student reminded that one is vibrations which may be felt and that the other audible vibrations. Here again an opportunity is afforded of noting the relationship of signs with conditions. In the same manner we take up the topographical anatomy, the physiology and anatomy of the heart. The sounds are studied with reference to cause, point of maximum intensity, relative intensity of the aortic and pulmonic second sounds and the rhythm of the first and second sounds. The heart is now carefully studied by palpation, percussion, and auscultation in accordance with the rules and methods used in the examination of the lungs. Traube's space is outlined. Then all this work is carefully repeated on the living body until each student is familiar with it. The blood vessels are next examined by means of the finger and the syphygmograph and the syphygmograph is studied and interpreted. The abdomen is divided into regions and the surface anatomy of the liver, stomach, pancreas, spleen, kidneys and colon is learned and each drawn on the body. Each student is now taught to make a systematic examination of the nervous system in regard to sensibility of the skin;, muscular sense; visual field hearing; smell; taste. Morements, voluntary, resisted, co-ordinated, etc. The eye and the various reflexes. This gives an exceedingly brief outline of the work done on the normal body as a preparation for the examination of the abnormal. The failure to establish this ideal standard of the normal is an important source of failure in the teaching of physical diagnosis. It is absurd to attempt to teach men in regard to the abnormal when they have no definite knowledge of the normal. The foregoing work is carried on under my personal direction, by Drs. Chester, Elliott and Campbell. At the same time synchronous with this course, the class is having daily instruction in the clinical laboratory under Prof. Zeit. The Didactic lectures begin at the commencement of the term and run parallel to the foregoing courses. There are 64 lectures during the term; two each week throughout the year. The necessity for the didactic lecture in economizing time, in making explanations, outlining topics, planning outlines, etc., is so apparent to any one of experience in this work that it needs no defence at my hands. Such subjects as heredity family history, previous illnesses and habits are very fully discussed. At this point we take up general symptomatology and pain is carefully studied in all its relations, and the difference between symptoms and signs clearly pointed out. The inquiry being completed, we are now ready for the second step, the general examination, the data obtained by observation, the objective phenomena of disease, the “handwriting on the wall.” Here at the outset the student is warned that if he would succeed he must not be one of those described by the French proverb "who go through the forest and see no firewood." He must use his senses and must learn to see with both eye and hand. He is taught that there is no such thing as "intuitive" diagnosis: that no mystery surrounds the recognition of the objective phenomena of disease. It is the same kind of "intuition" and "mystery" as attends the reading of difficult music at sight or the playing of the piano by a master hand. It means hard work and lots of it, accuracy of observations, logical conclusions, the proper use of well trained faculties, skill in technique, and opportunities for observing disease. This general examination includes the psychical condition, the general nutrition, diathesis, weight, height, vital index, attitude decubitus, posture, the face, eyes, nose, mouth, tongue, the hand, with its skin in regard to nutrition, tone, humidity, color and whether pigmentation or vascularization, oedema, Then temperature with diagnostic significance of types of fever. This completes the general examination and we have taken two steps in the diagnosis; the history of the case, and the general examination. scars. Time will not permit me to go farther in the details of the didactic work. Suffice it to say that in the same way, the work in regard to the lungs, heart, liver, spleen, etc., are all gone over with great care. Outlines are used as much as possible. The student is taught step by step to learn the symbolical language of disease, taught to see beyond the symbol to that which is symbolized; taught to associate signs, symptoms and physical conditions with pathological states; to see with the mind's eye the actual condition of the parts examined and of the patient as a whole. Amphitheatre Clinics have been going on meanwhile. It is just here that the good judgment of the teacher will be taxed to the utmost to know what to not teach. My general clinics are utilized first of all to illustrate the lectures of the previous days. For example, recently, after lecturing in regard to the skin, I was able to show in the clinic on the following day and at the same moment a case of jaundice and one of Addison's disease, illustrating general abnormal pigmentation. With these were a case of disease of the heart and another of chronic pulmonary tuberculosis, one illustrating a circulatory and the other a respiratory cause of a vascular abnormality, cyanosis. In this clinic, the discussion was confined almost exclusively to the diagnostic inferences to be drawn from the examination of the skin. The temptation to go outside of that which the student comprehends in order to use material and make a brilliant clinic is a strong one which should always be resisted. At another time after the class had learned all about the form, size and movements of the chest, I showed at one time two cases of emphysema, one eginning and the other advance, one case of typical alar chest. one of retraction of the left side from a thickened pleura. Here again the work of the hour was concentrated on departures from the normal in form, size and more ment. The point is this, and it is a very important one and not sufficiently recognized in the teaching of beginners: teach only one thing at a time and keep at it until it is understood, and don't go outside of the particular topic under discussion, no matter how inherently interesting it may be... To know what to present and when to stop requires rare good judgment. Observation is made a strong point in these clinics, and the men soon learn to take in the whole man, then the head, face, form, hands, etc., etc., in a systematic, orderly manner; first the general and then the special. After they have mastered the general examination, they are now ready to take the third step, the special examinations, such as the respiratory, circulatory, digestive glandular and nervous symptoms in their order. The Third Step the Special Examination. The student is now prepared to take up the study of disease. This is done first in the large clinic as follows: After a careful clinical history has been prepared by one of the assistants, and any necessary special examinations made in the clinical laboratory the patient is brought before the class. Here he is submitted to the general examination already outlined. Then the special examination of the respiratory organs is taken up, inspection, observation being especially thorough. The build, general nutrition, type of chest, any want of symmetry of size, form or movement are carefully noted. recorded and interpreted. Then palpation, percussion, auscultation, auscultation of the voice are practiced in the order named and the findings are all recorded and interpreted. A strong point is made of the association of physical signs and the fact that one never needs to depend on a single physical sign for the diagnosis of a given physical condition. If a single physical sign is thought to be present, there are always several others to confirm or refute it. For example, the examiner begins the examination of the base of the lungs by auscultation and is in grave doubt as to whether the crepitant rales at the end of inspiration are due to oedema or to pneumonia. With a correct history, a proper general examination, and a knowledge of the pulse, respiration and temperature, palpation, percussion, and auscultation of the voice, there is no possibility of doubt. The increased fremitus, greater dullness on percussion, bronchial breathing and bronchophony which are the associated characteristic signs of pulmonary consolidation are never present in oedema. In the same way, in the examination of the heart, the use of the stethoscope, instead of being the first, is invariably the last step in a systematic examination. The students are taught that all the most important questions in regard to the heart; compensation, dilatation, hypertrophy, the probability of valvular involvement and often even the valve involved, together with the condition of the heart muscle may all be answered without the aid of the stethoscope. I am confident that the majority of my class can at the end of the term answer all these questions and can diagnose aortic regurgitation and even the extent of it by inspection and palpation alone. They have first of all, the knowledge of the normal which has been previously outlined. They begin with a careful history in which careful inquiry is made in regard to antecedent infection. The family history, occupation, habits, etc., are all fully considered. The general examination discloses any breathlessness of effort, cyanosis, clubbing of fingers or oedema of the ankles, cough, indication of broken compensation. Since failure of compensation results from overwork, and overwork may be of the right or of the left side of the heart, and may be extrinsic as arteriosclerosis, emphysema or nephritis; or intrinsic from valvular defect or muscular weakness, the interrogation proceeds first along these lines. The patient is next examined for evidence of any of those diseases such as rheumatism, gout and syphilis which bear an etiological relationship to the disease of the heart. The blood vessels are inspected and palpated to see whether there is either cartoid pulsation, systolic venous pulsation, locomotive branchials or palpable hardening. The heart region is inspected and palpated at the same time and the location, force and character of the cardiac impulse and the apex beat are noted and a correct interpretation placed upon the findings. Systolic recession of intercostal spaces is looked for. The frequency of the beat and the character of the pulse are noted. Then percussion reveals the outline of the heart and shows at once whether it is that of hypertrophy or of dilatation. If the apex is out to the left and downward with, the enlargement almost all to the left, the beat strong, heaving, thrusting, the apex beat localized, and nephritis and arteriosclerosis can be excluded, the lesion is at the aortic valve. Throbbing carotids and a Corrigan pulse show it to be at least chiefly regurgitation. If there is no co-incident mitral involvement, then we are justified in going even further in our inferences and saying that the origin is probably syphilis. These details are mentioned merely to illustrate what may be learned about diseases of the heart and lungs by inspection and palpation alone, and that in disease of the former especially, the most important questions may be answered by the intelligent use of the eyes and the hands. Such a man knows the actual condition of his patient; and after all this is the important point. The man who is able to diagnose a mitral murmur but is unable to recog nize broken compensation; or who knows the technique or a Widal reaction, but does not recognize the symptoms of intestinal hemorrhage; who recognizes vaguely the consolidation of a pneumonia, but is unable to interpret the rapid weakening of the pulmonic second heart sound; or who recognizes absence of resonance over the base of the lung, but is unable to say whether due to consolidation or effusion, or who begins his examination with the microscope is not a safe man in the practice of medicine. In my own part of this work in the fourth year, special attention is given to differential diagnosis. This ward work has the following advantages: It enables the student to observe the methods and manners which he will find valuable as fitting him for private practice. It secures to him a maximum of individual instruction. He is taught to write a correct clinical history, to learn how to question, what to ask, to follow out correct methods of making complete general and special examinations, and to correctly interpret its findings and lastly to watch the effects of treatment. It is the laboratory method applied to clinical teaching. In all examinations, special attention is given to methods of questioning and order and method of examination. For example, all questions pertaining to the digestive system are asked and grouped together before inquiring in regard to the symptoms relating to the respiratory or the nervous system. In the examination of the lungs, or heart, the student who begins his examination with the stethoscope, is marked a zero even though his diagnosis is correct. This is because his method is wrong and because of the importance emphasizing the value of inspection, palpation and percussion. Differential diagnosis is taken up in both lectures and clinics in the latter part of the second semester of the Sophomore year and of course throughout the Junior and Senior years. Summary-A combination of didactic lectures, recitations, laboratory work in normal diagnosis, clinical laboratory work, amphitheatre clinics, ward visits and hospital clinics so arranged as to secure the greatest economy of the students' time with a maximum of individual instruction. Education in methods with the dominant idea that “the whole art of medicine consists in observation." Especial value placed on a thorough training, in the laboratory work of normal physical diagnosis. Teaching one thing at a time and never taking the student out beyond his depth. Teaching all students how to write a concise, accurate clinical history and to make a general examination before taking up special examinations. Teaching them to reason rather than to memorize, a drawing out rather than a pouring in. PRELIMINARY ANNOUNCEMENT. To Former Graduates and Friends of the University Medical College: It has been decided to tender to the former graduates and their medical friends a free course of Clinical instruction, lasting two weeks, which will follow immediately after closing of the present college course and during the time of the annual examinations. It will close with a grand rally of all former and present students of the University Medical College on Commencement Day followed by the annual banquet in the evening. All former graduates and medical friends of this institution are cordially invited to accept this unusual opportunity of Free Clinical Instruction. It will also afford an opportunity for graduates to visit their Alma Mater and witness the growth and development of the University Medical College in its several departments, beside meet once again old teachers and classmates of former years, as well as form new friendship with the present students and faculty. For further particulars apply to DR. JOHN PUNTON, DR. JABEZ N. JACKSON, *REPORT OF CASES. J. B. ROLATER, M. D., Oklahoma City, O. T. Mr. President and Gentlemen: The cases which I propose to report are not of unusual interest to the physician in general, but to the fellow who is doing them and watching their ultimate result such is not the case. I refer in this to some six hysterectomys, both abdominal and vaginal, done during this year. Case No. 1.-Mrs J. of Perry, O. T., age 34, came to me Feb. 1st, complaining of pelvic pain and suffering from a profuse, continuous hemorrhage. A thorough investigation of her case was made and cancer of fundus was decided upon, as revealed by microscopical report thereafter. A vaginal hysterectomy was done by the use of the angiotribe, on Feb. 5th, which was followed by a rapid recovery, temperature never reaching above 99 degrees; though mind, singe that time, has been slightly impaired. Case No. 2.-Mrs. K. of Oklahoma City, sent for me Feb. 4th, after having suffered for weeks with extreme pelvic pain and abdominal tenderness, dating her illness back to an abortion, which had occurred sometime in November of last year, and saying that she had been confined to her bed from Thanksgiving Day and that all the while she had been taking morphine for relief, which she obtained only so long as the effect of the opiate lasted. Upon examination I found uterus retro-displaced and tender, with a heavy bilateral mass, posteriorly, which I took for diseased tubes. Uterus and tubes were fixed and could not be moved in any way. Temperature, in this case, running to about 101 degrees during evenings. I informed her that in my judgment, the only thing that could be done was an operation, explaining what would be necessary in case she expected to live, to which she consented. On Feb. 7th I did, as in Case No. 1, a vaginal hysterectomy, finding pus in both tubes and uterus and tubes so badly adherent that I could scarcely break loose the adhesions. The angiotribe was used to control hemorrhage. The part which interested me, after getting through with the operation, was the determination of patient to have water. In less than 2 hours after her operation had been completed, while nurse had stepped out of room to refill hot-water bottles, she slipped two of these from her sides and drank more than one quart warm water. The water was retained but set up a most violent inflammatory condition of stomach and bowels, followed by a very heavy diarrhoea, which was extremely hard to control. Case recovered beautifully. Case No. 3.-Mrs. P. of Edmond, O. T., sent for me in consultation with Dr. S. of Guthrie, who had been called to her case. As reported by patient herself, and upon investigation of Dr. S. and myself, we found quite a large tumor in pelvis and abdomen, which we decided was fibroma of uterus (the correctness of diagnosis being verified by microscopical examination from specimen sent to New York after operation). Patient had passed the menopause at the age of 48, but two or three years after this an irregular hemorrhage began to appear, recurring about one year apart. This hemorrhage became almost continuous for several months prior to operation. Operation Feb. 28, abdominal hysterectomy with amputation through cervix and covering over stump with peritoneal covering before finishing operation. Hemorrhage in this case was controlled by ligatures. The only special feature in this case was her age, being 58, and the nice recovery made, she being now in perfect health. Case No. 4.-Mrs. H. of Perry, O. T., came to me March 16th, suffering from a retro-displaced and adherent uterus, with disease of tubes. the true nature of which I could not decide, but probably tubercular. I advised *Read before the Oklahoma Territory Medical Association, Nov. 13, 1901. |