fession produced a sentiment analogous to the superstitious awe still felt, though in diminished measure for the priesthood.

Nowadays there is practically no mystery about medicine, though there are many unsolved problems. The very popular and highly colored press places before the laity the most recent discoveries, not always with a high degree of accuracy but still with sufficient to give an insight into general principles and to afford an excuse for the remarkable facility in passing judgment on imperfect understanding which is characteristic of modern civilization. And it must be admitted that in large measure the laity is correct in regarding the bond uniting patient and physician as a loose one. The patient and his family may fear tuberculosis without any reason, but having it in mind they are quite right in holding that no amount of personal acquaintance as a family physician will compensate for a lack of equipment for modern diagnostic measures. Similarly, with regard to any special feature in medical practice, it is obvious that special equipment and skill are necessary and, unless the specialist consulted is a shark, no harm is done even by the unnecessary choice of the laity to lay their case before a practitioner without recourse to the family physician.

It must be admitted, also, that an excess of loyalty to the physician is not without. its drawbacks. Some time ago we were informed of a patient who had been continuously under treatment by one physician for eight years without relief. So far as could be judged a thorough study of the case and possibly an operation, perhaps more definite internal treatment, might have effected a cure. At any rate, the mere fact of loyal attachment for years without results was really hurting the physician's reputation far more than the worth of his fees. If he had frankly stated his inability to cope with the case and had sent the patient somewhere else, it would have been to his own advantage, possibly to that of the patient, certainly to that of some other physician. If, after fair trial of two or three

methods of treatment the case was pronounced incurable he might properly have retained it for palliative treatment.

Even in the case of incurable diseases a lack of excessive loyalty to any one physician enables a number of different men to obtain adequate experience with a variety of rare conditions. In the aggregate there is an exchange of patients so that no one suffers except the incompetent and, occasionally, someone receives an inspiration which enables a disease to be removed from the category of incurable.

It must also be admitted that the profession is to some degree responsible for the defection of patients to Christian Science, Osteopathy and various other cults. The insistence on faith in the physician, as an adjunct to definite therapeutic methods, the use of placebos, the more recent exploiting of hypnotism and psychotherapy, have their limit in Christian Science. The men who made a hobby of massage and movements, who insisted on their own particular highpriced masseur or masseuse, who talked loudly against drugging patients, were the real founders of osteopathy.

Experience has shown that, with few exceptions, a definite serious disease or injury will bring the adherent of any of these cults back to regular medical science. The palliative treatment of nurotics, the inefficient carrying along of "chronics" can no longer be depended upon by the physician. The very signal success of certain radical methods of treatment, surgical or medical, has set a standard which cannot be attained in many conditions. The laity, naturally enough, cannot understand this. The man with incipient gastric cancer cannot appreciate why he cannot be relieved as well as his neighbor who had approximately the same symptoms due to ulcer, hyperchlorhydria with ischochymia, or a curable hypochlorhydria with catarrh. The man. with a weak heart due to no organic lesion encourages his friend with a permanently deformed valve or degenerated myocardium to expect the same relief. A patient long treated medically and then suddenly relieved

by a brilliant operation sets the mark for a host of others whose condition involves no factor that can be dealt with mechanically.

EUGENICS.

THE future of the race in this country, either from the standpoint of numbers or of quality or of both, is becoming a matter of some anxiety to many thinkers. Heretofore the increase of the population has been the main item of interest so far as the welfare of the state was concerned. Numbers were necessary to keep the community intact by defending it against the various preda tory peoples that surrounded it. Men were needed as food for wars, and women for bringing forth human filling for military ditches. We are but a few generations removed from the days of the Napoleonic wars, and, as shown by our too frequent lynchings, we have only turned the corner from barbarism toward which it is easier to lapse than it is to progress to something beyond. There is evidently some ground for fear of lack of numbers, though most of us hope that militarism is really going out of fashion for good and all, notwithstanding the anomalous national outlay in scare battleships. To the most of us, at any rate, the mere decrease in the birth rate gives little concern either for the present or the future.

It is the quality of the race that seems of more moment, and the infant science of eugenics or the study of means and methods for producing a better race-must interest all whose thought and thoughtfulness reaches into the future. Already some practical advance has been made in the application of our knowledge in this direction. Laws have been passed in at least one state making a preliminary medical examination and a certificate of good health necessary to the procuring of a marriage license, while in other states laws for the sterilizing of certain criminals and defectives have been enacted. Through these regulations the number of the population of a less desirable type is to be de

creased, and there should be a corresponding improvement in quality.

The fault of insufficient increase in population is laid upon the middle and upper classes, who are accused of caring only for personal ease and of showing indifference to the welfare of the state in not rearing families as large as those of their forefathers or of their neighbors in much humbler circumstances. Various theoretic schemes have been devised, at least in Europe, for stimulating this class to be more prolific; such as the giving of state aid in rearing children. The funds for this purpose are, of course, to be raised by taxing those who fail to swell the number of the community.

Save for the aforementioned purpose of military defense against possible invaders, we are not aware that anyone has expressed alarm at our mere lack of numbers. There is some ground, however, for deploring the proportionate increase of the very lowest classes of society. This problem is not to be met by urging the better class to bring into the world more children than they feel that they can provide for on the scale which modern living requires, but rather in limiting the numbers who come into the world unwanted and unloved and to whom it is impossible for the parents to give a fair chance in life. There are those who have dared say that it is a crime to bring such children into existence. This is but putting into theory what the better classes are putting into practice. It is not all a matter of desire of "ease and comfort" on the part of these parents, but a foresight of what the large family now means in its bringing up. It goes without saying that where child follows child with the rapidity of unhampered nature, each cannot receive that care needed for proper health and development, for equipment in life means more nowadays than the possession of a breech-clout and some proficiency in wielding a boomerang. The better classes feel more keenly their responsibility to offspring, and they show their good sense in not overburdening their resources. We doubt whether the reduction in children from mere "love of ease" on the

surgery at the Harvard Medical School he asked his advance students to give the diagnosis in certain carefully described cases taken from his note books. In some of these cases there had been much difference of opinion among very experienced physicians; yet some of the students, interpreting the histories properly and drawing the correct conclusions gave invariably the right answers. Many of these successful students (and herein lies the difference between medical knowledge and medical wisdom) did not show the learning of the others, who generally reached wrong conclusions. "The student whose deductions were in every case correct will without question make much more successful practitioners than the students who, exhibiting much more learning, picked out the unimportant features in the histories of the cases, and on these unimportant features based correct deductions, which were, as to the real lesion, always wrong."

Chess-playing should help to develop the discriminative faculty in the medical fledgling.

Moreover, after the student has been well grounded in the essentials of medical science there is nothing so vital to his success as good case-taking; by no other means can he so surely be made a useful physician. Some of the most valuable works of our teachers are now in the case-history form; and in our sister profession of the law the "case" has been made the basis of classroom work.

The foundation of good case-taking is accurate observation; and this is no small thing to take into account.

Correct perception of phenomena, followed by correct writing of the findings, is not common; it is in fact rare. And the development of such accuracy in the use of the senses, and in the recording of observations, is one of the most valuable results to be hoped for in scientific training. For example, the accounts of eye-witnesses to any commonplace and ordinary scene are almost never in accord; newspaper "stories" of any event are well-termed thus, since they are not

at all likely to coincide though written in the best faith, by reporters presumably trained to observe and to record observations. (Le Bon, in his book "The Crowd," is here very illuminating.) For the matter of that, ask any six physicians to examine the same chest, but each in a room by himself; and note then, if their statements of the physical signs are altogether harmo

nious.

Another qualification imperative in casetaking is that no datum, however insignificant it may seem, shall escape detection and record. The ideal anamnesis must go back to the patient's grandparents, at least; and as much further as possible. It should continue thence to the family history, the previous illnesses and habits, the symptoms from the time of being seen, with the minutiæ of the physical signs and of the aids given in the pathological laboratory. Next are to be entered the diagnosis and prognosis; then every detail of temperature, respiration and the rest, every therapeutic measure, and the record of its effect; and finally, should the patient unfortunately for himself (but mayhap fortunately for science) have succumbed, the exhaustive record of the autopsy.

The sum-total of medical knowledge is achieved only by the study of cases that reach the post-mortem table. Thus only can we comprehend the statement concerning the success of an eminent consultant that at the outset of his career "he buried himself for ten years in the morgue." Attending physicians, pathologists, bacteriologists gathered together at the autopsy table are now able to review the whole case; the possible errors in diagnosis and treatment; the reasons why the therapeusis has not availed. The data collected during life are compared with those revealed after death; all correct antemortem findings are verified, all erroneous opinions disproved. Only by such rational and eminently practical study is medical science directly, and the race indirectly, benefited; not without these means is the student's education adequately achieved.

THE DIVINE WEED.

ONE of the most baffling problems of which explanation has been attempted is that of the reason for the enjoyment derived from the use of tobacco. Our modern laboratory researches in pharmacology elaborate as they are, have failed to make the matter one whit clearer. As stated by Cushny, "The enjoyment derived from the use of tobacco has never been explained, and it is not even proved that nicotine is essential to the pleasurable results; consideration of the pharmacological effects of nicotine gives no clue, for these are of the opposite nature. . . . It seems doubtful whether the nicotine ordinarily absorbed has any action whatever. Perhaps the local effects on the mouth, nose and throat play a larger part in the effects of tobacco than is generally recognized. A certain amount of rhythmic movement demanding an exertion seems in itself to have a soothing, pleasuregiving effect, for it is otherwise impossible to explain the satisfaction enjoyed by many in chewing tasteless objects such as gum or straws. A curious fact which goes to show that tobacco smoking is not carried on for the sake of the nicotine absorbed is that the pleasure derived from a pipe or cigar is abolished for many persons if the smoke is not seen, as when it is smoked in the dark."

That nicotine or some other contained substance has some effect upon the body everyone who has tried "his first cigar" has had indelibly impressed upon his conscious

ness.

There is proof universal here, and every man has been his own pharmacological laboratory in the matter. The leaves of the Pituri plant which is used by the natives of Australia in the same way as tobacco contains a substance which is practically identical, in its physiologic action, with nicotine. Except this plant, so far as we know, no other material, even in this day of substitutions, has ever been successfully used instead of tobacco. No young man, as far as we are cognizant, ever became habituated to the smoking of hayseed, or formed the corn silk habit for life, or be

came a pennyroyal or cubeb fiend. All these articles of juvenile experience furnish abundant smoke wreaths and as much "rhythmic movement" as tobacco itself.

Evidently there is something in the drug which appeals to the mind through its bodily effects, doubtless through some depressant action by which it partially closes the sensory approaches to the brain and allows it to dwell in less disturbed self-satisfaction. The very fact, however, that smoking in the dark gives less or no pleasure, attests the vast effect which sensory accompaniments play and how sadly these are missed, while it rules out the importance of rhythmic activity which goes on as well in the dark as in the light. Dr. Cavanagh, of London, has recently stated the smoke theory of tobacco more elaborately in connection. with the hygiene of the eyes. He says that the benefit claimed for tobacco would seem to depend upon the actual visual perception of the clouds of smoke which "acts as a rhythmically recurring shield from harsher eye stimulation . . . it soothes by its own color as well as by cutting off the sensations," and he believes it rests the eyes further by relaxing accommodation.. While this is all very ingenious, we doubt if the most extreme preacher of the most disastrous results of eye-strain could agree that tobacco smoke affords much relief to this condition, much less that this is the ground for the formation and continuance of the smoking habit. If so, it is exceedingly extravagant for smoke suitable for the purpose could be furnished much more economically. Doubtless it affords an infinitesimal effect in this direction, but we think the direct action on the conjunctiva or through the nasal mucous membranes would more than offset such results, and there are the dangers of toxic amblyopia. which would increase with the increasing amount of smoke clouds.

To the mind of the writer there is one thing in connection with smoking which, in addition to its probable influence in stupifying certain realms of the nervous system, helps to explain the effects of the habit,