THERAPEUTICS.

DELOS LEONARD PARKER, PH. B., M. D.

ADJUNCT PROFESSOR OF MATERIA MEDICA IN THE DETROIT COLLEGE OF MEDICINE.

ON THE INDICATIONS AND CONTRAINDICATIONS FOR THE USE OF DIGITALIS.

BLACKADER (The Therapeutic Gazette, October 15, 1908) says that although digitalis is a drug regarded with fear and suspicion by some, yet most physicians will agree that employed judiciously in suitable cases of failing circulation, it generally acts most satisfactorily. Within its limits, its action is most powerful. Einhorn says "digitalis belongs to the surest and best medicinal remedies we have, but how and when it should be used is the question of the day." Digitalis has been most carefully studied and its action definitely ascertained, but it has the disadvantage of containing several active principles, some of which may undergo chemical change and either become inert or acquire a new action. A reliable preparation of digitalis produces first, functional activity of the cardiac muscle; second, a stimulation of vagus inhibition, owing to which the heart is slowed and diastole lengthened; third, a distinct increase in the peripheral resistance, due to a constriction of the arterioles.

As a result of its action, the output of blood at each contraction is increased; intracardiac tension is raised; blood pressure in the arterial system generally is increased. Digitalis acts slowly and its effects pass off slowly, but with careful administration, the effects of the drug may be maintained without any indication of reaction. Under its prolonged influence, permanent results may be noted in the general nutrition of the heart, probably brought about by the improved circulation through the coronary arteries, combined with the effects of the diastolic rest. The effect on the nutrition of the heart may be illustrated by experiments on animals. If digitalis is administered to a young animal for two or three months and the animal then killed and its heart compared with controls from animals of the same litter, the digitalis heart will be found to weigh more than the others, and also show signs of distinctive hypertrophy.

Digitalis is indicated in all conditions where there is a weakening heart muscle. It has long been regarded as of particular value in valvular defects of the heart, particularly in mitral incompetence. It is only when the heart's muscle weakens, however, that digitalis is of service. During the early stages of aortic incompetence, or of mitral stenosis the heart muscle seldom shows any signs of giving way. In these lesions digitalis should best be withheld. In all forms of heart strain, the physician should not content himself with the administration of digitalis alone, but should direct his efforts to relieving the overstrain on the heart and maintaining its nutrition. Rest in bed is important, and may be imperative. Physical and mental strain should be moderated.

Once compensation has been lost, the physician should remember that time is required to effect a restoration. Patients are apt to think that with a subsidence of their symptoms a cure has been effected, and are apt to injure themselves by too rapid return to the duties of life. Compensation should always be the aim of the physician, and is best secured by a prolonged rest combined with careful use of digitalis. In suitable cases, compensation may be facilitated by employing carefully graduated exercises. Beginning with passive movements of the limbs, to be followed by active. and finally resisted exercises, according to the Schott method, while the patient still maintains the recumbent posture, will cause the heart to stand considerable strain.

In acute endocarditis and myocarditis, digitalis should not be used. In cases of high arterial tension digitalis should be withheld until symptoms. of heart failure set in, as always occurs in these cases. In these cases, it is advisable to administer one of the vasodilators, or the iodides.

In the acute infections, caffeine and camphor probably are superior to digitalis as a heart tonic.

Digitalis is a drug that can be used for long periods of time. In many cases its action is assisted by free purgation, by the administering of a mercurial, and occasionally by venesection. In fatty or fibrous degeneration of the heart muscle its action fails. A reliable preparation is essential to satisfactory results. A fresh infusion from recently dried leaves of the English plant, or the freshly powdered drug gives the best results.

EDITORIAL COMMENT.

THE RESIGNATION OF PRESIDENT ANGELL.

AT the February meeting of the Board of Regents of the University of Michigan, President James B. Angell presented his resignation, the same to take effect at the close of the present academic year. The reasons for this step are best shown by the words of the resignation itself which are as follows:

"Four years ago I tendered my resignation to you in the belief that the interests of the University would be subserved by the appointment to the Presidency of a younger man. You declined in such kind words to accept my resignation that I have continued at my post, and rendered the best service of which I was capable.

"But as I have now passed my eightieth birthday, it is fitting that I should renew the tender of my resignation. I therefore do so with the urgent request that you accept it to take effect at the end of the academic

year.

"May I take this occasion to express to you again my sincere thanks for all your courtesy and kindness to me?"

In addition to regretfully accepting the resignation, the Board passed the following resolution as expressive of its sentiment:

"This Board has received with regret the assurance of our beloved president, Doctor James Burrill Angell, that the time has come when, in his judgment, he should be permitted to retire from the active direction of the affairs of this university.

"We desire to record here and now some measure of our appreciation of his services to this institution, of which he so long has been the head.

"It is now nearly thirty-eight years since he assumed the presidency of this university. Under his leadership it has grown in student attendance from about 1,200 to more than 5,000, with a corresponding increase in faculty membership. Its advance in effectiveness of educational work and in all that goes to make a university great has been no less prominently marked. The proud position which this university has attained is due more than to all other elements combined, to the fact that for more than one-half of its entire life it has been blessed with his learning, his culture, his wisdom, his tact, and, above all, with the example and inspiration of his high-minded Christian character.

"It is impossible to calculate the impress for good given to the world by the 40,000 men and women who have carried with them from this institution into their work and in their lives the commanding influence of his rich character and personality.

"Proud as he may justly be of the homage which the world justly yields him as educator, diplomat and publicist, he has even greater cause for pride in the grateful affection of the people of this state, whom he has served so long and so abundantly, and in the love of the army of students whose lives he has directly enriched and to whom he will always stand for all that is highest and best in scholarly attainments, in private charcter, and in public and private citizenship."

President Angell has always advocated a high standard of medical education. Hence it is peculiarly fitting that he should lay aside the active duties of his office in the same year in which the medical department enters upon a new era, as far as its requirements for admission are concerned. For, beginning with the Fall of this year, the equivalent to a two years' college course will be required before a student can matriculate. Compare these requirements for admission, together with the four years' graded course necessary for a degree, with the conditions existing when Doctor Angell came to the University in 1871. At that time, although the medical department of the University of Michigan was the first school in the country to reject candidates for lack of preliminary education, the requirements for admission were meager indeed in comparison with those existing today. Instead of a four years' graded course, only two lecture terms of six months each, together with a year spent as a pupil of some reputable practitioner was required for graduation.

Doctor Angell has always been conservative in his administration of the medical department. He has consistently opposed any and every attempt to disrupt the University by a transfer of any portion of the medical department elsewhere for supposed greater clinical advantages. On the contrary, he has always advocated the building up of the clinical departments by increasing the hospital facilities. In 1869, two years before he came to Michigan, a small building was set aside on the north boundary of the campus for hospital purposes. This building contained but a few beds, yet it was a beginning and the precursor of the present University Hospital with its two hundred and twenty teaching beds.

Yet there is a limit to a man's active executive life even though he be blessed with Doctor Angell's constitution. Hence it is no wonder that at eighty he should desire to transfer the work to younger hands. For the work has only begun. In medical, as in other departments of education, there can be no marking time. Standing still means falling behind compared with other educational centers. Hence while giving all honor to the captains of the past, let us, as they would wish, pledge faith and allegiance to those who are to guide our destinies in the future.

THE PENINSULAR WARFARE AGAINST WHITE PLAGUE.

WARTHIN, of the University of Michigan, is the author of a paper which discusses the needs of this commonwealth in the fight against tuberculosis. As secretary of the State Association for the Prevention and Relief of Tuberculosis the doctor has enjoyed exceptional opportunity for observing conditions destined to propagate the infection and formulating plans designed to exterminate the disease. Michigan was one of the first states to inaugurate a campaign against tuberculosis, an enactment obtaining in 1895 which provided for the teaching in the public schools of knowledge pertaining to the dangerous communicable diseases, and although tuberculosis was not specified the intent of the measure contemplated the inclusion of this disease.

Notwithstanding much good has been accomplished by more or less faithful work along this line, an educational campaign must be conducted among the entire populace to secure the best results. The people seem to display apathy regarding the disease and as a consequence the germ is gaining ground. An instance of the interest manifested is represented in the fact that during the past year one hundred twenty physicians were solicited to establish local anti-tuberculosis associations but only thirty responded to the call. When the profession harbors this apathetic mood the laity hardly deserve censure for unconcern. This condition of affairs renders education the paramount issue, that the people may become interested. Acquaint the masses of their duty and thereby retard the progress of the disease. La Motte investigated 1,160 poor tuberculosis families and found nine were. capable of being adequately careful; 143 were fairly careful; 719 were careless; and 289 were grossly careless. Doctor Warthin says like conditions prevail in Michigan and constitute a perpetual menace to the public.

The paper concludes with the following enumeration of the needs of the state to combat tuberculosis if position in the progressive column is to be maintained: Firstly, proper organization and support of the State Tuberculosis Association until the fight against tuberculosis passes into state and federal hands; secondly, the vigorous pushing of an educational campaign to arouse the people from their apathy concerning tuberculosis; thirdly, the immediate passage of a tuberculosis law; fourthly, proper provision for the adequate teaching of hygiene in the public schools; fifthly, the provision of sanatoria for the open cases of tuberculosis; sixthly, the licensing and supervision of private sanatoria for the well-to-do; seventhly, adequate care of the tuberculosis cases in the almshouses; eighthly, the protection of the milk supply from tuberculous infection.

CONTEMPORARY.

THE OMNIPRESENT SEXUAL QUESTION.

[INTERSTATE MEDICAL JOURNAL]

IN spite of the formidable array of books and papers and medical sermons on the vital subject of publicity of the sexual question, with a view to the enlightenment of all classes, which have inundated us of late, we must realize that the sincerity and sobriety in our advocacy of new and important means to stem the tide of sexual gratification so as to lessen the potential eventualities which may ensue, has as yet been to small purpose. And this can be accounted for in many ways, principally because without oneness of thought affixed to any movement, confusional ideation obfuscates its simplicity and directness. That men of light and leading, men in our profession who have the moral and physical welfare of communities at heart, are not Laodiceans in the high endeavor to warn and advise, is proved by the more or less scientific manifestations in our various journals. But though talent is not wanting in the effective presentation of their pleas, chimeras, which should be foreign to a matter wholly mundane, are only too often present. If we mistake not, it was Carlyle who said, in speaking of a much agitated subject, "the talent is not the chief question here: the idea that is the chief question," and the truth of his lines comes home to us every time we read "another opinion on the sexual publicity subject" as advocated by a new luminary in the ranks of fervent votaries. For how can great good come out of a warring mass of argumentative flotsam and jetsam, no matter how talented the gloss, when the one idea which should be primal, is submerged?

Now to further the idea of the proper dissemination of knowledge on this subject, it is not necessary to cry aloud for transcendent purity, as those who are unacquainted with the behests of Nature would desire, or imagine, as Swift did, that nearly every man "combines in himself all the diseases and vices transmitted by ten generations of rakes and rascals." Fortunately for us there is a middle road which should be frequented