standing that those only who meet such requirements shall not be compelled to pass another examination upon removing to another State.

"However, reciprocity which does not take in the old reputable practitioner will not meet with very much favor from the rank and file of the profession. It does not seem consistent to admit the recent graduate to privileges which cannot be conferred upon the men who teach him."

We believe by a uniformity of law and standard alone, can a high ideal be acquired and maintained, and the greatest danger lies in the possible adoption of ineffective plans which will do harm.

Let us beware of blunders in so important a matter, for it is not a question of easy solution. Much argument advanced on this subject may be theoretically correct, but not practically so. A National Examining Board will not be practical until such time as reciprocity is started between the different boards of the United States, which will result in uniformity of requirements and a perfect organization. We admit, sometimes a modified or limited reciprocity may be established between States that is practical, and in due course of time bring about complete reciprocity.

The great complexity of the problem is largely due to a lack of knowledge, of definite information, by those agitating the question. Therefore, it is exceedingly important that unless the plan of reciprocity conforms with the idea of a higher educational standard, it never can be, and should not be accomplished.

So, let us ever follow Davy Crocket's rule: "Be sure you are right and then go ahead."

IS DIAGNOSIS A PREREQUISITE TO TREATMENT?

By B. F. Gamber, M. D., Lecturer on Haematology, Cleveland Homeopathic Medical College.

The article with this title, contributed to the "Hahnemannian Monthly" last September by John Preston Sutherland, M. D., Boston, Mass., suggested this one as an appropriate subject for our consideration. Dr. Sutherland says: There are few sub

jects on which there is not room for an honest difference of opinion, few questions which on impartial examination, do not present two sides. That is why I have chosen as title to my paper a question, and not a dogmatic assertion.

As Dr. Sutherland says: I have in my own mind a very definite answer to this question, as my own convictions upon the subject, but that personal conviction has not been permitted to prevent me from submitting opposite arguments which are honestly held by intelligent physicians.

On scanning this field several contributary reasons for this difference of opinion become apparent, one of which is due to expecting too much from various methods of diagnosis. This over-sanguine expectation depends necessarily upon ignorance of just what we have a right to expect.

Dr. Deaver says: If the practical benefit of the laboratory methods of diagnosis are not found as great as their originators hoped for, it is to those who report cases exactly as they find them, that we are indebted for the proper subjugation of these symptoms and their establishment as the valuable means of diagnosis.

Homeopathic physicians have been qual ified as simply "Symptom coverers."

Do we find reason to stint or refuse attention to the study of pathology and diagnosis, because the pioneers, to whose courage, skill and success the introduction of the homeopathic principles to popular faith and favor is to be credited, lacked time to pursue such study, being absorbed in their special and mighty task?

We all know that there are cases whose pathological nature is never settled till the sick-chamber is become the death-cham

ber.

Again when the physician is called generally something must be done. The disease may not have "spelled out itself" and the diagnosis may be held in abeyance, but the treatment cannot be held in abey

ance.

These non-diagnosable cases will occur and we must meet them. These cases are by no means always fatal and it tends to lessen the desire of the physician for more

perfect knowledge of the pathology and diagnosis of diseases and very probably increases his confidence in the efficacy of drugs and his therapeutic methods.

Again, should the unrecognized case prove fatal, the physician may comfort himself with the certainty that had he known the state of things as revealed by the post-mortem, he could have done no more to save his patient than he did in ignorance of it. But symptoms are existent, and readable, and classifiable where diagnosis may be blind.

His prescribing is based upon the totality of the symptoms as manifested in his patient, and he may prescribe with a tolerable amount of confidence when others similarly at sea might falter.

Then again an incorrect diagnosis may lead to mistaken and even dangerous treatment, whereas the totality of the symptoms might prove more reliable.

The physician as well as the patient are frequently buoyed up by the hope of a happy outcome through the indications of the symptoms, whereas both might be terror-stricken and lapse into total discouragement when they hear what seems his death-sentence in the diagnosis of "consumption," "Bright's disease," "cancer" and other diseases that may cause dismay.

Diagnosis is absolutely superfluous when we treat by "cure-alls" and proprietary preparations which flood the pharmaceutical market.

Physicians whose practice is moulded by the circulars and recommendations of these manufacturers are practically doing away with the question under consideration in this paper.

In passing to the discussion of the arguments on the other side of this question Dr. Sutherland confesses his choice and directs attention to the many diseases which present to the physician symptoms deceptively resembling each other, which, pathologically, differ by a dangerous world's width.

Without diagnosis as a guide to the character of our treatment, we are doing our patients a great and shameful wrong, and exposing ourselves to the chances of

deep chagrin following a mistaken diagnosis.

While sojourning in Nevada City my host informed me that years ago one of their magnates lost his wife through the lack of diagnostic abilities of a young homeopathic physician and since then none of that school have been able to earn their salt there. Dr. Sutherland says: I have known a case of diphtheria to be mistakenly diagnosed as follicular tonsillitis, the true nature of the disease not being recognized until two nurses and four members of the family contracted the disease, three fatal cases resulting.

This shows the danger to a community, from neglected or too long delayed recognition of the existence in its midst of a contagious disease.

Diagnosis as a prerequisite to treatment does not mean alone, diagnosis as a prerequisite to the administration of drugs, but a prerequisite to all the functions a physician may be called upon to assume.

Dr. Barnes was frequently called upon to treat patients for consumption who were suffering from some other malady.

Dr. Sutherland says: It has four or five times been my experience to have patients apply for treatment for "malarial fever." which had been so previously diagnosed and treated on account of the periodical chills, fever and sweats, with more or less prostration. But careful examination revealed the presence of pulmonary tuberculosis, which eventually proved fatal.

It was similar experiences which prompted Dr. G. W. Barnes to persuade me to purchase the $1,200.00 microscope and make a trip to Europe to learn modern methods of diagnosis.

His convictions upon this subject were so far awakened that he furnished all the money to accomplish this end and he likewise secured about two dozen sets of instruments for the study of climatology and caused their distribution all over the "far West."

Dr. Sutherland relates a case treated for months for symptoms ending in aphonia. Laryngoscopic examination which during this time referred to had not been made,

showed the presence of a small papilloma on the right vocal band. This suggested operative measures which soon resulted in gradual restoration of the voice.

M. D., age 46 years, of Cleveland, though treated closely by similars and with the aid of able consultants, was not correctly diagnosed in the early stages of anæmia, following chronic malaria.

A few weeks before her death a cytological examination of the blood revealed what should have been learned long before.

The blood showed that megaloblastic degeneration of the bone marrow had set in and other symptoms of pernicious anæmia marked a decidedly unfavorable prognosis, notwithstanding both physician and patient had been buoyed up by the hope of a happier outcome.

Dr. Sutherland refers to the dangers of delaying accurate diagnosis in jaundice and pernicious anæmia; intestinal colic and appendicitis; scrofulous glands and Hodgkin's disease and other diseases which might be mistaken for death-dealing dis

eases.

S. M., age 50, of Cleveland, has for many years been closely treated by similars and proprietary compounds for rheumatism and neuralgias and lost much of his time that might have been devoted in the development of his business, in nursing his aching limbs.

This last fall a blood examination revealed that he was suffering from chronic malaria, by the presence of parasites, and their eradication has left him well and happy in the enjoyment of all his natural abilities to run a first-class and lucrative business.

The more irregular and atypical the case of malaria, the less difficult it is to find parasites in the blood. Because sporulation then occurs during a longer period than in typical cases and therefore organisms, in various stages of development, may be seen at a single examination.

I have in my collection, from my own observations, a slide that contains spores, some just scattered and some having just taken up an abode in their host. Some of

the Plasmodia half fill the red corpuscle and some have entirely destroyed their host, and finally we find the segmenting cell.

Neoplasms present tissues so typical and which can be studied "in vivo" which make most valuable contributions to the accurate study of pathology and diagnosis.

Many diseases cannot be diagnosed positively "in vivo," only by an examination of the blood by modern Hematological methods. Great expectations were aroused when we discovered how to make counts of red corpuscles, but this process has given us disappointingly little help and hematology has solved some problems where least was hoped.

The Nidal test has won for itself a place in the field of diagnosis among such symptoms as rose spots, nose bleed, headache, abdominal pains, enlargement of the spleen.

Dr. Sutherland puts the question, What is the position of Hahnemann in relation to this matter? We are not left to guess the attitude of the founder of homeopathy on this matter. He quotes from the first and third paragraphs of the "Organon": "The physician should distinctly understand the disease and what is curable. He should clearly comprehend medicinal powers of drugs. He should adapt what is curative in medicine to what is morbid in a patient."

"Finally, when the physician knows in each case the obstacles in the way of recovery, and how to remove them, he is prepared to act thoroughly and to the purpose as a true master of the art of healing.

We have come into the inheritance of an almost innumerably greater number of aids to the precise determining of the nature of any given disease, than were accessible in Hahnemann's day.

In proportion as we use these aids intelligently, patiently, conscientiously, and give ourselves no ease this side of their mastery, and use of all the knowledge outained through their means, we work in the spirit of true physicians; masters of the art of healing.

Dr. Pritchard, of Monroeville, Ohio, says in review of Dr. Sutherland's article that: If a physician does not stand on the firm ground of a carefully thought out diagnosis he feels ill at ease; he cannot speak intelligently of the case either to the patient or his friends. How can he predict complications or the termination if he does not know what he has in hand? If a complication arises he is all at sea, he hesitates, calls it another disease, shakes the patient's confidence and prepares the way for trouble for himself and probably loses valuable time which should have been used in proper treatment.

How much blame would fall to a physician for having lost a simple case of typhoid fever, which really was one of tubercular meningitis, when the proper diagnosis would have enabled him to predict the outcome. If we are not willing to face these things intelligently, there certainly will come a day when they will thrust themselves before us and cause us humiliation and disgrace.

Dr. Pritchard has well said: "Diseases do not come to us labeled; we are obliged to seek for them in every way possible, and unless one gets into the way of first and foremost attempting to make carefully reasoned out diagnosis, one will miss many of them, and the golden opportunity for help slips by us.

Familiarity with diseases will inform us that patients more often recover from incipient stages, if we look for these beginnings instead of waiting until they are forced upon us in later stages, incurable. Bright's disease is not the incurable disease it once was thought to be. Symptom covering was very unsatisfactory and etiological therapy is far more satisfactory, but an early diagnosis is the key to the whole situation.

We are sometimes obliged to aim to remove symptoms withcut understanding their source, but this does not prove that we can remove them better without knowing their source. If the plasmodium in the blood can be demonstrated and an unswerving diagnosis established, the experimental efforts to cure chills and fever are

uncalled for and a direct blow can be aimed at the object to be removed to accomplish the cure.

One great advantage, indeed, of attending carefully to diagnosis, is that it enables us to use remedies knowingly and with decision. The treatment rises above the temporary considerations of the moment and takes into account what is for the patient's ultimate good. It is only from half-knowledge, from being satisfied with symptom-covering, that one lets cases slip on and on until they round up with something suddenly and humiliatingly different from what they on the surface seemed to be, that one gets into trouble. A few weeks ago I was called upon to test hemorrhagic sputum for tubercle bacilli. The sputum revealed hæmatoidin crystals in heart disease cells which led to the correct diagnosis of cyanotic kidney. The differential diagnosis of contracting kidney and auto-intoxication from obstruction in the bowels may frequently call for similar change of treatment.

We hope every reader of this review will read the address of the President of the New York Medical Society, which met at Albany, January 28th, 29th and 30th, 1902, which is published in "American Medicine" of February 1, 1902, Boston "Medical and Surgical Journal," January 30, 1902, and in the "Medical News" of February 1, 1902.

He says: "The development of medical science has been so rapid that to those who have been in practice twenty, or even fifteen years, who have not kept pace with the advances and scientific movements, the language of the medicine of to-day is almost unintelligible. Our only safeguard against quackery is continued recurrence to the scientific basis on which the practice of medicine rests. It is no secret that the charge has been made that too many patients in this country are often ignorantly and incompetently treated. The application of modern methods of diagnosis must always remain supplementary to bedside study."

There are a sufficient number of instances in which electricity offers data for

diagnosis which cannot be obtained from any other source and methods of inspection by the fluoroscope and skiagram have been of inestimable value to the physician and surgeon, and to deny their value in practice would be both absurd and unjust. Electric reactions, associated with a thorough study of the deep and superficial reflexes, lead to the interpretation of phenomena upon which depend localization and diagnosis in many obscure conditions.

The mere giving of drugs is a very unimportant part of the physician's duty, and each year sees more than one timehonored remedy become more and more limited in its use. When I was a student we loaded the pages of our note-books with complex formulas which were considered the very valuable instruments that the fathers in the profession used to cure disease.

An instrument of precision too little employed by the general practitioner is the ophthalmoscope. Its revelations early recognize diseases of the brain, arterial degeneration and renal complications. To those who for any reason are unable to refer these cases to special workers in the field, we suggest the new instrument invented by Thorner, which affords a beautifully illuminated view of the magnified fundus, in which the details are a veritable revelation. A professor of Jefferson College says that on several occasions he has shown to twenty-five or thirty students who were entirely unacquainted with any ophthalmoscope or fundus picture, except as book illustrations, in one hour or less, every detail of the eye-grounds of several patients, without difficulty and without uncertainty

No diagnostic methods in medicine give more conclusive evidence or offer more incontrovertible pictures than are revealed by those which we to-day include in our examinations of the blood. It is not the object of the evenly balanced physician to replace the knowledge gained at the bedside, by laboratory findings, or to limit diagnosis by considering only facts made positive by microscopic examination and staining of the blood, but to add the exact

knowledge which used to be unattainable. It has placed the physician upon a standing where he holds without fear of successful contradiction, that the positive diagnosis of the simplest forms of anæmia. cannot be made without the aid of data obtainable by blood examination. We so often failed in our differentiation of these anæmias, that our treatment would continue to be irrational.

Who shall be able to compute for the profession the gain which has accrued from our ability to diagnose malaria from the presence in the blood of its protozoon?

The examination of the blood has so greatly simplified the diagnosis of the malarial fevers, that it can truly be said that he who to-day loses a patient from malarial fever because of inability to recognize the disease bears upon his shoulders a heavy weight of responsibility, which no regret will lessen. The fact should ever be held in mind that any malarial fever may become pernicious, and the longer it runs unrecognized the greater the chances of its becoming so, and the greater the danger to the patient, and as Craig says, "It is in such cases as this that the microscope becomes a life-saving agent more powerful than the surgeon's knife or the therapeutist's art."'

The young man needs the knowledge and training afforded by laboratories and those who have grown old in the treadmill must take advantage of modern methods and ideas to retain their standing in the profession, and they need ever to study the methods which are included in the armamentarium of their juniors and pupils. The public demands painstaking investigations of every detail which their case may offer, by every method needed for accurate observation and ultimate diagnosis. Believing that modern methods of diagnosis lead to the trustworthy interpretation of symptoms, with a firm belief in the superior ability of those who have adopted these methods, the lay-world is fast removing its former prejudices against those who manifest thoroughness in the recognition and treatment of diseases.

It has been truly said that "practice