CHAPTER VI
THE COURSE OF STUDY
THE HOSPITAL AND THE MEDICAL SCHOOL
The Third and Fourth Years (a)
Let us make an inventory of the presumptive acquirements of the well trained medical student at the threshold of his third year. He knows the normal structure of the human body, the normal composition of the bodily fluids, the normal functioning of tissues and organs, the physiological action of ordinary drugs, the main departures from normal structure, and in a limited fashion the significance of such departures both to the organs and tissues immediately involved and to the general economy of the organism. He will have had his first lessons in physical diagnosis, learning, perhaps in the class-room through examination of his fellow students, the use of the stethoscope, the arts of palpation, auscultation, and percussion, accustoming his ear to the normal sounds, his fingers to the normal “feel,” of the chest and abdomen in health. His studies in pathology will have introduced him further to the essential clinical terminology, obviating the necessity of a separate detached course in "elementary medicine."[1]
It remains, then, in the first place to teach the student how to get from the direct study of the patient himself whatsoever data remain to be collected. He will then possess two sets of facts: one in a way indirectly obtained, through microscopic or other study of excretions, secretions, tissues, etc.; the other set procured directly at the bedside. He must learn the art of combining them; he must see them together as the total picture of the situation with which he is called on to deal. Upon this inductive process all intelligent therapeutic procedure is based: hence his final task—to learn through an extension of the elementary discipline that began in the pharmacological laboratory, the therapeutic measures calculated to meet the more or less precisely ascertained and inferred conditions, responsible for the disturbance he is trying to quell.
A somewhat absurd controversy has at times raged as to which is of the higher scientific quality or diagnostic value—the laboratory disclosures or the bedside observations. Occasionally champions of the laboratory prejudge the issue by calling pathology a real or pure or more or less accurate science, as against the presumably unreal or impure or inaccurate data secured from the patient himself. It becomes
- ↑ The place of pathology in the American medical curriculum—if the instruction takes advantage of it-saves us from the difficulty encountered in Germany, where pathology and clinical medicine begin together. "According to current use the study of general pathology and pathological anatomy begin simultaneously with attendance on the clinic. For that reason the first semester of the clinic is of very slight value. ... We ought first to procure for the student clear pathological conceptions; only then will it be easy for him to follow the clinical instruction intelligently and profitably. I consider it absolutely necessary that the instruction in general pathology and pathological anatomy should precede the clinic." Von Strümpell, loc. cit., pp. 16, 17.
