SUMMARY

The reference in the foregoing portion of this article which has a tendency to limit the field of usefulness of this drug to a nauseant and an expectorant is at variance with the results which I have secured.

The apparent specificity of tartar emetic in the treatment of granuloma inguinale which has been accorded it by Frontz and Ross has been found to, unquestionably, produce these specific therapeutic results.

The end results obtained in the treatment of 3 cases of granuloma inguinale were almost unbelievable.

The response of eye cases to this treatment is equally as satisfactory. Two of the 3 ear cases were regarded as clinically cured, while 1 was unimproved.

the least satisfactory results as none could be regarded as positively cured although improvement in some was manifest and 2 of the cases are now, apparently, free of any subjective or objective symptoms.

In the miscellaneous refractory cases of adenitis which were treated 1 was apparently cured, 3 markedly improved and 2 unimproved.

Traumatic ulcer cases which were treated with tartar emetic yielded the following: 1 cure; 1 improvement and 1 unimproved.

Two satisfactory results were obtained in the 3 miscellaneous cases cited.

In the 32 cases treated; 12 have been regarded as apparently cured; 9 more have shown improvement in various degrees; while only 11 were

(1) REMSEN: Organic Chemistry, p. 178. (2) SOLLMANN: A Manual of Pharmacology, p. 757.

(3) HATCHER AND WILBERT: Pharmacology of Useful Drugs, pp. 313-14.

(4) FRONTZ, W. A.: Johns Hopkins Uni

versity. Tennessee Venereal Disease Bulletin, Nashville, September 2, 1923, p. 1.

(5) Ross, CLYDE F.: Medical College of Virginia. Virginia Medical Monthly Richmond, September, 1923, p. 401.

THE SCIENCE OF PREVENTIVE MEDICINE

T

Intro

HE fourth Canadian meeting of the British Association for the Advancement of Science was held in Toronto during the month of August, forty years after its first meeting in Montreal in 1884. This last meeting is of especial interest to all medical men in that it marked a new epoch-the formal recognition of preventive medicine as a distinct branch of applied science. The presidential addresses on the occasions of the previous meetings had dealt with the advancement of knowledge in archaeology and physics; the new president, Major-General David Bruce, a noted investigator himself, took for the subject of his address "The Prevention of Disease." ducing his subject by showing the enormous loss of power to a community through sickness and disability, estimated at about £150,000,000 a year in England and Wales and at about £600,000,000 annually in the United States, he then briefly sketched the work of Louis Pasteur from whose "establishment of the germ theory we date the beginning of the intelligent, purposive prevention of disease." The president then quoting from Sir Clifford Albutt described "the new birth, the revolution in medicine" as its "enlargement from an art of observation and empiricism to an applied science founded upon research; from a craft of tradition and

sagacity to an applied science of analysis and law; from a descriptive code of surface-phenomena to the discovery of deeper affinities; from a set of rules and axioms of quality to measurements of quantity." He recalled the wave of enthusiasm that swept over the medical world when it was recognized that infectious diseases were caused by living microorganisms. He recalled to his hearers that at the time of the first meeting of the Association in Montreal in 1884, the microorganisms of tuberculosis, typhoid fever, Malta fever, cholera, malaria, diphtheria, tetanus and others of the

infectious diseases had been discovered and described. After their discovery and isolation the process of prevention of the diseases caused by them was soon begun. The mode of prevention of three of these infections, Malta fever, typhoid fever and tetanus, as illustrating the three principal methods of preventing bacterial diseases was described in detail: in Malta fever by getting down to bedrock and stopping the disease at its source by striking Maltese goats' milk out of the dietary; in typhoid by giving, as it were, a mild attack of the disease by vaccination or inoculation, so as to bring about a greater degree of resistance; in tetanus, by pouring in antitoxins, already prepared in the serum of another animal, in order that they may neutralize the toxins of the invading bacilli as soon as they are formed. In the case of Malta fever

the disease was blotted out at a single blow. Malta, from being the most. unhealthy of foreign stations actually became a sanatorium during the Great War. In the prevention of typhoid fever the establishment of a good water supply and good drainage had in itself made cases of typhoid fever in England fifteen times fewer than they were fifty years ago. But as good hygienic surroundings cannot always be obtained, especially among troops on active service, a further progress in the fight against typhoid was made by applying the method of inoculation or vaccination, as employed against small-pox. In the South African War, before this method had been developed, in an army the average strength of which was only 208,000, there were 58,000 cases of typhoid fever, and 8000 deaths. In the Great War, on the Western front, with an average British strength of one and a quarter millions, there were only 7500 cases and 266 deaths, in other words fewer cases of the disease in this war than there were deaths in the South African. The British soldiers were inoculated against typhoid fever from the beginning of the war. On the other hand, the French soldiers were not inoculated at the beginning. During the first sixteen months the French had some 96,000 cases of typhoid, with nearly 12,000 deaths. During this period the British had only 2,689 cases and 170 deaths. Afterwards the French soldiers were vaccinated with the result that their immunity became as striking as that of the British. What the number of cases and death-rate from typhoid in the great armies of the war might have been, had it not been for this

preventive inoculation, it is impossible to say, but undoubtedly it would have been appalling. Antityphoid inoculation was certainly one of the greatest triumphs in the prevention of disease during the recent war. A similar victory of preventive medical science attended the use of anti-tetanic serum. In August and September, 1914, before prophylactic injections were given about nine or ten out of every thousand wounded were attacked by tetanus, and 85 per cent of these died. After the anti-tetanic injections were introduced the incidence of tetanus fell to little more than one per 1000, and the mortality to less than half. During the entire war there were only 2500 cases of tetanus in the British Army, with 550 deaths. Had there been no prophylactic injection of antitetanic serum there would probably have been 25,000 cases with 20,000 deaths. In the case of other bacterial diseases, such as tuberculosis, the attack of preventive medicine is against the soil rather than the seed, and the remedy lies in the provision of a better environment and education in physiologic living. A second great group of diseases-the plagues of the tropics, malaria, amoebic dysentery, trypanosome sleeping sickness, kala azar and yellow fever the parasites of which belong to the protozoa, require other modes of prevention, and since the discovery that the carrier of the infective agent of these diseases is usually an insect or a tick, the obvious mode of prevention is indicated, an attack upon the carrier, and in many cases has been successfully carried out. In a third great group of infectious diseases, small-pox, influenza, measles, typhus, trench

fever, rinderpest, rabies and foot-andmouth disease, researches seem to show that the living cause is an organism so minute that it passes through the pores of a filter. The nature of these "filter-passers" is still unknown or doubtful, and against some of them there is at present no attempt made at prevention except isolation and quarantine; but even when the virus is unknown there are well-known methods of prevention, for some of them, as in the case of small-pox and rabies. Since the time of Jenner the ravages of small-pox have been controlled, and the continued existence of this disease in our communities is due to the ignorance or selfishness of those who refuse to have their children vaccinated. Through the genius and intuition of Pasteur rabies has been robbed of much of its terror, the mortality following the bites of rabid animals has fallen from 16 per cent to less than 1 per cent as the result of the Pasteur treatment. A more radical method would be to drive the disease altogether out of the country by muzzling and quarantine laws, as was successfully carried out in England at the beginning of the century. Trench fever, practically unknown as a disease before the war, was responsible for more than a million cases among the Allies on the Western front, and was one of the most important diseases causing loss of manpower in the fighting forces. Towards the close of the war, it was shown by the researches of the Trench Fever Committee that the louse, and the louse alone, was responsible for the spreading of this disease. Had this discovery been made at the beginning of the war instead of at the end the

allied armies would have been saved hundreds of thousands of cases of a disease, which never fatal, were often of long duration and led to much invaliding. The elimination of the louse would have completely blotted out trench fever from the armies on the Western front. Typhus fever and Rocky Mountain fever, carried by the louse and the wood-tick respectively, although their causal agents are still undiscovered, may be approached from several standpoints of prevention aside from direct attacks on the carrier. Antitoxic sera have also been used with some measure of success in the prevention of diseases of this group, as in the case of measles, scarlet fever and foot-and-mouth disease. Still more hopeful than protection by serum alone is the use of a vaccine to produce a lasting immunity, combined with antitoxin to prevent the vaccine from producing unpleasant resultsthe so-called toxin-antitoxin method. This method of prophylaxis has proved valuable in the diseases of animals, such as pleuropneumonia of cattle, rinderpest and foot-and-mouth disease; and the Dick test is now used in scarlet fever on the same lines as the Schick test for diphtheria. It is, however, not only against the infectious diseases that preventive medicine has won great laurels. The discovery of vitamins and their relation to the deficiency diseases, the revelation of the influence of the ductless glands in health and disease have come to the aid of preventive medicine in many afflictions of mankind that are not due to living microorganisms. The suppression of goiter by the addition of traces of iodine to the diet, and the treatment of diabetes by insulin are