pelled. The individuality of a surgeon is today as ever, his greatest asset both as a teacher and as a life saver. That individuality will accomplish most for the advancement of science and the benefit to humanity when it has behind it a well-rounded and complete preparation for the careful and correct study of the science before attempting to apply the art. That individuality which loses sight of self in the intense interest aroused by the study of principles as applied to the most complex, yet most perfect mechanism known, when he can look upon the human body as a machine without fault and with life endowed, the repair of which will be best done when all Nature's methods and natural relations are understood and sought to be imitated. In order that we may fully appreciate some of the thoughts which have been presented to me in relation to this subject, it will be necessary to review and possibly criticize more or less severely some of the operations which have held the boards the past few years. One of those which has not even the slightest base in philosophy, or the faintest excuse in surgery was that which came out of Gotham a few years ago, and is known by the title "Inversion of the Appendix." The entire profession has for years grappled with intussusception as a surgical condition of grave import, as one fraught with the most serious consequences, not the least of which was the sloughing of the part intussuscepted, and yet here we are converting a normal anatomic relation into a surgically produced intussusception. That theory which would invaginate any part of the intestinal tract is certainly not founded upon principle, and when we pause to think that only a comparatively healthy appendix can be inverted the fallacy becomes more marked. There is another thing in this proposition, viz., we have for years used the rectum or colon for the purpose of feeding our patients. If food can be readily absorbed and assimilated therefrom is it not reasonable to suspect that septic organisms will likewise gain entrance from the same source? Does the most radical advocate of this procedure assume that there is not very virulent infection in and about those appendices which demand surgical treatment? Another condition in which surgical princi. ple has been too much dominated by fanciful theory is osteomyelitis. The teaching

The en

has been and is today that we should wait until there is more or less necrosis before operating. That amputation will be necessary in a large percentage of cases, etc. tire surgery of this subject needs rewriting. Early recognition, prompt and efficient drainage will make necrosis almost as rare as it is now common, and will entirely banish ampu

tation. There are, then, three things which the profession should carefully consider:

1st. The study of surgery, which embraces, (a) requirements for admission to the surgical course; (b) methods of study; (c) the advis ibility of a special degree or qualification.

2d. Surgical teaching. This will involve (a) special instruction in embryology, pathology and regional anatomy; (b) surgical principles demonstrated upon animals; (c) original experiments upon animals; (d) clinical instruction to small numbers not to exceed such number as will prevent each member of class seeing the minutest detail and having privilege of careful, thorough study of case both before and after operation; (e) assistant position for such a length of time as will develop familiarity with the varied conditions and best methods of meeting them.

I am almost convinced that our modern post-graduate schools are, to both profession and the laity, a curse. The courses of six weeks or three months are calculated to place the student in the position where he will sooner or later exemplify the truth of the adage: "A little knowledge is a dangerous thing." Like the normal school in the literary course, when made to refresh and keep bright the minds of those who have already had a thorough training they serve a useful purpose, but so soon as they are supposed to equip men for life work in surgery or any other specialties they are a curse. If we expect the laity to second and respect our efforts for higher medical education if we desire to stamp out quackery in every form, if we expect to accomplish real scientific work and reform we must cleanse the professional robe from every spot or stain of commercialism, we must abolish every form of gallery play; we must make our every effort to teach an honest one. Our clinics must be robbed of all spectacular and mysterious show. The amphitheatre must be razed, and on its ruins must be erected the operating-room in which truth is sought, science is worshiped and the results of permanent character secured

Micro-organisms do not live in normal histological tissues. There must first be a devitalization or death of the tissue to produce a culture medium. Hence, if we injure or traumatize tissues we are doing that which favors infection. The practice to use forceps to seize intestine, appendix, or other abdominal structures is the most frequent error in this regard. Traumatism as a prime cause of infective processes is not limited to the abdomen. There is little doubt that there can be no infection in any part of the human body without a trauma of some kind, either chemical or mechanical. If this be

true the converse is equally true, viz., when there is an injury of any kind the gates are open for infection. Metchinkoff, when he taught the world the theory of phagocytosis, and subsequently proved the theory a fact, did much to explain many hitherto unan. swered questions. The great practical lesson which we ought all to have learned from it is that whenever we add to existing trauma, unnecessarily traumatize the tissues in our surgical field, we are calling upon Nature's reserved forces, and if those reserved forces have already been called into action by the disease or injury we are only favoring the slaughter of our soldiers, the phagocytic white blood cells, and this death means the formation of pus.

We have become germ-mad. Our "conscience doth make cowards of us all," aye, more, this conscience which doth prompt to use of instrument where the fingers can better serve, on the ground that the instrument can be and the fingers cannot be sterilized, makes surgical knaves of us, which crouch and cower at a fancied demon, while we hug in the arms of delusion the scorpion whose sting is death, viz., traumatism.

Again, we have theorized upon hygiene. We have measured to a nicety the exact number of cubic feet a sleeping room should have in our homes in order that those in health may remain so. We have cautioned the public against the dangers of segregation. We have looked wise and taught the horrors of infection. We have advised isolation, established quarantine, and had faith in our teachings. At the same time we have been building hospitals for the better care of those afflicted, and straightway gone contrary to our every teaching of hygiene, on isolation and on infection.

1st. We build a ward 40 x 16 feet, with a 10-foot ceiling, 6400 cubic feet, and we straightway put in eight, ten or twelve beds for afflicted humans. We argue that not less than 1000 cubic feet is necessary for a well person's sleeping room in order to maintain health, then we say by our work, that from 500 to 800 is quite enough for a sick person to regain health. Is this consistent? Then we talk about isolation preventing infection, and straightway place in this ward a case of appendicitis, one of cancer, and possibly one of absolutely aseptic operation. Is this good surgical principle, or is it subsidizing our honest scientific belief and knowledge for the commercial advantage?

Gentlemen, we must either be consistent in our own work, or we must not expect either the confidence of the public or that progress in the science of surgery which our earnest efforts should bring.

Another very suggestive thought is that many men who are the most careful observers and most accurate students refrain from giving the world the benefit of their efforts, because they feel that they have not the unlimited experience necessary to make their opinions valuable.

No greater mistake is made than that of thinking because a certain man sees a large number of cases his teaching is to be accepted as law, while the teaching of the man who sees but one-tenth as many is worthless. In entertaining such an opinion we forget to take into consideration two important factors. First, a teacher must have the ability and disposition of a close, accurate observer, the power of logical deduction and the gift of forcible expression.

Second. He must then have ample time to thoroughly study each case and fully digest and assimilate all facts to be learned from

it.

Keeping these two thoughts in mind it is not hard to see that the man who sees 300 or 500 cases yearly can more thoroughly study each case and have more time to carefully arrange his knowledge in concise and accurate form than is possible with the man who sees 3000, 5000 or more cases yearly; hence if he keeps from us his thoughts, because his number of cases is smaller than another, he not only wrongs himself, but robs science of that which he owes to it. The man of vast numbers must necessarily leave the larger part of details to others and accept other conclusions. This is weakness. Our modern ideas of specialism are all right so long as they are kept in certain well-defined bounds, but when we try to make our work easy by assigning each detail to some one specially qualified in that detail, we are lessening the value of our own conclusion in regard to the subject as a whole, if indeed we are not rendering all the teaching inert. The man whose business it is to replace broken mainsprings, or any other single part of a watch, could give very little valuable instruction on the subject of watch repair and the man whose special province is pathology is of still less value, unless his study of that pathology is supported by the clinical study of the case. The man who has the time to carefully work out both sides of the case will teach the most valuable truths.

1st. Surgery is either an art founded upon exact science, or it is a gigantic fake founded upon empiricism.

2d. Every science is and must be founded upon principles which are as enduring as truth.

3d. Every principle, every truth must be preceded by theory, which is only another word for ideal.

4th. To make our theories or ideals conform to truth and exemplify a scientific proposition is to convert that theory or ideal into a fact.

5th. To sacrifice on the altar of personal vanity or ambition one jot or tittle of truth or science is to sacrifice the entire principle.

6th. Empiricism has been the foundation of quackery from the earliest days and to encourage, practice or teach any of our surgical methods empirically is to justify and father quackery.

7th. It is unreasonable, therefore, to expect that any man can put into practice a scientific principle if he knows not a thing about any of those sciences upon which surgery rests, viz., philosophy, anatomy, physiology, pathology, psychology, embryology and biology, together with those collateral branches, chemistry, histology, bacteriology and therapeutics.

8th. The human body must be viewed as a machine. Its surgical or medical repair to be based upon the idea of the province of a thorough mechanism. There is no part of the body which is not constructed on a true philosophy, and its repair requires a knowledge of natural philosophy. All other ologies and osophies are useful only in determining the need of and character of repair, hence any surgical effort not philosophic is unsurgical.

9th. Teaching of the principles upon which the treatment of a surgical case is treated should be the most attractive, as well as the most important part of our efforts.

10th. To accomplish this our methods of teaching and our practice must be consistent, and both can be revised with benefit.

11th. Traumatism should be given the consideration due its importance as a factor in

infection.

12th. Fads and fancies should not command the respect of the profession, and nonessentials should not be given prominence in our teachings.

13th. Surgery should be taught as an art which rests upon exact or scientific principles, hence one in which philosophy is equally important with pathology, and anatomy of greater import than the microscope, although the latter is a necessary and satisfying adjunct.

14th. A man may be a good physician, but a poor surgeon, the converse, however, is not true, for a man cannot be a surgeon who is not a good physician, bence a special qualification might be advantageous.

15th. Hospital construction and hospital management should be consistent with the teachings of hygiene, segregation of patients, isolation of infected cases, space per bed, and

all minor details to be worked out by men trained in sanitary science instead of by architects and other laymen.

16th. Endowinents for the working out and proving surgical principles and honors to the workers might be worthy serious consideration.

17th. The one great principle, that a surgical condition is always surgical should be constantly emphasized to the end that "Dernier operations" may cease to be the bane of our profession and the boon of the undertaker.

The

The art of surgery is but the application of the principles taught by surgery as a science. It is the mechanical use of knowledge for the cure or relief of disease. The knowledge is either exact or empirical guess-work. This makes the distinction between science and theory or principle and theory. The art is a true art only if it is the result of or the application of true scientific principles. operator may be skillful, he may be a good anatomist, and yet be a poor surgeon, for the reason that he looks upon the operation as the great part of his work, whereas the operation is and ever must be to surgery only a means to an end, the necessity for which and import than the operation itself. It is infinthe plan of which must needs be the greater

ite detail that makes real surgical success, detail in consideration of each and every element in the case, detail in anatomy, pathology, symptomatology, clinical history, and all palpable evidence, detail in the preparation for and performance of the operation, detail in the case of the patient after operation. The art subservient to the science. The science free from all empiricism. A science which at no time can or will tolerate the interjection of commercial methods or interests. A science without personal ends or motives. Surgical principles and not surgical fads or theories. An "altruism" in practice which brings from the grave its secrets to serve and save a living but suffering being. Which touched by the fires of truth warms and illuminates the world, which delves into Nature's laws so deep and rising above the plane of self-interest can view God's work with a creates an ideal for surgery whose pedestal is mind of understanding. Altruism which Nature's interpreted law, whose body is art

clothed with science's robe and whose crown is illumined by the light of reason touched by a Hand Divine.

THE use of any considerable quantity of iodoformized gauze in the vagina involves the risk of a severe dermatitis of the vulva.

CLINICAL PSYCHOLOGY.*

FRANK PARSONS NORBURY, A. M., M. D.

JACKSONVILLE, ILL.

In all ages man has sought to solve the mysteries of his own ruling mind, but in spite of the extraordinary development of all of the physical sciences, the refinement in research, he is still in quest of the solution of the problem. While it is true, physiological psychology and psycho-physics have added their contributions, so that today the science of mind has been translated from terms of the metaphysician with its confusing verbiage; its almost unintelligible language, to words, that signify something by defining facts; yet, mind in all that the term im

DR. FRANK PARSONS NORBURY.

plies still offers a vast field for research and observation. It is, therefore, becoming to us as medical men, to delve into this almost unexplored field so far as our profession in general is concerned, that we may know mind in its growing, its maturing and its decay; that we may have adequate knowledge of its clinical value to us in the study of disease, whether it be in its relation to the body in general or to its own realms in particular.

In entering upon this study, we become practical clinicians, because we bring psychology down from its abstract heights to an organic basis and interpret mental function in terms of physical organization, bespeaking a material basis imbued with sense experi

Address in Medicine, delivered before the Mississippi Valley Medical Association, at Hot Springs, Ark., Nov. 6, 1906.

ence and signifying in the concrete properties which are physical. In further evidence of this changed position of psychology, an evolutionary and practical change, we know, as Wundt has said, that mental functions form a part of the phenomena of life, enter into its cycle of production, preservation and destruction, and are governed by the same inexorable law which falls to the lot of all animate beings, whether they be molluse or man. Wundt, in the study of the organic evolution of mental function, reminds us that we know the characteristics of mind, which are subjective, only from the contents of our own consciousness; hence, we must not begin our search for mental function among the lower types of organized nature, where its modes of expression are least perfect, but we must by working our way downwards from man to animals find the point at which mental life begins.

It is not our purpose, however, to pursue this line of inquiry, but rather to accept unquestionably all that physiological psychology has proven, and with this as a foundation feel secure in our position in accepting the belief in the physical basis of mind. James, in his masterly work on Psychology, supports this assumption in the general law which he lays down, viz., "that no mental modification ever occurs which is not accompanied or followed by a bodily change. Example after example in all of the phenomena of mind verify this statement, and it is this fact upon which we are constrained to found the term, clinical psychology, by which we mean a study of physical conditions, reactions following certain definite and well known reflexes, the reactions, the bodily change which follow mental modification according to James' law.

We must remember that, as DuBois bas pointed out so clearly, that the brain itself, the King of our organs which imperiously commands, is a passive organ because its cells upon which its activity depends, do not in themselves act, but react. The cerebral cell has no more spontaneity than the muscular fibre and it reacts only under stimuli of secret impulsions of organic sensations, or of stimuli which are received by our sense organs, those fine antennae which bring us into relation with the outside world. peripheral stimulus must strike the extremity of the end organs of our sensory nerves, by means of which there are successive transmission into the realm of mind and a reflex is there created, either sensory or motor, or higher psychical cell. It is this study which DuBois says is physiology in its essence, is today when applied, one of the most promising field of clinical inquiry. Unfortunately,

The

physicians in general have been frightened by the term psychology, and have little conception of its usefulness when understood and intelligently applied. To me, this applied psychology is and can always be made useful in clinical medicine and surgery. Every physician consciously or subconsciously is, and may be more so, a living potential of its subtle usefulness, and it is just as important that we discuss this feature as it is to discuss the technique of some surgical operation or some clinical problem in internal medicine; for it is true, "whether he wants to or not, the physician ought to be a psychologist, and in practice he will often see that his knowledge of the human heart is more useful than his ability in questions of normal or pathological physiology."

We have a right to use every means that, when ethically and intelligently applied, give peace, comfort, relief and cure to our patients, and we ought not only know how and when to approach psychological problems, but to know the real genuineness, precision and effectiveness of the methods when applied.

We owe to Herbert Spencer the masterly and profound exposition of the origin and nature of the normal mind; his classical, synthetical psychology has laid the foundation upon which has been built all of the practical work in psychology, both normal and morbid. To Drs. Hughlings Jackson, Charcot, Richet, Charles Mercier, Pierre Janet, Wilhelm Wundt, Henry Maudsley, James J. Putnam, Paul Du Bois, Kraeplin, Bianchi and other physicians, we owe the adoption of these principles of psychology to practical clinical medicine.

Unfortunately, medical men have not received in their college curriculum very much instruction regarding the normal mind as taught in psychology, and only within recent years have they received very much information regarding the abnormal mental states, as a result, the mind in disease is an unexplored wilderness to the average physician. I personally feel no apology is necessary for occupying this time in discussing what many physicians regard as a useless waste of time and a pernicious imposition on good nature when one speaks of psychology. It is important that medical men know at least the principles of psychology in order to formulate adequate knowledge of the abnormal states of mind. Obviously, therefore, in order to know the abnormal in its fullest and most comprehensive delineation, we must have a working knowledge of the normal mind in its relationship to the body. This field in recent years has been investigated thoroughly by laboratory, path

ological and clinical methods, and in consequence, mind now as investigated by modern methods is considered in correlated study with the nervous system. As evidence of the value of these correlated studies we have the masterly work on the "Psychology of Adolescence" by G. Stanley Hall.

Mercier says there is a large amount of writing about the mind and about the connection of the mind with the body, which is, strictly speaking, nonsense, and in using the word nonsense he does not use the word as a term of vague abuse, but in its strictest logical meaning to denote language which is unintelligible and meaningless, language which is neither true nor false, but is purely nonsense and is such because of the lack of recognition of the fact that a change of consciousness never takes place without a change in the nervous system, in the brain, and the change in the brain never takes place under the same conditions without the change in consciousness. This is in accordance with the law laid down by James. Now, why the

two occur together or what the link is which connects them we do not know, and most authorities believe that we never shall and never can know.

In view then of what has been said, let us follow Mercier in his practical statement of the facts we have to study in order to know of the nervous system in its relationship to the mind. We must first know of consciousness, and it is self-evident that there is only one way of knowing of the facts of consciousness, and that is by observing the operations the states and the sequences of one's own mind. This introspective method is a careful and systematic study of facts that everybody notices in a more or less superficial and perfunctory manner.

Further, it is evident that this method can only be pursued by investigation upon one's own consciousness. One cannot feel the emotions nor reflect the ideas of other peoples mind; one knows and draws by inference that other people have consciousness like one's self, but one can never directly observe them, Psychology takes all of this for granted, and in further evidence of the correctness of this assumption it has adopted methods of scientific observation to prove it.

Speculative philosophy in investigating consciousness has no place in the modern, or what is called the "new psychology,' wherein experimental methods have proven a source of valuable knowledge. Direct contributions to modern psychology in the study of consciousness have been made through physics, which, as Helmholtz has shown, is theoretically at least the co-ordinate science of psychology. Physics is the