vanced cases. If, however, we could see Our cases in the early stages, whether primary or secondary, provided the original focus in the secondary cases is under control or not far advanced, removal of the offending organs gives us our best percentage of cures. At present the rate of mortality is as high or higher than that of

cancer.

230 St. James Place.

suming that that particular case is not absolutely "incurable" (and, fortunately, there are very few conditions met by the progressive medical man that are entirely beyond his skill), the fault is to be found either in his investigation or his therapeutic acumen. Most frequently errors or shortcomings are in the diagnosis rather than the treatment, for the great and ever-increasing progress in medical science, especially along lines of treatment, is all duly chronicled in the various medical journals,

CHRONIC DISEASE.

BY

HENRY R. HARROWER, M. D.,

Chicago.

The average general practitioner is not, as a rule, especially overjoyed when an individual suffering from some disease of long standing comes his way seeking treatment. Most persons suffering from the class of diseases grouped under the broad term "chronic," have gone the the rounds of the physicians in the neighborhood, and perhaps elsewhere, and have received little or no lasting benefit whatever. If the physician expects to make a success in the treatment of these difficult conditions, a number of important maxims must be learned and learned well. It will be my endeavor here to impress a few of these ideas upon the mind of the reader and in this way enable him to carry out with much greater success the treatment of chronic disease.

Since a correct diagnosis is usually more than half the battle, it stands to reason that the time and trouble given to the investigation of a given case are time and trouble well spent. If a physician fails in the treatment of any chronic affection, as

physician at the remote country cross-roads as for the city physician with his medical society meetings and clinics-if they both read. On the other hand, while it is granted that there are many books and articles of special informative value to the man who is anxious to increase his diagnostic skill, there is, of course, no book or article that will tell just what is the matter with Mr. Brown or Mrs. Jones.

Successful work naturally entails close personal investigation, and unless more than the ordinary attention is given to this most important part of medical practice the results, or lack of results, must necessarily be unpleasant and unsatisfactory, both from the standpoint of the patient and of his physician. I might cite dozens of cases which have come to my notice in which failure was due solely to what might properly be called "scamped," superficial, or snap-shot diagnoses.

A diagnosis cannot be too thorough. Frequently the investigative procedures which the physician carries out may have led him to make an absolutely correct diagnosis so far as it goes, but it may not be as complete as it might have been, and as a result, unnoticed conditions are allowed to flourish whose existence curtails very

markedly the benefits which his well-directed therapeutic procedures might have. otherwise accomplished.

A prominent physician recently said, and rightly: "Shortcomings in diagnosis frequently allow human beings to suffer for years who might, were diagnosis made clear, be healthy useful citizens all that time." He spoke of a habit to which some of the profession are unfortunately addicted, "of skipping over the real diagnosis altogether, and rushing pell-mell into the treatment, so-called."

The diagnosis of chronic disease is not reached as rapidly as that of typical smallpox or diphtheria; nor does the patient expect it at once. I well remember a difficult case in which my diagnosis was not arrived at for three months-but it was finally right, and a condition of many years' standing was first modified and then cured.

In the majority of cases we must treat not merely a disease alone. It must be evident, for example, that a patient suffering from tuberculosis should not merely receive treatment with reference to the particular infection infection with the tubercle bacilli alone. The inevitably lowered vital resistance, and the associated infection with germs other than the tubercle bacillus, should be looked after just as thoroughly and systematically as the Tuberculinhygienic treatment is carried out. The digestive apparatus should be watched as closely as the temperature, and very great attention paid to the elimination of waste from the body, as evidenced in the urinary findings. Right here, it might be well to mention the fact that the old fad of “stuffing" a patient is hardly rational in the light of present-day knowledge, and if the physician takes the trouble to properly

look after the elimination of his patient and see just what the "dozen eggs a day" are doing to his patient's metabolism, he would easily recognize that this matter is worthy of closer consideration, because it is based on good common sense.

The estimation of the urinary acidity, the estimation of urea and ammonia, as well as the examination for indican and other abnormal substances in the urine, will all surprise the physician treating cases of the character under discussion, for by these means he will soon discover that the kidneys are being unduly overburdened, that the intestines are filled with a reeking mass of putrefying albumin, and that the patient is suffering from a toxemia probably equally bad, if not worse, than the toxemia due to the activities of the tubercle bacillus itself.

It will be plain that to accomplish these ends the usual abbreviated methods of physical investigation will not suffice. Recourse should invariably be had to certain laboratory procedures varying to some extent with the history, physical findings, etc. In every case a complete urine examination should be made. If there is reason to to suspect gastro-intestinal disturbance, do not be satisfied with answers to a few questions, or even with the most thorough physical examination. Procure and examine the stomach contents after a test-meal given in the proper way. Frequently a fecal examination (chemical and bacteriological) will throw so much light on a case, that the unpleasantness of the procedure will be altogether over-shadowed by the definite knowledge obtained, and the results that this may make possible. The microscopic examination of pus, sputum or other secretions, and not uncommonly a blood examination or a few

simple tests of the saliva will be of much valuable assistance in the work. In this connection it will not be out of place to remind the reader of the help that a Tuberculin reaction (either that of von Pirquet or Moro) may be. This comparatively new procedure is used altogether too little, and has not yet received nearly the attention it deserves.

The blood-pressure instrument or sphygmometer is not used as frequently as it might be. It is comparatively rare to see an instrument outside of the physician's office in the larger cities or in up-to-date institutions. The blood-pressure is a point of tremendous value and I am not overstating the truth when I say that it should be estimated as a routine in the investigation of every chronic case. The new Faught instrument is as simple and compact as one could wish, an ornament and an essential to every progressive physician's office.

Another factor which plays a very important part in the successful outcome of the treatment of chronic disease is the cooperation of the patient. It must surely be evident that if the physician is attempting to correct certain disturbances and at the same time certain pernicious habits or customs of the patient are adhered to in spite of advice to the contrary, the physician is very much handicapped in his treatment, and should not be held responsible for any failure that may possibly result. It might be well here also to refer to the need for regularity in the treatment. This is a very important point. For example: For the relief of any given condition, office treatment may only be required every ten days or so; again treatment may be necessary two or three times a week, and at times daily attention may be ad

visable in order to obtain the desired results. It must be plain that if one particular treatment brings a patient to a certain stage and in a sense prepares him for the next, the omission of a treatment, if a matter of common occurrence, will materially decrease the value of the whole series. It is because of this that the opinion is quite prevalent that chronic disease, to be successfully handled, requires the hospital or sanitarium regimen since the patient is under full control and can receive such treatment as may be deemed advisable without any break or inconvenience. This is true, but I believe, nevertheless, that any thinking individual by dint of a few gentle reminders would have sense enough to see to it that the treatment is as regular as possible and at the same time that the advice of the physician is explicitly carried

out.

A point might well be made here regarding the instructions given to patients. Many times dietetic and hygienic suggestions are made in the office, and because of these the patient starts out very well. He eschews certain articles of diet as suggested and regulates his living very carefully for a time. In a few days he forgets one item, then another, until finally he is back to the same old slough in which he was wading before he came to the office for attention. To obviate this, I believe it to be by far the best plan to give definite written instructions to the patient as to what he should eat and what he should not eat; to give him in black and white the most important general instructions regarding his method of living and make your ideas so clear that there may be no mistake regarding them. Of course, a copy of these instructions will be kept on file with the case history, prescription

copies, and other records. The instruction slip may well be shown to some member of the patient's family in order that their co-operation may also be obtained in helping the individual under treatment to faithfully "toe the mark."

The original initial examination of the patient is not enough. Careful watch must be kept of the changes which may be due to the treatment or to other circumstances. Personally I consider it of prime advantage to be able to make frequent uranalyses, for in this way the variations in the metabolism are shown up and the changes resulting from the treatment are made clear. It is often an excellent plan to administer certain remedies using the urinary findings as the guide to dosage. The results obtained are sometimes phenomenal, and no physician once accustomed to these methods. will revert to the older (but admittedly less arduous) way. As far as repeated examinations are concerned, the same holds true of the gastric contents, feces, etc. Ofttimes the treatment is having a decidedly beneficial effect, although for a time no great modification of the patient's subjective symptoms is apparent. The progressive favorable change in the laboratory reports, however, is always a source of encouragement not only to the physician but also, when properly explained, to the patient.

There is another matter which seems quite difficult to instil into the minds of individuals suffering from chronic disease. I refer to the need for a more extended and systematic oversight of themselves after they may have passed from the close attention or immediate care of their medical adviser. The human body is very like a machine, and if an engineer should mend some broken part, see that it worked prop

erly and then leave the whole machine to the tender mercies of chance without any regular supervision, he would very soon be in serious trouble. Instead, he feels the bearings, oils them carefully, tightens a loose nut here and there, and generally scrutinizes the machine with a special care and watchfulness, in this way anticipating trouble before it comes, and preventing what might frequently cause a serious accident. This same thing is just as true of the human machine and it becomes the duty of the physician to exercise just as much care and intelligent oversight as does the engineer. I firmly believe that a periodical and regular investigation of any individual who can be interested in this idea will lead to much more satisfactory work in the practice of medicine, and, at the same time, prevent, in their onset, a host of entirely needless chronic diseases. Such systematic care of an individual may often prove a means to very valuable ends, and if this article does nothing more than to impress upon the reader the great necessity for periodic, clinical as well as physical examinations, it will be well worth the time and trouble taken to write it.

In conclusion I might summarize the following essential points: 1. Obtain a thorough diagnosis, no matter how much it costs or how long it may take. 2. Find out all that is the matter with the patient. Do not be satisfied with simply finding some evidence of disease and overlook the rest of the body and other associated difficulties. 3. Be sure you are right, then go ahead, making use of the most rational methods that you know of, and pushing all your treatment to effect. 4. Always couple whatever therapeutic method you may be using with the most thorough elimination. possible under the circumstances. 5. Ob

, 1910

, Vol. V., No.

tain the confidence and complete co-operation of the family. 6. Make frequent repeated examinations of the urine and, if needs be, of other specimens. This favors thorough work, and gives confidence to the patient. 7. Teach your patient something at each office visit, send him away from your office with an increased knowledge of some matter he was not previously aware of, and thus educate him in the prevention of disease. 8. Make the patient realize that he is liable to get into trouble again, to consult you regularly, and thus prevent the recurrence of disease in its incipiency. 72 Madison Street.

ACTION OF GLANDULAR EXTRACTS UPON THE SECRETION OF URINE.

BY

ISAAC OTT, A. M., M. D., Professor of Physiology,

AND

JOHN C. SCOTT, M. D., Demonstrator of Physiology, Medico-Chirurgical College of Philadelphia. Schäfer and Herring1 have shown that the infundibular part of the pituitary body yields a substance soluble in water and not destroyed by boiling, which has a specific action on the kidney, dilating the renal vessels and increasing the secretion from the tubules. If the urinary flow is suppressed from operative procedures or the anesthetic, it causes a flow. They think it is as actively diuretic as caffeine citrate. They found when there was a general fall of blood pressure with no increase, but even a shrinkage of the volume of the kidney, a diuretic action indicating a stimulation of the renal epithelium. This shrinkage of the

kidney precedes the dilatation in some cases. Pituitary was found to diminish the flow of pancreatic juice.

Hypodermically, the pituitary also slightly raises blood pressure, dilates the kidney vessels and increases the rate of flow of urine. They also point out that the adrenals and pituitary each consist of two parts, one epithelium, the other part of neuroectoderm origin. The epithelial parts of these two glands do not yield any physiological effect, whilst those of the neuroectodermic origin furnish substance affecting the heart and arteries. Here the similarity ends, for adrenalin excites the sympathetic terminals in general, whilst the pituitary does not.

Houghton and Merril, (Journal Am. Medical Association, 1908, p. 1849), have studied the action of adrenalin and the active principle of the pituitary gland upon the urinary secretion. Pituitary slowed the pulse rate after the use of atropin and after section of vagi. Aldrich obtained a crystalline picrate and a sulphate from the infundibular part of the pituitary. They found adrenalin to increase the blood pressure and the flow of urine. They experimented on normal man for several days where the food, drink, habits, exercise and work were the same. Then pituitary extract was given internally. They found only a slight increase of urine in man.

Then they made experiments upon dogs. anesthetized by morphine and chloretone. with cannulae in the ureters. The drops of urine were recorded with the blood pressure and the respiratory movements. Adrenalin increased the blood pressure from 56 to 88 mm. of mercury which within six minutes had returned to normal. The urine increased from 8 minims per minute to 30 per minute, the maximum following