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teachings. He was ever an ardent advocate of clinical instruction, and in his early connection with the University of Michigan, earnestly favored the removal of the Medical Department to the City of Detroit, where much greater clinical facilities could be obtained.

REST AND EXERCISE AS THERAPEUTIC AGENTS.

The question of the proper therapeutic use of rest and exercise, has been made the subject of a very thoughtful editorial appearing in the British Medical Journal. The writer says:

We have reached an epoch when drugging, as such, has fallen into disrepute. When called upon to deal with a case of disease, the practitioner no longer regards the administration of medicines as his chief duty; nor does he expect, except in a very limited number of cases, that the Pharmacopoeia will yield him any medicament which can be fairly described as a specific remedy for the disease before him. While according drugs their due value for their power to control symptoms and to help the patient over the crisis of his malady, the physician is more and more disposed to rely for cure upon the removal of causes which promote disease, and the regulation of food, exercise, and general habits of life. In this connection one problem often presses itself strongly upon his attention, namely, shall the affected organ be permitted to rest, or shall it be stimulated to increased activity?

The difficulty of finding a clear rule of practice arises mainly in connection with chronic cases. In the case of an organ which is the seat of acute inflammation, we can have no hesitation in advising that it shall have as complete rest as the needs of the economy will permit. The inflamed joint, the inflamed eye, the inflamed stomach, and the inflamed kidney must be allowed to rest, entirely, if possible, and if that be impracticable, their functional activity must be reduced by all the means at our command. But when the acute symptoms have subsided, and the subacute is passing into the chronic condition, difficulties may at once arise.

Take, for example, the first case that we have instanced, namely, an inflamed joint. Rest is at first essential, but if the rest be too long continued, mischief results, and the failures of the surgeon in this matter often become the material for the triumphs of the bone-setter and the "miraculous cures of the itinerant quack. Few reflections can be more mortifying to the

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surgeon than the thought that by undue timidity and too prolonged adherence to a line of treatment which at the outset was perfectly correct, he has injured his patient and brought discredit both upon himself and his profession. Such errors would be less frequent if the practitioners were constantly on the alert to give rest and exercise their due place as therapeutic agents. A similar error is common in the treatment of gastric derangements. The practitioner begins, rightly enough, by checking undue indulgence and prohibiting the use of all injurious articles of food. Too often, however, he contents himself with mere prohibitions, and forgets to suggest suitable substitutes for the dietary which he interdicts. The patient becomes infected with the same Spartan zeal, and voluntarily adds to the strictness of his adviser's injunctions. Not very rarely the end is worse than the beginning. Instead, it may be, of a little functional dyspepsia, which, however disagreeable, is a very innocent malady, the patient, by his process of modified starvation, lowers his constitutional tone, and invites some serious organic affection. The practitioner began, no doubt, with the very sound principle of giving a disordered organ rest, but he forgot the wise aphorism Ne quid nimis.

For generations the main idea in the treatment of organic heart-disease has been physical rest to diminish the labor of the damaged organ. We have been in the habit of prohibiting all forms of active labor to the sufferers from cardiac disease, and the principle of our treatment has been the unexpressed but ever present idea, accepted as a self-evident axiom, that perfect rest was the best means of securing muscular compensation. Professor Oertel's experiments and results have come with starling surprise upon those who forgot to distinguish between a useful principle and the exceptions which the multiformity of disease renders it imperative to recognize. As is well known, he treats a considerable proportion of cases of organic heartdisease by regulated exercise, especially graduated ascents of mountains, and his results place the value of his method beyond reasonable dispute. There is nothing really surprising either in his treatment or the success which has attended it. A little reflection will suffice to convince us that, while rest is often useful and indeed quite indispensable in heart-disease, there are yet many cases in which well regulated exercise will improve the nutrition of the cardiac muscle, as of the rest of the muscular system, and hence tend to the promotion of circulatory vigor.

Nervous affections, again, afford many instances in which rest and exercise will call for very discriminating regulation. When the practitioner gets a case of brain-worry and brain-fag from over-work or undue excitement, he is apt, as a mere matter of routine, to order the patient off to the seaside or the mountains, and to tell him to take complete rest, and dawdle away his time as best he may. This plan sometimes succeeds, but the cases are not rare in which it fails utterly. The busy brain sometimes refuses to rest, and the usual channels of activity being closed, its energies flow out in novel and abnormal directions. Ill-temper, insomnia, ennui appear perhaps for the first time, and the treatment by rest is a complete failure. In such cases the indication is not abstinence from work but a change of mental occupation, which may be attained by travel, by the sedulous cultivation of some hobby, or perhaps by serious intellectual labor in some unaccustomed groove.

We are far from seeking to disparage the immense advantage of rest when wisely regulated and duly limited. But "rest in the recumbent position" is not the essence of all surgery, nor are a warm bed and a quiet room the sum and substance of the last will and testament of a moribund science of medicine.

ACTION OF CERTAIN DRUGS ON THE CIRCULATION AND SECRETION OF THE KIDNEY.

In a paper read at the Ninth International Medical Congress, Dr. Phillips briefly detailed some experiments made by him and Mr. Bradford, in the Physiological Laboratory of University College, London, on the action of drugs on the kidney, from a different stand-point to that usually adopted. The important factor, and the one generally omitted in the observation of the effects of any drug on the urinary flow, is the effect of the drug on the renal blood-vessels. Thus an ideal diuretic would be one that dilated the blood-vessels of the kidneys, but constricted all others in the body.

By an ingenious registering apparatus, which records simultaneously the general blood pressure, the expansion and contraction of the kidney, and the excretion of every drop of urine, they were able to determine the action of any drug with great accuracy.

The action of various drugs Dr. Phillips describes as follows, taking first citrate of caffeine. The effects produced by halfgrain doses are as follows:

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(1) On the blood pressure. The blood pressure is first lowered, and then is raised. Both effects are of short duration and slight, especially the rise of pressure.

(2) On the heart. There is first a diminution in the force of the beats, followed by a slowing, with beats of markedly increased force.

(3) On the kidney. There is at first contraction lasting two or three minutes, and accompanied by diminution or even arrest of secretion. This is followed by expansion, which (after a one grain dose) lasts sometimes over half an hour, the flow of urine being stimultaneously trebled. The effects on the kidney cannot be the result of the changes in the general blood pressure; this is shown by the fact that they do not occur simultaneously. The effects on the general pressure are slight, and last only a few seconds; those on the kidney being measured by minutes. Another drug which acts in a similar way is ulexin, a new alkaloid obtained from the seeds of common gorse (ulex Europæa). It has the objection that in animals the diuretic action is only maintained with doses, which would either kill through the respiration or produce violent convulsions.

It resembles caffeine in producing first a constriction and then an expansion of the renal vessels, with diuresis. It differs from caffeine in three particulars: (1) It is more powerful; (2) Its effects are more transitory; (3) Repeated doses of caffeine, rapidly injected, produce contractions only of the kidney, not followed by expansion; but similar excess of ulexin causes only expansion without contraction.

Among other substances that cause expansion of the kidney we may cite dextrose, urea, acetate and chloride of sodium, and probably all the constituents of the urine. The drugs producing constriction of the kidney are more numerous. Digitalin in doses of one-fortieth grain causes contraction, which persists for as long as half an hour. It is not easy to decide whether digitalis is a true diuretic, or only exerts its effects through the heart. During the contraction of the kidney, however, the flow of urine is not diminished, as is the case with caffeine, but is generally increased. The explanation seems to lie in the effect on the general blood pressure; digitalin raising it, caffeine depressing it. Spartein, on the other hand, though it acts similarly to digitalin on the heart, general blood pressure, and renal vessels, causes a great diminution of urine; and in disease its so-called diuretic effect is due to improvement of the general circulation. We have also made many observations with strophantin and

apocynein; their chief action is on the heart muscles; they produce little or no effect on the peripheral vessels. Both cause a slight temporary contraction of the kidney vessels, but with no definite increase in the urinary secretion. Finally, turpentine,. adonidin, and varium chloride all produce marked contraction of the kidney, without diuresis.

In summing up the results, we see that reputed diuretics more commonly produce contraction of the renal vessels, than expansion. Further, that expansion is either slight, as by acetate of soda; or, if large, as by citrate of caffeine, is only produced by small and initial doses. The powerful action of ulexin on the respiratory mechanism is a great drawback to its use; one-sixth of a grain was used in our experiments, but onetwelfth of a grain would completely arrest respiration. Then, again, such drugs as produce contraction of the kidney cannot be bracketed together, since, though they all have the same effect on blood pressure, digitalin alone has an obviously diuretic effect. We further see evidence of the truth that the flow of urine is not so much dependent on blood pressure as on the rate of the flow of blood in renal vessels. It is necessary also to remember that, although such drugs as strophantin produce a great increase in the force of the cardiac beats, yet the heart is very much slowed, so that it is possible that the amount of blood sent into such an organ as the kidney in a given time may remain the same; whereas, such a drug as digitalis, producing a rise of blood pressure and a contraction of the kidney vessels, may cause an increased quantity of blood to pass through those vessels, and thus it acts as a diuretic. Inasmuch as spartein has not a marked diuretic action, we must also assume that digitalin has some peripheral action on the secretory apparatus of the kidney. Our results may be tabulated briefly as follows, in three divisions:

A. Drugs that first contract and afterwards dilate the kidney. I shall mention two out of this class: (1) Caffeine, in small doses, induces in the stage of contraction a fall of blood pressure; the flow of urine may be arrested; during the latter it is always increased, such increase depending on dilatation of renal vessels. The possible arrest of secretion during the first stage is special to caffeine, and may be induced by large or repeated doses; (2) Ulexin, one-sixth of a grain, greatly raises blood pressure during the first stage (that of contraction); in the second, expansion is much greater in degree, but shorter in duration than under caffeine, and is accompanied by brief but

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