HYDROTHERAPY 1 . FOR STUDENTS AND PRACTITIONERS OF MEDICINE Embodying a consideration of the Scientific Basis, Principles and Practice of Hydrotherapy and some allied Branches of Physiologic Therapy BY GEORGE KNAPP ABBOTT, M. D. Dean of the Faculty and Professor of Hydrotherapy and Practice of Medicine in the College of Medical Evangelists Loma Linda, Cal. THE COLLEGE PRESS 1911 r\ v - n HI Copyright, 1911, by The College Press Loma Linda, Cal. TO THOSE WHO ARE SEEKING TO BE CO-WORKERS WITH THE GREAT PHYSICIAN IN THE HEALING OF DISEASE BY THE USE OF NATURE'S REMEDIES PREFACE NO APOLOGY need be given for the presentation of a work on hydro- therapy. In spite of the advances made in modern physiologic therapy in general, hydrotherapy is still a branch of therapeutics but little used by the general practitioner. The reason is not difficult to find. As a science it receives but scant attention from teachers of therapeutics, and in the medical curriculum is usually allotted a few hours from the combined course on materia medica and therapeutics, which is already over crowded by the presentation of a needlessly large number of preparations of doubt- ful or very limited usefulness. As an art even less time is devoted to it. It must, however, be acknowledged that this brief consideration is a distinct advance over twenty years ago, when the medical curriculum was quite innocent of even a mention of physiologic therapy. It is the author's firm belief, strengthened by years of experience in the teaching of both medical students and nurses, that the student or practi- tioner should first acquire a knowledge of the technique of hydrotherapy in the same way that nurses are taught, i. e., by actual drill under an experi- enced instructor. Insistence upon accurate, personal observation of patients during their treatment will help to strengthen in the mind of the student the necessity for close clinical observation. In the management of disease, such observation can not be replaced by instruments of precision. In this connection we can not refrain from expressing our opinion that instruction in practical therapeutics and the care of patients should not be left to the later years of the medical curriculum. With this practical knowledge of the visible results to be obtained, the student should devote careful study to the physiologic and therapeutic effects of each representative class of treatments. This study should include per- sonal laboratory investigation into the effects of thermic and mechanical stimuli upon blood pressure, the heart rate and force, general changes in blood distribution and its cellular composition, muscular capacity, and meta- bolic changes as revealed by chemical examination of the the excretions, particularly the urine. In the presentation of the subject, the author has tried to preserve the closest connection between experimental physiology and therapeutic deduc- tions and recommendations. We have at all times endeavored to seek out a reason for the results obtained in practice. It is only in this way that varying conditions may be successfully met. The modern search for "specifics" has greatly aided in the development of scientific medicine. The same principles, however, must not, without modification, be applied to hydrotherapy. Specific results are to be sought by proper adaptation of the treatment to the individual case in hand, rather than by rigid adherence to this or that type of application. For this reason physiologic effects have been dwelt upon quite at length and have been con- sidered apart from the technique. vi PREFACE The subject of therapeutics has been presented with a view to the eluci- dation of basic principles. It is the morbid physiologic or structural state present in a given disease that requires treatment rather than the "disease" as an entity. Diseases most amenable to hydrotherapy have, therefore, been grouped in classes according to the general principles involved in their treat- ment, after an explanation of which, each disease is given particular atten- tion. While hydrotherapy is the most important branch of physiologic therapy, it is not by any means a "cure all." The border line between physiologic and radical therapeutics can not be drawn by disease lists but must be settled by rational, conscientious consideration of the ends to be sought and the trend of the morbid condition in hand. In the presentation of this work, the author lays no claims to originality. In addition to personal experience, all available sources of information have been drawn upon. The text matter and diagrams are those used by the author in his lectures to medical students. The part on technique is an amplification of a brief treatise on the "Technique of Hydrotherapy" pub- lished by the author in 1908. G. K. A. LOMA LINDA, CAL. APRIL, 1911 CONTENTS PART I Scientific Basis and Physiologic Effects CHAPTER I THE PHYSICAL PROPERTIES OF WATER Communication and Absorption of Heat. Physics of Heat. Calories. Specific Heat. Latent Heat. Thermic Stimuli. Mechanical Stimuli. Sol- vent and Chemical Properties. 38 CHAPTER II PRINCIPLES OF EFFECTS AND THERAPY Therapy from Within. Warm and Cold-blooded Animals. Intrinsic Ef- fects. Reaction. Types and Degrees of Reaction. Conditions Influencing Reaction. Common Names of Temperatures. 916 CHAPTER III ANATOMY AND PHYSIOLOGY OF THE SKIN Muscular and Elastic Tissue. Blood Vessels. Lymphatics 1721 CHAPTER IV THE PERIPHERAL HEART Traube-Hering Waves. Principles of Vascular Effects. Quantity of Cir- culating Fluid 22-27 CHAPTER V ANATOMY AND PHYSIOLOGY OF THE SKIN (Continued) Sudoriparous Glands. Summary of Perspiratory Influences. Sebaceous Glands. Absorption by the Skin. Cutaneous Respiration. The Skin a Heat Regulator. Nerves of the Skin. 2832 CHAPTER VI THE CIRCULATION REFLEX EFFECTS Reflex Areas. Reflex Arc. Special Reflex Areas. Classes of Reflex Effects. Special Reflex Effects. 3343 CHAPTER VII THE CIRCULATION HYDROSTATIC EFFECTS Principles of Hydrostasis. Law of Antagonism. Areas for Deriva- viii CONTENTS tion. .. 44-49 CHAPTER VIII THE CIRCULATION BALANCE BETWEEN REFLEX AND HYDROSTATIC EFFECTS Laws of Balance. Examples 5051 CHAPTER IX THE CIRCULATION-BLOOD PRESSURE Force of Heart Beat. Amount of Circulating Fluid. Vascular Calibre and Action. Muller's Laws. 5258 CHAPTER X THE CIRCULATION CHANGES IN COMPOSITION .OF THE BLOOD Corpuscular Elements. Mechanism of Distribution. Viscosity and Reac- tion. Practical Application. 5963 CHAPTER XI NITROGENOUS METABOLISM AND EXCRETION Effects of Cold. Nitrogen Economy. Urea and Ammonia. Uric Acid and Purin Bases. Extractives. Phosphoric Acid. . Sulphates and Chlorides. Effects of Heat. - ...64 72 CHAPTER XII RESPIRATION' RESPIRATORY CHANGES AND CARBONACEOUS METABOLISM Tidal Air. Gaseous Interchange. Carbon Dioxide. Oxygen 7375 CHAPTER XIII MUSCULAR CAPACITY Effects of Cold. Effects of Heat. Ergograph and Dynomometer Experi- ments 7680 CHAPTER XIV THE HEAT MECHANISM Regulation of Heat Production. Regu'ation of Heat Loss. Experiments in Heat Production and Elimination. Summary 8189 PART II THERAPEUTICS CHAPTER XV THE REALM AND LIMITATIONS OF PHYSIOLOGIC THERAPY Functional and Organic Diseases. Natural Means. Radical Means. Basic Principles of Therapy. 9395 CONTENTS ix CHAPTER XVI FEVER AND ANTIPYRETIC EFFECTS Causes of Pyrexia. Symptoms of Fever. Principles of Antipyresis. Toxic Vasomotor Paralysis. Medicinal Antipyretics. Rationale of Hydria- tic Antipyretics. Pathogenesis of Fever. Variations that Produce Fever and their Relation to Treatment 96-107 CHAPTER XVII THE TREATMENT OF FEVERS Typhoid Fever. Malaria. Measels. Scarlet Fever. Influenza. ..108 126 CHAPTER XVIII INFLAMMATIONS AND ANTIPHLOGISTIC EFFECTS Derivation. Fluxion. Revulsion. Pathogenesis of Inflammation. Prin- ciples of Treatment. .1 127134 CHAPTER XIX THE TREATMENT OF INFLAMMATIONS Inflammations of the Eye. Erysipelas. Otitis Media. Mastoiditis. Alveolar Abscess. Pharyngitis. Tonsilitis. Boils. Septicemia. Poison Ivy. Pneumonia. Bronchopneumonia. Pleurisy. Pericarditis. Myocardi- tis. Rheumatic Fever. Meningitis. Biliary Inflammations. Appendicitis. Pelvic Inflammations. Phlebitis. Mucous Colitis. Cystitis. Specific Urethritis 135-155 CHAPTER XX STIMULANTS AND TONICS Hydriatic Tonics. Anemia. Neurasthenia. Splanchnic Neurasthenia. Hysteria. Dyspepsia. Insomnia. Chronic Inebriety. Chronic Articular Rheumatism. Diabetes. Sunstroke. Valvular Heart Disease. Obesity with Fatty Heart. Excitant and Stimulating Effects. Uterine, Vesical and Intestinal Stimulants 156179 CHAPTER XXI SEDATIVE EFFECTS General Sedatives. Pure Sedatives. Tonic Sedatives. Local Sedatives. Insomnia. Chorea. Paralysis Agitans. Spastic Spinal Paralyses. Loco- motor Ataxia. Parenchymatous Goitre. The Relief of Pain. Ulcer. Hemorrhoids. Neuralgia. Tenesmus. Dysmenorrhoea. Renal and Biliary. Colic. Burns. Sprains and Bruises. Fractures 180196 CHAPTER XXII EXPECTORANT EFFECTS Colds. Acute Coryza. Acute Bronchitis. Croup. Asthma. Chronic Bronchitis 197200 CHAPTER XXIII DIAPHORETIC EFFECTS Obesity. Icterus. Systemic Poisoning. Internal Congestions. __201 204 x CONTENTS CHAPTER XXIV DIURETIC EFFECTS Gout and Chronic Rheumatism. Bright's Disease. Uremia and Eclamp- sia. 205218 CHAPTER XXV PEPTOGENIC EFFECTS Atonic Dyspepsia. Gastrectasia. Hypochlorhydria. Hyperchlorhydria. 219-223 CHAPTER XXVI HEMOSTATIC EFFECTS Epistaxis. Pulmonary Hemorrhage. Gastric Hemorrhage. Uterine Hemorrhage. Apoplexy. 224225 CHAPTER XXVII HYDROTHERAPY IN SURGERY Preparatory Treatment. Immediate Care. Surgical Shock. Vasomotor and Cardiac Changes. Hydriatic Treatment of Shock. Drug Treatment of Shock. After-Treatment. _ --226-238 PART III TECHNIQUE LOCAL APPLICATIONS OF HEAT Fomentations. Hot Compress. Stupes. Alternate and Simultaneous Hot and Cold Treatments. Hot Water Bottles. Hot Water Coil. Radiant Heat 241-246 LOCAL APPLICATIONS OF COLD Cold Compress. Ice Pack. Ice Cravat. Ice Bag. Cold Water Coil. 246-248 HEATING COMPRESSES Moist Chest Pack. Dry Chest Pack. Moist Abdominal Bandage. Heat- ing Throat Compress. Heating Joint Compress. 248252 POULTICES White Clay and Glycerine. Charcoal 252 TONIC FRICTIONS Cold Mitten Friction. Wet Hand Rub. Cold Towel Rub. Wet Sheet Rub. Dripping Sheet Rub. Ice Rub. Salt Glow 252-256 SPONGING Hot, Cold and Tepid Sponge. Saline Sponge. Alkaline Sponge. Vinegar CONTENTS xi and Salt Rub. Alcohol Rub. Witchhazel Rub. Menthol Rub. Soap Wash 256-258 RUBS AND FRICTIONS Centripetal Friction. Oil Rub. Talcum Rub. Dry Friction 258-261 BATHS Partial Immersion. Hand and Arm Bath. Foot Bath. Leg Bath. Sitz Bath. Hot Half-Bath. Full Immersion Baths. Hot, Cold and Neutral Tub Baths. Brand Bath. Graduated Bath. Cold Shallow Bath. Hydro- electric Baths. Medicated Baths. Nauheim Bath. Russian Bath. Vapor Bath. Turkish Bath. Superheated Air Bath. Electric Light Bath. 261-274 SHAMPOOS Swedish Shampoo. Tub Shampoo. Turkish Shampoo 274275 PACKS Full Hot Blanket Pack. Dry Blanket Pack. Trunk Pack. Pelvic Pack. Hip and Leg Pack. Hot Packs with Ice Bags. Electro-thermal Pack. Evaporating, Neutral, Heating and Sweating Wet Sheet Packs. Heating Trunk Pack. Hot and Heating Trunk Pack. Heating Pelvic Pack. 276285 SPRAYS AND DOUCHES Shower Bath. Spray Bath. Revulsive, Alternate, Percussion and Spray Douches. Spray and Douche Prescriptions. Affusions. Pail Pour. 285290 ENEMATA Hot, Cold and Graduated Enemata. Cold and Alternate Rectal Irriga- tion. Coloclyster. Saline Enema. Proctoclysis. Soap-suds, Oil, Asafoe- tida, Glycerine and Epsom Salts, Starch, Quassia, Quinin Enemata. 290297 VAGINAL IRRIGATION Hot, and Alternate Hot and Cold Vaginal Irrigation. Disinfectant and and Styptic Vaginal Irrigation 297299 ILLUSTRATIONS FIGURE PAGE 1. Expansion of Water at Different Temperatures 4 2. Comparative Thermometer Scales 5 3. Diagram Illustrating Time Factor in Intrinsic and Reactionary Effects 12 4. Origin of Lymphatic Vessels in a Papilla of the Hand (Sappey) 19 5. Superficial Lymphatics of the Arm (Sappey) 20 6. Valves of the Mesenteric Chyliferous Vessels (Delamere) 20 7. Blood Pressure Tracings Showing Traube-Hering Curves taken from a Dog (Martin) 23 8. Rhythmical Vasomotor Waves of Blood Pressure in a Dog 24 9. Diagram to Show Vasomotor Reflex Arc (Howell) 35 10. Arterior Reflex Areas (Kellogg) 39 11. Sphygmograph Tracing Showing Effect of Proximal Application on Pulse Wave (Kellogg) 41 12. Plethysmographic Tracing Showing Effect of Proximal Applica- tion on Volume Curve (Kellogg) 41 13. Volume Curve of Right Arm During a Hot Sitz Bath Showing Derivative Effect (Winternitz) 45 14. Volume Curve of Right Arm During a Cold Sitz Bath Showing Retrostatic Effect (Winternitz) 46 15. Curve Showing Effect of a Sudden Rise in the Arterial Resist- ance on the Output and Volume of the Ventricles (Starling) 53 16. Cardiometer Tracing Showing Effect of Increasing the Volume of Circulating Fluid on the Total Output and Volume of the Heart (Roy) 55 17. Plethysmographic Tracing of Spleen, Showing the Spontaneous Rhythmical Contractions of this Organ (Howell) 61 18. Curve Showing the Effect of Cold Treatment on Fecal and Urin- ary Nitrogen (Strasser) 65 19. Curve Showing Effect of Cold Treatment on Urea, Phosphates and Ammonia (Strasser) 66 20. Curve Showing Effect of Cjld Treatment on the Oxidation of Purins (Strasser) 68 21. Curve Showing Effects of Cold Treatment on the Alkaline and Earthly Phosphates (Strasser) 70 22. Ergograms Showing Effect of Cold Bath on Muscular Capacity 76 23. Ergograms Showing Effect of Graduated Bath on Muscular Ca- pacity.. 77 xiv ILLUSTRATIONS 24. Ergograms Showing Effect of Graduated Bath on Fatigue 77 25. Ergograms Showing Effect of Cold Wet Sheet Rub on Fatigue 78 26. Ergograms Showing Effect of Warm Douche on Fatigue 78 27. Rubner's Chart Showing Manner of Heat Loss at Different Tem- peratures 83 28. Diagram Showing Quantitative Relation Between the Tempera- ture-Raising and the Temperature-Lowering Capacity of Differ- ent Treatments 104 29. Diagram Showing Dynamic Conditions in Valvular Heart Disease 170 30. Diagram to Show the Effects of Heat and Cold in Lessening the Pain of Inflammation (Brunton) 183 COLORED PLATES I. The Ihnervation of the Heart (Powell) opp. 35 II. Reflex Arc from Skin to Heart opp. 37 III. Depletion by Simultaneous Heat and Cold opp. 127 PART I SCIENTIFIC BASIS AND PHYSIOLOGIC EFFECTS CHAPTER I THE PHYSICAL PROPERTIES OF WATER In the application of any therapeutic agent, it is essential to obtain an understanding of those properties of the agent itself of which particular use is made in the treatment of disease. In the case of water, these essen- tial properties may be discussed under the following heads: 1. Its ability to communicate or absorb large quantities of heat by contact. a. Specific Heat. b. Latent Heat. 2. The intensity of thermic stimuli obtained by the use of water. 3. Its convenience in applying mechanical stimuli. 4. Its solvent properties and use in nutritive and metabolic' changes. 1. Communication and Absorption of Heat. Hydrotherapy consists chiefly in the application of heat and cold to the body by means of water. Its most helpful results are obtained from the heat applied. In its most scientific and practical phases it is a study of thermotherapy. This being true, in the power of water to communicate and absorb large quantities of heat, without itself undergoing a corresponding change in temperature, lies its most useful property. To rightly apply so powerful an agent, one should understand the physics of heat as it applies to water. A brief summary of this subject will not therefore be out of place. Physics of Heat When heated, the particles of any substance separate slightly, thus moving more freely upon each other when hot than when cold. Solids are thus made softer, more porous and pliable. With some solids this is so marked that they may be moulded into various shapes even before hot enough to become liquids. The body tissues are likewise made soft and pliable through the influence of heat. The skin is expanded, the muscles relaxed and the blood vessels dilated. In general, heat expands all substances, some however to a greater degree than others. Each metal, for example, shows a definite degree of increase in bulk when heated. Water expands, occupying more space as its temperature increases above 4 C. (39.2 F.). Nearly all substances con- tinue to contract indefinitely under the influence of cold; i. e. , the with- drawal of heat. But water, after cooling to 4 C. expands until frozen. Four degrees C., or 39.2 F., is therefore said to be the point of maximum density of water. (Fig. 1) At this temperature a given weight of water occupies (is crowded into) the least possible space. It is because of this 4 PROPERTIES OF WATER change (expansion) in freezing that ice floats. If water continued to con- tract on freezing, it then being denser, would sink to the bottom, and BO remain frozen for a much longer time, as solar heat loses its effect in penetrating so far. Did this occur, only very shallow bodies of water would ever entirely thaw out at temperatures common to temperate and frigid zones. Degrees or Intensity of Heat. The intensity or degree of heat is measured by a thermometer, (thermo heat; meter measure). Only the Fahrenheit and Centigrade scales need be described. The Fahrenheit thermometer, more commonly used for domestic and clinical purposes will be described first. The freezing point of water is marked as 32 F., that is, 32 above the zero or starting point of this scale. Water boils at 212 F. above freezing. ,55 853 . 3 Fig. 1, Expansion of water at temperatures from (f C. to 100 C. The Centigrade thermometer is a more simple instrument, as the freezing point of water is marked 0, while the boiling point is marked 100. From this we see that 32 Fahrenheit corresponds toO C., and 212 F. corresponds to 100 J C., and therefore 180 Fahrenheit degrees (212 minus 32) are the equi- valent of 100 Centigrade degrees or 1.8 F. equal 1 C. (Fig. 2) Equivalent Readings. To change a given reading on the Centigrade scale to Fahrenheit, it is necessary first to multiply by 9-5 (180-100). This gives the number of Fahrenheit degrees above the freezing point. Since this point on the Fahrenheit scale is 32 above zero, 32 should be added to the result to obtain the correct Fahrenheit reading. For example, find the HEAT UNITS Fahrenheit reading which corresponds to 35 C. Multiplying 35 by 9-5 gives 63 above freezing; adding 32 gives 95 G F. To obtain the correct Centigrade reading of a given Fahrenheit tempera- ture, it is only necessary to reverse the process. Take, for example, 98.6 F., the normal body temperature by mouth. This is 66.6 (98.6 minus 32) above freezing; 66.6 multiplied by 5 7 9 equals 37 C. Since C. is the freezing point, this is the correct Centigrade reading. Condensed rules: To change Centigrade to Fahrenheit, multiply by 9-5 and add 32. To change Fahrenheit to Centigrade, subtract 32 and multiply by 5-9. Heat Units or Quantity of Heat. a. SPECI- FIC HEAT. The amount of heat required to raise a gram of water 1 C. is called a heat unit, or calorie. The large Calorie (written with an initial capital) is the amount of heat necessary to raise 1000 grams (1 liter) of water 1 C., and is therefore equal to 1000 small calories. The amount of heat that would raise the temperature of a given weight of water 1 C. would raise the temperature of the same weight of mercury 30 C. Therefore, one gram of mercury in being heated through 1 C. would absorb only 1-30 of a calorie, i. e., 1-30 of the amount of heat absorbed by the same weight of water in being heated through 1 C. From this fact it will be seen that water absorbs a large amount of heat without manifesting a corresponding change in tem- perature; while a small amount of heat pro- duces a considerable change in the tempera- ture of mercury. The heat necessary to raise a given weight of water 1 is greater than that of any other substance. Therefore, water is said to have a high specific heat. Specfic heat is the ca- pacity of a substance for absorbing heat as compared with the capacity of a standard sub- stance. More accurately, it is the amount of heat a given weight of a substance absorbs in being raised in temperature 1 C. as com- pared with the amount of heat necessary to accomplish the same rise in temperature in the same weight of a standard substance. Since water absorbs more heat than any other substance, it is taken as the standard. A gram of mercury, absorbing only 1-30 the amount of heat absorbed by 1 gram of water, is said to have a specific heat of 1-30 that of water. Copper has a specific heat of 1-12 that of water. FAHRENHEIT CENTIGRADE 2IO ' 200 190 180 iro 160 ISO no iOO 90 80 70 60 50 40 70 60 SO I 40 mtzM POUT 20 Fig. 2. Comparative thermometer scales. 6 PROPERTIES OF WATER It will be seen from the preceding discussion, that a large amount of heat is stored in hot water. It is this high specific heat of water that makes it especially valuable in applying heat to the body. A pound of hot water will communicate thirty times as much heat to the body as a pound of mer- cury. And conversely, a pound of cold water will abstract from the body thirty times as much heat as a pound of mercury. In each case the temper- ature of the water or mercury will be changed only 1. The hot water not only stores up a great amount of heat, but it communicates this very readily to things with which it comes in contact. Conversely, cold water very readily absorbs heat by contact with other bodies; hence, if applied to the human body, it quickly cools the skin, adjacent tissues and their blood cur- rent. b. LATENT HEAT. A thermometer placed on ice as it is melting and another placed in the water just after, register exactly the same degree or intensity of heat, viz., C. Since it requires heat to melt ice, a mere change in physical state, we may very naturally ask, What becomes of this heat when the solid changes to a liquid? It is not apparent nor manifest by a change in the thermometer. We may call it hidden or latent heat. By careful experimentation, it is found that an astonishingly large quantity of heat is absorbed in this process; in the melting of one gram of ice, suffi- cient in fact to raise the temperature of one gram of water 79.2 C. This gram of ice in melting, therefore, absorbs 79.2 calories, with no consequent rise in the temperature, as measured in degrees. This amount of heat is made latent. The latent heat of fusion, or melting of ice, is thus fixed at 79.2 calories. This is the reason ice cools the body so much more rapidly than cold water, every gram of ice that melts abstracting nearly eighty times as much heat as the same weight of water warmed through 1 C. The value of the ice rub is thus amply demonstrated. For the same reason an ice bag produces a greater intensity of effect than a cold compress. The same principle applies to the boiling of water or the condensing of steam, except that a much greater number of heat units is respectively made latent or given off. Water at the boiling point registers the same degree of heat as steam just after it is formed; and yet this change from liquid to gas requires 537 calories to each gram of water. The latent heat of vaporization of water is therefore 537 calories. When steam condenses, it gives off this heat. In this phenomenon lies the explanation of the fact that a Russian bath gives a great intensity of effect, since much of the steam condenses, the water particles remaining suspended in the air of the room as a thick fog. For every gram of steam that thus condenses, 537 calories of heat are liberated. The intensity of burns pro- duced by the condensing of steam directly on the skin surface is readily understood when this fact is kept in mind. The marked cooling effects of the evaporating wet sheet pack, or hot and cold sponging are due to the large amounts of heat abstracted from the body by the process of evapora- tion. The practicability of employing water in all three states of matter (solid, liquid and gas) and its ready change from one to another within a comparatively short range of temperature, greatly enhances its utility as a therapeutic agent. THERMIC STIMULI 7 With all these facts before one, it is apparent that the great value of water as a thermic agent lies in its exceedingly high specific and latent heat coefficients. Specific heat refers to the amount of heat concerned in the temperature changes of matter within a single state. Latent heat refers to the amount of heat concerned in the change of matter from one state to another without any change in temperature. 2. Thermic Stimuli. It might, on first thought, seem that a thermic stimu- lus is identical with the communicating of heat. It, however, does not depend upon the amount of heat communicated to or absorbed from the body, but rather upon the impression made upon the nerves. In this respect, the temperature of the body, or rather, that of the skin, may be said to be the zero of the "temperature sense." Water of a temperature above this, creates an impression of heat, while water below this temperature gives a sensation of cold. A brief application of ice may give a sensation of cold as intense as one of longer duration. On the contrary, to abstract heat from the body to any appreciable extent, the application must be more or less prolonged. These thermic stimuli are of the greatest value in hydrotherapy; we may say, equally so with the actual transfer of heat. Here, also, the thermic capacity of water makes it of inestimable value. "The temperature-con- ducting capacity of water is twenty-seven times greater than that of air. Water conveys to the skin much stronger thermic impressions than does air at the same temperature, a fact easily discovered in exchanging a room temperature at 75 F. for a tub bath at the same temperature." ] And again, the accuracy with which we may regulate the temperature of hydriatic applications and so gauge the thermic impressions as well as the heat communicated or absorbed, makes it doubly convenient and valuable. 3. Mechanical Stimuli. The convenience with which water lends itself to the application of various mechanical stimuli is due to its most apparent physical property fluidity. Because of this perfect fluidity, its applica- tion can be controlled to a nicety not possible with other agents. With the proper appliances, the amount and temperature can be accurately gauged. The size, form, character and pressure of douches, sprays and pours can be varied to suit the varying needs of a great variety of cases. It is these four factors that govern the mechanical effect in the class of treatments mentioned. Water may be applied under very great pressure, thus enhanc- ing the ihermic effects, or it may be applied with little or no pressure. Not only may water itself be used to apply percussion, but its application may be advantageously combined with percussion and friction from other sources, as in the wet hand rub or cold mitten friction. In this case, it is the bare hand or rough mitten that is the chief source of friction. The Brand or cold rubbing bath is another example of this combination of mechanical and thermic stimuli, each enhancing each. It must not be sup- posed, however, that the marked effect of this form of bath is due merely to a combination of the thermic and mechanical stimuli. It is necessary 1 Baruch Principles and Practice of Hydrotherapy, p. 31. 8 PROPERTIES OF WATER that water be used. Apropos of this question, we quote the following from Baruch: "We would again insist upon the fact that neither in typhoid nor in cardiac inadequacy, can these effects, or anything like them, be produced by cold alone (for that has been thoroughly tried in both cases), by the tem- porary application of water alone, of whatever temperature, or by either dry saline or gaseous or mechanical irritants. It is absolutely necessary that, not merely cold, but cold water should be used, that the surface should be literally rubbed with this for a considerable length of time. " ? The same may be said of the cold mitten friction. The astonishing results of this procedure can be obtained, neither by the application of cold alone, nor by friction with the dry mitt. It is only by vigorous rubbing with the mitt, dipped in cold water, that the maximum effects are produced. 4. Solvent and Chemical Properties. That these properties are of less importance than the preceding will be granted by those familiar with hydriatic measures. The solvent properties of water are utilized in the shampoo, enema, etc. Its value as a solvent in the processes of osmosis and dialysis are likewise made use of in hypodermoclysis and saline enemata. Many body wastes are but sparingly soluble and for this reason require large amounts of water to hold them in solution. The flushing of the system consequent on free water drinking is therefore one of the greatest of all aids to elimination. 3 As a means of combining thermic and chemical stimuli, it is used as a solvent in the Nauheim or effervescent bath, saline baths, etc. Going a little further from the physical into the physiologic activities and almost outside of the range of hydrotherapy, unless it be in water-drinking, we may consider water in its relation to the nutritive and metabolic pro- cesses of the human body. It is the medium of all commerce and exchange in the carrying of nutrition to the tissues, and wastes from them to the excretory organs. It constitutes 75 per cent of the body weight. Without it, life would be impossible. Not only is it concerned in the mere physical interchange of nutrient and waste substances, but it is actually necessary in by far the greater number of all chemical changes which these substances undergo. The popular belief that particular virtue resides in the mineral constituents of water used for hydrotherapeutic purposes is almost wholly erroneous. This is rarely the case and is confined to a very few procedures such as the Nauheim bath above mentioned. The treatment of rheumatism and obesity at various hot springs derives but little advantage from minerals present in the water (unless it be that "faith" in these induces the patient to drink more water than usual). The results are due to the thermic effects of the hot water, combined with regulation of diet and copious water-drinking. Balneology, the use of mineral waters in the treatment of disease, therefore, adds little or nothing to the science of hydrotherapy. In addition to the above mentioned properties of water, its universal dis- tribution and accessibility to all mankind render these qualities agents of wide applicability. 2 Baruch Principles and Practice of Hydrotherapy, p. 12. 3 See Chapter IX, item 2. CHAPTER II PRINCIPLES OF EFFECTS AND THERAPY The basic principles of hydrotherapy are found chiefly in an explanation of the effects of heat and cold. Viewed in this light, the science is that of themotherapy. Effects similar to those produced by thermic impressions can be obtained by sunlight, friction, percussion, and in fact, all physiologic agents. This is most notably true of light, many of the physiologic effects of which *run parallel with those of hydrotherapy. In fact, thermic and actinic energies are so closely related that they overlap each other in the visible spectrum. From the lowest limit of the scale of energies, up through electric energy, heat, light and actinic rays to radium emanations and the X-Ray, there is laid out before the physician a greater supply of efficient curative means than can be found anywhere else in the whole science of therapy. Therapy From Within Those agents which, by their toxic action, arouse the body to resist their intrusion, can not be classed as physiologic means. They excite abnormal and unusual activities which are largely directed against the toxic agent itself, rather than heightening the normal activities which keep the body in health and repel the onset of morbid processes. Merely to relieve tem- porarily a distressing condition, without enabling the body itself to over- come that condition, is doing no permanent good. The sick can not always be applying special means. After discovery, they must depend upon the natural surroundings and ordinary agencies which keep the body in health. For example, to relive pain by cocaine, an ice bag, pressure or a fomenta- tion is productive of no lasting good, unless that cocaine, ice bag, pressure or fomentation causes the body to overcome the condition producing the pain; and its repeated application brings about such a change that the pain (or diseased condition) does not reappear after the curative agent is with- drawn. The body must be made to "cure" itself. The restorative power lies in nature. The natural God-given forces must be rejuvinated. The power from without must produce or "arouse power from within. Warm and Cold-blooded Animals The reason that thermic applications and impressions are so powerful in arousing body functions lies in the fact that life activities are carried on only within a certain limited range of temperature. With regard to body temperature, there are two general classes of animals, viz., the warm and the cold-blooded. The temperature of so-called "cold-blooded" (poikilothermic) animals rises and falls with their surroundings. The organism is not injured by 10 PRINCIPLES OF EFFECTS AND THERAPY comparatively wide variations. The frog, for example, is lively in water at 70 F., and sluggish in water at 45 F., but it nevertheless lives and remains normal in either. These variations do not seriously depress vital activities. The organism is able to withstand such radical changes in the temperature of its blood and body generally, without this change being inimical to its life. The body temperature of these animals remains slightly above that of the cold water they may be in and slightly below that of warm water. Cold-blooded animals are principally aquatic and amphibian. Certain other animals maintain a constant temperature under varying conditions. The surrounding air, whether hot or cold, does not materially alter their body temperature. The heat mechanism is so nicely adjusted that more heat is produced when the surrounding medium is cold, and less when the air or other medium is hot. This class of animals is called "warm- blooded" (homeothermic) because of the constant temperature at which their blood is kept. Arterial blood is slightly warmer than venous. The ordinary limits for man are about 101 103 F. Organs of constant activity, such as the heart, liver and brain have a temperature 2 C 4 higher than the average of the blood stream. At ordin- ary room temperature, the uncovered skin has a temperature of from 92 $y F. This fact is of importance in the adminstration of neutral baths. The water should be 1 or 2 higher than that of the general skin tem- perature. This secures a full sedation by adding a slightly relaxing effect. As noted above, the internal temperature of warm-blooded animals is com- paratively a fixed point, or varies within only very narrow limits, not more than one degree in health. Any radical or prolonged departure from this fixed point (98.6 F. by mouth) interferes with vital functions. Intrinsic Effects When the body becomes thoroughly chilled, as by a long ride in the cold, the pulse and respiration are slowed, the circulation is less rapid, the nerves benumbed, the muscles respond sluggishly and clumsily, the finer skilled movements are impossible, digestion is retarded, the body temperature is lowered. Cold is therefore, in itself, a vital depressant, i. e., it retards vital processes. This is its intrinsic effect. Kellogg records an experiment in which immersion of the body in water at 55 F. for ten minutes reduced the pulse rate from seventy-six to fifty per minute. Another, in which twenty minutes in water at 45 F., the patient being rubbed continuously, reduced the pulse rate from eighty to fifty-eight. Both experiments were upon healthy persons. In another experiment, exposure to cold showed tactile sensibility decreased. Before the exposure, the points of an esthesiometer were detected as two separate points at a minimum separation of 2 mm. After five minutes immersion in water at 40 F., the minimum distance was in- c -reased to 6 mm. Another, in which five minutes in water at 68.4 F., reduced the body temperature 0.8 F. These data serve to make definite, facts with which we are acquainted in a general way only. It will be seen from this that an overactive process may be retarded and brought back toward the normal by an application of cold, continued until it* intrinsic effects are manifest. The longer the duration of the cold REACTION n application, the greater its effect. The same is true of the degree of cold. The lower the temperature, the more pronounced the effects. While cold retards, heat stimulates vital activities. We know what it is to experience the vivifying effects of the warmth from a fire or sunlight after being in very cold air for some time. The circulation is quickened; the heart beats faster; respiration is more rapid; nerve sensibility is heightened; muscular action is quicker, more certain and precise, and digestion pro- ceeds more rapidly. In watching the activity of the white blood cell under the microscope, the stage must be kept warm or the movements will cease. The amoeba, paramcecium and other one-celled animals exhibit their peculiar movements only in the presence of a certain amount of heat. When cold, their movements cease entirely. Cold, per se, decreases oxidation and meta- bolic activities; heat increases the oxidizing capacity of the tissues and metabolic activities are hastened. When the body is overheated, its functions are abnormally increased and, if long continued, permanent injury may result. When heated only to a slight degree, however, sluggish activities are whipped up and, if the appli- cations of heat are repeated at intervals, the retarded functions tend to return to normal. Reaction The most interesting and phenomenal results of hydrotherapy are due to that complex process reaction, i. e., the part which the body itself takes in its own recuperation and healing. This interesting phenomenon, in its entirety, is observed only in homeothermic animals. Cold-blooded animals instead of reacting to their external medium are subject to the vicissitudes of their environment. On the contrary, warm-blooded animals maintain more or less uniformity of function because of the perfect control exercised over vital processes by the nervous system. This control is more highly developed and complicated than in poikilothermic animals. We have seen that the influence of cold is to depress vital activities; that is, if continued long enough, its intrinsic effect is manifest in depression. But let us notice the effects of a brief application of cold. A plunge into cold water increases the pulse rate and force, the skin becomes reddened because of a quickened peripheral circulation, and the respiration is deeper. The muscles are energized so that their capacity for work is increased. These heightened activities continue for a time, gradually returning to nor- mal. Reaction may be defined as a group or series of changes inaugurated by the body because of some disturbing external agent. More briefly, it is the response of the organism to an external agent. Rationale of Reaction. The explanation of these tonic and stimulating effects lies in the recognition of cold by the body as an agent which will depress its functions. Even though the contact be too brief to actually bring about this result, it immediately increases its activities in order to counter- act the anticipated depression. The body tends to resist or overbalance attempts to alter its temperature. In doing so it is said to react against this change, or attempted change. Cold, in and of itself, causes depression. But the attempt on the part of the body to resist this depression results in 12 PRINCIPLES OF EFFECTS AND THERAPY heightened activity. This is spoken of as the reaction or reactionary effect. It is always the opposite of the intrinsic effect. Some very common exam- ples of this will serve to illustrate the principle. An ice bag applied over the heart for five minutes slows the pulse rate, while slapping the chest with a cold wet towel, or a short cold douche to the chest, increases both the pulse and the respiration rate. A long cold application, as a cold tub bath, lowers the body temperature, while a short cold application, as a cold plunge or cold douche soon results in an increase of body temperature. If the external cause is long continued, the reaction may not be appar- ent, may be lost or obscured by the intrinsic effect. The body reacts or attempts to react to even prolonged applications of cold, so that what is seen as a result of these long applications is really a mixture of the intrin- sic and reactionary effects. l As to which shall predominate depends upon the intensity and duration of the application. With the more prolonged applications, the reaction is suppressed or obscured, while in those of inter- mediate duration, we often see as much of one as of the other. TIME UNIT Fig. 3. Diagram illustrating the time factor in the obtaining of intrinsic and reactionary effects. With heat, as used in actual practice, we observe its intrinsic effects when the hot application is short, i. e., of brief duration. The first effect of heat is that of a stimulant and tonic; but, if long continued, depression results. This depression is, by some, termed "a reaction. " Baruch objects to this term as applied to heat. If we define reaction as the vital response to an external force, or the attempt on the part of the organism to counter- act an external agent, we can see no great objection to the term, or to say- ing that the reaction to heat is of an atonic nature. 1 In discussing these two classes of effects, intrinsic and reactionary, some writers use the term "primary'' as synonymous with intrinsic and the term "secondary" as synonymous with re- action. Since the intrinsic effect of cold is neither primary in point of time, nor in all cases pri- mary in importance, the term leads to confusion. The same may be said of the expression, "secondary." The reaction often appears before the intrinsic depressant effect of the cold be- comes manifest and so can not be said to be secondary as far as time is concerned. Also, if from a certain application a reaction is desired, then the reaction can not be said to be secondary in importance. For these reasons we object to the terms as demanding different definitions under different circumstances of use. They must, therefore, prove confusing. REACTION 1S The accompanying diagram (Fig. 3) illustrates the relation existing be- tween the duration of the application and the obtaining of intrinsic and re- actionary effects. The thick ends of the wedges indicate prolonged appli- cations ; the thin ends, brief applications. Intrinsic effects are shown at the left and reactions at the right. Tonic effects are obtained from the, Intrinsic effects of heat (short); reaction to cold (short). Retarding and depressant effects are obtained from the, Reaction to heat (long) ; intrinsic effects of cold (long) . Abrams 2 makes the following statement: "Respecting the physiologic effects of heat, it suffices to say, that a prolonged application of a high tem- perature is primarily an excitant, and secondarily, a depressant; a brief application, however, is strongly excitant and the depressing effects, if any, are imperceptible." In discussing the effects of thermic stimuli (on secre- tion) Pope 3 says, "In general terms it may be stated that brief applica- tions of thermic stimuli, whether hot or cold, stimulate sepretion, differing in degree rather than in toto; long-continued applications depress." It must not be concluded from the above grouping that the depressant effects of a long cold application (intrinsic) and those of a long hot applica- tion (reaction) are identical in nature. The depression is manifest in dif- ferent ways. With cold the depression is in the nature of a simple retarda- tion of vital functions, whereas with the heat the depression is manifest chiefly in the nervous and muscular systems, 4 and is perhaps best described as atonic. That this is largely a nervous phenomenon is apparent from the fact that a vigorous cold treatment following prolonged heat often quickly restores the patient to a normal condition. Phases of Reaction. There are two important phases of reaction, viz., the circulatory and the nervous. The circulatory is most apparent and is that by which we judge the completeness of reaction. The skin should be- come ruddy and warm. The patient feels a warm glow over the entire skin surface. There should be nothing of stasis, no cyanosis or goose flesh. The skin should be smooth, soft and pliable. The nervous reaction is appre- ciated not only by the patient but by the observer. The dull listless appear- ance of the eye and countenance generally gives way to a decided brighten- ing. If there is delirium or stupor, as in typhoid, pneumonia, etc., it may be replaced by quiet sleep. In fact, the salutary effects are visible in all the nervous functions of the body. With a neurasthenic patient the feeling of langour, restlessness and weight in the abdomen is replaced by that of vigor and exhilaration. Another phase of reaction is that termed thermic. It is the response of the heat mechanism to stimulation. It is of less prac- tical importance since it can not be conveniently utilized in judging of the completeness of reaction. Types and Degrees of Reaction Suppressed Reaction. It is often desirable to suppress or limit the re- action arising from some application. This is especially true with long 2 Spondylotherapy, p. 175. 3 Hydrotherapy, p. 35. 4 Metabolic changes are hastened by prolonged heat. 14 PRINCIPLES OF EFFECTS AND THERAPY cold applications which are designed to delay vital activities or reduce fever. Of course the body attempts to react to all such measures as have been mentioned. The reaction may be limited, e. g., by a cold application such as an ice bag to a part. The nervous excitability is lessened by the continuous and severe cold so that the phenomena of reaction do not appear in their entirety and completeness. In the case of a Brand bath, the exciting stage soon gives way to a slower heart beat, slower and deeper respiration, etc., by reason of the continuance of the cold. In general, the suppression of the reaction depends upon the intensity of the cold and its duration, being greater with the lower temperatures and with the prolonging of the appli- cation. Repeated Reaction. In the giving of alternate hot and cold treatments the body is called upon to react several times. After two or three applica- tions, the reactions are less complete. The oscillatory changes occuring in the blood vessels become less and less in amplitude after each succeeding application. In order to produce complete reactions where the applications are repeated, it is necessary to increase the intensity of the stimulus. This may be done in the case of alternate hot and cold by using a higher tempera- ture for the hot and a lower temperature for the cold or by adding mechan- cal stimuli. Incomplete Reaction. Applications not properly suited to the reactive ability of a patient will result in an incomplete reaction. Should this occur, the patient experiences quite unpleasant symptoms such as chilliness, shiv- ering, cold feet, a feeling of fullness in the head, and even faintness and nausea. These are due mostly to the internal congestion which has not been relieved or has been made more intense. Conditions Influencing Reaction Age and Vitality of Patient. In either extreme of life the ability to react is quite limiied. Neither infants nor aged persons bear cold treatment well. We have treated persons in advanced life who were utterly unable to react to even cool water as applied by the wet hand rub, and who invariably chilled after a cold mitten friction. In certain diseases or states, the vitality is so reduced as to render reaction extremely difficult. This is true of nearly all those diseases which produce a profound asthenia. In anemia and extreme emaciation the same conditions prevail. In all such cases it is necessary to thoroughly warm the body pre- vious to the cold application and give vigorous friction during and following the treatment. Even these means will not always insure a reaction. Exercise, sufficient to warm the body, promotes reaction. This is true whether taken before or after the treatment. It quickens the circulation and brings the blood to the surface. Body heat is increased so that the surface blood vessels become dilated in order to increase heat elimination. Fatigue is not conducive to completeness of reaction. In case it is neces- sary to treat persons who are fatigued, a short hot application should be given first, quickly followed by some short but very vigorous cold treatment, accompanied by friction or percussion. CONDITIONS INFLUENCING REACTION 15 Warmth of the Body. When the body is warm, reaction appears promptly The internal heat of the body may be ever so much and yet reaction be im- possible if the skin is cold and clammy, pale, cyanotic or gooseflesh in ap- pearance. The skin should be warm and, if possible, ruddy before cold appli- cations are used. In case it is not, some sort of hot treatment should be used first, in order to draw the blood to the skin. The air of the room in which the patient is treated should be warm and he should remain in a warm room after treatment until reaction is complete. It may be necessary to give a drink of hot water in order to warm the body. More essential than all these is the warmth of the feet. It is impossible to secure full reaction or the best possible results, if the feet are cold. It should therefore be a general rule that the feet should be warmed by a hot foot bath or alternate hot and cold foot bath or hot foot pack, previous to any and all treatment. In the giving of even an enema, this is necessary. After treatment, it may be necessary to provide the patient with additional covering either in the form of bedding or clothing in order to secure full reaction. Psychic Attitude. It is difficult to produce complete reaction in a patient that dislikes certain measures. That the mind does exercise an inhibitory influence over body functions can not be doubted by those whose practice brings them in contact with profound neurasthenia. Those under great mental strain, worry or anxiety react poorly. Character of Treatment and Mode of Application. In all cases where re- action is likely to be tardy, the cold treatment should be preceded by a hot treatment. In ordinary cases the hot application should exceed in duration the cold application. It should thoroughly warm the body and make the cold a welcome change. The reaction is more prompt in its appearance if extreme cold is used and accompanied by friction or percussion. The colder the water, the greater the reaction. The cold treatment should be given quickly. The treating of one part at a time favors the quick appearance of the reaction. The larger an application or the more general the surface treated, the less promptly will the reaction appear. Friction with the dry hand or a rough towel following the drying, enhances the reaction. Per- cussion has the same effect. The drying from sprays and general applica- tions of water should be done as quickly and as thoroughly as possible. If moisture is left on the surface, the resulting evaporation cools the body and reaction is delayed. The patient should be dried in a warm room near the place where the last application of water was made. To properly shape circumstances so as to favor reaction, requires much care and forethought on the part of the attendant nurse. A little carelessness may undo much or all of the benefit which should accrue from a given treatment. Test of the Reactive Ability. Tne ability to react to cold applications varies with the climate of former residence, state of health, occupation and habits of the patient. As to the reactive capacity little can be determined by questioning the patient. Often those who say they are unable to take cold baths react as well or better than those who affirm their ability to re- act. What one calls very cold another regards as only cool. Some persons consider that they have been taking cold baths when bathing in water at 90_95 p. The response of a patient with anemia is usually in direct pro- 16 PRINCIPLES OF EFFECTS AND THERAPY portion to the degree of anemia. The state of the vasomotors and the readiness with which they react to mechanical stimuli serves as a rough test of the ability to respond to cold treatment. This test is mentioned by nearly all writers on hydrotherapy. Baruch 5 makes the following state- ment: "I have found that the response of the cutaneous circulation to mechani- cal excitation furnishes an index to the probable reactive capacity of the patient. Passing the back of the nail of the index finger rapidly but gently across the abdomen, and increasing the pressure of the nail with a second stroke parallel to the first, induces a more or less deep reddening of the irri- tated skin. The rapidity with which the red line develops after the nail is removed and the pressure required to produce it afford the trained eye a crude but fairly correct test of the patient's reactive capacity. By apply- ing this test frequently before each procedure, one may readily train the appreciation of this test and thus avoid the necessity of slow development of the reaction by gradual increase of the intensity of the treatment which the author adopts in most cases." Common Names of Temperatures Heat and cold are relative, not absolute, terms and must needs be defined. This can not be done with accuracy since patients differ in their toleration of heat and cold. What one designates as very cold may be only cool to another. The most satisfactory way is to define the limits in terms of de- grees. The following has been found practical: Very hot 104 F. and above Hot 100 104 F. Warm (neutral 94 97) 92-100 F. Tepid 80 92 F. Cool 70 80 F. Cold - 55 70 F. Very cold 32 55 F. 5 Hydrotherapy, p. 102. CHAPTER III ANATOMY AND PHYSIOLOGY OF THE SKIN The skin is the key-board of hydrotherapy. Comprising as it does such a large variety of tissue elements in an exceedingly complicated arrangement, every part of which is directly or indirectly connected with the functions of all other parts of the body, it is essential that its more important functions and their anatomic basis should be well understood. This is especially true of the vessels and nerves of the skin through which this connection with the internal organs is made, for by these connections, the physician is enabled to influence at will the circulation, and to a large extent, all the other func- tions of these organs. Only those points which serve to explain the practi- cal applications of hydrotherapy will be noticed here. The epidermal layer acts as a protection to the delicate and sensitive structures underneath. The dermis contains those structures with which we are most concerned. It is made up of two fairly distinct layers the pars papillaris, upon which the epithelium rests, and the pars reticularis beneath the former and lying next to the panniculus adiposis. The knob-like projections of the papillary layer are of two types, viz., those containing blood vessels (vascular papil- lae) and those containing nerve endings (tactile papillae). Both layers of the dermis consist of a reticulum composed of bundles of connective tissue, surrounded by elastic fibers. ' For the most part, the fibrous bundles lie parallel to the skin surface. Those fibers nearer the surface are finer and more densely packed, producing a felt-like texture, while those of the deeper layers nearer the subcutaneous fat, are coarser and more loosely arranged. Muscular and Elastic Tissue Smooth muscle fibers are intimately associated with the elastic fibers. The two together constitute one of the most important anatomic arrange- ments in the skin, as we shall see presently. In many parts of the skin the muscle fibers are present in the form of a network, contracting diagon- ally. - The muscular tissue exists mostly as the erectores pilorum disposed in bundles in connection with the hair follicles and lying in an oblique direc- tion through the thickness of the skin. These muscle bundles are sur- rounded and traversed by elastic fibers so that they are enclosed in a dense network of elastic tissue, threads of which serve as tendons to connect the ends of the muscular fasciculus to the connective tissue bundles of the cor- 1 Bohm, Davidoff and Huber Text Book of Histology, p. 382. 2 Baruch Principles and Practice of Hydrotherapy, p. 5. 18 ium. 3 The varied degrees of tension of the skin are due to the changes in this musculo-elastic mechanism. Baruch lays much stress upon these changes as being the chief cause of alterations in the cutaneous circulation, which are brought about by thermic impressions. Under medium temperatures the muscle fasciculi are at medium tension and the skin is ordinarily pliable. Cold causes contraction of these muscular bundles and these, embracing in there action the smaller vessels of the corium, especially the terminal capil- lary loops (both arterial and venous) of the papilla, produce blanching of the skin. Heat relaxes the muscles; the tension being relieved, the elastic fibers return to their usual condition and the skin is again soft, loose and pliable. Higher degrees cause increased relaxation up to a certain point, where heightened tension is again manifest. These facts explain the mech- anism and the great importance of the contractility of the skin in the pro- pulsive movement of both blood and lymph. This contractility supplies the place of the muscular coat of the blood vessels which is absent in this situa- tion. The elastic fibers forming as they do, a fine membrane around the blood vessels and opposing the action of the muscular fibers may be sup- posed to support vasodilatation. The disappearance of elastic fibers from the skin in arteriosclerosis (Meissner) where rigidity and high tension are essential accompaniments, may lend color to this view and possibly reveal something of the pathogene- sis of high tension and subsequent vascular sclerosis. The Blood Vessels The blood vascular system of the skin on the arterial side is arranged in two quite distinct horizontal networks an upper and a lower, besides being especially abundant about the hair follicles and coil glands. The latter structures are surrounded by a basket-like network of blood vessels. The lower or inferior plexus lies in the deepest part of the derma. It consists of comparatively large vessels. From this plexus, vessels extend more or less vertically upward to form the upper or subpapillary plexus. From this plexus, vascular loops extend directly into the papillae above. "In the papillary vascular system, the arteries are narrow and the veins wide." 4 Baruch states that the papillary loop may be so filled with blood, that it may double and fold over in spiral windings until it occupies almost the en- tire space of the papilla. This capacity for increasing or diminishing the size of the capillary loop furnishes an important agency by which hydrother- apy may affect the circulation. 5 Both papillary veins and arteries consist of an endothelial tube only. Near the middle of the subcutaneous tissue, the media and adventitia appear. In the veins the muscular coat is found earlier, i. e., in the plexus at the base of the derma, where they also seem to possess valves. 6 In the case of the capillary vessels, these coats are supplied by -the musculo-elastic tissues of the skin itself, as mentioned above. Vasomotor nerves are twined around these vessels in all their ramifications. " 3 Hyde and Montgomery Diseases of the Skin, p. 35. 4 Hyde and Montgomery Ibid., p. 29. 5 Baruch Principles and Practice of Hydrotherapy, p. 6. 6 Bohm, Davidoff and Huber-Histology, p. 386. 7 Hyde and Montgomery Ibid., p. 29. THE LYMPHATICS The Lymphatics 19 "The lymph vessels of the true skin are also distributed in two layers a deep and wide-meshed plexus (collecting trunks) in the subcutis and a super- ficial narrow-meshed plexus (capillaries) immediately beneath the papillae. " 8 The latter vessels (Fig. 4.) begin in the papillae as an exceedingly fine mesh- work of endothelial-lined and absolutely closed cul-de-sac spaces in the con- nective tissue. These culs-de-sac divide and anastomose in a very free man- ner. The capillaries of the subpapillary plexus also posses endothelial walls of their own. They are devoid of valves. While the lymphathic capillaries communicate neither with the connective tissue, nor with the blood vessels, they are nevertheless in very intimate physiologic relation with both these structures. Cellular migrations and os- motic exchanges take place readily, so that the capillaries fulfill their func- tions as drains, and according to Renaut, selective drains. 9 According to Unna, the interspinal spaces, delicate channel- ings in the cement substance between the epithelial cells, are in communica- tion with the lymphatic spaces of the papillary region of the corium. But, as stated above, this is not an ana- tomic communication, but a physiologi- cal relation and is doubtless the path taken by substances which are absorbed from the skin surface. Some affirm that absorption occurs partly through the coil glands. The epithelium of ex- cretory glands has, however, but slight absorptive powers. At their commence- ment in the capillaries, the lymphatics have a capacity equal to and greater than that of the veins. This diminishes, the nearer we approach to the thoracic duct, the calibre of which is much smaller than that of the vena cava. I0 Fig. 4. Origin of lymphatic vessels in a papilla of the hand. (Sappey) The deep, wide-meshed plexus located in the subcutis, forms part of the superficial lymphatics (collecting trunks) of gross anatomy (Fig. 5) are larger, though very irregular and sacciform channels, dividing and anas- tomosing freely. The wall consists of endothelium, together with an elastic and muscular coat. They are provided with valves at variable distances. From the fingers to the axillary glands, Sappey counted sixty to eighty. These are crescentic folds of endothelium, resembling the aortic semilunar valves and arranged in pairs (Fig. 6). The alternate constrictions swellings which give the lymphatic vessels their beaded appearance a to these valves. According to Delamere, the supravalvular enlarger 8 Bohm, Davidoff and Huber Histology, p. 387. 9 Fourier, Cuneo and Delamere-The Lymphatics, pp. 74, 75. 10 Fourier, Cuneo and Delamere Ibid., p, 62. 20 ANATOMY AND PHYSIOLOGY OF THE SKIN are true contractile sacs, similar to the lymphatic hearts of batrachians. From the standpoint of hydrotherapy, the fol- lowing statement by the same writer is signifi- cant. He says that because of the elastic fibers, connective tissue and muscle, the lymphatic walls are, in spite of their fineness, resistant, extens- ible and retractile. They withstand, without rupture, the pressure of a column of mercury of from thirty to forty centimeters. n 10. 12. We have noted above the various structures by which the blood and the lymph vessels are Fig. 5. Superficial lym- phatics of the arm, anter- ior surface. Lymphat- ic network of fingers and palm. Collecting trunks nf arm and forearm. (Sappy) 1 1 Fourier, Cuneo and Delamere The Lymphatics, p. 70. 12 Physiology 1898, p. 289. l:i Human Physiology 1905, p. 132. 14 Bohm, Davidoff and Huber Histology, p. 223. Fig. 6. Valves of the merenteric chylifer- ous vessels of the new born cat. (Delamere) rendered contractile. We ought now to consider briefly the contractility of the endothelium. This is of no little importance in those vessels, the blood and lymph capillaries, which possess no other coats. These endothelial cells contract and expand, causing changes in the calibre of the capillary channel. According to Foster 12 these contractions are allied to the changes in muscle fibers which constitute contraction. Landois '" states that these motor phenomena are to be observed especially after irritation in the living animal. Schmetkin found nerve fibers distrib- uted in the large blood vessels, not only in the adventitia and media, but also in the intima. 14 It seems, then, a well established fact that all THE LYMPHATICS 21 the parts of the vascular system, whether large or small, arterioles, capil- laries or venules, whether blood or lymph vessels, of whatever size, all pos- sess the power of contractility. We may next consider the behavior of these vessels in health, the extent, frequency and causes of contraction; also the influence of physiologic agents upon the extent and frequency of these changes. Practically all the vessels of the body are under the control of the nervous system, through those filaments known as vasomotor nerves, or are played upon by such contractile mechanisms as the skin, which is it- self influenced by stimuli similar to those of a vasomotor nature. These vasomotor fibers are said to be of two classes, first, those which when stimulated produce vasoconstriction; second, those that produce vasodilatation. The controversy as to the existence of the latter, or whether vasodilatation is produced by a cessation of vasoconstrictor influences, does not concern us in the practical application of physiologic measures. While the vasomotors originate in more or less definite centers, and seem to be more abundant in certain localities and in certain nerve trunks, they are nevertheless distrib- uted with other nerve fibers and are found in all parts of the body. CHAPTER IV That the heart beat and mere mechanical elasticity of the blood vessels (like the elasticity of rubber tubing) are not the only forces concerned in the propulsion of the blood has long been recognized. In a case of hemi- plegia, following an apoplexy, there is a decided lowering of blood pressure on the affected side and a consequent stasis, as evidenced by the cyanosis and lowered temperature on this side. This can not, of course, be due to any difference in the propulsive power of the heart, since the oppo- site side reveals no such marked changes in its circulation. It can only be due to some disturbance of the vasomotor mechanism, resulting in changes in the blood vessels themselves, since the causative lesion is confined to the nervous system. The writer was very forcibly reminded of this influence of the blood vessels on blood pressure in a case of depressed fracture of the left cranial vault, the pressure from which involved nearly the whole of the Rolandic area on this side, including the speech center. The radial pulse on the right side (opposite the lesion) was scarcely perceptible, while that on the left side was strong and apparently about normal. Numerous other ob- servations might be cited, showing the effects of vasomotor influences on blood pressure and the circulation. We may well ask, what is the normal action of the blood vessels which plays such an important part in the propulsion of the blood and the main- taining of blood pressure and which, when interfered with, results in such marked changes. These changes are, a priori, associated with and dependent upon alterations in the calibre of the vessels themselves. A lowering of pressure being due to a widening or dilatation of the vessels and an increase of pressure to the opposite condition, a narrowing or contraction of the ves- sels. The vascular condition entering into the normal rapidity of the circu- lation is neither the one nor the other extreme. A permanent widening of the vessels leads to stasis of blood, while a permanent narrowing results in heightened blood pressure, arteriosclerosis and its resultant chain of dis- asters. Traube-Hering Waves. In health, there are continuous and more or less rhythmic alterations in the calibre of the blood vessels. Speaking along this line, Landois ' says the diameter of the vessels "is subject to periodic varia- tions, not only in the vessels provided with muscular tissue, but also in the capillaries in the latter, in consequence of the spontaneous contraction of the protoplasmic cells that form their walls." Moreover, Sir Michael Fos- ter states that these changes which vary considerably, both in their rhythm 1 Human Physiology 1905, p. 180. TRAUBE-HERING WAVES and extent, occur without any obvious changes in either the heart beat or the general circulation and when the animal (under observation) is appar- ently subjected to no disturbing causes. He regards them as spontaneous, although subject to vasomotor control. In determining changes in the amount of blood in the arm by the plethys- mograph, the fluctuations in volume, as registered by the kymograph, per- mit recognition of the following phenomena. 2 (Fig. 7) 1. Pulsatory fluc- tuations due to each individual heart beat. 2. Respiratory fluctuations. 3. Certain peri- o d i c fluctua- tions dependent upon periodic- regulatory movements of the blood ves- sels, particu- larly the smal- ler vessels. "Waves are often observed on the blood pressure curve, which must arise in a slow rhythmic varia- tion of the con- strictor impul- ses sent out from the vaso- motor center. These waves are known as the T r a u b e- Bering cur- ves. " 3 Rela- tive to the blood pressure tracing as tak- Fig. 7. Blood pressure tracings showing Traube-Her- ing curves taken from a dog. (Martin) The upper trac- ing, taken while artificial respiration was being carried on, shows the three curves the pulse wave, represented by each double stroke; the respiratory wave, covering about five pulse waves; and the vasomotor or Traube-Her- ing wave, the slower undulations covering five respiratory waves. The lower tracing, taken just after the cessation of artificial respiration, shows only the pulse waves and the Traube-Hering waves. en with a mer- cury manometer (Fig. 8), Howell 4 says, " The latter waves (Traube-Hering) are . . . due to a rhythmic action of the vasomotor center. During sleep, certain much longer, wave-like variations in the blood pressure also occur that are again due, doubtless, to a rhythmic change of tone in the vasocon- strictor center." Changes similar to those producing the Traube-Hering wave may also be observed in the spleen (Fig. 17). 2 Landois Human Physiology, p. 190. 3 Starling Elements of Human Physiology, p. 276. 4 Physiology 1908, pp. 564, 565. 24 THE PERIPHERAL HEART In discussing periodic variations in blood pressure Janeway 5 gives the fol- lowing: "These are evident in the human being as in the animal. The res- piratory and the Traube-Hering waves, and the other less rhythmical but apparently spontaneous fluctuations in mean blood pressure, must be in mind during every clinical experiment. . . . Exact figures for the possible pressure variations due to these causes are hard to give, but their extent in animals, combined with my observations on the changes noted in patients from moment to moment, lead me to place 30 mm. Hg. as the probable maximum rise which may be attributed to them. One sees these larger fluctuations mainly in patients with hypertension. Ordinarily, 5 10 mm. would be a liberal estimate." In this connection Janeway gives a tracing by Mosso taken from a man at rest in which the Traube-Hering wave covers on an average of fifteen pulse waves, thus showing a fluctuation recurring about four or five times a minute. *(i^^ Fig. 8. Rhythmical vasomotor waves of blood pressure in a dog (Traube-Hering waves) . The upper tracing (1) is the blood pressure record as taken with the mercury manometer; the lower tracing (2) is taken with a Hurthle manometer. Events occuring in other parts of the body may give rise to large changes, so that the arterioles may become constricted almost to obliteration, or di- lated to more than double their usual diameter. These observations apply to arteries, capillaries and veins. In the vessels of the web of a frog's foot, direct treatment of the web may bring about the same changes. Since these rhythmic vascular changes normally occur quite independently of the heart beat, we have here a factor in the circulation which, under proper physiologic stimulation, may be utilized to relieve that organ of much of its work, so that when overburdened, it may obtain needed rest through the slowing of the rate and the increasing of the force consequent upon this help. Landois, 6 in discussing blood pressure as altered by changes in the size of the vessels, mentions the application of heat and cold to circum- scribed areas as influencing blood pressure through the vasomotor nerves. It is to the applications which bring about such changes as these that we MOW turn our attention. 5 Clinical Study of Blood Pressure, pp. 112, 113; see also pp. 1621. 6 Human Physiology, p. 166 THE PRINCIPLES OF VASCULAR EFFECTS 25 The Principles of Vascular Effects The underlying principle of applications calculated to awaken an activity of the circulation is found in the old dictum, ubi irritatio, ibi affluxus. Where there is an irritation, there is an afflux of blood. Rub vigorously the back of the hand and the skin becomes reddened with an increase of blood. Percussion or a dash of cold water produces the same results. These are examples of what we may term physiologic irritation. All forms of irrita- tion produce an initial contraction of the blood vessels, i. e., the primary effect of an irritation from any source is contraction. The oscillatory changes which soon result (reaction) are different with the different kinds of irrita- tion. In fact, it is this reaction with which we are principally concerned. In some cases, the first effect is of no practical importance, while in others, it is utilized. Heat, for example, causes an initial vasoconstriction. The secondary vascular contractions are slight and become less and less the greater the duration of the application, so that a prolonged application of heat results in a maximum dilatation. The remote effect is not a reddening of the skin from quickened circulation, but a slight duskiness from stasis of blood (passive hyperemia) . These are the effects of a fomentation, heating compress, radiant heat, etc. The reaction to heat is therefore of an atonic and depressing nature. With a cold application to the skin, the first effect is a blanching (vaso- constriction), but this is soon followed by a reddening (active hyperemia) which, as we know, is maintained for a considerable length of time and does not result in a dusky color. Here, the oscillations in vascular calibre are stimulated in such a way that they are greater, more forcible and do not tend to passive dilatation. This is the reactionary effect of cold. Mechani- cal irritation, such as friction and percussion, give similar results. How- ever, the two combined as in the cold mitten friction, cold percussion douche, etc., give quicker, better and more lasting effects. Kellogg 7 records the following experiment as showing the advantage of mechanical irritation, combined with cold. A cold compress and a percus- sion douche, both at 65 F. were simultaneously administered to opposite and corresponding parts for five seconds. After the cold compress, the re- action appeared in forty seconds, whereas, after the cold percussion douche, the circulatory reaction appears in five seconds. As the cold application is prolonged, the amplitude of the vascular oscilla- tions becomes less and less until the condition is more nearly that of a con- stant vasoconstriction. ' 'Following the process to an extreme point, we find that, by intensely low temperatures, the circulation in the capillaries is at first accelerated and the number of blood corpuscles diminished, when the part becomes pale. Quickly following this acceleration, there is a stasis in the capillaries, while in the smaller veins and arteries, the slowing of the circulation is followed by brief and rapid oscillations, which become slower and more infrequent. Slowly the vessels become more pale, less transparent, and finally, the movements cease." * This is, of course, providing reaction occurs at all, as it usually does if the cold is applied to a limited area. If 7 Rational Hydrotherapy 1901, p. 1126. 8 Baruch Principles and Practice of Hydrotherapy, p. 39. 26 THE PERIPHERAL HEART the reaction does not occur, as where there is a general application of cold without friction, the skin becomes blanched and goose flesh appears, due to the contraction of the erectores pilorum. In case an ice-cold application remains long enough on one part, paralysis of the vessels results and a con- sequent dilatation. Saline substances and certain gaseous irritants, chief among which is COs, when applied to the skin also produce an active dilatation and contract-" ion of the blood vessels which results in quickened circulation and increase of blood in the skin. Saline baths are of ten more effective than plain water. Carbon dioxide and salines are most effectually used in the combination con- stituting the Nauheim or effervescent bath. Here the cool water itself plays some part, since temperatures somewhat below neutral are used. "So marked is the effect of this skin tonic that in severe cases of dilatation (of the heart) the almost incredible result is attained, of causing the apex actually to retract three quarters of an inch toward its normal position in a single treatment. " 9 The heart beat is decreased in frequency and increased in force; its previously labored beat gives way to a steady, easy movement and, in some cases, we have actually been unable to detect murmurs which were previously distinctly heard. These results are by all, conceded to be due chiefly, if not almost wholly, to the stimulation of the great vascular area of the skin, the so called "peripheral heart" or "skin heart." When we consider the magnitude of this peripheral heart, it no longer becomes a wonder that its influence is so powerful. Vierordt estimates the combined calibres of the capillaries of the systemic circulation as 800 times that of the aorta in cross section. With this fact in mind, we may gather some idea of the magnitude of the effect produced by saline and gaseous irri- tants acting simultaneously upon such a great system of contractile tubes. Such results can not be obtained by digitalis or strychnine. That these results are not due to simple atonic vasodilatation is shown by the fact that these patients are frequently cyanotic, an evidence of already existing venous stasis and vasodilatation, while on emerging from the bath, the skin is of a brighter and more normal color. Neither vasodilatation nor vasoconsti iction are conducive to a slower, easier heart beat. The result is therefore not a passive change, but an active one. Electric currents applied to the skin also stimulate the vasomotors. Near the positive pole vasoconstriction is manifest, while in the region of the cath- ode vasodilatation occurs. With alternating or interrupted currents the vasomotors are much more powerfully stimulated. This "stimulation is great- est with the sinusoidal current, the use of which in the obtaining of vascular effects will be mentioned more in detail in the part on therapeutics. The Quantity of Circulating Fluids When we consider the total quantity of blood and lymph in the body, and the fact that the skin and adjacent tissues may contain a large share of this, or influence its distribution elsewhere, we see how powerful an agent the skin is in controlling the circulation of these fluids in the various organs. About 1-13 of the body weight is blood. Of this, nearly thirty per cent 9 Baruch Principles and Practice of Hydrotherapy, p. 10. THE QUANTITY OF CIRCULATING FLUIDS 27 may be contained in the skin under the influence of certain conditions and applications. Ordinarily, there is J of the blood in the heart, lungs and great blood vessels; J in the liver; J in the skeletal muscles; and J in other organs. The circulation of the skeletal muscles is influenced with that of the skin, and usually the same changes occur simultaneously in both. The amount of lymph in the body is variously estimated from J or 1-5 to J of the entire body weight. 10 This enormous quantity of fluid is affected in the same way by physiologic applications as the blood. Kowalski, ll in 1901, reported a series of experiments undertaken to deter- mine the effects of thermic irritants upon the movement of lymph and upon the vasomotor nerves of the lymph vessels. Briefly stated, his conclusions are as follows: Thermic irritants control the flow of lymph, not only indirectly, but also by altering the calibre of the lymph vessels. These changes are the same as those in the blood vessels, i. e., low temperatures contract them, while higher temperatures dilate them. These effects are produced through the nervous system, by way of the vasomotor nerves. The vasomotor nerves of the lymphatic vessels act independently of those controlling the blood vessels and general circulation. It will be seen from this that the use of the alternate hot and cold leg bath for oedema is based upon demonstrated physiologic facts, the lymphatics as well as the blood vessels taking part in the absorption of tissue fluids. Experiments on the production of lymph in the limbs have also brought out in a very striking manner the rationale of massage in dropsy. In the resting limb there is no flow at all from the tissue spaces. Berlin blue in- jected under the skin finds its way into the lymphatics with extreme slow- ness, unless absorption is facilitated by kneading the limb or by carrying out passive movements. "Ludwig has shown that the lymphatics of the aponeuroses are so arranged that every movement, active or passive, tends to pump fluid from the tissue spaces into the lymphatics and from the smaller into the larger lymph trunks. Experiments on the production of lymph in the limbs have therefore always to be associated with kneading or passive movements in order to get any lymph flow at all." Alternate hot and cold applications together with massage are more effectual in oedema than the combined effects of all other known agents. 10 Fourier, Cuneo and Delamere The Lymphatics, p. 7. 11 Blatter fur klinische Hydrotherapie, January and February, 1901. 12 Starling Fluids of the Body, p. "2. CHAPTER V ANATOMY AND PHYSIOLOGY OF THE SKIN (Continued) The Sudoriparous or Coil Glands The sweat glands are distributed throughout the entire skin. They are most numerous in the axilla, palms and soles, where they are also of unusual size. And, according to Krause, there are between 2000 and 3000 per square inch. The total number in the body is estimated at from 2,000,000 to 3,000,000 and their aggregate length uncoiled and placed end to end, as about eight miles; while the total surface of the ducts is estimated at 11,000 square feet. These figures serve to show the great importance of hygiene, directed toward the maintaining of their normal functions and the tremen- dous effect of bad hygiene in causing disease. The sweat gland consists of a long tubule, coiled at the deeper end. The globular coil (glomerulus) lies in the subcutaneous fat, or in the fat columns of the deeper part of the corium. Next to the epithelium in the coiled part of the tubule, are found smooth muscle fibers, disposed longitudinally, or spirally. The muscle fibers are doubtless concerned, along with the erectores pilorum, in the checking of perspiration which results from cold applications. Each tube is about four or five millimeters long. Three- fourths of this makes up the coil. J The sweat pore that part of the duct lying in the epidermis is a wall-less channel, spiral or straight in course. The outer end is funnel-shaped. The pore is in free communication with the juice spaces of the epithelium, as was mentioned in considering the lym- phatics of the skin. It will be seen from this fact that the drying of the skin is not alone a drying of the surface, but also a drying of the fluid found between the deeper cells of the epidermis. A capillary network of blood vessels surrounds the coiled part of the gland. Nerves from the sym- pathetic neurons end in the secreting cells. The secretion of the sweat glands varies with the character and amount of food and drink, the state of health, temperature and humidity of the air, etc. About 98 per cent is water, 2 the remainder being chiefly salines, pig- ment and a small amount of fat. In twenty-four hours, one and one-half or two pints of water are excreted. This is approximately double the amount exhaled by the lungs. Contrary to the general notion, the skin does not excrete large quantities of deleterious substances. In health the poisons excreted by the skin are very small in amount. 1 Bohm, Davidoff and Huber Histology, p. 397. 2 Hyde and Montgomery Diseases of the Skin, p. 46. THE SUDORIPAROUS OR COIL GLANDS 29 Vicarious Functions of the Skin. There is a great similarity in the struc- ture of the tubules and glomeruli of the kidney to the coil glands of the skin and their vascular tufts. This very similarity in structure suggests a similarity in function. The perspiration and urine are both excretions and, to a great extent may replace each other. In disease, this fact becomes very evident. When the kidneys become incompetent to excrete certain wastes these are often found in the sweat and, vice versa, when perspira- tion is interfered with, more work is thrown on the kidneys. In warm weather, excessive perspiration occurs, while the urine is scanty. In cold weather the perspiration decreases and the urine increases in amount. Urea, normal in the urine to the extent of about 2 per cent, is found in normal perspiration to the extent of 0.1 to 0.2 per cent. Schottein, in cer- tain cases of the uremia of cholera, saw the whole body covered with a thin white crystalline layer of urea. 3 In cases of pyemia, where the sta- phylococcus albus was present in the blood, the sweat induced by packs has shown abundance of the staphylococcus. The same is true of many other diseases in which there are germs in the blood (bacteriemia), the kidneys also excreting the germs. Bouchard 4 has called particular attention to the cutaneous eruptions which accompany auto-intoxication, especially with a dilated stomach, or after eating mussels, shell-fish, etc., as being due to ptomaines eliminated through the skin. In some forms of auto-intoxication, various poisons excreted by the skin may be appreciated by their odors. The special cdors about prisons and asylums are doubtless more or less due to the volatile poisons of faulty nutrition which the skin exhales. In cases of jaundice, bile pigments are found in the sweat so that sheets and bed- ding are stained by it. Sugar may be found in the sweat of diabetics and in the sweat of cases of forced glycosuria. Dr. Herbert U. Williams of Buffalo has recently 5 shown that in chronic nephritis the sweat glands are extensively altered in structure. He exam- ined skin from various parts in seventy cases of chronic nephritis and found a variety of conditions including desquamation of the epithelium, cystic dilatation of the tubules, atrophy of the tubules, and cast- like material in the tubules. In fourteen cases, arteriosclerosis of the arteries of the skin was present. In some cases, hypertrophy of the epithelium was observed, even to the formation of two or three layers of cells. Dr. Williams states that these studies were undertaken because, from the earliest ages, faith has been placed in the efficacy of active skin excretion in cases of nephritis. Summary of Perspiratory Influences Factors which govern perspiration: 1. Degree of internal or external heat. 2. Amount of water in the body. 3. Amount of blood in the skin. 4. Specific stimulation of secretory (sweat) nerves, as by electricity, shock (as cold sweat of fright, etc.), drugs. 3 Baruch Principles and Practice of Hydrotherapy, p. 26. 4 Auto-intoxication in Disease, pp. 20, 162. 5 Journal of American Medical Association, April 17, 1909. p. 1276. 30 ANATOMY AND PHYSIOLOGY OF THE SKIN Conditions that give rise to increase of perspiration: 1. Applications of heat, as hot air, hot water, steam, light, etc. 2. Water drinking, especially of hot water. 3. Exercise. 4. Mechanical irritation, as friction or percussion. 5. Diaphoretic drugs. Conditions that decrease perspiration: 1. Chilling or cold applications. 2. Excretion of large amounts of water by the kidneys or bowels. 3. Certain drugs, as atropine. 4. Local application of astringents, or cooling preparations, as alcohol, vinegar, talcum powder, etc. The facts listed in the above outline are perhaps too evident as matters of every-day experience to need comment. In practice, we usually combine two or more of these measures in order to secure quicker and better results. For example, the drinking of cold water before and during the electric light bath greatly enhances its results. The drinking of hot lemonade in con- junction with hot packs, vapor or Russian baths, likewise gives quicker results. Heat applied to the skin not only increases the blood about the coil glands, but also stimulates, directly, the secreting cells. Cold, applied to the skin, causes a decrease in the amount of the blood in the skin and so lessens the available fluid which the sweat glands utilize for secretion. It has been shown that drugs having a specific action upon the sweat glands, cause alterations in the structure of the secreting cells, thus prov- ing detrimental to their healthy activity. The Sebaceous Glands The sebaceous glands are sacciform in shape, found in connection with the hairs of the skin and pouring their secretion into the follicles of the hair and lanugo. The oil or sebum is produced by fatty degeneration of the gland cells themselves; more cells being produced next the basement membrane to take their place. It is designed to oil the hair and skin. The glands are situated next the hair follicle, between it and the piliary muscle. Heat softens the oil in the glands, and thereby brings about its extrusion. Oil is a non-conductor of heat. Covering the skin with oil hinders both the eli- mination of heat where the surrounding atmosphere is cold and the absorp- tion of heat where the atmosphere is heated. Absorption by the Skin We are not greatly concerned in hydrotherapy with the absorptive powers of the skin. Oily substances are most readily absorbed, watery solutions not at all. Absorption of oily substances, alcoholic or ethereal solutions is greater after a warm bath and cleansing of the skin, since the sweat pores are then open and the increased circulation favors absorption-. Guy Hinsdale fi gives an excellent summary of the subject of cutaneous (> Hydrotherapy, p. 21. THE SEBACEOUS GLANDS 31 absorption from which we quote the following: "James Currie, who wrote one of the first and best books on hydrother- apy, states that there is no increase of weight in the bath, and while the skin remains sound and entire no absorption of solid, liquid or aeriform elastic fluid takes place on the surface. In the instances that are supposed to favor the contrary opinion, it will be found that the article is forced through the epidermis by mechanical pressure, or that the epidermis has been previously destroyed by injury or disease." Roehrig in experimenting with a bath to which potassium iodide had been added, found that full immersion in this for three quarters of an hour gave rise to no iodine in the urine. Negative results have also been obtained by a number of other observers using various soluble substances. Substances causing injury to the skin may be absorbed, also ethereal solutions of certain alkaloids, but R. Winternitz found no evidence of the entrance of these substances from watery solutions. One must, therefore, conclude that the mineral constituents of water other than strong salines and gaseous constituents have no effect whatever upon the human system when applied to the unbroken skin. Hinsdale makes a very apt statement of the case, "We are thus forced to the conclusion pre- viously enunciated, that the mineral waters, the analysis of which are quoted with such particular exactitude unto the third or fourth decimal place of grains per gallon, are neither more or less efficacious on that account. Cutaneous Respiration To a limited extent, the skin acts as a respiratory organ when the tem- perature is above 85 F. About 0.5 per cent of the total gaseous exchange of the body occurs in this manner. The amount of CO2 exhaled at 91.4 F. may be doubled at 93 F., increasing in about the same ratio as the watery excretion. Hot, moist applications to the skin increase the elimination of COa, since diffusion of gases is hastened by the moistening of the surface and the larger amount of blood brought to the skin. It is said that, in dis- eases of the heart and lungs, where there is diminished excretion of CCte in the expired air, cutaneous exhalation is increased. In asthmatic dyspnoea when the skin becomes flushed and perspiration free, the dyspnoea is some- what relieved. General perspiration produced by hot applications also re- lieves dyspnoea. The Skin a Heat Regulator This will be considered again under the subject of Heat Regulation. The skin itself takes part in heat loss only, although through nerve connection, it is one of the most important means in controlling heat production. "The loss of heat by the skin amounts to about 77 per cent of the total heat loss. " It is therefore the most important factor in the elimination of heat. The regulation of heat loss by the skin is accomplished by variations in the amount of heat radiation and evaporation of sweat. It will be seen that heat applied to the skin increases heat loss in two ways: first, by dilating the surface vessels and quickening cutaneous circu- 7 Starling Human Physiology, p. 505. 32 ANATOMY AND PHYSIOLOGY OF THE SKIN lation, thus increasing heat radiation and convection; second, by inducing free perspiration and the consequent loss of heat by evaporation. Conversely, cold applied to the skin decreases heat loss by driving the blood inward and checking perspiration. It is chiefly through the temperature nerves of the skin that this organ influences heat production. So profound is this influence that extensive burns, covering more than two-thirds of the body are fatal through destruct- ion of the sensory nerve terminals. Not only is heat elimination interfered with, but metabolism becomes excessive and heat production is immensely increased. Internal congestion and inflammations result, with a fatal termi- nation. After a drunken debauch, the unfortunate victim is in great danger from exposure to cold, because the sensibility of the nerves is temporarily de- stroyed, so that the heat regulating centers are not apprised of the danger. The boy who died from gilding of the skin, to represent an angel, is an exam- ple of the disturbance of the heat mechanism due to interference with the regulatory functions of the skin. After varnishing of the skin, the tempera- ture at first rises and then falls, accompanied by symptoms of poisoning due to the defective oxidation. Nerves of the Skin We have already considered the secretory and vasomotor nerves of the skin. The third set of cutaneous nerves of importance in hydrotherapy are those already mentioned as forming the connection by which the skin regu- lates heat production and loss, viz., temperature nerves. These nerves are not uniformly distributed in the skin. They are more numerous in certain localities than in others and where more numerous, the temperature sense is more acute, such as in the tips of the fingers, the cheeks and backs of the hands. These are the parts we instinctively use to test the safety of hot water bottles and other hot applications. The recognition of heat is confined to the "hot spots" and that of cold to the "cold spots," as can readily be proven by experiment. Lightly resting the point of the pencil on the skin will produce a sensation of heat or cold according as it rests on a hot spot or cold spot. The two sensations are appreciated by different end organs and travel by different fibers. Applications to certain localities produce more intense temperature sensa- tions than to others. Applications to a large area produce a greater inten- sity of sensation than applications to a smaller area. These facts are utili- zed in controlling the circulation reflexly and mechanically (q. v.). The temperature sense is more acute when the skin is warm or after warm appli- cations. This fact is utilized to prepare the body for cold applications, so that the reaction will be greater and appear more promptly. As has been mentioned, the temperature of the skin is the zero of the temperature sense. The skin contains also the end organs of tactile sensation. They are more numerous in certain localities than in others, as are the temperature nerves, and likewise serve to make the connection by which cutaneous applications influence internal parts. CHAPTER VI THE CIRCULATION REFLEX EFFECTS During health, there are vasomotor influences constantly playing upon the arteries in all parts of the body. These influences hold the vessels in "tone," i. e., control the rhythmic oscillations in calibre, so that blood pres- sure is maintained. These influences seem to emanate from a vasomotor center which is located in the medulla oblongata in the floor of the fourth ventricle. "Irritation of this center causes contraction of all the arteries and, in consequence, increase in arterial blood pressure." "Paralysis of the center causes relaxation and dilatation of all the arteries, with enormous reduction in blood pressure. Under normal conditions, the vasomotor center is in a state of moderate tonic excitation." 1 While this center exercises a controlling influence overall, it is not the only vasomotor centre. "Centers for the vascular nerves, both vasomotor and vasodilator, are distributed throughout the entire spinal axis." "They can be excited reflexly, although they are subordinated to the dominating centers in the medulla oblongata. " 2 "It is obvious that such a mechanism as that described. . . . is susceptible of reflex stimulation through sensory nerves, and according to our general knowledge we should suppose that a tonic centre of this kind may have its tonicity increased (excitation) or decreased (inhibition)." 3 It is to the reflex stimulation of these centres that we now wish to turn our attention, for through this channel, hydrotherapy produces some of its most important effects. Maximilian Schuller, 4 in experimenting on trephined rabbits, observed that severing single nerve trunks on one side of the animal produced a dis- tinct (though transient) dilatation of the pial vessels on the corresponding side, thus proving that the blood vessels of the piamater are held in steady tone by continuous excitation from the cutaneous sensory nerves. This re- sult was observed only on the side of the severed nerve ao that it could not have been due to shock or pain. "Naumann has demonstrated clearly that the effects of external irritants upon the circulation within the body are really reflex. He separated the head of a frog from the body, leaving them connected by the medulla oblongata, only. He next severed one leg, after preventing loss of blood by ty- ing the vessels, so as to leave it connected with the body by the sciatic nerve. Now he applied thermal, chemical and electric stimuli to the foot of 1 Landois Physiology 1905, p. 762. 2 Landois Physiology, p. 735; see also Howell- Physiology, p. 564; and Foster Physiology 1898, p. 285. 3 Howell Physiology, p. 560. 4 Deutches Archiv fur klinische Medicin, No. 4, 1874. 34 THE CIRCULATION REFLEX EFFECTS the partially severed leg:, while he observed, under the microscope, the mesentery of the frog. Shortly after gentle irritation of the peripheral end- ings of the sciatic nerve in the foot, the circulation in the vascular network of the luna^s and mesentery was accelerated, and resumed the former condi- tion slowly after the withdrawal of the irritant. A more severe irritation produced retardation of the flow, and even stasis occurred, as if the heart had become temporarily paralyzed. A strong irritant produced dilatation; a feeble one, constriction of the vessels. The effect of these peripheral irri- tations upon the heart was also noted. A strong irritation of the skin weak- ened its circulation; a feeble irritant strenghtened it. As there was no pos- sible vascular or nerve channel from the part irritated to the part thus visi- bly affected, the conclusion is inevitable that the effect is entirely reflex. Hot water acted precisely as other irritants." 5 These experiments also prove that there are two reflex means by which the circulation may be influenced, viz., reflex stimulation of the vasomotors, producing changes in vascular calibre, and reflex stimulation of the heart muscle itself. Another point, brought out by the experiments of Roehrig, is that when intense cutaneous irritants produce considerable slowing of the heart beat, they also increase its force. This is the effect of a prolonged cold application, whether general, as with the Brand bath, or local, as with the ice bag to the precordia. Reflex Areas The fact of reflex stimulation being established, we may next consider the location (topography) of the various reflex areas. While the brain, heart and other viscera may be reflexly influenced by stimuli applied to many different cutaneous areas, some even very remote from these organs, the maximum effects are produced by stimulation of certain very definite and well recognized areas. In general, it may be said that the skin over an organ is reflexly related with that organ. In most cases, it is not difficult to trace the nerve connection. "In general, the skin overlying an organ is reflexly associated with it, which is the reason why applications of electricity over an organ usually influence it, and not altogether because the current is passed through the organ. When these areas are studied comparatively, it is noted that they are practically the same as those regions pointed out as showing reflex pain, which would suggest a nervous path from the organ to the skin and from the skin to the organ, the terminations of which are in the same visceral and cutaneous fields." 6 So definite and circumscribed are some of these areas that B. G. A. Moynihan has frequently observed, in cases of duodenal ulcer, a small hypersensitive spot in the skin covering the abdomen, directly over the ulcerated area. It is no larger that a six-pence and he attaches much value to this phenomenon in differentiating ulcer. ' It must not, however, be supposed that the reflex path from the viscera 5 Baruch Principles and Practice of Hydrotherapy, p. 37. 6. S. D. Ludlum The Relationship between the Spinal Cord, the Sympathetic System and Therapeutic Measures Journal of American Medical Association, May 2, 1908, pp. 1401 1405. 7 W. D. Haines The Differential Diagnosis of Duodenal Ulcer and Gall Stones Surgery, Gynecology and Obstetrics March, 1908, p. 279. PLATE I THE INNERVATION OF THE HEART (POWELL) REFLEX ARC 85 to the skin over which pain is referred is the same path as that utilized in therapeutics for reflex effects upon the internal organs. Nor are the skin areas to which pain is referred always the same areas that should be util- ized to influence reflexly the organ in which the cause of pain is located. For example in the case of liver and gall-bladder disease there is frequently a pain in the region of the right shoulder or shoulder blade, but it is not to this region that applications are made to relieve distress due to hepatic or biliary affections. The various cutaneous areas to which ceral disease is referred, are spoken of as the dermatomes of Head. They are in some cases of considerable service in diagnosis and are sometimes serviceable as a guide in the placing of therapeutic applications. They can not, however, be implicitly relied upon for either pur- pose. Relative to this unreliability Abrams 8 says: "The elicitation of the dermatomes of Head is a tedious method of examination and not always" accom- panied by satisfactory results for the reason that a great amount of experi- ence is necessary. Alsberg in the ex- amination of two hundred women (with gynecological affections) found cutane- ous areas of hyperalgesia in only seven- teen, ten of whom were hysterical. Therefore, he could attribute no diag- nostic import to the zones in question beyond commenting on the fact that hysterical stigmata must be excluded before the zones of hyperalgesia could be regarded as trustworthy." Diagno- sis and therapeutics based on para-spinal tenderness must therefore be of a highly imaginative character and especially so when approached from the standpoint of a prejudgment as to the causes of dis- ease and consequently its treatment. The law that the skin over an organ is reflexly related with that organ may be recognized as an amplification of Hilton's law, TJie principle nerve to a joint not only supplies the articular surfaces, but also some of the main muscles that move that joint and the skin over these muscles. 9 In the case of the viscera, however, the deeper part of the reflex arc consists of a sympathetic neuron. The reflex arc consists pf several parts (Fig. 9 and Plate II). In gen- eral, the following is the path taken by 8 Spondylotherapy, p. 71. 9 Treves Applied Anatomy 1901, p. 209. the pain or tenderness due to vis- Fig. 9. Diagram to show path of vasoconstrictor fibers from vaso- constrictor center to the blood ves- sels and the path for reflex stimu- lation, v. c. The vasoconstric- tor center; 1, the central neuron of the vasoconstrictor path; 2, the the spinal neuron (preganglionic); 3, the sympathetic neuron (gang- lionic); a, the arteriole; 4, the sensory fibers of the posterior root connecting by collaterals with the vasoconstrictor center and subcenters; 5, fiber from cortical cell acting upon the vasoconstric- tor center. (Howell) 36 THE CIRCULATION REFLEX EFFECTS a stimulus arising in the skin from a thermic application and traced as a reflex stimulus to the organ underlying the skin surface treated. From the skin, it is conveyed by a sensory (temperature) nerve along a nerve trunk to the posterior root of the spinal nerve; entering the posterior root ganglion, where the fibre is seen to the distal axon of a T cell; it passes on through the central axon of the T cell into the posterior side of the spinal cord. On entering the cord, the fibre immediately divides into an ascending and a descending branch, both located in the posterior white columns and which give off collaterals to the gray matter. 10 The ones we are concerned with end in tufts about the cells of the column of Clark. According to Starling, 11 the vasomotor center in the medulla corresponds in position to the column of Clark which is doubtless that which represents the vasomotor center throughout the rest of the cord. From these cells, axons pass either into Gower's tract and end in the cerebellum, 12 or pass out with the anterior root, and through the white ramus to the ganglion of the lateral sympa- thetic chain. 13 Passing directly through this, or up or down through an adjacent ganglion, they end in a peripheral ganglion from which the viscus is supplied. "The fibers of the white ramus which pass through the ganglion and go to the periphery are known as the splanchnic efferent fibers, and constitute the secretory fibers of the splanchnic glands and the motor fibers of the muscular tissue of the splanchnic blood vessels and viscera." 14 By studying carefully the above reflex path, it will be noted that a stimulus may affect (be shunted to) cells either above or below (Fig. 9) the level at which it enters the spinal cord. And again, the fiber that conveys the reflex stimulus to the viscera may pass up or down in the gangliated cord. This fact is of importance in explaining why cutaneous nerves are connected reflexly with splanchnic nerve trunks not arising in the same segment of the cord. 15 Of the many reflex paths, we may pick out two as serving to quite fully illustrate reflex effects. First, let us study the reflex arc concerned in the effect produced by an ice bag applied to the precordial region. And second, the arc concerned in the reflex between the skin of the epigastrium and the stomach. The Heart. Before considering the reflex arc, we should understand that the heart is supplied with nerves from two sources. (Plate I.) First, through the vagus nerve (fibers of accessory part of the spinal accessory nerve) with inhibitory fibers, i. e., fibers which when stimulated, slow the heart beat and increase its force. Second, by accelerator fibers, which when stimulated, increase the rapidity of the heart beat through the cardiac 10 Whitakei Anatomy of the Brain and Spinal Cord, p. 38. 11 Physiology, p. 259. 12 Ludlum Journal of American Medical Association, May 2, 1908, p. 1403. 13 Whitaker Ibid., p. 39. 14 Gray's Anatomy 1905, p. 1071. 15 Each segment of the spinal cord may be regarded as a unit and possessed of sensory, motor, vasomotor, secretory and trophic functions. The roots and peripheral nerves derived from a given segment are an integral part of that segment. The connection of one segment with another does not interfere with this conception. PLATE II REFLEX ARC FROM SKIN TO HEART 1. Third intercostal nerve. 2. Anterior root of spinal nerve. 3. Posterior root of spinal nerve. 4. Posterior root ganglion. 5. Inferior cardiac nerve. 6 Gangliated cord of lateral sympa- thetic chain, a Inferior cervical jranglion. b, c, d, e 1st, 2nd, 3rd and 4th thoracic ganglia. 7. White ramus communicans. 8. Afferent sensory nerve of temper- ature. 9. The same in the spinal cord (pos- terior white columns) . 10. Collateral branches of No. 9. 11. Direct cerebellar tract. 12. Gower's tract. 13. Clark's column. 14. Level of 3rd thoracic segment. 15. Skin of precordia. 16. Heart with superficial cardiac plexus. REFLEX ARC 37 sympathetic nerves from the inferior cervical ganglion. The acclerator fibers emerge from the spinal cord in the anterior roots of the second, third and fourth thoracic spinal nerves and, according to some authors, are found also in the first and fifth thoracic nerves. 16 From these spinal nerves, they pass to the corresponding sympathetic ganglia of the lateral chain, through the white rami communicantes and thence upward to the inferior cervical ganglion. The ice bag applied to the precordia covers the skin supplied by the second, third, fourth and fifth thoracic nerves. The stimulus (of a depressing nature) produced by the cold application is carried to the spinal cord by the nerve fibers of these thoracic nerves which end in the same segments in which the accelerator fibers of the heart arise. (Plate II) The reflex stimulus produced by the afferent impulse (sensation of cold) upon the cells in the column of Clark is conveyed outward by the axons of these cells through the anterior roots and by way of the white rami reaches the sympathetic ganglia through which they pass to the inferior cervical ganglion, and thence, by the inferior (sympathetic) cardiac nerve to the superficial cardiac plexus and the heart muscle. The accelerator mechanism being depressed, the heart beats slower and with greater force from the proportionately greater action of the inhibi- tory nerves. An ice bag over the heart produces its action by depressing the accelera- tor (sympathetic) nerves and not by stimulating the vagus, as has been claimed by some; which latter, it will be seen, would be impossible since the prolonged cold of the ice bag exerts a depressing and not a stimulating effect which must be the case were slowing produced through the vagus. The Stomach. The skin over the pit of the stomach is supplied by the seventh and eighth intercostal nerves. 17 The great splanchnic nerve is formed by branches from the thoracic ganglia between the fifth or sixth and the ninth or tenth. It terminates in the semilunar ganglion of the solar plexus. 18 From the solar plexus, (cosliac part) fibers accompany the blood vessels to the stomach. "The nerves supplying the abdominal muscles and the skin are derived from the lower intercostal nerves and are intimately connected with the sympathetic nerves supplying the abdominal viscera through the lower thoracic ganglia from which the splanchnic nerves are derived." These reflex arcs may be traced out in the case of other organs and areas. While an application to the skin over an organ gives a maximum effect, applications to even very distant areas may be quite effective. For exam- ple, hot applications to the feet do not, under ordinary conditions, influence reflexly the circulation of the brain. But under conditions of vasomotor instability, such as that following a sunstroke, a hot foot bath may cause congestion of the brain (personal observation) . 16 Howell Physiology 1908, p. 542. 17 Gray's Anatomy 1905, p. 997. 18 Ibid., p. 1079. 19 Ibid., p. 997. 38 THE CIRCULATION REFLEX EFFECTS Special Reflex Areas The following are the principal reflex areas employed in hydrotherapy (Fig. 10 after Kellogg) : 1. The skin areas of the face, scalp and back of the neck are reflexly related with the brain. 2. The skin of the neck is reflexly related with the pharynx and larynx. 3. The back of the neck is reflexly related with the mucous membrane of the nose. 4. The skin of the chest (front, back and sides) , dorsal region and shoulders has reflex relations with the lungs. 5. The precordia is in very perfect reflex relation with the heart through its accelerator nerves 6. The hands are related with the brain and nasal mucous membrane. 7. The skin over the lower right chest, with the liver. 8. The skin over the lower left chest, with the spleen. 9. The skin over the lower third of the sternum, with the kidneys. 10. The mid-dorsal spine (from fifth to seventh vertebrae) is related with the stomach. 11. Lower dorsal and lumbar spine, with the kidneys and intestines. 12. The lower lumbar and sacral spine, with the pelvic organs uterus, ovaries, bladder and rectum. 13. The epigastrium, with the stomach. 14. The skin of the entire abdomen, especially that of the umbilical region, is reflexly related with the intestines. The fact that the pain of colic, appendicitis, etc., is referred to the region of the umbilicus is an evi- dence of a similar nervous connection. 15. The lower abdomen, including the groin and upper inner surfaces of the thighs are reflexly related with the pelvic organs. 16. The skin of the feet and legs is reflexly related with the brain, lungs and pelvic organs. This is not as powerful a reflex area as some others. More practically stated, the circulation, secretory and muscular activities of the viscera may be influenced reflexly by applications, as follows: 1. The brain, by applications to the head, face, back of neck, hands and feet. 2. The nasal mucous membrane, by applications to the face, hands and cervical and upper dorsal spine. 3. The lungs, by applications to the chest, shoulders and dorsal spine. 4. The heart, by applications to the precordia and upper dorsal spine. 5. The stomach, by applications to the epigastrium and mid-dorsal spine. 6. The liver, by applications to the lower right chest and the abdomen. 7. The spleen, by applications to the lower left chest and the abdomen. 8. The kidneys, by applications to the lower third of the sternum, lower dorsal and lumbar spine. 9. The intestine, by applications to the abdomen, and lower dorsal and lumbar spine. Lungs Heart Kidneys Stomach Liver Spleen .. Intestines .-.\. 1- Pelvic Viscera Brain V Ovaries and Tubes I Brain, Nasal Mucou ' Membrane and Lu Lungs Brain, Lungs and Pelvic Organs Fig. 10. Anterior Reflex Areas 40 THE CIRCULATION REFLEX EFFECTS 10. The bladder, by applications ' to the lower abdomen, inner surfaces of thighs, and the feet. 11. The uterus, by applications to the lumbar and sacral regions, lower abdomen, inner surfaces of thighs, breasts, feet and cervix. In the large majority of cases, the ventral areas give stronger reflex effects than the dorsal areas. This is doubtless for the reason that, with a ventral area, the effect is concentrated upon a single organ, while in the case of a dorsal area, limited to the region of the spine itself, the effect would be spread out over several organs, or possibly, the viscera of both the chest and abdomen. "If an ice bag is placed in contact with the whole length of the spine, the same effect on the heart and lungs is produced as that which is desired on the intestines, and the whole process is negatived, whereas, if limited anteriorally to the sixth segment, the effect is localized on the abdomi- nal viscera." * A reflex effect is then an indirect effect produced through nerve connection. An application to one part of the body which influences, through nerve con- nection, another part of the body is said to exert a reflex effect. Abrams 21 gives the following definition: "A reflex refers to involuntary production of activity in a part brought about by conduction of a stimulus along an affer- ent (sensory) nerve to the motor cells in the cord or medulla. This stimulus is converted into an impulse by the motor cells, which impulse is then con- ducted to a part by means of an efferent (motor) nerve." Classes of Reflex Effects Having established the fact of reflex action and traced out some of these reflex arcs, let us now consider the nature of the various reflex effects. We have already noted that there are three kinds of fibers which make up the splanchnic efferents: viz., the secretory, viscero-motor and vasomotor. These are also the chief functions of the various viscera and by these, meta- bolism itself and all other functions are controlled. "By applying heat or cold or other stimuli to the segment of the skin whose endings are in a seg- ment in which arise viscero-motor, vasomotor or other activities, we can reflexly affect the organ supplied by these tracts. That this can be done has been shown by the researches of Brown-Sequard and others, .... chiefly through the vasomotors. The change may be observed by heat and cold, impact of water, hand pressure, steady or alternated, electricity, mechanical stimulation or other means, yet the underlying principle remains the same. The application of these physical forms of therapy must be made more and more accurately to get the best effect." K There are two general classes of effects produced by these applications. They may be designated as pressor and depressor, as stimulant and calma- tive, or excitant and sedative. Because the pressor, stimulant or excitant effects are usually mild and tend to restore to a normal tone, they are fre- quently designated as tonic. 20 S. D. Ludlum Journal American Medical Association, May 2, 1908. 21 Spondylotherapy, p. 26. 22 S. D. Ludlum Ibid., pp. 1403, 1405. REFLEX EFFECTS OF COLD 41 Special Reflex Effects In general, the reflex effect of an application is the same as its direct effect upon the skin. That it may be somewhat less quantitatively would be a natural result. The following is a comparison of the direct and reflex effects of prolonged cold. A long (continuous) local application of cold decreases the vital activities of the surface treated and the internal part reflexly related therewith. 1. Effects upon the part to which the application is applied, a. The blood vessels of the skin or mucous membrane are contracted. Fig. 11. Sphygmographic tracing of radial pulse, showing contraction of the vessels of the forearm resulting from applica- tion of ice to bend of elbow. (Kellogg) jj .'.'-: TIME Iff 5ECOND5 Fig. 12. Plethysmographic tracing, showing diminution in the volume, of the forearm resulting from application of ice to elbow. (Kellogg) b. The cutaneous sensibility is lessened and reflex excitability is de- creased and slowed because of this. c. Glandular activity is decreased. d. The skin muscles are contracted. 2. The reflex effects, a. The blood vessels of the deep (internal) organ are contracted and remain so. 6. The nerve irritability of the internal organ is lessened. c. The glandular activity of the deep part is decreased and secretion is lessened. d. The muscles of the deep organ are caused to contract more firmly. 42 THE CIRCULATION REFLEX EFFECTS The reflex effect obtains as long as the application is in place and for a variable length of time after its removal. The duration and intensity of reflex effects depends upon the duration and intensity of the application. The vasoconstrictor effects of prolonged cold may not be very marked in health, but in the case of a congested organ, an ice bag applied to the reflex area produces an astonishing result. Special Reflex Effects of Prolonged Cold. 1. Cold applied over the trunk of an artery causes contraction of the artery and its distal branches. (Figs. 11 and 12) Example, ice bags applied over the carotid arteries decrease the blood going to the brain and head generally. Such an application is called a proximal application. 2. Prolonged immersion of the hands in cold water causes contraction of the vessels of the brain and nasal mucous membrane. 3. Prolonged cold to the upper dorsal region causes contraction of the vessels of the nasal mucous membrane and lungs. 4. An ice bag applied to the precordia slows the heart rate, increases its force, and raises arterial blood pressure. 5. An ice bag applied over the thyroid gland (in parenchymatous goitre) decreases its vascularity and lessens its glandular activity. 6. Long cold applications to the chest, at the back, front or sides, con- tract the blood vessels of the lungs, slow respiration, and increase its depth. 7. An ice bag to the epigastrium or mid-dorsal region causes contraction of the vessels of the stomach and lessens gastric secretion, while the appli- cation continues. ** 8. A long cold application to the pelvis, groin or inner surface of the thighs contracts the blood vessels of the pelvic organs. 9. A long cold sitz bath causes firm contraction of the uterine muscle, thereby reducing subinvolution. 10. A much prolonged, very cold application to the sacrum, such as a large ice bag. dilates the blood vessels of the uterus, thus increasing men- strual flow and inhibiting pain. This paralyses the reflex. The posterior re- flex area being in less perfect relation with the uterus than the anterior area, makes this possible. 11. Long cold applications to the face, forehead, scalp and back of the neck cause contraction of the blood vessels of the brain. 12. An ice bag to the lower third of the sternum or over the lower dorsal and upper lumbar regions causes contraction of the blood vessels of the kid- ney. 13. Ice bags applied to the sides of the neck just below the jaw contract the blood vessels of the pharynx. Special Reflex Effects of Short Cold. Short cold applications to a reflex area produce tonic and stimulating effects in the deep part by virtue of the reaction which soon follows. 1. Short cold applications to the face and head stimulate mental activity. 2. A short cold application to the chest, as a cold rub, friction or cold 23 See experiments by Kasanski in chapter on Peptogenic Effects. SPECIAL REFLEX EFFECTS 43 douche at first increases the respiration rate. Soon it results in deeper res- piration with a somewhat slowed rate. 3. A cold douche to the precordia or slapping the chest with a cold towel increases both the heart rate and force. After the cessation of the applica- tion, the rate decreases while the force remains increased. 4. A short very cold percussion douche to a reflex area causes active di- latation of the blood vessels in the related viscera, as a short cold douche to the sacrum or feet causes dilatation of the vessels of the uterus. 5. Short or moderately prolonged cold applications to the breasts cause vigorous contractions of the uterus of use in inertia uteri. 6. Short very cold applications to abdomen, hands or feet cause contrac- tion of the muscles of the bladder, bowels and uterus. 7. A short cold douche or ice bag intermittently to the lower third of the sternum causes increased renal secretion. 8. A very short cold douche to the liver causes active dilatation of its ves- sels and increases its glandular activity. 9. The reaction from a moderately prolonged cold application to the epi- gastrium causes increased gastric secretion. ^ Reflex Effects of Hot Applications. 1. A very much prolonged hot application to a reflex area produces pas- sive dilatation of the blood vessels of the related organ. 2. Long hot applications to the precordia and to many other parts increase the heart rate, decrease its force and lower blood pressure. 3. Hot moist applications to the chest facilitate respiration and expectora- tion. 4. Long, moderately hot applications over the stomach after meals in- crease gastric secretion and hasten digestion. The same, if given before a meal, decrease gastric secretion because of the atonic reaction which ensues. 5. Prolonged hot applications to the abdomen lessen peristalsis. 6. Prolonged hot applications to the pelvis, as a fomentation, pack orsitz- bath, relax the muscles of the bladder, rectum and uterus and dilate their blood vessels, increasing the menstrual flow. 7. A large hot application to the trunk, as a hot pack, in biliary or renal colic, relaxes the muscles of the bile ducts, gall bladder or ureters and aids in relieving the pain due to spasm of these muscles. CHAPTER VII THE CIRCULATION-HYDROSTATIC EFFECTS Not all of the circulatory effects occurring in organs and parts distant from an application can be explained by reflex action. In fact, many of the effects produced by hydriatic applications are quite the contrary to what we might expect were the results due alone to reflex stimulation. When Schuller, in the course of his experiments upon trephined rabbits, placed a sponge dipped in cold water (52 F) upon the trunk of a peripheral nerve, he obser- ved narrowing of the pial vessels. This was the same result as that obtained by pieces of ice applied to the dura. In both, there was vasoconstriction of the vessels of the pia; and we have seen that, by reflex stimulation, the same effects are observed internally as occur externally in the skin area treated. But when he applied to the belly or back of the rabbit, a wet compress of the same temperature, it always produced a prolonged and decided dilatation of the pial vessels, just opposite to the effect obtained in the first experiment quoted, and which we know was due to reflex stimula- tion. Again, he found that the application of warm water to the nerve trunk produced dilatation of the vessels, while warm water applied to the general skin surface by immersion, produced a narrowing of the pial vessels. Since the effects are directly opposite, both can not be explained by reflex action. Moreover, Schuller observed that immersion in warm water pro- duced more decided narrowing of the vessels than a warm compress; and immersion in cold water, a more decided dilatation of the vessels than a cold compress. These effects were in exact proportion to the extent of surface immersed. When the ears of the animal were kept out of cold water, they likewise filled with blood in common with the pial vessels, but when they were also dipped into the water, the vessels of the pia filled still more. The explanation of these contrary effects is quite obvious and will occur to anyone acquainted with the principles of hydrostatics. When the warm compress was applied to the animal, the cutaneous vessels dilated, thus in- creasing the flow of blood to, and amount of blood in, the skin area treated. This left less blood to flow to the brain and, in consequence, the blood vessels of the pia were less completely filled. When a greater surface was treated, as by immersion in warm water, a greater number of blood vessels were di- lated and much less blood left to flow to the head, resulting in an increased narrowing of the pial vessels. Considering the experiment with the cold compress and bath, we have the same underlying principles. The cold compress produced blanching of the skin and a decreased amount of blood in the periphery, with a resulting in- crease in the filling of the blood vessels of the brain, because of retrostasis. Schuller observed that rectal injections of cold water always produced BLOOD PRESSURE AND HYDROSTATIC EFFECTS 45 some dilatation of the vessels of the pia. These effects have been confirmed by the experiments of Vinaj, Naumann, Winternitz and others. That these results are hydrostatic, or mechanical, and not reflex is also con- firmed by the changes in blood pressure observed at the same time. In dila- tation of the blood vessels due to vasomotor action, there is a fall of blood pressure. Quite the opposite occurred when the pial vessels dilated because of a cold compress or cold immersion, i. e., a decided rise in arterial pres- sure. This we know is associated with vasoconstriction and can not, there- fore, be due to paralysis of the vasomotors. But when we consider that the cold application produced blanching of the skin and vasoconstriction over quite a large area and consequently, an increase in blood pressure, the whole process is quite apparent. The retrostasis and increase of blood pressure causes the cerebral vessels, which are not under the influence of the cold, to fill in order to accommodate the blood. The opposite group of conditions prevailed with the hot application: viz., narrowing of the pial vessels with a fall in blood pressure. The same prin- Fig. 13. Volume curve of right arm during a sitz bath at 110" F., showing derivative effect. (Winternitz) ciples apply here as above, opposite conditions resulting from opposite causes. The hot bath produced afflux of blood to the skin through vasodilatation, with a consequent decrease in blood pressure, the cerebral vessels narrowed because of a relative anemia. If the narrowing of the pial vessels had been due to reflex action, there should have been a rise instead of a fall in blooc pressure. Schuller observed that prolonging the warm application produced an increas- ing constriction of the cerebral vessels. This may be explained by the fact that a passive and extreme dilatation of the cutaneous vessels occurs wher the heat is maintained for a long time. This is the effect of a long, hot pa( which, in practice, we utilize where decided derivation is desi The hydrostatic effects of both derivation and retrostasis have been demon- strated by Winternitz, ' by clinical experiments. By means of the plethys- 1 W. Winternitz-Physiologische Grundlagen der Hydro- und Thermotherapie, pp. 43, 44. 46 THE CIRCULATION- HYDROSTATIC EFFECTS mograph he determined the volume curve of the forearm during a hot sitz bath and also during a cold sitz bath. The hydrostatic results are graphically shown in Figs. 13 and 14- The cold sitz bath caused an increase in the volume of the forearm, due to retrostasis, consequent on contraction of the vessels under the influence of the cold water. In the case of the hot sitz bath the blood vessels under the influence of heat dilated, and being more completely filled, caused a fall in the volume of the forearm because of the derivative effect. Secondary II ydrostasis. When the cold applications were prolonged, Schul- ler observed the widening of the pial vessels give way after a time to narrow- ing. In the case of compresses, this change occurred after two or three min- utes; with immersion, after jive to ten minutes. It is apparent to all, that a cold compress, after two or three minutes, becomes a heating compress, because of the cutaneous reaction and hence, a warm compress which brings Fig. 14. Volume curve of right arm during a sitz bath at 50 F., shoiving retrostatic effect. (Winternitz) about the narrowing of the cerebral vessels. The same is true of the cold bath. When reaction sets in, the skin becomes reddened, its vessels are filled with blood, and the cerebral vessels contract. This secondary hydrostatic effect is of great importance in the practical application of derivative means. A hot and cold percussion douche to the feet reduces cerebral congestion because of blood being drawn to the extremities by the reaction in the feet. \\ hen congestion in an organ has been reduced by a hot pack, the deriva- tion may be secured (made more lasting) by completing the treatment with a cold mitten friction, thus retaining the blood in the skin. Law of Antagonism. These hydrostatic effects are well recognized by physiologists. There is an antagonism between the vessels of the skin and viscera, between the internal and external vessels, so that, when the peri- phery is well filled, there is a relative anemia of the viscera, and vice versa. AREAS FOR DERIVATION 47 The so-called Dastre-Morat Law of Antagonism is thus stated by Sir. M. Foster, 2 "Moreover, the vascular changes in the skin are accompanied by cocresponding vascular changes in the viscera (chiefly abdominal) of the re- verse kind. When the vessels of the skin are dilated, those of the viscera are constricted, and vice versa; so that the blood ebbs and flows, so to speak, according to circumstances, from skin to viscera and from viscera to skin." These mechanical effects are necessarily produced solely by vascular con- nection and not by nerve connection. Their extent depends upon nothing so much as upon the extent of surface involved, as was shown by the experi- ments with the compresses and baths. This action is not confined to the blood vascular system, but applies to the lymphatic system as well. A warm application which causes vasodilatation will, of necessity, draw blood from all other parts of the body; and conversely, a cold application, causing vaso- constriction, will, in the nature of the case, drive the blood elsewhere, prin- cipally to the interior. In either case, the blood is driven into or drawn from the deeper parts. In the normal body, these hydrostatic effects are more or less evenly distributed over the entire vascular system, so that the effect in any one part is not so marked. For example, a hot bath or pack in health draws the blood more or less equally from all the viscera; but in case of con- gestion of some particular organ, that organ will be affected more than others by either derivation or retrostasis. A common example is found in the in- crease of pulmonary congestion, produced by cold drafts to the shoulders. In a healthy person, this might not result seriously, but in one susceptible to colds, or with an already existing congestion, it may cause an extreme congestion in a very short time. In the same condition, a hot pack will draw, proportionately, more blood from the lungs than from other parts. Again, a large hot fomentation to the loins, or a hot pack would, under normal con- ditions, withdraw from the kidneys only a small amount of blood; but when these organs are congested, there is a marked depleting effect manifest. The patient is bled into his own limbs and skin. Not only may areas quite distant from a part be utilized for depleting that part, but in many cases, skin areas near-by may be used to advantage. That this is not a new principle in therapeutics will be seen by referring to "leech" bleeding. It is directed that the leech be applied to the skin over the inflamed part. It sucks blood from the superficial branches of the same vessels that supply the deeper inflamed part. If, by hot applications, the arteries of the superficial set of branches be widened out, there will be less blood to flow into the deeper branches. Thus, will a fomentation draw blood from a part near-by that received its blood from the same large artery. Where there are large thick muscles under the skin area treated, the total vascular capac- ity of both, when filled to the limit, may produce a very decided derivation. Areas for Derivation The various viscera are mechanically related to superficial and other areas as follows. In most cases, these areas are utilized for depleting (deriva- tive) effect, but the opposite condition (retrostasis) may obtain where these areas are chilled. 2 Physiology, p. 287. 48 THE CIRCULATION HYDROSTATIC EFFECTS 1. The Brain. Blood may be withdrawn from the brain by hot applica- tions to the feet, legs or entire lower limbs, also to the spine or entire sur- face of the trunk. It is not practical to utilize the emissary veins of the cranial circulation for this purpose, since the reflex effect in dilating the cere- bral vessels would be greater than the depleting effect. In cases of severe sunstroke, the vasomotors are so unbalanced that even a hot foot bath may reflexly produce cerebral congestion, rather than depletion, and must there- fore be avoided. 2. Spinal Cord. Congestion here, if not too extreme, may be relieved by large fomentations to the spine (entire width of the back). This diverts the blood from the spinal arteries into the posterior divisions of the intercostal and lumbar arteries. Also by hot applications to the feet, legs or the skin surface of the trunk. In cases of acute cerebro-spinal meningitis, it is best to utilize the more distant areas. 3. Eye. Applications may be made to the forehead and side of the face, thus dilating some of the terminal superficial branches of the carotids, and depleting the deeper branches. 4. Middle Ear and Mastoid. By applications to the entire side of the head; also by very hot applications to the legs, abdomen and spine. 5. Pharynx and Larynx. By applications to the neck, thus depleting the deeper organs and congesting the surface vessels. 6. Lungs and Heart. The feet and lower limbs, skin surface of the trunk and hips, also the hands, arms and shoulders. Where the congestion is limited to a small area, as in circumscribed pleurisy, a fomentation may be used directly over that area. This dilates the posterior, lateral and anterior cutan- eous branches of the intercostal arteries, thereby withdrawing blood from the inflamed pleura. 7. Kidneys. The circulation of these organs is decreased by hot applica- tions to the back, thus dilating the posterior branches of the lumbar and lower intercostal arteries, and leaving less blood to pass from the aorta to the renal arteries. In extreme congestion of the kidneys, it is necessary to utilize much larger areas, as the entire surface of the trunk, hips and legs, or one of these areas alone. 8. Stomach. By large applications centering at the epigastrium, but ex- tending over the lower chest and sides of the abdomen, and well down over the umbilical region; also to the entire trunk. 9. Liver. By applications to the liver, also to the lower dorsal spine of the right side, extending forward and covering the epigastric and umbilical regions. The skin area of the lower limbs and hips is as important, if not more so, than the nearer areas. 10. Spleen. Similar to the liver, on the opposite side, also lower limbs. 11. Pelvic Organs Bladder, uterus, ovaries, tubes, rectum and prostate. To deplete these organs, two principal areas are utilized; first, the entire skin surface of the hips, pelvis, etc., as in a hot sitz bath or hot hip pack; second, the lower limbs, as in a hot leg bath or hot leg pack. Both areas VASCULAR CONNECTION 49 may be utilized by the use of the hot hip and leg pack or hot half bath. The student who is familiar with the anatomy of the circulatory system will be able to figure out the vascular connections between the organs men- tioned above and areas named with each. In nearly every case, it is quite obvious. These areas are of importance, not alone in ordinary congestion, but of almost inestimable service in actual inflammation of these parts, as shown later. (See Treatment of Inflammations.) CHAPTER VIII THE CIRCULATION-BALANCE BETWEEN REFLEX AND HYDROSTATIC EFFECTS By reference to the observations recorded under reflex and mechanical effects, it will be seen that thermic applications to the surface exert two classes of effects a reflex and a hydrostatic effect which are directly oppo- site, and therefore, conflicting. Probably, an application produces more or less of both, though one or the other usually predominates. Since they are opposite, one will neutralize or overshadow the other. Kellogg ] makes the following statement: "Doubtless both of these effects are always produced. When the application is general, the mechanical effect is dominant; when the area involved is limited, the reflex effect is prominent. In general appli- cations, the primary reflex effect is quickly effaced by the succeeding mechani- cal effect, due (in case of cold) to the inrush of blood from the periphery. This diversion of blood from the surface vessels to the interior of the body is termed retrostasis. Marked retrostasis is produced only when the cold application is made simultaneously to a very large cutaneous area." These are essentially the views of Schuller, who considered that, at the beginning of the application, the pial vessels were affected reflexly, which effect is soon overbalanced by the thermic effect upon the vessels of the skin. "If the surface area to which the application is made is small, the reflex effect may be confined to the internal area in sympathetic relation therewith, and will be greater and more prolonged for the reason that the reflex influence is concentrated upon a circumscribed area; while the mechanical effect is distributed over the rest of the body so that it does not overshadow and wipe out the reflex effect on the smaller area involved." Baruch's comment 2 upon this subject is as follows : ' 'Baths and other procedures without mechani- cal excitation, when applied to large portions of the body, doubtless have a hydrostatic effect; while douches, which impinge on limited portions, and are combined with mechanical effects (irritation) , act chiefly by reflex influ- ence." Is it possible to determine which result will be greater in a given case, or which will be practically the only effect from a certain application? In reply to this very natural question, we may state that there are definite laws governing these opposing actions. By them, one may so time and regulate applications as to secure a desired and definite result. Laws of Balance The following are the laws; other things being equal, these conditions obtain: 1 Hydrotherapy, p. 103. 2 Principles and Practice of Hydrotherapy, p. 48. LAWS OF BALANCE 51 1. Size of Application or Area. A small application has a greater reflex effect. The mechanical effect predominates if the application is large, and the larger the application, the greater the mechanical effect. 2. Intensity of Application. An application of great intensity (very hot or very cold, or with percussion) has a greater reflex effect. An applica- tion of less intensity has a greater mechanical effect. 3. Area Involved (as to location) . The chief result of an application to certain areas (example, the precordia) is a reflex effect. The principal re- sult of an application to certain other areas (example, the feet and legs) is mechanical. Duration of Application. The duration and intensity of the effect de- pends upon the duration and intensity of the application. In the obtaining of either reflex or hydrostatic effects, these factors are not of equal importance in governing the results. The size of the area treated has a greater governing effect upon the result, than the intensity of the application. Stated in the order of their importance they are as listed above. With a few areas, however, the location is of far more importance than either the size or intensity of the application. These areas are the head, precordia and lower limbs. Applications to the two former, of whatever size or intensity, always give reflex effects chiefly, while applications to the latter nearly always give hydrostatic effects. Examples: The prolonged application of an ice bag (small application of intense cold) to the precordia (special area) produces a (reflex effect) pro- longed slowing of the rate of the heart beat, and a decided increase in its force for the same length of time. There is very little tendency to produce retrostasis of blood (mechanical) , or engorgement of the heart. A hot trunk pack (large area) withdraws blood from the viscera (hydro- static effect) rather than producing dilatation of their vessels (reflex effect) . A hot and cold douche to the chest (small intense application) stimulates the heart and respiration (reflex effect), rather than having any decided (mechanical) effect upon the blood current of these organs. Applications to the head (special area), whether hot or cold, have a reflex effect almost entirely. Many other examples might be given, but the principles involved in the above are the same as those which govern other applications. It will be seen that, although reflex and mechanical effects directly oppose each other, the reflex overshadows and obliterates the mechanical when certain areas are involved, and when those areas are small and the application intense. The me- chanical effect wipes out the reflex effect when the application is to certain other areas, is less intense, and especially, when these areas are very large. We have so far discussed these two classes of effects as to their opposing results. Reflex and mechanical effects may be made to assist each other in secur- ing depletion, when diverse applications are made to different areas simul- taneously. This will be discussed under the head of ' 'Derivative Effects. CHAPTER IX THE CIRCULATION-BLOOD PRESSURE Blood pressure is governed by the following three factors: 1. The heart beat. 2. The amount of blood. 3. Vascular calibre and action. 1. The Force of the Heart Beat, its rapidity and the volume of its out- put, are secondarily influenced by the other two factors. So closely related are these three, that practically one can not be studied without studying the other two. Influences which bring about a change in any one of these fact- ors, produce through that factor a change in the remaining two. (Figs. 15 and 16.) General hot baths, such as hot air, electric light, Russian, and full hot tub baths, increase the heart rate and decrease its force. This is due to reduction in the peripheral resistance occasioned by the extensive vasodila- tation which is itself the direct cause of the lowered blood pressure. Gen- eral cold baths or even fair sized cold applications, increase blood pressure because of the resulting vasoconstriction. Those things which directly affect the heart beat, come principally through reflex stimulation. All sorts of cold applications to the precordia increase the force of the muscular contractions and so raise blood pressure. After a brief rise, hot "applications to the precordia decrease blood pres- sure. Short cold applications to the precordia increase the heart rate, while long cold applications decrease the heart rate. In the normal person, both results are associated with a rise in blood pressure. Rapidly alternat- ing hot and cold applications to the precordia have much the same effect as short cold applications, except that the stimulation, being greater, causes a greater rise in blood pressure. This rise is less permanent than that ac- companying prolonged cold applications to the precordia. These points have been thoroughly discussed elsewhere. 2. The Amount of the Circulating Fluid. An increase in the quantity of blood in the vascular system, other things being equal, increases blood pres- sure. In order to intelligently apply those therapeutic measures which are designed to maintain blood pressure through changes in the amount of the circulating fluids, it is necessary to obtain an understanding of the laws governing the intake and output of body fluids, and also the absorption of extravascular tissue fluids. Modern knowledge of the fluids of the body has recently been summarized by E. H. Starling. l From this source we have drawn much of the following information. The absorptive membranes of the body possess a discriminating or irrecip- rocal permeability to fluids, i. e., fluids containing certain saline substances 1 Herter Lectures, New York, 1908. i 54 THE CIRCULATION-BLOOD PRESSURE are readily and rapidly absorbed, while fluids containing other salts are either not absorbed, or, only after long contact. "If the solutions contain sulphates or tartrates, i. e., salts to whose anions the gut wall is relatively impermeable, the course of events is very much the same as that which would occur if these solutions were separated from blood-plasma by a dead wall of parchment paper. If they are hyper- tonic, they increase in amount by the attraction of water from the circu- lating fluids, until their molecular concentration is equal to that of blood- plasma." 2 By long contact they are finally absorbed. "Very different is the fate of solutions of substances such as sodium chloride. These are rapidly absorbed even when they are slightly hypertonic. If the solutions are strong, i. e., two or three per cent NaCl, they at first increase in bulk by the diffusion of water into them. From the moment of their introduction, however, salt is passing from them into the blood, circulating through the intestinal wall, and as soon as their total osmotic pressure is reduced to a point a little above that of the blood-plasma, both water and salt begin to be absorbed." 3 This selective action is found to depend upon the vitality of the cells com- posing the membrane, since it ceases when the cells have been damaged by certain chemicals. The fate of fluid introduced into the gut then seems to depend entirely upon its concentration. The epithelial cells composing the mucous membrane of the intestine possess the power of pumping water and salts from one side of the cell to the other. "This conclusion is confirmed by certain experiments of Reid and Cohnheim, in which two identical solu- tions of sodium chloride were separated from one another by a membrane consisting of the whole living intestinal wall. In these experiments, it was found that there was active transference from the inner to the outer side of the membrane." 4 The same was found to hold true with the skin. When brought in contact with deleterious substances, the cells of the skin behaved like ordinary dead membrane, the irreciprocal permeability and the active transference of fluid totally disappearing. Saline solutions, somewhat less in concentration than blood serum, are very rapidly absorbed from the intestine, somewhat more so than even isotonic solutions. The rapid absorption of hypotonic or isotonic solutions introduced into the bowel, is then shown to be due to the specific activity of the epi- thelial cells, aided by the greater osmotic pressure of blood serum in the case of hypotonic solutions. The ready and constant absorption of fluid which occurs with the Murphy method of enteroclysis, is a most effectual means of maintaining blood pressure at an even point. In case of much loss of fluid or lowering of blood pressure, after a fairly normal amount of fluid and degree of blood pressure has been secured by the absorption of the saline fluid, the salt solution, if injected slowly, is eliminated by the kidneys at the same rate at which it is absorbed. 5 The laws of osmosis when working in connection with the intestinal wall above referred to, account for the hydrogogue action of hypertonic solutions 2 Starling The Fluids of the Body, p. 53. 3 Ibid., p. 53. 4 Ibid., p. 57. 5 Ibid., p. 139. ABSORPTION OF TISSUE FLUIDS 55 of such substances as Epsom salts, Rochelle salts and honey, when injected into the bowel. Strong solutions of these substances cause an exosmosis, i. e., when they remain a comparatively short time water is drawn from the circulating fluid and increases the bulk of the injected fluid. This "wash- ing" through the mucous membrane clears it of mucus, helps dislodge mucus casts, etc. These obser- vations furnish a ration- al basis for the use of the hypertonic saline en- ema, and the honey or molasses enema, in mu- cous colitis. In regard to the ab- sorption of interstitial fluids, and of fluid intro- duced by hypodermocly- sis, Starling concludes that this occurs mostly by the blood rather than the lymphatics, as has long been supposed. In- digo, carmine or methy- lene blue injected into the pleural or peritoneal cavities, may appear in the urine within six minutes after the mo- ment of injection at a time when the lymph in the thoracic duct is free from color. Strychnin or other drug injected under the skin of a limb Fig. 16. Cardiometer tracing from dog's exerts its poisonous ef- heart showing effect of increasing the volume of fects on the nervous circulating fluid on the total output and volume system long before the of the heart. Between the parts A and B, 30 c. c. of warm physiologic salt solution were in- jected intravenously, and between B and C, 20 c. c. more. Both the systolic and diastolic volume are increased, i. e., the heart is more distended during diastole, and does not contract to its normal size in systole. The result is a very largely increased output. (Roy) drug itself appears in the lymph flowing from the limb. It has been shown that blood re- turning from an edema- tous limb is more dilute than blood returning from a normal limb. The experiment con- ducted by Starling 6 is as follows: By means of cannulas inserted into the femoral artery and vein, defibrinated blood of the same osmotic pressure as normal blood serum, was caused to pass through the arteries, capillaries 6 Ibid., p. 95. 56 THE CIRCULATION BLOOD PRESSURE and veins of the normal leg of a dog. The same was done with the opposite leg made edematous by the injection of a one per cent solution of NaCl. Blood which had been led through the normal leg twelve to twenty-five times was unaltered or suffered trifling change, while that led the same number of times through the edematous leg had, in all cases, absorbed fluid. "From these experiments, we may affirm with certainty that isotonic salt solutions can be taken up directly by the blood circulating in the blood vessels." 7 Hypodermoclysis is the most rapid method (aside from direct vein injection) of introducing fluid into the circulation. Increase in the amount of fluid in the vascular system results in heightened venous pressure, which, in turn, produces an increase in diastolic filling, systolic output and arterial pressure and greatly hastens the velocity of the circulation. (Fig. 16) "Blood with its lower velocity passes readily through the dilated arterioles and capillaries, so that the velocity of the blood-flow may be easily increased from six to ten times." 8 Injecting salt solution equivalent to 50 per cent of the total blood, has been found to augment the velocity of the blood six to eight times the normal rate. 9 The rise in blood pressure occasioned by the absorption of fluid introduced by either hypodermoclysis or proctoclysis, is of special advantage in various conditions where the blood pressure has fallen very low, such as in collapse (after hemorrhage), in peritonitis, etc. The Murphy method of proctoclysis is especially recommended in the treatment of peritonitis after the institu- tion of surgical drainage. It is designed to flush the drained surfaces, and so aid in getting rid of septic material and infection. We believe its bene- ficial action is, however, due as much to the maintenance of blood pressure, as to the flushing of the absorbents and drained surfaces. Given in the order in which they most rapidly increase the volume of the blood, the methods of introducing fluid into the circulatory system may be listed as follows: a. Hypodermoclysis. b. Proctoclysis. c. Water drinking. 3. Vascular Calibre and Action. We have seen that a hot application dilates the blood vessels, producing an afflux of blood to the skin and super- ficial parts, increasing with the prolongation of the application. It has also been shown that the reaction to a cold application produces an afflux of blood to the skin. In both cases, there is a hyperemia established, but the two are of an entirely different nature. With the hot application, there is a fall of blood pressure because of a loss of tone in the vessels (passive dilatation) and a preponderance of venous blood in the part. While the dilatation which comes with the reaction to a cold application is accompanied by an increase in blood pressure, the tone of the vessels is preserved, and there is a pre- ponderance of arterial blood in the part. These conditions are respectively known as venous or passive hyperemia and arterial or active hyperemia. It is important to distinguish the physiologic difference between the hyperemia of cold and that of hot applications. In the case of the hot application, 7 Ibid., p. 97. 8 Ibid., p. 138. 9 Starling Physiology, p. 284. VASCULAR CALIBRE AND ACTION 57 there is a slowing of the circulation, a stasis of blood, which necessarily results in an increase of the venous over the arterial blood in the part. With the cold application, after the initial vasoconstriction and anemia have given way, the return to a normal condition (reaction) is accompanied by an in- crease of from three to five times in the rapidity of the circulation. 10 The blood flows rapidly through the part and consequently, arterial blood predomi- nates. This is no small factor in nutrition and healing. In fact, it is upon the blood that both depend; they are carried on and hastened in proportion to the amount of arterial blood supplied to the tissues. Bier, in his work on the treatment of disease by hyperemia, claims for the tissues a selective action, i. e., that they have the power to select arterial in preference to venous blood. It would appear irrational to suppose any- thing else. The essential feature is not in the selective action, but in the supplying of sufficient arterial blood so that the tissues may manifest their selective action. The cold has also a direct action on the hemoglobin in pro- ducing a higher degree of oxygenation, i. e., a greater oxygen carrying capacity. 11 The pumping action of the arteries under the influence of reaction to cold, drives the blood into the veins. Because of this, the right side of the heart is more completely filled, and there results a fuller output to the lungs and from the left side of the heart. These forces tend to produce a slower and more vigorous systole, and so the entire cycle of changes brings about a heightened blood pressure. These facts demonstrate the great value of the cold mitten friction in surgical shock. Muller's Laws. Very briefly stated, the following are the chief effects of external applications upon the blood pressure: 1. Effects of Cold. Baths and thermic applications, not accompanied by mechanical irritation, if given below the temperature of the skin, produce increased blood pressure with slowed pulse rate. 2. Effects of Heat. Thermic applications above the skin temperature, after a brief rise, produce a fall in blood pressure which later rises. Hot baths above 104 F. persistently increase blood pressure and the pulse rate. 3. Effects of Neutral Temperatures. Neutral baths equalize or regulate blood pressure. 4. Effects of Mechanical Stimuli. With douches and other procedures, where the mechanical irritation is the predominant factor, there is a rise of blood pressure less enduring than with cold applications. "Every hot or cold douche calls forth an increase of blood pressure, paradoxical as it may seem." 12 10 Baruch Principles and Practice of Hydrotherapy, p. 55. 11 This active arterial hyperemia is undoubtedly due to the action of cold on the tissues, hemo- globin and the blood vessels themselves. This has been confirmed by Ritter, who performed two very interesting experiments to demonstrate this fact. By means of an ethyl chloride spray, he froze a spot on the arm. After it had thawed, it became bright red from the reaction. He then applied an elastic bandage to the arm above the spot. The whole arm became dark blue, while the previously frozen spot remained bright red. He reversed the experiment by first producing cyanosis and venous stasis, and then freezing a spot on the arm below the bandage. After thawing, it became bright red, while the rest of the arm remained blue. 12 Hinsdale Hydrotherapy, p. 48. 58 THE CIRCULATION BLOOD PRESSURE The experiments of Schuller already quoted, sustain these observations. Many other experiments along this line might be quoted. Kellogg 13 records an experiment in which the drinking of a large quantity of cold fluid (50 F.) raised the arterial tension as taken by Gartner's tonometer from 13.5 cm. to 14.5 cm. The first observation was made immediately before, and the second immediately after the drinking of the cold water. In another clinical experiment H an initial arterial tension of 9 cm. was, by an electric light bath, raised to 10 cm. within one minute. At the end of five minutes, the tension had fallen to 8 cm. and in twenty minutes, to 7 cm. In another case, 15 fifteen minutes in a full bath at 102 F. reduced the blood tension from 9 cm. to 6 cm., as shown by Gartner's tonometer. 13 Rational Hydrotherapy, p. 1116. 14 Ibid., p. 1122. 15 Ibid., p. 1128. CHAPTER X THE CIRCULATION-CHANGES IN THE COMPOSITION OF THE BLOOD Corpuscular Elements Such a large volume of experimental work has been reported along this line, that we can not do more than tabulate the principal results observed. The investigations of Prof. Winternitz, and those of Strasser, undertaken at his request and reported in 1893, are considered the basis of our knowledge of these changes. The results obtained were so uniform as to leave little doubt of their reliability. After all sorts of cold procedures, involving the general skin surface and associated with mechanical procedures, after hot baths or douches when followed by cold applications, the blood counts revealed an increase in both the red cells and white cells, and a marked change in their ratio. The greatest increase in red cells amounted to 1,860,000 per cubic millimeter; in white cells, from 200 to 300 per cent and in hemoglobin, 14 per cent. On the first and third bath days of Strassers experiments, referred to in Chapter XI, blood counts were taken after the cold douche and after the graduated half bath. The counts were as follows: Effects of Cold Douche Before After Red Cells 4,570,000 5,200,000 White Cells 4,600 6,400 Hemoglobin (Fleischl) 85$> 95# Effects of Graduated Half Bath Before After Red Cells 4,880,000 5,420,000 White Cells 5,400 8,400 Hemoglobin ...85^.. ~ 950 These changes were maintained for from one-half hour or one hour up to two hours or longer after applications, gradually returning to normal. The increase in the white cells was maintained longer than the increase in reds. These observations have been confirmed by Thayer, Baruch and Kellogg, in this country. Where do these cells come from? Repeated cold applications stimulate hematogenesis, as they stimulate all other functions. But, of course, so great an increase as 30 or 35 per cent in the total number of reds and 200 60 BLOOD COMPOSITION per cent in the total number of whites could not result from a single appli- cation. This increase in the corpuscular elements in the peripheral circula- tion must be at the expense of the number elsewhere. Winternitz claims that this increase of cells in the peripheral circulation is due to the driving of large numbers of cells from the viscera, where stasis has taken place. Breitenstein l has confirmed this view by experiments upon rabbits. These animals were overheated in a hot box, before and after which the red cells in the peripheral circulation (ear) and viscera (liver) were estimated. Before the heating process, the cells in the ear and liver were equal in number.' After it, there was an enormous increase in the red blood cells in the liver. Tschlenoff observed a decrease of 50 per cent in the white cells in rabbits subjected to a temperature of 42 C. for five or six hours. These experi- ments also confirm the observation of Winternitz and others, that hot appli- cations decrease the blood count and the hemoglobin per cent, the white cells suffering a greater diminution than the reds. Mechanism of Distribution. The change in the distribution of the red and white cells produced by cold applications is, to a great degree, due to the stimulation of the peripheral circulation. This is not, however, the only factor in bringing about an increase of cells in the surface circulation. The viscera and their blood vessels are subject to the reflex stimulation produced by cold applications. The contraction of the viscera and the visceral blood vessels, caused by cold applications, drives their contained corpuscles to other parts, and these are taken up by the increased activity of the peripheral circulation and so redistributed. In both the liver and spleen the blood cells are especially prone to accumulation and stasis. The blood vessels of both may be rendered very active; but owing to the additional muscle fibers in the capsule and trabeculas of the spleen, this organ exerts a greater effect upon the blood current than that of any other viscus except the heart. "The most definite facts known about the spleen are in connection with its movements. It has been shown that there is a slow expansion and con- traction of the organ synchronous with the digestion periods. After a meal the spleen begins to increase in size, reaching a maximum at about the fifth hour, and then slowly returns to its previous size. This movement, the meaning of which is not known, is probably due to a slow vasodilatation, together, perhaps, with a relaxation of the tonic contraction of the muscula- ture of the trabeculae. In addition to this slow movement, Roy has shown that there is a rythmical contraction and relaxation of the organ, occurring in cats and dogs at intervals of about one minute. "Roy supposes that these contractions are affected throught the intrinsic musculature of the organ, that is, the plain muscle tissue present in the capsule and trabeculae, and he believes that the contractions serve to keep up a circulation through the spleen and to make its vascular supply more or less independent of variations in general arterial pressure. The fact that there is a special local arrangement for maintaining its circulation, makes the spleen unique among the organs of the body, but no light is thrown upon the nature of the function fulfilled. The spleen is supplied richly with motor nerve fibres which when stimulated either directly or reflexly cause the organ to diminish in volume. According to Schaefer, these fibres are 1 Archiv. fur Exper. Path, und Pharm., Bd. 32, 18%. MOVEMENTS OF THE SPLEEN 61 contained in the splanchnic nerves, which carry also inhibitory fibres whose stimulation causes a dilatation of the spleen." 2 The blood of the splenic veins contains a greater number of white cells than the arterial blood supplied to the organ. Miescher 3 experimenting with Rhine salmon found four times as many leucocytes in the splenic blood as in the cardiac blood. This increase in the cellular elements increases the viscosity, and consequently tends to diminish the rate of blood flow. The gathering up of these cells, together with the closeness of the splenic mesh- work in which, the blood circulates, makes necessary some mechanism for additional propulsive force. "It is evident that the blood must meet with considerable resistance in passing through the close meshwork of the splenic pulp. To ensure a con- stant circulation through the gland, we find that the muscular tissue of the CAROTID Doc. 8, 5 KILO ALL CONNECTIONS WITH SPLC.CN SEVERED EXCEPT ONE ARTERY & VEIN * PRESSURE Fig. 17. Plethysmographic tracing of spleen (upper curve) from dog, showing the spontaneous rhythmical contractions of this organ, (after Howell) capsule and trabeculae has the property of rhythmic contraction. If the spleen be inclosed in a plethysmograph, or splenic oncometer, and its volume be recorded by connecting this with the oncograph, it will be seen that it is subject to a series of large, slow variations, each contraction and expansion lasting about a minute, and recurring with great regularity. (Fig. 17. ) Super- posed on these large waves are seen the smaller undulations due to the res- piratory variations of the blood pressure, and on these again the little ex- cursions corresponding to each heart-beat. The contractile power of the spleen is under the control of the nervous system, and a rapid contraction may be induced by stimulation of the splanchnic nerves." 4 The use of cold applications, especially when accompanied by mechanical stimulation such as the cold mitten friction to the abdomen, and the cold splenic douche, have a decidedly stimulant effect upon the movements of the spleen. The same is true of the revulsive compress and the alternate hot and cold douche to the splenic region and abdomen. Such stimulation 2 Howell Physiology, 1909, p. 800. 3 Bunge-Physiologic and Pathologic Chemistry, Second English Edition, p. 229. 4 Starling Elements of Human Physiology, 1907. p. 514. 62 BLOOD COMPOSITION increases the extent and force and greatly enhances the efficiency of the splenic contractions thereby proving a powerful means of accomplishing the even distribution of the blood cells, especially the leucocytes. Not the least interesting of the observations made by Winternitz is that relating to the local increase in the blood count taken from circumscribed areas, treated by douches, partial baths, etc., while the count taken from a distant part showed a decrease in both the red and white cells. This experi- ment furnishes a rational basis for the local use of thermic applications to an infected part. Massage as well as hydrotherapy produces an increase in the number of the blood corpuscles as shown by counts taken before and after treatment. The effect is at first temporary, but lasts longer and longer as the massage is continued from day to day or week to week, until finally the improvement becomes permanent. Astonishingly good results have been reported by Mit- chell 5 in cases of anemia. Viscosity and Reaction Grawitz and also Burton-Opitz 6 have shown that cold applications increase the viscosity and specific gravity of the blood, while warm applications decrease both. This thinning of the blood continued even after prolonged heating with free perspiration. This result Burton-Opitz attributed to the blood becoming relatively richer in serum at the expense of the tissues. These facts have been confirmed by Loewy and agree with those of Winter- nitz and Knoepfelmacher. In general, it may be said that conditions that produce vasoconstriction increase the number of corpuscles in the vessels constricted, together with an increase in the specific gravity and viscosity of the blood. Conversely, conditions that relax the blood vessels, decrease the corpuscular elements in the dilated vessels, together with a thinning of the blood. Strasser 7 has shown that cold applications increase the alkalinity of the blood through a decrease in the quantity of acid phosphate, even to the extent of 50 per cent. Also, that hot applications decrease its alkalinity by increasing the amount of acid phosphate, in one case more than doubling it. Practical Application Some of the most beneficial results of hydriatic measures are due to the facts recorded above. In the majority of diseases, there is a reduction in the alkalinity of the blood. This is particularly true of fevers and infectious diseases. An agent which will tend to restore the blood to its normal alka- linity will hasten all the processes of repair. The role of the leucocyte (phagocytosis) in combating infection is now an established fact. The admirable researches of Metchnikoff along this line leave no doubt that the white cell itself is the prime factor (and that not excepting opsonin) in phagocytosis, the production and maintenance of immunity and the body's general resistance to bacterial invasion. He has 5 Journal American Medical Association, October 9, 1909, p. 1183. 5 Journal American Medical Association, October 9, 6 Journal of Experimental Medicine, January, 1906. 7 Deutsche Medizinal-Zeitung, June 15, 18%. PRACTICAL APPLICATION 63 shown 8 what signal disaster to the production and even the continuance of immunity, results from the administration of alcohol, quinin, opium and other medicinal substances; this disaster being manifest by a diminution in the number and especially in the activity of the white blood cells. We have every reason to believe that cold hydriatic applications not only increase the number of leucocytes in the peripheral circulation, but also energize their action amoeboid movements, phagoctosis and the production of antibodies. This we might safely infer from the results obtained by cold applications in increasing muscular capacity, glandular activity, etc. All protoplasm, whether of muscle cells, glandular epithelium, or leucocyte, responds alike to the tonic influence of short vigorous cold applications. The writer has repeatedly seen infections of the hand and arm clear up in four to six days, or even less time, when treated by alternating extreme hot and cold immer- sion, while other cases not so treated have required a month to accomplish the same results. Since the cells are -the source of opsonin, agglutinins, lysins and other antibodies concerned in immunity, it is but reasonable to expect an increase in these as a result of the cellular stimulation produced by cold or alternate hot and cold applications. This has been partially demonstrated by Graziani, 9 who found that of rabbits injected with the filtrates of typhoid cultures, and kept at different temperatures (plus 38, 37, 2 and minus 4 C.), those kept at low temperatures developed more agglutinin than those kept at higher temperatures. He also experimented with rabbits kept at 32 C., bathing half of the number morning and evening, in water at 20 C. for thirty min- utes. The animals treated by bathing produced more agglutinin than the others. These facts demonstrate the truth of the Scripture statement that the blood is the life. The statement has not only its spiritual application, but is also founded upon demonstrated physical facts. 8 The New Hygiene. 9 Centralblatt fur Bakteriologie, 1907, I. XLII, 633. CHAPTER XI NITROGENOUS METABOLISM AND EXCRETION Tissue changes lie at the foundation of all functional activity. There can be no vital action without corresponding qualitative and quantitative changes in tissue composition. It must therefore follow that agents, such as thermic impressions, in awakening functional activity, should at the same time pro- duce profound alterations in absorption, metabolism and excretion. Without giving undue prominence to this phase of the subject, it would be impossible to discuss it here in anything like a complete manner. Those desiring to become more thoroughly conversant with the behavior of metabolism under hydriatic therapy should study the original reports of such research. Along this line none are more instructive than those of Dr. Alois Strasser, assist- ant to P. of. W. Winternitz in the Allegemeine Poliklinik of Vienna, from whose monograph entitled, "The Behavior of Metabolism under Hydriatic Therapy," ' is drawn much of the data for the following discussion. Cellular activity is affected reflexly in the same way as other body func- tions. Tissue changes occur in all parts of the body, but those metabolic activities with which we are chiefly concerned may be traced to the muscles as the seat of the great majority of oxidative processes. The liver is also to a large extent concerned in metabolism, both nitrogenous and carbona- ceous. It is not necessary that the muscles be excited to perceptible con- traction in order to affect metabolic changes. Through the innervation of the muscles, oxidation is controlled and may be greatly increased by hot or cold applications, without visible contractions. This conclusion was arrived at by Roehrig and Zuntz who further confirmed their opinion by experiments upon animals "in which the innervation of the muscles was held in obeyance by "arrow poison. In such animals tissue change was not only not increased by cold, but was even reduced one-half." 2 Other stimuli than cold also aiFect tissue changes. The relative value of various cutaneous stimuli, vary- ing degrees of heat and the quantitative response of metabolism is best studied with carbonaceous metabolism (q. v.). Strasser conducted two series of experiments at different times. In the first series two young men were selected as subjects. The daily ration, urine and feces were carefully measured, and from chemical analyses and esti- mations from these the results were obtained. The procedures used were such as would ordinarily be administered to patients. In the second series 1 Das Verhalten des Stoffwechsels bei hydratischer Therapie Fortschritte der Hydrother- apie. Festschrift zum Vierzigjahrigen Doctorjubilaum deS Prof. Dr. W. Winternitz, herausge- K^ben von Dr. A. Strasser und Dr. B. Buxbaum, Wein, 1897. 2 Baruch Hydrotherapy, p. 80. NITROGEN ECONOMY 65 a single individual was chosen. In this series the intake upon a standard diet, also the output in feces and urine was measured for five days in order to establish the normal quantities of the various constituents for the indi- vidual under experiment. "The bath period lasted three days. On each day the man received in the morning at 8 o'clock a friction at 14 R (63.5 F.) Forenoons at 11:30 a. m. a general cold rain bath with moving fan douche, and afternoons a half bath at 22 cooled to 18 U K. (81.5 to 72.5 F.) of fcur Fig. 18. Showing the effect of cold treatment on fecal and urinary nitrogen reveals a heightened assimulation of proteid. (Strasser) minutes duration. Moderate exercise followed each procedure, as much as seemed necessary for warming, i. e., the attainment of a gocd reaction." The results of the first work as tabulated by Strasser are as follows: 1. Increase of nitrogen metabolism, i. e., increase of the nitrogen excre- tion in the urine; a simultaneous decrease in fecal nitrogen. 2. Absolute and relative increase in the excretion of urea. 3. High absolute increase in the excretion of uric acid, with relative pro- portion almost unchanged. 4. High absolute and relative increase in phosphorus excretion. 5. Small relative fluctuations in the ammonia excretion. 6. Decrease in the sum of the extractives to a minimum. The results in the second series of experiments entirely confirmed the findings in the first, and are of the same general character. Nitrogen Economy. The excretion of nitrogen (Fig. 18) on the first bath day was increased 8.3 per cent over the average of the preperiod; a maxi- mum increase of 11.4 per cent was reached on the second day, and on the last 6.0 per cent, thus averaging 8.6 per cent. The increase continued Fig. 19. Showing relative increase of urea and the phos- phates and relative decrease of ammonia. (Strasser) UREA AND AMMONIA 67 throughout the afterperiod. In the two first cases the average increase was respectively 10 and 16.4 per cent. The fecal nitrogen shows a corres- ponding decrease. The subject of the experiment remained practically in nitrogen balance throughout the experiment. The decrease in fecal nitrogen is to be explained by an increased absorption of proteid. The tonic influence of the reaction to cold procedures brings about an increased digestive efficiency, hastens the processes of absorption and assimu- lation and renders them more complete. Clinical observations have also established the fact that hydriatic treatment properly suited to the patient's reactive ability decidedly and enduringly enhances assimulation. Urea and Ammonia. In Strasser's experiments there was an absolute increase of urea in all cases. In the second series this increase averaged 12 percent during the bath period and 6.5 per cent during the after period. In the first series the greatest increase in the two cases was, respectively, 18 and 25 per cent and the averages 10 and 21.1 per cent. Relative to the total nitrogen there was also an increase as graphically shown in Fig. 19. From an average proportion of 86.9 per cent of the total nitrogen in the preperiod, the nitrogen content of urea rose to a maximum height on the third bath day of 92.5 per cent of the total nitrogen. Ammonia being a precursor of urea and both being derived from proteid, it might be expected that its amount would bear some definite relation to the amount of urea excreted. In the first cases there was both an absolute and relative increase in the excretion of ammonia. The absolute increase in one case reaching as high as 52.5 per cent and averaging 42 per cent in one and 36 per cent in the other. In the afterperiod one sank to 33 per cent below the level of the preperiod and in the other it remained 30 per cent higher than in the preperiod. In the second series it sank to normal in the afterperiod. Relative to the total nitrogen, the increase was less than might be expected and in the second series there was even a slight relative decrease. Strasser concludes that organic acids ordinarily derived from proteid by incomplete oxidative processess and which so powerfully contribute to less- ening the alkalinity of the blood, have, under the influence of the thermic stimulus, been burned up into carbon dioxide and water. This decreased amount of organic acids would, he reasons, require less alkali (ammonia) for their neutralization and so lessen the relative amount of the latter formed. 3 Uric Acid and Purin Bases. The accepted theries of nuclein metabolism are perhaps too well known to need explanation here. An increase in purin excretion may arise from either endogenous or exogenous purins. That the in- creased excretion of uric acid is due to heightened activity and breaking up of the leucocytes and therefore bears a definite relation to the leucocy tosis which always accompanies the reaction to cold procedures, can be correct in part 3 It would seem, however, that the small relative increase of ammonia is due to the relatively more complete conversion of ammonium carbonate into urea, its end product. As a product of proteid metobolism it is subject to increased oxidation in common with other nitrogen derivatives, a larger relative increase is prevented by the increased vigor of hepatic activity tending to push the change beyond ammonium carbonate to the formation of urea. Inorganic acids require alkali for their neutralization as well as organic acids and the former are not only not decreased in amount but are actually increased. For further discussion of the requirement of organic acids for ammonia and fixed alkali see Graham Lusk Metabolism in Dia- betes Journal American Medical Association, December 17, 1910. 68 NITROGENOUS METABOLISM only. The excreted purins must of necessity come from all the nuclear nitrogen of the body as well as from the leucocytes. The more complete oxidation of exogenous purins and the hastening of their excretion may also account for the increase in uric acid. The results obtained by different experimenters, all agree as to the abso- lute increase in uric acid excretion under the influence of thermic procedures. It runs parallel with the excretion of urea. In Strasser's experiments there was an immediate increase of uric acid on the first bath day, which reached a maximum of 25 per cent on the third bath day and an average of 22 per cent during the entire bath period. The increase, though somewhat less in Fig. 20. Showing effect of cold treatment on the oxidation of purins. (Strasser) per cent, continued throughout the entire afterperiod at an average height of 12.7 per cent above the level of the preperiod. The results in the two cases of his first series entirely coincided with this. In these cases the increase in the total purins averaged 10.4 per cent during the bath period and even a higher stage was reached and maintained during the entire three-day afterperiod. Relative to the total nitrogen there was also a slight increase. Of 100 parts of total nitrogen the nitrogen of the uric acid constituted 1.52 per cent PURINS 69 in the preperiod, 1.71 per cent in the bath period and 1.68 per cent in the afterperiod. Of particular interest in connection with nuclein metabolism is the behavior of the purin bases. As the uric acid excretion increases in amount the purin bases progressively decrease, until on the third bath day the entire purin excretion consists of uric acid, the bases having wholly disappeared. At the close of the treatment the purin bases again rise, to reach on the third day of the afterperiod, the height of the preperiod. This change in the proportion of the two constituents of purin excretion is graphically shown in Fig. 20. Letting 100 per cent represent the total purin nitrogen, 85.5 per cent appears as uric acid and 14.5 per cent as purin bases. On the bath days the per cent of uric acid rises to 96, then to 98 and finally to 100 per cent. The nitrogen content of the bases sinks to 4, then to 2 and finally to per cent. With the composition of uric acid and the bases in mind, the explanation of the above changes is not difficult. Uric acid is trioxypurin, while the bases all contain less oxygen, being mostly mono- or dioxypurin with amine or hydrocarbon side groups. Uric acid is therefore the most highly oxidized of the purin bodies. It is plain to be seen that the stimulus of the hydriatic procedures has resulted in oxidation of the bases to uric acid, a distinct cumulative effect being manifest by the progressive completeness of this oxidation, until on the third bath day no bases are left, all purin nitrogen appearing as uric acid. This result is of no little importance in the treatment of the gouty diathe- ses. With a kidney permeable to uric acid as it is in uncomplicated gout, the purins should come to both complete oxidation and complete excretion. The increase in the alkalescence of the blood and body tissues also resulting from cold applications greatly favors these changes. The condition in uratic diathesis, in reality, consists of an accumulation of all the purin bodies (uric acid plus bases). Because of this Kolisch proposed the term "purin diathesis" instead of uric acid diathesis. The excretion of the bases exercises a poisonous effect upon the kidneys, and the altered kid- ney is in turn less capable of excreting basic purins. This vicious circle would be done away with, were the bases excreted in a mpre completely oxidized state, i. e., as uric acid. As remarked by Strasser, tonic hydro- therapy breaks through this vicious circle and completely changes the aspect of purin auto-intoxication. The excretion of a waste, not as such, but in an altered and less toxic state may be considered "the removal of poison par excellence." Extractives. A summary of the relation of the nitrogenous extractives to the total nitrogen shows that they constitute respectively 3.86 per cent in the preperiod, 2.17 per cent in the bath period and 0.56 per cent in the after- period. As already mentioned, on the third bath day they disappear entirely and urea, uric acid and ammonia claim the whole nitrogen for themselves. Phosphoric Acid. The phosphorus of the urine arises from certain pro- teids in common with nitrogen and hence gives an added index to the pro- cesses of proteid metobolism. Strasser's experiments reveal an increased 70 NITROGENOUS METABOLISM absorption of phosphorus as well as of nitrogen, as shown by the decrease in fecal phosphorus during the bath period and an equal and simultaneous increase in urinary phosphorus. The absolute increase in the phosphoric acid of the urine reached a maximal height of 28 per cent on the second bath day. Compared with the total nitrogen, there is also a relative increase as shown in Fig. 19. This relative increase may be accounted for by the fact that phosphorus comes from lecithin as well a? certain proteids. In the first experiments the relative increase lasted throughout the whole of the after- period. The increased elimination of phosphoric acid accounts for the effect Fig. 21. Showing effect of cold treatment on the alkaline and earthy phosphates. (Strasser) of cold treatment in increasing the alkalinity of the blood by decreasing the per cent of acid phosphate contained in it. It is significant that only the more labile phosphates take part in the increase. This increase in urinary } hosphorus is wholly in the alkaline phosphates, the earthy phosphates remain unchanged (Fig. 21). Sulphates and Chlorides. The sulphur of the urine also comes from pro- teid substances and the urinary sulphates are therefore another end product of EFFECTS OF HEAT 71 proteid metabolism and would increase with nitrogen. The average increase was 10.4 per cent during the bath period, which height was maintained dur- ing nearly the whole of the afterperiod. The increase in the sulphates was almost entirely in the mineral sulphates, the ethereal sulphates suffering but a trifling change. This might be expected since more complete diges- tion and assimulation of proteid, together with completer oxidation, would tend to decrease putrefactive changes and so lessen the relative amount of ethereal sulphate. The increase in the excretion of sodium chloride was chiefly on the first bath day (15 per cent) and did not outlast the bath period. The excretion of sodium chloride in oadema is a matter of no little importance. In this con- dition hydriatic applications produce an increase in chloride excretion in two ways: first, by increasing the absorption of intestinal fluid and, second, by stimulating kidney activity. Effects of Heat The reported researches regarding the effects of heat upon metabolism are somewhat conflicting in their results. This is doubtless due to differ- ences in the mode of application, the intensity, duration and frequency of repetition of the treatment as well as in the reactive response of the organ- ism. Formanek observed that a single hot bath scarcely changed the nitro- gen but that after two or more such baths on successive days there occurred a decided increase of nitrogen elimination. It would seem that a single hot bath, if not too prolonged, should decrease the elimination of nitrogen for the time-being, as a result of the atonic reaction and the lessened amount of water excreted by the kidney. In general this agrees with the results obtained by two different ob- servers 4 one working with the Turkish bath and one with the Russian bath. Effects of Turkish bath at 122 F. for 50 minutes Day before Bath Day of Bath Amount of Urine 24 hours 1567. c. c. 950. c. c. Specific Gravity 1018.8 1027. Urea 45.47 gm 39.9 gm Uric Acid 0.683 gm 0.860 gm Effects of Russian bath at 113 F. for 25 minutes Day before Bath Day of Bath Amount of Urine 24 hours 1683. c. c. 900. c. c. Specific Gravity 1021 ..1027. Urea 52.68 gm 38.7 gm Uric Acid 0.858 gm._ 0.980 gm Bastels, Naunyn and Schleich found an increase of urea and total nitrogen excretion which later showed diminution. It is altogether possible that these opposite results may also be accounted for by the differences in amount of water ingested by the subjects during the respective experiments. Loss of water through sweating decreases the tissue fluids and therefore the urinary solvent if this loss is not replaced by water drinking. It has been 4 Hinsdale Hydrotherapy, pp. 22, 23. 72 NITROGENOUS METABOLISM shown by Hawk 5 that copious water drinking increases the excretion of nit- rogen in the form of urea due to the washing out from the tissues of pre- formed urea. He also observed a greater phosphorus excretion. The maxi- mum increase occurred regularly on the second day of the experiment. The secondary diminution in the nitrogen excretion observed by Schleich would tend to show that the metabolized nitrogen in the case of hot baths comes more from the tissue albumen than from any increase in the intestinal absorption of proteids. In case prolonged hot applications increase the efficiency of absorption, there should be a gradual return of the curve of increased excretion to the normal. Instead of this, lessened excretion occurs in an effort to restore the nitrogen balance. This also agrees with clinical experience. A course of hot baths unaccompanied by the tonic of cold applications results in loss of weight. It is true this is largely a loss of fat, but the tissue proteids are also concerned in the increased oxidation. All observers seem to agree that the excretion of uric acid is increased by hot baths. This being true, both hot and cold baths should be useful in gout. 5 University of Pennsylvania Medical Bulletin, 1905. CHAPTER XII RESPIRATION, RESPIRATORY CHANGES AND CARBONACEOUS METABOLISM In the previous chapter, we have considered tissue change solely from the standpoint of proteid metabolism and chiefly as regards the nitrogenous moiety. There remains, of course, a certain amount of carbohydrate when urea is split off from the proteid molecule, also the carbohydrate taken as such and the fat, all of which contain no nitrogen. Their metabolism is so intimately associated with respiratory interchanges that we shall consider them together; the respiratory excretion being quite as much a guide to these changes as is renal excretion to nitrogenous changes. We have noted that all sorts of stimuli applied to the skin produce more or less pronounced vasomotor and cardiac changes, through reflex action. The respiration is more readily affected by cutaneous stimuli than is any other function. One of the most efficient means of resuscitating the new born infant is the use of heat and cold. The same method, i. e., the alter- nate application of heat and cold to the chest, is scarcely less effective in the adult. The sudden application of either extreme heat or cold, especially if accompanied by percussion, produces an initial deep respiration, which is almost as suddenly interrupted, this being followed by other spasmodic efforts, so that the respiration assumes a staccato type. With prolonged applications of either heat or cold, the respiration soon becomes regular, the rate and depth depending upon the temperature of the application. Kellogg records the following experiments l as illustrative of the effect of thermic stimuli upon the volume of tidal air. To a subject whose tidal air measured 28 cubic inches, a wet sheet rub at 40 F. was administered. Im- mediately after the treatment, the tidal air measured 35 cubic inches, an increase of nearly 26 per cent. To another subject, with an initial tidal air volume of 33 cubic inches, a cold mitten friction was administered at 45 F. Immediately after, the tidal air measured 51 cubic inches, an increase of 55 per cent. In a third subject, the amount of tidal air before the treatment was 27 cubic inches. A wet sheet pack wrung from water at 45 F. was applied and continued for one hour. After the initial warming, the pack was kept at the neutral stage. Two minutes after the sheet was applied, the volume of tidal air was 36 cubic inches, an increase of 33 J per cent. In 15 minutes it was 33 cubic inches. The volume gradually decreased until at the end of the hour it was 28 cubic inches. During the entire period, there was an average increase of 18 per cent. 1 Rational Hydrotherapy, pp. 1122, 1133. 74 CARBONACEOUS METABOLISM In a fourth subject, a heating compress, wrung from ice water was applied to the chest only. The tidal air immediately rose from 507 c. c. to 751 c. c., an increase of 48 per cent. At the end of 20 minutes the tidal air measured 604 c. c., 20 per cent more than at the beginning. The average increase was 170 c. c., or 33 per cent. Another subject, whose tidal air was 43 cubic inches, was immersed in a hot bath at 108 F. After 12 minutes the tidal air had decreased to 27 cubic inches or a decrease of 37.2 per cent. Ten minutes after the bath, it had risen to 33 cubic inches; 30 minutes after, to 37 cubic inches. The loss in the volume of respired air amounted to 37 per cent. Brief, sudden applications of cold produce spasmodic respiration. The reaction to cold applications is accompanied by a slowed rate and greater depth of respiration, as shown by the above experiments. The rate is slowed and the amplitude of movement increased in proportion to the completeness of reaction. Warm baths or hot moist applications to the chest increase the ease of respiration, at the same time somewhat increasing the rate. Long, hot baths produce frequent, shallow breathing. Here again the conflicting results which have been reported are doubtless due to varying modes of applying the hot applications, also to the degree and duration of the heat. The inhaling of dry air produces difficult breathing. This may be due to the drying of the membranes, thus compelling deeper or more frequent respira- tion to obtain the same amount of oxygen. Inhalations of steam greatly facilitate respiration. It is decidedly beneficial in almost all forms of dys- pnoea. The moisture favors gaseous interchange, while the heat dilates the blood vessels, thus increasing the surface presented for the interchange. The steam may be made the vehicle of some volatile drug, so enhancing its antidyspnoeic properties. Having considered the physical changes in respiration, we may pass to the alterations observed in the chemical activities of the respiratory function. Since it has been shown that both hot and cold baths increase nitrogenous . metabolism, we might expect the same effects upon the oxidation of carbon- aceous material. This is precisely what occurs. Rubner 2 (1903) has given us some observations which are of a very practi- cal nature, since the results obtained were after hot and cold applications given as they are ordinarily applied in practice. The following table shows the effect of short baths upon the consumption of oxygen and the elimina- tion of carbon dioxide: Bath at Volume of Air CO-2 O2 Reap Quot. 61 n F. plus 22.9$ plus 64.8% plus 46.8 # 0.86 1.00 86 F. "7.3 " 31.0 " 16.2 0.95 0.93 91 F. " 1.8 minus 1.8 " 6.2 0.87 0.90 104 F. "16.1 "3.9 " 3.2 0.86 0.90 lll c F. " 18.8 plus 32.1 " 17.3 0.86 1.00 H. Winternitz (1899) in seven experiments upon the same individual, observed that, hot baths continued 30 minutes produce during that time, an 2 Archiv fur Hygiene, 1903, Bd. 46. LAWS OF RESPIRATORY EFFECTS 75 average increase in the consumption of oxygen amounting to 78 per cent and in COa elimination of 91 per cent. Observations made on an average nearly an hour after the bath, still revealed an increase of 22 per cent in the oxygen consumed and 16 per cent in CO 2 excreted. Rubner has shown that meta- bolism is at a minimum under temperatures from 91.4 to 95 F. (33 to 35 C.). A fall of every 1 C. in the surrounding temperature, increases meta- bolism by 2 or 3 per cent. From the above observations, we may deduce the law that applications below the skin temperature increase respiratory changes in proportion to the degree of cold. Neutral temperatures exert but little influence. Tem- peratures above that of the skin surface again increase the respiratory func- tion in proportion to the degree of heat. Rubner 3 found in his experiments that a douche produced more than double the change produced by a bath at the same temperature, each continued for the same length of time, viz., 3J to 5 minutes. The accompanying table shows the increase in per cent. Douche at 61 F. Bath at 61 F. Volume of Air. _ plus 54.5 # .. ,.plus22.95v C0 2 Exhaled _. - " 149.4 . " 64.8 O Consumed . "110.1 46.8 These observations prove the immense advantage of mechanical stimuli combined with thermic and also of exercise following hydriatic treatment, especially when taken in the open air. A swimming bath or cold rubbing bath produces more decided tissue change than quiet immersion for the same reason. The lung gymnastics produced by hydriatic applications are by no means the least important factor in the results produced by hydrotherapy. This seems to be the effect of first importance in the treatment of broncho- pneumonia in infancs and children. 3 Ibid., p. 390. CHAPTER XIII MUSCULAR CAPACITY The restorative effect of baths in relieving the sense of fatigue, and the tonic effect of the cold douche or spray in overcoming the effects of fatigue, are familiar to all who are acquainted with the practical application of hy- driatic procedures. These effects are extensively used by athletes in over- coming the exhaustion of severe or prolonged exertion. And medically con- sidered, they are by no means the least important of the results obtained by hydriatic applications. In 1892 and 1893 Vinaj and Maggiori 1 reported a series of experiments undertaken to show the effect of hydriatic measures upon the capacity of the muscles for work and their resistance to fatigue. These investigations were made with Mosso's ergograph. This instrument is so constructed as to hold the hand and forearm stationary in the body of the apparatus, while Fig. 22. Fatigue curve of right hand, (a) Normal; (b) after bath at 50 F. for 15 seconds. one finger is left free for flexion and extension. The forefinger, or middle finger, is usually employed so that, by means of a cord over a pulley, it raises and lowers a weight. This is kept up until the muscles are fatigued and unable to contract longer. Their experiments were done with a weight of three or four kilograms, raised every two seconds. In one experiment (Fig. 22 a), the middle finger of the right hand was, un- der normal conditions, able to execute 50 contractions, representing a work of 5.139 kilogrammeters. After a cold bath at 50 F. for 15 seconds, the same group of muscles executed, before fatigued, 74 contractions, repre- 1 Blatter fur klinische Hydrotherapy. EFFECTS OF COLD 77 senting a work of 9.126 kilogrammeters (Fig. 22 b). A graduated bath beginning at 96 F. and ending at 68 F. increased the number of contractions from 39, representing a work of 3.603 kilogrammeters to 87 contractions, the equivalent of 9.349 kilogrammeters of work (Fig. 28). When the muscles are already fatigued from active work, by cold appli- Fig. 23. Fatigue curve (a) before and (b) after graduated bath, 96" to 68? F. a Fig. 24. Effect of work and graduated bath upon fatigue curve. (a) Normal, (b) after active work, and (c) after work followed by bath. cations they may be restored to their usual power. This restorative effect is well ilustrated in Figs. 24 and 25. In Fig. 24 the first tracing (a) represents the fatigue curve of the nor muscle. The second (b) is the fatigue curve taken following active work, i. e., at a time when muscular capacity has already been partially exhaustec The third tracing (c) shows the restorative effect of a graduated bath giver 78 MUSCULAR CAPACITY following the fatigue of active work. In the case of the cold wet sheet rub following fatigue (Fig. 25 c) the muscular capacity has been increased to a point even above the normal. To what are these tonic and restorative effects due? This question may a b c Fig. 25. Effect of labor and cold wet sheet rub upon fatigue curve, (a) Normal, (b) after labor, and (c) after labor followed by wet sheet rub. Fig. 26. Effect of simple warm bath and of warm douche on fatigued muscles, (a) Muscular fatigue followed by warm bath, (b) after fatigue only, and (c) after fa- tigue followed by warm douche. be somewhat difficult to answer; but it would seem that the restoration of the muscle to its normal working power is due to more than one change. Among these changes may be mentioned the restoration of tone to the LAWS OF MUSCULAR EFFECTS 79 nerve and its central cell brought about by the cold application. It is prob- ably due also to washing out of the fatigue poisvns consequent on the quick- ening of the circulation; and third to the return of the blood to a condition of more normal alkalinity. With hot baths the opposite effects prevail. There is a decided lessening of the muscular capacity, amounting in one of Kellogg's experiments to a decrease of 44 per cent. His experiments cover a wide range and are very instructive. He used both Mosso's ergograph and the dynomometer; the latter, a machine of his own design. The following table is compiled from his experiments with Mosso's ergograph 2 : SUBJECT HOT 1 Age Weight 21 140 26 150 Initial Degree Strength 4.994 Spr. 113 5.395 not stated 1.312 D. 115 26 151 8.282 26 151 6.371 Gen. D. 112 26 151 8.033 B. 104 26 151 5.817 26 151 5.817 Neutral bath 21 140 5.761 21 140 4.791 Time 15 min. Result 4.432 COLD TREATMENT Degree 5 min. 0.927 15 min. 20 min. Spr. 60 D. 60 C D. 55 D. 60 4. 155 Gen. D. 56 4.459 Gen. D. 55 5.789 Shal. B. 65 W. S. P. 60 Time 10 min. 1 min. 15 sec. 3 min. 15 sec. Result 6.094 6.925 1.527 11.966 8.448 15 sec. 8.642 2 min. 20 min. 7.589 5.456 Considering both the dynomometer and ergograph experiments, there was, after cold procedures, an average gain in muscular capacity of about 30 per cent and, after hot applications, an average loss of 30 per cent in the work accomplished. Cold, therefore, increases the muscular working capacity; while warmth, not combined with mechanical effects, diminishes muscular power. After fatigue a simple warm bath may slightly increase muscular power although this effect is not decided (Fig. 26, first tracing). Warm procedures when combined with friction or percussion, as in douches, pro- duce an increase in muscular power, but to a less extent than cold (Fig. 26) . In practice, alternate hot and cold douches, when so given that the hot is short and used only to prepare the body for cold, produce the greatest in- crease in the working power. Mechanical effects alone, as massage, give the least increase of muscular power. The therapeutic points of practical importance which one may gain from the facts brought out by the above experiments, are these: Hot applica- tions are useful in decreasing the tonicity of hypertonic muscles, lessening their irritability, and relieving either clonic or tetanic spasm. The hot leaves no bad after effects. Unlike morphia or the bromides, it does not cover up or mask important symptoms. It does not poison or anaesthetise the nerve centers or endings. In cold applications, properly graduated to suit the needs of various con- ditions, we possess the most useful muscular stimulant and tonic known to 2 Recorded in Rational Hydrotherapy. 80 MUSCULAR CAPACITY medical science. The stimulating effects of strychnin are not comparable with it. The stimulation produced by strychnin is not constant or uniform. Its toxic action becomes manifest in even small doses. Its frequent repe- tition soon wears out the response, and depression results. When frequently repeated, the stimulating stage is of very transient duration and later, is absent altogether. It produces a feeling of exhaustion or irritability, rather than exhilaration. "On the whole, strychnin must be looked upon only as a temporary remedy. It must be remembered that it does not in any way permanently improve the condition of the central nervous system, nor does it increase any of the functions except reflex irritability. It is doubtful whether the permanent maintenance of this artificially raised irri- tability is ever of benefit." 3 3 Sollmann Pharmacology, p. 175. CHAPTER XIV THE HEAT MECHANISM All the energy liberated in the body by the decomposition and oxidation of food appears as work or heat. It has been calculated that about 0.9 of this energy goes to produce heat and 0.1 appears in the form of work. Next to the muscles in importance as a source of bodily heat, is the liver. The tem- perature of the blood in the hepatic vein is higher than in any other part of the body. This is doubtless because of the magnitude of metabolic changes which occur in the liver. "On the processess of metabolism the decomposition and oxidation of foodstuffs depend the maintenance of life. Hence all living animals are continually producing heat and imparting it to the surrounding bodies; and unless this heat production is more than counterbalanced by loss of heat in surface evaporation, they must have a higher temperature than the surround- ing medium, although the difference may not amount to more than two or three degrees in cases where metabolic processes are going on sluggishly. ' 'The temperature of an animal is the algebraic sum of two factors the amount of heat produced and the amount of heat lost in a given time. If, while the heat production remains constant, the amount of heat imparted to the surrounding medium be increased, the temperature will fall. If, on the other hand, heat loss remaining constant, heat production be raised, the temperature will rise in the same proportion. So the temperature may be regulated by alterations in the heat production or in the heat loss; and if the temperature is to remain constant, there must be an accurate correlation between the two processes. Regulation of Heat Production "It has already been mentioned that, if a frog or other cold-blooded animal be exposed to a higher temperature, its internal temperature will also rise. If, at the same time, we measure the respiratory interchanges of the frog, we find that at the higher temperature, more carbon dioxide is evolved and more oxygen taken up, showing that in this case a rise of temperature in the surrounding medium causes a rise in the temperature of the frog, and at the same time, increases the activity of its metabolic changes. Cooling has the reverse effect. If a frog be cooled to C., the chemical changes in its tissues are so reduced that it may be kept alive for some days in an atmosphere devoid of oxygen. The case is quite otherwise with warm- blooded animals. Exposure of one of them to a cold medium raises the amount of carbon dioxide given off and oxygen taken in, while the tempera- ture of the animal remains unaltered. This power of the animal to react to 82 THE HEAT MECHANISM changes in the temperature of the surrounding medium is dependent on the integrity of the nervous system and its connection with the muscles. If a dog or rabbit be poisoned with curare (which paralyzes the muscle end-plates), or if its spinal cord be divided just below the medulla, its temperature sinks continuously. It is then found that the animal reacts to changes in the tem- perature of the surrounding medium precisely like a cold-blooded animal rise of the external temperature causing rise of the internal temperature and increased elimination of C02, while a fall of the external temperature has the reverse effect." l It has been shown that metabolism and heat production are proportional to the skin area of the animal under observation. The temperature nerves of the skin constitute the mechanism by which thermic impressions are received. Quantitative results as regards heat production are therefore dependent upon the area stimulated. An animal whether of little or much weight, produces heat not according to its weight but according to the extent of the skin surface exposed to the surrounding medium. Regulation of Heat Loss From the standpoint of hydrotherapy, however, of more importance than the regulation of temperature by the production, is regulation by heat loss. Heat is lost from the body in three ways. Only the last two of these are of any practical importance and the third is of the greatest utility, for it is largely through this avenue that febrile temperatures are controlled. The three ways are as follows: 1. By the Urine and Feces. About 3 per cent of the total heat lost from the body, leaves it with excretions. 2. By the Expired Air. "The inspired air is taken in at the temperature of the surrounding atmosphere, and contains only a small amount of aqueous vapor. The expired air has a temperature of about 1 lower than the body temperature, and is saturated with water vapor. Heat is therefore lost in respiration in two ways: first, in warming the inspired air; second, in the evaporation of large quantities of water. These two sources of loss consti- tute about 20 per cent of the total heat loss. 3. By the Skin. "Here again the loss of heat is affected in two ways: first, by radiation and convection. By these means, an interchange of heat takes place between the surface of the body and surrounding objects, tend- ing to cool the body under ordinary circumstances when the external tem- perature is below 98.4 F., or 37 C., or to warm the body when the external temperature is higher than this, as during the hot season in the tropics or in a Turkish bath. The amount of interchange of heat between two bodies is directly proportionate to the difference of temperature between them. r \ hus, the warmer the surface of the body in comparison with that of sur- rounding objects, the greater will be the amount of heat interchange, which in this case implies a loss of heat to the body. Since very little heat is generated in the skin itself, its temperature is intimately dependent on the amount of blood flowing through it, and this in its turn on the condition of the blood vessels of the skin. When these are dilated, there is a constant 1 Starling- Physiology, 1907. pp. 500-503. HEAT LOSS 83 supply of warm blood from the deeper parts of the body to the skin, which therefore is kept warm and feels warm, both subjectively and objectively Hence dilatation of the blood vessels of the skin, under normal circumstances brings about increased loss of heat. If, on the other hand, the vessels are constricted, the small amount of blood supplied to the skin rapidly becomes cooled and the skin is also cool, and the loss of heat small. "Second, by the evaporation of the sweat. In the conversion of water into watery vapor, a large amount of heat becomes latent. This principle is made use of in making ice, or in cooling a bottle of water by surrounding it with damp cloths which are exposed to a draught of air to facilitate evap- oration. If the secretion of sweat is small, it evaporates as it is secreted, Hat Low i a Calorie* fier Kvloqram Fig. 27. Rubner's chart showing the manner of heat loss at different room temperatures in the dog. - -, heat loss in calories through evaporation ofivater, , heat loss in calories through radiation and convection. and the skin remains dry. This is spoken of as insensible perspiration. If the secretion be very copious, it may be formed faster than it can evapor- ate, and appears on the skin as drops of sensible perspiration. The forma- tion of sensible perspiration depends then on two factors the amount of sweat secreted, and the rapidity of evaporation, which latter again is depend- ent on the amount of saturation of the surrounding atmosphere with watery vapor. 84 THE HEAT MECHANISM "The loss of heat by the skin amounts to about 77 per cent of the total heat loss, and is therefore the most important of all the channels for the discharge of heat. The regulation of the the total heat loss is also effected chiefly by -changes in the loss through the skin. The nervous channels by which this is carried out are the vasomotor and the sweat nerves. If the external temperature be below that of the body, the loss by radiation and convection may be sufficient to get rid of the excess of heat produced. If, however, the external temperature be higher than that of the body, radia- tion and convection will serve only to warm the body still further, and the sole loss of heat that can be affected is by the evaporation of sweat (Fig. 27), which is accordingly, under such circumstances, secreted in large quantities. "Often, especially after severe muscular exercise, radiation and convection are not sufficient to carry off the excess of heat produced, and hence there is a copious secretion of sweat as well, even though the external tempera- ture may be cool." 2 The relative values of the different means of heat loss are estimated by Vierordt as follows: 1. By urine and feces 1.8 per cent 2. By expired air: warming of air 3.5 " " Vaporization of water from the lungs 7.2 " " 3. By evaporation from the skin 14.5 " " 4. By radiation and conduction from skin 73.0 " " "So perfect is the adaptation of the heat loss to the heat production, that a man may travel from the poles to the equator, may eat or fast, take exer- cise or rest, without causing any lasting alteration in his temperature of 1 C., though violent exercise may induce in many individuals a temporary rise of temperature of 2 C." 3 "We may at present adopt the conservative view that heat production and heat dissipation in the body are controlled not by a special heat-regulat- ing apparatus, composed of heat centers and heat nerves, but by the co- ordinated activity of a number of different centers in addition to the volun- tary means already specified. The unconscious regulation of the body temperature is effected chiefly through the following: " 4 Heat Dissipation. 1. The sweat centers and sweat nerves. 2. The vasoconstrictor centers and their nerve fibers to the skin. 3. The respiratory center. Heat Production. 1. The motor nerve centers and the motor nerve fibers to the skeletal muscles. 2. The quantity and character of the food. 3. Secretory and other glandular nerves. 2 Starling Physiology, pp. 504-506. 3 Starling Ibid., p. 506. 4 Modified from Howell Physiology, 1908, p. 866. EFFECTS OF BATHS 85 Experiments in Heat Production and Elimination For our purpose, no time need be spent on experimental proof of the effects of muscular, glandular and other vital activities on heat production and elimination. We wish, however, to quote more or less at length the experimental basis of the physiologic effects of hydriatic applications upon heat production and heat loss. Kellogg's experiments (Rational Hydro- therapy) along this line are very practical since the tests were made after applications of the intensity and duration actually employed in practice. W. was given a cold percussion douche for 30 seconds. The change in rectal temperature immediately after revealed an increase of nearly 90 heat units and this in spite of the increased heat elimination resulting from the reaction. Another experiment upon a subject A. revealed the fact that while quiet immersion in a bath at 82 F. for 5 minutes absorbed heat from the body, it did not cause any material increase in heat production above the normal amount or rate. When the same subject was placed in a bath at 77 F., and rubbed constantly during the 5 minutes, heat loss was increased 3 times and heat production 6 times the normal amount. P. was given a short hot spray at 106 F. By means of a bath-tub calori- meter, it was estimated that heat production had been decreased 22.7 per cent. By means of a d'Arsonval calorimeter, it was shown that oiling the skin decreased heat elimination 45 per cent. A series of four tests with the d'Arsonval calorimeter, were made upon W. In a room temperature of 70 F, when placed in the calorimeter, the elimination of heat from his body produced, as shown by the anemometer, an air movement at the rate of 123 feet per minute. After an electric light bath, sufficient to redden the skin without sensible perspiration, the air movement increased to 140 feet per minute. After an electric light bath to profuse perspiration, the rate of air movement was 170 feet per minute. After a cold percussion douche at 60 F. for 2 minutes, the air movement was 70 feet per minute. In 10 minutes, when reaction had taken place, it was 110 feet per minute. By means of a bath-tub calorimeter, it was ascertained that a certain subject when immersed in water at 70 F. imparted heat to the water to the extent of raising its temperature 0.72 in 5 minutes. When friction was applied, the temperature of the water rose at the rate of 1.08 F. in 5 minutes, or an increase of 50 per cent in heat elimination. The giving of copious enemata at 70 F. at intervals of 25 minutes for an hour and a half, to a subject S. , reduced the mouth temperature from 98 to 96.9 F., and the rectal temperature from 100 to 95.2 F. The drinking of seven glasses of lemonade at 58 F. in the case of M. pro- duced, in 20 minutes, the following changes: Temperature By Axilla By Mouth Per Rectum On Epigastrium Before 97.7 98.7 99.2 After 96. 1 G 98.0 98.0 It has already been mentioned that for every fall of 1 C. in the surround- ing temperature there is an increase of metabolism amounting to 2 or 3 per 86 THE HEAT MECHANISM cent. Rubner experimenting with a bath of one hour's duration, obtained the following results in the case of a man weighing 60 kilograms and in whom there was a normal heat production of 91 calories per hour. Effects of Bathing on Heat Production Temperature Increased Increase of Metabolism Total Effect During of Bath Heat Production in Grams of Fat and After Bath 95 F. 7 calories 0.7 grams 0.7 grams 86 77 " 8.0 " 9.0 " 77 167 " 18.0 " 22.0 " 68 297 " 31.0 " 37.0 " 59 407 " 43.0 " 52.0 " In regard to the heat loss it is estimated that in a bath at 86 F. the heat loss is doubled, in a bath at 77 F. it is tripled and at 68 F. it reaches 5 times the normal. It is interesting to note that more than half and some- times as high as two-thirds of the total heat loss in a cold bath occurs during about the first third of the treatment. In a cold bath at 80 F. of 15 minutes duration and with a total heat loss of 75 calories, 43 calories of this heat loss occurred during the first 5 minutes. In another case with a cold bath at 63 F. of 2 minutes duration and a total heat loss of 65 calories, nearly 44 calories of this were lost during the first minute. The reason for the greater heat loss early in the course of a cold bath, is doubtless due to the fact that the body is unprepared to resist the abstrac- tion of heat, consequently the high heat loss. But very soon the heat regu- lating centers set in motion vascular and other changes which are tended to economize the body heat as far as possible, i. e., resist heat loss as well as provide for increased heat production. The body tends to resist the abstraction of heat brought about by contact with cold water by making more unfavorable the conditions for heat elimination. The following are some of the results claimed by Otto PospischI as a result of his work as assistant to Prof. Winternitz. Thermic influences which cause goose-flesh, decrease heat elimination as much as 38.7 per cent. Partial cold wet rubbing may increase heat elimination as much as 80 per cent, and vigorous friction in the cold bath as much as 44 per cent. Cold shower baths, with rest following, increase heat elimination 25 per cent; with subsequent exercise, the heat elimination is increased 66.6 per cent over the normal. Warm shower baths with cold fanning and rest, increase heat elimination 60 per cent. Summary Heat Production (Thermogenesis) The following are some of the conditions and measures that increase heat productions: Vital activities such as, 1. Glandular activity. 2. Muscular activity. SUMMARY 87 3. Digestive activity. 4. Mental activity. External conditions, 5. Reaction to cold applications (either long or short). 6. Low atmospheric temperatures. 7. High atmospheric temperatures. The following conditions and measures decrease heat production: 1. Fasting. 2. Sleep and rest. 3. Reaction to short hot applications. Heat Elimination (Thermolysis) The following conditions increase heat elimination; the agents or means which produce these conditions are listed as subordinates. 1. Dilated surface vessels and rapid circulation, a. Heat. b. Short cold (reaction). c. Friction. d. Weak chemical irritants. 2. Increased perspiration (by evaporation of water), a. Heat. b. Friction. c. Water drinking. 3. Increased rate of respiration. More or less prolonged applications of cold, whether cold water or cold air, abstract heat from the body by conduction; but they tend to make the body resist this effect; that is, it attempts to counteract heat elimination. Conditions that decrease heat elimination: 1. Contracted surface vessels and slowed circulation (as in goose-flesh). 2. Decrease of perspiration (lessened evaporation) . 3. Slowing of respiration. 4. Very high atmospheric temperatures. 5. Oiling of the skin. The following measures, while they cause the body to make attempts at decreased heat elimination, do, by contact, abstract heat: 1. Cold baths, enemata and water drinking. 2. Contact with cold air. Since more than half the heat taken from the body by a cold bath is lost during the first third of the treatment, short cold baths, are proportionately to their duration, more effective than long cold baths. The activity of the surface circulation being the essential factor in the loss of heat during a cold bath, it follows therefore that whatever increases the amount of blood in the skin and the rapidity of the circulation in the skin will markedly increase heat loss during a cold bath. This is one of the chief reasons for the use of short hot applications preparatory to the use of the cold bath. 88 THE HEAT MECHANISM There are two local applications of cold whose chief effect upon the body temperature is not by the abstraction of heat. These are the ice cap applied to the head and the ice bag applied over the heart. Their action is reflex. The former influences heat production through its reflex effect upon the thermogenic centers of the brain. The latter reflexly slows the heart beat and thereby the general circulation, which in turn, decreases heat produc- tion. Of course, as previously stated, these effects are very slight in health, but of inestimable value in febrile diseases. Heat Regulation (Thermotaxis) The normal temperature of the body is maintained by the nicety of the balance between heat production and heat elimination. Increased heat pro- duction does not necessarily mean a rise of body temperature, since under normal conditions, the heat is dissipated as rapidly as produced. The natural conditions that tend to increase heat production usually stimulate the elimi- nation of heat as well, and so a balance is maintained. For example, the body is exposed to a draft of cold air. The skin assumes a goose-flesh appear- ance by contraction of the involuntary muscles; it is pale and contains less blood. While the cold air abstracts or conducts heat from the body, this lessened circulation in the skin decreases the amount of heat lost from the surface. The perspiratory glands are less active, and the consequent les- sened evaporation of water from the skin also decreases the amount of heat eliminated. At the same time, the sensation of cold influences the thermo- genic centers, and they cause the tissues to produce more heat. Even the shivering which follows the exposure to cold, being muscular action, is one method of producing heat. Thus, the temperature of the body is maintained at a constant point, rather than lowered by the cold atmosphere. The converse is true of a short, mod- erately warm bath. This would communicate heat to the body, and so tend to raise the temperature; but the body reacts in such a way as to preserve the balance. The skin is relaxed, the blood vessels dilated and the perspira- tion increased, so that more heat is lost by dissipation from the surface. At the same time, this relaxing effect causes loss of tone in the tissue generally, and so less heat is produced. These results are due to the control exercised by the heat regulating centers before mentioned. It must not be supposed, however, that heat always decreases heat pro- duction. Very high temperatures markedly increase heat production, so much so that fatal poisoning may occur in such conditions as heatstroke. Serious cases never wholly recover from the effects of the high external temperature and the internal heat produced by it. They are ever after extremely susceptible to even the moderate heat of tropical climates or direct sunlight. While an agent may increase both heat production and elimination at the same time, one is usually increased to a greater extent than the other. For example, a cold mitten friction at first abstracts heat from the body, but the reaction causes increase heat production, as shown by the "warming effect. ' ' The increased circulation of the skin, which is part of the reaction, causes more heat to be lost. The total effect, however, is an increase of SUMMARY 89 heat in the body, because heat production is stimulated more than heat elimination. As we have seen, thermic applications produce decided changes in heat production and elimination. However, these changes do not, in health, pro- duce wide alterations in the body temperature. On the contrary, the same influences applied in febrile conditions produce decided alterations. From the preceding experiments, it will be seen that water at the vary- ing temperatures and in the different ways in which it may be applied to the body, is capable ofiany and all possible variations and degrees of effect upon the heat mechanism. No possible alteration of heat production or elimina- tion can be conceived of, that water is not capable of producing. It is this versatility of application and effect that makes hot and cold water of so much service in fever and disturbances of the heat mechanism. On the contrary, drug action is particularly monotonous, and ideal combi- nations impossible to make. If they seem to act in a rational manner upon one part of the mechanism, it will be found that they have an adverse act- ion upon another part. And usually, this adverse action more than outweighs any good which may be accomplished. This will be considered under the subject, "Fever and Antipyretic Effects." PART II THERAPEUTICS CHAPTER XV THE REALM AND LIMITATIONS OF PHYSIOLOGIC THERAPY Therapeutics is the science and art of healing. Disease is an abnormal state of the body manifest in a morbid condition of structure or function. The departure from the normal, nearly always begins in some mild way. Even in acute diseases, the predisposition is laid in previous unhygienic habits or surroundings. There are two general types of disease usually recognized, viz., the functional and the organic. In the former, the actual structure of the diseased organ or part has not greatly deviated from the normal. The condition is manifest in a derangement of the function of the part. However, even in many so-called functional diseases, it is possible, by careful microscopic examination, to detect more or less of pathologic change. But even in this case, the alteration in structure has not gone on to such an extent as to preclude the possibility of a restoration to normal more or less complete. In the case of organic disease, such gross structural changes have been pro- duced as to be readily detected and of such a character as to preclude the possibility of a return to the normal. In this case, physiologic therapy can accomplish only aleviation of the symptoms and such building up of the general vitality and resistance of the patient as to more or less counterbal- ance the effects of the structual lesion. In many cases where no indispens- able part is involved, radical means may be used, such as the removal of a malignant neoplasm, or some operation may be done to overbalance or palli- ate the results of the disease, as in the case of Talma's operation for hepatic cirrhosis, or Edobohl's operation for renal insufficiency. Purely functional diseases are, however, nearly always best treated by physiologic means. In the course of many diseases a point is reached beyond which a return to the normal is impossible without the intervention of some radical proced- ure. This is especially the case in inflammations. In certain grades, stages and types of inflammation, it is entirely possible, by natural means, to aid or affect the return to normal structure without the intervention of radical measures. This is true of such an inflammation as dry or serous pleurisy, pneumonia or a simple surface infection, but where these inflammations have gone on to the formation of a suppurative focus or an abscess, physiologic means alone are unable to accomplish the full return to the normal condition. True, in time, the abscess might work its way to the surface, and so evacu- ate, but in most cases, it is a long, tedious process and the patient is very much reduced in vitality by such delay, which delay in many cases, may 94 REALM OF PHYSIOLOGIC THERAPY prove fatal from the absorption of toxic products. It is necessary, by some radical means, to accomplish the speedy evacuation of the pus and free drainage of the abscess cavity. The old dictum, ubi pus, ibi evacua, is just as true now as when it was first enunciated. Translated into terms of activity, it means, where there is pus, provide an outlet. It is necessary that evacuation be provided for. This, nature itself seeks to accomplish; but unaided, its attempts are accompanied by great destruction of tissue and much delay. By vigorous treatment, systematically applied, it is often possible to obviate the necessity for radical interference. But when the stage of suppuration has been reached or is imminent, surgical intervention is just as much an assistant to nature as physiologic means and therefore just as rational. The same principles apply to the use of vaccines and antitoxines. If the body has sufficient reserve power and the infection does not progress too rapidly, the system may provide adequate means of cure. Yet the course of certain infections teaches us that such circumstances can not always be relied upon. Where available and of demonstrated value no one would think of omiting the use of serum therapy. Nor when this is used should physiologic means be left out simply because other procedures are more essential in a given case. All measures of value should be used in order to still further assist the body in combating the infection. We may then, in general, say that where physiologic means are unable to aid the organism in re-establishing the normal structure and function, radical interference is necessary. This division line can best be determined by care- ful consideration of experience in the light of the usual trend of the particu- lar disease in question. Experience has shown that a certain type of inflam- mation in one organ or location may tend to a serious issue, such as abscess or gangrene, while in another organ or location, it usually tends to resolution. For example, we may cite the case of appendicitis on the one hand and of salpingitis on the other. In both cases, physiologic means may accomplish a return to the normal, but in the case of appendicitis, this return is not to be relied upon for permanent cure. The tendency is to recurrence and even, in a single attack, to perforation and peritonitis; while with the pelvic inflammation, physiologic means produce a return to the normal which can better be relied upon to' permanently restore to the normal with a safe issue; and under proper physiologic treatment, if taken early, there is little, or at least less, tendency to rupture or abscess formation. Even in the case of formation of pus in the tube, it is best to delay surgical interference until the acute inflammation has subsided and, if possible, the temperature has returned to normal. At best, it is dangerous and conducive to spread of infection, if salpingectomy be done during the continuance of the acute inflammation. It is quite otherwise with appendicitis. Not only does operation in the acute stage give good results, but because of the inability to determine the immediate issue, it is imperative to interfere as soon as possible. True, a patient may go through a number of acute attacks, all of which subside without serious complications, but this can not be relied upon to continue. In each succeeding attack there is greater liability to perforation. Considering all, we may, then, draw the conclusion that rational therapy ESSENTIALS OF THERAPY 95 is based upon three things, experiment, experience and judgment, the latter for the purpose of applying to the individual case the general laws and deductions relative to that condition. It requires an extreme nicety and perfect balance of judgment to determine whether a given border line case should be treated by physiologic or radical therapy. This faculty has been termed "surgical judgment." But its application requires more than a knowledge of operative technique. The surgeon who is pre-eminently a phy- sician and whose armementarium is well stocked with physiologic means, will meet with the best success. Let not the surgeon be over enthusiastic about operative treatment nor the physician so confident of natural means as to procrastinate when prompt surgical interference offers the best hope of speedy and permanent recovery. Basic Principles of Therapy The philosophy of the practice of therapeutics is summed up in three things. The proper application of these may be considered rational medicine. First, removal of the cause. Second, treatment of the existing condition. Third, relief of such symptoms as, by their severity, in turn become causes. After removal of the cause many functional diseases right themselves (sublata causa, tollitur effectus) l without further treatment, since perverted habits of function have not become fixed. In the large majority of cases in addition to removal of the cause, it is necessary to direct attention to the existing perversions of function and structure. Usually, the measures found most successful in the treatment of a disease meet all three of these indica- tions. It is, therefore, seldom necessary to consider them separately. For example, in typhoid fever, the cold bath increases phagocytosis, thus com- bating the cause infection; it relieves internal congestion, increases the oxidation and elimination of toxines; it relieves the nervous symptoms and lessens the fever. A single procedure meets all three indications. 1 When the cause is removed, the effect disappears. CHAPTER XVI FEVER AND ANTIPYRETIC EFFECTS Fever is a disturbance of the heat mechanism in which there is a more or less prolonged rise of temperature above the normal. The principal cause is the circulation of unusual toxic substances in the blood. It is the result of a protective effort, an attempt on the part of the body to cope with these poisons; but the organism may be overwhelmed by them and so be unable to oxidize them with sufficient rapidity to protect the body. Or, because of the nature of these poisons, the heat regulating centers and the vasomotor centers are disturbed and the balance unsettled. If heat elimination were to keep pace with the heat production, even though the latter were greatly increased, there could be no rise of temperature. Many toxines cause a sensation of chilliness and thus decrease the heat loss, and fever results. While the body attempts to protect itself, its efforts are not always well directed or governed. The poisons producing pyrexia are of various origin. They may be formed in the body or introduced from without. In the former case the toxemia may be due to the accumulation of body poisons, i. e., those which are normally produced in health by ordinary metabolism, but are usually elimin- ated as fast as formed. These poisons are called leucomaines. They do not produce the higher types of fever, nor fever of long duration. The poisons due to anger, worry and other nervous disturbances are classed under this head, although they are not normal to the body. Prominent among the leucomaines, as a cause of fever, are the purin bases. Apropos of this subject we quote the following from Lusk: J "However, there is a very noteworthy record made by A. R. Mandel that the rise of temperature in aseptic or surgical fevers is accompanied by a large increase in the purin bases in the urine of patients fed with milk. The temperature rises and falls with the quantity of purin bases eliminated. The uric acid elimination is reduced. ' 'That the purin bases can be the cause of the rise of temperature is indi- cated by the experiments of Burian and Schur who found that when nucleo- proteid was administered intravenously to a dog, a rise of temperature fol- lowed. Mandel showed that a subcutaneous injection of 40 milligrams of xanthin caused a marked rise in the temperature of a monkey, and that the administration of a strong decoction of 60 grams of coffee (containing tri- methyl-xanthin) to a man unused to coffee drinking, was followed by a febrile temperature." Toxines may be produced by saprophytic bacteria (those of decomposition) , 1 Science of Nutrition, 1906. p. 267. CAUSES OF FEVER 97 growing in the body or in the alimentary tract. These conditions are known as sapremia and auto-intoxication. Foods decomposed by bacterial action may serve as the source of poison, as in the eating of decomposed meat, cheese, etc. Such products of bacterial decomposition are known as pto- maines. Bacterial toxines produced by pathogenic bacteria, growing within the body itself, are the most usual causes of fever and those with which we are most concerned in the treatment of this condition. Ultimate Causes of Pyrexia. The following outline is modified and abridged from Sollmann. 2 Fever may be due to, 1. Exposure to excessive external heat, as in sunstroke. Also internal heat (over-oxidation) as in excessive muscular exercise. 2. Certain drugs, such as the convulsants, cocaine and strychnin, by the production of convulsions or spasm of the muscles. 3. Toxic Proteins. a. Bacterial toxines of infectious diseases. b. Ptomaines. c. Auto-intoxication (intestinal, biliary, urinary, etc.). d. Absorption of unconverted digestive products, as albiimoses and peptones in a diet too rich in proteid; or due to digestive disorders. Manifestations of Fever. In addition to the causes of fever, it is necessary to consider the symptoms, since these are an indication of the real condition of the patient and may be of such a magnitude as to, in turn, become a cause of additional trouble; in which case, special treatment must be directed toward their relief or palliation. The toxines, or the high temperature, cause the following symptoms, recognized as characteristic of fevers: 1. Nervous disturbances, such as malaise, headache, backache, insomnia, delirium, etc. 2. Hot dry skin, or cold clammy skin. 3. Increased pulse rate and blood tension. 4. Increased rate of respiration. 5. Excessive thirst. 6. Loss of appetite, foul breath, coated tongue. 7. Constipation. 8. Urine scanty, highly colored, high specific gravity, increase of urea. Principles of Antipyresis Since the body by increased oxidation attempts to get rid of toxines, this burning is to be encouraged rather that hindered. The fever should be con- trolled, not combated. The system is to be aided in its attempt to oxidize and eliminate the poisons. The idea that the reduction of temperature is the sole object in the treatment of fevers has become so firmly fixed in the minds of physicans and .laymen that it is hard to eradicate. It was this idea that led to the use of the medicinal antipyretics, the giving of which is not only wholly irrational, but productive of very serious complications and 2 Text Book of Pharmacology, 1901, p. 394. 98 FEVER AND ANTIPYRETIC EFFECTS sequellae. To a great extent, the same idea also prevails with regard to the use of the cold bath in fever, much to the discredit of hydrotherapy and rational therapeutics. Many, too, regard the reduction of fever as the only asset of hydrotherapy, and fever as the only condition in which hydriatic measures are applicable. That both ideas are erroneous has already been shown and will be made plainer as we consider the rationale and results of hydrotherapy, not only in fever, but in a host of other maladies. The basic object in the treatment of fevers is the same as in all other diseases, viz., the removal of the cause. This can be accomplished only by decreasing the toxemia. In only a few febrile diseases has medical science discovered a direct antitoxine or perfected a workable system of producing immunity. We are, therefore, under the necessity of directing our efforts toward increasing the oxidation and hastening the elimination of these bac- terial toxines; increasing phagocytosis; and assisting and conserving the powers of the tissues in the production of antitoxines, antibodies, opsonin, etc., this latter action being largely the work of the phagocytes themselves, upon the integrity and activity of which immunity depends (Metchnikoff). In addition to this basic object the removal of the cause it is necessary to prevent the over accumulation of heat, a thing which is accomplished by the same means. And third, to mitigate the symptoms, especially those referable to the nervous system. Combat headache, malaise, insomnia, delirium, etc. This also is done by the cold bath and other cold applications. In fact, all of these results can be and are obtained by properly applied hydriatic measures as has been demonstrated by the experiments cited in the previous part of this work. Further in regard to the connection of the circulatory system with the general manifestations of fever and especially with regard to the circulatory complications which contribute so largely to the mortality, experimental pathology has laid a very firm foundation for the use of hydrotherapy in fevers of infectious origin. The researches of Romberg and Passler are considered the basis of our knowledge of the state of the heart and blood vessels in these diseases. The reports of their work 3 have shown conclus- ively that circulatory failure is not primarily due to the heart itself, but to paralysis of the blood vessels brought about by damage to the vasomotor centers. In this connection we can not do better than quote from the brief resume of these researches given by Janeway and from remarks made by Forchheimer. 4 "They studied the fatal collapse which occurred in rabbits after infection with the pneumococcus, the bacillus pyocyaneus, and the diphtheria bacillus; the first producing a true septicaemia, the latter a local lesion with general toxaemia. All of the 250 animals used were autopsied, and the heart and other important organs examined microscopically. Their method consisted in observing the mean carotid pressure at different stages of the disease, and the effect upon it of (1) abdominal massage, which increased the work of the heart by supplying it with more blood; (2) compression of the aorta 3 Romberg and Passler Deutsch. Archiv. fur klin. Med., 1895, LXIV pp. 652-763: also Passler Munchen. Med. Wochenschrift, 1901 XLVIII, No. 8 4 The Clinical Study of Blood Pressure, pp. 155, 156; and Cardiac and Vascular Complica- tions in Pneumonia Journal of American Medical Association, Oct. 30, 1909, p. 1450. TOXIC VASOMOTOR-PARALYSIS 99 above the diaphragm, which makes the work of the heart maximal; (3) irri- tation of the nasal mucous membrane with a Faradic current, which causes extreme reflex vasoconstriction; and (4) short asphyxia (30 sees.), which acts similarly, only on both medullary and spinal vasomotor centers; while sensory stimulation affects only the center in the medulla. They reasoned that, should there be no rise in pressure from sensory irritation or suffoca- tion, while abdominal massage and ligature of the aorta still called forth a well marked one, then the heart must be functionally capable and the vaso- motor mechanism paralyzed. To determine whether the central or peripheral vasomotor mechanism was at fault, they used injections of barium chloride, which cause constriction of the arteries by purely local action upon them. "Their experiments showed that the blood pressure and the response to all the procedures remained perfectly normal throughout the early stage of the disease, being unaffected by the fever. The greatest elevation of pressure was obtained on stimulating the mucous membrane of the nose. When the animals showed signs of impending collapse in their behavior, the blood pressure, though still normal, began to sink, while the heart beat more forcibly. Hand in hand with this went a great reduction in the rise of pres- sure from sensory irritation, a moderate decrease in the asphyxial elevation, but as high a pressure as before after abdominal massage. In many cases the pressure did not fall until the reflex rise had been almost abolished, evidently being maintained by increased cardiac energy, in spite of the vascular dilatation. Finally, in complete collapse, which developed very rapidily, the aortic pressure fell to the lowest level, as after destruction of the spinal cord; no reflex rise could be obtained, but abdominal massage gave an immediate elevation. It was evident, therefore, that the circulatory disturbance at the height of the infection depended absolutely upon a par- alysis of the vessels, not upon any damage to the force of the heart. "As regards their reaction to compression of the thoracic aorta, the diph- theria animals showed a divergence from the pneumococcus ones; the latter evincing practically normal cardiac reserve force, while the former showed a distinct falling off. Anatomically, also, the diphtheria hearts had suffered damage, parenchymatous degeneration being well marked, as in clinical diphtheria. The pneumococcus animals had scarcely any change in their car- diac muscle. Thus evidence of weak ness in the heart muscle in diphtheria was of minor importance, the real cause of death in all cases being the complete loss of vasomotor tone. By intervenous injections of barium chloride they proved decisively that this was due to central paralysis. Their conclusions were, that all three organisms used damage the circulation through paralyz- ing the vasomotor centers throughout the medulla and cord; this vasomotor paralysis leads to a fall in blood pressure, and further, to a changed blood distribution; the splanchnic circulation is overfilled, the brain, muscle and skin vessels are empty; the heart is not affected, except secondarily through insufficient blood supply." Forchheimer's discussion on this latter condition splanchnic conges as follows: "Long ago it has been shown in animals, that on section of the splanchnic nerve, an enormous quantity of blood accumulates in the intes- tine, which is followed by intense anemia in other organs, especially 11 central nervous system, which may cause death. The splanchnic nerve u 100 FEVER AND ANTIPYRETIC EFFECTS vasomotor nerve of the intestines, and its section causes paralysis of vaso- motor function and enormous dilatation of the blood vessels. In paralyzing the vasomotor center with the pneumococcus the same result follows in man. In brief, in man there is first, dilatation of blood vessels in the splanchnic area; the blood pressure, which sooner or later is normally low in pneumonia, sinks; the heart, which is supplied by an insufficient quantity of blood, which is gradually becoming stationary in the affected area, continues to draw blood from other places, the liver, the skin, the muscles and central nervous system, and becomes more and more rapid and ineffectual, 'bleeding itself into the splanchnic area,' and finally stops. The intracardiac pressure is reduced so that the myocardium ceases to contract; moreover, the various cardiac and vasomotor centers become asphyxiated, and therefore paralyzed. " These above quoted facts and discussion very clearly show the rationale of hydrotherapy in infectious diseases. The vasomotor stimulation which results from hydriatic procedures amply meets the needs of the situation, which need it is impossible to meet by medicinal therapy of any sort. The Effects of Medicinal Antipyretics 1. Drugs having a collapse action, such as aconite and viratrum viride. These lessen the force of the heart beat and dilate the blood vessels, so lowering the blood pressure. Heat production is decreased, because of this latter action. Vasodilatation favors the loss of heat from the skin. This is not a tonic, but an atonic dilatation and so, in no way, restores the lost tone to the circulatory system. Both these drugs decrease fever at the expense of the heart's action and so prove dangerous in asthenic fevers, or where there is cardiac weakness, dilatation or incompetency already existing. 2. Alcohol. The only beneficial (?) action of alcohol, as relied upon in fever and as given in so-called therapeutic doses, is upon the smaller blood vessels, in which it causes an atonic or paretic dilatation and consequent loss of heat from the skin. At the same time, it dilates the visceral capil- laries which are already congested in febrile conditions. Their paretic condi- tion renders the viscera much more liable to suffer from retrostasis when the body is exposed to cold. Alcohol decreases metabolic processes and oxidation. :i The tissues are less active so that toxines, instead of being more rapidily oxidized and eliminated, tend to accumulate in the system. Alcohol lessens the phagocytic activity, the natural defense against infec- tion, and discharges immunity. Delearde has shown that the absorption of alcohol is a grave obstacle to immunization against hydrophobia. Abbot, in experimenting on animals, proved that those subjected to the influence of alcohol were more susceptible to the harmful effects of streptoccocci, bacillus coli and other bacteria. Both Delearde and Laitinen found it impos- sible to vaccinate against anthrax, animals that had been given alcohol on several successive days. 3 "Alcohol in excessive doses and prolonged anaesthesia both paralyze the heat-regulating mechanism. A man who is 'dead drunk' resembles a cold blooded animal; exposure to cold pro- duces not an increase but a decrease in combustion, and his temperature steudily falls. It is not surprising, therefore, that death from exposure chiefly occurs in the case of intoxicated persons." (Hutchison Applied Physiology, 1908, p. 67.) MEDICINAL ANTIPYRETICS m 3. The Coal Tar Products, as Acetanilid, Phenacetin and Antipyrin These decrease heat production by the direct toxic action of their aromatic radicles on the heat centers in the brain and on the processes of oxidation and proteid metabolism. " This is shown by the decrease in tissue destruc- tion, lessening of urea, etc. This effect is most marked in fever, where the rational procedure is to increase the burning up of poisons, (purins, toxal- bumens, bacterial toxines, etc.) in order to get rid of them. Neither do these drugs increase the elimination of poisons. They are very powerful cardiac depressants and possess a decided collapse action. This is most marked with acetanilid. They cause breaking up of the red cells with the formation of methemoglobin, thus in a second way, preventing oxidation by limiting the oxygen carrying capacity of the blood. The movements of the whites are arrested. Phagocytosis is prevented. This is another example of drugs that render the body less able to resist infection. 4. Quinin. This drug lowers temperature by decreasing heat production. Its action is said to be chiefly peripheral upon the thermogenic tissues, in decreasing nitrogenous metabolism. This decrease may reach as high as 39 per cent, with large doses. 5 The drug probably owes its toxicity to its aro- matic nucleus, the same as the coal tar products. It not only hinders the destruction of nitrogenous toxines, but is a powerful poison to the phagocy- tes, arresting their movements immediately on contact with them. This result obtains when only 0.5 to 1 part in 1000 of solution is used. A some- what larger dose causes their destruction (Binz, Sollmann). According to recent experiments by Manwaring and Ruh, larger amounts than 0.008 per cent of quinin causes complete suppression of phagocytosis. Since 1-13 of the body weight is blood, an individual weighing 130 pounds possesses 10 pounds of blood, totalling 70,000 grains. If, at any one time, there should be in the blood of a person of this weight, ten grains of quinin, there would then be acting upon the phagocytes an amount nearly double the minimum toxic dose. Quinin frequently causes hemoglobinuria. Metchnikoff 6 makes the following statement: "It is not only opium and alcohol which hinder the phagocytic action. A number of other substances regularly employed in medicine, cause the same results. Even quinin, the . . . effect of which in malarial fevers is indisputable, is a poison for the white blood cells. One should, therefore, as a general rule, avoid as far as possible the use of all sorts of medicaments, and limit one's self to the hygienic measures which may check the outbreak of infectious disease. This postulate further strengthens the thesis that the future of medicine rests far more in hygiene than therapeutics." 5. Diaphoretics, as Pilocarpin and Dover's Powder. These lower febrile temperature by producing sweating. This in itself, is not irrational. In the case of the former, it has recently been shown that this is at the expense of the heart's astion. The latter drug contains opium which has the same action on the phagocytes as alcohol, quinin and coal tar products. 6. Refrigerants, such as the alkaline citrates, organic acids and acid organic 4 White and Wilcox-Materia Medica and Therapeutics, 1900, p. 300; also Sollmann Text Book of Pharmacology, 1901, p. 355. 5 Sollmann Ibid., p. 346. See also Adami Inflammation, 1907, p. 152. 6 New Hygiene, p. 28. 102 FEVER AND ANTIPYRETIC EFFECTS salts. The alkalescence of the blood is diminished in auto-intoxication and infectious diseases. Bouchard failed to neutralize the excess of acid in the blood by the administration of inorganic alkalies. The citrates, tartrates, etc., do, however, favor kidney activity (diuresis) and sweating (diaphore- sis) and so aid in the elimination of toxines. Experience demonstrates that the natural fruit juices, containing these acids and their salts, give better results in these respects than artificial preparations and do possess a true refrigerant action. No great discernment is necessary to decide that antipyretic drugs are harmful in fever. The majority of fevers are due to infections, i. e., are bacterial toxemias. These drugs in no way remove the cause, nor do they assist the body to overcome the infection. On the contrary, they destroy or cripple the agents of natural defense the leucocytes, rendering them an easy prey to bacteria. Rationale of Hydrotherapy in Febrile Disease The principal object to be sought in the treatment of fever is the com- bating of the infection. The antiseptic treatment of infections has proven a failure. There are no germicides known which have given anything like even moderate success in dealing with bacteria. A few like hexamethy- lenamin are valuable aids, but of limited range. The chemical destruction of bacteria within the human organism is a disappointment and, as remarked by one, "we aim at the germs and hit the patient." The organism is hind- ered more than it is helped. The body itself, must be aroused to combat the infection. This is most effectually accomplished by those means which increase the vital resistance of the body, conserving its power, and especially those means which increase the number and efficiency of the phagocytes. It has already been shown how this may be accomplished. It will also be noted that cold applications as suited to the varying needs of different diseases, compass all these results. We have seen that cold produces a leucocytosis, restores the diminished alkalinity of the blood, produces an active arterial hyperemia, increases and sustains blood pressure, so that life giving, energizing blood circulates more rapidily where previously there was stasis, venous hyperemia, leucopenia, lowered alkalinity, and a blood laden with leucomaines, toxins and acid poisons. The elimination of toxic products of bacterial life is hastened and their oxidation increased by cold. The phagocytes and body tissues are so energized that the histogenous production of antitoxines, antibodies, opsonin, etc., is increased. While all these changes are being brought about, the lessened toxicity of the body fluids relieves the nervous system and it is quieted and invigorated by the tonic influence of the cold. Restlessness, insomnia or delirium gives way to clear, co-ordinated action or undisturbed sleep. The hot, dry skin or the cold, clammy skin is replaced by the warm moist surface. This remarkable group of changes, all of which are bene- ficial, and derived form a single agent cold water it is impossible to bring about by any other known therapeutic agent or combination of agents. It is simply unique in the realm of therapy. Let us now turn our attention to the differences in the effects of the vari- HYDRIATIC ANTIPYRETICS m ous thermic applications used in the treatment of fevers. The following classification will be found helpful: 1. Applications of cold. (a) Prolonged direct antipyretic, by abstracting more heat than is produced. (b) Short stimulate heat production as much or more than they increase heat elimination 2. Applications of heat. (a) Prolonged antipyretic by increasing heat elimination through pro- fuse sweating. (b) Short an adjuvant, prepares the body for cold applications. The physiologic effects of the four classes may be studied under the two following heads: 1. Effect on heat production. 2. Effect on heat elimination. Prolonged Cold. The Brand bath may be taken as a type of this class of hydriatic antipyretics, the effects of which are as follows: 1. Heat production is decidedly increased. This is due to the thermic stimulus arising from contact with the cold water. Oxidation and nitrogen- ous metabolism are both increased. There is not only an increase in the oxidation and consequent destruction of poisons, but their elimination in an incompletely oxidized state is hastened. This is proven by the decided increase in the toxicity of the urine after a cold bath, as shown by Bouchard, Roque and Weil. 2. Heat is transferred from the body to the water and in greater quan- tity than the heat produced, so that a fall of temperature results. This is made doubly necessary because of the above mentioned increase in heat production which would tend to increase the height of the fever if it were not combated. This is by purely mechanical means, i. e., conduction. The heat of the body is transferred to the water which will take up an exceed- ingly large amount without being greatly warmed. Heat elimination is increased by friction, i. e., the body is constantly kept in a condition favoring, the abstraction of heat. The rubbing produces vasodilatation and quickens the circulation. These conditions bring more blood to the surface which is exposed to the cold water. The same condi- tions and the friction itself serve to give a sensation of warmth to the skin and so prevent chilling and the resulting retrostasis of blood. Indications. These effects are indicated in long continued asthenic fevers, such as typhoid, typhus and in hyperpyrexia. The treatment must be fre- quently repeated over a considerable length of time, since it can not be hoped that the source of toxemia will be eradicated by a few applications. Short Cold applications are almost always accompanied by mechanical stimuli. The cold mitten friction is the best example of this class. 1. Heat production is increased by reason of the action of the thermic and mechanical stimuli on the heat centers. 2. The contact with the cold water is of too brief duration to abstract 104 FEVER AND ANTIPYRETIC EFFECTS much heat from the body. The cooling is not manifest except on the skin. Later, heat elimination is increased because of the vascular reaction in the skin. Indications. Short sthenic fevers, as grippe, colds, etc., or where the skin is cold and clammy, for the purpose of warming the skin and raising the blood pressure. This sometimes occurs in typhoid. Long Hot. Any of the sweating treatments used in fevers serve to illus- trate the effects of this class of measures. 1. Heat production is increased during the treatment, at least, to some extent. The atonic reaction which follows may result in decrease of heat production. 2 Heat is communicated to the body. This is the chief cause of the initial rise of temperature before perspiration becomes well established and general. Later, heat elimination is enormously increased because of the increased circulation in the skin and, especially, by the evaporation of the perspiration. This latter is the essential effect of sweating treatments. Temperature-raising: value D F W H R C M F 9 Crrt TJ WC T> . 1. K. . o. K. Bath Cold Bath Temperature-lowering value Fig. 28. Diagram showing quantitative relation between the temperature-raising and the temperature-lowering capacity of different treatments. Indications. Sweating treatments are indicated in the first stage of nearly all fevers, i. e., at the onset. It is at this time that the initial chill occurs. They are useful at this stage in such fevers as measles, influenza, scarlet fever, etc. Short Hot. Fomentations, short hot packs and the hot evaporating wet sheet pack are examples of this class of antipyretics. Their special advan- tage is the preparing of the skin to properly react to suceedin^ cold treat- ment. Heat elimination is increased through the warming effect. Some heat is communicated to the body. Heat production is little, if at all influ- enced. Wherever there is chilliness, cyanosis or goose-flesh in febrile disease, some form of hot application must be used before resorting to cold, since in the absence of the former, the cold may have a decidedly adverse effect. In addition to the effects noted in the general classes of treatments dis- cussed above, it should be understood that by proper variations in the manner of giving hydriatic treatment, it is possible to produce any desired effect upon the heat mechanism and upon febrile temperature. In the case of cold treatments these variations are produced by changes in the degree of MECHANISM OF FEVER PRODUCTION 105 friction used and in the quantity of cold water brought in contact with the skin surface. The more the friction and the less the contact with cold water, the greater the temperature raising capacity. The larger the amount of cold water brought in contact with the body, provided reaction be maintained, the greater the temperature lowering capacity. This relation is graphically shown in (Fig. 28.) The proportion of each block below the dotted cross line indicates the relative value of the treatment in lowering temperature as compared with its temperature raising value indicated by the proportion of the block above the line. Mechanism of Fever Production The mechanism of the production of fever is a large subject and one some- what outside of the scope of this work. There are, however, a few points that should be noted in order to gain an understanding of the principles involved in the treatment of fever, i. e., in order to treat such conditions intelligently. Graham Lusk 6 gives the following discussion : "A high fever may be accompanied by an increased metabolism of only 15 per cent. The cause of the fever must therefore be due to diminution in the ability to discharge the heat produced. In further support of this, Senator has shown that, the fever following pus injections in a dog begins with a retention of heat within the body. Nebelthau found that when the heat discharge of a normal rabbit was called 100, during the first 12 hours of infection in which the temperature rose from 38.6 to 40.1, the discharge of heat was but 96.3. Assuming the heat production to have been the same in these two periods (as was actually the case in the rabbits of May), then the heat retained would account for the pathological increase in temperature. At a later stage the discharge of heat rose to equalize its production at the higher temperature. ' ' In the state of lessened heat elimination manifest at the beginning of most fevers lies the reason for the initial use of hot applications so frequently advised in the subsequent pages of this work. "Nebelthau has shown a fall in temperature and heat production in a rabbit whose cord was divided between the sixth and seventh cervical ver- tebrae, and has also demonstrated that under these circumstances infection with erysipelas of the pig had no influence on temperature or heat produc- tion. The inference is that the febrile toxines act through the higher vaso- motor centers, whose regulatory control is lost in the above experiment. "A kindred interpretation may be placed on the experiments of Mendel- sen, who was unable to produce fever through pus injections when the dog was under the influence of chloral or morphin, although such treatment in a normal animal caused a rise in temperature of from 36.3 to 39.9 in 45 min- utes. Mendelsen also finds a constant constriction of the renal blood vessels in fever. "In intermittent fever profuse perspiration is certainly an important fac- tor in the reduction of temperature at the end of the febrile stage. 6 Science of Nutrition, p. 255. 106 FEVER AND ANTIPYRETIC EFFECTS "It may be concluded, as Krehl emphatically states, that insufficiency of water evaporation plays a not unimportant role in the febrile rise in tem- perature. The body might be cooled were the sweat glands freely active. "The production of heat in fever may be greatly increased during a chill, and a rapid rise in temperature may follow. This was shown by Lieber- meister in a case of malaria. The temperature rose from 36.9 in the first half hour to 39.5 at the end of another hour, while the carbon dioxide expired rose from 13.85 grams to 34.20 grams per hour. This was a case of chill with shivering. This increased metabolism is due to the mechanism of chemical regulation. The blood is driven from the skin by vasoconstriction, those end-organs of the skin which are sensitive to cold are strongly stimu- lated, with the result that there is a reflex increase of heat production. That this is true is shown by the fact that if the cold stimulation be removed by supplying a warm environment, the attending phenomena pass off (Krehl)." Variations that Produce Febrile Temperature and their Relation to Treatment Any unbalancing of thermoregulation whereby there is more heat produced than is eliminated will cause a rise of temperature. It will be seen from this that there are several possible variations in these two elements which might be the cause of fever. In a majority of fevers, the greater difficulty at first is in the faulty heat elimination. A rise of temperature will follow any of the conditions listed below: Heat Production Heat Elimination 1. Increased Normal 2. Increased Increased, but less than heat production 3. Increased Decreased 4. Normal Decreased 5. Decreased Decreased, but more than heat production These variations are, perhaps, largely of theoretical interest. However, there is a practical application to be made of the signs and symptoms which indicate a decided over-production of heat or a marked decrease in heat elimi- nation. The former counter-indicates vigorous tonic measures, such as the cold mitten friction, which are not accompanied by heat abstraction, i. e., more or less prolonged contact with cold water. The latter are of especial importance in revealing a condition which absolutely counterindicates the use of long cold applications, and in many cases even the short cold friction unless preceded by hot applications. In cases of pyrexia, the following signs indicate a great increase in heat production: 1. Full pulse and flushed face. 2. A hot, dry skin. A consideration of these will at once reveal the fact that a cold mitten friction would be inappropriate, since it has no tendency to lower blood pressure also because the treatment stimulates heat production, but the con- tact with cold water is of too brief duration to abstract much heat from the body. Neither would a hot application or a sweating treatment best meet HYDRIATIC ANTIPYRETICS 107 the condition. It is necessary to abstract heat from the body by some more or less prolonged cold application. On the other hand, the following symptoms show a decided decrease in heat elimination: 1. Cold skin, whether dry, or moist and clammy. 2. Cyanosis. 3. Goose-flesh appearance. 4. Chilly sensations. 5. Shivering. Again, consideration of these conditions reveals the fact that cold appli- cations, unless accompanied by vigorous friction, and not even then in some cases, will greatly increase the anemia of the skin and the internal conges- tion which exists because of the chilling. In these cases, hot applications or sweating treatments must be used until the cyanosis is overcome and the blood brought back to the surface, thus relieving the internal congestion and, at the same time imparting a sensation of warmth to the body and consequently checking the shivering. This is also indicated in the first stage of many fevers where the chill has actually begun or where chilly sensations indicate its approach. In general then, it may be said that long cold applications should be used where great increase of heat production is the chief cause of fever; and hot applications where the decided decrease of heat elimination is a prime factor in the fever. The following lists of hot and of cold treatments are given in the order of their efficiency and, when properly selected and suited to the individual case, the cold treatments meet the first indication and the hot treatments the second indication. Cold applications useful in febrile conditions: 1. Brand bath. 2. Graduated bath with friction. 3. Tepid or cool bath. 4. Evaporating wet sheet pack. 5. Cold to head and neck. 6. Ice bag or cold compress to heart. 7. Cold compress. 8. Cold rectal irrigation or enema. 9. Cold water drinking. 10. Fresh cold air in the sick room. Hot applications which may be used to reduce fever or assist the cold applications: 1. Hot blanket pack. 2. Hot bath (very short) . 3. Hot evaporating sheet. 4. Fomentations to spine. 5. Fomentations to abdomen. ?! CoTd^tten^WctiSn (reaction simulates the effect of a hot applica- tion) . CHAPTER XVII THE TREATMENT OF FEVERS Typhoid Fever Typhoid fever is an acute infectious disease, more or less self -limited, characterized pathologically by a localized inflammation of the lymphatic structures of the intestines and a general distribution of the bacteria (bac- teriemia) ; clinically, by fever of rather long duration which, at the onset, rises gradually in stepladder-like increase and gradually subsides; diarrhea, and a special tendency to hemorrhage and perforation. We say that the disease is self-limited because it is one of those infections which arouse the body to the production of antitoxines, bacteriolysins, agglutinins, etc., so that when the system has had time to produce these, the infection is over- come and the patient recovers. It is not possible to abort typhoid fever by therapeutic means. The so-called abortive type of typhoid fever is due to some peculiarity of the individual or of the infection and not to any treatment. The chief object to be accomplished in the treatment of typhoid fever is not the reduction of the temperature, but the sustaining of vital resistance until such time as the system has had opportunity for the production of antibodies. This building up of the vital resistance is accomplished chiefly in two ways, first, by stimulating the process of phagocytosis, i. e., increas- ing the numbers and efficiency of the leucocytes in the peripheral circula- tion, in order that they may combat the infection, the bacteria themselves. Second, the decrease of the toxemia by increasing the oxidation of the bac- terial toxines and hastening their elimination in an incompletely oxidized state. The body poisons, the leucomaines, are taken care of in the same way and by the same means. These are the two principal objects to be attained in the treatment. The reduction of temperature is only incidental to these and serves as a practical guide to the completeness of these results. How- ever, in the use of medicinal antipyretics, the degree of the fever in no way runs parallel with the accomplishment of these essential objects. With both quinin and the coal tar products, phagocytosis is interfered with, if not wholly abolished and the toxemia is increased because of a decrease in the oxidation and elimination of the poisons. Under the use of hydrotherapy, rationally employed, typhoid fever presents an entirely different clinical picture from that which we have been taught to regard as characteristic of this disease. The cold bath meets practically all of the conditions and symp- toms which require special attention. The heart and circulation are sus- tained and invigorated, the nervous system is aroused, and the nervous symptoms, usually regarded as an invariable accompaniment, either do not TYPHOID FEVER 109. appear or are mitigated in severity. The emunctories are sustained so that elimination is greatly increased. Treatment Since the cold friction bath is the best means of treating typhoid our con- sideration of this disease will largely be a discussion of the methods ration- ale and results of this measure. The original cold friction bath, as'devised by Brand, consists in the full immersion of the body in water at a tempera- ture of not less than 65 F. nor more than 70 F. As advised by Brand it continues 15 minutes, during which time, the entire skin surface immersed in the water, with the exception of the abdomen, is rubbed vigorously by the attendants. The object of the friction is the production of reaction so that the sensation of chilliness is abolished, and the circulation of the skin maintained, thus favoring the cooling of the blocd. If, at any time, the patient becomes cyanotic, or real chilling occurs, as indicated by continued shivering and chattering of the teeth, he must at once be removed from the bath. As to the appliances necessary, it has been found that some form of port- able bath is most convenient. Of these, there are two forms worthy of description, the bath tub on wheels and the bed tub. The former is made of various materials and sufficient in length to allow the full extension of the patient while immersed in the water and of such depth that the patient is covered with water up to the chin. This tub can be wheeled to the side of the bed, being placed a sufficient distance from the side of the bed to allow of two attendants reversing the patient in carrying him from the bed to the bath. The Burr Portable Bath is probably the best type of the bed bath. It consists of two parts a large rubber sheet with rings attached near the margin by elastic tapes, and a light wooden crib capable of being folded into a compact bundle. The rubber sheet is first slipped under the patient and brought up over the pillow, being tucked along the sides of the body. The frame is then unfolded, placed down over the patient so as to rest on the mattress, surrounding the patient, pillow and rubber sheet. The edges of the sheet are then drawn up over the top rail and fastened to the lower rail by its rings. When complete, it is capable of holding about twenty gallons of water. It may be filled by either a pail or hose attached to a faucet and emptied by a siphon. This arrangement demands less moving of the patient than any other form of bath. Before being immersed in the cold water, the head and face of the patient are bathed in ice water. If the tub is used, it is necessary to provide an invalid ring for the head and a similar cushion or water pillow should sup- port the nates. If the patient's skin is warm on entering the bath, and the friction is vigorous and kept up during the entire period of immersion, there is little danger of chilling or collapse. If, at any time, this should occur, the patient must be immediately removed and placed in a dry blanket, the surface being vigorously rubbed until the skin is warm and reaction fully established. A complaint of chilliness on the part of the patient may not be an indication for removal from the bath. The appearance of goose-flesh, 110 THE TREATMENT OF FEVERS however, necessitates removal. The patient should not be allowed to remain in the bath until the appearance of cyanosis or any other decided symptom of untoward effects. While the Brand bath seems to give the best results with young vigorous persons, where treatment can be begun during the first week, yet this method is not applicable to those cases which apply for treatment during the second or third week, since they have already become so weakened that there is not sufficient vitality to fully react to so vigorous a means. The Brand bath is also counterindicated in cases of much reduced vitality from any other cause, and in the very young and the aged. In regard to the use of measures other than the strict Brand bath Buxbaum l inclines to the view that the essential feature is the obtaining of the reaction by suiting the treat- ment to the needs of the individual case. He says, "With reference to the special measures to be employed, the desired result can no doubt be attained with the most varied hydriatic procedures, provided the thermic and mech- anical stimulations are graduated in accordance with the indications of the individual case. Hence, there can be no invariable and exclusive routine." With many patients, it is better to employ a bath at a higher temperature, the graduated bath of Ziemssen, or the wet sheet pack, cold sponging, com- presses, etc. A graduated bath begins at a temperature of 90 or even 95 F. and continues for half an hour, or longer, during which time, the tem- perature is gradually lowered by the addition of cold water, friction being employed as soon as the patient complains of any chilliness. The tempera- ture may be decreased to between 70" and 80 F., according to the condition of the patient. This bath is just as effective as the Brand bath in the reduc- tion of the fever; in fact, it is a mistake to suppose that the colder the bath, the greater is the reduction in temperature. This is not the case. A higher temperature for a longer time may reduce the fever just as effectively as a lower temperature for a shorter time. There is, however, this very essential difference, that the stimulating of the body functions is greater in propor- tion to the degree of cold. With the graduated bath, as efficient and thorough stimulation is not obtained as with the Brand bath. Whenever the temperature exceeds 102.5 or 103 F. the bath should be repeated. In practice, it has been found that repetition every three or four hours gives the best results. Of other methods, the following are useful in special cases or where the ideal treatment can not be carried out: 1. The Wet Sheet Pack is perhaps less objectionable to the patient than a cold bath. Liebermeister claims that four wet packs of 10 minutes dura- tion each, are equivalent to a cold bath of 10 minutes; and Baruch, that six such packs are equivalent to a Brand bath. The sheet should be wrung from ice water or very cold waterj It is applied in the usual manner and after the initial warming, maintained at the evaporating stage, being renewed by sprinkling of more cold water on the sheet. The rapidity of evaporation may be increased by fanning. 2. The Cold Towel Rub given with a towel well filled with very cold water is an excellent substitute for the wet sheet pack. The use of the wet sheet 1 Cohen System of Physiologic Therapeutics, Vol. IX, p. 134. TYPHOID FEVER ln pack necessitates more or less moving of the patient which is not the case with the cold towel rub. The wet towel may be applied several times to the same part and even ice water used. 3. The Ice Rub. H. A. Hare has employed the ice rub with good success. A flat piece of ice is wrapped in thin linen or gauze and, by rapid movements, different parts of the body are gone over. He recommends this application to the back only, avoiding the extremities. Others, however, utilize it as a general measure in place of the cold bath. 4. Cold Sponging and Cold Affusions are of decided advantage in those cases where the bath or pack can not be used. Cold affusions to the head are of great service in delirium and, in fact, whenever nervous symptoms are unduly prominent. 5. The Cold Abdominal Compress is an efficient means and should be kept in place between other treatments. The best results from this are obtained when the Winternitz coil is placed over one layer of the compress. The steady flow of cold water through the coil renders unnecessary the constant renewal of the compress, which requires so much time on the part of the nurse. It also avoids the shock from the renewal which prevents the patient from completely relaxing for any length of time. 6. The Cold Enema, or continuous rectal irrigation is another very effici- ent means. Since it has been shown by Schuller that the cold enema always produces more or less retrostasis; this treatment may be productive of harm; Kellogg mentions a case with a temperature of 104.2 F. in which three large enemata at 66, 62, 62 F., given in rapid succession, reduced the tem- perature to 99.2 within one hour. Such rapid and extreme reduction of temperature may be dangerous and is hardly to be recommended for general use. 7. The Leiter Coil or Cold Winternitz Coil to the head is a very efficient means, both of preventing the rise of temrerature, and alleviating the ner- vous symptoms. It should be used between other treatments. The ice bag or Leiter coil over the heart is also serviceable, especially where the pulse is very rapid and weak. Hot Treatment. In those cases where chilliness and cyanosis are produced by the cold bath and other cold applications, or in which this condition is more or less constant, it is necessary to thoroughly warm the skin, bring- ing the blood to the sift-face and effectually reducing the extreme internal congestion before any cold application can be made with success. For these preliminary hot treatments, one may use fomentations, the hot pack, the hot evaporating sheet or hot sponging, according to the circumstances and indications. They may be aided by hot water drinking. During the cold treatment, hot water bottles and spine bags should be used to keep the limbs warm and prevent chilling. The skin should be red and warm and the patient feel warm, before any cold treatments are given. The cold mitten friction and the cold towel rub are valuable adjuncts to the hot applications, since they increase the warming of the skin more than they cool the blood. Cold applications, such as ice bags and ice caps should be applied to the head and over the carotids, whenever any decidedly hot applications are made. 112 THE TREATMENT OF FEVERS These help to prevent any rise of temperature while the patient is being prepared by the hot treatment in order to react to the succeeding cold. The Diagnostic Bath. Baruch and Kellogg claim for the cold bath, a cer- tain value as a diagnostic means when employed during the first week of the fever. Baiuch uses the following method: When the rectal tempera- ture reaches 103 F. and other symptoms indicate typhoid fever, the patient is tubbed in water at 90 for 10 minutes, being rubbed continuously. Tem- perature is taken hour after the bath and again 4 hours after the bath. If, at the termfnation of this time, the temperature still registers 103 or over, the patient is bathed in water at 85, and the temperature recorded as before. If it still remains at 103 or above, a third bath at 80 is given, and the fourth time at 75, employing friction with each. Baruch's experi- ence with this bath leads him to believe that, if the temperature is reduced more than two degrees, typhoid fever is improbable, while if there is little or no reduction, the diagnosis becomes more positive. Rationale of the Cold Bath. The brunt of the infectious process and tox- emia in typhoid fever falls upon the nervous system, the circulatory system and the kidneys. 1. The Nervous System. In fever it is largely because of the imperfect action and control exercised by the nervous system that many of the body functions are deranged. It fails to control the heat mechanism, the vaso- motors are disturbed, glandular activity is depreciated. The toxemia is the principal cause of the derangement of the nerve centers. The congestion about these centers which occurs in nearly all fevers only increases the volume of toxines in the blood supplying them. The nerve cells are benumbed and lethargic, or they are irritable, restless and overactive in an irregular sort of way. The high temperature adds to the intensity of this state. It is necessary to eliminate the toxines and arouse the nervous system from its stupor, stimulating it to a normal activity and by tonic means, relieving its irritability so that rest may be secured. All these effects are produced by the cold bath. The more profound the stupor and intense the delirium, the more marked the relief experienced. Quiet, refreshing sleep usually follows each tubbing or other vigorous cold treatment. Subsultus and carphologia are relieved. Headache, hebetude and apathy are succeeded by a brightening of the mental powers. Post- febrile insanity and mental weakness are less liable to occur where hydro- therapy is systematically employed. All of the medicinal antipyretics dull and stupify the nervous system. The centers are not apprised of the danger and so can not properly regulate protective functions. 2. The Circulatory System. Heart failure is that to which we have been taught to ascribe all the failures in the circulation; and it is toward the heart muscle that many medicinal agents, designed to act upon the circu- lation, are directed. This idea has resulted in the deluging of the system with strychnin, digitalis and the like, and the already overworked heart has been compelled to do double service to no avail. That this idea is almost wholly erroneous has been quite fully discussed in the previous part of this work. TYPHOID FEVER 113 Romberg and Passler have shown that the chief danger to the circulation in infectious diseases comes through paralysis and derangement of the vaso- motors, and is not due to any damage to the heart itself. Passler further claims that this derangement is caused by loss of the control exercised by the vasomotor center in the medulla; the spinal centers, peripheral vaso- motor nerves and the muscles remaining intact. Reflex effects are still possi- ble. The heart is not at fault, but there is an absence of the natural physio- logic resistance normally maintained by the proper tone of the blood vessels, together with the loss of the rhythmic action of the peripheral heart. Hare very aptly compares the heart and vasomotors of the circulatory system, respectively, to a locomotive and the resistance offered to its driving wheels. He says, "The locomotive is intended to meet and stand any resistance, and if the resistance is removed by slippery rails, the wheels fly around ineffect- ually, racking the machinery and destroying its usefullness. From the above, some important diagnostic and therapeutic facts are learned: (1) that a rapid pulse may be due in no way to a disordered heart, but to vaso- motor relaxation; (2) that the proper way to treat this rapid pulse is to put sand on the track and increase the resistance, and not to make more steam or give digitalis which only cause the engine, or heart, to work away on slippery rails with more wear and tear, and make no progress." That this wear and tear may be considerable and result in a weaker and more rapid pulse, any one may observe who will, after 1-60 grain of strychnin has been administered to a typhoid patient every three hours for a week or more, discontinue the drug, recording the blood pressure before and after discon- tinuance of the strychnin, by means of some accurate blood pressure instru- ment. Indeed, the change for the better is so marked that it can be very readily appreciated by the finger without other aid. In one case that came under the author's observation, this was so marked and appeared so promptly, that it was observed at once by both the day and the night nurses. The cold friction bath meets the indication presented by the deranged vasomotors more fully than is possible with any other means. It stimulates the blood vessels to normal, rhythmic action and relieves the heart of the excessive burden imposed upon it by their failure. In typhoid fever, the blood is very much reduced in quality. The red cells and hemoglobin are decreased, the latter to a greater extent than the former, especially during convalescence. There is a decided leucopenia, the white cells being decreased in number one-third, or even more than one-half. The blood is laden with acid poisons and is therefore reduced in alkalinity (Bireger) . The amount of toxic extractives in the blood has been shown by Robin to be doubled or trebled in case of fevers. We have already quite extensively discussed the effect of the cold bath on the composition of the blood. Suffice it to say that observations made by Strasser, Breitenstein, Baruch and others prove conclusively that, in typhoid fever, every constituent of the blood is favor- ably influenced by the cold friction. The red cells in the peripheral circulation are greatly increased, the whitfe cells increased as high as two or threefold, the alkalinity is restored and acid products decreased. Be- cause of these, normal nutritive changes proceed more promptly. 3. The Kidneys. Elimination in febrile conditions is very defective. The quantity of urine is decreased and, while there may be an increase in 114 THE TREATMENT OF FEVERS the solid constituents, it is still quite insufficient to prevent the accumulation of toxic wastes in the blood and tissues. During convalescence, the solids of the urine increase from 10 to 20 per cent, or more, over the amount excreted during the febrile period. The poisonous wastes are more insoluble than those of little or no toxicity and so require a larger quantity of the solvent, water, for their efficient elimination. The cold bath greatly increases diuresis. The quantity of solvent is increased, thus increasing the toxines eliminated. But this alone, does not account for the great increase in the toxicity of the urine under the bath treatment. While the poisons of the urine in typhoid fever are double the normal amount, Roque and Weil found them increased five times after the cold bath. Bouchard also found the toxic co-efficient of the urine greatly in- creased by the cold bath. Robin, in one case, found the urea increased to 20 per cent. On the contrary, antipyretic drugs diminish the excretion of urea and nitrogen. The liver in those cases dying after treatment with an- tipyrin, is said to be heavier than the liver of those dying after the cold bath treatment. These drugs produce granular and fatty changes in the liver and kidneys. The respiratory elimination of COa and intake of oxygen are decreased in fevers, the amount of the decrease being in inverse proportion to the sev- erity of the fever. This is due, of course, to the lessened capacity of the body tissues to utilize oxygen. Both oxygen absorption and carbon dioxide elimination are enhanced by the cold bath. Robin found the increase approximating 20 to 30 per cent above the usual amounts in typhoid fever. That all these results are beneficial, needs no argument. There is no organ, tissue or function not favorably influenced by the hydriatic treat- ment of typhoid fever. Because of the maintenance of the vital resistance and the elimination of toxines during the febrile period, convalescence is much shortened when cold baths have been used. Counterindications and Treatment of Complications Pneumonia. The cold bath is counterindicated in pneumonia of the lobar type. The case should be treated as far as possible as simple pneumonia alone would be treated. Fomentations, cold compresses, alternate hot and cokl applications, the ice pack to the chest and such means are applicable where the pneumonia arises as a complication and may be used in much the same manner as is ordinary pneumonia. Special attention must be given to the extremities. They should be kept warm and the circulation active. The cold mitten friction, wet towel rub, sponging and affusions are service- able in place of the bath. Hypostatic pneumonia may be treated by alter- nate hot and cold applications, cold affusions or ablutions to the back. The warm bath graduated down to 90 F. may be used. Pleurisy. This condition absolutely counterindicates the use of the cold bath. No cold, whatever, should be applied to the chest over the inflamed area, until the acute stage is passed, that is, for 2 or 3 days. However, the cold towel rub and cold mitten friction, sponging, etc., should be kept up as usual, avoiding only the skin surface over the inflamed pleura for the first 2 or 3 days. If the cold baths are continued, or large cold compres- TYPHOID FEVER 115 ses used to the abdomen, a mild pleurisy may become so fixed as to require months for the eradication of the chronic inflammation. Nephritis. Contrary to what might be expected, the use of the cold bath is not wholly counterindicated in this condition. Mild cases of nephritis improve under the Brand bath. If the nephritis is severe, the graduated bath may be substituted. Yogi's experience demonstrates that nephritis is less common in those treated by the Brand bath and also that the mortality is less in those having nephritis. Both the urine and urea increase in quan- tity and the albumen decreases under the effects of the cold bath. Venous congestion of the kidneys is conducive to nephritis, albuminuria and the for- mation of casts. This condition is relieved by the stimulation of the circu- lation and derivation secured by the cold friction. Hemorrhage. The cold bath must be discontinued as soon as this condition becomes apparent, principally because of the rest needed. The limbs should be kept warm and some sort of cold application placed over the abdomen. We believe the most satisfactory measure is the Winternitz coil. This does away with the shock occasioned by the renewing of cold compresses and the temperature can be more accurately gauged and more perfectly controlled than with the ice bag. After the recovery from the hemorrhage, it is best to permanently discard the use of the bath, substituting sponging, affusions, the cold towel rub, etc. Perforation. Here, as in hemorrhage, the cold bath must be discontinued, the patient being treated by rest and means used to control the shock, so that operation may be done as soon as possible. If peritonitis supervenes, it becomes the chief objective point. The reduction in mortality from typhoid since the introduction of the cold bath has not been due to reduction in the mortality from hemorrhage and perforation. According to Hare 2 the mortality from these causes before and after the introduction of the Brand bath is practically the same. The mortality from all other causes was much less, dropping from 9.7 to 3.4 per cent and, in spite of no change from the above mentioned conditions, there was a total decrease in mortality of nearly 50 per cent. Menstruation. The menses frequently cease during severe febrile condi- tions, but cases in which it has continued have been successfully treated by cold baths, and under this treatment, cases of pregnancy, complicated by typhoid, have been carried to a successful issue. Tympanites. The cold bath greatly relieves this condition. The continu- ous use of the ice water coil, interrupted every hour or two by a fomenta- tion, gives great relief. The asafcetida or turpentine enema should not be omitted where more energetic means are needed. Mortality and Statistics Modern methods in the rational treatment of disease have accomplished few more striking changes than that accompanying the hydriatic treatment of typhoid fever. The reduction in mortality compares quite favorably with the lessened fatality in small pox since the introduction of vaccination and that of diphtheria since the employment of antitoxine. 2 Brisbane Hospital, Queensland, 1882 to 1896. 116 THE TREATMENT OF FEVERS Under the ordinary expectant plan with administration of medicinal anti- pyretics, statistics from Germany show, among 11,124 cases, a mortality of 21.7 per cent. In another collection of 27,051 cases, there was a mortality of 17.45 per cent. In still another collection of 80,140 cases, there was a mortality of 19.23 per cent. In one division of the German army, during 17 years among 1970 cases, the mortality was 26.3 per cent. In the English army for 6 years, ending with 1877, there was a mortality from typhoid of 32 per cent. In recent years, Delafield shows a mortality of 26 per cent from the New York Hos- pitals. And throughout American cities, the mortality from typhoid fever is claimed to be from 25 to 40 per cent, In the typhoid wards of the John Hopkins Hospital, during the first 10 years, 9 of which is since the intro- duction of hydrotherapy, Osier reports among 829 cases, a mortality of 7.5 per cent. During the first year of this time, the cases were treated by the ordinary expectant plan and moreover, this series includes all cases admitted, those dying within 1 or 2 days and those diagnosed at autopsy. From the Brisbane Hospital, Hare reports a typhoid mortality of 14.8 per cent previous to the introduction of hydrotherapy and 7.5 per cent since its employment. In 1887, Brand gathered statistics of 19,017 cases, showing under all forms of hydriatic treatment, a reduction in mortality from 21.8 per cent to 7.8 per cent. In another series of cases collected by Brand and enlarged by Baruch, in which the strict cold bath treatment was used, Baruch claims a reduction of mortality to 3.9 per cent. In the division of the German army above referred to, the mortality under the strict Brand system was reduced from 26.3 per cent to 4.3 per cent. Baruch further claims that among 1223 cases treated only by apostles of the Brand system, there was a reduction in mortality to 1 per cent (12 cases) and that ' 'not one of these twelve deaths occurred in any case that came under treatment before the fifth day." Contrary to what might be expected, the mortality is less in private practice than in hospitals. This is doubtless because the cases come under observation at once and can be treated from the beginning. The same is true of army and navy hospitals where all indispositions are at once investi- gated by the medical officer. The statistics gathered by Baruch 3 relative to the mortality from typhoid fever under the varying methods are the most extensive on record. The reduction in mortality seems to depend upon (1) the strict employment of hydrotherapy by the cold bath method where cases come under observation before the fifth day; (2) the discarding of all medicinal antipyretics; (3) judicious employment of various forms of hydrotherapy where cases can not be treated from the beginning; (4) private practice. Malaria Since this disease is of an "infectious" nature, being due to the malarial plasmodium, treatment must be directed toward the destruction of the para- 3 Baruch Principles and Practice of Hydrotherapy, p. 202. MALARIA 117 site. This may be accomplished in either of two ways, first, by the toxic action of quinin and second, by the phagocytic action of the white blood cell. That quinin does kill the parasite and thereby check the disease, no one can dispute. But that it also fails of effecting a cure in by far the larger number of chronic cases and many of the acute cases, is also indisput- able, being witnessed by the experience of all practitioners whose practice brings them in contact with this disease. The last word concerning malaria has yet to be spoken. It would seem that giving quinin in an acute case which has not previously been taking a course of quinin, if so administered that there is a maximum dose in the blood just previous to sporulation which produces the chill, stopping there, no more being given until the proper time before the next expected paroxysm, is productive of good results. However, it often fails in the estivo-autumnal type, since it is uncertain just when a paroxysm may be expected, sporulation being irregular so that the above program can not always be carried out successfully. It has also been shown that quinin fails of its best results or fails altogether where it has previously been administered for some time as a prophylactic, or in the treatment of other attacks. The following experience 4 related by Dr. E. R. Stitt, a United States Navy Surgeon, is worthy of careful thought: "While in camp along the canal route, we had a few cases of malaria. These were immediately treated with large doses of quinin, and without exception they responded promptly and satisfactorily to such treatment. The only member of the party who insisted on taking quinin prophylactically was Colonel Ludlow, the head of the commission; and strange to say, he was the only one who had malaria on the trip home." "To those who have thought of quinin prophylaxis as a true preventive the following instance is instructive: "On May 20, 1906, a battalion of marines, numbering 398, was organized at Philadelphia. Seventy-five per cent of the force was made up of recent recruits "from the Middle West. Leaving Philadelphia May 21, Colon was reached May 28. On June 4 the battalion was disembarked at Colon and stationed for a time at Camp Elliott, which is situated about 25 miles from Colon and which was comparatively free from mosquitoes. Later on, three companies were stationed at Camp Reed, 5 miles from Panama, at which place mosquitoes were numerous and troublesome. "On July 6, after a service of practically one month on the Isthmus, the marines returned to the ship (U. S. S. Columbia). During the month's en- campment, 9 grains of quinin had been served out daily as a prophylactic. In addition, such measures as head-nets for those on night sentinel duty and inspection of mosquito nets about the men sleeping in tents had been in force. There was very little malaria reported from these men while on the Isthmus. "The ship sailed from Colon on the night of July 7. On the first day out, 20 cases of malaria were admitted to the sick list, the next day 53, and the third day 45. In consequence of what appeared to the medical officer to be universal infection among the men, 10 grains daily of quinin were adminis- 4 Journal of American Medical Association, May 23, 1908, p. 1683. 118 THE TREATMENT OF FEVERS tered to every one as a prophylactic. Notwithstanding this almost curative dosage of quinin, the condition of the men was such when the ship arrived at San Juan, July 13, that it was deemed necessary to get the men out of the tropics, as several cases of a pernicious type and two of blackwater fever had appeared. Accordingly the ship sailed for Boston, July 16. "Notwithstanding the prophylactic use of quinin, under military observa- tion, for those who were not cinchonized, there were 215 acute malaria paroxysms among 298 men during the five days' trip from San Juan to Bos- ton. About 100 men of the original 398 had been transferred to other ships and stations prior to the sailing of the Columbia for Boston. The character of the paroxysms was atypical there was no frank chill. The men would feel fairly well until shortly before an attack they would then complain of chilliness and weakness and either lie down or fall down in a heap on deck. Passed Assistant Surgeon Butler, U. S. N., states in a report, that when the men arrived at Boston so many were anemic and weak that they were unfit to return to the tropics. Dr. Butler also noted the fact that these cases did not seem to respond at all satisfactorily to quinin even when given hypodermaticaMy. Before the cases became so numerous, blood examina- tions were made and the form of malaria was considered to be chiefly ter- tian. The clinical features, however, would indicate that there was estivo- autumnal infection in many of the cases. "In considering the experience of these marines who were given prophy- lactic, I might even say curative, doses of quinin during a period just exceed- ing a month, and when this was discontinued during the days of July 7, 8, 9 and 10, showed an extensive malarial morbidity, the question naturally pre- sents itself as to the explanation of this. Furthermore, we must note the fact that resumption of quinin prophylaxis at this time in those not cinchon- ized apparently had little effect in checking the outbreak, and that when quinin was administered in curative doses, at times hypodermatically, it did not seem to control infection as is usual. It is common experience that malaria responds readily and promptly to quinin properly administered. I can not but believe that malarial parasites may develop a resistance to qui- nin. ' 'Browning, reporting recent work in Ehrlich's laboratory, states that when mice infected with trypanosomes were not given sufficient doses to destroy the flagellates, these protozoa developed a resistance to the therapeutic agent during the time their development was held in abeyance. A most startling discovery was, too, that these trypanosomes retained their chemo- resistance through numberless generations. After passage during a period of 14 months through 144 mice these last generations of trypanosomes still retained their immunity to the exciting drug. Browning experimented with atoxyl, parafuchsin and trypan blue. Experiments with paramecium have also shown that these ciliates may develop marked resistance to agents primarily toxic to them." It is a well known fact that while quinin kills the plasmodium, it also kills the white blood cell. In fact the two are quite similar bits of protoplasm manifesting quite similar activities. The white blood cells acquire little or no resistance to it. If they are not destroyed, they are for the time being MALARIA 119 paralyzed and phagocytosis suppressed. We previously called attention to the fact that 10 grains in the blood of a patient weighing 130 pounds consti- tutes nearly double a toxic dose for the phagocytes. In these facts lies the explanation of the failure of quinin to cure chronic cases. The parasite becomes accustomed to the poison or as we might say, acclimated to its unfavorable environment, while the white blood cells succumb to the toxic action. The parasite has then nothing to oppose its action and it multiplies and thrives at the expense of the red blood cells. The latter are broken up and hemoglobinemia and hemoglobinuria result. This breaking up is increased by the action of the quinin itself and so the case goes on from bad to worse. In fact, it is claimed by many southern practitioners that blackwater fever, the hemoglobinuric form of chronic malaria, is due to quinin and not to the parasite. We must therefore, in these cases, abandon the use of quinin and search for some means of increasing the number of the leucocytes and enhancing their phagocytic activity. The reaction to cold applications when combined with mechanical means is that which best produces this result. Some enthusiastic hydriatists have endeavored to combat the disease by the use of hot, sweating measures applied as soon as there are any indications of the beginning of the chill and continued until sweating is well established, little attention being given to the frequent and systematic use of cold fric- tions, affusions, douches, etc. The sweating combats nothing but the effects of the chill; it in no way removes the cause, augments the vital resistance, or restores the blood to that condition in which it is best able to combat infection. On the contrary, if at all prolonged, the resistance is lessened. Quinin, the malarial toxine, and long hot treatments, all lessen the number of leucocytes, driving them into the viscera where they stagnate. 5 Nearly all who employ hydrotherapy in any regular manner have witnessed the beneficial results that may be obtained in the treatment of chronic mal- aria. The general plan to be followed is that of some systematic regime of tonic measures, carefully graduated and suited to the needs of the individ- ual case. We have seen chronic cases, in which 30 grains of quinin admin- istered daily had failed to check the fever, brought to a successful issue by the regular use of the cold mitten friction and alternate hot and cold appli- cations. The plan followed by Fleury in the treatment of over 100 cases of malaria in the German colonies in Africa is worthy of imitation. One or 2 hours previous to the expected paroxysm, he administered douches at 55 to 60 F. From his experience there, he concludes that in chronic cases of intermit- tent malarial fever with cachexia, anaemia, relapses, etc., cold douches are always to be preferred to quinin, also, that in acute intermittent fever it may be used instead of quinin. These conclusions were confirmed at the military hospital at Brussels by the investigations of a Royal Belgian Com- mission. Strasser, Fisher, Fodor and others, have reported cases success- fully treated by cold applications. H. F. Rand, formerly professor of Physiologic Therapeutics in the University of Colorado, has successfully 5 "In the first attack absolute and relative leukopenia is observed which is due to the col- lection of the white cells in the liver and spleen, to the destruction of the phagocytes, and, in coachexia, to lesions of the blood making organs." Edward's Practice of Medicine, 1907, p. 118. 120 THE TREATMENT OF FEVERS treated cases by the use of the cold mitten friction, cold towel rub and the cold half bath with friction. He begins a number of hours before the chill is due. He reports a case of chronic malaria in which no chill appeared after the beginning of the treatment. At the end of a week, the blood was free from plasmodia. As in other fevers, the rationale of these measures is not difficult of explanation. It has been shown by Maragliano 6 that contraction of the sur- face vessels in malaria begins 2 hours before the temperature begins to rise and about 3 hours before the paroxysm. The skin vessels continue to con- tract, and the fever reaches the highest point when the vessels are in a state of maximum constriction. During the sweating stage the vessels dilate and when maximum dilatation is reached the temperature returns to normal. During the 2 hours referred to, the constriction of the skin vessels and anemia of the skin becomes well "fixed," so that a severe prolonged chill is provided for. At the same time, there is an enormous retention of heat due to the failure in heat elimination. The internal congestion is intense. Under these circumstances the cold percussion or friction has a double effect. First, by the production of circulatory reaction the spasm of the peripheral vessels is relieved and the internal congestion gives way because of an equalization of the circulation. The chill is thus aborted. Second, the leucocytes are "mobilized" and phagocytosis encouraged. In malaria the leucocytes forsake the peripheral circulation and accumulate in the viscera, especially the spleen. Experiments with the oncometer show that cold applications cause contraction of this organ. This action together with the stimulation of the vasomotors of the peripheral vessels serves to distribute and energize this vast army of phagocytes. Hot applications, beginning just before the onset of the chill, would serve to dilate the peripheral vessels and so counteract the vasoconstriction for the time-being. But such intense and prolonged heat has no tendency to combat the cause, i. e., it does not produce mobilization of the leucocytes nor cause them to destroy the parasites. On the contrary it has the oppos- ite effect, viz., the causation of an increase in the visceral stasis of leuco- cytes and a lessening of phagocytic activity. Where a patient reacts poorly, a reaction must be "compelled" by the use of local hot applications simultaneously with the cold. This is for the purpose of producing a sensation of warmth, while the essential effect a brisk activity of the blood vessels is secured by the cold application accom- panied by friction or percussion. The following suggestive program will be found useful. It must be varied according to the reactive ability of the patient. Begin the first treatment of the series about 6 hours before the expected paroxysm and follow it with other treatments about every 2 hours. These should be con- tinued until the time for the chill is well past. The first treatment may consist of an enema followed by a hot foot bath and two fomentations to the abdomen of brief duration. As soon as the second fomentation has been placed, begin with a cold mitten friction. This latter should be given with very cold water and vigorous friction. Dry the 6 Plethysmograph experiment quoted by Buxbaum Lehrbuch der Hydrotherapie, 1903. MEASLES 121 patient and let him rest for an hour or an hour and a quarter. Next administer quickly alternate hot and cold to the spine, followed by an alternate hot and cold percussion douche to the spine, splenic and hepatic areas, and the legs. If necessary the patient may stand in a tub of hot water during this treatment or, if there is still less reactive ability manifest, give a hot shower while the cold douche is being administered. Let the patient drink freely of water both before and after each treatment. The third treatment may consist of a cold shallow rubbing bath lasting 4 or 5 minutes and preceded, if necess- ary, by a hot pail pour to the legs and lower spine only. Two attendants should be provided to administer the shallow bath. Succeeding treatments should be carried on along the same line. These may be the cold mitten friction with ice water, the wet sheet rub, the percussion douche, the salt glow with pail pour, etc. In conclusion we can not do better than quote the principles given by Bux- baum: " "The best water treatment for malaria consists in the employment of a cold application, combined with powerful thermic stimulation. The form of the application is a matter of indifference. The most important requirement, however, is the production of a good reaction. When this fails to take place, success will be wanting. With the powerful stimulating procedure, which may be chosen according to personal preference, a fan douche to the region of the spleen may serviceably be conjoined. The principal objects of the therapeutist's attention are the proper selection of the time, and the produc- tion of a good reaction. The shorter the interval between the procedure and the anticipated chill, the more certain the result. With regard to the procedures to be employed, they consist in cold vigorous shower baths; a cold rub in coarse sheets in combination with sheet-baths; cold sitz-baths of 10 minutes' duration; cold full baths; plunge baths and other suitable meas- ures. The treatment should be continued until the constitution of the blood, the digestion and circulation are restored to the normal briefly, until every sign of cachexia has disappeared. ' 'According to Strasser, the effect of hydriatic procedures is to be attributed to the fact that shortly before the attack the infected erythrocytes disinte- grate under the influence of the powerful stimulation of the cold, so that the plasmodia thus set free are destroyed by the phagocytes." Measles is an acute, contagious, febrile disease characterized by a blotchy exanthem and accompanied by coryza. It is usually uneventful in its course and not accompanied by any great mortality. However, the patient may be made much more comfortable during the febrile period, and the vital resist- ance so sustained that there is less tendency to bronchopneumonia. The eruption does not appear until the fourth day, so the treatment must be begun before a positive diagnosis can be made. In this disease, as well as in scarlet fever, the first thing to be accom- plished is the relieving of the internal congestion occasioned by the infect- 7 Cohen's System of Physiologic Therapeutics, Vol. IX, p. 136. 122 THE TREATMENT OF FEVERS ive process. If the case is untreated, the visceral congestion is considerably lessened on the appearance of the eruption. The old idea that measles is much more serious if the eruption "strikes in," or does not appear frankly, is not wholly without foundation. At the time the eruption makes its appear- ance the skin becomes markedly congested and this serves to, at least par- tially, relieve the visceral congestion. A treatment which most efficiently relieves the internal congestion is also conducive to the speedy appearance of the rash. In our practice, we have seen this best accomplished by means of some hot sweating treatment, either the hot pack or bath, accompanied by the drinking of some hot liquid. The head should be kept cold by com- presses or ice bags. In some cases, where there is not much chilliness, sweating is very well accomplished by the use of the wet sheet pack, pro- longed to the sweating stage. This draws the blood from the viscera and congests the skin. At the termination of such a treatment, the case, if one of measles, will show the characteristic dull red, blotchy eruption. Baruch recommends some form of cold treatment for the same purpose and as an antipyretic throughout the febrile period. He prefers the gradu- ated bath, or a warm bath in which the patient sits while cold water is poured over the chest and shoulders. The full expansion of the lungs occas- ioned by such treatment aids in the prevention of bronchopneumonia. Be- cause of the irritibility of the skin, it is not best to employ friction during the cold bath. Cold affusions to the head and back of the neck are useful in relieving stupor, delirium and other cerebral symptoms. We have found the wet sheet pack, frequently renewed by sprinkling cold water over it, an excellent means of reducing the temperature and, at the same time, it provides against chilliness, since between each renewal of the pack, it warms up and reaction is completed. This may be repeated until the tem- perature has been reduced to 101 F., or even less. The evaporating stage of the pack should last for a greater length of time than the heating stage, so that the total effect will be that of heat abstraction. Bronchopneumonia. Capillary bronchitis is the most serious and fatal of the complications arising during the course of measles. In this disease, there is a special tendency to congestion of the mucous membranes of the respiratory tract, as evidenced by the coryza which invariably accompanies it. The condition of the lungs may prove to be of a tubercular nature; this is not an infrequent sequel and one accompanied by a high mortality. In the treatment of bronchopneumonia, complicating measles, we employ the same methods used in the treatment of this disease when occurring alone. The child should be placed, at intervals of about 3 hours, in a bath at 90 to 95 . When sufficiently warm, let the child sit upright and cold affusions be applied to the chest, shoulders and back. The water for the affusion may be at a temperature of from 70 to 75. This vigorous means provokes an unusually deep inspiration, which is followed for a considerable time, by slower respirations of greater depth. It facilitates the expulsion of mucus. Another treatment that has given excellent success is the cold compress applied to the chest. This should be wrung from very cold water, applied quickly over the entire upper chest, allowed to remain for a very short time, and then renewed. This may be repeated from two to four times, the last SCARLET FEVER 123 compress used being allowed to remain for 30 to 60 minutes. The chest may be slapped in rapid succession with cold wet towels. This, of course, should not be done if the temperature is very high. In the latter case, the evap- orating wet sheet pack provides for the reduction of the fever and serves to stimulate respiration. Gaseous interchange and oxygenation of the blood are greatly promoted, the circulation is increased and the heart strength- ened. Among other measures that may be used to good advantage are cold spong- ing, hot sponging and the cold towel rub. Scarlet Fever Scarlatina is an acute, contagious fever characterized by a diffuse scarlet erythema accompanied by sore throat or tonsillitis. It has a higher mortal- ity than measles and is accompanied by more serious complications. In scarlet fever, as in all other febrile diseases, the chief objects to be attained by treatment are the maintaining of the vital resistance, increasing phago- cytosis in order to combat the infection, sustaining the heart and circulation, and controlling the nervous manifestations by tonic measures. Before the appearance of the eruption, scarlet fever should be treated in precisely the same manner as measles. Usually by the time the physician is called, the eruption has already begun to make its appearance and here, as in measles, we have found the use of the initial hot bath or pack most effectual in pro- moting a decided and general eruption. As soon as its appearance, or other symptoms give evidence that the internal congestion has been materially relieved, some form of cold treatment should immediately follow. Because of the sore throat and tonsillitis, it may be necessary to precede the general hot treatment by fomentations to the neck and upper chest. Cold compres- ses or ice bags should be applied to the head at the same time, and the treat- ment accompanied by a hot foot bath or leg pack. These partial hot appli- cations in themselves, may produce general perspiration, in which case, it is unneccessary to use other hot treatment. A full, hot bath may be service- able in place of the hot pack and when the patient has become thoroughly warmed, the succeeding cold treatment may be applied by proper graduation of the bath. The temperature must not be reduced too far, since it is impossible to employ friction on account of the rash. The wet sheet pack, kept at the evaporating stage and frequently renewed, is a very efficient means of reducing the temperature, energizing the nerves and circulation. After the eruption has once appeared, there need be no fear of "driving the rash in." However, it is necessary to produce a de- cided cutaneous reaction with every cold treatment used. The extreme cold bath is counterindicated. Affusions and ablutions, beginning with water at 90, gradually lowering the temperature until water at 70 or 75 is used, are also useful in controlling the temperature and assisting the heart's action. It is necessary that the patient drink a considerable quantity of water to provide for thorough elimination, because of the tendency to renal conges- tion and nephritis. This latter condition is the most important complication of scarlet fever. 124 THE TREATMENT OF FEVERS Nephritis. Should this condition appear during the febrile period, it is not necessary to stop all cold treatments, but the temperature should be somewhat moderated and the time shortened. Short hot applications may be made so as to enhance the reactive ability, and these immediately followed by such measures as cold affusions, cold sponging, wet sheet pack or the graduated bath. In the case of the graduated bath, the initial heating may be accomplished by beginning the bath at 95 to 98, raising the temperature a few degrees until the patient is well warmed, and then gradually" cooling the bath to 80 or 85. Chilliness should not result from any treatment, as this tends to increase the renal congestion. If the wet sheet pack is used, the sheet may be wrung from hot water and then maintained at the evaporating stage and renewed by sprinkling cold water over the sheet. During all this time, the drinking of large quantities of water should be encouraged. If the nephritis should make its first appearance after, or at the close of, the febrile period, it is perhaps best to employ the means commonly used in treating nephritis, that is, dia- phoretic measures. The hot bath with ice to the head and heart, the hot blanket pack or partial hot applications, such as the hot foot bath accom- panied by fomentations to the spine, chest or abdomen, are all useful in pro- ducing sweating. If the hot blanket pack is used, it may be very conven- iently followed by the wet sheet pack, wrung from water at 75 and continued to the sweating stage. Reaction should ensue promptly. The child may be left in this pack an hour or two, or until the sheet is nearly dry. The cold towel rub and cold mitten friction may be used to promote cir- culatory reaction, providing desquamation has well begun. It is best not to employ the cold mitten friction, should the nephritis occur before the erup- tion subsides. Under these treatments, the albumen gradually lessens and casts disappear from the urine. Should there be oedema about the feet and ankles, the alternate hot and cold foot or leg bath should be used and fol- lowed by centripedal massage. To aid desquamation and prevent spreading of the contagion, the cold mitten friction or salt glow may be used to hasten the removal of the scales. Either treatment should be followed by an oil rub to prevent further rubbing off of the contagion-carrying epithelium. Endocarditis. Should this complication arise, all cold tub baths should be discontinued, also cold affusions. The patient must be kept at absolute rest, with the ice bag to the heart intermittently. After the eruption has disappeared, there is no measure equal to the cold mitten friction in assist- ing the circulation and relieving the heart. For further treatment, see "Endocarditis." La Grippe Influenza The clinical condition in influenza is quite different from that of typhoid fever. In this disease, the fever is of the short, high type, with rapid pulse and high blood pressure. These are the manifestations that are found among young adults. With older persons, the disease is quite likely to be accompanied by considerable asthenia, the digestive system and the nervous INFLUENZA 125 system bearing the brunt of the infective process. With younger persons, the respiratory tract is more likely to be affected. Since this is a short sthenic fever, the treatment employed will differ con- siderably from that used in typhoid fever. Aside from cold applications to the head, it is unnecessary to employ long cold treatments for the purpose of reducing the fever and all generalized cold applications are counterindi- cated. With an individual that has been previously strong and well and is in good flesh, it may be possible to treat the case from the start by vigor- ous cold applications with friction. This enhances the vital resistance, increases leucocytosis and so combats the infection in a very direct manner. With cases as they usually present themselves, we have obtained the best results by the use of an initial sweating treatment such, for example, as the hot leg bath accompanied by fomentations to the spine or to the chest and throat, with cold compresses to the head and neck. At the same time, the patient should drink several glasses of hot lemonade. Chilliness is soon overcome and the patient begins to perspire profusely. As soon as profuse perspiration is well established, the patient may be given a graduated shower beginning at 106 to 108, gradually increasing the temperature to the limit of toleration. While in the hot spray, the patient should wear a cold compress to the head. As seon as he is again well warmed, the tem- perature should very gradually be reduced to 90. This abstracts much of the heat that has been communicated to the body by the sweating treat- ment. The patient should now be put to bed, with hot water bottles to the feet and allowed to perspire gently for a number of hours. Great care must be taken that the patient is not overheated by the sweat- ing treatment, since fainting is quite likely to result unless the cold com- presses to the head and neck are frequently renewed. In some cases, it is necessary that the patient be in the recumbent position while taking the treatment and, for this reason, the horizontal electric light cabinet is very serviceable in securing free diaphoresis. In case this treatment has been carried out in the evening, on the follow- ing morning the patient should be treated by preliminary hot applications for the purpose of relieving the aching of the back and limbs. This is best accomplished by the leg pack or large fomentations to the spine. They should not be continued long and should be followed immediately by a vigorous cold mitten friction. From this point on, it is best to treat the case as far as possible with tonic measures, such as the cold mitten friction, cold towel rub, or the hot and cold douche to the spine and legs, finishing with the alternating douche to the feet. The sweating treatment should not be repeated unless it seems quite necessary. Any plan of treatment may fail of its best results in case the bowel is not thoroughly unloaded at the beginning. This may be best accomplished by thorough enemata. Special complications require attention outside of the general plan of treating influenza. Bronchitis and cough, with pain in the chest, should be treated by large fomentations, followed by the heating chest pack. Pharyngitis or tonsillitis should be treated in the same manner, that is, with fomentations, and a cold heating compress applied between 126 THE TREATMENT OF FEVERS treatments. The nervous symptoms are best met by the ice cap, or cold compresses to the head. The pain may be very materially relieved by the use of very hot fomentations. In all cases, however, the treatment should be concluded with a vigorous cold mitten friction. It is not designed that the cold frictions shall materially lower the temperature in and of themselves, that is, the fall in temperature does not result immediately after the appli- cation, but rather succeeds in a few hours. If the temperature is very high, it may be effectually combated by the use of the ice bag to the heart, with ice applications to the head. Both should be continued with but little inter- ruption. The asthenic type of influenza, except in old people or chronic invalids, is not now as common as during the pandemic of 1889 and the years immedi- ately following. In the event of severe asthenia the treatment is to be carried on along general lines with special reference to those measures which will sustain the heart and circulation. The treatment of respiratory or digestive complications demand special care and is to be carried on along lines laid down elsewhere. CHAPTER XVIII INFLAMMATION AND ANTIPHLOGISTIC EFFECTS Before considering the conditions present in inflammations and their treat- ment, it will be well to understand the principles involved in the production of certain circulatory effects which are much used in the treatment of inflam- mations. We shall therefore first turn our attention to the methods and principles concerned in the production of derivation and fluxion. Derivation is the withdrawing of blood from an organ or part of the body by increasing the amount of blood in some other part. Practically, it is the reduction of congestion (and inflammation) by drawing the blood from the part congested into some other part. Fluxion consists in increasing the rapidity of the blood current in a par- ticular part, and consequently, the total amount of blood passing through that part in a given time. It is the production of arterial hyperemia. Derivation Depletion In derivation, there is produced a collateral hyperemia with local anemia. This is most effectually secured by the simultaneous application of both heat and cold in the following manner (Plate 3) : A large, very hot application is made to a distant part; in many cases, it extends up to and includes the congested part. At the same time, an ice bag, ice pack or ice compress is placed directly over the inflamed organ. In this way, collateral hyperemia is secured and local anemia re-enforced by the direct or reflex vasoconstrict- ing influence of the ice. The local anemia is made extreme by both a ' 'push ' ' and a "pull" effect on the circulation, the "pull" being secured by the vis a fronte of the hot application, and the "push" by the vis a> tergo of the reflex contraction of the blood vessels, due to the cold application over the part. The most effective derivation is secured by direct contact of the body with hot water. A hot leg bath is more effective than a hot leg pack, and a hot leg pack with the wet blanket applied directly to the skin is more effective than when a dry blanket intervenes. The following are the principal derivative measures indicated in the acute stage of the diseases mentioned: 1. APPENDICITIS. Hot hip and leg pack, with ice bag over the appendix. 2. PERITONITIS. Hot hip and leg pack, or leg pack only, with ice com- press to abdomen. 3. PUERPERAL INFECTION AND ACUTE SALPINGITIS. Full hot blanket pack, or hip and leg pack, with ice to the pelvis. 4. PNEUMONIA. Hot leg bath, hip and leg pack, or full blanket pack, with cracked ice compress over the lobe affected. 5. MENINGITIS. Hot leg pack, with ice cravat, ice cap and ice bag to the base of the brain and the upper spine. 128 INFLAMMATION AND ANTIPHLOGISTIC EFFECTS 6. MASTOIDITIS. Hot leg bath, with ice cravat or ice bag over cartoid artery, ice cap and fomentations to the mastoid. 7. ALVEOLAR ABSCESS. Same as above, except fomentations to the jaw. 8. OSTEOMYELITIS (of Tibia). Fomentations to leg or leg pack with ice over the femoral artery. 9. CEREBRAL CONGESTION. Hot leg bath, with ice cravat, ice cap or cold compress to the entire face and cranium. 10. RENAL CONGESTION. Fomentations to back. Hot trunk pack or full blanket pack, with ice bag to the lower third of sternum. Precautions: In order to maintain collateral hyperemia, the treatment must be concluded with such a vigorous tonic measure as a cold mitten fric- tion, applied to the part previously covered by the hot application. The hot application alone produces passive dilatation of the blood vessels. If the treatment is stopped here, the circulation will soon equalize itself or even a worse internal congestion may occur. The cold mitten friction, however, produces an active dilatation (alternate dilatation and contraction) of the blood vessels, thus maintaining for a longer time, the derivation secured by the hot. Derivation by Hot Alone. It some cases, sufficient blood can be with- drawn from a part by applying heat over the cutaneous branches coming from the artery supplying the deeper congested part or organ. In this case, the larger flow of blood is diverted into the cutaneous (and superficial) branches, leaving less to pass to the deeper branches. Examples of this are found in the treatment of, 1. PLEURISY. Large fomentations to the chest divert the blood flowing in the intercostal and internal mammary arteries from the pleural branches to the posterior, lateral and anterior cutaneous branches. 2. RENAL CONGESTION. Large fomentations over the lower dorsal and lumbar spine the entire width of the back. This diverts the blood from the renal arteries to the lower intercostal and lateral lumbar branches of the aorta. 3. SIMPLE SPINAL CONGESTION. Large fomentations to the spine divert the blood from the spinal arteries to the posterior cutaneous arteries supply- ing the skin and muscles of the back. 4. CONGESTIVE SCIATICA. Large fomentations to back and side of thigh divert the blood from the nerve to the skin. 5. TRIGEMINAL NEURALGIA. Fomentations to side of face divert the blood to the skin. This may be re-enforced by the use of an ice bag over the carotid, thus mechanically lessening the total volume of blood going to the head. Precautions: In pleurisy and neuralgia, cold increases the pain, hence can not be used. Fluxion When hot and cold applications are used to secure derivation, they are used simultaneously and to different areas. If the hot and cold are used alternately and to the same area, the result is fluxion. This may be either by direct effect in the part treated, or by reflex action in another part. This effect is intensified by friction or percussion. FLUXION 129 All alternately applied hot and cold applications are tonic, both locally and generally. We may here, for the sake of clearness and brevity, confine ourselves to the consideration of measures desired to produce chiefly violent circulatory reaction in a given part or organ. The following are the principal means used to produce fluxion: 1. Alternate hot and cold, using fomentations and ice, or fomentations and cold compresses (revulsive compress). 2. Alternate hot and cold douches or sprays, as to spine, legs, liver, etc. 3. Alternate hot and cold packs. 4. Alternate hot and cold, as to head or kidneys and sternum. 5. Revulsive or alternate hot and cold sitz bath. 6. Alternate hot and cold foot or leg bath. 7. Alternate hot and cold immersion, as of hand and arm. 8. Alternate hot and cold vaginal douche, rectal irrigation, etc. In all the above measures, the condition produced is that of active (arterial) hyperemia. The alternate dilatation and contraction of the blood vessels is stimulated. This condition is known as active dilatation. These alternating changes of vasoconstriction and vasodilatation are more rapid and extreme than the normal. They very markedly increase the number of white blood cells in a given part, and consequently the resulting phagocytosis. It is this which makes it especially valuable, and almost in- dispensable in some acute congestions and inflammations, such as an acute infection of a hand or a foot, where lymphangitis and lymphadenitis are likely to follow so quickly. Perhaps the largest field for the use of fluxion (arterial hyperemia) is in chronic congestions, whether a sequel to chronic infections or non-inflam- matory. In these cases the congestion is of a passive type, i. e., venous stasis. The treatment is also indicated in local anemias. Below are given some of the more important indications for the use of fluxion: 1. Acute infections, as of hand, arm or foot. 2. Convalescence from all infections (stage of passive or venous conges- tion). 3. Chronic congestion of liver. 4. Chronic pelvic congestion, as of uterus or adnexa, whether simple or following infections. 5. Uterine subinvolution. 6. Amenorrhea. 7. Myelitis (chronic stage). 8. Locomotor ataxia and other paralyses of spinal origin (in chronic stage) . 9. Alcoholic neuritis (after acute stage). 10. Muscular atrophies. 11. Tubercular arthritis and synovitis. 12. Chronic osteomyelitis. 13. Varicose ulcer. Precautions: In acute infections, massage effects, such as friction or percussion, should be avoided. Dire effects in the quick spread of the bac- teria to other parts, will result if these are used. 130 INFLAMMATION AND ANTIPHLOGISTIC EFFECTS Revulsion. According to Borland, this term is synonomous with deriva- tion and depletion. Kellogg evidently uses it to designate the mode of giv- ing a hot and cold application, the chief effect of which is fluxion. For example, a revulsive compress a treatment consisting of a single hot appli- cation, followed by a single cold application. Again, it is used to designate derivation secured by collateral fluxion, as in the use of hot and cold foot or leg bath, or a hot and cold percussion douche to the feet and legs to relieve cerebral congestion. When hot and cold are alternately applied to one part of the body, thus producing fluxion in that part, it will withdraw more or less blood from other related or distant parts. This diverse application of the term has led to no little confusion. While the term can not be fully dispensed with, the student should bear in mind that the effect is that of either derivation or fluxion. Pathogenesis of Inflammation "Inflammation consists of the series of changes constituting the local mani- festation of the attempt at repair of actual or referred injury to a part, or briefly, it is the local attempt at repair of actual or referred injury. Inflam- mation is the reaction of irritated and damaged tissues which still retain vitality." l The pathologic conditions in an inflammatory process may be partially understood by the five cardinal symptoms, viz., 1. Rubor redness. 2. Tumor swelling. 3. Calor heat. 4. Dolor pain. 5. Functio Iffisa loss of function. The primary cause of the inflammation, whatever it may be, is respons- ible for these conditions, which are largely circulatory disturbances. The condition in the acute stage is one of (1) arterial hyperemia with (2) a serous exudate, and (3) an increasing number of leucocytes in the blood stream and tissues; from the latter, they return to the blood stream less rapidly than normal. (4) The inflamed part is bright red. (5) The pain is severe and often throbbing in character because of the increasing tension on the nerves caused by the swelling. 2 In the chronic stage, the condition is one of (1) venous congestion (passive hyperemia) . (2) There is a beginning organization of the exudate, and (3) a dearth of leucocytes. (4) The part is of a dark red or bluish color. (5) The pain is less severe, and described as dull and heavy in character. In the intermediate stages, the inflammatory process passes gradually from the first to the last condition. The circulation begins to be slowed, and more and more blood accumulates in the capillaries and veins, less arter- ial blood being present, so that the total amount of blood in the organ is increased above normal. The severe or throbbing pain gives way to the more constant, but less severe, dull pain. The leucocytes find their way back into the circulation (lymphatic or blood) if no suppuration occurs, and the number in the tissue decreases. 1 Adami Inflammation, pp. 5, 227. 2 For the details of the process see, Adami Inflammation, pp. 34-36. PRINCIPLES OF TREATMENT 131 Principles of Treatment In the Acute Stage. (1) Limit the congestion, (2) hasten absorption of the exudate and prevent f uther exudation, (3) energize and assist the phago- cytes in combating the infection or noxious agent, (4) relieve the pain. While inflammation is a protective process, it must not be supposed that it is always well regulated, or able, unassisted to cope with the disturbing cause. The serous exudate of this stage consists of a more concentrate lymph than normal, i. e., a lymph containing more proteins, which doubtless serve for the nutrition of the cells necessary in the regeneration of tissue which follows. 3 It is necessary only to limit this to a proper amount and hasten its return to the blood and lymph vessels when its work is done. This means the restoration of the proper rate of exudation and absorption and is applic- able to the leucocytes as well as the fluids. In the Chronic Stage. (1) Stimulate and quicken the circulation by the production of arterial hyperemia, and (2) stimulate the process of phagocy- tosis, thus (3) promoting resolution and absorption of the exudate and thereby preventing its organization. In the acute stage of an inflammation, i. e., during the first few hours or first day or two, extreme cold should be used over the part continuously, or with only short intermissions, in order to lessen the congestion, relieve the pain, and, if possible, thereby abort the inflammation. In many cases it is necessary to re-enforce the continuous cold by hot applications to collateral areas (derivation) in order to effectually reduce the congestion. The cold energizes the white blood cells, increasing their number and efficiency in the destruction of bacteria, and hastens their return to the blood stream. After the acute stage has passed, i. e., at the end of a few hours, or on the second day, the cold applications should be replaced by a heating com- press; or, if cold compresses were used in the first stage, it is only neces- sary to leave them on, thus making a heating compress. These cold and heating compresses should be replaced at intervals of 1 to 3 hours, using short fomentations when the change is made. As the inflammation progresses toward the chronic stage, more heat and less cold should be used. After the acuteness of the inflammation has entirely subsided, the most vigorous hot and cold applications should be used in order to lessen venous stasis and bring to the organ a greater supply of fresh blood (fluxion), for the time producing an arterial hyperemia. It is possible to use fluxion even immediately following the first few hours of some inflammations, provided they are not in a dangerous area, i. e., where rupture would prove fatal or produce serious complications. It has been shown that in some cases the maintenance of a high external temperature is conducive to a more rapid and benign course of the inflam- mation than where cold is used. These are doubtless cases of inadequate reac- tion as suggested by Adami, 4 better results being due to the increased amount of blood brought to the part. In the majority of cases still greater benefit 3 Starling Fluids of the Body, p. 174. 4 Inflammation, pp. 199, 218. 132 INFLAMMATION AND ANTIPHLOGISTIC EFFECTS results from the use of alternate hot and cold applications, since these pro- duce an arterial hyperemia which has no after tendency to stasis. The stage of the inflammation may best be judged by the color. A bright red color is evidence of an acute process and a dull red, dusky or bluish color, of a chronic process. Inflammations in certain localities should be treated by hot alone, until after the first stage is passed. This is true of pleurisy. "For antiphlogistic purposes, it may be safely held that in the early stage of congestion, cold applications are useful so long as the circulation in the affected part is still open, which is indicated by the turgor. But when the parts assume a cyanotic hue, when leucocytes have begun to adhere in large numbers to the vessel wall and emigration has become active, applications of warmth further the latter and hasten suppuration when it is unavoidable. The cold compress diminishes congestion, retards leucocytosis and emigra- tion of white cells, while the warm applications have the contrary effect, each being most useful in the respective stage of inflammation. "The antiphlogistic effects of cold compresses are readily explained by the results of Genzmer's experiments upon local blood letting. He came to the conclusion that the favorable effect of bleeding upon the inflamed parts beneath was ascribable, not to their becoming more anemic, but to the fact that the blood stream became more rapid, and thus the corpuscles which had adhered to the vessel walls were loosened and driven into the general circulation. The fluxion therefore, which the application of cold or warm compresses produces, in the parts below them, is the true cause of the changes in the latter when inflamed. Thus may the old theory of derivation be satisfactorily explained. "This effect of cold applications may be called into action in some local inflammations in which the parts appear cyanotic and it is important to pre- vent impending suppuration. Here hot compresses or cataplasms are also useful to arouse the surface circulation; as they cool off, they widen the deeper vessels and thus re-establish the circulation which has become stag- nant. This being accomplished, cold compresses may succeed the hot, in order to limit leucocytosis and, by fluxion, remove stagnant corpuscles. It is evident that by the exercise of sound judgment, the proper temperature of the compress may be nicely adjusted to each case." 5 It must not be supposed that circulatory changes are the only effects pro- duced by the treatment as outlined above. Proper regulation of the circu- lation by means of heat and cold also stimulates the cells concerned in the healing process. From the above, we may draw the following conclusions, as in general, applicable to inflammations. During the acute stage, the treatment should be directed toward the reducing of the congestion, whether by collateral hot alone, or by hot assisted by cold over the part, or by cold alone. The philosophy of the treatment is summed up in the word derivation as under- stood in its broadest and practical sense, i. e., the reducing of congestion. In the chronic stage, all the pathologic indications are met by the produc- tion of fluxion. The accompanying outline will serve to make clear these principles: 5 Baruch Principles and Practice of Hydrotherapy, pp. 154, 155. PRINCIPLES OF TREATMENT 133 Conditions 1. Arterial hyperemia 2. Increasing serous exudate 3. Overplus of leucocytes 4. Bright red color 5. Pain severe and throb- bing Acute Stage Indications for Treatment Treatment Should Produce Limit congestion Derivation Cause absorption of (Reducing of congestion) exudate Energize leucocytes Relieve pain 1. Passive hyperemia 2. Organization of exudate 3. Dearth of leucocytes 4. Dark red, dusky or blu- ish color 5. Pain less severe and dull Chronic Stage Stimulate circulation Promote resolution Stimulate leucocytosis Fluxion (Increasing rapidity of circulation) We have already referred to Bier's hyperemic treatment of inflammation. The form of hyperemia upon which Bier places the greatest emphasis and which he lauds most highly is the passive hyperemia produced by lightly con- stricting bands, suction cups, etc. These partially obstruct the return flow of venous blood, so producing a stasis in the part. The writer can see no rational basis for this procedure; in fact, to us, it appears decidedly irrational and to in no way meet the needs of a chronic inflammation. In this condi- tion, there is already an extreme venous stasis. To still further slow the blood current, certainly does not tend toward a normal condition. 6 The leucocytes are neither renewed, increased or energized. The blood, already overcharged with acid products, is in no way restored to its normal degree of alkalinity. On the contrary, the production of active hyperemia meets all these needs as pointed out above. Meyer recognizes only three methods of producing hyperemia; viz., by elastic bandages, cupping glasses and hot air. " Of these only the hot air produces an active hyperemia and while it is exceedingly useful in many cases, it does not produce the most ideal vascular condition for the relief of chronic inflammations for the reasons already pointed out. While the ice bag over an inflamed part, accompanied by collateral heat for derivative purposes, effectually relieves the pain of an inflammatory pro- cess in soft tissue, it will not relieve the pain of a bony inflammation. To decrease the congestion and relieve the pain of an osteomyelitis or mastoidi- tis most effectually, the ice bag must be placed over the trunk of the large 6 There is only one organ in which a passive congestion, i. e, the retarding of the blood current can possibly result in an "arterial" hyperemia. This organ is the lungs. In the nature of the case any retarding of the outflow of blood from the lungs only results in increasing the amount of their oxygenated blood. This fact probably accounts for the relative inf requency of pulmon- ary tuberculosis accompanying valvular heart disease. 7 Meyer and Schmieden Bier's Hyperemic Treatment, 1909, p. 23. m INFLAMMATION AND ANTIPHLOGISTIC EFFECTS artery supplying the inflamed part and not over the part itself, while heat is applied directly to the inflamed part. Ice applied over an inflammation con- fined in bony walls usually increases the pain, while hot decreases it. Neither will the ice bag or cold compress relieve the pain of an abscess even in soft tissue or to only a slight degree, lasting only while the treatment continues. This very fact is of diagnostic importance. It is presumptive evidence that the inflammation has gone on to suppuration and must be opened. It should then be treated by hot applications to hasten the process and localize the abscess preparatory to drainage. CHAPTER XIX THE TREATMENT OF INFLAMMATIONS Inflammations of the Eye Iritis, Keratitis, Conjunctivitis, Dachryocystitis, Ophthalmia, Tracoma Because of the situation, it is necessary to use more cold than hot in treat- ing these inflammations, since long hot applications to the head produce cerebral congestion. The cold application may be made by means of four to six thicknesses of gauze wrung out of ice water or kept on a block of ice, and this applied almost continuously, being renewed as frequently as warmed. It may be necessary to use a hot gauze compress occasionally, often enough to renew the reactive ability and make the cold comfortable and acceptable to the patient. Short fomentations may be used over the side of the face to secure derivation or, with a small piece of ice wrapped in gauze applied over the eye itself, a larger fomentation may be applied so as to cover the eye, forehead and cheek. In all cases, the hot applications should be of short duration. After the acuteness of the inflammation sub- sides, small gauze fomentations may be used alternately with the cold com- press, the hot being used for a shorter time than the cold. It is usually nec- essary to renew compresses about every two minutes. The results are apparent in the relief of the congestion, inflammation and pain. In ecchymoses about the eye the revulsive compress should be used. In the inflammations mentioned above, the appropriate antiseptic treat- ment, the use of silver salts, etc., should be followed just as carefully as otherwise and in iritis, dilatation of the pupil should be secured by means of atropin. Glaucoma, Toxic Amblyopia Localized disturbances in the eye dependent upon systemic diseases may be greatly benefited by hydrotherapeutic treatment. In glaucoma the following treatment gives relief by reducing the vascular tension. For a period of about thirty minutes give a hot foot bath or hot leg bath together with ice bags over the carotids or apply the ice cravat. Conclude the treat- ment by a vigorous cold mitten friction to the legs or the alternate hot and cold percussion douche to the feet, keeping the ice over the carotids until its completion. During the period of highest tension full hot baths and other heavy sweating treatments must be discarded. In toxic amblyopias, such as tobacco blindness and similar affections, sweating treatments combined with tonic measures are indispensable. The bowels should be kept open by enemata, abdominal massage and a laxative diet, especially by the use of fruit. An occasional saline cathartic may be necessary. 136 THE TREATMENT OF INFLAMMATIONS Erysipelas During the first few hours, the ice bag should be used continuously over the topical application. The ice bag is used throughout this disease more than in other inflammations, since new parts are progressively involved and the advancing border is therefore in the acute stage. An occasional fomen- tation may be necessary to renew the reactive capacity of the tissues. In the case of meningeal involvement, or deep inflammation, strong derivative means should be used, as a hip and leg pack, with the ice cap over the affected part. The latter should be continued with but little interruption. Hot applications to the head only tend to increase the deep congestion. In the case of erysipelas migrans, very hot fomentations, or alternately extreme hot and cold, give the best results. These should not be used on the head or face, or about the neck. The migratory form usually affects the skin of the trunk or limbs. Otitis Media Acute Suppurative These cases rarely present themselves early enough to abort the formation of pus unless they come on the first indication of the closure of the Eustach- ian tube. The pain of catarrhal otitis and aural neuralgias is best relieved by fomentations. After hot treatment, the patient should be unsually care- ful, since he is rendered more susceptible to colds. If it seems probable that rupture of the drum may be prevented, or while waiting todoparacen- tesis tympani, the following treatment may be used: Direct the patient to take a hot foot bath, or better, a leg bath, with fomentation over the ear and side of face, cold compresses being used to the neck and opposite side of the head. In adults, the ice cravat, or ice bag to the carotid of the same side may be used. This derivation will reduce the congestion and partially, or entirely, relieve the pain. It may also lessen the liability to rupture of the drum. Otherwise, the condition should be treated according to plans outlined in any standard text on diseases of the ear. The use of hot air deserves men- tion as a most efficient means in both acute and chronic suppurative otitis media. Acute Mastoiditis Those cases which tend toward recovery, that is, where the inflammation does not go beyond turgescence and congestion of the lining membrane of the mastoid cells, may be aided to an uneventful recovery by the use of fomentations to the mastoid, dry heat, and derivation. In infants and younger children, the Leiter coil with ice water, may be used over the mastoid. At this age mastoid periostitis is very common, which condition is always benefited by the cold coil. In older children and adults, we have not been able to use cold over the mastoid because of the pain occasioned by it. In many cases the pain may be relieved by strong derivative means, as a very hot leg bath and fomentations to the mastoid, with the ice cravat or an ice bag to the carotid of the same side. This should be continued from ACUTE TONSILLITIS 137 20 or 30 minutes to an hour and finished with a vigorous cold mitten friction to the limbs and trunk. We have found this plan very successful in obviat- ing the necessity for large doses of hypnotic drugs in those cases which refuse operation, or while preparations are being made for surgical inter- ference. Alveolar Abscess This condition should be treated on precisely the same principles as mas- toiditis, always bearing in mind that the cure lies in securing drainage as promptly as possible. Simple Pharyngitis The soreness of the throat is most effectually relieved by large hot fomen- tations to the throat, coming well up under the jaw and back to the ears. If there is much fever, a mild sweating treatment will be beneficial at the beginning. This may be accomplished by a hot foot bath with the fomenta- tions to the throat, or an electric light bath. The treatment should be con- cluded with a cold mitten friction, and a heating compress applied to the throat to be left over night. The next day, use the hot foot bath and revul- sive compress to the throat. Each hot treatment should be concluded with some tonic measure, such as the cold mitten friction, cold towel rub, gradu- ated or hot and cold spray. It may be necessary to repeat the hot foot bath and revulsive compress two or three times a day, always leaving the heat- ing compress in place between treatments and over night. The inhalation of steam and gargling of hot water will aid in relieving the pain. The ordin- ary antiseptic throat gargles in hot water should also be used. Acute Tonsillitis The temperature is usually very high, but of a transient type. It is unnecessary to employ antipyretic measures. In fact, general applications of cold are quite likely to produce chilling. At the beginning of treatment, the patient should be given some sweating measure, such as a hot leg pack, full blanket pack, or hot leg bath with fomentations to the throat and ice compress or ice cap to the top and sides of the head. Because of the rapid pulse and extreme prostration, an ice bag should be applied to the heart. The patient may be taken out with a cold mitten friction, or, if able to stand, a graduated shower. A well covered heating compress should be applied to the neck. After the initial treatment, fomentations or the revulsive com- press should be applied to the neck at frequent intervals, always following them by the heating compress. Throughout the disease, very vigorous tonic treatment may be employed. The cold mitten friction, or cold towel rub, wet sheet pack, etc., have been found useful in maintaining the vitality of the patient. In case of quinsy, the paratonsillar abscess should be lanced at the proper time. Previous to this, fomentations frequently repeated will aid in hasten- ing suppuration, localizing the abscess and making more apparent the point- ing. 138 THE TREATMENT OF INFLAMMATIONS Boils and Carbuncles In the beginning, while the boil is only a pimple, it may be aborted by the prolonged use of ice over it, with a fomentation covering it and a larger area, applied at the same time. The use of extreme hot and cold applica- tions, alternately applied (fluxion), is also an advantage. When it is no longer possible to stop the progress of the boil, fomentations, poultices, heating compresses, etc., may be used to relieve the pain and hasten the localization of the pus. It should then be lanced. The absorption of the indurated residue about the boil may be hastened by hot and cold applications, such as fomentations and ice or the alternate hot and cold pour. Pressure about the boil, or friction to the skin should be avoided, as these measures tend to spreading of the bacteria and the infection of other areas. Acute Blood Poisoning Septiceniia of Hand, Foot, etc. These infections are usually occasioned by scratches, cuts, bruises, tharns, etc. While the initial lesion may seem to be trivial, serious results follow very quickly. For this reason, blood pois- oning should be treated most vigorously. The object to be accomplished is the increasing of phagocytosis and so increasing the circulation as to rapidly renew the blood flowing through the infected part, When first seen by the physician, the inflammation has usually gone beyond the primary stage. In the case of the hand, the part is very much swollen, blue and edematous. Extension of the infection is indicated by red lines (lymphangitis) extend- ing upward, and by swelling and tenderness of the regional lymphatics. When this occurs, most prompt and vigorous measures are neccessary. The following treatment, if applied reasonably early, has, in the writer's exper- ience, never failed of success: Provide two pails or receptacles sufficiently large to immerse the infected part. One of these should be filled with the hottest water that can be borne, more being added from time to time to the limit of toleration. The other pail should be filled with ice water, containing pieces of ice. The patient is instracted to immerse the part in the hot water for 2 minutes, then in the cold for 15 to 30 seconds, after which, it is returned to the hot water again for 1-J or 2 minutes, then re-immersed in the cold for 15 to 30 seconds. These changes are kept up for at least half an hour and repeated from two to four or five times a day, according to the seriousness of the infection. If thought best, disinfectants may be added to both the hot and cold water. We have used crystals of potassium permanganate in one and oxalic acid crystals in the other. It may be necessary to lance the part if there are signs of suppuration. This should be done anyway if the infection has stood some time without treatment, or if extreme swelling and edema exist. In the latter case, multiple openings may be necessary. Massage should be avoided altogether, as it spreads the bacteria along the lymph channels. Cases treated as outlined above require only a few days for a complete cure, while cases treated by poulticing, antiseptics, incisions, without hydro- therapy, usually run a course of from a week to a month, or even longer. PNEUMONIA 139 Some cases of gangrene are successfully treated by this method. The appearance of the line of demarkation may be hastened by the use of alter- nate hot and cold applications. Chronic cases of osteomyelitis, with much riddling of the bone and soft parts, with sinuses, sequestrum formation, etc., are successfully treated along the same lines. The use of von Mosetig's bone-wax followed by the alternate hot and cold pour, applied daily, gives good results. Poison Ivy and Oak These inflammations require some active antiseptic treatment. In the earlier stages, continuous cold compresses, or the ice bag may be used with benefit. Later on, vigorous hot and cold compresses, pours or sprays give the best results. This latter means has proven of inestimable value in long- standing, refractory cases. Pneumonia Pneumonia is an acute, self-limited infectious disease characterized by a general toxemia and, pathologically, by a definite series of changes in the lungs. The first stage is that of intense pulmonary congestion. In the second stage, there is exudation into the alveoli, so that the affected lobe becomes consolidated, the condition being known as red hepatization. The third stage gray hepatization is marked by the changes accompaning reso- lution. The clinical feature of the crisis marks the transition from the second to the third stage and the beginning of resolution. Clinically, the following symptoms are prominent: pain in the chest, dyspnoaa, with rapid respiration, more or less cyanosis, and cough accompanied by the expec- toration of "prune-juice" or "rusty" sputum. Pneumonia runs a short course and, if the resistance of the patient is sufficient, antitoxines are pro- duced quite rapidly, so that the progress of the infection Is arrested. It should be recognized that pneumonia is a general infection, much like typhoid, and therefore demands systemic treatment. The greatest danger in pneumonia arises from two causes principally, (1) deficient aeration of the blood and (2) failure of the circulation. The air hunger is manifest by the rapid respiration, dyspnoea and cyanosis. In all febrile conditions there is, on the part of the tissues, a lessened capacity for the absorption of oxygen. In pneumonia, beside this, the lung area for gaseous interchange is very much limited because of the consolidation. The stasis of the blood in the lungs tends to increase the difficulty. The right heart is particularly embarrassed because of the lung consolidation and the pulmonary stasis. It has difficulty in forcing a sufficient amount of blood through the lungs to provide the tissues with the proper amount of oxygen. There is increased pressure in the right ventricle, as evidenced by the accentuated second pulmonic sound. The absence of this sign is one of the evidences of failure of the right heart and dilatation of the right ven- tricle. In those cases due to alcohol, the blood vessels are in a state of passive dilatation from paresis of the vasomotors. Both the capillary vessels of 140 THE TREATMENT OF INFLAMMATIONS the lungs and those of the general periphery are in this condition. It is be- cause of this pare tic condition of the vessels and the failure of the narcot- ized cutaneous nerves to appreciate the danger from cold that retrostasis is so likely to occur. Pneumonia is especially fatal in alcoholics. There should be a high leucocytosis. The absence of this is one of the unfavorable signs. From the foregoing, we may select four indications of prime importance in the treatment of pneumonia. 1. Increase the aeration of the blood. 2. Sustain the heart and circulation. 3. Increase leucocytosis and pha- gocytosis in order to combat the infection. 4. Decrease toxemia. Treatment Pneumonia as such does not exist until the stage of exudation and consoli- dation. The pulmonary congestion, however intense, does not constitute pneumonia, although if pneumococci are present, it is quite likely to end in consolidation. It is impossible to abort pneumonia after the exudation has occurred, although it is possible, by strong derivative means, to reduce even a very intense pulmonary congestion. The presence of numerous crepitant rales is not, in itself, evidence of consolidation. The rales, together with rapid respiration, pain and fever, may be present in the stage of congestion before exudation has occurred. If treatment can be begun very early, even though there is no positive assurance that the condition is not more than a congestion, it is best to employ some derivative, or sweating treatment in order to reduce as much as possible the pulmonary congestion. The collat- eral heat may be either a very hot leg bath, a hot hip and leg pack, or full blanket pack. The latter will be best if the patient is very chilly. These measures should be re-enforced by the drinking of some hot liquid to pro- duce perspiration and thus aid in reducing the internal congestion. In apply- ing the cold to the chest, it must be born in mind that the lobes affected are usually the lower lobes and therefore present the greater surface at the sides and back of the chest. Over this area may be used a very large ice cap or ice pack. This Should not be placed until the patient is well warmed, since otherwise it may produce chilliness. The collateral heat and local cold should be continued until effectual derivation is secured. If this requires a very long time, the pack must be re-enforced by hot water bottles, bricks, etc., and the cold over the affected lobe replaced for a short time by a very hot fomentation to renew the nerve sensibility and promote the vigor of the reflex effect from the cold. It is well to use the ice bag over the heart if the pulse is very rapid. Treatment may be concluded with a cold mitten fric- tion. A very short fomentation may be applied to the chest, followed by a heating compress or a moist chest pack which should be left in place until the next treatment. The supplying of plenty of fresh cold air is of prime importance. It has been stated that, during the late war, cases of pneumonia treated in tents in the most rigorous weather did far better than those treated in hospital buildings. The open air treatment as carried out in some hospitals has greatly reduced the mortality. The laity fear the effects of cold air in this disease, believing that the patient is likely to take cold and so the pneumonia be made woi'se. Persons with fever are not likely to suffer from an "overdose" of cold air. For the reason stated above, it is very necessary that the lungs PNEUMONIA Ul be supplied with the greatest possible amount of pure fresh air. Neither should the air be warmed. The depth of respiration is stimulated by the cold. All the cold treatments given in the hydriatic management of pneu- monia increase the depth of respiration and so enable the body to make use of the oxygen supplied by the fresh air. This is true of the cold compress, the heating compress, the ice pack and cold rubs and frictions. If it is not possible, because of the season, to obtain very cold air, much might be saved in the mortality by providing means of refrigerating the air supplied to the patient. The air may be supplied through a hood fitted into the open- ing made by raising the lower sash of any ordinary window. The other end of the hood should fit down over the head of the patient and can be tucked in about the pillow, coming no lower than just under the chin. This may be arranged with glass windows so as to obviate the necessity of removing the hood for observation of the patient, etc. Those who have lived in the Arctic regions, Labrador and other very cold climates, tell us that pneumonia and tuberculosis are rare diseases there and in some places almost unknown. Relative to the beneficial effects of fresh air in febrile diseases, the fol- lowing is related of Dr. Alonzo Clarke: "It is interesting to read how he managed typus fever in Bellevue Hospi- tal. There were 250 cases constantly under his care, and as many more under the care of his colleagues. The mortality was great. Precautions against the draughts of air, for fear of pneumonia, were carefully adopted. Dr. Clarke, not having this dread, ordered that there should be the freest ventilation, with scrupulous cleanliness. Although it was winter, the win- dows were removed, stoves were placed before the open spaces to raise the temperature of the incoming air, clothing was increased, stimulants were given in moderate quantities, and other medicine mostly dispensed with. Of the 250 cases not a death occurred in the period of a fortnight. In two weeks they were convalescent. In other wards of the hospital where the management was unchanged, the mortality was undiminished. " The sustaining of the heart and circulation is best accomplished by judi- cious hydrotherapy. Romberg and Passler have shown that the toxic albu- minoid produced by the pneumococcus paralyzes the vasomotor center in the medulla, and Passler regards this as the most common cause of death in pneumonia as far as the circulation is concerned. Vasomotor tonics are as essential in pneumonia as in other febrile diseases and the effect of hydro- therapy as a vasomotor stimulant is its most important asset in this disease. Hand in hand with this effect goes stimulation of respiration and of the heart itself. The cold compress to the chest is applicable in all cases. An ordi- nary linen towel or hand towel may be used for this purpose, two or three thicknesses of cloth usually being sufficient. It should be wrung from ice water and applied to the front and sides of the chest and covered with a flannel cloth. If desired to greatly stimulate respiration and the heart action, it should be frequently renewed. In ordinary cases, it may be left on fifteen, twenty or thirty minutes at a time. While the patient is sleep- ing or when it is desired to give rest, the compress should be left on an hour or two. It then becomes a heating compress. The square or roller chest pack is an excellent means of applying the 142 THE TREATMENT OF INFLAMMATIONS principles of the heating compress. It has the advantage of the heating compress in that a greater area is treated and undue circulation of the air about the wet cloth more perfectly prevented. It should be left in place two or three hours, or may be put on and left over night, unless necessary to give other treatments. In case of strong, vigorous men, it is possible to use with benefit the ice pack to the chest. The ice may be supplied by means of several ice bags adjusted to cover the skin surface over the affected lobe, or it may be made by placing cracked ice in a Turkish towel and covering the whole with oiled silk or gossamer cloth so as to prevent wetting the clothing and bedding. These packs may be left in place almost continuously, applying every thirty min- utes or every hour one or two short fomentations; and every three or four hours, replacing the pack by the heating compress, allowing the latter to remain thirty minutes or an hour. The ice pack should not be used where the patient is inclined to be chilly, or with thin patients and those of low vitality. Whenever it is used, the limbs should be kept warm by the use of hot water bottles. It is well also to give a hot foot bath or leg pack at intervals of five or six hours. The cold mitten friction and the cold towel rub are invaluable in aiding the circulation and sustaining the heart. It may be necessary where there is cold clammy perspiration, chilliness or cyanosis, to precede the cold treat- ment by short fomentations applied to the limb or part just previous to the cold mitten friction. If the heart is very much embarrassed, it may be greatly relieved and the patient tided over a crisis by the use of short hot applications as just mentioned, and immediately succeeded by the cold mitten friction given until the skin is red and reaction complete. The part should then be very rapidily dried with a rough towel. Dry friction and percussion should follow in order to secure thorough reaction. There are two princi- ples involved in this method, first, the stimulation of the peripheral circula- tion so as to relieve the heart of its added burden; and second, because of the tonic dilatation of the surface vessels, there is produced a very decided and lasting derivation, so that the extreme engorgement of the heart and lungs is relieved. A warm bath at 98 or 100 gradually cooled to 90 is highly recommended by some. The effect of this treatment may be very much increased by allow- ing the patient to remain just long enough to secure a thorough warming, cold applications to the head and heart being kept in place during this time. The patient then sits up while he receives to the chest, shoulders and back two to four affusions of water at 90. This stimulates respiration and increases the efficiency of expectoration. Some have very highly recommended the Brand bath in lobar pneumonia. We can see no advantage in this measure over the others mentioned and can readily understand that in many cases it might prove dangerous, as the heart and lungs are unable to withstand the retrostasis occasioned by the initial anemia of the skin, which follows contact with the cold water. In general, it may be said that full tub baths are not applicable in pneumonia. Pain. The pain in pneumonia is due chiefly to the accompanying pleurisy. The inflammation is largely on the side of the visceral layer and so does not PNEUMONIA 143 counterindicate the use of cold applications. Pain is perhaps best relieved by the use of hot fomentations. These should be large enough to cover an entire side of the chest and are more efficient when applied from spine to sternum with the patient lying on the opposite side. The chest pack or heating compress should follow the hot treatment. Cough and Expectoration. All of the treatments recommended above are beneficial in aiding the expulsion of mucus. A severe cough may be relieved by the use of fomentations and the heating compress. Inhalations of steam are also beneficial. The revulsive compress is perhaps the most efficient means in stimulating expectoration. A large fomentation is first applied; as soon as the heat begins to subside, it should be replaced by a towel wrung from ice water. This should be left on until it has become slightly heated, perhaps 1 to 3 minutes. The part should be dried and the second fomenta- tion applied. Three or four changes are usually sufficient to accomplish the desired result. A revulsive compress also stimulates the heart and increases the depth of respiration and the consequent aeration of the blood. The patient should drink large quantities of water by taking it frequently in small amounts. This increases diuresis and the elimination of toxines. Either hot or cold water may be used according to indications. The bowels should be kept open by salines and enemata as needed. A very light diet low in proteid also aids in limiting the toxemia. Medicinal Treatment Quinin. So much has recently been written concerning the use of large doses of quinin in the treatment of pneumonia that no discussion of this dis- ease would be complete without reference to its effects. "It has been suggested that its efficiency in fever is due to an antiseptic action on the blood. This is not the case, since bacteria are very resistant to it and would not be affected by it in the concentration in which it could exist in the blood." l It does certainly reduce the temperature as we have previously noted, but this is not of prime importance in pneumonia. Anti- pyresis is of secondary importance, nor do patients bear great abstraction of heat, as is the case in typhoid fever. The temperature is lowered at the expense of the heart's action and oxygen-carrying capacity of the red blood cells. Both of these, it is necessary to sustain and enhance in pneumonia. Quinin limits leucocytosis and checks phagocytosis. If 20 to 30 grains are given daily, the disease is likely to run an atypical course, there being no frank crisis, which is replaced by very much delayed resolution, the fever declining by lysis. Moist rales may be heard in the chest long after resolution should be com- plete. One area will hardly more than clear up before another area is in- volved, so that by delayed resolution and re-involvement of another area, the pathology assumes a sort of migratory type. Probably the reason for the failure in the appearance of the crisis is due to the fact that the sthenic condition has been reduced to an asthenia, the system lacking sufficient vi- tality to produce a normal crisis. Anyone who will take the trouble to "read up" on the effects of quinin will soon be convinced of its harjnful- 1 Sollmann Text Book of Pharmacology, p. 350. 144 THE TREATMENT OF INFLAMMATIONS ness in pneumonia. The caution sounded by Dr. W. C. Alvarez in a recent letter published in the Journal of the American Medical Association is cer- tainly timely. 2 In a personal communication received from Dr. Alvarez, he states that among the many letters he received after the publishing of this communication to the Journal, one came from a fellow practitioner who was much in favor of the quinin treatment, but had recently had, among a small series, seven bad cases of empyema. On the ordinary expectant plan, it should take 200 to 400 cases of pneumonia to furnish seven of em- pyema. The white blood cells were paralyzed by the quinin and so easily succumbed to the infection. Too much can not be said condemnatory of the quinin treatment of pneumonia. . Strychnin. This drug has been very much vaunted as a specific in meet- ing cardiac incompetency in pneumonia. Much to the discredit of the pro- fession generally, a plan frequently followed is that of giving 1-60 grain of strychnin every 3 hours, this being kept up during the greater part of the illness. As some one has said, "continual doping with strychnin to the heart is like kicking a dying horse when he is down." As we have already shown, the results hoped from strychnin are best attained by proper hydriatic means. Frank Billings 3 says, "Strychnin and other drugs that are commonly used in failing left heart are absolutely valueless except to stimulate nerve cen- ters: strychnin will not raise the blood pressure 1 mm. I have used it over and over again. . . . Finally, the watchful and vigilant care of patients afflicted with pneumonia without the use of drugs is the ideal treatment." Relative to the routine use of digitalis in pneumonia F. Forchheimer 4 relates his experience following the use of large doses as advised by Petresco of Bucharest. He says the "mortality was greater than before. All the evil effects that can be produced by digitalis were noted, and after three days of administration of the remedy such cumulative effects were pro- duced as I shall hope never to see again." Alcotiol. When we stop to think of it, it must seem strange to any sane man to suppose that a drug which increases the liability to pneumonia and greatly increases its mortality should ever be recommended as a therapeutic agent in that disease. Yet that such has been done is evidenced by the num- erous articles which, a few years ago, appeared in many medical journals, recommending whiskey and brandy as a routine treatment of pneumonia. It is supposed that by dilating the peripheral vessels, it aids in decreasing the congestion of the lungs. This might be the case, did not alcohol act upon all the small blood vessels, those of the lungs included. Neither is alcohol a cardiac stimulant as has more recently been shown by numerous reliable experiments. Experiments by Martin and Stevens, conducted in the Biolog- ical Laboratory of the John Hopkins University, show that blood containing J of 1 per cent of alcohol diminished within a single minute the work done by the heart and that in certain animals experimented on, blood containing | to 1 per cent of alcohol so seriously affected its working powers that it was scarcely able to drive a sufficient amount of blood to supply its own 2 Journal of American Medical Association, June 13, 1908, p. 1996. 3 Ibid., October 30, 1909, p. 1453. 4 Ibid. p. 1450. BRONCHOPNEUMONIA U5 nutrient arteries. Doctor Monroe of Glasgow Royal Infirmary says, "It has yet to be proved that the heart muscle can be stimulated by alcohol." In a paper by E. Lewis Backman -before the Anti-Alcohol Congress at Stockholm, it was shown that when a solution containing from .0025 per cent to .5 per cent were passed through the vessels of the isolated heart, in the case of the rabbit, that if the amount were sufficiently large to produce any noticeable effect, there was manifest temporary irregularity and dimi- nution of the strength of the contraction, or a lasting arrythmia, and a considerable reduction in the volume and the number of the pulsations. Alcohol also limits or annihilates phagocytic action. John H. Musser 5 gives the following summary concerning the treatment of pneumonia: "In the majority of the cases I prefer to rely on fresh air, on judicious local treatment, on hydrotherapeutics, on regulation of the proper amount of food taken, and particularly on care that the patient is not overfed. I watch carefully for the phenomena so well pictured by Doctor Forchheimer, guarding against the possibility of the vaso- motor syndrome by proper renal elimination. Attention to proper elim- ination is of the greatest importance in the management of the cases of pneumonia, looking toward the prevention of cardiac failure; in other words, looking toward the reduction of serious toxic symptoms that arise and have expression more particularly in the phenomena just pointed out. To keep down the amount of food is of the greatest importance in the management of pneumonia patients. Watch carefully the state of the intestinal tract. Tympany is a serious toxic symptom in pneumonia and its increase with defective elimination is a point that I depend on as suggestive of the occur- rance of vasomotor failure. This can be prevented very largely. Colitis occurs with the pneumococcus infection, and this colitis is undoubtedly the cause of the development of tympanites; the colitis plus the toxemia invites an intestinal paresis. Hence to prevent this colitis which gives rise to the tympany, it is well to observe carefully the diet, regulating judiciously the amount and kind of food taken, and washing out the bowels with normal salt solution." Bronchopneumonia Under two years of age, lobar pneumonia is seldom ever seen. From this up to seven, either type may be found. After that age, lobar pneumo- nia is the prevailing form. In many ways, the treatment of bronchopneu- monia is conducted on the same principles as that for the lobar type. The first two indications, i. e., increase aeration of the blood and sustain the heart and circulation, are the most important. Bronchopneumonia is nothing more nor less than an extension downward of the inflammation of a bronchitis. It is a capillary bronchitis or lobular pneumonia. In order to accomplish the first result, the proper aeration of the blood, it is very necessary to increase the facility and the amount of expectoration, so that the lungs may be free for proper respiration. The child may be placed in a bath at 100 and, while sitting, receive to the chest and shoulders cold affus- ions at 75 to 90, depending upon the age and vitality. With infants, the wet sheet pack is perhaps the most efficient means. The pack may be 5 Ibid., p. 1453. 146 THE TREATMENT OF INFLAMMATIONS wrung from tepid, cool or cold water and spread out on a blanket. The child is then placed on the -wet sheet which is wrapped snugly about the body, the blanket being folded over. all. The child should remain in the pack to the sweating stage. At first, there is gasping respiration and the child cries. This aids in the expulsion of mucus. As the pack heats up, the respiration becomes deeper, easier and the expectoration much less diffi- cult. Fever may drop one or two degrees and the child pass into a quiet sleep. If this occurs, the child should be kept warm, being left in the pack until it awakes. It may then be taken out with a wet hand rub, or this may be done sooner if the child does not sleep. The moist chest pack and heat- ing compress to the chest are also efficient means of sustaining the heart and increasing the depth of respiration. If there is much cyanosis, espec- ially if accompanied by chilliness, it is best to place the child in a full warm bath; or, if the pack is used, it may be wrung from warm water or hot water. In case of the bath, after the skin has become well warmed, the child may receive an affusion to the chest or to the entire body just as it is taken from the bath. In case of the pack, after the child is well warmed, it may be taken out with a wet hand rub. Infants do not react well to either extreme heat or cold. Fortunately, however, they respond to milder temperatures in as decided a manner as adults do to greater extremes. Pleurisy There are several forms of pleurisy. Only the treatment of the dry and serous forms will be considered, since empyema of the pleura is a surgical disease. In the pleurisy usually accompanying pneumonia, the inflamma- tion is largely on the side of the visceral layer. In ordinary pleurisy, how- ever, the inflammation involves chiefly the parietal layer of the pleura. The blood supply of the two layers is quite different. That of the visceral layer is of course from the same blood vessels as the lung itself, while the parietal layer is supplied by the blood vessels from the intercostal arteries and with nerves from the anterior division of the intercostal. It has been shown that the severe, acute pain in both peritonitis and pleurisy originate in the parietal layer of these membranes. With these facts in mind, it will be seen that the circulation and consequently the congestion of the visceral layer will be most readily influenced reflexly; while with the parietal layer, the circulation and congestion are influenced to a greater extent by hydro- static means, since the blood vessels are connected directly with those of the superficial structures. For these reasons, while cold decreases reflexly the congestion in the lungs, it increases the congestion of pleurisy. In acute pleurisy, cold appli- cations greatly increase the pain and, if used persistently, may so prolong the inflammation that weeks or months are required for its entire relief. On the first indications of pleurisy, the patient should be given a hot foot bath for the purpose of warming the feet and providing for thorough reac- tion to any other treatment that may be given. This also aids sweating which helps to relieve internal congestion. That which is of the most impor- tance is the use of very hot fomentations applied over the affected area. These should be made of thick, heavy flannel, wrung from boiling water PERICARDITIS 147 and wrapped in one thickness of dry flannel. No cold should be applied between fomentations. From three to five may be necessary in order to completely relieve the pain. If one side only is affected, these fomentations should be applied/rom spine to sternum and not simply to the chest anteriorly. Given in this manner, the hot application dilates the posterior, lateral and anterior cutaneous branches of the intercostal arteries, thus withdrawing the blood from the congested and inflamed pleura. The fomentations to the chest should be followed by a heating chest pack. The partial pack, so arranged that the moist gauze or linen covers only the ^affected area, is better than the full pack. In the case of thin persons or those of low vitality, it is best to use the dry chest pack. In case the moist chest pack is used, it may be neces- sary to apply a hot water bottle over the area outside of the pack in order to warm it more promptly. After two or three treatments in which fomentations alone are used, with possibly a cold compress after the last one of each series, the revul- sive compress should be used, the cold compress being allowed to remain until thoroughly warm before the second fomentation is applied. Later, alternate hot and cold by means of fomentations and a cake of ice may be used; and when the patient is convalescing, the alternate hot and cold spray douche to the back, front and sides of the chest gives excellent results. Percussion or force should not be used in this treatment since the vibration occasioned by it tends to increase the effusion. Neither should any massage or percussion be given to the chest in concluding a treatment. Even the vibration of a vehicle, such as a street car, may cause the return of a pleurisy which has nearly recovered, and the temperature rise two degrees or more in a single hour. If this treatment is used from the beginning, that is fomentations and later the revulsive compress and hot and cold, tapping for excessive effu- sions will be less frequently necessary. The ice bag to the chest should not be used in any stage of pleurisy. The alternate hot and cold douche to the feet, or the alternate hot and cold foot bath should replace the hot foot bath while the patient is convalescing. This helps to steady the circulation and render exposure to cold much less dangerous. Pericarditis The conditions in pericarditis, while very similar to those in pleurisy, must be treated upon somewhat different principles, because of differing anatomi- cal relations. While the lung may, to a certain extent, be immobilized or restricted in amplitude of movement, this is impossible in the case of the heart. All that can be hoped in this line is to decrease the frequency of its beat. This is admirably accomplished by the use of the ice bag over the heart and especially by the frequent use of the cold mitten friction. The latter is perhaps the more rational measure since by its stimulation of the peripheral vessels, it relieves the heart of its excessive burden. The circu- lation of the parietal layer of the pericardium is more or less connected with the surface blood vessels, so that the inflammation may be reduced in the same manner as with pleurisy. Since fomentations over the heart increase 148 THE TREATMENT OF INFLAMMATIONS its rate and decrease its force through reflex action, it is not possible to apply them as we do in pleurisy. The best results may be obtained by the use of the ice bag applied directly over the heart, while a very large fomen- tation is so arranged as to cover it and a much larger area around the heart. The heat produces derivation, while the ice bag slows the heart rate. Three of these fomentations may be given at one time and the treatment followed by the heating compress; or the ice bag may be left on between treatments, being removed frequently enough to preserve the reflex excitability of the nerves. During the course of pericarditis, the cold mitten friction should be used one to three times a day, depending upon the degree of the heart embarrassment. In the later stages, the revulsive compress to the entire front of the chest should be used to promote absorption. Other treatments that are of advantage are the hot and cold foot bath after the first few days, also hot and cold to the spine and cold towel rub. It is not necessary to do para- centesis unless, by accumulation of fluid, the heart is seriously interfered with. Myocarditis This is very frequently met with in diphtheria. Since the introduction of antitoxine it is, of course, less frequent and less serious. Myocardial degen- eration and consequent asthenia are due to the diphtheria toxine. It may not become apparent until convalescence. That which is of most impor- tance is absolute rest. The ice bag to the precordia should be kept in place a good deal of the time. This slows the heart rate and increases its force without overstraining the cardiac muscle. The cold mitten friction decreases the work required of the heart itself. Both the cold mitten friction and the ice bag decrease the heart rate and increase its force. Digitalis and strych- nin are exceedingly dangerous in this condition and should never be used, since by extreme stimulation, they compel the heart to overexert itself. Great depression results from their use. Rheumatic Fever An acute, infectious disease, primarily an inflammation of the synovial membranes and periarticular tissues, with a special tendency to involvement of other serous membranes, the endocardium, pericardium, pleura and some- times the meninges. A more severe infection may be complicated by myo- carditis. In ordinary cases, the fever is moderate, 102.5 to 103.5, but it may be very high. Indications of first importance are (1) reduction and control of the inflam- matory process in the joints; (2) prevention and treatment of complications, chiefly endocarditis; (3) relief of the pain. Formerly synovitis was met principally by hot applications, heating compresses, counter irritation com- bined with anodyne mixtures for the relief of pain. The local applications which have proven helpful are fomentations, the dry pack or heating pack to the joint and the local electric light. They should be continued until a decided hyperemia of the skin is produced. After rubbing the part with oil of wintergreen a local heating pack may be applied and allowed to remain until the next treatment. The pain in the joints is greatly relieved by RHEUMATIC FEVER 149 these measures. The internal administration of the natural oil of winter- green in 20 minim doses every two hours also adds to the comfort of the patient and seems to shorten the course of the inflammation. We have never seen any harmful results from its use. Hot applications frequently fail to produce the best results. Where con- tinuous cold to the joints has been tried, in some cases it has been found to give better results than hot applications. The joint should be well covered with a thick flannel cloth, outside of which should be packed cracked ice or snow. This should be left in place until the part becomes almost numb, care being taken that actual freezing does not occur. At the same time, the warmth of the body should be sustained by hot water bottles, the foot bath, or fomentations to other parts. When the pack has been in place a sufficient length of time to do away with tenderness, it may be removed and and the skin rubbed thoroughly with the dry hand or snow until it is red. The ice pack should then be replaced. The rubbing -must be repeated at intervals to promote reaction and prevent freezing. If thought necessary, this opportunity may be taken to mobilize the joint. Two or three joints may be treated in this manner at the same time. When these extreme cold applications are used, the inflammation seems to run a much shorter course. Where moderate movement of the patient is not objectionable, the use of alternate extreme hot and cold immersion to the hands and wrists or feet and ankles is one of the best measures for controlling the pain and inflam- mation in these joints. The patient's general vitality should be sustained by cold mitten frictions, hot and cold to the spine, and the heart steadied by the use of the ice bag and cold mitten friction. Fomentations to the chest may be used every four or five hours, or of tener if necessary, in order to renew the reflex activ- ity where the ice bag is used for a considerable length of time. Free water drinking should be encouraged. An actual sweating treatment is beneficial and may be employed daily or two or three times a week. Both of these measures favor elimination of toxines. If this plan of treatment is thor- oughly carried out, endocarditis is less likely to occur. Endocarditis. Should the valvular endocardium become involved, it is necessary to keep the patient at perfect rest, both during the course of the fever and fora considerable time after. The ice bag to the heart should be used intermittently, that is, being put on for ten or fifteen minutes and left off for ten minutes, or even allowing it to remain in place for a longer time, depending upon the results produced. Buxbaum 6 and Laqueur " recommend the use of the cold coil to the precordia two or three times daily for a half hour to an hour, or even longer at a time. Cold mitten frictions should be given from one to three times daily, hot foot baths being used as frequently as necessary. It is needless to say that the heart should be examined daily, the findings being compared with the clinical manifestations. After the fever has subsided, the patient must be carefully guarded from all exposure to cold and damp. He should return to an active condition very gradually, rest in bed being kept up until the pulse 6 Lehrbuch der Hydrotherapie, 1903, p. 234, 7 Die Praxis der Hydrotherapie, 1910, p. 143. 150 rate is nearly normal. The wheel chair may be used from this point, but before further advancement may be made, the pulse rate must again return to normal. The patient may then be allowed to lounge about, being dressed and around the room part of the time. Walking should not be allowed if the pulse rises above 90. During all this time, such tonic measures as hot ' and cold to the spine, the cold mitten friction and cold towel rub should be used. After the subsidence of the fever, gentle massage may be permitted. The resistant movements of the Schott method, and the effervescent bath should not be given until well into convalescence; that is, after the fever has been normal for a month or two. From this on, the treatment is essen- tially that of chronic endocarditis (q. v.). Meningitis In acute cerebro-spinal meningitis, there is a purulent exudate covering the convex dorsal surfaces of the brain between the dura mater and the leptomeninges filling the meshes of the arachnoid and extending downward along the cord. The meninges of the brain are intensely congested. The intracranial pressure is increased. Quincke's lumbar puncture should be used for diagnosis and treatment. The most important treatment is the use of Flexner's serum, which has given 75 per cent of recoveries in 400 cases. The most commonly employed hydrotherapeutic applications are the ice cap and spinal ice bag applied continuously, or with but little interruption. The spinal ice bag should be filled with finely pounded ice and placed along the cervical and upper dorsal spine. Another smaller ice bag should be placed crosswise of the neck at the base of the brain. The ice cap or helmet should cover as large an area as possible of the convex surface and sides of the cranium. These applications, though extensive and extreme, do not usually cause chilling. It will be found helpful to apply heat to the extremities at intervals. The hot foot bath, hot leg pack, or large fomen- tations to the limbs and abdomen, may be used. They assist the action of the ice bags in reducing cerebral congestion. The ice bags and ice cap may conveniently be replaced by cold coils through which ice water is flowing. Rohrer reports a number of cases in which cold affusions to the head and neck were of great service in relieving or mitigating the severity of cere- bral symptoms and bringing about a successful termination. He also advises the cold affusion for the relief of cerebral symptoms, whether delir- ium or coma, accompanying infectious diseases such as pneumonia, acute meningitis and in sunstroke, neoplasms and tubercular meningitis. When made very cold and much prolonged, they are decidedly antipyretic. The tonic spasms, opisthotonos, and muscular rigidity are best met by the use of the full warm bath given at a temperature of 98 to 102 F. These rnay be continued from ten or fifteen minutes to an hour, according to the needs of the cases. The restlessness, delirium and headache are often entirely relieved. The rigidity of the spine and abdominal muscles is favor- ably influenced. We have seen coma give way to a fairly clear sensorium, following the bath. Where the temperature of the patient is above 102, the ice bag should be kept at the base of the brain and a cold compress to the head during the bath. This is especially necessary in the epidemic form APPENDICITIS 151 of cerebro-spinal meningitis. In tuberculous meningitis it may not be needed. Aufrecht, Waroschilsky, Wollisch, Netter and others report favor- able results from the full warm bath. Rogansky reports among 51 cases in women where the warm bath was used, a mortality of 33 per cent; and among 50 cases where the bath was not used, a mortality of 80 per cent. The warm bath acts as a relaxing and sedative agent. It also aids in deplet- ing the cerebral and spinal circulation and serves as a tonic to the circula- tory system. Excitant and stimulating measures should be avoided. Biliary Inflammations Cholecystitis, Cholangitis, Catarrhal Jaundice, Subacute Pancreatitis Inflammatory states in these ducts and organs are quite likely to be fol- lowed by conditions that require operative interference; but if taken early, the milder inflammations subside under proper treatment. In cases of sub- acute pancreatitis and catarrhal inflammation of the gall bladder and ducts, we have found the following method successful: Once or twice daily there should be given a treatment consisting of a hot footbath with fomentations to the abdomen and concluded by the cold mitten friction. The hot foot bath and fomentations produce effectual derivation, while the latter application relieves the pain and relaxes the musculature of the ducts and the gall bladder. The cold mitten friction is given for tonic purposes, to increase leucocytosis and combat infection. Fomentations and hot and cold to the spine are useful for sedative and tonic purposes. As the patient improves, the revulsive compress to the abdomen may be used, also the graduated shower, hot and cold spray and the alternate douche. Once a week a short electric light hath shouW be given. From the beginning of the inflammation, the patient should wear some form of heating compress to the abdomen. This is most conveniently ap- plied by means of the moist abdominal girdle. Continuous cold appli- cations to the abdomen should not be used in these conditions. In case of empyema of the gall bladder, should the patient refuse operation or a brief delay seem advisable, the same plan should be followed. It is impossible to use the ice bag in such a condition, since it tends to cause firm contraction of the muscular coat and might occasion rupture of the gall bladder. In fact it is a principle which should be quite generally followed that inflam- mations of the hollow viscera are best treated by hot applications. This is also true of the urinary bladder. The spasm of the muscles occasioned by the inflammation is relaxed and the congestion decreased. Catarrhal jaundice in about 60 per cent of cases is now considered to be due to the induration in the head of the pancreas occasioned by a subacute inflam- mation. Outside of the dietetic treatment of this condition and the special necessity for free bowel movement, it should be treated on the same general principles. Appendicitis As we have previously remarked, this is a surgical disease and should be surgically treated in practically all cases. Hydrotherapy produces such 152 THE TREATMENT OF INFLAMMATIONS marvelous results in the relief of pain and, in many cases, safe conduct to the interval that it might almost seem to be a specific. This temporary relief, however, can not be depended upon for permanent cure. Should it seem advisable to delay operation to the interval or, in case the patient refuses operation, hydrotherapy offers the best chances for immediate recovery. The patient should be given a hot hip and leg pack with an ice bag inserted under the edge of the blanket just over the appendix. By means of the combined effect of the hot, in drawing the blood from the inflamed part, and the ice bag, in causing contraction of the vessels reflexly, the most effectual derivation is secured. The pain is almost instantly relieved in those cases in which the inflammation has not produced rupture of the appendix. After twenty or thirty minutes in the pack, it should be removed and a vigorous cold mitten friction be given to all parts included by it, except the abdomen. This serves to fix the blood in the skin and so make derivation more per- manent. Following this treatment, the heating compress may be applied to the lower abdomen. The hip and leg pack with ice bag should be repeated as often as necessary to relieve the pain and make the patient comfortable. It is perhaps needless to say that the treatment should be preceded by a thorough enema. Cathartics should be avoided. A very large fomentation with an ice bag under the center over the appendix may be substituted for the pack. After the temperature has become normal and the acute tender- ness has subsided, the patient should be given general tonic treatments, always avoiding extreme measures to the abdomen or about the appendix, since excitation of peristalsis may cause return of the inflammation, or rup- ture of the appendix. In chronic appendicitis the fomentation to the abdomen is best calculated to relieve the pain and tenderness. Where pos- sible, these cases should be operated in the interval. Pelvic Inflammations ' Acute Endometritis from Puerperal Sepsis, Salpingitis, Ovaritis, Pelvic ( Vllulilis and Peritonitis It is necessary to differentiate between these conditions, although hydri- atic treatment is carried out along much the same line in all. IH the case of retained secundines following labor or abortion, it is imperative to per- form curettage as early as possible. In the case of simple salpingitis, opera- ation should not be done at all. Should the inflammation go on to the for- mation of a pyosalpinx, operation should be delayed until the temperature is normal and the acute inflammation has subsided. In pelvic cellulitis opera- tion is unnecessary and dangerous. Should abscess formation occur, either in the cellular tissue or in the peritoneal cavity, drainage should be provided. With these different conditions in mind and the possible outcome of each, the inflammation should be treated in the same manner as that outlined for appendicitis. The patient may be given the hot leg pack or hip and leg pack, with the ice bag applied to the groin, suprapubic region or other part nearest the inflamed organ. This should be continued twenty to thirty min- utes and concluded with the cold mitten friction. The heating compress MUCOUS COLITIS 153 may be applied or, if it seems wise, in some cases the ice bag may be left in place. In other cases, fomentations to the lower abdomen may be given every two hours. The hip and leg pack with the ice bag, followed by the cold mitten friction, should be repeated two or three times daily according to the necessities of the case. It is well, in nearly all of these inflamma- tions, to precede the pack by very hot vaginal irrigation. As the acuteness of the inflammation subsides, the revulsive compress and other alternate hot and cold applications may be used. Perhaps the most effectual means of treating chronic pelvic inflammations is found in the sitz bath. When it is considered safe to allow the patient to begin to walk, the hot sitz or revulsive sitz may be used. The temperature of the bath should be grad- ually lowered until the patient is taking a hot sitz followed by a brief appli- cation of cold or very cold water. The hot half bath is an effectual means of applying the principles of the sitz bath. In some cases, it is to be pre- ferred. The body is less cramped and both the limbs and hips are entirely immersed in the water. At the conclusion, the patient should receive a cold pail pour to the hips. It is not necessary to use the extreme, or pro- longed cold sitz in the conditions mentioned above. In place of this, the patient should be given alternate douches to the sacrum, feet and legs. Other tonic measures should form part of the course of treatment. The cold rubbing sitz is beneficial in delayed resolution. Hot vaginal irrigation or alternate hot and cold irrigation should be used until resolution is com- plete. Phlebitis During the early stages of phlebitis, the cold compress or ice bag should be used over the femoral vein. At the same time, the limb must be ele- vated and kept warm. All massage movements are strictly counter-indicated in this condition. After the first day or so, fomentations should be used frequently, the ice bag or cold compress being left in place between fomen- tations. While the patient is recovering, that is, after the temperature becomes normal and all signs of acute inflammation have subsided, the revulsive compress may be used. The edema should be treated by eleva- tion and such alternate hot and cold measures as the revulsive compress, hot and cold foot or leg bath and the alternate pour. When there is no longer danger from embolism, massage may be used, avoiding, however, the vein itself. Later on, when there remains only the stasis and edema, the most vigorous hot and cold measures such as the alternate douche, are bene- ficial. Mucous Colitis The first object to be accomplished in the treatment of mucous colitis is the removal of the mucous cast covering the mucous membrane. The thorough removal of this coating will be accompanied by more or less pain, since it leaves a raw, unprotected surface. That which most effectually removes the coating is some form of treatment which will produce a vigor- ous exosmosis. This may be accomplished by the hypertonic saline enema, or the honey enema. In preparing the saline enema, about double the 154 THE TREATMENT OF INFLAMMATIONS amount of salt should be added as in preparing a physiologic salt solution, or to each pint of saline solution there may be added a quarter of a tea- spoonful of Epsom salts. This tends to draw water from the tissues because of the concentration of the solution. Before using the salt solution, the bowel should be thoroughly cleansed, if necessary by both low and high ene- mata; after which the salt solution is introduced by means of the high bowel catheter, or by the ordinary enema given in the knee-chest position. A pint or even a quart of the solution may be used at one time. It should be retained as long as possible, 20 to 30 minutes is sufficient. Owing to the cathartic action, it can not be retained long. It usually brings away with it considerable of the tenacious mucus, often in cast form. The pain and tenderness occasioned by the enema may be relieved by fomentations to the abdomen, and the weakness induced by such drastic measures somewhat relieved by the cold mitten friction. The enema should be repeated about three times a week and continued until there is little or no mucus brought away with the passage of the salt solution. The molasses or molasses and soap suds enema may be substituted for the concentrate salt solution. If given, it is necessary to warm it slightly so that it may pass readily through the colon tube. From 3 to 6 weeks of such treatment may be necessary in order to thoroughly rid the bowel of the mucus coating. After this, the enemata should be entirely discontinued, the patient being given general tonic treatment, including fomentations to the abdomen. The following plan will be found helpful: In the morning a treatment consisting of a hot foot bath, fomentations to the abdomen and a cold mitten friction. The revulsive compress to the abdomen may also be used. In the afternoon, hot and cold to the spine followed by a cold towel rub or general massage, avoiding the abdomen. The patient rapidly regains the weight and strength lost during the first part of the treatment and after a few weeks there is usually no more mucus discharged by the bowel. Cystitis In the acute stage only hot treatment is permissible. These may be given by means of a hot hip pack, fomentations to the lower abdomen and pelvis, or the hot sitz or revulsive sitz. Neither the ice bag nor cold compress should be used. Both of these measures cause contraction of the bladder muscles and so increase the pain arising from the inflamed mucous mem- brane. The hot applications tend to relax the musculature and draw blood from the organ to the surface. The patient should drink freely of water in order to dilute the urine, thus lessening its irritating qualities. Regulation of the diet is fully as important as these measures. In the chronic stage more cold treatment may be used, such as the revul- sive sitz, graduated sitz, hot and cold perineal spray, hot and cold rectal irrigation, and the alternate spray douche to the pelvis. These alternate applications may, at first, occasion some vesical spasm, but if persisted in, tend to relieve the stagnant circulation. The hot saline enema and continu- ous hot rectal irrigation also produce good results. Bladder irrigation with hot physiologic salt solution or some mild antiseptic as boric acid or potas- SPECIFIC URETHRITIS 155 sium permanganate should be done once daily, rarely oftener. This plan of treatment is especially beneficial in those long standing cases in which the capacity of the organ is very much reduced and the walls have become greatly thickened and indurated. Specific Urethritis, Vaginitis, or Prostatitis In the acute stage, in addition to the local medication, the ice bag should be used almost continuously. The Leiter coil is an excellent means of con- tinuous cooling. Some form of internal cooler may be used. The hollow prostatic cooler whk-h is applied to the prostate through the rectum is use- ful in decreasing acute inflammations of that organ. Desnos recommends very hot (120 F.) rectal irrigation in the acute stages, forbidding it in the chronic stage. We would reverse this rule, using cold in the acute stage and vigorous hot and cold in the chronic stage. As these conditions progress toward the chronic stage, short hot applications should be used, alternating with the cold, and after the acute inflammation has subsided, the most vigor- ous hot and cold measures are necessary. That which is most serviceable is the alternate hot and cold perinea! spray. Chronic cases which have resisted all sorts of medication very readily respond to this measure. It greatly increases the circulation and stimulates local leucocytosis, both of which are necessary in order to combat the infection which frequently becomes cryptic in this stage and so is beyond the reach of topical medica- tion. The graduated sitz or even the cold sitz may also be used. In chronic prostatitis alternate hot and cold rectal irrigation produces astonishingly good results. CHAPTER XX STIMULANTS AND TONICS There is a decided difference in the physiologic effects of a stimulant and a tonic. The idea that stimulants are necessary for tonic purposes has lead to great confusion in the proper understanding of these terms. While ton- ics have a wide range of applicability, the necessity for stimulants is much more limited. We quote the following from Sir William Broadbent as giv- ing the best idea of the effects produced by stimulants: "A falsehood which dies hard is the idea that stimulants of whatever kind actually give strength and are necessary for the maintenance of health and vigor. Such is not the case and the well-worn comparison that they are the whip and spur, and not the corn and grass is strictly accurate. Anything accomplished under the influence of stimulants is done at the expense of blood and tissue and, if frequently repeated, at the expense of the constitution." On the other hand, a tonic tends to restore the body to such a condition that it is better able to perform its usual functions. It not only "stimu- lates" and hastens the normal expenditure of energy, but it also increases the vital capacity of the body for work. This it does by its action in aug- menting the processes of anabolism. It will be seen from this that the whip can not be a tonic since it in no way tends to restore an organ to its normal condition nor does it so shape circumstances that the tissues of the organ are built up. For this reason strychnin should be considered a stim- ulant, and a stimulant only. All tonic measures are physiologic in their nature, while stimulants may or may not be classed as natural means. Medi- cinal stimulants produce an unnatural condition which in no way tends to restore to the normal. On the contrary, while physiologic stimulants may excite an unusual expenditure of energy, greater in this direction than in the building up of the vitality, yet they do not have the bad after effects constantly observed following the use of such stimulants as strychnin. In the consideration of physiologic means, we may properly divide measures which enhance vital activity into two classes, those which are largely or wholly excitant and stimulating, and those which are chiefly tonic in their effects. Hydriatic Measures Chiefly Tonic in Nature Tonic effects are derived principally from cold applications. The reaction to vigorous cold measures has been shown to increase muscular capacity, quicken the circulation, enhance nerve activity, etc. In this sense, tonic effects may be considered to be a secondary result or reaction from the primary stimulation. Tonic effects may also be had from alternate hot and EFFECTS OF TONICS 157 cold applications, never from hot alone, except they be very short or where the heat of the body is much below par. That the wide-spread effects of tonic applications may be fully realized by the reader, we give below a tabulated list of such effects. These have been discussed in detail in the first part of this work. Cold applications produce the following tonic effects: 1. Quicken the circulation of the blood and lymph. 2. Strengthen the heart-beat. 3. Raise blood pressure. 4. Increase glandular activity. 5. Enhance nerve activity. 6. Augment assimilation. 7. Increase depth of respiration. 8. Increase amount of oxygen absorbed and carbon dioxide eliminated. 9. Leucomaines are more perfectly oxidized. 10. Increase oxidation and metabolism in general. 11. Stimulate heat production. 12. Equalize the distribution of red and white blood cells, increasing their number in the peripheral circulation and thereby preventing globular stasis. 13. Increase alkalinity of the blood. 14. Augment the production of agglutinin and other antibodies. 15. Stimulate phagocytosis. 16. Increase muscular capacity. 17. Decrease fatigue. Tonic measures, to a greater or less extent, are indicated in all forms of disease. In some conditions the tonic results derived from measures whose principal effects are other than tonic are sufficient to secure recovery, but in nearly all diseases some special tonic treatment is needed and in not a few, this alone is sufficient. In the majority of cases, it is necessary to begin with the mildest of tonic measures, increasing the vigorousness of the treat- ment as the patient develops the ability to react. The following are the principal tonic measures in the order of their sever- ity. Taken one after another, they may be said to constitute a therapeutic ladder. 1. WET HAND RUB. A few very anemic patients do not possess sufficient vitality to react at first to the cold mitten friction. These patients should be given a wet hand rub beginning with one or two parts only, and increas- ing the extent of the area treated as the patient's reactive powers increase. At first, tepid or cold water may tax the reactive powers. If so, the patient must be rubbed vigorously during and following the application. The tem- perature of the water should be decreased daily 2 or 3 F., until cold water or ice water is used. Usually, before this point is reached, the cold mitten friction may be employed. 2. COLD MITTEN FRICTION. Begin with cold water, dipping the mitten once for each part, and rubbing it vigorously until it is well warmed. It should then be dried and again rubbed with the dry hand. With each suc- ceeding treatment the temperature may be lowered and, in a day or two, the number of times the mitten is dipped for each part may be increased to 158 STIMULANTS AND TONICS two and later to three or four. When the patient is able to react to ice water used in this manner, other more vigorous means may be tried. 3. COLD TOWEL RUB. This is graduated in the same manner as the cold mitten friction. Since the cold water is applied to a greater surface at one time, it requires somewhat greater vitality to react to this measure. 4. PAIL POUR. After the warm bath or some other hot treatment, the patient may receive to the shoulders, chest and back, 2 or 3 pails of water differing in temperature from 5 to 15 F. The first used should contain water from 100 to 105. The second, from 80 to 90, and the third, from 65 to 80. As the patient shows ability to react to these measures, the temperature of the water may be decreased or additional pails used. 5. SALT GLOW. This may be made a mild or extreme measure accord- ing as fine or coarse salt is used, and much or little friction given. Since it is not accompanied by cold water, it does not severely tax the reactive powers. A pail pour or shower may be used to remove the salt and so com- bine it with other tonic measures. 6. COLD DOUCHE. This should be preceded by a warm or hot shower, or it may be given as a hot and cold douche consisting of three or four changes. The reaction is enhanced by the use of percussion. At first only a limited portion of the body should be treated in this manner, such as the feet and legs, later the spine and chest also. 7. WET SHEET RUB. The patient should stand in a tub of hot water. At first the sheet should be wrung nearly dry from cold water. This is wrapped about the patient in the manner directed under Technique. The patient should be rubbed over the sheet until warm and then quickly dried by means of sheets and towels. Later, colder water should be used arid the sheet wrung less thoroughly. 8. DRIPPING SHEET RUB. When the patient has acquired the ability to react to the wet sheet rub, the treatment may be increased in vigor by pour- ing over the shoulders while the patient is still wrapped in the sheet and after he has been warmed by rubbing, from 1 to 3 pails of cold water, at first using one containing cool water and later, 2 or 3 pails of colder water. After each pour, the rubbing should be renewed and continued until the patient is warm. 9. SHALLOW BATH. A full length tub should be partly filled with cold water. The patient then enters the tub, sitting upright while both patient and attendant rub the limbs and hips. The patient now reclines in the tub while he is again rubbed with cold water, it being dashed up over the body during the course of the rubbing. The water should hardly more than half cover the body. The temperature of the shallow bath may be gradually decreased. 10. COLD PLUNGE. This measure may be considered the last round of the ladder. By active swimming movements, the patient should promptly react to a plunge in cold water at 80 to 85 F., and later, to much lower tem- peratures. The plunge bath should not be continued long. At first, one or two minutes only are sufficient. Later, five, ten, or even fifteen minutes may profitably be spent in swimming. l 1 For more complete details of these treatments see Technique. ANEMIA -159 We have already mentioned that there are a large number of conditions in which tonic measures are indicated. In some, however, it is necessary to provide a special course of tonic treatment. The following is a partial list of such conditions. A few of these will be considered somewhat at length. Indications for Special Tonic Treatment. 1. Anemia. 2. Neurasthenia. 3. Melancholia and hypochondria. 4. Hysteria. 5. Dyspepsia. 6. Insomnia. 7. Chronic inebriety. 8. Chronic articular rheumatism. 9. Valvular heart disease and obesity with fatty heart. 10. Diabetes. 11. Cerebral congestion due to sunstroke. 12. Multiple neuritis (chronic stage). 13. Locomotor ataxia. 14. Hemiplegia. In the three last conditions the treatment should partake more of the nature of a true stimulant as extreme measures are necessary to provoke activity in atrophied nerve structures. Anemia Under this heading we include the various forms of secondary anemia. Primary, idiopathic, or pernicious anemia should be treated along much the same lines. As far as possible, all known causes should be removed. Irre- spective of the many ultimate causes of anemia, this state is due to deficient activity of the blood-making organs or increased rapidity in the destruction of the red cells. There is one factor that is an almost constant accompani- ment of anemia. This factor is defective digestion and malassimilation. Because of bad food, gastro-intestinal infections and putrefactions, the body may be unable to digest and appropriate from the food the ele- ments needed to sustain the system. It is not only the blood that is defi- cient, but the entire system is impoverished. Therefore one of the chief objects to be attained is improvement in digestion and assimilation. With- out this, all other treatment, no matter how good in itself, will be an almost total failure. The body may be given a more than sufficient supply of iron without the slightest effect unless the digestion and assimilation are improved by appropriate treatment. Artificial preparations of iron nearly always derange the digestion and so lessen the absorption of all nutriment, iron included. Preparations of iron, from Blaud's pill to the bad blood and marrow of slaughter-house animals, are all alike unnecessary in the treatment of anemia. The amount of organic iron contained in ordinary foods is abundantly sufficient to supply the hematogenic organs with the necessary amount for the formation of the 160 STIMULANTS AND TONICS normal per cent of hemoglobin. Prof. G. von Bunge 2 tells us that the yolk of eggs contains a stable organic compound of iron with neuclein and that this compound is doubtless a precursor of hemoglobin. So efficient is this in the formation of hemoglobin that he proposes to call it the "blood former" (hematogen) . We have recently been assured that the egg contains medicinal principles, which idea fully agrees with Professor Bunge's statement. The fresh green vegetables, fruits, grains and nuts contain considerable amounts of organic iron. Asparagus and spinach contain from 20 to nearly 40 milli- grams of organic iron to the 100 grams of dry substance. 3 Ten milligrams or 1-6 grain of iron, the daily amount required by an adult would be con- tained in four ounces of the yolk of egg. Moreover, this iron is in a form to be most easily digested and most fully absorbed. It is thus amply demonstrated that inorganic or artificial preparations of iron are not only entirely unnecessary, but also in many cases, positively injurious, since they derange the digestion. On the other hand, the best food, containing sufficient organic iron, will not suffice to cure anemia if intestinal putrefaction continues and, through lack of proper tone and cir- culation, the body is unable to appropriate the food it receives. In addition, then, to the necessity for a simple, natural diet and special attention directed toward improving the digestion, there are two other objects to be attained. First, the blood-making organs must be stimulated. Second, the circulation must be improved. That all these results can be accomplished by tonic hydrotherapy has been demonstrated as shown in the chapters on the circulation. That tonic hydrotherapy combined with a simple natural diet, outdoor life, fresh air and sunshine is far more efficient than iron, strychnin, arsenic, the hypophosphites, quinin and the like, is the daily experience of those who systematically employ physiologic means. It has yet to be proven that arsenic has any effect upon the blood but to impoverish it. That it lessens both the per cent of red cells and of hemoglobin when regularly administered has been amply proven. In searching for experimental data concerning any positive benefit that may be derived from the administration of arsenic, one is struck with the paucity of evidence along this line. We are asked to rely upon very vague assumptions, mostly empirical in nature. We have frequently treated cases of profound anemia in which the whole picture was that of chronic arsenic poisoning rather than simple anemia, the arsenic having been administered to cure the anemia. In the hydriatic management of anemia, it is necessary to provide a care- fully graded system of tonic treatment. In the extreme forms of anemia, the beginning must be at the bottom round of the ladder of tonic measures. Each application of cold should be preceded by a short hot application, such as fomentations to the spine or abdomen, hot foot bath, or local electric light bath. No long hot treatments should be used since the vitality is so much reduced as to illy bear the depression occasioned by sweating. How- ever, all forms of local applications of heat are indicated in anemia. Follow- ing one or more short moderately hot applications, the patient should be given a wet hand rub, cold mitten friction or cold towel rub, according to 2 Physiological and Pathological Chemistry, Second English Edition, p. 375. 3 Ibid., p. 376. NEURASTHENIA 161 his ability to react. This should be repeated about twice daily, or a light massage may be given once a day. Later on, as the circulation improves, the patient may be treated by the cold towel rub, hot and cold to the spine, and still later, alternate hot and cold douches and sprays. Advancement in the tonics should be made slowly. It may take several weeks for the patient to acquire sufficient vitality to react to a general shower bath. The salt glow may be used before the more vigorous cold applications can be borne. Following this, may be used the general affusion or pail pour, at first of warm or tepid water, later of cool and cold water. After some weeks a short full electric light bath may be given, followed by a vigorous hot and cold spray. When this point has been reached, advance may be made more rapidily, using the wet sheet rub, dripping sheet rub, cold shallow bath and the cold plunge. Massage is especially indicated in anemia before the patient in able to take much exercise. The manipulation should be what is termed "general massage;" i. e., it should combine all of the procedures usually given in Swedish massage. Of special importance are the movements of deep knead- ing. After a single massage, lasting 45 to 60 minutes, the red cells fre- quently show a gain of 25 to 50 per cent and may even be doubled in num- ber. These gains are of course not permanent but they last longer and longer as the treatments are repeated. The hemoglobin per cent rises more slowly than the red cells. Full sun baths are especially beneficial. The scientific basis for the use of the sun bath in anemia and chlorosis has been well demonstrated experi- mentally. 4 Exposure to sunlight increases the oxygen-carrying capacity of the red blood cells. It stimulates hematogenesis, increasing both the number of red cells and the hemoglobin per cent. It is a fundamental proto- plasmic stimulant. It hastens cell division and cell growth. Pure, fresh air supplies the needed oxygen that makes possible the best results from the sunlight. "Zuntz and his school have shown that the effects of moun- tain air are apparent, not only in their influence on red corpuscles, but also on the nitrogenous metabolism of the body as a whole, so that there is in most individuals a positive nitrogen balance, an actual reproduction of the conditions found in the growing organism." 5 The effects of sunlight and out door life among natural surroundings are apparent not alone in the physical changes they induce, but also in the psy- chic improvement of the patient. When proper attention is given to all of the items mentioned, also to digestion (see Dyspepsia) the maximum good may be obtained. Neurasthenia The management of neurasthenia by systematic hydrotherapy has been so universally successful that it is now regarded by neurologists as indespens- able in the treatment of this condition. Moreover, the necessity for change of environment and efficient training of the patient in proper habits of diet, 4 Cleaves Light Energy, pp. 271, 322. 5 Starling Fluids of the Body, p. 142. 162 STIMULANTS AND TONICS rest, exercise, etc., demand that for a time, at least, this be carried on in an institution fully equipped with the necessary appliances and manned with physicians and attendants trained in hydriatic technique. The manifestations of nerve exhaustion are exceedingly protean. For this reason, individualization is perhaps more imperative in this than in any other disorder. It is necessary to carefully observe the effects of each treatment. While the statements of the patient in regard to these are not a sufficient guide, they should not be wholly disregarded. It may be neces- sary to make several changes before the most suitable means has been set- tled upon. A mere education in technique is not all that is necessary for the physician to understand. He should be thoroughly conversant with the scientific basis of physiologic effects, by close observation adapting these to the needs of the patient as experience shall direct. The psychic element plays such a large part that, in case the patient takes a violent dislike to some procedure, not absolutely essential, it is best to substitute another of similar effect. We commonly encounter the idea that frequent baths are weakening. It is no small task to disabuse the mind of this. This and other imagined dangers are very real to the mind of the patient. Often, they may be overcome by utilizing some other notion as a placebo. We have, however, found straight-forward education the best all-around plan. This requires a great deal of time on the part of the physician, but the efforts are often well repaid in the long run. The neurasthenic state is almost invariably associated with faulty diges- tion. The digestive derangement may be a large cause, a contributing factor or a result of the nerve exhaustion. Where defective digestion is a promi- nent feature, special measures should be directed toward restoration of the normal function. The treatment of dyspepsia is considered in another place. The overworking of any organ or function leads to exhaustion. The chief cause of nerve exhaustion lies in overactivity of the brain and nerves, accom- panying deficient physical activity. Neurasthenia may, however, occur in an individual who is engaged in an accupation requiring constant bodily activity. Worry, grief, disappointment financial or social, these all have their place in the causation of nerve exhaustion. A comprehensive view of the disease and its causes reveals the necessity for two classes of phy- siologic effects, viz, tonic and sedative. Sedative, to assist in securing rest, the most essential element in building up lost nerve force. Tonic, to restore normal nerve activity and hasten the building up process. No hard and fast lines may, however, be drawn between procedures directed to these ends. Tonic measures are, of course, in the long run conducive to normal rest, but they may also be immediately sedative in their effects. This peculiar paradox, that tonic measures produce sedation and sedative meas- ures are tonic, exists only in the realm of physiologic therapy. One would not pick upon the bromides to restore the normal nerve tone or upon strych- nin to produce rest or sleep. The special treatment of insomnia and the irritative neurasthenic state will be considered more at length under Seda- tive Effects (q. v.). In beginning the treatment of a neurasthenic patient it is well, at first, to test the reactive powers by mild measures which will produce no shock. NEURASTHENIA 163 Since first impressions are often very lasting, the initial treatment may con- sist of such forms of the bath as are not greatly different from those used at h >me. This serves to make the patient acquainted with the attendant and the attendant with some of the peculiarities of the patient. The full warm tub bath and tub shampoo, finished with a warm and then a cool pail pour serves this purpose for a large number of patients. Since nearly all neurasthenics complain of cold -feet and more or less abdominal distress, we frequently use the hot foot bath with fomentations to the abdomen. This may be made the second treatment and concluded with a wet hand rub or cold mitten friction. With this, or following closely, we utilize hot and cold to the spine, the revulsive compress, the pail pour, salt glow and graduated spray. Later, after considerable reactive capacity has been developed, the cold towel rub and wet sheet rub may be used. The alternate spray, alter- nate douche and shallow bath are quite vigorous means and should not be ventured upon in the agitative form of neurasthenia or not until milder tonics have been used for some time. The wet sheet pack, although an excellent tonic, as well as sedative means, is often objected to by the neurasthenic. He complains that it makes him nervous, he feels restrained, etc. The sitz bath at the various temperatures at which it may be used, is capable of most excellent results. Provided there are no local conditions requiring treatment, the sitz tub may first be filled with water at 98 which is gradually raised to 102 or 103 and then lowered to 90 or 85 just before the close, or it may be concluded with a cold pail pour to the hips (revulsive sitz) . The second bath may be begun at 98 or 95 and, without raising the temperature of the water, gradually lowered to 85 or 80. On each succeeding day, it is begun at a slightly lower tem- perature and finished with colder water, until it is essentially a prolonged cold sitz. The bath acts by reducing the blood supply to the abdomen and pelvis, decongesting the abdominal and pelvic sympathetics and restoring their tone. It aids in the relief of general splanchnoptosis. About once a week the patient should be given a short electric light bath followed by a spray, or shampoo and spray. The electric light bath should be 3 or 4 minutes in length, sufficient to thoroughly warm the skin and pro- duce beginning perspiration. The old idea that the melancholic state is due to liver derangement (black bile) is not wholly without foundation. Wrong habits of diet, together with constipation, are large factors in the production of the depressed type of neurasthenia. Both of these crowd the liver with toxins and products of imperfect digestion. An overworked liver in time becomes a sluggish, tor- pid liver, incapable of performing its functions as a toxin destroyer and emunctory. In addition to general treatment and treatment directed toward the relief of indigestion and constipation, we have found alternate hot and cold applications to the hepatic area of special advantage. The revulsive compress, alternate hot and cold, and especially the alternate hot and cold percussion douche to the liver should be used frequently. For cerebral congestion nothing is superior to the alternate hot and cold foot bath or the alternate percussion douche to the feet. The latter may be preceded by a short hot leg pack or hot leg bath with cold compresses to the head and neck. 164 STIMULANTS AND TONICS The work cure for neurasthenia has been successful in the hands of a few phy- sicians who have formulated a definite plan for such treatment. That which has been reported is largely in the line of indoor work. Much more success- ful is the use of gardening, floriculture and horticulture to employ the time and occupy the thoughts of the neurasthenic patient. These occupa- tions take him out into the fresh air and sunshine, and to the extent he can be interested in "helping things grow," just to that extent the success of the plan is assured. It has also been shown by Pansini 6 that the actinic rays of sunlight or artificial light increase muscular capacity, while red light has the opposite effect.- Red light of course consists largely of thermic frequencies and hence its effect is essentially that of heat. Blue light (actinic ray) increases both the amplitude and number of contractions as shown by ergograms. In a control test the muscles were able to lift 1.736 kilograms; before re- covering from the fatigue of this test they lifted 1.455 kilograms; and after exposure to the light of a blue lamp the total of the curve showed 1.848 kilo- grams, indicating not only the recovery from fatigue but a gain of .112 kilo- grams over the capacity of the unfatigued muscles. The general program and the distribution of the treatments during the day are of importance. It will be found that the best results are obtained by one tonic treatment a day. A short sedative treatment may be given in the afternoon or at night. If more than this is used, the afternoon treatment may consist of massage or electricity in some form. Too continuous a round of treatment limits the time for rest and out-of-door life and recreation which are all important in neurasthenia. It is a mistake to allow the patient to insist upon local applications three or four times a day for local distresses such as "backache" or "indigestion." They only serve to more firmly fix the patient's attention upon some minor ailment and confirm his introspective tendencies. The measures and plan outlined above, when given under careful super- vision and combined with regulation of the diet, exercise, rest, etc., will, if proper psychic control be not neglected, invariably result in the recovery of the neurasthenic patient. Splanchnic Neurasthenia In many neurasthenic patients the distressing symptoms center about the abdomen. There is a feeling of weight and exhaustion accompanied by mental depression. The exacerbations of this state have not inaptly been styled "the blues," as the exciting causes are worry, disappointment and such like nervous disturbances which give rise to a temporary melancholia. The predisposing factors entering into this condition are constipation, auto- intoxication, dyspepsia, general nerve exhaustion, insufficient physical exer- cise, etc. The immediate physical basis of splanchnic neurasthenia lies in an engorge- ment of the splanchnic blood vessels, particularly of the veins. These ves- 6 Cleaves-Light Energy, pp. 301 to 303. SPLANCHNIC NEURASTHENIA 165 sels are capable of great distension when the vasomotors are rendered par- etic through intestinal autointoxication, worry, grief, etc. A very rational plan of treatment, as far as this condition is concerned, ,is advised by Abrams. 7 This consists of various means intended to increase the abdomi- nal tension and stimulate the splanchnic vasomotors for the purpose of re- lieving the visceral stasis of blood, and by means of a quickened splanchnic blood current, especially in the liver, directly increasing the hepatic destruc- tion of poisons and hastening their elimination. Abrams especially favors the use of the sinusoidal current for this pur- pose. Applied by means of a stationary spinal electrode and a labile abdominal sponge, the treatment is certainly most effective. The abdominal muscles are powerfully stimulated by the slow sinusoidal current, thus increasing intra-abdominal pressure, but the greatest effect is upon the splanchnic vaso- motors reflexly. These patients experience much relief by assuming the horizontal position. The movement of "inspiratory lifting" as carried out in abdominal massage also affords instant relief. The use of abdominal supporters and the appli- cation of broad bands of adhesive plaster to the abdomen in splanchnoptosis and splanchnic neurasthenia give relief as long as they are in place. Both these means however, ultimately result in weakening the abdominal mus- cles and so unless accompanied by other treatment defeat their own pur- pose. Where it is at all possible to strengthen the abdominal muscles, it is better to adopt some system of exercises especially calculated to develop them. Of hydriatic means the following combination is especially efficacious in splanchnic neurasthenia: A hot foot bath with the cold Winternitz coil to the abdomen and cold compresses to the head and neck, continued for twelve to twenty minutes, is the first part. A cold sitz of four to six minutes dur- ation follows and the treatment is concluded by a wet sheet rub. This is especially adapted to warm weather. During the winter months it may be necessary to apply more heat. With less vigorous patients, the first combi- nation of hot foot bath with cold coil to the abdomen and cold compresses to the head may be continued thirty minutes or longer and concluded with a cold mitten friction. These cold applications to the abdomen and pelvis produce decided and prolonged contraction of the visceral blood vessels. The fan douche to the hepatic region and abdomen also accomplishes much the same results. Hysteria While some cases require a greater proportion of sedative treatment, nearly all require more or less of tonic treatment. The chief result to be obtained by tonic treatment is the restoration of tone to the neurons, so that, by training, self-control becomes possible. The methods outlined for neurasthenia are all applicable in hysteria. Dyspepsia The special treatment necessary in this condition will be considered later, but local measures unaccompained by general tonic treatment are often insuf- 7 The Blues; also Spondylotherapy. 166 STIMULANTS AND TONICS ficient to accomplish fall return to health. The measures recommended for anemia and those necessary in neurasthenia are all applicable in altered states of the digestion. Insomnia t Treatment of this condition will be considered under "Sedative Effects." A large number of cases occurring in business or professional men may be treated almost wholly by tonic measures, since normal fatigue is lacking because of insufficient exercise. Tonic treatment is directed toward the production of moderate fatigue, so that sleep may be induced as a natural consequence. The tonic measures listed above are nearly all applicable in this condition and should be accompanied by active exercise in the open air. Chronic Inebriety In chronic alcoholic poisoning the tissues are in a state of lessened activ- ity. Alcohol circulating in the system for months or years tends to harden the tissues, causing an over-production of fibrous connective tissue and les- sening activity of parenchymatous cells. In order to overcome this partial pickling process, it is necessary to use the most extreme measures, such as extreme hot and cold, to wake up the deadened tissues, especially the brain and nervous system. Immediately following a spree, measures should be directed toward the rapid elimination of the alcohol imbibed. If the pa- tient is still under the influence of the liquor, he may be held under the cold shower to stimulate the nerves and hasten the circulation. After the immediate danger is past, he should be given full hot tub baths, or the elec- tric light bath, accompanied by the drinking of large quantities of water. These measures hasten the elimination of the alcohol. Any hot treatment f-hould be followed by the hot and cold spray or shower. The hot and cold douche is an excellent means of stimulating activity. In those cases that have been very much reduced by long years of dissipation, it may be neces- sary to employ milder measures, such as the neutral bath, the wet sheet pack, fomentations, and the cold mitten friction, etc. Chronic Articular Rheumatism It is the usual custom in gouty rheumatism to employ extreme sudorific measures. Such treatment, unaccompanied by tonic measures, is applicable only in obese rheumatics, and in those cases only fora limited time. While any form of cold treatment may temporarily increase the stiffness and soreness, it is quite essential that these patients should be given tonic treatment. The cold mitten friction is probably the best measure, since it quickly produces a reaction and can be given to all parts of the body, avoiding the joints. Tonic measures are necessary, not only to increase the oxidation and elimin- ation of toxins and the surplus of nitrogenous material which, by long crowding with proteid foods of high purin content has become well fixed; but also to increase the building up process and the general body weight. DIABETES 167 The nerve tone is very much reduced in rheumatism and requires special tonic measures. Diabetes Diabetes is a condition in which the system is unable to warehouse and consume the carbohydrate of an ordinary diet. The disease may be classified under two heads, First, an alimentary form in which withdrawal of carbo- hydrate from the diet for a time produces a cure, i.e., the body is thereafter able to utilize a moderate amount of sugar. This is looked upon as a func- tional disease, although as remarked in a following paragraph, it may be due to partial destruction of the ductless glands of the pan- .creas. Second, a permanent or organic diabetes in which excretion of of sugar continues after the withdrawal of all carbohydrate. It has been pretty well proven that destruction of the islands of Langerhans is the causative lesion in the majority of cases. These ductless bodies are believed to secrete a glycolytic or oxidizing ferment (oxidase) which has the ability to break up and oxidize the sugar molecules. This occurs in the general system, but principally in the muscles. If about one-tenth of the pancreas remains intact after partial extirpation, diabetes results only on ingestion of carbohydrate. According to Thoinot and Delamere, Langerhans insuf- ficiency is found in about 80 per cent of cases. Defect in the glycogenic function of the liver may also cause permanent diabetes. The usual treatment of diabetes is directed toward securing but one end, viz., decreasing the excretion of grape sugar by lessening the ingestion of carbohydrates; substituting protied, chiefly meat, as recommended by Von Noorden. Chittenden 8 has recently shown that the ingestion of pro- tied, about a certain minimal requirement, which he sets at about 35 to 60 grams, results in a very few hours in the excretion of practically all the nitrogen in the form of urea, the residue being simple carbohydrate not dis- tinguishable from the carbohydrate taken as such. Such a process can hardly be said to, in any way, conserve the body powers. The great amount of useless labor demanded of the liver by such a diet must result in over- working that organ. All this occurs, to say nothing of the detrimental effects of flooding the system with purins from the large quantities of meat which the Von Noorden diet necessitates. While temporay exclusion of carbohydrate from the diet with a gradual return to a moderate ingestion of starches and sugars is quite essential and an excellent plan for the dietetic management of diabetes, this alone does not meet the needs of the condi- tion. The real cause of the disease lies in altered carbohydrate metabolism. The sugar passing through unoxidized causes a loss of energy that should accrue from this source. In other words, the carbohydrate fuel falls through the grate before being burned because of lack of proper regulation of the fire. Lessening the amount of fuel only partially remedies the effect. The rational management must therefore aim at increasing the oxidation of grape sugar and thereby preventing its elimination in an unoxidized state with the consequent energy loss. There are no known medicinal agents or 8. Nutrition of Man, p. 131. 168 STIMULANTS AND TONICS even any mode of dietetic management which will accomplish this result. Experiment has revealed the fact that nothing so greatly promotes oxida- tive changes as exercise in the fresh air and tonic hydrotherapy. The effects of these agents on carbonaceous metabolism we have already considered. Because of the languor, lessened vitality, and great susceptibility to fatigue which is an almost constant accompaniment of diabetes, it is often difficult, not to say unwise, in many cases to pursuade the patient to exercise. When there is much loss of vitality the exercise must be of a passive nature, i. e., secured by massage. Massage stimulates the glycoly tic powers of the mus- cles, improves the circulation and aids nutritive changes. More important than this, however, are the effects derived from applications of cold water accompanied by friction or percussion. Cold frictions, cold douches and mild alternating hot and cold applications effectually stimulate metabolism. Those hydriatic measures which are accompanied by strong mechanical stimuli have double the effect of cold applications without friction or per- cussion. Cold douches have been shown to increase oxidation more than 100 per cent. These means also improve the nutrition of the skin, and so aid in preventing many of the annoying cutaneous complications. Because of the lowered vitality of almost all diabetics, the treatment must be carefully graduated and mild tonics used at first. Local hot appli- cations followed by the wet hand rub or cold mitten friction may be used to begin with, also the neutral faradic tub, graduated shower and cool affu- sions. After becoming accustomed to these treatments the patient may, if in good flesh, be given a wet sheet rub, dripping sheet rub, cold shallow bath and alternate douches. In some cases the cold plunge may even be ventured upon. As rapidly as able, the patient should be encouraged to take moderate exercise in the open air; the effect is greater if the air is cold. These measures improve the appetite and stimulate digestion and assimilation. The feeling of languor and debility gives way to a greater inclination to exercise, and so hydrotherapy indirectly makes possible the use of the other great aid in oxidation bodily activity. With thin diabetics, the prognosis is less favorable. They can take only the milder tonic treatments. Neither do they bear well any great reduc- tion in the diet. But even with such unfavorable conditions, astonishingly good results may be obtained by carefully graded hydrotherapy combined with light massage. Much time should be spent in the open air and sun- shine, careful attention being paid to general hygiene and especially to good skin activity. Cerebral Congestion Due to the Effects of Sunstroke or Heat Stroke Patients who have once suffered from sunstroke must select a cold climate in which to live. Even moderate heat for any length of time produces harmful results. It would seem that in this condition the vasomotor cen- ters have been so interfered with that there is a loss of vascular control. This may, in some cases, be so extreme that even a short hot treatment limited to a small area may induce general vaso-dilatation with a special VALVULAR HEART DISEASE 169 tendency toward cerebral congestion. The condition is best treated by cold applications accompanied by friction. No hot applications at all should be used. During all treatment, the head should be kept cool by cold compresses and the ice bag, or the ice cravat to the neck. The cold mitten friction, cold towel rub, wet sheet rub, cool or cold showers and sprays may all be used according as the conditions indicate. If the brain seems unduly congested a great deal of time, derivation is best secured by the cold percussion douche to the feet. Valvular Heart Disease Etiology and Pathology Organic heart disease refers to such diseases of the heart as are due to gross structural changes. The term is applied almost exclusively to chronic valvular disease. The larger number of cases are the result of some acute inflammatory condition on or about the valves. These valve inflammations may arise as complications of rheumatic fever, tonsillitis, scarlet fever, sep- sis, gonorrhoea, pneumonia, pleurisy, or pulmonary tuberculosis. Predis- positions are found in prolonged and heavy muscular exercise, autointoxica- tion, gout, alcoholism, syphilis, Bright's disease and arteriosclerosis. The result is a valve orifice either too large or too small. Scar tissue following the inflammation may cause the valve segments to adhere to each other and so, by partially obstructing the orifice, cause stenosis; the valve leaflets may be partially destroyed or their attachments weakened so that the ori- fice is too large, or the heart dilated so that the segments are incompetent to close the opening. In the first case, that is, stenosis, too little blood passes through the ori- fice and extra force is required to overcome the obstruction. In the latter case, part of the blood returns through the enlarged opening or past the incompetent valves so that regargitation takes place at every heart beat. Because of the former condition, the first change in the heart muscle is that of hypertrophy. In the second condition, the first change is that of dilata- tion of one or more cardiac chambers. If compensated, both conditions result in great hypertrophy and thickening of the muscular wall. The maxi- mum force of the heart will be greater than normal, but the work required of it is also greater, so that in this conditioj, its reserve force above what it ordinarily uses is less than the normal reserve. Here the heart is said to to be in a state of compensation, since the muscle is so much hypertrophied as to still be able to perform its work under ordinary circumstances. Some- times there is little or no such reserve, i. e., the heart may have barely enough force for its work when the body is at rest. In this condition, the heart is said to be in a state of broken compensation. This state, that is, where the maximum force is in constant use, is revealed by such symptoms as edema, cyanosis, dyspnoea, heart pang or distress, rapid pulse, palpitation, sleep start, enlarged liver, etc. Moderate muscular work demands four times the energy used at rest, and the total reserve power of the heart muscle is from eleven to thirteen times 170 STIMULANTS AND TONICS the normal output during rest. 9 This proportion is shown in Fig. 29, I. In the case of a valvular lesion so bad as to require three or four times the usual expenditure of energy, it will be seen that only during complete physical rest will the heart be able to accomplish its work (Fig. 29, II). Moderate muscular exercise will demand more energy than it possesses and so will be accompained by signs of broken compension. In order that com- 16 ^C^\\\\X /; _ '/ /, K> = 9 E= Q Ml \\X\\\\\\\X ^ NNXsN\\\Vv - 7 6 C PENSAT | SAT tO ^ S E Z o ^ Z Ul a / / 3 z ^ z 3 o u = / SO 2 (-H "/ v 1=1 .0 N 1 d f-O 1 Fig. 29. Diagram showing dynamic conditions in valvular heart disease. a. Force required at rest under conditions indicated. b. Additional force demanded by moderate muscular work. c. Reserve cardiac force above that needed for moderate work. pensation may be restored, the muscular wall must nearly double its thick- ness to possess even a little reserve force as shown in Fig. 29, III. Treatment It will be readily seen that the above conditions set forth two indications for treatment. First, so shaping conditions that the heart may be given opportunity to increase its muscular tissue and thereby its reserve force. Second, as much as possible, relieve the heart of part of its work, not only 9 Hutchison Applied Physiology, p. 116. VALVULAR HEART DISEASE 171 temporarily in order to bring about the condition just mentioned, but also to constantly assist the overtaxed organ. These indications are met in the following procedures: 1. Rest, Physical and Mental. This is first and foremost in importance. It is necessary that absolute physical rest be observed in the state of broken compensation. Exercise should not be permitted until the heart has acquired at least some reserve force. According to the gravity of the case, physical res\ may be secured by absolute quiet in bed, by rest in a wheel chair with an attendant, or by restricted exercise. While at rest, the body tis- .sues demand less oxygen and consequently less rapid circulation. It is quite as essential to eliminate all nerve strain, such as worry, apprehension, business or social cares, etc. Through the avenue of the sympathetic system, these irritate and overstimulate the intrinsic nerves of the heart muscle. 2. The Ice Bag to the Heart. This is one of the most efficient means we pos- sess in its ability to produce direct tonic effects upon the heart muscle. Pro- longed, continued cold lessens the rate and increases the length of the period of rest (diastole) . It also shortens the systole and increases its force. The ice bag should be well wrapped to modify the intensity so that the applica- tion may be prolonged. In some cases, the cold compress is to be preferred. While the ice bag tends to increase the force of the systole, it can hardly be said to come under the head of pure stimulants, since by its repeated use, the effects of overstimulation are never seen. It always exercises a bene- ficial effect in aiding hypertrophy of the heart muscle, since by its shorten- ing the systole and increasing the length of the diastole, the actual period of rest is increased. It may, therefore, be said to be a true physiologic meas- ure. 3. Measures which Stimulate the Peripheral Heart, performing part of the work of circulation, increasing its activity and so aiding the central heart In the chapter on the Peripheral Heart, we have discussed at length the physiology of the blood-vessels, there normal action and the rationale of the measures used to increase there action. We need here only briefly summarize the facts already pointed out. In- dependently of the heart, the blood vessels exert a pumping or propulsive action upon the blood stream. Lauder Brunton 10 makes the following observation relative to this activity: "When working under Professor Ludwig in 1869, he directed my attention to the contractile power of the small arteries apart from any nerve center, and while watching their movements I have sometimes seen a regular pen- staltic action take place, by which the blood was driven forward in the arteriole just as faBcal matter would be driven forward in the intestine." "Franke discusses the various theories prevailing in regard to the functional importance of the peripheral blood vessels. His conclusions reaffirm, he asserts, that the peripheral vessels have an independent pressure and suc- tion action similar to that of the heart; this assumption is sustained by their anatomic structure, physiologic experiments, direct observation of the blood vessels in living animals and in certain pathologic conditions in man. At 10 Therapeutics of the Circulation, p. 5. 172 STIMULANTS AND TONICS the points where there is the greatest resistance to the circulation Nature has placed a system of especially powerful blood vessels like a second peri- pheral heart, as in the portal and intestinal vessels. Compensation may fail from disturbances in the peripheral vessels as well as in the heart itself, and the peripheral system may compensate the heart at need; the vessels in the abdomen especially are the last resort of all means to maintain the balance of the circulation. These views, he considers, explain the beneficial effects of gymnastics, massage and baths." 11 In disease, as long as there remains any vasomotor control at all, the activ- ity of the blood vessels may be stimulated by applications to the skin surface. _ The condition of the blood vessels to be sought in the treatment of valvular heart disease is that known as active dilatation, not only of the arterioles, but also of the other blood vessels. It consists of an alternate contraction and relaxation occurring at regular intervals. It is, in short, a pumping action. It is often astonishing to note the amount of assistance rendered the circulation in this way, as shown by prompt decrease in the pulse rate fol- lowing or even during some of the procedures listed below. These may be given separately, combined in one treatment or at different times during a course of treatment, as indicated by conditions in the individual case. (a) Massage. Friction is perhaps the mildest of measures by which the peripheral circulation may be stimulated. It stimulates the arterioles and, by proper movements, the venous circulation is hastened. All the other pro- cedures of massage are also vasomotor excitants. The procedure of deep kneading accomplishes more than the other move- ments of massage. It acts upon the circulation in almost the same manner as exercise. The alternate compression and release of the muscles forces on their contained blo^/d so that the rate of flow is greatly accelerated. Lander Brunton 12 records graphically the results of some interesting experi- ments showing the increase in the rate of venous outflow from muscles dur- ing and after massage. In some instances the rapidity was increased two or three times the normal rate. Mechanical vibration is quite similar in its effect to manual massage. Vibration, when properly given, is an excellent means of assisting the peri- pheral circulation, especially that of the feet and limbs. Vibration may also be given to the back and other parts, as indicated. (b) Hydriatic Vasomotor Tonics. The cold mitten friction has the great- est range of adaptability in organic heart disease. It can be used in all stages from the inception of the acute endocarditis through all the varying conditions of established or broken compensation. This is largely due to the readiness with which it may be made a mild, medium or powerful vaso- motor tonic and stimulant. This can be accomplished by varying the tem- perature of the water used and altering the amount and vigorousness of the friction given. We have never observed, even after the most vigorous cold mitten friction, or its long use over a period of months, any overstimulation such as does sometimes occur with the effervescent bath. The cold mitten 11 Abstract in Journal of American Medical Association of article by M. Franke in Wiener klinische Wochenschrift, March 10, 1910 XXIII, No. 10, p. 347. 12 Therapeutics of the Circulation, p. 135. VALVULAR HEART DISEASE 17S friction and ice bag can be used in the acute stage of endocardia! inflamma- tion, while it might be dangerous to use the Nauheim bath in this stage. There are many other hydriatic measures similar in affect to the cold mitten friction. Each has its advantages and special indications, as well as limita- tions. The following is a list of the more important and commonly used hydriatic measures in the treatment of organic heart disease: The salt glow; hot and cold to the spine; hot and cold douche to the spine, legs and feet; the alternate hot and cold foot or leg bath. Short hot fomentations followed by a brisk but brief cold mitten friction may be given to any part of the body as a means of stimulating the peripheral circulation. (c) Nauheim or Effervescent Bath. The essential feature here is the . chemical irritation of the skin produced by the carbon dioxide and salines with which the water is charged. Natural carbonated waters can be secured in only a few localities, but the carbonic acid gas may be produced artificially in any one of several ways. It powerfully stimulates the vaso- motors, having, however, a cumulative action on the vaso-dilators l3 so that the heart is left without a resistance governor. For this reason it is neces- sary to discontinue the treatment at intervals in order to obviate palpitation and other disturbing symptoms. The cutaneous irritation also reflexly stimulates the heart (Here). This may be another factor in the produc- tion of palpitation by over-stimulation. The cooler the water the less likely its occurrence. When the patient first begins to take the Nauheim bath, it should not be continued longer than about eight minutes at a temperature of 95 F. Five minutes may be better in some cases. An ice bag or cold coil should be placed over the heart. The bath may be repeated two or three times a week for from two to four weeks. It is usually best to give a course of about twelve treatments, when two or three weeks should be omitted. In each succeeding treatment, the temperature of the water may be slightly lowered until the bath is taken in water even as low as 80. The duration of the bath may he increased up to twelve, or under exceptional circumstances, fifteen minutes. The longer the duration of each bath and the more frequent its repitition, the greater is the liability to over-stimulation. This is evidenced by palpitation, tachycardia, cyanosis and dyspnoea. (d) Resistant Gymnastics. This system is known as the Schott treat- ment. As carried out by the Schott Brothers, it is combined with the Nau- heim bath. It consists of a series or system of graduated exercises. At first the patient is assisted by an attendant; later, with apparatus or alone. First one group of muscles is exercised and then another until the principal muscle groups of the body have been gone over. For example, while the attendant resists, the patient gradually contracts the biceps, flexing the forearm. When the forearm has been flexed, the patient contracts the extensors while the attendant resists the movement. This is gone through with a number of times for each group of muscles. With each succeeding treatment the number of movements and the strength of the resistance is increased. The gradual contraction and relaxation of first one and then another group of muscles hastens the peripheral circulation and tends to induce the state of active dilatation of the blood-vessels. This treatment 13 Hare Practical Therapeutics. 174 STIMULANTS AND TONICS should not be applied in acute endocarditis, but is applicable in the chronic stage where compensation is not seriously broken. (e) Oertel Method. General exercises, such as walking, use of the arms, etc., follow as a natural consequence of the method just described. As a system, the Oertel method consists in graduated climbing exercises, up hills of various grades and finally even mountain climbing. At first, the patient walks for short distances each day; and later, longer distances and up steeper grades. This is, of course, applicable only where a fair degree of compen- sation has already been established; never, when the compensation is broken or in the slightest impaired. Where systematically followed for months or years, it has resulted in much good and will secure for the patient the maxi- mum cardiac reserve. These measures combined with careful diet regulation, fresh air and sun- shine will give results which often appear like a complete cure, but of course, do not remove the defect in the heart. Even in the beginning of the incompe- tency, the progress may be stayed for years. The promptness with which these measures act and their efficiency has to be seen to obtain a real appreciation of their value. For example, the ice bag to the heart, accompanied by a cold mitten friction, may reduce the pulse from 115 or 120 per minute to 100 or less within fifteen or twenty minutes. In cast of a dilated heart, the cardiac dullness may decrease more than an inch in diameter and the apex retract half an inch or more toward its normal position following a single treatment. In case the valve is relatively insufficient, the murmur occa- sioned by this insufficiency may entirely disappear, whereas before treat- ment, it may have been considered to constitute a real organic lesion. The minor murmurs of valves secondarily affected often disappear following a treatment of fifteen minutes with the ice bag to the heart and the cold mit- ten friction, or ten minutes in a Nauheim bath. Counterindications. Extreme stimulants and excitants are counterindi- cated in organic heart disease, unless it may be in emergency. For this reason, the percussion douche to the chest, wet sheet rub, the cold plunge and such measures should not be used. The use of electricity in any form may produce shock. The electric light bath is usually counterindicated or, if used at all, it must be in those patients which have acquired a good degree of compensation and then only for a short time. All other extreme sudo- rific measures are counterindicated. General Program We have already outlined under the head of "Endocarditis," the treat- ment for the stage of acute inflammation. As soon as the endocardial in- flammation subsides, the patient may be given daily or three times a week a light general massage, avoiding the chest. The ice bag should be applied to the heart four or five different times during the day, being kept in place from fifteen to forty-five minutes each time. Once daily, the patient should have a treatment consisting of a combination of some of the following meas- ures: Hot foot bath, fomentations to the abdomen, hot and cold to the spine, I'uld mitten friction and cold towel rub. This tonic treatment is best given during the forenoon. The massage may be reserved for the afternoon or VALVULAR HEART DISEASE 175 evening. If there is much restlessness or insomnia, it may be best to give a hot and cold foot bath just before retiring. During this time, the patient should be kept in bed; but when the pulse has become normal, he may change to the wheel chair, and later, be allowed about the room, walking a few steps or for short distances only. The pulse should become normal before any regular walking exercises are taken. The patient may now be given a salt glow, alternate douche to the feet and legs, graduated shower, etc. The Nauheim bath may be given after the temperature has been normal for a month or two. This should be followed by the Schott treatment which, at first, should last only a few minutes and consist of mild exercises. Later, this may be prolonged and increased in severity. In case the patient comes under observation during the chronic stage, with compensation broken, the treatment may be begun at this point or per- haps with milder measures. The resistant movements should not, however, be used during the stage of broken compensation. Care must be taken that the patient is not treated too frequently. This may often seem necessary, but it will be found better to allow the patient sufficient time for rest. Three treatments a day are usually ample and only one of these should con- sist of the more vigorous stimulating measures. The evening treatment should be mild in character, sedative and conducive to sleep. The after- noon treatment may be the hot and cold foot bath followed by massage. This at first should be mild and not last more than fifteen or twenty minutes. Complications Edema. The edema of the feet and legs accompanying cardiac disease will improve as compensation is restored, so that all of the measures recom- mended during the stage of broken compensation will aid in the reducing of the dropsy. The measure which we have found most useful is the alternate hot and cold leg bath. The water should come sufficiently high to more than cover the edematous part. The limbs should be immersed in hot water for one and a half to two minutes and then in the cold for ten to fifteen seconds. It is best to make the hot water as hot as can be borne, gradually adding more hot water as the toleration increases. The cold water may, at first, be used at a temperature of 50 to 70 F. Later, chunks of ice should be put into the receptacle for the cold water. From five to ten changes may be made at one treatment. The limbs should be dried from the cold water and the drying followed by massage consisting principally of centripetal movements. The limbs should be kept elevated until the edema has nearly all subsided. In the minor grades of edema, that is, where there is swelling only about the ankles, vibration may be applied to the feet by means of the vibrating foot machine. The hot and cold leg bath together with massage should be repeated daily. Congestion of Liver. The liver may remain congested for some time after the heart condition has materially improved. Because of the nature of the hepatic tissue, the organ tends to remain enlarged. The passive congestion does not readily respond to treatment. In spite of these facts, an enorm- ously enlarged liver may be caused to return to nearly normal size by a 176 STIMULANTS AND TONICS month or two of vigorous treatment. The patient should be given large hot fomentations over the liver. It will be found helpful to place an ice bag under the center of the fomentation. The ice, having a greater reflex effect, tends to contract the blood vessels of the liver, while the hot appli- cation shows its effect chiefly in derivation. Alternating with this treatment, the revulsive compress or hot and cold to the liver should be used. The alter- nate douche to the hepatic region is one of the best measures that can be used. While acting somewhat indirectly by a derivative process, the hot and cold leg bath will be found to be as efficient as the local treatment. Acute Edema of the Lungs. This condition may come on because of chill- ing or nervous shock. The heart becomes engorged and the chambers dilated at the same time. The patient should be immediately wrapped in a large blanket, the feet and legs being placed in hot water and an ice bag held against the precordia. It is usually necessary for the patient to sit up. The ice bag may be removed every three or four minutes, the skin being warmed by brisk rubbing. Another attendant should apply to the spine a large fomentation so as to cover its entire length and breadth. As soon as the skin is well reddened, a brief but very cold, brisk cold mitten friction should follow. Another fomentation may be applied to the spine, or the part may be dried well and covered with the blanket. Each arm and leg should be treated in a similar manner, that is, the skin well warmed and reddened by a fomentation and immediately followed by the cold mitten friction. Each part should be thoroughly dried with a rough towel and the drying followed by friction with the bare hand until the part is again warm and red. The object to be obtained in this treatment is the drawing of the blood from the heart and lungs to the skin and skeletal muscles. This can not, however, be effectually done by hot alone, but must be accomplished by what may be termed "collateral fluxion," that is, the blood vessels of the surface must be stimulated to unusual activity so that the blood will be held in the periphery. This not only acts powerfully, but leaves no bad after effects such as are frequently noticed when these complications are treated by digitalis, nitroglycerin and strychnin. Neither are these stimu- lants able to accomplish the desired result in extreme cases. In a few hours, the moist rales in the chest, which can at first be heard at some distance, will have entirely disappeared. The finer crepitant rales which remain in the bases of the lower lobes should clear up in one to three days. Palpitation and Arrhythmia. These conditions are largely, if not wholly, - due to digestive disturbances, especially that form of indigestion accom- panied by gas formation. Treatment should therefore be directed toward the relieving of constipation and decreasing of amylaceous dyspepsia. It may be necessary to avoid even moderate quantities of starchy foods unless most thoroughly dextrinized. Tachycardia is best controlled by the ice bag, cold mitten friction, rest, etc. Obesity with Fatty Heart It is not safe to employ extreme sweating measures in obesity accom- panied by fatty degeneration of the heart muscle. Consequently, the treat- ment of these cases at the hot springs is a dangerous procedure. The case PURE STIMULANTS 177 must be treated in much the same manner as one of organic heart disease. The patient should be kept at rest with an ice bag over the heart for a con- siderable portion of the time. Beside this, the patient should be given cold mitten frictions, cold towel rubs, hot and cold to the spine, general massage and later, the alternate douche to the spine and legs, hot and cold footbath, wet sheet rub, etc. Treatment should be very carefully graduated so that the heart is not subjected to overstimulation before it has sufficiently increased its strength. Excitant, Stimulating and Extreme Tonic Effects In many emergencies, it is necessary to employ extreme stimulating meas- ures. These aim at the sustaining of vital activity in order to tide the sys- tem over a crisis or until such time as the natural vitality of the patient comes to his assistance. Such measures are especially directed toward the heart, blood vessels and respiration. In collapse, surgical shock, drowning and asphyxia, these measures are indicated. As we have noted many times, the greatest amount of assistance to the heart can be given by vigorous stimulation of the peripheral blood vessels. In addition to such measures, certain applications may be used which have a direct reflex effect upon the heart itself. The most efficient reflex stimulation comes through the accel- erator nerves. Short, very hot fomentations may be applied to the front of the chest, well covering the heart area. This should Ije continued from thirty seconds to a minute and immediately followed by the rubbing of a cake of ice over the heart. The extreme change in temperature produces powerful stimulation. The part should be immediately dried, after which a second fomentation, very hot and continued for half a minute or more may be used, again followed by the ice rub. After three or four such appli- cations, it is well to rub vigorously with the bare hand the skin of the pre- cordia. These procedures may be given at the same time as artificial res- piration. A very efficient stimulating measure is the slapping of the chest with a cold wet towel. If this is done during the movements of artificial respira- tion, it should be given while the inspiratory movement is made. In the asphyxia of the new-born infant, thermic applications are indispensable. If slapping of the chest and buttocks does not produce respiration, it is well to employ the alternate hot and cold immersion. Two large dishpans will be found handy containers for the hot water and cold water. The hot water must not be hot enough to produce a burn or even erythema. It must be of such a temperature as may be well borne on the back of the hand or the cheek. The cold water should produce decided excitation, but ice water should not be used. The child should be held in the hot water for five or even ten seconds and then merely dipped in the cold water. It should then be returned to the hot for about the same length of time and again dipped in the cold. This procedure is usually the most effectual stimulating meas- ure that can be used. All other means of resuscitating the new-born have their place and applicability. The physician should not too readily become discouraged in working with an asphyxiated infant. It may require half or three quarters of an hour to so stimulate the heart and respiration that the child will continue to breath without artificial means. 178 STIMULANTS AND TONICS Uterine Stimulants Uterine excitation may be necessary in order to produce two different classes of effects, viz., contraction of the uterine muscle and production or increase of menstrual flow. Oxytocic Effects. In cases of inertia uteri, much may be accomplished with- out the use of forceps. That which has given us the best results, produc- ing the most powerful contractions, has been the use of the ice bag or cold compress to the lower abdomen, applied intermittently, especially just at the beginning of the pain, or short intermittent applications of cold to the breasts. Alternate hot and cold applications may also be made to the lower abdomen. Both areas are in direct reflex connection with the uterus and produce powerful uterine contractions. These measures are less disagree- able to the patient than manual stimulation through the abdominal wall and, on account of the tenderness often produced by this method, are to be preferred when they produce the desired result. Emmenagogic Effects. Wherever amenorrhosa is due to pelvic anemia, it is necessary to supplement the general tonic treatment by special stimulating treatments directed toward the pelvic organs. This may be accomplished by the cold percussion douche to the lumbar and sacral regions, or the cold douche to the lumbar spine and feet. Hot vaginal irrigation is applicable in all cases. In some cases, alternate hot and cold vaginal irrigation may be used. The revulsive sitz is applicable in cases of extreme pelvic anemia. It may be followed by the cold lumbar and sacral douche. This douche should be accompanied by considerable percussion and given for only a short time. Vesical Stimulants Nearly all sudden thermic applications to the feet, legs or trunk produce contractions of the dedrusor muscle. This is especially true of the cold per- cussion douche to the feet, or the alternate hot and cold douche to the feet. The same result may be accomplished by the sudden application of the ice compress to the lower abdomen or upper inner surfaces of the thighs. Intestinal Stimulants Intestinal excitation is indicated chiefly in constipation. There are a large number of measures which are useful in relaxed conditions of the intestinal musculature. The patient should be put upon some regular pro- gram. This may conveniently embody several of the measures which are efficient in stimulating peristalsis. Among these measures, are the hot enema, cold enema, or alternate hot and cold rectal irrigation. The grad- uated enema is an excellent means of accustoming the patient to the cold enema. It is especially useful in treating patients who have acquired the enema habit. Of external applications, there may be employed fomentations to the abdomen, the revulsive compress, hot and cold spray douche to the abdomen. These same measures may be applied to the spine from the middle of the dorsal region to the sacral region. The alternate hot and cold percus- sion douche to the feet and legs also tends to stimulate peristalsis. In atonic constipation, the cold rubbing sitz is an excellent measure. It INTESTINAL STIMULANTS 179 should last from two to four minutes and be followed by the alternate douche to the spine and abdomen. These measures should be carefully selected and utilized according to the severity of the case, special attention being given to the cause. The above treatments, except the hot enema and fomentations to the abdomen, are not applicable in spastic constipation such as that accompanying lead poisoning. In this case, it is best to use fomentations to the abdomen, the hot sitz, together with large warm enemata for thorough cleansing of the colon and relief of the pain. Oil enemata may be given at night to be retained over night or for several hours. A number of other measures not hydriatic in nature may be conveniently combined with hydrotherapeutic treatment. Among these are the following: Abdominal massage, spinal nerve stimulation, special exercises to strength- en the abdominal muscles, vibration to the abdomen, faradic electricity to the abdomen and spine, also sinusoidal electricity and the Morton wave from the static machine. Some of these forms of electrical stimulation may be applied by means of a rectal electrode and an abdominal sponge. All exercises which strengthen the abdominal muscles should be utilized, such as walking, rowing, horseback riding, bicycling, etc. Counterindications to Excitant, Stimulating and Extreme Tonic Measures. 1. Old age. 2. Infancy. 3. Arteriosclerosis. 4. Acute mania. 5. Tuberculosis (pulmonary). 6. Emaciation. 7. Thin diabetic patients. 8. Bright's disease. 9. Exhaustion due to any cause. 10. Hemorrhage. 11. Severe coughing. 12. Asthma. 13. Emphysema. 14. Organic heart trouble. 15. Chorea. 16. Extreme neurasthenia. SEDATIVE EFFECTS Measures which reduce or check the over-activity of an organ or function are said to have a sedative effect. Since there are many organs and functions, one might so elaborately classify sedative effects as to prove con- fusing, and so lose the distinctive principles governing hydriatic sedatives. Any application must of necessity affect more than one structure, as we have learned concerning tonic measures; but we have also learned that every application has its predominating effect. For the sake of clearness we shall, therefore, here discuss only nerve sedatives those measures which relieve irritation, nervousness, spasm and convulsion, and are con- ducive to rest, relaxation or sleep. The principal sedative measures may be classified as follows: I. GENERAL SEDATIVES. 1. Pure Sedatives. 2. Tonic Sedatives. II. LOCAL SEDATIVES. 1. For the relief of pain (analgesics). 2. For the relief of parsesthesia. The first (I) employs mild hypnotic, calmative and antispasmodic means, and mild tonics almost entirely. The second (II) must, of necessity, employ extreme means, since pain and abnormal sensations can not be relieved by mild applications. General Sedatives 1. Pure Sedatives: Temperatures at or not far removed from neutral. a. Neutral or warm bath 94 to 98 F., neutral wet sheet pack. b. Warm or hot shower, spray, douche or affusion. c. Sponging cool, tepid or warm. d. Heating compress, as moist abdominal girdle, spinal compress, throat compress, moist chest pack, etc. e. Fomentations moderately hot, especially to spine and abdomen. In addition to the above, the following sedatives are especially directed toward decreasing the congestion of nerve centers. a. Hot foot bath with cold to the head. b. Cold sitz bath. c. Cold water coil to abdomen or head. d. Alternate hot and cold percussion douche to feet. It will be noticed that all of these measures, unless it be the neutral bath, secure sedation by combining the purely sedative effects with that of deri- PURE SEDATIVES 181 vation. For example, the hot foot bath with cold to the head produces sleep and relieves nervousness and headache by reducing cerebral conges- tion. The wet sheet pack at 65 to 70 F. , given alone or followed by a graduated shower at 95 to 90 F., is effective because of the relief of cerebral hyperemia which it produces, combined with pure sedation. Relative to the effects of the cold wet pack, Baruch l says, "The experiments of Max Schuller and the observations of Mary Putnam Jacobi have so clearly demonstrated the calming influence of the wet pack upon the cerebral circulation that we have an exact basis upon which this treatment may be applied in many cases of neurasthenia, especially those troublesome cases in which insomnia is a pronounced manifestation. "This procedure is one of the most effective means of quieting the entire nervous system, whether the irritable condition be due to an essential increase of reflex excitability or to a cerebral hyperemia. The pronounced sinking of the brain substance, the positive diminution of the respiration and heart beat, the weakening of the reflex excitability and of activity of the cere- bral ganglia observed in trephined rabbits during the wet pack, combined with the positive diminution of the vessels of the pia mater, represent the fundamental conditions for physical calm and sleep. These are probably also present in man during the wet pack. Sleep is accompanied by a decided diminution of blood in the cerebral vessels; indeed the latter has been accepted as an essential condition for the production of sleep. This may explain why the wet pack, properly applied, is a useful procedure in the insomnia of neurasthenics." The cold sitz, cold coil to the abdomen, etc., produce sedation by reducing congestion of the sympathetic ganglia of the abdomen and pelvis. Fomen- tations to the spine withdraw blood from the spinal cord, and the heat is in itself relaxing and depressant. Heating compresses are mild derivatives and combine with this derivation a neutral temperature. All antipyretic measures are in the nature of the case antispasmodic and hypnotic, since they lessen toxemia and so relieve the nervous system. Cool sponging is sedative in both actual fever and feverishness. Hot sponging is usually most effective in conditions purely nervous. In acute mania, the wet sheet pack is a most excellent means, and serves a double purpose in restraining the patient while applying the neutral temperature. Indications for the use of pure sedatives. 1. Insomnia. 2. Agitative neurasthenia. 3. Hysteria. 4. Mania. 5. Chorea and choreiform diseases. 6. Paralysis agitans. 7. Spastic spinal paralyses. 8. Epilepsy. 9. Locomotor ataxia (first stage). 10. Nervousness due to congestive headache. 11. Clonic and tetanic spasms from various causes. 1 Principles and Practice of Hydrotherapy, p. 440. 182 SEDATIVE EFFECTS Precautions: The personal factor or idiosyncrasy has much to do with the selection of a sedative treatment. If the patient has taken a dislike to a certain measure, it is likely to produce agitation rather than sedation. Sedative effects are likely to be transient, and so must be frequently repeated. With neurasthenic patients a treatment which may have given good results in a certain case may be robbed of its effect by some unusual occurrence which may seem trivial in itself, such as slight alteration in the manner in which it is given, or the changing of an attendant. 2. Tonic Sedatives. Insomnia and nervousness may be due to a lack of normal fatigue such as follows active work, especially out of doors. This is particularly true of those in sedentary occupations, such as professional, business and office men. These persons may be of fairly good physique and health otherwise. It also occurs in enforced idleness, as after fractures, operations, etc., and in the case of chronic invalids. The rational treatment consists in the production of fatigue. Where possible, of course, exercise in the open air is the most efficient means of producing fatigue. Mild tonics are usually all that can be well borne. A few cases may be given even the most vigorous treatment. The following are the means most used as tonic sedatives: a. Hot and cold to the spine. b. Wet hand rub. c. Cold mitten friction. d. Hot and cold spray, shower or douche. e. Neutral faradic tub. f. Massage. g. Rapid faradic current. The Indications have been outlined above. Some of the principal con- ditions requiring tonic measures, in order to produce sedation are, 1. Insomnia. 2. Neurasthenia. 3. Splanchnic neurasthenia. 4. Chronic rheumatism. 5. Paralysis (flaccid). Local Sedatives 1. Analgesic (relief of pain) . For the purpose of relieving pain, extreme hot or cold applications are absolutely essential. Just which shall be used depends upon the particular cause and condition in each case. Some aim at the cause, and others at the immediate relief of the pain where the cause can not be removed in a short time. For the relief of pain hot applications are usually employed. We say that heat has a specific pain-relieving effect. This is true; but it must be remembered that the relief of the pain is due to the production of definite circulatory changes which remove the cause of pain. In inflammatory states the cause of pain is to be found in pressure upon nerve filaments occasioned by the congestion and heightened vascular tension. By deriva- tion, heat reduces the congestion or it relaxes the tension, and thus the ANALGESICS 183 cause of pain is removed. When properly applied, cold may accomplish the same results. These principles are well illustrated in a diagram devised by Lauder Brunton. 2 "The diagram (Fig. 30) is supposed to represent the end of the finger. The small star indicates the point of irritation, e. g., a prick by a thorn. The line in the center of each finger is intended to represent the nerve go- ing to the injured part; and at the side of each figure is an artery and vein connected by a capillary network. In a the capillary network around the seat of irritation is seen to be much congested; the nerve-filaments are thus pressed upon, and pain is occasioned; 6 represents the condition of the finger after the application of cold to the arm or hand. In consequence of the contraction of the afferent arteries the finger becomes anemic; no pressure Fig. 30. Diagram to show the effects of heat and cold in lessen- ing the pain of inflammation. (Brunton) is exerted on the nervous filaments, and pain is alleviated; c represents the finger after it has been encased in a warm poultice; the capillary network at the surface of the finger is dilated, and the blood is thus drawn away from the seat of irritation, and the pain therefore relieved." For the relief of pain the following treatments are useful: a. Very hot fomentations. b. Hot immersion, foot bath, sitz, etc. c. Hot pack, local or full blanket pack. d. Hot enema. e. Extreme cold, as ice bag, ice compress to painful part or over artery supplying the part, use of ice water or cracked ice by mouth. f . Cold immersion, as of a hand or foot, sitz bath, etc. g. Derivation. h. Fluxion by alternate extreme hot and cold applications. The Indications for the use of pain relieving measures are numerous. 1. Pain of deep seated inflammation. 2. Pain of superficial inflammation. 3. Gastric ulcer. 4. Rectal ulcer. 5. Hemorrhoids. 2 Therapeutics of the Circulation, p. 174. 184 SEDATIVE EFFECTS 6. Toxic neuralgia. 7. Inflammatory neuralgia. 8. Tenesmus rectal or vesical. 9. Dysmenorrhea. 10. Colic renal, biliary, intestinal. 11. Burns. 12. Sprains, bruises, etc. 13. Fractures. 2. Relief of Paraesthesias (abnormal sensations, such as burning, smart- ing, itching, crawling sensations). a. Ice bag. b. Immersion in cold water or ice water. c. Very hot sponging. d. Stupes. e. Weak chemical irritants, as neutral saline bath, bicarbonate of soda bath, saline sponging, alcohol rub, witch-hazel rub, menthol compress. f. Short sweating bath followed by tub shampoo and cool bath. Indications : 1. Pruritis from various causes. 2. Hives and heat rashes. 3. Formication. 4. Numbness and tingling. 5. Burning and smarting. Insomnia Baruch not inaptly styles the insomnia of neurasthenia an opprobrium med- icorum. If one were to form an opinion from the bad effects of medicinal treatment and the frequency with which such treatment is used, the condi- tion is indeed a discredit to scientific medical practice. The insomnia ac- companying neurasthenia is due to a peculiar association of nerve exhaustion with hyperirritability. Doubtless nerve poisons from auto-intoxication play- a large part in the causation. It would seem that congestion of the cere- bral and spinal centers is also a cause of nerve irritability and sleeplessness. It is present in the majority of cases. Because of the lack of nerve tone general tonic treatment as outlined for neurasthenia is quite as essential as sedative measures which aim principally at the insomnia. In many patients, lack of normal fatigue is the chief, if not the sole cause. In such cases a mild or even a vigorous tonic treatment given about an hour before bedtime will produce the best results. With some persons brisk exercise to the point of moderate fatigue, taken just before retiring, will accomplish the same results. We have principally to consider the insomnia due to increased reflex excit- ability and unusual irritability of the nerve centers. The condition may be perpetuated long after removal of the first cause has been affected. This is especially true of those patients who "can't go to sleep" because of con- stant worrying about their inability to sleep. These persons are the bane of the neurologists life. They are exceedingly introspective and often almost hysterical. In order to decrease reflex excitability it is necessary to INSOMNIA 185 remove as far as possible all external stimuli and at the same time decon- gest the spinal and cerebral centers. For these purposes the ideal means is found in the neutral bath or pack. The body is enveloped in a non-irritating medium, the skin is slightly warmed and both the skin and the skeletal muscles relaxed. The temperature of the neutral bath should be not less than 94 F. and it is often better to use water a little warmer, say 96 or 97 F., since the warmth secures a full relaxation. The bath should be given in a quiet, fairly warm room and last for fifteen or twenty minutes to a half hour or longer. The disturbing effect of draughts may be avoided by stretching a sheet across the top of the tub. It is well to lower the temperature of the water two or three degrees just at the close of the bath. A patient should never be put into a neutral bath with cold feet. All parts of the body should be warm beforehand. The neutral bath or warm bath has an effect similar to the neutral pack in causing the sinking of the brain substance. The rationale of the wet sheet pack has already been explained. With many patients it is the most effi- cient means that can be used. By means of woolen blankets the covering of the pack can, by an observant nurse, be so regulated as to be kept con- stantly at the neutral stage. The feet should be more warmly covered than the upper part of the body. An exceedingly restless patient who has had but little sleep for weeks may sleep for hours or all night in a neutral pack. The salutary effects of a drugless sleep are felt all the next day. There is not the usual after-tendency to drowsiness. The patient feels like him- self. Quite the contrary condition follows the rest obtained by trional, the bromides and other hypnotics. The patient is likely to be drowsy during the succeeding forenoon. For this reason medicinal soporifics often defeat their own end. The patient must be kept awake during the daytime so that natural fatigue may result and thus the system demand rest and sleep. There are many other measures which will be found useful. The milder types of insomnia respond very quickly to a set of three fomentations to the spine given just at bedtime. If thought best, this may be followed by a light rub either to the spine alone or to the body generally. The tepid spinal affu 1 sion has an effect similar to the spinal fomentation. It should be applied to the lower dorsal and lumbar spine. Some cases of insomnia seem to be due solely to cerebral hyperemia. This is common in brain workers. In these cases the feet are almost invariably cold. If the unbalance is extreme, a very hot foot or leg bath with cold to the head should be given for about ten or fifeen minutes. This should be followed by an alternate hot and cold percussion douche to the feet. Sometimes the latter will accomplish the results as well when given alone as following the hot foot bath. The vigor- ous fluxion produced in the feet by the combination of percussion with ther- mic stimuli results in more permanent cerebral derivation than a hot foot bath alone. The moist abdominal girdle is an excellent adjunct to a sedative treat- ment. As shown by the experiments of Schuller, it lessens the filling of the cerebral vessels. It may be used after any of the treatments recommended above. It should be worn all night. If properly applied, it will be dry or nearly dry by morning. If, because it does not promptly " warm up, " chilli- 186 SEDATIVE EFFECTS ness results, it must be removed. With some patients it produces "fidgets" and for this reason must be discontinued. Of tonic sedatives designed to aid in producing normal fatigue, the follow- ing may be used in insomnia: Hot and cold to the spine, the cold mitten friction, the alternate spray or a short electric light bath followed by a spray. The neutral faradic tub followed by a short massage gives good results. Either one may be used alone. The mild exercise occasioned by dry faradism or the faradic tub is often sufficient to induce sleep. In the management of most cases of neurasthenic insomnia it is best to give a tonic treatment in the forenoon, reserving sedative treatment and massage for the afternoon or evening. Following the plans outlined above, or simi- lar methods, carefully adapting the treatment to the needs of the particular case under observation, can not fail to produce cure provided the patient fully commits himself to the judgment of the physician and remains long enough to secure permanent results. Chorea The common or Sydenham's chorea is the form considered here. This is the type which is associated with rheumatic fever and endocarditis, occurring from five to twenty-five years of age and most frequent between the ages of five and fifteen. It may also occur during pregnancy. The cause is not definitely known. The chorea movements are sharp, decisive and irregular. The condition demands a period of absolute rest in bed with freedom from all excitement. Chorea can be best treated in an institution away from friends and relatives. All possible sources of auto-intoxication such as bad diet and constipation should receive special attention. The hydriatic man- agement, while very simple, is of great importance. During the period when perfect rest is demanded, pure sedatives should be used. Of these the neutral bath is most efficient. It should be given once or twice a day and prolonged from twenty minutes to an hour. The bath should feel warm, having a temperature of 96 or 97 F. The wet sheet pack may also be used, being kept at the neutral stage. It should last about the same length of time as the bath, or the patient may be allowed to sleep in it and be removed later with a wet hand rub. After some improvement has been secured, in a week or ten days, other sedative means which combine with them mild tonic effects may be used. These should at first be very mild, such as a wet hand rub, tepid sponging and the neutral spinal affusion or pour. The heat- ing abdominal compress or moist abdominal bandage may give good results. Fomentations to the spine, followed by the cold heating compress for 15 to 20 minutes is an excellent sedative. During the entire course of treatment, the neutral baths or packs should be continued. When convelescence is well established the cold mitten friction, cold towel rub, graduated and alternate sprays may be used, also light massage. All of these measures serve to remedy the anemia; even the neutral bath is helpful in this direction. The beneficial effects of out door life in the country, sunshine and fresh air can not be overestimated. In case chorea is complicated by endocarditis, the same system of treat- SPASTIC PARALYSES 187 ment should be followed as outlined for the endocarditis of rheumatism. The only alteration necessary is the substitution of sedative treatment once or more daily for some of the tonic such as the cold mitten friction used in rheumatic endocarditis. Paralysis Agitans While this is considered an incurable affection, the patient may be much benefited and the progress of the disease stayed for quite long periods of time by general hygienic management combined with sedative and mild tonic hydrotherapy. The measures recommended above for chorea are all helpful in shaking palsy. Dana 3 especially recommends the lukewarm (neu- tral) bath and mild massage. Oppenheim 4 has seen improvement following the use of the faradic bath. Vibrating chairs or vibrating machines adjusted to give a fine rapid movement may show good results. Out door life in the woods and country are especially beneficial. Spastic Spinal Paralyses There are a number of lesions of the cord which ultimately result in degeneration of the upper motor neuron, chiefly in the lateral column. The inhibitory control from the cerebral cortex being cut off, a condition of spastic paralysis results, i. e., a loss of control associated with rigidity and spasticity of the muscles. Such a condition occurs after various forms of myelitis, especially a transverse myelitis, also in amyotrophic lateral scle- rosis. If there is an acute onset as by trauma or inflammation, as fre- quently occurs in myelitis, the patient must be put to rest, either absolute or partial, according to the nature and needs of the case. In some cases gentle spinal extension should be used for some weeks and perfect quiet observed. In other cases, the patient may be allowed to move about the bed. During this time, spinal fomentations may be applied twice daily, fol- lowed by the heating spinal compress. The warmth of the limbs should be maintained by the hot foot bath or hot water bottles. It is necessary that the patient be given tonic treatment to keep up the nutrition and invigor- ate the circulation. These must, however, be quite mild, such as the wet hand rub and moderately cold mitten frictions. Later, light massage to the limbs may be used. As soon as the necessity for absolute rest is past, in the chronic stage when spasticity becomes marked, nothing has proven so helpful as the pro- longed neutral or warm bath. In those cases in which cure is possible this measure is almost specific. The patient should be made very comfortable in the tub by using a sheet hammock, rubber pillows, etc. The temperature of the water should be from 94 C or 95 to 97 F. It must feel slightly warm to the patient. At first, the bath may be twenty minutes to an hour in length, gradually increasing the time up to three or four hours of continuous immersion daily. Even six hours in the neutral bath may prove beneficial. The salutary effects are manifest in a lessened degree of rigidity, the limbs 3 Text Book of Nervous Diseases. 4 Diseases of the Nervous System. 188 SEDATIVE EFFECTS become more supple and can be separated to a greater extent. In order to obtain any permanent benefit, the patient must submit to treatment for many months. In the subacute stage, positive galvanism to the spine may be useful. During this time mild alternating hot and cold applications may be used to the part of the spine affected. Later in the disease, prolonged neutral baths give better results. Locomotor Ataxia In the treatment of tabes dorsalis we are concerned chiefly with the first two stages, the initial or pre-ataxic and the ataxic. In the paralytic or third stage, there is little that can be done. except to make the patient com- fortable and treat symptoms as they arise. In the pre-ataxic stage the patient must be put to rest. This may be accomplished by restricting or prohibiting exercise. It is usually best to proscribe exercise altogether for a time. The wheel chair may be used or, if thought best, the patient may be put to bed for two or three months. Simple, regular habits are imperative. During the period of rest, the patient may be treated by fomentations to the spine, cold mitten frictions and the warm bath. Dana recommends that this latter be given for ten to twenty minutes daily and followed by a single cold pour to the spine and rubbing. The object of treatment during this stage is to keep up the patient's general nutrition and afford rest, both mental and physical, so as to relieve the tax on the spinal nerves. If the progress of the disease can be stayed, the treatment outlined for the ataxic stage may be ventured upon, beginning mildly. The Fraenkel exercises may now be begun. These should at first consist of the more simple movements and the effort restricted to a few minutes. Later on, as co-ordination improves, they may be more prolonged and made up of more complicated exercises. Vigorous spinal tonics should be used during the ataxic stage unless the patient is becoming rapidly worse. Alternate hot and cold to the spine by means of the fomentation and ice may be used daily, or this may alternate with the Charcot (cold percussion) douche to the spine or hot and cold douche to the spine. These applications should be persisted in for months. The long static spark to the lower spine and legs may be used at the same time, say thrice weekly. Galvanic currents are also beneficial. It must be remem- bered that not all cases are susceptible of any marked improvement. The plans outlined above have proven very satisfactory in the hands of many neurologists. Nearly all agree that mercurial treatment is harmful unless symptoms of active syphilis still exist. Even in this case bad results have frequently been reported, and some observers believe that antisyphilitic medication may be the direct cause of tabes. For the arthritic complications (Charcot's joint) alternate hot and cold applications for the purpose of maintaining the local nutrition and improv- ing the circulation will be found helpful. These may be given by means of the revulsive compress, alternate pours, or alternate hot and cold immer- HYPERTHYROIDISM 189 sions. For painful joints, very hot fomentations may be given, followed by the heating compress. The treatment of the various crises is unsatisfactory. They may at times, be relieved by local hot applications. All forms of treatment, including hypnotics, may fail. The same may be said of the lightning pains. Build- ing up the general vitality of the patient will tend to remedy these distressing conditions. Parenchymatous Goiter The pathology 5 and morbid physiology of parenchymatous or exophthal- mic goiter must be fully understood if medical treatment is to be conducted to produce the best possible results. Exophthalmic goiter is now considered to be due to hypertrophy and hyperactivity of the thyroid gland. The dis- ease is better described as hyperthyroidism. The thyroid is one of the duct- less glands producing an internal secretion. The exact chemical nature of this secretion is not known. It is believed to be closely associated with some iodine compound. It is one of that class of substances known as chemi- cal messengers or harmones. It exercises a special influence over certain functions. In infancy, the absence of the gland is marked by the condition known as cretinism, in which both the mind and the body remain in an unde- veloped state. In adult life, atrophy or removal of the gland produces the condition known as myxoadema, or cachexia strumipriva. In these conditions, mental activity is below par, cerebration is exceedingly slow and all bodily movements are deliberate and physical activity much depressed. The oppo- site condition, known as hyperthyroidism, caused either by hypertrophy of the glandular tissue or by giving large doses of thyroid extract, produces a train of symtoms just the opposite of the above. The patient is nervous, restless, irritable and may be subject to insomnia. There is a fine temorof the fingers when the hand is held away from any support with the digits spread. During the early part of the disease, mental activity is excessive, ideation is rapid and all the brain functions are increased in acuity. If intoxication becomes intense, the pulse may be very rapid, running from 100 or 120 to 160 or more per minute; the skin is usually warm and moist, being covered with perspiration the most of the time. The blood vessels are dilated. Catabolic changes are increased and hastened as shown by the fever and increase in the excretion of nitrogen. There is a feeling of lan- ' guor; and asthenia may become very marked. In the gland itself, the col- loid material is deficient in amount, there is an increase in the number of secreting cells, even to the filling of the alveoli with cells; the bloodvessels of the gland are dilated and may be increased in number. Later, the par- enchymatous cells degenerate (cytolysis) liberating a large amount of thy- roid secretion; the most aggravated symptoms may be present while this is going on. The stethoscope applied over the gland frequently detects a sys- tolic bruit. Owing to this increased vascularity and the hypertrophy of the parenchymatous tissue, the thyroid is enlarged. Later in the disease, the eyes become prominent, the lids are closed with difficulty and the eyes feel 5 See articles on goiter among Collected Papers by the Staff of St. Mary's Hospital, 1905-1909. 190 SEDATIVE EFFECTS dry. It is supposed that the exophthalmia is due to dilitation of the blood vessels in the orbit. It will be seen that these conditions set forth the necessity for treatment directed toward decreasing and depressing the activity of the thyroid gland. In the spontaneous cure of this condition, the colloid material increases in amount, producing pressure upon the parenchymatous cells, thus causing their atrophy. The increase of the fibrous stroma of the gland has the same effect. In these facts lies the rationale of the beneficial action of the X-Ray. It has a specific effect in destroying or causing atrophy of highly differen- tiated tissue, while it favors the production of connective tissue. X-Ray exposures should not be given so frequently as to cause unduly rapid disin- tegration of the secreting cells, in which case thyroid intoxication may en- sue. The vascularity of the gland must also be decreased. Albert Kocker makes the following statements 6 "By reducing the hyper- trophic thyroid tissue or reducing its blood supply, we reduce the possibility of too extensive reaction to the primary cause and also enable the gland to adapt itself to counteract new outbreaks of primary causes which a nervous subject can easily show. "The fact that increased vascularization is indispensable for the develop- ment of the disease also proves that what reduces vascularization prevents its development." At the same time, it is necessary to slow the heart rate and restore the blood vessels to their normal tone. While all cases will not respond to the same treatment, or even to different measures arranged in different ways, yet in general, the treatment should consist of the means making up the following program: An ice cap should be placed over the goiter almost con- tinuously or for thirty minutes to an hour from two to five times a day. These cold applications reflexly contract the blood vessels of the gland, thus decreasing its vascularity and the amount of blood in the gland. They also tend to inhibit or depress the glandular activity, decreasing the formation of the internal secretion. At the same time, an ice bag should be applied to the precordia in much the same manner and for the same length of time as the ice bag to the goiter. It may be found convenient to alternate these applications, keeping the ice bag over the goiter for thirty minutes, then applying it to the heart for the same length of time, then reapplying it to the goiter, these alternations being continued more or less during the entire day. The vaso-dilitation and warm, moist skin require some treatment which will restore the vessels to their normal tone and check the over-activ- ity of the sweat glands. This is best accomplished by the cold mitten friction. It should be given from one to three times daily. Many of the principles governing the treatment of organic heart disease are involved in the treat- ment of parenchymatous goiter. The cold friction, by restoring the peri- pheral vessels to their normal tone, assists the heart action and so reduces the rate. The patient should be kept at absolute rest until the pulse has returned to nearly normal. Freedom from mental excitement and worry are fully 6 Surgical Treatment of Exophthalmic Goiter Journal of American Medical Association, October 12, 1907, pp. 1242-3. THE RELIEF OF PAIN 191 as necessary as physical rest. In fact, overtaxation of the mental powers, nervous excitement, etc., are often contributing factors in the causation of the disease and may constitute the immediate cause. In some cases, it may seem best to employ some of the sedative measures, such as fomenta- tions to the spine and the neutral bath. Usually both of these treatments are counterindicated. If the feet remain cold much of the time, the alternate hot and cold foot bath or alternate hot and cold douche to the feet should be used. We have yet to see a case which has not been brought to a successful issue when these measures have been applied early, and have seen complete restoration in cases that have come under treatment later in the disease when the pulse reached 160, while the patient was exceedingly nervous and unable to sleep, and there was very marked exophthalmia together with a large goiter. Those cases which come on after thirty respond much more readily to treatment than when the disease occurs in younger adults or under twenty years of age. But it is also true there is a natural tendency to recovery among young adults, nineteen out of twenty recovering with- out much treatment but rest. Hyperthyroidism beginning in persons from eighteen to twenty years of age is likely to run a course of three or four years and end in a spontaneous cure. Operative interference will be much less frequently necessary where these measures rest, hydrotherapy, etc. are given a thorough trial by those experienced in their use. The Relief of Pain Deep Seated Inflammations Those treatments which have already been outlined for the relief of con- gestion and inflammation in internal organs are also most effective in reliev- ing the pain occasioned by the inflammation. In the majority of cases, derivation by collateral heat, together with cold directly over the part, is used to relieve the congestion and pain. In others, hot applications alone are used. This is true of pleurisy, in which cold applications increase the pain. In many cases the pain is relieved best by very hot applications applied directly over the seat of the pain. 1^ has already been mentioned that cold may be used over an inflammatory process in soft tissue, while in bony parts it is necessary to use hot applications directly over the seat of the pain. In the case of osteomyelitis and usually in mastoiditis, cold appli- cations or the ice bag applied over the inflamed part increases the pain. When an inflammation has gone on to the formation of an abscess, cold applications, especially the ice bag, have very little influence on the pain as far as relieving it is concerned, and may make it worse. Fomentations over an abscess may relieve the pain for a time, but this does not last as long as the relief afforded previous to the formation of the abscess. In order to decrease the throbbing pain of an inflammatory process or collection of pus in the bone, it is best to apply the ice bag over the large artery supplying the inflamed part. The relief of the pain in this case is brought about chiefly by reducing the congestion. If, at the same time, a 192 SEDATIVE EFFECTS very hot fomentation is applied over the part, the effect is intensified by the specific pain-relieving action of the heat. Superficial Inflammation In the early stage of a superficial inflammation, a prolonged cold appli- cation is usually very effective in relieving the pain. This should be accomplished by immersion in cold water or ice water or by the use of the ice bag. Later on, it will be found that very hot applications more effect- ively relieve the pain. Either very hot fomentations or hot immersion may be used. Sometimes the neutral or warm pour is very grateful, there seenv- ing to be an added effect from the affusion that is not obtained by quiet immersion. The production of fluxion by alternate extreme hot and cold immersion is productive of good results where there is not much throbbing pain. Gastric or Duodenal Ulcer It is often the case that the pain is worse during the time that there is lit- tle, if any, hemorrhage from the ulcerated surface. In case hemorrhage of any moment occurs, it is necessary to use some cold applications, such as cracked ice by mouth, or the ice bag over the stomach. Otherwise, the pain is best relieved by very hot fomentations applied to the epigastrium, or the full hot trunk pack. These applications may be followed by either the moist abdominal girdle or by the heating wet sheet trunk pack. The effect of these applications is to relax the musculature of the stomach and so, by decreasing peristalsis, relieve the pain incident to muscular contractions. Rectal Ulcer The same principles apply here as above. The pain is most effectively relieved by applications which relax the bowel, thus decreasing the move- ment and consequent irritation of the ulcerated surface. This may be accomplished by the hot enema or fomentations. Usually the hot sitz-bath is much more effective. Hemorrhoids Two different plans may be followed in relieving the pain occasioned by rectal varicose vains. Very Jiot applications are effective in relieving the pain, but these have no tendency to decrease the size of the hemorrhoids. On the contrary, they may increase the dilitation of the veins, stasis of blood and consequent pain. Of the hot applications which may be used, the very hot sitz-bath is most effective. In case facilities for this are not at hand, fomentations may be used. For permanent results, we prefer cold applications, such as the prolonged cold sitz-bath, ice bag to the perineum, also the hot and cold perineal spray. To be effective, these treatments should be repeated once or twice daily for several weeks. The temperature of the cold sitz-bath may be decreased grad- ually as the patient is able to bear it. Neuralgia The classification of neuralgias into two types has aided in the treatment NEURALGIA 193 of this condition. Simple neuralgias, not due to pressure from tumors, exostoses, etc., we have classified as either toxic or inflammatory. By the term toxic, we designate such neuralgias as are due to rheumatic (uric acid) diathesis, or some form of auto-intoxication. The essential element in the causation of this form of neuralgia is the circulation of toxins in the body, or the accumulation of toxins about nerve centers or nerve trunks. By the term inflammatory neuralgia,* we understand such conditions as are due to actual inflammation, usually such inflammations as pass through the regular stages of an inflammatory process, from acute to chronic. It may often be difficult, impossible, and in some cases, unnecessary to make these distinctions. It will be readily understood that some of the changes occur- ring: in an ordinary inflammation are produced by the accumulation of toxins about nerve trunks. Local edema of tissues occurs in both cases. 1. Toxic Neuralgia. Where there is a local accumulation of toxins about a nerve trunk, it appears that hot applications most effectually relieve the pain while cold increases the pain. Nitrogenous extractives and other nitrogenous toxins are soluble with difficulty. They are more readily dissolved in hot water. Since prolonged hot applications raise the local tem- perature of the part treated, it might be supposed that the toxins are rendered more diffusible and hence may be gotten rid of more rapidly. The chilling of the tissues would result in a greater precipitation of these sparinglv soluble substances and so tend to increase the pain. It must, of course, be remembered that heat has a specific pain-relieving action which is possibly greater in importance than any action it may have upon the local accumulation of toxins. The pain of toxic neuralgia may be relieved by very hot. fomentations or the local electric light bath. For a prolonged application, the hot water bottle is very serviceable. Any of these appli- cations may be followed by the heating compress. This should be wrung from tepid or cool water; rarely, if ever, from ice water. The mode and duration of the hot application should be varied according to the character and location of the pain. In treating sciatica, the hot fan douche is a very effective means. Very hot affusions may be used. Sometimes the hot percussion douche is more effectual. It must always be borne in mind that the cure of the case requires the entire removal of the cause. For this reason, a regime embodying the prolonged use of tonic hydrotherapy, general eliminative treatment and proper diet, is necessary for the permanent relief of neuralgias. 2. Inflammatory Neuralgia. A very different plan should be followed where the pain in nerve trunks is due to real inflammation. Prolonged cold applications, even to almost freezing the part, give better results than hot applications. For this purpose, it is sometimes recommended to use the ethyl chloride spray. Cold may also be applied by means of the ice bag, ice pack or ice compress. These should not be too thickly covered and should be left in place a sufficient length of time to materially lower the temperature of the part treated. Sometimes derivation by direct cold and collateral heat is very effective. Cold affusions may be used. The pain of an inflammatory sciatica is often benefited by the alternate hot and cold douche applied up and down the thigh- over the sciatic nerve. 194 SEDATIVE EFFECTS In all cases of neuralgia, it is best to make repeated search for the cause. While the majority of cases of facial and other neuralgias are not due to conditions which can be remedied by operation, yet this is sometimes the case. In this condition, it might be mentioned that operation for facial neuralgia is, in the majority of cases, not only a failure, but an actual detri- ment to the patient. The relief of the pain is merely temporary and, because of shock, nerve exhaustion, etc., repeated operations render the patient much more susceptible to pain. Tenesmus Rectal or Vesical Pain in hollow muscular organs is chiefly due to the contractions of the muscular tissue. The activity of the muscular wall increases the irritation arising in the mucous membrane. To relieve tenesmus of the bladder or rectum, we have found the hot sitz bath most effectual. The heat should be prolonged a sufficient length of time to fully relieve the pain, Only a brief dash of cold water should be given at the close. In some cases, it should be omitted entirely. Large fomentations or the hot hip pack maybe used. In rectal tenesmus, a small hot enema or the starch enema affords relief. The enema should be given before fomentations or the hot sitz is applied. Cold applications increase the muscular activity, and hence the pain. Dysmenorrhea The condition here is somewhat similar to a tenesmus. It is most fre- quent in sharp anteflexions of the uterus, or may be occasioned by chilling. In order to afford immediate relief, it is necessary to relax the musculature of the organ. Cold causes contraction of the uterine muscle and so prevents the outflow of blood, while hot applications relax the muscle. Often simple fomentations are sufficient to afford relief. It may, however, be neces- sary to use the short hot sitz bath. No cold treatment should follow it. The application of the unwrapped ice bag to the sacrum may be used, accom- panying some hot application to the feet and legs. It may be necessary to continue this 20 or 30 minutes. Hot applications in front may be used at the same time. The ice bag when applied anteriorally has the opposite effect, that is, it causes contraction rather than relaxation. Probably, the explanation of the action of the ice bag to the sacrum in relaxing the uterus as has been pointed out, lies in the fact that the posterior area is in less per- fect reflex relation with the uterus; and for this reason, the reflex is easily paralyzed, the effect then being opposite to that which we usually expect from the ice bag. In addition to these measures, the hot enema and very hot vaginal irriga- tion may be administered prior to the use of the fomentation or hot sitz. In the case of suppressed menses with pain, when due to colds or exposure to dampness, it is well to use a hot foot bath; or better, hot leg bath, together with some local hot applications. This reduces the extreme pelvic congestion, renders the outflow easier and so relieves pain. Colic Renal, Biliary, Intestinal The pain of renal, biliary and intestinal colic is largely due to spasmodic SPRAINS AND BRUISES 195 contraction of the non-striped muscle of these parts. The irritation of the mucous membrane by the calculus stimulates the muscle to contract. To relieve pain from calculus or the pain of intestinal colic, it is necessary to use large hot applications in order to secure perfect relaxation. 1. Renal and Biliary Colic. It is usually considered that morphin is absolutely essential in these conditions. By the use of the full hot blanket pack or hot trunk pack, morphin may often be entirely dispensed with. If the pack does not fully relieve the pain, a much smaller dose of morphin than would otherwise be required, will be sufficient. The blanket should be wrung from boiling water, quickly spread out on the bed over a dry blanket and as quickly as possible wrapped about the patient. It is not necessary to include the arms in the pack. A hot water bottle over the abdomen and spine bags along each side of the trunk will help to maintain the heat of the pack. In cases where the pain is not so severe, large fomentations may be sufficient. The full hot tub bath gives good results in some cases. Wherever a hot application is much prolonged, cold compresses should be applied to the head and neck. No cold applications whatever should follow the hot pack. Even a very brief application of cold may bring on the pain. 2. Intestinal Colic. When intestinal colic is due to poisoning or simple diarrhea, it is well to begin the treatment by thorough cleansing of the intestinal canal. It may be necessary to use a cathartic in order to com- pletely remove the irritating toxic material. In all cases, hot enemata should be given until the lower bowel is thoroughly cleansed. If necessary, this may be followed by the starch or starch and laudanum enema. Following this, the most effective measure for the relief of the pain is the abdominal fomentation. This should be continued until the pain has been entirely relieved. The hot water bottle may be used between treatments. Fomenta- tions to the abdomen may be given every 2 to 4 hours or as frequently as necessary. Burns In the case of burns covering a somewhat limited area, the dressings usually applied are sufficient to relieve the pain. Cold immersion relieves the pain during the time the part is in the cold water. It has, however, been our experience that the pain is worse after removal from the water. On the contrary, while hot immersion is not very greatful during its continu- ance, its after effect is better than that of cold immersion. A neutral or warm pour to the burned part is very effective in relieving the pain. In extensive burns, it is often necessary to use a full immersion bath of either neutral or cool water. In the absence of facilities for this, a prolonged wet sheet pack renewed by frequent sprinkling with cold water may be used. With the exception of extensive burns or where the pain is unbearable, we do not greatly favor the use of hydrotherapy for the relief of the pain. The use of picric acid in saturated aqueous solution followed by dusting' the part with stearate of zinc has given such good results in the relief of pain, rapid dermatization and healing that we use it as a routine treatment. Sprains and Bruises Hot applications, including fomentations and hot immersion, are common 196 SEDATIVE EFFECTS household remedies for the relief of pain occasioned by sprains and bruises. These applications do effectually relieve the pain and relax the muscles. In many cases, much better results may be obtained by the prolonged cold immersion. This reduces the congestion and helps to prevent excessive exudation of serum into the soft tissues about the sprained part. Along this line, we may draw a practical lesson from the method instinctively pursued by wild animals. They usually seek a stream or body of cold water and stand in it for hours at a time. Whatever method is used at first, after a day or two, it will be found advantageous to utilize alternate hot and cold applications, such as the hot and cold spray, pour or immersion. These stimulate the circulation, thus hastening the absorption of the edema. Fractures There are two objects to be attained by hydriatic applications in fractures. These are the relief of the pain and the relaxation of the muscles. The limb should be enveloped in a large fomentation or immersed in very hot water. Care should be taken thafa burn or blister does not result. These methods are in too common use to need extensive discussion. It will always be found easier to set a bone if the muscles have been thoroughly relaxed by the preliminary use of hot applications. The same principles apply to the reduction of a hernia by taxis. CHAPTER XXII EXPECTORANT EFFECTS There is a definite series of changes accompanying the course of such con- ditions as colds, acute bronchitis and simple croup. In all congestions and inflammations of the mucous membrane of the respiratory tract, the first change is that of intense congestion accompanied by swelling and turgescence of the membrane which is dry and much irritated. In this condition the cold is said to be "tight" because of the extreme irritation and the fact that the dry mucous membrane renders difficult gaseous interchange. Very soon there begins to appear a secretion of a thick tenacious mucus, accom- panied by leucocytes. Later, the character of the secretion becomes altered. It is more fluid, contains frothy mucus and is more purulent in nature. When this change occurs, the cold is said to have "loosened." From this time on, expectoration becomes easier. During the first stage of the tur- gescence of the mucous membrane, there is no expectoration. Later, there is a very small amount of thick mucus which is expectorated with difficulty; and after the cold has thoroughly loosened, the quantity is very much increased, while the sputum is quite fluid. In the application of measures designed to relieve these conditions, that which appears most rational is the hastening of this series of changes and relieving such symptoms as pain and cough. During the first stage, that is, of congestion, and the second stage when there begins to be a secretion of thick mucus, it is necessary to decrease-the congestion and increase the fluidity of the secretion. This is best accomplished by moist heat such as the inhala- tion of steam, fomentations to the chest and throat, hot water drinking, the heating chest pack or some general sudorific measure. The moist heat dilates the blood vessels and stimulates the activity of the mucous glands, so that they produce a more fluid secretion. These measures should be con- tinued with but little change until the symptoms are considerably amelior- ated. Then, after the first day, it is best to employ alternate hot and cold applications, the revulsive compress, cold mitten friction, etc., in order to promote resolution, absorb the exudate and prevent further excessive secre- tion. This is best accomplished by stimulating the circulation, so equalizing it that congestion of the pulmonary mucous membrane and the mucous mem- brane of the nose and throat is decreased. These measures also stimulate the depth of respiration and increase gaseous interchange. All sudorific measures ease difficult respiration and increase the fluidity of expectoration. The following are the most useful measures: 1. Russian or vapor bath. 2. Inhalation of steam, plain or medicated. 198 EXPECTORANT EFFECTS 3. Fomentations to chest and throat, or the hot trunk pack. 4. Heating chest pack and heating throat compress. 5. Hot water drinking. Several of these may be combined: for example, fomentations to the chest and throat may be accompanied by hot water drinking, inhalation of steam and the hot foot bath. Expectorant effects are indicated in the following conditions: 1. Colds. 2. Acute bronchitis. 3. Chronic bronchitis. 4. Asthma. 5. Croup. 6. Bronchiectasis. 7. Pulmonary tuberculosis. Precautions: All of the applications recommended for expectorant effects are of a more or less diaphoretic nature, and consequently the patient is predisposed to colds and there is a greater liability to return of the symp- toms. For these reasons, it is best to employ such measures as the alcohol or witch-hazel rub at the conclusion of the sweating measure, or some mild cold application such as the wet hand rub or cold mitten friction. The chest should be protected by a dry chest pack. The clothing should be sufficient to provide warmth, and the patient should be cautious about exposure to drafts, dampness, etc. Colds, Acute Coryza, Pulmonary Congestion, Acute Bronchitis In these conditions, it is necessary to accomplish the following results: First, relieve congestion and pain. Second, ease the cough and aid the expectoration, first by increasing its fluidity and latter, the facility of expec- toration. Some general sweating measure is indicated during the first stage of a cold. The treatment already mentioned is indicated at this time. Fomen- tations to the chest and throat should be repeated at intervals of 3 to 5 hours followed by the heating compress to the throat or chest, according to the location of the congestion. Fomentations also relieve the excessive cough and the pain accompanying the cough. The drinking of hot water aids dia- phoresis and helps to increase the fluidity of the secretion by increasing the amount of water in the blood. From the beginning of the cold, the patient should, after every hot treatment be given a cold mitten friction or cold towel rub and later, such treatment as hot and cold to the spine, revul- sive compress to the chest, hot and cold foot bath, in order to equalize the circulation and promote return to the normal tone. In acute coryza (cold in the head) alternate hot and cold to the head may be used from the start and repeated several times. A hot foot bath should be given at the same time.. CHRONIC BRONCHITIS 199 Croup In diphtheretic croup, we are less frequently called upon to treat extreme conditions than before the introduction of antitoxin. However, in this dis- ease and also in simple and spasmodic croup, expectorant effects are indi- cated. In the latter conditions the child should be given some sweating treatment, such as a hot foot bath accompanied by hot moist applications to the chest and neck. This should be continued until the harsh, brassy cough gives way to free and easier expectoration. When this occurs, the dyspnoea and cyanosis will be relieved. The inhalation of medicated steam is a great aid in the treatment. Special inhalers may be provided, or an ordinary teakettle or basin may be utilized for the production of steam which may be conveyed to the patient by means of an inhaling funnel or mask. The drinking of some hot liquid will increase the sweating and hasten the loosening of the secretions. The heating compress or the moist chest pack should be applied after the fomentations and left in place from thirty minutes to two or three hours. The child usually falls into an easy sleep following such treatment. In some cases it may be necessary to dis- pense with the moist inside part of the chest pack, using only the dry pack. Asthma The treatment of the asthmatic paroxysm by means of hydrotherapy is a disappointment, and this in spite of the fact that by a more or less prolonged course of hydriatic, dietetic and climatic treatment, very severe cases of asthma of long standing are almost completely cured. . Permanent and very decided results are obtained in cases that submit to treatment for a suffi- cient length of time. Hydriatic applications, however, may be made to assist in relieving the patient during the paroxysm. Two objects are to be attained, the lessening of the dyspnoea and facilitating expectoration. These may be accomplished by some mild sweating treatment, fomentations to the chest, or the inhaling of medicated steam. As soon as the patient breaks out into a gentle perspiration, the dyspnoea begins to lessen. Chronic Bronchitis This condition is treated in much the same manner as any chronic inflam- mation. The results to be obtained are, first, relief of the cough; and second, lessening of the amount of expectoration and facilitating its expul- sion. The patient should be given a definite program of treatment such, for example, as the following: Hot foot bath, together with fomentations to the chest and the cold mitten friction; also fomentations or revulsive compress to the abdomen, revulsive compress to the chest, hot and cold to the spine, cold towel rub, salt glow. It is usually best to have the patient wear some form of a dry chest pack. All of these measures stimulate the 200 EXPECTORANT EFFECTS circulation, reducing the venous stasis in the lungs, and promote resolution. The fact that the circulation in the lungs is more rapid tends to decrease the amount of the secretion. The patient's general vital resistance is raised by such a course of treatment. The digestion requires special attention. "Stomach. cough" is not a bad name for many cases of chronic bronchitis, since the indigestion, auto-intoxi- cation and sluggish condition of the liver are very largely accountable for the excessive secretions. If the patient may be induced to give up all com- plicated dishes, desserts, meats, rich and highly seasoned foods, and limit him- self to a very simple diet, the condition will yield to treatment much more readily. The same is true of bronchial asthma. So astonishing are the results obtained in both these diseases by rigid dietetic regulation, accompanied by general tonic treatment that, although requiring a long time to produce, they seem almost miraculous. CHAPTER XXIII DIAPHORETIC EFFECTS There are a large variety of measures which induce general perspiration. Any hot application, even if local, may induce perspiration over the entire body. The measures to be selected as most efficient in treating a disease depend upon the causes of and conditions in that disease. The following is a list of the principal diaphoretic measures: 1. Electric light bath (general or local) . 2. Sun bath. 3. Turkish bath. 4. Superheated air bath (250 to 400 F.). 5. Russian bath or vapor bath. 6. Full hot bath. 7. Hot blanket pack. 8. Dry pack. 9. Electro-thermal pack. 10. Heating wet sheet pack. 11. Hot spray or douche. 12. Hot leg or foot bath. 13. Hot sitz-bath. 14. Fomentations to the spine. 15. Hot water drinking. 16. Hot enema. Each measure has its own range of applicability and special adaptability to the needs of the individual case. The more local and milder measures have a wide range of usefulness. The more extreme and general heating treatments have certain counterindications which must not de disregarded. Tonic cold applications should usually follow sweating treatment. The main effects of diaphoretic applications are as follows: 1. Increase perspiration (water chiefly). 2. Increase catabolic changes (spoliative or reducing). 3. Increase elimination of toxins through the skin and through the kid- neys indirectly by relieving these organs when overworked or congested, thus making more efficient the work which is done. In health, diaphoretic measures do not increase the amount of urine and may considerably decrease it, but in all conditions where there is lessened functional activity of the kidneys, diaphoretic measures tend to produce diuresis and hasten the elimi- nation of toxins through that channel. 4. Increase the activity of the sebaceous glands and skin in general, thus improving its nutrition. 202 DIAPHORETIC EFFECTS 5. Relieve internal congestion. 6. Decrease dropsical effusions. 7. Prepare the patient for cold treatment by promoting ability to react. There are a large number of conditions in which diaphoretic measures are indicated. In a few diseases the most vigorous sweating treatments may be used with great benefit. Below is given a list of diseases and morbid conditions which require special diaphoretic treatment. Very vigorous means may de used in all but the first three. Indications for diaphoresis. 1. Icterus. 2. Systemic poisoning (toxemia). 3. Internal congestions. 4. Obesity. 5. Acute rheumatic fever. 6. Chronic articular rheumatism. 7. Gout. 8. Bright's disease, acute and chronic. 9. Uremia. 10. Eclampsia. It will be noticed that nearly all of these diseases are intimately associated with, or due to, defective metabolism. The treatments that promote dia- phoresis and diuresis all powerfully affect metabolism. Internal tissue changes are of course the antecedents of, and are manifest by, changes in excretion. It is these tissue changes and the consequent elimination of car- bon dioxide and nitrogenous wastes that are of so much importance. For this reason the majority of the diseases considered under the two heads of diaphoretic and diuretic effects might with equal or greater consistency be considered under the single head of metabolic effects. We have, however, thought best to consider most of these in the following chapter after a general statement of the means of producing diuretic effects and the principles involved in such effects. Counterindications to extreme sudorific measures. 1. Asthma. 2. Organic heart disease. 3. Emaciated rheumatics and diabetics. 4. Sunstroke and heatstroke. 5. Pulmonary tuberculosis. 6. Asthenic fevers. 7. Icterus. 8. Emaciation and exhaustion. 9. Old age. Obesity In considering the effects of thermic applications upon tissue changes in respect to both nitrogenous and carbonaceous metabolism, it was shown that all forms of cold treatment increase catabolic changes, also that exces- sive heat or long continued heat has the same effect. The two extremes, OBESITY 203 however, do not have the same effect upon anabolism, heat having little or no tendency to increase the building up processes through increased absorp- tion and assimilation of food. Tonic cold applications often increase ana- bolism more than catabolism. It is for this reason that cold applications signally fail in securing any great reduction in weight. The patient may lose a few pounds. Of course, the general vitality of the patient and all nutritive processes are enhanced by alternating hot and cold applications. This is doubtless the more rational way to treat obesity, since it is more necessary to improve the general condition of the patient than to reduce the weight; but if the reduction of the weight is the objective point, it is necessary to resort to extreme sudorific measures, unaccompanied by cold applications. For this reason, it is not possible to greatly reduce the weight of persons suffering from fatty heart, accompanying the general obesity. Spoliative and reduc- ing measures aim at increasing catabolism without a corresponding increase in anabolism. All extreme sudorific measures available should be used in this condition. Those which will be found most helpful are the Russian bath, Turkish bath, electric light bath, full blanket pack, electro-thermal pack and sweating wet sheet pack. The full hot bath and the mud baths, commonly used at hot springs, may be used. These do not, however, have any advantage over the first three measures mentioned. The patient should have one prolonged sweating treatment daily. It is often necessary to finish with a very short cold spray. This should not be greatly prolonged for the reasons above mentioned. The patient should take as much vigorous exercise as possible. Heavy massage may also be used. It is needless to say that the following of such a program will result in weakening the patient as well as in reducing the weight. These measures may all fail unless the diet is reduced, especially as regard the total number of calories. As soon as the patient returns to his usual habits of inactivity and overfeeding, there will be a prompt gain in weight which will replace all that has been lost. Extreme sweating treatments do, however, materially reduce the weight and, by guarding the diet and encouraging exercise, the loss in weight may be quite permanent. It is usually impossible to employ prolonged or extreme diaphoretic treat- ment in this condition, but free perspiration should be encouraged, since by increasing the elimination of bile through the sweat, it relieves the nerv- ous irritability and aids in relieving pruritus. Local hot applications are illy borne because of the extreme sensitiveness of the skin. The electric light bath is a very efficient means, since its heat is evenly distributed. Systemic Poisoning In many conditions in which toxic substances circulate in the blood and lymph, free diaphoresis materially hastens their elimination. Such sub- 204 DIAPHORETIC EFFECTS stances may be produced by auto-intoxication from intestinal sources, or faulty metabolism. General poisoning may result from the ingestion of ptomaines, lead, mercury, alcohol, etc. In some cases, vigorous diaphoresis is necessary; in others, only mild diaphoresis with copious water drinking should be used. Because of the weakness and debility resulting from the poison, extreme sweating measures can not be used. A short electric light bath is often all that is necessary. Internal Congestions The use of sudorific measures in relieving congestion of the viscera has been considered elsewhere, especially in connection with inflammations and diseases of the kidneys. It is not possible for an extreme congestion to exist in the internal organs while the skin is red and congested as occurs in a sweating treatment. But in order to more permanently relieve the internal congestion, it is necessary that the blood be retained in the skin. This is not accomplished by the hot alone, but can be by the reaction hyperemia resulting from a cold friction. The principle of these effects has been con- sidered in connection with the subjects of derivation and fluxion. The relief of visceral congestions by general sudorific measures is indicated in acute nephritis, eclampsia, uremia, pulmonary congestion, acute pleurisy and the early stages of many infectious diseases such as influenza, measles, scarlet fever, etc. CHAPTER XXIV DIURETIC EFFECTS We have previously shown the close connection existing between the func- tions of the kidneys and skin in diseases of either of these organs. In the preceeding chapter a list of the various sudorific measures is given. All of these treatments are beneficial in conditions of defective kidney activity. It has long been known that nephritis and diseases of metabolism, closely associated with the functions of the kidney, are benefited by free diapho- resis. In these diseases all brisk sudorific measures indirectly increase uri- nary secretion. This is probably due to the fact that renal congestion is lessened, the stagnation relieved, so that while there is less blood in the kidneys at any one time, the rapidity of the renal circulation is increased. The secretion of urine is therefore more efficient and the quantity of the watery and solid constituents is increased. The increase in urinary solids is due not alone to stimulation of the renal epithelium by a quickened circula- tion, but also to heightened metabolic changes occurring in the tissues them- selves. The stimulation of the general circulation and especially of the hepatic circulation and of the liver cells produced by sweating treatment or accompanying the reaction to cold treatment, has been shown to increase the toxicolytic powers of the liver. Toxemia is thus lessened in a very direct manner. The blood being less toxic, irritation of the renal cells is decreased and the work done by the kidney is more efficient. The following are the principle diuretic measures which are useful in kid- ney insufficiency and allied conditions: 1. Full hot blanket pack. 2. Electric light bath. 3. Russian and other vapor baths. 4. Hot air baths. 5. Full warm tub bath. 6. Water drinking (especially with above). 7. Cold (or hot and cold) douche to lower sternum and lumbar spine (entire width of back). 8. Cold heating trunk pack or the rubbing wet sheet pack. 9. Fomentations to lumbar spine. Indications. 1. Bright's disease, acute or chronic. 2. Uremia, eclampsia and other toxemias. 3. Acute suppression of the urine. 4. Ether and post-operative nephritis. 5. Ptomaine poisoning. 6. Poisoning by lead, turpentine, alcohol, etc. 206 DIURETIC EFFECTS Gout and Chronic Rheumatism General Consideration The literature on the purin diathesis is most voluminous and much of it unreliable; there are, however, some important facts regarding purin metab- olism that have been sufficiently well proven to allow of their being used as a foundation for the basic principles involved in the treatment of these con- ditions. We can not here attempt anything like a complete consideration of this question, but merely point out those facts which seem to us to be of importance in determining the treatment. There seem to be three causes for the accumulation of basic purins and uric acid in the system. These are, first, excessive ingestion of purin-containing foods over long periods of time; second, defective and deficient xanthin oxidation and uricolysis; and third, decreased elimination of purins because of kidney insufficiency. To provide a diet free from purin is not difficult and so the removal of this first cause is a comparatively easy matter. To remedy the second is, how- ever, a more difficult matter. It has been shown how applications of both heat and cold accomplish a quite thorough xanthin oxidation, i. e., a change of the basic purins to uric acid. This change of basic purins to uric acid is a distinct advantage, as uric acid is less irritating to the renal epithelium than the bases. "Mammals form uric acid only from the purins and have the power of destroying some of the uric acid formed. This uricolytic power is relatively weak in man." 1 Nucleoproteids are converted into free purins and these, in turn, are changed into uric acid by the loss of nitrogen and the addition of oxygen. "Wiechowski has particularly studied the enzyme concerned in the destruc- tion of uric acid by the tissues, and the fate of free uric acid in the body. This uricolytic enzyme, which has been appropriately called uricase by Batteli and Stern, is an oxidizing enzyme, acting best in experimental diges- tions when a lively current of air is running through the digestion mixture, and which seems not to be present in the blood plasma and tissue fluids, but only in the cells. It acts rapidly and with striking effect, for active organ extracts are sometimes able to destroy quite considerable quantities of uric acid in a few hours; for example, one gram of powdered tissue, dry weight, can often destroy totally 0.1 gram of uric acid in four hours. Unlike the enzymes of autolytic disintegration of tissues, uricase is not inhibited by the presence of an excess of serum. Another interesting feature is that this enzyme acts reversibly, or at least tissue extracts which destroy uric acid with a current of air running through, soon build up the uric acid again u'li en the air is shut off." 2 The above facts show the benefit to be derived from hydrotherapy in stimulating the circulation, increasing the oxygen-carrying capacity of the red cells and increasing oxidation in the body tissues. Out-of-door life in 1 H. G. Wells Trans. Chicago Pathological Society, May 1, 1909. 2 Editorial in Journal of American Medical Association, October 9, 1909, p. 1191; see also The Oxidases, Bulletin No. 59, p. 103, of Hygienic Laboratory, Public Health and Marine Hospital Service of the United States. RHEUMATISM AND GOUT 207 the fresh air and sleeping out of doors furnishes the abundant supply of oxy- gen so necessary to uricolysis. In addition to the effects of hydrotherapy certain articles of diet play an important part in the prevention of uricacidemia. This is notably so of fruit. "Weis, in 1898, asserted that after eating fruit the uric acid of the urine is decreased and the hippuric acid increased." 3 "Wohler found uric acid, but no hippuric acid, in the urine of sucking calves, so long as they consumed nothing but milk. But as soon as they passed on to vegetable food, the uric acid disappeared and hippuric acid was substituted. It thus appears that the benzoic acid arising from vegetable diet siezes upon the glycocol and prevents the synthesis of uric acid. It is useless merely to give benzoate of sodium, as I have proved by many experiments. But here again it should not be forgotten that it is not in our power to make the benzoic acid reach the proper point at the proper moment when the glycocol, before its union with the cyanic acid could reach it. As already mentioned, the benzoic acid in vegetable food is not generally contained as such, but is formed in the body by the decomposition and oxi- dation of more complex combinations. It is quite possible that these latter are taken up by the cells in which glycocol occurs, while the benzoic acid already formed is rejected." 4 The use of medicinal substances in the treatment of gout, outside of those found in man's natural diet is a disappointment. This is true of benzoic acid, the salicylates and also of lithium. This latter neither affects the solubility of uric acid in the tissues nor in the slightest increases its elimination by the kidneys. Even if lithium exerted an influence on the solubility of uric acid, the amounts present in commercial lithia waters would be too minute to accom- plish anything. Relative to this fact, Dr. Henry Leffmann says, 5 "On the result of an analysis of about two score of the so-called mineral waters, the Bureau of Chemistry of the Department of Agriculture has recently issued a circular of inquiry the essential features of which I give herewith. It has been found that nearly all "lithia waters" either contain only spectroscopic traces of lithium (unweighable quantities in from 2 to 4 liters), or contain less than one part per million (approximately 0.05 grain per gallon) of lithium." Along the same line we quote the following from Bunge, (i "If it be desired to prevent the formation of uric acid sediments, or to dissolve concretions that are already formed, by the administration of alka- lies, it is more sensible to advise the use of fruits and potatoes than to order alkaline mineral waters, the contined use of which may produce disturbances which we are unable to estimate. Because the combination of uric acid and lithia is more soluble in water than its combination with soda or potash, it has been thought necessary to treat the uric acid diathesis with a few Journal of American Medical Association of February 19, 1910. 6 Physiological and Pathological Chemistry, Second English Edition, pp. 322 208 DIURETIC EFFECTS decigrammes of carbonate of lithia, or even with mineral waters containing one centigram of lithia to the liter. This naive idea simply implies ignor- ance of Berthollet's law. We know that in solutions of bases and acids, every acid is distributed to all the bases in proportion to their quantity. It follows that only the very smallest portion of uric acid will combine with the lithia, the largest proportion combining with the preponderating quan- tity of soda, which we introduce as chloride of sodium. The largest propor- tion of lithia will reappear in the urine, united with the chlorine of the chlor- ide, with sulphuric and phosphoric acid. There will be no increase in the solubility of uric acid." Treatment Chronic rheumatism, gout and allied conditions, such as the myalgias, lumbago, etc., are usually treated by diaphoretic measures. It must be con- fessed, however, that the majority of rheumatics are not able to stand such treatment. Only those who are obese or of more than average weight can stand extreme sweating measures. It is for these reasons that many a rheu- matic patient leaves a course of baths at the hot springs in worse condition than when he began. Many and many are the patients that year after year visit the various spas of this country and Europe, deriving each time only a temporary benefit. For this, there are two reasons. All are given the same routine of hot baths, regardless of the individual conditions and needs. Obese or emancipated, they are all treated alike. Second, there is a failure to eliminate from the diet all purin-containing foods and reduce to a mini- mum the proteid intake. Chittenden has shown that a daily ration contain- ing 35 to 60 grams of proteid is not only compatible with perfect health, but also conducive to gain in muscular capacity, increasing the endurance to prolonged muscular effort and lessening fatigue. In chronic rheumatism and gout, the proteid should be reduced to the least amount compatible with the actual need of the body for nitrogen. As pointed out by Garrod every particle of food not absolutely needed for the nourishment of the body merely nourishes the disease. One can not hope to cure disease unless the cause is removed. In rheumatism, the two chief causes are overfeeding and under exercise. The overfeeding is in the line of heavily proteid foods and foods containing purin. These must be eliminated from the diet if great benefit is to be derived from treatment. For practical purposes, we must divide chronic rheumatism into two classes, viz., obese rheumatics and emancipated, anemic rheumatics. In the first class, sweating treatment may be used with benefit when properly combined with tonic measures. In the second class, extreme sweating treatment is not permissible. Rheumatism with Obesity. Those patients who are well nourished may be given a thorough sweating treatment daily. Any of the sudorific meas- ures recommended in obesity are serviceable. The Turkish bath, Russian bath, electric light bath, hot blanket pack, sweating wet sheet pack, or elec- tro-thermal pack are all applicable. Their effects may be greatly enhanced by free water drinking. The mineral waters possess no advantage over any pure water. The beneficial results are derived from the free perspiration and diuresis it induces. It thus affords ample solvent for the increased GOUT AND RHEUMATISM 209 nitrogen excretion. F. Umber 7 claims that alkaline water has the opposite effect; also that the blood of gouty patients is able to dissolve larger propor- tions of free uric acid than it ever contains. He declares that none of the alkalies or mineral waters have any specific influence on the purin metabol- ism in gout and that the propaganda for the "lithium content," etc., of springs should be abandoned. Tonic measures should not be neglected. The strength should be main- tained and the circulation stimulated. All hot baths should be followed by some form of cold treatment. These may at first have to be mild, but obese patients stand cold treatment well. The alternate hot and cold per- cussion douche is an excellent means. It serves as a massage, stimulates the vasomotors, and restores the tone lost because of the hot bath. It should be applied especially to the spine and legs and should consist of from three to five complete changes from hot to cold. The patient should be dried from the cold and may either rest or take exercise after it, according to the con- ditions of the particular case under observation. Individualization is the life of therapy no less with rheumatism than with other diseases. Light or heavy massage may be given. The massage douche is highly recommended by some. It possibly possesses some advantage over the percussion douche. Other tonic applications may be used, such as cold affusions and general sprays and showers. Later in the disease, the wet sheet rub may be used to advantage. Rheumatism with Emaciation. This condition is doubtless in some cases the direct result of "hot springs" treatment. Hot treatment must be used with much caution. The vigorous sweating treatments are never to be employed if the patient is under weight. Local hot applications are permis- sible and a mild sweating treatment once a week may in some cases be ven- tured upon. Hot applications to the swollen joints, such as fomentations, local hot air baths, superheated air, or local electric light bath should be followed by a tonic friction. At first, this may be a wet hand rub with tepid water, then with cold water and later, the cold mitten friction. These frictions should be applied to the muscular portions of the body, the swollen joints being avoided. The joints should be enveloped in heating compresses or packs wrung from cold water. These should be thoroughly covered with several layers of flannel or absorbent cotton, if necessary, in order to exclude the air. The effect may be increased by counterirritants or anodynes. After a time the alternate soft spray douche may be applied to the joints and the body generally. When convalescence is well established, the patient should be given daily some general tonic treatment with only short preliminary hot applications. In real gout, i. e., where the disease is localized in the metatarso-phalan- geal joint of the great toe, the tonic measures outlined for chronic rheuma- tism must be used in the interval. Only hot applications can be made to the foot during the paroxysm. At first, the patient suffering from rheumatism will complain some of increased stiffness and possibly pain in the joints after even a mild cold fric- tion. This should not deter the physician from following the plan outlined 7 Therapie der Gegenwart, February, L, No. 2., pp. 73 to 120. 210 DIURETIC EFFECTS nor cause discouragement on the part of the patient. If much complaint is made, the alcohol rub may for a time be substituted. Faradization of the joints by the rapid faradic current helps to relieve the pain and the annoying parassthesias that keep the patient awake. Gentle massage of the muscles and rubbing to the spine are helps in treat- ing the insomnia. The myalgias such as lumbago may be treated much as obese rheumatics. In lumbago, however, the most vigorous hot and cold percussion douche to the back should be used, followed by heavy massage or firm, deep vibration to the large muscles of the back. These relieve the pain as milder measures will not. In some cases of rheumatism, notably where the patient is bed-ridden or must be closely confined to the wheel chair, it is best to follow a somewhat different plan than that outlined above. In these cases, only mildly hot local applications such as the fomentation, radiant heat and the hot foot bath should be used. The usual regime of cold treatment should be omitted and its place taken by carefully applied but thorough massage. This mas- sage should include special attention to nerve stimulation, spinal and abdomi- nal movements. The use of faradic and sinusoidal electricity for the same purpose is an addition of distinct advantage. In all cases of chronic rheumatism, special attention must be given to the alimentary tract and to the digestion. Modern investigations into the con- tributing causes of chronic articular rheumatism are turning more and more to alimentary stasis, intestinal infections and autointoxications for an explan- ation of the pathogenesis of gouty rheumatism. The routine use of gastric lavage and copious enemata for a limited time may be productive of excel- lent results. These treatments must be thorough to be effective. Purin accumulation through defective xanthin oxidation and very limited urico- lysis are a part of this autointoxication, and are surely to be traced to an overworked and functionally deranged liver as one source of their occur- rence. Bright's Disease Diaphoretic measures are valuable in both acute nephritis and in the various clinical and pathological varieties of chronic nephritis. It is hardly necessary for our purpose to discuss the structural alterations occur- ring in the kidneys in Bright's disease. Only in acute nephritis is there hope of any marked restoration of the normal stucture. However, the functional perversions may to a great extent, be corrected. The alteration of function which is the chief, if not the sole cause of the various clinical manifestations of nephritis, is the renal impermeability and insufficiency in the elimination of nitrogenous wastes and salines. There is also an abnor- mal permeability to albumen and, in some cases, to water, notably so in the interstitial variety of chronic nephritis. In interstitial nephritis and the kidney of arterio-sclerosis, the high blood pressure is a prominent symptom and is due, at least to a great extent, to nitrogenous toxins. "Experiments on patients with chronic nephritis have shown that rich protein diet increases tension and disturbs the general con- BRIGHTS DISEASE 211 dition of the patient for the worse. Muller describes an individual in whom a change from milk and carbohydrate diet to rich meat diet caused pressure to rise from 140 to 190. Rich meat diet causes, in nephritics, headache, one of the earliest and most constant symptoms of uremia, and one which has a definite relation to hypertension." 8 Treatment may, therefore, be directed toward the attaining of two objects: First, decreasing the amount of toxic substances and salines the kidneys are required to excrete. Second, increasing renal sufficiency, so shaping conditions that increased elimination may occur without increased strain and irritation of the kidneys. In' order to meet the first indication, it is necessary to bring about several changes. The ingestion of purins (exogenous) must be stopped. The consumption of proteids must be limited as far as the 'needs of the system will allow. By general hygiene, exercise, etc., one may decrease the formation of intestinal toxins and promote com- plete oxidation of nitrogenous wastes. These results may be attained by regulation of the diet and attention to digestion. For a time it is well also to limit the use of salt to what naturally occurs in the food. The experiments of Strasser prove conclusively that the second object, viz., increasing the elimination of nitrogen, salines and water, is best accom- plished by the systematic use of hydrotherapy ; and that what has been vainly hoped from diuretic drugs is produced by bathing. His experiments were largely with the full warm bath at 95 to 100 F. In all cases, there was a decided increase in the quantity of urine and chlorides excreted, which frequently continued several days after the cessation of treatment. In no case was there a storage of nitrogen or salines on the bath days. This was true alike of cases having edema and where there was no decrease in the chlorides or nitrogen in the diet. The full warm bath frequently increased the elimination of sodium chloride two or three times the usual amount. In one case, increase in the nitrogen and sodium chloride of the urine occurred without increase in the total amount of urine and continued for three days after the treatment. Relative to the relation of the two crystalloids, glucose and sodium chlo- ride, to dropsy and diuresis, some interesting facts have been pointed out by Starling. While the presence of unusual amounts of glucose in the circu- lating fluid induces diuresis at the ultimate expense of the tissue fluids, the chronic ingestion of much salt does, under certain circumstances, tend to increase the tissue fluids and limit diuresis, producing a "water logged" condition. "If a solution of 30 grains of glucose in about 30 cubic centimeters of water be injected into the jugular vein, the first effect is a great increase in the volume of the circulating blood, brought about by the osmotic attrac- tion of water into the vessels at the expense first of the tissue spaces, but ultimately of the tissue cells. The consequence of the hydremic plethora thereby induced is increased circulation through the kidneys and increased output of urine containing large quantities of sugar. . . . Under ordi- nary circumstances, the concentration of the tissues thus induced would produce intense thirst and increased intake of water, so that the urinary 8 J. H. Mussei Causes of Hypertension in Nephritis Journal of American Medical Associa- tion, November 27, 1909, p. 1791. 212 DIURETIC EFFECTS flow would be maintained at a high level until the whole excess of the glu- cose had been excreted." 9 "The ingestion of an excessive quantity of salt provokes thirst rather than diuresis. If this excessive ingestion were continued or became chronic, there would be a tendency for the amount of this salt in the body to contin- ually increase, the salt being associated with sufficient water to maintain the molecular concentration of the body fluids at their normal height. It is not surprising, therefore, that excessive quantities of salt have been found to exert a deleterious influence in cases of dropsy, or that marked benefits as regards the reduction of dropsy 'have been attained by the limitation of salt in the diet." 10 Edema is lessened by warm or sweating baths and sometimes very promptly. The dropsy responds even more promptly to alternate hot and cold applications to the edematous parts. The rationale of these hydriatic effects in lessening edema is a very interesting study. We have already dwelt quite at length upon the vascular changes produced by alternating thermic applications. Starling has recently correlated present knowledge regarding the causation of dropsy. In the summary he brings out a number of practical points. "Ranvier has shown that if, after ligature of the infe- rior vena cava, the sciatic nerve be divided on one side so as to produce dilatation of the arterioles on that side, the limb in which the nerve has been divided will become edematous." 11 There must be other factors beside venous obstruction if edema is to result. Starling concludes that the deter- mining cause, other than stasis, lies in an increased permeability of the ves- sel wall. This is due in disease to lack of the proper nutrition and oxygen supply to the cells of the vessel wall. "Cohnheim showed that, after long continued anemia of the rabbit's ear, the vessels became so permeable that restoration of the normal circulation was followed by pronounced edema of all the tissues." 12 The same results were obtained by Barlow. This anemia resulted in asphyxia and starvation of the cells. A long continued venous stasis must affect the vessel walls in much the same way, since it also decreases the oxygen and nutritive supply. In chronic nephritis there is usually a marked anemia with hydremic blood and this appears before the edema. From experiments by Bolton, one may conclude that edema results solely because of this series of changes occasioned by the stagnation of blood in dilated veins and that plethora or increased capillary tension are neither of them necessary for the production of edema. These facts have led Starling to the belief that alterations in the endothelium of the capillary wall must be regarded as the essential factor in the production of edema. The retention of nitrogenous wastes in nephritis must be an added cause of injury to the vessels. With these facts in mind, the rationale of hydriatic treatment is quite evident. The restoration of tone to the vessels, both blood and lymph, hastens the circulation, thus relieving the stasis and consequently improv- ing the nutrition of the vessel walls. The nutritive processes and activity 9 Starling: Fluids of the Body, p. 153. 10 Ibid., p. 154. 11 Ibid., p. 159. 12 Ibid., p. 162. ACUTE NEPHRITIS 213 of the endothelial cells are directly stimulated by hydriatic applications. In short, the entire series of morbid changes from the decreased permeability of the kidneys to the venous stasis and increased permeability of the vessel walls, is met by the one agent warm water. There is no evidence that free water drinking is harmful in edema where the amount of urine is less than normal. On the contrary, it has been shown that plethora is not a contributing factor in edema. The diuresis it induces greatly lessens nit- rogenous retention and thus, by decreasing the toxemia, aids recovery. Acute -Nephritis. Beginning as it does as an acute inflammation and pas- sing through the various stages of the inflammatory process, acute Bright's disease should be treated along the lines laid down for inflammations. The peculiar course of the disease is governed by the anatomic and physiologic relations of the kidneys, organs of necessarily constant activity, and activ- ity of such a character that it must militate against their recovery. The kid- ney is congested, swollen, edematous and tense at the onset of the first symptoms; later, venous stasis is the predominating physical change. To relieve these conditions sweating measures have abundantly proven their superiority. These congest the skin and relieve the kidney congestion. The patient should perspire freely for an hour or more, at least once a day. The skin should be warm and moist all of the time. Free diaphoresis may be accomplished in several ways. It is often best to resort to some of the milder measures, such as the hot foot bath with fomentations to the abdo- men or spine, or the hot trunk pack. If the symptoms are urgent, the" full hot pack may be used. The head should be kept cool and if the pulse is over 100, an ice bag placed over the heart. During the sweat, copious water drinking should be encouraged. This favors diaphoresis and, as soon as the renal congestion lessens, it aids in diuresis. The patient may be sponged off with tepid water and then placed between warm blankets to continue per- spiring gently for an hour or longer. A brisk cold mitten friction so given that the part treated is immediately dried, rubbed with the dry hand until warm, and then covered with the warm dry blanket, will prove a valuable adjunct to the sweating measure. It improves the general vitality and helps restore the cardio-vascular mechanism to normal tone. General cold applications, i. e., cold applied to a large surface at one time, such as the cold towel rub or wet sheet are counterindicated. The cold mitten friction given as described above counteracts the depressing tendency of the sweat- ing measures which must be repeated daily. The alcohol rub may be used, but it lacks the tonic effect obtained from the cold. The hot air bath, so prepared that it can be given in bed, is an excellent means of producing perspiration. Croftan 1S objects to the use of dry heat in cases unaccom- panied by edema, claiming that it increases the concentration of the blood. He favors the use of the full warm bath in acute nephritis. This should be at a temperature of 98 to 104 F., continued for ten or fifteen minutes. Others recommend a temperature not over 100 F., in subacute nephritis and the prolonging of the bath from thirty to sixty minutes. During this time, the head and face should be bathed in cold water or cold compresses applied to the head and neck. The tub ought to be covered with a sheet in order to limit the cooling of the surface and when the patient is removed, 13 Clinical Therapeutics. 214 DIURETIC EFFECTS the room temperature must be 85 or more to guard against chilling. The patient should be immediately placed between dry blankets, or in a sheet and well covered by warm dry blankets and allowed to remain in this heating pack for a time. The electro-thermal pack is a very convenient substitute for the dry pack. During the first few days of acute nephritis, in case it seems necessary to use the hot trunk pack or full hot blanket pack, an ice bag may be applied over the lower third of the sternum. Its tends to cause reflex vasoconstric- tion in the kidney. With these intensely hot applications, an ice .bag over the heart is usually necessary and, if a large ice cap is used, it will cover the sternal kidney area as well. Other forms of hot bath, such as the Russian and electric light, may be best left for subacute or chronic nephritis after the acute symptoms have largely subsided. Chronic Nephritis. In chronic nephritis, whether a sequel of the acute or coming on insidiously and complicated by cardiac and vascular changes, it is possible to utilize a greater variety of measures and more vigorous tonics can be borne. A southern climate is of advantage largely because free per- spiration is secured without effort and there is less tendency to chilling. We have utilized with success all of the hot baths, such as the Russian, Turkish, electric light and superheated air. These may be given two or three times a week. About once a week or once in two weeks, it is desirable to follow a vigorous sweating treatment by the Turkish shampoo. All these extreme sudorific treatments should be concluded by some form of the hot and cold shower, douche or spray. The douche is the best means since it combines percussion effects with the thermic stimulus and so lessens the tendency to chilling. The alternate application of fomentations and an ice bag to the lower sternum and kidney region produces mild fluxion in the kidney. The alternate hot and cold percussion douche to the lower sternum and the lower dorsal and lumbar regions is more vigorous and a very efficient means of stimulating renal activity. Nearly all hydriatists recommend very highly the full warm bath as the most serviceable measure in subacute nephritis. While we do not doubt its great utility, yet we have seen better results by employing, in about two out of three treatments, more vigorous means and means employing more tonic effects. These are obtained to only a slight extent by the warm bath. Where there are marked changes in the heart and vessels, we have found tonic hydrotherapy a necessity. Of tonic measures, one may use hot and cold to the spine, the revulsive compress to the kidney region or abdomen, the cold mitten friction, the ice bag to the heart and the alternating douche. The Nauheim bath is highly recommended both for the relief of dropsy and the treatment of cardio-vascular disturbance. That it is a powerful means can not be doubted. It must, however, be used with caution, remembering that it may result in overstimulation. For the edema of the feet and legs, alternate hot and cold immersion is as valuable as for the same condition in cardiac incompetency. Its beneficial action may be assisted by massage. Cathartics and Medicinal Diaphoretics. About the only diaphoretic drug recommended as a routine is pilocarpin. This must, however, be mentioned only to be condemned. It is dangerous where the heart may be involved in the general vascular changes and its use is entirely superfluous since we UREMIA AND ECLAMPSIA 215 have such efficient hydriatic means of accomplishing the same results. Saline cathartics or elaterium as a means of reducing ascites or anasarca may at times seem necessary. Their repeated use is not to be encouraged, since they induce great weakness and derange the digestion. It is necessary that special attention be paid to gastric digestion. The measures recommended for the various forms of atonic indigestion should be used as indicated. Attention should also be given the gastrectasia which so frequently accom- panies a chronic parenchymatous nephritis. It is a cause of faulty nutrition and is closely connected with morbid proteid metabolism. The free use of mineral waters may greatly increase the dilatation. Fluids must be taken in .small amounts, preferably as plain cold water. In interstitial nephritis, mineral waters or even the free use of ordinary water is unnecessary, since diuresis is the rule. In this form, whether simple or forming part of a gen- eral arteriosclerosis, extreme measures, either hot or cold, are counterindi- cated since the increase of blood pressure which both produce may determine an apoplexy. Mild diaphoresis is beneficial and this may be secured by short hot baths or the prolonged neutral bath at a temperature of 95 or 96. This tends to equalize the blood pressure and helps to relieve the nerve ten- sion which is a part of the clinical picture in many of these cases. It has recently been shown that the endogenous uric acid in the blood in interstitial nephritis varies according to the functional activity of the kid- neys. 14 These observations were made on a purin-free diet. This retention of uric acid is favorably influenced by exercise and hydrotherapy. Umber noticed that on a purin-free diet the elimination of uric acid decreased after exercise, owing to its participation in the increased oxidation incident to muscular exertion. That like results may be obtained by hydrotherapy has been shown by the researches of Strasser. Uremia and Eclampsia These pathologic states, while not identical, have many points in common. In uremia, there is, in the majority of cases, a retention of toxic urinary products because of the kidney insufficiency. While all observers are not agreed as to the constant occurrence of kidney insufficiency in eclampsia, yet nearly all agree that its manifestations are accompanied by a severe poisoning from some autotoxic source. Croftan says there is much chemical and clinical evidence to show that in uremia the general metabol- ism and, in particular, the manifold functions of the liver, are perverted. The kidney may not be primarily involved and possibly in some few cases not at all. In the majority of cases, however, there are demonstratable lesions in the kidney as well as functional inadequacy during life. A great variety of conditions have been reported among which are infarcts, acute and chronic congestion, edema, greatly increased tension and actual nephri- 14 In gout the endogenous uric acid in the blood is more constant and never exceeds a certain maximum amount (about 0.003 per cent) A demonstratable amount of uric acid is always pres- ent in the blood in gout, even when the food has been free from purins for weeks or months, while blood from normal individuals on a purin-free diet contains no uric acid. Journal of Ameri- can Medical Association, April 3, 1909, p. 1110. 216 DIURETIC EFFECTS tis. In a case of eclampsia reported by Wiemer 1S the tension was so marked that the kidney substance bulged out on incision in the course of Edebohl's operation. Braak and Mijnlieff I6 report a case in which the right kidney was much enlarged and so painful that the patient, in coma, reacted when it was palpated. They report 13 other cases of eclampsia accompanied by increased tension in the kidney. All were treated by decapsulation and, with one exception, recovered. Franck reports 10 cases with no bulging or increased intracapsular tension. Hepatic changes are almost universally present. In fact, functional and structural alterations of the kidneys and liver are very frequently associated. Their function^ are consecutive, i. e., the liver is the chief agent in the pre- parations of wastes for excretion and the kidneys receive these for purposes of excretion. This naturally leads to the view, which is also supported by clinical analyses, that in many cases the decrease of urea in the urine is due not to failure in its elimination, but to failure in its formation from the various precursors, including the ammonia compounds; uremia then, being due to these toxic antecedents, rather than to poisons retained with the urea, and of the amount of which the decreased urea excretion is a gauge. "Some- where in the organism there is a deficient changing of ammonia and amino- acids into urea. This has been called 'deficient desamidation' by Ewing, who asserts that the process is no more than an oxidation. This work is in a great measure performed by the liver, and therefore we are not surprised to find the liver most severely involved." u In this connection it is interesting to note the relation of one of the chief causes of uremia and eclampsia, viz. , a diet rich in meat, to the size of the liver. Dr. Chalmers Watson 18 calls attention to the difference in the size of the liver in meat-fed rats and in bread-and-milk-fed rats. From an exami- nation of the livers in the two cases it was shown that the average liver weight of the meat-fed rats was 6 grams, while the average liver weight of the bread-and-milk-fed rats was 4 grams. The meat. diet had caused an increase of 50 per cent in the size of the liver. Moreover it has been shown that a severe acidemia may cause the convul- sions and coma characteristic of uremia and eclampsia. Were this the case, sweating treatment, if much prolonged, would only deepen the difficulty since, if unaccompanied by cold, it increases the acidosis. For practical purposes, we may divide the treatment into two parts: First, the treatment of chronic uremia, the conditions that predispose to the acute attack, and the pre-eclamptic state. Second, the treatment of the acute attack of uremia or eclampsia, the convulsive seizures and coma. It should be borne in mind that in .eclampsia a neurotic temperment predisposes to the attack and that there is the added factor of pregnancy which may, in spite of vigorous treatment, demand hasty emptying of the uterus. "Chronic" Uremia and the Pre-eclamptic State. The principles involved in the treatment of faulty nitrogenous metabolism have been discussed in 15 Monatschrift fur Geburtsh und Gynakoloprie, March, 1908. 16 Centralblatt fur Gynakologie, October 19, 1908. 17 Davis and Foulkrod The Etiology of Eclampsia, Journal of American Medical Association, January 7, 1911, pp. 11, 12. 18 London Lancet, October 12, 1907. Llll- ,~^. ACUTE UREMIA AND ECLAMPSIA 217 the consideration of rheumatism and Bright's disease. Those persons living upon a highly nitrogenous diet, containing purins, are predisposed to the uremic state. Women who partake heavily of tea and coffee are predisposed to eclampsia. The reason for this is that the caffein greatly increases the amount of basic purins which must therefore be raked over by the liver and thrown out by the kidneys. Alfred Schittenhelm 19 has shown by experiments upon dogs the extent to which caffein increases basic purins and uric acid. We give below a table of averages showing these items. The dog was kept on a purin-free diet previous to the tests. The pre-period lasted 3 days. For 3 days following this, three daily doses each of 0.3 grams of caffein were administered. Next intervened a period of 2 days with purin-free diet, and following this the same daily amount of theobromin (as previously of caffein) was given for 2 days. Caffein Inter- Theobromin After Pre-period period period period period Uric acid in gm. N. 0.006 0.008 0.006 0.007 0.006 Purin bases in gm. N. 0.005 0.026 0.009 0.013 0.008 Chronic congestion of the liver as pointed out above and hepatic cirrhosis are also factors in the causation of uremia. The vicious cycle and disordered liver accompanying periodic sick headaches are additional causes. These conditions demand the exclusion of purins (meat, tea and coffee) from the diet, and the limitation of proteins. The diet should consist largely of carbohydrates, milk, fresh vegetables and fruits. Hydriatic treatment should be directed toward the oxidation and elimination of nitrogenous wastes. As a means to this end, special attention should be given to the liver activity, the circulation and renal activity. Extreme diaphoresis is not necessary, but gentle, free perspiration should be encouraged. To this "end, short electric light baths may be used once, a week. More or less per- spiration accompanies the use of local hot applications, such as the hot foot bath with fomentations to the abdomen and spine, warm showers and douches. A regular course of tonic treatment should accompany these measures: of these, mny be used hot and cold to the spine, revulsive compress, cold fric- tions, alternate showers, sprays and douches. The neutral or warm tub bath is an excellent means of quieting nervous symptoms and equalizing blood pressure. The patient should drink water freely and frequently". Fomen- tations and the revulsive compress to the liver, also the alternate douche to the hepatic region are efficient chologogues and stimulate all the other hepatic functions. In case pregnancy is complicated by a pre-existing nephritis, the patient should be under constant observation and treatment. The measures recommended for chronic Bright's disease may be employed. Acute Uremia and Eclampsia. So successful have diaphoretic measures proven in these conditions that they are almost specific. The repeated use of prolonged sweating treatments is not advisable unless there is a favor- able response from the first or second application. The measure which has given the best result is the full hot blanket pack accompanied by the inges- tion of an abundance of water. It may be necessary to use saline solution 19 Zur Frage der harnsaurevermehrenden Wirkung von Kaffee und Tee und ihrer Bedeutung in der Gichttherapie Therapeutische Monatshefte, March, 1910, p. 115. 218 DIURETIC EFFECTS by hypodermoclysis or enteroclysis. This can not result in damage from increase of blood pressure if the patient is perspiring freely. Many cases have been reported in which the giving of saline solution resulted in prompt diuresis. It dilutes the blood, decreases the toxemia and favors elimination by the skin and kidneys. It may be necessary to somewhat prolong the hot pack. Whenever it is used, the cerebral circulation should be guarded by the cold compress, ice bag or cold affusions to the head. An ice bag should also be used over the heart. The patient may be removed from the pack by a wet hand rub or other cold friction and put between blankets to continue perspiring gently. Croftan, Edwards and others favor the use of the full hot bath as recommended by Liebermeister. The bath begins at 98 or thereabouts and is generally run up 5 or 6, the head being kept cool by cold affusions. The rationale of these sweating treatments lies not alone in the elimina- tion of toxins by the skin. In fact, we believe this is only a part and perhaps often a small part of the real effect. Soon after free diaphoresis has been established, urinary secretion begins to increase and may, in acute suppression, appear very promptly. This is doubtless due to the relief of the kidney congestion and the reduction of renal edema and increased ten- sion in those cases in which these occur. Relieving renal stasis always results in freer excretion of urine. The case of eclampsia with great enlarga- ment of the kidney mentioned above as reported by Braak andMijnlieff, hav- ing refused operation, recovered under the use of wet packs with hot water bottles and medicinal measures. The coma subsided and the kidney gradu- ally returned to normal size. 0. M. Hay ward 20 reports a case of eclampsia in which two hot packs failed to relieve the coma. With the patient deeply comatose, pulse 160 and very weak, axillary temperature 105.2 F., and res- piration irregular and gasping, she was wrapped in a sheet, placed on a table, and a cold, rubbing pour administered. In five minutes, there was- some improvement and the cold pour and rubbing were continued. In thirty minutes, the patient was returned to bed with a temperature of 100 F., pulse 100 and respiration nearly normal. The failure in the hot pack was doubtless due to the fact that it was unaccompanied by a cold friction. This might have been administered by the cold mitten or, as was done later, by the cold pour and rubbing wet sheet pack. The use of a large ice cap to the heart and over the lower third of the sternum will prevent any damage to the heart which might result from the sweating treatment and serve also to cause, reflexly, contraction of the kid- ney vessels and thus lessen congestion and intracapsular tension. 20 Modern Medicine, March, 1908, p. 60. CHAPTER XXV PEPTOGENIC EFFECTS This term "peptogenic effects" is here used to designate a variety of effects upon the digestive organs and digestive activity in the sense of increasing the efficiency of these organs and functions. The measures di- rected toward improving the digestion also increase the activity of the liver. All tonic treatments increase the muscular and glandular activity of the stomach and intestines, also the glandular activity of the liver and pan- creas. They aid digestion and sharpen the appetite. In addition to gen- eral tonic treatments, it is necessary to direct special attention to the diges- tive organs themselves. The following are some of these special treatments which are useful in promoting digestion and absorption: 1. Winternitz pack (hot and heating trunk pack). 2. Hot trunk pack. 3. Fomentations to the abdomen. 4. Revulsive compress to the abdomen. 5. Hot and cold to the spine. 6. Hot and cold douche to the abdomen, liver and spine. 7. The Umschlag (moist abdominal girdle). 8. Hot water bottle or Winternitz coil over the stomach after a meal. 9. Ice bag over the stomach, or cold water drinking, before a meal. These treatments properly selected to meet the needs of the individual case are indicated in, 1. All forms of atonic indigestion. a. Hypochlorhydria. b. Anacidia. c. Gastrectasia. d. Gastroptosis. e. Lowered gastric motility. f. General splanchnoptosis. g. Biliousness. h. Periodic sick headaches (in interval), i. Amlaceous dyspepsia. 2. Chronic congestion of liver. 3. Anemia of liver. Atonic Dyspepsia This term is not used in its ordinary restricted sense as applying alone to painful digestion. We use it here to designate a great variety of digestive 220 PEPTOGENIC EFFECTS disorders associated with deficient gastric secretion, and lessened motility with more or less distress or discomfort after meals. These various condi- tions may be grouped in this manner for convenience in considering their hydriatic management, for this must be carried on along much the same lines in all. The aim is to produce a general increase of tone in both the glands and musculature of the digestive organs. We hardly need mention that special attention must be paid to the matter of diet, exercise, rest, favor- able environment, etc. These are all of prime importance. In the more severe grades of defective digestion, something like the fol- lowing program should be carried out: Half an hour before the meal, the patient should be instructed to take half a glass of cold water or even ice water. Bits of ice, or a small amount of a fruit ice may be taken 20 minutes to half an hour before the meal. Instead of cold internally, an ice bag may be placed over the stomach begin- ning half or three quarters of an hour before the meal and continued for 10 or 15 minutes. The skin over the stomach should warm up before the meal is taken. This will require about 15 minutes after the ice bag has been removed. The philosophy of these measures lies in the fact that the cold application produces a reaction which comes on at the time the meal is taken so that the glandular activity is increased during the period of digestion. The experimental basis of this old and very successful means of promoting gastric secretion has been worked out by Doctor Kasanski in the laboratory of Prof. I. P. Pavlov. ' By the application of cold the activity of the gas- tric glands is arrested while the cold continues. After the removal of the cold, the work of the glands rises above the normal and continues at a higher point for a longer time. In the following table will be noted the result of intense cold applied during the first hour of the digestive period. The reac- tion comes on during the second hour. Hour Normal Secretion Secretion as Affected by Cold 1st 11.6 c. c. 6.2 c. c. 2nd 8.4 " 11.6 " 3rd 3.5 " . 10.8 " 4th 1.9 " 5.6 " 5th 1.3 " 3.6 " Following the meal, the patient should use a hot water bottle over the stomach. This should be coutinued for 20 minutes to an hour, or even longer. In more severe cases, the Winternitz pack will be found very effi- cient. It should be applied immediately following the meal, or the pack may be applied first and the meal eaten while the patient is in the pack. It should be continued for from 30 minutes to as long as 2 or 3 hours and be concluded with a cold mitten friction. In applying the pack the hot water bottle may be used in place of the Winternitz coil. Since a constant tem- perature can not be maintained by the hot water bottle, the treatment is not so effectual. Fomentations of moderate heat may be applied to the abdomen over the stomach and liver, immediately following a meal. Two or three hours after the meal, the patient may be given a treatment con- 1 WorU of the Digestive Glands, Second English Edition, pp. 239, 240. ATONIC DYSPEPSIA 221 sisting of a hot foot bath with a revulsive compress to the abdomen, or hot and cold to the spine, together with the cold mitten friction or cold towel rub. Other applications which may be used are the hot and cold douche to the abdomen and liver, also to the spine. At night it is well to apply the moist abdominal girdle. It should be dry by morning. The protected girdle is not used in this condition. In addition to these hydriatic measures, the patient should be given general massage with special abdominal message, vibration to the abdomen, faradic or sinusoidal electricity to abdomen and spine, or the Morton wave to the abdomen and spine. Since these various measures are not applicable to all cases of atonic dyspepsia, they should be selected according to the needs of the individual case. All of them, with the exception of fomentations to the abdomen and the hot trunk pack, are counterindicated in hyperchlor- hydria and gastric or duodenal ulcer with much hemorrhage. Patients with dyspepsia soon become accustomed to cold applications and may be given most vigorous tonics. After a week or so of treatment a general cold affusion or pail pour may be used daily. The cold wet sheet rub may also be used after tolerance for douches and pail pours has been acquired. The cold morning plunge is not excelled as a general tonic and exerts a beneficial action on digestion. It sharpens the appetite, thus aiding in the production of "psychic juice" which Pavlov assures us is 5 times as efficient in gastric digestion as the chemically excited secretion. Pavlov has further shown that another of the circumstances favorable to the activity of the gastric glands is an abundant supply of water in the organism. He says,- "One of these favoring circumstances we discovered in the introduction of large quantities of water into the system. We based this upon earlier facts, showing that the quantity of juice was strikingly dependant upon the amount of water in the organism." This makes clear the necessity for free water drinking between meals in order to provide fluid for the formation of the requisite amount of gastric juice. In cases of motor insufficiency associated with marked dilatation, cold drinks can not be used before the meal since there is not sufficient power to empty the stomach in so short a time and the circulatory reaction is much delayed. Before the meal, the patient may be placed on a table or slab and a cold affusion administered to the abdomen. This should be intermittent, as it will be if, by means of a large dipper, water is dipped from a pail and poured over the abdomen. The temperature of the water at first should be about 75 F. and gradually reduced to 45 or 50 F. One full pail of water will usually suffice for a single treatment. Douching the mucous membrane, i. e., lavage of the stomach, with cold water may be found helpful. This measure, combined with intragastric electricity, is a most efficient means. After swallowing a glass of cold water the gastric electrode is introduced and, by means of either an abdominal sponge or plate placed to the mid-dorsal spine, the slow sinusoidal or slow faradic current is given for 5 to 8 minutes. One may frequently hear suc- cussion sounds or the gurgling of water through the pylorus, caused by vig- orous contractions of the gastric muscles. These treatments may be given daily or on alternate days. In one case, a month of such treatment with 2 Ibid., p. 245. PEPTOGENIC EFFECTS other tonic measures resulted in a retraction of the greater curvature toward its normal position of one and one-half inches on the left and one inch upward in the median line. On applying for treatment, the greater curvature lay three inches below and four and one-half inches to the left of the umbilicus. In connection with the use of gastric lavage, a caution should be uttered relative to the frequent use of large quantities of warm or hot water intro- duced into a dilated stomach. The relaxing effect is very marked and in the course of months or years, the stomach becomes extremely dilated and entirely loses its elasticity and contractility. A few years ago the author was present at the post mortem examination of a man who had, at frequent intervals for a number of years, resorted to warm gastric lavage to relieve the gastric retention and fermentation occasioned by an extreme pyloric stenosis. The stomach was found to be enormous, reaching from the greatest height of the f undus at the level of the fourth intercostal space on the left to the level of the anterior, superior spines of the ilia, 2 inches from the right iliac spine. It would easily hold 1 or 2 gallons. The pylorus, for a distance of 2 inches, admitted with great difficulty a small size lead pencil. The condition, of course, should have been treated surgically by some form of pylorectomy. The caution here is not against systematic washing of the stomach to free it from decomposing remnants of food but against the use of hot water for this purpose. If it seems advisable to resort to gastric lavage frequently and warm water is used first, it should be followed by a "dash" of cold. In those cases of gastric dilatation and lessened motility not associated with pyloric obstruction, hydriatic means produce excellent results. In addition to the measures recommended above, the alternate hot and cold douche to the epigastrium may be used; at first, with little or no force, later, with moderate percussion. The percussion douche to the mid-dorsal spine, also to the legs and feet, serves as a vigorous tonic. Gastrectasia, associated with a general splanchnoptosis, irritable, tender sympathetics, and a feeling of weight and dragging in the abdomen may be benefited by the cold sitz-bath begun as a graduated measure. The continuous cold coil to the abdomen acts in the same way. The cold sitz may be prolonged to 5 or 6 minutes and the cold coil left in place 20 to 30 minutes. 3 Hy perchlorhy d ria Nearly all cases of indigestion pass through the stage of hyperacidity at the beginning of the departure from the normal. In only a few, however, is this condition so marked as to require special treatment. The patient is of a nervous temperament, and eats rapidly, swallowing his food with very imperfect mastication. The free hydrochloric acid may be double or even treble the normal amount. The course to be followed is just the opposite to that outlined for hypochlorhydria. The patient may drink hot water or use a hot application over the stomach preceeding the meal, after which an 3 See also the treatment recommended for splanchnic neurasthenia. HYPERCHLORHYDRIA 223 ice bag should be used for 20 to 30 minutes, or even longer. The hot water drinking or the hot application to the epigastrium produces an atonic reac- tion. In this connection, it should be noted that among the experiments performed by Professor Pavlov, on one occasion the work of the large stom- ach was arrested for several days by the application of very hot water. Thus it will be seen that by applications of heat of a suitable temperature an overactive state of the gastric glands may be depressed and their activity be brought back toward normal. It is needless to say that dietetic regulation is the most important factor in the treatment of this condition. Oils, whether free or emulsified, have a specific inhibitory action upon the secretion of hydrochloric acid. The patient should discard the use of meats entirely. Other heavily proteid foods should be interdicted. The hyperacidity may be lessened by the use of the protected or sweating moist abdominal girdle. Tonic treatments should be replaced by sedative measures such as the neutral bath, neutral pack or heating pack. These may be given one or two hours before a meal or at night. Capillary hemorrhage and hemorrhage from smaller blood vessels does not usually require surgical treatment. Hemorrhage into the hollow organs tends to check itself, provided the circumstances are at all favorable, so that in many cases, absolute rest accompanied by the use of the ice bag, may produce all that is desired. Thermic applications may be made directly to the part or, so as to influence the blood vessels reflexly. Cold may also be used over the trunk of the artery supplying a part. If heat is used to check the hemorrhage, the application must be very hot and be made directly to the bleeding part. The reflex effect of even very hot water produces only a transient narrowing of the vessels, while in a short time, the vessels become dilated and the hemorrhage increases. Cold applications may be used either to the part itself or to, the reflex area. In fact, it is quite a general rule that cold is more efficient through reflex action, while hot is efficient only when applied directly to the bleeding vessels. In nearly every case where ice is used, it is well to employ some hot application for derivative purposes. The hot should not, however, produce sweating since this tends to dilate the blood vessels and increase the hemorrhage. Epistaxis Thermic applications are often very effectual in treating capillary hemor- rhage from the nose. Very cold water or very hot water may be drawn into the nose. An application of ice may be made over the nose itself. Of the more remote reflex areas, use may be made of that at the back of the neck and the hands by having the patient hold a chunk of ice at the back of the neck. The hands or feet may be placed in ice water or very cold water for a short time. These applications should not produce chilliness. Pulmonary Hemorrhage The patient should be kept at absolute rest. Warmth of the body and limbs should be maintained, hot water bottles being placed to the feet, or, after the hemorrhage has somewhat subsided, the patient may be given a hot foot bath. That which is of most importance is the applying of an ice bag to the front of the chest. This should be left in place continuously until all danger of hemorrhage is past. It should be a large ice bag or ice cap. This not being available, the ice cqmpress may be used. For some unknown reason, possibly through reflex action, the taking of salt on the back of the tongue is a very efficient means of quickly checking the hemorrhage. Gastric Hemorrhage Gastric hemorrhage most frequently occurs in cases of ulcer. The patient should be kept at absolute rest with an ice bag over the stomach. He may UTERINE HEMORRHAGE 225 be given cracked ice to swallow. It may be necessary to apply a large fomentation over the lower abdomen or to other parts for derivative effects. The cold compress is not as efficient as the ice bag, having a greater tend- ency to produce a hydrostatic effect, while the ice bag acts chiefly through reflex action. Uterine Hemorrhage We may, for convenience, divide hemorrhages from the uterus into two classes; first, prolonged and profuse menses; and second, hemorrhages fol- lowing labor or abortion. The means used to check the hemorrhage in these two conditions is usually quite different, since one is acute and would soon produce exsanguination; the other lasting for a number of days may be treated by less vigorous means. In case of profuse menses, the patient may be given a cold sitz-bath. This should be prolonged and accompanied by a very hot foot bath. In some cases, the shallow cold foot bath (water two or three inches deep) without other means serves to check the hemorrhage. This is through reflex action. In case it is necessary to keep the patient in bed, an ice bag should be placed over the pubes and another ice bag between the upper surfaces of the thighs. At the same time, the patient should be given a hot foot bath or leg pack. These means will often prove so effectual that packing or astringent douches are unnecessary. Post-partum hemorrhage, if occurring immediately after the delivery of the child, and of such an amount as to prove alarming, should be immediately treated by a very hot intra-uterine douche. If the hemorrhage is slight or not so alarming as to require the intra-uterine douche, the patient may be given a very hot vaginal douche with or without alum. An ice bag may be used over the pubes and replaced after the douche, or it may be kept in place without interruption. Any of these means which may be at hand should be applied at once, ergot hyodermatically, being given as soon as possible. Apoplexy The early treatment of cerebral hemorrhage should consist of an ice bag, ice cap or large ice helmet applied to the head, also ice bags or compresses placed at the back of the neck and over the carotids. The limbs should be kept warm by hot water bottles, etc. These applications may be left in place until there is reason to believe the hemorrhage has been checked. Usually the hemorrhage does not continue for any great length of time, but in some cases almost the entire cerebrum may become infiltrated with blood and the ventricles filled. Cold applications, if used promptly, may check such excessive hemorrhage as these. Perfect rest is an absolute essential to the success of any form of treatment. CHAPTER XXVII HYDROTHERAPY IN SURGERY Under various heads we have already considered the hydrotherapeutic treatment of many surgical diseases. The treatment of inflammatory dis- eases, many of which require surgical intervention, has been discussed under its proper head. In considering the effects of pure stimulants and under treatment designed to relieve pain, still other surgical conditions have been discussed. There remains then to be considered only the general rela- tion of hydrotherapy to operative treatment and the care of the patient. For convenience the subject of hydrotherapy in surgery may be divided into three sections, viz., preparatory treatment, immediate care and after-treat- ment. Preparatory Treatment The physical condition of the patient at the time of operation has a great deal to do with his behavior upon the operating table and with the comfort and rapidity of his subsequent convalesence. Of course in conditions demanding immediate attention there is no time for preliminary treatment, but in a very large number of surgical diseases it is neither necessary nor advisable to hurry the patient to the operating table. This is true alike of many inflammatory and many non-inflammatory conditions. In considering the realm of physiologic therapy we have already mentioned the advisability of delay in the operative treatment of certain inflammations, especially of pelvic inflammations. Even definite inflammatory states largely limited to the Fallopian tube or the ovary are usually accompanied by more or less cellulitis. Sometimes an inflammation whose most marked effects are in the cellular tissue involves other parts so as to necessitate removal of such parts or mechanical means for their release from plastic exudates or adhesions. In such cases the induration and residual thickening may be cleared up and quite a degree of the normal mobility restored as has been discussed under the treatment of the chronic stage of inflammations. These results may be so thoroughly accomplished that the remaining conditions will necessitate very much less operative work and work which can be easily and rapidly performed with a minimum of trauma and consequent shock. The resulting shortening of the peroid of anesthesia is also a distinct advan- tage. The stability of the circulatory system is still another factor of great importance in surgery. In those who have had chronic inflammatory or sup- purative lesions and in neurasthenia and other chronic invalids the circula- tion is unbalanced and the vasomotors fail to properly control the ebb and IMMEDIATE CARE 227 flow of circulatory changes. The anesthetic and the operative procedure both tend to still further unbalance the circulation. By interference with the vasomotors the liability to undue cooling of the surface and to consequent internal congestion are much increased. Slight chilling during or following operation may produce marked retrostasis of blood to the interior, and thus result in deepening an already existing inflammation. The preparation of the patient by a preliminary two or three weeks' course of vascular hydriatic tonics will guard against these dangers. In this length of time the vitality of the patient may be materially raised. Such a course of treatment will also result in ridding the system of the accumula- tion of half oxidized leucomaines which have piled up during the preceeding invalidism. Sweating treatments at intervals of two or three days may also be necessary to still further enhance elimination and incidentally to pro- mote the nutrition and healthy activity of the skin. The stimulation of kidney activity and the consequent increase in urinary leucomaines is another factor in the general clearing out process. Because of the more perfect oxidation and more complete elimination of waste pro- ducts the alkalinity of the blood is increased. Desirable conditions prepara- tory to operation are also produced by a low proteid diet and the free use of fruits. Free water drinking should be insisted upon whenever the elimi- nation is defective. All of these changes help to remove toxemia the principal cause of nerve irritation and hence aid in rest or in nerve tone and the stability of nerve action. The increased activity of the circulation and the restoration of the normal reaction of the blood and body fluids are large factors in the proper healing of wounds. The physiologic leucocytosis and consequently heightened phagocytic powers of the white blood cells help to prevent post-operative infections whether of the wound, of the respira- tory tract or other part subject to unusual conditions or strain during operation. Immediate Care The treatment of the patient during and immediately following operation resolves itself almost entirely into the use of means for the prevention and treatment of surgical shock and collapse. The keeping of all the vital func- tions in as nearly a normal condition as possible, consistent with the attain- ment of surgical anesthesia, will tend to prevent the occurrence of shock. The use of ether by the open drop method, discarding, unless specially indi- cated, all mixing of anesthetics or the hypodermic use of hypotics and analgesics, has done much to lessen the occurrence of shock. Let the ether be given slowly at the start; it should never be "pushed." To quite an extent this will obviate the occurrence of retching and vomiting. Where the alimentary tract is not the objective point of the operation, the giving of a glass of cold water by mouth, immediately before beginning the admin- istration of ether, will be found very helpful in diminishing the tendency to vomiting. It also adds that much water to the body fluids to aid in the sub- sequent elimination of the ether. The skill of the operator in proceeding rapidly yet with a minimum of trauma and hemorrhage is one of the chief factors in preventing surgical 228 HYDROTHERAPY IN SURGERY shock. In this connection W. J. Mayo 1 has said, "We hear a great deal about shock but we don't see it. We sometimes see collapse from loss of blood." The patient should not be weakened by repeated catharsis. Limit the preparatory use of cathartics to what is really indicated, and on the morning of the operation finish the cleaning out by means of a thorough enema of tepid or warm water. The patient should reach the operating table with warm feet and hands and during the operation the extremities should be kept warm by the use of blanket coverings and, if necessary, hot water bottles applied outside the blanket. The use of a hot foot bath, concluded by a dash of cold water, given just before entering the operating room, may do much to prevent or limit splanchnic engorgement. Surgical Shock Until the researches of Geo. W. Crile placed the subject of the causation of surgical shock upon a definite experimental basis, the ideas held by prac- ticing surgeons were most various and conflicting and these ideas underwent frequent change. If one might judge of these ideas by the therapy employed at that time and, it is to be regretted the therapy still used by a very large number of surgeons, one would unquestionably say that some derangement of the heart itself or its nerve supply has been looked upon as the cause of surgical shock. That the heart is not primarily at fault in shock has been proven beyond question. Crile makes a sharp distinction between shock and collapse. Although there are many contributing causes, he considers that the primary and prin- cipal alteration of function in surgical shock is a derangement of the vaso- motor mechanism. Collapse is due to loss of body fluid, i. e., to hemorrhage. It may also be due to direct damage to the heart muscle, the respiratory organs or the nerves of either. While both conditions may be present in a given case at the same time, yet they are essentially distinct entities. These are the views generally accepted by surgeons today. The prevention of shock is fully as important as its treatment, and to accomplish either result, it is necessary to understand the causes of the dis- ordered function. We may therefore with profit discuss briefly the causes contributing to the production of surgical shock. Crile 2 enumerates these under approximately six heads. These are, 1. Duration of operation. 2. Trauma. 3. Temperature. 4. Physical condition of subject. 5. Anesthesia. 6. Hemorrhage. To this list Yandell Henderson 3 has recently added another factor, viz., acapnia. The term is used to designate a state in which there is a deficiency of carbon dioxide in the blood. In connection with these seven contributing 1 Remarks made at clinic in St. Mary's Hospital, August 4, 1910. 2 An Experimental Research into Surgical Shock, 1899, pp., 135-144. 3 American Journal of Physiology. CAUSES OF SHOCK 229 causes we should also discuss the vasomotor and the cardiac changes pres- ent in shock. 1. Duration of Operation. The duration of an operation always bears a direct relation to the occurrence of shock. "In all the experiments in which pure shock was produced, it was found that a considerable time was required, usually half an hour or more." 4 With ether as the anesthetic, it was found that dogs would survive its continuous administration for a period of time averaging ten hours. 2. Trauma. As has been mentioned trauma is one of the chief external causes of shock, in fact the term "traumatic shock" is frequently used interchangeably with surgical shock. Trauma of nerve centers, nerve trunks or areas richly supplied with nerves, is especially liable to produce shock. Shock is also especially likely to occur on exposure of the brain, pleura and peritoneum. "Exposure of the capacious splanchnic area is attended by a rapid dilatation of the splanchnic vessels, leading to intense congestion, detracting thereby a dangerous amount of blood from the somatic circulation, and inducing a rapidly declining blood pressure." 3. Temperature. ' 'Contact with air is a very great irritant to local tissues, owing to the lowering of local temperature and to the drying." Animals operated in a cold room seem to succumb more readily than under ordinary warmth. The depressing effects of cold were plainly seen when cold water was brought in contact with the intestines or when an intra-venous injection of cold saline solution was given. The effects of warm towels applied to the exposed intestines or of warm saline solution in the abdomen immedi- ately improved the respiration and checked declining blood pressure. The same effect of cold and warm salines was noticed on the brain and exposed nerve fibers. 4. Physical Condition. Individuals in impaired health, poorly nourished, with sluggish circulation, too young or too old, are always bad subjects for operation. We have elsewhere mentioned various physical conditions which contribute to the occurrence of shock. 5. Anesthesia. Over-anesthesia, rapid anesthesia at the start, or awk- ward or irregular giving of an anesthetic, contribute to the production of shock. Chloroform requires much greater care in its administration than ether. Chloroform is more toxic than ether. Chloroform may cause sudden caidiac arrest; and if this occurs, it is usually before surgical anesthesia is attained. In this respect clinical experience coincides with experiment. For these reasons, in America, the majority of surgeons prefer ether, using it almost exclusively. 6. Hemorrhage. Loss of blood always predisposes to the occurrence of shock. Hemorrhage from veins is productive of more immediate harm than hemorrhage from arteries. "Hemorrhage from large venous trunks caused the most profound effect upon the"b'lood pressure, because the quan- tity of blood supplied to the heart was immediately diminished, while if the hemorrhage was arterial, the income of blood was not so suddenly diminished. The output of the heart does not depend at all upon the height of the arte- rial pressure, but is in direct proportion to the venous pressure." 4 Crile Blood Pressure in Surgery, 1903, p. 298. 230 HYDROTHERAPY IN SURGERY 7. Acapnia. Henderson holds that carbon dioxide is a harmone, or chemi- cal regulator, of respiration and that the phenomena of vasomotor failure in shock are due to diminution of this gas in the blood and body tissues. This, he claims, is brought about by the excessive respiration (and conse- quent over-ventilation of the blood) caused by excitement, fear, pain or forced breathing. Anesthetics tend to prevent shock because they dimin- ish the excessive respiration due to pain. The habit of covering the face and ether mask with extra layers of gauze, thus causing the patient to rebreathe some of his own carbon dioxide, is pointed out in support of this theory; it being believed that this practice helps to maintain more perfect narcosis and raise the blood content of carbon dioxide. Henderson states that "skillful anesthesia consists in maintaining the threshold of the respira- tory center for carbon dioxide at a nearly normal level, and in avoiding the development of either acapnia or hypercapnia. " The theory seems to have many points in its favor; it needs further confirmation. Vasomotor Changes. The experimental data upon which the vasomotor theory of traumatic shock rests is altogether too lengthy to be given here, even in abstract. It has, however, been shown that in surgical shock the changes in blood pressure are entirely independent of the working power of the heart itself. In an animal reduced to a state of shock, the heart con- tinues to beat with its usual force as long as it is supplied with the normal amount of blood, i. e., as long as it is furnished with something upon which to expend its force. In shock the vasomotors are at first over excited and reveal symptoms of irregular, disordered action. Vasomotor curves of blood pressure (Traube- Hering curves) become rhythmic over a large area and are exaggerated. Later, after some exhaustion has set in, vasomotor effects are more diffi- cult to produce. Rhythmic variations finally cease and changes in vascular calibre end in maximal vasodilatation. In animal experiments, after removal of the stellate ganglia, stimulation produced neither a rise nor a fall. In drawing conclusions from these phenomena, Crile says, "These several results, so many times obtained, are taken as evidence of a vasoconstrictor mechanism or action and a vasodilator mechanism or action, or, in other words, a pressor and a depressor action, and that the former is exhausted more readily than the latter." "In a number of vasomotor phenomena observed, it was apparent that there are regional vasomotor actions quite independent of each other." "There is no portion of the circulatory apparatus so delicate, whose equi- librium is so easily disturbed, and whose connection with all the parts of the body is so minute as the vasomotor. A priori, it would be the most readily disturbed as well as the most readily exhausted and to such conclu- sions do our observations lead us. The more richly supplied with vasomotor nerves was a given area, the rrtore rapidly was the vasomotor mechanism exhausted when such area was subjected to injury. This principle was abundantly illustrated in the experiments upon the splanchnic area." "The experiments of Mall show that the splanchnic nerves are vein-nerves and control this large and spacious vascular area. Every experiment in this area gave evidence of the dilatation of the vessels controlled by these CHANGES IN SHOCK 231 nerves, and the decline of the pressure occurred pari passu with this dila- tation." Cardiac Changes. It is perfectly evident as remarked by Crile that, "The heart is the base of support of the blood pressure, and any interference with its action at once causes marked changes in the pressure." The heart action is thus directly influenced by venous pressure in the vena cava. Hen- derson places special emphasis upon this latter factor in discussing what he has called the "veno-pressor" mechanism. The recognition of this factor in cardiac action is, however, not new. It was early pointed out by Crile in his researches into the causes of altered heart action (and lowered blood pressure) in shock. He says, "The output of the heart is in direct ratio to the pressure of the vena cava, and not at all to the height of the aortic blood pressure. The venous pressure, then, determines the heart's output and the venous pressure is, in a good measure, dependent upon the force and frequency of the heart-beats, together with the necessary vascular tone, which is under the control of the vasomotor nerves." Through vasomotor exhaustion the blood accumulates in the dilated veins, especially those of the splanchnic area which are so capacious. There has therefore occurred "a hemorrhage into the veins." This is due both to exhaustion of the vasomotors of the veins with consequent vasodilatation and to the failure of the arterioles to continue their pumping action. This latter is likewise a result of vasomotor failure. The results of vein engorge- ment may be temporarily overcome by pressure upon the abdomen or by the use of the pneumatic suit devised by Crile. Pumping Action of the Blood Vessels. The control or maintenance of a definite vascular calibre is not the only work of the vasomotors; vascular activity is also controlled by the vasomotor centers. Arterial vascular activity helps to fill the veins and venous vascular activity helps to maintain blood pressure in the vena cava. While laying great stress upon vascular calibre in its effects upon the work of the heart, nearly all observers entirely ignore vascular activity. To illustrate the three factors in the circulation, Henderson fl employs a diagram in which the arteries are represented by rigid tubes and changes in their calibre as equivalent to the widening or narrow- ing of nozzle outlets. While this may illustrate one factor in the work of the vasomotors, it entirely overlooks arterial activity, the result of which it is impossible to conceive of as illustrated by mere changes in resistance, brought about by the widening or narrowing of the nozzles. In conclusion it must therefore be admitted that failure of the vasomotor mechanism is the chief immediate cause of surgical shock. Neither the views of Porter and Quinby, Seelig and Lyon, or Yandell Henderson have greatly altered this conception of the pathologic physiology of shock. The Treatment of Shock There is no better place than the operating room in which to demonstrate the prompt, tangible results obtained by the use of hydrotherapeutic stimu- lation. In operations upon the head, in prolonged or extensive abdominal operations, breast amputations, etc., and in other cases where shock is likely 5 American Journal of Physiology, Vol. XXVII, No. 1, p. 159. 232 HYDROTHERAPY IN SURGERY to appear and prove dangerous, the success attained by the use of hydro- therapy has, in our hands, been uniformly gratifying. This has also been the experience of many others working in the association of medical institutions with which the writer is connected. The plan which we have followed is very similar to that outlined in Chap- ter XX for the relief of acute edema of the lungs and circulatory crisis in valvular heart disease. There are certain additional features to be taken into account so that it will be repeated here in full. The principles involved in the hydrotherapeutic treatment of surgical shock are neither complicated nor difficult to understand. Their intelligent effective application, however, requires a knowledge of the causation and morbid physiology of shock, a thorough acquaintance with the methods used, and an experience in their use in order to know how to adapt the means to the case in hand and bring results where these results are difficult to obtain. The vasomotor failure in surgical shock can be and is met ideally by only one method of procedure, viz, the application of cold water combined with friction. If hemorrhage has occurred, the loss of fluid must be met by the introduction of more fluid. Warm saline solution may be given by hypoder- moclysis or by proctoclysis according to the urgency of the case. It is usually well to give the hypodermoclysis while the patient is on the operating table and follow it with saline solution by either intermittant protoclysis or by continuous proctoclysis after the method of Murphy, begun as soon as the patient reaches his room. When shock appears during the operation the patient should be treated on the operating table. The effectual treatment of shock requires the atten- tion of two persons. On the appearance of the symptoms of shock, immed- iately place the patient's feet in hot water, care being taken that the water is not nearly hot enough to produce a burn; or quickly apply well wrapped fomentations so as to cover both feet and legs to the knees. As soon as the parts have been well -warmed and reddened, remove the hot applications and quickly administer to the same parts a cold mitten friction. The water used should be ice water and the friction most vigorously given. The mitts should be dipped 2 or even 3 times, another attendant holding the limb while it is being treated. The skin is now dried and rubbed with a coarse Turkish towel and immediately covered with a warm dry blanket. The thighs should be treated in the same manner, also the arms. While this is being done and beginning at the same time as the first treatment to the limbs, intense and quickly alternating hot and cold applications should be made to the anterior surface of the chest and especially over the precordia. This may be done by removing the ice bag from the precordia, which should have been placed there when the pulse first became unduly rapid, and after rubbing the skin briskly, applying a very hot but well covered fomentation. This should not be left in contact with the skin longer than 15 or 30 seconds. Next, rub the chest with a flat smooth piece of ice, using quick to-and-fro movements and wiping away the water with a Turkish towel. After this another fomentation is applied, again followed by the ice. These alterna- tions should be repeated 3 or 4 times, after which the well covered ice bag should again be placed over the heart. Wherever there is any hope at all of vasomotor response, these measures TREATMENT OF SHOCK 233 result in prompt rise of blood pressure and as prompt cardiac response to the increased venopressure. Where an abdominal operation is being done, it is, perhaps, needless to say that warm gauze napkins should be applied and, if feasible, some pressure exerted upon the splanchnic area in order to more quickly send the blood on to the heart. Rather than leave fluid in the abdomen, we prefer to give warm saline solution per rectum even while the patient is still on the operating table. Unless the shock is very severe it will not be necessary to repeat the vasomotor stimulation short of thirty or forty minutes. If the condition of the patient permits and repetition of the vigorous measures outlined above is not really needed, it will be better from now on to employ milder tonics after giving some efficient derivative treatment. The principle of this plan of treating shock lies in the effect of brief appli- cations of heat to the skin surface and especially to the limbs, in order to warm the skin and aid in reducing internal congestion. The quickly follow- ing cold friction produces vigorous stimulation of the vasomotors, so that the blood pressure rises immediately. The vascular condition is not at all comparable with that produced by the injection of adrenalin. It is not a stationary vasoconstriction that results from a cold friction, but a vascular activity a rapidly alternating dilatation and contraction of the blood ves- sels. This is a true pumping action which is in reality only a heightening of the normal activity of the blood vessels. The effect of different temperatures upon blood pressure has already been discussed in Chapter IX, where the laws deduced by Muller are recorded. Muller's studies into the effects of baths on blood pressure were carried out by means of a Riva-Rocci instrument and were very carefully done with apparently every precaution taken. Those who desire to study further these experiments will find a complete consideration of the question given in his paper. 6 In meeting Henderson's acapnia, what could be more ideal than raising the carbon dioxide content of the blood and tissues by stimulating its pro- duction from the tissues themselves through increased oxidation? That this can be efficiently done by thermic and mechanical stimuli and results very promptly from the application of such means, has already been shown in Chapter XII. The circulatory stimulation and the stimulation of respira- tion by the same means serve to maintain the proper per cent and proportion of oxygen and carbon dioxide in the blood. In concluding the consideration of the treatment of surgical shock, other than a practical experience in the satisfactory results attained, we could offer no better apology for the presentation of so simple a plan for its treat- ment than to summarize the experimental work and conclusions therefrom, reached by recognized authorities, showing the failure of older and more pretentious methods. Those who wish the facts at first hand will find the results of the most exhaustive and conclusive studies along this line given by Dr. Crile in his monumental work, "Blood Pressure in Surgery, "" which appeared in 1903. 6 Uber den Einfluss von Badern und Douchen auf den Blutdruck beim Menschen Deut. Arch, fur. klin. Med., 1902, volume LXX1V, p. 316. 7 Quotations immediately following-, unless otherwise credited, are from this work, pp. 261 to 300. 234 HYDROTHERAPY IN SURGERY Alcohol. "The immediate effect of intravenous' administration only was observed. The first effect usually noticed was a decline in the blood pressure. In the majority of such instances a compensatory rise followed; in a number of instances no change in the blood pressure was noted; in but few was there a rise. The average length of the stroke of the manometer (height of pulse wave) was increased. There was no evidence that the heart beat more forcibly. In animals reduced to varying degrees of surgical shock, the usual effect of an average dose of alcohol was the production of a fur- ther depression; in smaller doses but little effect was noted, while in larger doses a more marked decline often occurred. In few instances the administra- tion of a considerable dose in deep shock was followed by almost immediate death. In a number of experiments the decline in the blood pressure was as prompt and as marked as in the administration of the amyl nitrite and nitroglycerin. In no instance, in the normal animal, did death immediately follow the largest dose of alcohol; the more profound the shock, the more marked was the depressing effect of alcohol. In a number of experiments alcohol was given prior to procedures intended to produce shock. It is not certain that it rendered the animal more susceptible. It is quite certain that the susceptibility was not diminished." Nitroglycerin and Amyl Nitrite. "The immediate effect of nitroglycerin and amyl nitrite upon the pulse was an increase in its volume and a decrease in frequency. The immediate effect upon the respiration varied. At times there was a slight increase, more frequently a slowing of respiration. The immediate effect upon the blood pressure in almost every instance was a fall. The decline was usually rapid. There were but few exceptions, and in these there was usually no effect. A rise was rarely observed. In the latter it was but temporary and was usually followed by a fall. The descent in the blood pressure was gradual and rather rapid, the ascent, more gradual. " "In the experiments in which the animal was in deep shock, and the blood pressure was gradually falling, there was no evidence to show any decrease in the rapidity of the decline. On the contrary, as nearly as could be esti- mated, nitroglycerin distinctly increased the rapidity of the decline. The effect of nitrite of amyl was in every respect similar to that of nitroglycerin. In many instances the heart beat irregularly after the injection. On the whole, nitroglycerin and amyl nitrite increased shock." Digitalis. The administration of digitalis in the normal animal produces a rise of blood pressure which is well sustained. The drag is very likely to cause over-stimulation resulting in sudden cardiac failure. In varying degrees of shock, digitalis produces a less marked rise of blood pressure than in the normal animal. "The respiration when at all affected was either impaired or arrested. Death in the digitalis experiments, even in those in which the dosage was only therapeutic, was usually more sudden than in the controls. Although the data does not permit positive statements, it seemed on the average, that cases of shock treated by digitalis did not live as long as the controls. It may certainly be stated that they did not live longer than the controls." Strychnin. "In the majority of instances, in the normal animal, when sufficient amount of strychnin was given to cause an increased excitability of the spinal cord, as indicated by heightened reflexes and an increased STRYCHNIN IN SHOCK 285 muscular tone, a rise in blood pressure was noted. In smaller doses, occas- ionally, a slight immediate fall, a slight immediate rise, or later irregularities were noted, but on making 48 careful measurements of the effects, it was found that no noteworthy changes occurred." "In 48 experiments, it was found that strychnin in therapeutic doses does not cause a rise in blood pressure." 8 "The stage of increased excitability above mentioned, represented the border-land between the dosage without effect upon the blood pressure and that of maximum effect. When more was given after this stage had been reached, convulsions appeared, and the blood pressure rose abruptly, and high, sometimes even more than doubling the normal. The curve during the convulsions was exceedingly irregular, and continued for some time above the normal, exhibiting a secondary rise if later convulsions occurred. " In speaking of strychnin experiments in which both vagi and accelerantes were severed and curare given, Doctor Crile says, "On repeating the dose a period was soon reached in which no further effect was noted. After each dose, when the effect had worn off, the blood pressure fell to a lower level than it was before the injection was given, until finally it reached the level, usually between 20 and 30 mm. which was not altered by an additional dosage. ' ' "In a series of experiments in which strychnin was given in various degrees of shock in such dosage as to cause a stimulation, the effect was proportional to the degree of shock, i. e., when but little shock was present, a marked effect from strychnin was obtained; and when most profound, there was no effect. In the intervening degrees, the effects were proportional, but after giving the strychnin, the animals not yet incomplete shock always passed into a deeper degree of shock. In any degree of shock, after the administration of a therapeutic dose of strychnin, the animals passed into deeper shock. Later in the research, it was found that the most convenient and certain method of producing shock for experimental purposes, is by the administration of physiologic doses of strychnin. The treatment of shock, then by therapeutic doses of strychnin is inert and physiologic doses danger- ous. "It then follows that treatment of shock by vasomotor stimulants in the form of drugs, is on precisely the same basis as treatment by burning the animal or crushing his paws, or by subjecting it to injury or operation, it would seem to be as reasonable to treat strychnin shock by administering traumatism as traumatism by strychnin." 910 "Surgical shock is an exhaustion of the vasomotor center. Neither the heart muscle, nor the cardio-inhibitory center, nor the cardio-accelerator center, nor the respiratory center, are other than secondarily involved. Col- lapse is due to a suspension of the function of the cardiac or of the vasomotor mechanism. In shock therapeutic doses of strychnin are inert, physiologic doses dangerous or fatal. If not fatal, increased exhaustion follows. There is no practical distinction to be made between external stimulation of this 8 Crile Detroit Medical Journal, May, 1903, p. 38. 9 Ibid, pp, 38 and 39. 10 Doctor Crile shows sections of brain tissue revealing degeneration of the Purkinje cells from continuous use of strychnin. 236 HYDROTHERAPY IN SURGERY center as in injuries and operation, and internal stimulation by vasomotor stimulants, as by strychnin. Each in sufficient amount produces shock; and each, with equal logic, might be used to treat the shock produced by the other. Stimulants of the vasomotor center are contraindicated. Cardiac stimulants have but a slight range of possible usefulness, and may be injurious. . . . Adrenalin acts upon the heart and blood vessels. It raises the blood pressure in the normal animal; in every degree of shock; when the medulla is cocainized; and in the decapitated animal. It is rapidly oxidized by the solid tissues and the blood. Its effects are fleeting; it should be given continuously." 11 The effect of a single dose of adrenalin lasts from two to four minutes. "The longest time that the action of the extract on the blood pressure was prolonged was found to be four minutes. With the continuous flow of the extract into the vein, however, the pres- sure was kept up as long as the flow was continued, and for the usual time after it had been discontinued." After-Treatment Post-anesthetic Infections. The question of how best to prevent and treat post-anesthetic pneumonia, wound infections, and other infections following operations is an ever present one, and to the surgeon the cause of no little anxiety during the first 3 or 4 days of the after-care of the patient. Modern aseptic technic together with caution in regard to unnecessary traumatism in operating and in regard to injury of the tissues by strong antiseptics or the prolonged application of antiseptics, also the proper use of serum drainage, has reduced wound infection very largely to a matter of the resistance of the patient's tissues. We have already shown how the tissue resistance may be increased by preparatory treatment. There is, however, one cause of lowering of the vital resistance which, in the nature of the case, can not be eliminated. This factor in lowering resistance is nothing else than the anesthetic itself. It results in limiting or checking for the time being, both phagocytosis and leucocytic activity. After anesthesia, the power of the blood to destroy pathogenic bacteria is markely reduced. "In fact, the members of the entire group of alcohol, ether and chloroform reduce the power of the blood to combat bacteria; the state of a man after a long anesthesia is comparable to that of an alcoholic with bronchitis who has been sleeping off an overdose of alcohol in a door- way or a freight car. ' 'So important a subject is this post-operative pneumonia that much interest attaches to the recent studies of Graham on anesthesia and the bactericida powers of the blood. According to these experiments, it is not the power which serum itself has of destroying bacteria through bacteriolysis which is reduced by anesthetics, but the destruction of bacteria by phagocytosis is greately reduced. Now it so happens that the organisms which we have to fear in surgery, the pneumococcus aud the pus cocci, are destroyed chiefly through phagocytosis and not by bacteriolysis, which gives added importance to this depressing effect on the bactericidal powers of the blood. Appar- 11 Ibid., p. 45. AFTER-TREATMENT 237 ently ether, the anesthetic which Graham has studied, reduces both the effic- iency of the opsonins and the power of the leucocytes to take up the sensitized bacteria; these effects can be seen both in the blood of the patients or animals after anesthesia, and in drawn normal blood treated with ether in the test tube. The action of the ether is not permanent, the opsonic power being restored promptly on removal of the ether." M Dr. C. Achard has recently called attention to these facts and their impor- tance in the causation of certain post-operative accidents, in a paper read before the Academie de Medecine. 13 The use of morphin as an anesthetic aid, even where definitely indicated, must of necessity be an added source of danger from infections. L. Rey- nolds H has emphasized this fact and called attention to the disadvantage in using morphin. "From experiments performed by him, Reynolds concludes that morphin exerts a marked influence on the leucocytes. Not only does it check diape- desis, but phagocytosis is diminished in a marked degree. The growth of bacteria, on the other hand, is not appreciably affected. What bearing has this on the practice of medicine and surgery? It is probable that in most surgical operations a certain number of pathogenic organisms gain entrance to the wound, however carefully asepsis be observed. The further history of the case turns on this point. Will the phagocytes be able to destroy these bacteria before the latter have multiplied sufficiently to gain the upper hand? If morphin temporarily paralyzes the activity of the phagocytes, if this drug be given, time is lost during which the bacteria multiply. When the narcosis passes off, the phagocytes may be unable to destroy the bacteria on account of their number and the paralyzing effect of the toxins produced by them; in fact by giving the morphin the chances of sepsis have been increased." 15 It thus appears plain that the use of mixed anesthesia is not to be en- couraged unless very definitely indicated. The use of morphin may be necessary in operations for hyperthyroidism and in a few other conditions, but unless there are good reasons for its administration in other conditions, it should not be given. In the treatment and prevention of post-anesthetic infections, there are three things to be accomplished. These are, first, the rapid elimination of the ether; second, the raising of the leucocytic activity; and third, the reduc- tion of local congestions. Rapid elimination of ether is best accomplished by the giving of much water immediately following the operation. The use of the saline enema is specially helpful. In giving continuous proctoclysis, after the volume of the circulating fluid has reached normal, the added fluid is eliminated by the kidneys as fast as it is absorbed. This same measure also helps in decreasing the danger from post-operative nephritis. As soon as the patient is out from under the anesthetic, copious water drinking should be insisted upon. It will not be likely to cause vomit- 12 Editorial in Journal of American Medical Association, Feb. 18, 1911. 13 April, 1910. 14 London Lancet, Feb. 26, 1910. 15 Abstract of article by Reynolds in Journal of American Medical Association. 238 HYDROTHERAPY IN SURGERY ing, and if it should seem to have this effect, gastric lavage may be resorted to and continued until the stomach has been washed clean. Sips of very hot water or swallowing bits of ice will then relieve the trouble and in a little while the free use of water may be continued. An active circulation will also aid in the elimination of the ether; and this, together with the stimulation of leucocytic activity, may be accomplished by use of the cold mitten friction with the ice bag to the heart. Both these measures increase the depth of respiration and the volume of tidal air so that more thorough ventilation occurs. Considerable importance attaches to the prevention of internal congestions and visceral stasis of blood, especially in the lungs and about the site of operation. As a means to this end we have adopted as almost a matter of routine, the use of the hot foot bath, the hot leg pack or electro-thermal pack to the legs as soon as convenient, immediately following the operation. If the hot leg pack is used, a dry blanket should be placed next to the skin. A well covered ice bag is placed over the heart at the same time. The treatment is continued until the limbs are well reddened and should be con- cluded by a cold mitten friction to the same skin surface. This procedure will usually last about 30 minutes. It will probably not be necessary in ordi- nary cases to repeat it for several hours or until the next day. Transient albuminuria does not usually require any special treatment. If albumin and casts appear in the urine, derivative treatment is indicated and free perspiration should be encouraged. Sweating should never continue long at a time. If pneumonia occurs, use derivative measures and apply the cold coil or cold compress to the chest. These should be occasionally interrupted by the application of a fomentation or the revulsive compress used. The ice bag to the heart and the cold mitten friction are also of great service in treating post-operative pneumonia. For further details see article on pneu- monia in Chapter XIX. After gall-bladder, appendix, tubal, and some other abdominal operations, a right sided, diaphragmatic and consequently much hidden pleurisy may appear. It is usually not severe and will respond to the usual treatment. PART III TECHNIQUE FOMENTATIONS (Fo.) A fomentation is a local application of moist heat by means of cloths wrung fron hot water. a. Articles Necessary. In well equipped treatment rooms the fomenta- tion tank should be so arranged that the water, from which the fomenta- tions are to be wrung, can be heated by a coil of live steam. When properly arranged the escape of steam from this coil into the water will be noiseless and cause the water to boil more vigorously then over a fire. The outlet of the tank should be controlled by means of a valve, never by a plug. A wringer with extra long rollers should be clamped to the side or end of the tank and a table placed immediately beyond the wringer on which the fomen- tations may be wrapped. If treatment is given at the patient's residence a boiler or pail of hot water may be used. In an institution it is rarely neces- sary to carry a pail of hot water to the patient's room, as the fomentations will be hotter if prepared in the treatment rooms and packed in a pail in the manner described below. The nurse should also be provided with a set of six fomentation cloths, two Turkish towels for drying the patient, one large cotton sheet for covering the patient, a bowl of cold water or ice water and one or two hand towels. An oil cloth and extra sheets and towels will be necessary to protect the bedding. If the treatment is to be given in a patient's room, provide a grass mat on which the pail of fomentations or hot water may be placed. If the pail is placed on a carpet, a newspaper may be all that is required. When the pail is set on a chair with a newspaper under it the heat causes the paper to stick to the varnish. b. The Patient. All clothing should be removed. If the clothing is not removed, then bare a longer area than the part to be treated and thoroughly protect the clothing by thick Turkish towels. See that the feet are warm and kept so during treatment. If they are cold, a hot foot bath should be given, or hot water bottles applied. The hot foot bath is much more effec- tive than any other means of warming the feet. In giving fomentations to a bed patient great care should be exercised to avoid steaming the bedding, as a patient may easily take cold because of bed linen left damp after treatment. Protect the bedding underneath the patient by oil cloth, sheets and towels as necessary. After applying a fomen- tation, cover it with another dry fomentation or a newspaper in order to pro- tect the bedding over the patient. c. The Fomentation. Prepare a set of four or six fomentation cloths, thirty to thirty-six inches square. Four of these may be cut from a single blanket. The material should be half wool. Three cloths are necessary for one fomentation where they are to be very hot one for the dry covering and two to be wrung from boiling water for the inside wet part. Where 242 TECHNIQUE OF HYDROTHERAPY less heat is required one iriside cloth may be sufficient. Two such fomenta- tions are necessary if the best results are to be obtained. Spread out on the table the cloth for the dry covering. Fold together in three thicknesses so as to make a long narrow piece, the cloth or cloths to be used inside; and holding the strip by one end, immerse in the boiling water. When thoroughly saturated with the boiling water, pass it quickly through the wringer and after further folding or re-adjusting to the proper shape and size for the part to be treated, fold it quickly inside the dry fomentation cloth. It is now ready for use. By again doubling together the surface of the fomentation to be applied to the patient, it can be carried with less loss of heat. The fomentation should be large enough to cover a much larger area than the part affected. Where it is necessary to wring the fomentation by hand, partially twist the long folded piece while it is held doubled together with one hand holding each end. Both ends are now grasped in one hand and the fomentation dipped into the boiling water. When it is ready to wring, twist tightly, handling the fomentation cloth by the dry ends. Next, pull the ends apart. The water is thus squeezed out. The twisting and pulling may be repeated as necessary for thorough wringing of the cloth. By releasing one end while holding up the cloth by the other it may be quickly untwisted and at once wrapped in the dry covering. Where it is necessary to give the treatment in the patient's room, a set of three fomentations may be packed in a papier mache pail in such a way as to preserve their heat for a half hour or even longer. First, line the pail with large, dry fomentation cloths. Prepare each fomentation'as usual and pack in tightly or better still, wring by hand the inside cloths, leaving them twisted as tightly as possible and pack closely in the lined bucket. A hot water bottle may be placed in the bottom of the pail if thought neces- sary and another over the wet cloths. The necessary number of dry fomen- tation cloths may be packed into the top of the pail and the fomentations made up in the room as needed. d. Procedure. The fomentation should lie closely in contact with the skin, and be renewed in three or four minutes; or in case of pain, as soon as it becomes comfortable. If unbearably hot, rub the part with the hand under the fomentation or remove the moisture by firm rubbing once or twice wich a Turkish towel wrapped about the hand. The fomentations may be applied over a towel in order to temper the heat. Always be careful to protect from chilling, the area being treated by keeping it covered with the fomen- tation cloth or a towel. To renew the fomentation, prepare another similar one and apply immed- iately after removing the moisture occasioned by ihe first. Never apply another fomentation until this is done, as the water on the skin makes it more difficult t > endure the heat of the newly prepared fomentation. The second fomentation should be ready to apply before the first is removed. The removal of the inside cloth from the outer for purposes of renewal does not give the best results, although careful attention to details may still make the treatment very effective. Unless otherwise indicated or ordered, three successive applications are LOCAL APPLICATIONS OF HEAT 243 made. In all cases, however, they should be continued until the desired effect is obtained. After the last one, the part should be immediately cooled by a wet hand rub, cold compress, or rub with the cold wet towel. Dry thoroughly and cover at once to prevent chilling. In some cases o*f pain, the part should be dried without the cold applications. All changes should be made quickly, and the part treated should never be left uncovered. e. Precautions. Incasesof unconciousness, paralyzed sensation, diabetes, dropsy, under anesthesia or after operations, great care must be taken to avoid burning. The degree of each application should be tested by the back of the hand or face before being applied to the patient. In fomentations to the face or other sensitive part, gauze should be placed next to the skin. In case of general perspiration, a general cold friction, wet hand rub, wet towel rub or alcohol rub should be given. Sensitive surfaces, especially bony prominences such as the ilia, costal arches, clavicles or scapula may need to be protected by extra coverings of flannel or Turkish towel. Where the patient is liable to cerebral congestion, and always in case of fever, apply cold compresses to the head and also to the neck if needed. The same should be done where two or more applications of heat are made at the same time or general perspiration induced. In case of heart disease, usually in fever, and with rapid pulse from any cause, an ice bag should be placed over the heart. In order to relieve pain, the fomentation must be very hot, as hot as can be borne, and renewed as soon as it becomes comfortable. In some cases of pain the cold application at the close should be omitted, the part being dried and immediately covered with flannel or other dry covering. For sanitary reasons it is desirable that each patient furnish his own fomentation cloths. However, persons with communicable diseases should not be admitted to a general treatment room. f. Effects. The fomentation is used to relieve pain, produce derivation, as a preparation for cold treatment and for stimulating or sedative effects, according to the temperature and mode of application. Its first effect is that of a vital stimulant; unless followed by a cold application the reaction is atonic. A brief application is stimulating; prolonged applications seda- tive or depressing. For sedative effects the heat should be moderate and the application more prolonged before renewal. HOT GAUZE COMPRESS (H. Comp.) This is used when it is desired to apply moist heat to such sensitive parts as the eye, a wound or infected part where the cloth must be disinfected or discarded after being used. Several thicknesses of gauze, cheesecloth or ordinary cotton cloth of appropriate size and shape, are wrung from boiling water and applied in the same way as a fomentation. Because the compress is usually small and unprotected, it cools quickly, and for this reason must be more frequently renewed, nor does cotton hold heat as long as wool. From ten to fifteen 244 TECHNIQUE OF HYDROTHERAPY minutes will usually suffice to obtain the desired result. The treatment should be concluded in a manner similar to the fomentation. STUPES A stupe consists in the application of a medicament by means of a fomen- tation. When gauze compresses are used, the disinfectant or medicament may be put into the hot water from which the compress is wrung. In case of a large fomentation with flannel cloths, the medicament may be applied by compresses placed under the fomentation. Turpentine, mustard, menthol, etc., may be used in this way. However, the desired hyperemia and deple- tion can usually be obtained in a more cleanly manner by a plain fomenta- tion, and without the danger of a blister. In preparing the gauze or muslin for a mustard fomentation, use one teaspoonful of mustard to a cup of hot water. Spread out this mustard compress on the surface to be treated and cover with an ordinary fomenta- tion. REVULSIVE COMPRESS (Rev. Comp.) This is given in the same manner as the fomentation, with the addition of a cold compress after each application of heat. A hand towel is wrung from cold water or ice water, according to the ability of the patient to react. This is spread out over the surface immediately on the removal of the fomen- tation, allowed to remain a few seconds, and then turned over and allowed to remain about thirty seconds. The skin is now dried and the next fomen- tation applied. Three changes of hot and three of cold are usually employed. The revulsive compress is a mild stimulant and tonic measure, it also pro- duces mild fluxion in the part treated. ALTERNATE HOT AND COLD TO SPINE (H. & C. Sp.) Fomentations are given in the same manner as for the revulsive compress. After each a smooth piece of ice is quickly rubbed back and forth over the part, making from three to five or more to-and-fro movements. The part is then dried and another fomentation applied. In making these hot and cold applications, the next fomentation should be ready before the ice is applied. Alternate hot and cold applications may be made to other parts in the same manner. Alternate hot and cold to the spine is a vigorous stimulant and tonic meas- ure and is useful in a great variety of conditions. ALTERNATE HOT AND COLD TO HEAD (H. & C. Hd.) a. Articles Necessary: Two compresses of three to five thicknesses of gauze or cheesecloth about twelve inches square. Two ice bags filled with finely chopped ice and covered with cheesecloth. LOCAL APPLICATIONS OF HEAT 245 A spine bag partly filled with hot water and covered with a fomentation cloth or towel. A bowl of ice water and a pail of boiling water. b. Procedure. Place the spine bag crosswise of the cervical spine, bring- ing it well up under back of head and neck. Lightly wring cheesecloth from ice water and apply to face, covering top of head and ears. Press down firmly over forehead and temporal arteries; renew every minute. After three minutes replace spine bag by two cloth-covered ice bags, and the cold compress to face by another wrung quite dry from hot water; the latter should be renewed every minute. In another three minutes replace the first applications of spine bag to the back of the neck and cold compress to the face. Continue these alternations for three complete sets of hot and cold. Cool all the parts by wiping off with a cold compress and dry thor- oughly, especially the hair. c. Effect. These alternating hot and cold applications stimulate the cere- bral circulation and the treatment is, therefore, indicated in headache due to anemia of the brain, also in passive congestion and in a cold in the head. Any alternating hot and cold application produces fluxion. SIMULTANEOUS HOT AND COLD TO HEAD (Simul. H. & C. Hd.) Place an ice bag to the base of the brain and another ice bag, or better, ice cap to the vertex after moistening the hair so that the cold will pene- trate. Also place ice bags or ice compresses over the carotids. Now apply a fomentation to the face, covering the ears and forehead. Gauze or cheese- cloth should be used under the fomentation when applied to the face. The nose should not be covered by the fomentation as it is uncomfortable when so done, and it is better for the patient to breathe cooler air. This treatment is very effective in reducing cerebral congestion and reliev- ing congestive headache. It is well to conclude the treatment by an alter- nate hot and cold percussion douche to the feet, cold cervical and cephalic compresses being kept on during the douche. Simultaneous applications of heat and cold so given that the cold applica- tion is placed over a reflex area of, or the large artery supplying, the deep part, produce depletion. HOT WATER BOTTLES These should be partly filled with hot water (never boiling water) and wrapped in cloth, preferably flannel or a Turkish towel. Great care should be taken in applying them to patients with paralysis and during and after operations that burns do not result. The safety of the hot water bottle may be tested by holding it against the cheek. When not in use, the bottle should be hung bottom end up with the stopper out. It should never be left doubled sharply upon itself as it is likely to crack at the fold. Fomentations may be re-enforced or prolonged by the use of hot water 246 TECHNIQUE OF HYDROTHERAPY bottles, or the bag may be wrapped in a moist cloth covered over by a dry one, to give the effects of a mild fomentation. WINTERNITZ COIL This consists of a matted coil of rubber tubing about ten or eleven inches in diameter, through which a stream of hot water is caused to flow. A dry blanket is placed on the treatment table, and over this is placed a doubled sheet, wrung from cold water or ice water, so that it may be wrapped about the trunk. The patient lies down on the wet sheet and one end is wrapped tightly about the chest and abdomen. The coil is now placed on the abdo- men over the wet sheet, and the other end of the sheet, wrapped around the trunk over the coil. The dry blanket is folded over and about the patient. A small stream of hot water at 135 flows slowly through the coil from the center outwards. The treatment is continued from thirty to forty minutes, or even three hours in cases of very slow and defective digestion. It is con- cluded by a cold mitten friction. A hot water bottle may be used in place of the coil. (See hot and heating trunk pack.) The coil may be used for cold water in the same manner as the Leiter coil. In fact the cold coil is much more frequently used and for a greater number of purposes than the hot coil. RADIANT HEAT (Rad. Heat) The radiant heat is a local application of heat by means of electric lights arranged in a reflecting metal case. From one to twelve or more such lights may be arranged in a single case, and the case so constructed as to fit to any part of the body. An instrument with one light is perhaps the most useful. An oblong case containing three lights is a convenient means of applying heat to the spine. A case in the shape of a half cylinder and con- taining six or more lights may be made for the feet and legs. In applying the radiant heat, the body should be protected from the edge of the case by towels or fomentation cloths. The amount of heat may be regulated by the number of lights or the distance from the skin. Leave in place for ten to twenty minutes, or until the desired results are obtained. Cover the part well after drying perspiration, or use a cold wet towel. LOCAL APPLICATIONS OF COLD COLD COMPRESS (C. Comp.) A cold compress is a local application of cold by means of a cloth wrung from cold water. Hand towels or ordinary cotton cloths may be used. These should be folded to the desired size, and wrung from cold water or ice water. The wringing should be just sufficient to prevent dripping. They will be colder if taken immediately from a block of ice. As a continu- ous cold application, the compress must be very frequently renewed, always LOCAL APPLICATIONS OF COLD 247 before it is warmed to any great extent. The thicker the compress, the less frequently will it require renewal. A set of two compresses should be used and renewed at intervals of from one to five minutes depending on the thickness of the compress and the result to be obtained. Cold compresses may be applied to the head, neck, over the heart or lungs, to the abdomen, spine, etc. When applied to the head they should be pressed firmly down on the surface being treated, especially over the forehead and the temporal arteries. The pillow should be protected by rubber cloth covered by a towel. When applied to the abdomen in typhoid fever the bedding and patient's garments should be protected by Turkish towels. When applied over a large artery it decreases the amount of blood in the part beyond the application. Such an application is called a proximal com- press. Examples of this are found in such applications as a cold compress to the neck, over the femoral artery, at the bend of the elbow, etc. Ice bags are also used for the some purpose. ICE PACK (Ice Pk.) An ice pack is used where a large, continuous and very cold application is desired. Spread cracked ice over a thick Turkish towel, folding one end and the edges over this so as to retain the ice. Apply next to the skin or over a single layer of flannel. This may be used over the heart, also over a con- solidated lung area in pneumonia. In the latter case, it should never be applied until after the hot packs used in this disease have warmed the body sufficiently to prevent chilling. It should occasionally be interrupted by applying a fomentation. This helps to preserve the desired reflex effect. Snow may be used in place of the pounded ice. In applying an ice pack to a joint first wrap the part in flannel so as to prevent actual freezing, then pack the snow or pounded ice closely against the flannel forming a layer about one inch thick, retaining it in place by a larger flannel cloth wrapped about all and pinned together. Ice packs should be interrupted often enough to prevent freezing and the part either rubbed with snow or a fomentation applied to renew the local reaction. ICE CRAVAT The ice cravat or collar is made in the same way as the ice pack, the towel being filled with ice and folded so as to be about three inches wide and encir- cle the neck. If the towel is wrung from ice water, it must be more fre- quently renewed than when cracked ice is used. An ice cravat may also be made by using two narrow spinal ice bags. These should be filled with pounded ice and wrapped in a linen or cotton cloth. The effect is that of a proximal application. The carotid arteries and and their distal branches are contracted^ also the vertebral arteries. Thus the blood supply to the brain and head generally is very much lessened. The ice collar is frequently used in fever, in congestive headache, in acute 248 TECHNIQUE OF HYDROTHERAPY epidemic meningitis, etc. It should also be used in sunstroke and whenever prolonged sweating treatments are given as in eclampsia and uremia. ICE BAG AND ICE CAP (Ice Bg.) Ice bags are made in various shapes and sizes. The best ice bags are made of pure gum rubber and are usually elliptical in shape. They may be obtained in almost any size desired. The spinal ice bag is about three inches wide by seven to nine or ten long. Ice caps are usually round or elliptical and provided with a screw cap; some are also made with loops for holding them in place. Cloth covered ice bags offer no advantage, they usually leak after being used a few times and are also unsanitary. The ice bag or cap should be filled with finely cracked or pounded ice, never with large chunks. In the case of the ice bag, the neck should be doubled down, then folded several times across this, and tied with tape about one-fourth inch wide. Thread or fine twine should not be used, as it cuts the rubber. When applying the bag, wrap it in a towel or one thickness of flannel. The skin should not be severely chilled. The bag should be removed often enough to prevent this, the part rubbed briskly with the hand until warmed or a fomentation applied for a short time. COLD WATER COIL (C. Coil) The rubber coil (Winternitz coil) is the most convenient means of apply- ing a local application of cold. Matted coils ten or eleven inches in diameter may be purchased or a coil may be made of ordinary rubber tubing and held together by adhesive tapes. The inflow should enter at the center of the coil. The rate of flow may be very conveniently controlled by tying a knot in the outflow tube just above where it dips into the receiving pail. This knot may be loose or tight as desired for rapid or slow flowing of the cold water through the coil. The reservoir should be about two feet above the level of the coil and may be a large can with an outlet at the bottom, or an ordinary pail may be used and the outflow secured by siphonage. The coil should always be applied over a cold compress and covered with a dry flannel cloth or dry fomentation cloth. In applying it to the head the coil may be moulded into the shape of a cap and held in place by light band- ages or folded towels. Always wet the hair before placing the coil. The Leiter coil is not used as much as the rubber coil. It is a small flat coil of flexible metal tubing through which a stream of cold water or ice water passes. It may be moulded to fit any part, and is often used over the mastoid. The principle is the same as that of the Winternitz coil. HEATING COMPRESSES A heating compress is a cold compress so covered that warming up soon occurs. The effect is, therefore, that of a mild application of moist heat. A heating pack or compress consists of an application of heat to the body HEATING COMPRESSES 249 by means of three or four thicknesses of gauze or one of linen or cotton cloth wrung from cold water and so perfectly covered with dry flannel or mackintosh and flannel as to prevent the circulation of air and cause an accumulation of body heat. In case warming does not occur promptly, it should be aided by hot water bottles or the radiant heat. It is usually left in place for several hours between other treatments, or over night. If left on over night it should be dry by morning unless an impervious covering such as a mackintosh or oiled silk is used. On removal of the compress the part should be rubbed with cold water. According to the extent and location of the surface involved, the nature and thickness of the coverings, the temperature and the amount of water left in the wet cloth, and the duration of the application, it may have the following effects, viz., tonic, sedative, derivative or sweating. If the pack dries out before being removed, it will have a mild derivative and a mild sedative or tonic effect according to the part to which it is applied and the condition in which it is used. If the coverings prevent drying, the result will be that of a stronger derivative because of the local sweating. It also causes relaxation of the muscles and vasodilatation of the vessels in immediate or reflex relation with the surface treated. MOIST CHEST PACK (Ch. Pk.) Any sort of a jacket which combines the above requisites for a heating compress with ease and neatness of application and accuracy of fit, will answer the purpose of a chest pack. The roller, square and fitted chest packs are examples of these. 1. Roller Chest Pack. The inside piece consists of two to five thick- nesses of gauze eight to ten inches wide and about six or eight feet in length. One thickness of thin linen may be used. The outside piece of flannel is a little wider than the gauze and somewhat longer. The gauze or linen is loosely rolled in bandage form and wrung nearly dry from cold water. While standing in front of the patient the end is applied under one arm, more handily the right, then carried diagonally across the front of the chest and over the left shoulder, then obliquely across the back, under the right arm and directly across the front of the chest, under the left arm, across the back and over the right shoulder and fastened under the trans- verse front piece. The bandage must be snugly applied at all places but not so tight as to restrict the movements of the chest. The flannel is now applied in the same order, care being taken that the wet piece is well covered and then securely fastened with safety pins. The pack should be comfort- able and feel warm in a very short time. 2. Square Chest Pack. Both parts of the pack are of an oblong form, wide enough to reach from the top of the shoulder to the lower ribs, and long enough to give a double thickness in front. The ends of the bandage are slit into two strips one-third and two-thirds respectively of the total width, and each one-third of the length. The outer flannel part should be about two inches wider and of the same length and slit in the same fashion. The flannel part should be spread out on the treatment table and the linen over 250 TECHNIQUE OF HYDROTHERAPY it after being wrung from cold water. The patient now lies back on this. The narrow strips are brought up over the shoulder and across the chest. The top of the wider strips should fit under the axilla and be brought across the chest. The flannel should now be applied in the same manner and at all loose places be drawn tight or folded in and the whole fastened with safety pins. 3. Fitted Chest Pack. From flannel cut a front and a back piece in much the same shape as for a vest making the necessary carved cuts about the arms and neck. The front piece should be the larger so as to come back under the arms and lap over the back piece; also on each side of the neck, a strip four inches wide should be made long enough to overlap the back piece. An inside piece of the same shape should be cut from gauze or thin linen. This inside piece should be about one and one half 'inches narrower at all edges so that when covered by the flannel it will not be exposed at any place but be covered at least one inch beyond its edge. After applying see that it fits snugly and is well pinned with safety pins so as to prevent the entrance of air at any place along the edges. Various other forms may be improvised to meet the needs of the home not provided with the more perfect requisites. To retain the moisture and so give greater sweating effects the cloth may be covered with machintosh, gossamer cloth or oiled silk of the same size and shape. 4. Partial Chest Pack. It is often desirable to apply the moist cloth to only a portion of the chest. The gauze or linen may be cut to any desired shape and size and applied to the proper area under the square or roller flan- nel pack. The chest being covered principally by dry flannel, this form approaches in effect the dry pack. DRY CHEST PACK (Dry Ch. Pk.) With the dry chest pack only the flannel is used of either the roller, square or fitted style. It should usually be applied over a thin undergarment. The dry chest pack is desirable in thin persons, the aged and those having insuffi- cient body heat to warm up the wet pack. It is often difficult, not to say impossible, in the case of a thin person, to pin the wet pack so tightly as to prevent the air from circulating under the edges of the pack and yet loose enough to be comfortable and not restrict the breathing. ' In many cases a chamois vest may be worn over a thin undergarment to produce the effects of a dry pack. Chest packs are of much benefit in pleurisy, colds, influenza of the respir- atory type, during convalescence from pneumonia, in asthma, whooping cough, croup, etc. Under the pack, the skin should be warm and gently perspiring. The choice of a dry or moist pack will depend upon the vitality of the patient and the result to be obtained. MOIST ABDOMINAL BANDAGE (M. A. B.) The Umschlag or moist abdominal girdle is one of the most useful of the heating compresses. The inside part of the girdle consists of one thickness HEATING COMPRESSES 251 of linen or three or four of gauze, eight or nine inches wide and a little more than one and one-half times the circumference of the body. The outer flan- nel girdle should be about twelve inches wide and of the same length. The dry flannel is placed across the table and the gauze, wrung nearly dry from cold water, placed over it. The patient now lies back on the bandage so that the lower edge will be below the iliac crests. Each end of the wet linen or gauze is pulled tightly across the abdomen and tucked under the opposite side. Both ends of the flannel are now folded tightly over these and securely fastened with safety pins. Darts may be taken on each side by means of safety pins in the same manner as in pinning a bandage after an abdominal operation. The flannel piece should project one and one-half or two inches beyond the wet gauze or linen. Where it is difficult for the patient to warm up the bandage, it may be moistened only over the abdo- men. The moisture may be retained by a bandage of oiled silk or mackintosh of the same width as the linen and applied between it and the flannel. This is spoken of as a protected girdle. The sweating underneath will be more profuse than without the imper- vious covering. Since the moisture is retained it will not be dry by morn- ing. The protected girdle is indicated in hyperacidity and where it is desir- able to produce considerable relaxation. The ordinary moist abdominal bandage is useful in nearly all forms of atonic indigestion, in neurasthenia, anemia of the liver, insomnia, catarrhal jaundice, constipation, etc. In these conditions it is usually worn only at night. HEATING THROAT COMPRESS Four to six thicknesses of cheesecloth or two or three of ordinary cotton cloth about three inches wide and long enough to encircle the neck twice are used inside. The outside consists of two thicknesses of flannel not less than four inches wide. This compress being small, considerable water may be left in it and still be found dry by morning. The neck should be rubbed with cold water immediately after removing the compress in the morning. The "cold cloth around the neck" is a very common household remedy for sore throat, hoarseness, tonsilitis, etc. It is indeed a very efficient meas- ure; its usefulness can hardly be overestimated. The heating throat com- press is indicated in pharyngitis, acute laryngitis, tonsilitis, quinsy and in inflammation of the Eustachian tube. It is also useful in clergyman's sore throat. In tonsiiitis, quinsy and inflammation of the Eustachian tube, the compress should extend upward about the lower part of the ear and may be held in place by a bandage over the top of the head. HEATING JOINT COMPRESS Heating compresses may be applied to the foot, ankle, knee, hand, wrist, etc. Rarely more than two thicknesses of gauze are used. It is often necessary to use cotton for a covering to obtain close application to the skin surface. This may be held in place by a three-inch roller bandage or a broad flannel cloth. A dry pack may be made of cotton or soft flannel alone. In certain cases the joints may be rubbed with a medicated solution before 252 TECHNIQUE OF HYDROTHERAPY being covered, or the gauze dipped in it. Alkaline or anodyne solutions are very frequently used in this way in cases of rheumatism. In rheumatic fever the joints may be rubbed with synthetic oil of wintergreen before the heating compress is applied. It helps to relieve the pain and by its action as a counter-irritant, the heating and circulatory effects are enhanced. MEDICATED COMPRESSES Besides rubbing the parts with medicaments such as turpentine, camphor- ated oil, oil of wintergreen, etc., before applying the heating compress or pack, the gauze may be wrung from various solutions such as an alcoholic solution of menthol, mustard water, watery solution of bicarbonate of soda, saltpeter, etc. When counter-irritant drugs are used the effect of the heating compress is intensified. It is usually not desirable to produce a blister. For this reason the use of coal oil and turpentine should be discour- aged. Not only may they produce blisters, but being inflammable, they are also dangerous. POULTICES Poultices are very popular substitutes for the heating compress and have a similar effect. They consist of a mixture of various substances, having the consistency of mush and must be applied hot to produce the desired result. Flaxseed, onions, etc., are commonly used. The preparation may be applied directly to the skin or spread on a cloth and bound tightly to the part. They are often disagreeable not to say uncleanly. Probably the most useful poultice is that consisting of white clay and glycerine sold under various names. It is applied hot about one-quarter to one-half an inch thick and covered with cotton and a bandage. The results are partly due to the heat and partly to the water-absorbing (hygroscopic) properties of the glycerine. The charcoal poultice is especially valuable in foul, sloughing ulcers or wounds. It may be prepared of charcoal alone or by adding equal parts of flaxseed meal and powdered charcoal to boiling water until the resulting mixture is the consistency of mush. This is evenly spread on a cloth and applied to the part, or directly on the part and covered with a muslin cloth and some impervious cloth as oiled silk. TONIC FRICTIONS A tonic friction is an application of cold water so combined with friction as to produce decided thermic and circulatory reaction. The effects are briefly described as stimulant and tonic. These have been discussed in detail in the chapter on Stimulants and Tonics, q. v. Given in the order of their severity the tonic frictions are as follows: Wet hand rub, cold mitten friction, cold towel rub, wet sheet rub, and drip- ping sheet rub. To these may be added the ice rub and salt glow. While TONIC FRICTIONS 253 the latter is not particularly an application of cold, the friction gives tonic results similar to the others and the procedure is not far different. The ice rub may be used for stimulant or tonic purposes but it is more frequently used as an antipyretic. COLD MITTEN FRICTION (C. M. F. or Cmf.) a. Articles Required. A bowl or pail of cold water at 50 or 60 F. or ice water, a sheet, three Turkish towels, two friction mitts made of such coarse material as woolen moreene, and compresses for the head and neck. 6. Procedure. The patient should be warmly covered and the feet warm, if not, give hot foot bath. Bare one part of the body at a time. Do not expose any part longer than necessary; dry quickly and thoroughly and recover at once with warm dry covering. Before beginning the regular part of the treatment bathe the patient's face and neck with cold water or apply cold compresses to the head and neck. This is especially necessary in treat- ing patients with valvular heart disease. In this condition an ice bag should be placed over the heart before beginning the treatment. In other conditions it is not usually necessary. Beginning with the right arm, place one towel under the arm and another around the shoulder to protect the table and patient. With the mitts on the hands, dip them into cold water and shake or squeeze out the excess of water. While the patient holds the arm vertically, rub the arm and hand with rapid to-and-fro friction movements until it is in a glow. Quickly remove mitts, dropping them into the bowl and cover the entire arm with one of the Turkish towels, having the patient hold the upper corners by closing the hand on them. Dry by friction outside the towel, and then rub with the towel until the arm is thoroughly dry and well reddened. Treat the left arm in the same manner. Now covering the rest of the body, bare the chest and abdomen. Tuck a Turkish towel snugly under each side along the trunk and over the arms. Rub the chest with the mitten dipped in cold water in a manner similar to the arms, then cover the entire chest with one of the towels and have the patient catch the two upper corners as they lie next to the shoulders. Rub briskly with downward strokes over the towel. Then wrapping the towel neatly about the right hand, again rub the entire surface, around shoulders and down the sides so as to dry all parts that have been wet. Cover chest and expose the right leg and thigh. Flex the leg and place a Turkish towel under. Place another towel around the upper thigh at the groin. Begin the friction with the leg and foot; dip the mitts again for the thigh. Treat in like manner the left leg and thigh. Have patient turn over and lie on a pillow placed under the chest. Treat the back in the same manner as the front of the trunk. To dry, cover the entire back with a Turkish towel and have patient hold the upper end the same as for the chest; rub with downward strokes over the towel and then wrap the towel about the hand and rub the surface again until thoroughly dry. Some prefer to begin the treatment with the chest in cases of heart disease. To vary the severity and tonic effects, the temperature of the water may 254 TECHNIQUE OF HYDROTHERAPY be changed; more may be left in the mitts or the mitts dipped two or three times in treating each part, or the friction given more vigorously. WET HAND RUB (W. H. R. or Whr.) The same order and general procedure is followed as for the cold mitten friction. One part at a time is bared, rubbed with the hand dipped in cold water, followed by percussion, then dried, finishing with brisk rubbing with the dry towel and the hands. Dipping from two to four or more times increases the tonic effect. COLD TOWEL RUB (C. T. R. or Ctr.) In giving the cold towel rub a plain hand towel is used instead of the mitts employed for the cold mitten friction. The same order is followed as in the two previous treatments, beginning with the arms, then the chest and abdomen, legs and last, the back. The arm is held vertically with the palm toward the feet. The towel is dipped in cold water and wrung lightly, quickly unfolded and wrapped lengthwise around the arm, turning the upper corners into the palm to be grasped by the hand of the patient. The part is then rubbed with to-and- f ro movements outside of the towel. Percussion may also be given to insure a greater reaction. The towel is now removed and the arm dried as after the cold mitten friction. When the chest and abdomen are treated the wet towel is spread out over the entire surface and the patient grasps the upper corners next the shoulders and holds tightly while the nurse rubs with downward strokes outside the towel. The other parts are treated in a similar manner. It should be remembered that the cold towel rub takes more heat from the body than the cold mitten friction, and it therefore requires greater reac- tive ability on the part of the patient. Because it does abstract consider- able heat from the body, it is often used in fever as an antipyretic measure. By dipping the towel twice or more for a single part, its antipyretic effects are increased. WET SHEET RUB (W. Sh. R.) a. Requisites. Two sheets, two towels, a tub containing hot water for the feet, a pail of water at 60 to 70 F. Other temperatures may be used when indicated. b. Procedure. The patient should be warm to begin with. Apply a cold compress to the head. The patient now stands in the tub of hot water. A sheet is wrung from cold water so that it will not drip. Quickly wrap the sheet about the patient as follows: The patient holds up both arms. The upper left hand corner of the sheet is placed under the patient's right arm; the patient then lowers the right arm, thus holding the corner of the sheet in place. Pass the sheet quickly TONIC FRICTIONS 255 across the front of the body and under the left arm, which is lowered. The sheet should then be carried across the back, behind and up over the right shoulder, then across the chest and around the neck over the left shoulder, tucking the corner under the edge of the sheet behind. Now tuck the sheet between the patient's legs; it is thus brought into close con- tact with every portion of the skin. Rub vigorously and give percussion over the sheet, covering the whole surface as quickly as possible until the sheet is thoroughly warmed. The patient is not to be rubbed with the sheet, but over the sheet. Two attendants are necessary to give the best results. Dry with a sheet and towels. The wet sheet rub is a very vigorous tonic measure. It should not be used until the patient is able to react to the cold towel rub, the pail pour and the cold percussion douche. DRIPPING SHEET RUB (Drip. Sh. R.) For the dripping sheet rub prepare three pails of cold water at about 70, 65, 60 F. respectively. Proceed as with the wet sheet rub, using the water at 70 from which to wring the sheet. After the sheet and patient are warmed by rubbing and percussion, without removing the sheet pour over the shoulders the second pail of water, again rubbing vigorously until warm. Use the third pail in like manner. Dry as after the wet sheet rub. ICE RUB The order of parts treated and the procedure in an ice rub are substan- tially the same as in the wet hand rub and cold mitten friction. In giving the ice rub, however, it is necessary to more thoroughly protect the bed or treatment table by covering with oil cloth and towels. Turkish towels should be tucked closely about each part so as to absorb the water as it runs off the skin. The cake of ice to be used may be held in the hand, or better yet, wrapped in one or two thicknesses of gauze. The ice rub is not much used for general tonic purposes, but more fre- quently as an antipyretic. When used for this purpose, each part should be rubbed for some time and then dried without friction or percussion with the hands. Its prolonged application to the spine is more decidedly antipy- retic than the same length of application elsewhere. When given in typhoid fever, the abdomen should be avoided. Cold compresses should be applied to the head and neck and also to the heart, if necessary. SALT GLOW (Sgl.) Prepare about two pounds of coarse salt wet with cold water. The treat- ment should be given in a "wet room" or in a bath tub. The patient stands in a tub of hot water. While standing at the side of the patient begin with the arm. Wet the entire skin surface of the shoulder, arm and hand with hot water from the foot tub. This is done by dipping the water with the hands. Next apply the wet salt, spreading it evenly over the skin, now with one hand on each side of the arm, rub vigorously with to-and-f ro movements, 256 TECHNIQUE OF HYDROTHERAPY until the skin is in a glow. Stepping behind the patient to the opposite side, proceed in the same manner with the other arm. Retain the last position to treat the front and back of the trunk. With one hand in front and one behind, wet the skin surface with hot water from the foot tub. Now spread the salt as before and rub the entire skin surface of the chest, abdomen, shoulders, back and buttocks. Stepping behind the patient and with one hand under each arm, continue rubbing with the salt, treating the sides of the chest, abdomen and the hips. Next proceed with the legs in like manner. For each limb have the patient put one foot on a low stool so as to bring the thigh about horizontal. Wet with water as before and rub the thigh, leg and foot with the wet salt. Finish the treatment by thoroughly washing off the salt. This may be done by a pail pour, shower or general spray. Dry with sheets, towels and fanning with a dry sheet as from any general wet treatment. If for any reason the patient ought not to stand so long, he maybe seated on a low stool while the salt glow is given. Proceed as follows: The patient sits on a stool with the feet in hot water. Beginning with the feet and legs, apply the water and then the salt, rubbing briskly with short strokes, the hands being on either side of the part treated. Next treat each arm separately; then the chest, abdomen and back should be rubbed with the wet salt, the attendant standing at the side of the patient with one hand rubbing the chest and the other the back. The patient should stand while the buttocks and thighs are treated. Wash off the salt and dry as directed above. The salt glow is a vigorous circulatory stimulant. Since no great amount of cold water is applied to the body, it does not require as great reactive ability as the wet sheet rub or cold douche. SPONGING Sponging consists in the application of a liquid by means of a sponge, a cloth or the bare hand, in which the chief effect is derived from the liquid applied. The term ablution is also applied to sponging. PLAIN WATER SPONGING (Spg.) 1. Hot Sponge H. Spg. Hot sponging has a sedative effect because of the slightly atonic reaction which ensues. It is also used to reduce fever where chilliness exists. When prolonged to 40 or 50 minutes the temperature does not rise as rapidly after the treatment as it does following a cold sponge. A large, soft sea sponge be may used, a soft cotton cloth, a wash cloth of Turkish toweling, or several thicknesses of cheese cloth. The water should be as hot as can be borne. Bare one part at a time and treat in the follow- ing order: The arms, chest, abdomen, legs, thighs and back. The cloth or sponge should be dipped several times for each part. Dry thoroughly. 2. Tepid Sponge Tepid Spg. The tepid sponge has an effect similar to that of the neutral bath, i. e., it is sedative. It may also be used to reduce fever but is not as effective as either the hot or the cold sponge. SPONGING 257 3. Cool or Cold Sponge C. Spg. Cold sponging is much used in the treat- ment of fever where the skin is hot and there is no tendency to chilliness. Each part should be gone over several times. The temperature of the water and the duration of the treatment should be governed by the effect to be produced. SALLNE SPONGE (Sal. Spg.) About four ounces of common salt are dissolved in a basin or bowl of tepid water. The bare hand is dipped in the salt water and each part rub- bed lightly. The saline sponge has a mild tonic effect. Because of the salt it stimulates the vasomotors to a greater extent than plain water. ALKALINE SPONGE (Alk.Spg.) Use about two ounces of bicarbonate of soda to a small basin of hot or cool water according to the case. Apply with the bare hand, a soft cloth or sponge. The alkaline sponge is useful in itching, smarting and other abnormal sensations. It is usually applied only to the part affected. VINEGAR AND SALT RUB The vinegar and salt rub is very useful in checking the excessive perpira- tion or night sweats of phthisis. Prepare a half pint of equal parts of vinegar and water to which add one or two tablespoonfuls of salt. Apply with the bare hand, drying lightly afterward. The application should be thorough to the parts that perspire the most; other parts may be gone over less thoroughly. ALCOHOL RUB (Ale. R.) The alcohol rub is frequently used following a sweating treatment instead of the cold friction or spray. Its purpose is, of course, the prevention of taking cold. Use one part of alcohol to one part of water (proof spirit, 50 per cent). Dip the hands in the alcohol, and rub each part, dipping the second time if needed. No drying with the towel is necessary. WITCHHAZEL RUB (Wzr.) The witchhazel rub has about the same effect as the alcohol rub. It is sedative and a mild astringent. The same procedure is used as for the alco- hol rub. MENTHOL RUB (Menth. R.) The application of menthol to the skin gives a sensation of cold. The effect is similar to that of the alcohol rub or cold sponging. Use one ounce of menthol liniment (menthol cryst. 1 oz., alcohol 1 pint) to three or four ounces of water. 258 TECHNIQUE OF HYDROTHERAPY SOAP WASH The soap wash is used for cleansing the skin in the case of bed patients. Using a bowl of water at 102 F. with soap and wash cloth go over each part separately. With another bowl of water at 75 to 85 F. and another cloth, remove the soapy water and dry thoroughly with a Turkish towel. Each part is gone over with the soapy water followed by rinsing with plain cool water and then dried before the next part is treated. RUBS AND FRICTIONS These terms are applied to procedures in which the chief effect is derived from friction with the bare hands. CENTRIPETAL FRICTION (C. F. or cf.) The centripetal friction consists principally of friction strokes from the periphery toward the center. It is designed to hasten the circulation,,espe- cially in the superficial veins. General Order of Movements: 1. Light to-and-fro friction once. 2. Apply lubricant twice. 3. Centripetal friction three times. 4. Percussion twice. 5. Stroking (centrifugal) three times. Arms 1. Beginning at finger tips, give light, quick to-and-fro friction to the shoulder, being sure to thoroughly cover the whole surface. Let the hands glide back as in stroking the arm. 2. Apply lubricant with long strokes from finger tips to shoulder, return- ing with four rotary sweeps. Give twice. 3. Friction. Hand. a. Heavy centripetal stroking to back of hand, three times. b. Palm of hand same as back of hand, beginning at finger tips. Fin- ish with double rotary movement in palm. Give three times. Arm and forearm. a. Empty blood vessels by heavy, even stroking from wrist to elbow. The patient's elbow rests on the table. With one hand on each side and using hands alternately give three movements with each. b. Empty blood vessels from elbow to shoulder, sweeping well over shoulder. With hands in the same position and alternating as for forearm, give three movements with each. 4. Percussion. With one hand on each side of the arm, which is held up by the patient, and with hands working together, give percussion from shoulder to fingers and return. Give twice. Place the patient's arm on the table at his side, give percussion down and up to external surface as far as hand. 5. Stroking three times. RUBS AND FRICTIONS 259 Legs 1. Leg flexed and foot flexed. Placing one hand on the sole, the other on the dorsum of the foot, give light, quick, to-and-fro friction trans- verse of foot. Then placing the foot flat, continue with rapid strokes to the sides of the foot, the leg and front of the thigh. Glide hands to knee; quick strokes to back of thigh; glide to toes. 2. Apply lubricant with long strokes to back of leg and front of thigh, coming down to knee with three rotary sweeps, then long strokes to back of thigh, down with three rotary sweeps from knee to ankle. Give twice. _ 3. Friction. Foot (leg extended). a. Dorsum with one hand three times. b. Each side with one hand, opposite hand supporting foot; come well up back of ankle three times. c. Sole with palm of hand three times. d. Rotary strokes to heel three times. Leg and thigh (leg flexed). a. Calf empty blood vessels by heavy, even stroking. Hands following each other alternately three times with each hand. b. Empty blood vessels under knee, hands alternating three times with each. c. With one hand on knee to support leg, give heavy stroking to front of leg, beginning at toes three times. d. Rotary to knee, hands working together three times. e. Empty blood vessels of thigh, beginning with posterior surface, hands working together three times. f. Anterior thigh three times. 4. Percussion. With one hand on each side give percussion from hip to ankle, down and up give twice. 5. Stroking three times. Chest and Abdomen 1. Making the hands work together, stroke the neck downward three times and give rotary movements as follows: Three above the clavicle and to shoulder; six from below clavicle to level of elbow, (i. e., nine down each side) , returning up over median part of abdomen and chest. Give once or twice. 2. Apply lubricant with long strokes up center, four rotary sweeps down sides, covering whole surface thoroughly. Give twice. 3. Friction. a. Empty blood vessels of neck and shoulders by stroking from back of ears downward to chest and shoulders three times. b. Give strokes from shoulders to median line over the pectorals three times. c. Using the thumb and thenar surface, give heavy stroking outward from median line over ribs and abdomen about six times, advancing toward the pubes. d. Stroking from umbilicus outward and downward toward middle of Poupart's ligament three times. 260 TECHNIQUE OF HYDROTHERAPY 4. Percussion up and down left side, the same on right side, give twice. 5. Stroking three times. Back 1. Light friction with the full hand down spine, hands alternating three times each. To-and-fro friction, beginning well up on neck, covering shoulders, back and hips. Give three times. 2. Apply lubricant with long strokes up spine, four rotary sweeps down sides twice. 3. Friction. a. Heavy friction with full hand down spine hands alternating, each three times. b. Heavy rotary, full sweep to shoulders three times. c. From shoulders down, across arms stroking toward spine, following ribs six times. d. Lower back, heavy friction upward over buttocks toward spine three times. Upward on hips three times. Outward, using thumb and thenar surface over crest of ilium three times. 4. Percussion up and down on left side, same on right side. Give twice. 5. Stroking. a. Full sweeps covering back three times. b. Slow strokes with full hand down spine six times. OIL RUB (O. R.) The oil rub softens the skin and is frequently used as a protective after sweating treatments. It may be given in the same manner as the centrip- etal friction, omitting procedure number one, light friction and procedure number four, percussion. If desired, the following abbreviated method may be used, always omitting the percussion after hot treatments. General Order: 1. Apply lubricant. 2. Rotary friction. 3. Percussion. 4. Stroking (centrifugal) . Arms 1. Apply lubricant, beginning at hands with a long stroke, go over the arm up to the shoulder three times. 2. Beginning at hand, apply long stroke up to shoulder, returning with alternate rotary movements, three each to, shoulder, arm, elbow, forearm, wrist and hand three times. 3. Percussion up and down twice on external surface. Give same on inner surface. Six percussion strokes to the hand. 4. Finish with long strokes from shoulder to finger tips three times. Legs 1. Beginning at foot, apply lubricant with long strokes up to hip with both hands, covering the entire surface three times. RUBS AND FRICTIONS 261 2. Apply long strokes from foot to knee, returning with alternate rotary movements, three each to, knee, calf, ankle and foot twice. Return to hip with long stroke. With hands on anterior surface of thigh, from hip to knee, give eight or ten rapid alternate rotary friction movements. Give the same on the posterior surface of the thigh three times. Continue with rotary friction from knee down as at first once. 3. Percussion same as arm. 4. Long stroking movement from hip to toes three times. Chest and Abdomen 1. Lubricate, with hands working together, begin at median line below, going lightly up the median line and down the sides three times. 2. Hands working together, stroke the neck downward three times, then give rotary movements three each, above clavicle, to shoulder below clavicle, nine down each side, nine up over median part of abdomen and chest three times. 3. Have patient take and hold a deep breath. Beginning well over at lower left side, give percussion up that side to top of shoulder, down on same side of median line, up on right side of median line to top of shoulder, and down the right side twice. 4. Stroking movement same as in lubricating three times. Back Procedure the same as for the chest. Finish with six long, gentle, down- ward strokes to spine. TALCUM RUB (Talc. R.) The talcum rub is useful where oil is objectionable, as in warm weather or where there is a tendency to too free perspiration after treatment. It dries rather than softens the skin. It is also useful in hives, and should be given after a prolonged cool bath. The procedure is the same as with the oil rub. DRY FRICTION (I). F.) The procedure for dry friction or the dry hand rub (d. h. r.) is the same as for the oil rub except that no lubricant is used. If given briskly with vigorous to-and-fro friction and followed by percussion, the effect is to quicken the circulation in the skin and warm the surface. The treatment also stimulates heat production. Slow, heavy friction without percussion, as to spine, forehead, etc., is sed- ative. BATHS Various procedures more or less similar and commonly called baths are included under this head. 262 TECHNIQUE OF HYDROTHERAPY I. PARTIAL IMMERSION BATHS HAND AND ARM BATH The hand and arm may be immersed in neutral, hot or cold water, or the two latter alternately. For this purpose employ a foot tub (better one of elliptical shape) with sufficient water to immerse the hand and forearm to the elbow, or including the elbow. Very deep pails may be used. When hot water is used, it should be as hot as can be borne. Immersion of the hands in cold water is useful in controlling epistaxis. To give hot and cold immersion to an infected hand or arm (blood poison- ing) employ two pails or tubs, one of the hottest water that can be borne, and the other of ice water with a block of ice in it. To the cold water may be added one-fourth or one-half dram of crystals of permanganate of potas- sium, and to the hot water about five times this quantity of oxalic acid. Immerse the hand and arm in hot water for one and one-half to two minutes, then in the cold for fifteen to thirty seconds. Continue these alternations for twenty-five minutes to an hour, finishing with the cold. Hot water should be added to the tub as fast as can be borne. The procedure should be repeated from one to four times daily as indicated. Other parts of the body, as the foot, may be treated in a similar manner. Massage is strictly countra-indicated in infected conditions. FOOT BATH (Ft. B.) The foot bath is one of the most useful measures in hydrotherapy. Its chief use is as a preliminary or adjunct to other treatment. It may be given with the patient lying or sitting, and is sometimes given with the patient standing. Large pails may be used, but more conveniently tubs of an elliptical shape about sixteen inches long and eight to ten inches deep. If the foot bath is given in bed or on a treatment table, protect the bed- ding or table coverings with an oil cloth. Protect the patient with a blanket or sheet, covering the knees and the foot tub. Tuck this covering about the limbs and foot tub so as to prevent the circulation of air. When the feet are taken out of the water, dry them thoroughly, especially between the toes, and immediatly cover well with dry coverings or put on slippers. 1. Hot Foot Bath H. ft. B. The water should rise above the ankles. The bath may be at a temperature of about 105 F., and should be gradually increased as fast as can be borne to a maximum of about 120 F. It may be continued from five minutes to half an hour. At the close the feet should receive a pour or dash of cold water and be thoroughly dried. It is often necessary to use the cold head compress if the bath is very hot, continued for a long time, or if given with the patient sitting up, and in all cases where there is a tendency to faintness. Effects. The hot foot bath is an efficient means of securing a derivative effect. It draws blood from all other parts, especially those that are con- gested. The cold pour or douche given at the close helps to maintain the blood in the feet. It is sometimes desirable to use a mustard foot bath, in which case add three or four tablespoonfuls of mustard to the water. 2. Cold Foot Bath C. ft. B. The water should be from two to four BATHS 263 inches deep at a temperature of 45 to 60 F. The feet should be previously warmed and during the bath, rubbed with the hands or one foot by the other. Duration, one to five minutes. Effects. The shallow cold foot bath causes reflex contraction of the blood vessels of the brain, pelvic organs and liver; also contraction of the muscles of the uterus, bladder, stomach and intestines. The cold foot bath should not be given during the menstrual period or in case of acute pulmonary, abdominal or pelvic inflammation. 3. Alternate Hot and Cold Foot Bath H. & C. ft. B. Use two tubs of water deep enough to well cover the ankles, one as hot as can be borne (tempera- ture gradually raised) and the other at 45 F. Immerse the feet in the hot water for two minutes and in the cold fifteen to thirty seconds. Continue alternations for ten to fifteen minutes, wiping from the cold. Effects. The alternate hot and cold foot bath produces powerful fluxion effects in the feet. For this reason the derivation secured by its use is very decided and enduring. It is especially useful in congestive headache, in which case it is well to apply a cold compress to the head or head and neck at the same time. It is also useful in treating infections of the foot, Charcot's joint at the ankle, tuberculosis of the ankle or bones of the foot and in gangrene to hasten the production of the line of demarkation. LEG BATH (Lg. B.) For the leg bath a tub should be provided deep enough to immerse the legs to the knees. If used in the treatment room the tub should be fitted with an outlet at the base so as to obviate the necessity of tipping the tub over to empty it. It should be placed near or against the wall so that it may be filled from a hot and a cold wall faucet by two short rubber hose. Also pro- vide a stool an inch or two higher than the tub. The patient should be covered with a sheet or blanket and, if the room is not warm enough, a large fomentation cloth or Turkish towel placed over the knees. If necessary, place a doubled fomentation cloth under the knees over the rim of the tub. 1. Hot Leg Bath H. Ig. B. Begin with the water at 103 F. and increase the temperature as rapidly as can be borne. Use cold cephalic and cervical compresses (or ice bags) and renew before they are warmed. In case the leg bath is combined with other hot treatment, as fomentations to the spine, it may be necessary to use an ice bag over the heart, especially if the treat- ment is continued to profuse perspiration. The treatment should be con- tinued in a given case until the desired effect is produced. This may require from five to thirty minutes according to conditions and the particular effect desired. Finish with a cold dash to the legs. Effects. The hot leg bath is a much more powerful derivative measure than the hot foot bath and is one of the best treatments that can be used for this purpose. When combined with fomentations to the spine or chest, and especially when the patient drinks some hot liquid at the same time, very profuse perspiration is produced. If used in the home such a sweating trea- ment should be concluded by a cold mitten friction or, if given in the treat- 264 TECHNIQUE OF HYDROTHERAPY ment room, by a graduated or alternate hot and cold shower and spray. The pail pour is also sometimes used for the same purpose. 2. Alternate Hot and Cold Leg Bath H. & C. Ig. B. The procedure is the same as with the alternate foot bath. It is necessary to apply a cold com- press to the head and often an ice bag to the heart. Effects. The alternate hot and cold leg bath produces most powerful flux- ion in the legs and feet. It is especially useful in treating edema of these parts whether due to heart or kidney disease. After two or three treat- ments have been given, pieces of ice should be added to the cold water. The treatment may be followed by heavy centripetal friction to the feet and legs. SITZ BATH (Z.) For the sitz bath a porcelain sitz tub with special inlet and outlet is the most satisfactory; one of metal or an ordinary wash tub may be used. In addition there should be a foot tub for immersion of the feet in hot water. Also a pail of cold water with a hand towel for keeping the head cool. Protect the patient from contact with the tub by towels or fomentation cloths placed behind the back and under the knees. Cover he patient with a blanket or sheet. The temperature of the foot bath should be at least two or three degrees above that of the sitz bath. 1. Cold Sitz Bath C. Z. Sufficient water should be used to cover the hips and come up on the abdomen. Temperature 55 to 75 F. Foot bath 105 to 110 F. Time one to eight minutes. Rub the hips to promote reac- tion. Friction mitts may be used. If desired, the water may be flowing. It adds somewhat to the effect. Effects. If of brief duration two to four minutes, it greatly stimulates the pelvic circulation and the musculature of the bowels, bladder and uterus. When given with very cold water (55 to 65) and vigorous friction (cold rubbing sitz bath) these effects are intensified. The cold rubbing sitz bath is very useful in constipation, in subinvolution and in hastening the absorp- tion of residual thickening after pelvic inflammations. With the tempera- ture somewhat modified, it may be used in children in treating nocturnal enuresis. 2. Prolonged Cold Sitz Bath-C. Z. Temperature 70 to 85 F. Time- fifteen to forty minutes. Foot bath 105 to 110 F. This may be begun at a higher temperature and very gradually lowered to the desired point (gradu- ated sitz bath). It should not at any time cause chilliness and rubbing is not desirable. If necessary to give a sensation of warmth, a fomentation or wrapped spinal hot water bottle may be applied to the spine. Effects. The prolonged cold sitz bath causes extreme and lasting contrac- tion of the pelvic blood vessels and of the muscular wall of the uterus. It is therefore very useful in subinvolution. :J. Neutral Sitz Bath Neut. Z. Temperature 92 to 97 F. Footbath 102 C to 106 F. Apply cool compress to the head. Time twenty minutes to one or two hours. Effect sedative. 4. Very Hot Sitz Bath H. Z. Begin at a temperature of about 100 F. and BATHS 265 rapidly increase to 106 to 115 F. Foot bath 110 to 120 F; it should be kept at least 2 hotter than the temperature of the sitz bath. Keep the head cool by cold cephalic and cervical compresses. Duration three to eight minutes. At the close cool the bath to neutral for one to three minutes. If sweating has been produced, pour cold water over the shoulders and chest. Effects. The hot sitz bath is used to relieve dysmenorrhoea and pelvic pain from various other causes. It is very valuable in both acute and chronic cys- titis, hypertrophy of the prostate and acute retention of urine due to pros- tatic hypertrophy. It is also useful in amenorrhoea due to pelvic anemia, in sciatica and helpful in reducing femoral or inguinal hernia. For reduc- ing hernia the temperature should not be lowered at the close. 5. Revulsive Sitz Bath Rev. Z. Begin at a temperature of 100 F. and increase rapidly to 106 to 115 F. Foot bath 110 to 120 F. Keep the head cool by cold cephalic and cervical compresses. Duration three to eight minutes. Finish by a cold pail pour to the hips; temperature of the water 55 to 65 F. Effects. The revulsive sitz produces a fluxion effect in the surface and deep blood vessels. It is one of the most useful measures in treating chronic inflammatory conditions in the pelvic viscera such as various forms of salpingitis, ovaritis, cellulitis, prostatitis, prostatic hypertrophy, etc. ,HOT HALF BATH (H. 1-2 B.) The hot half bath is given in a full length bath tub. Fill the tub with water at 100 to 102 F. and deep enough to reach the patient's navel when the patient is sitting. The patient now sits down in the tub with the shoulders covered by a sheet and the head kept cool by a cold wet towel. It is usually best to apply this just before the patient enters the bath. The temperature of the bath is gradually raised to 108 or 110 F, and continued for three to eight minutes. If necessary, an ice bag should be used over the heart. Conclude the treatment by a cold pail pour to the hips. The effects and uses are the same as those of the revulsive sitz. This treatment must not be confused with the shallow bath which is given with cold water, and is a tonic measure. II. FULL IMMERSION BATHS The tub used for general or full immersion baths should be long enough so that the body may be completely immersed, a 6-foot tub for men, in many cases a 5^-foot tub is long enough for women. The head should rest on an air pillow or small invalid ring, and for emaciated patients, a folded sheet placed under the nates. In a hot bath, the head must be kept cool by a cold compress. In the case of full tub baths it is especially necessary that the temperature of the water be tested by means of a thermometer. In order- ing tub baths, the desired temperature should be specified on the prescrip- tion. PLAIN TUB BATHS 1. Hot Tub Bath H. B. or H. Tub. Temperature 100 to 106 F. Time- two to twenty minutes. Give cold water to drink freely. Keep the head 266 TECHNIQUE OF HYDROTHERAPY cool. If necessary, apply an ice bag to the heart and the back of the neck. It is usually best to begin the bath at about 98, gradually raising the tem- perature to the desired point. The treatment may be finished by cooling the bath, or by a cold pour or shower given immediately after rising from the bath. Effect. The effect varies according to the temperature and duration of the bath. If much prolonged or the temperature very high, profuse sweat- ing is produced. The hot tub bath may be used as a preparation for cold treatment. A warm bath at 100 to 102 is very effective in relieving opis- thotons in tubercular meningitis and is also beneficial in other diseases associated with spasticity of the muscles. 2. Neutral Bath Neut. B. Temperature 94 to 97 F. Time fifteen minutes to three or four hours; usually twenty to thirty minutes. Wet the forehead and face in cool water. Cool the bath 2 or 3 just at the close. Dry the patient with a sheet directly from the bath, Use no percussion or unnecessary rubbing as this destroys the sedative effect. Effects. The neutral bath is given for sedative purposes. To accomplish this it must exert a relaxing effect and so equalize the circulation as to reduce the amount of blood in the brain and spinal cord. Its temperature will therefore vary with the condition of the patient, especially as regards the skin temperature. The season of the year must also be taken into account. For these reasons it may frequently be necessary to employ the upper limit of the neutral temperatures or raise the bath to 98 or even 99. The air of the bath room should be warm, and if the bath is much prolonged, stretch a sheet over the tub. The cooling of the water 2 or 3 just at the close is usually. necessary to prevent the slight sensation of chilliness which is likely to be produced by contact with the air on emerging from the bath. When used for insomnia, it should be given just previous to retiring. ;$. Cold Bath C. B. or C. Tub. Temperature 55 to 90 F. Time a plunge only, to twenty or more minutes, depending on the temperature and effect desired. It is necessary to employ rubbing constantly or at frequent intervals. The patient's face should be bathed in cold water before enter- ing the bath, and it is imperative that the skin be warm before the bath is given. Effects. When given to a patient with a normal temperature and lasting for a few seconds or minutes only, the effect is that of a stimulant and tonic. The cold rubbing bath is the most commonly employed method of treating typhoid fever in institutions where tubs are available and convenient to use. The strict Brand bath is too severe a measure for many patients. The methods, indications for and the precautions in the use of the cold bath have been very fully discussed under the treatment of typhoid fever, q. v. 4. Brand Bath. As advised by Brand for the treatment of typhoid fever the procedure is as follows: Temperature 65 to 70 F. Bathe the face and head in cold water or ice water. Lift the patient into the bath. He should be rubbed constantly to keep the blood in the skin. If chilling can not be prevented by vigorous rubbing, the patient must be removed from the bath. Time fifteen min- utes. Repeat when the temperature reaches 102.5 or 103 F. Effect antipyretic. BATHS 267 5. Graduated Bath Grad. B. The graduated bath is as efficient in lower- ing febrile temperature when much prolonged and is less objectionable to the patient than the Brand bath. As the bath is frequently used in typhoid, the patient should be made comfortable by an air pillow and hammock, made by tying a sheet across the tub, fastening the corners and sides underneath. Temperature begin at 98 or above, depending on the height of the fever, i. e., from 3 to 5 lower than the mouth temperature. The skin must be warm to begin with. Apply cold compresses to the head. Gradually reduce the temperature of the bath to about 85 F; when below 90 F. or if the patient feels chilly or shpws goose flesh, he should be rubbed constantly to keep the blood in the skin, and so prevent or overcome chilling. A spine bag filled with hot water may be laid along the spine for the same purpose. Both pulse and temperature should be closely watched during the bath. The temperature of the patient should be taken every 12 or 15 minutes. On removal, immediately wrap the patient in a sheet, drying quickly, and if there is goose-flesh or chilliness, rub briskly with the hands until the blood returns to the skin. If very cyanotic, put the patient into a hot blanket pack for a few minutes and take him out with a cold mitten friction. Effect tonic chiefly or antipyretic according to the condition in which it is given. 6. Cold Shallow Bath C. S. B. Fill the tub four to six inches deep with water at 65 to 75 F. The patient's feet should be warm before entering, and the head kept cool by cold wet towels. The patient sits down in the cold water and rubs the arms, legs and chest vigorously while the attendant rubs the hips and back. Cold water dipped from the tub is dashed over the shoulders and back, and these parts are again rubbed. The patient now lies down in the bath and rubs the chest and abdomen, while the attendant rubs the legs. This procedure may be repeated once or twice if desired. The entire treatment should last from two to four minutes, and on emerg- ing from the bath, the skin surface should be in a decided glow, otherwise the proper effect has not been obtained. The cold shallow bath is one of the most vigorous tonic measures employed in hydrotherapy. HYDRO-ELECTRIC BATHS In giving the hydro-electric or electrothermal bath a neutral temperature is usually employed. The patient is completely immersed in the water with the head on an air pillow and kept cool by a cold wet towel. The elec- trodes should hang from the side of the tub, so they may be placed in any desired position along the sides or at the feet of the patient. The treat- ment is begun with one electrode at the feet and the other near the arm on the opposite side. The electricity is turned on to comfortable tolerance. Time five to twenty minutes. After half the time has expired the elec- trode should be reversed, the one at the foot of the tub being brought up along the arm of same side, and the other near the opposite arm, being placed at the foot on the same side. These directions do not apply to the galvanic bath. In using galvanism the positive pole should be placed at the head, preferably dipping into the water underneath the pillow, and the negative pole at the feet. Precautions. To avoid shock there should be no current passing when the patient steps in or out. Be sure all appliances are in good order before 268 TECHNIQUE OF HYDROTHERAPY the patient enters the bath. Keep all parts of the generator, switches, rheostat, etc. absolutely dry and clean. Do not handle the switches or the rheostat with wet hands. Do not start or stop the motor generator or turn the current on or off while the rheostat is turned on. After the patient enters the bath, the cur- rent switch is turned on and the motor or generator started; next gradually increase the current by turning the rheostat. Before the patient leaves the bath turn off the current by reversing these steps, i. e., first gradually lessen the current by turning down the rheostat then stop the generator and turn off the switch. 1. Faradic Tub Bath Neut. Farad. The induction coil used should be large enough to amply supply any current strength needed and the inter- rupter so arranged as to give any desired rate of vibration, at least both slow and rapid interruptions should be provided for. Effects. Slow or medium f aradic for five or six minutes is stimulating and tonic. It is beneficial in flaccid paralysis and in general atonic conditions of the muscular system. Rapid faradic, given with less current strength and continued for twelve or fifteen minutes is sedative. The faradic tub bath is less satisfactory than the sinusoidal as the alternations of the current are sharp and therefore less agreeable to the patient. 2. Sinusoidal Tub Bath Neut. Sinu. For the production of a sinusoidal current the sinusoidal dynamo devised by Kellogg is the most satisfactory. The slow sinusoidal current gives a maximum muscular contraction with a minimum of unpleasantness. The contraction of the muscles is vigorous and painless. Effects. The slow sinusoidal for five or six minutes is stimulating and tonic. Rapid sinusoidal for a longer time is sedative. The slow sinusoidal is useful in all forms of flaccid paralysis, atrophied muscles, weak abdomi- nal muscles, splanchnoptosis, etc. It is much more agreeable to the patient and more efficient than faradic electricity, and for these reasons should replace the faradic wherever possible. ',}. (ialvanic Tub Bath Neut. Galv. Unless given from a battery of cells or a small dynamo not connected with alighting system, galvanic electricity is dangerous. Even then burns may result if carelessly used. Its adminis- tration should not be entrusted to a nurse unless specially trained in the tech- nique and possessing the requisite knowledge of the physics of the galvanic current. Moreover the effects usually sought from the galvanic tub bath may be obtained in other ways without risk to the patient. Precautions. In the use of the galvanic tub bath all the precautions men- tioned above should be carefully observed. The current must never be turned on before the patient enters, and always be turned off before he steps from the bath. If this is not done a severe shock may be occasioned as the patient places one foot in the bath with the other on a wet floor, thus mak- ing a grounding contact through a cement floor or worse yet through some metal pipe near by. Always ascertain the polarity before the electrodes are placed. To do this, place the electrodes in water an inch or two apart and turn the current on. The bubbles formed at the negative pole are larger and more numerous BATHS 269 than those formed at the positive pole. Place the positive pole at the head of the tub and the negative at the foot. Be sure that they do not come in contact with the skin at any point. Sinusoidal and the secondary faradic are alternating currents and there can therefore be no distinction as to polarity. Effects. The positive pole is a vasoconstrictor, the negative pole a vaso- dilator. For this reason the positive pole decreases congestion, the nega- tive pole increases it. The positive pole has a sedative effect, the negative pole a stimulant or irritant effect. These are the reasons for placing the positive pole at the head and the negative pole at the feet of the patient. As a neutral temperature is used the total effect is decidedly sedative. All forms of the electric tub bath are disagreeable to some persons. These idiosyncrasies should not be ignored. The temperature and duration of the bath and the strength of the current should be specified on the prescription. The bath should last from ten to fifteen minutes and from twenty to thirty-five milliamperes be used. The amperage should not be high enough to produce an unpleasant sensation. If there are saline substances dissolved in the bath, the amperage will run much higher before the same effects are produced as with ordinary water. With thin subjects a comparatively low amperage must be used; with sub- jects in good flesh or over- weight a stronger current may be employed. MEDICATED BATHS A tub bath may be altered by the addition of various medicaments. Such baths are not of great practical importance except in a very limited number of skin diseases. 1. Saline Bath Sal. B. Add from three to five pounds of common salt to the tub of water at 90 to 94 F. Time ten to twenty minutes. The addi- tion of salt adds to the tonic effect through stimulation of the peripheral cir- culation so that the water may be a few degrees cooler than an ordinary neutral bath. The effect is similar to a bath in sea water. 2. Alkaline Bath Alk. B. Add one-half to one pound of bicarbonate of soda to the tub of water at a neutral temperature. One-fourth pound of carbonate of soda may be used. Time ten to twenty minutes. Effects- relieves cutaneous irritation, itching, etc. Useful in certain skin diseases, as eczema. NAUHEIM BATH The effervescent or artificial Nauheim bath is one in which the water is charged with saline substances and carbon dioxide gas. Many different formula are used to prepare such a bath. To produce the carbon dioxide gas in the bath, it is necessary that an acid come in contact with an alka- line carbonate, setting free the carbon dioxide; or salines may be dissolved in the water and the carbon dioxide added from a generator. Various pro- prietary mixtures prepared in cakes are offered for use. In using these, dissolve the sodium chloride and sodium bicarbonate in forty or fifty gallons of water. The bottom of the tub is then covered with rubber sheeting. On this rubber sheeting place the acid cakes. In about 270 TECHNIQUE OF HYDROTHERAPY three minutes, when effervescence is well under way, the patient should lie down in the bath. A very complete and satisfactory formularis the following: Sodium carbonate (sal soda) 1J Ib Sodium bicarbonate (baking soda) \ " Calcium chloride 3 " Sodium chloride (common salt) 2 " Sodium bisulphate 1 " After mixing the first four, dissolve in a few inches of warm water in the bottom of the bath tub. When thoroughly, dissolved, fill the tub with water at the desired temperature. The sodium bisulphate which is the acid part of the formula, should be granular or finely pounded and dissolved separately in a wooden or paper pail containing hot water. As it may require some time for this to dissolve, it should be prepared before the bath is to be given. When thoroughly dissolved pour into the tub and quickly mix with the rest of the water. The bath is now ready for use. The amounts of the saline ingredients may be gradually increased for the succeeding baths of a course. Three-fourths of a pound of commercial hydrochloric acid may be used in place of the sodium bisulphate. This should be mixed with two or three times its volume of water, and after the salts are all dissolved and the tub filled with water at the desired temperature, the bottle containing the acid should be opened under water". It may be moved about to hasten the diffu- sion of the acid into the water of the bath. The following is a simpler and less expensive formula: Sodium chloride 3 to 8 Ib Sodium bicarbonate f to 1 " Sodium bisulphate (commercial) 1 " The temperature of the bath should range from 85 to 92 F. The lower temperatures should be used for the later baths of a series. The duration of the bath should at first be from five to eight minutes. The time may then be gradually extended to fifteen or even twenty minutes. A cold com- press should be applied to the head and an ice bag to the heart. The patient should not be rubbed during the bath. About three baths a week may be taken for three or four weeks. Not over twenty baths should constitute a course. Effects and Therapeutic Use. The effects of the bath are due to the cutaneous stimulation of the vasomotors produced by the carbon dioxide and salines dissolved in the water. The peripheral heart is stimulated and the cutaneous circulation greatly hastened. The heart beats slower and with greater ease. In normal individuals there may be a fall of ten or fif- teen beats in the pulse rate following a single bath, while in case of a very rapid pulse the decrease may reach as high as twenty-five to forty beats per minute. Examination of the heart after the bath in cases of a valvular lesion or cardiac dilatation, show a stronger, steadier beat; the rhythm becomes regular, the sounds clearer, and certain murmurs may disappear entirely. The pulse becomes full and blood pressure rises 20 or 30 mm. The area of dullness of an enlarged, dilated heart is often lessened one-half inch or more all around its border. Both the systole and the diastole are lengthened. BATHS 271 The Nauheim bath also stimulates metabolism and hastens the elimination of gouty toxins. It exerts a beneficial effect upon nutrition and is therefore of much use in diseases of metabolism. If a course of baths is continued too long, over-stimulation results, pas- sive dilatation of the blood vessels occurs and the heart beats with less force. The rhythm is disturbed and there will be palpitation. This may be guarded against by keeping the duration of the bath well within fifteen min- utes, stopping short of the maximum number of baths that may be used in one course, and by using the ice bag over the heart during the treatment. The heart should be carefully examined by palpation, percussion and aus- cultation both before and after the bath. This will enable the physician to prescribe much more intelligently and obviate any difficulty that may arise. The Nauheim bath is useful in valvular insufficiency and stenosis, cardiac dilatation, hyperthyroidism and in cardiac neuroses. It is also useful in Bright's disease, chronic articular rheumatism, gout and obesity. The bath is countra-indicated in extreme arterio-sclerosis, in aneurism and in angina pectoris. It should not be used in acute inflammatory diseases nor in the acute stage of endocarditis. Some highly recommend its use in locomotor ataxia. III. MISCELLANEOUS RUSSIAN BATH The Russian bath consists in the immersion of the body in hot vapor. The steam, as it is turned into the Russian room, partially condenses and hangs suspended as a thick fog. For every gram of steam that thus condenses, 537 calories of heat are liberated. This fact accounts for the intense heat- ing effect obtained by the use of this form of hot treatment. For the Russian bath provide a steam tight room with a marble slab. A sliding window should be so arranged at the end of the slab that the patient's head may be outside of the steam room. The steam should enter below the slab so as not to strike the patient directly, and be controlled by a valve near the sliding window so that the attendant may regulate the amount of steam and keep the head cool at the same time by frequently changed cold compresses to the head and neck. Procedure. Move the bowels by an enema and give a preliminary hot foot bath. Have the patient drink water before, and frequently during, the bath. This is necessary in order to provide for the profuse perspira- tion which the treatment should induce. See that the slab is warm; if not, pour over it several pails of hot water. Warm the room to about 100 F., and cover the slab with a folded sheet. The patient is now assisted onto the table and lies on the back with the head on an air pillow just without the opening. The window is lowered and a towel wrung from ice water is placed about the neck, or hung across the lower end of the window and tucked around the neck. Another cold com- press is applied to the head and covers the temporal arteries. A third cold compress should be applied to the precordia. In some cases it will be neces- sary to use an ice bag over the heart. Next turn on the steam, gradually raising the temperature of the room to 115 or 120 F. A small amount of steam should be constantly escaping 272 TECHNIQUE OF HYDROTHERAPY to maintain the temperature. Change the compresses to the head and neck frequently. The patient should be closely watched during the entire time of the treatment The bath should last from ten to thirty minutes. Just before the patient rises from the slab, renew the ice compress to the head. Finish the treatment with a graduated or alternate spray or shower, or better still, a shampoo and graduated shower. The spray or shower should be in the Russian room or only a few steps from it. Effects. The effects of vigorous sweating measures have been considered elsewhere. The "washing out" effect is, perhaps, the greatest, and the thoroughness of this depends very largely upon the water taken before and during the treatment. Sweating measures greatly increase catabolism, especially of carbohydrates and fats. The products of nitrogenous metab- olism show more complete oxidation. The Russian bath is of great service in obesity, chronic rheumatism with obesity, gout, Bright's disease, autointoxications, chronic alcoholism, and in arterio-sclerosis unless extreme. It is countra-indicated in diabetes, val- vular heart disease, all diseases associated with emaciation and in extreme arterio-sclerosis. CABINET VAPOR BATH The principle involved in the cabinet vapor bath is the same as that of the Russian bath. Various water-proof cabinets are offered for sale. They are useful in a home where more elaborate facilities can not be provided. An alcohol stove heats water in a basin under or near the stool provided for the patient. This is continued until the cabinet is full of vapor, when it is ready to enter. The patient sits on the stool with the head outside of the cabinet. The duration of the treatment should depend upon the rapidity of vaporization and upon the effect desired. The preliminaries, procedure and precautions to be taken are the same as in the Russian bath. Conclude the treatment with a shampoo, cold towel rub, graduated shower or other cold application. TURKISH BATH The Turkish bath consists in the immersion of the body in hot air. The Russian room may be used for this purpose and conveniently heated by steam coils. The patient is treated in the same manner as in the Russian bath. The head and neck should be kept cool by cold compresses and, if necessary, an ice bag applied over the heart. The temperature of the room should be gradually raised from 120 to about 170 F. The bath may last from fifteen to forty-five minutes. Perspiration is often somewhat delayed, in which case brisk friction to the skin may hasten its appearance. If per- spiration is much delayed, the patient is likely to behave badly in the hot air bath and for this reason should be closely watched until free perspiration is established. Owing to the difficulty with which some patients react to dry hot air, the applicability of the Turkish bath is somewhat more limited than that of the Russian bath. SUPERHEATED AIR BATH In the superheated air bath the temperature reaches 250 to 350 F. Special metal cabinets for the entire body or various parts may be pur- BATHS 273 chased. The body or part to be treated should be thoroughly wrapped in Turkish toweling and should not rest on any part of the cabinet likely to become hot enough to burn. By means of a gasoline or other burner, the temperature of the air in the cabinet is gradually raised to 250 or 350 F. These burners are placed just below the cabinet; over them are fitted inverted funnels with a short, wide stem leading directly into the cabinet. The entering hot air should be spread by means of an asbestos shield so that it will not directly strike the skin surface. The patient's pulse and general condition must be watched very closely in giving a full hot air bath. An ice bag should be kept on the heart and ice compresses on the head and neck. These precautions are not so necessary where only a single part such as the knee or foot and ankle are being treated. The treatment may be concluded by an alcohol or witchhazel rub. Great care must be exercised that the patient does not take cold afterward. The Turkish toweling with which the body or limb is wrapped quickly absorbs the perspiration thus preventing its collecting on the skin in drops. Should it collect in drops, burning is more likely to result. Effects. The superheated air bath is a much more vigorous measure than the Turkish bath. It is of special advantage in articular rheumatism, whether occurring in acute rheumatic fever, chronic gouty rheumatism or in specific arthritis. Where one or two joints are being treated, the applica- tion should continue from twenty minutes to an hour after the temperature has reached 300 to 350 F. When the part is taken out a momentary dash of cold water may be given or the part cleansed from perspiration and a heating compress applied. In gonorrheal rheumatism this treatment may be followed by, or alternate with, the prolonged ice pack, i. e., prolonged to about one hour's duration. ELECTRIC LIGHT BATH (E. L. B.) In giving the electric light bath, special upright or reclining cabinets fitted with mirrors and incandescent lights are used. The feet should be warmed beforehand, or with the upright cabinet a hot foot bath should be used. Cover the stool with a folded Turkish towel. Turn on the desired number of lights; when the cabinet is warmed, have the patient enter. Then close the cabinet and apply a cold wet towel to the head and neck. Renew this frequently. If there is a tendency to f aintness or rapid pulse, use an ice bag to the heart as well. If a horizontal cabinet is used, cover the table with a folded sheet. Warm the cabinet and place a rubber pillow for the patient's head. The patient then lies down and is rolled into the cabinet, or the top is lowered according to the style of cabi- net used. The patient's head should be kept cool by cold compresses. There is less tendency to fainting with the horizontal than with the upright cabinet. The patient must be watched very carefully and constantly in order to guard against fainting. On leaving the cabinet, a blanket or sheet should be thrown about the patient if it is necessary to go more than a few steps for the next part of the treatment. Finish with a spray or shampoo and spray. Where only general tonic effects are desired, the electric light bath 274 TECHNIQUE OF HYDROTHERAPY should last from three to five or six minutes; for profuse sweating and elimi- native effects, continue it from ten to eighteen or twenty minutes. Effects. The incandescent electric light is not so much a generator of actinic rays as of heat rays. It is said that only five to eight per cent of the radiant energy of the incandescent light consists of actinic rays, while ninety-two per cent is in the form of heat rays. For this reason the use of blue globes adds nothing to the chief effect of the bath, but rather detracts from it, since the volume of the heat rays is lessened. The incandescent electric light bath is not a phototherapeutic but a thermotherapeutic appliance. The air of the cabinet is not warmed to the same extent as the skin of the patient, since the heat is aot in the form of radiant energy. In this parti- cular the electric light bath differs essentially from the Russian or Turkish bath and from the effect produced by hot applications applied directly to the skin. This means that the heat of the electric light is not communicated to the body by direct conduction or by convection, but by the absorption of the rays of radiant energy as they are retarded and stopped by the skin and subcutaneous tissues. On the other hand, for strong derivative effects, the electric light bath is unsatisfactory. For derivative purposes the heat must be brought in actual contact with the skin by applying the heated substance directly to the skin. For this reason, stronger derivative effects are secured by partial or full hot baths and hot packs. The uses of the electric light bath are numerous and considerable space would be required merely to enumerate them. However, it is of special advantage in Bright's disease, arteriosclerosis, lead poisoning and other toxemias, obesity, gout, acute and chronic rheumatism, neurasthenia, dia- betes, skin diseases and also for general tonic and sudorific effects. SHAMPOOS SWEDISH SHAMPOO (Ssh.) For giving the Swedish or slab shampoo, provide a pail of water at 103 to 105 F. on a stool of convenient height near the head of the slab, also a shampoo brush and a half bar of soap. If the slab is not kept warm by being in a warm room, pour over it two or three pails of hot water. Cover the slab with a doubled sheet, and assist the patient onto the slab, placing the head on an air pillow. Quickly lather an arm by dipping the brush and soap in the pail of hot water and rubbing together over the part. With brisk short movements go over the part thoroughly, using as much friction as is comfortably borne. Do the same with the chest, abdomen and legs. Next assist the patient to turn over on the slab by putting one arm under the neck and grasping the opposite shoulder, and the other arm under the near leg and grasping the opposite knee. Treat the back, hips and the backs of the legs in the same manner as the front of the body. Pour the remain- ing water in the pail over the patient to rinse off the soap suds. Follow the shampoo by a warm and cold shower, spray or pail pour. SHAMPOOS 275 TUB SHAMPOO (Tub Sh.) Fill a bath tub with water at 98 F. The patient may sit on a wooden stool in the tub or, if likely to chill, he should lie down in the tub with the water deep enough to cover the chest. If given with the patient sitting on a stool, begin with the arms, back, chest and abdomen, then the legs. If given with the patient immersed, raise one part at a time above the water and proceed as usual, having the patient sit for the back and chest. Finish by complete immersion in the tub followed by a cold pail pour or shower. TURKISH SHAMPOO (Tur. Sh.) The Turkish shampoo is given after sweating baths such as the Turkish, Russian or electric light bath. The shampoo proper is preceded by manipula- tions and heavy friction to loosen the outer epidermis (so-called dead skin) . It is the most thorough cleansing measure used. a. Articles Necessary. Two pails of water at 90 F., one at 100 to 105 C F. , loofah or shampoo brush, soap, two Turkish toweling mitts, two sheets and towels. In treating women, the hair should be protected by a rubber cap. 6. Procedure. If the sweating bath has not been taken in the shampoo room, it must be well heated and the slab warmed by pails of hot water poured over it. Cover with a doubled sheet and assist the patient onto the slab. Place an air pillow under the head. Manual Rubbing. Wet the face with water at 90 F. With the hands, dash water over every part separately, using long strokes and quickly covering the body. Beginning with the neck, about the ears, hair, forehead, over the nose and chin, rub until the dead skin is thoroughly loosened. Wash off the loosened epidermis, dipping the hands frequently. For the chest and abdomen, after applying the water, use transverse wringing and re-enforced rubbing, covering each part several times. Then wash off with water. For the arms use spiral friction and wringing. For the legs, the same; with the thumbs, rub well about the ankles, soles of feet, knees, etc. Turn the patient and proceed with the back in the same manner as with the chest, also the thighs and legs. Wash off the entire surface with water. Friction Mitt. Dip the mitt in the second pail of water at 90 F., and beginning with the back and backs of thighs and legs go over each part twice, rubbing all thoroughly. Then turn the patient and treat the chest, abdomen, arms and legs in the same manner. Wash off with the rest of the pail of water at 90 F. Shampoo. Treat each part as in the Swedish shampoo using hands, a loofah, or bath brush and the pail of water at 105 F. Finish with prolonged tepid or cool shower or spray, and at the close a short cold spray. Dry thoroughly with sheets and towels. The patient should be careful not to take cold afterward. 276 TECHNIQUE OF HYDROTHERAPY PACKS Packs are procedures in which a considerable portion of the body is enveloped in wet sheets or blankets for therapeutic purposes. I. HOT BLANKET PACKS The hot blanket pack is a procedure in which hot blankets are used to communicate heat to the body. FULL HOT BLANKET PACK (II. B. P.) a. Articles Necessary . Two double blankets or one single and one double blanket; one hot water bottle and three spine bags half filled with hot water at 160 F., a bowl or pail of ice water with compresses for the head, neck and heart; two Turkish towels; a tumbler, a drinking tube and pitcher of hot water for drinking. b. Preliminaries. Move the bowels by enema, give a hot foot bath, and have the patient drink hot water. c. Procedure. Spread a double blanket on the treatment table or bed. Adjust a cold compress to the patient's head while his feet are still in the hot foot bath. Fold the single blanket or another double blanket (the latter holds the heat longer) lengthwise in convenient width for passing through a wringer or wringing by hand. Wring from boiling water, quickly unfold and spread out over the dry blanket on the table. Assist the patient to lie on the hot blanket, or with a bed patient lift onto the blanket. As quickly as possible or as rapidly as can be borne, envelope the entire body except the head in the hot blanket. Place one spine bag between the legs with one thickness of dry blanket between it and the moist blanket, and the hot water bottle at the feet. The other spine bags should be placed along the sides of the trunk in the same way as the one to the legs. Tuck both wet and dry blankets in well, especially at the feet and about the shoulders and neck, so as to exclude the air. See that the wet blanket comes in contact with the body over its entire surface, so that no air spaces will be left. Place cold compresses about the head and neck and protect the chin from the hot blanket by a soft dry towel. Renew the compresses before they are warmed to any extent. For general sweating effects a dry blanket may be placed between the patient and the wet blanket, but for strong derivative effects the wet blanket should come into immediate contact with the skin. The patient should perspire in a short time. If perspiration does not begin in about ten minutes, give hot water to drink or a hot foot bath, or both. In giving the hot foot bath the blankets should fall loosely about the tub so as to prevent the circulation of air. Continue the pack for twenty to thirty minutes, i. e., until it ceases to have a heating effect. For tonic effects, five to ten minutes. Take the patient out by a cold mitten friction or a cold towel rub, removing the blanket from one part at a time and covering with a dry blanket or bedding immediately PACKS 277 after. It is usually most convenient to begin with the arms, then the chest and abdomen, legs last, giving the cold friction to the back after the wet blanket has been entirely removed. d. Precautions. Too much water left in the pack makes it feel very hot at first but it cools more rapidly than when wrung nearly dry. For this reason the pack should be wrung as dry as possible. If the hot water bags are too near the patient (not sufficiently covered) there is danger of burns resulting. If complaint is made, they should at once be covered more thoroughly. In some cases it is necessary to use a cold compress or an ice bag to the heart. General free perspiration should be induced by the pack. Long continued heat without perspiration results in harm. In giving packs in case of paralyzed sensation, unconsciousness, under or soon after anesthesia, in diabetics, dropsy and the insane, it is safer if a thickness of dry blanket intervene between the patient and the wet blanket. Hot water bottles should be more thoroughly covered and the water used in them should be at a lower temperature than ordinary. e. Effects. The hot blanket pack is a vigorous sweating measure. It also produces decided derivation. Any sweating treatment decreases inter- nal congestion, but this action is mach more marked when the wet blanket is placed next to the skin. Where the congestion is not localized in some particular part, but consists of a general internal congestion, a general sweating treatment is usually sufficient for its relief. This is the case in the first stage of many fevers, especially the exanthemata, in colds, la grippe, etc. In uremia, eclampsia and acute Bright's disease, both sudorific and strong derivative effects should be secured. In other forms of renal congestion this is also necessary.- In kidney insufficiency the skin excretes much larger quantities of poison than in health. Free or profuse perspiration greatly aids in this vicarious function. This effect is not, however, the only one nor the most important effect of sweating measures. The congestion of the skin secured by a hot pack reduces the congestion and high blood pressure in the kidney so that it soon begins to functionate when these causes are removed. The hoi blanket pack is also useful in pneumonia and sometimes in typhoid fever. It is almost indispensible in the treatment of renal colic and gallstone colic. In these conditions the pain is decreased immediately the pack is applied; in some cases it entirely obviates the necessity formor- phin, while in others the dose may be cut to one-third or one-fourth the amount that would otherwise be required. DRY BLANKET PACK (1). B. P.) Sweating may be produced by enveloping the body in a dry woolen blanket and using hot water bottles in the same way as with a wet pack. The same preliminaries should be observed, especially the giving of the hot foot bath before. It is quite essential that the patient take a considerable quan- tity of a hot drink during the treatment. Hot lemonade is ideal as it favors both diaphoresis and diuresis. The sweating may be as profuse as with the 278 TECHNIQUE OF HYDROTHERAPY wet pack but the derivation is less efficient. Since no wet blanket is used, the patient may be first wrapped in a dry sheet and then in the dry blanket. The perspiration will be absorbed by the sheet and so, in a short time, the effect will somewhat approach that of the sweating wet sheet pack. HOT TRUNK PACK (H. Tr. Pk.) The method of applying the hot trunk pack is the same afe with the full blanket pack. The wet blanket should include the pelvis but exclude the arms, reaching up to the axilla. The outside dry blanket should include the whole body but be used only for protection; it should not be wrapped tightly about the patient. It is usually best to apply a large dry fomenta- tion cloth between the patient and the wet blanket. Place a hot water bottle over the abdomen between the folds of the dry blanket, and spine bags on either side of the trunk. A hot foot bath should begin before and continue during the pack. Time twenty to thirty minutes. If given for the relief of the pain of any form of colic, omit the cold friction at the close. The hot trunk pack has the same general effect as the hot blanket pack. Since it covers less surface the derivative effects are less. It is especially useful in digestive disturbances and in relieving the pain of renal and biliary colic, also in intestinal colic. ALTERNATE HOT AND COLD TRUNK PACK (Alt. H. & C. Tr. Pk.) The alternate hot and cold trunk pack consists of a hot trunk pack given as directed above and followed by a wet sheet trunk pack. Only this one change from heat to cold is made. The wet sheet is wrung from water at about 60 F. and applied to the trunk after removing the wet flannel blanket. The method is described under the heading of wet sheet packs. The hot blanket should be removed while it is still hot and the wet sheet applied at once in much the same manner as for the revulsive compress. The wet sheet trunk pack should remain in place until the heating stage is reached when it may be removed and a cold mitten friction or alternate hot and cold spray douche given to the parts covered by the pack, finishing with the same to the feet. If desired, the wet sheet trunk pack may be made a hot and heating trunk pack by inserting a hot water coil or a hot water bottle over the stomach. The alternate hot and cold trunk pack is used for tonic purposes also in chronic congestions of the liver and the other digestive organs. HOT PELVIC PACK (H. Pelv. Pk.) The hot pelvic pack is applied in the same manner as the hot trunk pack. It should come well above the crests of the ilia and include nearly half of the thighs. It is useful in the relief of pelvic pain from dysmenorrhoea, cystitis, proctitis, etc. Its effects do not greatly differ from those of the hot sitz bath or large, very hot fomentations to the pelvis, both of which treatments are much easier to apply. PACKS 279 ALTERNATE HOT AND COLD PELVIC PACK Alt. H. & C. Pelv. Pk. This treatment is applied in the same way as the alternate hot and cold trunk pack. The cold pack should be prolonged to the heating stage. The effects are somewhat similar to those of the revulsive sitz and hot half bath. It is useful in chronic congestions and chronic inflammations of the pelvic organs, such as chronic metritis and endometritis with much thickening, also in subinvolution. HOT HIP AND LEG PACK (H. Hp. & Lg. Pk.) The hip and leg pack should include the feet, legs, thighs and pelvis, reach- ing slightly above the crests of the ilia. A hot water bottle should be placed at the feet within the folds of the dry blanket and a spine bag between the legs. Time twenty to forty minutes. Taking one limb out at a time, finish with a cold mitten friction to retain the blood in the limbs, thus maintaining the derivation secured by the hot pack. Effects. The hot hip and leg pack is one of the most efficient derivative measures used in hydrotherapy. It is indicated in a large number of condi- tions, and is especially useful in depleting acutely inflamed organs when combined with the use of an ice bag over the congested part. (See Hot Packs with Ice Bags) HOT LEG PACK (H. Lg. Pk.) The hot leg pack should include the feet, legs, knees and half or more of the thighs. Hot water bottles are used the same as above. Conclude the treat- ment in the same way. The leg pack is somewhat less effective than the hip and leg pack. It is used for the same purposes, and is convenient where it is undesirable to move the pelvis in giving treatment. A large fomentation may be used over the anterior surface and sides of the pelvis at the same time, so as to cover nearly as much surface as the hip and leg pack. Hot packs combined with the use of ice bags, or the ke water coil, are the most powerful and efficient derivative measures known to hydrotherapy. They are especially useful in reducing internal congestions, reducing or aborting local inflammation of deep parts and relieving the pain incident to the inflammatory process. For these purposes they are used only in the acute stage of the inflammatory process. The effects have been fully dis- cussed in the consideration of inflammation and antiphlogistic effects, q. v. The hot pack depletes the congested part by drawing the blood away to establish a collateral hyperemia (pull effect) while the ice bag drives the blood away by reflexly stimulating prolonged and extreme contraction of the deep vessels of the inflamed part (push effect). (PLATE III) The cold mitten friction given at the close causes retention of the blood in the skin by changing the passive hyperemia to an active arterial hyperemia. These treatments are sometimes spoken of as hot and cold packs, but this 280 TECHNIQUE OF HYDROTHERAPY designation may cause confusion with the alternate hot and cold pack in which a cold (heating) wet sheet pack follows the hot blanket pack. Ice bags may be used with the full pack or with any of the partial packs. The following combinations are useful in the acute stages of the diseases indicated: APPENDICITIS Hot hip and leg pack, with ice bag to the appendiceal region. PERITONITIS Hot hip and leg pack, or leg pack only, with an ice com- press or ice cap to abdomen. PUERPERAL INFECTIONS AND ACUTE SALPINGITIS Full hot blanket pack, or hip and leg pack, with ice to pelvis (suprapubic region). PNEUMONIA Hip and leg pack or full blanket pack with cracked ice com- press over lobe affected. MENINGITIS Hot leg pack, with ice cravat, ice cap and ice bag to base of brain and upper spine. MASTOIDJTIS Hot hip and leg pack or full blanket pack with ice cravat or ice bag over the cartoid artery, ice cap to head, and fomentations to mastoid. ALVEOLAR ABSCESS Same as mastoiditis, except give fomentations to the jaw. RENAL CONGESTION Hot trunk pack or full blanket pack with ice bag to lower third of sternum. Other combinations will suggest themselves to the resourceful mind. ELECTROTHERMAL PACK (Elec. Pk.) The electrothermal pack consists of a specially prepared blanket contain- ing flexible resistance wire. If it is to be used dry, the body or part to be treated should be wrapped in a dry sheet or thin flannel blanket, and then in the electric blanket, and the electricity turned on. The amount of heat and consequent effect may be governed by the strength of the current. If to be used wet, wrap the patient in a sheet wrung nearly dry from cold or tepid water, and then in the electric blanket. The treatment is concluded by a cold mitten friction, spray or douche. Effects. While the heat is not as intense with the electric blanket as with a blanket wrung from boiling water, it is a gradually increasing heat, and so, more desirable for some purposes. It is useful for general sweating effects, and for this purpose may be used with or without the wet sheet. The dry pack may be used where mild continuous heat is desired, as after an operation. In this case it should usually be applied only to the legs or the pelvis and legs. A Turkish towel should be placed so as to form a pad under the heels, and then folded over the toes. All bony prominences should be similarly covered. The electric blanket may be used to re-enforce other packs arid so increase or prolong the effects. The electric blanket should not be folded sharply at any place, as the wires are likely to be broken. PACKS 281 II. WET SHEET PACKS A wet sheet pack is a procedure in which the body is wrapped in a wet sheet, outside of which is a dry blanket covering designed to regulate the evaporation. FULL WET SHEET PACK (W. S. P.) a. Articles Necessary. Two blankets, a sheet, a large hand towel, a Turkish towel, a pail of water at 60 to 70 F., a hot water bottle. b. Preliminaries. The feet and entire body must be warm before the pack is applied. Chilliness, cold skin or cyanosis are countra-indications. In case the skin is not warm, it is necessary to give a hot blanket pack or some other general hot treatment. The head should be cooled by cold com- presses before entering the pack. c. Procedure. Place a double blanket lengthwise of the treatment table, with the edge opposite the attendant hanging further over the edge of the table than the near edge. The upper end should be about eight inches from the head of the table and cover the lower third of the pillow. Wring the sheet as dry as possible from cold water and spread out upon the blanket so that its upper end will be a little below the upper end of the blanket. The patient now lies down upon the wet sheet with the shoulders three or four inches below the upper edge. Both arms should now be raised while one side of the sheet is quickly wrapped around the body drawing it tightly in contact at all places and tucking the edge under the opposite side. Below the hips the sheet is wrapped around the leg of the same side. The arms are now lowered and the opposite side of the sheet drawn tightly over the body and tucked in. The sheet is now folded over the shoulders and across the neck. The narrower edge of the blanket is drawn tightly around the body and tucked in along the side. The wider edge is disposed of in a similar manner, pulling it tightly to bring all parts in close contact and the extra amount wrapped entirely around the patient. The foot end is doubled under the feet. A Turkish towel is placed about the neck to pro- tect the face and neck from contact with the blanket, and more perfectly exclude the air. An additional blanket may be laid over the patient and tucked in along the sides and about the feet, or two blankets may be placed on the table at first. d. Precautions. The wet sheet must come in close contact with the body at all points. The dry blanket must effectually prevent the entrance of air, otherwise chilling will result. "Warming up" should occur promptly. The feet must be kept warm during the entire treatment. It is permissible to place a hot water bottle to the feet to hasten reaction in case this is delayed. e. Stages. According to the degree of warming the pack undergoes, it passes through four stages, viz: cooling or evaporating, neutral, heating and siveating. It is often desirable to prolong the effect of one stage so that this effect may predominate. Accordingly the treatment is varied as follows: 1. Cooling or Evaporating Wet Sheet Pack Evap. W. S. P. This is the 282 TECHNIQUE OF HYDROTHERAPY first stage of the pack before the sheet has been warmed to the tempera- tu$e of the body. It requires from five to twelve minutes to accomplish this. If at the end of this time the sheet is removed and another applied, the effect is intensified, or the blanket may be folded back and cold water sprinkled on the patient over the wet sheet. In the case of vigorous patients the dry coverings may be omitted entirely, considerable water left in the sheet, and the patient fanned to hasten evaporation, more water being sprinkled on the sheet as soon as it is warmed slightly. Effects. The evaporating wet sheet pack is a powerful antipyretic meas- ure. It is useful in typhoid fevers and in other continued fevers where repeated antipyresis is necessary. It is usually best not to remove the pack for renewal but sprinkle on more cold water. As in the use of the cold tub bath in typhoid fever, rubbing is necessary if the water is very cold or the sheet sprinkled frequently. This is known as the rubbing wet sheet pack. Percussion should not be used. The greater the amount of water applied to the body, the stronger are the antipyretic effects, and consequently the quicker is the temperature of the patient reduced. If desirable, the sheet may be wrung from hot water, the coverings being omitted. This is spoken of as a hot evaporating sheet. It is useful where slight chilliness exists. This treatment is not only antipyretic but also les- sens heat production because of the initial heat and the consequent atonic reaction. 2. Neutral Wet Sheet Pack Neut. W. S. P. The neutral stage begins when the temperature of the pack reaches or slightly exceeds the tempera- ture of the skin, viz., about 94 F. It may be prolonged by removing all but one or two dry coverings after the warming up has well begun. This allows of sufficient evaporation to prevent the accumulation of heat above the temperature of the body. The protection must be uniform and the entrance and circulation of air prevented. Effects. The effects of the neutral wet sheet pack have been considered under the treatment of insomnia. A neutral temperature is secured the same as in the neutral bath. The marked sedative effects of the neutral pack are due more to the derivation secured than to the neutral tempera- ture. In normal sleep there is a lessening of the amount of blood in the brain and a local decrease of blood pressure. The neutral pack brings about these changes and so aids in inducing relaxation and sleep. If the pack is removed before sleep is produced, uncover one part at a time, drying thoroughly and wrapping it in a warm dry sheet, or entirely remove the pack and immediately wrap the patient in a warmed sheet, fin- ishing the drying as quickly as possible. If the pack is removed after the patient has slept, conclude the treat- ment by a wet hand rub or cold mitten friction according to the degree of tonic effect desired. The neutral wet sheet pack is also of use in the delirium of fevers, in mania, epilepsy, chorea, infantile convulsions and various other agitative neuroses. :J. Healing Wet Sheet Pack Heat. W. S. P. The heating stage begins when the warming of the pack raises the skin temperature slightly above its usual degree; it ends at the beginning of general perspiration which marks the establishment of a full reaction. For tonic effects the pack PACKS 283 should continue about twenty minutes. When the stage of a pack is not prescribed, this treatment is intended. Effects. Tonic and heating effects are secured by it. These may be pro- longed by applying cold water to the head and neck continuously so as to check extreme sweating. The chief effect of the heating wet sheet pack is the production of derivation. The reaction and heating up of the skin caused by the accumulation of body heat, congests the skin and so lessens the amount of blood in the internal organs. The heating pack possesses quite a range of usefulness in securing mild tonic and derivative effects. It may be used in anemia, chlorosis, infectious fevers, convalescence from fever, neurasthenia, diabetes, etc. 4. Eliminative or Sweating Wet Sheet Pack Sweat. W. S. P. The pro- duction of general perspiration marks the beginning of the sweating stage. The sweating may be increased or prolonged by additional coverings, hot water bottles placed within the folds of the dry blanket, or the drinking of hot water or lemonade at intervals. The cold compresses on the head should not be very cold or renewed too frequently as this depresses the thermogenic centers and prevents sweating. Effects. The sweating wet sheet pack is a very valuable eliminative and spoliative measure. It is one of the most useful means in the treatment of the transient fevers of infants and children, in capillary bronchitis, colds and the grippe. For purposes of elimination it is useful in such toxemias as alcohol and nicotine poisoning, lead poisoning and various autointoxications. It is use- ful in chronic Bright's disease and, if not too prolonged, it may be used in jaundice. For spoliative purposes it is useful in obesity and obese rheumatics. HALF PACK OR HEATING TRUNK PACK (1-2 Pk.) The heating trunk pack is given in the same manner as the heating wet sheet pack, except that it includes the trunk and hips only, the arms and legs being excluded. A full blanket should be spread out on the treatment table and over this placed a sheet wrung from water at 60 F. and folded to the proper width to include the trunk and hips. The patient now lies on the wet sheet and it is drawn tightly about the body. The dry blanket is next folded over so as to bring the wet sheet in close contact with the skin surface. A moderate hot foot bath is given at the same time and continued during the treatment. The dry blanket should be laid loosely over the limbs. The pack and the patient should not be so thoroughly covered as to produce general perspiration. It is well to have a dry sheet or towels intervene between the blanket and the patient at all places not covered by the wet pack. For this purpose a dry sheet may be spread out on the dry blanket before the wet sheet is placed for the trunk. The treatment should last about twenty or twenty-five minutes and be concluded with a cold mitten friction or an alternate spray douche to the parts covered by the pack and to the feet and legs. The effects, though less pronounced, are in general the same as those of the hot and heating trunk pack, q. v. 284 TECHNIQUE OF HYDROTHERAPY HOT AND HEATING TRUNK PACK (H. & Heat. Tr. Pk.) This treatment is the same as that previously described under the Winter- nitz coil. A single blanket is placed crosswise of the treatment table or bed so that the upper edge may reach well up under the arms. A sheet doubled (in case of feeble patients a single thickness) to a width which will reach from the axilla to below the hips is now wrung from cold water and placed over the blanket. The patient now lies down on this and while both arms are raised, one end of the wet sheet is pulled tightly across and around the trunk. Over the epigastric and umbilical regions outside of the sheet, place a three-quart hot water bottle half filled with water at 135 to 140 F. Wrap the other end of the sheet about the trunk over the hot water bottle and cover snugly with a dry blanket, folding over one end at a time. A Winternitz coil or an electric pad may be used in place of the hot water bottle. Continue the treatment from forty minutes to two hours. General sweating should not be produced. It may be begun half and hour before the meal. Take the patient out with a cold mitten friction or an alternate spray douche to the abdomen and spine. Effects. The hot and heating trunk pack is the most efficient hydrothera- peutic measure for the treatment of digestive disturbances. It promotes gastric secretion and gastric digestion. Liver activity and intestinal diges- tion proceed more normally. Excessive or reverse peristalsis is checked, and in decreased gastric motility, stomach movements are hastened. Because of more perfect digestion and more normal peristalsis, gas formation is markedly decreased or entirely checked. The hot and heating trunk pack is indicated in persistent vomiting, dys- pepsia, flatulence, splanchnic neurasthenia, chronic congestion of the liver and in anemia of the liver. In cases of almost complete arrest of gastric digestion or in persistent vomiting, the pack should be applied about twenty minutes before the meal and continued for two or three hours. A cold mitten friction should be given at the close. The feet should be warmed by a hot foot bath before the treatment and kept warm during the treatment. The hot foot bath may be continued while the treatment lasts, if this is not over thirty min- utes; otherwise it is well to dry the feet and wrap them in dry flannel so that the patient may rest more perfectly. For further details of the uses and effects, see treatment of atonic dyspepsia. HEATING PELVIC PACK (Heat. Pelv. Pk.) On the treatment table spread a blanket as for a full pack. Next fold a single blanket to form a square and then diagonally to form a triangle. Arrange this on the large blanket so that the base is upward and the apex downward where it may be folded about the pelvis when the patient reclines. Over this place a sheet similarly folded and wrung nearly dry from water at 60 F. The patient now reclines, and with legs flexed and knees separated, the apex of the wet sheet is brought into close contact with the perineum and spread over the abdomen. With legs extended, each lateral angle of SPRAYS AND DOUCHES 285 the wet sheet is drawn down tightly across the hips, lower abdomen and upper thigh. The triangular piece of dry flannel is now applied in the same manner, and the patient covered with the large blanket. Continue the pack twenty or thirty minutes. Effect. The heating pelvic pack is a mild tonic and derivative means the same as the heating trunk pack. It helps to equalize the pelvic circulation and reduce congestions of the pelvic viscera. It relaxes hypertonic muscles and stimulates atonic muscles. The heating pelvic pack is not used as much as the sitz bath in the treatment of pelvic disorders. It is indicated in chronic congestions of the pelvic organs, amenorrhea, chronic metritis, back- ache, chronic colitis, etc. When used ki cases of much pelvic pain or other pelvic distress, a hot water bottle or coil should be placed next to the wet sheet over the lower abdomen and suprapubic region in the same manner as in the hot and heating trunk pack. SPRAYS AND DOUCHES A spray or douche consists in the projection of one or more columns of water against the body. Many different appliances are used in giving these treatments. They possess such a wide range of adaptability that almost any desired effect may be produced by them. For this reason both the physi- cian and the nurse should become thoroughly proficient in the use of the spray and douche controller. The water supply to the controller should come direct from a hot and a cold water tank by pipes entirely independent of all other fixtures, and no other faucets or fixtures should be attached to these mains. The most perfectly constructed controller will fail to give satisfac- tory results unless this rule is observed. SHOWER BATH (Sh.) A shower or rain bath consists in the projection of water in many fine streams falling upon the patient. In the shower bath gravitation is the principal force utilized; the effect however is often enhanced by added pres- sure. The perforated disc from which the water descends should be about six inches in diameter and from ten to sixteen inches above the patient's head. There should be sufficient force to cause the water to flow rapidly. The room should be very small and protected from drafts. See that the patient's feet are warm before entering the shower. If the wetting of the hair is objectionable, as with women, protect by a rubber or mackintosh cap. Turn on the shower and adjust to the proper temperature before the patient enters. In making sudden changes in temperature see that the vents or discharg- ing outlets are opened during the change, otherwise difficulty will be experi- enced in securing an instantaneous change, or the hot water because of added pressure may crowd out the cold. 1. Hot Shower H. Sh. Begin the hot shower at 100 to 105 F., and gradually raise the temperature to from 110 to 115 F., or slightly above. Time thirty seconds to two minutes. It is used chiefly as a preparation 286 TECHNIQUE OF HYDROTHERAPY for the cold shower or douche. It may be necessary to use a cold compress to the head during the hot shower. If only a hot shower is prescribed, cool rapidly to 90 or 85 F.; and dry quickly with sheet and towels, finishing by fanning the patient with a dry sheet. 2. Cold or Cool Shower C. Sh. The cold shower is usually preceded by a hot shower. When the patient has been warmed, lower the temperature rapidly from hot to the limit of tolerance or reactive ability of the patient. Cool 70 to 90 F. Cold 55 to 70 F. At first, before the patient becomes accustomed to the shower, the upper limits should be utilized and in each succeeding treatment the temperature lowered by 1 or 2 daily and the time prolonged to from one-half to Three or more minutes. Effects tonic. ;j. Neutral Shower Neut. Sh. In giving a neutral shower, begin with the water at 100 F., and very gradually lower it to 97 to 94 F. The treat- ment should last from three to five minutes. The patient should be dried quickly without percussion or unnecessary friction. Effects sedative. 4. Graduated Shower Grad. Sh. After a prolonged or vigorous sweat- ing bath, it is desirable to lower the temperature of the shower slowly for gradual cooling and to abstract as much heat from the body as possible with- out producing a decided thermic reaction. Apply a cold compress to the head before the patient leaves the hot bath. Begin at 108 to 110 F., quickly raising the temperature to 115 or 118 F. Maintain this until the patient feels well warmed and is ready to welcome the cold. Gradually lower the temperature to between 80 and 90 F. Time two to six minutes. .Dry as quickly as possible with sheets and towels and see that the patient is not exposed to cold air or drafts for at least an hour after. 5. Alternate Hot and Cold Shower H. & C. Sh. To obtain the best results the changes must be abrupt from hot to cold. This can only be secured by a properly constructed spray and douche apparatus, having an alternating lever or other alternating appliance, and supplied by pipes with no other outlet and coming direct from hot and cold water tanks. With vent pipes open on both sides of the apparatus, regulate the hot to 108 to 110 F., allowing it to run through the shower. Regulate the cold to the prescribed tempera- ture, say 65. The patient may now enter the hot shower which is raised to the limit of tolerance and continued about one minute or until the patient is thoroughly warmed. Switch the alternating lever to the cold and con- tinue ten to twenty seconds. Reverse to hot again for one-half to one min- ute, then follow by a second cold and so on for three complete changes of hot and cold, closing with the cold and drying as usual. Precautions. If the vents are closed the hot will "run up" when not in use, since the hot water is usually at a higher pressure and forces back the cold. If this occurs, when the hot is turned on, the patient is likely to be burned. It is best to warn the patient of the change from hot to cold so as to avoid undesirable nerve shock in the case of nervous patients. Effects. The alternate hot and cold shower is a vigorous tonic and stimu- lant measure. To many patients it is more agreeable than the needle spray. SPRAYS (Spr.) A spray bath consists in the simultaneous projection of water against all SPRA YS AND DOUCHES 287 parts of the body by horizontal jets surrounding the patient. For this pur- pose four upright pipes, arranged in a square and having perforations on the side of each toward the center, are used. Since these pipes are stationary, it is necessary to have a short patient stand on a sto6l so that the water may not strike the face. A tall patient must bend the knees in order to have the spray cover the entire trunk. To overcome this inconvenience and to spread the streams of water still more, rosettes may be arranged along the pipes at intervals of ten or twelve inches, the upper row being movable. The effects and uses of the spray are the same as those of the shower with the possible difference that the application is somewhat more general and there is more or less mechanical stimulation due to percussion or pricking of the jets. This is greater as the pressure is increased by the full opening of the spray valve. Treatments are given in the same manner as with the shower. DOUCHES (D.) The douche is a local application consisting of a single or multiple column of water directed against some part of the body. It is certainly one of the most useful of all hydrotherapeutic measures. The effect of almost every other form of treatment commonly given to ambulatory patients may be approached and usually exceeded by the douche in the hands of one skilled in its application. The necessary attachments are not numerous. These should consist of a straight nozzle with or without a center needle for breaking and spreading the jet; a spray nozzle like the sprinkler of a watering pot except that the perforated dish should have a nearly flat face; a fan douche nozzle, a mov- able flat piece attached to the straight nozzle will answer the same purpose; a stool with an open seat and attached up-shot spray douche nozzle for adminis- tering the perineal douche. The jet nozzle is used whenever percussion effects are desired. The pres- sure may be increased by opening the valve wide, or by turning into the nozzle compressed air from a separate tube. Where a percussion douche (Perc. D.) is ordered the jet is understood. Both cold and percussion pro- duce a decided thermic reaction and increase the vigor and permanency of the circulatory reaction. The spray douche is useful where percussion is not desirable. The jet douche may be "broken" by placing the finger so as to interfere with the stream. It then resembles the spray douche in effect. The effects in general vary according to the mass, pressure and tempera- ture of the column of water striking the body. In prescribing douches the form of nozzle desired should be specified and such designations used as will indicate the part of the body to be treated. The cerebral circulation will be steadied and better general and local results obtained if all applications of the douche begin and end with the feet. The patient should dip the hands in cold water and bathe his face before the douche is applied. In applying the douche some definite plan should be learned and systematically followed, making changes when necessary for the particular case and condition in hand. In order to guard against burning, always keep the index finger of the hand holding the douche in contact with the stream of water as it emerges from the nozzle. This should be done with the most perfect of appliances and even when no trouble at all is anticipated. Keep a steady hand, apply the douche accurately to the part to be treated and have the thermometers under constant observation. The following are the general directions for douches of different tempera- tures. In giving these any form of nozzle may be used and any portion of the body treated. To enumerate all the possible variations and the particu- lar surface and reflex or hydrostatic effects derived from each would require a small volume in itself. As in all hydrotherapeutic procedures, practical instruction is of far more value than any amount of text description and text illustration. Such designations as the Scotch douche, Charcot douche, etc., are non-descriptive and as far as possible should be dropped from hydrotherapeutic nomenclature. 1. Hot Douche H. D. Where the hot douche alone is used it is given for a relatively long time two to five minutes, at a temperature of 105 to 125 F., and followed by a very brief application of cold, five to fifteen sec- onds, temperature 60 to 90 F. This is supposed to be just long enough to remove from the skin the heat communicated by the hot douche. The prin- ciple is identical with that of the revulsive douche except that in the latter, three or more changes are employed, while here only one is given. Effects. The hot douche produces dilatation of the cutaneous vessels and so where applied to a considerable area, effective derivation is secured. Where applied to a small area, the dilatation of the vessels in the deep part through a reflex channel may equal or exceed the hydrostatic effect. Per- cussion intensifies the reflex effect. The hot douche is used for the relief of pain, irritation, neuralgia, sciatica, etc. In these cases percussion is undesirable. The effect of the combina- tion of a hot with a cold douche is given below. 2. Neutral Douche Neut. D. Temperature 94 to 97 F. Time three to six minutes. The broken jet or spray douche are used since sedative effects are sought. The neutral spray douche is especially beneficial when given to the spine. No force should be used and the patient should sit on a stool with the back to the operator. 3. Cold Douche C. D. Temperature 55 to 70 F. The cold douche is seldom given alone, but when not preceeded by hot, the percussion jet should be used. Given in this way, vigorous fluxion is produced in the part treated with a corresponding derivation from other parts. 4. Revulsive Douche Rev. D. Three or more abrupt changes from hot to cold are used. Temperature of the hot 112 to 115 F. Time a half to two minutes. Temperature of the cold 55 to 70 F. Time five to ten seconds. Unless given with high pressure, (percussion) the reaction -is chiefly circulatory. Percussion is not usually desirable with the revulsive douche. Effects. It will be noted that the duration of the hot is exceedingly brief as compared with the duration of the cold. In this item lies the difference between the revulsive and the alternate hot and cold douche. The effect of the revulsive douche is chiefly circulatory and greater in the surface blood vessels than in the deep part, i. e., the reflex effect is not prominent. The surface effect is that of fluxion and if a sufficient surface is covered by the SPRAYS AND DOUCHES 289 treatment, a hydrostatic (derivative) effect upon other parts is produced. The revulsive spray douche is especially applicable to the chest, abdomen and over the liver and spleen, also to the spine, pelvis and perineum. 5. Alternate Hot and Cold Douche H. & C. D. The method of giving the alternate douche is the same as for the revulsive douche except that the cold application is of greater duration, being from one-third the duration of the hot to equal with it, so that where the hot is given for one minute the cold should last twenty seconds to one minute, depending upon the reactive powers of the patient. Percussion (H. & C. Perc. D.) adds much to the vigor and permanency of the reaction. Effects. The alternate hot and cold douche produces vigorous fluxion in the surface treated. When percussion is used the reflex effects become prominent especially if the douche is applied to only one or two parts of the body. As a general treatment, for example, the alternate hot and cold per- cussion douche to the spine and legs, powerful tonic and stimulant effects are produced. The alternate percussion douche to the feet and legs is a most efficient derivative measure, especially when preceded by the hot leg bath. The extreme fluxion it induces in the feet and legs produces a decided and enduring derivation. The following list of treatments, which may be given by means of the spray and douche apparatus, will help to show the technique and something of the principles envolved in the effects desired. As A GENERAL TONIC H. & C. Perc. D. to spine, legs and feet. To PRODUCE REACTION IN ONE UNACCUSTOMED TO COLD H. Sh. or Spr. with C. Perc. D. to spine and legs at same time. To RELIEVE CONGESTIVE HEADACHE H. & C. Perc. D. to feet with C. Com p. to head. CONGESTION OF THE LIVER Rev. D. (Perc. or Spr.) over hepatic area. SCIATICA Prolonged H. D. over sciatic nerve. VARICOSE ULCERS H. & C. Spr. D. to legs, six to ten changes. HYPOCHLORHYDRIA Rev. D. to epigastrium and mid-dorsal spine. LUMBAGO H. & C. Perc. D. to lower back. LOCOMOTOR ATAXIA AND OTHER FLACCID PARALYSES Rev. or Alt. D. to spine. SPASTIC SPINAL PARALYSIS Prolonged Neut. Spray D. to spine. CHOREA Neut. D. Shr. or Spr. RENAL CONGESTION (CHRONIC) H. & C. Perc. D. to lower third of ster- num and over kidneys at back. CHRONIC PELVIC CONGESTIONS C. D. to lumbar and sacral regions. AMENORRHCEA Short C. Perc. D. to feet. SPECIFIC URETHRITIS, PRURITIS ANI, CHRONIC PROSTATITIS, ETC. Rev. Spr. D. to perineum (called also "up spray"). CHRONIC PLEURISY, UNRESOLVED PNEUMONIA, ETC. H. & C. Spr. D. to chest over area affected (use no force) followed by H. & C. Perc. D. to feet and legs. 290 TECHNIQUE OF HYDROTHERAPY AFFUSIONS An affusion is the pouring of water from a convenient receptacle over the entire body or a portion thereof. Since the perfection of spray and douche apparatus, the affusion has fallen into disuse in institutions equipped with such appliances. However, the pour has certain advanages which are not outweighted by the greater convenience of more complicated appliances. The flow of a considerable volume of water over a part has a somewhat different effect from a douche. Since it may be used in any home, it has a wide range of usefulness. 1. Pail Pour or General Affusion P. P. The patient should be warm beforehand. If given in a bath tub he may sit, or if given while standing, the feet should be in a tub of hot water, and in either case apply a cold cephalic compress. Prepare three pails of water at different temperatures, accord- ing to the effect desired. These should be poured over the shoulders, using the warmest first. For a mild tonic employ pails of water at 100, 90 and 85 or 80 F., respectively. If the patient has just come from a warm bath of some sort, a lower temperature may be used for the first pail and the others correspondingly lower, or only two pails used. In succeeding treat- ments lower the degree of the applications until water at 50 to 60 is used for the third pail. Rub the patient vigorously after the last pail and dry as from spray or shower. The pail pour is conveniently used after the tub or slab shampoo, salt glow, etc. A cold pail pour to the hips is given after the hot half- bath and the hot sitz bath for revulsive effects. 2. Local Affusions. These may be designated according to the part treated and the temperature of the application. A hot affusion relieves pain. The circulatory excication soon gives way to a tonic reaction. A neutral affusion, especially to the spine, is sedative. A cold affusion, if short, is stimulating and tonic; if prolonged, it reduces congestion and inflammation, stimulating phagocytosis. A long cold pour to the head is strongly anti- pyretic. The alternate hot and cold pour is a powerful stimulant and tonic, producing fluxion in the part treated, with derivation from other parts. It produces a decided local leucocytosis and stimulates phagocytosis. Because of these effects it is a very useful measure in treating an infected part where it is impossible or undesirable to completely immerse the part in water. In giving an affusion to the spine, the patient may sit on the edge of a bath tub or on a stool in the tub. In giving a pour to the arm, hand, foot, etc., the part may be held over a small tub while the water is poured from a pail or large pitcher. To treat the head by a pour the patient should lie on a cot with head resting over the end and a tub underneath. In giving local atfusions tne water should fall a distance of three or four inches to one or two feet according to the part treated and effects desired. ENEMATA An enema is an injection of fluid into the rectum. General Directions: a. Articles Necessary. An enema can with a capacity of one-half to two ENEMATA 291 gallons or a fountain syringe or combination bag. Five or six feet of rubber tubing with cut-off. A glass or hard rubber enema tube. A disinfectant solution for the enema tube. One to three per cent lysol acts both as a disinfectant and a soap for cleansing. A water thermometer. Toilet paper. If given in the room, there should be in addition a standard or hook for suspending the enema can, a bed pan, slop jar and several newspapers. In the treatment room shelves or hooks are most convenient for holding the can, they should be so arranged that the elevation of the enema can may be varied from two to one-half feet to four feet above the patient. b. Procedure. Fill the enema can with from two- to six quarts of water at the proper temperture (test with a thermometer). The patient should be warm, especially the feet. All clothing not removed should be loose. Position of patient Dorsal, sitting, right Sims or knee-chest. Release the cut-off and allow the water to run until the stream is at the same temperature as the water in the can. Close cut-off and lubricate the enema tube, being careful to wash it beforehand, removing the disinfectant solution. The patient should insert the tube unless very ill or unable to do so. Instruct the patient to take as much water as possible. To make it easier to do this, stop the flow by pinching the tube two or three times during the taking of the enema. Close cut-off and remove the tube. If possible the patient should retain the water a few minutes before discharging. Repeat until a thorough bowel movement is secured or other desired result is obtained. I. PLAIN WATER ENEMATA RECTAL INJECTION OR ENEMA (E. or En.) In the ordinary enema the desired amount of fluid is injected, allowed to remain a short time and then passed. The procedure is different from rectal irrigation, in which there is a continuous inflow and outflow of fluid. 1. Hot Enema H. En. The temperature of the hot enema should vary from 103 to 110 F. according to the condition of the patient and the result desired. It is useful in relieving irritation, the pain of inflammation in the rectum or prostate and pain of hemorrhoids. It also aids in expelling gas, and helps to check diarrhoea by decreasing rectal tenesmus. It may be used as a preliminary measure in the treatment of dysmenorrhoea. The hot enema is also used to warm and stimulate the body in shock. 2. Warm Enema En. The ordinary enema for cleansing purposes should be given at a temperature of 95 to 100 F. Where it has to be repeated fre- quently it is better to use tepid water, i. e., 80 to 92 F., to avoid as far as possible the relaxing effect of warm water. 3. Cold Enema C. En. In giving the cool or cold enema the tempera- ture of the water may vary from 55 to 80 F. Up to about 70 F. it may be regarded as cold, and from 70 to 80 F. as cool. The cold enema is a power- 292 TECHNIQUE OF HYDROTHERAPY ful stimulant to bowel movements and should be more generally used for this purpose in place of the warm enema. For this reason it is useful in overcoming the enema or cathartic habits. If retained ten or fifteen min- utes or frequently repeated is useful in shrinking hemorrhoids. It may also be used in fever, but for this purpose prolonged rectal irrigation is much more convenient and effective. GRADUATED ENEMA (GRAD. E.) The graduated enema is not a single treatment but a series of treatments. It is used to overcome the enema or cathartic habits. As usually given, it extends over a period of ten to twelve days. It should be preceded on two or three successive days by thorough coloclysters of water at 90 to 100 F. to remove accumulated feces. The series of enemata is begun with a large amount of tepid water and finished with a small amount of cold water, one enema being given daily. 1st day 4J pints at 94 F. 6th day 2 pints at 74 F. 2nd " 4 " " 90 F. 7th " 1J " " 70 F. 3rd " 3& " " 86 F. 8th " 1 " " 66 F. 4th " 3 " " 82 F. 9th " } " " 62 F. 5th " 2J " " 78 F. 10th " J " " 58 F. The above program is suggestive only; the variations in the amount and temperature of the water should be made to suit the needs of the case. The entire series with the exception of the temperatures above 80 F., may need to be repeated. Cold enemata should not be given during the menses. Effects. After prolonged use of cathartics, the muscular part of the intestinal wall becomes relaxed and atonic because of overstimulation. The response to drug and chemical excitants is worn out and it is necessary that the atony be overcome by some more physiologic means. The restorative effect of cold upon muscular tissue and muscular capacity has been discussed in detail in Chapter XIII. Repeated use of the warm or hot enema also causes relaxation with stretching and distention of the wall of the rectum and lower sigmoid flexure. The contact with the cold water introduced into the bowel is an effective means of combating this atony and distention. The gradual reduction in the temperature makes it possible to bring about a response even after the atony has existed for some time. Both this treatment and alternate hot and cold rectal irrigation are very efficient in the treatment of atonic con- stipation. They may be advantageously combined with the use of slow intra-rectal and abdominal sinusoidal electricity, abdominal massage and spinal nerve stimulation. RECTAL IRRIGATION (Rec. Irrig.) In giving rectal irrigation a special tube is used which is provided with an inlet and a return flow, so that the fluid passes into the rectum bathing the mucous membrane, and returns through the outlet. These are made of hard rubber or metal. The patient should be in the dorsal or Sims position. EN EM AT A 293 The enema can should be eighteen inches to two feet above the patient. The outflow tube should be lengthened by attaching to it a piece of rubber tubing so as to carry the outflow into the toilet fixture or, if given to a bed patient, into a jar placed at the side of the bed. 1. Hot Rectal Irrigation H. Rec. Irrig. When the water used is at a tem- perature of 102 to 105 or 106 F., the treatment produces decided effects in the relief of pain and rectal tenesmus. It may also be used with great benefit in cases of chronic cystitis with frequent and painful urination. 2. Cold Rectal Irrigation C. Rec. Irrig. Cold rectal irrigation is a very useful antipyretic measure. For this purpose the water should not be very cold, but from about 70 to 80 F., and the treatment continued about forty- five minutes at a time. Cold irrigation is also useful in stimulating bowel movement, but for this purpose it possesses no advantage over the cold enema. 3. Alternate Hot and Cold Rectal Irrigation Alt. H. & C. Rec. Irrig. In giving alternate hot and cold irrigation it is necessary to use two enema cans with tubing connected by a Y-tube so that the alternations may be con- trolled. The hot should be allowed to run from one-half to two minutes and the cold from fifteen to thirty seconds. From five to twelve or more complete changes may be made in a single treatment. The greater the extremes of temperature the greater will be the effect. It is possible to use a plain enema tube, injecting but a small amount and allowing the water to pass out through the enema tube after each injection. This treatment is a most efficient measure in the relief of chronic inflam- mations of the pelvic organs, especially of the bladder, prostate, posterior urethra and rectum. For these purposes it should be given daily or three or four times a week. It is also one of the most effective means of combat- ing chronic atonic constipation. COLOCLYSTER (Ccl.) In a coloclyster the fluid is introduced into the colon. When the coloclyster is used to produce thorough cleansing of the large bowel, four to six pints of water or saline solution at a temperature of 100 to 104 F., are used for each injection. An ordinary enema, and if necessary a soap-suds enema, is first used to cleanse the lower bowel. Have the patient take the knee-chest or right Sims position. Use an ordinary enema tube, but if results are not obtained, it may be necessary to use the high bowel catheter (colon tube). As the water enters, rub along the colon up the left side, across the abdomen and down on the right side so as to fill well the large bowel. As much water as possible should be injected, but this should be done slowly. Remove the enema or colon tube and, as the water is expelled, reverse the movements along the colon to favor complete emptying. It may be necessary to repeat the procedure. Effects. The coloclyster is used to produce a full and complete evacuation of the bowels, and for cleansing the large bowel in cases where an ordinary enema does not produce the desired results. It is also used to remove fecal impaction. When some medicament or antiseptic is introduced it may be 294 TECHNIQUE OF HYDROTHERAPY used to disinfect the large intestine or destroy parasites, as the amoeba coli. (See quinin also quassia enema). II. MEDICATED ENEMATA SALINE ENEMA (Sal. En.) For whatever purpose the saline enema is used, it should be preceded by a thorough cleansing enema unless the bowel has already been cleared of feces. 1. Saline Enema to be Retained and Absorbed. The absorption of saline fluid from the rectum is useful in hemorrhage, surgical shock and pelvic and abdominal abscesses after drainage has been instituted. To be absorbed most rapidily, the sodium chloride solution should be isotonic with blood serum or slightly hypotonic. A physiologic salt solution is so called because it is isotonic with blood serum. Intermittent Proctoclysis. One-half pint of physiologic salt solution (0.95 per cent) at a temperature of 100 to 105 F., is given slowly or by high bowel catheter. To make this, use one level teaspoonful (4.5 grams or less) of salt to the pint of water. For a hypotonic solution (more rapid absorp- tion) use a little less salt. After this has been absorbed, another one-half pint may be given. If this amount is not readily retained, use four or five ounces only. Continuous Proctoclysis. Murphy Method. J The fluid should be adminis- tered through a fountain syringe to which is attached a three-eights inch rubber hose with a hard rubber or glass vaginal douche tip with multiple openings. This tube should be flexed almost to right angles, three inches from its tip. A straight tube must not be used, as the tip produces pres- sure on the posterior wall of the rectum when the patient is in the Fowler position. The tube is inserted into the rectum to the flexion angle and secured in place by adhesive strips, binding it to the side of the thigh so that it can not come out; the rubber tubing is passed under the bedding to the head or foot of the bed, to which the fountain is attached. Two or three inches from the fountain syringe interpose a Y-tube and to the upper limb attach a piece of rubber hose of the same size as the outlet tube. Fasten the free end of this to the top of the fountain syringe so that what returns through it will fall into the container. When flatus is voided, the gas passes more readily through the upper tube than directly into the foun- tain syringe. This reduces the pressure at such times and so aids in pre- venting expulsion of the fluid onto the linen. The fountain syringe should be suspended from six to fourteen inches above the level of the buttocks and raised or lowered to just overbalance hydrostatically the intra-abdominal pressure, i. e., it must be just high enough to require from forty to sixty minutes for one and one-half pints to flow in, the usual quantity given every two hours. The flow must be con- trolled by gravity alone, and never by a forceps or constriction on the tube, so that when the patient endeavors to void flatus or strain, the fluid can rapidly flow back into the can, otherwise it will be discharged in the bed. It is this 1 Slightly modified from the original description by J. B. Murphy. EN EM AT A 295 ease of flow to and from the bowel that insures against over-distension and expulsion onto the linen. The fountain had better be a glass or graded can, so that the flow can be estimated. The temperature of the water in the fountain can be maintained at 100 by encasement in hot water bags. The fountain is refilled every two hours with one and one-half to two pints of solution. Instead of the usual solution, a teaspoonful of calcium chloride may be added to the pint of saline solution. The tube should not be removed from the rectum after each emptying of the syringe but may be left in place for two or three days if necessary. For the effects of enteroclysis, see Chapter IX. 2. Saline Enema to Cause Exosmosis, acting like a saline cathartic. Used to produce exosmosis, the enema is designed for thorough cleansing of the mucous membrane and is of inestimable value in chronic mucous colitis. To produce exosmosis, i. e., draw water from the tissues into the bowel, the solution must be hypertonic, i. e., of greater concentration than blood serum. Three pints of warm or hot water are used, containing about two teaspoonfuls of salt or one-fourth teaspoonful of Epsom salts added to a phy- siologic salt solution. The enema should be intoduced into the colon by high bowel catheter or its flow into the colon aided by the knee-chest position. Let it be retained fifteen to twenty minutes or longer. If retained much over half an hour, some fluid will be absorbed. The treatment should always be preceded by an ordinary enema to remove feces. SOAP-SUDS ENEMA (S. S. En.) Prepare two or three pints of warm soap-suds solution, made by scraping castile or yellow laundry soap and mixing thoroughly in water at about 100 C F. Follow by a plain enema to remove the soap suds. Effects. The soap-suds enema facilitates evacuation of the bowels and should be used where the plain enema fails to produce results. OIL ENEMA (Oil En.) In administering the oil enema, use the colon tube with a small enema can giving one and one-half to three or four ounces of warmed cotton seed or other vegetable oil. It should be retained from two to ten or twelve hours or over night. Pass it the next morning and follow by soap-suds and plain enemata. Effects. The oil enema is used to remove hardened or impacted feces. It has a soothing, relaxing effect, and is therefore used to overcome spastic constipation, as of chronic lead poisoning. When given two or three days after an operation for hemorrhoids, it softens and loosens the clot so that it passes without causing pain or start- ing fresh bleeding. HONEY OR MOLASSES ENEMA Give one-half to one pint of warmed molasses or the same amount of two parts soap-suds and one of molasses by high bowel catheter. Follow by plain enema. 296 TECHNIQUE OF HYDROTHERAPY Effects. The honey or molasses enema has a purging effect similar to that of the hypertonic saline enema. It aids in removing the mucous casts and mucus accumulations of chronic colitis. ASAFOETIDA ENEMA To one pint of warm water add four ounces of an emulsion of asafcetida, prepared by agitating one-half dram of asafoetida powder in four ounces of water; or add one ounce of tincture of asafoetida to a pint of warm water. Give as an ordinary enema. It is used to expel flatus. TURPENTINE ENEMA To a pint of soap-suds solution add ten to twenty drops of oil of turpentine. Follow by a plain enema. The turpentine enema is given in the same way and for the same purpose as the asafoetida enema. Its action is somewhat more vigorous. It should be used where there is kidney irritation or Bright's disease. GLYCERINE AND EPSOM SALTS ENEMA The glycerine and Epsom salts enema is a vigorous purgative. It is used in cases of fecal impaction and obstinate constipation (obstipation). Just before using, prepare a mixture consisting of two ounces of mag- nesium sulphate, two ounces of glycerine, and sufficient warm water (about two ounces) to make it pass readily through the colon tube. First, cleanse the lower bowel from feces and then inject the mixture by high bowel catheter, using gentle pressure with a rubber bulb if necessary. Considerable patience and persistence may be necessary to secure results. In supposed cases of fecal impaction, great care should be exercised in diag- nosis that a case of intussusception is not treated in this way. STARCH ENEMA The warm starch enema is given to relieve irritation and check diarrhcea. Make a thin paste of starch in one or two ounces of cold water. Add hot water enough to make from four ounces to one pint of solution. Inject slowly after giving a hot cleansing enema. The sedative effect may be made greater and pain relieved by adding five to twenty drops of laudanum. ASTRINGENT ENEMA An astringent mixture is useful in controlling or checking diarrhoea and dysentery. Either of the following formulas may be used: a. A heaping tablespoonful of tannin to one pint of water at 100 F. b. An ounce of glycero of tannin to one pint of water at 100 F. QUASSIA ENEMA The quassia enema is used to destroy and remove thread or pinworms (oxyuris vermicularis). Prepare an affusion of quassia by pouring over one and one-half drams of finely rasped quassia wood, twenty ounces of warm water, let it stand twenty to thirty minutes and strain. Use a plain cleans- ing enema first; then cleanse the colon thoroughly with warm water contain- ing a teaspoonful of borax to the pint. Now inject into the colon (coloclys- VAGINAL IRRIGATION 297 ter) a half to a pint of the infussion of quassia; retain as long as possible. A 1 to 10,000 bichloride solution may be used instead of the quassia. It should not be retained very long. QUININ ENEMA The quinin enema is used for amoebic dysentery. After thorough cleans- ing of the bowel by low enema and colon flushing, inject by high bowel catheter, from two to four or more pints of a warmed solution of quinin, 1 to 1000 or 2500. Large and frequently repeated coloclysters of cold water may be used. Quinin kills the amoebae. Cold water paralyzes them for a time. Position of patient hips elevated. In very obstinate and long standing cases of amcebic dysentery, colonic flushings with cold water or the quinin solutions are sometimes carried out by means of appendicostomy. VAGINAL DOUCHES OR IRRIGATION A vaginal douche consists in the flushing or irrigating of the vaginal cavity by a fluid. General Directions: a. Articles Necessary in the Treatment Room: douche table, fountain syringe or douche can with a capacity of one to two gallons, five or six feet of rubber tubing, douche tube of glass or hard rubber, lubricant, disinfec- tant, sheets and napkins. Additional need in private room, standard or hooks for douche can, a douche pan, slop jar, and rubber sheeting or papers. b. Procedure. Preparation of the douche. Fill the can with from two to four quarts of water at the prescribed temperature and place it from three to four feet above the patient. Always use a thermometer in prepar- ing vaginal douches. Preparation of patient. If the clothing is not removed protect thoroughly. Always cover the patient with a sheet. Lubricate the tube with vaseline or soap. Release the cut-off and allow the water to run a few seconds. Instruct the patient to insert the tube unless helpless. Position of patient. Dorsal position with hips raised and thighs and legs flexed. I. PLAIN VAGINAL IRRIGATION VAGINAL IRRIGATION FOR ORDINARY USE 1. Hot Vaginal Irrigation V. I. This is used for cleansing purposes. Two to four quarts of water are employed at a temperature of 105 to 115 F. Finish with a pint of water at 70 F. In the treatment of pelvic inflammations, the hot vaginal douche is usually given as a preliminary to the use of the sitz bath, hot half-bath or the hip and leg pack. 2. Very Hot Vaginal Irrigation H. V. I. The very hot vaginal irriga- 298 TECHNIQUE OF HYDROTHERAPY tion is designed for the relief of pain or to check hemorrhage. Two to four quarts of water are used at a temperature of 110 to 125 F. 3. Alternate Hot and Cold Vaginal Irrigation H. & C. V. I. Alternate hot and cold vaginal irrigation is given for tonic and stimulating effects. It is also useful in chronic pelvic inflammations. Use two cans with a Y-tube connection. Put four quarts of water in one can at a temperature of 110 to 120 F., and two quarts of water in the other at a temperature of 70 F. Give the hot fifteen to twenty seconds and the cold five to ten seconds. Con- tinue the alternations for five to ten minutes, beginning with hot and finish- ing with cold. VAGINAL IRRIGATION DURING PREGNANCY During pregnancy certain precautions must be observed. The pressure of the water must not be too great, i. e., the douche can must not be placed too high. Very cold water or extremely hot water should not be used. It is positively necessary that the openings in the bulb of the douche tube be lateral and not directly on the end. During pregnancy vaginal irrigation is given chiefly for cleansing, for the treatment of leucorrhrea and for the relief of irritation. Use two to four quarts of water at a temperature of 98 to 105 F. Hang the douche can twelve to eighteen inches above the hips. II. DISINFECTANT AND MEDICATED DOUCHES SOAP-SUDS VAGINAL IRRIGATION (S. S. V. I.) Use two quarts of soap-suds solution prepared from laundry soap or green soap solution, at a temperature of 105 to 110 F. Wrap the tube in cheese cloth and swab the vagina carefully, but thoroughly, while the water is flow- ing. Follow by plain vaginal irrigation, then give a permanganate or bichloride douche. The soap-suds vaginal irrigation is used to prepare patients for surgical operations or for special cleansing and disinfectant purposes. PERMANGANATE OF POTASSIUM VAGINAL IRRIGATION (P. V. I.) To one quart of water add two drams (two teaspoonfuls) of a saturated solution of potassium permanganate (1 to 2000). Temperature 110 to 120 F. Precede by a plain vaginal irrigation. Oxalic acid (sat. sol.) will remove the stain. The permanganate douche is used as a deoderant and disinfectant in the treatment of vaginal inflammations, leucorrhrea, etc., also as a disinfectant preparatory to operation. BICHLORIDE OF MERCURY VAGINAL IRRIGATION (Bichlor. V. I.) Use one dram (a teaspoonful) of a saturated solution of bichloride of mer- cury to one or two quarts of water (1-4000 or 8000) . Temperature 110 to 115 F. Always precede by plain vaginal irrigation, so as to remove all mucus and VA GINAL IRRIGA TION 299 other secretions. If this is not done the disinfectant properties of the bichloride are lessened by its combination with albuminous substances. CARBOLIC ACID VAGINAL IRRIGATION (Carb. V. I.) Use one-half ounce of a five per cent solution to one quart of water. Temperature 110 to 115 F. Be sure that the solution is thoroughly mixed with the water, otherwise a carbolic acid burn may result. Always have alcohol at hand in giving this douche. CREOLIN OR LYSOL VAGINAL IRRIGATION Use a one or two per cent solution of either lysol or creolin in water at a temperature of 110 to 12(> F. These disinfectants are much used after con- finement where puerperal infection has occurred or in case of a suspicious odor to the lochia. ACETIC ACID OR VINEGAR VAGINAL IRRIGATION The acetic acid douche is used to check hemorrhage. Use one quart of boiled vinegar to one quart of water, or one ounce of glacial acetic acid to one quart of water. Temperature 115 to 120 F. ALUM VAGINAL IRRIGATION (Alum V. I.) The alum douche is also used to check hemorrhage or prolonged menses. Add one pint of a saturate solution of alum to one pint of water. In extreme cases the sat. sol. may be used. Temperature 115 to 120 F. Precede by plain hot vaginal irrigation. INDEX Abdominal bandage, 250 Abscess, 134, 191 alveolar, 137, 280 Absorption by blood vessels, 55 body membranes, 52 lymphatics, 55 skin, 30 Acapnia, 230, 233 Acetanilid, in fevers, 101 Acetic acid vaginal irrigation, 299 Aconite, in fevers, 100 Active hyperemia, 25, 56, 131, 133 Affusions, 290 in typhoid, 111 Alcohol in fevers, 100 pneumonia, 144 surgical shock, 234 Alcohol rub, 257 Alkaline bath, 269 sponge, 257 Alum vaginal irrigation, 299 Amblyopia, toxic, 135 Amenorrhoea, 289 Ammonia, influence of cold on, 67 in uremia, 216 Amyl nitrite, in surgical shock, 234 Analgesic effects, 182, 191 Anemia, 159 Anesthesia, relation to shock, 229 effect on phagocytosis, 236 Antagonism, law of, 46 Antiphlogistic effects, 127 Antipyresis, principles of, 97 Antipyretic effects, 96 Antipyretics, medicinal, 100 Aritipyrin, in fevers, 101 Apoplexy, 225 Appendicitis, 127, 151, 280 Arrhythmia, in heart disease, 176 Arteriosclerosis, relation of elastic tissue to, 18 Articular rheumatism, acute, 148 chronic, 166 Asafoetida enema, 296 Asthma, 199 Astringent enema, 296 Ataxia, locomotor, 188, 289 Balneology, 8 Baths, 261 air, superheated, 272 alkaline, 269 Brand, 103, 109, 266 cold, 266 rationale of, 112 diagnostic, 112 effervescent, see Nauheim electric light, 273 electric tub, 267 foot, 262 full immersion, 265 graduated, 110, 267 graduated shower, 286 half, 265 hand and arm, 262 hydro-electric, 267 leg, 263 medicated, 269 Nauheim, 26, 269 in heart disease, 173 partial immersion, 262 rain, see sprays Russian, 271 saline, 269 shallow, 158, 267 shower, see sprays sitz, 264 sun, in anemia, 161 in neurasthenia, 164 tub, 265 Turkish, 272 vapor, 272 Bier's hyperemia, 133 Biliary, colic, 195 inflammations, 151 Biliousness, 219 Blanket packs, 276 Blood, effects on composition of, 59 reaction of, 62 viscosity of, 62 Blood poisoning, 138 Blood pressure, 23, 45, 52 effects of heart beat on, 52 effects of volume of fluid on, 52, 55 effects of vascular calibre and ac- tion on, 56 in Bright's disease, 210 laws of effects on, 57 Blood vessels, 18 action of, 25, 56, 171, 231 calibre of, 56, 231 capillary loops in skin, 18 effects of heat and cold on, 25 pumping action of, 57, 171, 231 INDEX 301 in malaria, 120 reaction in, 25 Boils, 138 Bright's disease, 210 acute, 213 chronic, 214 Bronchitis, acute, 198 chronic, 199 Bronchopneumonia, 145 in measles, 122 Bruises, 195 Burns, 195 Caffein, see coffee Calorie, 5 Carbolic acid vaginal irrigation, 299 Carbon dioxide, effects on blood ves- sels, 26 influenced by heat and cold, 74, 114 in fevers, 114 in Nauheim bath, 269 in surgical shock, see acapnia respired by skin, 31 Carbancles, 138 Cardiac changes in shock, 231 Catarrhal jaundice, 151 Cathartics, in edema of nephritis, 214 Cellulitis, pelvic, 152 Centripetal friction, 258 Cerebral congestion, 128, 168 Charcoal poultice, 252 Chest packs, 249 Chlorides, effect of cold on, 70 Cholangitis, 151 Cholecystitis, 151 Chorea, 186, 289 Circulation, 33 balance between reflex and hydro- static effects, 50 blood pressure, 52, see also blood pressure composition of blood, 59 hydrostatic effects on, 44 in inflammations, 130 in pneumonia, 139 in surgical shock, 230 in typhoid fever, 112 quantity of fluid in, 26 effects on blood pressure, 52 reflex effects on, 33 Clark's column, 3<% 37 Clay and glycerine poultice, 252 Coal tar products, in fever, 101 Coffee, a cause of fever, 96 effects on purins, 217 Coil, cold water, 248 in typhoid, 111 hot water, 246 Leiter, 248 Cold 'air, in pneumonia, 140 Cold, effects on antibodies, 63 ammonia, 67 blood pressure, 22, 45, 57 blood vessels, 22, 44 carbon dioxide elimination, 74 carbonaceous metabolism, 73 chlorides, 70 composition of blood, 59 extractives, 69 fever, 103 heat elimination, 85, 87 heat production, 85, 86 muscular capacity, 76 nervous system in typhoid, 112 nitrogenous metabolism, 64 oxygen absorption, 74 perspiration, 29 phosphoric acid, 69 purin, 67 red cells, 59 skin muscles, 17 sulphates, 70 sweat glands, 29 toxin elimination in typhoid, 113 urea, 67 uric acid, 67 white cells, 59 Cold, hydrostatic effects of, 44 intrinsic effects of, 10 local applications of, 24u reaction to, 11 reflex effects of, 41 Cold-blooded animals, 9 Cold friction, effects on vasomotors, 25 in fever, 113 in heart disease, 172 in shock, 232 Cold plunge, 158 Cold treatments, see distinctive word in each Colds, 198 Colic, 194 biliary, 195 intestinal, 195 renal, 195 Colitis, mucous, 153 Collapse, 228 Coloclyster, 293 Compresses, 243, 244, 246, 248 cold in typhoid, 111 heating/ 248 hot gauze, 243 joint, 251 medicated, 252 revulsive, 244 throat, 251 Conjunctivitis, 135 Convection, heat loss by, 82 Coryza, acute, 198 302 INDEX Cough, 198 in pneumonia, 143 Cravat, ice, 247 Creolin vaginal irrigation, 299 Crile, investigations of, 228, 233 Croup, 199 Cystitis, 154 Dachryocystitis, 135 Depletion, 127 Depressant effects, 13 Derivation, 45, 133 areas for, 47 by hot alone, 128 definition of, 127 Dermatomes of Head, 35 Dermographism, 16 Diabetes, 167 Dialysis, 8 Diaphoretic effects, 201 Diaphoretics, medicinal, 101, 214 Diet, in Bright's disease, 210 in diabetes, 167 in uremia and eclampsia, 217 meat, effect on liver, 216 purin-free in gout, 207 vegetable in gout, 207 Digitalis, in fevers, 113 in surgical shock, 234 Diuresis, effects of cold bath on, 114 refrigerants on, 102 sweating on, 201, 205 Diuretic effects, 205 Douches, 285, 287 cold as a tonic, 158 vaginal, see vaginal irrigation Dover's powder, in fever, 101 Dripping sheet rub, 158 Duodenal ulcer, 192 Dysmenorrhoea, 194 Dyspepsia, 165, 219 Eclampsia, 215 acute, 217 Edema, absorption of, 55 complicating heart disease, 175 in Bright's disease, 211 of lungs in heart disease, 176 Effects, analgesic, 182 antiphlogistic, 127 antipyretic, 96 depressant, 13, 40 derivative, 45 diaphoretic, 201 diuretic, 64, 205 emmenagogic, 178 excitant, 177 expectorant, 197 hemostatic, 224 hydrostatic, 44 intrinsic, 10 metabolic, 64, 73, 202, 205 oxytocic, 78 peptogenic, 219 primary, 12 principles of, 9 reactionary, 12 reflex, 33 of cold, 41 of heat, 43 retrostatic, 46 secondary, 12 sedative, 40, 180 stimulant, 40, 156, 177 tonic, 13, 156, 177 vascular, 25 Effervescent bath, see Nauheim bath Eggs in anemia, 160 Elastic tissue of skin, 17 Electric light bath, 273 Electric tub baths, 267 Electro-thermal baths, 267 packs, 280 Emmenagogic effects, 178 Endocarditis, in scarlet fever, 124 in rheumatic fever, 149 Endometritis, 152 Enemata, 290 asafcetida, 296 astringent, 296 cold, in typhoid, 111 glycerine and Epsom salts, 296 graduated, 292 medicated, 294 molasses, 295 oil, 295 plain water, 291 quassia, 296 quinin, 297 saline, 294. 295 soap-suds, 295 starch, 296 Epistaxis, 224 Erectores pilorum, 17 Ergograph experiments, 76, 164 Erysipelas, 136 Ether, method of giving, 227 Exercise, effect on lymph movement, 27 effect on reaction, 14 in diabetes, 168 Expectorant effects, 197 Evaporation, effect on reaction, 15 heat Ipss by, 83 Faradic tub bath, 268 Fever, 96 causes of, 97 circulatory failure in, 98 hydrotherapy in, 102 manifestations of, 97 INDEX mechanism of production, 105 medicinal antipyretics in, 100 rheumatic, 148 scarlet, 123 treatment of, 108 typhoid, 108 variations that produce, 106 Flexner's serum, 150 Fluxion, 128, 133 definition of, 127 Fomentations, 241 Foot baths, 262 Fractures, 196 Friction, 258 cold mitten, 157, 253 centripetal, 258 dry, 261 tonic, 252 ' Frog, a cold-blooded animal, 10, 81 Galvanic tub bath, 268 Gastrectasia, 219, 222 Gastric lavage, in dyspepsia, 222 in surgery, 238 Gastric secretion, effect of cold on, 220 Gastric ulcer, 192 Gastroptosis, 219, 222 Glands, sebaceous, 30 sweat, 28 Glaucoma, 135 Glycerine and Epsom salts enema, 296 Glycerine and white clay poultice, 252 Goitre, 189 Gout, 206 Grippe, 124 Gymnastics, resistant, 173 Half -bath, 265 Heart, beat, effect on blood pressure, 52 force of in infections, 99 disease, valvular, 169 fatty, 176 failure in typhoid, 113 innervation of, 36 peripheral, 22, 26, 171 reflex arc to, 37 Heat, loss, 82, 84, 86, 87, 103, 105 mechanism, 81 production, 81, 84, 85, 86, 103, 105 regulation, 88 Heat, absorption and communication of, 3 effects on, blood pressure, 45, 57 carbon dioxide, 74 carbonaceous metabolism, 74 composition of blood, 59 fever, 103 metabolism, 71, 74 muscles of skin, 18 muscular capacity, 79 nitrogenous metabolism, 71 oxygen, 74 red cells, 59 respiration, 73 sweat glands, 28 white cells, 59 hydrostatic effects of, 44 intensity of, 4 latent, 6 local applications of, 241 physics of, 3 quantity of, heat units, 5 radiant, 246 reaction to, 13 specific, 5 Heat stroke, 168 Hemorrhage, gastric, 224 in typhoid, 115 pulmonary, 224 relation to shock, 229 uterine, 225 Hemorrhoids, 192 Hemostatic effects, 224 Henderson, work on acapnia, 228 work on veno-pressure, 231 Hilton's law, 35 Hip and leg pack, 279 Hip pack, see pelvic pack Homeothermic animals, 10 reaction of, 10 Hot and cold treatments, douche, 289 foot bath, 263 leg bath, 264 pelvic pack, 279 rectal irrigation, 293 shower, 286 spray, see shower to head, 244, 245 to spine, 244 trunk pack, 278 Hot water bottles, 245 Hydrogogue action of hypertonic solu- tions, 54 Hydrostatic effects, 44 balance between and reflex ef- fects, 50 secondary, 46 Hyperchlorhydria, 222 Hyperemia, active, 25, 56, 129, 130 arterial, see active Bier's, 133 collateral, 127 passive, 25, 56, 130 Hyperthyroidism, see goitre Hypertonic solutions, 54, 259 Hypochlorhydria, 219, 289 304- INDEX Hypodermoclysis, 56 Hysteria, 165 Ice bag, 248 effect of over heart, 37 in heart disease, 171 in goitre, 190 with hot packs, 279 Ice cap, see ice bag Ice cravat, 247 Ice pack, 247 in pneumonia, 142 Ice rub, 255 in typhoid, 111 Icterus, 203 Inebriety, 166 Infections, post anesthetic, 236 see also fevers, inflammations, puerperal, Inflammations, 127 biliary, 157 deep-seated, 191 defined, 130 of eye, 135 pelvic, 152 principles of treatment, 131 pathogenesis of, 130 superficial, 192 treatment of, 135 Influenza, 124 Intestinal colic, 195 stimulants, 178 Insomnia, 166, 184 Intrinsic effects of cold, 10 of heat, 11 time factor in, 12 Iritis, 135 Iron, in anemia, 159 organic, 160 Isotonic solutions, 54 Ivy, poisoning by, 139 Jaundice, see icterus catarrhal, 151 Joint compress, 251 Keratitis, 135 Kidneys in typhoid, 113, 115 Latent heat, 6 Law, Berthollet's, 208 Dastre-Morat, 47 Hilton's, 35 Muller's, 57 of antagonism, 46 of balance between reflex and hy- drostatic effects, 50 Leg bath, 263 pack, 279 Leucocytes, effects of alcohol on, 100 coal tar products on, 101 cold on, 59, 113 heat on, 59, 119 quinin on, 101, 119 in fevers, 98, 102 in inflammations, 130 in malaria, 119 Leucocytosis, from cold, 59 in malaria, 119 Leucomaines, a cause of fever, 96 Leucopenia, in malaria, 119 in typhoid, 113 Light, 9 Lithium in gout, 207, 209 Liver, congestion of, 175 effects of meat diet on, 216 Locomotor ataxia, 188, 289 Lumbago, 289, see also rheumatism Lymphatics, 19 absorption by, 19 effects of stimulation on, 27 lymphatic hearts, 20 movements of, 20 quantity of fluid, 26 valves of, 19, 20 Lysol vaginal irrigation, 299 Malaria, 116 Massage, effects on blood cells, 62 effects on lymphatics, 27 in anemia, 161 in diabetes, 168 in heart disease, 172 in rheumatism, 210 Mastoiditis, 128, 136, 280 Measles, 121 Meat diet, effect on liver, 216 Mechanical stimuli, 7 effects, 44 on blood pressure, 57 on carbon dioxide and oxygen, 75 on muscular capacity, 79 vibration, in heart disease, 172 Medicinal antipyretics, 100 Meningitis, 127, 150, 280 Menstruation in typhoid, 115 Menthol rub, 257 Mercury, specific heat of, 5 bichloride vaginal irrigation, 298 Metabolism, carbonaceous, 73 nitrogenous, 64 Mineral waters, 8 absorption of, 31 in rheumatism, 208 Mitten friction, see friction Morphin, effect on phagocytes, 237 Mortality, in typhoid, 115 Mucous colitis, 153 Muscular tissue of skin, 17 capacity, 76 Myelitis, 187 Myocarditis, 148 INDEX 305 diphtheritic, 99 Nauheim bath, 26, 269 in heart disease, 173 Naumann, experiments of, 33 Nephritis, 210 acute, 213 chronic, 214 in scarlet fever, 124 in typhoid, 115 sweat glands in, 29 Nerves, of skin, 32 secretory, 40 temperature, 32 vasomotor, distribution of, 18, 20 visceral, 40 Nervous system, after cold bath, 112 Neuralgia, 128, 192 inflammatory, 193 toxic, 193 Neurasthenia, 161 splanchnic, 164 Neutral bath, 266 douche, 288 electric, tub bath, 268 pack, 282 shower, 286 sitz bath, 264 temperature, 16 Nitrogen economy, 65 Nitrogenous metabolism, 64 Nitroglycerin, in surgical shock, 234 Obesity, 202 with fatty heart, 176 rheumatism with, 208 Oertel method, 174 Oil enema, 295 rub, 260 Ophthalmia, 135 Osmosis, 8, 54 Osteomyelitis, 128, 191 Otitis media, 136 Ovaritis, 152 Oxygen, effects of heat and cold on, 74, 114 Oxytocic effects, 178 Packs, 276 blanket, 276 chest, 249, 250 electro-thermal, 280 evaporating, 281 half-pack, 283 heating, 282, see also compresses pelvic, 284 trunk, 283 hip and leg, 279 hot and cold pelvic, 279 hot and heating trunk, 284 hot pelvic, 278 hot trunk, 278 hot, with ice bags, 279 ice, 247 leg, 279 neutral, 282 sweating, 283 wet sheet, 281 in typhoid, 110 Pail pour, 158, 290 Pain, relief of, 182, 191 in pneumonia, 142 Palpitation, in heart disease, 176 Pancreatitis, subacute, 151 Paraesthesias, relief of, 184 Paralysis agitans, 187 spastic spinal, 187, 289 Passive hyperemia, 25, 56, 130, 133 Pathpgenesis, of fever, 96, 105 of inflammation, 130 Pelvic cellulitis, 152 inflammations, 152 pack, heating, 284 hot, 278 hot and cold, 279 peritonitis, 152 Peptogenic effects, 219 Perforation in typhoid, 114 Pericarditis, 147 Peripheral heart, 22, 26 measures which stimulate, 171 Peritonitis, 127, 280 pelvic, 152 Phagocytosis, in fevers, 98 effects of anesthesia on, 236 cold on, 62 drugs on, 100 morphin on, 237 Pharyngitis, 137 Phases of reaction, 13 Phenacetin, in fevers, 101 Phlebitis, 153 Phosphoric acid, effect of cold on, 69 Physiologic agents, 9 effects, principles of, 9 stimulants, 156 therapy, realm of, 93 Pilocarpin, in fevers, 101 Pleurisy, 128, 146, 289 complicating typhoid, 114 Plunge, cold, 158 Pneumonia, 127, 139, 280, 289 complicating typhoid, 114 Poikilothermic animals, 9 Poisoning, ivy, 139 systemic, 203 Poultices, 252 Properties of water, 3 Proctoclysis, Murphy method, 294 absorption of fluid, 56 in surgical collapse, 232 Prostatitis, 155, 289 Proximal application, 42, 247 306 INDEX Psychic attitude, effect on reaction, 15 Puerperal infection, 127, 152, 280 Pulmonary congestion, 198 hemorrhage, 224 Purin, diathesis, 206 a cause of fever, 96 effects of coffee on, 217 effect of cold on, 67 in gout, 206 Pyrexia, see fever Quassia enema, 296 Quinin, enema, 297 in fevers, 101 in malaria, 117 in pneumonia, 143 prophylactic use of, 117 protozoan immunity to, 118 Radiant heat, 246 Radiation, heat loss by, 82 Reaction, 11 ability, test of, 15 circulatory, 13, 25 conditions influencing, 14 deep reflex, 42 inccmplete, 14 in blood vessels, 25 in malaria, 121 nervous, 13 of short cold, 11 phases of, 13 rationale of, 11 repeated, 14 suppressed, 13 thermic, 13 time factor in, 12 to heat, 13 types and degrees of, 13 Rectal injection, see enemata irrigation, 292 tenesmus, 194 ulcer, 192 Red cells, effect of cold on, 59 effect of heat on, 59 Reflex arc, 34, 36, 37 areas, 34, 38, 40 effects, 33 classes of, 40 Refrigerants, in fever, 101 Resistant gymnastics. 173 Respiration, 73 by skin, 31 Rest, in heart disease, 171 Retrostasis, 46 Revulsion, defined, 130 Revulsive compress, 244 douche, 288 sitz bath, 265 Rheumatic fever, 148 Rheumatism, chronic articular, 166, 206 with emaciation, 209 with obesity, 208 Romberg and Passler, researches of, 98, 113, 141 Rubner, chart on heat loss, 83 experiments of, 74 Rubs alcohol, 257 cold towel, 158, 254 in typhoid, 110 dripping sheet, 158, 255 dry, 261 ice, 255, 111 menthol, 257 oil, 260 vinegar and salt, 257 wet hand, 157, 254 wet sheet, 158, 254 witchhazel, 257 Rubs and frictions, 258 Russian bath, 271 Saline bath, 269 sponge, 257 Salpingitis, 127, 152, 280 Salt and vinegar rub, 257 Salt glow, 158, 255 Salt, relation to edema, 211 Scarlet fever, 123 Schott treatment, 173 Schuller, experiments of, 33, 44 Sciatica, 128, 289 Sebaceous glands, 30 Sedative effects, 40, 180 Sedatives, general, 180 local, 182 pure, 180 tonic, 182 Septicemia, 138 Serum, Flexner's, 150 Shampoos, 274 Sheet pack, wet, 281 in typhoid, 110 Sheet' rub, wet, 158, 254 dripping, 158, 255 Shock, surgical, 228 Shower bath, see sprays Sinusoidal electricity, in neuras- thenia, 165 tub bath, 268 Sitz bath, 264 Skin, 17, 28 heat regulation by, 31 respiration by, 31 vicarious functions of, 29 Soap-suds enema, 295 vaginal irrigation, 298 Soap wash, 258 Specific heat, 52 INDEX 307 Spinal paralyses, spastic, 187, 289 Splanchnic efferent nerves, 40 neurasthenia, 164 Spleen, effects on distribution of blood cells, 60 Sponging, 256 Sprains, 195 Sprays, 285, 286 Starch enema, 2% Starling, work of, 51 Stimulant effects, 13, 40, 156, 177 Stimulants, 156 drug, defined, 156 intestinal, 178 uterine, 178 yesical, 178 Stimuli, mechanical, 7, 75 thermic, 7 Stomach, reflex arc to, 37 Stupes, 244 Strychnin, as a general tonic, 80 in pneumonia, 144 in surgical shock, 234 in typhoid, 113 Sulphates, effect of cold on, 70 Sun baths, in anemia, 161 in neurasthenia, 164 Sunstroke, 168 Surgery, after-treatment, 236 hydrotherapy in, 226 immediate care, 227 preparatory treatment, 226 relation to physiologic therapy, 94 Surgical shock, 228 contributing causes, 228 drugs in, 234 hydrotherapy in, 232 treatment of, 231 Sweat glands, 28 in nephritis, 29 perspiratory influences, 29 vicarious functions, 29 Swedish shampoo, 274 Talcum rub, 261 Technique of hydrotherapy, 239 Temperature, common names of, 16 nerves of, 32 Tenesmus, 194 Therapeutics, 94 Therapy, basic principles of, 95 physiologic, realm of, 93 principles of, 9 Thermic stimuli, 7 Thermometers, 4, 5 Thermotherapy, 3 Throat compress, heating, 251 Tobacco blindness, 135 Tonic effects, 13, 156, 177 frictions, 252 sedatives, 182 Tonics, hydriatic vasomotor, 172 Tonsilitis, 137 in scarlet fever, 123 Towel rub, see rubs Tracoma, 135 Traube-Hering waves, 22, 230 Trauma, relation to shock, 229, 235 Trunk pack, heating, 283 hot, 278 Turkish bath, 272 shampoo, 274 Turpentine enema, 296 Tympanites, in typhoid, 115 Typhoid fever, 108 hot treatment in, 111 cold treatment of, 109 Ulcer, duodenal, 192 gastric, 192 rectal, 192 varicose, 289 Urea, effect of cold on, 67 in uremia, 216 Uremia, 215 acute, 217 Urethritis, specific, 155, 289 Uric acid, effect of caffein on, 217 effect of cold on, 67 effect of heat on, 71 endogenous, in gout, 215 formation and destruction of, 206 Vaginal irrigation, 297 Vaginitis, 155 Valvular heart disease, 169 Vapor bath, 272 Varicose ulcer, 289 Vasomotor center, 33, 36 paralysis of, in fevers, 99 in shock, 230 Vasomotor nerves, 18, 20 Vasomotors, effect on blood vessels, 21, 33 failure in fevers, 99 in shock, 230 in typhoid, 113 Vasomotor tonics, in fevers, 98 in heart disease, 172 in surgical shock, 232 Veno-pressor mechanism, 231 Vesical stimulants, 178 tenesmus, 194 Vibration, in heart disease, 172 Vinaj and Maggiori, experiments of , 76 Vinegar and salt rub, 257 Vinegar vaginal irrigation, 299 Viratrum viride, in fevers, 100 . Warm-blooded animals, 9 Water, expansion of, 3, 4 308 INDEX mineral, 8, 207, 209 Wet sheet pack, 281, see packs properties of, 3 in typhoid, 110 Water bottles, hot, 245 Wet sneet rubs, 158, 254, see Water drinking, cold, effect on blood White cells, see leucocytes pressure, 58 Wint^rnitz coil, 246 effect on urea excretion, 70 in dyspepsia, 220 in dyspepsia. 221 in typhoid, 111 in pneumonia, 143 Winternitz pack, 246, 284 in surgery, 227, 237 in dyspepsia, 220 Wet hand rub, 157, 254, see rubs Witchhazel rub, 257 ' University of California SOUTHERN REGIONAL LIBRARY FACILITY 405 Hllgard Avenue, Los Angeles, CA 90024-1388 Return this material to the library from which it was borrowed. UC SOUTHERN F fc WB520 A131h 1911 Abbott, George Khapp. Hydrotherapy MEDICAL SCIENCES LIBRARY UNIVERSITY OF CALIFORNIA, IRVINE IRVINE, CALIFORNIA 92664