THE SUCCESSFUL TREATMENT 
OF 
CHRONIC DISEASES. 
A PLEA FOR THEIR MORE 
Methodical Management. 
BY 
SIMON BARUCH, M. D. 
Physician to the Manhattan General Hospital, New York Juvenile 
Asylum and Montefiore Home for Chronic Invalids. 
Read at the 86th Annual Meeting of the Medical Society of the State 
of New York, February 2d, 1892. 
Reprint from the Dietetic Gazette, Jan., Feb., March, 1892. The Successful Treatment 
OF 
Chronic Diseases. 
A PLEA FOR THEIR MORE 
Methodical Management. 
BY 
Simon Baruch, m.d., 
Physician to the Manhattan General Hospital, New York Juvenile Asylum 
and Montefiore Home for Chronic Invalids. / . .' "J. 
Reprint from the Dietetic Gazette, Jan., Feb., March, 1892. THE SUCCESSFUL TREATMENT OF CHRONIC 
DISEASES. A PLEA FOR THEIR MORE 
METHODICAL MANAGEMENT.1 
By Simon Baruch, M.D., Physician to the Man- 
hattan General Hospital, New York Juven- 
ile Asylum and Montefiore Home for Chronic 
Invalids. 
The modern management of diseased conditions is 
a happy evolution from the more crude methods of 
our predecessors. In this most important department 
of medical activity we are, however, still compelled to 
acknowledge many deficiencies and shortcomings. 
While in other branches medicine has made great ad- 
vances since the day of Hippocrates, it must be con- 
fessed that in the treatment of disease, which is the 
chief aim of our lives, we may with advantage listen 
to the instructions of the Nestor of Medicine to-day. 
Ami there have been not very remote periods in the 
history of medicine when the prevailing practice, con- 
sisting chiefly of spoliative measures calculated to at- 
tack and conduct the disease by sledge-hammer 
blows, which to-day appear as stages of retrocession, 
ami which demonstrate the vast superiority of the 
Hippocratic idea of therapeutics to that prevailing in 
that period. W hat has been the outcome of the dis- 
1 Head at the 86th Annual Meeting of the .Medical Sociel#- 
of the State of New York, February 2d, 1892. 4 
putations of the schools ? What is the modern status 
of therapeutics ? To-day we stand in breathless ex- 
pectancy, awaiting the dawn of precision in therapeu- 
tics. This hope is vain ! Recent experience has 
demonstrated the fallacy of specific therapeusis after 
it had been promulgated by a master mind and 
adopted as an experiment by the best clinicians in 
every part of the globe. Just as in ancient warfare 
the agony was prolonged, the sufferings and serious 
incidents thereto multiplied, so has ancient therapy 
countedits vast numbers of victims ere the truth was 
ascertained. Just as in modern warfare the master- 
minds of miltary science crush one or the other army 
by improved arms and tactics, so do we find in mod- 
ern therapy a great clinical experiment made, which 
in a few months has almost decided the fate of a 
treatment, the determination of whose merits would 
formerly have required a hundred years and many 
thousands of victims. This, then, has been gained- 
that medicine is no longer under the thraldom of 
schools, but every idea is at once placed in the 
crucible of experiment, whence it emerges as useful 
or perishes if worthless. 
The result of the analytical methods of modern 
therapeutics is the realization of the fact that the 
physician must act as the alert assistant to the conser- 
vative powers residing within the body, and whose 
tendency is usually in the direction of restoration. 
In other words, we have come to recognize that as 
the healthy organism stands under the protecting and 
preserving influence of nature, so does the diseased 5 
organism owe its progressive stages to the same 
forces. As I said nearly twenty years ago in an ad- 
dress before the South Carolina Medical Association, 
" Disease, we are now taught, is not the negative of 
health, for the same forces which are silently evolved 
in the normal and peaceful actions of life are 
aroused from their quietude by unfriendly influences. 
Order and law reign even where the human eye dis- 
cerns only labyrinthian confusion and disorderly tur- 
moil. In the apparently discordant manifestations of 
diseased action, the sam^ guiding thread will be dis- 
covered whose just appreciation will guide us to the 
goal of success." 
Twenty years have elapsed since I uttered these 
words, and to-day observation convinces me more 
fully of their correctness. It is almost regarded as 
an axiomatic truth in therapeutics that in acute dis- 
eases, at least, the physician cannot throttle disease, 
but must watch and wait for a point of vantage, when 
he may come to the rescue of the system, which is 
battling against it. To weaken the influence of the 
disease, to strengthen the resistance of the organism, 
are the great principles of the modern treatment of 
acute diseases. 
Whether we do so by rest, diet, bathing, antipy- 
retics, anodynes, hypnotics or by specific agents like 
quinine and mercury, this is the recognized goal of 
the modern management of acute diseases. 
Unhappily, a long time elapsed ere this idea was 
realized ; and even to-day we occasionally encounter 
narrow minds who claim to fight disease with mighty 6 
weapons, regardless of the fact that the patient is the 
battlefield and must bear the brunt of both contend- 
ing forces. 
It is the aim of this paper to emphasize the neces- 
sity of recognizing the same therapeutic principles in 
the management of chronic disease that have happily 
attained almost universal adoption in acute disease. 
It cannot be denied that the former are quite as 
fatal and destructive of comfort, means and happiness 
as are the latter. Acute diseases almost always tend 
toward recovery. If the latter does not ensue, the 
case is sharp, short and decisive. Chronic diseases, 
on the contrary, invade the system insidiously in many 
instances. Like a thief in the night, they often come 
upon the unguarded organism, causing destruction of 
important tissue-elements, whose restoration is often 
well-nigh impossible when our aid is invoked. Years 
of suffering and sorrow ensue, involving loss of 
means and demanding sacrifices from the family of 
the afflicted which wreck their fortune, if not their 
own health also. 
When we are called upon to treat a case of typhoid 
fever or other acute disease, we stand at the bedside 
tilled with hope and courage, feeling a certain degree 
of security in the knowledge that we have a powerful 
ally in the vis medicatrix natune, to assist which all 
our energies are bent. How different is the idea which 
animates us when a case of diabetes or chronic 
rheumatism comes to us for treatment. Does the 
modern physician, who is so trustful to nature in 
acute disease that he has almost become a therapeutic 7 
Nihilist, feel inspired with hope or confidence in the 
issue? Far from it, alas! Palliation is the chief 
goal of his therapeutics ; he thinks not of restoration. 
No' wonder that he undertakes the case handicapped 
by his apprehensions and treats it in a half-hearted 
manner. He has certain ideas about diet in gout and 
diabetes, cod-liver oil in phthisis, iodide of potassium 
in chronic rheumatism, etc.; but he cannot often lay 
his hand upon his heart and say to himself that he 
has ever cured a correctly diagnosed case of this kind. 
This is a serious question. It would be the height 
of egotism were I to announce this dictum upon my 
own personal authority. It cannot be gainsaid that 
there are many chronic diseases, acknowledged to be 
incurable, which would yield to systematic, persistent, 
judicious treatment, applied as we apply it in acute 
diseases. I say this from my own experience of thirty 
years in private and hospital practice, in civil and 
military, in rural, village and metropolitan life. I say 
it, sustained by the published experience of clinical 
teachers like Ziemssen, Dujardin-Beaumetz and Sem- 
mola, representing three countries. 
The removal of the manifestations of acute disease 
is usually regarded as the cure of that disease. Its 
recurrence at a more or less remote period does not 
invalidate this opinion. And yet the professional and 
lay mind is loth to accept the same view with regard 
to chronic diseases. We sometimes hear it said: "This 
case of phthisis is no longer recognizable by physical 
signs nor subjective symptoms, the patient has re- 
gained his normal weight, appearance and activity, 8 
but he is not cured, because phthisis is incurable, it 
will recur under favoring conditions." The fallacy of 
such an argument is apparent if it be applied to pneu- 
monia or malarial fever or acute rheumatism. More- 
over, the best proof of its curability is found in the 
fact that autopsies have often revealed cicatrization, 
restoration of weight and normal conditions of a dia- 
betic patient, and their continuance under a moder- 
ately normal diet should be regarded as the recovery 
of that patient from diabetes. 
So it is with chronic gout and rheumatism, and 
more especially with all those functional nervous and 
gastro-intestinal diseases, whose entire removal is pos- 
sible under proper management. If all the manifes- 
tations of a chronic disease have ceased for a reason- 
ble length of time, such disease is, in my opinion, 
cured as completely as an acute disease, with the con- 
dition that, since chronic diseases are usually traceable 
to slow and insidious etiological factors, these must 
be sought out and removed in acute diseases. 
What are the elements of success in the manage- 
ment of chronic disease ? In order to answer this 
question we must narrow it down to definite diseases. 
I desire to refer here chiefly to 
1st. Diathetic diseases,ras phthisis, rheumatism and 
gout. 
•2d. Functional diseases-i. e., those in which no 
positive destructive change in tissue elements has 
taken place. 
In both classes of'disease the road to effective man- 
agement lies, as it does in acute disease, to sustaining 9 
the resisting power of the organism, and to weaken- 
ing the force of the disease. 
PHTHISIS. 
Phthisis offers a good illustration. This is a 
disease in which there is a local manifestation 
due to a general infection. Realizing this fact, its 
most modern management has become exceedingly 
simple, and more successful in proportion to its 
simplicity. We have the testimony of specialists like 
Dettweiler and others to the clinical fact that by re- 
moval of the patient from his unfavorable environ- 
ment to an institution in which pure, dry air, com- 
bined with appropriate food and other elements of 
treatment may be obtained, we weaken the disease 
and improve the patient's chances of recovery. The 
chief method by which the force of so progressive 
and destructive a malady as phthisis may be under- 
mined is to neutralize as far as possible its etiological 
factors. The latter are usually hereditary influences 
and a mode of life which has enhanced the vicious 
innate elements imparted by heredity. These cannot 
be removed, but they may be neutralized to a great 
extent, especially if recognized early, by removing 
the patient from a crowded city or from a badly- 
constructed country home, from sedentary occupation, 
from association with other tuberculous patients. 
This step is unhappily taken too late to afford the most 
satisfactory results. But that cases of early recog- 
nized phthisis may thus be brought to recovery is so 
well ascertained a clinical fact that climatic agencies 10 
have been the chief agencies of phthisis-therapy for 
many years. There is, however, much groping in 
the dark, much haphazard prescription of change of 
air, which has brought discredit in the lay and 
professional mind upon this all-important element of 
treatment. 
Simplicity is in this matter as important as it is in 
all therapeutic questions. It is a principle recognized 
by those best qualified to judge that the climate which 
affords the patients the best opportunity for the 
most continuous breathing of pure air, air free from 
dust or other vitiating matter, is the most useful 
climate. While other elements, such as altitude, etc., 
are important, absolute purity of the air and the 
possibility of utilizing it at all times, night and day, 
without interruption, is the chief. This is the kernel 
of rational therapy of phthisis. 
Allow me to cite an analogy for the purpose of 
emphasizing it. In the preaseptic (the antiseptic) 
period it was regarded as a sine qua non to treat 
wounds with strong solutions of antiseptics; the air 
even was impregnated with them. Now surgeons 
recognize absolute cleanliness of the field of opera- 
tion and of the operator as the cardinal principal. 
The poisonous antiseptics formerly deemed necessary 
are cast aside by many because they are harmful. 
The one great truth stands ever before the eye of 
the modern surgeon-cleanliness; absolute, scrupu- 
lous cleanliness leads to success. To its recognition 
modern surgery owes its greatest triumphs. Change 
of climate for consumptives is extremely valuable, 11 
but it involves many disadvantages, which are far 
more fatal to its success than the abuse of antiseptics 
is in wound treatment, and yet we continue to send 
patients away from comfortable homes to uncom- 
fortable hotels and boarding-houses, or incomplete 
sanataria, where many disadvantages in diet and 
probable indiscretions in exercise neutralize the most 
valuable element of all appropriate climates-pure air. 
It will be a glorious day for medicine when the 
physician will recognize that the constant exposure of 
the phthisical patient to pure air is the cardinal truth 
of climate-therapy, as cleanliness is now recognized by 
the surgeon in wound treatment. 
Formerly it was thought absolutely essential to 
send phthisical patients to the South. A semi-arctic 
region like the Adirondacks would have been regarded 
by our forefathers as absolutely detrimental, if not 
fatal. To-day many consumptives find relief and cure 
in the cold, dry air of mountainous New York and in 
distant Colorado, as well as in the mild atmosphere of 
the south of France, or Algeria, or Florida. 
To resume our analogy. The discussion as to the 
superiority of sublimate, the comparative merits of iodo- 
form and boracic and carbolic acid, which were replete 
with interest and profit at one time, are now of second- 
ary interest, since we know that pure, undefiled man- 
ipulation of the wound is the chief object of asepsis. 
When contending climates have exhausted their argu- 
ments (which are as interesting and profitable in con- 
nection with phthisis-therapy as once were the argu- 
ments on the various vaunted antiseptics in surgery) 12 
the cardinal principle of treatment will stand out in 
bold relief. It will then be clearly apparent that it is 
not this or that particular climate ; it is not this or 
that particular altitude which is most conducive to 
recovery, but methodical treatment under conditions 
which afford the patient the best opportunity for out- 
door life, in air that is free from dust and other vicious 
elements ; these are the true curative factors. 
This idea has been most successfully, because most 
intelligently, carried into practical execution at Falk- 
enstein, where Dr. Dettweiler looks with disfavor 
upon medicinal remedies and pins his faith chiefly to 
the curative influence of pure air, to which he ex- 
poses his patients, without regard to the rigorous cli- 
mate in winter even, at all seasons. The discipline of 
this institution is rigid, and almost military in exact- 
ing obedience. At 8 a.m. the patients are expected 
to be down-stairs, under penalty of a fine. Then each 
one stretches himself upon his reclining chair, of 
which there are a very large number in the large halls, 
which he leaves five or six times during the morning 
to take a ten or fifteen minutes' walk. "Patients are 
advised to walk slowly, on a gentle slope, with should- 
ers erect, and every fifteen minutes to fill their lungs 
to their full capacity by inhaling through the nose." 
Breakfast is served, consisting largely of milk, after 
which the patient returns to his reclining chair, and 
the rest of the day is passed in the same manner as the 
morning. Dettweiler is most autocratic among his 
patients, and teaches them to cough only three times 
a day. Hence each cough is followed by expectora- 13 
tion, and he never allows them to cough uselessly. 
Three times a day each patient takes his own mouth 
temperature and notes it upon the chart. At 10 p.m. 
each one returns to his bedroom, which has remained 
open the entire day ; the window is left partly open 
the entire night, covered by a light blind. 
No drugs whatever are used at Falkenstein, and 
and still the results are most satisfactory, thirty-seven 
per cent., including all grades, recovering completely. 
Prof. Bouchard has recently introduced this treat- 
ment into France. lie says : " The windows must be 
left open, even during winter nights. Certain precau- 
tions are necessary, but if the treatment is begun in 
the summer time one is easily accustomed to it. In 
the beginning it is best to leave the window open and 
draw the blind, and in very cold weather even the 
curtain may be pulled down. If patients object 
strongly to this, the windows in an adjoining room 
may be opened and the door left open. By this means 
a constant supply of fresh air is obtained. If the 
temperature goes below 50° F. a fire had better be 
lighted in the room. There is no danger of taking 
cold as long as one is well covered in bed. 
Dr. Nicaise has reported to the French Academy 
of Medicine his experience with this treatment, dur- 
ing the winter '88-'89, on the Mediterranean. He 
finds that there is no danger in leaving the window 
open during the coldest nights in winter without a 
fire, provided the temperature does not go below 509 
F. Below this point it is not advisable to allow the 
temperature to go. The aim is to enable the patient 14 
to inspire perfectly fresh (not cold) air, which is con- 
stantly made to stream in through open windows, 
chimneys and doors or window-cracks. 
This " open-window " method of treating phthisis 
has recently been practised with great success by Dr. 
M. Moizard, of the Hdpital Tenon, at Paris. He 
adopts Dr. Dettweiler's ideas in toto. " The rooms," 
says he, " must be ventilated in such manner as to 
avoid the possibility of a draught. The patient must 
not be covered with too many blankets, but should 
wear a warm night-gown, flannel underwear and a 
woollen vest. He should be taught to breathe through 
the nose." Dr. Moizard first accustoms his patients 
to sleep with open windows in the summer. The 
sleeping apartment chosen for his experiments had a 
lofty ceiling and a window on each of the four sides ; 
four beds were placed in it, each being occupied by a 
man. A large window facing to the south was left 
open day and night, but covered with a blind at night 
to prevent too great reduction of the temperature. 
The temperature of the room, which was observed 
from the beginning of the experiment, varied from 
8° to 17° C. Towards the end of November it fell to 
5P C. without giving rise to unfavorable symptoms in 
the patients. It was thought best, however, to keep 
the room heated during the cold weather. In this 
manner, while in the middle of January the tempera- 
ture outside was as low as 0. 10° C., that in the room 
never fell below 8° C. 
The most striking result observed was the increase 
of appetite, followed by a gain in weight. A certain 15 
number of patients, especially those suffering from 
incipient tuberculosis, gained in weight as much as 
three pounds every week. Cough and expectoration 
were diminished, and the night-sweats disappeared 
rapidly. The fever due to pulmonary congestion and 
breaking down of the tuberculous foci was promptly 
reduced ; but fever caused by the broncho-pulmonary 
complications was not modified, and these patients 
had to be removed from the influence of the cold 
air. If we eliminate the latter cases it may be said 
that the benefits derived from this treatment are al- 
most equivalent to a cure. 
The indications of Herotherapy are very extensive. 
Patients in the third stage of phthisis, with cachexia 
and high fever, are, however, not likely to be bene- 
fited. The most favorable cases are those in which 
there is a tendency to the formation of fibrous tissue, 
as in cases of chronic bronchitis, fibroid phthisis, em- 
physema and rheumatism. Fever and haemoptysis, 
although considered as serious symptoms in chronic 
tuberculosis, do not constitute a contra-indication to 
this treatment. On the other hand the inhalation of 
cold air will often prevent hemorrhages and reduce 
temperature of the body. In conclusion, Dr. Moizard 
states that, with the exception of cases of acute tu- 
berculosis and broncho-pneumonia, this method affords 
much relief in the ordinary progressive form of 
phthisis, arresting denutrition, fever, night-sweats 
and diarrhoea, especially if it is resorted to at an 
early period. 16 
At Brehmer's Institute, at Goerbersdorf, the same 
principle has long been adopted. The patient is almost 
constantly exposed to fresh air, without drafts, and 
well protected against too sudden changes. Even 
the dining-rooms are kept at a temperature of 
65° F. at all seasons, and the air is renewed five times 
every hour. The results obtained by this Nestor of 
simplified therapy are gratifying in the extreme. Of 
554 cases of phthisis treated in 1888, 49 (i. e. 8.8 per 
cent.) were completely cured, 71 (13 per cent.) were 
nearly cured-that is, neither bacilli nor elastic fibres 
were longer present in the sputum-28 were not 
helped and 34 died. The others were helped some- 
what, as shown by a gain in weight averaging 11 
pounds. Of the 150 who remained in the institution 
during the winter 1887-88, 17 died, 6 remained un- 
changed, and the other 127 showed a gain in weight 
averaging 19| pounds." 
This principle involving the paramount importance 
of a continuous supply of fresh air, seems to be so 
well established that it should be made the guiding 
star in all cases, whether they be under institutional 
or private treatment. 
II. The second indication is to endow the system 
with the power of resisting the inroads of the estab- 
lished disease and treating complications and sequel®. 
That indication may be met by the fulfilment of the 
first indication, residence in an appropriate climate, 
by a proper and carefully regulated diet and hygiene, 
by certain medicinal agents, and last, but not least, 
by a judicious hydrotherapy. It is not my aim to dis- 17 
cuss here the medicinal agents that have from time to 
time been recommended in phthisis, from cod liver oil 
to the more recent hypodermic medications. I desire 
chiefly to dwell upon the non-medicinal agencies- 
agencies whose value has been thoroughly tested and 
approved. Among these a brief reference to the 
errors of omission but too often practised, and which 
sad experience has taught me to learn, is the necessity 
of careful regulation of exercise. Much attention is 
usually given to regulation of the diet. While I re- 
gard this as important, it is secondary to exercise, be- 
cause when the patient is suffering from invincible 
onorexia nothing but the most simple food will be 
taken and assimilated. It is not so with exercise. 
Consumptives who are not bedridden are but too 
frequently allowed, if not advised, to indulge in exer- 
cise short of fatigue. This is an error which has 
cost many lives and much misery. If we would re- 
flect that we have a localized inflammatory action to 
deal with the fallacy of advising anything that must 
increase the labor of the inflamed organ must at once 
become apparent. 'No argument should be needed to 
enforce the most absolute quiescence of the diseased 
organ. On the other hand the lung needs thorough 
ventilation, the affected parts require the contact of 
pure air, the blood needs its invigorating influence ; 
the nervous system cries out for it. To " steer be- 
tween Scylla and Charybdis" in these cases is, indeed, 
a difficult problem. It is, in my experience, always 
best to err on the side of rest so long as the evening 
temperature is above 100Q. If the morning tempera- 18 
ture reaches 99°, moderate, gentle walking on level 
ground, with frequent respites or carriage exercise, 
may be resorted to at that time. The plan adopted 
by Dettweiler and Brehmer of exposing the patient 
to the constant influence of pure air and sunshine 
without the possibility of chilling them, is the most 
useful, and may be accomplished in private practice 
also, as I shall show. Abstention from exercise, 
then, when the temperature is habitually above 100°, 
should be the rule. But it would be equally unsafe 
to allow the patient to rest in illy-ventilated cham- 
bers ; indeed, it would be more unsafe to let him 
breathe the air vitiated by himself or others. 
The lungs should be treated as is every other in- 
flamed organ. So long as active inflammation exists 
they should be kept at rest, or slowly and gently ex- 
panded. When the presence of fever precludes out- 
door exercise simple out-door life must be substituted 
with massage or passive movements to stimulate the 
muscular system. Much of the ill-effect of absolute 
quiescence will be counteracted, as I shall show, by 
hydrotherapy. 
In this measure we possess an agent whose power 
for good is incalculable, and which has given me 
more valuable assistance than all other means com- 
bined. The judicious application of cold or cool 
water to the periphery produces a stimulus to the 
sensory nerves which is transmitted to the central 
nervous system, and thus refreshes every function 
dependent upon the latter. 19 
The respiration is gently but slowly deepened when- 
ever the cold water impinges upon the skin. The 
heart is made to contract with more vigor when the 
peripheral circulation is improved by the shock, and 
consequent contraction and subsequent dilatation of 
the cutaneous capillaries. The appetite is improved, 
tissue-change increases, and if there is a rise of tem- 
perature it is subdued mildly but surely. Of course 
these effects depend upon the intensity of the cold 
and the manner of its application. 
TONIC EFFECT OF HYDROTHERAPY. 
That hydrotherapy has demonstrated its value as a 
tonic agent is a well-known fact. Its value in phthisis 
has been recognized by Brehmer, who even claimed 
to be the first one to apply it in this disease. Win- 
ternitz has shown that it must be an agent of decided 
tonic power, inasmuch as out of 2,400 guests at his 
institute in Kaltenleutgeben, which I have personally 
visited, 56 per cent, showed an increase of weight. 
Therefore, as nutrition is the chief aim in phthisis-ther- 
apy we possess in this method a powerful weapon 
which, rightly used, has demonstrated its value. 
But, aside from this important consideration, the 
predisposition t® repeated colds and consequent prob- 
able aggravation of the local processes and general 
symptoms may be diminished by the neuro-vascular 
discipline to which the skin is daily subjected by ap- 
plications of cold water in some appropriate form. 
This hardening process has long been recommended 
for those predisposed to phthisis. Ziemssen speaks of 20 
it in his lectures on treatment of tuberculosis as " a 
remedy of extraordinary value for persons who are 
predisposed to have acquired phthisis." 
TECHNIQUE. 
The technique of these procedures varies with each 
case. Brief applications of low temperature, as by 
the douche or rain bath ; the wet pack, or rapid ablu- 
tions, are followed by rapid reactions, and, if well 
borne, are exceedingly useful as tonics ; while, on the 
contrary, in cases suffering from elevated tempera- 
tures and great debility more gentle procedures and 
higher temperatures are required. I have myself seen 
damage done to these cases by too cold applications, 
which are better indicated in a-febrile or mildly fe- 
brile, condition. This is contrary to views usually en- 
tertained on the therapeutic action of cold baths. 
My observation at the Montefiore Home for Incura- 
bles, in which cases of the most forlorn type, so far as 
previous hygienic surroundings are concerned, are 
received, has led me to adopt the following course, 
because the skin of many of these poor people have 
long been strangers to cold water, or, indeed, water 
of any kind. 
After a thorough cleansing warm-bath or soap 
ablution, a day is allowed to elapse. The patient is 
now wrapped snugly, quite naked, in a woolen 
blanket, so that his entire body is excluded from air; 
other blankets are piled over him ; the windows are 
opened, and he is given a small glass of iced water 
every ten minutes. Having lain in this position an 21 
hour, now one part of the body is exposed and 
bathed as follows : A basin of water at 75° is 
ready, into which the attendant dips his right hand, 
covered by a mitten or glove of Turkish toweling. 
With the wet glove the face is well bathed. Now 
one arm is exposed and rapidly washed and rubbed, 
then dried and replaced under the blanket. Other 
parts are then successively treated. At the termina- 
tion of this ablution the patient is rapidly rubbed all 
over with a coarse towel. This treatment is repeated 
daily, the temperature of the water being reduced 
two degrees on each occasion. 
'rhe next step is the dripping sheet. The patient 
standing in a tub of water at 100° F. has a sheet dip- 
ped in water at 70° thrown over his head and body 
from behind and is wrapped completely and snugly in 
it. The attendant now rapidly passes his outstretched 
hands over successive parts of the body, with some 
pressure upon the sheet. He rubs the sheet, not with 
the sheet. One or more pitchers of water, five to ten 
degrees colder, are thrown upon the parts that have 
been subjected to friction. The sheet is removed and 
the patient rapidly dried. This method requires great 
care and skilful application. Its success or failure de- 
pends upon ascertaining by previous treatment the re- 
active capacity of the patient. The most useful hydri- 
atic procedure in phthisis, however, is the rain bath. 
Unfortunately, this finely-divided douche can only be 
administered in institutions. The patient stands 
within a frame constructed of six semi-circles of inch 
tubing, the upper one on a line with the clavicles. 22 
Each tube has three lines of fine perforations, the 
upper line directed upward, the middle straight for- 
ward, the lower downward. The water should have 
a fall of not less than forty feet. The temperature 
adapted to the average case of phthisis is 65° F. 
Here the pressure with which the water strikes the 
body affords a kind of massage which assists in pro- 
ducing reaction even in feeble individuals. But it 
should not be applied without previous training of 
the skin as above described. The rain-bath is an 
antipyretic of great value, if its temperature is not be- 
low 60° nor above 70° ; it is a stimulant and tonic if 
between 55° and 65°F. The skin should become pink 
while under it, and the patient must not be chilled by 
it ; at least any coldness he may experience should 
disappear after he is dried. 7'his, indeed, is a test of 
the efficiency of all hydriatic procedures. Decided 
chilliness continuing after thorough drying and fric- 
tion is an evidence of improper selection of the tem- 
perature, duration or method of the bath. These 
should be modified as indicated by their effects. 
The following cases taken from the records of the 
Montefiore Home, by Dr. M. Rosenthal, the senior 
resident physician, may serve as an illustration of the 
clinical results of this treatment : 
J. J., tailor, ret 33, German ; admitted February 2, 
1890.-Family history negative. Illness of one and 
one-half years' duration. Began with a pulmonary 
hemorrhage, followed by cough ; spat blood two 
days and felt better after it. Continued to cough 
until December, 1889, when he had a most severe 23 
hemorrhage, became very weak and was confined to 
bed. Continues weak ; cannot work ; coughs a great 
deal ; expectorates a little mucus, often mixed with 
blood. Complains of pains in back, tickling in 
larynx ; appetite is good, bowels regular. Physical 
signs.-Dulness over right upper lobe, as far as first 
rib, posteriorly to border of scapula ; slight dulness 
over left apex ; uncertain and accentuated breathing, 
with prolonged expiration over the right apex, feeble 
respiration over left. Temperature normal ; pulse, 
84 ; respiration, 28. 
February 18.-Weight, 135 pounds. 
Treatment.-One minim creosote pill, two t.i.d. 
with coddiver oil Z ss. Rain-bath at 65° for 30 sec- 
onds daily. 
March 1.-Coughs only a little in the morning. 
Weight, 14 2^. 
March 10.-Doing well. Weight, 147^-. 
March 20.-In fair condition ; quite a little cough 
in the morning. Weight, 149d. 
March 27.-Weight, 152^. 
April 5.-No complaint. Weight 156. 
April 25.-Weight, 161|. 
Ahay 5.-In the last few days appetite is not so 
good ; otherwise feels very comfortable. Coughs 
sometimes in the morning; no expectoration. 
Weight, 160^. 
Dr. Dessau examined patient to-day. He found : 
Very slight broncho-vesicular respiration in the left 
apex. Impaired resonance on percussion over the 
same, ami very few mucous rales. On the left below 24 
the scapula very few subcrepitant rales, probably due 
to some old pleuritic adhesions. 
ATay 11.-Right apex, vesicular respiration and 
very slight impaired resonance, which is often found 
normally in right chest, so that practically we can 
find now only a very slight infiltration of left apex 
with some old pleuritic adhesions. 
Weight, 161 (a gain of 26 pounds). 
Discharged at his own request. He has been at 
work since that time. 
I. D., aged 36 years, ill two years and a half. Had 
hemorrhage two years ago ; since then night-sweats, 
cough, expectoration and pain in left side. Has been 
treated twice at Mount Sinai Hospital for phthisis. 
Physical Signs.-On admission dulness over left 
apex, impaired breathing ; pleuritic friction rales on 
right side along auxiliary space. AV eight, 1624 
pounds. 
Treatment.-General sustaining measures, with 
daily rain-bath at 65° for thirty seconds ; damp com- 
presses to chest. 
Result.-Improvement of all symptoms, and gain of 
fourteen pounds and a half during ten weeks. 
December 16, 1890.-He was subjected to tubercu- 
lin treatment until April 29, other treatment being 
suspended. The reactions were accompanied by 
marked changes in the physical signs, several times 
amounting to positive evidence of localized pneumonia, 
with temperature of 104° ; bronchial respiration and 
voice over left apex to third rib, and sibillant rales 
over right chest anteriorly. These usually disap- 
peared in forty-eight hours. 25 
The patient lost so much weight and general ap- 
pearance that I frequently felt misgivings as to the 
propriety of subjecting him to the experiment. The 
rain-baths were resumed, and his general condition at 
once improved and appetite returned. At the present 
time there is no cough, the least amount of expectora- 
tion, and but few pleuritic friction sounds over left 
apex. His weight is 178| pounds. Dr. Hodenpyl, 
who kindly examined all sputa, reported : First ex- 
amination, about 10 bacilli to the field ; second exam- 
ination, very few bacilli ; third, fourth and fifth ex- 
aminations, no bacilli. 
This patient may be regarded as recovered, judging 
from the physical signs, subjective symptoms, his gen- 
eral condition and the absence of baccilli. 
He steadily lost in flesh and strength and appetite 
until he resumed the rain-baths, when he again began 
to improve until he gained seven pounds over his 
weight just before the injections, and twenty-one 
pounds over his weight on entering. He was dis- 
charged on July 14, weighing 183 pounds, and is 
looking for work. 
II. S., aged 31, admitted May 2, 1890. Family his- 
tory negative ; always well until May, 1889, when he 
had first pulmonary hemorrhage ; was confined to bed 
eight weeks with cough, night-sweats and afternoon 
fevers. In September, 1889, and January, 1890, he 
had hemorrhages and went to .Mount Sinai Hospital, 
whence he was discharged improved in seven weeks. 
He had cough, expectoration and pain in the chest; 
no appetite when admitted. 26 
Idtysical Examination.-Dullness over right third 
anteriorly and posteriorly ; subscrepitant and friction 
rales ; broncho-vesicular respiration with prolonged 
expiration. On left side prolonged expiration with 
with some friction sounds over left apex. Weight 
129J pounds. 
August, 1890.-Sputum found to contain bacilli. 
In September, 1880, he had a hemorrhage. 
During this time he received rain-baths, syrup of 
the hypophosphites and creosote ; at times cod liver 
oil. Under this treatment he steadily improved, so 
that when he was subjected to tuberculin injections, 
on December 16, 1890, he weighed 146 pounds-a 
gain of 16| pounds in six months and a half-and no 
bacilli were found by Dr. Hodenpyl in his sputum. 
There were still, however, dullness over right apex, 
broncho-vesicular respiration and subscrepitant rales. 
His temperature was 90°. April 15 tuberculin injec- 
tions discontinued. 
There being no tubercle bacilli in the sputum and no 
cough or expectoration, and the physical signs being 
only a slight, jerky respiration, he was discharged as 
cured April 29, weighing 149 pounds. He has there- 
fore increased twenty pounds since his admission, and 
3^ pounds since injections were begun, during the 
continuance of which he lost very considerably. He 
is now at work in Bronxville, N. Y. 
A. V., a nurse in the Montefiore Home, weighed, in 
summer of 1890, 138 pounds. She was constantly en- 
gaged in the wards, in which her mother was also a 
nurse. She began to loose flesh while at work ; cough 27 
and expectoration were pronounced, and she had two 
slight hemorrhages. 
Physical Examination revealed impaired resonance 
over left apex, jerky, exaggerated respiration, fine, 
moist and pleuritic rales. Bacilli abundant in the 
sputum. Weight 126 pounds on January 5, when she 
was subjected to tuberculin injections. 
She received 21 injections, progressively increased. 
They were always followed by decided febrile reac- 
tion. The last injection of 45 milligrammes was ad- 
ministered on the 1st of April, and was followed by 
very slight reaction. During the entire treatment she 
had daily rain-baths. 
April 10.-Cough, expectoration, night-sweatsand 
physical signs have ceased ; her weight increased to 
132 pounds, and, no bacilli being found in the sputum, 
she was discharged at her own request as cured. 
She is now working as a private nurse, feeling per- 
fectly well. 
In these cases the effect of the tuberculin was either 
deleterious or negative, while that of the rain butts 
was excellent. 
The following case is cited to illustrate the tonic 
effect of hydrotherapy in a desperate and advanced 
case of phthisis: 
B. S., aged 18, architect, admitted November 19, 
1890. Mother died of chronic phthisis. Has been 
ill since he had an attack of pneumonia, two years 
ago, with night-sweats, troublesome cough and loss of 
flesh. 28 
Phyiscal Signs.-Tympanitic dullness over the 
upper third of left lung anteriorly, cracked-pot sound, 
cavernous rales, tubercular breathing, signs of catarrh 
in right apex. Complains of palpitation greatly. 
Weight one hundred and fifteen pounds. Bacilli 
n umerous. 
Treatment.-Rain-baths, 70° to 65°, for 30 seconds. 
Cod-liver oil and creosote. 
December 16.-Up to this time his weight had 
increased eight pounds, although the physical signs 
are the same as on admission. Temperature normal. 
Ue was now subjected to tuberculin treatment, under 
which he increased (as an exception to the rule), on 
April 10, to 138 pounds. Cough does not trouble 
him now, and he expectorates very little. A few ba- 
cilli at every examination. Physical signs not so 
pronounced. Rales few, and there is evidence of 
contraction of cavity. The palpitations, which 
troubled him greatly, have disappeared. 
Dr. Hodenpyl's report of examination is interest- 
ing : 
December 16.-One hundred tubercle bacilli to each 
cover-glass. 
January 7.-One hundred tubercle bacilli to each 
cover-glass. 
February 2.-Two bacilli to field. 
16.-Five bacilli to field. 
March 1.-Two bacilli to field. 
May 7.-His weight is one hundred and thirty-nine 
pounds. lie has been receiving rain-baths since the 
injections were stopped. He looks well, and may be 29 
regarded as markedly improved. He was discharged 
on July 14, weighing 140 pounds, and looking the 
picture of health. 
Hear with me while I cite a case from private prac- 
tice, which illustrates the air and water treatment, 
which has given me such satisfactory results that I 
would commend it to your attention despite the fact 
that it involves much trouble and demands much 
judgment. 
Mr. II. M., aged 28 years, whose brother died of 
phthisis, was sent to Minnesota seven years ago by 
Dr. A. L. Loomis, with the diagnosis of incipient 
phthisis. He settled in St. Paul, married, and his 
health improved, so that he regarded himself as cured. 
Last Winter, his father, tvhose family I attend, begged 
me to subject him to the lymph treatment. He had 
been rapidly running down of late with cough, night- 
sweats and fever. As I had no lymph for private pa- 
tients, I advised him to come to this city for observa- 
tion and possible hospital treatment. He arrived 
January 9, 1891. Without entering into his physical 
signs, suffice it to say that there was infiltration in 
right apex as far as the second rib. The general 
signs indicated a more advanced lesion. His tempera- 
ture ranged from 101 to 104; his cough was incessant, 
accompanied by uniformly blood-stained expectora- 
tion, containing bacilli abundantly; his appetite was 
entirely gone, sleep unsatisfactory, and accompanied 
by exhausting sweats. Altogether he presented a 
picture of rapidly advancing process, although there 
was no evidence of breaking up. 30 
The weather was extremely severe, snow being fre- 
quent. Being exhausted from the journey, he was al- 
lowed to rest a few days. The principle of the pure 
air treatment was adopted in the following simple 
fashion. During the night the windows of the parlor 
door were allowed to remain partly open. An hour 
before entering the room the windows in the parlor 
were closed, and a lire was lighted in the stove (this 
disadvantageous mode of heating was insurmounta- 
ble). The patient was now brought down, placed 
upon a steamer-chair, wrapped in furs from head to 
foot, the face alone being left exposed. All the win- 
dows, except one in his immediate vicinity, were 
opened. He remained in this position from one to 
four hours, daily increasing the time. The windows 
were closed at 12, when he was taken to his bedroom, 
which had been in the meantime thoroughly aired and 
warmed just before his return. He now received the 
treatment which will be presently referred to, after 
which he had luncheon and was again placed in his 
steamer-chair on the parlor Hoor. The bedroom win- 
dows, having a Southern exposure, were again left 
open until he returned. When he was snugly in his 
bed one window was left open from the top over 
night. 
The remainder of the treatment consisted in meet- 
ing the second indication above referred to, viz., an 
effort to endow the system with power to resist the 
inroads of the disease. The chief element in this 
treatment is hydrotherapy, as above stated. He was 
gradually educated to bear water treatment during 31 
the first five days. He then received the dripping 
sheet at 70°, with affusions at 65°; reducing both two 
degrees every third day until the former was 64° and 
the latter 58°. lie had abundance of milk, which he 
formerly loathed; and as his appetite improved, eggs, 
strong farinaceous broths and mushes. On March 14 
he had so far improved that he had registered a nor- 
mal temperature for two weeks, even in the evening ; 
he was entirely free from cough and expectoration, 
except early in the morning ; there were no night- 
sweats, he slept soundly. The physical signs had im- 
proved, so that it required a very careful auscultation 
to discover them. Bacilli continued to appear but in 
diminished numbers. He had attained his norma 
weight, gaining twelve pounds in flesh. I did not 
resist the importunities of the patient to allow him to 
return to St. Paul, inasmuch as he insisted that he was 
now in far better condition (feeling quite well) than 
he was when Dr. Loomis sent him there seven years 
ago. 
The second chapter in this case is equally interest- 
ing and relevant to my subject. A few days after 
his return home he rode in an open cable car in in- 
clement weather, contracting a cold which brought 
him to bed. Imperfect water treatment which he 
obtained at home probably contributed to this issue. 
Reports reached me that he was desperately ill, his 
physicians declaring it useless to treat him any longer. 
Felling that hydrotherapy had rescued him from des- 
perate straits before, he determined to make the jour- 
ney to New York. lie arrived the latter part of 32 
April in a most forlorn condition. Examination re- 
vealed a catarral pneumonia, involving the entire 
lower half of the left lung, with evidences of softening 
anteriorly just under the nipple. His temperature 
ranged from 102° to 105°, he had night-sweats, severe 
cough and expectoration, no appetite. Nevertheless 
I subjected him to the same course as in the first in- 
stance, without any result however. Wet packs, too, 
failed to reduce his fever. He now entered the Mon- 
tefiore Home for the purpose of more systematic 
treatment. Here the rain-baths always reduced his 
temperature ; otherwise he did not improve. He then 
was treated at home by my private nurse, but steadily 
failed. As a last resort, regarding the treatment at 
home as imperfect in some way, I had him brought to 
Long Branch, in order to have him under my personal 
supervision. The night-sweats were now so exhaust- 
ing that I gave him atropine without effect. He was 
again subjected here to a systematic water and air 
treatment. He was ordered to lie in a hammock 
under the trees all day; he had wet packs and the 
dripping-sheet under my personal direction. Im- 
provement was marked, showing itself first in a 
normal morning temperature, and better appetite. In 
three weeks he was so much better that he committed 
the imprudence of walking a mile to the Iron Pier to 
receive his wife. This act came near being fatal to 
him. The local process was again lighted up. He 
was put to bed, linen compresses wrung out of water 
at 65°, and later out of 50°, were wrapped around his 
chest and covered by a flannel bandage, renewed 33 
every hour, renewal being preceded by an ablution of 
the chest with water at 70°. He had a general ablu- 
tion morning and evening. Under this treatment of 
absolute rest, and without any medicine except a 
creosote mixture he again improved, with the excep- 
tion of a brief relapse caused by another imprudence. 
When he left Long Branch in September his appetite 
and general symptoms were greatly improved; there 
had been no sweats in four weeks, no fever in two 
weeks; he had gained flesh, coughed very little; there 
were evidences that the cavity was contracting. lie 
was sent to D. V. Ruck's Sanitarium in Asheville, N. ( 
in good condition. 
This case is given somewhat at length because it 
illustrates the necessity for rest and care as well as 
the method and value of the air and water treatment 
in mild and desperate cases. 
CHRONIC GOUT AND RHEUMATISM. 
Chronic gout is a diathetic disease in which there 
is misdirected tissue change. This essay being 
chiefly clinical, it is not my province to enter into 
a description of the opinions held regarding the 
nature of gout. Fortunately, most observers are 
agreed upon the essential point that gout is prac- 
tically a uric acid diathesis, or rather a disease in 
which there is a disturbed relation of the processes 
resulting in uric acid formation in the body. Whether 
there be decreased formation or elimination due, as 
Cullen claimed, to vicious nervous influences, or as 34 
Todd and the older writers, and more recently 
Charcot held, to disturbance of the digestive organs, 
especially the liver, or to interruption of the urea 
Excretions as Garrod insists, the undisputed fact is 
that an accumulation and retention of uric acid, re- 
sulting from insufficient elimination, occurs in the 
juices. Cantani has probably given us the most judi- 
cious therapeutic indication. lie holds that the excess 
of uric acid in the blood (actual urate of soda) does 
not signify the materia peccans which irritates the 
gouty joint; it does not furnish the cause of the local 
manifestation and basis of the local deposits; but, on 
the contrary, the uric acid dyscrasia of the gouty is 
really the consequence of a disturbance of tissue 
metamorphosis in the affected parts, especially in the 
joints. Tn this change of the innermost function of 
the histological elements of the tissue (perhaps in 
certain ones as in the joints, etc.), in this alteration of 
the chemical consumption activity, and not even in 
its anomalous products or in the presence of uric acid, 
instead of urea, nor in the deposits of urate of soda ; 
does Cantani find the real nature of the gouty diathe- 
sis. Tie regards it as an anomaly of the constitution 
of the individual, a disease of tissue change. Conse- 
quently, gout may be termed the result of a partial 
retardation of the latter with a stasis of the metamor- 
phosis and oxidation of nitrogeneous substances in 
the grade of uric acid. The apparent contradiction 
existing between the theories of the most able expo- 
nents of gout, may fortunately be readily reconciled 
therapeutically. 35 
With regard to liheumatism we have a simi- 
lar difference of opinion. The retention of lactic 
acid is according to Senator and other judicious 
observers, the essential element of this disease. 
The great tendency of muscles and joints to diseases 
due to cold is well known. Says he : (Diseases of 
the Apparatus of Locomotion, Ziemmsen's Handbook 
XIII.). "In both there are active processes of tissue 
change, especially are lactic acid and phosphate of 
potash formed in the muscles. These are not nor- 
mally eliminated when the skin is suddenly cooled; 
hence they accumulate. This is proved by the oc- 
currence of rheumatism in diabetic patients, reported 
by Foster and Kuelz, as having been treated by pro- 
longed use of lactic acid." Here, too, we have a per- 
verted nutritive process, whose products are turned 
into faulty channels. For therapeutic discussion 
therefore, we may combine these malidies; though 
they differ essentially in many respects both as to 
their etiology and nature. 
We have in both diseases the manifestation of a 
vicious mode of life or of exposure to other deleterious 
influences, combined nor ot with inherited ten- 
dencies ; which but too often play an important role in 
etiology. We must address our treatment in both to 
improving the digestion and assimilation of food, in- 
creasing elimination of effete products, and, by sup- 
porting the strength, enhance the patient's powers of 
resistance. The utter futility of medicinal treatment 
for these purposes is evidenced by the multiplicity of 36 
remedies which have accumulated in our books upon 
the subject. 
To accomplish any valuable result in such a malady, 
to rearrange as it were the entire nutritive system, to 
divert it from its vicious tendencies, to remove pro- 
ducts of retrograde tissue metamorphosis and to pre- 
vent their reproduction, experience has shown may 
best be done by physiological agencies, as diet, exer- 
cise and certain hydriatic measures. 
It is my custom to give these patients a diet con- 
taining the smallest possible quantity of nitrogenous 
material. Red meats are forbidden; also the white of 
eggs, fermented liquors-indeed all foods or drinks 
which tend to increase the production of urea and uric 
acid. So long as the best clinicians are unable to 
agree upon the true pathology of these diseases, and 
the best diet for them, a nutritious, medium diet, like 
the above, has seemed to me to be the most valuable. 
As Semmola has shown, there is no method of 
treatment which has given such remarkable result in 
these disturbances of tissue change as judicious diet, 
and exercise, combined with hydrotherapy. Massage 
in the more painful stages, passive exercise in the sub- 
acute conditions are indicated. Most observers are 
agreed upon this point. When the muscles are placed 
into action, the lymph and blood-vessels are compelled 
to do their work, absorption takes place, and the 
general activity of the system, thus evolved, must aid 
materially in the removal of fluid deposits. The judi- 
cious prescription and equally judicious observance 
thereof, of gentle muscular exercise, form an important 37 
element in the treatment of gout and rheumatism. It 
must be avoided so long as redness and local swelling 
are combined with pain. 
A powerful auxiliary to judicious diet and exercise 
may be found in the application of certain hydriatic 
procedures. It will be found useful to distinguish in 
this connection between the several types of gout and 
rheumatism which come under observation. 
1st. The anaemic type, rendered so by long con- 
tinuance of the disease and subsequent abstention of 
exercise, by loss of sleep, etc. 
2d. The plethoric form, usually, though not alto- 
gether, found among the better situated gouty. 
3rd. The intermediate form between these. 
In the first type, a tonic procedure being indicated, 
we have in gentle and judicious application of cold 
water our most valuable remedies. The skin should 
be educated as was described in the treatment of 
phthisis, first by the dry pack and subsequent cold 
ablutions, then by the dripping sheet, and rain-bath. 
In the third (intermediate) type the same course 
may be pursued. In these cases we have in the wet 
pack (i. e., patients are wrapped in sheets wrung 
out of cold water and covered with blankets like 
a mummy, to be followed in an hour by the half 
bath at 70 to 65°), a valuable means not only of pro- 
moting tissue change, but of removing debility, im- 
proving the appetite and building up the nerve tone. 
The second type (the plethoric), in which there is 
so much stiff ness in joints and muscles without general 
failure of health, is more difficult to manage. The 38 
resolvent method is the most useful. In these cases I 
have found the hot air bath, followed by the douche, 
most applicable. And here let me say a word of 
warning against the indiscriminate use of the Turkish 
bath. Being applied by ignorant attendants, the 
patient is subjected to treatment which may do him 
much damage. What is a luxury and comfort for 
the healthy is certainly not always best for the sick. 
The heating of the body in dry blankets for several 
hours, while the patient is made to partake freely of 
cold water (preferably alkaline) is a method by which 
Priessnitz has obtained remarkable (almost marvel- 
lous) results, as we are informed by reliable observers 
living to-day (for instance, Prof.) Semmola of Na- 
ples.) The box hot air baths, followed by the cold 
douche, is, after educating the patient's skin, a most 
valuable measure. It has been demonstrated by Frey 
and Heiligenthal that it increases tissue metamor- 
phosis ; and that there is consequently an increased 
elimination of urea and uric acid. The theoretical 
considerations involved cannot be discussed here. 
Suitice it to state that they produce a diminution of 
the quantity of urine, increase its concentration, as 
evidenced by greater specific gravity ; retention of 
uric acid at first, but a three-fold increase of elimi- 
nation later}, which, as well as the urea, continue to 
be eliminated more freely for several days. 
These authors justly claim that, "aside from the 
beneficent effect upon tissue metamorphosis in the 
gouty and rheumatic, the increased energy and power 
of resistance of the cutaneous nerves against atmos- 39 
pheric influences, is not to be underestimated." Colds 
must become more rare, and these are not only often 
the chief causative factor, but especially in rheumatism 
they form by their frequent repetition, the basis of the 
entire disadvantageous tissue change. Much benefit 
is claimed to be derived by hot sulphur and other 
mineral springs. It has been proved by Leichbenstern 
and others that the sulphur (or other mineral ingredi- 
ents, in these baths contributes absolutely nothing to 
the cure. Nothing is absorbed through the epidermis, 
unless it be in a volatile form. The soonei* this fal- 
lacy is removed from the professional mind the bet- 
ter. The psychical effect of the idea may be allowed 
to do its good work in the lay mind, but the physician 
should know exactly where he stands. Benefit is due 
to the long maceration in these hot baths. The ex- 
cellent regime to which the patients are subjected in 
the better class of resorts, the influence of tales of 
cures which among a large number of frequenters 
must occur occasionally, and which seem marvellous 
when exaggerated by the interested proprietors and 
their agents, the removal from vicious home sur- 
roundings-above all these that which I chiefly de- 
sire to emphasize in this paper as the most important 
element in the management of all chronic diseases- 
the systematic observation and treatment, obtainable 
from skilled experts, the same as we give patients in 
acute diseases, accomplishes results which must sur- 
prise those who treat cases at home in a necessarily 
slip-shod and perfunctory manner. Institutional treat- 
ment will show in all chronic diseases, what has been 40 
proved in that most intractable of all--phthisis. The 
following clinical history from Duval (p. 553), illus- 
trates the value of methodical treatment, even in des- 
perate cases. It is of the third type mentioned above: 
Z., a Pole, 65 years aet., well developed, of bilio- 
sanguine temperament, high color, was sent to me by 
my friend, Dr. Raciborski. Patient had suffered 
greatly from the political misfortunes of his country, 
cumbered with loss of his fortunes, which had com- 
pletely changed his mode of life, so that he was com- 
pelled to work as an engineer. He was subject to 
requent attacks of gout, for which he had had all 
kinds of treatment. When, on the 12th December, 
he applied to me, he presented nodosities on most 
of his fingers and metotarso-phalangeal articulation. 
Every week he had grievous attacks, lasting two to 
four days. No heart trouble, and no loss of sleep or 
appetite. 
Morning and evening he had a rain-bath of five 
seconds followed by a jet douche of a minute, played 
all over the affected articulation. On the 16th he had 
a severe attack ; he was placed in the hot air box, 
with wet compresses on head and feet ; and when the 
skin became warm he received several drinks of cold 
water every five to ten minutes. He perspired freely 
in 25 minutes and was now placed into a rain-douche 
for fifteen seconds, followed by a jet douche as above. 
He was well rubbed with warm, dry cloths, and was 
now able to walk, which he had not been able to do 
in two years so soon after an attack. The douches 
were renewed every day, the hot air baths every two 41 
days ; the paroxysms returned, but with less severity. 
On the 24th one commenced, which was completely 
aborted. Treatment was continued, but he had three 
more approaches to attacks in ten days. 
From the 15th January he had the hot air bath 
every day. He left on the 12th February, after 
having been entirely well for over a month. We have 
seen him time and again since, but he has remained 
well. 
The following case illustrates the successful treat 
ment of chronic rheumatism, which was regarded as 
so incurable as to pass examination for admission to 
the Montefiore Home. I am indebted to the Senior 
Resident, Dr. Max Rosenthal, for this valuable his- 
tory : 
Chronic Rheumatism. 
S. Z., 26 years. Single. Austria. Waiter. 248 
E. Second Street. Admitted November 14, 188tf. 
Family history : Father died at 45, tweny-one 
years ago, of phthisis ; mother is alive and well. 
Five brothers and two sisters, all alive and well. 
Personal history : Sick six months ; had measles 
and scarlatina as child ; at 6 both legs run over ; 
had typhoid about the same time ; was a weakly, 
delicate child ; at 14 had rheumatism with severe 
pains in the muscles, which were painful on move- 
ment ; no fever ; lasted about seven months. Cured 
by baths. Went to work in a hardware store at 17. 
Was ever since disturbed by headache, dyspepsia ; 
occasional winter cough with expectoration. Last 
absent for two years. Last July attacked by gonorr- 42 
hoea. Discharge slight. Treated by copaiba and in- 
jections. Two weeks after commencement of ureth- 
ral trouble noticed swelling at the root of toes of 
right foot and painful right knee. Employed the 
Russian bath as a curative measure. A week later 
right ankle became painful and slightly swollen on its 
inner aspect. Directly after attacked by a severe 
pain in the small of the back, with stiffness. Two 
weeks later left elbow became quite painful, especially 
on pressure. Would leave one foot and go to the 
other. Spent three days in August in the German 
Hospital. Went two weeks later to Mt Sinai for 
twenty-four hours. Treated outside by some medi- 
cine which induced profuse sweating. At time of ad- 
mission presented swelling of right ankle, especially 
marked upon its inner aspect. Also swelling of the 
eminences of the big and little toes ; the latter very 
painful on pressure. The other foot was about the 
same, but less marked. Knees very painful, especial- 
ly on extension. Standing was more painful than 
walking. Gait was stiff and much impaired. Appe- 
tite was poor. Bowels rather constipated ; urine was 
high-colored. Gonorrhoea had stopped four months 
before admission. Sleep was poor; was very anaemic, 
and badly nourished. Urine 1.022. 
Treatment.-Anti-rheumatic diet. Ferr. oxid. 
sacch. 3 t. i. d. Hot fomentations and pack and 
half-bath on alternate days. Cold compress to feet, 
daily; changed six-hourly. 
After admission appetite improved materially ; 
sleep poor; constipation continued. Rochelle salts 
oz i. in hot water at 6.15 a. m., daily. 43 
January 2, 1890.-Patient is entirely cured of his 
rheumatism. Feels in excellent health ; constipation 
relieved ; sleep still imperfect. Advised to stay a 
little longer to assure permanence in the obtained re- 
sult. 
Discharged cured. 
A few cases of chronic rheumatism from Duval's 
work may be cited with advantage (p. 693). On the 
19th April, 1875, Dr. D. Dubois (of Litte) brought 
me Monsieur X., who had been suffering for ten 
years from a most grave and rebellious rheumatic af- 
fection, which had received all kinds of medication. 
All the large and small articulations were tumified, 
his complexion was bilious, eyes glassy; he looked 
cachectic; he had a little fever, and suffered from com- 
plete insomnia. 
The treatment was preluded by a general ablution 
with water at 24° (82° F.), repeated in the afternoon 
with water at 16° (61y F.), followed by a rain douche 
of five seconds. After each operation he received 
half a glass of cold water. Every day afterwards he 
was placed in the hot-air box (6tuve s6che) ; during 
which he received large quantities of cold water and 
had his head moistened. This was followed by a rain 
douche over the entire body and an energetic jet 
douche on the joints. 
On the 10th May, Mr. X. left, entirely cured, and 
rejoiced at his unhoped-for transformation. (For 
further details see La Med. Contemp., April, 1876.) 
Additional histories would fatigue by their same- 
ness. These cases are very much alike. There is a 44 
history of long suffering, stiffness and impeded loco- 
motion, and general hopelessness due to the failure of 
a multiplicity of remedies and doctors of high and 
low degree. They have rarely had systematic, pro- 
longed treatment of any kind. None of these cases 
should be regarded as hopeless until such treatment, 
including hydrotherapy and its auxiliaries, have been 
fairly tiied. My personal experience and observation 
justifies this positive assertion. I have here, as in 
other diseases, intentionally omitted the recital of 
cases from my private practice; preferring to illustrate 
by cases recorded in hospitals and institutions, be- 
cause one is more or less liable to be biased in the re- 
porting of his own successful cases. 
Another disease illustrating the value of systematic 
treatment is 
DIABETES. 
Diabetes is a malady that has probably received 
more so-called systematic management than any 
other. It has been recognized that by the diminu- 
tion or entire removal of starchy and saccharine food, 
the quantity of sugar appearing in the urine may be 
limited that that the patient's health is improved by the 
diminution of the exhaustion incident to the per- 
verted functions, which robs him of his storehouse of 
force-Glycogen. This was indeed a great step in 
advance ; but it is, as was well said by Dr. Draper in 
a discussion of the subject in the New York Academy 
of Medicine {Medical Record, May 8th, 1886) an en- 
tirely empirical treatment. Put less sugar in and you 45 
have less to dispose of is a simple English dictum. I 
desire here to reiterate my remarks on that occasion, 
because I regard it as of paramount importance to 
impress upon the patient the need, not only of system- 
atic diet, but of systematic exercise. Unless the 
physician be convinced of this, he will permit the dis- 
inclination of all diabetics to exercise to overcome his- 
injunction. The latter cannot be made too strong. 
A certain definite amount of exercise must be pre 
scribed and taken. I advise the use of the pedometer 
for the purpose of measuring and recording the, 
amount of walking exercise ; which is by far the best 
taken by the patient. Why should we not have an 
exact estimate of so important an item of treatment ? 
The patient's statement may be a fair guide in some 
cases, but his physical condition renders him a preju- 
diced witness, be he ever so honest in his intentions. 
Whenever we shall dose our exercise as we do our 
medicines, and see to it that our prescriptions are fol- 
lowed as punctiliously as we are wont to do in medi- 
cine, we shall achieve greater precision in our results. 
In the discussion of the treatment of diabetes in the 
New York Academy of Medicine, on March 18thr 
1888, I endeavored to emphasize the importance of 
active and passive exercise adapted to the require- 
ments of each case. So convinced was I of the value 
of this therapeutical measure, that I had adopted the 
method of compensating my diabetic patients for tak- 
ing the prescribed exercise by a definite allowance of 
white bread (for which they all crave), graded ac- 
cording to the amount of exercise taken. 46 
This treatment, based upon the well-known recom- 
mendation (empirical at that time) of Bouchardat, has 
suffered unmerited neglect, if we are to judge from 
the absence of any allusion to it in the discussion re- 
ferred. Indeed one of the speakers, whose clinical 
experience is large, and whose opinions are justly 
esteemed expressed the regret that, aside from the 
dietetic treatment, there is nothing but empiricism in 
the therapeutics of diabetes. In reply to this assev- 
eration, I felt called upon to say that the recognition 
of muscular exercise as an important element in the 
treatment of this malady is the logical outcome of 
well established physiological facts, and therefore its 
application is strictly scientific. Physiology teaches 
that the liver and muscles are the most active agents 
in absorbing sugar from the blood and converting it 
into glycogen, which in its turn is utilized for the 
maintenance of the body. 
In diabetes, the glycogenic function of the liver is 
either in abeyance or greatly impaired, while the mus- 
cles also fail in a great measure to perform their func- 
tion of disposing of sugar. We resort to the restric- 
tion of sugar supply by diminishing or withdrawing 
those articles of diet which physiology has taught are 
sugar producing. We possess no remedy which stimu- 
lates the glycogenic function of the liver, but we are 
in a more favorable position regarding the muscles. 
By increasing their functional activity we can stimu- 
late the sugar-con verting function of the inner fibril- 
lar substance of the muscles, and thus we may dis- 
pose of a large portion of the excess of sugar circulat- 47 
ing in the blood. Clinical experience is fortunately 
entirely in accord with this deduction from the teach- 
ings of physiology. This fact has again and again 
been exemplified. It is nothing new ; but its true 
import is unfortunately but too often lost sight of in 
the eager search for anti-diabetic, diabetic, or medi- 
cinal specifics. The subject of exercise is often dis- 
missed by directing the patient to exercise in the 
open air without fatiguing himself. The insufficiency 
of this injunction is within the experience of every 
practical physician. It is a well known fact that dia- 
betics are, as a rule, loath to muscular exertion; lassi- 
tude is a common symptom, and something more than 
the mere suggestion is required to enforce the neces- 
sity of exercise upon these patients. Being based upon 
strictly scientific data, the prescription of exercise 
should be as precise and exacting as that of the diet, 
if we would obtain the legitimate advantages. And 
it will tax the skill and ingenuity of the attendant to 
the utmost to obtain the desired result. Dr. William 
Richardson, in his book on diabetes, furnishes us 
with a personal experience which all practical physi- 
cians will at once appreciate. He describes graphic- 
ally how he was himself overcome by weakness and 
indisposition to exertion when suffering from diabetes. 
" He could not walk a hundred yards without great 
fatigue ; he frequently fell." " I began to take exer- 
cise regularly two or three times a day ; wet or fine, 
I took it." " Gradually I gained strength, so as to 
be able to walk five or six miles a day without 
fatigue." "The exercise should be regularly sus- 48 
tained day by day ; even in wet weather it should 
not be intermitted ; of course great care should be 
taken against wet feet ; it should never be carried to 
real fatigue ; a feeling that exercise has been taken is 
the most that should be felt. To carry into effect 
regular and sustained muscular exercise requires great 
moral courage and energy, the languor and feeling of 
weakness are so great ; but if the exercise be 
carried out only patiently and perseveringly the task 
will become not only more and more easy-will soon 
no longer be a task, but positively a pleasure. 
We have ample testimony on the value of exercise 
in the discussion of diabetes in the fiftl German 
Congress for internal medicine. Prof. Stokvis of 
Amsterdam, said : "He insists on muscular exercise, 
by which alone the percentage of sugar can be greatly 
diminished." 
Prof. Hartman said: "Alkaline remedies, the 
opiates, active muscular exercise, or muscular mas- 
sage where the patient is not able to take active 
exercise, and observance of a good hygienic regime 
in general are the means he relies upon." 
Professor von Mehring "had invariably noticed 
considerable decrease, and even disappearance of 
sugar from the urine after prolonged, active and pas- 
sive exercise." 
Professor Finkler " has the records of thirteen 
cases of diabetes, in which he succeeded in reducing 
the sugar in the urine from four hundred grains to 
one hundred and fifty grains and less per day by 49 
active and passive exercise, allowing small quantities 
of hydrocarbons. In some cases the sugar disap- 
peared entirely." 
In the discussion of the subject in the New York 
Academy of Medicine, referred to above, the writer's 
earnest advocacy of muscular exercise in diabetes was 
met by the argument from the principal speaker, that 
it is very dangerous to make those suffering from the 
severe forms of diabetes take much exercise, although 
in ordinary cases exercise in the open air within the 
limit of fatigue is important and necessary; and 
another gentleman expressed himself wholly in ac- 
cord with this view, as he had seen coma in children 
develop shortly after admission to the hospital, due 
to the fatigue and excitement. In London it had 
been observed after long railway journeys. 
Fearing lest these opinions may deter many from 
resorting to a measure which is so full of promise to 
the diabetic, I desire to reiterate what I said on that 
occasion, viz., that all valuable therapeutic measures 
are potent for evil as well as for good, and that a 
judicious selection of cases will eliminate possible 
dangers. That the latter have been exaggerated 
would appear from Prof. Stokvis' essay, who says that 
diabetic coma might result from sudden and abundant 
production of acetone, etc., coming on after unusual 
exertion-the fatigue of a long journey. The Medical 
Record, of May 15, 1886, p. 549, has an able article 
by Dr. Devlin reviewing the histories of many cases 
of diabetic coma, among the important lessons drawn 50 
from which the most obvious is that in them the 
history of previous fatigue or over-exertion rarely 
appears. 
If time permitted I might cite a goodly number of 
cases from my private practice in which a combination 
of systematic exercise, bathing and diet has caused 
complete disappearance of sugar from the urine, and 
restoration of strength. Two of the most recent cases 
occurred last year. Two ladies desired prescriptions 
for pruritus vaginae of obstinate type. Examination 
of the urine revealed 4 per cent, sugar in one and 
3 per cent, in the other. They were both subjected 
to the above indicated treatment, with a mild domes- 
tic hydrotherapy, which they carried out faithfully 
with the result of being rapidly restored. Recent 
examination demonstrate that they continue free from 
sugar, although 18 months have elapsed, and one of 
them has eaten wheat bread, occasionally, and fruits, 
daily, of late. I have not had an opportunity of add- 
ing methodical hydrotherapy to the treatment because 
I have usually succeeded without it, and the trouble 
and loss of time involved disincline most patients to 
adopt it. 
In this connnection it may be of great value to 
refer to the Von Duehring treatment of diabetes. 
This physician formerly practiced in Hamburg, where 
he obtained great repute for his cures of diabetes, 
lie claimed that some failure in the digestive powers 
was at the bottom of most cases of diabetes, that urine 
sugar was produced not from what the patient eats, 
but from what he does not digest, and this was 51 
enhanced by defective respiration and skin action. 
His procedure was as follows : The patient received 
early in the morning a wet pack of an hour with open 
windows, followed by a cold ablution. He now got 
milk and lime-water with bread, or a soup made of 
rice, hominy or barley without butter, but with a lit- 
tle salt. Now followed a walk of one or two hours. 
At 11 to 12 a. m., half glass diluted rice or flour 
soup with or without milk. This was followed by a 
walk of one-half to one hour; now an hour's sleep 
or rest. 
Dinner at 2 or 3 p. m., consisted of rice, 250 
grammes roast or boiled meat, dried fruits and beans. 
From the fruit the skin was removed. Fats and 
sauces were forbidden. Green vegetables, even car- 
rots were permitted, bu^ they were cooked in salt and 
water only. Raw apples and cherries allowed, also a 
small glass of red wine, and water occasionally. 
This was followed by a walk of one to three hours 
in the evening, then rice grits or barley, water soup 
with salt and without butter, or milk and lime-water. 
Another walk of at least half an hour. At 9 or 10 
patient was put to bed with open windows. 
All the cereals and fruits were soaked in water over 
night, after being well washed. They were boiled in 
the same water, four hours for rice and flour, eight 
hours for barley, one and a half hours for baked 
fruits. Salt only was used for the cereals, bicarb-soda 
instead of sugar for the fruit. 
In the light of my personal experience this treat- 
ment would be more useful than appears to be to our 52 
preconceived ideas. The experience of Finkler, 
quoted above, coincides with my own, in that patients 
may be allowed a moderate quantity of starchy food, 
provided they dispose of the sugar formed by mus- 
cular exercise. I have found it advantageous to com- 
pensate my diabetics for a certain amount of exercise 
by an allowance of small quantities of hitherto forbid- 
den food. 
Such systematic attention to the needs and capabili- 
ties of the patient's system must inure to the 
patient's benefit, and enable us to attain more cures 
than is possible under the present purely dietetic man- 
agement. 
I would gladly enter into the discussion of other 
diseases, usually regarded as incurable or very difficult 
to cure. But I will content myself with simply 
referring to one which has long resisted varied medi- 
cation and diet, with only occasional recovery, but 
which has yielded beautiful therapeutic results since 
a simple but systematic method of management has 
been devised. I refer to 
GASTRIC ULCER, 
that most painful of all gastric troubles, which had 
defied the best directed efforts for a long time. 
Since Kussmaul and Leube have pointed out the 
true nature of ulcus ventriculi, and have devised the 
systematic rest and feeding treatment which is now 
so generally adopted in place of the former nitrate of 
silver and haphazard dietetic treatment, these cases 
afford the physicians great satisfaction. 53 
Three cases which were under my treatment re- 
cently, recall this subject vividly to my mind. 
In all the cases the pain was distressing ; it was 
supposed to be due to nervous dyspepsia in one, gas- 
tric catarrh in the others, as there was no vomiting. 
The usual remedies had been applied without effect. 
Hot water and beef pulp, kumiss and other dietary 
preparations, aided by pepsin, bismuth, and hydro- 
chloric acid had been diligently used. In all the cases 
the pain ceased immediately upon the recognition of 
its etiology, in the existence of a gastric ulcer and 
its correct systematic treatment by absomte rest and 
the exclusive use of milk with 50 per cent, lime 
water. That pain which had resisted all the usual 
remedies, including in one case large hypodermics of 
morphia, should yield at once to this regimen, is the 
most conclusive evidence of the rationale of this sim- 
plified therapeusis. The irritating effect of the gas- 
tric juice upon the abraded surface is neutralized by 
the bland food ; the gastric secretion is diminished 
by it. Rest to the stomach is secured as far as pos- 
sible, and thus the rational treatment, beautiful in its 
simplicity, triumphs over blind medication. Who- 
ever has observed the complete change from excruci- 
ating pain to calm comfort, which this simple measure 
has so often wrought in these cases, must commend 
the effort to imitate and emulate such simplicity in 
other maladies. 
These illustrations may serve to demonstrate what 
systematic management may accomplish in chronic 
diseases, and to designate as succinctly as may be done 54 
iii the time at our disposal the lines upon which it may 
be executed. 
My own clinical observation is confirmed by that of 
eminent teachers in Europe, who have striven to im- 
press upon the profession the great value of the natu- 
ral methods of treatment, aided by judicious medica- 
tion. Permit me to offer one quotation. 
Prof. Semmola of the Naples University, in his re- 
cent work (1890) on " Clinical Therapeutics," whose 
value is attested by a German translation and by a 
highly commendatory preface by Prof. Nothnagel of 
Vienna, says (p. 230) : "In visceral troubles, which 
defy all treatment because they are favored by 
special alterations in the tissue changes, the physician 
may accomplish in many cases a true and real cure 
by endowing all the functions of the organism with 
the highest activity without the aid of medicinal 
agents, i. e., solely and purely by the application of 
ordinary physiological agents, and, above all, of hy- 
dro pathy. 
" The methodical, internal and external, use of 
water, together with climate, exercise, etc., are the 
means by which hydropathy stimulates cutaneous 
activity, and, with it all, functions of tissue change and 
organic purification, so that often real marvels of re- 
covery are obtained in serious and desperate forms 
of disease. Unfortunately these wonderful effects are 
more rare to-day than they were in the time of Priess- 
nitz, and of which I was a personal witness. It is to 
be regretted that physicians in general do not give to 
hydratic treatment that attention which its great value 55 
deserves, for with the exception of the cold-water 
treatment of nervous diseases, which is often used in 
the most irrational manner, very little and very had 
use is made of it in diathetic diseases. Those who 
were in a position to follow the cures of Priessnitz 
will readily remember what wonderful and unhoped- 
for recoveries were obtained in Graefenberg by the 
water treatment. Let me impress deeply upon you 
this classical method of evoking and furthering a 
natural therapy which powerfully contributes to re- 
juvenate the organism and best secures therapeutic 
success. In all those cases which are united under 
the common term of retardation of tissue-change 
activity, hydropathy forms a truly rational etiological 
treatment, and it is therefore of certain and unfailing 
effect unless the local processes have advanced to 
atheroma, visceral arterio-sclerosis, etc." 
II. FUNCTIONAL DISEASES 
These offer a wide scope for the inculcation of the 
principles which this essay aims to advocate. 
Rarely do we have an opportunity to treat such 
maladies methodically, for even where they are 
far advanced the patient is often allowed to pursue 
his avocations or pleasures. Under the erroneous idea 
that diversion of the mind is an important factor in 
the management of these cases, they are permitted to 
escape the discipline which is the only true means of 
proper treatment. In recent years a flagrant 
illustration of the value of systematic treatment of 
some cases of functional nervous trouble, hitherto 56 
regarded as the opprobria of medicine, has been ob- 
served in the rest cure introduced by Dr. Weir 
Mitchell. Volumes have been written upon this in- 
geniously constructed method of our talented country- 
man, who has thus immortalized himself by simply 
applying the })rinciples I would now urge upon your 
adoption in other diseases-viz., a more methodical 
application of our remedial measures chiefly dietetic, 
hygienic and psychical. 
ANyEMIA. 
A faulty haematosis is frequently of functional 
origin. When it is a manifestation of organic disease, 
the latter must receive the chief attention. 
Observation has taught me that these cases are 
rarely subjected to any but desultory treatment. 
Exercise in the open air, change of scene, a nu- 
tritious diet and iron in some form are the main 
elements of treatment. The patient is allowed to 
drift along as best he may. Fortunately, many re- 
cover under this treatment. 
That our average results would be more favorable 
under a carefully planned and punctiliously executed 
management, every physician of experience will 
readily grant. Weir Mitchell has given us some 
beautiful illustrations upon this subject. Dr. Laache, 
of Christiana, has also recently demonstrated that 
absolute rest in bed is in many cases essential. Dr. 
Scholz of Bremen, treats obstinate cases successfully 
in his institution, lie has found small venesections 
of great value, together with hot air baths. This 57 
treatment has a rational basis, it having been demon- 
strated by Dogiel's experiments on dogs that bleed- 
ing with ten to fifteen leeches does not alter the 
tension unless it raises it slightly. If the bleedings 
are repeated every three or four weeks, the dog 
gains weight, sometimes considerably, and the number 
of red corpuscles increases, unless the bleeding is 
carried to excess or repeated too many times. Vogt 
also confirmed these experiments and states that the 
haemaglobin is positively increased by small bleed- 
ings. This depletion, accompanied by proper diet, 
etc., probably induces increased tissue metamorphosis. 
I refer to these reliable clinical and physiological ex- 
periments for the purpose of calling attention to the 
fact that the usual slipshod iron treatment of anaemia 
is by no means the ultimate resort of the physician, 
and that in desperate cases we have many other 
resources. But my chief object is to ask attention to 
the necessity of promoting and encouraging tissue 
change in all diseases, in which there is a faulty 
hcematosis. Here again I am able to furnish abun- 
dant testimony of the auxiliary value of hydrotherapy. 
Again and again have I observed cases of anaemia 
and chlorosis which had defied prolonged iron treat- 
ment under my own care as well as under the advice 
of colleagues yield readily, when a suitable hydriatic 
method was added. 
The most simple means for this purpose is the cold 
ablution taken every morning while still warm from 
bed, not with a wash-rag however, but by pouring 
water at 70? abundantly from a sponge or pitcher 58 
upon successive parts of the patient, who stands in a 
tub of hot water to prevent chilling. Gradually we 
may advance to the dripping sheet and wet pack. 
Several years ago our talented colleague, Dr. Mary 
Putnam Jacobi, wrote an able essay on the wet pack 
and massage in anaemia in which she furnished so 
exhaustive a description of the method and physio- 
logical action of the treatment that I refer you to the 
original for valuable data. Suffice it here to state 
that in no type of disease does this systematic treat- 
ment evince more brilliant effects, than inamemiaand 
chlorosis. 
FUNCTIONAL DISEASES OF THE STOMACH 
are a fruitful field for methodical treatment. How 
rarely these are subjected to systematic descipline, 
we have abundant daily testimony. These maladies 
have become so common, that we rarely encounter 
a student or professional man or woman who has not 
at some time suffered from " dyspepsia." 
In these affections I regard the application of cold 
water externally by various procedures and the lavage 
by warm water, as may be indicated in each case, as 
probably of greater therapeutic value than all other 
treatment combined. A single brief history may 
serve to illustrate the value of systematic treatment 
in which hydrotherapy and electricity played a promi- 
nent role. 
Miss W., daughter of an Ohio physician, aged 23, 
was sent to me by Dr. Francke Bosworth, the well- 
known rhinologist, on May 15, 1889. Pale, emaciated, 59 
despondent, the picture of woe and despair, she was 
brought into my office by her sister. She had been 
ill three years; suffering first from fainting fits at the 
menstrual period ; afterward from violent pains in 
the right hand, traversing the body and concentrating 
in the epigastrium. For these her father and brother 
had been compelled to administer morphia for a 
month. Iler stomach became irritable, and has con- 
tinued so up to the present time; she vomited and 
spat up nearly all her food, mostly the solids. Sea- 
baths did not improve her. She studied hard and 
grew worse. In the F'all of 1888 she lived on milk 
and farinaceous mush, and her stomach was regularly 
irrigated, without improvement. 
She grew worse, became emaciated; she took pep- 
tonized milk for a month, but vomited it; meat pro- 
duced the same effect. Last Fall she lived on grapes, 
which agreed with her. Now she had tonics, pepsin, 
and all possible medication which her father and 
brother could muster, without avail. She was sent to 
Dr. Bosworth, who is a friend of her brother. After 
being in the city for three weeks without improvement, 
the doctor sent her to me. She now vomits every day; 
she traces her ailments to painting lessons, but I drew 
from her the history of a potent pyschical factor 
as a cause of the sudden violent insanity of the 
favored nurse of her childrood. ZMy diagnosis was 
nervous dyspepsia. The stomach was washed out 
twice a week to remove mucus and fermenting mate- 
rial. She had general faradization daily. Every 
morning she received the dripping-sheet at 60° F., 60 
while standing in warm water. Under this system- 
atic management she improved slowly, vomiting 
ceased entirely; she went to the seaside improved in 
July. On her homeward journey she called to tell 
me that she had grown stout and felt perfectly well. 
Last year I received a letter from her informing me 
that despite family troubles, the death of her father, 
which necessitated her adopting teaching as a means 
of livelihood, her health had been perfect. " You 
would not know me," she wrote, "as the same gir 
you treated." 
CONSTIPATION. 
Constipation is one of those minor functional ail- 
ments which give us much trouble. After failure 
of medicinal agents I have obtained excellent results 
from systematic treatment. Witness the following 
obstinate case, for whose history I am indebted to 
Dr. Leo. Ettinger, formerly resident physician of the 
Montefiore Home : M. G., a painter, has a history 
of lead poisoning ; complains of marked abdominal 
distension, undefinable pains ; is sallow and anaemic, 
anorexia and severe constipation are the symptoms 
that drove him from work to seek a last refuge in 
this home for incurables. Being regarded as a hope- 
less invalid by all his previous attendants, he was ad- 
mitted, leaving his family to spend his remaining 
days in the Home. 
March 15, 1889, he weighed 139 pounds. He re- 
ceived a dry pack, followed by an ablution at 65° 
daily. On the 15th of March hot fomentations were 
applied to his abdomen, while he lay wrapped in the 61 
blanket pack, until his entire body perspired freely. 
He now received a rapid but gradual ablution with 
water at 65°, was dried and rubbed. An enema of 
5 ounces of water at 45° was administered before the 
pack and retained. This treatment was continued 
daily, the bowels being emptied daily by large, warm 
enemata. April 3.-Pil aloes and mastich before 
each meal without effect for three days, enemata 
being suspended. 
April 10.-Abdominal swelling has disappeared ; 
under one pill of aloes and mastich at bedtime. 
May 1.-He was discharged, cured, at his own re- 
quest, weighing 149 pounds, a gain of ten pounds in 
six weeks. 
He has remained well since that time. 
FUNCTIONAL NERVOUS DISEASES. 
This class of diseases is the plague of our lives, 
simply because the patient is rarely sufficiently ill to 
require constant attendance. I am satisfied that in 
all these cases we may imitate Weir Mitchell with 
advantage, without resorting to the extreme methods 
which he judiciously advises for some of them. 
Methodical Management is the sine qua non of suc- 
cess. Constant observation is requiied; punctilious 
reports and submission to dietetic, hygienic and 
medicinal directions alone will enable us to accom- 
plish the best results. . Without fatiguing you with 
histories, I insist that in cases of neurasthenia, hys- 
teria, chorea and allied troubles, I have derived 
great advantage from the systematic and judicious 
application of medicinal and non-medicinal remedies, 62 
especially from hydrotherapy. My essay having al- 
ready exceeded the limits I had designed, I must be 
content with the following confirmation of my per- 
sonal experience in these maladies from a source 
whose authority all will respect and honor. 
In his able work in Ziemmesen's Cyclopaedia, Prof. 
Erb, of Heidelberg, says : " Cold and cool baths, in 
various forms, belong to the most important thera- 
peutically active agents in the field. This method 
has, since it has been more carefully studied ami more 
rationally pursued, made notable advances. Its re- 
sults in all possible forms of chronic nerve troubles 
are extraordinarily favorable. There are few reme- 
dies which have an equally powerful influence upon 
the nervous system." 
This indorsement may be accepted as of far greater 
value than the clinical histories which I am able to 
furnish in large numbers. 
In conclusion, I beg to emphasize the following 
points : 
1. A systematic methodical management which 
includes all known therapeutic agencies accomplishes 
results in chronic diseases which must surprise those 
who treat these cases in the usual desultory manner. 
2. It would inure to the interest of both patient 
and physician, if chronic diseases were treated with 
the same regard to detail and precision as acute dis- 
eases, and if the medical attendant would prefer to 
dismiss the case to permitting the patient to follow 
his inclinations and neglect the advice of his physi- 
cians. 63 
3. Hydrotherapy is an important and much neg- 
lected auxiliary in the treatment of chronic diseases 
" In many chronic diseases it has proved so success- 
fid, after failure of medicinal agents, that no case 
should be yielded up as hopeless until hydrotherapy 
in some form has been tried. My experience at the 
Montefiore Home, which receives only incurable cases, 
demonstrates this fact. 
" Domestic treatment by the methods here indicated 
will suffice in most cases, but if these fail a methodi- 
cal treatment under an expert hydrotherapeutist may 
be of advantage to the patient. 
" The most important elements are the thorough 
mastering of the general principles of hydrotherapy, 
precision in their application and their perfect adapta- 
tion to the constitutional peculiarities of each case- 
i. e., not treating disease but the patient. 
11 For this reason the best consultants in Germany, in 
Italy and France-men like Leyden, Charcot, Senator, 
Semmola, Ziemmessen, Northnagel, Binswanger and 
Erb, send their patients to hyrotherapeutic estab- 
lishments, which are under the direction of educated 
physicians who have studied the subject, with their 
diagnosis and general suggestions, rather than with 
specific directions for the method to be employed- 
Finally, so much depends upon the reactive capacity 
of each patient that only systematic observations can 
determine the most useful hydriatic procedure in each 
case." (American System of Therapeutics, Edited by 
H. A. Hare, M.D., Vol. /. p. 514). SUMMARY OF CONTENTS. 
PAGE 
Introduction, - - - - - - 1 
The Physician Aids Nature, - 4 
Chronic Diseases Should be Treated as Methodically as 
the Acute, - - - - - 6 
Elements of Success, - 8 
Phthisis, as an Illustration of a Curable Chronic Disease, 9 
Absolute Purity of Air is the Great Climatic Essential, - 11 
Institution Treatment Illustrated, 12 
Importance of Pest, - - - - - - 17 
Hydrotherapy in Phthisis, - - - 18 
Technique Described. - - - - - 20 
Striking Illustrations of Successful Treatment of Phthisis, 22 
Chronic Gout and Rheumatism, - - - 33 
Methodical Treatment, - - - - - 36 
Varieties, ------ 37 
Hydrotherapy, - - - - - - 37 
Objection to Turkish Baths, 38 
Striking Illustrations of Successful Treatment of Gout 
and Rheumatism, - 40-43 
Diabetes, Exercise must be Exact in, - - - 44 
N. Y, Academy Discussion, - - - - 45 
Von I^uehring's Successful Method, - - - 47 
Prof. Semmola's Testimony, - - - - 54 
Anaemia, Success in Treatment, - - 56 
Diseases of the Stomach, Success in Treatment, - - 58 
Constipation, Success in Treatment, - - - 60 
Functional Nervous Diseases, - - - - 61 
Prof. Erb, on the Value of Hydrotherapy, - - 62 
Conclusions, - - - - - - - 62 
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