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Papers for the original department must be contributed exclusively to th's magazine, and should be in hand at least one month in advance. French and German articles will be translated free of charge, if accepted.

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COLLABORATORS.

ALBERT ABRAMS, M. D., San Francisco.
M. V. BALL, M. D., Warren, Pa.
FRANK BILLINGS, M. D., Chicago, Ill.
CHARLES W. BURR, M. D., Philadelphia.
C. G. CHADDOCK, M. D., St. Louis, Mo.
S. SOLIS COHEN. M. D., Philadelphia, Pa.
ARCHIBALD CHURCH, M. D., Chicago.
N. S. DAVIS, M. D., Chicago.

ARTHUR R EDWARDS, M. D., Chicago, Ill.
FRANK R. FRY, M. D., St. Louis.

Mr. REGINALD HARRISON, London, England.
RICHARD T. HEWLETT, M. D., London, England.
J. N. HALL, M. D., Denver.

HOBART A. HARE, M. D., Philadelphia.
CHARLES JEWETT, M. D., Brooklyn.
THOMAS LINN, M. D., Nice, France.
FRANKLIN H. MARTIN, M. D., Chicago.
E. E. MONTGOMERY, M. D., Philadelphia.
NICHOLAS SENN, M. D., Chicago.
FERD C. VALENTINE, M. D., New York.
EDWIN WALKER, M. D., Evansville, Ind.
REYNOLD W. WILCOX, M. D., New York.
H. M. WHELPLEY, M. D., St. Louis.
WM. H. WILDER, M. D., Chicago, Ill.

LEADING ARTICLES

No. 6

an exclusive milk diet* for the purpose of sparing the kidney and reducing intestinal putrefaction, we run great danger of underfeeding the subject and of flooding the stomach and the cardio-vascular apparatus with such enormous quantities of liquid that digestion is interfered with and the heart and arteries are subjected to a serious strain. If, again, we should reduce the liquid intake too much and place the patient on a dry diet the urine becomes too concentrated and consti- . pation with the absorption of bowel poisons that irritate the kidneys, the heart and the peripheral arteries is very apt to supervene.

The continuous use of drugs is also fraught with many inconveniences; for, in the first place, the prolonged use of medicines is bound sooner or later to injure those organs that are concerned with their absorption and elimination, notably, the stomach, the liver and the kidneys; moreover the effect of most drugs that we might give for the sake of reducing the blood pressure or stimulating catharsis or diaphoresis is exceedingly transitory and the organism soon becomes accustomed to them.

If the patient has been treated largely

THE USE OF SIMPLE HYDROTHERAPEU- by hydrotherapeutic means, and if his diet

TIC MEANS IN THE TREATMENT

OF CHRONIC NEPHRITIS.

ALFRED C. CROFTAN, M. D.

CHICAGO, ILL.

If we have erred in the past in giving too much medicine, we are inclined possibly to err nowadays in not availing ourselves as fully as we should of non-medicinal measures. Physical means of treatment are today regarded with much favor by the laity. There is a reaction in the popular mind against drugs, and, whereas, formerly our patients clamored for a prescription and thought nothing was being done for them unless they carried home a bottle of medicine and a box of pills or two, we nowadays more and more frequently encounter patients who urge that they be given no medicine at all, but that they be told instead what to eat and how to live.

The application of physical methods is especially useful in chronic disorders. For it is surely a matter of extreme difficulty to proceed safely in such cases with dietetic and medicinal means alone. This applies particularly to the treatment of chronic nephritis.

For if we feed the patient, for instance, on

has, at the same time, been properly regulated, then he always has drugs to fall back upon in emergencies should alarming symptoms develop that require energetic treatment. And as a rule it will be found that much smaller doses of the different medicines will be required in such cases to produce the desired effect than in patients who have been habituated for long periods of time to the use of cardiac tonics, vaso-dilators, cathartics, diuretics, diaphoretics, etc. is a great advantage.

This

As it is manifestly impossible to cure organic lesions of the kidney by any remedial measures, treatment must be directed towards the secondary consequences that follow renal disease; besides, the principle of rest to the diseased organ may be utilized, for if the kidneys are spared, the reparative processes of Nature can proceed unhindered towards the regeneration of diseased tissue in the kidney or vicarious hypertrophy of healthy parts to take the place of those that are diseased.

Until very recently we were inclined to believe that in most chronic diseases involving the kidneys, the kidneys were the primary

* See Croftan "The Dangers of an Exclusive Milk Diet in Nephritis." American Medicine, May, 1903.

organs affected and that the other manifestations about the heart, the arteries, the brain, the retina, the nervous system and the general metabolism were secondary to renal insufficiency. Of recent years we have learned to understand, however, that the renal affection is frequently the secondary event and the result of a variety of primary causes that affect the digestive tract, the liver, the general metabolism and act upon the kidneys either through intoxications that are engendered by these variations or through the medium of the cardio-vascular apparatus. Especially in Bright's disease have we arrived at what we call the newer conception of the disorder according to which a chronic intoxication is the primary cause leading directly to marked high arterial tension, and later to a variety of nutritional disorders, first functional and then organic in character, involving chiefly those organs of the body that are supplied by end arteries; for in the latter impairment of the circulation and changes in the caliber of the nutrient afferent arteries must needs first lead to degenerative changes. Such end organs are chiefly the kidneys, the retina, the brain, and possibly, the gums, and it is for this reason, as I showed in a recent article, that we so often see develop simultaneously in the brain, eye and kidneys symptoms of Bright's disease, and not unfrequently witness high arterial tension with apoplexy or retinal hemorrhages at a time when the kidneys are only slightly involved or not affected at all. Therefore, one of the most important elements in the treatment of any form of chronic nephritis is the treatment of the cardio-vascular signs, immaterial, as a matter of fact, whether we imagine these to be the primary event, or secondary to the kidney trouble; for most of our kidney cases die, not from the kidney trouble per se, but from the changes about the heart and arteries.

Three elements enter into the physiology of arterial tension, viz., the amount of the blood, the force of the contraction of the heart and the degree of peripheral resistance. From the heart emanates the force that propels the blood into the arteries and causes the tension of their walls. The peripheral resistance by creating an obstacle to the evacuation of the arteries causes an cumulation of the blood in these vessels and tension of their walls with a reactive elastic pressure that propels the blood onward. The mass of blood finally is the intermediary agency that driven from behind and compressed from in front distends the arteries to such a degree that the elastic powers of their

ac

See Croftan: "The Circumstances and Treatment of Bright's Disease," Jour. A. M. A., January 6, 1906.

walls can become operative. Increased or decreased, these three factors determine variations in the blood pressure; and all three factors can be profoundly influenced by hydriatic measures.

Changes in the peripheral resistance can applications. In chronic arterial diseases the be brought about both by cold and by hot for this reason:-The application of cold allatter, however, should have the preference ways at first produces a contraction of the peripheral vessels followed very shortly by a dilatation called "the reaction." This physiological reaction that leads to reduced blood pressure cannot be utilized with safety in most cases of chronic nephritis: (1) Because the primary contraction of the peripheral vessels causes a sudden increase of the arterial produce rupture of the weakened blood vessel tension and may, in predisposed subjects, walls in the brain, the retina or otherwhere; (2) because the cold causes an increase of the. heart's action by a nervous reflex that is transmitted directly to the cardiac ganglia; (3) because, in chronic nephritis, the reaction may fail altogether owing to lack of tone, or possiof the peripheral arteries, or on account of bly to anatomic changes in the musculature myocardial changes.

The method or choice, therefore, for reducing the peripheral blood pressure is the application of heat to the body surfaces; for hot applications, provided the degree of temperature is not too high produce from the beginning cutaneous hyperemia without preceding contraction of the peripheral blood vessels, and if continued, true relaxation of the muscular coats of the peripheral arteries with a corresponding fall in the blood pressure. Moreover, heat causes a long lasting loss of tone on the part of the peripheral blood vessels, in other words, a prolonged vaso-dilator effect, whereas the reaction following cold applications leads to what may be called a tonic congestion of the peripheral vessels, during which the tone of the blood vessels is fully preserved so that contraction soon follows. Heat, moreover, if applied for a sufficient length of time produces dilatation not only of the cutaneous vessels, but also of the deep blood vessels, whereas, the dilatation of the superficial vessels produced by cold is usually accompanied by intense contraction of the deep vessels, an effect that leads rather to high than to low blood pressure. The fall of blood pressure, therefore, following hot applications is much more permanent and its production fraught with less dangers than the decrease of arterial tension produced by cold or by medicinal vaso-dilators.

The simplest way of applying heat to the surfaces of the body for the purpose of reducing blood pressure is to give the patient what may be called a "hot soak," i.e., the patient is instructed once or twice a day (for practical purposes, best early in the morning and late at night) to lie perfectly still for for five or ten minutes in a bath tub filled with water a few degrees below the temperature of the body. If it is desired to increase the effect friction may be applied for a time by an attendant while the patient is immersed in the bath.

The addition of a few pounds of salt to the water or immersion in warm carbonated water is very useful because the salt and the carbonic acid both assist in relaxing the perpheral capillaries. The bathroom should always be kept very warm for the capillaries of the skin are relaxed after the bath and should be kept so as long as possible; if the room is cold sudden contraction of the cutaneous vessels ocours and therewith a rapid rise of blood pressure and an increased strain upon the heart; all effects that one is precisely trying to avoid. In cases, moreover, in which the vasomotor tone is below par, and this is common in cardio-nephritic cases, there is always considerable danger of catching cold. The best plan of all is to have the patient lie down in a warmed bed for a time after the bath.

One other important point must further be considered in using this plan, viz., the occurrence of collateral hyperemia in various parts of the body, especially the brain. For this reason the head should always be covered with cold cloths or an ice bag during all the time the patient is in the water. It will be found that this plan not only reduces the blood pressure for many hours thereafter, but also slows the heart and reduces the force of its contractions. Occasionally the rapidity of its action is slightly increased, especially after the patient leaves the bath. such cases the application of the ice bag to the precordial region or of cold cloths to the nape of the neck may be employed to reduce the number of heart beats. Moist heat is vastly superior to dry heat for reasons that will be presently discussed.

In

A marked effect can further be exercised by hydrotherapeutic measures upon the composition and the volume of the blood. From all that has been said above, it is clear that cold applications are absolutely counter-indicated in any case of nephritis owing to the sudden initial rise of blood pressure and the nervous shock to the heart that they engender. It is useless, therefore, to discuss in this place the interesting effect that cold applied to the surfaces of the body can exer

cise upon the percentage of leucocytes and red corpuscles, and upon the specific gravity and the volume of the blood; and we will concern ourselves therefore exclusively with the use of hot applications in order to see what effects may be beneficial in nephritis and that we usually attempt to produce by drugs or diet, can be produced by heat.

The application of dry heat, i. e., the electric light bath or hot air, applied in different ways, always produces a greater concentration, i. e., a decrease in the total volume of the blood. This is due, of course, to the loss of water through the sweat glands, and while this practice by accelerating the current of lymph may act beneficially in the absorption of edemas, I have never been able to convince myself that sweating produced in this way is beneficial in cases of nephritis without edema; for while some solids are lost through the sweat glands, the loss of water is immeasurably greater, and the concentration of the blood is so much increased by this practice that whatever toxic bodies may be circulating can undoubtedly exercise a more deleterious effect in a concentrated than in a diluted form. The reduction of the blood pressure that might result from a deorease in the volume of blood is offset by the greater toxicity of the circulating fluids, for the pressor principles they contain are not eliminated via the sweat glands. If dry heat is applied, then the patient, should at all events, at the same time be given very copious draughts of water to compensate for the loss of water by diaphoresis, but as this practice undoubtedly throws a great strain upon the heart and arteries that have to pump this water from the stomach to the emunctories of the body, I have always felt that the benefits accruing from sweating by dry heat are more than neutralized by all these disadvantages.

For this reason, if sweating is to be produced at all, it should be done by means of moist heat, and here again, the method of choice is without doubt immersion for five, ten or fifteen minutes in water heated slightly above the temperature of the body. It will be found that when this plan is adopted, the concentration of the blood does not increase, as manifested by determinations of its specific gravity, freezing point, and electric conductivity. It is possible, as Wick has suggested, that the loss of water through the sweat glands is compensated by the absorption of water from the tissues, superinduced and aided by the pressure exercised from without by the water of the bath; at all events, immersion in hot water, aside from lowering the blood pressure by prolonged vaso-dilatation causes a certain loss of ex

crementitious solids through the sweat glands without causing great concentration of the body, therefore, greater toxicity of the latter, and without consequently necessitating the administration of much water by mouth. In other words, if properly carried out, immersion in hot water really aids the body in getting rid of both solids and water with safety.

In all diseases complicated by high arterial tension and an irregular and excitable heart action, and to this category belong practically all cases of chronic nephritis, it is a matter of great importance to allay the nervous irritability. We should always endeavor to do this physically by allaying the patient's fear, trying to keep him from worrying about his condition and advising him not to lead too strenuous a life, and we usually enforce this effect by sedative remedies. Very much can be accomplished in this direction with complete safety by hydrotherapeutic means. This fact is so well established that nowadays the standard and most successful treatment of neurasthenia and of many psychoses complicated with excitement, consists in the use of hydrotherapeutic means. As a rule it is impossible to carry out such treatment at home. Certain simple measures that are of great value in quieting the sensibility of the whole nervous system, including the vasomotor nerves, can, however, be carried out in the house, and chief among these, again, is the use of warm water and by preference, the prolonged hot bath.

Upon the general metabolism the use of hot water also exercises a very profound influence that is particularly valuable in nephritis. For, immersion of the body in hot water for some time, by preventing the loss of heat by radiation. and incidentally, by causing dilatation of the blood vessels supplying the muscles, causes an acceleration of metabolism, particularly of the non-nitrogenous constituents. This is a valuable effect in nephritis as it prevents to a certain degree the accumulation of waste products in the blood and relieves the kidneys of the necessity of excreting them. In obese subjects a considerable loss of fat can be brought about in this way, especially when judiciously combined with proper exercise treatment, and that this is invaluable in any form of cardiorenal disease need hardly he emphasized.

The use of dry heat is again not safe in nephritis, on account of its effect upon metabolism because the body at once consumes an increased amount of its own nitrogenous constituents to make up for the loss of heat by radiation; in this way flooding of the blood stream with urea and bodies that are intermediary between albumen and urea is brought

about. Whenever this occurs increased labor is thrown upon the kidneys, as they must rid the body of this circulating waste material.

Upon the digestion, i.e., upon the secretory and motor function of the stomach and bowels, hydriatic procedures also exercise a profound influence. Unfortunately, however, the measures that are most efficacious in promoting increased secretion and improved motility are cold hydriatic means, and these we cannot employ. The one cold measure that is useful and that can be applied with safety is, the application of cold locally over the liver, either in the form of a Priessnitz compress or in the form of a cold stream of water directed upon the hepatic region with the rest of the body protected. This process stimulates the hepatic function and promotes an increased flow of bile. view of the presumably hepatic origin of many forms of Bright's disease, this is a useful adjuvant to treatment, especially since the entrance of much bile into the upper portion of the bowel reduces intestinal putrefaction. This is one of the most desirable effects that can be obtained in nephritis, an effect that we usually attempt to bring about by dietetic and medicinal means.

In

In conclusion, a word should be said in regard to the effect of hydriatic procedures upon the flow of urine. Cold applied to the surfaces of the body, as is well known, stimulates diuresis both by raising the blood pressure and presumably also by a reflex action upon the musculature and the sensory nervous apparatus of the bladder. This becomes manifest by the almost instantaneous desire to urinate that patients develop as soon as cold measures are applied. As cold is eschewed in nephritis, we cannot make use of this procedure, but I do not consider this a disadvantage, for I have never been able to convince myself that the stimulation of diuresis is a desideratum in chronic nephritis. Any measure that increases the flow of urine, by implication stimulates, even irritates the kidneys, immaterial whether the stimulus be a drug acting directly upon the secretory mechanism of the kidneys or upon the blood pressure within the kidneys. When the kidneys become diseased they at once fail to eliminate certain bodies properly, but to force them to eliminate, nevertheless, is a precarious procedure, for it violates one of the fundamental principles of the treatment of a functionally inadequate organ, viz., that this organ should be rested rather than irritated and forced to work. For rest alone will enable Nature to institute the necessary reparative processes

*See Croftan The Circumstances and Treatment of Bright's Disease," Jour. A. M. A., 1905.

and to hasten recovery. Consequently heat is again useful, for it lowers the blood-pressure in the kidneys, and consequently may somewhat reduce diuresis, but it also spares the kidneys by soothing rather than irritating the nervous apparatus that superintends the manufacture and excretion of urine.

It will be seen, therefore, that such simple measures as hot bathing, properly administered, and the application of hot or cold to various portions of the body, can accomplish much in the treatment of the nervous, metabolic, gastro-enteric and cardio-vascular manifestations of nephritis, that we ordinarily attempt by diet and drugs. That a judicious selection of the diet, especially with the end in view to maintain adequate nutrition is an indispensable adjuvant to treatment is, of course, not denied, for otherwise the organism cannot maintain those reactive and recuperative powers that alone can bring about an amelioration of the disease, and, as far as that may be possible a restitution to normal. Drugs, on the other hand, in my opinion, should be given very sparingly in chronic nephritis for reasons that have already been outlined. They should always be reserved as an emergency measure and hydrotherapeutic means should replace them wherever that is possible. That this can be done and how it should be done I have attempted to explain in the preceding paragraphs.

100 State street.

SYMPTOMS OF INTESTINAL OBSTRUCTION. These have been shown by Kukula to depend largely on autointoxication, particularly by hydrogen sulphid, methylmercaptan and pentamethylene diamin. Indicanuria is very marked with obstruction involving the small intestine.

UNRECOGNIZED EPILEPSY.-W. P. Spratling, Sonyea, N. Y. (Jour. A. M.A., March 10), notices the fact that many cases of epilepsy go unrecognized for years to the damage of any prospects of cure. He attributes this in part of a false conception of the disease that it is a convulsive disorder-and in part to the non-recognition of its early man. ifestation such as "worm fits," "teething fits," which are considered as innocent in character when they should be always looked on in the most serious light. If a child has these, even if they apparently disappear with infancy or childhood, its convulsive tendency should be respected throughout its natural life, especially at the critical periods of its existence. He pleads for the early recognition and correct estimation and due treatment of the convulsive symptoms of infancy that so often mean epilepsy in later life.

HEREDITY; ITS INFLUENCE ON DISEASES OF CHILDREN.

FRANK M. FULLER, A. M., M. D.

KEOKUK, IA.

THE problem of heredity seems, upon its surface, so simple that it is not until one has gotten beneath and seen its diversity, that it becomes alluring.

"Like begets like" seems a truism comprehensible to all. Many comprehend no more. The theories to account for heredity in reproduction have been argued till there are now several distinct schools. Most biologists and naturalists find their beliefs lying somewhere between the extreme presentation of Darwin on the one hand, and Wiesmann on the other.

To have any conception of how heredity is maintained it becomes necessary for us to understand and premise with one of these theories, as held by Spencer, Haeckel, Galton, Brooks, Darwin or Wiesmann.

Darwin's theory, which is one of pangenesis, holds that all cells of the body throw off minute granules, which are collected from all parts of the body, into the reproductive centers. That these granules, containing all the male and female elements, and representing every tissue of the body, under proper conditions will reproduce a new organism. In this reproduction, however, only a small portion of the granules are used, the rest lying dormant in the new organism to continue the reproduction of its kind in any future generation.

Weismann's theory as originally given is that the body is made up of nutritive cells called "soma" and reproductive cells called "germ plasm." That the latter only enter into the formation of a new being by union with germ plasm of an opposite sex. That only a part of this germ plasm is used reproducing the muscles, bone and organs while the remainder is stored in the reproductive centers, independent of all other cells and used only in again reproducing the kind.

Under the latter theory, the germ plasm, being entirely independent of the soma or nutritive cells, cannot be acted on by the forces of environment; consequently whatever change in function may be produced with its new tendencies, there can be no inheritance of these new acquirements, because the reproductive germ plasm remains unchanged.

This theory is strongly held by many biologists, and as strongly opposed.

Environment is simply the sum of the forces, whatever they may be, climate, heat, cold, wealth, poverty, civilization, barbarism,

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