ON C A S E - T A K I N G 273

ON CASE-TAKING.* BY ffoH~ Mow~.

The choice of so commonplace a subject as the taking of ease-histories has been forced upon me in an honest effort to co-ordina~ certain diver- gent views held by hospital staff men and their residents respectively in the matter of its essential importance. I~ t She pat ient be a victim of anything from abortion to zoster,--between which two alphabetical polo8 stand a few of the understood and all the misunderstood disea~es,--it ia essential to take his or her history. An electrocardiogram might con- oeivably be of interest, and an estimation of the calcium content of tim blood while away an idle hour, but the taking of the history is essential. (For the rest of this paper, for the sake of speed, the male persona] pronoun will embrace the female.) As an illustration of how important a history is, imagine a woman walking into the dispensary who is a deaf- mute. Think how helpless you would feel when it is finally borne in ~pon you that this deaf-mute can neither read nor write! Having dis- pelled by this unusual illustration any doubts which you may have entertained as to the absolute necessity for a history,--and that such doubts are entertained by some will be obvious to anyone who cares to peep behind the temperature charts of any hospital, or who has watched a panel doctor at p lay,- - I do not expect that the absolute necessity for a good case history can be further denied. As this is a students' society, I propose devoting the major portion of the counsel which follows t~ Shern,--eounsel distilled from sad experience. May I hope that i t will act like other distilled products, and go to their heads?

There is no more pitiable sight than that of a student on his first da~, of residency, taking his first case-history. The immensity of his task ~ga~gers him. He feels like the amateur explorer who takes his first step into ~ho jungle; after he has conversed with the patient for ashorS while he has the impression of having been handed A fiendishly tangled length of yarn; there is no beginning, no end, no sequence whatever~ hope is blotted out from his horizon. Waste no sympathy on him ; i~ was entirely his own fault; his was the hand that tangled the skein. What was his great mistake? Fie did no~ start at the beginning; and why? :Because he did not know how to begin. Probably he asked the patient Shag inan~ question: " What's wrong with you?" and the man who asks Shag deserves all that he gets. Some day a patient will answer " amyo- trephic lateral sclerosis," and may I be there to see!

Leg me tell you what is the beginning before we go any ~,urther. F u ~ name and address, Age. Occupation. Marr ied or s ingle? 1~

marr ied , how m a n y chi ldren? Now, these things must be /earned off intelligently. They are important questions, and must not be rapped out any old way. They are as they stand in stricg order of priority, l a$ress ~his point because a fellow resident of mine once hind an unfor- tunate experience in this. connection. He asked a lady of the fair, fat and forty class how many children she had, and then when she had answered: " Fourteen, doctor," absent-mindedly asked her was she married, l i e escaped with minor injuries.

Next enquire as to parents ' hearth i] alive, and ~! dead, the cause e l death . This is the time to ask these questions---don't wait until you have elicited the fact that the patient is complaining of a had cough and then ask her what her father died of. The look on the patient 's face who has to reply " Consumption " will be a lasting reproach to your tactlessness. The really important thing to find out in this country is whether there is a family history of either tuberculosis or lunacy. :I would ask you to obtain the family history quicldy~de mor tu i s nil n is i ~til, e - - a n d this is an art, because most hospital patients seem to think that if only they could leave in the resident's hands a permanent record in black and white of the morbid history of their complete genealogical trees they could lie back and die content. In quietly declining ~his laud- able task ]50 very c~reful~ghe Irish are proud of their ancestors. Be courteous, bu~ firm. If you gently reiterate a f.ew times " What exactly

* Paper read before the Medical Society, University College, Dublin, ]~areh 7th, 1928.

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did your f a t h e r die o f ? " i t will slowly b u t surely be borne in on t h e p a t i e n t t h a t you are concerned no t so much wi th w h a t h a p p e n e d to he r f a t h e r t he t ime he v is i ted his m o t h e r ' s people in Liverpool as wi th t h e diagnosis made by t h e doctor who a t t e n d e d h im d u r i n g his l as t illness. You mus t l i s ten w i t h o u t a smile while you hea r of " i n f o r m a t i o n of t h e bowels ," " ammon i a on the l u n g s , " " h a r i c o t beans in t he legs ," " w a t e r on t he sys tem " ; these t h i n g s a re no t p u t in to make i t ha rd , b u t a re largely duo to t he i l l i t e racy of t h e p a t i e n t .

We nex t proceed to ob ta in t he p a t i e n t ' s prev ious personal his tory . I n th i s connect ion I should l ike to s t a t e t h a t when you have asce r t a ined t h e fac t t h a t the p a t i e n t h a d measles and whooping cough in his ea r ly y o u t h you have no t by any means exhaus t ed your enquir ies . I t be t r ays crass s t u p i d i t y to follow up a h i s to ry of measles wi th one of cancer of t h e rec tum. As fa r as fevers a re concerned, the only ones t h a t seem of. any signif icance to me are r h e u m a t i c fever and d i p h t h e r i a , i na smuch as t h e y weaken t he h e a r t , and sca r l a t i na on account of i t s d a m a g i n g effect on the kidneys. The re s t a re mere inc iden ta l s of childhood. The impor- , tent t h i n g s to find ou t a r e :

(1) The general heal th of the p a t i e n t ? The bes t way to ge t an idea of t~nis is to ask h i m how m a n y t imes he a t t e n d e d t h e doctor . The o f t ene r he was u n d e r a doc tor ' s care, t he worse obviously would be his genera l hea l th .

~(2) Has the p a t i e n t led an indoor or an outdoor life ? (3) His average consumpt ion oI alcohol? No m a t t e r how s tupen-

dously big i t is, bel ieve t he p a t i e n t implic i t ly . I f he says a t th i s j u n c t u r e t h a t i t never crosses h i s lips, t r e a t all his s t a t e - men t s wi th t h e same suspicion.

<4) I t the pa t i en t has been away # o r e home? I n p a r t i c u l a r , if he has been to t h e t ropics , whose p r i n c i p a l expor t s seem to be cases of m a l a r i a a n d dysentery . The reason I include th i s ques t ion is t h a t when t h e r e s i d e n t is leas t expec t i ng it , a case of. m a l a r i a will a r r ive in one of his beds, and ius t because t h e p a t i e n t i s n ' t s i t t i n g up in bed w ea r ing a topee and smoking a cheroot t h e r e s iden t t h i n k s of eve ry o t h e r cause of fever excep t t h e P l a s m ed i um . Staff m en are a p t to t a k e a d v a n t a g e of a m i s t ake l ike t h a t , i t appea r s to be one of t h e i r very few pleasures in life.

(5) Las t ly , you enqu i r e has t he p a t i e n t ever been in t h e a rmy or navy . This is t he p rope r t i m e for t h i s ques t ion. I t seems u n k i n d , when a poor m a n has p leaded gu i l ty to venerea l dis- ease, to r a p o u t au t om a t i ca l l y : " Were you in t he a r m y ? " There is undoub ted ly a def ini te connect ion be tween so ld ier ing and syphilis , b u t t h e r e is no good purpose served in s t ress ing it .

N o w a t l as t we have a r r ived a t t he his tory of the presen t illness. This of course is t h e h i s to ry t h a t coun t s ; i t is also t h e one in which you will make most of your mis takes . L e t me w a r n you to beg in a t t he ve ry beg inn ing . F i n d ou t t he Ions et or igo- - tho absolute b e g i n n i n g of t h e t rouble . I t is h e a r t b r e a k i n g when you are jus t f in i sh ing up a h i s to ry �9 of a two years ' i l lness to be to ld casually by a benevo len t old p a t i e n t : "' Of course, doctor , t he v o m i t i n g w a s n ' t half. as bad as i t was t h e day of t h e F o u r Cour t s , " and you have to s t a r t all over aga in . Your stock eS: oO:s:hO o i; t now since y o u w e r e p �9 11 te l l ou § , ~ - er fect ly well P"

, o y p " " y thau ~ney never r e m e m b e r be ing hea l thy , b u t they a re in a class by themselves. W i t h t h e ave rage p a t i e n t you will f ind t h a t t h i s ques t ion will push aside most of his m e n t a l ddbr i s and give you a chance of t o u c h i n g bedrock. Some illnesses, especial ly those in which t h e d iges t ive t r a c t is no t behav ing itself , m a y have commenced p e r h a p s 15 years previously , and i t is only f rom the in i t i a l symptoms t h a t one can get any idea of t he pa thology, as by t h i s t i m e the s t a t e of affairs is so compl ica ted t h a t one day t he h i s to ry reads l ike visceroptosis and a n o t h e r day l ike cmeal tuberculosis . I n t h e begin- n ing e v e r y t h i n g is fa i r ly p la in and s t r a i g h t f o r w a r d , and in g e t t i n g a good p i c tu r e of t he symptoms a t t h a t stage, lies your bes t (in fac t your only) chance of m a k i n g a correc t diagnosis . U n f o r t u n a t e l y , however, �9 even in t e l l i gen t p a t i e n t s seem to t h i n k t h a t n o t h i n g is of i m p o r t a n c e excep t t he p a r t i c u l a r syndrome they possess a t t h e m o m e n t of going to press, and i t is difficult t o ge t t h e m to m a k e t he effort of memory you

ON CASE-TAKING 275

desire. Still, when you have jogged their memories by the question I have given you, most people will remember fairly distinctly the symptoms which marked thei r first departure from normal health. I have taken the digest ive t rac t as an example designedly, because there is no doubt t h a t in disease of this t rac t a good history is half the bat t le in making a diagnosis. We h a v e , I hope, grasped the first essential, namely, t h a t of s t a r t i ng at the absolute beginning by means of the stock quest ion: " How long is i t since you. were perfectly wel l?" Sup ose. the p a t i e n t says : " Las t J u n e , " follow up j,our first questlon by t~m one: " I f I had met you in May last, would you have told me you were p e r f ~ t l y h e a l t h y ? " You will be surprised how many times the answer to your second question will confound the answer to the first. So always make assurance doubly sure.

We' l l suppose n o w t ha t you have found out exactly when and hew the t rouble s tar ted. Your next difficulty is to keep a satisfactory sequence; the pa t i en t is very prone to introduce irrelevancies, to lead you astray, to flit about from one symptom to another, in fact to do everything but be helpful. The old motto should be always before you : " F e ~ t ~ a le~te. ~' Perhaps the best p lan is to correlate symptoms with time, and write your h i s to ry by the calendar. For e x a m p l e : ~

" The pa t i en t complained first of slight loss of appeti te in the begin- nin~ of June , by the end of which month he had a definite distaste far most foods. This s tate of affairs continued up til l August, when he vomi ted for the first t ime. P a i n was not experienced unt i l the beginning of J a n u a r y . "

N o w , although t h a t is only a skeleton history, I th ink you will agree t ha t i t gives a fa i r ly vivid pic ture of the t ra in of symptoms and signs. Af te r all, if we waht to be definite about anything, we must use the .calendar and the dock. So why divorc~ them from history tak ing? The next point is t h a t very ear ly on in the t ak ing of the history of the present illness you will have obtained a good idea of what system is at fault, and I would implore you to have the common equine sense to keep to tha t system. Noth ing sounds so ridiculous a s : -

" The cough beg~n to come in spasms and caused a sharp pain in the r i gh t side of the chest behind. About this t ime the pa t ient noticed tha t he was somewhat constipated, and the motions had a very offensive odour. He was also troubled with headaches and complained of neuralgia. He had the upper lef t canine ex t rac ted and the neuralgia cleared away. ' ~ . " . . , �9

party a pulmonary condition. You might as well ext ract a history of ingrowing toe-nail f rom a case of acute osteomyelitis. A history like t h a t is calculated to s t ra in the relations between staff man and resident, and the s tudent who finds t h a t in spite of his best efforts this faul t cannot be eradicated should forsake the groves of Aescupalius and break into a sharp t ro t for Leins ter House.

We see then tha t the his tory should date from the absolute beginning, t h a t symptoms should be correlated with time, tha t irrelevancies should be cut out with a pencil as ruthless as an editor 's, and now let me come ou t wi th the old saw: " Never, ~ e v e r , NEVER put a leading quest ion." No m a t t e r how often you hear your chief doing if~-and the number of t imes will be leg ion--do not on any account follow his horrible example; i t is a pract ice tha t will lead you into untold tribulation. Pa t ien ts are so te r r ib ly obligin~ in this mat te r . I f you ask her does she sweat much a t night , she th inks t h a t an answer in the negative is t an tamount to an insul t she wouldn ' t disauuoint you for worlds, so down on the history sheet goes : Pa t i en t sweats at mght , and you shake your he d mourn- fully as you look at the la tes t vict im to the White Scourge. The gentle- man on the staff comes along, looks at the patient , looks a t the history, looks a t you, and then asks her how many nights she sweated. The answer is made readi ly enough: " Oh, about five or six t imes ," and then the damning addi t ion : " I t was last July, and the nights were very ho t . " I t ' s no use menta l ly consigning the poor woman to a place where t he n ights will be ho t te r still. Her intentions were the best in the world, t he faul t was ent i re ly your own, you asked a leading question and obtained w h a t a leadin~ question near ly always e l i c i t s~a misleading reply. Pa t i en t s as a rule are misleading enough without any help from you.

I n t ak ing a history one must be constantly on one's guard against t h e

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effects of suggestion, whe the r i n t e n t i o n a l or unconscious. Where the facts of a case are set fo r th by an i n f o r m a n t they are near ly always p resen ted , consciously oz" unconsciously, in t e rms of inference. C e r t a i n facts which appear to the n a r r a t o r to be the lead ing fact.s are g iven wi th emphas i s and in detail , while o the r fac ts which a p p e a r to be subo rd ina t e or t r i v i a l are pa r t i a l ly suppressed. B u t th i s assessment of ev iden t i a l value m u s t never be accepted. The whole case mus t be considered and each f ac t ~veighed separate ly , and t h e n i t will commonly h a p p e n t h a t t h e l ead ing fac t t u r n s out to be t he one t h a t had been passed over as negligible.

Now I tklope i t w o n ' t scandat ise you when I tell you t h a t t h e 'preceding h igh-sounding p a r a g r a p h has been t a k e n word for ~'ord ou t of t he m o u t h of a wel l - 'known detec t ive of f ic t ion- -Dr . Thorndyke. R a t h e r should i t prove the close analogy between t he detec t ion of cr ime and t he de tec t ion of disease. Take every symptom and sign as a clue, the disease, t he cr iminal , yourself t he detect ive , and medic ine becomes a t once a f a sc ina - t ing ~tudy. Never forget t h a t every d e a t h is in rea l i ty a murde r by poisoning. W h e r e you differ f rom the de tec t ive is t t m t you are called in before the f a t a l i t y can occur, and your t a sk is to see t h a t the would-be murdered is removed.

Speaking of clues, I would warn you t h a t the mos t elusive, incons i s t en t and baffling of t h e m all is pain. And here the v i c t i m - - t h e p a t i e n t - - s e e m s to he in league wi th his would-be assass in in a t t e m p t i n g to m a k e thi~ clue as useless as possible to you. Near ly every p a t i e n t lass a pain, a n d most of tkmm have pains. The f i rs t t h i n g to g rasp is t h a t pa in is a re la t ive t h i n g m t h e young Tarzan f rom Tipperary will moan all day long wi th a b i t of an ache which would cause a Cuffe S t r ee t chalwcoman no more inconvenience t h a n her af ter-pains . There I d o g m a t i s i n g - - a t h i n g I abhor. I t is impossible ~o lay down rules where g~ pain is concerned.

Undoub ted ly the bes t way to inves t iga t e pain is to t ake i t under the same headings as you would a hear t~a lurmur , and find o u t :

l t s c h a r a c t e r . I t s t i m e ( in r e l a t i o n to mea ls , i ! d i ge s t i v e ) . I t s d u r a t i o n . I t s a r e a of m a x i m u m i n t e n s i t y . ~ t t a v e no mercy on the lady who says

~he has a pa in in he r s tomach and who, when asked to ~point ou t exact ly where t he pain is s i tua ted , . ,passes a large hand lazily across he r epigas- t r i c and hypochondr iac regmns, and t h e n wi th ano the r expansive sweep t akes in he r umbil ical and lumbar regions as well. T h a t woman is a menace. Trea t her as such. Close he r fist firmly, leaving only a s tubby index f inger p ro t r ud i ng , and ask he r to p u t the t ip of i t e x a c t l y on t he p l ~ e ~"here t he pain is worst . Sh9 will demur a l i t t le a t f i r s t - - w h a t good is the t ip of one finger te indicate he r vas t area of trouble~t t e r r i t o r y ? But , if you are firm and courteous, your efforts will be rewarded, and t he p e a u de ~ c h a q r i n will ac t accord ing to i t s bes t t rad i t ions .

I t s a r e a e l p r o p a g a t i o n . - - T h i s is where she gets her own back on you i" You have nar rowed h e r area of m ax i m um in tens i ty down to one small spot, and t h e n you ask he r " D~es is go a n y w h e r e ? " Doesn ' t i t , j u s t ! W a t c h ! W i t h a fine careless abandon she will demons t r a t e to you nerve p a t h s for re fe r red pain u n d r e a m t of in your philo.sophy. I t is a safer p lan ~o con t en t yoursel f wi th t he f irst three.

Suppos ing n o w t~hat we find the pa t i en t complains of a sharp pain in t h e e p i g a s t r i u m which has very l i t t l e area of p ropaga t i on , which comes o n about half an hour a f t e r food, las ts an hour , and is rel ieved by ~oda b i c . - -hew easy the diagnosis is to the tyro of the t ex tbook! I can h~ar h im m u r m u r confident ly " gas t r ic u lcer ." The poor young fool! I t ~s f a r more likely a case o,f h a b i t u a l cons t ipa t ion due to i r regu la r ~abi t s . I ha te ~o discourage the r i s ing genera t ion , bu t I feel i t my bounden du ty to warn them of th i s decei t ful jade who goes by the name of Pa in . By all means t ake a full and conscient ious h is tory , b u t d o n ' t jump s con- clusions.

Seeing t h a t we have slipped f rom the broad pa th of genera l i ty in to the nar rower , if more i n t e r e s t i n g pa ths of the par t icu la r , le t us t r ave r se t he se and wander rote the s~aort cul-de-sac known as " Surgical H i s t o r y . " I t will be conceded even by the surgeons t h a t , except for abdominal diagnosis , they can do wi thou t a h is tory . Who wants a h i s to ry for ha l lux val~zns?- Bu t wha t of abdominal diagnosis ? The K n i g h t s of the Gleaming ~calp~l have so of ten found a bag of gal l-s tones ins tead of a duodenal ulcer, a cyst ic ova ry and no t a n append ix , etc.~ t h a t they have a lmost g iven up ~bdominal diagnosis as a bad lob, and now some d o n ' t even a t ~ m . p t i t .

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They m a s t e r t he technique of resections, anastomoses , and, mos t essent ia l of all. h~mostas i s . Know how to open the jackpot and close i t , and the r e s t is easy. A th i rd year ' s s t u d e n t ' s knowledge of gross pathology is all t h a t is required to make a diagnosis once t he offending organ has been removed by laparotomy. Does a pathologis t waste t ime mak ing a dia.gnoss before doing a pos t -mor t em? I d o n ' t w a n t to preach sedit ion, b u t I r epea t emphat ica l ly t h a t surgical h is tory t ak ing seems pure was te of t ime, and wi th the . surgeon , t ime is money !

.Let us naw pick our way very carefully down the dubious p a t ~ which lea.ds to Venerea l His tory . I t is .strewn with obstacles, chief of which is t h e fac t t h a t venereal disease is no t only a disease b u t a crime, a source of shame and disgrace in itself. Natura l ly . therefore, the p a t i e n t is loa th t o plead gui l ty . He forgets a l toge ther t h a t i t is t he diseade and n o t the crime in which you are in teres ted, aml does not seem to rea l i se h o ~ i m p o r t a n t i t is in the realm of pathology. I t mus t he obvious to you t h a t t he res iden t who wishes to get a dependable venereal h is tory f rom a p a t i e n t mus t be armed with t h a t r a res t o[ all h u m a n endowments , Tact , spelled in Yhis irrstance wi th a capital T. How should one proceed? Always suspect it. Often, no doubt , your suspicions will be unfounded, bu t t h a t is the proper d i rec t ion in which to make a mis take . I n th is , us in all th ings , appearances are deceptive.

Suppose, first, t h a t your p a t i e n t is a young unmar r i ed woman. This is the mos t difficult ease Gf all. There is no harm, however, in ~sk~ng he r had she eve.r a heavy, yellow discharge, accompanied by cons t i tu t iona l s~mpboms. Owing to the fa2t t h a t a discharge occurs in such a large n u m b e r of eminen t ly s ta id condit ions, you can easily sat isfy yourself r egard ing gonorrhcca. In ~syphilis, neve r enquire about the pr imary sta~e, foi" a~l the obvions reasons, and also because not impossibly the chancre may have escaped the p a t i e n t ' s notice. The secondary s tage is much more respeotable, and you can ask about sore t h r o a t s and rashes wi thou t t he s l igh tes t ,fear of a rous ing your fa i r p a t i e n t ' s suspicions. In the ease of mar r i ed wGman whose .husband is still alive, t read very warily. I t is vi ta l ly i m p o r t a n t t h a t you ask her no quest ions f rom which she m i g h t g a t h e r t h a t she had acquired venereal disease from him. Many a com- pa ra t ive ly happy home has been wrecked by a b lunder ing doctor. The husband may be a waster , no doubt , and all t~be o ther th in~s which spr in~ to your ind.ignant tongue, bu t in her case, ignorance is undoubtedly bliss.

W i t h the man , you can be much more direct. W i t h same you will have to be explicit to the poin t of crudeness ; a pa t i en t has been known to deny all possibi l i ty of infec t ion even when t he c h a r t wi th his plus 4 hand icap is fionrisbe(l under his nose. (One res iden t whom I knew was invar iably successful in el ici t ing a venereal h ia tery in detail , when everyone else had faSJed. I t was uncallnv, and puzzled me a g rea t deal, unt i l in a moment of seI~-revetation he confessed ~hat he made i t a p rac t ice to plead gui l ty in a casual sor t of way to hav ing suffered on several occasions f rom the dread disease himself . Only o~e pa t i en t dur ing his period of residency presumed on thi~ k inship by a~ldressin~ him by his Chr i s t ian name. I expect, ~ow- eve,', t h a t this ,method wilt ha rd ly commend i tself to you. There are some sacrifices too g rea t to make, even in t he sacred cause of Medicine.) Las t ly , if you do elicit a posit ive h is tory of venereal infection, always find ou~. if t he p a t i e n t has hwd t r e a t m e n t , and if so, t he l eng th of same. I f I seem to ~bave le t my remarks on th i s subiect t ake up too much space, le t ~ e remind you t h a t syphilis is one- third of pathology.

Next on t h e ]i~t eozaes the t ak ing of a ma l inge re r ' s h is tory . The ve t e ran " G . P . " has indexed in his mind t he " malin, ge re r ' s facies " - - m o r e of t h a t invaluable knowledge t h a t never finds i ts way in to t he . t ex tbooks . Mal ingere r s are much more commonly men t h a n w o m e n ~ m e n were deceivers e v e r - - a n d very often are of the " old soldier " class. And r generic name for the i r complaint is " Co~npensationit is ." Pa in is their. g r e a t s tand-by. Well they know its in tangibi l i ty , i~s proaf aga ins t in- ves t iga t ion , t he average doc tor ' s dislike to deny i ts exis tence in a given case! They give a h i s tory of hav ing " s t ra ined themselves in te rna l ly " ; no th ing is to be seen or fe l t ; jus t pain, and no th ing more. W h a t a re yon to do when faced wi th a his tory of pa in? F i r s t become suspicious, and t hen ~ive th i s gen t leman any amount of rope. Be sympathe t ic , don t h a t " u n d e r s t a n d i n g " look. and let h im t h i n k he has you completely fooled. Ask is he qui te sure t h a t i t never com~s in any o the r s i t u a t i o n ; prob~bly a t f irst he will say " N o . " Appear to be p u z z l e d - - m u r m u r to yourself : " T h a t ' s curious ; t h a t pain usual ly t rave ls up to the lef t s ide of t h e neck beh ind . " Nine t imes out of t e n he w o n ' t l e t you do~n . 't Now

278 IRISH JOURNAL OF MEDICAL SCIENCE

tha t ~vou mention it , doctor, I did feel i t there once or twice ." You reply wearny : " Ah, once or twice doesn ' t mean any th ing . " Then i t will come to ~be once or twice a week, and finally three t imes daily af ter meals if you want it. He has hanged himself. That plan will work in nearly every case. Choose some path of referred pain t h a t would make a second medical smile even dur ing h i s exam., and if you appear sincere enough, y o u r mal ingerer will plead guil ty. Tell him then to be careful t h a t he is not being led into agreeing with you, because you should not have asked him a leading question. A neuras thenic pa t i en t will probably waver, but t he mal ingerer becomes adamant ine . Noth ing would al ter his decision now ; he is convinced you need i t to make a diagnosis, and far be i t f rom h im to pu t any obstacle in such a del ightful pa th down which he can s o , rol l ing a nice l i t t le nest-egg!

J u s t as i t i~ a joy to t rap a malingerer , so Jt is a humiliat ion to be fooled by one. You have, let us suppose, made out a history which is jus t shrieking " T.B. spine," your innate modesty alone having prevented you from commit t ing the diagnosis to paper. Imagine your feelings as you stand by and watch this l i t t le t ragedy in one act. Your chief comes along to the bed, reads the h~tory," asks a few questions,,, looks grave, and says: " We must have an z-ray of Vhis case a t once. Then, to t he pa t i en t : " Get up, my man, and pu t on your t rousers . " The flustered pa t ient dons his unmentionables rapidly, and then the staff man says: " No, on second thoughts , i t would be be t t e r without the trousers. Take them o f f . " The pat ient obeys, and, at a whisper from your chief, you Watch the unsuspecting pat ient bend his back nearly double without t race of pain, al*ghough when you had examined him the s l ightest bend in any direction was only accomplished with f requent and pious aspirations to the Holy Family !

Before concluding these remarks on his tory- taking, le t me take th ia oppor tuni ty to make a plea for a Br ighter His tory Movement . There is no necessity for a ~ted,gy narra t ive af stodgy fac ts ; clothe your facts in l ight , in teres t ing raiment , so tha t as they parade before your chief they catch his eye like a beauty chorus~ and don ' t forget Vhat l i t t le spice of humour which means so nmeh to the t i red medical man. Le t us take a p ros ta t ic history, and see what can be done with i t :

" Dates from July , 1927, during which month pa t ient noticed tha t the act of passing water~ the successful and effortless accomplis'hment of which he had up to t h a t t ime taken for granted, began to present some difficulty. He noticed i t mostly in public urinals, where his complaint proved embarrassing, part icularly during the rush hours, as any a t t emp t on his pa r t to force the s tream had the paradoxical effect of stopping it. By Xmas , his difficulty had become so marked Vhat every t ime he passed wate r in a public urinal i t cost him a penny. As well as this, his n ight ' s re~t began to be disturbed. He would awaken several t imes durin.g the dark hours with a s t ron~ desire to mieturate, which desire proved to be in inverse proport ion to ~he amount passed. All these symptoms became aggravated, unt i l wi th the advent of Svring his frequency was almost canine. On Tuesday, his wife lef t on a visi t to her sister in t he country. That night , he said he drank a lot of lemonade (?~, and the next day his bladder went on s t r ike a l together . He arr ived in hospital about 24 hours gone, and micturi t ion was induced by ca the te r . "

Notwi ths tand ing my ear l ie r s t r ic tures on surgical his tory- taking, I have chosen a surgical his tory for the B r i ~ t e r History Movement . Owing to thei r close connection with pure medicine, kidney and bladder affec- tions are the excevtion which approve the rule. I t should be obvious, anyhaw, tha t case~histories such a-s I ,have quoted here would ~o a long way towards improving ~'he not infrequently strained relations which exist between our s~aff men and the i r willing, if ineffectual residents.