differentiated by tophaceous deposits, its characteristic spindleshaped enlargement, and peculiar deformity. From gout, chronic rheumatism is distinguished by the difference in the pains and their location and the absence of deposits of urates. Bone changes appear early in the arthrophies of organic nervous diseases and are more apt to involve the large joints with their lesions corresponding to the segment of the cord involved.

There is a disease of joints, tendons and muscles occurring in the physiologically aged sometimes referred to by a term. used to perform more than double duty, rheumatoid arthritis, the symptoms of which resemble those of chronic rheumatism. It is chronic, painful and produces stiffness. Pathologically it is supposed to be associated with arterio-sclerosis. Sometimes it occurs before any arterial disease has been suspected. Early the general symptoms are looked upon as neurasthenic. Later, after sclerosis is decided, the state is recognized as due to similar senile changes. It is, of course, progressive, fast or slow, according to the rate of the retrogressive changes.

Treatment.

To discontinue rambling remarks about chronic rheumatism and its kindred, there is but a moment for consideration of treatment. There are many paths being followed, the best of them none too straight and the most of them devious and miry with a cloud of misty uncertainty overhanging, bewildering the guide. One affirms that massage or some method of manual therapeutics is the important element in soothing and restoring diseased joints and fibres. Another depends upon electricity and holds out the encouragement that a large majority of cases not only improve but recover under his batteries, sparks, wheels, lights and sprays. At one time everybody maintained that rest of the diseased joints must be maintained. Now we hear of breaking up the adhesions by violence and the recommendation of even violent exercise of the parts. Hot air vapor baths, mineral baths with the mineral mixed with water thick or thin, visits to baths far away, drinking of chemical waters natural and artificial, abstinence from certain kinds of foods, drinks, etc., are also a few more of the various things to try and to receive the credit if improvement follow reasonably soon afterwards.

I do not wish to seem severe in speaking of these agents. Some of them are of undoubted usefulness; but I am obliged to say that only in the hands of the expert are they of more than indifferent value. With the cases carefully selected and the treatments considerately applied, as no one but a specialist can do, they are of undoubted benefit. Like internal medicines they are not to be prescribed and taken except upon clear indications. If there is a science of medical electricity, dietetics, manual therapeutics, balneology and surgery, they have their foundations in definite, clear and reliable rules. I affirm my faith in in

ternal medicine, and employ, so far as my knowledge and experience bear me out, such other measures as I can command. The amplitude of our materia medica is so great that to even name the remedies that serve us well, would be a long repetition.

That a much larger number of medicines have to be brought into action in chronic than acute inflammatory diseases is a rule particularly noticeable in diseases of joints, their linings, coverings and attachments. As interesting as it would be to refer to some of them in detail, my closing remark must be that of the routine lecturer to his class: "Look it up carefully and differentiate the symptoms."

THE HOME AND SANATORIUM TREATMENT OF PULMONARY TUBERCULOSIS IN THE CLIMATE OF NEW

ENGLAND.*

BY HERBERT C. CLAPP, M. D., BOSTON, MASS.

Only a few years ago it would have been necessary to describe minutely to the bulk of the medical profession the main principles on which the modern successful treatment of pulmonary consumption depends, and to point out the difference between them and the former ways which led in the great majority of cases to death.

At the present time these principles are (or ought to be) understood by all physicians who try to keep themselves abreast of the times. And so we need not dwell on them here. On account of the breadth of the subject assigned to me and the narrowness of the time allotted, only a few general considerations can be presented.

For our present purpose the climate of New England is so much like that of New York and the other middle States, and indeed of a considerable territory beyond, that in the main the same principles will apply to those regions as well.

Until lately this climate has undeservedly had a bad reputation for consumption. After the Pilgrims landed it was known in poetry as the "stern and rock-bound coast." Its rainfall has been considerable, its cloudy days have been many, it has been called bleak much of the year. Among its chief products have been ice and granite.

Not only by outsiders, but also by natives, it has been considered that, although a consumptive might here do fairly well in summer, he never could stand the winters. This was true enough in the days when he was coddled and shielded from every breath of air which, on account of sadly mistaken views, was rigorously excluded. Give a dog a bad name and it will cling

*Read before the International Homoeopathic Congress, held in Atlantic City, S pt. 190.

to him. It is hard even now to persuade some folks that consumption can be cured in New England; and yet the Massachusetts State Sanatorium has been demonstrating on a large scale for eight years what a few of us had been proving with private patients on a smaller scale for a longer period of time, in a quieter and less spectacular way, that it can be cured here as elsewhere, if taken early enough. In both instances there has been imitation of the German Sanatorium methods, of which the Adirondack Trudeau was in this country the pioneer and original expositor.

The rational treatment is spreading, and now in every New England State, either in public sonatoria or in private practice, consumption is being cured, without any sort of doubt whatsoever. The chief danger now lies in the fact that its over-enthusiastic friends are apt to claim too much for the new method of treatment and to neglect to consider properly its limitations, on account of which it is liable to fall into disrepute to some extent in certain quarters.

It is no longer to be considered in New England that a tuberculosis patient's only chance for recovery is to go to Colorado or California or Arizona or New Mexico, or the Carolinas, or the Riviera, or to the ends of the earth. Especially fortunate. is this for our people who are poor or in moderate circumstances, who make up the bulk of our consumptive population; for most of those could not possibly go, and many could go only after mortgaging their property or otherwise running badly into debt. Even after reaching the desired climate, if scrimping and the most rigid economy in food and other comforts were necessary, in addition to the natural depression arising from homesickness, what a handicap there would be! Besides, it is generally admitted that, if possible, a consumptive should be cured in the same climate where he expects to live afterwards, in that case being less liable to a relapse.

As expressing laconically the pith of the whole matter as now generally accepted by the best authorities. I have been in the habit of putting it in this way: "How you live is far more important than where you live." After being told that a certain state or country has the best climate in the world for you, do not go there and live as you have lived at home and expect its geographical name to cure you, for it will not. On the other hand, cures have been made in almost all climates, if the right kind of a life is led; the most important part of this of course being a life passed almost constantly in the fresh air. In a word, those climates are the best which allow a patient to live the greatest proportion of his time in the open air, provided that the air is cool enough to act as a proper tonic to all his functions. The latter proviso I consider important, because a very hot country has surely not been proven to be so favorable for the cure of the disease, and also because it has been proved

again and again by all those of us who have in late years treated the disease on a large scale, in a climate as cold as New England, that our patients almost always make a much more satisfactory gain in the fall and winter months than in the spring and summer. The first and essential requisite is that the patient shall be exposed to the out-of-door air (including the time spent in bed) practically all of the time-and preferably at least 20 out of the 24 hours. Now if he is able to react properly, if he can stand this exposure in the New England climate in mid-winter, it will often do him more good than to go South or West to a warm climate. The tonic effect of the cold will give an edge to his appetite, will enable him to digest almost anything short of board nails, will make him sleep well, and will improve all his functions. Too warm a climate often acts as our summer, if very hot, is apt to do here, by lowering his tone and making him languid and causing loss of appetite and consequent failure of proper nutrition.

How many can stand this exposure in winter? My more or less intimate knowledge of several thousands of cases makes me feel sure that the great majority of curable New England consumptives can stand it. I say curable, because it seems to me cruel to expose to such cold those whom we have good reason to believe to be incurable. The great majority of consumptives are what we call young. The average age of our Rutland patients is 27 or 28. Exceedingly few of them are affected unfavorably by the cold, although many before they have tried it, are sure they cannot endure it. As a rule, their mothers are more sure of this than they are themselves.

Still, to our delight we have found that after being obliged to sleep with open windows for months, most people learn so to love it, that they refuse to have them shut when they go home, and complain of suffocation if they cannot have them open. Even girls apparently so delicate that the first gust of wind, it would seem, ought to blow them away, will thrive in zero weather. I do not say that they will always be comfortable. Some are and some are not, even after they have tried it for several weeks or months. Some gradually get used to it and finally enjoy it. With some it requires much heroism to expose themselves to the cold, from which they really suffer a good deal. Some die because they lack this heroism. It requires very little of this to live out of doors in the summer time, when the whole world wants to be out more or less. To get well of consumption anywhere requires a certain amount of heroism in other directions, even if the temperature is pleasant; and even in the best climate in the world, where a weak-willed man will fall out by the way, a man of strong character with the same amount of disease will sometimes recover. As to standing the cold, a Washington doctor who has spent much time in the arctic regions, has witnessed its beneficial effects in consumptives to

such an extent that he is anxious to fit up and send there expeditions for three or four months each summer, for their treat

ment.

A man who is rich enough, if he dreads the New England winter's cold and cannot get used to it, by the expenditure of money can and should, other things being equal, go to a warmer climate, where by pursuing the proper course of living and treatment he can recover with more comfort than in New England. Dr. Flick of Pennsylvania, the first Vice-President of the National Association for the Study and Prevention of Tuberculosis, a man of great ability and experience, believes with others that one climate is practically as good as another for the cure of the disease. The majority of us, however, think that certain climates do offer some advantages in certain respects over others, although all nowadays agree that the most important measure is right living, and with all today the question of climate holds nothing like the importance which it formerly held.

When the problem is to decide whether the patient who has money had better leave New England or be treated there, no solution is adequate which does not carefully take into account the disadvantages in going away, to see if they will balance the advantages to be derived purely from climatic influences.

What are some of our decided limitations? Tubercular patients with a very well-marked complication of chronic bronchitis or asthma or kidney disease, as a rule, do not take kindly to rigid exposure to our New England winters, and if possible should go to a warmer place. Elderly or even middle aged people with tuberculosis (I purposely leave the number of years indefinite) also very often have great difficulty in standing our Northern cold. If they can do so, they also should go to a warmer place. Luckily these and a few other exceptions constitute a decided minority of the cases which come to us.

In different parts of New England itself we have minor differences in climate, but the most important are those between the strip of seacoast a few miles wide and the interior. Lung patients generally do better in the latter region in New England, although in Europe the seashore has a great reputation for the bone and joint tuberculosis of children, and the recent remarkable successes at "Sea Breeze" on Coney Island, New York City (virtually a New England climate) seem to substantiate this view. Some think the distance should be 50 miles or more inland. Many have got well in Sharon, only 17 miles away from the ocean, in Needham and Wellesley, about 15 miles, and in many other places still nearer.

In general for pulmonary cases we shall derive an advantage if we can get far enough away from the shore to lose completely, or at least largely, the effect of the harsh, raw, piercing winds from the ocean.