in most instances that the symptom-groups are sufficiently classic to be recognized.

It is not strange that they should dread local disorganizations and constitutional infections that destroy life and discredit operative interference.

To nature as a conservator of life we pay obeisance, and humbly acknowledge our gratitude for her oft-times charitable preservation, yet many times the destructive processes of disease will not pause while a physician fails to recognize the condition, and consumes time in waiting and hoping, he knows not why, for improvement. However, it is understood that in some instances in the absence of indications for immediate interference, it is expedient to allow time to develop the case and make a diagnosis comparatively easily arrived at.

En passant it might be remarked that while exploratory incisions are, in not a few instances, necessary for diagnosis, and while, as a rule, they may be made with impunity, the tendency to treat hidden pathology indifferently and depend on exploratory surgery for a diagnosis should be deprecated, as it does not conserve to diagnostic ability, and is not always best for the patient.

Is it not evident that the most essential thing in the successful treatment of diseases is diagnosis, and is it not true that the physician who is awake to the best interests of his patients, his profession and himself, will not fail to appreciate the value of the new methods, as well as their limitations? It can be only by the diligent use of all the diagnostic resources at our command that we can hope for the development of faculties which make for that intuitive ability which is the art in its perfection.

Better things are expected of a physician than to treat a patient for a diseased stomach, whose stomach disturbance is incident to a nephritis or to the influence of hardened wax on the tympanic branch of the pneumogastric nerve; a renal congestion which runs away when pursued by dig

italin for Bright's disease; an appendicitis for bilious colic; a cord sclerosis or coxalgia for rheumatism.

More complimentary is it to him as a diagnostician when he is not deluded by a false sense of security, and he insists on the why and the wherefore when he sees in a subnormal condition a pretubercular or a precancerous state, and recognizes in lower-lid edema a symptom which may precede an albuminuria or a cardiovascular alteration.

The physician who by virtue of popularity, from any reason, is so busy in practice that he cannot give time and attention sufficient to determine the pathology of the disease of his patients should be generous and seek the assistance of his capable brethren, or accept less business and insist on more respectable fees, thereby being equally profitable to himself, and much to the advantage of his patients.

The physician that can in a large measure diagnose diseases is the man in his profession that is justly preeminent and commands admiration, and this is as it should be, as this enviable altitude is only attained by that industry which knows no tire, and that interest which knows no abatement.

The Status of Psychologic Medicine

BY CHARLES S. MCDOUGALL, ATHENS

Although insanity was recognized as a morbid condition by the oldest known civilized people, scientific alienism is a comparatively new department of medicine. From the beginning of the historic period of mankind to near the close of the eighteenth century insanity was attributed to the malignancy of Satin and the poor bedeviled lunatic was treated as an outcast, imprisoned, tortured, and punished. The theory of spiritual obsession and possession was thought infallible and not questioned until recently, and when Dr Gall began to found his so-called science of phrenology, the first attempt to study the relations of body and mind, though in the closing decade of the eighteenth century, the

questions raised were regarded as a presumption upon the religious dogmas of the times, and he was silenced as a public lecturer by the Austrian Government.

Coincident with this initiatory attempt to study mind, two independent movements for reform in the care and treatment of the insane were inaugurated, that of Dr Pinel in abolishing the dungeons and chains at Paris Hospital, (Bicetre), and William Tuke in founding the York retreat -a private institution in which humanity ruled.

Though successful and enthusiastically received by the civilized world, these two institutions with Salpetriere, where Pinel introduced his ideas of reform two years later, stood alone in their humanity, for humanity had not progressed sufficiently to encourage its application to the madman, and it required more than 40 years of the combined and successive efforts of the students, followers and emulators of Tuke and Pinel to overcome the wretched condition into which the insane had been plunged and maintained by ancestrial ignorance.

Progressive movements respecting the insane up to the middle of the nineteenth century had been mainly directed to their physical welfare. In 1855 Herbert Spencer, who as a writer shed more imperishable luster upon the intellect of the century than any other man, published his Principles of Psychology which was founded upon the doctrine of evolution, the basis and guide in all human affairs and the master-key to all biologic problems. It did not redound, however, to the immediate advance of alienism, for though the necessity of knowing the normal to understand the disorder of a function was not questioned in the other departments, in psychologic medicine it was not only thought unnecessary, but openly scoffed at and derided, and the absence of advance in this department, in contrast to the enormous strides made in the other departments of medicines, would seem due to this fact alone, and since Charles Mercier began to urge the correlated study of the evolution of mind and the nervous system, psychologic medicine has

advanced from a chaotic state to a scientifically founded and clearly defined department of medicine. Though like previous progressive movements in this department, Mercier's suggestion was at first unheeded, and for 10 years he was "as the voice of one crying in the wilderness," but after the publication in 1888 of his work on the Nervous Svstem and the Mind, his views attracted the attention of his associates in London, and were adopted by them. His views being an analysis of the normal states and processes, the disorder of which constitutes insanity, his work published two years later on Sanity and Insanity was accepted as a material advance in the knowledge of insanity. Previous to the publication of Sanity and Insanity by Mercier, insanity had been dealt with as a disorder purely of the mind, but it having been determined scientifically that the states and processes of consciousness invariably accompany the states and processes of the matter which compose the superior portions of the nervous system, and though the world of consciousness is entirely separate and distinct from the world of matter, no condition of consciousness can occur without the occurrence of some corresponding condition in the higher nerve regions, nor can any change take place in these higher nerve regions, without the accompaniment of a mental state or process; neither can there be disorder of one without disorder of the other; and in insanity there is always a disorder of mind and there is also disorder of the highest nerve arrangements; and as these highest nerve regions actuate conduct when disordered, as in insanity, then conduct must be disordered; and, in fact, conduct is the most important of all the factors that the alienist has to consider, for however disordered one's mind may be, the question of his sanity does not arise until evidenced by some overt act, and upon these facts Mercier says insanity is disorder of the highest nerve arrangements, disorder of conduct and disorder of consciousness, and in every case disorder of consciousness includes disorder of thought and feeling, of self-consciousness and of consciousness of the relations of

self to surroundings. In dealing with the mind and its disorders in connection with nervous activity and disorder of the nervous centers, Mercier lays claim to few newlyobserved facts, but to organizing into knowledge those already possessed, and if the doctrine of evolution is correct. and applicable to psychology as applied to all other biologic questions, then the stupendous biologic discoveries of the last half century, adapted as they have been by Mercier to psychologic medicine, has placed it within the pale of science.

The works of Mercier, though little known by the profession generally, and seldom referred to by specialists in this country, have with most European alienists superceded all others. His mode of studying mind, his definition, and classification of the forms and varieties of insanity, with his distinction of forms and varieties, are not only lucid and practical, but are regarded as scientific by the leading alienists of the world, as evidenced by many, and most notably the embodiment of his views in Hack Tuke's last and perhaps greatest work, Dictionary of Psychology Medicine.

The apology I. have to offer for consuming the time. with a subject seldom considered at a meeting of the general profession is the hope that I may be able to impress some with the belief that our knowledge of insanity is more than is popularly believed, a farago of meaningless words. The process of establishing relations in the organism in correspondence with relations in the environment has been worked out with such analytic skill that it is possible to say how and to what extent mind is affected, and the nervous mechanism and classification of conduct so scientifically established that by our knowledge of conduct, which scientifically considered is the active adjustment of self to circumstances (the pursuit of ends) and is in fact the only means we have to judge of one's intelligence, their insanity or sanity, has made it possible to say what kind of disordered conduct is necessary to constitute insanity and for a natural and intelligible classification of the undeveloped, as well as the forms of insanity.