FIRST PRINCIPLES OF DIAGNOSIS. JAMES FREDERICK ROGERS, M.D., New Haven, Conn. Knowledge. To be a good diagnostician the first essential is to know the anatomy and physiology of the human body. Not anatomy and physiology as we commonly understand them--not the structure and working of the body as described in a book -not the organs and their arrangement in a cadaver, nor the behavior of the organs of the frog and cat, but the anatomy and physiology (and psychology, if we consider it apart from physiology) of the living person who comes under the examination of our senses. It is well enough to know all the books have to tell us about these two inseparable subjects, and it is to be hoped we have made the most of our laboratory experience, but there is a mighty big difference between carving corpses, stimulating a frog's gastrocnemius, and finding what has gone wrong with a living human being. Many high-stand medical students make poor physicians. It is never too late to learn anatomy and physiology for purposes of diagnosis for if we are painstaking examiners we may add to our stock of knowledge of the normal body with every patient that comes to us. Every patient offers us opportunity for study, and if we feel that we are weak on any point-the location of the heart, the sounds of the heart, the location and size of the stomach, the normal curves of the spine, the normal degree of movements of the joints, etc., we can take up, one at a time, each of these for special study, and with the aid of a brief up-to-date book on the subject, and the latest suggestions from the medical journal we can (if we have any ambition) learn much. Taking Pains.-One diagnostician differeth from another in skill, however, not so much in his knowledge as in the quality of taking pains. Failure in diagnosis is more often due to carelessness and haste than to ignorance. The best diagnostician lets nothing escape him. He learns his patient's history from earlier generations to the present; he uncovers the secrets which are being withheld, for the patient often places the physician in the position of a clairvoyant and it is the business of the doctor to see clearly through this absurd weakness. On the other hand, the examiner avoids leading himself astray by the common fault of causing the patient to make inaccurate or false statements by suggestion. He is methodical in history-taking, never failing to get at the cause, actual or fancied, of the present condition. Symptoms and Signs.-Some diagnoses can be made from the history, others depend wholly on the physical signs, while in others both signs and symptoms must be taken into account. In his physical examination the good diagnostician is most methodical and he lets nothing escape him from a beginning alopecia to a flat foot. He neglects the use of none of his senses, and, because he does not happen to detect the abnormal by one sense, does not neglect to examine the same region with another sense. He begins at the head and goes down, examining without fail the cavity of the mouth with all it may disclose. He fails not to palpate wherever the sense of touch may bring a secret to light. Alas, how many abdominal derangements are misunderstood for the lack of this simple method of obtaining information. Percussion is not applied to a few spots on the chest, and the stethoscope is likewise given a chance to prove its value. Though what he finds in the great majority of cases may be approximately normal, he becomes, as it were, sensitized to the abnormal when it presents itself. What is the value of knowing all about the signs of disease, early or late, if one cannot appreciate them? The good diagnostician makes use of the instruments of precision which he considers of value, not forgetting the thermometer, and if necessary he sends his patient to a confrere skilled in some special field of examination. Getting Down to Naked Fact.-The accurate diagnostician does not hesitate to put his patient to the trouble of baring the skin of the part under examination, nor does he forget to turn him about and study him fore and aft. There is much to be learned from the back. We know of one case who was treated for months by a surgeon for "rheumatism," whatever was meant by that term in this instance, and who was finally sent abroad to a hot spring only to return unimproved. A glance at the naked back by a careful, thorough examiner, disclosed the cause of the rheumatic pains-there was a gibbus. The patient always appreciates a thorough overhauling even if he is put to a little inconvenience. It pays the diagnostician in everyway. The Diagnosis. -The diagnosis is not made -cannot be made-until all the returns are When in, until all the data is collected. this is accomplished it must never be forgotten that it takes more than one symptom or sign to make a diagnosis, just as it takes more than one swallow to make a summer. A rapid pulse may indicate a disturbance of the thyroid gland. A super-normal temperature without apparent cause may point the same way. The addition of enlarged thyroid practically clinches an early diag nosis. Usually there is some one unusual sign or symptom which stands out more prominently than the rest, and about which lesser abnormalities can be arranged to make up the diagnostic picture. The diagnosis may not be easy, but it is always more difficult if the examination has been incomplete. The thorough diagnostician finds fewer cases of rheumatism" and of neurasthenia" than other physicians because he gets down deeper into the roots of disease, and he does not forget that his patient has a psychic as well as physical nature. Unnecessary Examinations.-The conscientious diagnostician does not examine the very sick unnecessarily, where his examination may do more harm than good. There is more of art than science in the practice of medicine, and many of our very recent graduates are altogether too scientific for the good of some of their patients. There is a time to examine and a time to let alone. There should be a happy combination of exact science with sympathy for human life. Summary.-To be a good or the best diagnostician one must know the human body in health; he should keep himself keen for abnormal conditions by constant scrutiny of every part of the body; he will get at all the facts in the history; he will be thorough but humane; he will select the salient features of the history or examination and allow them to fall into their proper places as indicating where the trouble lies. The patient will be pleased with his thoroughness, the physician will be better sat isfied with his own work and he will be the better diagnostician in future. THE COFFEE QUESTION. ALBERT H. DOERSCHUK, Ph. G., Kansas City, Mo. Coffee satisfies an inner human craving that nothing else will satisfy. The many beneficial effects derived from coffee have made it the great national drink. All people enjoy it, some are benefited by it, to others it is positive danger, injury and harm. Heart, nerves, liver, kidneys and stomach are poisoned by coffee unless your vitality and constitution are such that you throw off the stimulating caffeine of coffee without breaking down under its effects. Average coffee beans contain around 11⁄2 per cent caffeine, and a pint of ordinary coffee carries about six grains of caffeine, and this drug when given as medicine is used only in doses from one-half to two grains. The increased blood pressure, dilated, irritable and rapid heart, headache, kidney pain, increased flow of urine, and the excessive excretion of solids to which coffee drinkers sooner or later fall heir are thus readily accounted for. Some years ago a process was perfected for extracting 90 per cent of the caffeine from the whole coffee bean without affecting those other ingredients which make coffee such a delightful beverage and article of diet. Coffee deprived of its poisonous caffeine, has long been a staple article of diet in European health resorts, such as Marienbad, Carlsbad, Ostend and Bath. Invalids arriving at these "cures" are taken off ordinary coffee entirely and given caffeine free coffee instead. This caffeine free coffee is now being generally offered at a price not much in excess of that of high class coffee, and is being consumed in large quantities by those to whom old style coffee is forbidden because of its deleterious effects. RETURN OF THE PETTICOAT. Because the fatted calves are all -Margaret Mason. Song Sermons G. HENRI BOGART, M. D., Paris, Ill. DREAM WOMAN MINE. Dream Woman, Dream Woman, into the mists, You came, warm breathing through sweet lips, love kissed, Blew shades to purpling haze, Came with clear vision of purposeful life, Dream Woman, Dream Woman, dreams must come true, Destiny plans naught all vain, Deep in futurity, just me, just you Pledge we each promise again, Pledging each promise, fear free, without bars, Longfellow's beautiful comparison of the bow and its string: "Useless each without the other," finds parallels all down the archives of history. Napoleon's star was in the ascendant, until that evil hour when he spurned the woman of his heart for reasons of state, then it steadily withdrew from its zenith, until it set in eternal gloom. It is not that we would imply that the counsels, or the military acumen of the unhappy Josephine were needful for her husband, or that the Austrian princess who supplanted her, gave misleading advice. Love and love's inspiration are as the leaven which leaveneth the whole lumpand what a lump mere man is until he is leavened, and under such spiritualizing influence, the whole tenor and career are as the rough bud when the sunshine falls upon it. Love and love's labor serve to vivify and fructify all the latent energies and potentialities of the worker, the doer, the thinker and the dreamer. None can tell just what is the potency of the sunbeam; much less the immeasurably finer and higher flames of a love worthy the name. Just how or why elements of character, hitherto unsuspected shall fuse, or the refractory stubborn ores of good, bound up in the rugged soul shall rise to the surface, when love's magic has found admitance into the heart is more difficult to understand or to map than that riddle of Solomon, "The way of an eagle in the air." Not all acorns are capable of growing into monarchs of the forest, many spring into growth in unlikely places; not all atoms of humanity are capable of the Great Passion, many yield to some passing fancy, and learn, when too late, that they are rooted in the shadows, where the full glow of light may not illumine and warm into perfect growth. Oh the tragedies and the waste of soul from conventional alliances, wherein the counterfeit was made to clog the growth of a glorious reality. Ideals may be realized, dreams should come true, and we would be wiser were we to acknowledge the Divine power, embracing All Wisdom, for has not the Evangel declared in Holy Writ, that "God is love." Dreams are the basis, the foundation of all good, no matter how gross and material; nothing could ever come out of the storehouses of the unknown of Infinity, save a dreamer, with prophetic vision, shall see it first. The young should cherish the dreamed ideal, the aged should know and teach the wealth of the worth of love's fullest effulgence, then there would be no divorce question to consider, to puzzle us, while the rearing of the children of perfect love would elevate the standard of the race faster than all other influences. Subscribe for the Medical Herald. "N not so. AN ARGUMENT AND AN APPRECIATION. WO DOCTOR who is not utterly enslaved to the 'shop' aspects of his calling-who has anything of an esthetic spirit in his make-up-can fail to be interested in the artistic side of his craft. The vulgar notion is that the doctor is not concerned with the beauty of the human body, on the principle that 'familiarity breeds contempt.' But that, of course, is No one has a keener or more esthetic appreciation of the beauty of the human form divine. Then, too, there is another phase of art as related to medicine-the artistic portrayal of its practice, and all the human sentiment that surrounds it. Both of these phases find ample embodiment in art. THE MEDICAL HERALD, of St. Joseph and Kansas City, Mo., is offering some beautiful, rare pictures of 'altogether' poses with a year's subscription for their journal, which are 'a thing of beauty and a joy forever.' And they have a few more copies of 'The Injured Finger' for those who prefer it. This is a capital instance of ministering to the esthetic spirit of the doctor. We heartily recommend our readers to send a dollar to THE MEDICAL HERALD, and get at once a live magazine and a beautiful work of art. (We have seen the pictures and know whereof we speak.")-American Journal of Clinical Medicine. Incorporating The Kansas City Medical Index-Lancet An Independent Monthly Magazine CHAS. WOOD FASSETT, Managing Editor. ASSOCIATE EDITORS P. I. LEONARD, St. Joseph CONTRIBUTING EDITORS ST. CLOUD COOPER, Fort Smith, Ark. S. S. GLASSCOCK, Kansas City, Kan. W. T. WOOTTON, Hot Springs, Ark. DEPARTMENT EDITORS KANSAS CITY H. C. CROWELL, Gynecology JOS. LICHTENBERG, Ophthalmology EDW. H. THRAILKILL, Rectal Diseases ST. JOSEPH J. M. BELL, Stomach C. A. GOOD, Medicine A. L. GRAY, Obstetrics J. W. MCGILL, Rectal Diseases L. A. TODD, Surgery F. H. SPENCER, Surgery OMAHA H. M. McCLANAHAN, Pediatrics H. S. MUNRO, Psychotherapy DES MOINES WALTER L. BIERRING, Medicine Address all communications to the Managing Editor. Vol. XXXIV MARCH, 1915 Editorial OPPOSING THE CURE OF CANCER. There have always been plenty of people who have clung to the coat tails of medicine to the end of impeding its progress. Though the quack and irregular healer have been allowed to go their way in peace, the medical investigator and practitioner have always been under suspicion and their labors have been zealously hindered. Though these obstructionists have seemed a nuisance and a detriment, yet doubtless they have often kept the medical man from traveling too rapidly in certain directions, and they have served the good turn of acting as a stimulus. An ameba travels faster against a stream than in stagnant fluid, and a muscle contracts more forcibly under a goodly load, and no doubt medical science has worked all the harder and all the better for its busy hinderers. The opposition to human dissection retarded medical progress for a long time and apparently without any good save that it No. 3 sharpened the eyes and sensitized the fingers of those who first dared to examine into the human form divine. The anti-human-dissectionist was finally shaken off, but his place has been taken by the anti-vivisectionist. The well-meaning person is too feeble to do much harm but if he has helped one iota to check any unnecessary experimentation or any needless cruelty on the part of the investigator he has served a worthy purpose. The strongest and most persistent outcry against medical methods in modern times, has been raised by the anti-vaccinationist. He seems to be the embodied ghost of smallpox, which, acknowledging that it is dead, gives no credit but endeavors to discredit its slayer. The anti-vaccinationists have as exalted an opinion of the human body as they who opposed its dissection, and they would not have it contaminated by the introduction of material from a calf even to save the human body from disease. The anti-vaccinationist, like other stay-athomes, has become stronger and more annoying to his preserver as the enemy has been rendered more and more harmless. The natural descendant of the anti-smallpox-vaccinationists are the just hatched opponents of the use of typhoid vaccine. Their war cry against compulsory vaccination, most naturally come by, is, "the rights of the individual" (to have typhoid if he wants to), "are being infringed." With the help of the Vivisection Investigation League they have published a booklet with the purpose of showing that the vaccine has never prevented typhoid, and, besides, has proven highly dangerous. It must be said that, considering the assiduity with which the literature, professional and lay, genuine and suspicious, has been raked over for anything to bolster their case, the vaccine has stood the test remarkably well. In fact its efficacy has not been damaged in the least. We must give this booklet in opposition to the use of antityphoid vaccine the credit of making a strong plea for thorough sanitation as a preventive of typhoid. Had the publishers been less suspicious of the medicine man and had threatened the public with anti-typhoid vaccination with all its horrors if it did not clean up and wipe out typhoid, this would have been a splendid literary effort in behalf of health. How ever, we should not expect too much assistance, and if they prove of any help in improving sanitary conditions, or cause the physician to exercise his greatest care in the use of the vaccine, the anti-typhoidvaccinationists will not have lived in vain. Though there is a great outcry for a cure for cancer or a preventive of cancer, yet we have no doubt that in the year in which such a treatment will be discovered and applied, there will also spring into existence the S.O.C.C., the Society for Opposition to the Cure of Cancer. Doubtless it will do good, if in no other way, by irritating us and keeping us keen for further progress. THE SAD END OF A GOOD DOCTOR. Dr. John Brown drank a good deal of whiskey, steadily every day, and in the opinion of his friends and patrons he was the brightest and most intelligent physician in all that country. The statement was reiterated over and over again, that even partially intoxicated he was the superior of all the average doctors in that section. Temperance people shook their heads in wonderment, and were forced to believe what public opinion pronounced so emphat ically. One day, Dr. Brown made the rounds of his patients, many of whom were suffering from malaria, and dealt out from one to five grains of morphine in the place of quinine by mistake. Later in the day when calls came to know why the patients where sleeping so profoundly, he discovered his error, and realizing what he had done, went to a river near by, and jumped off the bridge. The next day his body was found. It is needless to say that the community was greatly shocked. All the neighboring physicians worked night and day to awaken the poor victims several of whom were sleeping their last sleep. They buried the good doctor without much eulogy and a change came over public opinion of what constituted safe medical men. A year later a doctor who had moved to that town wondered why he was not called the second time. Finally it dawned that he like the good old doctor had an alcoholic breath and his usefulness was doubted. Now that community watches every new doctor with great suspicion and is anxious to know whether he is a whiskey drinker or not. There was no historian for this event, but it burned deeply into the history of that town, and it is certain that good old Dr. Brown will never have a successor, as long as the memory of man continues. T.D.C. A BRIEF RESUME OF THE HARRISON NARCOTIC LAW. In the absence of regulations from the Bureau of Internal Revenue regarding the national narcotic law we cannot give specific rules for physicians that would not be subject to revision. We can, however, present the following resume of the bill as enacted, in so far as it affects the physician: I. The medical practician must register on or before March 1, 1915, with the Collector of Internal Revenue of the United States Treasury Department and pay the annual statutory tax, which is usually one dollar ($1) per year, but for the first year will be proportionately less. Thereafter, on or before the first day of July of each year the medical practician must so register and pay the annual one dollar ($1) tax. II. Narcotic drugs specified may only be purchased upon official order forms issued by the Internal Revenue Department of the United States Treasury Department at a cost of one cent for each original order and duplicate thereof. Whenever the medical practician orders, therefore, the affected |