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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 judicious prescription and equally judicious observance thereof, of gentle muscular exercise, form an important 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 anæmic type, rendered so by long continuance of the disease and subsequent abstention of exercise, by loss of sleep, etc.

2d. The plethoric form, usually, though not altogether, 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 promoting tissue change, but of removing debility, improving the appetite and building up the nerve tone. The second type (the plethoric), in which there is so much stiffness in joints and muscles without general failure of health, is more difficult to manage. The 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 marvellous) results, as we are informed by reliable observers living to-day (for instance, Prof. Semmola of Naples.) 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. Suffice 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 elimination 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 atmospheric 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 ingredients, in these baths contributes absolutely nothing to the cure. Nothing is absorbed through the epidermis, unless it be in a volatile form. The sooner this fallacy is removed from the professional mind the better. 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 excellent 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 surroundings-above all these that which I chiefly desire to emphasize in this paper as the most important element in the management of all chronic diseasesthe systematic observation and treatment, obtainable from skilled experts, the same as we give patients in acute diseases, accomplishes results which must surprise those who treat cases at home in a necessarily slip-shod and perfunctory manner. Institutional treatment will show in all chronic diseases, what has been proved in that most intractable of all-phthisis. The following clinical history from Duval (p. 553), illustrates the value of methodical treatment, even in desperate cases. It is of the third type mentioned above: Z., a Pole, 65 years aet., well developed, of biliosanguine 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 completely changed his mode of life, so that he was compelled 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 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 history:

CHRONIC RHEUMATISM.

S. Z., 26 years. E. Second Street.

Single. Austria. Waiter. 248 Admitted November 14, 188.

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 movement; 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 gonorrhoea. Discharge slight. Treated by copaiba and injections. Two weeks after commencement of urethral 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 medicine which induced profuse sweating. At time of admission 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, especially on extension. Standing was more painful than walking. Gait was stiff and much impaired. Appetite was poor. Bowels rather constipated; urine was high-colored. Gonorrhea had stopped four months before admission. Sleep was poor; was very anæmic, 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.

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 result.

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 affection, 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 complete insomnia.

The treatment was preluded by a general ablution with water at 24° (82° F.), repeated in the afternoon with water at 16° (61 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 (étuve sèche); 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 sameness. These cases are very much alike. There is a history of long suffering, stiffness and impeded locomotion, and general hopelessness due to the failure of

a multiplicity of remedies and doctors of high and low degree. They have rarely had systematic, prolonged treatment of any kind. None of these cases should be regarded as hopeless until such treatment, including hydrotherapy and its auxiliaries, have been fairly tried. 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, because one is more or less liable to be biased in the reporting of his own successful cases.

white bread (for which they all crave), graded according to the amount of exercise taken.

This treatment, based upon the well-known recommendation (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 referred. 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 asseyeration, I felt called upon to say that the recognition

Another disease illustrating the value of systematic of muscular exercise as an important element in the treatment is

DIABETES.

I

Diabetes is a malady that has probably received more so-called systematic management than any other. It has been recognized that by the diminution 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 perverted 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 entirely empirical treatment. Put less sugar in and you have less to dispose of is a simple English dictum. 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 systematic diet, but of systematic exercise. Unless the physician be convinced of this, he will permit the disinclination of all diabetics to exercise to overcome his injunction. The latter cannot be made too strong. A certain definite amount of exercise must be prescribed 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 prejudiced 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 followed as punctiliously as we are wont to do in medicine, 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 18th, 1888, I endeavored to emphasize the importance of active and passive exercise adapted to the requirements 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 taking the prescribed exercise by a definite allowance of

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 muscles also fail in a great measure to perform their function of disposing of sugar. We resort to the restriction of sugar supply by diminishing or withdrawing those articles of diet which physiology has taught are sugar producing. We possess no remedy which stimulates the glycogenic function of the liver, but we are in a more favorable position regarding the muscles. By increasing their functional activity we can stimulate the sugar-converting function of the inner fibrillar substance of the muscles, and thus we may dispose of a large portion of the excess of sugar circulating in the blood. Clinical experience is fortunately entirely in accord with this deduction from the teachings 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 medicinal specifics. The subject of exercise is often dismissed 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 diabetics are, as a rule, loath to muscular exertion; lassitude is a common symptom, and something more than the mere suggestion is required to enforce the necessity 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 physicians will at once appreciate. He describes graphically how he was himself overcome by weakness and

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indisposition to exertion when suffering from diabetes. "He could not walk a hundred yards without great fatigue; he frequently fell." "I began to take exercise 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 sustained 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.

German

We have ample testimony on the value of exercise in the discussion of diabetes in the fifth 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 massage 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 passive 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 active and passive exercise, allowing small quantities of hydrocarbons. In some cases the sugar disappeared 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 accord 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

that

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 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 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 domestic 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 adding 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. He 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 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 little 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 carrots were permitted, but they were cooked in salt and

water only. Raw apples and cherries allowed, also a small glass of red wine, and water occasionally.

At 9 or 10 At 9 or 10

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. 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 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 treatment would be more useful than appears to be to our 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 muscular exercise. I have found it advantageous to compensate my diabetics for a certain amount of exercise by an allowance of small quantities of hitherto forbidden food.

Such systematic attention to the needs and capabilities 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 management.

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 medication 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,

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 simplified therapeusis. The irritating effect of the gastric juice upon the abraded surface is neutralized by the bland food; the gastric secretion is diminished by it. by it. Rest to the stomach is secured as far as possible, and thus the rational treatment, beautiful in its simplicity, triumphs over blind medication. Who

ever has observed the complete change from excruciating 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 in 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 impress upon the profession the great value of the natural methods of treatment, aided by judicious medication. Permit me to offer one quotation.

Prof. Semmola of the Naples University, in his recent 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

that most painful of all gastric troubles, which had ordinary physiological agents, and, above all, of hydefied 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.

Three cases which were under my treatment recently, 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, gastric 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 hydrochloric 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 absolute rest and

dropathy.

(To be continued.)

THE DIETETICS OF DISEASES OF THE STOMACH.

BY DR. J. BOAS.

[Continued from the March Number.]

IV. Directions regarding the manner of preparing foods are frequently necessary. The patient himself sometimes requests information on this point. The directions given should have reference to the preparation of meats (raw, rare or well-done), the use of gravies (an important point), the preparation of the latter, the artificial reduction of the meat to a finer state by chopping, mincing, etc., and the addition of condiments (salt, pepper, mustard, lemon, oil, vinegar, etc.). The same may be said of fish. The manner of preparing vegetables, farinaceous foods, stewed fruits, is also of importance; as regards the former especially,

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