in reference to ference to the study of practical surgery and practical phy- your future career as practitioners. By it you learn how siology.
to question a patient, what are the special points to insist Your clinical studies, gentlemen, should be carried on in on in making a diagnosis, and the most ready way of ara carefully regulated manner, and let me now give you riving at a correct opinion of the nature of a case. Three a few words of advice in reference to this subject. In months' work as clinical clerk, three months of careful the wards of this hospital you will have ample oppor daily case-taking, are far more useful than as many years tunities of seeing almost every variety of disease, but I of desultory, irregular, uncertain attendance in the wards. would warn you against the notion that you can learn to Let me add a few words in reference to the subject of practise your profession by hurriedly looking at a large diagnosis. It may seem to you an easy matter to make out number of cases. It is not by a rapid survey of numerous the nature of a case. A man of experience will put a few patients that you will learn to estimate aright the nature leading questions, make perhaps only a slight physical of their symptoms, or the treatment which is applicable to examination, and at once pronounce a correct opinion of them, but by a careful study of a few; and the plan which the existing ailment; and you may imagine that you will you ought, in my opinion, to adopt is, to take in the first readily be able to do the same. But do not be mistaken. place those cases which are well marked instances of their This power of rapid diagnosis has been the result of long kind; to note accurately and regularly from day to day all observation and great painstaking; and you will find even the details of each case, and record them at the time in that the man of the most matured judgment will often your note-book. Do not attempt too much at once. Take spend a long time over a case-will examine carefully all a few cases of disease of some organ, or of some general its details— before he will venture on an opinion of its malady, as acute rheumatism, and make them for the time nature. If you wish to attain to the power of accurate the subjects of your special study. Let nothing interfere diagnosis—of rapid diagnosis in ordinary cases,- you must with your daily visit to these cases, and especially make a begin by examining with the greatest care every detail of a point of being present when the physician under whose care series of cases which are the best-marked instances of their the patients are placed goes his rounds. You will gain from kind. The study of these will prepare you to understand him his opinion of the nature of the cases, and the progress the varieties and complications which so constantly present which they are making. You can compare the opinion themselves at the bedside. which you have formed with his, and have your views cor- In conclusion, I would therefore impress upon you the No. 2549.