Page:Introductory lecture delivered in the Adelaide Hospital, Dublin, at the commencement of the clinical course, October 31, 1864 (IA b21916433).pdf/16

16 will take the trouble of looking for them, but we place the stethoscope ourselves on the spot indicated, and by personal efforts endeavour to make the student realize exactly what he is in search of. It is astonishing how often mistakes will occur when least to be expected; and a pupil will sometimes say he hears a particular sound, and in reality thinks he hears it, when all the while his attention is directed to a different direction. Very recently we had a case illustrating this. A young woman labouring under anæmia was admitted into No. 8. She had a well-marked bruit on the side of her neck. I pointed it out to the students in attendance, and they all recognised it. I then asked them what was the name of the bruit; almost all of them declared it was a Bruit de Diable—a sound produced in the jugular veins, and owing its origin to the peculiar thin condition of the blood. But in this they were mistaken. It was a bellows' sound. No one familiar with these sounds could have the least difficulty in distinguishing them. The one is a continuous whir like the noise produced by a conch shell applied to the ear; the other resembles that produced by the use of the domestic instrument from which it derives its name. How was the mistake to be accounted for? Simply thus:—They knew the situation where the morbid sound existed was the precise spot where Bruit de Diable is commonly met with, and they also knew that the patient was suffering from that kind of disease in which it is most frequently observed. In addition to the evidence afforded by the peculiarity of the sound, the diagnosis was confirmed by the effect produced by change of posture. When the patient assumed the horizontal position the bruit was increased, which is what might be expected in a bellows' murmur, but the reverse of what ought to occur in Bruit de Diable.

Clinical instruction, in addition to affording an opportunity for the exercise of the several senses in their approximate functions, trains the student to habits of accurate observation. This he does when he watches closely the several changes that occur from one day to another in the patient's condition. Regular attendance is, of course, essential to this; otherwise