Embed Size (px)
fore, he would advise the students not to follow Trousseau’sprecept, who used to say " a little less science and a littlemore art." He could not understand this definition of artand science; and he thought it was the result of a mereconfusion. Trousseau’s savants were a narrow-minded, sta-tionary set; his artists, a lively race, with a stock of ideaseither good or bad. Artists, however, could not do withoutscience. There was need to observe nature assiduously, andto study all her movements attentively and closely. Alludingto the different doctrines which are upheld in medicine, thelecturer said that in clinical medicine these questions wereof small interest. All clinical teachers, whether vitalists ororganicists, acted in a like manner at the patient’s bedside.Whatever the general opinions, whatever the school towhich one belonged, clinical observation commanded the
practitioner at the bedside. The accessory sciences them-selves, which were at present so arrogant—and of course noone thought of denying their value,-were the mere tri-butaries of clinical medicine. When their answers were inaccordance with clinical results, it was well and good; butwhen the converse was the case, then those answers mustbe considered as wrong and of no value. It was just thesame with regard to physiology; and here, notwithstandingthe services which this science had rendered to medicine,he would put his hearers on their guard against the ten-dency which was manifested nowadays to refer everythingin medicine to physiological experiment. Clinical expe-rience was the supreme criterion of physiological research;it alone was capable of furnishing to physiology evidencewhich could not be dispensed with. Everything was broughtunder the control of physiology. This was carrying thingstoo far. With regard to himself, his pace would be slower,and, like St. Thomas, he would wait until it was said tohim : " Vide pedes, vide manus." Even facts were not so
very positive; and the ipse dixit, though pronounced inDutch or German, was not always acceptable. Physiologicalfacts, even when positive, did not always agree with clinicalexperience. As an example of this, the lecturer mentionedalcohol, of which he made great use in the treatment of in-flammatory diseases. He had formerly believed that itacted by removing the paralysis of the vaso-motor nerves,and by thus causing decongestion of the organs; but hehad given up this view. Some said it acted on the pneumo-gastric ; others on the cerebro-spinal centres. But wherewas the truth? The same criticism applied to the allegedaction of coffee, digitalis, bromide of potassium, &c. Ofcourse he did not mean to attack the experimental method ;on the contrary, he believed it involved the progress ofmedicine. But he condemned the inconsiderate haste andenthusiasm which were manifested. Things did not flow-on so smoothly as certain people thought. For his ownpart he would not fail to note every progress as it presenteditself; but he could not resign himself to present facts asaccomplished, whatever the authority which covered them,unless they were indisputably demonstrated.
HÔPITAL DES CLINIQUES.PROF. RICHET said he did not intend to follow the same
method of teaching which he had adopted during the pre-ceding year at La Pitie. There were several methods ofclinical teaching. The one which Trousseau followed wasbrilliant and animated, and for some time it predominatedover all the others. Rare cases were chosen, and irregularpathological forms analysed. This mode of teaching wascharacterised by the originality of the form and the saga-city of the views. But there was the inconvenience of
giving too great importance to exceptional cases, and ofneglecting the forms of disease which are observed in every-day practice. This method the lecturer had followed atLa Pitie, but he would now renounce it. Such a manner of
teaching accustomed the mind to seek after exceptionalcases, and prepared the way for many errors of diagnosis.There was another method-the opposite one, which con-sisted in choosing simple cases as the subjects of lectures,and which had been promoted by Rostan, Chomel, Boyer,-and Desault. Nelaton occasionally employed it, and Velpeauhad definitely adopted it towards the end of his life. Its
advantages were indisputable. The patients were studiedfrom the moment of admission into the wards to the timeof convalescence; similar cases were compared, and infer-ences drawn with regard to the natural course of the disease,
its possible complications, its duration, and the comparativevalue of different modes of treatment. This teaching shouldbe mostly conducted at the patient’s bedside. The lecturersaid he would barely refer to a third plan, which consistedin giving pathological, and not clinical, lectures. Thus, inconnexion with any single case, an exhaustive lecture wasdelivered on the subject of the respective disease. He wouldchoose an intermediate course, partaking of the first twomethods. Like Trousseau and Dupuytren, he would lectureon difficult and rare cases; but generally he would followChomel and Boyer’s wise and prudent practice.
LA CHARITÉ.PROF. SÉE referred to the various causes which had con-
duced to the sterility of clinical medicine. Grounded onobservation, on morbid anatomy, and on the study of thera-peutical indications, each of these departments had beenbadly investigated. The description of cases had becomea long, sterile, and fastidious enumeration of symptoms,and the signification and relative value of the respectivephenomena had not been studied. For instance, it hadbeen remarked that in nine out of ten cases of typhoid feverthere existed meteorism, and therefore meteorism had beentaken as a characteristic sign of typhoid. Yet this symptomwas present in other diseases, whilst it was sometimes absentin cases of well-marked dothinenteric fever; and it merelyindicated a paralysed condition of the intestines, or a fattyor waxy degeneration of the abdominal muscles. These
phenomena should be explained physiologically, and indoing this the observer should be free from all preconceivedideas, and not follow any predetermined direction. Theintervention of physiology in the study of morbid appear-ances was not less necessary. Bayle and Laennec had notforeseen the full value of their discovery. They thought itwas merely a means of distinguishing morbid tissues-ofclassifing lesions. Morbid anatomy had also served to de-termine the form, the volume, and the situation of morbidproducts, and thus elucidate the diagnosis. But it had notbeen expected that it would be utilised in regard to thetreatment. In this respect the microscope had not yet fur-nished any improvement, and had even been injurious tothe advance of clinical medicine. In attempting to takethe cellule as a means of diagnosis destined to overthrow
clinical observation, the science of histology had materiallyimpeded the progress of clinical medicine. Nowadays it hadbeen recognised that elementary normal forms underwentchanges in regard to time or situation; but, after all, theywere mere deviations from the normal type. They were not,therefore, noxious foreign beings, which invaded and de-stroyed the body; but their formation was under the de-pendence of physiological laws, which presided over thedevelopment of symptoms. Disease was therefore nothingelse than a mere deviation from the normal type, both inregard to its anatomical elements and to its functional dis-orders. The sick man had neither new organs nor new func-tions. Only there were new conditions created by the causesof the disease. Physiology presided over the whole scene.The disorder being functional, it was physiological actionsand means which must be employed to check them; andour idea of disease became much less alarming since wewere brought to believe that the lesion was often not morefatal than the symptoms. This view led to a more definitedetermination of disease. If the histological lesion ceasedto be a parasite, a sort of outlaw in the order of biology,its phases might be often followed, and its mechanism de-tected by the experimental method. Thus morbid anatomywould be vivified, and cease to be a caput mortuum. But itwas particularly with respect to therapeutics that clinicalmedicine had been backward since the beginning of thecentury. Medical men were now empiricists or statisticians,and they pretended to be free from the influence of formerdoctrines; but unfortunately this was a mistake. Thevarious doctrines which had successively reigned in medi-cine had left deep and pernicious traces. After havingdivided these doctrines into three grand classes-the solidist,the humoral, and the vitalist,-and after having shown inwhat way they acted injuriously upon medical practice, andhow they had led to great uncertainty and confusion, M.See proceeded to say that the modern tendencies of rationalempiricism and specialism were not worth much more. Toeach specific disease a specific remedy was offered; and