be recognized by state and national medical organizations, and is now under the guise of "public education," "health improvement," "protection of the public welfare,"

etc.

It seems to be a truism that the medical profession cannot survive under present-day conditions unless it has plenty of paid work to do. There is just as much illness, probably, as there ever was and yet the total volume of practice which is carried on by medical men is not nearly so great as it ought to be because of the inroads of the cults and healers. Certainly, public education is needed with respect to what the medical profession is able to accomplish. It seems necessary that the public should be helped to choose a doctor thru properly constituted medical organizations such as Academies of Medicine and County and State medical societies which up to now have busied themselves chiefly with "scientific medicine." Lists of physicians and surgeons having a high degree of skill in special operations or treatment should be readily available to the public. It might be possible to establish an "eligible list" determined upon by examination somewhat after Civil Service methods. As things are at present, how can the public find a brain surgeon, an appendix surgeon, a cleft-palate surgeon or even a tonsil surgeon of a high degree of skill?

Any physician who wishes to advance himself should be willing to go before a selected committee of his peers to be examined as to his proficiency. After he has qualified for his work thru "deadhouse" experience, laboratory studies and animal experimentation, and if he has developed a good degree of operative skill in public hospitals conducted for the benefit of the poor, he should be not only willing but ready to demonstrate this ability in order to establish his standing. Doubtless, there are many. physicians and surgeons having such qualifications at the present time who have not made a success in private practice because they have no sufficient means of displaying their wares, so to speak. The judgment of a board of examiners should be "on points" for example, skill in preoperative diagnosis, operating-room technic, and post-operative care leading to the best results.

It may sound strange, but it is doubtless true that the profession at large is not a

competent judge of the skill of its members. It has impressions of certain confrères which may, however, be quite as misleading as the impressions of the general public, either for or against a given physician. Examination and classification would make for standardization and greater medical efficiency. The inefficient would eventually be practically eliminated. "But," one may ask, "is all this necessary?" Well, let us suppose that a parent requires a cleft-palate operation for his child. Under present conditions, he consults his family physician, who may either undertake the job himself or call in a general surgeon. Like as not, the general surgeon has had little or no experience in this highly specialized field. He is, therefore, incompetent; yet, he does the operation, produces a failure, and thereby depreciates the value of the operation in the eyes of the public and all of the profession-save the successful cleft-palate surgeon of experience. Now, under ideal conditions the parent or the general physician would consult the Reference Board of the County Medical Society and would be given a list of surgeons who are specially qualified to do this work. From this list it would be easily possible to select the one nearest at hand or most available.

Turning the matter carefully over in mind, it would seem that the propaganda for acquainting the public with the ability of the medical profession to avert or relieve or cure diseases and abnormalities will not amount to much unless a given case can be directed to the proper physician having the requisite degree of skill to bring about the desired result. As hinted at above, the public has always considered itself able and has always sought to differentiate between physicians as to skill, but the public has often failed in this and has chosen unwisely. On the other hand, the profession has tried to maintain the utterly false notion that all medical men are capable of doing anything, and it has never permitted any individual member to assert his superiority or special adaptation for certain work without penalizing such boastfulness. This is a blind and foolish practice which ought no longer to be tolerated. Among ourselves. we draw sharp lines as to ability, but facing the public we are all-inclusive, that is, if we are "ethical."

Recently, the Medical Society of the State.

of New York published a little pamphlet entitled "Principles of Professional Conduct," and distributed it broadcast to the profession of this state. In the main, these principles are excellent and ought to be strictly adhered to, but like many other rules of guidance there are limitations. Why should it be considered "advertising" for a physician to have a card engraved or printed, stating his speciality, together with office hours, telephone number and address? The size of the card and of the print could be regulated by proper authority, and, we predict, would be followed to the letter without difficulty.

Again, there seems to be no good reason why, for the purposes of public education, a physician should not be allowed to publish articles in the public prints, not for the purpose of calling attention to himself but to distribute useful and practical ideas of public benefit. Of course, this had better be done thru organizations of which the individual physician is a member. His manuscript might even be censored and passed upon by a committee before publication. In this way, the subject-matter would be properly sponsored and the personal element minimized as much as seems neces-sary. There is no doubt that we are on the verge of a change of medical thought in these matters, and it is hoped that only good will come of it.

The Present Status of Radium in Malignancy. In a thoughtful and comprehensive article contributed to the New York Medical Journal for November, 1923, by Francis Carter Wood, the question of the value of radium in malignancy is thoroly thrashed out. The limitations of radium depend upon the actual supply to be obtained from minerals, the reaction of the patient, the size of the tumor and the biology of the tumor. Limitations of natural supply are being rapidly overcome, so that at the present time there is sufficient radium for experimental purposes in institutions which can afford to buy it. The price is still high, tho much lower than it was ten years ago.

Like most other therapeutic agents, radium is uncertain in its action and especially so in those patients who have an idiosyn

crasy to it. There is a form of illness which is called "radiation sickness" which is probably due to rapid destruction of the tissues and prompt absorption of "dead proteids" into the general circulation.

Radium is relatively easy to use in superficial growths, but in deep growths such as cancer of the liver or pancreas, its value is negligible because of its effect upon other organs. Certain patients showing cachexia are extremely susceptible to its use, and death may result in a few weeks from anemia, nausea and vomiting and a sort of pseudo-uremia without chemical changes in the blood. However well focused radium may be, there is a certain amount of scattered radiation which affects the bone marrow and therefore the red blood corpuscles.

As already mentioned, there are undesired and by-effects of the action of radium on other organs which may work actual injury to the adrenals, the thyroid, pituitary and salivary glands, but it is questionable whether even a superficial growth should not receive the benefit of surgery rather than radium; for example, cancer of the lip which has always been amenable to cure by taking out a V-shaped piece and dissecting out the glands of the neck at the same time.

The biology of tumors has a great deal to do with the action of radium. For example, skin tumors are radio-sensitive and respond promptly, but tumors in bone and cartilage are resistant even to massive dosage. Vascular tumors respond promptly because of thrombosis of the blood vessels, but this improvement is only temporary; for, altho the center of the growth is destroyed, the shell remains, the blood supplied to this shell becomes increased, and recurrence takes place quite promptly. Nonvascular tumors are resistant to radio activity something like bone and cartilage tumors. For example, lympho-sarcomata are responsive to the action of radium but the fibro-sarcomata are resistant. Wood seems to be of the opinion that all operable tumors should be surgically removed whether radium is to be used in conjunction with surgery or not. For For inoperable growths, he thinks radium has a field in affording relief, but it is doubtful whether any such can ever be cured by radiation.

It is important to bear in mind that there is no immunity to cancer either before or after the formation of a tumor.

TREATMENT OF DISEASES OF THE HEART AND THEIR SEQUELÆ.1

BY

ROBERT ABRAHAMS, M. D.,
New York City.

Associate Professor of Medicine, New York Post-
Graduate Medical School and Hospital;
Consulting Physician, Manhattan State
Hospital and Rockaway Beach
Hospital, New York.

Until the ideal treatment of acute and chronic diseases of the heart is discovered, drugs will be the mainstay and the indispensable agents in those affections. The ideal treatment will follow definite knowledge of the bacterial or other agencies which produce each and every lesion of the heart. The dawn of such therapeutic millennium is seen creeping and breaking on the medical horizon. Thus serums, vaccines, and chemical compounds like salvarsan, are employed in cases in which the causative factor is known and settled. It is not so many years since septic endocarditis was the despair of the clinician, the opprobium of the bedside. The adjective "malignant" vividly portrayed its dreadful nature. Today, many of us can point with pride to one or more cures of this heretofore hopeless malady. The results are obtained not by haphazard trial and speculation known as shrewd guessing, but

'Read before the Harlem Medical Society, 1922.

rather by, and thru, knowledge of the true nature of the causative organism. The millennium is on the way, but until it reaches its last syllable of recorded time we must approach the subject under discussion from the standpoint of practical, accumulated, clinical experience; this experience is intimately and inseparably linked, and bound up with drugs. The drugless treatment of chronic heart disease is the confused dream. of medical somnambulists. All the celebrated "springs" and "baths," and "graduated exercises" are a disappointing bourne from which physically broken-hearted travelers return to kiss again the "ladies' fingers," botanically known as digitalis. This is tragically true when sequelæ set in.

In the treatment of chronic heart disease, three points are to be kept in mind: (1) The condition of the heart muscle; (2) the nature of the defective valves; (3) the functional disturbance which, sooner or later, results from one or the other or both.

Muscle degeneration requires treatment from the very inception of the trouble. Myocarditis implies and produces improper contractions, and no matter what factor or factors bring about the condition of the myocardium, the heart needs the strong, stimulating influence of a cardiac drug. Even tho a known poison like. syphilis produces the degenerative process and antiluetic remedies be applied, yet digi

talis or its equivalent must be given at the same time. This conviction is borne upon me every day. I hardly except the case that is associated with high blood-pressure. In such an event, the digitalis should be given, combined or separately with nitrites or iodides. The compound nitroglycerine tablet, made after Da Costa formula, is very suitable here. The point to remember is that digitalis is not to be omitted. In myocarditis associated with low bloodpressure, the withholding of digitalis is rank injustice to the patient. The fear that digitalis, by increasing the contractions of the heart, may rupture the degenerated muscle of the heart is founded on a hoary, but hollow medical superstition. The ever-present dyspnea demands the use of the drug. Valvular disease may exist for years without in any material degree discomfort ing the owner. The absence of discomfort is due to perfect compensation. Under such ideal circumstances cardiac drugs are not only uncalled for but are injurious.

Syphilis and rheumatism are two prevailing agents in the production of heart dis

ease.

Both affect the muscle and both destroy the valves. Some differences exist between these two mischief makers, which it may be well to mention and important to bear in mind. Rheumatism frequently produces acute endocarditis, while syphilis very seldom does. Rheumatism prefers to lay hands on the valves, while syphilis likes to damage the musculature. Rheumatism shows a predilection for the mitral apparatus, while syphilis is attracted by the aortic system of valves. Armed with such clinical data concerning the etiology of some lesions of the heart, an attempt to capture and destroy the causative enemy is not only mandatory but may prove highly successful.

Spurred on by modern methods of diagnosis and impressed with their great value, we should avail ourselves of laboratory assistance, namely, the Wassermann test and blood culture. The latter should constitute an essential element in the examination of a patient who suffers from acute or subacute endocarditis coming and going at shorter or longer intervals. A blood culture may result in the discovery of the Streptococcus viridans, and then the treatment can be specific, either autogenous vaccine or autoserum intravenously.

Again a proper study of all heart lesions is not complete, both from the standpoint of etiology and treatment, unless and until a careful search has been made for small pockets of pus stored and hidden in some nook or corner of the complex machinery of the human body, principally, however, the teeth, tonsils, to say nothing of the gallbladder, appendix and anus. It is neither a subject for laughter nor matter of skepticism to read that the removal of the appendix resulted in the cure of an obstinate trigeminal neuralgia. We rather should stand in amazement at the evidence connecting ulcer of the stomach with a few drops of pus under a tooth, and admire the man who traced the connection. That endocarditis, valvulitis and arthritis are due to the Streptococcus viridans found in purulent and spongy gums, I have not the least doubt. Neither have you. Now, here is a fruitful indication for treatment and prophylaxis of heart disease. In search for the enemy, one should not stop at the gums, but stray lower where the tonsils grow. The tonsil, like the appendix, was born to make trouble. Scrutinize it; if necessary use a searchlight; examine its secretion and perhaps luck will crown your efforts. The comparison of the tonsil to the appendix is not far-fetched.

What the appendix is to the peritoneum, the tonsil is to the endocardium. Many and many a case of endocardial disease can justly be laid at the door of the tonsil. In the treatment of cardiac disease associated with attacks of tonsillitis, the pesky organs must either be ablated or else frequently bathed with a solution of permanganate of potassium 1/5,000. This is the best antiseptic for that purpose and its employment should be considered part of the daily toilet.

If syphilis be found to be the etiologic factor (80 per cent. is the accepted frequency of this infection in aortic disease), then mercury is the redeeming drug-the sheet anchor; mercury by inunction or injection, preferably inunction. The iodides are of value in the face of arteriosclerosis and high blood-pressure. Salvarsan is permissible and at times desirable, rarely, how ever, urgent. A syphilitic heart stands salvarsan very well. After the salvarsan, one rubbing of five grams of blue ointment should be made every day for fifty days in succession.

This method of treatment is indicated in cases of aortic disease even in the face of negative Wassermann reaction at the beginning of the treatment. The Wassermann may become positive during the treatment. It is a waste of time to wait for the autopsy to confirm the diagnosis of syphilis. No patient was ever benefited by autopsy findings. Action must sometimes be taken on the flimsiest suspicion, for syphilis is a disease of the hovel and the palace, of the sanctum and the saloon, of the wise and of the foolish, of the innocent and the guilty.

These considerations make it evident that the ideal treatment of heart disease rests in finding and removing the cause. But is this ideal attainable? It must be admitted that, excepting in particular instances, it is not,

for the reason that the present status of our knowledge of etiologic agents is still hazy, nebulous, uncertain. Besides, even in the case of lesions which are known definitely to have been produced by spirochetes or streptococci or any other of the multifarious. denizens of the microscopic world, if such lesions remain unrecognized and specifically untreated for a long time, specific therapy subsequently applied will not cure them. Changes which were wrought in the valves will persist, and changes which have occurred in the muscle of the heart will remain, notwithstanding the application of specific remedies. Etiologic treatment may and does ameliorate, in these late and distressing cases, annoying symptoms; it may also for a time stay the downward march of destruction of tissue, but sooner or later the diseased organ has to be considered and treated, from the standpoint of functional derangement.

To such consideration I would invite your attention.

Valvular Lesions.-Valvular lesions constitute the great majority of cardiac affections; it is fitting, therefore, to take them up first for consideration. To treat a valvular lesion intelligently, or to permit it to go without treatment, also intelligently, one must know the stage of the lesion which is present at the time of the examination.

There can be no objection to such a division. Tuberculosis is divided into stages, altho at times one finds all stages in the lungs yet the division is very useful. Pneumonia is divided into stages, so is cholera, so is smallpox, so is big pox, syphilis. I advocate the division of arteriosclerosis into three stages-a very helpful division.

The purpose of presenting the treatment of chronic heart disease may be better ful