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Present tendency of investigation in medicine.
AN
ADDRESS
DELIVERED BEFORE THE
SUFFOLK  DISTRICT MEDICAL  SOCIETY
3t fts Second gntifbetsarj? lf«eetfnfl,
BOSTON,  MARCH  28,  1851
SAMUEL PARKMAN, M. D.,  M. M. S. S.
   ONE OF THE SURGEONS OF THE MASS. GEN. HOSPITAL.
Published toy Request of <he Society.
              BOSTON:
DAVID CLAPP, PRINTER..........184 WASHINGTON STREET.
            Medical and Surgiral Journal Office.
                   1851. 
 
THE PRESENT TENDENCY OF INVESTIGATION IN MEDICINE.
                      AN

              ADDRESS
                 DELIVERED BEFORE THE

SUFFOLK  DISTEICT MEDICAL SOCIETY

           &t fts Second Stnttfoersars iWectfng,

        BOSTON,  MARCH 28,  1851.
                  BY
SAMUEL PARKMAN, M. D.,  M. M. S. S.
   ONE OF THE SURGEONS OF THE MASS. GEN. HOSPITAL.
Published toy Request of the Society.
              BOSTON:
DAVID CLAPP, PRINTER..........184 WASHINGTON STREET.
            Medical and Surgical Journal Office.
                   1851. 
         w

          P&SIp

           IS5T



NATIONAL LIBRARY  OF MEDICINE
     WASHINGTON. D. C. 
ADDRESS.
 Mr. President and Gentlemen of the
             Suffolk District Medical Society.
   In compliance  with  the request  which  your
 Committee has done me the honor  to make,  I ap-
 pear before you this evening, to occupy your atten-
 tion for an hour, with the address which our  rules
 direct  should be  annually delivered by one of our
 members.  In the choice of a subject, I  have  been
 guided  by the knowledge that I was about to speak
 to a collection of practical medical men, feeling the
 importance  of the profession to which  they  have
 dedicated their lives, and  a consequent  interest in
 the progress  of  the science upon which it is de-
 pendent.
   In addressing  such a body of gentlemen, I  have
 thought that it would  not be out of place  to vindi-
 cate before them their claims to be considered as the
 professors of a  real science, to show to them the
 path which must be followed to advance this science,
 and to comment in some few words  upon  the  ten-
 dency of investigation  at  the present time, the re-
sults of which must necessarily have more or less
bearing upon the practice of the art.  ( 
4
   The question is sometimes asked, Is there a medi-
 cal science, or a science of the practice of medicine X
 It will be the aim of a  portion of this discourse to
 answer this question, and to endeavor to place medi-
 cine  in its  real position with regard to the other
 sciences.  In doing this, it will not be without  in-
 terest to examine the requisites for the formation of
 a science, or  the possibility of discovering the laws
 regulating any particular set of phenomena.
   It will be granted by every one, that the phenome-
 na of the external world do not follow and succeed
 each  other  by a  blind  chance, but  are  subject to
 positive  and controlling lawTs.   These  governing
 laws  may  be now incomprehensible, and  perhaps
 in some  cases will never be  comprehended  by our
 natures; but the existence  of the  law binding  to-
 gether the phenomena by a chain, to which wc have
 given  the  name  of cause and effect, is universally
 allowed.   If  we had  not the certainty  that  like
 causes will always produce like effects if no counter-
 acting cause be present, we should be involved in a
 constant maze of doubt and  obscurity.  Experience,
 observation,  induction, reasoning, would be of no
 avail, and each day would be  the commencement of
 a new existence.  The reality  of this invisible chain
being recognized, science has  for its object  its dis-
covery—and  examining  the  sets of phenomena al-
ready grouped by nature, it endeavors to discover
the laws of their succession, to point out amidst  the
innumerable  variety the  one that is essential, to 
5
classify those that resemble each other;  that it may
be able definitely to predict future occurrences  and
their conditions.
  Now of some of these groups  of phenomena the
laws are  easily discovered;  we  know  clearly the re-
lation which each bears to the other;  the effects are
all referred to  their causes, and all the causes are
known.  Such a knowledge is  called a  complete or
exact science.   These sciences  thus  completed are
few, and  of them astronomy may be considered the
type.  The  opposite of this  may be  taken, by way
of example, as the science of the weather.  No one
doubts that rain and sunshine succeed each other by
distinct laws;  that the storm of to-day is the result
of all the meteorological changes since the  world
began; and that it, in  its turn, must  have its own
influence upon  all  relative  phenomena until time
shall be no more; and  yet we have  not  advanced
beyond the  rudest  laws.  But between these  two
extremes, there exists a great number of  subjects for
science, the laws of which we are enabled  partially
to explain.  In many,  our knowledge  is sufficient
for  much practical usefulness,  and of  it we daily
avail ourselves,  it being always understood that we
are  liable to be deceived in our expectations by the oc-
currence  of unforeseen events.   Thus we know most
of the laws regulating the ebb and flow  of the tides,
and we can predict their condition at any place and
time with a proximate degree  of certainty.   Our cal-
culations will  differ somewhat from actual occurren-
          1* 
6
 ces, but for these differences we know some undisco-
 verable cause must exist, and we hope by observation
 that their existence may be proved, and their impoiv
 tance weighed.
   Medicine must be ranked among these inexact or
 imperfect sciences; but that it is so, sb,ould  not  be
 considered as a  reproach, or as any  indication of
 want of skill  or attainment on the part of its culti-
 vators.  Those sciences only are complete and per-
 fect which have occupied themselves with the  phe-
 nomena of certain forms of brute matter, where the
 conditions are few and simple; and the degree of ex-
 actness which has been attained, is in proportion to
 the simplicity of  the  influences interfering with the
 chief causes  of the effects we may be examining.
 Medicine  occupies itself with the  highest type of
 Nature's  creation; it  studies  man,  the chief of the
 universe, and is kindred with those studies of mental
 and moral philosophy  which have occupied the world
 since history began.   The knowledge of man, men-
 tally, morally, or  physically,  can never be  perfect,
for we are ignorant of the very nature of  the object
we are studying.   We may hope to  acquire a know-
ledge of mere brute matter, for we may have it before
 us, we may confine it  and pursue it to  its ultimate
 elements;  but who shall tell us of the subtle essence
which marks  the difference  between  the moving,
 thinking, feeling portion of matter which constitutes
 our individuality, and  the  collection  of muscles,
bones and  sinews, ready to be dissolved  into their 
7
component physical  elements, when what we  call
Life has fled'?   Who shall tell us what this Life isl
And yet, without this knowledge, how shall we study
its manifestations 1 The astronomer employs the term
gravity as explanatory of the cause of an  effect,
which he observes to be always produced by the
action of bodies upon each other.  This reciprocal
action is subject to but few laws, and these  easily
comprehended and expressed, and the term is used
as an exponent of an effect always produced.   And
his science has become exact from the very simplicity
of these laws.  But  what gravity is  to the bodies
composing the solar system—their guiding and con-
trolling principle—that is  life  to the  bodies we
study.  On  the one  hand, the  conditions are  few,
simple, and  easily appreciable;  on the other, how
complicated and abstruse.  If we could define and
explain the principle which erects inanimate matter
into  breathing, sentient existence, then  would the
corner stone be laid, and the  edifice  would  rise at
once.  But this so necessary knowledge must always
remain veiled to us as mortals.  And this is no subject
for complaint, since  it may be  an occupation in an-
other  existence, possessed of this key, to solve the
many inscrutable and unfathomable problems which
have baffled us  here.  And as  Socrates hoped to
meet, beyond  the Styx,  the  Homeric heroes, and
" pursue with them  the debates  on ethical progress
and perfection," it  may be the happiness of the
medical philosopher to  question the sages who have 
8
preceded him, and to be finally enlightened by their
purified wisdom; and  the exercise of his faculties
in this existence may be only the preparation of the
ground in which the tree of knowledge  shall blos-
som hereafter.
   The science of medicine, then, is incomplete,  im-
perfect, inexact, only as is every science  which  has
relations with living  beings.   The metaphysician
speculates upon the laws which govern the manifes-
tations of mind, and labors to accumulate as many
conditions as he can comprehend, using the study
however  only as a species of mental gymnastics to
fit him for  the understanding  of himself.  The  sci-
ence of the moralist is  alike inexact or incomplete;
but it is considered no  reproach to its votary, that,
with his present faculties, he may never  hope  to
attain what he constantly strives  to reach.  We do
not abandon his precepts because there are occasional
conflicts and doubts as  regards duty, which are hon-
estly settled in opposite ways  by different persons.
Because there  is a supposed  conflict between  the
"higher" and the "lower" law, we do not abandon all
law.  Thus medicine is imperfect;  the laws of dis-
ease can never be fully  known, because of our igno-
rance of the laws of health.  But still we may bring
together many important phenomena, and their study
may enable us to  prescribe rules, which, although
imperfect, may be sufficient for our guidance, with
the recognition always of the uncertain ground upon
which we stand. 
9
   Medicine  has been  reproached  because, in the
 presence of that scourge, the  cholera, which has,
 with mysterious and deadly step, passed over nearly
 the whole  world,  it has remained inefficient and
 powerless as regards the discovery of its  real  cause
 and nature; not even having pointed out a sign by
 which its approach might be foreseen, even if it were
 ordained that we must  succumb  to  its devastation,
 as to a decree of fate.  The charge  is true ; but let
 only those who are free in this respect, cast the re-
 proach.  Has"  any naturalist  ever approximated to
 the  cause  or nature of the disease, which  in  like
 manner has spread over a large portion of the world,
 depriving  a nation of its subsistence X   And yet,
 which of the two has the most advantages and facili-
 ties for arrival  at discovery, the one  compelled to
judge of the hidden processes of disease by obscure
 signs, or only able to examine  its  effects after its
 ravages have been completed; or the other, who has
 merely  to walk into a potato field and make living
 autopsies of his  diseased  patients'?  A mysterious
influence has traversed the land, and a class of forest
trees, which had for years with each returning spring
spread their leaves for grateful shade, now raise their
bare branches—a deformity and a barrenness in the
midst of the beauty and  plenteousness of summer.
Has any one shown the causes of this 1  Has any
one advanced even a tenable theory, or made so much
as a probable supposition X
  The term  science  is frequently  coupled  with a 
01
sneer, or with some word  of reproach or  slight, as
if it were  opposed to the  practical  treatment of a
subject.  The practical man  says he has no time for
scientific speculations, and  takes credit to himself as
being occupied with something  tangible  and real,
while the other is wandering in the mazes and doubts
of hypothesis and vain theory.  In reality, however,
science is eminently practical—without it we must
be reduced to the vainest empiricism.  There is an
imagined opposition between science and art—an
opposition  falsely charged  by those claiming  to  be
the sole promoters of the practical and useful.  The
two are co-laborers in the same great field.   Art sur-
veys the  ground,  takes cognizance of the labor to be
undertaken, and  the ends  to  be accomplished, and
then asks  of its co-adjutor, science,  the  means  by
"which these purposes are to be effected.  No rule of
art can  be made without  the aid  of science.   All
knowledge must be first tested by this standard, and
its purity ascertained, before it can pass current  for
any value.   Science may employ itself in  the study
of subjects, the  practical importance  of wdiich may
not  readily be perceived,  and which possibly may
not exist; but if art is desirous of effecting any thing
useful and  permanent, of acting clear-sightedly and
distinctly,  it must  follow  the laws  which science
prescribes,  and must be willing to acknowledge the
assistance received.
   It may, however, well happen, that before science
can have fully mastered a subject, it  may be neces- 
11
sary that art should  act.  It is true  that we cannot
stand hesitating upon the bank, because we  have no
certainty whether the  stream be fordable or  no.
Something must be done, and we must cross as best
we may.  But  because  we cannot be certain of the
means, let  us not foolishly deny the desirability of
this certainty, or, scoffing at those who  labor to de-
velope it, be content with the hap-hazard results of
empiricism, although occasionally brilliant  and de-
cisive.
   Now science does not consist, in medicine, any
more than when it  occupies itself with other sub-
jects, in the simple accumulation of  facts, in the re-
cording of numbers, or  in the adding of columns of
figures.  Simple experience is not sufficient  to estab-
lish a law, or to render certain that events which
have always happened  together, or  succeeded  one
the other, should  continue  to be so connected for
time hereafter.  Experience may on the whole  be
the safest guide for practice in any particular in-
stance, but  it  cannot  when alone offer certainty to
science.   The reason of the connection of the events
must be discovered before we can have the certainty
which science demands.  To state an extreme  case,
experience has informed the world that the sun has
risen daily since  order came out of chaos; and  if
any observations had been made for a series of years
on the variations of its  times of rising and setting,
it  would undoubtedly  have been  noted that these
variations had followed a certain regular order: but 
12
  this knowledge would have  had only reference to
  past events—there would have  been no  certainty
  that the sun will rise to-morrow  at  about the same
  time  it did this morning.   The prediction of the
  future cannot be made from the past, on the ground
  of  mere experience.   Experience  is  merely  the
  record of facts that have taken place; and it is only
  when we have discovered the chain  of their con-
  nection, that  we can predict  the future.  Science
  knows the sun will rise to-morrow at a moment that
  it can predict, because it has discovered the laws by
  which the solar bodies are moved in their orbits, and
  it knows that, as long as the  solar system lasts, the
  sun  must rise at given hours;  that any aberration is
  impossible;  and, with this knowledge, to-morrow's
  sunrise might be predicted, if science were deprived
  of the fact that the present darkness had been spread
 over our portion of the earth within only a few hours.
   Science, then, is the discovery of the law of suc-
 cession—of the law of cause  and  effect.  It gives
 an answer to the question, Why ?   It is the employ-
 ment of the mind upon the  phenomena presented to
 the senses.  Its results are  the distinction between
 man and the brute, and are the highest objects upon
 which the intellect  can be employed.  And medi-
 cine,  that it may approximate towards a rank as a
 science, must apply itself in this direction, and, avail-
ing itself always of recorded  phenomena as facts,
must  endeavor to discover the  causes of these, and
their reciprocal action one upon another. 
13
  If the study of medicine were confined merely to
the record of events that  have taken place, and to
their announcement, that we might argue from the
past to the future;  the only advance that could be
anticipated would be in the perfection of the meth-
ods by which  these  observations are to be made—
that we may  not be deceived by any false appear-
ances.   If restricted within these bounds, medicine
would  be only an art, limiting itself to  simple ob-
servation of events which it  neither attempted to
explain or comprehend.   Experience is absolutely
necessary, for  by it facts are  collected that science
may judge of them.   The  doubt,  that  may fairly
arise, however, in any case, "will be whether experi-
ence has collected sufficient facts to permit the ad-
vance to be made.   To take this step  is what the
scientific observer in  medicine, at the present time,
proposes to himself.   Assuming that we are at this
point, I  shall endeavor  to  point  out  some  of the
means  by which the proposed  end is to be attained.
  Now, as medicine occupies itself with  the study of
this complex organization, the human body, wherein
are united two  sets  of forces, those belonging to
matter as matter, and those with which it  becomes
endowed when vitality is imparted to it, it  would
seem that there are two methods of investigation by
which   the ends  of science  are  to be obtained.
Physiology may be  defined as  the study of the  pro-
cesses by which  the human  body assimilates matter
of the  external world, applies  it to  its  own uses of
          2 
14
relation with  that world, and  finally returns it, in
another form, whence  it  was  originally received.
Medicine  is the science by which we propose to act
upon this human  body, when its functions are de-
ranged, as happens, in the large majority of cases,
by agents external to it, in order that it may resume
the  performance of its usual  actions.   Now  it is
clear, that both in physiology  and  medicine, the
effects of external agents, from their first connection
with the human body, are subjects of examination
in a  double point of view—first, the effect  which
they naturally have upon the body in virtue of their
properties, composed  of elements having affinities
chemical and other with the corporeal elements,—a
view which regards the human body and the  agents
connected with it only as  so much inert matter, and
proposes its examination  as such;  and, secondly, a
point of view from  which  only the essentially vital
actions  are considered, and which ignores or takes
comparatively little account of the mere material ac-
tions of these  elements after they have entered the
human  body;  a view, which  regarding solely this
inscrutable, invisible, perhaps incomprehensible prin-
ciple, styled life, desires to account for all pheno-
mena of organization by its agency—considering all
these phenomena as distinct from those  presented
elsewhere.
  Now, as the nature of this principle is confessedly
difficult, to say the least, of comprehension; and as,
living bodies  forming part of the material universe, 
15
our first investigation would be whether the laws  of
matter hold good as regards them, it would seem the
natural process to endeavor  to reduce  these  vital
phenomena as much as possible under laws which
we already understand, and  to seek  in a known di-
rection their explanation.  It is evident that if the
functions  of the  human  body were performed upon
an entirely distinct and  peculiar  set of principles,
there could be no assimilation between the two forms
of matter, the animate and  the inanimate—no re-
ciprocal action of the one upon the other.   The in-
gested food is composed of certain chemical  con-
stituents,  which must retain their chemical relations
equally within as without the body.  If principles
that should be ejected are retained, there is  nearly a
certainty  that they too must act in the same manner
in their new and false situation  as if they were re-
stored to  the world at large.   There is  reason, for
example,  to believe,  that the  poisonous  effects  of
arsenic are in some measure dependent upon its anti-
septic properties—upon  its power of arresting the
disintegration of the  component elements of tissue,
and thus retaining  within the economy principles
which should be discharged as effete.  And it may
be that all poisons, animal, vegetable and  mineral,
act in like manner by their chemical effects.  When,
therefore, we  have mastered  all these  and similar
phenomena,  and have  studied all the  reciprocal
actions in the human frame, then we  shall  be  enti-
tled to leave the  residue  to be accounted  for by this 
16
 unknown principle, the vital force or power, but it
 is only legitimate to employ this when  every other
 explanation has  failed.   It  should,  as  the god in
 the  ancient  tragedy,  not be admitted  unless the
 crisis were worthy of such interference.
   It  would seem, then, that in this  direction the
 studies of medical science should be applied, viz. to
 the investigation  of the changes which matter under-
 goes  after  its arrival  at  the  human  organization,
 and the investigation of these changes according to
 laws which we know to be established for the same
 matter elsewhere; endeavoring, as much as possible,
 to explain the phenomena by these, and searching
 always first in this quarter for light to illumine a
 darkened path.   By directing study to these points
 will the next great discoveries  probably be  made,
 and any great all-embracing laws be established.
   The ideal condition which medical science holds
 before itself is a condition of knowledge, when, in
 every disease, we  shall know the  manner  in which
 the system  departs from its normal  condition, either
by the reception of morbific influences from without,
by the mal-appropriation of substances  received, or
by the failure to eliminate injurious principles which
are the result either of the normal  or abnormal de-
composition of the tissues, or of  substances  foreign
to the system received in divers manners.   This ideal
condition is of course beyond our reach, because its
attainment  requires  the knowledge of more facts
than  humanity may hope  to analyze and compre- 
17
hend; but it is only by fixing her eye upon this ideal
and keeping it steadily in view, that medical science
can hope to master any of the problems  submitted
to her scrutiny.
   I have said that by this method the  great  disco-
veries remain to be  made—discoveries which  are to
advance more especially our means of prognosis and
treatment of  disease.    In  diagnosis,  as far as it
bears upon these two last mentioned points, it may be
said, with truth, that we have not a great deal to be
attained, especially  in acute diseases.  The  great
discovery of  this century,  that  of  Laennec—has
given us  almost a certainty of diagnosis  in a very
large class  of diseases.   And it  cannot  be denied
that within our  time an advance  in  the  facility of
diagnosis in all diseases has been made, greater than
during  any period  of many times its length  in the
previous history of medicine.  We have  in but few
cases doubts as regards the malady we  have under our
hands.   What we desire to know, and what we must
know, to enable us to prevent it, or to remedy it, is
the cause of its presence, the nature of the  morbific
influence,  its action upon  the  economy,  and  the
reaction  of the economy upon it.   We 'ought to
know the nature of the cause of the disease, and the
manner in which all the actions of the economy are
influenced by it.
   Without knowledge of this kind, it is evident that
the prognosis in any case,  as far as that case  is  con-
cerned,^ either a mere statement of chances founded
           <2* 
18
 upon  the observed results  in  a given number of
 similar cases, leaving it of course perfectly uncertain
 whether the one in hand  will finally be numbered
 among the majority or minority,  or it is the result
 of some peculiar  tact or gift  of the practitioner,
 who is enabled to make a guess, by  means he  can
 neither impart  nor  explain.  Now, in the  first of
 these  cases the prognosis is valueless, or  nearly
 so,  as  regards   certainty  in  the  individual case ;
 and  in the second, it may be said, that differences
 resulting from the possession of the tactus eruditus,
 from peculiarities of organization, as  shown  in fine-
 ness and  nicety of perception,  the employment of
 instruments necessary for  investigation, and the ma-
 nipulations peculiar to the practice of  any art, must
 necessarily exist among its  practitioners; but, the
 conditions being established and  agreed upon, the
 enunciation of the consequences should be clear  to
 all who can apply the rules of the science;  they
 should, in an exact science, follow like the working
 of a mathematical equation.  Or,  in  other  words,
 the diagnosis may fairly be supposed to be more or
less easily and clearly made out, according  to the
 skill and training of the individual practitioner; but
this being done, the ideal  condition would be  that
the prognosis should follow  as  a matter of course.
The  same, or similar  remarks, may be made with
regard  to what we should  propose for ourselves  in
 the search  for means or  rules in  the  treatment of
disease. 
19
  It is plain that the practice  of medicine,  if it
would free itself from  the charge of empiricism,
must give a distinct and  clear account of the reason
for the action of its drugs.   Now, although an equal
improvement has been made in methods of treatment
to that in diagnosis, still it cannot be denied that this
has consisted rather in the abandonment of old prac-
tices than in the substitution  of new.   We  do not
bleed as much, we do not purge as much, as did our
fathers;  but as yet we have substituted nothing in
their places.  The remedies which are efficient in
chronic  diseases have been discovered more  by a
species of  accident, the steps  leading to their intro-
duction  being for the most  part unknown, and a
reason can be given for the action of but very few.
   It should not, however, be regarded as any stigma
upon its practitioners that  so large a portion of the
improvement in the practice of medicine should con-
 sist thus  solely  in  the abandonment of methods
 which have been found inefficient.  A parallel may
 be found in an example drawn from political history,
 the history of the treatment of  the  body politic.
 Within the last thirty years, in Great  Britain, mea-
 sures have been passed of greater significance, and
 destined to have a greater influence upon her people,
 than those of perhaps any other  thirty years of her
 history ; and yet, as has been pointed out by a late
 writer,  each  one of these  has only been a measure
 of relinquishment, an abrogation of an act,  rather
 than  the substitution of any  new form of action, and 
20
 one of her greatest statesmen of this period rests his
 strongest  claim  to sagacity on the fact that he dis-
 covered and was read}- to acknowledge the errors of
 a previous political career.
   Now, inasmuch  as  it  is  to  a fluid state that all
 ingesta must be reduced, before they can be fitted for
 assimilation, and as it  is by the one great fluid, the
 blood, that all the elements of tissue  are  carried to
 the parts of the  body, and as it is to this  same fluid
 form that  the greater portion of the excreta are re-
 duced,  it  certainly is  by turning attention to the
 study of the fluids of the  system, and their changes
 in disease, that we may  hope  the next  great  dis-
 coveries to be made.   By the  fluids, all  principles,
 whether deleterious  or otherwise, must enter into
 and be carried to the  various points of the  economy;
 by the fluids, all  effete  and hurtful principles must
 be eliminated; and it is  fair to  suppose, that  the
 action of remedies, as they are alterative of  diseased
 action,  or  eliminatory of morbid principles, should
 be traced  in  changes which these fluids undergo
 under their influence.
   Furthermore, if what  has been advanced  be true,
 that we should endeavor, as far as possible, to reduce
 organic changes to the  laws which influence unor-
 ganized matter, it would seem clear  that  we  must
 attend especially to this part of the economy, since
it is the only part which during life can be  subjected
to our investigations.   We arc, by the circumstances
of the case, in a great degree debarred  from the 
21
study of the systemic relations with  external mat-
ter, except while it  is receiving and  parting  with
this matter.  We can know what enters  and  what
leaves  the machine, and from  these data  we  must
form  a proximate  idea of what the  actions of the
economy are, since these last must in a  great measure
be hidden from our  necessarily imperfect researches.
   Investigation of this nature is still quite in its in-
fancy, and what has been made offers  as yet but few
results bearing directly upon practice, and it certainly
would be premature to  claim any great advance or
even any decided approximation to have been made
towards the desired result.   It is mainly the present
 object to point  out the desirableness  of this result,
 and to show that this is a chief end for which medi-
 cal science should  strive, and to indicate  the direc-
 tion in  which  research will probably meet with
 the most success and  reward.   It is fair to presume,
 that, in any case, it being demonstrated that  a  ma-
 chine must work by  certain laws, it will  only be in
 the study of those  laws, as applied to the parts, and
 in the study of  the individual parts of the machine
 themselves, that an accurate knowledge of the struc-
 ture, sufficient to  enable  the repair of injury,  can
 be obtained.  And this must hold good  as  regards
 the human frame and its injuries and maladies.
    Medicine, hitherto, and  this  is said without  dis-
 paragement, has been occupied mainly in observation
 upon a gross scale, in the  collection of facts relative
 to diseased conditions, and in discovering the means 
22
 by which  these conditions may be recognized.   It
 has been employed mainly in the observation of the
 results of disease when  fully formed,  studying its
 products, classifying  its various  genera and species,
 constructing a natural history as it  were; forming
 for  itself  a  vast museum, which, although it may
 point out the ravages which have been made, throws
 little light upon the means by which the  evil has
 been done.  It has  been employed  in  surveying
 the  sphere of observations, and learning what was
 actually necessary to  be effected.  This  labor has
 been necessary, and all honor  to  those  who  have
 patiently toiled to build the tower which is now be-
 fore us, accumulating by slow degrees the material,
 and endeavoring to test, by the crushing  process of
 investigation, the individual blocks offered often  by
 minds as ready to impose upon themselves as upon
 others.  It  was necessary that the ground should be
 painfully and laboriously surveyed; the rough places,
 if possible, made smooth,  and the hills, perhaps, a
 little lowered. It was necessary that the whole army
 of laborers, from Hippocrates to Louis, should have
 toiled to fill the vast abyss  of ignorance, each bring-
 ing the  quantity of fact that he  could accumulate.
 Thanks to  them that this work has been done.   By
 their toil, the ground beneath  our feet  has become
 in a  measure hard and firm, and it behoves us, if we
 would show ourselves the worthy sons of such sires,
to step boldly upon the  causeway which they have
made ; and, unterrified by the seas of doubt, which 
23
still  dash  their waves up  its slippery sides, half
blinding us with  the spray, to push  for  the  other
shore, where is offered, as a prize, a solution, partial
though  it be, of the  enigma which has  been pro-
pounded to man, since the world began,  the know-
ledge of himself.
  I have said that, apparently, we have arrived at a
period in medical  science when it seems probable
that investigation  is about to take a new direction;
to turn  from the  previous  simple  watching of the
effects and proofs of disease, and  apply itself to a
more complete  analysis of the  nature  and causes of
these effects.  The investigation is about to become
more minute  and searching, directing itself  to the
primary and more simple actions of  the economy,
and laying the foundation of the knowledge of the
larger and  more marked manifestations of disease in
the understanding of the less complicated operations.
The results  of such investigations   may be  only
looked for  with the eye of a hopeful imagination ;
but it is something,  if sensible of our  wants, we are
encouraged to strive for their satisfaction.
   Patient investigation, and long continued observa-
tion, have  taught  us that there are a certain class  of
diseases, over which, when  once they have laid hold
of the  body, we  have  little, if any, control.  Such
diseases are typhus,  typhoid  fever,  the  eruptive
fevers, <&c, to which we have given the name of self-
limited  diseases, and which would seem all to agree
in this  point that  they  in fact are  the  endeavors 
24
of the system to free  itself from some poison which
it  has received  from without; which attempts  we
have learnt are not to be counteracted ; our attention
being  required only to give assistance if these  en-
deavors fail, or to meet any accident that may arise.
Now is it too dream-like to look forward to  the time
when  something may be known of  the nature of
these poisons, or at least their antidotes be discovered I
For the prevalence of smallpox,  it is necessary that
we should have the  presence of the poison  and of
individuals with constitutions liable  to  receive  the
disease.   One of the circumstances necessary for  the
propagation  of  the  disease is  removed, when, by
vaccination, we destroy the  susceptibility of the in-
dividual by the modification of his system.  For  the
spread of British typhus, we must have a community
composed of individuals susceptible to the disease,
as all probably are;  and the poison, dependent, as it
would seem, in a great measure, upon bad hygienic
conditions.  We destroy these conditions, and  we
stop or retard the spread of the disease.   In the one
case we act  upon the individual liable to  receive  the
poison; in the other we counteract, and  in part de-
stroy the poison itself.
   Now, perhaps some great discovery of this kind,
with relation, for  instance,  to scarlet fever, may yet
reward patient research,—some modifier of the  sys-
tem,  destroying its  liability to infection, or  substi-
tuting a milder and  less virulent form.   Such a  dis-
covery, it is true, can hardly be expected to be made 
25
by any investigation directed for the purpose, as it
would be impossible to  know  with what class of
agents to experiment.  If it  be made,  it  will be
the  result,  as  was  vaccination,  of the fortunate
chance  that  the fact of the immunity of the milk-
maid  was brought  under  the  observation of an ob-
server like Jenner.  But  the fact  that such a disco-
very has already been made  as  regards  one of this
class of diseases, should excite suspicion that a simi-
lar law  may obtain with the others;  and keep us on
the alert, lest like those  before Jenner, we neglect
opportunities, which are  seeds dropped  casually by
the sower, for the reception of which we are bound
to keep our ground fertilized, so that if we are the
fortunate recipients, they  may not wither for lack of
nourishment.
   But although for new facts like these  we have no
means of knowing beforehand the direction in which
we should look, and though their discovery must in
a great  measure, as far as scientific research can be
applied, be  the result of a species  of chance, and
although when discovered we  may  know  nothing
beyond the bare fact, the laws of causation  being
entirely concealed, we are not in all instances com-
pelled to a like inactivity.  We are not compelled
to sit beside the  stream, to  collect with uncertain
o-rasp and rude nets the rich debris which are wash-
ed by chance and irregular torrents  from the un-
known  mountains of knowledge and  truth.   We
may often explore  for ourselves to the source, or by
          3 
26
well contrived canals and scientifically  constructed
works  so  guide the stream, that it  may deposit its
golden treasure where we shall  be  free to use and
apply it as our wants may indicate.
  The change now taking place in  the direction of
the  studies of the medical observer, consists  espe-
cially,  as  I have  pointed out, in the more  exact
examination of the minuter  actions of  the econo-
my both  in health and  disease.  This more minute
examination  consists  in  the  study of the  phy-
sical  and  chemical changes   which  are  wrought
in the components of the fluids, and  through  them
in the solids of the  body in its various  conditions.
And surely, from the new light that has been thrown,
upon the  pathology of the blood for instance, and
its changes in  different  diseases,  we may anticipate
the arrival at some discoveries in treatment—disco-
veries, it may be, as yet far distant, but upon the  track
andscent of which  we feel ourselves well set. Hunter,
with that  power of anticipating truth  which would
seem the attribute  of genius, and which, gifting its
possessors with something almost like inspiration,
enables them  to  scorn  the slow process  through
which  the common herd  of observers must  struggle,
boldly  claimed organization for the blood.  What
he foresaw and announced, is now  proved and ac-
knowledged ; and as a consequence, already diseases
are beginning  to be  classified  as  this fluid is influ-
enced by them. If the results of modern research be
true, and  it would appear that  certain  points are 
27
well established, we  are authorized in regarding the
whole class of inflammatory diseases as presenting
this single circumstance in common, that the blood
becomes overloaded with fibrin ;  and moreover there
is some ground for belief that this fibrin is derived
from the tissues of the body, is in fact effete matter,
and must be discharged by the emunctory fluids ; or
in  other words,  inflammatory  fever  represents  a
condition of the system in which there is a more active
consumption of the body than  in health, and when
consequently the fluids of the system are surcharged
with the products  of  this  consumption.   One in-
 dication  clearly pointed out by these discoveries,
 would  then appear to be the re-dissolving of this
 fibrin,  by  which it might be enabled to pass the
 more  readily  from the  secreting  organs of  the
 system.  This may  not be all that is  necessary, and
 the  various local causes  of the  inflammatory fever
 may each  require  peculiar treatment; but here is
 one great  circumstance belonging to all, furnishing
 grounds for  at least one portion of the  medication
 which may be common to all.
    A theory in medicine is looked upon with an eye
 of distrust, the bad name  which it  has  earned  by
 centuries of misapplication has continued with it to
  the present  day,  and  has  deterred  the  minds of
  pathologists from  any  attempt to employ  it in its
  real and just sense.   But, in  truth, a theory is  the
  mere  assembling of facts that have  been observed,
  the statement of the laws governing those facts,  the 
28
attempt, by pointing out the resemblances between
various phenomena, to reduce  them under general
laws, and the expression by a formula of a demonstra-
tion satisfactorily proved, but  with the individual
steps of which we agree not to burden  our  memo-
ries, knowing  that  they are safely recorded for use
when needed.   The formation  of a well grounded
theory in medicine is of very considerable assistance
if not of vital importance to its progress.  It gives
force and direction  to  research.  By it  we are ena-
bled, in a measure,  to control the circumstances we
wish to examine,  and  to raise ourselves,  in some
degree,  above  mere passive  observers.   A theory,
even though it may be obliged  to depend upon hy-
pothesis for some of its supports,  may be an  aid
in progress and assist  in the  ultimate arrival  at
truth.   The  bold  theorizer, although   often  mis-
taken,  will probably accomplish more results than
the  one who  contents  himself  only  with  point-
ing out defects, declining any of the good, because
it is mixed  with evil.   The office of the  theorizer in
medicine may be not inaptly compared  to that of a
class, numerous at the present  day, who occupy
themselves  with the various questions of reform in
morals.  Their persevering insistance upon  one idea
renders them very disagreeable,  and sometimes even
may excite  the wish that Ave had lived in the times
of a blissful ignorance of so much moral duty; but
candor compels us  to  allow, that mainly,  by such
persevering action, are  the  great results obtained. 
29
That a great movement may be made, it is necessary
not to keep the eye fixed solely upon the ground, lest
perchance we may stumble, but we should endeavor
to give heart and strength to the limbs, by a hopeful
contemplation of the  end of the  journey, distant
though it  be, and  then we shall the more readily
recover from a misstep.   The vice of the old theorists
was, that  they first formed  the theory, and  then
either  endeavored to find facts to support it, or pro-
ceeded upon the supposition that they were already
found.  Modern medicine first observes, and on the
basis of its observations builds  its  theories.  Mo-
dern medicine attempts, from  its observation of the
minute operations of disease,  to  discover the active
principle, the  essence of  the disease, in the  hope
that the simplicity  of this may  be  some guide to
the discovery of the points of resemblance in  forms
now appealing  almost too complicated for  analysis
and reduction to simple laws.   And surely we should
apply  remedies  with more certainty, with  more ac-
curacy, if we could arrive  at what really is proposed
when  an attempt  is  made to establish a theory;
which, in good truth, is simply a statement of what
is actually the condition of the body under the  in-
fluence of the disease.
   The humoral pathology, with  its peccant humors
 and critical evacuations, was  dominant  in  medicine
for a series of years;  built upon no facts,  or  upon
those  which it misapplied, it crumbled before a so-
 lidism, which," while  it had  the advantage that it
           3*
NATIONAL L'-^Y OF MEDICINE
     WASHINGTON, D. C. 
30
was  able  to claim a foundation upon appearances,
which could be made evident to the senses, forgot
that  these appearances  were only the signs of the
ravages of the disease, and threw no light upon the
cause by Avhich they were effected.   It was necessary
that  medicine should pass through this condition,
since by this,  one portion of the  subject was tho-
roughly understood, but by this means  little light
was  thrown upon the treatment of disease,  except
in as far as it  pointed  out that certain  methods of
practice were  contra-indicated  and to be abstained
from; that with certain morbid conditions of inter-
nal organs certain drugs were incompatible—but it
furnished  few, if any, positive  indications.   One of
the  constant accompaniments of typhoid fever was
shown to  be ulceration of the  intestines; and this
led  to a distrust  in antimony as a remedial  agent,
but no substitute more efficacious  was pointed out.
It would  appear the tendency  of modern medicine,
that it  seeks  to  go behind these gross products or
effects of  disease; and in so doing,  adopts its own
theory of  a humoral pathology and  critical  evacua-
tions.  It assumes, for example, that there is ground
for belief  that a theory for an explanation of many
diseases may be found in the idea, that the materies
morbi is something entering the circulation, and con-
tinuing, either as an active agent by itself, or  so mo-
difying the other principles which it meets, that the
visible phenomena styled the disease are produced,
which phenomena are the Avorkings of  the  system 
31
for the discharge of this product or its  results, by
some  of the natural outlets.   The  theory  of the
action of the morbid principle may be found  in the
effects of an alterative drug, administered in excess,
in Avhich case Ave observe certain febrile  symptoms,
certain uneasinesses, complaints  in different organs,
and indefinable signs of mal-performance of function,
until  suddenly the fluid evacuations become loaded
Avith the offending substance  and order is restored.
   Noav, modern  medicine would appear to tend to-
Avards the belief, that disease in many instances acts
in this manner and by similar laws.   That the phe-
nomena of gout and its preceding conditions, show-
 ing clearly that  the relief  to the system comes after
 the deposition from the blood of the lithate  of soda
 in the different situations where the gouty swell-
 ing  takes  place,  or by the  great emunctory the
 urine, are  only  indicative  of  Avhat   occurs   in
 many other diseases; as for instance in rheumatism,
 although  in  this case  the actual morbid influence
 has  not been chemically  shoAvn to perfect  satisfac-
 tion.   In fact,  in many  diseases, it Avould appear
 highly probable that there is a defect of elimination
 of certain principles, perhaps inexplicable at present,
 the  result either of an introduction directly from
 without, or of the modified  actions of  the economy
 itself.  The  constitutional origin of local  diseases
 has been  long  since recognized, but modern medi-
  cine suggests that  the key to the right treatment
  of these  diseases is  the  recognition  of the elimi- 
32
nating  effort which  the  system is making ;   and
this elimination, it is clear, is not to be advanced by
an  indiscriminate application of drugs which have
the  reputation—and  often only the reputation—of
addressing themselves to  particular organs,  but in
the  accurate  study of their real  action  upon  the
fluids which are the vehicles of elimination.
  In other  words—as  in agricultural  chemistry.
when Ave find that the products of  a field  no longer
ansAver expectations, that the ears Avhich once stored
the barns of the farmer now only yield empty husks,
Ave do not indiscriminately apply a  manure, but seek
rather to discover the  principle abstracted from  the
soil, and endeavor artificially to supply that; so in
medicine, as modern science indicates, Ave must pro-
ceed if Ave hope for successful results.  The formula,
then, the theory of many diseases, as vieAved by mo-
dern medicine, being  represented by the one idea of
elimination of morbid influences, the medication must
necessarily consist in assistance  offered for this pur-
pose.  That  the  methods  of this medication are to
be found in discoveries made and to be made by chemi-
cal investigation, can hardly be doubted by any fair-
minded observer. The minute investigation to which
I have alluded, availing itself both of  chemical  re-
search and microscopical  examination,  and yet not
overlooking the existence of conditions, Avhich escap-
ing these, can only be  predicated from their effects,
must necessarily be the path to correct results, if cor-
rect results are attainable. 
33
  When avc learn that scrofula consists in the depo-
sition  in  the tissues, of an  unorganized  product,
Avithout connection Avith parts  in its vicinity, and
acting only secondarily by irritation ;  Avhile, on  the
other  hand, cancer is a product  endoAved Avith an
actual increase of vitality, appropriating to itself the
nourishment of the rest of the body, and draining like
a parasite the parent trunk that supports it, Avhile at
the same time it remains itself, at this primary stage,
without advancing towards  any higher condition;
when avc learn these facts, avc cannot hesitate to be-
lieve that Ave have a more satisfactory knowledge  of
 the nature of these products, than if we merely  con-
 sidered them in  their gross  appearances.  We  may
 not claim to have made any  advance  towards their
 better management or control; but assuredly, if Ave
 can ever hope to  attain this desired result, it must
 be by means furnished by this  and  similar know-
 ledge.  It is evident that avc are in the right path.
    Modern medicine, then,  may  be said  to address
 itself not  so much to the diagnosis of disease,  as to
 the elucidation  of its nature as indicating the appli-
 cation of remedies.   The manipulations,  which are
 peculiar to these  investigations, are  apart from the
 general routine of the daily practitioner.   It is not
 necessary that  he  should be a good chemist or a
 good microscopist;  for results of this kind, he must
  depend upon others.   He needs only to  be perfect
  in all the arts by which the diagnosis of disease may
  be made out;  he must decide upon its  actual pre- 
34
 sence  by broad and well-marked  characters which
 he has learned to  recognize ;  but his treatment may
 be influenced by Avhat he can learn from those more
 especially applying  themselves to these  researches.
 And in his  turn he may temper their enthusiasm,
 Avhich often leads the most cautious to theorize too
 rapidly, tempted, from the very distance of the result,
 to grasp  even a factitious  reAvard for their labors.
 The necessity that future investigation,  the direc-
 tion of Avhich I have pointed out, should not be left
 entirely in  the hands of mere chemists, unassisted
 by the true  medical  practitioner, may be seen in the
 many errors into Avhich a distinguished chemist has
 fallen, Avhen he attempts to  theorize upon the more
 complicated processes of disease.  The formation  of
 a theory of  disease is too vast an undertaking, and
 requires  an  analysis of too  many conditions, to be
 left in the hands of an investigator of only a single
 portion of the subject.  Knowledge must be brought
 from all quarters, and from  none must be scorned;
 and to point out from Avhat  quarter of the heaA^ens
 the next beam of light may appear, has  been the
 object  of this discourse.

   In conclusion, I may be  permitted to allude to
 the cause that  Ave,  as a society, have for congra-
 tulation  in  the successful result of Avhat last year
 Avas a commencing experiment.  The  principal ob-
ject of our organization is to  stand  in the place of
 the Parent Society to the indiA'idual  members of the 
35
District, Avhose Avants and  necessities  can evidently
be better understood, and the required legislation
better applied, by those immediately interested.  The
chief end  of this legislation is the management of a
medical police, having for its object the control of the
conduct of individual members. The exercise of this
right, Avhich is almost the only active step Ave can take,
at once opens  the question  of Iioav much an organiza-
tion like ours is conducive to  the advantage of the
public.  A superficial observer might ask Avhy, since
in the kindred profession, the law, no disadvantage
has  been  felt  from the abrogation  of  the Bar llules,
and leaving the mal-practising attorney to the keen
eye  of  the public, it avouIc! not be as Avell to leave
 the   rank and consideration  of the  practitioner of
 medicine to the enlightened  self-interest of his em-
 ployers, and by so doing, avoid those jealousies Avhich
 are  apt to be excited by the league of numbers, even
 for  a harmless purpose,  and Avhich  sometimes pro-
 ceed even to sympathy Avith the  offender, Avho  is
 receiving a  punishment  Avhich  is conceded to be
 just.
   This objection is specious, and if our organization
 had for one  of its  objects any direct advantage  of
 our own, as the establishing of belief in any particular
 medical dogmas as  a standard of membership, or the
 fixing of any sum Avhich  we  would  demand for our
 services, ostracising those Avho might be willing to
 serve the public for less,  the objection would carry
 considerable weight, and  our continuance would be 
36
a question of interest solely, to be decided according
as Ave had the power  to  maintain our  requisitions,
whether we avoie of so much importance4  to the public
that they would yield to our demands, or would sup-
ply themselves clseAvhere.   The same question Avould
arise as in a strike of a class of operatives, and Avould
be settled in exactly the  same Avay, according as the
supply  of, or demand for our services  should prove
to be the greater.
  But our organization  contemplates  no  such ad-
vantage for ourselves.   We are leagued  together,
but this league does not,  strange as it may sound, so
much confer adAantage upon ourseh^es, as it prevents
us from taking advantage of the public.  The skill,
talents, honesty,  &c, of an attorney, can be readily
estimated  by those Avho are desirous of employing
him, and the estimate is generally correct, because it
is  made upon a subject that  can be readily under-
stood by those interested.  But Avith our profession
there is this difference.   The public may perhaps,
in the main, be right in their judgment of the skill
of a medical practitioner, and  we do not attempt to
interfere in the formation of their opinion on this
point; but Ave do say that the public are peculiarly
prone to deception upon  the point of his  honesty,
Avhich is of  equal importance to them  as his skill.
No one  can  doubt that a Avell-educated medical man
might  actually make more money,  and create for
himself a greater reputation, and perhaps be of more
consideration among those who are accustomed, from 
37
their  talents and  education, to be regarded  as  in
some measure fixing social  position, if he chose to
divest himself of many of the  restraints Avhich our
Society imposes upon him.  Our Society says to the
public, Ave  will endeavor to  furnish  you with a
medical  practitioner, who, if you will  employ him,
Avill have for his first object your restoration  to
health.  He will not practise  upon your  credulity,
by exaggerating your actual condition; he will not
endeavor to impose upon you on subjects you cannot
understand, by claiming  superior sagacity, or  the
 possession of methods or means  peculiar to himself,
 increasing  his  demands  upon you from this pre-
 tended circumstance.   On the contrary, if, which is
 rarer than may be supposed, he shall  make any  dis-
 covery, he will not deprive suffering humanity of it
 for his  own advantage,  but will publish it, that its
 value may  be tested by  an experience larger than
 any individual may hope to have.  In one word, he
 Avill endeavor to  conduct himself as an honest man ;
 honesty being considered as a strict avoidance of all
 those tricks and  practices  which  are  calculated to
 deceive those Avho  are ignorant, as the public neces-
 sarily must  be.   If  we  chose,  we might practise
 upon the credulity of the public, and all the better
 for our education.  The ignorant quack is not the
 successful  one.  The public are the  prey of   the
 educated knave, and against him we would enter our
  protest.  In medicine, the public are prone to decep-
  tion, and  it is not to be wondered  at that the m-
            4 
38
 valid or his friends, in their  longing for health—a
 treasure, perhaps, gone forever—should be led  to
 disregard indications  wilich would render them cau-
 tious of employing an individual in any  other situa-
 tion of trust or  responsibility.   We, then, knowing
 the  ease Avith  which deception may be practised,
 voluntarily  relinquish our  poAver  to  deceive, and
 bind ourselves to be honest.  The advantage  is on
 the side of the public, and not  on  ours.   And this
 appears to  me the chief, if not the only argument
for an organization  like  ours, prescribing rules of
 conduct for its members, and requiring entrance into
its  ranks;  and, moreover, this  argument  appears
 perfectly conclusive.
  It is no proof against the doctrine I have advanced,
that Ave may not ahvays succeed, and that dishonest
men may be able to shelter themselves in our ranks,
 and defy  our attempts to expel  them.   We may be
 unable to do good, but Ave certainly can do no evil-;
 and even in cases of failure to execute our rules, we
cannot doubt that the knoAvledge that the vigilance
of members is aroused, Avill have a Avholesome influ-
ence, and the real vieAv taken of certain practices by
the upright members will be shown  to the public.
  Another object of our organization is the monthly
meetings for medical improvement. These have been
faithfully maintained  during  the past year.  If the
 attending numbers have been small  in  comparison
with the  whole  number of the  Society, the reason
should be  sought, not in any  lack of interest in 
39
scientific discussion and information, but rather  in
the fact that the ground has been already occupied
by two  other  societies  having similar  objects, and
that scientific subjects are better managed and dis-
cussed by individuals brought someAvhat closer than
is possible in a society as large as ours.   The zeal is
not wanting, but  has been  employed  in another
direction.
   The object of the Society has been attained in the
union of  respectable  practitioners in  the mainte-
nance of the medical character free from all reproach
 of dishonesty or charlatanism, and for this purpose
 there is  no doubt that it will be continued  suc-
 cessfully.

    In bringing to a close an address commemorative
 of an anniversary, it is natural to review our ranks,
 and to pause a moment over  the  vacant places of
 those who have gone  to receive the reward of their
 labors.   But Avhile we mourn with those who mourn,
  and maintain for the departed the  faithful and fra-
  ternal remembrance  Avhich we trust will be the meed
  of us all, let us not forget to offer up our thanks to
  the Power who still preserves to us, as bright exam-
  ples those fathers  of medicine, whom, through so
  long a series of years, we  have delighted to honor.
  Under their instruction the greater part of us have
  sat • to their counsels, their wisdom, their prudence,
  their  right-mindedness, we  owe  whatever of these
  virtues we may claim. 
40
   By their examples they have taught us, that while
a steady front is to be maintained against hasty in-
noA'ation, the part of true catholic Avisdom lies in a
candid  and fair examination of all vieAvs, and in
keeping the mind free from that blind distrust Avhich
scorns the  consideration of a proposition merely be-
cause it is  neAV.   By them, every improvement  has
been Avelcomed, and ever}- right endeavor appreciated.
And  we uoav see, in the mind's youth triumphing
over  the body's age, the reward of a loyal reception
of Truth.   May they long be continued to us as
guides,  and may their  remembrance enable us to
transmit to those  who  shall succeed  us, the inherit-
ance Ave have been so fortunate as to receive directly
from them. 
s 
NATIONAL LIBRARY OF MEDICINE
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