THE RECIPROCAL ATTITUDE OF THE MEDICAL PRO- FESSION AND THE COMMUNITY. THE ANNIVERSARY ADDRESS BEFORE THE MEDICAL SOCIETY OF THE STATE OF NEW YORK, AT THE SEVENTY- EIGHTH ANNUAL MEETING. DELIVERED AT ALBANY, FEBRUARY 6, 1884, BY ALEXANDER HUTCHINS, A.M., M.D., OF BROOKLYN, N. Y., PRESI- DENT OF THE SOCIETY. There is a medical science, but if medicine were a science only, there would be fewer medical schools than now exist. The former part of this proposition has been flatly denied. The im- pression is prevalent, and the expression of opinion frequent, that while much learning has been amassed in medical research, the results thereof are so unrelated, and the conclusions so untrustworthy as a basis for future observers, that, even conceding that some of its methods are scien- tific, in the catalogue of the sciences it is to be classed among the em- pirical, and not in the exact. The scope of intellectual activity has varied with many epochs and many climes, and the verbal definitions that have marked the limits of one epoch are not applicable to the ranges that have been traversed by thinkers and investigators of later periods. Aristotle, as a naturalist, holds a fixed relation to zoological science ; so, likewise, does Cuvier ; but the types of Darwin have disentangled and wrought into new shapes the words that defined the science of the Frenchman and the Greek. The schoolmen of the middle ages found the beginning of things far posterior to the times into which the Egyptologists of to-day have groped, and the forms of speech that outline ethnology in this year of grace would have been cabalistic and meaningless to the thoughtful brows in whose presence men paid homage in the days of Charlemagne. The marble busts in our own Pantheon cause in us obeisance to the venerable and 2 honored men who wrought and healed to the world’s great good ; but the man of Cos, who framed the oath to which we have all subscribed, would need to learn his alphabet anew, were he to attempt the terms that limit the medical science of this later century. Scholars there have been in all ages, and through each era in the growth of knowledge, as leisure or inclination prompted, the lines have been sharply drawn between those who have wrought into new forms truth that has been revealed, and those who have labored in the discovery of truth to which the world had, hitherto, been a stranger. No com- parison can be instituted between Bancroft and Agassiz. The scope of the sciences has been so enlarged as to affect many anti diverse directions of investigation, where the investigation has developed an orderly arrangement of facts and principles; and classified knowledge, in any special line, elevates that knowledge into the rank of the sciences. Still, words have a recognized application, and, although there is a legal science, the Supreme Court is not a scientific body. Knowledge is so interwoven, one branch with another, that a rich cul- ture in one line of research implies and necessitates extensive knowledge of related studies ; and this advance of general knowledge is the result of advance of special inquiry, and stimulates to the greater subdivi- sion of special study. The number of the sciences increases with each intellectual epoch, and the sciences themselves become the subject of grouping. Human anatomy is a science, and in its orderly classification of structure and relation, was a science long before the dependent science of histology unraveled the closely-woven web that held so many mys- teries in its fast embrace ; before physiological science lifted the veil and disclosed the inevitable necessities of related structure; before chemical science touched with her magic wand the sealed volume where lay in- scribed the hidden processes of waste and repair ; before pathological science began her study of the myriad variations from the ideal type of structure, and of the utmost bounds where the interrupted harmony of process becomes discord, beyond which is dissolution ; before the science of embryology all but touched the confines where the creative force starts the complex human mechanism in its infinite reproduction ; before com- parative science demonstrated the unity of animal organism ; before bio- logical science grouped all living organization, to make clear the intimate similarity that exists in all structures informed by the element called life. The results of the world’s labor, which have become the foundation of medical learning, are on open pages which all may read. Not with gigantic strides have the distances been traveresed, not by herculean labors have the stones been placed, but slowly, patiently, insensibly 3 have the toiling students of living things observed, recorded and grouped, one generation after another, names multitudinous and lost to history, till the student, who starts afresh to-day, stands debtor to a scholarly an- cestry, as remote as the world’s past, connected with a succession of humble ministers on nature, as remote as the world’s end, whose ab- sorbing inspiration is the genius of true scholarship the wide world over— the search for truth and its free gift to mankind. Though biological research is a new phrase in science, its multiform processes and the character of its results, have been identical, all along the history of the investigation of life, before they were compacted into the more modern classification. Medical science assumed her unique place among the sciences when the facts and phenomena, evoked by biological research, were made the basis of investigation, whose purpose is to prolong the vital process and arrest the untoward influences that perpetually threaten its extinction. This is her distinctive mission. The facts are not wanting to support the belief that, through the varying civilizations, the protection of communities has been the object of her forethought, and hygienic measures have shaped themselves into laws ; yet it has been reserved to the present century to enunciate the problem of how communities are to be protected, and to formulate laws in accord with strictly scientific methods, looking to the prevention of dis- order and the prolongation of human life ; yet the individual has always been the object of her solicitude and the record shows how persistently, according to the lights of each era, the precepts of personal hygiene have been inculcated, and how, with each marked acquisition in scientific knowledge, scientific methods have been applied to the preservation of the individual. There is a luminous record of proof to show that the brilliant achievements in principles and detail, that have been applied to the recovery from disordered process, have been the rational outcome from an antecedent advance in scientific inquiry, could not have been possible without that knowledge and have not been merely hap-hazard and accidental. It is clear, also, that the tremendous strides in scientific knowledge the present century has witnessed, springing from the in- creased facilities for the diffusion of knowledge and the rapid inter- change of thought, have been the impulse to the intelligent and far- reaching and exact methods, that have prolonged life and increased the sum of human happiness among the civilized races. The instruments of precision, that have contributed so much to exact knowledge of normal structure and activity, have been supplemented by instruments of pre- cision that settle the terms of definite prognosis. The appliances for dis- tortion, the agents that avert the shock of operation, the simplification of 4 treatment through the known sequence of morbid phenomena, the sep- aration of the active principles of remedies, the differentiating selection of therapeutic measures, the discriminating nomenclature, the humane treatment of the insane, and the skilled knowledge that has made possi- ble the bold measures of surgical interference, are results based on scien- tific research and but for that would not have been possible as instances of methodical procedure. Though some names are inseparably connected with the beginning of certain movements that have become classic, as Simpson with chloroform, McDowell with ovariotomy, Von Graefe with glaucoma, yet the rule is so invariable that the principles and details, which give accuracy to the rec- tification of morbid process, have had, for an antecedent, precise inform- ation of normal activity derived from so many sources, that priority of claim can rarely be made good. The body of medical science is the slow accretion of the centuries, and the contributions to its learning are too numerous for the historic pen. The results of yesterday are the alphabet of to-day. Dogma is flashing but evanescent The multitude of observers and the host of journals which give rapid interchange of thought, betoken the industry which gives it distinguished place in the procession of research. The unproven is rapidly discarded, the good is improved upon and becomes common property. Hut seventy-five years have gone since the ovarian cyst was exsected by the grave Kentuckian whose honored memory his grateful brethren have perpetuated by the granite obelisk* in the Danville churchyard, and by a skilful use of ex- ceptional opportunity the Scottish chieftain is justly credited with having added hundreds of years to woman’s life; and not only that, but, wher- ever this literature has reached, men, whose names can never become historic, are performing this merciful task with assurance and success. Hut fourteen years have gone by since the turf hid the gifted Germanf who revolutionized the operation for cataract, but, even now, the great centres show a phalanx of men whose skill is greater, as their experience has increased. Hv the very genius of the science this history of progress and change must always be repeating. The days rapidly hasten on when the names of McDowell and Von Graefe, of Keith and Sims will be prominent only as land-marks. The apotheosis of the laureate rings aloud of this company as of none other ; Men, my brothers, men the workers, ever reaping something new. That which they have done but earnest of the things that they shall do. Within the past yearj the father of English Vital Statistics, Dr. William Farr, died at the ripe age of 75 years. In 1837, at the age of 29 years, * Erected 1879. tAlbrecht Von Graefe. died 1870. (April 14, 1883. 5 he published the first English registration report of vital statistics. Bv a singular co-incidence the same month in which his death occurred, Mr. N. A. Humphreys read a paper before the Statistical Society on “The Recent Decline in the English Death Rate and its effect upon the Dura- tion of Life,” wherein he analyzes the Registrar General's mortality statis- tics covering 45 years (1838 to 1882). The comparison of Dr. Farr's and Mr. Humphreys’ new life tables shows that the mean duration of the life of males has increased from 39.91 years to 41.92 ; of females from 41.85 years to 45.25 years, or of a generation from 40.86 years to 43.56, showing an increase of 2.70 years equal to nearly seven per cent. Of course, the importance of this showing is due to the fact that these results are traceable to the enforcement of State medicine and hygiene during this same period. “Although a large proportion of young people cease to be dependent before twenty, and a large proportion of elderly persons do not become dependent at sixty, we shall not be far wrong in classing the forty years from twenty to sixty as the useful period of man's life. Table IX. shows us that of the 2,009 years added to the lives of 1,000 males by the re- duction of the death-rate in 1876-1880, no less than 1,407, or seventy per cent., are lived at the useful ages between twenty and sixty. Of the remainder of the increase, 445, or twenty-two per cent., are lived under twenty years, and 157, or one-eighth per cent., above sixty years. Thus of the total increase seventy per cent, is added to the useful, and thirtv per cent, to what may be called the dependent-age periods. The increased number of years lived by 1,000 females, according to the rates of mor- tality that prevailed in 1876-1880, is 3,405. Of these (see Table X.) 2,196, or sixty-five per cent., are lived at the useful ages between twenty and sixty ; 517, or fifteen per cent., under twenty years of age; and 692, or twenty per cent., over sixty years.” “Looked at from another point of view, there has been an addition of three minutes for men and five minutes for women in England to every hour of their existence, and under her present conditions a country with a population of thirty millions would, at the end of a generation, have two millions more inhabitants than under England’s previous conditions. “ Life is not only longer, but active life is begun later, and old age is more robust. We think Mr. Humphrey’s analysis of the Registration Reports will be acknowledged to amply justify sanitary legislation and expenditure.’* The one hundred years have just passed since Jenner’s observations and experiments in Gloucestershire f associated his name inseparably with the ♦Boston Med. and Surg. Jl., June 7, 1883. +1775. amelioration of small-pox. Fifty years later F.hrenburg and Dnjardin studied and described the various forms of monas, vibrio, spirillum, and bacterium, and the century hardly rounded before Schwann had shown that these bacteria are the cause of the putrefaction of organic substances, and Pasteur had extended this discovery so as to create the belief that all putrefactive changes are due to such minute organisms, when Lister had developed his antiseptic method based on these discoveries; when Koch propounded his theory that tubercular consumption was due to the bacillus ; when erysipelas and glanders and splenic fever and malignant charbon were shown to be due to special types of bacteria,* and Pasteur had inoculated the attenuated virus of malignant charbon as a protection to cattle and sheep from attacks of the severe forms of the disease, the immense importance of which discovery has been confirmed, this present year, by a report presented to the Veterinary Society of the Department of F.ure-et-Loire, showing that these vaccinations, practised on a large scale, had reduced the annual loss on these flocks from nine per cent, to iW of one per cent.f The ink is hardly dry from the presses that announce that Lacerda has discovered the yellow fever microbe, Xiehl the micrococcus of pneumonia, Koch the social bacterium of cholera, F.schbaum the micrococcus of gonorrhoea, Klein of diphtheria, Pohn-Pincus of scarlet fever, Leyden of cerebro-spinal meningitis, Fehleisen of erysip- elas, and Linard the bacillus of malarial fever, the intermittent activity of this latest “find’’ receiving a prompt quietus when immersed in a two per cent, solution of quinine—a baptism that would not involve regene- ration to much more highly organized creatures Whether all these and their similars are to stand the test of propagation by “pure culture, and wheel into the prophylactic column, who can say? Hut it would lie a risk to cast their horoscope. Whether the time is ripe to hang a man on microscopic evidence, or whether the time will ever come when the special vibrio of the assassin shall be diagnosticated from the spore of the bur- glar and the zoon of the concupiscent, are not questions angrily strug- gling for a reply. Humiliating as it has been to know, during the centuries, that “all flesh is grass,” the sentimentality of human affection is entirely upset as the apparent universal distribution of these swarming micro-organisms support the scientific accuracy of Festus when he in- formed his Helen that “The worm shall trail across thy unsunned sweets, And fatten him on what men pine to death for; Yea, have a further knowledge of thy beauties Than ever did thy best-loved lover dream of.’’ * Prof. Lankester’* Add res-, in Scttncr, Oct. ta, 1883. t Med. and Surg. Reporter, Aug. 17, 1883. 7 These discoveries increase rather than remove our doubts as to what lies beyond, but their far-reaching results, of which the foregoing are but hints, are the product of the present decade of investigation, and we stand but at the threshold of these directions of biological research. They serve, however, to show that “the results attained by those who have labored simply to extend our knowledge of the structure and properties of living things, in the faith that every increase of knowledge will ultimately bring its blessing to humanity, have, in fact, led with astonishing rapidity to conclusions affecting most profoundly both the bodily and mental welfare of the community/’ The attitude of the community toward scientific study is, primarily, that of antagonism. Innovation provokes opposition. There are many years, but one sentiment, between the persecution of Galileo and the on- slaught on vivisection. 1616 has somewhat of kinship with 1884. To the great mass, whose interests are mainly confined to the harsh treadmill of life, “ Storing yearly their little dues of wine and oil,” scientists and scientific study are a matter of indifference, not infrequently mingled with contempt. Popular government has never initiated any movement to promote research, for that implies a cultivated sentiment among the voters, and the English-speaking nations have done almost nothing in the way of State appropriations for scientific study. Germany, France, Russia, Holland, Belgium and Italy are, almost exclusively, the originators of the later methods. From their laboratories have come the great discoveries of modern times, and this, because, in these countries, the laboratories have been under State patronage. The most that has been done in England and the United States, has been done by those men whose capacity for scientific discovery has been accompanied by the possession of private fortune ; the remainder has come from work incidental to the occupation of professorial chairs. Professor Lankester, in an address to the biological section at the late meeting ofthe British Association, has gone over this subject in detail, and, while he has provided nothing new in the way of argument, in his comparison between the scientific resources of England and Germany, he has stated some interesting statistical facts. While Germany, with its 45,000,000 of population, has 21 universities with 100 institutes devoted to the prosecution of biological study, providing posts for 300 investiga- tors at an annual cost to the State of about $3,000,000, the annual ex- penditure of the 21 universities being about $4,000,000 ; England, with its 25,000,000 of population and its greater wealth, has but four univer- sities, which possess endowments and professoriates, containing but 38 8 positions. The author quotes the prime minister, who has taken much interest in science and learning, as saying that the $135,000, the capital sum expended on the Nottingham College of Science, “was a very im- portant contribution to the support of learning in that country.” In this country, neither the nation, nor, to my knowledge, any State has done the first thing to further scientific research directly. Much has been done for iudustrial education, and a great deal of research is really carried on under cover of state and government appropriations, but all is of secondary moment to the powers that be. We have, in the Govern- ment, the Geological Survey, the Coast and Geodetic Survey, the National Observatory, Museum, Nautical Almanac, Signal Service, &c., &c., Ac., and, in the States, the Fish Commission, State Geological and Topograph- ical Surveys, Museums, laboratories, Agricultural Stations, and what not, but all were established (and receive their support in view of the work they do) for some “practical" end. Valuable results have been ob- tained by the great and admirably conducted exploring expeditions in the West, but these have been incidental. The surveys had a practical aim which would have been accomplished without the scientific observa- tions and the collections which were made. Similarly, the valuable ob- servations of the Signal Service form contributions to scientific theory and practice, but the end is practical. The same may be said of the National Observatory at Washington. The Smithsonian Institution indirectly combines research, publication and collection. It has been magnificently managed from the first, but it was the endowment of an Englishman. The State Survey of New York and Pennsylvania, the former under Prof. Hall, the latter under Prof. I>eslie, have been prosecuted with a similar utilitarian purpose, though the results as published are a noble con- tribution to science. Scarcely any provision has been made until recently for biological science in an institution of learning, beyond elementary instruction. New research is contemplated in a few, notably in the Johns Hopkins laboratory and in the investigations by Dr. Martin in Cheseapeake Hay and at Hampton. This enterprise is due to private beneficence, and its results, especially in investigating the various modes of propagating the oyster, have induced the State to promote further studies in this single direction. Alexander Agassiz’s laboratory at Newport is supported en- tirely by his private purse. Prof. Baird’s work, viz.: that of the U. S. Fish Commission at Wood's Hole, has certain facilities placed at its dis- posal by the government, as a revenue cutter for soundings, &c., &c., but this was originally and mainly the work of the Smithsonian Institution, and remains in great part the same. The Museum of Comparative 9 Zoology at Cambridge is due to the enterprise of Louis Agassiz, though the State gave, in its aid, $293,000 in various bequests, while private individuals have given about $696,000.* President Eliot said, in an ad- dress in New York, that Alexander Agassiz’s gifts alone were worth nearly $1,000,000. He has built, at his own expense, a large addition to the museum.f George Peabody’s gift practically adds to the resources of the museum, though given for a specified purpose and under separate control. In some branches the museum surpasses, in its collections, the British museum and the Jardin des Plantes. Research is not the primary object here. Agassiz’s idea was to teach students how to observe nature, to educate naturalists ; but the great collections and the original investi- gations are now first, though courses of lectures and instructions are given. The Peabody museum at Yale is due to Geo. Peabody and to Marsh’s private fortune, while Cornell University in this State, which publishes bulletins of investigations by Prof. Comstock in entomology, the diseases of fruit trees, &c., by Prof. Prentiss in Botany, and others in agricultural chemistrv, veterinary diseases, &c., where Prof. Law is conducting a valuable series of experiments regarding inoculation for pneumonia, is again private munificence, supplemented bv the national land grant, which latter did not contemplate anything but instruction. This review includes most of the various scientific institutions, which exist in this country, and afford facilities for original research. There are, of course, several astronomical observatories, which have been established by private beneficence, as the Lick observatory in California, the Swift at Rochester, the Dudley at Cincinnati, and others, but these only illustrate the rule. The facts do not prove the basis of complaint. The scholars must always be the select few. Their audiences are gathered from narrow limits and, though their influence is to the bettering of the race, that influence is slow in diffusion. Scientific work is unselfish and not mer- cenary. Its productions possess, but rarely, any marketable value. Its inspiration is the discovery of the true and the zeal displayed has in it no element of personal aggrandizement. “There is generally little or no pecuniary reward for the success of the men of science. The public do not eagerly crave each new memoir on the higher mathematics. A crowd does not gather around the bulletin to read the discovery of a new- asteroid or organic radical." The bacillus of malarial fever might hollow- out the historic niche for its discoverer, though the discovery would not sell for a dime. The pursuit of that selected and diverse learning, which makes up the body of medical science, is entered upon and becomes an absorbing * Report of 1876. tReport of 1880. 10 passion from motives other than the expectation of livelihood or emolu- ment. Once within the arcanum and groping among the shadows and mysteries and uncertain lootholds of the strange land that lies above and below and around the crowded places, where the strile for existence and human greed trample one upon another, men will wade through mis- fortune, suffer privation, endure hardship and smile at penury, tranquil in the assurance that if, indeed they do not themselves enter the promised land, they will have made part of the road smoother for those who are to follow them. It is easy to see the force of what earnest men have plead for, that the tone and breadth of the civilization would be strengthened and enlarged were the community to recognize the ministry of its work- ers in science and foster thefr efforts, but the attitude of the public does not favor the expectation that this can be. The cultus of medical science must continue to share the experience of all original investigation and remain a personal factor among the diverse directions of human industry. Multitudes stand ready to seize the results of its labors and apply them, in ways that men can understand, to the satisfaction of human need. They whocull the flowers, enjoy the fruit, reap the harvest or sell the crop are of different mind and other station than they who till the ground, plant the seed, nurture the sapling and wait, through recurring seasons of sun and snow, till the sturdy limbs are shelter and refreshment to the unthinking life that recks not of its benefactors. There is a medical science, but if medicine were a science only, there would be fewer medi- cal schools than now exist There is an art of medicine and its multitudinous votaries attest the fruitfulness of its pursuit. In 1880 the States and Territories of this country held a population of 50,155,783, and of these 85,671 persons were enumerated as either phy- sycians or surgeons, a proportion of 1 to 585. In the State of New York there were 5,082,783 persons, of whom 9,272 were doctors, a proportion of 1 to 548. What the ample front doors of the medical colleges, with the signatures of numerous licensing bodies, have done, during the past four years, to swell the total, it would be hazardous to sj>eculate uj>on. But these salutary, health-forecasting and longevity-producing statistics stamp the effete and tottering governments of ?lurope with the die of derision, in their infamous disregard of human comfort, and put an extra gilding on Columbia’s protecting x*gis, prolonging the beauty of her daughters and the bravery of her sons ; for while the proportion of doctors to population in Switzerland is 7.06 per 10,000, in Italy, 6.10, in Hun- gary 6.10, in England 6, in Austria, 3.41, in (iermany 3.21, and in France 11 2.91, the United States with their 17.1 per 10,000 have consummated what Berkeley foresaw, but did not dare to write — WESTWARD THE EMPIRE HAS FULL SWAY. The causes of this disproportion are cotnplex and do not rest on the surface. If primeval man had no doctors, if the barbaric cultivate, here and there, a medical fetich, if the semi-civilized and the savage at times listen to the incantations of a medicine man, if free air and simple habits do not crave the overflow of medical schools and the smoking chimnies of manufacturing chemists, then, this great polyglot population, “in the foremost ranks of time,” with its superfluousness of civilization, and the interwoven tinsel and solidity of its citadel, must have need of this great standing army, “ to guard the chinks of stone against calamity.” When it is considered, what every one knows and what would be very difficult to put in statistical array, that large and sparsely settled sections of the country are below the average supply of the ratio of population to doctors, that a very large proportion of the population is not so materially favored as to contribute the average quota to the support of this body of men, it would appear, at the first blush, that the jeremiads, that have been pronounced by the pessimists over the decadence of the race and over the increasing disabilities of the people, superinduced by the demands of this intense civilization, had not been overdrawn. For, though it is fundamental in political economy that demand creates supply, it is also true that supply creates new demands, yet, beyond the point when supply exceeds demand, the supply begins to shrink. In the considered case, the demand seems not to be satisfied, for the number of doctors is increasing year by year, and that out of proportion to the increase of population, for the ratio is, likewise, becoming larger. Some solution of this problem may appear further on. Taking this State, for instance, and averaging the income of these men at the very modest sum of $1000 per annum, the sum total of their annual receipts is equal to the entire receipts of all the charitable institu- tions in the State for the last fiscal year ; and equal, also, to the amount expended on the public schools in the State during the same period, a total of about $10,000,000. As this average represents a cash income of about $3 a day per man, the basis of calculation is ridiculously small. Applying the same average to the entire force of medical "men in the country, the total income of the profession would be some $12,000,000 in excess of the total product of the precious metals during the past year. These are conspicuous comparisons, but one can form his own judgment as to how far these estimates are below the actual facts. However es- timated, they serve to show a liberal provision for one class of men, who, 12 with due explanation, cannot be said to belong, primarily, to the produc- ing interests of the country. As a means of livelihood, the profession of medicine is attractive, and little wonder need be, that its ranks do not, on this account, suffer depletion. From the social standard the profession elevates the man, no matter of what stuff he is made, if he does not ostentatiously disgrace himself. If he goes into Coventry, he goes in spite of the strong sentiment in favor of his guild, which would keep him back if it could. There are social grades, and physicians to fit each, and in each he is easily at th#e top, for no other class of men so promptly secures social place and recognition. The fact is patent and this .impulse is, certainly, not insignificant in the choice of a future. Combining the certainty of livelihood and the assurance of position it will, in this day, hardly be questioned that no other walk in life, in professions or affairs, holds out such positive promises of immediate reward and of continued permanence, to men of all ages and grades of ability, as does the medical profession. Coupled with the growing dis- taste for downright hard work and the'scramble for the easy places, facts go to prove that, with a determination not to outrage public opinion and an avoidance of nomadic tendency, any man, no matter what his ante- cedents of deficiency of culture, or failure in vocation, endowed with his doctorate, has an unshakable foot-hold in life. Despite the fact that every member of the profession is perpetually recipient of sympathy from his clientelle over his engrossment of time and irregularity of sleep, there is a larger success per thousand, with less bankruptcy, with freer and more varied opportunity, than belongs to any other class, in any of the lines of occupation along which men grope their way through time. It is superfluous, in this presence, to relate how gentle the acclivity that appears, how wide open the portals that invite, how roseate and ver- dant the paths that gladden, how radiant the sentinels that summon and assist the novitiates on their way to these easily-acquired places of esteem and support. With one chartered medical school to each half million of population, and the licensing authority of a vast number of other corpo- rations, the invitations to the profession are as urgent as the gifts of the degree are lavish. The restrictive barriers are so loosely set up, and the final test of fitness so daintily applied, that the former are cast down as easily as the latter is overcome. That a strong professional pressure, and a sense of the fitness of things, have elected some institutions to take a vigorous and exceptional stand on the side of rigidity, making their diplomas an assurance of capacity and a promise of an industrious and honorable career, does not affect the influence of the fact that in law, 13 privileges and immunities, all diplomas are on a level. There is not even the seclusion of an open secret, there is the common knowledge among medical men, that their ranks are recruited continually with men who, but yesterday, stood behind the counters and desks of all kinds of busi- ness, and who, by accident or vagary, suddenly were translated behind an office sign, having accomplished the distance in accord with the most perfunctory of formalities in the minimum of time. Whether this is wise or unwise, right or wrong, is not in the drift of this paragraph. The facility of admission is the pertinent fact. The time was, and the fiction has not wholly faded from common speech, when law, medicine and theology * were denominated the lear?ied professions, as distinguished from the professions of the army and navy, because a university education was a pre-requisite to these special studies. To-day, in the multiplication and distribution of special knowledge, this discrimination does not hold. The influences for the promotion of knowledge, and the manifold appliances of educational machinery have lifted up the entire people to a higher plane of culture, than any previous generation has enjoyed ; and the classes of journalism, literature and the polytechnic forms of industry, wherein certain lines are cultivated for purposes of livelihood, contain, within each, an amount of general learning, which can creditably accept the wager of any competitive comparison. Without abating one jot of regard for the supreme ad- vantage of early liberal education, it is, nevertheless, true that there are, in numerous professions and occupations, multitudes of instances of a liberal education not constructed within college walls. The profession of medicine has not kept her distinguishing place. Not that great men have arisen in other and various walks of life ; that is in the spirit of the of the time. Not that she has not had exponents in every decade, who have been the peers of the best; that is within the facts of her history. Not that general knowledge has increased so that her individ- uality has been lost; that would tacitly deny her immense scientific ad- vance and obscure the progress of her art. But her recruiting sources have been so many, her safeguards of loyalty have been so weakened, her probationary tests have become so insignificant, that however smile- provoking may be the mention of the wig and cane, there is scarce any- thing left of the old spirit of the knight and the prenx chevalier, and the proportion of medical men, who are in accord with the medical profes- sion at its best, both in knowledge of its results and in capacity to do, is rapidly lessening with the years. There is an inconsistency in all this which does not mitigate the com- *In 1880 there were 64,698 clergymen and 64,137 lawyers in the U. S. 14 plexity of the problem. The profession has never lost sight of the sacred- ness and importance of its trust, at least, if spoken words are not hollow and meaningless. Glowing periods of earnest speech have, over and over again, proclaimed its ministry of helpfulness, the value of human life to family and affairs, the supreme necessity of single-mindedness in this work of mercy, the rewards that come estimated in approving conscience, if not in coin, the need of persistent study and a ripening culture so that, faithful to his profession and loyal to his guild, the physician may be in- spired to unite the utmost wisdom of his time with the gentleness of sym- pathetic manhood, in restoring the stricken to the activities of life or soothing the inevitable passage into the beyond. These are familiar themes. And also, the inconsistency appears in the fact that there are no grades of responsibility. Men talk of important cases ; they mean, not gravity of disease, but the surrounding accidents of family, wealth, friend- ship and important trusts which stand in jeopardy of disruption or shock. And, yet, who shall stand arbiter over the relative value of human life? While it cannot be expected that all physicians shall be those who, en- dowed with varied resources, “unite the natural love of healing with the highest spiritual development," yet it would appear as if those, who are to stand on equal terms with the best, share the like rej)onsibilities and stand face to face with similar duties, should give some adequate guar- antee of fitness. If these statements misrepresent the facts, no charity should be permit- ted to condone the mistaken zeal that would abuse the opportunity of this platform and cast slander and reproach on the profession ; but if the statements are true, the safer plan is to examine the facts and it is priv- ileged to follow up the consequences. The profession of medicine, at its best and in its ideal condition, in- cludes a body of men, who, instructed in the medical sciences, studious in the observation of bodily disorder, conversant with the normal type of bodily condition, acquainted with the causes that subvert the normal type, expert in recognizing the tendencies to dissolution, and skilled in the devices that alleviate and restore, offer to serve the community for a consideration. The end of all medical learning is to make sick people well, to assuage the discomforts of the incurable and to promote the euthanasia. Abstracting this, medicai science, with the splendid results of its erudition and the achievements of its recondite research, is but a department of zoology, the natural history of the animal—man. The profession does not occupy a professorial or oracular tripod, from which knowledge is dispensed, on an endowment or a salary. On the contrary, personal time and labor are furnished, on which a price is set There 15 are no boundaries within which any one member has the monopoly. The restraints to destructive competition are based on the recognition that the wisdom of each is dependent on the experience of all. The matter of compensation for medical services has been handled with many degrees of sensitiveness, but, no matter what the particular fashion —of voluntary honorarium or established fee—the fact remains that the arts of medicine are practised as a means of livlihood. It is contrary to the popular understanding, but still the fact, that the cases, where money is amassed from the practice of medicine, are very exceptional. This compensation is governed by a variety of circumstances; but the rule holds generally true, that in any given locality or special department, the best is the most fully favored. “ We still talk of ancient heroes and even the lustre which clothed winners in the Olympian games, but nothing which the strength-worshipping Greeks could bestow in the way of popu- larity or public honors was comparable to the fame and substantial profits which fall now upon a man who much excels his fellows in no matter what.” Of course it is impossible to estimate how many of these 80,000 doctors confess the faith and reverence the lineage that are confessed and reverenced in this body, but it would be idle arrogance to assert that universal dishonesty is characteristic of the remainder which the com- munity is content to employ and compensate. When it is clear that the trade instinct does not exist in our own ranks, it will be time to attack competition on this ground. That special medical arts should be selected for purposes of trade is derogatory to the best interests of the profession as a whole, but where medical men are so numerous, and livelihood is at stake, competition will choose its own field of operations. It will hardly be doubted that the desire to benefit the patron is strong in most that practice medical art and that no class of practitioners is callous to failure. The sense of loyalty to the heritage and mission of medical learning has been so instinctive in its history, that any suggestion of its trade in- stincts has been met by prompt rebuke, and men have stood ready and valiant to oppose the charge that mercenary motives were the inspiration to the daily deeds of mercy and kindness, of forbearance and sacrifice, which have been its crown of glory and which none but those who have borne the burden and endured the trial, can ever know. It is, however, not only likely, but true that the increase of workers in a field, whose natural product would be sustenance for a less number, would develop ingenuity whose artificial forcing would prove a detriment to the soil. If impositions are practiced, are multiplied, if deceptions are in- stilled, so that the confidence of the community is abused or made sub- 16 servient to the material growth of any part of the profession, to that extent, or in that direction, the attitude of the profession is hostile to the best interests of the community, and the hostility is provoked by the mad rush into its ranks, which neither the profession nor the community have taken any measures to control. There is no need of the apology of this hypothetical statement. Charlataprv is rampart, and the name of doctor covers lies and practices which are a ruin and a curse to the people. Those who are true are forever on their defense against their titular par- asites and the stand for honorable manhood is weakened by the assaults of its irresponsible foes. In the multiplication and precision of the medical arts, in differential diagnosis and the consequent enlarged nomenclature, in the multifarious forms of therapeutic appliance and in the bold interferences of surgical practice, the best of the profession stand equipped with information and resource far in advance of any period of its history. By reason of this, its responsibilities are increased and the demand is greater for the exer- cise of conscientious and intelligent critical apprehension of the {>ar- tieular conditions to which this analytical knowledge is applicable. A good physician is not necessarily a learned man. Experience, sagacious observation, strong intuitive perceptions, with the minimum facility in advanced appliance, have made, and will continue to make, successful practitioners of medicine. But these are not the teachings of text-books and are not the themes of the medical lecturer. However, it will hardly be questioned that skill in differential diagnosis is the safe basis of treat- ment, and varied resources in medical art lead most rapidly to the best results; and the faithful student in the profession is the one most keenly alive to the importance of both. When the pre-eminent impor- tance of accurate diagnosis is considered, when the difficulties that environ its acquisition are appreciated, when it is understood how patient and enduring are the observations that lead up to the master} of the nomenclature of medicine and the comprehension of the varied ci n- ditions it represents, it is humiliating to hear the most profound dis- orders that afflict mankind bandied about in common speech as the veriest playthings of the hour. The diphtherias that come into homes as plentifully as summer showers over the landscape and pass away as soon; the peritonitis that disturbs the quiet Of the night and is dissipated with the morning dew; the pneumonia and spinal meningitis, that early recognition and prompt specific lead in a few days to vigorous health, are all recounted, with flippant unconcern,, in drawing-room and social circle, on the highway, in the mart. These are not the manufacture of the people, for the terms are foreign to domestic culture. It were refined 17 cruelty to charge upon the doctor such consummate ignorance; better far to credit him with the knavery that can command untruth to advance his interests of fortune. On the other hand, it is asking too much of credulity to believe that the attitude of the profession is friendly to the community, when the lavish gift of the doctorate puts into so many undisciplined hands the medical arts which are as potent for evil as for good. Is it too much to assert that uncertainty of diagnosis runs parallel with the free use of drugs, and that confidence in specific therapeutics decreases with experience at the bedside ? What inferences are deducible in this direction from the mul- tiplying drug stores and the rapidly enlarging business enterprise of the great manufacturing chemists? Is it supposable that the ingenious activity of pharmaceutic industry, in devising the protean forms and potencies of foods and medicine, is all on the side of the public interest? Does it appeal to the public direct, oris it profitable through the medium of the profession, who act as agents to benefit the manufacturer at the expense of the people—the only commission being the desertion of the tried for floundering experiment with the novel ? Does the per- centage from the truss-man and the druggist mean anything more than the struggle of incompetency to eke out a livelihood at increased cost to the people? Is the community safer with broadcast hypodermic morphia, aconitia and strychnia (vegetable medicines for- sooth) than with a blind surgeon exsecting a tumor from the axilla ? Whence comes this malaria, that has jaundiced the speech of men, but from the track of the scapegoat, making for the wilderness, burdened with the easy diagnosis of lazy incompetence? Has the clinical ther- mometer proyed an unmixed good, when every pyrexia is the impetus to indiscriminate quinine; and who is responsible for the “one cent a grain in pill or powder” that blazon in the sunlight, through colored globes in shop windows, along every thoroughfare ? Has the speculum contributed to the moral sense of the community, as prurient or needless interference, with most cruel vandalism, is invading the sanctity of the home and making the daughters of the land wise before the time ? Humiliating and unsavory though it be, the regnant fact holds true that, coupled with that large body of men, who acknowledge an ancestry of scholars and faithful students of nature, who base their art on principles which have survived criticism, who practice their art in the interest of the physical and spiritual well-being of their fellow-men. who.-e livelihood is a legitimate product of their worthy and acceptable service, there is an- other and large cl>s, known not only to the census enumerator but to the community, by the same name, with equal protection under the law, who, with insufficient culture and consciences dulled through habitual 18 and ignorant tampering with grave responsibilities, (described, lately, by an influential medical journal, as “hangers-on of whom any party would be ashamed ”), who are a standing menace to the community, which, accepting all as competitors in the race, gives to all alike its patronage and its support. While the history of research has proven that the community has been slow to recognize its duty to scholars, in facilitating their inquiries into the facts and phenomena of physical life, which have developed laws and expedients, so important and far-reaching in their influence on the well- being of the race ; yet the contrary holds true in the attitude the commu- nity sustains to medical art. Certainly, in this country at least, in the broadest sense, up to the limits of its education, the community has been a lavish patron of the agencies that alleviate disorder and a co-worker in enforcing the instrumentalities that prevent disorder. It seems a little absurd and contradictory that a life insurance company, whose assets are counted among the many millions, amassed through operations based on laws of heredity, statistical tables of mortality, the understanding of normal life and the natural history of diseased conditions, all of which are the product of the industry and acumen of medical men, should consider three dollars an equivalent for decision on a proposed risk which would mar or make its thousands. Hut it must be considered that special knowledge has a marketable value, according as it is possessed by the many or confined to the few. It is the characteristic and the glory of scholars, that their labors are a free gift to mankind, while the acquisition of knowledge, and the skill to apply it, are in the free oppor- tunity of any and all who may choose to avail themselves thereof. Whatever may be the criticisms leveled against the conduct of dispensary and hospital services, and apart from all considerations that attract ap- pointments thereto, it seems somewhat contradictory that the benevolent instincts of Christian civilization that cares for its poor, its helpless anil infirm, should accept as a gratuity, not the knowledge of the means of re- lief which is free to all, but the personal time and service of those who have acquired the means of applying the knowledge that relieves society of its burdens, and restores its pensioners to the ranks of industry and self support. But here, also, it must be remembered that the capacity to relieve is the instinct to ungrudging service, and, through all the history of medical art, in public institutions and wherever, in private life, distress has been found, the best gifts of the best men have been freely offered, without the least listening for the clink of coin. If the serpent had never trailed his way along the Euphrates' banks, primeval man might have been in this audience room, and biological 19 science might have spent its energies in extracting the secrets of normal life; but, “by sin came death,” and medical science exists to delay the inevitable doom. The community shrinks from the approach of dissolu- tion and simply asks of medical art that its pain be relieved and that it be restored to the plane where its activities may have full play. The saint, calmly and intelligently, looks death in the face; but the community is not a saint, is not calm, is not under the control of its intelligence, and, while there is hope of life, its emotions have the mastery, and it accepts any promises with docility and in full faith. The stolid indifference to life in the barbaric races, is replaced in the higher civilizations by an in- tense clinging to life, and the fear of death is the universal passion. In- telligence is in abeyance in alarm. If rational medicine marvels that its claims have not met with universal acceptance, it must admit that it has embraced too many incompetent interpreters and that its claims have not been properly presented; or it must, also, accept the common lot of ad- vancing knowledge, which is always ahead of the community, labor assid- uously and wait patiently, amidst opposition, for that larger culture which is of slow growth, when reason dominates emotion, and where supersti- tious awe, in the presence of the unknown, fades before enlightened comprehension of scientific truth. Certainly the community is not slow to accept the. offices of mercy, for while it submits patiently to all that is ordered by the profession, takes all its medicaments, undergoes all its operations, awaits the results of all its experiments and, unhesitatingly, believes everything it says, and quotes it, more or less correctly, for the neighborly benefit; the community, in its charity towards all, does not allow the profession monopoly in the practice of medicine, but, with its faith in drugs, and measuring their efficacy by the violence of their operation, it swallows on bare printed promises 60,000,000 dollars in proprietary medicines per year and assists the for- tunes of drug dealers to the extent per annum of 80,000,000 dollars more.* Such bland and childlike confidence is rudely shocked when a cosmo- politan daily asserts that “ expert testimony no longer occupies the place in public esteem it once held”;f when a well-known lawyer§ charges in open court that “you could buy the most honorable members of the medical profession as you could horses in the open market ”; and when a judge passes by the claims of the alienists || and appoints a dermatolo- ♦These figures are, doubtless, far below the actual facts. The census reports 563 patent medicine establishments, producing $14,682,494, and 8,592 drug and chemical establishments producing $3®*I Three times this amount, distributed .through the 30,000 drug stores would give an average total sales for each of $5,oco. tBrooklyn Eagle, Aug. 6, 1883. §Judge Tracy quoted in TV. Y. World. Iljudge Cullen in the Van Augen case. 20 gist and a gynecologist (both excellent men) as a commission to examine a man on a lunacy writ. But these assaults on virtue are not without parallel, and the fact still holds that the attitude of the community to the profession is eminently docile and receptive. On the other hand, the profession has no just complaint against the atti- tude of the community in the exercise of its law-making functions. I am not aware that any legislature has ever initiated any statute designed to restrain the freedom of the profession. On the contrary, the law-makers, in chartering medical institutions and societies and in legislating for the apparent protection of the j>eople, have granted about everything that every- body with a claim to respectability, has asked, distributing immunities with a free hand. That legislation has not infrequently been contradictory in any one State and multiform in the Country, by reason of the numerous law-making bodies, enforces, rather than impugns, the considerate attitude of the legislators in their respectful reception of professional petition. The direction of professional effort is so clearly in the public interest and so removed, in every detail, from clashing with the public interest, that those, who look to the legislature for relief and protection, have reason to be assured of an unprejudiced hearing. The convictions of medical men in the direction of sanitary precau- tions are so strong, and the thoretical argument in favor of these precau- tions is so convincing, that criticisms, amounting at times to denunciation, have been freely expressed in the medical press and in conventions for the discussion of these subjects ; on the one hand, against the apathy of the individual in not acting upon sanitary information so freely given, and on the other, against the hesitancy of the law-makers, State and municipal, to legislate radically on these matters. It will not hinder the work of sanitary reform if it is kept in mind that the argument is not yet con- cluded : that the utility of “costly and troublesome hygienic devices " has been called in question ; that medical men, themselves, have not mas- tered the subject and are very far from being agreed as to details ; that there is no inconsiderable share of the people who look upon sanitary intefference as an invasion of their personal rights, and that public health laws can so easily be made an engine of oppression. If it could be proven that the filth diseases never occurred in a house where the known condi- tions of perfect sewerage were fulfilled, there are plenty of citizens who would exhaust the last intricacies of the plumber’s art to fulfil those con- ditions, for their own personal safety; and if it could be proven that these same diseases could not occur in a city or a State, under similar condi- tions,there would be a moral obligation on the law-making bodies to levy appropriations needful to fulfil these conditions. But there are many fac- tors wanting and unproven in this and other sanitary problems, and in 21 default of accurate and exhaustive knowledge, legislators must move warily before setting in motion the machinery of a statute. The journals are not wanting in the cards of “ consulting sanitary engineers, ’ whose warrant for the title is more or less obscure, and the sign-boards of the “sanitary plumber ” meet the eye at every turn, but men maybe par- doned who decline to accept implicitly the opinion of the one or the handicraft of the other. Information of this kind is not confined to a class and men naturally chafe under oppression. When it is considered that, within fourteen years, twenty-nine States have authorized State Boards of Health, with large facilities for investigation, there is much to hope for and little to discourage, in the friendly attitude of the com- munity. On the contrary, the profession will look, with great inquisitive- ness, for the conclusions at which these State Boards may arrive. And once again, the instances are apparently increasing where the appointing power has seen fit to nominate other than doctors of medicine to the administrative offices in local health boards, an exercise of execu- tive function which has been duly reported to the medical journals as a grievance. If such a health officer is to exercise discretionary powers, or powers plenipotentiary, then the apointment of other than a medical man is a grievance, for none but he is supposed to possess the information qualifying for the exercise of such powers. But if the functions of such an officer are purely administrative, to execute certain well-defined pro- visions of a statute, such an appointment is not a grievance. On the other hand it may safely be called in question whether the habits and cul- ture of a medical man are such as qualify him to best discharge such duties. And it is a matter of much more serious moment whether the delicate questions that must necessarily arise in the execution of a health law in a large community, can rightfully be left to the decision of any one man. But there is another view of this matter. The various information which is included in what is being called sanitary science is not the re- sultant of any one man’s observation, nor of the men of one period, but a gathering together of the experience of men from remotest history. The scholarly element, which enters into the slow accretions of all science, prevails in this special department. It is intrinsically an inte- gral part of medical science, and, like all scientific truth, it is a gift to universal knowledge. Once given it cannot be withdrawn: and, once given, it takes its place among the sources whence the community draws its inspiration to a higher civilization. It differs to-day, from any past period, in that more exact and larger methods are employed in its study; and, in common with all other special knowledge, its area is widening 22 and its affiliations with kindred knowledge are multiplying. lake all other knowledge, it will have its epochs and these epochs will he co- incident with certain applications to human welfare; but, with each epoch, new' applications will be defined wherewith the wiser sense shall raise to a higher plane the dependent brethren who need protection and support. Beyond the period, when the people have appropriated the principles and formulated them into rules, and always in advance of the common thought, will be found the scholar still searching for the undis- covered and still adding to the knowledge out of which are to come the wiser rules for the production of better men. The outlook of a healthy and guarded community is more benificent, by far, than the pos- sible chances of a community threatened with the shadow of calamity. To claim that the medical profession is entitled to the emoluments of office in the execution of sanitary laws is to claim a royalty from the engineer and the plumber : and, because its ancestry discovered that soil-saturations from privy vaults in crowded localities is inimical to the public health, its descendants should have precedence in the competition for the office of night-scavenger. Devices, not principles, are patented. Medical men must always be advisory, executive they may be ; but to hold their executive seclusion as a grievance is to abuse the genius of their scholarly guild. The establishment of the various boards of health, municipal, state and national, is the one great acknowledgement the community has made to the achievements and helpfulness of medical science ; and this recognition is a gratifying recompense to all who have contributed to the result and are unfolding promise of reward to all who may labor, in this direction, for the bettering of their kind. If sanitary science really contains the “promise of the potency’ its advocates claim, and if its results should become formulated into laws for the sure protection of large communities, the reciprocal attitude of the medical profession and the community must, in the mean time, have undergone many radical changes ; so radical, indeed, that the imagina- tion might snap in the stretch to compass them ; so radical, indeed, that the “goneness ” of “ Othello’s occupation" would be nowhere in the immense hollow-ness of that vacancy that once was alive with the busy ministry to ills, that then shall be but a dismal retrospect. Of course, one cannot fail to grant that each new medical school is stepping friskily into line with its predecessors to supply the “ felt want not only of the community but of the profession, and one may, in all charity, concede the utility of appeasing the unquenchable desire to teach ; but one may, also, be justified in parting company with the prac- tice of the period and demand, in the interest of medical science, for the purity of medical art, for the maintenance of professional honor, and for the protection of the community, that the teaching and degree-grant- ing authorities be not one and the same. Let the community, through its law-makers, legislate into control an acceptable judicial body, in which shall rest the decision of the fitness of candidates to assume the responsibilities, enjoy the honors and reap the emoluments of profes- sional life, and the sharp contests of dogmatic rivalry, the destructive wiles of medical harpies and the weakening competition of medical schools would be rapidly equalized in the “survival of the fittest.-’ Fit- ness is, in some sense, a test of honesty, and this safeguard the commu- nity has a right to demand. No man has an inalienable right to practice medicine. He can choose to do so, but the public may adjust the tests of his fitness. When the great interests of the community are to be subserved, and when the com- munity is incompetent to judge of the accuracy of details and the cor- rectness of results, and, by the nature of things, never can acquire the competency to judge, the community is bound to seek its protection in exacting compliance with tests formulated by experts. “ The doctrines of free trade cannot be applied to professions. There cannot well be true freedom of trade where the power of judging of the article traded in or demanded is all and only on one side. It is for this obvious reason that the spirit of free trade has not been, and cannot be applied, to those avocations commonly termed professions. The inhabitants of civilized countries having desired legal or medical assistance, and well knowing that they were unable to form any immediate judgment on the quality of that assistance, have looked for and obtained external means of protect- ing themselves from bad law and bad medicine—means external to them- selves. Such communities have required that lawyers, doctors and others should give some evidence of qualification to official examiners, or have aided professional men to erect certain social barriers, known as etiquette and the power of the cold shoulder, for the exclusion of quacks charlatans, and other unqualified persons from their ranks.”* “A grave question arises at this point, whether society has not a right to protect itself against spread of these delusions ; whether, indeed, it is not the duty of the Commonwealth to interfere. For it is the very essence of charlatanism to misdirect the feeble, while the natural conse- quence of indulgence in error is to still further vitiate and impair the mind. The quack who makes a living out of the follies of mankind is apt to be contemptuously dismissed by the sane as a minor evil doer, as a scourge who may whip fools into wisdom, but in this view of the case, * Prof. John Attfield on The Relation of the State to Pharmacy. 24 namely, that he is increasing the public burdens by undermining the reason of his dupes, even while he fills his pockets by mocking the hal- lowed traditions of the people, he becomes a public enemy. Against him all good citizens, regardless of creed or school, are bound to unite for the defense of their helpless fellow creatures no less than for their own protection.”* This is solely a matter of agreement within the profession. If it sees fit to ask the community to take back the prerogatives it has bestowed and re-adjust them: experience has shown that the attitude of the com- munity to the profession is so friendly, that the change of base of the degree-conferring functions could be readily effected on the easy demon- stration of the added dignity of the profession and the increased protec- to the community. It is estimated that three-fourths of those enumerated as physicians and surgeons are up to the limits of their individual comjietency, applying to the healing of human ills the best methods of experience, based on the knowledge derived from scientific research. The remaining 20,000 are an o/la podrida of every conceivable specialty, having the common bond of applying each his own special method of cure to all diseases. The particular mode of cure is the trade-mark to attract patronage. If anv is honest enough to vary his method of cure, with the hope of benefit to his patron, he is dishonest to his advertisement. If any are so bigo- ted as to believe that one mode of cure is applicable to all diseases, or if any are so rigidly adherent to their special trade-mark as to apply it to all, regardless of all consequences save their personal gain, the community is not only defrauded but damaged. It would be idle to deny that each trade-mark covers some truth, or that some useful thing has been the stock in trade of some peripatetic healer, as witness the carbolic acid in- jection for hemorrhoids. It is very doubtful if scientific medicine is wanting in any of the appliances, which, taken alone, are the stock in trade of the exclusive practices. One afflicted with an incurable cancer, having exhausted all open knowledge, meeting with discouragement and denied all hope, is pretty sure to Hee to some advertised succor, to be again disappointed, and for the reason that these arts had been previously exhausted. This is all there is of the great body of exclusive practices, stripped to the skin. Granting honesty of purpose to all this motley crowd, the community may be benefited by the application of certain arts, but the community is deprived of the benefit of all the other related and substitutive arts. The personal factor enters so largely into individual success in the * Urooktyn Eagle, L. I., on the Monck Ca»«r. 25 practice of medicine, that the community judges of results mainly by its observations of the mode by which the results are obtained. The com- munity is influenced less by a system of practice than by its confidence in the man in whom it has trusted. The community is as incompetent to decide upon the merits of the former, as it is capable of being deceived by the skilful manipulation of the latter. This personal factor makes personal character take front rank in qualification for medical practice. The community may suffer seriously by its patronage of nostrums and exclusiveness, but the community undergoes greater peril and the corps d’esprit of the medical profession is outraged infinitely more by the in- competency to which it has given its diploma, and by the dishonesty and trickery in its ranks, which it sees and cannot control. Whoever can deny the one or the other is blind to human frailty, and he is to be credited with angelic confidence too pure and ethereal for this “ vale of tears." The physicians who are floundering through the uncertainties that ignorance imposes, or who abuse the confidence of the community for purposes of gain; who will take any other course than to tell the tiuth and employ the most experienced devices to secure the speediest results, are beyond the reach of all codes whether of human or archangelic contrivance. And, yet, the profession, in all consistency, having granted these the degree, with a free heart and a God-speed, must con- sult with them on equal terms, and, in an emergency, defend them in the public confidence. To turn a child from the door, as an outcast, is inhuman. Read McMaster’s delightful description of the Doctor in 1784; see the same men as they are adapted to the social relations in varying com- munities all through the land to-day, furnished with arts and information that make them acceptable by every hearth-stone; prepare, to fill their places, men whose accomplishments shall be the test of fitness; and, with the assurance that character is the result of responsibilities well met, and that character alone is influential to make the educating impress on the community, the day need not be far distant when the medical profession shall be in the wiser confidence of the community. There is a laudable pride in occupations, and its basis is the conscious- ness of doing a useful thing well. To defend his heritage is the chivalrous duty of the scholar.