A MANUAL

OF

CLINICAL MEDICINE.

CHAPTER I.

ON THE CLINICAL STUDY OF DISEASE.

SECTION 1. ON THE FACULTY OF OBSERVATION.

ALL who have studied the writings of the greatest of philosophers-Lord Bacon-must know that there are two especial sources to which he refers men for real increase of knowledge, namely, to observation and experiment, which he insists are but questionings of Nature in respect of specific matters. To cultivate the faculty of observation must then be the first duty of those who would excel in any scientific pursuit,' and to none is this study more necessary than to the student of medicine. To such an one it may be said, that the habit of correct observation is that mode of learning his profession which above all others he should most diligently cultivate; remembering that observation does not consist in the mere habitual sight of objects—in a kind of vague looking-on, so to speak-but in the power of comparing the known with the unknown, of contrasting the similar and dissimilar, in justly appreciating the connection between cause and effect, and in estimating at their correct value established facts. The great Newton has assured us that he knew of no difference between himself and other men but in his habits of observation and

"L'art d'observer est le seul moyen d'acquérir des connaissances utiles."-LA CROIX.

attention, and almost the same encouraging remark was mad by Locke.

The constitution of the human mind is such that the acquisition of knowledge can only be very gradual. Just as there is no royal road to learning, so there is no rapid method of gaining experience; and he who wishes to excel must not only work assiduously, but must be careful that he toils in the right direction. Although at first the difficulties in the way of observing correctly may appear insurmountable, yet as the habit is daily encouraged will the path become clear, until at last what was at first a labor becomes a matter of almost routine practice.

The most important part of a medical man's education is undoubtedly to be gained at the bedside. In the wards of our various hospitals every diversity of ailment, every variety of injury may be carefully observed and investigated, firstas disease appears naturally, when, as we may say, Nature is performing her experiments for our wisdom; and secondlyas modified by a careful use of those remedial agents which have been so bountifully bestowed upon us. In order, however, that the observation of disease may be profitable, it must be complete. It will be useless unless the malady be watched during its whole course, the symptoms as they arise noted, and the effects of medicines carefully observed until the termination in recovery or death. Especially is the termination of a case instructive, and not the less so when the result is death, since we may then mark the way in which the patient succumbed, and learn to guard against such an event in similar examples for the future. Just as a man who wishes to become acquainted with the nature and characteristics of a foreign country may read a whole library on the subject, inspect charts and panoramic views faithfully drawn, or study a series of paintings delineating separately all that is most worthy of observation, and yet certainly fail to obtain any correct idea of the distant land; so may a student learn the entire practice of physic by heart from books, and yet be unable to distinguish small-pox from measles when called upon to put his theoretical knowledge into actual practice. Valuable, therefore, and indeed indispensable, as is the assistance to be derived from a careful study of the writings of the masters of our profession, yet these writings must be regarded principally, if not solely, as guide-books, that is to say, as intended to smooth the difficulties which the observer will have to encounter, but by no means calculated to do away with the labor of self-observation; for it is not too much to

say that without practical experience all other acquirements are of no avail to the practitioner of medicine. Truly excellent, then, is the advice given by Dr. Latham to the student, "begin by learning to stand by the sick-bed, and make it your delight." He who will be content to do this in a right spirit, may be assured of becoming an eminently useful member of the noblest profession that can engage the attention or encourage the development of the highest qualities of the mind of man: let him but work diligently, perseveringly, and conscientiously, and he may be certain of ultimately acquiring -if not the purse of Fortunatus-at least a competency; but, above all, will he experience that happiness which princes may envy, but which they cannot bestow, the gratification of knowing that-in however humble a degree-he is the honored instrument of “God, who healeth our diseases."

SECTION 2. THE GENERAL CONDUCT OF THE MEDICAL

PRACTITIONER.

Although much might be advantageously written upon this subject, yet a very few words must suffice. The mere fact that the practice of medicine arose from an instinctive impulse to relieve the pains and sufferings of others is sufficient to show that the medical man, of all men, should be free from that vice which is the besetting sin of mankind—selfishness. He must, indeed, be thoroughly content to live, not for himself, but for others; not to look to his own interests, not to be guided in his actions by motives of policy, but to let the rule of his life be to do as much good to others as possible. He should think as little of pecuniary rewards as is compatible with his own interests and that of his brother practitioners, remembering the maxim adopted by La Bruyère from Confucius-that he who esteems gold more than virtue, will be likely to lose both gold and virtue. The physician, to be successful, must not only possess a sound practical knowledge of his profession, but he must also be careful that his moral character be free from blemish; that his general conduct be not only above vulgarity, but such as to excite the respect of his friends and neighbors; that he be conscientious, attentive, careful of the secrets of those who consult him, unmindful of the worldly condition of his patients, sympathizing, calm, and circumspect in his behavior generally. As it is his object to prolong life, so he must leave no means unpursued in order to attain such object, remembering that the mere prescribing of medicines is often the least part of his duty. It would

indeed be well if medical men generally thought more of the moral remedies at their disposal; and if more attention were bestowed upon soothing the fleeting moments of the afflicted, by inspiring them with hope, confidence, and ease of mind. A man who practises his profession conscientiously will never be unmindful of the duties which he owes to his colleaguesto those treading the same path as himself. He will carefully avoid all such short-sighted proceedings as may tend to elevate himself by depressing others; he will strictly eschew those disgraceful methods of obtaining notoriety, newspaper puffing or prescribing; and he will hesitate at giving, as a rule, gratuitous advice, where such is not needed by the circumstances of the patient, and where such a course of proceeding must injure those who are content to receive a small remuneration for their toilsome labors, and whose daily bread probably depends upon their obtaining such a return for their

exertions.

The encouragement bestowed upon medical men is for the most part very deficient, their worth and usefulness being unacknowledged, their fatigues and anxieties unheeded, and their unselfishness and disregard of wealth abused. While striving to diminish the sufferings of their afflicted fellowcreatures, can it happen otherwise than that their feelings should be hurt by observing the attention paid to men practising the most palpable absurdities and deceptions, by witnessing the success of homœopaths, table-turners, mesmerists, and such like? Has it not, however, always been so? Does not Bacon himself tell us, that "the weakness and credulity of men is such, as they will often prefer a mountebank or witch before a learned physician," and is the present age less credulous than that of the great philosopher? I fear not! But it is the prerogative of superior minds to rise with the occasion. Let us, therefore, individually and collectively, as students and practitioners, strive to improve our art: let us each endeavor to attain that mental sagacity which will enable us to perceive the important features of cases coming under our care and the salient points of diagnosis; that wisdom which can foresee the course and progress of disease; that judgment which will enable us to select the proper remedies; and that calm determination which will render us capable of insisting that the necessary measures are thoroughly carried

out.

The Advancement of Learning.