Section C: Non-Sequiturs and Other Random Thoughts

Table of Contents


by Lawrence Martin, M.D.
Mt. Sinai Medical Center
Cleveland, OH

PART 1 of 3

It may not be fair to blame medical schools for the abysmal history-taking skills of many house officers. Blame at times must also lie with other factors: lack of time from too many inpatient admissions; too many outpatients at a single clinic session; the large number of old medical records; unavailable past medical records; and, the general complexity of some medical conditions. While all these factors can certainly impede "getting a good history," more often the problem seems to be not knowing how. And that problem, I believe, stems at least in part from not being taught how.

Traditionally students are taught that the medical history begins with eliciting the history of the present illness (HPI), then in succession the past medical history, the social and work history, and so forth. This may be the universal framework for taking a history, but seldom are students taught the art of history taking. Can "the art" be taught?

Like any endeavor, the physician has to desire a good medical history; this means having the right attitude and a natural curiosity about the patient. Despite all the lip service given to "getting a good history," many physicians (in and out of training) simply aren't interested in 'history taking.' After all, they may reason, that skill was learned long ago in medical school. I will make no value judgment about such an attitude. However, if you are interested, read on.

The "art" of history taking means getting the story in as complete a fashion as possible, so that you learn what is worth knowing. What is worth knowing includes: 1) the sequence of events that culminated in placing the patient before you; 2) an understanding of the patient's complaint, and 3) an appreciation of the patient as a human being. It does no good to learn every detail of the HPI if you are clueless about the patient's anxieties, fears, and perceptions. Similarly, you may be the most empathic, perceptive doctor around, but if you don't know who treated the patient last week and for what, or don't know the medications your patient is taking and why, you won't be very effective.

Both aspects are important the medical detail and what you can learn about the patient as a human being. To keep in mind the former, envision that you will be expected to retell the history to a group of your peers, other physicians who will ask all sorts of questions and in an informal way grade you on your knowledge. You surely will want to know what medications your patient takes, what recent tests he has had, who he has seen in the past for the same problem, and what therapy was given. You don't want to be ignorant of obviously relevant medical history. If something isn't known you want to be able to say to your peers, "That information is not known" because it isn't, not because you didn't ask or try to find out.

To keep in mind the latter aspect, envision that your patient will be asked by his peers "did your doctor listen to you?" Was he interested in you as a person. Patients know when doctors are listening, when they are interested. If you don't listen and attempt to learn what's truly bothering the patient, your lack of real concern will be noticed. Assuming the patient is the source of the history, you won't get a good history if you don't listen, if you aren't truly concerned. To quote Dr. Francis Peabody: "The secret of the care of the patient is in caring for the patient."

SUMMARY: The history should be logical, complete, and answer all questions the reasonable reviewer might ask. To learn what is bothering the patient, you must care about, and listen to, the patient.


PART 2 of 3

Medical schools seem to teach history-taking as if physicians were still in the 19th century. In the 19th, and much of the 20th century, practically everything you needed to know about the patient was obtainable from the patient, or if necessary from the patient's family. Thus the time course and nature of the patient's symptoms, as embodied in the "history of present illness," has long been taught as paramount. And so it is.

But there's a problem. History-taking, as traditionally taught in medical schools, presupposes a worried but alert and oriented patient sitting before you, ready to reveal all if you but ask the right questions and spend enough time. But what if the patient is confused, comatose, disoriented, or simply medically unaware and unsophisticated? What if the patient has already seen four other doctors and hasn't a clue as to what she was told by any of them? What if the patient is in some distress and simply can't get her breath to talk for longer than a monosyllable? What history-taking skills are necessary in these situations, which are very common (particularly in hospitalized patients)?

Unfortunately, the house officer's response in many situations is all too often, "The patient is a poor historian," a response that suggests it is the patient's obligation to render a well-organized, coherent history! In fact, labeling the patient a poor historian often signifies one thing only: the physician is not trained to assemble a comprehensive history.

Instead of blaming the patient for an inadequate history, emphasis should be on the vitally important "verifiable past medical history." Verifiable PMH covers events one can document, usually meaning specific past medical contacts (doctor, emergency room, pharmacy, laboratory, radiology department, etc.). Pity the poor house officer who, after spending an hour with a patient eliciting every nuance of her vague symptoms, has failed to learn of a recent complete evaluation at another hospital for the same complaints! (Oh? Then why didn't the patient say so? Simple: because the house officer didn't ask.)

It is amazingly common that patients we see in the hospital, the ER, or the outpatient clinic, have verifiable, recent medical history pertinent to their current problem(s): lab tests; x-rays; office visits to other physicians; pharmacy prescriptions; hospital discharge summaries; workers' compensation records; operative reports. It is also amazingly common how often this verifiable history goes undetected by the treating house officer. Here are some true stories.

1) A slightly demented man was admitted to the ward with a complaint of shortness of breath. No family accompanied him. His chest x-ray showed a large right pleural effusion. Although the patient had an old medical record number, his previous records could not be found and he could not give any verifiable past medical history. A thoracentesis was performed and the results were non-diagnostic; cytology was negative for malignancy. On the third hospital day an infectious disease consultant was called; she observed that his hospital x-ray folder contained chest x-rays two months old, although chart records for that period were still not available. She went to the medical records department and demanded that the patient's old records be found. After a 10-minute search they were found in another physician's dictation box! These two-month old records revealed a hospital admission at that time for the same problem: shortness of breath and a right pleural effusion. While in the hospital a fiberoptic bronchoscopy had been performed, which revealed far advanced, inoperable lung cancer. The patient had been started on radiotherapy in the hospital, then discharged and lost to followup until readmitted two months later.

2) A 35-year-old woman was in the hospital for four days for workup of anemia, elevated sedimentation rate and joint discomfort. A series of tests had so far failed to elicit a unifying diagnosis. On the fourth day a medical student, just assigned to the case, talked to the patient and learned that she had been in another hospital a year earlier for the same complaints! To the student's surprise, no one else had elicited this bit of information. Later that day the other hospital's discharge summary was faxed over; it revealed a workup and diagnosis of lupus erythematosus. The patient had been lost to followup after discharge, only to reappear a year later when she was re-admitted to the second hospital.

3) A 67-year-old man was scheduled for thoracotomy for a suspicious lesion. The surgical note stated that there were "no old films." Indeed, in the hospital at the time there were no old films. But there were plenty of old films in another hospital, going back six years. They were obtained by a consultant and reviewed. The "suspicious lesion" was old and it had not changed. Radiologically it was clearly benign and did not need to be removed.

* * *

The reason verifiable information is so often overlooked is because the physician a) doesn't know it exists (as in the above three cases) or b) doesn't work hard to obtain it. Given most hospitals' 19th century record-keeping systems, it may be difficult to obtain old information. But you surely won't succeed if you don't even know old records exist. To find out if they exist, the box below lists some of the questions you need to ask (and sometimes re-ask) of patients or family.

You will be amazed how often your patients have been treated and evaluated for the same problems you are treating them for; or how often they are taking medications pertinent to their current problem which they "forgot" to tell you about. When you learn that important verifiable information exists, take advantage of those modern medical tools the phone and fax machine and work to get the information.

Questions to Ask the Patient (&/or patient's family as surrogate) Regarding Verifiable Medical History

  • What physicians have you seen in the past year? Where? What for?
  • When was the last time you saw a doctor for any reason? And the time before that?
  • Have you had any operation in the past 5 years?
  • Have you spent the night in a hospital in the last 5 years?
  • Have you visited an emergency room or urgent care center in the last 5 years?
  • Have you seen a podiatrist, chiropractor, or psychologist recently?
  • When was the last time you had a prescription filled? Do you remember what it was for?
  • What drugs do you take? What else do you take? What else do you take when these drugs don't work?
  • Where do you get your medicine? Where else do you get your medicine?
  • The task may not be easy. Say you've learned that verifiable information does exist, and you've requested it be sent via fax. How long should you wait for it to arrive? Not long. You can minimize delays by remembering three rules, listed below. (And when you do obtain fax'd records, treat them like found gold. Place them in the chart, note the principal findings in a progress note, and make other caregivers aware of their existence.)

    Rules for Obtaining Records by Fax

    Rule 1: Always record the name and phone number of the person you speak with, the one who agrees to send you the information.

    Rule 2: Records mailed will never arrive in time to help an already-hospitalized patient. They must be faxed or, alternatively, important information relayed verbally over the phone.

    Rule 3: Since record-keeping departments are often under-staffed and chaotic, the best intentions may not result in the records being sent to you. The record personnel may forget the request, or their fax machine may be inoperable, or the old records may not be found. After a reasonable wait (a few hours at most) call back: "Hello, this is Dr. Jones. I spoke with you earlier about records on my patient, Mr. Smith. We still haven't received those records. Have they been sent? Oh? Well, we need to make some important decisions; could you please fax them now?"

    Summary: Don't blame the patient for an inadequate medical history. Always assume verifiable past medical history exists and work hard to find out what and where it is. If you need prior records, find out where they are and set out determinedly to obtain them. Be polite but aggressive.


    PART 3 of 3

    I have placed some of the blame on medical schools for not effectively teaching the art of history taking. There is another and perhaps even larger reason, which must be acknowledged: No one pays for the time it takes to get a detailed, complete medical history. As a direct result, there are few mentors in training programs with the time and skill to teach history-taking by example.

    A practicing physician will be reimbursed the same fee for taking a 5-minute history or a 1-hour history, or for undertaking a 10-minute review or a 3-hour review of old medical records. Third-party payers, whether Medicare or commercial insurers, don't pay for a physician's time in taking a detailed medical history; they never have and they never will. That is why practicing physicians seldom take the time to plow through thick and jumbled medical records, or spend the time it might take to learn everything necessary about a patient's problem. This is not criticism, this is simply honest observation. It is reality, and the observation applies to all of us. Me. You. Everyone who sees and assumes responsibility for patients. The reality is that house officers emulate, sooner or later, what practicing physicians practice.

    This observation also explains why, in any malpractice litigation, the involved lawyers will usually know far more detail about the patient's medical care than the treating doctors. The lawyers are paid for learning every detail about the case: either by the hour (defense lawyers), or via a large percentage of any damage award (plaintiff lawyers). Lawyers have a tremendous financial incentive to make sure they don't miss anything pertinent about the patient.

    It's true that doctors in training usually spend a lot more time on history-taking than physicians in private practice. In fact, for a hospitalized patient, after the first day or two, the house officer will almost always know the patient's medical history better than the "attending physician of record." But the effort gradually wanes; the role models for obtaining a thorough, detailed history are simply not there. Eventually, of course, the house officer becomes the attending.

    Summary: No one pays doctors for time-consuming, high-quality history-taking. Nonetheless, it stands to reason that the more thorough your history, the better will be your care of the patient.

    -- END --

    The 1-800 Syndrome

    The physician dials a 1-800 number to get authorization for hospital admission. A synthetic female voice answers.

    "Quality Health, at your service. Please press 1 for authorization..."

    The physician presses 1.

    "All of our staff are busy. Please hold."

    Twenty identical messages and 5 minutes later a human voice answers, also pleasant and female, but this time human.

    "Quality Health, how may I help you?"

    "Yes, thank you for answering. This is Dr. Concerned. I am a psychiatrist with Quality Health here in Pittsburgh. I have a 35-year-old female patient who just tried to commit suicide. I need your authorization to put her in the hospital."

    "Thank you, Dr. Concerned. Tell me, how did she try?"

    "How did she try? She swallowed a bottle of tranquilizers. Say, are you a psychiatrist?"

    "No, I am a clinical specialist."

    "What is your name?"

    "My name is Nancy."

    "Nancy, are you a physician?"

    "No, no, Dr. Concerned, I am a clinical evaluation specialist. I just need to ask you a few questions before Quality Health can authorize hospital admission for your patient. You said she swallowed a bottle of tranquilizers? What type were they, and how many did she swallow?"

    "Ativan. About 20. Say, are you here in Pittsburgh?"

    "What state is Pittsburgh in?"

    "Huh? Pennsylvania, of course."

    The evaluation specialist gives a short giggle. "No, I'm in Omaha. Tell, me, where is your patient now?"

    "Omaha? You're in Nebraska? My patient's in the emergency room here in Pittsburgh. Why are you in Omaha, deciding about my patient being admitted in Pittsburgh?"

    "Oh, Quality Health has evaluation specialists all over the country. Your call just happened to be routed here. Has she been treated medically for the overdose?"

    "Yes, the emergency room doctors have medically cleared her for admission to Psychiatry."

    "OK. Please give me her name and Quality Health Certification Number."

    The physician gives Nancy the patient's name and her 17-digit certification number. Nancy has trouble with some of the middle digits, so Dr. Concerned has to repeat the number. Several minutes go by, then. . .

    "Doctor Concerned, our records show that on two previous occasions this patient was hospitalized for the same reason, 18 months ago and then again just 7 months ago. The first time she slashed her wrists; the second time she took some over-the-counter headache drugs."

    "Of course, that's right, I took care of her both times."

    "But she didn't kill herself then, did she?"

    "What? Of course not. She's here now. She just tried to kill herself! In the ER they pumped out her stomach. She's not going to die from the overdose. But she needs help. She needs to be admitted to the hospital. Why are you arguing with me?"

    "Oh, I'm sorry, I don't mean to be argumentative." Nancy's voice is smooth, controlled. She has been through this scenario before. "But unless your patient killed herself, I simply can't authorize this hospital admission. Our rules don't allow it. Your patient is now classified as repeat suicidal gesture, uncompleted. For your records this is code X56 dash 712. Her Quality Healthy policy does not allow for three gesture admissions in a 24-month period. I'm sure you can understand that."

    "But she's suicidal! She is going to try it again today, she swears. And she will succeed if she goes out of here now."

    "Well, you certainly need to help her, I agree," Nancy says. "Let me see. Yes, you are allowed to refer her to a Quality Health outpatient mental health clinic. Let's see . . ." Nancy consults a nationwide directory of Quality Health clinics. "Ummm. . . I'm checking . . . Pennsylvania, Pennsylvania, Pennsylvania. OK, we do have a mental health clinic in Philadelphia. Dr. Concerned, are you near Philadelphia?"


    Did You Ever Wonder Why Hospitals Are So Noisy?

    You are not alone. A New England Journal of Medicine Sounding Board article titled "Pandemonium in the Modern Hospital" highlights the modern problem (Grumet GW. NEJM 1993:328;433-437).

    . . . The hospital atmosphere of the 1940s and 1950s was one of austere silence, as in a library reading room. . .But that subdued setting has gradually been replaced by one of turbulence and frenzied activity. People now dart about in a race against time; telephones ring loudly; intercom systems blare out abrupt, high decibel messages that startle the unsuspecting listener. These sounds are super-imposed on a collection of beeps and whines from an assortment of electronic gadgets pocket pagers, call buttons, telemetric monitoring systems, electronic intravenous machines, ventilator alarms, patient-activity monitors, and computer printers. The hospital, designed as a place of healing and tranquility for patients and of scholarly exchanges among physicians, has become a place of beeping, buzzing, banging, clanging, and shouting. . .

    The Grand Canyon Syndrome

    Your patient is walking across the grand canyon on a tightrope. The wind is blowing and it is raining. Planes are buzzing overhead. It is 10 miles to the other side. Anything can tip him over. Which patients have the Grand Canyon Syndrome so fragile that any minor insult (e.g., a viral URI, a dietary indiscretion, a sudden exertion) can make them acutely worse and necessitate emergency care?

    Answer: Those patients with any one of the following lab test results.

    FEV-1 second <30% of predicted

    Cardiac ejection fraction <20%

    Resting room air PaO2 <50 mm Hg (sea level)

    PaCO2 >60 mm Hg

    Serum potassium > 6 mEq/L, < 2 mEq/L

    Serum sodium > 160 mEq/L, < 120 mEq/L

    CD4 count <20/cu. mm

    Neutrophil count <500/cu. mm

    pH <7.30

    Bilirubin >10 mg%

    Hematocrit <20%

    Hemoglobin <7 gm%

    Creatinine >5 mg%

    BUN >100 mg%


    The day is a hinder

    So much babble

    This conference, that meeting

    Those rounds interminable.

    The attendings, the visitants

    That inhabit the day

    The Chiefs, the Seniors

    All get in my way.

    The patient, the patient

    It seems so clear

    Is the one I serve

    Not some administrator.

    Daytime's chaotic

    Too full of process

    To care for my patients;

    I don't need this stress.

    6 p.m.! Can't wait

    til they all go home

    (Those wasters of time)

    And leave me alone.

    Alone with my patients

    That's all I ask.

    No meetings, no rounds

    No blocks to my task.

    Alas, morning comes

    And the night's work is done.

    Rounds must be served,

    Now I'm beat; they've won.

    PaO2 on Top of "Goddess Mother of the World"

    Mt. Everest, the world's tallest mountain at 29,028 ft., straddles the border between northern Nepal and Tibet. In Tibetan the mountain is known as "Chromolungma" which means "goddess mother of the world."

    In 1981 two members of a medical expedition to Mt. Everest, organized by John West, M.D., reached the summit and measured exhaled PCO2 and barometric pressure. The values were 7.5 mm Hg and 253 mm Hg, respectively. From these and other data, Dr. West (who did not attempt the summit) calculated the climbers' PaO2 without supplemental oxygen at just 28 mm Hg (West JB: High Living: Lessons from extreme altitude. Amer Review Resp Dis 1984;130:917-923). This PaO2 is at the lower limit of survivability, and is made possible only by the extreme hyperventilation. The PaO2 value is actually higher than Dr. West had predicted, mainly because the barometric pressure on the summit was higher than predicted. Since climbing Everest began in the 1920s, supplemental oxygen has been routinely used. However, since a PaO2 of 28 mm Hg is survivable, we now understand how a few incredibly daring climbers starting with the Italian Reinhold Messner in 1980 have been able to reach (and return from) the Mt. Everest summit without supplemental oxygen.

    Before and since Edmund Hillary and Tenzing Norgay became the first climbers to reach the summit in May 1953, hundreds have attempted to scale the mountain. Unfortunately, one out of every six climbers has died in the attempt, 140 fatalities through May 1996. Deaths are from accidents (e.g., falling into a crevasse), exposure, and high altitude sickness (including cerebral and pulmonary edema). On a single day in May, 1996 a blizzard near the summit claimed eight climbers, from three separate expeditions.


    Surveys indicate that many U.S. high school students think New Mexico is a foreign country, and that West Virginia is a section of Virginia. To help remedy any such deficiency in the medical profession, several geographic facts are presented below. Use them on trivia rounds.


    The southern most state: Hawaii (the southern tip of the big Island of Hawaii is much further south than Key West, Florida, the most southern point in the Continental U.S.)

    The western most state: Alaska

    The northern most state: Alaska.

    The eastern most state: Alaska (part of the Aleutian Islands chain crosses the international date line, making them thousands of miles more eastern than the tip of Maine)


    Until the 20th century every large U.S. city was located on navigable water, i.e., you could get there by boat. Now huge metropolitan areas flourish because of air and land trans-portation. The largest metropolitan areas in the country not reachable by navigable water are: 1) Dallas-Ft. Worth, 2) Atlanta, 3) Phoenix, 4) Denver. Note that almanacs lists San Bernadino, CA as another large, land-locked metropolitan area, but it is really just a spillover from Los Angeles, and an hour away from one of the country's largest ports.


    • Two state capitals not reachable by car from another state: Juneau, Alaska and Honolulu, Hawaii. OK, Honolulu makes sense. But Juneau? It's not on an island, but is nonetheless isolated on the southern coast of Alaska. There is simply no highway linking it with anywhere else. You can get there by boat or plane.
    • There is only one location where you can stand in four states at the same time: the junction of Arizona, New Mexico, Colorado and Utah. This point is called Four Corners USA.
    • The largest U.S. shopping mall is Mall of America, located in Bloomington, MN, just outside Minneapolis. Mall of America contains a giant indoor Amusement park surrounded by hundreds of stores. Its theme-park-within-a shopping-center design is patterned after an even larger mall in Edmonton, Canada.
    • The highest incorporated city in the U.S. is Leadville, Colorado, at 10,200 ft.
    • The westernmost section of Florida and easternmost section of Oregon are only one hour apart in time; they are in the Central Standard and Mountain Standard time zones, respectively.

    Do You Find Most Meetings a Waste of Time?

    You are not alone. Read the "Occasional Notes" article in the New England Journal of Medicine titled "Meeting Mania" (June 2, 1994, pages 1622-1623). Dr. Abraham Bergman, of Harborview Medical Center in Seattle, argues convincingly for a meetings moratorium:

    For reasons of economy and common sense, I propose that institutions declare an all-out war on meetings, task forces, and immediate 30-day moratorium on all gatherings of more than three people should be declared.

    If you ever find yourself wasting an hour in a meeting that accomplished nothing, you will find consolation in this article. It is more than a complaint; it is a blueprint for change.

    Medical and Osteopathic Schools in the U.S.

    • The U.S. has 126 medical schools and 17 osteopathic schools.
    • Cities with the most medical schools: New York (6); Philadelphia (5); Chicago (5). In addition to the 6 schools in New York City, there are two in the suburbs: State University at Stonybrook, Long Island and New York Medical College in Westchester County. Also, New Jersey Medical School is located in Newark, which some consider a NYC suburb. New York state has four other medical schools (Albany, Buffalo, Rochester, Syracuse), for a state total of 12, the most of any state. Runner-ups are California with 8; Pennsylvania, Texas and Illinois with 7 each; and Ohio with 6.
    • No city has more than one school of osteopathy. The first school of Osteopathy was established in Kirksville, MO in 1892 (see Section M).
    • The state with the fewest medical schools per capita: Florida, which has just three schools for a state population of about 14 million.
    • States with the most medical schools per capita: Vermont, North Dakota, South Dakota, each with one school for a population of less than a million, and Nebraska and West Virginia, each with two schools for a population of less than two million. (New York's 12 medical schools works out to one per 1.5 million people.)
    • The largest metropolitan area in the U.S. without a medical or osteopathic school is Broward County, FL, population about 1.6 million. Only one or two hospitals in the entire county operate any kind of post-graduate training program.
    • The first U.S. medical school (indeed the first medical school of the New World) was founded in Philadelphia in 1765, by John Morgan and William Shippen, colonial Americans who had obtained their medical degree in Edinburgh. It began as the Medical Department of the University of Pennsylvania, and is today the University of Pennsylvania School of Medicine.
    • Harvard Medical School was founded in 1782, when Harvard College was already 150 years old. Among the school's famed faculty in its first century were John Collins Warren, who first used ether anesthesia in surgery (1846), and Dr. Oliver Wendell Holmes, who published a paper on the cause of puerperal fever (in 1843, three years before Semmelweis).
    • The first modern U.S. medical school was Johns Hopkins, which opened in Baltimore in 1893. Hopkins was the first school associated with a hospital created expressly for teaching and research by the medical school faculty (the Johns Hopkins Hospital). The head of medicine was William Osler, of pathology William Welch, of surgery William Halstead, and of gynecology Howard Kelly all legends in their respective fields.



    (You fill in the blank, then read just that one journal on a consistent basis. You will find yourself "keeping up" much more than the doctor who gets 10 journals, skims them all and reads none.)

    Top Peer Review Journals by Circulation

    New England Journal of Medicine (founded 1812)

    Journal of the American Medical Association (1883)

    Mayo Clinic Proceedings

    The Lancet

    Annals of Internal Medicine

    British Medical Journal

    NEJM is the clear winner in total paid circulation (240,000) and frequency of scientific quotation. JAMA has a larger total circulation, but it is distributed as part of AMA membership. Also, according to an editorial in NEJM (September 7, 1995, page 654), NEJM is the most frequently quoted medical journal. The "citation index," as tracked by the Institute for Scientific Information, was 28.8 for the NEJM, 15.9 for Lancet, 9.3 for Annals of Internal Medicine, and 5.6 for JAMA. The NEJM publishes 15% of the papers submitted to it; a third of the scientific reports originate from Europe.

    Small Print Winner

    The small print winner for medical books goes to the annually published Sanford Guide to Antimicrobial Therapy, by Drs. Jay Sanford, David Gilbert and Merle Sande. A true pocket book, its dimensions are only 4 by 6 inches. And the print size? Well, in the print version of this book the print you are reading would be 10 point, the headline in 12 point. The Sanford Guide is much smaller, only 6 point, e.g.:


    Mycoplasma pneumoniae --- Erythromycin; Doxycycline

    With this type size a lot of information can be packed onto one page but, surely, this is print meant only for young eyes!

    Some Article Titles from The Journal of the American Medical Association, Volume 1, No. 1, Saturday, July 14, 1883.

    Annual subscription, $5.00. Single copies, 10 Cents.





    Stramonium Poisoning

    Effects of Tobacco Smoking in Children

    Atrophy of the Brain Following Amputation

    Electric Light for Medical Uses

    Arsenite of Bromide in Diabetes Mellitus

    Hypodermic Uses of Sulphate of Morphine

    And an advertisement from the first issue of JAMA, just as it appeared in 1883:







    M.J. Patterson, M.D., Superintendent


    END OF SECTION C, House Officer's Survival Guide
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    Copyright © 1996-1999 Lawrence Martin, M.D.
    Revised: March 1999