every patient whom he sees? There are four stages. First, the facts as to the history of his patient. This history is both personal and family. He not only wants to know when this present illness or tumor began, and the symptoms which have attended its development, but what was its cause-a cause which may be hidden in the present habits, earlier surroundings, or former diseases of his patients. More than this, so strong is the influence of one generation upon another that a large number of diseases are dependent upon tendencies inherited from ancestors; not from only one, but it may be even more than one, prior generation. And it is strange how very inaccurate large numbers, even of intelligent persons, are; their remembrance of facts so uncertain; their observation of physical conditions so vague and indefinite. It often requires all the skill in cross-examination that is expected of an acute attorney to get at the real facts of the case.

When these are set in order, then comes, secondly, the physical examination. Here nature is often treacherous and juggles with us, even on the edge of the grave. Touch, sight, and hearing must all be called into co-ordinate energy, and all be guided by a clear, logical mind, or again we shall not get the right facts as to the physical condition of the patient. The physical signs being ascertained, what are the deductions to be drawn from them? Here comes constantly the value of academic training. Many a fact, which seems at first glance to be important, simply because it is upon the surface and is first observed, is pushed aside at once by the logical mind of the college-trained man. He has learned by long experience how to see through the superficial to the deep, through the accidental to the essential; or, it may be, often through the mimicry of disease to the true disorder. Having, therefore, deduced certain logical conclusions as to the malady, or injury, or surgical condition, he is finally prompt in the selection of the remedy, whether it be drug or diet or the knife, and his decision of character impresses his patients with a

confidence in his skill, which a friendly and a kindly demeanor enhances. This assures him success in his profession.

IV. No man in any calling of life can live alone; nor can the doctor. Even with his very first patient he must use tact as well as skill clearly to set forth the nature of the trouble, and the need for the regimen or operation he advises, or to satisfy a timid patient with such thoughtful and guarded statement of the truth as will not needlessly alarm, and yet will invite and insure obedience. To state this accurately, truthfully, and convincingly, and yet not too bluntly, is one of the largest elements in the character of a successful practitioner. But not only is this required in relation to his individual patients. He must impart his knowledge to the profession; and the place that a man takes among his fellows, both of his own calling and in the entire community, depends not a little on his ability to set forth his ideas clearly, logically, forcibly. The training of tongue and pen that a man gets in Brown University is simply invaluable in training him to formulate such statements of truth. The man who in medical societies shows that his judgment is good, that he is familiar with the literature of the subject, that he knows what is going on, that he is progressive and keeps up with the times, and then can state his views in a forceful, convincing way, becomes a man of power; a man whose judgment is sought for, whose advice is asked by his brother-practitioners. And it does not take long for the public to find out what doctor is most trusted by other doctors. He is the man they want for themselves.

Such papers find their way usually into our medical journals, which stand in the same relation to the more elaborate and systematic, but less fresh, books which are issued from the medical press that the newspapers do to serious works of history. A man's reputation is built up largely on the papers which he writes and presents at such societies and are published in the medical journals; and all

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:

MY

Y 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.