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vanced cases. If, however, we could see suming that that particular case is not abour cases in the early stages, whether solutely "incurable" (and, fortunately, primary or secondary, provided the original there are very few conditions met by the focus in the secondary cases is under con- progressive medical man that are entirely trol or not far advanced, removal of the of- beyond his skill), the fault is to be found fending organs gives us our best percent- either in his investigation or his therapeuage of cures. At present the rate of mor- tic acumen. Most frequently errors or shorttality is as high or higher than that of comings are in the diagnosis rather than cancer.

the treatment, for the great and ever-in230 St. James Place.

creasing progress in medical science, especially along lines of treatment, is all duly

chronicled in the various medical journals, SUCCESS IN THE TREATMENT OF and in this way is just as available for the CHRONIC DISEASE.

physician at the remote country cross-roads as for the city physician with his medical

society meetings and clinics—if they both HENRY R. HARROWER, M. D.,

read. On the other hand, while it is Chicago.

granted that there are many books and arThe average general practitioner is not, ticles of special informative value to the as a rule, especially overjoyed when an

man who is anxious to increase his diagindividual suffering from some disease of nostic skill, there is, of course, no book or long standing comes his way seeking article that will tell just what is the matter treatment. Most persons suffering from with Mr. Brown or Mrs. Jones. the class of diseases grouped under the Successful work naturally entails close broad term "chronic,” have gone the personal investigation, and unless more rounds of the physicians in the neighbor- than the ordinary attention is given to this hood, and perhaps elsewhere, and have re- most important part of medical practice ceived little or no lasting benefit whatever. the results, or lack of results, must necesIf the physician expects to make a success sarily be unpleasant and unsatisfactory, in the treatment of these difficult condi- both from the standpoint of the patient tions, a number of important maxims must and of his physician. I might cite dozens be learned and learned well. It will be of cases which have come to my notice in my endeavor here to impress a few of these which failure was due solely to what might ideas upon the mind of the reader and in properly be called "scamped,” superficial, this way enable him to carry out with or snap-shot diagnoses. much greater success the treatment of A diagnosis cannot be too thorough. chronic disease.

Frequently the investigative procedures Since a correct diagnosis is usually more which the physician carries out may have than half the battle, it stands to reason led him to make an absolutely correct diagthat the time and trouble given to the in- nosis so far as it goes, but it may not be vestigation of a given case are time and as complete as it might have been, and as trouble well spent. If a physician fails in a result, unnoticed conditions are allowed the treatment of any chronic affection, as- to flourish whose existence curtails very markedly the benefits which his well-di- look after the elimination of his patient rected therapeutic procedures might have and see just what the “dozen eggs a day" otherwise accomplished.

are doing to his patient's metabolism, he A prominent physician recently said, would easily recognize that this matter is and rightly: “Shortcomings in diagnosis worthy of closer consideration, because it frequently allow human beings to suffer is based on good common sense. for years who might, were diagnosis made The estimation of the urinary acidity, clear, be healthy useful citizens all that the estimation of urea and ammonia, as time.” He spoke of a habit to which well as the examination for indican and some of the profession are unfortunately other abnormal substances in the urine, addicted, "of skipping over the real diag- will all surprise the physician treating nosis altogether, and rushing pell-mell into cases of the character under discussion, the treatment, so-called.”

for by these means he will soon discover The diagnosis of chronic disease is not that the kidneys are being unduly overburreached as rapidly as that of typical small- dened, that the intestines are filled with a pox or diphtheria; nor does the patient reeking mass of putrefying albumin, and expect it at once. I well remember a dif- that the patient is suffering from a toxficult case in which my diagnosis was not emia probably equally bad, if not worse, arrived at for three months—but it was than the toxemia due to the activities of finally right, and a condition of many

the tubercle bacillus itself. years' standing was first modified and then It will be plain that to accomplish these cured.

ends the usual abbreviated methods of In the majority of cases we must treat physical investigation will not suffice. Renot merely a disease alone. It must be course should invariably be had to certain evident, for example, that a patient suf- laboratory procedures varying to some exfering from tuberculosis should not merely tent with the history, physical findings, receive treatment with reference to the etc. In every case a complete urine exparticular infection with the tubercle amination should be made. If there is bacilli alone. The inevitably lowered vital reason to suspect gastro-intestinal disresistance, and the associated infection turbance, do not be satisfied with answers with germs other than the tubercle bacillus, to a few questions, or even with the most should be looked after just as thoroughly thorough physical examination. Procure and systematically the Tuberculin- and examine the stomach contents after a hygienic treatment is carried out. The di- test-meal given in the proper way. Fregestive apparatus should be watched as quently a fecal examination (chemical and closely as the temperature, and very great bacteriological) will throw so much light attention paid to the elimination of waste on a case, that the unpleasantness of the from the body, as evidenced in the urinary procedure will be altogether over-shadowed findings. Right here, it might be well to by the definite knowledge obtained, and mention the fact that the old fad of "stuf- the results that this may make possible. fing” a patient is hardly rational in the The microscopic examination of pus,

, light of present-day knowledge, and if the sputum or other secretions, and not unphysician takes the trouble to properly commonly a blood examination or a few





simple tests of the saliva will be of much visable in order to obtain the desired revaluable assistance in the work. In this sults. It must be plain that if one particuconnection it will not be out of place to lar treatment brings a patient to a certain remind the reader of the help that a stage and in a sense prepares him for the Tuberculin reaction (either that of von next, the omission of a treatment, if a matPirquet or Moro) may be. This compara- ter of common occurrence, will materially tively new procedure is used altogether decrease the value of the whole series. It too little, and has not yet received nearly is because of this that the opinion is quite the attention it deserves.

prevalent that chronic disease, to be sucThe blood pressure instrument cessfully handled, requires the hospital or sphygmometer is not used as frequently as sanitarium regimen since the patient is it might be. It is comparatively rare to under full control and can receive such see an instrument outside of the physician's treatment as may be deemed advisable office in the larger cities or in up-to-date without any break or inconvenience. This institutions. The blood-pressure is a point is true, but I believe, nevertheless, that any of tremendous value and I am not over- thinking individual by dint of a few gentle stating the truth when I say that it should reminders would have sense enough to see be estimated as a routine in the investiga- to it that the treatment is as regular as tion of every chronic The

possible and at the same time that the adFaught instrument is as simple and com- vice of the physician is explicitly carried pact as one could wish, an ornament and out. an essential to every progressive phy- A point might well be made here resician's office.

garding the instructions given to patients. Another factor which plays a very im- Many times dietetic and hygienic suggesportant part in the successful outcome of tions are made in the office, and because the treatment of chronic disease is the co- of these the patient starts out very well. operation of the patient. It must surely He eschews certain articles of diet as sugbe evident that if the physician is attempt- gested and regulates his living very careing to correct certain disturbances and at fully—for a time. In a few days he forthe same time certain pernicious habits or gets one item, then another, until finally customs of the patient are adhered to in he is back to the same old slough in which spite of advice to the contrary, the phy- he was wading before he came to the office

, sician is very much handicapped in his for attention. To obviate this, I believe it treatment, and should not be held respon- to be by far the best plan to give definite sible for any failure that may possibly re

written instructions to the patient as to sult. It might be well here also to refer what he should eat and what he should not to the need for regularity in the treatment. eat; to give him in black and white the This is a very important point. For ex- most important general instructions reample: For the relief of any given condi- garding his method of living and make tion, office treatment may only be required · your ideas so clear that there may be no every ten days or so; again treatment may mistake regarding them.

Of course, a be necessary two or three times a week, copy of these instructions will be kept on and at times daily attention may be ad

file with the case history, prescription

copies, and other records. The instruction erly and then leave the whole machine to slip may well be shown to some member the tender mercies of chance without any of the patient's family in order that their regular supervision, he would very soon co-operation may also be obtained in help- be in serious trouble. Instead, he feels ing the individual under treatment to faith- the bearings, oils them carefully, tightens fully "toe the mark."

a loose nut here and there, and generally The original initial examination of the scrutinizes the machine with a special care patient is not enough.. Careful watch must and watchfulness, in this way anticipating be kept of the changes which may be due trouble before it comes, and preventing to the treatment or to other circumstances. what might frequently cause a serious acPersonally I consider it of prime advantage cident. This same thing is just as true of to be able to make frequent uranalyses, for the human machine and it becomes the in this way the variations in the metabolism duty of the physician to exercise just as are shown up and the changes resulting much care and intelligent oversight as does from the treatment are made clear. It is the engineer. I firmly believe that a perioften an excellent plan to administer cer- odical and regular investigation of any tain remedies using the urinary findings individual who can be interested in this as the guide to dosage. The results ob- idea will lead to much more satisfactory tained are sometimes phenomenal, and no work in the practice of medicine, and, at the physician once accustomed to these methods same time, prevent, in their onset, a host will revert to the older (but admittedly of entirely needless chronic diseases. Such less arduous) way. As far as repeated systematic care of an individual may often examinations are concerned, the same holds prove a means to very valuable ends, and true of the gastric contents, feces, etc. Oft- if this article does nothing more than times the treatment is having a decidedly to impress upon the reader the great necesbeneficial effect, although for a time no sity for periodic, clinical as well as physigreat modification of the patient's subjec- cal examinations, it will be well worth the tive symptoms is apparent. The progres- time and trouble taken to write it. sive favorable change in the laboratory In conclusion I might summarize the folreports, however, is always a source of lowing essential points: 1. Obtain a thorencouragement not only to the physician ough diagnosis, no matter how much it but also, when properly explained, to the costs or how long it may take. 2. Find out patient.

all that is the matter with the patient. Do There is another matter which seems not be satisfied with simply finding some quite difficult to instil into the minds of evidence of disease and overlook the rest individuals suffering from chronic disease. of the body and other associated difficulties. I refer to the need for a more extended 3. Be sure you are right, then go ahead, and systematic oversight of themselves af- making use of the most rational methods ter they may have passed from the close that you know of, and pushing all your attention or immediate care of their medi- treatment to effect.

4. Always couple cal adviser. The human body is very like whatever therapeutic method you may be a machine, and if an engineer should mend using with the most thorough elimination some broken part, see that it worked prop- possible under the circumstances. 5. Ob


tain the confidence and complete co-opera- kidney precedes the dilatation in some tion of the family. 6. Make frequent re- cases. Pituitary was found to diminish the peated examinations of the urine and, if flow of pancreatic juice. needs be, of other specimens. This favors Hypodermically, the pituitary also slightthorough work, and gives confidence to the ly raises blood pressure, dilates the kidney patient. 7. Teach your patient something vessels and increases the rate of flow of at each office visit, send him away from urine. They also point out that the adreyour office with an increased knowledge nals and pituitary each consist of two parts, of some matter he was not previously aware one epithelium, the other part of neuroof, and thus educate him in the prevention ectoderm origin. The epithelial parts of of disease. 8. Make the patient realize that these two glands do not yield any physihe is liable to get into trouble again, to ological effect, whilst those of the neuroconsult you regularly, and thus prevent the ectodermic origin furnish substance affectrecurrence of disease in its incipiency. ing the heart and arteries. Here the 72 Madison Street.

similarity ends, for adrenalin excites the sympathetic terminals in general, whilst the


Houghton and Merril, (Journal Am. UPON THE SECRETION OF URINE.

Medical Association, 1908, p. 1849), have

studied the action of adrenalin and the acISAAC OTT, A. M., M. D.,

tive principle of the pituitary gland upon Professor of Physiology,

the urinary secretion. Pituitary slowed

the pulse rate after the use of atropin and JOHN C. SCOTT, M, D.,

after section of vagi. Aldrich obtained a Demonstrator of Physiology,

crystalline picrate and a sulphate from the Medico-Chirurgical College of Philadelphia.

infundibular part of the pituitary. They Schäfer and Herringi have shown that found adrenalin to increase the blood presthe infundibular part of the pituitary body sure and the flow of urine. They experiyields a substance soluble in water and not mented on normal man for several days destroyed by boiling, which has a specific where the food, drink, habits, exercise and action on the kidney, dilating the renal ves- work were the same. Then pituitary exsels and increasing the secretion from the tract was given internally. They found tubules. If the urinary flow is suppressed only a slight increase of urine in man. from operative procedures or the anesthet- Then they made experiments upon dogs ic, it causes a flow. They think it is as anesthetized by morphine and chloretone actively diuretic as caffeine citrate. They with cannulae in the ureters. The drops found when there was a general fall of of urine were recorded with the blood blood pressure with no increase, but even pressure and the respiratory movements. a shrinkage of the volume of the kidney, Adrenalin increased the blood pressure a diuretic action indicating a stimulation of from 56 to 88 mm. of mercury which withthe renal epithelium. This shrinkage of the in six minutes had returned to normal. The

urine increased from 8 minims per minute * Philosophical Transaction of the Royal Society of London, pages 1-29.

to 30 per minute, the maximum following



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