tributory causes must always be estimated in the light of degrees of aggravation of essential causes. What are the essential causes? There are many diverse and most, if not all, lie far back among constitutional defects (e.g., high blood pressure), early infections, toxic products of hypocatabolism, due to functional damage to the adrenal system, the chief defensive and regulative mechanism of the circulation.*

-This is about the worst indictment which can be formed against excessive bodily activities. It must be borne in mind that those instances which show clearly a history of excessive bodily fatigue (notably the cases of Thayer and Büsch, Jour. Am. Med. Ass'n., Sept. 10, 1904, cited by Sajous, Vol. II, p. 1555) are those who have suffered exhaustion, a very different thing from even excessive fatigue.

It is an interesting fact that those persons whose blood-pressure is constantly high, plethoric, overnourished folk, are superior in vigor till middle age; then they are liable to fall behind in the race; while essential organic interrelationships, may forge then to the front, last longer and do more.

Weak spots, when directly in the line of essential organic interrelationships, may readily become aggravated by overstimulation of the blood vessels by fatigue toxins, etc., until they give way. The giving way may be partial, occasional, relative and possibly reparable, in proportion to their persistency, rather than to any temporary severity. These starting points of damagement are only understandable and corrigible through an exact knowledge of the natural history and phenomena of disease, or there may be inherent in the individual such a

*These may be caused by toxic products of tissue catabolism, as those derived from muscles during violent exertion or from the brain during excessive mental strain, or both, the toxins of the infectious diseases septicemia, metallic poisons such as lead, mercury, etc. The adrenals are powerfully stimulated by waste products, disease and fatigue toxins, which induce extensive constriction of the vasa vasorum and arterioles, hence impairment of nutrition of larger arteries, inducing necrosis and hence atheroma, sclerotic patches, etc.

measure of restorability as can only be inferred.†

It will be plain, however, that the problem of giving way to strains is one thing.

It is quite another matter that the body shall be subject to such exercises as are well known and well calculated to enhance functional competence, hence structural integrity, the up-building of tissue, of power, of essential vigor.

It is with the last that the present contention has to do.

Other things being equal, the human organism advances by progressive degrees toward its highest efficiency by the steady, judicious active use of its various highly differentiated parts. Normal use contributes to higher and better degrees of differentiation. Neglect or disease opens the door to retrograde changes, the end of which is at least fraught with as many perils as overaction. The practicing physician sees vastly more evidences of harmfulnesses resulting from the reverse than the obverse. He may not always realize that the morbidities presenting are at bottom due to misuse or disuse, so uniformly is he called upon to apply remedies for functional depreciation. That physician is the wisest man who takes cognizance of both factors, and furnishes both correctives, radical measures for repair and education in symmetrical growth in reserve power.

It is too often the fault of the patient that he demands only immediate relief and fails to encourage prolonged supervision leading to radical repair

How then shall a person, say in middle life, proceed to secure that pleasurable, desirable state which may be called "good condition?" The term may be borrowed from the language of the athlete who, from being a person in vigorous health, yet proposes to use all known means to so enhance his vigor as to translate potential into kinetic energy, thence into the utmost power,

+Witness the mastery summary of the "Energies of Men," by William James (Science, March, 1907). or "The Factors of Safety," by S. J. Meltzer (Harvey Lectures, 1906), and other masters of physiology.

skill, speed, endurance, in short, concentrated vitality, of which his body is capable, to achieve victory.

Certain fundamental facts concerning the status of the body should be had in mind by everyone. The instinctive motor impulses of infancy and childhood are divinely implanted for the purpose of urging the individual to acquire symmetrical development, these normal activities leading to accurate adjustments and specializations of centers as well as of the grosser mechanisms. Moreover, this habitual utilization contributes not only to safety and efficiency as an animal, but also to intellectualization. Unless this habitual use is encouraged, along with suitable opportunities for the play of spontaneity, the individual is so limited in various directions that full competency is never attained. Few ever attain full development in any direction. Even in childhood there are constantly found evidences of deficient elaboration of parts. During the exigencies of varied forms of life these earlier defects frequently grow worse until they act as the weak links in an otherwise efficient chain.

It is entirely possible to attain sometimes extraordinary repair or development of these weak spots or parts, even in late life. I have cited, and can add to them, many instances of elderly persons overcoming defects by suitable developmental measures. Not seldom my experience with the individual is sufficiently prolonged to warrant the belief that life was not only made better and happier for them by these procedures, but actually prolonged. One notable instance is that of a dear friend who had been under my observation and direction for over fifteen years, who from such a state of feebleness that many regarded him as an irremediable derelict is now at sixty years, a man of full physical capacity, indeed, of wonderful vigor and endurance.

The one department of organic activity which demands chief attention is the heart and circulation, which stands at the base of much collateral functionation.

We may roughly define "condition" to be nice adjustment of the heart action to the

arterial pressure, and this to the respiratory capacity. There is much more, but this will serve as illustration.

Let me cite personal experience again. The narrative ensuing will serve to bring out several factors common to most other persons.

My professional work is similar to that of any active practitioner, continuous, irregular, exacting. The situation in summer is on the rocky Maine Coast near mountains. During the winters in the city I keep myself in as good a state of vigor as possible, but can get no time to pursue any open air sports other than an occasional walk. As stated elsewhere, my custom and pleasure is to utilize odd moments to elasticize, stretch, and make some active movements, mostly by systematic respiratory acts. Soon as the summer place is reached tests by walking uphill, etc., show my heart to be sadly out of condition. Each year I fear to find the effects of advancing age so serious as to forbid a return to full strength. Stiffnesses do advance, likewise painfulnesses in joints. There is only one period of the day available, between five and seven A. M. These two hours, or most of them, are devoted to bicycling to some attractive woodpath, donning moccasins, taking my cudgel and walking up slopes-often up one of several mountains of from 500 to 1,200 feet. At first breathlessness comes at once and limits climbing sadly. Every few yards of elevation compels rest. It was not the same at thirty-five that it is at fifty-three.

So much for leg exercises. The cudgel is valuable to activate the arms and torso; striking at bushes and occasionally devastating a small tree. This is far superior to golf for many reasons, chief among which is the fact that one may do this when and where he can find time.

(To be continued.)

OBSERVATION is a matter of education. It requires study to see things as well as it does to do things.-I. O. H. Advocate.

ALCOHOL: ITS PLACE IN MEDICAL PRACTICE.*

BY WILLIAM WAUGH, M.D.

Chicago, Ill.

WHEN the writer began the study of medicine the view prevailed that stimulation was but another name for whiskey. If any person was permitted to die of weakness it was the doctor's fault for not having pushed the whiskey. True, we knew that if enough whiskey was given the mental and physical faculties would be successively paralyzed, but we did not find it absolutely necessary then that we should be ready to explain everything; and the general truth and applicability of the above proposition were not seriously questioned.

Clinical experience gradually served to weaken this impression and the field for the application of alcohol became more and more restricted. The conviction was finally forced upon us that alcohol is not in any sense a stimulant, and that there is not a solitary clinical application that can be made of this agent, for which we have no other and better remedies.

It is now generally admitted that alcohol is in no sense a stimulant of either the mental faculties or the physical functions. In any dose it depresses the brain, the spinal cord and the nerves. The increased activity sometimes following its administration is not stimulation, but due to depression of inhibition, with consequent lack of control. This applies to the mental processes. Small doses of alcohol weaken self-control and destroy self-consciousness. There is in no sense an increase of mental power following. This is true, no matter what the dose of alcohol may be, or how it is taken.

It has been conclusively proved that alcohol is not an eliminant. After its administration there is often an increase in the excretion of urea and uric acid with the urine, and this led some to claim that herein lay the remedial virtue of alcohol. But it has been shown that this increased excre

*Read before the American Medical Society for the Study of Acloholism and Other Narcotics at Atlantic City, June, 1909.

tion is supplied by the food. The liver is so occupied with the task of intercepting and excreting the toxic alcohol that nitrogenous toxins in the food, that would otherwise be thrown back by this organ into the bowel for excretion, slip by this guardian of the vital portal and enter the blood, where they circulate, to the discomfort and detriment of the individual, to be thrown out by the kidneys. In nc conceivable condition of the human system could such a state of affairs be deemed advantageous.

From first to last alcohol is a depressant, weakening self-control, co-ordination, and the sway of the central nervous system over the physical functions, the control of the ego over the mental faculties. What then is the true cause of its repute? For there is always a reason underlying a popular belief.

Without advertising to minor consideration we may say that the value of alcohol is due to its power of quieting apprehension, and that of relaxing the tension of the blood-vessels. One action gives the patient a "Dutch courage" that is really due to benumbing that sense of danger that might otherwise lead to the avoidance of disaster. The other allows freer transpiration of heat by the skin and somewhat betters nutrition by permitting a freer supply of blood; and by relaxing mental, physical, -and moral-tension induces a pleasant sense of rest and comfort. I think that as we realize that this influence extends to the three spheres comprising our beingthe mental, the moral, the physical-and as we note how with the habitual drinker this sense of "ease" becomes continuous, we may see in it the sufficient explanation for the fascination exerted by this potent agent.

Relaxation, ease, rest, freedom from the obligations of labor, of endeavor, of conscience, from the spur of duty and the sting of remorse-surely there need be no quest for some mysterious underlying need of man's innate being to account for the universal craving for alcohol. The vinous pessimism of old Omar finds a ready re

sponse in many a world-weary soul. Lauder Brunton remarked that the reason so many men took to drink after passing middle age was that when they realized what fools they had been they got drunk to avoid going crazy. Which remark touched the center of a great truth. The realization by man of his own limitations and inefficiencies is not always accompanied by that abolition of self-conceit that prevents him expecting too much of himself.

In general, the objections to alcohol as a stimulant are, then, that it is not a stimulant at all, but in all doses and in every sense a depressant, lessening the control of the nervous system, relaxing vascular tension, weakening the heart, increasing the radiation from the cutaneous surface and lowering the vital resistance. It interferes with the action of all the enzymes and only aids stomach digestion by an irritation of the mucous membrane, which is very often undesirable; and when advisable may be induced by less objectionable means. It paralyzes the leucocytes and then restrains them in combating invading micro-organisms, rendering the assaults of the latter on the vital organism more effective. It interferes with elimination by occupying the powers of the liver, as we have shown.

With these general objectionable features it will be seen that alcohol contravenes every principle of modern therapeutics which looks to elimination of toxins, conservation of the vital forces, with moderation of disease processes, as three great indications for the exercise of the physician's art. This being the case, we have to ask what are the advantages in its clinical application that may counterbalance so many and such weighty objectionable features?

In shock, syncope and heart failure we have imminent peril of death from sudden cerebral anemia. Alcohol further paralyzes the vaso-constrictors of the abdominal vessels and allows the blood to accumulate in their capacious recesses. Glonoin sends the Glonoin sends the blood to the brain, acts much more quickly than alcohol, and is here a life-saver. The

effects of glonoin may be prolonged by the addition of atropine, whose power is developed more speedily when glonoin is simultaneously administered. The effect of this combination is exactly what is needed, it is certain, and where time is so precious that a human life hangs on a few seconds delay in getting one's remedy into action, its almost instantaneous action is too precious to be lost.

As a stimulant to counteract the depression caused by sedative poisons alcohol is dangerous as being itself a sedative poison. Strychnine is here the remedy, with atropine and glonoin whenever cerebral anemia is a feature. In poisoning by the strychnine group the vascular sedatives and analgesants offer remedies surer, quicker and more effective than alcohol.

The whiskey treatment of snake-bites is firmly inplanted in the affections of the people; yet nothing in medicine is better proved than the fact that to the essential action of venom alcohol is synergistic. The danger here lies in paretic dilatation of the great abdominal vessels, into which so much of the blood retreats that the brain is left destitute. Alcohol increases this vasomoter paresis and consequently adds to the danger. It has been shown that this vasomotor relaxation is exactly remedied by strychnine, and that the patient's life depends on giving enough strychnine to exactly balance the effects of the venom, even though the dose required is such as would certainly cause the patient's death if no venom were in his system. Here again we find the indication. for glonoin and atropine, but none for alcohol.

Typhoid fever: We have here presented one of the most remarkable contradictions in the history of clinical medicine. For in no disease has the use of alcohol been more urgently insisted upon than in this, nevertheless there is not an element of considerable danger in this malady which is not enhanced by this potent agent. Typhoid fever is a disease characterized in the first place by profound toxemia and consequent vital depression, and by a lack of that

protective leucocytosis which is present in almost every other infectious malady.

As we have seen, the toxemia is increased by the use of alcohol, which interferes with the natural elimination of toxins by occupying the forces of the liver for its own destruction or elimination. Besides that, it inhibits the action of the phagocytes, and thereby lessens the natural defenses of the body. Moreover, we do not have in this malady the excuse for the administration of alcohol which is present in such emergencies as snake-bite, because we have no sense of apprehension to allay, no need for Dutch courage. The patient is already saturated with toxins and there is a general vascular relaxation throughout the body, which constitutes one of the principal dangers leading to hypostatic congestion of the dependent parts, predisposing to a peculiarly perilous form of pneumonia.

The indication is for support and elmination, and support more decided than could be secured from alcohol, even though it really were a stimulant. All the elements of danger are enhanced by the use of alcohol, and it is a striking illustration of the truth, that in no disease can a patient go so low and yet recover as in typhoid, that despite the almost universal use of alcohol the proportion of recoveries has been as large as it has. The modern treatment of this malady is: first, to keep the bowels ciean and aseptic, and not leave poisonous fecal matter in contact with open intestinal ulcers. Elimination must be maintained, the vital forces must be sustained. In no malady is the problem of feeding presented with such difficulties, or of more importance. It is best solved when alcohol is omitted and foods given that can be absorbed from the stomach.

Much of what we have just said applies to the administration of alcohol in pneumonia. Here again we have peculiar difficulties; and the added toxemia, relaxation of the circulation and enfeeblement of the heart, with the increased afflux of blood to the lungs due to the action of alcohol, al!

add to the danger. The tendency to delirium in pneumonia is also increased by the use of alcohol. Altogether one is tempted to say that if any remedy is formally contraindicated here, it is alcohol. Great success has followed the treatment of this disease by lessening the bulk of the blood and moderating the pressure on the heart, which is over-excited and forcing too much blood into the suffering lungs; by strengthening the heart when the slightest evidence of coming weakness is manifested; by regulating the vasomotor equilibrium throughout the body and sustaining the vital forces; while subtracting from the sum total of the symptoms of disease such as are due to depravity of the blood, from absorption of fecal matter retained in the bowel beyond the normal time. This applies to every febrile disease. In all of them alcohol cannot but increase the danger, as interfering with elimination and relaxing vascular pressure, besides, paralyzing the defensive phagocytes.

The one advantage which comes from the increased radiation of heat from the body is easily secured by other remedies, which have not the same objections.

Alcohol has also been urged in wasting diseases, occasioned by long suppuration, by impaired digestion, or by tuberculosis. In the first place we have effective remedies in calcium sulphide and other calcium salts, whose use stops microbic destructive action and promotes the reconstruction of the wasted tissues. By the administration of nuclein we also have the means of restoring the number and increasing the activity of the leucocytes, which are being destroyed in vast numbers in the contest with the micro-organisms occasioning suppuration. These remedies directly increase the natural forces of the body, which alcohol as directly impairs.

In the second class of wasting diseases, those due to digestive derangements, the indication is to restore digestion by the use of such remedies as are needed in each case, by a carefully regulated diet, and by the institution of a correct personal and