that I have said above applies to such published papers, and still further, of course, to formal statements of knowledge in books. The wretched, slovenly style that one often sees both in journal articles and books is not surprising when we consider how relatively few men there are who cultivate the rhetorical graces of style. As Dr. Billings some time ago pointed out, even the very title of a paper is often badly chosen. If I am searching, for instance, for all the published cases of gunshot wound of the kidney for the purpose of analyzing them and determining the value both of the symptoms and the physical signs and of the methods of treatment, in going over the "Index Medicus" to collect the recorded cases am I likely to look at a paper which may relate a most interesting and important case of gunshot wound of the kidney which hides it under the vague title of "Two Interesting Surgical Operations"? The title of a paper or of a book is like the name of a man. It should be distinctive, so that one may always refer to it and know precisely what it is about.

But not a few doctors become prominent teachers. The number of men who teach in any one of our medical schools is relatively small, yet the aggregate number of teachers in the profession is very large. While the art of teaching is, to some extent, innate, no man will make a thoroughly good and successful teacher unless he has had more or less of such a college training. The ability to set forth his ideas in logical order, in natural sequence, passing from the known to the unknown, from facts to deductions, and with at least a reasonable degree of rhetorical grace is a gift which is susceptible of the greatest possible development by training. Even great geniuses who have lacked such training, such as John Hunter, have always been hampered to their very graves by their inability to express themselves in graceful and yet forceful English.

I might go further, did time permit, but I will only allude to one final advantage, as it seems to me, of a college train

ing, and that is on the moral and spiritual side. Whatever may be a man's relation to any individual religious belief, it is scarcely possible for him to go through the four years of a college course without rising to a higher moral plane, without having developed within him the spiritual side of his nature by his contact with earnest men of various faiths. I would trust a college man more quickly than I would any other man morally and spiritually, as well as intellectually, for I believe, though there are vices and evil influences in every college, yet, on the whole, the influence of a college life makes for righteousness as well as for knowledge. When we reflect that the physician's influence begins, even before birth and only ends with the grave itself; when we consider his intimate and personal sacred relations with all the members of a family; that he is the repository of facts which he must no more disclose than the listening walls of his consulting room; when we consider the confidence that is bestowed upon him, how intimately his advice affects the whole future, not only physical, but intellectual and moral, of so many of his patients, surely there is need for such a man to live, not only on the highest intellectual level, but on the highest moral plane. If he does not, he is unworthy of the noble profession which he ought to adorn.

LITERARY METHODS IN MEDICINE.*

GENTLEMEN:

M

subject this evening is "Literary Methods in Medicine," and I have selected it for this reason: I well remember how I floundered around in my early medical career, and the many mistakes I made, until I finally evolved from my own experience, together with suggestions from friends with whom I talked on the matter, a method of my own. This method I shall describe to you, and, as it has been very satisfactory to myself, I think it may be of use to you. If you will look in the "Medical News" for August 12, 1893, you will see a similar very admirable paper by Dr. Bayard Holmes, of Chicago, who, so far as I know, has done the best work in this country with a view of urging students of medicine and doctors to follow out a reasonable, feasible, and practical method of making their knowledge available, first to themselves, and secondly to others.

I purpose to speak to you on two topics,-first, "casetaking," and, second, the writing of papers, or "case-using." I would be very glad if you would make notes as we go along, as I think they will be useful to you hereafter.

I. Case-taking.-Some of you will become residents in the Jefferson and other hospitals. You will want to write up the history also of your private cases, and, therefore, you must know how to do it.

First, record the name of the person. If the patient is a child, always record the father's name, or, if the father be

* A lecture delivered before the W. W. Keen Surgical Society of the Jefferson Medical College. Reprinted from International Clinics, vol. i, seventh series, April, 1897, by permission of J. B. Lippincott Co.

not living, the mother's. You will very possibly, years later, want to find out the after-history of the patient. A child may thus be reached through the parents. If you are dealing with a married woman, record her husband's name, as, if his name is in the directory, you will be able to reach him, and through him the wife. Always record, also, the name of the family physician and his address, so that you may obtain later information from him. Next, note the residence, then the age, and then the occupation. The occupation has very often a great deal to do with disease. A recent case in the Jefferson Hospital, in which the cause of necrosis of a large part of the pubic bone was at the first glance inexplicable, is a good illustration. When I learned that the man worked in an iron foundry, and used an iron tool with a long handle, which he pushed forward by the pressure of his body, the cause became clear. This pressure was, of course, the cause of the necrosis.

I remember a good story told of a doctor who insisted that his patient did not take enough exercise, in spite of the man's protests that he did. Suddenly he asked the man's occupation. "Postman, sir," was the unexpected and embarrassing though convincing reply.

Next, note the height, and then the weight, so as to determine whether the person's weight is out of proportion to the height, and whether he is fat or thin. Get both the best weight and the present weight. If a year ago a man weighed one hundred and forty pounds and to-day one hundred pounds, there is some serious trouble, possibly cancer of some of the digestive organs or other part of the body. The loss of weight will often put you on the track of the disorder. Inquire into and record the patient's habits as to eating and drinking, and especially over-indulgence in either, particularly as to alcohol, and often into his sexual habits and illicit indulgence.

Having recorded these preliminary observations, you must

get the family history, to see whether heredity has had anything to do with the case. Inquire into the age and health of the patient's father and mother if living, or, if they are dead, how old they were and the cause of death; also the age and cause of death of the grandparents, as well as of the uncles and aunts on both sides. Ask especially as to tuberculosis and cancer. In this way you may determine the question of heredity.

Having thus obtained the family history, we next come to the personal history. You will first inquire what prior illness or accident the patient has had. You will very

often find that this is a difficult task. You must have the shrewdness of a lawyer in cross-questioning your patient in order to determine the facts of the personal history. As an illustration of this I may mention the case of a little girl who was brought to my clinic at the Orthopedic Hospital a few weeks ago, to be treated for curvature of the spine. That was all I was told of her history. I asked for more data, and only to-day her mother remembered that a year ago she was subject to very severe attacks of pain, especially in the right iliac fossa, and that she had had at that time, and at intervals of from four to six weeks since, a discharge of pus from the vagina. A discharge of pus from the vagina in a girl of seven was a fact of prime importance which the mother had entirely neglected to tell me about.

If in the previous history there is noted an accident, you will want to inquire particularly into the details of that accident. As an example of this, a man may tell you that he had a fall and injured his head. If you record only this, you have made a most imperfect record. You must know whether the man was struck severely enough to tear his scalp or fracture his skull; whether he was unconscious; if unconscious, when he came to himself, and whether he was able to get up and walk home, as well as what later symptoms were observed. All these details, you will observe, are very