THE FUTURE OF THERAPEUTICS. The Annual Address to the Detroit Medical and Library Association, Delivered on October 4, 1885. DAVID INGLIS, M.D., PROFESSOR DISEASES OF MIND AND NERVOUS SYSTEM DETROIT COLLEGE OF MEDICINE. Reprinted from the Journal of the American Medical Association, November 28, l88j. Printed at the Office of the Association. CHICAGO: i886. THE FUTURE OF THERAPEUTICS. The Annual Address to the Detroit Medical and Library Association. DAVID INGLIS, M. D., THE RETIRING PRESIDENT. Qentlemen:-Another year in the history of our Association brings us to-night to a point of observa- tion from which we naturally look back to note progress made, and forwards to plan how best to fulfil our coming duties and opportunities. In such a retrospect perhaps one of the most striking facts, and one of which our Secretary's interesting statistics make no note, is that during the entire year of active work in the Society there has occurred no instance of animosity or contention between members, but rather we have harmoniously worked together. Therein, I conceive, lies a valuable lesson as to the uses and value of a medical society. We are proud to count a membership of ninety-five active members, but prouder to show ninety-five physicians who have put aside personal animosities and united in a common effort for a common good. The expe- rience of such a society also demonstrates that much of the ill feeling which arises among medical men can be obliterated if they will but come in contact with one another. There is a treasure of philosophy in the statement that " no man is as good as his best deed nor as bad as his worst." Our professional life is, in its nature, one of an unusually personal character, and we are, all of us, in danger of taking too per- sonal a view of events. We are too much in danger of judging some professional brother by his worst act. It has happened, not once but repeatedly, in this Association, that meeting as we do, in a more general relation, some of us have learned that others are by no means as bad as our worst act had seemed to indicate. On the other hand, such a society just as_*ttrely tends to bring out the fact that we are, none of 2 fully as good as our best deed. This process of fric- tion, while sometimes disagreeable to the subject, is uncommonly salutary, and tends to a higher average of good work. In a word, the year's work has brought about an increase of good feeling, and pro- moted many friendships. It would be a great gain to many localities in the State, if working medical societies were formed and existing societies vitalized into more generous life. As part of the retrospect of the past medical year, it might be stated, that an amendment of the organ- ization of the State Medical Society has been pro- posed by which that Society shall be changed into a delegate body. It would seem to be a long step in advance, as tending to compel the formation of local societies and to raise the value of membership in the State Society. The great need of our profession is unity-no other profession allows personal animosity to so weaken its power as does our own. So, we should hold up our Association as a living example, yet modestly withal, for there are others in the same station. Indeed, to-night it is our great pleasure to welcome, as we do, so many members of our local sister societies. It is a pleasant testimony to the growth of friendly feeling that we can thus come together. While we each pursue our work in the coming year, let us carry ourselves simply as regiments in the same brigade, each jealous of our own honor, but all engaged in one purpose. To the gentlemen from neighboring cities, as well as the unattached of our own, we give a cordial wel- come, and are honored by their presence. In reviewing the past year, there is one fact which can well be, mentioned with pride, and that is, the number of pathological specimens which have been presented; enough, indeed, to have furnished working material for a good pathological society. Such an amount of material indicates increasing thorough- ness of scientific investigation on the part of our members, and ought to serve as a reminder that we can, with much advantage, during the coming year, 3 devote more time to pathological discussion. It also recalls the fact that a large part of the reported cases met with in the journals are shorn of half their value by the statement, "no post-mortem was allowed;" nothing confirms a diagnosis like a post-mortem ex- amination. Sometimes it disproves the diagnosis. In the year's work of the Society, one element has done much to maintain the interest and promote vigorous life. I refer to the plan of having set debates appointed. This plan seems to be unusual in medical societies, but its working has proved most successful; there is an unmistakable freedom of ex- pression and criticism, and much is gained by the vigorous discussion of both sides of a question. In a retrospect of the year's work, and contem- piating it, as we do, with pleasure, I cannot forbear embarrassing our Secretary by a testimony to his unfailing zeal, and attributing to him, in greatest measure, our success. And our retrospect brings to our minds that which the years unfailingly bring, the gathering of the ripened grain. We are all conscious that our work and our efforts are but part of the necessary growth of life, and " the end crowns the work." We ought to look forward pleasantly to the time of its completion; and, indeed, it is with pleas- ure that we recall how nobility of character in each, crowned lives which, in their short space, were of benefit and pleasure to us and to all whom they influ- enced. Yet the fields look barren in the autumn, and we could wish that Reynolds's cheery voice and good judgment and Pease's hearty good-will to everybody were with us yet. There are many other things which such a retro- spect suggests, but it is to the future I would call your attention. What are the duties and opportuni- ties which lie before us? To such a question there arise many answers, but from among them I would dwell upon one WHAT IS TO BE THE FUTURE OF THERAPEUTICS? It is obvious that much of the scientific work of the day is done by men who entertain but slight 4 regard tor faith in therapeutics, who themselves seem not to possess such a faith, and whose writings and statements of facts are such as to foster skepticism in regard to therapeutic possibilities. It can hardly be denied that, as a result of this, there prevails, in certain quarters, a more or less pronounced skepti- cism, and that among practising physicians. Now, the blame for this state of things does not lie wholly at the door of those pathologists who can conceive of no disease which does not have its origin in some demonstrable lesion, some atrophy or malformation, and who pass over functional diseases with contempt or an apology; but this lack of faith originates, fully as much, from the one-sidedness and the inefficient methods of therapeutical investigation itself. It is a good deal here as in religious matters; many people will not join the church on account of the claims of the world, the flesh and the devil, but about as many more keep out because of the inconsisten- cies of those who already are church members. Now, it behooves us, who have faith in therapeutics, to mend our ways. And, to my mind, the first thing to be done is to more accurately define and establish the place of action of our various drugs. While it is obviously true that, the body being a whole, general bodily states in many cases give the indication for treatment, yet it is also true that not only in diseases distinctly local, but also in general systemic diseases, our therapeutical endeavors are directed to localized functions. Instances could be given without num- ber, but the mere mention of the fact suffices. In anaemia, rheumatism, scrofula, the various fevers, and, indeed, in about all the general diseases, the constant demand upon the physician is to modify the function of one or other organ. Herein, I conceive, lies the success of the skilful physician; of many physicians using the same general group of drugs, one will achieve better results than the rest simply by a more accurate judgment of the adaptation of the remedy. This brings us .to the consideration of the next thing which ought to be done, namely, we should 5 more thoroughly work out the detailed symptoms of each case. It is much easier to formulate in our mind certain gross symptoms and, coupling them with certain physical signs, make a diagnosis of a disease, than it is to bear in mind, beside the grosser symptoms, the lesser manifestations, the finer shades, and to make the diagnosis thus: A patient in a cer- tain condition. If we hold in our minds the idea of a pneumonia, for instance, we are not far from falling into some routine treatment ofpneumonia; but if we have in mind the patient with a process going on which not only, tangibly enough, interferes with the function of respiration, but, just as certainly, with the functions of the nervous centres, the digestive, glandular and circulatory organs, and that the danger may make its appearance at any point, we will not only find indications for prognosis in the varying lesser symptoms, but still more important indications for treatment. In other words, we have fallen lament- ably behind in the study of symptomatology. The most cogent claims which medicine makes to be considered as one of the sciences are based upon the accumulated facts of pathological and physio- logical research. The pathologist, in spite of his therapeutic skepticism, has just cause for pride; so, too, has the surgeon. Time was when the surgeon- barber was held in low esteem, but our surgical breth- ren not only claim for themselves, but are credited by the laity with the highest place. Their claim is based like that of the pathologist, upon accumulated and unquestionable facts. Now it would seem that the only permanent basis for a scientific Therapeusis is to be found in an exact knowledge of two kinds of facts: first, what is the precise effect of a drug upon the functions of healthy organs; and secondly, what is the effect upon organs whose functions are already disordered ? 'rhe first class of facts are being accumulated in a gratifying manner by a number of competent investi- gators; the second class must, in the nature of things, be accumulated by the practitioners in direct contact 6 with the sick. Such men as Dr. H. C. Wood, in in- vestigating the first class of facts, pursue a very defi- nite course. The drug to be studied is used alone, of definite strength, accurate dosage; phenomena observed are recorded with accuracy and verified by many repetitions. Suppose we apply that plan to our purposes as practising therapeutists. Is it not evident that it would work a revolution in the methods of practice, and in the place of therapeutics in medi- cal science! It would first do away with complicat- ed prescriptions; it would compel the physician to pay attention to the quality of the drug used, he would ascertain how long it had been kept in stock, the reliability of the manufacturer, and the accuracy of the dispenser. He would be compelled to note accurately, not in his fallible memory, but in records which could be referred to again, all the variations both in the symptoms existing when the drug was first administered and the modifications of the symp- toms produced by the drug. 1 do not say after the drug was given, but " produced by the drug," for by this plan we would soon reach that certainty which constitutes a fact. It may be replied, that all these things are being done already, and I grant that here and there are men who are following out these lines, and who can justly claim to be scientific physicians; but a perusal of the insufficient notes taken by those whose notes become public in connection with reported cases, and a single thought of those who never take notes at all, establishes the fact that general practitioners have not yet fairly taken in hand the problems which general practitioners can only solve. On the con- trary, there is abundant and painful proof that the profession as a whole is seriously retrograding. We have just said that the scientific physician is one who accurately applies his remedies to accurately ob- served conditions to produce constant results; what shall we say of physicians who prescribe patent med- icines ! I do not refer to " Dr. Pierce's pleasant purgative 7 pellets," or " Ayer's sarsaparilla," or "Dr. Hartley's great South American cure." We all agree in our condemnation of these and their kind, their makers and their makers' methods. There may be some virtue in them, probably is; but not knowing their component parts, we cannot tell of their proper uses. They are vaunted to cure such a multiplicity of dis- eases that we at once deny the claim. They are advertised in what we consider an obnoxious manner; we will none of them! I hold in my hand some in- teresting medical literature. The first specimen is got up in somewhat startling red type, and is a treat- ise on nervous diseases. Celerina, I find therein, is of inestimable value in over fifty different diseases. It would take too long to mention them all, but a host of letters from the afflicted prove, among other things, that, to say nothing of spermatorrhoea, impo- tency and allied nervous diseases (?) locomotor ataxia, malignant jaundice and mollities ossium gracefully yield to this compound, which we are told contains in each fluid drachm the equivalent of "five grains each of celery, coca, kola, viburnum and aro- matics." The neurologist's occupation is practically gone! Here I hold a volume upon "Aletris Cordial." I do not know what is in aletris cordial, but seventeen diseases acknowledge its sway, and with seventeen gynecological diseases (among which, curiously, is typhoid fever) counted out the gynecologist is left but a stubble-field. We are not quite sure what con- stitutes " Fellows'Syrup of Hypophosphites," but a beautifully-bound series of text-books upon " Nerv- ous Diseases," " Pulmonary Diseases," etc., informs us of its remarkable effects in forty-six different diseases. These are great in themselves, but they pale their ineffectual fires before " Dr. Hayden's Viburnum Compound." A similar obscurity hangs over the contents of this prescription, and words fail me in giving any adequate account of its virtues. Caulo- coreB, lodia, Horsford's Acid Phosphates, Listerine, 8 Tongaline, Dyspepsine, Quineptus* Morrholine, Ne- phrilene, Asthmaticine, these and many more keep our medical journals alive in more ways than one. I do not need to go further; the plain and pitiful fact stares us in the face from nine-tenths of the medical journals, that the medical profession has allowed itself to become debauched; it has abro- gated its function, and it is impossible to draw auy line between the nostrums which the people buy and those which many physicians prescribe. I add Ayer's and Hostetter's almanacs to the pile; they are, on the whole, rather more modest than some of the others. No, gentlemen, it is high time that we enter our protest, and that we, each of us, purge ourselves. The present methods are unjust to the people, for they are entitled to scientific therapeutics at our hands, and to just prices for their medicines. (That they pay an unjust price is evident from the fact that one firm engaged in the manufacture of one of these articles is said to have paid last year, a dividend of 75 per cent, on its capital stock.) These methods are unjust to our pharmacists, for they cannot con- duct legitimate pharmacy at a fair profit. These methods are unjust to ourselves, for we are lowering the standard of our professional life. The future of therapeutics will be this: The pro- fession will find that using and recommending private and semi-private formulas, as well as the vast array of elixirs of unknown strength and composition, will result in serious detriment to all parties concerned, and self-preservation will compel recourse to scien- tific therapeutics. Let us all begin now.