CHAPTER V Every ambitious man has been impressed by certain lessons (Part 9)

the fact that some kinds of microbes are useful to each other, not only in helping to prepare the way and making food for other microbes, but in furnishing conditions particu- TO-MORROW'S TOPICS 313 larly favorable for the continued existence of our good mi- crobes (microbic symbiosis). Northrup and Zae have shown that certain yeasts which Hve upon lactic acid have the trait of keeping lactic acid bacteria in a condition of activity for long periods when the two are grown together in the same culture medium. These yeasts are stock farmers which cultivate and protect herds of lactic acid bacteria for their own purposes very much as ants tend their flocks of aphids. We shall Hkely enough find that people who carry such pathogenic bacteria as those of typhoid fever or of diphtheria for long periods with- out harm to themselves may owe this condition to a symbiotic relation between their pathogenic bacteria and some other species. In that case the medicine of the future may have to cultivate special bacteria for the purpose of destroying other bacteria which keep certain harmful bacteria alive. It will be a different class of medical practice from that which in former years treated "inflammation of the lungs" by putting liniments upon the chest and giving calomel internally. In the medicine of to-morrow we are to view our cases in such a new way that a practitioner of even the latter part of the nineteenth century who has not kept up to date will not know what we are talking about at all. Dr. Lewellys Barker says that one result of the almost explosive progress of the purely laboratory subjects has been to place internal medicine in an embarrassing situation. All at once the air has become thick with applicable facts of the most diverse origin, and only the younger clinicians have had opportunity for securing a training permitting of an understanding of even a part of them. Take for instance, psoriasis, as probably being one of the external manifestations of an internal protein poisoning. Let us say hypothetically (not upon known fact) that in one case it represents allergy to a protein of milk. We would then have the following formula representing the development A 314 TO-MORROW'S TOPICS of psoriasis, and the method of procedure by the twentieth century physician : - -.„ (microbe food — unmetabolized toxins, (man food — ^metabolized toxins. , ,. , ( proteolytic end-result toxins. Unmetabolized toxms y ^ , _^. ^ u r ui j ^ I proteolytic metabolizable products. psoriasis caused by dermal ex- Proteolytic end-result toxin { cretion of proteolytic end-result toxin in an allergic patient. fj f H i ^^y ^^^^^ — work. ( waste products — elimination by emunctories. The crudest method of treatment common to the present time — application of local remedies. A step in advance — application of local remedies combined with shotgun prescriptions aimed at colonic toxins. Treatment belonging to the future — determination of the presence of one particular microbe which chooses one par- ticular proteid for its food and which makes one final demon- stration with selective affinity end-products in the form of psoriasis. The treatment would consist in depriving this par- ticular microbe of its food, in attacking it with vaccines, or in destroying the microbe at some nidus. One reason why diabetic diets have been beneficial in the empirical medicine of the past is because in some cases they starve out microbes which are disturbing the pancreas and squeezing the islands of Langerhans. In our more enlightened medicine of the present moment we now know that the Bul- garian bacillus destroys these harmful bacteria rapidly and efficiently, and that when this bacillus is properly employed in TO-MORROW'S TOPICS 315 its capacity as a hound for the colonic bacteria, many cases of diabetes clear up at once, even while the patient is on quite ordinary diet. Our new medicine is to advance from the study of diets for the diabetic patient, and is now to include in addi- tion a study of diets for his microbes. The host is to be fed and the parasitic microbes are to be starved. Wechselbaum, after examination of the pancreas in 183 cases of diabetes, states that in every one of this series he found distinct and characteristic lesions in the islands of Langerhans, while in a large series of control cases represent- ing many other diseases no corresponding changes were found. He states that these lesions had been overlooked because ex- amination for discovering hydropic degeneration and special methods of preparation of tissue is required. All of our new knowledge on the subject allows us to observe the microbe as the leading causative factor in diabetes, and physicians who are sufficiently skilled in the use of the Bulgarian bacillus for destroying those bacteria which are harmful in their influence upon the pancreas, are reporting immediate and direct results from such treatment in selected cases. This is fully in hne with our medicine of the twentieth century, which is just now beginning to seek the microbe in diseases which previously were treated as idiopathic entities. Glycosuria is never anything but a symptom and it depends upon hyperglycemia. The latter is a disturbance of the sugar metabolism, which in turn is due to a variety of causes, a number of organs being involved in the work of sugar meta- bolism. The organs of internal secretion are the ones pri- marily involved, and the pancreas appears to stand first in importance among these organs. So long as the doctors treat glycosuria without knowing if the patient has chronic pancreatitis, and so long as they treat sciatica without knowing if a myoma of the uterus or of the 316 TO-MORROW'S TOPICS I prostate gland is present, so long will quacks thrive, and the profession complain about charlatans. The matter is in our hands. Treatment of dyspepsia may be classified historically in five stages : In early days it was due to dyspeptic "humors," — sometimes treated by blood-letting to let the humors out. The second stage was that of empiric use of drugs. The third stage included employment of drugs and of diet Hsts, based upon analysis of contents of the stomach and bowel. The fourth stage was marked by examination of the stomach with the fluoroscope, and determination of the general character of conditions which were present. The fifth stage upon which we are now entering, goes still further back. At the present time we seek for the fundamental toxic features associated with neurasthenia, and for anatomic or physiologic defects of various organs. Now that the whole number of patients of all sorts in the physician's clientele is being lessened by our methods of preventive medicine, physicians will have time for the proper care of dyspepsias. Gastric disturbances to- morrow will receive the sort of attention which has always been required and which seldom has been received by the patient. We often hear about cases of "gall-stones without symp- toms." That is because we have not recognized the symptoms in these particular cases. Doctors have been taught to look for biliary colic, or painful features of gall-stone disease, and they know little of the more common but comparatively pain- less features. There are glycosurias, dilated stomachs, chronic dyspepsias, and all sorts of distressing conditions precipitated by or continued by gall-stone influence. They are not recog- nized as having any relation to the gall-bladder condition. One of our most famous surgeons suffered from lumbago for many years, and it was only incidentally that he discovered I TO-MORROW'S TOPICS 317 that the lumbago was due to a glycosuria. This in itself was treated for a long while without much result, until consultants discovered tliat my friend had gall-stones. When the gall- stones were removed, his glycosuria cleared up, and the lum- bago ceased. If this history can happen to a man who was alive to all of the up-to-date knowledge in our profession, just imagine what a number of laymen must be suffering from gall-stone influence without hope of having the cause for their distress discovered. My friend's case was one of "gall-stones without symptoms." An instance of our unsettled position upon almost any question in medicine to-day is shown in connection with the condition of loose kidney, i. Thousands of practitioners have never recognized a case of loose kidney and would not know how to go to work to discover it. 2. Other physicians report loose kidney as occurring in at least ten per cent, of all of the women who come into their offices. 3. Some surgeons finding a loose kidney proceed systematically to determine if it really is a case for operation, or one for mechanical support. 4, Many doctors observe cases of loose kidney which manifest so many symptoms of neurasthenia later that the operation seems to have been a failure. They do not see the carefully selected cases in which patients have been made well, because well patients do not continue their visits to the doctor. 5. A few surgeons believe that all loose kidneys should be fixed, on the ground that this feature ought to be cared for no matter what other complications may be present, 6. Some physicians believe that no loose kidney should be fixed because the condi- tion is but one symptom of a general condition, 7. Some surgeons expend an hour in doing the operation of fixation of a kidney by one method, while others do the operation in ten minutes by another method. The ten-minute operation certainly removes one objection to the surgery of the subject. } The situation as a whole then is this : Although there are many physicians and many surgeons who know the various phases of the entire subject, the chances of any one patient getting into the hands of these men are comparatively small. Too few loose kidney patients are operated upon and too many loose kidney patients are operated upon. Whenever we cease calling a disease a disease there i hopeful progress. Arteriosclerosis is no more a disease of the arteries than typhoid fever is a disease of the spleen. In one group of cases it may be traced to the influence of cell poisons derived from proteins; and in the medicine of the future the physician will likely enough test the response of any given arteriosclerosis patient to various proteins. He will then pro- ceed to eliminate the protein which is found to immediately cause a rise of blood pressure in a given patient. Practically all organic activities are due to stimulation of cells by organic or inorganic products of other cells. Disease commonly means that we are simply taking over-doses of these necessary prod- ucts, which in overdose form are poisonous. The overdosing is due chiefly to lack of efficiency of the cellular agents of control, and we shall have a new definition of disease when this matter can be stated accurately in scientific terms in rela- tion to what we now call disease. While arteriosclerosis is only one symptom of a general condition, high blood pressure is commonly due to special sensitization of the arterial system, either directly through the influence of microbic toxins, or by some body cell toxin which sensitizes it to exaggerated influence of epinephnn. The kidney changes in these cases represent only a third or fourth stage in the sequence of events. The effect of microbes upon some of the body colloids appears to leave them with a tendency to pick up insoluble material, and to arrange it, by molecular attraction, in the TO-MORROW'S TOPICS form of concretions. All of our concretions which form in the luinina of viscera have a colloid element in their structure. Even the small uric acid gravel is reported to show colloid combination so often that we must look to the colon bacillus (which is believed to be harmless in some cases in which it occurs in the kidney) as the mischief maker. Just at present it is the fashion to believe that a few of these bacilli occurring regularly in the pelvis of the kidney are quite harmless, but we may look for some investigator soon to demonstrate their influence in producing calculi through colloid combinations. The history of the colon bacillus has been peculiar in the respect that it has so often been considered as non-pathogenic in various places in which it was found later to be a malefactor. In the early nineties a few men whom we commonly held to be visionary were making a large feature of "orificial surgery." They ascribed exaggerated importance to the influ- ence of rectal papilla. This idea was scouted by the majority of physicians, but whenever a subject receives so much atten- tion by any part of the profession it usually means that a germ of truth is to be found on investigation. I made a study of inflamed rectal papilla, finding them to be really a potent factor in many cases of peripheral irritation of obscure origin. Ma- terial was given to Dr. B. E. Stroud, who under my direction made a study of the anatomic structure (Dr. Stroud's paper was published in the Annals of Surgery for July, l8g6), and established the point that these papilix consist of especially arranged nerve elements, and have a special function. When inflamed they are capable of exciting reflex disturbance which is out of proportion to their insignificant size. One reason why Germany in particular has made greatest advance in medicine is because of the freedom with which post- mortem examinations are allowed in that country. At the hospitals in this country members of the house-stafl^ make a 320 TO-MORROW'S TOPICS sort of unconscious classification of members of the visitii staff who follow up their cases and observe post-mortem find- ings. These men are held in higher esteem than other members of the visiting staff who do not take the trouble, or who do not make a feature of learning what is to be learned from post- mortem examination. In the Journal of the American Medical Association a report has recently been made upon the per- centages of correct clinical diagnosis verified by autopsy find- ings in four large institutions. These were given as sixty per cent. ; forty-seven per cent. ; seventy-eight per cent. ; and seventy-one per cent, respectively. In one of the hospitals, in a series of two hundred cases, the autopsies showed a correct diagnosis in one hundred and thirty-three cases. There was a wrong diagnosis forty-three times and no diagnosis twenty- four times. If this represents a proportion of wrong or faulty diagnoses in institutions where men of the first class are in charge, one may readily understand that the percentages of correct diagnosis in general must be far below the forty- seven per cent, of one of these institutions. In three thousand' autopsies reported upon by Dr. Cabot, of Boston, and quoted iilj another note, many important diseases fell below fifty per cenL in recognition, and some below twenty-five per cent. The public does not reali2e this at all; in fact, the subject is not given serious thought as yet by the medical profession, because we are as yet only upon the verge of that study of medicine which is to belong to the twentieth century. The newspaper press has recently published under large heads the statement that half of the diagnoses made at Bellevue Hospital are incorrect. If one half of the diagnoses are correct and comprehensive Bellevue Hospital should take rank among the very first of hospitals of the world in representing scientific attainment on the part of its medical stafT. One reason why post-mortem examinations ons are not more I TO-MORROW'S TOPICS 321 often made in this country and in countries which may be dragging along behind the times in "internal medicine," is because of the prejudice against autopsies. The development of scientific medicine and therapy in any country has always been in proportion to the systematic performance of post- mortem examinations. In the first part of the nineteenth century scientific medicine in Germany was far behind that of France, or even of England, but in the latter half of the nineteenth century, one man, Virchow, lifted the entire pro- fession of Germany beyond that of all other countries. Ger- man medicine had previously occupied a very low position because of the tendency of the German mind to follow philosophy, very much as science has always remained hidden in the Orient because of the same tendency. Schelling applied the principles of an idealistic philosophy to the interpretation of the phenomena of nature (including the symptoms of diseases among phenomena of nature). His philosophy in particular had kept medicine in Germany at a low level, because speculative philosophy must always smother knowledge in proportion to the cleverness and intellectual power of the meta- physician. Medical thought was divided among four or five dissenting schools at that time, instead of acting upon well- founded universal methods of inductive scientific thought. Hahnemann as well as Schelling stood forth conspicuously in the early part of the nineteenth century. Virchow punctured the inflated pomposity of speculative advances of individual schools and ridiculous systems by his teaching at the autopsy table. He showed that every disease of every sort represented injury to the anatomy, and that in this injury to the anatomy lay the signs which gave us opportunity to read backward to the commencement of the history of illness in any given case. He insisted that we were not to attempt to have any conception of pathological processes excepting upon a basis of objective TO-MORROW'S TOPICS 323 case of death as a requirement for entering the hospital does not alarm people, as one might imagine. It seems to have the quite opposite effect of giving patients confidence in the sort of institution which is interested in science to that extent. People are pretty sensible for the most part when they stop to reflect.