SCIENCE 



[N. S. Vol. XLIII. No. 1119 



medical diagnosis has now made available. 

 Teaching hospitals should take the lead in 

 making suitable provision for these studies 

 of metabolism that are now indispensable 

 for satisfactory diagnostic and thera- 

 peutic work. 



As .an appendix to the doctrines of meta- 

 bolism, the methods of investigating the 

 disturbances of function of the endocrine 

 glands, so interesting at the present time to 

 all workers in internal medicine, should be 

 taught. Aside from certain pharmacody- 

 namic tests to be made with epinephrin, 

 atropin, pilocarpin, etc., judgments regard- 

 ing the activities of the several endocrine 

 glands depend largely upon (1) observa- 

 tions of the general exterieur of the body 

 (facies, height, bony skeleton, span, skin, 

 hairs, mass and distribution of subcutane- 

 ous fat, shape of pehds, appearances of the 

 acra, and of the genitalia, teeth) ; (2) syste- 

 matic metabolic studies; and (3) systematic 

 studies of the funptions of the autonomic 

 nervous system. The main diagnostic facts 

 in this active &rea of clinical medicine can 

 be quickly assembled and given in concise 

 form to the students; thereafter, they may 

 apply them in their work in the wards to 

 the analj'sis of endocrinopathic cases. 



pkj\.ctiCj:Uj applications of the principles 

 and methods thus learntld in the 

 actual study of patients en- 

 tering the clinic fob 

 diagnosis 

 The rather extensive proptedeutic clinical 

 training that I have just described should, 

 I think, be undertaken and finished before 

 the students take up the complete diag- 

 nostic study of single unknown cases. 



Students may then enter the wards for a 

 period of say three months of concentrated 

 clinical study of patients, and though still 

 under strict control become an integral 

 part of the working force of the clinic. If 



the wards of the clinic are imder the close 

 supervision of a junior and a graded senior 

 resident staff, and are also daily visited by 

 professors and associate professors, there is 

 no reason why students educated in the 

 way mentioned may not make possible more 

 exhaustive studies of the patients than 

 could otherwise be made by the staff, while 

 the students themselves are gaining an in- 

 valuable clinical experience. 



During this period of the clinical clerk- 

 ship, the student should spend practically 

 his whole day in the medical wards and in 

 the laboratories and library adjacent to the 

 wards, very much as does the regular med- 

 ical house officer. A certain number of 

 beds — say three or four — are assigned to 

 each student. "\\Taen a new patient enters 

 one of these beds, the anamnesis is taken by 

 the student, who submits it to the resident 

 house officer for criticism or approval. The 

 student makes a general physical examina- 

 tion, the results of which he records for 

 himself, though this record may or may not 

 be incorporated in the hospital records. 

 In anj^ case, the student has had an oppor- 

 tunity of making a physical examination 

 without prejudice and of recording a status 

 prasens, and he later has opportunitj^ to 

 compare his findings with those of the resi- 

 dent staff" and with those of the visiting 

 physicians. Certain routine laboratory 

 and instrumental examinations he makes 

 at once and records the results in the his- 

 tory, so that any member of the staff on 

 coming to the patient finds not only a com- 

 plete anamnesis ready for him, but also 

 some reports on the urine, the feces, the 

 blood and the blood pressure. After a re- 

 view of the anamnesis and of the general 

 physical findings bj^ a member of the senior 

 resident staff, further steps to be taken in 

 the diagnostic study are discussed and the 

 decision arrived at concerning the series of 

 examinations next to be applied. The stu- 



