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LITERARY METHODS IN MEDICINE.*

GENTLEMEN:

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.

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

important for you to obtain in connection with the prior history before the present illness began. When you have to do with a woman, you will wish to know her personal history in relation to her sexual organs; when menstruation. began and its character: when married; how many children; how many miscarriages; whether her labors were normal or instrumental; whether or not she nursed her children; whether or not she has had any trouble with her breasts or the pelvic organs. These facts may have a very important bearing on the history of your patient. In both sexes, but especially in men, you must inquire as to syphilis, acquired or hereditary. Here your ingenuity and tact will often be taxed to the utmost to get at the truth. If the facts observed are in favor of a syphilitic history, you must disregard denials, but you will record both the denial and the facts. In married women you must often avoid the direct question, and reach the facts indirectly by inquiring as to the loss of hair, sore throat, sore eyes, blotches on the skin, etc. In all cases observe the teeth for evidence of inherited syphilis.

Then you come to the history of the present illness,--first, when it began, and, second, how it began; what took place at the beginning of the illness, and whether any new features have developed since; whether the conditions first existing became worse or better, and as to there having been relapses. Next you wish to ascertain and describe the present condition. Frequently you will find this written as "S. P.," meaning status præsens, or the present condition of the patient. You will want to state whether the patient is apparently in good or ill health; whether there is any evidence of long-continued illness; note anything that strikes you particularly as to the general appearance of your patient. Then begin to describe the present symptoms. You will first state whether any pain exists anywhere; any tenderness, any swelling, or other evidence of a tumor. When you have described the present general condition and symptoms, you will wish

to ascertain the local conditions and the physical examination, as, for instance, of a tumor of the breast; in which quadrant of the breast it exists; if the nipple is retracted; and let me say here that if it is not retracted, do not let this fact pass without comment. It is important to state negatives as well as positives, not only as to this, but many other conditions. State if there is any discharge from the nipple when you squeeze the breast. If there is a lump, you must describe the size. Do not say it is as big as an apple or the size of a cherry. You may say it is the shape of a cherry if you choose, but you would better say it is globular. State the diameter, whether it be one inch or two inches, or better still use the Metric System. You feel the tumor, and state whether it is hard, elastic, lobulated, and whether it is ulcerated. In that way you give to the reader of your paper some idea of what you find. If it is possible, always give the circumference as well as the diameter. In the case of a goitre or other tumor, give not only the transverse and the vertical measurements, but also the circumference from one side to the other, and that the girth of the neck was so many inches. If possible, use French centimetres, as this is much better than English inches.

You will wish to preserve any photographs, drawings, or sketches that you may have secured in connection with the case. These various charts that I show you are very good for this purpose. These are "clinical charts" I devised many years ago, and can be had from P. Blakiston's Son & Co. in pads. These are stencil charts in use at the Orthopaedic Hospital. In the case of tumors, draw an outline of them, and state such things as that the right side was dull or tympanitic, etc.

I cannot too strongly urge that you should make a careful, thorough physical examination in every case. Some time ago I quickly discovered that a gentleman had a cancer of the rectum. He had suffered with tenesmus, pain,

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