Lectures on the Principles of Surgical Diagnosis: Especially in Relation to Shock and Visceral Lesions
Authors: F. Le Gros Clark
Journal: BMJ (1868)

THE many functions of animal and organic life are variously influenced in maladies which it is the lot of the surgeon to treat; those which are under the influence of the cerebro-spinal nerve-centre more directly, and those over which the cyclo-ganglionic system presides more indirectly.Disturbance of the assimilative functions, in some of its varied forms, is -commonly present in any local lesion which is of sufficient importance to produce a constitutional impression ; and for the purpose of correctly interpreting these deviations from a healthy standard, it behoves the surgeon to have acquired familiarity with many details in diagnosis, which it was formerly too much the custom to regard as the special pro- vince, if not the exclusive privilege, of the physician to expound.The tongue, the pulse, the state of the excretions, all afford invaluable as- sistance to the surgeon in diagnosis, and, therefore, in treatment; and where it is needed no trouble should be spared, no means of investigation should be considered beneath his careful attention, in order to elicit the requisite information to guide him in forming an opinion.Chemical analysis, especially of the urine, will throw invaluable light on many symptoms which are otherwise inexplicable, and where there are no other more direct means of learning that the kidney or bladder is the seat of functional disturbance or even organic change.And where chemistry fails, the microscope, with its simple lenses, or its polarising arrangement, will supply the required information.The varying de- velopment of heat, as tested by the self-registering thermometer, has a -significance which requires only the accumulation of facts, statistically arranged, to constitute a far more valuable guide in diagnosis, than is the case in the present limited state of our knowledge on this subject.It is not because the testimony we obtain from this source is, in some instances, apparently contradictory, that we are justified in disparaging its value; such, as 1 remarked in my last lecture, is often the case in the early steps of scientific investigation; and it is not unfrequently the most unpromising plant, that which requires most jealous watching and most careful tending, which ultimately bears the fairest and the richest fruit.The state of the Circulation, as tested by the pulse and by listening to the beating of the heart, is too important to need a comment.Yet, many precautions are needed, many influencing conditions are to be al- lowed for, and many accidental circumstances taken into consideration, in estimating the value of the pulse in diagnosis.In some individuals the normal standard is low in frequency, in others high ; or the power may be feeble, or the natural pulse strong and full; and these conditions are by no means determined by the general physical development, nor even by the codinary health of the individual, whether weakly or robust.Again, the nervous excitability of one patient, or the stolid indifference ,of another, necessarily introduces a discordant element into a source of information which we would willingly have precise.Further, the surgeon will not forget the anatomical lesson he has learned in the dissecting-room, that deviations in arterial distribution may, if overlooked, lead to serious error in testing the pulse at the wrist.For these and other reasons, I think the functional derangements of the circulation must be accepted, in many instances, with the allowance of a consider- '&-'L-str,4 JIMAY