of his calling, if he does not follow with the same interest a case that is unable to pay for his services as his most remunerative private patient, he can never expect to reap the full benefit or pleasure which the practice of his profession affords. He must recognize that his duties to his patients. take precedence over any and all others. Social pleasures and social engagements must always be made with the understanding that they are subject to the demands of his professional duties. If then the embryo physician enters upon his calling in this spirit, the question of a medical education becomes one not difficult of solution. It goes without saying that a general education of the best character is none too good for such a responsible profession. That a man may be more or less successful without it by no means argues against its desirability and necessity; for those who have, without the benefits of a good, broad, general education, attained eminence in medicine, must continually reflect that they could have done much more and done it with greater intelligence and less effort, if they had received the proper foundation. The purely medical part will be determined by the locality, cost, time and numerous other accidental considerations. The student may with benefit reflect, that if he applies himself diligently he can complete a good medical course in three years, and then with profit spend two more in hospital work. If his means be abundant, he can spend one or two additional years in college work, and instead of "walking" on hospital, serve as interne in a general hospital and in an institution devoted to special work. Of course, it is not possible for every graduate to get desirable hospital work; but it is eminently proper to make the effort, and not to give up until something has been attained in that line. It is only after a man has been in practice some years that he realizes at what a disadvantage a man works who has had no hospital experience. At the end of this time it may be said that a man has been prepared for work in medicine; and this does not mean that there is nothing left for him to learn, but that he has just reached the point where he can make the most of the opportunities daily offered to add to his store of information. He will compare the methods of work followed by different men and do so intelligently; and he will be better able to elect what is good and serviceable. It is one of the rarest and at the same time one of the most valuable accomplishments to be able from the great mass of good, bad and indifferent propositions weekly offered the profession, to select that which has real merit and which contains the germs of useful and prac tical worth.

We welcome to the study of medicine those who enter upon it with the proper understanding of its principles and responsibilities, and who feel that no other work will enable them to fulfil their mission in life.

In the consideration of this subject, the question naturally arises as to whether or not there is a progress in therapeutics which, when compared with the advance in other departments of our art and science, can properly be considered commensurate. The answer to such an inquiry can be most briefly and positively stated, and, with regret, is formulated in the negative, by a perusal of the latest standard works of reference. With few exceptions those diseases with which we are most frequently confronted, and which comprise the more common or prevalent, compel the realization of the fact that therapeutics cannot lay claim to much. when viewed from the standpoint of the physiologist, pathologist and surgeon. Let us consider such a frequently encountered affection as acute croupous or lobar pneumonia. decades ago, and the pages of volumes of reference, as well as the fiat from the professoral desk, teem with interrogations that should long. ago have been definitely and positively settled had the same careful and analytic study been instituted that characterizes research in other channels. Etiologically the almost exclusively mechanical interpretation of the circulatory function of the affected pulmonary lobe, if this is the only area diseased, which is submitted as an explanation for that peculiar exudate which it may here be remarked could not be caused by any interference, purely mechanical, with the venous or arterial side in loco-still obtains, and the advocates and adversaries of phlebotomy and the champions of aconite, tartar-emetic and veratrum viride all have disciples, who find the subject completely unsolved by the tests of practice as it was a

Its treatment to-day is still argued as it was

* Read before the Philadelphia County Medical Society, June 23, 1897.

century ago. The average mortality of twenty-eight per cent., now as then, substantiates the fact that in this disease therapeutics has not progressed.

Why, in the light of the facts, are these incomplete teachings still perpetuated? The great frequency of this disease and the opportunities. offered for lines of thought and investigation in channe's dissociated from the traditional beliefs, when still surrounded by this circulatory infatuation, in spite of its almost incessantly demonstrated uselessness, should, at least, direct attention to the study of its treatment upon an entirely different basis. If there is one fact established about pneumonia, it certainly is that it is not, per se, an inflammation of the lung. It is unquestionably an expression of a trophic derangement, followed, it is true, secondarily, by inflammatory phenomena, and why therefore the early treatment should still center about the antiphologistic notion is a question that can fittingly be propounded.

Syphilis will also serve as an illustration; its natural history, so to speak affords a clinical picture so distinct that, even though its materies morbi is still in doubt, the ultimate outcome is comparatively easily prognosticated, and yet its therapeusis is still debated around the mercurial and nonmercurial methods and such sub-divisions thereof as the interrupted and continuous, mixed, and several other useless combinations and modifications, which, when carefully followed as to their results, discloses negatives that should long ago have relegated them to the oblivion they so well deserve. There is scarcely any affection which, if skilfully treated according to the rules that should be determined by the conditions obtaining in the individual sufferer, offers such promise of relief as this disease, and when the notions that are formulated in the terms already indicated will have been abandoned and a proper advance made in its therapeusis, the psoriasis lingualis syphilitica and other commonly seen lesions of the mucous membrance will cease to be so frequent in cases that have been discharged as cured but improperly treated as the result of these modified plans.

Pertussis, notwithstanding our ignorance of Afanassiew's bacillus, has recommended for its treatment, in the latest works issued by a prolific medical press, a host of pharmaceutic preparations, the trial of which long ago incontestably proved their impotence, and yet there is perpetuated, to the discredit of the most important department of our profession, such teaching.

If the treatment of the acute inflammatory troubles most commonly met is examined, what do we find? In simple acute laryngitis, quinia is advised in quantities for which a caution is deemed necessary in order not to add to the existing trouble aural and cerebral difficulties that would

De decidedly worse than the affection to be treated. Are such absurdities unusual? Unfortunately they can be enumerated for too many diseases that long, ere this, should have ceased to be so managed.

As to the therapeutics of simple acute pleurisy, it suffices to point to the many instances of irreparably disabled victims, whose health has been damaged by a serious deformity resulting from changes of structure requiring an ultimate resort to surgery, necessitated by the consequences of a plan of treatment which advance in bacteriology and pathology has demonstrated to be no longer valid, and to rely upon applications, and the exhibition of absorbents which, over and over again have been proved to be almost useless, until an inocuous transudation has become the seat of retrograde changes, resulting in the development of a focus for infection and destruction.

Well may the injunction, intimated in one of our most recent and reliable works of reference, be seriously contemplated, with a view of establishing treatment at least different from that which has and still prevails: "That is medicatrix naturæ" is probably the chief remedial agent in many cases, non-rheumatic, in which (latter) cure takes place under the use of the salicylic compounds, potassium iodide or other specific drugs. It is better ofttimes to do nothing, in so far as remedial agents are concerned, than to institute procedures about which, if anything is known, the least and most that can be said is that no appreciable effects have been secured. To apparently be doing something and having as a result nothing, lends to nothing a dignity and value dangerous to the integrity of the profession!

It is needless to further consume time with additional illustrations, and attention is directed to some of the causes operative in the maintenance of the situation just depicted. The most important factor doubtless is a lack of knowledge on the part of the profession of the natural course and termination of disease. Very meager are the published facts governing this important theme, and teaching is conspicuous for the absence thereof, and consequently the clinician, no matter what plan of treatment is instituted, is incapable of recognizing whether or not morbid processes have been modified beneficially or injuriously.

Reflection upon this fact discovers much to account for the perpetuation of relatively valueless therapeusis. Dependence upon the goddess of fortune too commonly pacifies conscience and engenders a habit of thought and procedure pernicious to therapeutic progress. To such, at the bedside, the exhibition of almost anything, alone or in complex combination, suffices so long as the patient continues to improve, and when this does not take place there is a consultation or a change of physicians resulting in a resort to some ridiculous "pathy" and such careless

and defective therapeusis is crowned with a result just as good, or, more correctly speaking, just as bad from one plan as the other.

Another cause is our materia medica. Why the brain of a student must be engaged at the expense of energy and time that should be occupied in the acquisition of more valuable knowledge in memorizing the name, habitat, natural order, preparations and doses of a lot of obsolete and useless drugs is a question not inopportune. Such substances as castorum, camphoric acid, lactucarium, veratria, urethan, oxalic acid, geranium and an array of innumerable and superfluous preparations of even our standard drugs, should be relegated to regions remote and not be a cause for an anxiety in the green room, which, unfortunately, does not end there, but is in danger of inculcating a lack of confidence in medicines of value and unquestioned merit, frequently reaching far into later life.

Associated herewith is the congener pharmacy. The classification of drugs is based upon their especial and intrinsic or inherent properties, and as many are derived from the vegetable kingdom, in which according to conditions there existing, they must of necessity be characterized by complexity of composition and we have variable and uncertain means. Several active principles are contained in one crude drug, and according to the solubility of these in the medium employed in pharmacy do tinctures, infusions, decoctions, extracts alcoholic and aqueous, and the drug itself represent remedial agents from which it is impossible to obtain uniform, definite or specific results, and to look under these conditions for achievements in therapeutics which should be distinct and unmistakable is unreasonable.

Again, even the chief active principle, or that which classifies a drug, is present in such a varying percentage that it is impossible to prescribe any of these preprations, from this or that pharmacy, with anything like precision and accuracy. Among several remedies, I have investigated the tincture and fluid and solid extracts of aconite root, and repeatedly found such variation in therapeutic power as to render it impossible to regulate the dose with the hope of securing anything like definite results. One tincture, by carefully graded increasing quantities was found to be inert so far as physiologic phenomena were concerned until administered in doses of one fluid dram. Is it any wonder, then, that these conditions which obtain alike for all drugs thus derived, result in the abandonment of many most valuable remedies, and a consequent misinterpretation, not only of the virtue of remedial agents, but also of the modifi cation of the natural course of disease, and consequently of therapeusis.

Our preparations should be assayed not chemically only, but both chemically and physiologically, for to secure a uniform standard of