I THE CLINIC AS AN EDUCATIONAL AGENT. 'N AN article which we have abstracted elsewhere in this issue-it matters not by whom, or upon what particular subject, or from what journal, since these things have nothing to do with the point-the author, commenting upon the conclusions of a certain German clinician, throws doubt upon the soundness of this clinician's findings on the ground that he sees too many cases. The inference, of course, is that too many patients pass this man in a given time to permit of their all receiving that thorough and careful examination which is necessary to a scientific diagnosis. And undoubtedly there is a great deal of reasonableness in the objection. At all events, when the matter is considered from the point of view of its relation to medical education, whatever may be true of its influence upon the clinician himself, one cannot help admitting that a crowded, hurried clinic is hardly adapted to teaching methodical, painstaking diagnosis. Such a cloud of material can certainly do little more than dazzle the imagination of the average student or post-graduate, leaving no lasting or intelligent impression upon his mind, and serving to confuse rather than to discriminate between diagnostic differentiation. On the other hand, there is a very general conviction prevalent that large clinics furnish the most valuable means of teaching practical medicine—the larger the better. And it must be confessed that this view of the matter has also its powerful arguments, most powerful and irresistible of which, perhaps, is the undeniable connection that exists between the large clinical facilities of European medical schools and their acknowledged teaching superiority. There is, in fact, no other ground on which to explain this superiority, for this is the only point in which European schools of medicine excel American. And, in spite of the critcism of the gentleman whose remarks we took as a text for this editorial, it is a fact that the German professors of clinical medicine do derive their authoritativeness from the multiplicity of cases which pass their eye and hand. What, then, is the answer to the paradox? How are the two views of the matter to be reconciled? We believe the solution is to be found in a combination of both. We heartily agree with those who admonish against the dangers of the too large clinic as the only method of teaching practical medicine-although we are not disposed to think the American medical student stands in any great danger from this source. It is, we think, quite true that the exclusive use of large clinics is apt to induce a habit of scamping and generalizing. On the other hand, we are equally in agreement with those who hold that a multiplicity of cases is the only way to wide experience and familiarity with disease in any of its forms. The sight and study of two or three cases a year of any one form of disease will never make a practica! clinician, no matter how thoroughly and painstakingly they may be gone over. The range of practical medicine is so wide that its field of rehearsal can hardly be made too extensive. The irresistible conclusion is that there are two distinct and separate schemes of clinical demonstration, both of which call for equal attention in the student's curriculum. Unfortunately, neither of them is given the place that it ought to have in the American school of medicine. One is the plan which finds its highest expression, perhaps, in the English schools, namely, the bed-to-bed plan that is carried out in the English hospital schools, (whence comes the well-known English expression "walking the hospitals"), in which the student is brought face to face with actual sickness in the role of a bedside physician, and given both opportunity and instruction for the bedside handling of the individual case. The other is the distinctively German plan of public clinics, where hundreds of cases of the same general type are to be seen each day, and where the eye and other senses of the student may be made accustomed, from the very multiplicity of instances, to the manifestations about which he has learned in practical detail from his bedside study. We do not wish to be understood as implying that these two plans of clinical instruction are peculiar, the one to England, the other to Germany. Both are of course followed out in both countries. But it is in the former country that the first method excels, in the latter that the second is supreme. In America, unfortunately, where we ought to have a splendid combination of the two, we have nothing but the faintest imitation of either. We have, indeed, almost abandoned the English bed-tobed plan, and made a great palaver about general clinics, but the truth is we have not the clinics to justify our talk. What we need in this country, for the most effective teaching of practical medicine (and that is, after all, the only kind of medicine for which the public cares), is a universal hospital-college scheme, i. e., that every medical school shall own, or better still, be owned by, a hospital whose wards shall form the stamping-ground of the upper students; and second, a general system of municipal clinics under which the sick wards of the city or county should be properly distributed as clinical material among the legitimate schools of medicine. TH THE LIMITATIONS OF PSYCHO-THERAPY. HE employment of suggestion as a therapeutic agent, especially in those psychoses and neuroses which seem to lend themselves most peculiarly to this kind of treatment, is finding a very enthusiastic advocacy in many quarters; and, indeed, in the minds of some of its most ardent advocates there would seem to be no limit to its usefulness other than those which pertain to the capacity of the therapeutist. Given an operator who can wield the power of suggestion to an unlimited degree, and the benefits to be derived therefrom, according to these enthusiasts, are equally unlimited. In view of this rather misleading fanatacism it may not be out of place to call attention to one or two fundamental and inherent limitations which lie within this mode of therapy, automatically bounding the scope of its effectiveness. It may be noted, for one thing, that those particular cases of psychosis or neurosis in which suggestion is supposed to find its greatest usefulness are usually cases in which the essential defect is one of will-power; and no amount of suggestion can ever awaken will-power. On the contrary, the very essence of the power of suggestion is to substitute one will for another, or at least to make the patient's will subordinate to the suggestion of the operator's—a principle which carries on the face of it an irreconcilable antagonism to the development of the patient's individual will. It may, in fact, be laid down as a law of suggestion, that the more completely the subject is brought under its influence the less will-power he has of his own; and a patient who actually started out with some degree of will-power would, after a prolonged and "successful" course of suggestion finish up by losing what little he had. Now it may be quite reasonable to suppose that a person's will, like his pulse or his muscles, may occasionally need helping over a crisis; and for that purpose a little suggestion is a capital thing. But to completely "influence" a subject, while it may establish a “habit", is utterly destructive of will-power, and defeats the very purpose for which it is employed. Exceptions, of course, are to be seen in those rare cases where the will-power is hopeless, and must be replaced by habit. But cases of this kind do not enter into the argument, save as exceptions which prove the rule. What is, perhaps, a still more fundamental consideration—at least a much widerreaching one-is the comparative inefficacy of suggestion itself to do the things required of it. It is not by any means the all-puissant spirit that its worshippers imagine. It falls short of the efficacy of the actual event or condition suggested, by just so much as an imitation always falls short of the real thing. Just as a joke repeated, never so cleverly or opportunely, never produces the same natural merriment as the joke which tumbles spontaneously on the heels of a train of experiences; just as the sequence of events reeled off a cinematograph does not have the same effect upon the senses as the actual transpiring of those events; because they are detached, so to speak, from their living connection with the reality of things; sɔ the suggested states of mind in the psycho-therapeutic subject can never exercise the same influence that similar states of mind would exercise that arose naturally and spontaneously. And curiously enough, the more perfect we make the mechanism for producing the suggestive effect, the more unerringly the mind detects the false ring and resents it. What these psycho-therapeutic enthusiasts seem to forget is that the principle of the sub-conscious mind works both ways. The teachings of psycho-therapy on this point are a trifle inconsistent. It is never weary of assuring us how vigilant and keen and unerring the sub-conscious mind is; how it takes note of events, keeps track of time, and senses impressions with far greater accuracy than the higher brain. Yet in the same breath it asks us to believe that this sub-conscious mind can be easily and wholesalely fooled by any and every kind of suggestion, regardless of any vital relation which that suggestion may or may not bear to the reality of things. We are not attempting to discredit the power of suggestion; only to point out the common sense of the matter. We do thoroughly believe that much can be done by means of properly directed suggestion of the psycho-therapeutic kind, just as it can by suggestion of the ordinary sort. But every man knows that if he is to influence a customer, let us say, to buy an article by means of a certain line of demonstration, he stands a far better chance of being successful if he can so arrange it as to make the demonstration appear to fall naturally within the customer's mental routine, i. e., to give it a vital relation or continuity with his experience. For the instant the customer gets an inkling that the demonstration is being performed for the purpose of making him buy, he sub-consciously resents it, and the merchant has then this resentment to combat in addition to other obstacles. So it is with psychic suggestion. Unless the suggestion be skilfully and intelligently directed so as to synergize with the life-current of the subject's own thought and experience, and to set in motion, as far as possible, natural and spontaneous tides of mental activity, it will unquestionably stir sub-conscious resentment; which will do more harm than good. Able and expert psycho-therapists know these truths, and understand the limitations of the agency. For this reason they make least claims and achieve greatest results. It is for the admonition of those who have not the means of checking the wild claims of extravagant fanatics that we have said what we have. T OUR CRITICS. The editorials in the current Medical Brief on "The A. M. A. In Action at Los Angeles," and "The A. M. A. Going Into the Text-Book Business," illustrate again the propensity of mankind to ignore the originator of a movement, no matter how he toiled and suffered in season and out of season to place it before a world scarcely ready for it. Dr. G. Frank Lydston, no matter how we may differ as to whether he was "politic," literally forced upon the attention of the A. M. A. membership certain weaknesses of the institution that were not foreseen when the big society was reorganized. The very things the editor of the Medical Brief finds the courage at this time to inveigh against were first pointed out by Lydston; and it is remarkable that the very verbiage of the pamphlets issued by Lydston has been appropriated by the startlingly original editor of the Brief. In his pamphlet entitled "The Russianizing of the Medical Profession," the proposed text-book invasion, the domination of medical education, health boards and medical journalism was freely predicted. This is not the place to argue on the function of the A. M. A. to exercise control of these various fields, or whether the danger is imminent of placing autocratic power in the hands of a few. The fact is, this domination was predicted, and the attention of the membership drawn to the possibilities inherent therein by Lydston. His methods have been justly criticised, but he has certainly given an impetus to reform. HUS the editor of the Lancet-Clinic in stern and righteous indignation. Lordy, who would have dreamed we were bringing down upon our devoted heads such vials of contumely by our innocent and modest comment upon current events? Why confine the application of the accusation to Lydston? Why not charge us with plagiarizing Thomas Jefferson, or appropriating Lord Macaulay, or purloining from David Hume, all of whom, and thousands of others, have "forced upon the attention of institutions certain weaknesses that were not foreseen when they were organized?" The charge is puerile and gratuitous. No one in medical journalism has greater respect for Lydston and his work than the Medical Brief, and none has given him more loyal and outspoken support at a time when journals like the Lancet-Clinic were afraid to declare themselves. It may be a propensity of mankind, in approving a successful movement, to "ignore the originator who toiled and suffered to place it before a world scarcely ready for it"; but it is a great deal more characteristic of mankind, and of journal-kind too, to allow such a man to toil and suffer alone until the movement gives signs of success, and then to wax eloquent in his laudation. By-the-way-er-did anyone chance to see an article entitled "The A. M. A. and the Publishing Business" in the July 15 issue of the Lancet-Clinic? And did anyone happen to find in that article any reference to Lydston and his great work? D Pneumonitis.* BY ROBERT L. HAMMOND, M. D., MARYLAND. R. HAMMOND is not a therapeutic nihilist-on the contrary, quite the reverse. His article is a powerful plea for the vigorous and intelligent treatment of this dreaded disease, in a methodical fashion, by measures impelling the advent of the "crisis." In his system of therapeusis, wetting and douching the extremities, and fanning, to effect the rapid radiation of heat is a prominent adjunct of the treatment. Like all men who have faith in therapeutic measures, the author has an intelligent and broad understanding of what constitutes therapeutics. We present his article with a great deal of pleasure, as being a positive, practical, and helpful contribution to this important subject. "Pneumonitis" as its nomenclature cold, a predisposition to it is the most frequent. signifies is an inflammation of the lungs. In a descriptive sense, it is an acute sthenic or asthenic fever, attended by an exudate, "croupous" or "catarrhal" in character, into the vesicles, bronchioles and parenchyma of the lungs, with a "natural" tendency to terminate in a distinct "crisis." The substitles under which its pathology and treatment are studied are "croupous pneumonitis," named from the character of its exudate; and "catarrhal bronchopneumonitis" named from the constituent of its exudate, and the way in which it invades the lung tissue. "Croupous pneumonitis" invades with its exudate the air-cells, of a lobe or lobes, it is common to "all ages" and comprises about seven-tenths of all the forms reported. "Catarrhal bronchonitis" invades first the bronchioles, then the vesicles and interstitial tissue of both lungs with its catarrhal or muco-purulent exudate, it is "mostly confined to children" and embraces about three-tenths of all the cases reported. The great mortality attending this disease at present make its study one of the most important within the realm of medicine. Its causes are multiple, next to taking *The term "pneumonitis" is employed, by the writer, rather than pneumonia, because it more definitely implies the presence also of a localized inflammatory action. See Ziemssen's Cyclopaedia of Medicine, Vol. V.. Fol. 165-166. It is a peculiarity of this disease that at the time of a "normal crisis" the temperature is liable to become "subnormal' and this condition may occur and a state of collapse may supervene when positive antipyretic measures have been omitted altogether. This unfortunate circumstance was common in countries where "quinia" was used in unreasonable doses, and the "cold bath" was improvidently employed.° It was common everywhere when the "coal tar derivatives" were used in positive doses. The treatment here outlined is conservative, it is simply a peaceful invasion of the domain of nature, a clasping of the outstretched hands and a mutual declaration of dependence in times of dire dis tress. The preliminary purgation is best accomplished by a single dose of 10 or 30 grains of calomel triturated with one grain of sodium salicylate, assisted in four hours with a three pint slyster of warm salt water, from one to two teaspoonfuls of chloride sodium to each pint of water should be used, according to the amount of intestinal stimulation required. Lavage of the colon, with the foregoing solution, should be practised once daily, during the continuance of the case, unless specifically contraindicated, then sterilized water alone should be used. |