Contributions and Selections.

THE MANAGEMENT OF CHRONIC DISEASES.

BY SIMON BARUCH, M.D., PHYSICIAN TO THE MANHATTAN GENERAL HOSPITAL, NEW YORK JUVENILE 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 advances since the day of Hippocrates, it must be confessed 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. And there have been not very remote periods in the history of medicine when the prevailing practice, consisting chiefly of spoliative measures calculated to attack and conquer the disease by sledge-hammer blows, which to-day appear as stages of retrocession, and which demonstrate the vast superiority of the Hippocratic idea of therapeutics to that prevailing in that period. What has been the outcome of the disputations of the schools? What is the modern status of therapeutics? To-day we stand in breathless expectancy, awaiting the dawn of precision in therapeutics. This hope is vain! Recent experience has demonstrated the fallacy of specific therapeusis after it had been promulgated by a mastermind 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 counted its vast numbers of victims ere the truth was ascertained. Just as

in modern warfare the master-minds of military science crush one or the other army by improved arms and tactics, so do we find in modern 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 conservative 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 organism owe its progressive stages to the same forces. As I said nearly twenty years ago in an address 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 discerns only labyrinthian confusion and disorderly turmoil. In the apparently discordant manifestations of diseased action, the same guiding thread will be discovered 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 diseases, 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, antipyretics, anodynes, hypnotics or by specfic 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 weapons, regardless of the fact that the patient is the battlefield and must bear the brunt of both contending forces.

It is the aim of this paper to emphasize the necessity 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 towards 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 tissueelements, 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 filled with hope and courage, feeling a certain degree of security in the knowledge that we have a powerful ally in the vis medicatrix naturæ, 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 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. 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.

No

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 gainsayed 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 Semmola, 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 loath 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 regained his normal weight, appearance and activity, 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 pneumonia or malarial fever or acute rheumatism. Moreover, the best proof of its curability is found in the fact that autopsies have often revealed evidences of cicatrization, restoration of weight and normal conditions of a diabetic patient, and their continuance under a moderately 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 possible under proper management. If all the manifestations of a chronic disease have ceased for a reasonable length of time, such disease is, in my opinion, cured as completely as an acute disease, with the condition 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 management of chronic disease? In order to answer this question we must narrow it down to definite dis

eases.

I desire to refer here chiefly to

1st. Diathetic diseases, as 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 management lies, as it does in acute disease, to sustaining the resisting power of the organism and to weakening the force of the disease.

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 exceed ingly 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 removal of the patient from his unfavorable environment to an institution in which pure, dry air, combined 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 undermined 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-recognized phthisis may thus be brought to recovery is so well ascertained a clinical fact that climatic agencies 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 quá 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 operation and of the operator as the cardinal principle. 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, scrupulous cleanliness leads to success. To its recognition modern surgery owes its greatest triumphs. Change of climate for consumptives is extremely valuable, 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 uncomfortable 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.

(To be continued.)

CONCENTRATED FOOD IN THE TREATMENT OF PULMONARY

CONSUMPTION.*

BY THOMAS J. MAYS, M.D., PROFESSOR OF DISEASES OF THE CHEST AT THE POLYCLINIC, AND VISITING PHYSICIAN TO THE RUSH

HOSPITAL FOR CONSUMPTIVES.

The importance of nourishing diet in the treatment of pulmonary consumption is so trite that it barely deserves repetition; yet, old as it is, it is Indeed it no less true to-day than it ever was. may be laid down as a fundamental proposition that the cases of consumption which cannot be reached through the instrumentality of food have certainly slim prospects of recovery. It is, also, no less true, on the other hand, that if the patient can be made to partake of, digest and assimilate a sufficient amount of food, it matters little in what condition his lungs may be; he will, with ordinary good management, make a good recovery in the great majority of instances-failure to get well under these circumstances is the exception. To make the patient eat, then, is the great problem to solve in this disease, yet every one realizes the enormous difficulties which are constantly placing themselves in the way. Very little can be done to attain this end by only addressing medicines to

the stomach. You are required to rise higher than this, and to take a general survey of the whole condition of your patient. In other words, it is absolutely indispensable to regulate his exercise, his rest, his sleep and his eating; in fact,

*Abstract of a Lecture delivered at the Philadelphia Polyclinic.

must have a systematic supervision of all he does during the whole twenty-four hours. I arrived at the conclusion, long ago, that a consumptive patient who is fatigued cannot eat. So his appetite will greatly depend on how much, or how little, exercise is prescribed for him. If much exercise tires, then less must be taken; and if little exercise tires, then absolute rest must be insisted on. Many of these poor people exercise themselves to death. Digestion, like exercise, requires a certain degree of bodily strength. The strength which is expended in performing exercise deducts so much from the sum total of the bodily forces, and in most cases leaves too small a residuum to carry on the processes of digestion, absorption and assimilation, and is the principal cause of the persistent anorexia. I am well aware of the prevalent impression that exercise is one of the essential promoters of a good appetite, but all needed is to ask the patient to give an opportunity to demonstrate the falsity of this belief by a prolonged dose of rest, and I dare say that a single chance will be sufficient to dispel the illusion. Rest will not only restore his appetite and save strength, but will reduce fever, diminish cough and make him feel more comfortable in every respect.

If the patient eats, what kind of food should he have? It is that kind which concentrates a large amount of nutritive material in a small bulk, and requires a small amount of digestive energy on the part of the stomach and the digestive tract. Such foods exist, without question, in the freshly prepared juice of beef, oysters and clams. And they are prepared as follows: Beef, preferably the round steak, is cut in pieces of the size of a walnut, and placed in a pan and laid over the fire for a few minutes, in order to heat the outside slightly. The whole is then dumped into a large Bartett beef-press, which separates the juice from the fibre. About one and a half pounds of beef will yield a teacupful of beef-juice. The juice, divested of all fat, and well seasoned, is taken cold in halfteacupful doses three or four times a day. In the case of oyster and clam juice, the same process is followed in extraction, and it is likewise taken cold and seasoned. These juices contain the very essence of nourishment, require very little or no digestion, are easily absorbed and assimilated, and may be administered to the most fastidious stomach. They are very much superior to any kind of beef tea or extract that can be made. Additionally I prescribe five or six glasses of milk a day. Much may be done in feeding these patients by going about it in a systematic manner. Begin at 7 o'clock in the morning with a glass of milk, and repeat the same every three hours. If a whole glass is too much, be satisfied if only half a glass

is taken at first. At 8 o'clock, administer half a teacupful of beef-juice. At first this is given three times only, but as soon as possible four times a day. If desirable, oyster or clam juice may be substituted once during the day for the beef-juice. Besides, the patient must be persuaded to eat; for breakfast, an egg, oatmeal gruel with cream and sugar, and bread and butter and a cup of coffee; beefsteak, roast beef, mutton or lamb, with vegetables, for dinner; and lighter meal for supper. Beer, wine, champagne, whiskey or brandy may also be taken in moderate quantities throughout the day.-Clinique.

COMMON ERRORS AND FALLACIES IN THE TREATMENT OF CHILDREN.

BY W. B. CHEADLE, M.D.

Feeding of Infants.-No mistakes in treatment are more pregnant of mischief than those connected with the feeding of infants. No mistakes

are more common.

1. The Sudden Weaning of Infants on to Fresh Cows' Milk and Water.-This is a frequent source of disaster. The massive curds which distinguish cows' milk when brought into contact with the acids of the stomach are frequently beyond the feeble digestive powers of an infant. Dilution only diminishes the quantity of the casein, it does not alter its character; and the undissolved clots under the favoring conditions of heat and moisture ferment, and set up colic, vomiting, diarrhoea. Unboiled milk readily becomes sour, and affords a favorable soil for putrefactive bacteria and disease germs. Both clinical experience and actual experiments show that boiling milk sterilizes it as far as the putrefactive bacteria and disease germs are concerned. And yet, as has been well remarked by Dr. Jeffries, while older people are fed almost entirely upon sterilized-i.e., cookedfood, infants are fed on an unsterilized food peculiarly adapted to serve as a cultivative medium for bacteria. Boiled milk, moreover, clots less firmly and massively than raw milk, hence is more digestible. Children should be weaned on to boiled milk, with barley-water, which appears to separate the curd atoms and hinders massive coagulation. In the case of very young or very delicate children, however, the milk should always be peptonized at first, the degree of peptonization being gradually reduced. Whatever form of milk is used, the solution should be sufficiently dilute to begin with, the strength being gradually increased.

2. The Feeding of Children on a diet which is excessive or deficient, either in gross quantity