SECTIONAL MEETING.

DISCUSSION.

DR. LILIENTHAL: The idea of writing out this long paper was first suggested by the deaths in our hospital, and by the thought that they were due to our hospital practice, and that we ought not to have any insane asylum, but treat the patients, individually, just as they are treated elsewhere. The theory is that the patient is insane on one point, while on all other points he is perfectly rational. Now, of course, nursing and careful treatment, and, if you please, the weekly examination of the lungs, will do a great deal. It is true that on first sight it cannot be detected, but I believe the mortality can be reduced to a mere trifle. In a case of pneumonia and tuberculosis we know which part of the lung is attacked, just the same as in disease of the brain. Genuine tuberculosis can be detected, with the exception of the patient suffering from phthisis, or from catarrhal phthisis, for as Flint says, febrile phthisis-interstitial pneumonitis-is very often nature's last effort to keep tuberculosis in its place. I think that a phthisis which takes so many persons away, the paralysis of the insane, is a perfectly curable disease. It first commences by the manifestation of rheumatoid pains, when the patient gets extravagant in his manner, is ill-natured at home but very pleasant outside. If you take those patients in hand at this time I think they can be cured. I throw out these hints and would now be glad to hear from the members present about phthisis.

DR. FISHER, Montreal, Canada: Mr. Chairman: There is a case in print related by Sir William Wild, in Dublin, and is somewhat as follows: Stokes had a phthisical patient who came to him saying he wanted a sincere opinion about himself, as to whether he could live. Stokes said, "Well, if you want to know the truth, I will tell you that you are in the last stage of phthisis, and have only a short time to live." He said, "If that is the case, I will have a short life and a merry one." He took a bottle of whiskey and went up into the hills and walked about all day, and drank the whole bottle of whiskey. When he got back at night he felt rather better than he did in the morning. He did this for several days and eventually he got quite well; then he came back to Stokes after three

you

or four months, and Stokes looked at him and said, "Well, I see you are not dead yet, but you ought to be." What did this man do? He drank his whiskey, walked about on the hills, breathed the fresh air and recovered. DR. BROWN: I wish to make a statement in regard to a similar case. On the ninth day of December, a year ago, I was called to see a young lady who had been ill for three years and who was in a state of extreme emaciation. She had been in the hands of several old school physicians, and some of them had said that she was incurable. She was reduced down to seventy-five pounds weight before she took to her bed. She had been taking large quantities of medicine, and, worse than all, she had slept in a small room adjoining the bed room, and they took particular care to keep the windows and doors closed for fear of the night air. When I was called to the case I said to her, "I will cure you if will follow my advice." My first advice was that the window at the foot of the bed should be kept open four inches during the night and day, and that the stove should be kept going night and day to keep the patient warm. I did not see her again until the 7th of February following, when she had begun to eat. I said to her, "I shall not have to see you again if you do not discontinue following my advice. If you will only follow my advice, and take the remedy that I give you, you will recover." The remedy given was Lycopod.,200 as she had, as a very prominent symptom, a feeling of satiety. I did not see her again until the following November. the first of November a neighbor of hers came into the office and introduced her as a patient. She said she wished me to examine into her case as she was sick. She asked me to examine her very closely. I said to her that "I did not think I could tell what her disease was." She could not

stand it any longer and she said to me, "Don't you know me? I am your patient; I live at such and such a place." She weighed 159 pounds, and when I saw her two months ago she weighed 203 pounds. I do not know but we are carrying it too far in her case, but that is her condition. Now, the questions in my mind are these, whether it was laying off the irregular treatment, the Lycopodium, or, as reason calls it, living naturally her physiological life, that wrought the cure.

DR. LILIENTHAL: Why not give the devil his due?

DR. BROWN: I will give him all that is due. Was it the keeping of the windows open that cured her-was it the remedy that cured her? That is what I wish to know-which cured the patient? She is well now, and is likely to remain so. She is of a consumptive family. Three out of the family have died of consumption, and her grandfather died insane. If you can make any connection between that case and Dr. Lilienthal's remarks you are welcome.

DR. L. C. GROSVENOR: I think the position that Dr. Lilienthal takes in regard to phthisis pulmonalis is a tenable one. You know that such patients will tell us, even the day before they die, what they are going to do when they get well. We know, too, that a person with indigestion is dying all the time of dyspepsia. I think the reason why we see so many cases of phthisis pulmonalis in insane asylums is owing, as the doctor has said, to the surroundings and depressed mental condition, which prevents their getting well. In the case of the patient spoken of by Dr. Fisher, who went into the mountains with his bottle of whiskey, I think it may be said that the whiskey was a present stimulus in his rambles during the day and that he breathed more deeply and fully the fresh, pure mountain air. The chairman has given a case illustrating the value of fresh air. I will also give a case. A few years ago a patient was brought to me from the country, by her mother. She was carried from the car to my carriage, and from the carriage to her boarding house, in my arms. She was very much reduced with phthisis pulmonalis. After treating her for four weeks and caring for her hygienic conditions, such as fresh air, having her sleep in a room with the windows open, etc., she was able to walk to my office. I then told her mother to take her and put her in the saddle and keep her there until the snow flew. She was too weak to take exercise herself, and the pony would give her exercise and make her sleep well by giving her an increased circulation and carrying the blood to every part of her body. She commenced riding according to advice. The first time she rode a half an hour. She came home and said to her mother that she could not ride any more; she would have to give it up. In an hour's time, however, her mother had her out in the saddle again, and in six weeks from that day the young lady rode six miles at a gallop, and she recovered her health perfectly. So much for fresh air and exercise in phthisis pulmonalis. If there are real repairs to be made these repairs can be made by good food well digested, but a person cannot eat good food without exercise, and cannot digest it without exercise. We cannot carry it over the system, where it is to be used, without exercise. Exercise causes the blood to circulate more freely over the body. We do not breathe fully and freely without exercise; we do not expand the cells of the lungs unless we have some exercise to make us do it. So I say, that the best prescription we can have for phthisis pulmonalis is a hygienic prescription. Let them sleep in a room with the windows open. There should be plenty of air in the room; let the windows down half an inch from the top and raise them half an inch at the bottom. Give them plenty of exercise, thoroughly attend to all the hygienic conditions, and we will cure all cases that are curable.

DR. DAVID THAYER: This subject is so interesting that I am tempted to state to you a case which is very remarkable. It happened some years ago. I knew the young man, who is now an old man, on whom the death sentence had been pronounced by the wisest physician in Boston at that time I mean the wisest in diseases of the chest. The young man had a bad cough with hepatization of a portion of the left lung. He was fond of life and he was determined that he would not die. He bought for himself three pairs of stockings, three suits of clothing and underclothing-the third suit of silk-two suits of cotton and one suit of cotton flannel, so-called, two suits of woolen flannel, and one suit of buckskin. As the weather grew colder he added the cotton over the silk, and as it was colder still, he added the woolen over that, and when it was very cold he wore the buckskin over that; he enveloped himself entirely in this clothing. He attended vigorously to his business every day, was out of doors a great deal, and slept in the coldest room in his house, with the window open every night. At night he took off these clothes, one, two, three thicknesses, and sometimes four thicknesses, stripped himself naked, rubbed himself dry with coarse towels, put on another suit, went to bed and slept all night; in the morning when he got up he would have to break the ice in the water pitcher-it was before the time of the introduction of the Cochituate water into Boston. He broke the ice in his pitcher, washed himself all over, rubbed himself vigorously with coarse towels, put on one, two, three thicknesses, as needed (silk, cotton flannel, woolen and buckskin), and attended to his business the whole day. That man was entirely cured. I have come to this conclusion in regard to the treatment of lung diseases generally, that it is the better way to keep the skin warm; give to the skin the climate of Cuba, while the patient breathes the cold air of the north. That is the conclusion I have come to in regard to the treatment of phthisis. I am of the opinion, and have been for a long time, that phthisis can be in a great measure exterminated from our happy New England and New York. I may say not without medicine, but by proper regimen. The first important point is that of keeping the skin warm, and exposing the patient to the cold air as much as possible. It has been said, "horseback riding is the grave of dyspepsia," and I will say with my friend, Dr. Grosvenor, of Chicago, that horseback riding is one of the best agencies I know of for phthisis, especially in the incipient stage. The article written by my friend, Dr. Lilienthal, is very valuable, and I shall profit by it. I believe that if the ideas that are given there are followed out, in regard to the treatment and the care of phthisis patients, that they will greatly profit thereby.

DR. S. M. CATE: I have a great deal of hesitation in saying anything that would look like criticising Dr. Lilienthal's paper, but still it strikes me that he has fixed the thing up altogether too smoothly. I think that the best established opinion of pathologists is that progressive paralysis has no fixed pathology. That is the way I have been taught. Post-mortem examinations do not give any information as to any of its characteristics. That is what is told me by the best pathologists of Vienna, and it accords with my teaching on the subject. There is one point, and that is, that there is no pathological change uniformly found in post-mortems which can be considered characteristic of the disease. Again, so far as old school authority goes, the disease is uniformly and always fatal. I doubt, also, if the classification and the record of interstitial disease would bear strict determination, for we can find interstitial disease of the lungs, or of a portion of one lung, which still leaves the lung in a secure condition, so that a person may live comfortably for many years, and die of tubercular deposit, ulceration, or some other disease, long afterwards. If I am right in these facts, it makes something of a hole in his pretty story.

DR. LILIENTHAL: In answering Dr. Cate, I would say that paralysis of the insane is now considered to be a sclerosis of the anterior lobes of the brain and which extends through the medulla oblongata down to the spine, so that the nerve tissue is gradually absorbed by the cellular tissue. The disease lies in the neural substance, the same as you will find in interstitial pneumonitis. The non-cellular tissue is affected, and we have compression of the air vessels, which can be cured, but not if disorganization has taken place. You must make your cure before that point is reached. That is the very reason that paralysis of the insane has been so fatal, because it has been recognized too late. Now, the statistics of hospitals and asylums are not worth anything, because they get their cases too late; and for that very reason I have always insisted upon it, that the students in our colleges, and our physicians everywhere, ought to study closely the cases of insanity and mental diseases which come under their charge. It is not a specialty. You have the patients in your hands before they become insane; you have the patients in your hands before they suffer from phthisis, and that is the time to eradicate phthisis. That is the time to eradicate that tendency, call it scrofulosis, call it syphilis, call it psora, call it whatever you wish, they are all faults of mal-nutrition. That mal-nutrition has to be rectified by the cure of your patient. If you do not do it, but let it end in disorganization in the brain, lungs, kidney, wherever it will, the patient is bound to die.

DR. S. M. CATE: I only say very many cases of progressive paralysis