M. D. SEP v r jF ' " ' LEE " " MODERN PHYSIO-THEEAPY A SYSTEM OF DRUGLESS THERAPEUTIC METHODS INCLUDING CHAPTERS ON X-RAY DIAGNOSIS AND SUGGESTION BY OTTO JUETTNER, A.M., M. D. Author of "Daniel Drake and His Followers"; Physician to Seton Hospital, Cincinnati, Ohio ; Fellow of the American Electro-Therapeutic Associa- tion, the American Physio-Therapeutic Association, the American Association for the Advancement of Science, the American Acad- emy of Medicine, the Roentgen Society, London, England; the Royal Society of Medicine of England, the Royal Microscopical Society of England, the Royal Anthro- pological Institute of Great Britain and Ireland, the Society of Arts, London, England; the German Roentgen Society, Berlin, Ger- many ; the Academy of Medicine of Mexico, the Societe de Radiol- ogie et Electrologie, Paris, France, etc., etc., etc. THIRD EDITION KIRKSVILLE, MO. W. D. BLEDSOE 1913 /r mg "Youth fades; love droops; the leaves of friendship fall : A mother' s secret hope otitlives them all.' 11 OLIVER WENDELL HOLMES. PREFACE TO FIRST EDITION. IN submitting this book to the indulgent consideration of my readers I feet disposed to refrain from giving the usual explanation or making the customary apology. The two hundred or more physicians from all parts of the American continent whom it has been my privilege to in- struct in the theory and practice of modern therapeutic methods during the past three years, have always without exception expressed a desire to possess a book of instruc- tion which would enable them to refreshen their memory concerning the theoretical but more especially the clinical features of the work done at the CINCINNATI POST-GRADU- ATE SCHOOL OF PHYSIOLOGICAL THERAPEUTICS. Thus it seems but fair that those whose enthusiasm for drugless methods and good will for the author were instrumental in the conception and final birth of "Modern Physio-ther- apy" should shoulder a large share of responsibility if the progeny should prove a disappointment to its parents. In reproducing my lectures and demonstrations in book form I have adhered to the spirit and letter of delivery al- most throughout, if only to avoid the dryness and orthodox "correctness" of a text-book. Physio-therapy is in a med- ical sense the living issue of the day. Hence the realism and fervor of viva vocc presentation seem appropriate. The reader may miss the half-hearted, semi-apologetic way in which most of the books and journals refer to physiolog- ical methods as "valuable adjuncts." In view of the grad- ually waning drug-superstition and the wealth of light which the natural sciences have shed upon the theory and practice of medicine, physio-therapy does not require any 6 PREFACE. apologies. We are at this late day prepared to say that physio-therapy and scientific medical practice are well- nigh synonymous. If the reader, after perusing this book, does not agree with this statement, the fault lies with the author whose ability was not equal to the subject, never with the subject, than which there is none more exacting as far as the knowledge, adaptability and resourcefulness of an author are concerned. I imagine, however, that the book will be found serviceable enough to stimulate further thought and study along physio-therapeutic lines. The concrete conditions of medical practice give to the physiological methods a place in the treatment more espe- cially of chronic diseases. The general practitioner is not so situated that he can practice medicine in a strictly scien- tific way. He can only be a physio-therapeutist in a condi- tional sense. The modern hospital with its facilities and conveniences is the ideal place for absolutely pure medical work in the treatment of both acute and chronic diseases. At the bedside of a hospital-patient the physician need not bow to the prejudices, superstition and ignorance of a pa- tient's family and surroundings. He can allow his scientific conscience to dominate his actions. Habit, diplomacy and a utilitarian sense of making concessions to the lay-mind are bound to influence the actions of the general practitioner in no small degree. When these concrete conditions prevail, physio-therapy has but little chance. A full appreciation of these facts has influenced the plan of the book in keeping with the wants of the general practitioner. This accounts for the great prominence which has been given to the treat- ment of chronic diseases. Theoretically the book covers the entire field of clinical medicine. There is no doubt in the author's mind that a thorough perusal, study and compre- hension of the subject-matter of the first part of the book, more especially the first four chapters, ought to enable any scientific physician to elaborate clinically any problem in practical medicine. I trust that the book will be received in the spirit in PREFACE. which it is offered : as an earnest effort on behalf of thera- peutic progress. We all love the truth and try to find it. Our methods of seeking it may differ. Let those who find fault with the book, its plan, aims or tendencies, attribute its shortcomings to a defect in the method and not to any lack of earnest desire and sincere effort. The most agreeable feature of the circumstances that attended the preparation and final publication of this book is the lively interest with which many of my brother-prac- titioners far and near rewarded my humble effort. The mere announcement of the book being in course of prepara- tion, culminated in a veritable avalanche of demands for the book, resulting in the issuance of a first edition which is four times as large as was originally intended. For this display of interest and good will I am truly grateful. I hope to be excused for a bit of retrospection which may appear personal to all except those who are in a position to know something about the true inwardness of the subject I am discussing. My experience as a practical exponent of physio-therapeutic medicine has taught me that the prac- tice of modern physio-therapy is not an unalloyed boon. It would require the heroism of a Galilei to not be disheart- ened amid the pitfalls of open and covert abuse, misinter- pretation and calumny which beset the path of him who chooses to pursue the even tenor of his own way. My expe- rience has been a repetition of what has been the lot of others in my line of work. And to think that we all perse- cutor and persecuted are sheltered under the aegis of one great profession ! I make these statements on this auspicious occasion in order to encourage those whose hearts may be growing faint. The path of the consistent physio-thera- peutist is up hill. Per aspera ad astra! As long as purity of motive and sincerity of effort ease the mind and sweeten the conscience of man, the slings and arrows of outrageous fortune will avail nothing against him. Those who busy themselves casting the odium of char- latanism upon the practice of physio-therapy, have much to 8 I'KKKACK. learn. In fighting physio-therapeutic medicine and surgery they imitate their reactionary brethren of three hundred years ago who called one William Harvey a quack and per- secuted him with all the venom and arrogance character- istic of people of their ilk. Let the believer in modern methods who is suffering for a principle, find comfort and solace in the illustrious example quoted. OTTO JUETTNKK. Cincinnati, O.. New Year's Day, 1906. PREFACE TO THIRD EDITION. A FEW months after the first appearance of this book it became necessary to issue a second edition. The latter was merely a reprint of the first edition. There were no changes or additions of any kind. In presenting this, the third edition of "Modern Physio- Therapy," the author is grateful for the uniformly favor- able reception which has been accorded his modest effort. The remarkable success of the book is due to the increasing importance of non-medicinal methods. The preparation of a third edition has given the author a chance to add a chapter on "Suggestion," to make some practical additions to the Therapeutic Index and to revise the illustrations, many old ones being dropped to make room for new r er and better illustrations. It is to be hoped that the book in its altered and improved form will still better serve the great cause in the interests of which it was written. Acknowl- edgements are due L. A. Chatterton & Co., Xew York, for kind permission to reproduce Dr. Wm. H. Dieffenbach's splendid radiographs (Journal of Advanced Therapeutics, June, 1908) and Dr. H. C. Bennett, Lima, Ohio, for the loan of a number of cuts. OTTO JUETTNKR. CINCINNATI, ()., November 15, 1908. LIST OF CONTENTS. PART I. The Principles of Physiological Therapeutics. CHAPTER I. THE PHILOSOPHY OF PHYSIOLOGICAL THERAPEUTICS. Definitions. Physio-therapy. Physical methods. Physiologi- cal methods. Empirical methods. Biological conception of medicine.' Life. Health. Disease. Vis medicatrix naturae. Internal causes of disease. External causes. Mechanical causes. The rationale of symptoms. Causal symptoms. Re- storative symptoms. The rationale of treatment. Drug illu- sions. CHAPTER II. PERSONAL HYGIEXE. Applied physiology. Prophylactic medicine. Hygiene as a therapeutic measure. The skin. The lungs. The bowels. The kidneys. Individualization of general principles. The sexual instinct. CHAPTER III. DIETETICS. Definitions. Food. Food - stuff. Tissue - builders. Tissue- destroyers. Water. Digestion. Anatomical and physiological considerations. Hygiene and ethics of food. Influence of food upon character and temperament. Diet as a therapeutic fac- tor. Uses and abuses of food. Practical suggestions. CHAPTER IV. THE PHYSIOLOGICAL EFFECTS OF HEAT AND COLD. Hydrotherapy. Historical notes. Physiology of water applica- tions. Therapeutic indications. Clinical considerations. Vari- ous applications. Dry heat. Practical suggestions. CHAPTER V. MECHAXO-THERAPY. Different kinds of mechanical therapy. Massage. Physiologi- cal considerations. Practical instruction. Thure Brandt mas- sage. Swedish movements. Instruments for massage and movements. Vibration. Uses and indications. Vibration tables. Oscillation. 10 LIST OF CONTENTS. CHAPTER VI. FORCE AND FORCE MODALITIES. The physics of force-manifestation. Theoretical groundwork of the subject. CHAPTER VII. THE THERAPY OF LIGHT. Light in nature. The physics of light. Finsen's experiments. The physiological effects and therapeutic uses of light. Finsen lamps. Minin lamps. Electric light baths. Chromo-therapy. CHAPTER VIII. THE ELEMENTS OF ELECTRO-PHYSICS AND ELECTRO-MECHANICS. The rudiments of electrical science. Direct and alternating currents. Voltage. Amperage. Resistance. Induction. Polarity. Electrical terms. Uses of electricity in medicine. Galvanism. Faradism. Static electricity. High frequency. Electrodes. Apparatus. Technique. CHAPTER IX. THERAPEUTIC USES OF GALVANIC, FAR- ADIC, STATIC AND HIGH FREQUENCY CUR- RENTS. Physiological and chemical effects of galvanism. Therapeutic indications. Faradism. Its effects and therapeutic uses. Phy- siological effects and therapeutic uses of static electricity. The therapy of currents of high frequency. CHAPTER X. X-RAY DIAGNOSIS. Roentgen tubes. The fluoroscope. Radiography. Technique. How to take an X-ray picture. The photographic principles. How to interpret. Stereo-skiagraphy. X-ray accessories. Dangers of X-ray work. CHAPTER XL THE PRINCIPLES AND PRACTICE OF X- RAY THER'APY. The physics of the excited tube. Physiological effects of X- rays. Technique of X-ray therapy. Clinical indications. Sta- tistics. CHAPTER XII. SUGGESTION. The vast significance of suggestion. Physiological and psycho- logical considerations. The practice of mental medication. The modus operandi of suggestion. Hypnotism. Clinical sug- gestions. LIST OF CONTENTS. 11 PART II. The Practice of Phyiological Therapeutics. THERAPEUTIC INDEX. Alcoholism. Alopecia. Amenorrhea. Anal fissure. Anemia. Aneurysm of aorta. Angina pectoris. Angioma. Aphasia. Aphonia. Appendicitis. Arterio-sclerosis. Asphyxia. Asthma. Autointoxication. Bier's hyperemia. Birth-marks. Bright's disease. Bright's disease, acute and chronic. Bronchitis. Bruise. Bubo. Calculi. Cancer. Compressed air. Chancroid. Chancre. Chilblains. Chorea. Cicatrices. Colon irrigation. Constipation. Corns. Cough. Cirsoid aneurism. Cystitis. Dandruff. Deafness. Derivation. Diabetes insipidus. Diabetes mellitus. Diarrhea. Diet in acute fevers. Drug habits. Drugs. Dysentery. Dysmenorrhea. Dyspepsia (chronic). Electro-therapy. Emphysema. Endometritis. Enlarged tonsils. Enteritis. Epilepsy. Fatty degeneration of the heart. Fever. Fibroid tumors. Fistula in ano. Flexions of the womb. Freckles. Functional disorders. Gastric cancer. Gastric ulcer. Gastritis. Goitre. Gonorrhea. Gout. Granulated eyelids. Headache. Hemorrhage. Hemorrhoids. Hepatic cancer. Hepatic cirrhosis. Hydrocele. Hypochondriasis. Hysteria. Incontinence of urine. Inflammation, acute and chronic. Inoperable malignant disease. Insomnia. Intrapelvic inflammations. Jaundice (catarrhal). Lateral sclerosis. Leucorrhea. Liver spots. Locomotor ataxia. Lupus erythematosus. Lupus vulgaris. Malaria. Melancholia. Meningitis. Menorrhaeia. Mctritis. 12 LIST OF CON TK NTS. Metrorrhagia. Migraine. Milk secretion. Moles. Nasal catarrh. Nervous diseases. Neuralgia. Neurasthenia. Night sweats. Obesity. Occupation neuroses. Opsonic therapy. Orchids. Pain. Palpitation of the heart. Paralysis. Papilloma. Pelvic adhesions and exudates. Pericarditis. Peritonitis. Pharyngitis. Piffard rays. Pleurisy. Pneumonia (lobar). Premature labor. Prostate gland (enlarged). Pruritus vulva?. Reflex disorders. Rheumatism, varieties of. Rheumatoid arthritis. Salpingitis. Sarcoma. Sepsis (local). Sex-determination. Sexual weakness. Singultus. Skin diseases. Spasms. Sprains. Stenosis. Stiff joints. Stricture. Sunstroke. Superfluous hairs. Syphilis. Tetanus. Therapy of rest and recreation. Tobacco. Tonsillitis. Toothache. Tuberculosis of glands. Tuberculosis of joints. Tuberculosis pulmonum. Typhoid fever. Ulcer (chronic). United States (climate of). Uranium. Uremia. Uterine inertia. Vaginismus. Valvular diseases of the heart. Varicose veins. Versions of the womb. Vomiting of pregnancy. X-ray burns. X-ray coil (portable). X-ray statistics. PART I. The Principles of Physiological Thera- peutics. CHAPTER I. THE PHILOSOPHY OF PHYSIOLOGICAL THERAPEUTICS. "Some few, whose lamp shone brighter, have been led From cause to cause to nature's secret head And found that one fixed principle must be." DRYDEN. THE; term "physiological therapeutics" (physio-therapy) is used in centra-distinction to "empirical therapeutics." Some speak of physical therapeutics to express the same idea \vhich physiological therapeutics is supposed to convey. Practically "physiological" and "physical" refer to the same subject-matter in medicine. In a strictly logical sense, how- ever, the two terms are not synonymous. Physiological therapy (physio-therapy) is a mode of treatment whose rationale is suggested by the laws of physics and physiology. The term "physiological," there- fore, qualifies the meaning of "therapy" by suggesting the effect to be produced. Physical therapy is a mode of treatment by means of forces and agencies that are physical 1 in character. The term "physical," therefore, qualifies the meaning of "therapy" by suggesting Ihc means which are employed in producing physiological or therapeutic effects. From the standpoint of purely scientific medicine the term "physiological" is distinctly suggestive of a principle. The principle is: Therapy must correspond to and supple- ment established and demonstrable physiological and phys- ical phenomena. The term "physical therapy" does not sug- gest such a principle. It simply refers to certain agencies 1 The word " physical " is used synonymously with "mechanical." 16 MODERN PHYSIO-THERAPY. and means used, irrespective of their (scientific or empir- ical) character. Physical therapy is not necessarily phys- iological in character. Physiological therapy can never be empirical while physical therapy may be. As stated above, the two terms are used synonymously in practice, although they, strictly speaking, do not convey the same concept. The principle which is contained in the term "phys- iological therapy" places this term in logical antithesis to "empirical therapy." If therapeutic phenomena are pro- duced by a certain agent, i. e. a drug-preparation of some kind, and the same phenomenon has been known to follow the use of this agent at different times and in the hand of different observers, the relation between the phenomenon following and the drug-administration preceding is thought to be that of effect and cause. It is the frequency of the occurrence that suggests such a relationship. The relation is not explained by a logical process of reasoning because it can not be explained in this way. After the drug has been administered, there is a necessary gap in our reasoning. We are expecting something to happen, because it has hap- pened before under similar circumstances. We 'are satis- fied to note the -suggestive frequency of the relationship. This is the meaning of empirical or experimental therapy. The so-called physiological effect of a drug is a deduc- tion from the empirical phenomenon which is supposed to follow the administration of the drug. First the drug is administered, then the empirical effect is noted, and from the physical characteristics of the effect the physiological action of the drug is deduced. In applying a physiological therapeutic agent we know the physiological effect before it takes place, because we are familiar with the laws of physics and physiology which control the life of the organ- it m. There is no guess work, no empiricism, no experiment. The effect must follow the given cause under given condi- tions. This is the meaning of physiological therapy. Even the most ardent physio-therapeutist, however, will admit that the millennium of absolutely scientific medicine PEULOSOPHY OF PHYSIOLOGICAL THERAPEUTICS. 17 has not as yet arrived. That we have progressed and that we are nearer to it than \ve were fifty or even fifteen years ago, no one will deny. It can not be gainsaid that we avail ourselves of certain methods to-day that are purely scientific and can not and should not be compared with the empirical drug-methods of the past and present. These scientific methods are mechano-therapy, hydro-therapy, thermo-therapy, photo-therapy, and above all the funda- mental branches of medical practice, to-wit : hygiene and dietetics. Electro-therapy, including X-ray therapy, is not on the same plane of scientific exactness. Both the char- acter of the agent employed and the nature of the effect produced are subject to speculation. It is a strange fact that of all these modern methods, those that are truly scien- tific have not achieved the degree of professional favor and popular applause which has been accorded to electro- and radio-therapy in spite of the markedly experimental char- acter of the latter. The first step in our reasoning must be the clear recog- nition and statement of the premises. We must try to un- derstand the subject-matter before we can grasp its basic logic and extraneous relations. What is meant by health? What is disease? In viewing the human body from its origin to its disso- lution through various stages of development, the most striking feature of its life is the apparent unity of intention manifested in the preservation of the integrity of the whole and in the mutual co-operation of the parts. There is not only life, but coincidently the manifest desire to live in a state of the highest relative perfection. The living body contains an ever-active principle which guards the structural and functional integrity of every part and counteracts within the limits of its potency any internal or extraneous agencies which threaten such integrity. It tends toward a certain standard of well-being under any and all circumstances. The action of this principle or vital force, considered per se, 18 MODERN Piivsro-Tiu -KAPY. is LiEE itself, in its relation to the body and the parts thereof whose structural and functional perfection this force unceasingly tends to preserve and restore, it is HEALTH. Life and health are, therefore, the same concept from two different points of view. In its efforts to counteract inimical elements or to repair damage, it presents itself as the force \\hich medical men for want of a better name have desig- nated as the vis mcdicotri.v naturae. The period of activity of this principle in its restoring or repairing efforts is DIS- EASE. It is clear, therefore, that disease is not an entity, not a something definable, having clearly marked attributes, entering the body in a certain way, causing certain disturb- ances and producing certain ultimate effects. Disease is the force or principle of life (health) viewed in its efforts to protect, preserve, restore or to repair whenever the struc- tural or functional perfection of the body or any part is en- dangered or impaired. To consider a disease an entity per se would be fundamentally erroneous. Life, health and disease are, to all intents and purposes, only different as- pects of one and the same concept. Let me interpose that the activity of the life-principle in the individual body is analogous to the action of a corre- sponding force which is manifest in the existence and re- generation of the species. Nature protects the individual body in very much the same way as it guards the integrity of the species of which the individual body is a part. There is the same uniformity of intention in the aggregate (species) as well as in the integral (single body). In either there is the manifest desire or tendency to live in a state of relative perfection. The species demonstrates this tendency, not only by propagation of its integrals, but by sacrificing an imperfect part in the interests of the whole. This, for in- stance, is illustrated by the manner in which Nature tries to prevent the propagation of syphilitic or tubercular stock and thus prevents degeneration or corruption of the species. The unhealthy offspring dies in early childhood or even during fetal development. Thus the integrity of the species PHILOSOPHY OF PHYSIOLOGICAL THERAPEUTICS. 19 is guarded. Analogously the body will survive at the ex- pense of a part, for instance, in the case of a felon. Rather, than allow the morbid material of a felon to be absorbed into the general circulation and poison the whole system, Nature makes an effort to isolate the poison, even if the suffering part, e. g. a phalanx, is destroyed in the effort of getting rid of the poison. In the species as well as in the individual body, the integrity of the part is invariably inferior to the integrity of the whole. The species lives at the expense of the integral, analogously the body lives at the expense of the part, the organ at the cost of the cell. It is the universal struggle which ends in the survival of the fittest (Darwin). The "fitness" of the integral is determined by a fixed criterion of the viability possessed by the species. The fit- ness of the species as expressed in the preservation of its integrals is the viability (fitness to live) of the integral. Whenever the fitness of the part falls beneath the fitness of the whole, the part as such ceases to be viable, i. e. the part is destroyed by a more or less rapid process of dissolution. The process of dissolution may extend over a number of generations 2 before Nature's object, i. e. to destroy a de- teriorating member of the species, is accomplished. Upon this fact rests the biological explanation of heredity, atav- ism, etc. Thus, the scrofulous condition of an individual may be a part of a process of destruction which began two or three generations ago and ends in the extinction of a non- viable family. To the physician this process presents itself as a state characterized by lessened or entirely suspended activity of the vis medicatri.r nature. There is no attempt at restoration or repair, no "disease" in the sense suggested above. This distinction contains all the logic of pathology. Disease is never a something per se, a something passive or 2 The same may be said concerning qualitative improvement of the species as expressed in the relative perfection of an individual. Mental or physical improvement or deterioration is a process which concerns the species. The individual simply typifies a phase in the process. There is no doubt that criminals as well as gentlemen are made a hundred years before they are born. 20 MODERN PHYSIO-THERAPY. static; it is not a condition, but a process; not an accom- plished thing, but an accomplishing movement. It means either return to normal conditions or dissolution in parte or w toto. Clinically this biological concept of disease means everything. If disease is a well-planned restorative or de^ structive effort, it stands to reason that Nature does not pro- ceed in a blind, purposeless or haphazard manner, but fol- lows a certain method. To define and understand i.his method is the object of scientific medicine, to co-operate with and supplement Nature's method is the task of the physician. The statements made convey the great funda- mental truths upon which all rational medicine rests. The study of medicine logically resolves itself into an analysis of the phenomena of life (health or disease) and the mode of action of the vital principle under various conditions. To cure disease means to direct the activity of the vital principle in its efforts to bring the body or any part back to the normal state of well-being and in removing whatever obstacles might impede the work of this ever active force. Medicine, therefore, is an analytical science and by its very essence discountenances any tenets except those established by critical analysis, quod eral demonstrandum. In the light of the statements made we are prepared to look upon diagnosis as being the discernment, not of a con- dition produced by some internal or external cause, but rather as being the recognition of the cause itself. Biolog- ically the disease-process must appear to the physician as the effort made by the vital principle to counteract the cause and remedy its effects. Logically, therefore, the physician must be in sympathy and in co-operation with disease. His province is to understand Nature's efforts, to direct them into the proper channel and to augment them in keeping with their ultimate purpose. This strictly scientific view of the subject will enable us to construct a groundwork upon which we can erect a rational system of medicine. Phy- siological medicine is based upon facts, not upon coinci- dences, upon demonstration and knowledge, not upon as- PHILOSOPHY OF PHYSIOLOGICAL THERAPEUTICS. 21 sumption and belief. Thus, the physician must be a medical philosopher whose realm of thought is bounded only by the confines of truth, and should not be hemmed in by impene- trable walls of preconceived ideas, prejudices, schools and Since, as has been suggested, the knowledge of disease is substantially the clear recognition of the various causes, and of the means which Nature adopts in counteracting them and in restoring normal conditions, it stands to reason that we must above all things try to identify and classify these causes. In a general way we may say that these causes are either contained in the organism or are introduced from without, i. e. they are either internal or extraneous. We can conveniently recognize a third variety, comprising the action and effects of physical or mechanical forces acting irpon the organism from within and without. INTERNAL CAUSES. The objective manifestation of life in the human body is the process of nutrition by which all the parts of the body are kept intact and normally active. The chemical and physiological elements of the organism are constantly regenerated by the taking up of correspond- ing material from without, principally through the digestive ?nd respiratory organs. These elements are distributed to the body at large through the structures composing the cir- culatory system (lymph- and blood-vessels). Material which is unavailable or has been utilized and is ready to be cast off, is gotten rid of by the excretory organs (lungs, kidneys, bowels, skin). The internal causes of disease are the disorders affecting the whole or any part of this triple process of taking up food-elements, assimilating them and casting off waste material. Under this caption would come all disturbances of nutrition, local and general, (inflamma- tions, active and passive congestions, anemia, all disturb- ances of the hematopoietic process, interference with the chemical or physiological composition of the blood, throm- bus, embolus, neuralgia, rheumatism, etc., etc.). Most 22 MODERN PHYSIO-THKK .\i'v. nervous diseases belong under this head since they are pri- marily disturbances of the blood-supply to certain nerves or nervous areas, likewise all catarrhal conditions. A sec- cnd series of internal causes comprises the vast number and variety of conditions in which there is impairment of phys- iological digestion, assimilation of food-elements, etc., etc. A third series includes all disorders of excretion (imper- fect or perverted function of the skin, kidneys and bowels, diabetes, all forms of auto-intoxication, perhaps all malig- nant diseases, although the latter are probably with more propriety classifiable under the head of increased or per- verted nutrition). EXTRANEOUS CAUSES. Under this head belong all causes originating outside of the body and in reality foreign to the organism (vegetable and animal parasites, paludal, chemical and physiological poisons). The diseases due to these extraneous causes are principally tuberculosis, all the acute infections, tetanus, typhoid and typhus, trichinosis, helminthiasis, scabies, tinea, all parasitic diseases of skin and mucous membranes, malaria, conditions produced by chemical poisons, drugs and gases, ptomain-infections, etc., etc. MECHANICAL CAUSES. These causes are agencies oper- ating according to the general laws of physics. All trau- mata belong under this head, being the effect of the action of mechanical forces, i. e. wounds, contusions, the presence of foreign bodies, ruptures, fractures, luxations, compressions, strangulations, etc., etc., and the conditions accompanying or following them. Conditions produced by increased, les- sened or misdirected blood-pressure are included in this category, e. g. the results of disturbance of the hepatic or portal circulation, the various organic, particularly valvular, diseases of the heart, etc. These causes might operate singly, successively, or con- jointly. It devolves upon the clinician to analyze the indi- vidual case and identify the causes and their relations to each other. Thus, gall-stones, being concretions of one of PHILOSOPHY OF PHYSIOLOGICAL THERAPEUTICS. 23 the normal digestive secretions, belong to the first variety of causes. If they should obstruct the common duct and thus give rise to distention of t!:e gall-bladder and to all its distressing symptoms, the conditions produced, would be classified under the third variety. If a perforation should occur, giving rise to a purulent peritonitis, the presence and activity of pyogenic organisms would suggest the second variety of causes. The above classification is the first step toward the estab- lishment of a rational pathological method. Biologically, disease receives its identity from the cause or combination of causes which it tries to correct or combat. Nature al- ways adapts means to the end. We can, therefore, assume that the disease-process will plainly indicate the means which Nature adapts to the end, i. c. by which Nature re- establishes normal conditions. Hence, there is contained in the analysis of disease (i) the clear conception of a cause or a combination of causes, and (2) a sharply defined method which Nature adopts in its efforts of repair. There- fore it is plain that the idea of treatment in any given case is in reality suggested by the analysis of "disease" in con- nection with recognized laws of physics and biology, and the established principles of hygiene and physiology. Treat- ment is to all intents and purposes the physician's way of co- operating with, augmenting or anticipating Nature's plan. It is the logical correlative of disease, and can, therefore, never be vague or symptomatic unless the physician bluntly admits his inability to analyze and, therefore, his ignorance of a given case. In order to establish a rational system of medicine it is necessary to study Nature's bedside-method which might justly be called "clinical physiology." The Rationale of Disease and Symptoms, ^"henever any of the causes mentioned begin to act upon the organism, either singly or conjointly, there is a coinci- dent response on the part, not only of the structure attacked, but in a greater or less degree on the part of the whole sys- 24 MuDKkN I'lIYSin-TlIKKAPY. tern. The response will correspond to the nature of the cause, to its relative speed of action, to its intensity, to its more or less continuous character, and to certain peculiar- ities of the cause or causes, or of the structures acted upon. This response is the series of subjective or objective symp- toms accompanying' disease. Symptoms bear the same rela- tion to disease (or restorative effort) which language bears to thought, they are the outward form of disease, but not its substance. They are guide-posts along the path of iden- tifying an active cause. Biologically there are two kinds of symptoms : ( i ) Causal symptoms, i. e. those directly due to the activity of the cause (e. g. pain caused by a wound, dyspnea produced by a distended stomach, nervous disturb- ances due to ptomain-intoxication of the cerebral centers, etc.) ; (2) Restorative symptoms, i. e. those produced by and accompanying the disease-process proper (elevation of tem- perature accompanying fever, hyperemia coincident with active absorption, diarrhea following intestinal indigestion, etc., etc.). The classification given above seems scientific- ally exact and clinically useful. This will become more ap- parent as we progress in the discussion. An ordinary case of typhoid fever will illustrate these points. Typhoid fever is due to an extraneous cause, i. e. the entrance into the organism of vegetable parasites which attack the intestinal surface at certain places of selection, giving rise to ulceration of the places attacked, and after en- tering the general (lymph- or blood-) circulation, either per se or through certain morbid products generated by them, bring about a condition of poisoning. The entrance of the germs and their subsequent absorption is the cause, Nature's effort to eject the germs and their products, to heal the intestinal ulcers, and to repair whatever damage has been done, is the disease. Clinically, typhoid fever presents an array of causal and restorative symptoms. Thus, pain in the right iliac region, malaise, mental hebetude, delirium are causal symptoms ; diarrhea, fever, diaphoresis are re- storative symptoms. To the thoughtful observer there is a PHILOSOPHY ot PHYSIOLOGICAL THERAPEUTICS. 25 I great deal of logic in the semeiology of a condition. Thus, pain points to an affected part and is Nature's demand for rest ; anorexia is Nature's warning that the digestive ap- paratus is impaired. Similar examples could be quoted ad infinitiim. Treatment should be the assistance we give Na- ture in its efforts. It would be absurd to stand at the bed- side and deliberately cover up a causal symptom or hide a restorative sign without connecting either with the element of causation or restoration, from which neither can logically be separated. The distinguishing feature of the true physi- cian is not the euphony of scientific terminology or depth of therapeutic resources, but the intelligence of action. Thus, fever suggests to the true physician Nature's attempt to ac- celerate tissue-change and regenerate the organism by in- tensified oxidation, the object being the elimination of some material or element foreign to the organism. The thought- less empiric sees in the fever, not the means, but the end; not the remedy, but the disease. He aims at the fever as the thing to be attacked, to be treated. Incidentally let me say that there is hardly a subject in medicine the biology of which is so generally misunderstood and misapplied by most physicians as "fever." The great hydropath, Priessnitz, was wont to say : "What a glorious achievement it would be to find a way of producing fever and controlling it as a reme- dial agent in the treatment of chronic diseases ! What won- derful results would crown our efforts !" Only the man who is a biological thinker can appreciate the meaning of this re- markable statement made by one of the keenest clinicians in medical history. It can not be repeated too often, nor impressed too deeply, that disease is not an entity to be removed by treat- ment, but that it is a physiological movement toward repair or destruction of the organism or some special part. To treat disease scientifically means to understand this move- ment, and assist it in taking a certain course. It behooves us now to apply to concrete conditions the orinciples con- veyed. 26 MODKKN I'llYSin-TllKRAPV. The Rationale of Treatment. Before there can be any Thought of helping Nature to restore normal conditions it is essential to bear in mind the general- laws which govern the life and well-being of the human body while normal conditions prevail. These laws apply to the sick body with even more force than to the healthy body. They constitute the groundwork of scientific medicine, and necessarily take precedence of any methods we might devise, however rational the latter might be. These fundamental laws which control the health of the human body are the principles of hygiene and dietetics. Hygiene aims at the establishment of the surroundings and outward conditions which the human body requires for its well-being, and at the removal of deleterious elements. Hygiene provides air and light as required by the organism, regulates the periods of activity and rest of the body and its parts, inquiries into the sanitary condition of our sur- roundings, enforces cleanliness of the surface of the body, examines into the manner in which our bodies are clothed, and removes all external influences which might impair the integrity of the body or any part. Hygiene is of supreme importance to the body in the state of health, and, therefore, most emphatically so in the state of disease. Hence, the first duty of the scientific physician in the treatment of any diseased condition is the enforcement of the fundamental laws of hygiene. Numerous diseased conditions are due to the violation of hygienic principles. Analysis of the case should reveal the cause and point to methodical enforcement of the law which has been violated, as the logical treatment. Nature will gladly restore health if given a chance and as- sisted in an intelligent way. The science of dietetics is likewise of fundamental im- portance. The physician should be equally familiar with the physiology of the alimentary canal and the chemistry of foods. Since the stomach performs the lion's share of func- tion in supplying fuel to the slowly oxidizing organism, the knowledge of dietetics is of special import in all conditions PHILOSOPHY OF PHYSIOLOGICAL THERAPEUTICS. 27 which are characterized by intensified and accelerated oxida- tion (fever). A thorough knowledge of dietetics leads to a clear conception of the physiology of the process of excre- tion (throwing off waste through the skin, lungs, bowels, .and kidneys), impairment of which constitutes the pathology of not a few diseases. The physician having familiarized himself with the hygienic and dietetic requirements of the healthy human body is able to think physiologically in adapting any special mode of treatment to the sick body. In keeping with our previously given classification of causes of disease we can analogously classify the methods of treatment. Disturbances of the triple process of nutrition (nutritive function of lungs and alimentary canal, assimila- tion through the lymph- and blood-circulation and elimina- tion of waste through the excretory organs) can be con- trolled if we are able to control the physiological functions which are affected. Thus, if we are able to, by some method, cause hyperemia or anemia of any part of the body at will, we can certainly control a disease which is due to a dis- turbance of the blood-supply of the part. If the lungs, for instance, are hyperemic, and in spite of nature's effort at un- loading the over-supply by absorption or increased skin ac- tivity, the congestion continues, an inflammatory condition of the lung will be the result. It stands to reason that the logical way of meeting the exigencies of such a condition is to apply some method by which the over-nourished lungs can be unloaded without detriment to the organism at large. Thus, if we are able to force enough blood into the lower extremities so that they will hold three times the normal quantity, it stands to reason that the quantity of blood nor- mally present in the trunk and head is correspondingly les- sened, there must necessarily follow an unloading of the congested lungs. Are there methods by which the circula- tion can be thus controlled and diseases due to internal causes influenced? Can we cause hyperemia of an organ and thus stimulate its functional activity? Can we counter- act a hyperemia and thus prevent, jugulate or lessen an in- 28 MODERN PHYSIO-THERAPY. flammation? Can we increase the activity of the skin and thus encourage excretion? Can we relieve passive con- gestion? Can we influence the absorption of exudates? Can we accelerate, retard, or modify the process of nutri- tion locally and generally? If there are methods which are capable of producing these effects, we are ready to admit that medicine within the range of their usefulness is a science. To illustrate these points let us refer to some of these strictly physiological methods in their practical appli- cation at the bedside. By way of contrast, let me briefly discuss the subject of empiricism, both as a part of rational medicine and as a species of charlatanism. Empirical Methods. By empirical methods are meant modes of treatment based upon experience without, however, admitting of demonstration of their modus opcrandi. The relative value of an empirical method is determined (i) by the regularity with which an effect follows the activity of a certain cause, e. g. the administration of a certain drug, and (2) by the degree of knowledge we have concerning the effect in all its aspects. Thus, if we administer quinin to a malarial pa- tient, and produce a decided effect, even to the extent of causing morphologically destructive changes in the plas- ir.odium, we might consider this effect a propter hoc as well as post hoc. Yet this method is not a physiological one, be- cause while we can connect cause and effect we can not define the connection. What becomes of the quinin after absorption, what chemical changes it undergoes, what chem- ical and physiological elements of the organism it affects, how it affects them, its modus opcrandi in disintegrating the piasmodium, we can not demonstrate. To practically illustrate the distinction between a phy- siological and an empirical method let us consider the case of a patient who is suffering from a severe congestive head- ache. If we give this patient a moist pack from the feet to the costal border and find the patient within a few min- PHILOSOPHY OF PHYSIOLOGICAL THERAPEUTICS. 29 utes relieved of his pain and ready to fall asleep, we are fully conscious of the physiological process through which this effect was produced. Dilatation of the vessels of the region packed is followed by contraction of the cerebral and meningeal vessels (Schiiller's classical experiment with rabbits). The effect is a lowering of intracranial blood- pressure and a cerebral anemia. The result is relief and somnolence. This is the clinical application of a physiolog- ical method. If, instead of being treated according to the above plan, the patient is given ten grains of phenacetin and should find himself relieved, the therapist would tell us that coal-tar products depress the heart and thus lower the biood-pressure, -Hence the relief. How the effect is pro- duced, is subject to physiological speculation. The therapist has seen the same effect, with more or less promptness and intensity, follow the 'administration of the drug. His state- ment is a generalization of a proposition based upon re- peated experience. He associates effect and cause, but does not and can riot define the nature of the association. He presumes, but he can not demonstrate. After producing the effect he assumes a physiological modus opcrandi instead of demonstrating the physiological action in its various rela- tions to the organism, and then letting the clinical effect fol- low as a necessary sequence, just as a conclusion follows its premises. In regard to the moist pack the conclusion (clin- ical effect) follows the premises (physiological demonstra- tion). Every link of the argument is complete and clearly set forth. The action of the moist pack upon the skin, upon the cutaneous vessels,' upon the subcutaneous structures, can be seen and measured by the senses and by physiological instruments (Schiiller's experiments on rabbits, Goltz's ex- periments on frogs, Winternitz's observations on animals and patients, Ludwig's investigations concerning the "ther- mic" sense of blood-vessels, etc., etc.). Xot so in regard to phenacetin or. for that matter, any drug taken internally. What becomes of the drug after absorption, what path it takes, what chemical changes it undergoes, what physiolog- 30 MODF.KX PHYSIO-THERAPY. ical elements it attacks, how the organism a? a whole and in its parts responds to the presence of the foreign substance, all these are uncertain, ill-defined links in our argument. As long as they are, the use of drugs can not rise to the dignity of a scientific or physiological method. The cause may be clear, the effect may be distinct and characteristic, yet the method is empirical as long as the nexus causalis is a physiological speculation only. The internal administration of drugs is an art and not a science. Drug methods can never be free from uncertainty and doubt. Yet, while drugs do not cure or heal, they are frequently capable of relieving certain urgent symptoms without detriment to the organism. Even then they are at best but necessary evils. The longer we practice, the more skeptical we become in regard to the materia medica. The scientific physician prescribes little and rarely. The gun-shot prescription is notoriously an indication of an un- scientific mind, for the intelligent physician tries to be exact and to the point even in his symptomatic therapy. Materia medica is the least important branch of medical teaching because it contributes the smallest share to scien- tific medicine. It owes its prominence to the efforts of those \\ho make their school or pathy or ism the criterion of scientific medicine instead of proceeding lice versa. Its empirical character caused Mephisto to utter his caustic criticism about doctors and their work: "The work of doctors is not hard to grasp ; They rack their brains, and study high and low; Yet in the end the sick get well or gasp Their last, if Mother Nature wills it so." (Goethe's Faust.) In view of the vast amount of quackery which is prac- ticed at the bedside under the guise of therapeutics, would that the last two lines of Mephisto's remarks were true! What a boon it would be to suffering humanity to be left expectantly alone and at the tender mercies of ever-merciful PHILOSOPHY OF PHYSIOLOGICAL THERAPEUTICS. 31 Nature ! Xature is, indeed, generous and indulgent to a fault. The poor typhoid-fever patient who for weeks has been persistently dosed w y ith some coal-tar product, survives, though his blood has been subjected to constant deoxidation and his red blood-corpuscles have been destroyed in vast numbers. His heart bears up under the double burden of the fever-process and the drug-depression. Nature opens up the pores of the patient's skin to eject the offensive sub- stance. The patient finally recovers, in spite of the so-called treatment, an anemic or even cyanotic semblance of his former self. This kind of empiricism savors of blatant quackery. Even from the standpoint of symptomatic treat- ment it is totally unjustifiable. It is plain that -the external use of chemical agents is not open to these objections because cceteris paribus their modus opcrandi or rather medendi can be made as clear and logical as any laboratory-experiment, e. g. the use of silver nitrate on a mass of unhealthy granulations or the application of a solution of corrosive sublimate to an ex- posed surface representing an immense culture-bed of pus- producers. The action of these purely chemical agents is \\ell-defined, and for this reason is a logical major premise in the argument. The minor premise is the clinical prob- lem to be solved. If the reasoning of the physician in regard to the existing state of affairs is as sound as the logic pre- sented by the drug-agent and its chemical and physiological potency, the conclusion, i. e. the treatment adopted, must be correct. Such a therapeutic method is physiological. Internal medication can never be a logical argument of this kind, because both premises are incomplete. This reason accounts for the notorious discrepancy of opinions among doctors in regard to internal medication. The chemical use of drug-agents is subject to analysis and is, for this reason, never a bone of contention. The physiological therapeutist aims at a complete and thoroughly correct clinical syllogism. Drug-therapy can not be logical in this sense. Any sub- stance that enters the organism through the channels of 32 MODERN PHYSIO-THERAPY. r.ssimilation must necessarily be either a food or a poison. There is no other alternative. That which is supposed to be a physiological effect, e. g. the diaphoretic action of jabo- randi or the cathartic effect of calomel, is nature's means of getting rid of a poisonous substance. That drugs are capa- ble of producing effects on the system, no one questions. All poison? have some sort of action. The fallacy of drug- medication consists in the assumption that these ill-defined and ever-variable drug-effects are curative in the sense of influencing a disease-process physiologically. Thus, the physiological therapeutist establishes the same criterion for all agents that are used in the treatment of disease. In availing himself of the poisonous effects of some drugs he chooses the lesser of two evils, c. g. he prefers a mild de- gree of opium-poisoning to severe suffering. This is a mode of action which the concrete conditions of practice re- quire, e, g. the anodyne action of morphin, the anaesthesia produced by chloroform-poisoning, the parasiticidal action of antiseptics, anthelminthics etc. The argument between physiological and purely empirical (drug-) methods refers to their relatively curative action in influencing a patholog- ical process, using the word "curative" in its most exacting physiological sense. Physiological Methods. Among the methods which are in accord with biological reasoning and, therefore, might be designated as being strictly scientific, hydro-therapy occupies a most conspicuous place and may well serve as a type for illustration. In order to illustrate the theoretical points of our discussion about the rationale of physiological methods, I shall confine my- self to pointing out the salient features of hydrotherapeutics as a typical physiological method. Water as a carrier of temperature is the agent par ex- cellence by which we can control at will the circulation of the whole body and of any part. By exposing the surface of the body to the action of cold (heat) we can cause a PHILOSOPHY OF PHYSIOLOGICAL THERAPEUTICS. 33 condition of cutaneous anemia (hyperemia) and coinci- dently a congestion (depletion) of the deep vessels. Like- wise, we can by increasing the blood-supply of any special part cause a corresponding decrease in some other part. Goltz has shown that it is possible to almost entirely de- plete the head and the extremities and crowd all the blood into the abdominal vessels. The strictly physiological ac- tion upon the sensory cutaneous nerves, and through these upon the central and peripheral ganglia controlling the vaso- motors and thus upon the muscular coat of the cutaneous blood-vessels, necessarily affects the process of nutrition, of tissue-change (oxidation), of absorption and excretion. By hydrotherapeutic means we can arbitrarily accelerate or re- tard these processes, both locally and generally. An in- flammatory process in any part of the body can be acted upon in any stage. During the stage of congestion it can be aborted or jugulated by drawing the blood into some dis- tant part, thus depleting the affected area and depriving the inflammatory process literally of its working capital. In cases in which the stage of congestion is over and active inflammation has been established, the hydrotherapist again avails himself of the "derivating" action of water, and con- trols the severity of the process by carrying off the surplus blood crowding in upon the inflamed area. By acting upon the surface of the whole body he causes the body to oxidize more rapidly and absorb and excrete the products of inflam- mation. Thus he intensifies the action of Nature's great- est restorative agent, the fever-process proper. The phys- iological constituents of the body are regenerated, proving that water after all is directly the great alterative or blood- purifier. . To be able to arbitrarily control the quantity of blood and the rapidity of circulation in any part, means to be able to control nutrition, to relieve active and passive con- gestion, to promote the metamorphosis of tissue, to encour- age absorption and excretion. The vast usefulness of "de- rivating" water-applications can be best appreciated when we compare the results we achieve, with the uncertainties 34 MODERN I'IIYSIO-TIIKKAPY. and disappointments of drug-medication, especially in the treatment of chronic diseases, e. g. such conditions as chronic rheumatism, malaria, abdominal plethora, etc., etc. The marvelous effect of water-applications is emphasized by such an authority as Henoch, who quotes the following 1 interesting case of a gastric neurosis in this connection : A lady whose stomach would not retain any food and even re- jected water, was given up to die. A last attempt at treat- ment was made by a French hydrotherapist, who immersed the patient's feet up to the knees in hot water and applied a (cold) Kneippdouche to the head. The effect was remark- able. The sensory gastric nerves, which had been irritated by the passive congestion in the walls of the stomach, and perhaps, too, by the endless number and variety of drugs ad- ministered, became quiet in consequence of the "derivating" and the reflex sedative effect of the water-applications. The lady made a prompt recovery. That the therapy of water has received so little atten- tion from the majority of the profession is, in view of the strictly scientific character of the method, somewhat sur- prising. With the exception of the cold sponge-bath, the moist pack, and the hot-water immersion-bath in surgery, physicians know very little about water and its universal ap- plicability and efficacy. And yet, as a remedial agent, it is infinitely superior to any drug, or combination of drugs. The study of the physiology, therapy and technique of ex- ternal applications of water (hot, warm, lukewarm, and cold baths; douches, sponge-baths, complete and partial moist packs, s\veat-baths, etc., etc.), and likewise of the internal uses of water (irrigation of stomach and intestines, drinking of water of various temperatures, etc., etc.), forms one of the most fascinating subjects in medicine. Inci- dentally, let me say that water is not the only carrier of tem- perature for clinical purposes. The thermotherapist fre- quently avails himself of air, in order to apply heat or cold, with gratifying results. By way of illustration, let me refer to the use of hot air in cases of chronic rheumatism, in fact PHILOSOPHY OF PHYSIOLOGICAL THERAPEUTICS. 35 in all cases in which accelerated oxidation, or tissue-meta- morphosis, in the affected part is desirable. I remember the case of a woman who had a stiff, painful knee for many months, and after taking medicines without limit, was cured completely in one week by the daily use of the hot-air cham- ber, into which the limb was introduced. The physiology of these applications is as simple as it is exact. Another important physiological method is massage or the manual or instrumental manipulation of the tissues for a variety of purposes. Its effects resemble those of hydro- therapy. It affects local circulation, and in this way local nutrition, tissue-change, absorption and excretion. It re- stores impaired innervation, gives tone to the muscular coat of the arteries, and promotes the activity of the absorbent vessels, relieving passive congestion and encouraging the absorption and excretion of morbid material. It supple- ments the action of water most effectually. It would take me beyond the confines of my present subject to discuss at length the subject of physiological massage. I wish, how- ever, to correct the current impression that the practice of massage is beneath the dignity of the physician. This im- pression is the result of the erroneous notions entertained by the profession in reference to massage. The application of massage as a muscular and nerve tonic in cases of general debility and neurasthenia is only a small part of its field of usefulness. For these purposes it is the proper province of the professional masseur. There are many cases, however, in which massage requires the tact us eruditus of the educated physician. Whenever it is desired to cause the absorption of inflammatory products or to break up adhesions or cica- tricial tissue by massage, the physician should be the mas- seur. Pelvic exudates (Thure Brandt's method), chronic inflammatory swellings (rheumatic and otherwise), chronic synovites, etc., are of this character. It is remarkable how promptly the affected parts respond to treatment. It is not generally known that massage is an anodyne of great virtue, especially for the relief of rheumatic and neuralgic pain. It 36 MODERN PHYSIO-THERAPY. regenerates the part by relieving passive congestion, stimu- lating arterial circulation, and thus produces a powerful al- terative effect upon the nutrition of the part. As an anal- gesic its action is prompt, e. g. in cases of torticollis, lum- bago, pain in any of the accessible muscles of the body. In such cases the "laying on of hands" (by way of massage) will at times lead to miraculous results. During the treat- ment of a fracture or luxation, massage helps to reduce swelling and to preserve the functional usefulness of joints and muscles. Massage is a valuable adjunct to the treat- ment of many surgical 3 conditions. Its technique is as exact as its modus oberandi is scientific. The same may be said of certain other physiological methods which operate ac- cording to the same principles, c. g. the various forms of gymnastic therapeutics, Swedish movements, etc., etc. A strictly biological concept of disease should be the basis of our therapeutic methods. Let us rise out of the foggy recesses of exclusive drug-methods into the pure at- mosphere of physiological reasoning. The drug-dispenser is never an exact thinker. He could not be if he would. He many times hovers dangerously near the border-line of quackery. If he is conscious of this fact (and I dare say most physicians are), his mind is ripe for newer and bet- ter therapeutic ideas and methods. He is ready and willing 8 Incidentally let me say that physio-therapy is in principle and practice the ally of conservative surgery or the surgery that aims to preserve structure rather than mutilate or destroy it. The discovery of anaesthesia, the principles of surgical cleanliness, and the Esmarch method of bloodless operations, have made invasion of the body by the knife comparatively safe. This fact accounts for the great strides that have been made in the department of operative surgery and the assiduous cultivation of mechanical skill on the part of the operating surgeons of to-day. Whether the operative surgery of to-day signifies actual scientific progress in medicine is more than questionable. During the times of Billroth, Langenbeck, and Gross the essence of surgical education was the knowledge of when and ivhy to operate. To-day it seems to be all-important to know how to operate. Such is the effect of the example of a mechanical genius like Lawson Tait on the many men of much smaller caliber who attempt to follow in his footsteps. This accounts for the present age of unnecessary operations. Clinically operative surgery thrives PHILOSOPHY OF PHYSIOLOGICAL THERAPEUTICS. 37 to share in Nature's restorative work, not merely to go through the motions before his patients and prescribe some- thing "ut align id fiat." In most cases it is commendable to sit idly by and let Nature do the work. This is the success of homeopathy. The physio-therapeutist should be physiological, not only in his methods, but more especially in his ratiocinations. He must -absorb the spirit of physiological therapy, not merely its practice. To apply the methods without be- ing imbued with the spirit of their rationale is an injustice done to the most glorious achievement that has marked the history of clinical medicine. In doing clinical work try to elaborate within your minds the philosophical axioms embodied in the practice of drugless medication. After you have made the phi- losophy of physiological therapeutics a part of your inner consciousness, you will realize that you are not merely add- ing a new method or two to your way of practicing medi- cine, but that your work has become the embodiment of a new principle which, in its last conclusions and applications, means the disintegration and ultimate destruction of faith in the art of medicine and aims at the establishment of knoivledge of the science of medicine. at the expense of other lines of practice. That a reaction is bound to follow this era of surgical overwork, especially in gynecology, is plain to any one who is familiar with the history of medicine and knows the causes that led up to the present dominating influence of operative surgery. The development of conservative methods along physiological lines will eventually force surgery into its proper place as the handmaid of medicine. Abstracting from the glamour of a modern surgical operation and the mechanical skill displayed, there is usually not much of the true scientific medical element in it. Lawson Tait and his disciples defer a diagnosis until after the abdominal section. Joints are resected that might be restored, amputations are made that might be avoided, etc., etc., etc., ad ab- surdum. The physiological therapeutist has a well-equipped arma- mentarium to choose from before he resorts to the knife. Mechan- ical skill should not be the end and purpose of surgical education, but always be the means to the end. This statement characterizes the attitude of physio-therapy to surgery. 38 MODERN PHYSIO-THERAPY. CHAPTER II. PERSONAL HYGIENE. "I have thought that some of Nature's journeymen had made men and not made them ^vell, they imitated hu- manity so abominably." SHAKESPEARE;. HYGIENE (from the Greek hygieia "health") is the science of preserving- health and preventing disease. It in- volves the knowledge of all the means and agencies by which the health of the organism, wholly and in part, is sustained. It deals with the various potencies and activities by which disease is produced. Inasmuch as hygiene is the science of preserving health, ir is practically synonymous with applied physiology, using the latter term in its widest biological sense. Physiology indicates the principles of animal life, hygiene suggests their application. Hygiene, therefore, presupposes the knowl- edge of physiology. The science of preventing disease necessarily depends upon the various agencies and potencies by which disease is produced. It presupposes the knowledge of heredity, etiology and pathology, using the latter term in its widest biological sense. Thus hygiene is synonymous with propliv- lactic medicine. An exhaustive treatise on hygiene would practically be a complete expose of medicine and the collateral sciences. In a restricted sense we may refer to hygiene as a thera- peutic agent. As such it represents an important branch of physio-therapeutic medication. It involves the forces that affect the body of man directly and the immediate agencies PERSONAL HYGIENE. 39 which commonly are concerned in the production of the various ills to which his organism is liable to fall a victim (personal hygiene). The physical condition of man to-day represents a more or less well-marked deviation from the natural standard. His occupation, his manner of living, his diet, his environ- ments, his habits, are all calculated to impair his vitality and to cause partial or general deterioration and collapse. The demands of Nature are constant and fixed. Health depends upon certain conditions. In proportion as man complies with Nature's demands he will enjoy a corresponding de- gree of health. Let man deny nature's demands in toto or in parte and a proportionate amount of normal well-being will be denied to him. Disease does not put in a hap- hazard appearance. It follows like a logical sequence to the premises furnished by man. I have stated on another occasion, and beg to repeat and emphasize it, that the nor- mal man as intended by nature is not the average man as produced by twentieth-century civilization. There are a thousand illustrations which might be adduced in explana- tion and corroboration of this statement. Thus, the modern city is like an immense prison wherein individuals and fam- ilies vegetate, deteriorate and finally succumb. In spite of all our vaunted progress it can not be denied that man has improved only in accidentals, but is becoming more and more woefully deficient in essentials. In treating the sick human body the physician's concepts of hygiene should resolve themselves into a continued effort to restore natural conditions and environments and to en- courage man to return to the natural standard. Let the physician beware lest he forget the fundamental laws of health while he is busily engaged in remembering and pre- scribing the latest remedy for the relief of some conspicu- ous symptom. We live in an age of contradictions and ab- surdities. The ubiquitous medicine-bottle looms up like a specter of long-forgotten days, while anatomy, physiology, hygiene, dietetics and other branches of purest medical 40 MODERN PHYSIO-THERAPY. science can only be found on the shelves of medical libraries, carefully secured behind lock and key lest they escape. In presenting hygiene as a therapeutic measure in a practical form, we can summarize hygienic philosophy in the old and trite but eternally true saying of the father of medicine: "A man with active emunctories (skin, lungs, kidneys and bowels) can not be sick!" Apply this state- ment logically and consistently to its very last consequences and you will establish a system of personal hygiene as per- fect and modern as any man could to-day. The function of the four emunctories should, therefore, receive the first and constant attention of the physician in the treatment of dis- ease. Before proceeding to consider these and other special aspects of therapeutic hygiene, let me interpose a short reference to a feature of our subject which is not directly connected with the clinical purposes which we, in the en- forcement of hygienic rules of action, may have in view, but which is nevertheless closely interwoven with the physi- cian's work and its ultimate objects. Men and more espe- cially women sacrifice many a hygienic principle to a per- verted sense of the beautiful. A truly aesthetic apprecia- tion of the glorious masterwork of construction which the human body in its perfect lines and proportions represents, is a species of education of untold hygienic value. A sick, sickly or sickly-looking body is not beautiful. Man can not improve upon the splendid beauty of form and proportion which an all-wise Providence designed. An appearance of beauty must convey a suggestion of health and hygienic perfection. An attempt to mutilate or deform the human body is an aesthetic crime and a hygienic outrage. To im- pair the physical perfection of the body and to undermine its health in order to satisfy notions and fancies of a per- verted or morbid character are insults offered to what Lud- wig Buechner calls the godlike dignity of the human frame. Think of the ear-rings which are worn in imitation of the habits and customs of savages. Think of the modern high- PERSONAL HYGIENE. 41 heel shoe with its necessarily disastrous results on the poise of the whole superstructure and the perversion of the pur- pose which nature had in view in planning the human body and its finely adjusted bony frame. Think of that typical example of concentrated ugliness, the narrow waist, and that most cruel of modern instruments of torture, the tight corset, the disease-producer par excellence. Amid the men who, by virtue of their profession or their office, are to take care of the health of the people, there is not one who does not fully realize and understand the position of the tight corset as a pathogenic factor with a most sorrowful record. Why are disease-producers like this not fought like the tubercle-bacillus, etc.? Indifference in this respect and frantic sanitary activity in other directions, what a satire on human intelligence and modern civilization ! Na- ture is all beautiful, and true culture never offends against the intentions of Nature. Modern man and modern woman constantly do. The Indian who paints his forehead, cheeks and chin with gaudy colors, and decorates his head with leathers, beads and other ridiculous trinkets, while the scalp of a vanquished foe dangles from his belt, seems to be the prototype of the modern woman with powder and paint, with feathers and plumes, that speak many a mute but elo- quent necrologue on behalf of the gay songbird whose tune- ful lays were hushed when the singer was sacrificed in the interest of a woman's headgear. Try to behold before your mind's eye the classic type of feminine beauty, the Milesian Venus, clad in a waist-constricting corset. Fancy her go- ing through equilibristic performances on high-heel shoes, crowned with what looks like a hybrid between a botanical collection and an ornithological museum, while the thousand fragrant odors that emanate from her suggest the incense that the lord of creation offers up to his gaudily attired and gaily decorated mate. Surely the modern female biped must be a mental imbecile. This is the only plausible expla- nation of and apology for the insults to her physical perfec- tion to which she constantly submits. In fulfilling your mis- 42 MODERN I'm sio- sion as physicians, remember that you, as Hyrtl says, are to be apostles of true culture (hygiene of the mind). You are to be missionaries of that eternal religion which is preached in eloquent language by the myriads of stars above, by the merry songsters of the woodland, by the flowers that scent the shady banks of the brook and the sun-kissed brow of the distant hills. Teach your patients to have respect for the human body. Make them understand that normal form and natural function are the prime conditions of health and, therefore, of beauty. Having done so, you can begin to teach them the principles of personal hygiene. In applying the Hippocratic admonition concerning the four emunctories let us briefly consider the hygienic im- portance of the skin, the lungs, the kidneys and the bowels. FUNCTIONS OP THE SKIN. Physiologists tell us that the skin is an organ of excretion as well as of respiration. A man in good health loses by the skin in twenty-four hours approximately 1-25 of his body-weight. The skin resembles the lungs in its function, in that it takes up oxygen and ex- cretes carbonic acid. The skin is the great thermic regu- lator of the body. Therein lies its clinical importance. It is the protective covering of the body, at once shielding the latter and communicating outside impressions to the various parts of the body. \Yhat animal-heat means to the organism will be seen later on under the head of Hydro-therapy. The very life of the organism is bound up in the process of oxidation. Ra- diation of heat-units constantly takes place through the skin in the form of gases, vapors or even liquids. Through the skin we can influence the fever process, the metabolic changes in the organism and thus the very life of the latter. It is plain, therefore, that the skin should receive a large share of clinical attention. It not infrequently is the barometer by which conditions within are indicated. It serves as a sort of dumping-ground for the inactive sewers of the body, and becomes the seat of various forms of mor- bid conditions that are secondarv to functional disturbances PERSONAL HYC.IENE. 43 in the organism. Non-parasitic skin-diseases are never primary or local affections. They are evidences of trouble somewhere in the machinery of the body and should be looked upon as symptoms and not as diseases per se. (See SKIN-DISEASES.) It is easy to understand why the face is more frequently the seat of skin-disease than any other part of the body- surface. It is exposed to light and air more and, therefore, is functionally more active than any other portion. The skin of the face is doing compensatory work and is, there- fore, the seat of continuous congestion. Hence the fre- quency of facial skin-troubles. Exposure of the body at large is the beginning of logical treatment. The care of the skin depends on three factors of cardinal importance, to wit : cleanliness, air and light. Before cloth- ing was invented, the skin was well-nigh able to take care of itself. The skin being exposed to air and light was kept hvgienically clean. Excretion was unhindered. The dew of the morning, an occasional rainfall or a bath in the in- viting waters of a crystal-clear brook removed the deposit of dirt from the skin of primeval man. Fresh air and light kept the skin functionally active and the organism at large free from slack. This was in the happy days when even fig- leaves were a luxury and when man in all his pristine per- fection traversed the fields and meadows pure at heart and beautiful like all of Nature's works. Naturalia non sunt turpia! Eternal vigilance and constant physical strife kept him in prime condition. Disease was unknown beyond the injuries that were incidental to his mode of living. Compare these splendid physiological conditions with the innumerable hygienic sins which the average man of to- day, who is the prisoner and victim of unhygienic environ- ments and health-impairing influences, commits. The skin of the average man in the large towns who is poor and vegetates in the dust-laden atmosphere of a factory and in the ill-ventilated and badly lighted prison-cells of a tene- ment-house, is necessarily covered with a slimy and mal- 44 MODERN PHYSIO-THERAPY. odorous mixture of sweat, sebaceous material and oil from the cuticle. There is no sunlight, no fresh air to cleanse and disinfect his skin. Eventually the functional activity of the skin is impaired and favorable conditions are created for the development of the thousand and one forms of auto- intoxication. Thus the vitality of the body is lowered and the soil rendered fertile for the reception and development of microscopic scavengers. The resisting power of the or- ganism sinks below par. Thus liability to sickness and pre- mature death are the inevitable result. The beneficent hygienic effects of air and light on the skin, and thus on the whole organism, can not be overesti- mated. In all diseases of metabolism, the sun-bath should be given a foremost therapeutic place. The skin in all febrile conditions and all wasting diseases requires light and air, for obvious reasons. In all chronic diseases the patient's skin should receive the benefit of the alterant action of light and air. This and the use of water should be insisted upon as a matter of routine. Light and air are never contra- indicated. Remember this more especially in connection with that most neglected portion of our anatomy, the feet. Exposure to light and air is a prophylactic of prime im- portance and a therapeutic agent of marvelous power. It would carry me too far to fully discuss the hygienic aspect of clothing. The object of clothing should be to cover those parts of the body which conventional notions teach us to cover, and to protect the body against cold. It should not interfere with the function of the skin. This re- fers more especially to underwear which should be loose and of wide texture. Woolen underwear is nearly always ob- jectionable. The outer garment should be of denser texture in order to protect the body against atmospheric moisture. Tightly fitting clothing is never proper. Loose garments do not interfere with evaporation. The air should circulate freely between the skin and the clothing and between the different layers of the latter for purposes of ventilation. In addition to this it must be remembered that this volume of PERSONAL HYGIENE. 45 air in itself plays the part of an article of clothing because it prevents the too rapid radiation of heat. Underwear should absorb moisture, the outer garment should not ; both, however, should be poor conductors of heat, but should not be air-tight. In a general way, it must be admitted that the tendency is towards too much clothing. Perversions of taste and sense, as displayed in the garments especially of women, are prolific sources of bodily ills. A book might be written on the diseases and diseased conditions produced by high-heel shoes and tight corsets. The care of the skin involves strict enforcement of clean- liness through the consistent and liberal use of soap and water. This should be the beginning of the hygienic regime in all chronic disturbances of nutrition and metabolism. Soap and water are never contra-indicated unless the skin itself is the seat of disease and forbids violent manipulation. Discourage the habitual use of warm or hot water. Cold water is the skin-regulator par excellence, unless there are special indications against its use, e. g. in cases of chronic nephritis and whenever skin-reaction, owing to loss of vas- cular tone, is absent or deficient. FUNCTIONS OF THE LUNGS. The stomach is sometimes referred to as the furnace which receives the fuel, and by burning it up keeps the fire of life from going out. In real- ity this simile does not hold good. The stomach prepares the fuel for the burning-up process. The latter takes place in the lungs. The lungs take up the oxygen from the air. Over a space of from eighteen to twenty-two square feet (for such is the extent of the breathing surface in the chest) oxygen is absorbed by the blood, is carried by the coloring matter of the red blood-cells to all parts of the or- ganism and acts upon the combustible constituents of the body. The principal waste left from this burning-up proc- ess (oxidation) is carbonic acid, which is excreted by the lungs and discharged with the exhaled air. Complete ex- halation never takes place. Even after forced expiration there still remains a volume of residual air in the chest 46 MODERN PHVSIO-TIIKRAPY. (about one hundred cubic inches). About twenty cubic inches of air are taken in and given off during each act of normal respiration. Physiological oxidation requires a correspond- ing amount of oxygen. Thus we see that metabolism or the constant regeneration of tissue depends on normal lung- function. The clinical significance of this statement be- comes apparent when we consider that in most chronic dis- eases we are dealing with disorders of metabolism. Oxygen is the life-element par excellence. The first principle of hygienic medication, therefore, is to supply the organism with oxygen (fresh air) and to preserve the oxygen-receiving and oxygen-carrying power of the body. Sunlight has a marked affinity for oxygen. Therefore, fresh air and sunlight represent an inseparable duality. The per- fection of the mechanical act of respiration is necessary for the proper reception of oxygen. From a clinical point of view, therefore, the hygiene of lung-function consists in giving the body fresh air and sunlight and in training the individual to practice the mechanism of respiration in as perfect a manner as possible. In proportion to the physiological perfection of oxida- tion, the body will possess the power of resisting the de- teriorating effects of disease-producers. The less oxygen is actually utilized and consumed, the less resisting power the body possesses. The oxygen-consumption of the organism determines its degree of vitality. Both are in direct propor- tion to each other. This is a hygienic and therapeutic prin- ciple of overtowering significance. Disease-producing germs can not gain a foothold and will not grow and thrive, unless the vitality of the organism is low enough to make the latter a favorable soil for germ-culture. Micro-organ- isms are ubiquitous. Every one of us is exposed to the same danger of infection. Some are infected, others are not. Some recover, some succumb. The pathogenic germs are present everywhere and invade the organism of every one within reach of infection. The tubercle-bacilli are in- digenous in every community. Every one of us, at some PERSONAL HYGIENE. 47 time or another, inhales these germs. Yet only a certain number of individuals are infected and contract bacillary phthisis, \\~hy do others escape? A better opportunity will never offer itself for the discussion of the peculiar changes which the study of microscopic life has wrought in our clinical reasoning. The undue prominence of bac- teriology (biology of germs) has detracted from the atten- tion to which physiology (biology of the animal body) is entitled. The former has only a secondary importance as compared to the latter, which by its very nature must come first in theory and practice. Bacteria, like all plants, require a soil to furnish the necessary conditions favorable to their development. With- out a suitable soil or culture-medium germs can not grow. It is evident, therefore, that the preparation of the soil is the life-condition of the germ and its growth. The crusade against tuberculosis should not primarily be a warfare against the bacillus. The latter can be left out of consid- eration because its life and growth are secondary to the condition of the tissues of the human organism. These are the soil. Render the soil sterile and tuberculosis will, after another generation or two, be stamped out of existence. Teach the individual and the community the first principles of hygiene in connection with their mode of living ; compel them, if need be, by main force to practice hygiene in tak- ing care of their bodies, and the tuberculosis-problem will solve itself. This dire and murderous affliction is the logical punishment which nature metes out to those who sin against fundamental hygienic principles. The offender may be an individual, a family, a tribe, a race. In the struggle for ex- istence the fittest, i. e. the most viable, is bound to survive. Appease outraged Nature and the ban is lifted. If the hygienic quality, i. c. the resisting power of the body, is kept at a certain level, the tubercle-bacillus is not any more to be feared than the numberless forms of microscopic plant- life that inhabit Nature's vast domain. The term "scav- enger" is distinctly relative in its meaning. In discussing 48 MODERN PHYSIO-THERAPY. the philosophy of physiological therapeutics I had occasion to refer to that ever-present and ever-active tendency of Nature toward a standard of perfection characteristic of every species. The activity of the scavenger is ihe outward expression of Nature's desire to destroy what falls beneath this standard of specific perfection. Nature invariably sac- rifices the individual to the species, the part to the whole, in this sense the activity of the scavenger is constructive to the species while it may be obstructive to the individual. The scavenger is a pathogenic element in this provisional sense. The treatment of a tubercular subject is a problem of sanitation with a wide economic meaning. It really in- volves a triple task, to wit: i. To protect the integrity of the species (prevention of marriages between consumptives or, for that matter, all individuals whose physical standard is below that of the species) ; 2. To remove hotbeds of scavenger-breeding from our midst (by isolating all con- sumptives) and 3. By giving each consumptive patient the benefit of a rational therapeutic regime. To be able to cope with great problems of sanitation and hygienic therapy, such as indicated, a thoroughly conscious appreciation of the physiological meaning of lung-function is necessary. The lungs of the average person offer a sur- face of approximately twenty square feet to the oxygen- laden air. The process of physiological combustion ("life") depends on the supply of oxygen and its proper usage in the system. There are four important lessons in therapeutic hygiene contained in this statement : Fresh air to furnish oxygen; light to aid in the assimilation of oxygen; gym- nastics of the thorax to preserve the mechanism of respira- tion in a state of relative perfection ; muscular exercise of the ivhole body to preserve the physiological equilibrium in the exchange of gases. In all chronic diseases, especially of the blood and the respiratory organs, this fourfold aspect of lung-function should be the beginning and the basis of our therapeutic reasoning. FUNCTIONS OF THS BOWELS AND KIDNEYS. The com- PERSONAL HYGIENE. 49 Uistible material which is acted upon by the oxygen in the body and slowly consumed, enters the body mainly through the stomach in the form of food. We can easily under- stand the physiological wisdom in the Hippocratic dictum concerning the four emunctories. Slow oxidation means life. In the process of physiological oxidation the four emunctories play the most essential part, and, therefore, they are the true pillars of life. The functions of the bowels and kidneys are properly discussed under the head of alimentary hygiene or dietetics. The latter deals with the quantity, quality and preparation of food, with the physiological purposes of food, and with the therapeutic application of the principles involved. While it is properly a part of personal hygiene, it covers an im- mense field and comes home to the individual patient more than any other part of hygiene. I have, therefore, thought it wise to consider dietetics separately. I can not refrain, however, from calling attention to a few characteristic points in connection with alimentary hygiene. Bad habits are not infrequently the cause of dis- ease. The constipated hypochondriac is probably the only person who has the true heartfelt appreciation of the privi- lege, the luxury and the happy possibilities of a good evacua- tion. The latter is a boon to be thankful for and an accom- plishment to be proud of. Frederick the Great, who was as much of a philosopher as he was a strategist, was discuss- ing the wants of the common soldier on the field of battle. A field-chaplain suggested that the soldiers before a battle should be taught to pray. Frederick opined that soldiers who fall on the field of battle have done their full duty and would, therefore, go straight to heaven. Those who sur- vive have plenty of time to pray after the battle. The chap- lain thought that soldiers ought to be prepared in some man- ner or other. Frederick said : "Fill their powder-bags and empty their bowels ; all else is of no consequence." People should be taught to have some respect for the calls of nature and extend this respect to others who might 50 MODERN PHYSIO-THERAPY. be called. Catherine of Russia subordinated even diplo- matic functions of state to the peristaltic function of her large intestines. No assemblage of princes and diplomats, however distinguished and brilliant, superseded in her mind the importance of alimentary excretion. On one occasion o gorgeous delegation cf Oriental potentates had to wait over thirty minutes while Her Imperial Majesty occupied the throne where no one else could have taken her place. To- day with more definite knowledge of hygiene people are afraid to do the bidding of nature for fear of giving offense or because they are denied the chance. They invite the legion of troubles and complaints 1 which follow the disre- gard for the demands of health. Children in school, women m the midst of social obligations, men in business suppress and ignore what ought to be a welcome invitation. Thus a race of constipated malcontents is being bred in an age of alleged enlightenment. In some of our large cities where health-officials arrest a man who is supposed to aid in the propagation of tuberculosis by expectorating on the side- walk, there are no public commodities for the relief of urgent necessities. Thus the spread of disease is encour- aged among the human species, while horses, cows and dogs are well and happy in the enjoyment of the unconditional privilege of depositing their alimentary excreta unhindered on the public highway. O temporal O mores! The hygiene of the alimentary canal requires a sound and healthy condition of its several parts. The mouth should 'Auto-intoxication from the residual matter in the large intes- tines is by many considered the most prolific cause of disease and of the many phases of decay and retrograde metamorphosis included under the head of senility (BOUCHARD, METSCHNIOFF). There seems to be no doubt that man would be better off without his large intestines. After many ages of evolution man will no doubt be freed from the encumbrance of an appendage which is not only unneces- sary, but a constant source of infection, disease, and decay. The future man, under these improved conditions, will be in his prime when he reaches the biblical allowance of threescore and ten. Metschnikoff thinks that health (life) depends upon the degree PERSONAL HYGIENE. 51 receive its share of attention. It should be washed out, es- pecially in the morning. The teeth should be fit for their work of thorough and sloi^> mastication. In this age of superior dental surgery there is no excuse for poor teeth. They are not infrequently the cause of disease. Other points in connection with the subject of alimentary hygiene I will have occasion to discuss under the special head of Dietetics. The hygienic importance of water is not appreciated as it should be. It is nature's beverage and can never be sup- planted by artificial substitutes like beer, wine, coffee, tea, soda-water, etc. Father Kneipp, who was not a scientist, but made up for the lack of scientific training by a liberal supply of common sense, discountenanced the use of arti- ficial beverages as substitutes for water. In his character- istic picturesque language he appeals to his fellow-men to return to the simplicity and frugality of former, physically stronger generations, and refers thus to water: "You that are sickly and weak, nervous and irritable, that distend your stomachs with thin beer and strong coffee; you that reek with the dirt and filth of ill health, go and take from the hand of Nature the goblet of life filled with the pure, cold, crystalline blood of the meadows and mountains !" People do not, as a rule, drink enough pure water. The bulk of it should be drunk between meals, not during meals. Like a cadaverous voice from a musty grave comes the admonition of the modern health-officer to boil your drinking-water. of phagocytic power possessed by the corpuscular elements of the blood. He believes that the human body is the battling ground and that a continued contest takes place between the normal cell-ele- ments of the blood and the microscopic intruders from without. The problem of sustaining life (health) consists in preserving the fighting quality of the red corpuscles. This quality is contained in the hemoglobin, the oxygen-carrier. Gaseous combustion-products in the blood disintegrate the hemoglobin. Since the large bowel is always filled with these waste-derivatives, and since absorption from the large bowel constantly takes place, we are prepared to understand the pathogenic importance of auto-intoxication. 52 MODERN PHYSIO-THERAPY. Pettenkofer, of Munich, declared that he would rather eat live germs than dead ones, that he would rather make an aquarium than a cemetery out of his stomach. Boiled water is stale water and can never take the place of fresh water. If water is infected, it should be filtered, aerated and ex- posed to light. Geisler's experiments show that typhoid bacilli die, if the water containing them is aerated and ex- posed to sunlight. Oxygen and actinic rays of light are na- ture's own disinfectants. Water, after aeration and trans- lumination, can be cooled and served. The proper manage- ment of the water-supply in large cities is an economic and hygienic problem of stupendous importance. It involves the health of thousands of people. It is a problem which should be solved by men who have brains and hearts, and inde- pendently of politicians and rotten municipal governments. "The health of the people," says Lord Beaconsfield, "is the lirst duty of the statesman." Again we arrive at the same hygienic principle which teaches us that bacteria are not pathogenic unless the soil is favorable to their development. A healthy human body is proof against these microscopic scavengers. All these problems can be solved by making physiology and hygiene a part of the practical education of the people. Little Japan might in this respect serve as a shining example for the white races of the East and West that have had a monopoly on civilization. The liberal use of good drinking water is probably the best tonic that the physician can recommend. It keeps the kidneys active, prevents passive congestions and dilutes the renal excretion. There is hardly a condition in which water as a beverage is not indicated. Further reference to this important subject will be made under the head of Dietetics. It would be foreign to the purposes of our discussion to enter into the details of a subject of such proportions as hygiene. The question of sex, age, race, heredity, conta- gion, infection, environment, occupation, habit, etc., offer a vast field for research and speculation. The many aspects PERSONAL HYGIENE. 53 of domestic and civic hygiene are of absorbing interest and vital significance. I wish to restrict myself to what might be designated as therapeutic hygiene or hygiene as a thera- peutic agent in the treatment of disease. I wish to em- phasize the essentials of hygienic treatment in as far as they concern the physician in his clinical work. In the treatment of chronic diseases the tide is not infrequently turned in the patient's favor by the correction of a viola- tion of some hygienic principle. Many a patient goes from one physician to another without receiving any benefit until some simple phase of his case is discovered that clears up the situation. It is notoriously a fact that the elementary truths of medical science, the simplest laws of health, are not infrequently disregarded by the physician who takes too much for granted in investigating his patient's case or who tries to find something unusual which his predecessors have failed to discover. Five good clinicians in succession examined and treated a case of epilepsy in a young woman. The patient became worse until an old practical country doctor took hold of the case, stopped all medication, made the patient discard her high-heeled shoes and thus cured her. Her epilepsy was a reflex neurosis. (See REFLEX DISORDERS.) The simple fundamental laws of health which culminate in the hygienic importance of air, light, exercise, proper food, cleanliness and excretion, have lost none of their importance. They have become more significant and necessary because the tendency of modern man is to deviate from the normal standard more and more. The stereotyped advice given to patients to "get out more and take more exercise" should be formulated by a deeply rooted and conscious apprecia- tion of light, air, exercise, etc., etc., as therapeutic agents of fixed value in a given case. For this reason I have availed myself of this opportunity to emphasize and repeat things that every schoolboy is supposed to know, and that many a doctor forgets when it is most essential that he should remember them. 54 MODERN PHYSIO-THERAPY. The patient's daily life offers many a problem for in- vestigation and solution. Try to connect his condition or some conspicuous feature thereof with the kind of work he does, the position of his body during his working hours, the amount of recreation and sleep he gets, the bodily and mental influences to which he is exposed at different times or under various conditions, the manner in which he eats and what he eats, the amount of physiological exercise, light and air he gets, how his home-surroundings might react upon him, and a thousand other circumstances suggested by the personality, the surroundings and mode of living of your patient. Remember the all-powerful influence of mind over body, and analyze the factors that are liable to react upon his mind and through it upon his body. The mind should be at ease before we can hope to re-establish the equipoise of the physical man. More frequently the body acts upon i he mind. In such cases the body must be regulated before we can hope to remove the mental effect. The mind is as much a part of the man as the body. Either must suffer through the afflictions of the other. The attempts which have been made to impress the mind of patients through the organs of special sense, especially the eye and the ear, have not only shown the value of sen- sory suggestions, but have opened up a wonderful field of clinical and experimental possibilities especially in the treat- ment of nervous disorders. The development of the beauty- sense by a well-planned system of aesthetic culture has be- come a recognized branch of therapeutic hygiene. The effects of different colors and their combinations on the eye, and through the latter on the nervous system, can be made therapeutically available. The colors of the solar spectrum represent distinct physical potercies. Beginning with the red end of the spectrum and gradually passing through the green field to the violet end, the ef'ects on the animal organism, respectively, are stimulating ind seda- tive. Finsen himself, who was not a poetic dreamer but an exact scientist, attributed the healthful influence of life PERSONAL HYGIENE. 55 in the country in no inconsiderable degree to the prevalence of blue and green (sky and vegetation). That the undula- tions of light do not affect merely the nerve-structure of the eye but exercise an inestimably profound influence over the molecular elements of matter and their vibratory life- manifestations (see chapter on FORCE-MODALITIES), is suffi- ciently well established to justify further speculation along these fascinating border-lines of a new and tempting terri- tory. Who knows but what beauty is concord of vibrating force-modalities and that the beauty-sense is based on a purely physical relation of different forms of ethereal vibra- . tions? Richard \Yagner looked upon perverted taste, im- perfect taste or absence of taste as an evidence of disease, or rather as an evidence of a lower standard of health. The vibratory character of all force-manifestation (color, sound, heat, and the corresponding nerve-force-modalities which give a subjective reality to an objective potentiality "Kraftumwerthung") seems to give a physical basis to speculations of this kind. In regard to the effect of sound on the nervous system the evidence of physical reaction is unquestioned. Sound in its composite and perfected form (music) is undoubtedly an agent that is capable of affecting the potential energies of nerve-molecules and cause the lat- ter to arrange themselves in a state of more or less close ag- gregation (stimulation, sedation). Organisms that are not affected by these different force-modalities are certainly not normal, i. e. not in a state of perfect health. The lesion or defect is somewhere in the finest and most highly organized force-centers. It is the capability of undulations of light and sound reacting upon certain nerve-cells that has given us the therapy of color and music. Both light and sound are capable of affecting (establishing, changing, disturb- ing) the relation of the organism to its surroundings. Health has been defined : "A condition of perfect relation of the body to its surroundings." If this be health, both color and music must be powerful therapeutic agents. The therapy of color (Chromo-therapy) will be referred to 56 MODERN PHYSIO-THERAPY. under the head of Photo-therapy. Music offers a wide field for therapeutic experiment. It is distinctly a nerve-tonic, a nerve-restorer. Reference to this subject in medical jour- nals and books has always been made in a more or less jocular manner. This is unfortunate. In this age of nerve- exhausting activity music has become and is a social- economic necessity. It is a therapeutic agent like rest and physiological exercise. Considerable experimentation along this line has convinced me that music will bring about physiological and therapeutic effects which no other agent or agents are capable of producing. The music-sense (capa- bility of reacting upon sound-undulations) is normally pres- ent in every organism. Its absence (Lombroso, Wagner, Nordau) is a sign of degeneration. Shakespeare fore- shadowed this truth in his characteristic manner : "The man who hath no music in his soul, And is not moved by concord of sweet sounds, Is fit for treasons, stratagems, and spoils : Let no such man be trusted !" The hygienic importance of light and sound should teach UF. to avail ourselves of their capabilities in shaping the en- vironments of our patients, whose lives can be made hap- pier and whose physical tone can be improved by the gently invigorating and preserving power of these physical agents. In view of all that has been said we are prepared to agree with Wagner, who declared that artistic culture is a part of personal and public hygiene. A discussion of personal hygiene as a therapeutic agent would be incomplete without reference to that most active, most powerful and universally present agent for good or evil, the sexual instinct. No other force or impulse can compare with it in shaping the destinies of men and nations, the objections of prudes and religious sentimentalists not- withstanding. Religion, patriotism and all the other agen- cies that sway and move the human heart dwindle into in- PERSONAL HYGIENE. significance if compared to the sexual instinct. The craving for food is the only force that can be said to be equal to the power of the sex-instinct. Hunger is the tendency towards self-preservation on the part of the individual. The sexual instinct is the tendency toward self-preservation on the part of the species. If it were not for hunger and love, the human family would soon cease to exist. Says Schiller: ''Methinks that while philosophy Does not the world sustain, The race of man will live as long As love and hunger reign." Sexual hygiene has been and is the noli me tangere of moralists, ministers, educators and physicians. A sense of false modesty, a perverted conception of morality prevents the propagation of knowledge along this most important line. An agent of such gigantic power as the sex-instinct which is ever-active should certainly be regulated according to the physiological laws that control the sex-function. Sex- ual starvation, sexual overstimulation and sexual perver- sions are frequently the causes of disease and should be dis- covered by careful questioning and individualization. There is no subject that requires for its discussion as much com- mon sense, as much freedom from religious or other preju- dice and as much exact physiological knpwledge, as the sub- ject of sexual hygiene. Prudes, religious cranks and hys- terical bluestockings of both sexes forget that men and women are made of flesh and blood and that no amount of reasoning and preaching will remove the most characteristic trait of the animal body, i. e. the sexual appetite. To look upon it as an evil that ought to be feared and crushed, is a lamentable mental abberation. To allow it to rule and to ruin is an equally deplorable state of affairs. Sexual hygiene consists in applying the functions of sex in a phys- iological manner for physiological purposes. As a part of personal hygiene it presupposes good judgment and the power of individualization, as far as the medical adviser is 58 MODERN l'HYS10-THt:AJ'V. concerned. His knowledge and his judgment should prompt him to give advice and adapt it to the individual require- ments. What the advice should be, depends on a thousand different circumstances. I am satisfied to know that I have directed your thought towards this all-important and much neglected subject. In your diagnostic and therapeutic rea- soning the sexual habits of your patient should find proper consideration. In diseases of the nervous system the sexual element not infrequently furnishes the clew to diagnosis and therapy. In applying the principles of hygiene to any given clin- ical problem the criterion of judgment should be the nat- ural physical standard of man under relatively primitive conditions. Always go back to first principles. Civilization is not an unalloyed boon. In many respects it 'has brought about inferior conditions and appreciable deviations from the natural standard. In all cases of disease try to make the habits and environments of the patient conform to the standard established by Nature. Hygiene, after all, is physiology applied to actual conditions for the purpose of preserving health and preventing disease. It is, therefore, the true groundwork and support of physiological thera- peutics. DIETETICS. 59 CHAPTER III. DIETETICS. "Tell me what you cat and I will tell yon it'hat you are." HIPPOCRATES. INASMUCH as the food which we eat and drink is one of the conditions upon which the preservation of health de- pends, the subject of dietetics is in reality a subdivision of personal hygiene. While it is true that as a purely hygienic measure the food question is of inestimable importance, it rises to the level of a therapeutic subject of vital significance when viewed in connection with the sick human body. Many physicians attribute but little importance to the question of food, as shown by the vagueness of the dietetic instructions given to their patients. "Do not eat anything heavy ;" "Con- fine yourself to light, easily digested food ;" "Take liquid food only." These and similar vague directions are given to govern the patient's diet. The doctor who habitually makes statements of this kind could not, if pressed, give an intelligent account of what he means by "heavy food," "light food," etc. The truth of the matter is that the im- portance of the food-question both in the preservation and in the restoration of health can not be overestimated. In many chronic cases the dietetic directions represent the bone and sinew of scientific treatment. Let me begin our dis- cussion by a short resume of first principles. The process of low oxidation or combustion of the body, which is one of the outward evidences of its life, would soon lead to a consumption or a burning up of every vestige of tissue, if Nature had not provided for means of keeping the 60 MODERN PHYSIO-THERAPY. combustion a-going. Nature demands the proper kind of fuel to keep the fire from going out, and to keep the organ- ism from being consumed. The fuel is added, the process of combustion goes on undisturbed, material that has been utilized and is no longer available is gotten rid of in the form of waste. Since, however, the stomach is not merely a furnace and since food is not consumed like coal in a furnace, the process of burning and keeping the fire up is a trifle more complex than the burning up of coal in a fur- nace. The fuel which we utilize in continuing the com- bustion of the organism is not food unless it is available for taking the place, quantitatively and qualitatively, of sub- stance that has been consumed. This brings us to the physiological definition of food, which is any chemical sub- stance or combination of substances capable of aiding in the preservation of the quantitative and qualitative integrity of the body during the process of physiological consumption or of helping in the keeping up of the slow oxidation which constantly consumes the tissues of the body. This com- plex definition embraces the physiological meaning of food and suggests the fundamental classification of foods as tis- sue-builders and tissue-consumers. The latter and likewise the air we breathe conform to the definition given, and must, therefore, be classified as foods. In a dietetic sense we abstract from all foods except those that enter the organism through the so-called alimentary canal. Thus we get a dietetic definition of our subject and are prepared to say that food is any physiological tissue-builder or tissue-con- sumer that enters the organism through any part of the ali- mentary canal. Any substance which enters the organism through the circulation and is not a food in the sense indi- cated, is called a poison. Foods, therefore, must be either tissue-builders or tissue- consumers. If they aid in the preservation of the structure of the body, they are tissue-builders and are called proteids, proteins, albumens, albumines, albuminoids or nitrogenous foods. These names are synonymous. Foods may add heat DIETETICS. 61 or force by playing the part of fuel and being consumed. They are called carbo-hydrates. The large amount of liquids (i. e. water) and of mineral salts which the human body needs is to a large extent contained in the foods men- tioned. Quantitatively water is the most important element in the organism because it represents approximately 65 per cent of the body. The body of an adult requires about eighty ounces of water daily. One-third of this quantity enters through the solid foods in the chemical composition of which water represents nearly one-half. In some va- rieties of fruit, water represents 90 per cent and more. The importance of water as a food can hardly be over-estimated. The blood needs water in order to circulate with ease and carry its lifegiving elements to every cell in the body. The cells of the body, as Cohen remarks, are distinctly aquatic in their habits. Water represents the largest bulk of their substance and is in one form or another the element in which they exist. Water represents the bulk of excretion through bowels, kidneys and skin. The tissue-builders (nitrogenous foods) are principally lean meat, eggs, fish, milk, cheese, peas, beans, lentils and gluten of all cereals. This means that these foods, as far as their chemical composition is concerned, contain a. larger relative amount of tissue-building elements than of carbo-hydrates and mineral salts. The tissue-consumers (force producers, carbo-hydrates) are mainly fats, starch, sugar, gum and alcohol. The fats are frequently called hydro-carbons. Many of the foods in daily use really belong to both classes inasmuch as they contain approximately the proper proportion of tissue- building and tissue-consuming ele- ments. Milk, meat, eggs, wheat and oats contain both kinds of food-elements. Ordinarily, the animal-foods are con- sidered tissue-builders (nitrogenous) and vegetables tissue- consumers ( carbo-hydrates ) . 62 MODERN PHYSIO-THERAPY. The Digestive Process. The process of introducing food into the organism for the purposes of digestion, assimilation and nutrition begins in the mouth where the food is macerated by the grinding action of the teeth and slowly moulded into a. soft mass by the admixture of the secretion of the parotid, submaxillary, sublingual and buccal (mucous and serous) glands. The secretion of these glands is known as saliva and is an alka- line fluid which has the property of changing starch into sugar at a moderate temperature. The function of the mouth as an organ of perfect di- gestion depends upon (i) tne condition of the teeth, which are the organs of maceration; (2) the slow moulding of the food into a soft mass, it being necessary to grind slowly in order to macerate thoroughly and allow the fluids of the mouth to permeate the mass perfectly; (3) the good con- dition of the physiological digestive fluids of the mouth. The latter point refers particularly to cleanliness of the mouth, by which foreign more or less offensive substances are excluded and thus kept from causing a deterioration of the normal mouth-fluids. Keeping the mouth clean is, in more senses than one, a praiseworthy task. The filthy habits of the tobacco-chewer and the equally disgusting rumina- tions of the female gum-habitue are offensive alike to the aesthetic sense and to the physiological instinct. Both habits are frequently productive of digestive disturbances. The filth (bacterial and otherwise) of an unclean mouth may be carried into the stomach and absorbed into the system. The fact that the digestive action of saliva ceases above and below certain temperatures, proves the harmful effects of very hot and of extremely cold drinks or morsels, e. g. the habitual drinking of ice-water. That the continued action of extreme heat or cold is bound to injure the mucous mem- brane of the mouth, is readily understood. After a morsel of food has been prepared in the mouth, it passes through the oesophagus into the stomach, where it is acted upon by the so-called gastric juice, which is an acid DIETETICS. 63 secretion containing pepsin, hydrochloric acid and a mild curdling ferment called rennet. The gastric juice acts upon the tissue-builders (lean meat, eggs, milk, cheese, fish, peas, beans and the gluten found in wheat, oats and other cereals) and starts the process of disintegrating fat-cells and chang- ing the fats into fatty acids and glycerines. The gastric juice likewise converts cane-sugar into grape-sugar and in this way prepares it for absorption into the system. Cellu- lose (the substance out of which the cells are constructed which contain the starch granules) is not digested in the human stomach. It must be broken up by mastication or cooking, otherwise it remains totally indigestible. This holds good in regard to all starchy vegetables and cereals. Food remains in the stomach from one to six hours, de- pending on the kind of food, the manner of its preparation, the mixture of different food-substances and the condition of the stomach. Coagulated albumen is hard to digest. In the digestion of meat this is an important point. A piece of raw lean meat, if its fibrous elements are thoroughly broken up by maceration, pounding, scraping or grinding, is easily digested. The longer meat is cooked, especially roasted or fried, the }ess easily digestible it becomes on account of the coagulating effect of heat on albumen. It becomes harder to digest the more fat meat contains, on account of the limited action of the gastric juice on fat. If lean meat or eggs are fried in fat, they accordingly become harder to digest. The condition of the stomach determines, to a certain extent, the relative speed of the process of gastric digestion. There may be a dearth or an excess of acid in the gastric juice. The greater the amount of acid, the more rapid the digestion of nitrogenous foods. The stomach may tem- porarily lack the power of digestion. During its period of activity it requires approximately six times more arterial blood than ordinarily. If the required supply, for some reason or other, is not present, digestion will necessarily be slow. Cerebral hyperemia (mental anxiety, study, etc.) 64 MODERN PHYSIO-THERAPY. may draw the blood > to the brain away from the stomach and thus weaken the digestive power of the stomach. The general system may not require any food, and through the sympathetic nervous system an- nounce this fact to the stomach. The latter responds by declining to ask for food (physiological anorexia; absence of hunger or appetite, nature's demand for food). The stomach may be the seat of disease and through this fact be unable to digest, especially if afflicted by the mani- fold varieties of gastric dyspepsia. Sluggish digestion may be due to chemical action of one kind of food upon another variety, e. g. the presence in the same stomach of albuminous food (egg) and tannin, a large percentage of which is con- tained in strong tea. The tannin would precipitate the white of egg and render it totally indigestible. The change which food undergoes in the stomach is the second act in the process of digestion. Little by little the food is discharged into the small intestines through the pyloric end of the stomach. The peristaltic movements of a stomach after a meal affect the ramifications of the solar plexus posteriorly like gentle stimulating massage. Xerve- energy is assembled in the abdominal nervous system. Ten- sion in all other parts of the nerve-supply of the body is re- lieved. The organism lapses into a delightful condition of repose. Man is at peace with himself and with all the world. The brain is easy owing to reduced blood-pressure. It enjoys a state of absolute rest, which frequently merges into a condition of actual somnolence. I have never taken the old German adage seriously which tells you that "After eating you must talk, Or must take a little walk." It surely refers to an hour or two after eating, not imme- diately after the meal. The after-dinner nap is a physiolog- ical luxury which is sanctioned by that Providence to whom we bow in deference for being so fearfully and wonderfully made. With some persons the after-dinner nap is a phys- iological necessity. DIETETICS. 65 The most important part of the digestive process takes place in the small intestines, which represent a tube about twenty feet in length. The part which is known as the duodenum is equal in point of importance to the stomach and is sometimes called the second stomach. The digestive ferments are furnished by the pancreas (dissolution of ni- trogenous food elements, splitting up of starch, saponifica- tion of fats) and the liver (preparing fats for absorption, ren- dering the intestinal contents alkaline, preventing fermenta- tion) and numerous small intestinal glands (changing starches into sugar, preventing fermentation). Small pro- jections along the entire intestinal canal, called villi, take up particles of digested food and cause them to be received by the so-called lacteal vessels, which assemble their con- tents in the receptaculum chyli and the thoracic duct, and finally discharge them into the left subclavian vein. The chyle is lifted upward from the abdominal cavity through the mechanism of breathing, the upward movement of the chyle being facilitated by the valves in the thoracic duct which prevent regurgitation of the fluid. The fluid be- comes a part of the blood and is carried to all parts of the body. The contents of the small intestines diminish constantly, owing to the absorbent action of the villi, and practically represent a mass of residue or waste when they are dis- charged into the large intestines through the ileo-caecal valve. In the large intestines no digestion takes place. The residue of food and the admixture of mucus, etc., from the bowel is moulded into fecal matter and finally discharged through the anus in a state of fermentation. Physiologically the large intestines represent an unnecessary encumbrance. 1'athologically and etiologically they are of the greatest im- portance. (See AUTO-INTOXICATION.) The Hygiene and Ethics of Food. How often should man eat? Under normal physiolog- ical conditions man should eat when he is hungry. In the 66 MODERN PHYSIO-THERAPY. normal body hunger is the cry of the system for sustenance. It is impossible to say what, when, how often, how much a man should eat. Civilized man is in many respects the product of unnatural surroundings and conditions, and thus the results achieved by civilization (so-called) frequently present perversions and not logical evolutions of Nature's intentions. Decayed teeth, dyspepsia and constipation are some of the gifts of civilization in a dietetic way. Even the domesticated animals share in these doubtful blessings. The punishments which outraged Nature metes out to man for his deviations from the fixed standard, follow in logical se- quence. They are the thousand varieties of disease. In this sense disease is an artificial product which appears as the necessary sequence of given premises. What should man eat? A type of man which is dis- tinctly the product of modern civilization is the meat-eater par excellence, who manages to sustain his organism by ir.cans of immense quantities of nitrogenous foods served at the rate of three or four meals per day. Habit has caused this man to crave meat and to imagine that meat alone will sat- isfy his desire for food. Meat is food to him, everything else is an unimportant side-dish. The liquid elements which his organism needs, are introduced in the form of strong stimu- lating liquors. That the man with carnivorous instincts should want liquor is not surprising. He fills his stomach with tissue-building elements and naturally craves for stimulants to take the place of the force-producing or heat- furnishing carbo-hydrates. He is constipated because his food leaves but little waste. His circulation is constantly in an uproar, his blood not sufficiently liquefied, his nerve-cen- ters are in a state of continued agitation. As a result, the central organ of circulation is weak. This man is the type of a patient who quickly succumbs to an acute disease like pneumonia. The heart can not stand the strain. The or- ganism which has been sustained by immense quantities of nitrogenous foods, collapses, because the power of appro- priating food of such quality and in such quantity has been DIETETICS. 67 weakened. The fever-process destroys the organism which is not accustomed to rapid and intense combustion. The meat-eater can not stand capital surgical operations as read- ily as the vegetarian. The modern man who practically lives on meat is constantly paving the way for some form of disease or other. He is nervous beyond endurance, like the carnivorous tiger in his cage. His instincts gradually become those of the carnivorous beast. His intellectual powers wane while the instincts of his animal nature in- versely increase. He craves liquor to equalize the dispropor- tion between tissue-builders and tissue-consumers. Finally his stomach and bowels succumb to the strain and the end- less chain of diseases of the organs of assimilation with their complications and sequelae begins. The urea-laden renal excretion of the meat-eater undermines the function of the kidneys and chronic nephritis is the result. Skin-diseases of variable type follow in the wake of an excessive meat- diet, not to speak of rheumatism which is the meat-eater's disease par excellence. The champions of a nitrogenous diet point to the mag- nificent physique of the typical meat-eater, the lion, as an example of beauty and superb strength. The illustration is not well chosen. Aside from the fact that the lion belongs to an entirely different species, he eats a great deal at one time, but this does not happen every day nor every other day. In proportion he eats much less meat than the typical car- nivorous man, and exercises the muscles of his body much more. Lions in captivity become lazy and even sickly for obvious reasons. The large apes resemble the species of man more than any other group of animals. The apes are vegetarians, very healthy and strong, are long-lived and possessed of fine sen- sibilities and instincts. In captivity they become sickly, weak, learn to eat meat and appropriate many bad traits characteristic of the human species. Civilized apes usually die of tuberculosis. The influence of civilization and cap- tivity on the human and the simian species is interestingly 68 MODERN PHYSIO-THERAPY. shown by Darwin ("Origin of Species") and Brehm ("Thierleben"). The latter tells of a French naturalist in Africa whose party ran short of supplies and was compelled to live on berries, nuts, etc. Not being familiar with some of the varieties of fruit which the country produced, the men allowed themselves to be guided by the instincts of a large ape they had caught and tamed. Whatever the ape ate, they proceeded to eat. Whatever he refused, they did not touch. The ape instinctively avoided poisons and other substances not suitable for eating. The natural history of the entire animal kingdom testi- fies to the influence of diet over physical and mental quali- ties. The finer instincts and evidences of soul-life are ap- parent in the plant-eater more than in the meat-eater. The dove is the emblem of gentleness, the lamb that of purity. The noblest of all domestic animals, the steadfast friend of man behind the plow and on the field of battle, is a vegeta- rian, the horse. The horse combines all the excellent traits of character that we are wont to admire: courage, gentle- ness, fiery temper, generosity, intelligence, strength, en- durance and devotion to his master. Another of our do- mesticated animal-friends, the dog, is brutal and savage when fed to meat (the bull-dog), but represents the highest type of animal-intelligence and keen instincts if he is largely or entirely a vegetarian (the hunting dog). The hawk and the eagle are exclusively carnivora and, accordingly, carnal and cruel in their habits. In point of character and intelli- gence the herbivorous animals are, throughout the whole animal kingdom, superior to the meat-eaters. The physical effects of diet among the animals is no less characteristic. The plant-eaters possess marvelous endur- ance (birds of passage, camels, horses, elephants, hunting- clogs). The meat-eaters are vigorous and can make a won- derful display of strength, but they possess little endurance. The lion engages in a terrific battle, and, after it is over, feasts on the mangled carcass of his adversary and spends his time lazily in his haunts until hunger compels him to seek DIETETICS. 69 another bloody encounter. Endurance is the characteristic physical trait of the vegetarian. The winners in athletic contests where it is a question of endurance (swimming, walking, running, etc.) are usually plant-eaters. The en- during power of the vegetarian is shown in the work done by the Chinese coolies, who are not giants in strength and stature, but apparently never wear out. Who has not mar- veled at the accomplishments of the little brown men of Japan who are principally rice- and fish-eaters ? The world has never seen more admirable traits of mind and heart than those recently displayed by the pagans of Nippon. These are facts too well known to require any further demonstra- tion. The lesson which the study of animal life teaches us is too plain to be misunderstood. It conveys three dietetic principles which are as firm and .unshakable as the Rock of Gibraltar : 1. Modern man eats too much and too often in propor- tion to his physiological wants ; 2. Modern man eats too much meat in proportion to the amount of carbo-hydrates ; 3. The treatment of all general diseases and many local troubles must begin with a rational dietetic regime. I do not wish to be understood as saying that man should abstain from meat entirely. While total abstinence in this respect would certainly improve man physically and morally, and would take away the sting of many an avoid- able disease and prolong the life of the average man, it would involve many hardships and inconveniences because it would be at variance with the established order of things. In the large cities it is almost impossible to be a practical physiological dietarian. The average man thinks it is im- possible to live and remain well and strong without meat, lo disabuse the mind of man of this erroneous impression, would be, in its last consequences, an epoch-making accom- plishment in social economy. The belief in the dietetic 70 MoDKKN 1'IIYSIO-THKKAPY. necessity of meat is a sample of the ignorance that covers physician and layman alike with its nightly shades. The meat-habit (overindulgence in meat) does not dif- fer from the opium-habit or any other bad habit. It is a habit, never a physiological necessity. It is perpetuated by a perversion of the sense of taste, not by a physiological de- mand of the system. The need of tissue-building elements is amply filled by a mixed diet of vegetables (principally) and meat (sparingly). Meat in modest quantity should never be served more than once a day. In cases of constipation it should not be given. It leaves but little waste to engage the peristaltic activity of the large bowel, and, therefore, favors the absorption of toxines from the fermenting residue. Most meat-eating animals, especially in captivity, are constipated. Compare the frantic defecatory efforts of the constipated canine with the pastoral tranquillity of the ruminating bovine during the bountiful act of excretion through the primes vies. I could not illustrate the clinical physiology of food bet- ter than by a short reference to rheumatism. Rheumatism is a disease of nutrition. Uric acid, which is the form in which the nitrogenous derivatives of food exist when they have nearly reached the last stage of chemical change, is present in excess when nitrogenous foods are taken in undue quantity. When there is deficient oxidation or a lack of exercise, the uric acid is partly retained, gets into the blood- and lymph-circulation and causes the familiar symptoms of rheumatism. The modern treatment consists in giving but little nitrogenous food (i. e. give it in a vegetable form), in stimulating excretion and in augmenting oxidation. (See RHEUMATISM.) The same lo^ic prevails in the treat- ment of many other conditions due to deranged metabolism. Let it be remembered that many vegetables contain the proper physiological proportion of nitrogenous elements. They are capable of preserving the human frame in prime condition with all physical and mental forces at their best, as shown by the example of Sir Isaac Newton, who lived to the DIETETICS. 71 ripe old age of ninety and was a lifelong vegetarian. A vegetable diet stimulates tissue-change because carbo-hy- drates are most easily oxidized, prevents the accumulation of redundant fat and waste, keeps the body active and the mind sharp and clear. Shakespeare was a wonderfully keen judge of human nature, even in its physical aspects. The words spoken by Julius Caesar convey a remarkably correct lesson in dietetics : "Let me have men about me that are fat ; Sleek-headed men and such as sleep o' nights; Ycnd Cassius has a lean and hungry look, He thinks too much : such men are dangerous." Caesar is not afraid of the well-fed and ponderous meat- eater, but he fears the alertness, the ever-active tempera- ment and never-failing endurance of the wiry Cassius, who is evidently a vegetarian. From a purely physiological standpoint the Friday ordinance of the Catholic Church has much to recommend it. If the ordinance were extended to every second day, beneficent results would most certainly follow. Much good could be done if meat were rigidly ex- cluded from the bill of fare in all penal institutions, as is done in some parts of Germany. This would be a practical application of a physiological principle, /. c. that the animal functions are stimulated by nitrogenous foods, while carbo- hydrates preserve the finer instincts and emotions of human nature. The proper food for a well man is a mixed diet of nitrog- enous elements and carbo-hydrates. The proportion should be determined by our knowledge of the fact that nitrogenous elements are contained in many, in fact in all vegetables. When peas, beans, lentils and wheat are con- sumed in large quantities, meat is not needed to furnish the desirable proportion of nitrogenous food. A small amount of rare lean meat once every day or every other day should be a plentiful sufficiency for any one. People should be taught to look upon raw fruit as being a most important 72 MODERN PHYSIO-THERAPY. food. Eggs and milk should occupy a prominent position as food elements. Vegetables (raw or cooked) are supposed to be the dietetic mainstay of the healthy man. Meat should always be given the exceptional position of a dietetic luxury. It is not a dietetic necessity. There is no physiological or other kind of reason why an erroneous notion of this kind should be perpetuated. Diet as a Therapeutic Agent. As a therapeutic measure in the treatment of disease, the diet of a patient should receive painstaking attention. Re- membering the role which food plays in the physiological process of combustion and keeping in mind the sluggish metabolism which represents the raison d'etre of most chronic diseases (i. e. impairment of reparative power), we are prepared to appreciate the therapeutic value of the carbo-hydrates which are immediately concerned in the burning up of the tissues and in the forcing of the change of tissue. In conditions characterized by intensified com- bustion (febrile, hectic), the importance Of nitrogenous feeding is apparent ("feed fevers!" Fothergill). When the organism is losing ground without febrile reaction, the in- dication for a suitable mixed diet is plain. If the stomach or bowels present certain pathologic evidences of a local character, the chemistry of the food administered should be taken into consideration. Thus, the diet of a patient with a dilated stomach should, for obvious reasons, be suggested by the necessity of preventing fermentation. (See DYSPEP- SIA). In a general way we can systematize therapeutic dietetics in the form of four fundamental laws, to wit : 1. Loss of weight without fever calls for a mixed diet; 2. Continued fever is an indication for nitrogenous food ; 3. Sluggish metabolism which is typical of most chronic diseases requires carbo-hydrates ; 4. In disorders of the stomach or bowels the diet should be regulated by the chemistry and mechanism of the process of digestion with careful individualization. DIETETICS. 73 The first sub-division refers to cases of lowered vitality and general depression that present ill-defined diagnostic features, such as the thousand and one different functional diseases of the nervous system, e, g. nervous prostration (unless caused by a dilated stomach), the nervous disorders of the menopause, conditions produced by lack of fresh air and sunshine, etc., etc. Typhoid fever is a classical example of a continued fever. A continuous low fever, e. g. in tuberculosis, should dietet- ically be met by tissue-builders. In all these cases combus- tion is accelerated and intensified, and, for this reason, carbo-hydrates in excess are not indicated. \\ herever and whenever oxidation is sluggish, causing waste-products to be retained in the blood, the lymph-fluids, the bowels, the lungs, etc., etc., the diet should mainly con- sist of carbo-hydrates and foods that are largely aqueous. This should be the rule in all diseases of general and local nutrition, e. g. rheumatism, skin-diseases. In cases of dilated stomach all articles of food that are fermentable should be withheld. The generation and ac- cumulation of gas would dilate the stomach still more. In cases of overbad dity, nitrogenous foods would be easily di- gested. For mechanical reasons solid foods would be con- tra-indicated in gastric ulcer, intestinal ulcerations (typhoid fever), etc. The dietetic position of different foods is indicated by the following list, which shows at a glance the salient points of therapeutic interest in regard to the more common foods in daily use. The foods in common use, in the order of their nitrogenous food-value, are cheese (33 to 43 p. c.), beans (25 p. c.}, lentils (25 p. c.), mushrooms (24 p. c.), ham (24 p. c.), peas (23 p. c.), spring-chicken (23 p. c.), lean beef (22 p. c.), duck (21 p. c.), lean pork (20 p. c.), veal (19 p. c.), pigeon (19 p. c.), salted herring (19 p. c.), medium beef (18 p. c.). game (18 p. c. ), chicken (18 p. c.), meat-sausage (18 p. c. and less), oatmeal (16 p. c.), lamb (15 p. c.), fat pork (14 p. c.), corn (14 p. c.), eggs (12 74 MODERN PHYSIO-THERAPY. p. c.), wheat (ii p. c.), fish (10 p. c. and less), noodles (9 p. c.), rice (7 p. c.), rye (6 p. c.), oysters (6 p. c.), cream (5 p. c.), milk (4 p. c.), potatoes, spinach and cab- bage (2 p. c.). Foods in common use, in the order of their carbo- hydrate value, are beets and carrots (95 p. c.), rice (77 p. c.), noodles (77 p. c.), wheat (73 p. c.), corn (71 p. c.), honey (70 p. c.), oatmeal (64 p. c.), peas (57 p. c.), beans (56 p. c.), lentils (55 p. c.), mushrooms and wheat (51 p. c.), rye (48 p. c.), potatoes (21 p. c.), cherries (15 p. c.), apples and pears (12 p. c.), plums (8 p. c.), spinach and string beans (6 p. c.), strawberries (6 p. c.) cabbage (5 p. c. and less). Foods in common use, in the order of their fat-contents, are butter (85 p. c.), bacon (79 p. c.), fat pork (47 p. c. ), meat-sausage (40 p. c. and less), ham (37 p. c.), cream (29 p. c.), cheese (25 p. c. and less), salted herring (17 p. c.), beef (10 p. c. and less), lamb (9 p. c.), veal (8 p. c.), oatmeal (6 p. c.). Foods in common use, in the order of the quantity of water they contain, are cabbage, watermelons, cow's-milk (93 to 88 p. c.), strawberries, pears, apples, potatoes, cher- ries (88 to 75 p. c.), lean beef, lamb, lean pork, chicken, pigeon, game, duck, eggs (75 to 70 p. c. ), cheese, fat pork, salted herring, wheat, rye (48 to 42 p. c.), ham (28 p. c.), mushrooms (17 p. c.), cereals (15 to 10 p. c.), butter, bacon ( 10 p. c.). All foods mentioned contain a small admixture in varia- ble proportion (average 5 p. c.) of mineral salts and waste. It will be noticed that beans, lentils, peas and mushrooms head the list of nitrogenous foods, and that there is only one variety of meat (spring-chicken) that comes near these vegetables in tissue-building value. Cheese is the best nitrog- enous food. The large percentage of carbo-hydrates which beans, peas, lentils and mushrooms contain, give them a sin- gular fitness as parts of a mixed diet. From a purely nutri- tional point of view they surpass any and all other foods. DIETETICS. 75 The nitrogenous foods form the blood, the organs and tissues of the body. The fats are either deposited as such in the system or are burnt up (oxidized) through the action of the oxygen in the body, leaving waste or ashes behind in i he form of water and carbonic acid. The carbo-hydrates are the real fuel. They burn up and, in so doing, produce force and heat. The relative amount of nitrogenous matter in the body is not influenced by work or muscular exertion. Exertion means more oxygen, more fuel, more intense com- bustion and, therefore, more carbo-hydrates. A working n:an of me !ium stature needs daily about 2,818 grams of water, 100 grams of digestible albumen, 55 grams of fat, 500 grams of carbo-hydrates, 32 grams of mineral salts, and 7.54 grams of atmospheric oxygen. Food represents latent energy. To express the energy stored in a certain quantity of food, the energy is measured in units, called calories. A calorie is the amount of heat required to raise one gram of water i C. Approximately one gram of dried nitrogenous food represents 4,000 calories, the same quantity of carbo- hydrates J r ._oo calories, the same amount of fat 9,500 calo- ries. Adding the number of calories to the amount of nitrog- enous or protcid units (building material), we obtain the actual physiological value of the food estimated. Knowing the physiological requirements of the body as expressed in calories and nitrogenous units, and knowing the number of calories and nitrogenous units contained in any given food, v.e are able to estimate the food required by a body of given size and doing a certain amount of work. The length of time which is consumed in the digestion of special foods is an item of some importance. The following list indicates approximately in what space of time the diges- tion of different foods under ordinary circumstances may be considered complete. In one hour. Cooked rice. Boiled pigs feet. Tripe. In one hour and thirty minutes. Beaten raw eggs. Boiled trout. Barley-soup. Sweet soft apples. Roasted game. Parsnips. Calf's brains. 76 MODERN PHYSIO-THERAPY. In one hour and forty-five minutes. Cooked brain. Sago. In tuo hours. Tapioca. Barley. Milk (boiled). Fried beef-liver. Raw eggs. Sour soft apples. Sour cabbage. Raw milk. Codfish. Bouillon. In tzi'o hours and fifteen minutes. Fried eggs. Cooked turkey. In tivo hours and thirty minutes. Cooked gelatine. Raw beef chopped. Roasted turkey. Wild-goose roast. Shoat. Spring lamb. Cooked beans. Sponge-cake. Fried potatoes. Cabbage. Cooked marrow. Sweet-bread. In two hours and forty-five minutes. Chicken fricassee. Omelette. Milk pudding. Cooked beef. Sour hard raw apples. Raw oysters. In three hours. Soft-boiled eggs. Fried bass. Lean beef, medium. Fried steak. Pickled pork. Roasted lamb. Pickled pork stewed. Boiled lamb. Chicken-soup. Bean- soup. Apple dumplings. Corn cakes (baked). Fried pork-chops. In three hours and thirty minutes. Fried oysters. Pickled pork fried. Pickled lamb. Corn-bread. Carrots (boiled). Pork-sausage fried. Brown butter. Oyster-soup. Lean beef fried. Beef boiled in mustard. Melted butter. Old cheese. Lamb-soup. Fresh-baked wheat-bread. Turnips boiled. Boiled potatoes. Hard-boiled eggs. Succotash. Boiled beets. Raw ham. Caviar. Herring. Smoked tongue. In four hours. Pickled salmon boiled. Pickled beef stewed. Fried veal. Fried chicken. Chicken-stew. Fried cluck. Vegetable beef-soup. Beef-heart fried. Bacon. In four hours and thirty minutes. Pickled dried-beef boiled. Pickled pork fried. Marrow-soup. Pickled pork boiled. Veal pot-roast. Lamb-suet boiled. Boiled cab- bage. In five hours. Fried pork. Beef-suet boiled. In logical sequence I ought to discuss the preparation of foods, for hygienic cooking is a subdivision and an integral part of dietetics. It does not, however, concern the physi- DIETETICS. 77 cian directly. In connection with the preparation of foods we must bear in mind that the civilized man of to-day is not by any means the ideal or normal man. The finely culti- vated sensibilities of the former are perversions of the orig- inal natural instincts of the latter. The olfactory as well as the gustatory sense does not respond to the natural stimuli, but requires new and strong sensations. This is strikingly the case in regard to the foods we eat and drink and to the manner of serving them. That the normal man can live on and is amply satisfied with the food which nature offers di- rectly (water, milk, raw fruit and vegetables), there is no doubt. The raw-food fad which recently engaged the at- tention of Eastern society, proved that even the civilized stomach does very well with raw food. The remarkable cure of not a few dyspeptics by the raw-food diet, is worthy of passing notice. The educated sense of taste and the re- fined sense of smell resists food of this kind because, through habit, appetite for and relish of food depend largely upon the impressions which are made upon the senses of taste and smell. Thus the art of cooking originated by which the palate, the nose and the stomach can be stimulated, pleased and satisfied in a thousand different ways. To please a slowly degenerating sense of taste became the task of the cook, whose resourcefulness and artful devices have made him an important factor in the affairs of the human family. It Napoleon's cook had been able to please the stomach of the grim Corsican in its never-ending whims and caprices, he would have influenced the trend of history in no uncer- tain manner. I have referred to the sense of taste of the modern man as an instance of perversion or degeneration. Nature punishes digressions from the normal standard by inflicting the offender with disease. Diseases of the stom- ach are more common than any other. The reason is that the stomach is sinned against oftener than any other part or organ of the body. People sin against their stomachs in six different ways, to wit : I. They eat and drink too much ; 2. They eat too large a proportion of nitrogenous food ; 3. 78 MODERN PHYSIOTHERAPY. Food is not prepared properly; 4. The stomach is subjected to too much violent stimulation ; 5. The stomach is exposed to too many thermic shocks ; 6. Alcohol and other irritating stimulants are used at the wrong time and in too large quantities. In the treatment of all gastric disorders these six points serve a good diagnostic and therapeutic purpose. The first thiee points have already been touched upon. The fourth point refers to the use of spices and condiments. The latter are added to foods in order to please the palate or the olfactories. Taken in excess these spices and condi- ments can not help but be productive of harm. (See SKIN- DISEASES.) A sense of taste that always craves for highly seasoned food and an excess of salt, pepper, mustard, etc., is not normal. Inflammatory or catarrhal reaction of the gastric mucous membrane is bound to follow. The craving for liquor usually coexists. The use of spices and condi- ments at all times and in all foods is certainly the specific cause in not a few cases of stomach-trouble. The presence of sharp and irritating substances in the stomach can not help but impair the mucous membrane. The tannin and the alkaloids contained in coffee and tea are objectionable for similar reasons, if the two beverages mentioned are par- taken of in large quantities and in largely concentrated form. Much of what has been said concerning the use of stimu- lants holds good in regard to tobacco. Tobacco in moderate quantity is hygienically not objectionable in any form, al- though the chewing habit is hardly an indicator of personal cleanliness. If used constantly, tobacco becomes a poison, capable of destroying the functional integrity of the heart and of the nervous system. Thermic shocks are thought by many to be the most fruitful source of stomach-trouble. The sudden chilling of the gastric mucous membrane by cold drinks (ice-water, very cold beer, ice-cream), especially when the stomach is relatively empty, is certainly not calculated to improve its physical condition. Ice-water is by virtue of its tempera- ture a pathogenic element that must be reckoned with. It is DIETETICS. 79 distinctly an American product and its use a distinctly American form of idiocy. Dumb brutes have never been known to be guilty of the follies which man (homo ^a- picns) constantly commits. While fresh, pure drinking- water is a necessity and a luxury, its temperature should be in keeping with the tolerance of the body. The effect of an ice-cold drink on the unprotected surface of an empty stom- ach is bound to shock the nerve-supply of the stomach. It contracts the blood-vessels of the gastric mucous membrane and induces a reaction which leaves the membrane con- gested and irritated. It must be remembered that the tem- perature of the water has nothing whatever to do with its fitness to quench thirst. An equal amount of warm or hot water would serve this purpose as well as ice-water. Cold water pleases the palate. The moment a sufficient amount of fluid has been taken up by the system to supply the phys- iological demand, thirst ceases. The use of alcohol at the wrong time and in the wrong \vay is a prolific source of stomach-disorder. An alcoholic drink on an empty stomach is not proper. The "eye-opener," from the standpoint of health, is to be condemned. It is an irritant to the mucous membrane and can not be indulged in habitually without harm ensuing. The prevalence of whisky-drinking in this country is a fact much to be de- plored. \Yhisky is a medicinal stimulant, never a beverage. 1'ettenkofer considers whisky-drinking on a par with co- caine-eating. It is the abuse of a splendid food (alcohol). Ke suggests the substitution of beverages that are whole- some, nutritious and contain alcohol in comparativly small quantities, e. g. very light wines and, above all, the popu- larization of good beer. Therein lies the practical solution of the temperance-problem. Whisky-drinkers are usually drunkards, beer-drinkers hardly ever. Even in large quan- tities beer affects the stomach mainly through its bulk. On a full stomach cy includes the therapeutic uses of heat and cold if these agents are applied by means of water. Thermo-therapy refers to the therapeutic uses of elevated temperatures (heat) irrespective of the carrier which is used. Its meaning is limited to the effects of heat. I have confined the discussion of the physiology of heat and cold to hydro-therapy because the latter is the classical expo- nent of the whole subject and physiologically and clinically more important than any other method of applying heat and cold. PHYSIOLOGICAL EFFECTS OF HEAT AND COLD. 83 through the men who were identified with it and through the manner in which it was applied. The prejudice which in this way was engendered against the method among the practitioners of medicine became more and more estab- lished, there being but little effort made by physicians to in- form themselves concerning the method which they were condemning. In addition to this the successful application of hydro-therapy presupposes an exact physiological knowl- edge and familiarity with pathological processes not essen- tial in the administration of drugs and in the application of drug-methods. Another reason why hydro-therapy has as yet failed to find a place in the clinical armamentarium of most physicians is the fact of its being necessarily encum- bered with an amount of technical detail, taking up time and labor of both physician and patient. For all these reasons hydro-therapy has as yet not conquered the place which it so richly deserves. Some physicians are inclined to look upon it as a fad, an ephemeral innovation which will be relegated to oblivion whenever the charm of novelty is worn off or whenever some later fad commands professional attention. Few seem to know that hydro-therapy is among the oldest, if not the oldest clinical method known. To readers of Latin the grateful appreciation expressed by Horace con- cerning the splendid work of Musa, who had cured a num- ber of prominent Roman bon-vivants of gout and similar afflictions simply by water applications, is familiar. Long before the golden age of the Roman Empire water as a therapeutic agent was held in high esteem in Greece and Egypt, according to the statement made by Herodotus. The Romans were famous for the grandeur and luxury of their baths, where various hydro-therapy procedures were con- stantly en vogue for the treatment of different ailments. During the Middle Ages the hydro-therapists of Italy and France enjoyed a vast reputation. One of the greatest med- ical men of the sixteenth century, Ambroise Pare, was an enthusiastic admirer of water applications. With the ap- proach of the nineteenth century hydro-therapy was grad- 84 MODERN PHYSIO-THERAPY. ually usurped by empirics and charlatans, who, by the in- discriminate use of powerful hydro-therapeutic methods and by the bitterness and persistency with which they antago- nized all other therapeutic measures and scientific medicine generally, brought the whole subject of hydro-therapy into disfavor with the profession at large. Yet it can not be gainsaid that some of the empirics, notably Priessnitz, 2 con- tributed very largely to the elaboration of the subject of hydro-therapy, especially as far as the clinical uses of the various methods and the improvement of technical resources were concerned. Practically, the renaissance of hydro- therapy within the confines of legitimate medicine was con- summated by the introduction of the cold-water treatment of typhoid fever. Since that time increased interest in the subject has been manifested among the progressive mem- bers of the profession. Numerous books, especially Win- ternitz's great work, attest to the earnestness with which the subject is received by some of the brightest medical in- tellects of the day. The number of strictly scientific hos- pitals and sanitariums devoted to hydro-therapy is increas- ing from year to year. Hydro-therapy has achieved its greatest triumphs in the very home of scientific thought, Germany, where already at a number of universities special chairs for the theoretical and clinical teaching of hydro- therapy have been established. It remains to be seen which American institution will be progressive enough to admit hydro-therapy into its curriculum of studies as an inde- pendent and recognized branch of medicine. Verily, by vir- tue of its physiological exactness and clinical usefulness, hydro-therapy is entitled to a prouder and more dignified place among the various departments of medical teaching. 2 It is true that Vincenz Priessnitz was not an educated phy- sician, but he was a medical genius, who instinctively felt what many, after years of study, do not grasp. A doctor of medicine is not necessarily a physician. PHYSIOLOGICAL EFFECTS OF HEAT AND COLD. 85 The Physiology of Water Applications. Water as a therapeutic agent is employed both externally and internally. The science of hydro-therapy, however, deals principally with its external use, i. e. the various methods of applying it to the skin. I shall, therefore, confine myself to the discussion of the physiological principles underlying the diverse methods of employing water externally and the effects aimed at. Water in and of itself is not a therapeutic agent, to which could be attributed certain remedial poten- cies. "It serves, however, as a carrier of certain physical forces and properties which are capable of producing char- acteristic and profound physiological effects upon the system through the instrumentality of that most delicate and re- sponsive of finely organized structures, namely the skin. There are other agents, which possess in a measure the same physical properties. From a practical point of view, how- ever, water is by far the most available of all these agents, since it is inexpensive, easily obtained, and can be utilized in any number of ways and forms. Thus, as a carrier of temperature, air might be utilized as effectively as water, but the manner of making it subservient to our purpose and the method of handling it entails much technical difficulty. Ex- perience has shown water to be the most available of agents to serve as a carrier of heat and cold. This fact furnishes the practical basis for hydro-therapy. The logic of hydro- therapy, then, becomes apparent if we analyze the physiolog- ical effects of heat and cold primarily upon the skin, and secondarily upon the system at large. The idea of temperature is intimately bound up in and inseparable from all vital processes. All organic beings are affected by different degrees of heat and cold. The outward manifestations of life in every organism and in every part of an organism are dependent upon the degree of temperature by which the organism, wholly or in part, is surrounded. The manifestations of life are retarded or accelerated or entirely suspended by the variations of temperature. This holds good in regard to the most perfectly organized bodies 86 MODERN PHYSIO-THERAPY. as well as to the simplest forms of organic life. Ciliary mo- tion, ameboid movement, the vesicular contractions of the infusoria, the contractions of muscular fibers, etc., etc., all react upon thermic influences. Ordinary degrees of heat and cold respectively accelerate or retard motion, while extreme degrees completely arrest it, and, if continued, endanger the vitality of the organic body. Inasmuch as the motor func- tion of cellular bodies is affected by heat or cold, this effect is not characteristic of the action of heat or cold alone. Any irritant, e. g. contact with another body, is sufficient to affect the movements of the organism for the time being. Heat or cold, therefore, primarily act as irritants or ex- citants pure and simple. The study of physiological proc- esses within the animal economy of warm-blooded animals has taught us that these processes are necessarily dependent upon a certain degree of heat. Heat makes possible and accompanies the conversion of chemical elements into the forces and functions which constitute the life of the organ- ism. Furthermore, we know that heat is the principal product of the metamorphotic and functional activity which takes place within the animal economy. In the present state of our knowledge we can assume with a reasonable degree of certainty that heat and function, meaning by the latter the sum-total of force-manifestation within the organism, are dependent upon each other, are convertible into each other; that organic life, therefore, is a condition produced by a heatmaking process within the organism. We can deduct, furthermore, that function and heat-production are in direct proportion to each other. If we intensify the one, we ipso facto increase the other; if we depress the one, diminution of the other must necessarily follow. Since the functional activity of the organism, however, either is con- cerned in the taking-up of food (nutrition in its wide physi- ological sense) or in the expulsion of waste (excretion), it stands to reason that the degree of nutritive and excretive function is in direct proportion to the degree of heat pres- ent. A low degree of temnerature means slow oxidation, PHYSIOLOGICAL EFFECTS OF HEAT AND COLD. 87 retarded tissue-metamorphosis, and, therefore, slow nutri- tion and lessened function. This holds good in regard to the whole organism as well as to each and every part individ- ually. These physiological considerations enable us to draw a conclusion of momentous importance: If we can control (intensify or depress at will) the heat-producing process, then we can regulate oxidation, functional activity, nutri- tion and tissue-change. These strictly physiological pre- mises embolden us to go even further in our conclusions. If we can accelerate or retard the chemico-physiological ac- tivity in the organism at large, or locally in any of the organs of the body, then we certainly have snatched from the hands of Nature the magic wand which holds at bay the enemies of our bodies, which preserves our physical well- being during the onslaught of disease-producing germs and elements, which sustains our body in its integrity, and which enables the fittest to survive. That magic wand is FEVER. Fever is, as we at this late day are ready to admit, acceler- ated oxidation of the tissues of the organism, hastened nu- trition. All the engines of the organism are v/orking at full speed, large aggregations of slack and waste are hurled through the gateways of excretion, new food-material is de- voured and consumed by the roaring furnace within. Finally the organism returns to its normal speed and amount of work, the vicious elements of disease have been elimin- ated, regeneration has taken place, health again supervenes. That such a process of rapid oxidation (fever) should be ac- companied by an increased amount of heat (elevated tem- perature) is but natural to assume in view of the previously quoted physiological laws governing the vital processes within the organism. That we can radically modify the pro- cesses of heat-production and by so doin^ necessarily af- fect oxidation and nutrition, that we can, consequently, ar- bitrarily bring about a fever-process even to the extent of causing local or general temperature to rise and fall, is an undisputed fact, and can be abundantly demonstrated by ex- periment. 88 MODERN PHYSIO-THERAPY. The purely physical effect of heat and cold upon tissue of all kinds, both dead and living, is expansion and contrac- tion. The molecular elements of the tissues respond to the exciting cause and arrange themselves, as a result, at greater or less distance from each other, the intensity of the effect being in proportion to the difference between the tempera- ture of the tissue acted upon and the temperature acting upon it. The more marked the contrast between the two temperatures, the greater the effect of contraction and ex- pansion. The immediate result of this purely physical phenomenon is the production of a dynamic element, a force, resembling in its manifestations an electrical or magnetic potency, which, as all physicists know, springs into exist- ence whenever temperatures of different degrees come into contact and which travels in the direction of the lower tem- perature. If the substance acted upon is a living organism, the electrical potency generated will travel along the paths of the inherent vital energies or currents of nerve-force with which, as DuKois Raymond has shown, all living tis- sue is constantly charged. Thus, heat and cold are capable of affecting the .amount and power of the currents of nerve- force circulating in our nerve-fibers, and through the brain and spinal cord make impressions upon the whole (motor and sensory) nervous system (Winternitz). Whenever water the temperature of which is higher or lower than that of the body-surface comes into contact with the skin, this contact is perceived by the cutaneous nerves as a sensation of heat or cold. The capability of the skin- nerves to perceive heat and cold is called the "thermic sense," and manifests itself within certain degrees of tem- perature below which and above which the impressions are merely those of pain. Extreme heat and extreme cold re- semble all other nerve-stimuli or nerve-excitants inasmuch as they impair or even completely suspend the nerve-potency of receiving and conducting sensations. A state of tempo- rary anaesthesia is produced. A high but not excessively high temperature of short duration, likewise a low but not PHYSIOLOGICAL EFFECTS OF HEAT AND COLD. 89 excessively low temperature of short duration, intensifies the susceptibility of the skin for tactile impressions, i. e. the skin becomes hyperaesthetic. If the application is of longer duration, tactile impressions become more and more faint, anaesthesia of the skin supervenes. Hence we speak of overstimulation and subsequent exhaustion of the functional power of the cutaneous sensory nerves. In connection with this subject it is of interest to note that not a few physiolo- gists, among them Blix, Goldscheider and Herzen, recognize the thermic sense as being bound up in certain fine nerve- endings entirely distinct from the end-bulbs commonly cred- ited with receiving tactile impressions. Some of them, nota- bly Blix, whose ingenious experiments were made in the physiological laboratory of old Upsala, recognize two dis- tinct thermic senses (one of heat, one of cold), with sep- arate terminal structures and independent central connec- tions. All tnese authors, however, agree and numerous physiological and clinical experiments go to show that heat and cold applied to the skin are capable of affecting (in- and de-creasing) and altering the innervation of the organism wholly or in part. In connection with this subject it may be of interest to call attention to the statements made by Krebs and Heimann in explanation of the sedative action of com- plete immersion of the body in warm water. That aqueous elements do enter through the skin (endosmosis) has been demonstrated. It is claimed that in this way an edematous condition of the peripheral nerve-endings is produced, caus- ing the molecules within these endings to move sluggishly. Nerve-impulses are received and carried with less prompt- ness and a state of comparative quietude of the nervous sys- tem is brought about. These purely thermic effects on the skin-nerves, and through these on the nervous system, are immediately fol- lowed by, and can not practically be separated from, char- acteristic effects on certain vital processes within the or- ganism which are wholly or largely controlled by the nerv- ous system. These vital processes go to make up the two 90 MODERN PHYSIO-THERAPY. fundamental functions performed by the machinery of the body, i. e. nutrition (self-preservation of the organism) and excretion (expulsion of waste). Inasmuch as nutrition of a part is dependent upon the blood-supply of the part, we are ready to admit that to control the blood-supply means to regulate nutrition. Furthermore, since the degree of func- tional activity of any organ is in direct proportion to the amount of arterial blood and vice versa, we are prepared to say that, if we can control the blood-supply of the organs of excretion, we can regulate excretion. To control nutri- tion and excretion by regulating the blood-circulation means to control the very processes by which the life of the or- ganism is preserved. That these statements do not contain visionary notions, but strictly scientific truths which can be verified by clinical demonstration, the following physiolog- ical considerations will serve to show. A thermic stimulus perceived by the cutaneous nerves is communicated to nerve-centers situated in the brain, cord and in the peripheral ganglia. Through these the stimulus is reflected to the vaso-motor nerves of the area which re- ceived the thermic impression originally. In this way the circular muscular fibers of the arterial walls are made to contract .or relax, as the case may be. In addition to this reflex process the application of heat or cold to the skin has a purely physical effect, consisting in the contraction or ex- pansion of the contractile tissues of the skin, especially the muscular fibers. Hence, there necessarily takes place a con- traction or dilatation of the skin-capillaries independently of any reflex mechanism. This is shown by applying heat or cold to the skin after the nerve-supply has been rendered inert (e. g. by severing the nerve-fibers supplying the re- gion). Thus, the phenomenon known as cntis anserina (goose-skin) is produced by purely local action of cold. The non-striped muscular fibers of the skin and of the ar- terial coats violently contract, forcing the blood out of the skin. The skin looks anemic, sunken and wrinkled, causing the skin-papillae to appear more prominent than at other PHYSIOLOGICAL EFFECTS OF HEAT AND COLD. 91 times. Gradually the muscular contraction passes off and normal conditions are re-established. The contracted ves- sels are gradually rilled with blood, which rebounds into them with renewed vigor. The temporary contraction is followed by a temporary dilatation, anemia by hyperemia. The circular fibers of the arterial walls relax beyond their normal size, the process resembling the backward-swing- ing of a pendulum, which does not stop at the central point, but swings beyond it. This peculiar conduct of the arterial walls causing a hyperemic condition to follov/ an anemic state produced by cold, is the essence of what hydro-thera- pists call REACTION, and is the pivotal point upon which the science of hydro-therapy revolves. If a certain area of skin is rendered anemic by the action of cold, the blood is forced into the vessels whence the blood-supply of that particular area of skin comes (tributary circulation). Induced ane- mia of the skin is, therefore, necessarily associated with hyperemia of those parts into which the blood of the skin- vessels has been forced. When the action of cold ceases, reaction begins. The hyperemic parts unload their surplus of blood and the conditions are reversed : the subcutaneous tissues become comparatively anemic while the vessels of the skin are replete with blood. The intensity of reaction depends upon the suddenness with which the cutaneous ves- sels are contracted, and upon the extent of the area within \vhich anemia is produced. If the reaction involves a large area, the anemia or depletion accompanying it may affect deep and important structures at some distance from the hyperemic area. Thus, it has been practically demonstrated (hat forcible reaction involving the blood-supply of the ab- dominal wall will affect the vessels of the meninges. Schuel- ler trephined rabbits and through the opening made ex- posed a circumscribed area of the meninges. Whenever a c oW-water application was made to the abdomen of the ani- mal, dilatation of the vessels of the pia mater was distinctly noticeable A it'orw-water application to the abdomen was followed by contraction of the meningeal vessels. Immer- 92 MODERN PHYSIO-THERAPY. sion of the animal in cold water was promptly followed by wide dilatation of the meningeal vessels, immersion in hot water caused forcible contraction. Reaction involving the surface of the extremities and the trunk (e. g. during a com- plete pack) will almost deplete the encephalic circulation, as is shown by the somnolence of the patient during the pack. The physiological manner in which reaction takes place is still a matter of speculation. Some seem to think that the effect (arterial contraction) passes off the moment the cause (application of cold) ceases to act. "Cessante causa tollitur effectus." Others say that the forcible contraction of the muscular coat of the artery temporarily exhausts the tone of the vessel-wall and necessarily leads to a condition of re- laxation and fatigue. According to Winternitz, however, reaction is a more complex process. He states that the ther- mic impulse excites the vasomotors and thus produces con- traction of the artery. Gradually the functional potency of the vasomotors is exhausted, exciting the inhibitory nerves of the vessels to action, thus producing vascular relaxation. What are the necessary and possible physiological results of reaction as far as nutrition generally and locally is con- cerned ? In considering this question, we must distinguish between the area to which the thermic stimulus is applied (primary area) and the area which is rendered anemic by the resulting reaction (secondary area). Thus, if we apply A cold, moist pack (Priessnitz method) to the skin of the lower extremities, the surface packed would be the primary area. When reaction sets in, the primary area becomes act- ively congested, i. e. the lower extremities become replete with blood. It stands to reason that as the blood-supply in the primary area increases, some other part or parts of the body must lose some of its or their blood in order to make an over-supply in the primary area possible. The part which yields some of its blood-supply is as it were the tribu- tary territory. It is what I have previously designated as the secondary area. The necessary effect of a reaction in the primary area is a partial depletion in the secondary PHYSIOLOGICAL EFFECTS OF HEAT AND COLD. 93 area. This is a simple mechanical problem. To the mind of the intelligent practitioner there is contained in it a wealth of therapeutic suggestion. If the secondary area is the seat of a pathological (active or passive) hyperemia^ it is plain that partial depletion of the congested part means lessening of the hyperemia existing there. An inflamma- tion would necessarily be aborted thereby because the in- flammatory process would be deprived of its working cap- ital. The congested area is partly depleted and thus de- prived of the essential elements of inflammation. 3 If we apply the therapeutic indications of Schueller's experiments clinically in a case, for instance, of simple meningitis, we are clearly conscious of the modus opcrandi of our method. We know that a hydro-therapeutic reaction is the ideal anti- phlogistic. It is venesection without loss of blood. Thus we are in a position to summarize the broad therapeutic availability of reaction by saying that the production of re- action is indicated whenever depletion is desirable. It is cateris paribns the scientific remedy for the relief and cure of all inflammatory and congestive conditions. We can conscientiously go even farther and say : it is the prophy- lactic measure which prevents and aborts inflammation and congestion. Clinically the brilliant statistics of pneumonia 3 The hydro-therapeutic "derivating" method is the classical type of a rational antiphlogistic procedure. The principle is practi- cally the same as is contained in Priessnitz's "refrigeration" and Bier's "congestive method." Priessnitz, in the treatment of local- ized inflammations in the extremities, especially in joints, frequently succeeded in aborting the inflammatory action by continued cold applications above the seat of trouble to "cool the blood," and in- cidentally, by contracting the vessels, to lessen the blood supply. Bier's method consists in applying a constricting bandage above the seat of inflammation, thus causing a condition of stasis below the line of construction. The inflammation is literally starved out. Even in septic inflammations Bier's method is of service, principally through constriction of the lymphatics and prevention of the ab- sorption of toxins. Bier's "congestive method" is an effective ano- dyne, the pain-relieving effect being due to the lessening of blood- pressure. 94 MODERN PHYSIO-THERAPY. treated hydro-therapeutically fully bear out and confirm these statements. It is plain that reaction is the pivot upon which the whole practice of hydro-therapy revolves. Hydro- therapeutic science draws its clinical conclusions and makes its therapeutic applications, not from primary, but from the secondary effects. Between the two effects reaction is interposed as a necessary link in the chain. \Ye are ready to understand the difference between hydro-therapy and the clinical uses of superheated air (baking). The latter does not include the characteristic "reaction" in its modus operandi. The vessels of the surface are dilated at once by the action of heat and are kept in a state of dilatation by the continued and enforced application of heat. Therein lies the therapeutic rationale of superheated air applications. They are indicated ( i ) in all conditions in which "reaction" can not be brought about or only imperfectly ; (2) in cases where the production of primary anemia might cause aggra- vation of some congested state within the body; and (3) in cases where the condition of the vessel-walls would centra- indicate the violence of a reactive process. What has been said before expresses in a general way the broad principles according to which the hydro-therapist proceeds at the bedside. The strength of his method lies in the control which he is capable of exercising over circula- tion, and in this way over (general or local) nutrition. Even the mere emptying and refilling of the blood-vessels of a certain portion of the circulatory system affects nutrition in a manner most striking. Passively hyperemic organs are in this way unloaded, the healthy tone of the organs is re- established, the tissue-change within the organs is stimu- lated by acceleration and regeneration of the blood-current, products of decomposition and other morbid processes are washed away, retrograde metamorphosis is prevented. There can be no question that the employment of so pow- erful an agent presupposes familiarity with the condition of the organism at large, and sometimes even more than ordi- nary finesse of judgment. Calcareous vessel-walls, an apo- PHYSIOLOGICAL EFFECTS OF HEAT AND COLD. 95 plectic condition, luetic changes in the brain or spinal cord, congestive conditions of the kidneys, etc., are for obvious reasons centra-indications to the employment of heroic hydro-therapeutic measures. The dry-heat cylinder or the electric-light bath would in these conditions be better adapted, although their use should never be haphazard or become a matter of routine. On general principles, how- ever, it is easier to be successful in the use of the dry-heat cylinder and electric-light bath than in the employment of cold water. The latter requires more knowledge, better judgment and some experience. It is the more powerful and more effective agent. The marvelous effect of thermic stimuli upon regions at some distance from the seat of application has been prac- tically shown by experiments on man and beast. I have al- ready referred to Schueller's experiments on rabbits. The fact that not only the meningeal but the entire intra-cere- bral circulation is affected by the thermic stimuli, was shown by a plainly noticeable contraction and expansion of the brain-mass itself. Winternitz, who has done more than any other investigator to define the physiological laws govern- ing the effects of thermic stimuli, proved that during a warm sitz-bath the circumference of the arm decreased, while it increased during a cold sitz-bath. His observations con- cerning the effects of the thermic stimuli on the central or- gan of circulation, the heart, and also on the centers of respi- ration are most interesting. The decided effects of cold upon the local circulation are well shown by Winternitz, who made sphygmographic tracings of the radial artery be- fore and after ice-applications to the brachial artery. It has been stated that reaction is the process through which hydro-therapy accomplishes its great results. When- ever the primary thermic stimulus ceases to act or whenever a stimulus of the opposite character is substituted, reaction will take place. To explain: If we envelop a patient in a cold, moist sheet and place a woolen blanket over the sheet fPriessnitz pack), the action of the sheet will be of but 96 MODERN PHYSIO-THERAPY. short duration. In a brief space of time the normal body- heat supplemented by the woolen blanket will change the cold moist sheet to a warm moist sheet. The spaces be- tween the skin and the sheet and between the sheet and the blanket are filled with a warm vapor, which acts as a thermic stimulus opposite in character to the thermic stimulus rep- resented by the cold moist sheet. What takes place in and beneath the skin in response to the new stimulus is what we call reaction. Reaction must take place if we wish to ac- complish results and wish to prevent harm from being done. If reaction did not take place, the result would be conges- tions within the organism. Perhaps the patient's lungs or bronchial tubes would remain congested. In the language of the people, the patient has caught a cold. By a cold is meant a condition characterized by congestion of one or more internal organs or structures and produced by the action of low temperature on (i. e. chilling of) the skin. A cold, hydro-therapeutically speaking, is the result when- ever reaction is imperfect or absent. It must be our aim to produce reaction at all hazards. If there is a lack of tonicity in the arterial walls, causing the circulation to be sluggish and nutrition to be bad, we must augment the hydro-therapeutic procedure by other means. Friction and massage of the body-surface might be required to bring on reaction. The question of reaction again calls for nicety of judgment entirely inseparable from accurate physiological knowledge and from the ability to individualize cases. We are again prepared to admit that the successful hydro-thera- pist must needs be a scientific physician. It is of some importance to know the effect of a cold or a hot water application upon the body-temperature, or upon the temperature of any part of the body if only a partial ap- plication be made. We know that the self-consumption of the body is a process of combustion accompanied by a cer- tain degree of heat. The relative rapidity with which the body is burnt up and the amount of heat produced are in di- rect proportion. If combustion takes place more rapidly PHYSIOLOGICAL EFFECTS OF HEAT AND COLD. 97 than the normal physiological process of self-consumption, the process is called fever, and is accompanied by a corre- sponding rise of the ordinary heat of combustion. It is a well-established fact that the physiological heat of the body is maintained by certain automatic safety-apparatus, which equalize the contrast between the temperature within and that outside of the body. High temperature applied to the whole body-surface will necessarily cause a rise of the tem- perature within the body. The organism at once makes an effort to get rid of the surplus heat through the activity of the sweat-glands, the process of expulsion of surplus body- heat being known as "diaphoresis." If a very low tem- perature acts upon the surface of the body, the temperature within the organism will of course sink. The organism, however, makes a prompt effort to supply an additional amount of heat by causing the animal-economy to consume itself more rapidly. Metamorphosis of matter and heat- production are always in proportion. Therefore, fever means over-consumption. Its objective evidence is elevated temperature. Physiologically, fever is an attempt on the part of nature to regenerate the body, to burn up morbid material, to make new and healthy tissue. Fever, there- fore, is a salutary, curative effort ; it is the ally of dis- ease. The organism which is constantly regenerating itself, is doing so with increased vigor when fever supervenes. The surface of the body is studded with innumerable little openings through which gases and vapors constantly es- cape. When the excreted material is so copious that it can not all evaporate through the skin, it escapes in liquid form (sweat). It is clear what a close physiological relationship exists between fever and perspiration and what valuable therapeutic lessons can be learned from the knowledge of this relationship. The treatment of a febrile condition or to speak more correctly an attempt to aid nature in her efforts to save the organism from the ravages of disease, imperatively calls for close attention to the excretory func- tion of the skin. If there is little or no attempt to perspire, 98 MODERN I'JIYSIO-TIIKKAPY. h-ve, as a result of disuse or of inflammatory conditions, lost some of their functional power and have become atrophied or contractured, exercise of these parts is the physiological remedy. Therein lies the therapeutic importance of Swedish movements. Their power of modifying metabolism makes them a blood-producer of greatest value. They increase nutrition and improve it by augmenting the quantity and altering the quality of the blood. The function of the lymphatics is stimulated. Respi- ration is improved. The whole organism, in all its vital functions, receives the benefit. To illustrate these physiological considerations and their application in the practice of the therapeutic indications in- volved, I will confine myself to giving a few of the most characteristic movements. After the reader has thoroughly grasped the underlying principles of these movements in their relation to the functions of the organism and its parts, he will have no difficulty in enlarging the scope of applica- tion and in adapting many kinds of movements to the never- ending varieties of disease and diseased conditions. In the treatment of habitual constipation Swedish move- ments can often be employed with much advantage. The object of all these movements is to make pressure upon the abdominal contents, to firmly contract the muscles compos- ing the anterior abdominal wall and to act upon the celiac and hypogastric plexus which control the mechanism of the bowel-function. The simplest movement is the slow bend- ing of the body forward while the patient stands or sits. The patient while standing bends forward without bending his knees and until the tips of the fingers touch the toes. The movement, both forward and back to the standing posi- tion, should be performed slowly and repeated ten to fifteen times. Another movement is the slow raising of one or both legs without bending the knees, while the patient lies on his back. Still another is the suspended position, the patient alternately drawing his 1 legs up to his body and extending them. Some of these movements can be exaggerated and MECHANO-THERAPY. 131 thus be made more effective. Instead of lying on a couch full length, the patient can lie down on a table or bed with his hips on the edge, leaving the lower extremities without support. This position makes the movement of raising the extremities much more of an effort. Another variation, con- sists in lying down on a couch, drawing the knees up toward the abdomen and then extending the legs. In the treatment of many cases of tuberculosis pul- inoinun, Swedish movements are of great value, especially in increasing the expanding power of the chest. I beg to refer the reader to the second part of this book where, un- der the head of TUBERCULOSIS, this subject is considered at some length. Swedish movements are advantageously combined with massage, galvanism and faradism. The principal thing is to not abuse a good thing by overdoing it or by misapplying it. To have exhausted the patient completely is a sure sign that the judgment of the operator is at fault. Massage or movements should never cause pain, exhaustion or other damage. In some cases it might be desirable to shorten the duration of the treatment or to lessen its severity. One val- uable feature of massage and movements is that the dose can be adapted to even the weakest and most sensitive pa- tient. Mechano-therapeutic methods should not be applied while the stomach is full. Their effect might interfere with the function of the stomach, by drawing blood away from it and thus impairing its digestive power. The operator should keep the anatomical structure and the physiological function of the different parts of the organism in his mind. In adapting the Swedish movements to the condition of an individual patient, the habits and mode of living of the pa- tient should be inquired into. A clerk, for instance, who leads a sedentary life, needs Swedish movements applied to every part of his body as a substitute for exercise. A letter-carrier, who is constantly using his lower extremities might be in need of a proportionate amount of exercise ap- plied to the muscles of his back, chest or arms. In all these 132 MODERN PHYSIO-THERAPY. cases experience should shape the judgment of the operator in adapting means to the end and individualizing the cases. [N. B. For special forms of mechano-therapeutic ap- plications (notably the Nauheim Method in diseases of the heart) the reader is referred to the Therapeutic Index.] Instrumental Massage and Instrumental Movements. While there is no doubt that the human hand, if en- dowed with the necessary skill and guided by intelligence, is the most perfect instrument, it is often necessary to sub- stitute mechanical appliances for the trained hand, espe- cially when patients are treating themselves at home under the direction of the physician and in large institutions where there is a great deal of mechano-therapeutic work done. Instruments have been devised for the purpose of ad- ministering the different forms of massage, especially effleur- age and tapotement. These instruments (massage-rollers, massage-balls, massage-hammers, etc.) are supposed to be held and guided by the hands of the operator. In the simple forms of stroking and percussion they answer very well. Where, however, the iactus eruditus is necessary to itveal the local condition and its peculiarities, these instru- ments are, of course, practically worthless. On general principles their value has been overestimated by the laity. They can never supplant the hand of the trained masseur and are likely to do more harm than good on account of the ever-present temptation to use them. Only the physician can estimate the effect of the massage-instrument and the range of its proper use. On general principles, I believe that a vast amount of harm has been done by the misuse and overuse of these appliances. The multiple ball-roller (small Uii'ls on a cord), held by both hands of the patient and drawn across the abdomen, is useful in encouraging the ab- sorption of surplus adipose tissue in the abdominal wall. The cannon-ball as a massage-instrument in the treatment of constipation enjoys well-merited popularity. One point in its favor is that it frequently does good while it hardly ever 134 MODKK.N PHYSIO-THERAPY, does any harm. A splendid feature of many of these me- chanical massage-devices is their adaptability to the use of electricity in conjunction with massage. Galvanism and faradism can be combined with their use if they are properly constructed to serve as conductors of electricity. Of much greater importance than the massage instru- ments are the mechanical devices for the administration of movements and gymnastic therapy. The use of these ap- pliances for therapeutic purposes will always be associated with the name of Dr. Gustav Zander, a Swedish physician, w-hose set of Swedish-movement-machines are a monument to his mechanical genius which was only equaled by his splendid skill as a physician. Zander classifies his machines under four different heads, to wit : 1. Machines for active movements. There are alto- gether thirty-eight of these machines intended respectively for the upper and the lower extremities, movements of the trunk and machines for balancing ; 2. Machines for vibration, pressure, tapotement, petris- sage and effieurage. There are thirteen machines of this kind; 3. Five machines for passive movements; 4. Ten orthopedic machines, mostly for curvatures of the spine. These machines are wonders of mechanical construction. They are accurately adapted to their purpose and are ca- pable of the finest adjustment of speed, energy, etc. Most of them are operated by electric motors. The employment of complicated and expensive apparatus of this kind is necessarily restricted to very large institu- tions. The physician who wishes to add the movement-cure to his therapeutic armamentarium will have to confine him- self to the use of simpler and less pretentious devices. Quite a number of these have been placed on the market and arc easily obtainable. Home-made machines of primitive con- struction frequently render excellent service. A familiar example is the iron ball which is suspended by a rope. The MECHANO-THERAPY. 135 rope runs in the groove of a pulley which is mounted four or five feet above the ground. The patient has hold of the other end of the rope. With a little mechanical ingenuity on the part of the operator, this improvised Swedish-move- ment-machine can be adjusted in such a way as to give any number of movements. By holding the rope in his hand, by attaching it to his foot, by placing it around his chest or A. CYCLE FOR INDOOR EXERCISE. B. APPARATUS FOR EXERCISING THE UPPER PARTS OF THE BODY. The dial indicates the exact amount of work done. his abdomen and then making traction on the rope, the pa- tient can give- almost ever}- part of his body mechanical treat- ment. He can vary the technique and the effect by stand- ing, kneeling, lying or sitting on the floor or on a table, and by using different sizes of counter-weight. I have a distinct recollection of one case of incipient phthisis that received untold benefit from a primitive arrangement of this kind. 136 MODERN PHYSIO-THERAPY. The importance of good judgment on the part of the physi- cian must again be emphasized. The danger lies in over- doing things, especially at the start. The patient's organ- ism, especially the heart, must be educated by steady and careful training, first to become tolerant to exercise of this kind, and secondly to gain strength functionally and struc- turally while apparently sacrificing energy. Vibration. Vibration (from the Latin ribrare, to tremble) in its finest form is the manner in which all force in nature be- comes manifest. Matter proclaims its existence through force-manifestations. The latter are, in and of themselves, only varieties of vibratory movements. Sound is vibration, light is vibration, electricity is vibration, organic function is vibration, nerve-energy is vibration, thought is vibration, life itself is vibration. There is no life without force, no force without vibration. Vibration is the elementary basis of all biology. Vibration in its coarse form means the act of imparting a more or less intense trembling motion to an object, e. g. the tissues of the human organism. In the application of manual therapy the practice of manual vibration was, up to within a comparatively recent period, considered of much importance. Masseurs cultivated marvelous skill in adminis- tering digital or manual vibration. Since the introduction of the mechanical device known as the vibrator, the practice of vibration by hand has become almost absolete. The vibrator performs the act of vibration so much more perfectly and conveniently that manual or digital vibration can well be ignored in a discussion of the subject of vibration. The vibrator needs no introduction or recommendation. Vibra- tion has without a doubt become more popular than any of the mechano-therapeutic modes of application. From the exalted plane of the scientific physio-therapist down to the more commercial level of the progressive tonsorial artist, vibration enjoys an undisputed degree of popularity. The MECHANO-THERAPY. 137 genius of the American mechanic and manufacturer has made its employment simple and agreeable. Patients are being vibrated for every ill to which human flesh is heir. That the universal practice of vibration should involve a great deal of amateurish empiricism, is not surprising. Like all fads in medicine it is "being worked to death." The attempts which have been made by some manufacturing con- cerns to make vibration a complete system of medical prac- tice and, under the cover of a great deal of pseudo-scientific literature, sell a good many vibrators at exorbitant prices, have injured the cause of vibration as a therapeutic agent. The success of osteopathy, more than any other factor, sug- gested this systematizing of vibration as a cure-all, the vibrator taking the place of the osteopathic operator's hand. There are many good vibrators on the market. If the 'mechanical construction of a vibrator is such as to impart the vibratory impulse to the tissues of the patient and not to the hand of the operator, it is a point in its favor. There is no doubt that the vibrator is a therapeutic agent of great potency. Its use should, therefore, be preceded by an ap- proximately correct conception of its possibilities, physiolog- ically and therapeutically. The modern instrument used for generating and imparting vibration is usually operated by an electric motor. Considered in conjunction with the instru- ment which produces it, vibration is in reality but a succes- sion of strokes which follow each other more or less rapidly. These strokes may be long or short, severe or faint, and de- termine the depth of the vibratory impulse on the tissues. In response to these strokes every molecule within the sphere of the vibratory impulse trembles, the intensity of the re- sponse depending on the relative distance from the source of the vibratory movement. This, then, is vibration. What is its physiological and therapeutic effect when applied to the tissues of the living organism ? As has been stated before, the simplest and most ele- mentary form of a stimulus is contact. Any organic sub- stance which is at all capable of being stimulated, will re- 138 MODERN PHYSIO-THKRAI-Y. spond to mere contact with any object. Ciliary motion, amoeboid movement, etc., are stimulated by mere contact. Stimulation is more powerful if contact becomes more firm. In this case contact would be in the nature of pressure. If pressure is sudden and abrupt, we would call it a stroke or a blow. A succession of strokes would be vibration. Thus we are prepared to look upon vibration as being primarily a stimulus. It is a stimulus, using the latter word in the same sense in which we applied it to massage. It increases, quan- titatively and qualitatively, the local circulation. It tones up the arterial coats, and by increasing the arterial circulation and thus improving the nutrition of the part, it stimulates excretion and absorption of waste-products and corrects metabolism. The pulse becomes fuller and slower. \Ve can readily understand why it is indicated in passive con- gestion, especially when pain is present (torticollis, chronic rheumatism, lumbago, neuralgia, etc.). It causes disintegra- tion and absorption of low forms of tissue (obesity) and stimulates the heart, if directly applied to the precordial re- gion. It stimulates activity by increasing the tone of mus- cular structure (constipation). Its local physiological ef- fect corresponds accurately to that of massage. For this reason the term "vibratory massage" is entirely proper and adequate. Vibration and manual massage form a very ex- cellent therapeutic combination. The use of vibration as a species of local massage and the adaptation of the osteopathic idea of reaching the differ- ent parts of the body through the central nervous system (spinal cord), has given rise to the division of vibration into two varieties, i. e. peripheral (local) and central vi- bration. If the vibrator is applied to an aching part, for instance to the muscles of the neck in a case of torticollis or to the muscles of the back in a case of lumbago or in the rectum for the cure of constipation or to the course of an aching sciatic nerve, vibration would be peripheral or local. It resembles the local application of massage. Whatever has MECHAXO-THERAPY. 139 been said about the local effect of t!ic latter, can be re- peated, in a measure, concerning the local action of vibra- tion. There seems to be no doubt that its primary effect is produced on the peripheral nerves, the vaso-motors, and that the subsequent local phenomena follow in physiological se- quence. The direction, frequency and intensity of the stroke must not be lost sight of. It is of some importance, at what angle to the surface the vibratory force explodes, what de- gree of energy is spent, how often the stroke is repeated, how large the diameter of the vibrated area is and how much pressure is made by the operator's hand. On general prin- ciples it may be said that the stimulating effect on the deep tissues, e. g. the deep muscles of the back in a case of lum- bago, is in direct proportion to the relative intensity or depth of the vibratory stroke and, in conjunction therewith, to the relative diameter of the surface treated. Likewise it can be stated that the greatest action is produced by a down- ward stroke, i. e. at right angles to the surface. The lateral stroke, i. e. parallel to the surface, stimulates the skin and its component parts. It is but fair to state that while all these points are of value in a clinical sense, the technique of vibration has by some been burdened with a mass of detail altogether out of proportion to the relative value of vibra- tion as a therapeutic agent. The monomania of the opti- mistic enthusiast and mercenary instincts of the overanx- ious manufacturer who insists upon making a complete med- ical system out of a therapeutic method, are equally to blame. The former lacks exact knowledge and the latter conscience. A medical subject without critical knowledge to purify its theory and conscience to sanctify its practice, is indeed a miserable make-believe. The greatest therapeutic benefits are supposed to be derived from the vibratory stimulation of the spinal nerve- centers whereby peripheral effects are produced in the re- gions controlled by the vibrated centers. This is the form of vibration previously referred to as central vibration. I shall endeavor to present the subject in keeping with the 140 MODERN PHYSIO-THERAPY. clinical evidence which my own experience and that of other observers has adduced in support of this attractive form of drugless medication. Let us for a few moments recall some salient points con- cerning the anatomy and physiology of the spinal cord and its adnexa. The spinal cord is contained in the vertebral canal, the latter being formed by the so-called spinal fora- mina of the individual superimposed vertebrae. The cord lias the form of a flattened cylinder. On its anterior surface, in the median line, it has a narrow, deep depression known as the anterior median fissure. On its posterior surface it has the posterior median fissure, which, however, is not as deep as the anterior. On either side of the anterior median fissure are the points where the anterior roots of the spinal nerves emerge. The posterior roots of these nerves emerge on either side of the posterior median fissure. If, in a cross- section of the cord, we draw imaginary lines from the points of origin of the anterior nerves to the points of the origin of the posterior nerves on the opposite, we divide the cord into four distinct sections, which, as component parts of the cord, are known as the columns of the spinal cord. There are two lateral, an anterior and a posterior column. The bony framework which surrounds the spinal cord is com- posed of the so-called vertebras (seven vertical, twelve dor- sal and five lumbar). The vertebrae are separated from each other by the intervertebral cartilages and are placed one above the other, They are provided with foramina, proc- esses, etc., for the accommodation or attachment of mus- cles, ligaments, blood-vessels and nerves. The anterior and posterior roots of the spinal nerves unite and emerge through the two intervertebral foramina, and supply through their numberless ramifications all parts of the body. Before the union of the posterior and anterior roots of the spinal nerves takes place, each posterior nerve develops a so-called gan- glion (a knot-like expansion of nerve-tissue, largely com- posed of gray matter), which is of oval form, of reddish color, and is located near the inner margin of the interverte- MECHANO-THERAPY. 141 bral foramen. These ganglia are central nervous systems on a small scale ; they are, as it were, sub-stations of nerve- tnergy. The physiology of the spinal nerves rests upon the general law first announced by Bell, that the anterior roots control motion, whereas the posterior roots control sensa- tion. Xerves that communicate with each other form what is known as a ple.rus. It is of great clinical value to remem- ber the exact location of the more important nerve-ramifi- cations of this kind. Two cords of nerve-tissue extend from the base of the skull to the coccyx symmetrically on each side of the ver- tebral column in front of the so-called lateral processes. These two cords are studded with numerous ganglia which represent distinct centers of nerve-energy, and from which and to which branches pass in diverse directions. These vertical cords, running from the base of the skull to the coccyx, with their many ganglia and branches, are what is called the sympathetic nervous system. Its fibers com- municate with the spinal nerves, supply the numerous arter- ies nourishing the ganglia and pass to the organs of the thorax, abdomen and pelvis, forming many important plexus. In addition to the motor and sensory spinal nerves and the ramifications of the sympathetic, there are some of the cranial nerves that are accessible to manipulation after they have emerged from the cranial cavity where they originate. The fundamental idea of all osteopathic and central- vibratory manipulations is to preserve or restore the foun- tain-head of all life-energy, i. e. the roots of the nerves that control all evidence of vegetable and trophic activity in the organism. Such preservation or restoration consists in regulating the nutrition (circulation) in and near the nerves, ganglia and plexus, and to correct deviations from the nor- mal as far as the surroundings of these nerves are con- cerned. All disease is supposed to be due to lack or per- version of nutrition of these nerve-structures or to changes affecting the soft and hard tissues surrounding them. The 142 MODERN PHYSIO-THERAPY. vertebrae may be in faulty apposition, causing the interver- tebral foramina to be changed in size and contour. This would cause pressure on the structures (vessels, nerves) passing through these openings. The result would be evi- dence of disease in the part or parts of the organism which are controlled by the affected nerves. Anatomical research has revealed the frequency of deviations from the normal anatomical standard of the spine. From the number of ab- normal spines it would almost seem as though the normal spine was purely a theoretical ideal. This fact furnishes the plausible basis for a system of pathology that recognizes no disease or diseased condition except inasmuch as it is secondary or sequential to changes in or near the spine and its adnexa. The fact that such changes might give rise to peripheral disturbances and that removal or correc- tion of the central lesion might sometimes result in a cure of the "disease," is the basis of osteopathy and, in imitation thereof, of so-callecl "vibratory stimulation." To the mind of the osteopathic optimist the probability assumes the hope- ful appearance of an actuality and he proceeds to erect upon this interesting and attractive generalization a system of medicine as complete and scientific as any medical mind could wish for. It would all be well, if the premises were sound and logical. That the osteopathic pathology explains much that we never dreamt of in our philosophy, there is no doubt. That osteopathy opened up a neglected field of clin- ical research, can not be denied. That osteopathic manipu- lations frequently produce results that fairly stagger the drug-dispenser, no one who is well informed will attempt to question. But it is likewise true that osteopathy is a gen- eralization from limited premises and that it is bound to fail in many cases because the principle is insufficient. The same cateris paribus holds good in regard to systematic vibratory stimulation. The therapeutic effect to be produced should suggest the technique of vibration. From previous considerations we know that mere contact is the simplest form of stimulation. MECHANO-THERAPY. 143 If we add pressure up to a certain degree the stimulating ef- fect is enhanced. Continued firm pressure finally tires a nerve and a sedative action is the result. If we continue firm pressure beyond the sedative dose, the activity of the nerve is suspended, i. e. inhibition of nerve-function takes place. Since vibration is a form of interrupted pressure, we may reasonably assume that effects analogous to those of continued pressure can be produced. That rhythmical in- terruptions are in themselves capable of exciting nerve- action, is plain. Thus, we may summarize the effect of central vibrations in the following classification : 1. Mild Stimulation (very short strokes) ; 2. Powerful stimulation (deep strokes) ; 3. Suspension of nerve-activity from overstimulation (long-continued deep vibration). CENTRAL STIMULATION is a subject worth investigating. We are still at the threshold. It behooves any and all of us to investigate carefully and help in the elaboration of this new and promising field of physio-therapeutic work. I will attempt to give the general landmarks of the subject as far as our knowledge of neuro-physiology and actual experi- ence in central vibration justify any statements. Theoretically, the idea of acting upon pathological con- ditions through the central nervous system or, to be more correct and explicit, through the sympathetic nervous sys- tem is in perfect harmony with the pathological view which looks upon all diseased conditions as being either due to over-nutrition (hypertrophy, inflammation, catarrh), un- der-nutrition (atrophy, degeneration), or perverted nutri- tion (ischemia, toxemia in the widest sense, abnormal cell- formation). At all events, the essence of disease is thought to be some disturbance of local or general nutrition. Since, however, nutrition is practically synonymous with blood- circulation, the idea of controlling (increasing, decreasing, altering) local nutrition resolves itself practically into the idea of controlling (stimulating, depressing, changing) the circulation in an affected region. The sympathetic nervous 144 MODERN PHYSIO-THERAPV. system is, to all intents and purposes, the auditing office of the commissary department of the organism. It controls the supplies furnished to the different parts of the body., The sympathetic ganglia and plexus represent chiefs in charge of the supplies of special departments. These heads or chiefs have clerks under their control who look after the supplies of small portions of the region superintended by the chief. For example : The sympathetic plexus that con- trols the nutrition of (circulation in) all the abdominal viscera is known as the solar plexus. From it are derived ten smaller nerve-plexus, known as the phrenic, cceliac, gas- tric, hepatic, splenic, supra-renal, renal, superior mesenteric, inferior mesenteric and spermatic plexus, whose sphere of control is suggested by their names. To stimulate the solar plexus means to increase the nutrition of (circulation in) all the abdominal organs. The synonymous character of "circulation" and "nutrition" is suggested by the terms "vaso-motor" and "trophic," which are likewise synony- mous and refer to the sympathetic nervous system. The "vaso-motor" nerves are the "trophic" nerves. Both names are interchangeable with "sympathetic" nerves. The function of the motor and sensory nerves is con- trolled by the sympathetic nervous system. The degree of their functional capacity is determined by the nutrition of their fibers and ganglia. Mai-nutrition of motor and sen- sory nerves means corresponding impairment of motion and sensation in the areas supplied by them. Destruction of these nerves means suspension of motion and sensation. The lymphatic vessels and glands, the heart, the lungs, the skin, in fact any and every part of the organism is con- trolled by and, therefore, can be reached and acted upon through the nervous system. This is the basic theory of central vibration. For the practical application of the prin- ciples involved the following classification of spinal centers or regions might be of some service. Vibration over the cervical vertebra (in the median line or on either side of the median line in the intervertebral A I ECU A. \O~THERAPY. 145 spaces) is capable of causing impulses to be communicated to the motor, sensory and vaso-motor nerves supplying the head, neck, arms and of the body as far down as the dia- phragm. It will be remembered that the cervical plexus is formed by the anterior divisions of the four upper cervical nerves, the brachial plexus by those of the lower four. In the sympathetic nerve-supply of the neck are some of the most important centers and ganglia, controlling (stimulat- ing, inhibiting) the blood-supply (nutrition) of the head and brain. Respiration and the function of the heart can be influenced through vibration in this region. At the sides of the neck the phrenic nerve (coming from the cervical plexus and supplying the diaphragm) and the vagus (from the eighth pair of cranial nerves) which supply motion and sensation to the organs of voice, and motion to the pharynx, oesophagus, stomach and heart, are accessible to vibration. VIBRATION-TABLE; FOR CERVICAL REGION. Circulation (face, head, brain) ) . i. to 6. ^ vertebn- (general) ) ' Eye, i. to 3. " " Heart (muscular tone), i. to 5. " " (rhythm), 2. to 4. " Ear, 6. to 7. " " Organs of voice (larynx etc.), i. to 3. " Mechanism of respiration, 3. to 5. " Thermic centers, , 2. to 5. " Glands (lower jaw), 2. to 3. " Diaphragm, 3. to 5. " Plexus (cervical), 2. to 4. " " (brachial) 5. to 7. " There are twelve dorsal vertebra". They practically rep- resent the location of sympathetic centers and ganglia which control the functions of the organs of digestion and assimi- lation. It is through vibration along this region that we can influence the splanchnic nerves and above all the great solar plexus. In moderately well-nourished or thin per- sons, vibration through the abdominal wall is capable of 146 MODERN PHYSIO-THERAPY. affecting the nerve-tissue of the solar plexus and its branches. The motor nerves of the lower extremities orig- inate in the dorsal region. We must not lose sight of the fact that the fine interlacement of nerve-fibers establishes many direct paths toward distant nerve-centers and ganglia, so that many subsidiary ganglia are found in the dorsal re- gion that are connected with the important ganglia in the cervical region and, as it were, serve as sub-stations. Thus we find quite a few sub-ganglia from the second to the seventh dorsal vertebrae that share in the control of the mechanism of respiration. VIBRATION-TABLE FOR THE DORSAL REGION. Stomach, 3. to 12. dorsal vertebrae. Relaxation of pylorus, 4. to 5. " Liver, 9. to 12. " Pancreas, 8. to 9. " Spleen, 8. to n. " " Intestines (small), I. to 10. " Peristalsis 9. to n. " Chill-centers (connected with thermic ganglia) s . . 7. to 8. " Kidneys, 6. to 12. " Diaphragm (through phrenic fibers of solar plexus), . n. to 12. " Lymph-circulation (through splanchnic nerves), . 5.1012. " Lower extremities 2. to 12. " The remainder of the vertebral column is made up of five lumbar vertebra, the sacrum and coccyx. The nerve- ganglia and plexus in this region control principally the functions of the large intestines and of the genito-urinary apparatus. An important thermic sub-ganglion is situated near the fifth lumbar vertebra. The nerve-centers con- trolling the sexual function in both sexes are distributed over the whole lumbar region and are closely connected with similar centers situated near the three lower dorsal verte- brae. It is of interest and importance to remember the uni- versal distribution of ramifications of nerve-fibers which directly and indirectly connect with the sex-centers and are closelv interwoven with the nerves of the skin. It is well MECHANO-THERAPY. 147 known that the sex-centers can be powerfully stimulated through the skin. Therein lies the physiology of the caresses and strokings which are so closely connected with the awakening of the sexual appetite. Many forms of sex- ual perversion can be thus explained, e. g. the flagellations of some religious individuals in the Middle Ages, who sub- stituted the erotic sensations produced by this form of vio- lent skin-stimulation for the sinful pleasures of the sexual act. VIBRATION-TABLE; FOR THS LUMBAR REGION. Intestines (large), I. to 4. lumbar vertebrae. Mechanism of micturition, I. to 2. " Sexual desire, .- 2. " Sexual mechanism, i. to 5. " " Kidneys, . I. to 3. " " Menstrual function, 2. to 5. " " (also 8. to 10. dorsal vertebrae.) Central vibration should always be supplemented by vi- bration of the periphery. Thus after stimulating the small and large intestines centrally, the operator should apply the vibrator through the abdominal wall to the small intestines, then to the large gut and finally introduce a suitable at- tachment and practice rectal vibration. Another example would be the application of vibration over the cervical ver- tebrae, and afterwards in the precordial region, for the re- lief of certain conditions of the heart. The lymphatics (the sew r ers of the body) are reached peripherally. Vibration over the lymphatic glands and along the course of the lymph-flow stimulates excretion through these lymph-canals. Thus drainage of the arm may be accomplished through stimulation of the axillary lymphatics, drainage of the leg through stimulation of those in the region of Poupart's ligament, etc. In order to prac- tice this form of medication it behooves the operator to re- freshen his memory by an occasional reference to some good text-book on anatomy. (Also see vibration-tables un- der PARALYSIS Part II of the book.) 148 MODERN PHYSIO-THERAPY. pq <; H c h <; pi PQ O X Pi H CO s 04 O MECHAXO-THERAPY. 149 Oscillation. Oscillation in variable degrees of intensity is practiced manually by masseurs. It is really an exaggerated form of vibration. It means a violent shaking up of a part, e. g. the abdomen, by the hand of the operator. Oscillation is nowadays practiced with the aid of a specially constructed instrument, called an "oscillator." The physiological effect and therapeutic indications are similar to those of other forms of mechano-therapy, notably Swedish movements and peripheral vibration. It manipulates the tissues en masse by a violent and indiscriminate shaking up. It is an excel- lent muscular tonic and can be frequently employed with advantage in breaking up adhesions and stretching con- tractured tissues. Oscillation of the whole abdomen is a splendid auxiliary in the treatment of habitual constipation. A thorough understanding of the principles of massage and vibration will enable the operator to employ oscillation at the proper time and in the proper way. In conclusion let me again say that the possession of a vibrating or oscillating instrument should not be a reason for employing vibration and oscillation indiscriminately in each and every case. Never lose sight of the indications in each case and the limitations to the use of vibration and oscillation. Beware lest you become a fanatic in theory and a buffoon in practice. Always try to comprehend the purpose, to understand the means, and to adapt the latter to the former intelligently. Quidquid agis, prudenter agas et respice finem! 150 MODERN PHYSIO-THERAPY. CHAPTER VI. FORCE AND FORCE-MODALITIES. Tug true student of nature is not satisfied to merely ob- serve the phenomena of activity around and within him. He inquires into the reasons of things and tries to establish the connection between causes and effects. In attempting to do so he is obliged to analyze the manifestations of ac- tivity and find the laws which govern them and the man- ner in which these laws operate. He knows that nature represents the sum-total of the things that are. He is aware that these things possess certain properties which determine and influence their relations to their surroundings, and that these properties are the manifestations of force in- herent in the things that are. He knows that the things that are, represent matter in different states of aggregation and composition and necessarily possess inherent energy. To .him existence means the mutual relation of matter and force. Thus the study of this relation is in reality the very essence of natural philosophy. That which we call "light" is an evidence of some ac- tivity. The energy inherent in that compound of matter which we call "sun" becomes manifest and is perceived by that compound of matter which we call "organ of sight." This evidence of activity begins and ends with a manifesta- tion of energy inherent in matter. The two compounds of matter assume a certain relation to each other. This re- lation must affect other existing things which are inter- posed between one compound and the other, between the sun and the eye. This relation is real, not a figment of the mind, not an illusion. That which is interposed between FORCE AND FORCE MODALITIES. 151 two compounds of matter must likewise exist and must therefore, be matter. If it were not, it would be non-exist- ent. This would be absurd. It may be air, it may be gas. It must be matter of some kind. For the purpose of giving a name to matter in its simplest non-classifiable form, not any special kind of matter, but matter pure and simple, the term "ether" is used by physicists. Space would be a vague, meaningless abstraction unless we imagine it filled with a universally present, imponderable substance of some kind which represents existence pure and simple, /'. e. matter in its simplest and most elementary form. It makes space an actuality and gives to force-manifestations a medium of transmission. It is the carrier of the force-manifestations. Inasmuch as ether makes space a physical reality, it is divisible in the same sense in which distance between two things is divisible. We can imagine the distance to be divided into two, five, ten, fifty, a hundred, a thousand, a million parts. This would mean a division of the quantity of ether. There would necessarily be a physical limit to division. The smallest imaginable particle of ether is the molecule of ether or ethereal molecule. If ether en masse receives and transmits force-manifestations, the ethereal molecule must necessarily do so because it is what in the aggregate constitutes ether. We, therefore, look upon the ethereal molecule as being the real carrier of force-mani- festations. The only conceivable mode of transmission is more or less rapid motion of the molecule. It changes its relation to the neighboring molecules which receive the im- petus and also react upon it by motion. The rapid motion of the molecule is known as vibration or oscillation of the ethereal molecule. We can imagine an impetus to engage a whole series of molecules and be thus transmitted to the next series. From their resemblance to the motion of waves this form of serial motion has been called undulation. We are prepared to look upon force as a necessary prop- erty of matter. It is its inherent energy which is capable of causing ethereal oscillations and undulations, the latter 152 MODERN PHYSIO-THERAPY. being its mode of transmission. There is no limit to the variety of oscillatory and undulatory motion of the ethereal molecules. The oscillatory movement may be more or less rapid, may be fine or coarse. The undulations may be slight or well-marked, may be long or short. This gives us the concept of wave-length or the length of the series of molecules which is set in motion by an impetus before the latter is received by the next series. It is this variation of ethereal oscillation and undulation which modifies the manifestations of inherent, crude, ele- mentary force and gives them the specific character of light, sound, electricity, heat, etc., etc. All these manifestations of activity transmitted by the ethereal molecules are modali- ties of the original elementary force. In this sense we speak of light, sound, etc., as being force-modalities. They are not forces but modalities of the same elementary force, the modifying element being the motion of the ether molecularly and serially. This conception of force and force-manifesta- tion furnishes the only plausible explanation of the phe- nomena of light, sound, heat, electricity, radio-activity, mag- netism, animal magnetism and suggestion. It brings these diverse forms of activity under the general head of force- modalities. The modus operandi of force-transmission is easily un- derstood. The impetus which emanates from matter in the form of a manifestation of energy is carried from molecule to molecule, from series of molecules to series of molecules, the manner of molecular oscillations and serial undulations giving to the impetus a specific character, e. g. light, sound. If a stone is dropped into water, the impetus communicated to the body of water will be seen to travel through the lat- ter, giving rise to circular waves, emanating from the cen- ter and traveling towards the periphery. A cork dropped into the water will not be carried along by these waves (un- dulations), but will bob up and down. This example is to illustrate the idea of force-transmission through a medium which as a whole remains stationary. The molecules of FORCE AND FORCE MODALITIES. 153 water move, but their motion is a vibration or oscillation around their normal point of rest as a center. These mole- cules move and gradually return to their position of rest. If a rope is suspended and the lower end is given a sudden jerk, the impetus will be seen to travel upward in the form of waves formed by the rope. The rope is relatively sta- tionary. The impetus travels. Vibration of the molecule means motion around a given point of rest. Undulation of z series means motion around a given line of rest. Force is eternally and universally one and the same. It only differs in its modalities. Matter can likewise be con- sidered eternally and universally one and the same. It only differs in its states of aggregation. Ether permeates space, even the space occupied by matter whose state of aggrega- tion is such as to be perceptible by our organs of sense, e. g. a piece of lead which is seen and felt. The state of molec- ular aggregation of matter must necessarily affect the molec- ular ethereal vibrations within it. If an impetus has been received and is being transmitted by the molecules of ether, the vibrations of ethereal molecules can not help being im- peded to a certain extent by the gross or macroscopic media which the ether permeates, e. g. air, smoke, wood, metal or imy kind of matter which may be within the path of ethereal oscillations and undulations. These interposed media may serve as obstacles, e. g. a layer of lead to the X-rays, or as conductors of force-transmission, e, g. glass as a conductor of light, copper as one of electricity. The physical attributes of matter which give to the latter its power of conducting, altering, intercepting these vibrations are not clearly under- stood, although, as suggested before, the state of aggrega- tion of matter seems to give to the latter its relative fitness as a conducting or intercepting medium for different kinds of force-modalities. One state of aggregation may not offer any resistance to one form of molecular vibration, e. g. a piece of cloth to the X-rays, while it will completely arrest vibrations of another kind, e. g. vibrations of light from the solar spectrum. Certain interposed media may completely 154 M(I|):-;R\ I Mi vsio-Tn i-.R.M-y. stop vibrations of sound, e. g. a brick wall, while they would not interfere at ail with the force-modality emanating from the generator of a wireless telegraph-instrument. These points seem trivial upon first sight. Closer investigation will reveal their importance as auxiliaries in the solution of many an occulr physical problem. "Force," says Moleschott, "is the necessary property of matter, inseparable from the latter and inherent in it from the very beginning." Matter everywhere is, as it were, charged with it and constantly, under given favorable con- ditions, proves the presence of force. Matter possesses at all times the property of communicating impulses to the ether and causing these impulses to be carried by vibrating ethereal molecules. The latter give rise to different force- modalities. The change of elementary force into a special force-modality and the change of one modality into another are generally admitted scientific facts (Kraftumwerthung). Thus the elements of one modality are the elements of every other modality. Magnetism is converted into electricity, into X-ray radiations, into light-phenomena, into heat and so on. It would carry me beyond the confines of my sub- ject to refer, even in a brief way, to the physiological pos- sibilities of this view of force and force-modalities. That the sum-total of energy present within our solar system is in reality reflected sun-energy, that the sun is the original source of all force, is not altogether improbable. This view would furnish a modern scientific basis for the ancient sun- cult of Zoroaster. It would be in accord with the chron- ological events of the creation as related in the Genesis. The first act of creation refers to the sun upon whose phys- ical activity the existence of all other things depends. From this heliologic point of view the energy of matter is reflected sun-energy or a^charge received and re-supplied by the ac- tivity of the sun (helio-pantheism). Since force is that property of matter by which matter keeps the ethereal molecules in a state of agitation and since matter without this constantly active property can not be FORCI: AND FORCE MODALITIES. 155 conceived, we are prepared to consider all matter necessarily in a state of radio-activity, meaning by the latter term the property of imparting impulses to the molecules of ether by which the latter are made to oscillate and undulate. The force-modalities of an excited X-ray tube or of radium are coarse illustrations of radio-activity. There is no doubt that millions and millions of different force-modalities are con- stantly active without us and within, too fine for our coarse senses and means of investigation to discover. We have hardly learned the alphabet of this wonderful subject. We know nothing concerning the radio-activity of the human body and of every molecule within it. The neuron (nerve- cell) is radio-active and causes impulses to be communicated to the ethereal molecules. Within the range of this ethereal oscillation there is some particle of matter, some nerve-cell, some neuron whose state of aggregation and composition qualifies it to respond to these ethereal oscillations, just as the ear responds to sound, the eye to' light. Thus the second neuron vibrates in harmony with the first. What more plausible explanation can be given of the phenomena of telepathy and suggestion? What else can thought be ex- cept a form of radio-activity of brain-cells? In no other way can mental or psychic phenomena ( memory, conscious- ness, dreams, etc.) be explained. It can no longer be doubted that every molecule of the human body possesses some form of radio-activity. How many different forms of radio-activity the body possesses, what relative degree of radio-active force is present in dif- ferent molecules, what influences may affect the quantity or quality of radio-activity, whether there is but one com- plete force or a duality of forces (positive, negative), what the relations of these dual elements are, all these ques- tions are open and will remain so for some time to come. That certain radio-active forces exist in the body and give rise to strange phenomena, is admitted on all sides. Not very long ago I saw a radiograph which had been produced by the radiating energy from the hand of a so-called mag- 156 MODERN PHYSIO-THKRAPY. netic operator. The photographic sensitive plate was placed in a black and yellow envelope and put on a table. A key was deposited on the outside of the yellow envelope. For twenty minutes the operator held his hands over the plate, the tips of the fingers pointing towards the key. The plate was developed in the ordinary way and showed a faint radio- graph of the key. The room in which the experiment was made was dark. The magnetic or radio-active force ema- nating from the man's hands is just as real as the radio- activity of an X-ray tube or of radium. I dislike the word "animal magnetism" because it savors of charlatanism. It is not an illusion or a deception, however. It suggests a form of physical energy which we are unable to account for, al- though the effects of its activity can be seen everywhere. The phenomena of individuality, genius, talent, suggestion, hypnotism, telepathy, love, passion, maternal or pre-natal impressions, heredity, idiosyncrasy and temperament must be classified under this head. For the sake of illustration I beg to quote a few exam- ples without, however, attempting to classify them or ac- count for them. A sleeping person can be awakened by some one looking at him or pointing at him even in a dark room. Moll reports the case of a young lady who had lost over twenty pounds in weight in less than six months. There was no other indication of anything being wrong. She was a blonde with soulful blue eyes and a most amiable disposition. Upon inquiry it was ascertained that for six months she had slept with her younger sister, a brunette with snappy black eyes and a very positive disposition. The younger sister happened to be sent off to school and slowly but surely the older one regained her weight. Similar cases, especially among married people, have frequently been re- ported. Children often show a dislike for some strange person, there being no apparent reason for such dislike. The touch or the handshake of some people is distasteful. Even the lower animals are affected by these mysterious forces. The old adage, "Speak of the devil and he is sure to appear," has reference to the appearance of a person who FORCE AND FORCE MODALITIES. 157 is just being spoken of. It can be explained on the basis of ethereal oscillations. Presentiments, premonition and the telepathic influences of mind over mind likewise become in- telligible if explained on the ground of radiation. That the body radiates heat, is plain. That it has a phos- phorescence of its own and throws out rays (n-rays) re- sembling those of light, is believed by many. The influence of rays of short undulation and very rapid oscillation (ultra-violet field of the solar spectrum) on the sex of plants and animals is a strange biological phenomenon. What bearing has this theoretical discussion of force and force-modalities on the practical application of Physi- ological Therapeutics? In order to understand light, electricity and other phys- ical agents and their relations to each other, it is necessary to try and get a glimpse, however faint, into Nature's work- ' shop. That the greatest achievements along physical and biological lines are still to come, there seems to be no doubt. It behooves us to sharply define our concepts of radio- activity and its place in nature because it is the connecting link between matter and force, as we are at this late day prepared to admit. Suggestion is a subject which physicians usually avoid ; yet it is of overtowering importance, and should, therefore, be freed from the ballast of misconcep- tions and quackish notions with which it is encumbered. It should be studied and worked out like all other problems in natural history. The same might be said about somatic radio-activity (animal magnetism) which is a physical real- ity and offers an almost boundless territory for research and experiment, even in a therapeutic direction. By solving these problems we will get closer to the true inwardness of life, of nature, of our own place in the vast domain of exist- ing things and might lift the veil that hides the Whence? Where? and Whither? from the eyes of mortal man. The acquisition of knowledge for the improvement of our fel- low-men, or even for the sake of possessing knowledge, is the one ideal that makes life worth living. 158 MODERN PHYSIO-THERAPY. CHAPTER VII. THE THERAPY OF LIGHT. "Water is great; air is greater; but the greatest of all is light." PETTENKOFER. "Light is indeed a priceless gift of heaven. It is the life of every living thing." SCHILLER. "Mehr Licht!" GOETHE. AMONG the many brilliant achievements of modern scientific medicine the therapy of light occupies a com- manding position. Even the immortal work of Roentgen has not been able to obscure the brilliancy of the labors done by Finsen and his pupils. The practical results accom- plished by the scientific application of rays of light have gained for these methods a high and undisputed place among the therapeutic resources of to-day. In view of the fact that we have not as yet advanced beyond the threshold of this era of great achievements, it behooves us to add our mite to the sum-total of knowledge and experience and thus help in the elaboration of the vast possibilities which the subject offers. Among the various physical or mechanical thera- peutic agents known to modern medicine light is, in point of clinical usefulness and therapeutic efficacy, surely en- titled to a foremost place. Together with water and air it represents a disease-preventing and disease-curing factor of overtowering importance. It is one of the elements with- out which life is impossible. Upon this point all scientific men are agreed. Not all physiologists, however, seem to realize that the hygienic importance of light is not greater than its curative power. This is a categorical statement THE THERAPY OF LIGHT. 159 which I hope to demonstrate if only to stimulate thought along the lines of rational therapeutic methods. In considering light as a health-preserving and health- restoring factor, it behooves us to, in a general way, try to understand its enormous importance in conjunction with different phases of physical life, and more especially to ap- preciate its influence upon those changes in the animal economy which are included under the head of "Metabol- ism." If the absence of light is capable of causing disease, it is not unreasonable to assume that the presence of light will prevent disease. We may begin our reasoning by stat- ing that the human body requires light for its sustenance. The most vital of all physiological processes, namely respira- tion, both cutaneous and pulmonary, is directly affected by the presence or absence of light. The quantity of oxygen which is taken up by the tissues is directly dependent upon the relative amount of light to which the body surface is ex- posed. During the day the human body takes in more oxy- gen and excretes a relatively greater amount of carbonic acid. This is due partly to the increased amount of oxygen in the air during the day, partly to the greater receptive and assimilative power which the body possesses under the in- lluence of light. When the sun, the great source of light, approaches the horizon and leaves the world to darkness and to the analyzing physicist, it seems as though all nature were lulled to sleep. Its voices are hushed, and man and beast are slowly rocked to rest in the cradle of universal silence. The evidences of activity gradually disappear. Darkness supervenes, and with it a desire to rest becomes manifest throughout the living creation. The human organism, which is a part of the living creation, shares in this general de- pression of vitality. Its machinery works under lower pres- sure. Physiological respiration becomes more superficial, assimilation less active and excretion more sluggish. The more finely organized the structure, the more characteristic the change which comes over it in the absence of light. Onlv +h<* lower form of life, the fungi and other forms of 160 MODERN PHYSIO-THERAPY. micro-organisms, thrive, their greatest antagonist, light, having temporarily withdrawn from the field of contest. In view of all these facts we can readily understand that condi- tions which are due to perverted metabolism or produced by the action of bacterial life, are necessarily or intimately de- pendent upon the presence or absence of light. The researches concerning the biologic importance of light in conjunction with the functions of the human organ- ism have indeed revealed many interesting facts. It has been shown that light will affect the contractility of proto- plasm. The red blood-corpuscles, the direction, speed and duration of the movements of certain infusoria and dia- tomes are directly influenced by light. The muscular ex- citation and activity of frogs has been shown to be much more energetic under the influence of light than in the ab- sence of light. It has been proven that the quantity of col- oring matter in the red blood-corpuscles increases and de- creases in accordance with the amount of light to which the animal body is exposed. That light is fatal to bacterial life, had been suspected by many observers long before the time of Finsen. As far back as 1870, Esmarch exposed his sur- gical instruments to the rays of the sun for the purpose of disinfection. Light, in fact r occupies the position of the uni- versal disinfectant because without it the purification of river water would be inconceivable. There is no longer any doubt that the pathogenic bacteria are affected by the action of light. Geisler exposed a culture of typhoid bacilli to the light of a thousand candle power arc-light and after three hours of illumination the growth of the culture had been practically suspended. Aufrecht inoculated various ani- mals with the bacilli of Milzbrand. diphtheria and tubercu- losis. The inoculated animals which were kept in the dark died within two or three days. Those exposed to the light usually resisted the effects of the inoculation. The beneficial effect of light as a germicidal factor and an oxypfenator is seen in cases of tuberculosis of the peritoneum in which an exploratory incision is frequently followed by distinct im- provement. THE THERAPY OF LIGHT. 161 In order to understand the therapy of light it is necessary to know something about the physics of light. If we cause the white light of the sun or of the electric arc-light to fall through a prism, the result is a splitting up of the light into its component rays. Technically the arrangement of the component rays of white light is known as the solar spectrum. It having been shown that the spectrum of the arc-light is practically iden- tical with that of the sun, the difference in the light being one of intensity and not of kind, the physical and therapeutic attributes of the solar and arc-light can reasonably be sup- posed to be the same. Clinical and spectroscopic observa- tions have confirmed the correctness of the supposition. The seven different colors or rays of light are red, orange, yellow, green, blue, indigo and violet. These rays are known as the visible rays in contradistinction to numer- ous forms of in-visible light-energy situated beyond either end of the spectrum (infra-red and ultra- violet rays). Some of the rays, notably those emanating from the red and more especially from the infra-red fields of the spectrum, produce heat and are, therefore, known as thermic rays. Other rays, particularly the yellow and green, are light- producers and are known as luminous rays. The rays of the blue, indigo, violet and more especially the (invisible) ultra-violet fields are capable of producing characteristic changes in the chemical composition of organic and inor- ganic matter and are commonly known as chemical rays. They are also called actinic rays. The most powerful chem- ical rays emanate from the ultra-violet field and are invisi- ble. Let us remember once for all that the term "ultra- violet" refers to the spectroscopic location of these invisible rays and not to any particular color. The view held by some ill-informed physicians that ultra-violet means in- tensely violet or a deep violet, is therefore, manifestly ab- surd. In the year 1893 Niels R. Finsen, of Copenhagen, Den- mark, published the results of certain biological researches 162 MODERN PHYSIO-THERAPY. in reference to the action of the different rays of the sun (or, for that matter, of the electric arc-light), more espe- cially of the chemical rays, i. e. light minus the thermic and luminous rays. The effects of the chemical rays play a most important part in the life-process of the whole creation. They are the motive power by which the metabolism of the living world around us is made possible, from the life process within the organism of the tiny insect to the re- generation of the vast bodies of water which carry the ex- creta of millions of people and yet furnish healthful drink- ing-water after the sunlight with its regenerating chemical rays has caused the messengers of decay and death to be- come carriers of life and health. The chemical rays are the most easily refracted rays. They are broken by the moisture and gases in the atmosphere and by the surface of the earth. The heat-rays are the least refrangible rays. Thus it is that chemical rays permeate the dark of night long after the heat- and light-rays of the sun have ceased to act. The fact that owls and cats see at night is attributed to the peculiar construction of their visual apparatus, which is acted upon by the chemical rays. Finsen was not slow in applying the lessons which his studies had taught him. His first attempt to apply light to diseased processes and tissues gave the sanction of science to the empirical therapy of light which had been in vogue since the days of Hippocrates; they marked the birth of modern photo-therapy as an exact science with a vast sphere of usefulness. The first scientific fact which Finsen gave to the world as a result of close observation and study at- tracted universal attention to him and his work. It per- tained to the scars of smallpox, which Finsen showed to be due to the disintegrating effect of the chemical rays of light. He reasoned that these scars could be prevented, if the pa- tient could be protected against the chemical rays. By ex- periment he proved that the chemical ravs will not penetrate red media, and proceeded to applv this fact practicallv by causing the windows of the sick-room to be painted red, by THE THERAPY OF LIGHT. 163 causing the walls of the room to be covered with red paper, in fact by interposing red anywhere and everywhere in order to intercept the chemical rays. Finsen achieved his first triumph when the results abundantly proved the truth of his statement. The principle of the red-light treatment of smallpox can be interestingly illustrated by a very simple experiment. Take a piece of sensitized paper and place on it a piece of red glass. Expose the whole to the sun's rays FINSEN'S DEVICE FOR CONCENTRATING AND COOLING THE RAYS OF THE SUN. for a little while and it will be found that the part of the paper under the glass has remained unchanged while the rest of the paper has become rapidly discolored. The marked germicidal action of the chemical rays prompted Finsen to apply them to infected skin. The class- ical example of a condition of this kind is lupus or tuber- culosis of the skin. Finsen devised an apparatus which would be adapted to this purpose. He concentrated these rays by eliminating the heat- and light-producing rays from 164 MODERN PHYSIO-THERAPY. the mass of light emanating from the generating source, which was either the sun or a powerful arc-light. By caus- ing the light to fall through a sheet of water, all the heat- rays were practically absorbed, and the light was rendered cold. By adding methylene-blue, potassium permanganate or certain other coloring agents to the water, Finsen en- hanced the effect of eliminating the red or heat-rays. At the same time he found that many of the light rays were lost. His idea was to get as compact a concentration of chemical (ultra-violet) rays as possible. These concen- trated rays were condensed by means of a suitable lens, and were directed upon or against the affected part of the body. Finsen found by spectroscopic analysis that the ordinary glass lens was unavailable because glass absorbs the chem- ical rays either entirely or to a large extent. He, therefore, substituted lenses made of quartz or rock crystal, which al- lows the chemical rays to pass. He found by experiment that blood absorbs chemical rays. The experiment by which he established this fact is too clever and interesting to be omitted. Finsqn's helpmate in his great work was his wife, who gladly offered herself as a subject for experiment whenever her distinguished husband, after experimenting on his own skin, desired further experimental proof for any of his investigations. Finsen placed a piece of sensitive r holographic printing paper in direct contact with the pos- terior surface of his wife's ear. He directed a beam of chemical light to fall upon the anterior surface of the ear. No matter how long the exposure was continued, there was no effect on the paper. After placing the ear between two thin pieces of quartz, rendering it anemic by pressure, he icpeated the experiment. The paper turned black within a few moments, showing that the blood had previously pre- vented the passage of the rays. This fact suggested to him the necessity of covering the part to be treated with a piece of rock-crystal in order to render the part bloodless. Fin- sen evolved step by step the technical details of the method which was destined to become so powerful a factor in the THE THERAPY OF LIGHT. 165 treatment of a variety of conditions. The essential features of a Finsen apparatus, therefore, are : a source of chemical light, a large condensing lens to concentrate the rays ema- nating from the source, a water-receiver through which the light passes and in which it loses all its heat-rays, a small condenser to collect the chemical rays which have emerged from the water, and a pressure-crystal to render the skin anemic. These essential features are, to a larger or smaller extent, embraced in all the devices which have been con- structed after the type suggested by Finsen himself. Finsen's original type was open to many objections. In using the electric arc-light, Finsen constructed light-genera- tors of tremendous power. He speaks of 80 ampere arc- lights. It is needless to refer to the clumsiness and dangers of such an apparatus. An equally justifiable objection is the fact that the peculiar construction of the original Fin- sen lamp involved great loss of light. Over 60 per cent of the light produced by the apparatus were lost. Finsen sus- pended the 50 or 80 ampere lamp from the ceiling, placing four or six telescopic tubes at an angle below the lamp, one patient being treated under each tube. It stands to reason that more than half the light of the lamp is lost in this way because only a comparatively small portion of the light is received by the tubes. A perusal of Finsen's book ("Ueber die Wirkung der concentrirten chemischen Lichstrahlen") will show the principles underlying, as well as the imper- fections involved in Finsen's original lamp. The heat-pro- duction of so high an arc is also a factor of some conse- quence, not to speak of the expense of constructing and maintaining the apparatus. To make the Finsen idea practically available, many at- tempts have been made to modify, or rather to simplify, the original device. The best known modification is prob- ably the portable Finsen lamp devised by Sequeira and gen- erally known as the London Hospital Lamp. It is simple in construction, easy to handle, neat in appearance and possesses considerable therapeutic power. It furnishes a 166 MODERN PHYSIO-THERAPY. cold light, the cold water constantly circulating in front of the powerful arc-light. Another very useful modification of Finsen's device is the hand-lamp invented by Kjeldsen, of Copenhagen, and known as the Dermo Lamp. Katten- bracker, of Spandau, used one of Kjeldsen's lamps for the purpose of studying the effect of light on germ-life. The lamp is held by the operator. It is supplied with hollow iron-electrodes, through which cold water constantly flows, rendering the light cold. The cone of light is small, but LONDON HOSPITAL LAMP. qualitatively powerful. Kattenbracker used the light from this lamp at a distance of 10 centimeters (arc 5 amp. 40 v. direct current). He used 15 p. c. nutritive gelatine as a cul- ture-medium for gonococci and tubercle bacilli, 2 p. c. glycerine-agar covered with sterilized blood-serum for typhoid and other germs. The germs were grown in sur- face-cultures on plates at a temperature of 22 C. The con- trol-cultures were kept at 35 C. to allow for the slight rise in the temperature of the light from the lamp. Inoculation from the rayed cultures on glycerine-agar was made after forty-eight hours and the new culture kept at a temperature THE THERAPY OF LIGHT. 167 A "DERMO" EQUIPMENT. v and w are the rubber tubes for carrying (supply and waste) water to and from the lamp. The electrodes are iron and hollowed out to allow the water to circulate. h is the handle of the current-controller (). MS the current-switch, k is the fuse-box. m is the ammeter. / (l, 2, 3) is the current- supply. The wires from / 2 represent a loop in the circuit to prevent the formation of an arc in the lamp unless the water is flowing. The pressure of the water distends the rubber tube and by an ingenious arrangement completes the circuit. 168 MODERN PHYSIO-THERAPY. of 35 C. for forty-eight hours. The relative viability of the new culture was taken as a criterion for the relative germi- cidal power of the light. Typhoid Bacillus. After an exposure to Kjeldsen's light lasting one second there was no effect. After three seconds growth markedly impaired. After thirty seconds vitality almost suspended. After sixty seconds culture was dead. Comma Bacillus. No effect after five seconds. Impair- ment after thirty seconds. Death after two minutes. Tubercle Bacillus. Slight impairment after five seconds. Marked impairment after sixty seconds. Death after two and one-half minutes. Micrococcus Gonorrhoicns. Slight impairment after five seconds. Marked impairment after thirty seconds. Death after two minutes. Bacterium Coli Commune. Impairment after thirty sec- onds. Death after two minutes. Streptococcus Pyogenes. Impairment after thirty sec- onds: Death after three minutes. Anthrax. Impairment after five seconds. Death after thirty seconds. In the types of Finsen-lamps recently employed the luminous rays are not eliminated. Finsen's subsequent ex- periments have shown that exclusion of the light rays is not essential. I am even inclined to think that the presence of the light rays is not only not objectionable, but rather de- sirable. Light has a regenerating and germ-killing effect and likewise a strong affinity for oxygen. Its presence would, therefore, rather tend to enhance the action of the chem- ical rays. The principal thing is to get rid of the heat rays. What is the physiological action of the chemical light? If a beam of concentrated chemical light is allowed to fall upon healthy skin, the eventual result will be an erythema followed by much local irritation, dermatitis, molecular death and desquamation. The tanning of the skin in the summer is the result of the deposition of pigment in the skin. Pigment is nature's safeguard against the destructive THE THERAPY OF LIGHT. 169 action of the chemical rays, the latter being absorbed by it. Chemical light seems to affect the procreative function of plants and animals as far as the sex-production is concerned. Chemical light favors the production of males. The germ- killing power of chemical light has been proven beyond a doubt. It has a strong affinity for oxygen. It produces a disintegrating effect upon living tissues. The greater the resisting power of the tissues, the less intense will be the action of the chemical rays. Since morbid tissues are less viable than the normal, the destructive effect of the chem- ical rays upon the cutaneous tissues wherein tubercle-bacilli or other germs have found lodgment, can be readily under- stood. The treatment of lupus is the classical example of the physiological action of Finsen's rays. Their germ-kill- ing power strikes at the very essence of the affliction. They stimulate healthy action by attracting oxygen to the part. The morbid tissues of the afflicted portion are disintegrated by the rays. In this way a healthy reaction is set up, which tends towards restoration of the normal condition. The consistent and persistent use of the Finsen lamp is indi- cated in all parasitic skin-diseases. Lupus, sycosis, tinea, certain forms of chronic eczema, psoriasis, disease of the hair follicles, furuncle, carbuncle, alopecia areata, etc., fur- nish a rich field for successful clinical work. What degree of clinical usefulness may be attributed to these rays in the treatment of internal diseases, we are not as yet prepared to say. That the body is practically translucent or can be made so, can not be questioned. It is needless to point out the enormous importance of this fact in connection with the possibilities which chemical light offers in the treat- ment of tuberculosis of internal parts, especially in cases of incipient tuberculosis of the apices of the lungs. It may not be amiss to call attention to two interesting facts which seem to have been established through the biological researches of Finsen : i. Pigment in the skin absorbs chemical rays. The more pigment in the skin, the smaller the amount of chemical 170 .MOD::RX light which penetrates into the interior of the body, the less disinfection of the interior. Since anerobic germs thrive in the absence of light, we may reasonably suppose that the tendency toward tuberculosis is in direct proportion to the amount of pigment in the skin. The negro is notoriously a ready victim of the tubercle bacillus. 2. The plasmodium malaria? becomes inactive in the ab- sence of light. This has been shown experimentally. If light is excluded from the skin of a malarial patient, the malarial attack is modified or even aborted.. This has been demonstrated by the darkness-treatment of malaria adopted by American army surgeons in Puerto Rico. The treatment consists in confining the patient in a dark room for many days. Corroborative evidence is furnished by the fact that malarial attacks hardly ever occur at night, and by the addi- tional fact that the negro is practically free from malaria. (These conclusions are not altogether above criticism. See MALARIA.) Let us not forget that the mechanical devices which thanks to the genius of Finsen have assumed so important a place in our therapeutic armamentarium, are at best but poor substitutes for Nature's own light-producer, the sun. Sunlight that greatest and cheapest of all therapeutic agents how little the average physician appreciates its curative power ! The healthy human body needs it, the sick human body imperatively demands it. It is the beginning of hygiene in health and disease. It is a necessary condition of life under any and all circumstances. It is to the skin what oxygen is to the lungs. Life is impossible without either. In cases of tuberculosis pulmonum treatment is not complete unless sunlight is included. The skin performs a compen- satory function for the disabled and impaired pulmonic apparatus. In all chronic diseases the importance of sun- light, especially the light of the morning-sun which is rich in chemical rays with a comparative scarcity of thermic rays, can not possibly be overestimated. In the times of Pericles the daily sun-bath was as much a necessary health-measure THE THERAPY OF LIGHT. 171 as the ablution of the hands. This advanced and enlightened age of ours would do well to turn back to the days of Hip- pocrates and learn the eternal and immutable principles which in our busy evolution of a thousand unimportant de- tails, we have no time to remember. The helio-therapy and solarium of the old clinicians served an admirable purpose and deserve to be revived wherever opportunity or space will permit. The clinical uses of the thermic rays are suggested by the physiological action of heat. Wherever and whenever heat is indicated, the thermic rays will answer the purpose. The ordinary incandescent globe is a splendid source of dry heat and has recently risen to a high plane of clinical im- portance through the labors of Dr. A. W. Minin, of St. Petersburg, whose heat-reflector (blue incandescent globe of suitable candle-power in a parabolic reflector) is a sim- ple and, withal, an extremely useful device. It is neat, sim- ple, clean, easily manipulated and meets an almost endless number of clinical indications. It is more than the old-fash- ioned flaxseed poultice without the bulk, filth, labor, stench and other disagreeable features of the latter. The color of the globe is what gives to this light its pain-relieving action. Minin insists upon spectroscopic examination of the blue globes used to make sure of the presence of a large per- centage of blue light. The following points indicate in a general way the sphere of clinical usefulness which might reasonably be attributed to Minin's device : Minin showed that an incandescent light placed in a parabolic reflector could be employed to furnish dry heat, the calorific radiations giving to this form of application a remarkable penetrating power not possessed by any other means of producing hot air. In addition to this Minin availed himself of the peculiar effects which blue light is capable of producing on the sensory nerves. Blue, indigo, and violet are the visible chemical rays. They are not equal to the invisible actinic (ultra-violet) rays in germicidal power or in affinity for oxygen. They are sedative, while 172 MODERN PHYSIO-THERAPY. the actinic rays beyond the violet field are distinctly stimu- lating and even irritating. No one has ever heen able to account for this difference in a strictly scientific way. The Minin light is poor in ultra-violet radiations and rich in visible chemical rays. The luminous rays are comparatively scant, while the calorific rays abound. Thus it is plain that the Minin idea has nothing in common with the Finsen light. The object of the Minin light is to radiate deeply penetrating dry heat and to produce visible chemical rays. Therein lies the therapeutic and clinical value of Minin's device. The cutaneous hyperemia which follows an application of the thermic rays produced by Minin's device, stimulates the circulation of the areas treated, unloads the veins, stimu- lates the functions of the lymphatics, depletes the deeper structures and accelerates and intensifies local metabolism. In this way toxic material and inflammatory products are excreted or absorbed, the nutrition of the part is regen- erated and a powerful impetus given in the direction of the restoration of normal conditions. The peculiar change in the appearance of an ulcer or an abraded surface which has been exposed to thermic rays is due to the coagulation of the albumen which gives the surface an appearance as though a delicate skin had formed over it. The penetrating character of Minin's heat rays makes them available when other forms of dry heat, which explode on the skin or in the subcutaneous tissues, would inflict unbearable torture and eventually burn and destroy the tissues. Minin's device carries the beneficent effects of dry heat into the deep tis- sues. The effects on the local circulatory, metabolic and absorptive activities are most profound. In cases of deep muscular rheumatism (for instance, lumbago) the Minin light is, for the reasons given, one of the very best thera- peutic agents. The blue color of the globe gives to the light its wonder- ful sedative power. The Royal Mausoleum at Charlotten- burg, in Germany, has a reputation of being a veritable THE THERAPY OF LIGHT. 173 shrine where persons with shattered nerves can find peace and comfort. The story goes that the spirit of the sainted Queen Louise, the idol of the German people, hovers about this place and brings peace and happiness to those who seek refuge within the hallowed walls where the mortal frame of that angel of peace has found its last resting place. Physi- cians for science is brutally truthful attribute the seda- tive effects to the mellow blue light with which the magnifi- cent stained windows flood the interior of that historical place. Finsen explains the quiet and peace of the evening hours by the deep blue light emitted by the canopy of heaven. Many experimenters in hypnotism use blue light to enshroud the organisms of their subjects with the tranquility which facilitates concentration and suggestive control. I have demonstrated the sedative effects of blue light by plac- ing a Minin reflector ten feet in front of a person who is comfortable seated, and is told to rivet his eyes on the blue light in front of him. The average person falls asleep within five minutes. In the cutaneous tissues the sedative effect of blue light shows itself by a complete suspension of sensation. This fact makes blue light a local anesthetic with a great range of usefulness, especially in minor surgery and in dentistry. In emergency surgery blue light not infrequently takes the place of the hypodermic syringe. A few clinical examples will serve to illustrate the use- fulness of the Minin light. Discomfort and pain in the region of the stomach or radiating from the epigastrium, nausea or an uncomfortable sense of fulness in the stomach due to the presence of gas or presenting itself as a local expression of a general neuras- thenic state, or due to a neurosis of the stomach, can be eas- ily and quickly relieved by an application of blue light, the patient resting comfortably on his back and exposing his epigastrium to the radiations from a Minin reflector, which is placed over his stomach. Probably in no other variety of clinical cases is the sedative action of this light so charac- 174 MODERN PHYSIO-THERAPY. teristic as in the conditions named. Relief follows immedi- ately, and is accompanied by a sense of rest fulness of the whole system, the patient not infrequently lapsing into a quiet sleep. In the case of a physician who was badly shaken up in a railroad accident and suffered from severe pain in the muscles of the chest and soreness and anxiety around the heart I suggested the use of the Minin light on the exposed anterior surface of the chest. Relief was prompt and com- plete. In a case of severe contusion of the lumbar region, due to a railroad accident, the Minin light likewise was of great service. Motion of the lower extremities was painful and difficult, owing to the injury inflicted on the soft tissues surrounding the lumbar spine. I used the Minin light on the man's back every other day for a month. The cure was complete. It is but fair to state that each illumination was preceded by vigorous vibration of the lumbar region. I attended another physician who suffered from intense pain around the rectum, indicating an acute inflammatory condition in the circumrectal cellular tissue, with a proba- bility of abscess formation. The pain was most intense and had completely prostrated the patient. He remained under treatment three days. Each day he exposed his buttocks and anus to the light from a Minin lamp for one hour. The pain was relieved by the first treatment. After three treatments every vestige of the inflammatory condition had disap- peared. This case illustrated the remarkable absorptive power of the Minin light. A patient presented himself with a distinct bulging on the anterior chest wall in the center and slightly to the left of the sternum. His physician had told him that the swell- ing was in all probability due to an aortic aneurism. There was considerable precordial distress, frequenly aggravated by shooting pains. Reserving a diagnosis until some future time, I began to make applications of blue light, and suc- ceeded in giving the man a good deal of relief. The nature of the trouble was not clear to me, although I could not THE THERAPY OF LIGHT. 175 make up my mind to accept the provisional diagnosis made by the other medical attendant. The man returned day after day on account of the great relief which the blue light gave him. After a dozen applications of blue light the symptoms of a developing muscular abscess were too plain to be mistaken. A large abscess was eventually opened. Recovery was rapid and complete. In the treatment of chronic ulcers, chancres, etc., much good may be expected from the use of the Minin light. I have seen an immense varicose ulcer of twenty years' stand- ing heal up under blue light treatment. In cases of bubo the Minin light is of great service to abort the inflammatory process or to accelerate abscess formation. I remember a case of Hunterian chancre of the lower lip, with consider- able local disturbance, glandular involvement, etc. A local skin specialist had treated the patient without much benefit. The sore seemed to be of the -phagedenic variety and had recently become very painful. The seat of the trouble was exposed to the light from a small Minin lamp, the rest of the face being covered with towels. The patient was treated daily for thirty minutes. After the first treatment the pa- tient had no more pain ; after the third treament the sore showed signs of a favorable reaction ; after the eleventh treatment the patient was locally well. There are hardly any limitations to the therapeutic uses of the Minin light. By restoring the physiological tone of the affected area, by stimulating and correcting metabolism, by relieving pressure and promoting absorption the Minin light is useful in all conditions characterized by lowered vitality, by local auto-intoxication, passive congestion, etc. As a local pain-reliever it stands without a peer. All the various, much advertised incandescent lamps of high power, placed in a reflector or hood, are but imitations of the simple but withal powerful device originated by Minin. 176 MODERN PHYSIO-THERAPY. THE ELECTRIC-LIGHT I>ATH. After all that has been stated concerning the uses of various forms of light we are prepared to understand and appreciate the importance and usefulness of a mechanical device which enables use to make practical use of all tlie various physical agencies which are included in light. The light of the electric arc has approximately the same spectro- scopic composition as sunlight. The light of the incandes- cent globe is rich in thermic rays. Thus we are prepared to look upon the electric-light cabinet as a valuable addition to our therapeutic armamentarium, combining as it does, the power of the various rays in the destruction of disease- germs, in the re-establishment and stimulation of physiologi- cal metabolism and in the performance of the many im- portant functions of light in and on the animal economy. As a producer of copious diaphoresis 1 the electric-light cabinet rivals the dry-heat cylinder. Winternitz states that since the introduction of the light-cabinet he has practically abandoned the hot-air cylinder. The light-bath produces sweating without the intense heat of the hot-air apparatus. The light-bath is, therefore, indicated in all cases to which the dry-heat apparatus is adapted. Whenever cutaneous excretion is to be stimulated, the dry-heat cylinder, and, therefore, the electric-light cabinet will do the work. Either will alter, stimulate and rectify metabolism promptly. Either will augment absorption, stimulate the appetite, and help the organism to rid itself of all kinds of deleterious gases, vapors and fluids. The following statistical list of diseases, with the percentage of cured cases added, is taken from the reports of one of the numerous German photo-therapeutic institutions, and shows the clinical importance of the light- bath more eloquently than any physiological and therapeutic argument could possibly demonstrate it. The cases were all treated in the electric-light bath. J In the second part of this book frequent reference is made i<> the electric-light bath. This invariably refers to the incandescent- light bath unless the arc-light bath is spoken of as such. THE THERAPY OF LIGHT. 177 NAME OF DISEASE No. of Cases... Cured Much Im- proved 1 K i r Rheumatism TT6 8r V) Gout 86 e-J 11 " Deformative 3 Neurasthenia and Hysteria (nervous disorders) 87 4S *I 6 61 6 16 Obesity fr> TO 12 Asthma 49 4.O Gonorrhea and consequent disorders 18 20 TK Heart disease ?6 g Fatty Degeneration of the Heart W 20 I"7 Sciatica ' ^2 ->8 I Bronchial Catarrh and Emphysema -8 IO 18 Neuralg ia 24 6 17 I Ulcus Cruris Varicosum 2 3 IO 7 6 Stomach and Intestinal Catarrh 2O E JC Mild Affections of the Liver 2O IO 7 Affections of the Knee-joint 15 IO Nephritis 15 It: Lumbago 14 Catarrh of the Ear and Deafness J 4 I g Nasal Catarrh and Affection of the Larynx 17 c g Anemia 12 12 Diabetes IO IO Headache . ( Chronic Constipation 4. I 2 Professional Illnesses 3 2 I Erysipelas I z Influenza 7 2 2 Ulcus Molle I I Skin Diseases (Herpes, etc ) 63 24 7-1 6 Tabes 40 7 33 The following table shows the results of light-treatment in an- other one of the German institutions : NAME OF DISEASE No. of Cases... Cured g o s i* t _ -=r No Result Neurasthenia 23 4 9 IO Myalgia 14 14 Psoriasis Luetica i I Psoriasis 3 I i I 7 I 2 Chronic Rheumatic Arthritis 2O 7 IO I Chronic Muscular Rheumatism is IO Gout 2O 9 9 2 Neuralgia q 5 2 2 Abscess 4 i 2 T Influenza i i Furuncle 2 2 I I Pru ri go . . I I Plethora 2 I I Meningitis Spinalis I Lupus I I 178 MODERN PHYSIO-THERAPY. It behooves me to emphasize the importance of the light- bath in the treatment of wounds, injuries, and also as an ad- junct in the practice of operative surgery. Wounds under the influence of light heal promptly and without much local disturbance. In selecting an electric-light cabinet the physiological effect to be produced should not be lost sight of. In the arc-light cabinet the chemical rays abound. In the incandescent-light cabinet the heat-rays predominate. In addition to this it is important to remember that dis- tinctly local conditions are best treated in a cabinet cor- responding in size to the part to be treated. Electric-light cabinets and cylinders are made in all shapes and sizes. ECLECTRIC LIGHT BATH FOR SPECIAL PARTS OF THE BODY. The discussion of this interesting subject would not be complete without at least a cursory mention of the effects of different colors of light in the cabinet (chromo-therapy). Abstracting from the many illusory statements which have been made on this subject by physicists, poets and others from the time of Goethe up to the present, there can be no doubt that the human organism, even aside from the re- sponsive function of the visual apparatus, is affected by different colors in characteristic ways. Red is the nerve- stimulant par excellence. It acts upon the sympathetic nervous system and through this upon all the vegetable and more especially the animal functions of the economy. The THE THERAPY OF LIGHT. 179 INCANDESCENT AND ARC LIGHT BATH CABINET. 180 MODERN PHYSIO-THERAPY. THE THERAPY OF LIGHT. 181 sexual organs are easily affected by red color-effects. The red lights, gowns and furnishings of the shrines of Venus Vulgivaga are not without their purpose. Red has ever been known as the color of passion and love. Green is a mild sedative. It quiets the mind and eases the body. A sense of buoyant tranquillity and hopeful expectancy comes over the organism. Blue is still more distinctly sedative. It BIDET FOR APPLICATION OF LIGHT TO THE EXTERNAL FEMALE GENITALIA. is said to rectify metabolism, to cleanse the organism and to rejuvenate the weak and ill. White combines the effects of all the colors. So much for light and its therapy. "Let there be light !" The Creator wisely indicated a great photo-therapeutic truth in these words. First he wanted light, then he created life. We must have light before we can have life and health. Let us have light, for by the Shades of Hippocrates ! we can not get too much light in medicine. 182 MODERN PHYSIO-THERAPY. DIAGRAM OF AN INDUCTION COIL. Current starts at battery-post A, splits up at D, supplying the primary post C, the other branch connecting with the primary coil (D and B). From the primary coil the curent goes to the vibrator and hammer. The circuit is completed through the post B which carries the regulating screw G. From B the current goes back to the other pole of the battery, which is represented by the battery-post A 1 . The alternating character of the current is shown by the direction of the arrows, the arrow at D indicating the direction of current before it is reversed (arrow at B) by an interrupted. The diagram of the secondary coil can be readily understood. See page 191. (Bennett.) A FARADIC-GALVAXIC TABLE-PLATE. ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 183 CHAPTER VIII. THE ELEMENTS OF ELECTRO-PHYSICS AND ELECTRO-MECHANICS. MUCH valuable space, time and energy have been spent by authors and practitioners in the discussion and study of electricity. Electro-therapy and electricity are two alto- gether different things. In order to practice electro-therapy successfully and scientifically, it is not necessary to be an expert electrician or electro-physicist. A man may be a skillful pianist and good musician without knowing much about the art and science of piano-building or the physics of sound. The drug-dispensing physician need not be a phar- macist or a pharmacologist. The essentials in the make-up of a good electro-therapeutist are a genera.1 knowl- edge of physiological medicine, of electro-physiology and enough mechanical knowledge of his machines and their purposes to enable him to operate them and make incidental repairs. As a matter of fact, a good electro-physicist does not necessarily make a good electro-therapeutist. He is prone to become an electrical fanatic and is likely to be ac- cused of riding a hobby. In this way he is certainly not benefiting either the cause of electro-therapeutics or of gen- eral medicine whose servant, not mistress, electricity in the hands of the physician should be. I shall attempt to present the rudiments of electro- physics and electro-mechanics as briefly and simply as is consistent with intelligent discussion of the subject. The magnetic properties of amber (electron) were noticed by the ancients, who named the mysterious force in amber elec- tricity. The word magnetism is probably derived from the 184 MODERN PHYSIO-THERAPY. name of an ancient country, Magnesia, where (magnetic) iron ores abounded. Both electricity and magnetism were thought to be, up to within a comparatively recent time, im- ponderable fluids that were too fine for our senses to per- ceive. These fluids were supposed to flow through a wire or any other conductor as water flows through a pipe. Our own Benjamin Franklin held this view. Electricity is neither a fluid nor is it a distinct force which can be separated from matter. It is a force-modality which becomes manifest by a peculiar state of matter and consists in peculiar vibrations of the molecules of the inter- posed ether. The knowledge of the peculiar states of mat- ter or the favorable physical conditions which give rise to manifestations of this special force-modality is the science of electro-physics. We look upon electricity as being poten- tially omnipresent. Our knowledge of electro-physics enables us to produce the physical conditions which will change the potential force into an actual force-modality. Thus we distinguish between potential electricity or electricity at rest, and actual electricity or electricity in motion. To set anything. in motion there must be sufficient pressure at some point. Water would remain stationary in a pipe unless pres- sure is present to cause it to move, even if this pressure is only the force of gravitation. Analogously, there must be some motive power to cause electricity to "flow." This power, which is the vis a tcrgo of electrical motion, is known as the electro-motive force, also the voltage, the tension, the pressure of an electrical current. A unit of electro-motive force is known as a volt. Water running out of a faucet may be measured quan- titatively without regard to the speed or force with which it is running, by allowing the water to run into a bucket, capable of holding a definite quantity, say a gallon. When the bucket is full, we call the quantity of water contained in the bucket, a gallon of water. It may run out in two min- utes or in an hour. It is a measurement of quantity pure and simple. If we measure an electric current in an analo- ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 185 gous way without regard to electro-motive force or time con- sumed, we are measuring the amount of current pure and simple. A unit of quantity pure and simple is known as a coulomb. If, in meastiring the quantity of current, we wish to con- vey a definite statement concerning the rate at which a unit of quantity is "flowing," we express such quantity plus rate of flow in the amperage of the current. A unit of amperage is 'called an ampere. It represents one coulomb passing a given point during one second of time. The one-thousandth of an ampere is called a milliampere and is the unit of measurement which is used in electro-therapeutics. The currents commonly used in medicine have very low am- perage. A substance carrying or capable of carrying 1 electric currents or charges is called a conductor. Not all sub- stances allow an electric current to pass through them with the same degree of facility. Some of them make good con- ductors, like copper and most metals ; others are not so good (water, graphite, dry wood, etc.), while some sub- stances do not transmit or carry electricity at all (glass, silk, rubber, etc.). The latter are known as insulators. The less resistance a substance offers to the passage of a current, the better conductor this substance would be. We gauge the conducting quality of a substance by the degree of resistance it offers. The resistance offered to the pas- sage of a current is an item of some importance. A unit of resistance is called an ohm (named after Dr. G. S. Ohm, one of the early investigators of electricity). If a certain conductor offers a certain amount of resistance, it stands to icason that the force of the current must be sufficiently in- creased in order to overcome the resistance. If a certain amount of current is to pass a given point in a certain time, we must have a certain amount of electro-motive force. To cause one ampere (/. e. a certain quantity in a second of time) of current to overcome one ohm of resistance, it is necessary to have an electro-motive force of one volt. If 186 MODERN PHYSIO-THESAPY. the electro-motive force remains one volt, the amperage of a current must become less if the resistance increases and rice versa. The three factors, voltage, amperage and resist- ance, are so intimately related to one another that a varia- tion in one necessarily affects the other two. The neces- sary relation between these three factors was expressed by Dr. Ohm in his famous law (Ohm's law} which states that the amperage is always in direct proportion to the voltage and in indirect proportion to the resistance. By knowing the exact amount of any two of the three factors, we can figure out the amount of the remaining one. Ohm's law is expressed in the forms of an equation thus: Amperage= volta g e resistance Transposing the factors, the equation would read : amperage Voltage=amperageX resistance. An ohm is approximately equal to the resistance of a copper wire 250 feet in length and 1-20 inch in thickness. An instrument which will change a current of a certain amperage and voltage into a current of different amperage and voltage is known as a transformer. It would be a needless expense of energy to go into the technical details of the general subjects so far touched upon. It is not our aim to become electricians or electro-physicists but to get a clear conception of the theoretical part of the subject as far as the practice of electro-therapy requires it. There are some additional minor subjects that it is neces- sary to discuss. I shall present them in a brief and practical manner under special heads. How VOLTAGE is PRODUCED. Electro-motive force is principally generated by either chemical action (cells of various kinds) or by mechanical energy (dynamos, static machines). ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 187 Chemical Action. If a piece of zinc and a piece of copper are partly immersed in a weak solution of sulphuric acid, a current of electricity will flow from the copper to the zinc. The electrical energy is the direct product of the chemical action set up. The pieces of zinc and copper are known as the elements, while the medium in which they are immersed and in which the chemical action takes place is known as the electrolyte. The jar, receiver or container, including the elements and the electrolyte, is known as a cell. A number of cells properly joined together is called a battery. The parts of the elements which are outside of the electrolyte, are called the terminals. The exposed part of an element is opposite in polarity to the immersed por- tion, i. e. if the immersed portion is positive, the exposed part of the same element is negative. When we speak of the positive or negative pole of a cell, we always refer to the exposed parts of the elements or to the terminals proper. If zinc is the negative element of a cell, it is the exposed part or the terminal of the zinc that is referred to as being nega- tive. The negative terminal always belongs to the element which is acted upon by the electrolyte. If the electrolyte is a liquid, the cell is known as a wet cell ; if it is held in the pores of some porous solid, the cell is called a dry cell. When, owing to the collection of hydrogen on one of the elements, the electrolyte is no longer active, the cell is said to be polarized. Any agent by which polarization is re- moved is known as a depolarizer. The decomposition of liquids by means of electricity is called electrolysis. The atoms set free are called ions. The element from which the electric energy emanates toward the liquid is called the positive element or anode, the liberated atoms traveling in this direction being known as onions. The element which draws the energy away from the decomposing fluid is known as the negative terminal or cathode, the atoms travel- ing in the direction indicated being known as cathions. There are many different varieties of both wet and dry cells. An apparatus in which electric energy is accumulated which 188 MODERN PHYSIO-THERAPY. can be liberated in the form of an electric current is known as an accumulator, a secondary battery or a storage-battery. Electricity generated by wet, dry and storage-cells is said to be produced by chemical action. Mechanical Energy. If a piece of metal has the con- stant property of attracting or repelling other bodies it is called a natural magnet, the property of attraction and re- pulsion being known as magnetism. If this property is tem- porarily produced in a piece of metal by the passage of an electric current near or around the metal we speak of an electro-magnet and electro-magnetism. The magnet is sur- rounded by a field of magnetic force known as the magnetic field. By placing a conductor in the field of force surround- ing a magnet, a current of electricity can be generated. By placing a piece of suitable metal inside of a coil of wire car- rying a current of electricity, the metal will become magnetic and remain so, as long as the current "flows." The current magnetizes the metal (metallic core). When the current stops, the metal becomes demagnetised. To produce magnetism by an electric current and to generate electricity by magnetism is made possible by the close mutual relationship existing between the two force-modalities. It :s another illustration of the physical phenomenon which consists in the changing of one force-modality into another force-modality (Kraftumwerthung). The two instances quoted are of the utmost practical value and importance be- cause they contain the principles which underlie the modern dynamo, and, in a somewhat varied sense, the so-called electro-static induction-machine. The electricity generated by these different apparatus is said to be produced by me- chanical energy. DIFFERENT KINDS OF ELECTRIC CIRCUITS. An electric circuit is the path of the electric current from one terminal of the generating source through various conductors back to the other terminal of the generating source. As long as the electric current flows, the circuit is said to be closed ; if a break occurs, the electric circuit is said to be open and / SERIES LAMP 1)1 \GRAM SHOWING MANNER OF WIRING A GRAPHITE-RHEOSTAT. A MILLIAMPEREMETER 190 MODERN PHYSIO-THERAPY. the current ceases to flow. If the ground or earth is a part of an electric circuit, the latter is spoken of as a grounded circuit (frequently employed in static electricity). Some- times a circuit is split up into branches or smaller circuits. A branch of a divided circuit of this kind, carrying electric energy and being really a part of the circuit, is called a shunt. If the cells composing a battery, are joined, the posi- tive element of one cell connecting with the negative ele- ment of the next cell, the cells are said to be arranged in scries. If, on the other hand, the positive elements of the cells are joined together by wires which form one common conductor and the negative cells are likewise joined and form one common conductor, the cells are said to be ar- ranged in multiple or in parallel. The terms "in series" or "in multiple" ("in parallel") are used in an analogous way in regard to any kind of electrical attachment or apparatus. Whenever motors, incandescent lamps, etc., are put in a cir- cuit, they are wired "in series" or "in multiple," the mean- ing of the two terms being the same as suggested in regard to the wiring of cells. A short circuit is a circuit which is complete before it reaches the conductors. If, while a pa- tient is receiving a static treatment, e. g. a crown breeze, we were to bring the terminals of the machine (horizontal sliding rods) together, the patient would not get any more electricity because the machine is short-circuited, i. e. the circuit is complete before the current reaches the conductors which carry the current to the patient. DIRECT AND ALTERNATING CURRENTS. Whenever there is constant pressure (electro-motive force) in one direction, the current is known as a direct current. If the pressure (electro-motive force) changes from one direction to the other, the current is called an alternating current. The pressure begins at the zero-mark (no potential difference) and rises until it has reached the maximum and drops down to zero and beyond it, i. e. it exerts pressure in the opposite direction until it has reached its full degree of tension. It again returns to the neutral point and the same process as ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 191 before is gone through. The voltage of such a current might be represented by a curve or rather a double curve, one above and the next one following it below a neutral ievel. Each curve is called an alternation. Two successive alternations constitute a cycle. The time consumed in the completion of a cycle is called a period. The number of alternations which occur in one second is called the fre- quency of the current. Thus, a high-frequency current is one which is characterized by the high number of cycles which are completed in one second. The number may reach into the thousands and millions. INDUCTION. If a body holding an electrical charge or a conductor carrying an electric current causes electrical phenomena (attraction, repulsion, current) to appear in neighboring bodies which are in no way connected with the electrified body or conductor, such phenomena are said to be produced by induction. Induction, therefore, is an in- fluence by which electrical phenomena are produced without contact. The large balls in front of a static machine will attract bits of paper and other small bodies or repel them, showing that there must be a sphere or a field of electrical influence around these accumulators of static electricity. If a wire is brought near another wire, the latter carrying an electrical current, at once there will be an electrical current set up in the wire which is brought near it. This shows that the wire carrying a current is surrounded by a field of in- fluence which charges bodies or wires without there being any contact with the wire which carries the current. The influence which produces these phenomena, is called induc- tion. Charges or currents produced by induction are known as induced or secondary charges, induced or secondary cur- rents. The sphere of magnetic influence around a magnet is known as the magnetic field. If a magnetizable substance is brought within this magnetic field, it will become magnetic. The influence producing this phenomenon is called magnetic induction. Faraday took a core of iron, insulated it per- fectly and wound" a coil of wire over the insulated core. He 192 MODERN PHYSIO-THERAPY. then covered the ceil of wire with an insulating substance and wound another wire over this insulation. By allowing a current to pass through the wire covering the core, the core became magnetic and another current was set up in the outside .wire. The current in the outside wire is known as the induced or secondary current. This is the principle of the faradic coil. Another pertinent example of induction is the appearance of a current in the outer armature of a Ley den jar, there being no contact between the outer and inner coating of the jar. The current in the outer coating is an induced or secondary current. POLARITY. Electricity, although it is universally pres- ent, becomes an actual force-modality as soon as by chem- ical action or by mechanical energy the state of latency or neutrality is disturbed. The action which sets a current in motion in a cell, takes place between two suitable elements immersed in a suitable medium. It disturbs the potential or the level of the energy and, as a result, a current flows from the higher level to the lower one. The higher level is called the positive element or positive pole (anode), the lower level is known as the negative element or negative pole (cathode). COMMON ELECTRICAL TERMS. Binding posts are clamps, thumb-screws or any kind of device by which con- ducting wires are attached to an electrical apparatus. A pole-changer (polarity-switch, current-reverser, rheotrope) is a device for changing the direction of a current without disturbing the conductors. Electrodes are the instruments which are attached to an electrical apparatus by means of cords or wires and by which electricity is applied to the human body. Electrodes may be sponge-handles, metallic handles, brushes, rollers, large or small metallic balls, large or small crowns, needles, etc., etc., etc. A rheostat is an instrument by which a definite amount of resistance is brought into the path of an electric current. Practically, therefore, it is an instrument by which the strength of a current can be increased or diminished. A rheotome is an ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 193 instrument by which an electrical circuit is completely broken. An ammeter is an instrument by which the am- perage of a current is measured. If the current is of very low amperage (e. g. less than one ampere) an instrument, called juilliamperemeter is used, which measures the strength of the current in milliamperes. A switch is a device consisting of metallic bars movable on a pivot, used for the purpose of connecting or disconnecting conductors or of changing the path of an electrical current by turning it into a different conductor. ELECTRO-THERAPEUTIC CURRENTS. There are four kinds of electric currents used in medicine to-day, to wit : (i) the constant (galvanic, continuous) current which is generated by wet or dry cells or by some form of mechan- ical energy (central lighting and power station) it is a current of a given maximum amperage and traveling in one direction with certain pressure; (2) the interrupted (faradic) current, which is obtained by passing a constant current through an insulated coarse wire wound around an insulated piece of iron or a core made up of a bundle of pieces of iron-wire of equal length. The moment a current passes through the coil of wire wound around the iron-core, the latter becomes magnetic and the lines of magnetic force which surround it permeate the convolutions of wire around the magnetic core. The result is a rise in the electro-motive force. The little hammer which is mounted on a flat metal- lic spring and is stationed at one end of the core, is attracted towards the core the moment the latter becomes magnetic. The back of the flat metallic spring is in contact, or nearly so, with a platinum-point between which and the spring the electric spark passes. When the hammer is in contact with the core, the circuit of electricity is broken, because the metallic spring is drawn away from the platinum-point and no spark passes as a result. This is followed by demag- netization of the core. The hammer is no longer held by the core, but returns to its original position, thereby re-es- tablishing current in the coil of wire and magnetism in the 194 MODERN PHYSIO-THERAPY. core. The magnetism in the core again causes the hammer to be attracted and thus the current to be broken. It is a constant make and break of current and a coincident mag- netization and demagnetization of the core. The moment magnetization occurs, electro-motive force is generated in the wire surrounding the core. At the moment of demag- netization the direction of electro-motive force of the cur- rent is reversed. The coarse wire which is wound around the core is known as the primary wire, and the current which it carries, as the primary current. The coil of fine wire wound around the insulated primary coil is known as the secondary u'ire. This wire is in the magnetic field of the core and of the primary wire. The moment a current is generated in the primary wire, there is an induced or sec- ondary current in the secondary wire. According to an established electrical law the induced current travels in a direction opposite to that of the primary current. There are the same alternations of electro-motive force, only in the reversed order. Every twist of wire situated in a mag- netic field cuts the lines of magnetic force and increases the voltage. Owing to the greater number of convolutions of fine wire in the secondary coil as compared to the number of twists of coarse wire in the primary wire, the electro-motive force produced by breaking the lines of magnetism is neces- sarily much higher in the secondary current than in the primary. The hammer-attachment is what gives to this cur- rent its interrupted character. The presence of the mag- netized core accounts for the increase in voltage. Thus the faradic current is a galvanic current modified by the laws of magnetism and induction. To interrupt a galvanic current by a switch or by means of rheotome does not make a fa- radic current out of it. A faradic current is properly known as an interrupted current. A galvanic current frequently broken by means of a rheotome is known as an interrupted galvanic current. (3) The static current, generated by friction and variously known as Franklinic or frictional electricity, has recently risen to a high plane of therapeutic ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 195 usefulness. It is produced by the static machine, of which there are several types, which differ in their physical prin- ciples and mechanical construction. The static machine will be discussed under a separate heading. The static cur- rent is one of intense electro-motive force, the number of volts rising into the thousands, while the amperage is very low. (4) The high-frequency current is an alternating cur- rent characterized by a very high-frequency of alternations (500,000 and more per second). High-frequency currents may be applied in- various ways. The therapeutic impor- tance of the subject justifies its separate discussion under a special head. The so-called sinusoidal current, which is an alternating current and is hardly ever used by electro- thera- peutists nowadays, is generated by an armature or coil which is rapidly revolved within the magnetic field of an- other coil and core. The electro-mechanical education of an electro-thera- peutist consists largely in the knowledge of the apparatus and machines which are used for the purpose of generat- ing the constant, interrupted, static and hyper-static (high- frequency ) currents and in the possession of skill taking care of and operating these machines. Modern electro-therapy has eliminated many of the cumbersome mechanical devices which were en vogue years ago. The constant and inter- rupted currents are usually furnished by a combined switch- board (wall-plate, table-plate, galvano-faradic cabinet), which is connected with the street-circuit or supplied with cells. The switch-boards (galvano-faradic wall-plates) are to all intents and purposes variations of the same original type. Some may be richer in finish and more pretentious in technical construction. The addition of attachments for diagnostic lamps and cautery has enhanced their usefulness very materially. From a strictly electro-therapeutic point of view their value consists in their aptitude to furnish gal- vanic and faradic currents and to enable the operator to modify the administration of these currents in keeping with his clinical purpose. 196 MODERN PHYSIO-THERAPY. THE GALVANIC-FARADIC SWITCHBOARD. The switchboard, which is in general use for the purpose of controlling the constant (galvanic) and the interrupted (faradic) current, has the form of a wall-plate, roller-cab- A FARADIC-GALVANIC ROLLER CABINET. inet or table-plate. The electricity which is supplied to this switchboard is generated and furnished either by primary (wet or dry) batteries, secondary (storage) batteries or by the central lighting supply (street-current). c. A. Two sets of tips and handles. B. Straight and curved vaginal electrode. C. Bipolar uterine electrode. D. Uterine cup and stem electrode. E. Uterine copper electrodes. F. Rectal electrode. 198 MODERN PHYSIO-THERAPY. For the control and regulation of the current, which must be of sufficient quantity and of proper electro-motive force, the switchboard is supplied with a rheostat and with selector-switches. If the current is supplied by the street- circuit, a controller in the form of one or more incandes- cent lamps regulates the amount of current received. In order to adapt the amount of the available current to the requirements of therapeutic work, the strength of the current is modified by means of a rheostat. The rheostat is an instrument which enables the operator to introduce any desirable amount of resistance and to lessen the current- strength accordingly. The best rheostat is made of coils of German-silver wire. A fairly good and much cheaper in- strument is the graphite rheostat. The graphite rheostat has a handle, the movement of which influences the amount of current. The so-called selector-switches enable the operator to select, by proper use of a special switch, the kind of current he desires, e. g. a constant (galvanic) current or a primary or a secondary interrupted (faradic) current, as the case may be. It is impossible to do exact therapeutic work with the constant (galvanic) current without being able to measure the amperage of the current used. An instrument which is used for this purpose is called an ammeter. Since, how- ever, the amperage of a therapeutic constant current hardly ever exceeds one-half of an ampere (500 milliamperes), an instrument for measuring minute quantities of current is used. An instrument of this kind is called a milliampere- meter. One of the types of milliamperemeter ordinarilv used consists of a needle which turns freely on a pivot and is connected with a magnet which is influenced by the earth's magnetism. A coil of wire which is parallel to the magnet is traversed by an electric current, the result being deflection of the needle away from the earth's magnetic meridian. An- other type, known as D'Arsonval's milliamperemeter, con- sists of a powerful permanent magnet, between the poles of ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 199 D. A. Roller electrode, hard rubber, set with metallic points, for muscular faradization, with current interrupter. B. Bennett's multiple needle-holder. C. Brush electrode. D. Bennett's abdominal electrode. 200 MODERN Pnvsio-Tui R APV. which a core of soft iron, surrounded by a coir of wire, is suspended. An indicating needle is attached to this coil. When a current passes through the coil, the latter will tend to take a position at right angles to the poles of the perma- nent magnet. "This causes the needle to move over an indi- cating scale. The scale may be single or double. By being able to regulate the circuit in the milliamperemeter (usually by means of a plug-attachment), a fine and a coarse scale can be used to great advantage. Sometimes it is desirable to interrupt the galvanic cur- rent and administer it in the form of shocks of suitable severity and rapidity. The relative rapidity of these shocks is determined by an instrument called a rheotome, of which there are several types. Probably the best known is the clock-work rheotome. The polarity of the switchboard depends on the polarity of the current supplying it. The two wires carrying the current from the street or from the cells are respectively positive and negative. In installing the switchboard it is of vital significance to wire it with proper regard to the polarity of the supply-wires. Each switchboard is supplied with a polarity-switch (pole-changer). Connect the switchboard with the supply-wires and attach the conducting cords (i. e. the cords which are used in giving treatment). Place the metal-tips of these cords in a glass of salt-water after the current has been turned on. The negative current will de- compose the water and cause bubbles of gas to accumulate on the metal tip of the negative wire. Notice the position of the polarity-switch (pole-changer) and see whether the handle of the switch is on the left or the right side. You have already found out which one of the conducting cords i? carrying the negative current. Notice whether the cord is on the left or right side. This will tell you which side of the polarity-switch is negative (i. e. the side of the negative cord). The opposite side is necessarily positive. By bring- ing the handle of the polarity-switch over to the other side, you will reverse the order of things, making the heretofore ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 201 positive side negative and the heretofore negative side posi- tive. This is why the polarity-switch is frequently called the pole-changer. Sometimes the pole-changer is marked ''posi- tive." This is to say that the side of the pole-changer-handle is to be the positive side of the switchboard. In order to have it so, the supply-wires (from cells or street) must be Eustachian electrode devised by Dr. C. R. Holmes, of Cincinnati, O. Eye electrode devised by Dr. C. R. Holmes, of Cincinnati, O. Rectal hydro-galvanic electrode devised by Dr. Louis J. Krouse, of Cincinnati, O. Newman's urethral hydro-galvanic electrode. attached accordingly. The salt-water test should invariably be made. Every switchboard has a faradic induction-coil for the production of the interrupted (faradic) current. Its construction has already been referred to. The interrup- tions may be coarse or fine, depending on the character of the interrupting device ("vibrator"). There are several of, the latter en rogue. Some coils are supplied with a differ- ent kind of a vibrator at each end of the core. The different currents coming from the faradic coil may be decreased or 202 MODERN PHYSIO-THERAPY. increased. They may be coarsely interrupted by a rheotome. i'aradic current is not measured by a milliamperemeter. In addition to the parts mentioned a switchboard may be equipped with additional controllers, voltmeter, attach- ments for diagnostic lamps and cautery. The conducting cords are made of fine copper wire or brass tinsel, cotton or silk covered. They should be strong, durable and pliable. They terminate in metal tips, which are attached to the binding-posts on the switchboard, the free ends being connected to the electrodes, of which there is an unending variety. The work which an operator pro- poses to do, determines the kind of electrodes he is to use, e. g. sponge-electrodes, metal handles, electrolytic needles, uterine, urethral, rectal, nasal, laryngeal electrodes, etc. The Static Machine. The common type of static machine in use in this coun- try is constructed after the models originated by the two physicists Toepler and Holtz, and contains the physical prin- ciples of their machines. For any detailed discussion and description of the subject see any good text-book on physics. The generation of static electricity in the ordinary Toep- ler-Holtz machine takes place by friction (tinsel-brushes against brass knobs), conduction along the metal frame- work and induction on the glass-plates. The plates (glass, mica, rubber) are stationary and re- volving. The revolving plates move in a direction opposite to the movement of the hands of a watch, i. e. from right to left. The size of the plates determines the voltage, the number of the plates the amperage of the current. The discharge of the electric current takes place in front of the machine between two small balls which represent the ter- minals of two horizontal sliding rods. The distance between these balls determines the length of the spark. A static machine should be kept free from dust and moisture. A dry clean machine ought to work in all kinds of weather and in any climate. The outside of the case ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 203 should receive a dry cleaning (soft rag) every morning. The metal parts should be polished. Alcohol should be used sparingly. It has a tendency to take the lacquer off the metal. A dry polish-powder is preferable. Every two or three weeks the case should be washed with soap and water, A MODERN TOEPLER-HOLTZ MACHINE. and afterwards carefully dried. The inside of the case should be ventilated once or twice a week on dry bright days. The case and the plates should be wiped with a soft dry rag (silk). By wrapping the rag around a stick and hold- 204 MODERN PHYSIO-THERAPY. SKELETON OF A STATIC MACHINE. 1, Upper cross-bar with washers. 2, Lower cross-bar with washers. 3, Flange. 4, Comb-bracket. 5, Bracket with combs and plate-holders. 6, Bracket with plate-holders. 7, Plate-holders. 8, Oil-cup. 9, Brush-holder. 10 and 11, Special X-ray posts on some machines. 12, Main post. 13, Large brass ball (collector). 14, Small brass ball. 15, Sliding rod. 16 and 17, Leyden jars. 18, 19, 20 and 21, Attachment for turning machine by hand. 22, Curent-controller (of questionable utility). 23, Switch and current-indicator (on 'Some machines). 24, Base of Leyden jar. 25, Flanges on both .sides of the glass. 26, Washer. 27, Brass top of main posts. 28, Oil-cup. 29, Hub on main shaft. 30, Glass plates. 31, Support for stationary plates. 32, Bracket for crank- shaft. 33, Bracket for brushes and plate-holders. (Bciincit.) ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 205 ing the latter between the slowly revolving plates, the dust from the latter is easily removed. Sometimes it is neces- sary to slightly moisten the rag with alcohol before it is possible to remove the layer of dirt from the plates. If, after thoroughly cleaning the machine, the latter refuses to work, the trouble is due to moisture and the operator must resort to some artificial way of drying the inside of the case. H. C. Bennett gives the following directions for the use of ice and salt: "Take a one-quart glass fruit- jar with screw top, fill with a mixture of powdered ice and rock-salt, screw down the cover and wipe the moisture from the outside of the jar; place the jar in a saucer or bowl inside the case of static machine, close the door and set the machine in mo- tion, keeping the plates moving until the machine begins to generate at its best. After, say an hour, when the ice is fairly melted, remove the jar and quickly close the end door so as to prevent the outside air from getting into the case." By all odds the simplest, cleanest and most effective way of drying the inside of a. static machine is' the use of five or ten pounds of fused chloride of lime- (dry, hard lumps) in one or more earthen or porcelain dishes. The lime is mark- edly hygroscopic. The operator ought to watch the con- ditions of moisture in the case. A little cheap instrument, called a hygrometer, hung in the case, is very serviceable. Frequently the machine can be started by simply making a fire in the room. The static machine can be operated by hand or by dif- ferent kinds of power (water, electric). The best way of driving a machine is to run it by means of a good one-third horse-power electric motor. The current which is generated by a static machine is one of high voltage. It has been determined experimentally that it requires approximately 8,000 volts to produce a spark one inch in length. There are three modes of static dis- charge. If the electric energy travels along a conductor, c. g. a brass rod held by the hand of the patient, the current is discharged into the hand of the patient directly as though 206 MODERN PHYSIO-THKRAPY. the hand were a part of the conductor, which, in reality, it is. This is a conductive discharge (conduction). Helm- holtz assumed that the atoms of atmospheric air surround- ing' the surface of a highly charged conductor are dislodged and carry off minute charges of electricity. This takes place when the collecting-combs in the static machine discharge A HOLTZ INFLUENCE MACHINE. toward the revolving plates. This mode of discharge is called connective discharge (convection). This is the physics of the so-called static breeze or spray to be consid- ered hereafter. If the convection takes place in the form of a faintly luminous discharge from a pointed or small rounded positive conductor, it is known as a brush-dis- charge. If the electric discharge occurs suddenly across an ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 207 intervening non-conductor it is called a disruptive discharge (disruption), and assumes the form of a spark. The non- conductor interposed between two conductors (e. g. the air between the terminals of a static machine or the glass be- tween the inner and the outer coating of a Leyden jar) is called the dielectric. The mode of discharge is in no inconsiderable manner influenced by the surface whence it is given off. Even and uniform surfaces accumulate static electricity and for this reason favor disruptive discharges (sparks). In order to administer static sparks to a patient, the operator would use an electrode with an even and smooth surface (e. g. a ball-electrode). Small balls and points favor the formation of brushes or sprays (breezes), especially if the end of the electrode represents an aggregation of numerous points, e g. the crown-electrode, which is used to administer a head-breeze. THE GROUND-WIRE. An iron pipe (water, gas) con- necting with the earth can be used for a ground-connection. The side of the machine to be grounded is connected with the pipe by means of a chain or wire whenever the operator desires to make a ground-connection. Some physicians hook a chain to the metal portion of the machine on the side to be grounded and drop the end of the chain or wire on the floor. This is not sufficient. The connection mast be made with the earth deep enough to be in contact with moist ground. The object of grounding is to increase the potential of the current. In some applications of static elec- tricity it is essential for correct technique to ground one side of the machine, e. g. in giving the so-called wave-current. THE POLARITY OF THE STATIC CURRENT. To be able to tell which is the positive and which is the negative side of the machine is of the utmost importance, because the whole therapeutic part of static electricity depends upon it. The polarity of the machine must be tested before a treat- ment is given. No two machines are alike. Some machines change polarity frequently. There are several ways of tell- 208 MODERN PHYSIO-THERAPY. ing wnich is the positive and which the negative side of the machine : 1. Start the machine slowly, leaving a spark-gap of one inch. The first spark will be seen to travel from the posi- tive to the negative pole. 2. The positive end of a one-inch spark has a white, the negative a violet color. 3. A five-inch spark has a purple positive end and is bright at or near the negative pole. 4. The "fox-tail" discharge is on the positive side. The negative end of the spark is compact. 5. If a piece of wood is brought near the positive end of the spark, the spark will jump over to the wood. The negative side, if approached, is not disturbed in the least. 6. Ground one side of the machine. Start the machine with the sliding rods five inches apart. If there is no spark, the grounded side is positive. If the spark is more vigorous and thick than usual, the grounded side is negative. 7. Look at the discharging combs between the plates while the machine is running. The negative side will show streams of purple light, the positive side bright points on the ends of the comb-teeth. 8. If a burning candle is held between the terminals of the machine, the flame will point toward the positive side. 9. The positive side attracts dust very readily. The most valuable point is probably No. 7, because it enables the operator to see the polarity while the patient is being treated. THE POLE-CHANGER. Many static machines are pro- vided with a device for changing the polarity of the ma- chine. All of these apparatus (e. g. Cedergreen's excellent device) simply reverse the currents in the wires carrying the electric energy from the machine to the patient or to the X-ray tube. They do not in reality change the polarity of the machine. The device simply causes the positive current to be discharged through the wire on the opposite side and ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 209 vice versa. In X-ray work a pole-changing device is very serviceable. THE) LEYDEN JARS. To the human eye a static spark seems like a continuous discharge. In reality it is a succes- sion of discharges which follow each other with great rapidity. Each discharge is an oscillation of electrified ethereal molecules. The rapidity with which these oscilla- tions follow each other constitutes what is known as the "frequency" of the current. If the pressure (electro-mo- tive force) of the current is increased, by induction for in- stance, the frequency of the discharge will necessarily be augmented. This is the purpose of the so-called Leyden jars, one of which is placed on the shelf on either side of the machine. It consists of a glass jar with a metallic coating on the inside and the outside, the coatings (also called ar- matures) not extending to more than one-third of the height of the jar. To prevent the creeping of the electric charges over the glass in damp weather, the glass is varnished. The knob on top of the jar is connected with the inner metallic coating by means of a metallic chain. The conductor sup- porting the knob passes through a dry cork or plug of some insulating material. The knob on top connects with the metallic parts (prime conductors) of the machine on the positive or negative side respectively. When the machine is running, the inner coatings (armatures) of the Leyden jars receive a certain charge of electricity. By induction a charge is generated in the outer coating (armature) of the jar. The outer armature is supplied with a binding-post which may be situated on the shelf in front of the machine and is connected with the outer coating of the jar by a wire. If a conductor (cord, wire) is attached to this binding post, it will carry the current which has been induced in the outer armature. It is a current of higher voltage nnd greater frequency than the primary static current. It is known as the static induced current. The frequency of a current of this kind may be as high as, and even higher than 100,000.- ooo oscillations per second. Each oscillation is a wave of 210 MODERN PHYSIO-THERAPY. ethereal motion, separated from the preceding and succeed- ing oscillation by a distinct interruption. The greater the number of interruptions, the greater the pressure (electro- motive force). The coincident, previously discussed, re- versal of the direction of pressure, makes each oscillation equivalent to an alternation. The two terms, therefore, are in this sense used synonymously. The static-induced cur- rent, then, is a true high-frequency current. ELECTRODES. An instrument by means of which elec- tricity is administered to the patient is called an electrode. A set of suitable electrodes comes with each static machine. The most essential electrodes are, i. The insulating plat- form; 2. The large crown (breeze, spray); 3. The small crown (breeze, spray) ; 4. A ball-electrode (sparks) ; 5. A wooden electrode (brush) ; 6. A pointed electrode (brush, small sparks). In addition to these electrodes there ought to be an insulated hook to hold chains out of the way dur- ing a treatment and prevent unnecessary sparking. The ingenuity of individual operators has suggested different shapes and sizes of static electrodes, e. g. a wire cage for spraying the whole body. The massage-roller is used by some. The cataphoric electrode is worthless, because static cataphoresis does not exist. In giving static treatments the operator should not be hampered by his ignorance of static technique, or by his fear of electricity, or by his awkwardness in handling the machine and the patient. The constant use of sparks has justly become obsolete. A static treatment which causes pain is of doubtful therapeutic value. In a general way it may be said that the gentle and agreeable modes of appli- cation answer every therapeutic indication of static elec- tricity. THE MODES OF APPLICATION ordinarily recognized as such by electro-therapeutists are as follows : Insulation (positive or negative). Put the platform in its proper position about two feet in front of the machine and connect the sliding rod on the negative side with the ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 211 platform by means of a rod or chain. Ground the positive side. This gives your patient, who stands or is seated on the platform, a negative insulation. If the positive side is connected with the platform and the negative side grounded, the patient gets a positive insulation. This mode of static application is called (positive or negative) insulation, elec- trification or chargre. NEC. vy w POSITIVE INSULATION. AA and BB represent ground wires. Direct or Primary Spray and Breeze (positive or nega- tive). Connect the sliding rod on the positive side with the platform and the sliding rod on the negative side with the crown (multiple point) electrode, the rods being sepa- rated sufficiently to prevent sparks from passing. Hold the electrode at a suitable distance from the patient to allow a stream of bluish fire (shower of fine sparks) to pass. This 212 MODERN PHYSIO-THERAPY. A INDIRECT NEGATIVE SPRAY. INDIRECT POSITIVE (SMALL) SPRAY. ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 213 is the negative direct or primary spray. If the electrode is moved away until only a current of electrified air is drawn to the patient, it is called a breeze. A breeze is a mild kind of a spray. For a positive direct or primary spray connect the negative side of the machine with the platform, and the positive side with the electrode. If a ball electrode is used the result will be the passage of direct or primary sparks. POS. w \^/ V INDIRECT POSITIVE SPARK. Indirect or Secondary Spray and Breeze (positive or negative). Ground the positive side and connect the nega- tive side with the platform. The platform and the patient are charged negatively. By induction the room (walls, table, etc., etc.) is charged positively, the air intervening between patient and room being like the dielectric (glass) of a Leyden jar. Place a metal stand on the floor and con- nect this stand with the earth. By connecting the small crown (multiple point) electrode with the stand, the elec- 214 MODERN PHYSIO-THERAPY. trode will be charged with positive electricity, which, with the electrode held at the proper distance from the patient's body, will yield a positive spray, or, if moved farther away, a breeze. If there is a gas-fixture in the room, no stand is needed. The electrode is connected directly with the gas- fixture. This is what is called a positive indirect or sec- ondary spray or breeze. To give a negative indirect or sec- ondary spray or breeze, reverse the conditions. If instead of a crown (multiple point) electrode, a ball electrode is used, the tendency will be toward the formation of sparks instead of a spray. Sparks thus obtained are known as (posi- tive or negative) indirect or secondary sparks. The poten- tial of these sparks can be very much increased if the Ley- den jars are included in the circuit, their outer armatures being connected (short-circuited) by a wire or rod which passes from outer coating to outer coating. In this way charges of high potential are bound by the inner coatings (armatures), the charges being released when a spark passes between electrode and patient. The same holds good in re- gard to the direct or primary sparks. In all the applications named there is an air-space be- tween patient and electrode which must be bridged over before the circuit is completed. In this respect the appli- cations named differ from those which follow, the circuit in the latter not being broken between electrode and patient, but at some other point in the circuit. The Static Induced Current. Reference to this current has already been made. The Leyden jars are in the circuit. The cords are attached to the binding posts connecting with the outer armatures of the Leyden jars and the patient is placed in the circuit. The platform is not needed. The electrodes are in contact with the patient's body. The gap to be bridged over is between the sliding rods, the potential of the current being dependent on the length of the spark. Potential Alternations ( surging). Make all the con- nections for a positive insulation, adding, however, a sep- arate stand, which is grounded and placed in such a posi- ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 215 THE STATIC INDUCED CURRENT. Application with the roller is shown. POTENTIAL ALTERNATION (MONELL, MORTON). 216 MODERN PHYSIO-THERAPY. tion that a spark-gap is created between the positive slid- ing rod and a horizontal metal bar held by the grounded stand. The sliding rods of the machine are separated. The spark passes between the positive sliding rod and the rod -v F s) H. FOOT PUTE PATIENT'S ""CIRCUIT "* 5PONGE ELECTRODE INSULATED PLATTORM E. POTENTIAL ALTERNATION (MODIFIED). A is a wire connecting the positive side (P) with the foot-plate (F). C is a ground-wire from the negative side of the machine (Po to J). D is a curved insulated rod held by a post (I) and connected (B) with a wet sponge- pad (H), which is applied to the bare skin. G is a spark-gap which is closed or opened by moving the sliding rod Po. If the Leyden jars are in the cir- cuit the effect is more marked. It can be still more enhanced if the static in- duced current is short-circuited (connect outer armatures S and So by closing switch K). By alternately opening and closing spark-gap G a surging effect is produced. This form of potential alternation i? useful in rheumatism and for the relief of pain generally. It is effective in muscular and nervous weak- ness, sexual neurasthenia, dysmenorrhea, etc., etc. held by the grounded stand. Whenever a spark passes from the positive sliding rod to the earth, the patient will be traversed by an oscillating current. The arrangement spoken of was first used by S. H. Monell. Morton changed ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 217 ir by substituting a spark-gap electrode to be held by the operator's hand for the arrangement suggested by Monell. More recent modifications are shown in the accompanying diagrams. The Morton Wave-current is named after Dr. W. J. POTENTIAL ALTERNATION (MODIFIED). The static induced current is short-circuited, not by closing the switch (C), but by connecting the outer armatures (S and So) with a solenoid, the two ends of which are connected (A and B) with foot-plate and electrode. The middle third of the solenoid is a part of the closed static induced circuit. When a spark passes at G the two outer thirds of the solenoid carry shunt-cur- rents to the electrode and patient respectively. This form of application im- proves local nutrition and has marked anodyne properties. Morton, of New York, who in 1899 gave explicit direc- tions concerning this application. The spark-gap is be- tween the sliding-rods. The negative side is grounded, the positive side is connected with the platform upon which the patient is sitting or standing, the strength of the current 218 MODERN PHYSIO-THERAPY. is controlled by the spark-gap. If a local application is to be made, a piece of block tin of proper size is firmly placed on the skin of the part to be treated. The tin is connected with the positive side of the machine. Several pieces of block 'tin may be used on several parts of the body at the same time. Each piece must be directly connected with the positive side of the machine. Since everything depends on the proper execution of the details of static treatments, it behooves the operator to be- come proficient in the. technique of the different modes of application mentioned. Nothing equals the educational ad- vantages of self -treatment for experimental purposes. High-Frequency Apparatus. Reference has been repeatedly made to the subject of high-frequency currents. They are currents characterised by a high frequency of oscillations (alternations). Next to the constant (galvanic) current it is the currents of high frequency that are of superior therapeutic value and, there- fore, entitled to detailed consideration. The Question of Amperage. In order to understand some of the remarkable effects produced by currents of high frequency, it is necessary to think of some of the elementary principles of electro-physics. Owing to the tremendous pressure of a current of this kind, the rate at which the cur- rent flows, is very rapid. One coulomb of electricity pass- ing through a conductor in one second is called an ampere of electricity. If the pressure is great enough to force one coulomb through the conductor in one-tenth of a second, the quantity passing in one second would be 10 amperes. If one coulomb were to pass in the hundredth part of a second, the current-strength would be 100 amperes. If a current of this kind were to flow in one direction it would be most dangerous to life. These currents, however, are alternating and the alternations are so rapid that the sensory nervous system seems to be unable to respond to them. This fact ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 219 makes these currents safe to use. The lower the frequency, the more dangerous the current. Phenomena of Induction. The wonderful effects pro- duced by induction in secondary conductors will be better understood by a careful consideration of the subject of in- duction which has been discussed in connection with the OUDIN RESONATOR. physics of the faradic induction-coil. The electro-motive force in the secondary coil depends on the number of turns in the primary coil and on the frequency of the interruptions of the current in the primary coil. Every interruption, it will be remembered, is coincident with a change in the direc- tion of the current. Let us suppose that an- alternating cur- 220 MODERN PHYSIO-THERAPY. ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 221 rent of two amperes and a frequency of 1,000,000 is cir- culating in a primary wire consisting of two convolutions of wire. Let us place a solenoid (a cylindrical coil of wire with circular convolutions) in the magnetic field of the primary wire. The effect on this solenoid would be the same as if 200 amperes were circulating in a primary coil of 200 convolutions with a frequency of 100 alternations. The effect on the solenoid depends on the product of the am- perage and frequency in the primary wire. In this way the remarkable effects of induction of high-frequency cur- rents can be explained, e. g. the lighting of an incandescent lamp attached to a wire held near the conductor of a high- irequency current. Resonance Effects. The waves of electrified ethereal molecules which emanate from a current of high frequency are capable of causing electric oscillations in another cir- cuit which is of the same kind or has a direct physical rela- tion to it. The second circuit responds just as a string of proper length and thickness will vibrate in sympathy with some other string which has been set in motion. The phys- ical relation between these two strings is that they be of the same length and thickness or that the length and thick- ness of the second string be a simple fraction or a multiple thereof. Thus, the term "resonance" has an analogous meaning in electricity and is borrowed from acoustics to express this analogy. The high-frequency instrument which in its construction is based on this phenomenon of "re- sonance," is called a resonator. The instrument, device or apparatus by means of which high-frequency currents are generated, are principally the high-frequency coil of D'Arsonval and the resonator of Oudin. The solenoids which can be attached to an alter- nating light-circuit or the diasolenic cylinders which can be attached to a static machine are very useful and con- venient. The Tesla coil as a therapeutic instrument is hardly ever used at present. The High-Frequency Coil was originated by D'Arson- 222 MODERN PHYSIO-THERAPY. COIL AND DOUBLE RESONATOR. ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 223 val and is available in conjunction with a static machine or an X-ray coil. It consists of a solenoid which is in the cir- cuit of the outer coatings of the Leyden jars. Around the solenoid a secondary coil is placed which receives the cur- rent from, the primary coil (solenoid) by induction. The whole arrangement is incased in a box. The binding posts on top connect with the terminals of the secondary coil while the binding posts on the end or on the side of the box con- nect with the terminals of the solenoid which in this way can be connected with the outer armatures of the Leyden jars. The spark-gap to regulate the amount of current is between the sliding rods of the static machine. If an X-ray coil is used as a generator of the current a condenser is in- terposed between the X-ray coil and the high-frequency coil. The condenser plays the part of an accumulator analogous to the inner armatures of the Leyden jars. The current from a D'Arsonval high-frequency coil is applied by means of suitable (glass, metal, condensing) electrodes. The Resonator, originated by Oudin, consists of a sole- noid of which only a part is in the Leyden jar circuit, the remaining portion receiving its electric energy by resonance (see above) and by induction. The larger the portion of the solenoid which is in the circuit, the greater the amount of energy and the higher the frequency. The electrodes used are glass, metal or so-called condensing electrodes. The Condensation Conch consists of a sofa or lounge upon which the patient lies down. The couch is connected with one terminal of a solenoid while the patient is con- nected with the other terminal. The solenoid is in the cir- cuit circulating between the outer armatures of two Leyden jars. The connection between solenoid and couch is by means of a wire which is attached to a metal plate on the couch. The connection with the patient may be made by means of a wire and metal handle held by the patient. The patient lies on a cushion, beneath which the metal plate is put. The constant change of polarity in the rapidly oscil- lating discharges of the Leyden jars causes a coincident ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 225 VACUUM ELECTRODES. hi. HIGH TEXSIOX ELECTRODES. 226 MODERN* PHYSIO-THERAPY. change in the patient and the lounge, resulting in a rapid and continuous back and forth surging of high-frequency charges. The Auto-conduction Cage is a solenoid of immense size in which the patient stands. The solenoid is in the circuit of two Ley den jars, the patient's body constantly receiving in- duction-charges of high frequency. The Diasolenic Cylinder, ("dia" through, "solen" cylin- der,) suggested by the author, is a combination of the prin- ciples of condensation and auto-conduction. The cylinder is an immense solenoid which is connected with the outer ar- mature of a Leyden jar. The platform upon which the patient lies is connected with the outer armature of the other Leyden jar. The spark-gap is between the sliding rods of a static machine. A rapid change of polarity takes place in the platform, in the cylinder and in the patient's body. While the current is circulating, charges and inductive in- fluences of high frequency and potential constantly surge to and fro in the patient's body. Some operators connect cylin- der and platform with one side of the machine while the other side is grounded. The high-frequency electrodes are either glass (vacuum), metal or condensers. Condensing electrodes are made of hollow glass, filled with pulverized graphite or hav- ing an inner coating of tin-foil. The electric charge is re- ceived and condensed by the inner coating or graphite-pow- der and an induced charge is produced in the tissues of the patient which represent the outer coating (analogous to a Leyden jar). The metal electrodes have a small bulb or ball on the end and are supplied with an insulated handle. The vacuum-electrodes consist of partially exhausted glass tubes. the color of the light in the tubes depending on the condi- tion of the vacuum. These electrodes are applied to the skin directly. A very useful set of vacuum-electrodes with one universal handle has been devised by Dr. W. B. Snow, of New York. So much for the physics and mechanics of medical elec- ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 227 tricity. The electro-therapeutic achievements of the past have been chiefly along the line of galvanic electricity. The success of the future in an electro-therapeutic direction promises to be in the elaboration of the wonderful possi- bilities offered by currents of high frequency. DIAGRAM ILLUSTRATING THE MAGNETIC FIELD. 228 MODERN PHYSIO-THERAPY. CHAPTER IX. THERAPEUTIC USES OF GALVANIC, FARA- DIC, STATIC AND HIGH-FREQUENCY CURRENTS. THE; subject of medical electricity, more especially the part of the subject which refers to the action of electrical currents on animal tissue, has been encumbered with much unnecessary detail, theoretical speculation and a well-nigh endless list of distinctions, classifications and subdivisions. This fact, in and of itself, seems to be sufficient to show that the professional mind is by no means clear in regard to the principles of electro-therapy. The subtle and undefined character of electrical agencies in conjunction with the mys- teries of neuro-physiology and neuro-pathology offers a vast territory for speculation and hypothetical reasoning. Abstracting from that which is purely theoretical and of in- terest to the laboratory-physiologist rather than the clini- cian, it seems reasonable to recognize two kinds of effects which electrical currents might be able to produce on and in the animal -body. If the molecules individually and collectively are dis- turbed in their position and relation, if their nutrition is in- creased, diminished or altered, if function is stimulated or depressed, such an effect might be attributed to a physiolog- ical action. This would be a generic term, covering thermal, magnetic, electrotonic, physical, somatic, mechanical and many other kinds of effects referred to in the text-books. The salient point is that these effects consist in modes of ac- tion that are strictly in accord with the physiological inten- tions expressed in the activity of organic matter. There is ELECTRO-PHYSICS AND ELECTRO-MECHANICS. 229 no impairment of structural perfection. The molecule is neither physically incapacitated nor chemically disintegrated. In keeping with these facts, the salient point of these physio- logical effects might be expressed and emphasized by desig- nating them as non-destructive. They affect function by altering structure within physiological limitations. Another variety of effects would be produced by the ac- tion of electrical currents on structure, altering or destroy- ing the latter by disintegrating its chemical constituents or changing the proportion of the latter. These effects would be chemical, or destructive in a physiological sense. The electrolytic action of a galvano-puncture would be a chem- ical effect, while the stimulation of the vaso- motors by means of a negative static application would be distinctly a physiological effect. In keeping with the division given we may recognize physiological and chemical effects as following the employ- ment of the galvanic current. Physiological Effects of the Galvanic Current. The galvanic current seems to have an affinity for nerve-structure. The individual neurons seem to gratefully respond to the gentle and evenly flow- ing stimulant. In the order of their response to a mild galvanic current the motor nerves seem to react less promptly than the sensory nerves, and these again with less precision than the vaso-motor (sympathetic, trophic) nerves. The latter show the deep impression which even a compara- tively mild galvanic current is capable of producing, by the marked changes in the circulation and in the nutrition of the regions treated. The electrical tendency is toward the negative pole. Thus, there is an over-stimulation toward the negative pole and a compensatory tinder-stimulation at the positive pole. The vessels dilate near the negative pole, whereas there is a distinct contraction of the arteries at the positive pole. In keeping with the physiological law 230 MODERN PHYSIO-THERAPY. FARADISM IN RETROFLEXiOX. IXTRAUTERIXE USE OF THE BI-POLAR ELECTRODE. THERAPEUTIC USES OF VARIOUS CURRENTS. 231 FARADISM IN AXTEFLEXIOX. THE BI-POLAR ELECTRODE IN POSITION. 232 MODERN PHYSIO-THERAPY. \vhich makes function dependent on nutrition and, therefore, on circulation, it is but natural to see increased functional activity, augmented metabolism, accelerated oxidation, in- tensified absorption at the negative side and the opposite state of affairs (sluggishness of functional action) at the positive pole. The decrease in the amount of blood at the positive side lessens blood-pressure. This fact makes the positive pole a sedative and an anodyne of great value. The increased functional activity at the negative pole soon reaches the physiological limit. The effects of overstimiila- tion become apparent. The skin is red and irritated, the whole region hyperemic and on the verge of an inflamma- tory action. The trophic nerves have expended their force in response to the current. The physiological effects de- scribed explain the subjective symptoms which accompany an application of this kind. The patient experiences a sen- sation of heat or burning at the negative side while the posi- tive side feels numb. It is primarily the effect of a mild galvanic current on the trophic nerves, and through these on the blood-vessels and lymphatics, which accounts for the markedly absorbent action of the galvanic current. This action alone is fre- quently sufficient to account for the disappearance of hyper- trophies, morbid growths and effusions after galvanic appli- cations. In giving galvanic treatments the current should not be abruptly interrupted unless a special effect is desired. Sub- jectively a sudden interruption produces an exceedingly dis- agreeable sensation, especially if the application is made on or near the head or chest. A sudden interruption of the galvanic current acts mechanically on the muscular tissue at and near the seat of application. The muscles contract violently. In asthenic and atrophic conditions of the mus- cles and in paralytic and paretic states generally, these in- terruptions of a galvanic current are very effective, espe- cially if they are slowly and rhythmically applied. In these coarse, violent applications the operator can be guided en- THERAPEUTIC USES OF VARIOUS CURRENTS. 233 tirely by the mechanical effects produced. At all other times it is advisable to follow the indications of the milliam- peremeter. Mild galvanization (one to five milliamperes) of a spe- cial nerve or set of nerves is one of the neatest and best electro-therapeutic applications, especially if the operator is dealing with a clearly diagnosed condition of functional im- pairment or of pain. In many so-called reflex conditions the galvanic current is of great value. Reflex conditions are always due to a lack of balance on the part of portions of the nervous system, a disturbance of co-ordination. A nerve-impulse may travel over a nerve-trunk or through a series of neurons simply by following the path of least re- sistance. The lack of resistance is a functional ailment of some special nerve-structure. A functional disorder of a nerve is always an indication of malnutrition, usually lack of nutriment or the wrong kind of nutriment. The nerve, as a result, is functionally below par and possesses less than its normal resisting-power. This explains the causation of reflex neuroses, of neuralgias and many obscure nervous disorders. The vomiting of pregnancy is a classical type of a re- flex condition. The impulse is carried by fibers of the solar plexus in response to impressions received by some of the lower abdominal nerve-ganglia. The nerves of the solar plexus are temporarily ill-nourished on account of the physiological hyperemia in and near the internal genitalia, and in this way these nerve-fibers present the path of least resistance. In these cases it is of signal service to compen- sate for the lack of nerve-energy by mild galvanization of the vagus and phrenic (side of neck positive pole, epigas- trium negative pole). In facial neuralgia, in fact in all superficial neuralgias, mild galvanization often gives prompt relief. The positive pole should be placed on or near the aching part. The nega- tive pole should be put on some point in the continuity of 234 Moi.'KKX I'HYSIO-THKRAPY. the nerve or, if practicable, near the spinal origin of the nerve. In congestive headaches good effects are produced by placing the positive (sponge) electrode on the forehead and the negative (sponge) on the back of the neck or lower down, at the same time making firm pressure on either side of the occiput and back of the neck. A mild galvanic cur- rent can be thus applied for three to five minutes. To in- sure good electrical contact, sponge-electrodes should al- ways be thoroughly moistened. General galvanization by means of a mild galvanic cur- rent is valuable in all conditions in which a mild tonic-stimu- lant is indicated, e. g. neurasthenia, wasting diseases, con- valescence from continued fevers, etc., etc. The negative electrode is placed over the lumbar vertebrae and slowly moved upwards, while the positive electrode is slowly car- ried over the whole body-surface. The treatment should not last longer than ten minutes. In the atonic form of gastric and intestinal indigestion mild galvanization of the abdom- inal contents is of great value. In all these applications the operator should not carry the treatment to the point of irri- tation. It is plain that in many of the conditions to which mild galvanization is applicable, the effect can be enhanced by the discreet addition of massage. All these physiological effects are included under the general head of catalysis. Chemical Effects of the Galvanic Current. When the point of irritation has been reached in making an application of a galvanic current, certain changes occur in the tissues and fluids of the body, the severity of these changes depending on the duration of the application, on the amperage of the current used and on the pole used. The changes may consist in an actual destruction wrought by electro-chemical decomposition (electrolysis) or in chemical alterations due to the introduction of chemical agents into the tissues and fluids of the body (cataphoresis, metallic electrolysis). THERAPEUTIC USES OF VARIOUS CURRENTS. 235 POSITIVE; (ANODAL) ELECTROLYSIS. This designation comprises certain effects which occur near the positive pole of a galvanic current applied to the tissues. If a needle is in- serted into a piece of raw meat and a galvanic current of about 10 m. a. is allowed to pass with the needle as its posi- tive pole, the needle will soon be found to stick fast. The point of insertion will look dry, white and shrunken. If the needle is made of iron, steel, copper or any other oxidizable material, the needle will be oxidized and an oxide of the metal will be deposited around the point of insertion of the ELECTRODES FOR POSITIVE ELECTROLYSIS IN CAVITIES. No. I is the universal holder. Nos. 2, 3, 4, 5, and 6 are hard rubber tips which fit on the holder. They slip over the copper wire, which is a part of the holder, and are introduced into the cavity where treatment is to be given. The cavity is filled with normal salt solution. Tips of all sizes and shapes are made. needle, causing a staining of the tissues. If the current is strong .enough, the stain is permanent. The positive pole has an affinity for oxygen and for acids. The lat- ter coagulate the tissue-albumen and in this way interfere with the blood-circulation. This explains the styptic action of the positive pole. After the application has been made, the current is turned off and reversed. In this way the elec- trode used for positive electrolysis is released and can be easily removed. The electro-chemical destruction of tissue makes the 236 MODERN PHYSIO-THERAPY. positive pole available in the treatment of various conditions, to wit : 1. Growths consisting of dilated capillaries (angiomata, birth-marks, cirsoid aneurism, varices, acne rosacea, etc.). One or more needles representing the positive pole of a gal- vanic current are introduced into the growth until the coagu- lating and styptic effect has been produced. The negative pole is put in an indifferent place. 2. Growths of soft texture (moles, polypi, fungi, warts, etc.) can be cured by cutting off the blood-supply, the in- strument used being one or more needles. 3. Hemorrhage, active or passive, especially from tur- gescent mucous membranes, can be stopped by the positive pole, the application being made by means of a flat electrode. This application is available in gynecological practice to stop bleeding from the endometrium (by means of an intra-uter- ine electrode). Infected areas (lupus, tinea, etc.) are often successfully treated by positive electrolysis. It is well to know that gonorrhea, especially in the post-acute form, can be checked by positive electrolysis. The gonococcus can not withstand the action of the current and soon becomes non-viable. NEGATIVE (CATHODAL) ELECTROLYSIS. The negative pole of a galvanic current attracts hydrogen and alkalies. If a needle, charged negatively, is thrust into raw meat, the needle will not stick. A whitish foam will issue from the point of insertion of the needle, the foam being composed of bubbles of hydrogen. The tissues near the point of inser- tion are softened and even liquefied. Therapeutically the process of destruction set up by negative galvanic electricity can be utilized in the treatment of manifold conditions, to wit : Superfluous Hairs. The patient holds a metal-handle electrode in his hand. The other electrode is a fine needle which is introduced into the canal from which the hair emerges and the current is turned on, the needle-electrode being charged negatively, the handle-electrode positively. THERAPEUTIC USES OF VARIOUS CURRENTS. 237 The object is to destroy the matrix of the hair-follicle. As soon as a little whitish foam is seen to issue from the point of insertion of the needle, the current is turned off and the needle withdrawn. The hair is readily taken out by means of a suitable forceps. If the application is properly made the hair will not grow again. Cicatrices. Scar-tissue resulting from burns, inflamma- tions or various traumatic conditions, can be softened and stretched by negative electrolysis. In cicatricial strictures of an accessible canal this method is indicated. It is the ideal way of handling urethral strictures in the male. Rob- ert Newman, whose name will for all time to come be asso- ciated with this branch of conservative surgery, gives the following directions as to the modus operandi: The urethral electrode to be used should consist of one piece. The tips to be screwed to a universal handle are to be condemned because they are likely to come off as shown by a number of cases of this kind. Electrolysis must be con- fined to organic strictures. Spasmodic strictures are likely to be aggravated by this mode of treatment. The instru- ments should be clean. In lubricating the urethral electrode of proper size before inserting it, remember that the lubri cant should be a conductor. Use glycerine or white of e gg 5 avoid oil or vaseline. Let the patient stand, sit or lie down according to his sense of comfort. Let him hold the (positive) handle-electrode in his hand. Introduce the (negative) urethral electrode until it is arrested by the first stricture. Turn on the current. Guide the electrode, never use any force or pressure. The electrolytic action will soon enlarge the caliber of the urethra, enabling the instrument to advance slowly and pass the obstruction. If another stricture exists, proceed in precisely the same manner. When the canal is clear and open, turn off the current and withdraw the instrument. Never use more than five or six milliamperes of current. Watch the milliamperemeter care- fully. Remember that electrolysis is a species of absorption. It means neither cautery, nor heat, nor dilatation, nor divul- 238 MnnKKN I'llYSIO-Tlll KAPY. sion. The electrode should have a short curve. Begin and end the operation without current, i. e. turn the current on and off after the instrument has been introduced and before it is withdrawn. The operation can be repeated in a week. Never use more than one. instrument during one treatment. Remember that electrolysis will cure nearly every organic stricture of the urethra. Bad results are always attributable to faulty technique or mistaken judgment. Electrolysis of a urethral stricture should be bloodless, painless and product- ive of a quick and good result. (Robert Newman's record is a list of more than 2,500 cases without a single failure.) It is proper to add that negative electrolysis has been used to great advantage in cases of dysmenorrhea caused by stenosis of the cervical canal. Epithelial Hypertrophies, Warts, Fungi, Papillomata, etc. If a (negatively charged) needle is used, it should be inserted on a level of the skin or mucous membrane, the growth, if possible, being slightly raised by means of a suitable forceps. The growth is pierced and the current turned on. When electrolytic action is complete, the current is turned off and the needle removed. Another insertion at right angles to the first is made. Sometimes it is of advan- tage to use two or more needles at the same time by means of a suitable needle-holder. Different shapes of electrodes are often serviceable. On general principles it may be said that negative electrolysis is preferable in the non-vascular variety of hypertrophies and growths while positive elec- trolysis is better adapted to vascular growths where the cure is accomplished by obliteration of the vessels. Growths of the Connective Tissue Type (Fibromata, etc). The application is made by means of a suitable needle if the growth is easy of access, otherwise by means of a flat electrode placed on the skin directly over the growth. The possibilities of this method in cases of uterine fibroids (sub- serous, intramural, submucous, more especially the former two) have been amply demonstrated by Apostoli and his pupils. The usual mode of application consists in putting a THERAPEUTIC USES o;~ VARIOUS CURRENTS. 239 (negative) flat abdominal pad-electrode directly over the growth with a suitable (positive) electrode in the vagina. Apostoli inserted a (negative) intra-uterine electrode and placed a (positive) flat electrode on the abdomen. He em- ployed 50 to 250 milliamperes of current. In cases of easily accessible growths (submucous fibroids, polypi, etc.) he often used a needle or trocar charged negatively. The treat- ments are given every day or every other day for ten to fifteen minutes. In cases of goitre, negative electrolysis may be used, two sponge-electrodes being placed on the growth. Sometimes it is of advantage to put the negative electrode on the growth and the positive electrode in some indifferent place. The needle has been used successfully, but requires considerable technical skill and experience on the part of the operator. Bony and Cartilaginous Grozi'ths. Negative electrolysis is effective in removing bony outgrowths in the nasal fossa and in correcting deviations of the septum. By inserting a (negative) needle of suitable size into the substance of an accessible osteoma, exostosis, enchondroma or enchondrosis anywhere in the body, disintegration of the growth can often be effected. METALLIC ELECTROLYSIS is the employment of an elec- trode made of some metallic substance capable of forming chemical compounds by uniting with the ions at the positive or negative pole. It differs from cataphoresis pure and sim- ple because in the latter chemical substances en masse are introduced into the tissues of the body, whereas in metallic electrolysis the chemical substance is formed by a distinct chemical process which is set up by the use of a suitable metallic electrode. Thus, by using a positive electrode made of pure copper or pure zinc, oxides and chlorides of copper and zinc are formed by the action of oxygen and chlorine on the copper and zinc of the electrode. This therapeutic use of galvanism has been elaborated by many operators re- cently, and is available for a variety of clinical purposes. An interesting form of metallic electrolysis is the use of 240 MODERN PHYSIO-THERAPY. the zinc-mercury amalgam electrode at the positive pole, championed by G. Betton Massey. The action of the chem- ical products (oxy chloride of zinc and mercury), formed by the acid ions attacking the amalgam, is "sterilizing and alterant and is destructive to low forms of tissue." This mode of treatment is indicated in cases of local sepsis (ster- ilizing effect), of passive congestions (alterant effect) and in cases of cancer (destructive action). Gynecological practice seems to offer a vast field of usefulness for this method. Metallic electrolysis as well as simple (positive and negative) electrolysis are much-neglected branches of conservative or, in not a few instances, of palliative surgery. Many an inoperable case (e. g. osteo-sarcoma of the upper jaw) could be subjected to electrolysis and benefited. The electric current is in these cases a more humane and a more easily managed agent than the knife. CATAPHORESIS. The introduction of chemical agents (drugs) into the body by means of an electric current is called cataphoresis. The only current available for this purpose is the galvanic current. A sponge-electrode or piece of cotton is saturated with a liquid preparation of the drug and put on the skin. Very convenient cataphoric electrodes have been placed on the market which simplify the technique very much. The operator must know the electric affinity of the drug he is using. If the atoms of the substance he is using are attracted by the positive or negative pole of the current, the substance is said to be electro-positive or elec- tro-negative, as the case may be. In making a cataphoric application, electro-positive substances must be used with the negative pole and vice versa. Thus, iodine being at- tracted by the positive pole, is applied by means of the nega- tive pole. The positive pole is placed at some distance. The moment the current is turned on, the atoms of iodine will travel toward the positive pole Cocaine and all alkaloids are attracted by the negative and should, therefore, be ap- plied under the positive pole. Iodide of potash and all halo- gen salts are applied under the negative pole, to be drawn THERAPEUTIC USES OF VARIOUS CURRENTS. 241 toward the positive pole. For local anaesthesia the cata- phoric application of cocaine deserves to be better known and more frequently used than it is, especially in minor and in dental surgery. ELECTRODES. The shape, style, size and general con- struction of the electrodes used in the application of the various modes of administering galvanic electricity should be prompted by the purpose to which the electrodes are to be adapted. The surface to be treated and the canal or cavity to be invaded should call for certain shapes and sizes of electrodes. To enumerate them would be an endless task. The catalogues issued by the manufacturers of these goods are the best source of information. The principal and most important feature of an electrode is that it delivers current to the body without offering too much resistance. The elec- trical contact between electrode and skin should be perfect. If sponges are used, they should be wet. Water is an ex- cellent conductor. For this reason the complete or partial bath is frequently used as a means of administering elec- trical treatments. The region to be treated is immersed in the water, which plays the part of the electrode. A metal plate in the water is connected with one pole of the bat- tery, the other pole (e. g. sponge) being held by the patient or an attendant, who applies it to some part which is not in contact with the water. The technique is simple, the physio- logical action being in accordance with the principles out- lined above. The immersion in medicated water is a splen- did mode of administering cataphoresis. On general prin- ciples direct metal contact with the skin, e. g. the abdominal electrode, is not desirable. Contact is most effective and less irritating by means of a moist sponge, carbon, or by wet cloth wrapped around a metal electrode. Electro-thera- peutic applications that are painful are of questionable utility unless pain is unavoidable. If pain can be abided, it .should be. Some of the best and most useful electro- therapeutic applications are painless because the amperage used is slight. Next to producing a good therapeutic result, 242 MODERN PHYSIO-TIIKKAI-Y. the operator should strive to adopt an agreeable mode of procedure, if such is at all possible. This is a point of some importance, because much of the pain and discomfort inci- dental to electro-therapeutic procedures, is needlessly in- flicted and might be avoided by correct technique. Cleanli- ness is a necessary part of electro-therapeutic manipulations, especially with reference to the electrodes used. To use wet sponge-electrodes on one patient after another, is practically a cataphoresis of dirt and as such has no place in the arma- mentarium of a modern electro-therapeutist. Faradism. Compared to the therapeutic importance and usefulness of galvanic electricity, the faradic current dwindles into in- significance. Its therapeutic uses are suggested by the markedly excitant and stimulating action on muscular tissue. In response to a faradic current muscular fibers contract more or less violently. This means physiological activity for the contracted fibers and involves increased local oxida- tion and metabolism. The muscle-fiber requires more blood after exercise of this kind to furnish the oxygen required. In this way more nutriment is carried to the muscle, and the latter improves both in functional power and in sub- stance. The faradic current, therefore, is a muscular tonic within physiological limitations, i. e. if the exercise produced by the current is not overdone and if the blood drawn to the active muscle is of good nutrient quality. The exercise involved in faradic contraction of muscle-tissue must not be carried to the point of fatigue or exhaustion of the fibers. It must not bruise or jar them, but must be closely in imi- tation of physiological muscle-exercise. Only then will the distinctly tonic effect of the faradic current become manifest. Spasmodic contractions of muscle, e. g. cramps in the ex- tremities or the spasmodic form of dysmenorrhea, are al- ways due to some perversion of the functional activity of the nerves controlling the muscles affected. Since functional nerve-diseases per se do not exist but are always produced THERAPEUTIC USES OF VARIOUS CURRENTS. 243 by some unidentified change in the structure and mutual relation of the neurons, and are, for this reason, diseases of local nutrition, it is plain that the methodical use of the fara- dic current under these circumstances has a logical thera- peutic significance. It is a tonic in the proper sense of the word. It improves the tone of muscle tissue by altering, i. e. t>y improving the local nutrition. In this way it counteracts spasm because the latter is due to a lack of tone of the mus- cle or control of the muscle-function through the nerve- supply. It stands to reason that the intensity of the tonic effect of a faradic current will depend on the extent of the area treated and on the relative adaptability of the current to take the place of physiological exercise. A mild faradic current administered to a patient sitting in a bath-tub, the water reaching to the costal border (one pole in the water, the other applied to the neck, chest and back by means of a sponge-electrode), ought to other things being equal produce a fine, gentle stimulating effect. There must be no pain, only a gentle tingling. Through the muscular tissue the current is bound to affect contiguous structures. The faradic current is useful in cases of redundant pan- niculus adiposus in the abdominal wall. It improves the quality of the muscular tissue of the abdominal wall at the expense of the fatty layer. It stimulates the muscular fibers in the walls of the intestines and is, therefore, of value in the treatment of atony and dilatation of the stomach and bowels. In rectocele, cystocele, prolapsus, in fact in all conditions produced and aggravated by loss of muscular tone, the faradic current does very well. It enhances the effect of massage and may be combined with massage by causing one electrode to be held by the patient, the other by the unengaged hand of the operator. This is a splendid ad- dition to the technique of Thure Brandt massage. The use of the rectal electrode is of great benefit in the treatment of hysteria. The apparent anodyne action of a faradic cur- rent in neuralgic cases (e. g. sciatica) is due to its alterant action on the muscular tissue and through the latter on the 244 MODERN PHYSIO-THERAPY. circulation. The blood-supply is regenerated and the cry of the nerve for healthy blood is stilled. The use of violent faradic shocks is never indicated except in paralytic condi- tions where it is a question of making an impression on tissue that has hardly any vitality left in it. Painful applica- tions of the faradic current are never proper. Owing to the fact that the faradic current is an alter- nating current, it is of little consequence which pole is used. Polarity, which is everything in galvanic and static elec- tricity, is of no consequence in faradic applications. For obvious reasons, the faradic current can not be used for electrolysis or cataphoresis. What has been said concern- ing the electrodes used in applications of the galvanic cur- rent, might be repeated in regard to faradic applications. There are, however, fewer electrodes required because the therapeutic field of the faradic current is small compared to that of galvanic electricity. Static Electricity. "Static electricity is adapted to the scientific treatment of all diseases," "Static electricity, if administered by a judicious and skilled operator, is a valuable adjunct in the treatment of many chronic diseases." "Static electricity is a suggestive agent of no inconsid- erable efficacy." These three statements, quoted from three different medical text-books, represent the three camps into which the profession is divided on the subject of static electricity. The morbid enthusiast sprays and sparks his patients for every ill to which human flesh is heir. The skeptic who knows nothing about the subject, but assumes an ex cathedra tone in his denunciation, sees nothing but the suggestive in- fluence of ponderous machinery and mysterious perform- ance. Both the enthusiast and the skeptic are at fault. The former is usually deficient in his knowledge of general medicine, while the latter is positively ignorant about the THERAPEUTIC USES OF VARIOUS CURRENTS. 245 static machine and its legitimate sphere of usefulness. That this sphere of usefulness is much smaller than the popular- ity of the subject of static electricity would lead us to be- lieve, is unquestionably a fact. Static electricity is far from being a panacea. In point of therapeutic value it does not rank with galvanic electricity, although it seems to be supe- rior to faradic electricity. Its physiological indications, however, are less definite than those of either. There is a larger share of uncertainty and guesswork in the applica- tion of static electricity and a correspondingly greater por- tion of the suggestive element than in either galvanism or faradism. Yet static electricity possesses certain charac- teristic features of its own that make it valuable many times and actually invaluable sometimes. Therefore, the golden mean of conservatism expresses a fair estimate of the subject. There is no doubt that static electricity, if ad- ministered by a judicious and skilled operator, is a valuable adjunct in the treatment of many chronic diseases. What effect has static electricity on living organisms? The life of man is spent within the magnetic field of the earth. The earth is a magnet rotating around its axis and surrounded by induced positive electricity, the earth being the negative element. The particles of solid matter floating in the atmosphere about us, the moisture and vapor that fills space in many degrees of density, are all charged positively. All vegetation, using the latter word in its vast biological sense and including the animal and the vegetable kingdoms, is a phenomenon dependent on, and influenced by, positive electrical charges. The researches conducted by S. Len- strom at the physical laboratory of the University of Helsing- fors and by expeditions under his direction in different parts of the world and under varying climatic and meteorological conditions, have demonstrated the influence of positive elec- tricity on vegetative processes. The most interesting fea- ture of his experiments is the fact that he used electricity produced by a Holtz machine with the negative side 246 MODERN* PHYSIO-THERAPY. grounded. He studied the effects of positive charges of varying potential. His conclusions give to positive elec- tricity of high electro-motive force the greatest biological significance. There is no doubt whatever that animal and vegetable life with reference to the relative intensity of its out- ward manifestations, is directly influenced by the difference in potential between the positive and negative terrestrial ele- ments. The higher the potential of the positive element, the more active the processes of animal and vegetable life. Lenstrom showed that plants grow faster, develop better and procreate more plentifully under continued positive electrification. Negative charges at first seem to have a similar effect. Soon, however, the activity seems to lag. This indicates that the vital energy contained in the organ- ism and shown in its growth and reproduction, is closely re- lated to, if not identical with, the positive element which the rapidly revolving earth-magnet induces within its mag- netic field. Life on this planet, therefore, is electro-positive. 1 Translating these biologic considerations into therapeutic language it would seem as though a positive insulation (pa- tient on the platform charged positively, negative side grounded) represents an arrangement aiming at the preser- 1 It is not improbable that phagocytosis is an e'.ectro-magnetic process. Animal !ife is electro-positive. Since animal life depends on the action of oxygen on combustible elements, we are not sur- prised that oxygen is an electro-positive element. It has an affinity for elements which are foreign to the organism and, therefore, negative, e. g., microscopic scavengers. The latter are largely anae- robic and die when the oxygen-carrying corpuscular elements of the blood attack them. Considering the affinity of sunlight for oxygen we are prepared to understand the importance of sunlight in the treatment 'of tuberculosis. The plasmodium malariae which ema- nates from the earth, is eleciro-negative. We are aware that the electro-magnetism of the earth is subject to variation as the result of meteorologic influences, and that, therefore, the plasmodium must necessarily be affected by the variable electro-magnetic condi- tions of its habitat. This probably accounts for the variability (periodicity) of malarial manifestations. THERAPEUTIC USES OF VARIOUS CURRENTS. 247 vation of vitality and physical energy. Clinically this is true. Wherever and whenever a tonic-sedative is indicated, the positive insulation is the proper static application. Positive static electricity tends towards structural and functional preservation of organic tissue. In a much more emphatic sense this statement holds good when the potential of the positive current is raised by induction, e. g. by the use of I,eyden jars. Thus the Morton wave-current may be classed as an agent which is capable of increasing the physio- logical resisting power of the part to which it is applied. It restores the metabolic equilibrium which is disturbed in all conditions characterized by increased venous and de- creased arterial pressure. Passive congestions are removed by improving the physiological "tone" of the affected re- gion. Pain is relieved because nutrition is rectified and toxic material turned into the proper excretory channels. Health has been defined "a condition characterized by per- fect equilibrium of arterial and venous blood-pressure." Disturbance of this equilibrium results in locally increased arterial pressure (hyperemia, over-nutrition) or locally aug- mented venous pressure (anemia, under-nutrition), both conditions resulting in disturbed nutrition of the nerves whose cry for proper nutriment we call pain. Positive static electricity, especially of very high potential in restor- ing the physiological tone of the affected area, tends to re- establish the normal equipoise of the two forms of pressure and in this way counteract stasis and relieve pain. If the physiological tone of any region has been completely sus- pended and the life-principle is fighting for preservation under pathologic conditions (inflammation or its antipode "a-trophy" or lack of nutrition), positive electricity would be of no avail. All positive static application, including the wave-current, should be restricted to conditions which are characterized by lowered tone of the system or any part, c. g. nervous disorders, venous congestions, chronic in- flammatory conditions. In making applications of this kind, 248 MODERN PHYSIO-THERAPY. etiology and pathology mean everything. Symptoms have but little therapeutic significance. It is of some importance and assuredly of considerable interest to know something about the physiological modus operandi in which static electricity acts upon the tissues of the body. Neiswanger states that the nerves of the human system are like tuning-forks which will respond to a certain number and strength of force-oscillations. The supposi- tion is that the nervous system is made up of an unlimited number of "receivers," each one being capable of respond- ing to a certain kind of a vibratory impulse. The author supposes that in giving a patient a static treatment, one or more nerves in the body are bound to vibrate in unison with the vibrating force-modalities that are reverberating through the system. It is plain that the explanation is neither physiologically nor therapeutically admissible. The human body as a conductor of static electricity does not differ from other conductors in the manner in which it receives and stores this kind of energy. The latter accumu- lates on the surface of the conductor. It is the skin which is the real conductor, not the nerves nor any other structure in the body. The physiological or primary effects of static electricity are confined to the skin. The therapeutic effects are secondary and follow in physiological sequence the ac- tion which has taken place in the skin. The part which the skin plays in the animal economy has been repeatedly em- phasized, especially under the head of HYDRO-THERAPY. Analogous to the atmospheric pressure which regulates the intra-vascular blood-pressure, the functional energy of nerve-tissue is regulated by the terrestrial magnetic field by which we are surrounded. Diminution of air-pressure causes dilatation of the vessels along the external and in- ternal surface of the body. This accounts for the occurrence of hemorrhages, especially from the exposed mucosae, when atmospheric pressure is decreased. When the potential of the positive magnetic energy is lessened, it diminishes the degree of active control which the nerves, the carriers of THERAPEUTIC USES OF VARIOUS CURRENTS. 249 life-energy, exercise over the several parts of the or~anlsrn. Thus the muscular fibers in the blood-vessel walls are re- laxed and the vessel itself dilates, the moment the mag- netic or electrical tone of the vaso-motors is lessened. This occurs through the cutaneous nerves which are alone ex- posed to influences of a magnetic character. The skin- nerves receive the impetus, the vaso-motors show its physio- logical presence. This explanation is analogous to the physiological syllogism by which Winternitz explains the action of thermic stimuli. If the patient receives a negative t.pray, the positive potential of the region is lessened, nerve- tension decreases, the tissues relax and the arteries dilate. \\'e look upon negative applications of static electricity as being stimulating in character because the arteries dilate and the amount of arterial blood increases. The more the positive potential of the body decreases, the more stimulat- ing will be the effect of a negative static current. The stimulating effect will finally merge into an irritating action 2S seen by the redness and soreness of the skin which fre- quently follows negative local applications. If the poten- tial of the body is increased, the electrical action will be re- storative, tonic, sedative. If applied to the head, the posi- tive current will cause cerebral anemia and somnolence ; the negative current will stimulate, causing wakefulness and mental activity. The skin is undoubtedly the scene of action of static currents. Through the skin the whole system is reached, a sedative or a stimulating effect being reflected through the sympathetic nervous system as well as by contiguity of tis- sue. Thus we may produce a distinctly physiological ef- fect on the renal circulation by applying a wave-current to the small of the back in cases of chronic interstitial nephritis. That the static current is of the greatest value in disorders of the skin itself, goes v/ithout saying. A characteristic effect of static electricity is its action on oxygen. Oxygen has an affinity for positive electricity. When a positive charge of static electricity passes through a 250 MODERN PHYSIO-THERAPY. volume of oxygen, a disintegration of the gas and a rear- rangement of atoms of oxygen take place. A new gas is formed which has negative affinity and is tri-atomic. It is called ozone and has a characteristic odor. The passage of a flash of lightning through the atmosphere likewise pro- duces ozone (tri-atomic oxygen). Ozone has more power- ful oxidizing properties than oxygen. When a positive static spray is administered to the skin, some of the oxygen in the tissues and in the cutaneous vessels is changed to ozone and circulates as such, giving to the body, but more especially to the exhaled air, the characteristic smell of ozone. From what has been said concerning the physiological effects of static electricity, we are prepared to summarize the therapeutic indications of the several static currents as follows : 1. Positive static electricity is to be administered to counteract hyperemia, nervous irritability, pain due to con- gestion, exaggerated reflexes, and all conditions due to overstimulation. It is a gentle circulatory regulator, nerv- ous sedative and analgesic. 2. Negative static electricity is to be administered to counteract sluggishness of the circulation, lack of nerve- response, pain due to venous stasis (ischemia), absent or retarded reflexes and all conditions requiring stimulation. It is a decided stimulant, excitant and even irritant. The different methods of applying static electricity are partly a matter of preference on the part of the operator, partly suggested by the character of the case. For general treatments the insulation and the use of the head-breeze are the best modes of application. For local troubles the most useful methods are the direct and indirect spray, potential alternation and the Morton wave-current. The operator should endeavor to make a static treatment as agreeable and comfortable to the patient as possible. There should be no unnecessary sparking and shocking. Hats, combs and steel- corsets should be removed. THERAPEUTIC USES OF VARIOUS CURRENTS. 251 There is always a suggestive element in using static electricity. This is a fact which is too well estab- lished to be questioned. Let the operator direct the sug- gestive influence into the proper channel in the interests of the patient. Let the operator's efforts not be confined to this. He should look upon the suggestive effect as being in- cidental and secondary to a well-planned and well-adapted therapeutic method based on clearly defined diagnostic fea- tures of the case and on exact knowledge of the physiolog- ical indications and possibilities of static electricity. Currents of High Frequency. Next to galvanism the so-called high-frequency currents are the most interesting and promising agents along electro- therapeutic lines. Properly speaking, it is not in keeping with the present state of our knowledge to classify these agents under the head of electro-therapy except in a pro- visional sense. From a physical standpoint the classification is not open to objection. In a physiological sense, however, its correctness is not altogether well established. The currents of high frequency produce effects on the organism that have nothing in common with the physiological activities of gal- vanism, faradism or static electricity. The physiological effects of high frequency suggest the action of force-modali- ties that are properly included under the head of radiology. The mysterious rays of Roentgen and the ultra-violet rays of Finsen seem to bear a closer relationship to these cur- rents of high frequency than do the forms of electricity here- tofore discussed. It seems that we are at the border-line where electrical modalities merge into the force-manifes- tations of visible and invisible light-rays. It appears diffi- cult to identify the currents of high frequency as electrical phenomena when we consider their remarkable conduct un- der given physiological conditions. On the other hand, they are so closely related to currents of high voltage or static machine currents that it seems illogical to separate them from force-modalities so closely related to them. It 252 MODERN PHYSIO-THERAPY. is undoubtedly a fact that they are the link between elec- tricity and light, borrowing from either some characteristic physical properties and promising, therefore, to occupy a therapeutic place some day to which neither electricity nor light can aspire. The first form of a high-frequency current that received attention and study from a therapeutic point of view was the static induced current with which the name of Morton will always be associated. The physics of high frequency was elaborated by D'Arsonval and Tesla, principally by the former, to whom we are also indebted for much of our knowledge concerning the physiological aspect of the sub- ject. It was he and his colleagues Apostoli and Oudin who did the pioneer work in this new and wonderful field. The term "high frequency" is a relative one and refers to the excessively high speed of alternations of the current. The term "alternation" suggests the conduct of the electro- motive force, the direction of which is varying or alter- nates. In conjunction with the medium through which the electrical force-manifestations occur, namely the ether, the alternations are coincident with movements of the electrified ethereal molecules. These movements are oscillatory in character. For this reason, the term "oscillation" as the physical characteristic of currents of high frequency is used synonymously with "alternation." Strictly speaking, the two terms are not synonymous. All force-manifesta- tions depend on oscillatory movements of the ethereal mole- cules. The phenomena of non-alternating (direct) elec- trical currents are likewise oscillatory, so are all evidences of force-modalities. The very character of an alternation suggests a complex process of ethereal movement, consist- ing of at least two oscillations of each molecule giving to each wave (undulation) a distinct progressive movement serially, and transverse movement molecularly. Thus the ether is traversed by impulses of varying intensity, fre- quency and direction. In this way many lines of force- direction and vibration are established which belong to THERAPEUTIC USES OF VARIOUS CURRENTS. 253 other force-modalities, or rather which are the physical characteristics of the latter. Thus under given favorable conditions the complex process of vibration set up by a cur- rent of a certain high frequency may present the vibratory character (speed, wave-length) of the X-rays and many other force-modalities belonging under the head of ultra- violet force-manifestations. The friction and collision of the individual rapidly moving molecules are again a fruit- ful source of force-production and account for the wonder- ful induction-phenomena which are characteristic of cur- rents of high frequency. We are prepared to admit that the currents of high frequency represent a complex force- modality, or rather a variable combination of force-modali- ties. They are neither all light nor all electricity, but con- tain the potentialities of many varieties of visible and in- visible light, of X-rays, of electricity and perhaps of other modalities, the knowledge of which is still hidden in the bosom of the future. The therapeutic importance of high frequency is con- tained in the close relationship between currents of high frequency and the rays emanating from the ultra-violet field or fields of the spectrum. This relationship has been independently suggested by different observers. In 1902 the author became suspicious of this relationship when two of his assistants suffered from subacute conjunctivitis which they contracted from exposure to the Finsen-rays. Shortly afterwards an attendant developed a subacute conjunctivitis who had not been exposed to the ultra-violet radiations of the Finsen arc-lights. This attendant had worked with static and high-frequency electricity exclusively. The au- thor was unable to account for the eye-affliction of the nurse, when it occurred to him that the light from the vacuum-electrodes might have produced it. There was no doubt about the other two cases being cases of ultra-violet conjunctivitis such as are frequently seen in persons who work by electric arc-light. In thinking over the etiology of the third eye-case, the possibility of chemical rays being 254 MODERN PHYSIO-THERAPY. mixed with the high-frequency discharge suggested itself. The silicate-of-zinc test was resorted to. The silicate of zinc did not show the characteristic greenish fluorescence. The test was a dismal failure. Next sensitive photographic plates were resorted to, to ascertain the presence of chem- ical light. A number of these plates showed no effect after development, others did. One 5x7 plate was black after development. The results of these tests were suggestive enough, and were communicated to an authority in the East with a request for an opinion. His opinion was that the effect on the plates was due to rays of daylight which had not been excluded, that the experiments, while very inter- esting, were, deficient in technique, and, therefore, value- less. He gave it as his opinion that there was no connec- tion between high-frequency currents and chemical rays. Since the experiments were made, that which was a casual suspicion at that time, has become the basis of the therapy of high-frequency currents. Observations leading to the establishment of this basis were independently made by many observers in all parts of the world as far back as 1900. The incongruity of the opinions was the outcome of the endless number of degrees of frequency which are in- cluded under the general head of ''high" frequency. The fre- quency of the current determines the coincident oscillatory and undulatory phenomena. A current of a certain frequency may cause coincident ultra-violet undulations, while another current of a different frequency might produce no such inci- dental results. Yet both currents might belong under the general or rather under the generic head of high-frequency currents. This point was foreshadowed by Bloch, of Paris, who commented on the uncertain therapeutic character of high-frequency currents in the treatment of eczema, and attributed the variability of the therapeutic effect to the variability of the frequency of the current. He suggested that a better knowledge of the frequency of these currents would be essential for the establishment of therapeutic prin- ciples. He, of course, thought of high-frequency currents THERAPEUTIC USES OF VARIOUS CURRENTS. 255 as electrical agents pure and simple. He did not suspect that these currents might be classed as radiologic potencies. The therapeutic effects of currents of high frequency are both electrical and radiologic. A current of comparatively low frequency (500,000 oscillations or less per second) produces percussion-effects analogous to static currents. The cutaneous nerves respond and are principally concerned in the physiological reaction which follows. The effect is in the nature of an over-stimulation which results in hy- peremia and subsequent over-nutrition of the surface treated. If the application is continued the reaction will gradually become more violent, resulting in a dermatitis. Currents of this kind are produced by the high-frequency coil which is attached to the static machine. If the vacuum electrode is held at a slight distance from the skin, the sparks which pass between the skin and the glass resemble static sparks in their intensely irritating local action. A comparatively high frequency (500,000 and 1,000,000 or more oscillations per second) does not produce electrical effects of such a well-marked character. The stream of sparks is supplanted by the effluve-effect. For this kind of work the Oudin resonator is well adapted. The physiolog- ical action on the skin is analogous to, and not infrequently identical with, that of concentrated actinic light, even to the extent of the characteristic erythema and pigmentation. It is these true currents of high frequency that contain in their manifestations the ultra-violet element. It is safe to say that the therapeutic uses of these currents are largely dependent upon the chemical rays which are contained in the latter. The electro-motive force in both low- and high-fre- quency currents is very intense. ' Thus we obtain in all high- frequency applications the effects of high voltage, especially the disorganizing action on the oxygen in the tissues and in the red blood-corpuscles. Whether these currents pene- trate into the interior of the body or whether their electrical and physiological activity is confined to the surface of the 256 MODERN PHYSIO-TIIKRAPY. body, is not altogether clear, although it seems probable that their penetrating power, if at all present, is analogous to that of the radiations from an excited X-ray tube. The muscular contractions which currents of high frequency are capable of causing are amply accounted for if we look upon them as being due to the activity of the sympathetic nerves and not due to any direct penetrating action of the electric energy. The presence of heat-rays in the radiations from a high-frequency generator is easily demonstrated In justice to the subject, it may be of interest to know what opinions have been advanced by individual observers concerning the physiological effects of currents of high frequency. D'Arsonval considers the distinction between high and less high frequency of the greatest practical moment. He states that the sensory nerves can not be stimulated except within certain extremes of relative frequency. Below and above these extremes they will not respond. He says that cellular life is stimulated by high-frequency currents in the same sense in which an increase in the positive potential of the organism will stimulate vegetative function. Through the cellular elements metabolism is increased. The excre- tion of C O 2 is 50 p. c. more active, the output of urea is augmented, the excretion of uric acid diminished. Func- tions of the stomach and intestines become more active. D'Arsonval made his observations on patients who had been placed in his high-frequency cage. Hoorweg thinks that the physiological action of high- frequency currents consists of resonance-effects within the organism. Apostoli demonstrated an increase in the quan- tity of the urine and urea and an increase in the oxyhemo- globin of the blood. Patients are able to stand more ex- ertion. They digest better and sleep more soundly. Tripet found that high-frequency currents (general applications) caused the quantity of sugar in diabetic urine to be mark- edly diminished. Freund states that the quality of the blood is improved in every way and attributes this effect THERAPEUTIC USES OF VARIOUS CURRENTS. 257 lo the ozone which is formed in the body and carried by the red blood-cells. In diseases of the blood and blood-making- apparatus and in tuberculosis the high-frequency current is an agent of supreme value. The increase in the oxygen- appropriating power of the organism is well marked. The effects of high-frequency currents on bacterial life have been studied by many observers. The consensus of opinion is that germs are killed and their toxines modified and rendered innocuous by high-frequency currents. The latter modify the poison of scorpions and serpents, and ren- der it harmless. D'Arsonval succeeded in suspending the vitality of diphtheria-cultures by short exposures to high- frequency currents. Algae and fungi are permanently de- vitalized by these currents. Certain animals, especially rodents and the smaller felines, are susceptible to high-fre- quency currents and are easily killed without any apparent pain or struggle. Therapeutically the currents of high frequency repre- ;ent the most valuable agent in the treatment of skin-dis- eases, excelling any and all agents in this particular de- partment of clinical medicine. They are indicated in all cases of mal-nutrition of the skin, especially the dry form of eczema, in fact all disorders of the cuticle requiring stimulation of the circulation and of the functional activity of the skin. They render good service in cases of lupus erythematosus, psoriasis, tinea, acne, etc. The application is made by means of a vacuum-electrode. Reaction is in proportion to the distance between glass and skin. In cases of general diseases in which the quantity and quality of the blood are below par, general applications by means of an auto-conduction cage, a condensation-couch or a diasolenic cylinder are indicated. This holds good with special significance in cases of consumption. In honor of the distinguished professor of physiology at the University of Pans, who did so much in the interest of scientific elec- tro-therapy, especially along the lines of high-frequency 258 MoDKKN PlIVSIO-TlILRAPY. currents, this general application has been called "D'Arson- valization." The high-frequency currents are indicated in cases where metabolism, especially the excretion of waste through the kidneys, is at fault. Even locally these currents alter and improve tissue-change, which makes them particularly valuable in cases of rheumatism and neuralgia. The greatest accomplishments in this promising and in- THE D'ARSOXVAL COIL. teresting department of clinical medicine are yet to come. As soon as the exact relationship of the ultra-violet' radia- tions, the X-rays and the currents of high frequency has been identified, there will be unfolded unto our eyes a vista of untold clinical possibilities. More light to guide our faltering footsteps along the hidden paths that wind through this mysterious land of wonderful promises, is the consummation devoutly to be w:sh?d. X-R.\v DIAGXOSIS. 259 CHAPTER X. X-RAY DIAGNOSIS. 1 (The Roentgcn-tubc. The Fluoroscope. The Principles and Practice of Radiography.) THE success of radiographic as well as radio-therapeutic work hinges upon an accurate knowledge of, and skill in, the use of the vacuum-tube (X-ray tube, Crookes tube) by which the Roentgen rays are produced. Familiarity with the tube is the indispensable condition of successful X-ray work. Without a good and suitable tube it is impossible to do good work. The tube is by far the most important part of any X-ray equipment. The Roentgen Tube. The tubes which are generally used nowadays are varia- tions of the same original type : a glass globe with a num- ber of tubular projections communicating with its interior. The positive terminal (anode) is in the center of the globe and is represented by a platinum disc. The negative termi- nal (cathode) is a concave (cup-shaped) circular piece of aluminium, from which the so-called cathodal rays emanate and meet in a point on the anodal disc called the anodal focus. This point is plainly visible in tubes which have 1 The contents of the chapters on X-RAY DIAGNOSIS and X-RAY THERAPY have, in substance, been published by the author in the "Journal of Advanced Therapeutics," the "Journal of the Roentgen Society (London, England)," the "Archives of Physiological Therapy," the "Journal of Progressive Therapeutics," 'rtc. The diagrams are original with the ant!:cr. 260 MODERN PHYSIO-THERAPY. been used, either as a small discolored spot or by actual loss of substance at the focal point. The anode is frequently called "anti-cathode" on account of its position. The exhaustion of an X-ray tube is done by the tube- maker while a powerful current from the secondary wind- ing of a large induction-coil passes through it. When the a DIAGRAM OF AN X-RAY TUBE. G, positive attachment. K, negative attachment. J, anode of the regulating attachment. E, cathode of the regulating attachment. A, connection between tube and regulating device. exhaustion has been carried to the desired point, the tube is closed. If the degree of exhaustion is relatively perfect, the tube is called a hard tube, while a comparatively low de- gree of exhaustion produces what is known as a soft tube. Thus the relative hardness or softness of a tube depends on the degree of exhaustion or the vacuum. When the tube is properly lighted up, the connections being properly made, the hemisphere in front of the anodal disc is aglow with a characteristic greenish light while the hemisphere back of the anode remains practically dark. The plane which sep- arates the two hemispheres is known as the anodal plane. X-RAY DIAGNOSIS. 261 The X-rays are produced on the outside of the tube and represent lines which, if they were continued toward the interior of the tube, would all meet in the anodal focus. The latter, then, is the true center of radiation. When a tube has been used a great deal, the glass in front of the anode gradually takes on a bluish hue. This is due to the deposit on the internal surface of the tube of fine particles of plati- num and is always a sign of age. Owing to the fact that these particles of platinum have a tendency to absorb gas or air, an old tube is most likely to be a hard tube. All these points referring to the physics of the tube itself and the physical characteristics of the rays emanating from the tube will be fully discussed under special heads. The spark-length of a tube is the length of the electric spark between the terminals of a static machine or a coil which, with the tube in the circuit, would cause the tube to functionate properly. The vacuum of the tube determines the required spark-length. Thus, if a tube of a certain vacuum is lighted up properly by electric energy capable of producing a five-inch spark, the tube is supposed to have a spark-length of five inches. The form of electricity which is capable of lighting up an X-ray tube is characterized by high voltage and low amperage. For this reason the static machine is available for X-ray work. Static electricity has but little volume but tremendous electro-motive force. In the X-ray coil the ordinary street-current is transformed into one of high voltage by the action of the so-called in- terrupter and by the induction which takes place in the secondary winding of the coil. The original type of the X-ray induction coil is the Ruhmkorff coil, the construction and physics of which are analogous to the faradic coil. The relative usefulness of an X-ray tube consists in its degree of exhaustion (vacuuwC] and in its fitness to retain its vacuum for a reasonable length of time. The vacuum is changeable in all tubes. Even during one X-ray exposure the internal conditions of the tube gradually become differ- ent. The passage of the electric currents sets free mole- 262 MODERN PHYSIO-THERAPY. cules of gas or air that have been absorbed by particles of platinum. The constant tendency of a tube to change its vacuum makes it desirable to have some means of controll- ing the vacuity of a tube. This is the object of the so- called regulating device or attachment for softening or hardening the tube. The regulating device contains two terminals (a glass peg with a platinum spiral for the posi- tive side, a disc for the negative side). The negative ter- A GOOD STATIC X-RAY TUBE WITH REGULATING DEVICE. minal of the regulating attachment is connected with a movable wire which can be brought near or in contact with the negative (cathodal) attachment of the tube itself, i. c. the hook or eye for attaching the negative cord to the tube. If the movable piece of wire on the negative side of the regulating attachment is brought close enough to the cathodal end of the tube itself to allow a spark to pass from the cathodal end of the tube to the wire, the spark will travel along the wire and be communicated to the disc X-R.\Y DIAGNOSIS. A HEAVY ANODE X-RAY TUBE WITH REGULATING DEVICE. A WATER-COOLED X-RAY TURE WITH REGULATING DEVICE. 264 MODERN PHYSIO-THERAPY. which represents the negative terminal in the regulating at- tachment. The disc is made out of some chemical mixture which has the property of setting gas free when an electric current passes through it. The gas passes into the interior of the X-ray tube and loivers the vacuum, rendering the tube softer. If the movable piece of wire is turned up and and the negative cord is attached directly to the eye in the wire (near the upper end of the wire) the softening effect would be correspondingly prompter and more intense, be- cause all of the negative current would pass through the DIAGRAM ILLUSTRATING THE PRINCIPLE OF THE SPARK-GAP. chemical disc. If the negative cathodal cord is left undis- turbed and, instead, the positive (anodal) cord is detached from the tube and attached to the positive end of the regu- lating device, the positive current would pass into the plati- num spiral around the glass peg. The platinum spiral would eventually become hot and gradually absorb gas from the interior of the tube, thus rendering the vacuum liighcr and the tube itself harder. It is well to know that it takes a good deal longer to harden a tube than to soften it. If the tube, while in action, does not show the two hemispheres (green and dark) and is filled with a bluish light, it is too soft for the production of X-rays. In cases of this kind a spark-gap on the cathodal side will often make the tube X-RAY DIAGNOSIS. 265 available (see diagram). If a stream of blue light or a spark passes between anode and cathode, the tube is worthless for X-ray work, because too much gas or air is present in the tube, indicating a puncture. The same may be said when the anode is surrounded by an areola of reddish light. The tube, under these conditions, must be re-exhausted. Tubes that have become too hard may be temporarily restored by prolonged rest or by slowly heating them in a dry-heat cylinder (oven). These are the salient points in regard to all X-ray tubes. The geometrical, physical, chemical and physiological prob- lems involved in the handling of the tube and in the applica- tion of its force-modalities, we will have occasion to con- sider at some length under the special heads of RADIOGRAPHY and RADIO-THERAPY. The Roentgen rays, for purposes of diagnosis may be Used in two ways, (i) with the aid of the so-called fluoro- scope, and (2) as a means of affecting a photographic sensi- tive plate upon which the shadows of an object are recorded. Fluoroscopy. The fluoroscope is a screen made of pasteboard upon which a layer of some chemical mixture is placed, which be- comes fluorescent when acted upon by X-rays. The screen is usually incased in a quadrilateral pyramidal box, which is supplied with a handle, the screen representing the base of the pyramidal box, the apex of the pyramid being open. The fluoroscope is held by the hand of the operator, with the screen nearest the object. The most common fluorescent substances used in making fluoroscopes are calcium tung- state and barium cyanide. The fluoroscope enables the operator to get a direct image of many parts of the body, the shadow-picture being projected, on the screen. Fluoroscopy requires a softer tube than skiagraphy. Differentiation of the shadows of an ob- ject is more essential when the human retina receives the picture than when a sensitive plate is acted upon. Fluoro- 266 MOHKKX PnYsio-Tin KAPV. scopy should be practiced in a dark room, and not until the eyes of the operator have become habituated to the absence of day- or artificial light (ten to fifteen minutes). The less the eye of the operator is irritated by actinic light the greater will be its discriminating power in regard to the shadows of an X-ray ima^e thrown on a fluoroscopic screen. In order to prolong the life of a fluoroscope as much as pos- sible, the instrument should be kept in a dry dark place and protected against dust. The common size of a fluoroscope is 6x8 inches. For examinations of large parts (e. g. the chest) a fluoroscope of appropriate size should be em- ployed. In a general way it may be stated that the value of the fluoroscope has been and is very much overrated. Its use- fulness is restricted to comparatively superficial parts (hand, wrist, elbow, thin shoulder, foot, small knee, child's hip, neck and chest). Examination of an adult's hip by means of a fluoroscope is never satisfactory. Fluoroscopic examinations of the abdomen of adults are impossible, the statements of optimistic radiographers notwithstanding. The operator should guard against the suggestive influences of his own imagination, lest he see things, not because they are actually there, but because he expects to see them and wants to see them. The operator who seriously stated that the diagnosis of gall-stones can be made by means of a fluoroscopic examination, and that he could make out the pancreas and other viscera, was. certainly laboring under a powerful auto-suggestion. Even in superficial parts every- thing depends on the experienced eye of the operator. It may be safely said that the fluoroscope has a fourfold pur- pose and should be used accordingly : 1 . To ascertain the presence of a foreign body ; 2. To study a fracture or a dislocation ; 3. To study parts which are necessarily movable (intra- thoracic contents) and, therefore, do not make good sub- jects for skiagraphic work ; 4. To make an examination of a part which is to be skia- graphed. To explain : X-RAY DIAGNOSIS. 267 It is understood that the fluoroscope can not be used on parts of the body that do not project distinctly differentiated shadows on the screen. If the tube is too low, the shadow of a hand would be a jet-black silhouette. Such a shadow picture would be worthless in locating a foreign body. If the tube is too hard, the shadows of the bones would be too faint and not distinct enough to show the details of a frac- ture. It is essential, therefore, to use the proper kind of a vacuum. If the part to be examined is too dense, e. g. the abdomen, it is useless to attempt fluoroscopy. The chest offers a fairly good field for fluoroscopic examination. 'The movements of the diaphragm and the heart, the size and position of the heart, the presence of mediastinal tumors, calcareous deposits and foreign bodies in the lungs can be seen and closely observed. The fluoroscope serves a splen- did purpose in giving the operator a view of many parts of the body before he takes a skiagraph. Fluoroscopy should precede skiagraphy, whenever this is practicable. In the hands of an unskilled operator the fluoroscope has often proved to be productive of harm rather than good, because it offers a constant and strong temptation to permit imagina- tion to take the place of judgment. The ideal way of mak- ing an X-ray diagnosis is to allow the rays to project the shadow-picture on a sensitive plate. Radiography. (N. B. "Radiography" is the term generally employed by the profession. While it is etymologically objectionable, it is preferable to "skiagraphy." which practically means the art of making shadow- pictures ("skia," shadow}, irrespective of the agent _which is em- ployed. Both terms cover the ground not only of X-ray photogra- phy, but include all radio-active substances and agents. In accord- ance with the scientific tendency of classifying physical phenomena in keeping with the causes which produce them, radiography seems to be the better term because it refers to the cause, while the term "skiagraphy" suggests the effect produced.) There seems to be no doubt that the method of taking X-ray pictures is to a large extent the result of habit and 268 MODERN PHYSIO-THERAPY. convenience and is, therefore, with most operators an en- tirely personal problem. It is true that there are certain vague notions of fundamental principles which serve as a ground work for skiagraphic procedures generally. In point of detail, however, and with reference to the conscious adaptation of radiographic work to specific anatomical problems, making the former subservient to the latter, the subject is far from being a uniform and logically de- veloped system of scientific research. It represents a loosely connected series of methods and amounts to just as much as the diagnostic judgment, skiagraphic skill and reasoning power of the individual operator will allow. It seems to me that the topographic landmarks of this most fascinating and ever-important subject are clearly enough marked to admit of the recognition of more than the hitherto accepted vague 'and ill-defined outlines. What is meant by a good X-ray picture? A striking photographic result appeals to the average physician be- cause it possesses the elements of beauty which we are in the habit of admiring in pictures generally. The thoughtful radiographer, especially if he happens to be a good surgical anatomist, not infrequently remains indifferent at the sight of what others rave over, and often becomes interested when others see nothing of any consequence in a skiagraph. Why should this be so? The reason becomes apparent when we consider that the discriminating power of the eye of the layman is exercised in the differentiation of lights and shadows and the relation of these to each other. The eye i? not accustomed to any other kind of reasoning. It can appreciate the lights and shadows of the real object and can, therefore, see the features and details of a photograph of the real object. A skiagraph is not the photographic repro- duction of a real object. The innumerable waves of energy that emanate from the surface of the X-ray tube and, after traversing space and penetrating the object, strike every point of the exposed sensitive plate, leave a sum-total of im- pressions behind which are a truthful record of the density X-RAY DIAGNOSIS. 269 CHONDROMATA ATTACHED TO BONES OF THE HAND. 270 Moni'K.x I'IIYSIO-TIII-KAPY. of the object at every point. A photograph is a record of impressions made by rays of light of various degrees of in- tensity from the object. There is no suggestion of density or interception, partial or complete, of light rays. This, however, is exactly what the X-ray picture pre- sents. There are no light-rays coming from the object. The rays go through the object, each wave encountering a certain resistance determined by the density of the tissues traversed by that particular wave. The greater the degree of density, the more marked will be the interception of the quantity of force represented by that wave. When it finally reaches the sensitive plate, it leaves at one point a record of relative density of the tissues traversed. The sum-total of these density records is a skiagraph. The latter is not a picture of a real object, but the pictorial record of a phys- ical characteristic of the object. The skiagraph, therefore, is not a representation of an object, rather an abstraction from an object. To give this abstraction a physical reality requires the application of a radiographically trained eye and mind. The failure to grasp the fundamental difference between a photo-graph (light-picture) and a skia-graph (shadow-picture) explains many errors of judgment on the part of not a few X-ray operators. Radiographic Technique. The process of taking an X-ray picture consists of the proper use of five different elements in their proper rela- tion to each other : 1. The machine generating the form of electric energy which is available for the production of the Roentgen-rays. The static machine and the coil are the generators usually employed for this purpose. 2. The X-ray tube through which the high-tension cur- rent supplied by the generator is transformed into X-ray energy. The transformation is consequent upon (i) the concentration of the cathodal stream in a point upon the anode known as the anodal focus; (2) the radiation of TUBERCULAR JOINT. S*R10STtUM a BONE SYPHILIS OF BONE. 272 MODERN PHYSIO-TIII.RAPY. electric energy from the anodal focus through the hemis- phere in front of the anode ; and ( 3 ) the impingement of electrified molecules of ether upon the inner surface of the tube. The form of energy which is generated by induc- tion on the outside of the tube is known as X-rays. 3. A device by which other forms of radiating energy can be intercepted and thus kept from mixing with the diverging X-rays. The researches of Freund, Walter, Tesla, Stenbeck and Schiff have demonstrated the exist- ence of different forms of radiating energy emanating from the outer surface of the X-ray tube and capable of affecting a sensitive photographic film after penetrating an object, thus leaving a shadow wherever they have struck the film. What enormous importance this fact has in the production of a photographic result we shall see later on. 4. The object to be skiagraphed represents a mixture of substances of various degrees of density. The denser the substance, the harder it is to penetrate it by the Roentgen- rays and the fainter will be the shadow on the film after the latter has been developed in the dark room. Then, again, the position of the object has everything to do with the pro- duction of a shadow-picture (skiagraph) on the film. 5. The photographic sensitive plate which is properly protected against the actinic rays of sunlight or artificial light by being wrapped in a black and in an orange-colored envelope. The five points mentioned indicate the necessary tech- nical equipment for the taking of an X-ray picture. The first and last (current-generator and photographic plate) may be practically left out of consideration because their readiness and relative fitness for radiographic work are taken for granted. No one can expect to do good radio- graphic work unless he has the tools to work with. The best and most reliable generator for X-ray work is a good, well-constructed coil (15 to 20 inch spark-gap, 5. TO to 15 amp. capacity). A static machine is capable of doin^ fairly good work, especially if its efficiency is supported by a good, X-R.\Y DIAGNOSIS. 273 - o o - o H C/5 274 PHYSIO-THERAPY. well-adapted tube. Taking it for granted that the operator is supplied with a generator of suitable capacity and that he is using a good quality of photographic plate, the dis- cussion of the technique of X-ray photography practically resolves itself into a detailed consideration of (i) the tube, as the real generating source of X-ray energy; (2) the me- chanical device which is to intercept foreign and disturbing forms of radiating energy and known as the X-ray Camera ; and, last but not least, the density and the position of the object. FIGURE i. Geometrical Features of Lines of Radiation. The lines or waves of electric energy arise or emanate from the cathodal surface and meet in a point on the anodal disc or plate. The concentration of cathodal waves in one point is made possible by the construction of the cathode. The lat- ter is cup-shaped and represents a segment of a globe. The cathions (smallest particles of cathodal electric energy) arise from each point on the cathodal surface at a right angle to the tangent. In Fig. i, A B represents the curve of the cathode. C D is a tangent touching the curve at E. X-RAY DIAGNOSIS. 275 A wave of cathodal energy arises at E at a right angle to CD. F is a point on the anodal disc in which all cathodal waves meet. The dotted lines represent two more waves and the tangents of the points of issue. F is known as the anodal focus which does not necessarily represent the center of the anode (G H). From the anodal focus (F), where the cathodal rays meet and are united with the anions (smallest particles of anodal electric energy), radiation of FIGURE 2. force-waves takes place in all directions in front of the anodal disc. Thus the tube when lighted up shows the hemisphere in front of the plane of the anode aglow with a characteristic greenish light, while the hemisphere back of the anodal plane remains dark. When the radiation from the anodal focus takes place, causing electrified molecules of ether to impinge upon the inner surface of the tube, the outer surface of the latter gives rise to peculiar phenomena of force-production. Different kinds of waves of ray- energy arise from this outer surface, among them the waves 276 MODERN PHYSIO-THERAPY. of that mysterious force discovered by Roentgen and called by him the unknown-quantity-rays or the X-rays. The X-rays arise on the outer surface of the tube at right angles to the tangents of their points of issue. In Fig. 2, BAG represents a segment of an X-ray tube. The wave of energy which arises at F (anodal focus) and impinges upon the inner surface of the tube at A, is, by induction, trans- formed into an X-ray (A G) which begins at A (outer sur- -1-7 FIGURE 3. face) and is practically a continuation of F A. D E is the tangent of the point of issue (A). For practical purposes we may look upon F as being the source of the X-rays and the center of the X-ray hemisphere. I shall refer to it in this way hereafter. In Fig. 3 the relation of the X-rays to a photographic plate is diagrammatically shown. & B is the segment of an X-ray tube. Rays emanating /rom F strike a photographic plate (a f ) which is lying on a teble or some other solid support. It will be noticed that X-RAY DIAGNOSIS. 277 the anode is parallel to the photographic plate. This is tke ideal relation of the two. One ray emanates at right angles from F and strikes the plate at right angles (c), anode and plate being parallel. The rays which strike the plate at a or at b or at d or at e or at / increase in length the further they are removed from the median line (F-c). This median line is the shortest line because it strikes the plate at right angles. This line is of the greatest importance in X-ray FIGURE 4. photography. It is known as the anodal axis. Remember this definition once. for all: A line drawn from the anodal focus to the photographic plate at right angles to the latter, is known as the anodal axis, and is the shortest line between anodal focus and plate. The anodal disc and the photographic plate, however, do not necessarily have to be parallel. In Fig. 4 the anode and the photographic plate are not parallel. F-c is the anodal axis. It makes no difference how the X-ray tube is 278 MODERN PHYSIO-THERAPY. placed ; the photographic plate or, for that matter, the ob- ject placed above it, should be struck by the anodal axis in or near the center. If this rule is not followed, distortion of the shadow-picture is bound to occur. To illustrate this point, make the following simple experiment : Take a book in your right hand and a lighted candle in the left. Hold the book six inches away from the wall and parallel to the latter. Hold the candle six inches away from the book in a line corresponding to the center of the book. The shadow of the book on the wall will be larger than the book. If you keep the book stationary and move the candle away from it, the shadow of the book will become smaller. If you move the candle toward the book, the shadow will enlarge. If you keep the candle stationary, but move the book toward or away from the wall, the shadow will become smaller or larger, as the case may be. As long as the book and the wall are parallel and the source of light remains in the median line, the shadow may be large or small, it will be a proportionate representation of the book. If you move the candle out of the median line or if you hold the book slanting toward the wall, a distorted shadow will be the result. The wall in this case represents the photo- graphic plate, the candle-light is the anodal focus. The median line is the anodal axis. What principles does this simple illustration convey? 1. Avoid too large a shadow, i. e. put the object as close to the plate as possible ; 2. The plane of the object should be parallel to the photographic plate ; 3. The object should not be beyond the sphere of radio- activity of the excited tube ; 4. The anodal axis should pass through the center or through the most important part of the object. Fig. 3 exemplifies these principles. C D represents an object placed parallel to the photographic plate (a-f). The shadow of the object (E G) is larger than the object (C D). If C D were closer to the plate (a-f), its shadow would be X-RAY DIAGNOSIS. 279 more nearly the size of the object. F-c is the anodal axis passing through the object through or near its most impor- tant part. If C D represents a hand which is supposed to contain a needle or some other foreign body, we would place the hand directly upon the photographic plate and allow the anodal axis to pass through the supposed location of the foreign body (H). Let C D represent the region of the hip- joint. We will place the object in such a position that the point of greatest interest (for instance, the sup- posed seat of a fracture) is in the anodal axis. There is another reason w^hy the anodal axis represents the most important line of X-ray energy. The power of the X-ray decreases in proportion to the distance between anodal focus and object. The longer the ray, the weaker it becomes. Since the anodal axis is the shortest line between anodal focus and object, it is necessarily the most powerful quod erat demonstrandum. The Question of Vacuity. The vacuum of the, tube is the physical condition of the latter produced by more or less perfect exhaustion. The more perfectly the tube is ex- hausted, the greater, of course, is the pressure or tension. The tube is called a high or a hard tube if the exhaustion is relatively perfect. Depending on the degree of exhaustion, the tube may be high (hard), moderately high (hard), moderately low (soft), low (soft). In the low (soft) tube the exhaustion is relatively imperfect, /. e. the pressure or tension is low. If the pressure or tension is too low, i. e. if the tube is too soft, there will be no X-rays produced. The shadows which a hard tube casts upon the fluoro- scopic screen, are very light. The bone-shadows even are faint. The less hard the tube is, the more distinct will be the shadows, the more marked will be the difference be- tween the shadows of the soft and hard tissues. The typical X-ray picture of the hand (faint shadows of the soft tissues, dark and well defined shadows of the bones) is produced by a moderately soft tube. The softer the tube, the more easily are the X-rays which are produced by it intercepted by an 280 MODERN PHYSIO-THERAPY. interposed object. This is because the softer the tube, the less penetrating are its X-rays. A thin part, like the hand, offers but little resistance to the waves of X-ray energy com- ing from the tube. For this reason, penetration is easily effected. Everybody is familiar with the skiagraphic or fluoroscopic picture of a hand. The greater density of the bony tissue makes the shadows of the phalanges darker than the shadows of the soft parts, which are less dense and, therefore, cast a lighter shadow. The point to be remem- bered is that it is not a question of thickness, but of density. It makes no difference whether we lessen the transverse diameter of a part by pressure and thus make the part thinner. Compression of a part diminishes the thickness, but does not change the density. The tissues are matted to- gether, occupy less space, but are not rendered less dense. It is plain, therefore, that compression of an object, while it may lessen the distance between tube and object, does not change the density of the object. This is a point of some importance in connection with skiagraphic technique. The vacuity of the tube suggests the law which under- lies the adaptation of the excited X-ray tube to any skia- graph or therapeutic purpose, to wit : "Hard tube, scant output, great penetration; soft tube, copious output, slight penetration." The conclusions to be drawn from this well-established law are: 1. Use a relatively hard tube whenever a high degree of density is to be overcome. The harder the tube, the greater its penetrating power. The harder the tube, the longer the exposure of a deep part on account of the scant output of energy. The harder the tube, the slighter its therapeutic usefulness. The hard tube is the skiagraphic tube par ex- cellence. 2. Use a relatively soft tube in skiagraphing thin parts which do not require much penetration. The softer the tube, the more intense its effect on superficial parts on ac- count of the copious output of energy and comparatively X-RAY DIAGNOSIS. 281 slight penetrating power. The softer the tube, the greater its therapeutic usefulness. The soft tube is the therapeutic tube par excellence. The proper therapeutic field of the X-rays is the skin and the subcutaneous tissues. In gauging the thickness of a part, the question of density is of prime importance. Three inches of soft tissue are not by any means as hard to penetrate as three inches of bony tissue. In gauging the diameter of a portion of the body, it is principally the bulk of its bony structure which we are interested in. The length of exposure depends on the thickness and density of the object and the degree of exhaustion of the tube. In recent times there has been much talk about in- stantaneous skiagraphy (X-ray snapshots). As far as my experience has taught me, instantaneous X-ray photography does not exist, except in the minds of overanxious coil- agents or visionary optimists. To be able to time and ex- posure properly, is largely a matter of experience. There are no iron,-clad rules by which the operator can be safely guided. Experience, backed up by positive knowledge of the subject, is in this, as in many other lines, the conditio sine qua non of scientific and successful work. It is the wall that separates the amateur from the master, the me- chanic from the scientist. Let the X-ray operator remem- ber that short exposures (3-5 seconds) refer to skiagraphy of very thin parts, the tube used being moderately soft. The thicker and denser the part, the longer should be the exposure, the harder should be the tube. An exposure of three minutes to skiagraph the spine of a medium-sized adult by means of a tolerably hard tube, is not too long. I have made exposures of five minutes' duration with splendid results. Operators who use static machines will have to expose two and even three times as long as those who work with good-sized coils. On general principles I feel that it is better to over-expose than to under-expose a tolerably deep structure. Most failures in these cases are due to under- exposure. With a moderately soft tube the duration of an exposure should be : 282 MODERN PHYSIO-THRRAPY. For a medium-sized hand 10-20 seconds ; For a medium-sized wrist 15-25 seconds; For a medium-sized elbow 20-30 seconds ; For a medium-sized shoulder 40-60 seconds ; For a medium-sized ankle, 20-40 seconds ; For a medium-sized knee 30-60 seconds. X-RAY COIL SHOWING INTERRUPTERS FOR DIRECT AND ALTERNATING CURRENT. With a tolerably hard tube the duration of an exposure should be : For a medium-sized hip 1-3 minutes ; For the spine of an adult 2^2-4 minutes. Large coils with an immense output of current lessen the time of exposure. Much depends on the steadiness of X-RAY DIAGNOSIS. 283 the tube. Some tubes do not hold out well, but become gradually softer while the exposure is being made. All these uncertainties affect the modus operandi in a given case. The only criterion to go by, therefore, is the per- sonal equation of the operator. Theoretical skiagraphy is a myth. Experience alone gives it a place in the diagnostic armamentarium of modern medicine. Vice versa, expe- rience is of little value unless it embraces the knowledge of the Why ? and the Wherefore ? It is theoretical knowledge that places upon experience the stamp of authority. Tangential Radiations. Reference has already been made to a peculiar form of radiation first described by Wal- ter under the name of secondary radiations. There seems to be sufficient evidence to show that these radiations come directly from within the tube, and belong under the general head of ultra-violet rays. The radiations coming from the extreme red end of the spectrum are characterized by short waves and comparatively slow vibrations. As we approach the violet end, the waves increase in length and in rapidity of vibration. We also know that the angle of refraction be- comes more acute as we leave the red and approach the violet field. Adding to this fact the positively known pas- sage of true chemical rays from the inside of the tube through the glass, we have no hesitancy to identify those rays which have been described as Walter's secondary or tangential radiations. They are without a doubt these in- tratubular chemical (ultra-violet) rays refracted by the glass wall of the tube which acts like a prism. After being thus refracted they pursue a straight path, intersecting the diverging X-rays and penetrating any obstacle as far as their carrying power will permit, and possibly being again deflected from their path if they should meet with any ob- stacle capable of refracting and deflecting them. (See Fig- 5-) In this way they may reach a sensitive plate, leaving a faint density-record upon it, which, of course, will not coin- cide with the" X-ray shadow, but as a secondary shadow, not 284 MODERN PHYSIO-THERAPY. sufficiently well marked to possess any individuality, but just enough to have a blurring effect. This blurring effect causes the X-ray outlines of a picture to appear less sharp and well-defined. As a result, we get flat X-ray shadows, without character, detail or perspective, whenever we at- tempt to make a direct exposure of an object to the X-ray tube. A device for the interception of the tangential rays has become a necessity without which skiagraphic work nowadays is practically impossible. In the light of modern radiologic observations it would not be preposterous to as- sume an active phosphorescent state of the tissues, produced by the diffused tangential radiations and the absorption of the X-rays by the blood (pigment of the red blood-cells). This phosphorescent state has been explained as being due to the absorption of the X-rays by the hemoglobin. That the X-rays do not represent the only force-modality given X-RAY DIAGNOSIS. 285 off by the X-ray tube, is generally admitted. The sum-total of energy generated is composed of high-tension electricity (sparks, brush-discharges and a surplus of static electrical force which accumulates within the magnetic field of the tube), heat-rays, ozone, dynamic waves, induction-products and many other forms of force-manifestation mentioned by numerous authors (Freund, Schiff, Bang, Tesla, Kaposi, etc.). In order to increase the beauty and usefulness of an X-ray picture, an attempt should be made to bring out de- tails and lines with more precision. To prevent the phos- phorescence of the tissues and to intercept the so-called tan- gential radiations is nowadays an important part. of skia- graphic technique. The more successful we are in this, the clearer and better defined will be the outlines of the shadows even of faint and insignificant details. We must prevent the phosphorescence of the tissues produced by the indiscrim- inate diffusion of secondary radiations. To accomplish this purpose the German investigators, notably Albers-Schoen- berg, use an 'adjustable lead-lined cylinder which is inter- posed between the tube and the object and allows a cone of X-ray energy to pass through it down to the object and sen- sitive plate. The tangential rays are held up by the cylin- der and are thus prevented from scattering through the object. The Germans call this device a Blende (a "blind," device to keep side-lights out of horses' eyes). "Com- pression-diaphragm" is a bunglesome translation, because the device is neither a diaphragm nor does it compress. Since the "Blende" is analogous to the camera in photog- raphy which gathers in the desirable rays and shuts out side-rays, it seems to me that the term X-ray Camera is the best and most befitting appellation. A very useful device of this kind is on the American market under the name re- ferred to. The Interception of Secondary Radiations. The X-ray camera, as the name indicates, is a chamber (camera) for the reception and transmission of X-rays and, we might add, 286 MODERN PHYSIO-THERAPY. for the exclusion of other forms of radio-activity. It is an open cylinder which is interposed between the X-ray tube and the sensitive plate upon which the object rests. The cylinder is adjustable to any position, perpendicular, tilting, high or low. Its length can be regulated. By means of suitable diaphragms the cone of light passing through the cylinder can be reduced to any thickness. The X-ray tube can be placed in any desirable position above the cylinder. The mechanical adjustments for both cylinder and tube are simple and easily handled. The whole apparatus is mounted in such a way that it can be placed on any table and is always ready for work. Some prefer it to be suspended from the ceiling directly above the table. It can be imme- diately put out of the way when the patient is ready to leave the table. However, the question of choosing between a stationary or swinging type of camera is purely a matter of taste. Fig 8 is a diagrammatic representation of the X-ray Camera. Figures 6 and 7 show the modus operandi of the camera. C H I G is the cylinder, C D E G representing the trans- verse section of a diaphragm placed inside. The lines from F represent the X-rays, the broken lines coming from the surface of the tube being the tangential or secondary rays. The X-rays pass through the cylinder (C H I G), through the object (K L) to the plate (M N). The tangential rays are stopped by the diaphragm (CD and E. G.) and by the cylinder. In both figures one tangential ray is seen passing through the object to the plate. This indicates the necessity of being able to elongate the cylinder and to adjust different sizes of diaphragms. In order to understand the disturbing role which the tangential rays play, it is only necessary to think of the il- lustration previously referred to. Let us imagine the book six inches away from and parallel to the wall. The candle- light in the median line represents the X-rays coming from the anodal focus. Let us hold a smaller light near the candle-light. The result will be the production of a second X-RAY DIAGNOSIS. 287 but much fainter shadow of the book on the wall. The ad- ditional light represents the tangential energy coming from the surface of the tube or Walter's "secondary radiations." These tangential rays are responsible for the poor results which follow free exposures without any attempt to inter- FIGURE) 6. cept or eliminate these disturbing rays. The pictures are flat and ill-defined, without character, expression and per- spective. The ideal position for the cylinder is at right angles to the plate so that the anodal axis and the axis of the cylinder 288 MODERN PHYSIO-THERAPY. (line through the center) will coincide. In this ideal posi- tion a cone of X-ray radiance will fall through the object upon the plate, the base of the cone being the exposed part of the plate, the apex being the anodal focus. The transverse diameters of the cone will depend on the size of the opening in the diaphragm and the length of the cylinder. To put the cylinder in this ideal position, place the anodal focus directly over the axis of the cylinder, the latter being at right angles to the plate. The anodal disc may be parallel to the sensitive plate or may not. The parallel position is the ideal position. The essential point is that the anodal X-RAY DIAGNOSIS. 289 focus be in the longitudinal axis (central line) of the cylin- der. The position of the anodal disc with reference to the cylinder is theoretically immaterial, practically dependent on certain conditions of convenience. If it is parallel to the sensitive plate which is lying horizontally on a solid base, such as a table, the adjustment of the whole arrangement from plate up to the tube is simple. The longitudinal axis of the cylinder strikes the anodal focus above and the cen- ter of the sensitive plate below. It is needless to say that it strikes the anodal plane and the sensitive plate at right angles, the two being parallel. Thus we get a cone of light, whose apex is the anodal focus, whose base is the circle of light corresponding to the shape of the lower end of the camera-cylinder from which the symmetrically diverging rays emerge. The principal part of the arrangement is that the anodal focus is strictly in line with the longitudinal axis of the cylinder. Hence it makes no material difference whether we. place the anode parallel to the sensitive plate or not. Even if the anodal plane were not parallel to the plate, the anodal focus being in the median line (longi- tudinal axis), the cone of the light would remain the same. An entirely different effect would result if the anodal focus were not in the median line. The cone of the light would be distorted, the rays striking the plate at different angles. The anatomical peculiarities of certain regions of the body sometimes make it imperatively necessary to tilt the cylinder and allow the rays to strike the object and plate obliquely. What I have previously stated concerning slanting rays and resulting distortion of the shadow, should be remembered in taking the picture and in interpreting the skiagraphic result. Let us illustrate these points by a pertinent example. We are about to take an X-ray picture of a bullet which is lodged somewhere in the lumbar spine. In placing the pa- tient over the photographic plate, we would put him on his back in order to get the bullet, which in this case is the object, as close to the plate as possible. (If the bullet is 290 MODERN PHYSIO-THERAPY. supposed to be near the abdominal wall, the patient would, of course, be put on his stomach.) The cylinder is placed over the abdomen directly over the supposed location of the foreign body. The X-ray tube of proper internal re- 8. sistance is in its proper position over the cylinder. The anodal axis passes from the anodal focus through the space intervening between the tube and the upper rim of the cylin- der. It passes through the center of the cylinder, then X-RAY DIAGNOSIS. 291 through the patient's abdomen, through or near the foreign body down to the plate. This is the ideal mode of proced- ure, because the shadow-picture will be an approximately correct reproduction of the region X-rayed. There will be no distortion, because the anodal axis passes through the median line and strikes the plate at right angles. In Fig. 9 F represents the anodal focus, the anodal disc being shown in two positions, parallel and oblique. F B C is the cone of light, whose diameter is determined by the size of the lower opening of the cylinder D F E G, through which the rays pass. F A is the longitudinal axis, which coincides with the median line of the cone. The diffusion of light is symmetri- 292 MODERN PHYSIO-THERAPY. cal. The dotted lines represent the effect which is produced by the anodal focus being away from the median line of the cylinder, as a result the cone is distorted, which in skiag- raphy is equivalent to an asymmetrical distortion of the shadows. In order to immobilize the object to be skiagraphed it is not necessary to compress it because lessening of the bulk does not mean reduction of density. Compression is not only unnecessary, but in many instances decidedly unde- sirable. Aside from the discomfort which a patient is bound to suffer, a certain change of relative location or a malposi- tion of the parts is liable to occur and thus a diagnostically worthless picture is apt to result. This is especially the case when we are dealing with a freely movable foreign body. Aside from the damage which is liable to be inflicted upon the surrounding tissues by sharp and pointed contour of a foreign body, compression of the part containing the for- eign body is certain to change the relative position of the latter, the change of position being determined by the tendency of the foreign body to move in the direction of least- resistance, i. e. away from hard or resisting tissue and in the direction of soft, non-resisting tissue. I have demonstrated this point to my satisfaction before the class of the "Cincinnati Post-graduate School of Physio- logical Therapeutics" by skiagraphing a bullet which was imbedded in the fleshy part of the thigh. By using a so- called compression-diaphragm I was able to obtain six dif- ferent X-ray pictures of the subject, no two pictures show- ing the foreign body in the same relative position. I could have added pictures of the same subject ad libitum, the de- gree and direction of the pressure determining the skia- graphic result. There is not the least doubt that com- pression is theoretically wrong and practically misleading to the surgeon and uncomfortable to the patient. The idea of compression was probably suggested by a misconception of the principle of immobilization, which in skiagraphy as well as in photography is a factor of prime importance. X-RAY DIAGNOSIS. 293 Since snapshots are unknown in X-ray work, the objects we attempt to skiagraph must remain unmoved during the time of exposure. To aid in preventing change of position, we can immobilize almost every object in a simple, effective and painless manner. This is accomplished by mere con- tact with or very gentle pressure of the lower end of the cylinder which is interposed between tube and object for the purpose of eliminating various disturbing forms of ray- energy emanating from the X-ray tube and interfering with the X-rays proper. . PRACTICAL SUGGESTIONS. Always remember 1. That the object should be as close to the plate as possible, so that too large a shadow may be avoided ; 2. That the planes of object and plate should be parallel ; 3. That the object should be within the radio-active field of the tube ; 4. That the anodal focus should, if possible, be directly over the center of the object ; 5. That in placing an object beneath the cylinder of the camera for the purpose of skiagraphing it, no removable foreign substance, e. g. clothing, should intervene between the cylinder and the object or the object and the sensitive plate ; 6. That, in order to protect the plate against heat and moisture it is sometimes permissible or even necessary to put one or more blotters or a layer of some water-proof non-opaque material between object and plate (e. g. in ab- dominal work on fat persons or if the exposures are long) ; 7. That the plate should not be brought into the room until everything is ready; 8. That a skiagraphic error is always due to some short- coming on the part of the operator- either in placing the ob- ject, in making the exposure or in interpreting the result; 9. That the relatively good result will depend on the knowledge of the vacuity of the tube, on the adaptation of the tube- vacuum to the density of the object and on the proper timing of the exposure; 294 MODERN PHYSIO-THERAPY. 10. That a good home-made substitute for the camera consists in a piece of sheet-lead with a circular opening in the center, the lead being turned up two or three inches along the periphery of the opening (the object is skia- graphed through this opening, the lead being laid on the object) ; 11. That X-ray exposures, especially of deep parts, are frequently undertimed ; 12. That it is incomparably easier to become a good X-ray photographer than it is to be a reliable X-ray diag- nostician. It is simple to take a picture, but by no means so easy to interpret it. The Photographic Part of the Work. The exposure having been made, the plate is taken into the dark room, and there taken out of the two envelopes and put in the developing fluid. In order to do this portion of the work successfully it is necessary to understand the elements of photography and photographic technique. The film which is on one side of the glass plate is called sensitive because it contains silver which is sensitive to the action of actinic rays. Corresponding to the relative in- tensity of these rays there is a chemical change in the silver. This change becomes apparent to the human eye the mo- ment the plate is acted upon by a "developing" fluid. The film becomes transparent showing the discoloration in the silver. Some parts are strongly discolored, others less so, still others hardly discolored at all. Where no light has struck the film, no discoloration is seen, i. e. the film is ab- solutely transparent. It is the manifold degrees of dis- coloration of the silver that constitute the picture. Wher- ever an intense action of actinic rays has taken place, a cor- respondingly strong discoloration is seen, i. c. the impres- sion left by the rays is black. \Vhere only a faint action oc- curred, the discoloration is slight. Thus the lights and shadows of the object are reversed in the reproduction on an exposed plate. Photographers call such a picture a nega- X-RAY DIAGNOSIS. 295 tive. The white face of a man is black in the negative, while his black coat is represented by a portion of the film which has hardly been acted upon by the light. If we take some sensitized paper and place the negative over it, what happens when the sun's rays are allowed to act upon the paper*? The discolored portions of the negative offer some resistance to the rays and thus the paper is but slightly dis- colored by the rays. The transparent parts of the nega- tive allow the rays to pass readily. The result is that the paper is quickly discolored. Thus the print on the paper reverses the conditions of the negative and, in doing so, shows the original lights and shadows of the object. The white face of the man is white in the print, while his coat is black. Such a picture is properly called a photograph be- cause it represents a sum-total of //' 7tMmpressions made on a sensitive plate or paper. Strictly speaking, the word "X-ray photography" is a contradiction in terms. If we expose a sensitive plate to the action of X-rays, the latter will penetrate the envelopes which contain the plate and act upon the silver in the film just like sunlight. If the whole plate is thus exposed, the whole plate will turn black. If we place a silver dollar on the envelope containing the plate, the space covered by the coin will not be acted upon by the X-rays because they are intercepted by the metal. The negative will show the whole plate black except the part which was covered by the coin. If we place on the envelope containing the plate, a silver dollar, a piece of wood about the size and thickness of the coin and a piece of cloth having the shape and size of the coin, the negative would be black except in three places. The coin would intercept the rays completely, the wood slightly and the cloth hardly at all. Thus we would have no discoloration, a slight discoloration and a hardly per- ceptible discoloration corresponding to the places covered by the dollar, the piece of wood and the piece of cloth. If we place a square block of wood, one inch thick, on the envelope containing the plate and put the dollar on top of 296 MODERX PHYSIO-THERAPY. the wood, the negative would show a square space of slight discoloration corresponding to the space occupied by the block of wood. The position of the coin would be marked by a circular space without any discoloration. Thus, the X-ray negative is a record of shadoi^s, not of lights; a skia- graph, not a photograph. The depth or blackness of the shadow on the negative is in inverse ratio to the intercept- ing power of the object, /. c. the greater the intercepting power (opacity) of the object, the slighter the shadow, and vice versa. Thus, the X-ray negative of a hand shows deeper shadows of soft tissues than of bones. The work of developing an exposed plate (making a negative out of it) is done in a properly equipped dark- room. It would be foreign to the purposes of this discussion to give technical directions concerning the equipment neces- sary for the technical part of this work and the modus operandi to be followed in doing the work. The X-ray operator who is ambitious and wishes to do his own develop- ing, should take up amateur-photography and in this way acquire the necessary knowledge and skill for successful work in the dark room. He should use properly prepared plates of suitable size (5x7, 8xio, 11x14). The medium size is the most generally useful. For skiagraphs of the whole chest the 11x14 plates are the most available. It is difficult to overdevelop an X-ray plate. In common photography we are dealing with plates that have been superficially acted upon by actinic rays. In X-ray work the effect has penetrated down to the glass. For this reason X-ray plates should be developed slowly. Let me formulate the modus operandi by way of a few f imple rules : 1. Keep your hands clean; 2. Scrupulous cleanliness applied to the trays is indis- pensable ; 3. Always use fresh and clean solutions; 4. The temperature of the solution should not be under 65 F. and not exceed 70 F. ; X-RAY DIAGNOSIS. 297 5. Do not think of developing any X-ray picture in less than ten minutes ; 6. Negatives will not last unless they are carefully washed and every vestige of the fixing salt is removed. There is no end to the developing agents that are recom- mended and used by different authors and operators. I have used two developers that are as good as, if not better than, any other developer used. The first was suggested by G. G. Burdick and is as follows : (A.) Ortol 15. Metol 15. Meta bisulphite of potassium .75 Bromide of potassium i. Distilled water 1000. (B.) Distilled water 1000. Sod. sulphite (c. p.) 40. Sod. carb. (c. p.) 60. Take 30 c. c. of each and dilute with from 30 to 120 c. c. of water, according to the effect desired. The less water, the more contrast; the more water, the more detail. The second developer is recommended by Pizzigelli and is thoroughly reliable : (A.) Glycin 30. Xatr. Sulf 100. Natr. Carb 20. Distilled water 1000. (B.) Xatr. Carb 100. Distilled water 1000. (Mix the two solutions and develop in the mixture.) After developing the plate, the process of handling it (fixing, washing, drying) does not differ from that fol- lowed in ordinary photography. 298 MODERN PHYSIO-THERAPY. To Interpret An X-ray Picture. The diagnostic value of an X-ray picture is in propor- tion to the interpreting power of the operator. Thus a good X-ray picture may possess incalculable diagnostic value, or it may be valueless. To be able to interpret is the crown- ing effort and the most essential part of radiographic work. Diagnostic X-ray pictures are taken for the purpose of determining I. Change in normal structure (disease of bone) ; 2. A change in the relation of normal parts (c. g. fractures, dislocations) ; 3. The presence and location of an abnormal structure (e. g. a tumor) ; 4. The presence of some physiological concretion (e. g. stone in the kidney) ; 5. The presence and location of a foreign substance or body (e. g. a bullet, a needle). Examination of an X-ray picture always means exam- ination of the negative in a proper light. The first and most essential requirement on the part of the operator is famil- iarity with the appearance of negatives of normal parts. By experimental radiographic work on the normal body he can educate his eyes and his judgment. He can develop his sense of proportion and relation and, above all, become familiar with the meaning of shadows and the many fine nuances of the latter. We should not forget that an X-ray picture is always true within the limits of the physical conditions which pro- duced it. The shape and relation of the shadows are al- ways dependent on the relative position of the tube and the object to the plate. The relative faintness or depth of the shadows may be due to under-exposure, over-exposure, faulty vacuum of the tube, tinder-development or over-de- velopment. Inasmuch as these physical conditions are sub- ject to never-ending variations, we can readily see how the X-ray picture depends on, and is true only within, the limits established by these physical conditions. Thus : an X-ray picture will not show a foreign body unless the latter is ca- pable of casting a shadow. A greenstick fracture may not show in the picture if the bend during the exposure points X-RAY DIAGNOSIS. 299 towards the plate or toward the tube and in this way pro- jects no shadow of an actual angle in the continuity of the bone. An over-exposed plate may not show the existence of a line of fracture. The picture may not show the pres- ence of a foreign body, even if the latter is as large as a set of artificial teeth. In Cleveland, Ohio, a man was subjected to an oesophagotomy because the X-ray operator stated posi- tively that the teeth were lodged in the oesophagus. The man died and the teeth were found under his bed. In an- other large town in Ohio a man who was supposed to have swallowed a set of teeth, was told that he was mistaken. Repeated X-ray examinations showed no teeth. The man went 'to Xew York, had the teeth located in his oesophagus by X-rays, was operated upon and recovered. The two instances show plainly enough that the success of X-ray work depends on the knowledge and skill of the operator. The X-rays never fail, never err, never bungle. The so- called X-ray mistakes are always due to incompetency of an amateurish operator. The X-ra"y picture per se is always cceteris paribus a true picture. Its interpretation, however, is influenced by variable conditions. From the very nature of things, there- fore, the X-ray picture is hardly ever more than one of the aids to diagnosis. Its province is to corroborate, to con- firm, to add the testimony of an eye-witness to circumstan- tial evidence. There should be a history of the case under consideration, there should be a chain of symptomatic evi- dence to prepare for the reasoning involved in the inter- pretation of the skiagraph. As a link in the chain of diag- nostic reasoning the skiagraph is invaluable, especially in the practice of surgery (fractures, dislocations, removal of foreign bodies). If the diagnosis involves questions of grave import, repeated skiagraphic examinations should be made. In locating a foreign body the part containing the for- eign body should be skiagraphed in the line of its perpen- dicular as well, as its horizontal diameter. A skiagraph of 300 MODERN PHYSIO-THERAPY. the knee, taken from above downward, the posterior surface resting on the sensitive plate, may show a bullet. Diag- nostically and surgically this picture is valueless because it reveals nothing concerning the depth at which the foreign body is located. A picture from the side is necessary to en- able the surgeon to make a diagnosis and operate accord- ingly. In order to read a skiagraph intelligently, it is neces- sary to be familiar with the peculiarities of X-ray pictures. For example : Skiagraph an elbow after putting the dorsal side of the joint on the sensitive plate. The uninitiated will diagnose a transverse fracture of the olecranon. The space between the humerus and ulna makes the bony tissue of the ole- cranon behind it appear so faint that the line of faint- shadow corresponding to the space between the bones looks strikingly like a line of fracture. Another example te the shoulder- joint. The space between the end of the clavicle and the acromiom misleads the uninitiated in nearly every instance. He invariably diagnoses a fracture of the clav- icle. I know of one instance in which the diagnosis of kid- ney-stone was made. The "stone" was one of the spinous processes, the extremity of which happened to cast an unusually deep shadow. In children mistakes are often made by operators who forget that ossification is not complete, and that allowance must be made for this fact. Many ex- amples of the whims and peculiarities of X-ray pictures could be cited. Many mistakes in interpretation are made through the purely photographic features of a picture. I remember an instance in which the nude knee of a physician was skia- graphed for purposes of demonstration. The picture showed faint lines running irregularly around the joint. These lines looked for all the world like folds of garments. Vet every one knew that the knee had been exposed nude. No one seemed to be able to account for the appearance of these faint lines. The solution was simple. In immersing X-RAY DIAGNOSIS. 301 the plate in the developing fluid the latter did not flow rapidly and evenly over the entire plate, but covered only a part of the plate causing a line to appear where the fluid had halted for a fraction of a second. Lack of cleanliness frequently leads to serious blunders. The X-ray picture as a positive means of diagnosis sh6uld be furnished by a radiographer who is equally famil- iar with the technical part of X-ray exposures and with the technique of developing plates. Nothing has injured the cause of X-ray work more than the bulk of poor radio- graphic work which is done by unskilled and inexperienced amateur-radiographers. Stereo-Skiagraphy. Stereo-skiagraphy is the most recent and promises to be 'the most valuable achievement of radiography. Its object is to make pictures which have the distance, perspective and plasticity of the real object. It is analogous to stereoscopy. Its technique has been well described by M. K. Kassabian, of Philadelphia, who summarizes the subject as follows: The ordinary photographs and images look flat, while stereoscopic pictures which are made by two lenses, each being two and one-half to two and three-quarters inches from each other (corresponding to the distance between the two pupils of the eyes) will be impressed on the retina as one picture thus giving a perspective view. The technique of stereo-skiagraphy consists of taking two separate skiagraphs of the same part, on two different sensitive plates, without changing the position of the parts, but displacing the posi- tion of the Crookes tube two and one-half to two and three- quarters inches (6 cm.), corresponding to the distance of the pupils of the eyes. In order to produce two negatives of equal density the degree of penetration of the rays should be as nearly alike as possible. There are no two tubes that have the same de- gree of vacuum, and the same tube changes its vacuum dur- ing exposure. The operator should judge the time of ex- 302 MODERN PHYSIO-THERAPY. posure of the second plate from experience. A self-regulat- ing tube is preferable in all cases. It is proper to give a little longer time for the second exposure than the first be- cause the tube runs down a little and the penetration les- sens. Short exposures are most desirable. In order to have two negatives of equal density, the FIGURE 10. DIAGRAM ILLUSTRATING THE PRINCIPLE OF STEREO-SKIAGRAPHY. process of development should be carried on with great care. The developers should be the same for both according to the degree of density desired. Soft negatives are preferable. The advantages of stereo-skiagraphy are obvious. In both long and short bones the trabeculae are seen, and in the long bones we may see the arrangement of the lamellae in the shafts and in the cancellous tissue. The spiral ar- rangement of the lamellae is distinctly shown, especially in X-RAY DIAGNOSIS. 303 the humerus and femur, as also is the change in their direc- tion near the articular surfaces, bringing them into columns perpendicular to the surface of the pressure. In examining the dry skull, the grooves for the meningeal arteries are seen, the concave appearance of the skull processes, the frontal sinuses, the antra of Highmore, the turbinated bones, etc. It is very interesting to view these results in the living subject as well as in the skeleton. In studying the mechan- ism of the joints, these pictures give a perspective view of the relations of the articular surfaces of the bones and the actual depth, and the relation of the processes to the ob- server. Arteries, veins, bronchi, and excretory ducts, when injected with opaque materials, such as lead or mercury, show their exact relations (their depth) to the bones, the muscles, etc. Stereo-skiagraphy is, without a doubt, the most satisfactory method of locating foreign bodies. The same statement holds good in regard to fractures, the method procuring definite views of injuries, namely the ex- act location of the fragments, the amount of over-lapping, the separation, the degree of apposition in deformities, etc. The ordinary skiagraph does not show the variety and char- acter of a dislocation. The stereo-skiagraph, however, over- comes this difficulty, producing a clear and definite view of the existing condition, so as to differentiate between an an- terior and a posterior dislocation. In viewing the thorax we may see either an anterior or a posterior aspect, depend- ing on the position of the plates. The heart, its position ; the aorta, its relation to the vertebral column ; the beautiful cage-appearance of the thorax, the location of a cavity or consolidation, etc., are interesting from a practical as well 1 as from a scientific standpoint. X-ray Accessories. Walter's Skiameter. In order to be able to determine the vacuity (hardness, softness) of a tube, most operators examine the shadows of their hand through a fluoroscope. This is a thoroughly bad habit on account of the too fre- 304 MODERN PHYSIO-THERAPY. quent exposure of the hand to the rays. Dr. B. Walter, of Hamburg, has devised a little instrument which reveals the vacuity of the tube in a definite and reliable manner. The base of the instrument consists of eight small pieces of tin- foil of different thickness, which are covered with a bario- platinum screen. By holding the base of the instrument up to an excited X-ray tube, the bario-platinum will iluoresce in proportion to the amount of penetrating power which the rays possess. If the tube is soft, with but scant pene- WALTER'S SKIAMETER. trating power of the rays, there would be no visible fluon-s- cence of the screen, except where it covers the thinnest piece of tin-foil. Over the remaining seven spaces the tin-foil would be too thick. The rays would be intercepted and no fluorescence visible. If the tube is a trifle harder, two spaces might be seen to fluoresce, or three or four, depend- ing on the penetrating power of the rays and the corre- sponding thickness of the tin-foil. Thus a very hard tube would light up seven or even eight spaces. The instrument is called a skiameter and is indeed a very useful addition to an X-ray equipment. X-RAY DIAGNOSIS. 305 The X-ray Table. A solid wooden table, 6^2x2 feet, answers the purpose. It ought to be fenestrated at two places, one fenestra to correspond to the location of a pa- tient's chest, the other to his knees. The chest-fenestra should be eight inches square, the other one six inches square. The corresponding shutters should drop out, not lift out. When they are in position they should be secured from below so that there may be no unevenness on the sur- face of the table. They should be arranged so that they can be taken out altogether. Hinges are not desirable. The object of the fenestra is to enable the operator to make a fluoroscopic study of a part with the patient on the table and the tube secured below the table. The operator looks down at the part through the fluoroscope. The fenestra should be closed unless it is being used. X-ray Tubes. Every operator should have at least three or four good tubes. For radiographic work he should have a water-cooling or a heavy anode tube. For X-ray treat- ments any kind of a tube will answer. The static machine will meet the- requirements of radio-therapy, but only in a limited sense those of radiographic work, the statements of some operators notwithstanding. A good-sized coil is in- dispensable if good radiographic work is to be done. Special therapeutic tubes (Caldwell's, etc.) are not of great prac- tical value. X-ray Stand. It should be made of heavy wood and be solid. It should have a square, adjustable, lead-lined shield- attachment (18x12 inches). The tube is mounted about six inches above a perforation (four inch diameter) which represents the center of the shield. The latter, when in its proper position is approximately parallel to the table upon which the patient lies. Most X-ray treatments are best given with the patient on the table. By placing pieces of sheet-lead on the upper surface of the shield, the central opening can be given any size or shape to correspond to the surface to be treated. In treating the face, it is a good rule to cover the eyes separately. A shield can be made by 306 MODERN PHYSIO-THERAPY. any carpenter and attached to any solid X-ray stand. In radiographic work it may be used as a diaphragm to inter- cept tangential radiations. Lead. Lead is the cheapest and most useful metal to intercept the X-rays. The operator should keep a dozen or X-RAY DERMATITIS. more pieces of sheet-lead on hand. One of the essential points of X-ray work is to cover sound parts carefully. X-ray Camera. Ever)' operator should provide him- self with some device to intercept tangential radiations. Even if he does not wish to invest in cue or other of the X-R.\Y DIAGNOSIS. 307 more or less expensive devices which are on the market, he can improvise an apparatus of this kind in a primitive and yet effective manner. Suggestions as to the manner of doing it have been given previously. The X-ray shield de- scribed above may be used for this purpose to good ad- vantage. Dangers of X-ray Work. X-ray Dermatitis, etc. The occurrence of any degree of an X-ray "burn" in a patient (molecular destruction of CARL BECK'S TUBULAR DIAPHRAGM. sound tissue) is almost invariably due to faulty technique. The proper use of sheet-lead and a reasonable amount of knowledge of the Roentgen tube should prevent it under all circumstances. The cases of X-ray idiosyncrasy (unusual susceptibility to X-rays) are very rare. The subject of X-ray "burns" is considered more at length under the head of "RADIO-THERAPY/' Local reaction should never pass be- yond the point of pigmentation. In looking after the comfort and safety of his patient, the operator should not forget that his own body is liable 308 MODERN PHYSIO-THERAPY. to be injured by constant exposure to the X-rays. He should avoid unnecessary exposure and should protect his body as effectively as is possible, while he is compelled to expose himself. Recently a complete line of very serviceable opaque gloves, aprons, shields, masks, etc., has been placed on the market. A very simple and effective plan is to put a substantial stationary screen in one corner of the room. The screen should be lead-lined and can be suitably covered or draped. A mirror can be placed behind the screen, en- abling the operator to watch the patient and the details of the treatment through the mirror. Among the disastrous results which may follow con- tinued exposure to the Roentgen rays are : Chronic inflammation of the skin, attended with great pain and intolerable itching; Sloughing (gangrene) of the skin and subcutaneous tissues. This condition is not infrequently progressive, gradually involving more and more of the healthy tissue. In some cases it has led to complete destruction of the soft parts, necessitating amputation of one or more fingers of the hands and even of both arms ; Loss of hair (eyebrows, scalp) and deformity or total loss of nails ; A red, glossy appearance of the skin on both hands ; A wrinkled and shriveled appearance of the hands ; More or less acute or chronic conjunctivitis, sometimes followed by granulated lids ; Impairment of sight ; A tendency towards malformations and growths on the exposed parts ; Pruritus of the exposed portions of the skin ; A peculiar form of urticaria on the back of the hand which is badly aggravated by heat, actinic rays and gastric influences ; A general systemic depression characterized by a waxy skin, dull expression of the eyes, sunken features, impair- ment of the sweat function, mental hebetude, melancholia, X-R.\Y DI/.GXOSIS. 309 w * w 2 H d w o JO H w Cfi O 310 MODERN PHYSIO-THERAPY. illusions, sluggishness of the circulation and a general de- cline (two cases of this kind have been seen and treated by me during the past two years) ; Sterility due to impairment and death of the sperma- tozoa. SKIAGRAPH OF UNPROTECTED HAND EXPOSED TO X-RAYS, Explosion of an X-ray Tube. X-ray tubes do not really explode, but collapse with tremendous violence. The noise is deafening and the force with which the glass-tube is re- duced to dust is terrific. The glass-dust is scattered in all directions with great violence. Explosions of tubes do not occur often. I witnessed an occurrence of this kind a year X-R.\Y DIAGNOSIS. 311 or two ago. Fortunately no one was injured. It seems that tube-explosions are due to changes in the temperature caus- ing contraction or expansion oi the glass. Explosion of an X-ray Coil. On February 22, 1904, 9 A. M., I was about to treat a case of epithelioma of the lip. SKIAGRAPH OF HAND PROTECTED BY AN X-RAY GLOVE. The patient and the tube were in position. The moment the current was turned on, the top of the Scheidel coil which I was using was blown out with great force amid clouds of smoke and a deafening noise. The explosion caused a great deal of damage in the room, although the patient and myself escaped without injury. I have no com- 312 MODERN PHYSIO-THERAPY. ment to make beyond demonstrating the possibility of an oc- currence of this kind. In conclusion let me add a word or two of advice to those who make a specialty of radiographic work. If they wish to remain true to the interests of the profession and to the interests of radiographic work, it is a good idea to be guided by three distinct and immutable rules of action, to wit : 1. Never do radiographic work unless it is to benefit some physician and through him some unfortunate patient. If a "layman wants radiographic work done, he should be your or some other physician's patient, and the request come from the physician. If a patient asks for radiographic work without his physician's knowledge and consent, be careful. If the request comes from a lawyer, be doubly careful. 2. Give one or two copies of the X-ray picture to the physician for whom the X-ray work was done. If the pa- tient is to get a picture, let his physician give it to him. Your dealings are with the doctor, never with the patient. Never give up a negative to any person at any time or un- der any circumstances. 3. Never pretend to interpret an X-ray picture to any patient. If the doctor asks for your opinion, give it. At all times remember that the X-ray expert should not be ex- pected to give an expert surgical opinion unless he is called upon to do so. In this case he ought to get an additional fee. By acting upon the suggestions given, the X-ray oper- ator will be loyal to his colleagues, will be legitimate in his radiographic work, and last but not least he will keep out of much unnecessary trouble. PRINCIPLES AND PRACTICE OF X-RAY THERAPY. 313 CHAPTER XL THE PRINCIPLES AND PRACTICE OF X-RAY THERAPY. THE average physician looks upon the therapeutic use of the Roentgen rays as an interesting experiment which at one time promised a great deal, but has accomplished comparatively little. That this "experiment" possesses positive therapeutic value with well-defined clinical indi- cations is denied by the bulk of the profession, while even radio-therapeutists of experience hesitate to make an uncon- ditional statement of this kind on behalf of the mysterious X-ray. And yet the Roentgen rays as a therapeutic agent do occupy an established position. The disappointments which have followed in the wake of X-ray therapeutic work are attributable to one factor: misuse of a valuable thera- peutic agent in the hands of misinformed or unskilled opera- tors. The popularization of the static machine has placed the Roentgen rays in the hands of every physician who cares to invest in a machine. His equipment includes an X-ray tube. He is told how to attach the tube properly and then proceeds to bungle along, treating one case after another without diagnostic consideration for his case and utterly disregarding the physical conditions of his tube. Thus he adds to the bulk of X-ray work which is clone throughout the country. After his first optimistic ardor has cooled off he neglects the work and joins the vast army of the skeptics who smile at the claims which are made on be- half of radio-therapeutic work. Adding to the skepticism of the bulk of the profession the untold injury which yellow journalism has inflicted upon this modern branch of thera- 314 MODERN PHYSIO-THERAPY. peutic work, we can readily understand the unjust position of X-ray therapy and the reasons therefor. Yet, it is an undeniable and easily demonstrated fact that the X-ray is an established therapeutic agent, with a clearly denned sphere of usefulness. It is not a panacea nor is it a specific. Like all other therapeutic agents in medicine and surgery it meets certain conditions within certain limitations. The personal equation of the patient's physical make-up is al- ways a factor which can not be defined with accurate pre- cision. It is always the unknown quantity in any thera- peutic problem makes the concrete application of any thera- peutic agent an art, however scientific the abstract physio- logical activity of the given therapeutic agent may be. In this sense X-ray therapy is on precisely the same level with the bulk of therapeutic agents at our command. The suc- cess of X-ray therapeutic work depends on an accurate knowledge of the physical phenomena which are included in the radio-activity of an excited X-ray tube. Without some knowledge of the physics of the X-ray tube the thera- peutic use of the Roentgen rays is nothing but haphazard guess-work. The Physics of an Excited X-ray Tube. What happens when the converging beam of cathodal light is concentrated in the anodal focus and unites with the electro-positive element? The appearance of the illumi- nated X-ray tube is familiar. One hemisphere is aglow with a greenish light while the hemisphere behind the anodal (anti-cathodal) disc remains dark. These phenomena were known long before the time of Roentgen (Crookes, Geiss- ler). Roentgen's discovery concerns a force-modality of some sort originating on the external surface of the excited tube. Roentgen could not account for the evidences of this mysterious radiating energy and designated them, there- fore, as the unknown-quantity rays or X-rays. They are the product of an induction-process of some sort, or, to speak with more accuracy, it seems that the phenomena which PRINCIPLES AND PRACTICE OF X-RAY THERAPY. 315 takes place in the excited tube induce a series of correlative force-manifestations outside of the tube. I say "correla- tive" because the X-ray phenomenon depends in all its physical characteristics on the ever-varying physical con- ditions which prevail in the interior of the tube. The term "X-ray," then, is rather a generic term covering an almost endless variety of manifestations and degrees of intensity of this mysterious induced force. The most important physical element of the tube is the degree of exhaustion. Upon it depends the relative in- tensity of the phenomena induced on the outside of the tube. From the lowest degree of exhaustion to the highest vacuity compatible with the safety of the glass tube, there is a constantly changing activity on the outside of the tube. As the degree of exhaustion becomes higher, the X-ray- waves seem to travel with greater velocity and penetrating power. The wave-length diminishes in inverse ratio to the internal resistance of the tube, while the number of undula- tions, measured in units of space-dimension as well as of time, increases. As the internal resistance of the tube de- creases, the wave-length of the force-manifestations on the outside of the tube increases, while the number of undula- tions per inch or per second is gradually diminished. In making these statements, we are reasoning from premises which are furnished by the vibratory theory of force-mani- festation, now generally accepted by physicists, and by the experimental evidence adduced by carefvil observers. The computation of the length and velocity of luminous vibrations of the different parts of the solar spectrum is not altogether a theoretical calculation. Wave-speed and wave- length, while they are results of abstraction and deduction, furnish the only plausible explanation of the various phenomena of light, light-transmission, and, in fact, of all manifestations to force by which matter proclaims its ex- istence in nature. The X-rays, being one mode of energy, must have their undulations and their wave-length analo- gous to those of other forms of force-manifestation. When 316 MODERN PHYSIO-THERAPY. the vacuum of the tube is too low for X-ray production, there is, nevertheless, an abundance of chemical light-en- ergy. These radiations are located in the spectral field be- yond the violet end and, therefore, classified as ultra-violet ladiations. This is a distinctly generic designation, because it refers to perhaps thousands of different forms of radia- tion, whose wave-speed is greater and wave-length less than those of the rays in the violet field. The length of a ray from the violet field is approximately given as the 0.0000167 of an inch, while the number of undulations per second is about 727,000,000,000,000 (Eisenlohr, Silliman). The ra- diations from the ultra-violet field diminish in wave-length as they get further away from the (visible) violet field, while the vibrations increase in number. All these vibra- tions belong to the invisible chemical field of the spectrum. That the force-manifestations which take place on the outside of an excited X-ray tube generically include an in- definite variety of force-modalities representing different speed and length of oscillation and undulation of ethereal molecules, is plain. That some of these modalities are char- acterized by relatively slow oscillation and comparatively long waves is proven by the presence of heat-rays, while, strangely enough, spectroscopic analysis of cathodal rays shows a scarcity of luminous rays, but an abundance of chemical rays. It seems justifiable, therefore, to consider the Roentgen rays a generic aggregation of force-modali- ties rather than one specific kind of radiation. The question of refrangibility is of some importance in solving the problem of the physics of the X-rays. The least refrangible rays are the red. The refrangibility increases toward the violet end of the spectrum. It has been stated that a certain quantity of ultra-violet radiations comes from the inside of the X-ray tube and penetrates the glass. Con- sidering their extreme refrangibility, it would not be diffi- cult to imagine these radiations to be refracted by the curved surface of the tube, which in this case acts like a prism. This seems to offer a plausible explanation for the PRINCIPLES AND PRACTICE OF X-RAY THERAPY. 317 tangential waves which Walter has described under the name of "secondary radiations." They are unquestionably refracted ultra-violet radiations from within the tube. That the X-rays belong under the generic head of ultra- violet radiations is further shown by their action on sensi- tive photographic plates. They affect photographic plates like actinic rays. The greater penetrating power of the Roentgen rays is due to the speed and intensity of trans- mission. The ordinary chemical solar or electric arc-light does not affect the silver throughout the entire thickness of the film, but only the superficial layers of the film. The X-rays penetrate the film down to the glass,. In this way the different manner in which a sensitive plate acts after an X-ray exposure, or after exposure to sunlight, is easily explained. It is almost impossible to over-develop an ex- posed X-ray plate, because the whole film down to the glass has been acted upon. The intercepting power of glass is another feature which suggests the similarity of the two forms of radiation. Fin- sen discarded glass because of its absorptive action. He used rock-crystal in its place. It is peculiar that glass will cast a decidedly deeper shadow on the fluoroscopic screen than rock-crystal. The latter, if of good, pure quality, seems to offer absolutely no obstacle to the Roentgen rays. The therapeutic effects seem to furnish the best evi- dence. The destructive action of the X-rays results in necrosis due to impairment of the trophic nerves, which causes an obliterative endarteritis. The so-called X-ray burn is distinctly a necrotic process. The same effect, on a smaller scale and more superficially, is noticed after forced application of concentrated actinic rays. Beginning with the primary erythema, the subsequent dermatitis and the re- sulting deposit of pigment, the effects of the two forms of radiation are certainly only different in degree of intensity ?nd in depth of penetration. I have seen a typical derma- titis and superficial necrosis follow prolonged actinic ex- posures, the gross features and microscopic appearances 318 MODERN Pnvsio-'liii-R APV. not differing in the least from analogous effects produced by the X-rays. The relative degree of germicidal action of the two forms of radiation is unquestionably an argument in support of the views expressed. The ultra-violet rays are distinctly germicidal ; so are the radiations from a low tube. The higher the internal tension of the tube, the slighter is the effect on germ-life. This fact has established the thera- peutic value of the soft tube and, at the same time, ex- plains the futility of the therapeutic efforts made with the higher-tension tubes. No one thinks nowadays of X-ray therapy in connection with deep-seated lesions. The harder the tube, the more meager the amount of energy generated, the more rapid the penetration and diffusion. The softer the tube, the greater the output of energy, the more concen- trated and powerful the effect. The softer the tube, the more striking is the resemblance between the action of the X-rays and the effect produced by concentrated chemical rays. My object in dilating upon these physical characteristics of the X-rays is plain. I desire to demonstrate that they are true ultra-violet radiations, and thus find a solid scien- tific basis for the therapeutic indications of X-ray work. We are fairly well acquainted with the physical character and the physiological activity of actinic rays. Finsen's re- searches have given us much information concerning this subject. If the X-rays are generically ultra-violet radia- tions, we are no longer at sea in regard to their therapeutic possibilities. One additional point indicates the strong generic relationship between the two force-modalities. Fin- sen has shown that the deposit of pigment in the skin is Nature's way of protecting its organism against the de- structive action of the actinic rays. Pigment absorbs these rays. Experience has taught me that the skin of the negro offers more resistance to the X-rays than non-pigmented cuticle. It is harder to get a good skiagraph of a negro's than of a white man's spine. The large surface exposed PRINCIPLES AND PRACTICE OF X-RAY THERAPY. 319 ( abdomen and back ) contains so much pigment that a good deal of X-ray energy is lost, being absorbed by the pigment. The pigment in the red blood-cells absorbs X-rays. Thus we can explain why it is comparatively easy to skiagraph a bloodless part (hand after an Esmarch bandage has been applied to the arm). Radiographers know that anemic per- sons make excellent subjects for radiographic work. The practical conclusions from these theoretical pre- mises may be summarized thus : 1. The X-ray and the actinic and ultra-violet rays of the solar spectrum belong under the same generic head ; 2. The difference between the two force-modalities is the greater speed of oscillation and the shorter wave- length of the Roentgen ray ; 3. The penetrating power of the X-rays is in direct pro- portion to the pressure of the vacuum in the tube ; 4. Penetrating power and quantity of energy are in in- verse ratio to each other ; 5. Like all induced forms of energy the X-rays lose their volume in proportion to the distance from the source of in- duction, i. e. the tube ; 6. The X-rays like all actinic rays are slightly inter- cepted by pigment in the skin and in the blood (hemo- globin) ; 7. The destruction wrought by the X-rays is due to dis- integration of the pigment-carriers (skin and red blood- corpuscles) ; 8. The therapeutic action of the X-rays is confined to the place of greatest interception, ;'. e. the skin. These eight points contain the principles of X-ray therapy. Translating the language of the theoretical physicist into the therapeutic directions which the X-ray operator needs in his practical therapeutic work, the eight points enumerated above could be formulated as follows : i. Generically speaking, the active principle of X-ray therapy and of Finsen-light and sunlight is the same, i. e. 320 MODERN PHYSIO-THERAPY. the germicidal, stimulating and destructive ultra-violet force-modality ; 2. The ultra-violet ray of Finsen is closer to the violet field of the solar spectrum than the X-rays ; 3. The harder the tube, the more penetrating the rays, the softer the tube, the more superficial the effect ; 4. The harder the tube, the less X-ray energy, the softer the tube, the greater the amount of X-ray energy, making the soft tube the ideal therapeutic tube ; 5. The closer the tube is to the skin of the patient, the more intense the effect ; 6. The X-rays are partly taken up by the pigment in the skin and in the blood. The greater the amount of X-ray energy, the greater the amount absorbed ; 7. The X-ray, after being partly absorbed by the skin- pigment and the hemoglobin, first produces a stimulating effect. Through the sympathetic (vaso-motor) nerves the stimulating effect is reflected and thus a stimulating and pain-relieving effect is obtained in distant or deep struc- tures. If the application is continued, overstimulation takes place, resulting in irritation of the pigment-carriers (skin and blood-corpuscles). The skin reacts by a distinctly in- flammatory process. The red corpuscles are disintegrated and the small arteries are occluded, causing local necrosis by lack of nutrition. If the part is composed of morbid tis- sue, the latter dies, leaving a comparatively healthy ulcer behind. The absorption of the X-rays by the red corpuscles explains the phosphorescence of the tissues which fre- quently interferes with the skiagraphic result. It also ex- plains the appearance of an X-ray "burn" in parts that have not been directly exposed. If an X-ray treatment is not pushed to the extent of overstimulation. it may stimulate local nutrition and metabolism. This explains the absorp- tion of growths after X-ray treatment. 8. X-ray therapy should be confined to superficial lesions. The cure is accomplished by disintegration and subsequent destruction of the pigment in the red blood- PRINCIPLES AND PRACTICE OF X-RAY THERAPY. 321 corpuscles. Keeping in mind the physics of the X-rays and the physiology of their action on organic tissue, we can readily see that deep-seated lesions are inaccessible to the therapeutic action of the Roentgen rays.. In addition to this, we know that the therapeutic effect is in proportion to the amount of X-ray energy. Since the latter is in inverse ratio to the penetrating power of the rays and since the deeper the lesion, the greater the penetration required, it stands to reason that energy is lost according as we in- crease the depth of penetration. The Technique of X-ray Therapy. The fundamental law of therapeutic X-ray work is sug- gested by the necessarily superficial character of the thera- peutic effect produced by the Roentgen rays. The soft or low vacuum-tube produces an abundance of X-ray energy with but scant penetrative power. The .soft tube is, there- fore, the therapeutic tube par excellence. Gauged by Wal- ter's skiameter it should light up three or four of the test- holes of the instrument. The standard for an exposure is ten inches distance between the tube and the surface to be treated. The duration of the standard treatment is three minutes, a. treatment to be given every other day. This kind of a treatment (soft tube, distance ten inches, duration of treatment three minutes) would, under ordinary circum- stances, produce a stimulating effect and result in more ac- tive granulation and absorption. It would be indicated in indolent ulcers, in various forms of skin-diseases due to malnutrition, in fact in all conditions which demand an increase in local metabolism. In most non-bacterial skin- diseases the results are not usually permanent because these diseases are but local expressions of systemic conditions. By lessening the distance between tube and skin, or by con- tinuing the exposure for a longer time, or by repeating the treatment every day, the effect would be intensified. It would be like increasing the dose of a remedy. \Yhen the action of the rays gets beyond the stimulating point, the 322 MODERN 1'n VSIO-THERAPY. effect is best marked. Whether the latter is produced by the action of the ray on organisms of but little resisting power, or whether the germicidal effect is coin- cident with the accumulation of oxygen in the part treated, is not quite clear. It has been demonstrated, however, both by laboratory-experiments and on the living subject, that pus-germs and the tubercle-bacillus soon are rendered inert and finally die if they are exposed to oxygen. We know that currents of high voltage and high frequency have an effect on the composition of the atmospheric air by their affinity for oxygen. How far this affinity will affect the oxygen in the body we are as yet not prepared to say. There is, however, no doubt about the germicidal action which fol- lows applications of the X-rays. If the X-ray dose is in- creased still more, we arrive at the point at which destruct- ive effects are to be expected. A destructive treatment would be administered by a soft tube used every day for five to ten minutes at a distance of ten inches. This is the typical X-ray treatment for superficial cancer. It is under- stood, of course, that the stimulating, germicidal or de- structive effects do net follow one treatment, but represent the accumulative therapeutic effect of a series of treatments. It would be folly to recognize iron-clad rules which must prevail under any and all circumstances in every case. The personal equation of the patient, as apparent to the indi- vidualizing judgment and to the experienced eye of the operator, is the unknown quantity which can not be forced into the tight-fitting limitations and indications of a stereo- typed law. As long as every patient presents a personal equation of his own to be solved by the personal equation of the physician, every kind of therapy must necessarily con- tain an uncertain element which makes therapeutic practice an art rather than a science. The suggestions given are hypothetical. In applying them, the experience of the operator must adapt them to concrete conditions. This may mean shortening or lengthening the exposures, chang- ing the distance of the tube from the skin, etc. It is under- PRINCIPLES AND PRACTICE OF X-RAY THERAPY. 323 THE CUSTER X-RAY SHIELD. 324 MODERN PHYSIO-THERAPY. stood, however, that the tube must at all times receive its full capacity of current. The current should not overheat the anode before the time of exposure is over. The surface to be treated and the anodal disc should be placed approximately parallel to each other. An imaginary line drawn through the center of either should be at right angles to the plane of the anode and to the plane of the sur- face to be treated. Thus, if the patient is lying on his back on a suitable table, the tube should be placed directly over the affected area. The anode should be parallel to the sur- face and should be directly over it. The glass of the tube should be ten inches from the area to be treated. This is CALD WELL'S THERAPEUTIC TUBE. the ideal position. Variations from this position are fre- quently necessary owing to the peculiar location of the trouble. The tube-stand should have a lead shield attached which has adjustable diaphragms in its center and is in- terposed between the tube and the patient. This tube-stand is not an absolute necessity, but a most desirable con- venience. The perforation in the center of the diaphragm is placed directly over the area to be treated. Pieces of sheet- lead are put around the perforation so that only the area to be exposed remains uncovered. When no shield is used, the patient has to be covered carefully with sheet-lead (not lead-foil) so that the X-rays can not impinge upon any part except the area which is to be treated. If the hand or the arm of the patient is to be treated the patient can sit on a chair and place his hand or arm on a table. Otherwise it is PRINCIPLES AND PRACTICE OF X-RAY THERAPY. 325 by all odds best to place the patient on a properly con- structed table. The recumbent position is most convenient and comfortable for both patient and operator. Always be careful to cover every bit of skin that is not to be exposed to the X-rays. The lead-dressing is the most important part of the whole procedure because it limits the action of the rays and in this way prevents X-ray "burns." The latter are really not burns. They are evidences of reaction, and if they occur in the right place, have the highest therapeutic significance. Inasmuch as reaction is necessary, the cure in cases of morbid growths depends upon it. X-ray burns over large areas of healthy tissue are in the majority of in- stances due to faulty technique on the part of the operator. Exposures should be made in a darkened room so that the operator can watch the phosphorescence of the tube, should be noiseless in order not to frighten the patient, and should be painless. The tube should be properly attached to pre- vent sparking. The operator should not expose himself unnecessarily, especially his hands and eyes. The delete- rious effects of the X-rays on the procreative faculty of oper- ators have been emphasized by many observers. A tube which has become hard from constant use should be allowed to rest a week or longer and then softened. The employ- ment of the regulating (softening or hardening) device on overworked tubes is not conducive to preserving the tubes. Clinical Indications. The triple action of the X-rays (stimulating, germi- cidal, destructive) should be remembered in adapting means to the end. The operator should have a clear pathological conception of his case before he can attempt to make X-ray exposures intelligently. The X-ray is at its best in condi- tions, where morbid tissue is to be destroyed and where the lesion is extensive and involves the subcutaneous tissues. The following list of diseased conditions probably repre- sents the present status of the question, as suggested by the study of over 500 cases which have been under observa- 326 MODERN PHYSIO-THERAPY. tion during the past four years at the Cincinnati Post-grad- uate School of Physiological Therapeutics. The directions given should be modified to suit the individual case. ACNE. In the common form of acne the results are very good. Exposures every day or two for five minutes. Dis- tance of moderately soft tube ten inches. Protect the eyes. In acne rosacea the results are not so uniformly good. Con- dition is likely to return. CARCINOMA. Cancer of the breast does very well in the early stages. Treatment every other day with moder- ately soft tube for ten minutes. Distance ten inches. When- ever the lesion is at some distance below the skin in this or any other kind of a case, the tube should be correspondingly harder to insure penetration. The results are correspond- ingly less certain. After the first stages of breast-cancer amputation is the proper remedy. It should be followed by X-ray treatment. In cancer of the stomach, bowels, rec- tum, uterus or any other deep organ the X-rays, like all high potential force-modalities, relieve pain and produce an alterant effect, thus prolonging life. I have never seen a case cured and doubt whether the reported cured cases of this kind could stand critical analysis. I have known of pain being relieved by the X-ray, that resisted opiates of all kinds. Exposures should be at long range (15-20 inches) with a comparatively hard tube. Ten minutes every day or two. ECZEMA. In many cases of chronic eczema, especially the .vesicular variety, the X-rays produce a cure. In nearly all cases they relieve itching and lessen or stop the dis- charge. Treatments with moderately soft tube for three to five minutes every other day. Distance five to ten inches. Constitutional treatment is imperative in all these cases. Locally the high-frequency current seems to be better adapted than the X-rays. EPITHELIOMA, or common skin cancer, is nearly always curable by the X-rays. Usually located in the face (lips, nose, angle of eye). Patients should be treated every day PRINCIPLES AND PRACTICE OF X-RAY THERAPY. 327 for five to ten minutes. Distance of soft tube five to ten inches. If there is much induration of surrounding or sub- cutaneous tissues, vacuum of the tube should be somewhat higher. As soon as the induration disappears and condi- tions assume a healthy aspect, the addition of Finsen's ac- tinic rays seems to accelerate the process of repair. Ex- posures should last from thirty minutes to an hour. In reality this is equivalent to using a force-modality of less rapid oscillation and greater wave-length in order to sup- plement the work done by more rapid vibration and shorter undulation. The Finsen-treatment can be advantageously added to X-ray exposures as soon as the process of repair has begun. As a substitute for the Finsen-ray in these cases, a (positive) brush-discharge from a static machine (wooden electrode) answers nicely. FAVUS. Two cases treated and both cured. Technique same as in the treatment of eczema. HYPERTRICHOSIS. I have not been able to produce more than a temporary effect in these cases. Recurrence seems to be the rule. KELOID. Results were negative in three cases. Pa- tients were colored. KERATOSIS SEXILIS. Results are good especially if the excrescence is removed and the remaining denuded surface treated. Technique same as in the treatment of eczema. LEUKEMIA. Results seem favorable as shown by gen- eral improvement and in a few cases by blood-count. .Ex- posure over region of spleen with comparatively hard tube for ten to fifteen minutes every two or three days. LICHEN PLANUS. Out of six cases two were cured, two relieved and two passed from notice. Technique similar to that of eczema. LUPUS VULGARIS. In the hypertrophic form, character- ized by nodular enlargement and much contiguous involve- ment the X-rays are superior to the actinic rays of Finsen while the latter are preferable in the ulcerated form. Com- paratively hard tube for five to ten minutes every day or 328 MODERN PHYSIO-THERAPY. two. In suitable cases the X-rays are almost a specific. In the erythematous form of lupus (seborrhea congestiva) results have not been satisfactory. In two cases aggrava- tion seemed to follow X-ray treatment. The high-frequency current seems to be the proper agent. PRURITUS. The neurotic form seems to respond very well. Three cases, two cured, one relieved. Frequent but very short exposures by means of a soft tube. The itching of many skin-diseases is relieved by the X-rays. SARCOMA. Results uncertain and seem to vary even in similar cases. Radiotherapeutic treatment should supple- ment surgical interference. One case of post-nasal sar- coma, which was operated upon and referred to me by a local laryngologist, was cured. SYCOSIS. Results are good. Technique as in acne. TINEA TONSURANS. Results usually good. Technique as in acne. TUBERCULOSIS. In the glandular form the results are good if the infected glands are not too deep. See technique under Cancer of the Breast. In peritoneal tuberculosis I have seen temporary improvement, general and local. Tech- nique as in deep-seated cancer. Tuberculosis of joints re- sponds favorably in many cases, if energetic general and local treatment is added. Technique same as in cancer of the breast. Use a comparatively hard tube. Skin-tubercu- losis responds to frequent exposures with a soft tube. Tech- nique as in lupus. . In tuberculosis of the lungs X-ray therapy seems to be of doubtful value. The proper agent locally seems to be the high-frequency current applied by means of a double resonator. The best results from X-ray treatment are obtained in epithelioma of the face, in the hypertrophic form of lupus and in acne. In these conditions the X-rays surpass any and all other agents, because they are painless, are almost specific in their action, and serve an admirable cosmetic purpose, especially in the common skin-cancer of the face. The first and essential condition of success in the use of the PRINCIPLES AND PRACTICE OF X-RAY THERAPY. 329 Roentgen rays is knowledge of their physical properties and the effect they are capable of producing on organic tissue. Without any knowledge of this most important part of the subject,- the art of skiagraphy becomes amateurish guess- work, the science of X-ray therapy a conglomerate of em- pirical notions. There can be no progress without logical elaboration of the principles that underlie the work we at- tempt to do and the technique we adopt. Sit modus in rebus! 330 MODF.RX I'llYSIO-TllKKAI'Y. CHAPTER XII. SUGGESTION. "Cure her of that. Canst thou not minister to a mind diseased, Pluck from the memory a rooted sorrow, Raze out the written troubles of the brain, And with some sweet oblivious antidote Cleanse the stuffed bosom of that perilous stuff Which weighs upon the heart?" Shakespeare. If we were to eliminate the suggestive element out of the practice of medicine, there would not be enough left to merit serious discussion. The theory of medicine, as gleaned from the laboratory or the post-mortem room, can subsist independently of suggestion. The moment, however, the theory is translated into intelligent action in the treatment of a living organism which is more than an aggregation of cells or composition of chemical substances, it is not any more impossible to eliminate the suggestive element than to take away the personal equation of either physician and pa- tient in the relations of one to the other. Such being the case, suggestion should be studied and- understood like all other methods of therapy. As a matter of fact, it has always attracted the really great minds in medicine who have variously discussed this subject under the head of men- tal medication, animal magnetism, hypnotism, suggestive therapeutics, psycho-therapy, etc. Suggestion is said to be "a method of conscious or un- conscious control of a person's mind." Neither the opera- tor nor the subject need necessarily be aware of the act of suggestion. The medium through which the suggestive in- fluence is communicated is said to be one or more of the SUGGESTION. 331 special senses, the eye, the ear, etc. This is true in the majority of instances, although the action of mind upon mind by means of thought-waves (vibrations of the ether intervening between brain-cells) does not necessarily de- pend upon the interposition of the special senses. If thought-waves travel from nerve-cell to nerve-cell within the same nerve-organism (brain of the same person), the term "auto-suggestion" is used. There is no doubt that communication between nerve-cells of different nerve-or- ganisms (different persons) without the instrumentality of the organs of special sense is possible, e.g., controlling the mind of a sleeping person or that of an absent person. (See chapter on "FORCE AND FORCE MODALITIES.") In order to understand the phenomena of suggestion, it is necessary to remember that the term "mind" refers to the totality of impressions left by the environments of a person throughout that person's life. A person born with- out the use of his special senses, i.e., born blind, deaf, etc., could not possibly have "mind." He might have brain-cells capable of receiving and storing up impressions. Without "impre'ssions," however, these brain-cells would be like an electric battery without wires or conductors. From the first moment of life the organs of special sense carry im- pressions to the brain-cells. The sum-total of these im- pressions is the "mind" of the person. The store-house of the impressions is the aggregation of brain cells. These brain-cells have a functional power peculiar to themselves just as all cells in the body, e.g., those in the liver, in the kidneys, in muscle-tissue have some characteristic inherent power peculiar to themselves. This diversified functional capacity represented by cells of different kinds is bound up in the physical or anatomic-physiological make-up of the person and, therefore, necessarily a phenomenon of heredity. With reference to brain-cells this functional power determines the degree of fitness of the individual to utilize and combine the sense-impressions. There are in- numerable degrees of this fitness and, therefore, there are 332 MODERN PHYSIO-THERAPY. innumerable degrees of mentality from abject idiocy to superlative intellectuality. The "fitness" is the hereditary element of mind because it is primarily and absolutely a result of stock-breeding, in the same sense as physical size, strength or peculiarity are matters of pedigree. Analyzed down to its simplest form the functional power of the brain-cells represents the ultimate trace of the sense-im- pressions gathered by generations of ancestors. Thus we see that "mentality" is by no means an arbitrary concept but a composite picture made up of the sense-impressions gathered by the individual and by the numerous individuals that represent the stock whence he was bred. The patient that presents himself or herself for treat- ment represents an organism within which the brain is en- throned as the controlling element. In as much as you are able to control that brain,' you are able to master the organism, or, for that matter, the person. Keep in mind that the brain or control-station of your patient is a com- pound of heredity and environment. The suggestion must be within the range of impressions gathered and elaborated by the individual, and must, therefore, be adapted to the individual's mentality. The object in every case must be to direct the patient's mind-operations in conformity with the suggested idea or mind-image. Since the so-called "prevalent ideas" control the operations of the individual mind, it is of importance to adapt a suggestion to the "prev- alent ideas" of the individual brain. By "prevalent ideas" are meant impressions that are strongest and of dominating influence. Impressions which by environment and training are constantly repeated until they become a part of a pa- tient's mental individuality, are called "prevalent ideas." The sum-total of these "prevalent ideas" is what we ordi- narily mean by will-power. The will is free in the con- ditional sense indicated. It is plain that suggestion is the constant and ubiquitous companion of the physician in his successful professional work. There is no way of practicing medicine without sug- SUGGESTION. 333 gestion. Everywhere and at all times the physician's mind controls mind and, through the latter, matter. The sugges- tion does not only emanate from the physician's mind. His appearance, his demeanor, his voice, his mode of dealing with people, his habits, his reputation, his surroundings, the appearance of his office, etc., etc., they all are full of suggestions to the mind of the patient. What the sugges- tion will be, depends on the mind that receives the impres- sions. The confidence of the patient in his doctor is a sug- gestive influence emanating from the latter. The old say- ing that "confidence is half the cure" contains a world of truth. It expresses that condition of attunement between the controlling mind and the mind controlled which makes the former the complete master of the situation. The phy- sician must control the patient's mind in order to be able to influence his body. It is unnecessary to point out the tremendous impor- tance of the psychic element in its direct bearing on the physical phenomena that constitute health and disease. The thought or sight of food is capable of causing a flow of saliva. The act of yawning or even the thought of yawn- ing is frequently productive of a similar performance in others. Diarrhea following an attack of fear or fright, the fainting at the sight of blood, the shock produced by sud- den announcements, death following psychic shock are il- lustrative of the great influence of mind over body. The practice of suggestive therapy consists in adapting the pos- sibilities of this influence to the requirements of clinical problems. The misapplication of this principle is shown in the production of disease or symptoms of disease following suggestion or auto-suggestive influences. The hypochon- driac who rivets his mind on his heart and constantly sug- gests all manner of heart disturbances to himself, will never fail in producing the symptoms about which he has read or heard. The pregnant woman who is haunted by the spectre of some physical defect in her child, not infre- quently brings on the very things she abhors and fears. 334 MODERN PHYSIO-THERAPV. Maternal impressions illustrate the influence of mind over body. The physician, in treating a patient, must make this tremendously powerful psychic agent subservient to his purpose. His suggestions to his patient must be few, clearly defined and constantly repeated. They must be few in order not to attenuate the effect by scattering the force of impressions. They must be clearly defined in order to make a definite and positive impression. They must be constantly repeated in order to produce a lasting effect and an increasingly intense impression. Thus : In treating any kind of a case, pick out the one feature or symptom of the case upon which the latter hinges as far as the patient sub- jectively is concerned. This one feature is usually pain or some other neurotic or nervous phenomenon. Rivet your suggestive therapy upon this one feature. Your suggestion, counteracting a symptom, should be direct, firm, clear and continuous. Suggestions need not necessarily be couched in words. Your whole attitude and conduct should be a clearly defined and deeply impressed suggestion to remove, alter or relieve the condition whatever the latter may be. The exact form in which suggestions are given is variable. It depends on the personality of the physician and indi- viduality of the patient. It is a case of personal equation on both sides. The choice of the vehicle which is to carry a suggestion is also a matter of personal equation. A dose of medicine of indifferent composition might act as a pow- erful and prompt anodyne. This is what doctors call a placebo. A few gentle stroking movements of the hand over a painful spot might give instantaneous relief by the suggestion which accompanies the application. The prin- cipal part of the performance is the complete attunement of the patient's mind and the expectation of and belief in th result.. What a marvelously effective agent for good this form of mental medication is, has been shown by the results achieved by the Christian Scientists. Their thera- peutic agent is suggestion. The vehicle is prayer and a more or less melodramatic exhibition of stage-effects. SUGGESTION. 335 AYhile Christian Science is misnamed and, in its practice, has all the ear-marks of charlatanerie and buffoonery, it contains a grain of truth which properly belongs to the science and legitimate practice of medicine. The grain of truth is the therapy of the mind for the cure of ailments of the body (psycho-therapy, suggestive therapeutics, mental medication, suggestion). The range of usefulness of suggestive therapy is as large as the entire field of medicine, nay even larger. Sug- gestion is the principal element in the dealings of men with each other at all times and under all circumstances. In the training and moral hygiene of childhood and ado- lescence suggestion is a most powerful factor. The ethics of religion stripped of its outward garb of form and cere- mony is nothing but suggestion. In the management of temperamental aberrations, lack of balance, melancholia, bad habits and many forms of mental disease suggestion is the one great curative factor. In the treatment of insomnia, paralytic or spasmodic conditions, sexual neuroses and psy- choses and all forms of functional and reflex disorders sug- gestion offers the best of results. Suggestion should be persistently tried in constipation, in incontinence of urine, dysmenorrhea, hysteria, epileptic and epileptoid conditions, in drug addictions, alcoholism; in fact, whenever and wherever the will-power of the patient needs toning up suggestion js the ubiquitous curative agent. Suggestion often takes the place of chloroform in obstetrics. That operations can be rendered painless by suggestion is a well- accredited fact. In the successful treatment of morphine and cocaine habitues as well as alcoholic subjects much can be accomplished by suggestion. Many cases are on record that were cured of the drinking habit by a powerful sugges- tion given to the patient that he would not be able to touch he glass to his lips any more. All attempts to bring a glass of liquor to his lips failed. Suggestion controlled the move- ment of his arm. In the treatment of the morphine habit the hand is controlled and is rendered unable to wiejd the 336 MODERN PHYSIO-THERAPY. syringe. In the alleged cures of drug-habits of various forms supposed to have been produced by advertised nos- trums of different kinds the real curative factor is sugges- tion. The nostrum is merely the vehicle of suggestion. There are no contraindications to suggestion properly applied. It is the necessary bond that links doctor to pa- tient and patient to successful therapy. The suggestions of hopefulness should be conveyed to' the patient and to his surroundings, his friends and his family. It should be preceded by constant auto-suggestion of the physician upon himself. It will invariably be perpetuated and intensified by the auto-suggestion of the patient upon himself. As the case develops, suggestion should be adapted to special phases and symptoms and persistently applied. Its efficacy is as unquestioned as its field unlimited. The American people are splendid subjects for suggestion. Individually and collectively they respond to suggestive influences of the press, the pulpit or even of a designing individual like Mrs. Eddy or John Alexander Dowie. The destructive and demoralizing influence of a morally tainted or ethically irresponsible press is incalculable because of its suggestive influence. It is capable of literally creating a nation of moral weaklings and criminals. Every physician is sur- rounded by a sphere of the suggestive influence that eman- ates from him. It should be made subservient to the real purposes of a physician's work, to-wit : for the good of the body and soul of his fellow-man. What is the modus operandi of suggestion? We may recognize two states of the mind. The conscious state is characterized by the reflection of the mind upon its own acts. Whether this act of reflection is the function of special brain-cells or whether it is due to peculiar combina- tions of the dendrites and other appendages of brain-cells, giving rise to new paths along which vibratory nerve-im- pulses may travel, is immaterial. When the fitness of the mind to reflect upon its own acts does not exist, the mental status is called the sub-conscious state. It is the realm of SUGGESTION. 337 all those mysterious manifestations and phenomena of soul- life that have always been a fruitful subject of psychologic experiments and speculations. In keeping with the division previously given, the sub-conscious state concerns that part of the mind which is the sum-total of hereditary impres- sions. The life of countless generations of ancestors is reflected in the sub-conscious state. The conscious state includes the element of individual experience, the sum-total of impressions gathered from the environments and experi- ences of individual existence. It is the individual added to the genus. The conscious state bears a relation to the sub- conscious analogous to that of plant to soil. In keeping with the division given we may recognize a twofold variety of suggestion received, the conscious and the sub-conscious. A suggestion given is received by the conscious mind and eventually percolates through the latter down to the sub- conscious state. It becomes a part of the power that is the motive element of soul-life (Kant's Impcrativus catcgori- cus). The individual thinks, says and does certain things in response to the presence of a vis a tergo which is more powerful than the individual. Therein lies the explanation of the phenomena of suggestion in its most intense form or hypnotism. The latter divides the mind into its several potencies or faculties and engages one or more of the latter independently of each other. It would take us beyond the scope of our purpose to go more deeply into- the physiology of these phenomena. The following illustrations will serve to make the subject practical and intelligible. In many patients it is a difficult matter to act upon the conscious mind by suggestion. Lack of concentration scatters the suggestive influence. In these cases the sub- conscious mind must be made to receive the suggestion di- rectly. This means that the resistance of the conscious mind must be eliminated by hypnotic influence. The pa- tient is made to sit or lie down comfortably clad in a loosely fitting garment. The room must be quiet and not too light. Impress the patient in a quiet but firm manner 338 MODERN PHYSIO-THERAPY. with the value of the suggestive method and with the bene- fit he will derive therefrom. Tell him to put his mind at ease by trying to go to sleep. Tell him to close his eyes and go to sleep, sleep, sleep. Accompany the process of gradually supervening somnolence by gentle soft sugges- tions such as: "Your eyelids are beginning to feel heavy; your eyes are tired ; you cannot open them ; your eyelids are getting heavier; you are beginning to feel drowsy; you are asleep." From time to time gentle strokings of the eyelids or of the arms might be added to the spoken suggestion. By and by the conscious mind becomes inactive and the sub-conscious mind is ready for the suggestion which is intended. When the conscious mind reawakens, the sug- gestion, now firmly planted in the sub-conscious mind, re- mains and is a part of the patient's mentality. The alco- holic subject no longer craves his liquor, the drug habitue shows a strange aversion to his favorite drug, the tobacco- fiend does not ask for the weed, insomnia, somnambulism and all nervous symptoms seem to have disappeared, afflic- tions of the mind do not seem to exist any longer. In the ordinary class of cases it is not necessary to hypnotize the patient. It is sufficient to suggest to the con- scious mind by words, by environment, by sense-impres- sions, etc. This is the kind of suggestion that is practiced by physicians consciously or unconsciously in a more or less intense degree at all times and under all circumstances. Let this form of suggestion be systematized and adapted to individual conditions. The physician should practice auto- suggestion, to begin with. This begets confidence in one's work and fitness to accomplish results. It should be fol- lowed by suggesting to the patient firmly and persistently the things that are essential in the successful issue of the case. The control of the physiological life-phenomena through the brain-cells is a subject physicians should study in all its wonderful mysterious relations. There is no rea- son why the marvelous work done by Charcot, Moll and Bernheim cannot be imitated by others. Let us consider, SUGGESTION. 339 in conclusion, various forms of suggestion and illustrate the possibilities of this vast subject by a few pertinent examples. Superstition, more especially if connected with some religious subject, has always been a fruitful source of sug- gestion. Evidences and examples of this kind are found among the peoples of all ages. That these forms of sug- gestion were used for the treatment and cure of disease there is, likewise, no doubt. Practices of this kind were common among the ancient nations, particularly these of the Orient, where the sick were cured by being wrapt in the skins of sacred animals, by being made to swallow sacred fluids, by the laying on of hands, by songs and incantations. Among the Christian nations suggestive ther- apy found its expression in innumerable forms of worship, in the use of prayers, relics and holy water. Mesmerism (named after the great magnetic healer, Friedrich Anton Mesmer, born 1733, died 181-5) was a form of suggestion that held sway during the second half of the eighteenth century. The existence of a mysterious force, called "animal magnetism" was recognized and its activity studied in the treatment of the sick. Some thought that this form of magnetism was a physical force (Mes- merism proper) and that it passes from the operator to the patient. Others imagined that the whole world is alive with spirits and spirit-agencies and that the phenomena of ani- mal magnetism were due to the intervention of suirits who responded to the beck and call of the operator. Braidism (named after James Braid, an Englishman who produced an artificial sleep by fixation of the eyes of the subject) was the earliest form of hypnotism proper (sleep produced by suggestion). It is thought by some, notably Charcot, to be a neurosis or a hysterical state. Others, especially Bernheim, call it a psychosis. These two investigators are the founders of the two great schools of hypnotism, Charcot the founder of the Paris school, Bernheim of the Nancy school. 340 MODERN PHYSIO-THERAPY. Dercum summarizes the methods of inducing the hyp- notic state under the following three heads : 1. Sensory impressions, sudden or monotonous, will produce hypnotic sleep. Among these are :gazing steadily at an object, listening to monotonous sounds or being gently stroked at regular intervals. The impressions may be sud- den or violent like the flare of a bright light, a loud and sudden noise. Sense-impressions that are fatiguing are particularly apt to produce sleep. Fixation of the eyes is a most common method of this kind. 2. Stroking or "passes" were used by Mesmer and are still employed by some hypnotiseurs. That the "passes" of some persons produce a distinct sensation of heat in the region over which the "passes" are performed, while the "passes" of others are productive of ice-cold, otherwise disagreeable, sensations, is a phenomenon which I have repeatedly witnessed. 3. Verbal suggestions have already been referred to. In the use of verbal suggestions everything depends on the influence and resourcefulness of the operator. Physical effects of suggestive sleep are noted in the pulse, the respiratory movements, functions of the special senses, in the occurrence of paralyses, spasms and other nervous phenomena (catalepsy, convulsions, contractures, general lethargy, somnambulism). What is the difference between hypnotism and sugges- tion? Hypnotism is a form of suggestion involving a species of artificial sleep. It is classified under the head of suggestion and represents a special form of the latter. Hypnotism ordinarily has no practical therapeutic interest for the physician. It belongs to the neurologist or patho- psychologist. The general practitioner should interest him- self in the subject of simple suggestion (suggestion with- out hypnotic sleep). His success will be in proportion to the degree of his appreciation of this wonderful agent. Let me conclude by a practical review of the clinical SUGGESTION. 341 uses of suggestion, as proven by the experience of different investigators, notably Wetterstrand. Insomnia. The form of insomnia that can be success- fully treated by suggestion is due to neurotic or psychic causes. Wetterstrand considers suggestion the foremost therapeutic agent in these cases, provided the latter are carefully individualized. He often resorts to chloroform to start the suggestive state. Suggestion must be firm and commanding. Frequently the mcst stubborn cases become the most easily tractable subjects. MacFarlane combines suggestion with massage for the production of sleep. Bern- heim confines himself to verbal suggestion and succeeds in nearly every case. In a case of insomnia in a hysterical subject I was able to bring about a cure by vibration of the spine and a firm suggestion of sleep. The patient fre- quently fell asleep during the treatment. Headache. Under this head I classify conditions that cannot be referred to definite causes, but are ill-defined in their etiology and pathology, frequently associated with a dread of noise, with photophobia, general lethargy and various nervous symptoms (nervous headache). These conditions offer a most promising field for suggestive therapy. Neuralgia. The pain of so-called "neuralgic" condi- tions can usually be relieved by suggestion, accompanied by stroking or "passes" over the aching part. Suggestion should be tried in all stubborn cases of intercostal neural- gia, tic douloureux, sciatica, etc. The use of other physical methods in conjunction with suggestion is desirable. Paralyses Due to Organic Causes. Bernheim speaks of many cases of this kind (hemiplegia, paraplegia) that im- proved under suggestion. My own experience shows that the improvement in not a few cases of paralysis, treated physio-therapeutically, is largely due to suggestive influ- ences which accompany the treatment. In case of partial paralysis of the arm which I treated some years ago im- 342 MODERN PHYSIO-THERAPY. provement ceased when patient removed to another city where the physio-therapeutic treatment was continued by a perfectly competent physician. When 1 again began to treat the patient, she again improved. The importance of the suggestion in some of these cases should never be lost sight of. Locomotor Ataxia. As a means to relieve pain sug- gestion is serviceable in many cases. I once witnessed a "magnetic treatment" performed by a "magnetic healer" who knew nothing about medicine but certainly had a re- markable control over some of his subjects. He applied "passes" to the back and legs of a patient suffering from tabes and gave a great deal of symptomatic relief. In pass- ing his hands over any one's skin he was able to produce sensations of intense heat or cold. Epilepsy. There are many authenticated cases of epi- lepsy on record that were cured by suggestion. Wetter- strand attributes most cases of epilepsy to psychic causes and explains in this way the favorable effect of suggestive therapy. I know from observation that suggestion will affect the time and frequency of epileptic attacks. Chorea. All observers agree concerning the value of suggestion in the treatment of St. Vitus' dance. Goodhart combines it with liberal feeding and daily general massage. Bernheim, Wetterstrand and Moll depend on suggestion pure and simple. Wetterstrand emphasizes the importance of definite and firm suggestion, especially in susceptible children. He often resorts to suggestion while the patient is asleep. He places his right hand gently and cautiously on the forehead of the sleeping child and makes a few "passes" over the body with the other hand. In an under- tone he suggests to the sleeping child to continue sleeping. He raises the arm of the child and finds it in a cataleptic condition, showing that the suggestion has been successful and thst the operator and the subject are en rapport. Lie- bault calls catalepsy under these conditions "the visible ex- SUGGESTION. 343 pression of the will of the operator." When rapport has been established, further suggestion can be given. The results are often surprisingly good. Stuttering. Wetterstrand treated thirty-one males and seventeen females, curing eleven of the former and five of the latter by suggestion. Fourteen males and five females were materially improved. In the remainder there was no change. In many cases, especially in children, the sug- gestion was given during sleep, as indicated under the head of chorea. Neurasthenia. Suggestion added to Weir Mitchell's rest and feeding seems to offer good prospects in the treat- ment of even seemingly hopeless cases. Every physical method is indicated, in one way or another, in the handling of neurasthenics (hygienic measures, mechano-therapy, etc.). If the condition of the patient present some promi- nent symptom of a psychic character, especially that of despair or utter hopelessness, suggestion of recovery must be resorted to. In many cases complete hypnotization is necessary. Suggestion during the hypnotic state offers the best results. . Psychic and Mental Disorders. Neurologists and alien- ists agree that suggestion has a well-nigh unlimited sphere of therapeutic usefulness in the treatment of these condi- tions. From the mildest psychoses to the severest forms of mania suggestion is applicable. Many interesting cases of nostalgia, sexual psychoses, drug addictions, hysteria, etc., that have been treated successfully by suggestion have been reported. Wetterstrand, in his interesting book on Hypnotism, in- cludes in his long list of diseases amenable to suggestive treatment, all of which he illustrates by exhaustive case reports, anemia, chlorosis, rheumatic afflictions, hemor- rhage, especially uterine, asthma, nervous cough, diseases of the heart, local congestions, stomach disorders, espe- cially nervous dyspepsia, diarrhea, constipation, inconti- 344 f MODKRX 1'lIYSIO-TllEKAPY. nence of urine, irritation at the neck of the bladder, men- strual disorders, etc. Suggestion is useful in the ameliora- tion of distressing symptoms of many diseases, such as tuberculosis and Bright's disease. It has successfully taken the place of the anesthetic in surgical and obstetrical cases. As a therapeutic agent in the treatment of functional dis- eases of the nervous system it occupies the foremost place. PART II. The Practice of Physiological Thera- peutics. THERAPEUTIC INDEX. 347 THERAPEUTIC INDEX. Alcoholism. The acute form can -be successfully handled in the dry-heat cylinder. Flushing out the stomach and irrigation of the colon should precede the treatment. Chronic alcoholism requires isolation, abstinence, active elimination through the skin and bowels and stimulating (hydro-therapeutic or electrical) applications to the lower extremities. Suggestive influence, hygienic surroundings, a vegetable diet are indicated. Symptoms of individual cases should be met when they arise. Daily positive static insula- tion is very serviceable. Alopecia. Baldness may be the result of some consti- tutional disorder (syphilis, acute fevers) or disease of the skin (eczema, psoriasis, etc.) or may be due to parasitic in- vasion and gradual destruction of the hair-follicles. The curability of the condition is in direct proportion to the tractability and removability of the cause. This holds good with special emphasis in regard to the first two varieties named. Localized baldness (alopecia areata) is due to invasion of the hair-follicles by fungoid parasites. The prevalence of the disease in this country is frequently due to ignorance of the first principles of scalp-hygiene. The bad habit of many people hardly ever removing their head-gear deprives the scalp of the benefits of the actinic rays of sunlight. These rays are destructive to germ-life. Exposure to sun- light is. therefore, the first condition of treatment. Liberal use of soap and water is next in importance. In well- marked cases of gradually spreading and coalescing spots of baldness the Finsen-rays and the high-frequency currents are indicated (ten to fifteen minutes of each every day). The application of a negative static head-spray (ten minutes 348 MODERN PHYSIO-THERAPY. every day or two) is of value. Cold douches thrown against the infected area have a tendency to stimulate the nutrition and resisting power of the skin. Alternate applications of heat and cold are frequently employed. Exhaustion by means of a suitable vacuum-apparatus is useful, especially if combined with high-frequency applications. X-rays are of doubtful efficacy. The general condition of the patient, especially the excretory functions, should not be ignored. Where the hair-follicles are dead, treatment is useless. Amenorrhea. If it is due to some general condition, treat the cause. Hygienic directions are of the utmost im- portance (fresh air, sunlight, nourishing food, open bowels, active skin- function). Curran Pope advises the use of the general electric-light bath followed by a cold general spray (needle-douche). At 'the time of the expected menstrual flow, hot foot-baths and a sitz-bath (vapor) should be given. General massage is useful, following a lukewarm general bath (mild faradic current carried by the water). Vibra- tion over dorsal and all lumbar vertebrae should be given every two or three days. Applications of mild galvanic current (ten to twenty milliamperes) every three clays for ten to twenty minutes, negative pole over pubes, positive pole on the back. In suitable cases use mild faradic cur- rent by means of a uterine electrode, other pole in cul-de- sac or on the back. High-frequency applications by vaginal electrode are useful. Negative static spray over pelvis answers well in some cases. Auto-intoxication as the re- sult of suspended or insufficient menstruation explains many nervous disorders of women, hysteria, melancholia, head- ache, reflex neuroses, etc. Anal Fissure. Positive zinc- or copper-electrode to fissure, negative to abdomen, galvanism three to eight mil- liamperes for five minutes. If one treatment does not cure, repeat it after eight or ten days. (See HEMORRHOIDS.) Anemia. To correct disturbances in the hematopoietic apparatus and its functions a perfect hygienic regime must be instituted. (See chapter on PERSONAL HYGIENE;.) THERAPEUTIC INDEX. 349 Colon-irrigation, general massage, vibration of the spine, over the region of the spleen and over the solar plexus, a vapor-bath once a week, cold douches to spine and daily sun-baths, with an abundance of gentle exercise and fresh air, are the fundamental conditions of success in the treat- ment of a case of anemia. The diet should be liberal and nourishing, including more especially green vegetables, salads, cocoa, raw egg, fruit and almost any kind of meat. Spinach, raw egg and scraped beef have always enjoyed a reputation as good foods for anemic persons; Sour, sweet, salty and high-seasoned food is to be avoided. Milk is of questionable value in some cases. Respiratory gymnastics (see TUBERCULOSIS PULMOXUM and VALVULAR DISEASES OF THE HEART) and long walks in the woods, especially in cedar and pine woods, are to be recommended. Co-existing conditions should receive proper attention. (See FUNC- TIONAL DISORDERS.) The general high-frequency treat- ment (cage or diasolenic cylinder) is of service in all cases of anemia. Static insulation (positive for neurotic sub- jects, negative in sluggish cases) or the positive and nega- tive static crown breeze alternately is very useful. The same regime is applicable in CHLOROSIS, PERNICIOUS ANE- MIA and LEUKEMIA. Sometimes the X-rays seem to affect leukemic cases favorably. The high-frequency current is equally effective and a great deal safer. Aneurysm of the Aorta. Some cases are benefited by systemic dehydration. (See VALVULAR DISEASES OF THE HEART.) The object is to render the blood thick and coagulable. Tufnell's diet consists of bread and milk, each two ounces, for breakfast ; bread, meat and milk, each three ounces, for dinner ; bread and milk, each two ounces, for supper. Rest in bed with this diet for a number of months. Locally galvano-puncture might be tried (both needles in the tumor; some use only the positive needle in the tumor). The diagnosis offers an interesting radiographic problem. Angina Pectoris. During an attack apply a hot pack to the whole thorax c.nd to the lower extremities and a cold 350 MODERN PHYSIO-THERAPY. compress to the head. Immersing the patient in hot water up to the umbilicus is beneficial. Other means of breaking up an attack are given under the head of PALPITATION OF THE HEART. Try to locate the cause and remove it. Gal- vanism (positive over the heart, negative in lumbar region) can be given every day for ten minutes as a heart-tonic. For additional information see FUNCTIONAL, DISORDERS, RE- FLEX DISORDERS, DYSPEPSIA, VALVULAR DISEASES OF THE HEART. Angioma. (See VASCULAR TUMORS.) Aphasia. Mild faradism (electrode in each infra-max- illary space pressing inward and towards each other) is useful. Same current, frequent interruptions by means of rheotome. High-frequency current over neck, also rapid, mild vibrations. Galvanism (positive over spine, negative over neck, both constantly moving) is useful. Negative static spray in front and on both sides of neck. Look for cause of the condition. (See PARALYSIS and HYSTERIA.) Aphonia. Treatment identical with that of aphasia. (See APHASIA.) Appendicitis. The treatment of an acute attack does not differ from that of acute inflammatory conditions any- where else in the body. The general principles are dis- cussed under the head of INFLAMMATION ( ACUTE) and FEVER. Post-inflammatory irritation is due to a catarrhal condition in the para-typhlitic connective tissue or to a localized chronic inflammation of intestinal or peritoneal tissue in the right iliac space. These conditions are anal- ogous to the catarrhal and the post-inflammatory states in the female pelvis. The common cause of inflammation in the right iliac space (appendicitis, typhlitis, peri-typhlitis, para-typhlitis) is constipation, i. c. the retention of waste in the large intestines. Physiologically the large intestines are an unnecessary encumbrance. The appendix is prob- ably a remnant of an additional coil of intestine which has disappeared. The colon is a stagnant sewer and as such the cause of most diseases to which human flesh is heir. (See THERAPEUTIC INDEX. 351 COLON-IRRIGATION and FUNCTIONAL DISORDERS.) Chronic appendicitis requires eliminative treatment. (See INFLAM- MATION, CHRONIC.) Irrigation of the colon is of the ut- most importance. Locally positive galvanic applications, gentle massage of the surrounding parts, hot packs are in- dicated. Arterio-sclerosis. The therapy consists in the enforce- ment of mental and physical rest, open emunctories, espe- cially kidneys and bowels, abstinence from tobacco, alcohol and from medicinal heart-tonics. (See VALVULAR DIS- EASES OF THE HEART.) Cold applications and intense heat are not safe. Condition is incurable. Asphyxia. Strong faradic current (one pole side of neck, other pole over epigastrium ) interruption by means of a rheotome every three or five seconds. Cold douches to spine. Make thorax expand and contract. Asthma. The regime consists in the enforcement of general hygienic directions, active elimination and locally of mild but rapid vibration or oscillation of the thorax, mas- sage of the muscular framework of the chest, depletion of the circulation in the lungs by hydro-therapeutic treatment of the lower portions of the body. Principles of treat- ment are discussed under the head of VALVULAR DISEASES OF THE HEART, TUBERCULOSIS PULMONUM, EMPHYSEMA. If there is an underlying cause, it should receive proper at- tention. (See REFLEX DISORDERS, FUNCTIONAL DISORDERS, DYSPEPSIA, BRIGHT'S DISEASE, CHRONIC.) To relieve an acute attack of spasmodic asthma give patient a hot sitz- bath and alternate hot and cold douches to the back. Gal- vanism (positive side of neck below ear, negative over ante- rior chest- wall), weak current, is useful. In treating a case of hay-asthma (hay- fever) the exist- ence and tractability of a predisposing cause should be taken into consideration. General eliminative and tonic treatment lessens the liability to attacks of this kind by in- creasing the resisting power of the organism and remov- ing systemic predisposing conditions. (See FUNCTIONAL 352 MODERN PHYSIO-THERAPY. DISORDERS and Ri FLEX DISORDERS.) Positive copper-elec- trode (galvanic) to nasal mucosa, five to ten milliamperes for ten minutes daily, is useful. High-frequency applica- tions (vacuum electrode) to nasal mucosa frequently give relief. Auto-intoxication is n conditirn o!" the blood pro 1 need by the absorption or reabsorption of substances which are foreign to the physiological purposes of the organism. It is by all odds the most prolific cause of chronic diseases, especially the so-called functional disorders. The toxic de- rivatives which are the true etiological factors in the causa- tion of many chronic diseases, may be products of the phy- siological digestive secretions and fluids, of normal prod- ucts of digestion and of abnormal products of bacterial dis- integration of normal food. Active putrefaction in the intestinal canal, especially the colon, is produced by differ- ent forms of anerobic bacteria. (See reference to organ- isms of this kind under the head of SKIN-DISEASES. ) The toxic character of these derivatives has been dem- onstrated by the effects on some of the lower animals that were inoculated with them, e.g., rabbits and guinea-pigs. The common symptoms produced were tetanic in character and resembled the spasms which are frequently caused by intestinal troubles in children. Injection of ammoniacal urine sometimes produced fatal results in animals. Ab- sorption of toxines from the alimentary tract usually gives rise to nervous phenomena or cutaneous disorders. Auto- intoxication is the true etiological factor in the majority of cases of headache, vertigo, malaise, biliousness, nervous- ness, neurasthenia, melancholia, hypochondriasis, the "blues," muscular pains, skin diseases, nervous diseases, in fact, chronic diseases of all kinds. (See FUNCTIONAL DIS- ORDERS, REFLEX DISORDERS, RHEUMATISM, DYSPEPSIA, DIABETES, BRIGHT'S DISEASE, NEURALGIA, etc., etc.) Bier's Hyperemia. The passive hyperemia ns a thera- peutic measure with which the name of August Bier is as- sociated (Bier's stasis) is physiologically antipodal to by- THERAPEUTIC INDEX. 353 drotherapy because it aims to produce its characteristic effects through control of the venous circulation primarily, while the action of hydrotherapeutic applications is mainly due to changes in the arterial circulation. That the arterial system in Bier's method and the venous system after hydro- therapeutic applications share in the physiological sum- total of effects is understood, but these effects are secon- dary to the direct action of the two methods, as suggesed above. Bier's stasis is produced either by compression or by suction. Compression is brought about by the application of a rubber bandage. Bier applies the bandage rather loosely in several layers, overlapping each other. The site of ap- plication is above the place which is to be rendered hyper- emic. The degree of pressure is suggested by the effect to be produced. Suction is applied by placing the limb in a suitably con- structed cylinder preferably made of glass. The cylinder should be long enough to cover the part from above to below the region to be subjected to stasis. Compression of the part above the cylinder is made by means of a 'rubber bandage. The cylinder is at each end supplied with a snugly fitting "cuff" which encircles the limb and allows no air to enter or to escape. The air is now pumped out of the cylinder, the degree of intra-cylindrical pressure being suggested by the action desired. Cylinders of this kind of different size can be purchased for this purpose. "Dry cupping" for the production of stasis is a modification of the motion method. The frequency with which compression or suction is applied, the length of time consumed by a treatment, and the relative severity of the latter must be adapted to the requirements of each individual case. The physiological effects which may be produced by Bier's stasis are principally: Relief from pain. This is supposed to be due to the diminution of toxic material in the part treated. The nerve- 354 MODERN PHYSIO-THERAPY. endings are less irritated by the lessened amount of toxic elements and by attenuation of the material which is present (Bier). Germicide! action. The destruction or, at least, attenu- ation of germs in the part treated has been abundantly demonstrated. Some explain it by assuming bactericidal properties of carbonic acid. That passive hyperemia fre- quently raises the opsonic index of the part has been con- clusively shown. Absorptive action. Increased activity of the lymphatics during and after stasis has been observed and demonstrated by Heidenhain and others. Solvent action. Morbid substances undergo disintegra- tion and solution as to the result of stasis. Increased nutrition. Hypertrophy of certain parts due to stasis is an often observed phenomenon. Bier attributes much importance to this over-nutrition in explanation of the salutary effects of stasis. The therapy of Bier's method is applicable to a vast number of diseases. Bier mentions particularly four con- ditions which respond favorably to the use of his method, to-wit: (1) Tuberculosis of the joints; (2) inflammatory conditions of the joints; (3) inflammatory conditions gen- erally; (4) stiffness of the joints. By way of a general statement Bier adds that stasis is indicated in the treatment of neuralgia, rheumatism, or, for that matter, any kind of painful affliction, on account of the markedly anodyne effects which follow applications of stasis. The therapy of stasis has been much enlarged and elaborated by others. In order to render the lungs passively hyperemic and thus apply the principle of stasis to tuberculosis pulmonum, Bier proposed the very simple manipulation of making these patients inspire through the nostrils under slight com- pression of the nose, allowing them unobstructed exhalation through the mouth. Lately he also used glass suction ap- paratus of various sizes and shapes, principally over the apices of the lungs. Another observer tried to accomplish THERAPEUTIC INDEX. 355 the same end by placing the patient in a pronounced Tren- delenburg posture. Of course, this procedure is rather dis- agreeable for the patient, and less effective, since in this way the blood can only gravitate to the lungs. However, the method, if applied in moderate degree, should not be lost sight of as an adjuvant. Krnst Kuhn invented an inhalation-mask for the treat- ment of pulmonary tuberculosis and reports good resvtlts from its use. The object is the production of a passive hyperemia in the lungs, inhalation being slightly impeded. That patients with passively hyperemic lungs hardly ever die of tuberculosis is a fact which was already pointed out by Rokitanski who commented on the apparent immunity of persons suffering from heart disease, and explained it by the existing passive congestion in the lungs. The advantages of the mask, as pointed out by Kuhn, are: 1. The healing of the tubercular foci in the lungs. 2. The increase of red and white blood corpuscles as well as hemoglobin in the blood. 3. The beneficial influence of the mask will nantraliy be best shown in cases of incipient pulmonary tuberculosis, or, better still, when used as a prophylactic. 4. Advanced cases are greatly benefited by it, as !o*:j as chronic toxemia and pronounced weakness of the htH'ri do not render impossible any kind of improvement. 5. The risk of hemorrhage from the lungs does not for- bid its use; on the contrary, there seems to be a diminished liability of a return, as the granulations in the Inn;* tissue apparently get stronger under the application of the mask, same as we observe this in granulations on the surface of the body, while under hyperemic treatment. 6. Postmortem observations of the lungs of a patient who died of chronic intestinal tuberculosis, and in whom the mask had been used for several months, has shown the foci isolated and surrounded by a mass of new-formed con- nective tissue, the latter being in the stage of cicatrisation 356 MODERN PHYSIO-THERAPY. 7. On account of the larger quantity of blood being as- pirated into the lungs, more oxygen enters the circulation; furthermore, that in consequence of the resistance offered to inspiration, the entire system of respiratory muscles is strengthened, on the basis of the idea underlying the well- known "Swedish movements" method. 8. By thus improving the constituency of the blood, the use of the mask not only incidentally improves the usual anemia of phthisical patients, but promises to become one of the most powerful physical aids, so far as known to us, in our fight against ordinary anemia. 9. According to the degree of obstruction to inspiration arranged for, the mask produces the effect of various alti- tudes on the general system; that is to say, it rapidly in- creases the number" of red and white blood corpuscles, of the latter especially the polynuclear neutrophiles, and the perecentage of hemoglobin. This is produced by the irri- tating effect of the condition of reduced tension of oxygen in the blood on the blood-producing tissues of the body, principally on the bone marrow. Inasmuch as the increase of the blood elements begins very early, one hour after applying the mask, it will be interesting to watch whether this obstructed inspiration might not be used to advantage in surgical patients, espe- cially after abdominal operations, to produce artificial leu- cocytosis. 10. The mask incidentally has proved of great benefit in relieving the pulmonary circulation in cases of advanced valvular disease of the heart, as also in cases of obstinate asthma. The effect of Bier's hyperemia on infectious processes was studied by Baumgarten, who inoculated the lower ex- tremities of rabbits with anthrax, pus-germs, tubercle ba- cilli, etc. He found that suppurative processes in the skin and joints ran a much more rapid and benign course if Bier's method was used. Extensive infiltrations did not do as well, probably owing to the rapid dissemination of the THERAPEUTIC INDEX. 357 toxins after removal of the compression bandage. There seems to be no doubt that the exudate produced by Bier's compression has bactericidal properties, although it is in this respect inferior to serum. The presence of a germi- cidal fluid is of some therapeutic significance. We must, however, not lose sight of the danger of liberating virulent toxins and endotoxins. Results are doubtful if absorption is slow, or if the arterial circulation has been impaired, and thus the oxygen-supply has been lessened. For further information along these lines see OPSONIC THERAPY. Ex- cellent results have been produced by stasis in the treat- ment of gonorrheal arthritis and incipient mastitis. In a general way it is proper to state that Bier's applica- tions are mild, constriction being moderate and exhaustion only slight, so that treatments can be continued for hours and repeated daily without causing the patient pain or even inconvenience. Birth-marks. (See VASCULAR TUMORS.) Bright's Disease (Acute). The therapy consists of a mild, non-irritating vegetable or milk diet, colon-irrigation, active diaphoresis (dry heat, hot pack, electric-light bath) and many suitable symptomatic measures. (See BRIGHT'S nephritis may be one of three varieties, the difference be- tween the three varieties depending on the pathological DISEASE (CHRONIC), INFLAMMATION (ACUTE) and FEVER.) Bright's Disease (Chronic). The chronic form of changes which take place in the kidney or some part of the kidney-structure. The condition known as tubal nephritis, parenchymatous nephritis or large white kidney is charac- terized by an inflammation or catarrh of the tubules in the renal cortex. Another form of chronic Bright's disease is an inflammatory condition of the connective tissue resulting in a shrinking and hardening of the organ (cirrhosis, scle- rosis, chronic interstitial nephritis, small red kidney). After long-continued suppuration in cases of bone-disease, cancer, consumption and other wasting diseases, the struc- ture of the kidney and other internal organs is infiltrated 358 MoDKKX PlIYSIO-TlIKRAPY. by a waxy substance and undergoes a lardaceous or amy- loid degeneration. The infiltrate, while it causes an enlarged appearance of the organs, presses upon the kidney-structure proper and produces atrophic changes. The condition is known as the amyloid kidney and is analogous to similar conditions in other organs. There are two other forms of chronic nephritis, which, however, are comparatively rare and are not, strictly speaking, to be included under the head of chronic Bright's disease, e. g. suppurative nephritis (pus in the pelvis of the kidney) and hydronephrosis (cystic con- dition produced by retention of urine in cases of obstruc- tion in the ureter or pressure of a growth, the ascending and accumulating fluid gradually causing atrophy of the kidneys by pressure). The common forms of chronic Bright's disease are the parenchymatous and interstitial varieties. In the former the onset is gradual, the disease pursuing a chronic course throughout, at times involving the inter-tubular connective tissue. The interstitial variety usually co-exists in the latter stages of chronic diseases of the heart and liver. Both varieties are essentially chronic, sometimes lasting for many years. Much can be done towards alleviation of these dis- tressing conditions. Before degenerative changes have oc- curred, the prognosis under physio-therapeutic regime is favorable in many cases, especially if the condition is not produced by and is not co-existent with some systemic dis- ease or disease of some other organ, e. g. the heart. If it is, the treatment would necessarily have to be directed towards the exciting cause. The triple object of all methods of treatment in chronic Bright's disease is : ( i ) to re-establish the proper relation of arterial and venous blood-pressure in the kidneys; (2) to prevent the accumulation of waste products in the system, and (3) to relieve incidental symptoms. How per- fectly the objects of treatment can be realized by the in- telligent application of physio-therapeutic means, can be easily seen in the logical character of these agents and in THERAPEUTIC INDEX. 359 the remarkable results which are effected by them even in many cases in which drug-therapy is without avail. To re-establish the physiological equilibrium of venous and arterial blood-pressure. To unload the congested struc- tures, various hydro- and thermo-therapeutic applications to the lumbar region, to the anterior abdominal wall and to the lower extremities, are serviceable. The best local applica- tion for this purpose is without a doubt the cold moist pack (Priessnitz method). It is indicated particularly in the earlier stages of the disease and only in cases where the systemic symptoms are either absent or are of a very mild type. If the amount of albumen is large and symptoms of uremic poison are present (headache, vertigo, nausea, etc.), hot applications are safer and more effective. The reason for this is obvious and suggests the danger of all cold appli- cations in chronic Bright's disease, more especially if the latter are used over large areas of the body-surface for the purpose of stimulating excretion through the skin. It is a notorious fact that in all cases of kidney-trouble the char- teristic reaction upon which the therapeutic effect of a typ- ical, hydro-therapeutic application depends is very uncer- tain and even when it does take place, rather imperfect. The danger of internal congestions following cold applica- tion, is a factor which must not be ignored in cases of chronic renal inflammations. The hyperemia in the sec- ondary area which is the result of a cold application to the primary area would mean a disastrous exacerbation of the inflammatory condition, unless by a prompt and vigorous reaction, the primary area becomes hyperemic and the sec- ondary area correspondingly anemic. With a complete and prompt reaction the cold hydro-therapeutic applications would be ideally available in cases of chronic Bright's dis- ease. They would be by their "derivating" action most effect- ive antiphlogistic agents. However, owing to the tendency towards venous congestions in all cases of chronic kidney- trouble and the notoriously uncertain character of reaction, the hot, moist application is by far safer and more effective. 360 MODERN PHYSIO-THERAPY. It should be long-continued and often repeated. Incidentally it is a splendid anodyne, if applied to the small of the back. General massage judiciously administered two or three times a week is a valuable depletent agent. It has a diuretic ac- tion, increases the amount of uric acid and solids in the urine, stimulates assimilation and facilitates the conversion of albumins in the economy. These effects can be intensi- fied by deep vibration over the first three lumbar vertebrae, given every other day for five or ten minutes. The renal ganglia are thus kept active and well nourished. The tend- ency in many cases is towards atrophy of the ganglia. Dietetic directions are of great importance because they are capable of affecting the circulation in the kidneys by lessening the functional activity of excretion. The object is tc relieve the effort of renal excretion. Exclude nitrog- enous food as much as possible. Milk should be the main- stay of the patient. Suitable quantities of fats, cream-butter and starchy foods should be allowed. Water should be given freely. If digestion is good, weak coffee or tea is not objectionable. Strong coffee or tea should never be al- lowed. Alcoholic stimulants should be positively excluded, because they are renal irritants in proportion to the amount of alcohol they contain. Irrigation of the colon by means of hot water is useful. The drinking of large quantities of hot water has been recommended by many observers. Raw fruit is of the greatest value in these cases. Electricity might be employed in various ways in these cases to produce counter-irritant and depletent effects. Gal- vanization by means of 3 large (negative) plate-electrode over the lumbar region and a (positive) sponge-electrode at some distance, might be advantageously employed every day or every other day for ten minutes. An indirect static spray or the wave-current with pieces of block-tin applied to the lumbar region is of benefit. A high-frequency current applied by means of a vacuum-electrode to the small of the back, has a good effect, especially in cases suffering from pain in the back. THERAPEUTIC INDEX. 361 Similar effects may be produced by the Minin light, the local electric-light bath and the small dry-heat cylinder. The object is to increase the cutaneous circulation and excretion in the lumbar region and to deplete the kidneys in this way. Care must be taken not to overstimulate or even burn the skin. To prevent the accumulation of ifaste-products in the system. The skin in all these cases must be forced to per- form a compensatory function. Its activity should be stim- ulated. In this way the excretion of toxic material is facili- tated and the occurrence of grave systemic complications prevented. The advantages of a dry, warm climate are ap- parent. Cold air contracts the superficial vessels and lessens the activity of the skin. Warm air keeps the skin active. If the air is dry. it enhances the exhalation and evaporation of moisture from the lungs and skin. Patients should be taught to wear woolen underwear. Therapeutically the employment of intense dry heat is of the greatest value. There is no single therapeutic agent that can be approximately compared to the dry-heat cylinder or the electric-light bath in cases of chronic Bright's disease. In most cases, especially if the heart has not given rise to symptoms on the part of the venous circulation (edema), two or three mild sweat-baths in the dry -heat or electric- light cylinder have the proper diaphoretic and excretory effect. The bath should not be carried beyond the point of tolerance. It should not weaken the patient nor cause too active excretion. The stimulating effect of light makes the electric-light bath especially valuable. After a bath in the dry-heat cylinder the patient should rest for hours and par- take, of liberal potions of water. On the intervening days the sun-bath is of value. In administering baths in the dry- heat cylinder, gentle diaphoretic effects should be aimed at. It is by far better to give these baths every other day and thus promote continuous excretions without depression than to subject the patient to a powerful drain on his system once a week. Patients of this class do not recuperate very 362 MODERN PHYSIO-THERAPY. promptly after depressing sweat-baths. Heart-symptoms frequently arise in cases that had previously been free from circulatory disturbances. If mild baths are administered frequently, the organism usually responds most gratefully ELECTRIC LIGHT BATH. by continuing moderately active excretion through the skin for many weeks even after the dry-heat treatment has been discontinued. In this way most wonderful improvement can be brought about. THERAPEUTIC INDEX. 363 The physiological effects of intense heat which take place in the organism independently of the diaphoretic action, are to a large extent illusory in cases of nephritis. The employ- ment of 200 -300 F., until profuse diaphoresis takes place, is recommended by Winternitz and is advocated by most observers who have had experience in these cases. The ob- ject in these cases is elimination. If the dry-heat or electric-light bath is not available, hydro-therapeutic applications may be employed with ad- vantage. The best are the hot-immersion bath and the hot moist pack. Cold applications are nearly always contra-in- dicated in these cases. The use of the hot needle-spray (fine douche) is followed by most salutary effects. In the parenchymatous variety of chronic nephritis con- stant albuminuria is the rule. Under the dry-heat eliminat- ive treatment the quantity of albumen will gradually lessen, while the quantity of urine may increase. Edematous swell- ings are gradually absorbed. The number of blood-cor- puscles in the urine decrease while the evidences of anemia eventually disappear. In most of these cases the urine is loaded with all kinds of renal casts, epithelium and pus- cells. Urates and phosphates are present in large quanti- ties. By careful examination of the urine the course of improvement during the eliminative treatment can be watched. Casts and blood-cells will disappear while epithe- lial cells may continue to show. The amount of urates and phosphates slowly diminishes. In cases of chronic interstitial nephritis the evidences of improvement are even more striking. In these cases certain systemic symptoms predominate while the kidney-symp- toms (albuminuria) are frequently absent. The heart- symptoms in these cases are characteristic (hypertrophy of the heart, increase of arterial tension). Casts in the urine are rarely found. Uremic attacks are the rule in these cases. Apoplexy frequently occurs. The eliminative treatment by means of the dry-heat cylinder or electric-light bath les- sens the severity of the uremic symptoms. Eventually the 364 MODERN PHYSIO-THERAPY. uremic attacks cease. The heart-symptoms are the most stubborn to handle. Owing to the increased arterial pres- sure and the coincident liability to hemorrhage from rup- tured vessel- walls, the treatment must be administered with a great deal of care. In chronic parenchymatous nephritis the indirect nega- tive static spray is of value. It enhances elimination. In cases of interstitial nephritis the positive insulation may be employed as an effective circulatory sedative. The use of the high-frequency cylinder is indicated in both varieties The high-frequency current acts as a trophic (vaso-motor) alterant and stimulates the organs which are concerned in the process of catabolism. The use of a mild galvanic cur- tent by means of a warm half-bath (positive pole in the water, negative pole to the neck) frequently produces a good effect. Blue-light exposures have been found service- able in many cases. The diet of a nephritic subject has already been referred to. I beg to remind the reader that the production of Bright's disease in dogs and men by an exclusive nitrog- enous diet has been experimentally shown. A nitrogenous diet is, therefore, contra-indicated in cases of nephritis. The diet should be mixed, with a preponderance of carbo- hydrates and vegetable albumen. Fats in moderate quan- tity are allowable. Red meats are less objectionable than white meats. Milk is the most important food. Fruit, green vegetables and rice can be given in liberal quantities. According to Tyson the precise line of dietetic procedure may be facilitated by indicating the daily physiologic quan- tity of food which is, approximately no gm. to 130 gm. of albumin, 350 gm. to 400 gm. of carbo-hydrates, 75 gm. to no gm. of fat, 2,500 gm. to 3,000 gm. of water, and 18 gm. to 30 gm. of inorganic salts. Expressed in different terms, the body" needs from 2,000 to 2,400 calories per diem during rest, and 2,400 to 3,000 calories during hard labor. This should consist of about 600 calories of proteids, 1,200 calo- ries of carbo-hydrates, and 600 calories of fat. It may THERAPEUTIC INDEX. 365 prove helpful to remember that 100 gm. of meat represent 213 calories, and one glass of milk equals 128 calories, and an ordinary slice of bread (30 gm.) equals 64 calories, while 1 8 gm. of butter equals 8 calories. The maximum amount of food physiologically required is also required in chronic nephritis, otherwise subnutrition will manifest it- self by anemia and loss of flesh and strength. The experi- ments of Van Noorden have shown that, calculating on the basis of 70 kg. body-weight, that in men from 13 to 16 gm. of nitrogen, and in women n gm. to 14 gm., are ingested daily by nephritic patients who enjoy good general health. When the ingestion of albumin is increased, so that consid- erably more than 15 gm. of nitrogen daily have to be ex- creted by the kidneys, elimination becomes irregular and uncertain. Van Noorden also demonstrated that most me- dicinal substances (potassium iodide, salicylic acid, quinin, atropin, etc.) are not eliminated by the kidneys but act as irritants, which is a point of some importance in connection with the subject of chronic nephritis. The advantages of water-drinking in these cases can not be too often repeated no too strongly emphasized. To Relieve Incidental Symptoms. Attacks of acute uremia and symptoms due to uremia (headache, vertigo, nausea, vomiting, defective vision, asthma) require active eliminative treatment. Hot baths, dry-heat baths, electric- light baths are indicated. Catheterization and Colon-flush- ing should be practiced in acute attacks of uremia. Hot water should be introduced in large quantities into the stom- ach and the colon. Forcible dilatation of the rectal sphincter reacts on the vaso-motors of the skin and augments the excretory efforts of the skin. Irritability of the bladder can be allayed by applications of heat to the supra-pubic region and irrigation of the blad- der with hot water. Hot rectal injections frequently give prompt relief. Vibration over the lumbar vertebrae and peripheral vibration by means of a soft rubber tube intro- duced up to the neck of the bladder are serviceable. Kara- 366 MODERN PHYSIO-THERAPY. dization (one pole on perineum, other pole over bladder) is useful. Galvanization answers better in some cases. Static sparks to the perineum and to the lumbar centers are recommended by some. The wave-current applied to the perineum is useful. In some cases the indirect static spray (positive) to the supra-pubic region is of service. For the relief of edema, especially of the feet, deep cen- tripetal effleurage should be practiced. Neuralgic pains, which are common in chronic Bright's disease, usually yield to the eliminative measures spoken of. Vibration along the course of the aching nerve is a valuable addition. The effect can be enhanced by a positive static spray or a high-frequency application. Local applications of heat are always serviceable. Cupping (by means of ex- haust-pump and vacuum-tube) is useful. General anemia, weakness and disorders due to disturb- ance of central nerve-function are best treated in D'Arson- val's cage or in the diasolenic cylinder. Failure of the circulation, especially attacks of syncope, call for stimulating measures. Cold douches to the back are proper in extreme cases. Faradism applied to the pneumogastric and phrenic nerves, static sparks to the car- diac apex, general faradization in the bath and alternate applications of heat and cold to the cervical and upper dor- sal regions will frequently bridge a patient over difficulties of this kind. If chronic kidney-troubles are secondary to some other disease o: co-existent with disease in some other organ, the clinical indications will have to be modified and adapted ac- cordingly. Bronchitis. The management of an acute attack should be governed by the therapeutic principles given un- der the head of PNEUMONIA. (See also COUGH, INFLAM- MATION (ACUTE) and FEVER.) The treatment of chronic bronchitis (bronchial catarrh) requires careful individualization. Bronchial catarrh in the advanced stages is frequently due to and associated with THERAPEUTIC INDEX. 367 diseases of the heart, lungs, kidneys and other chronic con- ditions. Chronic bronchitis may be due to atmospheric con- ditions, insufficient skin- function or a catarrhal tendency which is common in persons whose circulation is sluggish. The general features of treatment are discussed under the head of INFLAMMATION (chronic) and COUGH. The local treatment should be adapted to the symptoms of the indi- vidual case. Breathing exercises and chest-massage, as discussed under the head of TUBERCULOSIS PULMONUM, are useful in many cases, especially if the cough is dry and periodical (winter-cough). Many electro-therapeutic ap- plications are serviceable, to wit : faradization or galvaniza- tion of the vagus (side of neck to intra-clavicular space or epigastrium or moved about), galvanization of the cord (nape of the neck to front of chest), negative static spray to chest, if intra-thoracic congestion is well marked. Vibra- tion over cervical region and over thorax is useful. Electro- therapeutic and vibratory treatment should not last longer than fifteen minutes and should be given every day or two. Inhalation of largely diluted ozone sometimes relieves cough and dyspepsia. A static insulation often checks spasmodic cough. At times a change of climate is necessary. If bron- chial catarrh is secondary to some other condition, treat the latter. Recurrent bronchial catarrh in an apparently healthy person should call for energetic measures to harden the patient and to improve the reactive tone of the skin. Cold moist packs to the chest, cold douches to the back and to the thighs and walking in wet grass should be prescribed for the patient. Outdoor sports, especially rowing, swimming and horseback exercise, are very serviceable in these cases. Bruise (Contusion). In recent and comparatively mild cases reaction and absorption should be produced by suita- ble means of applying heat or counter-irritation (thermic cylinder, Minin light, electric-light bath, exhaustion by cups as suggested by Bier, hot-water applications, immersion in hot- water bath). After treatment with any of these agents, the skin should be lubricated and massage gently and uni- 368 MODERN PHYSIO-THERAPY. formly applied to help in the distribution of extravasations and exudations. Static spray and galvanization (positive pole to affected area) are sometimes useful. When absorp- tion has begun local applications of a high-frequency cur- rent are of advantage. If the contused region is very ex- tensive, heat and massage should be depended upon. If the arm or leg is the seat of the contusion, constant immersion in hot water (flowing, if possible) is indicated. If the in- jury to the tissues is so severe as to have caused sloughing or gangrene, the constant immersion in hot water is by far the best treatment. It preserves the viable elements and facilitates excretion of the discharges and sloughs. In this way it promotes repair and prevents sepsis, not to speak of the prompt and decided analgesic effect. In these cases no other treatment should be resorted to as long as there is any morbid material left in the affected part. In superficial cases exposure to sunlight is beneficial. If the bruises are multiple and involve different parts of the body, the whole body should be immersed in hot water and then subjected to gentle stimulating massage. The electric-light bath and the sun-bath are very useful in these cases. If extravasation is considerable, vacuum-cupping should be resorted to. The application of cold is contra-indicated in cases of contusion. Calculi. The statement made by Schroth that concre- tions in the bladder, kidneys and liver are but rarely found in vegetarian animals, seems to have a deep therapeutic sig- nificance in the treatment of the underlying condition. It is essential to increase the watery constituents of a patient's diet. Schroth's statement is borne out by the comparative rarity of calculi among the Chinese. Radiographically it is of interest to know that gall-stones offer little or no obstacle to the X-rays and can, therefore, not be skiagraphed. I have come to this conclusion after at least a dozen attempts to skiagraph gall-stones which had been removed surgically and were placed directly upon the envelope containing the plate. In one or two instances a very faint shadow was produced, probably due to the presence of a large quantity THERAPEUTIC INDEX. 369 of bile-pigment or lime-salts. Gall-stones held up to the fluoroscopic screen by the hand of the operator can not be seen. The statements made by Wm. B. Snow in his excellent book on Static Electricity, etc., in regard to this subject I have not been able to verify. The internal use of hot olive oil in the treatment of gall-stones is to be com- mended. The effect is mechanical. Cancer. (See chapter on X-RAY THERAPY, also INOP- i::ve. Faradization of the vagus if the heart-beat is weak, gal- vanization of the vagus if the heart is irregular, are useful. To control a tumultuous heart, vibration in the interscapular THERAPEUTIC INDEX. 411 region and tapotement over the precordial space can be ad- ministered. High-frequency applications along the spine and over the temples and the forehead may be administered to restore the nervous equilibrium. Positive static insula- tion is useful in many cases. Positive head spray has a tendency to relieve vascular pressure in the eyes. Pressure over occipital region has a fine effect in cases of pain in the head and in the eyes. The general health of the patient should not be lost sight of. Many nervous symptoms in these cases are the result of auto-intoxication from the in- testinal canal. Sun-baths are excellent in these cases. (See FUNCTIONAL DISORDERS.) Gonorrhea is the type of a self-limited disease with a well-marked tendency towards recovery, if not meddled with. There is no doubt that most cases of protracted specific urethritis. chronic gonorrhea, gleet, etc., are due to misapplied methods of treatment. The inflamed mucosa should be left severely alone. In the latter stages of the disease, when the discharge has practically ceased, clear, warm water should be used by way of injection or irrigation. Puring an attack of gonorrhea the patient should abstain from all alcohol, tobacco, meat, eggs, coffee and tea. He should be encouraged to drink water frequently and co- piously. He should observe absolute cleanliness about his person. Immersion of the penis in very hot or cold water will usually relieve local irritation or pain. The diet should be continued for one or two weeks after the discharge has ceased. Colon-irrigation, hot sitz-baths and general elim- ination through the skin are indicated throughout the course of the disease. After the acute stage the high-fre- quency current and mild vibration may be used over the pubes and perineum to stimulate healthy local reaction. In chronic gonorrhea positivej^lectrolysis (very mild) by means of a sound or high-frequency applications by means of a urethral vacuum electrode has been found serviceable. Gonorrheal rheumatism is referred to under the head of RHEUMATISM. 412 MODERN PHYSIO-THERAPY. Gout. The systemic treatment of a case of gout should be conducted along the lines indicated under the head of RHEUMATISM. Locally dry heat, massage, vibration and electricity as suggested under the same head are serviceable. The dietetic management is of the greatest importance. Johann Schroth gave his gouty patients dry bread to eat and clear water to drink. Locally he used hot moist com- presses and applied massage to the contiguous territory. His results won for him an international reputation. In convalescent cases powerful derivation by packs applied to the feet or walking in the wet grass is beneficial. General and local vapor-baths are serviceable in many cases. The diet suggested under the head of RHEUMATISM must be faithfully adhered to for a long time. The static brush-dis- charge (wooden electrode) is a good local anodyne and can be given daily for fifteen minutes. Depletion by leeches is not infrequently necessary. Bier's stasis might be indicated in obdurate cases. Granulated Eyelids. Trachoma is best treated by slowly moving a copper-tip electrode (positive) over the af- fected surface for two or three minutes with a current- strength of two to four milliamperes. A sponge electrode (negative) is held in the patient's hand. Treatment can be given once or twice a week. Negative electrolysis, with needle in each granule, positive sponge-electrode in hand, is recommended by some. Finsen-rays (dermo-lamp) some- times give relief (fifteen minutes every other day). A. C. Geyser everts the lid, secures it in position by adhesive strips, places a piece of sheet-lead with a suitable perfora- tion in front of the face and makes X-ray exposures for five minutes every two or three days. After five or six treat- ments a reaction sets in, whereupon high-frequency treat- ments with a dull-pointed vacuum-electrode are given for three to five. minutes every day or two for two or three weeks. It is important to protect the eyeball. Headache. Always a symptom. (See AUTO-INTOXICA- TION, DYSPEPSIA, REFLEX DISORDERS, FUNCTIONAL DISOR- THERAPEUTIC INDEX. 413 DERS, etc.) Symptomatic relief can be obtained from pres- sure over back of neck and head, pressure over temples and forehead, massage of temples and forehead, suggestion of sleep, positive static crown-breeze. (See PAIN and NEU- RALGIA. ) Hemorrhage. The treatment depends on the cause, character and location of the hemorrhage. If the site is accessible, pressure, heat, cold or ligation might be required. If the bleeding vessels are inaccessible, surgical interference might be necessary. The more common forms of hemor- rhage encountered in general practice are : EPISTAXIS. In many instances epistaxis is a therapeutic measure adopted by nature to counteract intra-cranial con- gestion. If bleeding persists, apply copper-electrode to bleeding cavity (positive, ten to twenty milliamperes, five to fifteen minutes, negative sponge nape of neck.) Make patient sit up. Apply cold compresses to forehead, temples and back of neck. Cold applications to the nose and the introduction of small pieces of ice are proper. In mild cases let the patient lie down and join his hands over the occiput. Instruct him to breathe deeply and hold his breath as long as possible. In threatening cases apply a cold, moist pack to the lower extremities. HEMOPTYSIS. Patient should be at rest, lying down with head and shoulders slightly elevated. If bleeding is profuse, improvise a hot vapor-bath from the feet to the stomach. Technique similar to that which is given under the head of FEVER. Hot applications to the lower extrem- ities up to the iliac crest, frequently renewed, answer equally well. If the hemorrhage is slight the cold, moist pack from the feet to the umbilicus is better. A hot compress should be kept to the feet. The object of all these applications is to lessen the blood-pressure in the lungs by drawing the blood to the lower extremities. Cold compresses to the back of the neck and the chest are useful. Diet should consist of cold liquid food. Swallowing small particles of ice is very serviceable. 414 MODERN PHYSIO-THERAPY. HEMATKMKSIS. Patient should be at rest in the hori- zontal position. Swallowing small pieces of ice is benefi- cial. Cold compress on the stomach, derivating pack to the lower extremities. The general regime does not differ from that in cases of hemoptysis. CKKEBRAI, HKMOKKHAGK (Aroru-;\Y.) Patient should be p'aced on his side to prevent the tongue and the secre- tions from dropping into his air-passages. Cold applications to the head and back of the neck should be made. Pressure over back of neck is useful. Decrease intra-cranial blood- pressure by derivating applications as indicated in the treat- ment of hemoptysis given above. Powerful derivation to the lower extremities and to the abdominal wall should be practiced as given in the chaper on THE TIIJ:RAIM:UTIC EF- FECTS OF HEAT AND COLD. This can be accomplished by hot baths, dry-heat cylinder, packs, vapor-bath, etc., etc. The vapor-bath described under the head of FEVER is excellent as a cerebral depletent. The sec- ondary object in all these depleting applications is to stim- ulate skin-activity whereby the proportion of liquids in the body is lessened and the absorptive activity of the organism is thus given a powerful impetus. There is no method of treatment in cases of cerebral hemorrhage, cerebral conges- tion, cerebral toxaemia, etc., and their concomitant symp- toms (coma, violent headache, severe nervous phenom- ena, etc.) that equals in promptness and intensity of pal- liative and curative efficacy the "derivating" pack or bath whereby the blood mass is directed toward the lower por- tions of the body. It is universally applicable in all cases in which it is desirable to relieve the brain of pressure. This form of treatment comes first in point of usefulness in cases of cerebral hemorrhage and also in cases of typhoid coma. In the former, blood-pressure is reduced, bleeding steps and absorption of the clot begins. In the latter, the passive congestion is counteracted, the local toxaemia less- ens and brain-function is re-established. Enemata should be frequently and cautiously given without moving the pa- tient out of the horizontal position. Catheterize the patient THERAPEUTIC INDEX. 415 as soon as practicable. If the patient's face is red and con- gested leeches should be applied to the temples and venesec- tion practiced. The after-treatment consists in frequent general luke- warm sponge-baths and massage to keep the skin active. A weak galvanic current (one electrode on each mastoid process or positive pole moved over temples and forehead, negative pole in back of the neck) helps absorption. Par- alyzed muscles should be faradized. Food should be prin- cipally non-nitrogenous and not solid. Static positive in- sulation is useful. It might be well to add that persons who are prone to suffer from congestion of the head (apo- plectic tendency) can do nothing better than to increase the circulation in the lower extremities by frequently walk- ing in the wet grass or fresh snow. (Kneipp.) It is a prophylactic of great virtue. UTERINE HEMORRHAGE. Therapeutic directions are given under the head of METKORRHAGIA. If uterine hem- orrhage occurs post-partum, the employment of vigorous massage to force contraction of the uterine body is very es- sential. Faradization with a tolerably strong current (ab- domen and cervix) is often very helpful. INTESTINAL HEMORRHAGE. In thin subjects make cold applications to the abdomen, hot applications to the lower extremities. In fat persons a cold, moist pack over the ab- domen is preferable to the cold compress. The latter would not penetrate while the former would draw blood away from the intestines and assemble it in the abdominal wall.. Abso- lute rest is imperative. In thin persons the galvanic cur- rent (positive abdomen, negative on back) can be used with benefit. In fat persons the faradic current might serve to contract muscular tissue and in this way counteract hem- orrhage. It is wise to withhold liquids even if the patient complains of thirst. Coagulation is thus favored. A firm abdominal bandage is sometimes useful. All these direc- tions can be advantageously employed in intestinal hemor- rhage occurring as a complication of typhoid fever. 416 MODERN PHYSIO-THERAPY. Hemorrhoids. Regulate the patient's mode of liv- ing. Exclude meat, spices, salty, sour and highly seasoned food from the patient's diet. The latter should consist of wheat-bread (from the whole grain), rye-bread, Schrot- brot, Pumpernickel, green vegetables, raw fruit, cider, fruit- jam, buttermilk. Fresh water at every meal. Irrigation of the colon carefully performed is valuable. The patient should avoid tight-fitting clothes (corsets, etc.) , Massage of the stomach and bowels, Swedish movements to exercise the abdominal muscles, horseback exercise, mountain-climbing, gardening, are indicated. Hot sitz-baths, vapor-baths, ab- dominal hot pack, hot foot-bath before retiring, are very serviceable. Locally galvanism (positive copper-electrode to pile, negative to abdomen, ten to twenty milliamperes for five to fifteen minutes every day or two). Hard exter- nal piles should be treated with needle (negative electrol- ysis), hemorrhoidal varix with positive electrolysis. (See VARIX.) Vibration by means of a rectal attachment some- times is useful in irritable hemorrhoids which are intact. Vi- bration over lumbar region, perineum and abdomen relieves congestion. High-frequency applications by means of a rec- tal vacuum electrode answer well in some cases. Hepatic Cancer. Treatment, is purely symptomatic. Therapeutic suggestions are given under the head of Hii- PATIC CIRRHOSIS, DYSPEPSIA, GASTRIC CANCER. Hepatic Cirrhosis. The enforcement of the Schroth diet (stale bread, rice, oatmeal in small quantities, but little liquids, no alcohol) and the dehydration-method of Oertel (see VALVULAR DISEASES OF THE HEART) hold out fairly good prospects in the first stages of the disease. Cold moist packs on the abdomen, vibration and massage of the ab- domen and daily irrigation of the colon are splendid ad- juncts to the treatment. A large positive pad-electrode over the liver, negative to the feet and hydro-therapeutic applications to the lower extremities to unload the stagnant portal system, are valuable. The patient should avoid starches and fats. In the later stages of the disease the THERAPEUTIC INDEX. 417 treatment is purely symptomatic. Diet, derivating water- applications to the lower extremities, massage of the stom- ach, colon-irrigation, sun-baths and plenty of fresh air are the necessary conditions of treatment. Vibration of the liver is sometimes beneficial in the early stages of the dis- ease, but injurious in the advanced stages. Hydrocele. Xeiswanger recommends galvano-puncture (negative in scrotum, positive on abdomen, current grad- ually increased to forty milliamperes for five minutes). A different plan is to draw off the fluid, then inject one-third as much strong solution of KI, introduce large needle con- nected with positive pole, negative pole on abdomen, ten minutes, galvanism gradually increasing until fifteen to twenty milliamperes are reached. Hypochondriasis is a disorder of the nervous system produced by disturbances of alimentary function and is mostly found in men. It is closely allied to the hysteria of the female. (See FUNCTIONAL DISORDERS, REFLEX DISOR- DERS, DYSPEPSIA, NEURASTHENIA.) Hysteria may be defined "a condition of the nervous system of women, characterized by a suspension or impair- ment of initiative will-power and by the dominant influence of imagination or emotion over the sensory and motor functions." It corresponds to the hypochondriasis of men. The etymology of the word "hysteria" points to the sexual organs as the primary seat of the disorder, while the term "hypochondriasis" suggests the digestive organs. The lit- eral meaning of the two words shows the wisdom of the ancients whose primitive notions concerning etiology and pathology have in not a few instances outlived the many upheavals in medical lore that have marked the history of the healing art. In treating functional diseases of the nervous system, always look to the sexual organs first and to the stomach second if the patient be a woman. In a man reverse the order named and think of the stomach first and then of the sexual apparatus. Woman is more a creature of sex than man. The manifestations of both hysteria and 41S MODERN livpochondriasis are probably symptoms of auto-intoxica- tion. (See FUNCTIONAL DISORDERS, REFLEX DISORDERS, DYSPEPSIA, NEURASTHENIA.) Try to find out the cause and remove it, if such is possible. Let the environments of the patient be ideally hygienic (sunlight, fresh air) and give due attention to the four emunctories. Suggestion is a most powerful agent for good in the management of a case of hysteria. It should be given through the mind of the patient by the presence and by the moral and personal influence of the physician. The patient's surroundings- should, through the special senses, serve to accentuate the suggestion. Every- thing should be done to rouse and fortify the patient's will-power without hurting, frightening or shaming her. The patient should be removed from the presence of people and from their meddlesome influence. Sometimes a patient will have to be put to bed. Weir Mitchell's plan of isola- tion, massage, faradism and forced feeding (Mastkur) has but little to recommend it. Massage of the stomach and abdomen is very beneficial in most cases. It can be combined with rapid and light vibration of the whole spine, especially the dorsal and lum- bar regions. If the patient is anemic, general massage and a daily protracted sun-bath can be given. If the case pre- sents violent symptoms, the positive static spray along the spine will be found very serviceable. If the patient inclines toward introspection and melancholia, the negative static spray or the negative static insulation are indicated. If the patient's condition is associated with menstrual disturbances or sexual aberrations, vibration or firm pressure over t!i? ovaries sometimes gives relief. In many cases Swedish movements are followed by improvement. Forcibly rais- ing and rotating the arms and legs in the standing or lying posture serves to deplete the bodv toward the periphery. Eventually these movements can be executed with an at- tendant resisting. Warm applications over the abdomen, while a cold moist pack is applied to the lower extremities, THERAPEUTIC INDEX. 419 is frequently of service. Cold douches over the spine and over the lower extremities are useful. In some cases of paresis warm baths (carrying a mild faradic current) have a good effect. Hysterical paralyses require suggestion, lo- cally vibration, faradization and massage. The high-fre- quency current applied by means of a vacuum-tube is a splendid adjunct, especially in aphonia and dysphagia. The diet of a patient should be vegetable for well-nourished in- dividuals, nitrogenous for frail and anemic subjects. Hysteria is distinctly the disorder of an individual nerv- ous system. It is impossible to treat a case of this kind without painstaking individualization. There is no disease where so much depends on the personal equation of the phy- sician as in hysteria. Suggestion is by al! odds the foremost therapeutic agent. It should be practiced persistently in these cases. Hysteria offers a fruitful field for studies in animal magnetism. The "laying on of hands" as practiced by Charcot, Bernheim and Fuchs has demonstrated the clinical possibilities of animal magnetism in cases of hys- teria and allied disorders. Under the head of LOCOMOTOR AT AX i A the movement-cure of Frankel is discussed. The patient who has lost co-ordination is taught to perform cer- tain muscular acts mechanically. The suggestive therapy in hysteria is analogous. It educates a mind whose co-ordi- native power has been lost, to functionate in a sort of me- chanical way in keeping with certain suggestions. If there are remediable features about the case, they should be met by suitable means. In young girls mental hygiene and reg- ulation of the menstrual function should be the object of treatment. A love-hungry old maid who has become hys- terical should be married off to re-establish the balance. In hysterical widows the regime is similar. If a married wo- man is denied the privilege of motherhood, the case can of- ten be cured by directing the misspent energy into proper channels. Such a woman should find an object in life to take the place of a child of her own flesh and blood. Let her adopt a child. The principal thing is to find an object 420 MODERN PHYSIO-THERAPY. to act as a constant source of suggestion to a hysterical sub- ject. Interest her, arouse latent ambition. Stimulate force and let her spend it. Therein lies the psychology of Wo- men's Rights Associations, Temperance Societies, etc. So- ciologically they might be a nuisance, therapeutically they serve an admirable purpose in many cases. Incontinence of Urine. Cold douches to the spine, vi- bration over the lumbar vertebrae and regular evacuation of the bowels are helpful. Mild vibration over perineum in boys is advised by some, but seems of doubtful efficiency (might cause greater evils). Galvanism (ten milliamperes, positive over pubes and spine by means of a bifurcated elec- trode, negative to feet) or faradism (lumbar region and pubes) are recommended by some. Static spray (positive) over sacral and pubic regions might be tried. Try foot- baths containing negative pole and warm wet pad around pelvis, connected positively, mild galvanic current every day. Local causes should be inquired into, also condition of general health. (See HYSTERIA and FUNCTIONAL DISOR- DERS. ) Inflammation (Acute). The amount of blood which is carried to any part is regulated by the vaso-motor (sym- pathetic) nerves in keeping with the physiological needs of the part. Increased need calls for increased blood-sup- ply (physiological hyperemia). Increased need may be brought about by increased activity (function) of the part or by the presence of some element by which the integrity of the part as such is endangered (trauma, septic matter, etc.) To protect the part, an enormous increase in the ar- terial supply takes place. This means over-nutrition, more active local metabolism and oxidation. Incidentally nature isolates the part by surrounding it with a wall made up of congested blood-vessels, lymphatics and infiltrated con- nective tissue. In this way the system at large is protected against invasion. Locally, there is heat, pain and swell- ing. If the affected part is near the surface, the skin will appear red. Vaso-motor control is lost and changes occur THERAPEUTIC INDEX. 421 in the contents of the blood-vessels (exudation of serum, transmigration of white blood corpuscles), and new cell- formation outside of the vessels takes place. This com- posite local process is called inflammation. Eventually vaso-motor control reasserts itself, absorption takes place and the normal condition again supervenes. If the resist- ing power of the part is not equal to the ordeal of so severe a local reaction, the part may die molecularly or en masse. Thus, inflammation may terminate in ulcer or sloughing. If pus-germs are present, the inflammation may merge into an abscess (localized suppuration). The agencies which may cause a part to become inflamed are : vicious sys- temic conditions, irritation by intense heat or cold, infection by germs, destruction of tissue by injuries of any kind. The system at large may co-operate with the affected part by intensifying general metabolism. In this way a (local) 'inflammation may cause a (general) fever. Biologically speaking, both inflammation and fever are restorative agents. In this sense we may say that inflammation is to a part what fever is to the general system. There are certain therapeutic principles which hold good in all cases of inflammation. Clinically we may recognize three stages of inflammation, to wit: congestion, exudation and restoration (absorption). CONGESTION. During this stage our efforts should be directed towards aborting inflammation by dispersing the blood-mass. The older physicians practiced depletion by venesection. The same result without loss of blood can be achieved by hydo-therapeutic methods (derivation). If the congested area is accessible, practice massage (effleuragc centripetal) on the healthy tissues near the periphery of the inflamed portion in order to stimulate absorption. The fundamental therapeutic principle during congestion in any part of the body is : Deplete the region by causing the blood to be drawn to some distant part. The modus operandi is exhaustively discussed under the head of HYDRO- THERAPY. 422 MODERN I'HYSIO-TI;KKAPY. The local treatment of the congested part is of great clinical significance. Cupping and the use of leeches are de- pletent measures. The ice-bag is a much abused becati.s-e ill-understood measure. If the inflamed part is near or at the surface and, therefore, easily reached by thermic influ- ences, the continuous application of ice can never be >roper, c. g. during the congestive stage of appendicitis in a tol- erably thin patient. To freeze the part means to suspend all evidences of vitality. Blood-vessels are contracted, the skin becomes inactive, the local temperature drops below the point of health. Even granting that in this way the in- flammation has been literally frozen out, is it possible for the part to recover without some damage having been done to its functional tone (nutrition) ? The vaso-motor nerves are irreparably damaged by the devitalizing effect of in- tense cold. The part is bound to lose some of its resisting power and congestion and inflammation are more than likely to recur. With the local physiological tone below par, pus-germs have a splendid soil for development. The continuous application of ice lessens the resisting power cf the part, favors recurrence of local circulatory disturb- ance and facilitates suppuration. This is well shown by the clinical history of not a few cases of appendicitis. The direct action of intense cold on an inflamed part is n -t conducive to restoration without damage. The more healthy tissue intervenes between the ice-bag and the in- flamed area, the less objection there is on this score. In a fat patient suffering from congestion in the right iliac space, the application of ice is less objectionable than it would be in a thin person. The same may be said of the use of the ice-bag on the head and on the chest. The cal- varium and thorax neutralize by their interposition the ob- jectionable feature of the intense cold. In inflamed joints the continued application of ice is often directly responsible for disastrous results. This holds good more especially in children. Priessnitz was in the habit of causing cold water to THERAPEUTIC INDEX. 423 flow over territory contiguous to the inflamed area. In this way stimulation of the surroundin ; tissues was pro- duced and a mild depletent action followed. Moderate heat (like the heat of a poultice) or moderate cold (like the tem- perature of well-water) are therapeutically available. Both are stimulants, the cold application more so than the warm. ]n choosing between them the comfort of the patient should be consulted. Whichever application gives relief should be chosen. Ordinarily the hot application does well in cases where the inflammatory action is not cutaneous. The more superficial the inflammation, the lower should be the temperature of the application. It should, however, never be the temperature of ice or ice-water. The indica- tions for massage and vibration increase in proportion to the distance of the inflamed area from the skin. It should be remembered that the greatest benefit is derived from manipulation of the contiguous tissues. For obvious rea- sons intense heat (dry-heat cylinder) is available for the purpose of depleting deep structures by drawing blood to the surface and stimulating the latter. In this way its action would be analogous to the modus operandi of a hot poultice. Fine therapeutic effects can at times be produced by modifying the application of the principle of derivation with the aid of the dry-heat cylinder. Deplete a congested area by baking a neighboring part, e. g. by giving a dry- heat treatment to the femoral region and knee -for the pur- pose of relieving a cellulitis in the foot. Exposure to the Minin light has a depletent effect if the inflammation is comparatively deep-seated. The physiological principles involved are plain. If the inflamed region is comparatively superficial and not very extensive, good effects can often be produced by placing a (positive) sponge-electrode directly over it (neg- ative pole at some distance) and allowing a mild galvanic current to pass through it. A positive static spray is very serviceable. EXUDATION. When the second stage of inflammation 424 MODERN PHYSIO-THERAPY. has begun, it is no longer possible to abort the process by depletion. On the contrary, the condition is one of stasis. The blood is partially disintegrated by exudation of some of its aqueous elements and a loss of some of its corpuscular constituents. During this stage pressure or massage is useful if the part is accessible, the object being to stimulate the absorbent vessels. Alternate applications of heat and cold are a powerful alterative. Pressure may be accom- plished by a bandage, adhesive strips, by bags of sand or shot. Massage and vibration of the surrounding parts, especially between the inflamed area and the heart, are very useful. It. stands to reason that in inaccessible inflamma- tions (meningitis, pneumonia, etc.) these direct therapeutic methods are not applicable, although much good can be done by increasing metabolism in distant parts or in the whole system. (See PNEUMONIA.) Ordinarily, warm ap- plications are best adapted in the second stage of in- flammation. The faradic current can be employed during the second stage of inflammation. It contracts muscular tissues and in this way can be made to compress an inflamed part. The high-frequency current has been known to shoVten the stage of exudation and hasten absorption. Good effects can often be produced by placing the inflamed part between the poles of a galvanic circuit. The applications should be mild, short -and frequent. Polarity should be reversed with each succeeding application. ABSORPTION, SUPPURATION, SLOUGHING. Restoration in favorable cases takes place by absorption. Hydro-therapy again offers the best means of intensifying and accelerating the last stage of inflammation. General derivation (com- plete cold moist pack) is indicated if the inflammatory area has any extent at all. In accessible cases massage and vibration along the lymphatics centripetally are valuable, es- pecially if the affected area is in the arm or leg. Central vibratory stimulation to promote absorption is useful as an adjunct to local massage. If the symptoms of inflamma- THERAPEUTIC INDEX. 425 tory reaction persist, especially pain, the formation of pus may be looked for. (See SEPSIS.) The result may be more or less disintegration of tissue. (See ULCER.) In addition to the surgical rules which must prevail in these cases (incision, evacuation, surgical cleanliness), the circulation in the affected area 'and in the contiguous struc- tures should be stimulated by suitable means. In the treat- ment of the extremities the virtues of the continuous immer- sion in (flowing) hot water can not be too highly spoken of. SYSTEMIC CONSIDERATIONS. Fever is the most con- spicuous evidence of the part which the system at large plays in conjunction with a local inflammatory condition. (See FEVER.) The diet in these cases should be bland, easily digested and non-stimulating. (See DIET IN ACUTE FEVERS.) Even if the local inflammatory condition in- volves important internal structures of vital significance in the economy, a starvation diet will often help to shorten the inflammation and hasten the absorption. Keep the patient's bowels open and restrict the patient to dry bread or crackers, with a little fruit-juice. Give but little water. ,If the patient is weak, add a little light wine to the water. A diet of this kind for two or three days makes a deep im- pression en metabolism. The system is compelled to force absorption. Thus the inflammatory process is shortened and its severity lessened. If the inflammation is the result of a systemic disorder, the latter should receive proper attention. Inflammation (Chronic). If, for some reason or other, an acute inflammation has not terminated in absorption, suppuration or sloughing, but continues in a mild degree, the condition is called chronic inflammation. It is char- acterized by passive congestion, thickening or hardening of the tissues and a liability to acute exacerbations. Even- tually changes occur in the structure of the tissue, owing to the altered conditions of nutrition. The most character- istic sign of a chronic inflammation is the absence of a re- storative tendency. The part affected apparently remains 426 MODKRN I'lIYSIO-TKKRAI'Y. in statu quo. There is no resisting power in the affected region. Acute symptoms are likely to arise at any time. The structural changes may consist in the formation of cicatricial tissue, firm adhesions, thickening of membranes, proliferation of connective or other forms of low tissue, or- ganization of exudates, etc. There may be complete sus- pension of function owing to atrophy or destruction of the functionating elements, exaggerated or perverted func- tion. At times the chronic inflammation begins and con- tinues as such. The word "catarrh," which in the minds of the public has a well-established significance, refers to these conditions. They may be the local expression of a deteriorated state of the system, acquired or inherited. They may be due to long-continued irritation of the part. This irritation might be due to the mistreatment of an acute inflammation. The catarrhal conditions in the right iliac fossa which are essentially chronic and after a number of acute exacerbations might become the culture-soil of pus- germs, are illustrative of a class of cases that are not infre- quently produced by the wrong kind of therapeusis, ?. g. the continuous use of the ice-bag. The catarrhal conditions in and near the uterus are the products of abuse (irritating vaginal douches, cold douches, sexual errors, etc.), causing changes in the circulation ar.d nutrition of the part. That, under these conditions, latent embryonic cells might be stimulated and developed, leading to malignant formations, there seems to be no reasonable doubt. That this is the etiology of uterine cancer seems to be more than plausible. Chronic inflammation or catarrh may gradually give rise to atrophy, hypertrophy, degeneration of diverse kinds, hyper- plasia, ulceration, cicatrization, exudation, suppuration and may be associated with any number of intercurrent affections. From a clinical point of view chronic inflammations or catarrhal conditions might be divided into those which involve inaccessible, and those which affect accessible parts. In the latter the local treatment would necessarily be an element of great therapeutic importance. THERAPEUTIC INDEX. 427 In cases of inaccessible chronic inflammations hydro- therapy enables us to control, alter, increase or decrease the circulation in and near the affected region ("derivation"). The possibilities of water-applications are well-nigh unlim- ited. In all cases of chronic inflammations or catarrhal conditions, irrespective of their location, duration, extent or' severity, elimination through the cl.in should be the be- ginning of all rational therapy. A local circulatory dis- turbance can not exist for any length of time without in- volving the system generally. Sluggish circulation in the affected part disturbs the local metabolism. Retained waste, effete matter and combustion-products gradually are ab- sorbed from the chronically congested area into the general system, giving rise to the thousand and cne possible forms of auto-intoxication in variable degrees of severity. Thus we get the typical picture of a chronic ailment, local in its pathology but constitutional in its symptomatic expressions. Not infrequently the general symptoms detract from the local disturbance. Through the sympathetic nervous sys- tem whose fibers and ganglia are irritated by absorbed toxic piaterial, an unending variety of symptoms might be pro- duced. (See FUNCTIONAL DISORDERS and REFLEX DISOR- DERS.) Chronic inflammatory conditions of the gastric, in- testinal or bronchial mucous membrane, of the pelvic cellular tissue, of the Schneiderian and pharyngeal membranes, of the ovarian tissues, of the connective and fibrous tissue in the muscles of the back are in this way responsible for any number or variety of toxemic symptoms, erroneously called icflex symptoms. The term "reflex symptom" is a much- abused mantle of charity which covers a multitude of diag- nostic inaccuracies. Reflex symptoms, e. g. headache, neuralgia, vertigo, palpitation of the heart, malaise, irri- tability, etc., etc., are usually evidences of auto-intoxica- tion and require general eliminative treatment. This is most emphatically proper in cases where an acquired or inherited vicious condition of the system prevails. In all chronic conditions the first step in the treatment should be 428 MODERN PHYSIO-THERAPY. to open the avenues of excretion. Colon-irrigation should be practiced twice or three times a week. The skin should be kept active by general packs, dry-heat baths, vapor- baths, etc. On general principles it might be stated that in most chronic conditions excretion is sluggish and reaction imperfect. Therefore, the hot applications (dry-heat cyl- inder, vapor-bath) are preferable to the more exacting cold moist packs. The latter are to be substituted after the system has become habituated to active metabolism. General massage should be added to all general treatments outlined above. Dietetic directions should be given in keep- ing with the physiological requirements of the individual case. Afebrile conditions require a preponderance of car- bohydrates (bread, Graham-bread, Schrotbrot, crackers, rice, oatmeal, zwieback, milk-toast, fresh fish, oysters, pota- toes, fresh fruit and vegetables, with the exception of peas, beans and lentils). The idiosyncrasies of the patient and individuality of the patient's stomach should be considered. Fresh water is always proper. Weak coffee and tea are per- missible ; alcoholic stimulants are contra-indicated in most cases. In view of the vast importance of air and light on metabolism, exercise in the open air and exposure to sun- light should be insisted upon. No sanitarium for the treat- ment of chronic diseases is complete without a solarium. Electricity is a splendid helpmate in the general treat- ment of chronic inflammatory conditions, the object of electrical applications being to aid in general innervation and help in the restoration of metabolic activity. General faradization is proper in cases of muscular asthenia. Gen- eral galvanization answers well in cases of sluggish lymph- circulation and inactive skin. Both currents can be ad- ministered by means of a water-bath which carries one pole while the other pole is applied to some portion of the patient's skin (out of the water). Static applications are useful (potential alternation, insulation). Last but by no means least, general high-frequency applications are ca- THERAPEUTIC INDEX. 429 pable of producing splendid effects on metabolism (D'Ar- sonval's cage, diasolenic cylinder). To improve the tone of the vegetative functions of the organism, vibratory stimulation (mild rapid strokes, three to five minutes daily) along the sixth to the twelfth dorsal vertebrae on either side of the median line should be prac- ticed. Manual manipulations may be given with the patient lying on the right, patient's left arm raised up, his hand rest- ing on left side of his head. The operator should stand on the side of the table toward which the patient's face is directed, pass his left hand over the patient's shoulder, his right hand over lower ribs of patient, until his fingers rest on the left side of the spine between the sixth and twelfth dorsal vertebrae. AYith his fingers firmly placed on the line described, the muscles of the spine should be drawn upward, downward and outward successively by regular movements of the operator's hands. Let the patient turn -over on his left side with his right arm, operator facing the patient for treatment of the muscles on the right side of the median line. This mode of manipulation is an excellent stimulant for the general metabolic functions through the splanchnic nerves and may be followed by vibration, as indicated above. The therapeutic directions given comprise the general treatment of chronic inflammatory or catarrhal states. They should be applied, singly or in combination, with due regard to the peculiarities of the individual patient. The object of general treatment is to improve the system at large and in- cidentally remove the evidences of auto-intoxication (reflex symptoms). General treatment is indicated in all chronic catarrhal conditions. If the seat of the trouble is directly accessible, e. g. in many diseases of women, the local treat- ment is equally important. Since the local management of a catarrhal state depends upon many incidental contingen- cies, it is necessary to discuss the details thereof separately under the head of special conditions. Inoperable Malignant Disease. The uses of the X-ravs and Finsen-ra<:s in the treatment of cancer have 430 MODERN PHYSIO-THERAPY. been referred to in the chapters on X-RAY THERAPY and PHOTO-THERAPY. Many cases of cancer, especially those who are suffering from an inoperable variety of malignant disease, should be given the benefit of a form of electro- therapeutic treatment, which is by no means as well known and as extensively employed as it deserves to be, to wit: cataphoresis. The rationale and technique as well as the practical results achievable are sufficiently well-established to justify the classification of cataphoresis as one of the foremost of non-surgical therapeutic methods in the treat- ment of cancer and surely in inoperable cases the most avail- able. It it the one method that holds out hope after all else has failed and has the great advantage of being compara- tively a mild and simple procedure. Cataphoresis by means of zinc-mercury electrodes for the destruction of cancer-cells consists in the diffusion through the tissues of nascent salts of zinc and mercury, which are the products of the chemical action taking place when the fluids of the body act upon the metallic substances of the electrode. The products of this electrolytic process invade the tissues in all directions from the point of appli- cation, combining with the albumen of the tissues and form- ing albuminates of zinc and mercury. Cancer-cells have but little resisting power and rapidly break down. Normal cell-elements, having a higher degree of resisting power, withstand the action of these destructive agents. The range of activity of the latter is marked during the first forty- eight hours by a reddened and puffy area, which G. Bet- ton Massey, who is the champion of this method, designates as the "zone of sterilization." Granger speaks of the selec- tive and detective action of the zinc and mercury salts, which seem to follow up and ferret out the proliferations of the malignant tissue much more perfectly than the knife of the surgeon or the Roentgen ravs do or can. The technique of this form of cataphoresis is simple and can be modified to suit the indications of any kind of a suitable ca?e and the varying ideas of different operators. THERAPEUTIC INDEX. 431 Short applications frequently repeated with a current- strength of thirty to fifty milliamperes might be made, or the cataphoric destruction may be accomplished in one sit- ting with the patient under the influence of an anesthetic, five hundred and more milliamperes being employed. The application can be made by a suitably shaped electrode which is placed on the surface, or by means of pointed elec- trodes introduced in one or more places into the very sub- stance of the growth. The tip of the electrode is a zinc- mercury amalgam. The electrode must be connected posi- tively. The application is continued until the discoloration of the surrounding tissues indicates that the local reaction is complete. Eventually the diseased tissue will break down and be discharged. The remaining cavity or ulcer is sup- posed to be healthy and heals accordingly. It is understood that cleanliness and attention to surgical details should not be lost sight of. The method has been used in all kinds of sarcomatous and carcinomatous diseases, especially those which were inoperable. In rodent ulcer, indolent ulcers, etc., the method has been employed with much success. The late Dr. Gaston, of Atlanta, advocated the cataphoric introduction of Donovan's solution (liquor hydrargyri et arsenii iodidi) in th* treatment of malignant growths and ulcers. The method was used in a case of inoperable sar- coma of the abdominal wall, the ultimate outcome of the case being a perfect cure. Zinc-mercury cataphoresis has been used in cases of malignant disease of the breast, tongue, upper maxilla, glands of neck, rectum, uterus, face, pelvic bones, coccyx, etc. A mild form of metallic cataphoresis is the use of a mer- cury-covered electrode. It produces alterant and solvent effects and has been employed successfully in cases of pelvic adhesions. The use of a zinc electrode is indicated in tuber- cular glands and in all conditions requiring a powerful local germicidal reaction. The dietetic aspect of the cancer-problem is of some in- 432 MODERN PHYSIO-THERAPY. terest. That the use of meat has some connection with the etiology of cancer, seems certain. Cancer cases are more frequent in the United States than anywhere on earth. It is a well-known fact that there is more meat consumed by the American people than by any other nation or race. In China cancer is comparatively rare. Among the (fruit- eating) natives of the East Indies cancer is unknown (Dar- win). There seems to be no doubt that the increasing prevalence of cancer suggests a physical degeneration of the race. All cancer-cases should be given the benefit of invigor- ating general treatment (static electricity to improve the nervous system, dry-heat cylinder to promote excretion, colon-irrigation to improve bowel-function). Insomnia. Find the cause. Symptomatic relief might be obtained from positive static head-breeze, galvanism (positive to head, negative to spine) galvanic bath (nega- tive in water, positive to back of neck), effleurage over fore- head and suggestion of sleep, irrigation of colon, hot appli- cation to abdomen, firm pressure over nape of neck to in- duce cerebral anemia, hot foot-bath, vibration over cervical vertebrae and centrifugally along the arms and legs, a cold moist pack from the feet to the neck, a short hot bath, a protracted warm bath or a general dry-heat treatment. Se- lect the proper regime in keeping with the cause of the sleeplessness. Intra-pelvic Inflammations. The term has reference to the numerous inflammatory conditions which may pre- vail in the female pelvis, involving the uterus, the tubes, the ovaries and the connective and peritoneal tissue closely related to the intra-pelvic organs. We may encounter acute, subacute and chronic inflammations of the uterus (metritis), tubes (salpingitis), ovaries (ovaritis), of the connective tissue around the uterus (para-metritis) or in the pelvis at large (pelvic cellulitis), of the serous covering of the in- ternal genitalia (peri-metritis, pelvic peritonitis) in various degrees of severity and due to a variety of causes. The eti- THERAPEUTIC INDEX. 433 ology of the inflammatory state should carefully be con- sidered in adopting a therapeutic regime. Sexual hygiene should be enforced in all these cases, ( i ) by cleanliness (vag- inal douches and warm ablutions), (2) regulation of cohab- itation, and (3) in certain cases by attention to the functions of the bladder and rectum (catheterization, rectal injec- tions). ACUTE INFLAMMATIONS. Rest is the first and most im- portant therapeutic factor. The general management does not differ from the regime which is indicated in all acute inflammatory conditions. (See INFLAMMATION.) Diet and hydro-therapeutic measures are probably the most es- sential therapeutic agents in the treatment of inflammatory affection in the female pelvis. The same holds good in regard to subacute conditions, especially if pain is a pro- nounced symptom. CHRONIC INFLAMMATIONS. The broad features of treat- ment are suggested in the discussion of catarrhal condi- tions generally. (See INFLAMMATION,CHRONIC.) In the individual case the local treatment will depend on many accidental features. There may be a low form of inflam- mation involving the tissue of the cervix or uterus and associated with considerable enlargement of the affected portions owing to proliferation of connective tissue (hyper- plasia). The catarrhal surface may be engorged and may bleed easily. It may be broken down in places, giving rise to ulcers and granulation. The catarrhal state may involve some of the connective or peritoneal tissue. There may be foci of inflammatory reaction that nature attempted to repair in the presence of abnormal nutritional and functional conditions, the result being the formation of cicatricial tis- sue. The latter may have caused neighboring parts to be dragged out of their normal position, c. g. the uterus. Inflammatory exudates, instead of being absorbed, may continue to exist in a more or less advanced state of organ- ization, causing changes in the relation of the pelvic con- tents or giving rise to pain, disturbed defecation and mic- 434 MODERN PHYSIO-THERAPY. turition, various disorders by pressure on special struc- tures (nerves, rectum, bladder, etc.). Then there may be the thousand and one symptoms produced by reflex irrita- tion of the nervous system or by absorption of toxic ma- terial from the sluggish venous and lymphatic circulation in the pelvis. In all these conditions the object of the treat- ment should be to stimulate- metabolism in the affected re- gion, to tone up innervation, to restore normal relation by breaking up adhesions and forcing the absorption of exu- dates. (See PELVIC ADHESIONS AND EXUDATES.) Many of these cases present purely surgical problems, but by no means as frequently as the gynecologist of to-day would lead us to believe. Operative treatment in many of these cases is unnecessary and not infrequently useless. Physio- therapy has established a conservative system of gynecol- ogy for which the world is indebted in no small measure to the genius and resourcefulness of the American physio- therapeutists. In order to stimulate metabolism in the pelvis, and in this way to help in the absorption of exudates, extravasa- tions and effusions, depleting applications to the external parts and to the abdomen are useful. Some gynecologists, notably G. M. Blech, have championed the local use of light as a substitute for hydro-therapeutic applications. The treatment is given by means of a specially constructed chair, which is provided with incandescent lamps. Powerful stim- ulation of skin function primarily and metabolism second- arily follows the application, the effect being partly due to the action of the thermic rays, partly to that of the lumi- nous rays. A treatment lasting fifteen to thirty minutes may be administered daily. It is advantageously followed by a vaginal high-frequency application for ten minutes. In this way the reaction is intensified, not to speak of the disinfectant action of the high-frequency radiations. The galvanic current is adapted to these cases in a va- riety of ways. In applying it we must bear in mind that THERAPEUTIC INDEX. 435 the positive pole attracts oxygen and contracts the blood- vessels. It temporarily increases local oxidation, but less- ens the actual amount of blood which is carried to the part. In intensifying oxidation it stimulates the lymphatics and promotes absorption. By contracting the vessels it forces the veins to evacuate their contents and regenerates the quality of the nutriment which is carried to the part. Or- dinarily an application (five to twenty milliamperes) should last from ten to twenty minutes to produce these effects. It can be repeated once every other day. The negative pole can be put in a convenient place near by. The abdominal wall is a splendid place of application for the negative pole by means of a flat pad-electrode. In all conditions in which it is desirable to intensify the change of tissue-elements locally and thus to help in a physiological regeneration of the affected part, the positive pole should be used as the active pole. It should be brought as close to the affected portion as possible by means of a suitable (vaginal, uterine) electrode. The styptic action of the positive pole makes it ideally available in treating surfaces that are congested and have a tendency to bleed. After pathological changes have taken place, the con- structive effect of the positive pole must be supplanted by the destructive action of the negative pole, especially in chronic inflammatory conditions of the mucous membranes, attended by hyperplasia, thickening and hardening of the underlying tissues. The dehydrating action of the negative pole causes disintegration of the morbid tissue and gives a powerful impetus to the process of repair by. the reaction which follows, and resembles a mild type of an obliterative inflammation. The positive pole is placed on the back or on the abdomen, the negative pole being applied directly to the affected surface or part by a suitable instrument. The effect can be enhanced by wrapping moist cotton or chamois around the tip of the electrode. A current of from five to fifteen milliamperes can be advantageously employed for five to ten minutes every two or three days, depending on 436 MODERN PHYSIO-THERAPY. the degree of reaction which is desired in the individual case. In cases where a germicidal effect together with an astringent action is desired, the use of a copper electrode with the positive pole (cupric electrolysis) is of advantage. The affinity of the positive current for oxygen causes the latter to combine with the copper, forming an oxide of cop- per. The sodium chloride contained in the blood is decom- posed, the free H Cl combining with the copper oxide, the result of the combination being oxy-chloride of copper, which has strongly germicidal and astringent properties. It is even carried into the deeper tissues by cataphoric action and can be advantageously employed in many in- fective (purulent) conditions of the pelvic contents. Chronic suppuration in the pelvis (c. g. in one or both Fallopian tubes) may follow an acute infective process. After the acute stage has passed, the purulent fluid loses its specific infective character and becomes more or less innocuous. The pus-germs cease to be active. In cases of this kind conservative electro-therapeutic treatment in conjunction with other means to promote local metabolism leads to absorption and excretion of the fluid, leaving a healthy, dry cavity behind. In addition to the therapeutic measures mentioned, galvanization of the pelvis (one elec- trode in a sitz-bath, the other on the back, poles frequently reversed) is a local alterant of great virtue. A similar action can be produced by using a douche as a conductor. (See LEUCORRHEA.) To restore the muscular tone of the pelvis, faradization is an agent of unquestioned value. It can be administered by means of a suitable vaginal or uterine electrode or by the hand of the operator, who holds one sponge-electrode in the unengaged hand while the other electrode is placed on the patient's abdomen or held in her hand. Faradization by means of a local or general bath is likewise useful. Additional points of interest pertaining to the treatment of these chronic diseases of women are contained in the THERAPEUTIC INDEX. 437 discussion of a number of special subjects. (See TRITIS, PERITONITIS, PELVIC ADHESIONS AND EXUDATES.) Jaundice (Catarrhal). The diet of the patient should consist of carbo-hydrates principally (fats and starches ex- cluded), fresh fruit, soups, olive-oil and plenty of water. Highly seasoned foods, spices, sweet or sour foods, should be avoided. Colon irrigation, hot applications to the liver, "derivating" packs to the lower extremities, galvanism (positive pad-electrode over right hypochondrium, nega- tive over lumbar region), vibration and high-frequency cur- rents over spine and general sun-baths, are valuable auxil- iaries. The hot vapor-bath or dry-heat cylinder should be used once or twice weekly to stimulate skin-elimination. The regime outlined is applicable in all congestive condi- tions of the liver. Lateral Sclerosis. The therapeutic regime does not differ from that which is resorted to in cases of degenera- tion of the posterior columns. (See LOCOMOTOR ATAXIA.) Leucorrhea. Catarrhal conditions of the vaginal, cer- vical or uterine mucous membrane require local cleanliness (warm douches) daily. Applications of a high-frequency current by means of a suitable vaginal glass-electrode are of advantage. Local vapor-baths (sitting over a vessel con- taining very hot water) or local exposure to light, as recom- mended by G. M. Blech, once daily, has an alterant effect and helps to correct the local circulation. To counteract passive congestion of the vaginal mucosa, introduce a posi- tive vaginal copper electrode, negative pad-electrode on abdomen, twenty milliamperes for ten minutes every other day. Some wrap a wet cloth or wet cotton around the vaginal electrode. Intra-uterine applications are made in the same manner, care being taken to loosen the electrode by reversing the current. The use of an aluminium or nickel vaginal electrode connected negatively, the positive pad-electrode on the abdomen is sometimes advantageous. Duration, dosage and frequency as above. This application is contra-indicated, if parts are hyperesthetic. Bennett 438 MODERN PHYSIO-THERAPY. recommends the so-called hydro-electric douches by means of a syringe, the tip of which carries a copper wire and thus allows an electric current to pass through the water over the affected area. Technique as before. For other local and general measures see INFLAMMATION (CHRONIC). Coi- tion should be avoided, especially in vaginal leucorrhea. Deep vibration from last dorsal vertebrae down to coccyx, and manipulation of the muscles of the region named, can be added to the treatment in cases where circulation is sluggish. Liver-spots (Chloasma). Negative electrolysis. (See FRECKLES.) Locomotor Ataxia. The impotence of drug-medica- tion in the treatment of the slow but steady degeneration of the posterior columns of the spinal cord and of the pos- terior nerve-roots is admitted on all sides. On the other hand, it is a well-recognized fact that the physical and me- chanical methods are capable, not only of relieving some of the disagreeable and distressing concomitant phenomena Lut influencing the course of the disease itself. The clinical picture presented by a typical case of tabes dorsalis is familiar. The disease presents three distinct phases. The first stage is marked by sensory disorders. During the sec- ond stage co-ordination is impaired and lost. During the hist stage paralysis supervenes. Destruction of nerve-tis- sue is complete. Death closes the scene. The cause of the disease is obscure, although it is not unlikely that it is fre- quently a late manifestation of a syphilis acquired by an an- cestor, not necessarily belonging to the preceding genera- tion. It may be an atavistic appearance of lues or rather of a luetic taint. Syphilis is undoubtedly the predisposing cause, although the potency of exciting causes (excessive venery, sexual perversions, excesses of various kinds, etc.) must not be lost sight of. The four familiar pathognomonic symptoms of tabes dorsalis are (i) absence of the patellar reflex; (2) inability to remain in a firm erect posture with eyes closed; (3) loss of pupil reflex to light, but preserva- THERAPEUTIC INDEX. 439 tion of reaction to accommodation ; (4) ability of the patient to fully extend his legs while lying on his back with knees drawn up. The therapy of an incipient case of locomotor ataxia should begin with the enforcement of an absolutely perfect hygiene, physical and mental rest, fresh air and sunlight. If the stomach of the patient is in good condition, the pa- tient can be fed to a liberal nitrogenous diet, care being taken that the bowels are kept open and that the stomach is not overtaxed. If the stomach is in poor condition, the course of the disease will be more rapid. The diet under these circumstances will have to be in keeping with the actually existing conditions. (See DYSPEPSIA.) It may be of interest to know that fish and oysters have always en- joyed a great reputation as parts of the menu of tabetic subjects. Alcohol and tobacco must positively be excluded. The general management of a case should include a general eliminative treatment in the thermic-cylinder or electric- light cabinet, followed after an hour's rest by general mas- sage. A treatment of this kind should always be given twice a week. Its relative severity should be adapted to the tolerance of the individual patient. If other eliminative procedures are resorted to, the above general treatment must be given less often and modified to suit existing condi- tions. For the sake of classification and convenience, the available therapeutic methods are presented under special heads. The physician will have no difficulty in adapting therapeutic details to the requirements of the individual case. MECHANO-THERAPY. The tendency of modern thought seems to be in the direction of carefully regulated exercise for tabetic subjects from the hips up and the application of systematic massage from the hips down, and, for that mat- ter, massage of the whole body every day. I can not quite agree with the idea of no exercise afoot, as J. K. Mitchell puts it. During the early stages of the disease, exercise on foot is inseparable from the enjoyment of fresh air, sun- 440 MODERN PHYSIO-THERAPY. shine and mental hygiene (occupation of the patient's mind with pleasant objects). If exercise is well-regulated and not carried to the point of fatigue, it can not but be pro- ductive of much benefit. Kneipp sought to deplete the con- gested medulla by forcible derivation to the lower ex- tremities. He made his tabetic patients walk barefooted in wet grass to get the benefit of exercise, derivation, fresh air and mental occupation. Massage is valuable as an anodyne for the relief of the lightning pains in the lower ex- tremities and also the attacks of pain in the region of the spine. Centripetal effleurage of the lower extremities and deep petrissage over the spine are indicated. To compensate for the impairments or loss of muscular co-ordination the patient should be taught to learn certain movements mechanically and by constant repetition edu- cate his muscles to execute these movements in obedience to his will. Many methods and systems have been proposed for this purpose. They are all modifications of Frankel's movement-cure for tabetics. The patient whose co-ordi- nation is deficient, must be shown what movements he is supposed to execute. With the co-operation of his eyes to guide him, he will make a faint attempt. The attempt must be repeated over and over again until the muscles which are concerned in the movements have been mechanically educated to go through the motions easily and safely, even- without the guidance of the eyes. With infinite patience and tactful consideration on the part of the physician and an equal amount of cheerful co-operation and willingness on the part of the patient much good can be accomplished. To keep the patient in a cheerful and tractable mood, the exercises or movements must not be carried to the point of exhaustion or even fatigue. The easiest and least fatiguing movements must be tried first. To relieve the patient of carrying his weight, he should take his first exercises in the dorsal decubitus, after- wards in the sitting posture, and finally standing and even walking. The first exercises must be simple, e. g. extend- THERAPEUTIC INDEX. 441 ing or raising a foot or flexing the toes. Afterward the ex- ercises can be more complex, e. g. combining the two movements named. In very weak cases it might be neces- sary to begin with passive movements or to combine active and passive movements. The patient must be taught to go through the motions accurately, not merely to move the limbs, but to move them in keeping with well-defined and well-understood directions. After a certain movement has been learned and can be performed without the assistance of the sense of sight, the physician can institute concentric or excentric resistance-movements of the muscles and parts that have been trained. (See chapter on MRCHANO THERAPY.) The movements themselves can be varied in an infinite variety of ways, c. g. by bending, straightening, ab- ducting, adducting, raising, inverting, everting, rotating a toe, several toes, one foot, both feet, one leg, both legs in the lying-down, sitting or standing position. The patient may be taught to stand, to balance himself on one foot, to elevate his foot, his leg, his thigh, to place his foot forward, backward or in any other position, to walk a chalk-line or to step from one given point to another, to turn around, to step over obstacles, to sit down and rise, to ascend and de- scend stairs, etc., etc. Little by little the patient must be trained while his mind is kept in a cheerful frame. It is by no means easy to superintend a course of mechanical edu- cation as outlined above. Much judgment is necessary lest the patient be injured by too much exercise. He usually remains unconscious of fatigue and is liable to suffer irreparable damage. The best results are achieved in insti- tutions where tabetics are taught in classes under the direc- tion of a competent instructor. The treatment does not aim at a cure, but at removal of the most distressing symptom of the disease, i. e. loss "of co-ordination. This form of kinesi-therapy is applicable in many allied disorders, prin- cipally in the treatment of paralytic conditions. The suspension method, which has been championed by Charcot and Weir Mitchell, is a form of local mechano- 442 MODERN PHYSIO-THERAPY. therapy that deserves to be better known and more exten- sively employed than it is. The seances should be short and be carefully watched. The method can be combined with the movement-cure or be independently used for the relief of pain along the spine. A special apparatus should be used. It resembles the Sayre-device for applying the plas- ter-jacket. HYDRO- AND T HER MO-THERAPY. Kneipp's heroic hydro- therapeutic methods in the treatment of tabes, which have many advocates among physio-therapeutists, consist prin- cipally in the employment of cold moist packs to the ex- tremities and cold douches to the back, thighs and knees. In patients who are in fair general condition this method can be used with much benefit. After loss of co-ordination, vaso-motor disturbances usually supervene, which are a centra-indication to these severe applications. In their place hot applications might prove to be of value (small thermic cylinder to the back). Alternate douches of hot and cold water are productive of much good, especially in cases that suffer from pain in the spinal region. The gen- eral thermic eliminative treatment previously alluded to is of importance in view of the syphilitic character of prac- tically all cases of tabes. PHOTO-THERAPY. The sun-bath in the treatment of tabes is a therapeutic agent of cardinal virtue. The effects of sunlight in the management of chronic diseases have been suggested in the chapter on PHOTO-THERAPY. T.he local use of ultra-violet rays in cases of tabes offers an in- teresting clinical problem, although the published reports of cases in which this form of photo-therapy was used sug- gest the optimism of the reporters rather than any well-es- tablished efficacy of the actinic rays under the conditions referred to. To render the .parts -bloodless and thus enable the rays to penetrate down to the degenerating nerve-tissue, cataphoresis of adrenalin is resorted to, as suggested by H. G. Piffard. The subject is interesting enough to justify further study. The Minin apparatus is useful as an ano- THERAPEUTIC INDEX. 443 dyne and also as a counter-irritant, taking the place of the more severe application of the actual cautery. Its use is painless and can be continued for hours. ELECTRO-THERAPY. In the first stages of the disease (negative to back, positive to feet, ten to fifteen milliam- peres for ten to twenty minutes every day or two). Dur- ing the second stage, opposite polarity should be used. Far- adization helps to tone up the muscles. It can be applied in a warm-water bath. Static sprays or sparks to the spine are serviceable (negative during first stage of the disease, positive in the second stage and for the relief of pain). The high-frequency current applied by means of a vacuum-elec- trode is excellent and is only surpassed in therapeutic effi- cacy by a general application of high-frequency energy (D'Arsonval's cage or diasolenic cylinder). The general application is probably the best electro-therapeutic pro- cedure in the treatment of locomotor ataxia. VIBRATION. Central vibration in the treatment of tabes i? synonymous with peripheral vibration. The "center" happens to be the locus morbi. Pain and disorders of sen- sation frequently yield to rapid, gentle vibration, especially if vibration is preceded by massage of the afflicted portion. That vibration can influence the retrograde metamorphosis in the nerve-structure, is hardly likely. For the relief of many concomitant symptoms vibration is useful. Dyspepsia often adds an element of additional discomfort and may require deep vibration to stir up the solar plexus. Consti- pation is a common condition in tabetic subjects and may have to receive special treatment. (See CONSTIPATION.) I once had an opportunity of seeing Arnold Snow admin- ister rectal vibration to an ataxic patient in the second stage of the disease. The patient suffered from spasmodic attacks of rectal tenesmus. The vibration gave the patient much relief. The treatment of tabes dorsalis offers a vast field for therapeutic research and reasoning. It is essentially a chronic disease with a kaleidoscopic variety of symptoms. 444 MODERN PHYSIO-THERAPY. While it is unfortunately a fact that the disease is practically incurable, there can be no doubt that a world of good can be done by physio-therapeutic means, not only in the relief of symptoms, but also in retarding the degenerative process which marks the pathology of the disease. Lupus Erythematosus. The treatment of this stub- born affliction by X-rays has not been uniformly successful, although some observers speak well of it. The Finsen- method is not effective unless arc-lights of immense am- perage are used on comparatively small patches. The portable Finsen-lamps (five to ten amperes) are of no avail. Metallic electrolysis, as described under the head of LUPUS VULGARIS, is sometimes effective. Heat-rays (Minin-light, or sunlight concentrated by means of a sun-glass) have been known to cure superficial cases. The high-frequency current applied by means of a suitable vacuum-electrode is productive of good results in many instances. Even in cases of long standing the high-frequency current has been used successfully. Applications should be made every two or three days for five to ten minutes. A vapor or dry-heat bath once or twice a week is indicated in these cases. Lupus Vulgaris. The treatment of common lupus by concentrated chemical solar or electric arc light rays (Fin- sen-method) is referred to in the chapter on PHOTO- THERAPY (Part I of the book). The X-ray treatment is discussed in the chapter on X-RAY-THERAPY. Good results frequently follow well-applied metallic electrolysis by means of a positively charged copper-tip electrode which has been moistened with salt water and is slowly moved about. Negative (sponge) electrode is placed near by. Green dis- coloration indicates formation of copper oxy-chloride. Ap- plications of high-frequency currents by means of a vacuum- electrode are often beneficial in the non-ulcerative variety of lupus vulgaris. The thermic solar rays concentrated by means of a sun-glass have been successfully used in the destruction and cure of lupus. The method is somewhat ob- jectionable on account of the pain involved. THERAPEUTIC INDEX. 445 Malaria. The different types of the plasmodium of Laveran thrive best where the conditions are favorable for fermentation and decomposition, e. g. in swampy, marshy, humid places, where the temperature is high and the air stale or even foul. This description mutatis mutandis applies to the conditions prevailing in the system of a pa- tient suffering from the malarial poison : sluggish circula- tion, sub-oxidation, deficient elimination. Whether we be- lieve that the anopheles is the carrier of the plasmodium, makes little difference. Swampy, marshy places can be made healthful by ventilation, air and sunlight. A malarial system can be restored by stimulating the circulation, pro- moting metabolism and increasing elimination. In either case the plasmodium can not thrive. Active regeneration of stagnant places makes it impossible for the plasmodium to become a pathogenic factor. Therein lies at once the principle of prophylaxis and treatment of the malarial state in and out of the human body. The details of treatment in all cases of malaria are: a carbo-hydrate (vegetarian) diet, irrigation of the colon, a sweat-bath every two or three days, as much sunlight and fresh air as possible. The liver must be kept active. Sluggishness of the whole system is usually coincident with and produced by sluggishness in the portal circulation. To counteract stagnation of this kind give abdominal massage, vibration over the stomach and liver and advise horseback exercise. Keep the blood fresh, metabolism active, elimination perfect, and the ma- larial state in its many forms will cease to exist (malaria, remittent fever, intermittent fever, biliousness, malarial cachexia, typho-malarial fever, etc.). For additional clin- ical information see FUNCTIONAL DISORDERS, DYSPEPSIA, MIGRAINE. Immunity against malaria consists in a per- fect physiological equilibrium of metabolism. If the latter can not be established owing to a wretched condition of the system characterized by but little regenerating power, the only advice to give such a patient is to look elsewhere for more healthful surroundings. 446 MODERN PHYSIO-THERAPY. An acute attack can undoubtedly be broken up tem- porarily by complete cinchonization of tbe system. In many cases the cure seems to be as bad as tbe disease. The stomach and liver are completely enervated and often re- main so, even after a change of climate. Thus the mo- mentary action of quinine which is gratefully acknowledged as a necessary evil, is not an unalloyed boon. Quinine does not remove the malarial state. To do this, the physio-thera- peutic measures mentioned must be resorted to. In the chapter on the THERAPY OF LIGHT, reference is made to the darkness-treatment of malaria. Patients were confined for days in dark rooms. The conclusion to be drawn from the apparently good results is not that the ab- sence of light killed the plasmodium, but probably that the anopheles had no access to the dark room. The ap- parent immunity of the negro is easily understood when we consider that negroes are accustomed to an outdoor life and are usually free from disorders of digestion, assimila- tion and metabolism. The experience of physio-therapeutists living in malarial sections has shown that a treatment in the dry-heat cylinder will break up an acute attack two or three hours after. While I have had bountiful opportunities to verify the value of physio-therapeutic methods in chronic malaria, I have had no personal experience with the acute form of the dis- ease. Melancholia. The management of a case of melan- cholia does not differ from the therapeutic regime outlined under the head of NEURASTHENIA. The essential part of the treatment is to occupy the patient's mind. Suggestion is a valuable therapeutic agent. Change of surroundings is necessary in all cases. The most distressing feature in most cases is insomnia. This should be combated by cold moist packs to deplete the brain, and general massage to keep metabolism active. Galvanism (positive to temples and forehead, negative to spine) is beneficial. If there is a special cause for melancholia, remove it. THERAPEUTIC INDEX. 447 Meningitis. The therapeutic directions for the man- agement of inflammatory conditions of the brain, the cord and the enveloping membranes are practically identical and therefore, refer to all forms and varieties of pachymen- ingitis, leptomeningitis, cerebral congestion, cerebro-spinal meningitis, myelitis, etc. Absolute rest in bed is essential. It is of advantage to change the position of the. patient from time to time. The patient should not remain on his back constantly. The intestinal canal should be washed out. The bladder-function must be watched. "Derivation" to the lower extremities and subsequent depletion of the upper parts of the body must be accomplished by hot vapor-baths, cold moist packs, hot dry packs or baths, dry-heat baths in thermic cylinder, or electric-light baths. Any of these pro- cedures are applicable. The most effective plan is to give a vapor-bath (from feet to epigastrium) and follow it with a hot moist pack. The technique of the application is in- dicated in the chapter on THE THERAPEUTIC USES OF HEAT AND COLD and under the head of FEVER, INFLAMMATION, PNEUMONIA and other special subjects. When the stage of exudation has begun, the depleting methods indicated above riiust be pushed to the point of tolerance in order to force absorption. This is a matter of the utmost importance. In syphilitic cases the prognosis depends on the firmness and consistency with which these directions are enforced. For dietetic directions see DIET IN ACUTE FEVERS. Locally leeches, cupping, cold applications or alternate applications of heat and cold are of value, but only as ad- juncts. The essential features of treatment are the details of general management indicated above. The ice-bag on the head should be supplanted by a head-coil. The gal- vanic current is serviceable in helping to deplete the area of inflammation. The positive pole should be applied to the spine. Later on, faradization of the muscles, especially of the extremities, may be resorted to. Statistical evidence goes to show that the therapeutic regime outlined above not only improves the prognostic features of inflammation of 448 MODERN PHYSIO-THERAPY. the brain, cord and meninges, but ameliorates the severity of the symptoms, shortens the duration of the attack and counteracts the permanent damage which the nerve-struc- tures frequently sustain as a result of severe inflammatory disturbance. Menorrhagia. Therapeutic directions analogous to those given under the head of METRORRHAGIA. Metritis. General regime and local treatment are iden- tical with the therapeutic directions given under the head of ENDOMETRITIS, with which metritis is usually associated. Metrorrhagia. Treatment should be planned and ad- ministered with due regard to the cause. To control bleed- ing, cold applications should be made to the abdomen and to the sacral region. In the extreme cases very hot vaginal douches might be necessary. Forcible massage and com- pression of the uterus, both through the abdominal wall and through the vagina, are often effective. It can be combined with faradic electricity (one pole in the uterus, the other on the abdomen, or one pole in the operator's unengaged hand, the other in the patient's hand while massage is being applied). The use of a (positive) copper-electrode (gal- vanic current) in the uterus is useful in some cases. Pack- ing with gauze-tampons during the interval between treat- ments is indicated. Hydro-therapeutic "derivating" appli- cations are always proper. Migraine. "Bilious headache" is the classical type of an acute auto-intoxication. The object of treatment should be to eliminate the absorbed toxines and to prevenv. a re- accumulation of toxines. TREATMENT OF AN ACUTE ATTACK. To prevent or abort an acute attack of migraine, the patient should be given a thermic treatment in the dry-heat cylinder or eiec- tric-light cabinet. The colon should be thoroughly irrigated and food withheld for at least eight hours. Locally the static head-spray (positive if face is flushed, negative if patient feels faint) should be given for ten to fifteen min- utes once or twice during the attack. Pressure over occiput THERAPEUTIC INDEX. 449 has a sedative effect. Galvanization (positive pole on pain- ful place, negative between scapulae) is useful. Massage over the forehead and temples is helpful. Vibration over lower cervical and upper dorsal vertebrae is serviceable. After the thermic treatment the patient should be placed in. the high-frequency cylinder (cage or diasolenic) for fifteen minutes. TREATMENT DURING THE INTERVAL. Outdoor life, sun- light, a vegetable diet, exclusion of alcohol, tobacco, tea and coffee, avoidance of excesses and excitement, daily ir- rigation of the colon, a reasonable amount of exercise and a weekly sweat-bath are indicated. Static spray to the back is useful. Galvanization (one. pole over epigastrium, the other pole to spine) is a valuable adjunct. If the patient is plethoric and suffers from congestions, place positive pole on back. If patient is anemic and sluggish, use negative pole on back. The dietetic peculiarities of the patient should be studied closely. Frequently one special kind of food pre- cipitates an attack. If the patient has trouble with his eyes, an oculist should be consulted. Milk-secretion. To increase the functional activity of the female breast, .place negative pad-electrode on the breasts, positive on the back and treat daily for fifteen min- utes with mild galvanic current. Also use negative static spray locally. Hot applications and massage are useful. To decrease milk secretion use positive current on the breasts, negative on the back. Technique as before. Cold applications and compressions are useful. In threatening mastitis use Bier's stasis by means of a suction apparatus. Otherwise see INFLAMMATION ( ACUTE) and SEPSIS. Moles. (See VASCULAR TUMORS.) Nasal Catarrh. Acute rhinitis (cold in the head) re- quires general treatment similar to that given under the head of TONSILLITIS. A good sweat in the thermic cylinder frequently aborts an attack. (See INFLAMMATION ( ACUTE) and FEVER.) The chronic variety of nasai catarrh is one of the most 450 MODERN PHYSIC-THI.KAPY. common conditions encountered in practice. It is seldom cured because the atmospheric conditions are a constant source of irritation and because local treatment is inade- quate. General hygienic regulations must be enforced. (See INFLAMMATION, CHRONIC.) Locally the high-fre- quency current (nasal electrode) or metallic electrolysis (positive copper- or zinc-electrode to the affected surface, negative back of neck) ten milliamperes for five minutes every day or two. Mild, rapid vibration over the cheeks near the nose is beneficial. Local treatment is useless un- less systemic treatment is enforced. Underlying causes (syphilis, etc.) should receive attention. Nervous Diseases. The therapy of degenerative dis- eases of the cord is suggested under the head of LOCOMOTOR ATAXIA. For therapeutic information concerning other reuropathic subjects see INFLAMMATION ( ACUTE), IN- FLAMMATION (CHRONIC), PARALYSIS, REFLEX DISORDERS, FUNCTIONAL DISORDERS, HYSTERIA, NEURASTHENIA, MEL- ANCHOLIA, EPILEPSY, etc. Neuralgia. The treatment depends on the cause be- cause neuralgia (nerve pain) is always a symptom, never a disease. Hilton's famous definition of pain ("cry of a nerve for healthy blood 7 ') is a complete and expressive exposition of the nature of neuralgia. The latter is a symptom rarely of neuritis, sometimes of pressure of a tumor, foreign body, etc., on a nerve, not infrequently of toxaemia (syphilis, ma- laria, rheumatism, metallic poisons, etc.), but most com- monly of auto-intoxication (absorption of derivatives of normal excreta and secreta due to dyspepsia, constipation, anemia so-called and disorders of nutrition produced by grief, worry, mental strain and other psychic factors). In all cases of stubborn neuralgia look to the stomach and its function (see DYSPEPSIA). GENERAL TREATMENT. The importance of increased elimination can not be too often repeated nor too strongly emphasized. What has been stated in this regard under the head of RHEUMATISM holds good in connection with THERAPEUTIC INDEX. 451 neuralgia. Elimination is the alpha and omega of success- ful treatment. The dry-heat cylinder, the electric-light bath and the sun-bath have a deep therapeutic significance in all cases of neuralgia. If the patient is plethoric, f nil-blooded and of a nervous temperament, put him on a simple vegetable diet. Exclude alcohol, coffee, tea and tobacco. If the pa- tient is weak and pale, let him live on copious nitrogenous food. Improve his surroundings, physically and psychically. Even in cases of special neuralgia the general application of general high-frequency currents (cage or diasolenic) should be included in the treatment. LOCAL TREATMENT. Heat and manipulation are the best and most effective local agents in the treatment of neuralgia. Heat can be applied by means of the Minin ap- paratus, a small dry-heat cylinder or the local electric-light bath. The skin becomes hyperemic, the venous supply of the part is regenerated and waste-products are absorbed or excreted. The cry for healthy blood is stilled. More in- tense effects on local metabolism can be produced by cold applications if they are properly administered so as not ,to fail in their invariable object to bring on a reaction. Cold douches, thrown against the part with considerable force, were used by Kneipp. Cold moist packs applied to a dis- tant part ("DERIVATION") were employed by Priessnitz. Kneipp's famous depleting method (walking in the wet grass or fresh snow) has cured many a case of sciatica and other forms of neuralgia. All these methods and agents, however, are incomplete without direct manipulation of the affected area. When the suffering nerve and the contiguous territory should be manipulated, is an open question. It seems, how- ever, as if local thermic treatments (such as indicated above) should be followed by an hour of rest before manip- ulations are begun. They are given in the form of pressure, manage, Swedish movements, vibration or oscillation. Simple pressure usually relieves neuralgic pains. When the part admits of the application of a firm compression- 452 MODERN PHYSIO-THERAPY. bandage, the latter should be applied and worn as a pallia- tive measure. Massage of the aching nerve is worse than useless if it causes discomfort or pain. Massage in its various forms should be applied to the surrounding parts, not to the nerve-trunk directly. After the circulation of the contiguous territory has been stimulated, passive move- ments or in suitable cases excentric movements can be em- ployed to intensify the effect of massage. . It goes without saying that all massage-movements should be centripetal. Vibration is useful both centrally and peripherally. Vi- bration of the affected nerve or plexus should never cause discomfort or pain. The technique is. correctly given by Arnold Snow, who advises interrupted vibration with a fairly slow rate of speed. "It should be applied lightly at first ; but, with increasing tolerance, be intensified, the dim- inution of pain being a guide as to the increase of pres- sure. If after a reasonable effort the pain does not cease or markedly lessen, vibration should not be persisted in. Treatments should be given daily. In obstinate cases it may be best to treat twice daily." Powerful vibration of the surrounding parts is always proper and adds in no small measure to the sum-total of benefit which the patient derives from vibration. The effect of vibration is undoubtedly due to intensified molecular motion, followed by an increase in animal-heat, oxidation and accelerated metabolism. It stands to reason that the applicability of the directions given depends to a large degree on the anatomical location of the nerve treated. The same holds good in regard to oscil- lation. Central vibration for the relief of neuralgia has fre- quently yielded very good results. The vibration-table given under the head of PARALYSIS will be found service- able in locating the spinal segments corresponding to cer- tain anatomical regions of the body. There is no doubt whatever that the effects of central vibration are primarily in the general improvement of the nutrition of a (peripheral) part and secondarily in the benefit which accrues to an in- THERAPEUTIC INDEX. 453 dividual structure through improved nutrition of the re- gion of which it is a component part. Thus, for obvious reason, vibration over the lower dorsal and the upper lum- bar vertebrae would be indicated in cases' of sciatica. The idea expressed by M. T. Pilgrim that instrumental vibration increases the natural vibration in a nerve and in this way produces physiological effects, is hardly tenable. Natural vibration in a herve is its medium of carrying and trans- mitting impulses. Pain, considered in connection with nerve-physiology, is composed of accentuated sensory im- pulses. To increase the natural vibration of a nerve means to magnify the sensory impulses which it carries. Beyond a certain point of accentuation of sensory impressions the sub- jective condition is called "pain." This is a pathologic state. 11 'instrumental vibration relieves pain, it either does so by obtunding the natural nerve-vibration or by increasing the natural nutriment of a nerve, thus enabling the latter to carry intensified sensory impressions without subjectively perceiving them as "pain." The therapeutic suggestions given apply in all cases of so-called neuralgia. The stomach and the skin must re- ceive the lion's share of attention at the hands of the cli- nician. For the sake of completeness the more common forms of neuralgia are added with suitable suggestions: Tie-DouLouREux (NEURALGIA OP THE FIFTH NERVE). "Derivating" baths or packs. Cold douches to lower ex- tremities. Walking in wet grass or fresh snow. Sun-bath locally. Galvanism (mild current, positive pole moved over forehead, negative to back of neck). Positive galvanic current to aching points directly, negative to back of neck. Static spray (large or small) positive to head, negative to platform. Gentle stroking to painful spots. Locally dry heat. Cataphoresis of cocaine, chloroform or aconite is bad practice. ODONTALGIA. Sometimes a problem for a dental sur- geon; Otherwise treatment does not differ from that of tiodouloureux. 454 .VHI>I-:K\ I'IIYSJO-TIIKKAPY. CEPHALALGIA. Xot a true neuralgia. Usually con- gestive headache or due to auto-intoxication from stom- ach and intestines. Derivation as in the treatment of tic- douloureux. Positive static spray. Pressure over occipital region. Massage of forehead and temples. Vibrate over cervical vertebrae. Sometimes an ophthalmologic problem. INTERCOSTAL NEURALGIA. Dry heat. Galvanism, posi- tive pole over painful spots. Derivation as before. Strap- ping the affected side is useful. GASTRALGIA. Heat externally by hot applications, in- ternally by hot drinks. Positive galvanic pole in epigas- trium, negative on the back. Static spray (positive) or wave-current to epigastrium. Hot sitz-baths. Liquid food. OVARIAN NEURALGIA. Hot sitz-baths. Galvanism (positive pole directly over aching spot or in the vagina, negative in lumbar region). Static spray (positive) to ab- domen. Priessnitz pack to abdomen. Hot vaginal injec- tions. Pressure over ovarian region. LUMBAR NEURALGIA. Rheumatic in character. (See RHEUMATISM, MUSCULAR.) SCIATICA. Pressure, compression-bandage, massage and vibration. Dry heat. Rest limb in elevated position. Galvanism as before. Static spray (positive) locally. Local sun-baths. The local treatment of any neuralgia must always be secondary to the general treatment of the system. Local treatment is desirable, general treatment is necessary. Even in old, obdurate cases good results can be achieved if the physician will persist in handling his patient generally and locally according to the directions and suggestions given above. Neurasthenia. Nervousness in the widest and, there- fore, in a constantly varying sense of the word is supposed to be a functional disorder of the nervous system. It is al- ways a symptom and may be due to any number of causes. Hartholow's definition is probably as good as any: "Mor- bid mental condition produced by exaggerated suscepti- THERAPEUTIC INDEX. 455 bility to physical impressions." In looking for the cause of the affliction, give the stomach a large share of your at- tention. The symptomatology of the affliction is infinite. Neurasthenia is found in conjunction with most chronic diseases. In attempting to handle a ' case of neurasthenia the physician should provide for his patient the best of hy- gienic surroundings. The four emunctories should be kept active, especially the bowels and the skin. Sunlight is in- dispensable. Occupy the mind of your patient pleasantly. This might be accomplished by a change of surroundings, travel, relief from business and other obligations and by suitable companionship. General massage, followed by a lukewarm rub-down and an hour's rest, is very serviceable in the neurasthenia of women. Exercise in the open air proportionate to a patient's tolerance, swimming, horseback riding, outdoor sports, etc. If the neurasthenic state is the result of, or is associated with, some chronic ailment, treatment should be directed to the cause. The patient's sexual life often furnishes the clew to the situation. The mental state of the patient is frequently a problem which can only be solved by one who is familiar with the patient's family history and with the details of the patient's private life. These should be taken into consideration and should be made the means of reach- ing the patient's mind and nervous system by suggestive influences. In a few instances the rest-cure as advocated by S. Weir Mitchell will be found serviceable. In many cases, however, absolute rest and isolation mean aggravation of the neurasthenic state. The application of the high-frequency current to the spine by means of a vacuum-electrode or a general high- frequency treatment in the diasolenic cylinder or D'Ar- sonval's cage is a powerful therapeutic agent in cases of neurasthenia, especially if the patient is an ill-nourished, anemic subject. Galvanization or faradization of the spine is useful in many instances. Vibration in carefully selected 456 MODERN PHYSIO-THERAPY. cases is very beneficial. In the form of neurasthenia which is associated with nervous dyspepsia, vibration over the dorsal, epigastric and both hypogastric regions is very ef- fective. If the patient is a malarial, rheumatic or syphilitic subject, general eliminative treatment is necessary. The diet of a patient should be adapted to his general condition and to the tolerance of the stomach. Usually a moderate nitrogenous diet, excluding fats, pastry, spices, coffee, tea and alcohol, is adapted to these cases. Tobacco should not be allowed. Most cases do better if they are treated away from home. Many times it is possible to act upon the pa- tient's nervous system and mind through the special senses. (See chapter on PERSONAL HYGIENE.) Night-sweats are produced by auto-intoxication and resulting vaso-motor disturbances in the skin. Patients who are handled according to the regime outlined under the head of TUBERCULOSIS PULMONUM do not usually suf- fer from night-sweats. It is only patients who are housed up, improperly fed and treated without regard to the more or less hygienic character of the surroundings, that sweat at night (Brehmer). A positive static insulation toward evening followed by a lukewarm sponge-bath usually breaks up night-sweats. Treatment should be given every evening. Obesity. Oertel's treatment of obesity consists in sys- tematic dehydration of the system (see VALVULAR DIS- EASES OF THE HEART) and augmented oxidation (mountain- climbing to expand the thorax and augment the amount of oxygen). He emphasizes the necessity of counterbalancing the physiological effects of these methods by a suitable diet (albumen in excess, carbo-hydrates in moderate quantity, fats and starches excluded). If the reduction of fat is done at the expense of the digestive function, it is harmful. The drinking of vinegar, the eating of soap, the use of cathartics are objectionable for the reason indicated. The treatment of obesity is diffi- cult because cases must be properly individualized and on account of the co-existence of other diseased conditions. In THERAPEUTIC INDEX. 457 rheumatic and gouty cases of obesity the diet should consist of garden vegetables well cooked and cut crosswise to the fiber (carrots, parsnips, turnips, spinach, lettuce, onions, celery, cauliflower, cabbage, beets, string beans). In addi- tion to these, fresh-water fish, wheat gluten, white of egg and skimmed milk. Keep bowels open. If there is- no rheumatism or gout, lean beef, mutton or chicken might be allowed and milk excluded. Starches and fats (all fried foods) should be forbidden. Coffee, tea or alcohol can be allowed in very small quantities, water as little as possible. If the heart is good, the dry-heat cylinder or general elec- tric-light bath can be employed every three or four days. Chest-exercise, mountain-climbing, general massage and Swedish movements, fresh air and sunlight should be added to the dietetic regime. (See chapter on DIETETICS. See RHEUMATISM.) Occupation-neuroses. This term refers to a number of conditions characterized by painful cramping, weakness or extreme sensitiveness and irritability of certain muscles as the result of overexertion of these muscles. The most familiar form of an occupation-neurosis is writer's cramp. Other types are observed in the hands and wrists of piano- players and violinists, in the calves of dancers, in the lips of cornetists, all of whom constantly use certain muscles until muscular tone is exhausted. The therapy consists in rest, massage, mild faradization or galvanism of the afflicted muscles. Vibration along the course of the principal nerve- trunks of the part, also central vibration as indicated in the vibration-table under the head of PARALYSIS. In treat- ing the wrist, a dry-heat treatment in a small thermic cylin- der or local electric-light bath, followed by a high-frequency treatment of the whole arm, is useful. Massage of the muscles near the afflicted part helps to tone up the mus- cular structure of the whole member and incidentally strengthens the afflicted arm. Treatment should be given every day or two. Later on, Swedish movements of the affected region can be added. 458 MODERN PHYSIO-THERAPY. Opsonic Therapy. No scientific achievement of recent years has made such a deep impression on the medical mind as the remarkable biologic work that has given us the knowledge of those elements which in their totality repre- sent the self-sustaining force of the organism (i'is medi- catrix naturae). These researches, in their ultimate con- clusions, are so closely allied with the philosophic basis of physio-therapy that intelligent discussion of the latter now- adays would hardly be possible without due consideration of the additional scientific evidence which these researches furnish on behalf of strictly physiological methods of therapy. The pioneer work in this important department of biol- ogy was done by MetschnikorT, who studied the role which the white corpuscles of the blood play in the protection of the animal body against germs of disease and their destruc- tive activity. Metschnikoff showed that the white cor- puscles in reality are the protectors and defensors of the body in as much as they actually wage war against the intruding germs of disease, attack and destroy them. He called them phagocytes (eating cells), because they devour the invading bacteria. The process itself he called phago- cytosis. This subject was taken up, studied, and elaborated by many observers, who elicited many new and interesting details. It was found that the fighting quality or eating capacity of the blood-cells is variable and dependent on many circumstances. The so-called phagocytes do not at all times possess the same degree of power to cope with pathogenic intruders. Sometimes their power is very slight, under other circumstances it is very considerable. If this power is so great that germs of disease can enter the body without being able to do harm, the body, as a result, is practically proof against their activity. This condition is called immunity. It represents the highest phagocytic power of the blood-cells. Leishman, Wright, Douglass, Bulloch, and others have studied the subject of phagocytosis from many points of THERAPEUTIC INDEX. 459 view. It was elicited that the fluids of the blood themselves possess certain properties that affect the phagocytic action of the blood-cells. Wright used for his earliest experi- ments the cultures of one of the pus-producing gerrns, the staphylococcus pyoyenes aureits. He attributed the pecu- liar effects observed to the action of certain elements con- tained in the blood fluids. These elements modify the bac- teria, weaken them and in this way render them a ready prey to the phagocytes. Since the bacteria are devoured by the phagocytes, the action of the elements in the blood- fluids is similar to the function of the cook who prepares the food for eating. In this case the bacteria are the food. The cook is represented by the elements in the blood-fluids which modify the bacteria or render the food eatable. These elements in the blood-fluids were for this reason called opsones or opsonins. The Greek word opson means a "side-dish." The verb opsonco means "to provide food" or "to prepare food." Thus the meaning of the word opso- nin becomes plain. The conclusion which Wright and Douglass drew from their early experiments were mainly : 1. The opsonic power is possessed both by the serum And by the plasma of the blood. 2. When serum is heated to 60 C. it loses its opsonic action. It becomes "devitalized" or "inactivated" serum. 3. Inactivated serum has the same influence on phago- cytosis as physiological salt solution. 4. If blood-fluids are allowed to stand, they gradually lose their opsonic power (about 50 per cent, in five or six days). Ross in a splendid monograph on the subject, summar- ized the subject as follows : "1. Opsonins act by chemically uniting with the invad- ing bacteria, and so altering them that the leucocytes are able to phagocyte the bacteria and destroy them. It is im- portant to remember that these substances do not stimu- late or otherwise affect the leucocytes. 460 MODERN PHYSIO-THERAPY. "2. It is probable that there are present many varieties of opsonins in the blood plasma, each one having to do with combating a particular kind of microbic invasion. "Opsonins have been shown to be distinct from other bacteriotropic substances, such as bacteriolysins, the agglu- tinins and antitoxins." The comparative estimation of a patient's power of resistance to an invasion of a given germ is called the "op- sonic index" of the patient. To find the opsonic index of a patient for any given microbe, the serum to be tested is mixed with fresh human leucocytes and the mixture ob- served in its action upon the particular bacterium under investigation. The method is well described by Ohlmacher, who states that by the ingenious methods of Wright and his associates, Leishman and Douglass, it is possible to study experimentally, outside of the living body, the action of the blood serum called opsonic. If one takes fresh blood of man or any other common mammal and washes the corpuscles free from serum, the polymorphonuclear leuco- cytes will not ingest such pathogenic bacteria as the pyo- genic cocci, color! bacilli, or tubercle bacilli when these are mixed in the form of a fluid suspension with the washed corpuscles and incubated fifteen to thirty minutes. If, however, to this mixture of washed corpuscles and bac- teria blood serum be added, the phagocytic leucocytes at once begin to take up the bacteria, and, in proportion to the opsonic power of that particular serum against that particular kind of bacterial parasite, the number of bac- teria engulfed by a given number of leucocytes in a certain period of incubation will vary. In virtue of its opsonin, which sensitizes the bacteria so as to allow the white blood cells to take them up by phagocytosis, the blood serum pro- duces the effect just described. Against a given pathogenic microbe, as, for example, the staphylococcus aureus, the serum of one individual tested by a refinement of the method just outlined will permit the leucocytes to take up an average number of the cocci, the number representing THERAPEUTIC INDEX. . 461 this individual phagocytic index for staphylococcus. The relation which exists between the phagocytic index of one individual and that of others, presumably normal, constitutes the so-called opsonic index. This opsonic index assumes practical importance because it seems to bear a definite re- lation to an individual's resistance against a given disease- producing microbe. With subacute and chronic infections the opsonic index is usually low for the corresponding bac- terial species. Wright has shown that by artificial bacterial autoinocu- lation one may increase resistance against the correspond- ing organism to a point at which healing of infectious processes occurs. The bare fact that immunity could be induced or heightened by the use of pathogenic bacteria or their products has been established and extended from the day of Pasteur's epoch-making studies in the bacteriology of infectious diseases; and from Buchner's day it was shown that the blood serum bore an important part in the body's combat against micro-parasites ; while the role of the living body cell was demonstrated by the brilliant Metschnikoff. But figuratively it remained for Wright to so modify the vaccine of Pasteur as to arouse in the serum ; of Buchner a substance which prepared the disease-pro- ducing microbe for destruction by the phagocyte of Metsch- nikoff; thus bringing to practical humanitarian usefulness the laboriously studied theories of three pioneers in bio- logic therapy (Ohlmacher). The diseased conditions in which the method of Wright is applicable may be classified bacteriologically thus : 1. Conditions due to entrance of the staphylococcus py- ogenes (acne, furuncle, sycosis and many similar skin dis- eases) ; 2. Conditions produced by the bacillus coli communis (cystitis, fistulous afflictions, etc.) ; 3. Gonococcus invasions (acute and chronic gonorrhea, gonorrheal rheumatism, gleet, etc.) ; 462 MODERN PHYSIO-THERAPY. 4. Lotalizecl or general conditions caused by the bacil- lus tuberculosis. The chief and only object in the treatment is to raise the opsonic index. A patient with a localized infection will have, as a rule, a constantly low index, while one suffering from a general infection will have a fluctuating index at one tirrte high above normal, and at another time below normal. Auto-inoculation takes place in the latter case, while it does not in the former, and it is obvious from these two statements why infections of a general nature are not appreciably benefited by this treatment. Wright's method is limited to bacterial infections and is most favorable in those cases having a low opsonic index. For the sake of illustrating the plan, let us assume that we have to treat a case of pustular acne. The first thing to do is to examine the pus to determine the organism present. Next find the patient's opsonic index. If it is low, vaccine inoculations should be made. A vaccine as it is understood here is a standardized, sterile emulsion of the organisms found in the pus of the lesion. Under aseptic precautions inject into the patient a vaccine of two hundred and fifty million cocci. When this is done it becomes very interest- ing to watch and observe what takes place in the patient. Immediately following the injection there is a fall of the opsonic index, but a reaction soon takes place and the index begins to rise, and within four to six days the index will reach normal and go. above it, remaining stationary for a few days and begin to fall again. The curve will graphi- cally represent the exact conditions. The falling index is called the "negative phase," the increasing index is called the "positive phase," the stationary condition is called the "high tide." The patient's blood is kept under examination, and when the second "negative phase" appears and the index is returning to normal, another inoculation with vac- cine should be made. The index continues to fall after the second injection is given, but reaction soon follows and the index shoots up again, probably higher than before, THERAPEUTIC INDEX. 463 remains stationary and begins to fall. In. such cases an inoculation should be made about every ten days, but in all cases they should be controlled entirely by the index. After a few inoculations, as a rule, marked improvement will be observed in the patient (King). Wright's fundamental rules for therapeutic applications in cases of bacterial infections are: 1. Isolate in pure culture the causative micro-organism. 2. Estimate the opsonic power of the patient's blood to this micro-organism. 3. If the opsonic index be at or below normal, prepare and standardize a vaccine from this micro-organism. 4. Inoculate the patient with this vaccine with appro- priate doses and at proper intervals, as shown by a syste- matic estimation of the opsonic content of the patient's blood. What the influence of Wright's attractive and ingenious theory will be on the therapy of bacterial diseases, it is, as yet, too early to tell. No one questions the tremendous im- portance of Wright's biologic researches, equalled only by the brilliancy of MetschnikofF s original investigations. To the physio-therapeutist who, by virtue of his work, takes a biologic view of disease and, amid the confusing multi- tude of therapeutic methods and agents has never lost sight of the supreme position occupied by the vis medicatrix naturae, the opsonic theory of Wright naturally appeals with more than ordinary force. In the light of Wright's researches the i'is mcdicatri.v naturae ceases to be a theoret- ical abstraction or a convenient generalization. It becomes a physical entity accessible alike to the chemist, the path- ologist and bacteriologist. Strangely enough, the brilliant work of two such master-minds as Metschnikoff and Wright bears out the truth of a statement of a humble layman, who more than sixty years ago said that all con- tagious diseases contain in their contagion the materials necessary for their cure. That humble layman was Vin- cens Priessnitz. the crude father of modern hydro-therapy. 464 MODERN PHYSIO-THERAPY. Orchitis. General therapeutic principles under IN- FLAMMATION (AcuTE). Ice-applications are of doubtful propriety. In the chronic forms of the disease the Alinin light is of value. Galvanism (testicle between the two sponge-electrodes) is useful. Bennett recommends im- mersing scrotum in a cup of water, using the water as one of the conductors. In acute orchitis put positive wire into the water, negative to feet. Galvanism, ten milliamperes, ten to fifteen minutes. In the chronic form reverse polarity and use for five or ten minutes. Massage of the enlarged testicle is beneficial. Pain. Find the cause. Symptomatic relief may be had from the judicious employment of pressure (in accessible passive congestions, some forms of neuralgia), massage (muscular rheumatism, passive congestions), heat (in most inflammatory conditions), cold (in some inflammatory states, suppuration), Minin light, X-rays, high-frequency currents, positive pole of galvanic and static currents, vibra- tion, sun-bath, various kinds of hydro-therapeutic applica- tions and last but not least suggestion. (See FUNC- TIONAL DISORDERS, REFLEX DISORDERS, RHEUMATISM, etc.) Pain is never a pathological condition, but always a guide- post to some seat of disturbance. The proper treatment always depends on the cause. Palpitation of the Heart. A cold application to the precordium usually has a sedative effect. Other means of relieving an acute attack are : positive static insulation, deep vibration over upper dorsal vertebrae, galvanization (negative side of neck, positive precordium), lukewarm bath, hot pack to lower extremities. Try to find the cause and remove it. (See DYSPEPSIA, FUNCTIONAL DISORDERS, REFLEX DISORDERS.) Paralysis. Impairment, perversion or loss of motion, inasmuch as it is a peripheral effect, is only a symptom and must be dealt with, with due regard to the cause primarily concerned in the production of the paralytic state. The cause may be disease of nerve-tissue, inflammation of THERAPEUTIC INDEX. 465 nerve-sheaths, hemorrhage and subsequent pressure of a blood-clot, tumors, etc., etc. It may be a hemiplegia, if it involves a lateral half of the body ; a paraplegia, if it in- volves the body from the waist down ; a monoplegia, if it involves a single member. Not all paralyses are effects of structural lesions. Hysterical paralyses are not infrequent. Sometimes paralyses are evidences of auto-intoxication and disappear when the cause ceases to act. Some forms of paralysis are toxemic in character (e. g. the post-diphthe- ritic variety). At times paralysis appears as the symptom of a gradually supervening or progressive deterioration of the nervous system. On general principles we may consider the curability of the paralytic state in direct proportion to the tractability of the underlying condition. In keeping with the anatomical site of the lesion paralyses are said to be of encephalic, spinal or peripheral origin. GENERAL TREATMENT. If a paralytic condition is due to auto-intoxication, toxemia, or some systemic (blood) disease, it is of vital importance to correct the hygienic sur- roundings, to adapt the dietetic habits to existing conditions and to regenerate the nutritional state by promoting and correcting metabolism. Stimulate oxidation by fresh air and sunlight. Feed the patient on an excess of tissue-con- sumers (vegetable diet), unless there is a slow and gradual loss of weight which would have to be met by a supporting nitrogenous diet. Keep the kidneys active by liberal potions of fresh water. Irrigate the colon every day or two. The general electric-light bath or the dry-heat body-cylinder should be used every three or four days. General massage, static insulation, the galvanic or faradic water-bath, the wave-current to the spine, the body-diasolenic or auto-con- densation couch may be added for their powerful .tonic effects. LOCAL TREATMENT. Among the various therapeutic agents that are used to restore the functional power of mus- cles, the most available one is undoubtedly massage. The afflicted parts should be manipulated by effleurage, petris- 466 MODERN PHYSIO-TIIF.KAPY. sage, friction, tapotement, successively and conjointly. Thermic stimuli (local electric-light bath, Minin light, hot applications, alternate hot and cold douches) are useful to improve local nutrition. The electric (faradic or galvanic) water-bath can be employed if an arm or a leg is to be treated. Vibration over the affected region is a valuable adjunct. Static sprays and in suitable cases sparks may be given locally. The electric massage-roller answers nicely in some cases. Central stimulation by manipulation and vibration of the spine is of importance hi the treatment of paralytic cases. The following list of control-stations may serve as a guide in the manipulation and vibration of the different portions of the spine : Segment of the cord corresponding to the location of the first cervical vertebra; controls motion of the following muscles: recti laterales, rectus capitis, anticus, posticus, sterno-hyoid, sterno-thyroid. Second and third cervical: sterno-mastoid, trapezius, scaleni, omohyoid, diaphragm. Fourth cervical: diaphragm, deltoid, biceps, coraco- brachialis, supinator longus, rhomboid, supra-spinatus, in- fra-spinatus. Fifth cervical: deltoid, biceps, brachialis anticus, long I'.ncl short supinator, deep scapular muscles, rhomboid, clavic- ular portion of pectoral muscles. Si.rth cervical: deltoid, biceps, brachialis anticus, sub- scapular, pectoralis, serratus magnus, triceps, pronatores, latissimus dorsi. Seventh cervical: triceps, extensores, pronatores, flex- ores, subscapular pectoralis, latissimus dorsi. Eighth cervical: triceps, flexores digitorum. First dorsal: extensores pollicis, musculi manuum in- terni, musculi thenares et hypothenares. Second to twelfth dorsal: muscles of back, abdominal muscles, and spinal erectors. First lumbar: none. Second lumbar: vastus internus. THERAPEUTIC INDEX. 467 Third and fourth lumbar: sartorius, adductors, abduct- ors, flexores and extensors of thigh. Fifth lumbar: flexors of knee, flexors of ankle, peronei, extensors of toes. First and second sacral: muscles of calf, glutseal mus- cles, peronei, extensors of ankle, small muscles of the foot. Third, fourth and fifth sacral: muscles of the rectum, bladder and genital organs. Paralysis may be associated with loss, perversion or im- pairment of sensation (anesthesia, loss of sensation; pares- thesia, perverted sensation; hyperesthesia, increased sensi- bility). Manipulation and vibration of the spine is capable of influencing thsse conditions. The following list may serve as a guide : Second and third cervical: occipital region and back of neck. Fourth cervical: neck, front of shoulder and outer por- tions of arm. Fifth cervical: back of shoulder, outer portion of arm to the wrist. Sixth cervical: outer portion, front of forearm and back of hand. Seventh cervical: radial side of hand, palm, index and one-half of middle finger. Eighth cervical: ulnar portion of hand, dorsum of hand and inner portion of forearm. First dorsal: inner side of forearm and arm. Second dorsal: inner side of arm near and in axilla. Second to twelfth dorsal: chest, abdomen, upper glutasal region. First lumbar: groin and front of scrotum. Second lumbar: lumbar region, outer and upper portion of thigh. Third lumbar: front and outer side of thigh. Fourth lumbar: inner side of thigh, leg and foot. Fifth lumbar: back of thigh, outer portion of leg and ankle, sole and dorsum of foot. 468 MODERN PHYSIO-THERAPY. First and second sacral: back of buttock and thigh, side of leg and ankle, sole and dorsum of foot. Third, fourth and fifth sacral: anus, rectum, penis, ure- thra, vagina and perineum. Knowledge of these anatomical points enables the phy- sician to make direct application of any suitable therapeutic agent to the spinal centers for the purpose of influencing peripheral manifestations. The osteopaths aim to loosen the muscular structure of special parts of the back and cor- rect the relative position of the vertebrae by manipulation and by Swedish movements. The application of vibration is based on the same principle, although, as far as thera- peutic efficacy is concerned, it is not equal to the osteopathic method of manipulation, the claim of some anxious vibrator- makers notwithstanding. It is always wise to combine vi- bration of the spine with vigorous massage of the muscles of the back and with Swedish movements to engage certain muscles and in this way force motion of the individual ver- tebrae in relation to the contiguous vertebra. The same principles, in a somewhat varied sense, apply to hydro- therapeutic procedures (douches and packs of the back). The direction in which electrical force travels can not be perfectly controlled when applications of a galvanic, faradic, static or high-frequency current to the spine are made. In cases of paralysis and loss of sensation the static spark ap- plied directly to the spinal region is probably the most direct and most effective mode of application. Its action may be peripherally supplemented by sparks or faradic shocks ap- plied to the affected muscle or muscles. For this purpose the rheotome in connection with a faradic current is very serviceable. The wave-current applied to a paralyzed mus- cle by means of one or more pieces of block-tin is very use- ful. The region treated will, by its anatomical location and peculiarities, to some extent determine the exact manner of electro-therapeutic application and technique. To in- crease the nutrition and metabolism in any affected region local applications of a mild galvanic current or a. static spray THERAPEUTIC INDEX. 469 or a high-frequency current may be added. For faradic and galvanic applications one pole should be placed over the point of insertion (or origin) and the other over the belly of the muscle. Electrodes carrying galvanic currents should be shifted about. The average duration of an elec- trical treatment in these cases is fifteen minutes, to be re- peated every day. Sparking should not be done for more than five or ten minutes. Unnecessary irritation of the skin must be avoided. CUNICAL SUGGESTIONS. In treating a case of paralysis the physician should never forget that he is dealing with a symptom and not with a disease per se. He should never lag in his efforts to find the cause. This, of course, is not always possible. General eliminative treatment by means of the dry-heat cylinder, the general cold moist pack, the electric-light bath, will benefit the majority of these cases, especially those that suffer from some form of intoxication. The stomach of the patient should receive painstaking at- tention. (See DYSPEPSIA.) The patient should not be al- lowed to suffer from constipation. The skin must be kept active. In this way the absorption of a clot is promoted, ill-nourished nerves and nerve-centers are stimulated struc- turally and functionally and toxines of all kinds (disinte- gration-products of normal secreta and excreta, ptomaines, derivatives of germ-cultures as in post-diphtheritic paraly- sis, lead in plumbism) are eliminated. There is no doubt that even in cases of paralysis produced by psychic causes the actual etiology of the paralytic state is an auto-intoxica- tion due to disturbed nerve-function and a retention of de- rivatives of normal secretions and excretions. The physio- logical equilibrium of metabolism is disturbed, auto-intoxi- cation is the result, with neuroses of divers kinds as the ex- ternal evidences of poisoned nerves and nerve-centers. If our neurologists, most of whom are satisfied to treat their patients symptomatically and cover up a dearth of diag- nostic exactness with a formidable mass of neurological and neuropathic termini technici, would only learn to return to 470 MODERN PHYSIO-THERAPY. the simplicity of physiological facts and name causes and not concomitant or consequential phenomena ! There was once an old maid in Cincinnati who developed paralysis and was pronounced hopelessly afflicted by a number of prominent physicians, among them three nerve-specialists. She went from bad to worse until an empiric outside of the profession took hold of her case, treated her with massage, a vapor-bath cabinet and a rectal syringe and cured her in less than three months. The therapeutic suggestions given hold good in all cases of paralysis, especially those that are of recent origin and are not produced by a trauma. In cases of long standing structural changes, especially the proliferation of connective tissue and the consequent atrophy or degeneration of the neurons, have taken place, the prognosis is accordingly unfavorable (c. g. in advanced cases of locomotor ataxia). Hysterical paralyses are ac- cessible to suggestive influences in not a few instances. If the paralysis is due to a trauma or pressure of a tumor, foreign body, abscess, etc., the case offers a distinctly surg- ical problem with a prognosis proportionate to the tracta- bility of the cause and the extent of the structural damage already done. In making a diagnosis the actual existence of paralysis must be determined. Incomplete paralysis (or paresis, to use a term frequently employed ) may be in real- ity a weakness of muscular tissue and may be due to some local trouble, e. g. disease of a neighboring joint. The adaptation of the therapeutic suggestions for the general and local treatment of paralysis will necessarily de- pend upon the etiology of the affliction, the seat of the lesion and the varying features of the clinical picture which the individual case presents. By way of recapitulation and specialization the following therapeutic summary is of- fered for practical guidance : HYSTERICAL PARALYSIS. Hygienic measures. Sugges- tion. Regulation of sex-function. General massage. Far- adization of spine. Faradic bath. Faradization of affected part. Isolation of patient and forced feeding are recom- mended bv S. Weir Mitchell. Everv form of static elec- THERAPEUTIC INDEX. 471 tricity can be employed. In many cases the stomach is at fault. (See DYSPEPSIA.) Frequently it is possible to affect hysterical subjects favorably through the special senses. (See chapter on PERSONAL HYGIENE.) The influence of music on patients of this class has often been demonstrated. INFANTILE PARALYSIS. Hygienic measures. General depletent baths or packs. "Derivating" hydro-therapeutic applications. Local massage and faradism are very useful. General high-frequency applications. DIPHTHERITIC PARALYSIS. Elimination through the skin. Diasolenic cylinder. Faradic or galvanic bath. Lo- cally faradism and massage. BULBAR PARALYSIS. Liberal diet, food being introduced per rectum or by means of a stomach-tube. Massage, es- pecially to affected parts. Galvanism to muscles of neck and floor of mouth. Cold douches and static sparks to back and affected portion. In some cases of hyperesthesia the hot douches and a mild galvanic current to the spine are bet- ter borne. Static spray to neck and lower portion of face. Mild vibration to back of neck. ATROPHIC PARALYSIS (PROGRESSIVE MUSCULAR ATRO- PHY). General high-frequency treatments, faradic and gal- vanic baths alternately given. General massage. Locally rest, galvanism or faradism, massage and hot applications. Dry heat cylinder in syphilis and other underlying systemic conditions. Sun-baths. FACIAL PARALYSIS (BELL'S PALSY). Open bowels. Dry heat or electric-light bath. Fresh air. Sun-baths. "Der- ivating" hydro-therapeutic applications. Locally massage, galvanism and faradism. Cupping in front of ear. Static spray. High-frequency current to affected region. PARALYSIS AGITANS. Hygienic measures. Eliminative measures. Nourishing diet. Static insulation. High-fre- quency currents. Locally faradic or galvanic applications (bath or otherwise), high-frequency currents, massage, vapor-baths to affected parts. Vibration, alternate hot and cold douches to spine. 472 MODERN PHYSIO-THERAPY. GENERAL PARALYSIS OF THE INSANE. The general di- rections given above apply with supreme emphasis in this most peculiar and most unfortunate condition. The treat- ment should aim to promote the constructive metamorphosis of the organism. (Hughes.) The proper therapeutic indications for all other forms of paralysis and pseudo-paralysis (paresis) can without much difficulty be deduced from the previous considera- tions and suggestions. In some cases of paralysis the movement cure of Frankel can be employed with success. (See LOCOMOTOR ATAXIA.) Papilloma. (See VASCULAR TUMORS.) Pelvic Adhesions and Exudates. Many chronic dis- eases of women consist of, are associated with and are ag- gravated by the presence of adhesions and inflammatory exudates. The latter are the etiological factors in not a few cases of versions and flexions of the uterus. Adhesions should be broken up by intra-pelvic massage as suggested by Thure Brandt. Reference to this subject has been made in the chapter on MECHANO-THERAPY. Faradization (one pole in the cul-de-sac, the other on the abdomen) frequently enhances the effect, especially in old cases. If pain and a subacute catarrhal condition super- vene, massage is usually contra-indicated. In these cases hydro-therapeutic applications should be made to force de- pletion and absorption. A suitable electrode (positive) in the cul-de-sac (negative pad on abdomen) should be used every other day, galvanism twenty milliamperes for five minutes. The seat of the trouble should, if possible, be brought between the two poles. The application can often be made on the abdomen (positive) and on the back (nega- tive). The older the case, the safer and less discomfort- ing it is to use the negative pole in the vagina as close to the affected region as possible. If the symptoms are acute, the positive pole should be used in the vagina, or, better still, the electro-therapeutic treatment should be desisted from. Cases of old pelvic adhesions have been cured by means of THERAPEUTIC INDEX. 473 mercuric cataphoresis. (For additional information con- cerning the latter see INOPERABLE MALIGNANT DISEASE.) The applications in these cases are made by means of mer- cury-covered electrodes placed in firm contact with a sur- face close to the adhesion to be broken up. Faradization and massage are valuable adjuncts. The same holds good in regard to exudates. If they are old and can be handled without giving rise to pain, intra-pelvic massage should be given to start a reaction. Electro-therapeutic indications as before. In many cases the intra-vaginal use of the high- frequency current is of advantage in helping to regulate the circulation and promote absorption. Massage is practiced by one or two fingers in the cul-de-sac as close to the seat of trouble as possible, the other hand of the operator being used on the abdomen to steady and immobilize the affected region. If the exudate can be plainly felt through the ab- dominal wall, massage and galvanization are easily admin- istered. Vibration locally is of advantage if the exudate is accessible through the abdominal wall or the vagina. Ad- ditional therapeutic directions are given under the head of INFLAMMATION (CHRONIC). Pericarditis. The regime in all inflammatory affections of the heart (pericarditis, myocarditis, endocarditis, peri- cardial effusions) is practically the same. Mental and physical rest are of the utmost importance. Leeches or cup- ping are of advantage in the early stages of the disease. Locally cold applications by means of a water-coil are serv- iceable. They should not be ice-cold. Heat is usually not well borne. Cold moist packs to the lower extremities and other hydro-therapeutic measures to stimulate skin-func- tion and elimination are to be depended upon to sustain the heart and to absorb effusions. The general principles are discussed under the head of PNEUMONIA. The bowels should be kept open and the patient fed on milk and other concentrated food-drinks as suggested in the treatment of acute gastritis. Other therapeutic suggestions are given under the head of INFLAMMATION ( ACUTE) and FEVER. 474 MODERN PHYSIO-THERAPY. Peritonitis. The acute form is usually secondary to some other condition (trauma, sepsis, perforation of intes- tines, inflammation in contiguous territory, etc.) and de- pends, therefore, for its treatment on the management and removal of the cause. Considered independently of any causative or associated condition, its treatment, as far as the general features are concerned, is conducted according to the principles which should prevail in all inflammatory and febrile conditions. (See INFLAMMATION and FEVER.) Rest is imperative. If the bowels are intact, they should be freely and frequently evacuated by enemata. An abdom- inal compress (Priessnitz pack, local vapor-bath) has a depletent effect and is a very useful local anodyne. In many instances the question of treatment may be altogether a surgical problem from the beginning. The chronic form of peritonitis requires rest, depletion by hydro-therapeutic derivation and many other therapeutic measures indicated under the head of INFLAMMATION (CHRONIC). In the tubercular variety X-ray treatment (moderately hard tube, fifteen to twenty inches above ab- dominal wall, five to ten minutes every two or three days) has been recommended by some. High-frequency applica- tions over the abdominal wall are sometimes beneficial, like- wise local galvanization (two flat electrodes, positive on ab- domen, negative on the back, weak current for five minutes every day). The value of fresh air and the actinic rays is shown by the wonderful improvement which at times fol- lows mere opening of the abdomen, enabling air and light to enter. Vibration, massage, and all other violent forms of manipulation are contra-indicated locally, but might be ad- vantageously employed in contiguous territory (legs, back) to stimulate absorption. Pharyngitis. (See TONSILLITIS.) Piffard Rays are produced by a spark-gap lamp devised by Henry G. Piffard, of New York. They are different from the ultra-violet rays, do not affect the silver in pho- tographic plates, but cause a quick and decided reaction on exposed skin. Little is known about these rays. They have THERAPEUTIC INDEX. 475 been used with apparent benefit in cases of lupus erythema- tosus. Pleurisy. The regime is similar to that outlined under the head of PNEUMONIA. Cupping or venesection are of benefit. Strapping the affected side by means of adhesive plaster is indicated as an anodyne. Absorption of effusions is best accomplished by powerful stimulation of the skin- function (general cold moist pack, thermic cylinder, general vapor-bath, as described under the head of FEVER, electric- light bath, Alinin apparatus). For general therapeutic di- rections see INFLAMMATION ( ACUTE) and FEVER. Pneumonia (Lobar). Acute inflammation of the lungs is classified among the infectious diseases produced by a bacterial cause. The specific micro-organism which is sup- posed to be the etiological factor in the disease is the diplo- coccus of Frankel, although the pneumococcus of Fried- lander, the typhoid bacillus, the various pus-germs and a number of other micro-organisms are credited with being capable of producing the disease. The vast difference of opinion makes the specific etiology of pneumonia very doubtful. There are not a few clinicians who look upon the bacterial element as being purely incidental to the in- flammatory process. It is thought that the germs are pres- ent everywhere and at all times, but that they never develop and multiply until inflamed lung-tissue furnishes a favorable culture soil. Inoculation-experiments make the bacterial cause of pneumonia appear very doubtful. That atmos- pheric conditions, draughts, exposure to cold, sudden changes in the temperature are predisposing, if not pro- ductive causes, is admitted on all sides. That it may occur as a complication in .the course of typhoid fever (typho- pneumonia), rheumatism, gout, diabetes and chronic disease of the kidneys, there is no doubt. Pneumonia attacks by preference young, vigorous males. Alcoholism, tobacco- habit and addiction to an exclusive meat-diet make the prognosis very grave, because of the loss of resisting power on the part of the nervous system and the heart. 476 MODERN PHYSIO-THERAPY. Croupous pneumonia (acute inflammation of the lungs) is the classical type of a self-limited disease. In an indi- vidual having ordinary good health, the disease, if left alone, and the ordinary hygienic regime being enforced, ought to run its course and terminate in recovery. There is no acute disease which is more interfered with by meddlesome drug- therapy to the detriment of the patient, than pneumonia. The drugging usually begins at the outstart when aconite and veratrum, strychnine and alcohol are called into requi- sition. In years gone by, venesection was practiced during the first stage of pneumonia. It has become obsolete, al- though its rationale as an antiphlogistic is unquestioned and a good deal more logical than the action of the various medicinal agents which have supplanted it. The loes of blood incidental to venesection has a tendency to lessen the patient's resisting power. Venesection without loss of blood would be the ideal antiphlogistic method. This is what hydro-therapy has given us in the various modes of water-application which are known as "derivating"' meth- ods. "Derivation" (depletion of the congested area) is the alpha and omega of treatment during the first stage of the disease in every case. It has a tendency to abort or jugulate the disease or, failing in this, to render the course of the disease comparatively mild. The onset of pneumonia is usually announced by a tem- pestuous reaction on the part of the system (chill, convul- sions, severe vomiting), followed by a rapid rise in the temperature. Embarrassment of the pulmonary circulation is marked by a rapid but full pulse, quick breathing, short inspiration and long expiration accompanied by a moan, anxious facial expression, pain near the nipple, intense pros- tration, etc. The picture is too characteristic to be mis- taken. The treatment in this condition (I am almost tempted to call it specific treatment) hinges upon the appli- cation of the cold moist pack from the feet to the costal border. The technique of this most useful hydro-therapeu- tic application is clearly set forth in the first part of this THERAPEUTIC INDEX. 477 book under the head of HYDRO-THERAPY. The congested area must be depleted by drawing the bulk of the blood to the lower portions of the body. This is venesection with- out loss of blood. The pack should last an hour and be re- peated two or three times daily. It should be applied with- out disturbing the patient. In some cases it is of advantage to make a cold application to the chest while the first pack is being applied. An ice-cap to the head is useful, especially where head- and brain-symptoms are present. The air in the sick-room should be fresh and pure, not too cold and not too dry. The room should be well-venti- lated, the patient being protected against draught. If the room is cold, a grate-fire can be kept up. The temperature should not exceed 70 F. If the air is too dry, a little water in a pan can be placed over a spirit-lamp and slowly evap- orated. The inhalation of moisture-laden warm air is a splendid means of relieving cough. The room itself should by no means be allowed to become too moist ; 80 to 90 per cent of moisture in the air, as shown by the hygrometer, is desirable in cases of pneumonia, especially if the cough is distressing. After a pack has been removed, a gentle dry rub-down over the whole body should be administered. In this way the skin is kept active. A local hot application is made for the relief of pain in the chest. If after the first two or three packs the general condition of the patient is improved, the temperature reduced and the skin appears moist, the pack may be given from the feet to the neck. Physical and psychical rest is of the greatest importance in cases of this kind. The bowels should be opened by an enema. Gentle massage of the abdomen should be administered from the right iliac space upwards toward the liver, then horizontally across toward the left hypochondrium, then downward toward the left iliac space. In this way distention of the ab- domen is prevented and regular evacuations are promoted. (See DIET IN ACUTE FSVERS.) The regime indicated leaves the patient's heart in good 478 MODERN PHYSIO-THERAPY. condition. The second stage of the disease (exudation, red hepatization) is mostly feared on account of the con- dition of the heart. The most common cause of a lethal result is cardiac failure. The arterial pressure is consid- erable, the strain on the right side of the heart taxes the organ to the utmost. The vaso-motor exhaustion is seen in the relaxed peripheral vessels. This grave condition of affairs is best marked in those cases that have been sub- jected to the action of heart-irritants (stimulants, depress- ants). For this reason the alcoholic subject is notoriously a ready victim of pneumonia. The best argument in favor of non-medicinal treatment during the first stage and the enforcement of a strictly hydro-therapeutic regime is the gradual change in the professional opinions concerning the propriety of any special form of medication. The best clinicians to-day recommend to open the bowels and to ad- minister some therapeutic agent to keep the skin and the kidneys active. The most favorable statistics in pneumonia have been furnished by the hydro-therapeutic institutions in Europe. (Winternitz.) During the second stage of the disease the object of treatment is to keep up the heart and to control hyper- pyrexia. If the temperature exceeds 103, cold sponge- baths should be administered followed by a dry rub. The temperature is not reduced by the cold water, but by the increased activity of the skin which radiates heat-units in response to stimulation. To keep up the heart, the patient should remain in the recumbent posture. Stimulating packs of the lower extremities should be given two or three times daily. A hot application to the feet should be kept up con- stantly. The skin of the lower extremities should be moist. Occasionally a lukewarm sponge-bath, followed by a dry rub, should be given to the lower limbs. During this stage of the disease, judicious use of coffee, tea or of alcoholic stimulants in any form is of advantage. Locally the use of ice-bags has been recommended. ( See reference to this subject under INFLAMMATION.) Recently THERAPEUTIC INDEX. 479 the employment of intense dry heat (thermic cylinder) has been championed. Neither the one nor the other should meet with unqualified endorsement, although the ice-bag seems to meet physiological indications in a certain sense. The objection to extreme heat and extreme cold is clear. Both have a tendency to suspend vital functions in the skin and the underlying tissues. They produce anesthesia by paralyzing the sensory nerves. The effects of either in- tense cold or intense heat on the seat of the disease are illusory. If the temperature in the inflamed lung-tissue can be so lowered or so elevated as to destroy the vitality of the pathogenic germs, the tissue itself would be impaired, because life is not possible beyond certain physiological ex- tremes of temperature. Intense heat continuously applied to the inflamed lung (if such could be imagined) would dis- integrate the aqueous elements of the blood by coagulating the albumen and by destroying the white corpuscles which are supposed to play the part of phagocytes. That the heart is bound to suffer by aggravation of the local reaction, is clear. The thermic cylinder, locally us~ed in pneumonia, seems, therefore, to be of questionable utility. In inflamma- tory conditions of the pleura its use is productive of good results. The employment of the ice-bag in pneumonia is less objectionable. It frequently relieves the local symp- toms, although its exact physiological modus operandi is not quite clear. Both for the purpose of producing a local antiphlogistic effect and also to relieve pain, cupping by means of a vacuum apparatus is frequently useful. A small portable faradic battery can frequently render good service in supporting a weakening heart. Mild fara- dization of the vagus is a splendid heart-tonic. To relieve headache, gentle massage on both sides of the nape of the neck or pressure over the occiput may be resorted to. A moderately cold bath to the face, followed by stroking from the median line of the forehead towards and over the temples on both sides simultaneously is a use- 480 MODERN PHYSIO-THERAPY. ful sedative. In case of threatening' collapse the hypoder- mic injection of normal salt solution should be resorted to. During the third stage of the disease (resolution, gray hepatization) the treatment does not differ from the regime during the second stage. Rest and perfect hygienic sur- roundings should be enforced throughout. Inhalation of oxygen or ozone is of value in many cases. A liberal con- structive diet should be allowed when convalescence has begun. The therapeutic suggestions pertaining to the treatment of acute pneumonia practically contain the therapy of many allied conditions such as congestion of the lungs, edema of the lungs, hypostatic pneumonia, catarrhal pneumonia, etc. In conditions in which, owing to weak heart-action, blood-stasis occurs in the most dependent portions of the lungs, an occasional change in the position of the patient is necessary. Premature Labor. Justifiable abortion can be induced by secondary faradic current (one pole in uterus, other pole on abdomen) for five minutes. Rapidly interrupted galvanic current does as well. Prostate Gland (enlarged). Newman advises nega- tive electrolysis analogous to electrolysis of strictures. Cata- phoresis of K I is advised by some (positive on sacrum, negative on cotton saturated with K I solution to peri- neum). Positive static spray or wave-current to perineum and supra-pubic region is very soothing. Hot vapor sitz- baths and hot rectal injections are useful. Pruritus Vulvae. After enforcing absolute cleanliness of the vagina, an application of positive galvanic electricity (five milliamperes for five to ten minutes every day) should be made. A local positive static spray is very useful. The high-frequency current applied by means of a flat vacuum- electrode is very serviceable. Cold douches to the vulva improve the local circulation and skin-function. The local electric-light bath is very valuable for the same reason. Reflex Disorders. Xerve-function may be disturbed by conditions of auto-intoxication. (See FUNCTIONAL Dis- THERAPEUTIC INDEX. ORDERS.) In addition to this the influence of sense-im- pressions received by the organs' of special sense ( skin, eyes, ears, nose, tongue) is an element of importance in the causa- tion of many so-called reflex disorders. Last but not least, the mind has a controlling interest in the economy. An im- petus received by the mind (psychic impression) or by the organs of special sense is capable of increasing, decreasing and otherwise altering the nutrition and, therefore, the ac- tivity of the nerves. The sympathetic nervous system is the one incalculable factor in the functional potency of the whole organism. Its action is past human ken and specula- tion. It is the eternally personal and soul element in the in- dividual body. It is the one factor which creates the ever- changing variability of subjective disease-symptoms. The sympathetic nervous system is in touch with every fiber and cell in the body. Thus it is that impulses reverberating through its exquisitely fine network may cause sympathetic vibration anywhere and everywhere in the organism. The path along which the impulses travel have as yet not been explored by either chemist or physiologist. As long as they are not, the pathology of most reflex disorders will remain 'a biologic mystery. Inasmuch as many reflex disorders are true conditions of auto-intoxication, the therapy of the latter, as indicated under the head of FUNCTIONAL DISORDERS, is applicable in their treatment. Frequently the so-called reflex disorders are produced by impulses received by the mind and the or- gans of special sense. The mind and the special senses are, as it were, receiving stations through which the nervous sys- tem communicates with the outer world. We know that the organism can be reached through these open gates by im- pulses addressed to the receivers and transmitted by them to the nervous system. It is plain that such impulses, if they are properly applied, can serve a therapeutic purpose. Therein lies the therapy of suggestion and of the different agencies which are capable of acting upon the sight and hearing and the other special senses. 482 MODERN PHYSIO-THERAPY. Suggestion is unconsciously practiced by physicians at all times. It is the one all-important factor that makes or breaks a physician. Let him practice suggestion consciously and for a purpose, not only on the patient but on the pa- tient's surroundings. The control of mind over mind pri- marily, and mind over body secondarily, is the one great psycho-physiological marvel in practical medicine. Inas- much as the so-called reflex disorders represent a vast pro- portion of chronic nervous diseases, suggestion is necessary to control the subtle caprices of nerve-action that mark these reflex-disorders. That physical effects can be produced by suggestion, no one disputes. If it were not possible, the world would never have known anything of so-called mira- cles. The rest-cure, as advocated by S. Weir Mitchell, is a negative illustration of this subject. Absolute rest is en- forced in order to put an end to untoward suggestive in- fluences of surroundings. The special senses can be acted upon for therapeutic purposes in the treatment of morbid reflexes. The sug- gestive influence of colors is undeniable. Whatever we see has color. The nervous system responds to these impulses. Experimentally it has been shown that, beginning with the thermic end of the solar spectrum, the red, orange, yellow, green, blue, indigo and violet radiations have irritating, stimulating, sedative and hypnotic effects, respectively, on the system. Color-effects can be added to the patient's sur- roundings in order to stimulate or quiet the nervous system. The adaptation of the means to the end will depend on the therapeutic requirements of the individual case. Morbid reflexes might be due to the effects of a certain color on the patient's eyes and skin. Charcot speaks of a lady who suffered from a nervous headache which would not yield. The headache became worse when the lady returned to her room, which was decorated with gay colors, red predominat- ing. Charcot suggested to the lady to take another room, with blue wall-paper and plain furnishings. The reflex headache promptly disappeared. The same author speaks THERAPEUTIC INDEX. 483 of the advantage of gay colors in the treatment of certain forms of melancholia. (See chapter on THE THERAPY OF LIGHT.) The skin is not infrequently the origin of reflex disor- ders. The case of a woman is recorded who suffered from enuresis whenever she wore woolen underwear. The enuresis was purely a reflex disorder produced by an irrita- tion received and transmitted by the skin. The necessity of giving the skin some prophylactic and therapeutic consid- eration in the presence of obscure reflex disorders, is ap- parent. The sense of hearing readily receives impressions that react en the nervous system. Therapeutically this has been demonstrated by the effects which sound is capable of pro- ducing on the human organism, both in conjunction with and independent of melody, harmony and rhythm. The therapy of sound (music) ought to receive more serious at- tention than lias heretofore been accorded to it. Its avail- ability in the correction of morbid reflexes has been amply demonstrated. It is not a question of attributing certain effects to a certain kind of music under any and all circum- stances, although there can be no doubt that scientific ex- perimentation will clear up much of the speculative nature of the subject. The character of the existing reflex disor- der and the personal equation of the patient are important factors. A German neurologist was in the habit of admin- istering to his hysterical patients suggestions in the form of suitable musical selections. One woman was suffering from a hysterical paralysis of the lower extremities. The acoustic therapy consisted in the daily rendition of a Strauss waltz played in the most fascinating and suggestive manner every two hours. After two days the spell was broken. The pa- tient danced. In another patient maniacal manifestations were subdued by full chords played softly and slowly in a darkened room. A case of hysteria was relieved of dys- phagia by the Sextette from Lucia and selections of a simi- lar character. Music in these cases is the carrier of the 484 MODERN PHYSIO-THERAPY. suggestive influence. Its availability and power in this ca- pacity can only be appreciated by those who have had oc- casion to witness demonstrations of the efficacy of acoustic therapy. The gustatory and olfactory senses are closely allied to reflex disorders. I know of a physician who attributes at- tacks of sciatica to the odor of certain drugs, notably penny- royal. That the smell of certain flowers is capable of caus- ing depression of the nervous system, even to the point of anesthesia, is well known. That the odors of some flowers, when inhaled by certain persons while asleep, may produce singular nervous phenomena in those persons after they have awakened, has likewise been observed. These effects are reflex disorders due to what appears to be a toxic con- dition of the nerves of smell. Suggestions addressed to the nervous system through the brain or the special senses are agents of unquestioned power in the treatment of obscure reflex disorders. The thera- peutic directions referred to are given in all seriousness. I am not unmindful of the fact that the subject of suggest- ive influence such as outlined above can not be formulated, analyzed and systematized in the strictly scientific manner which modern medicine expects and demands of therapeutic agents. Yet these suggestive agents have unquestioned power, even if the latter is ill-defined and oscillating. The worst that could be said in regard to them, holds good in regard to much of the drug-therapy of torday with its un- certainty of physiological action and its ever-ready psychic efficacy. Rheumatism. That rheumatism is a disorder of metab- olism and that certain predisposing conditions of tempera- ture, climate, environment, diet, habits, etc., are capable of producing it, all physicians are agreed. Objectively it pre- sents itself as the local expression of a general disturbance, or rather as a general disturbance with local expressions. The term "auto-intoxication" in its wide biological sig- nificance expresses the pathology of rheumatism perfectly. THERAPEUTIC INDEX. 485 It is of no consequence whether we look upon this disease as belonging under the acute infections. The pathology of the affliction teaches us that the outward conditions named above and the internal elements of disturbed metabolism are primarily concerned in the causation of the rheumatic state. That germs might develop under these conditions is not im- probable ; that toxines derived from germ-growth might add an element to the sum-total of the symptomatic evidences of the disease is quite likely. The essence of the disease proc- ess, however, is some disproportion in the intake of food and output of waste, using the latter term in its widest physiolog- ical sense. The disproportion arises from the retention in the blood of waste-products of oxidation and the formation and absorption of toxines from the retained excreta. When, through any external agency or cause whatsoever, the nervous mechanism which presides over the assimila- tion of supplies and the expulsion of waste is disturbed so as to be unable to dispose of the ultimate derivatives of the tissue-building foods (principally uric acid and C O 2 ) and excrete them through the natural channels, the result is a re- tention of a part of these derivatives and their products in the system and a consequent condition of poisoning. These poisons may give rise to any number of toxemic conditions depending on the manner in which they attack the organism or any special part thereof. Under suitable conditions this toxemia might present itself in a most tempestuous manner, characterized by hyperpyrexia and severe inflammatory phenomena on the part of certain structures which draw large quantities of secretion from the vitiated blood-fluid and become inflamed as a result (serous membranes .of joints, pleura, peritoneum, pericardium, etc.). Why this selective action of the vitiated fluids of the blood should af- fect certain structures more than others is probably due to the fact that the number of lymph-glands is .proportionately greater near joints, that the veins are tortuous in these re- gions and carry relatively more venous blood, and that, as a result, the effects of disturbed metabolism are more keenly 486 MODERN PHYSIO-THERAPY. felt by the structures surrounding a joint. That the tissues concerned in the functions of motion (joints, muscles) should be more frequently the seat of rheumatism is easily understood when we consider the more active oxidation which is constantly taking place in these structures. The same reason might explain the liability of serous membranes to rheumatic irritation. They are functionally most active. This would be the etiology and pathology of the acute ar- ticular variety of rheumatism, or in a less severe and more protracted form, of chronic articular rheumatism. That these structures are readily affected by other kinds of toxines besides the derivatives of the tissue-building foods, is shown by the irritating action of gonorrheal toxines in the blood, manifesting their presence by the appearance of a gonor- rheal arthritis (gonorrheal rheumatism) in the proximate joints. The toxemia might be of a comparatively mild type and show itself locally by affecting certain regions, muscles or other places of lessened resistance (muscular rheumatism, torticollis, lumbago, pleurodynia, etc.). The toxines may gradually accumulate and attack one joint or two (gout). In the latter condition the activity of gravitation is probably a factor of some importance. Both in muscular rheumatism and in gout the action of the direct, exciting cause may de- termine the character of the attack. Thus in a predisposed subject exposures to a draught might result in a local meta- bolic disturbance affecting the sterno-cleido-mastoid muscle and resulting in a stiff neck (torticollis). In another (pre- disposed) subject the indulgence in pleasures of the table might cause the disturbance of metabolism to explode in the big toe and produce an acute attack of gout. In a third individual the muscles of the back are sore (lumbago) as the result of exposure to cold. The cold draught causes contraction of the cutaneous vessels. The blood is forced into deeper tissues. Stagnation takes place in the deep tis- sues. Waste-products accumulate. The small nerve-fila- ments suffer from the want of fresh blood and are sur- charged with an excess of C Q 2 . The result is the pain of THERAPEUTIC INDEX. 487- Inmbago. If "reaction" had occurred after the forcible contraction of the cutaneous vessels took place in response to a draught, there would have been no stagnation, no ac- cumulation of waste-products, no lumbago. The overtower- ing importance of "reaction" is clear to every thoughtful hydro-therapeutist. Why did not reaction set in after the blood had been foiced into deeper vessels? Why did not hyperemia in the primary area follow? (See chapter on THERAPEUTIC EFFECTS OF HEAT AND COLD.) The presence of uric acid toxines in the blood has impaired the functional power of the local vaso-motor nerves. This is what is meant by rheumatic predisposition. It is the remote cause of the attack while the cold draught is the exciting cause. All this goes to show ( i ) that the various kinds of rheumatism are due to the same cause acting under different .conditions, and (2.) that success in the treatment of all rheumatic con- ditions is in direct proportion to our ability to restore the disturbed metabolism generally and locally. Since, however, the metabolic disturbance consists in deficient oxidation, it is plain that the rational treatment of rheumatism consists in intensifying oxidation and increasing the expulsion of waste. In view of what has been said, we are prepared to look upon rheumatism in all its forms as being due to accumu- lation in, and absorption into, the system of waste-products. It is a common affliction of meat-eaters because of the in- ability of the organism to excrete the uric acid which is in excess. It frequently attacks persons whose circulation is poor. Stagnation of the intestinal excreta may produce it, as shown by the beneficial results of active catharsis in these cases. Not very many years ago an optimist declared colon- irrigation to be a specific in rheumatism. That it has a cura- tive effect in selected cases, there is no doubt. Enough has been said to indicate the principles of rational treatment, to wit: i. Forced excretion and expulsion of waste by powerful stimulation of the excretory organs ; 488 MODERN PHVSIO-THERAPY. 2. Regulation of the physiological supplies to lessen or 1 're vent waste-accumulation ; 3. Increased oxidation to help in the re-establishment of the physiological proportion between the burning of fuel and the expulsion of slack ; 4. To give symptomatic relief while the physiological treatment is in progress. These directions, in a varied sense to meet individual re- quirements, hold good in all rheumatic conditions (acute and chronic articular rheumatism, muscular rheumatism, gout). Therapeutically the modes of treatment might be classified as general or local, according as they aim at correcting un- derlying systemic conditions or relieving local manifesta- tions. For the sake of convenience it might be wise to con- sider gout and the muscular variety of rheumatism sep- arately because they have characteristic clinical features of their own. The management of the inflammatory varieties (acute and chronic articular rheumatism) is practically identical. The advantages of the hospital or sanitarium where all modern therapeutic aids in the treatment of rheu- r.iatism are available, are apparent. ACUTE; AND Cnuoxic ARTICULAR RHEUMATISM. In or- der to accelerate and intensify the expulsion of waste it is, above all things, necessary to open the bowels by repeated irrigation of the colon, or, if the patient can not be handled without causing great pain, by rectal injections. To flush out the kidneys, allow the patient to drink copious quan- tities of fresh, clear water. The latter direction holds good in all rheumatic cases. Water dilutes the offensive waste and helps in the excretion of the latter through the kidneys and through the skin. The sick-room should be light, airy and well-ventilated. Exposure of aching joints to sunlight \\as recommended as early as in the days of Hippocrates. The skin must be stimulated by suitable means. If the pa- tient is totally helpless and can not be handled without great pain, a general hot moist pack can be applied. If tbe weight of the pack is not well borne by the patient, a hot vapor- T ii KR A PHUT ic INDEX. bath should be improvised as suggested in the treatment of cxanthematous fevers. (See FuvER. ) A bath of this kind can be given once or twice daily and may be followed by a pack if the patient stands the copious diaphoresis well. This is shown by the pulse and the respiration. Reduction of the body-temperature after each bath, and a general decline of the pyrexia after a series of baths, are good prognostic signs. If the patient can be handled, nothing equals the efficacy of the dry-heat body-cylinder. The object of a dry- litat bath in these cases is to cause diaphoresis and for this reason the duration of the treatment is of greater moment than the degree of heat employed. Ordinarily 200 to -50 F. for forty-five to sixty minutes are sufficient to pro- duce a complete therapeutic effect. If the patient stands the treatment well, the so-called after-sweat will enhance the therapeutic effect. Ordinarily it is proper to rub the patient down with lukewarm water and add massage over regions which are not painful but are contiguous to the af- fected parts. Dry-heat baths are more trying to a rheumatic subject than vapor-baths and for this reason can not be as frequently administered. The same may be said of the electric-light bath, which is an agent of wonderful power in rheumatic cases, but must be used with great care and discretion. One of these dry-heat or electric-iight baths can be given every day or two. If the weather permits, the l>;itient will derive a world of good from a continued sun- bath. In administering any of the powerful sweat -producing baths, it is wise to inquire into the medicinal treatment vrhich a patient might have had previously. One of these baths is sufficient to cause acute symptoms of iodism or salicylic-acid poisoning if iodides or salicylates have been administered for a few days previous to the diaphoretic treatment. The latter seems to provoke accumulative ef- fects of the drugs. To lessen or prevent the accumulation of uric acid in the system, it is necessary to administer food which will help 490 MODERN PHYSIO-THERAPY. in the oxidizing process without forming 1 much slack. This makes the carbo-hydrates the ideal food-stuffs for rheu- matics. Avoid meat, eggs, beans, peas, salt, pepper, mus- tard, all spices and highly seasoned foods, coffee, tea, alcohol in any form, in fact all foods that are not bland, light and easily assimilated. An excellent food as well as refreshing beverage, sanctioned alike by the advice of all experienced grandmothers and by the clinical records of dietetic insti- tutions, is buttermilk. It can be given at all times and in any quantity, provided the patient's palate or stomach does not rebel against it. Water can be freely given. Sweet milk is an excellent food for rheumatics. On general principles the enforcement of a rigorous exclusive vegetable diet is indicated in all cases of rheumatism. The diet may include vegetable soups (except bean or pea), raw oysters, bread, oatmeal, toast, Zwieback, crackers, rice, milk-pudding, fresh fruit unless excessively acid, potatoes and occasionally, if the patient desires it, a cup of very weak tea, preferably without milk or sugar. The dietetic regime of Schroth known as the "Trocken- kur," has been successfully used in many cases of rheuma- tism. It is discussed under the head of SYPHILIS. In the management of the local manifestations o-f artic- ular rheumatism, i. e. inflamed joints, dry heat is admittedly the foremost therapeutic agent. A cylinder of suitable size is employed for this purpose. The patient is put in a com- fortable position, the part or region to be baked is wrapped in three layers of Turkish toweling, introduced into the dry- heat cylinder, where it rests upon a hammock and the ends of the cylinder closed by means of hoods provided for this purpose. The hot air must not come in contact with any uncovered skin. Any part of the skin exposed to the heat must be properly covered as indicated above. The prepara- tions being thus properly made, the heat is turned on. For local applications of this kind ?oo to 450 F. are suitable and productive of much benefit. Treatments of this kind should last thirty minutes and longer. The physiological THERAPEUTIC INDEX. 491 effect aimed at differs most decisively from that of the gen- eral application in the body-apparatus. Stimulation of skin- function is secondary to the effects of intense heat per se. The object of the local application is to increase the arterial blood-supply and in this way to stimulate the venous and lymphatic circulation. In this way the local metabolism re- ceives a most powerful impetus, the effect being a physio- chemical regeneration of the part. The whole region is heated up, the rise in the local temperature being coincident with more intense oxidation and tissue-change. The sec- ondary effect of active diaphoresis helps to deplete the part and to diminish the amount of inflammatory exudates. The lessened pressure is experienced by the patient as a distinct relief from pain. Treatment of this kind can be given daily and even oftener. After the treatment the part should be allowed to rest for an hour, when it can be subjected to massage or any other additional treatment deemed neces- sary. The technique of dry-heat treatments is of the great- est importance. The occurrence of burns is most deplor- able because it prejudices the patient against further ther- ,mic treatment. Burns of this kind are very stubborn. To prevent burning the toweling, the latter can be prepared by being immersed in the following solution which makes it fire-proof. The solution, which is recommended by C. E. Skinner, is as follows : Thirty ounces of water in which enough tungstate of sodium is dissolved to make a saturated solution. To this add six ounces of water containing two ounces of phos- phate of sodium. The toweling is soaked in this solution, hung up in an oven containing 350 F. until dry. The tungstate precipitate which remains in the fiber makes it fire-proof. Personally I know nothing about this process. With ordinary care thermic treatments can be given without untoward accidents. The electric-light bath is an adequate substitute for the dry-heat cylinder. An hour after the thermic treatment, the affected area, if the inflammatory condition is comparatively mild, can be 492 MODERN PHYSIO-THERAPY. subjected to kneading and centripetal massage. Vibration along the neighboring lymph-channels is of value. In acute cases the affected area should not be manipulated after the thermic treatment. Massage applied to the contiguous structures is permissible and beneficial. In a general way it might be stated that massage and electricity should be re- served for the subacute or chronic forms of articular rheu- matism. Galvanism may be advantageously employed in the sub- acute and chronic form of rheumatism. Place one pole on cither side of the affected part (ten milliamperes for ten min- utes daily). If the negative pole causes pain, place it at a distance. The affected part can be immersed in water, the latter being used as the conductor of the positive current. A static brush-discharge (wooden electrode) and the wave- current answer well in many cases. High-frequency cur- rents have a fine effect on local metabolism. Some recom- mend cataphoresis of lithium salts (positive sponge sat- urated with a solution and applied locally). After a joint has ceased to be painful, massage is of the greatest value. Deep kneading and centripetal stroking will do much towards restoring the part. Faradism is useful to tone up the muscles and prevent loss of muscular power. During the course of rheumatic inflammation of a joint many uncommon features might arise. Locally leeches, cupping, etc., may be required. Ice-applications are harm- ful. The rheumatic condition might involve other struc- tures, especially the serous membranes. Treatment must be adapted to circumstances. At all times, however, the gen- eral regime, as suggested above, must be adhered to, and, if necessary, still more heroically enforced. The results of the physio-therapeutic treatment of rheumatism have robbed the salicylates of much of their glory as alleged specifics. The salicylates do not enhance the therapeutic effects of the agents spoken of, but frequently ruin the stomach and make a chronic case out of an acute attack. Coal-tar products are harmful because they deoxidize the blood by destroying the THERAPEUTIC INDEX. hemoglobin and, therefore, aggravate the general state of the system which made the development of rheumatism pos- sible. Least objectionable are the alkaline waters so fre- quently resorted to as anti-rheumatic remedies, although their therapeutic value is likely to be overrated. They are certainly not equal to the sulphate of magnesia, which by its dehydrating and cathartic action promotes the excretion of waste and the restoration of normal metabolism. In the go n or r heal variety of articular rheumatism the treatment would consist in dry heat locally, active peristalsis, vegetable diet, and suitable therapy to remove the real cause. Bier's stasis has been employed successfully in these cases. Rheumatism (Muscular). The principles of treatment do not differ from those underlying the therapeutic man- agement of articular rheumatism. The greatest value is to be attributed to massage, heat and electricity. In all forms of muscular rheumatism the dietetic regime as outlined un- der the head of articular rheumatism must be rigorously en- forced, the bowels must be kept open and, if the general con- dition of the patient indicates sluggishness, the dry-heat body-cylinder or the general electric-light bath should be resorted to. TORTICOLLIS. Effleurage over the aching stiffened mus- cle, first gentle and superficial, afterwards deep and firm, and followed by vibration, ought to practically cure the pa- tient. If necessary the part can be exposed to the Minin light, the face and healthy part of neck having been covered with towels. The application of the wave-current or the static positive brush-discharge (wooden electrode) is bene- ficial. The galvanic current (positive to affected muscle, negative to other side of neck) or faradic current applied to aching muscle will remove pain and restore mobility. PLEURODYNIA. Treatment is the same as in cases of wry-neck. The larger the area of the affected muscular tissue, the more effective will be the use of the general treat- ment by means of a body-cylinder or electric-light bath. Locally the most remarkable results can be promptly 494 MODERN PHYSIO-THERAPY. achieved by massage and vibration. Immobilization by ad- hesive straps is frequently of value. LUMBAGO. Local application of heat by a small dry- heat cylinder is an excellent anodyne and counter-irritant. Deep massage and vibration with due regard to the sensi- bilities of the patient should be judiciously added. The positive indirect static breeze, the wave-current, the gal- vanic current (positive pole to aching muscles) relieve pain very promptly. All positive applications should be com- bined with deep vigorous massage. Swedish movements to engage the lumbar muscles can be begun after the pain has disappeared. The cold douche to the lumbar region is ex- cellent. Strapping the back by means of adhesive plaster is frequently required in the interval between treatments. Rheumatoid Arthritis (Arthritis Deformans). That this obdurate and destructive disease belongs under the head of true rheumatic afflictions, there seems to be no doubt. It is rheumatism in the trophic nerves of the joints and usually affects rheumatic subjects who have suffered frequent at- tacks of articular rheumatism. The trophic nerves, as a result of the rheumatic infection, are functionally impaired and perverted trophic (nutritional, developmental) processes take place in and near the joints. Some doubt the true rheumatic character of the etiology and point to heredity, frequent pregnancies, bad hygiene, psychic impressions, worry, etc., as causative factors in many cases. The prog- nosis, as far as the local condition is concerned, is bad be- cause the cause is usually beyond reach. Local treatment seems to be of no avail. Improve the patient's general health by sunlight, fresh air, exercise, open emunctories, mild but invigorating diet, etc. The body- cylinder is useful. General high-frequency treatments (cage or diasolenic) are very beneficial. Vibration and static sprays along the spine should always be resorted to. If the local symptoms require it, administer local treatment in keeping therewith and according to the directions which have been given under the head of articular rheumatism. THERAPEUTIC INDEX. 495 Salpingitis. (See INTRA-PELVIC INFLAMMATIONS.) In the chronic form galvanism (positive pole in cul-de-sac near affected part, negative pole on back, ten to fifteen milliam- peres for fifteen minutes every second day) is useful. Gen- eral directions under INFLAMMATION (CHRONIC). Sarcoma. Negative electrolysis (multiple needle). (See INOPERABLE MALIGNANT DISEASE and chapter on X-RAY THERAPY. ) Sepsis (Local). The treatment of an acute abscess or acute localized suppuration is to all intents and purposes a surgical problem. Abscess or localized pus-formations may be large or small. They may be diffused or circumscribed. They may be due to the activity of any number of pus-pro- ducers. Thus the local sepsis may be a stitch-hole abscess, a felon, a furuncle, a carbuncle, a suppurating bubo, an empyema. The predisposing cause of local pus-production should receive the first attention of the physician, e. g. the furuncle in diabetes, the suppurating bubo caused by a chan- croid. The location of the local sepsis determines to a cer- tain extent the therapeutic indications. ABORTIVE TREATMENT. The formation of an acute ab- scess is always preceded by local inflammation. If the seat of inflammation is accessible, e. g. in the extremities, or comparatively superficial, heat is the proper agent to hasten pus-formation or to abort it by causing absorption of the inflammatory material. The small dry-heat cylinder, the hot-immersion bath, the hot moist pack, the Minin light, are serviceable for this purpose. If the seat of the inflammation is very superficial, the positive galvanic pole will often serve to abort suppuration, e. g. in furuncles. If heat ceases to give relief but rather increases pain, it is usually a sign that suppuration has already begun. The indications during the inflammatory stage are discussed under the head of IN- FLAMMATION (AcuTE) and FEVER. The impropriety of in- tensely cold applications to comparatively superficial in- flammations is referred to under the head of APPENDICITIS. POST-SURGICAL TREATMENT. After an abscess has been 496 MODERN PHYSIO-THERAPY. evacuated by incision, the rules of surgical cleanliness should prevail. It should be remembered that Finsen-rays or sunlight have powerful germicidal and restorative prop- erties. TREATMENT OF CHRONIC ABSCESSES. The contents of a chronic abscess gradually lose their infective character. For this reason there is no contra-indication to attempts to en- courage absorption in many of these cases (massage of the contiguous tissues, stimulating hydro-therapeutic ap- plications). If the abscess is open and directly accessible, it can be disinfected with chemical rays (sunlight, arc- light). To start reaction pack the cavity with cotton, moisten the latter thoroughly by allowing it to absorb water and place a wet negative sponge electrode over it, positive pole at a distance, allowing a mild galvanic current to pass for five to ten minutes. Remove the cotton and wash out the cavity. If the cavity oozes or bleeds, pack it with cot- ton, wet the cotton as before, but reverse the polarity, using the positive pole on the cavity. A high-frequency appli- cation to the surrounding part promotes absorption. (See INFLAMMATION (CHRONIC) for systemic therapeutic direc- tions.) Tubercular abscesses in the extremities have been successfully treated by passive congestion (Bier's stasis). Additional information under ULCER. Sex-determination. The sex of an unborn child is not an accidental occurrence, but is determined by factors about which but little is known. Many observers seem to think that semen which has had time to mature will produce boys. Men who are temperate in their sexual life are more likely to have male offspring. Women who are in the open air and exposed to the chemical rays of the sun a great deal, are more likely to bear male children. Parents who are strong meat-eaters are not likely to be very prolific. They usually have but few children, mostly boys. A nitrogenous diet during pregnancy is supposed to favor the development of boys. (Darwin, Brehm, Finsen, Schenck and others.) Conception during the last half of the inter-menstrual period THERAPEUTIC INDEX. 497 is supposed to favor male offspring. The Mosaic law for- bade coitus for seven days after menstruation. This seems to explain the greater proportion of. male children among the Je\\s. Sexual Weakness. If the condition is a part of a gen- eral neurasthenia, treat the latter. (See NEURASTHENIA, HYSTERIA, FUNCTIONAL DISORDERS.) Suggestion is a pow- erful therapeutic agent. Locally the ice-cold catheter (re- flux without bladder-opening) is useful ; also steel sound connected with weak negative galvanic current, positive to the back or feet. Vibrate perineum and lumbar region, cold douches to the spine, especially lower end. Static sparks to perineum and spine. Vacuum treatment of penis, followed by faradization of the organ. Sexual abstinence must be enjoined in every case. Average duration of a daily elec- trical treatment should be ten to fifteen minutes. Singultus (Hiccough). Cold douches to the upper spine, galvanization or faradization of the phrenic (side of neck below ear to epigastrium), vibration over epigastrium. Deep inhalation while deep pressure over epigastrium is be- ing made. Forcible dilatation of the anal sphincter some- times interrupts an attack. Faradism (stomach to back) is serviceable. Skin-diseases. Disorders of the cuticle per se are al- ways parasitic in character (scabies, pediculosis, tinea ton- surans, sycosis, tinea circinata, favus, etc.). In these dis- eases the skin itself is the seat of the disease-process at- tributable to a specific cause which is located in and active in the skin. Disorders of the skin which represent some disturbance of nutrition, development or function and are not due to the presence of an animal or vegetable parasite in or on the cuticle, are always symptomatic of, concomitant with or con- sequential to irritation elsewhere. 'In a few instances this irritation results from the activity of external causes (the use of irritating cosmetics, soap, wearing apparel, bedding and the lack of cleanliness). In the vast majority of in- 498 MODERN PHYSIO-THERAPY. stances, however, the irritation acts from within. Some nu- tritional (metabolic) disorder of the organism or some part of it is the cause, disease of the skin is one of the effects. The skin is the place where the metabolic disturbances may explode. The physiological importance of the skin, its posi- tion anatomically as the protective cover for the whole body, its importance as an excreting organ, its function as the seat of the tactile sense, its share in the heat-control of the or- ganism, its close relation to the respiratory function, its in- tricate structure, all these factors give the skin a position of singular prominence in the economy. It is not surprising, therefore, that the physiological weal and woe of the sys- tem or any part of it should find sympathetic and symptom- atic expression in the skin. The vast majority of the so- called skin-diseases are not disorders of the cuticle per se, but are only the outward showing of something that is wrong within. Under this head are included all the ex- anthematous manifestations, the different forms of ery- thema, the varieties of eczema, the disorders of the sweat- glands, of the tactile corpuscles (pruritus), all inflamma- tory and catarrhal affections of the skin, all hypertrophies, pigmentations, atrophies and new formations of the skin and any of its component parts. It is plain, therefore, that nearly all of the so-called skin-diseases are merely symp- tomatic. Local treatment is frequently futile. Recurrences are common. The reason is that the physician has treated a symptom and not the condition causing it. PARASITIC SKIN-DISEASES. The treatment of all these true diseases of the cuticle consists in the destruction of the parasite that represents the true cause of the disorder. If the parasite belongs to the animal kingdom ( c. g. the acarus scabiei, the pediculus) it should be poisoned just as the larger varieties of parasites, e. g. roaches, bedbugs, rats, etc., are gotten rid of by poisoning. Mercury, sulphur and other chemicals serve an excellent purpose as parasiticides. If the parasite is an anaerobic organism (e said that the process of preparation frequently be- gins in the preceding generation or, still further back. A wretched physique, small, flat chest, poor blood and other evidences of physical inferiority may be the heritage of a human being in whom the sins of its fathers are thus being THERAPEUTIC INDEX. 525 avenged. Scrofula, tertiary or inherited syphilis, rhachitis and many other conditions of bodily wretchedness are the punishment which nature metes out to those who sin against fundamental principles of hygiene. (See chapter on PER- SONAL HYGIENE.) The offender may be an individual, a family, a tribe, a race. The sufferer may be another indi- vidual, another family, another tribe, another race. To save the species,, nature gradually destroys the part. This is the biology of tuberculosis. Tuberculosis is not inherited per se, but all the conditions favorable to its development are. The moment the individual is born, the struggle for existence begins. If the weapons of defense are absent, the doomed victim of a progenitor's misdeeds succumbs. The fittest survives. Marriage is a crime against society if one or both of the contracting parties are consumptives or otherwise physically or mentally inferior. It should be prevented by law. This phase of the subject is a hygienic and economic problem which should be solved now so that the countless unborn in the bosom of the future may live. It is a problem that will never be solved unless man in the aggregate returns *to first principles of hygiene. This would be the crowning effort of civilization in its most exalted sense. The habitat of the tubercle-bacillus is not always in- herited. Sometimes it is acquired or even assiduously cul- tivated. The surroundings, the habits, -the occupation of an individual may prepare a suitable soil. Lung-function may be neglected, resulting in a corresponding atrophy, shrinkage or degeneration of the lung and its container, the bony frame- work. The result would be deficient oxygenation of the blood and a corresponding deterioration of the quality of the whole system. The diminution of the amount of oxy- gen assimilated by the lungs leads to a gradual lessening in the number and quality of the red blood-cells. Thus the resisting power of the system is constantly waning. Alco- holism and other bad habits may add their share to the gen- eral collapse. The soil is ready for the crop of hungry 526 MODERN PHYSIO-THERAPY. scavengers that are being carried in with every breath. The battle for existence has begun. In these cases of incipient phthisis the therapy should begin at the seat of the trouble. The lungs should be de- veloped, the chest-wall be made to expand, the organism should receive its physiological share of fresh healthy blood. This can be accomplished by strict enforcement of the hy- giene of respiration by a rational system of lung-gymnastics. Patients must be taught to breathe and must be given the proper kind of air for this purpose. This is the philosophy of chest-gymnastics in a nutshell. A consumptive must sleep, eat, play, live in the open air. He must under no circumstances be confined where the sup- ply of fresh air is limited. This is rational therapy for the individual and effective prophylaxis for those whose health he imperils by contact. It is admitted on all sides that the prevention of infection is even a greater problem than the treatment of the individual patient. Light, air and water are the victorious phalanx that never loses a battle against pathogenic organisms. They are, as L,. F. Flick, of Philadelphia, Pa., correctly remarks, the natural enemies of the tubercle bacillus. Sunlight and air kill it, the water dissolves it out of its cache, so that light and air may get at it. The bacillus comes out of a host wrapped up in broken-down tissue which serves as a cache. When this broken-down tissue is deposited in a house, it dries and hardens, and the bacilli inside remain alive for a long time. When it is deposited in the open, it is dissolved or dis- integrated and soon becomes devitalized. This is why an en- closure of some kind plays such an important role in the propagation of tuberculosis. In an enclosure sunlight, air and water can not get at the tuberculous matter and it re- mains vital ; out-of-doors sunlight, air and water get at it, and it soon becomes sterile. Houses of one kind and an- other are the ordinary means of spreading tuberculosis. The home is the most frequent means and the workshop the next. This is so because it takes prolonged, intimate con- THERAPEUTIC INDEX. 527 tact with a person, place, or thing that has been intensely contaminated with tuberculous matter to give rise to an im- plantation. The home and the workshop are the two places where environment of sufficient intensity of contamination, and contact of long enough duration for implantation, most readily can exist. Probably three-fourths of all cases of tuberculosis which are conveyed from person to person are contracted in the home, and the other fourth is contracted in the workshop. With the importance of air as a prophylactic agent firmly fixed in our minds we are prepared to understand the mean- ing of inhalation as a therapeutic measure. To exhort pa- tients to breathe deeply while walking in the open air is ex- cellent advice, but' not of much practical value, because pa- tients tire of monotonous and irksome exertion of this kind. We must, therefore, resort to some other means of enforcing deep inhalation. Therein lies the principal therapeutic value of all inhalation-methods irrespective of the agent used (oxygen, ozone, .medicated vapors, etc.). The value lies in the act of inhalation, not so much in the character of the substance inhaled, unless it is the normal physiological lung- food, namely atmospheric oxygen. The inhalation of manufactured oxygen out of an oxy- gen-tank is being advocated by some. Theoretically speak- ing, the inhalation of oxygen ought to be the ideal treat- ment of tuberculosis. It ought to, as it were, supply the missing link in the chain of vital elements which are antag- onistic to the bacillus and its development. More especially ought this to be the case when the expanding capacity of the lungs is being increased by breathing exercises or by thoracic gymnastics. Clinical experience does not confirm this optimism of the theoretical physiologist. The absorp- tion of oxygen is regulated by the physiological oxygen- carrying capacity of the blood. This again is in direct pro- portion to the relative number and quality of the red cor- puscles. It is plain, therefore, that the forced introduction of oxygen into the air-passages does not necessarily produce 52$ MODERN I'IIVSIO-TIIER'APY. an equivalent oxyg-enation of the blood. In order to ar- rive at distinctly physiological, i. c. curative, effects from this method, oxygen must be not only inhaled but absorbed. The blood of a consumptive is wretchedly poor in oxygen, because the elements which carry it are poor in quality and reduced in number. Hence it is clear that the benefits of oxygen-inhalation are to a large extent illusory in character. Then again, there is present in the organism that indefinable element which demands bulk or mass of physiological fuel rather than concentration or extraction. The experiments which have been made with concentrated food-elements as a pure unmixed substitute for food in bulk or mass, apply analogously to the problem of oxygen- feeding. The disap- pointments which have followed these experiments have demonstrated that the human body and the test-tube of the physiologist are alike only in a provisional sense. The lungs demand bulk, not an extracted element. They crave ^ for air, not for oxygen. Yet oxygen-inhalation is not al- together valueless. Aside from being a potent psychic fac- tor it gives the chest a gymnastic training and helps the pa- tient to breathe deeply. What has been said concerning oxygen-inhalation holds good in regard to ozone-inhalation. Ozone is an irritating gas and, for this reason, is not very well borne by the air- passages of the average consumptive. The popularity of the static machine has brought ozone prominently before the professional mind. Every static machine has its ozone- generating attachment, and the enthusiastic owner of such a machine never wearies of extolling the virtues of ozone. That the enthusiasm of these men has given rise to many an extravagant claim in its behalf, it is quite natural to sup- pose. The odor of the gas, not unlike chlorine gas, is dis- agreeable to many persons. Unless the gas is largely diluted with air, it is very irritating and can hardly be borne by the average consumptive. If it is administered in a badly ventilated room, the procedure is of questionable value. Ozone is in no way superior to oxygen as an inhalant, and THERAPEUTIC INDEX. 529 possesses many disagreeable features which oxygen cioes not. After all, it is the mechanical act of deep respiration wherein lies the good of any inhalation method. The mechanical act of deep breathing does the good. The sub- stance inhaled (and there are thousands recommended) is the psychic and persuasive factor. A record of chest-ex- pansion should be kept. Deep breathing must be enforced cost what it may. Nie- meyer had an ingenious system of making his consumptive patients breathe deeply. He divided them into classes. Each class was compelled to go out into the open air and walk slowly until they were tired. Then the members of the class were given a chance to lie down in invalid chairs or ham- mocks and rest. One of the number had to read aloud until another one took his place. Occasionally the whole class had to read, sing, whistle or play on wind- or brass-instru- ments. In this way the lungs were constantly active. The children were allowed to romp over the grounds at pleasure. Those that were too weak were allowed to sit in the open air and make soap-bubbles with straws. No patient's lungs were allowed to remain idle. It makes no difference how inhalation is effected. The principal thing is to enforce it. There is a sanatorium in ^the Black Forest, in Germany, which with due apology to the author of "The Divine Comedy" has a sign over the entrance to the grounds which reads thus : "Walk slowly and breathe deeply, who- ever enter here !" Sudden changes in the temperature of the inhaled air should be avoided, especially if the bronchial symptoms are well marked. DIET. The criterion of dietetic directions is the toler- ance of the individual stomach together with the state of individual digestion. Food should be largely tissue-building but non-stimulating. The best nitrogenous foods for the average consumptive with a fairly good stomach are lean beef, lamb, chicken, milk, eggs, peas, beans, lentils, spinach. The liberal use of whisky, by many thought to be indis- pensable in these cases, should be reserved until the last 530 Moni-ikx I'll YSIO-TIIKK.M-Y. stages of the disease. As a beverage, mild stimulant and tonic, beer is preferable in most cases. Too much care can not be exercised in preserving the stomach and avoiding ir- ritating articles of food. The stomach is the mainstay of the patient. If necessary, the bowels should be kept open by tepid enemata. The diarrhea of consumptives is best con- trolled by irrigating the colon with warm water. In cases that do not show much febrile reaction a non-irritating mixed diet is permissible. Extremes of temperature in foods and all articles that are not strictly foods should be avoided as much as possible (spices, condiments, etc.). A consump- tive should sleep or rest for a half hour to an hour after a meal. If patients can readily digest cold milk, the latter is a good substitute for cold water. In many cases the ap- petite can be stimulated by massage and hot applications to the stomach. The weight of the patient should be watched. Individualization is the key-note of success. PHOTO-THERAPY. Next to fresh air, sunlight is the most vital therapeutic element. When we call to mind the part which the actinic rays of sunlight play in the economy of nature, no further argument is necessary to prove that the treatment of tuberculosis pulmonum without actinic light is unconditionally a hopeless task. To begin with, light regulates the output and consumption of oxygen. It is, therefore, the necessary and all-powerful regulator of oxida- tion, the fundamental basis of all organic life. In addition to this, it is the great and universal disinfectant by whose presence .and quantitative influence the degree of resisting power is determined by which animal and vegetable bodies maintain their integrity in the universal struggle for exist- ence. Germ-life, which requires but little oxygen and is devitalized by atmospheric oxygen, is suspended by actinic light (i) on account of the directly germicidal power of the chemical rays; (2) on account of the affinity of oxygen and light. For this reason the continued exposure to actinic light comes second in point of importance to inhalation of pure oxygen-laden air. The whole body c f the patient THERAPEUTIC INDEX. 531 should be exposed so that the whole body-surface ma)' re- ceive the benefits of regeneration and oxidation. Light coun- teracts the effects of auto-intoxication by encouraging th;* escape of toxines, mainly CO 2 , through the skin, both in the form of gas and vapor, not to speak of the active excre- tion which is coincident with dianhoresis. The use of the concentrated chemical rays of one or more arc-lights is a valuable therapeutic agent. In cases of apical infection concentration of the liorit on the chest-wall directly in front of the seat of infection has been practiced with some degree of success. That the germ is thus killed in its haunts by the direct action of light, is questionable. That the intense effect on the oxidation and general activity of a region so near the nidus of bacterial vegetation is bound to increase the resisting power of the infected parts, is more than likely. While all these photo-therapeutic applications are interesting and not without great therapeutic effect, it must not be forgotten that sunlight over the whole body- surface is the ideal light-treatment. During the summer- months it should be given in the open air. When the weather is cold, the solarium should be resorted to. RADIO-THERAPY. The X-rays promise to be of great diagnostic value. Whether their therapeutic effect in cases of tuberculosis pulmonum is worth considering, is doubtful. The researches of Pott have shown that the tubercle-bacillus resists the action of the X-rays. Even if such were not the case, it must be remembered that the rays from a soft tube do not penetrate, while those from a hard tube lack thera- peutic quality. In addition to this the danger of destruction of relatively sound tissue is not inconsiderable in view of the length and frequency of the exposures which would be re- quired, and the low vitality of the tissues of a consumptive. This seems to be the status of the question at present. For the relief of pain (pleurodynia and pleuritic stitch) the X- ravs seem to render good service. ELKCTRO-THERAPY. Galvanism, faradism and static electricitv have a field of usefulness in the treatment of 532 MODERN PHYSIO-THERAPY. tuberculosis. Within the range of their physiological action they are capable of relieving certain symptoms. Cataphore- sis has received but scant recognition at the hands of electro- therapeutists although its usefulness in suitable cases seems to be beyond question. Mild positive electrolysis in thin persons (one electrode in front, another posteriorly, both charged positively, the negative electrode at some distant point) seems to promise much in view of the affinity of the positive pole for oxygen. The force-modality which prom- ises to become a very important feature of treatment in the future, is the high-frequency current. The reader will re- member the remarkable effects which currents of high-fre- quency are capable of producing on the most vital functions of the whole organism. The ideal mode of application is the use of D'ArsonvaFs cage or the diasolenic body-cylindT. The systemic effects are so marked, even after three or four treatments, that the virtue of this method can not possibly be questioned. To intensify the effects of the general treat- ment and to concentrate the action of the current on the seat of the disease, Oudin's double resonator is the proper instru- ment to use, the patient being comfortably seated between the discharging discs of the instrument, one anteriorly and the other posteriorly. The salutary effects of these applica- tions have been verified by many observers, who kept a rec- ord of the sputum-examinations and of the patient's weight. TREATMENT AS A SOCIAL AND ECONOMIC PROPOSITION. The rational solution of the tuberculosis problem consists in the cure of the infected person and in the protection of those who are not infected. At this advanced day, with all our knowledge of the biology of the disease, the home-treatment of this disease is out of the question. Consumptives must be given a superlative degree of air and light at all times. At the same time they must be removed from places where they can endanger the health of others. This logically places the tuberculosis-problem in the hands of the health-authorities, municipal or, better still, state or, best of all, national. In each county there should be one or more sufficiently large THERAPEUTIC INDEX. 533 tracts of land to accommodate tents and cottages for con- sumptive patients, who must live here among healthful primitive surroundings and under the care of a competent medical officer. A centrally located administration-building, equipped with all modern resources of hygiene and therapy, should be at his disposal. He should be an accomplished physio-therapeutist and bacteriologist. He should not be hampered by lack of funds or assistance, but be given ample sway to carry out modern principles of hygiene and therapy. He should have the authority of the law to back him up in his work and the co-operation of a medical state-board to control the work. Housing a consumptive should be on a par with housing a small-pox patient. The old stereotyped advice of doctors who tell their patients to go to California, Colorado, Mexico or the Carolinas, involves hardships, financial and otherwise, that are hardly in proportion to the good which most of these patients derive. Many a poor sufferer might have remained near his home and received the benefits of rational treatment along the lines indicated. The climatic and atmospheric advantages of the States named hardly compensate for the inconveniences, the dis- comfort, the homesickness and the lack of competent pro- fessional attention which are in store for all but the wealthy. Cincinnati is the first municipality in the United States where a municipal hospital for consumptives is being con- ducted with as much success as the insufficient resources will allow. Patients are housed up in several buildings, but have the advantage of air, light and natural surroundings. By conducting a vigorous educational campaign throughout tiie country, the people might be taught the necessity of system and united effort in the treatment of consumptives and the protection of the non-infected. The National Gov- ernment, through a department of public health, must eventually take hold of this problem. This is the only way in which the nation as a whole can be protected and pre- served. Additional information concerning the clinical features of tuberculosis will be found under the head of 5.U MODERN PHYSIO-THERAPY. FUNCTIONAL DISORDERS, REI ; UCX DISORDERS, AUTO-INTOXI- CATION, and in the chapter on the THERAPY OF LIGHT. Symptomatic therapy is suggested under the head of COUGH, NIGHT-SWEATS, HEMORRHAGE, DIARRHEA, etc., etc. Typhoid Fever is the disease in the treatment of which the earliest laurels were won by strictly physiological therapy. There is not an intelligent practitioner to-day who does not practice physiological methods persistently, at least in the treatment of this one disease. Typhoid fever was at one time one of the most murderous infections, the mor- tality being as high as one death in two or three cases. To- day the mortality is not more than one in twenty cases. This is an achievement of hygiene, diet and hydro-therapy. In conjunction with this statement it is but fair to correct the historical error which gives Dr. Brand, a military surgeon of Stettin, credit for originating a method which he really adopted from Vincenz Priessnitz who taught and practiced the hygienic, dietetic and hydriatic method in the treatment of typhoid fever forty years before Brand published his statistics. In order to understand the rationale of the modern treat- ment of typhoid fever, it is above all things necessary to be familiar with the physiological effects of cold water and the relation of these effects to the fever-process. The state- ment that the febrile condition in and of itself is an element of danger, is not unequivocally true. Fever, as we at this advanced day are ready to admit, is essentially salutary be- cause it is the process of intensified combustion and metab- olism by which nature effects the expulsion of morbid ele- ments and restoration of normal conditions. Those who fear fever, commit the fundamental error of confounding fever and high temperature. The latter is usually the out- ward manifestation of the former. The intensity of the one, however, is not necessarily in proportion to the other. Or- dinarily the body burns up at a temperature of 99 F. If the oxidation of the body is accelerated and intensified, the heat of combustion is greater and the temperature corre- Tr.i.R. \PEUTIC INDEX. 535 spondingly higher. In this sense fever and high temperature are correlative to each other. If the organism has been in- fected with toxic material, direct irritation of the heat-con- trolling centers may result in great variations in the body- temperature. In a case of this kind the temperature would be in no way dependent upon the fever-process. We must remember two facts, /. c. ( i ) fever per sc is not a destructive, but a constructive element ; and (2) fever and temperature are in no sense of the word synonymous. In -applying cold water to the body-surface, the reduction of the temperature is only a secondary consideration, physio- logically speaking. Cold applications are made to bring about a cutaneous anemia. The sudden and forcible con- traction of the blood-vessels of the skin is followed by a reaction consisting in the so-called secondary hyperemia. (See chapter on HYDRO-THERAPY.) The vessels dilate and in this way warmth and increased function of the skin are produced by a primary cold application. Increased skin- function is coincident with more active excretion of morbid material and more intense radiation of heat-units. Thus the temperature is reduced by a lessening of the amount of fever-producing toxines and by elimination of heat. Hence it is absurd to leave a patient in a cold bath until the tem- perature drops. This plan is based on an amateurish con- ception of the action of cold water in typhoid fever. Cyano- sis, collapse arid even death have followed this misinter- pretation of hydro-therapeutic principles. The best illustra- tion of the principle involved is furnished by the antipyretic effect of the warm and even the hot bath. In cases where the system is much depressed and cutaneous reaction is un- certain, the warm bath is a safer water-application. The cutaneous vessels are directly affected and the activity of the skin is at once stimulated. Excretion (by gas, vapor or sweat) begins and the temperature drops. The continued ap- plication of cold to the skin can not be too emphatically con- demned. Suddenly induced anemia of the skin must always and promptly be followed by increase in the cutaneous circu- 536 MODERN PHYSIO-THERAPY. lation and stimulation of skin-function. Any hydro-thera- peutic measure that fails in this, is wrong in principle and incorrect in practice. This holds good, not only in typhoid fever, but in all conditions characterized by high tempera- ture. Let us remember that sweat is concentrated heat. A continued fever like typhoid fever should be watched with the aid of the thermometer. If the temperature is not more than 102 F. one or more cold sponge-baths daily are sufficient. If the temperature exceeds 102 F., the ap- plication of a general cold moist pack for forty-five minutes to an hour is indicated. One of these Priessnitz packs every day is sufficient if the temperature is not higher than 102 F. If the temperature rises within three hours after the pack, another application should be made or the patient subjected to immersion in a tub (Brand's method). In cases charac- terized by continued high fever it is excellent practice to give three packs daily and an immersion (tubbing) in the interval, unless the patient shows signs of great weak- ness, when the cold sponge-bath (either by direct applica- tion of a towel or sponge or by rubbing the patient through a cold moist sheet in which he is enveloped) should be sub- stituted. Tubbing can be done, especially in children, by wrapping the patient in a dry sheet, grasping the latter be- low the feet and above the head of the patient, and grad- ually lowering patient, sheet and all, into the water. Undue excitement and exhaustion are centra-indications. If cu- taneous reaction is sluggish or imperfect, warm and even hot water should be used. Sometimes alternation of heat and cold is indicated. In this way the antipyretic effect can be combined with powerful stimulation. At all times it is of vital importance to be able to individualize. Brisk rub- bing of the skin during and after a cold bath is an effective way of promoting reaction and preventing collapse. In cases characterized by headache and severe brain-symptoms the cold moist pack gives considerable symptomatic relief, delirium, stupor, subsultus, etc., being lessened. Persistent headache may call for cold applications to the THERAPEUTIC INDEX. 537 head and hot applications to the feet. In cases which are treated with the general cold moist pack this is hardly ever necessary. Abdominal symptoms (tympanites) may require a local cold moist pack to the abdomen. Diarrhea is usually controlled by starch- water or rice-water injections. Con- stipation is best treated by means of rectal irrigation. Bed- sores should be prevented by cold ablutions and the use of air-pillows. The sick-room should have a wealth of air and light. The temperature in the room should be 65 F. or a trifle higher. Mental rest is imperative. The bed should be kept scrupulously clean. Feather-beds are an unhygienic nuisance. The ejecta should not be allowed to remain in the room. The food is to be regulated according to the directions which are given under the head of DIET IN ACUTE FEVERS. From the end of the second week the diet is of great significance. Food should be small in quantity but liberal in quality. Stimulants like coffee or alcohol are in- dicated in cases of great weakness. Patient should not take solid food until the temperature has been normal for at least two weeks. Peritonitis is a serious complication, but not necessarily fatal. It should be treated by "derivating" packs applied to the abdomen and to the lower extremities. Perforation is fatal unless the opening is closed by agglutination or by surgical means. Owing to the ajmost invariably fatal char- acter of perforation, abdominal section under these circum- stances offers the only prospect, and is, therefore, justifiable. Symptoms and complications must be met pro re nata. The principal feature in the management of a typhoid-fever case is the hydro-therapeutic treatment of the febrile condi- tion. All else pales into insignificance. Proper hygienic and dietetic regulations are taken for granted. The nurse in charge of the case is the one overtowering figure in whose hand the weal and woe of the patient are placed. Without intelligent co-operation and a strong will on the part of the nurse, the most modern treatment planned by the best phy- 53S MODKRX PHYSIO-THERAPY. sician will avail nothing. For this reason the modern hos- pital is by all odds the best place for typhoid cases. (For further information concerning symptomatic features and complications of typhoid fever see HEMORRHAGE and other special subjects.) Ulcer (Chronic). To overcome the indolence of a broken surface and encourage the formation of healthy granulations, the surface should be exposed to the actinic rays (sunlight or Finsen-apparatus) as often and as long as practicable. Once every day, or every other day, the ulcer should be exposed to the Minin light (heat-rays to increase arterial blood-supply and local metabolism). If this regime is persistently carried out, healing will promptly take place. Exuberant granulations can be removed by simple positive electrolysis or by metallic electrolysis (copper, zinc or mer- cury-amalgam, positive electrode to ulcer) or by a sun-glass. A negative static spray is useful. High-frequency applica- tions produce most happy results in many cases. The greater the spark-gap between ulcerated surface and elec- trode, the more intense the local reaction. X-rays are fre- quently effective (soft tube every other day for five to ten minutes at short range). Prolonged immersion in hot water is of value if the ulcer is on the arm or leg. Immersion of the whole limb is proper. These directions hold good in all forms of chronic ulceration. In many cases attention to the general condition of the patient is essential. Locally the rules of surgical cleanliness should be enforced. United States (Climate, etc.). Change in the sur- roundings of a patient is often a therapeutic measure of great significance. In order to adapt the new surroundings to the needs of the individual patient's condition, knowl- edge of the climatic and other peculiarities of different sec- tions of the country is essential. The following practical classification is quoted from Cohen's "System of Physio- logic Therapeutics" (Blakiston, Philadelphia) where more detailed information will be found. The list includes Canada, the United States, Mexico and neighboring islands. THERAPEUTIC INDEX. 539 MARINE CLIMATES. Warm sedative: Bermuda, the Bahamas, the West In- dies. Moderately cool: The channel islands of California. Cool stimulant: Long Island, Nantucket, Martha's Vineyard, Cape Cod, the Isles of Shoals. Cold stimulant: Newfoundland, Cape Breton, Nova Scotia, Campobello, Mount Desert. COAST CLIMATES. Warm sedative: The shores of South Carolina, Georgia, Florida, Gulf of Mexico, San Diego, Coronado. Cool stimulant: New Jersey coast, Lakewood, Long Island Sound, Narragansett Bay, western end of Cape Cod, north shore of Massachusetts, coast of New Hampshire and Maine, San Francisco. Cool sedative: Portland, Ore.; Tacoma, Seattle, Olympia. INLAND CLIMATES (low elevation, 0-1500 feet). Warm and moist: Louisiana, eastern and central Texas, Mississippi, eastern Arkansas. Warm and dry: Aiken, S. C. ; Thomasville, Ga. ; Phoe- nix and Salt River Valley, Yuma, Ariz. ; Redlands, River- side, San Bernardino, Pasadena, San Gabriel, Ojay Valley, Cal. ; lake districts of the interior of Florida during the winter. Moderately warm and dry: Pine region of New Jersey in the summer months. Desert climate: Mojave desert. Cool ami moist: St. Lawrence Valley, northern Califor- nia and western Oregon and Washington (not on the coast). Cold and moist: Winnipeg, Port Arthur, Sault Ste. Marie, Duluth. Cold and moderately dry: Southern Minnesota, North and South Dakota, Muskoka Lake region in Ontario, south- ern counties of New York and adjoining counties in Penn- sylvania, pine region in Wisconsin and central Michigan, 540 MODERN PHYSIO-THERAPY. northwestern Connecticut, Berkshire district in Massachu- setts. INLAND CLIMATES (moderate elevation, 1500-4000 feet). Warm and dry: Mesilla and Lower Pecos Valley, Las Cruces, southern New Mexico, Guadalajara, Monterey, southern Arizona, southeastern California near the Sierra and coast ranges. Moderately warm and dry: Asheville, N. C. Cool and dry: Eastern Oregon and Washington, valleys of Idaho and Montana, southern Wyoming, El Paso, Texas. Cool and Moist: Adirondack Mountains, White Moun- tains, Mount Kineo, Me. ; Eaglesmere, Pocono, Pa. ; Deer Park, Md. ; western Virginia and North Carolina. INLAND CLIMATES (high elevation, over 4000 feet). Warm and dry: Northern New Mexico, central Mexico, southern Colorado, northern Arizona. Cool and dry: Denver, Colorado Springs, Manitou and mining regions of Colorado, Montana and Idaho, Yellow- stone Park, Lake Tahoe, Nev., Glacier, Field, Banff, Cal- gary, Rossland, B. C. Cool and moderately moist: Roan Mountain, N. C. ; Mountain Lake, Va. Uranium is found in metallic ores containing pitch- blende (uraninite), the latter being a compound oxide con- taining 8i^< per cent of uranium, 4 p. c. of lead and l /2 p. c. of iron with oxygen and water, and sometimes magnesia, manganese or silica. Pitchblende is found in Bohemia, Saxony, Cornwall (England) and in Colorado. Prof. Henri Becquerel, of Paris, discovered in 1896 re- markable radiations emanating from uranium and, through his discovery, established the phenomenon of "radio-ac- tivity" as a scientific fact. The radiations from uranium are known as "Becquerel rays." In investigating Becquerel radiations from uranium Prof. Pierre Curie and his talented wife, Mme. Sklodowska Curie, in 1898 extracted a substance from uranium which had four times the radio-active power of metallic uranium. THERAPEUTIC INDEX. 541 The new substance -was called POLONIUM in honor of Mme. Curie's native land, Poland. In the same year the Curies found another radio-active substance in pitchblende and called it RADIUM. It requires 5,000 tons of uranium-residues to produce approximately two pounds of radium. What therapeutic significance is to be attached to radium future developments will show. It has been used in cases of superficial tuberculosis with ap- parently good results. In superficial cancer radium has been of service in a few authenticated cases. The author has verified the analgesic effects of radium in several cases of malignant disease. Caspari's experiments have shown that radium possesses marked germicidal properties. It suspends the vitality of the micrococcns prodigiosus in about three hours. In 1899 Debierne extracted another radio-active sub- stance from uranium and called it ACTINIUM. Its rays are deviable. Another radio-active substance extracted from uranium is THORIUM. In point of radio-active power it ranks next to radium. The radio-activity of uranium is the unit of measure- ment. Radium, if it has a radio-activity of 7,000, possesses 7,000 times the radio-active power of uranium. Reference to this important subject is made in the chapter on FORCE AND FORCE-MODALITIES. For detailed information on ra- dium and other radio-active substances the reader is re- ferred to an excellent monograph on the subject, written by Wm. J. Hammer, of New York. Uremia. The therapy consists in active elimination (hot bath, dry heat, hot packs, colon-irrigation, catheteriza- tion, cupping or leeches over the loins, venesection). For additional information see BRIGHT'S DISEASE; (CHRONIC). Uterine Inertia. Faradism up to the point of tolerance, one pole in utero, the other on the abdomen or over lumbar region. A bi-polar vaginal electrode is useful. Massage of fundus. Also applicable to post-partum. hemorrhage. 542 MODKRN PHYSIO-THERAPY. Vaginismus. In addition to forcible dilatation the vise of a mild faradic current (very rapid interruptions) is indi- cated as a muscular tonic. If local nutrition is poor, a mild galvanic current is preferable (current reversed frequently). These applications are made by means of a vaginal electrode, one pole on the abdomen. A bi-polar vaginal electrode is sometimes useful. Applications every day or two for ten minutes or more. Intra-vaginal vibration is effective in some cases in which the spasm is of local origin (derange- ment of local sensory nerves). A soft-rubber attachment of suitable thickness should be employed. Local hot vapor- baths followed by cold douches have an excellent effect. Valvular Diseases of the Heart. The condition of one or more of the heart-valves may be one of insufficiency giv- ing rise to a regurgitation (backward flow) of the blood. Thus there may be mitral, aortic, tricuspid or pulmonic in- sufficiency and resulting regurgitation. The valve-openings may be narrowed by cicatricial formations, deposits or veg- etations producing a condition of stenosis causing a partial obstruction to the blood-current. Thus there may be mitral, aortic, tricuspid or pulmonic stenosis and resulting obstruc- tion. Familiarity with the anatomy of the heart and the physiology of the circulation is necessary in order to under- stand the peculiar changes in the heart itself and the sec- ondary effects on the circulatory system which follow in- sufficiency or stenosis of one of the heart-valves. These changes are subsequent to the crowding back of the blood- mass, and as a result the increase of blood-pressure in a retrograde direction and the alterations in the whole cir- culatory system. Nature tries in conditions of this kind to stay the inevita- ble result by fortifying the weakening heart-muscle. In this way the disturbed relation of arterial and venous pres- sure is temporarily restored. The heart-muscle increases in size to meet the demand for more pumping power. The changes in the structure of the heart are the so-called com- THERAPEUTIC INDEX. 543 pensatory hypertrophies. They represent Nature's attempt to prolong the life of the patient. The therapeutic indications in all cases of valvular dis- ease of the heart are necessarily similar because the ef- fects of all valvular regurgitattons or obstructions are prac- tically identical. In the case of a regurgitation, we are deal- ing with a decrease in the pumping power of the central circulatory organ. In the case of an obstruction, the pump- ing power per sc is unimpaired, but the caliber of a main- pipe is reduced. In either case the proportion between the quantity of blood in the pulmonary circulation and in the general circulation is disturbed. Stagnation is the result with uneven distribution of the blood-mass in the different parts of the circulatory system. The lungs are overfilled, the flow of the blood in the large veins of the general circu- lation becomes more and more sluggish, more blood is crowded back, while the blood coming from the lungs or en- tering the aorta becomes less and the arterial pressure in the system at large is gradually reduced. The pulmonic hyperemia causes dilatation of the pulmonic vessels, espe- cially of the capillaries surrounding the alveolar spaces. Eventually the delicate capillaries can not resist the pressure of the constantly increasing blood-mass. Rupture of capil- lary vessels, a hypostatic congestion and catarrhal conditions are the result. The chronic hyperemia causes hyperplastic and hypertrophic changes in the tissues. The lung- parenchyma increases in size, connective tissue proliferates and a cirrhotic or fibroid condition of the lungs is the result. The stagnating blood-mass increases the pressure in the venous circulation of the liver, the spleen, the pancreas, the kidneys, in fact all the organs of the body. Chronic passive hyperemias in these organs, especially in the kidneys and im- pairment of the secretory and especially the excretory func- tion cf these organs are the result. The lowered heart's action and the pressure of the sluggish venous circulation produce capillary stagnation throughout the system. Owing 544 MODERN PHYSIO-THERAPY. to the defective excretion there is a retention of liquids in the body, causing distinct liquefaction of the blood. The aqueous elements of the blood pass through the vessel-walls in large quantities and enter the connective tissue causing edematous swellings. The natural history of valvular heart-disease as outlined above contains the therapeutic indications. The objects of the treatment should be to diminish the quantity of fluids in the body (depletion of the pulmonary and the general ve- nous circulation, unloading the heart and the kidneys) and in this way to re-establish as far as possible the proportion between arterial and venous pressure and thus counteract the pathologic changes in the different structures and or- gans of the body. These effects represent the physiological purposes of ra- tional therapy in the treatment of organic diseases of the heart. In this respect the physio-therapeutic methods oc- cupy a commanding position because they are directly adapted to the working out of these mechanical problems. The physiological effects of diminution of the liquids of the body concern primarily the vascular system. The less- ened amount of the blood which circulates in and through them causes the vessels to accommodate themselves to the diminished blood-mass and blood-pressure. As a result the vessels contract unless the walls of the vessels have by long- continued intra-vascular pressure lost their tone. This is the case in the last stages of circulatory disease. After forced abstraction of fluid from the body, the physiological equilib- rium can be maintained by regulating the amount of the fluids which enter the body (drink). The secondary effect of forced abstraction of fluids from the body is the absorp- tion of the serum which has accumulated in the cavities of the body and in the connective tissue (dropsy). Systemic exercise is of superlative value as an agent for the reduction of liquids in cases of organic heart-disease. The Swedish method consists in thorough massage and pass- ive movements of all parts of the body administered every THERAPEUTIC INDEX. 545 day or two. This plan is applicable in weak patients or during inclement weather. It must be carried out in a thor- ough and systematic manner to be of any avail. Slight im- provement usually follows after two or three weeks of treat- ment. The Nauheim plan was evolved from the Swedish method. It consists in massage and in the systematic ap- plication of mild concentric and excentric Swedish move- ments. The patient's strength must not be taxed. Resist- ance must be slight and never carried to the point of fatigue, dyspnea or palpitation. Individualization means everything in these cases. The patient is treated every day, massage and movements being properly measured and alternated. In addition thereto baths in saline water and other hydro- therapeutic measures are employed to stimulate the skin and aid in the eliminative process. M. J. Oertel, whose excellent monograph on this subject should be read by every physician who attempts to treat heart-disease, advises active exercise and gives explicit directions concerning respiratory gym- nastics, which are accentuated by the patient walking up hill. The patient is made to take ten or twelve steps ascending a hill and then instructed to rest in the standing posture. In- spiration is long, deep and forcible, while expiration is short and rapid. Excretion through the lungs and through the skin is increased and the exchange of gases in the lungs becomes more nearly normal. Oertel supplements thera- peutic mountain-climbing with inhalation of compressed air. The object of the latter is the mechanical expansion of the lungs after the decrease of aqueous elements has begun. After four to six weeks of respiratory gymnastics as out- lined above, inhalations of compressed air four or six times daily, thirty minutes each time are given, beginning with i-ioo atmosphere and gradually increasing the pressure. The treatment must be continued for months and years. The degree of blood-pressure in the veins depends largely upon the position of the body as a whole, the posi- tion of the several parts of the body and the relative state of contraction and relaxation of the muscles. Pressure is less- 546 MoDKKX I'lIVSIO-TlIKKAPY. ened by putting the body in the horizontal position. It would appear, therefore, that the best effects can be pro- duced by putting the patient on his back and administering deep centripetal effleurage. Passive movements of the ex- tremities should be added to enhance the depleting effect. This is a -good mechano-therapeutic measure for advanced cases and where the application of Oertel's method is not practical or practicable. Vibration can be added to accentuate the effect of mas- sage. Vibrate centripetally along the course of the large venous trunks in the extremities. If compensation is good, vibration over the precordial space improves the quality and retards the rate of the heart-beats. Central stimulation along the upper dorsal vertebrae is useful in many instances. Vibratory treatments should not be too long continued. Hydrortherapy and thermo-therapy are powerful agents in the treatment of organic heart-diseases. In careless or reckless hands they are dangerous agents. If properly used, their value can hardly be overestimated. They help in the slow dehydration of the system which should be the first aim in the therapy of heart-lesions. The large thermic cylinder is, in my estimation, a most valuable adjunct. Its use should be mild and be adapted to the features of the individual case. It should be used as a gentle diaphoretic agent once or twice a week. The temperature need not exceed 200 F. The patient should perspire without much heat or depression. General massage should always be administered after a sweat-bath of this. kind. Instead of the the"rmic cylinder, the general electric-light bath, the warm vapor-bath, the warm sitz-bath or hot sparks to the lower portions of the body, might be made use of. Cold applications are contra-indi- cated in heart-cases on account of the sudden congestion of the deep vessels coincident with the primary cutaneous ane- mia which is produced by cold packs, etc. (See chapter on THE Usrs OF HEAT AND COLD.) The heart might not be equal to the suddenly imposed tasks of increased function. The benefits from gaseous baths as given at Nauheim are largely suggestive. THERAPEUTIC INDEX. 547 All the therapeutic agents named, especially active move- ments and dry heat, are contra-indicated in cases of imper- fect compensation, of dilatation, atheromatous degeneration of the vessel-walls, arterio-sclerosis of the heart and blood- vessels. They are only applicable when the vessels are in fairly good condition and the heart is protected by a com- pensatory hypertrophy. Inflammatory conditions of the heart are a contra-indication to precordial vibration. The patient must be enjoined to avoid anything and everything that might tax the working power of his heart, c. g. excitement, fright, exertions, sexual indulgence, etc. All the energy of the patient, especially in the advanced stages, should be therapeutically utilized. Regulation of the patient's diet is very essential. The quantity of liquids must be reduced as much as the patient will stand. This is in keeping^ with the idea of dehydration of the system, which Oertel considers the alpha and omega of therapy in these cases. Alcohol and tobacco should be avoided. Meat can be allowed in moderate quantities if the stomach will stand it. In the first stage of valvular dis- ease of the heart a consistent vegetable diet is physiologically indicated to aid in the process of oxidation and prevent waste-accumulation. In the advanced stages the adminis- tration of tissue-building foods is necessary. (See FATTY DEGENERATION OF THE HEART.) The colon should be irri- gated every second or third day with the patient lying down on the left side. The general management of a case should include all the hygienic necessities that people ordinarily are apt to ignore. Sun-baths help to dehydrate the system. Pleasant surroundings and agreeable mental impressions preserve the vitality of the nervous system. It must be remembered that valvular heart-disease per se is incurable. The object of the therapeutic directions given is to establish a modus I'i'i'cndi that will enable the patient to live as long and as comfortably as is possible under the circumstances. The pa- tient is on the down-grade. If he follows the plan outlined 548 MODERN PHYSIO-THERAPY. he will postpone the inevitable and render his life more agreeable to himself and more useful to his surroundings than he could if he fails to adapt his mode of living to the requirements of his condition. The habitual use of so-called heart-tonics, heart-stimulants, etc., can not be too emphat- ically condemned. (Oertel.) Their use is analogous to the whip by which a wind-broken horse is made to run until exhaustion of the vital forces causes it to collapse. Digitalis, spartein, strophanthus, glonoin, etc., undoubtedly produce a display of increased energy on the part of the heart, which tact makes them available as ready means of bridging a patient over a momentary weakness. Their use is in such a case the lesser of two evils. To employ them in the regu- lar treatment of these ailments is purely symptomatic treat- ment and physiologically not justifiable. The treatment of circulatory disturbances must be centrifugal. Regulate the circulation in the vascular system and you will regulate the heart. The drug-dispensing empiric proceeds rice versa, i. e. in a centripetal direction. He whips up the heart in order to adjust irregularities of the vascular system. He whips up the kidneys by diuretics in order to prevent waste-retention, which is the physiological sequence of the disproportion in the arterial and venous pressure in the kidneys. It may be more convenient to proceed in this manner, but it certainly is not on the level of physiological knowledge which the researches of Leyden, Pettenkofer, Schott, Funke, Seguin, l.andois and others have given us on the subject of the physiology of the circulatory apparatus. A number of electrical modalities can be advantageously employed in valvular disease of the heart. Systemically the high-frequency current is of the greatest benefit (D'Arson- valization). It can be applied locally by means of a vacuum- tube to the dorsal section of the cord and to the sides of the neck (vagus). Galvanization or faradization is useful in impending heart-failure. The positive sponge-electrode is placed below the ear, the negative over the heart and moved about. The current should be mild, and, if it is a faradic current, rapidly interrupted. Static electricity can be ad- THERAPEUTIC INEEX. 549 ministered by means of insulation (positive sedative, nega- tive stimulating), negative spray to spine (stimulating), general positive spray (sedative). The electric water-bath is beneficial, but requires great caution. Exposure of the precordium to Minin rays frequently has a prompt anodyne effect. The details of treatment depend to a large extent on the features of the individual case. The suggestive influence of the physician is a powerful factor in preparing the soil for physiological treatment. Much will depend on the func- tional integrity of the stomach. It should be preserved and protected at all hazards. Keep the mind of the patient off his physical condition. For this purpose a change of sur- roundings is often advantageous. The beneficent effects of the Nauheim treatment, with all due regard for the impor- tance of mechano-therapy and hydro-therapy, are in no small measure attributable to the suggestive influence of the place itself, a veritable paradise on earth, about which hover the traditions of the thousands of invalids who have thither wended their weary way to find hope and health in the ro- mantic pine-forests of the Taunus and its world-famed health resort. Varicose Veins. Locally, attempts should be to lessen the pressure of the venous blood (horizontal position, elastic bandage). Centripetal massage is valuable. Begin half- way between hip and knee and force the venous blood into the abdominal cavity. After five minutes' massage start at the knee, a few minutes afterwards below the knee, etc., the object being to empty the veins above in order to make room for the ascending venous blood from below. Massage must be gently and carefully executed and should be followed by a warm compress to stimulate local metabolism. Large varices should receive special massage. Instead of the pack a negative static spray can be given for ten minutes. The general treatment should include abdominal mas- sage, irrigation of the colon and a strictly vegetarian diet (See AUTO-INTOXICATION.) 550 MODKRN I'lIYSIO-TllKKAPY. Varix. Insert positive platinum-needle in the vein, negative pole near by, galvanic current, ton milliamperes for five to ten minutes. When clot has formed, reverse the cur- rent to loosen the needle. Cleanliness is essential. Vascular Tumors. Positive electrolysis (see first part of the book) is commonly used in the removal or rather in the destruction of angiomata, birth-marks, cirsoid aneurisms, varices, nodules and dilated vessels in acne rosacea, moles, polypi, fungi, warts, verrucse, and wine-marks. One or more needles are used, depending on the depth and extent of the lesion. The object of positive electrolysis is to oblit- erate the small arterioles. Bennett recommends the appli- cation of a positively charged small wet cotton or sponge pad after using sodium- chrom-ethylate on the -surface, negative pole near by, five to ten mil- liamperes, five to ten minutes every week. Xeis- wanger advises introduction of several needles by means of a multiple needle-holder connected negatively, positive pole near by or in patient's hand, application to be continued un- til considerable blanching around the point of needle-punc- ture has taken place. This is negative electrolysis. The same autnor advises the use of a negative needle introduced below the epidermis parallel to the skin until blanching oc- curs. Several punctures of this kind can be made during the same sitting. If the vascular element predominates, posi- tive electrolysis is preferable. In ordinary warts and other growths largely composed of cellular and fatty tissue, nega- tive electrolysis is given preference. X-rays have been used successfully in the treatment of wine-marks and other telangiectatic conditions. Applica- tions are made with soft tube, five to ten minutes every other day until local reaction shows. Finsen-rays cause pigmenta- tion in the naevoid surface, thus substituting a yellowish dis- coloration for the red mark. To produce this effect an arc- light of fifty amperes and more must be used. Cases of wine-marks have been successfully treated by thermic solar rays, concentrated by means of a sun-glass. In using posi- tive or negative electrolysis, much depends on the technique THERAPEUTIC INDEX. 551 of the operator, who must be careful not to cause too much destruction and subsequent disfiguring cicatrization. Versions of the Womb. Principles of treatment sim- ilar to those mentioned under the head of FLEXIONS. Re- moval of the cause is paramount (inflammatory conditions, exudates, adhesions, etc.). Pessaries are obsolete. Mas-, sage and faradism are the most valuable agents after in- flammatory symptoms have subsided. Vomiting of Pregnancy. Galvanization of the vagus (side of neck below ear to intra-clavicular space) or phrenic (side of neck to epigastrium) is beneficial. Positive static spray to stomach and spine. Vibration to side of neck, stom- ach and dorsal vertebras is useful. (See REFLEX DISOR- DERS.) X-ray Burns. Moist warmth or heat seems to possess considerable palliative and curative virtue. If the "burn" is on the arm or leg, continuous immersion of the extremity in warm water is by far the most effective treatment. X-ray Coil (portable). Diagnostic X-ray work will never serve its purpose adequately until X-ray coils of suffi- cient power are constructed that can be moved from place to place. Many a patient can not be taken to a hospital or a radiographer's laboratory for an X-ray examination (e. g. injuries of the hip-joint, severe gunshot wounds, etc.). These patients can riot be given the benefit of X-ray diag- nosis unless the X-ray machfhe is brought to their bedside. The accompanying illustration shows a portable equipment, the energy being furnished by a secondary battery. X-ray Statistics. In the chapter on X-RAY THERAPY and elsewhere reference has been made to the manifold therapeutic uses of the mysterious rays of Roentgen. The references made were largely suggested and influenced by the author's experience. For the sake of completeness and in order to afford the reader a broader view, of the subject, the author has gathered the statements of at least fifteen of the best and most reliable observers from all parts of the world and offers the following resume as a fair estimate of the clinical uses of the Roentgen rays at the present time. 552 MODERN PHYSIO-THERAPY. All observers agree that in the treatment of skin-cancer (epithelioma) the X-rays are at their best. The time which elapses before a healthy action is noticeable, is subject to variation. The location of the trouble, the general condi- tion of the patient and the relative skill of the operator have A PORTABLE X-RAY EQUIPMENT. much to do with the comparative promptness with which the individual case yields. On general principles it may be stated that the cases of skin-cancer which are not curable by means of the X-rays are exceptional. Cancer of the tongue, soft palate and larynx are some- times benefited by X-ray treatment, although the cured cases are rare but sufficiently well authenticated to demon- strate the possibilities of the X-rays in the conditions re- ferred to. Nearly all observers agree that the progress of THERAPEUTIC INDEX. 553 the diseased condition is retarded by the X-rays and thus the life of the patient prolonged. In regard to cancer of the breast a singular diversity of opinion seems to prevail, even concerning the propriety and relative efficacy of the X-rays in the early stages of the dis- ease. That the cure of primary breast-cancer is possible under radio-therapeutic treatment, is admitted in view of a number of cases of this kind which have been reported. Most of the observers favor surgical interference followed by X-ray treatment. A few cases of uterine cancer that are supposed to have been cured by the X-ray, have been reported. In all these cases the seat of the malignant process was in the cervical portion and treatment was given per vaginam. The vagina is protected by an opaque speculum. Treatment through the abdominal wall is admittedly of doubtful value. In rectal cancer, if the seat of the trouble is not extensive arid directly accessible to the rays, good results might be looked for. The use of the Roentgen rays in cases of this kind requires considerable technical skill. In cancer of the stomach and other deep-seated structures, X-ray treatment seems to offer no encouragement. All authors admit and emphasize the wonderful power of the Roentgen rays in relieving the pain of malignant disease, even if the lesion is deep-seated. In the treatment of lupus vulgaris the X-rays are equal to any other agent and superior to most modes of treatment. The points in favor of X-ray treatment are : it is easily given, is painless and consumes but little time. The Fin- sen-rays are equally effective but require prolonged ex- posures. In the erythematous variety of lupus X-ray treat- ment does not seem to be of much avail. Splendid results by the proper application of the Roent- gen rays have been achieved in all the parasitic diseases of the hair- follicles and nails (tinea tonsurans, sycosis, etc.). In many papular skin-diseases the X-rays are of great value. In psoriasis splendid results are frequently achieved, even in cases that had resisted all other modes of treat- 554 MODERN PHYSIO-THERAPY. merit. In acne the X-rays are admittedly of great value, if used properly. The Roentgen-rays are probably the most valuable therapeutic agent in the treatment of pruritus. It is im- material whether there is a concomitant skin-lesion or not. If there is, it is favorably influenced by the X-rays. Splen- did results have been reported in all the pruriginous skin- afflictions (anal, vulvar, intertrigo, neurotic, etc.). In these respects the X-rays rival the high-frequency currents. The effects are attributable to the tonic-stimulant action of the X-rays referred to by the author (see page 297). In a general way the summary of opinion offered does not differ from the statements made in the chapter on X-RAY THERAPY (see page 301). From a biologic point of view the preponderance of opinions seems to favor the supposi- tion that the action of the X-rays is spent on and in the blood, more especially the erythrocytes (red cells). It is generally thought that at first the X-rays cause an increase in the absolute number of white cells in the cutaneous cir- culation. This effect is noticed within eight to twelve hours after the exposure. After twelve hours the number of white cells decreases, especially if a hard tube had been used. During the first twelve hours no appreciable effect is noticed on the red blood-cells. After the first twelve hours many red blood-cells appear broken up. The hema- globin gradually diminishes in quantity. In cases where the red corpuscles are thus affected even after one exposure, a therapeutic reaction usually follows, i. c. devitalization of morbid tissue and a coincident tendency towards granu- lation. In these rapidly yielding cases pigmentation of the cuticle does not usually occur. In the negro the therapeutic effect is not infrequently associated with disintegration of skin-pigment, resulting in the appearance of permanent blanched blotches. If the action of the X-rays could in every case be with certainty foretold in connection with the relative degree of resisting power of skin-pigment, the at- tempts to turn negroes white could be made with a reason- able amount of success and without any damage to the sys- tem at large. GENERAL INDEX. Abdominal congestions, 104-105. Ableitendes Verfahren, 103. Abortion, justifiable, 480. Abscess. See Sepsis. Absorption, 98, 176. Adrenalin-cataphoresis, 442. Acne, 257, 326, 501, 553. Acne rosacea, 236, 326. Actinic rays, 161. Actinium, 541. Active movements, 128. Acute infections. See Fever. Affusion ( Kneipp-douche), 105. After-dinner nap, 64. Agalactia, 449. Alliers-Schoenberg, 285. Alcohol, 78-79. Alcoholism, 347. Alopecia, 347. Alopecia areata, 169, 347. Alternating currents. 190. Amenorrhca, 348. Amperage, 185, 218. Anal fissure, 348. Anemia, 257, 348. Aneurysm. aortic, 349. Aneurysm, cirsoid, 236. Angina, 104. Angina pectoris, 349. An.uioma, 236, 3oO. Animal kingdom, 67. Animal magnetism, 120.155.330, 339, 419. Ankle sprained, 122. Ankylosis, 503. Anodai axis, 277. Anodal electrolysis, 235. Anode, 259. Anorexia. See Dyspepsia. Anteflexion, 231. 404. Ante-version, 551. Anthrax, 168. Anti-cathode. 260. Aphasia, 350. Aphonia, 350. Apoplexy, 104, 414. Apostoli's method, 238, 404. Appendicitis, 105, 350. Applied physiology, 38. Arc-light, 161, 180. Arterio-sclerosis, 351. Arthritis. See Stiff Joints. Bier's Stasis. Tuberculosis of Joints. Arthritis deformans, 494. Asiatic cholera, bacillus of, 168. Asphyxia, 351. Asthma, 351. Atavism, 19, 438. Atheromatous vessel-walls, 104. 110, 125, 351. Atmospheric pressure, 248. Atrichiasis. See Alopecia. Atrophic paralysis, 471. Atrophy, 143, 247. Aufrecht's experiments, 160. Auto-conduction cage, 226. Auto-intoxication, 50, 104, 352. Auto-suggestion, 331. Bacteria, 22, 46, 47, 160, 168, 322, 453, 475, 530. Bacteriology, 47. Bacterium coli commune, 168. "Baking," 110. Baldness, 169, 347. Barber's itch. See Sycosis. Basedow's disease. See Exoph- thalmic goitre. Beck's tubular diaphragm, 307. Becquerel rays. 540. Bell's palsy, 540. Bier's method, 93, 352, 495. 516. Biliary Calculi. See Calculi. Biliousness. See Auto-intoxica- tion. Dyspepsia. Jaundice. Billroth, 36. Bi-polar electrode, 230-231. Birth-marks. 236. 357. 550. Bladder, inflammation or ca- tarrh of, 381. Bloch on high frequency. 254. 556 (IKXKKAL INDKX. Blood-purifier, 33. Blood-spitting, 413. Blue light, 172-175, 181. Boas on massage, 123. Boas on diet in constipation, 374. Bone-setting, 114. Bony growths, 239, 269, 273. Bouchard, SO. Bowel-function, 48. Bowels, congested, 104. Braidism, 339. Brand's water-treatment, 534- 536. Brandt's massage, 35, 126, 472. Breast, cancer of, 326, 431, 553. Breast, function of female, 449. Breeze, static, 213-214. Bright's disease, 101, 112, 357. Bronchitis, 366. Bruise, 101, 367. See Blue Light. Bubo. See Sepsis, Syphilis. Buechner, Ludwig, 40. Bulbar paralysis, 471. Buttermilk in rheumatism, 490. Calculi, 368. Caldwell's tube, 324. Calories, 75. Cancer, 326, 369, 408, 551. Carbuncle, 169. Carcinoma. See Cancer. Carnivora, 67. Catalysis, 234. Cataphoresis, 210, 234, 240, 435. Catarrh, 426, 449. Catarrhal state, 426. Catchin^ cold, 96. Cathodal electrolysis, 236. Cathode, 259. Causal symptoms, 24. Causes of disease, 21-22, 40-41, 50, 77. Cedergreen, 208. Central stimulation, 143. Cephalalgia. See Headache. Cerebral hemorrhage, 104, 414. Chancre, 370. Chancroid, 370. Charcot, 339, 441, 482. Chemical effects of electricity, 229. Chemical sources of electricity, 187. Chemistry of foods, 73. Chest-massage, 521. Chilblains, 370. Chloasma, 438. Chorea, 342, 370. Christian Scientists, 334. Chromo-therapy, 178, 482. Cicatrices, 237. Cirsoid aneurysm, 236. Clap. See Gonorrhea. Clothing, 44. Coal-tar products, 31, 402. Cocaine, 240. Cohen, 61, 538. Coil and double resonator, 222. Cold, 82. Cold in the head, 449. Colic. See Enteritis. Pain. Colon irrigation, 371. Color, effects of, 178, 482. Colors, oo, 178. Comedo, 501. Comma bacillus, 168. Compressed air, 369-370. Compression (Bier), 353. Concentric movements, 128. Condensed air. See Compressed air. Condensation-couch, 223. Conductors, 185. Congestion, 93, 96, 106, 247. Conjunctivitis. See Inflamma- tion. Conjunctivitis, ultra-violet, 253. Conservative surgery, 36. Constant current. See Galvanic current. Constipation, 49, 138, 372. Contusion, 101, 174, 367. Convection, 206. Copper-electrodes, 239. Copper oxy-chloride, 239, 434, 444. Corns, 379. .Corset, 41. Cough, 379. Coulomb, 185. Cupric electrolysis, 235. Curie, Pierre, and wife, 540. Currents, 190, 193. Cutis anserina, 90, 99. Dandruff, 382. D'Arsonval, 221, 252, 256-257. D'Arsonvalization, 258. Darwin, 19, 68, 496. Deafness, 382. GENERAL INDEX. 557 Degeneration, 19, 56, 143. Debierne, 541. "Derivating" method, 103. Derivation, 103, 382. Dercum, 340. Dermo-lamp, 167. Destructive action of current, 229. Developing fluid, 297. Diabetes insipidus, 382. Diabetes mellitus, 383. Diagnosis, 20. Diagram of induction coil, 182. Diagram of magnetic Held, 227. Diaphoresis, 97. Diarrhea, 385. Diasolenic cylinder, 220, 226, 257. Dielectric, 207. Dietetics, 26, 59. Diet for the sick, 72, 386. Digestive process, 62. Dilated capillaries, 236. Dilated stomach, 73. Diphtheria-bacillus, 160 Diphtheritic paralysis, 471. Direct current, 190. Disease defined, 18-20. Disruption, 207. Disturbances of nutrition, 27. Donovan's solution, 431. Double resonator, 222. Dowie, J. A., 336. Drinking water, 51. Drug-action. 16, 30-32, 484, 548. Drug-habits, 386. Drugs, 30, 39, 108, 387, 476. Dry heat, 1C8. Dubois-Raymond, 88. Dysentery, 388. Dysmenorrhea, 216, 388. Dyspepsia, 388. Eccentric movements, 128. Eczema, 169, 2s7, 326, 501. Eddy, Mrs., 336. EfHeurage, 118. Electrical terms, 183, 192. Electricity defined, 184. Electric Light Bath, 176, 362. Electro-cautery, 397. Electro-chemical effects. 234. Electrodes, faradic and gal- vanic, 197. 199, 201, 241. Electrodes, high frequency, 224- 225. Electrolysis, 235. Electro-mechanics, 183. Electro-physics, 183. Electro - therapeutic currents, 192. Emphysema, 397. Empirical methods, 28. Empirical therapy 16. Emunctories, 40. Enchondroma, 239, 269. Endometritis, 398, 432. Endosmosis, cutaneous, 89. Enlarged tonsils, 400. Enteric fever. See Typhoid fever. Enteritis, 400. Epididymitis. See Orchitis. In- flammation. Epilepsy, 53, 342, 400. -Epithelial hypertrophies, 238. Epithelioma, 326, 328, 551. Epistaxis, 413. Esmarch's antisepsis, 160. Ether, 151. Ethereal molecule, 151. Ethics of food, 65. Ewald's salol experiment, 122. Exanthematous diseases, 402. Excentric (eccentric) move- ments, 128. Excretory organs, 21. Exercise, 114. Exophthalmic goitre, 410. Exostosis, 239, 269, 273. Explosion of coil or tube, 310- 311. External medication, 31. Exudates, 105, 434, 472. Eyelids, granulated, 412. Facial neuralgia, 453. Facial paralysis, 471. Faraday's experiment, 191. Faradic current, 193, 242. Faradism, i93, 242. Faradic coil, 201. Fatty heart, 401. Favus, 327. Fever, 27, 87, 401, 534. Fibroid tumors, 238, 403. Fibroma, 238. Fifth nerve, 453. Finsen, Niels R., 161, 319, 444, 495, 01. Fistula in ano, 404. Flexions of the womb, 404. GENERAL INDEX. Fluoroscope, 265. Fluoroscopy, uses of, 266. Fraenkel's movement-cure, 440. Freckles, 405. Frequency, low, high, 255. Freund en high frequency, 256. Food defined, 60. Force, 150. Force-modalities, 150. Friction, 118. Frictional electricity. See static electricity. Friction-machine, 203. Functional disorders, 405. Fungus, 236-238. Furuncle, 169, 499. Galactorrhea, 449. Gall-stones, 266. Galvanic current, 193, 229. Galvanic current, absorbent ef- fects of, 232. Galvanic current, action of pos- itive pole of, 235. Galvanic current, action of neg- ative pole of, 236. Galvanic current, anodyne ef- fects of, 232. Galvanic current, chemical ef- fects of, 234. Galvanic current, electrolytic ef- fects of, 235-238. Galvanic current, general appli- cations of, 234. Galvanic current, interrupted, 232. Galvanic current, mild applica- tions of, 233. Galvanic current, physiological effects of, 219. Galvanic current, sedative ef- fects of, 232. Galvanism, 193, 229. Galvanization, 234. Gaston's method, 431. Gastralgia, 454. Gastric cancer, 409. Gastric ulcer. 409. Gastritis. 409. Geisler's experiments, 52, 160. General paralysis of the insane, 472. Germs. See Micro-organisms. Gevser's treatment of trachoma, " 412. Goethe, 30. Goitre, 239, 410. Goitre, exophthalmic, 410. Gonococcus, 166, 236. Gonorrhea, 236, 411. 493. Gonorrheal rheumatism, 493. Goose-skin, 90. 99. Gout, 412. Granger, 430. Granulated eyelids, 412. Graves' disease. See Exophthal- mic goitre. Green light, 181. Ground wire, 207. Gymnastics of the chest, 521- 524. Gynecological massage, 35. 126, 472. Hammer, Wm. J., 541. Hair-follicles, diseases of, 553. Hair, superfluous, 236, 327. Hard tube, 264. Hay-fever, 351. Headache, 28, 104, 117, 234, 341, 412. Health defined, 18, 247. Heart, fatty degeneration of, 401. Heart and adnexa, inflamma- tory conditions of, 473. Heart, palpitation of, 464. Heart, valvular diseases of, 542. Heat, 82. Heat-stroke, ICO. 504. Helio-pantheism, 154. Hematemesis, 414. Hemoptysis, 104. 413. Hemorrhage, 104-413. Hemorrhoids, 416. Hepatic cancer, 416. Hepatic cirrhosis, 416. Hepatic congestion, 104. See Jaundice. Herbivora, 68-70. Herdman. W. J, 512. Heredity. 19. Herpes, 501. Hexenschuss. See Lumbago. Hiccough, 497. High frequency apparatus, 218. High frequency currents, 195, 25 1. 256-257, 554. High tension electrodes, 223-22^. Hilton's definition of pain, 450 Hippocrates, 40, 59. Homeopathy, 37. GENERAL INDEX. 559 Hoorweg on high frequency, 256. Hydrocele, 417. Hydro-electric bath, 389. Hydro-faradic application,?, 243. Hydro-galvanic applications, 241. Hydro-therapy, 32, 82. Hygiene, 26, 38, 65. Hygrometer, 205. Hypertrichosis, 236, 327, 501. Hypertrophy, 143, 232, 234, 240. Hypochondriasis, 417. Hysteria, 101-102, 417, 470. Ice-applications, 101. Impotency. See Sexual weak- ness. Incontinence of urine, 420. Indigestion. See Dyspepsia. Induction, 191, 219. Induction coil, diagram of, 182. Inertia, uterine, 541. Infantile paralysis, 471. Inflammation, acute, 420. Inflammation, chronic, 425. Influence-machine, 206. Influenza. See Fever. Inoperable malignant disease, 429. Insolation, 100, 504. Insomnia, 104, 341, 432. Instrumental massage, 132. Instrumental movements, 132. Insulation, 185. Intercostal neuralgia, 454. Interrupted current. See Far- adic current. Intestinal hemorrhage, 415. Intestines, congested, 104. Infra-pelvic inflammations, 432. Intra-uterine electrodes, 230. Invisible rays, 161. Jaundice, catarrhal, 437. Joints, stiff, 503. Kant's Imperativus categoricus, 337 Kassabian, M. K., 301. Kattenbracker's experiments, 166. Kellogg, 111. Keloid, 327, 501. Keratosis senilis, 327, 501. Kidney-function, 48. Kinesi- (properly therapy, 127. Kjeldsen's lamp, 166. Kneipp, 49, 105-106, 108, 442. Koumiss, 409. Kraftumwerthung, 55, 154. Laboratory-methods, 395. Laryngitis. See Tonsillitis. Lateral sclerosis, 437. Lead poisoning. See Constipa- tion. Paralysis. Lenstrom's experiments, 245. Leucorrhea, 437. Leukemia, 327. Leyden jars, 209. Lichen planus, 327, 501. Light, 158. Light, biologic importance of, 159. Light, germicidal effects of, 160, 168. Light, physics of, 161. Line of rest, 153. Ling, P. H., 117, 127. Liver, cancer of, 416. Liver, cirrhosis of, 416. Liver, congestion of, 104. Liver-spots, 438. Locomotor ataxia, 342, 438. Lombroso, 56. London Hospital lamp, 166. Lues. See Syphilis. Lumbago, 36, 138, 454, 494. Lung-exercise, 524. Lung- fever, 475. Lung-function, 45. Lungs, congestion of, 104, 105. Lupus erythematosus, 257, 328, 444, 501, 555. Lupus vulgaris, 236, 327, 444, 502, 553. Maggiora on massage, 124. Magnetic field, diagram of, 227. Magnetism, 183. Malaria, 445. Malignant disease, inoperable, 429. Marriage of consumptives, 525. Massage, 34, 114, 117. Massage of the chest, 521. Massage of the stomach, 393. Massey's method, 240, 434, 444. Mastitis, 449. Mastkur, 418. Mastoiditis. See Inflammation. Maternal impressions, 334. 560 GENERAL INDEX. McCaskcy, G. W., 513. Moat, 66. Meat, relation to cancer, 432. Mechanical sources of electric- ity, 188. Mechano-therapy, 114. Melancholia, 446. Meningitis, 104, 447. Menorrhagia, 236, 415, 448. Mental disorders, 343. Mercury in lues, 510. Mesmerism, 339. Metallic electrolysis, 239, 434, 444. Metritis, 429, 448. Metrorrhagia, 236, 415, 448. Metschnikoff, 50, 408, 458. Metzper, Prof., 117. Micrococcus gonorrhoicus, 168. Micrococcus prodigiosus 541. Micro-organisms, 22, 46, 47, 160, 168, 322, 475, 530, 541. Migraine, 448. Milk-secretion, 449. Milliamperemeter, 193. Milzbrand, 160. Mind control, 333. Minin, 111, 171 371. Mitchell, Weir, 377, 418, 441,. 470. Mogigraphia. See Writer's Cramp, under Occupation- neuroses. Moles, 236, 449. Moleschott, 154. Monell, 216. Morton wave current, 217, 247, 250. Movement-cure, 127, 440. Music, 56, 483. Myalgia. See Rheumatism, mus- cular. Nails, diseases of, 553. Nasal catarrh, 449. Nasal septum, 239. Nature's be.dside method, 23. Nauheim carbonated baths, 546. Nauheim massage, 545. Negative electrolysis, 236. Negatives, 294-295. Negroes, pigment in the skin of, 170, 554. Neiswanger, 248, 417, 550. Nervous diseases, 450. Nervousness, 101, 216, 454. Nervous system, 140. .\\-phritis. 101, 112, 357. Neuralgia, 341, 450. Neuralgia, facial, 233, 453. Neurasthenia, 216, 234, 343, 454, Neurosis, case of gastric, 34. Newman's method, 237, 480. Night-sweats, 456, 520. Non-destructive action of cur- rents, 229. Non-reactive water-applications, 107. Nnrdau, Max, 56. Nose-bleeding, 413. N-rays, 157. Nutrition, 27, 90, 144. Obesity, 108, 132, 243, 456. Occupation-neuroses, 457. Odontalgia, 453. 515. OerteFs method, 387. 398, 456, 542, 548. Ohm's law, 186. Operative surgery, 37. Opsonic therapy, 458. Orchitis, 464. Organs of special sense, 54 Orthopedics, 114. Oscillation, 115, 149. Oscillator, 147. Osteoma, 239. Osteopathy, 115, 142. Otitis. See Inflammation. Deaf- ness. Oudin resonator, 223. Ovarian neuralgia, 454. Oxidation, 59, 86, 129, 235. Oxygen, 45, 46. 159, 322, 499, 527. Ozone, 250, 528. Pain, 24, 29, 35, 124, 171, 175, 217, 233, 24r, 464 Palpitation of the heart, 464. Fapilloma, 238, 472. Papular skin diseases, 553. Paralysis, 232, 341, 464, 470,472. Paralysis, different forms of, 471. Paresis. See Paralysis Parametritis, \32. Passive movements, 128 Pelvic adhesions, 472. Pelvic cellulitis, 432. Pelvic exudates, 434, 472. Pericarditis, 473. Perimetritis, 432. J Vritonitis, 1U5. 474. GENERAL INDEX. 5rl Fetrissage, 113. Pettenkofer, 52, 79, 158. Phagocytosis, 246, 458, 479. Pharyngitis, 474. Photography, 268, 294. Physics of electricit/, 184. Physics of light, 160. Physics of X-rays, 3(1 Physiological methods, .^2 . Physio-therapy define-!, i.x Piffard's cataphoresis, 442. Piffard rays, 474, 550. Pigment, 170, 318, 550. 554. Piles, 416. Pitchblende, 540. Placebo, 334. Plasmodium, 170, 246, 445. Pleurisy, 475. Pleurodynia, 486, 493. Plexus, 141. Plumbism. See Constipation. Paralysis. Pneumatic cabinet or chamber. See Compressed air. Pneumonia, 105, 475. Point of rest, 153. Poisons, 32. Polarity, 192, 2CO, 207, 244. Pole-changer, 208. Polonium, 541. Polypus, 236. Pope, Curran, 348. Positive electrolysis, 285. Post-diphtheritic paralysis, 471. Potential alternations, 214-217. Premature labor, 480. Prevalent ideas, 332. Priessnitz, 25. 84, 93. 95, 98, 102, 106, 422, 501, 534. Primary area in hydro-therapy, 92. Proctitis. See Inflammation. Progressive muscular atrophv, 471. Prostate gland, enlarged, 480. Pruritus, 328, 502, 554. See Auto-intoxication. Psoriasis, 169, 257, 501, 533. Psychic disorders, 343. Ptomaine-poisoning. See Auto- intoxication. Pus-germs. See bacteria. Radio-activity, 155, 315, 540. Radiography, 267. Radio-therapy, 313. Radium, 541. Rarefied air. See Compressed air. Rationale of disease, 23. Rationale of symptoms, 23. Rationale of treatment, 26. Raw food, 77. Reaction in hydro-therapy, 91, 94, 110, 487. Reactive water-applications, 102. Recreation, 511. Red light, 163, 178. Reflex disorders, 480. Resistance, 185. Resistance-movements, 128. Resonance-effects, 221. Rest-cure, 377, 511. Restorative symptoms, 24. Retention of urine. See Cystitis. Reflex disorders. Retroflexion, 230, 404. Rheumatism, 35, 70, 101, 112, 128, 484. Rheumatism, muscular, 493. Rheumatoid arthritis, 494. Rhinitis, 449. Rock-crystal, 164. Roentgen-rays. See X-rays. Rokitanski, 516. Roller-cabinet, 196. Roman-Irish (dry heat) bath, /JS. Russian bath (hot steam barh followed by douche and massage). See hyJro'chor- apy. Salpingitis, 432, 495. Sarcoma, 240, 328, 49^ Scars, 162, 237. Scheidel coil, explosion of, 311. Schroth, Johann, 408, 409, 411, 490, 507. Schueller's ernerimepfs ( )1. Schwedische Heilgymnastik, 127. Sciatica, 243,, 454. Scleroderma pigment >sij>n, 502. Sclerosis, 437-438. Secondary area in hydroiher- apy, 92. Secondary radiations, 2^3. Sepsis, 495. Sex-determination, -tOfi. Sexual instinct, 56. Sexual weakness, 147, ISM, 206, 497. Shunt, 1?G. 562 ( iK.XKKAI. I.XDK.X. Singultus, 497. Sinusoidal current, 195. Skeleton of static m^chin-.-, 3)4. Skiagraphy. 267. Skin-clisea"si-s. 369, -HJ9, 4'V. Skin-fi nction, 42. Skinner, C. E., 491. Smallpox, scars of, 162. Snow, Arnold, 443, 452. Snow's electrodes, 2^6. Soft tube, -64. Solarium, 171. Spasm, 502. Species, 18. Spinal cord, 140. Sprains, 101, 112, 502- Spray, static, 207. Static applications, 210. Static electricity, 194, 202, 244, 250. Static induced current, 214, 215. Static machine, 202, 204. Static machine, how to clean, 203. Static machine, how to dry, 203. Static machine, polarity of, 207. Steam-bath, 107. Steam-bath for fever cases, 403. Stenosis. 503. Stereo-skiagraphy, 301. Stiff joints, 503. Stitch in the side, 475, 531. Stomach, catarrh of. See Dys- pepsia. Stomach, inflammation of. See Gastritis. Stomach-massage, 393. Stone. See Calculi. Streptococcus pyogenes, 168. Strictures, 503. Strictures, urethral, 237, 504. Stuttering, 343. St. Vitus' dance. See Chorea. Suction (Bier), 353. Suggestion, 156, 157, 251, 330, 481. Suggestive element in static electricity, 251. Sunbath, 170. Sunlight, 161, 170. Sunstroke, 100, 504. Superfluous hairs, 236, 327, 506. Surgery, conservatism in, 36, 240. Surging, 214. Survival of the fittest, 18, 19. Suspension method in tabes, 441. Sweat, 97. Swedish movements, 127. Swimming for consumptives, 524. Sycosis, 169, 502, 553. Sympathetic nerves, 141, 144. Syphilis, 5C6. Tabes dorsalis, 438. Table-plate, faradic-galvanic, 182. Tait, Lawson, 35. Tangential rays. 2S3. Tapotement, 188. Testicles, inflammation of. See Orchitis. Tetanus, 511. Therapy of rlectric currents, 228. Therapy of light, 158. Therapy of water, 99. Therapy of Roentgen- (X-) rays, 313. Thorium, 541. Tic-douloureux, 453. Tinea circinata, 502. Tinea tonsurans, 236. 328, 553. Tissue-builders, 61. Tissue-consumers, 61. Tobacco, 62, 514. Tonsils, enlarged, 400. Tooth-ache, 453, 515. Torticollis, 36, 138, 486, 493. Trachoma, 412. Tripet on high frequency, 256. Trockenkur. See Schroth, Jo- ham. Tubercle bacillus, 47, 160, 168, 170, 322, 519. Tuberculosis, 47, 328. Tuberculosis as an economic problem, 48, 532. Tuberculosis of glands, 515. Tuberculosis of joints, 516. Tuberculosis pulmonum, 517, 355. Tumors. 232, 234-240, 313. Typhoid fever, 24, 52, 84, 534. Typhoid fever, relation of water to, 51. Ulcer, 533. Ulcer, gastric, 409. Ultra-volet element in high fre- quency, 253. Ultra-violet element in X-rays. 316. Ultra-violet rays, 161, 251, 253, 283, 318. GENERAL INDEX. 563 Undulation 151. United States, climate of, 538. Uranium, 540. Uremia, 541. Urethral stricture, 504. Urethritis. specific, 411. Uterine fibroids, 238. Uterine hernorrhage, 415. Uterine inertia, 541. Vacuum electrodes, 224. Vacuum of the X-tube, 261, 279. Vaginismus, 542. Valvular diseases of the heart, 542. Vapor-bath, 107,_ 402. Varicose veins, 549. Varix, 236, 550. Vascular tumors, 236, 551. Vegetarian diet, 67. Versions of the womb, 551. Vertigo. See nervous disorders. Constipation, Dyspepsia. Vibration, 115, 136. Vibration-tables, 145-147, 466. Vibrator}' stimulation, 142. Vis medicatrix naturae, 18, 507. Voltage, 184, 186. Vomiting of pregnancy, 233, 551. Wagner, Richard, 55, 57. Walter's radiations, 283, 317. Walter's skiameter, 304. Warts, 236, 238. Water as a physiological ele- ment, 61. Water, hygienic importance of, 51. Water-applications, different kinds of, 100. Water applications, physiologi- cal effects of, 85. Wave-length, 152. Wetterstrand, 343. Will-power, 332. Wine-marks. See Birth-marks. Winternitz, Prof. Wilhelm, 88, 92, 95, 122, 176, 249, 478. Wounds, 178. Wright, 458. Wrist-drop. See Paralysis. Writer's cramp. See Occupa- tion-neuroses. Wry-neck. See Torticollis. X-rays (Roentgen-rays), 258, 313. X-rays, anodyne effects of, 553. X-rays in biology, 320. X-rays, physics of, 314. X-rays, ultra-violet element in, 316. X-ray accessories, 303. X-ray burns, 307, 551. X-ray camera, 285. X-ray coil, portable, 551-552. X-ray diagnosis, 258. X-ray errors, 298. X-ray gloves, 311. X-ray statistics, 551. X-ray therapy, 313. X-ray tubes, 258. Zander's method, 134. Ziegenspeck, 126. Zinc-mercury cataphoresis, 431. Zinc silicate, 254. Zone of sterilization, 430. Zoroaster, 154. DATE DUE PRINTED IN U S 3 1970 00592 4599 UJ LU ca