,-^,-„,,HEBHBESIONAL, 000 005 729 9 -'i>^ Bought of / THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES Gift of ur. \'i. L. Grant ■ L. GRiifiir, iw. a FARGO, N. DAK. G>C^ A HANDBOOK OF THERAPEUTICS BY SYDNEY RINGER, M.D. PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE IN UNIVERSITY COLLEGE, PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL ^iwiftix '^amon NEW YORK WILLIAM WOOD AND COMPANY 56 & 58 LAFAYETTE PLACE 1889 i Bismedical libiaiy 300 im PEEFACE TO THE TWELFTH EDITIOK As ill previous editions, so with this, I dwell much more on the indications for the use of drugs in disease than on their physiological action. The book is, in fact, a work on clinical therapeutics. In preparing this edition, I have carefully revised every portion, and added much fresh information, not only on new drugs, but also on old. I am anxious again to express my great obligation to my friend, Dr. George Bird, who has assisted in revising this and several previous editions of this Handbook, and who has increased its usefulness by many suggestions. Octobei', 1888. 6n.^rt.^4 INTEODUCTIO:^'. I HAVE thought it might prove useful to the student and to the young practitioner to insert in this edition a brief account of the symptoms of disease. Of late years, since attention has been more drawn to the signifi- cance of physical signs, too little heed seems to me to be paid to the detec- tion and appreciation of symptoms, objective and subjective. This is a marked defect among students. One often meets with a student, thoroughly equipped with all the resources pertaining to physical diagnosis, who yet is sorely puzzled with the indications afforded by the pulse or tongue. The reason is obvious. Physical signs are soon learned, whilst it requires a longer time, more patience, and a more discriminating obser- vation to appreciate the meaning and to estimate the value of symptoms. The indications of disease are divided into symptoms and " physical signs." The direct information to be obtained from the pulse, the skin, the tongue, the breathing, the evacuations, etc. , are for convenience, termed objective symptoms. The indirect information we gather from the patient's description of his own feelings and sensations, which are detected only by the patient himself; these, likewise for the purjiose of convenience, are termed subjective symptoms. Important though physical signs un- doubtedly are, yet symptoms, especially objective symptoms, are far more valuable. Physical signs, as a rule, help us to detect only coarse and de- cided changes, and are chiefly useful in diagnosis, whilst symptoms are far more useful guides in prognosis and in treatment. It may be said, that before we can efficiently treat a patient, we must first form a correct diagnosis; hence physical signs, by greatly assisting us in this respect, must likewise greatly aid in the treatment. In some measure, this proposition is no doubt true; but when we have accurately diagnosed the disease, we treat, in most cases, the secondary effects rather than the primary disease; and these secondary effects generally make themselves apparent solely as symptoms. Only in a few instances, as ague and syphi- lis, can we directly cure the disease itself; but in other instances we must be content to combat the secondary and often fatal effects. A disease often neither endangers nor destroys life by its direct effect on the organ attacked, but through a secondary effect manifested on another organ or organs. Thus to take the case of pneumonia; here, by no means unfre- quently, the dangers depend, not on the condition of the lung, but on nervous or cardiac depression. The fever depresses the nervous system, V VI INTRODUCTIOJ^. shown in sleeplessness and delirium, and this depressed state of the nervous system causes cardiac weakness and so endangers and destroys life; or the fever may directly depress the heart and so weaken it that the patient dies. Xow in both these instances, the effects on the nervous system and on the heart are manifested solely by symptoms, and without due appreciation of, and proper attention to these symptoms, so much the worse for the patient. Instances like this might be multiplied to any extent. Moreover, there is the wide range of diseases in which physical diagnosis is unavail- ing and when there are only symptoms to guide our treatment; and unless trained in the recognition and estimation of symptoms, these are just the cases in which the young practitioner is more likely to find himself at sea. CONTENTS. PAGE Introduction, v The Tongue, 1 The Pulse, 4 The Skin, 15 Tlie Temperature of Health, 18 Temperature in Disease, 18 Abnormal Elevation of Temperature, or Fever, etc 19 Chronic Fever, 24 On Dropsy, 32 The Effects of Cold on the Body, 35 The Cold Bath, including Sea-Bathing, . 38 The Sitz-Bath, 43 On Packing with the Wet Sheet, 44 Cold Baths in Fevers, 45 The Warm Bath and the Hot Bath, 50 Hot- Air and Vapor-Baths, 53 Shower, Douche, and Sponge Baths, 54 The Turkish Bath, 58 Poultices and Fomentations, G2 The Medicinal Uses of Ice, G7 On the Spinal Ice-Bag and the Spinal Hot-water Bag, .... 69 The Spinal Hot-water Bag, 71 The Internal Use of Water, 71 On Enemata, 74 On Acupuncture, 77 Irritation and Counter- Irritation, 81 Carbon, Animal Charcoal, Wood Charcoal, 86 Carbonic Acid, 88 Sulphur, 88 The Sulphide of Potassium, Sodium, Ammonium, and Calcium, . . 92 Chlorine Gas, Chlorine Water, Chlorinated Soda, Chlorinated Lime, and their Solutions, 98 Iodine, 100 Vlll CONTENTS. PAGE A few Introductory Remarks regarding the Relative Effects of Potas- sium and Sodium Salts, 104 Iodide of Potassium, Iodide of Sodium, Iodide of Ainiuoniuiii, . . 107 Bromide of Potassium, Sodium, Ammonium, and Lithium, . . .114 A Theory concerning the " Topical " Action of Acids and Alkalies on Secretion, 123 Sulphuric, Hydrochloric, Nitric, Phosphoric, and Acetic Acid, . 123 Sulphurous Acid, Sulphites, Hyposulphites 130 Chromic Acid, 132 Boric or Boracic Acid, 133 Group embracing Caustic Potash, Solution of Potash, Carbonate and Bicarbonate of Potash, Acetate of Potash, Citrate of Potash, and the corresponding Preparations of Soda, Potash Soap, Soda Soap, Borax, 133 Ammonia, Carbonate of Ammonia, Spirits of Ammonia, .... 146 Magnesia, Light Magnesia, Carbonate of Magnesia, Light Carbonate of Magnesia, Solution of Carbonate of Magnesia, 150 Lime, Caustic Lime, Lime-water, Liniment of Lime, Saccharated Solu- tion of Lime, Carbonate of Lime, 151 Phosphate of Lime, 155 Hypophosphite of Lime, Hypophosphite of Soda, 158 Chloride of Potassium, Chloride of Sodium, Chloride of Ammonium, . 158 Group containing Sulphate of Potash, Sulphate of Soda, Sulphate of Magnesia, Phosphate of Soda, Tartrate of Potash, Bitartrate of • Potash, Tartrate of Potash and Soda, IGO Nitrate of Potash, Nitrate of Soda, 165 Chlorate of Potash, 168 Alum, Dried Alum, Acetate of Alumina, 169 Preparations of Iron, 172 Salts of Manganese, 178 Nitrate of Bismuth, Carbonate of Bismuth, 180 Lead Salts, 181 Nitrate of Silver, Oxide of Silver, 187 Mercury and its Preparations, 191 Preparations of Copper, 206 Preparations of Zinc, 207 Preparations of Antimony, 210 Preparations of Arsenic, 215 Phosphorus, 232 Collodion, . . . • 236 Cod-Liver Oil, Almond Oil, Poppy Oil, Hemp-seed Oil, Linseed Oil, Cocoa-Nut Oil, Dugong Oil, Palm Oil, Lard, Suet, Wax, etc., . 237 CONTENTS. IX PAGE Castor Oil, Croton Oil, 244 Glycerine, 247 Tannin and its Compounds, on Gallic Acid, 248 Hanianielis Virginica, 252 Coto Bark, 253 Petrolevini, Vaseline, etc., 253 Tar, Creosote, etc., 253 Carbolic Acid and Sulpho-Carbolates, 256 Musk, Castoreum 260 Alcohol, 261 Chloroform, 2G9 Ether, 278 Iodoform, 279 lodol 281 Hydrate of Chloral, 281 Paraldehyde, 287 Urethan 288 Hydrate of Croton-Chloral, 288 Nitrite of Amyl, 292 Nitro-Glycerine, 298 Nitrite of Sodium, 300 Camphor, 301 Turpentine, Oil of Turpenthie, 303 Group containing : — Nutmegs, Cloves, Canella Bark, Cinnamon Bark, Cajeput Oil, Oil of Anise, Fennel Fruit, Caraway Fruit, Coriander Fruit, Dill Fruit, Elder Flowei's, Lavender Oil, Oil of Rosemary, Oil of Sandal Wood, Menthol, Oil of Peppermint, Oil of Spearmint, Oil of Rue, Oil of Lemons, Cubebs, Buchu Leaves, Balsam of Tolu, Balsam of Peru, Copaiba, Mezereon, Sassafras, Storax, Juniper, Benzoin, etc., 306 Eucalyptus, 309 Valerian, Valerianate of Zinc, Valerianate of Quinia, Valerianate of Ammonia, 310 Assafoetida, Ammoniacum, Galbanum, 310 Cantharides, 311 Mustard, 313 Capsicum, 315 Ipecacuanha and its Preparations, 316 Apomorphia ^ 327 Veratrum Viride. . . . . . _ . ^ 327 Veratria, . . . . ^ . . . . 328 Colchicum, ... ..... ^ . . . _ 330 X CONTENTS. PAGE Poilopliyllum, '^'•^■^ Guaiacuiii, ^'^6 Actaea (Ciiuicifuga) Racemosa, 337 Aconite, 338 Digitalis and its Preparations, 345 Convallaria Majalis, 357 Strophanthus (Kombi Arrow Poison), 357 Spai'teine, 358 Adonidin, 359 Tobacco, 360 Coniuni, 361 Calabar Bean, 365 Muscarin, 368 Jaborandi, 373 Gelseniium Sempervirens, 375 Grindelia Robusta, 382 Belladonna, 383 Ethyl- Atropium, Methyl- Atropium, 400 Hyoscyauius, 401 Hyoscine, 402 Stramonium, 403 Duboisia Myoporoides, 403 Hydrocyanic Acid, Cyanide of Potassium, 404 Opium, 405 Nux Vomica, Strychnia, Brucia, Thebaia, 419 Lobelia Inflata, 426 Cannabis Indica, 427 Ergot, 429 Coffee, Caffeine, 432 Cocaine, 435 Cinchona and its Alkaloids, 441 Salicine, Salicylic Acid, SaUcylates, 448 Salol, 452 Antipyrine, 453 Phenacetin, 455 Quassia, 456 Chamomile, 456 Pareira Brava, 456 Elaterium, 457 Colocynth, 457 Aloes, 457 Squill, 460 J CONTENTS. XI PAQE Jalap, Scammony, 460 Rhubarb, 461 Senna 462 Cascara Sagrada, 462 Euonyiuus, 462 Senega, 463 Anthelmintics : — Filix Mas, Kousso, Kamela, Santonin, Turpentine, Areea ]N^ut, Bark of the Pomegranate Root, Powdered Tin, Mueuna, etc 463 Dietary for Invalids, 467 Index to Therapeutic Agents, 479 Index to Diseases, i A HAND-BOOK OF THERAPEUTICS. THE TONGUE. "We examine the tongue to ascertain whether it is clean or furred; dry or moist; its color, etc. What is the meaning of a furred tongue ? A tongue may he furred from febrile disease; from local causes; or from sympathy with the stomach, intestincB, or liver. The condition of the tongue in fever is, perhaps, more a help in prog- nosis than in treatment. In most fevers the tongue at first is covered with a moist fur; but in some cases the tongue, strange to say, remains quite clean. Sometimes this is the case in typhoid fever. Now the coated tongue in fever does not give us much suggestion with regard to treatment, for whether the tongue is clean or foul, if there is constipation the bowels must be relieved; and if the tongue is very foul, that is, thickly coated, a mercurial purge is best, though whilst the fever continues some fur usually remains. Local causes often foul the tongue. Enlarged tonsils often coat the back of the tongue. Decayed teeth often fur a portion of the tongue. If one tonsil only is enlarged, or if the decayed teeth are situated on one side, then only one longitudinal portion of the tongue is furred. In neu- ralgia of the fifth, when the lower branches are affected, the tongue on the neuralgic side is apt to become furred. Excessive smoking almost always furs the tongue. The tongue very frequently indicates derangement of the stomach, bowels, or liver. For instance, if there is no fever, and no local cause, as en- larged tonsils, bad teeth, etc., then a coated tongue indicates some dis- turbance of the primge via?. What does a coated tongue under these circumstances indicate ? We shall rarely go wrong in taking this furred tongue as an indication for giving one of four medicines, or some of them combined : namely, mercury, podo})hyllin, tincture of nux vomica, or nitric acid. How are we to determine which to give and its dose ? If there is con- stipation then give a mercurial preparation or resin of podophyllin in pur- gative doses. Any purgative, it is true, will here be useful, especially the natural purgative waters, as Pullna, Friedrichshall, or Carlsbad; but these, though valuable remedies, are in many instances inferior, in the cases in question, to mercurial and podophyllin purges. As regards mercury, our choice falls either on calomel or blue pill for adults, or calomel or grey powder for children. The calomel or blue pill should be combined with extract of belladonna or of hyoscyamus, since this addition obviates the griping and certainly seems to enhance the ac- tion of these drugs. An effective dose is half a grain of calomel with 1 iJ THE TOXGUE. three grains of extract of liyoscyamus, for tlireo consecutive nights; tlie first pill generally purges pretty freely, the second much less freely, and the tliird scarcely at all, though it helps to clean the tongue. Which should we choose — mercurial purges or podophylli.n resin ? The answer to this question depends on the color of the stool. If the motions are too light-colored mercurial purges are best. If, on the other hand, the motions are too dark then podophyllin is needed. For this clin- ical fac^t I can give no explanation. What is to bo done when the l)owels are freely open, or have been re- laxed by medicine, but where the tongue still continues furred ? Such cases Ave often meet with in gastric, biliary, or intestinal disturbance, and sometimes in the early convalescence from acute illness the tongue does not clean so quickly as it should — a sure sign of impaired digestion. Here again a mercurial preparation or podophyllin is useful, given with tincture of nux vomica and nitric acid. If the motions are too light then give a third or half a grain of grey powder, night and morning or three times a day; if the motions are too dark then give a small dose, say a thirtieth to twentieth of a grain of podophyllin resin, night and morning. Five drops each of tincture of nux vomica and dilute nitric aid thrice daily, will much promote the action of the mercury and the podophyllin. Sometimes the fur is dirty or brown, and the patient complains of a dis- agreeable bitter taste, especially in the morning, and this symptom is an additional indication for the foregoing treatment. Sometimes, however, in spite of this treatment, the disagreeable bitter taste persists in the morning, or even during the greater part of the day. Einsing the mouth with a weak solution of permanganate of potash will generally temporarily remove the annoyance. As the tongue cleans the fur recedes from the tip and edges and grad- ually becomes thinner, especially at its margin. With a little practice we can generally detect when the cleaning process is going on. After an acute illness, like typhoid fever, the tongue sometimes parts w^ith its fur in flakes, leaving clear smooth patches, especially at its back. This tongue denotes a slow convalescence. In typhoid fever this tongue may a second time become dry, with a return of the abdominal symp- toms. In a case like this turpentine is indicated in 10 to '^*0-minim doses every two or three hours. A dry tongue occurs most frequently in fever. The dryness first invades the tip and extends up the centre, spreading meanwhile lat- erally, till the whole tongue becomes dry. It grows moist in the inverse order of its invasion. A dry tongue generally indicates nervous depres- sion, often shown by delirium, usually of a low muttering kind. This nervous prostration is often dependent on want of sleep. Narcotics there- fore, like choral, bromide of potassium, or opium, by inducing sleep, soothe and strengthen the nervous system, and indirectly moisten the tongue. Opium is often more useful than bromide of potassium, or choral, for opium appears to have a greater effect on the tongue than either of the other drugs, probably inducing a moist condition by its direct action on the tongue and stomach as well as through its sleep-producing effect on the nervous system. Being frequently a sign of nervous depression, the dr}' tongue becomes also an indication for giving alcoholic stimulants. If, liowever, the nervous depression is due to wakefulness it is better, if possible, to secure refreshing sleep by a soporific, which, by soothing and strengthening the THE TONGUE. 3 nervous system, renders the tongue moist, promotes digestion and assim- ilation, and incites the patient to take more food. The two chief uses of alcohol are to assist digestion and to sustain the nervous system. Now sleep is the best restorative; hence fever patients who sleep well do not as a rule require stimulants. If sleep cannot be secured, or if in spite of sleep the tongue remains dry and the delirium persists, then alcohol is indicated, though the ]Hilse is a better guide. Usually, however, a patient with a dry tongue has a frequent, quick and compressible pulse calling for alcoholic stimulation. Whilst the tongue often affords evidence of the necessity for alcohol, sometimes it shows when it does harm, for if the tongue grows coated or drier, it is evident that the stimulant is doing mischief. The tongue in an aged person often readily becomes dry even in non- febrile illnesses; hence a dry tongue has not quite the same serious import as a dry tongue in a younger person. If with the dry tongue there is sleeplessness we must be careful how to give soporifics; for though in many cases a soporific is very beneficial, yet in old people sometimes it produces great excitement. If the dry tongue is associated with depression or exhaustion we not at all rarely find that alcohol increases the dryness and destroys the appetite; hence, at first, stimulants must be given to aged patients in a small quantity, the effect of which must be carefully Avatched. The color of the tongue is a useful sign. A broad, pale, flabby teeth- indented tongue, indicates anfemia with a relaxed condition of the tissues. It is met with in simple antemia, and chlorosis, and in some chronic diseases, as in Bright's disease, in which, in addition to anaemia, there is hydremia — an excess of water in the blood. This tongue always signifies the need for iron; and the astringent preparations in large doses, are, as a rule, far the best. A swollen teeth-indented tongue during a course of mercury, is one of the earliest signs of salivation. In diabetes, in severe and advanced cases, the tongue is often charac- teristic. It becomes smooth, glazed, shiny, beefy-looking, abnormally clean, often with a tendency to become dry, and sometimes quite dry. The tongue may be red, with prominent red papilla? most marked at the tip; and this red tongue too clean, too smooth, or, slighty furred points to ' ' the irritable tongue " and a coi-responding state of the stomach. It is met with in certain dyspeptic cases, sometimes in drunkards, and especially in phthisis when the intestines are ulcerated or there is tuljer- cular peritonitis. Small doses of arsenic, say one minim of the liquor, given shortly before food, will generally improve this tongue aiid the as- sociated conditions. It should be borne in mind that great irritation of the stomach or intestines or tubercular peritonitis may exist, unaccom- panied with this irritaljle tongue. In scarlet fever, a few days after its commencement and before the fever declines, this tongue is met with, and it continues during the eiwly part of convalescence. It is the very characteristic " strawberry tongue," always suggestive of scarlet fever. Its appearance arises from desquama- tion of the tongue, for the cuticle of the tongue being moist is more easily separated than the cuticle of the skin, hence the tongue desquamates some days before the skin. I need hardly say, that whilst the fever lasts, we should not treat the tongue with arsenic, though, if convalescence is te- dious and the tongue retains its strawberry cliaracter, arsenic and nitric acid will be found useful. THE PULSE. The " nervous tongue " is also very noteworthy: generally it is very slightly coated and covered with a slight froth, most marked close to the edge. We meet with it in persojis of nervous temperament, especially during the period of excitement, and in cases where the nervous system has been depressed by overwork, and worry. THE PULSE. With each contraction of the heart, a wave is sent through the arterial system, which, in its journey along the vessels, distends them, and this periodical distention, readily felt when the fingers are placed on an artery, is the pulse. Dr. Broadbent. however, denies that the pulse is due to distention of the artery, and ascribes it to the wave forcing or trying to force the vessel flattened by pressure of the finger back to its cylindrical form. The pulse, therefore, depends on the heart; and varies with the condition of the heart. It is influenced also by the condition of the vessels, the pulse varying according to the contracted or dilated condition of the arteries; moreover, it is also modified when the walls of the vessels become fibrous or calcareous. The pulse is an accurate index of the condition of the heart, and is therefore the most valuable guide in disease. The importance of the pulse is manifest when we consider that disease kills by arresting the heart. Whilst tlie heart beats there is life and hope. In many instances, the pulse gives the promptest signs of danger and the earliest indications for treatment. To illustrate this by an example, take the case of pneumonia, in which disease so long as the pulse continues good we have fair hopes of our patient. In some patients the heart fails early and the pulse soon reveals this condition; the patient fails, Ave say, at the heart. In other instances, the nervous system first gives way, shown by sleeplessness and muttering deli' :um: but though these symptoms cause anxiety, yet so long as the pulse remains good, we hope to save our patient. The anxiety we feel with regard to this nervous perturbation arises from its depressing effect on the heart; for if the patient does not sleep, this unrest, with the consequent dehrium, rapidly depresses and weakens the patient, and at last arrests the heart. The disease, therefore, may directly tell on the heart, or it may indirectly affect this organ by its depressing effect on another system. In any case it is the ultimate effect of the dis- ease on the heart that destroys life. It is hardly possible, therefore, to over- estimate the cardinal importance of the ptilse. The pulse-beats may be frequent or infrequent; slow or quick; small or large; compressible or incompressible; regular or irregular; or intermittent. By the frequency of the pulse we mean the number of beats in a given time. In a quick pulse each beat occupies less than the usual time, that is, each wave is of short duration relatively to the pause between the waves. When the volume of the pulse is greater than usttal. it is said to be large; or the volume may be less than usual, when it is said to be small. THE PULSE. 5 When the fingers can easily stop the pulse it is said to be compress- ible; when, on the other hand, it can be arrested only with difficulty or not at all, the pulse is said to be incompressible. The pulse may be irregular or intermittent. In an irregular pulse, succeeding beats differ in length, force, and character. In an intermit- tent pulse a beat is from time to time lost. The frequency of the healthy pulse varies; thus in some persons the normal pulse is 100, in others as low as 50 a minute, but these extremes are rare. Five conditions produce a frequent pulse: Fever, debility, excitement, hysteria, and cardiac disease, as in some cases of mitral disease; and the pulse in exophthalmic goitre is greatly accelerated. We seldom experi- ence difficulty in determining the cause of the accelerated pulse. In ex- citement the acceleration is not persistent and lasts only whilst the excit- ment continues. Hysteria may greatly and permanently accelerate the pulse to even 150 or 160 beats per minute. But in a grave illness, whether febrile or not, liysteria, if present before, generally passes away at unce, so that we may safely attribute the frequent pulse to the invasion of another and more serious disease. In fevers the pulse is generally accelerated in proportion to the eleva- tion of temperature, though the proportion between the pulse and tem- perature varies in different fevers. In scarlet fever, the pulse is more frequent than in typhoid fever with the same temperature, hence a fre- qvTent pulse is of less serious import in scarlet than in typhoid fever. The same elevation of temperature accelerates the pulse relatively much more in children than in adults. When a pulse is more frequent than the temperature will explain, it in- dicates cardiac weakness — the weakness being proportionate to the want of ratio between the temperature and pulse. In this way the pulse affords important information in prognosis and treatment. A pulse that day by day progressively increases in frequency, the tem- perature remaining the same, shows increasing cardiac weakness. In all febrile diseases, a pulse in adults over 120 is serious and indi- cates cardiac weakness, a pulse of 130 or 140 indicates great danger, and with a pulse at 160 the patient almost always dies. There is, however, a notable exception to this rule, in rheumatic fever. In estimating the value of the pulse in this disease, we must carefully ascertain whether rheumatic fever itself or pericarditis occasions the increased frequency. A pulse of 120, if due to the rheumatic fever, indicates great danger. In such a case the temperatu.re is high, 104 to 105, the patient is prostrate, the tongue pro1)ably dry, and sordes collect on the lips: a case like this often ends fatally, and when the pulse rises above 120, say to 130 or higher, the patient will pretty surely die. If pericarditis causes the frequent pulse, it becomes then of far less serious import, though the pulse may rise to 150 to 100 per minute. Not unfrequently we meet with such cases where, with but slight rheu- matic fever, severe pericarditis with perhaps extensive effusion sets in. The temperature is not greatly raised, rising only to 101° or 102" Fah., the tongue remains clean or but slightly coated. Now in a case of this kind, though the beats rise even to ICO and the pulse becomes very bad in other qualities, being very compressible or even small and compressible, yet we may reasonably expect the patient to recover. The heart's sub- stance too is generally inflamed; and this weakening of the heart's sub- b THE PULSE. stance, coupled with the mechunical embarrassment arising from the peri- cardial effusion, excites very hurried, even panting breathing. Thus attacked, the patient often looks very ghastly, the face l)ecomes dusky and distorted with the hideous risus sardonicus; yet if these symptoms can be clearly traced to the cardiac mischief, we may hold a well-grounded hope of the patient's recovery, even without the aid of large doses of alco- holic stimulants. In fact, acute pericarditis is rarely immediately fatal; it remotely destroys life only by leading to dilatation with valvular incom- petency, or to fatty degeneration of tne heart. Rheumatic fever with other complications generally ends favorably, no matter how serious the aspect of the patient. Pneumonia, even Avhen double and further complicated with extensive pericarditis, seldom de- stroys a patient. Again, an irregular pulse from mitral disease may be very frequent, 120, 130 or more, without indicating extreme danger. Sometimes in acute fever, as typhoid fever, though the temperature is high, the pulse remains normal throughout the attack; such a pulse certainly shows absence of cardiac weakness, and is of course a favorable sign. In chronic diseases a frequent pulse very generally indicates cardiac weakness. With increased frequency other signs of cardiac weakness are associated. The weakened heart propelling the blood less energetically than in health diminishes arterial tension and the pulse becomes soft and compressible. Relaxation of the arteries plays a part still more important in producing a compressible pulse; this condition permits the blood to pass with greater readiness into the veins, and so to lessen arterial tension. This relaxed condition of the arterioles, unless the heart is very weak, causes the pulse to be large and voluminous. At first one might erroneously suppose that this pulse indicated an energetic arterial circulation and a well-beating heart, but the compressibility soon corrects this error. It is therefore highly important always to test the compressibility of the pulse. If the heart becomes still more weak, and the arterioles still more relaxed, then each beat propels little blood into the arteries, and these allowing the blood to pass readily into the veins, the pulse becomes small as well as quick and compressible. Smallness of the pulse, therefore, indicates still greater weakness. When the pulse is very small it is said to be thready. When the heart is weakened its contraction often becomes sudden and sharp, rapidly reaching a maximum and rapidly declining, giving rise to a quick pulse, which thus often gives evidence of cardiac weakness, es- pecially when combined with the other and surer indications of this state. Therefore, in estimating the condition of the heart, we pay regard to the frequency, especially with reference to the temperature, to the com- pressibility, and to the size of the pulse. The more frequent, the more compressible, the smaller the pulse, the greater the cardiac weakness, and the more imminent the patient's danger, and the greater the need of car- diac stimulants. These pulse signs, therefore, both in febrile and non-febrile disease, are indications for giving cardiac stimulants, especially alcohol. These pidse signs, moreover, afford an accurate index of the effects of alcohol and of the amount required; for alcohol strengthens the debilitated heart, reduces the frequency of its beats, and contracts the vessels, and so heightens arterial tension and lessens the compressibility of the pulse. ISoth in acute and chronic affections cardiac weakness is, as a rule, ac- THE PULSE. T companied by evidence of general weakness, though this by no means is always the ease. We may be called to a patient with an acute illness who at first shows no evidence of Aveakness; his temperature is found to be from 102° to 103°; he easily turns over or sits up in bed; his voice is strong; his tongue moist and but little furred, per- haps even clean ; he takes his food and apparently digests it well. He sleeps well at night and is free from delirium; in fact the general appearance of the jjatient indicates no danger; but the pulse beats say 130 per minute, and it is small, compressible, and quick; and not due to excitement, as we ascertain by repeated observations; in fact this patient is in considerable danger. Are we to pay regard to the pulse or to the general condition ? Certainly to the warning pulse, for in a case like this, just described, serious symptoms will set in in a few days, and the patient will sink. The pulse here is a much prompter and surer danger-signal than the other symptoms. To take another instance: — A febrile patient when first seen presents no serious symptoms, but as the case goes on, and whilst the patient's general state remains apparently satisfactory, the pulse gradually increases in frequency and loses in force. Here again the pulse is the better guide, giving early indications of ap- proaching general prostration. We must, however, bear in mind that owing to individual joeculiarity, the pulse in some persons is easily made very frequent, and a moderate amount of fever may accelerate the pulse and make it 130 to over 150, without this frequency indicating any danger. Our previous knowledge of the patient will alone enable us to rightly estimate the frequency of the pulse in these cases. Again, we meet with cases of this kind: a patient suffers from a moderately severe attack of fever, and the j)ulse is by no means frequent in proportion to the fever, but it is very small and very compressible. In forming our prognosis are we to be guided by the small- ness and compressibility, or the frequency of the pulse ? In most cases certaiidy by the frequency. The size and compressibility of the pulse varies in health very considerably in different persons. In some persons in perfect health and capable of vigoi'ous exertion, we find a very small and compressible pulse — that might even be called thready. Such a pulse often occurs in various members of the same family. Now if such a person becomes febrile the pulse becomes more frequent, and without any cardiac weakness is of course small and compressible — and it is obvious if we dis- regarded frequency and paid attention only to the size and compressibility, we should be misled, both as regards prognosis and treatment. Of course our previous knowledge concerning the patient will, in many instances, save us from falling into error; but should we see the patient for the first time in a febrile attack, if we regarded the size and compressibility rather than the frequency, we should probably be misled. Of course if a pre- viously good pulse becomes small and compressible this change is significant, but it rarely happens that this change occurs without a corresponding increase in the pulse's frequency. ^ It is true that sometimes signs oi danger arise first in other organs, perhaps in the nervous system, in the form of sleeplessness and delirium, yet, as I have pointed out, so long as the pulse remains good we feel that our patient is comparatively safe. If the nervous perturbation neither spontaneously declines nor yields to treatment, the pulse will ultimately fail and the patient will sink. An infrequent pulse occurs in some cases of blood-poisoning, as in jaundice, uraemia, and in these cases the temperature is often subnormal. 8 THE PULSE. In some cases of pericarditis at its commencement the pulse jjreatly falls in frequency; and in rheumatic fever if the pulse changes suddenly and greatly in frequency, especially without corresponding cliange of temperature, we should expect the onset of pericarditis or other cardiac complications. An infrequent pulse is met with sometimes in fatty degeneration of the heart, and in aortic obstruction, in irritation of the vagus or its root, as in meningitis, cerebral tumors or compression. In defervescence, the frequency of the pulse may be much diminished. 'I'he size of the pulse varies in disease. It is often large at the com- mencement of fever, the ventricle acting strongly whilst the arterioles are relaxed. It is rendered larger too from arterial excitement. In aortic regurgitation, the pulse is very large during systole, but during diastole becomes very small from the great emptying of the arteries. The pulse is small in inanition owing to the small quantity of blood. It is small too in mitral obstruction, mitral regurgitant disease, and in aortic stenosis, also with cardiac debility. In an intennitfent pulse, an occasional beat is missed, the rhythm being otherwise regular. The omitted beat may occur frequently or unfre- quently, at an equal or irregular interval. It must be clearly understood that an bdenniUent pnlse is very different from an irregular jmlse, and has an altogether different significance. Some persons have a life-long intermittent pulse, but ordinarily, it does not occur till after middle age. It may be persistent or occasional; and when occasional only it is often due to an idiosyncrasy, and is caused by some article of food, as tea, perhaps green tea, smoking, or indigestion. Certain patients are unconscious of the inter- mission, and as Dr. Broadbent points out, this is especially the case when the intermission is habitual. Other persons are made very uncomfortable and nervous by a sensation as if the heart stopped or rolled over. The intermission often occurs in the artery only simultaneously with a weak beat of the heart. In most cases an intermittent heart is of no significance, and does not appear in any way to imperil life, though Dr. Broadbent states that a patient so affected succumbs more readily to any illness; when, however, associated with unequivocal evidence of heart disease intermittency is of more serious import. An irregular is of far more serious significance than an intermittent pulse. The pulse is irregular both in force and rhythm, succeeding beats differing in length, force, and character. It is generally due to mitral and rarely occurs in other forms of heart disease, though sometimes met with in great cardiac prostration, as in an acute febrile illness a few hours before death. It occurs too in fatty degeneration of the heart and in the first and second stage of meningitis. It may be called the mitral pulse, and generally indicates the need of digitalis, which in most instances lessens or removes the irregularity. Whilst an irregular pulse alm(^t always indicates mitral disease, it must be borne in mind that a perfectly regular pulse may accompany ex- tensive mitral disease; either obstructive or regurgitant, or both combined. Some hold that the occurrence of irregularity in mitral disease is a sign of deficient compensation, the compensation being insufficient to meet the obstruction to tlie cir- culation offered by the initnil disease. But were this view correct, how does it hap- pen that a few doses of digitalis will in many cases restore regidarity, and that with the discontinuance of the digitalis the irrregularity does not return V The irregular pulse is very rare in children under twelve, though the THE PULSE. y conditions which produce it in adults are well marked. If, say, between six and seven, mitral disease is established, and the child, though suffering from its effects lives till it is over twelve, the intermittency then becomes gradually developed. Though irregularity from mitral disease is rare in children, yet I have seen aconite, in half-drop doses repeated hourly, several times produce marked irregularity of the pulse. Irregularity of the pulse in children is common in the first and second stages of tubercular meningitis; in fact its existence is often a valuable diagnostic guide. In some cases of cere- bral disease, with Cheyne-Stokes breathing, the pulse is affected by the respirations; as these grow more and more shallow the pulse grows slower and slower, and then becomes frequent when the patient takes a deep sigh- ing breath. An irregular pulse may be due to much smoking, to venereal excess, and to tea-drinking. Hitherto I have referred to the dependence of the pulse exclusively or mainly on the condition of the heart. But the condition of the blood- vessels themselves also influences the pulse. Through the action of the vaso-motor nerves on the muscular coat of the arteries, the small blood-vessels undergo relaxation or contraction. When the vessels are relaxed the blood passes easily from the arteries to the veins, hence arterial tension is slight, and the pulse is soft and com- pressible, but owing to the relaxed state of the vessels it is also large. A relaxed condition of the arteries, therefore, produces a large, soft, com- pressible pulse. In most diseases, a relaxed condition of the arteries is associated with a weak heart. Sometimes, however, we have arterial relaxation with a normal heart, in which case the pulse is soft and compressible, but large. This pulse is met with in the early stage of some fevers. Arterial relaxation, or, in other words, diminished arterial tension, pro- duces dicrotism. In this pulse one of the normal secondary waves of oscil- lation becomes greatly exaggerated, so that it can be easily felt by the fin- ger. Indeed it may be so distinct that an inexperienced person mistaking it for the primary wave, might easily be led erroneously to think it indi- cated a cardiac contraction. Indeed a nurse has been known to make this mistake and thus to double the number of true pulsations. Dicrotism always indicates marked arterial relaxation, and often coincides with car- diac weakness. Some writers insist that this pulse indicates the use of alcohol, which should be pushed till the dicrotism ceases. JSTow, in this opinion I cannot concur, feeling convinced that in many cases with marked dicrotism no alcohol is needed. We must look rather to the frequency of the pulse, and if this shows the need for stimulation, then no doubt dicro- tism affords additional evidence in favor of giving alcohol. A dicrotous pulse is frequently met with in typhoid fever. I now come to the pulse of liigh arterial tension; here the vessels are much contracted, and then as the blood escapes with greater difficulty from the arteries into the veins, the arterial tension becomes high. In some of the following remarks, I largely borrow from Dr. Broadbent's valuable lec- tures on the pulse; and the pulse in question cannot be better described than in his own words: — "The artery, usually rather small but sometimes large, is hard and cord-like; it can be rolled under the finger and is easily traced in its course up the forearm, where it feels like another tendon lying amidst those in 10 THE PULSE. front of the wrist. It reminds one, as I have often said, of the vas defer- ens. " With the vessels in this condition the pulsation is often so slight that it might readily be mistaken for a weak pulse, but that its incompressi- bility prevents our falling into this error. It can be compressed only by using considerable foi'ce. It is, in fact, a sligbtly pulsatile pulse, for owing to the high arterial tension the vessel with each beat of the heart undergoes but little dilatation, hence the pulsation is indistinct. In addi- tion to being small the pulse is slow and hard. The following conditions give rise to arterial tension — 1. Degeneration of vessels. 2. Bri gilt's disease, especially the contracted kidney. 3. Gout, jaundice; lead-j)oisoning; ergot; gallic acid. 4. Affections of the nervous system. 5. The rigor of fevers. High arterial tension accompanies some forms of Bright's disease, oc- curring in the fatty, but especially in the acutely-inllamed and contracted kidney; in fact high arterial tension, and hypertrophy of the heart, asso- ciated with an increased quantity of urinary water containing a small quan- tity of albumen, enable us to diagnose the contracted form of Bright's disease. The albuminoid kidney is not associated with high arterial ten- sion. Although it is quite true that, in general, a soft compressible pulse of low tension accompanies a weakly acting heart, we meet with exceptions to this rule. For a patient prostrate, nay, even moribund, and conse- quently with a very feebly acting heart, may have a high tension pulse, the radial artery feeling hard and remaining to the touch like a firm cord, and is distinctly traceable some way up the forearm, even during diastole; whilst the temporal artery is also firm and resistant. This combination of a high tension, and therefore small and resistant pulse, with great cardiac and general weakness is, I think, more commonly seen in children, and is sometimes strongly marked in tubercular meningitis and capillary bron- chitis or broncho-pneumonia. It is obvious from these facts that we must not be led to give a too favorable opinion because of the high tension pulse. "When the frequency and the tension point in opposite directions we must rely on the frequency rather than the tension. In those cases where the heart is feeble, though the pulse shows high tension of the vessels, we can, from the feel of the pulse sometimes detect the condition of the heart, and thus estimate the true state of the patient, without having regard to the frequency of the pulse. The jiulse, even during diastole, feels hard and resistant, and we can trace it a long distance beyond the point where it is usually felt, but each systolic distention feels smaller than usually, even with high tension of the vessels; moreover, with slight jiressure, Ave can easily arrest the pulse-wave along the vessel. Here, perhaps, I may profitably introduce, though at the risk of some repetition, an account of the modifications the pulse undergoes in the stages of an acute illness. First I will refer to the characters of the pulse of a man previously -vngorous and robust smitten with an acute disease. The pulse differs in the separate stages of the fever, in the chill, the acme, and the decline. During the rigor or chill the arteries contract, and pro- duce a pulse of high arterial tension. The pulse is fi*equent. small, often verv small, hard, incompressible, and long, or as it is otherwise ternietl. THE PULSE. 11 slow. The chill over and the fever established, the arterioles relax and the pulse becomes larger; but as the heart is not yet weakened the pulse is large, full, and not easily compressed, — bounding as it is called. When the fever persists during many days and the patient grows weak, the pulse becomes softer, and more compressible, short (or quick) and often dicro- tous. In the case of a fever with great prostration the pulse is very frequent, small, short, very compressible, these characters becoming still more marked if the illness terminates fatrdly. If in the supposed case the patient, previously in weak health, is suddenly attacked with an acute ill- ness, the pulse from the first would assume this character. During the decline of the fever, especially when it ends abruptly, and accompanied by free sweating, the pulse, unless the patient has been greatly weakened, is large, very soft, easily compressed, dicrotous,and short — all the characters, indeed, of extreme arterial relaxation. Indeed in febrile diseases, even dur- ing their height, and in non-febrile diseases too, when tlie skin perspires freely, this is generally the character of the pulse. And this also is the pulse of acute rheumatism, because this disease is usually accompanied by sweating. Again, in a febrile disease, when by means of a drug we con- vert the dry into a moist skin, we find the pulse becomes soft, large, but compressible. In well-marked aortic regurgitation, the pulse is often characteristic. It is a pulse of extreme low tension. In this afl^ection the blood during diastole flows back into the ventricle, so that the arteries become more or less emptied of blood. The ventricle being hypertrophied and dilated, propels a larger quantity of blood with greater force than usual into the partially emptied arteries, and suddenly distends them. This explains most of the phenomena of the aortic regurgitant pulse. The pulse in great arterial relaxation (low tension) may simulate the pulse of aortic regurgitation, for great arterial relaxation by unduly facilitating the passage of blood from the arteries into the veins empties the arteries more than usual, and these unfilled vessels becoming suddenly distended by the normal contraction of the ventricle, especially during excitement, give to the finger some of the characters of an aortic regurgitant pulse, but in a much less marked degree. The pulse is somewhat sudden, and this quality, as is the case with aortic regurgitation, is accentuated by raising the arm above the level of the heart. Further, if the radial is at all visible with the limb dependent, this visibility becomes much more marked on raising the arm. Indeed it may become visible only on raising the arm. The pulse of aortic regurgitation is of two kinds, depending on the amount of regurgitation and the strength of the heart. The pulse in early cases gradually rises as usual till it reaches its acme, and suddenly collapses, the collapse being due to the regurgitation of the blood into the ventricle. In more advanced cases the pulse gives to the finger a sharp, quick stroke. The extreme suddenness in the commencement of the pulse, as Dr. Galabin observes, gives to the finger in marked cases the impression of a sudden blow or jar. This is the diagnostic quality of the pulse. In some cases, especially when the heart is weak, if several fingers are placed on the artery, and the pressure is graduated, the pulse feels at a certain degree of pressure as if a small ball or shot was puffed under each finger. This is the shotty pulse. 12 THE pulsp:. This cbiiractor of pulse can often be felt best by gT'asping the wrist with the Avhole hand, so as to feel both nlna and radial arteries; and these characters are also increased by raising the wrist high above the level of the heart, thereby enal)ling gravitation to assist the aortic regurgitation to empty the arteries. This quality of pulse is often oidy felt when a cer- tain degree of pressure is made on the artery, becoming much less by diminishing or increasing this pressure. In aortic regurgitation, as Dr. Corrigan points out, the pulse is often yisible in the more conspicuous arteries. In fairly nourished persons the radial pulse is not visible in health, but is often distinctly visible in healthy thin ]iersons. In aortic regurgitation it becomes far more visible at the wrist when the arm is raised over the head. This visible pulsation is probably due, as Corrigan points out, to the empty condition of the artery during diastole. The blood flows easily into the veins, and much is poured back by the aorta through the patent aortic orifice into the ventricle, hence the imperfectly filled arteries, on receiving the impact of the blood from each contraction, become widely dilated. Is visible pulsation diagnostic of aortic regurgitation ? Certainly not. Yisible arterial pulsatioi\ of the neck and head accompanies not only aortic regurgitation, but also fibroid degeneration of the vessels, great arterial relaxation, and high arterial tension. Mere excitement, by increasing the force of the heart's contraction, often in nervous persons produces visible carotid pulsation, and this phenomenon is more frequent in women. But this nervous pulsation rarely extends more than half way up the neck, and hence can generally be at once detected from the visible carotid pul- sation due to more serious causes. Visible pulsation of the whole length of the carotid to the lobe of the ear and of the temporal, and perhaps of the facial artery, is far more frequently due to aortic regurgitation than to high arterial tension or to the opposite condition, low arterial tension, or to degeneration of the arteries. Therefore extensive visible arterial j)ulsation in the neck, that is, when the pulsation can be distinctly seen as far as the back of the lobe of the ear, is strongly suggestive of aortic regurgitation; though I should mention that visible pulsation is well marked in pericarditis accompanied by carditis or pericardial effusion, con- ditions generally associated with marked arterial relaxation. Aortic regurgitation, degeneration of the arteries, and high arterial tension, will produce distinct visible pulsation not only of the carotid, but likewise of the brachial, radial, ulna, etc. These three conditions— aortic regurgitation, arterial degeneration, and high arterial tension — may be combined. Aortic regurgitation is es- pecially a disease of middle or advanced life; the endo-arteritis and endo- carditis producing aortic and arterial degeneration being due to age and strain from some laborious occupation. Ulie chronic inflammation often afl'ects the entire arterial system even to the smallest vessels, and by ren- dering them inelastic, and by narrowing the lumen of the smaller vessels friction is increased — a greater hindrance is ofliered to the passage of the blood, and the tension of the vessels rises. How can we distinguish between the visible brachial pulsation due to some simple arterial degeneration, and that due to simple aortic regurgita- tion ? In arterial degeneration the arteries become elongated and tortuous, easily visible in the brachial Just above the elbow. A tortuous pulse, therefore, always suggests arterial degeneration. Moreover, in arterial degeneration the arteries feel hard and cordy even when all blood is THE PULSE. 13 pressed out of them, and sometimes calcareous plates or atheromatous hardenings can be distinctly felt. A tortuous condition of the arteries, as of the bracliial, does not, however, always point to degeneration, for as Dr. Broadbent tells me in confirmation of my own experience, this tortuosity may be produced by high arterial tension, but says it occurs only when high arterial tension has endured for some time, and is not seen in the cases of high arterial tension accompanying acute Bright's disease. Long ago. Dr. Corrigan pointed out that raising the arm increased the visibility of the radial pulse in aortic regurgitation, and he used this fact to support his theory of the production of visible arterial pulsation in aortic regurgitation. This increased visibility of the radial pulse on raising the arm will not, however, enable us to diagnose aortic regurgita- tion, for in arterial degenei'ation the visible radial jDulse becomes decidedly more obvious in this position, though perliaps not so great in a degree as in well-marked aortic regurgitation. I may mention, that in children even with considerable aortic regurgitation the pulse is rarely visible. In many cases of advanced aortic regurgitation, when the observers ear is placed in the palm of the patient, raised above the level of the heart, each beat of the pulse is distinctly audible. Extreme arterial re- laxation without aortic regurgitation will produce this thud-like sound. It is probably due to the sudden distension of the relaxed arterial walls. In advanced cases a double murmur, too, may be produced by pressing the stethoscope on a large artery. This double murmur is heard best over the femoral, just at Poupart's ligament. The diastolic murmur is only audible with a certain degree of pressure, and is often quickly lost by any increase or diminution of it. The systolic murmur can, of course, be produced in health by pressure. It is the diastolic murmur which points to aortic regurgitation. In aortic regurgitation we often meet with the capillary pulse, first noticed by Quincke, who points out that it also sometimes occurs in health, and is best seen under the finger nails. It is not visible, I believe, in the skin of the forehead in healthy jiersons, but a slight pulsation some- times occurs in cases of very low arterial tension. I have seen it after a copious ha3morrhage. It is much more marked in aortic regurgitation, if the regurgitation itself is marked. "When the skin is reddened by irritation, the blush pulsates synchronously with the heart's beat. It is observed best in parts situated on a higher level than the heart, as the forehead and temporal region. With each diastole the skin becomes pale and reddens again with the systole. The explanation of these changes is obvious. During diastole the blood flows back into the ventricle, and the arteries become comparatively empty, those especially situated above *the cardiac level; hence during diastole the irritated skin grows pale, but the systole again fills the dilated vessels, and a blush diffuses itself over the skin. The capillary pulse is also visible in the extremities, but is much more marked when hand or foot is raised above the heart's level. This capillary pulse is well exemplified in the sole after reddening the skin by putting the foot in hot water or mustard and water. It is well brought out by wrinkling the skin, by strongly extending the foot and flexing the toes. The skin along the wrinkles becomes pale, but reddens with each systole. The pulsation is well marked even Avhen the foot rests below the heart's level, for the wrinkles in the skin press on the capilla- ries and empty them; but the systole is strong enough to refill them and 14 THE ruLSE. to redden the previously pale skin. As would be expected, pressure on the artery supplying the surface under observation arrests the visible capillary pulsation. Brunton describes a capillary pulsation synchronous with respiration as Avell as the heart's beats. He also suggests that there may be a third cause of the increased redness, namely, the peristaltic contraction of the arteries, and certainly one sees blanching and redness which are not de- j)endent on the heart or breathing occurring less frequently than the res- pirations and lasting longer than a respiration. The pulse of aortic obstruction, so long as the left ventricle remains imdegenerated, is slow, generally small, infrequent, and often hard. It is slow" and small, because even the hypertrophied ventricle can force the blood but slowly through the narrowed aortic orifice. It is infrequent because of the great length of each systole. If there is co-existing in- sufficiency, of coiirse the character of the pulse is much modified. When compensation fails, the pulse becomes small and compressible. In marked mitral obstructive disease, the pulse, when not irregular, is small and compressible. In arterial degeneration the vessels become elongated, tortuous, and the pulse-beats become very visible. The artery feels hard and like a cord, or like the vas deferens, and sometimes the calcareous plates may be felt even in the radial ratery at the wrist. This is a very significant condition, being evidence of senile decay of the arteries, a condition which leads to atrophy and degeneration of the organs. Many j^ersons are con- stitutionally much older than their years will warrant — they are, in fact, jH'ematurely old; while, on the other hand, many old people show few signs of old age. In individuals prematurely old the arteries are found in a state of degeneration, while in hale old peoi^le their arteries show few or no signs of degeneration; it has been well said that a man is as old as his arteries. The pulse in this condition is weak, and if the artery is rigid there may be no pulse. In a sphygmogram the line of ascent is slow, and less than normal. The top of the trace is rounded, and the line of descent is more gradual with less distinct secondary waves. The pulse may be delayed at a distance from the heart. This occurs in arterio-sclerosis (fibroid). If this condition is more marked on one side, or if the origin of the vessel as it arises from its trunk is narrowed, then the pulse beats later on this than on the opposite side. Aneurism of the aorta, too, often delays the pulse, and it may do this on one side more than the other, or on one side alone. In aneurism of the aorta in- fluencing the arteries of one arm only, the artery on this side can be felt to fill more slowly, and sometimes the distension of the artery is dis- tinctly divided into two parts, by two impulses almost continuous, the second being the less considerable. These effects are still better seen in a sphygmogram, where the line of ascent is delayed (and it may consist of two parts), the top of the trace is rounded and the waves in the line of descent are much less distinct. Dr. Augustus AValler describes a " recurrent pulsation in the radial artery." After compressing the radial pulse and completely obliterating it, he points out that in many cases the pulse still beats at the distal side of the fingers. The arterial wave Avhich produces the pulsation, he ex- jilains, comes from the ulna artery and travels through the radio-ulna inosculating arteries, and so reaches the radial artery. If the ulna artery i THE SKIN". 15 likewise is compressed this pulsation at .the distal side of the fingers ceases. -This " recurrent pulsation " is found generally in persons with relaxed arteries, in wiioni the heart beats fairly well; for a weak heart is unable to propel a wave from the ulnar to the radial artery. Dr. Wal- ler finds this recurrent pulse* twice as often in women as in men. THE SKIN. The condition of the skin affords us a series of instructive symp- toms; but in this j)lace I must restrict myself to speak only of a dr}', a moist, and a profusely wet and sodden skin. In most fevers with persistently high temperature the skin is hot, often pungently hot. Now, if we make the jDatient's skin comfortably moist, we shall considerably promote his comfort and well-being. Small often-repeated doses of tincture of aconite, or tartar emetic, or full doses re})eated every three hours of spirit of mindererus, will induce perspi- ration. Aconite and tart:ir emetic are the most efficient; in fevers with- out lung implication aconite is best, but in catarrh, bronchitis, or pneu- monia, tartar emetic is preferable. In many cases of diabetes and Bright's disease, it is very difficult to make the very dry skin perspire. The occurrence of sweating often suggests hints for treatment or assists the prognosis. The two chief causes of sweating are weakness and a fall in a febrile temperature, two causes often combined in the same person in exhaust- ing febrile disease, as in phthisis. In a non-febrile patient, the readiness to perspire often indicates weakness, and even measures its amount; thus, in depressed health, a person finds that exertion, even slight exertion, or any excitement, causes too free sweating. A trainer knows well that a trainee is in bad condition when he perspires too freely. Again, in exhausting diseases, and during the weakness of convales- cence, slight exertion, or even sleep, produces sweating, often profuse. It must, however, be borne in mind, that in sound health great differences in respect to the amount of sweating are met with in different individuals. A person returning from a residence in a hot climate where his skin has habitually acted very freely, finds on his return to a colder climate that, under slight exertion, he still continues to perspire very readily. Profuse sweating occurs during the sudden fall of a febrile tempera- ture, as in the sweating stage of ague, or during the fall of temperature after a rigor in pygemia. Phthisical jiatients, too, in whom there occurs a great diurnal variation of temperature, rising to 102° or higher at night and falling in the early morning hours, commonly undergo with this fall a drenching perspiration. The amount of sweating in febrile cases depends on the extent of the fall of temperature and the weakness of the patient; where the weakness is great, the sweating is often profuse, though the fall in the temperature may measure only two degrees or less. These two forms of perspiration when uncombined can be easily dis- criminated. Except in the case of pyaemia, there occurs in febrile dis- eases only once daily, a rise and a fall pf temperature, and consequently 16 THE SKIN. sweating when due to a fall in a febrile temperatnrc occurs only once daily, and chiefly early in the morning. In weakness, on the other hand, sweating breaks out at any hour, and many times a day, Ijeing occasioned by exertion, sleei), or excitement. In my experience, profuse sweating as a rule is more common and lasts longer in the convalescence from scarlet fever than in other acute febrile disease; hence during the recovery from scarlet fever, sudamin a in large crops often occur, greatly hastening desquamation, the skin some- times coming off in large patches. AVith the exception of rheumatic fever, profuse sweating at the com- mencement of an acute febrile disease, when the temperature remains permanently high, indicates great weakness and adds to the gravity of the prognosis; when besides profuse sweating, there is duskiness of the face, ears, and under the nails, showing weak circulation from enfeeblement of the heart, the serious aspect of the case is strengthened. Again, the feel of the skin shows the condition of a patient. With much perspira- tion, the skin soft and sodden, points to general weakness, a state accom- panied with a soft, perhaps large compressible pulse. These signs often indicate the need of alcoholic stimulants. TEMPERATURE OF HEALTH. 17 w o H w W H o t-l H W k; o H :^ < fed CO O t> Q 18 TEMPERATURE IN DISEASE. THE TEMPERATURE OF HEALTH. Within" certain narrow limits tlio body maintains its temperature in health, hut within these limits the temperature varies in a definite daily cycle. During the day the temperature remains about *.yS% but towards evening it begins to fall, and generally reaches its minimum at midnight. At this point it remains steady during a few hours, and then begins to rise, reaching its maxmium about 9 a.m. The diagram of the tempera- ture of a lad twelve years of age illustrates the daily course of the tempera- ture in health. The chart shows at once, that a temperature normal during the day would be abnormal at night, and vice ver.su. During the day, between 9 a.m. and 4 p.m., the healthy temperature is usually about 99°; thus it may not be higher than 98°, or it may rise to 99*5° Fall. Any rise above 99*5° constitutes fever. About four in the afternoon the evening fall begins, and at midnight the temperature is about 97°or even 96° Fah. Whilst in many robust adults the temiieratnro runs the same course as in children, yet with others the course is scmiewhat modified from that just described; thus the daily cycles are not so considerable, the maximum temperature and the evening fall being less. In persons under 25 the daily variation is 2° Fah. ; whilst the varia- tion in persons over 40 is more restricted, being often only 1° or even less. Jaeger finds that the daily variation is greater in persons whilst labor- ing than when at rest At rest he finds the average daily variation to be 2.2, whilst during hard physical work the daily variation amounts to 4.7. His experiments were made on soldiers, the observation being taken in the rectum. TEMPERATURE IN DISEASE. "Whilst any elevation of temperature above 99.5° indicates disease, it need hardly be pointed out that a normal temperature does not necessarily indicate health. Many diseases, both acute and chronic, during their whole courses are unattended with fever. Indeed, in some diseases, the temperature is depressed below the health standard. The daily course of fever varies Avitli the severity of the disease. In a mild attack there is a considerable diurnal variation, the temperature rising toward night and falling in the early morning hours; but in a severe attack of febrile illness the diurnal variation may be very slight or even absent, the temperature remaining persistently high. In private practice, as a rule, it is convenient to make but two daily observations, and these should be taken at such times as to obtain the highest and lowest temperature of the day. The likeliest times to give these minimum and maximum temperatures are 8 to 9 A. M. and 8 to 9 p. M. Though as a rule the morning temperature is lower than the evening, in rare cases the reverse happens. In some, especially in chronic cases, as in phthisis and sometimes in subacute rheumatism, the fever may last only for a few hours betAveen 8 a.m. and 8 p.m., and thus observations taken at these times, though the temperature is then normal, do not absolutely TEMPERATURE OF FEVER. 19 prove that the patient is fever-free. If only one observation daily is made it should be taken in the evening, as, even in the diseases so severe as scarlet fever, the morning temperature may be nearly normal through- out the attack, while the evening temperature may rise to 103°; hence a morning observation only would lead to a great mistake concerning the severity, and possibly the nature, of the illness. ABNORMAL ELEVATION OF TEMPERATURE, OR FEVER. Many diseases, contagious and inflammatory, are accompanied by a rise of temperature. It must be borne in mind that the same amount of disease produces in children a relatively higher temperature than in adults, and that there are, moreover, probably individual or family pecu- liarities apt to raise the temperature in disease beyond the ordinary standard. Some chronic diseases modify the fever, for in Bright's disease and diabetes an inflammation may produce little or no rise of temperature. The derangement of function in a febrile disease is largely often mainly due to the rise of temperature, which depresses the functions of the body, and if of much intensity or duration induces parenchymatous degeneration of the tissues, which likewise depresses function. The dan- gers, therefore, in a febrile disease are mainly dependent on the high temperature, and are in proportion to the amount of elevation; so that we take the degree of fever as a measure of the depressive effect of the disease. The danger from a high temperature may, of course, be aug- mented by other circumstances as the diarrhoea of typhoid fever. It may be said, perhaps, that the symptoms — the general weakness, the frequent, feeble pulse, the loss of appetite, and the delirium, are due to the elevation of the temperature; and this remark no doubt is true, for by treatment which tends to reduce the temperature to the normal standard we can abate or remove all these symptoms; and the abnormal elevation of temperature not only immediately depresses and weakens all the bodily functions, but in proportion to the height and duration of the fever it likewise produces degeneration of all the organs, and this degen- eration greatly weakens the activity of the organs. If the symptoms are till referable to the direct depressing effect of the fever temperature, and indirectly through the degeneration it produces, it would seem a plausible supposition that the height of the temperature should be an exact measure of the patient's danger. A little reflection will soon show that this is but partially true, for though, no doubt, most of the symptoms arise from the high temperature, it must be recollected that its depressing effect must greatly depend on the previous condition of an invaded organ; thus, if previous illness, excesses of any kind, or unhygienic conditions have al- ready depressed the organs, high temperature will inflict on them much graver mischief. If, for example, rheumatic fever has slightly damaged the heart, a febrile attack will considerably increase the dangers to the patient through failure by the heart. If intemperance has injured the nervous system a febrile disease will intensify the danger of delirium and 20 TEMPERATURE OF FEVER. depression of tlio nervous system. AVe estimate tlie resistive power of ouch organ by the severity of its symptoms in comparison with tlie lieight of the fever. Thus, if delirium is excessive, while the temperature is but slightly elevated, it shows that the nervous system has but little power to resist; and if the pulse becomes very frequent, small and compressible, it shows that the heart's resistance is but slight. If, on the other hand, with the fever severe nervous symptoms are slight, and the pulse, not very frequfent, is full, and not very comjiressible, then we conclude that the condition of the nervous centres and the heart is satisfactory and our prognosis is good. Therefore, in estimating the dangers of a febrile attack, we must re- gard not only the severity of the disease, as measured by the temperature and other depressing causes, but the resisting forces of the body. 'J he temperature largely measures the severity, but the power to resist fever is estimated only by careful attention to the condition of the different organs, especially the heart, the brain, and the stomach. To illustrate these remarks take two ordinary cases of typhoid fever. One patient with high temperature takes and digests his food fairly well ; he sleeps well, his heart is not much weakened, and yet, in spite of the high fever, or, in otlier words, the severity of the attack, he makes a good recovery. Another patient, with decidedly less fever, is troubled with sickness, sleeplessness, delirium, and weak heart, and so, though his attack as indicated by the temperature is not severe, yet he dies worn out. Again, take two cases of phthisis. One patient, in spite of consid- erable daily fever, eats, digests, and assimilates fairly well, and for the most part maintains his ground. Another patient, though his fever may be slight, and indeed sometimes even after it has become normal or below normal, the appetite, digestion, or assimilation being greatly impaired, slowly but surely wastes away. In certain rare cases, though the appetite is good and the digestion is apparently well performed, yet if assimilation is at fault the patient, in spite of plenty of food, wastes away, even in cases when the temperature has become normal. Hence in a case of phthisis, in addition to the fever and the appetite, we must note the weight, for in a case where plenty of food is ingested but assimilation is defective, the patient's weight is the sole measure of his progress. Does the course the temj)erature runs give evidence of the nature of the disease ? While, on the whole, this question must be answered in the negative, still it must be remembered that certain diseases generally have a somewhat characteristic temperature; indeed, in many cases of ague and pyaemia the temperature itself is diagnostic. The thermometer assists us in diagnosis in cases of the following kind : — A patient becomes ill, and the temperature is found raised above the healthy standard. This fact, especially if the temperature is high, makes it incumbent on the doctor to search carefully to discover its cause. To narrow the range of our instances, let us restrict our attention to the com- moner causes of fever. The fever may be due only to the acute contagious diseases, acute inflammation of some organ, rheumatism, gout, or to the diseases causing chronic fever. The doctor, we will suppose, has been called in on the first day of the attack, and his duty is carefully to inves- tigate whether the fever is due to inflammation of any organ. In most instances the symptoms and physical signs will enable him to arrive at a diagnosis, an attack of rheumatism or gout being so characteristic that he will detect either at once. If the fever cannot be thus accounted for. I TEMPERATUKE OF FEVER. 21 then lie probalDly has to deal with one of the acute specific diseases; its nature, however, cannot ordinarily he diagnosed with certainty till the characteristic rash appears. Still, even before the advent of the rash he may give a shrewd guess as to the nature of the illness. Thus, the patient may have been in the company of an infected person, or an acute contagious disease may prevail. Moreover, even before the appearance of the characteristic rash, the symptoms may suggest one of the acute specific diseases. Thus, sore-throat would point to scarlet fever; severe backache, headache and sore- throat to small-pox; coryza with cough to measles. Severe fever, ushered in by a severe rigoi*, with severe headache, and pain in the limbs, would suggest typhus; whilst dull frontal headache with diarrhoea, would strongly point to typhoid fever. The mode of onset of the fever, that is the more or less rapidity with which the temperature mounts, and the more or less elevation which it reaches, also assists the diagnosis; but this point will be more dwelt an presently. Having then in many cases a strong suspicion as to the nature of the attack, he must Avait for the rash to confirm or to correct his impression. If the second day passes with out the occurrence of a rash, the case in all probability is not one of scarlet fever; for the rash of this disease appears on the second day, being very rarely delayed longer, more frequently, indeed, occurring before the sec- ond day, sometimes even in twelve hours. If the third day lapses with- out a rash, he is not dealing with a case of small-pox, for this rash usually appears punctually on the third day. In measles, it is commonly said that the rash appears on the fourth day, but in many cases this statement is certainly erroneous, for the rash often appears on the first day of the fever, and I have seen it even precede the fever. In many instances, however, though there is no fever, the patient suffers from coryza and cough for three or four days; but these symptoms may not occur till the rash appears on the very day the temperature rises. This being so, it may, however, be fairly taken that if the fourth day passes without a rash, the case is not one of measles. If the fifth day passes without a rash, the case is not typhus, for typhus rash appears punctually on this day. The foregoing diseases being excluded, there is then left only typhoid fever, and one of the diseases producing chronic fever; and the diagnostic diffi- culty will lie between typhoid fever and acute tuberculosis, the other dis- eases causing chronic feve^ being, in many cases, easily detected. As the eruption of typhoid throughout the attack may be either alto- gether absent or be manifested by only a very few spots, which may possi- bly escape detection, we must in some cases diagnose this disease irre- spective of the rash. The rash, however, appears between the eighth and twelfth day, which makes the diagnosis certain. If we are led to exclude typhoid, then, as I have just said, we have probably to deal with a disease which causes chronic fever. The diagnosis of the disease referable to this head will be treated of when we speak of chronic fevers. I now give another instance of the diagnostic value of temperature. A patient is suddenly seized with severe pain on tlie side of the chest. The pain, shooting or stabbing in character, is intensified on coughing or deep breathing. This is the characteristic pain of pleurisy and of pleuro- dynia; — one an inflammatory disease, the other a non-inflammatory dis- ease — which is it ? A physical examination, it may be said, will at once discriminate one from the other. But suppose the doctor has been sum- moned at the very onset of the attack, when the signs are undeveloped, the pain on moving the chest is a symptom common to both diseases; 22 TEMPERATURE OF FEVER. no doubt con2,-li, present in pleuris}^ may be absent in pleurodynia; but pleurodynia may occur in a patient with slijjht catarrh of the bronchial tubes, and* one would not venture to base his distinction, Ijetween these diseases, simply on the presence or absence of cough. The thermometer alone solves the difficulty. If the attack is pleurisy, an inflammatory disease, there is fever (elevation of temperature), whereas if the attack is pleurodynia, a non-inflammatory disease, fever is absent. In studying the temperature of fever, we must notice the mode of its rise (initial period), its character whilst at its height, and in a lesser degree, as of less importance, its declination to the standard of health. The character of the rise often helps us to form an opinion of the nature of the illness. In most febrile diseases the temperature rapidly rises, reaches its acme in twelve to twenty-four hours. This rapid rise occurs in the fever of most inflammations, and of typhus, scarlet fever, measles, erysipelas, etc. Where the rise is sudden and rapid, the onset of the symptoms is equally sudden and accentuated, and the rise in the tempera- ture is generally accomjianied by chills or rigors; or, as in typhus and pneumonia, by a single severe rigor. This sudden and rapid rise, being common to so many attacks, is of little diagnostic use beyond serving to exclude those diseases in which the invasion is more gradual. On the other hand, in some diseases, the temperature rises more grad- ually and takes three or more days before it attains its maximum. This happens in most cases of tuberculosis and in almost all cases of typhoid fever, and sometimes in rheumatism and pleurisy. This gradual rise of temperature is therefore suggestive of the invasion of these diseases, and if there is no joint pain, the case is likely to prove either typhoid fever or tuberculosis, diseases which often closely simulate each other so closely at the commencement as to baffle the discrimination of the most experi- enced. As in diseases with slow invasion of the fever, the doctor is seldom summoned till the temperature has become well developed, he has not often the opportunity of ascertaining how it has comported itself at the beginning of the attack. Hence, at this stage, the temperature is seldom a serviceable guide; the mode of its rise must be estimated from the slow or quick onset of the symptoms. From the course the temperature runs during the time the fever is at its height, we learn much more than from the mode of its onset. At this juncture we must regard the height of the thermometer, the extent of the daily variations, and the duration of the fever. The height of the temperature with its daily variations measures the severity of the attack. The greater the daily variations the more favoraljle»tlie case. The high temperature, as we have seen, immediately and directly depresses all the functions, and further indirectly lowers them by producing degeneration of all the tissues; these effects of course being manifested in proportion to the height of the temperature. Hence they are far more marked in cases when the temperature all day keeps high, than in cases when, during many hours, the temperature is but little or not at all raised above the limits of. health. A temperature of 105° always marks a severe attack of any disease, especially if the diurnal variation is very slight, A tempera- ture above 105° threatens considerable danger; and from a temperature of 107° patients, unless treated by cold baths, very seldom recover. A tem- perature of 110° to 112°, unless it yields to the application of cold, is very quickly fatal. In the early days of the clinical thermometer it was taught that in TEMPERATURE OF FEVER. 23 some diseases, as in typhoid, tlie temperature always readied a charac- teristic heiglit, so that in a given case, if by the fourth day the temperature failed to reach 103.5° Fall, the case was said to be not one of typhoid fever. This absolute rule a more extended experience has shown to be erroneous. Typhoid and other fevers may run their course with any tem- perature above the normal standard. Some writers, indeed, go so far as to maintain that typhoid fever may exist without any abnormal tempera- ture, and if typhoid, they say, why not other "fevers"? Still it must be admitted that the temperature is a serviceable guide in the discrimina- tion of diseases. For example, in the majority of cases of typhus and typhoid fever, measles and inflammations, the temperature reaches 103'^, and certainly if the temperature never exceeds lOl"" then probably the case is not typhoid, typhus, scarlet fever, measles, nor any important acute inflammation. Sometimes the thermometer greatly assists us in discrimi- nating measles and scarlet fever from German measles (rotheln). Thus, in German measles, the patient often complains of sore throat, and some- times its rash is so like the rash of scarlet fever, and sometimes so like the rash of measles, that simply by the aspect it is difficult or impossible to distinguish them. In this dilemma the temperature, though not an absolute proof, affords strong presumptive evidence; thus in German measles the temperature generally is scarcely or very slightly raised, not higher than 100° or 101°, Avhilst in measles and in scarlet fever, in the great majority of cases, the temperature runs higher than this. The course of the temperature wdien at its height indicates, as I have said, not only the severity of the attack, but also helps us likcAvise to dis- tinguish its duration. If the te^uperature is high, and the daily variations are slight or non-existent, a severe attack threatens, sure to persist longer than a case with considerable daily falls in the temperature. The infor- mation thus obtained is especially instructive in typhoid fever, for if dur- ing the second week there are daily great variations, we have reason to hope that the disease may terminate, possibly on the fifteenth, though more probably on the twentieth day; but if during the second week the daily variations are but slight, then the fever will probably last twenty- five or thirty days. When the temperature has remained persistently high, the occurrence of morning falls shows the beginning of the decline of the disease. The duration of tlie fever helps us to detect the nature of the disease; and indeed in obscure cases it often greatly aids the diagnosis. In most inflammations, in scarlet fever, in measles, the fever usually passes away by the fifth or tenth day, and in typhus on the fourteenth or fifteenth day. If the fever persists beyond this time it is fair to conclude that we have not to deal with one of these diseases; but as, in the majority of instances, they are easily diagnosed early in their course, it is evident that in such cases the duration oi^ the fever is of little practical use; but by enabling us to discriminate between typhoid and tuberculosis and Ijetween the diseases causing chronic fever, the duration of the fever does give us very trustworthy and important evidence. In some cases of typhoid fever, the symptoms are not sufficiently marked to enable the doctor to decide whether the case is one of typhoid fever, tuberculosis, or phthisis. If the fever goes on beyond thirty days then probably the patient sutlers from consumption; and each additional day of fever strengthens this conclusion. In most cases of phthisis, before the thirtieth day, the lungs or other organs will, it is true, gener- 24 CHRONIC FEVER. ally manifest the nature of the ilhiess; hut not unfrequently the fever of consumption may persist thirty days or more without the concurrence of any characteristic physical signs or symptoms of its existence, AVhen I come to speak of chronic fever I shall point out with more particularity that sometimes the thermometer will enable us to detect consum})tion earlier than by the combined aid of the symptoms and the physical signs. Any sudden and considerable temperature variation generally fore- bodes some complication; and a sudden and considerable rise, always. A sudden and considerable fall may, of course, indicate the natural ter- mination of the attack, for in many diseases the temperature falls very rapidly; in pneumonia notably, it is not uncommon for the temperature in twelve hours to suljside from 105° to the normal standard. A sudden and marked rise in the course of a disease foretells the onset of some inflammatory complication. On the other hand, it is important to bear in mind that an inflammatory onset, interposed in the course of a febrile disease, may not heighten the existing temperature; hence the fact of the temperature running the ordinary course pertaining to the original attack, does not preclude the necessity for close watching, lest an inflammatory complication should supervene. Thus, an attack of pneu- monia or of pleurisy may leave the temperature of pre-existing fever un- affected. It is important to recollect that, as a rule, the onset of pericar- ditis in acute rheumatism does not increase the fever. This is hardly to be wondered at, seeing that when a fresh joint becomes implicated the temperature does not alter, and inflammation of the pericardium may be regarded as analogous to inflammation of a joint. A sudden and considerable fall, if not due to the natural termination of the illness, means sudden collapse. It is oftenest met with in typhoid fever, and it means haemorrhage into the bowels, or perforation of the intestine. It must, however, be recollect(3d that each week in typhoid fever a great morning fall often occurs. A fall equal to that due to ligemorrhage or perforation, may occu-r at any time, but the fall with these accidents is more persistent, and is always accompanied by the symptoms of collapse. A sudden great fall with collapse and without tenderness of the abdomen, is always very ominous of haemorrhage into the bowel. This ligemorrhage, though considerable, may yet be retained for some hours in the intestines. CHEOXIC FEVEK. In some diseases fever may persist for weeks or months, and by its very duration helj) the diagnosis. It is true that in most cases, whilst the fever has lasted only a short time, perhaps only a few days, the other symptoms reveal the nature of the disease; but not unfrequently the nature of the malady remains for a long time obscure, and then the per- sistence of the fever is an important help to the diagnosis. Between acute and chronic fever there is no sharp line of demarcation. Certain acute diseases, for instance, typhoid fever and pleurisy, may each run more than thirty days; whilst, on the other hand, febrile diseases, like deep-seated abscesses and consumption, which often continue several Aveeks or months, or even longer, may run a short course of only a fortnight or three weeks. CHRONIC FEVER. 25 Since most acute illnesses, even typhoid fever and pleurisy, which persist longer than others, come to an end, in the great majority of cases, before the thirtieth day, we may take that as the limit of acute fever. Chronic fever occurs in jjhthisis, abscess, syphilis, ague, rheumatism, in most cases of leucocythfemia, lymphadinosis, pernicious ansmia and chronic pyaemia, including malignant endocarditis. As in acute diseases, so in acute and subacute phthisis, the tem- perature is a fairly accurate measure of the activity of the disease. In other words, there occurs a daily elevation of temperature of the body, in most cases in which a formation of tubercle is taking place in any of its organs. This elevation is an index of the activity of the disease; the fluctuations of temperature indicating corresponding fluctuations in the rate of the disease. One exception, however, I must mention to the above general rule. In tubercular meningitis, it is by no means uncommon, though certainly it is not the rule, for the temperature to remain normal throughout the course of the attack ; or at all events during most of its later stages. In some cases, for a short period, the temperature is slightly elevated, and then becomes natural, or falls even below the normal point. In by far the greater number of instances the temperature is elevated, sometimes, indeed, mounting to 105° to 108° Fall. It has been asserted that, during acute miliary tuberculosis of the lungs, the temperature, in rare instances, may remain normal. AYith regard to this statement, I believe that the deposit of tubercle has gone on by very slight and scarcely appreciable increments; or has become obsolescent at the time the temperature was first taken, so that the fever stage was overlooked. It must be admitted that, in some very chronic cases of phthisis, pneumonia, the disease advances too slowly, and the deposit, at any one time, is too slight to be adequate to elevate the tem- jDcrature unless to a very small extent. Thus, we meet with cases in which, some time before death, the tem- perature was always natural, yet the post-mortem examination reveals much fibroid degeneration from old standing tubercle or catarrhal pneu- monia; and adjacent to the fibroid portions, in the otherwise healthy lung tissue, we see a few recent miliary tubercles easily counted, or a few small patches of recent tubercular pneumonia. Indeed, in these diseases, we meet with every degree of activity to which the temperature corresponds. In some cases the disease advances so slowly that the tem- perature is scarcely raised, and we should naturally expect so very slight an amount of morbid action would be insufficient to raise the tempera- ture appreciably. Where there is no elevation of the temperature, we may conclude that the progress of the disease is almost insignificant; although the patient is exposed to the lurking danger that, from some slight cause, this comparatively harmless condition may be aggravated into a severe and dangerous attack. The apparent exceptions to this statement can, I think, be ex^jlained in this way : — With phthisis, as with other causes of chronic fever where the disease goes on but slowly, it must be borne in mind that the fever may last only a few hours in the day, sometimes not more than three or four, sometimes only in the middle of the day, so that a morning and evening observation may miss the fever, and may lead to the erroneous conclusion that the patient was fever-free. 26 CIIEONIC FEVER. Another source of error arises from the mode of taking the tempera- ture. Phthisical patients are often very thin, and hence the bnlh of the thermometer, when pLaced in the axilla, instead of being embraced all round by the tissues, lies half exposed in a hollow cavity, and never ac- quires the temperature of the body. This source of error is, moreover, often coupled with another. When the patient is perhaps dressed, or has had his arms out of bed, and his axilla has become cooled, it would take half an hour or an hour before the skin of the exposed parts would recover its lost heat so as to mark the temperature of the body. Over and over again, in hospital practice, I have been told that the temperature was normal, or even below normal, but on taking the temperature under the tongue, or in the rectum, have found the patient suffering from several degrees of fever. In some cases, it must be admitted, there ajopears to be a dispropor- tion between the progress of the disease and the temperature. This dis- proportion occurs, I believe, only in cases of long standing, and when the disease has lasted a considerable time, perhaps it produces less eleva- tion than at first, the patient becoming accustomed to the disease, and, as in the case of medicines, it produces less constitutional effect. As the result of my experience, I am inclined to think that the same amount of disease in middle-aged and in elderly people produces less fever than in the young, and that less fever is produced toward the end of the dis- ease, when the patient's powers are greatly depressed. The temperature is a more accurate indication of the activity of tuber- culosis or of catarrhal pneumonia, than either the physical signs or the symptoms. Thus, only a considerable increase in the amount of disease can be detected by physical signs; and in disseminated tuberculosis, where the granulations are pretty equally scattered throughout the lungs, and, indeed, often through most of the organs of the body, there may be entire absence of physical signs. Thus, it is apparent that the physi- cal signs, even in very acute cases, only give ns evidence of the continu- ance of the disease after the lapse of a considerable interval: while it has been shown that in almost all cases there is an elevation of temperature during the formation of tubercle, and that this elevation being propor- tionate to the activity of the disease, the thermometer will, unerringly at any time, point out the continuance and the amount of disease, except indeed, in those very chronic cases where the amount of tuberculization or of catarrhal pneumonia is slight and almost insignificant. When it is thus borne in mind that only considerable deposits in the lungs can be detected by physical signs, while even a small amount will raise the temperature even considerably for some time, it becomes evident that the thermometer will give a far better estimate of the amount of mis- chief than the physical signs. Moreover, after the cessation of tubercu- losis or catarrhal pneumonia, consolidation from the fibroid lung remains, and from the physical signs it is impossible to tell the condition of such a lung, to tell whether disease is progressing or not; the temperature will answer the question for us. If the temperature is natural at all joeriods of the day, we may safely conclude after a few days that active disease has very nearly or entirely ceased. It must be recollected that the fever is a measure of the increase of the tuberculization, not of the damage already done. Thus the disease may cease to extend and the tem})erature become normal; but the ex- tensive consolidation of the lung may begin, and continue to soften and CHRONIC FEVER. 27 lead to cavities. Hence, because the fever ceases, and the formation of fresh tubercle of catarrhal pneumonia ceases, we must not conclude that the patient is free from danger, for the softening and suppuration may lead to fatal exhaustion. Observation of the temperature often saves us from error, and ena- bles us to form a correct judgment of the true condition of the patient. A patient with only a moderate amount of fever, say 102° to 108°, last- ing only a part of the day, has been losing weight and growing weaker. She goes to the country, her appetite and assimilative powers increase, she grows much heavier and stronger, and regains much of her lost color. On a physical examination of the chest, we detect no increase in the physical signs, but during the whole time the temperature has risen to its accustomed height, 102° to 103°, showing that the disease still pro- gresses, but that the improved appetite has more than obviated the waste from the fever. In other words, nutrition is in excess of waste. On the other hand, we must be careful not to pay too much heed to the temperature, nor to build our prognosis entirely on it. For it often happens that there is a marked disproportion between the general symp- toms and the degree of tuberculization, or the rate of formation of the products of catarrhal pneumonia. A patient, with very slow progressive phthisis and moderate fever, associated with the very slight physical signs which develop slowly, has a flagging appetite and he quickly wastes; or sometimes a good appetite, but assimilation is at fault, and so, in spite of plenty of nourishment, he progressively grows thinner and thijiner. Therefore, we must regard not only the temperature as a measure of the progress of the tuberculization, but must likewise take into consideration the patient's appetite and weight, the occurrence of complication, as diarrhoea from ulceration of the intestines, the presence of albumen in the urine from fatty kidiiey, and whether albuminoid de- generation has implicated the liver, spleen, or kidneys. Fibroid phthisis remains now to be considered. Tubercle, behaving as an irritant, induces increase of the connective tissue with formation of fibroid bands, which cause the lung to become tough and fibrous. This condition of lung often co-exists with progressive formation of tubercle. When the further progress of these two diseases is stayed this fibroid condition is left. This is the most common cause of a fibroid lung, but it may originate in a different way. The temperature in fibroid phtliisis varies. In some cases it is quite natural, or if the health is much depressed, it is even below normal. In those cases which go on to cure it is natural. The walls k.^ the cavities become dry, rhonchus and expecto- ration cease, the cavities slowly contract, and the patient recovers health and strength; but the induration, very obvious on a physical examina- tion, still remains. Now in a case like this, the temperature often be- comes of the greatest importance. A patient presents himself with a history of a previous attack of phthisis. We find marked evidences of consolidation of the apices of the lungs. The jDatient's health is good, his appetite and digestion vigorous. Are these physical signs simply due to his jirevious illness, or is the phthisis progressing? If his tem- perature remains for several days quite normal, we may conclude either that there is no progressive tuberculization, or that it is very small in amount ; as we shall shortly see, there may be probably a slight amount of catarrhal pneumonia, without a rise of temperature. In other cases of fibroid phthisis, even when the formation of tuber- 28 CHRONIC FEVER. cle hiis ceased, we may have a slight daily rise in the temperature to 100° or even 101°, due to the suppuration in the cavities. This suppuration can, of course, raise the temperature just like suppuration in an open discharging psoas, or other discharging abscess. Thepersistence of a slight amount of fever does not, therefore, con- clusively prove the continuance of the tuberculization. Nor, on the other hand, I think, can we possibly say that while the temperature is normal the tuberculization may not be in a very slow degree extending. Clinical experience shows us that a very small formation of tubercle or of catarrhal pneumonia may occur without a rise of temperature. We very often meet with mixed cases, where the upper part of the lung has become fibroid, while active disease goes on in the lower part. In cases like this the temperature is raised in proportion to the activity of the acute disease. If the disease progresses slowly, and raises the temperature to only 100° to 101° Fall., it is difficult to determine whether the fever indicates an extension of the tuberculization, or of catarrhal pneumonia, or is due to suppuration in the cavities. As in acute phthisis, so in chronic, with fibroid lung, we must be careful not to pay sole regard to the temperature. Thus the formation of tubercle ceases, and the temi^erature becomes normal; but before this comes to pass the health may become damaged beyond recovery, or the kidneys may become seriously implicated, or through lack of appetite and digestive power, the patient may wastef away and die; or the uncer- tain weather incidental to this country may irritate the cavities and keep up continuous suppuration, which drains away, exhausts the strength, and destroys the patient by j^roducing wide-spread albuminoid degen- eration. Therefore, in a case of fever-free phthisis, we must take into consider- ation the general condition as well as the temperature. When appetite, digestion, and assimilation are good, then the patient quickly regains strength and health. Therefore, in forming an ojDinion of a case, we must regard the temperature, the appetite, and the weight. The temperature in phthisis affords us still further guidance. A patient throws up a large quantity of blood from the lungs, and the grave questions arise, — is the haemorrhage due to the congestion which accompanies acute phthisis ? or is it independent of phthisis ? If the temperature is normal we may at once exclude acute phthisis; and if the temperature remains normal we conclude that the hemoptysis has not excited catarrhal pneumonia. Again, a patient having recovered from a previous attack of phthisis, which has left well-marked physical signs, spits a little blood. Does this show that he is again the subject of pro- gressive phthisis, or is the bleeding due to ulceration of the avails of an old cavity? Here the temperature, if normal, and continuing normal, enables us to conclude that the lia3moptysis does not depend on another attack of phthisis. The thermometer in many cases is of still more signal service in giv- ing early and significant warning. By its aid we can often diagnose phthisis, before we can detect any physical signs, and at a period when symptoms themselves are insufficient to justify a grave diagnosis. A patient suffers from chronic fever. What is the cause of it ? So far as we at present know chronic fever occurs only in tuberculosis, cat-arrhal pneumonia, large abscesses, rheumatism, ague, occasionally in syphilis, in some cases of leucocythgemia, in lymphadenoma, and in pernicious CHRONIC FP^VER. 29 anasmia and chronic pyaemia. The diagnosis of ague and rheumatism is rarely difficult, the characteristic symptoms in most cases rendering their identification quite easy. Large superficial abscesses j^resent no diffi- culty, but it may not be so easy to detect deep-seated abscesses; and in some cases the diagnosis is for a considerable time impossible. As a rule, however, they give more or less jDain, often to a considerable degree, in the neighborhood of the abscess or over the spine-, moreover, a tumor is generally detectable after the fever, if at all high, has lasted a few weeks. Local symptoms, too, as pain on movement, stiffness, lameness, etc., will, in most cases, point out the nature of the disease. Sometimes, however, deep-seated abdominal abscesses run a much more chronic course, the temperature assuming then the character so common in fibroid lung; thus the temperature rises to 101°, even perhaps to 102°, and daily mounts to this height for a few days, then becomes natural for a varia- ble time, but some cause, as over-exercise, once mor^ excites the fever, and the temperature again stands high for a week, a fortnight, or longer. It is very often difficult to determine the nature of the disease, so as to exclude phthisis. True, there are no pulmonary physical signs, but these may be absent in phthisis, whilst the local symptoms may be too few to justify the diagnosis of abscess. Having but a limited experience of deep-seated subacute abscesses I would wish the following remarks to be accepted with caution. In general there is pain in the abdomen, not constant, but brought on by slight walking; sometimes there are marked dyspeptic symptoms, amongst Avhich flatulence predominates. A slight daily rise of temperature continued for a considerable time, or running the irregular course just described, if accompanied by deep pain and tenderness in the abdomen, the lungs being free from evidences of disease, will, I am inclined to believe, justify the suspicion of a deep-seated subacute abscess. These rules at all events have enabled me to diagnose doubtful abscesses, when, unaided by the thermometer, their detection seemed impossible. I lean to the belief that, with these abdominal ab- scesses, the fever-free periods not unusually ]3ersist longer than in suba- cute phthisis ; moreover, the rise can sometimes be traced distinctly and repeatedly to exercise, a bout of fever, accompanied by an increase in the other symptoms, occurring after each undue exertion. When an abdomi- nal tumor is detectable by the hand, or when there are evidences of dis- eased spine, then, of course, the diagnosis is far more easy. Again, a large discharging sore, or a discharging psoas or iliac abscess, frequently produces a course of fever like that described under subacute and chronic phthisis. In some cases there is a slight daily elevation lasting for months, in other cases the abnormal temperature continues for only a few days, or lasts one or two weeks, and then for a short time falls again, and this alternation may be repeated for a considerable time. Here the diagnosis is easy, for there is a discharging sore with absence of pectoral physical signs or symptoms. In cases of constitutional syphilis with chronic fever, the diagnosis in many cases is more difficult, and, unfortunatch^ little of this subject is known at present. The temperature may be high, rising to 103° and 104° Fall, daily; the morning remissions are usually great, the tempera- ture often falling to 98°. In these respects sy2:)hilitic fever corresponds to moderately severe cases of phthisical fever, but distinct and easily recognizable constitutional symptoms generally set in concurrently with the fever. The disease may assume the rheumatic form; and thus the 30 CHRONIC fp:ver. diagnostic difficulty Avill lie. not between i)lithisis and syphilis, but be- tween simple acute rheumatism and syphilis. In some cases the diagno- sis has seemed impossible until, on the administration of iodide of potas- sium, the temperature at once became normal, or declined gradually, reaching the temperature of health in one or two weeks. Very large doses may be required. In syphilitic affection of the lung, the diagnosis may be impossible, though other manifestations of syphilis may suggest the correct diagno- sis, which becomes confirmed on the rapid improvement produced by large doses of potassium (iodide). Assuming the exclusion of the foregoing causes of fever, the question arises — How long must the elevation of temperature persist before we can w4th probability suspect j^hthisis, in cases free from physical signs or characteristic symptoms, as, for instance, haemoptysis ? From ten to twenty days, I think, each day facilitating and strengthening the diagno- sis. In the first few days the diagnosis is well-nigh impossible, but each successive day serves to exclude sources of error. Thus, on the second day, if the rise is due to scarlet fever, its characteristic rash ought to appear; if due to small-pox, the rash should apjiear on the tliird day; if in measles, about the fourth; and in typhus, on the fifth day. Before this time, if the rise is due to acute inflammation of the brain, lungs, kidney, etc., characteristic symptoms and physical signs will have set in. In most cases of typhoid fever the rose spots w^ill appear between the eighth and tenth day; and at this stage we may exclude most cases of simple inflammation, which usually decline before the tenth day, when the fever ceases. Thus, on the tenth day, or thereabouts, assuming, as we have said, the exclusion of the other causes of chronic fever, the diagnosis lies between tuberculosis and t^qihoid fever. In the early stages the discrimination of one from the other is difficult, and may in- deed be impossible. Each begins gradiially, and is not usually ushered in with chills, convulsions, or rigors; nor have we ordinarily to assist our judgment, distinctive symptoms, like the back and headache of small- ]30x, the sore-throat of scarlet fever, the coryza and cough in measles, before the advent of the characteristic rashes. It is true that in the be- ginning of many cases of typhoid fever, before the appearance of the rash, there is diarrhoea and headache; but though these symptoms point strongly to typhoid fever, yet they m;iy be present at the commencement of acute tuberculosis. Moreover, diarrhoea and even headache may be absent in typhoid fever. But by the tenth or the fifteenth day the diag- nosis in most cases becomes easy; still it must be admitted that now and then we encounter perplexing cases of typhoid fever, which render the diagnosis between it and tuberculosis or catarrhal pneumonia doubtful for a much longer time; the thirtieth day once passed, should the disease have remained so long undetermined, it is in all probability not typhoid fever, for this usually ceases either before or at this time. Yet it is well knoAvn that typhoid fever occasionally lasts six wrecks, or longer. In children, the diagnosis between typhoid fever and acute miliary tuber- culosis is often extremely difficult, the symptoms of typhoid being in some cases so ill-defined that many good observers refuse to consider them to denote typhoid fever, and call them simple continued fever of children. Many of these cases are probably acute tuberculosis, the de- posit ceasing, and the tubercles becoming obsolescent and harmless. Of course the diagnosis is difficult only when, in acute miliary tuberculosis CHRONIC FEVER. 31 and cutarrhal pneumonia, there are neither physical signs nor charac- teristic symptoms. Again, after typhoid fever, a period of fever may set in lasting six "weeks or two months, the temperature becoming almost natural, then daily rising higher and higher to 101'', 102°, even 103°, and after about four or five days again gradually falling, this course being often re- peated. Occurring after typhoid fever, such a temperature does not show lung disease. This condition may co-exist with a clean tongue, in- crease of appetite and weight, and a steady amendment of the health. It thus appears that the temperature alone may enable us to diagnose tubercle phthisis, in cases where the physical signs and symptoms are absent, or are too indefinite to assist the diagnosis. The following typical instances illustrate the usefulness of tlie ther- mometer in doubtful cases of phthisis : A patient is taken rather suddenly ill. His face is flushed, eyes bright, pulse quick. The temperature is very high. There is no headache, no delirium, no diarrhoea. So weak is he that he stays in bed. At the end of ten or fifteen days he remains much in the same plight, but has grown weaker. His tongue has become dry. There are no typhoid spots, no diarrhoea, and the stomach is not distended. He has neither cough nor expectoration, and there are no physical signs in the chest. For a month or five weeks he continues in the same state, when distinct physi- cal signs at the apices of the lungs appear, accompanied by expectoration, and possibly slight hasmoptysis. Soon he begins to improve, the fever grows daily less severe, his tongue becomes clean, appetite slowly returns, cough diminishes, and at last both cough and expectoration cease. All moist chest sounds disappear, and at the expiration of about two months the temperature becomes natural, strength returns, his weight increases, although he will always carry evidences of consolidation at the apices of his lungs. A woman, between 30 and 35 years of age, fails slightly in health, complains of slight weakness, is soon tired, but is never ill enough to be confined to bed. Her appetite is rather bad. There is a trifling cough, and perhai:)S on one or two occasions the ex- pectoration of a slight streak of bright-colored blood, so slight and so seldom repeated that it is hoped the blood may have come from the mouth or throat. There may be a strong family predisposition to phthisis. !No physical signs are apparent; yet the temperature, rising nightly to 101° or 102° Fall., declares the true nature of the disease, which, perhaps, in the course of some months, decided physical signs render too evident. How important is it to detect this early and slight stage of the disease! By means of the temperature we can diagnose tuberculosis, even when during the whole course of the disease there are no physical signs indicative of tubercular deposit in any of the organs of the body, and when the symptoms are quite inadequate to enable us to form such a di- agnosis. Thus, we commonly meet with cases of acute miliary tuberculo- sis in children, where, throughout the whole course of the disease, the only guiding symptom is iDreternatural heat of the body, except, perhaps, a small amount of sonorous or sub-mucous rhonchus, and yet after death most of the organs of the body are found studded with miliary tubercles. Again, we occasionally meet with patients, generally among children ten or twelve years old, who complain of pain in the head, and whose man- ner is peculiar, being semi-idiotic, in whom the temperature daily rises 32 DROPSY. considerably for weeks or months, and after death small masses of yellow tubercle, the size of a large pea or bean, are found embedded in the sub- stance of the brain, with sometimes miliary tubercles scattered through the thoracic and abdominal organs. ON DROPSY. Ix health, nutritive plasma escapes from the blood-vessels into the adjacent tissues, and is afterwards absorbed by the lymphatics and veins. This transfusion and absorption counterbalance each othei*, and hence only a moderate amount of fluid is found in the parenchymatous tis- sues. But if a disturbance arises in the balance between these two pro- cesses, the parenchymatous fluid increases, producing dropsy, or ana- sarca, a condition due either to too large a quantity of fluid transfusing through the blood-vessels, or to deficient absorption. Nutritive plasma passes from the blood-vessels by filtration, difl'usion, or secretive attrac- tion of the tissues for the fluids in the blood. Dropsy never probably happens through increased attraction of the tissues for the jDlasma, but generally on filtration. The amount of fluid escaping from the tissues by filtration depends on the difference between the pressure of fluid in the blood-vessels and in the parenchymatous tissues. In health the pressure of the fluid in the blood-vessels is higher than that of the fluid outside the capillaries, and hence a constant current of nutritive plasma flows through the blood-vessels to the tissues outside them. Most cases of general dropsy depend on hydremia, and this is pro- duced by diminished action of the kidneys, whereby the urine is greatly diminished in quantity, while the patient takes the same quantity of liquid into the system ; hence the excess of ingestion over that eliminated through the kidneys accumulates in the blood, and produces hydremia, and, as Bartels has pointed out, the amount of dropsy is for the most part in projDortion to the diminution of urine. The inaction of the kidneys may be j)roduced in three ways — by disease of the kidneys, as Bright's disease, especially the acute and fatty kind; by diminished arterial pres- sure in the glomeruli from general diminution of arterial pressure depend- ing on heart disease; and on retardation of the circulation through the kidneys from venous congestion due to tricuspid regurgitation. In those forms of Bright's disease, the fibroid or the albuminoid, where the quantity of urine is normal or even excessive, there is no dropsy, while in the acutely inflamed or fatty kidney, in both of which diseases the quantity of urine is often greatly lessened, the dropsy is often marked, and almost always occurs when the quantity of urine is notably dimin- ished, while it is absent in those cases where the secretion of urine is free. In all valvular affections of the heart, and in a weak heart, less blood is propelled into the arterial system, and consequently arterial tension is lowered. This is the result of emphysema, which hinders the passage of blood through the lungs. It is the result of mitral and of aortic affec- tions. To overcome the obstruction the heart undergoes compensatory hypertrophy, and if this is perfect then arterial tension is kept up, but if this is imperfect, or if the left ventricle after hypertrophy undergoes de- generation, then arterial tension immediately falls in the glomeruli as DROPSY. 83 well as in the body generally. Now the amount of water that filters through the walls of the vessels in the glomeruli depends on the differ- ence of lateral pressure inside and outside the blood-vessels. If arterial tension is much reduced, then less water filters through the vessels, and the water accumulates in the blood. But the quantity of urine dej^ends not only on the degree of arterial tension in the vessels of the glomeruli, but also on the rapidity of the circulation through the kidneys. If arterial tension is lowered then the rate of circulation is reduced. But general venous congestion from tri- cuspid regurgitation also lessens the rate of the circulation ; hence tricus- pid regurgitation in this way tends to lessen the secretion of urine and so to produce hydrasmia. How does hydra3mia produce dropsy ? The ques- tion canuot at present be satisfactorily answered, but it is often assumed that the volume of the blood being increased arterial pressure is aug- mented, hence more serous fluid filters into the parenchyma, and filtration is easier from watery than normal blood. Cohnheim finds that injecting water into the vessels of a dog will not cause dropsy unless the vessels themselves become altered, and he con- cludes that in anaemia and hydremia the vascular walls undergo change and so favor the escape of fluid into the connective tissue. Dropsy then is in pro])ortion to the amount of hydraemia, and the amount of water in the blood is generally dependent on the action of the kidneys. AVe meet, however, with cases that at first sight appear excep- tions to this statement, for we see patients troubled with extensive and progressive dropsy who pass two, three, or even four pints of urine daily; but it will generally be found that these patients are troubled with great thirst, and drink far more tlian they void through the kidneys or skin, and the excess of their drink over the quantity of urine accumulates in the blood, causing hydrsemia and dropsy. Are we right, however, in asserting with some writers that mere venous obstruction caniiot cause though it may favor dropsy, but that without some affection of the nervous system dropsy will not occur ? Thus, the ascending vena cava in dogs has been tied without producing dropsy of the posterior limbs, but on cutting the nerves of the sciatic plexus, dropsy came on immediately; and as the division of the nerves inside the spinal canal (that is before the vaso-motor nerves join them) does not produce dropsy, it is concluded that paralysis of the vaso-motor nerves is the cause of dropsy. (Kanvier.) Clinical facts, however, certainly prove that mere venous obstruction will cause dropsy. Cirrhosis of the liver, or a tumor pressing on the vena porta?, or coagulation in the vein as it enters the liver, will produce ascites. Are we to conclude that these dis- eases paralyze the vaso-motor nerves of the abdominal blood-vessels ? I think, then, we must admit that mere venous congestion may cause dropsy, but that paralysis of the vaso-motor nerves greatly favors dropsy. Is the venous congestion consequent on tricuspid regurgitation suffi- cient to cause dropsy, or is the dropsy chiefly due to hydraemia ? Chiefly to hydremia, for we meet with cases of extreme tricuspid regurgitation, with full pulsating jugulars, much lividity and dyspncea, and yet no dropsy, and it is found these patients pass a normal quantity of urine; but when the urine diminishes, dropsy sets in, and in proportion to the scantiness of the urine. Still, no doubt venous congestion from tricuspid rf.gnrgitation favors dropsy in other ways than by causing hydraemia, for distension of the right side of the heart, with general venous obstruction. 34 DROPSY. must lessen absorption by the veins and lymphatics, and in this way cause the parenchymatous fluid to accumulate. Kemedics may remove dropsy: — (i.) By diminishing lateral pressure on the walls of the blood-vessels, and so lessening transfusion from the blood-vessels, (ii.) Increasing absorption, (iii.) Both ways combined, (iv.) By increasing the lateral pressure in the blood-vessels of the glo- meruli and so increasing the quantity of urine, (v.) By removing those diseased conditions of the kidneys which hinder their secretion. Digitalis affords a good example of a remedy acting through several of the foregoing methods. By its action on the diseased heart it obvi- ates the effect of mitral disease; hence more blood is sent into the aorta. Arterial pressure is thus raised in all the organs, and amongst other parts in the glomeruli of the kidneys, and hence more urine is secreted, the blood is purged of its excess of water, and the dropsy is thus absorbed into the circulation, and quickly eliminated through the kidneys. But it also acts in other ways. By obviating tricuspid regurgitation, through its influence on the left side of the heart, digitalis lessens or removes passive congestion, diminishes blood-pressure, and consequently filtration, reduces the amount of transfusion from the blood-vessel, and j^revents further development of the dropsy. By obviating venous obstruction, it removes lymphatic obstruction, and thus favors absor2)tion by the lym- j)h:itics; hence the excess of liarenchymatous fluids is taken up by these vessels. Moreover, if there is much dropsy, on removing the congestion, the pressure of the fluids outside the blood-vessels very probably be- comes greater than the pressure in the vessels, and hence the fluids will flow into the blood-vessels. The water in the tissues is then brought back into the circulation, and eliminated by the kidneys. But digitalis also by its indirect influence acts on the kidneys. During tricuspid re- gurgitation the kidneys become congested, hampered, and inactive. Ee- moving general congestion by its effects on the heart, digitalis relieves the kidneys, and allows them to return to their natural state, and hence they quickly eliminate the excess of water in the blood, due to the ab- sorption of the drojjsical fluid. When all the water has been absorbed from the tissues into the blood, and eliminated by the kidneys, digitalis no longer causes an excessive flow of urine, as would happen if it acted directly on the kidneys. It may be urged that we have regarded the dropsy of tricuspid regur- gitation as in part due to heightened vascular tension through the great venous congestion, and that if digitalis increases arterial tension it should increase rather than diminish the dropsy; but it must be borne in mind that digitalis removes the tricuspid regurgitation and venous congestion by the same means that it causes more blood to be sent into the arterial system, and so heightens arterial tension. There is another form of dropsy needing descrijition, that due to anaemia. After severe loss of blood, or exhausting drains of albuminous fluid, as in diarrhoea or chronic dysentery, a patient often becomes very dropsical. A small amount of dropsy at the ankles also is common in other forms of ana?mia, as in chlorosis. How is this dropsy produced ? It cannot be explained satisfactorily by ascribing it to hydraemia ; for though the Avater is relatively increased to the amount of albumen and corpuscles, the total volume of the blood is diminished by hemorrhage, and there cannot, therefore, occur increased lateral pressure from increased volume of the blood, as occurs when water is retained in the system from dimin- EFFECTS OF COLD ON" THE BODY. 35 ished excretion from the kidneys; an increased pressure leading to in- creased transfusion through the capillaries into the parenchyma. If not due, then, to an absolute excess of water increasing the total amount of blood, how is the dropsy explained ? Is it due to the deficiency of red corpuscles or of albumen ? It is not due to deficiency of the red corpuscles; for in chlorosis, where the red corpuscles are greatly dimin- ished while the amount of albumen remains much the same, very little or no dropsy occurs, and it is in those cases only when the blood is greatly drained of albumen that extensive dropsy ensues. From Cohnheim's experiments it is assumed that in anaemia the vessels undergo change and permit fluid more easily to transude through the vessels. THE EFFECTS OF COLD ON THE BODY. Before treating separately of the various kinds of cold baths, I think it will save repetition, and j)rove otherwise useful, to make some j^re- iiminary remarks on the efl'ects of cold on the human body. These effects are various, according to the way cold is employed. Cold is a refrigerator, an aneesthetic, a tonic, an excitant, or a depressant. Cold applied to the surface of the body, either as the douche or cold bath, affects the system through its influence on the nerves, reflected on the skin, or to distant parts, and by abstracting heat. The application of cold withdraws heat from the body, and cools both the sujDcrficial and deep parts. The general cold bath will produce a very considerable reduction of, the heat of the surface to the extent even of 10° Fall, in the trunk, and even considerably lower in the extremities. The general cold bath might be supposed capable of reducing the heat of the body's surface for a considerable time; this, however, is not the case, for the skin of the trunk speedily becomes warm again, although for some hours afterward the extremities may remain cold, and the tem- perature in the axilla almost recovers itself in a few minutes, although the bather may have been immersed half an hour, or longer, in water at a temperature of 60°. Of course, it is not here maintained that heat is not abstracted from the body; but, as will be shown in another place, the loss is so raj^idly restored that the cold bath will not depress the skin's temperature in a healthy person for any notable time. Cold sponging, so often employed in fevers with such evident relief, exerts a very slight and transient influence on the heat of the body, as may be ascertained by aid of the thermometer; hence the sense of com- fort derived from the sponging cannot be ascribed wholly, or hardly in part, to its refrigerating influence. This relief may be due to the re- moval of impurities which perhaps irritate the skin, or annoy by their odor, and by mitigating the parched condition of the surface; for a skin hotli hot and dry is a source of much greater discomfort than a moist though even hotter skin. Sponging with tepid water, so as to restore moisture to the parched skin, gives marked comfort to the patient. The foregoing remarks apply only to the surface of the body; but the general cold bath will likewise reduce the temjierature of the inter- nal organs. This reduction, never very great, is restored to the deep 36 EFFECTS OF COLD ON THE BODY. even more quickly than to the superficial parts; so that, as might be inferred, the general cold bath is still less efficient as a refrigerator of the internal than of the superficial organs. In fever-free persons, there- fore, the general cold bath must rank very low as a refrigerator. It is, however, otherwise with the body of a jiatient whose tempera- ture is unnaturally raised with fever. The immersion of fever-stricken patients in the cold bath, or packing them with the cold sheet, will jiroduce a considerable and durable lowering of the temperature. Whether this reduction is eifected by abstraction of heat, or by prevent- ing its unnatural formation, it is impossible at present to decide. The application of cold, partly by its topical action, but chiefly through the vaso-motor system, first contracts the blood-vessels of the skin, which on discontinuing the cold dilate, and the surface becomes redder, warmer, and glowing. Moreover the vessels of distant and in- ternal parts are similarly affected, as experiments have shown in the case of the mesentery and the membranes of the brain (Schiiller, Frank). Winternitz maintains that he has experimentally proved that it is jios- sible to control the effect of cold and direct and localize its influence ; he finds that cold applied to the foot affects chiefly the inter-cranial circu- lation ; cold to the thigh, the pulmonary circulation ; and cold to the back, the circulation of the pituitary region. The moderate and brief application of cold not only heightens arterial tension, but likewise increases the frequency of the heart's action, and if this practice is continued daily, it increases the corpuscular richness of the blood, and the haemoglobin of the corpuscles, and it removes anemia. Cold, when judiciously employed, is well known to be a powerful tonic. A cold climate and cold bathing are tonic and bracing. The theory of the tonic action of cold may perhaps be stated thus : — During exposure to cold, the body's loss of heat, as tested by the thermometer, is by no means a measure of the quantity withdrawn. Many observers have shown that at such times increased combustion occurs, whereby much of the lost heat is compensated, and the temperature is maintained or soon restored. This increased oxydation of the tissues is demon- strated by the greatly increased quantity of carbonic acid thrown off by the lungs on exposure to cold. Now the most vigorous health is main- tained by a rapid construction and destruction of tissues, within certain bounds, provided these two processes are fairly balanced. On exposure to cold, the lungs absorb more oxygen, the tissues are more rapidly and freely oxydized, and thus the processes of destruction and reparation go on in larger measure. How is this eff'ected ? In the process of nutrition, apart from the nerves, we have three factors, the nutritive plasma, the tissues, and oxygen. When food is taken, digested, and introduced into the blood, both formation and de- struction of the nitrogenous tissues begin, formation being limited by destruction; and Avhen the destruction of tissues ceases, the further as- similation of the nutritive materials of the blood comes likewise to an end. These destructive changes take place in proportion to the amount of oxygen absorbed^ and when this gas is exhausted, many products of destruction remain only partially oxydized. further tissue disintegration ceases, and assimilation is suspended. (Parkes.) Under exposure to cold, oxygen being abundantly absorbed, the effete products in the blood are first consumed, thus purifying the blood, and rendering it fit to nourish the body; next, by its consuming action on the ;bffects of cold ois" the body. 37 tissues, oxygen promotes tlio cycle of changes just described, food is taken and assimilated, and the destruction and construction of the tissues rapidly go on, so creating great physical Angor. Thus it is that cold climates are invigorating. Applied locally, cold may act as a tonic (see Douche) ; but if too long continued, or excessive, it depresses; for, by contracting the vessels too sharply or too continuously, it lessens the supply of Ijlood to the tissues, and thereby diminishes their cell-growth and tissue change. Ijitense cold, applied for some minutes, will abolish sensation, and in this way be- comes an anaesthetic; and, if the cold is too long contiiuied, the part will die and become gangrenous. The sudden partial application of .cold may act reflexly as an excitant. A cold hand applied to the abdomen excites contractions in the parturient womb. Cold water smartly sprinkled on the face of a swooning person is a familiar way of restoring consciousness. The same treatment will help to establish breathhig in weak or apparently still-born children, or to recover persons over-dosed with chloroform, or narcotized with opium or tipple. The local application of cold may affect deep-seated vessels reflexly. Kossboch finds in his experiments on animals that the application of an ice-bag to the skin, as on the abdomen, affects the vessels of the trachea, the mucous membrane becoming first pale, followed soon after by slight redness, passing later into a blue-red tint, when a copious watery secre- tion ensues. Here, then, we have an instance of the induction of venous congestion by the local application of cold, and, as Brunton remarks, these experiments explain '* how readily a draught of cold air on some ]3art of the body may cause inflammation of the respiratory organs." Experiments on cold-blooded animals show how greatly temperature modifies the action of drugs on voluntary and cardiac muscle, on motor and secretory nerves, on the spinal cord, and probably on all tissues. As a rule poisons act more energetically on frogs in hot than in cold weather, a dose sufficient to produce great effect in hot weather being inoperative in cold. Brunton finds that great heat or great cold prevent the action of veratria on voluntary m-uscle; and I find heat greatly increases the susceptibility of the heart and muscle to veratria and modifies its action. Lucdisinger shows that temperature influences the motor nerves, for he finds that extremes of temperature abolish the action of guanidine on the motor nerves. Temperature also modifies secretion, probably by its influence on the secretory nerves, for pilocarpine acts less on animals whose temperature is reduced by placing them in a cold chamber (Brunton); and it is well known that this drug acts much more powerfully when the patient is in a warm bed or before a fire than if his skin is exposed to cold. Some poisons, like chloral, alcohol, etc., act in part by reducing the temperature of the body; by lessening combustion, and by disturbing the mechanism regulating the production and loss of heat, so that the temper- ature is more quickly raised or cooled by heat or cold (Brunton). In such cases, by maintaining a proper temperature of the body, may avert death. 38 COLD BATH. THE COLD BATH, INCLUDING SEA-BATHING. Cold water may be applied for the sake of its moisture, its tempera- ture, or both coujoined. If we require merely moisture, and temperature is of no consequence, tepid or warm water is both preferable and more agreeable. Cold water is generally employed to abstract heat from either the whole surface of the body, or from some particular ])art of it, or to induce general or local excitement and shock. Since the skin absorbs neither the water of the bath, whether it be warm or cold, nor any substances, soluble or insoluble, which may be added to the water, it follows that whatever may be the effect of baths it must be explained by their direct action on the skin. In speaking of the general cold bath, we shall speak mainly of cold sea- bathing, this being a far more powerful medicinal agent than the simple cold bath, although, indeed, their action is identical, the difference in their effects being one merely of degree: and, as we proceed, we shall point out how these differences affect the body. On entering a cold sea-bath, there is at first a sensation of depression, great or little, according to the coldness of the water. The skin becomes pale and shrivelled, and presents the familiar appearance "goose-skin," a condition produced by the contraction of the skin, and the consequent protrusion of the hair-roots and follicles. There is a general shivering, some blueness of the lips, nose, and extremities, considerable reduction of the temperature of the skin, quickened pulse, convulsive and sobbing breathing as the water rises to the chest, especially when the bath is en- tered slowly. The system soon becoming roused to meet and to resist the depressing effects of cold, in a few seconds a sensation of general exhilara- tion ensues. The skin becomes ruddy and glowing; tiie breathing full and easy; the pulse rather quick and strong; the spirits exalted, and the bather feels increased vigor, both of mind and body. If he quits the bath now, or before the period of exhilaration ceases, the buoyant condition endures more or less for the rest of the day, showing that the bath thus acts as a tonic to the system. On the other hand, if the bath is prolonged, depression again comes on. The bather feels cold, shivers, becomes blue and numb in the more exposed and smaller parts, whence, on account of their size, warmth is more readily withdrawn, and he is seized with a sensation of depression and wretchedness. Baths prolonged to this injudicious extent often pro- duce damaging results, which may continue for hours, and even days, sometimes, indeed, inflicting serious injury on the health, especially in a weak or growing person. For many hours after the bath he complains of general languor, with a repugnance to exercise, whether of body or mind; his temper is fretful and morose, the circulation feeble and languid, with sinking at the epigastrium, loss of appetite, chilliness of the surface, and cold extremities. It need scarcely be said that consequences like these are to be carefully avoided: yet rliese risks will often be encountered, unless the doctor gives specific and minute directions, so great is the prevailing ignorance and error on the subject of bathing. If the exposure in the cold bath is continued beyond this point, or if the cold is severe, its effects become more manifest; great depression and a sensation of utter misery set in, followed shortly by heaviness and drow- siness, Avliich deepen sometimes into coma, till a kinel of apoplectic state is COLD BATH. 39 readied, then asphyxia and death from paralysis of the muscles of respi- ration. Baths, then, on the one hand, judiciously employed, are very powerful tonics, while on the other, if unwisely used, they induce great depression of the bodily powers and produce serious mischief. The superiority of sea-baths has been placed beyond mere surmise; for direct experiment has established the fact that a sea-bath acts far more powerfully on tissue metamorphosis than the simple water-bath. While the sea-bath increases the process both of destruction and of construction of tissue, yet that of construction is in excess of that of destruction, with the effect of inducing not only increased vigor of the functions of the body but an actual aug- mentation of its weight. Sea-air, it is true, acts in the same way, so that it is difficult to determine to what extent improved health results from sea climate or sea- baths. The cold bath is almost universally employed for its tonic virtue. To obtain this wished-for result, the bath should be discontinued at the time it causes general exhilai'ation, for the system then appears to be roused into action to resist the depressing influence of cold, and if at this point the bath is discontinued tlie general healthful stimulation persists; for, whilst taking the bath, and probably for some time afterwards, oxidation of the tissues is increased, the blood is purified of effete products, and the process of construction and destruction of tissue, on which vigor of both mind and body depends, are intensified. Bathing therefore increases appetite, improves digestion and the assimi- lation of food. The bath, then, is a tonic in the strictest sense of the word. Used in accordance with the rules to be immediately laid down the good effect of the bath soon becomes apparent, and the patient gains in weight, his complexion becomes ruddy and clearer, his muscles, especially if he conjoins exercise with the baths, acquire firmness and strength, the mental debility arising from deficient nutrition of the nervous system speedily passes away, and he soon recovers mental and bodily vigor. The important question arises — IIow can we best obtain these invigor- ating effects ? Our object clearly is to secure the greatest possible amount of stimula- tion, and to ensure as long as possible the persistence of the increased vigor of nutrition. To obtain the greatest degree of stimulation we must duly apportion the temperature and duration of the bath to the patient's strength; and to ensure the continuance of nutritive vigor as long as pos- sible the patient should leave the bath at the climax of general exhilara- tion and stimulation, avoiding carefully the onset of the next stage, that of depression. The bather, if very weak, manifests but little functional energy to resist the depression from the cold. Indeed, if this is intense, the stage of stim- ulation may not come on at all, but, depressed from the first, the patient may so remain for a long time. Injudicious bathing often seriously injures, and even endangers the lives of weakly persons. The depressing effects of a cold bath are proportioned to its coldness and duration. The colder the water, the greater the depression it occa- sions — greater, too, when the water is in motion than Avhen at rest. More- over, the longer the period of immersion the greater is the degree of de- pression. When the patient is weak and prostrated by illness, the bath must not be too cold, nor continued too long, and the water should be at rest. 40 COLD EATir. Thus, wo must have regard to the strength of the patient, tlie temperature of the water, and the duration of the bath. • Here it will be convenient to consider in what respect sea- baths differ from simple water-baths, and to explain the tonic superiority of sea-baths. 1st. In sea-water various ingredients are held in solution. 2d. The variations in temperature of sea- water, in the varying seasons of the year, are much less than those of river-water. 3d. While the sea is always more or less in motion, river- water is com- paratively at rest. The salts in solution are supposed to act as invigorating stimulants to the skin, so that a patient unable to bathe in simple water without suffer- ing great depression can bathe in sea-water with great benefit. Moreover, as the sea's temperature never falls very low in winter, sea-bathing may often be continued late in the autumn, or even into the early winter months. The motion of the waves increases the depressing effects of the bath, but if the bather is strong enough, it also increases the ensuing reaction; and thus the commotion of the waves, while more bracing to the strong, is at the same time highly exhilarating. These guiding principles borne in mind, we shall be able under all cir- cumstances to give correct answers to the various questions paticmts may put to us concerning bathing. One most frequently asked is — How long shall the bath be continued ? Our answer must be regulated by the strength of the patient and the coldness of the water. If the water is cold, or the patient is very weak, we must at first forbid out-door sea-bathing and substitute a tepid bath, the temperature of which should be slowly reduced until that of the sea is reached. Then, if the day is fine and the sea calm, the bath may be taken in the open air. Though it may be considered safe to let the patient bathe in the sea, yet if he is very weak and unaccustomed to bath- ing, his stay there must be very brief; it Avill often suffice to allow tAVO or three waves to pass completely over him, when he should at once come ashore and wipe himself thoroughly dry, using plenty of friction to the skin, for which purpose Cash's towels are well adapted. With increasing strength, and becoming accustomed to the effects of the water, he may continue the bath for a longer time, but it is seldom advisable for a con- valescent to bathe longer than from five to ten minutes. Some patients, nay, even some healthy persons, can bear a sea-bath only every other day. Then as to the time of day best suited for bathing the greatest igno- rance prevails, before breakfast being currently believed to be the best time; yet this practice is not without risk even for the robust, who are often made ailing and fatigued by it for the rest of the day. Our object in using the bath, as we have before said, is to obtain pro- longed and energetic stimulation. We must therefore choose that time when the body is most refreshed, invigorated, and nourished. These con- ditions, it might be supposed, would co-exist in the early morning after a sound and refreshing sleep. It must be borne in mind, however, that before breakfast the body has undergone a fast of several hours, and is in want of food, without which the bodily functions may very readily become depressed. In fact, only a robust person is able to bear a sea-bath before breakfast. Thus theory and practice are both opposed to this period for bathing, both pointing to a time between breakfast and dinner as the most appro- priate. COLD BATH. 41 This leads us to the consideration of another question; namely, after a meal, how long a time should pass before a bath may be taken; and, after a bath, what time should pass before taking food ? Now cold bath- ing produces a great shock to the skin and system generally; and any powerful mental or bodily impression will check or even arrest for a time many of the functions, even if in active operation. This is the case with digestion. Any great excitement, it is well known, can stay this process more or less completely, and the cold bath is generally sufficient entirely to arrest it; therefore, before the bath, an adequate time should elapse, so as to permit the almost complete digestion of the breakfast, that is, an interval of about three hours. ISTor, for the reasons just pointed out, should the bath be taken immediately before a meal; otherwise, little or no gastric juice is secreted, and food lies half-digested in the stomach. And for a reason somewhat similar, the bather should not go into the water whilst under the influence of any great emotional excitement. The nervous force (on which there appears to be set a limit) being directed strongly in one channel, the bath will not produce nervous stimulation, so that the patient will feel languid, cold, shivering, and depressed. Obvi- ously, for the same reason, children must be coaxed, not dragged into the water against their will. In early life there is often much terror of bathing; and if, in spite of this, the child, while screaming with fright, is forcibly dragged into the sea, very ill effects may follow; for, missing the stage of stimulation, the child may remain, often for days, depressed and ill. Is there any age rendering sea-bathing dangerous, and to be prohibited ? It is generally accepted that young children, — say under two years of age, — being very impressionable, ought not to undergo the shock of a cold sea-bath. At the other extreme of life, when the enfeebled powers of the body are incapable of strong reaction, sea-bathing is inadmissible, for it is as well known that in old people the heat-forming force is much re- duced. Moreover, undue vascular excitement ma}' prove dangerous; the vessels in the aged, often brittle through degeneration, are in danger of giving way, and thus under any unusual strain causing apoplexy. The foregoing remarks imply that fatigue is a condition strongly ad- verse to cold bathing. Even if other conditions are favorable, it is seldom advisable for weakly persons to take a bath on the day following their arri- val at the sea-side. They should wait till all fatigue has passed away. Does pregnancy forbid sea-bathing ? If a woman has miscarried or aborted, or if of an excitable tempera- ment, baths may be expected to do harm; and in far advanced pregnancy a sea-bath may perhaps produce abortion. But under other circumstances, and with due regard to the conditions previously laid down, bathing will benefit both mother and child. Nor, if accustomed to the practice, need a woman discontinue bathing at the menstrual period, although it is always inadvisable to begin at such a time, since the shock may check or arrest the secretion, and thus induce perhaps many months of amenorrhoea. In the choice of coast, and the time of year, we must have regard to the condition of the patient. If not very weak, with the health only a little undermined, then a rugged coast, where the sea is rough and bois- terous, should be recommended. However, should the health be much broken, then a smooth sea is preferable, and, in a cold climate, the sum- mer is the only suitable time. Exercise taken while bathing soon induces fatigue and even exhaus- 42 COLD BATH. tion; whereas weakly patients must be cautioned to Le moderate in this respect. Another evil should be guarded against: on leaving the bath, a patient invigorated by it is in danger of taking too much exercise, fatigu- ing himself, and so counteracting the bath's good effect. The amount of exertion permitted must be strictly in accordance with the patient's condition, who, if very weak, should take only horse or carriage exercise. A course of sea-bathing sometimes causes the hair to fall off abundant- ly, naturally exciting much anxiety, especially in women. Their fears, however, may be quieted by the assurance of a rapid new growth. Other troubles may arise. Bathing sometimes induces constipation, more or less obstinate; but this need not lead to the discontinuance of the bath. The constipation should be removed by exercise, regulated diet, or, these fail- ing, by purgatives, Dyspepsia and diarrhoea also sometimes occur dur- ing sea-bathing. The bather should be discreet as to the hour of the bath, the time spent therein, and if, notwithstanding every care, dyspepsia or diarrhoea continues, the bath must be temporarily or permanently discon- tinued. In fact, sea-air alone will, in some constitutions, induce these disorders. Eestlessness at night is sometimes attributed to sea-bathing. Many people, no doiibt, find that living too near the sea-shore often produces broken and sleepless nights. On the shores of the Mediterranean, especi- ally along the Eiviera, this is notably the case. On removal inland, a mile or thereabouts, this restlessness vanishes: for instance, sleep unattainable at Cannes itself is secured at Cannet, a mile or so inland. Broken rest may often be traced to dietetic irregularities, or to late hours. A late and heavy meal will sometimes cause restlessness, whilst a good night will fol- low an early, light, and digestible repast. iSome patients mar their rest by taking stimulants shortly before bedtime, while, on the other hand, others cannot sleep without a " nightcap.'" A bather should plunge into the waves at once, and on no account stand undresssed and hesitating till he becomes cold and shivers. It is a com- mon and pernicious error to suppose that it is necessary to be well cooled down before plunging into the bath. If needful, a short, brisk walk should be taken just before the bath, to warm the surface and extremities. The effect of cold is, in proportion to its degree, to lessen the perspi- ration. A cold bath at first checks perspiration, but soon afterward this secretion becomes considerably augmented, and in a greater degree after sea than after simple water-bathing. Driven from the skin, the blood floAVS into and fills the internal organs, and the kidneys partaking of this congested state, probably explains the frequent and transitory occurrence of a small quantity of albumen in the urine, during the bath. The effects of cold baths on tissue change have already been pointed out, and the observations on this subject will be supplemented and con- firmed in those we have now to make relating to the influence of sea-baths on the constituents of the urine. Baths augment the quantity of urea or sul- phuric acid of the urine. Whether this increase exceeds the limits of the natural healthy variations, and whether the experiments are sufficiently nu- merous to prove it, has been called in question. It is not to lie expected that the tissue change would at once be greatly augmented, nor that the increase at any time would exceed the maximum amount of health; consequently the increase of urea in its turn would not exceed the maximum quantity excreted in health, lint surely, if for some time the excretion of urea is maintained at its maximum, this single fact would alone establish the in- THE SITZ-BATH. 43 fluence of baths, so far as they coukl be expected to operate, and would show that sea-bathing increases disintegration of the nitrogenous tissues. Beneke's observations lead to the same conclusion. AVhen food was taken, just sufficient to maintain the weight of the body at a fixed point, he found that baths immediately reduced the weight of the body, a loss certainly due to heightened disintegration of the tissues. But this increased consumption of the tissues being accompanied by increased appetite, and by increased assimilation, more food is taken, and his body gained in weight. Baths, it was said, increase the quantity of uric acid, although this is lessened by sea-air; but on this point observations are as yet insufficient. The urinary water is temporarily and often greatly increased, though the whole day's urine is lessened in quantity, probably owing to the sub- sequent excessive elimination by the skin. In Beneke's observation the intestinal secretions were also large, so some water may have escaped in this way. It is scarcely necessary to occupy much space with a narration of the cases likely to derive benefit from sed-bathing. In chronic illness at- tended by debility sea-bathing yields the best results; but it is especially useful to those recovering from acute diseases, and to persons whose health has been broken by over-work, by residence in towns, by sedentary employment, or by injurious excesses. It is a question of much impor- tance whether phthisical j^ersons should take sea-baths, and our answer must be qualified by the circumstances of the case. When the disease is chronic, with little or no elevation of temiperature (little or no fever), when, indeed, the case is one of fibroid degeneration of the lungs, with- out active formation of tubercle, sea-baths may be permitted, due regard being paid to the rules just laid down. When the cold bath or cold sponging cannot be borne, it is often useful vigorously to rub the body with a towel wrung out in tepid or cold water, or the naked patient may have a sheet wrung out with cold Avater thrown over his shoulders, and be rubbed down with the sheet. This plan is useful to prepare the way for the cold sponge-bath, and is applicable to the same class of cases, since it excites reaction and pro- duces tissue change and stimulates digestion ; like the sea-bath, it is a true tonic. It is useful, too, to relieve fatigue after a hard day's walk, etc. THE SITZ-BATH. The sitz-bath is largely and beneficially used in hydropathic institu- tions. The Avater should be between 60° and 80°, and the patient should sit in it from five to thirty minutes, once or twice a day. At first it causes contraction of the arterioles, not only of the immersed skin, but also of the intestinal vessels; hence more blood is sent to the head and upper extremities. After the bath is discontinued the reverse process sets in, more blood being sent to the abdominal organs, diminished sup- ply flowing to the brain. The sitz-bath greatly relieves fatigue and soothes an irritable restless state of the nervous system. It often les- sens headache, and regulates the bowels; it often augments the catame- nial flow by lessening the amount of blood in the brain, and is in many instances usefully employed to procure sleep. After the sitz-bath reac- tion should be promoted by friction or exercise. 44 ON PACKING WITH THE WET SHEET. ON PACKING WITH THE WET SHEET. Packixg Avitli the cold wet sheet, although at present seldom employed outside hydropathic establishments, is undoubtedly, in many diseases, a very efficacious treatment. Dr. Johnson, in his work on hydropathy, directs the patient to be placed on a mattress Avith a pillow to support his head; then, " upon the mattress, and extending over the pillow, two blankets are spread, and over this a sheet wrung out as dry as possible with cold water. The patient lies down on his back, perfectly unclotlied, with his head comfortably placed on the pillow; an attendant now approaches, say on the patient's left, and first puckering the blanket from the back of the head down to the back of the neck, reaches across his chest, seizes the right upper cor- ners of the blanket, and brings them tightly across under the chin to his own side (the left), and tucks them well and evenly under the left shoulder, where it joins the root of the neck, and under the point of the same shoulder. He now reaches across the body again, and brings over all the rest of the right sides of the blankets to the left side of the patient, and then proceeds to tuck them well and evenly under the left side, beginning where he left off, at the point of flie shoulder, and proceeding quite down to the heels. The patient is now entirely enveloped in one half of the blankets, and the attendant finishes the operation by passing over to the right side of the patient, and then proceeding to tuck the left sides of the blanket under the right side precisely in the same manner as we have seen him tuck the right sides of the blanket under the left side of the patient. The attendant, standing on the right side of the patient's leg, finally insin- uates his left hand under the backs of the ankles, lifts them up, and then "with his right hand turns back the lower ends of the blankets under t^e heels." The wet sheet should reach to the ankles, and " be wide enough to overlap in front of the body about eight or twelve inches; over the whole four or five blankets placed, and pressed down close to the sides." This pack is useful in specific fevers and acute inflammatory diseases. It has long been employed in scarlet fever, and should be used from the beginning and throughout its course. In moderate attacks it is sufficient to pack the patient from thirty to fifty minutes; but if the fever is very high, if the rash comes out slowly, imperfectly, and of a dull color, if the l^atient is restless and wandering, the packing must be continued an hour or longer, and be repeated three or four times a day. This treatment develops the rash, greatly reduces the fever, quiets the pulse, renders the skin moist and comfortable, and abates the restlessness and wandering. A short time after the application of the wet sheet a patient, previously restless and wandering, commonly falls into a quiet refreshing sleep, and awakes calm and free from delirium. Its influence on the pulse and tem- perature is striking; the pulse in a few hours falling fifteen to twenty beats in the minute; a repetition of the packing greatly reduces the fever. The packing is especially indicated on suppression or recession of the rash, when serious symjitoms are apt to arise; the cold sheet will then bring out a brilliant rash, followed, generally, by immediate improvement in the patient's condition. It has been recommended to dash two or three pailfuls of cold water over the patient after each packing. During the whole course of the fever a cold wet compress, renewed every three hours. COLD BATHS IN FEVERS. 45 slionld be worn round the throat; and if, on the decline of the fever, the tonsils remain large, or there is chronic inflammation of the fauces or larynx, this ajiplication, renewed less frequently, or applied only at night, should be continued till these morbid conditions cease. The compress should be composed of linen several times folded, and fastened round the throat by another piece of folded dry linen. Cold packing is beneficially employed in other fevers, and in acute inflammations, as measles, small- pox, pneumonia, pleurisy, rheumatism, and gout. In acute rheumatism, when the pain forbids the patient to be moved, the front of the body only should be packed, and a wet cold compress, renewed every two or three hours, should be wrapped round each of the painful joints. If the prejudices of the patient's friends prevent the use of the cold sheet, the body should be sponged with tepid or cold water several times a day, and if the perspiration is abundant and foul, soap should be used. In addition to sponging, the wet cold compress, as pre- viously described, should be applied to the painful joints. There can be no question of the superiority of this treatment over that of swathing the patient in flannel clothes, and covering him in blankets to make liim sweat. To avoid the supposed danger of catching cold, these woollen clothes are worn day after day, till, saturated Avitli putrefying perspira- tion, the stench sickens and de-appetizes the patient, and a crop of irri- tating miliary vesicles is engendered, which breaks the patient's sleep. In pneumonia some pack the chest only, and renew the cold appli- cations hourly, or even oftener; a mode of treatment which is said to remove the pain, quiet the pulse, calm the breathing, and reduce the fever. When, as often happens, the patient's friends object to the cold pack- ing through fear of " inflammation," or of '' turning the disease inwards," the sheet may be wrung out in tepid water, and by the time it is spread for the reception of the patient it will be sufficiently cooled to answer the purpose. A pedestrian, after great exertion, will find it an agreeable restorative, preventing stiffness and aching of the muscles, to strip and wrap himself in a dripping wet cold sheet, well rubbing himself afterwards; but if stiff- ness still remains, a few drops of tincture of arnica taken internally will remove it. Cold or tepid packing is useful in the summer diarrhoea of children. A daily cold wet pack is often a very useful application in chronic diarrhoea, like that often met with in persons coming from a tropical climate, and due probably to chronic catarrh of the intestinal mucous membrane. COLD BATHS IN FEVEES. The elaborate investigations regarding the action of cold applications in fevers, made during the last fifteen years in Germany, induce me to devote a separate chapter to this important subject. These investigations confirm the conclusions' of Currie and Jackson, and give precision to our knowledge concerning the employment and effects of cold to the surface. This treatment has been employed in typhus, typhoid, and scarlet fevers, measles, and other febrile diseases. More re- 46 COLD BATHS IX FEVERS. cently, Dr. Wilson Fox and others have cured patients suffering from the hyperpyrexia occasionally observed in rheumatic fever, a condition, owing to its sudden onset and rapid course, hitherto regarded as almost neces- sarily fatal. Many of the symptoms, and therefore tlie dangers, of fevers, depend in great measure on the elevation of the temperature. The effects of fever, whether specific or inflammatory, are due either to elevation of the temperature, to the specific cause of the fever, or to the inflammation. The s^^mptoms common to all fevers are due simply to the elevated tem- perature of the body, whilst the characteristic symptoms are due either to the specific poison, or to the inflammation. This increase of temperature affects the organs in a twofold manner; in the first place, it perverts, de- presses, or, if the rise is very high, abolishes function; and, in the sec- ond place, produces fatty degeneration, or, as it is termed, parenchymatous degeneration of all the tissues. That the common symptoms of fever, as headache, delirium, quick pulse, dry skin, and general weakness, are due to the heightened temperature is well shown by the effects of a treatment which will re- duce this abnormal temperature: that is, by the aid of the cold bath or quinia we lower the temperature to the normal standard, and then these pyrexial symptoms at once disappear. Fatty degeneration of the tissues sets in during the progress of a fever, especially when prolonged. This degeneration has been observed more particularly and fully in the liver, kidneys, heart, blood-vessels, and volun- tary muscles. This fatty degeneration is in all probability due to the fever, for the degree and extent of the changes correspond in amount to the degree and duration of the elevation of temperature; and similar changes occur when the temperature of an animal is raised by keeping it in a warm chamber. The cells of the liver and kidneys become cloudy, then granular, till the nucleus becomes obscured, and the entire cell dis- tended with granules, and, in the case of the liver, the cells contain an excess of fat, and ultimately many cells burst and perish. The muscular tissue of the heart and of the voluntary muscles becomes granular, then fatty, and in severe cases their fibres undergo extensive destruction. These effects of high temperature, the symptoms and the deteriorating changes, can obviously be combated only by means which either lower or 23revent the undue development of body-heat. Foremost amongst these means must rank cold baths. Employed early enough, the\" obviate the im- mediate depressing effect of the temperature on the tissues, and prevent the oncoming of parenclwmatous degeneration. Thus they reduce the frequen- cy of the pulse, strengthen the heart, and so avert danger from failure of the heart, and from hypostatic congestion. They tend likewise to prevent delirium, and to produce sound and refreshing sleep; to improve diges- tion and assimilation, and to promote the general nutrition of the body, and thus to ward off or to lessen the risk of bed-sores and exhausting suppuration. The period of convalescence, though some deny this, is shortened by promoting assimilation, and thus preventing parenchymatous degeneration. It is true that the specific poison of some fevers, as typhoid or t^^hus, will itself probably in some degree affect the heart, brain, and functions generally; but that the depression of the heart and brain is mainly due to the elevated temperature is shown by the great abatement of the symptoms referable to these organs when the temperature is reduced; though, indeed, it may be plausibly urged that without elevation of tern- i COLD BATHS IN FEVERS. 47 perature the specific poison cannot be formed, and kence anti-p_yrctic treatment will likewise obviate its depressing effects. Cold bathing is applied in varionsways, — by means of the general cold bath, affnsion, packing, sponging, and by the nse of ice. Brand, to whom the revival of this hydropathic treatment is chiefly due, has employed it largely in typhoid fever. In mild cases he uses cold' wet compresses, or frequent -washing with cold water, or repeated pack- ings in a cold wet sheet, or a warm bath gradually cooled. In severe cases he recommends affusion, the shower-bath, or the general cold bath. He generally places the patient in a sitz-bath, and pours water of 50° to 55° Fall, over his head and shoulders, for ten or fifteen minutes, wraps him afterwards unwiped in a sheet, and covers him over with a coverlet, and to his chest and stomach applies compresses wrung out of iced water; but if the patient complains of the cold he covers the feet more warmly or applies hot bottles to them. Hagenbach employs a general cold bath of 68° to 77° Fall, for ten or twenty minutes, and if there is much delirium, or coma, he at the same time pours cold water over the patient's head. He disapproves the fre- quent cold washings and packings, asserting that they abstract but little heat and that they fatigue the patient. The method employed by Ziemssen and Immerman is the most agreeable to the patient, and being equally efficient, it is the treatment most likely to be generally adopted. They immerse a patient in a bath of 95°, and in the course of twenty to thirty minutes gradually cool it to 60° Fah. by the addition of cold water. This Ixitli is agreeable to fever patients. These observers do not employ affusion, since the patient much dislikes it, nor cold compresses, since these do not affect the rectal temperature. Cold packings they find, however, do reduce the temperature of the rec- tum. For young children and old persons the severity of the application must be apportioned to the strength of the patient. Brand wraps a child in a wet sheet, and placing it on a table pours cold water over its head. For children and the aged Hagenbach employs for half an hour a warm bath, gradually cooled by the addition of cold water to 8Q° or 75° Fah. Weakly patients should be well rubbed on leaving the bath. Hagenbach adopts this treatment whenever the temperature rises above 102° Fah. , while Brand recommends it whenever the temperature mounts above 103° Fah. In private practice I find the assiduous application of cold cloths wrung out of ice-cold Avater more convenient than the use of the general cold bath. This plan, if effectually carried out, promptly reduces the tem- perature. Thus, by the method I am about to describe, I have seen the temperature in hyperpyrexia reduced in two or three hours from 107° to 101°, or even lower. Dip four napkins, or small towels, into iced water, and wring them nearly dry, so that they may not drip and wet the bed, then ajjply them one below the other from the chest downwards. As soon as the four cloths are disposed over the chest and abdomen, re-dip and re-wring the uppermost, then the second, third, and fourth, seriatim, then the first again, and so on continuously. Supplementary napkins to the head, thighs, and arms will of course still more quickly lower the temperature; and indeed, should be employed to a big and stout patient, since large quantities of heat have to be withdrawn through the bad conducting fatty layer beneath the skin. If the napkins are very frequentl}^ changed, this method is most efficacious, and is often highly agreeable to the patient. 48 COLD BATHS IN FEVERS. being in this respect preferable to the nsually very disagreeable general cold bath. In some instances, even after the discontinuance of the cold cloths the temperature steadily falls for several hours. The rcjietition of the processes must be regulated by the subsequent course of the fever. If in three or four hours the temperature again rises to 103°, Brand repeats the aifusion. In most cases he finds that six affusions are enough, and afterwards he applies cold cloths wrung out of water at 60° Fah. two or three times a day; these applications, provided the temperature does not rise higher tlian 100° Fah., being made smaller and applied less frequently as the case progresses. In very severe cases the affusion must be employed every two hours. When the patient is comatose and the foregoing treatment fails to restore consciousness, Brand applies a cold affusion of 45° Fah. to the head every half-hour. Dr. Stolir recommends the continuance of this treatment in typhoid even to the middle of the third week; but it maybe required longer, and here the thermometer is the test. Ziemssen and Immerman find that with their plan four or five baths are necessary the first day, and that subsequently two or three daily will suffice, the^ repetition, however, being regulated by the information afforded by the thermometer. They prescribe the bath at 6 a.m., and 1 to 3 P.M., and at 7 p.m. Ziemssen and Immerman found, as might be ex- pected, that in typhoid the degree of cooling and its duration differed according to the patient's age, and the severity of the case. Thus they find the usual reduction is 3.6° Fah. in children, and 2.5° Fah. in adults. In severe adults cases, however, the temperature falls only 1.8° Fah., and the effect of the bath is least evident in cases where the morning remission is slight. In severe infantile cases they fouiid that the temperature re- covers its former height in six hours, in adult cases of moderate severity in seven hours, and in severe adult cases in six hours and a half, and in cases with slight morning remissions in three hours. A single bath often effects a considerable reduction of the febrile temperature. Thus Mosler reduced the temperature in a case of typhoid to T° Fall., and the late Dr. "Wilson Fox, in one of his interesting cases of rheumatic hyperpyrexia, 13.4° Fah. Dr. Wilson Fox's exact and continuous observations on some cases of rheumatic hyperpyrexia add precision to our knowledge of the effects of cold baths. He has shown that the fall of temperature continues every six or more degrees, forty or fifty minutes after the discontinuance of the bath. It is important, therefore, to obserxe the temperature in the rec- tum while the patient is in the bath, and to remove him before the heat is too far reduced, lest too great a withdrawal of it might lead to collapse. This indeed appears sometimes to occur, for we read of cases becoming cvanotic, although German observers aver that this is not important, and advise in such a case the application of warm bottles to the extremities. Still I am convinced that it is important to avoid depressing, to this haz- ardous extent, as I have seen a child, suffering from scarlet fever, killed by an over energetic employment of cold. German observers show conclusively that this treatment greatly reduces the mortality of typhus and typhoid fever. Thus Brand treated 170 cases of typhus, and Bartels treated thirty cases of typhoid without a single death. The mortality of Hagenbach's typhus patients was five per cent, provided the cases were treated early, and Dr. Stohr reduced the mortality of his patients from thirty to six per cent., and the results he thinks COLD BATHS IN" FEVERS. 49 would have been still more favorable could he have treated some of his cases earlier. Liebermeister lessened his mortality from twenty-seven to eight per cent. Notwithstanding the enthusiastic laudation of the cold-bath treatment of fevers by German writers, this plan is not at present commonly employed in this country. If there is reason to hesitate whether we should treat the acute specific fevers or inflammatory fever by this heroic method, there can be no question respecting its great value in the treatment of hyperpyrexia. This most dangerous condition generally arises from rheumatic fever, and to it, no doubt, most of the fatal cases of rheumatism are attributable. It may occur, however, in the course of any fever; and may, indeed, seize a person apparently in perfect health. The first case of hyperpyrexia ever recorded occurred whilst I was resident officer at University College Hospital, and this was an instance of a sudden attack in a woman who had recovered from rheumatic fever, and was on the point of leaving the hospital apparently in fair health. On being called to her assistance I was surprised at the pungent burning heat of her skin, and to my aston- ishment found her temperature to be 110°, and a little later 111°. She died in eight hours. This phenomenon, so startling then when hyper- pyrexia was unheard of, has beeji noticed in hundreds of cases. Hyper- pyrexia not uncommonly attacks children just previously in apparent good health. I have often seen children in severe convulsions, and have found their rectal temperature 107° and 108° Fah. The hyperpyi-exia may have been due to the onset of an acute specific fever or of an acute inflammation, but as these children all died it was impossible to ascertain the cause of the onset of the fatal hyperpyrexia. Ordinarily, no doubt, hyperpyrexia occuijs in the course of a fever, and generally, perhaps, when the tempera- ture runs very high; but this by no means rarely comes on in rheumatic fever when the fever is moderate and the symptoms mild. In a typical case of hyperpyrexia the temperature rapidly rises, reaching in the course of a few hours 110°, 112°, or even higher. This severe fever perturbs and depresses the functions. At first the patient is restless and delirious, the delirium being either slight or so decided that he must be restrained. Sometimes before delirium the patient becomes blind. The delirium soon subsides, he becomes quite unconscious; the pulse, at first full and bound- ing, becomes exceedingly frequent and feeble; the respirations are much hurried; the skin is generally dry; but it may be drenched in sweat. Then the coma deepens, the breathing becomes more frequent and shallow, and in few hours the patient dies. Not a single case of hyperpyrexia, as far as I know, recovered till Dr. Wilson Fox first treated his cases with the cold bath. Since then this treatment has been largely employed, and with a larger measure of success; indeed, it is not an exaggeration to say that the majority of the cases thus treated have been saved. In my own practi<;e, in a considerable number of cases, this treatment has generally proved successful; and it is a source of great gratification to me that by means of Dr. Fox's treatment I have certainly saved many lives. In hospital we mainly use the general cold bath, but in private practice the application of iced-cold cloths in the way previously described will I believe, prove more convenient, pleasant, and safe. Several cold baths' are usually necessary, for after the reduction of the temperature, and con- sequent removal of the sjanptoms, the temperature generally rises again. It is interesting to note the passing away of the deadly symptoms as the temperature falls. The patient wakes out of his coma, and next his mind 4 50 AVAR.M BATH AND THE HOT BATH. becomes quite clear; his pulse falls and becomes stronger, and he passes quieklv from most imminent peril, from the very shadow of death, to his condition })revious to the onslaught of the hyi)erpyrexia. Though T have said several cold baths are generally needed completely to subdue the hyperpyrexia, yet in three cases after the first reduction of the tempera- ture the hyperpyrexia did not return, but the })atients forthwith passed at once from a condition of urgent danger into convalescence, without undergoing a single unfavorable symptom. This treatment not only reduces the excessive heat of fever, but it allays the nervous symptoms, limits the wasting, and Brand says it also prevents meteorism, bleeding, and lessens diarrhoea in typhoid. On the other hand, Hagenbach and Jurgensen assert that this treatment fails to lessen the meteorism and diarrhcjea in typhoid fever, and to reduce the size of the spleen and the dicrotism of the pulse. All observers agree that cold baths do not shorten the course of typhoid, typhus, and other acute specific fevers, but Brand asserts, while Hagenbach denies, that they shorten the stage of convalescence. This treatment, it is said, rarelv, if ever, induces either bronchitis or pneumonia, and the co-existence of either with a fever does not con- tra-indicate the use of cold baths. Liebermeister even says that hypo- static congestion or pneumonia afford no reason for suspending the baths — that, indeed, under their use, hypostatic pneumonia sometimes disappears. I have several times seen all the signs of double pneumonia arise after the bath; for instance, dulness. tubular breathing, bronchophony, and yet these patients have done well. LudAvig and Schroder find that this treatment of fevers greatly reduces the quantity of carbonic acid exhaled by the lungs and the solid constit- uents of the urine, and thus lessens the tissue change; a very singular fact, since cold baths, in health, have the very opposite effect. Dr. Fox observes that sometimes the rectal temperature rises a little directly the patient is 2:)laced in the bath; and Dr. Fiedler and Hartenstein point out that immediately after the bath the axillary is much lower than the rectal temperature, but half an hour aftei-wards this discrepancy is reversed, the rectal temperature becoming from 1° to 2° Fah. lower than the axil- lary, and so continuing during three-quarters of an hour. THE WAEM BATH AXD THE HOT BATH. The effects of heat on the body are, of course, for the most part, the opposite of cold. By surrounding the body with a temperature higher than its own, the destruction of the tissues by oxidation is considierably diminished. Moreover, experiment has shown that increased heat im- pedes or destroys the electric currents in the nerves, Avhence it may be fairly presumed that when subjected to this influence they are less able to conduct impressions either to or from the brain. These two considera- tions may perhaps account for the enfeebling influence on the body. The general warm bath, if not too hot, is at first highly pleasurable, but if unduly indulged in, throbbing at the heart and in the large vessels soon comes on, with beating in the head, and a sense of oppression and anxiety. These sensations, however, when perspiration breaks out. WARM BATH AND THE HOT BATH. 51 greatly diminish or altogether cease; but if the bath is continued too long, the foregoing uncomfortable sensations return, accompanied by great pros- tration, even to the extent of fainting; the pulse becomes greatly accelerated and enfeebled, while the temperature of the body rises very consider- ably, and, if the heat of the bath is great, may even reach 104° Fah., that is, to a severe fever height. Warm baths are employed in Bright's disease to increase the perspira- tion, so as to lessen the dropsy, and carry oif from the blood any dele- terious matter retained in it through the inaction of the kidneys. We must always bear in mind the purpose of the hot bath. It is too much the ]n-actice to employ hot baths in Bright's disease before the occur- rence either of dropsy or ura?mia. As the baths weaken the patient con- siderably, they increase ana?mia and so favor dropsy. They should only be employed when dropsy or urajmic symptoms are marked. Then, no doubt, they are often very serviceable by removing a large quantity of water from the blood, and lessening the hydra^mia on which the dropsy depends; but whilst of undoubted service, if often repeated, they induce much weakness. In my experience baths are greatly inferior to the plan of making incisions over each external malleolus in the way described in the section on acupuncture. This treatment reduces the dropsy much more speedily, and far more certainly. The hot bath is also used in nra?mia with the view of eliminating the urea through the skin. There can be little doubt that this treatment is serviceable in removing many of the cerebral manifestations of uraemia; but it is very questionable whether the baths so act by eliminating urea. It is, at best, doubtful whether the uraemic symptoms depend on the re- tention of urea in the blood; moreover, it is uncertain to what extent, if any, the bath can eliminate nitrogenous products through the skin. It is certain that in health very little, if any, iirea escapes by the skin, though it is probable that in some cases of Bright's disease urea is actually sepa- rated with the perspiration. Bartels records cases where crystals of urea covered the face, and by their accumulation on the beard gave it a f I'osted appearance. The general warm bath is of signal service either in simple or inflam- matory fever of children. If a child is not very weak, a bath night and morning, for a time varying from five to ten minutes, soothes and quiets, and often brings on refreshing sleep. In the febrile diseases of grown-up people, it is generally difficult to employ the general warm bath, but, in its stead, sponging with hot water often induces perspiration, calming at the same time the restlessness of the patient, and favoring sleep. The same means will soothe the restlessness of convalescence and induce sleep. In inflammatory affections warm or tepid baths are supposed to act by dilating the blood-vessels of the skin, and so withdrawing blood from the internal organs, including of course the inflamed organ, and thus by lessening the amount of blood in any given part the bath diminishes in- flammation. Further, by withdrawing blood from the brain the warm bath favors sleep. The warm bath mitigates or removes the pain of colic, renal, biliary, or otherwise. Whether its effects in relaxing spasm are induced through its soothing influence on the skin, or from weakness caused by the bath, is difficult to say; the bath certainly seems to ease the pain before any no- ticeable weakness is produced. In skin diseases of various kinds the general warm bath is invaluable. In psoriasis, eczema, icthyosis, urticaria, lichen. 52 WARM liATII AND THE HOT BATH. prurigo, and scabies, it may generally be employed Avith benefit. It is especially useful in the acute state of eczema and psoriasis. Rain or boiled water should be i^sed; but if tiiese are not available, the water should be made more soothing by the addition of small pieces of common Avashing soda, gelatin, bran, or potato-stai'ch. These baths allay inflam- mation and itching. The body must be dabbed dry with soft towels. If there is much itching, flannel should not be worn, .and scratching should be prohibited. It has been recommended to keep quiet a patient Avith se\'ere burns immersed for days in the warm bath; this treatment is said to ease pain, diminish suppuration, promote the healing process, and to lessen the con- traction of the cicatrix. As a means of oliA-iating the A'arious symptoms occurring at the change of life. Dr. Tilt recommends the general Avarm bath of 90° to 95° Fah. for an hour once a Aveek, so as to promote free perspiration. The hot sitz-bath is very useful in cystitis and dysmenorrhoea. It allays pain and the incessant desire to micturate and straining. If the symptoms are urgent it may be employed tAvo or three times a day from tAventy to thirty minutes in cystitis, and even longer in dysmenorrhoea. The local Avarm bath is used for a variety of purposes. It is hardly necessary to refer to the common household practice of putting the feet into hot Avater just before going to bed^ to induce general perspiration, and so relieve catarrh. The hot foot-bath, or the sitz-bath, is of great service Avhen the menstrual floAV is either deficient or absent. To this bath, mustard may be added Avith advantage: but, as the late Dr. Graves insisted, this stimulating bath should be used only at the menstrual period. Employed nightly, or night and morning, for six days, com- mencing one or tAvo days before the period begins, this mustard bath is a very useful auxiliary to other treatment, and often succeeds in establish- ing menstruation. The sitz-bath is often effectual Avlien, through expos- ure to cold, or from other circumstances, the menstrual floAv is suddenly stopped, to the patient's great annoyance and sulfering. Immersion in water as bot as can be borne is said to be very useful for sprains, in their earliest stage. Dr. Druitt points out that sponging the body with very hot water Avill for some hours diminish the excessive perspiration of phtbisis. Hot water to the legs and feet sometimes removes headache, and ac- cording to Dr. Graves relieves distressing palpitation. Sponging the face, temples, and neck with water, as hot as can be borne, often relieves the headache of influenza, catarrh, and other diseases. The immersion of the feet in hot water, with or Avithout mustard, will often arrest nose -bleeding. The vessels of the loAver extremities, and probably reflexly the vessels of the j^elvic organs, become much di- lated, and hence blood is Avithdrawn from the upper part of the body, and vascular pressure is lessened. Brine baths, as those at Droitwich, are very useful in chronic rheu- matism, rheumatoid arthritis, gout, and sciatica. A brine bath can be made by adding from twenty to thirty pounds of common salt to thirty gallons of Avater at a temperature of 100° Fah. The patient should take one daily from twenty minutes to half an hour's duration, gradually ex- tending the time to an hour. This produces no depression like a plain hot-water bath. On the contrary, it exhilarates. When only one or tAvo HOT-AIR AND VAPOR BATHS. 53 parts are affected or painful, as the ankle or wrist, I have found that the immersion of the parts in a saline bath gives much relief. Many chronic cases of sciatica are more effectually relieved by the bath than by any other treatment. The efficacy of the salt-bath is the more singular as the salt is the efficient constituent ; hot baths will not replace the saline baths; yet little or none of the salt being absorbed, this bath must exer- cise the topical influence action of salt on the skin. HOT-AIR AND VAPOR BATHS. The hot-air bath very generally succeeds in promoting free perspira- tion; but when it is difficult thus to establish a free flow of perspiration, the hot-air bath may be preceded by the general warm bath. Vapor-baths are used for the same purpose, and are less depressing than the general warm bath. Vapor and hot-air baths produce much less elevation of the temperature of the body, a circumstance which j)robably explains their difference in this respect. The usual hot-air bath, with the lamp or hot bricks, does not in most instances cause heat enough to induce copious sweating. Gas is more efficient, but it is difficult to handle unless with a special apjjaratus. The lamp-bath under a cape often induces very free sweating if the jiatient is strong enough to sit up. The copious perspiration thus in- duced is very efficacious in relieving ura^mic symptoms, and this treat- ment is much more efficient and less depressing than hydrogogue pur- gation. 54 SHOWER. DOUCHE, AND SPONGE UATHS. SHOWER, DOUCHE, AND SPONGE BATHS. The forcible impact of water upon the body, and the impression it makes on the nerves, or, to use the general expression, tlie shock it pro- duces, is sometimes very great, sufficient sometimes, even with strong and healthy jiersons, to produce considerable depression and languor, lasting hours and occasionally days. The shower-bath is a remedy not much used, patients ordinarily mani- festing great repugnance to it. The sponge- bath, or the local douche, may usefully supply its place. In the sponge-bath we have all the conditions of the common batli. Both are cleansing, bracing and invigorating; and the action of each is identical. The sponge-bath is often employed, not merely for its tonic effects, but for the sake of the shock it causes to the nervous system. In the treatment of laryngismus stridulus, cold sponging is more suc- cessful than anything else. The practice of confining little children thus affected in a warm close room, sousing them in warm baths several times a day, is positively injurious, and inevitably aggravates the severity and frequency of the crowing breathing. Cold sponging twice or thrice daily, according to the severity of the case, will scarcely ever fail to modify the disease, however severe the attack. So prompt is the relief of cold sponging that a child subject to hourly attacks dunng the day, and to ceaseless attacks at night, is frequently instantaneously delivered from them. At all events a decided improvement always occurs, and the in- tervals between the attacks are much prolonged; it rarely happens that the strident crowing resists this treatment more than two or three days. The mother should be directed to keep the child out of doors the greater part of the day, no matter how cold the weather — indeed the colder the better. Laryngismus seldom attacks children more than a year old. At so tender an age it might be feared that they would run great danger of catching cold from the sponging treatment; but no such fears need be entertained. With the necessary precautions, even the youngest child may be sponged with perfect safety several times a day. Nor does a child catch cold even in the coldest weather when carried out of doors; but one prone to bronchitis had better be kept indoors when the weather is very severe, and should undergo the cold-water sponging only. After a very extensive experience of this treatment I have rarely found that children suffering from laryngismus catch cold, and in such exceptional cases the catarrhal symptoms have been insignificant. This treatment frequently saves life, and averts not only the crowing breathing, but dangerous symp- toms, such as partial convulsions in the form of carpopedal contractions and squinting, for laryngismus, when fatal, generally destroys by exciting an attack of general convulsions. Laryngismus stridulus is sometimes ac- companied, and is indeed apparently induced, by laryngitis, indicated b}^ the peculiar hoarse voice. In such cases cold sponging must be cautiously used, for it often, though by no means invariably, increases the laryngitis, and therefore the laryngismus. Among the poorer classes, at certain sea- sons of the year, laryngismus is one of the most common causes of convul- sions, Avhich tend so often to a fatal issue. The surest and ^speediest way of arresting a paroxysm of crowing breathing is to dash cold water over the child. At the onset of a jxxroxysm SHOWER, DOUCHE, AND SPONGE BATHS. 55 cold water snonld l)e daslied on the child's face; and if this does not at once arrest the attack, water should be applied to the whole body. Laryn- gismus fortunately prevails In the early spring, when the cold weather itself is a ready source of cure. Since by this treatment laryngismus is usually cured at once, or rarely lasts more than a few days, it is obvious that cold water does not act as a mere tonic, although in this respect it is very useful, because laryngismus generally attacks weakly, sickly and rickety children. Any irritation aggravates laryngismus, and impedes its cure. Hence, if the relief from cold sponging is less marked than might be expected, some other sources of irritation should be sought for and removed. The gums if swollen, red and hot, must be freely lanced and the cut main- tained open, for if they close the irritation recurs; thus it is necessary to lance the gums every few days. Worms must be removed, and the faulty state of the mucous membrane favoring their production treated. At the cutting of each tooth, laryngismus is apt to recur in spite of cold spong- ing, but the relapse is seldom severe. When the tension of the gums is removed, and the tooth set free, the fit ceases. Irregularities of the bowels, diarrhoea, constipation, flatulence, etc., tend to increase the frequency of crowing, and to render the case less amenable to cold sponging. It may here be useful to advert to a condition, not uncommon in in- fants. An infant in poor health frequently wakes up at night from "a, catch in the breath." From some unexplained reason, it cannot for a time get its breath, and wakes up with a loud snore. This condition is alto- gether different from that of laryngismus stridulus, and the fault appears to lie in the soft palate, not in the larynx; moreover it is not due to en- larged tonsils, as this " catch in the breath " occurs in children of ten- der age, long before the morbid condition of the tonsils takes place. Cold sponging night and morning, will improve or even cure this curious com- plaint. Cold sponging, several times a day, holds also deservedly a very high place in the treatment of chorea. It is at present impossible to decide whether its efficacy is due solely to its tonic properties, or whether the shock plays any part in promoting the cure. Of the value of this treat- ment there is no question, yet circumspection must be exercised or the patient may be made worse. It must be avoided if there is any rheuma- tism, which is generally made worse by cold sponging, thus inducing an increase of choreic movements. If there is no fever, and no pain in any of the joints, then cold sponging may be reasonably expected to yield most satisfactory results. In the treatment of rickets, cold sponging, by virtue of its tonic prop- erties, holds a very high place. Here, again, care must be observed, or much harm may be done. We must remember that a rickety child is often not only very weak, but, on account of its tender years, very im- pressionable, and for these reasons it is important to adapt the application of the cold sponging to the patient's condition. If the child is old enough to stand, he should be placed up to the ankles in warm- water before a good fire, and then, except the head and face, be sponged all over with cold water from two to five minutes; he should then be carefully wiped dry, and well rubbed with a soft towel. If weakly, the child may be re- placed for a short time in a warm bed, to encourage reaction. The spong- ing should be administered as soon as the child leaves his bed; but if very weak or unaccustomed to sponging, it is advisable to give a light and early 56 SHOWER, DOUCHE, AND SPONGE BATHS, breakfast about an bour beforehand. There is another excellent method of administering cold sponging to weak persons or to timid children, and therefore a plan to be adopted Avhen this agent is used in the treatment of chorea. The water, at first tepid, should be gradually reduced in tem- perature by drawing olf the warm water and substituting cold. The shock is thus avoided, whilst the tonic virtue of the bath is obtained. This latter method succeeds admirably with timid children, who. often much fi-ightened by the bathing, sometimes scream so violently as to lead their friends to fear an attack of convulsions. Cold sponging is very invigorating for adults in impaired health; it is useful also in ansemia, leucorrhoea, amenorrhcjea, spermatorrlicea, and in that low nervous state induced by working in hot, close, ill-ventilated rooms. In cold weather, the water at first should be made a little warm, after- ward the temperature should be daily lowered. By a little light food taken about an hour before the bath, and after its completion a return to bed for half an hour to restore warmth to the skin and extremities, will generally prevent depressing effects on weakly subjects. Affusion and the Douche. — Cold water thus applied impinges on the body with considerable force, and the resulting nervous impression is cor- respondingly considerable. Water is directed against the body in a full stream, and is applied sometimes to every part of the surface in succession. The depression it produces is too great to admit of its frequent employ- ment. It is generally modified, and the cold affusion used in its place: cold water is dashed in pailfuls over the surface of the body. Affusion is recommended in sunstroke when a patient is struck down and rendered unconscious. Many years ago cold afi:usion was employed in the treat- ment of the acute specific fevers, and was especially recommended in scarlet feyer, — a well-tried mode of treatment coming down to us sanc- tioned by the authority of many of the ablest physicians of the past gene- ration. Yet in the present day the reaction against all energetic treatment is so great that this means is now very rarely adopted. Fears are expressed lest serious consequences should ensue; but if the affusion is employed at the right period, no apprehension need be entertained, as the experi- ence of Currie and Jackson abundantly testifies. It should be employed during the early days of the fever, when the skin is hot and the rash bright red. Currie and Jackson recommended that the patient should be stripped, and that four or five gallons of very cold water should be dashed over him, a process to be repeated again and again when the heat of the surface re- turned. This treatment diminishes the fever, and sometimes, it is stated, even extinguishes it. The douche and affusion are generally employed for their local effects. They are of the greatest service to rouse a patient from the stupor* of drunkenness, or from that of opium poisoning; when a certain stage of the poisoning has been reached no other treatment is so efficacious. Ex- cessive tippling or an overdose of opium induces stupor more or less pro- found, when the movements of respiration, at first languidly performed, soon stop, and death by asphyxia results. At this most critical stage, cold affusion, or the cold douche, applied freely to the head, is generally sufficient to remove the conditions within the skull on which the stupor depends. Consciousness is restored, the breathing simultaneoi;sly again becomes natural, and for a time, at least, the fear of a speedily fatal ter- SHOWER, DOUCHE, AND SPONGE BATHS. 57 miuiition is set at rest. The water should be poured on the head from a good lieight, so as to secure as great a shock as possible. The vigor of the application must be regulated by the pulse and general state of the patient. The breathing becomes deeper and more frequent, the livid, bloated aspect of the face soon disappears, while the pulse grows in strength. It often happens that relapses occur, when the affusion must be again and again employed, so as to sustain life long enough to admit of the elimination of the poison. If promptly and efficiently applied, life may be saved even in the most unpromising cases. It is all-important to ply the water abundantly for some time, and from a good height. Some time may elapse before any good effects become visible, but if the pulse and breathing improve, or become no worse than before the douche was tried, its application should be continued, and perseverance will often be rewarded by success. Dr. Sayre, and more recently Dr. Broadbent, have drawn attention to the use of the cold douche to induce sleep in delirium tremens, and in the pyrexia after childbirth, and probably in febrile diseases generally. A large sponge soaked with cold water, iced if possible, is dashed against the head, face, and chest several times. The skin is then rubbed dry with a rough towel, and sleep follows in some instances almost immediately. If the sleep is too brief repeat the application. In deirium tremens I have often seen similar good results follow the application of the general cold pack, and when the sleep was short I have repeated the pack hourly for several hours, each repetition inducing refreshing sleep. Probably this treatment by dilating the cutaneous vessels withdraws blood from the brain and so produces sleep. Many cases of furious maniacal delirium may be quieted by the cold douche. It must be borne in mind that the douche is a powerful remedy, Avhich makes it necessary to carefully watch its effect on the patient's strength. To obviate excessive depression, it is an excellent method to place the patient in a warm bath, and to apply cold to the head in the manner just described. Severe pain in the head, met with in acute specific fevers, or resulting from gastric disturbance, may be relieved very gratefully and effectually in the way recommended by Dr. Hughes Bennett: "A washhand-basin should be placed under the ear, and the head allowed to fall over the ves- sel, by bending the neck over the edge; then a stream of cold water should be poured from an ewer gently over tlie forehead, and so directed that it may be collected in the basin. It should be continued as long as agreea- ble, and be repeated frequently. The hair, if long, should be allowed to fall into the cold water, and to draw it up by capillary attraction." The ice-bag may be conveniently substituted for this application, or Thornton's cap, composed of two rolls of india-rubber tubing, through Avhich iced cold water is made to flow. This application greatly relieves headache and lessens or even prevents delirium and favors sleep. Dr. Hughes Bennett agrees with Graves, that in some cases very hot water acts even more effi- . ciently than cold. The cold douche is also an excellent local tonic to individual parts of the body. It may be employed to remove that stiffness in joints remain- ing after slight injuries, or resulting from rheumatism or gout, and salt may advantageously be added to the water. The force of the douche's impact on the affected part, with the duration of its application, must be regulated by the condition of the tissues. If very weak, it is better at first 58 THE TURKISH r>ATII. to play the water in tlie noigliborhood of the injured or weakened joint. It is also useful in chronically inflamed and swollen joints. In the early stages, especially when tenderness persists, it is useful to immerse the part in hot water for twenty to thirty minutes, and immediately on removing- the joint to cold douche it either in a single stream or through a rose for one to two minutes, well rubbing the joint afterward till it glows. Dr. Fuller recomAiends the cold douche to be played for one or two minutes upon joints affected with rheumatic arthritis; or the water may be slightly warmed in winter, and then the parts rubbed till they are Avarm and dry. Much good may be effected in spermatorrhoea by the free application of cold water to the j^erinsum and buttocks several times a day, and by the suspension of the testicles in cold water for a few minutes night and morning. The same treatment is useful in varicocele. A cold-water in- jection of about half a pint every morning before going to stool relieves or cures piles in many cases, and is always a useful addition to other treat- ment; and injections of cold water are highly recommended in chronic diarrhoea and chronic dysentery. The cold anal douche is very useful in pruritis ani, as well as for piles. Many persons, especially women, are troubled with cold feet, particularly at night; so cold, indeed, as to effec- tually prevent sleep for hours. This condition, which may rank as a distinct ailment, is best treated by immersing the feet nightly for a few minutes in cold water, rubbing them, whilst in the foot-bath, diligently until they become warm and glowing, and then, after thorough drying, clothinsf them in thick over-large woolen or "fleecy hosiery" socks. A cold or tepid sitz-bath is a very useful api^lication. At first it contracts the vessels of the cooled skih, also the intestinal vessels, and increases the blood in the upper part of the body, causing even a rise of temperature in the axilla. Subsequently, and especially if followed by vigorous friction with a rough towel, the constricted vessels become dilated, and the abdominal circulation is increased and gives tone to the abdominal organs, and so relieves constipation and strengthens the bladder. I have often used, with advantage, a sitz-bath for ten minutes of a temperature between 70° and 80° Fah., for overworked patients who return from business tired, restless, and irritable. They should take the bath about half an hour to an hour before a late dinner. It removes restlessness and invigorates and favors sleep. For the troubles occurring at the change of life or in women weakened by excessive menstruation, I often obtain considerable benefit by sponging the spine with equal parts of white vinegar and spirits of wine, night and morning, for five to ten minutes. Or by spongnig the spine first with water as hot as can be borne, and then for a few seconds with a sponge wrung out of cold water. The first application is the most successful. It invigorates and soothes irritable nerves and prevents the fidgets. The same applications often relieve " cold feet." THE TURKISH BATH. This bracing and depurating bath combines many of the properties of the hot and cold bath. The body, subjected to great heat, is made to perspire copiously. If the bath ended here, more or less weakness would ensue; but at this stage the free application of cold water stimulates and THE TURKISH BATH. 59 braces the body, and produces the tonic effects of the cold bath. At each stage of the process, the Turkisli bath cleanses the system; the perspira- tion carrying off, and the cold consuming,' by increased oxydation, effete and noxious substances in the blood. The Turkish bath, like sea-air and sea-bathing, is a true tonic. By a tonic, I understand, any means which will increase both the destruction and the construction of tissue, provided the constructive remains in excess of the destructive process, and by promoting the nutrition of the muscular, nervous, and other systems, tonics increase the potential force of the bodily organs; in other words, tonics increase the capacity for function. By increasing tissue change, tonics promote appetite and digestion (see Cold). The baths, says Dr. Goolden, are useful in gout, rheumatism, sciatica, Bright's disease, eczema, and psoriasis; they benefit bronchitis, the cough of phthisis, the aching of muscles from unusual exertion, pains in the seat of old wounds, colds in the head, quinsies, and common winter coughs. It is not amiss here to caution persons prone to colds, that the habit of over-clothing increases this liability. This cold-catching tendency may be obviated by using a moderate amount of clothing, taking a cold sponge- bath every morning, and occasional wet-sheet packing, or the Turkish bath once or twice a week. On catching cold, a patient Avith lungs previously healthy becomes troubled for some time with chronic catarrh, accompanied by considerable expectoration and some shortness and oppression of breathing. In such a case, the Turkish bath generally affords prompt and great relief/ checking the expectoration and easing the breathing. In bronchial asthma and em- physematous asthma, a course of Turkish baths, say one every second or third day, is very useful; this subdues chronic bronchitis and renders the patient less liable to catch cold. A large chamois leather waistcoat reaching low down the body and arms, and worn over the flannel, affords great relief in bronchial asthma and emphysematous bronchitis. This jacket is ex- tremely warm, and protects the chest against the vicissitudes of weather. It is a nasty practice to wear it next the skin. At the commencement of a feverish cold, a Turkish bath will cut the attack short, remove the aching pains, and relieve or cure the hoarseness at once. The bath will still prove very useful for a cold of several days' standing, though its good effects are less striking. The Turkish bath will relieve or carry off the remains of a general severe cold, as hoarseness, cough with expectoration, and lassitude. Whilst in the hot chamber the voice generally becomes quite clear and natural, though the hoarseness may afterward return in a slight degree; but it usually continues to im- prove, becoming natural in a day or two, a repetition of the bath aiding complete recovery. In more obstinate cases several baths may be re- quired. Great improvement of the voice in the hot chamber may be taken as a proof that the bath will benefit, even though, after the bath, the hoarseness returns to a great extent. The Turkish bath is serviceable to persons who after dining out, not wisely but too well, suffer next day from malaise and slight indigestion. A course of Turkish baths is very beneficial to town-dwellers leading a sedentary life, Avho, especially if they live freely, are apt to become stout with soft and flabby tissues, are easily tired, suffer from lack of energy and some mental depression. Under the influence of the bath, their mus- cles become firmer, the fatness decreases, and they acquire more spirit and energy. 60 THE TURKISH HATH. A course of Turkish hatlis is useful to patients whose health has broken down Ijy residence in a tropical climate, who suffer from general debility, enfceblement of mind, dull aching pains in the head, and broken sleep. I have heard the Turkish bath, even its daily use, recommended highly for convalescents from acute diseases, to promote assimilation, digestion, and appetite. Patients suffering from jaundice, acquired in a tropical climate, or from malaria, have often testified to the beneficial effects of Turkish baths; but it is necessary, as indeed it is with all persons with shattered health, to caution them against the too vigorous and unre- strained use of the bath. The patient should leave tlie hot chamber as soon as free perspiration occurs, and should not plunge into the cold bath, but take a douche with slightly tepid water, especially i]i cold weather. ]\Iany dread the Turkish bath lest they should catch a cold, and one often hears complaints of a cold coming on after a bath. So far from tending to give cold, these baths, as we have said, obviate the tendency to catarrh, and fortify delicate persons against a cold-catching tendency. If ever the bath is answerable for a cold, it is almost always owing to the bather leaving the bath-house too soon, perhaps in inclement weather, whilst his skin is still perspiring freely, or his hair is soaking wet. Again, it is not unusual to hear complaints that the bath has induced considerable depression, or even exhaustion, lasting perhaps several days; but here again the fault rests with the bather. The bath must be adapted to the strength of the patient, and it is always prudent to take the first bath circumspectly, the bather not staying too long in the hot chamber, and undergoing the bracing application only n few seconds, with water not very cold. It is difficult to point out the precise time a bather ought to remain in the hot chamber. If delicate, and it is his first bath, he should not enter a chamber hotter than 130° to 140° Fah., and should stay there only twenty minutes or half an hour, or less, should he feel faint or tired. The patient's sensations are the best guide; sometimes, especially if suffering from pain, the bath soothes and eases, and then he can remain in the hot chamber an hour, the first bath; but, I repeat, he should at once leave when he feels faint or tired. At first, the patient, not seldom, on commencing the bath, fails to perspire; in this case, he should be removed from the chamber in ten minutes, have warm Avater poured over him, and be well shampooed, and, unless he is tired and faint, should then return to the hot chamber. It is a rule in these establish- ments to advise even an old bather not to enter the hotter chamber of 180° to 220° Fall., till the skin has become moist with perspiration; though many disregard this injunction with apparent impunity. Even if the first bath causes some depression, this need not happen afterward, partly be- cause the bather will have become accustomed to the process, and partly because he will know how to adapt it to his strength. Yet it must be ad- mitted that some persons, even with every precaution, cannot take a Turk- ish bath without experiencing much depression. Acute rheumatism and acute gout have been treated with these baths; but, as in most instances, the severity of the pain renders it impracticable to take patients thus affected to a Turkish bath, a modified substitute for it, shortly to be described, may be taken at home. The acute j)ain of gout, it is said, disappears in the hot chamber, to return soon afterward in a diminished degree. The Turkish bath is particularly valuable in subacute and chronic gout, but, as might be expected, it is not in all cases equally serviceable. THE TURKISH HATH. 61 In long-standing cases in whicli the attacks have occurred so frequently as to distort the joints by deposits, and patients are, perhaps, liable to repeated relapses, and are scarcely ever free from pain, the efficacy of the bath, though striking, is less apparent than in milder and more tractable forms; yet even in these severe cases, the bath affords considerable relief by diminishing the frequency and severity of the relapses, and by remov- ing the pervading sensation of invalidism. The Turkish bath is, perhaps, more efficacious than other remedies in a case of the following kind: — A patient inclined to stoutness complains of slight and fugitive pains; the joints, but little swollen, are merely stiff and a little red and hot. The gout affects many parts often in succession — the joints, the head, the back, and perhaps some of the internal organs, as the bladder, etc. During an attack tiie patient complains of malaise, and his complexion often be- comes dullish. The tissues are often soft and flabby, and, in spite of judi- cious diet and abundant exercise, the patient may be seldom free from some evidence of gout, sufficient to annoy but not to disable him for work. After one or two baths the pains, the swelling, and the malaiae disappear, the joints become supple, and after a time, the baths being continued, the complexion loses its sallowness, the tissues become firm, and the undue stoutness undergoes diminution. On discontinuing the baths, the gouty symptoms will often recur, again to disappear on the resumption of the treatment. A gouty patient may advantageously supplement the action of the Turkish bath by drinking certain suitable natural mineral .waters. The Turkish bath is useful in the various kinds of chronic rheuma- tism. A patient who, in damp weather, or during an east or north-east wind, suffers from stiffness and pains in several joints, will derive much benefit from a Turkisli bath. The shoulder joint is often affected, the pain and tenderness being frequently limited to a small spot. Again, a patient without any previous history of rheumatism finds his shoulder set fast, is unable to move it, except to a limited extent, without great pain. Here, again, the pain and tenderness may be very circum- scribed. In such a case a Turkish bath generally affords great relief. Galvanism too, even one application, will often entirely remove or greatly lessen the pains and stitt'ness. Again, the Turkish bath gives much relief in mild and chronic rheumatoid arthritis, and often retards the march of this disease. The bath often relieves lumbago. Mr. Milton finds the bath useful in allaying the tormenting itching of prurigo unconnected with lice. Should it happen that the regular Turkish bath is not available, then one or other of the following modifications of it may be substituted: — The patient, quite naked, seated on a wicker chair, with his feet on a low stool, is enveloped in two or three blankets, the head alone being exposed, and a spirit lamp with a large wick is placed under the chair. In about a quarter of an hour perspiration streams down the body, and tiiis secretion may be increased by drinking plentifully of water, and by placing a pan of water over the lamp. When the patient has perspired sufficiently the blankets are quickly removed, and one or two pailfuls of cold water are poured over him; or, if this affusion is too heroic, he may step into a general bath at 80°, or, better still, a few degrees lower. Dr. Taylor, of Nottingham, finds this treatment useful in obstinate skin affections, rheu- matism, catarrh, syphilis, and in reducing stoutness arising from an inac- tive life. The instrument makers now supply convenient forms of the 62 POULTICES AND* FOMENTATIONS. domestic Turkish bath. It is far better, however, when practicable, to em- ploy the Turkish bath itself. Dr. Nevin highly recommends the following handy steam-bath in the treatment of acute rheumatism, available when tlie patient is lying help- less and irremovable in bed: — A couple of common red bricks are placed in an oven hot enough for baking bread, and in half an hour or a little more, they are sufficiently heated for the purpose. The patient's body linen having been previously removed, these two bricks are folded in a piece of common thick flannel, thoroughly soaked in vinegar, and laid on two plates; one is to be placed about a foot distant from one shoulder, and the other about equally distant from the opposite leg, and the bed-cloth(,'s are then to cover the bricks and the patient closely round the neck. A most refreshing acid steam-bath is thus obtained; and tiie supply of steam may be kept up, if necessary, by remonng one brick and replacing it by an- other hot one kept in reserve. When the patient has been in the bath for fifteen or twenty minutes, the bed-clothes and plates should be removed, and the patient instanthi mopped all over, eery rapidhi, with a. towel wrung out in cold water, and then quickly rubbed dry. Dry warm linen must be put on at once, and dry bed-clothes must replace those which Avere on the Ijed previously. The under-sheet can be removed, and a dry one sub- stituted by fastening the corners of the dry sheet to those of the damp one; generally very little difficulty is met with in simply drawing the old sheet from under the patient, when the dry one follows it, and is left in its place. The patient ordinarily experiences great and speedy relief from this bath. The exhausting sweats are usually diminished, and the neces- sity of opium much lessened. The change of the body linen can be easily accomplished by tearing the night-shirt open from top to bottom down the back. The steam-bath and subsequent cold douche should be con- tinued after the patient is able to walk about, as they contribute to the healthy action of the skin and promote free mobility of the joints. After the patient is able to get out of bed, the bath may be administered in the manner previously described. The steam-bath, according to Dr. Sieve- king, relieves the pain and checks the perspiration in acute rheumatism to a degree he has failed to attain by any other treatment. Or the following method may be used as in some degree a substitute for a Turkish bath. After a general hot bath sponge all over with tepid or cold water; or sponge the whole body first with hot water and then for a short time with cold water. Some persons cannot stand the usual morning cold tub can substitute these methods with much benefit, and obtain the tonic invigorating effects which follow the morning flat sponge-bath. POULTICES AND FOMENTATIOXS. Poultices and fomentations, in such common use, are simply local baths applied to the skin. When its surface, or the structures beneath it are inflamed, poultices and fomentations are a convenient and efficacious means of utilizing warmth and moisture in the treatment of diseased parts. The warmth and moisture relax the vessels, and increase the collateral circulation, and in some degree abate the tension due to POULTICES AND FOMENTATIONS. 63 inflammation, and so relieve pain. Applied at the very beginning to inflamed tissues, to abscesses, inflamed pimples, and the like, poultices often summarily check the inflammation, and prevent the formation of pus. Fomentations with water as hot as can be endured also arrest inflammation and check the formation of matter, and should be gen- erally employed as adjuncts to poultices. Hot fomentations will often disperse or restrict the development of acne indurata, herpes labialis, and similar inflamed jjimples apt to appear on the face. These applications are of further use when suppuration has set in and matter requires to be expelled. Poultices greatly facilitate the passage of the matter to the surface and further its expulsion, while, at the same time, they limit considerably the spread of inflammation in all directions. Here, again, very hot fomentations, often repeated, continued for some time, are a useful supplement to poultices. It should be remembered that much depends on the heat of the appli- cation. Poultices should be always applied as hot as they can be borne, and should be frequently changed, lest they become cold and hard. Indeed, they can scarcely be changed too often; in hospital practice it is difficult to con- stantly renew poultices; yet even in such institutions, where the supply of nurses is limited, poultices should be changed at least every two or three hours. Where applied to disperse inflammation, or to hasten the maturation of abscesses, the poultices should be large, reaching beyond the limit of the inflamed tissues; but as soon as the abscess or boil has matured and burst, the poultice should be very little larger than the opening in the skin through which the matter escapes. A large poultice, applied over- long, soddens and irritates the skin, and is liable to produce an eruption of eczema, or to develop fresh boils around the base of the original one. Open sores, like discharging abscesses, or sloughing sores or ulcers, are best treated with lint soaked in a saturated solution of boracic acid, or some other antiseptic agent, to destroy germs, and so prevent sup- puration and further destruction of tissue. The boracic application is useful in the inflamed stage of eczema. In the treatment of boils, carbuncles, abscesses, and inflamed lym- phatics, it is an excellent plan to smear over the inflamed tissues a com- j)ound of equal parts of extract of belladonna and glycerine, and on this dressing to superimpose a poultice. The belladonna eases pain and re- duces inflammation. (See Sulphides.) In order to protect the adjacent tissues from the undue action of the poultice, so as to check the production of fresh boils, it is a good plan to place over the boil a piece of opium plaster with a circular hole, and to apply the poultice only over the plaster. Another jjrotective plan is to smear the contiguous surface with zinc ointment. Poultices moderate the inflammation and alleviate the pain in skin dis- eases, as eczema, etc., when the skin is inflamed, painful, red, and swollen. Poultices are not only soothing when in direct contact with inflamed tissues, but they appear to act in the same manner on deep-seated parts. Large poultices applied very hot, and removed as soon as they become cool, are of great service in pneumonia, pleurisy, bronchitis, pericarditis, peritonitis, etc. To avoid exposure of the warm moist skin, the old poul- tice should not be removed till the new one is ready to replace it. These applications are extremely useful to children attacked with bronchitis, broncho-pneumonia, or lobular pneumonia. As young chil- dren are apt to be restless, and to toss about in bed, the entire chest 64 POULTICES AND FO. "MENTATIONS. should 1)0 cnvolopod in a jacket-poultice. The ordinary poultice soon be- comes rucked up, and converted into a narrow band encircling only a very limited portion of the chest, whilst the uncovered part of the chest is ex- posed to cold. The jacket-poultice should be constructed with a piece of linen sufficiently large to go quite round the chest, and tapes should be sewn to it in such a manner that they can be tied in front, and over each shoulder. It is as well to have three pairs of tapes, so as to admit of three fastenings down the front of the chest. A poultice, to retain its heat, should be spread an inch or more thick, or it may be made thinner, and externally coated with a layer of cotton- wool. The cotton-wool being light, does not hamper the breathing — a matter of importance, especially with children. In inflammation of deep-seated organs the same methods, modified to suit the part, should be adopted. In peritonitis it is of great importance to spread the poultice thin and cover it with a layer of cotton- wool; if heavy it aggravates the pain. Poultices are useful in acute rheumatism, lumbago, sciatica, pleuro- djTiia, myalgia, and in those so-called rheumatic pains which often attack limited parts of the body, as one arm, etc' They are soothing and pleasant to the inflamed joints in rheumatic fever, although cotton- wool is often preferred. In acute lumbago, poulticing often brings speedy relief, the severest cases being greatly benefited in a few hours, and generally cured in one or two days. The poultice must be very hot, and large enough to cover the whole loins or part affected, and thick enough to remain quite hot for half an hour, when it must be changed. If the pain is persistent this treatment shmild ])e continued for three hours, or longer; the skin must then be covered with a piece of flannel, and the flannel covered with oil-silk; this after-treatment promotes, what is most desir- able, free perspiration. When electricity, the needle, or poultices, fail to give more than slight temporary relief, it will often be found that the lumbago is accom- panied with high fever, being sometimes the first symptom of an attack of rheumatic fever. Sciatica may be treated in the same way, but the result is not often so satisfactory. (Vide Ether.) Poultices applied in the same way as for lumbago, and followed by the application of lint and oilskin, are often useful in severe forms of pleurodynia and myalgia. Belladonna liniment is usually sufficient, and even to be preferred in pleurodynia; and sometimes ether spray at once and permanently removes the pain of this annoying affection. As we have said, poultices may be made of various substances, lin- seed meal, oatmeal, bread, or starch. Each has its peculiar character. Linseed-meal and oatmeal poultices have most properties in com- mon; they make compact and only slightly porous poultices, retaining heat and moisture longer than other kinds, and are consequently often to be preferred to bread or starch. Rut linseed contains an acrid matter, wdiicli sometimes irritates, especially if the skin is of a fine and delicate texture, or if it is inflamed by some eruption, in which case ' Galvanism is highly useful in some forms of these complaints, especially in lum- bago. In sciatica it gives at least temporary relief, and in some cases a few applications effect a curg. Sciatica and deep-seated pains about tlie shafts of the long bones, even the dull aching pain in the joints, which not unfrequently remams after an attack of acute rheumatism, will often yield to galvanism. POULTICES AND FOMENTATIONS. 65 oatmeal or bread must lie siibstitiited. Bread poultices are more porous and blander than those of linseed-meal, but the porosity depends very greatly on the way of making them. Bread poultices cool more quickly and give less moisture to the skin, than those made of linseed-meal. Starch poultices retain their heat for a considerable time, and are very ^land, unirritating applications. It is as well to mention that linseed -meal poultices are more tenacious than those made of bread, and are therefore less liable to break up and fall about the bed and clothes of the patient, rendering him uncomfort- able. In making a poultice, care should be taken that the water boils, and that all the materials, linseed-meal, linen, strappings, bandages or tapes, wool and oil-silk, are close at hand ready for use, and placed before a good fire to be thoroughly w^armed. To manufacture a linseed poidtice, suffi- cient boiling water should be poured into a heated bowl, and the meal must be quickly sprinkled into the bowl with one hand, while with the other the mixture must be constantly stirred Avitli a knife or spatula, till sufficient meal has been added to make a thin and smooth dough. The mixture should be compounded as rapidly as possible, otherwise the poul- tice when made will be almost cold. Only an experienced hand can make a model poultice. By adding the meal to the water, with constant stir- ring, instead of the water to the meal, a thorough blending of the two in- gredients is ensured, not a knotty, lumpy, uncomfortable mass, too often vexing instead of soothing the patient. The dough must then be spread quickly and evenly on the warm linen, already cut of proper size and shape, the edges of the linen turned a little way over the meal to prevent any portion escaping beyond the linen, and to protect the patient's clothes. There are two methods of making bread jioultices. One way is to cut the bread in thickish slices, put it into a basin, pour boiling water over it, and place the soaking mass by the fire for five minutes; then pour ofE the w^ater, add fresh boiling w^ater, and place by the fire; afterwards draining the bread, beat up with A fork, and spread the poultice. The other plan is to cut stale bread into thick slices into a saucepan and pour enough boiling water over it to cover it; place the whole by the fire, and allow it to simmer for a short time, then strain and prepare the poul- tice. The first plan makes a porous poultice, the second a more compact poultice, sharing the character of linseed-meal. As w'e shall see, each pojiltice has its fitting application. Bran poultices are useful on account of their lightness. Starch poultices are entirely unirritating, and retain their heat for a considera];)le time. The way to proceed is to add a little cold water to the starch, and to blend the tw^o into a pap; then add sufficient boiling water to make a poultice of the required consistence, which must be spread on linen in the manner already described. Starch poultices soothe open cancers, and allay skin eruptions, when there is much inflammation, heat, and pain. There are several ways of employing charcoal as a poultice. It is used to prevent disagreeable odors from foul sores, and it is thought also to pro- mote a healthy condition of the tissues. When employed for this double purpose, charcoal is added to the poultice. As a porous poultice is here reqiiired, bread is better for the purpose than linseed-meal. A portion of the charcoal should be uniformly mixed wnth the bread, but the greater part should be sprinkled over the surface of the poultice. It is doubtful 5 66 POULTICES AND FOMENTATIONS. wht'tlier a charcoal poultice is greatly superior to a simple bread poiiltice; for the charcoal must soon cease to absorb gases, and thus lose its deodoriz- ing property. It may, perhaps, promote a healthier condition in the sore. If the object is merely to prevent disagreeable smells and to keep the air of the room pure, the plan pointed out in the section on charcoal is to be preferred. • It is a good practice to sprinkle foul, sloughing, putrid sores with dry charcoal, and over the charcoal to place a simple poultice, or to make the poultice of well-toasted or of burnt bread. This treatment apj)ears to hasten the separation of the sloughs, and to promote a healthier state of the tissues, and may be applied to a boil when the core is separating, or to a bed-sore while the black slough still adheres to the living tissues. Some maintain that a yeast poultice is useful in sloughing sores, and that it prevents destruction of the tissues, and promotes the separation of sloughs. Yeast poultices are made m two ways. Yeast and water may be added to floiir till ordinary dough is made, and the dough is applied while fermentation is going on. In this case it is simply an application of *' rising dough. ^' The other way is to smear warm yeast over the surface of a simple bread poultice. A carrot poultice, which is supposed to make wounds cleaner and healthier, is made by boiling carrots till they become quite soft, mashing them with a fork, and spreading the pulp on the linen in the ordinary way. To sloughing sores, as we have seen, better apply some efficient anti- septic. They should be washed with saturated boracic acid solution, or with carbolic acid solution, etc., and then covered with lint or cotton- wool soaked in one or other of these solutions. Laudanum is sometimes added to poultices to ease pain; and it is es- pecially effectual when the skin is broken. Solutions of chloride of lime or of soda may be added to poultices to destroy offensive gases given off from unhealthy sores. In eczema, with much inflammation and sensation of heat. Dr. McCall Anderson recommends a cold potato poultice sprinkled with a small quan- tity of absorbent powder, containing camphor. The powder, a useful dusting powder without the poultice, is composed of half a drachm of camphor, reduced to powder, with rectified spirit and three drachms each of powdered talc and oxide of zinc. Professor Marshall employs an iodide of starch poultice to clean slough- ing sores. A jelly is made with two ounces of starch mixed with six ounces of boiling water, to which before it cools should be added half an ounce of liquor iodi. The mixture is spread on lint, and applied cold. Fomentations by means of flannel wrung out of boiling water are em- ployed for similar purposes as poultices. They are used for the sake of their moisture, but especially for their warmth, and they differ from poul- tices in being less weighty, and therefore less likely to increase the pain of very tender parts. The flannel is wrung out by means of a wringer made of stout towelling attached to two rods. The boiling wet flannel is placed in the wringer, which is then twisted round the flannel very strongly till the water is thoroughly squeezed oiit. As the flannel when fi.rst taken from the boiling water is too hot to be held in the hands, the wringer is useful. In the absence of a wringer an ordinary towel will ansv/er fairly well. Wrung as dry as possible, these fomentations may be used very hot without fear of scalding or blistering the skin. The fomentation should be covered outside with a piece of macintosh, and tied on with bandages. As hot fomentations quickly cool, and being chiefly used for the sake of THE MEDICINAL USES OF ICE. 67 lu'iit, they must be frequently renewed: when finiilly removed, the skin must be carefully wiped dry, and covered with flannel or cotton-wool to prevent catching cold. Fomentations, in a less degree poultices, relax spasm in the internal organs, as in intestinal, renal and biliary colic. In very extensive inflam- mation fomentations are preferable, as a large poultice is heavy and un- comfortable. Thus fomentations are employed when a limb is extensively affected with erysipelas, or when the tissues have been widely contused and have become inflamed. Sponging the face Avith water as hot as can be borne is a very useful application in acne indurata; it will disperse the incipient spots, and limit the size and hasten the maturation of the more matured ones, and at the same time greatly lessen for some hours the redness of the eruption. Twenty or thirty drops of turpentine sprinkled on a hot fomentation of the above description makes a good counter-irritant, useful when it is needful to combine a stimulating with a warm, soothing action. An alkaline poultice, composed of nine parts of linseed-meal and one part of bicarbonate of soda, is a useful application in gout. Sometimes it is desirable to apply heat to a part of the surface of the body, when at the same time it is important to avoid relaxation of the tissues which moisture Avould produce. In such cases various drv, strongly heated applications are used. Flannel, almost scorched before the fire, or in an oven, is sometimes employed, but it speedily loses heat. Sand or chamomile flowers retain heat far better; they may be strongly heated over the fire in an iron pan, and then be run into a heated linen bag made for the purpose, of such shape and construction that the contents shall form a thickish and even layer. Each substance |x»ssesses its re- spective advantages; sand, though heavy, retains heat; chamomile flowers, though light, soon lose their warmth. A tliin piece of flat tile heated in the oven, and wrapped in flannel, is lighter than sand, retains its heat for a considerable time, and is easily procured. These apialications are of great service in relieving the pain of spasms. THE MEDICINAL USES OF ICE. Ice is frequently used to abstract heat, to check bleeding, to allay inflam- mation, and to destroy sensation. Ice broken up with the help of a large needle into fragments may be enclosed in a bladder or thin india-rubber bag, flrst squeezing the air out of the bag. After fllling the bag about one third of its capacity, its mouth should be tied on a cork, so as to afford a purchase for the twine. The ice-bag may then be adapted to almost any shape, and fitted to the inequalities of the body, and, if re- C|uired, may be fashioned into a sort of cap for the head. This cap is applied to the head in tubercular and simple meningitis, and may be employed to allay the severe headache of the early stages of acute fevers. Sometimes the ice-bag laid on the epigastrium will ease the severe pain and vomiting of chronic ulcer, or of cancer of the stomach. It may be applied in prurigo of the vulvae; other treatment, however, is generally to be preferred. In typhlitis and typhoid fever an ice poultice applied over the right side of the lower part of the abdomen is often useful in relieving inflam- mation and pain. 68 THE MEDICINAL USES OF ICE. A lump of ice inserted into the uterus, or jiushed into the rectum, IS sometimes used to arrest uterine hfemorrhage after delivery. Ice is used internally for a variety of purposes. Sucking ice allays thirst, and is very grateful to fever patients. It is likewise sucked to check bleeding from the mouth or throat, stomach or lungs. To check bleeding from the stomach small jneces should be swallowed. The constant sucking of ice is most efficacious in combating acute in- flammation of the tonsils or throat ; it also is very beneficial in the sore throat of scarlet fever, and other acute specific throat diseases, and even in diphtheria. It often proves most soothing, allays the heat and pain, and checks the abundant secretion of mucus, which is so harassing from the constant liaAvking and deglutition it occasions. In tonsillitis, and indeed in all inflammations of the throat, the good effects of ice, especially when used at the very beginning of the attack, are most marked. The ice should be sucked as constantly as possible, and be continued till the disease has fairly declined. In the same way ice is employed to allay the nausea, sickness and pain of disease of the stomach. Ice may be applied to an inflamed and prolapsed rectum or uterus, to reduce inflammation and swelling, so as to enable these parts to be re- turned to their proper place. 8ome apply ice to the head in delirium tremens and in the convulsions of children. The application of a small bladder or india-rubber bag of ice will dull or even neutralize pain from inflamed piles, or after an operation for piles or fissure of the anus. ^I. Diday strongly recommends the local application of ice in certain painful affections of the testis, as neuralgia and blenorrhagic orchitis. Two pigs' bladders partially filled with ice are applied one under the other over the testis, the neighboring parts being protected with napkins. The pain in orchitis is at first rather increased, but soon declines, and in a few minutes altogether ceases. The continuous application of ice bladders for twenty-four to forty-eight hours in many cases permanently removes the pain. If on pressure any tenderness remains, the pain will return, and the ice must be continued three or four, and even five days accord- ing to circumstances. On discontinuing the ice, wet cold cloths should be used, to permit the tissues to return gradually to their normal temperature. Two parts of finely pounded ice with one part of common salt produces cold sufficient to freeze the tissues, and to deprive them of sensibilitv. This mixture, largely used by Dr. Arnott, is confined in a gauze bag and placed in contact with the skin till sensation is abolished and the skin has a leathery feel, and assumes a shrunken tallowy appearance. If applied too long, this mixture may vesicate; but this will not occur under five or six minutes. This application is employed to prevent the pain of minor operations, as extraction of the toe-nail, and the opening of abscesses. Dr. Arnott recommends it in chronic rheumatism, in erysipelas, lumbago, and in wounds. In chronic rheumatism, it should be applied to the diseased joints for six minutes; it should then be replaced for a short time by pounded ice, to prevent the occurrence of inflammation from too rapid a return of heat to the tissues. An attack of lumbago may be often cured by freezing the skin over the painful ])art. Dr. Arnott asserts that when applied to wounds this mixture prevents inflammation without hindering union by the first intention. SPINAL ICE-BAG SPINAL HOT- WATER BAG. G9 When applied for some hours, this mixture destroys sensibility to Tjuch a degree that chloride of zinc paste may be used in sufficient quan- tity to destroy the tissues to a considerable depth, without inducing pain or '^inflammation. But ether spray, so conveniently and rapidly used in the manner introduced by Dr. Kichardson, is now generally preferred for the purpose of freezing the tissues. Chloride of methyl spray ap- plied by a suitable instrument from the condensed gas is more certain in its freezing action than ether spray. A single application of ether spray Avill often remove lumbago; ' ether spray sometimes relieves sciatica, and those frontal headaches commonly called nervous, arising from either mental or bodily fatigue. Frontal headache, dull and uniform in character, lasting many days, occurring not nncommonly after excitement or an acute illness, such as erysipelas, a severe cold, or a sore throat, often succumbs to ether spray; but it is generally requisite to freeze the skin of the forehead. An ice poultice, i.e., finely broken ice in a thin india-rubber bag, is a useful application to the throat in tonsillitis, scarlet fever and diphtheria, especially when the lymphatic glands become greatly swollen and threaten to suppurate. I have seen swelling of the glands behind the angle of the jaw so great that swallowing was well-nigh impossible, become so mucii reduced after a few hours' application of an ice poultice that the child was able to take food easily. ON THE SPINAL ICE-BAG AND THE SPINAL HOT- WATEK-BAG. The profession is indebted to Dr Chapman for the introduction of these appliances. Concerning the spinal ice-bag, Dr. Chapman says, " I have proved by numerous experiments that cold applied to the back exerts not only a sedative influence on the spinal cord, but also on those nervous centres which preside over the blood-vessels in all parts of the body. The modus operandi of this influence on those centres, and its effects, may be thus stated: ' 1st. It partially paralyzes them. 2nd. By means of the partial paralysis thus eft'ected it lessens the nervous currents in the vaso-motor nerves emerging from the ganglia or nerve centres acted upon, and stimulating the muscular fibres surrounding the arteries influenced. 3rd. By thus lessening those currents it lessens the contractile energy of the muscular bands of the arteries to which those currents flow, and by doing so facilitates the dilatation of those arteries themselves. 4th. By thus inducing the condition of easy dilatability in the arteries acted upon, it enables the blood which flows in the direction of least resistance, to enter them in greater volume, and with greater force than before.'" These elfects are analogous to those obtained by Claude Bernard. On ' The pain and stiffness of the muscles of the back in lumbago may often be instan- taneously renio\e(l by running a needle an inch or more into the painful part; Avhen the lumbago is double, this almost painless operation should be performed on both sides of the loins. Inserted along the course of the sciatic nerve, the needle sometimes affords instant and marked relief, even in very chronic cases of sciatica. This treatment indeed, sometimes, as if by magic, cures severe and long-standing cases. The passage of an interrupted galvanic current will speedily relieve lumbago. 70 SPINAL ICE-BAG SPINAL IIOT-WATER EAG. dividing tlie PN-mpathetic nerve, he fouiul that the vessels of the parts supphed with this nerve became dilated and received an increased supply of food, with a proportionate augmentation of the vital properties. Chapman avers that. "Those phenomena which Professor C. Bernard produced in the head of an animal by section of the cervical sympathetic I have induced in the head, thorax, abdomen, pelvis, and four extremities of man, by the application of ice to the different parts of the back.'' To supply an increased afflux of blood to any part of the body. Dr. Chapman ai)plies the ice-ljag to various parts of the spine; to the neck and between the shoulders, when more blood is needed for the head; to the upper part of the back, for the chest and arms; to the lower part of the back, for the abdomen, pelvis and legs. Dr. Chapman says: I. " Muscular tension is diminished by tlie application of ice along the sjiine." In support of this statement he asserts that the ice-bag will prevent the cramps of diarrhoea and cholera, and is useful in laryngismus stridulus, chorea, tetanus, infantile convulsions and epilepsy, and " in prolonged muscular rigidity due to acute or chronic disorder of the nervous centres."' II. " Sensibility is lessened by the applicatioti of cold cdong the spine. This is proved conclusively by my experience, which has been considera- ble, in the treatment of neuralgia." III. "Secretion is lessened by the application of cold cdong the spine. I have assured myself by experience in numerous cases of the truth of this proposition. Morbidly excessive sweating, broncJiorrhcea, the excessive action of the alimentary mucous membrane constituting the chief cause of diarrhoea, excessive action of the kidneys, leucorrhoea, and spermator- rhoi'a. I have restrained over and over again by cold properly applied to the appropriate part of the spine." IV. *' The jjeripheral circulation, and consequently bodily heat, is increased by ice applied along the spine.'' He narrates the following singu- lar cases in confirmation of this proposition: " A woman, aged sixty, who for more than twenty years had always been cold to the touch, even over her shoulders and bosom, though she was warmly clothed; and her feet were habitually and extremely cold. After using ice during three weeks, several hours a day. the whole surface of the body, including her feet, became wonderfully Avarm. She was extremely astonished by the increase of the temperature of her body, as well as by the subsidence of every symptom from Avhich she had suffered for so many years; and when she called upon me a week after the treatment had ceased, her newly-acquired increase of general circulation, denoted by her increased warmth, still continued. Case 2 of this series affords a remarkable proof of the propo- sition in question: The patient, a man aged fifty-six, who seemed nearly seventy, suffering from paralysis, epilepsy and other grave troubles, com- plained that he was always 'cold all over;' that he suffered especially from coldness of the feet, even in the hottest weather, and was obliged, as his wife said, ' to sit near the fire in summer.' Within one week after the treatment, which was continued three months, this patient had become warm all over — especially the feet. "Within a month he said, ' I feel as well as possible; but very hot, very hot.' In this case, after the ice had been left off for some days, the patient became cold again." Dr. Chapman asserts that ice applied along the lower dorsal and lumbar vertebra?, by increasing the amount of blood supplied to the pelvic organs, promotes menstruation, and will even restore the supjjressed monthly flux. INTERNAL USE OF WATER. 71 The ice-bag, by increasing the flow of blood to tlie legs, proves very com- fortable to persons harassed with cold feet; and I have often seen the feet become comfortably warm a few minutes after the application of the ice. _ _ • r)r. Chapman asserts that ice applied along the spine is extremely useful in cholera and tetanus, in sea-sickness, and the vomiting of preg- nancy. THE SPINAL HOT-WATEE BAG. The physiological effects produced by heat to the spine are, as might be inferred, the opposite of those induced Ijy cold. Dr. Chapman says that, "1st. The temperature of the sympathetic ganglia being raised, the flow of blood to them l3ecomes more copious, and the functions consequently become more energetic than before. 2d. Their nervous influence passes in fuller and more powerful streams along the nerves emerging from them, and ramifying over the blood-vessels which they control. 3rd. The mus- cular bands surrounding those vessels, stimulated by this increased nervous afflux to contract with more than their usual force, diminish proportionably the diameter of the vessels themselves. 4th. The diameter of the vessels being thus lessened, the blood flows thongh them in less volume and with less rapidity than before; indeed, it is probable that, while the nervous ganglia in question are made to emit their maximum of energy, many of the terminal branches of the blood-vessels acted upon become completely closed." The temperature of the hot-bag should not exceed 120°. Dr. Chapman employs heat along the spine to contract the blood-ves- sels, and states that if properly applied, it will not only lessen but will arrest the menstrual flow. He asserts, as the result of his experience, that it will arrest menorrhagia and bleeding from the nose and lungs. In bleeding from the nose or lungs, the hot spinal bag must be applied along the cervical and upper dorsal vertebrae; in menorrhagia, along the lower dorsal and lumbar vertebrse. THE INTERNAL USE OF WATEE. A FEW remarks may be made here conveniently on the drinks best suited to fever patients. The importunate and distressing thirst often causes much restlessness and irritability, whilst these in their turn often increase the fever. Therefore, the urgent thirst must be allayed; but if left to himself a patient, to satiate his craving, will always drink to excess, Avhicli is very liable to derange the stomach, impair digestion, produce flatulence, and even diarrhoea. Theory and experience both show that drinks made slightly bitter and somewhat acid slake thirst most effectu- ally. A weak infusion of cascarilla or orange-peel, acidulated slightly with hydrochloric acid, was, with Graves of Dublin, a favorite thirst-quelling drink for fever patients. Easpberry vinegar is a useful drink. Sucking ice is very grateful. Sweet fruits, although at first agreeable and refresh- 72 INTEKNAL USE OF WATER, ing, must be taken with care and moderation, for they often give rise to a disagreeable taste, and are apt to produce flatulence or diarrhoea. There is no advantage in "curtailing beyond a moderate degree the amount of water drunk by diabetic patients. The urine and sugar may by this means be lessened, but the general distress increased " (Koberts). In the thirst of diabetes Prout recommends tepid drinks. Rincing the mouth with water as hot as can he borne will often relieve and indeed sometimes, subdue toothache, though occasionally cold water answers better. Water is necessary both for the digestion and solution of food, but an insufficient as well as an excessive quantity are alike harmful. Tlie char- acter of the fermentations, it is well known, depends on the amount of water present; for instance, Avith sugar, if there is ]:)ut little water present, no fermentation will take place; while, on the other hand, with excess of water, acetous, instead of vinous fermentation, will be set up. It is more than probable that the quantity of water taken with the food may, in a similar way, affect the changes which it undergoes in the stomach. This much is certain, that the drinking habitually an excess of water with the meals often aggravates dyspepsia, and, on the other hand, indigestion ap- pears in some cases to be connected with an insufficient quantity of fluid. Flatulent dyspepsia is often traceable to excess of drinking at meal times. Too much water taken with the food impairs digestion, simply by di- luting the gastric juice, and so weakening its solvent power. The popular idea proves to be correct, that