ORIGINAL ARTICLES.

ADDRESS IN MEDICINE.

By James Jamieson, M.D., Ch.M. Glas., M.D.
Melb., City Health Officer, Melbourne,
Victoria.

At the Intercolonial Medical Congress. Hobart,
February, 1902.

THE SIGNIFICANCE OF THE TERM "CURE" in MEDICINE.

POPULAR beliefs and superstitions are often survivals, representing, with little substantial change, the opinions of the wise and learned of some earlier time. This is certainly true in respect of medicine, and it may well inculcate modesty and caution in those who think that they have attained to the ultimatum of truth. The history of medicine is not by any means one of steady progress, in which, with constant growth of knowledge, there was equal improvement in its practical application. One of the chief causes, which led to the growth of a feeling of doubt as to the power of medicine to produce cures, was undoubtedly the rise of homœopathy. It was not that Hahnemann himself was sceptical of the powers of medicine and his more orthodox followers even now err rather in the direction of credulousness-but those who could not accept the fundamental doctrine of homoeopathy, similia similibus, or its peculiar mode of practice, the use of infinitesimals, had often to admit that results as good as their own were obtained by its practitioners. But, if doing what was tantamount to nothing had as good results as doing much, it was manifest that the progress of the disease could not have been materially influenced for good by either method. And, if Hahnemann did not succeed in converting the medical profession to his peculiar doctrines and practices, his work was not, on that account, of no effect. His speculations and experiences did, indeed, influence the progress of medical science, though it was in a way that he dreamt not of. If the first effect was to encourage a spirit of scepticism, which became almost absolute, especially in some of the schools of Germany, that scepticism did not remain barren. A large need of inquiry was thus opened up. If it be true that a scientific knowledge of the nature and causes of morbid processes is the essential basis of sound practice, it is manifest also that, to most men, the chief

pleasure and satisfaction in their study must lie in the hope that, with increase of knowledge, will come increase of power in the direction of therapeutics. The results have already been considerable, and we may confidently hope that the means at our disposal, for dealing effectually with many forms of disease, will yet be largely increased. Indeed, the most recent tendency in therapeutics is rather towards over activity, especially in the way of treating symptoms; the administration of powerful drugs being made almost too easy by the improvements in pharmacy. But though the spirit of scepticism is no longer dominant, the established principles of therapeutics are not so numerous or so fixed as to put aside altogether the inquiry whether there is any such thing as a cure of disease, in the sense of a restoration to health, actually brought about by artificial means. Whatever may be the causes by which disease is set up, diseases themselves are states of the organisms, disturbances of normal physiological processes. And just as the organism is subject to constant changes, so diseases must be, to a greater or less extent, subject to variations.

The Natural Processes of Cure. The symptoms, by which a disease is recognised represent a chain of organic processes, dependent on the cause in which they took origin. Often after the cause has ceased to operate, there are results which in their turn become causes of a secondary order, The agents or forces which act as causes of disease were dealt with, in the stricter sense. The system, left to its own powers, is in most cases virtually helpless against parasites, whether animal or vegetable, when they have once gained a footing It is only by the intervention of medicine that intestinal worms can be expelled, or parasitic diseases of the skin cured, in the great majority of instances. But the agents which produce so many acute and chronic infective diseases stand on a different footing. They are chiefly of the lower order of vegetable organisms, and so minute that their presence is first revealed, not by their individual appearance to the eye, but by the effects they produce. These are not merely of a local kind, for bacteria have such power of rapid multiplication, and of diffusing themselves or their products in the fluids and tissues of the body, that several effects of a general kind result. Unless modern medicine is completely on a wrong track, minute organisms are the cause of by far the most of the dangerous diseases to which human

beings are subject. The list of these infective diseases is steadily increasing, and even where full proof has not been supplied, we are often led, by almost inevitable inference, to assume that bacteria are the actual and efficient cause. In whatever other ways bacteria may manifest their pathogenic influence, it is now generally believed that the chief and most characteristic symptoms are due mainly to specific poisons, which they produce. With regard to most of these diseases, and especially in the case of the acute infective forms, it is evident that the body, though for a time seemingly overwhelmed by the invasion, has extraordinary powers of recuperation. Unless death takes place quickly, the multiplication of the invaders is checked. They are killed or expelled, or in some other way rendered innocuous, and complete recovery, as a rule, takes place. Sometimes, of course, effects remain, in the form of local structural alterations, which may last long, and ultimately prove more serious than the original affection. Such are, for example, the kidney and the ear complications and sequelae of scarlet fever; but the rule stands good-death or complete recovery, Few questions in medicine have excited more attention, or are of more genuine scientific interest, than the inquiry into the method by which acute infective processes are brought to an end by the native powers of the organism. The process of recovery is in part easily understood. The poisons formed, whether directly produced by the bacteria themselves or as by-products in the breaking-down of the tissues, are steadily being destroyed, or are carried off by the kidneys and other organs of secretion. But it is now known that the destructive or expulsive action of the organs and tissues is largely helped by antitoxins, apparently the products of reactive cell activity. These neutralise the toxins, perhaps by entering into chemical composition with them. As regards the poisonous products of bacterial action, we can say that their injurious effects are first kept in check, and ultimately brought to an end by a combination of destruction, elimination, and antidotal neutralisation. As to the bacteria themselves, the question is, if possible, even more complicated. Some are killed by some constituent of the blood and fluids of the body, possibly a normal albumen, the so-called alexin; others are taken up and destroyed by the cells; many escape by the various excretory surfaces; while others again may long remain in various parts of the body, incapable perhaps of doing further injury to their host, or only producing local effects of a more or less harmful kind.

It

So much is known about the natural process of cure, or recovery, in the most successfully investigated class of diseases. And it is evident that the process is extremely complicated, and one which we can hardly hope to imitate fully in any kind of artificial or medicinal way. is possible, of course, that the natural method is not always so complicated as that described, even in some of the infective diseases; but it may be well for the present to confine ourselves to that which we best know.

The Principles of Vaccination and Injections. We possess vaccines, in use against various forms of disease, typhoid, cholera, and plague, the best established, perhaps, being the Pasteurian inoculation against hydrophobia. But the use of any living virus, however carefully treated, is liable to be attended with risks. The method of obtaining protection by the injection of blood serum, from a person or an animal which has acquired immunity, and has completely recovered, is a more rapid and essentially safer method than either of the others, and its advantages have been notably shown in the case of diphtheria, which has supplied a triumphant demonstration of the fruitfulness, in most practical fashion, of pathological experiment and research. Even as an isolated fact it has enormous value, but it is far more, since it opens up quite a new path of inquiry. It allows us to cherish the hope that, before very long, any or all of the acute infective diseases may be rendered amenable to treatment in a similar way. But it also supplies demonstration of the principle that, in all our therapeutic efforts, we should imitate as closely as possible Nature's own curative methods. Probably in every case of acute infective disease a spontaneous effort at cure is made. But it may be insufficient, because the amount of toxin produced is so great that the protective mechanism breaks down, and the anti-toxin is produced too late or in insufficient amount. By the use of the anti-toxin serum an extra supply of the needful antidote is provided, and thus recovery is made. possible, or greatly hastened. The use of anti-toxin in diphtheria is not merely the empirical application of a new and powerful remedy, but stands for the introduction of a new principle, and entirely new method into therapeutics, for the full fruit of which we may have to wait, the fruit itself being certain. There does not seem to be the same opening for the use of either vaccines or curative serums in the chronic infective diseases. They have not the self limiting power seen in the acuter forms, and therefore no definite natural

method of cure to be imitated. However powerful Koch's tuberculin may be, in either of its forms, and whatever its value for diagnostic purposes, it is generally believed to have failed as a curative agent. The same doubt holds with reference to the remedies of the serum order, introduced by Maragliano and others. It is plain that the disinfection of the blood and fluids of the body, as a whole, may almost be dispaired of; but if the protosa of malarial fever can be destroyed or their growth at least inhibited, by means of quinine, there may surely be other medicinal agents discovered, capable of acting in a similar way in other forms of disease.

Of late years the question has been seriously raised, whether the febrile process, as marked by an elevation of temperature, may not be part of nature's curative effort. Certain pathogenic organisms have been shown to have a very limited power of growth at temperatures not many degrees over the normal point. The critical fall of temperature in such diseases as pneumonia, and relapsing fever, suggests or admits of the explanation that the crisis is due, at least in part, to inhibition of bacterial growth, when a range of temperature, injurious to the particular organism, has been reached or long enough sustained; and there is the occasional observation that chronic infective diseases, such as phthisis, take a favourable turn, apparently as the result of an intercurrent attack of some other disease of an acute febrile kind. Nothing is more dangerous, or essentially more unscientific, than the habit of using powerful remedies for the relief of symptoms. Causal conditions must be discovered and the causes themselves attacked, or there can be no cure. The method of treating disease by means of animal extracts though in a way of old date, has received great development of late years. We are still greatly in the dark about the true physiology of internal gland secretion. It is the popular belief that every disease must or should have its specific remedy, if that could only be found out. Serum and organic extract methods will doubtless find much wider application in times not distant. All that has been gained, and probably all or most that is yet to be gained, is and will be the result of patient inquiry into the nature and causes of disease processes, and the practical adaptation of physiological principles, with such assistance as can be got from drugs, whose properties have been tested in the laboratory or at the bedside. The best illustration of this truth, as it is at present one of the most interesting, is to be seen in the modern treatment of consumption. From the

scientific use of rest or properly regulated exercise, open air life in a pure atmosphere, and a full supply of nourishing food, results which would once have been declared impossible are now obtained. Very often they are attained without the help of drugs; but, under certain indications, unmistakable help can be got from creosote, guaiacol, and other remedies. And in many other diseased conditions, both acute and chronic, very much can be done to bring about recovery, to bring about, in fact, what is tantamount to a cure, temporary or more permanent. The functions of the stomach and intestine can be regulated, the excretory capacities of the skin and kidney stimulated, the heart's action strengthened, and vascular tone heightened or lowered. More food can thus be assimilated, the quality of the blood improved, and its distribution favourably influenced, and the escape of waste and poisonous material made easier.

The period of sceptical inaction has now been over-passed, and there is no disease, however obstinate or malignant, which we may not cherish the confident hope of yet being able to overcome. We do not at all despair of yet finding some means of effecting the cure of cancer, that most dreaded of human ills. For, if the myxedematous state, with no natural tendency to recovery, can be removed, and if syphilitic growths can be caused to disappear, by means of mercury or iodine, why should the tissue change which we call sarcoma be insusceptible of cure? In the same way, if acute processes like rheumatism and malarial fevers can be kept in control, by salicylic acid and quinine, how can we give up the hope of controlling other conditions of an allied kind?

We enter on the new century with the hope and expectation of triumphs even greater than those which have marked the period just passed. The last half-century has been marked by the great progress made in surgical science and practice.

Is there any cure other than that which nature herself effects? The answer may fairly be, "Yes." We can effect genuine cures by removing causes of diseases, killing or expelling parasites, or putting an end to sources of irritation; or by counteracting or getting rid of poisons which have entered the body or been produced within it. In many of these cases the natural efforts by themselves fail to take effect, and art must intervene if there is to be cure. The cause being removed, it, of course, remains for the natural forces to bring about recovery from the effusion, ulceration, or other results, which have in

the meantime been occasioned. For certain diseases of the infective order, and others due to gland destruction or derangement, we can come to nature's help, in such a way that cures are produced, where her more tardy efforts would have come too late. Where we seem to produce a cure, almost entirely by means of drugs, as in the case of syphilis or malaria we are doubtless coming to nature's help in a similar way, though her own part in the process is not yet clear. These are the most striking instances of actual cures for which we can claim credit. But in very many other cases much can be done by a judicious com bination of general and pharmaceutical methods

My first duty is to gratefully acknowledge the high distinction which members have conferred upon me by my election to the Presidency of the section of obstetrics and gynecology at this, the Sixth Intercolonial, or as it is now, Australasian Medical Congress. No one more clearly recognises than myself how imperfectly I must appear to fill a position which has recently been adorned by that patient hero and true scientist, the late Dr. Way of Adelaide, and by my learned and eloquent fellow-countryman, Dr. O'Sullivan of Melbourne. I can only hope you will remember that "to have meant well, tried a little, and failed much" is as high an encomium as can truthfully be spoken of the majority of mortals.

Custom has ordained that discussion shall not follow a presidential address, and, therefore, it is good taste for the matter of such address to be as little controversial as possible. This necessarily limits one's choice of a subject and entails an increasing difficulty for each successive president.

In thinking over the question it appeared to me that as this, the sixth Congress, completes the round of the various capitals of Australasia, one might with propriety and advantage glance over some of the advances in obstetrics and gynecology which have taken place since the

first Congress at Adelaide, sixteen years ago. I do not intend to weary your patience by making it in any sense an exhaustive review, but shall merely touch upon those points which have most impressed myself.

First As regards Obstetrics.-Perhaps the greatest advance is the perfecting of the technique of Cæsarean section, and the firm establishment of this operation as the proper procedure in all cases in which a living child exists in utero and cannot be delivered alive through the natural passages. I would here state my belief that where there is permanent and insuperable obstruction, instead of excising portions of the fallopian tubes in order to sterilize the patient, it is wiser to do a supravaginal amputation of the uterus, leaving the ovaries. By this means future pregnancies are prevented with absolute certainty, which cannot be said when even the entire length of both tubes are excised. A case in proof of this statement I have myself seen. The operation can be performed more quickly and more safely, for the patient is spared all the immediate dangers of the puerperium and the more remote dangers of intestinal obstruction and rupture of the uterus, should another pregnancy occur. Finally, the operation--if the Porro's method be adopted-can be approached with more confidence by country practitioners who may possibly have but a limited experience in abdominal surgery, and no skilled assistant.

The rapid removal of the child, a piece of rubber tubing tightly encircling the cervix, two knitting needles placed above the rubber tubing to prevent slipping, the amputation of uterus above the needles, which fix the pedicle outside the wound, constitute a procedure, first described by Tait, not in any way difficult, and giving the patient a fair chance.

It is, of course, understood that except under the above-mentioned circumstances the modern supravaginal amputation of the uterus and retroperitoneal treatment of the stump is infinitely to be preferred to the older Porro's method.

Craniotomy on the living foetus, except in very unusual conditions, is now universally condemned. I remember in the handbook of midwifery which I read as a student—I think it was by Lloyd-Roberts, of Manchesterthere occurred a passage which more accurately translates medical opinion of to-day than it did that of 1878. "The man who would plunge a perforator into the head of an unborn babe would not hesitate, under the cloak of night, to use the dagger of the assassin.”

Symphysiotomy, after a vigorous resuscitation, appears to be again receding in favour, and deservedly so, in my opinion.

The next great advance is, I think, the recognition of the immense value of abdominal palpitation in obstetrics. There is nothing which will give greater satisfaction and bring more credit to the practitioner than knowledge of this subject. By it he can ascertain the presence of twins, the position of the fœtus, the progress of labour, malpresentations of the head-such as occipito-posterior, or brow and thus he is able to avoid useless and injurious attempts to deliver with forceps before the position has been rectified. Finally, all this information, and more, can be obtained without subjecting the patient to the slightest risk, which cannot be said of examination vaginam.

per Since the first Congress, the teaching regarding the conduct of the third stage of labour has been greatly altered. I "teaching" advisedly, for I am inclined to think the practice of a large proportion of the profession in this matter is not in accord with the teaching of the chief schools, and most modern text books.

In looking over my notes of consultations of puerperal sepsis I find that in nearly half these cases there is a history of "some trouble in getting away the placenta," and perhaps "a little hæmorrhage," and the conclusion I have come to is that there is no one factor connected with the management of puerperal cases so potent for evil, so productive of death and invalidism as the forcible and early expression or extraction of the placenta. I am often asked "How long do you wait before expelling the placenta ?" and I answer, "there is no fixed time." So long as the placenta is still in the uterus, and there is no hæmorrhage, one should patiently wait; keeping the hand on the fundus to detect uterine contraction and the movement of the placenta into the vagina, which elevates and makes more movable the upper uterine segment. I have upon one occasion waited one hour and three-quarters, and was then rewarded by the placenta coming away with scarcely any loss of blood.

If I might venture to give a word of counsel to those about to engage in midwifery practice, it would be this: Do not hurry the third stage and you will avoid much worry, loss of time, and loss of credit.

Another matter about which we have altered our ideas is the routine use of the douche before and after labour. We know now that douching is not necessary; that the antiseptic

as if we were entitled to no end of credit. Now such cases are of almost weekly occurrence in the chief hospitals of Australia.

In the diagnosis I have come to attach great importance to a steady drain of dark venous blood continuing for many days in some instances as suggestive of ectopic gestation, and as distinguishing it to some extent from uterine abortion, where the haemorrhage is brighter, and more in gushes or clotted. In the very acute cases, no tumour is to be felt; merely a boggy, tender fulness in the vaginal vault. This is not clearly stated in some text books, and is a matter of great importance.

As a means of clearing up the diagnosis in doubtful cases, I should like to call attention to vaginal cœliotomy. It is practically free from danger, and therefore no harm will have been done should our suspicions prove to be unfounded; while if vascular adhesions be present, as is not infrequently the case, the opening can be used for gauze drainage.

Secondly: In the domain of Gynaecology, no change is so striking as the modern view regarding the treatment of uterine myomata, and the immense improvement in the technique of hysterectomy. Sixteen years ago such cases were generally left until the health had been seriously undermined, and the patient's sufferings were such as to induce her to beseech operation. Koeberle's serre

noed held the field as the method which gave the lowest rate of mortality, but it could not be used in what Lawson Tait called "the terrible cases," those in which there was extensive downward burrowing beneath the