THE PRACTICAL iSPECTS OF MEDICAL SCIENCE. By JOHN DOLE, M.D OF AMHERST. / «0 Read at the Annual Meeting of the Mass. Med. Society, June 7, 1871. THE PRACTICAL 1SPECTS OF MEDICAL SCIENCE. By JOHN DOLE, M.D^ OP AMHERST. /rfOl Read at the Annual Meeting op the Mass. Med. Society, June 7, 1871. THE PRACTICAL ASPECTS OE MEDICAL SCIENCE. Since the days of Sydenham, practitioners of medicine have been divided into two classes—scientific, and the so- called "practical” men. The distinction is an altogether arbitrary one, but, through constant reiteration, has come to be looked upon as valid. Members of the profession, sometimes wittingly but oftener through carelessness, have adopted the distinction, as they have winked at the term " allopathy,” endorsing the false note and giving it currency, greatly to our own detriment. The injury might have ended with us, in such looseness of thought as the vague use of terms always begets, had it not opened the way for mis- apprehension on the part of the laity concerning the abilities and duties of doctors. This misunderstanding is much more wide spread and pernicious than would appear at first glance—amounting to almost terror of science on the part of the ignorant, and in the minds of the more intelligent to a belief in a supposed inherent distinction between scientific men and " family physicians.” The public mind, always inapt in respect of nice discriminations, cannot dissociate science from mere theory, hence have arisen the whole catalogue of slurs, inexpressibly foolish when applied to rigid students of the phenomena of disease : "impractical,” "wanting in com- mon sense,” "book-worms,” "vagarists,” et id genus omne. To a close observer and thinker, however, the broadest dis- tinction exists between science and vague theory, and what 4 THE PRACTICAL ASPECTS I have to say to-day is in illustration of the proposition that Science is not opposed to Practical Results in Medicine, but on the other hand its Researches constitute the basis of all True and Permanent Advance in the art of Healing. It may be that, from a candid consideration of this subject, we shall come to better understand our daily obligations to science, and that some corollary for practical every-day use may suggest itself. The " Art of Healing ” considered abstractly and in exact definement, presents itself as a problem composed of two elements : the "Natural History of Disease,” and the exact physiological action of means of relief or cure—such means including not only articles for topical or internal exhibition, but all constituents of the Materia Medica—Subjecta,Ingesta, Circumfusa and Medicamenta. The first element, that of " Natural History,” is the re- sultant of many factors : cause, duration, seat, temperature and pathology, itself a factor capable of subdivision, while our relation to this clement expression in diagnosis and prognosis. The value of this relation to ourselves and to our patients depends primarily upon our appreciation of all these factors, the methods of their determination, their exactness, positive and negative characteristics, limitations, &c., rather than in any ignorance or unqualified assumption of them as parts of a proved proposition. As a rule this appreciation evinces itself in our justness of bearing towards experiments and researches looking to the elucidation of these points—discoveries in anatomy, normal or morbid, re- searches in chemistry and physiology—improvements in general surgery or elaborations of its special departments— the eye, ear, uterus, larynx, venereal disease, dermatology, &c.—in short, towards Science in any of its workings and manifestations. OF MEDICAL SCIENCE. 5 Beginning, then, with the subdivisions of our first element we find that the causation of diseases, especially those of the zymotic type—always the object of guesses more or less happy—has of late been subjected to rigid investigation. Typhus fever yields to patient observers some secrets of its predisposing and exciting causes, and to drinking-water impregnated with organic impurities may be ascribed the especial severity of some outbreaks of cholera. That at St. James Westminister, London, in 1854, owed no small part of its fatality to the water of a well in Broad Street, " famous,” says Dr. Anstie, " for its sweetness and freshness.” Repeated analyses of the water by Dr. Snow, demonstrated the presence of these impurities, and discontinuance in the use of it was attended with immediate abatement of the disease. So also the development of cholera among the inmates of the houses supplied by the " Lambeth,” or "Southwark and Vauxhall Water Companies” respectively —the mortality (even in the same street, and in houses di- rectly opposite one another) being in exact ratio to the amount of organic impurities in the water used. Again, the exciting cause of typhoid fever has been even more carefully and laboriously determined. The war now raging between Murchison and Dr. Budd, is a war of words merely to determine which link in the great chain of cause and effect shall be considered "immediate causation.” The tide of battle surging between the maintainers of the " pytho- genic” theory and its opponents, leaves at each ebbing a deposit of scientific truth—the outcome of rigid studies, exact calculations, innumerable chemical analyses of water and the vapor of sewage—all of which serves to lift Etiology above the plain of happy guessing to that of a science—a science not all-embracing nor as yet very broad, but close and compact, to which much may be added but from 6 THE PEACTICAL ASPECTS which nothing shall be taken away in the coming years. And this science finds expression in such sanitary and pre- ventive measures—cleanliness, deodorization, pure water and drainage, as make disease less fearful and more manage- able, epidemics less prolonged and fatal. Surely this is practical. Knowledge of the seat of disease — the exact organ or tissue affected, and the liability to complications more or less serious — increases pari passu with advances in medical sci- ence. Observations of the external phenomena of disease, if unsupported by rigid tabulation and comparison in the milder cases, or in the severer by post-mortem verification, would leave us still in the open field of conjecture. It has fallen to the experience of the youngest of us to learn that symptoms the most prominent and obtrusive often prove unimportant, or of but secondary significance; brain symp- toms in carditis, diarrhoea in pneumonia, hydrocephaloid in the acute enteritis of children, spasm of the glottis at the onset of rickets, albumenuric retinitis, irregular action of the heart, or dyspnoea in organic disease of the kidneys. So, too, the "signs,” that for want of clear comprehension on our part have been styled diseases, resolve themselves latterly, under nicer study, into mere evidences of a broader underlying cause. Vague terms are fading from our noso- logical tables; special plans of treatment with reference to stomach or spirits are abandoned; liver diseases in adults, and worms in children, are playing subordinate roles, and "slow,” "infantile remittent,” "low,” "gastric,” "bilious,” and " continued ” fevers are disappearing, swallowed up in that broader condition known as typhoid, whose seat and pathological concomitants are known with even microscopic exactness. Such recognition of these symptoms and com- plications as simplifies our nosology, and so relieves mental OF MEDICAL SCIENCE. 7 confusion, tends to render clear and easy diagnoses other- wise impossible, and puts treatment, if treatment other than hygienic be deemed necessary, upon a more rational basis. This, too, has a "practical” aspect, as has also the introduc- tion of the element of temperature into our calculations. The thermometer, though at first unduly praised and criti- cized, like other adjuvants in investigation has gradually asserted and maintained its claims to notice—claims based upon nothing so little as guesswork, or even upon statistics imperfectly interpreted, but upon critical observations now almost innumerable—those of Wunderlich at the Liepsic Clinic alone amounting, in the year 1865, to more than 600,000. Over and over again these observations and the deductions therefrom have been verified by Virchow, Grie- singer and Traube, in Germany; by Becquerel, Bernard and Breschet, in France ; by Parkes and Jenner, Bennett and Anstie, at Edinburgh ; at Guy’s, St. Thomas’s, at West- minster, and later by the leading observers of our own great Hospitals. While these observations throw but little light upon the question of the absolute cure of disease, they offer, as practical outcome, proof that preternatural heat is a constant and essentially dangerous concomitant of fever, and that rigor is a wholly subjective phenomenon, dependent on the condition of the peripheric nerves and not accom- panied by any decline in temperature. They have taught us the typical laws of particular forms of fever, " supply a basis by which to determine whether any individual case is progressing as it ought; ” enable us to anticipate the onset of fever in puerperal women; to prognosticate with certainty paroxysms of ague; afford a means of absolute differential diagnosis between typhus and meningitis in cases otherwise obscure ; point inexorably to the thorax in acute tuberculosis in the absence of cough, expectoration, or even hurried res- 8 TIIE PRACTICAL ASPECTS piration, and in the exanthemata enable 11s to forestall, by palliative means at least, the days of greatest discomfort. Of Pathology, the last, and possibly the most important subdivision of our first element, we may speak but briefly. The light thrown upon the " Natural History of Disease ” by researches in this department of study, enables us to posit a line of demarkation between the curable and essen- tially incurable — a line varying somewhat in its individual increments from year to year, but which always holds a place consistent with all known data — and even anticipates, by position and tendency, new developments in therapeutics. It proves that inflammation is but modified nutrition, of which pain, heat, redness and swelling are the accidents and not the essence ; furnishes us, to dwell only upon the more obvious matters, with exact data concerning healing of wounds by " first intention ” and by granulation—the granu- lations of ulcers — the anatomical peculiarities of the walls of abscesses ; tells us what tubercle is, what it indicates and how it tends to fatality wherever found ; tells us the how and why of the duration of certain diseases, and indirectly teaches us what Nature can and will probably do—at the same time suggesting, by implication at least, the proper moment for interference or the judiciousness of withholding our hands. Viewed from the surgical side it affords still more important revelations concerning the healing of frac- tures, the function of the periosteum, diseases of joints and foreign bodies therein—anchylosis, curvatures of the spine, caries and necrosis and the nature of tumors. IIow imme- diately practical such revelations may be in their bearing on wise procedure, no one of us can have failed to observe. In truth in tumors, what concerns us chiefly, perhaps wholly, is their tendency rather than their topical or plastic manifes- tations (excepting always those outgrowths, which, though by OF MEDICAL SCIENCE. 9 nature innocuous, tend to fatality through rapid recurrence). Vascularity to aneurismal thrill, or non-vascularity and density to the appearance of cartilage, rapidity or slowness of growth, excess or deficiency of fibrous, cellular, gland- ular, serous or epithetial tissue, are but the inconstant local peculiai'ities of any outgrowth under whatever form occurring. The one significant fact concerning it, cceteris paribus, is the presence or absence of some cell which fails of correspondence with the ultimate element of any tissue recognized as typical. This cell, never so much as imagined after centuries of study and observation in the gross, stamps, in the present state of therapeutics, the seal of fatality upon all such outgrowths as contain it in great numbers, and proves to be the constant outcome or cause of a malignancy of which all other conditions are the insignificant concomitants. This is the one practical matter for us to know concerning tumors, for on such knowledge must be based, if it would be wise, our treatment and prognosis. So much for our first element of "Natural History.” The stock criticism urged against us as a class has of late assumed the form of a complaint that though we are coming to know more of what disease is, we fail to advance propor- tionally in our knowledge of the means of cure. The criticism is specious, but neither altogether true nor sound, since the very knowledge ascribed teaches us, as we have seen, the essentially incurable nature of some diseases — restrains us — tells us that many formerly supposed cures could have been but coincidences, and suggests caution in the exhibition of our remedies. The new light thrown by science upon one element of our problem of cure, even when faint, sometimes serves only to bewilder us, as morn- ing or evening twilight blinds and bewilders men long im- mured in dark dungeons. As an effect of this knowledge, 10 THE PRACTICAL ASPECTS resulting in an enlightened skepticism, Chomel’s rule of "doing nothing when uncertain what to do,” is usurping in wiser quarters the old English and American practice of when doubtful giving a dose of calomel—a result of incalcu- lable advantage to our patients. But this negative virtue has its complement in positive acquisition. We know, as the result of chemical and physiological investigation, more than formerly of the action of certain drugs—their time of ab- sorption and elimination — duration of action and reaction ; that gallic acid does its work and is eliminated in two hours, acetate of lead in not less than six or eight hours ; that the seemingly safest dose of turpentine, too large for stimulation of the primal vise, too small for catharsis, in spite of its conservative name of "medium,” is the really dangerous dose. Specialists have taught us much to be followed and to be avoided in the employment of certain remedies — Hydropathists of water, Oculists of belladonna, Venerealists of mercury and iodide of potassium, Dermatologists of arse- nic and the external application of alkalies. Brown-Sequard teaches some, and suggests more, uses of the bromides, by first showing their physiological action on the blood-vessels of the nervous system. The science of chemistry in one of its exactest attitudes gives us the antidotes of poisons. Out of a German laboratory came the inspiring whisper of the possible therapeutic value of chloral hydrate. Parkes and Wallowicz, Schulinus of Dorpat, Anstie and Dupre, are revolutionizing our belief in alcohol; RadclifFe, working from a different stand-point, confirming the latter observers as to neuralgia and its appropriate treatment by gentle stim- ulation, and within a few years Briquet has solved for us scientifically and almost exhaustively, the action of Peruvian bark and its alkaloids. Practically, our brothers came back to us alive and in health from Southern swamps, where every OF MEDICAL SCIENCE. 11 exhalation was pregnant with disease ; and only months ago, around Metz, following, as he himself testifies, the hints afforded hy laboratory experiment on the antipyretic action of quinine, Prof. Binz brought back to life German sol- diers dying of septicaemia, as if by some miracle of healing. Indeed, there is now, not opposed to but supportive of the practice of therapy strictly empirical, a science of therapeu- tics on whose teachings, consciously or unconsciously, each one of us relies with a degree of assurance in his attempted control of haemorrhage, in his choice of a remedy for the inducement of sleep, for mastery of the miasmata, and in the treatment of all diseases characterized by periodical exacerbations—a science not more responsible for the pre- tensions of quack panaceas than is this Society for Town- send’s Sarsaparilla or the Russia Salve. Let us pause here for a moment to see how and where we stand. Practicality or Empiricism claims for itself the dis- tinction of resting on a basis of facts. Well, Science, through its disciples — philosophers, general practitioners, or specialists — working patiently and with catholic tendency, discovers facts on every hand. More than this, it collocates, groups, and arranges them, and furnishes us with principles to which those now known and all subsequently discovered facts can be referred. Therapy looks to method, rather than to isolated observations, in the study of drugs for its great- est advances, and the profession owes much of its knowledge of the "natural history” of disease to accurate and system- atized investigation, which is Science. The especial advantages, negative and positive, of such knowledge, mani- festing themselves in non-interference no less than judicious treatment, suggest as a practical deduction the primal and essential importance of diagnosis. Improvements in treat- ment, better statistics, smaller percentages of death other 12 THE PRACTICAL ASPECTS things being equal, marked sanative results, follow thorough comprehension of disease in such direct causative rela- tion as to defy the suggestion of accident or mere coincidence. Indeed, approximation to nearness of understanding of the disease in question, and only this, renders possible the sure aiding of nature by enforced sanitary measures, or otherwise. Complement such knowledge by clearness of view of some therapeutic means, and our cure-problem, if in the nature of things resolvable, becomes comparatively simple. The most critical examination may leave us to conjecture after all, but to a reasonable conjecture, and not to the flippant, arrogant guess-work that fails oftener than it succeeds. " The con- jecture which guides the physician,” says Dr. Latham, "is rigorous and calculating and honest. It acts strictly by rule, and leaves nothing to chance. It does not see the thing it is in quest of, for then it would no longer be con- jecture. But because it does not see it, it ponders all its accidents and appurtenances, and noting well whither they point, it takes aim in the same direction, and so oftener hits the mark than misses it. And succeeding thus, it knows why it succeeds, and it can succeed again and again upon the same conditions. Next to knowing the truth itself, is to know the direction in which it lies.” This is the peculiar praise of a sound conjecture, and any assistance, instru- mental or other, tending to render such conjecture possible, should not be neglected. All adjuvants in medical diag- nosis, as in other departments of science, incur the double risk of undue laudation and distrust. The solar and chemi- cal microscopes not long ago, and lately the thermometer, suffered apotheosis—were so bepraised as to excite all con- servative minds to ridicule, till Dr. Holmes’s " Stethoscopic Fly,” exceptionally an entity, was claimed under imaginatien as existing every where—the reactionary wave of skepticism OF MEDICAL SCIENCE. 13 in its turn rolling beyond the point of rest. But the oscil- lations ceasing, no wise man ignores, in critical examinations, microscope or stethoscope, ophthalmoscope or thermometer. " They are but artificial and refined means of scrutiny. They cannot enlarge human capacity nor strengthen human understandingbut beyond the reach of human eye or dis- crimination of human ear or accuracy of human touch, they find their proper work, bringing within cognizance objects and elements otherwise unknowable. No most delicate musical ear, unaided, can always distinguish the fine crepi- tus of incipient phthisis from the rale of capillary bronchitis, yet a world-wide difference lies in the treatment and proba- ble prognosis. The hot, dry, pungent skin, at the onset of scarlet fever, coexists with a temperature of 102® Falir., while the softer, moister, and less burning feel of the climax, is coincident with 105° or 106° Fahr. "It is not,” said Lord Bacon, "the insufficiency or incapacity of man’s mind, but the remote placing thereof that breedeth mazes and incomprehensions; for as the sense afar off is full of mis- taking, but is exact at hand, so is it of the understanding— the remedy whereof is not to quicken or strengthen the organ, but to go nearer unto the object.” This our instru- ments enable us to do, and so serving should be employed, judiciously, as subsidiaries, not substitutes, when unaided sense fails. All power, every instrument, all knowledge of each and every branch of medicine, all faculty of clear or logical reasoning, should be bi’ought to bear upon our diag- nosis. No supposition should satisfy when exact knowledge is attainable. No appeal to a limited personal experience is justifiable when the records and deductions of combined experiences are accessible. No amount of time or patience can be considered superfluous until the problem is solved or is proved too intricate for solution, and, whatever treatment 14 TIIE PRACTICAL ASPECTS may be under the light afforded us through such critical inquiry, and it is often confessedly faulty, without it it is altogether pretentious, impertinent, shallow. But hypercritical attention to unimportant details is some- times mistaken, by performers and bystanders alike, for scientific thoroughness. Elaborateness is not of necessity accuracy, though it is often the wearisome concomitant of accuracy, and the nicest discrimination of symptoms is per- fectly consistent with rapid generalization. A moment’s touch of the radial artery determines for the trained brain its quickness, force, rapidity and volume, though no wise look be assumed or watch consulted. The record books of great hospitals often furnish an example in point of how much can be written, how many observations—each elabo- rate and accurate in itself—can be recorded without fur- nishing one with any adequate conception of the appearance of patient or a hint concerning diagnosis, prognosis, or treatment. It is wearisome to remember how the memories of students are overloaded with details—daily records of chest measurements in cases of pleurisy, where the question of effusion had been determined beyond the shadow of doubt; records of pulse in diseases whose natural history shows every variety of cardiac action ; records of dejections always normal; records of urine tests where no kidney involvement was to be feared; records of sleep in hours and minutes, where sleep, or the absence of it, within wide limits, was utterly irrelevant to the treatment or issue ; examinations of blood-corpuscles in short-lived functional derangements with- out suspicion of previous organic or zymotic disease — and so on, if not ad infinitum at least ad nauseam, the salient cardinal points of the cases either forgotten or brought down to the dead level of ordinary symptoms. This is the disease of Science—the cant of its sham disciples who substitute OF MEDICAL SCIENCE. 15 shadow for substance, who seek to comfort pneumonic pa- tients dying for want of proper food and stimulus, by the assurance that their urine has been frequently and critically tested for the chlorides ! The most patient and rigid study for diagnosis, if it be wisely honest, is conscious of conditions beyond its ken—of knots of symptoms where the most pertinent revelations seem tied up the tightest — of points that defy scrutiny. More- over, it is conscious of exigencies that demand immediate action on the basis of their broader features ; haemorrhages that must be checked at any hazaial; attacks of pneumonia presenting such complete and overwhelming congestion as to demand the lancet in full view of the long convalescence or even possible death from asthenia; spasmodic colics, where in wisdom no cause may be sought, but where pain demands instant relief — in short, cases where all attempts at study are as foolish as they are ill-timed. Treatment in such emergencies, far from being rationalized, is only crippled by inquiries into the scientific aspects of the case. "The real physician,” said Broussais, "is the one who cures. The observation which does not teach the art of healing is not that of a physician, it is that of a naturalist.” Still, such cases, necessarily occasional, should not render us illogical. They cannot invalidate the rule that we owe to each problem the deference of attempted resolution, any more than the birth of sporadic genius of insignificant parents invalidates the rule that like begets like. Nor do they detract an iota from the significance of Cullen’s dictum "that neither the acutest genius nor the soundest judgment will avail in judg- ing of particulars in which they have never before been exercised.” I would not be understood by these remarks in any way to decry or undervalue experience. More than two centuries 16 THE PRACTICAL ASPECTS ago the wisest and most philosophical of then living men concentrated in a single clause all that could be said upon that point—"they be the best chirurgeons which being learned incline to the traditions of experience; or being empirics, incline to the methods of learning.” Out of such union springs the highest curative skill, as naturally as out of the elements of earth and air, by selective capacity in root or tendril, and by a method which God knows, some consum- mate flower is elaborated. But all unrecorded experience, even when evidenced in daily practice, is necessarily exclu- sive—confined in its benefits to those in immediate contact with its possessor. Moreover it is by nature arbitrary, quite as often possessing men as they it. It has great value for us in the vast fields of learning and labor, yet intrinsically and alone is worthless. It is often crude, blind—leading men to false no less than sound conclusions ; deals in the post hoc rather than the propter hoc; supplies reason'with materials for work, yet is powerless to work; is accretive, prehensive—gathering anatomical, chemical, therapeutical, physiological data, as results of its labor. But just here the specific work of experience, as such, ends. Science objectively, or the methodizing faculty which is the subjec- tive analogue of science, seizes upon these materials : inquires the how and why ; rigidly examines each body of seemingly analogous or similar data; draws its lines of impenetrable distinction between truly logical deductions and specious though unsound inferences; systematizes, compresses, and makes portable what before was clumsy and useless through clumsiness ; tabulates, formulates, coordinates ; broods over this chaos of elements until a kosmos is evolved Avhose beauty and symmetry excite admiration, and whose use no sane man may deny. And these results, so elucidated and arranged; so interpenetrated by a method which allows the broadest OF MEDICAL SCIENCE. 17 freedom of observation, while it binds us to rigor, and nicety and exactness of inference, enter in as an element of the later, and so wiser, experiential philosophy of all subse- quent students of medicine, if they be students indeed. Who can doubt the practical worth of all this ? Yet this Science of which I have been speaking, in no wise encroaches upon individual thought or philosophy. It gladly bends its ear to the persuasions of genius — to all prophecies and intuitions that carry with them the stamp of reason. It knows well that McLeod suggested long; ago in India its own present pet treatment of typhoid fever and dysentery, and reverentially remembers that Gibson antici- pated, by more than thirty years, the surgical propositions established by the American and later European wars. It simply holds to the proposition that " the laws of nature are to be discovered by accurate observation and generalization of a sufficient number of phenomena, and not by any ab- stract philosophical mode of reasoning.” Holding firmly to this ground, and recognizing fully the truth that the grace of prophecy comes to but few Sydenhams or Abercrombies, McLeods or Gibsons, it simply attempts to give to all data so proved and arranged as to furnish a basis for reasoning approximatively correct—leaving to the acumen and ability of each one of us the solution of the problems of individual cases ; in its broadest and truest expression accomplishing what Hufeland declares its highest possible attainment—to generalize the disease and to individualize the patient. If there be any truth in what has been said, the deduction is an obvious one. There can be no valid distinction be- tween the Science and Art of Medicine, since it is the sub- stratum and informing method of science that renders our daily practice other than a confused jumble of guesses, even artistic. Ail attempts at invidious comparisons between our 18 THE PRACTICAL ASPECTS art and medical science are mischievous and to be reprobated. They have crept into our literature, and essays upon the " Art of Medicine,"’ as something inherently distinct from the visible practical results of scientific training, have come upon us of late like the locusts upon Egypt, and with analogous result — working mischief in our thoughts, and paralyzing our great schools in their attempted reforms. The fact stares us in the face that our students seek other means of instruc- tion than those furnished at home, while we who are in the whirl of active practice look to the incoming steamer for food for medical reflection. We but beg the question in stating or reiterating our belief that "it is the fashion,” so long as the best and most promising and eager, those who have used faithfully every offered opportunity, feel most acutely their need of something more—so long as the very teachers of whom we are most justly proud, almost without exception, received their final instruction as students in Lon- don, Paris, Edinboro’ or Dublin, or in later years at Berlin, Leipsic, Gottingen or Vienna. The record of the American students in Europe is one to be proud of, and the fashionable traveller in search of some easy road to medical fame, or the dilletante, has played but an unimportant role among them. They have shown equal capacity with their foreign brothers when equal opportunities for observation and study have been offered them. Our schools are realizing this, and trying to remedy their defects —encountering their great- est opposition in the careless attitude of medical men as mani- fested either in passive indifference to change, or in an active warfare on the ground of an imagined want of practicality in these movements; as though aught could be more prac- tical than the training, and exercise in its self-appointed work, of the human mind, the centre whence radiate all practicalities. Surely it is useful to be able to distinguish OF MEDICAL SCIENCE. 19 a peri-uterine tumor from a foetal head—the dyspnoea of car- diac complication in Bright's disease from asthma. There are no diseases, save those of a strictly theological type, cured by wise or pompous looks, or even by the mere "lay- ing; on of hands,” scrofulosis Ions? ago having ceased to be amenable to the affluence of the royal touch. These re- formatory measures, to be successful, need the cooperation of all medical men, and a full and hearty recognition of the fact that marked improvement in clinical instruction, or in therapeutical teaching, implies a more rigid ground-work of scientific training. Certainly the need is an imminent one so long as things knowable are as yet unknown, so long as the imagination must be invoked in explanation of causes purely physical, or the terms "spinal disease,” "consump- tion,” "bilious,” "nervous,” and "alterative,” cover for us such a multitude of the sins of ignorance. " The human eye,” says Carlyle, "sees in all objects that which it brings with it the power of seeing,” and student eyes, trained in the results which science has arranged out of the invaluable but crude materials of united experiences, as expressed in best books, and in acute observations of the phenomena of bedside mys- teries, growing achromatic at their work, see in new reme- dies, in all adjuvants of diagnosis, prognosis or treatment, not objects for ridicule on the one hand or mad overpraise on the other, but clearly defined desiderata, each with a value of its own, the measure of which only time can deter- mine. It must be admitted that Science, studied either in a single salient aspect or in its entirety, can in no wise change the inherent power of its students, but it trains and moulds existing faculties. It cannot, as has already been said, "enlarge human capacity nor quicken human under- standing,” but it tends to elevate executive power to its maximum, and to reduce mistakes of belief and of action to the minimum. 20 PRACTICAL ASPECTS OF MEDICAL SCIENCE " With brains, sir,” said a famous painter, when asked with what he mixed his colors ; and " with brains,” I doubt not, Avould be the answer of any great physician or surgeon if asked with what he mixed his prescriptions. The science of optics may teaeli the painter the distinction between pri- mary and secondary colors—the exact proportions that give in combination violet or brown or orange, but genius oidy can elaborate from these scientific details landscape or por- trait. Chemistry will teach the student the laws of com- patibles ; Physiology, the broader laws of life ; Anatomy, normal and morbid, the parts affected and how ; still the ultimate appeal for adaptation of means to the ends of relief or cure must fall upon the brain of the prescriber—upon his personal sagacity. But the failure of any artist who should attempt landscape or portrait without some exact knowledge of the science of linear perspective and color, is as certain as to-morrow’s sunrise. May not a like failure be predicted of any so-called Doctor of Medicine attempting cures without first studying and understanding, in so far as they are known, the laws of disease or the laws that underlie and control the substances and elements composing the broadest Materia Medica ?