my own first day as Junior, except of one occurrence, so startling to my inexperienced nerves as to blot out all other impressions of that day. It was the rather sudden death of a patient at the moment when I was approaching his bed to execute an order which I had received. It was my first acquaintance with the grim reality of the tragic scenes which physicians must so often witness.

When a young man reports for duty on the House-Staff, he usually has a mind well stocked with the knowledge which books and teachers can impart; but he has seen little of a practical sort. Books and teachers can do no more than does an artist who paints what seems to him an accurate representation of a living human face. To some the work may appear to be a good and truthful portrait; others may see little resemblance to the subject. After all, it is only as accurate as the mind of the artist permits him to see, and his skill enables him to represent by means of pigments on a plane surface. A portrait may enable one to recognize the sitter-may even give an idea of some of his mental characteristics-but it is neither an absolutely accurate reproduction of the sitter's physical nor mental attributes. To know these one must meet the original face to face. So one must see disease in order to know disease. Some of the men just entering upon their hospital service are a little too well satisfied with themselves to be pleasant; but a month or two of experience usually convinces them that they do not know so much as they had supposed.

The Junior Assistant Physician of the Roosevelt Hospital at the time of which I speak, had the following duties to perform:

To record the temperature, pulse, and respiration of all patients whose condition required such records, twice or oftener daily. To make and record all the usual clinical microscopic and chemical examinations. To accompany the House-Physician on his daily morning rounds—which lasted from one to three hours. To accompany the Attending Physician when he made his regular visit-which occupied from

fifteen minutes to two hours. To do various medical chores. To copy patients' histories into the record-book. Last, but not least, to visit and examine applicants for admission whose sickness prevented them from applying personally at the hospital. The duty of visiting was performed dur ing alternate weeks by the medical and surgical Juniors. His working day began about 8.45 A.M., and never ended before 6 P.M.; often it lasted until 10 P.M.

It is not surprising that the most vivid recollection of the first six months' service should be of its weariness. During the first few days or weeks, the sense of fatigue is intense; for most of the work is done in a standing or stooping position, and, not being accustomed to this sort of exertion, the legs and back ache intensely. It may not seem that much pain could come from merely standing up for a few hours, and occasionally bending over a bed or table; but, if anyone not used to it will try the experiment of standing up for three or four hours, during which time he must not walk more than four hundred feet or take any exercise to vary the strain upon the muscles save by stooping from time to time low enough to bring the head within a foot of the surface of a rather high bed, he will feel, for a day or two, much as he would had he walked fifteen or twenty miles at a rapid pace, without any previous training save an occasional stroll of half a mile.

The Senior Assistant writes the medical history of each patient. He learns, as soon as possible after admission, as much as he can about each case, and records not only the story of events which are said to have occurred prior to the date of entrance, but also notes the exact condition of the patient when admitted. While he had plenty to do, and sometimes more than he could finish in a day, he had the most comfortable position on the House-Staff in the old days; for his work was less monotonous than that of the Junior, and his responsibilities less than those of the House-Physician.

After a year's preparatory training the grade of House-Physician was at

tained. I do not believe that anywhere but in this country the responsibilities would be borne, or the duties be so well done by a succession of men selected by competitive examination, as our internes are, and as young as most of them are. Our system works well, on the whole. It seems adapted to American conditions, and, although it has serious faults, none better has been proposed which would be practical in this city at the present time. It is safe to assert that hospital patients are more kindly, and to that extent at least, better treated in the United States than in any other country, except perhaps England. Whether or not the purely medical and scientific parts of hospital work are as well done in any institution here as they are abroad, depends more upon the ability of the attending Physician or Surgeon in charge than upon the House-Staff. The average House-Physician or Surgeon is a very satisfactory man as far as ability to do the work required of him is concerned. His most common fault is an unpleasant manner toward strangers. The habitual exercise of his great authority in the hospital is apt to result in a certain arrogance similar to that which is so commonly exhibited by the younger officers of the army or navy.

The experiences of a House-Physician during twenty-four hours, when his wards contain about the average number of patients, and the work is of average severity, may be described as follows:

A

The nurses who have been on duty during the night report to him between 7 and 8 A.M. Breakfast must be finished in time to begin morning rounds at nine. Every patient in the division is seen during these rounds, which last from one to three hours. certain amount of ceremony, the result of the daily repetition of routine work, characterizes the progress through the wards. The physicians are met at the door of each ward by the head-nurse and one or more assistant nurses. The House-Physician enters, with a stethoscope in his hand. This instrument, by the way, is so often seen in his possession that some patients suppose it to be a sort of wand of office and badge of

authority. Beside him walks the Senior Assistant bearing a lot of manuscript histories and blank paper for writing notes. Behind walks the Junior always carrying a book in which he has recorded the results of his chemical and microscopic work of the previous day, and, frequently, with some instruments which he has been told to bring. When this procession has filed in, the doors are closed, the House-Physician turns to the patient nearest to the door, and asks him how he feels. The man is in the last stages of consumption, but with the strange cheerfulness of that disease, answers that he thinks he is better. A few questions to learn whether he is as comfortable as may be, and we pass to the next. He is out of bed, convalescent, and little time need be spent over him; but the next is a case of severe acute disease, and calls for careful attention. His pulse is felt and he is examined as thoroughly as the conditions call for or permit. The temperature chart and other ward records are studied. The nurse is questioned as to the symptoms presented while the doctors were absent from the wards. Any changes in treatment are ordered by the House-Physician and written down both by the Senior and Nurse. In the next bed is a new case. Senior reads his history; the Junior reads the results of the examinations made by him; and a thorough investigation is begun of the actual condition of the patient.

The

The entire circuit of the ward is made in this manner. When the last patient has been interviewed the necessary medicines are ordered from the drug-room, the House-Physician writing the quantity required and the directions to be put on each label, in the order-book. The doors are then opened and the procession passes to the next ward.

After rounds the House-Physician has plenty of work to do before lunchtime. He orders the diet of each patient, specifying the articles to be supplied which are not part of the ordinary food provided for the ward. He examines applicants for admission when they come to the hospital; admits and discharges patients, and prescribes what

ever treatment he deems necessary in urgent cases during the absence of the Attending Physician. He may even entirely disregard the orders of the latter, should symptoms arise which, in his judgment, make such action imperative. Of course he reports all that he has done to his superior. He is expected to maintain discipline in his division, and to enforce all the rules of the hospital as far as he can, reporting any infraction thereof to the proper officials. He interviews anxious friends and relatives of patients, and has notice sent to the friends when any case has become desperate. He inspects all eatables, etc., sent to the hospital by outsiders for any patient's use, and prevents improper articles from being delivered. Extraordinary things are often sent as delicacies fit for a sick person. Sodden cake, stale pies, onions, sausages of various degrees of virulence, are frequently selected as offerings from some loving heart to the possessor of a delicate stomach.

Much tact is necessary in successfully dealing with some of the problems incidental to the work. Visitors are referred to the House-Physician, some of whom wish to see the hospital, some are doctors desirous of asking information, some are reporters. Friends of patients call to inquire about their condition-or, it may be, to enter a just complaint, or to abuse the institution and the doctor without cause.

Once a day the Attending Physician is expected to make his rounds. The House-Staff accompany him, and the House-Physician ought never to be absent at the time his superior arrives. The fact that the hour when the latter is to be expected is seldom the same on any two successive days, and the additional fact that at any moment a desperately ill person may be brought to the hospital, or one of the patients may become suddenly worse, make it impossible to set aside any regular time for exercise or amusement in the afternoon. Members of the staff, therefore, are accustomed to take recreation when the chance occurs, and the House-Physician is not likely to have much uninterrupted leisure during the daytime. He makes formal evening rounds about

five o'clock, and whatever outing he takes must not interfere with this duty. This time he goes through the wards with little formality, unaccompanied by his assistants. He sees all the patients, however, and dictates the orders for the night to the Nurse to take down in writing, and does whatever is required to prepare for the night work.

There is almost always a lull in hospital activity between six and eight in the evening. During these hours the internes have dinner and time to talk and smoke. It was the inflexible rule in the Roosevelt Hospital in the old days, never to permit the slightest reference to "shop," either at dinner or breakfast. Whether the rule was ever general in hospitals, or whether it still obtains at Roosevelt, I do not know. With us it was established by the wife of the first Superintendent, who, with her husband, always took these two meals with the Staff. If the custom has passed away it is a pity, for it is a great blessing to compel all whose business is narrow in its field and confining in its nature, as is that of an interne, to turn to something else for an hour or two at least every day.

The evening, after the night-nurses have reported to the House-Physician for orders shortly after eight o'clock, is more or less free. Before going to bed it is his custom to make one more tour through the wards to see that all is well. Even when in bed he has not cast aside his responsibility. He may be aroused once or oftener during the night. I knew one interne who for ten days and nights was never permitted to sleep two consecutive hours. This is an exceptional case, but interrupted sleep is the rule, and the doctor regards a knock at his door and a message which calls sometimes only for a few words in answer to a question, sometimes for active and prolonged work in the ward, as a matter of course. soon learns to wake quickly and to wake thoroughly. He also learns to fall asleep quickly, when the opportunity occurs.

He

At night the ward is strangely picturesque. After nearly fourteen years of familiarity with hospital scenes, never enter one after the lights have

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