REVIEW OF THE AIMS & METHOD OF INTERNAL MEDICINE


The care of the sick is one of the greatest problems that has confronted the human race since its very beginning. There have always been sick people. Even among primitive people there are those who are injured by accidents of various sorts, bitten by snakes, or who contract infections and so from the very beginning of the human race this problem of taking care of sick people has been an important one.


Introductory Address Delivered Before the Senior Students.

of the Hahnemann Medical College, Philadelphia.

G. HARLAN WELLS, M.D., F.A.C.P., PROFESSOR OF MEDICINE

You gentlemen are about to start your work in internal medicine in the Medical Wards of the Hahnemann Hospital. I think that I am justified in saying that this is the most important work that you have to do in your career as medical students. The kind of work that you do at beside of patient will determine whether or not you are fit to be a doctor.

Some of you will be surgeons, and I hope good ones, some, obstetricians, and a few will be nose and throat specialities, but all of you should have a basic training and a basic experience in general medicine; and it is here in the Wards that you must get that experience.

I think that it is important for us to consider first, “What is the duty of a doctor ?” Well, that has been very clearly defined for us by Hahnemann in the opening chapter of the Organon, when he said very concisely, “The duty of the doctor is to heal the sick”. Later there has been added “and to prevent disease”. In these two statements are contained “all the law and all the prophets” as far as the duty of the doctor is concerned.

The care of the sick is one of the greatest problems that has confronted the human race since its very beginning. There have always been sick people. Even among primitive people there are those who are injured by accidents of various sorts, bitten by snakes, or who contract infections and so from the very beginning of the human race this problem of taking care of sick people has been an important one.

Lucretius, describing the sick of his day, states that “with cries and gestures they taught with broken words that it is right for all men to have pity on the weak.” Dr. Osler quotes the well- known medical historian Dr. Payne saying “The basis of medicine is sympathy and the desire to help others and whatever is done with this end in view must be called medicine.”.

You have heard a great deal about the medical sciences, but I want to say definitely to you now, what I have said many times before, there is no such thing as the science of medicine. The practice of medicine is an art. There are medical scientists, but they are not doctors, in the sense that Hahnemann had in mind when he described the duty of a physician. The doctor is not only a medical scientist, but also a keen and sympathetic student of human nature, with the ability to apply the practical facts of science to the needs of the individual patient for the sake of getting him well or of relieving his distress.

The problem of the doctor is a much more difficult one than that of the medical scientist. The medical scientist deals in the main with chemical, anatomical, and pathological problems. The doctor deals with human problems. The doctor does not treat diseases. He treats people who have diseases.

Unless he has an understanding of people, unless he is able to impress with his sincerity and with his sympathy for their suffering he will never succeed in the practice of medicine. He may know all that there is to be known about the science of chemistry, of anatomy or of pathology, but he will never be a successful doctor, “The physician,” said Socrates, “must treat the whole man, body, mind and soul.”.

If you want to know what the average patient expects of you, as a doctor, all you have to do is to get a good old fashioned bellyache. Your one desire is to get relief. You dont want a doctor who is going to make a diagnosis, and then perform a post- mortem examination on you to see whether he is right. You want somebody who will relieve your bellyache. Now what you want is what every other sick man wants, and he is only interested in diagnosis in diagnosis in so far as that helps you to get him well or to relieve him of his symptoms.

In internal medicine, we have a certain technique or plan in order to attain this ultimate purpose of medicine, which is the healing of the sick, and we being by what we know as diagnosis. Diagnosis, of course, in the broad sense is an attempt to evaluate the physical condition of the patient for the purpose of determining why he is ill. It is much more than labelling a disease by a specific name.

It isnt necessary for me to spend much time impressing on you the importance of diagnosis. In the first place, diagnosis is necessary from a legal standpoint. People with diphtheria, small- pox, and with similar diseases are not allowed to roam the streets because they are a menace to the community. Therefore, the law places upon the doctor the responsibility of making a diagnosis for the purpose of protecting the community.

Secondly, diagnosis is important in order that you may be able to give intelligent answers to the patient and his family. One of the first questions that you will be asked when you enter a sickroom is, “Doctor, is Mary going to get well ?”

Or you may be asked, “How long is she likely to be sick ?” Now, if you dont know whether Mary has “a cold,” or ordinary bronchitis, or influenza, or tuberculosis, or typhoid fever, how are you going to answer those questions intelligently ? You cant. Therefore, in order that the patient may be given satisfactory answers and may have some confidence in your experience and ability, it is necessary for you make a diagnosis.

And lastly and very important, a diagnosis is necessary in order to apply proper treatment. It is true that we sometimes get people well, or people get well, when the doctor has no idea of the nature of their malady, but in the majority of cases, a proper diagnosis is an important step in the application of proper treatment.

I recall a boy some years ago who was brought here with a discharge from the nose. The doctor had prescribed very carefully for him, but the boy did not improve and finally he was examined by one of our rhinologists who found a sand-burr in his nose, This boy was from Jersey, as you may have suspected. When the sand-burr was pulled out of his nose, the indicated remedy worked, but until you got the sand-burr out of his nose, you might have prescribed all the medicine in the world with no effect.

We have heard in the past that a homoeopath doesnt need to make a diagnosis. He simply prescribes the remedy, and the patient gets well. Well. I wont waste much time in discussing that problem because a man who makes that statement knows very little about medicine and very little about homoeopathy.

Hahnemann told us that it is necessary for us to know what is curable in disease before prescribing a drug. That applies not only to homoeopathy, but on all kinds of therapy. If you dont know what the disease is, how are you going to determine what is curable about it ? So it is just as necessary for a homoeopathic prescriber to make a diagnosis as it is for a surgeon or any other therapeutist.

Very properly diagnosis is the first step that we must take in the handling of sick people. There are doctors who say, “When I make a diagnosis, I make a diagnosis, I have no further interest in the case.” That kind of doctor never will get very far, because the patients interest only begins at that point. It is folly for me to tell you, if you are suffering from an acute biliary colic, that you have gallstones, and then walk out of the house.

You want to get relief from the pain and, therefore, the diagnosis in important to you only in so far as it leads me to determine what should be done to relieve you, If I dont relieve you, and you are an intelligent person, you will get somebody else who will.

The influence of doctors, in any community, depends upon the fact that they bear in mind they are there primarily to help sick people; and whenever doctors forget their true function people lose confidence in them. They seek the help of people who are not scientific physicians at all, because these people at least try to do, or promise they will do, that which the doctor neglects.

The doctor who loses interest in the case when he has made a diagnosis isnt a doctor at all, he is merely a medical dilettante.

When we come to the question of therapy, we must bear in mind that there are a great many methods of healing sick people, and all of these methods have their proper place. We have been condemned by some, especially in the past, because, they said, “You dont teach enough homoeopathy at Hahnemann.” There was a time when almost the entire practice of medicine consisted in the administration of drugs. A physician was a person who gave drugs, and the bulk of medical care centered around the administration of drugs.

That time has passed. Drug therapy of any type today occupies a more or less secondary place in the treatment of disease, and we have to utilize in the care of the sick, any method of therapy that is likely to help. As a matter of fact, I believe we teach a broader range of therapy in this institution than is taught in most of the medical schools in this Country, because we have for years endeavored to teach every method of medical therapeutics, as well as any other methods of therapeutics, that has proved to be of value.

There are very few medical schools that do that. We have been called sectarian by some, but actually we are more catholic, as far as our methods of therapy are concerned, than most medical schools that I am familiar with.

For some years I happened to be Physician-in-Chief of a large hospital near Philadelphia where we had medical interns from almost all the medical schools in this Country, and I was surprised to learn how limited was their knowledge of medical therapeutics. For example, I recall one day having a case of influenza in the Ward. I said to the intern, who happened to be a graduate of a Class A medical school, “I think we ought to give this man gelsemium.”

He replied, “Whats that, doctor ?” I said, Did you ever go to a medical school ?” “Oh, yes, for four years, but I never heard of gelsemium.” I said, “Dont you know that the Pennsylvania Board of Health, a few years ago during the great epidemic of 1918-1919, sent a letter to all the doctors in this State, asking them if they would not prescribe gelsemium for cases of influenza instead of aspirin and codeine ?” He said, “I heard of that.” I said, “You dont even know what that medicine is ?”

He said, “No.” I said, “If I had a student in my class who didnt know what digitalis was or who didnt know what morphine was, Id feel very much abashed; and yet when you learn of a drug that the State Board of Health has asked the doctors of this State to administer to people because of its curative value, you dont even know what it is !”.

The essence of sectarianism is that a physician has one method which he tries to apply to every form of disease. There is no one method of treatment that applies to everybody, and the best doctor is not the man who takes pride in the fact that he knows only one method of treating people, but is the man who has the widest knowledge of various therapeutic measures and applies each when it is indicated.

If we begin with drug therapy, and that is, of course, an important part of medicine, it is common knowledge that there are various methods of drug therapy. First, I want to refer to what is known as the antipathic method. The antipathic method is the administration of a drug which has an effect that is the opposite to that of the disease. For example, if a man is suffering from constipation, we give him Epsom salts, because Epsom salts produces diarrhoea; if he has diarrhoea, we give him opium, because opium has the effect of producing constipation.

This is what we know as the antipathic method, a method that is very old and at times a very effective method of treating illness. It, of course, has great limitations. For example, what is the opposite, of a headache ? The fact that you dont have a headache isnt the opposite of a headache. And what is the opposite of a pain from a gallstone? Well, there is no opposite. So it is a method which has very definite limitations not only because there are no opposites for many symptoms but also because the production of the opposite condition may not be helpful to the patient.

For example, if a patient has a diarrhoea that is the result of uremia and I give him opium to constipate him. I stop the diarrhoea, but I may kill the patient. If the patient has typhoid fever with a temperature of 104 degrees and I give him phenacetin. I many reduce his temperature to 97, but the patient will probably die. So you see there are a great many limitations to this method of therapy, valuable as it may be under certain conditions.

Next we have what is frequently spoken of as the allopathic method. Now the law of the State of Pennsylvania provides for homoeopathic, electropathic, and allopathic representatives on the State Medical Board, but if you want to get the graduate of the average medical college mad, just refer to his method of prescribing drug as “allopathic.” It is very much like flaunting a red flag in the face of the proverbial bull. There are a few words that offend the average doctor, “Homoeopathic” is one and “Allopathic” is another. There is no scientific basis for such an attitude as they are both perfectly proper and scientific terms by which to designate certain types of drug therapy.

The allopathic method is the administration of a drug, chiefly for its palliative action, without any definite known relationship existing between the effect of the drug, and the disease to be treated. For example, for many years the Peruvian Indians found that if they gave Cinchona bark to people who had malarial fever they got well. They did not know anything about quinine or about malarial parasites. They just knew if you swallowed this bark, a certain percentage of the people got well of the disease.

To-day when a person has syphilitic gumma of the brain and shows certain types of paralysis, we give him potassium iodide; the gumma in the brain is absorbed and the paralysis disappears. We dont know why; we simply know that it does. There is no particular physiological action of potassium iodide that would suggest to you that if a man had gumma in his brain or liver it would disappear under the administration of potassium iodide. This is what we call the allopathic method. It is more or less empirical–a method of trial and error.

This method has often proved to be of great value in therapeutics. It is a method that has been used in medicine for many hundred of years; and we have some very effective drugs that are applied in accordance with this method. Some of them are curative, but mostly they are palliative.

Now we come to another method–the use of what we know as antipathogens. Antipathogens are medicinal agents that are used for the destruction or the elimination of the cause of disease. The other methods of treatment that I have referred to are largely palliative. For example, you have a cough, and I give you a half grain of codeine. That relieves the cough, but it doesnt cure the bronchitis that causes the cough. Or you have a boil on your neck, and I give you a hypodermic injection of morphine. I relieve the pain, but that doesnt cure the boil.

There are a number of antipathogens, and first I wish to discuss is the homoeopathically indicated remedy. The homoeopathic method is based upon the conception that the administration of an agent capable of producing symptoms similar to those from which the patient is suffering, will bring about in the cells of the body a vital reaction which will result in the production of antibodies or substances antagonistic to the disease.

Probably the simplest and best known example of this method is the use of vaccination against small-pox. Here we take a minute particle of the cow-pox vaccine, inoculate the skin and there is produced in the body a cellular reaction resulting in the formation of antibodies that protect the patient against small-pox.

You can readily see that the drop of material that we put on the patients arm does not stimulate his heart, or his liver, or his kidneys, or his nervous system, nor does it circulate around in the blood for the next fifteen years and kill the germs of small-pox that may come along. That is inconceivable, but we do know that the minute quantity of cow-pox virus produces in the living cells of the body a curative or protective reaction, and the curative or protective substances are formed by the living cells. So we have what we call a dynamic or vitalistic reaction.

Now homoeopathy is not limited, as many people imagine, to the administration of sugar pills. Homoeopathic remedies can be given on sugar pills, or in powders, or in liquid, or by hypodermic injections, or intravenous methods. There are a variety of ways by which it can be given, but the basic principle of homoeopathy is the stimulation of living cells to curative reactions; and such reactions can only be induced in accordance with the principle of “similars”.

For example, if I want to protect you against small-pox, I cannot use organisms of typhoid fever, I must use the virus of small-pox itself or of cow-pox, which is a very similar disease. If I want to produce antibodies against the organism of pneumonia and its toxins, I must start by inoculating with the pneumococcus and not with the diphtheria bacillus. In other words, I must proceed on the principle of similars, and the basis of all vaccine and serum therapy is pure and simple homoeopathy.

Another important method of antipathogenic therapy is chemotherapy. By chemotherapy we mean the introduction into the body of certain chemical substances that will inhibit the growth of organisms or antidote their toxins. Of course the most brilliant example of chemotherapy we have today is the sulfanol compounds, certain concentrations of which in the blood will destroy or inhibit the growth of the pneumococcus, the streptococcus and other bacteria. In this type of therapy the living cells play no part.

If we could get all the pneumococci that are in the body of a man who has pneumonia, in a test tube and pour the sulphopyridine solution on them, it would be the ideal way to kill them. This is in direct contrast to the homoeopathic method, where we depend upon the reactive power of the living cell to produce the curative substances. In chemotherapy, the curative substance is introduced into the body already formed and the cell plays no particular part in the process.

Another from of antipathogenic therapy is the use of parasiticides. These are substances used to destroy, parasites. For example, the use of the oleoresin of the male fern to destroy tapeworms or thymol to kill hookworms. Then there are substances that when applied locally will destroy various parasites and organism and fungi that involve the skin or the mucous membrane of the mouth or the vagina and so forth. These are antipathogens because they attack the cause of the disease.

From what has been said you can see that when you are confronted with a patient, the first thought to come into your mind should not be what is the indicated homoeopathic remedy, but “what kind of drug therapy does this patient need”? Does he need a palliative to relieve his symptoms, or does he need a substance that will attack the cause of disease ? He may need both. A man with a boil on his neck may need a sedative to relieve the pain; he may need a parasiticide to destroy some of the organism; and he may require another-method of therapy, namely, surgery, that the boil may be incised and the pus drained from it.

In addition to various methods of drug therapy, the modern physician must use a great many other forms of therapy. For example, he must use surgery-mechanical removal of defects, and so forth. The boy with the sand-burr in his nose did not need medicine. He needed surgical removal of the sand-burr. We recognize that surgery plays a very important part in modern therapy.

Then we have dietetics–the treatment of disease by certain types of diet. This is an important method of therapy in the treatment of diabetes, of gout, of various metabolic diseases, tuberculosis and so forth. I might also mention electrotherapy, phototherapy, radiotherapy, hydrotherapy, massage, osteopathy and psychotherapy.

G Harlan Wells