CHAPTER V Every ambitious man has been impressed by certain lessons (Part 10)

Most of the patients who enter this hospital know well enough they are not going to die anyway. In any given hospital, success in obtaining permission for post-mortem examination depends largely upon the personality and tact of some one official. Some of the prejudice against post-mortem examination has no doubt resulted from the knowledge that unnecessary disfigurement has sometimes resulted from autopsy work. This is a feature requiring niceness of taste and genuine human sympathy toward the feelings of relatives. There is much opposition to post-mortem examination work on the part of undertakers and burial societies, because under- takers often find that it causes interference with embalming methods, and they influence members of a family by promising that "no mutilation will be allowed" if they are given oppor- tunity to take charge. This form of statement has a profound effect upon relatives who have a wrong idea about the nature of post-mortem examination, which commonly enough would cause no mutilation worthy of the name. There are some burial societies which are active in preventing autopsies upon any of their deceased members. In time the public in this country will come to imderstand the benefit to the family in having exact knowledge of the causes of death in any given case. Benefit to the public from knowledge gained by the physician will aid in avoiding sorrowing of the same sort for other families through the advantage to science from the opportunities given by objective lessons. As we advance in civilization these obstacles to our learning the way for being of best service to the family and to the public will to-morrow over- i TO-MORROW'S TOPICS 325 ceived support from such a fund? In all probability waste in research work is maple seed waste — representing a part of nature's large plan. In the early days of ovarian surgery in general I took an unpopular stand against it. From my viewpoint of training as a surgeon it was evident that a great deal of unnecessary work was being done in this field, upon incomplete diagnoses. So long as the trend of opinion was toward operation for all sorts of neurasthenic pelvic disturbances it was difficult for a few voices crying in the wilderness to stay the movement, and I was simply looked upon as one who chose to be on the opposite side of questions — desirous of radically operating immediately upon acute appendicitis patients because the pro- fession at that time was upon the other side, and preferring to take a stand against indiscriminate ovarian surgery because the profession at that time was upon the other side. This note is inserted because of a call this morning to operate upon a young woman with gastroenteric disturbance and pelvic pain and tenderness. Everything was in readiness for an operation. The physicians in charge said: "We have not been able to agree upon the cause of her trouble and would like to have you go in and find out." The case was one in which I made a tentative diagnosis of splanchnic disturbance precipitated by nasal hypertrophies, in a neurasthenic patient. The abdominal operation was not performed. It was a purely medical case, but the doctors in attendance would have operated had this opinion not been given. The question sometimes arises if insanity follows ovari- otomy. When reading over a list of quoted cases, one will observe that a certain number of them are definitely of the sort belonging to cyclothemia or to some other psychosis. Ovarian symptoms which led to the operation were merely those ordinary symptoms of psychosis which almost any TO-MORROW'S TOPICS psychiatrist would have recognized, and the following insanity was simply an increase of symptoms of the depressive stage, intensified perhaps by the shock of operation or by the pomp and circumstances of such a procedure. There is no need for mutual recrimination in this matter. The psychiatrist would have treated quite as many cases of actual ovarian tumor without examining the pelvis at all. My point is simply that the time has about arrived for placing more confidence in that general diagnostician whose decision is to be looked upon as authoritative and who can be trusted by men in all special fields of medical work. We have a few diagnosticians of that type now. They are so over- whelmed with work that time limitation restricts their best efforts. They are constantly overlooking features of casjss which are recognized by others later. In a single year I have seen four cases of rectal cancer that had been over- looked by a single famous diagnostician who had prescribed laxatives or tonics for each patient and then had gone on to the next case. A London hospital report showed that in seven- teen per cent, of cases sent in with the diagnosis of appendi- citis that was not the disease at all. If this is the proportion in a locality where there are well-trained physicians, what pro- portion of mistakes would be likely to occur in diagnosis by poorly equipped men or by medical faddists? A resource which is apparently small in range may really have its efficiency extended to the saving of thousands of lives. Take, for instance, the method of making frozen sections of small tumors of the breast when they are first discovered and determining at once from microscopical report whether an extensive operation or a limited operation is to be done. In former years we did not like to ask a patient to have a dis- figuring operation performed when she appeared at the office with a small tumor of the breast. We quieted her fears and L ^ TO-MORROW'S TOPICS waited to see how the growth would behave. When we were sure that a growth had become malignant it was then too late for a cure as a rule. The little resource of having a pathologist present to make a frozen section at the time of operation allows us to catch some cases of malignant disease in their very incipiency when they are quite curable. Patients who in former years postponed operation until we were sure it was necessary are now quite willing to have a small tumor removed in order to satisfy their curiosity and ours. If a growth proves to be benign a trifling operation suffices. If we find epithelial nests in a small growth and are thus shown the need for a radical operation, we have commonly saved a life through the aid of this method. Making frozen section examination when small breast tumors are first observed would lead to the .saving of life of practically every woman who now dies of cancer of the breast. It is probable that we shall have fewer breast cancers to care for, when the profession has awakened to the fact that toxins appear to be responsible for the development of many kinds of malignant and benign neoplasms of the generative organs. In the meantime we have a means for preventing deaths from cancer of the breast, if people choose to avail themselves of that means. Incidentally it may be worthy of remark that W. J. Mayo has collected statistics showing that cancer of the stomach and duodenum forms one third of all cases of cancer in civilizec man. but not in other animals. This would be in line with the idea that man in the course of decline suffers more than other ^L' animals from influences which lead to inefHciency of protective ^P glands. ^V Very few people are physically perfect. There is something H wrong with most of us; therefore if we get into the office ^M of almost any specialist, the specialist will find something ^B belonging to his department and may believe it to be the chief 328 TO-MORROWS TOPICS thing wrong with the patient, idien in fact it may be only a trifling part or no part at alL If I send a patient to a heart ii|>coinlist and the patient comes bade without heart disease, it i^ l>ccause the doctor was not in. To-morrow the highly fihicateil general diagnostician will give proper direction to l^ticntH after making out a brief of their cases very much Hii the lawvcr makes out a brief. In aiklitii>n to structural weaknesses which appeared when man gut up on his hind legs and assumed the erect position, a lar|l;c number of secondary complications have developed, causing a pretty important part of invalidism in general. The ^iaj^King of viscera leads to interference with nutrition and aaiiiiuiilation. and favors the development of inimical bacteria. Tii.\iu2i iT\m\ these bacteria intensify the effects of other weak- ue«*i.^ii. Man assuming the erect position not only had a tend- ency to bring out structural defects which are observable on cvvrv siile. but also a resulting series of pathologic changes of most insidious character, which threaten to hasten the iutluenoes of decline for our species. (>nc reason why we have so many breast tumors, uterine tumors, ovarian tumors, and other neoplastic growths of the generative organs of women at the present time appears to be Ihh'husc defective tissues have a tendency to revert atavistically to primitive cell growth under the influence of enteric and other toxins. There seems to be a loss of control over em- bryonic cell rests. These latent cell rests do not spring into activity so frequently when the surrounding tissues are fully developed. It is time now in this part of the twentieth century for diHTtors to take up the subject of neurasthenia in a scientific way, because the condition is one which is increasing rapidly in frequency and will call for more and more skilled attention on the part of our profession. Various separate features of TO-MORROW'S TOPICS 329 a neurasthenic condition have been considered by different specialists in the hght of diagnostic entities belonging to their special departments. It has been a fault belonging to the present stage of our cultural period. The surgeon, for in- stance, has done a great many unnecessary operations upon neurasthenic patients, because from his point of view some organ out of place or crying with neuralgic pain was the cause for the neurasthenic condition. Sometimes this organ has really been the precipitating factor at least and the patients have been so much benefited that the surgeon has been misled into mistaking a precipitating factor for a causative factor. The psychiatrist takes up the subject of neurasthenia from an entirely different viewpoint. He is apt to hold that the causes for neurasthenia rest in the psyche of the patient and if he can give proper direction to the psyche, through suggestion aided by other therapeutic resources, a cure will be accom- plished. The neurologist follows still another line of thought. He believes that treatment which will increase the general nerve tone of a neurasthenic patient will dispose of features belonging both to physical defect and to mental aberration. The hygenic faddist follows still another line, and has abun- dant statistics to show that neurasthenic patients subjected to his methods have been very much benefited. The mystic healers, somatologists, thaumaturgists, and other pretenders, have about as good a list of cures of neurasthenic patients as have members of the regular medical profession. All of these cures by the regular medical profession or by pretenders are genuine so far as they go, but they have to be reported quickly. Further than that they are commonly reported in the form of support for special pleading, with failure to report relapses and cases in which no benefit was received at any time. Many of our neurasthenic patients do not want to be neurasthenic. There are no braver or more courageous people, no dearer or i lovelier natures than may be found among neurasthenics whom we brutally healthy critics are inclined to speak of lightly, if not in actual terms of opprobrium. Pity the neurasthenic — ad- mire the neurasthenic — blame him not. When making a study of fundamental conditions which are present in cases of neuras- thenia, it seems to me that we must at the outset consider the close relationship which in general exists between structure and function. This relates to daily cell construction of various organs (belonging to flux of protoplasm) tjuite as well as it does to arrested development of organs. It belongs also to abnormal mechanical relation of organs one to another. On this tripod basis, it is essential for us when taking a view of neurasthenia to step back to our fundamental position and ask why various effects should occur in the protoplasm of cells, or in the arrangement of cells in organs, or in abnormal posi- tion of organs in relation to each other. Let us recapitulate certain points that have been made in these notes. We know in the first place that man when assuming the erect position brought out our mechanical structural weaknesses. We know also that cell construction, development of organs, and the position of organs, must depend more or less upon the stimulus given by hormones. Secretion of hormones depends upon dictation from the secretion of ductless glands; physical cells of ductless glands are influenced by toxins. We know further that toxins which influence the ductless glands abnormally are largely derived from the bacteria of the colon, more than sixty species of which have been described. Toxins produced by many of these bacteria are definitely known to be injurious to protoplasmic contents of cells of organs. Under conditions of modern civilization an abnormal proportion of various species of colonic microbes develops, and our intellectually arranged methods for oxidizing toxins or for conducting them through safe metabolic processes are not as yet placed upon a scientific basis. Oiir methods for treating the neurasthenic patient are at present chiefly upon the basis of art at the hands of various artists, but we have as yet applied neither science nor art in the full sense of either word when dealing with our cases of neurasthenia. When making a diagnosis relating to this condition as a whole we must go back to the basis fur- nished by bacteriology. Bacteriology gave us the first light in treating surgical infections; then later it cast a light over the subject of contagious diseases and infections in general. It is now lighting up another vista in which we may observe that all human activities, and all organic cell construction upon which such activities depend are under the controlling influence of the microbe. Protoplasm is the fundamental constructive unit of organic life and is arranged in cell form for purposes of work. A microbe is the inimical unit of destruction for protoplasm other than its own. The higher organic cell being an aniceba is in constant conflict with the microbe, the heredi- tary enemy of the amceba. When taking up the subject of neurasthenia then, in a given case as a whole, or in various features of the case, we must begin from the standpoint of the bacteriologist. Neither surgeon nor psychiatrist, nor neurologist, nor hygienic faddist can intelligently comprehend the nature of any given case of neurasthenia, excepting from the basis of the bacteriologist's report. Toxins of colonic bacteria which produce the indols, skatols and phenols often occur in excess of the metabolizing efficiency of an individual. Such toxins interfere with the protoplasmic daily cell construction of ductless glands. Func- tion being closely related to st.iicture the secretion of these glands becomes abnormal in character and stimulates the secre- tion of hormones which are also not normal in character. All this work is under control by the sympathetic nervous system which is obliged to do work out of the ordinary and becomes 332 TO-MORROW'S TOPICS perverted or exhausted. Splanchnic neurasthenia is one of the results. This allows relaxation of peritoneal supports of abdominal viscera to occur, and the viscera begin to sag. With splanchnic neurasthenia there is also loss of efficiency of the secretions which carry on digestion. Enteric microbes then have in consequence a store of pabulum which is used for their own purposes. The well fed guests do not remain under a sufficient degree of control, and we have next the establishment of a vicious circle, toxins interfering with the processes of nutrition, and disabled processes of nutrition allowing bacteria to increase still further in the gastro- intestinal tract. Such a vicious circle occurring in parents must result in more or less injury to the developing ovum, causing abnormal cell construction with more or less arrested development of various organs of the fetus. The progeny of these parents present stigmata belonging to arrested develop- ment. Some of the stigmata may be very clearly in evidence, as we note in the decadent ear, high arched palate, and guo- stock scapula. We assume that an individual with arrested development of structures which may be observed, has pari passu some degree of arrested development of organs which are not readily observed. A child presenting features of arrested development of organs is commonly giving evidence of toxic cell injury which has been suffered previously by parents. This individual child as a variant from the mean type has a tendency according to the laws of mutation to recede from the dominant type. The treatment of neurasthenic conditions begins then from the standpoint of the bacteriologist's report. no matter whether it relates to a well constructed individual suffering directly from the influence of toxins or whether it ^L relates to the progeny of such individuals, whose stigmata may ^K render them even more susceptible to microbic influences than ^H were the parents. I TO-MORROW'S TOPICS 333 The treatment fur neurasthenic conditions is divided into two separate and distinct parts. First, expediency measures for relief of troublesome symptoms. Such measures may be conducted by the surgeon, by the psychiatrist, by the neurolo- gist, by the hygienist or by the suggestion fakir. The next part consists in controlling the output of toxins from the gastro-intestiiial tract, and this latter part in the problem as a whole is the more