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The expenditure of $50,000 or $100,000 by Iowa for a sanatorium will within a few short years greatly reduce our annual loss of over $10,000,000.

Under the present systematic enforcement of isolation and disinfection, tuberculosis will be extinct in Prussia in 1927, in England in 1947.

Are not our citizens of as much value as are those of any foreign country? Does not the medical profession owe to humanity the truths which it knows, and knows absolutely?

"The new shall do

The unknown things, the wondrous deeds Earth's future needs demands;

Its hand shall shape the course;

Its brain devise the plan

To win the richest prize that man can winThe betterment of man."

THE PRESENT STATUS OF THE ALKALOIDAL MOVEMENT.

W. C. ABBOTT, M. D.

CHICAGO, ILL.

WHEN Boswell first met Samuel Johnson the latter was giving his views as to some other man with considerable vigor. Boswell endeavored to moderate the storm by remarking that he hardly thought the man as bad as Johnson said; when the latter turned on him with "Sir, I do not see what right you have to an opinion on the matter!"

Very often we have the opportunity to ask this question, when people advance their views with an ex cathedra air, as if that settled the matter in dispute.

When a distinguished surgeon, professor of surgery in Rush Medical College, says flatly, "there is no medical treatment for pneumonia" we feel warranted in respectfully asking-what right have you to an opinion on this subject? and, for whom do you speak thus? For yourself, for your colleagues, or for the medical profession in general? If for yourself, we submit that you should have said that you knew of no such treatment; and with that statement we should have no quarrel. If you spoke for your colleagues, we ask if they authorize this assertion, and if this is the present teaching of Rush? If so, the physician who has medical students may well consider whether they will get from Rush the teaching he deems best. If Dr. Bevan speaks in behalf of the medical profession, we ask by what authority does he assume the right to do so? And as a member of that profession we repudiate his assumption to speak for us, and deny the truth of his assertion.

Dr. Bevan is a surgeon, whose attainment

in that restricted sphere have made his name known all over the land; and in his line he has few superiors. has few superiors. But we have searched in vain through the records of medicine to find any indication of his having practised medicine in his days of maturity, or contributed anything of value to non-surgical medicine, much less to therapeutics; or that indicates that he has paid any attention to the developments in the latter during the last twenty years. In fact, we must give his startling assertion about the credit that our own would receive, were we to state that there was no surgical treatment for appendicitis.

But the influence exerted by such statements does not stop with the medical profession. They form part of that enormous system of detraction and pessimism by which the profession has been undermined in the estimation of the public, and the way opened for the operations of quackery. The intelligent layman says: "According to the leaders of your own profession you have nothing to offer me except the sharp point of the knife. I don't want it." The quack says: "Regu lar medicine acknowledges she has no remedies but surgery. I have." And he has. Nowadays the quack is a graduate of regular medical colleges, and as well qualified as the average practician-perhaps a little better, while relieved of the trammels of ethics and possessed of an infinitely greater knowledge of human nature and of business methods. He is devoid of prejudices and quick to pick up and utilize any improvements in medicines and methods that arise-far quicker than the plodding general practician. The latter may have in his office a microscope he never uses, and an electric outfit that is out of order, but he continues to prescribes squills and paregoric for every cough, opium for every pain, whisky for everything else.

Let me state as my profound belief, after studying quackery in all its aspects for years, that its existence has a tangible, easily comprehended reason. That reason is little creditable to ourselves. If the profession is poor, if the doctor finds it yearly more difficult to make both ends meet, to provide himself with the needs of an up-to-date practice, if quacks multiply and the public accepts and enriches every new one, however absurd may be his claims, whose fault is it? It is our belief that the whole matter may be summed up, by saying that the therapeutics of the regular medical profession is not good enough to meet the requirements of the present day. It is this miserable, outworn therapy, I and my colleagues are endeavoring to reform.

Well, what's the matter with our therapeutics? It is uncertain, inefficient, wrongly directed, unpalatable and crude, antiquated,

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Uncertain. It is scarcely necessary to expatiate on this point. The writer has seen a man with dilated heart die within an hour of taking a dose of fluid extract of digitalis, that happened to be weak in the cardiac tensors and rich in the cardiac depressant, digitonin. He has given jaborandi to increase a mother's milk and had the drug dry up the secretion entirely, because it was weak in pilocarpine and rich in jaborine. Even with cinchona, whose alkaloids are phenomenally synergistic, we have practically dropped the cruder preparations for quinine. How much more necessary this is with plants that contain antagonistic principles. I will only allude to hyoscine, which is completely smothered by the accompanying atropine except in some rare specimens of hyoscyamus; arbutin, which is accompanied by thirty-five times its weight of tannin, so that effective dosage was unknown until the arbutin was separated and administered alone.

But I must speak of the alkaloids of hydrastis: Berberine contracts relaxed connective tissue, while hydraṣtine contracts the smaller blood vessels, especially of the uterus. The former is a much needed remedy for dilatation of the stomach, for uterine, gastric and intestinal ptosis, for all relaxed states of ligamentous tissues. Hydrastine is a useful remedy for menorrhagia and especially metrorrhagia. The man who administers preparations containing both when but one is indicated, loses much of the satisfaction that comes from an intelligent practice of medicine. In a word, there is in the crude preparations uncertainty as to the nature and the degree of effect we are going to get, whereas with the active principles we have certainty as to both.

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Wrongly Directed.-Here we come to the crux of the matter. We have been directing our attacks against diseases as entities, when there are no such things. Leaving out the influence of quinine over malaria, mercury over syphilis, and where have we a third instance of a specific for any disease? We are in truth not called on to treat diseases, but conditions. No matter what may be the disease, we recognize the presence of autotoxemia, and remedy it; of hyperpyrexia, and quell it; and if we are qualified, of disturbances of the vasomotor equilibrium, and correct them. Well were it if we did away with these things the prescription books, the ready-made remedies for single diseases, and the belief that a name-diagnosis is an essential preliminary to drug treatment.

Here is how we get wrongly started in our work; we see a patient; wait some days till able to make a name-diagnosis-eight days for a Widal-and then turn to our formula collection-select the one that has the biggest name behind it, or contains the most ingredients, and give it throughout the attack. we construct our own prescription we select the remedy we prefer-not knowing just what it will do we throw in a few others, any one of which may hit the case, and let her go at that.

If

formulas leaves us at the mercy of the manu. The difficulty is that the dependence on facturers who promote specific remedies for specific diseases; and abdicating our functions as prescribers we follow the lead of patent medicine makers.

Instead of this, our attack should be directed against just what we see to attack-the symptoms present.

We have fever-moderate it; we treat what there is to treat, and study our cases instead of our books. We do condition-diagnosis on which we base our not wait for a name-diagnosis, but make a therapeutics. We can not stop to ascertain what is the cause of hyperpyrexia, because before we can do this our patient will be dead

we just apply ice and cool him off-then we hold an ante-mortem instead of a postmortem to complete the diagnosis. This we term condition-therapy.

Unpalatable and Crude.-Because we administer uselessly a lot of inert woody fiber, gum, sugar, pectin, albumen and other ingredients of the plant, which add no useful element to the dose but make it larger, more unpleasant, slower to act, less likely to be retained by the stomach, and materially interfere with the absorption of the active principles presented.

Antiquated. Here is our final point. The basis of scientific therapeutics is the known

action of remedies. This has been ascertained mainly through the medium of physiologio experiment; and this is of necessity confined to the definite, uniformly acting principles, because certainties can not be deduced from uncertainties and the experimenters were driven perforce to these agents. It results that we have concerning them a wealth of information, reaching down to the minutest details, that enables us to prescribe them with full knowledge of the effects to be expected.

The active principles are not substitutes for the tinctures and extracts, but each has a therapeutics of its own. We offer them on their own merits. They may resemble the crude drugs, but this is incidental. Study the alkaloid for itself, without reference to the parent plant. Of what possible consequence is it to us whether hyoscine comes from henbane or from scopolia? Or what these plants were used for in the earlier day? We give hyoscine for its own powers, as shown by scientific experiment.

In the Text-book of Alkaloidal Therapeutics there are 155 remedies described; but these are far too few. Many alkaloids are known to the chemist but not yet tested for the physician. There is a whole group of tetanizants of which strychnine is the type, embracing brucine, thebaine, laudanine, gelsemine, calabarine, curarine, all having similar effects-but not identical necessarily. They have not been studied yet, except that we know brucine is a local anesthetic, and that thebaine has shown powers in certain cases of paralysis superior to those exerted by strychnine. We are convinced that a thorough study of this group would show valuable diversities in the powers of the different members that could be fitted to like diversities in the symptoms of diseases. For instance, at present the writer is struggling with a case of so-called asthma. The vascular tract of the lungs becomes dilated, allowing congestion, with strenuous cough and followed by dyspnea. The indicated remedy is one that will increase the tonicity of the vessels walls in the pulmonary tract without affecting those of the general circulation, which are in a spastic state already. What is this remedy? Hydrastine does this exactly for the uterine tract. Adrenalin does it for the general circulation, for exactly the part we do not need it in. That there is such a remedy as we need we cannot doubt; but as long as the profession is satisfied with crude drugs there is no incentive to add to our list by the careful and painstaking investigations necessary to establish the place of new alkaloids. When this has been done we will have a collection of finely selected remedies that

will admit of an accuracy of application of which we now see only the possibilities. The great need is for clinical workers, who will apply these agents and make careful observations as to their effects. For instance, there are two new remedies for epilepsy-verbenin and solanine. Each has won more than popular repute. Verbenin has proved curative in a series of cases studied by Prof. French, of Carbondale, who believes it acts upon intestinal parasites. Solanine is the active principle of the bull or horse nettle, of bittersweet, and of several other plants that have proved useful in this malady. How, why, what its action and the limits of its effectiveness, are yet to be determined. We have gathered these facts; and we ask the profession to ascertain further facts by clinical trials; but they ask us for information instead. We proffer brotherhood, they insist on forcing us into an undesired leadership.

I have recently traveled from the Atlantic to the Pacific, addressing many medical societies, in the endeavor to arouse an interest in purely scientific, purely ethical, non-secret, non-monopolistic, therapeutics. The alkaloids form a very important part of this, but by no means all. Many synthetics and sera are as strictly scientific as they. The results have proved highly satisfactory. The profession shows signs of waking up to the importance of this movement-the need of reform in therapeutics is universally admitted. The scope of our work is being better comprehended. The cry of "commercialism" is silenced. It is an absolute necessity that there should be a source of standard supply for these delicate instruments, or the propaganda would be emasculated. Of what possible use would it be for us to recommend strophanthin, and send the physician out for it into a market where the supplies vary in strength from one to ninety? But when a non-secret, non-monopolized remedy is advocated, which every druggist, every physician, may prepare and dispense if he chooses, the cry of interested motives becomes trifling. The only opposition now manifested against the alkaloids comes from men who supply ready-made prescriptions to physicians and who find their sales decreasing under our advice for physicians to study their cases, and do their own prescribing with drugs they know all aboutand of such opposition we are rather proud than fearful.

We are not contending for the alkaloids. but for drug-therapeutics, based on agents worthy of trust, because their effects are sure, uniform, perfectly well known; drugs neither secret nor monopolized, with no commercial backing as such, but depending for popularity on their effectiveness and nothing more.

And on this basis we ask from the profession a renewal of confidence in such drugs, and a trial of the therapeutic methods based on them; promising in return a renewal of that optismitic faith that moves away mountains of disease.

This may to many readers be a many times told tale; but it is one that has traveled far and met no serious attempt at controversion. Many of the foremost men of our day have assured me that we are right; and that the only trouble has been that the world required time to catch up with us. But we who are advocating this reform are painfully conscious that it is a thing far bigger than the men now in it and that at the best we may hope in time to be known as "forerunners, "but no

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IN presenting this topic for your discussion it is well to consider the frequency with which the condition is met, and the usually unsatisfactory course of the disease. I say disease; it is not entitled to be set aside as a special disease, but the peculiar features presented by tubercular adenitis when located in the cervical region justifies its study apart from general tuberculosis or tuberculosis of lymph glands in other localities of the body. It differs in no essential from tuberculous glands in any portion of the anatomy.

The frequency with which glandular disease is met in the first decade of life is striking. Owing to it being the time of second dentition and to the predilection for the exanthemata this is the period of the greatest susceptibility to glandular disease. It has been shown that about 85% of child. ren in this period are affected. These are largely simple infections of non-pyogenic organisms, and remain without producing any symptoms indefinitely. The number of these that are already tuberculous, and the number which may at a later time become so cannot be expressed in numbers. But coming to the second and third decades of life we find 76% of cases of the affection, and that a large per cent of these give a history of glandular disease in childhood. So we know that a large per cent of those in the first decade are

*Read before the Western District Medical Society of Illinois, at Alton, October 21, 1905.

tuberculous or have a strong predisposition to tubercular infection.

The importance of tubercular disease of the neck is made apparent by recalling that in 14% of cases of tubercular disease in other parts of the body show these glands infected. The conclusion cannot be escaped that to arrest the disease in the neck we would reduce tubercular disease by just so much. It is a very familiar sight, I dare say, to every one present to see persons in his practice, children, adolescents and aged ones with these tuberculous lymph nodes.

It is no reproach to the profession of course, but at this day of general awakening of both profession and laity against tubercular disease, and especially along the line of prophylaxis it is our duty to detect and remove these nidi.

It would be begging the question to say this condition is secondary to and dependent on primary foci in the mouth of upper air passages, and that to correct these should be the aim of treatment I am thoroughly assured that no modern physician would hold this view; it would be a striking parallel to the assertion that because the Chicago drainage canal pollutes the stream, those living on its. banks at Peoria, Alton and St. Louis should not filter the water that is carried to their every home.

The answer to the query, why is 90% of glandular tuberculosis shown to be in the neck? is found in the fact of the abundant lymphatic supply of this region, and the great exposure of the mouth and upper air passages to the lodgment of germs.

When you reflect that 95% of all tubercular disease becomes infected by way of the mouth or nose, and that these cavities are constantly invaded by living germs, is it any wonder that the lymphatic chains of the neck, these faithful sentinels, ever on watch for the enemy, should sometimes suffer defeat? Greater is the wonder that they should achieve such numberless victories against the arch enemy of the human body, so insidious and so relentless.

It is needless for our purpose to discuss the numerous infections that may disturb the glands of the neck. It is sufficient to say that any considerable enlargement of them, occurring in the second and third decades of life, that are not lympho-sarcoma or pseudoleukemia, or syphilitic, or that does not rapidly progress to suppuration or resolution, is in all probability tubercular and at once a surgical disease.

I think we are forever divorced from the scrofulous disease of the older writers as meaning other than tubercular disease. I do not concede that there is such a condition or

entity, certainly not from a practical point of view, as simple chronic hyperplastic adenitis. This classification is based on the characteristic long period of involvement, the inactivity and the sometimes spontaneous cure by absorption.

This I maintain is illogical. These glands will in the great majority of cases prove themselves to be tuberculous, and will surely go on to caseation and suppuration. Not to so consider them would compare well with the argument that says, let the appendix alone until it suppurates. It can only be said for taking this chance course that it may be justified by results. It is poor argument, as the evolution in the treatment of appendicitis plainly shows, and the analogy is so true that it must carry conviction. Why not remove the doubt along with the disease? I would, therefore, make a plea for the early extirpation of these glands. What do we gain by an early operation, and what may we not suffer by delay? These are pertinent questions, and their correct answers should determine the course of all toward an early operation.

What do we gain? In the first place we save from more extensive and widespread tuberculosis 14% of patients. Secondly, we treat a simple uncomplicated surgical disease of the neck and we get an ideal and perfect recovery. These things accomplished for the patient and humanity are not to be despised. If any plan of treatment could reduce the mortality of pulmonary tuberculosis 14% it would be hailed as a dispensation from heaven. This is what early and complete operation does if statistics are true, and my premises, and conclusions are correct. do we suffer by a delayed operation? cannot escape the suppurating abscesses of the neck and the hazard they carry to life and happiness.

What

We

Tubercular disease of the lymph glands of the neck considered as a surgical disease may be classified in three divisions. Tubercular infiltration, which is the early stage of all tuberculous glands; caseation and softening is the second division, and is the next step in the progress of the disease, and third the periadenitis when the disease is no longer confined within the capsule of the gland, and has penetrated into the contiguous tissue, and we have those large indurated masses involving all the tissues whose center is a suppurating chain of glands connected by sinuses and discharging purulent matter. This third division is, unfortunately for the patient, and also for the complacence of the doctor, the one he is most often called upon to treat. Now who is blameless or most to be blamed for this distressing and

menacing condition? I would lay the blame equally on the patient or his parents, on the doctor and on the patent medicine man and his congeners; the doctor in many instances for not insisting on an early operation; the patient for following the misleading claims of the uneducated or vicious, and the patent medicine man for his crime of hypocrisy against the credulity and fixed superstitions of the average man. What should be the rule in the treatment of these conditions? First, excise every tuberculous gland found, and do it at the earliest stage if possible.

It would follow as a rational principle that the source of infection should be sought out, and if possible corrected, whether it be the tonsil, post adenoids, caries of the teeth or abrasions of the mouth, nose or pharynx. If the case is not presented at this early and favorable period, but belongs to the second, excision should still be the rule.

Do not temporize with iodoform injections or bichloride injections or iodine injections; you may get results, but the chances are against you, so do a clean excision, and do not be satisfied with the removal of one caseated gland; remember that there are always three or more involved at this stage. I am impelled to speak rather strongly on this point. In my own cases, at least, those that have done badly were those that had been treated expectantly in the first stage and by injections in the second, and have reached the third by progressive gradation.

What is the rule for this third stage of the disease? Excision excision! broad, bold and deep if there is any possibility of entirely removing the masses. The excision should include all tissues involved in the disease, skin, fascia, muscle, and if need be vesicles and nerves, excluding of course, the carotids, and the pneumogastric, the cervical, sympathetic and recurrent laryngeal nerves. It should be remembered that the structures mentioned can in most instances be avoided and protected. The carotid sheath by some fortunate principle of immunity is seldom involved.

It is not within the province of this paper to discuss surgical technique, this is fully treated by all modern works on surgery. After a rather extensive experience I am convinced that the principles herein set forth, and sought to be made impressive are correct, and I may add that they are not my dictum, they are the doctrines enunciated by all surgical authorities, and if I have made them forceful and effective for some hesitating and vacillating brother, then my plea has not been in vain and his grateful soul will answer to his satisfied conscience

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