No less important than the dietetic treatment of contracted kidney is the physical treatment. The question arises whether we should attempt to change the water balance of the body by physical means. Practitioners in general maintain that in contracted kidney sweating is as strongly indicated as in acute forms of nephritis. Hot bathing followed by packs, Roman and Turkish baths and, of recent years, electric light baths all play an important role in the customary treatment of contracted kidney. Here we again encounter an apparent contradiction; for on the one hand we give as much water as possible for the purpose of flushing the kidneys and all the tissues of the body; on the other hand, we attempt to eliminate a large part of the water given in this way through the pores. The heart has to bear the brunt of the additional labor imposed on the body in this way, for the circulation is at all times overloaded with an excess of fluid. I do not quite understand what advantage is expected to accrue in this disease from sweating; in the later stages of the disease when there is much oedema I can of course see how the patient may be slightly benefited by this means. There is in fact no rational explanation for this practice; our only guide should be practical experience, and my personal experience teaches me that these patients are to say the least not benefited by this method of treatment; it is possible that the employment of hot water and steam-baths or of the electric light baths do no harm if used in moderation; if used in excess they certainly damage the patient very much, for they favor the development of heart weakness and insufficiency. We frequently find that certain manifestations of heart weakness disappear as soon as we stop the bathing. If my advice is followed and the patients are allowed to drink only moderate quantities of water there will be no call for the employment of diaphoretic measures of any kind.

Generally speaking I should say that the same hydrotherapeutic principles apply in the treatment of contracted kidney as in heart disease. At home cold rubs or luke-warm sitz baths followed by a brisk rub, the water being cooled from 3 to 4 degrees during the bath; brine baths of 30 to 32 degrees with the addition of pine needle extract to stimulate the skin. In watering places simple brine baths, carbonated brine baths, and, in particular, carbonated steel baths. I have studied many patients with contracted kidneys of recent years who took the carbonated baths of Nauheim, Homburg, Kissingen, Soden and Schwalbach and have frequently had occasion to convince myself that these baths exercised a strengthening effect on the heart and on the whole body. I agree with Groedel, however, who warns expressly against sending patients with advanced degrees of nephritis to watering places of this kind. They stand this treatment badly and it seems to agree even less with such cases than with cases of heart disease; and we know that more harm than good is done to the latter class of patients in the last stages of the disease if they are sent to some place where they are expected to take carbonated brine baths.

In regard to muscular exercise and massage the same principles again apply to the treatment of contracted kidney as to the treatment of heart disease. Both these adjuvants to treatment are intended to strengthen the heart and in case it is weakened to raise its functional powers. Some clinicians hold the view that patients with contracted kidney should avoid all physical exercise; this idea is wrong and should be discarded; fortunately modern physicians are beginning to give up this plan of treatment in kidney troubles just as they have given it up in heart disease, thanks to Oertel. In contracted kidney it is true we must exercise still more care than in heart diseases; for in renal cases we must consider the heart as much as in heart cases proper, and in addition the blood vessels and the kidneys. The exact amount of muscular exercise that is to be permitted in each case must be determined by a study of the individual peculiarities of each patient. The reaction of the heart and, of course, the constitution of the urine are the chief determining factors. Physical exercise influences the degree of albuminuria in contracted kidney as well as in acute and subchronic nephritis, also in juvenile cyclic albuminuria, although not to such a marked extent as in the first named disorders. Rest in bed frequently leads to a considerable decrease in the excretion of albumin, but that does not justify us in keeping patients of this kind in bed; if we were to adopt this plan we would have to keep them in bed for months and years without really benefiting them to any great extent. In patients who are up we also frequently find considerable differences in the amount of exercise they take. The increase of albuminuria is however only transitory if the patients are gradually accustomed to greater physical efforts (by gymnastic exercises, mountain climbing, etc.); in the great majority of cases we will find that the degree of albuminuria drops back to the original level as soon as the heart and the muscles grow stronger. In many cases we may even fail to notice this transitory in crease in the excretion of albumen; when it does occur both patients and physicians are apt to be misled and to attach too much importance to it, so that they are in this way prevented from systematically carrying out the exercise treatment; this is always to be regretted, for this method is of the greatest benefit to the muscles, the blood forming function and the circulation of the blood through all the organs - the kidneys included. Muscular exercise should only be stopped in the terminal stage of the disease, that is, as soon as the function of the kidneys becomes insufficient or the heart becomes weak or other intercurrent complications threaten to hasten the death of the patient. At this stage of the disease there is really no rational treatment of contracted kidneys. We must content ourselves with symptomatic treatment and attempt the fruitless but nevertheless humane task of giving the sufferer as much relief as it is in our power to grant.