June 9, 1916] 



SCIENCE 



809 



dent accompanies the patient to the special 

 examining rooms and assists with the tech- 

 nic of the roentgenologic, immunologic, 

 ophthalmologic, urogenital and other meth- 

 ods of examination employed. 



Gradually the data bearing on the case 

 are accumulated. The student is asked his 

 opinion of their meaning, and every effort 

 is made to lead him to form his own inde- 

 pendent ideas regarding (1) the structural 

 changes that have occurred in the patient's 

 body; (2) the pathologic-physiologic proc- 

 esses that are going on; and (3) the etiol- 

 ogy and pathogenesis of the disease. To 

 his surprise, the student often finds that, at 

 first, he can not see the woods on account of . 

 the trees. He is confused by the wealth of 

 abnormal findings the study has yielded. 

 He is in doubt as to the relative importance 

 of the several findings, and may have diffi- 

 culty in seeing internal connections that 

 exist. He does not know yet how to ar- 

 range the findings in logical sequence. He 

 has had no experience in the epitomizing of 

 a group of observations in the form of a 

 so-called "syndrome." He is not yet an 

 adept in the construction of a clinical (or 

 pathological-physiological) picture. And 

 this is as it should be. The student who 

 begins his clinical studies by looking for 

 ready-made clinical pictures or syndromes 

 goes at his work at the wrong end. Only 

 after long experience at clinical analysis is 

 the synthetic work of sjmdrome-formation 

 desirable or profitable. For working in the 

 right way, he finds that what is called a 

 syndrome is only a generalization, or kind 

 of shorthand expression, to abbreviate de- 

 scription — for proper use, not for abuse. 



Through the whole period of the pa- 

 tient's stay in the hospital, the student fol- 

 lows the case closely. The course of the 

 disease is observed and recorded. Compli- 

 cations are watched for. Early erroneous 

 impressions are corrected. The student 



goes to textbooks, monographs and journals 

 in search of descriptions of similar cases. 



When therapeutic measures are insti- 

 tuted, their eifects are observed. Should 

 surgical operation become necessary, a stu- 

 dent knows it and is present to observe 

 what is found. Should death occur, the 

 student assists at the autopsy, makes histo- 

 logic and bacteriologic examinations of the 

 organs, and, later, attends the clinical- 

 pathological conference at which the case is 

 discussed by the professor of pathology 

 and the professor of medicine. After the 

 study of any case has been finished, the 

 student writes down his final impression of 

 the whole case, in the form of an "epi- 

 crisis. ' ' 



It is a disadvantage to the clinical clerk 

 to be responsible for over three or four pa- 

 tients at once. He should not be hurried or 

 overburdened at this stage of his develop- 

 ment. It is better that he study one pa- 

 tient thoroughly and read and reflect on 

 the case carefully, than that he study 

 superficially a dozen different patients. 

 During a clerkship of three months he will 

 have studied a number of patients in a 

 careful way, and rubbing elbows with his 

 fellow clerks in the ward will have bene- 

 fited by their studies of patients nearby. 



Moreover, at the daily ward rounds he 

 hears staff and students discuss various 

 cases, and at the amphitheater clinics, 

 which he can now really begin to enjoy, he 

 listens to the presentation of a case, or of 

 a subject in its entirety, and revels in the 

 beauty and artistry of the clinical pictures 

 that the experienced clinical teacher finds 

 it possible and legitimate to compose. 



In the clinics he hears also the results of 

 the original inquiries that are under way, 

 and if he has an original mind, the atmo- 

 sphere of the clinic may incite in him visions 

 of some new application of an ancillary 

 science to the solution of some clinical prob- 



