COMPLETE SERIES, VOL. LVIII, No. 9 NEW SERIES, VOL. III, No. 9

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THE STATE LABORATORY AS A SAFEGUARD TO THE PUBLIC HEALTH.

By GUTHRIE MCCONNELL, M. D., Bacteriologist to the Missouri State Board of Health.

Until comparatively recent years the field of medicine had not reached the point where it was impossible on account of its magnitude for one man to thoroughly know the subject. Phy sicians in the past were not only well acquainted with their profession, but they were well versed in many of the allied branches, as zoology, botany, chemistry, etc. This condition has, however, greatly changed as a result of the never-ceasing work of investigation that is going on the world over.

As the extent of medical information increased it became necessary for the physician to direct his efforts along a narrower field and to omit to a large degree the collateral branches. The science of medicine continued to grow until one man could no longer deal authorita tively with all its manifestations. Conse quently, the era of specialists came, men de voting their time to one or several branches of the art, principally as surgeons or internists. Finally these were again split up into numer. ous subdivisions, as oculists, dermatologists and a dozen others.

Up to this time the laboratory worker had been a clinician who incidentally did what he could along the line of research, but the men who devoted their time to this subject could be easily counted. As pathology, physiology and chemistry revealed new fields, in conse. quence of the aggregate studies throughout the world, a new class of men took an important position. They were those who devoted their entire time to research work. It being soon discovered that one individual could not be an active clinician and at the same time devote his attention to his laboratory, research being a jealous mistress.

The general practitioners who graduated twenty years or more ago did not have labora tory facilities in those days, for the simple rea

*Read before the State Medical Society of Missouri, Jefferson City, May 18, 1909.

son that there was little work of that sort in existence. The successful physician was the one who by his large clinical experience and accurate observation was best able to make correct diagnoses and to successfully treat his patients. The clinical thermometer in the earlier days was unknown and the severity of the fever had to be estimated from the sensations given to the investigating hand.

As time went on various laboratory methods were passed on to the clinician. The schools increased their facilities for training as the knowledge of such procedures became more and more extensive. This meant that clinical instruction was being broadened by the introduc tion of new methods, not so much to supplant the older style of teaching as to aid it.

For a long time this new idol was bowed down to by the majority and many sins were committed in its name. The older men who had acquired their skill from long association with the sick saw themselves being thrust down by the recent graduate who thought that, be cause he had seen tubercle bacilli through a microscope, he was a true scientist. In many instances the newcomer was, however, able to prove his superiority along definite paths and clinical experience was relegated to the background in the face of modern laboratory methods. The man with the laboratory training reigned supreme for some time, but he was found to be not omniscient. He would send out reports from his laboratory and in the course of time they would be proved to be incorrect. It was not the result of deficiences in the method, but in the men who had not had the experience required in order that proper deductions and correct conclusions could be drawn.

As conditions now are there is a much saner and safer balance between the clinician and the laboratory worker. The latter is no longer so sure of his findings and the former is now better able to properly value the reports given him. The necessity is now appreciated of the great importance of correlating the clinical manifestations with the results of the labora tory investigations. The man working with the test tube and the microscope has realized the value of having on review as many clinical

not typhoid, a tumor thought benign may prove malignant and so on.

Although the value of laboratory examina tions may be thoroughly appreciated yet there may be, and frequently are, very satisfactory reasons for not employing them. In the first place there is the necessity of having proper laboratory equipment. Such an outfit even in its simplest form is expensive and not many men, excepting in the larger cities, have a practice that justifies the expenditure. In addition to the laboratory it is essential that there shall be someone in charge who has had an adequate training. The usual practitioner has not had the proper instruction and conse quently when he does make some examination he does not feel sufficiently sure of himself to put much reliance upon his results.

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In many small communities there is some man, usually a comparatively recent graduate, who, while waiting for his practice to increase, devotes his time to making examinations for his fellow physicians. As his patients in crease in number his laboratory work is nec essarily neglected, and the physicians, and the community as well, suffer unless some other man has appeared to carry on the work. Such a method, although better than none, is not very satisfactory. As a result of these inter ruptions there have been formed in various cities large private laboratories where the de sired examinations can be undertaken. A great drawback to this is the expense. work requires special training and special apparatus and consequently prices that may seem high have to be charged. This, however, means that a very large portion of a physician's prac tice has to get along as well as possible without having the latest methods of science em ployed in its behalf. This does not seem right either to the individual in question nor to the community. That the public should be exposed to an epidemic of typhoid fever or diphtheria because a patient is unable to pay for a Widal test or for an examination of a culture from a throat is absurd. Such matters should be attended to by the larger aggrega tions of citizens.

The first to recognize this responsibility to the community were the larger cities. It was soon realized that it was much cheaper to spend money to keep the citizens well than to attempt to cure them after they became sick. One epidemic of typhoid, or diphtheria or par ticularly small-pox, would cause a loss to the city of an amount much greater than would be required to conduct an efficient health depart ment. In consequence, one of the early acts of the health boards was the establishment of city laboratories where investigations of con ditions bearing upon the city's health could

be conducted. The physicians were urged to have examinations made of sputum from sus pected tuberculous patients, and of cultures from inflamed throats or of blood when ty phoid fever was suspected. In this way a care ful watch could be kept over the people's health and proper methods be employed to safeguard the community. The expense of such an insti tution being borne by the city from the money obtained by taxation. Such an employment of the city's funds being fully warranted by the saving that it brought about, not only of mon ey but of lives.

Such a method as the above can be satis factorily maintained in the large and concentrated settlements but a much more difficult matter it becomes when the sparsely settled areas are taken into consideration. They do not have the money to expend in paying a sufficient sum to equip a laboratory and to pay a man to take charge, yet their lives are just as valuable to the state as the lives of those who live in the cities.

In a number of states this matter has been solved to a large extent by the establishment of county laboratories. Such, however, seem to occupy a position between the free laboratory of the city and those conducted by private individuals. The county supplies what money it can and the patients pay what they are able for the examination undertaken. This plan works well in a county that contains many people amongst whom are physicians who not only themselves recognize the value of such methods but who are willing to work for the advancement of medical science. If, however, the county is not thickly inhabited nor contains a leaven of intelligent physicians such a laboratory becomes an impossibility. There is then nothing for the physician to do but either to send his specimens to a pri vate laboratory or to neglect that important side of his profession. He cannot send his specimens to a city laboratory as the oppor tunities there are of necessity restricted to its own inhabitants. They are the ones paying the taxes and consequently those who reap the advantages. If there is no county laboratory the physician is then helpless unless the state comes to his aid.

A number of the states have appreciated the importance of this and their various legisla tures have appropriated the money necessary to build and equip laboratories and to pay the salaries required to obtain competent men. In these states the county practitioner is enabled to carry on his work to the best advantage to his patients, to himself and to the community. When in doubt concerning some case he can bring to his aid the advantages that are placed at his disposal. All that is required is that

he shall send the material to the laboratory in such a condition that it can be examined to the greatest advantage. The greater the use made of laboratories the greater will be the realization by the medical profession of the value of such examinations. The more familiar the physician becomes with laboratory findings the better able will he be to properly interpret and apply the knowledge so obtained. In due time he will wonder how he ever got along without employing such assistance and he will find that a desire for accurate diagnosis will soon arise. The doctor will no longer be willing to wait till his patient dies or recovers before deciding whether or not a given tumor were malignant. Cases of "typhoid-malaria" will diasappear and the patient will be found to be suffering from either typhoid fe ver or malaria, according as to whether the Widal reaction is positive or the plasmodium is found in the blood.

The control of the infectious diseases, such as tuberculosis, diphtheria, typhoid fever and small-pox, is by no means a matter of senti ment, it is one of great economic importance. It is being more and more widely recognized that sickness is a source of great monetary loss to the public as well as to the individual, not to mention the suffering that it may in flict upon those dependent upon the sick per

son.

When one takes into consideration the value of the lives lost each vear by preventa ble diseases, and tuberculosis, diphtheria and typhoid fever certainly belong to that class. it can be readily seen that a trifle of that amount if expended for better control of the state health would result in a tremendous saving. Various courts have placed an average value of five thousand dollars on a person's life and when one multiplies the number of deaths from the above three diseases the fig ures obtained are appalling. In 1900 there were in Missouri 3,459 deaths from consumption, 1,682 from typhoid fever and 1.075 from diphtheria, all due to conditions that need not exist.

In a paper read by Professor Wm. T. Sedge. wick some months ago he shows that Mr. Al len Hazen's theorem that for every death from typhoid fever avoided by the purification of a polluted water supply, two or three deaths from other causes are avoided, is not only pos sible but probably conservative. A hundred deaths from typhoid fever in one year would be a loss to the community of a half million dollars. Then according to Hazen's theorem two or three hundred deaths from other causes attributable to the conditions that also bring about typhoid fever might have been avoided. Consequently it is a much wiser plan to pre

vent people becoming sick than it is to cure them afterwards, even if that were always pos sible.

It would seem, therefore, that there should be no hesitation on the part of a state to fur nish a proper laboratory. One that is large enough and sufficiently well equipped to al low, not only that the routine duties should be carried out to the best advantage, but to permit, as well, the undertaking of investi ical knowledge is largely the result of experi gative work. The great advancement of med mental work carried on in the laboratories. Before new methods can be employed by the profession at large, they must be shown to be

of value but at the same time harmless to the individual. Much of the information has to be acquired from the clinician before the laboratory results can be verified. Consequently the closer the relationship between the two classes of workers the better will it be for the science of medicine.

A state laboratory should therefore be a centre for acquiring and disseminating medical knowledge. From it should come an inspiration for the rest of the state. The men employed should be those of enthusiasm capa ble of carrying on the work to the greatest good of all concerned. In order that this might be accomplished it would be best that the laboratory be established in a locality that is an active medical centre, so that its work can be seen and felt by those directly concerned in the teaching of medicine. The constant contact with other men doing similar work provides a stimulus that is unequalled by anything else. The spirit of rivalry and emulation, when not carried to an excess, has done more for the advance of science than any other factor.

Another important reason for having such a laboratory in a large medical centre is that it is at such a place that many students of medicine can come to take post-graduate work, to examine into the methods of teaching, or to view the work of other men. Each one of these visitors is an unknown factor in the spreading of information in his own community. He goes to the state laboratory, meets aetive workers, learns new methods or obtains the relative value of old ones. The greater the number of such missionaries the greater the progress of medicine in the state. As the advance of medical knowledge means an increase in the health and wealth of the community any reasonable method to bring about that end is certainly justifiable. Of such methods there seems to be none so valuable or so needed as a well equipped laboratory, well equipped not only in apparatus but in men.

By BYRON ROBINSON, B. S., M. D., LL. D., Head of the Department of Diseases of the Abdominal Viscera, and Professor of Surgery of the Abdomen in the Chicago College of Medicine and Surgery. (Medical Department of Valparaiso University.)

The basis of this article is 1000 personal autopsic abdominal inspections and some 20 years of special practice in the abdomen. The triumvirate of classical symptoms of cholecystitis calculosa is pain, nauseau, icterus. How ever, this classical triumvirate belongs to an established pathologic condition in which considerable structural and functional damage has occurred. From 1000 autopsies and and two decades of practice in special abdominal labors,

C

D. Klopper

mon symptoms of many abdominal diseases. The errors in diagnosis of heptic calculus are numerous, but especially arise from misinterpretation of functional disturbance from physi cal symptoms and mistaken diseases of adjacent organs. Marked functional disorders of the stomach-neurologic stigmata-should be differentiated from gastric pathology if gastric surgery is to be respected.

A safe surgeons is the one who combines the pathology of the dead and living for the benefit of the patient. Surgery should not be lent to psycho-therapy-operations for neurosis is ir rational, it is fakirism, it is surgery gone mad. By reference to Figure 5 it will be evident that there are numerous chances for error in diag

DIVERTICULUM.

I am convinced that the diagnosis of gall bladder calculus is different and uncertain. The diagnosis of disease in the right proximal quadrant of the abdomen includes significant organs, as gastrium, duodenum, liver, pancreas and kidney (with perhaps non-descended appendix). The more we know the more we doubt and fear.

Pain and nausea are com

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