opportunity to inaugurate means of preventing grave structural lesions, rather than wait for the exhibition of more pronounced physical signs, proceeding from advanced and often irreparable conditions.

This would seem (sound differentiation) quite an indispensable qualification to the physical diagnostician, susceptible as it is of development by practice. It must, however, of necessity itself be a natural inheritance. So every one embarking in medicine cannot hope, even by application and persistence to achieve the distinction of an expert physical diagnostician. I would say from a rather limited observation, this enviable acquirement is accorded to but few in the realm of medicine. The plea which we wish to particularly emphasize in this paper, is the value to be derived, by the application of physical means, in the line of preventing rather than curing diseased processes by incipient detection of their presence. While in a sense therefore a physical diagnostician is born, not made, much can be done in the line of this achievement by practice, and nothing without it. Mozart, Wagner, Handel, Beethoven and other great musicians of the world were born in a sense, in an atmosphere resonant and reverberant with musical rhythm. So Flint, Loomas, Janeway, and others of our day were a thousand years ago, in prophecy, eminent physical diagnosticians.

It is not all to be musical in the above sense, capable of sound differentiation, though this qualification would seem valuable, and an usual accompaniment of others found in the fabric of men distinguished in this branch of medicine. We have been sleeping and not using the privileges of this art. We have been waiting, and not detecting the insidious approaches of disease till our patients were in the very vortex of irremediableness. Let us be impressed, that the greatest hope of medicine today (prevention of structural disease) can only be realized by the aid of the correct and full application of the methods of physical exploration.

May I say no two organs or structures in the human body, whether healthy or diseased, reflect to the eye, ear, or sense of touch exactly the same interpretations, or more properly speaking, opportunity for interpretations, of existing states on the application of physical methods. The slightest difference of density of structure commensurately alters the tone imparted to the cultivated ear, it changes correspondingly the vibratory impulse, perceived by the competent touch, and even the eye if highly qualified should detect a difference however slight on respiratory moveDensity therefore plays a very significant part in the art and science of physical exploration.

ment.

It becomes therefore quite necessary for one who would become expert in physical diagnosis, to possess a knowledge, and quite an intimate one, of natural philosophy, to know of the laws which govern solids and fluids, sound and its conduction, etc. Equally necessary is it for him to have a well grounded knowledge in mental science, that he may invoice mental phenomena expressed through the physical, in applying methods of physical exploration. The evidences of the production of tenderness and pain in the application of these various methods of physical diagnosis would bring into play psychical qualifications which but few possess to any considerable degree. From the foregoing statements it becomes obvious that the skilled examiner, as regards the application of physical means must be one well educated in the various departments of

learning. He should be an anatomist, physiologist, pathologist, mental philosopher and natural philosopher of no mean proportions should he hope to embrace in his capabilities all that is promised in the scope of a physical diagnostician and the privileges that lie before him. The foundation thus laid fortified by a good moral character, which latter every true physician should and does possess, would handsomely equip one to apply properly, efficiently, and fruitfully these much abused, though indispensable, means of detecting diseased conditions and processes in the human body. Only in this complete preparedness can one locate disease and individualize it as it manifests itself by sound, vibration, etc., through the various media of fluid, tissue, air and their combinations.

To apply our knowledge thus far gained let us note some of the unvarying signs in an elementary way in a common disease of the chest. known as croupous or lobar pneumonia. In the first or engorgement stage of this disease, inspection gives us a diminished movement of the chest on the effected side-and why? Perhaps for this there are two reasons: less air to expand the lung diseased, and pain produced in the respiratory act owing to the generally co-existent pleurisy. You see plainly the reason back of and producing these phenomena. Placing the hand on the side (palpation) detects a slight increase in the vocal fremitus, because the inoreased solidity, the better conducts vibratory impulses to the hand. On percussion dullness proportionate to the solidification because the less air in the air cells the more dulness elicited on percussion. On auscultation the respiratory murmur is diminished while the resonance is increased in other, and especially adjacent portions of the diseased lung. To the extent the air cells become filled with the exudate there is a substitution of the bronchial for vesicular respiration, as one would naturally expect, owing to the increased solidity of the diseased lung conducting to the ear the tubular sound of the bronchial tubes, through pulmonary tissue, replacing tc that extent the normal or vesicular. As the cells become more and more filled with the inflammatory exudate we catch that very valuable and pathognomonic sound by auscultation during the latter part of the inspiratory act, termed the crepitant rale.

The presence of these evidences gained by the application of physical signs, together with other clinical signs and symptoms, one should seldom if ever be mistaken in diagnosing this disease in its first stage.

The remaining two stages, the signs are equally pronounced and equally explainable. The same laws govern the conduction of sound and vibratory movement through these various media in all pathological states and conditions, as in this very simple elementary illustration of lobar pneumonia.

May I mention two conditions which are largely determined by methods of physical diagnosis, and in the treatment of which there is much misapplied effort, viz., cardiac hypertrophy and cardiac dilatation. These conditions are often associated, and in many instances have common causes. When we use the term cardiac hypertrophy we have special reference to the ventricles, and generally the left. Hypertrophy must ever be viewed, when applied to the heart as a compensatory process. It is nature's remedy to overcome an obstructed circulation, its over-action, or the numerous causal factors of dilatation.

A weak inefficient valve or a stenosed orifice, non-resilient blood vessels, the poisonous toxins of infectious diseases, a degenerated myocardium (and hence a weak one), over-exertion, are calling for relief at nature's hands, and she at once thickens and strengthens the walls of the heart, and compensation is thus maintained. A long term of good health is often furnished an individual in these crippled states above suggested, even in the presence of considerable dilatation. An hypertrophied heart is a strong heart and manifests itself to the diagnostician plainly through the methods of physical diagnosis.

The enlarged area of cardiac dulness; the bounding pulse; the headache; flushed face; active carotids; the sounds of the heart made stronger (especially the first); the shifting of the apex beat to a position lower and to the left than normal; the slow, strong pulse; the bulging of the chest wall overlying the heart, particularly marked in children are in striking contrast to the signs produced by cardiac dilatation, which reverses the picture. These signs are those of a weak circulation, and hence are the opposite in character of those just given denoting cardiac hypertrophy. So is the condition a reversed condition, so should the treatment be very different, if not wholly so, in these two cardiac states.

We have said that these states often co-exist, and then what will the dual state be termed? If dilatation predominates with but slight hypertrophy, the condition should be called one of dilatation; if hypertrophy largely predominates, one of hypertrophy; if about equal, then the term hypertrophy with accompanying dilatation would perhaps be most appropriate. We must be brief and close this part of our paper. We will suppose we are confronted with a condition which the physical signs tell us, is one of hypertrophy with dilatation, but compensation is maintained, what shall be done therapeutically and otherwise?

Keep the health of your patient in good condition and avoid extreme exercise, practically little medicine at this stage is called for. At this point so many physicians freely give digitalis (and thus abuse it), when the patient fares better if therapeutically almost left alone; certainly better than to administer digitalis and its congeners, while in this state.

For this one point largely have I alluded to the heart in these two diseases.

In the course, however, of the march of these twin brothers, when dilatation manifests the stronger physical signs than hypertrophy, in short where compensation is broken, when nature yields to opposing and superior forces (which she is almost sure to do in time), then digitalis and allied drugs should by all means be administered, but not until then should it or they be touched. Thusly you equalize strength and cardiac weakness. A very large class of physicians fail to get results beneficial to their patients, because they do not fit therapeutic remedies to pathological states. So soon as a heart lesion is detected of the above character, this class at once begins the deleterious practice of prescribing the above series of drugs, and add to, rather than diminish the dangers and discomfort of their patients. You had better give nothing, except perhaps a little nitroglycerin or some such, till nature begins to evidence signs of being overpowered, dethroned, subdued; in other words, till weakness gets the better of cardiac strength, then extend the work nature began by giving such remedies as digitalis, strophanthus, etc. You cripple nature by

striving to support her till she falls. She does not need a crutch till she is lame. So remember in lesions of the heart, digitalis and its congeners are misfits till the pathological state arises suitable to their use, which in the above illustration we trust is made manifest.

One of the contentions of this paper is to know the normal conductive properties of air, fluid, and solid tissues, and their various combinations, then if you know your anatomy of tissues and blood-vessels, you are qual ified to recognize almost any departure therefrom which makes itself manifest through physical signs. The valuable evidences of disease elicited on percussion must ever be recognized only as a mediate form of auscultation. Suppose for instance, on percussion you get a flat sound in a region as the infraclavicular, what would you expect or know existed? You would at once conclude an abnormal state in the region peroussed was present. You would say that the resonance in this region, if normal, should be of variable intensity (owing to force of blow, etc.), low in pitch and possessing a peculiar yet indescribable quality called vesicular. Instead of this normal resonance you get simply a sound, void of pitch or quality, and would at once conclude if well informed, that underlying a tumor was present, a solid lung or fluid either in the air vesicles, pleural sac, pulmonary cavities or the substance of the lung. Now in the same region suppose you would apply the method of auscultation, normally we would elicit an inspiratory sound of variable intensity, low in pitch, and as in percussion vesicular in quality, an expiratory less intense (than inspiratory, lower in pitch, non-vesicular, non-tubular or simply blowing in character. Any departure from this would evidence disease. This normal reflection of sound and vibration of the particular region being examined, through physical signs, must ever be in mind when searching for abnormal processes.

In the foregoing illustrations where we have attempted to apply percussion and auscultation, such diseases early in their course, as pneu. monia and tuberculosis, would change the signs expressed by these two physical methods as to be readily detected by an astute examiner. Where two or more abnormal states would express like physical signs in whole or in part, the clinical history and other aids would come to our relief in efforts at differentiation and individualization.

The importance of early detection of diseased processes by the aid of physical exploration has a large application in pulmonary tuberculosis. The ear that catches the faintest rale or the faintest alteration of normal respiration; the ear that responds to perhaps the revealments of a delicate tap of the finger in percussion and preceives thereby the initial departure into the realm of this disease, and others of grave character and insidious approach, is the ear most promising to the present and future generations of mankind. A grave heart disease threatened, whether primary or secondary in the light of these diagnostic possibilities, demands and should receive prophylactic aid ere organic structural changes occur in its valves and in its walls.

In prophecy what a field lies before these methods as aids towards the prevention of organic disease. They must, however, be used to their fullest and completest advantage. Their scope of usefulness must be appreciated, and additions made to them as we become more and more educated in the science and art of medicine. The time should be but

a memory when the mere pretender listens and does not hear, feels and does not feel, sees and does not see, in the realm of physical diagnosis. Time forbids our dealing with anything like a specific application of our subject. We must deal in the light of its great scope, only in generalities. A word in regard to organic structural changes in tissues which the early recognition by physical methods could often pervent, may I say most generally avert should we be alive to the full possibilities of these aids.

There are no means known to us of restoring organic diseased tissue changes. Prevention becomes therefore our only weapon of defense and our hope. An arrest may be affected but not a restoration of normal structure or function. Our hope of arresting the great white plague, the cause of one-seventh of those who die, lies not in creosote or lymph restoratives, or even climate, but in prophylaxis to which these physical methods are indispensable aids.

Do you suppose for an instant that an organio stricture of th urethra is ever cured, the tissues fully restored in structure and function, or a valve in the heart altered in structure by disease, or a myocardium, or an ovary, a tube, or any other functionating organ in the body? Nay verily. The surgeon can artfully remove dead or abnormal tissue as the woodman can the dead limb of a tree, though he can never replace it by normal structure.

In conclusion, let us look upon these methods of physical exploration only as aids in determining diseased processes by comparative methods often alluded to in this article, but as aids from which hitherto we have not obtained more than one-half of their full possible value.

Thoughtfulness, education, a more developed recognition of duty, a fuller and more complete preparation of patient and examiner which time certainly insures us, we can hope for greater things in this line in the future than the present prepares us to believe or conjecture.

413 Rialto Building.

DISCUSSION.

DR. LEROY CRUMMER, Omaha, Neb.-I am very glad indeed to have heard this paper although I freely confess that I totally disagree with Dr. Hardin in some of his statements. I hope he is wrong about a diagnostician necessarily being a musician. This is not a new issue as this point was considerably discussed at one time amongst the German clinicians and they finally came to the conclusion that at some time it was a disadvantage for an internist to have a musical ear as in the examination that man would be looking for tone production and musical sounds and at the same time he would overlook sounds which did not fit into musical expression.

Now a certain knowledge is necessary. Perhaps Dr. Hardin and I will have the same idea, but he will consider the knowledge of the physics of sound a musical knowledge. To my mind they are totally different. A man without an atom of music in him can make a diagnostician and can hear, appreciate and interpret everything that the musically inclined mind can, if he has a knowledge of the physics of sound, method of tone production, tone propagation and vibration. Now if it were not so, Mozart, Beethoven and the other great musicians would have made excellent physicians. I doubt if they would, however. When you get a musical man, that is a man who is a musician, pure and simple, you get an emotional man and your music is certainly as much of a handicap as the lack of a musical ear.

Another point that I cannot quite agree with-on what is implied but not expressly stated in this paper-that auscultation is one of the most prominent and most important of the methods of examination. Auscultation should absolutely be reserved until the last, and diagnosis should almost be made before you put your ear or the stethoscope to the chest. The power of cultivating your eye or your