medicine direct to the patient by the physician. This is evidenced by the discussions in both medical and pharmaceutical journals, by the acknowledged marked diminution of prescription work in the leading pharmacies, both East and West, and in the greatly increased business reported by all the great manufacturing pharmacists who cater directly for the physicians' trade. Is this a step backward or forward? We have noted in our own country the evolution of the modern physician, with his smart little case, containing practically no medicine, from he of the capacious saddle-bags and ample attic supply of fifty years ago or more. We have seen at least one generation of doctors rise up who are as profoundly ignorant of the physical, chemical or botanic properties of the drugs which he uses in his battle with disease as it is possible for any educated man to be. We have seen students graduate from the foremost medical colleges, who, after four full years of most diligent study and research, knew of no way of differentiating potassium iodid from common salt, or epsom salts from oxalic acid, at the bedside. We have seen many older practitioners who did not know what the U. S. Pharmacopeia was, or its authority. And must we not, nearly all of us, admit that we receive even to-day a large part of our supposed therapeutic knowledge from the innumerable alleged journals which flood our mails and which are published solely in the interest of secret and proprietary remedies, often combined in "prescriptions" fearfully and wonderfully devised? Should we not hesitate, then, before changing to a system which will at least presuppose a confidence in the remedial effects of the drugs we use, a knowledge of their physiological action and the ability and willingness to observe results closely and to judge fairly?

We recognize that in times past a dispensing physician has been term of opprobrium no less severe than that of a prescribing druggist, but this should not prevent our willingness to study present conditions and future prospects along this line.

There are doubtless many men whose time is SO fully occupied and who have at their command an educated and conscientious pharmacist, that they seldom would care. to consider the question of their dispensing any medicines whatever except in some emergency, but the average practitioner, even in the city, I find is constantly using a more generous pocket-case and seldom cares to-day to write a prescription for a few tenth-grain calomel powders, or for a couple of Dover powders. It is vastly easier to hand them out from his pocket-case in the form of tablets.

But to those of us who practice in smaller towns or in the country, where perhaps we must rely upon the ordinary druggist of uncertain attainments, of limited experience and of doubtful stock, this becomes a more vital and important question than many others upon which we devote much time at our annual meetings and in our journals.

Can we be more certain in the results, more accurate in our .dosage, more satisfactory to patients and their friends, by dispensing our remedies ourselves at the bedside, than by sending our prescriptions to the pharmacist, if there be one? If all these points can be answered in the affirmative, our duty is plain and discussion useless, except as to ways and means. It is true that in many of the country districts we have been compelled by our environment to adopt this plan, whether it is really best or not, because of the long distance from any other source of supplies; but the question is, should the practice be more general and from choice, not necessity.

First, as to certainty in results. I do not belong to the school of therapeutic nihilists myself. I do not believe that six weeks in bed is the only efficient treatment for rheumatism, or that four weeks in bed with cold baths and proper diet is even a rational complete treatment for typhoid fever, notwithstanding its advocacy by honored clinical teachers. Still, as I have stated in a previous paper presented to this society, I do believe that most of the galenical preparations of even our best pharmacists are uncertain and unreliable from their very nature and because of the necessary constant variation in their real medicinal content. The remedies dispensed by the modern physician are not so, being as a rule definite, permanent alkaloids or active principles, accurately divided in definite doses by the granule or tablet form in which they are used, and expressly prepared for this purpose, makes the medication as certain as possible in its results; while its form, which may be modified as pill, powder or solution, one remedy or several combined, gives unrivalled opportunity to adapt the remedy to the particular case in hand.

Second, is it more satisfactory to the patient and friends? That must be a matter of personal observation in each community. My own experience is very strong that it is. We all recognize the value of the personality of a physician in inspiring confidence in his patient, and where the patient observes this physician in whom he has such confidence selecting and preparing his medicine right there at the time of his visit, his confidence in a favor

able results is immensely increased and no chance is left for those lurking suspicions so natural at such a time, that maybe the druggist did not prepare it properly. It is true that under such circumstances, if the results are not what the physician would wish, he cannot lay the blame on the druggist. I cannot too strongly urge this point of the increased satisfaction which medicines given by the doctor give both patient and friends. Another great advantage is the opportunity for making such changes as the progress of your case may demand without attracting notice. We may leave medicine in the morning and find in the evening that conditions are quite different from what we supposed or expected. A new prescription, the discarding of the previous medicine, all attract attention and comment, while the dispensing physician may modify, renew or discard, with none but himself to consult.

Another important point is the ease with which we may obtain our results by this method. I suppose that there are few of us to-day who do not recognize the general rule of giving any medicine which may be indicated, by itself if possible, until its definite therapeutic or physiological effect has been obtained. This means an extremely variable dose, which can seldom be provided for as the case progresses, unless you are dispensing the medicine yourself; but never, under any circumstances, where you are drawing your supplies from galenical preparations of varying strengths, differing ages, unknown origin and from competing pharmacists.

If, then, we conclude that this system is better, safer and more satisfactory to the patient, is it practical, is it wise, is it desirable for the physician?

I have already intimated several ways in which it is of advantage to him, and I might mention another point of no little importance to those of us who depend solely upon family practice, and that is, that in this way we retain a large amount of minor work which otherwise would not come to our office at all. There are very many cases of slight fevers, indigestions, headaches, coughs and bowel troubles which are commonly treated in the family, by advice of friends or of the druggist, which under this system come to be placed more and more under the care of the family doctor. Not always do these cases mean a straight office fee, but at least they mean something, besides giving one a closer hold upon the family. On the other hand, the question arises, is such a plan practical for the average practitioner? Does

it not involve too much expense without return? Are not there chances for serious mistakes? In a word, does it not add to the burdens of the physician, rather than lighten? I have not found that any of these objections hold good. Almost the only reason why our predecessors so largely abandoned dispensing and began prescribing was because of the skilled labor and complicated process necessary to extract the medicinal activity from plants, the bulky and inconvenient form in which nearly all medicine existed and the liability to mistakes and errors in guessing at the different doses by the bedside. Now all of this has been wholly changed. Granules and tablet triturates enable one to carry in convenient, accurately divided doses the equivalent of one quart of syrup of ipecac, and proportionally of other remedies. In fact, a thin pocket-case will to-day hold more real medicine than the largest buggy-case of twenty years ago. For we must recognize that pharmacy has changed during the past thirty years no less radically than medicine and surgery. No longer does the druggist gather his herbs himself or buy them of those who do. Seldom does he even make his own preparations from them, and never does he pretend to extract the active principles or to manufacture his chemical salts. No, progress in this line, as in all others, has been toward eliminating all of these operations on a small scale and confining them to those great manufacturing houses, where unlimited capital provides the highest skill, the most perfect apparatus, the most extensive gathering of their supplies and their most rigid testing, chemically and physiologically. Now, if the average druggist has become by the force of these conditions merely the merchant, whose business is the buying and selling of certain articles, and such is the case in more than nine-tenths of our pharmacies, why should we still possess the delusion that he is a necessary professional partner?

It is objected that when once a physician limits himself to those remedies which he himself carries, he gets into ruts and makes a limited assortment answer when perhaps he would make a wider selection more accurately fitted for the case in hand were he prescribing from a well supplied drug store. Theoretically this appears to be true, yet it is almost humiliating to find within what narrow therapeutic lines our most prominent men confine themselves. There are to-day in our pharmacopia more than 900 official remedies, and we know that very many of those most used are not yet official, yet in one of the largest hospitals in this country, with their staff of over 100 physicians, I found their dis

pensary to contain less than 100 remedies and almost threefourths of their 300 daily prescriptions were prepared from twentyfive of these. My experience of many years behind the prescription counter in this and other cities proved to me again and again that ninety out of every hundred consecutive prescriptions by any one man could be prepared with a list of thirty-five remedies. Of course, a larger number, taken consecutively, would show a wider variation, owing to the changing seasons and the trial of newly recommended drugs. So I would submit that an average practitioner can readily select, say, fifty remedies or combinations which will include all that he will under any circumstances use in ninetenths of his work, and with them he will form combinations more efficient and more acceptable in every way to the patient than the prescriptions he writes, for in this way he will learn how atrocious some of the recommended formulæ in our standard textbooks are to sight and taste, especially if he tries to administer them to children. These fifty selected remedies would not occupy six feet of narrow shelf room and half of them would be needed in the pocket-case. Now, one's location and surroundings and his own experience would say to what extent this stock should be increased. In my own case, although I have for years owned the only drug store in our community, I have found it far more satisfactory in every way to attach a complete dispensary to my office, and provide it with every convenience for easy and accurate work; so I find that I have over 600 remedies and preparations on my shelves; yet, of my last 1,000 prescriptions—for I keep as accurate a record of all medicines dispensed as though the prescription was to pass through another's hands-920 were drawn from a group of forty remedies, of which twenty-two were alkaloids, five synthetics and thirteen chemical salts.

In conclusion, I would only enter a plea for a thoughtful recognition of the changed conditions of to-day and for a return to that accurate, well-trained clinical observation of the actual effects of every remedy administered by the physician in each case that he treats, to the end that the vast mass of therapeutic trash which now confuses and misleads us may be wholly swept away, and that the physicians of the present and future may be so trained and educated as to give to this important branch of our profession that same skilled attention, born of scientific laboratory methods, which they now give to differential bacteriological diagnosis or to blood examinations.

This will only be when our colleges and the profession at large will have turned from the traditions and customs of the past and brought themselves into the closest possible contact with the nature and peculiarities of the weapons which they are using.