NORTH AMERICAN REVIEW.

No. CCXL.

JULY, 1873.

ART. I.-1. Medicine in Modern Times, or Discourses delivered at a Meeting of the British Medical Association at Oxford. London: Macmillan & Co. 1869. 12mo.

(1.) The General Relations of Medicine in Modern Times. By HENRY W. ACLAND, M. D., F. R. S., LL. D., etc., Regius Professor of Medicine in the University of Oxford, President of the Association.

(2) Clinical Observations in Relation to Medicine in Modern Times. By SIR W. W. GULL, Bart., M. D., D. C. L. Oxon.

(3.) Therapeutical Research in Relation to Medicine in Modern Times, as illustrated by Researches into the Action of Mercury on the Biliary Secretion. Report by PROFESSOR J. HUGHES BENNETT, M. D., F. R. S. E., etc.

2. The Physiology and Clinical Uses of the Sphygmograph. By F. A. MAHOMED, Student of Guy's Hospital. London Medical Times and Gazette, 1872, Jan. 20, Feb. 3, Feb. 24, March 2, March 23, April 13, May 18, etc., etc. 3. On the Use of the Ophthalmoscope in Diseases of the Nervous System and of the Kidneys; also in certain other General Diseases. By THOMAS CLIFFORD ALLBUTT, M. A., M. D., Cantab., etc. London and New York: Macmillan & Co. 1871. 8vo. 4. On the Temperature in Disease, from the 2d German Edition [Das Verhalten der Eigenwärme in Krankheiten. Leipzig. 1870]. By C. A. WUNDERLICH. Translated by W. B. NO. 240.

VOL. CXVII.

1

WOODMAN. New Sydenham Society's Publications, Vol. XLIX. London. 1871. 8vo.

5. De l'Électrization Localisée et de son Application à la Pathologie et à la Therapeutique par Courants induits et par Courants galvaniques interrompus et continus. Par le DOCTEUR DUCHENNE (de Boulogne). Troisième édition entièrement refondue, etc., etc. Paris. 1872. 8vo.

6. On the Pathology and Treatment of Cholera. By GEORGE JOHNSON, F. R. C. P., Physician to King's Hospital. MedicoChirurgical Transactions. Vol. L. Art. X. London. 1867.

THE long array of titles in medical literature we have thought proper to associate with this article need not excite in the reader any apprehension that he will be called upon to assist in the process of conventional criticism. But we have selected them for the reason that, each and all, they march upon the highest planes of medical thought, and are themselves the very standard-bearers of its advance. Upon their authority we shall rely for the ideas we hope to develop, and it is with their assistance that we propose to sketch in consecutive narration such accepted general principles and such special but essential technicalities as shall constitute in reality an essay upon the thesis of Modern Medicine.

Medical men are charged with a liability to fall into one or the other of two opposite errors. They are charged with either being too content to regard their profession exclusively as an art, and with rather exulting in the assumption of an attitude of pure empiricism, or, on the other hand, there is ascribed to them an ambition to associate medicine with the dazzling but often delusive propositions asserted from time to time with a confidence which rarely accompanies even the best demonstrated facts in science. The truth is, we cannot establish with exactness or logical precision many of the fundamental notions to which medicine, as a profession, owes its very existence. Often we have to depend upon personal conviction alone, reasoning to ourselves from facts which we cannot explain, and acting in emergencies solely upon our rapid estimates of the probable. Pure Science admits no uncertain elements, but we cannot wait for her elimination of them; and when a phy

sician, upon a balance of probabilities alone, acts, as he must, with a promptness flush with his decision, he is only like the navigator who trusts to his instincts in the tempest as readily as to his observations in the calm.

The older physicians conducted their observations in the true spirit of science, and reasoned with a caution which grew out of their consciousness of the uncertainty of the ground to be explored, and of the intrinsic inadequacy of their methods. Within certain limits we can place far more reliance upon the results of our own observations; but with more extended and precise methods comes the possibility of being found wanting in their characteristics of patience and care; while the ingenious mechanical appliances upon which we depend may be as much the measure of weakness as the proof of strength; and though by their aid the immediate judgment is rendered less difficult, the art of judging as a process of reasoning may eventually come to languish from disuse.

Without any sympathy with purely empirical medicine, we are still less in accord with that disposition to remote theorization which assumes that the spirit of modern medicine requires us to subordinate its advance to the vast and exhaustive generalizations of the science of the day. We can fit to no place in practical medicine the new dicta of the speculative physicists which assert that "an action of which we are immediately cognizant is but the result of the operation of the solar heat upon and through independent and correlative existences; that all things in this system are capable only of interchange; that there can be no destruction of that which exists, and no creation of new energy"; "that the human mind itself, emotion, will, and all their phenomena were once latent in a fiery cloud"; "that all our poetry and science and art, Plato, Shakespeare, Newton, are potential in the fires of the sun."

Now, instead of demanding upon what rests this projection of human thought into the infinite unknown, some of our outposts concede the very key to our position by the surrender of all notion of a vital principle or a Final Cause. This theorem of the conservation of energy controlling the laws of affinity and bringing all vital phenomena within the domain of physical necessity enters into every conception of organic

change; and as a corollary, if we cannot separate medicine from the indirect any more than from the direct influence of science, we must be governed by such remote physical speculations, and, abandoning all previous inductions, substitute for them a mere collection of undemonstrable postulates.

We pretend to have learned the methods by which the earth's crust became fitted to produce the chemical conditions which render the evolutions of organisms possible, but we cannot describe the commonest chemical changes going on every moment of our lives in our own bodies. We assume to fix the periods of the earliest geological transformations, but we cannot define the simplest of the vital processes. In the words of the chemist Bertholet, "We know nothing of any one of them thoroughly, since a perfect knowledge of any one involves the perfect knowledge of all the laws and all the forces which combine to produce it; in other words, a perfect knowledge of the universe."

The difficulties with which medicine has to deal are not due to the vastness of its included subjects, nor to any doubt as to their basis in science, but to the fact that it is itself a science which is complicated with an art and operating upon one of the obscurest of chemical processes. Nothing can be true in medicine that is not based upon unalterable law, and the law that underlies all therapeutic effort rests upon the maxim that living matter must act definitely in definite conditions. When failures are explained (says Mr. Mill, we believe), they become part of the law to which they were supposed to be an exception. Chances in disease are its variable causes, and there can be no assumption of erratic procedure, only to account for deviations for which no better reason can be given.

While the advance in medicine is in a great measure, but not so absolutely as some of our authors imagine, correlative with the general advance in science, it is by no means so certain that those departments with which medicine is the most closely connected are marching with the rapidity and precision of others with which we can claim no immediate relations. In the discussions of vital theories, which surely is where general science impinges most undeniably upon our pre-emptive domain, we find little else than opposed and controverted theories, with

mere fancies more or less whimsical, and dogmas in every stage of assertion and rebuttal. Chemistry, on the contrary, till quite recently exclusively analytical, has just entered upon a new career of combinations; and as there are really no limits to the possibilities of synthesis, we can follow it no further than the threshold, and must henceforth gaze upon its progress from afar, content with what our pharmacist shall distil from it, and grateful for what the chemical physiologist shall give us (and take back again) from year to year. But apart from all lofty connections and in its own career, medicine, while stationary with all learning for many centuries, is now fairly abreast of its tributary sciences, while as a practical art it lays under contribution the highest developments of all other arts.

As the physician can never more hope to comprehend more than an insignificant portion of any one of the allied sciences, it is consolatory to feel that in limiting the conception of professional duty and requirements to the single department of clinical medicine, the pure medical scientist of the future will be a far superior intellectual resultant to the quasi-universal sciolist of the past. For, as Sir William Gull says, "if it were possible to conjoin in one human intelligence all that is now known of all other sciences, such knowledge would be compatible with entire ignorance of clinical medicine." And bringing the subject into these narrow limits which we intend to claim as the only proper sphere of the medicine of the day, as the phenomena of living tissues are not explained by their chemical composition, so the phenomena of disease are not explained by the knowledge of healthy tissues or by the action of healthy organs. There are problems to which we are not bound to give a scientific solution, but which involve an action within the resources of art. We find ourselves surrounded by ailments and suffering, and in the main we know how to relieve them. The outcome of our knowledge is not philosophical contemplation, but it is adaptation and action: we cannot wait for absolute methods, nor shun the contingency of failure. And then we apply our art, "leaving physiological questions to the physiologist, and chemical questions to the chemist."

Having thus reduced our conception of medicine to its clinical phases alone, in dissent from the more ambitious flights of