REPORT ON Progress in Medicine By J. B. MARVIN, M. D., Professor of Theory and Practice of Medicine and Clinical Medicine in the Kentucky School of Medicine. Read before the Kentucky Medical Society, at Paducah, June 14, 1887. [Reprint from South- Western Medical Gazette. PROGRESS IN MEDICINE. In preparing this report I have had in mind the words of a distinguished physician, recently deceased (Dr. Walter Moxon) : “ Why can not we combine against the con- tinual heaping up of unverified heresay ? Ingenious men, with large memories, con- nect together various well-meant quotations, until some far-away propositions, uncertainly drawn from uncertain sources, go for the progress of medicine.” While it can not be rightly claimed that any “ epoch making ” discoveries have been made in practical medicine, during the year since we last met, yet the record will show much activity, and no halting in the onward march of the medical art. Bacteriology continues to be widely studied, and the characteristics of the vari- ous septic and pathogenic microbes are be- BACTERIOLOGY. 4 coming more widely known. Bacterial pathology dominates all teaching at the present time. I shall not attempt even a cursory review of this subject, but with a brief reference to some recent views will dismiss this part of my subject: Croupous pneumonia is very generally held to be an acute, specific fever, depend- ant on a micro-organism. The so-called pneumo coccus of Friedlander has received a large share of attention, an interesting point being the discovery by Frankel of the same microbe in cerebro-spinal-meningitis, which certainly is closely related etiologi- cally to pneumonia. "VVeichelbaum has differentiated the varieties of microbes in the several kinds of pneumonia. The most that can be claimed in this matter is that it is still sub judice. Wyskowitch and Orth have contributed an important fact to the etiology of endocar- ditis, by producing the disease by intro- ducing streptococci into the circulation of animals whose valves had been injured. Dr. Shakespeare, of Philadelphia, commis- sioned by the President of the United States to investigate cholera in Europe and India, has submitted his report. In the main he is in accord with the views of the German and Belgian commissioners. He regards Koch’s comma baccillus of the greatest diagnostic value of true cholera. He has less positive opinions as to its patho- genic properties; while it is probably the active cause of cholera, Dr. S. thinks the proof is not yet absolutely convincing. Dr. D. D. Cunningham, of India, and Klein, of England, have retracted to a cer- tain extent their former statements, and ac- cept the claims of Koch as to the diagnos- tic value of the comma bacillus. The Joint Commission of the Royal Society, the University of Cambridge, and the Associ- ation for the Promotion of Scientific Re- search, has recently published their prelimi- nary report. They reject the claims of Koch, and claim to have discovered in the intestinal mucosa, liver, and kidneys of every case examined, a fungus, consisting of granular masses, and a delicate mycelium belonging to the class chytridiaceoe. Councilman, of Baltimore, and Osier, of 5 6 Philadelphia, have published important ar- ticles concerning the presence of peculiar micro-organisms in the blood of malarial patients. Both confirm the discovery of Lavaran, that the blood during a febrile par- oxysm contains a peculiar parasitic infusi- orium presenting different phases of develop- ment, sometimes existing as an actively motile flagellate organism. Klein claims to have discovered the mi- crococcus of scarlet fever, and to have traced the disease to infection from cows. Nu- merous observers have confirmed the claims of Eberth, Koch, and Gaffky as regards the presence of a peculiar bacillus in the intestinal glands, spleen, and other organs in typhoid fever. Among bacteriologists but little doubt exists as to etiological rela- tion of this bacillus to typhoid fever. HEART DISEASES. The possibilities of scientific therapeutics are nowhere more clearly apparent than in the treatment of the diseases and functional disturbances of the circulatory system. Iodides and nitrites of the greatest value in spastic and degenerative changes. 7 Henry Houchard, after five years expe- rience, claims cures of angina pectoris and valvular lesions by long continued use of iodide sodium, 5 to 15 grain doses, 3 times daily, continued for 1 to 3 years, with inter- ruptions of 6 or 8 days in each month. These agents are of value only in chronic, so-called sclerotic inflammation of the endo- cardium. New cardiac tonics have appeared with almost menstrual regularity. It is to be hoped the climacteric will soon be reached. Most of them have proved to be inferior or supplemental only to digitalis. I shall call your attention to only one, which I believe is an important addition to our therapeutic resources, viz., strophanthus. This agent is attracting a great deal of attention, and reports, so far, accord it a distinct value in organic, as well as certain functional cardiac disorders. It is more rapid and powerful in its action than digi- talis, the-dose smaller; it is a heart energizer, acts but slightly, and only in large doses on the blood vessels—not haemostatic, is not cumulative, and rarely causes gastro-intesti- 8 nal disturbances. It lowers temperature, increases arterial pressure, and acts as a diuretic—is preferable to digitalis in cardiac dilitation, etc. PROGNOSIS OF VALVULAR TROUBLES. A remarkable, paper of special interest to every practicing physician, was read by Sir Andrew Clark, at the last meeting of the British Medical Association, entitled “ Cases of Valvular Disease of the Heart, known to have existed over five years, without symptoms.” The very title of this paper is comforting, and will attract a wide hearing Every physician of much experience has doubtless detected cases of valvular dis- ease which had caused no cardiac symp- toms, and had been previously unsuspected. While the conviction has been slowly, forc- ing itself on the profession, that there was a vast distinction to be made between the pathological and clinical import of valvular murmurs, no such extensive experience has heretofore been available. Sir Andrew Clarke has tabulated from his case-book of private practice between the 9 years 1873 and 1886, 684 cases of chronic valvular disease, the presence' of which was not indicated by symptoms, and which did non sensibly interfere with health. He ex- cludes from his tables all instances of mere murmurishness, all inconstant and intermit- tent murmurs, all which were doubtful and en- docardial, all in the pulmonary and tricuspid areas, and all cases which, independently of cardiac examination, had subjective or objective symptoms of heart disease. In his elaborate tables he gives the age, sex, valve affected, character of murmur, proba- ble cause and duration, habits, general health, etc. Of the 684 cases cited, 326 were suffering from digestive disorders, 134 had disorders of the nervous system, 61 had rheumatic affections, 47 disorders of respiratory system, 30 affections of the skin, and 23 gout, etc. As conditions favorable to immunity from the secondary consequences of valvular trouble, he mentions “ a simple, regular, oc- cupied and moderately active life, early hours, a tranquil mind, disciplined control of the emotions and will, regular, but not 10 too frequent nor full supplies of fresh nourishing food, extreme moderation in the use of tea, coffee, tobacco, and alcohol, avoidance of sudden and extreme forms of exertion, of hurry and worry, of serious and depressing cares and fears.” The author lays down the following con- ditions, which, assuming on the part of the patient, obedience to properly adjusted rules of health, would justify us in permitting him to continue the ordinary duties and en- joyments of life, in sustaining an applica- tion for life assurance, in sanctioning mar- riage, and in speaking favorably of his pros- pects of longevity : “a. Good general health, b. Just habits of living. c. No exceptional liability to rheumatic or to catarrhal affection, d. Ori- gin of the valvular lesion independently of degeneration, e. Existence of the valvu- lar lesion without change for over three years. /. Sound ventricles of moderate fre- quency and general regularity in action, g. Sound arteries with a normal amount of blood and tension in the smaller vessels. h. Free course of blood through the cervi- cal veins, i. Freedom from pulmonary, hepatic, and renal congestion. “The conditions of a favorable prognosis differ for different valves, and for each valve according to the character of the lesion. A comparatively small ‘ loading ’ might justify assurance in a favorable case of mitral regurgitant disease, whilst no ‘loading,’ however heavy, for a time how- ever short, would warrant acceptance of a case of regurgitant disease of the aortic valves. The person with aortic might pos- sibly live as long as the person with mitral disease; but there would be such small security for the transaction that, considering the possibilities of disaster, it could not be regarded as other than a reckless specu- lation.” The chief points are summed up as follows . “i. That there are many persons with long-standing valvular disease of the heart, engaged in the active business of life, who without any symptoms of heart-disorder have enjoyed good health and have reached an advanced age. “2. That the mitral regurgitant mur- 11 12 murs so often encountered in chorea, for the most part disappear within eight or nine years of the attack. “3. That valvular inflammation, and their effects arising in the course of rheumatic fever, do sometimes disappear, and leave behind no clinical evidence of their former existence; and that this occurring for the most part in the young, also occurs some- times in the middle aged. “4. That the signs of valvular defects arising out of the degenerative changes of middle life do also, on rare occasions, dis- appear, and that, when circulatory and respi- ratory disturbances accompany their com- mencement, they sometimes subside, and permit of apparently complete re-adjust- ment. “5. That as there must be in the histories, habits, occupations, and surroundings of patients with valvular disease conditions which, in one case, bring about secondary disorders, and, in another case, exempt it from them, it is desirable that the respec- tive differentia should be discovered, and made capable of application to practice.” 13 The commonest and most constant indi- cation of departure from health has at all times pressed itself upon the attention of clinical observers. A subject full of inter- est and of important clinical bearings, it re- mains almost as mysterious as at the dawn of medicine. Two scholarly and ingenious contribu- tions on this subject have recently been published, viz.: a series of papers by Dr. T. J. Maclagan on “Pyrexia and Hyper- pyrexia,” and the Gullstonian Lectures “on the Nature of Fever,” by Dr. D. Macalis- ter. These gentlemen treat the subject from different standpoints, and their conclusions are not in entire accord, but they represent the outcome of physiological teaching on animal heat, and each suggests, according to their respective views, hypotheses more or less satisfactory in explanation of the na- ture of fever. Both start from the same premises, viz.: that fever is essentially a dis- order of body heat; that in health body heat balances heat loss; hence the stability of temperature. FEVER. Dr. Maclagan includes heat among the excretory products to be eliminated from the system at the same time and manner as urea and carbonic acid. He rejects Traube’s theory that fever is due to retention of heat, consequent on contraction of minute arte- ries. Such a condition, except in the ini- tial stage, is inconsistent with the thermo- metric course of pyrexia. As a matter of fact, there is an increased elimination of heat in fever, due to heat acting as a stim- ulant to heat elimination. Increased form- ation of any product leads to stimulation and increased activity of the organ by which it is eliminated. Increased formation of heat gives rise to increased activity of the heat eliminating function of the skin. Hence before an attack of fever has lasted many hours or days, increased formation of heat is balanced by increased elimination, and no further rise of temperature occurs, though the fever process continues unabated. Example—-Typhoid Fever.—A healthy adult gives off heat enough every half hour to raise the temperature of his body i° C. Were heat to be formed uninterrupt- 14 15 edly at this rate without elimination, the body would reach the boiling point in thirty- six hours, but owing to balance between heat production and elimination the temper- ature remains at 98.5° F. In fever, heat production is greatly increased. Were elim- ination to remain as in health there would be no limit to the febrile range of tempera- ture. In fact, owing to increased elimina- tion and not retention the temperature in pyrexia rarely goes above 106° F. Ord’s hypothesis that in the process of tissue for- mation heat is rendered latent and is liber- ated in the febrile state is rejected as inad- equate to explain the excessive heat product tion that occurs — pure hypothesis. Dr. Maclagan draws a sharp line between py- rexia and hyperpyrexia. All pyrexiae he explains in term of metabolism by the so- called combustion theory. Regarding heat as an eliminatory product, in the specific fevers, the contagion consumes the store albumen intended for the repair of the tis- sues, and the water necessary for tissue metabolism, causing the tissues to consume their own substance for lack of replenish- 16 ment from albumen and water normally in- tended for them, giving rise to increased elimination of excretory products, heat, urea, C02. Hyperpyrexia consists in tem- perature running from 1070 to no° F. or higher, with coincident development of alarming nervous symptoms, usually result- ing in death by coma. Examples : hyster- ical, heat apoplexy, and rheumatic. The combustion theory is inadequate to explain these cases. The nervous symptoms are not caused by the hyperpyrexia, but are in- dicative of the nervous disorder which pro- duces the hyperpyrexia. The neurotic the- ory explains these cases, as well as most ephemeral fevers and fever due to non- inflammatory lesions of the nervous centers. These theories are not antagonistic. Both are necessary. Dr. Macalister’s lectures will deservedly attract wide attention. He gives us a new terminology and new conceptions, and places the pathology of fever in closer ac- cord with modern physiological teachings. He makes no mention of the etiology of fe- ver, nowhere refers to bacteria. He expands 17 the neurotic theory to cover all forms of py- rexia. This thermotaxic mechanism is the highest and most essential of all the factors concerned in the maintenance of the body heat. It is the easiest deranged, and is the connecting link of all pyrexiae The ner- vous mechanism concerned in heat loss (thermolysis) is that of the vaso-motor and respiratory systems, each possessed of mo- tor and inhibitory functions. The vaso- motor system is the great agency by which heat loss is regulated. Heat production (thermogenesis) takes place largely in the muscles, not dependent upon, but largely increased by their contraction. A nervous mechanism presides over thermogenesis sim- ilar to thermolysis. This mechanism is two-fold, one exciting thermogenesis, and accompanied by destructive metabolism; the other inhibiting thermogenesis and sub- serving destructive metabolism. One is catabolic, the other anabolic; one motor, the other inhibitory; one exciting muscular contraction, the other relaxing the tissues. Thermogenesis is placed in the vital scale a little higher than circulation and respira- 18 tion, and a little lower than voluntaryjnus- cular action. As yet there is but scant evi- dence of the existence of these thermal nerves. Wood claims to have found a thermoge- netic center near the crucial sulcus, and Aronsohn and Sachs find a heat-generating center near the inner side of the corpus striatum. The thermal nervous system has three parts—thermotaxic or adjusting, thermoge- netic or producing, and thermolytic or dis- charging. Disorder of the first (thermotax- ic) implies irregularity of temperature only; of the first and second (thermotaxic and thermogenetic) implies heightened tempera- ture and increased body heat: that is, ordi- nary fever. Of all three (thermotaxic, ther- mogenetic, and thermolytic) hyperpyrexia, dangerous increase of heat and steadily ris- ing temperature. The three mechanisms are successively evolved as we ascend in the animal scale. Cold blooded animals have little more than a thermolytic or heat- losing mechanism. Infants have only the thermogenetic and thermolytic, there being 19 hardly any adjusting mechanism, as is shown by the instability of their temperature. Fe- ver is a dissolution process. The last mech- anism involved (the thermotaxic) gives way first, then the thermogenetic, and lastly the thermolytic. Conversely, when the patient convalesces, thermolysis is first restored to normal, then thermogenesis, then thermo- taxy. In regard to antipyretics, the same re- marks apply as to heart tonics. I am sat- isfied that acetanelid, or antifebrin, as it is sometimes called, is the safest and best of the antipyretics. It is cheap, quick in action, dose small. I have seen no bad effects from it. I forbear speaking of the various febrile conditions in which it may be used, and direct your attention to its marked analgesic properties. I have used it with decided benefit in migrane, neural- gias, especially of the head and face, in the mental excitement in certain cases of hys- teria at the menstrual periods, in the pains of acute rheumatism, for the atrocious pains in one case of locomotor-ataxia, etc. Gen- ANTIPYRETICS. 20 erally give 5 grains in powder, capsule, or dissolved in whisky or brandy, or aromatic spirits of ammonia. The dose may be re- peated in an hour or two; seldom find it necessary to give more than two doses. PHTHISIS. No subject in medicine has been more the sport of credulity than the treatment of consumption. The frequent non-success of scientific medicine to arrest the down- ward progress of this disease has given rise to a host of remedies, by “happy thera- peutists, whose large promises are of value only in stimulating hope and energy in their own patients, and among too credulous doctors.” Phthisis dogs the steps of man wherever he is found, and claims its vic- tims among every age, class, and race. Cod liver oil, hyperphosphites, malt ex- tracts, koumiss, forced feeding, compressed and rarefied air, inhalation of oxygen and nitrogen, antisepsis, cold and salt baths and douches, external applications, etc., have been launched before the profession, but the disease continues in its fitful and trium- phant course undaunted and unchecked. 21 All so-called cures, after a brief reign have found their proper place, at best, as useful remedial agents in certain cases, under cer- tain circumstances. Recent specifics for this disease tread upon each other’s heels, so fast do they follow—all based on the view of the etiology of phthisis that has gained credence since the discovery of the tubercle bacillus. I but mention tannin, injections of eucalyptus, aniline inhalations, and hydro- fluoric acid, etc., and call your attention especially to Bergeon’s method by sulphu- retted hydrogen enemas. As the disease has resisted so far attacks a fronte, we are asked to change our tactics, and attack it a tergo. This method was published last summer, but attracted no attention in this country, until the first of this year. The letter to the British Medical Journal, December 11, by Dr. J. Henry Bennett, caused certain of the profession in this country to give the method a trial. Unfortunately the method has been heralded by quacks and the public press as a certain cure. Phthisis as we ordinarily see it is a chronic process, and it is the height of absurdity to claim that any method will cure it in a few weeks. Since 22 the discovery of cocaine nothing has cre- ated such a furore in this country. Reports in this country, up to date, have been uni- formly and enthusiastically favorable. I show you the apparatus and method of using it. PERSONAL EXPERIENCE. About the ist of February I began using this treatment in the wards of the City Hos- pital under my care. For two months fif- teen patients in various stages of phthisis received the treatment. I used at first Blue Lick water, then artificial sulphur water made with sulphuret of potash, and finally a saturated solution of sulphuretted hydro- gen in distilled water. I found that patients bore the latter as well as the gas from weak natural waters. I noticed no special bad effects from this treatment, though the ne- gro patients, failing to appreciate this novel method of attack, were loud in their com- plaints. My experience was far from en- couraging, and in many respects at variance with the claims of most writers on the sub- ject. In not a single instance could I detect the gas in the expired air, either by smell or by white filter paper moistened with solu- 23 tion of acetate of lead held before the mouth. Tubercle bacilli in the sputa were neither diminished nor destroyed, neither did I ob- serve any appreciable or permanent good effect on the expectoration, temperature, or night sweats. In the face of such an over- whelming mass of favorable testimony by competent observers, I can only hope that my experience is exceptional, and that fur- ther experiment will substantiate the claims of its advocates. Safety lies midway. The positive deductions of certain writers after only a few weeks’ trial of this method were ill judged and premature. Already evidence is forthcoming that the curative effects of the gas have been greatly over estimated. Its good effects are seen chiefly in asthma, bronchitis, and local pulmonary affections. Acute febrile pulmonary processes do not seem to be benefited. A fresh series of observations by M. Per- ret proves that this agent is as good as, hut no better than other bronchial remedies. It has no microbicidal action; it diminishes expectoration, influences nutrition for good in apyretic forms, andis of value in reliev- ing particular symptoms. Drs. Spillman and Parisot find it only pal- liative, and not curative. They find it pow- erless to arrest tuberculous exacerbations; much less is it capable of arresting the de- velopment of phthisis. Night sweats are not influenced, temperature is not perma- nently lowered, appetite not disturbed. It causes intestinal uneasiness; weight re- mains unchanged; general condition in this and with other medicaments was de- pendent upon progress of the disease. Sleep was quiet, due solely to carbonic acid. Dupont claims better results by inhalation of carbonic acid gas. A specific treatment for consumption is a consummation devoutly to be wished. It is clear that at present we have no thera- peutic or hygienic art by which rapid phthis- ical processes can be surely arrested. Some cases are curable; the majority probably are not. To claim that all consumption is cura- ble is as untrue as to say that all consump- tion is incurable. Cases have been cured and will continue to be cured by resources at our command. Let us give this method, irrational as it may seem, a fair trial. 24