ments of instruction. To illustrate, suppose the junior class is about to take up the gastrointestinal tract. The central studies as elsewhere are applied physiology and applied anatomy. Lecture courses are arranged beforehand in pathology, practice, surgery and every other subject pertaining to the region. All instruction is coördinated and made as nearly synchronous as possible. In other words, the symposium method is employed as completely as the subject matter will permit.

The correlated system of instruction as it is now employed in the Temple University Medical College has the hearty support of every member of the faculty. They find it helpful in the preparation and presentation of their subjects. They would choose no other plan. Students are much less apt to grow weary than under any other system. In fact they grow enthusiastic as the subjects unfold logically. No persons are louder and more emphatic in their praise of the correlated system than the graduates of the school. Moreover, the system has the hearty endorsement of medical teachers outside the college, who have personally inspected the work or inquired into the methods.

ADVANTAGES OF CORRELATED SYSTEMS.

To enumerate in detail the several particulars in which the new scheme has proven itself unquestionably superior to any and ali the older schemes would unduly lengthen this article. Briefly, the following are some of the main features of merit in the correlated curriculum.

Students are taught naturally day after day to correlate their knowledge in taking up each new subject. As a most essential part of their training they early develop the power to correlate. which becomes to them a habit and a most valuable asset in their college work. The importance of this feature is not easily overrated. Teachers feel its force in the greater ease with which students comprehend new and difficult subjects. Students from other medical schools are deeply impressed, by comparison, with the greater progress they can make by reason of this natural scientific procedure. The only knowledge a practising physician finds of value at the bedside and in his clinics is that which he is able to correlate, at the time, in its bearing upon the case in hand. Suppose he is consulted in a case of disease of the liver. He first uses his knowledge of the normal organ and its function (physiology and anatomy) to ascertain the location and nature of the morbid condition (pathology). He next recalls the local and general effects of perverted function (physical diagnosis) and thus, step by step, proceeds to methods of treatment (applied therapeutics). In other words, a physician must be able to correlate his knowledge of the medical sciences. The cor

related curriculum takes cognisance of this fact. If the system. had not a single additional point of merit this one alone would be enough to commend the scheme to the attention of every medical faculty in the world.

HOW THE CORRELATED SYSTEM SAVES TIME AND LABOR IN COLLEGE

WORK.

The provisions of the correlated schéme make it not only easy but quite natural for each professor to present intelligibly every essential of his branch in its logical relationship to the remaining branches. Students come prepared to grasp the subject. The emphasis of subject falls where it belongs. There is the minimum of fruitless overlapping of minor facts for instructors and of worthless memorising for students. In short, the system effects a great saving of time and labor because based on common sense. It is the only scheme that permits of reviewing the entire work of a given period within the allotted time. Not only is a complete review possible, it is at the same time also the most effective. The single aim of the Temple University Medical College is to prepare its undergraduates for the best work in the field of general medical practice, not for the Specialties. However, the experience of the time when the correlated curriculum was giving its best service, during the past five or six years, shows not only that our graduates are better fitted as general practitioners but also that they are better anatomists, better physiologists, better pathologists, better diagnosticians-in one word better doctors,by reason of the correlated system of instruction.

TH

Pneumopericardium-with Report of a Case'

BY JOSEPH BURKE, D. Sc., M. D.

Attending Surgeon, Emergency Hospital, Buffalo, N. Y.

HE presence of air in the pericardium is an occurrence of greatest rarity. Up to 1854, there were recorded but three authentic cases, those of Bricheteau, Stokes, and McDonald. Bamberger, as late as 1857, said that neither he nor Rokitansky (the greatest pathologist of his era), had ever seen a case of pneumopericardium. Schrotter, another famous Viennese physician, in his thirty-five years of earnest and intelligent observation of thousands of cases in the Vienna General Hospital, affirmed that neither he nor his venerated teacher Skoda, had ever seen a case; hence, I feel that the extraordinary rarity alone of this pathological condition and the fact that I have a personal clinical case to report, will serve as my apology for its introduction and discussion here this evening.

1. Read at Buffalo Academy of Medicine, April, 13, 1909.

ETIOLOGY.

The etiology of pneumopericardium is interesting; for, first, air can exist in the heart-sac spontaneously, as, for example, from the disintegration of a foul exudate, as in the case reported by Bricheteau; or, second, it can enter the pericardium from without the sac; (a) rupture of an air-containing abscess cavity, as in Graves's case of abscess of the liver which perforated the pylorus and pericardium; (b) communication of a tubercular vomica, or

of a pneumothorax, or ulcer of esophagus; (c) from external trauma, such as a stab wound and the like.

SYMPTOMATOLOGY.

From the standpoint of symptomatology, the condition seems to have excited a great deal more attention. in the early days of physical diagnosis than we find in the textbooks or medical journals of the present generation. I presume this lack of interest from the clinical point of view is due to the rarity of the affection. However, in many textbooks in the early 50's, especially in that of Stokes in 1855, we find portrayed most vividly the ex

traordinary physical signs that accompany it and are decidedly characteristic.

A painstaking review of the literature shows that in the cases reported, the physical phenomena were described so uniformly alike and were so remarkable, that in spite of the rare occurrence of the affection, its presence was very easily recognised. One must not forget however, that analogous to the behavior of pneumothorax, the pericardium can simultaneously contain not only air, but fluid as well, especially pus; therefore, one finds

physical signs, according to whether fluid is also present or not. Classically, there is to be found bulging of the precordia, due to paresis of the intercostal muscles, remarkably shown in our own case and which first directed our attention; there is absence of the apex beat and cardiac impulse, when the patient is in the recumbent position which, however, reappears when he assumes the upright or lateral position, or bends the chest forward. Since the air in the pericardium occupies the upper portion of the sac, the law of gravity here obtains the heart and exudate sink to the lower portion; the percussion phenomena become extraordinary. In the recumbent posture in place of the normal cardiac dulness, there appears a high pitched tympanitic note with accompanying metallic sound which, with diastole and systole, changes in character. As the patient changes from the horizontal to the upright position, the tympany gives place to normal cardiac dulness, and the apex beat reappears. In Walter James's case-I must say here that the clearest summary of the literature and most scientific exposition of the subject, pneumopericardium, was written by Dr. James in 1905-the study of the heart dulness in different positions of the body was

Fig. 3. Percussion dulness, lying on right side.

carefully observed and resulted as follows: "When the patient is lying on the back, there is pulmonary resonance with slightly tympanitic quality over the entire pericardium, as far down as the fifth costosternal junction, the line of dulness coming horizontally at this point. When the patient sits up, the percussion note from the third left space to the fifth rib becomes distinctly more dull; when lying on the right side, there is an area of dulness extending laterally from the right border of the sternum to a point half an inch to the left of the left border of the sternum, and longitudinally from the second interspace downward, until it merges into the liver dulness below."

I append herewith, figures 1, 2 and 3, illustrating Dr. James's case, and which are characteristic, taken from the Medical Record, June, 1905. The auscultatory phenomena are, according to Leube, more pregnant than percussion; the most important sign is the metallic character of the heart tones, which are so strong sometimes that they can be heard a distance away from the patient; if fluid be also present, there can be heard a peculiar succussion or splashing sound, which resembles the churning sound caused by a water wheel in motion,

In our own case the percussion findings were similar to those of Dr. Walter James's case, but the auscultation phenomena differed in this that instead of succussion sounds there could be heard two dull, distant heart tones and a third dull, metallic sound, separated from these by a seeming interval; in other words, there could be heard three distinct tones, the first and second, dull and faint, the third characterised by a "metallic click" there was no musical character to these sounds.

The functional signs that accompany pneumopericardium vary in different cases; in some there is dyspnea; in others, the difficulty in breathing is less. In our case there was neither cyanosis nor dyspnea; the patient acted as if there was nothing at all wrong with him.

DIFFERENTIAL DIAGNOSIS.

When one considers the above described individual physical signs of pneumopericardium. one cannot very easily confound this condition, if present, with any other; but, notwithstanding this, the following conditions may possibly be mistaken for it: dilated stomach, tubercular cavity and circumscribed pneumothorax. The one feature common to all of these conditions is 'the ability of the physician to determine the cardiac dulness and apex beat, when the patient is in the recumbent posture, readily determines the differential diagnosis.

J. F., male. 35 years, Italian. One Sunday, (April, 1908) about 4 P.M.. while walking, patient was stabbed with a stilletto;