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A Journal of British and Foreign Medicine, Physiology, Surgery, Chemistry,
Public Health, Criticism, and News.

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165, 341 June 4





Delivered at the Liverpool Royal Infirmary,
BY A. T. H. WATERS, M.D., F.R.C.P.,


GENTLEMEN,-I wish to call your attention to-day, not specially to any of the cases in the hospital, but to the subject of clinical study. It will be my duty, during the next few months, to give you a course of clinical lectures independently of clinical instruction in the wards. I am anxious therefore that this, the first occasion of our meeting, should be devoted to an endeavour on my part to enlist your interest in this portion of your work, and to point out to you its paramount importance. All the other studies in which you are or have been engaged are but introductory to that of disease at the bedside, and must be made subservient to it. It is in the wards and in the clinical lecture room that you will see the living examples of the various affections which are treated of in your theoretical discourses on medicine and surgery, that you will learn the practical application of the principles of diagnosis, and that you will be able to observe the manner in which disease or accident becomes amenable to treatment or baffles the skill of the physician or surgeon. And let me tell you that if you wish to become successful practitioners of medicine you must begin early to observe the phenomena of disease, to familiarise yourselves with its various aspects, and to learn the manner in which the examination of a patient should be conducted. I do not think that the student of the present day is overtasked as regards attendance on theoretical lectures, nor are the requirements in this direction such as to prevent his daily visit to the wards. There has been, in fact, a tendency of late to curtail very largely the more formal lectures, and to give a practical character to our teaching. Indeed, the examinations of our licensing boards are now of a nature to test, much more than was formerly the case, the practical knowledge which a man possesses; and if the system of making candidates for a diploma examine cases of disease, and perform some of the manipulations of surgery, become more general, it cannot fail to have a beneficial influence on the education in our schools of medicine. A step in the right direction has recently been taken by the College of Surgeons, for which it deserves all credit, in reference to the study of practical surgery and practical physiology.

Your clinical studies, gentlemen, should be carried on in a carefully regulated manner, and let me now give you a few words of advice in reference to this subject. In the wards of this hospital you will have ample opportunities of seeing almost every variety of disease, but I would warn you against the notion that you can learn to practise your profession by hurriedly looking at a large number of cases. It is not by a rapid survey of numerous patients that you will learn to estimate aright the nature of their symptoms, or the treatment which is applicable to them, but by a careful study of a few; and the plan which you ought, in my opinion, to adopt is, to take in the first place those cases which are well marked instances of their kind; to note accurately and regularly from day to day all the details of each case, and record them at the time in your note-book. Do not attempt too much at once. Take a few cases of disease of some organ, or of some general malady, as acute rheumatism, and make them for the time the subjects of your special study. Let nothing interfere with your daily visit to these cases, and especially make a point of being present when the physician under whose care the patients are placed goes his rounds. You will gain from him his opinion of the nature of the cases, and the progress which they are making. You can compare the opinion which you have formed with his, and have your views corNo. 2549.

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 undivided attention to your clinical work, or be able to appreciate, as you will after you have been well grounded in your anatomical, physiological, and other studies, the features of disease or the nature of surgical lesions. But let not these 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 you have passed your preliminary examination, a very large share of your attention should be given to clinical work. It is then that you should take the office of clinical clerk, and devote yourselves assiduously to the duties which it involves. The appointment of clinical clerk is one of great it. Some, if not all, of the examining boards require that value, but it depends upon yourselves how far you profit by

a student shall have filled this office before he can be admitted to examination for a diploma. This is a wise regulation. But before you undertake the duties of a clinical clerk you should have prepared yourselves for the work by taking your own notes of cases; you will thus not only render yourselves much more useful to your physician, but you will derive far more benefit from your clerkship than you otherwise could.

One word with reference to the attendance on post-mortem examinations. You should never fail to be present at these examinations. If you have watched the progress of a patient during life you will gain information of the most valuable kind from a study of the appearances which the autopsy reveals. But of what avail will these be to you if you see the case for the first time in the dead-house, or if you do not carry there with you a well-grounded knowledge of healthy structure.

portant part of your clinical work. It is that which, after And with regard to case-taking. This is the most imthe primary difficulties are overcome, will be the most interesting to you. It is impossible for you to estimate the nature or progress of cases without carefully placing them on record in language of your own. The cases of which you preserve notes will dwell in your memory in after-years, and will serve as references in the treatment of cases of a similar character. Many of you, when you have once passed from your school and obtained your qualification to practise, will have no opportunities of clinical study except such as your private practice may afford, and you will then find the value of the accurate knowledge of clinical facts which you have acquired by systematic case-taking. But casetaking is not only important in impressing on the mind the features of disease; it is also a most valuable training. It leads to clearness of thought, exactitude of language, and habits of regularity-all of the utmost value in reference to your future career as practitioners. By it you learn how to question a patient, what are the special points to insist on in making a diagnosis, and the most ready way of arriving at a correct opinion of the nature of a case. Three months' work as clinical clerk, three months of careful daily case-taking, are far more useful than as many years of desultory, irregular, uncertain attendance in the wards.

Let me add a few words in reference to the subject of diagnosis. It may seem to you an easy matter to make out the nature of a case. A man of experience will put a few leading questions, make perhaps only a slight physical examination, and at once pronounce a correct opinion of the existing ailment; and you may imagine that you will readily be able to do the same. But do not be mistaken. This power of rapid diagnosis has been the result of long observation and great painstaking; and you will find even that the man of the most matured judgment will often spend a long time over a case-will examine carefully all its details-before he will venture on an opinion of its nature. If you wish to attain to the power of accurate diagnosis-of rapid diagnosis in ordinary cases, you must begin by examining with the greatest care every detail of a series of cases which are the best-marked instances of their kind. The study of these will prepare you to understand the varieties and complications which so constantly present themselves at the bedside.


In conclusion, I would therefore impress upon you the

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