Vol. XXX

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COLLABORATORS.

ALBERT ABRAMS. M. D., San Francisco.
M. V. BALL, M. D., Warren, Pa.
FRANK BILLINGS, M. D., Chicago, Ill.
CHARLES W. BURR, M. D., Philadelphia.
C. G. CHADDOCK, M. D., St. Louis, Mo.
S. SOLIS COHEN, M. D., Philadelphia, Pa.
ARCHIBALD CHURCH, M. D., Chicago.
N. S. DAVIS, M. D., Chicago.

ARTHUR R EDWARDS, M. D., Chicago, Ill.
FRANK R. FRY, M. D., St. Louis.

Mr. REGINALD HARRISON, London, England.
RICHARD T. HEWLETT, M. D., London, England.
J. N. HALL, M. D., Denver.

HOBART A. HARE, M. D., Philadelphia.
CHARLES JEWETT, M. D., Brooklyn.

THOMAS LINN, M. D., Nice, France.

FRANKLIN H. MARTIN, M. D., Chicago.
E. E. MONTGOMERY, M. D., Philadelphia

NICHOLAS SENN, M. D., Chicago.

FERD C. VALENTINE, M. D., New York.
EDWIN WALKER, M. D.. Evansville, Ind.
REYNOLD WEBB WILCOX, M. D., LL. D., New York
H. M. WHELPLEY, M. D., St. Louis.
WM. H. WILDER, M. D., Chicago, Ill.

LEADING ARTICLES

ERRORS IN MEDICINE AS A SCIENCE.

JOSEPH CLEMENTS, M. D.

KANSAS CITY, MO.

Member of the American Association for the Advancement of Science, etc.

THESE errors are to be seen both in the basic principles, and in the nomenclature used in general medical literature, the later, however, unnecessarily exaggerating the former, thereby tending to their perpetuity. This is a serious bar to medical progress.

It is certainly a disquieting fact that medicine as a science does not keep pace with the other branches of general science in the advancement which distinguishes the last two decades, for instance, astronomy, physios, and chemistry. In the art of medicine, surgery in particular, brilliant strides have been taken and marked progress achieved, while in the science of medicine, that is, in the basic principles giving knowledge of diseases, and on which principles and procedure in therapeusis are founded, in this medicine is in the background, and the cult not in the highest repute. Permit the evidence of the above as a statement of the facts in the case.

The only, and therefore correct and scien

No. 8

or,

tific basis or foundation in medicine is, in the language of Virchow, "an objective picture of the nature of the vital processes, in other words, to see nature at work, and to think of nature as nature operates the organic phenomenon.

Organic processes and functions are not operated, or "run," by external factors of any kind, the organism operates itself, it is automatic. Its potentiality is inherent, it has its own vis a tergo, and vis a fronte. Vis medicatrix naturae is the sovereign potentiality and active agency in all therapeusis, nor does the organism share the onus or the honors of therapeutic achievement with any of the factors which may play a part in the comedy or tragedy enacted within the vital domain-nature's forces being sole as well as sovereign within her own domain. All external things, whatever part they play, are contributory, are adjuvant, ancillary to the organic furces and activities-nothing more. Organic potentiality is inherent, an endowment of the germ or seed, and is in active operation in physiologic respiration in the earliest or incipiency of organic existence. All the tissues and organs of the body, with their activities and functions, come into entity and into active operation by the potencies and activities originating and proceeding, and having basis in the physiologic respiration of the germ. The initiation in evolution of the given organism takes rise in response to the causal factorship of the environments in the primal activities, being dominated and governed by the hereditary potentialtiies of the organic germ. Organic life, the organic phenomenon, originates de novo as to external things, yet is dependent upon factors external to itself, these being conditions in initiation of activities and functions, influencing and modifying their processes, and, as already said being adjuvant and ancillary in their role and part.

Now, it is the province of medicine as a science to distinguish these facts in the ultimate and primal of the organic phenomenon, establishing the principles of its science and art on this as its foundation. All conception of disease, all diagnosis of present conditions,

and institution of measures in interest of threapeusis must arise in view of these basal and primal facts, and in non-recognition of these we surely err and stray. Not having this picture of the nature of the vital processes limned and clear attempt to manipu

late these vital processes in medical interference one is working in the twilight if not in the dark.

I have endeavored to make it apparent that the operative potentiality and agency are in a sole and sovereign sense those of the organism itself. Yet while it is automatic, selfoperative, its phenomena are not without cause, and in a very practical and external sense. Organic processes and functions may only be said to originate de novo in a special and relative sense. Organic life and evolution are only possible under certain conditions, and suitable temperature, nutrient supply, with other environmental factors are the conditions and causes of organic processes in this evolution. These are, however, only conditions and casual factors, being adjuvant and ancillary to the sovereign operative agency the organic processes and functions

themselves.

There can, therefore, be no "germ" of disease, scientifically speaking, nor "remedies" therefore. The remedy is within. These terms, used as they are by the thoughtful physician in a general sense of accommodation are, nevertheless, unscientific because inexact and also misleading. Strictly and scientifically speaking, and according to the facts in the primal processes, the organism originates its own diseases, for disease is not an entity, it is a process, a congeries of organic activities which are an aberration, an aberration, a departure from and perversion of the normal operations and functions. No external factor can be other than conditionally causal, or secondarily contributory to the organic factors, processes and functions. The organism originates and operates its own factors and functions, utilizing the external environmental factors in its activities to this end.

First and foremost, then, it depends primarily upon the organism itself whether it may be put into the conditions and activities designated disease. A dead person will not A dead person will not respond, and no disease phenomena may be induced. To a patient "too far gone," may be called the great physician, who may have all skill and never failing remedy, but he stands powerless, and admits that be was called a "day too late." The organism is supreme! it is sole and sovereign here and in this, and equally in disease as in its "cure."

Certain environments and causal factors. are known to be followed by disease in persons exposed to their influence, and the rational inference is that a casual relation exists between them, the malady was so caused and induced. These facts are observed with a degree of uniformity so as to establish the

relationship. The uniformity is not perfectly constant, in many instances no results follow the exposure, but enough to maintain the autonomy of the vital organism. Some doctors and nurses serve in contagious conditions and never respond, while others yield at once, or soon. And in those who yield or succumb the response is varied. The cause no way varying, yet the results of the response to the infection are as varied as the victims vary.

There is a very interesting article in American Medicine for August, by Prof. Willis P. King, which both illustrates and points the matters discussed in this paper. The doctor cites seven cases of "syphilis," all doctors, which he had treated. The malady was identical in all the cases, with primary lesion, secondary irruptive stage, and followed by the so-called "tertiary" lesions and stage or phenomenon. In two of the cases mercury was used in the second stage, and these recovered, no mercury was employed in the other five and they died. The notable thing is that none of the seven doctors had been exposed to the infection of syphilis, Dr. King being one of them, and all had been exposed to the infection of cancer. Five of the men refused to take mercury because of their non-exposure, the five that died.

Now, if there is a "germ" of cancer all these should have had cancer! They each responded to the cancer infection by means of an abrasion of their fingers while treating cases of cancer, and there was the "primary

sore.

Also if there is a "germ" of syphilis these doctors could not have had the disease they suffered and died of, for all were "classical" cases of syphilis. As we have seen, five resented being considered and treated as syph-. ilitics, and I suppose died martrys to their faith and sense of honor.

And here we reach the point of special interest. Dr. King says: "I have always held that all of the contagious or infectious dis eases originate de novo, etc.," and I believe the doctor is correct in the position taken, and think this discussion may afford some light on the perhaps necessary proviso or explanation.

It is a fact that with a degree of uniformity the administration of mercury is followed by response in therapeusis that is, a degree of certainty in response, and of uniformity or sameness in the general character of the results-a more or less return to health. However, there are limitations here. The response is varied as the characteristics of the patient vary, but enough of uniformity and constancy is found to constitute the drug in the nature of a specific. There are a few other

drugs of this character that are almost to be designated specifics because of the uniformity and certainty of their action, and of the response elicited. Especially is this found in the alkaloids, given single or cautiously combined. Aconitine will astonish the man who has been using aconite in tincture or otherwise, as also calcium sulphide, and iodide, and the single salts of the hypophosphites. Our more exact knowledge of the nature of the vital processes render imperative and vital agents of exactness and certainty by which we are to manipulate and guide to our will those aberrant, yet so intricate and complex activities and functions. The exact, the precise, the uniformly certain in action and response attained, in the matters of life or death with which we deal, should surely take precedence of the crude and polypharmio of the times that should be winked at.

Of a few alkaloids and glucocides, and a few salts, properly isolated and prepared (and the highest possible grade of scientific pharmacy is here demanded) there has been secured such uniformity and specificity of drug action that certainty of organic reply in measured and precise modification of vital action as to both astonish and reward the scientific man at the helm of this vital barque. And the whole phenomenon of drug action, and all other measures adopted in threapeusis, when traced to their ultimatum, do but evidence and establish the fact and principle of the sovereign part and place of the organism itself both in the origination and effective operation of disease, and in those processes and functions by which return to health is achieved. The arrest of the aberrant or disease processes is effected by the action of the drug, purely chemical in the onset, the effect of which is the modification, or it may be radical change in the direction of the primary forces and activities, the nature and quality of this modification of vital motion being determined so largely by the chemistry of the drug.

Iodid of potassium is believed to be and doubtless is a really casual and operative fac. tor, in initiating such chemical reactions as disintegrate the molecular compounds of the injured and destroyed capillaries forming the irruptive lesions of the later stages in syphilis, rendering feasible and aiding in the elimination so imperatively needed. But to say that "iodid of potassium not only dilates the capillaries, but it extends them to points and areas needing new blood" lands us again in the region of error, and leaves us groping in the twilight or in darkness. In a science of medicine according to the facts the drug simply undergoes disintegration, under the new environment, initiates and is a factor

in chemisms now ensuing, and is eliminated as debris, or otherwise disposed of. This settles, doubtless, the account of the drug. What may follow and accrue upon this is to the account of the organism in its own factors and processes. Iodid of potassium has no physiologio action, or lethal or therapeutic, it is wholly chemical, as it is simply an isolated chemical compound. The physiologic, or therapeutic action is wholly organic, modified as may be by the chemic action of the drug.

The vital picture shows removal of the defunct and destroyed capillaries, in which chemical reaction the drug was a factor. But construction of new arterioles and capillary endings is no repair in the way of patching or adding on, as it must be with iodid of potassium as agent, or even as a factor in it. Repair, as in all primary evolution or development, is by growth, and originating in centers of life, intracellularly-from within out, centrifugal. Tissues do not form tissues, much less do drug compounds. The construction of tissue in therapeutic restoration is the primal function, effected intracellularly, cognate with and issuing or coming into entity in the vital metabolism.

In a phenomenon of the metaphysical and exact nature and character of that with which medicine deals, the utmost scientific exactness and clearness in knowledge of the facts in the phenomena, and in the terms used in description and interpretation, is vitally important and imperatively demanded.

IN varicose veins inject twenty drops of hamamelis tincture behind the vein; whilst the vein is being lifted up with a fold of the skin. One injection will generally produce a cure; the after treatment is simply rest.

THE number of horses slaughtered for food in public abattoirs in Germany during 1905 was 15,522 more than in 1904, the numbers being 96,834 in 1905, against 81,312 in 1904.

THE nut trees of the world could, it is calculated, provide food all the year round for the population of the globe. Brazil nuts grow in such profusion that thousands of tons of them are wasted every year.

WHEN the floor of the operating theater of the old hospital at Canterbury, England, was torn up the other day, the rings were discovered through which were passed the cords for tying patients down on the operating table prior to the discovery of anesthetics.

A TYPICAL "CHAUFFEUR" INJURY.*

OBERARZT DR. RICHARD MUHSAM,

From the Surgical Department of the City Hospital Moabit in Berlin.-Direction of Geh. Rat. Prof. Dr. Sonnenburg.

The automobile, the modern speed wagon, has already led to a certain kind of injury to the chauffeurs who drive these wagons which looks like a classic injury. Lucas Champonniere, Ghilleni, Walther and Madelung have described a fracture of the lower end of the radius, occurring when the chauffeur attempts to start the motor of his machine. In starting a machine the chauffeur grasps hold of the crank handle with the right hand and whirls it around until the machine starts working. If the machine starts quickly, it reverses the crank handle suddenly; as is

wellknown to all automobilists this sudden reversal of the crank is responsible for the acccident, which 1 have twice observed.

Both patients were 20 years old, strong men, each noting a sudden pain in the right wrist after the crank handle had suddenly reversed. The first patient had a typical fracture-pain over the end of the radius, slight crepitation but no deformity.

It looked like a typical fracture of the lower radial epiphysis. The second patient showed a decided deformity. The right hand was turned dorsal-ward and ulnarwards, and the lower end of the radius was pushed

•Translated from the Deutschen Medizinischen Wochenschrift, 1906, No. 28, by R. B. H. Grad wohl, M. D.

thumb. By strong pulling, the dislocation was reduced, and the hand placed upon a splint with the bones in correct position.

Both patients returned to their respective physicians and I have not seen them since. Presume that union took place without incidents of note.

Lucas-Champonniere has divided the mechanism of the fracture into divisions, first, direct fracture through the blow and force of the reversing crank handle striking the lower end of the fore-arm, and secondly, the indirect fracture by the blow in hyperextension (fracture par arrachement). Both are frequent. It is but seldom that the fracture occurs by a push against the ball of the

Fig. 4.

hand-compression-fracture-and by present pressure and counter-pressure through attempting to stop the reversal of the crank handle. Walther claims that a fracture of of the lower end of the radius can occur through tearing.

Ghillini thinks that the fracture occurs by reason of the lower epiphysis of the radius being pushed against the carpal bones without any intervening elastic cushion to break the force of the blow. The ulna is more protected by ligaments than the radius which is moreover tightly fixed in position by the ligamentum interosseum. If a break does not occur, the force spends itself at the elbow where there is pain. The fracture is either a clean break or the smaller fragments are

dislocated, or there is a break with bending, or even a comminuted fracture. Madelung thinks that the break occurs because the hand is in strongest dorsal flexion and the sudden reversal of the crank handle causes the end of the radius to be torn off.

When we think of this fracture from a pure theoretical standpoint, we must divide them, as does Lucas-Champonniere, into direct and indirect fractures. If the chauffeur loosens his hold slightly at the moment of reversal of the crank handle, there is a fracture. Both bones of the fore-arm can be fractrued in certain cases. If the chauffeur is holding tightly to the handle, the fracture occurs, dependent upon the exact position in which the handle is at the time of the reversal-the hand is in hyperextension and the hand is flexed dorsalward. The forearm is at this moment in strong backward motion, and there is consequently a fracture with dislocation. If the handle is below and towards the left (turning) then there is a fracture by tearing off of the end of the radius, as in my first case. If the reversal occurs when the handle is up at the top of the circle of its motion, going towards the left in its descent, there is a fracture, as described by Walther.

I believe that the severity of the fracture depends upon the kind of mechanism that produces it. If the reversal occurs when the hand is moving towards the top of the circle made, then the dislocation is greater than if the reversal occurs at the starting point of the circle made by the crank-handle.

There is not much to say concerning the prognosis and therapy. Fixation upon a splint as in the treatment of similar fractures of therapeusis followed by good results, together with gentle massage.

As to prophylaxis, the chauffeur should watch this process of starting the machine and observe the size of the spark. The automobile manufacturers should devise some less dangerous method of getting their machines in action.

THE SOUTHERN MEDICAL ASSOCIATION.The Tri-State Medical Society of Gecrgia, Alabama and Tennessee has been merged into the Southern Medical Association, which embraces Mississippi, Louisiana, Georgia, Tennessee, Alabama and other Southern States. The election of officers resulted as follows: President, Dr. H. H. Martin, Savannah; vice-presidents, Dr. Mack Rogers, Birmingham, Ala.; Dr. J. B. Cowan, Tullahoma, Tenn., and Dr. J. R. Tackett, Meridian, Miss.; secretary, Dr. Raymond Wallace, Chattanooga; treasurer, Dr. Y. L. Aberna. thy, Chattanooga.