Original Articles.

BY RUFUS W. GRISWOLD, M. D.

When I began looking into medical books preparatory to practice, fifty years ago, the standard authors given us to read were not backward in recommending blood-letting in the acute diseases; and a little later, when an attendant at lectures at the College of Physicians and Surgeons at New York, the professors were not lacking with the like advice. But there has come a change, and so much of a change that, in this section of country at least, the lancet has mostly gone out of use. That the frequent use to which it was put seventy-five or a hundred years ago was not at all times wise is likely; but the extent to which it has been given up is also not wise. Rather more to notice some of the reasons why it has so largely been abandoned than to argue for a reintroduction of that ready and efficient instrument is the purpose of this paper.

A prominent point in the consideration of this comparative abandonment of the lancet is presented in the question: Has there been such a change in the type of the acute inflammatory diseases from three or four generations ago as to render the abstraction of blood less necessary and less useful? There are plenty of sound, hard-headed old doctors who will give a negative reply to this query; and occasionally we may notice some of them putting themselves in print to that effect. A Baltimore practitioner not so very long ago said: “The necessity for the use of the lancet is as great at the present time as it ever was in thepast; the type of the disease has undergone no such changes as to render the abstraction of blood unnecessary or improper in the successful management of all cases attended with a full, tense, and quick pulse.” Others speak the like; but the majority of opinion is not pronounced in that direction, but rather adverse. Conversations during a forty-four years’ practice with men who began their professional calling sixty years ago, when the lancet was in often call, is to the import that therehas beensuch a change in diseases as renders the frequent resort to blood-letting less important than formerly; that there is less of the sthenic type in even inflammatory fevers, a more general disposition to take on what we call typhoid forms, and thus depletion, either by the evacuation of blood or the exhibition of reducing drugs, is not so beneficial in even the acute inflammatory diseases as formerly. This is the view that has been entertained by a large part of those who began practice half a century or more ago, and this view has been sustained by a large amount of written authority; but it does not go to the extent of justifying that degree of abandonment of bleeding that has prevailed for the last forty years. The general opinion of to-day is, that while positions like that taken in the quotation given are too positive, on the other hand ourpracticeis quite too lax; for while we still believe in blood-letting to some extent, we but seldom make use of it. Now as to thewhy.

Perhaps the first reason why the lancet is less used than formerly is found in the fact, or rather in the belief, of the change indicated. It is largely accepted as true by the older men in the profession that patients do not bear blood-letting as well as three generations ago. Accepting this as correct, it rationally follows that we should bleed less. But this is only one of the factors in the account, and not the largest one. The opinion that the physicians of the early part of this century used the lancet too often is beyond doubt correct. The doctrine of the purely symptomatic nature of fever put prominently forward by Brousais, and earnestly championed by active and pushing minds a century ago, and which was generally received in Europe and in this country, gave such an unfortunate impetus to the use of the lancet as finally led to its abuse. Patients were bled for almost every thing; not only for the fevers of acknowledged inflammatory type, such as acute pleurisy and the like, were bled for, but also cases of typhus, typhoid, etc., upon the ground that the fever in the case was only a symptom of the inflammatory action and was to be subdued or lessened by antiphlogisticremedies, chief of which was the abstraction of blood. The theory of the essentiality of fever became lost sight of, and the doctor treated for an inflammation rather than for a fever.

Without giving up the theory in which they had been educated, some physicians began to see that in some epidemics of disease a larger percentage of cases were lost among those where venesection had been used than among those similarly sick who were not bled. The deduction from this was that it would be better to bleed less. But a change was not to be made without a struggle. Reference to the medical literature of the first half of the century shows that there was a deal of warm discussion between the blood-letters and the anti-blood-letters. Out of the observations and discussions made there was cultivated a prejudice, professional to a moderate extent but popular to a large one, against bleedingper se, and without reference to the character of the disease under treatment or to the differing conditions that might exist, which helped to carry the usage from its former abuse at times to the opposite extreme of general abandonment. It is a universal law in nature that the farther the pendulum swings in one direction, the farther will it swing in the opposite on its return. The pendulum of venesection had swung too far forward for the best in the treatment of disease, and the return carried it quite beyond the best in the backward reaction.

Beyond the reasons noted for the present comparative non-use of the lancet, there has been added a pressure of an erroneous and illegitimate nature that has aided to put bleeding under a general ban more unfortunate for the sick than was the former rather indiscriminate use. Somewhat contemporaneously with the warm discussion upon bleeding carried on in the profession, and perhaps partly out of that discussion, there started up in various parts of the country an illegitimate class of practitioners, mostly illiterate and destitute of preliminary culture, interchangeably known as Botanics, Thompsonians, Eclectics, etc., whose chief stock in trade for public acceptance was denunciation, without regard to the conditions that might be met in a case, of leeching, bleeding, blistering, scarification, and other agents for cures. This denunciation found ready public credit. Not only from the mouths of the class named, but in various other ways, the prejudice they sought to create was widely diffused. Outside of the libraries of the profession you seldom see a medical book; anywhere else they have been rarities. But in many sections of the country for the lastsixty years a canvass of the families would show an abundance of books, published for family reading, emanating from irregular practitioners, all of them saturated with lying abuse of the methods of treatment of the regular physicians. These books were loaned from one family to another, much as the weekly papers or the cheap novel; and they were read and believed in. The result was that many who read were indoctrinated with the belief that bleeding, no matter what the disease or the conditions, was not only not necessary, but pernicious, and often the cause of death; and there was little printed contradiction offered to disabuse the public mind of this false accusation.

Co-ordinating with this means of false instruction has been and is the public press. As respectable practitioners do not stoop to the quackery of advertising, the pecuniary interest of the press, so far as means and methods for the cure of diseases is concerned, is identical with the pecuniary interests of advertising quacks. The public press sells itself to the broad diffusion of the ways and means of medical quackery in all its forms. The subsidies of impostors and patent medicine men fill up one carotid artery for the support of the press; and the influence of that press, however weak the intellect that bestrides its tripod, is more potent than a hundred of the ablest men in the profession, for the sufficient reason that the voice of the men in the profession seldom strikes the public ear through the same broad and forceful channel.

The result of the false teaching of the class of books alluded to and of the medical advertising, and of the bleating of the tramping lecturers was that a large part of many communities came to believe that blood-letting was a crime against health, and a hindrance to recovery from disease, no matter what might be the conditions. The average intelligence of even well-educated communities goes no further than to accept the plausible teaching that is every day thrust upon its tympanum; it does not stop to criticise the motives nor to analyze the arguments of the advertiser, nor is it cultured in this direction to the capacity of justly weighing them according to their true significance. The average intelligence of even well-educated communities is not up to that grasp of the science of medicine necessary to determine between false and fallacious teaching and that which is rational and correct; it does not differentiate between clap-trap and honesty; it does not separate humbug from truth, and as an ocean of humbug passes the public gullet easier than an ounce of truth, it is not strange thatthe condition obtaining about bleeding is not so much that the physician has discarded it as improper, or has lost sight of its value in many cases, as that the community will not tolerate him in the abstraction of blood. Public prejudice overrides professional opinion, unless the opinion runs current with the prejudice. To bleed your patient and then have him die is to be damned; if he dies without being bled, no matter whatever else you may do or leave undone, the chances of being cursed are largely lessened. Besides this, very little or nothing is gained against the prejudice by recovery after bleeding, since the popular opinion will be that the patient would have gotten well quicker and better without it—an opinion that can seldom be disproved. Exactly in the same way in any case where venesection has been practiced and the patient does not get well, the opponents of the operation will assert that the bleeding caused the death, and that, in the absence of it, the patient would have got well; which also is difficult to disprove. The average mind proceeds from supposed causes to effects with most unreasonable logic.

As a matter of fact, the whole art of the practice of medicine is involved many times in many uncertainties as to the effects that are to follow the administration of drugs or the institution of any procedure, however simple, that it may puzzle the most sagacious to determine the exact weight of any factor introduced, whether it be for good or for ill. It should not therefore surprise us that to minds quite unacquainted with the therapeutical effects of blood-letting in disease, a death that follows a bleeding, however remote in point of time, should be credited to the operation rather than to the disease for which the operation was performed. An uncertain percentage of cases of many acute inflammations will recover, whether bled or not; an uncertain percentage of them will die, whether bled or not, and no matter how treated; and, while it will sometimes happen that of two cases of the same disease the one that is bled will get well and the one that is not bled will succumb, it will the next week happen that of two other cases of the same trouble the one that is bled will slip off and the one not bled will hold on finely. And it is a notorious fact that in some communities, if a patient is bled and then dies, nine out of every ten persons in the neighborhood will say, and part of them will believe, that the bleeding was an accessory if not the chief cause of the untoward event; and it is usually quite impossible for the doctor to show that the nine are not right in their view of the matter.

Under these circumstances it can hardly surprise us that the use of the lancet has gone out of fashion. It is not so much that we have less faith in its beneficence, rationally employed, as that our patients are opposed to it. Whether in spite of the opposition we should employ it oftener than we do is a question that every one must settle for himself. It might be possible for a bold and determined man to work up that road to confidence with his patients in it, but the path is so beset with difficulties that a hundred will fall by the way where one succeeds. A single death after phlebotomy will do more to impede the success of a young man in the profession than a dozen deaths without it; it is wise therefore to be cautious in the use of so potent a remedy, and to sin less in commission than in omission of opening a vein. It may be said that whether he succeeds or fails it is the duty of the physician to do in all cases what he thinks will be the best for his patient. This position may have its merits but it is a better thing to teach than to act upon. There is no law of right that demands of the practitioner that he shall assume the responsibility of the stupidity and ignorance of all his patients, and, worse still, of all the irrational prejudice they have allowed themselves to imbibe, and which no amount of logical facts will dispossess them of.

The writer, in the nearly fifty years of his practice as student and graduate, has had an average share, perhaps, of his patients die; but he has never had one die of any sort of fever after he had been bled as an aid in subduing that fever. On the other side, he has had patients die of the acute inflammatory diseases when they have not been bled; and, to-night, recalling those cases, he is of the opinion that some of them, if they had been well tapped in the arm at the outset of the sickness, they would have been saved.

Rocky Hill, Conn., December, 1897.

TAKA-DIASTASE IN THE TREATMENT OF AMYLACEOUS DYSPEPSIA.

BY WALTER P. ELLIS, M. D.

Pepsina porci, the pepsin of the hog, was one among the first of the animal products to be used in medicine, and many physicians, not well versed in organic chemistry, supposed that in it they possessed a sovereign remedy for indigestion in all its forms and stages, and the confirmed dyspeptic had only to apply the specific to have his digestive apparatus restored to its youthful health and vigor. Unfortunately for this view and for the sufferers, the fact was overlooked, or not duly appreciated, that pepsin is only one of several substances which Nature employs in the complete digestion of food, and that the products or secretions of several different glands have a part in the process, each of which is essential to the proper preparation of food for the nourishment of the human body.

It has been estimated by competent observers that as great a proportion as seventy-five per cent of all the intractable cases of dyspepsia in this country are caused primarily by faulty saccharification of the starchy foods which constitute such a large portion of the diet of the American people. This being the fact, is it any wonder that the administration of pepsin alone should fail to give relief in many cases? It fails because the fault lies, not in the stomach, but in the salivary and other glands whose secretions possess the amylolytic property, and the remedy is the administration of substances that will restore that property to the secretions, or which possess it in and of themselves.

Until quite recently the practitioner was compelled to rely for this purpose upon the various malt extracts upon the market, the diastatic power of which was so feeble that the service they rendered was but slight. What was needed, and for which many of the most patient investigators were searching, was a diastase which would do for the starchy elements of the food what pepsin does for the proteids. The digestion of food in man has been the subject of much patient and methodical study and investigation during the last two decades, notably by Ewald, Kellogg, Hayem, and Winter, and others, resulting in the placing of the therapeutics of disordered digestion upon an exact scientific basis. It is not, however, necessary for the purposes of thispaper to go very deeply into theminutæ; a superficial survey will suffice.

Digestion begins in the mouth with the act of mastication, the presence of food in the mouth, or even the thought of it, acting upon the salivary glands to produce a free flow of saliva, which, being thoroughly incorporated with the food by the act of mastication, exerts its peculiar influence upon the starchy constituents, converting them into dextrose, maltose, etc. This amylolytic action lasts but a short while, the ptyalin of the saliva being active only in neutral or slightly alkaline media; consequently when the food reaches the stomach and peptic digestion begins, its effect ceases.

The saccharification of the starchy elements of the food before reaching the stomach serves to separate or disentangle them, as it were, from the proteids, and deliver the latter to the stomach in the condition most favorable to the action of the gastric ferment or pepsin.

The stomach, after a variable length of time, during which the peptic ferments accomplish their allotted task more or less thoroughly and completely, delivers the resultant mass over to the small intestine, where the secretions from the pancreas, liver, and intestinal glands, by finishing the transformation of the starch begun before the stomach was reached, emulsifying the fatty constituents, etc., complete the complex work of digestion.

It will be seen from the foregoing that the derangements of digestion may, for ordinary clinical purposes, be divided into three classes, each of which is distinct from either or both of the others, although they shade into each other by imperceptible gradations, so that there are no well-defined boundary lines separating them. The first class includes all those cases which are characterized by a deficiency, in quality or quantity, of the salivary secretion, and a consequent failure of or interference with the digestion of the starchy elements of the food—amylaceous dyspepsia. The second includes those in which there is difficulty in the digestion of the proteids, due to a variety of causes—gastric dyspepsia. In the third is placed those cases in which the trouble is located below the stomach, and are caused by inability of the pancreas and other glands to normally perform their function—intestinal indigestion.

One constantly meets with cases belonging to each of these varieties, and he must correctly diagnose each case if he would apply the treatment necessary to produce the best results. For the present, however,we have only to do with the first variety, as my object in the preparation of this paper is to direct the attention of the profession to a new diastatic ferment which acts with as much or even greater energy upon the amylaceous foodstuffs as does pepsin upon the proteids.

Such a substance has long been a desideratum with those who treat many dyspeptics, and who have been compelled to content themselves with malt extracts with which the market is supplied. The substance referred to was discovered by a Japanese chemist, Jokichi Takamine, not as the result of accident but while working scientifically with that exact end in view, and is now supplied to the profession by Parke, Davis & Co. under the name of Taka-Diastase. The writer has had frequent occasion to use it since it was first brought to his notice about a year and a half ago, and in that time has not had a single case in which its administration was not attended by the very best results. Notes of several cases were kept, three of which will be presented here as the most appropriate conclusion.

Case 1.L. A., white male, age thirty-eight, a barber by occupation, consulted me first in the fall of 1894. He was at that time, as he had been for several years, the victim of a most obstinate and intractable form of dyspepsia. He had been a coal miner until forced by ill health to quit that for some lighter occupation. He, however, continued to grow worse until, when coming under my care, he was very much emaciated, weak, nervous, and irritable, his stomach unable to retain any thing save the blandest articles of diet, and those only in small quantities. Treatment was begun by regulating his habits, diet, etc., and putting him on an emulsion of bismuth subnit. and pepsin pur. immediately after eating, and tr. nux vom., hydrochloric acid, and tr. colomba before eating. His condition improved somewhat under this treatment, but only to a limited extent, and it became evident that more efficient measures must be resorted to if we hoped to accomplish permanent good. It had been noted that a meal, however scant, composed mainly of starchy substances was always productive of an acute attack, and acting upon this suggestion extract of malt was added to the remedies he was using, and, to a certain degree, with good effect. He, however, did not go on to complete recovery, but the improvement ceased at a certain point, and in spite of continued treatment with the remedies mentioned his condition remained about stationary. Unable to work, morose, cross, and irritable, existence was a burden to himselfas well as family and friends. At this juncture my attention was attracted to Taka-Diastase and a supply was at once procured. The patient was given a number of capsules containing five grains each, with instructions to take one capsule at the beginning of each meal, continuing the bismuth and pepsin mixture as before, immediately after eating. In a very short time improvement was discernable, and from that time was rapid and continuous. The treatment was kept up, with the addition later on of ferruginous and bitter tonics, until there could be no doubt of his complete and permanent restoration to health. He has now been at regular work in the shop for several months, and says that he “never felt better in his life.”

Case 2.Mrs. J. H., a white woman, aged forty-six, wife of a well-to-do farmer. Until within the last year or two had enjoyed the best of health, and was inclined to stoutness in consequence. Dyspeptic symptoms had troubled her more or less during the time mentioned, and of late had increased in severity so much that she asserted, at the time she consulted me, that if she dared to eat any thing at all she suffered the greatest agony in consequence. A neighboring physician had treated her for some weeks previous to her visit to my office, and, as I afterward learned, had given her the regulation treatment with pepsin, bismuth, hydrochloric acid, etc., with results so discouraging that she had lost all hope of receiving any benefit from “doctor’s medicine,” as she called it, and it was only at the urgent solicitation of husband and friends that she came to me for treatment, being careful to inform me that she had no idea I could help her in the least.

Her case was diagnosed “amylaceous dyspepsia,” and she was given Taka-Diastase in eight-grain doses, half of which was to be taken before eating and the remainder during or after, with tr. nux vom. and hydrochloric acid, in moderate doses,ter in die.

Despite her determination not to be benefited by “doctor’s medicine,” the improvement was prompt and continuous, and so manifestly due to the treatment that she soon forgot or overcame her antipathy, and with characteristic inconsistency now asserts that it is impossible to get along without it. She eats three meals regularly every day, and suffers no inconvenience whatever in consequence.

Case 3.W., a white male, aged forty, had never had any serious illness, and digestion had been especially good until about four weeks before consulting me. At that time he, in company with some friends, ate quite heartily of watermelon. He had always eaten watermelonfreely and with impunity prior to that occasion. It did not agree with him so well that time, and in a few hours he was seized with an acute gastralgia of the most severe character, and from that time to the present he has had more or less trouble of that kind, even a very small quantity of food, especially if it be of a starchy nature, giving rise to the most distressing symptoms.

The diagnosis of amylaceous dyspepsia was also made in this case, and he was at once put upon the Taka-Diastase in doses of five grains given with the meals, and temporarily excluding starchy foods from his diet as much as possible without too great inconvenience. There was also great torpidity of the liver, and for that he was given sod. phosphate in teaspoonful doses every morning before breakfast, taken in a gobletful of hot water. Under this treatment improvement was satisfactory and rapid, and with the addition of bitter tonics later on he was ultimately restored to complete health.

Remarks.Case 1 was an example of that class with which, prior to the introduction of Taka-Diastase, the general practitioner was too often compelled to acknowledge his inability to cope successfully. In them there is difficulty in the digestion of both amylaceous and proteid substances, and the remedies usually recommended were efficacious only so far as digestion of the latter was concerned, and did not reach the former at all. The cure was incomplete, and must have remained so until the substance we have been considering, or something analogous to it, was furnished the physician with which to complete it.

Cases 2 and 3 were examples of the first class mentioned above, viz., amylaceous dyspepsia, and while under treatment with pepsin, etc., they were considered the most intractable of all; under Taka-Diastase they yield rapidly, and are cured in a surprisingly short time.

Livermore, Ky.

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