SYSTEM OF Physiologic Therapeutics VOLUME IXSystem of Physiologic Therapeutics Eleven Octavo Volumes American, English, German, and French Authors A Practical Exposition of the Methods, Other than Drug-giving, Useful in the Prevention of Disease and in the Treatment of the Sick. Edited by Solomon Solis Cohen, a.m., m.d. Electrotherapy. Thoroughly Illustrated. 2 Volumes By George W. Jacoby, m.d., New York, with special articles by Edward Jackson, a.m., m.d., Denver, Col.—By William Scheppegrell, m.d., New Orleans.—By J. Chalmers Da Costa, m.d., Philadelphia.—By Franklin H. Martin, m.d., Chicago—By A. H. Ohmann-Dumesnil, m.d., St. Louis. Climatology and Health Resorts, Including Mineral Springs. 2 Volumes. With Colored Maps By F. Parkes Weber, m.a., m.d., f.R.c.p., London ; and Guy Hinsdale, a.m.„ m.d., Philadelphia. With a special article on the Climate of Hawaii, by Dr. Titus Munson Coan, of New York. The maps have been prepared by Dr. W. F. R. Phillips, of the United States Weather Bureau, Washington, D. C. Prophylaxis—Personal Hygiene—Nursing and Care of the Sick. Illustrated By Joseph McFarland, m.d, Philadelphia; Henry Leffmann, m.d., Phila- delphia; Albert Abrams, a.m., m.d. (University of Heidelberg), San Fran- cisco; and W. Wayne Babcock, m.d., of Philadelphia. Dietotherapy—Food in Health and Disease By Nathan S. Davis, Jr., a.m., m.d., Chicago. With Tables of Dietaries, Relative Value of Foods, etc. Mechanotherapy—Physical Exercise. Illustrated By John Kearsley Mitchell, m.d., Philadelphia; and Luther Gulick, m.d., Brooklyn, N. Y. With a special article on Orthopedic Appliances, by Dr. James K. Young, of Philadelphia. Rest—Mental Therapeutics—Suggestion By Francis X. Dercum, m.d., Philadelphia. Hydrotherapy—Thermotherapy— Phototherapy—Heliotherapy— Crounotherapy—Balneology. Illustrated By Dr. Wilhelm Winternitz, Vienna, assisted by Drs. Strasser and Buxbaum, and Dr. E. Heinrich Kisch, Prague. Translated by A. A. Eshner, m.d., Philadelphia. Includes notes by Guy Hinsdale, m.d., of Philadelphia ; a Chapter on Classification of Mineral Waters, by Dr. A. C. Peale, of the National Museum, Washington, D. C.; an Article on Photo- therapy, by J. H. Kellogg, m.d., Battle Creek, Mich.; and an Article on Saline Irrigations and Infusions, by Harvey Cushing, m.d., of Johns Hopkins Hospital, Baltimore. Pneumatotherapy and Inhalation Methods. Illustrated By Dr. P. Tissier, Paris. Translated by A. A. Eshner, m.d., Philadelphia. Serotherapy-—Organotherapy—Blood-letting, etc.—Principles of Therapeutics—Digest and General Index to all Volumes By Joseph McFarland, m.d., Philadelphia.—O. T. Osborne, m.d., New Haven, Conn.—Frederick A. Packard, m.d., Philadelphia.—The Editor, and Augustus A. Eshner, m.d., Philadelphia. Descriptive Circular upon ApplicationA SYSTEM OF PHYSIOLOGIC THERAPEUTICS A PRACTICAL EXPOSITION OF THE METHODS, OTHER THAN DRUG- GIVING, USEFUL IN THE PREVENTION OF DISEASE AND IN THE TREATMENT OF THE SICK EDITED BY SOLOMON SOLIS COHEN, A.M., M.D. PROFESSOR OF MEDICINE AND THERAPEUTICS IN THE PHILADELPHIA POLYCLINIC; LECTURER ON CLINICAL MEDICINE AT JEFFERSON MEDICAL COLLEGE; PHYSICIAN TO THE PHILADELPHIA HOSPITAL AND TO THE RUSH HOSPITAL FOR CONSUMPTION, ETC. Volume IX Hydrotherapy, Thermotherapy, Heliotherapy, and Phototherapy by DR. WILHELM WINTERNITZ PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF VIENNA; DIRECTOR OF THE GENERAL POLYCLINIC IN VIENNA ASSISTED BY DR. ALOIS STRASSER, and DR. B. BUXBAUM, INSTRUCTOR IN CLINICAL MEDICINE AT THE CHIEF PHYSICIAN OF THE HYDROTHERAPEUTIC UNIVERSITY OF VIENNA INSTITUTE IN VIENNA AND Balneology and Crounotherapy BY DR. E. HEINRICH KISCH PROFESSOR IN THE UNIVERSITY OF PRAGUE; PHYSICIAN AT MARIENBAD SPA Translated by AUGUSTUS A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic, etc., and with notes on American Springs by Guy Hinsdale, A.M., M.D. Including Special Chapters on The Classification of Mineral Waters and their Distribution in the United States, by A. C. Peale, M.D., Aid in the National Museum, Washington, D.C., In charge of Mineral Water Statistics of the United States Geological Survey ; On the Practice of Phototherapy and Thermotherapy, by J. H. KELLOGG, M.D., of Battle Creek, Michigan; and on Saline Irrigation and Infusions, by Harvey Cushing, M.D., of Johns Hopkins Hospital, Baltimore; also an Appendix by the Editor. ILLUSTRATED PHILADELPHIA . BLAKISTON’S SON & CO. IOI2 WALNUT STREET 1902 PCopyright, 1902, P. Blakiston’s Son & Co£ WM. F. FELL & CO., ELECTROTYPERS AND PRINTERS, 1220-24 SANSOM STREET, PHILADELPHIA.EDITOR’S PREFACE The subjects discussed in this volume have a twofold association: that of fundamental principle, and that of convenience. Much of the therapeutic utility of water depends upon what Professor Winternitz terms its ‘ thermic influence ’; that is to say, upon its physical availability for altering the body-temperature, generally or locally, primarily or secondarily, by addition or by abstraction of heat The consideration of other methods of thermotherapy—as also that of psychrotherapy or excessive cold—is thus naturally associated with the study of hydrotherapy; and, as a part at least of the physiologic, therapeutic, and morbific powers of the radiations of the sun and other luminous bodies is due to heat, the subjects of heliotherapy and of general phototherapy likewise find here an appropriate connection. If, on the other hand, the chemical effects of the actinic solar rays and of the electric light be given prominence, it is to be remembered that baths of water, and especially of mineral waters, have important chemical relations, and that these, moreover, may vary with tempera- ture ; so that the association from this viewpoint is no less intimate. Furthermore, neither direct chemical nor direct thermic influences, alone or in association, will fully explain the remedial actions of water, of heat, or of light; but there must also be considered certain indirect, and largely innervational, changes, governed in each case by the same physical and biologic principles, and brought about in all by similar, or even identical, physiologic mechanisms. These changes and their effects, constituting as a whole the ‘ physiologic reaction ’—perhaps even better termed the 4 therapeutic reaction ’—upon which Professor Winternitz rightly lays so much stress, are of the highest import in treatment, and, indeed, form the immediate object of most of the measures discussed in the present volume. It has, therefore, seemed best to bring together, and in the same book with the exposition of these reactions, the descriptions of the various expedients by which they can be evoked. Moreover, the procedures described, whether in the use of water, of heated air, or of light, are largely of the nature of baths, general or partial; and are not only similar in method and in the character of the apparatus employed, but are often and of necessity associated in their applica- tion. This is true alike of th^^^Qi^atively simple measuresVI EDITOR S PREFACE available at the patient’s home, and which it is the purpose of this volume to emphasize in the hope of extending their use ; of those, slightly more elaborate, that can be applied in the physician’s office ; and of those which, because of their complexity or of their time- consuming character, require the facilities and elaborate apparatus of special institutes. Thus, both from the viewpoint of theory and from that of practice, the association is necessary. The medical and surgical uses of irrigations and of saline infu- sions form an important part of hydrotherapy ; and with the external use of water, its internal administration for other than dietetic pur- poses must likewise be considered. This is the more necessary in the case of the complex solutions derived from mineral springs, whose use, indeed, trenches upon the borders of pharmacotherapy—a further illustration, were one needed, of the absence of sharp division-lines in nature or in art. The important subject of drinking-cures with mineral waters—here given a new name, ‘ Crounotherapy,’ or ‘ spring- treatment ’ (y.pou'Mjq and ftepa-sia), to distinguish it from balneotherapy,1 or ‘ bath-treatment ’—deserves more attention than it has yet received from others than physicians practising at spas. Especially does the classification of mineral waters need to be cleared up. The text of Professor Kisch, authoritative from the therapeutic standpoint, con- forms largely to the German usage in respect to classification and has been left practically unchanged, because that usage is, on the whole, a convenient one clinically. It has been deemed wise, however, to insert an introductory chapter, comparing and correlating the differing schemes of American, English, French, and German writers. Dr. A. C. Peale, of the United States National Museum, whose original studies of the subject are well known, and whose scheme of classifica- tion seems to the editor the best yet proposed, has written this valu- able article, which should serve to dissipate much of the unnecessary obscurity and confusion hitherto prevailing. At the same time, Dr. Peale has contributed a much-needed systematic arrangement of the mineral waters of the United States, grouped according to their pre- dominant chemical constituents, with descriptive reference to their geographic distribution, and with comparisons of analogous European waters. This work, here done thoroughly for the first time, will doubtless assist in making more widely known and more readily available the great natural resources of the United States in balneo- therapy and crounotherapy; and, together with the description of American health resorts in volume iv of this series, places within reach of the American physician information that hitherto has had to 1 This term, although objectionable as a mixture of Greek and Latin, is retained on account of its established use in medical literature. Loutrotherapy (from Tiovrpov) would, perhaps, be better.editor’s preface vii be sought in many scattered and even recondite sources, and much of which, indeed, has not previously been published. Other supplementary chapters are those by Dr. J. H. Kellogg, upon ‘ Phototherapy and Thermotherapy/ detailing experiences which Professor Winternitz and his collaborators omit or refer to but briefly ; by Dr. Harvey Cushing, upon ‘Saline Irrigations and Infusions,’ a subject believed to be worthy of considerable detail in descrip- tion ; and the editorial Appendix, dealing with certain hydriatric methods as practised in the United States—especially cold baths and other procedures applicable in typhoid and other fevers, and artificial carbonated baths. The notes upon American mineral baths and waters incorporated with the text of Professor Kisch are largely by Dr. Guy Hinsdale. The editor is indebted to his clinical assistant, Dr. R. Max Goepp, for valuable aid in preparing the manuscript for press and in reading proof.CONTENTS HYDROTHERAPY, THERMOTHERAPY, AND PHOTO- THERAPY PART I—PHYSIOLOGIC BASIS OF HYDROTHERAPY CHAPTER I PAGE Fundamentals, ................................................. 17-26 Definition. Primary Thermic, Mechanical, and Chemical Stimulation. Effects upon the Nervous System. Secondary Thermic, Mechanical, and Chemical Effects. Local Cooling and Heating. General Cooling and Heat- ing. ITeat Regulation. CHAPTER II Effects of IIydrotherapeutic Measures upon Special Tissues and Organs,................................................ 27-38 Muscular Tissues—The Heart and Vessels. Circulation and Blood Pressure. Constitution of the Blood. Metabolism. Secretion and Excretion. CHAPTER III The Chemical Effects and Internal Use of Water,................ 39-45 External Application—Influence of Carbon Dioxid. Internal Use of Water —Drinking; Irrigation; Effect on Pulse and Temperature; Vasomotor Effects ; Absorption ; Effect upon the Blood. Therapeutic Methods— To Increase Fluidity of Tissue ; To Increase Absorption and Elimination. Effects upon Metabolism and Excretion. CHAPTER IV The Reaction,................................................. 46-48 Effects Due to Reaction. Conditions Governing the Reaction. The Neces- sity of Complete Reaction. Recapitulation. CHAPTER V Fundamental Principles and Practical Applications of Heliotherapy and Phototherapy,...................................... 49-55 Physics and Physiology—Thermic, Luminous, and Actinic Rays. General Effects of the Various Rays. Special Effects of Actinic Rays. Therapeutic Experiences—Sun Baths ; Electric Light Baths. PART II—THE TECHNIC AND THE METHODS OF HYDROTHERAPY CHAPTER I General Baths,..................................... 59-70 General Considerations. Precautionary Measures. The High Bath. The Plunge Bath. The Half-bath. The Ziemssen Graduated Bath. The Cold Full Bath. IXX CONTENTS CHAPTER II PAGE Partial Baths and Other Procedures,................................. 71-89 The Occipital Bath. The Elbow-bath. The Hand-batli. The Foot-bath. The Sitzbath. The Cold Rub. Ablutions. Douches and Affusions. CHAPTER III The Wet Compress,................................................... 90-103 Cold and Warm Compresses. The Stimulating Compress. Buxbaum’s Steam Compress. The Thermophore and Electrothermophore. Head, Throat, Chest, Trunk, Hemorrhoidal, and Genital Compresses. The Abdominal Binder. Winternitz Combination Compress. The Sural Compress. Circu- lar Compresses. CHAPTER IV Wet and Dry Pack; Bags and Coils; Irrigation,.......................104-117 The Wet Pack. The Dry Pack. Bags, Coils, and Irrigation Apparatus. CHAPTER V Sweat Baths; Additional Local Applications of Heat and Cold, . . 118-128 Sweat Baths. Steam Cabinet Bath. Hot-air Bath. Electric Light Bath. Sand Baths. Baking Apparatus. Psychrotherapy. PART III—SPECIAL HYDROTHERAPY CHAPTER I Acute Febrile Infectious Diseases, .............................131-142 Preliminary Considerations. Typhoid Fever. Malaria—Malarial Cachexia. Intestinal Infections—Cholera Asiatica ; Cholera Nostras; Dysentery. Acute Exanthematous Infections—Pulmonary Complications of Measles; Scarlet Fever. Diphtheria. Acute Articular Rheumatism. CHAPTER II 'Intoxications; Anemia; Metabolic Disorders,....................143-151 Chronic Saturnism. Chronic Arsenic Poisoning. Alcoholism. Chlorosis and Anemia. Obesity. Diabetes. Gout. CHAPTER III Diseases of the Nervous System and of the Muscles and Joints, . . 152-172 Neurasthenia—Analysis of Symptoms. Hysteria. Epilepsy. Chorea Minor. Hemicrania. Exophthalmic Goiter. Occupation Neuroses. Neuralgia. Paralysis. Neuritis and Polyneuritis. Spasmodic Tic. Tabes Dorsalis. Myelitis. Diseases of the Brain and its Membranes—Acute Cerebral Lep- tomeningitis ; Cerebral Anemia; Cerebral Hyperemia; Cerebral Hemor- rhage ; Cerebral Embolism ; Psychoses. Diseases of the Muscles and Joints —Chronic Articular Rheumatism; Rheumatoid Arthritis ; Gout; Arthritic Muscular Atrophy ; Acute Myopathies ; Chronic Muscular Rheumatism. CHAPTER IV Diseases of the Respiratory Organs,...........................173-180 Pulmonary Tuberculosis. Bronchitis. Pneumonia. Pleurisy. CHAPTER V Diseases of the Circulatory Apparatus,........................181-189 Acute and Chronic Endocarditis. Treatment of Cardiac Insufficiency. Peri- carditis. Arteriosclerosis. Hemorrhoids.CONTENTS xi CHAPTER VI PAGE Diseases of the Digestive Organs,.........................190-197 Diseases of the Stomach—Nervous Dyspepsia ; Chronic Gastric Catarrh ; Acute Gastric Catarrh; Ulcer of the Stomach ; Atony and Dilatation. Dis- eases of the Intestine—Diarrhea ; Intestinal Catarrh ; Constipation; Acute Enteritis ; Catarrhal Jaundice. Acute General Peritonitis and Perityphlitis. Diseases of the Biliary Passages and of the Liver—Cholelithiasis ; Hyper- emia of the Liver. CHAPTER VII Diseases of the Urinary Apparatus, of the Female Sexual Organs, AND OF THE SlvIN. VENEREAL DISEASES,...........................I98-206 Diseases of the Kidneys. Acute Nephritis. Uremia. Nocturnal Enuresis. Chronic Inflammatory Dermatoses. Ulcers and Burns. Eczema. Psoriasis. Syphilis. Gonorrhea. Cystitis. Prostatitis. Amenorrhea. Menorrhagia. Dysmenorrhea. Metritis and Endometritis. SUPPLEMENTAL CHAPTERS—HELIOTHERAPY, PHO- TOTHERAPY, THERMOTHERAPY, AND SALINE INFUSIONS AND IRRIGATIONS CHAPTER I Heliotherapy : General and Local Uses of Sunlight,...........209-225 Preliminary Considerations. Physiologic Effects of Light. Sunbuyn. Photo- therapy. The Sun-bath—Technic; Physiologic Effects; Indications and Counterindications. Local Applications of Sunlight—Mode of Action and Effects; Indications. CHAPTER II Electrophototherapy, .........................................226-241 Physiologic Effects. Electric Sunstroke. The Arc Electric Light Bath— Description and Technic ; Physiologic Effects ; Indications. Local Applica- tions of the Arc Electric Light. The Incandescent Electric Light—Technic ; Physiologic Effects; Therapeutic Effects and Mode of Application; Indi- cations. CHAPTER III Principles of Thermotherapy,................................ 242-261 Definitions. General Physiologic Effects—Effects of Heat on Skin ; Muscles ; Nervous System ; Circulation ; Blood ; Respiration ; Body-temperature ; and on the Viscera. Anatomic Basis. Cutaneous Reflex Areas; Correlated Vascular Areas. The Practice of Thermotherapy—General Indications; Modes of Application. CHAPTER IV General and Local Applications of Heat, ......................262-278 The Turkish Bath—Description ; Physiologic Effects ; Indications ; Counter- indications and Precautions. The Hot-air Bath—Description and Technic ; Indications. The Local Hot-air Bath—Description and Technic ; Appa- ratus; Special Precautions; Indications, The Dry Pack—Technic; Mode of Action ; Indications. Rubber Bags ; Hot Water Bottles or Jugs; Heated Sand-bags, Bricks, Blocks of Wood, and Other Objects. The Heating or Stimulating Compress. CHAPTER V Saline Irrigations and Infusions,............................ 279-296 Introduction. Methods of Administration—Enteroclysis; Subcutaneous Infu- sion ; Peritoneal Infusion; Intravenous Infusion ; Intra-arterial Injections. Concerning Infusion Solutions. Some of the Special Indications.Xll CONTENTS BALNEOLOGY AND CROUNOTHERAPY INTRODUCTION PAGE The Classification of Mineral Waters with Especial Reference to the Characteristics and Geographic Distribution of the Medicinal Springs of the United States,.........V . . . . 299-365 part i—mineral waters and their uses Section I—Mineral Baths CHAPTER I Constitution and General Effects of Mineral Baths,......369-375 Definition. Lack of Absorption. The Promotion of Absorption. Endos- mosis and Exosmosis. Other Factors in the Efficacy of Mineral Baths— Chemical Stimulation ; Gaseous Interchange ; Electric Irritation ; Thermic Irritation; Mechanical Irritation ; Influence upon the Blood and General Metabolism. Classification of Mineral Baths. CHAPTER II Acratothermal Baths, ...................................376-379 Definition. Constituents. Temperature. ^Therapeutic Division. Baths of Indifferent Temperature—Effects ; Indications ; Localities. Temperature- elevating Baths—Effects ; Indications ; Localities. CHAPTER III Acid Baths and Brine Baths,.............................380-387 Acid, Carbonated, or Effervescing Baths—Effects and Uses. Auxiliaries to the Efficacy of Acid Baths. Artificial Gas Baths. Common Salt or Brine Baths (Soolbader)—Definition ; Effects and Uses. Thermal Brine Baths— Indications ; Localities. Inhalation of Brine Vapors. .Cold Brine Baths— Indications ; Localities. Artificial Brine Baths. CHAPTER IV Sea-baths,.....................................................388-394 General Considerations. Effects and Uses. Indications. Seasons. Lo- calities. CHAPTER V Sulphur Baths ; Iron Baths,....................................395-400 Sulphur Baths—Composition ; Effects ; Indications ; Methods ; Localities. Steel Baths—Composition ; Effects ; Indications ; Methods ; Localities ; Vit- riol Baths—Effects; Indications; Localities. CHAPTER VI Gas Baths ; Peat Baths and Mud-baths ; Mineral Steam Baths ; Medi- cated Baths,........................ ..............................401-413 Dry Gas Baths—-Composition. Carbonic Acid Gas Baths—Effects ; Indi- cations ; Methods; Localities. Sulphurous Gas Baths—Indications and Methods. Peat Baths and Mud-baths—Peat Baths: Composition ; Effects ; Indications; Localities—Iron Peat Baths ; Sulphurous Peat Baths. Mud- baths—Effects and Uses ; Localities. Salt Mud-baths—Localities. Mineral Steam Baths ; Methods ; Effects ; Indications ; Localities. Irish-Roman Baths—Indications. Mineral Water Spray Baths. Medicated Baths— Preparation; Effects and Uses. Thermal Calcium Baths—Indications.CONTENTS Xlll Section II—Crounotherapy: The Use of Mineral Waters for Drinking-cures CHAPTER I PAGE Principles of Crounotherapy,....................................414-416 General Considerations. Constituents of Mineral Springs. Classification. CHAPTER II Alkaline Mineral Waters,........................................417-425 Simple Acidulous (Carbonated) Waters—Effects and Uses. Alkaline Acid- ulous Waters—Constituents ; Effects ; Indications; Localities. Alkaline Muriated Acidulous Waters—Effects and Uses ; Indications; Localities. Alkaline Saline Mineral Waters—Constituents ; Effects and Uses ; Indica- tions; Dosage; Localities. CHAPTER III Sodium Chlorid Waters, ..........................................426-432 Constituents. Effects and Uses. Indications. Dosage. Localities. Lithia Waters. Iodin Waters—Constituents ; Effects and Uses ; Localities. CHAPTER IV Bitter Waters ; Sulphurous Waters,...............................433-440 Bitter Waters—Constituents; Action and Effects ; Indications and Counter- indications ; Dosage; Localities. Sulphurous Waters—Constituents and Classification; Effects; Indications and Counterindications ; Dosage; Lo- calities. CHAPTER V Iron or Chalybeate Waters,.......................................441-447 Constituents. Carbonated Iron or Steel Waters—Effects and Uses ; Dosage ; Indications and Counterindications; Localities Vitriol or Iron Sulphate Waters—Indications ; Localities. Arsenical Iron Waters—Indications; Localities. CHAPTER VI Earthy Mineral Waters ; Acratothermal Waters,...................448-452 Earthy Mineral Waters—Constituents ; Effects and Indications ; Localities. Acratothermal Waters. PART II—BALNEOTHERAPEUTIC AND CROUNO- THERAPEUTIC INDICATIONS FOR THE INDIVIDUAL FORMS OF CHRONIC DISEASE CHAPTER I Constitutional Diseases and Disorders of Metabolism, ...........455-468 • Anemic States. Scrofulosis. Excessive Deposition of Fat and Obesity. Diabetes Mellitus. Gout. Rachitis. Constitutional Syphilis. CHAPTER II Diseases of tile Respiratory Organs,................. ... 469-472 Chronic Rhinopharyngitis, Laryngitis, and Bronchitis. Chronic Emphysema of the Lungs and Bronchial Asthma. Chronic Pulmonary Tuberculosis. CPIAPTER III Diseases of the Heart and the Blood-vessels,.................... 473-476 Functional Disorders of the Heart. Valvular Lesions—Arteriosclerosis. Neurotic Disorders of the Heart. Fatty Heart.XIV CONTENTS CHAPTER IV PAGE Diseases of the Digestive Organs,................................477-483 Diseases of the Stomach. Diseases of the Liver and the Biliary Passages. Diseases of the Spleen. CHAPTER V Diseases of the Nervous System, .... ...................484-488 Diseases of the Brain. Paralysis. Diseases of the Spinal Cord; Periph- eral Neuroses. CHAPTER VI Diseases of the Urinary Organs,..................................489-493 Diseases of the Urinary Bladder. Diseases of the Kidneys. Urinary Con- cretions CHAPTER VII Diseases of the Genitalia,.......................................494-498 Diseases of the Female Genitalia—Chronic Inflammatory States ; Menstrual Abnormities ; Neoplasms. Diseases of the Male Genitalia. CHAPTER VIII Diseases and Injuries of the Joints,.............................499-501 Chronic Muscular and Articular Rheumatism. Traumatic Injuries of the Organs of Locomotion. CHAPTER IX Diseases of the Organs of Special Sense,.........................502-503 Diseases of the Skin. Diseases of the Eye. Diseases of the Ear. APPENDIX Additional Methods for the Therapeutic Use of Water, Heat, Cold, Light, and Mineral Baths,................................5°7~538 Apparatus. Typhoid Fever—Cold Bathing; Brand Bath; Sprinkling; Abdominal Coil; Wet Pack; Sheet Bath; Towel Bath ; Ice Rub ; Ablution ; Ice Pack ; Accessory Measures. Portable Tubs and Bed Baths. Ice Cradle. The Continuous Bath. To Make Rubber Coils. Pneumonia. Laryngitis and Pharyngitis. Thermic Fever and Heat Exhaustion. Applications of Heat. Irrigation of Hollow Viscera. Artificial Carbonated and Nauheim Baths. Refrigerated Light. Index, .............................................................. 539LIST OF ILLUSTRATIONS FIG. PAGE 1. Half-bath with Affusion.—{Polyclinic Hospital, Philadelphia; German Method), . 2. Half-bath with Friction.—(Polyclinic Hospital, Philadelphia ; German Method), . 3. Lifting Patient into Tub.—( Typhoid Fever, Polyclinic Hospital, Philadelphia), . 4. Rubbing the Patient in the Tub. Cold Douches to Head and Shoulders. (Ther- mometer Exaggerated to Show Its Presence.)—(Typhoid Fever, American Method, Polyclinic Hospital, Philadelphia),.............................. 5. Lifting Patient into Bed after Tubbing.—(Typhoid Fever, American Method, Poly- clinic Hospital, Philadelphia)........................................... 6. Drying the Patient after Tubbing. Ice-cap to Head ; Hot-water Cans to Lower Extremities. — [American Method, Polyclinic Hospital, Philadelphia), .... 7. Head-coil Ready for Use,.................................................... 8. Head-coil Flattened,...................................................... , 9. Head-coil in Position,................................................. 10. Cold Rubbing Sitzbath.—[After Kellogg),..................................... 11. Cold Rub. Passing the Sheet across Chest and Abdomen,...................... 12. Cold Rub. Bringing Slack of Sheet over Right Shoulder,...................... 13. Cold Rub. Sheet in Final Position; Friction Begun,.......................... 14. Rain Bath,.................................................................. 15. Combined Rain Douche, Horizontal Jet, and Multiple Circular Douche.—(After Kellogg), ........................................................... 16. Ascending or Perineal Douche.—(After Baruch), .............................. 17. Ombrophore Packed,.......................................................... 18. Ombrophore in Use,.......................................................... 19. Construction of Carbonic Acid Douche in Ombrophore,......................... 20. Filiform Douche, ........................................................... 21. Winternitz’s Douching Table,................................................ 22. Baruch’s Stationary Douche Apparatus, Showing also Circular Douche with Mov- able Roses,............ ......................................... 23. Lindemann’s Electrothermic Compresses,...................................... 24. Lindemann’s Electrothermic Cabinet,......................................... 25. Lindemann’s Electrothermophore,................ ............................ 26. Cold Collar, ............................................................... 27. Throat Coil,................................................................ 28. Crossbinder,................................................................ 29. Trunk Compress, ............................................................ 30. The Winternitz Combination Compress with Epigastric Coil, .................. 31. Abdominal Binder,............. ............................................. 32. Circular Join! Compress.—(After Kellogg),................................... 33. Wet Pack in Readiness.—(Polyclinic Hospital, Philadelphia), ................ 3 b Wet Pack; Sheet Drawn from Left to Right; Patient’s Arms Elevated.—(Poly- clinic Hospital, Philadelphia),............................. ................... 35- Wet Pack ; Sheet Drawn from Right to Left; Patient’s Arms Included.—(Poly- clinic Hospital, Philadelphia),................................................. 36. Wet Pack ; Adjusting the Blanket.—( Polyclinic Hospital, Philadelphia), . . . 37- Wet Pack Complete.—(Polyclmic Hospital, Philadelphia),...................... 38. Buxbaum’s Modified Wet Pack with Precordial Coil, .......................... 39- Towel Chest Pack.— (After Kellogg),......................................... 40. Chapman’s Bags, ............................................................ 41 • Spinal Coil,.............................................. , 63 63 65 67 68 69. 72 72 73 74 77 73 79 81 86 86 86 37 37 88 91 92 93 95 96 97 99 100 101 102 105 105 106 107 108 109 no 112 ^3 XVXVI LIST OF ILLUSTRATIONS fig. 42. Psychrophore of Winternitz,................................................. 43. Atzperger’s Rectal Irrigator,............................................... 44. Rectal Dilator, ............................................................ 45. Vaginal Dilator,............................................................ 46. Hydrophore,................................................................. 47. Lahmann’s Horizontal Steam Cabinet (Open), ............... 48. Lahmann’s Horizontal Steam Cabinet in Use, ................................. 49. Baruch’s Hot-air Cabinet, Open to Show Construction, ....................... 50. Winternitz’s Steam Tub Bath,............................................. 51. Frames for Winternitz1 s Steam Tub Bath,.................................... 52. Indoor Sun-bath, ........................................................... 53. Finsen’s Method of Localized Heliotherapy,.............. ................... 54. Effect of Heliotherapy (Finsen),............................................ 55. Kellogg’s Arc Light Cabinet, ............................................... 56. Finsen’s Apparatus for Localized Electrophototherapy,.................. 57. Lortet-Genoud Lupus Lamp, ............................ ..................... 58. Kellogg’s Incandescent Electric Light Apparatus for Spine and Feet,......... 59. Kellogg’s Horizontal Incandescent Electric Light Cabinet,................... 60. Kellogg’s Electric Light Apparatus for Joints,.............................. 61. Anterior Cutaneous Areas Reflexly Associated with Internal Parts,........... 62. Posterior Cutaneous Areas Reflexly Associated with Internal Parts,.......... 63. Cutaneous Vascular Areas Collaterally Related with the Vessels of the Viscera (Front View),........................ ................................... 64. Cutaneous Vascular Areas Collaterally Related with the Vessels of the Viscera (Back View),............................................................. 65. Kellogg’s Hot-air Cabinet, ................................................. 66. Domestic Hot-air Cabinet,................................................... 67. Simple Hot-air Box for the Limbs,..........»................................ 68. Hot-air Chamber for the limbs,.............................................. 69. Dry Pack,.............. . . ................................................ 70. Abdominal Coil (Typhoid Fever),....................... .................... 71. Temperature Chart Showing Antipyretic Effect of Sprinkling in a Case of Typhoid Fever; Editor’s Service, Polyclinic Hospital.—{Courtesy ofii American Medi- cine”), ............................................................... 72. Sprinkling with a Watering-pot; Ice Rub (‘ Ice-ironing’),................... 73. Sprinkling with an Irrigating Apparatus ; Ice Rub,....................... . 74. Baruch’s Portable Hospital Tub,............................................. 75. Burr’s Bed-bath,........................................................... 76. Burr’s Portable Frame for Bed-bath,........................................ 77. Ice Cradle (Partial Application),.......................................... 78. Throat Compress. Correct and Incorrect Application.—{After Baruch), . . . . 79. Placing the Hot Blanket in.the Wringer, ................................... 80. Wringing Out the Blanket,................................................... 81. Method of Giving Hot-air Bath in Bed,.......... ............................ 82. Kemp’s Rectal Irrigator,................................................... 83. Hemmeter s Improved Recurrent Stomach-tube,............................ 84. Fouveau-Trouve Chemical Radiator,........................................... PAGE 114 115 116 117 117 119 119 120 123 123 215 223 224 228 229 231 232 233 234 251 252 255 256 268 270 272 273 276 512 5H 515 5*8 Si8 518 520 524 526 527 528 529 533 538A System of Physiologic Therapeutics HYDROTHERAPY, THERMOTHERAPY, AND PHOTOTHERAPY By Professor Dr. Wilhelm Winternitz OF KALTENLEUTGEBEN ASSISTED BY DR. ALOIS STRASSER and DR. B. BUXBAUM OF VIENNA Translated by AUGUSTUS A. ESHNER, M.D., of Philadelphia Part I PHYSIOLOGIC BASIS OF HYDROTHERAPY BY Dr. Wilhelm Winternitz PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF VIENNA; DIRECTOR OF THE GENERAL POLICLINIC IN VIENNAA SYSTEM OF PHYSIOLOGIC THERAPEUTICS Hydrotherapy, Thermotherapy, and Phototherapy PART I PHYSIOLOGIC BASIS OF HYDROTHERAPY CHAPTER I FUNDAMENTALS Defijiition, Primary Thermic, Mechanical, and Chemical Stimulation. Effects upon the Nervous System. Secondary Thermic, Mechanical, and Chemical Effects. Local Cooling and Heating. General Cooling and Heat- ing. Heat Regulation. Hydrotherapy may be defined as the systematic application of water at various temperatures and in varying form to the surface of the body for dietetic, prophylactic, and therapeutic purposes. The definition as given is as incomplete as definitions generally are and must be—a fact that at once becomes apparent when it is con- sidered that in order to attain a successful result, mechanical, chemical, and other influences must often be operative simultaneously. We shall better arrive at a conception of what is comprehended by hydrotherapy if we attempt to present in general lines an analysis of the mode of action of this remedial procedure. Water, in liquid, solid, or gaseous state, brought into contact with the normal surface of the body, acts (i) through its temperature, or (2) through its volume ; also (a) mechanically, and (b) chemically, ix—2 17i8 FUNDAMENTALS Primary Thermic, Mechanical, and Chemical Stimulation Cold and heat are appreciated as cold or heat, or also as pain, in accordance with the difference in the temperature of the media brought in contact with each other. As sensations are conveyed only through the nervous system, we may speak of cold and heat and all gradations of temperature as nerve-stimuli. Careful investigation has shown that when substances warmer or colder than the animal body are brought into contact therewith, and in accordance with the degree of temperature employed, there results an increase or a reduction in the energy, or a modification in the quality, of the innervation at the point of contact. The sensory peripheral nerve terminations are brought to a state of more delicate or more dull perceptive power; therefore, to a state of increased, or diminished, or altered function. The result to be expected in advance is dependent upon the absolute difference in temperature between the skin and the medium employed ; upon the duration of the action ; its suddenness ; the extent of the surface of the body exposed ; the variable sensibility of the subject treated, and other cotemporaneous factors that may affect stimulation ; the physical form of the irritant measure; and, as I may anticipate, the simultaneous mechanical and chemical stimulation. Thus, an endless diversity of effects due to the possibility of innu- merable combinations of these various irritant factors is theoretically to be expected. Those that follow immediately upon the application of the irritant are in part to be observed locally at the point of irritation and in part are conducted, communicated, or reflected throughout the organism, by means of the nervous system. The influence of the irritation is not concluded with this. Secondary effects also may be observed, and these in part represent the reaction of the living organism to the irritation, but in part also are dependent upon primary and secondary alterations in the organism due to the supply or the withdrawal of heat. That these complicated processes have not been and cannot be studied with mathematic certainty in the living healthy or diseased organism will surprise no one ; as the same diffi- culties and deficiencies exist everywhere in the domain of therapeutics. Effects upon the Nervous System Demonstrable changes in innervation can be induced in the healthy and the diseased organism by means of hot, warm, tepid, cool, and cold applications, as well as by electric, mechanical, and chemical influences. These changes consist in increase, inhibition, reduction, modification, or destruction of the nervous influence at the point of application, or in sensory, motor, and sensorial paths; and they are conducted, reflected, and otherwise communicated throughout the entire nervous system. Not only, therefore, may we increase, diminish, modify, or destroy the perceptive power of the sensory nerve-endings at the point of applica-EFFECTS UPON THE NERVOUS SYSTEM 19 tion by thermic, mechanical, or chemical stimulation,—and thus acquire an influence over hypesthesia, hyperesthesia, and paresthesia,—but we may also accelerate, retard, modify, or inhibit conduction in the nerve channels. Furthermore, we may, through the medium of the conduct- ing paths within the central organ, induce both quantitative and quali- tative central changes of innervation, and, again, through the efferent and reflex nerve paths, influence peripheral organs. Inasmuch as the nervous system incites, stimulates, inhibits, and regulates the func- tions of all the organs, it will be possible to make an impression upon the functions of all organs through an influence exerted upon the nervous system. Every advance in our knowledge of inner- vational processes must therefore naturally indicate a similar advance in the comprehension of the effects of water. Although it is known that mechanical and chemical agencies applied to the skin act as irritants, and the significance of the stimuli with regard to life or vital processes may be considered as established, —inasmuch as life is scarcely conceivable without irritation,—the comprehension of the process of irritation, of the transformation of the physical force applied into vital energy in the cell, in the nerve, in complex organs, is as yet wholly wanting. Only hypotheses and phrases can be brought forward with regard to the nature of the irritation. This much is known : that the withholding of irritation may give rise to enfeeblement and even to derangement of function and of structure, while the application of irritation, so long as it is adequate, stimulates and strengthens, and, in excess, injures. A comprehension, not of the mode of action, but of the value of stimuli for the relief of nutritive disorders, may be afforded by the simplest possible examples. If an undersensitive or an oversensitive area of skin be exposed to a transitory thermic or, as I may anticipate, to a mechanical irritation, such as contact with a bit of ice or with a current of hot air, or dry friction, or transitory sprinkling with cold or hot water, the sensibility of the skin exposed to the thermic or chemical irritation will have undergone a change. The stimulation has modified the innervation, and, if properly applied, has corrected the existing derangement of innervation. It will not be difficult to give also illustrations of the remote effects of peripheral thermic and mechanical irritation. To what is due the restoration of a person who has fainted, by sprinkling the face with a few drops of water, but to the conveyance of the irritation from the sensory peripheral nerve terminations to the medulla oblongata ? Also the cerebral hemispheres, the common sensorium, are accessible to thermic irritation from the periphery. The changes in our nervous state, mood, capacity for woik, and desire for activity following cold and hot spongings, affu- sions, etc., represent nothing more than the result of adequate nerve-stimuli, and are available hygienically and therapeutically.20 FUNDAMENTALS The excitation and the inhibition of peripheral stimuli are among the most powerful hygienic, dietetic, and therapeutic factors at our command. Primarily they act by stimulation and depression ; the systematic repetition of which induces a cumulative effect in the desired direction, and thus transforms the temporary reaction into a permanent result But the primary nerve-stimulation will also cause demonstra- ble changes in the function of almost all other organs ; and these secondary effects are of considerable importance. The nerve-cell exposed to thermic irritation requires, for example, just as does every other organ, more or less nutritive material in accordance with its in- creased or diminished activity. Thus circulation, metabolism, diges- tion, and other nutritive processes and the organs of such processes are stimulated or depressed. The formal comprehension of thermic and mechanical, and also of chemical, effects is simplified by the demonstration that, together with nerve-stimulation, inhibiting and stimulating impulses are conveyed to the corresponding vascular terri- tories, rendering possible simultaneous increase or diminution in the supply of nutritive material, and, as a result, increase, diminution, or modification in function, local and general. The transmission of the innervational impulse to muscular tissue—animal as well as vegeta- tive, striated as well as unstriated—constitutes one of the best-studied chapters of the physical influences that may be exerted on the living organism. Vascular contraction and dilatation, with preserved and in- creased, but also with diminished and abolished, vascular and tissue tone; changes in the vigor and in the frequency of contraction of the heart are the most important thermic and mechanical effects attainable by hydrotherapeutic measures. By means of these we are able to regulate the circulatory processes in a manner often to be de- termined accurately in advance; thus obtaining a control over the most important nutritive conditions that may, in the presence of nutritive disorders, enable us to modify them in any desired manner. Thus, we may regulate the influx of blood and the efflux of blood, thereby not merely producing localized arterial hyperemia and venous stasis, but controlling the general distribution of the blood, and thus influencing local and general nutrition. Not only the heart and the muscular coat of the vessels fall within the range of our therapeutic irritation, but also the muscular coat of the intestine and striated muscular masses; and all of these are not alone susceptible of increase in function, but may also be restricted in their activity. Instances of this are found in the stimulation and inhibi- tion of peristaltic movement, and in the invigoration and enfeeblement of the musculature of the entire body. From this point of view it is com- prehensible that an influence will be gained, by means of the stimulat- ing measures at our command, over more complex organic functions.SECONDARY EFFECTS 21 By means of the primary stimulation we may modify the respiration as well as the action of the heart. The absorption of oxygen and the elimination of carbon dioxid are increased by suitable irritation, and, as a result, intra-organic oxidation is favored. The most diverse disorders of metabolism, the most varied secretions and excretions, undergo alteration qualitatively and quantitatively. It is hardly neces- sary to cite illustrative instances. I may refer to the manner in which the function of the skin may be modified at will, either to heighten or to diminish the sensible and insensible perspiration ; to the elimination of various odorous substances through the skin ; to the in- crease and diminution in the secretion of urine ; to the chemical changes in this secretion ; to alteration in the secretion of bile, etc.; with regard to all of which, further evidence will be presented in the course of this treatise. Secondary Thermic, Mechanical, and Chemical Effects The living animal organism is not exempt from the power of purely physical laws. Heat is conveyed to it by means of high tempera- tures, and heat is abstracted from it by exposure to low tempera- tures. The organism must therefore be heated by the former and cooled by the latter. Although the absorption, and likewise the dis- sipation of heat, even in the living body, are dependent upon the dif- ference in temperature between the media brought in contact with each other, the final result is not the same as that which would occur in the case of inanimate objects of different temperature. The living body generates heat, and gives it off, and the balance between these two functions is responsible for the constancy of the temperature in the body of warm-blooded animals. This balance can be maintained when heat is conveyed to or abstracted from the body, only by increase in heat dissipation in the first instance, or diminution thereof in the second instance; or by diminution in the production when heat is conveyed to the body, with increase in the production when heat is given off from the body. Thus by increase in the amount of heat-dissipation through cooling, when there is increase in the production or simultane- ous reduction in the loss, or by exciting an opposite alteration in both factors, influences affecting the temperature of the body through the conveyance or the abstraction of heat arouse the nervous and func- tional regulating (taxic) and protecting mechanisms for maintaining the body-temperature at a cr tant level. As the organic processes take place normally only wf . the body-temperature is normal, and this depends upon an equi) ium between heat-production and heat-dissi- pation, the supply an the withdrawal of heat must have an influence lesulting in increase or diminution in both these functions. We are thus able to increase or diminish each at will. As the generation of heat takes place principally at the expense of nonnitrogenous body/ 22 FUNDAMENTALS substances, we become able arbitrarily to govern metabolism in a definite direction by controlling the production and the dissipation of heat. The processes to be taken into consideration in this connec- tion are the results of heat abstraction and heat conveyance, as secon- dary or reactive manifestations. Local Cooling and Heating The effects of the local application of cold and heat may be sum- marized as follow : 1. There results cooling or heating of the surface of the part in con- tact with the thermic medium, and, provided the period of application be sufficiently long, until the temperature is almost that of the medium em- ployed. The superficial temperature always remains somewhat higher, however intense the cooling, so long as this does not destroy the vitality of the part, and likewise somewhat lower when heat is applied, if this be not unduly excessive, and not incompatible with the continu- ance of life. 2. Local cooling and heating do not modify the general body- temperature, or, at most, but inconsiderably, even after prolonged application, unless the field of application comprises almost one-fourth of the surface of the body. 3. Every portion of the body can be warmed or cooled locally to any desired depth by supply or withdrawal of heat for a sufficient period of time and in sufficiently intense degree. 4. Heating and cooling in the sequence of reduction and elevation of the temperature take place the more rapidly, the higher and the lower the surrounding temperature after the thermic application. 5. The promptitude and the degree of the reaction succeeding heat abstraction and heat supply are directly proportional to the intensity and inversely proportional to the duration of the application. 6. The condition of the part after the thermic application likewise exerts an influence upon the promptitude (rapid or gradual occurrence) and the degree of the reaction. Thus, active and passive move- ments of the part under treatment bring about more rapid restoration of heat or cold than occurs when it remains at rest. 7. Individual circumstances, especially affecting innervation and circulation, exert a great influence upon the reactive processes follow- ing thermic applications. 8. Local warming is followed by cooling of the surface in the vicinity, and local cooling by warming—a sign of altered heat distri- bution. 9. Metabolism is retarded in the cooled tissues and accelerated in the warmed organs. In the cold, inflammations exhibit, as Samuel has demonstrated experimentally, a considerably slower and milder course. This is due in part to contraction and slowing of the blood current, inGENERAL COOLING AND HEATING 23 part, however, also, to the reduction in temperature itself. The chemico- physical process and the intimate vital process are always related to a given temperature. They are retarded by cooling, possibly in some respects entirely inhibited. Experimental investigation shows that the process of diffusion between fluids of different chemical constitution— endosmosis and exosmosis—undergoes the greatest variation qualita- tively and quantitatively in consequence of alteration in temperature. Exudation and suppuration subside under the influence of cold, the pus becomes more diffluent, more nearly serous, more deficient in pus cor- puscles. When heat is applied locally, the suppuration becomes more profuse and the pus richer in cells. Esmarch has called attention to the slowing and prevention of chemical decomposition and the retardation and inhibition of fermen- tation and putrefaction by cold, and their acceleration by warmth; and also to the significance of these facts with regard to the treatment of wounds, ulcers, and zymotic processes. Also the acceleration of metabolism in the period of reaction following local reduction of tem- perature, and the slowing following such elevation of temperature, will be found to be susceptible of therapeutic application. General Cooling and Heating What is true of the local effects of cold and heat—namely, that it is ultimately possible through them to overcome the local automatic re- sistance of the living body to temperature influences—is true also of general thermic temperature influences. There are several automatic protective agencies against general reduction of body-temperature. 1. There is a reduction of the temperature of the surface of the body. Thereby is brought about a diminution in the heat ten- sion between the skin and the heat-abstracting medium employed ; thus, according to physical laws the loss of heat is diminished. 2. There is a limitation of the circulation through the skin, and in consequence collateral hyperemia in the muscular layer surrounding the entire body. Thus, while the former process is at- tended with diminished loss of heat, the muscular layer, well supplied with blood, and therefore also warmer, prevents too deep and too ready extension of the cooling influence to the internal organs. 3. The rise in temperature of the muscular layer when heat is withdrawn, which is recognizable from the rise of axillary tempera- ture, is brought about, not only by the collateral hyperemia, but also by reflex thermal influences. While cold causes contraction of the cu- taneous vessels, its effect upon the vessels of the muscles, as appears from the observations of various investigators, is to induce dilatation. 4. The increased amount of blood thus brought to the muscles appears to give rise to increased production of heat in the tissues.24 FUNDAMENTALS The most powerful protection against the too rapid penetration of cold to the internal organs is this muscular layer that, storing up and generating heat, surrounds them like a shield, and is itself protected in turn by a covering of bloodless skin, poorly conducting heat. The automatic protective measures against the effect of heat are : 1. Dilatation of the cutaneous vessels and acceleration of the circulation through the skin and the subcutaneous connective tissue. If a medium of a higher temperature than that of the skin and the blood is brought in contact with the surface of the body, the cutaneous vessels become dilated, the circulation in the skin accelerated, the secretion from the cutaneous organ stimulated. By this means the dissipation of heat from the skin is increased; the sweat, at the tem- perature of the blood, deposited upon the surface of the body, evap- orates under favorable circumstances; and in this way considerable amounts of heat are abstracted from the body. In consequence of the sweating and the evaporation of the sweat, the blood circulating in the skin is cooled, and returning to the internal organs at a lowered temperature, prevents overheating of them. 2. Should the action of the heat be continued for a longer time, a large amount of blood will be retained in the skin in consequence of loss in tonicity of the cutaneous vessels; the cutaneous circulation will be slowed, and thereby the blood heated at the surface of the body is prevented from returning to the internal organs and heating these. 3. In consequence of the increased accumulation of blood in the skin, a diminished amount of blood will remain in the internal organs; thus the activity of these, and thereby also the production of heat, will be lessened. In these processes will be found a safeguard against excessively rapid penetration of the heat to the internal organs, and against the unduly rapid elevation of the body-temperature through thermic influ- ences. This is the automatic protection against heat residing in the living animal organism. Heat-regulation The important role that must be played by the cutaneous circula- tion in affording protection against heat and cold will have been made clear from these considerations. Only a quantitative investigation into the difference in the degree of heat given off in accordance with vary- ing circulatory conditions in the skin, would be capable of affording a conception of the actual significance of the cutaneous circulation with relation to the thermal economy of the body. I have shown that the amount of heat given off may vary between more than 60 per cent, in a downward direction, and more than 90 per cent, in an upward direction. The importance that must beHEAT-REGULATION 25 attached to the function of the skin with relation to heat-regulation will thus become clear. Within the limits in which constancy of the body-temperature persists, this may be explained by alteration in loss of heat alone. It is thereby in no way implied that heat-production may not cause variations; and, as a matter of fact, the quantitative in- vestigations of the end-products of metabolism afford sufficient sup- port for such an assumption. Although the function of the skin is capable of compensating for one-half of the normal average heat- production, as my calorimetric studies of heat-dissipation from the skin have shown, experience has taught me in this connection that by means of voluntary and involuntary muscular activity the greatest loss of heat can not only be compensated, but even overcompensated by increase in the production of heat. From this may be deduced a practical rule of great importance—namely, that by systematic repeti- tion of powerful demands upon the heat balance (as by extremely hot and extremely cold baths) the regulation is placed at a higher or a lower degree ; the first after cold, and the latter after warm baths. As a result of careful investigations and determinations of the con- sumption of oxygen and the elimination of carbon dioxid, according to the method of Geppert-Zuntz, Dr. A. Lowy reaches the follow- ing conclusions as to that which is actually established with regard to the regulation of the body-temperature in human beings : That, as a result of the stimulating influence of cold, there first occurs contraction of the skin and its vessels, which, by restricting the dissipation of heat, brings about perfect compensation if the abstrac- tion ot heat be but slight, and but partial compensation if the abstrac- tion of heat is more marked. In the latter event the body-tempera- ture will continue to decline in greater or lesser degree, while in the former it will remain constant. Alterations in heat-production may be superadded. They depend upon tonic or clonic muscular con- tractions ; that is, muscular tension or tremulous movements that occur involuntarily, or even in opposition to the will, as a result of the profound effect of severe cold, just as they do in the sequence of other forms of irritation. Their importance as a heat-regulating measure is far less in man than is that of the skin; for they are incapable of pre- venting reduction in the body-temperature. It has now been determined that abstraction of heat causes increase in metabolic activity only if at the same time voluntary or involuntary muscular contractions occur. So long, therefore, as with abstraction of heat the temperature in the muscular layer is increased and remains increased, the stimulation induced thereby will obviously be the cause of increased production of heat, and this is certainly also a powerful factor in the regulation of heat. By systematic exercise the heat-regulating powers of the body are so greatly strengthened that they become capable not alone of com-26 FUNDAMENTALS pensating, but also of overcompensating, the supply and the dissipa- tion of heat. The Japanese, accustomed to a hot bath at a tempera- ture of from 420 to 440 C. (107.6° to m.2° F.), exhibits a temperature scarcely higher than normal; while I have observed in the case of Dr. Tschurtschenthaler that after a cold bath of twenty- five minutes’ duration at a temperature of 6° C. (42.8° F.) the body temperature was almost 390 C. (102.2° F.) on leaving the bath. This illustrates how powerfully exercise improves heat-regulation. On the whole, the function of the skin controls the loss of heat; voluntary or involuntary increase or reduction in muscular tone and in muscular contraction controls the production of heat. Both can be increased or diminished at will by thermic and mechanical influences.CHAPTER II EFFECTS OF HYDROTHERAPEUTIC MEASURES UPON SPECIAL TISSUES AND ORGANS Muscular Tissues—The Heai't and Vessels. Circulation and Blood Pres- sure. Constitution of the Blood. Metabolism. Secretion and Excretion. THE INFLUENCE OF INNERVATION UPON THE ' MUSCULAR TISSUES Next to the influence exerted upon the nerves themselves, the trans- mission of modified neural impulses to muscular tissues is of the greatest importance in the practice of hydrotherapy. By means of cold, heat, and mechanical effects, increase and diminution in the tension of all muscular tissues can be brought about. Both striated and unstriated, both voluntary and involuntary muscles, can thus be influenced, and almost with physical certainty ; physiologic function being heightened or reduced—even abolished for the time—as predetermined. ! Adequate thermic stimulation, particularly that of cold, and also adequate mechanical stimulation,—massage, friction, concussion,—> induce a heightened tonicity in all the voluntary muscular struc- tures in the area directly or reflexly affected by the irritation. In accordance with the intensity of the stimulation there may result simple increase in muscular tension or even clonic and tonic spasm— chill. The reaction of voluntary muscle under the influence of topical or general application of cold constitutes one of the most in- teresting and, with relation to hydrotherapy, one of the most impor- tant processes. The increased muscular function due to thermic and mechanical stimulation causes increased production of heat and aug- mented resistance of the muscles to fatigue. It has been demon- strated with relation to the topical and general influences of thermic measures that heat temporarily produces effects similar to those of cold, but if the application be long continued, weakness, fatigue, and diminished heat-production result. The thermic and mechanical nervous stimulation, however, affects also striated and unstriated involuntary muscular tissue. In this connection the influence upon the heart and the muscular coat of the vessels, and upon the stomach, the intestine, and the bladder, should be mentioned. 2728 EFFECTS ON SPECIAL TISSUES AND ORGANS Thermic Influences upon the Heart The action of the heart may be influenced by cold and heat in a manner subject to determination in advance. Whether the application be made directly over the precordium (topical), or to the whole body (general cutaneous application), there results, in the case of cold, acceleration of the heart’s action at the instant of application, with subsequent slowing; in the case of heat, primary slowing, with subsequent acceleration. The ultimate degree of accelera- tion and retardation will be inversely proportional to the frequency of the heart’s action prior to the thermic and mechanical application. Other things being equal, the individual contractions become more vigorous after the application of cold, and are enfeebled by the application of heat. The influence of high and low temperatures upon the heart is thus twofold: First, the innervational reflex following immediately upon the application; and, second, the effect of the actual cooling or heating of the body or of the blood. The therapeutic significance, however, that is to be attached to the slowing and the strengthening of the action of the heart that can always be brought about, may be indicated in a few words : It is the action of digitalis without toxic and cumulative effects—-namely, prolongation of the diastolic pause and thus of the period of nutrition for the heart. Effects upon the Circulation and the Blood Pressure The thermic and mechanical nervous stimulation has not only ar. influence upon the central organ of the circulation, the heart muscle, but also upon the muscular coat of the vessels; or, as it may be not inaptly phrased, upon the peripheral heart. Contraction and dilatation of the vessels by action of their muscular coat can be brought about at the point of application, and in other areas standing in functional relation with the nerve-endings acted upon. Vascular contraction and dilatation induce anemia and hyperemia respectively. The primary vascular contraction under the influence of heat and cold is followed, more or less rapidly, in accordance with the intensity of the nervous stimulation and the susceptibility of the parts to irrita- tion, by vasodilatation. I have presented arguments tending to show that the vascular dilatation resulting from the influence of heat or cold or mechanical stimulation cannot be in each case the same pro- cess. It has been assumed that the contraction of the vessels under the influence of either cold or heat is an irritative effect, while the dilatation in both instances is looked upon as a paralytic condition re- sulting from overstimulation. This view I cannot accept. I regard the vascular dilatation occurring as a result of the action of low tempera- ture and of moderate mechanical irritation as an active process, perhapsVASCULAR CONTRACTION AND DILATATION 29 due to the influence of inhibitory nerves. The vascular dilatation occurring as a result of the action of heat, on the other hand, appears to me to possess the character attributed to it in so far that it is a passive relaxation, and possibly paralytic in origin. There is no analogy to warrant the conclusion that moderate degrees of cold such as suffice to bring about dilatation of the vessels are capable of causing paralysis. Vessels dilated as the result of the action of heat and cold respectively, exhibit quite opposite relations to the entering wave of blood. Whereas the vessel dilated by heat is flaccid and exhibits all the signs of loss of tension, the vessel dilated under the influence of cold exhibits tonic resistance and all the signs of heightened tension of its walls. I cannot concede that one is justified in denying significance to the pulse tracing. This is the less justifiable, as measurements of the blood pressure also yield results of a like character. Tschlenoff also has confirmed my statements in this connection. New measurements, that I have made with the aid of Gartner’s tonometer, of the blood pressure in vessels dilated as a result of the influence of heat and cold show quite constant and uniform results, such as could not be obtained with the instruments formerly employed. Following local and general applications pushed to the verge of complete vasodilatation, I was able to observe increase in blood pressure up to 30 mm. of mercury, after the application of cold; and an equivalent lowering of the blood pressure, after application of heat. I was, moreover, able to demonstrate by still another method, one that had not previously been employed, the different effect upon the circulation of the vasodilatation resulting from the influence of heat and the vasodilatation brought about by cold. This is the influence upon the pressure in the tissues, which I tested according to the method of Landerer. Landerer has shown that a portioiyof the blood pressure is conveyed through the walls of the capillaries to the tissues. If the tissues are in an elastic state and their tension is sufficient, this portion of the blood pressure will be thrown back upon the vessels, and continues to contribute its effect to the onward movement of the blood. If, however, the tissues have lost their elasticity, the blood pressure is correspondingly diminished. This condition is observed as a result of the action of heat. To this cause are due the hypostasis and the hypostatic inflammation that are so frequently observed, for instance, in cases of typhoid fever treated without hydriatric applications. I have adduced a number of clinical arguments in favor of this fact in connection with the consideration of the effects of hydriatric antipy- resis. Here I must again insist, in spite of the contrary opinion of Matthes, that the vasodilatation occurring as a result of the action of heat represents quite a different process from that which is brought30 EFFECTS ON SPECIAL TISSUES AND ORGANS about by cold ; and while the former exhibits, in fact, a paretic char- acter, the latter does not. The theory of overstimulation or paralysis has obviously arisen in consequence of our inability to conceive how dilatation of the vessels can be brought about by contraction of their longitudinal muscular fibers. Nevertheless, Exner, in a communica- tion presented to the Academy of Sciences at Vienna in 1877, has called attention to the physical possibility of active dilatation of the lumen of the vessels. By stretching a rubber tube in its longitudinal axis we may imitate approximately the conditions that obtain in the vessel. When the tube is stretched, the lumen is contracted ; on relaxing the traction, or, in other words, upon shortening the longitudinal fibers, the lumen of the tube is widened. It is certainly inconceivable that cold is capable of bringing about a reduction in tone simulating the effect of paralysis. The influence transmitted to the muscular coat of the vessels, in consequence of thermic and mechanical impression upon the peripheral nerve-endings, constitutes one of the most powerful effects of the physical remedial forces under consideration, inasmuch as by this means active and passive hyperemia and anemia can be brought about in the most varied areas of circulation. There will be, in the section on “ Hydriatric Technic,” opportunity to present a sufficient number of instances of the influence upon blood-distribution, of thermic and mechanical derivation of the blood from individual organs, of active hyperemia and modification of the blood current, and of a re- vulsive influence upon the circulatory processes in organs remote from the point of application of stimuli. Changes in the Constitution of the Blood It was an extremely surprising observation when I was able, more than seven years ago, to demonstrate that after the action of cold and heat the morphologic and chemic constitution of the blood exhibits changes. At first I found that immediately after the influence of cold, marked leukocytosis was present. As a result of continued investigations by myself, and by my pupils, Strasser and Wertheimer, the following facts have been demonstrated : 1. After the application of all general thermic (cold) and mechan- ical procedures to the entire surface of the body, there is observed, with rare exceptions, not only an increase in the number of leu- kocytes, but also a considerable increase in the number of red corpuscles in a specimen of blood obtained from the tip of the finger or the lobule of the ear. It is possible also to show that, following general procedures, the percentage of hemoglobin in the blood is likewise increased. 2. The maximum increase in the number of red blood-cor- puscles in 80 cases examined was 1,860,000 in the cubic millimeter.CHANGES IN THE CONSTITUTION OF THE BLOOD 31 The maximum increase in the number of leukocytes was almost thrice the previous number, and the hemoglobin percentage was increased 14 per cent. 3. The maximum increase was not observed in all cases imme- diately after the application. The highest figures were often obtained only after the lapse of an hour. 4. It is noteworthy, and possibly important in its bearing upon the significance of certain clinical observations, that often an increase in the number of leukocytes was still observable at a time when the number of erythrocytes had begun to diminish. 5. These remarkable alterations in the constitution of the blood persist for varying periods. Often the increase in the number of erythrocytes, as well as in that of leukocytes, could be demonstrated so long as two hours after the application. Usually, however, both varieties of blood-corpuscles had begun to diminish again by this time. 6. In some cases, particularly in the presence of anemia, the re- duction in the number of erythrocytes did not progress to the original level. In other words, the increase induced by thermic and mechani- cal influences did not entirely disappear. There is, therefore, no doubt whatever that, after the action of cold affecting the surface of the entire body, blood removed from the superficial vessels exhibits the alterations described. In experiments upon animals, moreover, *■ Rovighi has observed that also blood obtained from internal organs— as, for instance, the liver and the spleen—exhibited like alterations. 7. Our own investigations showed, further, that active muscu- lar movements had a similar, though less pronounced, effect. The number of red blood-corpuscles, which had increased immediately after the action of the cold, was in many instances augmented by the reactive movement, and even in the absence of any antecedent action of cold the number of erythrocytes increased after active movement. 8. Steam cabinet baths, warm water baths, as also warm electric ferrated baths, were followed immediately in many cases by moderate reduction in the number of erythrocytes. This was followed after a time, particularly in the case of healthy and full- blooded individuals, by a moderate increase. 9. Of importance in connection with this alteration in the morpho- logic elements brought about by thermic influences, is the observation that if, for instance, the thermic irritation affected only a limited portion of the body, such as the feet and the legs, the number of erythrocytes in specimens of blood obtained from the lobule of the ear or the tip of the finger exhibited a reduction, while in those parts of the body exposed directly to the thermic and mechanical irri- tation a marked increase in both varieties of cells was observed. 10. The changes in the blood that have been described were wanting32 EFFECTS ON SPECIAL TISSUES AND ORGANS only in those cases in which it was not possible to bring about marked hyperemia of the skin in the sequence of the application of cold. Under such circumstances a reduction in the number of erythrocytes was often observed, and generally in the number of leukocytes also. 11. The local action of cold causes mostly an increase in the cellular elements of the blood, in the percentage of hemoglobin, and also in the specific gravity of the blood-mass at the point of ap- plication, and a reduction in parts remote from this point, and in peripheral portions of the body ; thus, for instance, when running foot-baths are employed, an increase is observed in blood taken from the toes and a reduction in that taken from the tips of the fingers, or from the lobule of the ear. This is also an evidence of the alteia- tion in the distribution of the blood in the body that can be effected through thermic and mechanical influences. 12. Warm sitzbaths generally cause a reduction in the cel- lular elements, in the hemoglobin, and in the specific gravity, by the same method of examination. [I may mention here, because it has as yet received little attention, in spite of my publications relative thereto, the highly surprising fact that comparative observations of the constitution of the blood from peripheral portions of the body and from the trunk yield widely varying re- sults. A comparison of the constitution of the blood, as exhibited in specimens obtained from the skin of the finger and that of the abdo- men respectively, disclosed in all instances a great difference. Thus, in one instance taken at random the blood from the tip of the finger contained 4,955,000 red corpuscles in the cubic millimeter, with a hemoglobin percentage of 91 per cent.; while the blood from the abdominal wall, obtained at the same time, contained 7,266,000 erythrocytes, with a hemoglobin percentage (or color test) of more than 115 as estimated upon the scale of FleischL] 13. The results of the following observations were, however, far more surprising. A determination being made of the constitution of the blood taken from the tip of the finger and from-the abdominal wall, a stimulating, that is to say, a cold, compress, well surrounded by a dry covering was applied about the abdomen, and after complete warming had been effected, therefore after about an hour, a second examination was undertaken of specimens of blood taken, as before, from the tip of the finger and from the abdominal wall. The difference between the two specimens was found to be greater than at first. While the cellu- lar elements in the blood from the tip of the finger exhibited a mate- rial reduction, a marked increase in the erythrocytes and in the hemo- globin percentage, as well as in the specific gravity, was observed in that from the abdominal wall covered by the stimulating compress an in- crease that in some cases equaled 2,000,000 for the erythrocytes;CHANGES IN THE DISTRIBUTION OF BLOOD 33 while the hemoglobin, estimated with the apparatus of Fleischl, could only approximately be determined, as it exceeded 120, the highest figure upon the scale. 14. Cataplasms and warm fomentations, however, exhibit quite a different, almost opposite, effect As a result of these applications there is generally an increase in the number of leukocytes and a reduction in the number of red corpuscles. If an attempt be made to interpret the alterations in the physical ele- ments of the blood that have been described as following the general and local action of cold ; following the action of stimulating and directly warming influences ; following mechanical procedures ; and following muscular activity ; the question will at once arise : Can this increase in the number of red and white cellular elements of the blood, following immediately upon the influences named, be considered a reproduction so rapidly brought about ? This explanation is characterized by but slight probability. If it be remembered that one may endeavor fruit- lessly, often for months, and by all the measures at his command, to bring about an increase in the percentage of hemoglobin and in the number of blood-corpuscles even in a case of simple anemia or chlorosis, it must appear highly improbable that hematopoiesis should take place with such marked rapidity following the action of cold. Numerous facts indicate that the additional cells that gain entrance into the gen- eral blood stream and the channels of circulation after the procedures described have existed preformed in the blood. The tumefaction of dependent portions of the body that can be demonstrated with the aid oi the plethysmograph, and the reduction in size of elevated parts, the globular stasis of Huter, the well-known sudden increase in the num- ber of red blood-corpuscles to the extent of several millions in the course of a few hours in connection with the critical termination of febrile diseases, indicate that when there occurs a sudden increase in the number of erythrocytes in the circulating blood, the phenomenon requires a different explanation from that of reproduction. The circumstance that, following the action of heat, the number of erythrocytes appears to be diminished, is indicative of the direction . in which is to be sought the explanation for the increase following the action of cold and muscular activity, but particularly the state of affairs attending the local action of cold. It resides obviously in changes in the circulation, in the action of the heart, in the tone of the vessels, and in the tissue tone. From organs in which, under ordinary conditions, there is stagnation, stasis, accumulation of white and red blood-corpuscles, the blood-cells will, under the favorable circulatory conditions brought about by the influence of cold and muscular activ- fty, be swept out into the general stream. To demonstrate this was, I believe, the successful endeavor of numerous of my earlier studies, ix—334 EFFECTS ON SPECIAL TISSUES AND ORGANS Thus, from the most diverse tissues and organs the stagnating cells must be thrown into the general circulation. This takes place as a result of the action of cold affecting the entire surface of the body. The reduction in the number of red blood-corpuscles at what may be termed indifferent points that is associated with local applications of cold, together with the increase that occurs in the portions of the skin directly affected,—as in the toes following the foot-bath,—indicates, furthermore, that there occurs a change in the distribution of the cellular elements of the blood in the vascular stream. The so- called derivative method is hereby given an experimental basis. It must not, however, be overlooked, that the effect of this al- teration in the blood upon the intimate metabolic processes will be the same as if an actual increase in the number of corpuscles had taken place. The blood elements previously stagnating in various organs and tissues, and not subserving their functions, are carried into the circulation and are saturated with oxygen in the lungs ; thus being rendered serviceable to the metabolism in the tissues and organs pre- cisely in the same way as if they were actually newly generated cor- puscles. From this it will be understood, as was determined in the study concerning the respiratory interchange of gases, undertaken with Dr. Otto Pospischil, my assistant at the time, how, after the action of cold, the absorption of oxygen and the excretion of carbon dioxid must be so greatly increased. Blood containing a larger number of cells, each well laden with oxygen, will, moreover, render the total metabolism more complete. That which has hitherto been difficult of comprehension—namely, how thermic influences act upon all of the functions—is brought much more nearly within our range of knowledge. The curative influence of cold or heat will, as I have maintained for years, no longer be sought in their effects upon the body-temperature alone ; but still another aid, which has long been sought in vain, appears to be furnished by this method of investigation. It may be found that the more or less marked increase in the number of red blood-corpuscles may serve as an indication of the complete or incomplete reaction of the individual to thermic and mechanical applications, and that the completeness of the reaction is in direct relation to the increase in the number of erythrocytes following the procedures employed. This is true, for instance, especially of anemic patients. In these, the number of blood- corpuscles and the percentage of hemoglobin increase for a few hours. The blood thus approaches more nearly the normal, while at the same time also, in all probability, all nutritive processes are similarly height- ened ; and, as a result of methodic repetition, this temporary effect is rendered permanent. The interesting investigations of Friedlander may also be looked upon as supporting this view.INFLUENCE UPON METABOLISM 35 Influence upon Metabolism As there can be no doubt that organic heat is to be considered as the end-product of all organic processes ; and as the body-tempera- ture, when lowered by means of physical measures, quickly regains its previous level, while by preventing or diminishing the heat-loss this reactive elevation of temperature can be avoided, it is obvious that the effect has been to induce an increased generation of heat; that is to say, an augmentation of the total metabolism. All trustworthy studies of metabolism have shown that oxidation processes, as estimated upon the elimination of carbon dioxid and the absorption of oxygen, are considerably increased in the cold, and that in general the opposite effects take place in the heat. Careful inquiry, however, shows that this is the case only so long as the body-temperature remains approxi- mately constant. The greater the thermic nervous irritation, in con- nection with any procedure, the more considerable, under otherwise like conditions, will be the reflex acceleration of metabolism. This pri- mary acceleration of metabolism is neither marked nor persistent. “ Of itself, the increased reflex disintegration would not be capable of protecting the inhabitants of Arctic regions from freezing. It is even not sufficient to render unnecessary the use of clothing at a temperature of 7.5° C. (45.50 F.).” The acceleration of metabolism brought about thorough the reflex influence of cold occasions no increased consump- tion of proteid. The increase in interchange primarily brought about through the action of the cold affects principally nonnitrogenous sub- stances (Hagenbach, Rohrig, Zuntz, Voit). The conditions are different, however, with regard to the accelera- tion of metabolism induced secondarily as a result of heat abstraction. This resembles the metabolism attending artificial ele- vation of the body-temperature, or which characterizes fever. Consis- tent and systematic abstraction of heat causes, as a secondary effect, an increase in the body-temperature, which may even attain a febrile level, and will always bring about analogous modifications in metab- olism. Reactive elevation of temperature, and increase in metabolism, after abstraction of heat, stand in direct relation to the degree of actual cooling. If, in a normal person, the body-temperature be reduced below the normal by means of measures that abstract heat, the body exhibits a tendency to regain the normal temperature; and under such circumstances the reactive tendency may even carry the temperature above the normal. It is certain that sev- eral hours after a cold bath there may be observed a higher hourly average of the body-temperature than prevailed before the employment of the bath (Jurgensen). Obviously, under such conditions increased heat-production is associated with disturbed dissipation of heat. In this connection reference may be made also to my experiments with cold sea-baths (50 C.—410 F.) of excessive duration. Under the influence36 EFFECTS ON SPECIAL TISSUES AND ORGANS of systematic daily repetition of such marked loss of heat, there occurs gradually, as a result of the voluntary and involuntary muscular activity, an increase in heat-production sufficient to prevent cooling of the body, often even to cause elevation of temperature. With regard to the influence of heat-abstraction upon the metab- olism of individuals with a normal temperature, it is highly probable that the thermic nervous stimulation, and the actual reduction in temperature, as well as the reactive elevation of tempera- ture, exert quite varying influence upon the metabolism. The thermic nervous stimulation brings about by reflex action, prin- cipally in the muscles, increased tissue change, involving chiefly nonnitrogenous substances; while the secondary or after-effect of heat-abstraction consists in febrile increase in metamorphosis, prob- ably, therefore, also in heightened proteid metabolism. The increase in the absorption of oxygen and the augmentation of carbon- dioxid elimination are proportionate to the voluntary and involuntary muscular activity brought about as a result of the thermic and mechanical stimulation, and particularly of the increase in muscular tone, which may, indeed, in highest degree be manifested as ‘chill’; a condition that must be considered as a protective measure of the organism against the reduction in temperature. Speck’s, Lowy’s, my own, and Pospischil’s investigations have demonstrated this fact. As a general result of studies in metabolism it has been found that hydriatric therapy influences metabolism quantitatively and qualita- tively in a special manner—namely, by producing an increase in the general normal activity of the living organism, which, however, in the presence of an adequate state of nutrition, never passes beyond normal limits. Thus, it was never possible to observe among many hundreds of individuals, at times treated with vigorous measures, any evidence of pathologic increase in proteid metamorphosis, such as acetonuria and the like (Strasser). As numerous clinical observations show that it is possible to confine the action to an increase or a diminu- tion in the functions of all organs, down to the simplest cell, it should be feasible at all times, by accurate regulation of the thermic and mechanical measures employed, to control the total metabolism under all circumstances with certainty. It is thus possible so to grad- uate the individual procedures that any special irritative effect is forced into the background ; and, instead, there is effected a general increase in function, with a heightening of innervation and with any desired guidance of circulatory processes, and thereby also of metabolism. Details concerning the adjustment of the individual elements of metabolism will be found in the investigations of numerous observers (Rohrig, Zuntz, Senator), in the publications from the laboratory of Pfliiger, in numerous Russian publications emanating from the schoolINFLUENCE UPON SECRETION AND EXCRETION 37 of Manassein, all of which arrive at almost the same results. The most recent of these publications is by Strasser, and is contained in the “Fortschritte der Hydrotherapie,” by Strasser and Buxbaum. INFLUENCE UPON SECRETION AND EXCRETION Cold, warm, and mechanical applications induce changes also in the functions of all of the secretory and excretory organs of the body. The Skin.—Whether or not the accelerated desquamation of the horny cells of the epidermis facilitates gaseous interchange, or the dilatation of the peripheral vessels, particularly of the superficial capil- laries, renders possible the percutaneous absorption of oxygen, even though in small degree, has not yet been determined with certainty. The circumstances that irrespirable gases have caused symptoms of intoxication when brought into adequate contact with the uninjured skin is certainly an indication thereof. Increase in the perspiratory and transpiratory elimination of water, that is to say, ofi the insensible and sensible perspiration, as a result of thermic and mechanical applications, has been demonstrated by Weyrich. The secretion of sweat certainly undergoes considerable augmentation. Tjrie small amount of organic matter eliminated at the same time, the trace of urea, the various fatty acids, and the numerous aromatic substances, as well as gases, particularly carbon dioxid, should certainly be given consideration in this connection. That toxic substances, probably various kinds of infectious matter, and even micro-organisms, may leave the body with the sweat, has already been demonstrated by numerous investigators. The depurative action of the sweat is in this way revived in the modern sense. It may be said in general that, as a result of profuse sweating, the body loses some of its water. If this loss through the skin be con- siderable, the elimination of urine becomes diminished and the urine more concentrated ; the excretion of nitrogenous matters appears, on the whole, to be diminished. “ In the simplest manner a retention of urea in the blood takes place/’ says Beneke, “ if the elimination of water through the skin is increased in abnormal degree, or the supply of water of the organism is in general materially diminished.” The principal utility of sweating when the functions of the kidney are normal, may be sought (i) in the changed channel for the elimi- nation of water, and (2) in the altered diffusion processes thereby brought about in certain internal organs ; (3) in the distribution of the blood so greatly altered by the process of sweating—the change in current; and (4) principally in the depurative effect of the sweating. The Kidneys.—That increase in the secretion of urine is a result38 EFFECTS ON SPECIAL TISSUES AND ORGANS of thermic influences upon the surface of the body is a long-estab- lished fact, and it appears to depend not alone upon the antagonistic relations between the excretion process of the kidneys and that of the skin, but to be attributable principally to innervational and circulatory alterations. Alimentary Tract and Glandular Apparatus.—With regard to other secretions than sweat and urine, it may be said that it is possible in many cases to exert an influence upon the quantity of the secretion of the glands of the stomach. In innumerable instances in the sequence of general or local thermic and mechanical applications, a profound alteration in the gastric secretion has been observed on re- peated examination ; the quantity of hydrochloric acid being found normal, or even increased somewhat above the normal. Also the re- maining clinical symptoms agree often with these findings ; for instance, the digestion, previously sluggish, is completed within the normal limit of time. It appears to me that an influence is exerted by thermic and mechanical stimulation upon the secretion of bile. This is indi- cated not only by the clinical experience that stimulation of peristaltic activity, increase in the blood pressure in the radicles of the portal system, and accelerated movement of the blood in the portal vein may be brought about by thermic and mechanical applications, but also by the surprising fact that in some cases of jaundice the dejection, ordi- narily free from bile (clay-color stool), exhibits an admixture of bile after a cold irrigation or after a cold sitzbath. Possibly this obser- vation may serve as a stimulus to the study of the pathogenesis of certain forms of jaundice. In addition, cursory reference may be made to the fact that in rare cases icteric discoloration of the skin, and also hemo- globinuria, have been observed immediately in the sequence of cold baths. At this point I do not wish to enter more fully into the theo- ries relating to this occurrence, and shall only point out that attention has been called by several observers to a more rapid destruction of red blood-corpuscles under conditions as yet not understood.CHAPTER III THE CHEMICAL EFFECTS AND INTERNAL USE OF WATER External Application—Influence of Carbo?i Dioxid. Internal Use of Water —Drinking; Irrigation; Effect o?t Pulse and Temperature; Vasomotor Effects; Absoiptiow; Effect upon the Blood. Therapeutic Methods—To Increase Fluidity of Tissue; to Increase Absorption and Elimination. Effects upon Metabolism and Excretion. Not only physically—that is to say, by reason of its temperature, its volume, and its pressure—does water induce in the organism changes susceptible of therapeutic utilization, but also chemically; and this chjemical effect, dependent upon the varying constitution of the water, reacts upon physiologic and pathologic nutritive processes, whether the agqnt be employed internally or externally. EXTERNAL APPLICATION When applied externally, the chemical composition of the medium that comes in contact with the surface of the body influences both the quantity and the intensity of the effect The stimulation of the periph- eral sensory nerve-endings must vary also in accordance with the chem- ical constitution of the stimulant As Scouttetten, Heymann, Krebs, and others have demonstrated, the intensity of the electric contact cur- rent—temperature and mechanical impression being the same—varies in accordance with the varying composition of the fluids employed. The heat-absorbing and the heat-conducting power of waters of different composition differs; and Basch, Santlus, Beneke, and others have shown that diverse fluids differ in their influence upon the organs of touch. Finally, as appears from the studies of Rohrig and others, the reflex influence upon metabolism is subject to similar variation. The chem- ical effect of various waters applied externally will be discussed in the balneologic section of this volume. I cannot, however, refrain from pointing out at this place the special effect of the chemical constitution of the water associated with the thermic stimulation, in so far as car- bon dioxid may play a part. This gas, when contained in the water used for external application, has quite a special role. It augments the physical influence of heat and mechanical stimuli. It is possible, by this means, to employ water of lower temperatures with- 3940 THE CHEMICAL EFFECTS OF WATER out the consciousness of the individual exposed to its action, inas- much as the bubbles of carbon dioxid collecting upon the skin so stimulate the sensory peripheral nerve terminations as to benumb the thermal sensibility. Attention will be recalled to these carbon dioxid baths in the chapters devoted to “Technic” and in those concerned with “Special Hydrotherapy.” (The preparation of artificial carbon- ated baths is described in the appendix.) THE INTERNAL ADMINISTRATION OF WATER The Drinking of Water Even the systematic drinking of ordinary water is employed for remedial purposes, and the mode of action of the water when thus employed, although discussed in the volume on “ Dietotherapy,” must receive additional consideration here. In this connection weight must be given to the thermic and chemical effects of the water, which have an influence directly upon the organic economy and the temperature, as well as upon metabolic processes. Water, when introduced into the stomach, is actually taken up by the body. It remains in relation with the body for a considerable period of time, and through the stomach and the intestinal canal it enters into direct contact with the most diverse portions of the digestive apparatus. By reason of the equalization of its temperature with that of the body, as a result of absorption into the fluids and the blood-mass, and by reason of its chemical constitution, water must .have an especial effect upon the most intimate nutritive processes. When taken internally, water will play an important role also as an imbibition material, inasmuch as it enters and penetrates all of the tissues and their interstices, and renders them permeable to water-soluble substances. Effect on Pulse and Temperature.—Lichtenfels and Frohlich found that if 0.3 liter (quart) of water at a temperature of 180 C. (64.4° F.) were drunk rapidly, the frequency of the'pulse was at first diminished by 22 beats in thirty seconds, but that after the lapse of twelve minutes it had resumed its original rate. The temperature declined in the course of six minutes from 37.050 C. (98.7° F.) to 36.95° C. (98.5° F.), and continued at this level for ten minutes after ingestion of the water, then returning to 37° C. (98.6° F.). When 0.3 liter (quart) of water at a temperature of 16.3° C. (61.3° F.) was drunk rapidly, the pulse declined 16 beats in twenty-two seconds, and rose in the course of fifteen minutes to its original frequency. The temperature of the body declined 0.4° C. (0.7° F.) in the course of six minutes after ingestion, and returned to the original level in the course of seven minutes more. In my earlier observations a liter (quart) of water at a temperatureCOLD WATER ENEMATA 41 of 6.7° C. (44.10 F.) was drunk in the morning when the stomach was empty. The pulse-frequency declined from 72 to 52 in the minute; respiration increased by 5 m the minute; the axil- lary temperature declined from 37-3° C. (99. i° F.) to 36.5° C. (97.70 F.); while the temperature of the recently voided urine declined 0.70 C. (1.30 F.). Nevertheless all of these investigations have yielded but incomplete results. In order, therefore, to determine accurately the influence upon the temperature and heat-distribution of water introduced by the mouth or the rectum, I have instituted a series of careful experi- ments. The temperatures were first taken in the axilla, in the rectum, and in the stomach. Then the desired amount of water was drunk at short intervals or introduced into the rectum by means of a tube. The thermometers, previously carefully compared with one another, were now read at convenient intervals, and the temperature noted. The de- termination of the temperature in the stomach was effected by attach- ing securely a maximum thermometer, 4 cm. (1 y2 in.) long, in a soft rubber tube, which was then swallowed by the patient, precisely in the same manner as for lavage. I believe that I was the first to make tem- perature-observations in the stomach of the living human being. In this, way the thermic influence of water taken internally can be deter- mined more accurately than has hitherto been possible. \As a result of my observations I may state that the tempera- ture of the stomach is lowered considerably, and for a con- siderable time, by the drinking of cold water. Fully thirty minutes after the ingestion of 500 c.c. of water, I have been able to demon- strate a reduction of o.6° C. (i° F.) in the temperature of the stomach as compared with that observed before the ingestion of water. Even after the lapse of three hours the original temperature had not yet been completely regained. The temperature in the rectum observed at the same time was quite remarkable. Immediately after the inges- tion the rectal temperature declined continuously for twenty-five min- utes, until a reduction in the temperature in this situation of 1.050 C. (1.90 F.) was observed. After a transitory ascent, a decline in tem- perature occurred also in the axilla, and this continued for an hour and fifteen minutes. After the lapse of seventy-five minutes more a reduction of the axillary temperature of 0.22° C. (0.40 F.) could still be demonstrated. The pulse at the same time exhibited a reduction of ten beats. In order to verify also by control observations the striking relations between the stomach and the rectum that have forced themselves upon me in this and similar experiments, I introduced cold water into the rectum by means of enemata. The previous experiments, as stated, had disclosed the remarkable fact that after the drinking of cold water, the greatest reduction in temperature, next to that of the’42 THE CHEMICAL EFFECTS OF WATER area immediately cooled, was appreciable in the rectum. So, also, after the introduction of cold water into the rectum the most marked reduction of temperature was noted in the stomach. The tempera- ture of the stomach declined 0.90 C. (i.6° F.) after cold enemata. In addition to the demonstration that it is possible to influence the body-temperature effectively by the internal administration of cold fluids, these experiments showed that by means of the ingestion of water and of cold enemata it is possible to regulate at will the tem- perature in even deeply seated organs of the abdominal cavity. It is possible, as I have shown, by means of an injection into the rectum, to lower the temperature in the stomach and adjacent viscera in the shortest period of time, and, conversely, through the stomach to reduce the temperature of the organs of the pelvic cavity. These facts afford explanation for various general and local therapeutic effects, such as may be secured by the systematic drinking of water, and through sys- tematic irrigation. The effects described are not dependent upon the actual physical cooling alone, but vasomotor influences are certainly to be taken into account as well. In favor of this view there are numerous phenomena ; thus, the change in the state of the skin ; its pallor; the decline of the temperature at the periphery after the injection of cold water ; and the reduction in pulse frequency, which possibly may be brought about by stimulation of the intragastric terminations of the fibers of the vagus. That, however, reflex transmission of the irritation due to cold takes place from the stomach and the intestine to the vasomotor center, I demonstrated years ago by means of pulse tracings taken before and after the ingestion of cold and warm fluids. Only on the basis of this conception can the results obtained with the aid of such manipulations in the presence of hyperemic and inflammatory disorders of paren- chymatous abdominal organs be comprehended. The channels by which the water introduced into the stomach may be conveyed into the blood .stream are the lymph vessels and the veins, as has been shown by Bouisson, who found in animals after the drinking of water a greatly distended portal vein containing blood with a large propor- tion of water. Absorption of Water and its Effect upon the Blood.—Vari- ous circumstances have an influence upon the rapidity of the absorp- tion of water. The lower the degree of tension in the vascular system, the more rapid, under otherwise like conditions, will be the absorption of water into the blood-vessels. After considerable loss of fluid, as by diarrhea, hemorrhage, profuse sweating, copious elimination of urine, or other normal or pathologic process, more rapid absorption of water from the intestinal tract will be observed. Water holding less saline matter in solution is more readily taken up into the blood stream thanTHERAPEUTIC METHODS OF WATER DRINKING 43 water containing much saline matter. Free alkali increases consider- ably the attractive power of a fluid, especially for one with a feebly acid reaction. Thus a fresh water rich in carbon dioxid, and deficient in saline matters, is likely to be most rapidly absorbed, and is particu- larly suitable as a beverage. Water containing saline matters is absorbed much more slowly, and will therefore cause a sense of pressure and fullness in the stomach, even when taken in small quantity. Schultz, Nasse, and others, have demonstrated that after the abun- dant ingestion of water the blood contains about 5.7 per cent, more water than after thirst of long standing. The rapid absorption of water into the blood stream increases the tension in the vascular system, as a result of which, as Magendie and Falk have shown, dropsical states may readily develop. The circumstance, however, that the blood retains its constitution with great persistence is responsible for the fact which Bocker especially has shown, that this increased amount of water can be demonstrated in the blood for but a short time, scarcely more than fifteen minutes. So early as half an hour after the inges- tion: of a large quantity of water, however, the blood is again more dense, more consistent, and less rich in water than even after absti- nence from fluid for twenty-four hours. The proportion of fibrin present in the blood is said to increase or diminish with that of water, while the number of blood-corpuscles in a given volume of serum of course varies inversely with the dilution. Bocker has further made the interesting observation that after the in- gestion of water the blood-clot contains a smaller number of red blood- corpuscles incapable of respiration and therefore failing to become red on exposure to the air, than was .the case prior to the drinking of the water. Therapeutic Methods Upon the facts set forth I have evolved, and have found verified by experience, a method for the internal administration of water for therapeutic purposes. When it is desired to flood the tissues with fluid, to increase the weight of the blood-column, to augment the ten- sion in the vascular system, to increase the capillary pressure, water should be administered in small single doses, but repeated at short intervals of from twenty to thirty minutes throughout a considerable period of time. When, however, it is desired to cause disappearance of fluid effusions and to stimulate absorption power- fully, it will be possible—however paradoxical it may seem—to effect this by the drinking of cold.water if we alternate the administra- tion of fluid with considerable intervals of abstinence from all drink. By this means the blood becomes more consistent, more impoverished in water, and best suited to take up fluid from the. tissues and to initiate44 THE CHEMICAL EFFECTS OF WATER absorption and elimination. The ingestion of somewhat larger quantities of fluid from every six to every eight hours, and the withholding of all fluids in the intervals, best fulfil these indications. The more rapid absorption, once initiated, does not remain con- fined to the elimination of fluid. It will thus not only be possible, by means of the systematic drinking of water, to render a useful service in the presence of dropsy, but also opportunity will often be afforded of observing the more rapid absorption and elimination of solid products of exudation and inflammation. As Bocker likewise has shown, the loss from the body is in general much greater after generous administration of water; and if the amount of food is not enlarged, or is even restricted, the blood, in order to retain its normal constitution, must regenerate itself from the tissues of the body and not alone from the circulating fluids. In this way increase of waste and of retrogressive metamorphosis is brought about. The gain in body-weight that occurs with moderate increase in the amount of water consumed and a corresponding supply of food, is dependent upon the fact that constructive metamorphosis may under such circumstances be stimulated secondarily. With ex- cessive ingestion of water, however, the body-weight declines, although it is soon restored if the amount of water be restricted. The increased ingestion of cold water exerts a diuretic effect in the strict sense. The organism relieves itself, especially through the kidneys, of the larger amount of water taken. Coincidently with the increased elimination of water through the kidneys, the solid constituents of the urine also are excreted in greater amount, as numerous investigators have found. This is true especially of the urea. In this way also the metamorphosis of the nitrogenous tissues of the body is materially augmented. That under the same influences the oxidation processes are heightened and become more complete is shown by the reduction in the amount of uric acid eliminated ; and by the reduction and even the complete disappearance of the oxalic acid that may have been present in considerable amount before the increased ingestion of water. The stimulation of oxidation processes attending increased ingestion of water can be demonstrated also directly by the measure- ment of the greater quantities of carbon dioxid eliminated and oxygen absorbed. Likewise, salts and inorganic substances, such as the potassium salts, which result principally from muscular metab- olism, the incombustible salts of the bones, the phosphates and sulphates of the brain and the glandular structures, are excreted in increased amounts. This universal stimulation of retrogressive metamorphosis and acceleration of metabolism by means of systematically increasedINFLUENCE ON THE SECRETION OF BILE 45 drinking of ordinary water has hitherto been employed far too little therapeutically. Excessive cooling of the stomach during digestion, together with excessive dilution of the gastric juice, will be a reason for avoiding excessive ingestion of water with the taking of food. Mosler has found that with rapid ingestion of considerable quantities of water, the direct elimination of solid matters through the kidneys is smaller than with gradual ingestion of the same quantities. The drinking of cold water has an influence also upon other func- tions. It appears to stimulate actively the peristaltic move- ments, thereby exerting a favorable influence upon the circulation in the vessels of the stomach and the intestine. This accelerates, more- over, the rapidity of the current in the portal vein, and thus favorably influences the functions of the liver and augments the secretion of bile. The latter effect has been pointed out especially by Bidder, Schmidt, Nasse, Lehmann, and recently by Rohrig.CHAPTER IV THE REACTION Effects Due to Reaction. Conditions Governing the Reaction. The Neces- sity of Complete Reaction. Recapitulation. A large part of the effects described in the foregoing chapters are not attributable to the direct influence of the measures employed, but are to be ascribed to the automatic processes of the organism in countereffect against the alterations primarily induced ; that is to say, to the physiologic reaction. The intensity of the reaction in response to a given procedure varies, however, with the individual and with divers circumstances, and is only partially dependent upon the char- acter of the therapeutic procedure itself. The production of complete reactive processes is one of the most important and most difficult tasks of the hydrotherapeutist, the thermotherapeutist, and the balneothera- peutist. The mechanical or thermic nerve-stimulation must be care- fully proportioned to the irritability of the individual organism, gener- ally or locally, at the given instant, and the abstraction of heat often must be minimal. In many cases some means of supplying heat generally or topically must be used in supplement to the application of cold, in order to bring about the complete reaction desired. The restoration of heat after heat-abstraction, which is the essential factor in the reaction, exhibits the greatest variations in different indi- viduals, and these variations may indicate certain points of support and attack in regard, to pathogenesis, to prognosis, and to treatment. In treatment it is of especial importance that the reactive temperature elevation following reduction of temperature should be efficiently con- trolled ; and, accordingly, we so adapt our measures as to increase or diminish its rapidity and its degree. This restoration of heat, at once the most reliable indication and the most prominent symptom of the reaction,—which may be recognized, further, by alterations in innerva- tion, in circulation, and in metabolism,—depends, other things being, equal, upon : 1. The absolute degree of heat-abstraction : the greater, within certain limits, the reduction in temperature, the greater will be the reactive elevation of temperature. 2. The time occupied: the more rapid the abstraction of heat, the more rapid will be the secondary rise of temperature. 46THE NECESSITY OF COMPLETE REACTION 47 3. The duration of the cooling has an influence in determining whether the restoration of heat shall set in early or after a consider- able length of time. Protracted and gradual abstraction of heat is followed by a slower and less intense reactive elevation of tempera- ture than cooling of short duration, even to a lower temperature. 4. The state of the body-heat before the cooling likewise in- fluences the reactive elevation of temperature. A body previously highly warmed reacts more markedly than a cool body. 5. The supplying of heat before the application of cold in- creases, together with the irritability of the body, the intensity of the reactive processes. 6. The combination with cold of a mechanical stimulation increases the reaction. 7. The state of the body after the abstraction of heat also has an influence upon the more or less prompt occurrence of the re- action. A condition of quietude delays, while exercise and muscular activity accelerate and increase, the reactive processes. 8. The internal administration of stimulants, especially of al- cohol, after the abstraction of heat, favors the reactive processes. 9. In general, the reaction as well as the production of heat is in direct proportion to the thermic nerve stimulation ; the more power- ful the latter, the more pronounced the former. 19. Excessive cooling may give rise to delayed and excessive or to incomplete reaction. While the former may manifest itself by fever- like qr actually febrile conditions, the incomplete reaction exhibits rather the character of algidity and collapse. 11. The reactive processes are dependent also upon the adapta- tion of the body and all of its functions to systematically repeated thermic and mechanical stimulation, and the loss of heat. The Necessity of Complete Reaction It must be considered as an essential condition of every systematic course of hydriatric procedures that the individual measure should always be followed by perfect reaction. It may be a part of the plan of treatment that the reaction should take place but slowly, and should not become excessive. This is true especially of the treatment of febrile diseases. It may be desired to bring about rapid and adequate reaction. This will be the case in the presence of most chronic nutritive disorders, and of all conditions attended with retarded metabolism. In no event, however, will an incomplete reaction be considered desirable, as this is always attended with morbid manifestations, such as nervous disturbance, lassitude, pallor, small pulse, constant chilliness, unequal heat-distribution, and derangement of various functions; and it may even be followed by serious nutritive disorders. Observance of the foregoing rules will readily contribute48 THE REACTION to the avoidance of this danger. The cumulative after-effect of the baths may have a beneficial influence upon the nutritive disturbance through its influence upon metabolism and secretion, but through the same influence it may have an injurious effect in certain individuals and in the presence of certain processes. Both conditions are com- prehensible if the changes in metabolism that take place as a result of abstraction of heat are borne in mind. Recapitulation The effects upon the organism of thermic and mechanical stimula- tion, as described in the foregoing pages, will be brought about only when the action is followed by a corresponding and complete reac- tion. It is this reaction alone that arouses and intensifies the natural and independent protective and defensive forces of the organism. This fact explains also the effect of physical remedial agents when di- rected against any recognized or suspected infection, intoxication, or autointoxication. It thus appears that the judicious employment of appropriate physical remedial measures is to be considered as a natural vital stimulus, which supports, hastens, and facilitates that restoration of nutritive and functional balance, which in a suffi- ciently vigorous organism would take place without the aid of the phy- sician. A study of the natural independent remedial resources of the human body has been undertaken on numerous sides, and I havfe my- self attempted to show that the actual remedial value of the measures applied in treatment—as the editor of this series has likewise pointed out—is to be found in the invigoration of the organism and of all of its functions ; and that hydrotherapy, balneotherapy, thermotherapy, and phototherapy exhibit these effects only when the processes of re- action are efficiently controlled. The description of the technic of hydrotherapy that is given in Part II will make this fact even more clear.CHAPTER V FUNDAMENTAL PRINCIPLES AND PRACTICAL APPLICATIONS OF HELIOTHERAPY AND PHOTOTHERAPY1 Physics and Physiology—Thermic, Luminous, Actinic Pays. General Effects of the Various Pays. Special Effects of Actinic Pays. Therapeu- tic Experiences—Sun Baths ; Electric Light Baths. ) PHYSICS AND PHYSIOLOGY Phototherapy—the employment of natural or artificial light to influence a diseased or disordered organism in the attempt to restore integrity of structure and function—may for convenience be discussed at thijs point; the more appropriately that I had originally entertained the view that all of the effects that can actually be brought about by mean; ther vatioi wish s of natural and artificial light baths were to be attributed only to mal influences. Enlarged experience and more careful obser- 1 have shown, however, that this view was incorrect, and I now demonstration that light is not a defi- to retract it in view of the nite Entity, and that the various known and as yet unknown elements constituting the light ray exert widely different effects. What I shall have to say concerning light therapy must be limited in various direc- tions. I shall not discuss radiotherapy and X-rays, but shall confine myself to sun baths (heliotherapy) and light baths as remedial agents, and refer cursorily to the studies of Finsen and the results obtained by him. At the same time I shall consider it my duty to present the physiologic action of this powerful remedial agent in so far as it is known. Not even the physicists have progressed much beyond the begin- ning of their labors in this direction, in spite of recent remarkable in- vestigations. It has even been proposed that light should be considered a chemical element, if it be definitely confirmed that the substance, radion, found in uranium, is capable of furnishing light indepen- dently, and of penetrating opaque substances and rendering them trans- parent. I shall, however, not undertake a discussion of such future science. It is known, moreover, that the radiant force which we For further discussion of this subject, see the special article contributed to this volume 7 -Or. J. H. Kellogg (pp. 209 to 225). ix - 4 495o FUNDAMENTAL PRINCIPLES OF PHOTOTHERAPY recognize as light is no simple element. The light ray is a composite thing of which we are as yet scarcely able to grasp the individual con- stituents ; hence a portion thereof are designated X-rays. Even that which manifests itself in the solar spectrum as various colors is only light more or less refracted, and nevertheless each of these rays, in accordance with the angle of refraction, has a different mode of action. Just as within recent years we have stood in surprise before new de- velopments daily in the field of acoustics,—phenomena that are depen- dent upon comparatively coarse vibrations of the demonstrable air,—so is it also, and so in still greater measure will it be, with the more delicate force, light, dependent upon vibrations of the ether that can only be imagined. In the study of the physical properties of light, in the physiology of the visual sense, in spectral analysis, white light is considered as a combination of the three primary colors—red, green, and violet. From the view-point of the therapeutist, a distinction is made between heat rays, light rays, and chemical or actinic rays. The heat rays pass principally through the red and the ultra-red of the spectrum • the actinic rays can be found principally in the violet and ultra-violet; while the remaining portions of the spectrum, particularly greeil and yellow, include most of the luminous rays. For the physiologic investi- gation of the effects of light no exact method has yet been devised. ' The results hitherto obtained in this connection are therefore by no means sufficient for a scientific basis of treatment, although many writers have occupied themselves with the question in comparatively numerous publications, some of which have much empiric value. If, however, I raise objections to premature dogmatizing upon light as a remedial agent, it is not only the failure of tuberculin that should be a warning against immature therapeutic experience. Heliotherapy I may briefly summarize that with which I anr familiar—and let me premise that this will not be much. We may discuss, first, unmodi- fied natural light—that is, sunlight. I can only confirm the old knowledge that is applicable to every physical force—namely, that sunlight may be a source both of usefulness and of injury. I will omit consideration of the general cosmic and telluric effects of the sun. It may be admitted that sunlight, and in a similar way also the electric light, although in less marked degree, is to be considered as an irritant that may exert both a useful and an injurious effect upon living protoplasm, upon the cell, and upon the entire organism. Its mode of action upon all of the organs and functions has not as yet been so thor- oughly studied as that of heat-irritation. Investigations by numerous observers have seemed to show that the pure light separated from the heat rays is also an irritant. It is possible, it is true, to separate the heatRED LIGHT 51 rays from the luminous rays, so that the effect of the latter is alone manifested, but this pure light is then no longer, as Schonenberger happily points out in his industriously prepared inaugural dissertation, natural light—that fortunate combination of heat rays, actinic rays, and illuminating rays upon which probably depends the great hygienic significance of the sun. The first question that will always be asked—as to the influence of light upon metabolism—may be answered thus : 1. It has been established that absorption of oxygen and elimination of carbon dioxid in the living organism undergo an increase under the influence of light. 2. It has been established that the nerves exhibit irritability under the influence of light. heightened 3. lit is affirmed that the muscles powejr under the influence of light. greater functional The names of Moleschott, Pet- tenkofer, Voit, Fubini, and many others, go to support this view. SS long as the ether-vibrations of light pass through the medium withoiut obstruction, so long as they are not interrupted, refracted, or reflected, so long will they exhibit no other effect than that of the illumilnating rays. The depth to which the light rays penetrate into the tissues is not known. It was extremely interesting to me to have been able to furnish a demonstration that it is not, as I formerly believed, simply the thermic effects that are observed in the therapeutic employment of sunlight or of electric light. I have on innumerable occasions noted the remark- able |fact that, for instance, in Lindemann’s electrotherm quite high degrees of temperature could be borne by the patient without evidence of peiin, so long as the space was heated by dark rays. When, how- ever, the small incandescent lamp was turned on for the purpose of viewing the part of the body inclosed within the electrotherm, severe pain-reaction was immediately induced in the member in question, without material elevation of temperature. When the incandescent lamp was turned off, the pain at once disappeared. I therefore made the experiment of using an incandescent lamp inclosed in a red globe, or covered simply with translucent red material, usually silk. As soon as this was done the patient no longer reacted with pain. This is there- fore an evidence that the cutting off of the chemical rays that is effected by means of the red glass, or the covering of red material, is alone sufficient to render tolerable the high temperature of the electrotherm. I availed myself of this hint also in the employment of sun baths, and I have succeeded in the simplest manner by covering the parts of the body exposed to the sun, or the entire body, with red material. With the sole aid of this simple means of preventing access of the chemical rays, have I found it possible to obtain the effect upon the52 FUNDAMENTAL PRINCIPLES OF PHOTOTHERAPY skin and various cutaneous affections that I have elsewhere described —namely, lessening of chronic hyperemia of the skin; the induction of ischemia in hyperemic portions of the skin; the im- provement and cure of eczema. I have also seen various chronic rheumatic affections of the joints and of the feet influenced most favorably by sun baths when the affected parts were covered with red material. Concerning the effects of the heat rays it can be demonstrated that they differ from those due to heat in other forms, and that they induce elevation of temperature at varying depths. The chemical rays behave in a different manner. Concerning these it is known that they apparently pass through opaque struc- tures. The proof of this is furnished by the fact that silver chlorid sealed in the dark in capillary tubes, and introduced at varying depths beneath the skin, exhibits the effects of penetration of the chemical rays by its decomposition. Likewise indicative of the absorption and resorption of chemical rays is the interesting observation that portions of the body previously exposed to the sun or to some other form of light and soon afterward placed in a dark chamber still have an influ- ence upon sensitized paper, so that, for instance, it is possible to photograph in the dark chamber a hand that has previously been exposed to the sun (Moleschott, Fubini, Godeneff). The quantity and the quality of light have a widely varying influence upon the intensity of these effects. Incandescent lamps give off more heat rays and fewer actinic rays than arc-lamps and sun- light. The actinic rays have a greater influence upon protoplast^ and cells. The effects of the heat rays will be discussed in the considera- tion of the therapeutic methods. At this point a few words will be devoted cursorily to the physio- logic effects of the chemical or actinic rays. Various investiga- tors, and especially Finsen, the leader in questions relating to the physiologic effects of light, have confirmed the observation that the actinic rays are direct stimulants for animal and vegetable life, and the carriers of vital energy in all forms. This may possibly be of great importance in its bearing upon treatment. The wonderful results yielded by sun baths must probably be attributed in large part to the effects of the chemical rays. The most thorough investigations hitherto made as to the influence of light, and especially its chemical rays, upon micro-organisms, and especially bacteria, are those of Finsen. He has shown that the actinic rays, in accordance with their intensity, inhibit the development of various organisms within a longer or a shorter time, and, if the expo- sure be sufficiently prolonged, also destroy them. The observations of hygienists, particularly those of the pupil of Pettenkofer and Voit,SUN BATHS AND OTHER LIGHT BATHS 53 Professor Soyka, who died prematurely, with regard to the self-purifi- cation of streams, would indicate that this is probably attributable in part to the chemical rays of the sun. The chemical rays are responsible for solar erythema, an affec- tion that differs markedly from a burn, inasmuch as it appears only several hours after the affected part has been exposed to the sun or to an intense electric light. This solar erythema is constantly followed, as is likewise the direct action of the sun’s rays, by deep pigmentation of the affected portion of the skin, which then protects this area against further effects of the chemical rays. Most writers attribute to the pigmentation of the skin the protection enjoyed by negroes against the injurious effects of intense sunlight. Schonenberger has also made investigations as to the constitution of the blood under the influence of light and with exclusion of light. It was found that with exclusion of light the percentage of hemoglobin and the number of erythrocytes undergo increase, a statement that at the p/resent day can scarcely be harmonized with the results of thera- peutic experience. My own observations with ordinary incandescent- light-baths in the case of anemic patients showed that after each bath an increase in the percentage of hemoglobin and in the number of erythrocytes occurred. These investigations also cannot be consid- ered ;ks by any means conclusive. ( .. To summarize : The chemical rays penetrate all tissues. They are most thoroughly absorbed by the blood. Only light that bodies take up is of influence upon them. The chemical effects of light are in direct proportion to the amount of light absorbed. Provisionally, it must be assumed that the chemical rays in large amount are injurious; but in appropriate amount, probably beneficial. The pigment of the skin is a protection against the chemical rays. In any event, the light is a stimulant to all irritable matter, and the dosage thereof must be determined by future investigation. Light, in itself, as well as its effects upon inanimate bodies and upon living beings, thermically and chemi- cally , and by means of its luminous as well as of its dark rays, requires unlimited study before we shall be informed concerning its physiologic action as a whole or in detail. therapeutic experiences with sun baths and OTHER LIGHT BATHS It seems more convenient to continue here the account of my ex- perience with light as a remedial agent, rather than to make this the theme of a separate section, as in the case of the more extensive sub- ject of hydrotherapeutics. “ All experienced physicians consider the54 HELIOTHERAPY AND PHOTOTHERAPY great value of the sun’s rays to consist in a stimulation of organic processes,” and a large part of these effects may be obtained also by means of appropriate baths in electric light. It is principally chronic disorders of hemogenesis, derangements in diges- tion, some dyscrasic processes, and especially states of debil- ity of a congenital character and during convalescence from j'exhausting diseases, that furnish the indication for this procedure. If at this point, I shall to a certain degree give only an outline of the !nutritive disturbances amenable to sun baths and electric lioht baths, j o 7 this will be owing to the fact that we are in this connection still de- pendent upon an empiric rather than upon a rationally comprehensible explanation of our observations. That enfeebled innervation can be relieved by sunlight and electric light; that the movement and the constitution of the blood can be influenced thereby; that all the functions of metabolism are stimulated; that certain injurious influences—I may refer here again to the influence of chemical rays upon micro-organisms—can be removed directly or indirectly; that superficial disease dependent upon micro-organisms, such as divers diseases of the skin, as lupus and the like, can be affected favorably; that it will be possible to increase elimination through the various emunctories—these facts will cer- tainly establish our sun baths and electric light baths as an empiri- cally justifiable remedial agency. I have been able to observe quite specific effects as the result of the judicious employment of sun baths, and also from the use of electric incandescent-light baths in cases of anemia, chlorosis, and scrofulosis. It is particularly scrofu- losis that, according to the view of other physicians also, can be favorably influenced by sun baths and light baths. Rheumatic affections ; disorders due to exposure to cold; gout, as numerous trustworthy reports show; nephritis; obesity; some forms of neu- ralgia ; and, what perhaps appears more comprehensible at the present time, various forms of autointoxication and the neuroses depen- dent upon them, may be influenced by phototherapy, in part sympto- matically, and in part by action upon the cause. I have personally ob- served tuberculous ulcers disappear as a result of systematic expo- sure to the sun. Naturally my observations are not simple, inasmuch as I employ other agents of a thermic, mechanical, and dietetic char- acter in my course of treatment. Among the most interesting facts is the employment of phototherapy in Ophthalmology. I may call attention to the publication of Daxenberger in the “ Wochenschrift fur Therapie und Hygiene des Auges.” This writer attributes to light baths especially a powerful sorbefacient effect in the presence of chronic inflammations of the sclera, the iris, the choroid, the retina, and similar affections. The foregoing are the principal effects of unmodified light rays, inINDICATIONS FOR LIGHT BATHS 55 which heat, light, and chemical rays act in association. To the future must be left the determination of the mode of action of the different classes of rays. The bactericidal properties of the chemical rays promise much in the treatment of superficial bacterial affections of the skin. Finsen’s treatment of lupus belongs to this category. On the other hand, the exclusion of the chemical rays has been successfully practised by Finsen in the treatment of variola. In more than 70 cases this simple method of treatment in cases of variola by exposure to red light prevented suppuration and suppurative fever, as well as the development of cicatrices ; and thereby the whole disease was trans- formed into a comparatively mild one. The symptomatic indication for the treatment of various diseases by means of light baths may be found if it be borne in mind that pro- fuse -perspiration without excessive acceleration of circu- lation can be brought about in the electric light bath. This renders pos- sible 'its employment in the presence of heart disease, when there might be objection to the employment of ordinary diaphoretics. Some dys- cras/ic processes demand powerful stimulation of definite secretory orgaths. Some good effects of the incandescent-light bath for which othetf explanations have been given may be attributable to this fact. Thus’ various results considered as specific effects are to be attributed only (to the symptomatic effect. Ijn conclusion, it may be said that the whole question is still the subject of heated discussion. It has not yet been cleared up in all directions, and extended investigation will be required before the indi- cations and counterindications can be laid down with precision. That, however, the entire field is most promising is evident from the fact that '.we have to do here likewise with a natural vital stimulus of great potency. It would be presumption to attempt at the present time to lay down the limitations of this powerful agency. The matter is deserving of thought and labor on the part of the best investigators.Part II THE TECHNIC AND THE METHODS OF HYDROTHERAPY BY DR. ALOIS STRASSER INSTRUCTOR IN CLINICAL MEDICINE AT THE UNIVERSITY OF VIENNA; ASSISTANT TO PROFESSOR ' WINTERNITZ IN THE HYDROTHERAPEUTIC CLINIC OF THE GENERAL POLICLINIC OF VIENNA.PART II THE TECHNIC AND THE METHODS OF HYDROTHERAPY CHAPTER I GENERAL BATHS General\ Considerations. Precautionary Measures. The High Bath. The Plunge hath. The Half-bath. The Ziemssen Graduated Bath. The Cold Full Bajth. Generjal Considerations The technic of hydrotherapy has, it is true, attained a high state of development; nevertheless the description of any of its procedures must nlot be viewed as the statement of an inflexible prescription. The physician familiar with the physiologic effects of thermic and mechanical measures will himself devise the technic for his therapeutic applica- tions, selecting the procedure appropriate in the given case from among those familiar and described by authors, or modifying these extempora- neously in accordance with necessity. His prescription must never- theless in every instance have a definite purpose and be expressed in precise terms. The technic to be described here is that practised by Winternitz; it is at present sufficient for most therapeutic requirements and was based upon the technic of the older hydrotherapeutists, especially that of Priessnitz. The most important consideration in the technic is that the ‘measure of stimulation’ (Winternitz)—that is, the temperature, the duration, and the mechanical elements (water-pressure, friction, otc.), and not the form—must be the distinguishing feature of the pro- cedure adopted. In other words, by varying these elements, different effects can be produced by the same form of procedure and similar and even identical effects with a variety of procedures; for whatever 596o GENERAL BATHS be the difference of routine pursued, it is possible, after all, to vary only the degree and the quality of the resulting irritation. Precautionary Measures.—Before every general cool or warm application it is customary to cool the head thoroughly, and to envelop it in a cool covering, which is kept in place during the pro- cedure. The reason for this lies in the fact that on applying the stimu- lation of cold to the surface of the body, the blood expelled from vascular areas (skin, intestinal vessels), affected directly or reflexly, must find its way into other parts of the body. Winternitz designates this manifestation as ‘retrograde hypostatic congestion’. The marked overdistention of the vessels of the head may be a source of discomfort subjectively, and under certain conditions (arteriosclerosis and the like) objectively as well. Provision against this manifestation has become the rule, from which exception is made when cooling of the head is attended with unpleasant subjective sensations, or when congestion of the head is considered not injurious or even useful—as in the cerebral anemia of some eases of chlorosis, etc. In many cases a cold application about the neck (ice collar) may suffice. In making hot applications also, cooling of the head is nerfessary. Under such circumstances the cerebral condition to be prevented is not one of hypostatic congestion, but of fullness of the vessels and true congestion, as a result of overheating. Ice collars here render better service than when cold applications are made. It may further be mentioned as a general rule that after the application, unless it be specifically prescribed otherwise, the patient should be rubbed thoroughly dry. He should feel comfortably warm and should then complete his reaction (warming) by movement. The principal methods and applications used in the practice of hydrotherapy, all of which may be general or partial, or even strictly localized in their use, are (i) baths; (2) douches and affusions; (3) wet and dry packs ; (4) steam, hot-air, and electric light baths (the last-named two being mentioned here because they are used in combination with hydriatric measures strictly so called); (5) compresses ; (6) bags and coils for hot water, cold water, and ice; (7) irrigation. With most of these, manipulations by attendants and movements of the patient are associated. In all, the elements already referred to,—namely, temperature, pressure (intensity), quantity, and duration,—as well as the character, force, and duration of the manipulations, must be prescribed ac- curately and with careful individualization; as has been so forcibly insisted upon by Baruch in his admirable treatise.1 1 “Hydrotherapy,” p. 404, New York, 1899.PLUNGE BATH 61 I. BATHS We distinguish (i) general and (2) partial baths. GENERAL BATHS The general baths comprise (a) the high bath, (b) the plunge bath, (c) the half-bath, and (d) the full bath. The High Bath This is a form of tub-bath in which the water reaches above the shoulders of the seated patient. The temperature of the water should be high—from 320 to 38° C. (89.6° to 100.4° F.); the duration of the bath should be rather long—from five to twenty- five minutes; and the mechanical manipulations are confined to a minimum. The patient is gently rubbed, or rubs himself gently, with- out materially changing the semirecumbent posture. The high bath is wholly a sedative measure, and is employed in cases of erethis- tic neurasthenia; of hysteria; in the presence of marked diffuse nerve-pain (polyneuritis, tabes); for the relief of the'marked itching attending- disease of the skin—in which case mucilaginous substances may sometimes be added ; and, finally, as a hypnotic. When in the course of hydriatric measures a condition of heightened nervous irritability, sleeplessness, etc., develops—'nervous reaction’—high baths are employed until sedation occurs. The Plunge Bath This form of bath, in contradistinction from that just described, is cool (or cold—from 22° to 150 C. (71.6° to 590 F.)—and brief—one or two minutes. The water reaches about half the height of the tub, and the patient should engage in active movement. The brief irritation induced by the cold generally gives rise to rapid and good reaction, and the bath therefore has a stimulating effect upon innervation, circulation, and function in general. The patient acquires a sense of warmth. The effect can be greatly increased by previous warming of the patient’s body and by using water of the lower temperatures. The abstraction of heat by this method, in view of the good reaction, is slight. Heat-dissipation may be some- what increased, but this cannot lower the temperature materially because heat-generation also is increased by reason of the stimulat- ing influence of the cold. Cool and cold plunge baths are indicated whenever general stimulation is desired, without material abstraction of heat; and they constitute a good stimulating measure by reason of their brief,6 2 GENERAL BATHS active irritative effect through cold. The effect, as stated, can be materially augmented by previous warming, as the temperature-differ- entiation is then greater. These baths may even be employed for hypnotic purposes, as the resulting reaction is generally followed by sedation. When it is desired to induce sleep in this manner, it is advis- able not to dry the patient, but to place him in bed while still moist, and to permit him to dry between the sheets. The Half-bath This measure is much employed, and, on account of the readiness with which it may be modified, meets a considerable number of indi- cations. The mode of application is as follows x: The head being first cooled and the chest sprinkled with water, the patient enters (or is lifted into) the tub, in which, with the bather in the sitting posture, the water should reach to the level of the umbilicus. After an initial immersion to the level of the shoulders, t\(ie patient assumes the sitting posture while the upper portion of the body is actively douched (Fig. i). Subsequently he assumes a semire- cumbent dorsal posture, when friction is applied successive(y to the chest, the abdomen, and the extremities (Fig. 2). In typhoid fever, however, the abdomen is not manipulated. After repeated rdouching the bathps terminated. Douching with the water of the bath,, and even with colder water, is especially indicated in depressive nervoui manifes- tations such as stupor or coma. Effects.—The action of the half-bath varies in accordance with the mode.of administration. On entering the bath there results general stimulation from the cold, and reaction must be brought about or in- creased through the mechanical manipulations. In general, tme follow- ing considerations should be borne in mind in connection with mode of action : A greater stimulating effect is produced by 00col baths of short duration with considerable mechanical manipulation ; while more protracted baths at a higher temperature with little ipiechan- ical manipulation are less stimulating, and may even have a sedative effect. The quantitative heat-abstraction depends on the reaction or the volume of blood passing through the skin ; from wh^ch con- sideration, the great importance of the reaction is apparent. * Methods and Uses.—The mode of employment of t[:he half- bath and the indications therefor may be summarized as Ifollows : Brief, moderately cool half-baths—from 28° to 20° C. (8*2.4° to 68° F.) for three or four minutes—serve as a hygienic measure; in the case of full-blooded patients, baths of somewhat longer duration 1 The illustrations, figures 3 to 6, of the method of bathing in typhoid fever co mmonly used in the editor’s service at the Polyclinic Hospital, Philadelphia, differ in some pr-irticulars from the description in the text. The subject will be discussed more fully in the Aj ipendix.HALF-BATH 63 Fig. 1.—Half-bath with Affusion. — [Polyclinic Hospital, Philadelphia; German Method.) Fig. 2.—Half-bath with Friction.—[Polyclinic Hospital, Philadelphia; German Method.)64 GENERAL BATHS may be employed, and vigorous friction applied as soon as the general reflex irritability, which serves as a guide for the degree of stimulation, permits. Used in this manner half-baths constitute a good general, stimulating, refreshing measure, and may be employed as such under all conditions. In disease of the central nervous system (diseases of the spinal cord) half-baths of a somewhat higher temperature (from 320 to 270 C.—89.6° to 80.6° F.) are indicated. The amount of mechanical manipulation should only be sufficient to make the patient comfortably warm in the bath. In the choice of a temperature within the limits named the preponderance of irritative or paralytic symptoms should be the guide. In the presence of the former the temperature should be higher, and the duration longer; and in the presence of the latter, the temperature should be lower and the duration shorter. Thus, for instance, to relieve the lancinating pains in a case of tabes dorsalis warm baths will be employed, and for paralytic symptoms and marked ataxia, cool baths of short duration. In functional neuroses and psychoses the existing degree of irritability will serve as the guide. In gastro-intestinal affections the dietetic half-baths just mentioned are employed, but when atonic states and circulatory disturbances in the abdominal cavity exist, a modification is prac- tised, in so far as the half-bath is combined with high douches to the abdomen. An assistant scoops water with a large dipper from the tub and pours it from a considerable height (from 1 to meters— 3 to 4^ feet) upon the abdomen of the patient. This combination of thermic and mechanical stimulation (‘thermic massage,’ Winter- nitz) has a good effect. In infectious diseases, as in fever generally, the half-bath has to meet a number of indications; it is believed to abstract heat, to strengthen the action of the heart and to overcome circulatory weak- ness, to improve conditions of nervous depression and muscular weak- ness, and to have a favorable effect upon gaseous interchange, metab- olism, and diuresis. As a matter of fact it is capable of exerting a good influence in all of these directions. In general, temperatures of 70 or 8° C. (12.6° or 14.50 F.) below that of the body are selected for the first baths ; thus, from 32° to 30° C. (89.6° to 86° F.), the water being cooled 2° or 30 C. (3.6° or 5.40 F.) while the patient is seated in the bath. Subsequently, lower temperatures (down to 20° C.—68° F.) are employed and con- tinued so long as the body-temperature inclines to an ascending type. Rarely is a bath temperature below this made use of, and then only when states of profound depression appear to render necessary the marked stimulation of the low temperature. When the body-tem- perature again assumes a declining course, the temperature of theHALF-BATH 65 bath is again increased until it reaches that of the first baths. Baths of a higher temperature will be required when the patients are greatly stimulated or excited by those of a low temperature. Often, especially in the presence of fever of short duration, lasting for a few days, it is not at all necessary to depart from the higher temperature of the initial baths. The variations in the temperature of the bath mentioned refer rather to intense fever of long duration, as typhoid fever. (See also Appendix, pages 508 to 512.) The practice of giving the patient a warm drink, with or without alcohol, or the latter alone, before the bath, should be omitted only in the case of strong patients. The reactive power of the patient appears Fig. 3.—Lifting Patient into Tub.—{Typhoid Fever, American Method.) to be increased by this procedure, and the action of the heart is un- doubtedly strengthened. Warm drinks (milk, tea, coffee) or alcohol given even during the bath are useful in protecting the patient against chilliness. The duration of the half-bath in cases of fever will be determined as follows : For purposes of observation, and to avoid abruptness in beginning, short baths of from three to six minutes are at first employed ; gradually the duration is increased, so that in cases with intense fever the bath may be continued for from twelve to fifteen k—566 GENERAL BATHS minutes. As a matter of course, individual peculiarities may render necessary wide variations in this connection. Every patient shivers on entering the bath. This chilliness is neutralized by vigorous rubbing and douching, and as soon as reaction has developed, the heat-abstracting effect of the bath sets in ; the well- flushed skin being capable of giving off considerable amounts of heat. In Ziemssen’s method of bathing, which will be discussed later, a second chill is induced, and even Brand believes that the antipyretic bath should be continued until a second chill occurs. In our method the second chill is unconditionally to be avoided, and the patient should be removed from the bath as soon as he becomes chilly notwithstanding vigorous rubbing. As a rule, baths of from ten to twelve minutes’ duration will suffice, even in the presence of intense fever and severe infectious diseases ; in the case of robust individuals the bath may be continued for as long as twenty minutes. The frequency of the bath will be governed in accordance with various considerations. It will generally be observed that immediately after the bath the febrile temperature declines more or less (i° or 2° G.—1.8° or 3.6° F.). The reduction in temperature may persist for a variable time; as a rule, however, it will be found that after a good cooling bath one or two hours elapse before the previous temperature is again attained. Nevertheless it may occur in severe fever that the temperature again rises to a high level in the course of an hour or even a still shorter time. In practice it has been found to be a good rule that the patient should be bathed as soon as the axillary temperature reaches 390 C. (102.2° F.). In general, this rule may be observed, but it has certain drawbacks, inasmuch as, on the one hand, other in- dications may be present which may render necessary the repetition of the bath, and, on the other hand, a strict observance of the rule may at times bring about an undue frequency of bathing. At the beginning the patient is bathed twice or three times a day ; later the frequency is increased in accordance with circumstances, so that in the course of twenty-four hours so many as seven or eight baths may be given ; although even in severe cases from four to six baths during the day, and one or two during the night, will completely suffice. In addition to high temperature, conditions of debility and depression involving the nervous system—stupor, coma, delirium—and the circula- tion—weak heart-action, marked dicrotism—are indications for the repetition of the bath. Undue frequency of bathing is equally injurious with unduly low temperature, because the cumula- tion and increase of the stimuli give rise to a pathologically increased reaction. The stimulation of the cool bath and of the rubbing also excite the processes of heat-production to increased activity ; and we have often observed that frequently repeated cold baths not only doHALF-BATH 67 not reduce the febrile temperature, but may even cause it to rise. The nervous system responds to such cumulative and increased stimuli with states of marked excitement—great restlessness, delirium, car- phologia (versatile nervous fever artificially induced). The occurrence of such states of excitement may necessitate immediate elevation of the temperature, or suspension of the bath-treatment fora half 01- even an entire day, or the substitution of other measures for the half-bath. On the other hand, great weakness or profound nervous Fig 4.— Rubbing the Patient in the Tub. Cold Douches to Head and Shoulders. (Thermometer Exaggerated to Show its Presence.)—(Typhoid Fever, American Method, Polyclinic Hospital, Philadelphia,) depression may necessitate frequent repetition of the bath within a short time without reference to the occurrence of possible states of excitement. After the half-bath it is customary to dry the patient and place him in bed. (See Figs. 5 and 6.) Brand and many others followed the practice of removing the patient from the bath and placing him upon a linen sheet spread upon the bed, and permitting him to lie, well68 GENERAL BATHS covered by the sheet, without being dried. The subsequent evapora- tion that takes place increases still further the dissipation of heat from the periphery in a short time, it is true, but permits the temperature to rise again rapidly. This procedure, however, is eminently sedative, and is especially indicated in the presence of violent cardiac ac- tion, which is not sufficiently corrected by the half-bath. With us the patient after the half-bath is often placed in a chest compress, a large cool compress which covers the trunk and prevents the eleva- tion of temperature for a considerable time. It is, in any event, ad- vantageous to make use occasionally of each of these three methods, the choice being determined by the conditions in the individual case. Fig. 5 —Lifting Patient into Bed after Tubbing.—( Typhoid Fever, American Method, Polyclinic Hospital, Philadelphia.) The Ziemssen graduated bath belongs also in this category. Ziemssen has the patient sit in a bath the temperature of which is 5° or 6° C. (90 to ii° F.) lower than that of the patient’s body, and, in ad- dition to vigorous chafing, permits the addition of cold water at short intervals until the temperature of the bath is reduced to about 20° C. (68° F.) in the course of ten or fifteen minutes. The dura- tion of the entire bath is from twenty to thirty minutes, until the patient does not cease to shiver in spite of vigorous friction and affu- sion. He is then removed and placed in a previously warmed bed.COUNTERINDICATIONS FOR HALF-BATHS 69 The bath is far more efficacious in its antipyretic effect than the cool baths of short duration. There will be observed a decline in the tem- perature of so much as 2^° C. (4.5° F.) ; but the stimulating influence upon the vascular and the nervous systems is wanting, and depression is often more serious than even a considerable elevation of temperature. It is possible also to induce a marked revulsive effect by means of one or two baths, if the water is abruptly cooled from 350 C. (950 F.) to 220 C. (71.6° F.) by the sudden addition of cold water, or by giving alternately baths at different temperatures in two Iug. 6.—Drying the Patient after Tubbing. Ice-cap to Head ; Hot-water Cans To Lower Extremities.—(American Method, Polyclinic Hospital, Philadelphia.') tubs placed side by side. Vinay has described an apparatus permit- ting the removal of water from the tub by means of large discharge openings, and the immediate addition of previously prepared water of other temperature through a lateral opening. The apparatus is com- plicated, and can readily be replaced by a more simple procedure. Alternating half-baths are indicated wherever a general revulsive effect is desired, especially in cases of neuroses and neuralgias. Counterindications for half-baths scarcely exist, in view of the readiness with which the method can be modified. Half-baths of considerable duration may not be employed when abstraction of70 GENERAL BATHS heat is forbidden, as, for instance, in conditions of great weakness, under which circumstances the giving of the bath is both difficult and dangerous; and in collapse with subnormal temperature. Every variety of half-bath is interdicted during a chill and when hemorrhage is taking place. The Cold (Full) Bath In a reservoir of from to 2 meters (4 to 7 feet) long and wide, and 1 y2 meters (4 feet) deep, that is to say in a very large tub, the water should be kept at a low temperature (from 8° to 120 C.—46.5° to 53-6° F.) by means of constant addition and removal. The dura- tion of these baths is exceedingly brief, from one-half to at most one minute, and the patient is directed to submerge himself in the water once or twice, and to engage in active movement. Preliminary careful cooling of the head is indispensable. The action depends upon the intense stimulating influence of the cold upon the entire surface of the body. The reaction following the initial marked stimulation is in most cases rapid and adequate ; the skin becomes reddened, circulation and respiration are powerfully stimulated, even during the bath ; the cutaneous vessels become dilated, so that the bath, though brief, abstracts a certain amount of heat. These baths are among the most powerful measures in the domain of hydro- therapy. They are not often employed alone, but rather in combina- tion with heat-conserving and heat-producing measures (hot pack, sweat chamber, etc.). The patient may be permitted to pass directly from the heat into the full bath, when an extremely intense stimulus is desired—providing the vascular system is intact. Under other cir- cumstances it is advisable to prepare the previously heated body for the full bath by a tepid application—for instance, by means of a half-bath or a douche—and to employ the full bath as a final most intense stimulus. An especially marked antipyretic effect can be induced by permitting the patient to step from the full bath into a half-bath of not too low a temperature (from 160 to 20° C.—60.8° to 68° F.). This bath will feel tepid after the full bath, and render possible a considerable reduction in temperature. Indications.—Cold full baths are employed when metabolism is retarded, in states in which excretory activity is to be greatly increased, especially in obesity, in syphilis, in some cases of gout, in scrof- ulosis, in chronic metallic poisoning, less commonly in dia- betes, and, without combination with warming procedures, in tuber- culosis. The cold full bath without previous warming of the patient is highly lauded by Aberg in tuberculosis ; it is claimed that pulmon- ary hemorrhage or other complications have never occurred during courses of treatment by this procedure. A counterindication is found in all states of debility of any considerable degree, and in states of exhaustion.CHAPTER II PARTIAL BATHS AND OTHER PROCEDURES The Occipital Bath. The Elbow-bath. The Hand-bath. The Foot-bath. The Sitzbath. The Cold Rub. Ablutions. Douches and Affusions. PARTIAL BATHS This group includes (a) the occipital bath, (A) the elbow-bath, (c) the hand-bath, (d) the foot-bath, and, finally, (e) the hip-bath or sitzbath. The Occipital Bath The head of the patient, who is in the horizontal position, is immersed in a basin resembling a shaving-dish, into and out of which water at ordinary temperature flows continuously. The dura- tion of the bath is from five to ten minutes. The mode of action has not been thoroughly investigated, but experience has shown that the bath is capable of exerting a reflex influence upon the nervous system through the medulla oblongata, and it is employed to relieve anemic headache; but much more commonly in states of sexual excitement (pollutions, vaginismus); in cardiac neuroses; and in nervous asthma. A simplification of the method consists in cool- ing the occiput by means of a suitable coil. (See Figs. 7, 8, and 9.) The Elbow-bath Immersion of the elbow-joint in (running) cold water,—8° to 14° C. (56° to 570 F.),—the forearm being supported on a rubber pillow. The duration is from ten to twenty minutes. Action and Indications.—The action of this procedure depends on the tense contraction of the brachial artery, which diminishes the blood supply to the peripheral parts—forearm and hand ; and on the anesthesia induced in the distribution of the ulnar nerve by over- stimulation. The indications are limited : inflammatory processes in the forearm and hand, such as phlegmon and panaris; neural- gia and neuritis of the trunk and branches of the ulnar nerve. Hand-baths and Foot-baths The hands or the feet are immersed in water in suitable basins or small tubs, the water being maintained at the original temperature 7172 PARTIAL BATHS AND OTHER PROCEDURES by frequent changes or continuous supply and discharge. Both high and low temperatures maybe employed, from 38° or 400 C. (say, ioo° or 104° F.) down to 8° to 120 C. (say 46° to 540 F.); inter- mediate temperatures are less commonly employed Action and Mode of Employment.—The object of these baths is to stimulate remote vascular areas and to exert a revulsive effect—that is, direct derivation. When hot hand-baths and foot- baths are employed, marked dilatation of the vessels soon results ; when cold running baths are employed, the dilatation must be induced through reaction, which is encouraged by vigorous rubbing. The bath is continued until the feet in the water become intensely red. Cooling of the head is indispensable until the reaction in the extremities has set in. Subsequently the decongestive effect is evident both subjec- tively and objectively. The reflex effects have been determined empirically, being exerted from the hands upon the innervation of the thoracic organs (heart and lungs), from the feet upon the entire abdom- inal and pelvic circulation, as well as upon the meningeal vessels. Marked peristalsis, uterine contractions, and spasm of the bladder may also be induced reflexly. The indications are obvious from what has been stated, but are generally confined, in spite of the theoretic possibility of extensive employment, to states of congestion and hyperemia, as meningeal irritation, headache, angioparalytic migraine. Hot hand- baths and those of alternating temperatures are employed occa- sionally with success for the relief of asthma and angina pectoris; foot-baths of a similar character may be used as emmenagogues; Habitual coldness of the extremities, as well as sweating ofSITZBATHS 73 the hands and the feet, maybe successfully treated by the sys- tematic employment of cold baths and those of alternating tempera- ture. The decongestive effect of foot-baths just mentioned permit their employment either hot or cold for hypnotic purposes. These measures are counterindicated in cerebral anemia, and cold foot-baths especially in cases of irritable bladder and of uter- ine colic.1 * * * Sitzbaths Sitzbaths or hip- baths are taken in the well-known tubs of wood or zinc (Fig. io). The amount of water necessary for adults is from 20 to 25 liters (5 to 6 gal- lons) ; that is, about enough for the water to reach the level of the patient’s umbili- cus. During the con- tinuance of the sitz- bath the patient is carefully covered in order to protect him from becoming cold. The t e mp e r ature and duration of sitzbaths vary within ~ wide limits. We em- Fig. 9.—Head Coil in Position. ploy sitzbaths with very cold to very hot water, and of from quite brief to quite long duration. The mode of action of the sitzbath varies in accordance with the temperature of the water and with the duration of the bath, and de- pends upon reflex stimulation of the abdominal and pelvic vessels. We are taught that the more deeply lying vessels, when a stimulus is pip5 '/ cl 1 Standing in water up to the level of the ankles, for a period of one or two minutes, and the well-known practice of walking on the grass, or so-called dew-walking, etc., are similar m their mode of action. These procedures were at one time much in vogue, and especially- walking on the grass became fashionable as a method newly discovered by Kneipp. Stand- ing in water in the tub may take the place of running foot-baths, and can readily be carried out m any house. Walking in the wet grass has the advantage of associated movement in the open air; but it is very apt to be overdone.74 PARTIAL BATHS AND OTHER PROCEDURES applied, act like those directly affected ; that they contract when the application of cold is of considerable duration, and dilate when warm applications are used; and it is also our belief that the vessels con- tracted as a result of reflex influences become dilated in reaction when the effect of the cold has ceased. If the effect of the cold persists for a considerable time, it will give rise to ischemia of the intestinal wall and of the glandular organs. The movement of the intestines Fig. io.—Cold Rubbing Sitzbath.—(After Kellogg.) —that is, peristalsis—also is affected, inasmuch as brief irritation by cold is stimulating, and excites reflex muscular contraction, while long- continued sitzbaths exert a paralytic effect on the muscular fibers of the intestine, the diminution in peristalsis being due probably to ischemia, brought about by the action of the splanchnic nerve. Warm sitzbaths exert a distinctly sedative, antispasmodic, and anodyne effect.HOT SITZBATHS 75 The indications and the mode of employing sitzbaths may be summarized as follow : Cold sitzbaths of short duration, at a temperature of from io° to 20° C. (50° to 68° F.), and of from two to five minutes’ dura- tion, are indicated in all diseases of the abdominal and pel- vic organs, attended with anemia, passive hyperemia, motor weakness or insufficiency, nervous depression, and torpid metabolism; also in chronic catarrhal gastro-intestinal disorders, constipation, hyperemia of the large glandu- lar organs, amenorrhea, menostasis, torpid endometritis, anemic leucorrhea, impotence, diminished sexual desire, prostatorrhea and spermatorrhea, atony of the bladder, and fecal incontinence. The reaction, which brings about a flow of blood to the abdomen, has a decongestive effect upon the head, and renders these sitzbaths available for hypnotic purposes. The counterindications for cold sitzbaths of short duration con- sist in acute inflammatory processes in the abdominal and pelvic organs, in profuse uterine hemorrhage, in marked irritative motor and sensory states, especially in seminal emissions, and in acute diseases of the bladder. The protracted cold sitzbath, at a temperature of from io° to 20° C. (50° to 68° F.) for from eight minutes to half an hour, induces anemia of the intestinal mucous membrane and lessens peristaltic activity. It is, therefore, indicated in acute and chronic diar- rhea and even in dysentery and choleriform diseases; in acute inflammatory processes in the abdominal and pelvic organs, especially inflamed hemorrhoids; and in general inflam- matory disorders of the rectum and its vicinity. Uterine and vesical colic constitute counterindications. The tepid sitzbath (20° to 30° C.—68° to 86° F. ; twenty minutes to an hour) exerts essentially a sedative and to a certain degree an antiphlogistic effect, and is employed for such purposes in all acute and chronic inflammatory processses. In con- stipation with anemia brief sitzbaths, beginning at 86° F. (3O0 C.) and reduced daily two degrees until 6o° F. (15.5° C.) is reached, are some- times useful. Warm sitzbaths, of from 30° to 38° C. (86° to 100.4° F.), are always protracted and are employed to relieve spasm and pain, especially colic of all kinds. Their action as an emmenagogue is well known. Very hot sitzbaths of 40° C. (104° F.) and above are niuch employed in France, especially in the treatment of chronic intestinal catarrh. The temperature is rapidly raised to 420 °r 430 C. (say, 108° or no° F.) by constant addition of hot water. The effects are said to be similar to those of protracted sitzbaths.76 PARTIAL BATHS AND OTHER PROCEDURES THE COLD RUB Mode of Employment The cold rub is employed by us in the following manner: A linen sheet 2*4 or 3 meters (yards) long and or 2 meters (yards) wide, is folded lengthwise and immersed in water of the prescribed temperature. The sheet is now partly wrung out, and wrapped about the patient in the following manner (see Figs, n, 12, and 13): The attendant unfolds a portion of the folded border, about 1 meter (yard) long, with the left hand, approaches the patient, who is in the erect posture, from in front, washes his face and chest, introduces the free border of the sheet in the right axilla, passes the sheet transversely across the chest and abdomen, and through the left axilla around the back, and finally brings the remainder of the sheet over the shoulders so as to envelop the entire body. The end of the sheet is tucked in securely at the neck. Now the mechanical manipulation is begun, which consists in vigorous chafing of the entire body through the sheet. The effect of the cold rub consists in active stimulation, which includes the primary stimulation of the cold affecting the entire body at once, and the mechanical manipulation on the part of the attendant. The purpose of the procedure is to bring about increased activity of the circulation, which not only becomes apparent upon the surface of the body, but, extending from the skin, also involves the entire circulation. At first the cold shock induces deep, quick- ened respiration and increased pulse-frequency. Both effects , soon subside, and after reaction has set in, the distribution of blood is changed and the skin is reddened. The duration of the cold rub cannot be specified. The attendant must continue rubbing until the patient has become warm, and this will vary greatly in individual cases. The stimulating effect is in- creased by having the patient as warm as possible before the cold rub is begun ; therefore the patient is generally rubbed on getting out of a warm bed, or after being previously warmed by some other procedure. As a result of the contrast in temperature, the stimulation is increased and reaction is accelerated. It is further customary to precede the cold rub by brief warming in a steam-bath or hot-air bath. It is a matter of practical importance that debilitated and sensitive patients tolerate a cold rub much better if their feet are warm. Upon this is based our practice to have such patients stand in water at a tem- perature of 40° C. (104° F.) or to cover their feet with hot cloths dur- ing the rubbing. When the cold rub is over, the warm feet are chafed separately. Then the patient is either rubbed dry or partly dry, is placed in bed, and is carefully covered.THE COLD RUB 77 The cold rub itself does not exert any special antipyretic effect; or at most, only in so far as the skin being in a state of reactive hyperemia gives off an increased amount of heat. If, however, it be desired under these circumstances to effect considerable abstraction Fig. ii.—Cold Rub. Passing the Sheet across Chest and Abdomen. of heat, cold water is again poured upon the sheet in which the patient is enveloped after the rubbing has been completed, and renewed slapping is practised. The freshly moistened sheet then becomes less quickly warmed, and thus abstracts a greater amount of heat from78 PARTIAL BATHS AND OTHER PROCEDURES the body. This combination is designated by us ‘ Lakenbad ’ (sheet-bath). The temperature of the water that we customarily use for a cold rub is rather low. Naturally, the reaction obtained is the better, the lower the temperature employed. It is not wise to rub patients with Fig. 12.—Cold Rub. Bringing Slack of Sheet over Right Shoulder. water of a higher temperature, because a good reaction may then fail to take place on account of absence of stimulation. In the case of a sensitive patient, we begin with a temperature of 20° C. (68° F.) and are generally in a position to employ water at a considerably lower temperature in the course of two or three days, without causing thePARTIAL ABLUTION 79 patient discomfort. It should, however, not be forgotten that the action of a cold rub of brief duration, but with vigorous chafing, is much better than that of a rub with one with tepid water. Should the sudden stimulation of the entire surface of the body appear excessive, as may be the case in febrile, or otherwise debili- Fic. 13.—Cold Rub. Sheet in Final Position; Friction Begun. tated, or very sick patients, a partial rub may be employed—so-called partial ablution. This is one of the mildest procedures applied to a patient at Ivaltenleutgeben. It consists in rubbing the various parts of the body separately while the patient lies in bed, so that while, for8o PARTIAL BATHS AND OTHER PROCEDURES instance, one extremity is being subjected to treatment, the entire re- mainder of the body remains carefully covered. The shock in this method is naturally slight, but the effects are cumulative, and the total result of a partial ablution is, on the whole, the same as that of a total rub, possibly only slightly less quantitatively. Indications.—The general indications for partial ablutions coincide with those for the cold rub, and are set forth in that connection. The most important special indication for partial ablutions resides in the ability to estimate, by means of this procedure, the irritability and the capacity of the patient for irritation. It is a fact of great impor- tance that in the practice of these procedures guidance may be ob- tained as to whether a febrile patient, for instance, suffering from an infectious disease, may be treated with half-baths. The general indications for the cold rub comprise almost all dis- eases. The procedure often serves as a dietetic measure ; that is, as a general invigorating procedure, improving the circulation, metabolism, etc. Beyond this, the chief indications are presented by diseases of the circulatory and respiratory organs, by ca- tarrhal conditions of the intestinal tract,—thus, in disease of the heart, lungs, blood-vessels, stomach, and intestines, etc.,—and, further, by disorders of metabolism. Partial ablutions are also readily applicable in the last-named diseases, and the resulting effect is quite favorable. The cold rub is counterindicated in inflammatory disease of the skin, in pronounced general nervous irritability, and in dis- eases in which marked augmentation of circulation, with increase in blood pressure, is interdicted—for instance, marked arterio- sclerosis. Drip Sheet A procedure similar to the cold rub is the more familiar drip sheet. According to Baruch, its technic differs from that of the cold rub in that the sheet is not wrung out, but is taken from the water dripping, and wrapped around the patient as shown in the illustrations (Figs. II, 12, and 13). The attendant applies rapid friction over the sheet, occasionally slapping the surface to increase mechanical irritation. A basinful of water about ten degrees cooler than the sheet water is poured over the head and shoulders two or three times at short inter- vals, and this is alternated with friction for from five to ten minutes. Baruch insists upon the exact technic. In his experience the effect of the cold rub, in which the sheet is only moist, is more stimulating and evanescent, because less heat is abstracted, while that of the drip sheet is more sedative, and these apparently slight differences are important elements in the production of different therapeutic results.THE SCOTCH DOUCHE 8l DOUCHES AND AFFUSIONS The most characteristic feature of these procedures consists in the circumstance that the mass of water falling from a certain height gives rise to constantly renewed mechanical stimulation. There are jet, fan, and spray douches, according as the stream of water is thrown upon the body directly, In the form of a fan, or through a per- forated nozle, varieties which at the same temperature differ in greater or lesser degree in the amount of stimulation. With reference to the direction of the stream, there are vertical and horizontal douches, the former generally fixed, the latter movable, and so arranged that the entire body may be acted upon by them. The t emperature em- ployed varies from the lowest to the highest, and the pressure of the water varies in ac- cordance with the char- acter of the orifice or orifices through which it escapes, inasmuch as an interrupted stream itself exerts a lower pressure than an uninterrupted one. A pressure of not less than two atmos- pheres (about thirty pounds to the square Fig. 14.—Rain Bath. inch, i. e.y 60 inches or 1 520 millimeters of mercury) suffices for all purposes. A pressure of less than from one to one and a half atmospheres, or one of more than from four to five atmospheres, cannot be employed without a certain diminution in effect, or, on the other hand, without the risk of unpleasant results. The douche, by means of which high and low temperatures are applied alternately to the same part of the body,— that is, a long-continued douche of alternating temperatures,— has received the special designation of the 4 Scotch douche.’8 2 PARTIAL BATHS AND OTHER PROCEDURES Affusions of various kinds are much employed as general and partial measures. Their modification—that is, the application from a greater or lesser height—is within the control of the attendant. The affusion is regarded by Baruch as an important measure. He applies it by dipping up water at the required temperature—using a basin with a handle—and pouring it with some force upon the upper parts of the trunk and upon the head. In home treatment the affusion is a useful substitute for the douche, if given with force and regardless of wetting the floor, which may be protected with cloths or blankets. The patient should, according to Baruch, always sit or stand in hot water (90° to ioo° F.—320 to 38° C.). Varieties and Mode of Employment.—Among douches, those most employed are (1) the vertical rain douche,—rain bath or shower- bath (Fig. 14),—in which the water, passing through a number of small openings, falls upon the entire body; (2) the movable jet or fan douche (Fig. 14), by means of which applications can be made to certain parts of the body or to the entire body; (3) the ascending spray (Fig. 16), which is arranged in a manner analogous to the rain douche, only directed from below upward; and, finally, (4) the Scotch douche just mentioned. The action of the douche consists in a combination of thermic and mechanical stimulation, in which the latter can scarcely ever be entirely excluded, since the water, as has been mentioned, is always under a certain pressure. The degree of stimulation that is intended may be modified as desired by combining temperature and pressure. If the entire body is treated, the effect is the same as that of every other general stimulating procedure. Parts treated locally will exhibit a local reaction. The most pronounced effect that can be induced locally is brought about by the Scotch douche, in which a marked mechan- ical impression and the stimulating effect due to the contrast of the high and the low temperature are considerable. We employ live steam1 and cold water for the Scotch douche. In other apparatus warm water and cold water escape from two tubes placed side by side. Both varieties have their advantages and disadvantages. Live steam renders possible a high temperature (up to 90° C.—1940 F.). Warm water maintains its original temperature for some time even at consid- erable distances. By means of the rapid alternation in the application of the high and low temperatures to the same part of the body, the most profound local revulsive effect is brought about that is possible by any local measure. It is employed wherever local circulatory enfeeble- ment, motor weakness, and accumulation of toxic products are to be overcome. 1 Before applying the steam douche, the water of condensation that has collected in the tubes must be expelled. Neglect of this precaution is the most common cause of scalding.ACTION OF THE DOUCHE 83 Mode of Action.—The mode of action may be summarized as follows: Cold douches of short duration at a temperature of Fig. 15.—Combined Rain Douche, Horizontal Jet, and Multiple Circular Douche.—(After Kellogg.) from io° to 200 C. (50° to 68° F.), and up to half a minute in duration, or exceedingly hot douches, of from 350 to 40° C. (95084 PARTIAL BATHS AND OTHER PROCEDURES to 104° F.), act as a vigorous stimulant, cause hyperesthesia of the surface of the body, and increase muscular vigor and elec- tromotive irritability. More protracted cold or hot douches have the opposite effect, so long as the pressure is not so great that the effect of the temperature is exceeded by the effect of the mechan- ical irritation. Tepid and warm douches at a temperature of from 26° to 350 C. (78.8° to 950 F.), for from half a minute to two min- utes, have a sedative and relaxing effect, and diminish the general tone and the muscular vigor. The same statement is, on the whole, applicable to partial douches. Here also the following law may Fig. 16.—Ascending or Perineal Douche.—{After Baruch.) serve as a guide : Douches of low temperature, of brief duration, and of high pressure, have a more stimulating effect; while those of higher temperature, longer duration, and low pressure, may have a less stimulating, and even a sedative effect. The indications for douches, by reason of the possibility of numer- ous combinations, comprise almost all kinds of disease. Cold shower- baths, at a temperature of from io° to 20° C. (50° to 68° F.), are employed as a nutritional measure whenever profound general stimu- lation is desired, in part in a manner analogous to the cold rub. The indications here also are almost the same. A greater measure of heat- abstraction can take place if the pressure is reduced and the douche is permitted to continue for a longer time. This necessity may arise when, for instance, the douche is employed for cooling purposes afterCARBON DIOXID DOUCHES 85 warm applications. Tepid rain baths serve as an invigorating meas- ure for sensitive patients, and, on account of their sedative effect, in the case of nervous persons. Further, they are employed as an intermediate measure between hot and cold applications. Warm douches are employed only in erethistic cases of neurasthenia and hysteria; they cause slight relaxation, quiet the entire nervous system, and are employed for hypnotic purposes. The ascending spray (the patient being seated upon a stool with a central opening of from 25 to 30 cm.) is invariably employed at low temperatures ; it is indicated in weakness of the bladder, in states of sexual de- pression, and in psychic impotence. The movable jet or fan douche is employed variously in accordance with the part of the body to which it is applied. If the entire body is exposed to its influence, the effect is comparable with that of a general stimulating procedure. Partial douches, applied to the nape of the neck, act well in asth- matic states and cardiac neuroses (low pressure). Douches at low pressure applied to the entire length of the vertebral column increase the general reflex irritability, and especially the irritability of the sexual organs, when the temperature employed is quite low. This method has been designated by us ‘ running irrigation of the backd The attendant applies the hose directly to the nape of the neck, permits the water to flow down over the vertebral column, and rubs the back throughout the entire procedure. In functional diseases of the spinal cord, such as spinal neurasthenia or sexual de- bility, the application is made to the entire spinal column. Applied to peripheral nerves, the douches are useful, especially in the treatment of paralytic states and neuralgia of various kinds. Fan douches are applied to the chest in catarrhal states, for the purpose of stimulating absorption of exudates and facilitating expectoration; to the abdomen in conditions of torpid circulation and muscular weakness of the abdominal viscera; to the hypo- gastrium and to the inner surface of the thighs to favor menstrua- tion and in conditions of sexual depression; to the feet as a deriv- ative measure analogous to the foot-bath ; and to certain joints to favor absorption of exudates. Under all of these local conditions the best effects can be obtained by the application of the Scotch douche. In domestic practice affusions can be given from pitchers suitably elevated ; douches and sprays, by means of tubing attached to any con- venient faucet, when the bath-room is not fitted with the elegant appli- ances now so easily obtained. Carbon Dioxid Douches.—Quite recently the technic of the douche has been improved by an apparatus introduced by Winternitz and Gaertner under the name of ‘ ombrophore,’ which permits the ap- plication of a douche with water saturated with carbon dioxid. The de-86 PARTIAL BATHS AND OTHER PROCEDURES vice will be readily understood from the accompanying illustrations (Figs. 17, 18, and 19). The receptacle for the water is connected by Fig. 18.—Ombrophore in Use. Fig. 17. —Ombrophore Packed. means of a reduction valve for regulating the pressure with a carbon dioxid tank (Fig. 18). The carbon dioxid not only furnishes the pressure; it is also absorbed by the water, and confers upon the douche a number of advantages. It is not necessary, even when the object is to obtain a good stimulat- ing effect, to employ water at a low temperature, as the carbon dioxid itself also acts as a strong cutaneous irritant; on the other hand, the lowest temperature may be - em- ployed without causing discomfort, as the bubbles of carbon dioxid upon the skin cause a sense of warmth. The apparatus is appli- cable especially in the case of debili- tated patients ; and naturally when- ever douches are at all indicated. Recently a number of other methods have been proposed in which certain parts of the body may be heated by means of circulating hot air, or circulating heated carbon dioxid. The methods are not complicated, especially those of the latter character, which emanate from Fig. 19.—Construction of Carbonic Acid Douche in Ombrophore.HOT CARBON DIOXID DOUCHES 87 the establishment of Dr. Bom and Dr. Herz in Vienna, and in which the carbon dioxid, from a carbon dioxid tank, is driven through an appara- Fig. 20.—Filiform Douche. Fig. 21.—Winternitz’s Douching Table. A, Cold shower. B, Adjustable shower. C, Steam douche. D, Cold fan douche. Ey Adjustable fan douche. F\ Lever for regulating adjustable douche. Gy Mixing kettle. Hy Thermometer. Jy Foot valve for cold shower. tus heated by electricity, and the movable nozle can be directed to any desired portion of the body from a greater or lesser distance.88 PARTIAL BATHS AND OTHER PROCEDURES Indications.—These hot-air or carbon dioxid douches do not differ in their mode of action from ordinary steam douches ; neverthe- less they possess certain technical advantages, and render possible the application of much higher temperatures under greater pressure. Their range of indications extends to all of those diseases in which the Scotch douche is employed, but it comprises also the essentially more subtle manifestations, inasmuch as, for instance, the course of a single nerve, or minute areas that are not accessible to the large Scotch douches,—such as, for instance, certain branches of the trigeminus,— may be treated by means of this fine apparatus. Fig. 22.—Baruch’s Stationary Douche Apparatus, showing also Circular Douche with Movable Roses. The douche filiforme of Laure (Fig. 20) is an apparatus by means of which a capillary stream of water is driven under high pressure through a hard, yet flexible tube. The stream maintains its compact- ness for a distance of several centimeters (from 5 to 6 cm.—2 inches), and, acting somewhat like the point of the cautery, at once causes the formation of a small blister. The water penetrates into the sub- cutaneous connective tissue, and intense redness soon appears about the point of contact. The penetrating stream gives rise to consider- able pain, which continues until the penetrating fluid is absorbed, and which may persist in lesser degree for many hours, even for so long as twelve hours. The reaction at the point of application diminishesPORTABLE AND STATIONARY DOUCHE APPARATUS 89 coincidently with derivation from remote regions. Reflex effects appear in accordance with the site of application, as, for instance, slowing of the action of the heart and of respiration when the application is made to the nape of the neck. The procedure is most frequently employed in cases of migraine and of cerebral hyper- emia; of irritative states of the meninges (applied to the mas- toid process) ; in cases of spinal irritation (along the vertebral column); and in cases of neuralgia (in the course of the affected nerves). The indications for the Scotch douches are included in the fore- going. They are employed especially to effect absorption of ex- udates (pleurisy, diseases of the joints) ; in motor disorders of the stomach and intestine; in various forms of neuralgia, espe- cially sciatica; and, finally, applied directly to the genitalia, in the presence of conditions of sexual depression. Reference may be made, further, to the portable douche appa- ratus shown in figure 14, page 81. The water is subjected to pressure in an air chamber by means of a portable pump, and by this means rain douches and movable fan douches may be applied. Baruch, of New York, has described a stationary douche appa- ratus (Fig. 22), by means of which the utmost precision can be attained, and which fully meets all the requirements. It permits both the temperature and the pressure to be regulated most ac- curately, so that applications may be made with scientific precision. Although practical experience shows that the physician in personally applying the douches will make the necessary modifications in ac- cordance with his own observation, even without refined apparatus, nevertheless such devices for securing precision in hydrotherapy are of great importance.CHAPTER III THE WET COMPRESS Cold and Warm Compresses. The Stimulating Compress. Buxbaum's Steam Compress. The Ther??iophore and Electrothermophore. Head, Throat, Chest, Trunk, Hemorrhoidal_, <2/2^ Genital Compresses. The Abdominal Binder. Winternitz Combination Compress. The Sural Compress. Circular Compresses. A wet compress (Umschlag) consists of a number of folds of linen, raw silk, or other suitable material, more or less thoroughly wrung out of water of suitable temperature, and applied to the body. In general, two varieties may be distinguished: (1) cold, and (2) warm, while the former are subdivided into cooling, and stimulat- ing or heating. Mode of Employment.—The cooling—in the true sense of the word, cold compresses—and the warm compresses must either be frequently changed or be kept at the desired temperature by means of the well-known tubular apparatus with circulating water (Letter’s coil), so much used in clinical and in private practice. It is customary with us to cover the wet compress with flannel or with a dry piece of linen, partly to prevent loss of heat, and partly to prevent evaporation of water when the application is long continued. It is especially im- portant for the reason first named to cover warm compresses, which, if left exposed to the air, soon become cool; and when stimulating compresses are employed, covering is likewise requisite for reasons that will be more fully discussed later on. It is less necessary to cover cooling or cold compresses, but it is customary to do this also, the manner being a matter of indifference. Warm compresses are covered with dry, or, still better, impermea- ble material. In the case of stimulating compresses, the character of the covering is of some importance. They are often covered with impermeable material, but in our practice only with dry material (linen, flannel, etc.), as it has been our experience that the heating effect is not materially better beneath an impermeable, than beneath a good dry covering. Furthermore, a wet compress does not become dry under an impermeable covering, as evaporation is entirely pre- vented, and, in consequence of maceration of the skin, irritative conditions of this structure may be much more intense and much 90THE STIMULATING COMPRESS 91 more frequent. Only certain conditions may render an impermeable covering necessary, and these will be more fully discussed later on. The frequency with which the wet compress is renewed de- pends upon the purpose for which it is applied. Cold and warm compresses are renewed, as has been mentioned, with sufficient fre- quency to maintain the desired temperature ; thus, cold compresses are renewed so soon as they begin to be warm, and warm compresses as soon as they have lost an undesirable degree of their original tem- perature. It is of importance to know, especially in the case of cold Fig. 23.—Lindemann’s Electrothermic Compresses. compresses, that, if not renewed with sufficient frequency, they act less as cooling, and rather as stimulating agents, so that their effect is opposed to the object of true cooling compresses. Thus, an inflam- mation that it is intended to subdue by the application of cold com- presses may be intensified if the compresses are renewed infrequently, and become rather warm. The cooling or heating apparatus pre- viously referred to, obviates the necessity of changing the compress. With regard to the stimulating compress, it may be stated as a general rule that it should be changed as soon as it has become dry. The course of events, when stimulating compresses are employed, is92 THE WET COMPRESS that the covered portion of skin, following the primary stimulation of the cold, exhibits a state of reaction. The compress becomes warm, evaporation takes place through the permeable dry covering, and the compress becomes dry in a shorter or longer time. The compress may become dry within an hour, especially if the skin is hot, as in the case of febrile patients, in phlegmonous conditions, etc. ; so many as four or five hours may, however, elapse before this takes place. Apart from individual variations, there may be general and local causes that delay the warming up or drying out of the compress, and in some cases even prevent this en-* tirely. Thus, the wet compress warms up and dries out slowly in individuals with slug- gish peripheral circu- lation, in cachectic persons, and in vari- ous exhausting dis- eases, such as tuber- culosis, diabetes, and hyperidrosis. In acute processes a temporary reduction in the cu- taneous circulation may occur locally, giving rise to defi- cient reactive power. Baruch calls attention to an important point. The cold compress (6o° F.—150 C.) is regarded by him as very useful in all febrile conditions in which the temperature is above ioo° F. (38° C.). This is a stimulating compress if renewed every hour, or, in very high body-temperatures or conditions of stupor or other nerve depreciation, every half hour. The antithermic effect is increased, according to Baruch, by wringing the cloth out less, and he makes it a rule to warn the nurse to allow the compress to remain beyond the period ordered if it is not thoroughly warm. Winternitz has called attention to the fact that in otherwise healthy Mod K.L Fig. 24.—Lindemann’s Electrothermic Cabinet.THE STEAM COMPRESS 93 persons wet compresses applied to the abdomen become warm more slowly when acute dyspeptic conditions are present. Hence, reaction under such circumstances occurs late or not at all. Patients do not experience the desired sense of warmth, but a sense of chilliness ; the skin covered by the compress feels moist and cold, and this feeling persists until the application is removed and the skin is made warm by friction. Under such circumstances an impermeable covering may be employed, but even this does not always suffice to bring about reaction. On the other hand, the local reactive powers may be im- proved by means of certain preliminary procedures. These consist either in dry rubbing of the skin before the compress is applied, or in rapid cold ablution, and it is especially im- portant for the compress to be immersed in water at the lowest possible temperature, for the more powerful the primary stim- ulation, the better, under otherwise similar circum- stances, is the reaction. Should all of these pre- cautions, and even an im- permeable covering, not suffice, then the applica- tion of cold compresses should be abandoned. Application of Heat by Means of Compress- es and Other Appara- tus.—A form of compress used for supplying heat and causing stasis has been advocated by Buxbaum and described under the name of steam compress. The selected portion of the body is covered with dry flannel, upon which is placed a very hot compress, and over this another layer of flannel. This is a form of hot compress readily applied in practice. A considerable number of apparatus are employed for making local applications of heat; among them are the devices recently intro- duced by Lindemann and shown in the accompanying illustrations (Figs. 23, 24, 25). For a general electrothermic bath, the patient sits in the cabinet with his head free ; local applications are made by means of the electrothermophore. The effects of these electric heating apparatus can be accurately regulated. Fig. 25.—Lindemann’s Electrothermophore.94 THE WET COMPRESS Actions and Uses The mode of action of the wet compress does not require elaborate discussion. The generaPrules for the action of local cold and warm applications relate also to cold and warm compresses, and for this reason they need not be further detailed, but reference can be made to the section in this article dealing with the physiologic effects of local applications of heat and cold. In the employment of stimulating compresses a reaction is sought, the occurrence of which will be clear from a knowledge of the physi- ologic processes. When the compress is applied, the peripheral vessels in certain parts of the body and even in the deeper parts con- tract. The human organism evinces a strong tendency to neutrali ze the difference in temperature; the vessels dilate, the circulation be- comes greatly increased ; with the hyperemia are associated its effects —namely, increase in local metabolism and in the local vital processes generally. It is clear that under these circumstances a materially greater effect can be obtained by means of procedures with alternating temperatures, such as cold and warm compresses applied in succession to the same part of the body, just as with Scotch douches. General indications for the wet compress are as follow : Cold compresses (cooling) are employed in the treatment of all local processes dependent upon hyperemia, congestion,« or in- flammation, and whenever heat, pain, hemorrhage, exuda- tion, or processes of decomposition are to be prevented or cor- rected. The warm compress is employed to favor the escape of the cellular elements of the blood; that is, to promote suppuration, to increase the local nutritional and vegetative processes, metabolism, and the disintegration and absorption, as well as the regeneration of cells. It is therefore indicated in local anemia, stasis, unyielding exudates and infiltrates; and as a sedative and antispasmodic application to relieve pain of a noninflammatory character, such as neuralgia or cramp. It is exceedingly difficult to summarize the general indications for the stimulating compress. They may, however, be easily inferred from a consideration of the mode of action. These compresses, as well as compresses of alternating temperatures, may often be em- ployed as substitutes for other procedures with alternating temperatures (Scotch douche, etc.), that serve the purpose of inducing local revul- sion and increased absorption. By wringing out the compress less completely and allowing it to remain in place longer an effect similar to that of a poultice is obtained, and in this form the stimulating compress may be used to hasten suppuration.THE THROAT COMPRESS 95 VARIETIES OF COMPRESSES In accordance with the different portions of the body, various forms of compresses are distinguished—namely, head, throat, chest, trunk, hemorrhoidal, and genital compresses; the abdominal binder or compress ; the sural (calf) compress ; and long, narrow, circular compresses (Longetten). The Head Compress The application of compresses to the head is a generally familiar measure. Several layers of linen in the form of a hood or cap serve for this purpose. To keep the compress cool the well-known cooling apparatus shown in figures 7, 8, and 9, on pages 72 and 73 (head coil), are employed. Indications.—Cold compresses are applied to the head in hyper- emia and every variety of congestion involving the head, especially inflammatory states of the brain and of the cerebral meninges; for the relief of hypo- static congestion, in conjunction with all hydriatric procedures, as has been detailed at the beginning of this section. Cooling com- presses to the head may Fig. 26.—Cold Collar. be applied continuously for a considerable period of time, even for days and weeks. Ex- perience has shown that, in order to prevent the development of rheumatic disorders, it is advisable to rub the head dry after removing the compress. A stimulating compress—that is, a cool compress covered by a dry one—is applied when it is desired to establish hy- peremia about the head; thus, in anemic migraine, anemic states of the head, in some cases of neuralgia, especially neuralgia of the first branch of the trigeminus and of the occipital nerve; accord- ing to Winternitz, it is also a useful measure in cases of chronic coryza. Hot compresses are employed when it is desired to correct spastic states of the vessels as quickly as possible, as in angiospastic hemicrania, particularly if this occurs in a severe form. The Throat Compress The various forms of this application should be generally familiar, as well also as the various rubber coils and ice-bags that serve as9<5 THE WET COMPRESS cooling applications to the throat—cold collars (Fig. 26). Their employment is confined to diseases in the region of the throat, espe- cially inflammatory processes of the soft palate, laryngitis, glandular affections, and the like. The following observation appears to me important. In the pres- ence of inflammation of the throat cold is applied locally, as a rule, and always with good results, particularly when the inflammation has not yet attained an especially marked degree of severity. In the latter event, however, as experience has shown, cold compresses increase the pain and exert an unfavorable influence, if any, upon the inflammatory process. The reason for these manifestations is to be sought in the fact that in the highest grades of inflammation with complete circula- tory stasis, the circulation cannot be reestablished by means of cold ; under such circumstances it is far more advisable to employ a stimu- lating compress. Even a hot compress applied for a short time, and replaced by a stimulating compress, renders better ser- vice, as by this means the circulation is put in much better condition. The ex- ternal evidence of these pro- cesses is cyanosis of the mucous membranes, such as occurs especially in phlegmonous angina. It is a matter of course, and need not be especially men- tioned, that warm compresses (fomentations or poultices) are applied to promote suppuration in suppurating glandular enlargement. Chronic inflammatory processes are best influenced by means of the stimulating compress. The Chest Compress Cooling compresses, in any desired form, are generally applied only to certain parts of the chest. They are indicated in hyperemia, pulmonary hemorrhage, and in inflammatory processes of the lungs and pleura. Of the commoner forms of chest compress, the most important is the precordial compress, which is kept cool by means of the pre- cordial coil (see Fig. 38, p. 109). It is not advisable to apply the precordial coil directly upon the cutaneous surface, but to interpose a thin layer of linen, moistened, and then to cover the whole with a dry cloth. The temperature of the water employed should be low, even down to that of ice-water. Nevertheless, it appears to be better to reduce the temperature gradually ; that is, to employ rather high tem- Fig. 27.—Throat Coil.THE CROSSBINDER 9 7 peratures at first, and reduce them rapidly. The duration of the ap- plication should at first be not more than ten or fifteen minutes; later, it may be continued for one or two hours and more. The effect of the precordial coil is powerful. The accelerated pulse be- comes slower, arrhythmia is corrected, the pulse-wave and vascular tension are increased, and the arterial blood pressure is augmented. The precordial coil appears to be indicated in all diseases of the heart, principally in cases of valvular disease of not too severe a de- gree, of slight disease of the myocardium, of functional ar- rhythmia, and especially of increased frequency with diminished vigor of contraction, such as occurs most frequently in connection with the cardiac weakness of infectious diseases. The effect is some- what less certain, but nevertheless attended with satisfactory results, in cardiac neuroses, severe valvu- lar disease, and grave disease of the myocardium. In profound de- generation ofi the myocardium the heart-muscle may react with paralysis instead of with vigorous contraction to the stimulation of cold, and then the heart, instead of exhibiting strong contractions, becomes irritable and arrhythmic, and on theoretic grounds may be arrested in diastole. This occurs with extreme rarity. Such an unfavorable effect may be exhibited objectively in the occurrence of ar- rhythmia, in increased restlessness, and eventually in cyanosis of rapid development; in this way the pre- cordial coil serves as an agent in differential diagnosis in cases of profound myocardial degeneration. The application of heat, which may be made by passing hot water through the precordial coil, also causes stimulation, and reduces the number of cardiac contractions. The stimulating chest compress, which is applied to the entire thorax, is designated crossbinder (Fig. 28), on account of its shape. It is applied in the following manner : One of two linen bandages, 1 y2 to 3 meters (yards) long and 1 5 to 40 cm. (6 to 15 inches) wide, in accordance with the size of the thorax, is well wrung out of cold water, rolled up, and applied to the chest as follows : Beginning at the right axilla, the bandage is carried over the left shoulder, across the back to the point of origin ; it is now brought forward across the front of the chest to the left axilla, and finally transversely across the back ix—7THE WET COMPRESS and over the right shoulder, terminating on the front of the chest. The second, dry bandage is applied in the same manner as the wet one, and should accurately cover the latter at every point. The ends of the bandages are provided with tapes for securing them to the chest. A woolen shirt or tricot body over the bandage insures its being kept in place. A large number of bodies and various kinds of shirts have been proposed as substitutes for the crossbinder, but their application always requires a certain degree of precision. In the ambulatory ser- vice of the Vienna Policlinic (in Winternitz’s department) it is our practice to advise patients to apply two- towels well wrung out of water crosswise over the chest, and to cover these with two dry towels. Effects and Uses.—This form of compress has great advantages in the treatment of diseases of the lungs if reaction is sufficient The principal effect consists, probably, in the rest afforded the thorax in the uniformly warm atmosphere, as a result of which the desire to cough is diminished, the viscid secretion in the bronchi softens, and the expectoration as a rule becomes considera- bly easier. The same favorable effect is usually exhibited in dis- eases of the pleura, the absorption of the exudate being acceler- ated. In acute inflammatory diseases the crossbinder is employed only after the fulminant symptoms have disappeared. In ambulatory cases it should be applied only during the night. In bed-ridden patients it should be renewed three or four times daily. Whenever the binder is changed, and, in general, whenever it is removed, the thorax should be well rubbed or dried, especially if, in consequence of enfeebled reaction or perspiration into the bandage, it has not become dry spontaneously. It is well with such patients to follow removal of the bandage in the morning directly by a partial or total rub. The Hot Chest Compress.—The steam compress of Bux- baum, or the hot-water coils, previously mentioned, may be employed as the source of heat. Hot chest compresses are, however, applied only to portions of the chest. They hasten absorption and quiet the nervous system; and are employed to promote absorption of viscid exudates; in chronic infiltrations; and in intercostal neuralgia. The Trunk Compress Action and Mode of Employment.—These consist in com- presses applied by means of sheets, which cover the entire trunk, including the thorax and abdomen (Fig. 29). The moist sheet is covered by a dry one, the margins of the latter extending a short dis- tance beyond those of the former. As the trunk compress is large, itTHE TRUNK COMPRESS 99 is capable of taking up a large amount of water. It warms up slowly and may therefore abstract a considerable amount of heat. If the compress is changed frequently,—every hour or so,—the abstrac- tion of heat will be quite considerable. Antipyretic, that is, fre- quently renewed, compresses are often employed in the treatment of fever, either in combination with other measures or alone, and under such circumstances they constitute a valuable therapeutic agent. In many diseases, especially in children, these simple large compresses serve as the sole remedy, meeting perfectly all the re- quirements. In applying the compress the dry sheet is spread upon Fig. 29.—Trunk Compress. the bed, and in it the wet sheet is then placed. Next, the patient lies upon the prepared compress, and, finally, is enveloped in the moist, and then in the dry compress. It may happen that in the case of profoundly ill patients—as, for instance, typhoid fever or intestinal hemorrhage—movement of the patient, which cannot be avoided in changing the compresses, is either impossible or forbidden. Under these circumstances the compresses may be changed in such a manner that only the dry sheet is withdrawn from beneath the patient, while the moist compress remains applied to the entire trunk, anteriorly and laterally, all but a small portion of the back which, it is true, remains uncovered.IOO THE WET COMPRESS In addition to febrile diseases, the cold trunk compress is indi- cated in all inflammatory disorders of the abdominal and pelvic organs, and in all varieties of hemorrhage from these organs ; a low temperature is maintained by means of cooling appa- ratus of suitable size and shape. The stimulating trunk compress may be permitted to remain in place for so long as four or five hours. In all ambulatory cases it is applied once or twice daily for one or two hours at a time. Trunk compresses for local stimulation are indicated in all cases of local hyperemia, in all forms of inflammation of the abdominal Fig. 30.—The Winternitz Combination Compress with Epigastric Coil. and pelvic organs, and in all insidious inflammatory processes, to hasten the absorption of exudates. They yield better results also in cases of acute gastro-intestinal catarrh than frequently changed cold compresses. When reaction occurs, hyperemia of the abdominal organs with anemia of the head results ; hence these com- presses are serviceable in many cases as a valuable hypnotic. Hot trunk compresses are applied only to certain parts, rarely to the entire trunk. They are employed for the relief of colic, and also for the purpose of promoting absorption of old exudates. A useful combination has been proposed by Winternitz, who inclosesTHE ABDOMINAL BINDER IOI within a stimulating cool trunk compress a rubber coil through which circulates water, at a temperature of from 50° to 6o° C. (1220 to 132.8° F.). The apparatus and the mode of employment are shown in the accompanying illustration (Fig. 30). The application of this Winternitz combination compress with epigastric coil is attended with great success in cases of catarrhal and nervous disorders, and of functional insufficiency of the stomach. Nervous symptoms, irritative sensory as well as motor states, such as cardialgia, nausea, flatulence, singultus, and eructation, are especially favorably in- fluenced. This method answers equally well in the treatment of secretory disorders and, when suitably applied, to relieve colic of any variety. Of all of the indications named, that which is most suc- cessfully met is, in our experience, obstinate vomiting. The patients gradually become able, under the influence of the compress, to take milk as well as other readily digestible food, and finally more solid nourish- ment. The patient is laid within the compress, and water is permitted to flow through the coil. After the lapse of perhaps a quarter of an hour an attempt is made to administer nourishment, and then warm water is made to flow through the coil, for at least a quarter of an hour, the patient being permitted to lie in the compress for a further quarter or half hour with- out running hot water. The Abdominal Binder The abdominal binder, or stimulat- ing abdominal compress, also called Neptune girdle (Fig. 31), is applied as follows: A linen bandage 2 y2 to 3 meters (yards) long and 30 to 50 cm. (12 to 20 inches) wide is wrung out of water for such a length that the wet portion will suffice for one and one-half turns around the abdomen ; the bandage is then applied in such a way that the abdomen is covered first by the wet portion and then by the dry portion. The ends are secured by means of tapes. This compress plays quite an extensive role in the field of hydrotherapy as a dietetic, sedative measure. The binder is generally applied m the evening, and remains in place overnight. When the weather is favorable, the binder may be worn also during the day, and is then changed about every three or four hours. On account of its small size it is of no special significance as an antipyretic measure, but it102 THE WET COMPRESS exerts a favorable influence in diseases of the stomach and in- testines, hyperemia of the liver, and venous stasis in the abdominal organs. The abdominal binder is counterindicated in all conditions of sexual irritation, erections, and emissions. Under these cir- cumstances it should at least not be applied at night. Hemorrhoidal and Genital Compresses T-Bandages are used; the horizontal portion is passed around the abdomen, while the vertical portion of the genital compress passes Fig. 32.—Circular Joint Compress.—(After Kellogg.') from before backward, and that of the hemorrhoidal compress from behind forward, and is fastened to the horizontal portion. The application of these bandages is limited to hemorrhoidal con- ditions, inflammatory processes in the vicinity of the rectum, states of sexual debility, and inflammatory disease of th e testicle. Sural Compresses A bandage from to 1 meter (yard) long and 25 cm. (no inches) wide is moistened for one-third of its length, and applied to the calvesCIRCULAR BANDAGES 103 as a stimulating compress. As soon as the application becomes warm it exerts a depletory and decongestive effect upon the head; it is employed in hyperemic states of the head, and headache, and as a mild though useful hypnotic. Wet stock- ings may take the place of these compresses if covered by woolen stockings. Compresses applied to the entire lower extremities induce in women a flow of blood toward the genital organs, and are employed in amenorrhea. Circular Compresses These are long, narrow compresses (Longetten) wrapped around an extremity or a joint (Fig. 32). Short strips of linen ^ to 1 meter (yard) long, and from 5 to 10 cm. (2 to 4 inches) wide, preferably old linen that has been frequently washed, are wrung out of water, and applied to joints or extremities in the form of a bandage, the wet layer of linen being covered with cotton batting or flannel and secured by tapes. In this way a stimu- lating compress may admirably be applied to the extremities, and especially to joints. Baruch claims great diminution of the duration of acute articular rheumatism from hourly applications of the circular compress at 6o° F. (150 C.), covered with one layer of flannel to permit evaporation. He applies this in conjunction with large doses of salicylic acid ex gaultheria. The effect, in cases of articular disease, is quite satisfactory. The applications are indicated especially in acute inflammation of the joints, and in ulcerative processes in- volving the skin of the extremities. Under such circumstances the wet covering can be moistened repeatedly, without being removed, thus avoiding irritation or injury of the ulcerated parts. The latter form of application is valuable especially in the treatment of burns, inasmuch as the secretions are well removed. In torpid ulcers the application of hot circular bandages for many days successively, ex- erts a favorable effect; being replaced by ordinary circular bandages as soon as a good circulation has been established. It should be noted that when the circular bandage is constantly moistened with cold water for a long time, as may be the case in the treatment of burns, all shock from the falling water should be avoided; and that low tem- peratures cause considerable pain.CHAPTER IV WET AND DRY PACK; BAGS AND COILS; IRRIGATION The Wet Pack. The Dry Pack. Bags, Coils, and Irrigation Apparatus. THE WET PACK A procedure well known and much employed is the wet pack. Mode of Employment.—It is applied in the following manner: A woolen blanket (bath-robe), 2 y2 meters (yards) wide, and 2 or 3 meters (yards) long, is placed upon a large couch. Upon this is laid a recently immersed and rather well-expressed coarse linen sheet. The patient, after the head and face have been previously cooled, and a cold turban applied, lies upon the sheet (Fig. 33), which is so wrapped about him as to be smoothly applied to all parts of the body. This is accomplished in the following manner : The patient’s arms are elevated above his head and one-half of the sheet is drawn across the body, its upper portion being tucked along the side of the trunk, and the lower portion dipping down between the lower extremities (Fig. 34). The arms are now brought down to the side of the body, and the other half of the sheet is brought around the body so as to include them, and its border is tucked in along the opposite side (Fig. 35). The sheet is so tucked beneath the arms and between the lower extremities that no two surfaces of skin come in contact. Finally the woolen covering is accurately brought together at all points, especial care being taken that close approximation is secured at the neck and shoulders by infolding the blanket (Fig. 36). The patient is now well surrounded with poor conductors of heat (blankets) (Fig. 37). A large blanket will go around the chest of a person of moderate size one and a half times, and the feet about three times. It is neces- sary in enveloping the patient to draw the blanket rather firmly in older that the application to all parts of the body be quite intimate, and the mobility of the extremities be in some degree at least restricted. If the blanket is drawn too tightly, however, the patient may be made uncomfortable, and may at times suffer pain. The feet, which often aie warmed with difficulty, either are made to react more vigorously by friction before the pack is undertaken, or are left out of the wet pack in such a manner that the moist sheet extends only down to the knee, or a small hot-water bag, or a thermophore, which is applied to the soles, is included in the pack. Mode of Action.—The effect of the wet pack is as follows: At IO4Fks. 34.—Wet Pack; Sheet Drawn from Left to Right; Patient’s Arms Elevated.—(Polyclinic Hospital, Philadelphia.) 105 33-—Wet Pack in Readiness.—(Polyclinic Hospital, Philadelphia.)106 WET AND DRY PACK ; BAGS AND COILS ; IRRIGATION first the stimulating influence of the cold upon the entire body, with all of its consequences, induces deep respiration, accelera- tion of the action of the heart, and hypostatic congestion of the head, which must be counteracted. As soon as the wet pack has become warm, the secondary effect is pretty much the same as that attending a stimulating compress. There are persons in whom the sense of cold disappears in the course of from ten to fifteen minutes, and who in the course of half an hour become quite warm, as the radiation of heat is prevented by the blanket. The cause of this manifestation is to be Fig. 35.—Wet Pack; Sheet Drawn from Right to Left; Patient’s Arms In- cluded.—(Polyclinic Hospital, Philadelphia.') found in marked dilatation of the peripheral vessels. The effects of this reaction are visible in various situations. In conse- quence of the resulting anemia of the brain, drowsiness appears, and the action of the heart becomes markedly slow, in some cases to the extent of 30 or 40 beats in a minute. As a result of the complete muscular rest a state of marked tranquillity develops, and finally, at least in most cases, sleep follows. If the pack is continued for more than an hour, the amount of heat may accumulate to such de- gree that sweating takes place. This may attain considerable pro-THE WET PACK 107 portions if the pack be continued for six or seven or even eight hours, a practice that is followed by us only in rare and exceptional cases. The duration of the pack varies with us in accordance with the ends to be attained. The pack is employed as a preparatory measure or a preliminary warming measure for subsequent stimulating courses of treatment, and for such purposes a period of from twenty to thirty minutes suffices to render the patient warm. If the pack be changed as soon as the patient becomes warm, consider- able abstraction of heat naturally takes place, and therefore every subsequent pack becomes less rapidly warm. Thus it happens that Fig. 36.—Wet Pack; Adjusting the Blanket—(Polyclinic Hospital, Philadelphia.) in febrile cases the first pack becomes quite warm within five minutes, the second and the third not before ten minutes, and a fourth or a fifth remains cool for so long as one-half or three-quarters of an hour. That considerable reduction in temperature can be effected in this way is obvious. During the afternoon, when the body-tempera- ture naturally exhibits an ascending tendency, the packs generally become warmed rapidly. It is customary with us to follow each pack by a suitable cooling procedure, in order to dissipate the accumulating heat from the surface of the body, and to restore the tone of the re- laxed cutaneous vessels. The character of the cooling procedure108 WET AND DRY PACK; BAGS AND COILS; IRRIGATION varies with the conditions present in the case under treatment. Con- sideration should be given to the nature of the disease and to the degree of irritability of the patient. The indications are as follows : Frequently renewed packs are employed in cases of fever. They exert a useful antipyretic effect, and are especially valuable when the pulse-rate is high. The patient should, however, not be kept in the pack long enough for the action of the heart to become impaired, a condition that may be a source of danger, especially in infectious diseases. Otherwise these Fig. 37.—Wet Pack Complete.—(Polyclinic Hospital, Philadelphia.) packs are attended with a sedative effect upon the action of the heart. The number of renewals will depend upon the conditions present in the individual case, and may reach as high as ten or even twelve in hyperpyrexia. Should the patient become chilly, and should the pack be no longer capable of making him warm, its continuation must naturally be suspended and the treatment terminated by some stimulating measure, by means of which the patient is warmed. Wet packs are counterindicated when the power of the heart is greatly lowered in cases of fever. In one infectious disease,—namely, diphtheria,—and in othersUSES OF THE WET PACK IO9 closely related to it (angina, even of the gravest character), the com- bination of frequently renewed packs in association with a subsequent stimulating measure constitutes almost a specific. For the considera- tion of these measures reference may be made to the appropriate place in the special section (Part III). In functional motor neuroses, as chorea and athetosis; in neu- ralgia; in nervous disorders of the heart, as in exophthalmic goiter; in articular and muscular rheumatism; and in deforming arthritis, a wet pack of one or one and a half hours’ duration renders good service. In cases of polyneuritis, even before the acme of the disease has been reached, wet packs may well be em- ployed. They lessen the tenderness, and appear to shorten materially the course of the disease. In disease of the kidneys, and in Fig. 38.—Buxbaum's Modified Wet Pack with Precordial Coil. chronic metallic poisoning, this procedure is employed with advantage; and even in disorders of metabolism, especially diabetes. It is true no influence of the treatment upon the elimination of the sugar is demonstrable. Nevertheless a number of symptoms of the disease are most favorably influenced. The dry skin becomes pliable, the excretion of water from the skin is increased, in consequence of which a part of the burden is lifted from the kidneys and diuresis is generally diminished. The tendency to skin affections is not only not increased by the wet pack, but is even favorably influenced. I have observed distinct improvement in some cases of ichthyosis, pruri- tus, and furunculosis under the influence of the wet pack. The counterindications for the wet pack consist in great weakness, and especially weakness of the heart.no WET AND DRY PACK; BAGS AND COILS; IRRIGATION Partial Packs.—The three-quarters and half packs that are so much employed, and in which the body is enveloped from below up as far as the armpits or the umbilicus respectively, in the same manner as in the full pack, exert a correspondingly lesser influence. They do not, however, wholly interfere with the activity of the patient, and this is an advantage in the case of nervous, timid patients. On the other hand, they do not possess the sedative effect in the same degree as the full pack. Priessnitz employed half packs for the relief of severe lancinating pains in cases of tabes, leaving his patients in the wet pack for from four to six hours, and even throughout the entire night, but without conspicuous success. The half pack exerts also a depletory and a sedative effect, and it is frequently employed with advantage for hypnotic purposes. Fig. 39.—Towel Chest Pack.—(After Kellogg.) For persons in whom fright develops when they are placed in the full wet pack, and in whom one would be unwilling to dispense with the effect of the full pack, Buxbaum’s modification (Fig. 38) may be employed. He applies a crossbinder well covered with flannel or a woolen cloth, and over this a three-quarter pack extending up to the armpits. The patient is almost wholly enveloped in the pack, but is able to move his arms freely, and this assists materially in relieving his anxiety. In addition, it is possible when this form of wet pack is used, to make a cooling application to the precordium. As a result, the possibility is afforded of employing the pack also when the force of the heart is reduced.TECHNJC OF DRY PACK III THE DRY PACK The application of the dry pack is practised in the same manner as that of the wet pack, with the single difference that only a dry sheet, if any, is placed within the blanket. According to Baruch, the linen sheet is objectionable. He uses a flannel sheet, which can be washed more readily, covering it with a blanket. Mode of Action.—It is customary with us to employ the pack without the sheet, and this seems to be the better method. The skin is irritated by the rough surface of the blanket and cutaneous hyperemia is speedily induced. The vessels become dilated, and the body is rapidly warmed. The dissipation of heat is prevented by the blanket, and the heat of the pack is increased to such a degiee that perspiration appears considerably earlier than in the wet pack. The occurrence of sweating takes place with varying rapidity in different persons. In favorable cases it may begin within half an hour, while at times one or two hours may elapse befoie it sets in. The average period until free perspiration takes place is about one and one-half hours. The temperature of the body rises, and all of the symptoms of a simple fever make their appearance. The tongue becomes dry, pulse and respiration are accelerated, and the head feels full. Mode of Employment.—If it be desired to hasten the appearance and increase the amount of sweating, certain preliminary procedures are employed. One method consists in warming the patient by put- ting him in a *bath at a temperature of about 40° C. (104° F.) f°i about ten minutes, before wrapping him in the blanket. This measure is but seldom practised, except in nephritis and uremic states, when sweating must be rapidly induced. The mode of preparation as commonly practised by Winternitz is simply that usually employed. Preceding the dry pack, the patient, dressed in clothing as warm as possible, engages in active muscular exercise, such, for example, as hill climbing or wood-sawing, in consequence of which the produc- tion of heat is enormously increased, and not until he is thoioughly heated, or even in a dripping perspiration, is he placed in the pack. In the course of ten or fifteen minutes sweating will generally have appeared. After free perspiration has been induced, the patient may be given one or two glasses of cold water, both in order to increase the sweating still more and to quench his thirst. The dry pack also is generally practised in the afternoon, at which time, as has already been mentioned, the temperature of the body exhibits an ascending tendency. After the dry pack, cooling procedures (cool baths, douches, even cold full baths) are employed, on the one hand, to cool the heated patient, and, on the other hand, to exert a marked stimulating influence112 WET AND DRY PACK; BAGS AND COILS ; IRRIGATION and thus obtain the greatest possible effect from a measure intended especially to increase metabolism in marked degree. It should, how- ever, be noted that a daily repetition of the dry pack does not seem advisable, as the frequent practice of this procedure makes too pro- found an impression upon the body, and causes marked loss of weight and a state of exhaustion and depression. Indications.—On account of its severity the indications for this procedure are rather restricted. Chronic metallic poisoning, obesity, and syphilis are the principal conditions in which it is employed. It should not be forgotten that the greatest importance is to be attached to the action of the heart. Wasting diseases, as well as severe organic disease of the heart, are counterindications to the employment of the dry pack. A relative counterindication may be presented by persons of debilitated constitution, even although no grave organic disease can be demonstrated. BAGS, COILS, AND IRRIGATION APPARATUS Chapman’s Ice-bags and the Spinal Coil.—The first-named apparatus, not much employed at present, are ordinary rubber bags, usually filled with a cold mixture, cold water, or ice, but also used with hot water (Fig. 40). The bags are applied to the patient’s back, care being taken to adapt them to the vertebral column. The rubber coil for the spine is probably better known. It permits an uninterrupted application, without changing the ap- paratus. It consists of thin rubber tubes, through which it is possible to pass a continuous current of water of any de- sired temperature (Fig. 41). It should be noted that this apparatus is always to be applied upon a thin moist compress, and never directly upon the skin. The effect of the application of cold and heat varies in accordance with the part of the vertebral column to which the apparatus is applied. The local the vertebral column in disease of the bone, in meningitis, and in myelitis is probably familiar to every one. The application of cold to the entire spinal column is practised in erethistic cases of spinal neurasthenia. By this means the general reflex irritability is diminished. The appli- Fig. 40.—Chapman’s Bags. application of cold alongTHE PSYCHROPHORE 113 cation of cold to the nape of the neck and to the cervical portion of the spinal column is practised in asthma, in conditions of great sexual irritability, and in cardiospasm. When cold is applied to the nape of the neck and occiput, the primary effect is a stim- ulating one. Subsequently the action of the heart and the respira- tion are quieted. The application of cold to the sexual organs likewise exerts an eminently sedative effect. It has been observed, though not regularly, that applications of cold over the lumbar spine cause a flow of blood toward the periphery, especially toward the pelvic organs, and toward the lower extremities. An antiphlogistic effect can be produced uniformly by means of local applications of cold, and a reflex effect upon certain remotely situated organs is obtained by applications at various places. The action of hot-water tubes applied over the lumbar spine is not to be depended upon. They are said to lessen profuse menstruation. The head coils (see page 95) and the precordial coil (see pages 96 and 97) have been discussed in previous chapters ; the abdominal coil and the gen- eral construction and method of using coils over any portion of the body are referred to in the appendix. IRRIGATION The Psychrophore (Cooling Sound for the Urethra).—This instrument has been devised by Winternitz, and is a two-way catheter, completely closed at its extremity (Fig. 42). Fia 4q3^SpINAL Mode of Employment.—It is introduced in pre- cisely the same way as a solid sound, and to such a distance that the tip of the instrument extends to the bladder, but, as a rule, is not introduced into the viscus. With regard to orientation, the following rules should be observed in practice : If the patient is in the hori- zontal posture, and the instrument after it is introduced occupies a vertical position, the tip of the instrument has entered the membranous urethra. If the instrument is now rotated forward through about 30 degrees, the tip will pass into the prostatic urethra and almost up to the sphincter. It should be noted that while a thin instrument is selected at first in the case of patients unaccustomed to such manipulations, it should not be used for subsequent introductions, unless special sensitiveness exists. Otherwise treatment is, as a rule, continued with the thickest of these instruments that can be intro- duced. At first the temperature of the water passing through the tube should be about 210 or 220 C. (69.8° or 71.6° F.). Subse- ix—8WET AND DRY PACK ; BAGS AND COILS } IRRIGATION 114 quently the temperature may be gradually reduced to io° or 120 C. (50° or 53.6° F.). Before the application of the psychrophore the patient should empty his bladder. On introducing the instrument, and at the com- mencement of the application, the occurrence of vesical tenesmus is extremely common, but this soon subsides. The duration of the application should at first not be extended beyond four or five minutes. Subsequently the application may be continued for so long as half an hour. Effects.—As a result of the cooling effect upon the urethra, especially the prostatic portion, and the surrounding muscular struc- tures, an improvement in the tone of these structures and of the surrounding tissues, especially of the excretory orifices of the seminal passages, is brought about. This invigorating effect can be recognized on withdrawing the instrument, which is then grasped by the contrac- tion of the muscular fibers, and is therefore removed with some diffi- Fig. 42.—Psychrophore of Winternitz. culty. As a result of the introduction of these sounds, irritation is produced, and this is followed by a profound cooling effect upon the mucous membrane. This, in turn, gives rise to anesthesia, which may persist for so long as an hour. Indications.—The field of employment of the psychrophore is pretty extensive. The instrument renders good service in cases of nocturnal enuresis, and also in cases of neuralgia of the tes- ticle. In the latter condition, however, it should be noted that it cannot be determined in advance whether the employment of hot or of cold water will be beneficial. The psychrophore is employed, further, for the correction of psychic impotence. The treatment should, however, not be repeated too frequently; at most, once or twice weekly. At times treatment with the psychrophore has been followed by apparent impairment of erectile power in patients suffering from premature ejaculation ; this, however, proved to be only temporary. Improvement has set in after a time,—occasionally, it is true, only after several weeks,—so that in any event this procedure appears toRECTAL IRRIGATION US be attended with success. The employment of the psychrophore is at times followed by most favorable results also in the presence of enfeebled sexual power. Under such circumstances, how- ever, it seems necessary to forbid sexual intercourse. The psych- rophore often renders good service also in the treatment of spermat- orrhea and prostatorrhea. To these conditions is generally contributory a state of obstinate constipation, and this must therefore be promptly corrected. Treatment with the psychrophore is likewise to be advised in chronic gonor- rhea, in which case the thickest instruments should be selected in order that, in addition to the ther- mic effect, by means of which it is thought the circulation in the mucous membrane will be im- proved, a special mechanical effect may also be obtained. Neverthe- less the application of the cold psychrophore should, under such circumstances, not exceed ten minutes- in duration. If a pro- nounced revulsive effect is de- sired, psychrophores of alternat- ing temperatures are employed. The Atzperger Rectal Irri- gator.—This is a faucet-like hollow instrument (Fig. 43), which permits the inflow and outflow of water, the temperature varying with the object to be attained. Before being used the instrument is anointed, after which it is introduced into the rectum. Mode of Employment and Effects.—The employment of water at a low temperature at the outset Fig- 43-—-Atzperger Rectal Irrigator. is counterindicated, especially in the presence of acute inflammatory processes at the neck of the bladder, as otherwise disagreeable tenesmus and strangury may be excited. Therefore the treatment is begun with water of a temperature of 20° C. (68° F.), and this may be lowered subsequently to io° C. (50° F.). The effect induced by the cooling thus caused is manifest in the improved tone of the rectum and adjacent structures up to the neck of the bladder. The cooling also exercises an anesthetic,Il6 WET AND DRY PACK; BAGS AND COILS; IRRIGATION decongestive, and antiphlogistic effect. The duration of one application with this apparatus varies greatly. In some cases it does not exceed ten minutes, but it may be several hours. Indications.—This apparatus may be used successfully in hem- orrhoidal states, in which its systematic employment has often rendered operative treatment unnecessary; also in cases of chronic, as well as of acute, inflammatory processes. If the hemor- rhoidal nodules can be reduced, it will be necessary to push them back into the rectum before applying the apparatus. If it be desired to exert a softening and a sorbefacient influence in chronic inflammatory processes and atrophic pro- cesses involving the prostate gland and its vicinity, with exudates and old infil- tration, or if it be desired to stimulate existing suppura- tion, the indication is to make an application with hot water. In the presence of marked sexual irri- tability the employment of warm water is not permissible. If the application of a power- ful thermic irritation be de- sired, alternating applications of hot and cold water will be employed. Rectal Dilator.—This apparatus, also, which per- mits thermic massage of Fig. 44.—Rectal Dilator. the walls, of the rectum by means of periodic disten- tion and collapse, was originally proposed by Winternitz. By means of a rubber covering surrounding the catheter (Fig. 44), and through which a current of water is passed, a sac is formed in which the degree of pressure and of distention can be modified as desired by increasing the inflow or preventing the outflow. With regard to the indications, they are the same as for the use of the Atzperger irrigator. In the rectum, the apparatus, if filled with hot water, acts like a cataplasm. It exerts an anti spas- modic and a sedative effect. Suppuration is also favored by it. It may be employed also in the vagina, and either with hot water, for the relief of tenesmus and strangury, or with cold water, to allay vulvitis and vaginismus.THE HYDROPHORE II7 Vaginal Dilator.—This consists of a cylindrical apparatus (Fig. 45) provided with a supply and a discharge tube. The apparatus is first anointed and then introduced into the vagina. The mode of application is pretty much the same as that of the rectal dilator. The Hydrophore.—This apparatus has been devised by Schutze. It consists of a short grooved catheter (Fig. 46), which is introduced into the urethra, where it acts as an irrigating dilator. The fluid enters Fig. 45.—Vaginal Dilator. through the central opening and escapes through longitudinal slit-like openings, at the extremity of the groove. It then flows back in the grooves, and as a result the mucous membrane, which covers the grooves, is irrigated. Mode of Employment.—In regard to the pressure that should be exerted by the inflowing water, this should not be too great. The height from which the water enters should not be more than half a meter, as otherwise secretion and fluid may be carried into the blad- der, and there is also a possibility that the resistance of the sphincter may be overcome. In the employment of this instrument water is used for irrigation, and this is principally the practice of Schutze, but antiseptic solutions also, if not too strong, render the same service. Fig. 46.—Hydrophore. Indications.—It is thought that the development of strictures can be prevented by the employment of this apparatus. In irrigation with cold water the principal end to be attained is strengthening of the circulation and cleansing of the mucous membrane. Special results are yielded by treatment with this apparatus in cases of subacute and chronic gonorrhea. In cases of acute gonor- rhea the application of the hydrophore should be begun only when the marked inflammatory manifestations have subsided. Then, however, treatment with the apparatus should be instituted as early as possible.CHAPTER V SWEAT BATHS; ADDITIONAL LOCAL APPLICATIONS OF HEAT AND COLD Sweat Baths. Steam Cabinet Bath. Hot-air Bath. Electric Light Bath. Sand Baths. Baking Apparatus. Psychrotherapy. Steam Cabinet Bath, Hot-air Bath, Electric Light Bath.— In the practice of hydrotherapy those steam baths are almost exclu- sively employed in which the body, with the exception of the head, is exposed to the action of the hot medium. Therefore steam-chamber baths will not be considered here, but exclusively hot cabinet baths. Description.—The steam cabinet should, as nearly as possible, be steam-tight. A number of varieties are on the market. The accom- panying illustrations will show those most commonly employed by us. The steam is either generated in apparatus contained within the cabi- net itself and is heated, or it is conveyed to the cabinet from without from a separate source (boiler). The form most commonly employed by us is the upright steam chest, which is extremely simple in con- struction, the pipe for conveying the steam emptying into the cabinet by means of many small openings. The patient is seated upon a stool the height of which can be adjusted, and the head projects through the opening in the top. Of horizontal steam cabinets I may mention here that of Lah- mann as the most practically useful. The cabinet is constructed of sheet-iron covered with wood, and provided below on both sides with a network of iron pipes. This cabinet subserves two purposes : Either the steam may be driven through the opened tube into the cabi- net, or the cabinet itself may be heated through the system of pipes, and be employed as a hot-air bath. The patient lies upon a lattice support, while the head rests upon a leather-covered roll, as will be seen in the illustration (Figs. 47 and 48). Sweat cabinets with heated air are made in the same form as steam cabinets. The heating of the air is also effected in a protected space of the cabinet itself (generally beneath the seat), or by means of a system of heating pipes, or, finally, heated air is forced into the cabinet. Baruch deprecates the use of steam for the cabinet bath, and employs the steam-pipe radiator merely to heat the air about the seated patient, who is wrapped in a sheet, and has a cold compress applied to the head (Fig. 49). 118STEAM CABINET BATHS 119 Effects.—The effect of the steam cabinet baths depends upon the general influence of heat upon the body. Even after a short period of time, in the course of two or three minutes, the cutaneous ves- sels become dilated and the surface of the body warm. After five or six minutes sweating begins, often with redness of the Fig. 47.—Lahmann’s Horizontal Steam Cabinet (Open). Fig. 48.—Lahmann’s Horizontal Steam Cabinet in Use. skin, and this may be maintained for a long time and greatly increased by protracted exposure and continuous heating. The internal temperature of the body is increased, the action of the heart and the respiration are greatly accelerated, and the metabo- lism is augmented. Diuresis is influenced in accordance with the profuseness of the sweating ; and if this be excessive (loss of water),120 SWEAT BATHS; LOCAL APPLICATION OF HEAT AND COLD diuresis may be greatly diminished. The state of the blood with reference to its corpuscular elements is most variable. In experiments on animals (Breitenstein, et al.) a reduction in the number of blood-cor- puscles at the periphery (ear vein) was observed. In sweating persons the condition, so far as is known from relatively few observations, is Fig. 49.—Baruch’s Hot-air Cabinet, open to Show Construction. variable. At times there is a reduction, but generally there is a more or less marked increase, which, when the sweating is considerable, is probably an indication of inspissation of the blood. These changes involve only the red corpuscles ; the white are almost always in- creased. As a result of the sweating, reduction in body-weight takes place, even as much as 1 kilogram (2-^- pounds) and more, inINDICATIONS FOR STEAM BATHS I 21 from twenty-five to thirty minutes. This is to be attributed exclusively to loss of water. It is known that in conjunction with the sweating a number of toxic and bacterial, as well as metabolic products, are eliminated. Thus, bacteria themselves, urea, uric acid, or metallic poisons (mercury, lead, etc.) may at times appear in the sweat in con- siderable amount. The temperature of the steam bath rises more or less quickly in accordance with the rapidity with which the steam enters. A tem- perature above 6o° C. (140° F.) is rarely necessary; a temperature of 50° C. will fulfil most indications. In general, patients become accustomed in time to tolerate the higher temperatures, and therefore it would appear advisable that the heat should gradually be increased. The subjective sense of burning in the skin becomes most pronounced before the patient begins to sweat. After the secretion of sweat has once become profuse, this feeling generally disappears or at least dimin- ishes considerably. The cooling of the head throughout the sweat bath is, as was mentioned at the beginning of the section, an indispen- sable condition. It is often of great advantage to prevent the develop- ment of congestion by cooling the neck. To increase greatly the secretion of sweat, it is useful to permit the patient to drink cold water during the process. This is subjec- tively most agreeable, and the sweating, which diminishes in the course of about thirty minutes, may again be increased. The patient should not be permitted to leave the bath apartment while the skin is hot, and it is our custom, when the sweating is not to be continued by means of subsequent dry covering, to cool the patient after the steam bath. The choice of the cooling procedure depends upon the object to be accomplished. When special stimulation is desired, we usually employ marked contrast stimulation; that is, the influence of decided cold immediately after the steam bath. Better abstraction of heat is effected, however, if moderate temperatures, from 250 to 30° C. (77° to 86° F.), are employed at first, gradually passing from these to cool applications, or even to cold full baths. The duration of the steam bath also depends upon the object to be accomplished. We employ steamr baths of quite short duration, from two to five minutes, as a preparatory measure, in order to intensify the effect of a stimulating procedure ; baths of longer dura- tion, from ten to thirty minutes, for the establishment of sweating under the conditions about to be considered. The steam baths of exceed- ingly long duration, an hour and more, employed in some places, are used by us only with extreme rarity. They constitute an enormously powerful measure, and presuppose the possession of great powers of resistance. Indications.—The indications for steam baths are extremely varied. We employ steam baths of short duration as a preliminary122 SWEAT BATHS; LOCAL APPLICATION OF HEAT AND COLD warming procedure in the presence of general atony, and of depres- sive neuroses, and especially in cases of anemia and chlorosis. Steam cabinet baths of considerable duration are employed in the following morbid conditions: (i) Metabolic disorders, especially obesity and oxaluria, less commonly in the obese forms of dia- betes; (2) throughout the whole range of articular diseases, such as rheumatism, gout, and deforming arthritis; (3) dyscrasic pro- cesses and constitutional disorders, torpid scrofulosis, syphilis, chronic metallic poisoning (as, for instance, with lead, zinc, mer- cury) ; (4) diseases of the kidneys, and dropsical states in which the injurious influence of the steam baths upon the heart is counteracted by simultaneous application of the cold coil or ice-bag to the precordium ; and, finally, (5) as a fomentation in cases of chronic diseases of the skin, with thickening of the epithelium, and slug- gish, imperfect peripheral circulation. The secondary procedures by which sweat baths should be fol- lowed vary in accordance with the disease present. Vigorous proce- dures will be selected in cases of obesity and syphilis, and less intense measures in the presence of diseases of the joints and metallic poisoning. The cooling process should be very carefully carried out in cases of nephritis. Steam cabinet baths and general hot-air baths are counterindi- cated in febrile diseases in general, in profound structural disease of the central nervous system, and in marked arterio- sclerosis. Among febrile diseases, an exception to the counter- indications may be made when recent febrile affections due to exposure to cold (coryza, influenza) are to be treated with sweating proce- dures. The selection of cases should, however, be made with great care, and presupposes due resisting power. On the other hand, do- mestic procedures to produce sweating, as the hot foot-bath or tub bath with a hot drink, and followed by a hot pack, are, in the editor’s experience, applicable and useful at the beginning of nearly every case of influenza, coryza, severe laryngitis and the like, and even in many cases of pneumonia. Both steam and hot-air cabinets may be employed in reduced size for the application of heat to the lower half of the body. Such half sweat baths enlarge the range of indications so as to include cases in which there is some doubt as to the employment of general sweat baths, especially cases presenting dropsical conditions in connection with disease of the heart, and cases of nephri- tis. The simultaneous application of cooling apparatus to the pre- cordium will insure protection against undue cardiac depression. A valuable, practical, and simple arrangement for the application of hydrotherapy at home consists in the steam bath in the tub, pro- posed by Winternitz. The procedure is exhibited in the accompanyingWINTERNITZ’S STEAM TUB BATH 123 illustrations (Figs. 50 and 51). By means of a continuous supply and discharge of hot water, which gives off steam in the tub, an exceed- ingly high temperature (up to 50° C.—1220 F.—and above) can be attained, if the tub is well covered. Metallic tubs must be appiopii- ately lined with blankets, as otherwise they might become unduly heated and give rise to burns. The tolerance of high temperature varies in ac- cordance with the follow- ing principle, based upon experience. The degree of temperature that can be borne depends upon the rarity or density of the medium supplying the heat, and particularly upon its hygroscopic power, in ouiei words, when the medium rapidly absorbs water, thus both facilitating perspiration and, in case of local application, avoiding the danger ot scalding the patient in his sweat, a much higher tempeiatuie is per- missible than under other conditions. A human being can toleiate a water bath at a tem- perature of 45° C. (113° F.) for eight minutes, with danger to life, so to say (Landois), while general hot-air baths of eight minutes’ duration at a temperature ol 1270 C. (260.6° F.) are well borne, and temperatures exceed- ing this are endured, in properly applied local baths of hot air. Sweat- ing (the physical regula- Fig. 51.—Frames for Winternitz’s Steam Tub tion^ ig easy [n tpe hot-air BA1H' bath, more difficult in the water-saturated steam cabinet bath, and still more difficult in the water bath, in which the presence of the water interferes with the secretion of sweat. An exception to this rule is constituted by the electric light baths shortly to be mentioned, in the case of which the markedly stimulating effect of the light rays upon the neivous system renders impossible the toleration of high temperatures for a considerable length of time.124 SWEAT baths; local application of heat and cold Light baths constitute a form of sweat bath introduced several years ago by Kellogg, of Battle Creek, and at present widely employed. These are given with the aid of cabinet-like apparatus supplied with electric incandescent lamps or arc lamps, which serve as a source of heat. The reflection of the light rays is effected in the apparatus of Kellogg by means of mirrors within the cabinet. With us (Win- ternitz) experience has shown that celluloid plates (which, however, are combustible and therefore not entirely desirable), and, still better, thick glazed paper, serve the same purpose at a lower cost. With reference to the action of the electric light bath, we are as yet not clearly informed. We do not know with certainty whether it is to be considered as a simple hot-air bath, or whether a part of the effect is due to the chemical rays. Undoubtedly the chemical rays, and especially those of the arc light, exert a profound though hitherto not accurately defined influence, not alone upon the skin, but also upon deeper structures, and even upon metabolism. Kellogg 1 himself, whose ingenious investigations are thus far the most complete, explains the difference in the action of the light baths and that of hot- air baths by the circumstances that the elimination of carbon dioxid in the light bath is the greater, and that the occurrence of sweating, as we have also been able to confirm in hundreds of cases, generally sets in earlier, that is to say, at a lower temperature, and is more abundant, than after the use of other forms of sweat baths. It is often stated that the action of the heart is less accelerated in the electric light bath than when the steam bath is employed, but we are unable to confirm this statement. # The indications for light baths coincide inThe main with those for steam and hot-air baths. The effects are quite noteworthy. The baths are found quite agreeable, the manipulations are cleanly and simple, and the regulation of the temperature can be pretty accurately governed by changing the number of lights as necessary. It is possi- ble to keep the patient for a considerable length of time in the light cabinet at a temperature of 45° C. (1130 F.) ; if the temperature does not become higher, changes in the action of the heart can be avoided. The light bath is thus well adapted for obese persons with diseases of the joints, also for a number of hysteric and neurasthenic patients, in whom, it is true, a part of the effect is due to suggestion. In any event, more attention will have to be given in the future to this form of applying heat, and Kellogg is deserving of much credit in this connection. Sand Baths.—For the general application of heat, and as a sweat- ing measure, sand baths are of importance. 1See article on phototherapy by Dr. Kellogg in this volume, pages 226 to 241.LOCALIZED APPLICATIONS OF HEAT 125 Mode of Employment.—Originally sand heated by the sun was employed, but the method has been elaborated in recent years, espe- cially by Dr. Sturm, of Kostritz, and by Grawitz, of Berlin, and its indications have been defined. At present, artificially warmed, fine, hard, sea or river sand is used ; the heating being effected in ovens especially constructed for the purpose. In the tub—a quadrangular wooden box upon rollers—is placed a layer of hot sand from 1 5 to 30 cm. (6 to 12 inches) high, and upon this the patient lies. With the exception of the head, which is elevated, the body is covered with sand, and finally with warm blankets. The floor of the cabinet is gen- erally made of sheet-iron, and is heated by means of tubes placed below. The sand has a temperature of from 450 to 50° C. (1130 to 1220 F.), and even a temperature of 53 0 C. (127.40 F.) is well borne. The pulse, it is true, becomes accelerated, as in the case of other methods of overheating the entire body; and also the respiration is quickened; but serious discomfort is exceptional. The head must always be well cooled. Sweating occurs rapidly, and becomes abundant, as the sand exerts a hygroscopic influence, and favors the secretion of sweat. The sand bath is continued for from one-half to one and one-half hours, and is concluded with a tepid or cool bath. The chief indications for sand baths are to be found in rheumatic, arthritic, and gouty processes, and in cases of neuralgia, especially of the sciatic variety. Favorable reports have been made as to the treatment of parenchymatous nephritis (Sturm), and of chlorosis (Grawitz). LOCAL APPLICATION OF HEAT In the chapter on the wet compress the means of making local applications of heat were in part discussed. At this place will be con- sidered rather newer methods, that have been employed for a number of years, for the purpose of subjecting portions of the body to tempera- tures at times abnormally high. The tolerance of high temperatures on the part of portions of the body depends precisely, as in the case of general applications of heat, upon the character of the thermal medium. If the skin can regulate its own temperature by means of sweating and protect the deeper structures, far higher temperatures are bearable. Burns occur only when the thermal medium is a good conductor of heat. In the construction of the various forms of apparatus use is made of a chamber that can be adapted to different parts of the body, and affords the possibility of ventilation, as otherwise the air within the chamber might become saturated with water to such a degree that sweating would be suppressed and scalding occur. The source of126 SWEAT BATHS; LOCAL APPLICATION OF HEAT AND COLD heat may be any steam-generating stove ; a gas flame or other flame applied to a metallic cylinder externally ; a flame with a chimney ter- minating within an apparatus of non-conducting material, or the like. Varieties.—The number of apparatus already known is quite large, and the description of a few types will suffice. The most com- mon, and the simplest, are the small steam and hot-air apparatus with chambers of varying form for the different parts of the body. The apparatus of Reitler, of Vienna, to which those of Bier and Quincke are sfmilar, convey heat by piping from a number of lamps to a canvas or other stout frame in which the body or limb is placed. The apparatus of Tallerman for the extremities, the trunk, the shoul- der, or the neck, are constructed of copper and are lined with asbestos. A gas flame beneath the apparatus supplies the heat. The tempera- ture in the chamber rises rapidly, as high as 8o° C. (176° F.), and even up to 150° C. (3020 F.). The application is continued for from fifteen minutes to an hour. Sprague, of New York, has improved upon this and also adapted it to inclose the body. The apparatus of Lindemann 1 are shown in the illustrations on pages 92 and 93 (Figs. 24 and 25); one form is adapted only for application to the extremities. The source of heat consists in two wire rheostats on the floor of the cabinet, which are connected by means of a spiral rheostat with an electric current. The chamber can be raised to a higher or a lower level by means of an appropriate support, so that the extremity can be placed in a comfortable position. The source of heat (electric current) is easily regulated, and the extremity can readily be observed through a small window in the upper plate. The wire rheostats are not incan- descent ; therefore a small lamp with a separate connection with the electric current is placed in the interior of the cabinet for purposes of illumination. The use of this lamp shows that the sensitive, hyperemic skin does not bear well the effects of the chemical rays of light; for as soon as the extremity becomes greatly heated, the turning on of the light is often appreciated as a sense of tingling pain. If a red lamp be substituted for the white light, the painful effect does not occur. Fraley, of Philadelphia, has constructed a somewhat similar apparatus both for the body and for the limbs. Kellogg has constructed appliances analogous to his electric light cabinet for individual portions of the body, the extremities, etc., concerning the application of which not much need be said. They are admirable in action and in application. In addition, there are various devices in the use of which hot air or hot carbon dioxid (passed over plates heated by electricity) is driven into the cabinet. Apparatus of this character are described by Reich, under the name of thermoaerophore, by Frey, Herx, and Bum. The instruments are em- 1 “ Miinchener med. Wochenschrift,” 1898, No. 46.PSYCHROTHERAPY 127 ployed either for the local application of hot air or, in the case of those devised by.Herx and Bum particularly, as local hot douches. The indications for all of the varieties of local treatment with heat are familiar. Rheumatic and arthritic processes, dis- eases of muscles and tendons, neuralgia (sciatica, etc.), occupy the foremost position in this connection. The treatment of gonorrhea and tuberculous joint affections, in accord- ance with the suggestion of Bier to utilize the influence of hyperemia, should be mentioned. Further, local overheating is useful in the treatment of chronic ulcerative affections of the skin, on account of the favorable influence exerted upon regeneration of tissues, and cicatrization of the ulcerated surfaces (Ullmann, of Vienna). It is customary with us, after the application of heat, to cool off the greatly heated portion of the body, or at least to refresh the skin by means of affusions of short duration or by frictions, and subse- quently to cover the part thoroughly. If the part is very tender it is often serviceable, after the overheating, to continue the sweating pro- cess beneath heavy covers, and to apply the cooling measure after about an hour. PSYCHROTHERAPY Under this head will be mentioned only those methods in the prac- tice of which abnormally low temperatures are employed. The effect of local cold is familiar, and its employment as an antiphlogistic and analgesic, in so far as this is customary by means of water of low temperature, down to that of ice, has been considered in the chapter on the wet compress. The marked cooling of circumscribed por- tions of the body (nerve, trunk, etc.) by the spraying of ether or of ethyl chlorid or rhigolene is a pretty well-known method, so that it will not be necessary to say more concerning it. In the presence of trigeminal neuralgia or spasmodic tic this application is often of use. Extremely low temperatures may be employed therapeutically by means of applications of solidified carbon dioxid. If liquid car- bon dioxid is permitted to flow into a sac loosely filled with cotton, so much heat will be taken up that the carbon dioxid freezes into a snow-like mass. The stream of carbon dioxid from the cylinder should be directed downward. In the presence of obstinate anorexia in cases of tuberculosis, such a sac, filled with 1 or 2 kilo- grams (2 to 4 pounds) of carbon dioxid, has been employed, it is stated, with surprising success, in the form of an application to the stomach, where it should remain in place for from one-half to three-quarters of an hour. A thick layer of cotton should be interposed between the skin and the cold sac. Necrosis of the skin does not result from the employment of this measure.128 SWEAT baths; local application of heat and cold Of methods of applying abnormally low temperatures to the entire body, only the cold spring or fountain constructed by Pictet1 is well known. A hollow double-walled cylindric chamber, 2 meters (yards) high, incloses the patient up to the neck, the head remaining free. By evaporation of sulphocarbonic acid, and condensation by means of a high degree of pressure, an atmospheric temperature of —1 io° C. (—-1660 F.) can be obtained; a temperature that, by reason of the lesser activity of the long-waved rays, is not at all appreciated as abnormally cold by the fur-wrapped patient The sitting lasts from fifteen to twenty minutes, and is said to give rise to marked effects. Pulse, respiration, and metabolism are increased, and, what alone is decisive in its therapeutic employment, the appetite is said to be excessively stimulated. Animals became abnormally hungry in Pictet’s experiments. In cases of neurasthenia, especially of nervous dyspepsia, the results have also been most satisfactory. Unfortunately, the method is not susceptible of extensive employment on account of its great cost and relatively limited range of application. 1 “ Blatter fur klin. Hydrotherapie,” 1897, No. 2.Part III SPECIAL HYDROTHERAPY BY DR. B. BUXBAUM ASSISTANT TO PROFESSOR WINTERNITZ IN THE VIENNA GENERAL POLICLINIC; CHIEF PHYSICIAN OF THE HYDROTHERAPEUTIC INSTITUTE AT VIENNA. ix—9PART III SPECIAL HYDROTHERAPY CHAPTER I ACUTE FEBRILE INFECTIOUS DISEASES Preliminary Considerations. Typhoid Fever. Malaria—Malarial Ca- chexia. Intestinal Infections. — Cholera A sialic a ; Cholera Nostras; Dys- entery. Acute Exanthematous Infections—Pulmonary Complications of Measles; Scarlet Fever. Diphtheria. Acute Articular Rheumatism. Preliminary Considerations The physiologic effects of thermic and mechanical stimuli teach that hydrotherapy constitutes a powerful remedial measure, symptomatic and radical, which, as has been shown, exerts a marked influence on nu- tritive disturbances. From a consideration of the wide range of indi- cations for thermic and mechanical stimuli and the remaining physical remedial measures, it will not be difficult to understand that they possess a therapeutic value far beyond that of mere hygienic exercises, and it would really be necessary to review the entire field of special therapeutics and the whole subject of hygiene to give a comprehensive description of the effects of hydrotherapy upon all forms of disease. Inasmuch, however, as we shall confine ourselves to a consideration of the tonic and invigorating effects of thermic and mechanical nerve- stimulation, as we have pointed out, we may omit a detailed discussion of the great hygienic and nutritional value of cool and cold water applied every morning. At the same time the qualification should always be borne in mind that the special methods outlined in the fol- lowing chapters are not to be looked upon as inflexible formulas. Accuracy in individualization, and adaptation of the effects of our physi- cal remedial measures to the given case, are the first principles of special hydrotherapy. In what follows an attempt is made to formulate the principles that should guide us in laying down definite indications for treatment; and an effort will be made to show, in connection with certain forms *3*I32 ACUTE FEBRILE INFECTIOUS DISEASES of disease, how our therapeutic principles can be applied. It is not necessary to describe all forms of disease in detail; but by means of one or two examples of a group of diseases it will be shown how the clinical picture is to be analyzed, and what measures are to be em- ployed in conformity with this analysis. It will then be comparatively easy for each physician to institute for himself the proper method of treatment in those forms of disease which are not analyzed in detail in this work. ACUTE FEBRILE INFECTIOUS DISEASES There are practically two questions that perpetually engage the attention of all physicians. The one has reference to the nature and the genesis of fever, and the other to its significance. Upon the answers to these questions depend the entire treatment of fever, and the solution of the further questions whether fever is necessary for the termination of the disease or not, and whether the fever should be combated or not. In the most remote times fever was considered simply and solely as an elevation of temperature, and the febrile ele- vation of temperature was also regarded directly as an important remedial measure. This view was at one time sustained and at another contradicted, and the discussion was renewed when bacteriologic inves- tigations began to exercise their important influence. On the one hand, it was contended that the high temperature exerted no injurious influence upon the organism, while, on the other hand, the paren- chymatous and fatty degenerations occurring in the various organs were attributed to the pyrexia. Finally, great importance was again attached to the elevation of temperature, in so far as it was considered as a natural curative effort and as a means of defense against the infec- tious agent. It is a demonstrable fact that beyond certain limits, high tempera- ture ought to be combated. It should not be forgotten, however, that efforts to lower the temperature as much as possible not only may prove unsuccessful, but are not even useful, since the infectious diseases under such conditions do not pursue either a more rapid or a more favorable course. It should therefore be borne in mind that there are febrile symptoms other than elevation of temperature which demand an equal, if not a greater share of attention. Circulatory derange- ment, next to elevation of temperature, is one of the most constant febrile symptoms. This is exhibited in acceleration of the heart action, in increase in the frequency of the pulse, and in an unfavorable influ- ence upon the organs of the central nervous system and the vasomotor center. If it is recalled that the blood pressure falls, and that this may readily produce hypostasis in the lungs, stasis in various otherCIRCULATORY DISTURBANCES 133 organs, unequal distribution of blood and heat, various metabolic dis- turbances, diminished diuresis, bed-sores, and like disorders, it will be evident that these symptoms must be accorded the same attention as the elevation of temperature. Of great importance, further, are the derangement of digestion and of respiration, the nervous manifestations, the febrile secretory and excretory disturbances, the reduction in the excretion of water through respiration and insensible perspiration, and, not least of all, the changes that take place in the blood in febrile infectious diseases. The per- centage of hemoglobin, the number of red and white blood-cor- puscles, and the alkalinity of the blood undergo changes during febrile infectious diseases, and these likewise furnish important indications for treatment. It will thus be seen that a number of symptoms of equal importance demand the attention of the therapeutist. But even if all these be remedied, it will not suffice. Advances in the field of pa- thology require that a rational therapeusis shall also be guided by the etiology. Treatment therefore should be directed against the infec- tious agents and their products. Are we in a position by means of hydrotherapy to meet all of the requirements? That hydrotherapy is capable of reducing temperature has never been doubted. Winternitz was the first to show how this is brought about. He has demonstrated that heat-dissipation is increased and heat-production is diminished ; in other words, both factors that cause elevation of temperature can be influenced by suitable hydriatric measures. Only when it is possible to cause dilatation of the cutane- ous vessels by active thermic and mechanical stimulation, and to main- tain this dilatation, can the dissipation of heat be increased; and under the same conditions the production of heat may be diminished. Nevertheless, a mere lowering of the temperature is not sufficient; an effort should also be made to maintain the temperature permanently at a suitably low level. The second important question is whether it is possible by means of hydriatric measures to guard against circulatory disturbances, or to correct them when present. This question also has been answered by Winternitz. By means of both local and general measures it is possi- ble to counteract, to overcome, and finally to remove the circulatory disturbances. The action of the heart may be slowed and strengthened, the blood pressure increased, and tone given to the vascular system, and, as a result, stagnation, hypostasis, bed-sores, and cardiac collapse are extremely rare. It is possible also, by combating the pyrexia, to lessen the digestive disorders, which are in large part attributable thereto. By lowering the temperature, moreover, the respiratory dis- turbances are corrected. The bactericidal power of the blood is favor- ably influenced by augmenting its alkalinity and increasing the number of red and white blood-corpuscles active in the circulating stream.134 ACUTE FEBRILE INFECTIOUS DISEASES Thus the organism in its entirety is strengthened in its struggle with bacteria and their toxins, and the elimination of the latter is hastened by stimulating the action of the skin and kidneys. These facts firmly establish from the most modern viewpoint, that superiority of hydro- therapy over other methods of treatment which has long been recog- nized empirically. The procedures that we employ in the treatment of acute febrile infectious diseases are partial ablution, the partial rub, the cold rub, the wet pack, the half-bath, the trunk compress, stimulating compresses, and cold applications to the pre- cord ium, to the head, and to the abdomen. Full directions as to the methods of application have been given in the section on Technic and need not be repeated here. Following will be found the statement of certain necessary details in relation to various forms of infectious diseases. TYPHOID FEVER1 It is, above all things, absolutely necessary to begin the treatment of typhoid fever early. It has been demonstrated statistically that if the treatment of this disease is begun early enough, the mortality is not more than three or four per cent. It is equally important, how- ever, that the hydriatric measures in typhoid fever be continued suffi- ciently long. The number of relapses is certainly lessened in this way. With reference to the special measures to be employed, the desired result can no doubt be attained with the most varied hydriatric proce- dures, provided the thermic and mechanical stimulations are graduated in accordance with the indications of the individual case. Hence there can be no invariable and exclusive routine. Nevertheless it will be well to begin with partial ablution. With the aid of this procedure the irritability of the vasomotor nerves, the strength of the heart, and the intensity of the febrile process can be determined. It is, briefly, a measure for testing the reactive power of the body. If the reaction is not good, as will be indicated by a marbled, cyanotic appearance, or pallor and coldness of the skin, partial ablution with cold applica- tions to the precordium should be practised repeatedly, in order to improve the heart-action and thereby to strengthen the powers of reaction. If the reaction following the partial ablution is good, tepid or moderately cool half-baths—28° to 26° C. (82.4° to 78.8° F.)—may be employed, and the temperature gradually lowered. The duration and temperature of the bath should be regulated 1 For further details, see Appendix.TYPHOID FEVER 135 according to the following principles : When vigorous nerve-stimu- lation is desired, or when the circulation is to be improved,—the state of the body-temperature occupying a subordinate place among the symptoms,—cold hydriatric applications of short duration (150 to 210 C.,—6o° to 70° F.,—from five to eight minutes) are employed. When, however, a reduction in body-temperature is to be effected for a considerable time, a higher temperature (29° to 320 C.—85° to 90° F.) is at first selected and gradually lowered; and the bath is continued for as long a time as possible. The number of baths varies in accordance with the severity of the case. With reference to the temperature of the patient, it should be kept in mind that bath- ing should be practised whenever the temperature is above 39.50 C. (103.i° F.) ; the state of the nervous system and the circulation may, however, justify, or even call for, the earlier repetition of the bath. By applying a trunk compress immediately after the half-bath, and changing it hourly, it is generally possible to maintain the tem- perature for several hours at the level attained. A procedure that is also employed in typhoid fever—much less commonly, it is true, than the half-bath—is the wet pack, renewed at frequent intervals. This is indicated when the action of the heart is greatly accelerated, and in conditions of great excitement. Whenever a conservative measure is to be employed, as in profound anemia; when it is desired to abstract heat gradually ; when the skin is burning hot and dry, and marked redness of the skin cannot be induced even by means of vigorous friction ; finally, when the means for applying other procedures are wanting, the fever will be most effectively combated by means of a cold wet pack systematic- ally renewed at regular intervals. The temperature and duration of these applications must be governed by the effect in the individual case. Only when the power of the heart is greatly depressed, in profound disturbance of consciousness, and when deep inspira- tion is to be induced will wet packs be counterindicated. The effect of general measures may be materially augmented by means of various local applications. First of all is the Leiter or rubber coil applied to the precordium, the employment of which cannot be too urgently recommended ; it is a prophylactic against collapse. It should be employed daily for one or two hours. It is also a useful agent for the correction of cardiac weakness that has already set in, more efficient than the large doses of alcohol so much employed. Cold water (120 to 180 C.—540 to 64° F.) is generally used in the precordial coil. Further, consideration should be given to the symptoms referable to the central nervous system—stupor, coma, delirium, excitability. In general, these will be most effec- tively combated by general procedures; and they are rarely ob-136 ACUTE FEBRILE INFECTIOUS DISEASES served in patients treated from the outset with hydriatric measures. In stupor, or even when the mental symptoms are merely subjective, the head coil or compress should be used as an adjunct to general procedures. This should be applied for a long time, and the temperature regulated in accordance with the conditions present. On the occurrence of intestinal hemorrhage, a trunk com- press is applied, in conjunction, if necessary, with the abdominal compress or coil. Under such circumstances every procedure involving mechanical stimulation should be omitted. If hypostatic pneumonia occur, a crossbinder and precordial coil are indicated. Neither this condition nor the occurrence of bed-sores is a counterindication for general treatment; on the contrary, recovery from these complications will by this means be accelerated. MALARIA The best water treatment for malaria consists in the employ- ment of a cold application, combined with powerful thermic stimulation. The form of the application is a matter of indiffer- ence. The most important requirement, however, is the production of a good reaction. When this fails to take place, success will be wanting. With the powerful stimulating procedure, which may be chosen according to personal preference, a fan douche to the region of the spleen may serviceably be conjoined. The principal objects of the therapeutist’s attention are the proper selection of the time, and the production of a good reaction. The shorter the interval between the procedure and the anticipated chill, the more certain will be the result. With regard to the procedures to be employed, they consist in cold vigorous shower-baths; a cold rub in coarse sheets in combination with sheet-baths; cold sitz- baths of ten minutes’ duration; cold full baths; plunge baths, and other suitable measures. The treatment should be con- tinued until the constitution of the blood, the digestion, and the circu- lation are restored to the normal—briefly, until every sign of cachexia has disappeared. According to Strasser, the effect of hydriatric procedures is to be attributed to the fact that shortly before the attack the infected erythrocytes disintegrate under the influence of the powerful stimula- tion of the cold, so that the plasmodia thus set free are destroyed by the phagocytes. The treatment of the malarial cachexia is quite difficult; often more difficult than that of primary malarial infection. The anemic forms are the most frequent, and their general hydriatric management should follow the rules given for anemia. (See page 144.) In theCHOLERA 137 case of patients presenting this condition, as well as in that of other greatly reduced persons suffering with profound nutritive disturbances of an ill-defined nature, it should not be forgotten that the cachexia results from a sort of chronic intoxication. We thus have a certain therapeutic guidance in the direction of an elimination of toxins. The particular manner in which this is to be brought about can readily be decided upon according to the special circumstances ol each case. The suggestion to have the patients sweat periodically may in any event be adopted. ACUTE INTESTINAL INFECTIONS Cholera Asiatica and Cholera Nostras The hydriatric management of cholera must begin with the pro- phylaxis. Personal disinfection, which consists in the most scrupulous cleanliness, is the fundamental prophylactic principle. The second important factor consists in combating the tendency to diarrhea. The cold rub in a sheet wrung out of very cold water (8° to io° C.—46.4° to 50° F.), or in a dripping sheet, according as it is desired to abstract a greater or lesser amount of heat, fulfils these indications. A cool half-bath (26° to 2o° C.—say, 8o° to 68° F.) lasting from two to five minutes, or a cold rain-bath of very brief dura- tion, say, from thirty seconds to one minute, may also be employed. Perfect reaction is absolutely indispensable. If the disorder has already advanced, and the premonitory choleraic diar- rhea is present, or possibly only vomiting and cramps in the calves, which are indicative of the commencement of an attack of cholera, the object of the physician will be to check the discharges from the stomach and bowel. The control of diarrhea and vomiting is the principal indication in the treatment of cholera. There is no remedy more certain, more prompt, and more reliable than the appropriate hydriatric measure. The method by which the desired end is best to be attained is probably a cold rub in a sheet partially wrung out of very cold water, as near o° C. (32° F.) as possible, followed imme- diately, without preliminary drying, by a very cold sitzbath (hip- bath)—8° to 120 C. (say, 46° to 540 F.)—for a period of from fifteen to thirty minutes. The patient is well covered in the sitzbath, the parts that are not immersed being well enveloped, and the abdomen should be vigorously rubbed. Following this pro- cedure, a wet abdominal binder, covered by a dry one, is applied ; the patient is placed in bed, well covered, and, if necessary, the extremi- ties are vigorously rubbed beneath the blanket. As a result of this treatment, complete reaction, frequently accompanied with profuse sweating, generally occurs in a short time. In the event of a renewed exacerbation of the symptoms, the entire procedure is repeated.138 ACUTE FEBRILE INFECTIOUS DISEASES In fully developed cholera, the cold rub, the sitzbath, and the abdominal binder should be employed. Under these circum- stances water of the lowest available temperature, often cooled by the addition of ice, should be employed, and the mechanical fric- tion must be practised for a long time and energetically in order to bring.about the desired reaction. Dysentery The treatment of dysentery is based upon the same general prin- ciples as apply in cholera. In this disease also the cold rub and cold sitzbaths of long duration are indicated. Ice supposi- tories are also recommended by English writers ; a fresh suppository is introduced every three or four minutes, and the procedure is con- tinued for one to one and one-half hours at a time. The treatment by means of enteroclysis, with cold water,—12° to i6° C. (say, 540 to 6i° F.),—is most efficacious. The patient assumes the knee-elbow posture, and a glass vessel with a capacity of from two to two and one-half liters (quarts) serves as an irrigator. The extremity of the tube is well oiled and passed into the rectum for a distance of at least 8 centimeters (3 inches). The fluid is retained in the bowel for at least ten minutes. The irrigation is practised twice or thrice daily, and is continued until the symptoms have entirely subsided. ACUTE INFECTIOUS EXANTHEMATA General Considerations The treatment of the acute exanthematous infections is in general based upon the principles that have been laid down in the introductory portion of this chapter. Among the individual symptoms it is the fever and its accompanying manifestations that especially require therapeutic intervention. It should be emphasized here with relation to childhood, which is the period in which the acute exanthematous infections occur most frequently, that the organism of the child responds violently, with a number of profound cerebral symptoms, to elevation of temperature. Children give off much more heat than do adults from the surface of the body, which is much larger in proportion to the body-weight; more moderate temperatures therefore suffice to bring about the necessary effect, while collapse occurs much more readily for the same reason. Under such conditions, also, partial ablutions, half-baths with water of but moderately low temper at u re, as well as wet packs changed at intervals,—the latter especially in the presence of cerebral symptoms,—are indicated.SCARLET FEVER 139 Measles The diseases of the respiratory organs attending measles, such as bronchitis, capillary bronchitis, pneumonia, and bronchopneu- monia, naturally require thorough consideration. The pulse should be the guide in the treatment of these complications. Cold half- baths with vigorous douching and friction of not excessive duration, at most five minutes, in combination with local appli- cations, are the measures most to be depended upon in the treat- ment of diseases of the respiratory organs during childhood. No single hydriatric procedure suffices to fulfil all the indications or to provide for individual symptoms occupying a prominent place in treatment so effectually as the half-bath, if its duration and the thermic and me- chanical stimulation are skilfully adapted to the individual case. In gen- eral, I would recommend moderately cool baths—26° to 220 C. (78.8° to 71.6° F.). A bath of five minutes’ duration will suf- fice, as a rule, to induce a positive hydriatric effect with reference to all the symptoms. In no event should the bath be continued if the child begins to shiver. When the heart-action is feeble and the circulation begins to be poor, the respiration superficial and frequent, and the innervation sluggish, cold affusions in the half-bath are indicated. Affusions to the nape of the neck, by reason of their influence upon the respiratory and circulatory centers, will have a particularly good effect. In extremely severe cases momentary immersion in cold water,— 16° to 120 C. (610 to 540 F.),— followed by vigorous friction, is practised. A number of local applications may be mentioned as valuable adjuncts to the procedure described. Various forms of compresses, crossbinders, trunk compresses, and wet packs of the lower extremities are most frequently used. The crossbinders are applied continuously, being changed every two or three hours. Trunk compresses are employed when renewed elevation of the tem- perature is to be prevented. The lower extremities are wrapped either for the purpose of supplying heat, when warm compresses are used; or as a derivative measure to reduce cerebral hyperemia, when stimulating compresses are employed. Scarlet Fever Special attention should be directed to the vascular system, as here the peripheral vessels generally are relaxed and their tone lost. The secondary effect of this manifestation is apparent in reduction of the blood pressure, in acceleration of the action of the heart, in a tendency to stasis, and in a diminution of the amount of heat given off from the skin. Jurgensen very properly points out that the circulatory dis- turbance results in diminished functional activity of the blood, and treatment should have for its special object the diversion to the threat-140 ACUTE FEBRILE INFECTIOUS DISEASES ened point of as much functionally active blood as possible, an object that can probably be brought about by improvement in the circulation. The therapeutic indications are thus clearly defined : to strengthen the heart and raise the tone of the peripheral vessels. The pro- cedures employed for the attainment of these ends are the same as those that are indicated in all infectious diseases—namely, partial ablutions, half-baths with thorough friction, and affusions. In my experience, temperatures of from 26° to 22° C. (78.8° to 71.6° F.) are the best The duration of the bath will depend upon the reac- tion. The more rapidly it is possible to bring about a good reaction, the briefer will be the duration of the bath. With regard to the angina of scarlet fever, this should be treated with stimulating throat compresses, renewed every one or two hours. It should, finally, be emphasized that the frequency of scarlatinal nephritis is appreciably reduced when hydriatric measures are employed, a result that has been confirmed by all observers. Saline infusions are here of great use, and in cases of actual suppression of urine may follow the hot bath—370 to 40° C. (98° to 104° F.)—or the hot pack, or a vapor or hot-air bath, employed to induce prompt sweating, DIPHTHERIA It is a thankless task to describe at the present day, in the era of antitoxin, the hydriatric management of diphtheria. Nevertheless, it is worthy of consideration, and all the more so, as the desired results had to be, and actually were, attained by means of appropriate meas- ures at a time when antitoxin did not yet exist. The fortification of the resisting powers of the organism, the augmentation of the bac- tericidal elements of the blood, the neutralization of the toxins and their elimination from the organism, have at all times and in many cases been brought about by means of hydriatric applications. The procedure that is best adapted to the treatment of diphtheria is the wet pack, renewed at regular intervals. The patient remains in the last pack, about the fourth or fifth, until sweating occurs. Following this, a moderately cool half-bath,—28° to 240 C. (82.4° to 75.8° F.),—with vigorous affusions, is to be given. The temperature falls, the prostration disappears, and the action of the heart becomes stronger. The subjective state also becomes materially improved. A most important factor in the treatment of diphtheria consists in the application of throat compresses, which are some- times indicated for stimulating, at other times for cooling purposes. In cases of laryngeal croup, the respiratory disorders, continuous dyspnea, and threatening cardiac weakness constitute the most urgent indications. Winternitz explains the type of respiration in cases of laryngeal croup as due to paresis of the dilators of theACUTE ARTICULAR RHEUMATISM 141 glottis beneath the inflamed mucous membrane. Only upon the basis of this explanation is it comprehensible that the most important re- quirement of hydrotherapy consists in the relief of this paretic state of the dilator muscles (abductors). The method consists in applying a powerful thermic and mechanical reflex stimulus, which experience has shown affects the respiratory center. Thus, a vigorous cold rub, and half-baths with cold affusions, are indicated. ACUTE ARTICULAR RHEUMATISM The general treatment does not differ essentially from that of other febrile diseases, except that here, even more than in other diseases, the greatest importance should be attached to inducing hyperemia of the skin. For the most part, such procedures are chosen as per- mit of slow abstraction of heat and at the same time produce the marked hyperemia desired. These consist in repeated wet packs. It is possible to attain the desired end with the aid of a few packs, especially as in this hydriatric procedure we possess a powerful means of stimulating the function of the skin. The patient is permitted to remain for a considerable length of time in the second or third pack, until sweating has taken place, which occurs quite early in cases of acute articular rheumatism. The sweating is permitted to continue for some time, and followed by a half-bath of moderate tempera- ture. Should sweating not have taken place in the pack, the half- bath should nevertheless be given. Should the fever persist after the wet pack has been repeatedly changed, a cold rub should be given after the last pack ; this will often lower the temperature. The cold rub is not readily applicable in some cases, on account of marked tenderness and swelling of the joints ; or it may be impossible for the patient to stand up to be rubbed in the erect pos- ture. In the latter event it is advantageous to rub the recumbent patient. Enveloped in a wet sheet, he lies at first upon the right side, when the front and back of the body are well rubbed. Then he turns upon his back, and the lateral aspects of the body are rubbed. It is useful to permit evaporation from the body to continue for some time after the rub. Should marked tenderness be present, a sheet bath may be given. Repetition of the procedures mentioned is indicated either by recurrence of the fever or by extremely severe pain. Following the general procedures, trunk compresses, and circular (long, narrow) compresses about the affected joints, may be applied. The circular compresses are wrung out of water and covered simply with cotton, which can easily be removed without annoying the patient, while renewed and rapid saturation of the compress is possible by allowing water to drop on it from a sponge. If the shoulder-joints also142 ACUTE FEBRILE INFECTIOUS DISEASES are affected, it is advisable to apply a crossbinder, as this incloses the shoulder-joints most completely. The heart must from the outset receive attention, and the develop- ment of endocarditis and other complications averted so far as possible. Should the slightest symptom referable to the heart appear, the imme- diate employment of the precordial coil will be indicated. This maybe applied twice or thrice daily for from half an hour to an hour at a time, and even oftener and for a longer time. Whether it is possible by this measure to prevent involvement of the endocar- dium and of the pericardium cannot, of course, be determined posi- tively, but it is a fact that endocarditis is observed with extreme rarity in patients thus treated. Another advantage of hydrotherapy, as com- pared with other methods of treatment, may be mentioned—namely, the rarity of relapses. Probably it is the general invigoration and the improved tone of the skin that increase the powers of resistance. Even after complete recovery the patient should continue for some time with a cold rub in the morning. Residual processes in certain joints, swellings, with tenderness or immobility, are rarely observed. When these are present, however, circular compresses, together with general procedures, should be employed. When these do not suffice, massage and electricity, especially faradization of the joints, may help to diminish the sensitiveness. Large joints may be treated successfully with Scotch douches.CHAPTER II INTOXICATIONS; ANEMIA; METABOLIC DISORDERS Chronic Saturnism. Chronic Arsenic Poisoning. Alcoholism. Chlorosis and Anemia. Obesity. Diabetes. Gout. INTOXICATIONS In acute intoxications those procedures should naturally be first employed that are capable of expelling from the alimentary tract such portion of the poison as has not been absorbed,—thus, irrigation of the stomach and the intestine, bearing in mind the well- known counterindications. In the second place, in addition to chemi- cal antidotes are those measures that combat dangerous symptoms, such as respiratory disorders, cardiac weakness, cramps. When paralytic symptoms are present, vigorous mechanical and thermal procedures are indicated, such as the cold rub and cold affusions in the warm bath. On the other hand, in the presence of increased motor activity, as eclampsia or convulsions, sedative procedures, such as prolonged warm baths, and wet packs, are to be employed. In alcoholic intoxication especially, and in many septic conditions, saline infusions are useful. (Seepage 279.) In cases of chronic poisoning also, two indications are present. In the first place, the toxic substances should be eliminated from the body through the natural emunctories ; and, in the second place, certain symptoms, such as paralysis, excitement, and functional disorders, should be relieved. For the fulfilment of the first indica- tion we possess in dry and wet packs a well-known and powerful adjunct to steam cabinet baths, while the respiration and the functions of the kidneys and the intestines are most powerfully stimu- lated by means of a cold rub, the shower-bath, sitzbaths, and half-baths. Chronic Saturnism For the elimination of the lead, steam cabinet baths of con- siderable duration—about fifteen minutes—render admirable ser- vice. They may be followed by a bath of alternating temperature or a cold rain-bath. The distressing gastric neuroses and intestinal colic 143144 INTOXICATIONS ; ANEMIA ; METABOLIC DISORDERS are most favorably influenced by means of a trunk compress and hot abdominal coil applied for about an hour, and by means of warm, high enteroclysters and protracted tepid baths. At night a wet abdominal binder is applied. The characteristic palsies are influenced by alternating douches and cold, rapid, fan douches. Chronic Arsenic Poisoning The same procedures are applicable for the elimination of the metal as in cases of saturnism. The severe pain in the back and in the extremities is ameliorated by partial and full wet packs. For the correction of the cachexia invigorating measures of short duration and great momentary stimulation, the alternating douche, a steam cabinet bath followed by a co 1 d douche of short duration, or other similar measures, are employed. Chronic Alcoholism Of the varied symptom-complex of chronic alcoholism it will be possible to select only some of the most important manifestations. In the presence of states of excitement, of sleeplessness, and even of delirium, wet packs of long duration render admirable service. The same statement may be made also concerning the multiple neuritis that not rarely occurs. Alcoholic pseudo-tabes is generally treated with half-baths, and with hot or cold coils to the back, according as symptoms of depression or of irritation pre- dominate. CHLOROSIS AND ANEMIA With reference to the hydriatric procedures that are applicable to the treatment of chlorosis and anemia, it should be pointed out here that it is less the form of the procedure than the manner of its appli- cation that is important—in other words, that the proper dosage of the thermic and the mechanical irritation plays the most important role in determining the indications. The rules for the treatment of chlorotic and anemic states should be: 1. Avoidance of a reduction of the body-temperature below the normal, therefore absolutely little abstrac- tion of heat. 2. Increase in the irritability of the peripheral nerve terminations by means of preparatory heat-accumula- tion or heat-supply. 3. Vigorous nerve-stimulation by means of water at the lowest possible temperature.CAUSAL TREATMENT IN ANEMIA 145 The manner in which the objects outlined can best be attained will vary, but one can hardly go astray if the rules laid down are kept in mind. Avoidance of reduction in temperature and of increase in the irritability are to a certain degree necessary conditions in order that a favorable final result may be secured from the subsequent vigorous nerve-stimulation. These conditions can be satisfied by causing an accumulation of heat on the surface of the body of the patient, or by supplying heat in any one of a variety of ways. The patient may be enveloped in a wet or a dry pack until the body is warmed; or she may be placed for a few minutes in a steam cabinet; or a tepid douche—28° to 3o° C. (82.4° to 86° F.)—may be applied as a preparation for the subsequent actually effective cold application. The warmth that accumulates during the night upon the surface of the body may also be utilized for the purpose of fulfilling the first two conditions mentioned. An accumulation of heat takes place on the surface of the body after a night spent in bed beneath suitable cover- ings. The antithermic procedure is therefore practised preferably immediately after the patient arises from the warmth of the bed. At this time also water of quite a low temperature is much more readily borne. Vigorous nerve-stimulation must be brought about by having the water of the lowest possible temperature, and by means of proce- dures of very brief duration. Partial ablution or a cold rub for one or two minutes; douches lasting from a few seconds to half a minute, fulfil this indication. Often these procedures are ill borne by profoundly anemic patients when the stomach is empty. A glass of warm milk or tea, given from half an hour to an hour before the procedure is undertaken, generally induces the desired tolerance. With regard to the treatment of the patient after the procedure, this will depend upon the individuality. Spare patients with impaired nutrition, who are always chilly, should be permitted to remain in bed until the reaction—that is, the restora- tion of heat—takes place. Pasty patients, however, will accelerate the appearance of an appropriate reaction by active exercise in the open air. In general, a deficiency of iron in the blood is considered the cause of chlorosis and of many cases of anemia, and by some also a congenital deficiency in the blood-making or circulatory apparatus is regarded as a condition for the development of chlorosis. Neverthe- less other causes of chlorosis and anemia must be sought for before a rational treatment can be instituted. If this were done more systemat- ically, it might help to discover the reason why, in many forms of anemia, iron proves useless, while suitable hydriatric measures render good service. Unequal distribution of the blood as the result of altered mechanical conditions constitutes one of the most frequent causes of IX—10146 intoxications; anemia; metabolic disorders profound anemia and chlorosis. Many years ago Winternitz reported under the distinctive title ‘ anemia spuria acutissima ’ a case in which profound anemia developed in consequence of traumatism. The patient did not lose a drop of blood by the injury; nevertheless, though perfectly well previously, she presented the symptoms of grave anemia, such as commonly occur only as a result of hemorrhage. The patient had preserved intact the total amount of blood—no other conclusion could be reached ; nevertheless there occurred, obviously under the influence of the traumatism, just as in the percussion- experiments of Goltz, a relaxation of the vessels of the abdominal organs, and the larger portion of blood had collected in these channels —the patient had bled into her own vessels. A rational therapy, which I shall discuss more fully later, corrected the stasis of blood in the vessels in question, and the marked symptoms of profound anemia. The conditions are similar, in my opinion, in enteroptosis. The total amount of blood and its qualitative condition undergo no mate- rial change, unless the disorder be complicated by profound general disturbances of nutrition ; the absolute number of red and white blood- corpuscles and the percentage of hemoglobin in the blood suffer no reduction, and it is more than probable that the condition is one of unequal distribution of the circulatory fluid. I am far from believing that abdominal plethora in the ordinary sense of the word exists. This is due to active processes, and is dependent upon the special and more intense activity of one or more abdominal organs. In enter- optosis, however, the condition is certainly one of venous hyperemia —a passive hyperemia, which, on the one hand, is the consequence of enfeebled or insufficient visceral activity, and, on the other hand, is the cause of varied symptoms dependent upon passive circulatory dis- turbances. The venous hyperemia is not a sign of insufficiency in the forces that serve the purpose of propelling the blood, but it depends upon a temporary or permanent diminution in the average tone of the tissues, which makes room for considerable amounts of blood. It is an established fact that the activity of the organs is of great impor- tance in the propulsion of the blood. When sufficient intraorganic acceleration does not take place, the supply, but still more the escape, of blood must be obstructed. Of quite special significance for the circulation in the intestinal vessels is the peristaltic wave of the intes- tine ; in conditions of enfeebled peristalsis there undoubtedly results an accumulation of venous blood in the smaller and larger vessels, a mechanical embarrassment of the vascular system, which is one of the most characteristic peculiarities of enteroptosis. With reference to the treatment of such cases, the following statement may be made: While in the cases of anemia spuria acutissima described by Winternitz a good result was obtained byOBESITY 147 means of general and local hydriatric procedures improving the cir- culation, I have obtained the desired result in cases of chlorosis and anemia in consequence of enteroptosis, only by the employment of such procedures as also improved peristalsis and the tone of the intes- tinal musculature, and accordingly increased the activity of the bowel. Cold sitzbaths of brief duration, half-baths with high abdominal affusions, shower-baths, with vigorous douch- ing of the abdomen, will be in place under such conditions. Anemia following hemorrhage can in some cases be improved, if not cured. In these cases, also, the method of treatment previously described is applicable. In cases of secondary anemia, causal treat- ment must necessarily be instituted. Of individual symptoms attending chlorosis, coldness of the feet should first be mentioned. By improving the circulation and the dis- tribution of the blood this condition will naturally be overcome. Success may, however, be attained also by means of running foot- baths of short duration. Naturally, these are not applicable when headache is present as the expression of cerebral anemia. Under such circumstances the headache would be increased, and cold rubs of the lower extremities should therefore be employed instead of foot- baths. For the relief of the anemic headache a stimulating head compress or hot water coil to the neck (cravat) may prove useful. The gastric disturbances of anemic origin will be effectively combated in many cases by means of a trunk compress and stomach coil with very hot running water—40° C. (104° F.). Cardialgia, eructation, pyrosis, and vomiting all yield to this treatment. The exciting cause of the symptoms explains the prompt action of the procedures named. In conclusion, it may be mentioned that Scholz, of Bremen, recom- mends sweating-cures (hot-air baths) in the treatment of chlorosis. Baruch, of New York, reports favorable results from the use of hot- air baths followed by gradually cooled douches in order to overcome the spasmodic contraction of the arterioles, to increase metabolism, and thus to improve the assimilation of proteids. DISORDERS OF METABOLISM OBESITY In the treatment of this condition quite remarkable results are attained by means of hydriatric procedures. What conditions attend the presence of obesity? The disorder is often considered as a retarda- tion of metabolism, but this is only partially true, inasmuch as the nitrogenous balance remains within normal limits, or close thereto.148 intoxications; anemia; metabolic disorders The combustion of fat alone is diminished, so that retardation or diminution in the activity of the cell-protoplasm is present only in a limited sense. As a matter of fact there is a disproportion between fat destruction and fat production in favor of the latter—deficient com- bustion of fat. Whether the percentage of hemoglobin is too low, and therefore the ability to form oxygen is less than normal, or whether the process of oxidation in the tissue-cells does not take place with normal activity, has not been decided. Cohnheim considers the latter as the more probable. However this may be, the object of treat- ment is to increase fat combustion, by bringing about increased oxidation. Our treatment is one of oxidation, as has been brilliantly shown by the labors of Winternitz, Pospischil, and Strasser. It will therefore be capable, as is no other form of treatment, of fulfilling the conditions arising out of the nature of the disease. The denutrition- cures most commonly employed are, as a rule, withdrawal-cures; courses of treatment by means of which a certain degree of emaciation is brought about, but which in many cases may be followed by condi- tions of debility, and even of chronic disease. They depend upon the fact that the patients are restricted within such narrow dietetic limits that in the course of time symptoms of inanition make their appear- ance, as one or the other of the elements of food necessary to main- tain metabolic equilibrium is withdrawn; and thereby in the place of the existing nutritive disturbance another is substituted that at times is even more severe. The advantages of hydriatric measures in the management of obesity, as compared with other methods of treatment, consist in the fact that by stimulating the oxidation processes—that is, the natural processes—the stored-up fat is burned up; that at the same time the general state of nutrition and hemogenesis are improved ; and, finally, that it is possible without special difficulty, even after the period of actual treatment, to incorporate one or another of the physical procedures in the mode of life of the obese patient. It should further be stated that muscular activity also increases the oxidation processes. Sys- tematically increased muscular exercise will, therefore, be included in the therapeutic program as one of the most important agencies in the combustion of fat. Increase in muscular activity is attended with elevation of temperature. In order to prevent the latter, the tempera- ture of the body must be vigorously reduced before the muscular exercise is begun. Under such circumstances care should always be taken that the cutaneous vessels during and subsequent to abstraction of heat are and remain greatly dilated. Finally, sweating proce- dures should precede those directed to reduction of the tempera- ture, and these bring about favorable conditions, especially for the ab- sorption of fat. Three factors are, accordingly, to be taken into consideration inDIABETES MELLITUS 149 the treatment of obesity: induction of sweating, abstraction of heat, and muscular exercise. For the purpose of inducing sweat- ing, packs, steam baths, hot-air baths, and electric light baths of varying duration are employed. As heat-abstracting meas- ures, the following may be considered : the cold rub, sheet baths, half-baths, full baths, immersion baths, douches, par- tial ablutions. Muscular combustion is increased by means of active and passive exercise. If the effects of these procedures are kept in mind; if, further, the entire constitution, the capacity for reaction, and the individual symptoms are taken into consideration, it will be possible in all cases to make a proper selection and combination from among the procedures named. Routine treatment may result in serious injury. This is more apt to be the case with denutrition-cures than with other forms of treatment, and especially with reference to the circulation and the heart. I would further particularly emphasize the fact that in cases of obesity with circulatory disorders or with fatty heart, the condition of this organ should first of all be taken into consideration, and hence those methods be employed—such as the cold precordial coil, partial ablutions, and the like—that improve circulation. DIABETES MELLITUS In the treatment of diabetes mellitus regulation of the diet has always played the principal, or the almost exclusive, role. In spite of a rigid diet, in spite even of drinking-cures, it is not possible in many cases to bring about improvement or cure. Our knowledge concerning the nature of the disease or syndrome is inadequate. Whether the condition depends upon acceleration or retardation of metabolism—or even whether and how this factor may vary—has not yet been determined. Equally little is known with regard to the powers of oxidation in diabetic patients. By some observers it is accepted as firmly established that the powers of oxidation are reduced, but this is denied by others. In the present state of science it is therefore impossible to explicate theoretically the fact noted empirically, that hydrotherapy is capable of rendering good service in cases of diabetes mellitus. Experience teaches us that properly applied hydriatric measures greatly increase the power of assimilating carbohydrates. They are capable, moreover, of increasing the ab- sorption and the utilization of nitrogenous food, and thus of support- ing the organism in its endeavor to maintain its nutritional equilibrium without loss of the fixed elements of the body, by drawing upon and stimulating all of the reserve forces. A further value of hydro- therapy consists in the circumstance that it prevents the acid intoxication so dangerous to the diabetic, which is exhibited in150 intoxications; anemia; metabolic disorders marked elimination of ammonia in the urine, and, finally, in diabetic coma. In addition, certain symptoms, such as the distressing bulimia and thirst, gradually disappear, and the body-weight in- creases. Especially favorable changes take place in the condition of the skin, which, in cases of diabetes, is generally brittle and dry, and, in consequence of the poor circulatory conditions, is cold. The func- tions of the skin are markedly improved as a result of the water-cure. Finally, hydrotherapy is capable of relieving a number of profound disturbances on the part of the nervous system—neuralgia, neuritis, and diminished sexual power. With regard to the form of hydriatric application to be employed, invigorating stimulating procedures directed to improvement of metabolism are generally used. A good reaction is the object to be attained here also. The treatment of obesity associated with diabetes is identical with the treatment of obesity described in the previous section. GOUT Hydrotherapy plays a double role in cases of gout, inasmuch as it aims at relief or cure of the defective metabolism upon which the arthritis depends and, on the other hand, tends to combat the local disorder, the acute attack of gout. The treatment of the acute attack will first be considered. The most conspicuous symptom, and that which most urgently demands relief, is the pain. Among procedures capable of improving the local metabolism and of regulating the circulation, improvement is observed to take place most quickly under the influence of cold stimulating applications; that is, local cold applications of short dura- tion. Only after these local cold applications of short duration are cold stimulating compresses employed, in the form of circular compresses, which, covered with cotton, remain in position for several hours. As soon as the acute manifestations have disappeared, general treatment of the gouty diathesis must be begun. In gouty patients whose disorder has been caused by high-living, rich food, abundant drinking of wine and beer; in whom, therefore, the accumulation of fat is considerable and the veins are distended with blood, a hydriatric course like that recommended for obesity is indicated. In the case of patients in whom there has been reduction in weight, loss of muscular power, and derangement of digestion, in whom irri- tability and mental depression increase the intolerableness of the dis- order, it will be necessary to employ hot and cold applications alternately, particularly wet packs of from three-quarters to one and one-half hours’ duration, followed by a cold rub, or a douche of short duration and of low temperature. TheLOCAL APPLICATIONS 151 degree of thermic and mechanical stimulation, and the duration of the procedure, will be governed here also in accordance with the condi- tions present in the individual case, and under such circumstances it will be necessary for an experienced physician to supervise the treatment. The selection of the application that shall follow the pack depends, further, upon the sensitiveness of the patient. In the presence of marked tenderness, it is obviously not wise to increase this by vigorous friction. In such cases the rain douche is much more suitable. Diaphoretic measures, steam cabinet baths, hot-air baths, and electric light baths, with subsequent stimu- lating applications, are highly recommended by many writers. If symptoms of general cachexia have developed in cases of arthritis, if symptoms of deranged hemogenesis, pallor of the mucous membranes, edema of the feet, appear, then invigorating measures especially should be employed. In addition to the general treatment, local applications also are indicated. Not only in acute attacks, but also in chronic cases, circular compresses and steam compresses may be utilized to favor absorption and to avert deformities. Of other disorders of metabolism, oxaluria and phosphaturia may be mentioned, and in the treatment of both of these conditions, hydriatric measures increasing oxidation are to be recommended.CHAPTER III DISEASES OF THE NERVOUS SYSTEM AND OF THE MUSCLES AND JOINTS Neurasthenia—Analysis of Symptoms. Hysteria. Epilepsy. Chorea Minor. Hemicrania. Exophthalmic Goiter. Occupation Neuroses. Neuralgia. Paralysis. Neuritis and Polyneuritis. Spasmodic Tic. Tabes Dorsalis. Myelitis. Diseases of the Brain and its Membranes—Acute Cerebral Lep- tomeningitis ; Cerebral Anemia; Cerebral Hyperemia; Cerebral Hemor- rhage; Cerebral Embolism ; Psychoses. Diseases of the Muscles and Joints —Chronic Articular Rheumatism ; Rheumatoid Arthritis ; Gout * Arthritic Muscular Atrophy ; Acute Myopathies; Chronic Muscular Rheumatism. DISEASES OF THE NERVOUS SYSTEM NEURASTHENIA The hydriatric management of neurasthenia is one of the most difficult tasks of the physician. The difficulty in treatment resides first in the fact that almost nothing is known with regard to the nature of the disease and concerning the pathologic processes taking place in the organism. It is known that certain functions, or a whole series of functions, are morbidly altered, increased or diminished; that sensory, motor, and secretory disturbances are present. It is known, moreover, that these disturbances occur quite indiscriminately ; that some patients present sensory disorders, others motor disorders, still others secre- tory disorders, while in a fourth group two or more classes of symp- toms occur in combination. It is, however, not known why these disturbances take place, and this ignorance makes the whole question of treatment obscure and complicated. The institution of causal treatment, moreover, is not merely difficult, but is absolutely not to be depended upon. It is true the exciting cause can be discovered in most cases; it is not usually a hard matter to determine the factors that have converted the patient into a neurasthenic. It is known that excesses of every kind—includ- ing mental overwork, psychic injuries, and the like—may induce the disorder, but therapeutically little can be accomplished with the aid of this knowledge. It is especially in connection with this form of dis- ease that the statement that “ with the cessation of the cause the effect will disappear has lost its validity. Although sexual excesses survive 152NEURASTHENIA 153 only in memory, their consequences, the neurasthenic symptoms, per- sist Under these circumstances hydrotherapy might effect its greatest triumphs if it possessed no other significance than that of psychic or suggestive treatment. It must, however, be insisted upon that the suggestive treatment that has recently come into vogue has, in spite of all, yielded less success than systematically employed hydrotherapy. In the form of neurasthenia that follows brain-fag the conditions are not much more favorable. In spite of cessation of mental work the morbid manifestations fail to disappear in many cases ; in others, it is true, the symptoms remain in abeyance during the period in which work is abstained from, but as soon as intellectual activity is resumed, they reappear in all their unpleasantness. Thus it is impos- sible to fulfil either indications arising from the causal factors, or those furnished by an incomplete pathology. Symptomatic Treatment It is possible, however, to render good service from the sympto- matic viewpoint, and thereby the physician's duty is in many cases fulfilled. The sufferer is relieved of his most distressing sensations, is imbued, with courage and hope, with both the desire and the ability to work. Only in this way is the treatment to be termed psychic : that, noticing a degree of relief, hypochondriacal tendencies yield, and the patient begins to think of the possibility that he may be freed from all of his symptoms; that his condition is, after all, curable. But this is because under the influence of rationally directed hydro- therapy, symptoms of a certain order have, in fact, disappeared. Naturally, all available physical methods of treatment—all regiminal and hygienic measures at command, as discussed in the various volumes of this series—should be employed in order to support the effects of hydrotherapy. Here, also, strict individualization must be practised. Analysis of Symptoms.—If it be desired to regulate the treat- ment of neurasthenia upon a symptomatic basis, it will be necessary to note and to take into consideration especially those symptoms that are present in all, or at least in a large number of neurasthenic pa- tients. There will then be found changes in the vascular system, in the blood, in the nutrition, and in the metabolism. The heart is small and its walls thin, the vessels are small and their walls thin, the capillary system is delicate and extensive; the blood is watery, defi- cient in morphologic elements, particularly in red blood-corpuscles, and poor in hemoglobin. These conditions are pretty constant accompaniments of neurasthenia ; some of them may be considered to be congenital and thus to have afforded a physiologic basis for the development of the disorder. Under such circumstances also met- abolism is abnormal; there are formed in the organism metabolic154 DISEASES OF THE NERVOUS SYSTEM products that exert an injurious, toxic influence. Of such products, especially uric acid, leucomains, alloxurs, and numerous aro- matic substances are known to be present, and to their development from time to time exacerabations in the condition are to be attributed. As a further symptom, common to almost all neurasthenics, may be considered the changes in the blood pressure brought about through the vasomotor center. In almost all neurasthenics an increase in blood pressure is to be observed; this is especially marked when the general symptoms are exaggerated. Of equally great importance, further, is the marked instability of the blood pressure. It is known that the blood pressure is dependent upon position, upon physical and mental activity, and, finally, upon the mental state ; that as a result of mental and physical activity the blood pressure increases, and that excitement of any kind will alter it. The range of alteration, how- ever, is not large in healthy persons, not exceeding from 20 to 30 mm. of mercurial pressure. In cases of neurasthenia the fluctuations are considerably greater. Slight physical exertion, still more, however, mental activity, but most powerfully psychic shock, may increase the blood pressure enormously. Sudden differences of from 40 to 50 mm. in mercurial pressure and even more, are observed. In addition, there is another factor that likewise is of great significance—namely, that this increased blood pressure does not persist for a long time, and is followed by an inverse reaction; that is to say, by a reduction below the normal. Therefore, increased irritability and rapidity of ex- haustion—in other words, the readiness of fatigue that is in general considered as characteristic of neurasthenia—are observed especially in the state of the blood pressure—an appreciable factor indicative of the fulcrum on which the therapeutic lever is to be applied. The greater the irritability, the greater will be the exhaustion. If one must depend solely upon the subjective statements of the patient, this fact will be apparent. It will, however, be confirmed also if the reflex irritability and the subsequent exhaustion are studied. The latter occurs more rapidly, and is the more persistent, the greater the reflex irritability has been. Highly important therapeutic conclu- sions are to be drawn from these facts. Those hydriatric measures that lessen the irritability, that make allowance for the existing circu- latory and innervational conditions, that influence metabolism in accord- ance with the changes indicated, that, finally/improve the state of the blood, will meet the requirements and will yield successful results. It is far from my intention to attach undue importance to definite hy- driatric directions. This is the less required, because, as is well known, the most varied and even opposite effects can be brought about by means of the same procedure, in accordance with its dur- ation and its thermic and mechanical gradations. With reference especially to this latter factor, I would nevertheless earnestly recom-NEURASTHENIC IRRITABILITY 155 mend, in the choice of the application to be used, that the subjective sensations of the patient be not ignored, but that in so far as prac- ticable cheerful attention be given to them. The patient’s sensations must indeed be considered as an important, and for the physician a most reliable, factor in determining the treatment of neurasthenia. Nothing is more injurious than rigid, unyielding adherence to a defi- nite formula. While, on the other hand, it certainly does not appear wise to make undue concessions, especially to neurasthenic patients, with reference to the measures of treatment, yet there will never be reason for regret that as regards one or another efficient factor of hydriatric procedures, the comfort of the patient has reasonably been taken into consideration. Every hydriatric measure that gives rise to persisting disagreeable sensations will certainly be injurious rather than useful, just as, conversely, the feeling of well-being is generally a certain sign that the procedure is indicated and will be attended with success. One should naturally not be led astray by patients who make fallacious observations upon themselves, and who are fond of deceiving the physician to their own injury. I have thus far invariably observed that neurasthenic patients do not well bear strong thermic and mechanical stimulation at the begin- ning of treatment. This is entirely in accord with the foregoing explanation. Moderate temperatures, those most closely ap- proximating the point of indifference, will therefore be the most appro- priate at first. They are especially suitable for the purpose of reducing the increased irritability. The patients feel best after such proce- dures, and in, the last analysis, the subjective feeling of well-being on the part of the patient is far more important than all theoretic explanations. Tepid half-baths,—300 to 26° C. (86° to 78.8° F.),—with affusions and gentle friction, which, supported by the active participation of the patient, should be continued so long and be of such intensity that a suitable reaction is induced, have always yielded the best results. There are many neurasthenics who do not tolerate even this pro- cedure. I have often enough been told that the symptoms persist even after such measures. It would be a serious mistake if, neverthe- less, one should adhere to the procedure prescribed. If the patients fail to secure the necessary tranquillity, the desired sense of well-being, after a half-bath, I should then consider it most advisable to employ wet packs of from one-half to three-quarters of an hour’s duration, and then a half-bath in the manner described, or a brief plunge bath. Only after the lapse of some time can one proceed with the vigorous thermic and mechanical stimulation. The transition should be gradual, never unduly rapid. Half-baths at a low temperature and with vigorous affusions, shower-baths of shorter or longer duration, but always with an appropriate degree ofDISEASES OF THE NERVOUS SYSTEM 156 pressure, and the cold rub may be employed successfully in accord- ance with the indications present. It should further be kept in mind that an excessive degree of heat should never be abstracted from the patient. The efficacy of the pro- cedure not only does not suffer, but, on the contrary, is increased by antecedent heating, either by supplying heat or by causing accumulation of heat on the surface of the body. Either the cool or cold application is made immediately upon getting out of a warm bed— and this is preferable, in view of the fact that neurasthenic patients feel worst in the morning—or a heating procedure is selected in accordance with the existing conditions. A hot shower-bath, or a hot wet pack, until the body is warmed, will best effect the desired result With reference to the steps to be taken after the procedure, no rules susceptible of general application can be laid down. It is, how- ever, most appropriate to engage in exercise capable of bringing about a good reaction. I am not influenced in this connection by the sub- jective sensations of the patient, as neurasthenic patients are not always favorably disposed toward physical activity; but a good walk in fresh, dust-free air is in every respect advantageous. Only in the case of anemic patients, with impaired nutrition, do I make an ex- ception, and permit the development of the reactive warming to take place in bed. The actiyity and the field of usefulness of the hydrotherapeutist is not by any means exhausted with the general procedures described, although favorable results can be and are attained with their aid alone. The irritability and the stimulation subside, the functional activity increases, although at first only for a short time ; but there remains a number of symptoms that must be relieved. Sensations, subjective symptoms, form the principal burden of the neurasthenic patient’s complaint, and it is on this account quite natural that especial attention should be directed to them, without, however, -ignoring the objective symptoms. It is as impossible as it would be supererogatory to discuss individually the various sensory disorders, the hyperesthesias, the hypes- thesias, the anesthesias, and the neuralgias in various portions of the body, that are complained of. It would likewise be supererogatory to discuss separately the hyperesthesias of certain organs, including, for instance, nervous asthma, angina pectoris, cardialgias, various sensations of fear, and the like. One familiar with the mode of action of hydriatric measures will be able in every case to find a means of relief, and will avail himself of both stimulating and sedative procedures with a local effect, as well as of those acting reflexly, and influencing especially cir- culation and respiration. Insomnia.—The treatment of the sleeplessness is of the greatest importance in this connection. For this purpose a large number of admirable hydriatric hypnotics are available, in addition to theHYSTERIA 157 regiminal and mechanical adjuvants. The most efficient hydriatric procedure is the wet pack, which by reason of its sedative effect, as also of its derivative effect upon the blood supply of the brain and its membranes, is one of the most certain hypnotics. Almost equally effective are partial packs, trunk compresses, and abdom- inal binders. Warm full baths—320 to 340 C. (89.6° to 93.2° F.)—of from fifteen to twenty minutes’ duration; also moderately cool half-baths,—28° to 26° C. (82.4° to 78.8° F.),—with not too vigorous affusions and frictions, are further worthy of recommendation. Friction should, in general, be avoided as much as possible, as it causes irritation of the peripheral nerve- terminations, and through these of the central nervous system, where- by a result is obtained that is the opposite of the sedation desired. It is, therefore, desirable to permit the patient, after the application of the procedure, to enter his bed without being dried. The favorable effect of the bath can be increased by the addition of demulcent substances, as, for instance, a decoction of bran. An excellent proce- dure, which influences reflexly the circulation in the brain and its mem- branes, and thus acts by a sort of derivative effect, consists in the running foot-bath; or, as a substitute for this, a sural com- press while the patient stands in water may successfully be em- ployed for the purpose of inducing sleep. In conclusion, it should expressly be pointed out that in cases of neurasthenia, more than in any other disease, persistent treatment for a long period is absolutely necessary. Although the patient is often dismissed from treatment improved, or apparently cured, the resistance of his nervous system is still feeble, and only a slight im- pulse is necessary to bring about a revival of the larger number of his symptoms or, indeed, of all. The end to be attained, therefore, con- sists in increasing the power of resistance, in invigorating the nervous system,—in a process of hardening. Tonic procedures, as shower-baths, and cold rubs of short duration, are now indicated. Relapses are rarely observed, if, after the conclusion of treatment in an institute, one of the procedures mentioned is prac- tised at home daily in the morning. HYSTERIA The treatment of hysteria is not less difficult than that of neuras- thenia. The nature of this disease likewise is unknown ; the indica- tions arising from the morbid process cannot be fulfilled, and the causal indications can be accepted in a few instances only. Consequently the treatment must be directed against certain symptoms. The choice will be governed by the conditions present in the individual case,DISEASES OF THE NERVOUS SYSTEM 158 so that all that is possible in this connection is to discuss the general outlines. The observations of Runge, that the disease is attended with abnormal alterations in vascular tone, have been confirmed by other investigators, and, beyond doubt, constitute a valuable guide in treatment. They are, however, not sufficient to explain all, or even a large part of, the morbid phenomena of hysteria, and we are thus again forced to the employment of symptomatic measures. I desire at once to point out that it is as little possible by means of hydriatric procedures as by other methods of treatment to remove the mental peculiarities of the hysteric patient, which are, indeed, only the ex- pression of the psychopathic predisposition. It is nevertheless true that the specific hysteric symptoms, those physical disorders that involve especially the motor and sensory spheres, can be favorably influenced. That the psychic treatment of these patients plays an important role cannot be denied, but that hydriatric procedures possess another and greater significance than merely that of psychic treat- ment is shown by the results of observation and experience. Hysteric Paralysis.—We may begin at once with paralysis, which may appear in all possible varieties, as hysteric monoplegia, hemiplegia, paraplegia ; at times rapidly, at other times slowly ; without any ex- traneous cause, or as a result of any slight psychic determining factor. The paralysis is generally associated with anesthesia. At times it assumes the character of astasia and abasia. In the discussion of fundamentals (see Part I) emphasis was placed upon the circumstance that cold applications of short duration increase the innerva- tion, while procedures of longer duration diminish the inner- vation. As in these cases the condition is one of impaired innerva- tion, it will be clear that the indication is for cold applications of brief duration. As a matter of fact, it is possible to cause disappearance of the paralysis by means of these procedures. Cold shower- baths of brief duration, plunge baths, the cold rub, cool half-baths—20° to 180 C. (say, 68° to 64° F.)—of short dura- tion, yield good results under such circumstances. Duration of Treatment.—I have repeatedly succeeded in causing the disappearance of hysteric paralysis by means of a single application. In many cases the period required is rather long. In the case of a girl suffering from astasia and abasia, weeks elapsed before this condi- tion had disappeared. In the case of another girl, likewise suffering from astasia and abasia, recovery was complete after two half- baths. Anesthesia also yields quite rapidly to brief applications of cold. I have often succeeded in causing the disappearance of local anesthesia, for instance, by means of an ice rub, continued for a short time—about half a minute. It should especially be pointed out in this connection that in the choice of the special measure to be applied,HYSTERICAL CONTRACTURES 159 consideration should be given to the general constitution of the patient The patients, for instance, are often anemic and chlorotic. Under such circumstances the application of cold should, as is well known, be preceded by some warming measure, the form of which is to be determined in accordance with the local conditions present. Hysterical hyperesthesia and pain should in general be treated with cold applications of considerable duration. The localization of the pain and the individuality of the patient influ- ence the choice of method. Cold compresses, with or without cooling coils, cold movable fan douches, with cold shower-baths, rubbing, etc., with or without previous warming, will yield successful results under such conditions. Whenever it is at all possible I employ Scotch douches, and have always observed good effects from their use. There are many hysteric patients who do not bear low temperatures. There is no objection, under such circum- stances, to the initial employment of any suitable method to induce warmth, after which the cold application will be much better borne. Motor irritability occurs in cases of hysteria in a great variety of forms. Among these, singultus occupies a prominent place. The treatment of this symptom, like that of other states of motor irritability, of hysterical cough, of hysterical respiratory spasm, is quite simple, and the results are extremely gratifying. In cases of singultus I have observed good results from the employment of the epigastric application proposed by Winternitz—namely, an abdom- inal binder with a coil heated by a continuous flow of hot water. The cold water coil for the back has often rendered good service in this condition and also exerts an admirable effect in hysterical cough and in respiratory spasm. The latter condition will at times yield rapidly to transient thermic stimuli, as, for instance, sprink- ling the face with a few drops of cold water; a cold douche of brief duration, which induces deep inspiration ; or for slightly longer periods, a cold rub. That this mode of treatment is not merely psychic is shown best by the circumstance that distinguished observers, such as Strumpell, report success from its employment after direct psychotherapy had failed. Hysterical contractures, whose cause is to be found in morbid motor irritation, will, if recent, yield rapidly to warm applications. Hot water coils, warm douches, full baths, and the like are indicated under such circumstances. In the presence of contrac- tures of considerable duration success can be attained with no form of treatment, but in a number of cases I observed favorable results from comparatively long-continued wet packs. In any event, iti6o DISEASES OF THE NERVOUS SYSTEM will be well to devote attention to the atrophy that develops with contractures of long standing, and to improve the nutrition in the atrophied or atrophying muscles by means of general as well as local measures. Partial ablutions and partial rubs, in connection with which great importance is to be attached to the mechanical factor of the procedure, exert a good effect. EPILEPSY The best results are obtained from the combined method, com- prising treatment by bromids and hydriatric measures. It has been observed in many cases that the epileptic attacks remain in abeyance or diminish in intensity—that at least the intervals between attacks become longer—if small doses of a bromid are employed in conjunction with hydriatric procedures. With regard to the choice of the form of application, it has been found that tepid half-baths —3o° to 28° C. (say, 86° to 82° F.)—yield the best results. CHOREA MINOR Wet packs combined with the rubber coil for the back constitute the most appropriate application in the presence of this disease. The profound sedative effect of wet packs, of from three- quarters to one hour’s duration, is especially important in this con- nection. The rubber coil for the back, if employed for a considerable time, diminishes markedly the reflex irritability and contributes to heighten the good effects of the pack. After each pack a cooling, invigorating procedure, preferably a tepid half-bath—30° to 28° C. (86° to 84° F.)—should be employed. Cardiac complications do not constitute a counterindication for hydriatric measures. It is, however, a matter of course that consideration should be given to any existing disease on the part of the heart. By means of an appro- priately applied precordial coil, incorporated with the pack, the indications arising from cardiac complications will be met. With reference to the number of applications to be employed daily, this will depend upon the severity of the case. In mild cases a single application will suffice, in severe cases a repetition of the procedures named will be required. HEMICRANIA A severe task is imposed upon the therapeutist in this disease. In almost every individual case experimental observation must be made, and the treatment here advised must be understood to have no greaterEXOPHTHALMIC GOITER 161 significance than that of a procedure which may bring about recovery in some instances. The course to be described has yielded us good results, both in cases of spastic hemicrania and in those of paralytic hemi- crania, as well as in cases of the mixed form, in which at times symptoms of sympathetic spasm, and at other times of sympathetic paralysis, are present The procedures consist in wet packs of considerable duration, from one to one and one-half hours, followed by a cold rub. The admirable reflex effect upon the vas- cular center and that for the vasomotor nerves reflexly produced by the rubbing led me to employ this procedure. The wet pack was designed to heighten the irritability and thus render the patient more amenable to the good influence of the cold rub. Diaphoretic measures, followed by rubbings, have been recommended by some writers. EXOPHTHALMIC GOITER Modern studies in the field of etiology of this disease have also directed the treatment into new lines. Upon the view that the condi- tion depends upon autointoxication is based the practice of organo- therapy. This, however, has not much success to its credit. On the other hand, hydrotherapy, which increases the processes of intra- organic oxidation through a natural influence upon organic function, and stimulates the elimination of organic matters, is wholly justifia- ble, both from the etiologic and from the symptomatic standpoint. All the symptoms of exophthalmic goiter—the cardiac and vas- cular manifestations, the struma, the nervous symptoms, the tremor, the hyperidrosis, the intestinal disorders, and the metabolic derangements—can be influenced by hydriatric measures, and a large number of observations demonstrate the actual value of hydrotherapy in this affection. Naturally, it cannot be suffi- ciently emphasized that the treatment must be carried out systemati- cally, and that it should be properly varied in accordance with the conditions present in the individual case. With reference to the method to be employed, the majority of writers have expressed them- selves in favor of low temperatures. Many writers, and among them the editor of this series, advocate the application of cold (as by the coil or ice-bag) over the precordium. For a paroxysm of tachycardia, Weir Mitchell advises a general ice rub. The most serviceable applications, according to the experience of Winternitz and his pupils, are wet packs in combination with the spi- nal coil. 4 Particularly the application of cold to the vertebral column has an excellent effect. With reference to the cardiac and vascular symptoms, as palpitation of the heart, it is far more efficient than applications of cold to the precordium. The explanation resides in the nature of the process, which is a nervous one. The applica-162 DISEASES OF THE NERVOUS SYSTEM tion of cold to the vertebral column will combat still another symp- tom—namely, the tremor of the extremities. As is well known, reflex irritability is diminished by long-continued applications of cold. The patient is permitted to remain in the wet pack for from three-quarters of an hour to one hour, and with this, as stated, is combined the spinal coil. After this pack has been completed a moderately cool half-bath—26° to 240 C. (say, 790 to 750 F.)—is given. OCCUPATION NEUROSES The occupation neuroses are attended principally with spasm involving those groups of muscles that are engaged in the frequent repetition of a given movement, generally one required by the occupa- tion. The spasm does not occur spontaneously, but only when an attempt is made to execute the movement in question. The first indication, therefore, will comprise withdrawal from the injurious employment. In the choice of hydriatric methods two factors will require consideration. In the first place, as experience has shown, the patients are nervous and readily exhausted; and, in the second place, the con- dition is one of local exhaustion, either of central or of peripheral origin. The admirable investigations of Vinay and Maggiora have shown that vigorous thermic stimulation, particularly as induced by low temperatures, increases functional power and also the resisting power to fatigue. Low temperatures are still more efficacious when combined with vigorous mechanical stimulation. That mechanical stimulation—massage and gymnastic exercise—is attended with good results in cases of the various kinds of occupation neuroses is well known, and this agency plays an important role in the treatment of the diseases of this group ; but hydriatric procedures also, providing they comply with the foregoing principles, undeniably exert a favorable influence. Vigorous shower-baths at a low temperature and of brief duration, in combination with labile cold fan douches to the affected member, are attended with excellent effects. Stimulating compresses supplement the treatment. Perse- verance and systematic repetition of the procedures are indispensable for the attainment of the most favorable results. I have observed both spastic and paralytic forms to disappear entirely under this method of treatment. NEURALGIA In order to comprehend the mode of action of hydriatric proce- dures an answer must first be given to the question, How does neural- gia arise ? In most cases the disorder develops when a disproportion occurs between the demand for blood and the supply, as a result ofSCIATICA 163 thermic or other injurious influences of a vasoconstrictor character. The products of retrogressive metamorphosis accumulate under such conditions, and give rise to irritation, nutritive disturbances, functional derangement, and pain in the affected nerve. In this way arises the so- called rheumatic neuralgia. In the case of neuralgia developing in the sequence of infection, the conditions probably depend upon changes induced and maintained by the presence of micro-organisms, or their metabolic products. Other forms of neuralgia depend upon intoxication with mercury, lead, alcohol, and the like. Objects of Treatment.—The task for the therapeutist in cases of rheumatic neuralgia is to bring about an increased supply of blood to the affected structures, as well as a more effective removal of blood from them, and more active metabolism. This increased ac- tivity of circulation and augmented interchange between the blood and the tissues will have the general effect of removing, altering chemi- cally, or neutralizing the inflammatory products, or the products of retrogressive metamorphosis or of function. In cases of neuralgia developing in the sequence of infection, the object is to stimulate the processes of oxidation by means of diaphoretic measures. The neu- ralgia dependent upon intoxication should, on the other hand, be treated with measures directed to elimination of the poison from the organism, with removal of the alterations that the poison has brought about in the nerves and the nerve-sheaths. The douche of alternating temperature, or the Scotch douche, proves ^especially efficacious, particularly in cases presenting the rheu- matic forms of neuralgia. The results are brilliant; it is possible de- finitely to cure recently developed neuralgia by this means. Often it happens that patients suffering from recently developed sciatica, and hardly able to undertake treatment with the douche, can dry and dress themselves without aid after the first sitting, and even walk to their homes without serious difficulty. Naturally, failures also may attend the use of the Scotch douche. It is a matter of course that, for instance, an attack of sciatica resulting from carcinoma of the pel- vis, or from periostitis of the vertebrae, cannot be cured, and in most cases in which success is not attained it will be found that recovery is prevented by the presence of the diseases named, or similar serious affections. In default of the Scotch douche good results can be ob- tained by means of other measures utilizing alternation of tempera- ture ; that is to say, procedures supplying heat or causing accumulation of heat, followed by cold applications. Such measures as the steam cabinet, or the dry pack, with the cool half-bath, or cold ablution to the point of removing the heat accumulated upon the surface of the body, can always be utilized. It is not the special pro- cedure employed, but rather the correct combination of heat and cold, upon which success principally depends. In the same manner not164 DISEASES OF THE NERVOUS SYSTEM alone sciatica, but also trigeminal, brachial, and intercostal neu- ralgia, is treated. A few words may be devoted specially to tri- geminal neuralgia. Here it is less the local than the general pro- cedure influencing the entire surface of the body by means of which a favorable effect may be produced. As a matter of course, in the choice of a special method of application the etiology of the disorder is to be taken into consideration. The forms of neuralgia dependent upon intoxication and infection yield most rapidly to diaphoretic measures, which naturally should be selected in accordance with the conditions present in the individual case, and should be followed by invigorating procedures. PARALYSIS The hydrotherapy of paralysis does not differ essentially from that of neuralgia. This is comprehensible from a consideration of the etiology of this form of disease. Apart from central disorders, from profound traumatism destroying continuity, from inflammatory affec- tions of the bones, or from tumors the pressure of which gives rise to the paralysis, and which are not amenable to hydrotherapeutic measures, the cause of the paralysis, in the overwhelming majority of cases, is rheumatism or exposure to cold. Toxic influences and overexertion, and, finally, infectious diseases, must further be kept in mind. It is scarcely necessary again to emphasize the powerful man- ner in which hydriatric procedures influence the elimination of toxic substances, of infectious agents and their toxins. I need not again relate how the hydriatric procedures are capable of correcting the changes brought about by cold; and how, finally, as a result of therapeutic intervention, fatigue products also are eliminated or neutralized. I shall here deal with the practical results that are attained by means of hydriatric procedures,- and desire especially to emphasize that it does not appear to me to be advisable to sit with folded hands, even in the presence of those paralyses, particularly facial paralysis, that often get well spontaneously. I have often enough observed a prolongation of the paralysis, especially in cases of facial paralysis designated rheumatic and treated expectantly. I have had come under treatment cases of paralysis of this character after six months’ duration, during which a normal termination was vainly awaited, and in which it would, at any rate, have been better to have instituted a rational plan of treatment immediately after the onset of the palsy. I would likewise point out that in some cases of paralysis—I have in mind, for instance, a case of paralysis of the external popliteal nerve in consequence of alcoholic intoxication—the removal of the causative injurious factor should not be considered all- sufficient treatment. How often have I observed such cases ofNEURITIS AND POLYNEURITIS 165 paralysis in persons who had long been removed from the sphere of influence in which the lesion developed ! The laming persisted, how- ever, and only after prolonged and active treatment was it possible to restore motion. The same statement is applicable to paralysis due to lead and like causes. I wish by the foregoing to imply that, in addi- tion to removing the causal factor, causal treatment should be instituted as early as possible, even in cases in which experience has shown that spontaneous recovery may be expected. Improvement of the circulation in the paralyzed part and throughout the entire body, and stimulation of metabolism and of the excretions, are essential factors to be kept in mind in the treatment. Procedures with alternating temperature of various kinds are the measures that will lead to the desired end under these circumstances. Shower-baths of alternating tempera- ture, wet packs of from forty-five minutes’ to an hour’s duration, followed by a cold general invigorating applica- tion, a steam cabinet bath of from eight to ten or fifteen minutes’ duration, succeeded by a cold ablution or rub, and, in addition, stimulating compresses, will in most cases yield good results/provided that irremediable alterations in the structure of the nerves have not already taken place. Even in neglected cases success frequently attends these procedures. In the case of a man in whom facial paralysis developed after mercurial poisoning of two years’ standing, I obtained an unexpectedly favorable result by means of steam cabinet baths and subsequent rubbing. Paralysis following infectious diseases, particularly in the sequence of typhoid fever and diphtheria, calls for invigorating treatment. Under such circumstances I have obtained the most gratifying results from moderately cool half-baths—22° to 20° C. (71.6° to 68° F.) or from 20° to 180 C. (say, 68° to 64° F.)—with vigorous affusion of from two to five minutes’ duration. NEURITIS AND POLYNEURITIS Exposure to cold, infection, and intoxication play an important role also in the etiology of neuritis and polyneuritis. In addition, anemia, chlorosis, diabetes, dyscrasias, and marasmus have fre- quently been observed as causative factors. ‘ Not too active treat- ment ’ is the rule laid down by writers in this connection also. Al- though my experience is based on only a small number of cases,— neither isolated neuritis nor polyneuritis is a disease that daily comes under observation,—I can nevertheless state that careful hydriatric methods—that is, treatment adapted to the needs of the individual patient—possess great advantages. Above all things, the object under such circumstances should beDISEASES OF THE NERVOUS SYSTEM 166 the institution, so far as possible, of causal treatment—namely, elimination of organic and inorganic toxic substances, and invig- oration of the entire organism. In addition, improvement in the local nutrition of the nerve-trunks should be aimed at. Tender- ness and impairment of motility will, it is true, in many cases, compel the adoption of the opposite course; that is, attention to the local dis- order. Nevertheless, by means of proper treatment it will soon be possible to fulfil the indications furnished by the etiology. Mode of Treatment.—Enveloping the affected extremities or parts of the body in circular compresses is often the sole, as well as the most efficient, mode of treatment that can be employed under such circumstances. Such compresses meet all of the indi- cations present. The relief of tenderness is, in particular, one of the first beneficent results of this mode of treatment. At the same time the circulation is improved and the nutrition is heightened; so that those indications also are fulfilled that arise from the local nutritive disturbance, and from the deficient nutrition within the dis- tribution of the affected nerves. Pospischil further urges the employment of the cool spinal coil, and the cool precordial coil, by means of which the circulation and the nutrition in general, and especially in the extremities, are improved, and, particularly in cases of polyneuritis, the occurrence of bed-sores will be prevented. So soon as the tenderness has diminished, and this early takes place in consequence of the anodyne effect of the stimulating com- presses, measures should be directed to the fulfilment of the causal indication. This is met by wet packs. I need not here repeat the factors upon which the efficacy of these measures depends. Only with reference to the method of application will a few words be added. Pospischil also maintains the view that a partial pack— that is, one up to the axilla—is at first more suitable than the full wet pack, and that only after some time should the entire body be in- cluded. The indication exists, further, to continue the procedure at first for an hour, and later, in accordance with the conditions present in the individual case, for a longer period; that is, until dia- phoresis occurs. After the pack, naturally, a cold, stimulating application should be made to the entire surface of the body. Polyneuritis attending diabetes or gout will require treatment directed to the underlying disorder. Progressive chronic polyneuritis of chil- dren is likewise to be treated in accordance with the principles laid down. SPASMODIC TIC I have observed a number of cases of spasmodic tic m which re- covery took place within a short time, and others that persisted inTABES DORSALIS 167 spite of treatment continued for months or even years. Both groups of cases included patients some of whom came under treatment with the disease of recent development, while in others it had existed for years. In view of the circumstance that organic disease at any point in the peripheral or central course of the facial nerve may give rise to twitching and to spastic conditions in the face, and that, further, ane- mia, emotional disturbances, hysterical conditions, exhaustion-neuroses, and organic disease of the brain, may cause facial spasm, the foregoing statement will be readily comprehended. If a peripheral sensory irri- tation be found, this of course should be removed—so far as it is pos- sible. In the presence of organic cerebral lesions all treatment will be fruitless. Under other circumstances it will be necessary to employ invigorating measures of the most varied form, yet in accord- ance* with the conditions present. The best results are obtained from the employment of cold shower-baths of brief duration. I saw a case with Fodor in which the affection had been present for two years, and in which recovery occurred after five days’ treat- ment with brief cold shower-baths. On the other hand, I have had under observation for three years a woman, thirty-three years old, suf- fering from hysteria, in whom the entire range of invigorating meas- ures—shower-baths, half-baths, frictions, the thermic and mechanical stimulation being varied in degree, with or without preceding supply and accumulation of heat—were employed, and in which the intensity of the tic was lessened only at times. DISEASES OF THE SPINAL CORD TABES DORSALIS The most efficient thermic treatment of tabes dorsalis consists in the employment of alternating hot and cold applications with only a slight difference of temperature, combined with mechanical manipu- lations of moderate force. We employ almost exclusively tepid or moderately cool half-baths,—30° to 28° C. (say, 86° to 82° F.),—of from four to eight minutes’ duration, with friction of not too vigorous a character, and affusions from not too great a height. The most favorable results conceivable have been obtained from these procedures, which produce a surprisingly good effect even in the case of patients who are considered incurable. Quite frequently paralysis of the bladder and rectum is observed to disappear under the influence of this simple measure. If, however, only that degree of success is brought about that the morbid process remains stationary for years, and that aggravation does not take place, this form of treat- ment will have accomplished enough to justify it.168 DISEASES OF THE NERVOUS SYSTEM Careful attention should be given to the state of reaction. The patient should become warm after the application. Should this not be the case, then the thermic stimulation must be modified. The subjective sensation of the patient is a sufficient indication of appro- priate choice of the temperature and the duration of the application. If there is a feeling of increased strength, then the bath has been correctly applied ; but if there is a feeling of increased languor and debility, and if the patient is slow to warm up, a corresponding modification in the temperature of the water or in the duration of the bath should be made. With reference to the number of half-baths to be given, it should further be pointed out that two such procedures may be practised daily. For the treatment of the gastric crises and the lancinating pains various measures have been recommended. Not much of an encouraging nature, however, is to be looked for from any of them. Compresses of alternating temperature, stimulating compresses, hot baths,—320 C. (89.6° F.),—and sitzbaths of alternating temperature may, nevertheless, be tried. Some- times the lancinating pains may be mitigated temporarily also by means of the cold spinal coil. The method of treatment here outlined is applicable also to other chronic diseases of the spinal cord—amyo- trophic lateral sclerosis, progressive muscular atrophy, spastic tabes, etc. Acute and Chronic Myelitis With reference to chronic myelitis, the same principles are appli- cable that have been laid down for the forms of disease just discussed. Only with reference to acute myelitis must some modifications in statement be made on account of the inflammatory character of this disease. In the first place, attention should be called to a mistake often observed. Hot baths and diaphoresis are frequently employed, and for a considerable length of time. Such measures are not alone useless, but even injurious. A patient suffering from myelitis needs above all things rest, and although, by reason of advances in technic, it is possible to administer applications of steam with the patient in bed, they are distinctly counterindicated; not only on account of the neces- sary manipulations attending them, but still more on account of the inflammatory hyperemia, which such procedures as cause elevation of the blood-temperature for a considerable time are calculated only to increase. At the beginning of the disease, and until a distinct standstill in the development of the morbid process has occurred, the only rational procedure is the application of the trunk com- press with the cold water coil to the spine. The patient may lie for hours, and even days, upon this tubular apparatus. Care should be taken to secure constant renewal of the water, in order thatCEREBRAL ANEMIA 169 the desired temperature (from 12° to 140 C.—-’53.6° to 57.2° F.) be maintained. By this means the best service will be rendered the patient The acute inflammatory process will subside or reach its acme. This procedure will, in addition, have a marked prophylactic influence with reference to certain symptoms, particularly the devel- opment of bed-sores. Only after the acute inflammatory symptoms have subsided, when a distinct standstill has taken place, may resort be had to half-baths. With reference to the mode of application and the technic, the same statement is applicable as was made in this connection in the foregoing section. DISEASES OF THE BRAIN AND ITS MEMBRANES The therapeutic success that can in general be obtained in cerebral affections is quite small. The more noteworthy, therefore, are the re- ports by a number of writers of the results of the hydriatric manage- ment of certain diseases of the brain and its membranes. With refer- ence to the treatment of cerebrospinal meningitis, Aufrecht 1 and others report excellent results from very hot baths—400 C. (104° F.)—of ten minutes’ duration. The mode of action of these baths is not quite clear. Derivation of the blood from the brain and its meninges to the skin, increased secretion of sweat, and thereby elimination of toxins, no doubt play an important part. The baths are said, further, to exert an invigorating influence upon the action of the heart, and to exhibit an anodyne and sedative effect. In addition to the baths, provision should in any event be made for the application of a cold head compress, and cold applications to the nape of the neck, and the vertebral column. Cooling apparatus of all kinds play an important part in the treat- ment of the disorders under consideration. In acute cerebral leptomeningitis they are almost the sole remedial measures at our command. Recovery, it is true, will not be brought about. The application of cold to the head is useful in relieving irritation of the meninges, in which the condition present is dependent upon cir- culatory disorders, or transitory intoxication, or reflex irritation. Cerebral anemia is not an independent disease, but only a symp- tom of a number of diseases of varying character; nevertheless it occupies a far more prominent position from the therapeutic stand- point than a number of organic diseases of the brain, because it not rarely represents a prodromal stage of the latter, and yields to treat- 1 ‘ ‘ Therapeutische Monatshefte,” 1894, No. 8.170 DISEASES OF THE JOINTS AND MUSCLES ment, while the organic disease of the brain, developing out of the anemia, is often incurable. The acute attack of cerebral anemia re- quires generous sprinkling of the face and the chest with cold water. In addition, the disease underlying the anemia should be treated. Cerebral hyperemia, also, is only a symptom, but one that must receive consideration as the cause of many subjective manifestations and as the point of origin of serious diseases. Under such circum- stances all those measures are indicated that were mentioned in the discussion of sleeplessness. Cerebral hemorrhage, both during the apoplectic seizure, and immediately thereafter, is treated in the same way as cerebral hyperemia—namely, with the ice cap or cold coil, the trunk compress, sural compresses, and the like. The treatment of the paralysis is begun after all irritative mani- festations have subsided, and consists in partial ablutions and tepid half-baths (30° to 28° C.—86° to 82.4° F.). Good re- sults are often obtained from these measures. The treatment of em- bolism varies with the cause. The treatment of the causative disease comprehends also the prophylaxis of hemorrhage and embolism. In the treatment of psychoses, hydriatric procedures can often be em- ployed with the greatest utility. The sleeplessness, the states of fear, the maniacal excitement, the sexual excitement, the melancholia, indicate the employment of hydriatric measures; those appropriate in the various special conditions have already been discussed. DISEASES OF THE JOINTS AND MUSCLES With regard to the treatment of acute rheumatic polyarthritis, as well as rheumatoid arthritis, and arthritis urica (gout), the statements in previous sections may be referred to. CHRONIC ARTICULAR RHEUMATISM At this point some remarks may be made with reference to the simple form of chronic rheumatic arthritis, with or without villous formation; for although the pathogenesis is different from that of de- forming arthritis, the treatment of this form of inflammation is quite the same as that of the latter disease. In this connection also general measures, particularly those stimulating the functions of the skin and the kidneys, are to be taken into consideration; especially wet packs, steam baths in various forms and of varying duration, fol-CHRONIC ARTICULAR RHEUMATISM I7I lowed by a cold rub; sheet baths; half-baths at a low temperature, and of three to five minutes’ duration; shower-baths of alternating temperature and of varying duration, in accordance with the conditions present in the individual case. Likewise local stimulating compresses, particularly circular compresses, are employed. The latter are changed only every twelve or even twenty-four hours, and bring about marked improvement, inasmuch as they stimulate the local circulation and thereby absorption of the exudates, and greatly mitigate the severity of the pain. Max Schuller, of Berlin, speaks favorably of this method in the treatment of chronic rheumatic arthritis, and states that with its aid a mitigation of the pain and improvement in mobility can be brought about. Actual recovery occurs only when thickening of the capsule alone, without demonstrable villous formation, has taken place, or when the villi are still relatively small and not too numerous. Dense capsular thickening, as well as moderate villous formation, may undergo complete absorption. If the villi are more marked and more numerous, then the measures mentioned will have only a transitory influence, but in any event they relieve pain and render movement easier. Some cases may by this means be main- tained for years in quite a tolerable condition. In diseases that exhibit a tendency to ankylosis, and in which capsular shrinking exists, mobility may be restored by means of wet packs and Scotch douches. The hot-air apparatus recom- mended by Lindemann and Tallerman, the mode of application and uses of which are discussed elsewhere (see pages 126 and 272), should also be mentioned. Of great importance is the maintenance or the restoration of muscular activity. Especially in the disease under consideration should the greatest attention be given to atrophy of the muscles. In affections involving single joints, in cases of mon- arthritis, muscular atrophy is a marked feature. Under such cir- cumstances the articular disease, as well as the muscular atrophy, may be treated by simple procedures, and especially with the Scotch douche. The powerful thermic and mechanical stimu- lation of this measure, the ‘thermic contrast’ effect, induces a better state of nutrition in the tissues, and, as a matter of fact, increased functional capacity is exhibited after their employment, as may be illustrated by dynamometric tests. The increased functional activity must, however, be maintained and increased, and accordingly the pro- cedures must be repeated frequently. The application to the atrophied or atrophying muscles of a simple cold shower-bath, followed by a movable cold fan douche, both of exceedingly short duration, has an excellent effect in this condition. I may recall the experiments of Vinay and Maggiora, who demonstrated by ergogra- phic means the usefulness of such measures. The wet packs are172 DISEASES OF THE JOINTS AND MUSCLES further lauded also, among Russian writers, by Stellmachovich and Tscherniavsky. These applications are doubly efficacious, as they influence favorably the articular disorder, and distinctly increase the muscular vigor. Massage is of great utility; it should, of course, be employed without giving pain, and only after the electro- cutaneous sensibility has been diminished by the method of Dros- dorff. A faradic current is passed through the joint for a period of from ten to fifteen minutes. This is followed by such- marked lessen- ing of the tenderness in the joints that massage can be employed. ACUTE AND CHRONIC MUSCULAR RHEUMATISM Of diseases of the.muscles, the ‘rheumatic’ affections, acute muscular rheumatism, involving certain muscles or groups of mus- cles, should be mentioned. The muscles of the neck and of the lum- bar region are specially predisposed to this disease, which accordingly appears most frequently in the form of lumbago, and of rheumatic torticollis. Nevertheless not all patients comprehended under this designation suffer from rheumatism. Strain and laceration of muscle-fibrils, and muscular spasm, are frequently confounded with muscular rheumatism. Fortunately, they disappear under the same procedures as the true rheumatic diseases. With reference to the mode of origin or pathogenesis of these affections, which is practically the same as that of neuralgia, the same procedures should be employed that we have seen to be success- ful in the treatment of the latter. The underlying principle of the treatment is comprised in the formula, thermic contrasts. Pro- cedures with alternating temperature in varying form, as has been repeatedly stated, are often attended with incredibly rapid success. The earlier the treatment is instituted, the more rapidly does recovery take place, and in cases of recent development, the symptoms may often be observed to disappear after a few applications. In chronic muscular rheumatism, procedures with alterna- ting temperature, which of course must be adapted to the indi- cations in the individual case, will likewise yield good results.CHAPTER IV DISEASES OF THE RESPIRATORY ORGANS Pulmonary Tuberculosis. Bronchitis. Pneumonia. Pleurisy. PULMONARY TUBERCULOSIS Hydrotherapy is capable of effecting much good at nearly all stages of pulmonary tuberculosis. It is of great prophylactic im- portance when a predisposition to tuberculosis exists ; it may do excellent service in the treatment of the developing disease ; and it sometimes brings about remarkable results in cases of the developed disease, even in those of florid tuberculosis. Suppression of the fever and of the night-sweats, increase in body-weight, diminution in cough and in expectoration, subsidence of the subjective symptoms, improve- ment in the local condition, are among the constant results of rationally directed hydrotherapy. Prophylaxis The question to be answered first is, What indications are to be met by hydrotherapy in the prophylaxis of pulmonary tuberculosis, and what remedies are available for this purpose? It is a fact, ad- mitted by all writers at the present day, that the tubercle bacillus alone is not capable of causing tuberculosis, but that, in addition, there must be either a congenital or an acquired predisposition. The ques- tion as to what is really to be comprehended in predisposition is difficult of answer. If it be described as an enfeeblement of the vital processes, reduced activity of the organic functions, diminished resist- ance and so forth, little information is thereby imparted. It is not known upon what the enfeeblement of the vital processes depends, and we must be satisfied with the knowledge that certain indefinable alterations in circulatory and innervational conditions, in metabolism, in the cells and tissues, and in the state of the blood, exist. It is admitted by all writers that in cases of tuberculosis, and in individuals predisposed to this disease, there is a specially marked increase of reflex irritability in the peripheral terminations of the sensory nerves. It is further known that all persons included in these groups exhibit a blood-state resembling that of anemia or chlorosis. The reduction in the number of red blood-corpuscles, and in the percentage of hemo- 173174 DISEASES OF THE RESPIRATORY ORGANS globin is a constant feature in individuals predisposed to pulmonary tuberculosis. Likewise, lowered blood pressure and accelerated action of the heart are among the manifestations almost constantly observed. All of these factors must be taken into consideration in the institution of those prophylactic measures that occupy the first place in the treat- ment of pulmonary tuberculosis, and which may be comprehensively included under the term hardening. The purposes to be accom- plished by this process are clearly indicated—namely, improve- ment in innervation and circulation, invigoration of the heart, and improvement in hemogenesis and in respira- tion; and it should always be a fundamental principle to avoid every unnecessary loss of heat. The hardening process thus corresponds with invigoration, and powerful thermic and mechanical measures and those of short duration are therefore best adapted for the purpose. This process should be begun in earliest youth. It is best, in the case of infants and very young children, to proceed as follows: At the end of the first week cool water is added to the usual daily cleansing bath, and it is gradually reduced to a tempera- ture of 30° C. (86° F.). At the conclusion of the bath, cooler water, at a temperature of about 240 C. (750 F.), is poured upon the trunk of the child. This is followed by vigorous fric- tion with a dry towel. The bath should not be colder during the first year, although the temperature of the water employed for the affusion should gradually be lowered. Toward the end of the period of. lactation a temperature of 20° C. (68° F.) may be reached. From the second year on, the affusion alone will suffice. This should be practised daily in the morning. The temperature of the water need not now be accurately determined. During the winter, also, water that has stood for several hours in a closed room will be suitable. Subsequently, still colder water should be employed. A point that has already been mentioned, and that cannot be too strongly emphasized in this connection, is never to abstract heat. The bath or the affusion should be employed as the patient gets out of the warm bed, and should never be too protracted. It is to be remembered that the more vigorous and the shorter the thermic and mechanical stimulation, the more pronounced will be the reaction, and with slight loss of heat. If the person to be treated is a delicate adult, the cold rub, immersion baths, short cold vigorous shower-baths, and also partial rubs may be employed for the purpose of hardening. Some writers recommend after previous ablution or cold rub that the patient return to bed, in order to await restoration of the heat of the body. I do not consider this advantageous in general, although it may be indicated in the case of anemic individuals with impaired nutrition, or for those in whom the treatment is begun at an advanced age.PULMONARY TUBERCULOSIS 175 Treatment of Pulmonary Tuberculosis We may now take up the treatment of fully developed pulmonary tuberculosis. The treatment of tuberculosis must be a potentized hygiene. The most favorable conditions for recovery will not be provided by any single curative factor, but by an intelligent combina- tion of all physical methods of treatment. Let emphasis be given by repetition : All physical remedial measures and methods of treatment must be drawn upon in the treatment of pulmonary tuberculosis. Then, and not till then, will the physician have performed his whole duty in the management of his tuberculous patients. The question has been asked repeatedly, whether the indications from the bacterial standpoint will be fulfilled by hydriatric measures. We can answer this question emphatically in the affirma- tive. Numerous investigators have made the curative process in the lungs dependent upon the active circulation of this organ, on the assumption that the active circulation of normal blood constitutes the best bactericidal agent. No form of treatment is capable of inducing active hyperemia, an increased flow of blood to and from the diseased parts, in such a degree as is hydrotherapy. One of the essential effects of this method is the strengthening of the circulation, the removal of the circulatory weakness in the lungs, of the obstruc- tion in the lesser circulation, and the improvement in the flow of blood through the lungs. The simplest, and at the same time the most efficient measure for the attainment of this object is the use of the crossbinder. By means of this the best circulatory conditions in the lungs are established. The employment of the crossbinder for months brings about conditions that are inhibitory to the develop- ment of the bacilli, and induces reactive inflammation, limitation, destruction, elimination, and also absorption of the diseased tissues. A second and highly important measure for improving the circulation and for fulfilling all of the requirements present is the cold pre cor- dial coil. A strengthening of the action of the heart, an increase in vascular tone, an induction of active hyperemia in the diseased organs, will be certainly brought about by means of this application. Finally, general invigorating procedures involving the entire surface of the body will, in addition to the effects enumerated, render possible the invigoration of the organism as a whole. Certain individual symptoms may likewise be successfully attacked. Anorexia, upon which depends essentially the unfavorable out- come of the disease, may be combated by means of an abdom- inal binder, containing a rubber coil heated by water at a temperature of 40° C. (104° F.). Cough and difficult expectoration are best relieved by means of the crossbinder.176 DISEASES OF THE RESPIRATORY ORGANS Pulmonary hemorrhage is most efficaciously treated by means of small ice-bags placed in the supraclavicular fossa over the thin- nest portion of the crossbinder, and covered with the dry portion of the latter. In this condition, also, the precordial coil renders good service. If, however, the pulmonary hemorrhage is of a passive character, as occurs frequently in cases of tuberculosis, invigorating measures are indicated. Fever.—Hydrotherapy subserves an important function in the treatment of the fever. The requirements of any form of therapy in this condition are quite clearly defined ; they are evident from the origin of the fever. Relief from heat-retention, prevention of excessive temperature, checking of sweating, are the indications under such circumstances, and these are best fulfilled by means of partial ablutions or the cold rub. In this connection hydrotherapy is far superior to all other methods of treatment. I would summarize the plan of treatment to be pursued in a case of pulmonary tuberculosis, as follows: In the morning imme- diately upon getting out of bed, a cold rub—io° to 120 C. (50° to 53.6° F.)—or a partial ablution with water of the same tempera- ture, is practised. In the case of febrile, bedridden patients, this should be followed by the application of a crossbinder in which, in the course of the morning, the precordial coil is introduced for from half an hour to an hour. A febrile patient should lie down for the necessary period of time in the course of the morning, for the purpose of applying the precordial coil. In the afternoon the appli- cation of the precordial coil should be repeated, and on its' removal, a very cold shower-bath—1 o°toi2°C. (50° to 53.6° F.)—of a quarter of a minute’s duration be taken. Before going to bed a partial ablution or-a cold rub should be given as in the morning, and this should be followed by the application of a crossbinder. Individual symptoms should be treated in accord- ance with the principles previously stated. Aberg,1 a distinguished Swiss physician, recommends a special method which is readily carried out, is really serviceable, and has also been highly praised by Winternitz. Three procedures repre- sent, as it were, three different stages or grades of the treatment : I. Sponging the neck, back, face, and chest, at first for only a short time and superficially, with an expressed sponge, followed immediately by thorough drying of the parts treated. At the begin- ning this is practised only in the morning, but later, both morning and evening, the sponge being less thoroughly expressed. Reaction is 1 “ Reichs- Medicinal-Anzeiger,” 1895.BRONCHITIS : PNEUMONIA 177 permitted to take place in bed or in the open air. The temperature of the water should be o° C. (3 2° F.). 2. As a measure of the second degree Aberg applies affusions to the head, neck, back, face, and chest, from a watering-pot. The application is repeated, and the subsequent treatment is the same as with the measure of the first degree. The temperature of the water is also o° C. (32° F.). 3. The third degree of Aberg is the full bath of but momentary duration, the entire body being immersed, including the head. Thorough drying is practised as after the other procedures. The temperature of the water is from 70 to 12° C. (44.6° to 53-6° F.). Aberg presents his method as the outcome of twenty-two years’ experience, and gives the records of cases as an evidence of the ex- tremely favorable results of his plan. BRONCHITIS The treatment of acute, chronic, and capillary bronchitis is based upon the same principles that have already been laid down. At this place especial attention need be directed only to certain factors. It should first of all be pointed out that acute bronchitis can be and is successfully aborted by means of artificially induced diaphoresis. For this purpose the wet pack of a duration of at least one and a half to two hours is most serviceable. This is followed by fric- tion. Especial consideration should be given to acute bronchitis in the aged, particular attention being directed to the heart. Further, the fever should be counteracted as far as possible. The p re cor- dial coil, the crossbinder, partial ablution, with vigorous thermic and mechanical stimulation, frequently repeated, three or four times daily, are the most suitable measures. The trunk com- press may, if necessary, be resorted to in the treatment of the dis- ease. The same considerations are applicable also to the treatment of emphysema. Capillary bronchitis is likewise treated by means of vigorous thermic stimulation. In this connection I would refer to the treat- ment of pneumonia in childhood (p. 139). In the treatment of chronic bronchitis the cold rub and the crossbinder play the most important part. PNEUMONIA With regard to the treatment of pneumonia reference rfiay be made to what has already been stated. In that connection pneumonia in ix—12i;8 DISEASES OF THE RESPIRATORY ORGANS childhood especially was discussed, but from such standpoints as are applicable as well to the treatment of pneumonia in adults. In adults also two factors must be taken into consideration : the fever and the action of the heart. With regard to the treatment of these symp- toms reference may be made to the sections dealing with the infectious diseases in general. At this place I would direct especial attention also to the circulatory conditions in the aged. Here a double object is to be fulfilled—namely, the prevention of cardiac weakness, and correction of such weakness of the heart as has already developed. In obese patients, too, especial consideration should be given to the heart. In both instances temperatures of not too low a degree, with vigorous mechanical stimulation, are indicated. It is best to begin with partial ablutions, and then to pass onto moderately cool half-baths — 2 5 ° to 230 or 22° C. (77 0 to 73.40 or 71.6° F.). When the patients are greatly debilitated, colder water should be employed, and the duration of the bath should be shortened; or the bath may be given at a higher temperature, at about 26° C. (78.8° F.), but with a copious affusion of cold water. The employment of the precordial coil plays an important part here also. “ One who undertakes the treatment of pneumonia with cold baths will do well to administer wine as a stimulant for the heart before and after the bath.” This advice of Jiirgensen’s can be fully indorsed. If cardiac weakness develop unexpectedly, tepid baths at the tem- perature of the body, with cold affusions, render good service in addition to the usual subcutaneous injections of medicinal substances. In drunkards, also, especial attention should be given to the heart. In America especially, following the suggestion of F. P. Henry, of Philadelphia, saline infusions are extensively used in cases of acute lobar pneumonia (see p. 294). PLEURISY The treatment of pleurisy is one of the most thoroughly investi- gated chapters in therapeutics. It is therefore the more remarkable that in few books can even a single word be found concerning the hydriatric treatment of this disease. Nevertheless hydrotherapy is most valuable in this connection. In dry pleurisy the indication is the relief of the principal symp- tom, the stabbing pain upon the affected side of the chest, the resulting dyspnea, and dry cough. Under these circumstances a crossbinder containing a rubber coil, through which cold water is passed, renders remarkable service. The reduction in tem- perature, as has been shown by thermometric observations, extends to a sufficient depth to exert an antiphlogistic effect upon the disease-PLEURISY 179 focus. An effect of this method of treatment that should not be underestimated is, further, the relief of pain. The patient becomes conscious of great amelioration immediately after the application. The usefulness of the cold water coil is further increased by the fact that the changing of compresses—so annoying and painful, when frequent— is omitted for a considerable time, this being done at most twice daily for the purpose of making other applications or of changing the cloths used for the compresses. Wet packs of one or two hours’ duration, followed by friction, or a cool half-bath (2 2 0 to 2o0 C.—71.6° to 68° F.), are further successfully employed in the treat- ment of dry pleurisy. They exert a causal influence when the disease is dependent upon exposure to cold. Often the process subsides after a single application. In the after-treatment of simple dry pleurisy it is advisable to practise daily in the morning a cold rub in a sheet dipped in very cold water—io° to 120 C. (30° to 33.6° F.)—and well wrung out. The cold rub fulfils the purpose of adequate respiratory gym- nastics, and facilitates the correction or the prevention of extensive adhesions. In the treatment of exudative pleurisy two phases must be distinguished. In the first stage antiphlogistic and anodyne measures occupy the first place, and those to be employed are naturally those that are used in the treatment of dry pleurisy. The control of the fever generally plays a subordinate role, inasmuch as the elevation of temperature is usually moderate. The wet packs, which have already been spoken of, may, however, be employed here, in case the fever is excessively high, in the form of alternating packs, for the moderation of the fever, and then as a pack of long duration, as in the treatment of dry pleurisy. I11 the second phase of the treatment the principal object is to induce absorption of the exudate. Naturally, the discussion will apply only to serous exudates. Absorption can be hastened by in- creasing elimination. All measures that tend to increase diaphoresis and diuresis will lead to the desired result. Steam cabinet baths, or hot-air baths of ten to fifteen minutes’ duration, fol- lowed by stimulating procedures, or wet packs of long dura- tion, followed by similar measures, will bring about rapid absorption of the exudate. At the same time these measures will bring about a general improvement, and this is a matter of considerable importance in the presence of pleuritic exudates, which, in the majority of cases, develop upon a dyscrasic basis ; or, if of long standing, cause a reduction in the resistance, and, as a result thereof, tuberculous disease of the lungs. A crossbinder changed every three hou rs supplements the treat- ment directed to the absorption of the exudate. An admirable method of stimulating sluggish absorption has been proposed by Fodor, of180 DISEASES OF THE RESPIRATORY ORGANS Vienna. This consists in the application of a vigorous horizontal douche, with a divided or a concentrated stream, to the affected half of the chest for a period of several seconds. The procedure is believed to act as a sort of vigorous concussion in a manner similar to the method of vibrations practised by Swedish mechanotherapeutists for the purpose of hastening absorption of deeply situated exudates. The application of the local douche is made after a half-bath or after a rub. In the acute stage of pleurisy, and in the presence of exudates occupying the entire pleural cavity and giving rise to symptoms of suffocation, vigorous procedures will naturally be avoided, and those sorbefacient measures resorted to that are applicable with the patient in a state of rest—such as packs and compresses. Subsequently, if necessary, the more radical remedial measures described may gradu- ally be resorted to. If the pulse becomes frequent and small, an attempt should at once be made to avert the threatened cardiac weak- ness. The precordial coil is the cardinal remedy.CHAPTER V DISEASES OF THE CIRCULATORY APPARATUS Acute and Chronic Endocarditis. Treatment of Cardiac Insufficiency. Pericarditis. Arteriosclerosis. Hemorrhoids. ACUTE AND CHRONIC ENDOCARDITIS In accordance with the course hitherto pursued, we shall first take up for consideration here the indications to be fulfilled, and the man- ner in which hydrotherapy meets the demands. Therapeutic Indications.—The general indication in chronic car- diac disease is to favor the development of compensatory hyper- trophy, which may require as special objects : (a) to stimulate the heart to increased activity, (h) to maintain the functional activity of the heart for so long a time as possible, or (y) to overcome the abnormal resistance in any given portion of the vascular system. Stimulation.—As shown by the investigations recited in a pre- vious chapter, there is not the slightest doubt that it is possible by means of hydriatric measures to stimulate the heart to increased activity—to bring about adequate and vigorous contractions and thereby a strengthening of the heart muscle with the development of compensatory hypertrophy. For this purpose we make use both of local measures—that is, applications to the precordium—and of general applications involving the entire surface of the body. Winternitz,1 Pospischil,2 Silva,3 and many others have shown by means of sphygmographic and sphygmomanometric studies how greatly the local application of cold stimulates the action of the heart and strengthens the contractions. The invigoration of the heart muscle brought about through such measures is in many cases so persistent that the effect continues for a long time after the application has been withdrawn. General measures acting on the periphery of the entire body also exert a favorable effect in this connection. Every thermic stimulation affecting the surface of the body induces at first acceleration and invigoration of the action of the 1 “Blatter f. klin. Hydro therapie,” 1891, Nos. 6 and 7. 2 Ibid., 1894, No. 12 ; 1895, No. 4. 3 “ Riforma Medica,” 1886, p. 253. 181182 DISEASES OF THE CIRCULATORY APPARATUS heart, acting upon the heart muscle in the manner of gymnastic exercises. Without doubt a great danger resides in strain of the diseased heart and the resulting dilatation of its cavities. This danger must be the greater, the more pronounced is the resistance to be overcome by the heart. Reduction of the Resistance.—The heart may become in- capacitated in consequence of disease of the myocardium (absolute incapacity) ; or it may become incapacitated with reference to the existing resistance.(relative incapacity). In both instances treat- ment is capable of accomplishing much good by removing or lessening abnormal resistance. Hydriatric measures cause especially, in sequence to temporary contraction, an active dilatation of the peripheral vessels—that is, dilatation of the vessels with preservation of their tone ; provided, of course, that appropriate thermic and mechanical stimuli are employed. In this active dilatation of the cutaneous ves- sels resides the great value of our treatment. It can readily be under- stood that by means of a diminution of the resistance in a vascular system of such great extent and importance as that of the skin, the heart is relieved of much of its burden ; but this is not the sole benefit afforded. The peripheral vessels are stimulated by the thermic irrita- tion to an independent activity which assists in the propulsion of the blood, and by means of which the heart is additionally relieved. In some instances, however, a counterindication to the employ- ment of measures involving the entire surface of the body arises from an effect already mentioned—the primary contraction of the peri- pheral vessels. The cold rub, for instance, induces primarily power- ful contraction of all of the cutaneous vessels affected. It increases, thereby, although only for a short time, the resistance in the peripheral circulation, which, in certain cases, is carefully to be avoided. Increase of Nutrition.—A further favorable effect of hydriatric measures is the prolongation of the nutritional rest-intervals of the heart. The greater the interval between two systoles, the more vigorous will each be. Therefore the greatest importance has always been attached, in the treatment of diseases of the heart, to measures that tend to quiet the cardiac activity, and to lessen the frequency of contractions. The cold precordial coil, which in many other respects is comparable to digitalis in action, induces, like digitalis, slowing of the pulse, by prolongation of the diastole—the anabolic rest-interval—of the heart, and thereby a more vigorous systole with increased pressure in the arterial system. The effect of hydriatric procedures in deepening respiration is of great importance ; by this means a more rapid movement to the right heart, of the blood stagnating in the veins is inaugurated. The deep- ened breathing provides room for the entrance of blood into the lungs,DIAPHORETIC PROCEDURES I 8 3 favors better absorption of oxygen, and facilitates the discharge of blood from the lungs back to the left heart. Dropsy.—Next to dyspnea, the most serious consequence of high degrees of general circulatory disturbance is dropsy, the lessening or the removal of which is accordingly one of the most important objects of treatment. The use of the precordial coil is calculated to fulfil this indication. In this connection also the precordial coil exhibits an action analogous to digitalis. The increased pressure in the aortic system induced thereby gives rise also to a change in secretion. It increases the latter, stimulates powerfully the absorption of transudates, and in- creases their elimination. For the attainment of this object those measures, further, are available that prepare the way for increased elimination of water through the skin. As has already been pointed out, the insensible cutaneous transpiration may be doubled or more greatly increased by simple friction with a dry cloth. If the mechanical stimulation be combined with thermic stimulation, the elimination of water will be still further increased. Partial ablutions completely fulfil this object; as do also wet packs to individual parts of the body, particularly the lower extremities. Circular com- presses, about dependent parts, likewise increase the perspiration, and contribute materially to the removal of edema. A favorite diaphoretic procedure consists in stimulating the secre- tion of sweat in the steam bath. Before the employment of the steam cabinet bath is decided upon, it is, however, advisable to bear in mind that the secondary effects of the steam bath consist in elevation of the body-temperature and acceleration of the action of the heart; effects that in the conditions under discussion are not only not desired, but which, on the contrary, must be counteracted. The only good effects of such procedures are the increase in transpiration and the stimu- lation of metabolism. We know how injurious, in acute febrile disease, is the influence exerted by the elevation of temperature upon the heart’s action and the vascular tone, and for this reason great caution is advisable in the employment of the steam bath. By means of the Winternitz steam tub bath the possibility is afforded of stimulating the secretion of sweat, while keeping in view the factors mentioned. The action of the heat is limited to the lower half of the body, or below the costal arch, inasmuch as the blanket is not closed about the neck, but beneath the arms. We combine with the steam bath prepared in this manner the application of the cool pre- cordial coil, and in this way have provided a measure which will exert a useful effect in two directions with reference to the absorp- tion of transudates and of edema, but in which the injurious effects are in part greatly diminished by restricting the application to the lower half of the body, and in part effectually neutralized by the simultaneous cooling application to the heart.184 DISEASES OF THE CIRCULATORY APPARATUS We have thus in the practice of hydrotherapy means by which to fulfil all of the indications presented by chronic cardiac disease. In- vigoration of the action of the heart, now. with coincident retardation, now with acceleration of its rate ; enlargement of the volume of the pulse-wave; heightening of the tension and better filling of the arteries; lessening of the irregularity of heart or pulse ; reduction or increase in the circulatory resistance ; deepening of the respiration ; improvement in secretion and in the elimination of exudates, are the requirements at different times ; and these, as has been shown, we are able to meet by hydriatric procedures. The ultimate object of our treat- ment is the attainment of increased power with diminished work; and although it is also possible to attain this end by means of drug- giving, we must for many reasons give the preference to hydrotherapy. Digitalis and Hydrotherapy.—A comparison may be made be- tween the cardiac medicament most commonly employed—digitalis— and hydriatric methods of treatment. It should be stated here that the hydrotherapeutist cannot dispense with the use of digitalis, and has no wish to do so ; but he employs it much less frequently than is cus- tomary in ordinary practice. That the effects of judiciously selected hydriatric measures are like those of digitalis, is evident from the fore- going description. They may, therefore, be used as a perfect substi- tute for this drug in those cases in which the employment of digitalis is, for the hydrotherapeutist, not yet indicated. For example, it is not necessary to resort to digitalis when the patient complains only of unpleasant sensations in the precordium, of palpitation, of shortness of breath, of irregularity in the action of the heart. One application of the precordial coil is sufficient to relieve these symptoms. Resort to digitalis is thus deferred; and, in consequence, its aid may prove effec- tive at a time when those who had already begun its employment at the stage under consideration are no longer able to obtain results, because the muscular and nervous structures of the heart are no longer susceptible to the action of the drug. Advantages of Hydrotherapy.—The advantage of hydrotherapy over treatment with drugs consists, therefore, first, in the fact that the susceptibility to the measures does not diminish by reason of their early or protracted employment. A second advantage consists in the fact that whereas the effects of digitalis are brought about in part by contraction of the peripheral blood-vessels, hydriatric measures raise the blood pressure through increase in muscular power; and thereby we avoid a contraction that heightens resistance and thus draws upon the final reserve power of the heart muscle. Further, an important advantage of hydriatric measures consists in the fact that it is possible through them to stimulate the heart to dueACUTE ENDOCARDITIS 185 activity at a time when this organ has become insusceptible to the action of the entire range of heart-tonics of the materia medica. In this way it is possible still further to improve the action of the heart, to change the quality of the pulse, and to render the heart muscle amenable to the influence of digitalis. Finally, the circumstance must be taken into consideration that the cumulative effect of digitalis does not appear when the precordial coil is employed. The precordial coil also plays the role of a prognostic aid. Should digitalis fail,—and this is the case when there is marked degeneration of the myocar- dium,—but the heart muscle still react to the precordial coil, the prog- nosis may, as an abundant experience has shown, be considered fav- orable, both with regard to the continuance of life, and to improvement, even though but temporary, of the condition. If the precordial coil fails to produce a good reaction, then the prognosis must be consid- ered unfavorable. It will not be difficult, from what has been said, to formulate the treatment in the individual case. The ends to be attained, and the mode of action of the available hydriatric procedures, are questions that must constantly be kept in mind, if the proper indications are to be laid down. Acute Endocarditis In acute endocarditis the indication for treatment is to quiet the heart. Any violence of cardiac action must be prevented on account of the danger of embolism. The precordial coil alone meets fully the indications present under such circumstances. It may be permitted to remain in place for hours, and even for days. Every other form of active treatment should be avoided on account of its useless- ness. Only when cardiac weakness is threatened are stimulants indicated. During convalescence, gymnastic exercises for the myocardium are indicated. The heart muscle must be strengthened in order that it may attain at the earliest moment possible that meas- ure of power that it will require permanently to overcome the circu- latory obstruction. Partial ablutions and partial rubs are admirably adapted for this stage. As soon as the first signs of cardiac weakness appear that arouse fear of the development of disturbance of compensation, or when the beginnings of the latter have already made their appearance, then rest and cooling apparatus are again appropriate. The duration of each application of the precordial coil under such circumstances depends upon the factors present in the individual case. If the power of the heart is increased, if the quality of the pulse is improved, if the irregularities and the subjective symptoms are relieved, then the cooling apparatus has fulfilled its purpose. I do not mean by this to say that the coil should then be entirely abandoned as a remedial measure, as it should still be applied186 DISEASES OF THE CIRCULATORY APPARATUS once or twice daily for from half an hour to an hour at a time with the object of invigorating the heart muscle. The occurrence of disturb- ance of compensation will thereby be prevented. Partial ablu- tions practised daily in the morning immediately on getting out of bed complete the plan of treatment. In addition to the neces- sary exercise of the heart muscle, they will induce active dilatation of the peripheral vessels, overcome circulatory resistance, and thus favor recovery. Treatment of Derangement of Compensation As soon as the familiar symptom-complex—edema, diminished secretion of urine, small, irregular pulse, dyspnea—has developed, the question will arise, What is the condition of the heart muscle ? If the myocardium is insufficient because degenerative changes have taken place in it, then I generally proceed in the following manner : Par- tial ablutions are practised before the precordial coil is applied. Under such circumstances the peripheral circulatory resistance should, above all things, be overcome, the vis a tergo increased. Perhaps it may be possible by this means to stimulate the heart enough to enable it to perform the lessened amount of work thus prepared for it. It has already been mentioned that the primary contraction of the vessels attending partial ablutions constitutes a sort of gymnastic exercise for the heart. In order that the heart shall not be strained, I do not practise partial ablution of the entire body on the first day. I make a partial ablution of the lower extremities suffice. Not before the sec- ond day, or perhaps on the first day, but at a later hour, I extend the partial ablution to the trunk. On the following day the entire body is sponged, and now for the first time I apply the precordial coil. Success has never been wanting when this method has been pursued, and I have always secured the desired results from the two procedures at this stage of the disease. Treatment of Cardiac Insufficiency If the cardiac muscle be insufficient with reference to the existing circulatory obstruction then the indication is all the more urgent to employ general procedures; that is, such as involve the entire surface of the body. Under such circumstances also it is advisable to begin with partial ablutions, which, however, should later be ex- tended to the entire body. Immediately after the partial ablution I apply the p re cor dial coil for one or two hours daily. If necessary, the partial ablution may be practised twice daily. At this stage the application of a rubber coil to the nape of the neck also is indicated. This reinforces the action upon the heart of the partial ablution and of the precordial coil, through its effect upon the sympathetic and the vagus. The heart, which has become insufficientPERICARDITIS 187 in the effort to overcome abnormal resistance, will most readily regain its contractile power as a result of this treatment. When the circula- tion is as completely restored as possible, the work of the heart may be progressively increased. In addition to massage and passive gymnastics, which are strongly indicated at this stage, the employ- ment of half-baths, vigorous cool shower-baths of short duration (one-quarter of a minute), and cold rubs of one to two minutes’ duration, are advisable. The degree to which an increase in the demands upon the heart appears permissible will always be best determined by observing whether or not the procedure gives rise to marked palpitation of the heart or dyspnea of consider- able duration. If the cases are individualized carefully,—and this is absolutely necessary,—it will not rarely be found that patients with profound circulatory derangement regain their original functional ability. On the other hand, cases frequently occur in which, in con- sequence of premature or excessive use of applications involving at once the entire surface of the body, the cardiac insufficiency that has just been corrected immediately returns. Care is therefore demanded in the institution of the measures named. Should the edema not subside under the treatment outlined, should hypostatic manifestations and albuminuria persist, cautious employment of the steam bath in the tub should be resorted to. As has already been mentioned, the application of the precordial coil should be conjoined with this procedure. Under such circum- stances the treatment may so be carried out that the steam bath is preceded by the employment of the precordial coil, and that the latter remains in position throughout the duration of the bath and even for some time afterward. The duration of the steam bath is from five to ten minutes, that of the application of the precordial coil from thirty minutes to one hour. It may therefore be readily deduced from this statement how long before and how long after a steam bath the precordial coil should remain in place. Circular compresses around the lower extremities, and trunk compresses changed every three hours, will contribute, as has been mentioned, to the stimulation of absorption and to the relief of the symptoms of stasis. PERICARDITIS In addition to the rest that will naturally be observed, it is from the precordial coil, cooled by the continuous flow of cold water, that the best results may be expected in the treatment of pericarditis. This measure plays the part of a powerful antiphlogistic, quieting the action of the heart and mitigating the severity of the pain. The188 DISEASES OF THE CIRCULATORY APPARATUS application of cold is continued as long as necessary to bring about complete disappearance of the inflammatory manifestations. It may be continued for weeks without unpleasant or injurious secondary effects. If the application of cold becomes annoying to the patient, it may be suspended for a short time and be replaced by a stimu- lating compress. In cases of chronic pericarditis, with'the persistence of an effu- sion for a long time, unless tuberculosis be the cause of the pericar- ditis, diaphoretic procedures may be employed, naturally with the care that has been described as necessary in the use of dia- phoretic procedures in the treatment of endocarditis. A wet pack in combination with the precordial coil, for a period of an hour to one and a half hours, is best borne by these patients. The fever may in this disease reach an unusually high level. Under such circumstances intense cold in the form of half-baths is indicated. ARTERIOSCLEROSIS The most important point in the treatment of arteriosclerosis is to lessen the resistance that is both the cause and the effect of the disease. In a prophylactic direction great service will be rendered by means of all measures that diminish circulatory resistance, increase the blood stream in the arterial system; and lower the blood pressure. The applications that may be employed under such circumstances consist, first, in the cold precordial coil and cold spinal coil. In addition to these, resort maybe had to wet packs of three- quarters of an hour’s duration, with subsequent cooling pro- cedures ; or to diaphoretic measures that do not greatly increase the circulatory activity, therefore in combination with the precordial coil; or steam baths, with subsequent cooling, may be employed. In the presence of marked arteriosclerosis the treatment is most advantageously begun with partial ablutions. After this pro- cedure has been employed for a considerable time, resort may be had to the full cold rub, or to shower-baths at alternating tem- peratures. If there exists a tendency to congestions, running foot-baths, sural compresses, and trunk compresses are indicated. In all cases of arteriosclerosis especial provision should be made to prevent hypostatic congestion before the employment of any procedure. Neither arrhythmia nor albuminuria constitutes a counterindication to hydriatric measures. Collateral symptoms, such as sleeplessness, asthma, angina pectoris, digestive disturb- ances, constipation, and bronchial catarrh, should be treated in accordance with the principles already laid down.HEMORRHOIDS 189 DILATATION OF THE HEMORRHOIDAL VEINS In the treatment of this disorder the etiology, with reference to possible disease of the liver, heart, or lungs, and constipation, should especially be taken into consideration. Cold sitzbaths of short duration are the most important procedures in the treatment of hemorrhoids. They are capable of relieving not alone the constipa- tion, but also the venous stasis. A further most important aid is the use of Atzberger’s rectal irrigator. Inflamed venous nodules and freely bleeding nodules are advantageously treated with cold sitzbaths of long duration. In proctitis and peri- proctitis following hemorrhoids, the cold sitzbath of long duration and the rectal cooling apparatus are indicated.CHAPTER VI DISEASES OF THE DIGESTIVE ORGANS Diseases of the Stomach—Nervous Dyspepsia; Chronic Gastric Catarrh; Acute Gastric Catarrh; Ulcer of the Stomach; Atony and Dilatation. Diseases of the Intestine—Diarrhea; Intestinal Catarrh; Constipation; Acute Enteritis; Catarrhal Jaundice. Acute General Peritonitis and Perityphlitis. Diseases of the Biliary Passages and of the Liver—Chole- lithiasis; Hyperemia of the Liver. DISEASES OF THE STOMACH Hydrotherapy plays in the domain of digestive diseases not alone the role of an auxiliary measure, but also that of a curative agency; and it is applicable almost unexceptionally, at least with some degree of success, in every form of gastric disease. Its influence upon motility, secretion, absorption, and sensibility is more marked than is observed from any other method of treatment. A most important influence is to be attributed to hydrotherapy in increasing the general strength and the functional power of the organism, while it powerfully stimulates the absorptive power and the utilization of the food. Nervous Dyspepsia The prototype of all chemical, motor, sensory, and secretory disor- ders of the functions of the stomach is presented by nervous dys- pepsia. In this disease hydrotherapy is of great service, both from the symptomatic standpoint and with relation to the general condi- tion. The postulates that should be applied to a rational method of treatment are : Improvement of innervation, but no powerful stimula- tion ; rapid restoration of warmth, but no abnormal elevation of tem- perature ; invigoration, but with simultaneous consideration of the action of the heart; increase in the number of red corpuscles in the circulating blood ; deepening and slowing of the respiration. In this sense—always, of course, making allowance for the conditions present in the individual case—good results will be obtained from a cold rub immediately on getting out of bed, in a sheet at a temperature of from 12° to i8° C. (53.6° to64° F.), for a period of two or three minutes ; the patient being permitted to lie in bed without being dried, with the 190CHRONIC GASTRIC CATARRH I9I windows open, particularly in the case of debilitated patients incapable of engaging in exercise for the purpose of bringing about successful re- action. Vigorous cold shower-baths of short duratio n, brief plunge baths, and rapidly applied cold affusions to the en- tire body—io° to 160 C. (50° to 60.4° F.)—will be equally successful. The amount of blood and the activity of the circulation in the gastric mucous membrane, and the tone of the muscular layer, are responsible for the secretion furnished by the glands of the stomach. By means of procedures, therefore, that increase or diminish the circulation, the innervation, and the tone of the stomach, it will be possible to exert an influence upon the secretion that is of great importance in the treatment of nervous dyspepsia. In this connection sitzbaths, by means of which, as is well known, it is possible almost arbitrarily to control innervation and circulation, play an important role. Cold sitzbaths of short or of long duration will be employed successfully in accordance with the indications present. Of equal importance is the abdominal binder; further, the combination trunk compress, with the hot rubber coil. The cramp and peristaltic unrest especially will be favorably influenced by the latter procedure. The reflex irritability of the stomach will be diminished. Such good results are obtained from this application that it is appropriately considered one of the most valued hydriatric measures in gastric cases, and, next to the abdominal binder, it has, of all the procedures of hydrotherapy, most rapidly found its way into general use. Its action in the presence of gastralgia of nervous origin, and of vomiting of nervous origin, is actually brilliant. Chronic Gastric Catarrh A similar course is pursued in the treatment of this disease. Independently of the cause to which the chronic gastric catarrh is to be attributed, the conditions to be dealt with consist especially in changes in the circulation in the gastric mucous membrane, which nat- urally exert an injurious effect upon the secretion of the gastric juice and the absorption of the contents of the stomach. The secretory dis- turbance soon becomes associated with atony of the muscular layer, with deficient peristalsis, which in turn may give rise to marked dilata- tion. Under such circumstances likewise it is desirable to improve innervation and circulation, both generally and locally, by means of general tonic measures. Further, the endeavor should be made to ful- fil the indications presented by local symptoms by means of local treat- ment. These indications will be found in full measure in cases of chronic gastric catarrh. Sitzbaths, the abdominal binder, and Winternitz’s combination compress constitute here also the cardinal remedies, after the general procedures; and even in neglected cases successful results will be obtained such as would fail to follow with equal promptitude upon the institution of other measures. In sympto-192 DISEASES OF THE DIGESTIVE ORGANS matic catarrhal conditions rational dietetic regulation must, of course, be insisted on. Acute Gastric Catarrh Active intervention is rarely called for. All indications will gen- erally be met by the application of an abdominal binder, which is changed every two or three hours. The elevation of temperature, like other febrile manifestations, has a tendency at times to attain a high degree. It then indicates the employment of those hydriatric procedures that were mentioned in the discussion of febrile diseases. Exceptionally, individual symptoms may render necessary special therapeutic measures. Particularly, obstinate vomiting and per- sistent nausea when the stomach is empty may require sedative measures. Small bits of ice administered internally or small amounts of ice-water given at long intervals, and the use of Winternitz’s combination compress, will suffice to relieve these symptoms in most cases. Ulcer of the Stomach Two important indications must be fulfilled: In the first place, to avert the development of an ulcer; in the second place, after an ulcer has developed, to provide the most favorable conditions possi- ble to bring about its healing. In order to be able to avert a morbid process it is necessary to be familiar with the conditions underlying its development. With refer- ence to ulcer of the stomach the circumstances are pretty clear. The predisposing factor is diminution in the alkalinity of the blood circulating in the gastric mucous membrane, and the secretion of an excessively acid gastric juice. A rational treatment will find its most important function of a causal nature, and for this purpose hydro- therapy is best adapted. The procedures that should be employed are especially those that have been mentioned as advantageous in the treatment of chlorosis—namely, applications with alternating tem- perature, by means of which improvement in the circulation in gen- eral, and an increase in the alkalinity of the blood, are probably with greatest certainty brought about. In addition, those measures are employed that improve the circulation locally; that is, in the wall of the stomach—namely, cold sitzbaths of short duration (from io° to 120 C.,—50° to 53.6° F.,—and lasting from three to five minutes); stimulating compresses about the abdomen, trunk compresses, in combination with the hot stomach coil, which, however, should remain in place for only a short time. A second important indication to be fulfilled in treatment consists in control of hemorrhage, of vomiting and of cardialgia. A powerful remedy for hematemesis is found in thermic influences.DIARRHEA 193 Small ice-pills are often a source of disappointment. Small bits of ice introduced into the rectum exert a powerful effect As Winternitz has shown, these are capable of influencing strongly the circulatory conditions in the stomach. The abdominal binder, in combination with the rubber coil cooled by a continuous flow of cold water, has an excellent effect in controlling the hemorrhage. It may remain in place for hours, or even for days. Vomiting and cardialgia will, by reason of their causative factor, have to be treated by means of Win tern it z’s combination compress. Only in the presence of gastric hemorrhage would I omit the use of this remedy. Dilatation and Atony of the Stomach.—The primary enfeeble- ment of motor power and the state of functional debility constitute the points of attack for hydriatric procedures. Shower-baths of alternating temperature, in combination with brief movable cold fan douches to the abdomen; Scotch douches; a cold rub, immediately followed by a cold sitzbath of short duration; or half-baths with high abdominal affusions, act directly by stimulating the muscular layer of the stomach and the contractions of the abdominal muscles, and reflexly by their tonic effect on the entire nervous system. DISEASES OF THE INTESTINE It seems appropriate to discuss in this place two symptoms, diarrhea and constipation, as these occupy a prominent place in the symptomatology of all diseases of the intestine. Diarrhea This can be treated successfully, it matters not whether the cause reside in the abnormal character of the food and drink, producing simple increase in the intestinal secretion, excessive peristaltic activity, or some pathologic state of the intestinal mucous membrane ; in mor- bid states of the intestinal mucous membrane, as acute and chronic catarrh, particularly of the large intestine ; or in the secondary catarrh accompanying ulceration or other profound structural change. The diarrhea dependent upon the disturbances of innervation may also be favorably influenced by hydriatric measures. With reference to the procedures to be employed under the cir- cumstances in question, it will be understood that it is absolutely necessary for the indications to be laid down with precision ; but, on the other hand, the statement is also applicable here that it is not any single measure that leads to the desired result. In all of the cases in which the abnormal character of the food and drink gives rise to diar- ix—13194 DISEASES OF THE DIGESTIVE ORGANS rhea, it will be necessary to accelerate peristaltic movement. Apart from enemas and irrigations, it is especially cold sitz- baths—I o° to I 8° C. (50° to 64.4° F.), of one to five minutes’ duration,—that will stimulate peristalsis both by reflex action and by inducing hyperemia of the intestine. The paradoxic diarrhea, or so-called stercoral diarrhea,—that is, the variety that is attended with fermentation and the generation of irritating matters in conse- quence of stagnation of the intestinal contents,—;must be treated in the same manner. Quite a different course must be pursued in cases of diarrhea due to increased peristalsis, caused principally by excessive irritability of the muscular layer of the bowel. Under such circumstances the peristaltic activity should be restrained. This may most advantage- ously be accomplished by means of the direct supply of heat or warm- ing measures. Half-baths and sitzbaths at a temperature only a few degrees below that of the blood, and of considerable dura- tion,—from half an hour to an hour,—wet packs in sheets well wrung out, for a period of one to two hours, followed by a mod- erately cool half-bath (28° to 26° C.— 82.4° to 78.8° F.), and an abdominal binder until the body has become completely warm and dry, are examples of relaxing sedative measures of the character that will check peristaltic activity. I may additionally recommend the hot stomach coil, applied over a wet compress, as a useful remedial measure belonging in this category. Intestinal Catarrh The most important variety of diarrhea is that dependent upon catarrhal affections of the intestine.' This includes the most ob- stinate and most dangerous cases. These are at the same time, how- ever, the cases in which hydrotherapy is capable of exhibiting its specific effect. Reduction of the amount of blood in the intestine, reduction in the secretion of the intestinal mucous membrane, lessen- ing of peristaltic activity, are the indications to be met in this connec- tion. This will be accomplished by diverting the blood stream to the skin. Vigorous rubbing with a coarse sheet well wrung out of cold water is the most suitable procedure under such circumstances. This is followed by the sitzbath. Keeping constantly in mind the conditions present in the. individual case, and the susceptibility of the patient to irritation, it will rarely be permissible to employ water at a temperature above 140 C. (57.2° F.), and it will often be neces- sary to resort to a temperature so low as io° C. (50° F.). The duration will be from eight to ten minutes, and it will often have to be extended even to twenty or thirty minutes and more. The abdominal binder must also be considered as an additional measure having a local derivative effect.CONSTIPATION 195 The plan of treatment will be as follows : A cold rub followed by a cold sitzbath of considerable duration. After the rub the patient, without being dried, enters the sitzbath, is thoroughly cov- ered, and is directed to rub the abdomen vigorously. After the sitzbath the abdominal binder is applied, and this is changed after it has become completely dry. The same treatment is applicable also to chronic forms of diarrhea. Here especially hydrotherapy attains its best results. In cases of nervous diarrhea, the procedures directed against the neurotic state in general, particularly half-baths, will be appropriate. Constipation We may now take up the consideration of constipation. This condition may result from atony, as well as from spasm, of the intes- tine. The latter condition particularly has received far too little attention, although it is one of the most common causes of constipa- tion. The spasmodic contraction of the intestinal musculature may give rise to marked stenosis of the lumen of the bowel, and even to complete occlusion, so that grave structural disease may be simulated. The treatment of constipation, which constitutes one of the most difficult problems presented to the physician, must accordingly be governed primarily by the causative factors. The condition of atony must be treated quite differently from one of spasm, and the failures so frequent in the treatment of constipation are principally attributa- ble to the fact that far too little consideration is given to the differ- ences indicated. With both varieties irrigation plays an important role. In case of atony, cool irrigations and cold enemas are employed. Under these circumstances it is well to introduce at first small amounts of cold water—22 0 to 1 8 0 C. (71.6° to 64.4° F.)— in order to evacuate the lower portion of the intestine ; and then to permit a somewhat larger amount—from one-third to one-half liter (quart)—of cold water to enter through an intestinal tube of con- siderable length. Retention of the injected water for as long a time as possible will then yield a satisfactory result. In the treatment of atony the cold rub followed by a cold sitzbath, of a maximum duration of five minutes, is further attended with admirable effects. Both procedures exert powerful stimulation. The friction improves the tone of all of the tissues ; the short, cold sitzbath in- creases the flow of blood to the intestine, and stimulates peristaltic activity by heightening innervation. Moderately cool half- baths,— 270 to 220 C. (80.6° to 71.6° F.),—with high abdom- inal affusions; and shower-baths, with a movable fan douche to the abdomen, exert a good effect. In the spastic form of constipation it is the hot irrigations that196 DISEASES OF THE DIGESTIVE ORGANS will be attended with success. For purpose of irrigation, water at a temperature of 40° C. (104° F.) will suffice. Sodium chlorid may be added. The external use of warm applications is of great importance—namely, protracted warm baths, sitzbaths of considerable duration, warm abdominal compresses, steam compresses, the hot rubber coil in combination with a trunk compress, the thermophore, etc. Warm douches of short duration are likewise to be commended. Acute Enteritis First of all, the abnormal intestinal contents must be removed. Only after this indication has been fulfilled are such procedures to be employed as are capable of controlling the existing diarrhea. In cases of chronic enteritis also, persistent diarrhea or persistent con- stipation, or both in alternation, will require consideration. The treat- ment will be guided by the principles already laid down. Mucous colic is favorably influenced by the cold rub and cold sitzbaths of ten to fifteen minutes' duration. Catarrhal Jaundice Enteroclysis in the form of the so-called high irrigation, twice or thrice daily, with water at a temperature of 120 to iy° C. (53.6° to 62.6° F.), in amounts of one to two liters (quarts), is most suitable. Small retained enemas, which, like applications of ice within the rectum, exert a reflex influence upon the circulation in the uppermost portion of the intestine, are also of great value in this connection. Such enemas with about one-tenth of a liter (quart) of very cold water—io° to 120 C. (50° to 53.6° F.)—should be given twice or thrice daily. Cold sitzbaths, the duration of which will be governed by the presence of constipation or of diarrhea, may be employed additionally. The application of the abdominal binder will materially aid the action of the procedures mentioned. Of general measures, those of a stimulating character are indicated. The treatment of intestinal hemorrhage is the same as that of hemorrhage from the stomach. Nervous enteralgia requires general treatment such as has been laid down for cases of neurasthenia and hysteria. Hot applica- tions are indicated for the relief of the attacks of pain. ACUTE GENERAL PERITONITIS AND PERITYPHLITIS The treatment of these affections with compresses in combina- tion with cooling apparatus lessens the pain, as well as theHYPEREMIA OF THE LIVER 197 vomiting and the meteorism. Cold is at first not well borne by some patients. Under such circumstances stimulating compresses are first indicated. In cases of perityphlitis, operative intervention will often be averted by the timely institution of antiphlogistic treat- ment. It is quite often possible to place the intestine at rest and to relieve and remove hiccough, vomiting, and pain by means of trunk compresses with a cold abdominal coil. It is absolutely necessary to keep the apparatus in place for days at a time. The employment of irrigation should be avoided at first, but if it is absolutely necessary, it may be undertaken with the greatest care. Excessive pressure must, in any event, not be permitted. DISEASES OF THE BILIARY PASSAGES AND OF THE LIVER Cholelithiasis probably is amenable to hydrotherapy only during an attack of biliary colic. It is a fact to which Leichtenstern also has called attention that the antispasmodic and anodyne effect of morphin is materially increased, or, if the colic is of lesser severity, can be sub- stituted, by a number of hydriatric measures. Particularly heat applied in various ways fulfils this object. I may mention here again the trunk compress with the hot rubber coil, steam compresses, the thermophore, and the like. The drinking of very hot water is of great utility. Although the water first swallowed is generally vomited, it is nevertheless advisable to continue giving it in small quantities. The hot water exerts a powerful antispasmodic influence ; as does also a hot bath—40° C. (104° F.)—of considerable duration. Swift Walker recommends baths as hot as can be borne. I have seen no benefit from the use of the ice-bag as advised by Bricheteau. The treatment of jaundice due to gall-stones is similar to that of catarrhal jaundice, which has already been described. Hyperemia of the Liver Of the disorders of the liver, only hyperemia will be considered. Venous hyperemia of the liver is most frequently brought about by disease of the lungs or of the heart. Its treatment is that of the cause. In arterial or active hyperemia of the liver, in addition to strict regu- lation of the diet, both quantitatively and qualitatively, hydriatric applications may be used with the hope of success. Very cold sitz- baths — 8° to io° C. (46.4° to 50° F.)—of ten to fifteen minutes’ duration, administered daily, are especially to be recommended in this connection. Derivative procedures applied to the skin, particularly cold shower-baths, in combination with the movable cold fan douche, applied over the liver, also exert a good effect.CHAPTER VII DISEASES OF THE URINARY APPARATUS, OF THE FEMALE SEXUAL ORGANS, AND OF THE SKIN. VENEREAL DISEASES Diseases of the Kidneys. Acute Nephritis. Uremia. Nocturnal Enure- sis. Chronic Inflammatory Dermatoses. Ulcers and Burns. Eczema. Psoriasis. Syphilis. Gonorrhea. Cystitis. Prostatitis. Amenorrhea. Menorrhagia. Dysmenorrhea. Metritis and Endometritis. DISEASES OF THE URINARY APPARATUS DISEASES OF THE KIDNEYS Acute Nephritis The employment of baths, in conjunction with the dietetic and hygienic treatment of diseases of the kidneys, has always been most extensively practised. In cases of acute nephritis the bath is prac- tically the only form of therapeusis available, and its good effects are generally admitted. The treatment is based upon the view that the skin and the kidneys bear functionally reciprocal relations, so that the skin to a certain degree may vicariously assume the work of the kidneys. It is true that the ability of the skin or of the sweat glands to take the place of the kidney has definite limitations for although water in considerable amount can be eliminated through the sweat glands, the conditions are different with regard to the fixed elements of the urine. Even in case of the most profuse sweating, not more than one-tenth at most of the nitrogen eliminated through the urine in twenty-four hours escapes through the skin, as has been shown by Leube. That, therefore, diaphoretic methods of treatment are prin- cipally indicated for the purpose of stimulating the compensatory agencies that reside in the skin is clear, and is also generally known. Nor is much to be said with reference to the methods to be pursued. In cases of acute nephritis it is principally hot baths that are em- ployed in order to bring about adequate diaphoresis. The tempera- ture of the water is from 38° to 42 0 C. (say, ioo° to 108° F.), and the duration of the bath from fifteen to thirty tfiinutes. Excessively high temperatures, as wTell as excessive prolongation of the bath, exert an injurious rather than a favorable influence, as the 198SCARLATINAL NEPHRITIS I99 invigorating effect of the hot bath may readily be converted into a debilitating effect if the application is too long continued. The con- ditions are analogous to those that obtain with the use of cold, which also exerts an invigorating effect within certain limits of time, beyond which it gives rise to excessive irritation. Excessive duration of the bath, or excessive diaphoresis, is attended with an additional serious disadvantage that should not be overlooked. The fact has already been pointed out, that even after the most profound sweating only a small portion of the solid constituents of the urine is eliminated ; thus there is danger of hastening the development of profound uremic symp- toms in consequence of retention and concentration of the excrementi- tious metabolic products in the tissues of the body. The endeavor should therefore be made to induce gentle diaphoresis by means of warm baths, in order to relieve the kidneys of a part of their function and to maintain elimination through the skin. The action of the bath may be aided by permitting the patient to sweat subsequently between woolen blankets; but forced sweat- ing should, so far as possible, be avoided. There is no advantage in causing rapid disappearance of the edema or of the fluid in the serous cavities. If I have not discussed the etiology of acute nephritis in the beginning of this analysis, it is because the treatment is so rarely governed by causal indications, but is pretty much the same in all cases. Special emphasis need not be placed upon the fact that considera- tion should be given to the danger of nephritis in cases of infectious disease, and particularly of scarlet fever. Should albuminuria, or even nephritis, develop in the course of an acute infectious disease, the withdrawal of hydriatric treatment would, as a matter of course, be not only useless, but even a mistake, inasmuch as by its continuance the morbid process might be restrained. The effects of extreme cold, however, should be avoided under such circumstances, and moder- ately cool half-baths—250 to 230 C. (77 0 to 730 F.)—be given. The vigorous friction pertaining to this measure takes the place of the thermic stimulation. It should be pointed out here that mechanical stimulation—dry friction—has been especially recommended by Sem- mola, because it increases elimination through the skin, as will be clear from previous considerations. Chronic Nephritis The treatment of chronic nephritis is based upon the same prin- ciples. Here, too, the most important point is to relieve and shield the diseased organ, and although actual cure cannot be brought about, as in cases of acute nephritis, it is at least possible to save a portion of the renal parenchyma, and to maintain the function of the organ at such a level that the patients may continue to live for years200 CHRONIC NEPHRITIS in comparative comfort. There are naturally other therapeutic in- dications in certain cases of chronic nephritis that do not exist in acute nephritis. These consist of diverse disturbances in the various organs, among which those connected with the circulatory and respiratory apparatus occupy the first place. With reference to diaphoretic methods of treatment, after again emphasizing the importance of the two factors, duration and intensity, it may be mentioned that not only hot baths, but also a large number of other diaphoretic procedures, are available in this connection; Thus, wet and dry packs, steam cabinet baths, steam tub- baths, hot-air baths, electric light baths, and similar meas- ures may be used. If the different effect of these procedures with reference to respiration and pulse frequency, and with reference to the action of the heart and innervation, be kept in mind, it will not be difficult to make a proper selection from among them. It should always be remembered that the wet and the dry pack exert a sedative influence upon innervation and cardiac action, and that they lower the blood pressure ; hence the propriety of their employment in the treatment of chronic parenchymatous nephritis. It should further be borne in mind that marked acceleration of respiratory and pulse frequency, violent heart action, and elevation of blood temperature, take place in the steam bath, as well as in the hot-air bath and in the elec- tric light cabinet. In making a selection from among these measures it is well to remember that much higher temperatures can be borne in a hot-air bath than in the steam cabinet. The consideration of the action of the heart, which is especially necessary, will in many cases indicate the precordial coil, which should be applied throughout the continuation of the heating procedures. The cold precordial coil plays an important role also in the treatment of the various forms of chronic nephritis, as it is often necessary to quiet and to strengthen the action of the heart, and to increase its vigor. In this way the symptomatic indication will be met. In consequence of the retention of urinary matters reactive irritation of the vascular nerves results, with increased blood pressure, and consecutive hypertrophy of the heart. All causes that lead to strain on the part of the heart are therefore to be avoided, and the measures that confine the activity of the heart within approximately normal limits are to be employed. Treatment of Uremia.—The systematic application of the pre- cordial coil is of great importance in the prevention of uremia, in- cluding under this term not only the profound morbid manifestations, such as convulsions, coma, or Cheyne-Stokes breathing, but also the headache, the vertigo, the asthma, the sleeplessness, and minor symp- toms. The increased vigor of the heart that is brought about by this procedure causes a better flushing of the kidneys with arterialCONTRACTED KIDNEY 201 blood and a more abundant elimination of water and of toxic matters. With reference to the employment of hot baths in the treatment of uremia, attention may again be called to the danger of forced diaphoresis. One question further should be raised here—namely, What procedures should be employed after the diaphoretic measures ? As the necessity has been made clear in several places for a cooling procedure following applications that supply heat or cause accumula- tion of heat, the reply to this question raises another—namely, May cold be employed at all in cases of nephritis ? The fear of cold applications is almost universal, but their danger is by no means pro- portionate thereto. The principal desideratum of the hydrotherapeu- tist is to insure a good reaction. When this is attainable, cold applica- tions in the form of shower-baths at a temperature of i6° C. (6o.8° F.), or of cool half-baths (220 to 20° C.—71.6° to 68° F.), may be employed—always, however, in sequence to diaphoretic measures—in the most diverse forms of chronic nephritis. The favorable effect will be exhibited in increased diuresis, strengthening of the action of the heart, and improvement in the general condition. Contracted Kidney Hydriatric procedures—diaphoretic measures and others—are of great usefulness in the treatment of contracted kidney, particularly the variety dependent upon arteriosclerosis and the gouty diathesis. “ The genuine contracted kidney, it may be stated incidentally, bears the same relation to acute infectious parenchymatous nephritis as does cirrhosis to acute yellow atrophy of the liver. In the one case, there occurs rapid destruction of the organ, immediately threatening life ; and in the other case, slow progressive destruction, which may to a certain degree be rendered relatively uninjurious by means of com- pensatory processes in the organism. On the basis of this conviction we should interpose no objection to subjecting an individual with cir- rhosis of the kidney to hydriatric procedures if demanded by certain symptoms constituting a part of the morbid process, or independently thereof, and if inflammatory processes in the kidney can be excluded.” Thus writes Kraus 1 in summarizing an admirable study of the treat- ment of albuminuria with hydriatric measures, and with this opinion I am in entire accord. M oderately cool half-baths at a tem- perature of from 22° to 20° C. (say, 720 to 68° F.) will relieve many of the distressing symptoms attending contracted (sclerotic) kidney. Digestive disorders will be mitigated and bronchial catarrh improved. Cold ablutions also will render invaluable service. After their employment for some time the cold rub may be resorted to. Refer- Blatter f. klin. Hydrotherapie,” 1897, No. 3.202 DISEASES OF THE SKIN ence has repeatedly been made to the beneficial influence of the cold or cool precordial coil. Stasis in the kidneys in consequence of disorder of the circulatory organs should be treated according to the methods that have been described in the section dealing with diseases of the heart and vessels. Diseases of the Bladder A few words may be in place here with reference to nocturnal enuresis. The object to be attained in the treatment of this condi- tion is invigoration of the vesical sphincter. General stimula- ting measures, cold rubs, cold brief shower-baths, cold plunges—I 6° to i8° C. (6o.8° to 64.4° F.)—will aid in invigorat- ing the entire organism of the debilitated individuals that, as a rule, suffer from the disorder under discussion. Under some circumstances cold sitzbaths of short duration, or, in the case of old persons, the employment of the psychrophore or of Atzberger’s irri- gator, which is directed to invigoration of the bladder through the rectum, will lead to the desired result. Hyperesthesia, spasm, and paralysis of the bladder may be improved, and eventually even cured, by means of measures that diminish sensibility in accordance with well-known laws—as cold applications of considerable duration in the form of sitzbaths; or by means of those that relax spasm—warm applications of considerable duration; or such as increase vigor and improve functional power—cold applications of short duration. Cystitis is mentioned elsewhere (p. 204). DISEASES OF THE SKIN, SYPHILIS, AND VENEREAL DISEASES DISEASES OF THE SKIN It is a matter of course that a form of treatment whose point of attack and whose gate of entry into the complicated structure of the human organism is found in the skin should also be applied to this important organ itself; and it is, in fact, possible to induce therein local hyperemia and ischemia, active congestion, and passive stasis, in accordance with physical laws, and thereby to influence cutaneous pathologic processes at their seat in a powerful manner, that is possi- ble with but few specifics. In acute inflammatory dermatoses, cooling antiphlogistic compresses are employed, with or without cooling apparatus. By this means heat, pain, and exudative, hemorrhagic, and destruc-ECZEMA 203 tive processes are counteracted. In chronic inflammatory derma- toses, macerating procedures, such as the steam cabinet, wet packs, and the like, and, in addition, measures that stimulate and accelerate absorption and regeneration or cicatrization, such as stimulating compresses and circular compresses, are indi- cated. The latter render admirable service especially in ulcerative and atonic processes ; dense, unyielding exudates ; burns of the third degree ; and leg ulcers. In secretory disorders (seborrhea or universal hyperidrosis) general invigorating applications that restore normal circulatory and innervational conditions to the skin and the sudoriferous glands may be employed with good results. Burns of the first degree may be treated antiphlogistically by means of cooling compresses ; burns of the second and of the third degree by means of the permanent hot water bed (370 C.— 98.6° F.), and with especially good results by means of circular compresses. Acute eczema may be treated with cooling compresses, and finally with compresses in combination with cooling apparatus. In vesicular, pustular, and impetiginous eczema, circular com- presses are useful locally, and general invigorating procedures assist the cure. In cases of squamous eczema, the softening and macerating procedures are employed. In the treatment of ordinary psoriasis, two sets of indications are to be fulfilled. In the first place, the scales should be macerated and detached, and this is best brought about by means of prolonged tepid baths. In the second place, the causative factors should be combated by improving the chronic inflammatory state of the papil- lary layer, together with the hyperemia in the vascular loops. Under these circumstances, such procedures should be employed as will improve the vascular tone in a definite manner—namely, shower- baths of alternating temperature, the cold rub, sheet baths, wet packs, together with subsequent cold applications. In the treatment of cutaneous pruritus, symptomatic and causal measures should be employed. In a symptomatic way tepid and warm high baths have long been in repute, as well as shower- baths of alternating temperature, and wet packs followed by half- baths. To remove possible causes, any digestive disturbance should be treated in accordance with the principles previously laid down.204 VENEREAL DISEASES SYPHILIS In addition to systematic courses of treatment with mercury and iodin, tested and sanctioned by observations in thousands of cases, hydriatric procedures may at the same time find a useful place. The treatment is begun with a sort of preliminary course, which con- sists in the employment of vigorous mechanical and thermic stimula- tion. Thus, vigorous cold rubs, cold shower-baths, and half-baths are employed for from three to five days, being pre- ceded, as a rule, by wet packs for thirty minutes to an hour, or steam cabinet baths. These are followed by the so-called major procedures, which influence metabolism in the most powerful manner and exhibit an active depurative and spoliative action. As a result of the disintegration of the body-proteid, the syphilitic virus, which probably is bound to this organic substance, is in successive quantities dislodged and thrown into the circulation, to be eliminated through the increased activity of all of the emunctories. All writers therefore recommend diaphoretic measures under these circum- stances. As the most vigorous of these are appropriately considered the dry pack, which acts by causing accumulation of heat, and the steam cabinet bath, which acts by supplying heat. The natural fear that the absorption of mercury would be interfered with in con- sequence of hydriatric measures has not been substantiated. GONORRHEA In cases of acute gonorrhea, local applications of cold are indicated, in addition to the treatment usually employed. In cases of chronic gonorrhea, the psychrophore will find employment. This is generally introduced twice or thrice daily for a half hour at a time, and through it is passed cold water—12° to i6° C. (53.6° to 60.80 F.). Of the more important complications, cystitis may be mentioned. In the treatment of this condition, moderately warm sitzbaths,—30° to 350 C. (86° to 950 F.),—of from half an hour’s to an hour’s duration, yield admirable results. In com- plicating prostatitis Atzperger’s irrigator is employed. If the condition be acute, a current of cold water—io° to 120 C. (50° to 53.6° F.)—is permitted to pass continuously through the instrument, while in cases of chronic prostatitis warm and cold water are employed alternately. DISEASES OF THE FEMALE SEXUAL ORGANS The utility of hydriatric applications is exhibited especially in the treatment of menstrual derangements. In all cases of amenorrhea,PREGNANCY 205 in addition to causal treatment, a generous flow of blood to the uterus must be brought about. For this purpose warm uterine douches, warm sitzbaths, stimulating compresses to the lower extremities, and cold movable fan douches to the inner surface of the thighs are available. Menorrhagia likewise requires both local and causal treatment, the object being, on the one hand, to stimulate contraction of the dilated uterine vessels and of the uterine mus- culature, and, on the other hand, to divert the blood from the con- gested genital apparatus to other portions of the body. With rare unanimity, both high degrees of heat through the vagina—two or three injections daily of a liter (quart) of water each time—and also cold vaginal irrigation—the injection of ice-water and intro- duction of bits of ice into the vagina—are advised. Protracted cold sitzbaths, as well as cold tubs and cold shower-baths, will aid the local measures. In cases of passive menorrhagia the tone of the genital vessels should be improved. Under such circum- stances cold sitzbaths of short duration, five minutes at most, occupy the first place. Dysmenorrhea should first of all receive causal treatment. The spastic variety will require avoidance of, or relief from, the spasm of the uterine musculature and of the vessels, and this it is possible to bring about by means of hot applications—sitzbaths, hot com- presses, trunk compresses in combination with the hot water coil, and similar measures. Another variety of dysmenorrhea is that which is believed to depend upon disease of the nervous system. The treatment should be general, and be directed to improvement of the innervation. If the painful menstruation be due to rigidity of the tissues of the cervix, such as may remain after cervical metritis, the vaginal dilator may be used with water of any desired temperature. The hydriatric management of metritis, parametritis, and endo- metritis enjoys general recognition. In view of the circumstance that the treatment of these disorders is based upon familiar principles already laid down, it is not necessary to consider them in detail again. In this connection also, the local and general measures previously mentioned are employed in accordance with the indications present. Pregnancy and Hydriatric Measures A few words may be devoted to the question whether or not the employment of hydriatric measures is permissible during pregnancy. It is impossible to lay down rules susceptible of general application ; every case must be judged on its own merits. In the presence of a tendency to abortion, great care will obviously be necessary; as also in the first months of any pregnancy. Exceedingly high and exceedingly206 VOMITING OF PREGNANCY low temperatures, vigorous mechanical stimulation, and such measures as directly or reflexly excite contraction of the uterus or induce hyper- emia of this organ, or diminish the amount of blood present in it, are counterindicated under all such circumstances. In an acute disease occurring during pregnancy the choice of a proper procedure will not be difficult Chronic diseases during pregnancy should likewise be treated with due consideration of the latter. Disorders resulting from pregnancy may briefly be mentioned here. In cases of hyperemesis of pregnancy, trunk compresses with the hot rubber coil at times render good service. Eclampsia is most efficiently combated by means of hot baths of long duration (half an hour). Puerperal fever is an infectious disease and should obviously be treated as such.SUPPLEMENTAL CHAPTERS HELIOTHERAPY, PHOTOTHERAPY, AND THERMOTHERAPY By J. H. KELLOGG, M.D., OF BATTLE CREEK, MICHIGAN SALINE INFUSIONS AND IRRIGATIONS By HARVEY CUSHING, M.D., ASSOCIATE IN SURGERY, JOHNS HOPKINS MEDICAL SCHOOL, BALTIMORE, MD.SUPPLEMENTAL CHAPTERS HELIOTHERAPY, PHOTOTHERAPY, THER- MOTHERAPY, AND SALINE INFUSIONS AND IRRIGATIONS CHAPTER I HELIOTHERAPY: GENERAL AND LOCAL USE OF SUNLIGHT1 Preliminary Considerations. Physiologic Effects of Light. Sunburn. Phototherapy. The Sun-bath—Technic; Physiologic Effects; Indications and Counterindications. Local Applications of Sunlight—Mode of Action and Effects ; Indications. Whatever may be the ultimate nature of light, it seems to be clearly proved that a so-called ray of sunlight, or white light, is in fact composed of several different kinds of rays. The existence of three different sorts of rays has been clearly demonstrated, and there are hints that others exist. Those well known have been designated as (a) calorific or heat rays ; (b) luminous or light rays ; (c) actinic or chemical rays. Very recent observations have demonstrated that, as Clark-Maxwell maintained on theoretic grounds, light exerts a measurable pressure. The heat rays are for the most part invisible, as they do not stimulate the optic nerve, although they powerfully impress the nerves of the skin. Being the least refrangible, they are found in and below the red end of the spectrum. The chemical rays are found in the violet and ultra-violet portions of the spectrum. These also make slight impression on the eye, but stimulate the skin in a remarkable manner, making their presence known in other ways as well. The efflo- rescence of solutions of quinin, kerosene oil, and other substances is due to absorption and retention of the ultra-violet rays. It is by the 1 Supplemental chapters I, II, ill, and iv are by J. H. Kellogg, M.D., of Battle Creek, Mich. IX-14 209210 heliotherapy: general and local use of sunlight aid of these rays that a photograph can be taken of writing in which a solution of quinin has been used in place of ink, the former being absolutely invisible. It is a curious fact that it has also been found possible to take a photograph of the eruption of smallpox before it appears. The luminous rays are centered in the yellow portion of the spectrum. These several rays may be separated or filtered out from the com- pound ray of light by employing colored glass and other media. A solution of alum, for example, allows the luminous rays to pass readily, but excludes heat rays. A hollow convex lens, filled with a solution of iodin in carbon disulphid, permits the passage of the heat rays, but excludes the luminous and chemical rays. Red and yellow rays allowed to fall upon a mixture of hydrogen and chlorin produce no effect, while the violet rays give rise to an ex- plosion by inducing chemical combination of the gases. Godneff showed that silver chlorid in sealed tubes, placed under the skin of a naked animal, is blackened by the chemical rays, proving that the skin is readily penetrated by them. The phenomenon of translumi- nation shows that the tissues are also permeable to the luminous rays. The abdominal wall may be made to glow by a very small lamp introduced into the stomach by the aid of a proper instrument. That the heat rays possess even greater penetrating power has been shown by various experiments. These remarks are true of light in general, irrespective of its source; although compound light rays differ much in quality on account of the varying proportions in which the classes of rays mentioned are found in light from different sources. The electric arc light and sunlight are very similar in character. The arc light is said to have a somewhat larger proportion of actinic rays as compared with sunlight, when beams having an equal lumin- osity are compared. The incandescent electric light contains a much larger proportion of heat rays and a much smaller proportion of actinic rays, as compared with the arc light. Physiologic Effects The physiologic effects of light are chiefly due to the actinic and calorific rays, the effects of which must be studied separately. That light exercises a most potent influence upon life in all its higher manifestations, both animal and vegetable, is a fact of common observation. Plant growth seems especially to be influenced by the yellow rays. The ultra-violet rays increase flowering, while red light increases the aroma. Experiments made by Finsen and others tend to show that blue light retards growth. The phenomenon of heliotropism, the turning or bending of flowers, leaves, and even stems toward the sun, demonstrates most conclusively the powerful influence of lightINFLUENCE UPON METABOLISM 21 I upon vegetable organisms; but intense light and continuous exposure to light may prove injurious to plants, which seem to require rest or the absence of sunlight at intervals, as do animals. Concentrated sun- light destroys plant cells, shriveling their protoplasm. EFFECTS OF THE ACTINIC OR CHEMICAL LIGHT RAYS A common illustration of the effect of light upon the healthy organism is to be found in the phenomenon commonly known as sun- burn, more properly termed solar erythema. So long ago as 1859, Charcot suggested that sunburn might be due to the influence of the ultra-violet rays. Wilde made the assertion, of which Finsen has since furnished very positive proof, that so-called sunburn is not really a burn at all, but is an erythema set up by the irritative action of the ultra- violet, or fluorescent, rays upon the skin. White cows are subject to sunburn the same as white men, while red and black cows, as well as dark-skinned men, are protected by their color. The pigmentation of the skin that occurs in connection with sunburn guards against recur- rence. The curious observation has been made that light-colored animals, especially cows, and even pigs, when exposed to the sun after having been fed on buckwheat, are especially subject to sunburn. This is supposed to be due to the development of a fluorescent element in the blood of these animals under the influence of light acting upon some peculiar constituent of the food. The pigmentation following exposure to the sun, commonly known as tanning, as well as that which follows solar erythema, has been attributed to destruction of the red blood-corpuscles occurring under the influence of intense light. Sunburn is more likely to occur in elevated regions, because of the greater intensity of the violet light rays at high altitudes. The Influence of Light upon Metabolism An animal eliminates more carbon dioxid under the influence of light than when confined in the dark. This has been found to be true of hibernating animals also. Starving animals lose less weight at night than during an equal number of hours of daylight, although kept equally quiet. Certain animals, as crabs, when painted with dark varnish, are quickly killed, although unaffected by transparent varnish (Heile). Eggs develop more rapidly when exposed to the influence of sunlight than when kept in the dark. This is also true of the larvae of insects. Metabolism is unquestionably stimulated by the reflex action set up by the light rays impinging upon the nerve-endings of the skin and retina. Oxidation of living tissues is increased by the action of sun- light (Quincke), while in human beings, as well as in animals, less carbon dioxid is eliminated at night than during the same number of212 heliotherapy: general and local use of sunlight hours of daylight, even though an equal degree of quiet be observed (Pettenkofer and Voit). Country children, who are more exposed to sunshine than those in the city, are much healthier in appearance and less subject to rickets, tuberculosis, and other grave disorders. Cretinism is most frequently found in deep valleys from which the direct rays of the sun are largely excluded. Eskimo women suffer from amenorrhea during the long polar night. The Influence of Light upon the Nervous System The powerful influence of light upon the nervous system is shown by many facts ; as, for example, the effects of strong light in pro- ducing headache, giddiness, and even nausea, through the reflexes set up by overstimulation of the optic nerve. Similar effects are produced by prolonged exposure of the naked skin to the sun’s rays, and espe- cially by exposure of the head without ample protection. In Egypt, the natives habitually protect their heads from the powerful rays of the midday sun by wrapping them in shawls or scarfs, forming a huge mass, the heat of which would doubtless be intolerable were it not for the relief afforded by the exclusion of the exciting actinic rays. Sunstroke affords a very forcible illustration of the pernicious effects of intense sunlight upon a human body not trained to tolerate it. Tolerance is established in a person exposed to the sun in part by habituation of the nerves to the peculiar stimulus of the sun’s rays, and in part by pigmentation of the skin, which excludes some of the actinic rays. The natives of the South Sea Islands when obliged to expose their naked bodies for some time, protect themselves from the injurious effects of the sun’s rays by blackening their skins. Although the accumulation of heat is increased by the color of their skin, its impenetrability by the actinic rays renders the dark-skinned races better able to endure exposure to the sun. The Influence of Light upon the Functions of the Skin Exposure to the sun’s rays rapidly induces profuse perspiration, even though the temperature of the surrounding air may be consider- ably below that of the body. The activity of the sweat glands thus induced is probably due to the combined action of the actinic and of the calorific rays. It may be induced, however, by the heat rays alone, as is shown by the fact that very profuse perspiration follows exposure of the skin to the rays of the sun when protected in such a way as to exclude the chemical rays. The coloration of the skin, consisting in tanning and freckles, produced by exposure to the sun is the result of stimulation of the pigment cells by the actinic rays. This coloration is a conservative reaction to shield the sensitive structures situated immediately beneath the skin and in its deeper layers.THE SUN-BATH 213 The Action of Light upon Bacteria Bacteria as well as most other low organisms of a parasitic char- acter, including fungi, are sensitive to light and easily killed by it. Some bacteria which are not readily destroyed even by strong solu- tions of germicides, or by the action of steam, are quickly killed by exposure to light. Koch showed this to be true of the tubercle bacil- lus, and Kitasato made the same demonstration for the plague bacillus. Dieudonne showed that the ultra-violet rays are decidedly bactericidal. The germs of tetanus are killed more quickly by direct sunlight than by a 1 : 1000 solution of mercury bichlorid. The influence of sun- light upon bacteria accounts in part for the well-known and remarkably rapid purification of running water after contamination with sewage. Many bacteria are killed by exposure to diffused light, but for most positive effects the direct rays of the sun are required. THE THERAPEUTIC USE OE LIGHT Light is employed therapeutically in the following forms : 1. Sunlight.—The application of the rays of the sun is made to the uncovered or partially protected skin. For intense localized effect, the sun’s rays are concentrated by means of convex lenses or concave mirrors. The solar rays are also modified by passing them through vari- ous media, more or less perfectly isolating the several different kinds. 2. The incandescent electric light. 3. The arc light. Experiments have shown that the essential nature of light is the same, no matter what the source from which it may be obtained. The source of light, however, is a matter of considerable importance in re- lation to the convenience of application and the especial therapeutic results required, since there is a decided variation in the quality of light obtained from different sources. Sunlight contains very power- ful luminous, calorific, and chemical or actinic rays, and hence is the most important and valuable of the various forms of light employed for therapeutic purposes. The light from incandescent electric lamps contains a large proportion (95 per cent.) of heat rays with a compara- tively small proportion of luminous and chemical rays. The arc light, on the other hand, is fairly comparable to sunlight in luminosity and chemical activity, but is inferior to the incandescent light in the quantity of heat emitted when compared on the basis of equal candle-power. THE SUN-BATH Since the clothing, or at least a considerable part of it, must be re- moved, it is usually necessary that a special place or apartment should214 heliotherapy: general and local use of sunlight be prepared for the administration of this bath. To obtain the most complete effects, the sun's rays should fall upon the surface of the body, if possible, without passing through glass, for the reason that the ultra-violet rays, which are the most active in producing thera- peutic effects, are to some extent excluded by ordinary glass. The sun-bath is best administered in an outdoor gymnasium, provided with suitable couches, a sand bank, and other appliances. Several patients of the same sex may be treated at once in such an inclosure, the demands of modesty being satisfied by the scantiest of bathing attire. Male patients commonly wear very small trunks, jock-bands, or narrow loin-cloths. A very convenient protective garment may be made of a small towel by attaching at each corner a tape twelve or sixteen inches long. The towel is passed between the thighs and each end is attached to the waist by tying the tapes together in front and behind. If white or light-colored garments are worn, a consider- able amount of light will reach even the covered portions of the body. When it is desired to expose the entire skin surface,—and this is always an advantage,—tight screens maybe placed about the patient in such a way as to protect him from observation while permitting the sun’s rays to fall directly upon his uncovered body. Small, roofless cabinets may be arranged upon a flat roof. A very efficient sun-bath may be arranged in almost any sick-room which is so situated as to admit the sun’s rays between 9 a. m. and 3 p. m., by taking out the window-sash and placing the patient naked on a bed or cot before the open window. In cold weather the patient may be placed before an unshaded window while the sun is shining. Technic.—Either the whole surface or any desired portion of the body may be exposed to the action of the sun’s rays. As a rule, it is best that the head should be protected. This may be accom- plished by shading the head with a parasol, or by lightly covering it, first, with a moist towel, then with some dark-colored fabric. Ex- posure of the head often gives rise to nausea and other unpleasant symptoms through overexcitation of the brain and central nervous system, the natural result of the great penetrating power of the solar rays. This excitation is not necessarily due to overheating of the brain, but to the influence of the chemical or actinic ray, which is a powerful nerve stimulant. When the whole surface of the body is to be exposed to the direct rays of the sun, it is sometimes well to protect the cerebral circulation still further by applying to the face, or to the neck and face, a cheese- cloth napkin wrung out of water at 6o° to 65° F. (15.50 to 18.30 C,). In the case of children and men the whole hairy scalp may be moist- ened as well as the face. When the exposure is continued for more than a few minutes, the wet napkin should be renewed one or more times. After a person has become accustomed to the bath, this pre-INDOOR SUN-BATH 215 caution is unnecessary, and it is not often required except in the case of feeble patients, and those who are very susceptible to the stimulat- ing effects of the sun’s rays. In the treatment of various local affections which are especially amenable to phototherapy, it is seldom necessary to limit the action of the solar rays to the affected part, as great benefit may be nearly always derived from the general improvement in metabolism induced by the application of light to the entire cutaneous surface. When localized applications are considered necessary, however, the exposure may be confined to the affected parts. I have found it convenient, Fig. 52.—Indoor Sun-rath. in these cases, to employ white sheets or blankets as a protective, as this secures at least a partial exposure of all parts of the suiface. Feeble patients will necessarily recline during the application. More vigorous patients may walk about in an outdoor gymnasium 01 solarium, and may even engage in light gymnastics of some soit, or gymnastic games, with advantage, especially when it is desiied to increase oxidation to as high a degree as possible, as in obesity, diabetes, and the lithemic diathesis. The duration of the bath will vary considerably, according to the patient, the season of the year, and the condition of the atmosphere.216 heliotherapy: general and local use of sunlight A feeble patient who has not been accustomed to the sun, should, at the first sittings, be exposed, at least to a very hot sun, for not more than three minutes ; longer exposure is likely to produce headache, lassitude, insomnia, and depression. Such sensitive individuals are also very likely to be sunburned by a prolonged exposure. It is well to guard against this accident, for although no serious or permanent injury is likely to result, it is very disagreeable to the patient, and may discourage further efforts in a direction essential to recovery. The only treatment ordinarily required is the application of dry starch or a little zinc ointment; if there is considerable swelling, the cooling compress should be employed for a day or two. The sun-baths need not be interrupted ; it is only necessary to cover the affected parts during the application. In persons with light hair and blue eyes—blondes—the skin is always thin and very sensitive. The skin of persons with dark com- plexion and dark hair,—brunettes,—and of those who belong to the dark-skinned races, is much less susceptible to the influence of the actinic rays, and hence less likely to suffer from overdoses of sunlight. In such persons the exposure may be prolonged to half an hour or even an hour without detriment. After considerable training it is possible, in fact, for the patient to expose the greater portion of the body to the influence of the sun’s rays for several hours daily, not only without ill result, but with great benefit. When the bath is applied daily, the skin rapidly acquires a brown- ish.tint through the increase of pigment. The protection afforded by this pigmentation not only permits a longer exposure without injury, but also seems to make a longer application necessary to insure the desired results. I have often seen patients in the outdoor gymnasium whose naturally white skins had become as dark as that of a mulatto, or a half-caste Hindoo, or South Sea Islander. This darkening of the skin indicates approximately the metabolic and therapeutic activity of the solar rays. The intensity of the sun’s rays is very much greater in north temperate latitudes, during the three months from the middle of June to the middle of September, than in any other season of the year, increasing as the sun approaches the summer solstice and diminishing as it recedes. A clear or rarefied atmosphere also increases the intensity of the sun’s rays. This fact should be borne in mind in the application of the sun-bath in elevated regions. In the clear, rare atmosphere of a region elevated five thousand or more feet above the sea, the sun’s rays are so intense that equal effects are obtained in half the time required at the sea-level. To produce the best results, the sun-bath should be taken daily, and the duration should rapidly be increased until the patient can bear exposure for from thirty to sixty minutes, at least once a day.AFTER-TREATMENT 217 A finishing treatment of some sort is always required at the conclusion of a sun-bath. This will differ according to the patient. In general, it is best to make a tonic hydriatric application. The measures most serviceable in cooling and invigorating the skin, and in counteracting, by a general tonic impression, any depressing effect which may have been induced by superheating of the blood, are the following : The Cooling Douche.—This may consist of a simple shower- bath or rain douche, a needle spray or circle douche, the hori- zontal rain douche or spray, or the horizontal jet. (See Fig. 15, p. 84.) The vigor of the application must depend upon the patient; a strong patient who is accustomed to cold water applications will be benefited by a full horizontal cold jet, while a feeble patient will require the broken jet, the spray, the shower, or even the fan douche. The temperature of the application may be from 70° to 450 F. (210 to 70 C.). For most patients, 6o° F. (15.5° C.) is a suitable tempera- ture. The higher the temperature, the more prolonged the application should be. When the temperature employed is so low as 50° to 45 0 F. (Io° to 70 C.), the application should not last more than twenty to forty seconds. At 6o° to 70° F. (150 to 210 C.) the duration may be forty to sixty seconds. A very good plan, which is adapted to the great majority of cases, is the application of the rain douche at 700 F. (210 C.) for forty seconds, the patient meanwhile rubbing himself well and the application terminating with the full jet or the per- cussion douche at 6o° to 50° F. (150 to io° C.) for fifteen seconds. In the application of the douche special attention should be given to the spine, which may receive the stream at full force, care being taken to avoid any sensitive points which may exist. In the absence of a douching apparatus, a very useful substitute may be found in the pail douche. The patient sits in a full bath while water, previously prepared at a proper temperature, is dashed over him from a common water-pail. The temperature of the water should be the same as for the douche.. It is well to have three pails filled with water at different temperatures. The first pailful should have a temperature of about 750 F. (240 C.), while the temperature of the second should be io° F. (say, 50 C.) lower, and that of the third 50 to io° F. (say, 30 to 50 C.) lower still. Cold Wet Rub.—The patient is rubbed with a mitt of coarse cloth dipped in cold water or with a cold wet towel, or a wet sheet rub is administered. In giving the cold towel rub, the towel is wrung out of water at 6o° F. (say, 150 C.); it is then quickly applied to the patient’s body and rubbed on the outside until warm. The patient assists in hold- ing the towel in place. When the towel becomes warm, at the end of a quarter to half a minute, it should be removed, the parts should2l8 heliotherapy: general and local use of sunlight be rubbed dry, and the towel, freshly wrung out, applied to another part, the process being repeated until the whole surface of the body has been rapidly gone over. The wet sheet rub is simply an extension of the towel rub. (See also pages 77 et seq.) A sheet wrung out of water at a tempera- ture of 6o° F. (say, 150 C.) is quickly wrapped about the patient while he stands erect. The sheet is fastened about the neck to prevent its slipping down ; then two persons rub vigorously upon the outside of the sheet until it is warm, after which the sheet is removed and the patient is rubbed dry. The Shallow Bath.—The patient sits in a tub containing four inches of water at a temperature of 750 to 65° F. (say, 240 to 180 C.). The head, face, and neck should be well cooled before he enters the bath, and while in the water he should be protected by a cheese- cloth napkin wrung out of water at 6o° F. (say, 150 C.) and applied to the head and neck. During the bath he should be well—even vigorously—rubbed by an attendant, who, at intervals of half a minute or so, dips up water and pours it upon the spine. The patient assists by rubbing his own chest. The duration of the bath should be from about thirty seconds to a minute and a half. The Swimming-bath.—The swimming-bath is one of the best of all hydriatric measures to be employed after the sun-bath. It is most conveniently utilized in connection with the outdoor gymnasium. The temperature of the swimming-bath should be 70° to 750 F. (say, 2i° to 240 C.) for the average patient. Robust patients may endure a temperature of from 5° to io° F. (say, 30 to 50 C.) lower. After some training, patients may advantageously alternate several times between the sun-bath and the swimming-bath, remaining in the sun until perspiration begins, then plunging into the swimming-bath for two to five minutes, then returning to the sun again; thus repeating three to five times. The patient should drink freely, both before, during, and after the bath. The best drink which can be recommended is carbonated dis- tilled water, with the addition of a little fruit juice of some sort, such as the juice of lemon, orange, raspberry, or grape, to enable the patient to drink a larger quantity. The carbonic acid gas promotes absorption. From two to four glasses of water should ordinarily be taken during the bath. The Alcohol Rub.—In the case of feeble individuals, espe- cially those subject to general neuralgic pains, very cold hydriatric applications are sometimes inadmissible. The necessary toning of the cutaneous vessels may be accomplished in these cases by means of the alcohol rub. Alcohol is applied to a small area, as an arm, or the front of the chest, in sufficient quantity to moisten the part well. Light friction is then applied by the hands until the alcohol has whollyPHYSIOLOGIC EFFECTS 219 evaporated. Another part is then treated in like manner until the whole body has been gone over. By this means the skin is cooled without chilling the patient or producing a general retrocession of blood by universal contraction of the cutaneous vessels. Combined Sun-bath and Sand Bath.—The sun-bath may be advantageously combined with the sand bath for the reason that the sand being warmed by previous exposure to the sun, the whole sur- face is equally heated, so that perspiration, with the maximum effects of the bath, is more rapidly induced. This is particularly true in the treatment of rheumatic individuals, who are especially benefited by sun-bathing. Sufferers from chronic rheumatism, especially those whose joints are painful, should not receive a general cold application at the conclusion of the bath, but should be sponged with tepid water, placed in a sheet, lightly wrapped, and allowed to cool off gradually. Immediately after the sun-bath the joints should be wrapped in cotton or wool and covered with mackintosh to avoid chilling by evapora- tion. Significance of Body-temperature.—The temperature of the patient should be taken before, during, and at the conclusion of the bath. The superheating which naturally results from an exposure sufficient to induce perspiration will be accompanied by an elevation of temperature amounting to one or two degrees F. (o. 50 to i° C.). At the beginning, in the treatment of feeble patients, the temperature should be taken every ten to fifteen minutes, and the patient should be withdrawn from the bath when the body-temperature reaches ioo° F. (say, 38° C.). The thermometer is a very good criterion of the effects of a bath. Patients who do not perspire readily, naturally show a higher tem- perature than those in whom perspiration is easily induced. Diabe- tics; chronic dyspeptics with dry, sallow skins ; chlorotics ; and persons in whom the allox uric diathesis is strongly developed are especially subject to overheating, and hence require careful watching. Free drinking of water is a precaution that should be resorted to in these cases. There is little danger of overheating in the case of patients who perspire readily. An ancient method of employing the sun-bath, which is now obsolete, consisted in wrapping the patient in the skin of an animal, and then exposing him to the intense heat of the sun’s rays until vigorous perspiration was induced. A favorite place for making the application was the sandy beach of the seashore. After the bath, the patient was cooled by plunging him into the cold sea water. Physiologic Effects of the Sun-bath.—The effects of the sun- bath include all those physiologic influences which have already been pointed out as characteristic of light. In sunlight the calorific, luminous, and actinic rays are all present in the highest degree220 HELIOTHERAPY : GENERAL AND LOCAL USE OF SUNLIGHT of intensity, and the reactions induced represent the combined influence of these three powerful natural agencies. The heat rays give rise to an elevation of body-temperature, thus producing thermic effects practically identical with those induced by hot water, hot air, vapor, and all other means that increase the temperature of the blood, whether by causing an accumulation of heat within the body, or by preventing its escape through radiation and evaporation. The elevation of the body-temperature stimulates the heart, brain, and every other organ. Metabolic activity is increased. There is an increased production of carbonic acid, indicating an increased consumption of hydrocarbon and carbohydrates, which also occurs when the body is exposed to cold ; and there is likewise an increased oxidation of proteid, one of the characteristic effects of all measures which raise the temperature of the blood. These physiologic effects have an exceedingly important bearing upon the therapeutic effects and indications of the sun bath. As a result of the thermic stimulation, the cutaneous vessels are dilated, whereby, in conjunction with the increased activity of the heart, the movement of blood, and consequently metabolism through- out the whole body, are greatly accelerated; while the heating of the blood stimulates the activity of the sweat glands, giving rise to exceed- ingly active perspiration. The amount of sweat produced may be increased from the normal average of one and one-half ounces in an hour to as much as two or three pounds, and even more, in an hour, especially when the patient engages in active exercise. The overfilling of the cutaneous vessels diverts from the interior of the body a considerable amount of blood, since, when filled, the vessels of the skin may contain one-half to two-thirds the total quantity of blood in the body. The natural result is a draining of all the viscera; a condition allied to collateral anemia is estab- lished in the brain, liver, kidneys, stomach, spleen, and other viscera. Cerebral anemia manifests itself in drowsiness, which often causes the patient to fall into a profound slumber. This is one of the charac- teristic and noticeable effects of the sun’s rays on the nervous system. While the thermic rays of the sun are producing these profound effects upon the circulatory system, the chemical rays are acting with equal intensity upon the nervous system. That this is a real and not a fancied influence has been thoroughly established by the observations of Finsen and others who have carefully studied the subject. The phenomena of sunstroke and sunburn are also indubit- able evidences of these effects, as well as of the general influence of light upon animal and vegetable life, which has already been pointed out That sunlight is one of the most powerful tonics that can be brought to bear upon the animal organism cannot, in the light of modern researches, be doubted.INDICATIONS AND COUNTERINDICATIONS 221 Indications.—The sun-bath is applicable in all forms of disease accompanied by defective metabolism, especially in conditions character- ized by deficient oxidation, as obesity, diabetes, and the uric acid diathesis. The dry, sallow, leathery skin of chronic dyspepsia— an evidence of the defective oxidation and profound autointoxication— rapidly becomes moist, lively, and velvety as the result of an hour’s daily sunning. Neurasthenia, in all its forms, is materially influenced for good, the quality of the blood is improved, and all the tissue-build- ing and energy-storing processes are stimulated. In anemia and chlorosis, the blood-making processes are encouraged, toxins are eliminated, and the spasm of the cutaneous vessels, which results in chronic visceral congestion, is rapidly relieved. In myxedema and exophthalmic goiter the sun-bath is of great value when employed with proper precautions. Care must be taken to guard the heart dur- ing hot baths of all sorts by placing an ice bag or cold coil over the precordia. In Bright’s disease, as in cirrhosis of the liver and in all other forms of visceral degeneration, patients often receive surprising benefit from this simple measure, when it is employed with proper adaptation to individual needs. In such affections great care must be taken in cooling the patient after the bath. The cold mitten friction, the cold towel rub, and the wet sheet rub are excellent means of ton- ing the skin. The cold plunge, the shallow bath, and similar measures, are unsafe in the majority of cases. In chronic rheumatism, rheumatic gout, and even in tuberculous joint disease, the sun-bath often accomplishes wonders, always affording amelioration, and sometimes aiding the patient to recover in cases which seemed quite hopeless. Winternitz has recently called attention to the great benefit that may be derived from exposing the skin to the sun in various cutaneous disorders, especially eczema. He covers the skin with a thin red cloth, and then exposes the parts thus protected to the influence of the full solar ray for some hours daily. Psoriasis also yields to this method. I have met with success in several cases of chronic acne of the face and shoulders. Counterindications and Special Precautions.—-The sun-bath is counterindicated in all febrile disorders, except in cases of chronic pulmonary disease with slight elevation of temperature. Decided febrile activity, however, should always be regarded as a counterindi- cation to general sun-bathing, or as necessarily limiting the exposure to a very few minutes, never long enough to increase the elevation of temperature. It should be remembered that in cases of this sort the thermotactic functions of the body are disturbed, and an elevation of the temperature is very easily induced. In eruptive fevers, especially in smallpox, the chemical rays should be excluded altogether. This may be accomplished by the use222 heliotherapy: general and local use of sunlight of red glass or translucent red paper in the windows of the sick-room, or by hanging heavy red curtains before them, as practised by John of Gadsden. Finsen and others have shown that this precaution pre- vents the formation of pustules, and shortens the course of the disease. In cases of insomnia, great care must be taken to avoid over- heating the head; the cold application following the bath should be carefully graduated, and at its conclusion a cold spray may be applied for ten or fifteen seconds to the legs and feet. In cases of rheumatism, gout, and rheumatoid arthritis, the cold application following the sun-bath must not be too intense or too prolonged. It is often better to cool a patient, especially at the beginning of a course of treatment, by a tepid shower or fan douche or the broken jet. The temperature should be from 85° to 750 F. (say, 30° to 240 C.), and the duration, twenty to sixty seconds. Care must be taken to avoid allowing the stream of cold water to fall directly upon the affected joints, as this will increase the pain. In cases of cardiac disease, in which there is marked evidence of failing compensation, prolonged exposure to the sun should be avoided, and the succeeding cold application should be very moderate in character, the temperature not being lower than 6o° F. (say, 150 C,), and the duration from ten to twenty seconds. If the cold application is in the form of a douche, the precordial region should be avoided ; the legs, the back, and the liver region receiving chief attention. In these cases, how- ever, it is, as a rule, better to cool the patient by means of a cold towel rub or a wet sheet rub. When skin eruptions are present, very cold applications and friction must be avoided. The patient may be cooled by a prolonged rain douche at 85° to 78° F. (say, 30° to 25° C.) or a tepid bath at 90° to 85° F. (say, 320 to 30° C.) for two to six minutes. Reaction should in these cases be promoted by exercise after the bath rather than by friction. LOCAL APPLICATIONS OF SUNLIGHT Local applications of sunlight are commonly made with lenses or concave mirrors by which the sun’s rays may be concentrated. I first employed the concentrated rays of the sun in this manner in the summer of 1883. The method was then successfully used in the treatment of a case of inveterate neuralgia of the posterior branches of the spinal nerves, and later in various other classes of cases. Experiments have shown that these concentrated rays have considerable penetrating power. Mode of Action and Effects.—In these local applications of the concentrated solar rays, the chemical ray must be regarded as the active agent. The principal embarrassment which arises in the employment of concentrated light is the great intensity of the calorificfinsen’s method 223 rays, which renders the application intolerable after the first few sec- onds. Finsen first succeeded in overcoming this difficulty. He fil- tered out the calorific and luminous rays by passing the solar rays through a blue solution made by dissolving copper sulphate in dilute ammonia water. The strength of the solution may be varied to suit the intensity of the sun’s rays at different seasons. It should be just sufficient to reduce the heat to a degree which the skin will tolerate when the rays of the sun are brought to a focus, the purpose being to obtain the highest degree of activity of the chemical rays while reducing the action of the heat rays to the point of tolerance. Fig. 53.—Finsen’s Method of Localized Heliotherapy.—(From a Photograph loaned by Dr. H. IV. Stelwagon.) The patient suffers no pain during the application, although there is sometimes intense itching. The surface under treatment reddens during the seance, and a few hours later the tissues may be slightly swollen. Twenty-four hours later a vesicle filled with clear serum usually appears. In a few days this is dry, leaving thin crusts, which are readily removed by means of dressings moistened with a solution of boracic acid. Sloughing never occurs. The effect is simply that of an intense sunburn. Technic.—In order to increase the influence of the chemical rays224 HELIOTHERAPY : GENERAL AND LOCAL USE OF SUNLIGHT Finsen found it expedient to compress the tissues, thus emptying the blood-vessels and rendering the skin nearly transparent, experiments having shown that the opacity of the tissues is chiefly due to the presence of the red blood-corpuscles. This compression is accom- plished by means of a hollow glass disc, which is made to act as a refrigerant of the tissues by means of a constant stream of cold water passing through it. It is thus possible to concentrate the sun’s rays to a degree that would otherwise be intolerable. In an emergency, the same thing may be accomplished by a very simple though less practicable means. An ordinary lens about six inches in diameter is employed to concentrate the solar rays, which are allowed to fall upon the skin after passing through a thin disc of ice an inch or two in diameter, held Fig. 54.—Effect of Heliotherapy. — (Finsen.) upon the skin. The ice is pressed firmly upon the part and thus empties the blood-vessels, blanching and cooling the tissues. The cut on page 223 (Fig. 53) shows the devices employed by Finsen in the use of the solar rays. The duration of the application is from an hour to an hour and a half. The application is confined to an area of one to three square centimeters, and is renewed daily, until the part is well cicatrized. Then another part is similarly treated. There is no danger whatever in these local applications of the solar rays. The necessary apparatus is somewhat expensive ; but the only inconvenience attending its use is the considerable length of time required.INDICATIONS FOR LOCAL HELIOTHERAPY 225 Indications.—The actinic rays have been employed by Finsen and others in the treatment of various forms of lupus, epithelioma, and several varieties of acne, alopecia, and other maladies of the skin. The method has proved especially successful in lupus vulgaris. The accompanying illustration (Fig. 54) shows the effect of treatment. When visiting the Light Institute of Copenhagen in 1899, I was informed that benefit had been derived in nearly all cases, and that failure had occurred only when the patient had not remained under treatment for a sufficient length of time. Note was also made of the interesting fact that better results were obtained during the summer season, when the patients were treated by the solar rays, than during the winter season, when the treatment was administered indoors by the aid of the arc light; this difference is probably due to the tonic effects of the general exposure to the sun. The success obtained in the treatment of epithelioma of the skin was also highly encouraging, nine cures being obtained out of eighteen cases treated. Of twenty-nine cases of alopecia areata, twenty-two were cured. None of the rest were discharged as incurable, but some were obliged to discontinue treatment for various reasons. The treatment of lupus by this method must be carried out with great perseverance. Finsen states that his patients remain under treat- ment, on an average, for about four and one-half months. In some cases two or three applications effect a cure, while in other cases in which the disease covers a considerable area a long time is required, since in many cases the applications must be repeatedly made to each part before a permanent cure is effected. It is well to note that the cure is not effected by destruction of the tissues, but by destruction of the parasitic elements upon which the disease depends, and a quickening of the vital activities of the tissues, whereby their power of defense is increased. ix—15CHAPTER II ELECTROPHOTOTHERAPY Physiologic Effects. Electric Sunstroke. The Arc Electric Light Bath— Description and Technic; Physiologic Effects ; Indications. Local Applica- tions of the Arc Electric Light. The Incandescent Electric Light—Tech- nic ; Physiologic Effects; Therapeutic Effects a7id Mode of Application; Indications. THE THERAPY OF THE ELECTRIC LIGHT Physiologic Effects.—Experiments for the purpose of deter- mining the effects of the electric light upon vegetable life were first made by William Siemens in 1880. His conclusions may be sum- marized as follow: 1. That the electric light is efficacious in producing chlorophyl in the leaves of plants, and in promoting growth. 2. That an electric center of light equal to 1400 candles, placed at a distance of two meters from growing plants, appears to be equal in nutritional effect to average daylight in March, while greater effects may be attained by more powerful light centers. 3. That while under the influence of the electric light, plants can sustain increased stove heat without collapsing—a circumstance favor- able to forcing by electric light, and showing the influence of light as a vital stimulant. Herve-Mangon,1 Prillieux,2 Sarat, and other later investigators confirmed the experiments of Siemens. Sarat showed that potatoes and tomatoes ripen sooner, and that hemp grows sixteen inches longer, under the influence of th$ electric light. Experiments con- ducted at the Cornell University Agricultural Station, in 1889 and 1890, showed that: 1. The electric light properly employed compares favorably with sunlight in its power to promote protoplasmic activity. 2. Electric light acts as a tonic to plants, enabling them to endure adverse conditions which they would not otherwise be able to resist; and acts as a true vital stimulus, the effect of its use at night to supplement the influence of daylight being practically identical with that of the prolonged solar day of the Arctic regions. 1 “ Compt. Rend.,” 53, 243. 226 2 “Compt. Rend.,” 69, 410.THE ARC ELECTRIC LIGHT BATH 227 Bacteria are killed in a few minutes by exposure to the concen- trated rays of an electric arc lamp of 6000 candle-power. Electric Sunstroke.—A condition which has been termed by the French ‘ electric sunstroke ’ affords convincing evidence that the physiologic effect of a powerful arc light is practically the same as that of sunlight of equal intensity. Electric sunstroke was care- fully described by De Fontaine, who witnessed an experimental exposure of a surgeon (Maklakow) to a powerful electric arc light used for welding metals in a factory near Moscow. The result was a most pronounced erythema of the face, chemosis of the conjunc- tiva, coryza, lacrimation, photophobia, and intense burning of the skin. At the end of the second day the inflammation began to sub- side, and on the third day desquamation began. Pigmentation of the skin remained for some time. The effects of the electric light upon the skin are the same as those induced by the sun—profuse perspiration, pigmentation, and erythema. These effects indicate that the same powerful influence exercised by the sun’s rays upon metabolism and the nervous system is likewise present in the light rays emitted by the electric arc. THE ARC ELECTRIC LIGHT BATH The electric light, as has been shown, possesses properties identical with those of the sun’s rays; in the arc light the luminous and chemical rays predominate, in the incandescent light the heat rays. The difference in form between the arc lamp and the incandescent lamp, and the decided difference in the quality of the light obtained from these two sources, naturally divide the devices by which these two forms of light are utilized therapeutically into two distinct classes —arc light baths and incandescent light baths. In the earliest forms of the arc light bath, a single arc lamp was employed and a reflector was placed behind it in such a position as to focus the rays upon the patient’s back. Baths of this sort were employed empirically in the United States more than twenty years ago. In 1891 I had constructed various forms of electric light apparatus, employing for the first time incandescent lamps ; later I constructed cabinets with both arc and incandescent lamps, with which exact observations were attempted. Description and Technic.—The arc light, while emitting much more powerful rays, has not thus far proved to be so useful for general purposes as the incandescent light. Its bulk, the expense attending its installation, and the numerous inconveniences attending its employment are perhaps sufficient reasons why its use has thus far been quite limited. For general application I have found most228 ELECTROPHOTOTHERAPY convenient a square cabinet of such shape and height as to permit the patient’s head to be excluded from the bath while he sits erect upon a stool in the center of the cabinet, a recess being provided at each corner in which is placed a powerful arc light arranged in such Fig. 55.—Arc Light Cabinet. a manner that it may be adjusted to any level. Its construction is imperfectly shown in figure 55. The cabinet is lined with aluminum, nickel-plated copper, or silvered glass, so as to direct the rays toward the center. Mounted glass screens attached by hinges at either sidePHYSIOLOGIC EFFECTS OF ARC LIGHT 229 of the recess are so arranged that either a red or a blue screen can be interposed at will between the lamp and the patient. By this means it is possible to employ the unfiltered rays or either the chemical or the calorific rays alone. When the chemical rays are required, it is only necessary to interpose the blue screen ; while the red screen allows the passage of heat rays only. The recess containing the lamp is open at top and bottom, so that, by a free circulation of air, the heating of the glass screen, and con- sequently the heating of the air of the cabinet, may be, so far as possible, prevented. The cabinet itself is also freely ventilated, so that the effects of the bath are practically confined to the direct influ- ence of the radiant energy emitted by the electric light. Fig. 56.—Apparatus for Localized Electrophototherapy. — (Finsen.) Physiologic Effects.—The results obtained by the employment of this bath are essentially the same as those obtained from the sun-bath. Patients, however, begin to perspire more quickly than when ex- posed to an ordinary sun-bath. This may perhaps be due to the greater number of actinic rays in the arc light, which exercise a powerfully stimulating effect upon the sweat glands. A short application of the bath is highly tonic in its effects. A prolonged application produces depressing effects similar to those observed from the prolonged sun- bath. The duration of the bath maybe from five to twenty minutes.230 ELECTROPHOTOTHERAPY Indications.—These are precisely the same as those for the sun- bath. The measures described as suitable for after-treatment in con- nection with the sun-bath are equally applicable in connection with the arc light; and the precautions and counterindications are the same for both procedures. Our knowledge respecting the value of the arc light as a local therapeutic measure, and the methods of application, are almost wholly due to the inventions and observations of Finsen, who, after demonstrating the value of the actinic rays of the sun in the treat- ment of lupus and various other maladies of the skin, showed that the same results may be obtained by the employment of the arc light by the aid of suitable apparatus. The general directions for the use of the arc light in the treatment of lupus are the same as have already been given for the use of sunlight for the same purpose (see page 225). The Lortet-Genoud Lupus Lamp.—This recent improvement of Finsen’s original apparatus has practically brought the treatment of skin lesions by electric light within the reach of all. With an ordinary arc lamp of 10 to 15 amperes the patient can be brought close to the light, and the action on the skin in this way is increased so that the time of exposure can be reduced from one hour to fifteen minutes, while the cost of installation and current is considerably reduced. Although with the Lortet-Genoud lamp it is possible to treat only four patients with one lamp in one hour,—that is, thirty-two patients in an eight-hour day,—yet these thirty-two patients require only one attendant to look after them instead of four. The chief feature is that the use of a condenser is dispensed with. In doing this it becomes necessary, first, to make use of the chemical rays as near as possible to their origin before dispersion, since the degree of concentration increases directly with the proximity to the luminous source ; and, second, to protect the patient from the action of the heat rays. These indications are met by the apparatus in question (Fig. 57) in the following way : Between the light and the patient there is inter- posed a screen consisting of a metallic vessel in which a constant circulation of water is kept up to obviate heating. This vessel has a central orifice which allows the light to pass through, the orifice being in its turn closed by a hollow obturator, the two faces of which con- sist of quartz lenses. One of the faces of the obturator is in close contact with the skin and exercises compression, hence it is also known as the compressor. As it also has a constant circulation of cold water, the tissues with which it is in contact are subjected to constant refrigeration. The luminous rays from the electric arc fall upon the surface to be treated only about 3 or 4 cm. from their source, having undergone no concentration. Thus the available luminous zone is ofINCANDESCENT ELECTRIC LIGHT 231 considerable extent, instead of being about the size of a shilling, as in the ordinary method. The lamp is a continuous-current arc, taking a current of 12 to 15 amperes and from 55 to 65 volts. Fig. 57.—Lortet-Genoud Lupus Lamp. THE INCANDESCENT ELECTRIC LIGHT After the sun-bath, the incandescent electric light is the most useful and generally serviceable measure employed in phototherapy. Various appliances have been devised for both general and local ap- plications of the incandescent electric light. The first of these were constructed for me in 1891, and consisted of a number of simple devices for applying the electric light to small areas. The very first consisted of a cone of polished metal, about a foot in length, and ten to twelve inches in diameter at the base. In the apex was fixed a single elec- tric light socket, in which could be placed a lamp of any candle-power required. The cone was placed over the abdomen, the chest, the back, a joint, or any other part to which it was desired to make an application. The results obtained were so excellent that other de-232 ELECTROPHOTOTHERAPY vices for applying the light to special parts, as the spine, the trunk, the feet, and the joints, as well as apparatus for applying the light to the whole body, were rapidly constructed. The first general incandescent light bath consisted of a frame about two feet in width and six feet in length, upon which were sup- ported a metal reflector and twenty to thirty incandescent lamps. This frame was attached by hinges to a support in such a way that it could be raised and lowered. A couch was placed beneath it, on which the patient lay during the treatment. After the application had been made to one side of the body for a sufficient length of time, the patient turned over and received the light upon the opposite side. Fig. 58.—Author’s Incandescent Electric Light Apparatus for Spine and Feet. A little later cabinets were constructed—first a vertical, and then a horizontal one. Other cabinets of various forms and sizes have since been constructed by those who have interested themselves in the development of this therapeutic measure, particularly Winternitz. The horizontal cabinet employed by me is shown in figure 59. In this cabinet the patient lies upon a movable couch, mounted on wheels, and easily run in and out. The couch is provided with a thick glass top, beneath which a number of electric lights are placed so that the lower as well as the upper surface of the body is exposed to the influence of the light, making it unnecessary for the patientTECHNIC OF INCANDESCENT LIGHT BATH 233 to change his position in order to secure exposure of the whole surface. The small vertical cabinet, constructed with the head excluded, requires twenty to forty lamps. The horizontal cabinet contains ninety lamps of sixteen candle-power each. Other devices permit applications to the spine, trunk, joints, and other parts of the body. (See Fig. 58 and Fig. 60.) Fig. 59.—Author’s Horizontal Incandescent Electric Light Cabinet. Portable apparatus for making local applications of the incan- descent electric light have also been constructed. Technic.—For the application of the general incandescent electric light bath the patient’s clothing is removed just as he enters the bath, care being taken that the feet are warm, and the head, face, and neck234 ELECTROPHOTOTHERAPY cooled in preparation for the bath. The intensity of the bath is regulated by means of suitable switches, which render it possible to increase or diminish, at will, the number of lights. A rheostat may be used for the same purpose, leaving all the lights in operation all the time, but controlling the intensity of the light by increasing or decreas- ing the resistance. The duration of the bath must be determined by the effect de- sired. If tonic effects alone are required, the duration will be three to ten minutes, or until the skin becomes slightly moist. If it is desired to heat the skin thoroughly, then the patient remains in the bath until free perspiration is established. If eliminative effects are desired, the patient remains in the bath until vigorous perspiration has been continued for the time desired, say from fif- teen to forty minutes. In cases in which the applica- tion is considerably pro- longed, an ice-bag or the cold precordial coil should be placed over the heart, and a cold wet napkin should be wrapped about the head, or the head and throat, and this should be renewed as often as it be- comes warm. The temperature of the bath may range any- where from 150° F. (65.5° C.) to the highest temper- ature tolerable. It should be remembered that in this bath the heat is not derived from the air, as in the hot- air bath, but is communicated to the body by means of the heat rays or radiant energy thrown off by the incandescent filaments within the lamps. These rays pass through the air surrounding the patient without heating it to any very considerable degree. As the rays enter the body, they come in contact with various opaque structures, the resistance afforded by which converts the radiant energy into heat. It is apparent, then, that the temperature of the air surrounding the patient is a matter of very little consequence. It is important that the bath should be well ventilated, so that the moisture arising from the patient’s body may be carried off rapidly. The dryer the air, the higher the temperature the patient will be able to bear. Some French Fig. 60.—Author’s Electric Light Cabinet for Joints.PHYSIOLOGIC EFFECTS OF INCANDESCENT LIGHT BATH 235 observers report the employment of temperatures ranging from 400° to 500° F. (say, 200° to 3150 C.). These authorities employ, in taking the temperature of the bath, a thermometer whose bulb has been covered with lamp-black, and which is fully exposed to the light, being usually placed upon the patient’s body. Superheating of the air about the patient may be practised, when desirable, by simply restrict- ing the air space within the cabinet. It is thus possible to combine the hot-air bath with the light bath. In cases in which patients are rather intolerant of heat, the temperature may gradually be raised by connecting only a part of the lamps at the beginning of the bath, and bringing into use additional groups as the patient becomes able to bear a higher temperature. Care should be taken in the treatment of patients whose eyes are sensitive to bright light, to protect the eyes by means of a napkin laid across the face, or by glasses suitably colored. The after-treatment to be employed in connection with the in- candescent electric light or radiant heat bath is precisely the same as that employed after the arc light bath or the sun-bath. A cold appli- cation should be made in almost all cases. The only exceptions are those in which cold is counterindicated. General applications must be made after the general bath ; and after local applications, cold in some form should be applied to the parts which have been exposed to the action of the light and heat. For local applications, the douche and the cold towel rub are most satisfactory and efficient measures. Physiologic Effects.—My observations may be summarized as follow : 1. The most important property of the electric light bath is that of a superior heating agent. 2. An intense or a considerably prolonged application of the in- candescent electric-light bath, whether local or general, produces intense reddening of the skin, with dilatation of the superficial vessels. Its effect, in this respect, is comparable with that of a vapor or a hot-air bath. When the application is repeated many times, the parts become pigmented, or brownish in color, just as when the sur- face is exposed to the sun’s rays. It is proper to call attention here to the interesting observations of Conrad Klar respecting the rate at which heat is eliminated from the surface of the body when fully exposed to a temperature below that of the body. He found that the rate, during the first five minutes, was ten times the normal, or eighteen calories per minute ; in the second five minutes the amount of heat eliminated was only twice as great, the diminution being due to the contraction of the blood-vessels, resulting from the contact with cold air. In an electric light bath the radiant heat maintains continuous relaxation of the superficial vessels236 ELECTROPHOTOTHERAPY without heating the air about the patient to any appreciable degree, if free circulation is maintained. It is thus possible to maintain continu- ously, for a considerable length of time, conditions most favorable for heat-elimination, while at the same time heat-production is being stimu- lated by the thermic impression made, and the elevation of the tem- perature of the blood through exposure to the action of the heat rays in the widely distended vessels of the skin. This especial characteristic of the electric light bath unquestionably accounts for the increased production of carbon dioxid, which is a proof of the powerful influence of the bath upon metabolism, and of its remarkable alterative and reconstructive effects. 3. General perspiration is induced more quickly by the incandes- cent electric-light bath than by any other known procedure, generally appearing within three to five minutes after the patient enters the bath, and quite regardless of the temperature of the air about the patient. This observation has been confirmed by Winternitz and others. Winternitz reports having seen perspiration appear within a very short time, at a temperature not above 85° F. (30° C.); the time required to produce perspiration in the Turkish or hot-air bath is generally much longer. Cutaneous activity is considerably greater in the electric light bath than under the influence of any other sweating procedure. That the sweating is caused by the radiant energy and not by the contact of hot air with the body is shown by the fact that vigorous perspiration may be induced in a small area of the body, as in an arm or a leg, by subjecting the part to the influence of the light rays without confining it. Winternitz has observed that perspiration in the electric light bath begins first on the outer surfaces of the thighs, which are most exposed to the influence of the light. The profuse perspiration induced by an incandescent electric-light bath is doubtless due, in large part at least, to the stimulating effects of the light rays upon the nerve-endings in the skin. 4. There is a quite rapid rise in the body-temperature in the electric light bath. I have noted an elevation amounting to four or five degrees above normal in from fifteen to twenty minutes. This fact renders the bath of special value in the treatment of rheumatism, gout, and other phases of the uric acid or alloxuric diathesis. 5. Study of the respiration products shows a decided increase in the elimination of carbon dioxid, an evidence of the active oxida- tion and tissue changes set up by this procedure. In my observations made in 1894, the average percentage of carbon dioxid eliminated during an electric light bath of thirty minutes was found to be 5.13 per cent, in a patient who, previous to the bath, was eliminating 3.60 per cent.—an increase of 44 per cent. In a Russian bath the same subject eliminated an average of 3.96 per cent., an increase of 10 perTHERAPY OF THE INCANDESCENT LIGHT BATH 237 cent. ; while in a Turkish bath of thirty minutes the average elimina- tion was 4.1 per cent., an increase of 11 per cent The acceleration of oxidation indicated by the increased elimination of carbon dioxid was thus four times as great in the light bath as in the Turkish bath, and the difference was still greater as compared with the Russian bath. It should be noted also that respiration is free and without embarrassment, though somewhat quickened, contrasting widely with the distressed breathing often observed in the Turkish and Russian baths. 6. The blood-count, especially of the red cells, is increased to a marked degree (10 to 20 per cent.) by the electric light bath, fol- lowed by the usual cold bath ; the increase appears within half an hour, and continues for a longer time, and in cases of marked anemia, the increase is usually permanent, provided the application is repeated daily. 7. Under the influence of the incandescent electric-light bath, the pulse is at first slowed, but later is quickened. 8. The blood pressure is at first increased, later diminished. The therapeutic effects and modes of application of the incan- descent light bath may be summarized briefly as follows : 1. It is one of the most effective of all means of producing general and local revulsive effects, by dilating the cutaneous vessels. The reddening of the skin begins within a very few moments after the influence of the light is brought to bear, and becomes more and more intense as the application is continued. The permanency of the effects produced may be greatly increased by a short cold application follow- ing the light bath. The effect of such an application is to fix the blood in the skin by converting the passive venous congestion into an active arterial hyperemia, in which the * peripheral heart* is brought into active play. 2. The incandescent electric-light bath certainly has no equal among therapeutic means as a sudorific measure ; it induces per- spiration more quickly and 'more vigorously than any other agent, and with the least amount of inconvenience and discomfort to the patient. When employed for this purpose, especially when the bath is considerably prolonged, care must be taken to protect the heart and the head by means of cold compresses. The patient should be made to drink water very copiously, both to encourage diaphoresis and to maintain the normal blood volume. 3. The incandescent electric-light bath is a most effective means of promoting the absorption of exudates. For this purpose both general and local applications are valuable. In France the general electric light bath has been used successfully in promoting the absorption of exudates in the cornea of the eye, vitreous opacities,238 ELECTROPHOTOTHERAPY and other pathologic products of a similar nature. I have used it with most gratifying success in promoting absorption of exudates from the pleural and peritoneal cavities, and in and about the joints. There is no known means by which the absorption of exudates in the joints may more rapidly be induced than by general applications of the elec- tric light bath, combined with local applications of the light to the affected parts, and suitable hydriatric measures. Care should be taken to administer a cooling bath after general applications, and the alternate spray or douche after local applica- tion to the joints, this to be followed by the application of a heating compress, consisting of a linen towel wrung as dry as possible out of cold water and wrapped about the part, then covered with mackin- tosh and the whole covered with several layers of dry flannel so as to retain the heat. The local application of light should be made at least twice daily, the general application once a day. The heating compress should be changed at least twice daily. Massage and, in some in- stances, electric applications to the parts, and especially to the adjacent muscles, are important adjuvants. 4. For tonic effects no other means excels short applications of the incandescent electric light (three to eight minutes). A sensation of well-being, similar to that experienced by one who stands before a glow- ing fire, is most pronounced, and when followed by a proper hydriatric application, the stimulation to nutrition is of the highest possible degree. This statement is not made at random, but after ample experience. Indications.—In the treatment of the alloxuric diathesis in all its forms, and especially rheumatism, gout, lithiasis, and neuras- thenia due to alloxuremia, the increase of oxidation and general improvement in metabolism aid in the burning up of the nitrogenized waste matters and in the elimination of toxic elements. In cases of this sort, the bath should be applied two or three times weekly to the extent of producing vigorous perspiration and elevation of .the body-temperature two or three degrees. Copious water-drinking, an antilithemic diet, and abundant exercise out-of-doors, must support the phototherapeutic measures. Diabetes and obesity are benefited by the electric light bath through its potent influence upon carbon dioxid formation by the stimulation of the oxidation processes within the body. Fat dia- betics are especially likely to be benefited by the electric light bath. The inactive skin is caused to sweat freely under the powerful stimu- lus of the light bath. The increased oxidation lessens the excretion of sugar. The alkalinity of the blood is increased, and the organism is thereby better prepared to correct the disorder to which this malady of symptom-complex is due.THERAPY OF INCANDESCENT LIGHT BATHS 239 Obesity is in a high degree amenable to the powerful influence of the electric light. The incandescent light bath does not, like most other sweat baths, simply extract a considerable amount of water by increasing the activity of the skin. In addition, owing to the penetrating power of the light rays, much more is accomplished: the deeper structures of the skin are excited to activity ; the heat-making processes, by which fat may be consumed, are stimulated to an unusual degree, as shown by an increased elimination of carbon dioxid. When it is recollected that at least three-fourths of the energy of the body is consumed in heat-production, it is apparent that an increase of tissue consumption, amounting to much more than forty per cent., as shown by the author’s experiments, is a matter of the highest importance. Suppose this increase to be continued for the space of one hour only, as the result of a general electric light bath ; this alone would represent a considerable loss of fat. But, as Conrad Klar has shown, the heat- elimination may be increased to more than ten times the normal amount, and this may be continued, not for a few minutes only, but for a considerable length of time, when the temperature of the air surrounding the patient is below the temperature of the body, provided the blood-vessels are maintained in a state of active dilatation, as is possible in the electric light bath, but in no other heating procedure. Sciatica, intercostal neuralgia, vague neuralgic pains, and myal- gia yield readily, in the majority of cases, to the use, daily or thrice weekly, of the incandescent electric-light bath, especially when combined with carefully administered tonic hydriatric measures, massage, a proper dietary, and an outdoor life. Autointoxication and chronic metallic poisoning find in the incandescent electric-light bath a most efficient remedy. The enor- mous elimination of water through the skin secures the ingestion of water in abundant amount, and at the same time promotes absorption through the mucous surface, thereby subjecting the tissues to a veritable water bath and cleansing them of accumulated wastes and other toxic agents, which disturb metabolism and interfere with normal tissue activity. In chlorosis and anemia the most excellent results are obtained by the systematic employment of the incandescent light bath. There is no more efficient means of dilating the cutaneous vessels, to whose con- traction is due the pallor characteristic of these disorders, thus relieving the visceral congestion necessarily present. This prompt balancing of the circulation establishes the primary condition essential to aid the recuperative powers of the body in their effort to re-establish normal blood-making processes. In nephritis the electric light bath, by diverting half to two- thirds of all the blood in the body into the skin, affords prompt relief of the congested and inflamed parts. In this condition, perspiration240 ELECTROPHOTOTHERAPY may be prolonged for many hours if necessary, care being taken to refresh the patient at intervals by a very brief energetic cold rub with a friction mitt, by an ice-bag over the heart, and by protection of the head with cold compresses. Great care should be taken to avoid chilling the patient. A very slight chill, such as might result from momentary exposure of the body to the influence of evaporation from a moist surface, might be sufficient to cause contraction of the cuta- neous vessels, and counteract the good effects of the bath. Im- imediately after the administration of the bath, the patient should be wrapped in flannels. This process should be repeated at intervals of four to six hours, and perspiration should be maintained from twenty-four to thirty-six hours, or until the renal function is established. According to Rieder, the incandescent electric-light bath affords good results in syphilis, in chronic bronchitis, and in bronchial asthma. The same author also obtained good results from the use of this bath in cardiac hypertrophy, and in cardiac dropsy. In these conditions, however, according to my experience, the bath must be used with a considerable degree of caution. The temperature should be low at first, and very gradually increased, always avoiding excessively high temperatures. The heart must be guarded by an ice-bag or cold precordial coil placed over it before the heat is turned on, and the application should be brief, barely sufficient to induce gentle perspiration. Cold mitten friction should be applied immedi- ately afterward, and great care should be exercised that the patient does not become chilled by exposure following the bath. The cutaneous activity induced by the procedure, with the precautions suggested, greatly relieves the overburdened heart by diminishing the distention of the right ventricle, by lessening the resistance in the peripheral vessels, and by setting at work the ‘ skin-heart/ which is often most inactive in this condition. Chronic tuberculous or inflammatory disease of bones, chronic leg ulcers, paralysis, and trophic disorders, may be bene- fited by exposure of the parts to the full sunlight, and by the appli- cation of the concentrated solar or electric light rays. It might almost be said in conclusion that to mention all the con- ditions for the treatment of which the incandescent electric-light bath has been recommended with more or less reason, would involve the discussion of almost every important chronic affection known to medical science. The procedure is certainly a most effective means of bringing into activity and maintaining in operation those natural recuperative forces by means of which all actual curative processes must be instituted and carried forward. The hygienic value of the electric light bath can scarcely be overestimated. In cities, where the sun-bath is available to only aHYGIENIC USES OF ELECTRIC LIGHT 241 limited degree at any season of the year, and during the winter, when the sun’s rays are of little intensity, and are for a large part of the time obscured by clouds, the electric light bath affords a capital substitute for sunlight. The exposure of the naked body to the influence of the active radiant energy of the incandescent electric light during a period of from five to-ten minutes daily or thrice weekly, is a measure certain to- afford ample compensation for the trouble and expense involved. Care should be taken, however, to follow the bath by a short plunge at a temperature of 65° to 750 F. (say, 18.50 to 240 C.), or a vigorous application of the douche at a temperature of 6o° to 50° F. (15.50 to io° C.). The cool half-bath, or even the cold sheet rub, is a less vigorous but an effective substitute for the douche or the plunge when these are not available. ix—16CHAPTER III PRINCIPLES OF THERMOTHERAPY Definitions. General Physiologic Effects—Effect of Heat on Skin ; Muscles ; Nervous System ; Cirdelation ; Blood; Respiration ; Body-temperature ; and on the Viscera. Anatomic Basis. Cutaneous Reflex Areas; Correlated Vascular Areas. The Practice of Thermotherapy—General Indications; Modes of Application. THERMOTHERAPY Definitions The employment of heat as a therapeutic agent technically includes applications at all temperatures and irrespective of the nature of the media through which the application is made. Properly speaking, hydriatric applications of all sorts, both hot and cold, vapor baths, hot- and cold-air baths, and even light baths, are thermic applica- tions, and they are so spoken of in preceding chapters. Here, how- ever, attention will be confined to the consideration of such applica- tions as are capable of directly communicating heat to the body ; hence, cold applications of all sorts will be excluded. Vapor and Russian baths, which may properly be termed thermic applications, are also omitted from this chapter, having received consideration else- where. Media of any sort having a temperature .above that of the body are said to be hot. Temperatures above 104° F. (40° C.) are termed very hot. Temperatures near that of the skin are termed warm. These terms, with others relating to temperature, are commonly used rather loosely. To secure accuracy in prescription it is better to indi- cate the exact temperature. When ordinary terms are employed, they may be understood as expressing approximately the following tem- perature values: Very cold, 320 to 550 F. (say, o° to 12.50 C.); cold, 550 to 65° F. (say, 12.50 to 180 C.); cool, 65° to 8o° F. (say, 18° to 270 C.) ; tepid, 8o° to 920 F. (say, 270 to 33.50 C.) ; warm, 920 to 98° F. (say, 33.50 to 370 C.) ; neutral, 920 to 95° F. (say, 330 to 350 C.); hot, 98° to 104° F. (370 to 40° C.) ; very hot, 104° F. (40° C.) and above. For a full understanding of thermotherapy, it is essential that one should be familiar with the fundamental principles of hydrotherapy, as set forth in Part I of this volume. The limitation of space will here 242PHYSIOLOGIC EFFECTS OF HEAT 243 permit only a brief statement of the physiologic effects resulting from warm and hot applications, general and local, which will be followed by a description of the technic of hot applications and a summary of their therapeutic uses. For convenience in discussion some of the facts and principles already set forth may be repeated on occasion. GENERAL PHYSIOLOGIC EFFECTS OF HEAT The primary effects of heat are those of an excitant or a phys- iologic stimulant. Within physiologic limits, the application of heat to living cells increases the activity of their protoplasm, an effect easily recognized in the quickened movements of the amebae, leuko- cytes, and other minute animal forms, when placed upon a warming stage under the microscope. Heat is thus one of the most powerful of all vital stimulants, exciting the function of all tissues upon which it may be brought to bear—glands, nerves, nerve-centers, and the like. These effects, however, are temporary, and are followed by sec- ondary effects of an opposite character,—depression,—a sort of negative or atonic reaction after the withdrawal of the hot application. To these secondary depressant or atonic effects are attributable the weakening or exhausting effects of thermic measures when improperly managed or inappropriately applied. These mixed effects are due to the different functions of the various structures which are directly excited by the elevation of temperature following the immediate contact with a heated medium. Elevation of temperature of the sweat-glands and nerve structures heightens their activity. If the application of heat is continued for a sufficient length of time to raise the temperature of the blood, all the vital activities of the body are accelerated. At the same time, however, there is set in operation a series of inhibitory effects which result from the stimulation of the heat-nerves, the tendency of which is to lessen heat-production and lower blood pressure, and diminish the disposition to and the capacity for mental and muscular activity. Cold acts in precisely the opposite way. In lowering the temperature of the structures of the skin, it acts as a depressant, diminishing the activity of the sweat-glands and other structures. If continued long enough to lower the tempera- ture of the blood, heat-production and other forms of vital activity are lessened. Cold acts, however, as an excitant to the cold-nerves of the temperature sense. (These nerves as well as others may be paralyzed by an intense or prolonged application of cold.) Stimulation of the cold-nerves reflexly produces strong excitation of almost every bodily function. The force of the heart contraction is augmented, the blood pressure is raised, heat-production increased, metabolic activity quick- ened, and the disposition to and the capacity for mental and muscular activity heightened. The effects of heat are, then, directly excitant,244 PRINCIPLES OF THERMOTHERAPY indirectly depressant; while the effects of cold are directly depressant and indirectly excitant. These mixed effects afford opportunity for an infinite number of variations in the form and intensity of hydric and thermic applications, and in therapeutic effects. The actual effects of a thermic application depend (a) upon its temperature, duration, and form; and also (p) upon the con- dition of the patient. A prolonged application at a high temperature is at first excit- ant, and then decidedly depressant. The excitation is the natural result of the elevation of the temperature of the blood. The depress- ing effects appear to result from the lowering of the nerve tone and the exhaustion of nervous energy by overstimulation. A very brief application at a high temperature is strongly excitant, and the depressing effects which follow may be so slight as to be quite imperceptible. A less intense and moderately prolonged thermic application is excitant to a moderate degree at first, depressant effects appearing later, after the conclusion of the application. A very complete statement of the physiologic effects of thermic applications upon the various bodily organs and functions has been given elsewhere in this volume, by Professor Winternitz (see pages 18 to 38) in a discussion of hydrotherapy. As the principles of ther- motherapy rest upon the same foundation, it will be necessary to dis- cuss here only such points as relate specifically to hot applications, and especially those which require somewhat fuller elucidation. Effects of Heat upon the Skin A very brief and very hot application produces a goose-flesh appearance from contraction of the smooth muscle-fibers of the skin. Heat contracts the yellow elastic tissue, but relaxes the white fibrous tissue that constitutes the chief element of ligaments and tendons. Heat may cause increase in perspiration to more than twenty times the ordinary amount. Tactile sensibility increases at 98° F. (36.7° C.); decreases at 1130 F. (450 C.); and disappears at 130° F. (54.40 C.), when painful sensa- tions are experienced. Momentary pallor occurs when the temperature is high (iio° F. —say, 430 C.—and upward), and is quickly followed by reaction, with reddening of the skin from dilatation of the vessels. Lower tem- peratures produce immediate reddening of the skin with dilatation of the small blood-vessels, especially the veins. Contraction of the cuta- neous vessels, with pallor, occurs some little time after the withdrawal of heat, the result of atonic reaction and chilling of the surface from evaporation.EFFECTS OF HEAT ON CIRCULATION 24s Following a hot application there is increased heat-elimination, which is the result of the quickened movement of blood through the skin, dilatation of the surface vessels, increased conductivity of the skin, and the more active evaporation occasioned by the great amount of moisture thrown upon the surface by the sweat-glands. Effects of Heat upon the Muscles The energy of the striated muscles is increased by short, hot appli- cations. Prolonged warm or hot applications lessen the excitability and the energy of voluntary muscles. It is thus that heat becomes of service in relieving muscular cramp. Cold produces the opposite effect. Very hot applications—104° to 130° F. (40° to 54.5 0 C.)—increase the excitability of smooth or involuntary muscles. Effects of Heat upon the Nervous System Very short hot applications excite the brain, nerves, and nerve-cen- ters through the impressions made upon the skin. Prolonged general hot applications may give rise to pronounced exhaustion of the brain and spinal cord. Warm and hot applications lessen general nervous sensibility to a remarkable degree. This is especially true of very hot applications. The effect may be due in part to the absorption of moisture by the terminal nerve filaments in the skin ; or it may be brought about by the stimulation of the tem- perature nerves. It is well known that the skin is much more sensi- tive to thermic impressions than to any other form of stimulus that it is capable of recognizing. Applications of heat to the skin generally produce an agreeable sense of comfort and well-being. If the application is continued too long, languor, lassitude, and depression result. Very hot applications of short duration, like brief cold applications, have both a direct and a reflex excitant effect. Effects of Heat upon the Circulation Heart.—In general, heat applied over the heart tends to quicken the systole, while cold produces the opposite effect. General hot applications at first slow the pulse, then increase its frequency. Cold produces exactly the opposite effect. Blood-vessels.—Very hot applications at first cause the blood- vessels to contract, then to relax. Under the influence of heat the skin quickly assumes a dusky red hue from slowing of the cutaneous circulation. The vascular activity accompanying the reaction which follows a cold application concerns the arteries especially, and gives the skin a bright red hue. The vascular dilatation due to heat is passive, while that due to cold is active.246 PRINCIPLES OF THERMOTHERAPY Large arterial trunks are dilated by hot applications prolonged sufficiently to heat the intervening tissues, or made at points at which large vessels lie near the surface, as in the groin, the axilla, the neck, the bend of the elbow, and the popliteal space. The principle of derivation or revulsion, which furnishes the foundation for one of the most important therapeutic uses of heat, depends upon the fact that, when the vessels of one portion of the peripheral area supplied by an arterial trunk are in a state of dilata- tion, the vessels of the remaining portion or portions are contracted. In other words, the local hyperemia induced by an application of heat gives rise to a compensatory or collateral anemia in correlated vascular areas. This explains the relief afforded by an application of heat about a rheumatic joint, or over an inflamed or congested nerve or muscle. The same fact likewise affords an explanation of the relief of visceral pain which results from a general hot application. Blood Pressure.—Cold raises blood pressure, while general hot applications lower blood pressure, though the blood-vessels may be dilated in both cases. The dilatation which is part of the reaction following a cold application does not lower blood pressure, being accompanied by increased vigor of the heart’s action resulting from reflex stimulation and increased activity of the small vessels—termed by some writers the ‘skin heart,’ but for which I prefer the name of the ‘peripheral heart,’ because the arterioles of the muscles and of various internal organs are influenced as well as those of the skin. A very hot application may raise blood pressure by reflex excitation of the heart, producing a quick, strong pulse; but, in general, hot applications lower the blood pressure by dilating the cutaneous vessels and thereby lessening peripheral resistance. The skin is capable of holding from one-half to two-thirds of all the blood in the body. Hence a general hot application, by dilating the surface vessels, and especially the veins of the skin, withdraws a large amount of blood from the internal circulation. The pressure in the ventricles of the heart is reduced, and the cardiac contractions are lessened in force. A hot douche produces an elevation of blood pressure, at the same time dilating the surface vessels to the fullest degree by its strong mechanical or percutient effect. The tension of the tissues, as well as that of the blood-vessels, is diminished by the mechanical influence of heat upon the connective- tissue and muscular elements which form the framework of the tissues, and upon the unstriped muscle-fibers found in the skin and in most of the viscera. The Effects of Heat upon the Blood General hot applications diminish the number of red cells. LocalEFFECTS OF HEAT UPON BODY-TEMPERATURE 247 applications of heat, either moist or dry, produce a very marked in- crease in the number of leukocytes, although reducing the number of red cells. Heat also lessens the alkalinity of the blood, thus dimin- ishing vital resistance, as has been shown by Charrin. This fact em- phasizes the importance of concluding every general hot application with a general cold application of some sort, the effect of cold serving to maintain the normal alkalinity of the blood, and thus to inciease vital resistance. When profuse sweating is induced, the volume of the blood is diminished, unless the loss is made good by the ingestion of water. Effects of Heat upon Respiration Heat and dryness of the air hinder the gaseous exchanges in the lungs, and render respiration more frequent and superficial. Heat and moisture to the point of saturation interfere with elimination through the lungs. A general hot bath increases the rate and frequency of respiration. The depth of respiration is at first diminished ; but if the bath is con- tinued sufficiently long to raise the temperature of the blood, and in- crease carbon dioxid production, the respiratory movements are aug- mented. A frog breathes with its skin ; a dog sweats with its lungs ; man not only sweats with his skin, and breathes with his lungs, but, like the frog, to some extent, breathes with his skin, and, like the dog, sweats with his lungs. Hot baths promote not only the perspira- tory activity of the skin, but also the elimination of moisture through the lungs, thus aiding the escape of those toxic sub- stances which, as Charrin has pointed out, are probably eliminated through the bronchial mucous membrane. The Effects of Heat upon Body-temperature A general hot bath at a temperature above that of the body causes elevation of the temperature of the blood by interference with heat-elimination. For example, in a series of experiments in my laboratory, the temperature of a young man weighing 108 pounds was increased 3.2° F. (i.8° C.) in thirty minutes, representing an accumulation of 88.2 calories, by a bath at ioo° F. (say, 38° C.). A bath at the temperature of the body (98.4° F.—say, 370 C.) caused a rise of o.6° F. (0.30 C.). Baths at a neutral temperature of 920 to 96° F. (330 to 350 C.) did not elevate the body-temperature. A Russian bath of twenty-five minutes’ duration raised the temperature 2.10 F. (1.160 C.). An elevation of the same amount was observed as the result of an electric light bath lasting twenty-three minutes. A rise of 1.70 F. (0.940 C.) resulted from a Turkish bath of one hour at 146° to 158° F. (63° to 70° C.). The increase of body-temperature248 PRINCIPLES OF THERMOTHERAPY induced by prolonged hot baths is not wholly due to diminished heat- elimination, since it has been shown that in dogs exposed to a temper- ature of 104° F. (40° C.) heat-production is augmented to three and one-half times the normal. A short application of heat is followed by a fall of temperature, the result of increased heat-elimination through dilatation of the sur- face vessels, and a diminution of heat-production through the reflex influence of the thermic nerves upon the thermogenic processes. The General Effects of Heat upon the Abdominal Viscera As already observed, heat lowers the tone of voluntary muscles, while cold raises it. In other words, heat relaxes muscles, while cold contracts them. This effect is particularly marked when applications are made to the muscles of the abdominal wall, a fact which has long been taken advantage of in the treatment of strangulated hernia, and more recently in the practice of examining the pelvic and abdominal vis- cera while the patient lies in a hot bath. The tension of the abdominal muscles is a matter of no small importance in relation to respiration, and especially to the blood move- ment in all the viscera lying below the diaphragm. With relax- ation of the abdominal muscles intra-abdominal tension is diminished, and the portal vessels become engorged with blood. All the viscera are congested. The stomach and intestines become distended with gas and their walls yield to the tension, resulting in dilatation, with stasis in the stomach and colon, and gastric indigestion and constipa- tion, accompanied by fermentations and putrefactive processes that lead to autointoxication and various disturbances of nutrition. Cold, when applied to the abdominal wall, contracts not only the external voluntary muscles, but the internal, involuntary muscles of the stomach and intestines, urinary bladder, and gall-bladder, together with the muscular structures found in the spleen and liver, and the muscular walls of the blood-vessels. Hot applications to the abdominal walls produce the opposite effect. It is apparent that hot applications of this sort are therapeutically valuable for the relief of conditions of muscular spasm, either in the external voluntary mus- cles, or the internal involuntary muscular structures, as, for example, in intestinal or renal colic, and gall-stones. Long-continued warm applications to the abdominal surface appear to lead to concentration of blood in the portal circulation, doubtless by relaxing the visceral vessels. Very hot applications divert blood from the internal viscera by widely dilating the surface vessels. This effect is made possible by the anatomic connection that exists between the cutaneous vessels and those of the viscera, and which will be mentioned in detail a little later. By the alternate application of heat and cold, the blood move-EFFECTS OF HEAT UPON THE LIVER AND SPLEEN 249 ment through any internal viscus may readily and almost perfectly be controlled. Cold contracts the visceral vessels by reflex action through the thermic nerves, while heat produces the opposite effect. By the alternation of these effects a veritable pumping action may be in- stituted, whereby functional activity may be heightened, and morbid processes profoundly influenced. Very hot water, when brought in direct contact with 'the gastric mucous membrane, excites both motor and secretory activity, producing also a very decided stimulating effect upon the heart. Cold applications to the epigastrium, as well as cold ap- plications to the general surface, increase the peristaltic movement of the stomach and stimulate the secretion of gastric juice. Very hot applications, either general or local, unless greatly prolonged, produce similar effects. It should be noted, however, that when the general hot application is prolonged until profuse perspiration has been induced, the secretion of gastric juice is greatly diminished. Puschkin has asserted from experimental observation that the amount of the gastric juice and its digestive activity are greatly increased by the application of heat to the epigastrium after eating. Results observed during more than a score of years, in the large use of this measure as a means of promoting digestion, enable me to say that Puschkin’s claims are fully corroborated by clinical experience. Applications, to be beneficial in this way, must be very hot. Warm applications doubtless tend to diminish the secretory activity of the stomach and to lessen activity. The Effects of Heat on the Liver and the Spleen According to the exact observations of Kowalski, hot applica- tions over the region of the liver, followed by cold applications, in- crease the secretion of bile. This effect is doubtless produced by the increased movement of blood through the organ induced by an appli- cation of this sort, the rationale of which has previously been ex- plained. The beneficial results obtained in hydriatric practice by the employment of fomentations over the liver, followed by the heating compress, fully corroborate Kowalski's conclusions. For more than a hundred years this measure has been employed, largely empirically, but nevertheless successfully, in the treatment of hepatic affections, especially catarrhal jaundice, so that it cannot be doubted that the liver may be influenced powerfully by this means. The effect of thermic applications—hot, cold, or alternately hot and cold—over the spleen is clearly shown in the rapid diminution in size which may thus be brought about in cases of splenic enlargement from malarial infection and allied conditions, when not involving definite structural changes in the organ.250 PRINCIPLES OF THERMOTHERAPY The Effects of Heat upon Renal Activity General hot baths promote renal activity, and increase the amount of urine when the temperature is sufficiently high to increase blood pressure—104° to 1 io° F. (40° to 430 C.). Renal secretion is diminished, however, when a general hot application is prolonged sufficiently to induce profuse perspiration. The powerful influence of general hot applications upon the kidneys is shown by the remarkably beneficial results obtained by the employment of the hot bath and other general hot applications in the treatment of acute nephritis. The Effects of Heat upon Metabolism General applications of heat, if sufficiently prolonged to elevate the temperature of the blood, increase carbon dioxid produc- tion. Nitrogen oxidation appears also to be particularly favored by the elevation of temperature induced by general hot applications. Experiments show that the elevation of temperature induced by general hot applications aids the body in the formation of alexins and antitoxins. Animals suffering from infectious diseases live longer when subjected to the influence of moderate heat. The re- cognition of this fact has led to the revival of the dictum of Hippoc- rates, that the elevation of temperature that occurs in connection with most acute infectious diseases is, within limits, remedial in purpose and effect. By parallel reasoning, we are led to the conclusion that a slight degree of pyrexia artificially induced by a general hot applica- tion may be beneficial in aiding resistance to infection, especially when followed by a short cold bath. Local applications of heat in many instances operate beneficially by increasing the blood supply of the affected parts as well as by greatly increasing the proportion of leukocytes. THE ANATOMIC BASIS OF THERMOTHERAPY The physiologic effects of thermotherapy are determined experi- mentally. The therapeutic applications are suggested by inference, or determined by clinical experience. For a full understanding of the rationale of both physiologic and therapeutic effects, it is necessary to bear in mind a few anatomic facts of special interest in this connec- tion. This is more particularly true in relation to local thermic applications. The effects of thermic applications to the surface depend upon: 1. The elevation of the temperature of the parts to which the application is made, and of the general body-temperature; 2. The changes induced in more or less remote parts through nervous reflex influence; andCUTANEOUS AREAS OF REFLEX EXCITATION 2 51 A .. Brain. Lungs. Heart Kidneys- Stomach. Li den Spleen. Bowels and Abdominal Viscera. 6/cdder, Uterus ondQeories. Genifo-t/rinory Organs. drain and Lungs. Fig. 6i.—Anterior pelvic Organs^ .. ftitesrines,drain: Cutaneous Areas Reflexly Associated with Internal Parts.2J2 PRINCIPLES OF THERMOTHERAPY Brain, 3/omoch, Fig. 62.—Posterior Cutaneous Areas Reflexly Associated with Internal Parts.CORRELATED VASCULAR AREAS 253 3. The vascular relations existing between different organs and regions. Cutaneous Reflex Areas.—The effects depending upon reflex nervous action are the result of the association, through nerve-trunks and centers, of the internal viscera with clearly defined cutaneous areas. Each viscus has its own area from which the most intense reflex impres- sions are received, while at the same time it is more remotely related with all portions of the surface. These cutaneous reflex areas, in general, overlie the individual viscera. The accompanying cuts (Figs. 61 and 62) show diagrammatically the principal cutaneous areas that have been definitely worked out, and that are clinically important. Correlated Vascular Areas.—Careful anatomic studies have shown that there is an equally intimate and more direct relation between the blood-vessels of deeply seated organs and overlying or adjacent cutaneous vessels. The vessels of the brain are freely connected with those of the scalp and of the nose through the parietal foramen, the foramen caecum, the mastoid foramen, the posterior condyloid foramen, the foramen of Vesalius, the foramen ovale, the foramen lacerum medium, the carotid canal, the anterior condyloid foramen, as well as through the diploe of the cranial bones. The meningorachidian veins, which form dense plexuses in the spinal canal, are freely associated with the cutaneous veins of the back, and with the dorsospinal veins through the anastomosing veins which issue from the canal through the intervertebral foramina, and unite with the intercostal, vertebral, lumbar, and sacral veins. The blood supply of the eyelids and of the skin covering the eyebrows and adjacent portions of the forehead is collaterally related with branches of the internal carotid which supply the eyeball. The circulation of the middle ear is collaterally related with the circulation of the skin of the face and head of the same side through the common carotid. The circulation of the internal ear, on the other hand, is associated with the skin of the back of the neck, being derived from the vertebral arteries. The vessels of the mucous membrane of the nose and pharynx are associated with those of the face and the sides of the head through the common carotid. The circulation of the lungs is collaterally related with that of the skin covering the arms, the chest, and the upper part of the back.- The pericardium and the parietal pleura of the anterior portion of the chest are collaterally related with the skin covering the anterior portion of the chest-wall, through the internal mammary artery. The parietal pleura of the posterior portion of the chest and the254 PRINCIPLES OF THERMOTHERAPY visceral pleura are collaterally related with the intercostal vessels. A collateral relation also exists between the bronchial arteries—the nutrient arteries of the lungs—and the intercostals, especially those of the right side. The skin covering the arms is collaterally related with the pleura of the upper and anterior portion of the chest through the subclavian artery. There also exists a collateral relation between the nutrient vessels of the lungs and the vessels covering the anterior portion of the neck through the inferior thyroid arteries. The colla- teral relationship existing between the vessels of the skin and of the lungs is still further extended by the connection of the bronchial veins with the azygos veins of the right side, and with the superior intercostal or the azygos veins of the left side. It is in the highest degree interesting to note these extensive communications between the pulmonary circulation and that of the cutaneous surface, all of which are of high therapeutic interest. The kidneys are associated with the skin covering the loins, through the renal branches of the lumbar arteries. The vessels of the prostate in man, the uterus and ovaries in woman, and the bladder in both sexes, are associated with the cutane- ous vessels overlying the sacrum, the buttocks, the perineum, the external genitals, the groins, the inner surface of the thighs, and the suprapubic region, these parts being chiefly supplied by branches of the internal iliac artery. These parts are also associated with the skin of the leg through the common iliac artery. The rectum is similarly associated with the skin covering the anal region and the perineum and that of the lower extremities. There is a collateral relationship, both venous and arterial, be- tween the stomach, liver, spleen, intestines, and even the pan- creas, and the skin of the trunk which overlies those deeply seated organs. The portal circulation communicates with the systemic circula- tion, thus establishing a collateral relationship with the cutaneous vessels at half a dozen or more points, especially the following : the hemorrhoidal plexus, the esophageal veins, the left renal vein, the phrenic vein at the surface of the liver, the epigastric veins at the um- bilicus, the circumflex iliac vein (Treves, Schiff). In a similar way, it may be stated that the upper half of the body is collaterally related with the lower half; a fact of which constant use is made when the lower extremities are warmed to divert blood from the head. The cutaneous vascular areas connected with the several viscera are roughly indicated in the accompanying diagram (Figs. 63 and 64). It should be remembered, however, that every portion of the cutaneous surface is vascularly related, at least remotely, to every in- ternal part. It is also interesting to note that the vascular areas con-CUTANEOUS VASCULAR AREAS RELATED WITH VISCERA PULMONARY _ .HEAD AND CHEST LIVER STOMACH PANCREAS SPLEEN LARGE AND SMALL I INTESTINE _ARMS PELVIC VISCERA [HEAD AND UPPER I PORTION OF BODY 255 Fig. 63.—Cutaneous Vascular Areas Collaterally Related with the Vessels of the Viscera (Front View).256 PRINCIPLES OF THERMOTHERAPY ^PULMONARY HEAD AND CHEST KIDNEYS.. PELVIC VISCERA [HEAD AND UPPER PORTION OF BODY Fig. 64.—Cutaneous Vascular Areas Collaterally Related with the Vessels of the Viscera (Back View).COMBINED REFLEX AND FLUXION DERIVATION 257 nected with the several internal viscera do not altogether correspond to the reflex cutaneous areas connected with the same parts, although in the main the reflex areas and vascular areas are practically identical. For example, the skin covering the front of the chest is of greatest importance as a means of reflexly influencing the pulmonary circula- tion ; whereas, the cutaneous vessels of the skin covering the back of the chest are more intimately related with the vessels of the lungs than are those of the anterior surface. A most important reflex relation exists between the skin covering the lower portion of the sternum and the kidneys, whereas the principal vascular relation exists between the kidneys and the skin covering the loins. The portion of the body below the umbilicus is collaterally related with the head, the arms, and the upper half of the trunk ; and the legs are likewise in collateral relation with all parts of the body above them, especially those which occupy the pelvic cavity. These relationships render it possible to employ the reflex and the fluxion methods at one and the same time, a cold application of small extent being made over the center of greatest reflex activity, while a hot application or heating compress is applied over the area which is in closest vascular relation with the interested part. When the vascular cutaneous areas and the reflex areas concerned are identical, the cold application is made to the reflex area, while the hot application is made to the feet, legs, or lower half of the body, or even to the entire cutaneous surface when the largest possible effect is desired. Understanding these interesting anatomic relations, it is readily seen that the volume of blood in any internal viscus, no matter how remote from the surface, may be diminished either by a general hot application to the surface, whereby one-half of all the blood in the body may be diverted into the skin ; or to a lesser degree by local applications. Thus, by means of heat suitably applied, the vessels of different portions of the brain may be drained into the communicating areas of the skin. The longitudinal sinus is drained by means of applications to the sides of the head; the lateral sinus may be drained by applications to the skin areas behind the ears ; the cavern- ous sinus by applications over the face, ears, and side of the neck; the occipital sinus by applications to the back of the neck. Congestion of the spinal cord may be relieved by hot applications to the back from the base of the cranium down. Congestion of the eyeball may be relieved by hot applications made over the eye and the forehead above, not extending below the eye. Congestion of the middle ear is relieved by hot applications over the sides of the head and face ; of the internal ear by hot applications to the arms and legs ; of the nasal cavity and the pharynx by a hot application to the face and sides of the head; of the larynx by hot applications to the ix—17258 PRINCIPLES OF THERMOTHERAPY front of the neck, the arms, the back, the upper part of the chest, and the legs ; of the lungs by an application over the whole thoracic cage and the arms, an additional advantage being gained by a hot applica- tion to the legs ; of the kidneys by general hot applications to the whole surface, or local hot applications over the lumbar region ; of the pelvic organs by hot applications to the hips and legs ; of the stomach and other viscera by hot applications over the interested part, or, better, to the entire trunk, or trunk and legs. As Treves very well remarks, these facts give “an anatomical demonstration of the value of counterirritants in inflammatory affec- tions of certain of the viscera, and also a scientific basis to the ancient practice of poulticing the loin and the iliac region in nephritis and in inflammations about the caecum.” PRACTICE OF THERMOTHERAPY As is the case with all physiatric measures, the therapeutic action of heat is clearly foreshadowed in its physiologic effects. General Indications.—The general excitant effects of heat ren- der highest service in most conditions of extreme exhaustion, as in surgical collapse, extreme fatigue from violent exertion, the collapse of typhoid and other infectious fevers; in certain cases of poisoning; and in acute autointoxications. Thermotherapeutic measures are of value in all cases in which active diaphoresis is called for, as after taking cold, in acute rheumatism, in certain forms of chronic rheumatism, some cases of pneumonia and other acute infectious febrile disorders, and as an alterative or spoliative measure in obesity and other diathetic maladies. General applications of heat serve an extremely useful purpose in modifying metabolism. Short applications lessen heat-produc- tion and oxidation, and encourage heat-elimination ; while prolonged applications raise the body-temperature by preventing heat-elimina- tion, and by communicating heat to the body. The increase of oxida- tion which accompanies a prolonged hot bath renders applications of this sort of the highest value in cases of obesity, in diabetes, and in the uric acid diathesis. Their effectiveness in increasing the oxidation of proteid wastes renders general hot applications of some sort almost indispensable in the treatment of spinal sclerosis, tabes dorsalis, and many other affections accompanied by organic change, in all of which some form of autointoxication is probably of causative importance. General hot applications are indicated in all forms of chronic visce-PRACTICE OF THERMOTHERAPY 259 ral congestion, including chronic bronchial catarrh, chronic gastritis, intestinal catarrh, chronic inflammation of the pelvic viscera, and chronic cerebral congestion. The skin being capable of holding one-half to two-thirds of all the blood in the body, the filling of this immense vascular area—comprising a surface of more than ten thousand square feet, if we include the capillary net- work distributed in the walls of the tubules of the sweat-glands— relieves visceral congestion by diverting the blood to the surface, and accomplishes a therapeutic purpose which cannot be so satisfactorily achieved in any other way. To make permanent the effects thus ob- tained, the hot application must be followed by a short cold applica- tion, whereby strong reaction effects are produced, with accompanying dilatation of the small arteries and an increased rhythmic activity of the ‘ peripheral heart.’ Still another important indication for general hot applications is the preparation of the skin for the cold douche, the shallow bath, wet- sheet rub, wet-sheet pack, or any other hydriatric application of a tem- perature below that of the body. This preparation is especially im- portant in feeble patients. It may be advantageously employed in all cases. The application should be of brief duration, ordinarily from three to five minutes, or only sufficiently long to heat the skin thor- oughly. The maximum effect desirable is obtained when the skin be- comes slightly moistened by perspiration. General hot applications are of service as a means of intensifying the effects of cold hydriatric procedures. When employed for this purpose, the hot and the cold applications are made in alternation. A hot application of two of three minutes may be followed by a brief cold application of five to twenty seconds. Such an application is strongly excitant to the circulatory system, and produces profound re- vulsive effects. Short applications of equal duration,—ten to twenty seconds,—the so-called alternate applications, are powerfully ex- citant ; they are generally made by means of the alternating general douche, for which the horizontal jet or the circle or needle douche may be employed. The vapor douche and a cold-air douche may be thus employed in alternation, or the patient may be exposed alter- nately to the heat of the vapor bath, the electric light bath, or the hot- air bath, and to the refrigerant effects of the cold horizontal jet, the shower, or the plunge. Finally, hot applications are of value as a means of inducing toler- ance to cold applications which could not otherwise be borne, as in the simultaneous hot and cold bath. Various combinations may be made ; as, for example, a hot shower-bath combined with a cold douche to the spine, or to the hepatic, gastric, lumbar, or hypogastric region, or to the extremities, as may be desired ; or a cold douche may be admin- istered to any part of the body while the patient is enveloped in hot26o PRINCIPLES OF THERMOTHERAPY vapor in a Russian bath or warmed by means of the vapor douche. The ideal application of this sort is to combine the cold douche and the incandescent light bath. The patient stands in a recess, surrounded on three sides by incandescent lights, closely placed in front of a re- flecting surface, by which the skin is strongly heated, while at the same time a jet of cold water is made to play upon any part of the surface that it is desired to impress in this way. Modes of Application General thermic procedures include the Turkish bath, the hot-air bath, the Russian bath, the vapor bath, the incan- descent light bath, the sand bath, the mud-bath, the hot im- mersion bath, the hot blanket pack, and the dry pack. Local thermic applications are made either by limiting the fore- going measures or by the use of heated objects, such as jugs, bottles, or rubber bags filled with water, the cotton poultice, the elec- trotherm,—ra dry compress containing metallic objects affording re- sistance, through which a current is passed,—or the thermophore (a rubber-bag containing a chemical solution capable of giving off heat for a long time during the process of crystallization) or the Japanese * hand stove ’ (a little cloth-covered, perforated, metallic receptacle, containing sticks of a slow-burning compound). The last-named is specially useful for domestic practice. Deep-seated inflammations may be controlled by either general or localized applications to the appropriate cutaneous surface. This is well illustrated in pelvic inflammation, for example, by the great relief to pain afforded by the hot hip-and-leg pack, the hot hip pack, the general hot blanket pack, the hot immersion bath, or any other hot application. This use of heat is suggested by the natural instinct which leads one to protect any painful part, such as an aching tooth, eye, or ear, by the application of the warm hand, and is further shown in the drawing up of the legs when abdominal pain is present, an in- stinct possessed by the lower animals in common with man. In ovarian inflammation, an ice-bag should be applied over the ovary simultaneously with the use of the hot hip-and-leg pack. After the hot application is removed, the ice-bag should remain in place, the limbs being kept warm by hot bags and wrappings. By the cold application the vessels of the inflamed part are made to contract reflexly, while the hot application, acting derivatively, empties the ves- sels of the part, thus securing the complete co-operation of two impor- tant therapeutic principles at one time and place. This principle is illustrated in the common employment of the very hot foot-bath, in association with a cold compress to the head for the relief of cere- bral congestion. The same principle m.ay be extended to the treat- ment of congestions and inflammations of any deep-seated organ.AFTER-COOLING 26l Thus in a combined hydriatric application for relief of a congested kidney, an ice-bag applied over the lower third of the sternum causes reflex contraction of the renal vessels, as shown by Beni-Barde, while an application of heat made to the lumbar region relieves the congested organ by diverting blood from its arteries and veins into the overlying muscular structures. In simultaneous application of heat and cold for relief of congestion of the pelvic viscera, the ice-bag applied to the hypogastrium and to the groins causes contraction of the branches of the internal iliac, which supplies the uterus and ovaries; while the hot hip-and-leg pack, by dilating the cutaneous vessels, diverts a large volume of blood into the external branches of the internal iliac and the cutaneous branches of the external iliac. In conclusion, attention should again be called to the fact that thermotherapeutic measures of all sorts, whether general or local, should, almost without exception, be followed by a cool or cold hydriatric application, so as to restore the tone of the surface vessels and to fix the blood in the skin, thus rendering permanent the temporary benefit derived from the hot application. When‘the hot application has been prolonged sufficiently to cause an elevation of the body-temperature, the temperature of the cooling procedure should be moderate, ordinarily 90° to 750 F. (32.2° to 23.8° C.), and sufficiently prolonged to restore the thermic equilibrium of the body. The time required ordinarily should be one to three minutes. The duration should never be sufficient to produce chilliness, and the application should be made with sufficient vigor to maintain the dila- tation of the surface vessels. When applications of heat have been limited to small areas or have been of short duration, the cooling application should be at a lower temperature and of shorter duration (6o° to 450 F.,—15.5° to 7.20 C.,—three to fifteen seconds).CHAPTER IV GENERAL AND LOCAL APPLICATIONS OF HEAT The Turkish Bath—Description ; Physiologic Effects ; Indications ; Counter - indications and Precautions. The Hot-air Bath—Description and Technic ; Indications. The Local Hot-air Bath—Description and Technic ; Appa- ratus ; Special Precautions; Indications. The Dry Pack—Technic; Mode of Action ; Indications. Rich her Bags ; Hot Water Bottles or Jugs; Heated Sand-bags, Bricks, Blocks of Wood, and Other Objects. The Heating or Simulating Compress. THE TURKISH BATH Description.—A scientifically arranged Turkish bath establish- ment consists of a series of rooms which provide, besides dressing- rooms and a cooling room furnished with couches on which patients may recline after a bath, at least the following separate compart- ments : 1. A room heated to a temperature of no° to 130° F. (440 to 540 C.), the ‘ tepidarium ’ of the ancients. 2. A hot room, heated to the temperature of 150° to 200° F. (65° to 930 C.), the ' calidarium/ In some establishments another small room is provided, in which a temperature of 230° to 300° F. (no° to 148° C.) may be obtained. 3. An adjacent room, conveniently furnished with marble slabs and hot and cold water with other necessary paraphernalia, provides for the shampoo. Close at hand must be found a well-arranged douche apparatus, and in a well-equipped establishment there will be also a plunge or swimming bath containing water at a temperature of 6o° to 70° F. (150 to 210 C.). In some European establishments the temperature of the plunge is so low as 450 F. (7.30 C.); but 6o° F. (15.50 C.) is low enough to secure all essential therapeutic results, and is safer for the average patient than a lower temperature. Any intensity of effect desired may be attained by increasing the duration of the bath. The hot room may be heated by steam coils, or by hot air pro- vided by a furnace, or an indirect steam heater. When direct radia- tion from steam pipes is employed, the air is generally very impure, by reason of the absence of adequate provision for ventilation. When, however, hot-air heating is employed, the ventilation is easily made 262TECHNIC OF THE TURKISH BATH 263 ample, air change being essential as a means of maintaining the tem- perature of the room. The foul air outlet must be near the bot-. tom of the room, and must communicate with a ventilating shaft. The opening for the inlet of warm air may be either at the floor or the ceiling ; it is perhaps best located at a point about two or three feet above the level of the floor. Technic.—The patient disrobes, places a loin cloth about his body, drinks a glass of water, either hot or cold, enters the warm room, and lies down upon a couch. Usually, by the end of ten to fifteen minutes, and sometimes sooner, the skin becomes slightly moistened, and a little later the subject finds himself in a state of pro- fuse perspiration. In cases in which perspiration does not promptly appear, the activity of the cutaneous glands may be encouraged by superficial massage, or friction of the skin by an attendant. The na- tive shampooers of Cairo and Constantinople rub the bather with mitts made of coarse fabric somewhat resembling haircloth. A very hot foot-bath or a short, hot spray, or full bath, is also an effective means of encouraging perspiration. In the case of patients who can- not drink freely, a hot enema (no° F.), administered just before the bath, will aid in inducing prompt sweating. In extreme cases the patient may be sponged with hot water. If he does not perspire either with or without the aid of the meas- ures mentioned, he should not be allowed to remain in the bath for any considerable length of time, as serious injury may possibly result from a long exposure of the body to intense heat without the protect- ing influence of evaporation. After the patient begins to perspire, he may, if he desires, enter the second hot room, to remain but a few minutes, until very vigorous perspiration is induced ; or if more moderate cutaneous activity is de- sired, he may remain in the warm room. When perspiration has been maintained as long as it is desirable, the patient is conducted to the shampooing room, where he is first rubbed with the bare hands or with Turkish mitts from head to foot, beginning with the head, and in such a manner as to remove every particle of the superficial layers of the epidermis that has been loosened by the profuse perspiration. Finally the patient is shampooed with soap, the lather being well rubbed upon the skin, either by a thoroughly aseptic brush, the Egyptian ‘ loofa/ or a properly arranged mass of flax, manila, or other fibrous material. Great care must be taken, in the employment of shampoo brushes, to avoid conveying infection of any sort from one patient to another. The only safe precaution when a common brush is used—a practice which is certainly not to be commended—is to drop the brush for five minutes into boiling water each time it is264 GENERAL AND LOCAL APPLICATIONS OF HEAT used, after thoroughly rinsing the soapsuds out of it. There is an advantage in the use of manila and other fibers; the material is so cheap that it may be thrown away and a new supply provided for each patient, and at each bath. The brush or mass of fiber or horse- hair is applied at first to the upper part of the neck and chest, then to the arms, then to the lower parts of the body. The shampooing and rubbing should be continued until the whole surface feels like polished marble. After the shampooing the patient is conducted to the douche. If he is still quite warm, a cold douche may be administered at once. If he has become slightly chilled, he should be thoroughly warmed up by a warm shower or rain douche before the cold applica- tion is made. The bath should end with a douche of cold water at a temperature’ of 6o° F. (150 C.) or less. If the patient is inclined to perspire freely after the bath, a graduated’ rain douche at a temperature of 84° to 76° F. (290 to 24.50 C.) should be given for one to three minutes before the final cold application. After the douche, which serves the double purpose of removing the soap and counteracting any depressing effects from the prolonged exposure to heat, the patient may enter the plunge or the swimming bath, or may wrap a sheet around him, and lie down upon a couch until the skin becomes perfectly dry, and the pulse returns to its normal rate. Massage or joint movements, or both measures, may be advantageously employed in many cases. This practice is a decided aid to reaction in feeble patients. To feeble subjects the Turkish bath should not be administered more than one to three times weekly. The ordinary patient may take a short Turkish bath daily, and when the bath is employed for reduc- tion of weight, it may often be administered twice a day, provided the exposure in the hot room is not longer than thirty to forty minutes. It is not usually necessary to apply cold to the head of the patient during the bath, as perspiration of the face and scalp begins early, and this prevents overheating of the head. For persons who are unaccus- tomed to the bath, the application of a dry towel or napkin over the face and forehead will usually be sufficient. The distention of the surface vessels diverts the blood from the brain, and thus obviates any danger from cerebral congestion. The only exceptions are those cases in which the heart is unduly excited and the brain congested by the elevated temperature of the blood. Physiologic Effects.—The physiologic effects of the Turkish bath are essentially the same as those of other general hot applica- tions. There are, however, certain characteristic differences which it may be well to note. The exposure of the entire body to a superheated atmosphere, and especially the inhalation of dry hot air, excites the pulmonaryPHYSIOLOGIC EFFECTS OF THE TURKISH BATH 265 mucous membrane, as well as the skin. The great extent of this membrane—about 2000 square feet—gives importance to this fact. The great dryness of the air, and the excitation ot the mucous surface with which it comes in contact, unquestionably facilitate the elimina- tion of those volatile toxins which find exit through the pulmonary mucous membrane (Charrin). Shortly after the patient enters the bath, the pulse is found con- siderably accelerated, and tension increased. The higher the temper- ature of the bath, the more rapid the pulse. During this period of increased blood tension, the patient experiences a sense of fullness in the head, some respiratory distress, and general discomfort. As soon, however, as the skin becomes reddened and moistened with perspira- tion, the pulse-rate diminishes, tension is lowered, respiration becomes easy, and uncomfortable sensations disappear. The breathing is usually thoracic in character. The sweat glands are powerfully stimulated. The amount of secretion may be increased from one and a half ounces in an hour to fifteen or twenty times this amount. I have often seen patients lose two pounds or more in weight as the result of an hour’s sweating in the hot room of a Turkish bath. This rapid loss of fluid indicates the importance of copious water drinking during the bath, as the heart’s action may be lessened in power, and various other functions inter- fered with as the result of so considerable a reduction of the blood volume. The profuse discharge from the skin, moreover, promotes absorption from the alimentary canal. As a result, patients who are taking Turkish baths daily are likely to suffer from constipa- tion, unless this tendency is counteracted by copious water drinking. The activity of the sweat glands excited during the bath continues in a modified degree for some hours after the bath as the result of the improved cutaneous circulation. Hence, water drinking must be prac- tised after, as well as before and during, the bath. The intense congestion of the skin induced by the Turkish bath withdraws an enormous amount of blood from the liver, spleen, stomach, intestines, brain, and other internal organs. The deconges- tion of these deep-lying vascular areas is one of the most important results obtained by this procedure, although one which seems to have been very little appreciated by many of those who have written upon this subject. While it is not probable that any considerable amount of heat is communicated to the body from the heated atmosphere of the bath, heat-production is increased to such a degree that a very decided elevation of temperature may generally be noted when the patient remains in the bath for half an hour or more. Experiments with the dog have shown that exposure to an atmosphere of a few degrees above the temperature of the body may increase heat-production as266 GENERAL AND LOCAL APPLICATIONS OF HEAT much as 350 per cent. At this rate, the heat-production during an hour’s exposure in the Turkish bath might amount to nearly 400 calories, or nearly one-sixth the daily output of energy, representing more than an ounce and a half of fat, or three ounces of carbo- hydrate. Heat-elimination also must be greatly increased, for the rise in body-temperature is comparatively slight. In the treatment of obese persons, it must be remembered that these patients have a much smaller skin surface in proportion to their weight than have smaller persons, and hence that heat-elimination is greatly hindered. For example, a person weighing three hundred pounds has a skin area of only thirteen and a half square inches to the pound, while a person weighing 120 pounds has a cooling cutaneous surface of eighteen square inches for each pound of weight, or nearly fifty per cent. more. The obese person labors under a further disadvantage in that the surface vessels are in large part buried in fat, so that they do not come near the surface, whereas in a thin person the close approach of the ten thousand square feet of capillary network to the surface secures a rapid cooling of the blood. Indications.—The Turkish bath renders valuable service in the treatment of obesity, alone or combined with diabetes; in the autointoxication so commonly present in chronic dyspeptics; in the uric acid diathesis; and in many cases of neurasthenia, hypochondria, and melancholia. Most forms of chronic ner- vous disease, even cases of locomotor ataxia, chronic mye- litis, paresis, paralysis, neuritis, and other equally obstinate maladies, are materially helped by the judicious use of the Turkish bath, even though a radical cure may, be, in the majority of cases, impossible. In all forms of anemia and chlorosis the Turkish bath is an admirable measure, promoting blood formation and relieving visceral congestion. Care must be taken, however, to avoid extreme temperatures and prolonged exposure in these cases, on account of the degeneration of the blood-vessels, which is sometimes present As a hygienic measure, the Turkish bath has long justly held a high place in the confidence of the laity, as well as of the profession. The thorough cleansing of the skin which it secures is alone an advantage of no small consideration, yet its highest value is due to the fact that the combined hot and cold applications which it involves, in the highest degree promote vital activity and the building up of the powers of resistance to disease, thus counteracting to some degree the evil consequences of the artificial conditions imposed by civilized life, and affording a considerable degree of protection against various infective agents. The Turkish bath affords an opportunity to produce the most pro- nounced effect possible upon the circulation of any internal viscusHOT-AIR BATH 267 that it may be desired to influence. For example, in cases of chronic gastritis or chronic intestinal catarrh, chronic spinal con- gestion, cerebral hyperemia, or renal congestion, the gen- eral effect of the bath in relieving visceral congestion may be intensi- fied by a suitably placed cold application, consisting of an ice-bag, a cold compress, or a cooling coil. In cerebral congestion an ice- bag may be applied to the head, or an ice collar may be fitted about the neck. A towel wrung out of ice-water may be applied to the face and ears. In renal congestion an ice bag may be applied over the lower third of the sternum. In uterine and ovarian congestion, or the so-called chronic inflammation of these organs, an ice-bag may be applied to the groins and the hypogastrium. In chronic in- flammation of the stomach or intestines, or congestion of the spleen or liver, a cold application should be made over the parts indicated. The application of cold in the manner suggested, especially to the head, renders a higher temperature tolerable, and may permit of a longer duration of the bath. Counterindications and Precautions.—The Turkish bath is counterindicated in cases of cardiac dilatation, tachycardia, and arteriosclerosis; in exophthalmic goiter; in organic affections of the heart in which there is evidence of deficient or failing compensation; in irritable skin affections and all febrile disorders ; and for apoplectic subjects. The bath must be used with great care in all forms of nephritis, and is counterindicated in advanced stages of renal disorder. The pulse should be watched carefully, especially during the first seances, and the first few moments after the patient enters the bath. Undue cardiac excitation may generally be relieved by the application of cold over the heart. If the effect desired is. not readily induced, the patient should be removed from the bath, and the incandescent electric light bath or some other unobjectionable heating procedure adopted. THE HOT-AIR BATH This bath resembles the Turkish bath, the essential difference being that the head is excluded from contact with the heated air, so that the patient is able to breathe air at the ordinary temperature, while the entire body, with the exception of the head, is exposed to dry superheated air. Description and Technic.—The hot-air cabinet may be a per- manent structure of wood, zinc lined (Fig. 65), or it may consist of a portable cabinet of rubber cloth, or other impervious material. In268 GENERAL AND LOCAL APPLICATIONS OF HEAT the absence of a specially constructed cabinet, a substitute can easily be improvised by placing the patient in a chair, and covering him with a rubber blanket or with ordinary blankets, between the folds of which newspapers have been placed. Various sources of heat may be employed, as a small kerosene stove, a large kerosene lamp or an alcohol lamp, a small gas stove, or even heated stones or bricks. For a permanent arrangement, a steam coil is most convenient. Fig. 65.—Author’s Hot-air Cabinet. Figure 66 shows a convenient arrangement for a domestic hot-air bath. In all such contrivances the greatest care must be taken to avoid burning the patient. Lives have been lost by carelessness in this regard. When an alcohol lamp is used as the source of heat, it should be placed in a vessel of water. The lamp should beTREATMENT AFTER THE HOT-AIR BATH 269 lighted before the patient enters the bath. If the flame goes out, the patient should be removed from the bath before it is relighted. The same precaution should be taken if gasoline or kerosene is used as the means of heating. When the patient is not able to sit erect, the bath may be administered in bed, either by means of a special device or by an arrangement which may easily be improvised. It is only necessary to provide a space about the patient by means of a proper framework, covered first with rubber cloth, then with ordinary blankets. Heat is supplied by means of a tin pipe, which can be made by any tinner at a small expense, so arranged that one end can be slipped over the top of an ordinary lamp chimney, while the other enters the inclosed space about the patient. In preparation for the bath, the patient should remove all his clothing in a warm room, and should be wrapped in a Turkish sheet or woolen blanket while passing from the dressing-room to the bath cabinet. He should drink a glass of water or lemonade, either hot or cold as preferred, before entering the bath. Carbonated water is the best. Perspiration may be promoted by repeated water drinking during the bath. It is also important that before the patient enters the bath, the head or the face and neck, and, in the case of men, the scalp also, should be well cooled by wetting with water at 6o° F. Towels should be applied to the face and neck in treating women, and to the head and face of men (Fig. 65). The temperature may vary from 150° F. to 250° F. A still higher temperature may be tolerated if the air is perfectly dry, but offers no advantage. The duration of the bath may be six minutes to an hour, accord- ing to the effect desired. When administered to feeble persons, and when the purpose of the bath is simply to heat the skin in preparation for a cold application, the duration should be brief—not more than six to twelve minutes. When prolonged sweating is desired for eliminative effects, the duration may be twenty to sixty minutes. Or- dinarily, however, the bath need not be employed for more than thirty to forty minutes to secure the maximum beneficial effects. After the bath a cooling procedure of some sort should be em- ployed. The rain douche, horizontal douche, wet-sheet rub, shallow bath, and pail douche are the most generally useful measures. For feeble persons the cold towel rub and the cold mitten friction are preferable, and should be employed at the beginning of a course of treatment. Later, when the patient has, by systematic training, acquired greater ability to react, more vigorous cooling measures may be applied. In certain cases, sudden cooling of the skin is not desirable. This is especially the case with chronic rheumatics when suffering from an acute exacerbation, with more or less elevation of temperature, and much pain and tenderness in the joints. In such270 GENERAL AND LOCAL APPLICATIONS OF HEAT cases, the patient, on removal from the bath cabinet, should be quickly wrapped in warm blankets. If it is desirable to continue the per- Fig. 66.—Domestic Hot-air Cabinet. spiration, he is warmly covered, and made to drink freely. If, how- ever, prolonged perspiration is not desirable, he is more lightlyLOCAL HOT-AIR BATH 27 I covered, and the face is from time to time bathed with a little cool or tepid water until sweating has ceased spontaneously and the usual pulse-rate has been re-established. The wrappings are then carefully removed, uncovering small areas at a time, as an arm, the chest, or a leg, and an alcohol rub is administered. Indications.—The therapeutic applications of the hot-air bath and the counterindications therefor are essentially the same as those of the Turkish bath. It should be mentioned, however, that the hot-air bath may be employed in cases in which the Turkish bath is inadmissible on account of the embarrassment experienced by the patient in the inhalation of hot, dry air. Indeed, in most cases all the therapeutic advantages of the Turkish bath may be obtained by the proper employment of the hot-air bath. THE LOCAL HOT-AIR BATH Hot air may be applied to any circumscribed portion of the body, either by means of a current of superheated air, directed upon the part, or by inclosing the part in a chamber the air of which is superheated. The hot-air douche was employed by me some eighteen years ago, but was not found to possess advantages over the simpler methods of making local applications of heat. Description and Technic.—Recently, various excellent devices have been offered for local applications of hot air, especially to the joints. None of these, however, is greatly superior to a simple device that can readily be constructed by any tinner (Fig. 67). It consists of a tin box, so arranged that it may easily be opened while the limb is being placed in position. The limb must be protected from contact with the metallic portions of the box. This is easily accomplished by making the end pieces of wood. Arrangement must be made to permit the entrance of air and escape of vapor to avoid scalding the patient by his own sweat. The box is so placed that a large kerosene lamp may be set beneath it, with just sufficient space between the chimney and the bottom of the box to secure a clear flame. In a short time the air within the box will become sufficiently heated to secure the effect desired. With dry air, a temperature of 300° to 400° F. (148° to 205 0 C.) is tolerated. The effect of this application is to produce powerful revulsion by dilatation of the surface vessels. It is possible that certain trophic effects may also be induced by the impression made upon the thermic nerves. At the conclusion of the application the parts should be quickly rubbed with the hands dipped in cold water, or, if the parts are pain-272 GENERAL AND LOCAL APPLICATIONS OF HEAT ful, a towel wrung quite dry out of cold water may be applied for ten or fifteen seconds. The parts are then quickly and carefully dried or bathed with alcohol and covered first with dry cotton, then with mackintosh, and finally with flannel, so that the effect obtained by the application may be continued. In cases in which an active inflamma- tion is present, as indicated by elevation of temperature and pain, the heating compress should be applied instead of the cotton poultice. This consists of a single thickness of linen cloth, or three or four folds Fig. 67 —Simple Hot-air Box for the Limbs. of cheese-cloth, wrung quite dry out of water at 6o° F. (15°° C.), smoothly wrapped about the part, and covered with flannel and mack- intosh. The compress should warm up at once. If it remains cold, injury will result. Great care should be taken to extend the mack- intosh sufficiently above and below the flannel wrappings to leave no opening through which air can enter or evaporation take place. Apparatus.—The Tallerman-Sheffield local hot-air bathHOT-AIR CYLINDERS 273 apparatus consists of a cylinder of copper, of shape and size adapted to the part to be inclosed. One end of this cylinder is closed by a cap attached in such a way that the opening can be completely or partially closed. The limb to be treated is introduced at the other end, air being excluded by means of a rubber sleeve, one end of which is attached to the cylinder, the other being gathered closely about the limb. Several openings on the upper side of the cylinder provide for additional ventilation, thus avoiding the accumulation of moisture. The cylinder is heated by gas burners placed beneath. The temperature is indicated by a thermometer supported in the top of the cylinder. The apparatus of Lentz (Fig. 68) is an im- provement upon that of Tallerman-Sheffield. It consists of a copper cylin- der of similar construc- tion, to the bottom of which is attached a fire- box of Russian iron in which is placed a Bunsen burner, consisting of two tubes, in each of which there is a row of small flames similar to those employed in heating an ordinary gas oven. The cylinder is lined with sheet asbestos, the lower third of the lining being sepa- rated from the cylinder a distance of one and one- half inches and supported by iron bars running the whole length of the cylinder. On the cradle of this frame rests a thick piece of magnesium, an excellent non- conducting material. This forms a safe and suitable bed upon which the limb may rest without danger of burning. The remaining arrangements are practically the same as those in the Tallerman- Sheffield apparatus. The temperature employed in the Tallerman-Sheffield apparatus is 240° to 260° F. (1150 to 126° C.). The Lentz apparatus produces a higher temperature, ranging from 300° to 350° F. (148° to 176° C.), in from ten to fifteen minutes after the limb is introduced. The temperature may be controlled by the cap or door at the closed end of the apparatus. On opening this, the temperature very quickly falls, ix—18 Fig. 68.—Hot-air Chamber for the Limbs.274 GENERAL AND LOCAL APPLICATIONS OF HEAT By regulating the size of the opening, the amount of air passing through the apparatus can be regulated and the temperature adapted to any individual case. The duration of the treatment may be from twenty to forty minutes, or even longer. Effects.—The effect of the local hot-air bath is to produce the most powerful local diaphoresis and intense cutaneous con- gestion. If the application is continued for some time, general diaphoresis is also produced. This effect renders necessary some general cooling procedure at the conclusion of the application as well as the local cooling which has before been referred to. It should be remembered that the hot-air treatment produces relaxation and lowered tone of the vessels and tissues of the parts brought under its influence. A short local cold application is necessary to produce a tonic reaction by which the blood is fixed in the skin and the activity and tone of the surface vessels increased. This will prevent subse- quent injury from slow cooling by evaporation. A general cooling application is necessary for the same purpose. If this is neglected, the patient is liable to be chilled by the evaporation of moisture from the skin, and all the possible good effects of the application will thereby be neutralized and the disease may possibly be aggravated. Local and general thermic and hydriatric applications are often brought into discredit by a neglect to employ the proper means to prevent these untoward effects of hot applications. The best general applications for most cases are the cold mitten friction, the cold towel rub, and the alcohol rub. The latter is especially indicated for feeble persons and for those whose joints are the seat of much pain and tenderness. Special Precautions.—In order that the patient may readily re- ceive this general treatment and to prevent moistening of the clothing, all the clothing should be removed (underclothing as well as outer garments) in preparation for the local treatment, although the part to be treated may be only a single joint, as the wrist, elbow, or ankle. This precaution involves some little trouble and inconvenience, but its observance is necessary in order to secure uniformly satisfactory results. Great care must be taken to avoid burning the patient, not only because of immediate ill effects, but because burns are very slow to heal in chronic rheumatics, and thus necessarily interrupt treatment for a considerable length of time. Wrappings about the part exposed to the hot air increase the dangers of fire and scalding. The flame should always be lighted for a few minutes before the limb is introduced, so that the instrument may be warmed, and also to avoid the possibility of injury to the patient from explosion of gasTHE DRY PACK 275 if too large an amount should escape before the application of the match in lighting. If for any reason the flame should go out during the application, the limb should be removed while the burner is being relighted. The increase of heat must be gradual, and proportioned to the individual reaction. Indications.—This procedure has proved of most extraordinary service in subacute and chronic articular rheumatism, gout, traumatic arthritis, synovitis, tenosynovitis, fibrous anky- losis, rheumatoid arthritis, chronic leg ulcer, joint tuber- culosis, and sprain. Decided benefit has also been derived in cases of acute gout and rheumatism, although the method is less readily applicable in these cases because of the great pain involved in moving the limb. Local hot-air baths have been found especially beneficial in removing the stiffness, swelling, and pain left behind as a result of gonorrheal and other infectious forms of rheumatism. The benefit derived from these applications is in part due to the general effect as well as to the heating of the affected parts. This is demonstrated by the fact that when applications have been confined to a single joint in cases where a number of joints have been affected, all the joints have been improved ; evidently as a result of the increased oxidation and elimination of waste, as in the general hot-air and vapor baths. In chronic cases improvement may generally be hastened by judicious massage following the hot-air bath, or on alternate days. THE DRY PACK Technic.—This is a very effective, but rather inconvenient, mode of bringing the body as a whole under the influence of heat. The patient is closely wrapped in blankets (Fig. 69), with hot water bottles or bags to the feet, thighs, and back. Care must be taken to tuck the covers in closely about the neck, and to bring the wrappings closely in contact with the body everywhere, so as to prevent the slightest movement of air about the body. This will prevent evapo- ration and consequent cooling. Mode of Action.—In this procedure the source of heat is the body itself. Heat-elimination is favored by the warm coverings, so that there is a gradual accumulation of body-heat, which after a time results in a sufficient increase in the body-temperature to produce perspiration and all the other effects of a general hot application. This measure accomplishes all that can be accomplished by any other sweating procedure. The chief inconvenience lies in the length of time required to produce active sweating, which sometimes amounts to several hours, and the considerable degree of discomfort276 GENERAL AND LOCAL APPLICATIONS OF HEAT which the patient experiences during the heating period before perspiration begins. The indications and counterindications for this procedure are the same as for other general hot applications to produce sweating. The special uses of the dry pack are the induction of perspira- tion in cases where other general thermic applications are not readily available; especially when for any reason the application of water is not deemed advisable—as when a chill from malarial infection or pyemia is anticipated, in most cases of surgical shock, and in some cases of acute and chronic rheumatism. Local applications of the dry pack are often required in surgical cases, in cases of paralysis Fig. 69.—Dry Pack. of the limbs, after the ligation of arteries, in threatened senile gangrene, and in neuralgic affections. OTHER LOCAL APPLICATIONS OL HEAT The fomentation and the heating compress, perhaps the most useful of all the local measures known to thermotherapy, have been elsewhere described in connection with other hydriatric procedures. Dry hot applications may be made by a variety of means, of which we need mention only a few. For example, the application of dryEFFECT OF LOCAL HEATING 277 heat, like that of cold, as already described, may be made by means of the coil of rubber or aluminum, through which a stream of water at the required temperature is made to flow continuously. The temperature of the coil is easily regulated by a tube compressor, which controls the outflow. A rubber bag with an opening at each end may be employed in place of the coil, but is somewhat less con- venient. To avoid the inconvenience of emptying the water which is passed through the coil and refilling the heating reservoir, I have arranged a tank heated by a gas jet, from the top of which a pipe carries the water to the coil, while a return pipe enters the tank at the bottom. The rate of flow is regulated by a stop-cock. Rubber bags, bottles, or jugs may be filled with hot water ; sand- bags, salt-bags, bran-bags, bricks, blocks of wood, stove lids, Japanese hand stoves, and other objects may be heated and em- ployed for localized applications. These should be properly wrapped to avoid blistering the patient, an accident that has been known to occur through a nurse’s carelessness. Thermic massage, which is especially useful in myalgias (as lumbago and torticollis), is accomplished by stroking and pressing the affected part with a heated object. The use of the flat-iron is familiar. Goldscheider employs a special thermophore—a hollow metallic roller or rocker containing chemicals that give off heat upon the addition of water. It is usually advisable to protect the skin with a piece of thin, dry flannel. Effects and Mode of Action.—Localized applications of heat aie among the most useful of all means of relieving pain. The rationale of the effect produced differs in different cases. In neu- ralgia, for example, the relief may in some cases be due to the simple relaxation of the nutrient vessels of the nerve-trunks. Du Bois- Raymond has shown that the pain of neuralgia may be due to pressure upon the nerve filaments by spasm of their nutrient vessels, as well as by compression of the nerve-trunks by the overfilling of the blood- vessels in contiguous areas. It is evident that in the latter case the neuralgic pain may be relieved by simple revulsion, or diversion of the blood, to some other part, adjacent or remote. It is important to bear in mind that the therapeutic effect desired can be obtained only by a long continuation of the improved conditions induced by the application. An application lasting from ten to twenty seconds may, for example, give perfect relief for the time being; but, as a rule, the pain, unless due to some transient cause, will return, and often with very discouraging promptness. The disappointment thus occasioned frequently leads the physician to resort to an opiate when a more skilful application would wholly obviate the necessity for an anodyne of any sort. Cases are extremely rare in which pain even of a most excruciating sort cannot be very promptly relieved by thermic measures, or at least mitigated to such a degree that tolerance is278 GENERAL AND LOCAL APPLICATIONS OF HEAT easily possible until the cause of the pain can be removed by natural or artificial means. Duration.—It would be an error to suppose that the best results are always to be obtained by very prolonged hot applications. If the object of the application is to divert blood from a part to some re- mote part, as when a hot application is made to the feet and legs for the relief of cerebral congestion, or to aid in controlling a pleuritic pain or an acute bronchitis, the application may be continued for one hour, or even longer; but it should be remembered that the applica- tion of heat to so extended an area as the legs may after a time elevate the general temperature, especially when febrile activity is already present, and the heat-regulating power of the body thus lessened. In general, the hot applications should be at least briefly inter- rupted at the end of fifteen to twenty, or, at the longest, thirty min- utes. This is especially true when heat is applied directly over the affected part, for the reason that a long-continued hot application under such circumstances leads to an overaccumulation of heat in the part and dilatation of the deep-lying vessels, thus diminishing the derivative or revulsive action. On withdrawing the hot application, a well-wrung cool compress should be applied to the parts for one or two minutes, so as to restore the tone of the vessels and remove the heat which has been stored in the skin. The Heating or Stimulating Compress.—The duration of the heating process and of the derivative effect induced by the hot appli- cation may be prolonged by the use of a heating compress. This consists of one thickness of a linen towel, or of three or four thick- nesses of cheese-cloth, wrung out of water at 6o° F. (15° C.) and applied over the same area to which the hot application has been made, the wet cloth being covered with mackintosh extending an inch beyond the moist cloth in all directions, and all being finally covered by several thicknesses of flannel bound firmly in place so as to prevent access of air to the moist cloth. If air is admitted, evaporation will take place, and chilling will result. The cold cloth should be applied the instant the hot application is removed, and should be warmed up within a few seconds. Prolonged chilling will counteract the bene- ficial effects of the hot application. The latter may be renewed at the end of two or three hours, or at shorter or longer intervals, as may be required. By this means the affected part may be kept continu- ously under the influence of the thermal agents employed, and definite results may be obtained. In many cases the application of a cotton poultice, consisting of dry cotton closely covered with mackintosh and flannel, affords the most convenient means of maintaining the effect obtained, until another application is made. Lamb’s wool (the ‘carded wool’ of the dry-goods shops) is even better for a chest- jacket, as in pleurisy and pneumonia.CHAPTER V SALINE IRRIGATIONS AND INFUSIONS1 Introduction As a result of physiologic experimentation, it was first demon- strated by Kronecker and Sander, little more than twenty years ago, that dogs which previously had been bled from an open artery to the point of death could, by a subsequent infusion of so-called physiologic salt solution (0.6 per cent, sodium chlorid), be restored to life. Control animals brought to a corresponding degree of acute anemia and untreated, invariably died. The way had been paved for these investigations by Goltz, who in his oft-quoted paper had established the principle that under circum- stances of profuse hemorrhage, cardiac action ceases, not from the loss of any specific constituents of the blood, but for mechanical reasons alone. As a natural sequence of these revolutionizing experiments the infusion of sodium chlorid solutions as a therapeutic measure im- mediately stepped in to supplant in all cases of hemorrhage the dangerous and uncertain methods of direct blood transfusion, at the time much in vogue, but which, for many reasons better under- stood to-day, never could have found permanent favor. That the establishment of these fundamental principles should subsequently have led to the advocacy of similar therapeutic procedures for the treatment of most diverse conditions of disease is again a matter of natural sequence : procedures, however, both rational and otherwise, but in the majority of which entirely new physiologic principles are involved—of the saline combinations in the body-fluids, of osmotic pressure and glandular activities, of solubilities of toxins, and the like; a discussion of which is hardly appropriate at this place. Needless to say, they are far removed from the simple principle con- cerned in hemorrhage—namely, that of refilling ‘ die leere Pumpe * of Goltz. 1 By Dr. Harvey Cushing. The writer makes no attempt in this brief sketch to give the usual bibliographic references to the results of investigation or clinical experiences embodied therein. The literature of the subject within a few years has assumed large proportions. An excellent “ Sammelreferat ” by Laufer, containing two hundred and eiglity-six references to the more important contributions up to the year 1900, will be found in the “ Centralblatt fur die Grenzgebiete der Medizin und Chirurgie,” Bd. in, S. 422 et seq.y 1900.28o SALINE IRRIGATIONS AND INFUSIONS As a matter of fact, the rapid progress, that has been made in recent years by physiologic chemistry and physics toward a better understanding of the parts played in organic activities by the inorganic salts of the body-fluids and tissues, gives us but an indication of the line of development along which saline infusion as a therapeutic measure must proceed. At the present time, unfortunately, this method of treatment, though firmly established along certain lines, must nevertheless in others be regarded as still tentative or formative; and in only a few isolated conditions can we as yet make an intelligent attempt to vary the constituent saline percentages of our infusion solutions for the purpose of combating existing abnormal states of the body-fluids. The conditions in general for which artificial serum treatment is recommended, appropriately or otherwise, may be classified roughly into a few large groups. Primarily, and of greatest importance, stands the great division of cases suffering from the effects of direct loss of blood from an open vessel. Here the therapeutic indication from first principles is plain. A second large group of conditions comprises those which are associ- ated with a depletion of the body-fluids, usually by way of the alimentary canal, such as accompany persistent vomiting, diarrhea, and the like. The associated concentration of the blood and dehydration of the tissues gives here, as well, an evident therapeutic indication. In a third group may be included the various intoxications, whether bacterial in origin or otherwise, the infectious diseases and septice- mias, poisonings from mineral or organic substances,—indeed, all the diseases for the relief of which the procedure aptly termed by the French writers 'lavage du sang’ has been advocated. Here the treatment is more or less empirical and the exact clinical indications for its employment are far less clear. Lastly, in a fourth group may be placed a multiplicity of conditions—certain specific diseases and numberless special symptoms of others, for which saline infusion has without much reason been recommended. It is in these two latter groups that not only the method of admin- istration, but, above all, the percentages and varieties of the saline constituents which go to make up the solutions employed, become matters of the greatest moment. Although the future promises much, in the present state of our knowledge the infusion therapy for these conditions must be regarded as being in a larval state. METHODS OF ADMINISTRATION Fortunately, several methods of introductiomof the saline solutions present themselves. Unfortunately, however, those which are unat- tended by risk or by difficulties of administration are subject in their application to distinct limitations. Primarily among these may beENTEROCLYSIS 28l mentioned the introduction of the solution by way of the rectum or large bowel, termed enteroclysis. Enteroclysis Rectal injections are naturally to be preferred to all other methods, both from the ease of administration as well as from the simplicity of preparation of the solutions. It is unnecessary that the latter be sterile; their saline percentages need not be calculated to a nicety. In cases of acute secondary anemia the rapidity with which ordinary salt solution is absorbed from the large bowel demonstrates the efficacy of the treatment. It has been claimed by some that so much as one or two liters (quarts) may thus be absorbed in very few minutes—four and a half minutes, according to Warmann. On one occasion in my own experience, after an emergency operation in the country for ruptured tubal pregnancy, other methods of infusion at the time being precluded, two quarts of saline solution were slowly introduced into the rectum and were apparently absorbed as though sucked up by a sponge. After the high introduction of the rectal tube or catheter,—prefer- ably one of sufficient caliber and thickness to avoid kinking or turning backward,—or, if nothing other is at hand, of the rubber tubing attached to an ordinary douche bag, the fluid, at or slightly above the body-temperature, should be allowed to enter the bowel slowly. Re- flex efforts at evacuation, such as follow a low administration of the fluid, are thus avoided. The patient, meanwhile, should be placed in the left lateral Sims’s position, or else should have the pelvis raised on pil- lows or the foot of the bed should be elevated. The Trendelenburg position is a most favorable one for the administration of a rectal in- fusion. Many gynecologists take advantage of the fact, and as a routine at the end of an operation and before recovery from the anesthetic introduce a saline enema. For purposes of enteroclysis, an emergency solution may readily be made by adding a teaspoonful of table-salt to a pint of warm water. This form of infusion of course has its limitations, especially so, since in a very large group of condi- tions in which infusion is called for there is attendant disease of the intestine ; here other methods must be employed. Enemas of salt solution containing a hyperisotonic percentage of sodium chlorid have been recommended in ascites and ana- sarca; for the purpose, however, of abstracting fluid from the body rather than of administering it. For purposes also of cleanliness, to remove secretions and products of bacterial growth, saline solutions are frequently employed as rectal irrigations. When there is present ulceration of the bowel, the greatest care must be taken even in this apparently simple form of treatment. In a case of amebic dysentery, in which the customary quinin irrigation had been ad-282 SALINE IRRIGATIONS AND INFUSIONS ministered, I have seen perforation of the bowel occur as a result of the procedure. In view of its simplicity, it is unfortunate that enteroclysis is counterindicated in diseases of the intestine, in which circumstances so often arise demanding saline infusion therapy. For these condi- tions one of the more elaborate methods must be employed. Subcutaneous Infusion Previous to its general introduction, in 1881, or thereabouts, this form of infusion had been recommended by Cantoni as a treatment for Asiatic cholera, and had been called hypodermoclysis. At the present time it doubtless represents the most useful and widely applicable of all methods proposed for the administration of artificial sera. In view both of its simplicity and of its efficacy as a therapeutic measure for most diverse conditions, it is difficult to under- stand why its employment as yet has not been more widely popular- ized, but remains almost limited to its use in hospitals. Every apothecary should have sterilized and ready for immediate use an infusion needle and a flask with the proper saline solution, and every physician as well who is likely to be called to an emergency case of hemorrhage should be similarly prepared. Apparatus.—In its simplest form, all the apparatus that is neces- sary is an ordinary douche bag with rubber tube attachment, four to six feet in length, and a hollow aspirating needle at the open extremity of the latter. Indeed, an ordinary hypodermic needle may be used, though it is desirable to have one of somewhat larger bore. Prefer- able, of course, to the rubber bag, is a graduated glass flask with an opening at the bottom to which the rubber tubing may be attached ; and a glass joint in the course of the delivery tube is also an advan- tage. In this way the quantity infused and the rapidity of flow may more readily be estimated. The very elaborate forms of apparatus which are described, especially by the Germans, are unnecessary. Precautions.—Cleanliness—i. e.y surgical cleanliness—naturally is indispensable. The fluid used for the infusion must have been filtered, to remove all foreign particles, and must have been sterilized. It may conveniently be kept in narrow-necked flasks of glass which endure high temperatures, like Florentine flasks, holding one to two liters (quarts), and which have been stoppered by cotton plugs in the same manner as culture-tubes. When once sterilized, such solutions may be kept indefinitely as stock solutions, requiring only to be warmed to the necessary temperature when desired for use. The apparatus destined to hold the fluid during administration, together with the needle, should be boiled before using, or else sterilized after being pinned up in a towel, in which original cover it may be left until there is demand for its use.HYPODERMOCLYSIS 283 Preparation.—The skin of the patient, at the area selected, should be cleansed carefully with green soap, alcohol, and sublimate solution. The sterilized fluid, warmed to a few degrees above the body-temperature, should be poured into the infusion bag or bottle, and before the insertion of the needle under the skin the fluid should be running from it freely and without air-bubbles. The infusion receptacle may then be raised or lowered to the desired height, the static pressure of the fluid being sufficient to cause it to enter the tissues. The place selected for the infusion is largely a matter of personal choice. Some prefer to infuse directly into the belly of a muscle like the gluteus maximus, but the majority prefer the loose subcutaneous connective tissue of one or another region. Slight distention in such localities is less painful, and there is less danger of shutting off the circulation of the part, through the tension of the infusion-holding tissue. I greatly prefer to infuse in the loose tissues at the anterior border of the axilla; that is, at the posterior edge of the pectoral muscle, the needle lying almost parallel with the muscle edge and pointing toward the axilla. The region is not sensitive ; there is no danger of doing injury ; the tissues are lax; the lymphatics are abundant; and absorption is rapid. In the female, possibly the place of election is in the loose tissue between the mammary gland and the chest-wall. The breast should be lifted and the needle introduced from the outer side, care being taken that it does not enter the gland tissue itself. In one instance of which I have cognizance, when this accident occurred, a painful nodule persisted for months after the infusion. The retro- mammary tissue may easily take a liter of fluid in a short space of time, and large amounts are likewise accommodated in the loose tissue of the axillary or supraclavicular region without the production of undue distention. However, it is not well to force the infusion under any circumstances, and it should never be allowed to enter the tissues much faster than absorption takes place. The rapid introduction of the fluid either through static pressure due to considerable elevation of the solution-flask above the patient’s level, or by forcing it into the tissues through the agency of a pump or syringe (injection method), as I have seen practised in foreign clinics, should for many reasons, aside from its uselessness, be avoided. The tumor that results from such a local distention is painful, and, together with the massage that is often practised as an aid to the absorption, gives an insult to the tissues sufficient to encourage the localization of a chance infection at this point; furthermore, it leaves a tender and painful area, preventing the utilization of the same region for subsequent infusion. Such a repetition of the infusion may be called for. If the infusion is given slowly, large amounts may be introduced in the same area without284 SALINE IRRIGATIONS AND INFUSIONS the production of painful distention. In this way I have introduced 2500 c.c. (2y2 quarts) of salt solution at the pectoral margin with no appreciable swelling ; the fluid meanwhile was allowed to enter slowly from a static pressure of 40 to 60 centimeters (one to two feet) and in a constant flow, during a period of twelve hours, of about 200 c.c. (6}4 ounces) an hour. In many conditions, as in anuria, some forms of septicemia, and intoxications, such a slow prolongation of the infusion is distinctly more beneficial than the rapid administration of a large amount of fluid, so often attempted. As suitable for infusion, many localities other than the two that have been mentioned are highly recommended by various writers : such are the lumbar region; the buttock; the abdominal wall; the outer side of the thigh; at the posterior border of the scapula, etc. Where, however, tissues are somewhat tense and the blood supply is not especially abundant, great care must be exercised. I have seen an area of gangrene as large as the open hand follow an emergency infusion given under considerable force in the outer side of the thigh. The accident was due, no doubt, to the shutting-off of capillary circulation from the part in consequence of the local tension. Peritoneal infusion may be mentioned as a modified form of hypodermoclysis. The saline solution may be introduced into the peritoneal cavity after puncturing the abdominal wall with the infusion needle—a procedure, however, attended with some risk. The more common practice, which is only applicable in cases of abdominal operation, is to pour the fluid directly into the peritoneal cavity dur- ing or at the end of the operation, before closure of the abdominal wound. Thus, as in the conditions described above, the fluid enters primarily a space of the lymphatic system, passing thence by way of the lymph-vessels, and always through glands, before entering the blood. This fact precludes many sources of danger to the indi- vidual which, as we shall see, accompany direct intravenous infu- sions. Solutions are thus administered intraperitoneally with one of two objects in view: either for the sake of adding a fluid to the economy, —as in cases of shock with hemorrhage; for the purpose of preventing post-operative thirst; to stimulate the kidneys to action, etc.,—or else for the sake of flushing out septic material. The propriety of the latter procedure, as well as that of irrigation of an infected peritoneum under any circumstances, is the occasion of much discussion. It is a question whose decision must rest with the operator in relation to the individual case. The same thing is true as regards the position into which the patient should be put after the treatment—whether with elevated or lowered head and shoulders.INTRAVENOUS INFUSION 285 Doubtless both forms of treatment and of posture have in certain instances their justification. Intravenous Infusion Of all forms of infusion this represents the most difficult of appli- cation, the most dangerous, the most uncertain in its effects, and yet, at the same time, one most essential for certain special emergencies. Although, as a form of treatment in general, it possesses at the present time many limitations, doubtless the day will come when a great number of the intoxications, of septicemias, of poisonings of one sort or another, may intelligently be combated in this way with antitoxic substances. The Method of Procedure.—The fluid selected, the infusion apparatus with flask, rubber tubing, and cannula should be sterilized and prepared as described in connection with subcutaneous infusions. Any convenient superficial vein of sufficient size may be chosen. A vessel at the bend of the elbow, the radial vein as it crosses the ‘anatomist’s snuff-box,’ or the saphenous vein, are favorite ones. A bandage snugly applied to the extremity, proximal to the point selected for the infusion, usually suffices to bring the vein into promi- nence. The part should be cleansed scrupulously, as for an operation. One of two methods may be used for the introduction of the fluid—a closed or an open method. The former, more simple but less certain, consists in the introduction obliquely into the lumen of the prominent vessel of a small, sharp, hollow needle; a simple puncture of the skin being made, as in hypodermoclysis. In the latter—the method usually employed, and preferable for many reasons—the vein is exposed by a longitudinal incision through the skin and carefully isolated for a length of two or three centimeters (say, one inch). Local anesthesia should be employed. The vein should be handled as little as possible during this procedure, for such an isolated vessel contracts markedly under manipulation. A simple ligature should be placed under each end of the freed portion of vein and, unless it is desired to remove a quantity of blood prior to the infusion, the distal ligature should be tied. Otherwise the vein should be opened first, as in the ordinary procedure of blood-letting. In opening the vessel, a small oblique cut should be made with a sharp-pointed pair of scissors ; and through this, into the proximal portion of the vein, the needle or cannula with the infusion fluid meanwhile flowing from it to prevent the entry of air, should be introduced and the proximal ligature tied in a single knot over it. It is convenient to have a blunt- pointed slightly curved glass or metal cannula especially constructed for this purpose. An ordinary hollow aspirating needle may, however, suffice ; though it is more difficult to introduce and may injure the vessel wall. The loose bandage tourniquet is then removed and the286 SALINE IRRIGATIONS AND INFUSIONS fluid allowed to enter the vessel. After the infusion has been given, the needle is withdrawn as the single knot of the proximal ligature is tied down, and the wound is closed. As will be emphasized under “ Special Indications/’ there are cer- tain particular conditions in which this form of infusion is demanded, but, under all circumstances, its dangers and uncertainties are such that, in consideration of the efficacy of the less heroic methods, there must always be some hesitation in its employment. This is especially the case, since in the light of our present knowledge we cannot be absolutely certain of utilizing the proper saline combination or percen- tage in our solution ; one of too great saline percentage (hyper isoton- icity) may produce a most marked toxic effect, whereas one too weak in saline content (of hypisotonicity) is likely to have a solvent effect on the red blood-corpuscles.1 Infusion fluids, on the other hand, which have entered by way of the lymphatics, unless in too great amount, may be supposed to acquire from the tissues, by osmosis, saline percentages which render them innocuous by the time they have reached the blood current. Thus, pure water is harmless when in- jected in the tissues, but may be fatal when introduced into a blood- vessel. Furthermore, there are always certain dangers, as of an embolus from injury of the vessel wall, as well as from the accidental introduc- tion of some fine particle in suspension in the fluid. There is some liability to air embolism, though this, it must be admitted, is usually exaggerated. It is difficult to estimate the correct temperature, a matter which is of much less importance in the subcutaneous method. There is considerable risk, also, that the wound will not heal kindly, since in individuals who are in such general condition that there is a reasonable necessity for intravenous infusion, such a wound is apt to break down, especially when situated in one of the flexures, as at the elbow, where movements are difficult to restrict. In addition to these disadvantages, assistance is almost indispensable, the operative preparations must be more or less elaborate, and the same region can- not be used for a subsequent infusion. I remember to have seen a patient who had been so infused in both basilic veins for the treatment of traumatic shock and hemorrhage, following the amputation of a leg for septic gangrene. Doubtless a general infection was already pres- ent to encourage the localization of a wound infection. The patient 1 It is in the experience of all who have employed this intravenous method of infusion extensively to have seen unpleasant symptoms occasionally follow soon after the administra- tion of any large quantity of fluid. These symptoms resemble very closely those of a ma- larial paroxysm with a severe chill and rise in temperature, a rapid pulse, and quickened respiration. It seems to me not impossible that this may be, as in malaria, in some way associated with the breaking up of red blood-corpuscles ; here, of course, the destruction being caused by the hemolytic effect of a hypisotonic solution.INFUSION SOLUTIONS 287 recovered, but with a suppurating wound and venous phlebitis of each arm. Intra-arterial Injections This method of infusion, at one time quite widely employed and highly recommended, consists in the introduction of the infusion fluid centripetally into a peripheral artery. Certain special advantages were supposed to accrue from the direct mechanical effect exerted on the heart by an injection so administered. Many accidents, however, re- sulted therefrom, and the method is mentioned merely to be dis- missed. CONCERNING INFUSION SOLUTIONS It is a matter of no little historic interest that so called ‘ normal ’ or ‘ physiologic ’ salt solution was first used by the anatomists as a means of preserving fresh tissues for histologic examination, its supe- riority over pure water having been recognized. Its subsequent adop- tion by physiologists to preserve the normal irritability of isolated tissue preparations undergoing investigation, and its wide employment in the physiologic laboratory in practically the same saline concentration as that which was originally recommended,— a 0.6 per cent, solution of sodium chi or id,—has led to the general acceptance to-day of the belief that such a solution is the normal physiologic salt solution. As a matter of fact, this is a most misleading designation, if we mean to imply by the term a fluid which is isotonic with the body-fluids, and thus one that may be used with impunity in large amounts to replace directly in the circulatory system the loss of normal blood-serum. A 0.6 per cent, salt solution is, in the first place, sufficiently hypisotonic to lake the corpuscles perceptibly if used in sufficient quantity, and, furthermore, the recent observations of Loeb and his pupils have demonstrated the actual toxicity toward cellular activities of the pure sodium chlorid solution, that is to say, when uncbmbined with other salts. In spite of these facts, I presume that nine out of every ten individuals who infuse intravenously still use the 0.6 per cent, solu- tion. This statement holds true as well for the practice in the major- ity of hospitals. Sidney Ringer, some twenty years ago, through an accidental observation, discovered the fact that minute doses of calcium and of potassium salts, when used in combination with the usual percentage of the sodium salt, made a solution possessing a much more beneficial effect in conserving the activity of an isolated heart than the sodium solution when used alone. Thus for the first time was pointed out the antagonizing action of small amounts of calcium and potassium toward the toxicity possessed by the single sodium ion, and thereby was given288 SALINE IRRIGATIONS AND INFUSIONS the first indication of the necessity of combining salines in order to obtain a more perfect infusion solution. For such solutions, therefore, as contain the proper proportions of saline elements, or, in other words, in which the injurious effects toward tissue protoplasm possessed by any individual salt, are counterbalanced by the presence of others, Loeb has introduced the term ‘physiologically balanced solutions.’ The entire subject is comparatively young at present, and until the relationship of the inorganic salts and the body-fluids are better under- stood, so that infusion solutions of varying percentage can be adapted to different pathologic conditions, we can do little more than accept the foregoing few facts as a basis for the selection of proper solutions for purposes of infusion. From what has been hinted at in the section on intravenous infu- sion, it may be understood that the extreme precautions laid down, in so far as they concern saline percentages, are applicable chiefly to the procedure in which the fluid is directly introduced into the vessels. Solutions administered in other ways will probably have acquired, by osmosis from the storehouse of inorganic salts of the tissues, charac- teristics that will render them harmless to blood-corpuscles, nerve- cells, and other constitutents of the tissues, by the time they have reached the blood stream. This presumably is especially true of infu- sions given by the rectum. Here water itself, aside from its irritability to the mucosa,,answers the purpose, in large degree, of a physiolog- ically balanced solution. For similar reasons, the usual ‘salt solution’ of 0.6 per cent, sodium chlorid, provided it has been filtered and is sterile, may with propriety be used for hypodermoclysis, and the same may be said for peritoneal infusions, though a solution of higher percentage (0.75 per cent, to 0.9 per cent), which corresponds more closely to the molecular con- centration of the tissue fluids, is far preferable. When, however, we come to the introduction of fluid intravenously, we are confronted by a more complex problem. The very fact that numberless fluids with most variable combinations and percentages of saline constitutents have been advocated gives evidence of the uncer- tainty in which the matter rests. Solutions containing no sodium chlorid whatever, or else this really essential constituent in propor- tions all the way from 0.4 per cent. (Cantoni) to 1.0 per cent. (Malas- sez), are recommended with or without auxiliary sodium salts—the carbonate and bicarbonate, sulphate or phosphate; also cal- cium, potassium, or magnesium salts in one form or another; sugar solutions (Landerer, Schiicking); and many others. Queirel has recommended, as a proper solution, sea water in the proportion of 83 parts to 190 parts of distilled water, in order to obtain ‘ready- made ’ a proper proportion of salines. There can be no doubt that the pure sodium chlorid solutionSPECIAL INDICATIONS 289 alone may in certain ways be injurious from its toxic effects ; that, fur- thermore, a solution of the single salt, as weak as the 0.6 per cent, com- monly employed, has a hemolytic effect upon the red corpuscles. The desirability, therefore, of administering a fluid which shall not only be nontoxic, but which shall be as nearly as possible isotonic with the blood,—that is, shall have a molecular concentration corre- sponding to that of the liquor sanguinis,—is evident. This isoton- icity of the blood naturally varies considerably under different clinical conditions, and at the present time we have no way of determining it for the individual case. Under normal conditions, Hamburger, by a test which depended on the determination of that percentage of saline which failed to lake the red corpuscles, and von Koranyi, who estab- lished the molecular concentration by determination of the freezing- point, have shown that the proper proportion of salt in a sodium chlo- rid solution varies from 0.9 to 1.3 percent. A nine-tenths per cent, solution may therefore be considered safe and proper to employ for human beings under ordinary circumstances ; and as a modification of Ringer’s solution a combination such as the following : Sodium chlorid (NaCl),......................................... 0.9 Calcium chlorid (CaCl),.......................................... 0.026 Potassium chlorid (KC1), ................................... 0.01 Distilled water (H20),...........................................99.064 100.0 may, in the present state of our knowledge, be recognized as the most nearly perfect solution to be applied for the generality of cases.1 * * * * SOME OF THE SPECIAL INDICATIONS The Acute Anemia of Hemorrhage The entire therapy of saline infusions, as has already been indi- cated, is the outcome of its original successful employment as a means of combating the acute primary anemia from loss of blood. It is unnecessary to pass in review the circumstances of hemorrhage that might lead to the demand for this form of treatment. The 1 Such a solution is employed as the routine infusion fluid in several hospitals where attention has been given to the subject. When great quantities are employed, it is con- venient to have a concentrated solution of the saline carefully made by the apothecary, a certain number of cubic centimeters of which, necessary to make the desired percentage, can be added to a liter of distilled water when it is made up for sterilization. Thus the tedium and errors incidental to the weighing out of the salts for each separate flask of solu- tion are avoided. [This may be termed 6 clinical saline solution.’ Certain manufacturing chemists have placed upon the market somewhat similar solutions, presumably prepared with due care, in sealed vials containing each the correct quantity for one liter for ciuartl of water.—Ed.] ^ \ i ) IX—1929O SALINE IRRIGATIONS AND INFUSIONS clinician meets them chiefly in hemorrhages from the esophagus, stomach, intestinal canal, and lungs; the surgeon in traumatic cases with or without associated shock and either with concealed or ex- ternal bleeding ; the gynecologist in the ruptures of tubal pregnancy, in hemorrhages from uterine tumors ; the obstetrician in many com- plications of labor; the condition, in fact, of acute primary anemia may be encountered by any and every practitioner of medicine. When encountered, however, there are more things to be taken into consideration than the fact of a great loss of blood for which we may desire to compensate by replacing it with an artificial serum. Among the questions which arise is, Shall the infusion be given before the open vessel or vessels are secured or the bleeding has ceased spon- taneously? As a general rule, it is safe to answer in the negative, since clinical experience shows that the associated rise in blood pres- sure is apt to increase the loss of blood, or even to start up afresh the oozing from vessels that previously were dry. There is, however, something to be said on the other side, and, paradoxic as it may seem, the infusion, even though it increases the blood volume, may in certain cases actually check the hemorrhage. This hemostatic effect has been demonstrated experimentally by numerous French investigators, who have shown, however, that it follows the adminis- tration of comparatively small quantities of saline solution. Pro- vided, therefore, that the bleeding point has not been controlled,—as in many cases of internal hemorrhage it cannot be,—the infusion may be indicated; but in these cases particular care should be exercised lest it be carried too far—namely, to the point of relaxation of vas- cular tone. Such a condition often results from the infusion of a large amount of fluid. In the case of an adult, from 200 to 250 c.c. (say, 6 to 8 fluidounces) will often suffice to improve the general condition and to check the bleeding. Later, when the vessels have become securely thrombosed, a larger quantity of infusion may be introduced with safety (Haeberlin). The rationale of the administra- tion of a moderate quantity of saline solution as a preliminary to an operation which promises to be bloody can thus be seen to exist. The proposition has been made to use larger quantities of calcium chlorid, and even to add gelatin, for hemostatic effect under such circumstances. The method to be employed, whether intravenous or otherwise, depends largely upon the degree of anemia reached. Some authors have attempted on experimental grounds to subdivide the condition of profound hemorrhage into stages which depend upon the amount of blood lost, each having a more or less definite symptom-complex. For example, there is a first stage, with a loss of from 1000 to 2000 grams (one to two quarts) of blood, causing pallor, with a rapid compressible pulse having a rate of 120 to 140; a second stage,SHOCK 29I when something over 2000 grams (two quarts) have been lost, pro- ducing cold extremities, an almost indistinguishable pulse, fainting, and precordial anxiety; a third stage, when the loss exceeds 3000 grams (three quarts), manifested by relaxation of sphincters, imperceptible pulse, fibrillar twitching of the muscles, and similarly grave phenomena that accompany an unavoidable exitus (Cholmogoroff). In desperate conditions, as represented by these later stages, an intravenous or even intra-arterial infusion is absolutely necessary for the saving of life. It is practically only in hospitals, where mate- rials are in sufficient readiness, that the exigencies of such extreme states may be met successfully. In the earlier stages, subcutaneous infusions, or, when the symptoms are comparatively mild, rectal in- jections, meet fully the therapeutic requirements. The rapidity with which the fluid should be given, as well as the quantity to be infused, must remain a matter of personal judgment in the individual case. In my estimation, not only are too copious infu- sions apt to be introduced at one sitting, but they are, as a rule, intro- duced with much too great speed. Within reasonable limits, the more slowly the infusion proceeds, the better. Continuous observations should meanwhile be made on the volume and rapidity of the pulse and on the blood pressure. The latter may be estimated roughly by the palpating finger, or, still better, by some form of measuring appa- ratus, such as that described by Riva-Rocci. If an appreciable improve- ment has ensued on the administration of 500 c.c. (one pint), more or less, it is well to discontinue the infusion temporarily. It is a rule too often followed that because a small amount is good, more must be better; and, in consequence, patients are often deluged with saline solution, to the extent of 1500 or 2000 c.c. (3 to 4 pints)—a procedure which of itself may occasion collapse, profuse sweating, flabby pulse, and the low blood pressure of splanchnic dilatation, from which there may be no recovery. These warnings are especially applicable to the conditions of shock with hemorrhage; states in the treatment of which infusion is indicated, but in which it must be given with the greatest care. In cases of pure traumatic shock without loss of blood, I have never seen the treat- ment do more than temporarily to improve the pulse. If this condition be due, as is generally supposed, to a relaxation of the great splanchnic vas- cular area, the therapeutic indication is to furnish these vessels with some artificial support or to improve their tonicity. The former object may be attained in a measure by abdominal bandaging and by posture. The infusion of a physiologic salt solution will not improve the local vascular tone ; indeed, in large amounts it tends to lower this still more. Howell has suggested, on experimental evidence, the possibility that small amounts of sodium bicarbonate, when added to the usual infusion fluid, have some direct local influence in contracting292 SALINE IRRIGATIONS AND INFUSIONS the splanchnic area in shock. I know of no clinical observation as yet in corroboration of the statement, but if it shall prove true, it will be a most valuable addition to the infusion therapy. The treatment, nevertheless, of traumatic shock by the routine administration of saline infusions has its warm adherents, and its employment is wide-spread. Conditions of Abnormal Loss of Fluid from the Tissues The indications here are to replace in the body the watery elements that have been withdrawn from the tissues by morbid processes. As a noteworthy example of the beneficial effects of infusion in meeting such conditions may be mentioned its use in Asiatic cholera. Michael’s statistics have shown that 40 per cent, of the cases so treated in a particular epidemic recovered, in contrast with 22 per cent, of the cases not infused. The drying out of the tissues and concentration of the blood, due to the excessive loss of fluid by the bowel, is doubtless provocative of many of the serious symptoms of the disease—symptoms which are largely counteracted by the artificial serum. The same therapeutic principle holds good for all diseases in which there is an abundant loss of serum from the tissues, as in dysentery, typhus, or profuse diarrhea from any intestinal infection. In the summer diarrheas of children especially is it a most valuable thera- peutic measure. It is almost like a resurrection to see an infant, emaciated and in the profound collapse accompanying those conditions, brought back to life by the infusion under the skin of a few hundred cubic centimeters of salt solution. Similarly, in cases of uncontrolla- ble vomiting, whether of a toxic or a nervous origin, but in which there is great loss of fluid from the body, correspondingly beneficial results may be seen. Analogous conditions are those in which the individual is suffering from the need of fluid, not because it is rapidly withdrawn, but be- cause it cannot be taken in the natural way; in obstructive processes of the upper portion of the alimentary tract—esophageal or pyloric stricture, for example. Here the daily administration by hypoder- moclysis of 300 to 500 cc. (10 to 16 ounces) of a saline solution will completely remove that most unbearable symptom, thirst. Inas- much as rectal feeding must oftentimes be instituted, under extreme circumstances of this kind, the bulk of the nutritive enemas may thus be greatly reduced by giving the watery elements demanded by the patient in large part under the skin. The procedure of feeding by the rectum may in this way, by sparing the lower bowel, be continued over a much longer period than otherwise. There are many other occasions of a similar sort when, as symp- tomatic treatment, infusions may be called for to alleviate symptomsINTOXICATIONS AND INFECTIONS 293 due to a deficiency of fluids which cannot be taken in sufficient quantity by the mouth. Especially is this so during the hours of post-operative nausea, when thirst and diminished renal activity may be prominent and annoying symptoms, owing their presence partly to the direct influence of the anesthetic and partly to some loss of blood and the abundant perspiration which often has accompanied the state of narcosis. In consequence, many operators administer a few hun- dred cubic centimeters of sodium chlorid solution by the rectum or under the skin as a routine, after a general anesthetic has been em- ployed. The indication is plain and the results most satisfactory. Comparative statistics (Clark) have shown the efficiency of the proce- dure in increasing renal activity after operations and in controlling thirst. For similar purposes, after abdominal operations, the fluid may conveniently be left in the peritoneal cavity, from which its rapid absorption takes place. In the Various Intoxications, Infectious Diseases, etc. The possibility of using infusions as a means of washing out from the blood stream (‘ lavage du sang ’) toxic products of one sort or another had its first advocates in Dastre and Loye. These authors by experimental evidence furnished a scientific basis for this form of treat- ment. Such a lavage of the blood may be carried out in one of two ways: either by preliminary extraction of blood and a subse- quent intravenous infusion to take its place ; or, on the other hand, as a perfusion, by a slow continuous administration of the saline solution, which is found to be productive of a diuresis sufficient to carry off the fluid as rapidly as it is introduced. These authors dem- onstrated in animals that four times the volume of the blood may thus slowly be given, and that a corresponding quantity of fluid will in the same time be passed through the renal epithelium. Such an actual perfusion naturally has the tendency to wash away and dilute toxic products ; at all events, those which are soluble. An immense field of therapeutic possibilities was thus opened by these investigators, and the experimental observations have been in a degree corroborated by clinical experience. However, as has been stated earlier in this paper, it is in the treat- ment of conditions of this sort that the proper saline percentages of complex saline solutions become matters of moment; and inasmuch as at present no fixed rule can be laid down for their selection, the treatment must be considered to be decidedly in its probationary stage. It remains for institutions in which large groups of cases are treated to determine the appropriateness of the treatment in special diseases, and for the experimentalists to determine the solutions best fitted to combat the varying conditions of toxicity. These criticisms, however, which I wish to make concerning the usage of saline infu-294 SALINE IRRIGATIONS AND INFUSIONS sions in this group of cases, apply especially to its intravenous in- troduction. If therapeutists would confine themselves for the present, or until appropriate and safe solutions can be determined upon, to the method of subcutaneous infusion, the dangers of the treatment would be reduced to a minimum and the results, in so far as they are due to the principle of perfusion, be almost equally good. A great number of the acute infectious diseases have been so treated, usually with the so-called ‘ normal salt solution ’ (0.6 per cent, sodium chlorid), and by one method or another of infusion. In typhoid fever (Landouzy) it has been compared favorably with the bath treatment. The method was inaugurated by Sahli, and it is said to be effectual as an antipyretic and diuretic, and to be especially useful in cases in the typhoid state which are suffering from an intoxication or bacterial septicemia. In pneumonia also, especially as a cardiac stimulant, has infusion been warmly recommended by numerous writers, following F. P. Henry. Cases of tetanus have been so treated; also erysip- elas and the great variety of traumatic or so-called surgical infec- tions ; and it has been found useful in sepsis, of whatever bacterial origin.. If treatment with saline solution is instituted for condi- tions of this sort, unless there is some especial emergency indi- cating the need of intravenous infusion, it is much safer to limit the procedure to the subcutaneous method. In prolonged febrile diseases of the typhoid type the daily administration of from 200 to 300 c.c. (say 6 to 10 fluidounces) has been advocated. Much larger doses, however, are sometimes given. Lenhartz reports a re- markable instance in which a patient suffering from a severe case of typhoid was given twenty-three liters in seventeen days, a distinctly beneficial effect on the vascular tone and general condition having been appreciable after each administration. In a great number of autointoxications from disease, especially in cases associated with renal insufficiency, infusions may be, from their diuretic effect, most helpful. In the uremia of chronic nephritis it often has a most favorable influence ; sometimes, in the presence of acute symptoms, it is associated with blood-letting. When subcuta- neous infusion has produced a good effect, it may be maintained by rectal injections. The latter, indeed, systematically given, are often useful as a prophylactic measure, against the severe symptoms of uremia (Cohen). Sahli has claimed that the presence of anasarca is ordinarily no counterindication to a subcutaneous infusion, since by the infusion an unusually free lymph circulation in the edematous part may be established. In the condition of coma, a combined blood-letting and direct intravenous infusion have been recommended.VARIOUS APPLICATIONS 29$ Similarly, in eclampsia many cases have been reported with recovery following the extraction of a few hundred cubic centimeters of blood and subsequent infusion. For another profound intoxication, that producing diabetic coma, the saline infusion is*the most approved therapeutic measure. Stadelman’s demonstration of the fact that these symptoms of coma were due to a form of acid intoxication has led to the introduction of an alkaline infusion, as much as 0.3 to 0.4 per cent, of sodium bicarbonate or chemically pure sodium carbonate being added to the sodium chlorid solution. This neutral- izing treatment in diabetic coma is one of the few instances in which known abnormal chemical conditions of the blood give a definite indication for the saline constitution of the clinical infusion. For the intoxication associated with extensive superficial burns, saline infusion is the most efficacious treatment we possess. Tomma- solli has shown experimentally that infusion will save a certain percentage of animals that have been extensively burned, while those not treated all die ; also that the serum of dogs that have suffered from extensive burns is fatal when injected into normal animals, but that a following infusion may keep them alive. In many forms of poisoning other than these intoxications has the treatment been recommended, with or without preliminary or coincident venesection, according to the special indications of toxic agent and individual patient; thus, in phosphorus poisoning, in mercurialism (Sahli), in iodoform intoxication, in acute alco- holism (Cohen), in chloral, chloroform and carbolic acid poisoning, in the various putrid meat intoxications, in poisoning from carbon monoxid, from carbon dioxid, from illuminating gas and many other agents. In morphin and strychnin poisoning no successful result has as yet been recorded, which is presumably due to the marked tissue fixation of these drugs ; whereas in the various forms of autointoxication mentioned, as well as in the toxemias of febrile diseases, and of poisons such as alcohol, the greater or less value of the treatment depends presumably on the degree of solubility, or the ready loosening from tissue combinations of the poison, which, owing to the induced renal activity, is carried off with the urine. Lastly, we come to a miscellaneous group of diseases in the treatment of each of which there are certain therapeutists who champion the cause of saline treatment. On the ground that the various psychoses are of toxic origin, lavage of the blood with salt solution has been recommended (Boeclc), and favorable results reported in cases of mania, neurasthenia, and hysteria. It has been advo- cated as a treatment in certain forms of malignant syphilis, in mycosis fungoides, in eczema; as a local measure in numerous296 SALINE IRRIGATIONS AND INFUSIONS diseases of the eye in the form of subconjunctival infusions; as a means of stimulating local lymphagogic action in the neighborhood of chronic local processes, as ulcers, glandular swellings, and the like ; and so the list might be indefinitely increased. Summary After the foregoing brief review of infusion therapy, it may in summary be stated that this form of treatment, although its employ- ment has extended over but a score of years, has firmly established itself as one of the most useful of remedial measures ; that for certain conditions, especially those associated with the loss of blood and its concentration from dehydration of the tissues, no other efficacious form of treatment is available ; that in a great number of intoxications and infections the infusion, chiefly by inducing an associated renal activity, plays the part of diluting and washing out the toxic products ; that the method of hypodermoclysis is the method of choice for almost all conditions, whereas the intravenous method possesses many danger- ous features owing to the present insufficiency of our knowledge re- garding the proper makeup and percentage of the saline constituents of the infusion solutions.BALNEOLOGY AND CROUNOTHERAPY By Professor Dr. e. Heinrich kisch OF PRAGUE AND MARIENBAD, BOHEMIA Translated by AUGUSTUS A. ESHNER, M.D., of Philadelphia With Notes for America by GUY HINSDALE, A.M., M.D., of Philadelphia Secretary American Climatological Association AND AN Introductory Chapter on the Classification of Mineral Waters, with Especial Reference to Those of the United States, by ALBERT C. PEALE, M.D., of Washington, D.C. Aid in the Geological Department of the United States National Museum. In Charge of the Mineral Water Statistics for the Division of Mineral Resources of the United States Geological SurveyBalneology and Crounotherapy INTRODUCTION THE CLASSIFICATION OF MINERAL WATERS WITH ESPECIAL REFERENCE TO THE CHARACTERISTICS AND GEOGRAPHIC DISTRIBUTION OF THE MEDICINAL SPRINGS OF THE UNITED STATES BY A. C. PEALE, M.D. In charge of the Mineral Water Statistics for the Division of Mineral Resources of the United States Geological Survey; Member of Committee on Mineral Springs of American Climatological Association Definition of Mineral Waters Water being an inorganic body—a compound of definite composi- tion—hydrogen monoxid—is itself a mineral; moreover, as it is a universal solvent, absolutely pure water is a product of the laboratory alone. From a strictly scientific standpoint, therefore, all waters should be considered as mineral waters. Even glass is to a certain extent soluble in pure water ; and rain-water, the purest natural water, in its passage through the atmosphere acquires small quantities of solid organic and inorganic matters as well as of ammonia, carbonic acid, and other gases. The definition of a mineral water will thus depend largely upon the point of view ; that of the chemist differing from that of the physician or that of the layman. In common usage the term mineral water has been applied to waters containing appreciable quan- tities of foreign matters; some of the definitions restricting it to such waters as contain an unusual amount of matter in solution, or have a decided taste or a particularly high temperature. Many writers con- sider as mineral waters only those used in the treatment of disease; that is, that are utilized solely for medicinal purposes—a definition too narrow for practical use. These writers go to one extreme, while the chemist may possibly go to the other. The definition given long ago by Daubeny perhaps covers the ground as well as any other. He says 1 : “ The term mineral water in its most extended sense comprises 1 “ Sixth Report, British Association for the Advancement of Science, 1836,” p. 1. 299300 THE CLASSIFICATION OF MINERAL WATERS every modification existing in nature of that universally diffused fluid, whether considered with reference to its sensible properties or to its action upon life.” From the therapeutic standpoint, a mineral water is any water that may alter in any way the physiologic functioning of the human system, no matter how feebly mineralized the water may be ; that is, it is any water that possesses medicinal virtues, whether they be due to the presence of organic or inorganic, solid or gaseous contents, or to temperature. This is practically the definition found in most works on mineral springs. Under it would be included many waters that from a chemical standpoint might be considered comparatively pure—the chemically indifferent waters of some classifications. Many of them are less highly mineralized than the ordinary potable waters of most localities ; yet the fact that they have some specific effect, from the therapeutic point of view, entitles them to consideration under this definition. Small quantities of some constituents are often more effec- tive as remedial agents than larger quantities of others. The medicinal effect of weakly mineralized waters may therefore be due to the pres- ence of some substance effective in small quantities ; or it may depend upon the purity of the water, permitting large quantities of fluid to be used. Classification That a systematic arrangement of the various mineral waters is not only desirable, but important, is a proposition from which no one dis- sents ; and various schemes have been outlined. Unfortunately almost every one who has written on the subject has presented a classifica- tion differing in some respects from all others. It is a matter attended with much difficulty, from whatever standpoint it may be approached. Any classification must be to a certain extent arbitrary, as we find that the various waters shade imperceptibly into each other in respect to their various ingredients ; the principal ones must there- fore be emphasized in main classes, the minor ones determining sub- ordinate groupings ; and in some cases this may be a matter of individual judgment. Classifications may be made from a geographic, a geo- logic, a therapeutic, or a chemical standpoint; the first two, in view of the general uses of mineral waters, being of little value except for special scientific study. We are practically confined to a choice between the therapeutic and the chemical classification. The universal use of water for drinking purposes led at first to the division into potable and nonpotable (or drinkable and nondrinkable) waters; but,mineral waters were very early differentiated, and divided into classes according to their predominant character or the qualities which appealed most strongly to the senses of taste and smell. In the time of Aristotle they were classified according to the vapors orVARIOUS SCHEMES OF CLASSIFICATION 301 gases they contained. Pliny divided them into acidulous, sul- phurous, saline, nitrous, aluminous, and bituminous; and many of our classifications of to-day have advanced but little beyond this early scheme. If existing classifications are in any sense chemical, they are generally based upon properties that are not analogous ; terms denoting gaseous contents being given equal value with those referring to the solid constituents. Usually, however, there is a mixture of classes based on chemical and therapeutic qualities with classes based on characteristics referable to physical sensations ; the various proper- ties being considered in these schemes as coordinate. Thus, in most classifications,the terms ‘alkaline,’ ‘purgative,’ ‘thermal,’ and ‘sulphur,’ as applied to waters, are found of equal rank. The ideal scheme of classification from the standpoint of the medi- cal practitioner, who is perhaps more largely interested in the subject than any one else, is a therapeutic one, which should be based on careful and thorough clinical study. The conditions at present, in the United States especially, are such as to render this impossible ; there are few, if any, of our springs whose waters have been studied so thoroughly from the clinical viewpoint as to give us accurate knowledge of their effects upon correctly diagnosticated diseases. We are there- fore restricted to a chemical classification based upon the predomi- nance of one or more of the ingredients. In the absence of complete therapeutic data, we can rely with a reasonable degree of certainty upon the chemical composition, and may expect certain effects from the probable combinations indicated by the analyses. We may be guided, moreover, by analogies based upon recorded experience with well- known springs in Europe, where the subject has been accorded a prominence which it will no doubt eventually receive in this country. A chemical classification is furthermore necessary as a preliminary to the construction of one based upon the application of the waters in the treatment of disease. It presents some inherent difficulties, and is further embarrassed by the great variations in the methods of stating results used by different analysts. Thus, an inspection of some thousand analyses of American mineral waters revealed forty-two different methods of statement. On the whole, however, a chemical classifica- tion is preferable, especially if it can be made broad enough to include all mineral waters already analyzed or to be analyzed hereafter. The scheme that follows is applicable not only to American waters, but to all others. The designation of a mineral water according to this system gives at once a definite idea of its general chemical composition and affords a clue to its probable therapeutic effect. Thus it becomes feasible to pick out certain waters as probably suitable for a certain class of cases ; after which, a more careful study of the analysis of a given spring will permit one to determine whether or not it is likely to meet all the requirements of the individual patient.302 THE CLASSIFICATION OF MINERAL WATERS AUTHOR’S SCHEME OF CLASSIFICATION! Class: Group : (A) THERMAL (B) NONTHER- MAL / L ( II. Alkaline Alkaline- | SALINE < \ Sulphated- muriated [Borated \ ) III. Saline -j rSulphated- 1 muriated [Borated ( \ IV. Acid -j rSulphated- ' muriated [Silicious . . f Sulphated l \ Muriated / Sodic Lithic Potassic Calcic Magnesic Chalybeate Aluminous I(i) Nongaseous (free from gas) (2) Carbonated (containing carbonic acid . gas) \(3) Sulphureted (containing hydrogen sulphid) (4) Azotized (containing nitrogen . gas) I (5) Carbureted (having carbureted hydrogen) (6) Oxygenated (containing oxygen) In the first place, all waters are characterized by their tempera- ture ; they are cold, tepid, warm, or hot. In theforegoing table, therefore, the first column divides them into two great groups: (A) Thermal and (B) Nonthermal, and the two groups are treated pre- cisely alike so far as their solid constituents are concerned. Each contains four main classes: Alkaline ; Alkaline-Saline ; Saline ; and Acid. An alkaline, a saline, or an acid spring may be either thermal or nonthermal. A thermal water may belong to any one of the subordinate classes or their subdivisions, and the nonther- mal water may duplicate the thermal in any or all particulars except that of temperature. In Class I, alkaline waters, are included all waters containing the alkaline carbonates, whether they are of the alkalies, or the alkaline earths, and carbonates of manganese, iron, etc. Usually the iron carbonate is associated with the alkaline carbonates. Generally these waters are characterized by the presence of free carbonic acid gas (carbonated)—the ‘ acidulous waters ’ of some classifications. Class III, saline waters, includes all those characterized by a predominance of sulphates or chlorids; they are subdivided, ac- cording to the predominance of one or the other, into sulphated and muriated, or when these two classes of salts are present in about equal amounts, the term sulphated-muriated may be em- ployed; when sodium biborate is present as the predominent ingre- dient, the waters are termed bo rated. Class II, alkaline-saline waters, is intermediate between Classes I and III, and contains all those waters in which there is a mixture of carbonates with sulphates or chlorids, and maybe subdi- vided into sulphated, muriated, and borated. 1 This scheme was first outlined by the writer before the American Climatological Asso- ciation in 1887. See “The Transactions of the Amer. Climat. Assoc.,” 1887, p. 156.GASEOUS CONSTITUENTS 303 Class IV, acid waters, includes all those characterized by the presence of free sulph uric acid ; free hydrochloric acid; or free silicic acid. The subdivision into sulph ated and muriated waters holds here according to the presence of sulphates or chlorids, as it does for the saline and alkaline-saline classes. It might be argued that waters containing free carbonic acid (carbon dioxid) should also be included here ; but as the latter exists in a gaseous state, such waters may be found in any one of the four classes. Thus, we can have a carbonated alkaline water, a carbonated saline water, or a carbonated acid water. These four classes are further subdivided according to their pre- dominant basic solid constituents. When sodium carbon- ate, sodium sulphate, or sodium chlorid predominates, the water is known as sodic, sodic sulphated, or sodic muriated respectively, and similar designations are applied to waters character- ized by potassium, calcium, lithium, or any other predominant basic constituent. If iron is present in great quantity, the water is known as a chalybeate. It may be an alkaline chalybeate; an alkaline- saline sulphated or muriated chalybeate; a saline sul- phated or muriated chalybeate; or an acid sulphated or muriated chalybeate. An iron spring, therefore, may belong to any one of the four classes. The fact that waters contain iron should not relegate them all to one class, any more than the presence of sodium should cause waters characterized by a predominance of so- dium bicarbonate to be placed in the same group with those con- taining sodium sulphate as their principal ingredient. Any other ingredient, such as manganese or arsenic, if found in sufficient quantity, can be indicated by designating the water as manganic or arsenic, etc. The terms in the fourth column of the table can thus be extended indefinitely to include any kind of mineral water. Frequently there is a combination of the various constituents, in which case the character of the water can be expressed by a com- bination of terms, as sodic-magnesic; calcic-magnesic; so- dic-chaly beate ; calcic-chalybeate; etc. Lastly, any water belonging to any subdivision of the four classes in our table may be characterized, according to the absence or pres- ence of its gaseous constituents, as follows : 1. Free from gases : Nongaseous. 2. Containing carbonic acid gas: Carbonated. 3. Containing hydrogen sulphid: Sulphureted. 4. Containing nitrogen gas: Azotized. 5. Containing carbureted hydrogen: Carbureted. 6. Containing oxygen gas: Oxygenated.304 THE CLASSIFICATION OF MINERAL WATERS These gaseous constituents are expressed by the terms in the fifth and last column of the table. When more than one gas occurs in a water, this fact can be indicated by combining two or more terms; thus, a water may be sulphocarbonated—containing both free carbon dioxid and free hydrogen sulphid. The term carbonated is used in preference to 'acidulous/ as we may have a carbonated acid sulphated water (i. e., a water with free carbonic acid, free sul- phuric acid, and sulphates), and in such a case, the term 'acidulous acid water’ would be awkward. In the scheme just outlined the term 'indifferent’ or 'chemically indifferent’ is not used; as it is one upon the application of which agreement would be impossible. The spring-owner would perhaps draw his line of indifference at one place, the physician who prescribes the water might draw it at another, and the chemist at still a third point. The various analyses can be arranged in order according to the proportion of the classifying ingredient; beginning with the least highly mineralized water or with the one containing the largest quan- tity of solid contents. The waters sometimes called ' neutral ’ or 'chemically indifferent’ are not always therapeutically indifferent. For instance, in the Poland spring-water the total solid contents amount to less than four grains to the gallon (0.06 gram to the liter); and at the Hot Springs of Arkansas some of the waters contain less than ten grains to the gallon (0.15 gram to the liter). Many other waters from widely separated localities might be cited, but these are well known and will suffice to prove the point. Illustrations Three cases will suffice to illustrate the applicability of the scheme: The High Rock Spring and most of the other springs at Saratoga would be described as carbonated sodic-muriated alkaline-saline springs; i. e.y the water contains free carbonic acid gas, its predominant solid constituent is sodium chlorid,but it also contains alkaline carbonates. It belongs to Group A, as no temperature is given, it being a cold spring. The water of the Gilroy Hot Springs of California would be described as a hot sulphocarbonated sodic-muriated saline water; i. e.y it contains both free carbonic acid gas and free sulphureted hydrogen, and its principal solid constituent is sodium chlorid. It belongs to Group B, as it is a hot water. A third example is the Hot Springs of Virginia. The water of the Boiler Spring, one of its many springs, may be described as a hot carbonated calcic alkaline water; i. e., it contains free carbonic acid gas, the principal solid ingredient is calcium carbonate, and it belongs to Group B (thermal waters).GERMAN CLASSIFICATION 305 COMPARISON OF CLASSIFICATION SCHEMES Owing to the fact that so many different schemes of classification have been proposed there has been more or less confusion in their ap- plication. In order that consideration of the subject may be some- what simplified, an attempt is made here to correlate them. Although differing in details, these various schemes may nearly all be reduced to one or the other of four typical schemes, which can conveniently be designated as the German, French, English, and American. In the tables that follow, these are briefly summarized and each is com- pared with the scheme outlined by the author ; while their relations are described and briefly discussed. It is not purposed to criticize these various schemes except in so far as it facilitates their comparison and is necessary in order to correlate them with that of the author. Each undoubtedly has certain merits ; but all, being more or less artificial and arbitrary, must to some extent be unsatisfactory. It remains, as a prelude to uniformity, to reconcile differences so far as possible ; and a careful comparison should throw more light on the whole subject and lead to practical results. In the last column of each of the following tables is given the equivalent of each division in accordance with the author’s scheme already outlined. GERMAN CLASSIFICATION Correlation with Author’s Scheme I. Alkaline, . . . . II. Glauber’s Salt, , III. Iron (Chalybeate), IV. Common Salt, or Sodium Ciilorid, 1. Simple carbonated or acidulous. 2. Alkaline or acidulous alkaline. 3. Alkaline with common salt or alkaline hydro- chloric (or muriated) acidulous. 1. Pure or simple. 2. Alkaline and saline. 3. Earthy and saline. 1. Simple sodium chlorid. 2. Concentrated sodium chlorid or brine (Soolen). 3. Sodium chlorid with bromin and iodin. } V. Epsom Salt,.................................| VI. Sulphur,....................................| VII. Earthy and Calcareous, . ...............-] VIII. Indifferent, Carbonated alkaline and alkaline. Muriated alkaline-saline. Sodic sulphated saline. Alkaline chalybeate. Alkaline-saline chaly- beate. Alkaline-saline or saline chalybeate. Muriated saline. Iodobromic muriated saline. Magnesic sulphated sa- line. Sulphureted waters of any class. Calcic alkaline and calcic sulphated alkaline- saline or saline. Waters that may be of any class, whether thermal or nonthermal. ix—203°6 THE CLASSIFICATION OF MINERAL WATERS The scheme outlined above is the one used, with slight modifica- tions, by practically all German writers on mineral waters. Dr. Kisch in his scheme (as detailed in this volume, page 416) places the waters con- taining large amounts of sodium sulphate and magnesium sul- phate under one head, designated ‘bitter waters/—a plan followed likewise by many other German writers. Instead of the term carbo- n ated, Kisch uses ‘ acidulous/ and for the indifferent waters of elevated temperature he employs the term ‘acratothermal’ or ‘indifferent ther- mal’ waters. He also arranges his groups in a somewhat different order from that of the table, putting the ‘sulphur waters’ ahead of the ‘ iron waters ’ and the ‘ bitter waters ’ between the ‘ sodium chlorid ’ and ‘ sulphur waters.’ In agreement with nearly all schemes, the ‘alkaline waters’ here include those characterized by the pre- ponderance of carbon dioxid and the alkaline carbonates. He divides them into four sub-groups—‘ acidulous waters/ ‘alkaline acidulous waters,’ ‘alkaline hydrochloric (or muriated) acidulous waters,’ and ‘ alkaline-saline acidulous waters.’ This is to all intents and purposes Division I of the table page 305. Division II, ‘Glauber’s Saltwaters’ of the German classifica- tion, includes the waters characterized by the presence of sodium sulphate, occurring usually in large amount; this is one subdivision of the ‘bitter waters.’ Division III, ‘ iron waters,’ includes all the chalybeates. Kisch defines them as “containing iron in notable amounts, without the sum- total of their constituents being large”; and divides them into carbo- nated or ‘steel waters,’ sulphated or ‘vitriol waters,’ and ‘iron and arsenic waters.’ Division IV, the ‘common salt,’ or ‘sodium chlorid waters,’ con- tains common salt as the characteristic ingredient. They are sub- divided into ‘ simple,’ ‘ concentrated ’ or ‘ brines,’ and those containing bromin and iodin. Division V, ‘Epsom Salt waters,’ includes waters in which magnesium sulphate predominates; this is the second sub- division of the ‘ bitter waters.’ Division VI, ‘ sulphur waters,’ includes all waters containing hydrogen sulphid or some other binary sulphur compound. Division VII, ‘earthy or calcareous waters,’ includes the waters characterized mainly by the presence of calcium sulphate or carbonate. Division VIII, ‘ indifferent waters,’ includes the waters that con- tain no especial solid or gaseous ingredient in large amount. Kisch includes this division in his scheme only in so far as “ they are charac- terized by their high temperature” ; that is, only the thermal waters (‘acratothermal’) of this class. Some objections to the German classification are evident. In theFRENCH CLASSIFICATION 307 first place, the terms are based on properties that are not analogous. Sulphur waters are characterized by the presence of a gas—hydrogen sulphid. If, however, the gas is carbon dioxid, the water is placed under a sub-group of the alkaline division. The iron waters are divided into pure, alkaline and saline, and earthy and saline ; and yet alkaline waters also constitute one of the principal divisions of the scheme, being made coordinate with the iron, sulphur, and common salt divi- sions. The subdivision of the common salt or muriated waters is based mainly on the amount of sodium chlorid contained, a difference in degree that can just as well be shown by arranging the waters according to their strength under the head of muriated saline waters. Another objection to this scheme is that many of the thermal springs would be included under the head of ‘indifferent waters/ whereas it would seem that they should be distributed among the various classes in accordance with their predominant solid constituents. FRENCH CLASSIFICATION Correlation with Author’s Scheme f Sulphureted sodic- \ muriated saline. f Sulphureted calcic- \ muriated saline. Sodic muriated saline, f Sodic muriated alkaline- \ saline. f Sulphureted sodic-muri- \ ated saline, f Carbonated sodic alka- \ line. , Carbonated sodic-calcic, I calcic-magnesic,sodic- j chalybeate, etc., alka- ^ line. Sodic sulphated saline. Calcic sulphated saline, f Magnesic sulphated 1 saline. f Sodic-calcic-magnesic sa- I line, or alkaline-saline, I etc. f Carbonated chalybeate \ alkaline. C Sodic chalybeate, calcic J chalybeate, or alumino- 1 chalybeate sulphated v. saline. J Manganic chalybeate al- \ kaline or saline. The French classification given above is a mixed scheme; waters characterized by their gases being placed on a line with those in which a solid constituent—iron, or sodium chlorid—is the classifying ingre- J Carbonated calcic alka- \ line. Sulphur Waters Sodium Chlorid Waters, Bicarbonated Waters, Sulphated Waters, With salts of sodium. With salts of lime. Simple. With bicarbonates. Sulphureted. Sodium bicarbonate. ' Calcium bicarbonate. Mixed bicarbonates. Sodium sulphate. Calcium sulphate. Magnesium sulphate. Mixed sulphates. Bicarbonated. Ferruginous Waters, . < Sulphated. With salts of manganese.3°8 THE CLASSIFICATION OF MINERAL WATERS dient, while two of the divisions are made, not in accordance with the predominant chemical bases, but from the fact that these exist in the waters in the form of bicarbonates or of sulphates, respectively. Saline waters are found under all the divisions except one. The * fer- ruginous’ or chalybeate waters are separated from the saline and alka- line divisions and have a subdivision to include the wraters which contain both iron and manganese. The term ‘ thermal ’ as a class designation does not appear in this scheme of classification ; probably for the very good reason that a water referable to any one of the divisions of this scheme may be a thermal water or a nonthermal water. There have been many other classifications of the French mineral waters ; but the one given here is probably the one that has been most widely used, most of the others differing only in unimportant details. Some of them employ the term ‘ saline ’ for the sodium chlorid waters, and ‘ alkaline (sodaic) ’ for the bicarbonated waters. .ENGLISH CLASSIFICATION Simple or Indifferent Thermal Waters,............. Common Salt or Muriated Waters, .................. 1(a) Simple alkaline waters (£) Muriated alkaline waters. ( consists of three apartments, a dress- ing-room, the actual bath-room, land a room for douching and rubbing. In the latter is a tile stove with a niche that can be closed by doors and windows, and contains hot bricky. If it be desired to fill the room with steam, water is poured upon the; bricks. Against the wall nearest the stove three wooden benches placed one above the other like terraces are generally found, upon which the douching and switching of the body with birch twigs is practised. 1 See vol. m, p. 114 and p. 145.408 gas, peat, mud, mineral sieam, and medicated baths Effects The experiments of Frey and Keiligenthal have yielded the follow- ing results with regard to the mineral steam baths given at the sodium chlorid thermal springs of Baden Baden, with an atmospheric tem- perature of 50° C. (1220 F.) and cf a half-hours duration : Increase in delicacy of the sensibility of the skin for touch and temperature, during and particularly after the bath ; improvement in the general —condition and the feeling of a sersation of increased strength. On entering the bath there is brief, transitory contraction of the capilla- ries of the skin and, as a result, increased pressure in the arterial system and moderate acceleration of the pulse. This is soon followed by enormous dilatation of the cutaneous capillaries, reduction in blood pressure and cardiac vigor, and further acceleration of the pulse. During the bath the flow of blood to the skin is increased, while that to the internal organs is diminished. In the bath perspiration occurs. On the days of the bath there is reduction in the amount and increase in the specific gravity of the urine. There is diminution in the elimi- nation of urea and uric acid on the first day and increase in this elimi- nation on the next succeeding days. It is customary in the steam baths to practise cold affusions, fric tion of the skin, beating with twigs, kneading, massage, and similar mechanical manipulations, in order to increase the redness of the skin and stimulate the secretion of sweat, and, on the other hand, to exert a stimulating effect upon the sensory peripheral nerves and, through them, upon the cardiac nerves. The duration of the bath should not be too protracted. In mineral steam baths, in which the steam-saturated air contains particles of salt and of carbon dioxicl and hydrogen sulphid, depend- ing on the composition of the spring; the influence of the steam upon cutaneous hyperemia and secretion ik reinforced by the chemical and mechanical effects of the gaseous ancj solid constituents. Indications ( Mineral steam baths are indicated in obstinate chronic rheuma- tism, in exudations into muscles and joints, in arthritis and sci- atica, general derangement of metabolism, obesity, syph- ilis, and mercurialism ; they halve recently been recommended also in cases of anemia and chlorosis. Counterindications to the employment of such steam baths ary furnished by heart disease, a tendency to internal hemorrhalge, and arteriosclerosis. Localities Mineral steam baths have been provided at many sodium chlorid thermal springs, sulphurous thermal '^springs, earthy thermal springs, and alkaline-saline springs. In somej localities in Italy, Iceland, andIRISH-ROMAN BATHS 409 America there are grottos in the vicinity of volcanoes and thermal springs, which represent natural mineral steam baths. One of the best known of these is the grotto of Monsumano in Italy, Province of Lucca, which is filled with steam and represents a steam bath at a tem- perature of 33-5° to 350 C. (92-3° to 950 F.). The air contains in 1000 c.c. 4 c.c. of water in the form of vapor, and 3.25 per cent, car- bon dioxid, as well as a quantity of calcium carbonate in a finely divided state. In this connection reference may be made to the Irish-Roman baths, which are likewise provided at many health resorts, and in which dry hot air at exceedingly high temperatures is employed. The dry- ness of the air, making it a poor conductor of heat, and the cooling of the skin by evaporation of the sweat, combine to render high tem- peratures more endurable under such circumstances than they would be in the steam bath. The temperature of the blood is less mark- edly raised and the increase in pulse-frequency is slighter than in the steam bath. The Irish-Roman bath is therefore to be preferred to the steam bath, when it is desired to employ high degrees of temperature and at the same time to produce a less pronounced effect than with the employment of steam, and when it is desired to induce marked desqua- mation of the epidermis. The Irish-Roman bath consists of an ante-room at the ordinary room-temperature, 190 or 20° C. (66.2° or 68° F.), and communicating rooms at a temperature of from 350 to 40° C.—950 to 104° F.—(tepi- darium), and of from 45° to 50° C.—1130 to 1220 F.—(sudatorium). The two latter are well ventilated, and uniformly heated by means of hot-water pipes, which pass beneath the floor and along the lower por- tion of the walls. In some Irish-Roman baths there is a fourth room, with a temperature of from 65° to 90° C.—1490 to 1940 F.—(calda- rium). The bather is covered only with a bath robe and wears sandals to protect the feet against the heat of the floor. Sweating generally takes place after a stay of from fifteen to twenty minutes in the tepi- darium. Indications These hot-air baths are practised preferably for the purpose of stimulating the elimination of morbid products or foreign bodies through the skin, and of exerting a sorbefacient effect upon exudates and morbid secretions. They are therefore indicated in cases of arthritis, rheumatism, syphilis, metallic poisoning, and paralysis of various sorts. In this connection the mineral water spray baths (bains a Thy- droftre) recommended by French clinicians may also be considered.410 GAS, PEAT, MUD, MINERAL STEAM, AND MEDICATED BATHS By means of an especial spraying apparatus the skin of the patient is continuously brought in contact with a fresh layer of water in a finely divided state. If mineral waters are employed, the effect of the gase- ous and solid constituents is superadded to that of the spray, and the absorption of the former through the skin is increased in consequence of their fine division. These spray baths have the advantage over ordi- nary baths that the mechanical impact of the sprayed mass upon the skin exerts a more marked sedative effect upon the nerves of the part, that the uninterrupted renewal of the stream upon the skin facilitates the removal of secretion from the latter, and, finally, that absorption through the skin takes place more readily. MEDICATED BATHS For the sake of completeness, artificially medicated baths may be mentioned at this point. In these baths vegetable and animal mat- ters are added to the water for the purpose of inducing irritation of the skin ; softening indurated areas of the epidermis through imbibition ; exerting a sedative effect upon abnormally irritated skin; or, finally, improving the general bodily nutrition. Preparation and Effects The best known of these baths are the pine needle baths. To the bath-water is added a decoction of the needles and young shoots of firs or pines, or, what is more serviceable, preparations made from these, namely, the ethereal oil (fir-wool oil) and the alcoholic extract and infusion of pine needles. One-half to one teaspoonful of the ethereal oil, or from y to y2 kilogram (about y2 to i pound) of the extract, should be added to the bath. The volatile ethereal con- stituents penetrate the epidermis, excite the cutaneous nerves, stim- ulate the capillary circulation of the skin, and are eliminated through the skin, lungs, and kidneys. Similar effects may be obtained by the addition to the bath water of aromatic plants, as chamomile, wild thyme, elder- flower, calamus (sweet flag), spearmint, lavender, sweet marjoram, balm, peppermint, sage, and milfoil. Of these herbs from y to i kilogram (i y2 to 2 pounds) is used for a full bath, from 25 to 150 grams (1 to 6 ounces) for a local bath or a child’s bath. The herbs are tied up in a sac and scalded with 4 liters (quarts) of boiling water; the juices are then expressed and the decoction added to the bath. An equally efficient and simpler method of pre- paring an aromatic stimulating bath consists in adding the alcoholic extracts of the above-mentioned herbs, or the aromatic spirits of theASTRINGENT BATHS 411 Pharmacopeia; from 50 to 125 grams (2 to 4 ounces) of the latter suffice for a full bath.* 1 Still more efficacious is the addition of ethereal oils to the bath- water; only 1 gram (1 5 minims) of the ethereal oil is required to bring about the desired effect upon the skin. In order to induce a sharp, half-corrosive effect upon the skin of the patient, lye-baths are employed. In the preparation of these 2 or 3 grams (30 or 45 grains) of crystalline soda or a decoc- tion of wood-ashes is boiled with 8 liters (quarts) of water and the strained fluid is added to the bath. Local lye-baths, especially foot- baths, constitute a universally familiar derivative measure in the pres- ence of congestive states of the head and the thoracic viscera. Mus- tard baths—made by the addition of from 100 to 250 grams (4 to 8 ounces) of mustard-seed to the bath, or of 100 grams (4 ounces) to the local bath—act in the same manner. Baths intended to allay irritation are prepared by adding bran, starch, or malt to the water. From ^ to kilograms (]/2 to 2^/2 pounds) of wheat bran, or from to y2 kilogram (% to 1 pound) of starch or malt, is boiled for about half an hour in from 4 to 6 liters (quarts) of water, and the decoction added to the bath. The addition of oil to the bath, practised since antiquity, has recently been recommended for the treatment of burns and local inflammations of the skin, as well as for exudates situated in the deeper tissues. In the latter event it is thought that absorption is favorably influenced by the interference with evaporation due to the coating of oil on the skin. For astringent baths substances containing tannic acid are 1 The following preparations are officinal in Aqua amygdalae amarae. “ anisi (Br.). “ aurantii florum. “ carui (Br.). “ cinnamomi. “ foeniculi. “ menthae piperitae. 1 i menthae viridis. • “ sambuci (Br.). Decoctura aloes comp. (Br.), “ papaveris (Br.). “ quercus (Br.). “ sarsaparillae comp. Infijsum anthemidis (Br.). ** aurantii ( Br.). “ calumbae (Br.). “ caryophylli (Br.). “ lupuli (Br.). Oleum coriandri. u foeniculi. “ gaultheriae. “ juniperi. the United States and Great Britain : Oleum lavandulae florum. “ menthae piperitae. “ menthae viridis. “ myrciae. “ pini sylvestris. “ rosmarini. “ sabinae. ‘i sassafras. “ sinapis volatilis. “ terebinthinae. “ thymi. Spiritus amygdalae amarae. “ anisi. “ aurantii. “ gaultheriae. “ juniperi. “ lavandulae. ** menthae piperitae. “ menthae viridis. “ myrciae. ** rosmarini (Br.).412 GAS, PEAT, MUD, MINERAL STEAM, AND MEDICATED BATHS employed, such as oak bark, elm-willow bark, or walnut leaves. A decoction of to i kilogram (i to 2 pounds) of the vegetable substances in 3 liters (quarts) of water is the quantity for one bath. Animal baths are applications of the parts of recently slaugh- tered animals, especially the intestines, to the (paralyzed) extremities of human beings. In this category may be included also the sedative baths prepared by adding glue, 1 kilogram (2 pounds) dissolved in boiling water, or gelatin obtained by boiling calves’ feet; the use of these baths was probably at first suggested by a primitive conception of the absorptive power of the skin in the bath. Milk, whey, buttermilk, and beef-broth, which were formerly employed to increase the invigorating action of baths (bouillon baths), are now administered internally to better advantage. THERMAL CALCIUM OR LIME BATHS The efficacy of baths prepared with thermal earthy waters, thermal calcium or lime baths, depends chiefly on their high tempera- ture, and to some extent, according to certain authorities, on the pres- ence of calcium salts. There is little to support such a view, however, since all that is known of the physiologic action of calcium salts when applied externally is that they have a “desiccating effect on the skin and diminish secretion.” I do not believe that it is possible to distin- guish the effect of these baths from that of those acratothermal baths which increase the temperature. They are therefore mentioned here only for completeness. In some of the earthy mineral baths—as, for instance, at Leuk—the continuous application for several hours (from five to eight) is the main therapeutic factor. The bath then acts as a prolonged thermal bath and exerts a powerful influence on the cutaneous structures through imbibition and maceration (swelling) ; acts as a sedative to the irritated nerves ; hastens the healing process in open wounds and ulcers; and, finally, stimulates the excretory organs of the body. Indications Thermal calcium or lime baths are accordingly indicated in the fol- lowing conditions: Chronic diseases of the skin and ulcers; hyperesthesia and hyperkinesia ; syphilis and mercurialism ; old exudates in muscles, joints, and bones ; rheumatism ; arthri- tis; periostitis; and caries. Localities Calcium thermal baths are found at Bath, in England, 490 C. (1200 F.); Bormio, in Veltlin, 410 C. (105.8° F.) ; Buda-Pest, inNITROGEN INHALATIONS 4U Hungary, from 430 to 50° C. (108.4° to 122° F.) ; Leuk, in Switzer- land, 510 C. (123.8° F.); Lippspringe, in Westphalia, 21.2° C. (70.2° F.) ; Szkleno, in Hungary, from 410 to 53° C. (105.8° to 127.4° F.); Ussat, in France, 39° C. (102.2° F.); Weissenburg, in Switzerland, 26° C. (78.8° F.). " In the United States, Hot Springs, in Arkansas, is the most noted locality at which baths of this nature can be obtained. The nitrogen escaping from the thermal springs is also employed at some of these baths by inhalation, the efficiency of which is thought to be considerable, particularly in cases of pulmonary disease. How- ever, this gas can have only a negative effect. It is in nowise utilized by the organism, and its effect consists only in attenuation of the inspired air, in a diminution of the amount of oxygen contained, and thereby in an increase of the respiratory demand. If, however, the nitrogen replaces the necessary amount of oxygen in excessive degree, it may even induce the injurious effects resulting from an insufficiency of oxygen in the air.Section II CROUNOTHERAPY: THE USE OF MINERAL WATERS FOR DRINKING-CURES CHAPTER I PRINCIPLES OF CROUNOTHERAPY1 General Considerations. Constituents of Mineral Springs. Classification. General Considerations In the employment of mineral waters for drinking-cures it should especially be borne in mind that much more elaborate and complex pharmacologic preparations are concerned than those obtained from the apothecary ; and, moreover, their use at health resorts takes place under such peculiar conditions that a curative agent is raised to the dignity of a therapeutic method. Nevertheless, the inference must be rejected that mineral waters are capable of any specific action not explicable by the chemical and physical laws applicable to other reme- dies of the pharmacopeia. Although an adequate explanation either of the peculiar composition of mineral waters or of the activity of all their constituents is yet to be given, pharmacologic investigations have materially contributed to an estimation of the effect induced by. the sodium salts (chlorid, carbonate, and sulphate), the magnesium sulphate, the calcium carbonate, and the iron carbonate conveyed to the body even in minimal amounts through the mineral waters. It is now properly emphasized as a point of especial importance that the active constituents of the mineral waters, even though in small quan- tities, are present in a finely divided state 2 and are capable of easy absorption ; as also that the combination of several substances chemi- cally different, but having similar action, is of especial curative value. I would also lay stress upon the distribution of the dosage in several portions repeated throughout the day, as a means of favoring absorp- 1 From k{)ovv6(;, spring; and Oepaneta. For this word, which is needed, as * balneo- therapy ’ should be restricted to the medicinal use of baths, the editor is indebted to the Greek scholarship of his friend, Dr. David Riesman, of Philadelphia. 2 The recent chemical doctrines concerning the ions, and physiologic investigations based upon those doctrines, lend much importance to these conditions.—[Ed.] 4*4CONSTITUENTS OF MINERAL SPRINGS 415 tion and stimulating the activity of the tissues as well as the secretory and excretory processes. In the application of drinking-cures with mineral waters two principles especially are to be kept in mind : First, that in the practice of crounotherapy we are provided with agents capable of exerting powerful stimulating effects upon the individual diseased organ and its vital functions, and, at the same time, of influencing in no less degree the functional metabolism of the whole cellular aggregation constituting the organism ; and, second, that it is the duty of the physician at a health resort to regulate these stimulat- ing effects in each case in accordance with the individual susceptibility, and with the modification of irritability induced by morbid processes. The importance and the efficacy of drinking-cures with mineral waters at health resorts can be greatly increased if they are closely associated with dietetic treatment and general hygienic measures; and thus, when in conjunction with the effects of the drinking-cure, an alteration in the proportions of the integral elements of the blood and the body-fluids is brought about through the influence of climate, diet, exercise, and the like, the spa becomes a curative place for cases of chronic disease. The mineral springs, whose waters differ from ordinary drinking- water in the greater quantity of solid or gaseous constituents they contain or in their higher temperature, owe their origin to the contin- uous circulation of the water that is responsible for all springs. The water of the air, which reaches the soil by precipitation, penetrates to a greater or lesser depth accordingly as the earth or the rocks are more or less permeable to water, and reappears at various situations upon the surface of the earth in the form of springs. If the springs abstract from the rocks through which they flow considerable amounts of gaseous or mineral constituents, or if they arise from a great depth and, accordingly, are endowed with a high temperature, they constitute mineral springs. Constituents Among the gaseous constituents that the mineral waters derive from the strata of the earth from which they originate, carbon dioxid and hydrogen sulphid occupy the first place, and their escape is generally dependent upon communication with the deeper strata of the earth. The solid substances that occur most frequently in mineral waters include alkaline or earthy salts, of which principally sodium, potassium, calcium, magnesium, alu- minum, and, less commonly, barium and lithium act as bases. The acids combined with these salts are carbon dioxid, sulphuric acid, hydrochloric acid, silicic acid, boric acid, and phos- phoric acid. Metallic salts, of which iron occurs quite fre-416 PRINCIPLES OF CROUNOTHERAPY quently, and salt-forming elements, particularly iodin, bromin, chlorin, fluorin, and sulphur, may also be present. Of organic nitrogenous matters, partly vegetable, partly animal, coni ferae, algae, and infusoria are at times found. Classification The customary classification of the mineral waters, in accordance with their chemical constitution, is as follows : Alkaline mineral waters, characterized by the preponderance of carbon dioxid and alkaline carbonates; with the following sub- groups: simple acidulous waters; alkaline acidulous waters; alkaline muriated acidulous waters; and alkaline saline acidulous waters. Sodium chlorid waters, which contain sodium chlorid as the preponderant ingredient; with the following subgroups: simple sodium chlorid waters; sodium chlorid springs contain- ing iodin and bromin; brine or saline waters (Soolen), which contain also other salts, chiefly chlorids. Bitter waters, characterized by the presence of large amounts of sodium sulphate and magnesium sulphate. Sulphurous waters, which contain hydrogen sulphid or some other binary sulphur compound as a constant normal ingredient. Iron waters (chalybeate waters), which contain iron in large amounts, the sum-total of their solid constituents not being large. The subgroups are: carbonated iron waters; sulphated iron waters; and iron and arsenic waters. Earthy mineral waters, characterized by the presence of cal- cium sulphate and carbonate, which are present in large amounts, both absolutely, and relatively to the remaining constituents. Acratothermal waters (simple or indifferent thermal waters), which contain no especial solid or gaseous ingredient in large amount, and are characterized by their high temperature.1 1 The subject of classification is considered at greater length, and with some differences from the scheme outlined in the foregoing paragraphs, in a special chapter contributed to this work by Dr. A. C. Peale, of the United States National Museum and United States Geological Survey. In the same article will also be found extended lists of American waters of various classes, which should be consulted in connection with the notes on the location of mineral springs in the United States contained in the following chapters. See pages 299 to 365.CHAPTER II ALKALINE MINERAL WATERS Simple Acidulous ( Carbonated ) Waters—Effects and Uses. Alkaline Acid- ulous Waters—Constituents; Effects; Indications; Localities. Alkaline Muriated Acidulous Waters—Effects and Uses; Indications; Localities. Alkaline Saline Mineral Waters—Constituents; Effects and Uses; Indica- tions; Dosage ; Localities. SIMPLE ACIDULOUS (CARBONATED) WATERS Among the springs in the alkaline group the simple acidulous (carbonated) waters are quite deficient in solid ingredients, and are characterized especially by the large amount of carbon dioxid they contain, which is not less than 500 c.c. in 1000 c.c. of water. Effects and Uses The carbon dioxid contained in these carbonated waters excites an increased peristaltic action of the stomach and the intestines, as well as an increased secretion of the intestinal juices, exerting also a stimulat- ing effect upon the central organs of the circulation and upon the ner- vous system generally. Upon this is based the dietetic, rather than the therapeutic, significance of the simple gaseous waters, which, dis- tributed and used as table-waters, constitute mild stimulants for the digestive organs. These simple carbonated waters may also be employed for systematic drinking-cures in the presence of slight dyspeptic and cardialgic disturbances, as well as of mild catarrhal states of the respiratory organs. Among the best-known and most widely used of the carbonated waters of Europe is the Apollinaris water of Ahrweiler, in Rhenish Prussia, in the German Empire. Other waters often classed with these as 4 table-waters/ although many of them contain appreciable quantities of calcium, iron, and other salts, as well as of sodium chlorid and bicarbonate, are—In Belgium: the Adonis water. In Bohemia: the Dorotheenquelle at Carls- bad; Giesshuebl; and Krondorf. In France: Bussang; Bondo- neau ; Condillac; Chateldon; Teissieres les Boulies. In Ger- many: Bellthal; Birresborn; the Taunusquelle, near Frank- furt; Gerolstein; Goeppingen; the Wilhelmsquelle, at Kron- thal; Rosbach; Selters; and the Johannis Spring, at Zollhaus. In Great Britain : Malvern water artificially aerated is sometimes ix—27 417413 ALKALINE MINERAL WATERS used, on account of its great purity and its freedom from excess of calcium carbonate (Weber). In the United States the waters of Geyser Spa in California and of Manitou Soda Spring in Colorado are highly carbonated and contain but small quantities of solid ingredients; they may therefore be placed in this class. ALKALINE ACIDULOUS WATERS Constituents The alkaline acidulous (gaseous or carbonated) waters con- tain, in addition to large amounts of carbon dioxid, considerable quantities of sodium carbonates. Effects When used in moderate doses, they stimulate the secretory activity of the mucous membrane of the digestive tract, of the respiratory and of the urinary organs, and favor liquefaction of these secretions. These gaseous alkaline waters, both those from the cold and those from thermal sources, dissolve the mucus that has collected in the pharynx and the stomach, and, when the stomach juices are too highly acid, are capable of neutralizing a portion of the free acid and thus of aiding digestion by the production of a proper degree of acidity, and by counteracting abnormal fermentative processes. These waters may, through the sodium carbonate, which enters into combin- ation with the bile and the pancreatic juice, also exert a modifying influence upon the secretion of the intestine, neutralize the excessive acidity of the chyme that passes through the pylorus, and further stimulate intestinal peristaltic activity. After the use of the alkaline gaseous waters there is increased excretion of fluid mucus from the respiratory tract, or a liquefaction of abnormal viscid collections of mucus in the air-passages. These mineral waters increase further, at least in a transient manner, the alkalinity of the blood and of the body-fluids, induce increased elimination of carbon dioxid and absorp- tion of oxygen, and, as a result, increased metabolism of nitrogenous and nonnitrogenous matters within the body. The urine acquires a neutral or an alkaline reaction in most marked degree ; earliest if the alkaline gaseous water be taken when the stomach is empty, and most persistent when large quantities of these waters are used. Such waters are thus capable of liquefying the accumulations of mucus consequent upon catarrhal conditions of the urinary bladder, and of allaying the irritation of the diseased mu- cous membrane by the acid urine. The solvent effect upon uric acid of the alkaline gaseous waters rich in sodium has recently been empha-LOCALITIES OF ALKALINE CARBONATED WATERS 419 sized by Pfeiffer. This action is the greater, the larger the quantity of sodium bicarbonate contained in the water, and it persists for some time after the cessation of treatment. The alkaline springs of Fach- ingen, Vals, and Vichy are reputed to be especially effective in this connection. In the United States the Saratoga Vichy, of New York, the Idan-ha Spring, of Idaho, the Napa Soda Springs (Pagoda Spring) and the Mendocino County Seltzer Springs, of California, have similar qualities, while they do not in strictness belong to this class. These mineral waters are, furthermore, believed to exert a cholagogue effect—they have at least the property of causing long- continued and marked dilution of the bile. I have observed, more- over, that after the alkaline waters have been taken for several weeks, a diminution takes place in the quantity of oxalic acid excreted with the urine. The warm alkaline waters exert a mildly stimulating effect upon the digestive organs, and are more rapidly absorbed than the cold sodic gaseous waters containing considerable amounts of carbon dioxid, which latter, on the other hand, exert a more marked diuretic effect. Indications The indications for drinking-cures with alkaline acidulous waters are dyspepsia, with the formation of excessive gastric juice; mild gastric catarrh; catarrhal conditions of the respira- tory organs; catarrh of the urinary bladder; the formation of uric acid concretions and the presence of oxalates in the urine; catarrhal affections of the biliary passages; biliary calculi; and, finally, gout and diabetes. Localities Cold alkaline acidulous (carbonated) waters can be obtained, on the Continent of Europe—In Austro-Hungary: At Bilin, in Bohemia; Giesshuebl, in Bohemia; Krondorf, in Bohemia; Preb- lau, in Carinthia; Salvator Springs, in Hungary. In France: At Vals, in the Department of Ardeche. In the German Empire : At Facpiingen, in Hesse-Nassau ; Salzbrunn, in Prussia. In the United States : In addition to those previously mentioned, and more strictly an alkaline carbonated water, is that of Bladon Springs in Choctaw County, Alabama. Warm alkaline acidulous (carbonated) waters are found, on the Continent of Europe—In Austro-Hungary : Bilin, in Bohemia ; Salvator Springs, in Hungary. In France : Mont Dore, in the Department of Puy-de-Dome ; Vals, in the Department of Ardeche ; Vichy, in the Department Allier. In the German Empire : Fach- ingen, in Hesse-Nassau ; Neuenahr, in Rhenish Prussia; Salzbrunn,420 ALKALINE MINERAL WATERS in Prussian Silesia. Neuenahr and Vichy are well-known health re- sorts suitable in catarrhal states of the digestive tract and the urinary organs; and in diabetes. One liter of water contains at— Bilin, of sodium bicarbonate,..............................3.31 grams Fachingen, of sodium bicarbonate,..........................3.57 (f Neuenahr, of sodium bicarbonate,...........................1.09 “ Salzbrunn, of sodium bicarbonate,..........................2.15 “ Salvator Springs, of sodium bicarbonate, ..................0.3 gram Vais, of sodium bicarbonate,...............................7.28 grams Vichy, of sodium bicarbonate,..............................4.88 “ Bladon (Vichy), of sodium carbonate,.......................0.8 gram California Seltzer, of sodium bicarbonate,.................0.9 “ Idan-ha, of sodium and magnesium bicarbonates, . . . .1.2 grams Napa Soda (Pagoda), of sodium and magnesium carbon- ates and bicarbonates, ....................................o. 7 gram Saratoga (Vichy), of sodium bicarbonate,...................1.42 grams of calcium and magnesium bicarbonates, 2.35 “ ALKALINE MURIATED ACIDULOUS WATERS The alkaline muriated acidulous (or gaseous) waters differ from the foregoing groups of acidulous waters in the predominance of sodium chlorid present, in addition to sodium carbonate. Effects and Uses The sodium chlorid not only supports and increases the effect of the sodium carbonate upon the solution of albumin, in increasing the alkalinity of the blood, and in favoring retrogressive metamorphosis, but, in addition, facilitates the digestion of albuminoid food by increasing the activity of diffusion processes in the endosmotic absorption of chyle. The sodium chlorid is readily absorbed, and then exerts a diuretic effect Only large amounts exert a purgative effect. The quantity of sodium chlorid present in the alkaline muriated acidu- lous waters varies between 0.17 and 4.61 grams to the liter of water (approximately from 10 to 300 grains in the gallon). Through the presence of sodium chlorid the action of these mineral waters after absorption differs from that of simple alkaline gaseous waters in the greater solvent power upon uric acid, and in an especial fluidifying action upon the secretions of the mucous membrane of the respiratory tract. Certain disadvantages of the alkaline gaseous waters, such as the marked neutralization of the gastric juice after their pro- tracted use, disturbance of digestion, and impairment of the bodily vigor, are, further, overcome by the admixture of sodium chlorid in the alkaline muriated gaseous waters, which are considered as the mineral waters exerting the least stimulating effect upon the organism. The weaker waters of this class, in fact, approximate the constitutionLOCALITIES OF ALKALINE MURIATED WATERS 421 of a physiologic saline solution (0.6 per cent, of sodium chlorid). In general, the stronger waters of this group influence osmosis from and toward the blood, and in this way lead to a dehydration from the swollen tissues that is comparable to drainage, and that finds expres- sion in a notable increase in diuresis. The weaker waters and the thermal waters are especially adapted to cases in which the mucous membranes are in a condition of subacute inflammation and are exceed- ingly sensitive. On the other hand, the stronger cold waters of this group are more effective in the presence of atony of the mucous membrane, in which condition, moreover, the active stimulating effect of the carbon dioxid is desirable. Indications Drinking-cures with alkaline muriated gaseous waters are indicated for the relief of catarrhal affections of the mucous membranes, especially chronic bronchial catarrh in scrofulous individuals ; and of pulmonary tuberculosis in its first stage, as these waters under these conditions, on the one hand, mitigate the distressing bronchial and laryngeal catarrh, and, on the other hand, improve the digestion, as well as the nutrition of the entire organism. They are indicated for the same reason in the presence of residua of previous pleurisy. A favorable influence is exerted also upon several varieties of chronic gastric catarrh, as well as upon chronic catarrhs of the bil- iary passages and of the urinary organs. In addition to drinking-cures, the alkaline muriated gaseous waters are especially employed for gargling and inhalation and for cleansing the air-passages. For this purpose various forms of vaporizing apparatus, gargling chambers, and inhalatoriums are pro- vided at the health resorts where they are found. These waters are employed further for baths, and exert varying effects as bath media in accordance with their temperatures and the greater or less amounts of carbon dioxid and of sodium chlorid present. Localities Well-known alkaline muriated gaseous springs are located, on the Continent of Europe—In Austro-Hungary : At Gleichenberg, in Styria ; Luhatschowitz, in Moravia ; Radein, in Styria ; Szczawnica, in Galicia. In France: Royat, in the Department of Puy-de-Dome. In the German Empire : Assmannshausen, in Hesse-Nassau ; Ems, in Prussia ; Roisdorf, in Rhenish Prussia ; Selters, in Hesse-Nassau ; Weilbach, in Hesse-Nassau. The waters of Gleichenberg and Weil- bach, as well as the thermal springs of Ems, have an especial reputa- tion in the treatment of chronic laryngeal and bronchial catarrh; Assmannshausen and Royat particularly in the treatment of gout and422 ALKALINE MINERAL WATERS uric-acid deposits in the urine; Luhatschowitz and Szczawnica in the treatment of disorders in torpid scrofulous persons. The waters of Radein, Roisdorf, and Selters are generally employed for export. In the United States1 waters analogous to those just mentioned are—In California : TEjtna Springs, in Napa County ; Azule Spring, in Santa Clara County ; Glen Alpine Mineral Springs, in El Dorado County. In Michigan : Plymouth Rock Mineral Well, in Wayne County; Salutaris Spring at St. Clair Springs, in St. Clair County. In New York: Saratoga (Vichy), in Saratoga County. In Virginia: Colemanville Mineral Springs, in Cumberland County. In one liter of water there are contained : At : Sodium Carbonate Sodium Bicarbonate Sodium Chlorid ZEtna, 0.41 gram Assmannshausen, 0.13 gram 0.57 “ Azule, . . . .1.0 gram 1.56 grams Ems, 2.03 grams 1.0 gram Gleichenberg, . . 2-54 “ 1.85 grams Glen Alpine, . . Luhatschowitz, . 0.56 gram 0.36 gram 6.76 grams 4.45 grams Radein, .... 301 “ 0.6 gram Roisdorf, . . . 1.24 “ 1.84 grams Royat, .... i-35 “ 1.73 “ Salutaris, .... 0.08 gram 1.40 “ Saratoga Vichy, . 1.48 grams 2.20 “ Selters, .... I.23 “ 2.33 “ Szczawnica, . . 8.44 “ 4.61 (i Weilbach, . . . 1.35 “ 1.25 “ ALKALINE SALINE MINERAL WATERS Constituents The alkaline saline mineral waters (sodium sulphate waters) are most important by reason of their constitution, which comprises sodium sulphate in addition to sodium bicarbonate and sodium chiorid. They occur in both cold and thermal springs. In the former the large amount of carbon dioxid and generally also of iron, and in the latter the high temperature, are effective factors in conjunction with the ingredients already named. The amount of sodium sulphate varies between 0.5 and 5 grams in the liter of water (approximately, 30 and 300 grains in the gallon) ; of sodium bicar- bonate, between 0.6 and 4.8 grams (approximately, 36 and 287 grains in the gallon); and of sodium chlorid, between 0.2 and 3.6 grams (approximately, 12 and 215 grains in the gallon). 1 For more extended lists of these and other waters consult the introductory chapter, by Dr. Peale, pp. 299 to 365.DOSAGE 423 Effects and Uses The cold sodium sulphate waters exert a marked diuretic effect, particularly if the amount of carbon dioxid contained is large ; and, further, if given in large quantities, a purgative action, induc- ing semiliquid intestinal evacuations. The principal effect of the sodium sulphate consists in a stimulation of intestinal peristaltic activity and liquefaction of the intestinal contents, the latter principally because the salts are absorbed from the stomach and the upper portion of the intestinal tract in small amount only, so that considerable quantities enter the terminal portion of the bowel. The warm waters contain sodium sulphate in small amounts, and diminish the secretion of urine not inconsiderably; exerting a less stimulating effect upon intestinal activity, though favorably influencing the digestive processes. The body-metabolism is in- fluenced by the alkaline saline mineral waters in such a manner that retrogressive metamorphosis of nitrogenous matters is retarded, and the decomposition of fat is increased. Similarly to other alkaline mineral waters, those of this group also exert a solvent effect upon uric acid, as well as a stimulating effect upon the secretion of bile. Indications The warm alkaline saline waters are indicated particularly in severe cases of gastric and intestinal catarrh, and in cases of ulcer of the stomach; in connection with which their good effects are exerted notably through reduction of the hyperacidity and the secretion of the gastric juice. They are useful, likewise, in cases of catarrhal jaundice, hyperemia of the liver, and cholelith- iasis; in cases of gout and lithemia; and in the presence of urinary concretions. They have an especial vogue also in cases of diabetes, more particularly of the gouty type. The cold sodium sulphate waters are suitable for the same conditions in plethoric, well-nourished individuals, and when, in consequence of organic changes in the heart or in the large vessels, water of a high temperature would be too stimulating. They have, further, a more powerful effect upon the reduction of fat in the organism, and their purgative action is also more pro- nounced, so that they are adapted for the relief of the large group of symptoms due to abdominal plethora. Dosage.—The sodium sulphate waters are generally taken when the stomach is empty, in amounts varying from 200 to 1200 grams (6 to 40 ounces). They should not be taken immediately after eating or in the course of a meal, because at this time they may readily neutral- ize too much of the acid gastric juice. For delicate persons a com- bination of the cold waters with warm milk or whey may be employed.ALKALINE MINERAL WATERS 424 Localities Cold alkaline saline springs are situated, on the Continent of Europe—In Austro-Hungary : At Franzensbad, in Bohemia; Marienbad, in Bohemia; Rohitsch, in Styria. In the German Empire: Elster, in Saxony. In Switzerland: Tarasp-Schuls, in Canton Grisons. In Canada: Caledonia Springs, Province of Ontario; Sand- wich Springs, Ontario ; St. Catherine’s Wells, Ontario ; Caxton Springs, Province of Quebec. In the United States corresponding waters are—In California : Agua de Vida Springs (Lower Spring), at Arroyo Mucho ; Cas- talian Mineral Springs, in Inyo County; Gordon Springs, in Lake County. In Colorado: Springdale Seltzer Springs, in Boulder County. In Kansas: The Topeka Mineral Wells, in Shawnee County. In Kentucky : Harrodsburg Springs, in Mercer County. In Texas : Gibson Mineral Well, in Palo Pinto County. Thermal alkaline saline springs are found, on the Continent of Europe—In Austro-Hungary : At Carlsbad, in Bohemia. In the German Empire : At Bertrich, in Rhenish Prussia. In the United States waters of this group are found—In Arizona: Castle Creek Hot Springs, in Yavapai County. In California: Geyser Spa, in Sonoma County; Harbin Hot Springs, in Lake County. In Colorado : Idaho Hot Springs, in Clear Creek County ; Manitou Springs, in El Paso County; Pagosa Hot Springs, in Archuleta County; Royal Gorge Hot Springs, in Fremont County. One liter of water contains : At : Sodium Sodium Sodium Sodium Sulphate Carbonate Bicarbonate Chlorid Agua de Vida (Lower Spring), . 0.24 gram 0.05 gram o.°5 gram Bertrich, Carlsbad, 0.88 “ 0.72 gram 0.21 “ 2.40 grams I.29 grams 1.04 grams Elster, 5.16 “ 1.68 « 0.82 gram Franzensbad, 2.80 “ 0.67 gram 1.14 grams Geyser Spa, 0.04 gram 0.08 “ 0.34 “ 0.14 gram 0.40 “ Manitou (Manitou Spring), . . 0.20 “ 0.02 “ 1.82 grams Marienbad, 5.04 grams 2.04 grams Rohitsch, Royal Gorge (Iron Duke Spring), 3.02 “ 1.07 “ 0 07 gram 0.19 gram 1.24 grams 1-34 grams Springdale Seltzer, 1.74 grams 0.09 gram 0.08 gram Tarasp, 2.IO “ 4.87 grams 3.67 grams The most important of these health resorts with alkaline saline springs are Marienbad and Carlsbad. The special indications for the former are, as I have elsewhere published, conditions of stasis in the portal area, caused by overeating, habitual constipation, and a sed- entary mode of life; excessive deposition of fat; and the distur-CARLSBAD AND MARIENBAD SALTS 425 bancesof the climacteric period in women; whereas Carlsbad is specifically effective in the treatment of the various disorders of the stomach and the liver; gall-stones; urinary concretions; and diabetes. Franzensbad and Elster are particularly adapted when the indications for cold sodium sulphate water occur in anemic individuals with impaired nutrition ; Rohitsch and Bertrich, when the pathologic changes have occurred in but a slight degree; and Tarasp, when the effect of high altitude is desirable. The therapeutic employment of the salts obtained from the sodium sulphate waters, and particularly of those of the springs at Carlsbad and Marienbad, is also worthy of mention. In the preparation of the salts, the water is evaporated, the precipitated amounts of earthy carbonates, iron oxid, and silicic acid are filtered, and the moist salt, which contains sodium sulphate, sodium bicarbonate, and sodium chlorid, is treated with carbon dioxid. There results a mixture that contains sodium sulphate, sodium bicarbonate, and sodium chlorid in exactly the natural proportions in which these salts are present in the springs. The salt is employed by dissolving from 3 to 5 grams (45 to 80 grains) in a glass of simple or carbonated water. There are contained in : Carlsbad Sprudel-Salt Marifnbad Spring-Salt 54.38 per cent. 23.81 “ “ 20.40 “ “ Sodium sulphate, . . Sodium bicarbonate, . Sodium chlorid, . . . . . 43.25 per cent. . . 36.20 “ “ . . 16.81 “ “CHAPTER III SODIUM CHLORID WATERS Constituents. Effects and Uses. Indications. Dosage. Localities. Lithia Waters. Iodin Waters—Constituents; Effects and Uses; Localities. Constituents The sodium chlorid springs include those mineral waters, both cold and warm, that contain sodium chlorid as the principal ingre- dient, and, in addition, other chlorin combinations in small amounts— as, for instance, magnesium chlorid, potassium chlorid, and calcium chlorid, as well as minimal amounts of lithium chlorid, aluminum chlorid, and, at times, also combinations of iron, iodin, and bromin, and of gaseous elements, especially car- bon dioxid. The mineral waters of this group occur in almost all strata of the earth thus far exposed, as sodium chlorid is distributed in all rocky formations. In all sedimentary formation^, likewise, particularly where adjacent strata contain extensive deposits of mineral salts, large amounts of sodium chlorid are found. For drinking-cures, the simple sodium chlorid waters and the springs containing lithium, as well as those containing iodin and bro- min, are mainly employed. Simple sodium chlorid waters are derived from springs of this group that contain carbon dioxid in considerable quantity, and in which the total amount of solids does not exceed 2 per cent., more than one-half consisting of sodium chlorid and other chlorids. Effects and Uses Sodium chlorid, which, as we know, is indispensable in the nutri- tion of man, stimulates more active secretion on the part of all the mucous membranes, and exerts an important influence particularly upon the stomach, whose digestive power appears to be increased. The sodium chlorid contributes not only to an increase in the se- cretion of the gastric juice, but also to the better solution of the albuminous and amylaceous elements of the food, and thus favors the more complete utilization for the body of the nutritive values of the food. The albuminous metabolism, according to Daepper, is 426DOSAGE 427 not increased by sodium chlorid waters, and the use of these waters likewise does not interfere with the absorption of fat. The excretion of uric acid remains unaltered, or is slightly increased. The sodium chlorid waters, both cold and thermal, exert, further, a diuretic effect; but if the amount of sodium chlorid administered is too great to be absorbed completely, the stools become thin and diuresis suffers diminution. Indications The most common indications for the use of the simple sodium chlorid waters are chronic catarrhal states of the pharynx and the nasopharyngeal space, with involvement of the larynx and the bronchi; chronic catarrh of the stomach, the duo- denum, and the biliary passages; abdominal stasis and its sequels; scrofulosis and rachitis; arthritis and lithiasis. With regard to the two diseases last named, particular importance has recently been attached to the presence of lithium in the sodium chlorid waters. Lithia Waters.—An especial solvent effect upon uric acid has been attributed to lithium salts, and springs containing any appre- ciable amount of these substances have been designated lithia waters. It has not yet been demonstrated experimentally that the introduction of the lithium salts into the human body is sufficient to convert the precipitated uric acid into readily soluble combinations ; and, further, the quantity of lithium salts in the waters under con- sideration is usually infinitesimal. Nevertheless, it is certain that lithium possesses considerable diuretic activity, even when present in this great dilution,—perhaps for that reason,—and therefore the systematic employment of such waters is to be recommended in cases of gout and renal calculi: on the one hand, to prevent attacks of gout, and, on the other hand, to aid in the expulsion of the urinary concretions. Dosage The quantity in which the simple sodium chlorid waters can be taken varies between 120 and 1200 grams (4 and 40 ounces) daily. The ingestion of a single draft in the morning, when the stomach is empty, is to be preferred to repeated drafts several times,in the course of the day. When the constitution of the patient is torpid and in- sensitive and a powerful impression is desired, large amounts of the simple cold sodium chlorid waters are indicated; whereas in the presence of more marked irritability of the gastric mucous mem- brane, the thermal sodium chlorid waters are to be preferred, or warm milk or whey is to be added to the cold waters.SODIUM CHLORID WATERS 428 Localities Cold simple sodium chlorid waters are found, on the Conti- nent of Europe—In Austro-Hungary : At Also-Sebes, in Hun- gary. In the German Empire : Arnstadt, in Thuringia ; Homburg, in Prussia ; Kissingen, in Bavaria ; Kronthal, in Prussia; Mergen- theim, in Wurtemberg ; Neu Rakoczy, in Prussia; Niederbronn, in Alsace ; Pyrmont, in Waldeck-Pyrmont; Rehme (Oeynhausen), in Westphalia; Schmalkalden, in Hesse-Nassau. In the British Isles—In England : At Droitwich, in Worcestershire; Harrogate, in Yorkshire; Nantwich, in Cheshire. In Scotland: Bridge-of- Allan, in Stirlingshire. Waters corresponding to the foregoing are found in the United States—In California : Byron Springs, in Contra Costa County. In Colorado: Canon City Mineral Springs, in Fremont County; Parnassus Springs, in Pueblo County. In Kentucky : Lower Blue Lick Springs, in Nicholas County; Upper Blue Lick Springs, in Nicholas County. In Maine : Lubec Saline Spring, in Washington County. In Missouri: Akesion Spring, in Saline County. In New York: Ballston Spa, in Saratoga County; Columbia Springs, in Columbia County; Congress, Excelsior, Hathorn, High Rock, Seltzer Springs, at Saratoga Springs, in Saratoga County; Hal- leck’s Spring, in Oneida County. In Pennsylvania: Salt Spring near Alba, in Bradford County. In Wisconsin : Sheboygan Min- eral Well, in Sheboygan County. Thermal sodium chlorid waters are situated, on the Continent of Europe—In France: At Balaruc (50° C. —1220 F.), in the Department of Herault; Bourbonne-les-Bains (58° C.—136.4° F.), in the Department of Haute-Marne. In the German Empire: Baden-Baden (68° C.—154.4° F.), in the Grand Duchy of Baden; Cannstadt (20° C.—68° F.), in Wurtemberg; Mondorf (240 C.— 75.2° F.), in Luxemburg; Nauheim (210 C.—69.8° F), in the Grand Duchy of Hesse; Soden in the Taunus (230 C.—73.40 F.), in Hesse-Nassau; Wiesbaden (68° C.—154.40 F.), in Hesse-Nassau. In Italy: Battaglia (58° C.—136.4° F.), in the Province of Venice. In the British Isles springs corresponding to the foregoing are to be found—In England: At Bath (40° to 48.8° C.—104° to 1200 F.), in Somersetshire. In the United States waters of this group are—in Colorado: The Liberty Hot Springs, at Wagon Wheel Gap, in Rio Grande County (65.5° C.—150° F.); Glenwood Springs, Garfield County (124.6° to 126.4° F.—51.40 to 52.4° C.); Siloam Springs, Garfield County (103° F.—39.50 C). In Utah: Salt Lake Thermal Springs (43.30 C.—no° F.), in Salt Lake County; Utah Hot Springs, near Ogden (1310 to 1440 F.—550 to 62.2° C.). Of the springs named, those of Kissingen particularly are indi-LOCALITIES OF LITHIA WATERS 429 cated for the diseases previously mentioned, when the bodily metabol- ism is impaired, or anemia or scrofulosis is present, and only a moderate influence upon the digestive organs is desired. The Eliza- bethbrunnen at Homburg exerts a powerful solvent effect. Of the thermal springs, those of Wiesbaden are the most active. One liter of water contains of sodium chlorid: At : Baden-Baden, ............................................. 2.01 grams Bath, .................................................... 0.20 gram Bourbonne,............................................. 5.8 grams Byron Springs (Liver and Kidney), ........................10.08 44 Byron Springs (Byron Surprise),..........................304.27 44 Cannstadt, .... 2.45 44 Congress, at Saratoga Springs,............................ 6.49 44 Droit wich, .................. ........................310.0 44 Glenwood Springs (Yarnpa), . . . *........................17.66 44 Harrogate,................................................12.70 44 Homburg, ................................................. 9.86 44 Kissingen,................................................ 5.82 44 Kronthal, ............................................... 3-54 44 Liberty Hot Springs,...................................... 0.33 gram Mondorf,.................................................. 8.71 grams Pyrmont,.................................................. 7.05 44 Seltzer, at Saratoga Springs,............................. 4.97 44 Soden in the Taunus,...................................... 3.42 44 Upper Blue Lick,........................................ 8.37 44 Utah Hot Springs,....................................... 17.05 44 Wiesbaden,................................................ 6.82 44 Lithia Waters.—Among lithia waters may be mentioned the followingJ with the lithium compounds in a liter of water : On the Continent of Europe—in Austro-Hungary: The Josefsbrunnen, at Bilin,in Bohemia—0.01 gram; at Radein (Sauer- brunn), in Styria—0.041 gram; the Salvator Spring, at Eperies (Szinye-Lipocz), in Hungary—0.022 gram. In the German Em- pire : Assmannshausen, in Hesse-Nassau—0.027 gram; Bonifacius Spring, at Salzschlirf, in Hesse-Nassau—0.218 gram; Elizabeth- brunnen, at Homburg, in Hesse-Nassau—0.021 gram; Kaiser Friedrich Spring, at Offenbach on the Main, four miles from Frankfurt—0.019 gram; Koenigsquelle, at Elster, in Saxony —0.108 gram; Kronenquelle, at Salzbrunn, in Prussian Silesia— 0.011 gram; New Spring, at Duerkheim, in Rhenish Bavaria— 0.039 gram ; Oberbrunnen, at Salzbrunn, in Prussian Silesia—0.013 gram; Rakoczy Spring, at Kissingen, in Bavaria—0.02 gram; Ungemachquelle, at Baden-Baden, in the Grand Duchy of Baden— 0.053 gram ; Weilbach (sodium and lithium spring), in Hesse-Nassau —0.009 gram ; Wilhemsquelle, at Ems, in Prussia—0.01 gram. Of the lithia waters in the United States the most important are —in Arkansas: Arkansas Lithia Springs, in Hempstead County— 6.35 grains in a gallon—0.102 gram in a liter. In California:43° SODIUM CHLORID WATERS Howard Springs, Lake County (Excelsior Spring No. i), 8.35 grains in a gallon—o. 13 3 gram. In Georgia: Bowden Lithia Springs, in Fulton County—1.67 to 4.45 grains in a gallon—0.027 to 0.072 gram in a liter. In Massachusetts : Ballardville Lithia Spring, in Middlesex County, the strongest lithia spring in the world, containing. 22 grains of lithium carbonate in a gallon of water—0.356 gram in a liter. In New Hampshire : Londonderry Lithia Spring, in Rock- ingham County—7.29 grains—o. 118 gram. In New York: Geneva Lithia Spring, in Ontario County—10.03 grains—0.162 gram; Saratoga Springs (Champion Spouting Spring, 6.25 grains— o. 101 gram; Congress Spring, 4.76 grains—0.075 gram; Crystal Springs, 4.33 grains—0.070 gram; Empire Spring, 2.08 grains— 0.033 gram; Geyser Spouting Spring, 9 grains—0.145 gram; Hathorn Spring, 11.45 grains—0.184 gram; Kissingen or Triton Spring, 5.13 grains—0.083 gram; New Putnam Spring, 9.83 grains—0.143 gram; Pavilion Spring, 9.49 grains—0.153 gram; Red Spring, 0.94 grain—0.015 gram; Saratoga A or Alum Spring, 1.72 grains—0.026 gram; Seltzer Spring, 0.9 grain—0.015 gram; Star Spring, 1.5 grains—0.023 gram; Union Spring, 2.61 grains—0.042 gram; United States Spring, 4.85 grains—0.078 gram; Vichy Spring, 1.76 grains—0.628 gram), in Saratoga County. In Pennsylvania: Cloverdale Lithia Spring, in Cumberland County, 0.17 grains—0.002 gram; Tuscarora Lithia Spring, in Juniata County. In Virginia : Buffalo Lithia Springs, in Mecklen- burg County—2.25 grains—0.036 grams; Crockett Arsenic Lithia Springs, in Montgomery County—0.07 grain—0.001 gram; Daggers Springs, in Botetourt County; Farmville Lithia Springs, in Prince Edward County—3.76 grains—0.060 gram; Nye Lithia Spring, No. 1, in Wythe County—6.41 grains—0.103 gram; Virginia Magnesian Lithia Springs, at Staunton, in Augusta County; Virginia Waukesha Lithia Springs, at Staunton, in Augusta County; Otterburn Magnesia and Lithia Springs, in Amelia County. IODIN WATERS Those sodium chlorid waters that contain a compound of iodin or bromin in relatively large amount are designated iodin waters or bromin waters. Constituents -The iodin compounds present in the mineral waters are magnesium iodid containing 91 per cent, of iodin, calcium iodid containing 86 per cent, of iodin, and sodium iodid containing 84 per cent, of iodin. The bromin also occurs principally in the form of sodium bromid and magnesium bromid. The quantities ofLOCALITIES OF IODIN WATERS 431 iodin introduced in the course of a drinking-cure with iodin waters are naturally quite small, and they have therefore been considered by several observers to be of no significance. Nevertheless, investiga- tions quite recently made have shown that even such minimal amounts of material in spring-waters are capable of a pharmacodynamic effect. Moreover, the discovery of Baumann—that the effective agent of the thyroid gland-substance is an organic iodin combination, thyro-iodin, which when used for a considerable period of time, in daily doses containing but 0.003 gram C2V °f a grai°) °f iodin, exerts a marked influence upon metabolism—is an indication of the possible activity of the iodin waters. Effects and Uses The salts of iodin and bromin stimulate greatly the activity of the lymphatic vessels and increase absorption, particularly in the glandular organs, but also in all other tissues. Their employment in drinking-cures is, therefore, indicated in cases of scrofulosis, characterized by disease of the glands and the lymphatic vessels, or, in the further course of the case, by affections of the bones and joints ; in cases of syphilis, and particularly syphilitic disease of the bones, enlargement of the lymphatic glands, and cutaneous syphilids; in various diseases of the glands, particularly goiter; in obstinate exudates in and around the female genitalia, and in diseases of the skin. The amount of the strong iodin waters to be taken must be regulated^with care; from 1 to 5 deciliters (3 to 16 ounces) being given in divided doses throughout the day. Usually, saline baths containing iodin are conjoined with the drinking-cure. The internal employment of iodin waters is counterindicated in the presence of chronic inflammatory states of the digestive organs, as well as in anemic and cachectic states. Localities Among iodin waters available for drinking purposes the follow- ing may especially be mentioned : On the Continent of Europe—in Austro-Hungary : Hall, in Upper Austria ; Ivonitch, in Galicia ; Lipik, in Hungary ; Zaizon, in Siebenbuergen, Transylvania. In the German Empire: Heilbrunn, in Upper Bavaria ; Krankenheil, in Bavaria ; Kreuznach, in Prussia ; Sulzbrunn, in Bavaria; Salzschlirf, in Hesse. In Switzerland: Wildegg, in Canton Aargau. In the British Isles waters corresponding to the foregoing are found—in England : At Woodhall Spa, in Lincolnshire. I11 the United States iodin waters are found—In California: Tolenas Springs, in Solano County; Tuscan or Lick Springs (Red432 SODIUM CHLORID WATERS Spring), Tehama County. In Colorado: Springdale Seltzer Springs, in Boulder County. In Georgia: Lower Bowden Lithia Spring, in Fulton County. In Kentucky: Louisville, or Dupont's Artesian Well, in Jefferson County. In New York: Ballston Spa Springs (Artesian Lithia Spring and Franklin Artesian Well), in Saratoga County; Deer Lick Springs, or Seneca Spa Springs, in Erie County; Saratoga Springs (Champion Spouting Spring; Congress Spring; Excelsior Spring; Hathorn Spring; Kissingen or Triton Spring; Union Spring), in Saratoga County. In North Carolina: Lincoln Lithia Spring, in Lincoln County; Thompson’s Bromine-Arsenic Spring, in Ashe County; Ashley’s Bromide and Arsenic Spring, in Ashe County. In West Virginia : Salt Sulphur (Iodin) Springs, in Monroe County. Of these iodin waters employed for drinking purposes, that of Hall has an especial reputation in the treatment of various forms of scrofulosis and of struma, as has also the Adelsheidsquelle, at Heilbrunn, whereas Krankenheil is preferred for its high altitude. There are contained in one liter of water: At : Sodium Chlorid Magnesium Iodid Sodium Iodid Sodium Bromid Champion Spouting Spring, . (Grams) (Grams) (Grams) (Grams) 12.02 0.0039 0.061 Excelsior Spring, 6-34 0.0708 Franklin Artesian Well, . . 11.28 0.004 Hall, 12.17 0.042 Heilbrunn, 4-97 0.03 Ivonitch, Krankenheil, 8-37 0.016 0.29 0.0015 Kreuznach, ........ 10.52 0.0004 Lippik, . . . 0.61 0.0209 Lower Bowden Lithia Spring, 2.13 0.012 Red Spring (Tuscan Spring), . Salzschlirf, Salzbrunn, . . o-35 10.24 0.005 0.073 (Iodin) 1.9 0.015 Saratoga (Kissingen Spring), . 5-96 0.0006 0.0308 Wildegg, 10.02 0.03 Woodhall Spa, 19.50 0.0075 (Pot. iod.) 0.02 (Pot. brom.) Zaizon, 0.92 0.001 CHAPTER IV BITTER WATERS; SULPHUROUS WATERS Bitter Waters—Constituents; Action and Effects; Indications and Counter - indications; Dosage; Localities. Sulphurous Waters—Constituents and Classification; Effects; Indications and Counterindications; Dosage; Lo- calities. BITTER WATERS Constituents The mineral waters designated bitter waters are distinguished from all other springs employed for drinking purposes by the large amount of solid substances they contain, of which the principal are sodium sulphate and magnesium sulphate. In addition to these two salts, magnesium carbonate, calcium carbonate, sodium chlorid, magnesium chlorid, and magnesium nitrate also are present in considerable amounts; the gaseous constituents, par- ticularly carbon dioxid, are uncommon. This is explained by the origin of the bitter waters from rather superficial strata of the earth, through the washing-out of the mineral ingredients by the water of percolation. For this reason the bitter waters are not invariably of the same composition, as are other mineral waters, but the amount of saline matters present depends upon atmospheric influences and the duration of the contact of the water with the source of the spring. Likewise the bitter waters are, by reason of their superficial origin in the strata of the earth, always cold springs. Action and Effects The action of the bitter waters depends partly upon the purgative property of the magnesium sulphate, with its stimulating effect upon the secretions of the intestinal canal, its influence in liquefying the fecal matter, and its pronounced stimulating effect upon the mucous membrane; partly upon the action of the sodium sulphate. These effects are manifested if the strong bitter waters are taken in but small doses of from ioo to 200 grams (3 to 7 ounces). Upon this purgative action probably depends also the influence of the bitter waters upon metabolism, inasmuch as the metamorphosis of fat is increased by stimulation of peristaltic activity; and after long-continued use of large amounts, a reduction in the albuminous constituents of the ix—28 433434 BITTER WATERS ; SULPHUROUS WATERS body, and impairment of hemogenesis, result. The stimulating effect of the strong bitter waters is often not merely transient, but persists even after expulsion of the salt with the intestinal evacuations, so that opportunity is readily afforded for the development of gastric and intestinal catarrh. The bitter waters should, therefore, be given only in small quantities, which vary naturally in accordance with the amount of saline matters contained in the particular water; and their use should not be continued for too long a time. They are not used at the springs in systematic ‘ cures,’ but they are exported for use at the patient’s home. Indications The use of the bitter waters in small doses continued for some time is indicated in the presence of conditions in which long-con- tinued stimulation of intestinal activity is desired, but in which the administration of carbonated waters is counterindicated to avoid stimulation of the vascular system—as, for instance, during pregnancy, and in the presence of arteriosclerosis or of marked organic disease of the heart. Considerable quantities of bitter waters, given on a single occa- sion, or repeated several times, are indicated in the presence of habitual constipation, when rapid and copious evacuation of the bowels is desired; or if foreign bodies, such as migrated worms and concretions, are to be expelled from the intestinal tract; or when a derivative effect is desired for the relief of stasis in various organs, or of inflammatory processes, such as cerebral hyperemia, meningitis, or pleuritis. The use of the bitter waters is counterindicated in the presence of catarrhal affections of the stomach and the intestines, and in the presence of a tendency to diarrhea. Dosage Generally from So to 160 grams (2^ to 5 ounces) of a bitter water may betaken in the morning on an empty stomach, and in urgent cases from 200 to 300 grams (6 to 10 ounces^) may be given in a single dose. At times the bitter waters are given in small amounts, as an addition to other mineral waters. Localities Well-known bitter waters are found, on the Continent of Europe —In Austro-Hungary: At Alap, in Hungary; Buda-Pest, in Hungary; Puellna, in Bohemia; Saidschitz, in Bohemia. In the German Empire : Friedrichshall, in Saxe-Meiningen ; Kissingen, in Bavaria; Mergentheim, in Wurtemberg. In Switzerland: Bir- menstorf, in Canton Aargau.CONSTITUENTS OF SULPHUROUS WATERS 435 In the British Isles bitter waters are found—In England : At Cheltenham, in Gloucestershire; Leamington, in Warwickshire; Melksham, in Wiltshire; Scarborough (North Well and South Well), in Yorkshire. In the United States waters of this class are—In California: Castalian Mineral Springs, in Inyo County. In Colorado : Idaho Hot Springs, in Clear Creek County; Pagosa Hot Springs, in Archuleta County; Royal Gorge LIot Springs, in Fremont County; Springdale Seltzer Springs, in Boulder County. In Kentucky : Crab Orchard Springs (Epsom or Foley’s Spring), in Lincoln County; Harrodsburg Springs (Saloon Spring), in Mercer County. In Pennsylvania : Bedford Springs, in Bedford County. In Wyoming : Leroy Springs, in Uinta County. One liter of water contains : At : Sodium Sulphate Magnesium Sulphate Alap, Bedford Springs, 2 90 grams °-55 g™m Birmenstorf, Bu da-Pest bitter waters : . 7.0 “ 22.0 grams Apenta, • • 154 H 24.4 Hunyadi Janos, • • 22.55 it 22.35 “ Franz Josef, ■ 23.18 “ 24.78 “ Victoria, Castalian Mineral Springs, . . . Crab Orchard Springs (Epsom • ■ 33-5 . . 11.14 or (i (i 24.19 “ Foley’s Spring), . . 1.01 i i 3-51 44 Friedrichshall, a 5-15 Kissingen Bitterquelle, Le-Roy Springs, . . 58 i i t i 5.0 Mergentheim, Pagosa Hot Springs, . . 6 67 • • 2.57 a (i 5-43 44 Puellna, Saidschitz, • ■ 9-59 t i 10.85 “ t i 10.96 “ SULPHUROUS WATERS Constituents and Classification The sulphurous waters include those mineral waters that contain as a constant normal ingredient some binary sulphur compound, either free hydrogen sulphid and carbon oxysulphid, a carbon dioxid in which one atom of oxygen is replaced by sulphur, or an alkaline sulphid—sodium sulphid, calcium sulphid, magne- sium sulphid, or potassium sulphid. Frequently both solid and gaseous compounds of sulphur exist in the same water. In addi- tion to these ingredients that characterize the springs of this group other salts may be present, in accordance with which the sulphur waters are subdivided into sulphurous sodium chlorid waters, con- taining considerable amounts of sodium chlorid; alkaline sul- phurous waters, containing considerable amounts of sodium car-436 BITTER WATERS ; SULPHUROUS WATERS bon ate; sulphurous calcium waters, which contain especially calcium sulphid and carbonate; sulphurous sodium waters, in which the sulphur is especially combined with sodium. The sulphurous waters are in part cold and in part thermal waters, and they occur generally in the calcium portions of more re- cent formations, which are characterized by large deposits of calcium sulphate and organic remains of a destroyed flora or fauna. Effects and Uses Although the pharmacodynamic actions of hydrogen sulphid and carbon oxysulphid have been but little investigated, and although the alkaline sulphids are present in these waters only in small amounts, em- piric observation has demonstrated the efficacy of the latter in various directions. Further, H. Schulz has shown recently by experiment that the sulphur, even in such small doses as are present in sulphurous waters, is capable of a fairly active stimulating effect upon healthy organs. Still smaller amounts of this substance therefore are capable of exciting in diseased organs reactions through which it may induce therapeutic results. Hydrogen sulphid affords a combination that permits the introduction into the body of sulphur in the finest conceiv- able division. The sulphur, it is thought, is capable, under certain conditions, among which the presence of substances of alkaline reaction plays a material part, of acting .as a carrier of oxygen; thereby augmenting not inconsiderably the energy of certain processes of oxi- dation, and perhaps rendering possible the intramolecular com- bustion of albumin. Indications The favorable effects that experience has shown to follow the use of sulphurous waters in the treatment of syphilis and chronic metal- lic poisoning is attributed to the fact that through such drinking- cures, particularly when supplemented by the appropriate baths, elimi- nation through the kidneys, intestines, and skin is materially increased. With regard to the action of the sulphurous waters in cases of syphilis, the rapid saturation of the tissues by the hydrogen sulphid taken up by the stomach and intestines renders not improbable a solution of metallic albuminates and elimination of the metallic molecules through the liver and the urine. The view formerly so much emphasized, of the specific action of the sulphurous waters upon syphilis, or the capability of these waters to render latent syphilis apparent, and thus their diag- nostic value in doubtful cases, can by no means be sustained. The internal use of the sulphurous waters in cases of syphilis has no advantage over the use of drinking-cures with sodium sulphate waters or sodium chlorid waters, which also stimulate excretion and improve the body-metabolism. Likewise, the recommendation ofLOCALITIES OF SULPHUROUS WATERS 437 these waters for drinking-cures in the presence of abdominal ple- thora, hemorrhoidal disorders, and hyperemia of the liver, is based upon stimulation of intestinal activity, with increase in the se- cretion of bile. Chronic catarrhal conditions of the pharynx, the larynx, and the bronchi are improved by the use of the sul- phurous waters containing sodium chlorid or sodium. With the thermal waters the solvent influence of heat upon the secretion of mucous membranes must be taken into consideration. Drinking-cures with sulphurous waters are counterindicated in individuals with greatly enfeebled digestion or profound anemia. Further, great care is required in their use by persons suf- fering from functional disturbances of cardiac activity, as symp- toms of cardiac irritability sometimes occur in the course of drinking-cures with sulphurous waters. Dosage The daily amount of sulphurous waters employed in drinking-cures varies from 150 to 1350 grains (5 to 45 ounces), generally taken in the morning when the stomach is empty. At times milk, whey, gruel, or syrup of acacia is added to these waters, or they may be taken together with bitter waters or laxative salts. Generally the drinking-cure is combined with a course of baths. At some sulphur springs inhalations of vapor are conjoined with the drinking-cure, as a result of which, increase in the secretion of the mucous membranes of the respiratory tract, relaxation of the tissues, and desquamation of epithelium take place—an effect that is favorable in the presence of chronic catarrhal states of the respiratory organs. In the fumaroli of Puzzuoli, near Naples, the solfatara or crater of a partially extinct volcano, from which sulphurous vapors escape, is utilized for inhal- ation. Localities Of the sulphurous waters employed for drinking purposes the fol- lowing may be mentioned: Cold sulphurous waters are situated, on the Continent of Eu- rope—In the German Empire : At Eilsen, in the Principality of Lippe- Schaumburg, containing 0.019 gram of calcium sulphid and 0.19 gram of sodium chlorid in a liter of water; at Langenbruecicen, in the Grand Duchy of Baden, containing 0.056 gram of calcium sulphid; at Meinberg, in Lippe-Detmold, containing 0.008 gram of sodium sulphid and 0.29 gram of calcium carbonate; at Nenndorf, in Hesse- Nassau, containing 0.07 gram of calcium sulphid; at Weilbach, in Hesse-Nassau, containing 0.038 gram of calcium sulphid and 0.27 gram of sodium chlorid. In Switzerland: at Gurnigel, in Canton438 BITTER WATERS ; SULPHUROUS WATERS Bern, containing 0.004 gram of calcium sulphid and 0.005 gram of sodium chlorid in a liter of water. In the British Isles cold sulphurous waters are found—In Eng- land : At Askern Spa, in Yorkshire; at Harrogate, in Yorkshire, the ‘Old Sulphur Spring,’ containing 0.07 per mille of sodium sulphid and 37 volumes per mille of hydrogen sulphid. In Ireland: At Ballynahinch, in County Down, containing 3.5 volumes per mille of, sulphureted hydrogen gas ; Lisdoonvarna, in County Clare—the Gowlaun spring contains 5.5 volumes per mille of sulphureted hy- drogen gas; Swanlinbar, in County Cavan, possesses cold sulphur springs fashionable in former years. In Scotland: At Strathpeffer, in Ross-shire, containing 0.02 per mille of potassium sulphid, 0.007 per mille of sodium sulphid, and 40 volumes per mille of hydrogen sulphid. In Wales: Builth Wells, in Brecknockshire; Llandrin- dod Wells, in Radnorshire—the Park Spa contains 0.04 per mille calcium sulphid, and about 22 volumes per mille sulphureted hydro- gen gas; Llanwrtyd Wells, in Brecknockshire, possesses a sulphur spring containing 36 volumes per mille of sulphureted hydrogen. In the United States cold sulphur springs are the following—In Alabama : Cullum’s Sulphur Spring, near Bladen Springs, Choctaw County, with 97.10 cu. in. hydrogen sulphid in one U. S. gallon; Talladega Spring, near Fayetteville, Talladega County,—82 cu. in. hydrogen sulphid in one U. S. gallon. In California : Anderson’s Sulphur Springs (Cold Sulphur Spring), in Lake County,— 4.20 cu. in. hydrogen sulphid and 243.50 cu. in. carbon dioxid in one U. S. gallon; El Paso de Robles (White Sulphur Spring), in San Luis Obispo County,—9.40 cu. in. hydrogen sulphid, 5.10 grains (0.08 gram in a liter) other sulphids, and 5.25 cu. in. car- bon dioxid in one U. S. gallon ; Lane Mineral Spring, in Calaveras County,—105.00 cu. in. hydrogen sulphid in one U. S. gallon. In Georgia: Powder Springs (Spring No. 3), in Cobb County,— 75.00 cu. in. hydrogen sulphid and 0.05 grain (0.0008 gram in a liter) other sulphids in one U. S. gallon. In Indiana : French Lick Springs, in Orange County,—17.00CU. in. hydrogen sulphid and 10 12 cu. in. carbon dioxid in one U. S. gallon. In Kentucky: Grayson Springs (Eye Spring), in Grayson County,—1.39 cu. in. hydrogen sulphid and 0.58 grain (0.0099 gram in a liter) other sulphids in one U. S. gallon. In Michigan : Alpena Magnetic Sulphur Spring, in Alpena County,—7.38 cu. in. hydrogen sulphid and 210.61 grains (3.78 grams in a liter) other sulphids in one U. S. gallon; Clark’s Riverside Mineral Springs, in Wayne County,—40.76 cu. in. hy- drogen sulphid in one U. S. gallon; Moorman Mineral Well, at Ypsilanti, Washtenaw County,—26.84 cu- in. hydrogen sulphid and 8.42 grains (0.144 gram in a liter) other sulphids in one U. S. gallon. In Missouri: Montesano Springs (Casco Spring), in JeffersonLOCALITIES OF THERMAL SULPHUROUS WATERS 439 County,—43.20 cu. in. carbon dioxid, 1.60 cu. in. hydrogen sulphid, and 0.43 grain (0.007 gram in a liter) other sulphids in one U. S. gal- lon. In New York: Avon Sulphur Springs (Congress Hall Spring), in Livingston County,—22.04 cu. in. carbon dioxid, 27.63 cu. in. hydrogen sulphid, and 99.5 5 grains (1.74 gram hi a liter) other sulphids in one U. S. gallon; Chittenango Sulphur Springs (Mag- nesia Sulphur Spring), in Madison County,—19.44 cu. hu carbon dioxid, 5.62 cu. in. hydrogen sulphid, and 1.68 grains (0.029 gram in a liter) other sulphids in one U. S. gallon; Richfield Springs (White Sulphur Spring), in Otsego County,—14.21 cu. in. hydrogen sulphid and 1.81 grains (0.030 gram in a liter) other sul- phids in one U. S. gallon. I11 Tennessee : Cascade Springs, in Franklin County,—23.04 cu. in. hydrogen sulphid and 9.76 grains (0.167 gram in a liter) other sulphids in one U. S. gallon; Crocker Springs, in Davidson County,—37-99 cu. in. carbon dioxid and 40.25 cu. in. hydrogen sulphid in one U. S. gallon. In Virginia : Cold Sulphur Springs, in Rockbridge County,—5.65 cu. in. carbon dioxid and 253.0 cu. in. hydrogen sulphid in one U. S. gallon; Orkney Springs (Orkney Powder Spring), in Shenandoah County,—8.62 cu. in. carbon dioxid, 5.91 cu. in. hydrogen sulphid, and 0.53 grain (0.009 gram in a liter) other sulphids in one U. S. gallon. Thermal sulphurous waters used for drinking-cures are to be found, on the Continent of Europe—In Austro-Hungary: At Baden (340 C.—93.2° F.), near Vienna, containing 0.195 gram of calcium sulphid and 0.25 gram of sodium chlorid in a liter of water; at Mehadia, in Hungary (48.2° C.— 118.8° F.), containing 0.03 gram of calcium sulphid and 3.2 grams of sodium chlorid. In France: Bag- neres-de-Luchon (55.2° C.—131.40 F.), in Haute-Garonne, with 0.02 gram of sodium sulphid and 0.06 gram of sodium chlorid in a liter of water; Cauterets (39.40 C.—102.90 F.), in Hautes-Pyrenees, contain- ing 0.02 gram of sodium sulphid. In the German Empire: Aachen (5 50 C.—1310 F.), in Rhenish Prussia, containing 0.014 gram of sodium sulphid and 2.61 grams of sodium chlorid in a liter of water. In Switzerland: Schinznach (36° C.—97.0 F.), in Canton Aargau, containing 0.008 gram of calcium sulphid and 0.58 gram of sodium chlorid in a liter of water. Of the sulphurous waters mentioned, the thermal springs of Aachen and of Mehadia have the greatest reputation in the treatment of syphilis and mercurial poisoning, whereas Cauterets and Bagneres-de-Luchon are especially well known for the treatment of chronic catarrhal disorders of the respiratory organs. In the United States hot sulphur waters are found—In Cali- fornia: Calistoga Springs (23.8° to 85.5° C.—750 to 189° F.), in Napa County, containing 4.75 cu. in. hydrogen sulphid in one U. S.440 BITTER WATERS ; SULPHUROUS WATERS * gallon; El Paso de Robles Hot Springs (Main Hot Sulphur Spring, 40.50 to 43.30 C.—105° to no° F.), in San Luis Obispo County, containing 3.75 cu. in. hydrogen sulphid and 8.90 cu. in. car- bon dioxid in one U. S. gallon ; Gilroy Hot Springs (42.20 to 46. i° C.—1080 to 115° F.), in Santa Clara County, containing 9.25 cu. in. hydrogen sulphid and 12.17 cu. in. carbon dioxid in one U. S. gallon; Harbin Hot Sulphur Springs (50° C.—1220 F.), in Lake County, containing 11.74 cu. in. hydrogen sulphid and 4.26 cu. in. carbon dioxid in one U. S. gallon ; Santa Barbara Hot Springs (370 to 50° C.—990 to 1220 F.), in Santa Barbara County, containing 9.16 cu. in. hydrogen sulphid and 19.14 cu. in. carbon dioxid in one U. S. gal- lon. In Colorado: Glenwood Springs (Yampa Spring, 51.50 C. —124.6° F.), in Garfield County; Hot Sulphur Springs (32.70 to 47.2° C.—910 to 1170 F.), Middle Park, Grand County. In Utah : Beck’s Hot Sulphur Springs (53.30 C.—128° F.), in Salt Lake County; Salt Lake Hot Springs (43.30 C.—no° F.), in Salt Lake County.CHAPTER V IRON OR CHALYBEATE WATERS Constituents. Carbonated Iron or Steel Waters—Effects and Uses ; Dosage ; Indications and Counterindications; localities. Vitriol or Iron Sulphate Waters—Indications ; Localities. Arsenical Iron Waters—Indications ; Localities. Constituents Iron is an exceedingly common ingredient of mineral waters ; but only when it is present in considerable quantity, while the total amount of other solid constituents is not large, is the water designated an iron water. When the iron occurs in the form of the carbonate, or, as is usually stated, the bicarbonate,—i. e., ferrous carbonate held in solution by carbonic acid,—these waters are designated carbonated iron waters, or steel springs; when it occurs as a sulphate (fer- rous sulphate), they are termed sulphated iron waters, or vitriol waters. The carbonated iron waters usually contain also large amounts of carbon dioxid. In these steel springs the amount of iron equals not less than of the total weight of all the contained solids, and it may be even as much as ^ of this weight, so that such a pure iron water will rarely possess any other solid ingredients. Iron waters are generally cold ; but a few of the iron springs have an ele- vated temperature. They occur in rocks of igneous as well as of aqueous formation. Effects and Uses of Steel Waters In the drinking-cures with steel waters, the effects both of the iron and of the carbon dioxid are important. With regard to the former, it has been established that after the use of the iron waters for several weeks an increase in the number of red blood-corpuscles and in the amount of hemoglobin takes place; and, in connection therewith, augmentation of the body-weight and of the elimi- nation of urea; an elevation of from half a degree to a degree C. (l° to 2° F.) in the body-temperature; acceleration in pulse frequency. The appetite generally is improved in the course of such drinking-cures, and intestinal activity is retarded, so that constipation is the rule. It appears that when the waters contain small amounts of iron in dilute form, the mineral is absorbed more readily 441442 IRON OR CHALYBEATE WATERS than from waters containing large amounts. This view is supported by the experiments of Schroff, Hamburger, and Bunge. The manner in which it exerts its favorable influence upon the blood, whether through direct titilization for the formation of hemoglobin or through protection against decomposition of the iron supplied with the food, or whether the iron serves only as a stimulating agent to the blood-form- ing organs (von Noorden), has not yet been decided. It is also dis- puted whether or not the principal utility of the iron waters consists, as Glax asserts, in their dehydrating effect upon the organism, thus rendering it more capable of absorbing iron from any source. A number of subordinate constituents of the iron waters modify their action. Thus, to the presence of large amounts of free carbon dioxid is to be attributed a stimulating influence upon the motility of the stomach and intestinal peristalsis ; and to the small amounts of sodium chlorid, sodium carbonate, and sodium sulphid, a favorable influence upon digestion. Dosage The quantity of steel water to be employed in a drinking-cure should be divided into several portions, to be taken throughout the day, and should amount to between 400 and 800 grams (about from 12 to 25 ounces). According to Quincke, it is important for the ab- sorption of the oxygen-salts of iron that the metal should come in contact with the wall of the stomach in a greatly diluted form ; for this reason it is advisable that the iron waters be taken with the prin- cipal meal of the day. Indications and Counterindications The principal indication for drinking-cures of steel waters is any oligemic condition, whether primary or dependent upon diseases of various kinds: Chlorosis, anemia following acute diseases or overexertion, or the result of malaria or exhausting condi- tions; diseases of the nervous system associated with anemia or caused thereby; sexual diseases associated with conditions of debility, in the male and in the female. Drinking-cures with pure iron waters are counterindicated in the presence of all febrile states, organic disease of the heart, arteriosclerosis, and pulmonary tuberculosis. Location of Steel Springs Pure carbonated iron waters are located, principally, on the Continent of Europe—In Austro-Hungary: At Bartfeld, in Hungary; Franzensbad, in Bohemia; Koenigswart, in Bohemia; Krynica, in Galicia ; Marienbad, in Bohemia. In Belgium : Spa, in the Province of Liege. In the German Empire : Booklet, inLOCALITIES OF IRON THERMAL SPRINGS 443 Bavaria ; Cudowa, in Prussia ; Driburg, in Prussia; Elster, in Sax- ony ; Imnau, in the Principality of Hohenzollern ; Liebenstein, in Saxe-Meiningen ; Lobenstein, in Reuss-Schleiz ; Petersthal, in the Grand Duchy of Baden ; Pyrmont, in Waldeck-Pyrmont; Reinerz, in Prussian Silesia; Rippoldsau, in Baden ; Schwalbach, in Hesse- Nassau; Steben, in Bavaria. In Switzerland: St. Moritz, in Canton Grisons. Of the steel springs mentioned, the following are especially char- acterized by the great amount of carbon dioxid and of iron they contain, with an almost total absence of other solid ingredients : The steel springs of Schwalbach, the Ambrosiusbrunnen at Marien- bad, the steel springs at P'ranzensbad, the Victorquelle at Koenigswart, the Hauptquelle at Pyrmont, and the Tempel- quelle at Steben. In the British Isles waters corresponding to those just named are—In England: At Harrogate (the Kissingen Well), in York- shire, containing 0.13 gram of iron bicarbonate in a liter of water; Tunbridge Wells, in Kent, containing 0.06 gram of iron bicarbonate. In the United States springs of this class are—In California : Geyser Spa, in Sonoma County (4 grains in the gallon); Napa Soda Springs, in Napa County (8 grains); Pacific Congress Springs, in Santa Clara County (14 grains). In Colorado: Manitou Springs (Iron Ute Spring), in El Paso County (3 grains). In Indiana: Tar Spring, in Crawford County (4 grains). In Michigan: Owosso Spring, in Shiawassee County (16 grains). In New Mexico: Ojo Caliente, in Taos County (6 grains). In New York: Adirondack Mineral Spring, in Washington County (4 grains); Richfield (Iron Spring), in Otsego County (5 grains). In Pennsylvania : Cresson Springs, in Cambria County (5 grains). In Tennessee: Montvale Springs, in Blount County (2.4 grains). In Virginia: Rock Enon Springs, in Frederick County (14.25 grains of iron protoxid); Wash- ington Springs, in Washington County (0.52 grain). In Wisconsin: Sparta Mineral Wells (Artesian Well), in Monroe County (6 grains). Iron thermal springs are situated, on the Continent of Europe —In Austro-Hungary : At Szliacs (230 C.—73.40 F.), in Hungary ; Vihnye(36° C.—96.8° F.), in Hungary. In France : At Barbotan (150 to 37.70 C.—590 to ioo° F.), in the Department Gers ; Lama- lou (150 to 47.20 C.—590 to 1170 F.), in the Department of Her- ault; Rennes-les-Bains (450 C.—1150 F.), in the Department Ande. In Russia : Jeleznovodsk (20° to 44.40 C.—68° to 1120 F.), in the Caucasus. In Switzerland: Acquarossa (250 C.—770 F.), in Can-444 IRON OR CHALYBEATE WATERS ton Ticino; Andeer-Pignieu (18.80 to 20° C.—66° to 68° F.), in Canton Grisons. In the United States thermal iron waters are found—In Colo- rado : Chalk Creek Hot Springs (65.5° C.—150° F.), in Chaffee County; Elbert Iron Springs (32.20 C.—90° F.), in La Plata County. In Florida: Wesson’s Iron Spring (22.70 C.—730 F.), in Hamilton County. In New Mexico : Ojo Caliente Hot Springs (32.2° to 50° C.—90° to 1220 F.), in Taos County. In New York : Lebanon Thermal Springs (23.8° C.—750 F.), in Columbia County. In Virginia: Sweet Chalybeate Springs (23.8° to 26.i° C.—75° to 790 F.), in Alleghany County. One liter of water contains : At: Iron Bicarbonate Iron Carbonate Free Carbon Dioxid Bartfeld, . . 1683 c.c. Booklet, “ 1505 “ Cresson Springs, . . Cudowa, a 1200 “ Elster, . 0.084 a 1266 “ Franzensbad, a 1528 “ Imnau, . ...... Iron Ute Spring, . . . . Koenigswart, . . 0.052 “ 987 “ . 0.085 a °.°57 gram 1163 “ Krynica, “ 1513 “ Liebenstein, Marienbad, ....... “ 906 “ . 0.166 a 1173 “ Ojo Caliente, Owosso Spring, . . 0.273 a 0.102 “ Pacific Congress Springs, . • 0-239 a Pyrmont, “ i486 “ Richfield Iron Spring, . . . 0.085 a Rock Enon Springs, . . . Schwalbach, , . 0.08 a 0.243 (protoxid) 1571 “ Spa, a . . 3°4 “ Sparta Artesian Well, . . . . O.OI a . . Steben, Szliacs, ........ a . » .1382 “ i i 894 “ St. Moritz, ■ 0.035 a 1282 “ Vihnye, a 337 “ Sulphated Iron Waters The sulphated iron waters contain the ingredient that distin- guishes them—namely, ferrous sulphate, in amounts varying from o. 1 to 4.2 grams in a liter of water (about from 6 to 250 grains in the gallon), and, besides this, small amounts of sodium sulphate, mag- nesium sulphate, and calcium sulphate, and, at times, also alum, free sulphuric acid, and arsenic. These waters are cold, deficient in gases, and occur where combinations of iron sulphid are present in the rocks through which the water flows, and these are in process of disintegration. In the employment of these iron waters for drinking-cures, in addition to the action of iron in improving hemo-LOCALITIES OF SULPHATED IRON WATERS 445 genesis, the influence of iron sulphate in exerting an astringent and a disinfectant effect upon the gastro-intestinal tract is to be taken into consideration. They are, in general, more difficult of digestion than the carbonated iron waters. The quantities to be taken are, therefore, smaller, being in general 500 grams (one pint), and for children, 300 grams (10 ounces), in divided doses, throughout the day. Drinking-cures with iron sulphate waters are especially indicated in cases of chronic diarrhea in anemic and cachectic children, cases of chronic gastric catarrh and ulcer of the stomach, and cases of chronic malarial cachexia. One liter of water contains : At : Iron Sulphate Alexisbad,...............................................0.046 gram Church Hill Alum Springs,................................2.718 grams Kittaning Mineral Spring,................................0.410 gram Mitterbad,...............................................0.29 “ Muskau, .................................................0.19 “ Oak Orchard Springs,.....................................0.565 t( Parad,...................................................1.1 grams Ratzes,..................................................0.3 gram Ronneby,.................................................2.49 grams Schuyler County Spring,..................................1.197 “ Localities Iron sulphate waters are situated, on the Continent of Europe.— In Austro-Hungary : Mitterbad, in the Tirol; Parad, in Hungary ; Ratzes, in the Tirol. In the German Empire : Alexisbad, in the Duchy of Anhalt; Muskau, in Prussia. In Sweden : Ronneby, in the Laen of Blekinge. In the British Isles sulphated iron waters are found—In England : Brighton (St. Anne’s Well), in Sussex; Dorton, in Buckingham- shire ; Flitwick Well, near Ampthill, in Bedfordshire; Gilsland Spa, in Cumberland; Horley Green, near Halifax, in Yorkshire; Lady Ida Well, at Knockin, in Shropshire; Sandrock, near Black- gang Chine, on the Isle of Wight. In Scotland : Hartfell Spa, near Moffat; Vicar’s Bridge, near Dollar. In Wales: Trefriw, in North Wales. In the United States waters containing ferrous sulphate are —In Illinois: Schuyler County Spring, in Schuyler County (69.96 grains). In New York: Oak Orchard Spring, in Genesee County (33 grains); Sharon Chalybeate Spring, in Schoharie County (1.4 grains). In Pennsylvania: Kittaning Mineral Spring, in Arm- strong County (24 grains). In Virginia: Bath Alum Spring, in Bath County (26.78 grains); Bedford Alum Springs, in Campbell County (19 .grains); Church Hill Alum Springs, in Henrico County (!58.79 grains); Fauquier White Sulphur Springs, in Fauquier446 IRON OR CHALYBEATE WATERS County (2 grains); Rockbridge Alum Springs, Spring No. 2, in Rockbridge County (1.95 grains); Stribling or Augusta Springs, Alum Spring, in Augusta County (13 grains) ; Variety Springs, in Augusta County (5 grains). Arsenical Iron Waters Those iron sulphate waters that contain considerable amounts of arsenic, and are, therefore, designated arsenical iron waters, are of much therapeutic importance. The small quantities of arsenous acid contained in these waters are quickly absorbed from the stomach and enter the blood stream. They exert their effect especially upon the skin, which appears to be better nourished; upon the respiration, which is rendered considerably easier; and upon the blood, the hemo- globin of which becomes increased. According to the investigations of Schulz and Binz, the process of transformation of arsenous acid into arsenic within the body may possibly cause a to-and-fro movement of the oxygen atoms in the protoplasm, which, in connection with the direct effect of small doses of arsenic, stimulates the processes of tissue formation. As a result of the use of these arsenical iron waters there occur marked improvement in the general condition and in the nutri- tion, and, finally, subsidence of certain morbid manifestations in ane- mic, chlorotic, and neurasthenic individuals, and this, even in cases in which other preparations of iron have been ineffective. The indications for drinking-cures with arsenical iron waters include oligemic states and chlorosis, especially if attended with emaciation; tumors of lymphatic glands in anemic persons; chronic malarial fever; neuralgia and other nervous disorders of anemic origin ; and the torpid varieties of scrofulosis. The arsen- ical waters may be used at their source, but they are also bottled and exported. Dosage At first, one or two tablespoonfuls are given daily, after the prin- cipal meals of the day, not when the stomach is empty ; the amount is increased gradually to from four to six tablespoonfuls in the course of the day. Children receive but half this quantity. Should symp- toms of intoxication appear, such as pain in the pharynx, conjunctiv- itis, derangement of appetite, or pressure in the epigastrium, the use of the arsenical water must at once be suspended, or, at least, the dose be diminished. Localities Strong arsenical waters can be obtained, on the Continent of Europe—In Austro-Hungary: Guberquelle, at Srebernik, in Bosnia; Levico, in the Tirol; Roncegno, in the Tirol. In theLOCALITIES OF ARSENICAL WATERS 447 German Empire : Lausigk, in Saxony. In Italy : Recoaro, in the Province of Vicenza. In the United States the principal waters containing arsenic are— In California : Harbin Hot Sulphur Springs, in Lake County. In North Carolina: Thompson’s Bromine-Arsenic Spring, at Crump- ler, in Ashe County ; Ashley’s Bromide and Arsenic Spring, in Ashe County. In Virginia : Crockett Arsenic Lithia Springs, in Montgomery County; Swineford Arsenic Lithia Springs, in Os- ceola County. One liter of water contains : At.: Iron Sulphate Crockett Arsenic Lithia Springs, . 0.0006 gram Guberquelle (Srebernik), .... 0.37 “ Harbin Hot Sulphur Springs, . .0.03 “ Lausigk,......................4.18 grams Levico, ..........................2.56 “ Recoaro,.......................3.2 i( Roncegno, . . .........3.0 “ Arsenic Acid Arsenous Salts . . 0.0003 gram 0.0061 gram . . . . 0.005 “ 0.0001 “ . . 0.0086 “ . . 0.0039 “ . . 0.15 “ . 0CHAPTER VI EARTHY MINERAL WATERS ; ACRATOTHERMAL WATERS Earthy Mineral Waters—Constituents ; Effects and Indications ; Localities. Acratothermal Waters. EARTHY MINERAL WATERS Constituents Among the earthy mineral waters are included those waters, both cold and warm, that are characterized by the presence, almost exclu- sively, of large amounts of the salts of calcium and magnesium. Frequently the amount of carbon dioxid, and at times also that of sodium chlorid and iron, is notable, and some springs contain moderate amounts of nitrogen. Effects and Indications The carbonates of calcium and magnesium inhibit the produc- tion of acid in the stomach, and diminish the secretions of the mucous membranes of the respiratory, digestive, and urinary tracts. They are believed also to induce changes in the composition of the urine favorable to the solution of uric acid. That the introduction of calcium into the body is of importance in the formation of bone has long been known. The cold earthy mineral waters, containing carbon dioxid in considerable amounts and also calcium carbonate, exert a markedly diuretic effect, and are more easily digested than the thermal earthy waters or the earthy waters containing large quantities of calcium sulphate. Drinking-cures with the earthy waters are indicated in the pres- ence of chronic catarrhal conditions of the urinary organs, with a tendency to the formation of concretions in the kidneys and the bladder; in the presence of the uric acid diathesis and gout, of chronic gonorrhea, of chronic bronchial catarrh with profuse secretion; in cases of cheesy pneumonic processes, of scrofulosis, rachitis, and osteomalacia. 448LOCALITIES OF COLD EARTHY MINERAL WATERS 449 The quantity to be taken may, in general, be from three to five glasses, each of 200 grams (say 7 ounces), and it should be increased only when a more marked diuretic effect is desired. In addition to drinking-cures, inhalation of the gases, particularly the nitrogen, that escape from the earthy mineral waters at the springs is also practised. Localities Cold earthy mineral waters exist on the Continent of Europe —In Austro-Hungary : At Borszek, in Hungary; Marienbad, in Bohemia. In France: Contrexeville, in Department of Vosges; Cransac, in Department of Aveyron ; Siradan, in Hautes-Pyrenees. In the German Empire: Driburg, in Prussia; Wildungen, in Wal- deck. In Switzerland : Faulensee-Bad, in Canton Bern ; Peiden, in Canton Grisons. The cold earthy mineral springs in the United States are—In Cal- ifornia: Napa Soda Springs, in Napa County (10 grains of calcium carbonate in a gallon). In Colorado : Manitou Springs, in El Paso County (from 23 to 65 grains of calcium bicarbonate); Seltzer Springs, at Springdale, in Boulder County (43.31 grains of calcium carbonate). In Georgia : Catoosa Springs, in Catoosa County (from 40 to 45 grains of calcium sulphate). In Idaho : Idan-ha Springs, in Bannock County (58 grains of calcium bicarbonate and 62.4 grains of magnesium bicarbonate). In Kentucky : Estill Springs (Chaly- beate Spring), in Estill County (26.36 grains of calcium sulphate and 3 grains of calcium carbonate). In Michigan : Butterworth’s Mineral Spring, in Kent County (75 grains of calcium sulphate) ; Eastman Springs, in Berrien County (from 5 to 8 grains of calcium bicarbonate) ; Eaton Rapid Wells, in Eaton County (from 45 to 55 grains of calcium sulphate) ; Moorman Mineral Well, in Washte- naw County (1573 grains of sodium chlorid and 175 grains of cal- cium sulphate); Mt. Clemens Mineral Springs, in Macomb County (from 44 to 100 grains of calcium sulphate and 11,900 grains of so- dium chlorid) ; Owosso Spring, in Shiawassee County (25.67 grains of calcium bicarbonate) ; St. Clair Mineral Spring, in St. Clair County (144 grains of calcium sulphate and 8120 grains of sodium chlorid). In New York : Cherry Valley Springs (North Spring), in Otsego County (150 grains of calcium sulphate); Chittenango Sulphur Springs (Chittenango Magnesia Sulphur Spring), in Madison County (115 grains of calcium sulphate) ; Clifton Springs, in Ontario County (9.68 grains of calcium carbonate and 69.2 grains of calcium sulphate); Richfield Springs (White Sulphur Spring), in Otsego County (112 grains of calcium sulphate). In Pennsylvania: Bedford Springs (Magnesia Spring), in Bedford County (107.8 grains of calcium sulphate); Bedford Chalybeate Spring, in Bedford County (11.62 grains of calcium salts); East Clarion Spring, in Elk ix—29450 EARTHY MINERAL AND ACRATOTHERMAL WATERS County (9.8 grains of calcium bicarbonate) ; Gettysburg Katalysine Spring, in Adams County (16 grains of calcium bicarbonate); Mc- Carthy’s Springs, in Huntingdon County (95 grains of calcium bicarbonate and calcium sulphate); Parker Mineral Springs, in McKean County (282 grains of sodium chlorid and 12 grains of cal- cium carbonate). In Tennessee : Tate Epsom Spring, in Grainger County (161 grains of calcium sulphate). In Vermont : Guilford Mineral Springs, in Windham County (15.18 grains of calcium car- bonate). In Virginia : Alleghany Springs, in Montgomery County (115 grains of calcium sulphate); Blue Ridge Springs, in Botetourt County (100 grains of calcium sulphate); Houston Springs, in Scott County (20 grains of calcium sulphate); Yellow Sulphur Springs, in Montgomery County (63 grains of calcium sulphate). In West Virginia: Capon Springs (Beauty Spring), in Hampshire County (8.32 grains of calcium carbonate and 0.59 grain of calcium sul- phate) ; Greenbrier White Sulphur Springs, in Greenbrier County (78 grains of calcium sulphate) ; Irondale Springs, in Preston County (60 grains of calcium sulphate) ; Salt Sulphur Springs, in Monroe County (from 10 to 33 grains of calcium carbonate and from 68 to 84 grains of calcium sulphate). In Wisconsin : Allouez Mineral Springs, in Brown County (24.69 grains of calcium bicar- bonate and 27.53 grains of magnesium bicarbonate) ; Waukesha Mineral Springs, in Waukesha County (from 13 to 17 grains of calcium bicarbonate and from 9 to 13 grains of magnesium bicar- bonate); Arctic Springs, in Trempeleau County (13 grains of calcium bicarbonate and 10 grains of magnesium bicarbonate). Thermal earthy mineral waters are situated, on the Continent of Europe—In Austro-Hungary: At Gran (28.6° C.—83.6° F.), in Hungary ; Szkleno(53° C.—127.40 F.), in Hungary. In France : Audinac (21.10 C.—70° F.), in Department of Ariege ; Capvern (21.10 to 24.40 C.—70° to 76° F.), in Hautes-Pyrenees. In the German Empire: Inselbad (18.2° C.—64.8° F.), in Prussia; Lipp- springe (21.2° C.—70.20 F.), in Prussia. In Italy: Bagni di Lucca (540 C.—129.20 F.), in the Province of Lucca ; Chianciano (37.7° C. — ioo° F.), in Tuscany. In Switzerland: Leukerbad (Loeche- les-Bains) (510 C.—123.8° F.), in Canton Valais ; Vals (250 to 26.i° C.—770 to 790 F.), in Canton Grisons ; Weissenburg (26° C.—78.8° F.), in Canton Bern. In the British Isles waters of this group are found at Bath (40° to 490 C.—1040 to 1200 F.), in England. In the United States thermal earthy springs are located—In Arkansas : Arkansas Hot Springs (33.8° to 69.4° C.—930 to 1570 F.), in Garland County, containing, in a gallon of water, 7.15 grains of calcium carbonate. In California: Alum Rock Springs (29.40 C.—85° F.), in Santa Clara County (19 grains of calcium carbonate).ANALYSIS OF THERMAL EARTHY MINERAL WATERS 451 In Colorado: Idaho Hot Springs^.40 1048.9° C.—85° to 120° F.), in Clear Creek County (9.52 grains of calcium carbonate and 3.44 grains of calcium sulphate). In Virginia: Warm Sulphur Springs (35.50 C.—96° F.), in Bath County (15 grains of calcium sulphate). In West Virginia: Berkeley Springs (23.8° C.—75° F.), in Morgan Cpunty (5 grains of calcium carbonate); Old Sweet Springs (26.1° C.— 79° F.), in Monroe County (13 grains of calcium sulphate and 30 grains of calcium carbonate). In Wisconsin: Palmyra Mineral Springs (22.2° C.—72° F.), in Jefferson County (from 9 to 15 grains of cal- cium bicarbonate). Some of these have been mentioned in a previous chapter among waters suitable for acratothermal baths, their mineral constituents falling below 0.75 gram in a liter (or 50 grains in a gallon). They are likewise the waters to be employed for so- called thermal lime baths. Of the springs named, those at Wildungen, then the Rudolfs- quelle, at Marienbad, both of which contain carbon dioxid in large quantity, have the greatest reputation in the treatment of chronic nephritis, catarrh of the bladder, and uric-acid concretions; whereas Lippspringe and Inselbad are especially noted for their good effects in chronic catarrhal conditions of the larynx and the bronchi. One liter of water contains : At : Calcium Sulphate Calcium Bicarbonate Calcium Carbonate Alleghany Springs, 1.8 grams 0 06 gram Allouez Mineral Springs, .• . 0.42 gram 0.47 magn. bicarb. Arkansas Hot Springs, .... 0.12 gram Bath, .... . . 1.5 grams Bedford Springs (Magnesia Spring), 1.84 “ Clifton Springs, 1.18 “ 0.16 gram Contrexeville, 1.1 “ 0.45 gram Driburg, 1.04 “ I.44 grams Eaton Rapid Wells, Greenbrier White Sulphur Springs, 0.77 to 0.94 gram . . . 0.34 to 0.78 gram 1.33 grams 0.12 gram Inselbad, . . . . Leukerbad, 1.42 grams 0.3° gram 0.09 “ Lippspringe, Manitou Springs, 0.82 gram 0.41 “ 0.4 to 1.11 grams Marienbad (Rudolfsquelle), . . I.60 grams Old Sweet Springs, 0.22 gram 0.51 gram Szkleno, 0.10 gram Warm Sulphur Springs, .... 0.24 gram 0.08 gram Weissenburg, 1.27 grams • • . Wildungen, 2.0 grams . . .452 EARTHY MINERAL AND ACRATOTHERMAL WATERS ACRATOTHERMAL WATERS The acratothermal waters ('simple’ or 'indifferent’ thermal waters of English writers), those mineral waters that are characterized by their high temperature, but that contain no conspicuous solid or gaseous ingredient in amount sufficient to explain their activity, are seldom employed for drinking purposes; but, as has already been mentioned, they are generally employed for thermal baths. Their usefulness for drinking-cures is merely that of the ingestion of large quantities of warm water.Part II BALNEOTHERAPEUTIC AND CROUNOTHERAPEUTIC INDICATIONS FOR THE INDIVIDUAL FORMS OF CHRONIC DISEASEPART II BALNEOTHERAPEUTIC AND CROUNOTHER- APEUTIC INDICATIONS FOR THE INDI- VIDUAL FORMS OF CHRONIC DISEASE CHAPTER I CONSTITUTIONAL DISEASES AND DISORDERS OF METABOLISM Anemic States. Scrofulosis. Excessive Deposition of Eat and Obesity. Diabetes Mellitus. Gout. Rachitis. Constitutional Syphilis. ANEMIC STATES In the various forms of anemia, whether the result of altered blood composition or due to profuse loss of blood or chronic disease, as well as in conditions of debility following acute diseases (protracted con- valescence), balneotherapy is indicated especially to stimulate hemo- genesis, as well as to counteract the weakness. For this purpose the mineral waters containing iron are particularly to be recom- mended, both for drinking purposes and for bathing. Both the pure carbonated iron waters, which, in the presence of a small amount of solid constituents, contain a considerable quantity of iron, and certain alkaline carbonated waters containing quite a large quantity of iron, are available. In the selection of the health resort, the presence of well-arranged steel baths and ferruginous peat baths, as well as the question of an appropriate climate, are to be taken into consideration. The pure iron springs of Booklet, Driburg, Elster, Fran- zensbad, Imnau, Koenigswart, Marienbad, Pyrmont, Schwalbach, Spa, Steben, St. Moritz, and Szliacs are characterized especially by their richness in iron and free carbon dioxid, and in these places excel- 1 Regarding the recommendations under the various headings of this part, see also the volumes on “ Climatotherapy ” and, in this volume, Dr. Peale’s lists of American springs. 455456 CONSTITUTIONAL AND METABOLIC DISORDERS lent steel baths and, as a rule, also strong iron-peat baths are to be had. For flabby, torpid constitutions, for simple anemia and chlorosis, a certain elevation is of material significance. The iron baths of Ger- many, Austria, and Switzerland of highest altitude are located at St. Moritz (1770 meters—5841 feet—above sea- level), Steben (730 meters—2409 feet—above sea-level), and Marienbad (630 meters— 2079 feet—above sea-level). When the condition of the digestive organs in anemic patients is such that the pure iron waters are not well borne ; further, when a slight stimulating influence upon the digestive tract by means of salines appears desirable, then alkaline-saline chalybeate or alkaline-muriated chalybeate waters are to be preferred to the pure iron-waters. Under such circumstances the Salzquelle and the Luisenquelle, at Franzensbad, the Moritzquelle and the Mar- ienquelle, at Elster, the Ferdinandsbrunnen at Marienbad, the Wenzelquelle at Rippoldsau, the Hauptquelle at Bartfeld, the springs at Petersthal and Freiersbach, the Eugenquelle of Cudowa, and many others, may be prescribed. In the United States suitable springs are the Rawley Springs, Church Hill Alum Springs, Bath Alum Springs, Rock Enon Springs, Bedford Alum Springs, and Massanetta Springs, in Vir- ginia ; Richfield Springs (Iron Spring) and Sharon Springs (Chalybeate Spring), in New York. Schooley’s Mountain Spring (Heath House Spring), in New Jersey, is a weakly saline chalybeate water. The Pacific Congress Springs, in California, contain an excellent chalybeate water, mildly saline. If chronic intestinal catarrh, persistent diarrhea, and malarial disease are associated with the anemic conditions and states of debility, the sulphated iron waters may be drunk instead of the carbon- ated iron waters—that is, those mineral waters in which the iron is present in considerable quantity as a sulphate, together with alum and arsenic acid. In any case, only small, gradually increased amounts —from 100 to 500 grams (3 to 16 ounces) daily for an adult—maybe given. Such greatly emaciated and anemic individuals may drink the waters of Alexisbad, Levico, Mitterbad, M'uskau, Parad, Ratzes, Roncegno, Ronneby, and Serebrenica. In the British Isles, among waters locally termed chalybeate and principally sulphated, are : Cheltenham, in Gloucestershire; Gils- land Spa, in Cumberland; Sandrock, near Blackgang Chine, Isle of Wight; Tunbridge Wells, in Kent; the last is a pure chalybeate. Of American waters the Adirondack Mineral Spring, in New York ; the Bedford (Iron Spring), and Rockbridge Alum Springs,SCROFULOSIS 457 in Virginia, and the Cloverdale Lithia Spring, in Pennsylvania, are suitable. The last-named spring is only slightly chalybeate. Ojo Caliente Spring, in New Mexico ; and Thompson’s Bromine and Arsenic Spring, in North Carolina, are waters adapted to the treat- ment of anemic conditions. In European health resorts, baths containing sulphated iron waters, so-called vitriol baths (see p. 400), may also be taken; these appear indicated especially in the presence of diseases of the genitalia in anemic women. Under such conditions the advisability of brine baths may also be considered, especially those situated at mountainous elevations, as at Ischl, Aussee, Reichenhall, Gmunden, and Kreuth. At Droitwich, in Worcestershire, England, artifi- cially heated brine baths are provided. In the United States hot brine springs at mountainous elevations are the Utah Hot Springs (4246 feet) and the Salt Lake Hot Springs (4345 feet), in Utah ; the Yampa Spring at Glenwood (5200 feet) and Royal Gorge Hot Springs (5200 feet), in Colorado. Sea-baths, which frequently are useful in mild anemic states, especially when nervous symptoms are marked, as an after-cure fol- lowing the drinking-cures with pure carbonated iron waters, are not, however, advisable in the presence of advanced anemia. SCROFULOSIS In the presence of this constitutional disorder, characterized by an especial tendency to irritative processes and pathologic deposits in the lymph-glands, mucous membranes, and joints, as well as bones, and both in the erethistic and in the torpid variety, the object of the drink- ing-cure with mineral waters is improvement of the metabolism, whereas by means of the mineral baths an influence is exerted espe- cially upon the local disorders. For internal use the mild sodium chlorid waters and alka- line muriated carbonated waters are especially to be considered for the reason that the sodium chlorid contained in these mineral waters is believed to cause increased proteid metabolism ; further, in the severe cases of scrofulosis, with a preponderance of glandular infiltrations and important localizations upon the skin, in the bones, and in the joints, the drinking of sodium chlorid waters containing iodin and bromin, which powerfully stimulate the activity of the lymphatic glands, increases absorption in the glandular organs and other tissues. The use of drinking-waters containing decided quantities of so- dium chlorid, such as those of Elizabethbrunnen at Homburg,458 CONSTITUTIONAL AND METABOLIC DISEASES the Rakoczy at Kissingen, and the sodium chlorid thermal waters at Baden-Baden, Wiesbaden, Soden, and Nauheim, is generally suitable for cases of torpid scrofulosis with slight glandular infiltration, limited scrofulous lesions of the mucous membranes, conjunctivitis, otitis, scrofulous ozena, blennorrhea of scrofulous origin, and the general scrofulous habitus. In the British Isles, suitable sodium chlorid waters are found —In England: at Ashby-de-la-Zouch, in Leicestershire; Droit- wich, in Worcestershire ; Malvern, in Worcestershire ; Nantwich, in Cheshire; Woodhall Spa, in Lincolnshire. In Scotland : at Bridge- of-Alan, near Airthrie, in Stirlingshire. In Wales : at Llangam- march Wells, in Brecknockshire. . In the United States waters suitable in these cases are those of Ballston Spa and Saratoga Springs, in New York; Bedford Springs, in Pennsylvania; Greenbrier White Sulphur Springs, in West Virginia; Sheboygan Mineral Spring, in Wisconsin; Ypsil- anti Mineral Well and Salutaris Spring, in Michigan; and Tolenas Spring, in California. In cases of erethistic scrofulosis the milder alkaline muri- ated carbonated waters, less rich in sodium chlorid and contain- ing also iron, are to be preferred; for instance, the Constantins- quelle at Gleichenberg, the Vincenzbrunnen at Luhatschowitz, or the thermal springs of the same character at Soden, the Fuer- stenbrunnen at Ems, and the waters of Royat. In the United States the Cambridge Springs, in Pennsylvania ; Rockbridge Alum Spring and Sweet Chalybeate Spring, in Virginia; and the mildly saline sulphureted Red Sulphur Spring, in West Virginia, are useful in the conditions under consideration. The waters of Royat are suitable also for cases of scrofulosis in which digestion is seriously impaired, or in which the differentiation between scrofulosis and tuberculosis is difficult. Two or three glasses each of 200 grams (6 or 7 ounces) may be drunk daily (half this quantity for children), and often in combination with milk, whey, and meat-broth. The iodin waters, which enjoy a good reputation in the treat- ment of the severe forms of scrofulosis particularly, are the Elis- enquelle at Kreuznach ; the Trinkquelle at Hall, in Upper Aus- tria; the Adelheidsquelle at Heilbrunn ; the Roemerquelle at Wildbad-Sulzbrunn ; the drinking springs at Iwonicz, Krankenheil, Lipik, Saxon, and Zaizon. (For iodin waters in the United States see p. 431.) The amounts in which these strong sodium chlorid waters containing iodin and bromin may be taken should be determined with care in the individual case, the dose varying from one to ten liters (quarts) daily, given in divided portions throughout the day. The drinking of the iodin-containing waters appears counterindicated,BRINE BATHS 459 however, on the part of scrofulous individuals, in whom acute inflam- matory conditions, especially in the digestive organs, are present, or in whom anemic-cachectic conditions have developed. Torpid scrofulous individuals, who exhibit marked symptoms of anemia, also scrofulous girls at the period of puberty, who do not exhibit erethistic states of the vascular system, may with advan- tage drink iron waters that contain considerable quantities of cal- cium carbonate and iron carbonate—as, for instance, the springs at Pyrmont, Driburg, Imnau, Booklet, and Buzias, as well as the iron springs rich in sodium chlorid and lime-salts at Bartfeld, Kry- nica, Liebwerda, and Reinerz. Among suitable waters in the United States are the Rock Enon Springs (1200 feet) and Rawley Springs (2000 feet), in Virginia; Londonderry Lithia Spring, in New Hampshire; Cresson Springs (Iron Spring) (2300 feet), in Pennsylvania; Bailey Springs (Rock Spring), in Alabama; Newsom’s Arroyo Grande Springs (400 feet) and Pacific Congress Springs (835 feet), in California. In the treatment of scrofulous individuals great stress must be placed upon the use of baths that stimulate the activity of the skin, thus increasing metabolism and absorption. Among these the brine baths have a high reputation, particularly for torpid persons. Such brine baths, in conjunction with the drinking-cure, bring about admir- able results if the resort be so selected that favorable climatic influ- ences may operate also. Such favorably situated brine baths may be found at Aussee, Arnstadt, Bex, Colberg, Gmunden, Goczalko- witz, Ischl, Koesen, Reichenhall, Duerkheim, Elmen, Kreuznach, and Hall in Upper Austria. At the last four places are brine baths containing iodin and bromin, and therefore having a good effect upon scrofulous affections of the bones, as well as upon glandular infiltration. In the British Isles, celebrated brine baths are found at Droit- wich, Malvern, Nantwich, and Woodhall Spa, in England. In America brine baths are found—in Canada, at Caledonia Springs and St. Catherine’s Wells, in Ontario ; Caxton Springs, in Quebec. In the United States similar baths are the St. Clair Springs, in Michigan, and the Salt Lake Hot Springs, in Utah. Owens Lake, in California, called the ‘ American Dead Sea,’ contains 245 1 grains of sodium chlorid and 24.28 grains of sodium sulphate in a gallon of water. The strongest brine baths in the United States are the Mt. Clemens Mineral Springs, containing a total of 13,654 grains of solids, 11,900 of which are sodium chlorid, and Clark’s Red Cross Mineral Well, containing 17,825 grains of solids, of which 13,048 grains are sodium chlorid, both in Michigan.460 CONSTITUTIONAL AND METABOLIC DISEASES All brine baths, especially, however, those containing iodin, must be regulated carefully with regard to temperature and degree of con- centration, in accordance with variations in individual irritability. Increase in heat and in strength (from 1 to 6 per cent, of sodium chlorid) must be made gradually and methodically. In the treatment of scrofulous children at home, iodin-brine baths may be prepared artificially. The iodin salts of Hall, Krankenheil, Kreuznach, and Darkau may be procured for this purpose—from one-fourth to one kilogram of these salts being mixed with an equal quantity of sodium chlorid, in accordance with the age of the child. Locally, especially in the presence of lymphomata, the iodin brine is applied in the form1 of cataplasms ; these are covered with gutta-percha, and are kept moist and warm. Upon children with a scrofulous tendency, but in whom there has been no development of definite localizations, as well as in the mild varieties of scrofulous enlargement of the glands and affections of the mucous membranes, sea-baths exert an excellent effect. The choice of the sea-bath depends upon the constitution of the child. For the torpid, a vigorous surf and waters containing a large propor- tion of salt, such as those of the German Ocean (North Sea) resorts, are to be recommended ; for instance, Blankenberge, Heligoland, Norderney, Ostend, Scheveningen, and Wyk. For the erethistic, bathing in the Baltic Sea, which contains a smaller amount of salt and whose surf is less violent, as at Cranty, Colberg, Doberan, Heringsdorf, Misdroy, Warnemuende, and Zoppot, is to be preferred. Delicate and sensitive patients may be advised to take sea-baths in the warmer, southern seaside resorts. If scrofulous individuals exhibit great hyperesthesia, it is advisable to begin the course of sea-water bathing with lukewarm baths at a temperature of from 32° to 340 C. (about 89.5° to 930 F.), and only gradually progressing to cold baths. In general, children under the age of five years should not take cold sea-baths. It is worthy of note, further, that scrofulous affections of the eyes are frequently aggravated at the seaside, whereas bone affections and indurated, scrofulous gland tumors remain unaffected. In recent years charitable establishments for the treatment of scrof- ulous children of the poor have been erected at a number of seaside resorts. Such seaside sanatoriums have been established, on the Continent of Europe, in Austro-Hungary, at Abbazia and Grado ; in Germany, at Norderney, Wyk-on-the-Foehr, Sylt, Colberg, and Zoppot ; in France, at Cannes, Berck-sur-Mer, and elsewhere. In Great Britain, may be mentioned the Royal Sea Bathing In- firmary at Margate. In the United States seaside sanatoriums for children have been established at Atlantic City and Cape May, in New Jersey; in NewOBESITY AND FATTY INFILTRATIONS 46 I York there is a Floating Hospital for Children under the man- agement of St. John’s Guild. The protracted sojourn at the seaside and the persistent enjoyment of the sea air exert a most favorable influence upon scrofulous chil- dren, even if they do not take the sea-baths. EXCESSIVE DEPOSITION OF FAT AND OBESITY In the presence of an excessive deposition of fat in the organism and its consequences, denutrition-cures with mineral waters play an important part; next to the dietetic methods, preferably, however, combined with these, they are of the greatest efficacy. In this con- nection it should be carefully noted, however, whether the obesity be plethoric or anemic in character. From the mild degrees of obesity to the most marked stages—threatening life by fatty degeneration of the myocardium—the best results have unquestionably been obtained from alkaline saline springs characterized by the presence of large quantities of sodium sulphate—Glauber’s Salt waters. In the front rank stand the cold Glauber’s Saltwaters, the Kreuzbrunnen and Ferdinandsbrunnen, at Marienbad ; then the similar springs at Tarasp-Schuls ; both to be preferred on account of the large quan- tity of carbon dioxid and iron they contain, together with the sodium sulphate. In cases of plethoric obesity they will be found more useful than the thermal springs of Carlsbad, because the cold water exerts a more marked diuretic effect and is less irritating to the vascular system, whereas the thermal Glauber’s Salt waters of Carls- bad are to be preferred when obesity is associated with diabetes and the uric acid diathesis. The springs at Marienbad, already referred to, are especially efficacious for drinking-cures if the obesity is due to luxiis nutrition, or if the tendency to obesity is hereditary; they are useful, further, to reduce the accumulation of fat in women at the cli- macteric period, and in cases in which obesity is associated with ab- dominal stasis, hemorrhoidal conditions, and gout. By suitable employment of the cold Glauber’s Salt waters in drinking-cures of from four to six weeks’ duration it is possible to effect not only a mate- rial reduction in the amount of superfluous fat, but also to exert a favorable influence upon the sequels in the circulatory organs by stimulating an abundant secretion of urine, and causing intestinal dis- charges of a liquid or semiliquid character. In determining the dosage of these mineral waters care should be taken to maintain a correct relation between the ingestion and the elimination of fluid, so that the obese patient shall drink only so much water as he is capable of eliminating within a short time. For anemic, pasty persons with marked obesity it is necessary to462 CONSTITUTIONAL AND METABOLIC DISEASES combine, with a drinking-cure of cold Glauber’s Salt waters, the drinking of pure carbonated iron waters ; or the weaker Glauber’s Salt waters containing iron—for instance, those of Elster, Franzens- bad, or Rohitsch may be selected. Less energetic in action, and therefore less available in the presence of marked obesity, are the cold sodium chlorid waters of Homburg and Kissingen, or the warm springs of similar character at Wiesbaden. Drinking- cures, combined with the employment of carbonated acidulous baths, peat baths, brine baths, iodin baths, and steel baths, to be chosen accordingly as certain symptoms, such as cardiac dis- orders, anemic manifestations, cutaneous diseases, or local ac- cumulations of fat, predominate, are exceedingly useful. Further reference will be made to this subject, particularly in connection with fatty heart. If, in cases of obesity, the heart is still in good condition and arteriosclerosis is not present, steam baths and Irish-Roman baths may be employed with success for the purpose of denutrition, as they cause powerful cutaneous irritation and greatly stimulate the secretion of sweat. For domestic use by the obese, baths exerting a stimulating effect upon the skin,—baths of lukewarm water to each of which from one to three kilograms (two to six pounds) of ordinary washing soda (sodium carbonate) are added,—with subsequent cold frictions and douches, are suitable. An effect similar to that of steam baths is exerted by the electric-light baths (radiant heat baths), which have recently been recommended for the obese, and which like- wise cause profuse secretion of sweat. The light bath, which induces considerable loss of weight, is more agreeable than a bath in the ordinary steam chamber, but otherwise it possesses no special advan- tage over the latter for this purpose. Sea-baths are suitable for the obese only when the patient is still of robust constitution, and, further, so long as no symptom of arteriosclerosis or fatty degeneration of the myocardium is present. DIABETES MELLITUS In those varied morbid states in which glycosuria is a constant and characteristically prominent symptom, experience has shown that mineral waters often exert an extremely favorable influence, suppress- ing or diminishing the elimination of sugar with the urine, as well as aiding in the improvement of the general state of nutrition. The well-earned reputation of certain springs in the treatment of diabetes is not to be affected by the skeptical objections that have recently been raised. As experience in general is in favor of the employment of alkalis in the treatment of diabetes, drinking-cures with thermal alkaline waters rich in sodium carbonate have been most highly recommended. The thermal alkaline waters of Vichy, Neuenahr,TABLE WATERS FOR DIABETICS 4-63 Mont-Dore; the thermal alkaline saline (sulphated) waters of Carlsbad; and the thermal alkaline muriated waters of Ems, Royat, and Assmannshausen ; and, in Great Britain, the muriated sulphurous waters of Harrogate and Llandrindod, are indicated in such conditions. The best results are obtained at Carlsbad and Vichy. The favorable effects of these drinking-cures are to be expected only when the organism still possesses sufficient powers of resistance, when the digestive organs still perform their functions normally, and when a generous meat diet is well borne. Under such conditions diabetics who, previously to the use of these mineral waters, excreted sugar on a mixed diet may acquire a greater tolerance for sugar and starches ; moreover, patients who excreted considerable amounts of sugar on a purely animal diet may, after the use of the thermal alkaline waters mentioned, excrete no sugar at all or much less than formerly. The body-weight increases considerably during the course of treatment; the thirst and the dryness of the mouth diminish ; the secretion of the urine becomes less abundant; sleep improves ; and the patients gain in strength. The diminution in the elimination of sugar is, in the majority of cases, maintained. In the later advanced stages of diabetes the use of the thermal alkaline waters is of only limited use- fulness. The course at the springs at Carlsbad should last from four to five weeks, but in no event longer than two months, in order not to debilitate the diabetic patient too greatly. Occasionally it is advisable to repeat the course of treatment after an interval of from three to four months. The treatment is begun with the less warm springs, and the hot waters are reached gradually. The cold alkaline saline waters of Marienbad are indicated in the presence of glycosuria occurring in obese individuals, in cases of ‘ lipogenic diabetes ’ (Kisch), in which the quantity of sugar eliminated is small and dis- appears entirely or largely with reduction in the obesity. Following a drinking-cure with the alkaline mineral waters, and especially in cases of diabetes presenting marked anemia, the use of the pure carbonated iron waters of Schwalbach, Spa, Pyrmont, Franzensbad, Steben, and similar resorts is indicated as an after- cure, and may then be combined with the employment of steel baths and ferruginous peat baths, on account of their favorable influence on hemogenesis. In the winter, and for a considerable time, diabetics can be advised to use at the table the alkaline acidulous waters —as, for instance, of Giesshuebl, Bilin, Fachingen, Selters, Kron- dorf, and Malvern, because these acidulous waters, through the pres- ence of carbon dioxid, allay thirst and stimulate the gastric nerves ; they also seem desirable on account of their alkalinity. For protracted domestic use for drinking purposes by children with diabetes and by greatly reduced diabetic patients, the arsenical waters of Levico, Roncegno, and the Guberquelle of Srebernik may be advised.464 CONSTITUTIONAL AND METABOLIC DISEASES With the drinking-cure, the employment of warm baths should always be conjoined, because these influence favorably the condition of the skin, which is so important in cases of diabetes. For this reason after-cures at high altitude resorts with acratothermal waters are at times to be recommended ; thus, especially, Gastein, Johannisbad, Ragatz, and Wildbad. Sea-baths are suitable only for those among diabetic patients whose bodily vigor is still sufficient to insure adequate reaction, in order to bring about a hardening against the influence of cold. In the United States there are no waters of particular efficacy in the treatment of diabetes. The Saratoga waters, especially the Hathorn and Congress Springs, in New York, which contain lithia, may be found useful in diabetes associated with gout. The Poland Springs in Maine, the Waukesha waters in Wisconsin, Ballardville Lithia Spring in Massachusetts, Crockett Arsenic- Lithia Spring in Virginia, and Wootan Wells in Texas may be mentioned as among the most popular of American waters in the treatment of diabetes. GOUT In the balneotherapeutic management of gout (arthritis urica) the objects of treatment are to counteract the underlying derange- ment of metabolism, to neutralize the excess of uric acid, and to stimulate its elimination, as well as to influence symptomatically the affections of the joints, muscles, tendons, and fasciae, caused by depo- sition of uric acid. For drinking-cures in cases of gout the alkaline and alkaline saline mineral waters are preferably employed. Of the former, the thermal springs of Assmannshausen, Ems, Neuenahr, Royat, and Vichy are suitable in those cases of gout that exhibit periodic attacks and a rather acute character. Of the alkaline saline waters, the springs of Carlsbad and Marienbad are best suited for those gouty patients who are plethoric and robust, who have a hereditary predis- position to the disorder, and who present associated symptoms of disease of the stomach, intestines, liver, and kidneys. The sodium chlorid waters of Kissingen, Homburg, Baden-Baden, Bourbonne- les-Bains, Harrogate, and Wiesbaden, deserve especial recommen- dation in cases of chronic gout in which the patients are greatly de- bilitated. For long-continued domestic use in the milder cases of gout the alkaline acidulous waters of Bilin, Fachingen, Giesshuebl, Sal- vatorquelle, and Vals may be used as dietetic beverages on account of the presence of alkaline carbonates. About one bottle, containing between 400 and 500 grams (12 to 16 ounces), is the daily dose. InLOCAL HEAT IN GOUT 465 obstinate cases of gout, waters containing lithium are prepared for this purpose—those of the Bonifaciusquelle at Salzschlirf ; the Oberbrunnen and the Kronen quelle at Salzbrunn; the Natron- lithionquelle at Weilbach ; the Koenigsquelle at Elster, and others. The annoying local effusions that so often remain after repeated attacks of gout, indicate the employment of the most varied thermal baths of high temperature. In the presence of local gouty affections of long standing, as well as for the consecutive palsies and neuralgias, baths may be taken at the acratothernial springs of Teplitz- Schoenau, Warmbrunn, and Plombieres. For debilitated and re- duced individuals Gastein, Pfaefers-Ragatz, Wildbad, and Loeche- les-Bains are suitable. If large gouty nodules, contractures, anky- loses, and disorders of the locomotor apparatus resulting from effusions are present, peat baths and mud-baths may be used in the form of full baths and as local affusions. Among those most suitable are the baths at Marienbad, Franzensbad, Pistyan, Teplitz- Trenczin, Loka, and Warasdin-Teplitz. In cases in which gout is complicated by chronic diseases of the skin, or when suspicion of syphilis exists, the sulphurous thermal baths of Aachen, Baden in Austria, Baden in Switzerland, Bagneres-de-Luchon, Bareges, Amelie-les-Bains, and Cauterets are to be preferred. For individuals of impaired vigor and cardiac enfeeblement suffering with arthritis, the thermal brine waters of Nauheim, Rehme, Kissingen, and Soden afe selected. For domestic use by gouty patients steam baths are suitable. Of these, a considerable number—from thirty to fifty—may be taken, and their influence will be augmented by friction. Hot sand-baths are likewise useful. For local application cataplasms of peat earth, sulphurous mud, and fango may be employed. The peat cataplasms are applied in the form of sacks containing heated peat. The fango is heated, and spread in a thick layer upon a linen sheet laid upon the bed, and upon this the affected portion of the body is placed. The upper aspect of the body also is then covered with heated fango, and the patient is enveloped in the sheet, over which are placed a rubber cloth and woolen blankets, so that by means of this pack profuse perspiration is induced. Finally, in severe cases of gout, apparatus may be employed for the purpose of securing the local action of hot air. The affected part of the body being stripped of clothing and protected from burning by means of asbestos, is exposed in a suit- able appliance (see page 271) to the influence of a hot-air bath at a temperature of from 750 to 950 C. (167° to 203° F.). Of American waters for external use those of Hot Springs, in Virginia; Hot Springs, in North Carolina; Mt. Clemens, in Michigan ; Hot Springs, in Arkansas; and Fas Vegas Hot Springs, in New ix-30466 CONSTITUTIONAL AND METABOLIC DISEASES Mexico are most efficient in the treatment of gout and rheumatism. For internal use various lithia waters, Saratoga Vichy, Mount Hartford, and Poland Water—a plain diuretic water—are to be recommended. The waters of the Gettysburg Katalysine Springs, Minnequa Springs, Glen Summit Springs, and Sweet Springs, in Pennsylvania; Capon Springs,in West Virginia; Glenwood Springs, in Colorado; Coronado Springs, in California—are all useful. RACHITIS The crounotherapeutic measures employed in cases of rachitis are the same as those that have been mentioned for scrofulosis. A spe- cial action is attributed, however, to the earthy mineral waters containing lime. It is assumed that calcium carbonate, which is intro- duced into the body with these waters, will correct the intestinal catarrh, attended with increased acidity of the secretions and with diarrhea, so often observed in rachitic children ; and thereby will restore the con- ditions for the assimilation of the lime-salts and normal nutrition. Such abundant administration of lime is brought about by the drink- ing of the iron waters rich in lime-salts, such as those of Driburg, Imnau, Booklet, Marienbad, St. Moritz, Bartfeld, Krynica, Franzensbad, and Reinerz, which the children may take in doses of from a tablespoonful to 150 grams (5 ounces), several times daily, according to age; at times in combination with milk, whey, or meat- broth. In the British Isles suitable waters are found at Harrogate and at Tunbridge Wells. In the United States there are numerous springs of this kind, among which the following may be mentioned: Adirondack Min- eral Spring and Richfield Springs, in New York; Cresson Springs, in Pennsylvania; Rock Enon Springs, in Virginia; Napa Soda Springs and Pacific Congress Springs, in California; Manitou Springs, in Colorado. For rachitic children brine baths, peat baths, steel baths, and sea-baths are indicated, in accordance with the physical condition in the individual case. Baths with rock-salt are much preferred for domestic use. For an infant, one-eighth of a kilogram (about 4 ounces) of rock-salt is added to the bath ; for older children, from one-fourth to one-half of a kilogram (about from 8 ounces to 1 pound). Kreuz- nacher salt or Halleiner mother-lye salt (Mutterlaugensalz) may likewise be employed. These salt-baths are taken twice or thrice weekly.SYPHILIS 467 CONSTITUTIONAL SYPHILIS Although any specific influence upon syphilis of mineral waters of whatever character, such as was formerly assumed, must be denied at the present day, drinking-cures and bathing-cures are, nevertheless, of utility in this connection. They are capable of invigorating the organ- ism in general, and of improving the impaired nutrition resulting from the constitutional disease or from injudicious courses of treatment. They have, however, a special purpose also, inasmuch as they hasten the appearance of the delayed local lesions of the skin, causing latent syphilis to become manifest, and in this way verifying the diagnosis in doubtful cases. The thermal sulphurous waters especially, em- ployed for drinking and bathing, are the best adjuvants to the specific treatment of syphilis by means of mercurial inunctions. By the employment of these thermal baths not only is the power of the skin to absorb mercury increased, but also the action of this remedy is aug- mented by elevation of the body-temperature and heightening of proteid metabolism. These thermal sulphurous baths constitute, moreover, an admirable remedy against the varieties of rheumatism, arthritis, and mercurialism associated with syphilis. A special reputation is enjoyed by the thermal sulphurous waters of Aachen, Baden in Aus- tria, Baden in Switzerland, Bagneres-de-Luchon, Mehadia, and Pistyan. In obstinate cases of syphilis in which it becomes necessary to intermit the employment of specific measures, drinking-cures and bath- ing-cures with the sodium chlorid waters containing iodin and bromin maybe prescribed in the interval. These waters are useful also for after-cures following vigorous mercurial treatment, and, finally, in the so-called tertiary stage of syphilis, in the presence of periosti- tis and exostoses. Under such circumstances Kreuznach, Hall in Upper Austria, Ivonjtch, Lipik, Krankenheil, and Heilbrunn are especially suitable. For collateral reasons the prescription of courses of treatment with those sulphurous waters that are known among the laity as ‘antisyphilitic’ must at times be avoided. Under such circum- stances drinking-cures and bathing-cures with the strong Glauber’s Salt waters of Marienbad and Carlsbad are suitable on account of their influence in stimulating diuresis and intestinal secretion ; for experience has shown that not only the increased activity of the skin, but also that of the intestine and the kidneys, contributes to the suc- cessful treatment of syphilis and aids materially the effects of specific treatment. As an after-cure following vigorous drinking- and bathing- cures by syphilitics, the internal use of iron waters is at times ad- visable, as well as steel baths and ferruginous peat baths.468 CONSTITUTIONAL AND METABOLIC DISEASES In the United States thermal sulphurous waters are found at Calistoga Springs, El Paso de Robles Hot Springs, Santa Bar- bara Hot Springs, in California; at Glenwood Springs and Hot Sulphur Springs, in Colorado ; and at Salt Lake Hot Springs, in Utah. The waters of Hot Springs, in Arkansas, are much used externally in the treatment of syphilis. The baths, in conjunction with appropriate medicinal treatment, tend to dispel cachexia and im- prove vitality, and thus favor the constitutional action of the drugs employed.CHAPTER II DISEASES OF THE RESPIRATORY ORGANS Chronic Rhinopharyngitis, Laryngitis, and Bronchitis. Chronic Emphysema of the Lungs and Bronchial Asthma. Chronic Pulmonary Tuberculosis. CHRONIC RHINOPHARYNGITIS, LARYNGITIS, AND BRONCHITIS ' In the presence of chronic catarrh of the nasopharyngeal, laryngeal, and bronchial mucous membrane systematic drinking- cures with the alkaline muriated mineral waters of Ems (Salz- brunnen), Gleichenberg, and Luhatschowitz are especially to be advised, if these catarrhal conditions are dependent upon persistently injurious influences—as, for instance, in teachers and singers; or if they occur in delicate individuals of scrofulous or lymphatic tendency, and are characterized by great irritability and scanty secretion from the mucous membrane. A mild and moist climate at the health resort selected exerts a favorable influence upon the cure of such catarrhal conditions. In the same way, in the presence of chronic bronchial catarrh with abundant secretion and bronchiectasis, the feebler sodium chlorid waters of Soden, Baden-Baden, Canstatt, Kronthal, and Mondorf are indicated ; and in this connection, the favorable climatic conditions contribute materially to the curative results. In the United States suitable waters are the mild saline chalybeate Rock Castle Springs (2000 feet), in Kentucky, and the Suwanee Sulphur Springs and White Springs of Florida. The Orange Spring, in Florida, said to be the largest spring in the world, is also useful in the condition under consideration. In most of the European health resorts, inhalations of the respec- tive mineral waters are also practised, and these are especially suitable for those cases in which the secretion of the mucous membrane is viscid and its production is to be increased. The same purpose is fulfilled by inhalations of brine in spray, as is practised at Ischl, Reichen- hall, and Rehme, or by inhalations of the brine vapor that develops in the seething of the brine—as, for instance, at Achselmannstein, Kis- singen, Koesen, and Muenster. In cases of chronic bronchial catarrh in torpid, scrofulous individuals, as well as in gouty subjects, and in the presence of laryn- 469470 DISEASES OF THE RESPIRATORY ORGANS geal disorders complicated by syphilis, sulphurous waters, and especially those containing sodium chlorid, such as the springs at Weilbach, Nenndorf, Langenbruecken, Wipfeld, and, in the United States, Saratoga and Mt. Clemens, as well as the thermal sul- phurous waters of Aachen, Baden in Austria, Baden in Switzerland, Eaux-Bonnes, Buda-Pest, and Mehadia may be taken internally. By reason of especially favorable climatic conditions the sulphurous thermal springs of Amelie-les-Bains, Bareges, Bagneres-de- Luchon, Cauterets, and Saint-Sauveur, in the Pyrenees, are well suited. In the United States Roanoke Red Sulphur Springs, in Virginia, an alkaline chalybeate carbonated water, is used in the treat- ment of chronic bronchial, pulmonary, and throat affections and for hay-fever. Red Sulphur Springs, in West Virginia, a light saline sulphureted water, is also useful. At many of the European resorts mentioned there are excellent arrangements for the inhalation of hydrogen sulphid gas, a use- ful expedient in the presence of marked irritability of the mucous membrane of the larynx, the trachea, and the bronchi. Inhalation of the nitrogen escaping from the earthy springs is provided for at the earthy mineral waters of Inselbad, Lippspringe, and Weissen- burg, and is recommended in the presence of a markedly erethistic bronchial mucous membrane, with a tendency to hemoptysis. (See volume on “Inhalation Methods.”) For the chronic catarrhal conditions of the larynx and bronchi in drunkards, hearty eaters, and gluttons, in whom circulatory disturbances and stasis in the pulmonary circulation constitute the etiologic factor, the laxative sodium sulphate waters of Marien- bad, Tarasp, and Carlsbad, exerting a derivative effect upon the intestinal tract, as well as the stronger sodium chlorid waters of Kiss ingen and Homburg, are indicated. For domestic purposes in the treatment of simple, chronic catarrhal conditions of the pharyngeal mucous membrane of moderate severity, and of chronic laryngeal and bronchial catarrh, the alkaline acidulous waters of Bilin, Giesshuebl, Fachingen, Geilnau, Krondorf, Malvern, and Preblau may be recommended as table waters mitigating the tendency to cough, stimulating the secre- tion of mucus, and facilitating its expulsion. In the United States Saratoga Vichy Spring, in New York, Londonderry Lithia Spring, in New Hampshire, Bethesda Spring and Clysmic Spring, in Wisconsin, Capon Spring, in West Virginia, and Sweet Spring, at Bedford in Pennsylvania, correspond fairly well with the foregoing waters, but are not used for similar purposes. At times, in the presence of marked irritative states, the addition of milk or whey to the mineral water is most appropriate. Lukewarm mineral baths, especially brine baths, supplementCHRONIC PULMONARY TUBERCULOSIS 471 the effect of the drinking-cure ; the invigoration and stimulation of the skin tending to prevent relapses of the catarrhal condition. After the catarrhal conditions are entirely healed, cold frictions of the skin with brine water, and also with sea-water, may be practised for the purpose of hardening the skin. Sea-bathing, however, is not to be recommended. CHRONIC EMPHYSEMA OF THE LUNGS AND BRONCHIAL ASTHMA What has been said with regard to chronic bronchial catarrh is applicable also to the crounotherapy of chronic pulmonary emphy- sema, which is almost invariably accompanied by such catarrh. Under these conditions, the alkaline muriated acidulous waters as well as the alkaline saline mineral waters are to be recom- mended, preferably at health resorts possessing a favorably high mountainous elevation with stimulating fresh air and extensive pine woods—as, for example, Salzbrunn, Luhatschowitz, Szczawnica, Marienbad, and Tarasp. If, however, a state of marked irritation of the mucous membrane of the respiratory tract is additionally present, drinking-cures at Ems, Gleichenberg, Baden-Baden, Canstatt, Kronthal, and Soden, with weaker waters and a milder climate, will be indicated. Also the French baths in the Pyrenees, at Amelie-les- Bains, PAux-Bonnes, Cauterets, and Bagneres-de-Luchon, have a speciaUreputation for the relief of the bronchial asthma dependent upon pulmonary emphysema. In the United States the waters of Castle Creek Hot Springs (2300 feet) in Arizona, with a temperature of 45.6° C. (1140 F.), and those of Manitou in Colorado, are suitable in these conditions. CHRONIC PULMONARY TUBERCULOSIS The favorable influence that, according to diverse and unequivocal experience, mineral waters exert upon pulmonary tuberculosis, de- pends upon the fact that these waters, including, in the first place, the alkaline muriated acidulous waters and the mild sodium chlorid waters, are calculated to correct the accompanying catarrh of the respiratory mucous membrane, and, at the same time, to improve digestive activity and nutrition in general. Inasmuch as they thus increase hemogenesis and assimilation, augment the resist- ing powers of the organism, and, on the other hand, locally diminish the hyperemia of the lungs and improve the catarrhal state, these min- eral waters aid in depriving the tubercle bacillus of its appropriate cul- ture-medium and in bringing the tuberculous process to an end. In the choice of a health resort for the carrying out of such drinking-cures, the favorable climatic situation of the place is of great importance.472 DISEASES OF THE RESPIRATORY ORGANS In this connection the health resorts of Baden-Baden, Gleichen- berg, Luhatschowitz, Kronthal, Rejchenhall, Salzbrunn, Soden, Canstatt, and Weilbeck appear to be advisable for young individu- als presenting the suspicious so-called phthisical habitus, who suffer frequently from recurring catarrhal conditions of the respiratory organs ; further, for developed and even advanced cases of pulmonary tuberculosis, with marked infiltration at the apices, and even formation of cavities of moderate size—providing only that fever and hemoptysis are not present. Caution is necessary with regard to the presence of carbon dioxid, and to the temperature of the mineral water. This should be only lukewarm and the carbon dioxid should be in part dispelled by heating or by the addition of warm milk and whey. In suspicious, recurring obstinate cases of bronchial catarrh, in which, however, tu- bercle bacilli cannot be demonstrated, the waters of Ems also exert a favorable anticatarrhal influence. The same may be said of the ther- mal sulphurous springs with a favorable climatic situation in the French Pyrenees, among which Eaux-Bonnes and Mont-Dore are the principal representatives of the French health resorts for tuberculosis ; whereas St. Honors, Allevard, Amelie-les Bains, Le Vernet, and Enghien are recommended for cases of suspicious catarrh at the apices. In the presence of pulmonary tuberculosis in delicate, anemic individuals, when the morbid process has be- come completely stationary, and, in general, in cases of suspicious catarrh at the apices in debilitated young persons, when the improve- ment of the general nutrition is the object of primary importance, drinking-cures with alkaline chalybeate acidulous waters in favorably situated places—as, for instance, in Cudowa, Charlotten- brunn, Reinerz, Rippoldsau, Petersthal, and Flinsberg—render good service. In the United States no attempt has been made to systematize the use of mineral waters in the treatment of tuberculosis. Many of the springs in the mountains of Pennsylvania, North Carolina, Virginia, Colorado, New Mexico, Utah, or Southern California would, no doubt, be available, but the benefit derived from their use would most likely be attributed to the good influences of the air, the sunlight, and the mode of life, rather than to any special virtue of the waters. The pure carbonated iron waters are counterindicated in cases of pulmonary tuberculosis, because they readily give rise to hyperemia of the lungs and to hemoptysis. Lukewarm baths at a temperature of 350 C. (95° F.) may be recommended to patients suf- fering from pulmonary tuberculosis, in order to increase the comple- mentary respiration through the skin, which is especially important to them, and to augment the general cutaneous activity. Care is neces- sary to avoid the bad effects of exposure to cold. On getting out of the bath, the patient should be carefully covered and rapidly dried.CHAPTER III DISEASES OF THE HEART AND THE BLOOD- VESSELS Functional Disorders of the Heart. Valvular Lesions—Arteriosclerosis. Neurotic Disorders of the Heart. Fatty Heart. FUNCTIONAL AND NEUROTIC DISORDERS OF THE HEART Functional Disorders of the Heart Although diseases of the heart were, until within a few decades, considered as a counterindication for all balneotherapeutic measures, at the present day both drinking-cures and bathing-cures are largely recommended for a number of functional cardiac disorders, as well as in the treatment of organic disease of the heart; and the reputation they enjoy is well deserved. Among the drinking-cures, those with the cold sodium sul- phate waters of Marienbad, Tarasp, Elster, and Rohitsch,- as well as the cold sodium chlorid waters of Homburg, Kissingen, Gleichenberg, Woodhall Spa, Harrogate, Luhatschowitz, and Salzbrunn, exert an especially favorable influence upon the cardiac symptoms of those who eat largely of rich food and suffer from hyper- trophy of the heart. They are useful, as well, in the dilated hyper- trophy of the heart dependent upon chronic pulmonary emphysema, by relieving blood stasis and facilitating the movement of the circulating fluid, and in this way lessening the labor of the heart; and, on the other hand, by actively stimulating intestinal secretion, and thereby utilizing a portion of the blood collected in abundance. In order to avoid overstimulation of the heart by the carbon dioxid, the cold car- bonated mineral waters should be freed from gas as thoroughly as possible by being stirred and permitted to stand before they are drunk. The thermal springs are counterindicated because the high temperature increases the action of the heart and causes greater fulness of the arteries. Valvular Lesions In the same way as in these functional cardiac disorders, the min- eral waters indicated are employed also in the presence of valvular lesions of the heart, providing that serious derangement of compen- 473474 DISEASES OF THE HEART AND THE BLOOD-VESSELS sation or dropsy is not present. They bring about considerable allevia- tion and improvement in the symptoms of stasis and in the gastro- intestinal catarrh, the hemorrhoidal symptoms, the enlargement of the liver, and abnormalities of menstruation dependent upon the stasis. When the action of the heart is excessively violent, and the blood pressure is extremely high, all carbonated mineral waters should be avoided as beverages, and, under such circumstances, in order to afford symptomatic relief and to overcome rapidly the manifestations of venous stasis in the abdominal viscera, bitter waters, such as those of the Bitterquellen of Ofen, and those of Friedrichshall, Pullna, Victoria Spa, and Saidschitz, may be employed in small but effective doses for a short time. These bitter waters are suitable also for cases in which arteriosclerosis is marked, whereas in the presence of lesser grades, the milder alkaline saline and alkaline muriated waters render good service, inasmuch as they lower the arterial pressure and lessen the work of the heart, by stimulating both intestinal activity and diuresis. Nevertheless, these waters must, so far as possible, be freed from the carbon dioxid. Neurotic Disorders of the Heart In cases of cardiac neuroses various forms of drinking-cure are indicated in accordance with the underlying cause : thus, for cardiac symptoms dependent upon the anemia and chlorosis of puberty, the ferruginous waters of Franzensbad, Elster, Schwalbach, Spa, Pyrmont, Cudowa, Reinerz, Steben, Rippoldsau, Harrogate, and Tunbridge Wells ; in the cases of tachycardia of the climacteric period, as well as in the cases of cardiac neuroses caused by copro- stasis, the laxative sodium sulphate waters of Marienbad and Tarasp, as well as bitter waters, are indicated. The cardiac palpi- tation in cases of exophthalmic goiter is often materially relieved by the use of the pure iron waters at health resorts situated at an altitude, such as St. Moritz, Steben, Marienbad, and Koenigs- wart, and, in the United States, the Iron Ute Manitou Spring, in Colorado, and the Ojo Caliente Spring, in New Mexico. Baths.—In the presence of various cardiac symptoms and func- tional disorders of the heart, carbonated baths have recently been recommended, and are employed with great success in the treatment of the enfeebled heart, on account of their stimulating effect and their influence in causing hypertrophy of the myocardium. These favora- ble effects have been credited especially to the thermal carbon- ated muriated springs of Nauheim, but also to the carbonated steel baths of Cudowa and the acidulous baths of Marienbad. All such carbonated baths, applied in the proper manner and adapted to individual conditions, are capable of bringing about a reduction inFATTY HEART 475 the action of the heart and an improvement in the tone of the myo- cardium, and thereby dissipating the threatening symptoms due to dis- tention of the wall of the ventricle. Artificially prepared carbonated baths may be employed at home in certain cases of heart disease. (See ‘Appendix/ p. 536.) Baths that exert an excessively irritating effect upon the skin, or of too high or too low a temperature, as well as of very long duration, but especially steam baths, Irish-Roman baths, and electric hot-air baths, are counterindicated in the presence of cardiac disorders. In the United States so-called Nauheim baths may be had at Glen Springs and Saratoga, in New York, and at Lakewood, in New Jersey, as well as in most large cities. Climbing Exercise.—In most health resorts for patients suffer- ing from disease of the heart, there are associated, with the drinking and the bathing, systematic courses of exercise, including walking upon the level and upon moderate grades, on specially prepared paths, in traversing which an invigorating influence is exerted upon the heart. Generally four classes of paths are distinguished, in ac- cordance with their gradients : Horizontal, easily traversed paths over an undulating surface ; paths leading to heights of slight eleva- tion ; paths of greater inclination, leading to summits of higher alti- tude ; hills, and steep, mountainous paths, difficult of ascent. The dynamic demands of the ascent must be regulated carefully in accord- ance with the individuality of the patient and the condition of his heart and his respiratory organs. By means of markings with lines, the distances along the paths are divided into parts, each of which can be traversed in a period of a quarter of an hour, as the normal. This form of treatment is employed in the United States at Glen Springs, in New York ; and in a modified form the topography of the patient’s place of residence mayBe utilized. (See volume iv, ■ - Climatotherapy,” P- 339-) FATTY HEART The cardiac symptoms of the obese—the ‘ heart of hypernutri- tion ’ (Kisch)—constitute a frequent and amenable object for courses of treatment with drinking and bathing. If, in an obese person, the car- diac impulse is feeble, the pulse is small, enlargement of the area of cardiac dulness is demonstrable, and thus the suspicion of the presence of the heart of hypernutrition is justified, a systematic drinking-cure with the cold sodium sulphate waters, especially of Marienbad, is indicated. These not only prove efficacious in the milder forms, but also are indicated when, in consequence of the deposition of fat upon476 DISEASES OF THE HEART AND THE BLOOD-VESSELS the heart, serious symptoms have already been produced; even if car- diac asthma and marked symptoms of stasis in the venous system are manifest. In the same class of cases Tarasp is likewise suitable, and, in slighter degrees, the use of the cold sodium chlorid waters of Kissingen and Homburg. In the United States suitable waters are those of Saratoga Springs, Halleck Spring, Verona Springs, and Ballston Spa, in New York; Blue Lick Springs, in Kentucky; Lubec Spring, in Maine ; Akesion Spring, in Missouri. Careful and discriminating medical supervision of the use of these mineral waters is necessary, and for a considerable period. Drastic courses of treat- ment with active purgatives are to be avoided. In cases of advanced, fatty degeneration of the myocardium witli anasarca due to stasis, hydremic conditions, and loss of strength, these drinking-cures are counterindicated. For anemic individuals with a fatty heart, the use of the iron waters of Franzensbad, Pyrmont, Schwalbach, Harrogate, Tun- bridge Wells, and others, is to be recommended, especially as after- treatment following the drinking of sodium sulphate waters. In the United States, iron waters serviceable for anemic patients are: Sharon Chalybeate Spring, Adirondack Springs, and Oak Orchard Springs, in New York; Sparta Artesian Well, in Wis- consin ; Schuyler County Springs, in Illinois; Tar Spring, in Indiana; Thorp’s Spring, in Texas ; Napa Soda Springs, in Cali- fornia ; Bedford Chalybeate Spring, in Pennsylvania; Bedford Iron, Alum, and Lithia Spring, and Massanetta Springs, in Vir- ginia ; Berkeley Springs, in West Virginia. With the drinking-cure may be associated, for persons with fatty heart, courses of bath-treatment with carbonated or acidulous baths, steel baths, or brine baths, all having in common the effect of causing powerful stimulation of the skin, of increasing the activity of the kidneys, and of augmenting the entire metabolism. Steam baths and electric-light baths, as well as Irish-* Roman baths, which materially aid in reducing the amount of fat, are to be taken into consideration only when, in the presence of fatty heart, the myocardium itself is still intact and the vessels have not become sclerotic.CHAPTER IV DISEASES OF THE DIGESTIVE ORGANS Diseases of the Stomach. Diseases of the Liver and the Biliary Passages. Diseases of the Spleen. DISEASES OF THE STOMACH Chronic Gastro-intestinal Catarrh Of mineral waters that are employed in the form of drinking-cures, in the presence of chronic gastro-intestinal catarrh, as well as of the various dyspepsias, the alkaline springs—and both the alkaline acidulous waters and the alkaline saline waters—are of the greatest importance. By reason of the large amount of sodium carbonate they contain, they are capable of neutralizing the excessive amount of acid in the stomach and of inducing renewed and continued secretion of gastric juice. In addition, because of the presence of carbon dioxid and sodium sulphate, they exert a profound influence upon the intestine, its peristalsis, and its secretion. In the mild cases of dyspepsia and gastric catarrh, when abnormal production of acid, acid eructation, flatulence, and cardialgia are present, the thermal alkaline waters of Vichy and Neuenahr, and, in the United States, Idaho Hot Springs, in Colorado, Ojo Caliente Springs and Hudson’s Hot Springs, in New Mexico, and Arrowhead Hot Springs, in California; and thermal alkaline muriated waters, as those of Ems, in the German Empire, render especially good service. In the severe cases, when the mucous membrane of the stomach is very sensitive and the nutrition is greatly impaired, with the presence of disorders of the liver and the kidneys in associa- tion, the thermal saline waters of Carlsbad are to be preferred to all others. The cold alkaline saline waters of Marienbad, Tarasp, Rohitsch, Elster, and Franzensbad are indicated in cases of chronic gastric catarrh of long standing, with abnormal pro- duction of mucus ; atony and torpor of the muscular coat of the stomach ; diminished reflex irritability of the mucous membrane ; and stasis of the gastric contents; in the presence of chronic gastric catarrh in gourmands and drunkards ; and in dyspeptic states resulting from a sedentary mode of life. In the United States the waters of Waukesha Springs, in Wisconsin ; Cambridge Springs, in Pennsyl- 477478 DISEASES OF THE DIGESTIVE ORGANS vania ; Holly Spring, in Rhode Island; Aspinock Spring, in Con- necticut; Saratoga Springs, in New York; Topeka Mineral Wells and Waconda, or Great Spirit, Mineral Springs, in Kansas ; Manitou Spring, in Colorado ; Azule Mineral Well, in California —meet similar indications. If torpor of the intestine and constipation are associated with these conditions, the waters of Marienbad (Kreuzbrunnen) and Franzensbad, and, in the United States, of Bedford Springs, in Pennsylvania, exert a good effect. The Salzquelle of Franzensbad is especially suitable for dyspeptic disturbances attended with anemia and chlorosis. The milder thermal sodium chlorid waters of Soden, Canstatt, Baden-Baden, and Wiesbaden, as well as the cold waters of similar character at Homburg, Kissingen, and Woodhall Spa, have indications similar to those of the alkaline saline waters, and are suited for debilitated, emaciated, scrofulous individuals with gastric catarrh. In the United States suitable waters include Clar- endon Springs and Alburgh Springs, in Vermont, and Glenwood Springs, in Colorado. In cases of chronic ulcer of the stomach the waters of Carls- bad, given in small amounts, particularly the less warm springs,— namely, Schlossbrunnen, Theresienbrunnen, Marktbrunnen, —enjoy the highest reputation. The Kreuzbrunnen and the Waldquelle of Marienbad may be taken warmed. In selecting a health resort for patients suffering from disease of the stomach, it is advisable to recommend the tentative use, for a few days at home, of the mineral water that is under consideration, in order to determine whether or not it is well borne. In cases of chronic gastric catarrh only small amounts of the mineral water are to be taken, and always distributed over several periods in the course of the day. At the beginning of the course of treatment the cold mineral waters should be warmed before being drunk. For domestic use, in cases presenting mild dyspeptic symptoms, the alkaline acidu- lous table waters of Bilin, Giesshuebl, Fachingen, and Preblau are suited. American alkaline acidulous waters include those of Bladon Springs in Alabama, Geyser Spa in California, and Manitou Soda Spring in Colorado. The crounotherapeutic indications for chronic intestinal catarrh coincide with those for chronic gastric catarrh. If this is associated with atony of the bowel, with habitual constipation, and with hemorrhoidal disturbances in consequence of unsuitable food, a sedentary mode of life, or stasis in the portal area, the strong cold sodium sulphate and sodium chlorid springs are indicated—CHRONIC DIARRHEA 479 namely, the Ferdinandsbrunnen of Marienbad, the Lucius- quelle of Tarasp, the Salzquelle of Elster and that of Fran- zensbad, the Rakoczyquelle of Kissingen, and the Elisabeth - brunnen of Homburg. In the United States similar waters are Crab Orchard Springs, in Kentucky; Glen Springs, in South Carolina; Spring Lakewell, in Michigan; Manitou Soda Springs, Springdale Seltzer Spring, and Vichy, Pagosa, and Iron Duke Springs, at Canon City, in Colorado. Obese, well-nourished individuals suffering from habitual consti- pation and the symptoms of chronic gastro-intestinal catarrh, with hemorrhoids or well-marked enlargement of the hemorrhoidal veins, constitute the principal contingent for the drinking-cures at Marien- bad. For emaciated, enfeebled individuals, especially if the intestinal catarrh is associated with chronic diarrhea, the thermal sodium sulphate and sodium chi or id waters at Carlsbad, Ems, Vichy, Neuenahr, Wiesbaden, and Baden-Baden are indicated. Of the springs at Carlsbad, the Sprudel, drunk in small quantities, acts favorably upon the diarrhea resulting from chronic intestinal catarrh or following dietetic error, as well as upon the diarrhea caused by exces- sively increased or qualitatively altered secretion of bile. In the United States similar waters are found at Geyser Spa and Harbin Hot Springs in California; Manitou Springs, Royal Gorge Hot Springs, Liberty Hot Springs, and Glenwood Springs in Colorado; Utah Hot Springs in Utah. For the diarrhea of anemic and feeble children, the sul- phated iron waters of Alexisbad, Muskau, Parad, Roncegno, Levico, or Guberquelle, at Srebernik, are often effective. In the British Isles sulphated iron springs are Brighton, Gilsland Spa, Hartfell Spa, in Scotland ; Trefriw, in Wales. In the United States : Oak Orchard Springs and Sharon Springs, in New York; Kittaning Mineral Spring, in Pennsylvania; Bedford Alum Spring, Church Hill Alum Springs, and Fauquier White Sul- phur Springs, in Virginia. For the chronic diarrhea of scrofulous as well as of rachitic individuals, the earthy waters containing lime-salts, as well as earthy iron waters, are recommended; as, for example, the waters ofWlLDUNGEN, LlPPSPRINGE, LlEBWERDE, REINERZ, DrIBURG, BOCKLET, and the Rudolfsquelle of Marienbad; but these mineral waters can be drunk only in small quantities and for but a short time, on account of the disturbance of digestion they cause. In the United States waters corresponding to those just mentioned are: Richfield Magnesia480 DISEASES OF THE DIGESTIVE ORGANS Springs, Cherry Valley Springs, Chittenango Springs, and Clif- ton Springs, in New York; Capon Springs and White Sulphur Springs, in West Virginia; Waukesha Springs, in Wisconsin; Catoosa Springs, in Georgia; Tate Epsom Spring and Mont- vale Springs, in Tennessee ; St. Louis, Owasso, and Butterworth’s Springs, in Michigan; Chalybeate Springs, in Kentucky; Newbury Springs, in Orange County, Vermont; Manitou Springs, in Col- orado; Mineral Park Bitter Spring, in Arizona. Baths often supplement the drinking-cure in cases of chronic disease of the gastro-intestinal tract. As a rule, moderately warm acidu- lous, brine, steel, and peat baths are indicated. For highly irritable persons with cardialgia and enteralgia, the acratothe rmal waters of Bath, Schlangenbad, Gastein, Johannisbad, and Tueffer render good service as after-cures following the drinking-cures. In the United States, Hot Springs and Warm Springs, in Virginia; Hot Springs, in South Dakota; and the baths at Lakewood, in New Jersey, are indicated. In the presence of great sensitiveness of the gastric nerves, severe cardialgic attacks, and also chronic gastric ulcer, if hemorrhage has not occurred, the application of hot peat poultices in the gastric region is to be recommended. DISEASES OF THE LIVER AND THE BILIARY PASSAGES Chronic hyperemia of the liver as a symptom of stasis in the portal circulation resulting from overfeeding, from a sedentary mode of life, or from habitual constipation, as well as the form induced by disease of the heart, the lungs, the spleen, or the uterus, is frequently sub- jected to mineral-spring treatment. If the condition occurs in vigorous persons with good powers of resistance, and if the liver is found to be large, hypostatic, and tender on pressure, drinking- cures at Carlsbad, Marienbad, Kissingen, and Homburg are indi- cated ; for flabby, anemic, scrofulous individuals, drinking-cures at Franzensbad, Elster, Soden, Ems, and Gleichenberg are suitable. Among American waters suitable for the first group of cases are: Bedford Springs, in Pennsylvania; Ballston Spa and Saratoga Springs, in New York; Greenbrier White Sulphur Springs, in West Virginia; Crab Orchard Springs (Epsom Spring),in Ken- tucky; American Carlsbad Springs, in Illinois; Byron Springs, Gordon Springs, and Coronado Springs, in California; Canon City Mineral Springs and Springdale Seltzer Springs, in Colorado. For anemic and scrofulous individuals the waters of Sharon Springs (Chalybeate Spring), in New York; Cresson Springs (IronDISEASES OF THE LIVER AND BILE-DUCTS 481 Spring), in Pennsylvania; Sweet Chalybeate Springs and Heal- ing Springs, in Virginia; Geyser Spa and Harbin Hot Springs, in California; Manitou Springs and Royal Gorge Hot Springs, in Colorado; and Castle Creek Hot Springs, in Arizona, may be employed. The springs of the first-named group—sodium sul- phate and sodium chlorid waters—are indicated also in cases of fatty liver as a symptom of general obesity. In the presence cf marked general obesity, and in combination with arthritis, Marien- bad or, in the United States, the Hot Springs of Virginia, Las Vegas Hot Springs in New Mexico, or the Hot Springs of South Dakota are appropriate. When there is a tendency to diarrhea, the alkaline thermal waters of Carlsbad and Ems may be used with ad- vantage. For scrofulous individuals, Homburg, Kissingen, and Wiesbaden are of benefit. In the presence of marked anemia, Franzensbad and Elster are to be preferred. Catarrhal jaundice, if it has not caused profound alterations and has existed for but a short time, often yields to the domestic employ- ment of the alkaline acidulous waters of Bilin, Fachingen, Selters, and Gleichenberg. If, however, the jaundice has persisted for some time and the liver is considerably enlarged, drinking-cures at Carlsbad, Ems, and Vichy, with the thermal waters of these places, are indicated, especially if the jaundice is attended with irrita- tion of the lower portions of the intestinal tract, and diarrhea is accordingly present. Appropriate waters in the United States are those of Bedford (Magnesia) Springs, in Pennsylvania; Saratoga (Vichy) Springs, in New York; Greenbrier White Sulphur Springs and Irondale Springs, in West Virginia; Bedford Alum, Iron, and Lithia Springs, Rockbridge Alum Springs, and Bath Alum Springs, in Virginia; Bladon Springs, in Alabama. For full-blooded, strong, easily excitable individuals with jaundice ; or when coprostasis is present, the cold waters of Marienbad, Kissingen, Homburg, and, in the United States, Saratoga, are to be preferred. The same differential indication is applicable in cases of gall- stones, in which, as Frerichs had previously pointed out, complete courses of treatment at Carlsbad, Marienbad, Vichy, and Ems have proved the most effective remedy. This opinion remains completely sound at the present day, in spite of current operative tendencies. These mineral waters may be used at the patient’s home, or may be more effectively drunk at their source, for from four to six weeks. A considerable number of gall-stones often are expelled as an immediate result. In order to prevent the formation of further concretions, the ix—31482 DISEASES OF THE DIGESTIVE ORGANS course of treatment is repeated, annually or at shorter intervals, for two or three years or longer. Even after operative intervention for gall-stones such a course of treatment should certainly be undertaken. At Carlsbad the patient first drinks the cooler waters, gradually, in the course of two weeks, reaching the Sprudel. At Marienbad the course is begun with heated Kreuzbrunnen, and subsequently the waters of the F e r di n a n d s b r u n n e n are drunk. At Vichy the waters of the Grande Grille and Source de L’Hopital are drunk; at Ems the waters of Kesselbrunnen and Kraehnchen. During the winter, patients with gall-stones should drink regularly the waters of Bilin, Fachingen, Preblau, and Salvator ; these acidulous waters contain sodium carbonate and carbon dioxid. Regular action on the part of the bowels should be secured by the administration of a bitter water. In the presence of cirrhosis of the liver, good results following the internal administration of the sodium chlorid waters contain- ing iodin and bromin at Hall, Kreuznach, and Krankenheil are doubtful. In amyloid degeneration of the liver quite as little is to be expected from the alkaline thermal waters of Ems and Neuen- ahr ; these waters and their American analogues (see pp. 419, 421, and 422) may, nevertheless, be tried. Warm baths of any kind act as adjuvants to the drinking-cure in all forms of disease of the liver. In the presence of considerable enlargement of the liver, as well as of cholelithiasis and obstinate catarrhal jaundice, warm peat cataplasms are useful. (See p. 404.) CHRONIC ENLARGEMENT OF THE SPLEEN The chronic enlargement of the spleen that remains after malarial fever, as well as the hypostatic enlargement of the spleen dependent upon circulatory disturbance or digestive disorders, and the like, responds favorably to drinking-cures with the sodium sulphate waters of Carlsbad, Marienbad, Tarasp, and Rohitsch, in connec- tion with which an after-cure with pure ferruginous waters is necessary, in order to improve the disturbed hemogenesis. As the most efficient adjuvant to bring about reduction in the size of existing enlargement of the spleen, and to improve the anemic and the leu- kemic state of the blood, the use of the peat baths containing the greatest quantity of iron sulphate at Marienbad, Franzensbad, Elster, Meinberg, and Muskau is highly to be recommended. If the enlargement of the spleen is one of the manifestations of a constitu- tional disorder, such as syphilis or mercurial cachexia, the sul- phurous waters, especially of Aachen and Baden in Austria, andCHRONIC ENLARGEMENT OF THE SPLEEN 483 the iodin waters, as, for instance, those at Hall, Kreuznach, Krank- enheil, and Lippik, are indicated; brine baths and sulphurous baths being employed in addition. The enlargement of the spleen that occurs in scrofulous and rachitic individuals is favorably influ- enced by drinking-cures at Kissingen, Homburg, Nauheim, Kreuz- nach, Baden-Baden, and Wiesbaden ; and by the employment of the baths provided at these resorts. Among suitable resorts and waters in the United States are those of Saratoga, Sharon, Richfield, and Glen Springs in New York; Roanoke Red Sulphur Springs in Virginia; Parkersburg Mineral Well in West Virginia; Ypsilanti and Mt. Clemens in Michigan; Calistoga Hot Springs and Coro- nado Springs in California; Tampa Spring at Glenwood, Colo- rado ; and Lower Blue Lick Springs in Kentucky.CHAPTER V DISEASES OF THE NERVOUS SYSTEM Diseases of the Brain. Paralysis. Diseases of the Spinal Cord; Periph- eral Neuroses. DISEASES OF THE BRAIN Chronic hyperemia of the brain frequently constitutes the indi- cation for depletion of the cerebral vessels by derivation, through the intestine and the skin, in order thereby to avert the dangers of cere- bral hemorrhage. In the absence of urgent symptoms this indication will be met by drinking-cures with the laxative cold sodium sul- phate and sodium chlorid waters. Of the former, those of Mar- ienbad and Rohitsch are suitable, while Tarasp, on account of its high altitude, is to be avoided in such cases. Of the sodium chlorid waters, those of Homburg and Kissingen may be chosen. Employed systematically for a considerable period of time they consti- tute an admirable prophylactic against cerebral hemorrhage in ple- thoric, obese individuals. In the United States the waters of Saratoga, Oak Orchard Acid Springs, and Ballston, in New York; Topeka Mineral Wells, in Kansas ; Crab Orchard and Blue Lick Springs, in Kentucky; Magnesia Spring, at Bedford in Pennsylvania— may be used with advantage. The thermal waters, on the contrary, are counterindicated in those cases of cerebral hyperemia that exhibit a tendency to apoplexy. Warm, full baths, especially mineral baths rich in carbon dioxid, peat baths, and, as a matter of course, ‘ in still greater degree, steam baths, Irish-Roman baths, and electric light baths are to be avoided in the presence of cerebral hyperemia. When a rapidly derivative effect is desired, as when threatening symptoms of cerebral hyperemia arise, the most active bitter waters, such as Hunyadi Janos, are indicated, because they act promptly upon the intestines, even when given in small doses. Recent cerebral hemorrhage, and the resulting palsy, do not constitute an indication for drinking- and bathing-cures with mineral waters. Only after the lapse of from three to six months, and in cases in which the irritative apoplectic symptoms have been or are in process of involution, are balneotherapeutic measures applicable. 484PARALYSIS 485 In cases of stationary apoplectic paralysis baths of acratothernial waters, such as those of Toeplitz-Schoenau, Gastein, Ragatz, and Wildbad, are suitable, and possess a long-established reputation; so, too, the waters of YVarmbrunn, Plombieres, and Toeplitz-Krapina may be employed advantageously. In highly irritable individuals the less hot acratothermal baths of Badenweiler, Johannisbad, Landecic, Liebenzell, Schlangenbad, and Neuhaus are to be recommended. The thermal sodium chiorid waters of Baden-Baden, Wies- baden, Balaruc, .Bourbonne, and Lamotte also may be found useful. When the apoplexy is not of recent date and the paralytic symptoms prove resistant to the influence of the acratothermal waters and thermal sodium chlorid baths, the thermal brine baths rich in carbon dioxid at Nauheim, Rehme, and Kissingen, or the ferru- ginous peat baths of Franzensbad, Marienbad, and Elster, as well as the sulphurous mud-baths at Pistyan and Warasdin- Toeplitz, may be employed ; the latter tend especially to correct the flaccidity and contracture of the muscles and tendons. The sul- phurous thermal waters at Aachen, Baden in Austria, Toeplitz- Trencsin, and Mehadia, and, in the United States, at Richfield Springs and Sharon Springs, in New York, the Potash Sulphur Spring and Gillen’s White Sulphur Spring, near Arkansas Hot Springs, are to be preferred in the treatment of a paralysis of which syphilis must be assumed to be the cause. In all these morbid conditions, in which the existing cerebral hyperemia should be taken into consideration, the bathing should be begun carefully, with water at moderate degrees of temperature, as well as with half-baths; cold affusions being applied to the head during the bath. Hot douches to the head are to be avoided. The baths should not be taken daily. When, in the course of the bath treatment in apoplectic patients, headache, vertigo, muscular twitching, or contractures occur, indicating increased irritation of the morbid process in the brain, the bathing should be intermitted at once. Carbonated steel baths, steam baths, and sea-baths are counterindicated in cases presenting apoplectic paralysis. Paralysis In paralysis after exhausting diseases, such as typhoid fever, the acute exanthemata, puerperal processes, and diphtheria, drink- ing-cures and bathing-cures with iron waters render good service in improving the general nutrition, and thereby relieving the paralysis. Especially such chalybeate spas should be selected as are situated at high altitudes among mountains, such as St. Moritz, Steben, Marienbad, Rippoldsau, Reinerz, Tatra-Fuered, Griesbach, Anto- gast, and Flinsberg. In these, as in other well-known health resorts486 DISEASES OF THE NERVOUS SYSTEM with iron waters, steel baths should be taken, or brine baths con- taining a considerable quantity of carbon dioxid, such as are to be had at Rehme, Nauheim, or Kissingen ; or the ferruginous peat baths at Franzensbad, Elster, Marienbad, Parad, Muskau, or Cudowa, repeatedly mentioned, are prescribed. In the United States suitable brine baths are found at Byron Springs, in California, and Salt Lake Hot Springs, in Utah; steel baths may be had at Sweet Chalybeate Springs, in Virginia; Geyser Spa, in California ; Sparta Mineral Wells, in Wisconsin. Arrowhead Hot Springs, California, enjoys some repute on account of its mud-bath. On the other hand, sea-bathing is counterindicated in the presence of such forms of paralysis because the organism in general possesses too little reactive power after severe disease processes. In the presence of hysteric paralysis steel baths, ferrugi- nous peat baths, and strong brine baths are useful. Carbon- ated gas-baths likewise exert a powerful stimulating influence upon the peripheral nerves and an active alterative effect upon the entire nervous system, especially upon the genitalia. They may be em- ployed in the form of full gas-baths, and, in addition, local gas douches may be applied to the paralyzed members. These dry carbonated gas-baths can be taken at Franzensbad, Marienbad, Pyrmont, Nauheim, Homburg, and Cudowa, and, in the United States, at Glen Springs, in New York, Lakewood, in New Jersey, and St. Augustine, in Florida. When the subjects of hysteric paral- ysis exhibit considerable reflex irritability and hyperesthesia, the favorably situated acratothermal waters of Gastein, Schlangen- bad, Johannisbad, Tobelbad, and Neuhaus ; Bath, in England; and, in the United States, Arkansas Hot Springs; Healing Springs, Vir- ginia ; Santa Barbara Hot Springs, California ; and Las Vegas Hot Springs, New Mexico, should be employed. In cases of traumatic paralysis the acratothermal waters of high temperature, such as those of Toeplitz-Schoenau, Gastein, Ragatz, Warmbrunn, and the peat baths and mud-baths, as well as the thermal brine baths, render admirable service. In such cases the baths should be taken at as high a temperature as can be borne,—from 36° to 40° C. (96.8° to 104° F.),—and be com- bined with strong hot douches for a considerable length of time— from thirty to forty-five minutes. They should be followed by rest in bed for at least one hour. Reflex paralysis and rheumatic, arthritic, and syphilitic paralyses require the drinking- and bathing- cures suitable for the underlying diseases.DISEASES OF THE SPINAL CORD 487 DISEASES OF THE SPINAL CORD ; PERIPHERAL NEUROSES Diseases of the Spinal Cord By means of baths, which play the most important part in the treatment of diseases of the spinal cord with mineral waters, it is pos- sible to exert a reflex influence upon the cord, and thereby, to a ceitain degree, to improve its circulatory and nutritive conditions. In cases of functional disturbances of the spinal cord, as spinal irritation, or spinal weakness, or slight spinal commotion, the baths at the acratothermal springs, at the gaseous thermal brine springs, and at the carbonated steel springs, are to be employed, in ac- cordance with the individuality of the patient, in the mannei that has been described when speaking of the various forms of paralysis: Thus, for irritable, debilitated individuals the acratothermal waters at a favorable altitude—Gastein, Johannisbad, Badenweiler, Landeck, Schlangenbad, Liebenzell, and Wildbad; for torpid individuals the warmer springs of Toeplitz, Ragatz, and Warmbrunn, and the thermal brine springs of Nauheim, Rehme, and Kissingen, as well as of Wiesbaden and Baden-Baden; for anemic individuals the steel baths of Schwalbach, Pyrmont, Driburg, and Spa. (For American waters corresponding to the foregoing see page 443-) chronic.inflammation of the spinal meninges, especially with fluid effusions, in addition to the baths named, the ferruginous peat baths__Marienbad, Franzensbad, Cudowa, Elster, and Muskau —are to be recommended to stimulate absorption. The same meas- ures are applicable in the treatment of the chronic structural lesions of the spinal cord itself, although success can be hoped for fiom peat baths, acratothermal baths, thermal brine baths, and steel baths only in the early stages and in mild cases. If syphilis is believed to be the cause of a given case of tabes, the sulphurous thermal waters are those most recommended; for the myelitis dependent upon spondylarthroses or deforming or gouty arthritis of the verte- bral articulations the thermal brine waters are appropriate. The technic of the baths must be carefully regulated and super- vised, in the treatment of diseases of the spinal cord. The tempera- ture of the baths should not be too high—preferably between 29 and 32° C. (84° to 90° F.). The bath should not be of prolonged dura- tion, and should not be taken daily, but at intervals; all exhausting measures should be avoided, in order to prevent exacerbations in the hyperemia of the spinal cord. For drinking-cures the milder sodium sulphate waters and sodium chlorid waters that have been recommended for cerebral hyperemia should be employed, in order, in the presence of special488 DISEASES OF THE NERVOUS SYSTEM hyperemia, to secure a derivative effect through the intestinal tract. Further, alkaline hydrochloric acidulous waters, to correct the dyspeptic disorders so often present, and saline ferruginous acidulous waters, to improve the general nutrition, maybe utilized. Peripheral Neuroses Balneotherapy is employed for the relief of peripheral neuroses ; neuralgias ; and hyperesthesia in accordance with the same indica- tions as those mentioned in the treatment of cerebral and spinal diseases. The mountainous acratothermal waters at not too high an altitude, as at Schlangenbad, Landeck, Tuffer, Lieben- zell, Tobelbad, Wildbad, and, in the United States, Lebanon Springs, in New York, and Warm Springs, in Georgia, as well as the thermal calcium baths of Lippsspringe and Inselbad, exert a sedative and antispasmodic effect. For the neuroses induced by trauma or by rheumatism, arthritis, malaria, scrofulosis, and syphilis; for the neuralgia accompanying chloranemia, gastric disorders, and uterine disorders, the underlying dis- ease must furnish the indication for the employment of the various baths and drinking-cures. In the United States the waters of Hot Springs, in Virginia, Las Vegas Hot Springs, in New Mexico, Tate Springs (cold), in Tennessee, Hot Springs, in Arkansas, and Hot Springs, in South Dakota, are employed in the conditions under consideration. It should be pointed out that recently the favorable influence of drinking-cures with alkaline saline mineral waters upon trigeminal neuralgia, hemicrania, and sciatica of long stand- ing, dependent upon habitual constipation, has been extolled. For the relief of obstinate sciatica, peat baths, hot acratothermal baths, sulphurous thermal baths, and sulphurous mud-baths are most to be recommended; Russian steam baths and hot sand baths are also useful. Hypochondriasis, hysteria, chorea, and epilepsy may be subjected to balneotherapy with various forms of mineral waters in accordance with the underlying disease, or with the most prominent symptomatic manifestations.CHAPTER VI DISEASES OF THE URINARY ORGANS Diseases of the Urinary Bladder. Diseases of the Kidneys. Urinary Concretions. DISEASES OF THE URINARY BLADDER In chronic catarrhal states of the urinary bladder, as well as of the pelvis of the kidney, drinking-cures with the alkaline min- eral waters are serviceable in several ways : By abundant and long- continued drinking of these waters, in consequence of the entrance of sodium carbonate into the blood, the reaction of the urine is rendered neutral or alkaline, the irritation of the acid urine is lessened, the mucus is liquefied, and the diseased mucous membrane is favorably influenced. In the presence of chronic catarrhal states of the bladder and the pelvis of the kidney following blennorrhea of the urethra, and in catarrh of the bladder in elderly persons, as well as in catar- rhal irritation resulting from the presence of urinary calculi, drink- ing-cures with the alkaline thermal waters of Vichy and Neu- enahr, with the alkaline saline thermal waters of Carlsbad ; and, in the United States, Hot Springs, Virginia; Geyser Spa, Cali- fornia; and Manitou Springs, Colorado, are useful. The alkaline muriated springs of Ems, Salzbrunn, Gleichenberg; and, in the United States, Saratoga (Vichy Spring), New York ; Glen Alpine Mineral Springs, California; Plymouth Rock Mineral Well, Michigan, also render good service. The vesical catarrh occurring in hearty eaters and drinkers from the ingestion of an excess of irritating food and drink, or dependent upon stasis and circulatory disorders,—- so-called vesical hemorrhoids,—is an indication for the use of the sodium sulphate waters of Carlsbad and Marienbad, and, in the United States, of Crab Orchard Springs, PIarrodsburg Springs, and Louisville Artesian Well, in Kentucky; Pagosa Hot Springs, in Colorado; Alburgh Springs, in Vermont; Glen Springs, in South Carolina; Castle Creek Hot Springs, in Arizona. The sodium chlorid springs of Elster and Franzensbad, or the sodium chlorid waters of Homburg, Kissingen, Luhatschowitz, Wies- baden, and Baden-Baden, also may be employed with advantage. Of similar utility are, in the United States, the waters of Saratoga 489490 DISEASES OF THE URINARY ORGANS Springs, Washington Lithia Well (the old Ballston Conde Den- tonean Spring), and Halleck Springs, in New York; Blue Lick Spring, in Kentucky; Byron Springs, in California; and the saline springs of Michigan and Wisconsin. In chronic catarrhal states of the bladder and the pelvis of the kidney, when the secretion of mucus is profuse ; in chronic gonor- rhea; in severe neuralgia of the neck of the bladder and the ure- thra, and in hemorrhages and weakness of the bladder, the earthy waters containing carbon dioxid inconsiderable amount are espe- cially indicated, particularly the Helenenqu elle at Wildungen, the Rudolfsquelle at Marienbad, the Hester quelle at' Driburg, the Source Pavilion at Contrexeville; and, in the United States, the Richfield Magnesia Spring and Chittenango Cave Spring, in New York; Eastman Springs, Eaton Rapids Wells, and Leslie Magnetic Wells, in Michigan; Capon Springs, Old Sweet Springs, and Berkeley Springs, in West Virginia; Otterburn Lithia and Magnesia Spring, Osceola Spring, and Rockbridge Alum Springs, in Virginia; Tate Springs, in Tennessee; Warm Springs and Catoosa Springs, in Georgia ; Napa Soda Springs (Iron Spring), in California. All the American springs mentioned are earthy waters containing carbon dioxid, except those of Virginia, Tennessee, and Georgia. The last are, however, suitable for the affections indicated. For anemic women with vesical catarrh as a result of disease of the uterovaginal mucous membrane, the calcic ferrugin- ous acidulous waters of Krynica, Franzensbad, Elster, Bors- zek, Eloepatak, and Recoaro, are to be recommended. In the United States suitable waters are the Rockbridge Alum Springs, Wallawhatoola Alum Springs, Sweet Chalybeate Springs, and Bath Alum Spring, in Virginia; Harrodsburg Springs, Estill Springs, and Crab Orchard Springs, in Kentucky ; Texas Sour Springs, in Texas. For long-continued domestic use in chronic catarrhal conditions of the uropoietic tract the pure alkaline acidulous waters of Vals, Bilin, Preblau, Fachingen, the Sal- vator quelle near Eperies, Geilnau, Giesshuebel, and Krondorf are useful, preferably taken when the stomach is empty. DISEASES OF THE KIDNEYS When symptoms of chronic passive stasis in the kidneys mani- fest themselves, such as occur as the result of heart disease, pulmonary emphysema, general obesity, and in drunkards, carefully conducted and supervised drinking-cures at Carlsbad, Marienbad, Rohitsch, Ems, Gleichenberg, Soden, and Wiesbaden, render good service;URINARY CONCRETIONS 49 1 these alkaline mineral waters acting upon the disordered lesser circulation and, for the time at least, influencing favorably the renal symptoms. In the treatment of marked chronic nephritis, the waters just named often likewise act favorably upon the symptoms; particularly as they improve the deranged digestion and the abnormal assimilative conditions of the blood. For these reasons Carlsbad and Marien- bad especially are recommended when albuminuria is present. Drinking-cures with pure carbonated iron waters and with sulphurous iron waters at home, as well as at the respective resorts, are advisable also as an after-cure, in order to check hemo- lysis. If, however, the quantity of albumin in the urine is large ; if the patient is considerably debilitated ; if nephritic asthma is frequent; and if the development of anasarca is rapid, the systematic employ- ment of mineral waters would be injurious and would hasten the process of dissolution. In disease of the uropoietic system warm baths of every kind exert an important sedative and anodyne influence, especially when of prolonged duration. In the presence of great irritability of the vesical mucous membrane with dysuria and ischuria, bathing- cures at the acratothermal springs are useful. In cases of chronic^nephritis warm baths at temperatures of from 38° to 430 C. (100.4° 1° 109.40 F.) may be given at the patient’s home. After the bath, the patient should be wrapped in woolen blankets. URINARY CONCRETIONS In the treatment of uric acid sediment and concretions in the kidneys and the bladder, drinking-cures with alkaline mineral waters are of great utility. The benefit derived from their use is not to be attributed to any solvent effect upon the calculi, as was formerly assumed, though by no means demonstrable, but is due chiefly to the diuretic effect exerted by the constituents of these mineral waters,— the carbon dioxid, the sodium carbonate, the sodium sul- phate, and the sodium chlorid,—resulting in a mechanical washing out from the tissues, and especially from the uriniferous tubules, of the urinary sediment, and facilitating the expulsion of the calculi. Further- more, the alkalis influence favorably the underlying (uric acid) diathesis itself. Finally, they relieve the annoying symptoms—the pain in the region of the kidneys and of the bladder, the reflex manifestations, and the vesical tenesmus. Among excellent springs for drinking- cures in the treatment of uric acid calculi of large size are the thermal alkaline springs of Vichy and Carlsbad; also Neu-49 2 DISEASES OF THE URINARY ORGANS enahr, especially when severe pains are present. In the United States similar waters are : Harbin Hot Springs, in California, and Manitou Springs, in Colorado ; Castle Creek Hot Springs, in Arizona. When abdominal stasis is associated with arthritis, the cold sodium sulphate waters of Marienbad are to be preferred. In cases of uric -acid sediment in which the deposit is less abundant the waters of Ems, Salzbrunn, and Gleichenberg ; in the United States SEtna Spring, California; Plymouth Rock Mineral Well, Michigan; Saratoga Springs (Vichy), New York, are useful. When, in addition to uric acid concretions, an excessive secretion of mucus takes place in the urinary passages, the earthy waters of Wildungen are highly to be recommended. A few of the more im- portant American earthy waters are Bedford Springs (Magnesia Spring), and Bedford Chalybeate Spring, in Pennsylvania; Cherry Valley Springs and Chittenango Sulphur Springs, in New York; Butterworth’s Mineral Spring, in Michigan (see p. 449). The waters just mentioned and the others belonging to the group of alkaline springs are suitable also in cases of uric acid lithiasis. Even in the presence of vesical calculi of large size that render operative intervention necessary, they are useful, both as a preliminary measure before the institution of surgical treatment, and as an after-cure, to wash away the remaining sediment and to neutralize the uric acid diathesis in general. The dose is regulated in accordance with the conditions present in the individual case. When the calculus is made up of uric acid, sufficient of the alkaline mineral waters is taken—preferably in small amounts several times in the course of the day : the first dose when the stomach is empty—to render alkaline the reaction of the urine, without impairing digestion or inducing diarrhea. At the end of the treatment, the mild alkaline table-waters, preferably such as contain considerable amounts of lithium, may be drunk at home for months. In this connection especially the Bonifacius- quelle of Salzschlirf, the water of Assmannshausen, the Sauer- brunnen of Radein, the Salvator quelle of Eperjes, the Kaiser Friedrichsquelle of Offenbach-on-the-Main, the Oberbrun- nen and the Kronenquelle of Salzbrunn, the Sauerbrunnen of Bilin, and the sodium lithium springs of Weilbach are to be recommended for domestic use. In the United States suitable waters are the Londonderry Lithia Springs, of New Hampshire ; Ballardvale Lithia Spring, of Mass- achusetts ; Bedford Iron, Alum, and Lithia Springs, and Buffalo Lithia Springs, of Virginia; Bowden Lithia Springs, of Georgia. When urinary calculi consisting of calcium phosphate and cal- cium carbonate exist, the abundant use of mineral waters containing a large amount of carbon dioxid, but little sodium chlorid, is indicated,PHOSPHATIC AND OXALATE CALCULI 493 whereas the earthy springs are strictly counterindicated. Alka- line-saline and sodium chlorid waters also exert rather a dele- terious than a beneficial effect. The pure carbonated acidulous waters, on the other hand, may, owing to the presence of carbon dioxid, increase the acidity of the urine, and thus limit the growth of calcium calculi by the deposition of lime-salts, and possibly constitute a solvent also for small phosphatic calculi. Under such circum- stances, therefore, the simple acidulous waters of Selters, Koenigswart, Apollinaris Springs, Heppingerbrunnen, Lands- kroner, Sinnberger, and Wernatzerbrunnen ; in the United States the waters of Geyser Spa, in California, and Manitou Soda Spring, in Colorado, may be recommended for drinking purposes. For oxalate calculi both the simple and the alkaline acidulous car- bonated waters may be employed in large quantities for drinking purposes, and be continued for a considerable period of time. Warm baths exert an anodyne and sedative influence in the presence of urinary concretions of any kind.CHAPTER VII DISEASES OF THE GENITALIA Diseases of the Female Genitalia— Chronic Inflammatory States ; Menstrual Abnormities; Neoplasms. Diseases of the Male Genitalia. DISEASES OF THE FEMALE GENITALIA—CHRONIC INFLAMMATORY STATES Menstrual Abnormities In the presence of chronic inflammatory conditions of the female sexual organs, of chronic metritis and endometritis, of perimetritic and parametritic exudates, chronic oophoritis, and pelvic peritonitis, drinking-cures with cold sodium sulphate waters and sodium chlorid waters are most important These purgative waters, through a derivative influence upon the intestinal canal, induce a lowering of the hypostatic pressure in the abdominal blood-vessels; overcome the hyperemia of the uterus and its adnexa, stimulate absorption of exudates. By improving the digestion, more- over, they promote the nutrition of the entire body. For women otherwise of robust constitution, whose digestion is torpid and who exhibit a tendency to constipation, the following waters may be recom- mended : The Kreuzbrunnen and the Ferdinandsbrunnen at Marienbad, the Salzquelle at Franzensbad, the Salzquelle at Elster, the Tempelbrunnen at Rohitsch, the Rakoczybrun- nen at Kissingen, the Elisabethbrunnen at Homburg, and the Luciusquelle at Tarasp. Waters of similar efficacy in the United States are the Saratoga Springs, in New York ; Bedford Magne- sia Springs, in Pennsylvania; Crab Orchard Springs and Har- rodsburg Springs, in Kentucky; Springdale Seltzer Springs, in Colorado, and California Seltzer Spring, in California. (See p. 435-) For delicate debilitated women with chronic metritis, in whom the catarrhal symptoms referable to the various mucous membranes are conspicuous, the alkaline muriated springs are suitable, among which those of Ems have long enjoyed a good reputation. Those of Gleichenberg, Luhatschowitz, Neuenahr, and Vichy also are useful. In the United States the waters of Waukesha Springs, in Wisconsin, may be employed. 494AMENORRHEA 495 If the patient has become chlorotic, or, in consequence of hemor- rhage, anemic as well, the use of the pure iron waters of Schwal- bach, Pyrmont, Driburg, Steben, Franzensbad, Cudowa, Booklet, Reinerz, Spa, St. Moritz, and others, is appropriate as an after-cure following the drinking-cures mentioned. Suitable waters in the United States are the Berkeley Springs, in West Virginia, and Schooley’s Mountain Spring, in New Jersey. The drinking-cures are followed by, or combined with, bathing cures with carbonated steel baths and peat baths, the latter especially at Franzensbad, Marienbad, Elster, Cudowa, Muskau, and Meinberg ; as well as the thermal brine baths at Rehme, Nau- heim, and Kissingen, or the springs most favorably situated climatic- ally at Ischl, Aussee, Reichenhall, and Kreuth. In the United States chalybeate springs used for bathing purposes are: Sweet Chalybeate Springs, in Virginia; Geyser Spa and Napa Soda Springs, in California; Owasso Spring, in Michigan, and a number of others. Thermal brine baths are to be had at Byron Springs, in Cali- fornia ; Pagosa Hot Springs, in Colorado; Salt Lake Hot Springs, in Utah. In the presence of moderate exudates that are not readily ab- sorbed, the iodin brine baths of Kreuznach, Hall in Upper Austria, Duerkheim, Aschaffenburg, and Saxon-les-Bains ; or in cases of marked sensibility, the mountainous acratothermal springs of Schlangenbad, Landeck, Badenweiler, and Wildbad may be em- ployed. Corresponding baths in the United States are: Gentle- men’s Pleasure Bath at Hot Springs ; and Healing Springs, in Virginia; Warm Springs, in Georgia; and some of the springs at Hot Springs, Arkansas. In cases of chronic metritis, ophooritis, and perimetritis, warm baths are taken as full baths and as sitzbaths ; in addition to which use is made of local irrigation of the vagina and the cervix with the respective mineral waters at a temperature of 350 C. (950 F.), as well as of uterine douches of varying temperatures and pressure; the latter, when there are marked induration of the tissues and scanty menstrual discharge. Peat poultices to the hypogastrium, local affusions of brine, and fomentations with concentrated iodin brine are employed as bathing procedures to favor absorption. When abnormities of menstruation, a tendency to abortion, and sterility are present, the underlying constitutional alterations, anemia, chlorosis, obesity, and scrofulosis, on the one hand, and the existing genital affection, on the other hand, should be taken into consideration in order to apply the appropriate balneothera- peutic measures. In the presence of amenorrhea or scanty men-496 DISEASES OF THE GENITALIA struation, the iron waters, the saline ferruginous acidulous waters, and the sodium chlorid waters containing iron are accord- ingly prescribed as drinking-cures for chlorotic and anemic individuals. In obesity, the ferruginous sodium sulphate waters may be used. In scrofulosis, the alkaline hydrochloric acidulous waters are indicated. For the relief of the symptoms that attend the menopause at the climacteric period, the cold sodium sul- phate and sodium chlorid waters, and, finally, the bitter waters are useful. These waters are taken for the relief of menor- rhagia due to circulatory disturbances in the pelvic organs. Of baths, the employment of carbon dioxid in the form of dry gas douches, or of steel baths, gas sprudel baths, car- bonated gas vapor baths, as well as hot peat baths, peat poultices, and packing of the vagina with peat, exert a good effect locally in the presence of conditions of amenorrhea. For menorrhagia due to atony of the uterus or hypostatic hyper- emia of the uterine mucous membrane, cold steel baths and peat baths yield good results. At the climacteric period car- bonated acidulous baths, steel baths, and brine baths are in general counterindicated. Women suffering from disease of the sexual organs should not bathe during the menstrual period, and only exceptionally can this be permitted if, in the presence of scanty men- struation, it is desired, by means of baths, to bring about increased congestion in the genitalia during the menstrual period. During pregnancy, only moderately warm acratothermal, sodium chlorid, and alkaline baths may be permitted, and only with the observance of the following precautions : the temperature of the bath should be from 28° to 340 C. (82.4° to 93.2° F.); the duration should not exceed fifteen minutes ; the bath should not be repeated daily, and should be suspended at once if reflex irritation in the abdominal and pelvic organs becomes manifest. Steel baths, peat baths, acidulous (C02) baths, steam baths, and sea-baths should, however, be forbidden to pregnant women. Neoplasms For myomata of the uterus, bathing-cures may be taken with advantage, not for the purpose of effecting a cure of such new growths, but in order to relieve the secondary manifestations ; symptoms of irritation of the uterus and its surroundings, and hemorrhages induced by such tumors ; also to improve the tone of the muscular coat of the uterus, and thereby to effect a reduction in the size of submucous and interstitial myomata. Upon this depends the favorable influence of brine baths, particularly those containing iodin and bromin, as at Kreuznach, Hall in Austria, Duerkheim, Elmen, Salzhausen, andIMPOTENCE; SPERMATORRHEA 497 Sulza, and, in the United States, Glen Springs (Deer Lick), in New York; Parker Mineral Springs, in Pennsylvania; Mt. Clemens Mineral Springs and St. Clair Springs, in Michigan. The car- bonated brine baths of Kissingen, Nauheim, Rehme, Ischl, and Reichenhall; and the ferruginous peat baths of Marienbad, Franzensbad, Elster, and Muskau, may also be recommended. Care in bathing is required, particularly when myomata are attended with profuse hemorrhage. The baths should not be taken too warm, and their duration should not be too prolonged. The drinking of ferruginous waters may advantageously be associated with the bathing- cure ; but, on the other hand, the internal use of iodin waters is not to be advised, on account of its debilitating influence. For incipient ovarian tumors, the employment of brine baths and iron peat baths containing iodin is indicated, in order to miti- gate the complicating inflammatory symptoms. The internal use of iron waters and saline ferruginous acidulous waters sub- serves the purpose, under such conditions, of improving the general nutrition and invigorating the individual for the necessary operation. In some cases of ovarian tumor, as well as in cases of uterine tumor, when the operation is impossible or is not permitted, drinking- cures with ferruginous sodium sulphate waters or sodium chlorid waters are indicated for obese women, in order, by reduc- ing the" amount of fat, to afford more room in the abdomen and to lessen the pressure symptoms to which the tumor gives rise. DISEASES OF THE MALE GENITALIA Of the diseases of the male sexual system, impotence is the con- dition most frequently subjected to balneotherapeutic measures, in so far as springs and baths are applicable for the relief of the etiologic factors of this condition. Accordingly, it is the nerve-invigorating baths,—steel baths, peat baths, and sea-baths,—in combination with drinking-cures at the steel springs of Pyrmont, Schwalbach, and Franzensbad—in the United States, Richfield Iron Spring, in New York; Cresson Springs, in Pennsylvania; Rock Enon Springs, in Virginia; Pacific Congress Springs, in California— that are capable of improving the condition in cases of sterility in anemic and neurasthenic men ; when the intestinal functions are slug- gish, and, as a result, a hypochondriacal tendency is present, with lowered sexual vigor, a systematic course of treatment at the springs of Carlsbad, Marienbad, and Kissingen is capable of yielding favorable results. Likewise, in the presence of pollutions and spermatorrhea, as a result of anemia and enfeeblement of the ix—32498 DISEASES OF THE GENITALIA nervous system, the ferruginous waters, as well as the saline ferruginous acidulous waters, may be employed for drinking- cures, and be supplemented by cool steel baths and ferruginous peat baths. When a hyperemic state of the pelvic organs is responsible for the pollutions, in consequence of abdominal stasis, hemorrhoidal conditions, or habitual constipation, the cold sodium sulphate waters and sodium chlorid waters are indicated for drinking purposes; in cases of marked congestive states, the bitter waters are useful. All mineral waters should be freed from gas, as thoroughly as possible, and be drunk in small quantities, in order to lessen the irritative effect of the carbon dioxid upon the genitalia, and not to fill the bladder unduly. In chronic inflammatory affections of the testicle and the epididymis, following gonorrhea, or caused by scrofulosis and syphilis, the internal use of the iodin waters for drinking, and the employment of the iodin peat baths—Kreuznach, Woodhall Spa, Hall, Lipik, Krankenheil, Koenigsdorf-Jastrzemb, Sulzbjrunn, and Bex; in the United States, Saratoga Springs (Excelsior), in New York; Salt Sulphur (Iodin) Springs, in West Virginia; Tuscan Springs (Red Spring), in California—for bathing, as well as the thermal brine waters, prove efficient; and also ferruginous peat baths, sulphurous mud-baths, as well as peat poultices and mud cataplasms locally, are useful. Less success is to be ex- pected from similar balneotherapeutic measures in cases of hyper- trophy of the prostate, certainly not in the presence of senile en- largement and induration of the prostate, but rather when such swelling is attributable to syphilis or scrofulosis.CHAPTER VIII DISEASES AND INJURIES OF THE JOINTS Chronic Muscular and Articular Rheumatism. Traumatic Injuries of the Organs of Locomotion. CHRONIC MUSCULAR AND ARTICULAR RHEUMATISM In the presence of chronic rheumatic inflammation of the muscles and joints, the various thermal baths are indicated: Acratothermal baths, sodium chlorid thermal baths, thermal brine baths, sulphurous thermal baths, brine baths, peat baths, and mud-baths. These baths have in com- mon the property of exerting a favorable influence upon involution of the anatomic alterations, and absorption of the effusions, by stimulating metabolism, by increasing the secretory activity of the skin, and by locally inducing favorable changes in the affected parts through dilatation of the vessels, by influencing the circulatory condi- tions, and by irrigating the tissues ; in connection with which, besides, the high temperature of the bath neutralizes the increased sensitive- ness and irritability of the diseased parts. Nevertheless the stimu- lation induced by the baths at various places is different, and permits of a selection in accordance with the needs of the individual case. The action of the hot peat baths and mud-baths is the most intense in the large number of cases of chronic rheumatic affections, whether involving the muscles, the fasciae, the periosteum, the syno- vial capsule, and the ligamentous structures, or other fibrous struc- tures. These baths contain, in greatest abundance, salts, gases, and other cutaneous irritants, and are capable of exerting pressure and friction mechanically; besides, they can be employed at higher tem- peratures than mineral water baths. Peat baths and mud-baths, which combine the effects of a bath and of massage, favor, often to a sur- prising degree, the absorption of fluid effusions, and the retrogressive metamorphosis of inflammatory products of some standing. They exert a useful influence also in rheumatic palsy, as they restore nerve conduction, which had been deranged by the presence of exu- dates, and, in unfavorable cases, at least counteract the rapid atrophy of the paralyzed muscles. 499500 DISEASES AND INJURIES OF THE JOINTS In the operative and orthopedic treatment of rheumatic anky- losis a course of peat baths and mud-baths is useful as a pre- paratory measure and during the after-treatment. Among antirheu- matic baths of this character the highest reputation is enjoyed by the peat baths of Marienbad, Franzensbad, Neudorf, Elster, and Muskau, and by the sulphurous mud-baths of Pistyan, Trencsin, Warasdin, Nenndorf, and Eilsen. The acratother- mal waters of Toeplitz-Schoenau, Warmbrunn, Ragatz, Plom- bieres, Daruvar, Toeplitz-Krapina, Topusko, and others; and, in the United States, Hot Springs, in Arkansas, and Lakewood, in New Jersey, are useful, especially for the chronic rheumatic affections due to cold, and their consequences, as well as in the presence of marked hypersensitivenes and a tendency to rheumatic relapses. Such thermal baths as are situated at not too high an altitude, but enjoy a sheltered climate, shielded from sharp winds, and with not too wide variations in the daily temperature, are deserving of consideration. Chief among resorts that meet these requirements may be mentioned Wiesbaden, Baden-Baden, Ischl, Reichenhall, Ems, and Leuk. In the United States Hot Springs, in Arkansas, Hot Springs, in Virginia, Mt. Clemens Springs, in Michigan, and Hot Springs (the Minnekahta Spring), in South Dakota, are suitable waters. When, in chronic articular rheumatism, valvular disease of the heart exists as a complication, the thermal brine baths of Nau- heim, Rehme, and Kissingen deserve the preference. In obstinate rheumatic disorders of long standing, particularly of the joints, the vigorous stimulation of the sulphurous thermal baths at Aachen, Baden in Austria, Buda-Pest, Pistyan, Toeplitz-Trencsin, Mehadia, and Baden in Switzerland may be employed. Recourse may be had, in Canada, to St. Catherine’s Wells, in Ontario, and Banff Hot Springs, in Alberta; and, in the United States, to Richfield Springs or Sharon Springs, in New York, or Las Vegas Hot Springs, in New Mexico and Klamath Hot Springs and Ojai Hot Sulphur Springs, in California. All these baths should be employed at the highest possible temperatures, and the cutaneous hyperemia induced by the bath should be maintained subsequently by means of the warmth of the bed. At times subsequent sweating, induced by enveloping the patient in woolen blankets, is to be recommended. In addition to the full baths, local baths and warm douches to the affected joints are employed as vigorously stimulating sorbefacient measures; or peat poultices or mud poultices are applied locally. Besides thermal baths, Russian steam baths, Irish-Roman baths, and electric light baths render good service in recent cases of muscular rheumatism. In cases of longstanding hot sand baths at temperatures of from 45 ° to 5 5 0 C. (112.5 0 to 1310 F.), and varying from thirty to ninety minutes in duration, are also serviceable.INJURIES OF BONES AND JOINTS 501 For domestic purposes in the treatment of cases of rheumatism pine-needle baths, prepared by the addition of fresh broken branches of pine, or of pine-needles, to the bath water at a temperature of between 36° and 40° C. (970 to 104° F.), may be employed, fol- lowed by rest in bed for several hours. Recently poultices of hot fan go, the volcanic mud exported from Italy, have been introduced into domestic use. At some of the health resorts previously mentioned—at the acrato- thermal springs, the sulphurous thermal springs, and the sodium chlorid thermal springs—the waters are employed also for drinking purposes in addition to the bathing-cure, in order to maintain the diaphoresis in- duced by the bath or to subject the organism to a thorough flushing. INJURIES OF THE ORGANS OF LOCOMOTION The balneotherapy of the sequels of traumatism involving the organs of locomotion employs the same baths that have just been re- ferred to in connection with the treatment of chronic rheumatism; preferably, peat baths, mud-baths, acratothermal baths, and thermal brine baths. These varieties of baths are succesfully em- ployed in cases of fracture, although only after complete bony union has taken place ; in the presence of gunshot wounds of the soft parts ; false ankylosis in consequence of fractures caused by gunshot wounds; contractures of the muscles and ligaments the result of traumatic exudates ; after sprains, luxations, and fractures. The various forms of obstinate neuralgia persisting after traumatism, often yield to courses of treatment with such thermal baths.CHAPTER IX DISEASES OF THE ORGANS OF SPECIAL SENSE Diseases of the Skin. Diseases of the Eye. Diseases of the Ear. Diseases of the Skin Of diseases of the organs of special sense, those of the skin are most frequently subjected to treatment with drinking-cures and bathing- cures, in so far as the cutaneous structures are frequently diseased in consequence of other morbid states of the organism—disorders of the digestive organs, uterine disorders, and constitutional abnor- mities. Accordingly, chronic urticaria and chronic eczema resulting from gastric disorders require drinking-cures with alka- line and alkaline saline waters; the chronic cutaneous dis- orders of scrofulous individuals, drinking-cures and bathing-cures with iodin waters; the furunculosis so frequently dependent upon abdominal stasis, the waters of Marienbad ; the furunculosis, as well as the pruritus, caused by diabetes, the waters of Carlsbad. Those suffering from syphilitic cutaneous disorders secure benefit from the use of sulphurous waters and iodin waters. For the relief of acne, associated etiologically with menstrual disturbances, the use of ferruginous waters for drinking purposes, and steel baths or peat baths, and the like, may be recommended. For the tendency to habitual erysipelas the less warm acratothermal waters enjoy a good reputation. For chronic eczema brine baths and sulphur- ous baths, and for psoriasis, long-continued thermal lime baths, brine baths, and sulphurous baths of prolonged duration are rec- ommended. For inveterate impetigo sulphurous baths and brine steam baths are useful. In the United States a large number of mineral springs are recommended for the treatment of skin diseases. Those most frequently employed are: Hot Springs, in Arkansas; Oak Orchard Acid Springs and Massena Springs, in New York ; Las Vegas Hot Springs, in New Mexico ; Blue Lick Springs, in Kentucky; Healing Springs, in Alabama; Healing Springs and Rockbridge Alum Springs, in Virginia; Hot Springs, in South Dakota. Diseases of the Eye In ocular disorders such as retinal hyperesthesia, the result of 502DISEASES OF THE EAR 5°3 excessive cerebral irritability; passive hyperemia and chronic inflam- mation of the choroid—choroidal congestion and choroiditis; and incipient glaucoma, the active derivative cold sodium sulphate waters and sodium chlorid waters may be employed with excel- lent results. The scrofulous inflammations of the eye, chronic palpe- bral conjunctivitis, and chronic blepharadenitis, furnish the indi- cations for courses of treatment with iodin waters and brine baths, directed to the constitutional improvement of the condition. Chronic catarrhal inflammations of the conjunctiva dependent upon the rheumatic or the gouty diathesis are improved by the sodium chlorid thermal waters and by the drinking of purgative waters having a derivative effect. For a number of ocular dis- orders resulting from sexual excesses or anemic states of the blood, and dependent upon depression of the nervous system, ferruginous waters are recommended. Diseases of the Ear Of affections of the ear, otorrhea in scrofulous individuals, and catarrhal conditions of the tympanic cavity arising by extension from the pharyngeal mucous membrane, are at times treated by means of drinking-cures with iodin waters and inhalations of brine vapor and brine steam. The same statement is appli- cable to chronic nasal catarrh in scrofulous individuals.APPENDIXAPPENDIX1 ADDITIONAL METHODS FOR THE THERAPEUTIC USE OF WATER, HEAT, COLD, LIGHT, AND MINERAL BATHS In their descriptions of the hydriatric technic and in their recommendations as to the management of special disorders the collaborators of Professor Winternitz have, in specified terms, restricted themselves to the practice of their great master ; pointing out, however, the necessity of modification in accordance with the requirements of individual cases, and fully setting forth the principles involved. I have, therefore, refrained from making material additions or changes. These articles are in no sense incomplete ; yet it is my desire to make the passages devoted to methods among the most important of those pertaining to physiologic therapeutics, in the highest degree useful to physicians whose previous acquaintance with the subject may not have been sufficient to enable them, without further guidance, to undertake the modifications advised. Moreover, in the United States within recent years, and largely under the impetus given by the devoted labors of Dr. Simon Baruch, of New York, certain special developments in hydrotherapeutic technic have come into more or less general use, and therefore demand description. Thus, as illustrations of the manner in which the Winternitz technic may be modified upon occasion, and of the additional methods available in the treatment of certain classes of patients and in various acute and chronic disorders, I deem it advisable to append a number of Dr. Baruch’s recommendations. At the same time opportunity is taken to utilize some suggestions of Dr. Kellogg’s ; to describe and illustrate a few expedients that I have personally found useful and readily available both in hospital and private practice ; and to emphasize the merits of certain methods belonging to the general stock of knowledge and practicable in every home. Hydrotherapy and allied methods are devoid of mystery; their employment should not be relegated either to specialists or to institutes. As in every other branch of medical practice, however, certain cases may present themselves in which the counsel of physicians of special experience, or the apparatus and facilities of special hospitals or institutions, may be necessary. Moreover, every practitioner cannot devote himself to the training of skilled attendants, or equip his office with elaborate instruments. For this reason there should be maintained in every city an establishment to which any physician might refer his patients with a definite hydriatric prescription, just as he can now send them to the apothecary with a definite pharmaceutic prescription. If such institutions can, in addition, be equipped to fulfil prescriptions for the application of all the methods of physiologic treatment, a further and important step toward the goal of scientific therapeutics will have been taken. 1 Much of the material for this appendix has been taken from the editor’s lectures, par- ticularly the course on “Special Therapeutics,” delivered in the summer term at Jefferson Medical College, 1887 to 1891, and from various of his journal articles, among which may be cited “The Cold Water Treatment of Typhoid Fever, According to the Method of Brand,” “Medical and Surgical Reporter,” Philadelphia, June 25, 1887 ; “Extra-Routine Therapeutics,” “The Polyclinic,” Philadelphia, September, 1887; “Lavage in the Treatment of Gastric Affections,” “Journal of the American Medical Association,” Decem- ber 10, 1887; and a number of editorial contributions to the “Medical News,” “The Philadelphia Polyclinic,” and “American Medicine.” Miss Marion E. Smith, Chief Nurse of the Philadelphia Hospital, has kindly supplied the description of some of the routine methods of that institution. 507508 APPENDIX APPARATUS Baruch's Douche Table.—It seems wise to give a more detailed description than occurs in the text of Dr. Strasser, page 89, of Baruch's douche table, the first practical device for scientific and exact control of temperature, pressure, and other elements of the hydriatric prescription. It consists of a series of one-inch pipes compactly arranged within a marble box and supplied with mixing chambers which admit of rapid temperature changes. The supply comes from a two-inch pipe, which must be inde- pendent of the pipes supplying the house, to prevent fluctuation in tempera- ture and pressure. By an ingenious arrangement on the top of the table a number of quickly opening levers connected with faucets turn on the rain, jet, circular (needle), perineal, and fog douche. Two sensitive ther- mometers indicate all temperatures and a pressure gage shows every pound of pressure. The latter is regulated by faucets at the back of the table behind which stands the attendant, who is thus protected against dripping water and may wear ordinary nurse’s garb. The circular douche differs from the ordinary needle-bath in that it consists of a series of roses with removable plates for cleansing. Another important advantage is the mobil- ity of the upper row of roses, which enables them to be adapted to the height of the patient. The rain douche in this apparatus is not vertical, so that the shoulder receives the larger part of the stream. The perineal or ascending douche rises from beneath the slatted floor of the douche room and strikes the patient while sitting on an open seat (Fig. 16, p. 84). Baruch correctly insists that the douche is the most valuable procedure for clinical purposes in large institutions because of the ease with which large numbers may be treated, and because it is adapted chiefly for cases which have resisted other hydriatric measures. In his last report as medi- cal director of the Hydriatric Department of the Riverside Association, which was the first hydrotherapeutic dispensary outside of Germany and Austria, Baruch states that treatment has been administered to patients sent by the principal dispensaries and hospital outdoor departments in New York. He concludes that the sixfold increase of patients shown in three years indi- cates the great value of the douche treatment in cases having resisted all other methods. The chief diseases treated are neurasthenia, chlorosis, the neuralgias, neuritis, rheumatism, gout, obesity, chronic bronchitis, phthisis, and hysteria. TYPHOID FEVER The use of cold bathing in typhoid fever, as described by Strasser in this volume, differs in certain respects from the general practice among American clinicians, which derives through S. Baruch, of New York, from Ernst Brand, of Stettin, by whom the methodic application of the cold1 bath in typhoid fever, not as a mere expedient to reduce temperature, but specifically as an antityphic measure, was first suggested, in 1861.2 After a 1 Baruch terms it ‘full bath,’ but in this volume the German designation ‘half-bath’ has been retained. The expression most common in the United States is simply ‘ tub- bing.’ 2 Currie and others had preceded Brand in the use of cold water in fevers, but reference is here made to a special technic applied to a special affection and persisted in, despite ridicule and opposition, with a propagandist fervor worthy of the highest honor.TYPHOID FEVER 509 period of considerable controversy, the method of Brand has been accepted not only in Germany, but practically over the whole civilized world, as at least the basis for the successful treatment of this affection. The following specific directions include the points upon which greatest stress is laid. Technic.—The bath-tub is to be brought to the side of the patient’s bed, and filled with water at the temperature decided upon. Brand and those who follow him strictly begin with water at 68° F. (20° C.), and may in sub- sequent tubbings reduce the temperature, but not lower than 590 F. (15 C.). The patient, wearing swimming trunks or covered merely with a sheer, is gently lifted1 by two attendants (see Fig. 3, page 65) and so laid in the tub that he is thoroughly immersed in the water, his entire body being covered up to the chin, and the head being best supported out of the water upon a rubber air pillow suspended from the top of the bath-tub. Cold water—6o° F. (150 C.) or less—is poured upon the head and face during the immersion, and the limbs and body, with the exception of the abdomen, are briskly rubbed during the entire period of the bath. In hospitals it is convenient to apply a cold douche to the head and shoulders by means of a current from an elevated reservoir—the irrigating apparatus of the surgeons, in fact (Fig. 4, page 67). The cold affusion and the brisk friction are important features of the treatment, and to their neglect may be attributed failures and unpleasant results. The duration of the bath is from ten to twenty minutes, according to the reactive power of the patient. Unless cyanosis or decided shivering, chattering of the teeth, general failure to react, or untoward effect upon the heart is noticed as a result of the bath, Brand in- sists that it be repeated every third hour so long as the rectal temperature shall exceed 390 C. (102.2°F.), and that this is to be done day and night, regardless of sleeping or other consideration. As a rule, I deem it better not to disturb a sleeping patient even to take his temperature ; rarely, how- ever, urgent indications, such as continuous high temperature above 105° F. (40.50 C.) or great depression calling for a brief stimulating plunge, may modify the rule. Each case is best managed in this respect, as in all others, according to its individuality. Before the patient is put into the bath, and after he is taken out, Brand advises that he be given a glass of red wine. This is a common practice in Germany; in America alcohol is usually given in the form of whisky. I prefer to give aromatic spirit of ammonia, 30 to 60 minims, suitably diluted, or, in some instances, a small cup of hot coffee; reserving alcohol for cases presenting special indications. In the course of the bath the patient may drink a glass of cold water. While the strict Brand method is favored by many physicians in America, among them J. C. Wilson,—to whom we are indeb'ed for a statistical demonstration of the value of the treatment as carried out systematically at the German Hospital of Philadelphia and in his service at the Pennsyl- vania Hospital,—others prefer to begin the tubbing at a temperature vary- ing according to the condition of the patient, and to reduce this gradually by the addition of ice or of very cold water during the progress of the bath ; 1 Wilson allows his patients, if the symptoms are mild and the bath treatment is in- stituted early, to rise and step into the tub assisted by the attendants, and has never observed any harm to result from permitting them to do so. This practice is, however, generally deprecated, and as a routine measure is hardly safe.APPENDIX 5IQ the degree of reduction, as well as the initial and final temperatures of suc- ceeding baths and the duration of each bath, to be governed by the general effect upon the individual patient, together with the height of his tempera- ture, the vigor of the heart, and the severity of his nervous symptoms at the time of immersion. This is my own practice. It is a flexible method, based on strict individualization. As has been sufficiently pointed out, the method is not antipyretic, but antityphic. The patient’s temperature is a useful index as to the effect and the necessity for repetition of the bath, but nothing more. No greater mistake can be made than to try to reduce the pyrexia as far and as fast as possible. The charts resembling hectic fever seen in so many hospital wards are distinctly bad charts. In the normal progress of typhoid fever toward recovery no sudden change occurs in temperature or other symptoms, and no sudden change should be pro- duced by treatment. Even during the fastigium in cases with quite high temperature a single bath should not be allowed to bring it down more than i° C. or, at most, 2°F.1 A reduction of i°F. (o.5°C.)is often better. After this moderate fall the former height is rarely regained ; and each bath produces a further slight reduction in the range of pyrexial activity, not by mere abstraction of heat, but by antagonizing the morbid process as a whole—especially by the stimulation of metabol sm and the improved function of the emunctories. In this way successively lower levels are reached, the course of the disease becomes more mild, and the therapeutic lysis anticipates and reinforces the normal lysis. The patient’s reactive powers are gaged by means of an initial bath of five minutes’ duration at 90° reduced to 8o° F. (320 to 270 C.) or a cold rub or a simple ablution; and the initial temperature, the reduction, and the duration of the follow- ing bath are determined accordingly. After this, each bath serves in a measure as a guide to that which succeeds it; the predetermined plan being held subject to modification during the procedure if necessary. Whenever it is possible—in hospital practice always—a medical attend- ant should be present during the bath, not so much to guard against the occurrence of shock, as to insure that the benefits of the procedure are not needlessly curtailed by too anxious interference and too early termination of the bath. Chattering of the teeth may be disregarded in most patients, alarming as it may appear, nor is cyanosis of the extremities alone to be re- garded as a signal to terminate the bath; but if a decided blueness is noted about the face, especially about the nose, the patient should be taken from the water at once. This will be found a more reliable sign than the condi- tion of the radial pulse, which is necessarily influenced by the local chilling of the arms. Few patients tolerate a bath of more than fifteen minutes’ duration in water at 68° F. (20° C.). Continuous cold affusions are usually helpful, but absolutely indicated only when stupor is profound, and respira- tion superficial and labored. In most cases it suffices to cover the patient’s head with an ice-cap or a wet turban and have it bathed at short intervals either by himself or by the attendants; care being exercised that the water does not run into the ears. The patient’s comfort while in the tub will be 1 It is a fact of some diagnostic import that a cold bath at any temperature will rarely reduce the body-temperature more than two degrees in the first week of typhoid fever, while in croupous pneumonia even a moderately cool bath, say, at 85° to 8o° F. (290 to 270 C.), may reduce the temperature from 2 to 4 degrees (Baruch).TYPHOID FEVER 511 materially increased by providing him with a rubber air cushion to support the buttocks, as well as with an air-pillow for his head. In lifting the patient out of the tub, the attendants should, if possible, allow the water to drain off for a fraction of a minute, to prevent flooding of the blankets (Fig. 5, page 68). The preparation of the bed for the reception of the patient after the tubbing is very important, but is often neglected. To this neglect may be attributed many of the unpleasant results that some physicians imagine to have been caused by the bath, and that have, therefore, rendered them timid in the application of the method. Everything should be in readiness before the patient enters the water, so that there may be no delay should it be necessary to remove him from the tub sooner than was anticipated, and Fig. 70.—Abdominal Coil. to relieve his anxiety at the thought of possibly having to remain longer in the tub than necessary while the bed is being prepared. There are needed, first, two warm blankets at a temperature of not less than ioo° F. (38° C.). Three hot-water cans or bags should likewise be ready, properly wrapped, to be placed one at his feet and one to each thigh; and an ice-cap or rub- ber coil should be at hand for his head. Over the lower blanket should be placed a dry sheet, equally warm, and upon this the patient is laid when he is lifted out of the tub. The sheet is then wrapped about him from the two sides, and tucked between the arms and the trunk, and between the two legs, so that no two surfaces of wet skin shall be in contact (Fig. 6, page 69). Friction is made over the sheet until the patient is thoroughly dry, when the sheet is slipped out and he is allowed to lie between the blankets,512 APPENDIX with the hot-water cans at his feet and against his legs, and the ice-cap upon his head. The patient continues thus for from fifteen to twenty minutes, when he is again robed in his nightdress and permitted to lie between the sheets of his bed. After the hot-water cans have been removed, a cold compress, an ice-bag, or a cold coil (Fig. 70) is applied over the abdomen, unless too low a temperature for this has resulted from the bath. The ice- cradle (Fig. 77), which is described elsewhere, furnishes a convenient means of applying continuous cold to the abdomen, especially when the patient is restless under the weight of the coil or compress. In this matter of the application of continuous cold to the abdomen the patient’s sensations cannot be depended upon as a guide; there is no doubt that the procedure has a distinct effect in keeping the temperature down and reducing the number of baths required. In some cases it seems to obviate the necessity Fig. 71.—Temperature Chart Showing Antipyretic Effect of Sprinkling in a Case of Typhoid Fever ; Editor’s Service, Polyclinic Hospital.—(Courtesy of (i American Medicine." ) of routine bathing. It certainly diminishes the tendency to tympanites and probably reduces to a minimum the danger of hemorrhage. Neither coil nor ice-bag should be placed directly upon the skin, but a flannel or linen cloth wrung out of ice-water should be interposed. Some physicians prefer to place the ice-bag' over the right iliac fossa, and this practice is often advantageous. In some cases these applications have a better effect when occasionally intermitted for an hour or so, or when the coil or ice-bag is shifted at intervals. To enumerate the advantages of the Brand or cold-water treatment of typhoid fever, and the statistics on which the popularity of the method rests, would to-day be a work of supererogation ; but a few salient facts and figures may not be out of place.SPRINKLING 513 In cases treated by the Brand method from the beginning, before the fifth day, the entire course of typhoid fever is changed. The severe symp- toms of the classic picture are wanting; and the patient passes through the various stages in comparative comfort. Brand boldly asserts, on the strength of 1223 cases treated by Jiirgensen, Vogl, and himself up to January, 1887, that all cases of typhoid fever coming under treatment before the fifth day should recover. Conservatively stating the results of the analysis of some 35,000 cases reported from all parts of the world, it may be asserted that the cold-bath treatment has reduced the mortality of typhoid fever from more than 20 per cent, to less than 8 per cent., while in 5573 cases collated by Brand it was but 3.9 per cent. The statistics of Vogl, who reports a mortality of only 2.7 per cent, among 221 cases treated by the strict Brand method, are unusually valuable from the fact that the patients were all of the same type—soldiers of about the same age and condition of previous health. Among 667 cases taken from the same clinical material, in which a combined water and pharmacal —so-called antipyretic—treatment was employed, the mortality during the same period was 7.6 per cent. It may, therefore, safely be said that, should a routine treatment of typhoid fever have to be pursued, least harm and most good will result from the employment of systematic bathing in cold water after the method of Brand. Iam, however, opposed to any routine treatment, and, as I had the pleasure of advocating the Brand system1 and of employing it according to my then limited facilities while antipyrin was yet in vogue, I do not hesitate now to place myself on record against the extreme views enunciated by some authorities of more recent acquaintance with the method. In severe cases, or in cases that promise to be severe, if seen before the tenth day, systematic plunging in cold water should be instituted at once, and the directions of Brand should be followed with reasonable strictness. The in- expert will do better by following them to the letter, than by attempting modification. The experienced will adapt his directions to circumstances. Between the tenth and the twelfth days it is doubtful whether plunging should be begun. After the twelfth day the inexpert should never begin plunging. Plunging begun earlier will of course be continued or discon- tinued according to circumstances. When the course of the disease is essentially mild; when tubbing is dreaded notwithstanding its good effect; when the baths are not well borne ; or when facilities for the bath treatment are not available, other hydriatric methods may be tried. Mention may here be made of some of the most useful; they are available in pneumonia, in febrile tuberculosis and the like, as well as in enteric fever. Sprinkling.—As an antipyretic procedure this may be said to rival tubbing (see chart, Fig. 71). It is better borne by most persons,— although there are exceptions to this rule,—and is particularly well adapted for private practice, as it requires no bath-tub and the patient does not have to be lifted bodily from his bed. The method is as follows: The head of the bed is raised about a foot from the floor; under the mattress to keep it from sagging and to insure a uniform flow toward the foot of the bed, three ordinary pine boards, as long as the bed is wide, are introduced crosswise; 1 “ Medical and Surgical Reporter,” Philadelphia, June 25, 1887. ix—335 H APPENDIX and the mattress is covered with a large rubber sheet, on which are placed a pillow and a linen sheet. The patient is stripped as for tubbing and sprinkled with water at the desired temperature either from a watering pot (Fig. 72) or, more conveniently, from a tube with rose nozle attached to an irrigating reservoir (Fig. 73)' The water as it flows off is received in a pail, or, better, a foot-bath, placed at the foot of the bed, and can be used again and again, the temperature being maintained if necessary by the addition of ice. The temperature of the water and the duration of the procedure are to be regulated according to existing conditions as in the bath treat- ment ; it is usually advisable to employ water at about io° or 120 F. (say, 50 or 6° C.) cooler than would be used for bathing the same patient under the same conditions. The patient’s head is covered with a turban and active Fig. 72.—Sprinkling with a Watering-pot; Ice Rub (‘Ice-ironing’). friction is kept up during the entire procedure, exactly as in the case of the Brand method, the mode of action in both being the same. The water should be poured, from not too great a height, chiefly on the abdomen and lower extremities, as the patients find this less distressing and the effect is quite as good. After the sprinkling, the patient is wrapped in a dry sheet covered with a blanket and rubbed dry until reaction has set in. The body- temperature is to be taken every three hours, and if it is found to exceed 102.20 F. (39° C.) in the rectum, repetition of the sprinkling is indicated. The Wet Pack.—This procedure, which is fully described in the text (see p. 104), is often used as a substitute for tubbing, and has found many advocates. To obtain an antipyretic effect the pack must be renewed at frequent intervals, requiring almost constant manipulation of the patient.THE ICE RUB S15 Baruch has abandoned the wet pack in typhoid fever, believing that it ex- hausts the patient too much. He considers the sheet bath (referred to under the term ‘Lakenbad,’ page 78), applied as presently to be described, to be in every respect more effective. The Sheet Bath.—The sheet is laid dripping from water at 8o° F. (270 C.) upon blankets on an adjoining bed, couch, or table, and the patient, raising his arms above his head, is snugly wrapped up in it. Water is poured upon successive parts of the trunk, which are rubbed with the flat hand until warm and then cooled by pouring colder water (6o° to 50° F.— I5° t° io° C.) upon them. When a part ceases to warm up, another is similarly treated, until the entire trunk has been gone over. Baruch states that the sheet bath is second only to the cold tub bath in the treatment of Big. 73.—Sprinkling with an Irrigating Apparatus ; Ice Rub. typhoid fever, and is a good substitute for the Brand treatment when the latter is refused by the patient. The Towel Bath.—This is another useful measure. The patient is stripped and laid upon blankets; the back is first treated by laying a towel dripping from water at 750 F. (240 C.) smoothly upon it; friction is made over the latter until it warms up, and water at 6o° F. (150 C.) is then poured from a cup or pitcher over the warmed surface until it cools. It is then warmed up again by renewed friction, and this is repeated until the part ceases to be- come warm. The gluteal region is then similarly treated. After the back of the patient has been thoroughly dried by rubbing, the anterior surface of the trunk is, in the same way, cooled, warmed, cooled again, and dried. The Ice Rub.—This procedure is illustrated in connection with5i6 APPENDIX sprinkling. (See Figs. 72 and 73.) Ice cut to a flat surface and held within a piece of gauze or thin cloth is rubbed over successive parts until they are cooled, and the patient is then thoroughly dried and made comfortable. Ablution, or Sponging.—The patient is divested of his clothes and placed between blankets, or sheets if preferred and in very hot weather, and with a well moistened carriage sponge the whole body is wetted. Long light strokes are used, the different parts being gone over in succession and then exposed to the air. A film of water must be left on the skin for evaporation if the temperature is to be reduced. Simple and well known as this proce- dure is, certain points in regard to its application in typhoid fever need to be emphasized. Cold water should first be applied to the head, face, and neck. The remainder of the body should then be sponged in the following order: Upper extremities, lower extremities, chest, abdomen, back. The abdomen should be handled lightly, and the patient should not be turned until the time has come to sponge the back. It is best to begin with water at 750 to 70° F. (240 to 210 C.) and reduce gradually; in cases of very great pyrexia, reaching ice-water in the course of ten minutes, and continuing the low temperature for ten minutes; in other cases reaching 50° F. (io° C.) in the course of fifteen minutes; but here, too, individualization is necessary. It is best to expose only that portion of the body which is being sponged, and not to dry the patient until the application is concluded. When the temper- ature in the mouth does not exceed 103° F. (39.50 C.), the patient may be sponged every third hour. When the temperature exceeds 104° F. (40° C.), sponging must be done every second hour. These procedures, like the bath, “appeal to the depreciated nerve- centers and arouse them bom the lethargy of toxemia/’ provided that decided chil'ing is not produced. Ice Pack.—The patient is stripped and laid on a cot covered with a rubber sheet. An ice cap having been applied to the head, large pieces of ice are disposed along the sides of the body, between the legs, and in the axillae, and the surface of the body is at the same time rubbed with ice as in the application of the ice rub described above. The ice may be brought into immediate contact with the cutaneous surface or a cold wet sheet be interposed. The patient is kept in the pack until a decided fall in the temperature takes place. The ice pack is urged by some writers as of great use in typhoid fever and in pneumonia; I have not employed it in either. I have found it service- able in septic hyperpyrexia when tubbing was not available. It is a popular procedure in hospitals in the treatment of thermic fever and is mentioned in standard text-books as one of the most useful methods at command in cases of sunstroke. On the other hand, the practice is condemned in no measured terms by Baruch,1 who cites statistics tending to show its inferiority to forcible affusion with ice-water. It is an antipyretic not a stimulating measure. Whatever may be the method selected as a routine treatment, the gen- eral and antipyretic effect will be materially enhanced by the systematic employment of some form of continuous cold application to the trunk or abdomen. My own practice has been described (p. 511). Kellogg advises that when the temperature is high, and particularly when it resists the hydri- 1 “ Hydrotherapy,’ ’ New York, 1900, pp. 316 to 324, esp. p. 322.APPLIANCES FOR HOME USE 517 atric measure employed, a large abdominal compress, about one-fourth the size of the body, or four to five square feet for a person of ordinary size, should be applied and changed every twenty to thirty minutes, or as soon as it is appreciably warmed and before it becomes either hot or dry. Baruch, however, insists that in febrile diseases the cooling effect of hydriatric meas- ures is secondary to the nerve-arousing, stimulating effect, and that a con- tinuous cold application is therefore objectionable. In the stimulating com- press (6o° F.—150 C.), covered with one layer of flannel, the cooling effect is not neglected, but encouraged by evaporation through the thin flannel. In addition to cooling applications, there are certain accessory meas- ures that are not without value in typhoid fever. The patient should be encouraged to drink freely and frequently of cool water, the temperature of which should be that found most refreshing, except that ice-water should not be used. Carbonated waters are especially grateful. The bowel should be cleansed by enema on admission, unless after the tenth day, after which, according to circumstances, a few small doses or one large dose of calomel should be given. After the ‘ calomel stool,’ suitable intestinal disinfectants may be employed. If there be constipation, it should be relieved by enema every forty-eight hours except during the period when ulceration is at its height,—say, from the twelfth to the sixteenth day,—when the bowel should be let alone. Diarrhea should not be interfered with unless excessive, but daily saline irrigation may be found to diminish it by relief of irritation. If, notwithstanding the free use of water internally and externally, the urine is not excreted in sufficient quantity, enteroclysis or hypodermoclysis may be employed, or some mild diuretic given. Certain appliances not described in the preceding pages may for con- venience be mentioned here, as they are especially useful in typhoid fever. Baruch’s Portable Hospital Tub.—This tub, 50 or 57 inches long and 27 inches wide, was designed to economize room in crowded hospital wards, and possesses certain advantages over the ordinary six-foot tub. It is made of wood lined with copper, of the shape indicated in the accom- panying illustration (Fig. 74). It consists of two parts so arranged that the patient’s lower extremities are bent at right angles to his recumbent body, the feet resting upon a double bottom which is filled with hot water. A tube with a funnel-shaped opening (seen in one of the upper corners) gives entrance, and a faucet (the lower one in the cut) upon the posterior aspect gives exit to the hot water. The object of this tub is to afford the patient an easy recumbent position, and prevent the cold water from chilling the feet and producing painful cramps during the bath. Its short and com- pact form renders it more portable than the ordinary tub, and its height, which is on a level with an ordinary hospital bed, saves much back-strain to the nurses, whose constant attention is required for friction during the con- tinuance of the bath. Tubs for Home Use.—The stationary bath-tub in an ordinary city bath-room, which contains a water-closet, should never be used. It is in- convenient for the nurses, and oppressive to the patient to be brought into the contaminated atmosphere of so small a room. For private practice the ordinary tin bath-tub, between five and six feet long, which may be obtained at the tinner’s or at the large city department stores, is perhaps the best5i8 APPENDIX adapted. When for any reason this cannot be obtained, or the patient or his friends will not consent to tubbing, one of the forms of bed-baths, of which several have been devised, will be found convenient. Fig. 74.—Baruch's Portable Hospital Tub. Fig. 75.—Burr’s Bed-bath. Fig. 76.—Burr’s Portable Frame for Bed-bath. Dr. A. H. Burr’s ‘portable bath’ consists, first, of a large rubber sheet with rings attached near its margin by elastic tapes; second, of a lightICE CRADLE 519 wooden crib, with fastenings along the lower rail to hold the sheet. This frame can be folded into a compact bundle. A hose with a metal yoke for a siphon, a sponge or wash-rag, and a bath thermometer complete the outfit. The rubber sheet is first slipped under the patient, brought up over the pil- low, and tucked up alongside the body. The frame is then unfolded and placed over the patient, so that it rests on the mattress and surrounds patient, pillow, and rubber sheet. The edges of the sheet are then drawn up over the top rail of the crib down to the lower rail and fastened by the rings. This completes a light and perfect tub, capable of holding twenty gallons of water. It can be emptied by siphon in four minutes (Fig. 75). Dr. U. F. Martin’s device for what he terms the 'slush bath’ in typhoid fever differs from the foregoing chiefly in the fact that the upright pieces of the crib are provided with several holes so that the side bars can be inserted at different levels and the capacity of the bath thus be increased or diminished. To drain off the water, the rubber sheet is unhooked at the foot of the bed and the water is allowed to flow into a bucket. The pro- cedure consists in pouring water at the proper temperature over the patient and applying active friction to the body ; in other words, affusion with friction. . Dr. A. C. Haven’s device for a bed-bath is the simplest and least expensive. The materials required are, some clothes-line, a dozen ordinary wooden clothespins, and three yards of table oilcloth. "Tie a loop of rope firmly round the headboard, another round the footboard, and connect by two parallel ropes; attach the oilcloth with clothespins, and you have as comfortable a bath as the most expensive, at a cost not exceeding seventy-five cents. The loops around the headboard and footboard may be dispensed with in metal beds. Four feet of garden hose with a wooden plug in one end makes an excellent siphon.” 1 Dr. Wilmer Batt’s portable bath-tub is a more elaborate contri- vance. The dimensions of the tub when ready for use are: length, 75 inches; width, 22 inches; depth, 18 inches. The dimensions of tub when folded for carrying are : length, 33 inches; thickness, 9 inches. The dimen- sions of box containing the frame are: length, 39 inches; width, 8 inches; depth, 3 inches. The tub part is made of heavy canvas covered with rub- ber, and is seamless. The tub is supported by hooks inserted through the canvas before the rubber is applied. The frame is composed of brass pipe, nickel plated. Both tub and frame can be rendered aseptic by boiling. The Ice Cradle.—This simple measure for cooling continuously the air about the patient’s body or any part of it was proposed for the treat- ment of pneumonia by S. W. Fenwick.2 I frequently use it in various febrile conditions, especially in typhoid fever. It is allowed to remain on the bed so long as the temperature in the mouth exceeds ioo° F., except when bathing, sponging, or other unavoidable manipulations call for its temporary removal. An ordinary iron frame or cradle, such as is used in every hospital, and sufficiently wide to permit the patient to change his position occasionally without interference, is placed over the patient’s chest or abdomen or entire body. For localized effect, one or two ice-bags, 1 “Med. Record,” N. Y., Jan. 8, 1898. 2 W. Soltau Fenwick, “The Lancet,” Feb. 7> I^9I> P* 3°3*520 APPENDIX wrapped in cotton covering, or for general cooling, a row of zinc pails filled with rather large pieces of ice, are suspended from the ridge pole. The bottoms of the pails should be covered with lint to prevent dripping. When ice-bags are used, they are so adjusted as just to clear the surface of the body. Wooden hoops, properly braced, may be used in a patient’s house if the iron cradle is not available (Fig. 77). The patient is stripped ; a hot-water can is placed at his feet to prevent chilliness; and the cradle is so covered with a thin counterpane as to leave openings for free circulation of air. Fenwick’s statistics show great benefit from this continuous cooling in those cases of lobar pneumonia in which the temperature tends to rise above 103° F. The Continuous Bath The continuous bath, otherwise known as Hebra’s water bed, may Fig. 77.—Ice Cradi.e (Partial Application). be mentioned here as having been strongly advocated by James Barr for the treatment of typhoid fever.1 The tank employed by Barr consists of a wooden box, about six feet long, two feet ten inches wide, and sixteen inches deep, lined with lead, painted, and covered with a thick coating of shellac or white enamel paint. It is provided with a large discharge pipe communicating with a soil pipe leading down to the sewer; the 70 gallons of water which it contains can thus be drawn off in about three minutes. Inside the tank, a light wooden frame fits closely to the sides with sufficient play to be easily moved up and down for the purpose of raising the patient 1 “The Treatment of Typhoid Fever,” London, 1892.TO MAKE RUBBER COILS 521 out of the water and immersing him again. A canvas sheet is fastened to the frame to prevent the body of the patient which it supports from resting directly on the bottom of the tub; at the head there is another strip of can- vas about a foot wide on which rests an air-pillow to keep the patient’s head above water. If a specially constructed tank is not available, a continuous bath may be improvised with an ordinary bath-tub and a hammock or a stout linen sheet. The hammock can be suspended from hooks attached to the walls or ceiling of the room, and allowed to sag into the bath-tub suffi- ciently to submerge the patient; or a sheet may be supported by means of a frame with pegs or holes, properly adjusted to the top of the tub. While suitable arrangements are being completed, the patient may be placed on one or more folded blankets in an ordinary tub, or on air-pillows filled with water at the same temperature as the bath. Pillow-cases filled with excel- sior, or several large water bags, may be employed in the same way. Hebra was the first to use the continuous bath m the treatment of various skin diseases, and especially in the treatment of burns. He kept his patients in the bath for weeks and months. In one instance a patient lived in a bath for over a year, during which time he gained fourteen pounds. The contin- uous bath has also been advocated in meningitis, locomotor ataxia, para- plegia and hemiplegia, intractable sciatica, chronic rheumatism, cutaneous hyperemia, and bed-sores. When the bath is to be employed for a long time, it is well to anoint the skin with vaselin, to avoid excessive maceration. Technic in Typhoid Fever.—The patient is wrapped in a blanket and completely immersed, except the head. A blanket is better for this purpose than a sheet, because it is a bad conductor of heat, and if a portion of the chest temporarily rises above the water, there is then less danger of chill. The tank is covered with a half lid, to relieve the patient of the weight of the bed-clothing, a rubber sheet, and one or two additional blankets to keep in the heat of the water. The temperature of the water, which need not rise above 940 to 950 F., is readily maintained by dipping out a pailful of the bath water from time to time, and adding either hot or cold water, as required. Barr gives the following directions: So long as the patient’s temperature in the mouth is over ioo° F. (37.70 C.), the tem- perature of the tank water need not rise above 90° to 930 F. (320 to 340 C.) ; but as the body-temperature approaches the normal so should the tank tem- perature. The patient is kept in this continuous bath during the entire febrile period, and is not even removed, in severe cases, to allow him to move his bowels, a special device being employed to carry off the feces directly into the sewer. To Make Rubber Coils for Hot and Cold Water.—A serviceable rubber coil can be made by any nurse or sewing woman. The materials re- quired are about forty feet of red or black rubber tubing, No. 20, and a piece of rubber sheeting large enough to extend several inches in every direction beyond the coil when finished, say, half a yard square; or, instead of the sheeting, six strips of tape, half an inch wide and 16 inches long, may be used. The tubing is coiled into a circle 12 inches in diameter for a head or a precordial coil, or into an oval with a transverse diameter of 14 inches and a longitudinal diameter of 11 inches for an abdominal coil. An oblong of about 14 by 6 inches makes a convenient spinal coil. About six feet of tubing are left free for a supply pipe to convey the water by siphon- age from a vessel placed above the head of the bed, and another piece of522 APPENDIX about four feet at the other extremity serves to carry off the water into a pail by the side of the bed. The coil is sewed fast to the piece of rubber sheeting, or to the strips of tape extending from the center to the circum- ference, after the pattern of a spider’s web. As a cooling application to the head or the abdomen, particularly in the case of fever patients when the continuous action of cold is desirable, the rubber coil is much more con- venient than the ordinary ice-bag. There is no wetting of the pillow-or disturbing the patient to replenish the ice. I desire to emphasize in this connection the great value of the precordial ice-bag for coil) in the febrile manifestations of pulmonary tuberculosis. It should be used continuously while the temperature exceeds ioo° F. (370 C.). If otherwise deemed advis- able, the patient, suitably clothed and with the ice-Mg in position, may lie on a couch or reclining chair out-of doors. It is also very useful in cases of pulmonary hemorrhage. When nothing else is available ice may be wrapped in a towel, and the bed-clothes protected by several thicknesses of newspaper. PNEUMONIA Packing the thorax or the affected side in ice is strongly urged by many good observers as a part of the treatment of acute pneumonia, both croupous and catarrhal. My own observation, however, has not led me to regard the practice favorably, and I still employ heat; choosing, according to circumstances, the hot-water bag, the wool-jacket, or the old-fashioned poultice, to be considered in a succeeding volume. The use of the ice cradle has been mentioned. The rules laid down by Dr. Lees 1 for the use of the ice-bag in pneu- monia are as follow: 1. Apply the ice-bag over the dull area, and especially over the advancing edge of the consolidation. 2. If the area is large, use two ice-bags at least, or three. Even young children may require two. 3. Expect to find a distinct local effect (improvement of percussion note, less bronchial breathing, looser rales) on careful physical examination, after the ice has been applied for twenty-four hours. 4. If fresh areas of consolidation develop, use additional bags. Four, or even more, may be used in a bad case. Correct dosage is as important as it is with drugs. 5. Take the temperature every half-hour for the first three hours; after- ward every two hours. 6. Apply hot-water bottles to the feet and legs. For children apply these before the ice is applied. 7. Examine physical signs twice daily, and shift the bags accordingly. 8. If pericarditis is present, place one ice-bag over the heart. 9. If the temperature be below 990 F., or the hands cold, or the lips bluish, remove the bags for an hour, then replace them, and use them for two- or three-hour periods, with one- or two-hour intervals. 10. If in a severe case there is a distinct cyanosis, and a rapid, feeble pulse, consider whether leeches (in urgent cases venesection) would not relieve the right heart. 1 “ Birmingham Medical Review,” November,. 1896.LARYNGITIS AND PHARYNGITIS $23 11. In all cases see that sleep is secured during the first three or four nights. If the relief afforded 4by ice-bags does not suffice for this, medica- tion is necessary. 12. Pneumonia treated vigorously with ice within twenty-four hours after the rigor may sometimes be aborted. The Chest Compress.—The full bath in pneumonia is very distress- ing to the patient by reason of dyspnea, pain, and cough. Baruch has therefore abandoned it in adults in favor of the chest compress. The rectal temperature is taken every hour when the patient is not asleep. So long as the temperature registers over ioo° F. (37. 70 C.) a compress made of three folds of old coarse linen wrung out of water at 6o° F. (150 C.) is wrapped around the chest from the clavicle to the umbilicus. It should be long enough to lap over one inch in front, and so slit in its axillary portion that it may rise easily up to the clavicle without leaving rough folds in the axilla. This compress is smoothly wrapped around the chest and covered by one layer of thin flannel, an inch wider and longer. In the case of young children, who are easily lifted, a full bath of moderate temperature (950 to 8o° F.—350 to 26.5° C.) is more convenient and does not distress the little patient; affusions of water at a lower temperature (70° to 6o° F.—210 to T5° C.) are most useful in bronchopneumonia with obstruction, because pleurisy is usually absent, and the shallow breathing and deficient oxygena- tion due to bronchial obstruction are greatly relieved by the agitation, cry- ing, and coughing incident to the procedure. The effects of the chest compress may be materially modified by changing the manner of its preparation. If, for example, the body-temperature is not very high,—say, from ioo° to 102° F. (37.70 to 38 8° C.),—the compress may be more thoroughly wrung out, so as to make the impression of cold more brief, reaction more rapid and less enduring. If the temperature is high,—103° F. (39.5° C.) or above,—the water temperature may be raised to 65° F. (18.50 C.), and more water maybe allowed to remain in the com- press, thus rendering the reaction slower and more enduring,and abstracting more heat. In the first instance the application will be more stimulating, in the latter more soothing and antipyretic. LARYNGITIS AND PHARYNGITIS The Throat Compress.—The usual method of applying this compress by folding a handkerchief or napkin into a narrow bandage and winding it around the neck is faulty. Such a compress is displaced in a very short time by the movements of the patient, air enters freely from above, and the compress dries rapidly, thus defeating the object for which it is applied. When it is intended to treat some tracheal or laryngeal trouble, if one end of the bandage be well wetted and covered over by the other end to delay evaporation; or if a mass of absorbent cotton, or a handkerchief folded four-square be wetted and covered with a dry handkerchief, it will often suffice. I desire to emphasize here the good effects of these simple forms of throat compress in subacute and even chronic irritative laryngitis, as well as in the acute form. The action is enhanced when preceded by mild counter- irritation, as with spirit of camphor. When intended for the treatment of tonsillitis, diphtheria, and other pharyngeal affections, however, the throat compress should be applied as follows: A piece of linen, of sufficient length524 APPENDIX to reach from below the ear on one side to the same point on the other, is folded into a compress of four layers. A piece of flannel, 8 by 24 inches, provided with a slit for each ear, is also made ready. These bandages are fitted by actual measurement to the patient’s h.ad, so that they may pass under the chin from ear to ear. The linen compress is now wrung out of water at 6o° F. (150 C.) and laid upon the middle of the dry flannel bandage. While the wet bandage is placed under the chin, the flannel bandage is unrolled from the top of the head and passed over the right side of the head, the right ear being made to protrude through the slit, and then passed under the chin to the left side, where the left ear is also allowed to protrude. The entire bandage is now firmly drawn over the head and secured by pins (Fig. 78). Two sets of bandages are required, one being allowed to dry while the other is in use. THERMIC FEVER AND HEAT EXHAUSTION Hydrotherapy is universally employed in the treatment of conditions, whether of exhaustion or of hyperpyrexia, result- ing from exposure to ex- cessive heat, comb ned usually with overexertion and too often with alco- holic abuse. The indi- cations are unmistakable. In sunstroke or thermic fever the excessive tem- perature must be reduced as speedily as possible if life is to be saved. Hos- pitals are provided with ten's containing couches covered with rubber Fig. 78.—Throat Compress. Correct and Incorrect sheets and within reach Application.—(After Baruch.) of water connection. The most convenient method of applying water is with an ordinary hose, so-called slushing. When a patient suffering from thermic fever is brought to the hospital, he is at once divested of his clothing and placed on one of the beds in the tent, and a stream of cold water is played on him until the temperature begins to fall. As the decline is usually rapid, it is advisable to stop before the temperature goes below ioi° F. (38° C.). If the patient fails to respond to this treatment within a reasonable time,—say, half an hour,—he should be tubbed in water at 750 F. (240 C.), rapidly reduced to 6o° F. (150 C.), vigorous friction being applied as in the case of a typhoid fever patient. The tubbing must be repeated every two hours, if necessary to control the temperature. In the intervals, ice-bags or ice-water coils may be ap- plied to the precordium and the abdomen or the ice cradle utilized. Sprinkling with very cold water may be substituted for the tub-bath. With it is combined the process of ‘ironing’ with ice, already described under the term ice rub, in which a flat piece of ice is passed rapidly over the chestHOT WET PACK 525 and back. Another measure much used, but of inferior efficacy, is the ice pack, either alone or in combination with sprinkling, slushing, and tubbing. The ice must be shifted about during the pack, though there is little danger of freezing a part which is 1 io° F. Ice-water enemas are also employed. In heat exhaustion the indications are equally clear. Cold applica- tions are of course useless, and even harmful. The temperature in this con- dition is subnormal, hence tepid or warm baths and warm applications, such as the hot wet pack, are in order. Care must be taken not to bring on excessive reaction. In addition to hydriatric measures, stimulation with alcohol, strychnin, and other drugs must also be resorted to. Convulsions must be promptly relieved by chloroform inhalations; hot saline infusions by rectum or skin, or into a vein, may be useful. APPLICATIONS OF HEAT Acute Eruptive Fevers.—Except in cases exhibiting very high fever I have seen better results from warm or hot baths (85° to ioo° F.) than from cold or cool baths in the eruptive fevers of children, and in the measles of adults. Especially in the prodromal stages, and in cases of delayed or incomplete eruption, does heat seem useful. Hot drinks are also to be given. Comegys, of Cincinnati, advocated repeated hot baths in scarla- tina, even when pvrexia was marked. When the temperature reaches or exceeds 410 C. (106° F.), however, I prefer tepid or cool ablution (8o° to 70° F ) i and in cases of persistent elevation, often make use of graduated tubbing, as in typhoid. In some instances, a tepid bath (85° to 90° F.) for four or five minutes, followed by a cold ablution (50° to 6o° F.) of the same or briefer duration, is even better. Cholera.—In that rare disease, winter cholera of temperate climates, of which I have seen one case, persistent application of heat externally, with hot irrigation of the bowel, seemed to save life. In the absence of personal experience with cholera Asiatica, I can only call attention to the fact that in place of the cold frictions and the like advocated by Dr. Bux- baurn, many authorities prefer hot infusions, hot irrigations, and a high degree of external heat applied by any available means. For example, pa- tients well wrapped in blankets have been placed in beds of ‘ setting’ lime to impart heat to the body during collapse. Unquestionably, from a theo- retic standpoint, it is preferable to excite therapeutic reaction by means of cold applications, if time permits—which means that collapse is not to be waited for. Brief hot packs or hot baths, followed by cold rubs until re- action sets in, would thus seem to combine the advantages of both methods; and, in fact, I have seen these measures in combination with hot irrigations and saline infusions do much good in cholera morbus and cholera infantum. To Prepare the Hot Wet Pack.—One of the difficulties in the employment of the hot wet pack is the wringing out of the blanket, which is of course too hot to be handled with comfort with bare hands. A useful and simple device to obviate this difficulty, and the manner of using it, are shown in the accompanying illustrations (Figs. 79 and 80). A piece of heavy crash or toweling about half a yard long and ten or twelve inches wide, is fastened at each end to a short stick—a piece of broom handle will do—after the fashion of a jack towel, and a wringer is thus obtained with which the hottest blanket can be wrung out thoroughly without danger of526 APPENDIX scalding one’s hands. A single blanket is dipped into boiling water; or perhaps a better way is to twist it up and roll it, twisted, into a large bowl or basin, then pour over it a kettleful of boiling water. The hot blanket, when wrung out, is applied directly to the patient’s skin, while it is very hot, care being of course exercised not to scald him. It is then covered with a dry blanket, and outside of that with a large rubber sheet; or the dry blanket may be omitted or placed outside the sheet. The essential thing is to make sure that the air is excluded. The patient is allowed to sweat for about twenty minutes, when the pack is removed and the body rubbed dry Fig. 79.—Placing the Hot Blanket in the Wringer. with a warm towel. I he patient should continue to lie between blankets for an hour. Additionally to the uses of the hot wet pack stated in preced- ing pages,, it may be noted that for sciatica and neuritis Baruch recommends highly a compress of several thicknesses of old blanket wrung thoroughly out of boiling water. The patient is loosely wrapped in blankets, the painful part covered with flannel, and over this is laid the steaming hot compress, which is secured by a flannel strip. The compress is to be renewed every ten min- utes until the patient perspires, when he is allowed to continue in the pack an hour. Hot-air or Vapor Bath to Induce Sweating.—A method of giv-HOT-AIR BATH IN BED 527 ing a hot-air bath in bed is shown in figure 81. The patient is stripped and laid upon a blanket or blankets with a wet compress or an ice-cap upon his head. Two large half hoops to support the coverings are placed crosswise on the bed. These should preferably be of metal; but trundle, or barrel hoops, protected by flannel wrappings, may be utilized in an emergency. An alcohol lamp on a stand or tripod, an oil lamp, or other convenient heat generator is placed at the foot of the bed, and hot air is conveyed by means of an elbow of stovepipe resting on the metal hoops and covered by a blanket and sheet. The illustration shows a long horizontal section of pipe, which is desirable but not imperative. The coverings should be well tucked in to Fig. 80.—Wringing Out the Blanket. retain the heated air and exclude cold air; leakage will always be sufficient for safe circulation. Steam may be generated in a large kettle and conveyed about the patient in a similar manner. In the Philadelphia Hospital, par- ticularly in cases of acute nephritis and of uremia, I have given the patient a hot tub-bath in water at 108° F. (420 C.) for ten to fifteen minutes, and then placed him in the hot air bath; thus inducing profuse perspiration when other means have failed. Sweating may be favored by having the patient drink a pint of hot fluid (tea, lemonade, or water) just before leaving the tub, when consciousness is preserved, or by a hot saline enema when the528 APPENDIX patient is unconscious. Often, the hot-tub bath, or even a hot mustard foot- bath, with the hot drink, and followed by a hot blanket pack with hot cans about the patient, will suffice, without the hot-air bath, to produce sweating. ‘ Simpson ’ Sweat Bath.—As practised at the Philadelphia Hospital, the patient is divested of clothes and placed between blankets, the mattress being protected with a rubber sheet. Hot-water cans or bottles are then filled with nearly boiling water and some squares of flannel or old blanket are wrung out of very hot water and wrapped around the cans. These are then placed around the patient; a single blanket being interposed between the cans and the cutaneous surface. The greatest care is necessary in the case of delirious, unconscious, or extremely restless patients to prevent the occur- rence of a burn. After twenty minutes the hot-water cans are removed, and the patient is well dried with a warm towel. Additional uses of these sweat baths to those mentioned in pre- ceding pages are, to abort a coryza, or even an attack of influenza; to Fig. 8i.—Method of Giving IIot-air Bath in Bed. render less severe an attack of acute bronchitis or bronchopneumonia, or even of lobar pneumonia, when the patient is seen early; to avert grave complications in severe cases of acute laryngitis; to relieve edematous con- ditions in the lungs or elsewhere, especially general anasarca; and to pro- mote rapid elimination in cases of metallic poisoning or of syphilis, espe- cially when late syphilitic lesions, such as cerebral gumma or optic neuritis, are treated coincidentally with large doses of mercury by inunction, by inhalation, or subcutaneously. Local Shock Baths.—Two large carriage sponges with two basins, one filled with very hot water, the other containing a lump of ice, are the appliances required. The bath consists in alternate sponging of the part with hot and cold water; it should last about twenty minutes and should terminate with a cold sponge. It stimulates and improves the nutrition, its action being similar in kind to that of a Scotch douche. The chief indica-IRRIGATION OF HOLLOW VISCERA 529 tion for a local shock bath is neuritis. It is also useful in sprains and to reduce pain and swelling in injuries about joints. In the case of the foot or ankle, the member may be placed alternately in a basin of hot water and a basin of cold water. Similarly hot and cold water may be poured from pitchers at any height desired. The Hot Alcohol Sponge.—This is invaluable in cases of insomnia, particularly when resulting from alcoholism. Equal parts of alcohol and boiling water are to be used if obtainable; if not, half the proportion of alcohol will do. The entire body is sponged for ten or fifteen minutes with a somewhat firmer stroke than is used when reduction of temperature is desired. IRRIGATION OF HOLLOW VISCERA Irrigation of the Colon.—The double-current method of irrigating the rectum and colon is said by Kemp1 to possess distinct advantages. The temperature of the solution, and its quantity as well, are readily controlled ; the fluid does not cool since fresh hot fluid is constantly taking the place of the cooler which passes out; the desire to defe- cate and the straining to overcome the resistance of the sphincter can be relieved at once by checking the inflow and allowing a freer outflow. In Fig. 82.—Kemp’s Rectal Irrigator. this way a prolonged irrigation, lasting an hour if desired, maybe given. In diarrhea continuous irrigation appears to clear out the intestinal tract more rapidly by allowing the small intestine to evacuate its contents contin- uously into the lower bowel. Tympanites is more readily relieved than by any other method, as the gas is carried off by the return flow instead of collecting behind the injection, as often happens when a single tube is used. There are several good instruments on the market. Kemp’s irrigator is made on the principle of a tube within a tube, the central tube, which is connected with the supply pipe, opening at the apex of the instrument (Fig. 82) and passing through a cap which, when screwed in position, closes the outer extremity of the outer tube. To this cap is attached the discharge pipe, opening into the outer tube, which is provided with two lateral fenes- tra. The irrigators are made of either hard or soft rubber. A simple method of improvising a double-current irrigator is as follows: Two cathe- ters, one of larger caliber than the other, are tied together for about two- thirds of their length with fine cotton or silk, so that they will adhere sufficiently to be introduced. The tip of the smaller catheter may project 1 “ Enteroclysis, Hypodermoclysis, and Infusion,” New York, 1901. IX—34530 APPENDIX one or two inches above the larger, so that the inflow will be on a higher level than the outflow, and a longer projecting portion remains externally for an outflow. The eyes of the catheters should be directed laterally outward. This improvised irrigator is passed through a perineal pad of gauze or cotton, covered with oiled silk or a piece of oil-cloth or a dress shield, and then inserted in the bowel. The pad keeps the fluid from running out of the bowel, even if there is incontinence. If only drainage-tubes are at hand, the rough edges can be trimmed off, and then, by heating over a flame and wiping quickly with a moistened finger or cloth, a smooth and rounded edge and ‘velvet eyes ’ can be obtained. The usual method of administering a colon irrigation is by means of a colon tube, which should have fairly thick walls and be as large as can con- veniently be passed, thin tubes and those of smaller caliber being apt to kink and double on themselves. I usually employ the long tubes made for siphoning the stomach-contents. It has been objected that with the ordinary colon tube, which is at most eighteen inches long, it is impossible to enter the colon. This is probably true, and the longer tube is not, as a matter of fact, made to penetrate any further than the sigmoid flexure; but even with a penetration of but seven or eight inches, with the patient on his left side or preferably in the knee-chest position, the method is clinically satisfactory in the usual run of cases. Kemp has abandoned the use of the colon tube altogether, and believes that the descending colon can be reached more easily with a five-inch irrigator provided the patient be placed in the proper position, with his hips elevated. Certain precautions should be observed before and during the introduction of either instrument. The fluid is to be allowed to flow through the tube so as to force out all the air and the flow is then checked. As the tip of the tube passes through the sphincter into the bowel, the flow is started so as to force the mucous membrane away from the irrigator and fenestra. In this way also the entrance of the tube is not interfered with by the resistance of the mucous membrane. The tube should be warmed and well lubricated, and with the tip directed toward the sacrum it is inserted with a gentle rotary movement—not forced in. In withdrawing the instrument it should be rotated slightly, first in one direction and then in the other, to prevent the mucous membrane from catching in the eyes, or to free the tube if this acci- dent has occurred. The patient may be placed in the dorsal position, or on either side, with the hips elevated and the shoulders at a lower level. In the dorsal position a douche pan or a Kelly’s pad will add to the convenience of the procedure, or a trough may be extemporized with a rubber sheet and used in any posi- tion. The most satisfactory position, however, is the knee-chest; it insures the entrance of the fluid into the colon and is not more fatiguing to the patient than any other. The chief object of intestinal irrigation is to effect a thorough cleansing of the bowel. Except in those cases in which the thermic factor enters into the question, when the character of the fluid is of secondary importance, the irrigating fluid usually employed is the clinical saline solution—a dram of sodium chlorid to each pint of water. If desired for any reason, how- ever, whether to allay irritation or to introduce an active antiseptic or sol- vent agent, the solution may be medicated. Thin soap emulsions are often used, and are to be preferred when volatile oils are to be added. Of theIRRIGATION OF THE BOWEL S3i latter, turpentine is the most common, in the proportion of a fluidram to the pint. The oils of peppermint or cinnamon are often used in the dose of 5 to 15 drops to the pint. Potassium permanganate up to 10 grains in the pint, and mercuric chlorid in the strength of 1 : 10,000, are among the antiseptic solutions commonly recommended. Formaldehyde, not exceed- ing one minim of the 40 per cent, solution to the ounce of irrigating fluid, and rarely reaching this strength, may be used on occasion. Silver nitrate solutions not, as a rule, exceeding in strength 8 grains to the pint of water may be used if there are old dysenteric ulcers; they should always be fol- lowed by saline irrigation. The quantity of fluid to be used depends alto- gether on the indications to be met in the individual case; as a rule, it should not be more than two quarts nor less than a pint. The indications for the employment of colonic irrigation are gener- ally familiar; they embrace practically all morbid conditions of the intes- tinal tract in which a thorough cleansing is desired for the purpose of re- moving irritating substances and enabling the mucous membrane to resume normal function; thus, in acute and chronic diarrhea and dysentery, in mucous enteritis, in certain cases of typhoid fever, in cholera, in certain cases of intestinal hemorrhage, and similar conditions. By utilizing the thermic element it may be employed also to combat fever, on the one hand, and to supply heat, as in cases of shock, or, locally, to allay spasm and dissipate con- gestion. According to Hyde, rectal irrigation is of distinct value as a sub- stitute for vaginal douching in young girls; in leukorrhea; in acute and chronic ovarian and tubal lesions, with the exception of pyosalpinx; in in- testinal paralysis following sepsis; after pelvic operations, to relieve abdom- inal discomfort or tympanites. Continuous irrigation for half an hour to an hour is indicated in shock and in uremia. A large quantity of fluid is employed; and from a pint to a quart maybe kept continuously in the bowel by pinching the outflow tube and regulating the inflow, and by watch- ing the quantity of fluid in the fountain syringe. The temperature of the fluid in these conditions should be between iio° and 120° F. (430 to 48° C.). If it is desired to increase renal secretion without increasing pulse-tension or temperature, fluid at ioo° to 104° F. (38° to 40° C.) should be employed. The same treatment is warmly recommended in diphtheria, and may be used in conjunction with antitoxin, providing the irrigation does not follow'too closely on the injection of antitoxin. If the irrigation is given four or five hours after the injection of antitoxin, the latter will not be eliminated before its effects are secured, and yet the renal congestion is relieved and the elimi- nation of toxins accelerated. In fecal impaction the obstructing mass is first dissolved by an enema of hot oil. The patient rests for an hour, with a hot application on the abdomen, after which the irrigation is made; and this method is continued until the obstruction disappears. Robertson, of Warren, Pennsylvania, states that crude petroleum is the best solvent of impacted feces, and this material is commonly employed by physicians in the ‘oil regions.’ Constipation in typhoid fever yields to hot oil enemas, with the least amount of distress to the patient and danger to the integrity of the bowel. In intussusception good results are reported by some author- ities, while others deny its usefulness and believe that the condition always demands surgical intervention. In any case the procedure must be employed with caution, avoiding excessive pressure and increasing the height of the fountain syringe very gradually. Congestion, acute inflammation, and532 APPENDIX chronic enlargement of the prostate gland, and prostatorrhea have been treated with success by continuous rectal irrigation. Both heat and cold have been employed; the best results seemingly being obtained with pro- longed irrigation—in some cases even to an hour. Gout, lithemia, some forms of anemia, diabetes of intestinal origin, and many vague disorders dependent upon absorption of toxic material are sometimes corrected, or at least improved, by systematic cleansing of the intestinal tract. In cases of intestinal hemorrhage, as well in typhoid fever as in other conditions, it is often useful to wash the bowel with water as hot as can be borne (i io° F. or more), containing 120 grains of pure calcium chlorid to the pint. Only when hot water fails to do good should ice-water be substituted. After the cleansing, a suppository of opium and belladonna should be inserted. Gastric Lavage.—In the original and simplest apparatus, an esophageal tube of flexible rubber, about 28 inches long, with blunt double-eyed ex- tremity, and from one-fourth of an inch to a little less than half an inch in diameter,—practically an enlarged catheter and made of similar material,— is attached by a small section of glass tubing to a soft rubber tube of about one yard in length, in the free extremity of which a glass or rubber funnel of from six to eight ounces capacity is inserted. Long rubber tubes with funnel attached, some having a bulb in their course to facilitate siphonage, and tubes with single lateral eyes, with multiple small perforations, and with a single central opening are now furnished, and each form has its advocates. The patient sits or stands, facing the physician. The esophageal tube, having been dipped into warm water or warm milk, is placed within the entrance of the esophagus and is then propelled by successive steps into the stomach; the process being facilitated by efforts at deglutition on the part of the patient. Many patients learn to introduce and swallow the tube without assistance. A mark on the tube shows when a sufficient length has been introduced; say, eighteen or nineteen inches. The funnel is then elevated to the level of the patient’s forehead, ami from a pint to a quart or more of the lavage solution is slowly poured in ; the glass junction-tube permitting its passage to be watched, and obstruction or attempted regurgitation to be detected. The patient’s sensations will indicate when a sufficient quantity of the solu- tion has entered the stomach. As the last portion of the liquid is disap- pearing from the funnel, the soft rubber tube is pinched near the junction with the funnel, the latter is rapidly inverted over a receptacle placed on the floor, and the contents of the stomach are thus removed by siphonage. This is repeated until the fluid returns clear. The first introduction of the tube, and possibly the second, will occasion dyspnea, often nausea and retching, rarely vomiting. These effects, though partly physical, are chiefly psychic, and will disappear with tolerance; the dyspnea may quickly be checked by insisting on full inspirations. Nausea is overcome as soon as the fluid enters the stomach, floating the tube away from immediate contact with the mucous membrane. In highly neu- rotic subjects it may be well to prepare for the operation at first by adminis- tering full doses of bromids. In rare cases a local anesthetic must be used. Sometimes during the withdrawal of the solution solid particles of food may become impacted in the eyes of the tube and the flow of liquid will cease. A little more fluid must then be introduced, both to wash away the obstruction and to reestablish the siphon current. If the tube is pushed tooGASTRIC LAVAGE 533 far into the cavity of the stomach, it may curve upon itself and the siphon will not work. Withdrawal of the tube for a few inches will remedy this. When lavation alone is the object of the procedure, a weak alkaline or saline solution is employed; a dram of sodium sulphate, sodium chlorid, sodium borate, or sodium bicarbonate in each pint of water at about ioo° F. (37.5° C.). Should it be considered necessary, however, various sedative or antiseptic medicaments may be added to the lavage solution. Among those recommended are resorcin (one per cent.), boric acid (one per cent.), creosote (one per cent.), carbon bisulphid (one part of a solution contain- ing fifteen grains to the quart, to two parts of water), charcoal powder (two to four tablespoonfuls), chloroform water (saturated), bismuth subnitrate (two tablespoonfuls to the pint— Dujardin-Beaumetz’s 'milk of bismuth ’). Lavage should be performed when the stomach is practically empty, and for that reason many prefer the hour of rising in the morning. Late in the afternoon is sometimes more convenient. In an ordinary case lavage should be done every day or every other day for about two weeks, after which the intervals between successive washings may be lengthened, and finally the process entirely omitted. When for any reason lavage cannot be carried Fig. 83.—Hemmeter’s Improved Recurrent Stomach-tube. out, the slow sipping of a pint of hot water one hour before meals (or before breakfast or dinner only) will sometimes prove an efficient substitute. Sodium phosphate may be added to the water if necessary. Stomach douches and various appliances for irrigating and spraying the stomach, utilizing stationary reservoirs of glass and rubber and various sys- tems of valves and stop-cocks, have been devised. These are, as a rule, more elegant, more accurate, and more convenient than the original method. A good form of recurrent stomach-tube is illustrated in the accompany- ing cut (Fig. 83). The tube and tunnel are, however, sufficient for practical purposes and have the advantage of simplicity, the necessary technic being acquired readily. Lavage may be employed to empty the stomach in cases of poisoning, or of obstinate vomiting, or when the stomach cannot empty itself into the duodenum. It is most useful in cases of dilatation of the stomach, in which delayed digestion, with retention and fermentation of the534 APPENDIX contents of the viscus, gives rise to distressing symptoms. It is applicable in all pronounced catarrhal conditions | in some cases of gastralgia; in can- cer of the stomach, as a palliative; and in the chronic gastritis of drunk- ards, even if there be some hematemesis. It is indispensable in hyperchlor- hydria. In actual ulceration of the stomach it is usually counterindicated, though in some cases, used with caution, it is of service in removing clots and facilitating healing. Lavage has been successfully employed in the treatment of ileus. This result is explained by Kussmaul on the theory of relief to the tension above the point of constriction, caused by gases and accumu- lated feces; with concomitant restoration of normal peristaltic action. It should always be employed as a preliminary to surgical operation in cases of intestinal obstruction, in which category strangulated hernia is to be included, for, in its absence, the vomiting sometimes induced by ether may turn the balance against recovery. Gavage, or forced feeding, is the utilization of the stomach-tube and funnel for the introduction of liquid food. As much as a quart at a time may often be introduced. Milk, previously peptonized if necessary, and of course heated, is the basis of the nutritive mixtures employed. To this may be added meat-powders, eggs, or farinaceous powders. It is especially applicable as a method of superalimentation in tuberculosis, but is also em- ployed in other wasting diseases, with insane patients who refuse food, and when swallowing is difficult or painful. It may usefully follow lavage. Irrigation of the Bladder.—A number of two-way catheters are to be found in the shops. In the ordinary method with a fountain syringe or funnel and a single-current soft rubber catheter, the connection between the syringe and the catheter should be made by means of a Y piece to pro- vide a separate channel for the outflow. The irrigating fluid should be in- troduced in small quantities and under rigid aseptic precautions, the blad- der having been emptied previously. But little force should be used and the water should be allowed to flow out immediately, without, however, pressing on the viscus so as to avoid the irritation produced by forcible con- traction of the bladder upon itself. A convenient device for irrigating either the urethra or the bladder is that of Dagget. The instrument, which is Y-shaped, is first introduced into the urethra and then connected with the tube from the syringe, the outlet being stopped with the finger. The fluid gradually distends the urethra and finally enters the bladder; as soon as the latter is filled the supply pipe is compressed with the fingers and the fluid is allowed to escape. The use of this instrument obviates the danger of ure- thral fever, which is likely to develop when catheterization has to be prac- tised daily. In addition to cystitis the conditions in which irrigation of the bladder is indicated are atony of the bladder and paralysis of the bladder associated with paraplegia, locomotor ataxia, and other nervous diseases. Very hot irrigation, ii8° to 1220 F. (47.70 to 50° C.), is useful to control hemor- rhage from the bladder, a cold application being made to the abdomen at the same time. Vaginal Irrigation.—A fountain syringe, a rubber tube, and a glass or hard-rubber nozle are the instruments required. The ‘ household syringes 1 now obtainable in all shops are supplied with various forms ofIRRIGATION OF THE UTERUS 535 nozles, of which the rather large grooved cylinder with lateral perforations is to be preferred, except in the comparatively trivial ailments of the un- married. The woman lies on her back with the hips elevated and the but- tocks supported on a rubber (Kelly) sheet-pad or douche-pan to catch the return flow. The nozle of the syringe should be introduced behind the cervix, to avoid injecting the fluid into the uterine cavity. The value of vaginal irrigation as a cleansing procedure', with or without the use of anti- septic or astringent drugs, need not be enlarged upon ; and its general use- fulness in gynecologic practice has already been alluded to in the text and in the article on irrigation of the colon. Hot irrigation lessens uterine excit- ability and contractility ; cold irrigation has the opposite effect and aggra- vates neuralgic and other pelvic pain ; it is therefore very little used. Hot irrigation is employed to relieve pain and to promote the absorption of exu- dates; it is useful, also, in chronic metritis and endometritis, and in ovarian and tubal disease. I have observed persistent hot douching bring about recovery in cases of nonsuppurative inflammation in and about the uterine appendages, even after it had seemed best to discuss with a gynecologic sur- geon the propriety of operation. Very hot irrigation of the vagina is use- ful in cases of menorrhagia and in certain other forms of hemorrhage in which surgical intervention or packing is not required. Calcium chlorid may be added to the water, which must be as hot as can be borne, even so high in temperature as 1250 or 130° F. (say, 51.50 to 54.50 C.). If the application is continued too long, paralytic phenomena with venous con- gestion of the uterus are induced. Prolonged hot irrigation is thus useful in the first stage of labor to dilate the cervix and relax the perineal muscles. Pregnancy is not a counterindication to the employment of vaginal irriga- tion, provided the application is made with due care. Vaginal douches be- fore and after parturition are used under certain circumstances concerning which all obstetricians are not agreed. Intrauterine Irrigation.—Double-current or irrigating sounds have been devised by Kellogg and others for intrauterine irrigation. The rate at which the water flows through the instruments is readily regulated by com- pressing the outflow tube; and by allowing the water at the outlet to fall on a thermometer, the temperature may be kept under constant observation and regulated at will. The necessary aseptic precautions must always be observed strictly. The fluid employed in this, as in most other forms of irrigation, is the clinical salt solution, which is less irritating to mucous membranes than pure water. If desired, the fluid may also be medicated with various anti- septic and other substances—mercury bichlorid, boric acid, and potassium permanganate, in suitable strengths, being the substances in most common use. The cavity of the uterus is irrigated in connection with curetment and other operations on the interior of that organ, and after labor when blood- clots or portions of the membranes are retained. Adrenalin chlorid (1 : 4000) and calcium chlorid (1 per cent.) might be added when a decided hemo- static effect is desired. Irrigation is also employed m catarrh of the cervix and endometritis, in subinvolution, and in conditions associated with re- laxation of the uterine muscle. Eye, Ear, and Nose.—For the sake of completeness only, cleansing and medicinal irrigations of the eye, ear, and nasal cavities may be mentioned ; but need not here be dilated upon.536 APPENDIX LOUTROTHERAPY Artificial Carbonated and 4 Nauheim ’ Baths For the carbonated bath continuous evolution of carbon dioxid gas is necessary; for the Nauheim bath this must take place in a warm brine solution. Attempts have been made to utilize liquid carbon dioxid. It is difficult to secure solution of carbon dioxid in hot water, or to heat the cold carbon dioxid solution ( Baruch, S., 80,82, 89, 118, 147, 507, 508, 515, 516, 517, 518, 523 Baruch’s douche apparatus, 89, 508; portable hospital tub, 517 Basch, 39 Bath, 379, 412, 428, 429, 450, 451, 480, 486 Bath Alum Springs, Va., 314, 346, 353, 400, 445, 456, 481, 490 Bath, bed, 518, 519; exanthemata, 373 Bath House Spring, N. Y., 360 Bath, portable, Batt’s, 518; Burr’s, 519 Baths, animal, 412 Artificial carbonated or Nauheim, 382, 536; acid sodium sulphate for, 536; administration of, 536 ; duration of, 537 ; extemporaneous genera- tion of carbonic acid gas in, 536; graduated baths, table for, 537 ; preparation of, 536 ; resist- ance exercises during course of, 537 ; strength of, 536 » Astringent, 411 Bed, in typhoid fever, 519 Bouillon, 412 Brand, in typhoid fever, 509; statistics of, 5i3 Carbon dioxid, 39, 380, 536; gas, 401 Cold friction, in typhoid fever, flexible method, 508, 510 Continuous, description of, 520; in the treat- ment of burns, 521; of skin diseases, 521; of typhoid fever, 520; technic of, 521 Elbow, 71; indications for, 72 Electric ferrated, 31 Electric light, 54, 118, 227, 232 Electrothermic, 93 Foot, 71; indications for, 72 Full, cold, 70; counterindications to, 70; indi- cations for, 70 Gas, 401. See under Baths, Mineral. General, 59, 61 Graduated, antipyretic, after Ziemssen, 68 Half, 61; counterindications to, 69; duration of, 62; frequency of, in fevers, 66; indications for, 64; manipulation in, 64; methods and uses of, 62, 63 ; temperature of, 64 Hand, 71 ; indications for, 72 Head, 71; indications for, 72 High, 61; as a sedative, 61 Hip, 73. See Sitzbaths. Hot, in the eruptive fevers, 525 HOT AIR> general, 118, 267, 526; description of, 267 ; duration of, 269 ; indications for, 271; preparation of, 527; technic of, 269, 527 ; tem- perature of, 269 ; local, 271; apparatus for, 272, 273 ; description of, 271; effects of, 274 ; indica- tions for, 275; precautions to be observed in, 274 ; technic of, 271 ; temperature of, 274 LIGHT, 49, 124; electric, 54, 118, 227, 232; arc, 227; after-treatment with, 230; counterin- dications to, 230 ; description of, 227 ; duration of, 230 ; indications for, 230; physiologic effects of, 229; technic of, 227; incandescent, 232 ; after-treatment with, 238; cabinets for, 232; duration of, 234 ; hygienic value of, 240 ; indica- tions for, 238; modes of employment of, 237; physiologic effects of, 235; on "body-tempera- ture, 236; on the blood, 237 ; on carbon dioxid elimination, 2365011 perspiration, 236; on the skin, 235; on the superficial blood-vessels, 235 ! portable apparatus for, 233; technic of, 233 ; temperature of, 234; therapeutic effects of, 237. Sun, 49, 214; effects of, 51, 219; thera- peutic experience with, 53, 221. See also Helio- therapy ; and Baths, Sun. Medicated, 410; aromatic, 410; bran, 411; drugs and preparations used for, 410, 411, 412 ; lye, 411 ; malt, 411; mustard, 411; oil, 411; pine needle, 410; starch, 411 Mineral, 369. See special paragraph below. Occipital, 71; indications for, 72 Partial, 71 Plunge, 61 Pool, 396 ; swimming, 397 Russian, 407 Sand, 118, 124, 219 SEA, 388 Shallow, 218 Sheet, 177; drip, 80; in typhoid fever, 514 Shock, local, 528; indications for, 529; technic of, 528 Sitzbaths, 73; counterindications for, 75, 76; effects of, 74, 75 ; indications for, 75 ; varieties of, 74, 75 ; warm, effects of, on blood, 32 Steam, 31, 118, 122; in endocarditis, 183; cabinet, 31, 118; tub, 122 SUN, 49, 214 ; cold wet rub after, 217 ; combined sun bath and sand bath, 219; cooling douche after, 217 ; counterindications to, 221; duration of, 215; indications for, 53, 221; physiologic effects of, 51, 219 ; technic of, 214 ; wet sheet rub after, 218 Sweat, 118, 526, 527, 528. See under Sweat baths. Swimming, 218. Towel, in typhoid fever, 515 TURKISH, 262 ; counterindications to, 267 ; de- scription of, 262 ; indications for, 266; physio- logic effects of, 264; technic of, 263 Vapor, 526; preparation of, 527; technic of, 527 Warm, in the eruptive fevers, 525 Ziemssen graduated, 68 BATHS, MINERAL, 369; absorption in, 370; chemical stimulation in, 372 ; classification of, 375; constitution of, 369; definition of, 369; effects of, general, 369 ; on blood, 374 ; on meta- bolism, 374; electric irritation in, 373; en- dosmosis in, 371; exosmosis in, 371; gaseous in- terchange in, 372 ; mechanical irritation in, 374 ; paresthesias in, 373; thermic irritation in, 374 Acid, 380; diuretic action of, 381; effects on heart, 381; effects and uses of, 380; indications for, 381; in heart disease, 381 Acratothermal, 376; constituents of, 376;542 INDEX definition of, 376; effects and uses of, 377; localities of, 378 ; temperature of, 377 Brine, 383; action of, 384; artificial, 387, 537; definition of, 383 ; effects and uses of, 384; indi- cations for, 384; localities of, 386; mother lye in, 383; thermal brine, 385; indications for, 385 Calcium, thermal, 412; indications for, 412; localities of, 412 Carbonated, 39, 380 (see Acid baths)-, artificial, 382, 536. See Nauheim baths. Effervescing, 380, 536. See Acid baths. Ferruginous, 398, 404. See Peat baths ; Steel baths ; and Vitriol baths. Gas, dry, 401 ; composition of, 401 ; effects of, 401; indications for, 402 ; carbonic acid, 401; duration, 402; localities, 402 ; douches, local, 85,402; sulphurous, 403 ; effects of, 403; indi- cations for, 403; localities of, 403; methods of administering, 403 Gaseous steam baths, 403 Iron, 398, 400; steel, 398; composition of, 398; effects of, 398; indications for, 399; localities of, 399 ; methods of administering, 399 ; vitriol, 400 ; effects of, 400 ; indications for, 400 ; local- ities of, 400 Lime, 412. See Calcium baths. Mud, 404, 406 ; effects and uses of, 406; local- ities of, 406; sea mud baths, 406 Peat, 404 ; effects of, 404 ; indications for, 405 ; localities of, 405 ; ferruginous, 404; mineral, 404 ; saline, 404; sulphurous, 404 Soolbader, 383. See Brine baths. Spray, 409 Steam, 407; effects of, 409; indications for, 409 ; localities of, 409 ; preparation of, 407 Steel, 398. See under Iron. Sulphur, 395; auxiliaries in, 396; composition 3951 duration of, 396; effects of, 395; in- dications for, 396; localities of, 397 ; methods of administering, 396; steam sulphur baths, 397 ; sulphur vapor baths, 397 Vitriol, 400. See under Iron. Bath Springs, Colo., 379 Bath-tubs, 517; Baruch’s portable hospital, 517, 518 ; Batt’s portable, for home use, 510 ; Burr’s portable, for home use, 518 ; Haven’s Ded-bath, 519 ; Martin’s slush bath, 519 Batt, Wilmer, 519 Battaglia, 379, 428 Batt’s portable bath-tub, 519 Baumann, 431 Bayport Mineral Well, Mich., 338 B. B. Spring, Bowling Green, Mo., 335 Beacon Mountain Spring, N. J., 319 Beauty Spring, Capon Springs, W. Va., 450 Beck’s Hot Sulphur Springs, Utah, 337, 365, 386, 440 Bedsores, in fever, 136; in fever, prevention of, 133 ; in myelitis, hydrotherapy of, 169 Bedford Alum Springs, Va., 346, 356, 445, 456, 479 Bedford Chalybeate Spring, Pa., 327, 449,476, 492 Bedford Iron, Alum, and Lithia Springs, Va., 357, 476, 481, 492 Bedford Magnesia Spring, Pa., 335, 449, 451, 481, 494 Bedford Springs, Pa., 435, 449, 451, 456, 458, 470, 478, 480, 492 Bedford Sulphur Spring, Pa., 364 Bee Hive Geyser, Yellowstone, 348, 352, 355 Beissel, 395, 396 Belcher’s Artesian Well, Mo., 337, 343 Belknap Hot Medical Spring, Oregon, 338 Bellmer Springs, Calif., 362 Bellthal, 417 Bench Spring, Yellowstone, 345, 347 Beneke, 37, 381, 384, 39° Beni-Barde, 261 Bentley Springs, Md., 320 Berck-sur-mer, 460 Berkeley Springs, W. Va., 321, 356, 357, 451, 476, 490,595 Berry Hill Spring, Va., 335 Bertrich, 424, 425 Bethesda Spring, Waukesha, Wis., 320, 470 Bex, 386, 459, 498 . Bidder, 45 Bier, 127 Big Sulphur Spring, Colo., 398 Bile, secretion of, effect of alkaline acidulous waters on, 419 ; effect of alkaline-saline waters 011,423; effect of water-drinking 011,45; effect of mechanical and thermic stimulation 011, 38 Biliary calculi (see under Calculi, also Chole- lithiasis); passages, catarrhoi, alkaline acidu- lous waters in, 419 ; alkaline muriated acidulous waters in, 421; saline waters in, 423; sodium chlorid waters in, 427; diseases of, drinking- cures for, 480; hydrotherapy of, 196, 197 Bilin, 322, 419, 420, 429, 463,464, 470, 478, 481, 482, 490, 492 Binder, abdominal, 101 Binghamton Mountain Vichy Spring, N. Y., 330 Binz, 446 Birchdale Springs, N. H., 321 Birmenstorf, 434, 435 Birresborn, 417 Bismuth, milk, of, 533 Bitterquelle at Kissingen, Bavaria, 435 Bitterquellen, Ofen, 474 Bitter waters, 332, 416, 433 ; definition, 416. See under PVaters, Mineral. Black Barren Spring, Pa., 335 Black Sulphur Springs, Ark., 362 Black Sulphur Spring, Byron Hot Springs, Calif., 338, 342, 386 Black Sulphur Spring, McAlister Springs, Mo., Black Sulphur Springs, Tenn., 365 Blackwell’s White Sulphur Springs, N. C., 364 Bladder, atony of, ascending spray for, 85 ; bath- ing- and drinking-cures for, 489, 491; carbonic gas baths for, 402 ; cold sitzbaths for, 75; hydro- therapy of, 202 ; Irrigation for, 534; catarrh of, alkaline acidulous waters in, 419 ; diseases of, bathing-cures for, 491 ; drinking-cures for, 489 ; hydrotherapy of, 202 ; hemorrhage from, bathing-cures for, 491; drinking-cures for, 490 ; irrigation for, 534; hemorrhoids of, bathing- cures for, 491; drinking-cures for, 489 ; hyper- esthesia of, hydrotherapy of, 202 ; irrigation of, 534 (seealso under Irrigation)-, irritability of, bathing-cures for, 491; neuralgia of neck of, bathing-cures for, 491 ; drinking-cures for, 490; paralysis of, hydrotherapy of, 202 ; in tabes dorsalis, hydrotherapy of, 167 ; irrigation for, 534; spasm of, hydrotherapy of, 202; weakness of, bathing-cures for, 491 ; drinking- cures for, 490 ; dry gas baths for, 402 Bladon Springs, Ala., 319, 419, 420, 478, 481 Blankenberge, 460 Blanket compress, hot, 526. See under Com- presses. Blank’s Hot Sulphur Springs, Calif., 362 Blennorrhea of urethra, bathing-cures for, 491 ; drinking-cures for, 489 Blepharadenitis, chronic, bathing- and drinking- cures for, 503 Blodgett Springs, California, 319 Blood, effect of absorption of water on, 42 ; effect of alkaline acidulous waters on, 418; effect of alkaline muriated acidulous waters on, 420; effect of cold on, 33; effect of light on, 53; effect of steam cabinet bath and heating meas- ures on, 31 ; effect on, of vapors inhaled from mineral baths, 375; constitution of, effect of heat and cold on, 30; distribution of, effect of thermic and mechanical measures on, 33, 253, 257; lavage of, 293 ; pressure, effect of acrato- thermal baths on, 378; effect of brine baths on, 384; effect of carbonated baths on, 381; effect of mineral steam baths on, 408; effect of thermic and mechanical stimulation on, 28, 29; temperature, action of Irish-Roman baths on, 409INDEX 543 Blood-vessels, diseases of, partial ablution for, So (see also Arteriosclerosis) ; effect of thermic and mechanical measures on, 28, 245 ; visceral, relations of, with skin areas, 253 Blount Mineral Springs, Ala., 330, 342, 356, 357 Blue Hill Springs, Me., 321 Blue Lick Springs, Ky., 428, 429, 476, 484, 490, 502 Blue Lick Springs, Mo., 337, 338 Blue Ridge Springs, Va., 335, 352, 450 Blue Sulphur Springs, W. Va., 356, 365 Bocker, 43 Bocklet, 442, 444' 455- 459> 466, 479, 495 Bodine Spring, Eaton Rapid Springs, Mich., 327 Boeck, 295 Boiler Bath, Va., 379 Boiler Spring, Hot Springs, Va., 304, 325, 356 Bom, 87 Bones, diseases of, electric light bath in, 240 ; old exudates in, lime baths for, 412; and joints, diseases of, iodin water in, 431; sunlight in, 240 ; syphilis of, iodin water in, 431 Bonifaciusquelle, Salzschlirf, 429, 46s, 492 Bonisson, 42 Boothbay Medicinal Spring, Me., 363 Borland Mineral Well, W. Va., 328, 342 Bormio, 379, 412 Borszek, 449, 490 Boudoneau, 417 Bouillon baths, 412 Boulder Blot Springs, Mont., 330, 364 Bourbonne-les-Bains, 312, 333, 428, 429, 464, 485 Bourboule, la, 352 Bowden Lithia Springs, Ga., 329, 341, 342, 353, 430, 492 Bowel, atony of, drinking-cures for, 478; hydro- therapy of, 147,194, 195 ; irrigation of, 529. See Intestine. Bowling Green, Mo., 335 Brain, inflammatory states of, cold compress for, 95 ; diseases of, baths and waters counter- indicated in, 484 bathing-cures for, 485 ; drink- ing-cures for, 484 ; hydrotherapy of, 169 ; hyper- emia of, drinking-cures for, 484 ; thermotherapy of, 257, 267. See also Cerebral; Congestion; and Hyperemia. Bran baths, 411. See under Baths, Medicated. Brand, Ernst, 66, 508, 509, 512, 513 Brand (cold friction bath) treatment of typhoid fever, 509 ; advantages of, 512 ; statistics of, 513 Breeseport Springs, N. Y., 357 Breitenstein, 120 Bremont, 371 Brides-Salines, 386 Bridge-of-Alan, 428, 458 Brighton, 445, 479 Bright’s disease, sun-bath for, 221. See also Kidney ; and Nephritis. Brine baths, 383, 457, 537. See under Baths, Mineral. Brines, 306, 332, 337, 340, 416, 426. See under Waters, Mineral. Brom-Magnesia Well, Kan., 341 Bromin Waters, 340, 430. See under Waters, Min- eral. Bromo-Hygeia Spring, Mich., 339, 343 Bronchial catarrh, drinking-cures for, 469 ; earthy waters in, 448; fan douching for, 85; heat for, 259 ; inhalations for, 469 ; sodium chlorid waters in, 427 ; sulphurous water in, 437 ; in scrofulous individuals, alkaline muriated acidulous waters in, 421. See also Bronchitis and Catarrh. Bronchiectasis, drinking-cures for, 469 Bronchitis, bathing- and drinking-cures for, 469 ; acute, hydrotherapy of, 177,523; sweat baths in, 528; arteriosclerotic, hydrotherapy of, 188; capillary, complicating measles, 139; hydro- therapy of, 177; chronic, electric light bath in, 240; hydrotherapy of, 177; of drunkards, domestic treatment of, 470 ; drinking-cures for, 470. See also Bronchial catarrh. Bronchopneumonia, chest compress in, 523 ; com- plicating measles, hydrotherapy of, 139, 177; ice-pack in, 522 ; sweat baths in, 528 Bronson Vitalis Spring, Minn., 321 Brown Wells, Miss., 346 Buda-Pest, 397, 412, 434, 435, 470, 500 Buffalo Lithia Springs, Va.,325, 326, 350, 353, 430, 492 Builth Wells, 438 Bulimia in diabetes, 150 Bum, 126, 127 Bunge, 442 Burns, circular compress for, 103; continuous bath in the treatment of, 521; hydrotherapy of, 203 ; saline infusions for, 295 Burr, A. H., 518 Burr’s portable bath, 518 Burtscheid, 397 Bussang, 417 Butterworth’s Mineral Springs, Mich., 335, 449, 480, 492 Buxbaum, B., 37, no, 525 Buxbaum, B., 131-206 Buxbaum’s modified wet pack, no Buxton, 378 Buzias, 459 Byron Hot Springs, Calif., 330, 337, 338, 342, 343, 357, 386, 403, 406, 428, 429, 480, 486, 490, 495 C Cabinets, electric light, arc, 228; incandescent, 232; electrothermic, 92; for carbonic acid gas baths, 402; for heated carbon dioxid, 126; for sulphurous gas baths, 403; hot air, Baruch’s, 118 ; Kellogg’s, 268 ; improvised, 268, 270; steam, 118; sweat, 118 Cachexia, arsenical, hydrotherapy of, 144 ; gouty, hydrotherapy of, 151 ; malarial, hydrotherapy of, 137; mercurial, splenic enlargement in, bathing-cures for, 483 ; drinking-cures for, 482 Calcareous waters, 306. See under Waters, Mineral—Alkaline ; Alkaline-saline ; Earthy ; and Saline. Calcic waters, 303, 310, 318, 319-339. See under Waters, Mineral; also Earthy. Calcium baths, thermal, 412. See under Baths, Mineral. Calcium carbonate, calculi of, 492,493. See under Calculi, Urinary. Calcium chlorid irrigations to check hemorrhage, 532 Calculi, biliary, alkaline acidulous waters for, 419; cold sodium sulphate waters for, 423; drinking-cures for, 481 ; warm alkaline-saline waters for, 423 ; warm peat cataplasms for, 482 (see also Cholelithiasis) ; renal, drinking-cures for, 491 ; earthy waters for, 448; lithia waters for, 427; urinary, drinking-cures for, 491; warm alkaline-saline waters in, 423; of calcium carbonate, 492 ; drinking-cures for, 493 ; of calcium phosphate, 492; drinking-cures for, 493 ; of oxalates, alkaline acidulous waters for, 419; drinking-cures for, 493 ; of uric acid, alkaline acidulous waters in, 419; drinking- cures for, 492 ; lithia waters for, 427 ; vesical, drinking-cures for, 491 ; earthy waters in, 448 Caledonia Springs, Ontario, 424, 459 California Geysers, Calif., 314, 335, 336, 344, 345, 346, 362 California Seltzer Spring, Calif., 320, 322, 494 Calistoga Hot Springs, Calif., 338, 340, 341, 379, 439>468,483 Calomel stool in typhoid fever, 517 Calorific rays, 209 Cambridge Springs, Pa., 458, 477 Cameron Springs, Ind., 356 Camp Springs, Ga., 321 Cancer of stomach, lavage in, 534 Cannes, 460 Canon City Mineral Springs, Colo., 428, 480 Cantoni, 282, 288544 INDEX Canstatt, 428, 429, 469, 471, 472, 478 Cape May, N. J., 460 Capon Springs, W. Va., 319, 356, 450, 466, 470, 480, 490 Capvern, 450 Carbon dioxid, absorption of, in mineral baths, 371 ; in mineral baths, stimulation of heat- nerves by, 372 ; gas baths, 401 ; production of, increased by carbonated baths, 381; - gas douche, 85, 86; local, 402; local heated, 126; indications for, 88; elimination of, effect of cold, heat, and hydrotherapy on, 25, 34; effect of light on, 51, 211, 236 ; effect of water-drinking on, 44; liquid, for artificial Nauheim bath, 536 ; solidified, application of, to produce intense cold,127 Carbonated baths, 39, 380 ; artificial, 382, 536 (see under Baths, acid); mechanical irritation of, 374 ; waters, 306, 311, 339, 355, 417, 418 ; alka- line, 418 ; iron, 317, 349,441. See under. Waters, Mineral. Carbonic acid gas baths, 401; douches, local, 402 Carbureted waters, 357. See under Waters, Mineral. Cardiac insufficiency, acid baths in, 381; hydro- therapy of, 186 ; neuroses, occipital bath for, 71, 474; weakness, in infectious diseases, hydriatric management of, 133 ; cold affusion for, 149 ; pre- cordial coil for, 97 ; in typhoid fever, precordial coil for, 135. See also under Heart disease. Cardialgia, carbonated waters in, 417; hydro- therapy of, 192, 193; in anemia, 147; Winternitz combination compress for, 101 Caries, thermal calcium or lime baths in, 412 Carlsbad, Bohemia, 311, 331, 342, 417, 424, 425, 461, 463, 464, 467, 470, 478, 479, 480, 481, 482, 489, 490, 491, 497, 502 Carlsbad Spring, Saratoga, 328 Carlsbad Sprudel salt, 425 Carroll White Sulphur Springs, Md., 363 Cascade Creek Sulphur Springs, Wyoming, 365 Cascade Springs, Tenn., 342, 360, 439 Casco Spring, Mo., 361 Castalian Mineral Springs, Cal., 328, 424, 435 Castalian Springs, Miss., 336, 364 Castle Creek Hot Springs, Ariz., 424, 471, 481, 489, 492 Castrocaro, 386 Cataplasm, warm peat, 482. See also Compresses, warm. Catarrh of bladder, chronic, bathing-cures for, 491; drinking-cures for, 489; irrigation for, 534; bronchial, mineral waters for, 469 (see also Bronchitis) ; gastric, drinking-cures for, 477 (see also Gastritis) ; gastro-intestinal, bathing-cures for, 480 ; drinking-cures for, 477 ; intestinal, drinking-cures for, 478; heat for, 259 ; hot sitzbath for, 75 ; hydrotherapy of, 194 ; irrigation for, 531; Turkish bath for, 267; laryngeal, bathing- and drinking-cures for, 469; nasal, bathing- and drinking-cures for, 503 ; nasopharyngeal, bathing- and drinking-cures for, 469 ; inhalations for, 469 ; of mucous mem- branes, alkaline muriated acidulous waters in, 421; of pelvis of kidney, bathing-cures for, 491; drinking-cures for, 489; of respiratory organs, fan douches for, 85; of tympanum, bathing- and drinking-cures for, 503 ; of uropoi- etic tract, bathing-cures for, 491 ; drinking- cures for, 490 ; of uterine cervix, irrigation for, 535. See also under Air-passages; Larynx; Stomach * Intestines, etc. Catoosa Springs (No. 4), Ga., 326, 343, 346, 363, 449, 480, 490 Cauterets, 397, 439, 465, 470, 471 Caxton Springs, Quebec, 424, 459 Cerebral anemia, hydrotherapy of, 169 ; gumma, sweat bath in, 528 ; hemorrhage, hydrotherapy of, 170; hyperemia, hydrotherapy of, 170; meningitis, hydrotherapy of, 169. See also under. Brain; Congestion; Hyperemia; and Meninges. Cervix, uterine, catarrh of, intrauterine irrigation for, 535 Chalk Creek Hot Springs, Colo., 379, 444 Chalybeate Springs, Ga., 326 Chalybeate Spring, Bedford, Pa., 327 Chalybeate Spring, Estill Springs, Ky., 449, 480 Chalybeate Spring (No. 3), Stribling Springs, Va., 321 Chalybeate Spring, Roanoke Red Sulphur ' Springs, Va., 321 Chalybeate Spring, Sharon Springs, N. Y., 336, 480 Chalybeate waters, 308, 310, 317, 318, 320, 321, 326, 330, 336, 339, 349, 416, 44»• See under Waters, Mineral; also Iron; Steel; arid Vit- riol. Chameleon Springs, Ky., 363 Champion Spouting Spring, Saratoga Springs, N. Y., 32S, 342, 354, 430, 432 Chapman, 112 Charcot, 211 Charleston Artesian Well, S. C., 328 Charlottenbrunnen, 472 Charrin, 247, 265 Chateldon, 417 Chattolanee Springs, Md., 319 Cheltenham, 435, 456 Chemical effects of water, 39; rays of light, 50, 209; bactericidal properties of, 52, 55, 213; effects of, 52, 53, 209, 211; proportionate distri- bution of, 213; stimulation of skin in mineral baths, 372 Cherokee Magnetic Spring, Iowa, 321 Cherry Valley Spring, N. Y., 325, 360, 449, 480, 492 . . , . Chest compress in pneumonia, 523; stimulating, 523. See under Compresses. Chianciano, 450 Chick’s Springs, S. C., 336 Children, bronchopneumonia of, - chest com- press, 523 ; cool affusions, 523 ; tepid bath, 523 ; following measles, hydrotherapy of, 139 ; fevers of, applications of moderate temperature in, 138; collapse readily induced by too low tem- perature, 138; hot baths in, 525; Summer diarrhea of, saline infusion for, 292 Chippewa Spring, Wis., 319 Chittenango Cave Springs, N. Y., 490 Chittenango Magnesia Sulphur Spring, N. Y., 439 > 449 Chittenango Magnesic Spring, N. Y., 360 Chittenango Springs, N. Y., 480 Chittenango Sulphur Springs, N. Y., 439,449, 480, 490, 492 Chittenango White Sulphur Spring, N. Y., 326 Chlorosis, arsenical iron waters in, 446; bathing- and drinking-cures for, 456, 474 ; causes of, 145; coldness of the feet in, 147; electric light baths for, 239; heliotherapy for, 54, 221; hy- drotherapy of, i44 ; iron waters in, 442 ; mineral steam baths for, 408 ; phototherapy of, 54, 221, 239; sand bath for, 125 ; steam bath for, 122; steel baths for, 399 ; sun bath for, 221; sweating- cures for, 147 ; Turkish bath for, 226 Chlorotics, care in giving combined sun and sand bath to, 219 Cholelithiasis, alkaline-saline mineral waters for, 423 ; hydrotherapy for, 197 ; drinking-cures for, 419, 421, 423, 481 ; bathing-cures for, 482. See Biliary passages ; and Calculi, Biliary. Cholera, colonic irrigation in, 531 Asiatic, 137; abdominal binder in treatment of, 137, 138; cold rub in treatment of, 137, 138; cramps in, hydrotherapy of, 137; diarrhea in, hydrotherapy of, 137; external use of heat in, 525 ; half baths, cool, in, 137 ; hot baths in, 525 ; hot colonic irrigation, 525; hot pack in, 525; hydrotherapy of, 137; lime bed in treatment of, 525 I prophylaxis of, 137 ; rain bath, cold, in treatment of, 137 ; saline infusion in treatment of, 292, 525; sitzbath, cold, in treatment of, 137j i381 vomiting in, 137INDEX 545 Infantum, hot baths in treatment of, 525 ; hot colonic irrigation in treatment of, 525 ; hot pack in treatment of, 525; saline infusions in treat- ment of, 292, 525 Morbus, hot bath in treatment of, 525; hot colonic irrigation in treatment of, 525; hot packs in treatment of, 525; saline infusions in treatment of, 525 Nostras, hydrotherapy of, 137, 525 Winter, external use of heat in treatment of, 525 ; hot baths in treatment of, 525 ; hot colonic irrigation in treatment of, 525; hot pack in treatment of, 525 ; saline infusions in treatment of, 525 Choleriform diseases, protracted cold sitzbath for, 75 Cholmogoroff, 291 Chorea, bathing-cures for, 488 ; hydrotherapy of, 160 ; wet pack for, 109 Choroiditis, bathing- and drinking-cures for, 503 Chrome Spring, 348, 352 Chrzonszewski, 370 Church Hill Alum Springs, Va.,336, 400, 445, 456, 479 Cincinnati Artesian Well, Ohio, 338 Cincinnati Sulpho-Saline Well, Ohio, 329 Circulation, effect of carbonated baths on, 381; effect of mechanical and thermic stimulation on, 20, 23, 24, 28, 253 ; effect of medicated baths on, 410; effect of water-drinking on, 45 ; in skin, accelerated by acratothermal baths, 377 ; stimulation of, cold rub for, 80 ; torpid, fan douches for, 85 Circulatory apparatus, disorders of, balneother- apy of, 381, 473 ; cold rub for, 80; crounother- apy of, 473 ; hydrotherapy of, 181 ; photother- apy in, 240 ; thermotherapy in, 183, 253 ; dis- turbances in fever, hydriatric management of, 971 133 Angina pectoris, 72, 188 Arteriosclerosis, 188, 474 Asthma, cardiac, 72, 182, 186, 188 Endocarditis, acute, 181; chronic, 181 Exophthalmic goiter, 161, 474 Heart, dilatation of, 182, 473 ; disease, chronic, 181, 381, 473, 536; disease, myopathic, 182, 474, 476 ; disease, valvular, 181,473 ; disease, dropsy in, 43, 183, 187, 240, 281; disorders, functional, 473; disorders, neurotic, 71, 474; fatty, 475; fatty and anemic, 476 ; hypertrophy of, 240, 473 ; muscle, insufficiency of, 186, 475 Hemorrhoids, 189 Pericarditis, acute, 187 ; chronic, 188 See also Cardiac ; and Heart, Diseases of. Circulatory enfeeblement, local, Scotch douche for, 82 Cirrhosis of the liver, sun baths for, 221. See Liver, Diseases of. Clarendon Springs, Vt., 319, 356, 478 Clark, 293 Clark’s Red Cross Well, Mich., 338, 459 Clark’s Riverside Mineral Springs, Mich., 337, 362,438 Clear Creek Springs, Ky., 319 .Clementine Spring, Mt. Clemens, Mich., 338 Cleopatra Spring, Mammoth Hot Springs, Calif., 348, 352 Cleveland White Sulphur Springs, N. C., 364 Clifton Springs, N. Y., 325, 357, 398, 449, 451, 480 Climacteric period, bathing during, 496. See Menopause. Clinical saline solution, 530 Climax Springs, Mo., 343 Clinton Artesian Well, Mo., 338 Clinton Lithia Spring, Franklin Springs, N. Y., 553 Cloverdale Lithia Springs, Pa., 326, 430, 457 Clysmic Spring, Waukesha, Wis., 320, 470 Cohen, S. Solis, 48, 122, 294, 295 Cohen, S. Solis, 507-538 Cohnheim, 148 Coils, rubber, 60, 104 ; method of making, 521; IX—35 abdominal, 113; in typhoid fever, 511, 512; epigastric, 101; head, 113; in typhoid fever, 136; in cerebral hyperemia, 170; hot water, 277; ice-water, in thermic fever, 524; pre- cordial, 96, 1x3; in acute endocarditis, 185; in chronic heart disease, 182, 184; in exophthal- mic goiter, 161; in obesity, 149; in pericarditis, 187; in rheumatism, 142; in tuberculous fever, 522; in typhoid fever, 135; spinal, 112 ; in ex- ophthalmic goiter, 161; in hysterical cough, respiratory spasm, and singultus, 159 ; in mye- litis, 168; throat, 95 Colberg, 386, 459, 460 Cold affusion in cardiac weakness of infectious fevers, 139 ; in typhoid fever, 63, 134, 509 ; appli- cation of, general, 118 ; local, 127 ; applications, effects of, 18; general, 23 ; local, 22 ; secondai y, 21 ; upon the alimentary tract and glandular apparatus, 38; upon the blood, 30; upon the blood pressure, 29; upon the heart, 20, 28; upon the metabolism, 35; upon the muscular tissues, 20, 27 ; upon the kidneys, 37; upon the nervous system, 18; upon the secretions and excretions, 37 ; upon the skin, 37 ; upon the stomach, 41, 45; upon the vessels, 20, 28; therapeutic uses of, 507; bathing, in typhoid fever, 134, 508 (see under Fever, Typhoid) ; fountain, Pictet’s sulphocarbonic acid, 128; rub, 76; after sun-bath, 217; counterindica- tions to, 80; duration of, 76; effect of, 76 ; in- dications for, 80 : temperature of, 78 ; spring, Pictet’s sulphocarbonic acid, 128. See also Cooling. Cold Sulphur Springs, Anderson’s Sulphur Springs, Calif., 438 Cold Sulphur Springs, Va., 327, 361, 439 Coldness, habitual, of extremities, hand-baths and foot-baths for, 72 ; of feet in chlorosis, hy- drotherapy of, 147 Colds, thermotherapy for, 258, 528 Colemanville Mineral Springs, Va., 327, 422 Colic, hot trunk compresses for, 100 ; warm sitz- bath for, 75 ; Winternitz combination compress for, 100; biliary, 197 Collapse of typhoid, heat for, 258 ; collapse, sur- gical, heat for, 258 Columbia Springs, N. Y., 428 Columbia White Sulphur Springs, N. Y., 364 Columbia White Sulphur Springs, W. Va., 365 Columbian Spring, Saratoga Springs, N. Y., 329, 34i Coma, saline infusions in, 294 ; diabetic, hydro- therapy of, 150; saline infusions in, 295; in fever, balf-bath for, 66 Comano, 378 Comegys, 525 Commonwealth Spring, Mass., 319 Compresses, 60; actions and uses of, 94; vari- eties of, 95 ; abdominal, 101; stimulating, 101; in typhoid fever, 517; binder, 101; blanket, hot, in neuritis and sciatica, 526 ; chest, 96,523 ; hot, 98; crossbinder, 97; circular, 103; in rheumatism, 141 ; cold, indications for, 94; combination, Winternitz’s, 101, 147, 193 (see under Compresses, Winternitz); genital, 102; head, 95; heating (see Compresses, Stimulat- ing); hemorrhoidal, 102; precordial, 96; steam, 93 ; stimulating or heating, 94, 100, 278, 523 ; effect of, on blood, 32 ; indications for, 94 ; sural, 102; stimulating, 103; throat, 95, 523; trunk, 98; stimulating, 100; warm, indica- tions for, 94; wet, 90; cold, 90; cooling, 90; indications for, 94; mode of employment, 90; stimulating, 90, 91; warm, 90, 91; Winter** nitz combination, 101 ; in acute gastric ca- tarrh, 192; in anemia, 147; in cardialgia, 101, 193 ; in chronic gastric catarrh, 191 ; in eructa- tion, 101; in flatulence, 101; in gastric ulcer, 193; in nervous dyspepsia, 191; to control vomiting, 101, 193 Concretions, biliary, 481, 482 (see also under Cal- culi; Cholelithiasis ; and Gall-stones) \ urinary,546 INDEX alkaline-saline waters for, 423 ; drinking-cures for, 491 ; effect of lithia waters on, 427. See also under Calculi; Oxaluria • and Uric acid. Condillac, 417 Congestion, cold compresses for, 94; combined hot and cold applications for, 257 ; hand-baths and foot-baths for, 72 ; hypostatic, cold head compresses for, 95; involving head, cold head coil or compresses for, 95; irrigation of bowel for, 531; abdominal ana pelvic, sitzbaths for, 75; cerebral, bitter waters for, 434; douche filiforme for, 89 ; cold sitzbath for, 75 ; Turkish bath for, 267; chronic, heat for, 259; of liver, Turkish bath for, 267 ; ovarian, Turkish bath for, 267; renal, Turkish bath for, 267 ; spinal, chronic, Turkish bath for, 267; of the spleen, Turkish bath for, 267; uterine, Turkish bath for, 267; visceral, Turkish bath with local cooling for, 267 ; chronic, heat for, 259. See also under Derivation ; and Hyperemia. Congress Hall Spring, Avon Sulphur Springs, N. Y., 360, 439 Congress Spring, Saratoga Springs, N. Y., 328, 34T 354, 428, 429, 430* 432, 464 Conjunctivitis, catarrhal, chronic, bathing- and drinking-cures for, 503; palpebral, chronic, bathing- and drinking-cures for, 503 Constant Geyser, Yellowstone Park, 347, 352, 355 Constantinsquelle, Gleichenberg, 458 Constipation, bitter waters in, 434; cold sitzbath for, 75 ; drinking-cures for, 478 ; hydrotherapy of, 195; in obesity, drinking-cures for, 479 ; in typhoid fever, hot oil enemas for, 531; obsti- nate, psychrophore in, 115; with anemia, tepid sitzbath for, 75 Constitutional diseases, balneotherapy of, 455; crounotherapy of, 455 ; hydrotherapy of, 143 Constitutional disorders, steam bath for, 122 Continuous bath, 520; cold applications in ty- phoid fever, 511 Contractures, atrophy from, hydrotherapy of, 160; hysterical, hydrotherapy of, 159; of muscles and ligaments, bathing-cures for, 501 Contrexeville, 311, 331, 449, 451, 490 Convalescence, bathing- and drinking-cures in, 455; protracted, from febrile and infectious diseases, acratothermal baths in, 377 Convulsions, hydrotherapy of, 143 Cooks Springs, Calif., 321 Cooling after applications of heat, 121, 122, 127, 261, 269, 271, 278 ; douche for, 84, 264; after sun- baths and electric light baths, 217, 235, 241; and heating, general, effects of, 23; local, effects of, 22; before application of heat, 60, 369; during acratothermal bath, 372; sweat bath, 121, 122; Turkish bath, 264; effects of, upon heat regulation, 25; on special tissues and organs, 27; local, with Turkish bath, to re- lieve visceral congestion, 267 Cooper’s Well, Miss., 356 Coprostasis, 474; drinking-cures for, 481 Coral Spring, Yellowstone, 347 Cord, spinal, diseases of, bathing- and drinking- cures for, 487 ; hydrotherapy of, 167 ; functional disorders, 487 ; meningitis, chronic, 487 ; mye- litis, 167 ; tabes dorsalis, 167, 487 Coronado Springs, Calif., 329, 392, 466, 480, 483 Correlated vascular areas, 253 Corry Artesian Mineral Well, Pa., 319 Coryza, sweat baths for, 122, 528; chronic, stim- ulating compress for, 95 Cotton poultice, 278 Council Spring, Montesano Springs, Mo., 343, 360 Crab Orchard Springs, Ky., 335, 435,479, 480,484, 489, 490, 494 Cramp, warm applications for, 94, 245; hyster- ical, spinal coil for, 159; Winternitz combina- tion compress for, 101 Cransac, 449 . Cranty, 460 Cresson Springs, Pa., 328, 336, 351, 443, 444, 459, 466, 480, 497 Crisp Springs, Tenn., 360 Crocker Springs, Tenn., 325, 362, 439 Crockett Arsenic Lithia Springs, Va., 327, 352, 430, 447, 464 Crook, J. K., 301, 317 Crossbinder, 97 ; action of, in pulmonary tubercu- losis, 175 ; effects and uses of, 98 CJEtOUNOTHERAPY, 299; principles of, 414; Special, 455 Crum Mineral Springs, Ohio, 321 Crystal Spring, Mo., 336 Crystal Spring, Saratoga Springs, N. Y., 354, 430 Cudowa, 400, 443, 444, 456, 472, 474, 486, 487, 495 Cullum’s Sulphur Spring, Ala., 361, 438 Cumberland Mineral Spring, 111., 328 Currie, 508 Cushing, Harvey, 279-296 Cutaneous affections characterized by torpor, dry gas baths for, 402 ; hydrotherapy of, 202 ; treatment of, by sulphur baths, 396 (see Skin diseases); debility, vitriol baths in, 400; nerves, stimulation of, by acratothermal baths, 377 ; re- flex areas, 253; syphilis, iodin waters in, 431 ; stimulation in mineral baths, 372; vascular areas correlated with viscera, 253 Cuyahoga Bitter Water Spring, Ohio, 353 Cuyahoga Lithia and Magnesia Springs, Ohio, 335 Cuyahoga Lithia Well, Ohio, 335^337, 353 Cystitis, hydrotherapy of, 204; irrigation of blad- der for, 534 D Daggers Springs, Va., 430 Dagget’s urethral and vesical irrigator, 534 Dalby Springs, Tex., 337 Danberry, 299 Daniel’s Spring, Ga., 336 Dardanelle Sulphur Springs, Ark., 362 Darkau, 460 Daruvar, 500 Dastre, 293 Dax, 379 Daxenberger, 54 Debilitated patients, carbon dioxid douches for, 86 Debility, acratothermal baths in, 377; following acute disease, acid baths in, 381 ; half-bath for, 66; steel baths in, 399 ; sun and sand baths for, 221; sexual, genital compress for, 102 ; run- ning irrigation of the back for, 85 Deep Rock Spring, N. Y., 338 Deer Lick Spring, Glen Springs, N. Y., 342, 497 Deer Lick Springs, N. Y.,432 De Fontaine, 227 Degeneration, myocardial, 97, 186, 381, 466; vis- ceral, sun bath for, 221 Delirium, alcoholic, hydrotherapy of, 144 ; saline infusions for, 295; febrile, half-bath for, 66 Depression, nervous, cold sitzbaths for, 75 ; half- bath for, 66, 67; sexual, ascending spray for, 85 ; fan douches for, 85 ; scalp douches for, 89 Derivation methods, 34, 253; combined reflex and fluxion, 257 Dermatoses, inflammatory, acute, 202; chronic, 203; hydrotherapy of, 203. See also Skin dis- eases. Des Chutes Hot Springs, Oregon, 328 Devil’s Ink-pot, Yellowstone Park, 346 Devil’s Lake Sulphur Springs, N. D., 364 Devil’s Tea-Kettle, Calif., 345, 347 Diabetes, acid intoxication in, 149, 295; alkaline acidulous waters for, 419; anemia in, 463; associated with obesity, bathing-and drinking- cures for, 463; associated with obesity, hy- drotherapy of, 150; associated with obesity, steam baths for, 122; baths for, 463, 464; bulimia in, 150; cold full bath for, 70; colonic irrigation for, 532; coma in, alkaline infusion for, 295 ; coma in, hydrotherapy of, 150; drink-INDEX 547 ing-cures for, 419, 423, 462, 479; electric light baths for, 238 ; glycosuria in, 462 ; hydrotherapy of, 149; intestinal irrigation for, 532; lipo- genic, bathing- and drinking-cures for, 463; lipogenic, hydrotherapy of, 122, 150; neuralgia and neuritis in, hydrotherapy of, 150; photo- therapy of, 238 ; polyneuritis in, hydrotherapy of, 166; prolonged hot bath for, 258; pruritus in, drinking-cures for, 502 ; sea-baths for, 464 ; sun bath for, 221; thirst in, 150; Turkish bath for, 266; wet pack for, 109 Diabetics, care in giving combined sun and sand baths to, 219 Diaphoresis by acratothermal baths, 378 ; by elec- tric light baths, 124, 229, 237 ; by dry pack, in, 275 ; by hot-air bath, 526 ; by sulphur baths, 395 ; by thermotherapy, 258; by sweat baths, 118, 528 ; by wet pack, 106. See also under Perspir- ation. Diarrhea, acute, protracted cold sitzbath for, 75; bathing- and drinking-cures for, 456 ; chronic, protracted cold sitzbath for, 75; chronic, sul- phated iron waters for, 445; colonic irrigation for, 531; hydrotherapy of, 193 ; saline infusion for, 292; stercoral, hydrotherapy of, 194 ; Summer, saline infusion for, 292; in typhoid fever, management of, 517 Diathesis, alloxuric, care in giving combined sun and sand baths in, 219; electric light baths in, 238; gouty, hydrotherapy of, 151; prolonged hot bath for, 258; sun bath for, 221; Turkish bath for, 266. See also Allox uremia; Gout; Lithemia ; and Uric acid. Diathetic maladies, thermotherapy for, 258 Dieudonne, 213 Digestion, effect of .alkaline acidulous waters on, 418 ; effect of alkaline muriated acidulous wa- ters on, 420; effect of alkaline-saline waters on, 423. See also Gastric juice; and Secretion, Gastric. Digestive organs, diseases of, bathing- and drink- ing-cures for, 477 ; hydrotherapy of, 190 Digitalis, action of, in heart disease, compared with precordial coil, 184; effect on heart, from hydriatric measures, 28; prognostic use of, in conjunction with hydrotherapy, 185 Dilatation of heart, 186 (see also Heart) ; of stomach, lavage for, 533. See also Stomach. Dilators, rectal, 116; vaginal, 117 Diphtheria, colonic irrigation in, 531 ; hydro- therapy of, 140; half-oath, cool, in, 140; wet pack in, 108, 140; throat compress in, 140, 523; paralysis after, hydrotherapy of, 165 Disease, chronic, indications for the treatment of individual forms of, with bathing- and drink- ing-cures, 455 Dislocations, bathing-cures after, 501 Disorders, trophic, electric light for, 240; sun- light for, 240 Diuretic effect of alkaline muriated acidulous waters, 421; effect of brine baths, 384 ; effect of carbonated baths, 381 ; effect of sodium chlorid waters, 427; effect of water-drinking, 44. See also Elimination ; Excretion; and Secretion, Renal. Dixie Mineral Well, Tenn., 328 Doberan, 460 Dorotheenquelle, Carlsbad, 417 Dorton, 445 Douche, 60, 81; mode of action, 83; indications for, 84 ; apparatus, portable, 89; stationary, 89, 508; ascending, 82; carbon dioxid, 85, 86, 402; indications for, 88, 403; cold, preparation of skin for, by heat, 259; fan, 81, 82 ; filiforme, 88; horizontal, 81; jet, 81, 82; partial, 85; rain, vertical, 82; Scotch, 89, 528 (see also under Scotch)-, spray, 81; sulphurous gas, 403 ; vertical, 81; table, Baruch’s, 508; Winter- nitz’s, 89; treatment, in chronic affections, indications for, 508 ; value of, 508 Douching, hot, for inflammation of uterine ap- pendages, 535 Doxtatter’s Mineral Well, N. Y., 324 Driburg, 403, 4°6, 443, 449, 45T 455, 459, 466, 479, 487, 490, 495 Drip sheet, 80 Droitwich, 386, 428,429, 457, 458, 459 Dropsy in chronic heart disease, hydrotherapy of, 183 ; incandescent electric light bath for, 240; water-drinking in presence of, 44 Drosdorff, 172 Dry gas baths, 401 Dry pack, 60, 104, in, 276; counterindications to, 112; indications for, 112, 276; mode of action of, m ; mode of employment of, in, 276 Duerkheim, 429, 459, 495, 496 Duerrheim, 386 Duffaus Sulphur Wells, Tex., 365 Diijardin-Beaumetz, 533 Duke Bitter Well, Tex., 335 Du Mesnil, 371 Duncan Springs, Calif., 319, 322 Duodenum, chronic .catarrh of, simple sodium chlorid waters in, 427 Dupont’s Artesian Well, Ky., 432 Dvscrasic processes, steam bath for, 122 Dysentery, hydrotherapy of, 138 ; cold rub for, 138; cold sitzbath for, 75, 138; infusion for, saline, 292 ; irrigation for, colonic, 531; entero- clysis for, 138; ice suppositories for, 138 . Dysmenorrhea, carbonic acid gas baths in, 402 ; hot applications for, 205; bathing- and drink- ing-cures for, 495; hydrotherapy of, 205 ; vaginal dilatation for, 205. See also Menstrual disor- ders. Dyspepsia, alkaline acidulous waters in, 419; carbonated waters in, 417; drinking-cures for, 477 ; chronic, sun bath for, 221; Turkish bath for, 266; nervous, hydrotherapy of, 190; cold sea baths for, 390. See Catarrh, Gastric; Digestive organs, Disorders of, etc. Dyspeptics, care in giving combined sun and sand baths to, 219 Dysphagia, gavage in, 534 Dysuria, bathing-cures for, 491 E Ear, diseases of, bathing- and drinking-cures for, 503 ; irrigation of, 535 Earthy mineral waters, 306 (319 seq., 325 seq.), 416, 448. See under Waters, Mineral; also Alkaline; Alkaline-saline; Calcareous; Cal- cic; Lithia ; and Magnesic. East Clarion Spring, Pa., 449 Eastman Springs, Mich., 320, 353, 449, 490 Eaton Rapids Springs, Mich., 326 Eaton Rapids Wells, Mich., 449, 451, 490 Eaton’s White Sulphur Well, Ind., 363 Eaux Bonnes, 470, 471, 472 Eaux Chaudes, 397 Echinus Spring, Yellowstone, 347 Eclampsia, hot baths and hot pack for, 143, 206; saline infusions for, 143, 295 Eczema, saline infusions for, 295; sun baths for, 52, 221 ; acute, cold circular compresses for, 203 ; chronic, bathing- and drinking-cures for, 502 Edema of lungs, sweat bath for, 528. See under Lungs. Effervescing baths, 39, 380, 536. See also Acid baths, under Baths, Miner ail; and Baths, Car- bonated. Effusions, fluid, treatment of, by water-drinking, 43 Ejaculation, premature, psychrophore for, 114 Eilsen, 358, 406, 437, 500 Elbert Iron Springs, Colo., 444 Eldorado Springs, Mo., 326, 336, 351 Electric ferrated baths, warm, effect on composi- tion of blood, 31; irritation from mineral baths, 373. See under Baths, Mineral. Electric light baths, 49, 60, 118, 227, 232 ; effects548 INDEX of, 53, 124, 229, 235 ; for the purpose of diaphor- esis, 124, 229, 237; indications for, 55, 124,230, 237 ; therapeutic experiences with, 54, 230, 238. See also Baths; Light, Electric; and Photo- therapy. ELECTEOPHOTOTHEEAPY, 226. See also Baths ; Light, Electric ; and Phototherapy. Electrothermic cabinet, Lindemann’s, 92, 126 (see also under Cabinet)-, compress, 91. See also under Compresses. Elimination, effect of alkaline acidulous waters on, 418; effect of brine baths on, 384; efEect of cold sea baths on, 390; effect of Irish-Roman baths on, 409; effect of medicated baths on, 410; effect of mineral steam baths on, 408; effect of water-drinking on, 44, 45; effect of light on, 210, 211, 236, 238; effect of thermic influences on, 21, 36, 37, 250, 258; of metal- lic poisons, by hydrotherapy, 143; by mineral baths, 378, 396; by sweat bath, 528; by wet pack, 109. See also Excretion. Elisenquelle, Kreuznach, 458 Elizabethbrunnen at Homburg, 429, 457, 479, 494 Elliott’s Well, Mo., 360 Ehnen, 386, 459, 496 Eloepatak, 490 El Paso de Robles (Calif:) Hot Spring, 356, 438, 440, 468; Sulphur Springs, 328, 360, 406 Elster, 400, 406, 424, 425, 429, 443,444,455,456, 462, 465, 473, 474, 477, 479, 480, 481, 482, 485, 486, 487, 489, 490,494, 495, 497, 500 Emmenagogue action of fan douche, 85; action of foot-bath, 72; action of warm sitzbath, 75. See also Amenorrhea; and Menstrual disor- ders. Emphysema, pulmonary, bathing- and drinking- cures for, 471 Empire Spring, Saratoga prings, N. Y., 329, 342, 354, 430 Ems, 312, 331, 421, 422, 429, 458, 463, 464, 469, 471, 472, 477, 479, 480, 481, 482, 489, 490, 492, 494, 500 Endocarditis, acute and chronic, 181; acute, 185 ; gymnastic exercises during convalescence from, 185; partial ablutions and partial rubs for, 185, 186 ; precordial coil for, 97,185 ; rest in, 185; chronic, 181; compensatory hypertrophy in, measures to favor the development of, 181; diaphoretic procedures in, 183 ; dropsy in, 183 ; circular compresses for, 183; partial ablutions for, 183; precordial coil for, 97, 183; nutrition in, measures to increase, 182; respiration in, deepening of, 182 ; stimulation of heart in, 182 ; by general applications, 182 ; by local measures, 182; vascular resistance in, reduction of, 182 ; Winternitz steam tub bath in, 183. See also Heart disease. Endometritis, bathing-cures for, 495; drinking- cures for, 494; hydrotherapy of, 205; intra- uterine and vaginal irrigation for, 535 ; torpid, cold sitzbaths for, 75 Endosmosis, 370 Enemas, cold water, effect of, 41; in catarrhal jaundice, 196 ; in dysentery, 138; high, technic, 530; uses of, 531 ; hot, for hemorrhage in ty- phoid fever, 531; oil, hot, for constipation in typhoid fever, 531; for fecal impaction, 531 ; petroleum, for fecal impaction, 531 Enghien, 472 Enteralgia, hydrotherapy of, 196 Enteritis, hydrotherapy of, 196 Enteritis, mucous, colonic irrigation for, 531 Enteroclysis, 281; indications, 281, 289; in catarrhal jaundice. 196; in dysentery, 138. See also under Irrigation. Enteroptosis, 146; blood changes in, 146; treat- ment of, 146 Enuresis, nocturnal, hydriatric management of, 202 ; nocturnal, psychophore for, 114 Eperies, 429, 490 Epididymitis, bathing- and drinking-cures for, 498 Epigastric coil, 101, 147. See under Coils. Epilepsy, combined method of treatment of, 160; bathing-cures for, 488 Epithelioma, sunlight locally for, 225 Epsom salt waters, 306, 332. See under Waters, Mineral. Epsom Spring, Crab Orchard Springs, Ky., 335, 435, 480 Equinox Spring, Vt., 320 Erckenbrecker’s Salt Well, Ohio, 339, 343, 351 Eructations, Winternitz combination compress for, 101; in anemia, trunk compress and hot epigastric coil for, 147 Eruptive fevers, acute, hot baths in, 525; hydro- therapy of, 138 Erysipelas, saline infusions for, 294 Esophageal stricture, saline infusions in, 292; tube, 532 Estill Spring, Ky., 325, 449, 490 Ether spray for neuralgia, 127 Ethyl chlorid spray for neuralgia, 127 Eugenquelle, Cudowa, 456 Eureka Spring, Saratoga Springs, N. Y., 329, 34i Eureka Spring, Calif., 337, 341 Exanthemata, acute infectious, 138 ; hydrother- apy of, 138, 525; bath, 373; chronic, hydro- gen sulphid gas baths in, 403 ; sulphur baths in, 396 ; vitriol baths in, 400. See Skin diseases. Excelsior Geyser, 348, 352 Excelsior Mineral Spring, Mich., 343, 386 Excelsior Spring, Saratoga Springs, N. Y., 329, 338, 341, 428, 432, 498 Excelsior Spring, Howard Springs, Calif., 328 Excitement, sexual, occipital bath for, 71 Excretion, effect of lime baths on, 412 ; effect of thermic and mechanical stimulation on, 37 ; effect of water-drinking 011,44; urinary, effect of mineral baths on, 373 Exercise, climbing, in heart disease, 475; muscu- lar, effect of, on blood count, 31 ; muscular, effect of, on heat regulation, 25, 47 ; muscular, with sun baths, 215; in treatment of obesity, 149 ; to produce reaction, 47, 60 Exercises, resistance, in heart disease, 537 Exhaustion, extreme, heat for, 258; heat, treat- ment of, 525 Exophthalmic goiter, hydrotherapy of, 161; iron waters in, 474. See Goiter. Exosmosis, 371 Expectoration, fan douches to facilitate, 85 Exudates, absorption of, fan douches for, 85; hot irrigation for, 535; incandescent electric light baths for, 237; iodin waters for, 431; Irish-Roman baths for, 409; Scotch douches for, 89; water-drinking for, 44; of old, hot trunk compresses for, 100; of old, lime baths for, 412 ; of unyielding, warm compress for, 94 ; chronic, brine baths in, 384 ; peat baths in, 405 ; gouty, rheumatic and traumatic, acratothermal baths for, 378; in muscles and joints, hot air for, 275 ; mineral steam baths for, 408 ; thermal calcium and brine baths for, 412 ; parametri- tic and perimetritic, bathing- and drinking- cures for, 494, 495; hot irrigation for, 535; pelvic, acratothermal baths for, 378; brine baths for, 384; solid, absorption of, water- drinking for, 44 ; traumatic, bathing-cures for sequelae of, 378, 501 Eye, diseases of, bathing- and drinking-cures for, 502; diseases of, subconjunctival infusion for, 296 ; irrigation of, 535 Eye Spring, Grayson Springs, Ky., 361, 438 F Fachingen, 318,419, 420, 463, 464, 470, 478, 481, 482, 490 Falk, 43 Farmville Lithia Springs, Va., 324, 327, 353, 430 Fatigue, excessive, heat for, 258INDEX 549 Fatty heart, 149, 462, 475 ; bathing-cures for, 462, 476 ; drinking-cures for, 475, 476 ; in anemic individuals, 476. See also Heart muscle, De- generation of. Faulensee-Bad, 449 Fauquier White Sulphur Springs, Va., 327, 365, 398, 445, 479 Favorite Spring, Saratoga, N. Y., 328, 343 Faywood Hot Springs, New Mex., 327 Fearless Geyser, Yellowstone Park, 348 Febrile disorders, acute, thermotherapy for, 258 Fecal impaction, 531. See under Impaction. Female genitalia, diseases of, 204, 494 ; acid baths for, 381; brine baths for, 385; peat baths for, 405 ; steel baths for, 399 Fenwick, S. W., 519, 520 Ferdinandsbrunnen, Marienbad, 456, 461, 479, 482, 494 Fernvale Springs, Tenn., 335, 360 Ferris Hot Springs, Montana, 348 Ferruginous baths, 398; peat, 404; peat baths, 405 ; waters, 308, 320, 326, 330, 334, 336, 339, 349, 441. See also under Baths, Mineral; Chaly- beate; Iron; and Waters, Mineral. Fever, ablution in, 516; cold water coils in, 522 ; colonic irrigation in, 531; genesis of, 132; gen- eral hydrotherapy of, 133, 134 ; half-bath in, 66 ; ice cradle in, 519 ; ice pack in, 516; ice rub in, 515 ; irrigation of bowel in, 531; nature of, 132 ; reduction of, 132 ; sheet bath in, 77, 515 ; spong- ing in, 516; sprinkling in, 513; towel bath in, 515; wet pack in, 108, 514; in pericarditis, hydriatric management of, 188 ; in pneumonia, hydriatric management of, 178, 523; ice cradle for, 519; ice pack for, 527; in pulmonary tuberculosis, hydriatric management of, 176; precordial coil or ice bag in, 522; puerperal, hydriatric management of, 206 Fever, cholera Asiatica,.i37 ; cholera nostras, 137 ; diphtheria, 140; dysentery, 138; endocarditis, acute, 185; malaria, 136; measles, 139, 525; pneumonia, 177, 522; rheumatism, acute artic- ular,]^; scarlet, 139, 525 ; typhoid, 134, 508, 521 Fever, typhoid, abdominal coil in, 512 ; com- press in, 517 ; ablution in, 516 ; partial in, 134 ; accessory measures in treatment of, 517; alcohol in bath treatment of, 65, 134, 509; aro- matic spirit of ammonia as a substitute for, 509 ; affusions in bath in, 509; bedsores, not a counterindication to bath treatment of, 136; Brand treatment of, 507, 508; advantages of, 512, 513 ; statistics of, 513 ; cold friction bath- ing in, 134, 508, 510; after-treatment, 67, 511; antitvphic effect of, 510; appliances, useful for, 517; applications, cold, following, 512, 516; duration of bath in, 65, 109, 110, 135, 510; editor’s method of, 510; flexible individualiz- ing method of, 510; home methods of, 518; indications for terminating bath, 510; prepara- tion of bed after, 511; repetition of bath in, 66, 67, 135,510; substitutes for, 513; suspension of bathing in, 67, 135, 513; technic of, 62, 69, 509 ; temperature of water in, 64, 509; tubes for home use in, 517; collapse of, heat for, 258; colonic irrigation in, 531; constipation in, management of, 531 ; continuous bath in, 520; counterindications for bath in, 509; diarrhea in, management of, 517; friction during bath, importance of, 509; half-bath in, 65, 66, 67, 68, 134; hemorrhage in, treatment of, 136; calcium chlorid infusion for, 532 ; irri- gation for, 531; hypostatic pneumonia in, management of, 136; ice-cradle in, 512; ice pack in, 516; ice'rub in, 515; lysis in, thera- peutic, 510; nerve stimulation in, 135, 516; number of baths in, 65, 509 ; paralysis follow- ing, hydriatric measures for, 165; precordial applications in, 134, 135; reactive powers in, determination of, 510; saline infusion in, 294; sheet-bath in, 514 ; sponging in, 516; sprink- ling in, 513; chart showing effect of, on tem- perature, 512 ; stimulants during bath, 65,134, 509 ; towel bath in, 515 ; wet pack in, 135, 514 Typhus, saline infusion in, 292 Fevers, acute, hydrotherapy of, 138 ; eruptive, hot applications in, 525; in children, baths of moderate temperature for, 138; acute infec- tious, 132 ; heat for, 258 Finsen, N., 49, 52, 55, 211, 220, 222, 223, 225, 230, 537, 538 Finsen’s apparatus, 223, 230, 537; method of applying sunlight locally, 223; of applying electric arc-light locally, 230 Flat Rock Spring, Saratoga Springs, N. ¥., 354 Flatulence, Winternitz combination compress for, ior Flechsig, 381, 399 Fleischer, 371 Fleischl, 32, 33 Flinsberg, 472, 485 Flitwick Well, 445 Floating Hospital for Children, N. Y., 461 Florida Springs, N. Y., 360 Fluid, supply of, by saline infusion, 280, 284, 292 Fluids, depletion of body, saline infusion for, 280 Fodor, 179 Foley’s Spring, Crab Orchard Springs, Ky., 435 Fomentations, warm, effect of, on composition of blood, 33. See Compress, Warm. Fonticello Lithia Spring, Va., 320 Forbes, 314 Fort Crawford Mineral Well, Wis., 329 Fort Scott Artesian Well, Kan., 363 Fountain Geyser, Yellowstone Park, 348, 352, 355 Fountain Park Magnetic Springs, Ohio, 329 Fouveau de Courmelles, 537 Fouveau-Trouve chemical radiator, 537 ; descrip- tion of, 537 ; advantages of, 538 Fractures, bathing-cures after, 501 Fraley’s electrothermic apparatus, 126 Frankfurt, 417 Franklin Artesian Well, Ballston Spa Springs, N. Y., 353, 432- Franklin Lithia Springs, N. Y., 353 Franklin Springs, N. Y., 353 Franzensbad, 311, 400, 402, 405, 424,425,442, 443, 444, 455, 456, 462, 463, 465, 466, 474, 476, 477, 478, 479, 480, 481, 482, 485, 486, 487, 489, 490, 494, 495, 497, 500 Franz Josef bitter water, Buda-Pest, 333, 435 Freiersbach, 456 French Lick Springs, Ind., 356, 362, 438 Frerichs, 481 Frey, 126, 408 Friction in half-bath, 62; necessity of, in bath treatment of typhoid fever, 509; to promote absorption in mineral baths, 371 Friedrichshall, 312, 333, 340, 434, 435, 474 Frohlich, 40 Fruitport Well, Mich., 338, 343, 356 Fubini, 51, 52 Fuerstenbrunnen, Ems, 458 Fulton Wells,.Calif-, 326, 350 Fumaroli, 437 Furunculosis, bathing- and drinking-cures for, 502 ; from excessive use of mineral baths, 373; wet pack for, 109 G Gadsden, John of, 222 Galbraith Springs, Tenn., 319 Gall-stones, drinking-cures for, 481. See Calculi, Biliary ; and Cholelithiasis. Gangrene, senile, threatened, local dry pack in, 276 Gargling, alkaline muriated acidulous waters for, 421 Gartner, 29, 85 Gas baths, 401; baths, carbon dioxid,4oi; baths, hydrogen sulphid, 403. See under Baths, Min- eral. Gas chambers for dry gas bath, 402550 INDEX Gas douches, carbonic, local, 85, 402 ; douches, hot carbonic, 86, 127; douches, sulphurous, local, 403 Gastein, 312, 379, 464, 465, 480, 485, 486, 487 Gastralgia, lavage for, 534 ; Winternitz combi- nation compress for, 101 Gastric catarrh, 101, 191, 477 (see Catarrh and Stomach); alkaline acidulous waters in, 419; al- kaline muriated acidulous waters in, 421; warm alkaline-saline waters in, 423 ; sulphated iron waters in, 445 ; table waters for, 478 ; chronic, drinking-cures for, 477; health resorts for, 478. Crises in locomotor ataxia, 168. Juice, exces- sive dilution of, by water-drinking during di- gestion, 45 ; secretion of, effect of alkaline acidu- lous waters on, 419 ; effect of alkaline muriated acidulous waters on, 420; effect of alkaline- saline waters on, 423; effect of sodium chlorid waters on, 426. Ulcer, vomiting in, treatment of, 192. See also under Ulcer and under Stomach. Gastritis, acute, hydrotherapy of, 192; chronic, heat for, 259; hydrotherapy of, 191; lavage for, 534 Gastro-intestinal affections, half-baths for, 64; catarrh, acute, stimulating trunk compress for, 100; catarrh, chronic, cold rub for, cold sitzbaths for, 75; drinking-cures for, 477; in the obese, drinking-cures for, 479; Turkish baths for, 267 Gavage, 534; in conditions of dysphagia and odynphagia, 534; in insanity, 534; in tuber- culosis, 534 Gaylord and Gulick Mineral Spring, Pa., 346 Geilnau, 470, 490 Geneva Lithia Springs, N. Y., 325, 326, 353, 430 Genitalia, diseases of, in anemic women, steel baths for, 457 ; female, diseases of, bathing- and drinking-cures for, 494; exudates affecting, iodin waters for, 431 ; hydrotherapy of, 204; male, diseases of, bathing- and drinking-cures for, 497 ; hydrotherapy of, 204 .Gentlemen’s Pleasure Bath, Hot Springs, Va., 378, 495 Geppert-Zuntz, 25 Gerolstein, 417 Gettysburg Katalysine Spring, Pa., 327, 450, 466 Geuda Springs, Kan., 338, 386 Geyser Spa, Calif., 321, 400, 417, 424, 443, 478, 479, 481,486,489,493,495 Geyser Spouting Spring, Saratoga, 430 Gevser Spring, Saratoga Springs, N. Y., 328, 342, 354 Geyser Springs, Calif., 362, 379 Geysers, Hot Sulphur Spring, Calif., 339 Geysers of California, 344; of New Zealand, 344 Giantess Geyser, Yellowstone Park, 348, 350 Gibson Mineral Well, Texas, 335, 340, 424 Giesshuebl, 419, 463, 464, 470, 478, 490 Gillen’s White Sulphur Spring, Ark., 485 Gilroy Hot Springs, Calif., 304, 328, 398, 440 Gilsland Spa, 419, 445, 456 Gland, prostate, chronic enlargement of, rectal irrigation .for, 532 Glands and vessels, lymphatic, diseases of, iodin waters in, 431; effect of thermic and mechan- ical stimulation on, 38; lymphatic, swelling of, brine baths in, 384; saline infusions in, 296 Glandular affections, cold collar for, 96 ; organs, congestion of, Turkish bath for, 267; effect of sitzbath on, 74 Glasgow Mineral Spring, Mo., 337 Glauber’s Salt Waters, 306, 332, 335, 423, 461. See under Waters, Mineral. Glaucoma, incipient, bathing- and drinking-cures for, 503 Glax, 442 Gleichenberg, 312, 421, 422, 458, 469,"471, 472, 473, 480, 481, 489, 490, 492, 494 Glen Alpine Springs, Calif., 328, 356, 422, 489 Glen Flora Spring, Illinois, 320 Glen Springs, N. Y., 319, 338, 342,403,475,483, 486, 497 Glen Springs, S. C., 336, 479, 489 Glen Summit Springs, Pa., 310, 329, 466 Glenola Springs, Virginia, 319 Glenwood Springs, Colo., 379,398, 428, 429, 440, 457, 466, 468, 478, 479, 493 Gmunden, 386, 457, 459 Goczalkowitz, 386, 459 Godbold Mineral Well, Miss., 339 Godeneff, 52, 210 Goeppingen, 417 Goiter, exophthalmic, 161 ; hyperidrosis in, hy- drotherapy of, 161 ; struma in, hydrotherapy of, 161; iodin waters in, 431; sun bath for, 221 ; tachycardia in, spinal and precordial coil and ice-bag for, 161; iron waters in, 474 ; tremor in, cold spinal coils for, 162 ; wet pack for, 109, 162 Golconda Hot Springs, Nev., 364 Goltz, 146, 279 Gonorrhea, 204; hot application for, 127; acute, hydrophore for, 117; hydrotherapy of, 204; chronic, hydrotherapy of, 204 ; bathing-cures for, 491; drinking-cures for, 490; cystitis in, hydrotherapy of, 204; hydrophore for, 117; earthy waters in, 448; prostatitis in, hydro- therapy of, 204; psychrophore for, 115; sub- acute, hydrophore for, 117 Gordon Springs, Calif., 324, 424, 480 Gout, 150, 464; acute, local hot-air bath in, 275 ; alkaline acidulous waters for, 419; ankylosis in, bathing- and drinking-cures for, 465 ; brine baths for, 384; cold full bath for, 70; colonic irrigation for, 532 ; contractures in, bathing- and drinking-cures for, 465 ; diseases of skin in, bathing- and drinking-cures for, 465 ; drink- ing-cures for, 464 ; earthy waters for, 448 ; effect of lithia waters on, 427 ; electric light baths for, 238; hydrotherapy of, 150; in the obese, 461; local applications for, 465; local effusions in, bathing- and drinking-cures for, 465; local hot- air bath for, 275; myelitis in, bathing- and drink- ing-cures for, 487; neuralgia in, bathing- and drinking-cures for, 465 ; nodes in, bathing- and drinking-cures for, 465 ; palsies in, bathing- and drinking-cures for, 465; phototherapy of, 54, 238; polyneuritis in, hydrotherapy of, 166 ; rheu- matic, sun bath for, 221; steam bath for, 122; table waters for, 464; warm alkaline-saline waters in, 423 Gouty affections, peat baths in, 405 ; sand bath for, 125 ; sulphur baths in, 396 Gouty diathesis, 221. See Alloxuria ; Lithemia ; Uric acid, etc. Gowlaun Spring, Lisdoonvarna, 438 Grado, 460 Graduation house, 385 Gran, 333, 450 Grand Haven Mineral Spring, Mich., 338, 342, 392 Grande Grille, 318, 322, 482 Granite White Sulphur Springs, Okla., 364 Graves’s disease, 161, 431, 474. See Goiter, Ex- ophthalmic; and Exophthalmic goiter. Grawitz, 125 Grayson Springs, 327, 361,438 Gray Sulphur Springs, W. Va., 356, 365 Great Bear Spring, N. Y., 320 Great Fountain Geyser, Yellowstone Park, 348, 352 Great Red Spring, Dalby Springs, Texas, 337 Greenbrier White Sulphur Springs, W. Va., 335, 356,365*451,458,480,481 Green Springs, Ohio, 326, 343, 350 Green Sulphur Springs, W. Va., 365 Griesbaeh, 485 Groedel, 384 Grotto Geyser, Y. P., 348, 355 Griitzner, 372 Guberquelle, Srebernik, 446, 447, 463, 479 Guilford Mineral Springs, Vt., 450INDEX Gumma, cerebral, Simpson sweat bath for, 528 Gunshot wounds, bathing-cures after, 501 Gurnigel, 437 Gynecology, colonic irrigation in, 531 Gypsum Spring, Detrital Valley, Ariz., 337 H Hacket’s Spring, Wis., 319 Haeberlin, 290 Hagenbach, 35 Hailey Hot Springs, Idaho, 328 Hales Red and White Sulphur Springs, Tenn'., 365 Half-bath, 62 ; after-treatment with, 67, 511; alter- nating, 69; chill in, avoidance of, 66; drinks, alcoholic in, 65; drinks, warm in, 65 ; duration of, in fevers, 65; effects of, 62; frequency of, in fevers, 66; graduated, 68; indications for, 62 ; methods and uses, 62 ; mode of application, 62 ; modifications of, 69, 70 ; repetition of, indi- cations for, in fever, 66, 67 ; suspension of, indi- cations for, in fever, 67; temperature, regula- tion of, 64; use of, for abstraction of heat, 62, 64, 69; for revulsive effect, 69; for sedation, 64, 67, 78; for stimulation, 64, 66, 67; in hygiene, 62; in infectious diseases, 64,134; in gastro- intestinal affections, 64, 193, 194,195; in nervous diseases, 64, 69, 155, 157, 158, 160,167; in typhoid fever, 65, 66, 134, 508 Hall, Upper Austria, 386, 431, 432, 458, 459, 460, 467,482,483,495,496,498 Hall in Wurtemberg, 386 Halleck’s Spring, N. Y., 357, 428, 476, 490 Hallock, Wm., 315 Hamburger, 289, 442 Hamilton Spring, Saratoga, N. Y., 329, 341 Hapsal,407 Harbin Hot Springs, Calif., 326, 330, 352, 424, 440, 447,479,481,492 Hardening process in pulmonary tuberculosis, 175 Harkany, 397 Harris Lithia Spring, S. C., 325, 353 Harrodsburg Springs, Ky., 335, 424, 435, 489, 490, 494 Harrogate, 386, 397, 428, 429, 438,443, 463,464,466, 473, 474, 476 Hart Well, Rose Hill, Willow* Island, W. Va., 328 Hartfell Spa, 445,479 Hartford Cold Spring, Me., 328 Hartford Sulphur Spring, Ind., 363 Hartsel Hot Mineral Springs, Colo., 362 Hathorn Spring, Saratoga, N. Y., 328, 342, 354, 428, 430, 432, 464 * * ‘ ‘ - Hauptquelle, Bartfeld, 456 Hauptquelle at Pyrmont,443 Haven’s bed-bath, 519 Haywood White Sulphur Springs, N. C., 364 Head, anemic states of, stimulating compress for, 95 , Head, hyperemic states of, sural compress for, 103. See also Brain; Cerebral; Congestion; and Hyperemia. Headache, sural compresses for, 103; anemic, 95,147; occipital bath for, 71. See also Hemi- crania. Head-coil, 96; method of making, 521. See also under Coils. Healing Springs, Ala., 502 Healing Springs, Va., 327, 378, 481, 486, 495, 502 Heart, action of, effect of carbonated baths on, 381; effect of heat on, 28, 245 ; effect of general and local cutaneous applications on, 23, 28 ; effect of water-drinking on, 40; effect of ther- mic stimulation on, 28, 181: weak, half-baths for, 66; weak, in infectious diseases, precordial coil for, 97; weak, in infectious fevers, hydro- therapy of, 133; weak, in measles, cold affu- sions for, 139; weak, in typhoid fever, pre- cordial coil for, 135 SSi Disease of, 181, 473 ; acid baths in, 381 ; albu- minuria in, hydrotherapy of, 187 ; baths for, 474, 475; baths, varieties of, counterindicated in, 408; carbonated baths for, 382,475,536; cervi- cal coil for, 186 ; climbing exercises for, 475 ; coil, precordial for, 97 ; cold rub for, 80; coun- .terindications to carbonated baths in, 475; counterindications to hydrotherapy in, 182; dropsy in, hydrotherapy of, 186; drops}' of, phototherapy in, 240 ; hypostatic manifestations in, hydrotherapy of, 187 ; partial ablutions for, 85; precordial coil for, 97, 186; Schott exer- cises for, 381, 536; thermal brine baths in, 385 ; Turkish bath counterindicated in, 267 ; waters counterindicated in, 473; fatty, 475; bathing- cures for, 476; drinking-cures for, 476; func- tional, bathing- and drinking-cures for, 473, 474; precordial coil for, 97 ; hypertrophy of, drinking-cures for, 473 ; phototherapy in, 240; insufficiency of, carbonated baths for, 381; hydrotherapy of, 182, 186; bathing- and drink- ing-cures for, 474; nervous disorders of, drinking-cures for, 474 ; precordial coil for, 97 ; spinal coil for, 161; wet pack for, 109 ; organic disease of, bitter waters in, 434 ; incandescent electric light bath in, 240; palpitation of, drinking-cures for, 474; valvular lesions of, acid baths in, 381, 474; coil, precordial for, 97, 186; drinking-cures for, 473; precordial coil for, 97; in rheumatism, bathing-cures for, 500 Heart, peripheral, 28, 246 Heat, applications of, 241, 253, 525 ; in the acute eruptive fevers, 525; in cholera Asiatica, 525 ; in cholera infantum, 525; in cholera morbus, 525; in cholera nostras, 525; in measles, 525 ; in scarlet fever, 525; local, 125, 271, 276 ; baking apparatus for, 118, 271; by bags, bottles, etc., 277; by compresses, 91, 93; duration of, 278; indications for, 127, 275, 276; varieties of, 126, 271, 273, 277 (see also under Baking; and Hot- air) ; physiologic effects of, general, 22, 23, 243; on abdominal viscera, 248; on blood, 31, 32, 33, 246; on blood pressure, 29; on body temperature, 247; on circulation, 23, 245; on heart, 28; on liver and spleen, 249; on metab- olism, 250; on muscles, 245; on nei'vous sys- tem, 245 ; on pain, 277 ; on renal activity, 250 ; on respiration, 247 ; on skin, 22, 23, 244 ; on ves- sels, 28, 29, 253, 257 ; reactive or secondary, 22 ; therapeutic use of, 258, 266, 271, 275, 276, 277, 507, 525. See under Thermotherapy. Heat-abstraction, 22, 28, 30, 46; ablution for, 516; effect of, on metabolism, 35, 64, 69; ice cradle for, 519; cold full bath for, 70; sprink- ling for, 513 ; half-bath for, 62 ; sheet bath for, 78,515 ; wet pack for, 107, 515. See Antipyretic ; Cooling ; and Cold Heat-exhaustion, 524; hot saline infusions for, 525 ; hot wet pack in, 525 ; treatment of, 525 Heath House Spring, N. J., 339 Heating, general, 23, 243 ; effects of, 23,243 ; local, 22, 125, 271; effects of, 22, 274 Heat-rays, 52, 259; effects of, 52 Heat-regulation, 24 ; effect of hot and cold baths on, 25; systematic exercise of, 25 Heat-restoration, 46 Hebra, 520 Hebra’s water-bed, 520. See Continuous bath, under Baths. Heidenhain, 372 Heilbrunn, 386, 431, 432, 458, 467 Heile, 211 Heiligenthal, 408 Helenenquelle, Wildungen, 490 Helicon Springs, Ga., 356 Heligoland, 391, 460 HELIOTHERAPY, 49, 209 ; fundamental prin- ciples of, 50; In acne, 221, 225; alopecia, 225; anemia, 54, 221; arthritis, rheumatoid, 222; autointoxication, 54 ; cardiac disease, 222 ; chlo- rosis, 54, 221 ; cirrhosis of liver, 221; conval- escence, 54 ; cutaneous hyperemia, 52 ; debility,5$2 INDEX congenital, 54; diabetes, 221; digestive disor- ders, 54; disorders of hemogenesis, 54; dys- crasic processes, 54; dyspepsia, chronic, 221; eczema, 52, 221; enfeebled innervation, 54; epi- thelioma, 225 ; eruptive fevers, 221; febrile dis- orders, 221; fevers, eruptive, 55, 221 ; goiter, exophthalmic, 221; gout, 54, 222; gout, rheu- matic, 221; insomnia, 222 ; lupus, 52, 225 ; lupus vulgaris, 225; myxedema, 221 ; nephritis, 221 ; neurasthenia, 221 ; neuroses, 54; obesity, 221 ; ophthalmology, 54; psoriasis, 221 ; rheumatic affections, 54, 222; rheumatoid arthritis, 222; rheumatism, chronic, 52, 221; scrofulosis, 54; skin diseases, 54; tuberculosis of joints, 221; tuberculous ulcers, 54; uric acid diathesis, 221; variola (exclusion), 55 Hemicrania, 160, 488; bathing-cures for, 488; drinking-cures for, 488 ; hydrotherapy of, 160 ; angiospastic, hot compress for, 95. See also Migraine. Hemmeter, 533 Hemoglobinuria after cold baths, 38 Hemorrhage, debility after, acid baths for, 381; saline infusion for, 279, 289, 291; from bladder, bathing-cures for, 491; drinking-cures for, 490 ; irrigation for, 534; cerebral, drinking-cures after, 485 ; hydrotherapy of, 170; internal, min- eral steam baths counterindicated, 408; intes- tinal, colonic irrigation for, 531, 532 ; hydro- therapy of, 196; pulmonary, cooling chest compress for, 96; hydriatric management of, 176 Hemorrhage, uterine, hot vaginal irrigation for, 535 Hemorrhoidal disorders, sulphurous waters m, 437; states, Atzperger’s rectal irrigator for, 116 Hemorrhoids, 189, 461 ; drinking-cures for, 478; hydrotherapy of, 189; inflamed, protracted cold sitzbaths for, 75; vesical, bathing-cures for, 491; drinking-cures for, 489 Henry, F. P., 178, 294 Heppingerbrunnen, 493 Herculesbad, 397 Heringsdorf, 460 Hernia, strangulated, gastric lavage for, 534 Herve-Mangon, 226 Herx, 126, 127 Herz, 87 Hesterquelle, Driburg, 490 Heymann, 39, 373 High bath, 61 High Island Mineral Springs, Texas, 330 High Rock Spring, Saratoga, N. Y., 304, 329, 342, 428 Highland Seltzer Spring, Calif., 321 Highland Spring, Me., 321 Hiller, 389 Holly Spring, R. I., 478 Holston Springs, Va., 450 Homburg, 312, 403, 428, 429, 457, 462, 464, 470, 473, 476, 478, 479, 480, 481, 483, 484, 489, 494 Home use, affusions for, 82, 85; carbonated baths for, 382, 536; douches for, 85; hot-air cabinet for, 268; saline baths for, 536; tubs and bed- baths for, 518, 519 Horley Green, 445 Hot air, apparatus for, 126, 272; bath, 267; after-treatment with, 269; duration, 269; indi- cations and counterindications for, 271; prepa- ration for, 269 ; temperature of, 269 ; bath cab- inet, 118, 268; domestic, 268; domestic, dan- gers of, 268; bath, local, 271 ; apparatus for, 271, 272, 273 ; duration, 274 ; effect of, 271; tem- perature, 273 ; baths, 60, 118, 267, 271, 526; in- dications for, 275 (see also under Baths) ; douche, 86, 271 Hot Borate Spring, Calif., 339 Hot Mud Springs, Calif., 406 Hot Salt Spring, Byron Spring, Calif., 343, 386 Hot Springs, Ariz., 338 Hot Springs, Ark., 304, 315, 319, 341, 378, 379, 413, 465, 468, 488, 495, 500, 502 Hot Springs, N. C., 327, 379, 465 Hot Springs, S. D., 335, 480, 481, 488, 500, 502 Hot Springs, Va., 304, 314, 320, 325, 356, 379, 458, 465, 480, 489, 500 Hot Sulphur Spring, Harbin Springs, Calif., 352 Hot Sulphur Springs, Colo., 328, 339, 352, 398, 440, 468 Hot Sulphur Springs, Canada, 398 Hot Well, Clifton (Eng.), 378 Hot wet pack in heat exhaustion, 525; prepara- tion of, 525; uses of, additional, 526. See also under Pack. Howard Springs, Ark., 353 Howard Springs, Calif., 328, 353, 356, 430 Howell, 291 Hubbardston Magnetic Spring, Mich., 321 Hudson’s Hot Springs, N. M., 477 Hueter, 33 Hughes’ Mineral Well, Ga., 336 Hunter’s Hot Springs, Mont., 319, 329, 348 Hunter’s Pulaski Alum Springs, Va., 346 Hunyadi Janos, 333, 435, 484 Hurricane Springs, Tenn., 360 Hyde, 531 Hydriatric institution, necessity for, 507 Hydrofere, bains a 1’, 409 Hydrophore, 117 Hydrotherapy, 17 ; compared with digitalis, 184; definition of, 17; effect on alimentary tract, 38; on bile secretion, 38; on blood, 30; on blood pressure, 29; on circulation, 28; on excretion, 37; on glandular apparatus, 38; on heart, 28, 133; on kidneys, 37 ; on metabolism, 35; on muscles, 27 ; on secretion, 27 ; on skin, 36; on special tissues and organs, 27; funda- mental principles of, 17 Methods of, 59, 507 ; possibilities of, in fevers, I33 j prescription in, 59, 131 Physiologic basis of, 17 Special, 131 ; considerations, preliminary, 132; Of Albuminuria in heart disease, 187; alcohol- ism, chronic, 144 ; amyotrophic lateral sclerosis, 168; anemia, 135, 144, 165; anemia, cerebral, 147, 169; anemia following hemorrhage, 147; anesthesia, hysterical, 158; angina of scarlet fever, 140; angina pectoris, 72, 188; ankylosis, rheumatic, 171 ; anorexia in pulmonary tuber- culosis, 175; arsenic poisoning, chronic, 144; arteriosclerosis, 188; arthritic mus- cular atrophy, 171 ; arthritis, chronic rheumatic, 170 ; arthritis urica, 150 ; asthma in arterioscle- rosis, 188; astasia-abasia, 158 ; atony of intes- tine, 195 ; atony of bladder, 202 ; atony of stom- ach, 191, 193 ; atrophy of muscles, 171; Bedsores in chronic myelitis, 169; bladder diseases, 202; brain and its membranes, diseases of, 169 ; bron- chial catarrh in arteriosclerosis, 188 ; bronchitis, 139 ; bronchitis, acute, 177 ; bronchitis, capillary, 139, 177; bronchitis, chronic, 177; broncho- pneumonia, 139, 522 ; burns, 203, 521; Cachexia, gouty, 151 ; cachexia, malarial, 136; cardiac insufficiency, 186; cardialgia, 147, 192; cere- bral anemia, 169; cerebral hemorrhage, 170; cerebral hyperemia, 139, 170; cerebrospinal meningitis, 169; chlorosis, 144, 165; cholelith- iasis, 197; cholera Asiatica, 137; cholera nos- tras, 137; chorea minor, 160; coldness of the feet, 147; colic, 143; coma, 135; constipation, 195; constipation in arteriosclerosis, 188; con- stipation in typhoid fever, 531 ; convulsions, 143 ; cough, hysterical, 159 ; cough in pulmonary tuberculosis, 175; cramps, 137; croup, laryngeal, 140; cystitis, 202, 204; Delirium, 66, 135, 144; dermatoses, acute inflammatory, 202; derma- toses, chronic inflammatory, 203 ; diabetes, 150, 165; diarrhea, 193; diarrhea, stercoral, 193; di- minished sexual power, 150; diphtheria, 140; digestive disturbances in arteriosclerosis, 188; dilatation of hemorrhoidal veins, 189; dilatation of stomach, 191, 193; disorders of metabolism, 147 ; dropsy in chronic heart disease, 183 ; dys-INDEX SS3 crasias, 165; dysentery, 138; dysmenorrhea, 205; dyspepsia, nervous, 190; dyspnea, 140; Eclampsia, 143, 206 ; eczema, acute, 203; endo- carditis, acute, 185; endocarditis, chronic, 182; endometritis, 205; enteralgia, nervous, 196; enteritis, acute, 196, enteritis, chronic, 196; enteritis, mucous, 196; enteroptosis, 146; enuresis, nocturnal, 202; epilepsy, 160; exan- themata, acute, infectious, 138, 525; exoph- thalmic goiter, 161; Female sexual organs, diseases, 204; fever, cerebrospinal, 169; fever in pneumonia, 178, 519; fever in pulmonary tuberculosis, 176, 522; fever, malarial, 136; fever, scarlet, 139; fever, typhoid, 134, 508; Gastric catarrh, acute, 192; gastric catarrh, chronic, 191 ; gastric crises in tabes, 168; gas- tric disturbances, 147; gastric neuroses, 143; gastric ulcer; 192; gonorrhea, acute, 204; gonor- rhea, chronic, 204; gout, 150, 170; gouty dia- thesis, 150; Heart affections in the aged, 178; heart weakness in fevers, 139 ; heart weakness in pneumonia, 178; hemicrania, 160; hemor- rhage, cerebral, 170; hemorrhage in gastric ulcer, 192; hemorrhage, intestinal, 136, 196, 531; hemorrhage, pulmonary, in pulmonary tuberculosis, 176,522; hemorrhoids, 189; hic- cough in peritonitis, 197; hyperemia, cerebral, 139,170; hyperemia of liver, 197 ; hyperemesis of regnancy, 206; hyperemia of the skin, 141; yperesthesia of bladder, 202; hyperidrosis, 203; hypostatic congestion in arteriosclerosis, 188; hypostatic congestion in acute endocar- ditis, 187; hypostatic pneumonia, 136; hysteria, 157 > hysterical contractures, 159; hysterical cough, 159; hysterical hyperesthesia, 159; hysteric paralysis, 158; Infectious diseases, acute febrile, 132 ; insomnia, 156; insomnia in arteriosclerosis, 188; irritability in neuras- thenia, 155; irritability, motor, 159; intestinal catarrh, 194; intestinal diseases, 193; intes- tinal infections, acute, 137 ; intoxications, 143; Jaundice, catarrhal, 196; jaundice due to gall- stones, 197; joints and muscles, diseases of, 170; Kidney, contracted, 201; kidney diseases, 198; Laryngeal croup, 140; leg ulcers, 203; leptomeningitis, acute cerebral, 169 ; liver and biliary passages, diseases, 197 ; Malaria, 136; malarial cachexia, 136; marasmus, 165; measles, 139, 525 ; meningeal irritation, 169; meningitis, cerebrospinal, 160; menorrhagia, 205; met- abolism, disorders of, 147 ; meteorism in peri- tonitis, 197; metritis, 205; monarthritis, 171; muscular spasm, 172; myelitis, acute, 168; my- elitis, chronic, 168 ; Nephritis, acute, 198 ; neph- ritis, chronic, 199; nephritis in infectious dis- eases, .199; nephritis, scarlatinal, 140, 199; ner- vous system, diseases of the, 152 ; neuralgia, 150, 162; neuralgia, brachial, 164; neuralgia, intercostal, 164; neuralgia, rheumatic, 163; neuralgia, trigeminal, 164; neurasthenia, 152; neuritis, 144, 150, 165; Obesity, 147; occu- pation neuroses, 162; oxaluria, 151; Paral- ysis, 143, 164; paralysis of bladder, 202; paral- ysis of. bladder and rectum in tabes, 167; paralysis from cerebral hemorrhage, 170; paralysis, hysteric, 158; paralytic sequelae of infectious diseases, 165; parametritis, 205; pericarditis, 188; pericarditis, chronic, 188; periproctitis, 189; peritonitis, acute general, 196 ; perityphlitis, 196; phosphaturia, 151; pleurisy, 179 ; pneumonia, 139, 178, 521; pneu- monia, hypostatic, 136; poisoning, chronic, 143; polyneuritis, 165; pregnancy, 205; proc- titis, 189; progressive muscular atrophy, 168; prostatitis, 204; pruritus, 203; pseudo-tabes, 144; psoriasis, 203; psychoses, 170; puerperal fever, 206 ; pyrosis, 147 ; Rheumatism, articular, acute, 141; rheumatism, articular, chronic, 170; rheumatism, muscular, acute, 172; rheu- matism, muscular, chronic, 172; rheumatic neuralgia, 163; rheumatoid arthritis, 170; Saturnism, chronic, 143; scarlatina, 139; sciatica, 164; seborrhea, 203; secretory dis- orders, 203; singultus, 159; skin diseases, 202; spasm of bladder, 202 ; spasm, muscular, 172 ; spinal cord diseases, 167 ; stasis in kidney, 202 ; stomach diseases, 109; stupor, 135; sweating in pulmonary tuberculosis, 176; syphilis, 204; Tabes dorsalis, 167; tabes, spastic, 168; tic, spasmodic, 166; tuberculosis, plumonary, 173, 176; typhoid fever, 134, 508; Ulcerative and atonic processes, 203 ; ulcer, gastric, 192 ; ulcers, leg, 203; urinary apparatus, diseases, 198; uremia, 200; Venereal diseases, 202 ; vomiting, 137, 147, 192, 197 Technic and methods of, 5p, 217, 508 Hygeia Spring, Waukesha, Wis., 320 Hygeia Spring, Yellowstone Park, 348, 352, 355 Hygienic uses of cold water, 131 ; uses of electric light, 241; uses of half-bath, 62 ; uses of sun- light, 212 ; uses of Turkish bath, 266 Hyperacidity of stomach, warm alkaline-saline waters for, 423 Hyperchlorhydria, lavage in, 534 Hyperemia, cold head-compress for, 95 ; hand- baths and foot-baths for, 72; relief of, by thermotherapy, 250, 259; relief of, by local cold and Turkish bath, 267; cerebral, bitter waters in, 434; douche filiforme for, 89; heat for, 259 ; hydrotherapy of, 170 ; Turkish bath for, 267 ; cutaneous, effects of mineral steam baths on, 408; of large glandular organs, cold sitz- batlis for, 75 ; of liver, abdominal binder for, 102; acute, hydrotherapy of, 197; local, trunk compresses for, 100 ; passive, pelvic, coldsitz- baths for, 75; pulmonary, cooling chest com- press for, 96; local processes dependent upon, cold compresses for, 94. See also under Con- gestion ; and Irritation. Hyperemic states of head, sural compress for, 103 Hyperesthesia, acratothermal baths in, 377 ; bath- ing- and drinking-cures for, 488; thermal calci- um baths in, 412; general, hydrogen sulphid gas baths in, 403; in hysteria, hydrotherapy of, 159 Hyperidrosis, general, hydrotherapy of, 203; in exophthalmic goiter, hydrotherapy of, 161 Hyperisotonic saline enemas in ascites and ana- sarca, 281 Hyperisotonicity, 286 Hyperkinesia, acratothermal baths in, 377 ; ther- mal calcium or lime baths in, 412. See also Irritability, Motor ; and Spasm. Hyperpyrexia, ice rub and ice pack for, 517 ; wet pack for, 108 ; slushing and sprinkling for, 524 ; tubbing for, 69, 517, 524 Hypertrophy, cardiac, incandescent electric light bath in, 240. See also Heart, Diseases of. Hypisotomcity, 286 Hypnotics, hydriatric, 157 ; cold sitzbaths as, 75 ; hand-baths and foot-baths as, 78 ; high baths as, 61; partial packs as, no; plunge baths as, 62; sweat compresses as, 103 ; trunk compresses as, 100; warm douches as, 85; wet packs as, 106, 157 Hypochondriasis, bathing-cures for, 488; ir- rigation of colon for, 531; Turkish bath for, 266. See also Neurasthenia, Hydrotherapy of. Hypodermoclysis, 282, 296. See Infusion, Sa- line, Subcutaneous. Hysteria, 157, 488; bathing-cures for, 488 ; high bath for, 61; hydrogen sulphid gas baths in, 403 ; hydrotherapy of, 157 ; warm douches for, 85; anesthesia in, hydrotherapy of, 158; con- tractures in, hydrotherapy of, 159; hyperesthe- sia in, hydrotherapy of, 159; motor irritability in, hydrotherapy ol, 159; pain in, hydrother- apy of, 159; paralysis in, hydrotherapy of, 158; saline infusions for, 295554 INDEX I Ice bags, 95, 112 ; Chapman’s, 112 ; in pneumonia, 522; in thermic fever, 524; in tuberculosis, fever of, 521; collars, 60 ; cradle, 519 ; hoops as home frames for, 520 ; in pneumonia, 520, 522 ; in thermic fever, 524; in typhoid fever, 512; ironing, 514 ; pack, 516; in pneumonia, 516, 522 ; in thermic fever, 516, 525 ; in typhoid fever, 516; rub, 514,515; in thermic fever, 524; sup- positories, in dysentery, 138; water coils, in thermic fever, 524; water enemas, in thermic fever,- 525 Ichthyosis, wet pack for, 109 Idaho Hot Springs, Colo., 324, 424, 435, 451, 477 Idan-Ha Spring, Idaho, 320, 322, 353, 419, 420, 449 Ileus, lavage for, 534 Ilidze, 397 Imnau, 443, 444, 455, 459, 466 Impaction, fecal, colonic irrigation in, 531; oil enema in, 531; petroleum enema in, 531 ; treat- ment of, 531 Imperial Spring, Saratoga, N. Y., 329 Impetigo, bathing- and drinking-cures for, 502 Impotence, bathing- and drinking-cures for, 497 ; cold sitzbath for, 75; nervous, carbonic acid baths in, 402 ; psychic, ascending spray for, 85 ; psychrophore for, 114 Incontinence, fecal, cold sitzbaths for, 75 Indian Medical Spring, Minn., 319 Indian Spring, Calif., 379 Indian Springs, Indiana, 327, 356, 363 Infection, intestinal, colonic irrigation for, 532; saline infusion for, 292 Infections, surgical or traumatic, saline infusion in, 294 Infectious diseases, acute febrile, 131, 132, 293; cardiac weakness of, precordial coil for, 97 ; cardiac weakness of, half-bath for, 66 (see also Heart-action, Weak) ; saline infusion for, 280, 293 Infiltrates, warm compress for, 94 Inflammation, absorption and elimination of solid products of, water-drinking for, 44 ; cold compress for, 94; of uterine appendages, hot douching for, 535; rectal irrigation for, 531; thermotherapy of, 250-258; chronic, of pelvic viscera, heat for, 254, 259; thermotherapy of, 250, 258; residua of, acratothennal baths for, 378 Inflammatory disease of the bones, application of concentrated electric light rays for, 240; sunlight for, 240; processes, bitter waters in, 434; brine baths in, 384; elbow baths for, 71; acute, Atzperger rectal irrigator for, 116; protracted cold sitzbath for, 75; tepid sitzbath for, 75; chronic, Atzperger rectal irrigator for, 116; stimulating compress for, 96; tepid sitz- bath for, 75; insidious, trunk compresses for, 100 Influenza, sweat baths in, 528 Infusion, saline, 279 ; hot, in heat exhaustion, 525 ; indications for, 280 ; methods of administration of, 280 ; solutions for, 287 ; special indications for, 289; intra-arterial, 287; intravenous, 285; dangers of, 286; indications for, 286; technic of, 285; peritoneal, 284; indications for, 284; subconjunctival, 296; subcutane- ous, 282 ; apparatus for, 282 ; precautions in, 282 ; sites for, 283 ; technic of, 283 INFUSION THERAPY, 279 ; in Alcoholism, 295 ; in anasarca, 281; in anemia, acute primary, 289 ; in anuria, 282 ; in ascites, 281; in autointoxi- cations, 294, 295 ; in Cholera, 292, 525 ; in Diar- rhea, profuse, 292; in diarrhea, summer, 292; in diseases of the eye, 296 ; in dysentery, 292 ; in dysentery, amebic, 281; in Eczema, 295; in erysipelas, 294; in Fever, scarlet, 140; in fever, thermic, 293 ; in fever, typhoid, 293, 517 ; in Glandular swellings, 296; in Heat exhaus- tion, 525; in hemorrhage, 289; in hemorrhage from uterine tumors, 290; in hysteria, 295; in Infections, surgical, 294 ; in infectious diseases, 280, 293, 294 ; in intoxications, 280, 282, 293, 295 ; in Mania, 295 ; in meat intoxication, 295 ; in mercurialism, 295; in mycosis fungoides, 295; in Nausea, postoperative, 293; in nephritis, chronic, 294; in neurasthenia, 295; in Pneu- monia, 294 ; in poisoning, 280, 295 ; in poisoning with carbolic acid, 295 ; with carbon dioxid, 295 ; with carbon monoxid, 295; with chloral, 295 ; with chloroform, 295; with illuminating gas, 295; with iodoform, 295; with morphia, 295; with phosphorus, 295; with strychnin, 295; in psychoses, 295 ; in Sepsis, 294; in septicemias, 280, 282 ; in shock, traumatic, 291 ; in shock with hemorrhage, 282, 290, 291; in stricture, esopha- geal, 292 ; in stricture, pyloric, 292 ; in syphilis, malignant, 295; in Tetanus, 294; in toxemias of febrile disease, 295 ; in tubal pregnancy, 290 ; in typhoid fever, 293, 517 ; in typhus, 292 ; in Ulceration of the bowel, 281; in ulcers, 296; in uremia of chronic nephritis, 294; in Vomit- ing, uncontrollable, 292; To flush out septic material, 282; to prevent postoperative thirst, 282 ; to stimulate the kidneys, 282 Inhalation, alkaline muriated acidulous waters for, 421; as a factor in the efficacy of mineral baths, 375; of nitrogen, 413; of saline vapor, 385; of sulphur vapor, 397, 497 ; of vapor of mineral waters, 469 Insanity, gavage in, 534 Inselbad, 450, 451,470, 488 Insomnia, in arteriosclerosis, hydrotherapy of, 188; in neurasthenia, 156; hot alcohol sponge for, 529. .See also under Hypnotics, Hydri- atric. Institution, hydriatric, necessity for, 507 Insufficiency, cardiac, bathing-cures for, 474 ; car- bonated baths for, 381, 475, 536 ; drinking-cures for, 474; hydrotherapy of, 187; phototherapy of, 240. See Cardiac ; and under Heart. Intestinal catarrh, alkaline-saline waters in, 423 ; cold rub for, 80 ; hydrotherapy of, 194 ; chronic, hot sitzbath for, 75 (see also under Catarrh; and Digestive Disorders) ; hemorrhage, hy- drotherapy of, 136 ; irrigation of bowel for, 532 ; infections, acute, hydrotherapy of, 137 ; irriga- tions for, 532 ; saline infusion for, 292 ; obstruc- tion, lavage for, 534; paralysis, bowel irriga- tion for, 531 ; in tabes, treatment of, 167 ; peris- taltic activity, effect of sitzbaths on, 74, 75; restraint of, in diarrhea, 194 ; stimulation of, by hydrotherapeutic measures, 147; stimulation of, in diarrhea, 194; stimulation of, by warm alkaline-saline waters, 423 ; stimulation of, by watei'-drinking, 45 Intestines, action of carbonated waters 011,417; chronic inflammation of, Turkish bath for, 267 ; diseases of, hydrotherapy of, 193 ; abdominal binder for, 102 ; cold rub for, 80 ; partial ablu- tion for, 80; motor disorders of, Scotch douches for, 89 ; torpor of, drinking-cures for, 478 Intoxications, hydrotherapy of, 143 ; alcohol, 144, 295 ; arsenic, 144 ; lead, 143 ; saline infusions for, 280, 293, 295. See also Autointoxication ; and Poisoning. Intussusception, colonic irrigation in, 531 Iodin brine baths in scrofulosis, 460; waters, 430. See under Waters, Mineral. Iodin Spring, Salt Sulphur Springs, W. Va., 325, 342432,498 Iodobromic waters, 340, 341, 430. See under Waters, Mineral. Iola Mineral Well, Kansas, 356 Iowa Acid Spring, Iowa, 346 Irish-Roman baths, 409; indications for, 409; counterindicated in heart disease, 475 ; methods of administration of, 409; in obesity, 462 Iron baths, 398 (see under Baths, Mineral) ; sul- phate baths, 400 (see under Baths, Mineral).INDEX sss Waters, 306, 307, 320, 326, 330, 349, 416, 441; acid-sulphated, 345, 351; aluminous, 345 ; cal- cic-aluminous, 346 ; calcic-magnesic-aluminous, 346; magnesic, 346; magnesic-aluminous, 346; sodic-magnesic-aluminous, 345 ; alkaline, 320, 350 ; calcic, 321; calcic-magnesic, 321; lithiated, 321; magnesic, 321 ; sodic,32o; sodic-calcic, 321 ; alkaline-saline sulphated, 326, 350 ; calcic, 326; calcic-magnesic-aluminous, 327; calcic-potassic, 327 ; calcic-sodic, 327 ; calcic-sodic-magnesic- aluminous, 327; potassic-calcic, 326; sodic, 326; sodic-magnesic, 326; alkaline-saline-muri- ated,2>30, 351; calcic-sodic, 330; magnesic-so- dic, 330; sodic, 330; sodic-aluminous, 330; sa- line-sulphated, 336, 351; calcic, 336; calcic- magnesic, 336 ; calcic-magnesic-aluminous, 336 ; calcic-sodic, 336; sodic, 336; sodic-magnesic, 336; saline-muriated, 339, 351; calcic-sodic- aluminous, 339; magnesic-sodic, 339; sodic, 339; distribution of, in the United States, 349. See under Waters, Mineral. Iron and arsenic waters, 306, 352, 446. See under Waters, Mineral. Irondale Springs, W. Va., 336, 450, 481 Iron Duke Spring, Canon City, Colo., 329 Iron Duke Spring, Royal Gorge Hot Springs, Colo., 424 Iron Geyser Creek, Calif., 378 Iron Lithia Springs, Va., 346, 353, 356 Iron Pipe Spring, Byron Springs, Calif., 342 Iron Spring, Anderson Mineral Springs, Calif., 336 Iron Spring, Byron Springs, Calif., 343 Iron Spring, California Geysers, Calif., 336 Iron Spring, Cresson Springs, Pa., 336, 480 Iron Spring, Harbin Springs, Calif., 326 Iron Spring, Napa Soda Springs, Calif., 321, 490 Iron Ute Springs, Manitou Springs, Colo., 320, 444, 474 Irrigation, 60, 104, 113, 279, 529; hot, in cholera, 525 ; hot, in ovarian and tubal lesions, 531 ; pro- longed hot, in first stage of labor, 535 ; running, of the back, 85 ; solutions for, saline, 287 ; spe- cial indications for saline, 289 Bladder, 114, 534 Colon, 529; double-current method of, 529; fluids for, 530; improvised irrigator for, 529; indications for, 531; in intoxications, 143; methods of, 530 ; position for, 530 ; quantity of fluid for, 531 ; technic of, 530 Ear, 535; of eye, 535; nasal, 535 Intrauterine, 535; indications for, 535; solu- tions for, 535 Rectal, 115, 282, 532; counterindications, 282; indications for, 115, 282, 532 Saline, 279; indications for, 280 Stomach, in intoxications, 143 Urethral, 114, 117 ; indications for, 115, 117 Vaginal, 534; cold, 535; hot, 535; indications for, 535 ; technic, 535 Irrigators, 115; double-current, 115, 529; impro- vised, 529; rectal, 115, 529; urethral, 113, 117, 534; vaginal, 117, 534; vesical, 114, 534 Irritability, general reflex, douche for, 85 ; hys- terical motor, treatment of, 159; neurasthenic, treatment of, 155; of sexual organs, douche for, 85 Irritation, meningeal, hand-baths and foot-baths for, 72 ; spinal, douche filiforme for, 89. See also Congestion and Hyperemia. Irritative sensory states, Winternitz combination compress for, 101 Ischerniavsky, 172 Ischl, 386, 457,459, 469, 495, 497, 500 Ischuria, bathing-cures for, 491 Ischurtschenthaler, 26 Itching in diseases of the skin, high (mucilagi- nous), bath for, 61 Ivon itch, 431, 432, 467 Iwonicz, 458 J Jacob,381 Jaundice, after cold baths, 38; catarrhal, alka- line-saline mineral waters for, 423; drinking- cures for, 481 ; hydrotherapy of, 196 ; peat cataplasms in, 482; warm alkaline-saline waters in, 423 ; from gall-stones, hydrother- apy of, 196 Jaxtfeld, 386 Jeleznovodsk, 443 Jemez Hot Springs, N. Mex., 386 Johannis Spring, at Zollhaus, 417 Johannisbad, 378, 464, 480, 485, 486, 487 Joints, acute inflammation of, circular compress for, 103 ; diseases of, hydrotherapy of, 170 ; light baths for, 124; mud baths in, 406; Scotch douches for, 89; diseases and injuries of, bathing- and drinking-cures for, 499 ; injuries about, local shock baths for, 529; old exu- dates in, lime baths for, 412; tuberculosis of, local hot-air baths for, 275 ; sun-baths for, 221. See also Ankylosis; Arthritis ; and Rheuma- tism. Jones Sulphur Well, Tenn., 360 Jordan’s White Sulphur Springs, Va., 325, 341, 350, 357< 365 Josefsbrunnen, at Bilin, 429 Juhl, 371 Juliushall, 386 Jiirgensen, 35, 139, 513 K Kaiserbad, Buda-Pest, 397 Kaiser Friedrichsquelle, Offenbach-on-the-Main, 429, 492 Kane Geyser Well, Pa., 341 Kane Sulphur Spring, Pa., 364 Karfunkel, 374 Katalysine Spring, Gettysburg, Pa., 327 Keller, 384 Kellogg, J. H., 124, 126, 507, 516, 535 Kellogg, J. H., 209-278 Kelly, 530, 535 Kemp, 529, 530 Kertch, 407 Kesselbnmnen, Ems, 482 Kickapoo Magnetic Spring, Ind., 319 Kidney, contracted, hydrotherapy of, 201 ; pelvis of, chronic catarrh of, bathing-cures for, 491; drinking-cures for, 489 Kidneys, diseases of, bathing-cures for, 491; drinking-cures for, 477, 490; hydrotherapy of, 198 ; steam bath for, 122 ; wet pack for, 109 (see also Nephritis); effect of heat on, 250 ; of water- drinking on, 44; of thermic and mechanical stimulation on, 37 ; stimulation of, peritoneal infusion for, 284 Kirkland Mineral Spring, N. Y., 353 Kisch, E. H., 306, 318, 358, 463, 475 Kisch, Professor E. H., 369-503 ICissingen, 312,333, 386,428, 429, 434, 435, 458,462, 464, 465, 469, 470, 473, 476, 478, 479, 480, 481, 483, 484, 485, 486, 487, 489, 494, 495, 497, 500 Kissingen Spring, Saratoga, 329, 354, 430, 432 Kissingen Well, Harrogate, 443 Kitasato, 213 Kittanning Mineral Spring, Pa.. 336, 445, 479 Klamath Hot Springs, Calif., 500 Klar, Conrad, 235, 239 Kletzinsky, 370 Koch, R., 213 Koenigsdorf-Jastrzemb, 386, 498 Koenigsquelle at Elster,429, 465 Koenigswart, 442, 443, 444, 455, 474, 493 Koesen, 386, 459, 469 Koestlin, 384 Koestritz, 386 Koranyi, 289 Kowalski, 249INDEX 556 Kraehnchen, Ems, 482 Krankenheil, 431, 432, 458, 460, 467, 482, 483, 498 Krankenheil-Toelz, 386 Krapina-Toplitz, 379 Kraus, 201 Krebs, 39, 373 Kreuth, 457, 495 Kreuzbrunnen, 461, 478, 482, 494 Kreuznach, 313, 333, 340, 386, 431, 432, 458, 459, 460, 467, 482, 483, 495, 496, 498 Krondorf, 417, 419, 463, 470, 490 Kronecker, 279 Kronenquelle, Salzbrunn, 429, 465, 492 Kronthal, 417, 428, 429, 469, 471, 472 Krynica, 442, 444, 459, 466, 490 Kurbrunnen at Nauheim, Germany, 333 Kussmaul, 534 L, Labor, first stage, hot irrigation in, 535 La Bourboule, 312 Lady Ida Well, 445 Lafayette Artesian Well, Ind., 356 Lafayette Spring, Saratoga Springs, N. Y.,328, 342 Lahmann, 118 Lakewood, N. J., 475, 480, 486, 500 Lamalon, 443 Lamb’s wool jacket, 278 Lamotte, 485 Landeck, 378, 485, 487, 488, 495 Landerer, 29, 288 Landouzy, 294 Landskroner, 493 Lane Mineral Spring, Calif., 346, 361, 438 Langenbruecken, 358, 437, 470 Lansing Magnetic Well, Mich., 328, 331, 356 La Preste, 397 Laryngitis, bathing- and drinking-cures for, 469; cold collar for, 96; sweat baths in, 528; throat compress for, 523, 524 Larynx, chronic catarrh of, alkaline muriated acidulous waters in, 421 ; simple sodium chlorid waters in, 427; sulphurous waters in, 437 Las Cruces Hot Springs, Calif., 362 Las Vegas Hot Springs, N. Mex., 379, 406, 465, 481, 486, 488, 500, 502 Lauderdale Springs, Miss., 357 Laure, 88 Lausigk, 447 Lavage du sang, 280, 293 Lavage of the blood, 280, 293 ; gastric, 532 ; ap- paratus for, 532, 533; counterindications to, 534; indications for, 533, 534; technic, 532; time of performing, 533 ; with recurrent stomach tube, 533 Lavation, 533 Lavey, 397 Lead-poisoning, hydrotherapy of, 143 Leamington, 435 Lebanon Springs, N. Y., 315, 488 Lebanon Thermal Spring, N. Y., 326, 356, 357, 36i,444 Lees, 522 Leg ulcers, application of concentrated electric light rays for, 240; circular and stimulating compresses for, 203; incandescent electric light baths for, 240 ; local hot-air bath for, 275 ; saline infusion for, 296 ; sunlight for, 240 Lehmann, 215, 370, 372 Leichtenstern, 197 Leiter, 90 Lemonade Spring, California Geysers Calif., 344, 345, 347 Lenhartz, 294 Lentz, 273 Leroy Springs, Wyoming, 435 Leslie Magnetic Wells, Mich., 490 Leslie Well, Mich., 321 Leube, 198 Leucorrhea, colonic irrigation in, 531 ; vaginal irrigation in, 534 ; anemic, cold sitzbath for, 75 Leuk (Leukerbad), 311, 356, 412,413,450, 451,500 Le Vernet, 472 Levico, 400, 446, 447, 456, 463,479 Levin, 371 Liberty Hot Springs, Colo., 428, 429, 479 Lick or Tuscan Springs, Calif., 431 Liebenstein, 443, 444 Liebenzell, 378, 485, 487, 488 Liebreich, 372 Liebwerde, 459, 479 Ligaments, contractures of, bathing-cures for, 501 Ligation of arteries, local dry pack following, 276 Light, composition of, 50, 209 ; influence of, on absorption of oxygen, 51, 21 r ; on bacteria, 52, 55, 213 ; on blood, 53, 237 ; on elimination of carbon dioxid, 51, 211; on metabolism, 51, 211 ; on muscles, 51 ; on nervous system, 51, 212; on plant life, 210; on skin, 212; physiologic effects of, 210; therapeutic use of/53, 213; baths, 49, 124; indications for, 50, 54, 55, 124, 221; counterindications and special precautions, 221 ; therapeutic expe- riences with, 50, 53, 213; electric, 54, 118, 227,232 (see also under Baths, Light ; Helio- therapy and Phototherapy) ; electric, 226 ; arc, 210, 213 ; incandescent, 210, 231 ; local ap- plications of, 222, 230, 233; Fouveau-Trouve chemical radiator, 537 ; Lortet-Genoud lupus lamp, 230 ; rays, 51, 52, 209, 211; refrigerated, therapeutic use of, 537 Limans, 407 Lime baths, thermal, 412. See also under Baths. Lincoln Lithia Spring, N. C., 432 Lindemann, 51, 126, 171, 389 Lineville Mineral Springs, Mo., 335 Lipik, 431, 432, 458, 467, 483, 498 Lippspringe, 413, 450, 451, 470, 479, 488 Lisdoonvarna, 397, 438 Lithemia, colonic irrigation in, 532 ; warm alka- line-saline waters in, 423. See also under Di- athesis, Alloxuric; and Diathesis, Gouty. Lithia waters, 353, 427. See also under Waters, Mineral. Lithiasis, electric light baths for, 238; simple sodium chlorid waters for, 427; uric acid in, drinking-cures for, 492. See under Calculi, Urinary. Lithic waters, 303. See also under Waters, Mineral. Lithium Springs, Attica, Ind., 338, 353 Little Chief Spring, Manitou, Colo., 325, 331 Little Sulphur Spring, Colo., 398 Little Ute Spring, Canon City, Colo., 329 Litton Seltzer Springs, Calif., 330, 339, 355 Liver and Kidney Spring, Byron Springs, Calif., 338, 343, 429 Liver, amyloid disease of, drinking-cures for, 482 ; cirrhosis of, drinking-cures for, 482 ; sun bath for, 221; congestion of, Turkish bath for, 267 ; diseases of, bathing-cures for, 482 ; drink- ing-cures for, 477, 480 ; hydrotherapy of, 197 ; hyperemia of, chronic, abdominal binder for, 102 ; drinking-cures for, 480 ; sulphurous waters in, 437; warm alkaline-saline waters in, 423; functions of, stimulated by water-drinking, 45 Livingston Artesian Well, N. Y., 338 Livingston Warm Springs, Montana, 364 Llandrindod, 463 Llandrindod Wells, 386, 397 438 Llangam-March Wells, 458 Llanwrtyd Wells, 438 Lobenstein, 443 Locomotion, organs of, injuries of, bathing-cures for, 501 Locomotor ataxia. See Ataxia, Locomotor. Lodi Artesian Well, Ind., 338, 343 Loeb, 288 Lo£che-les-Bains, 450, 451, 465. See also Leu- kerbad. Loka, 406, 465INDEX 557 Londonderry Lithia Springs, N. H., 327,353,430, 459, 470, 492 Longetten, 103 Lortet-Genoud lupus lamp, 230 Louisville Artesian Well, Ky., 337, 340, 342, 357, 432, 489 Loutrotherapy, 536 Lower Blue Lick Spring, Ky., 337, 342, 428, 483 Lower Bowden Lithia Spring, Ga., 432 Lowy, A., 25, 36 Loye, 293 Lubec Spring, Me., 426, 428 Luciusquelle, Tarasp, 479,494 Luhatschowitz, 331, 421, 422, 458, 469, 471, 472, 473,489,494 Luisenquelle, Franzensbad, 456 Lumbago, hydrotherapy of, 172 ; thermic massage in, 277 Luminous rays, 50, 209 Lungs, diseases of, cold rub for, 80; partial ablu- tions in, 80; edema of, sweat baths for, 528; inflammatory processes of, cooling chest compress for, 96. See also Asthma; Bron- chitis ; Emphysema ; Pneumonia ; Respiratory organs; and Tuberculosis^ Pulmonary. Lupus, arc electric light for, 230; phototherapy in, 54, 225, 230 ; sunlight locally for, 225 Luxations, bathing-cures after, 501 Luxenil, 379 Lye baths, 411 Lymphatic glands and vessels, effect of iodin waters on, 431. See also under Glands, Lymph- atic. M McAlister Springs, Black Sulphur Spring, Mo., 337 Macbeth Mineral Well, New Mex., 338 McCarthy’s Springs, Pa., 450 McClelland’s Well, Mo., 361. Madison Spring, 348 Magendie, 43 Maggiora, 171 Magnesia Spring, Bedford Springs, Pa., 484, 492 Magnesia Spring, Cresson, Pa., 328 Magnesia Sulphur Spring, Chittenango Sulphur Springs, N. Y., 439 Magnesia Spring, Hot Springs, Ark., 319 Magnesia Spring, Kane Co., 111., 319 Magnesic waters, 318, 319. See under Waters, Mineral. Magneso-saline Mineral Springs, Mo., 337 Magnetic Spring, Saratoga, N. Y., 329 Magnetic Mineral Springs, Ind., 338, 357 Magnetic Spring, Colfax, Iowa, 325 Main Hot Sulphur Spring, El Paso de Robles, Calif., 440 Maklakow, 227 Malaria, bathing- and drinking-cures for, 456; hydrotherapy of, 136; splenic enlargement in, drinking-cures for, 482 Malarial cachexia, hydrotherapy of, 137; cach- exia, sulphated iron waters in, 445; fever, chronic, arsenical iron waters in, 446 Mallassez, 288 Mallow, 378 Malt baths, 411 Malvern, 386, 417, 458, 459, 463 Mammoth Spring, Hot Springs, S. Dak., 335 Mammoth Hot Springs, Yellowstone Park, 348 Manassein, 37 Manhattan Artesian Wells (No. 1), Kansas, 346 Mania, saline infusion in, 295 Manitou Soda Springs, Colo., 478, 479, 493 Manitou Spring, Colo., 319 Manitou Springs, Colo., 319, 320, 322, 417, 424, 443, 444, 449, 451, 466, 471, 478, 479, 480,481, 489, 492 Marchisio, 395 Mardela Spring, Md., 321, 350 Margaretta Island, Buda-Pest, 397 Margate, 460 Marienbad, 311, 331, 400, 402, 405, 424, 425, 442, 443, 444, 449, 45L 455, 456, 461, 463, 464, 465, 466, 467,470, 471, 473, 474, 475, 477, 478, 479, 480, 481, 482, 484, 485, 486, 487, 489, 490, 491, 492, 494, 495, 497, 500, 502 Marienbad Spring, salt, 425 Marienquelle, Elster, 456 Marktbrunnen, 478 Martin, N. F., 519 Maryland Strontia Spring, Md., 338 Masino, 379 Massage in connection with local hot-air bath, 275 ; thermic, 277 Massanetta Springs, Va., 321, 350, 352, 357, 456, 476 ' .......^ Massasoit Spring, Mass., 319 Massena Springs, N. Y., 337, 502 Matchless Mineral Wells, Ala., 336, 400 Matilija Hot Springs, Calif., 362 Matthes, 29 Mattock Bath, 378 Maxwell, James Clerk, 209 Mayer, 395, 396 Measles, application of heat in, 525 ; hydrothera- peutic management of, 139 Measure of hydrotherapeutic stimulation, 59 Mechanical and thermic stimulation, effects of, 18, 21,30,48; irritation of mineral baths, 374; manipulation in acratothermal baths, 378 ; man- ipulations with hydriatric measures, 60 ; man- ipulations with mineral steam baths, 408 Medea Spring, Mich., 338 Medical Lake, Wash., 322, 328 Mehadia, 406, 439,467, 470, 485, 500 Meinberg, 313, 358, 403, 406, 437, 482, 495 Melancholia, Turkish bath for, 266 M elk sham, 435 Mendocino County Seltzer Springs, Calif., 419, 420 Meninges, cerebral, inflammatory states of, cold head compress for,.95; diseases of, hydro- therapy of, 169 ; irritation of, douche filiforme for, 89; hand-baths and foot-baths for, 72 ; hydrotherapy of, 169 Meningitis, bitter waters in, 434 ; cerebrospinal, hydrotherapy of, 169 Menopause, bathing during, 496 (see under Cli- macteric period); obesity in, bathing- and drinking-cures for, 461 Menorrhagia, bathing- and drinking-cures for, 496; hydriatric management of, 205 ; vaginal hot irrigation in, 535 Menostasis, cold sitzbaths for, 75 Menstrual abnormities, bathing-cures for, 496 ; drinking-cures for, 494 ; hydrotherapy of, 205 Menstrual disorders, acid baths in, 381 ; carbonic acid gas baths in, 402 ; hydrotherapy of, 205; peat baths in, 405 ; steel baths in, 399 Mercurialism, splenic enlargement in, bathing- cures for, 483 ; drinking-cures for, 482 ; mineral steam baths in, 408 ; in syphilis, bathing- and drinking-cures for, 467 ; thermal calcium baths in, 412 Mercury, inunction of, sweat baths with, 528 Mercy Medicinal.Spring, Calif., 338 Mergentheim, 428, 434, 435 Messena Sulphur Springs, N. Y., 364 Metabolism, effect of alkaline acidulous waters on, 418; of alkaline-saline waters on, 423; of blood changes on, 34; of brine baths on, 384; of heat abstraction on, 35, 36; of hydrotherapy on, 36; of light on, 51, 211; of sodium ehlorid waters on, 426; of thermic and mechanical stimulation on, 35; of water-drinking on, 44; defective, sun bath for, 221; disorders of, bath- ing- and drinking-cures for, 455 ; cold rub for, • 80; electric light bath for, 238; hydrotherapy of, 147 ; partial ablution for, §0; steam bath for, 122 ; wet pack for, 109 ; general derange- ment of, mineral steam baths in, 408; re-558 INDEX tarded, cold (full) bath for, 70; stimulation of, by acratothermal baths, 377; by chemical irritation of mineral baths, 373; cold rub for, 80 ; torpid, sitzbaths for, 75 Metallic poisoning, hydrotherapy of, 143 ; hot-air baths in, 409 ; chronic, sulphurous waters in, 396,436. See also Arseniy Lead; Mercurial- ism ; and Poisoning. Meteorism, in peritonitis, cooling and stimu- lating compresses for, 197 Metritis, hydrotherapy of, 205 ; vaginal irrigation for, 535; chronic, bathing-cures for, 495; drinking-cures for, 494 ; peat baths in, 405 Michael, 292 Middletown Springs, Vt., 321 Midland Mineral Springs, Mich., 337 Midway Warm Springs, Utah, 326 Migraine, cold rub for, 160; diaphoretic measures for, 160 ; douche filiforme for, 89 ; wet pack for, 160; angioparalytic, 160; hand-baths and foot-baths for, 72 ; angiospastic, 161 ; anemic, stimulating compresses for, 95. See also Hemi- crania. Milford Mineral Spring, Texas, 336 Milk of bismuth, 533 Mill Creek, Montana, 319, 322 Millboro Springs, Va., 325 Mineral Hill Hot White Sulphur Springs, Nev., 364 Mineral baths, absorption in, 369 ; as a cause of skin eruptions, 373; chemical stimulation in, 372; constitution and general effect of, 369; definition of, 369; effect of, on excretion, 373; effect of, on metabolism, 373; effect of, on re- spiratory gaseous interchange, 373 ; effect of, on sensory nerves, 373 ; effect of, on unstriped mus- cular tissue, 373 ; factors in the efficacy of, 372 ; mechanical irritation of, 374; therapeutic uses of, special, 455 ; thermic irritation of, 374. See also Baths, Mineral. Mineral Park Bitter Spring, Ariz., 335, 480 Minnekahta Spring, Hot Springs, S. Dak., 500 Minnequa Springs, Pa., 466 Min-Ni-Yan Spring, 111., 327 Misdroy, 460 Mitchell, Weir, 161 Mitterbad, 400, 445, 456 Moinak, 407 Moleschott, 51, 52 Monarthritis, Scotch douches for, 171 Monatiquot Spring, Mass., 325 Mondorf, 386, 428, 429, 469 Monegaw Springs, Old Black Sulphur Spring, Mo., 338 Monfalcone, 397 Mono Lake, Calif., 339 Monsuramano, 379 Mont-Dore, 419, 463, 472 Mt. d’Or, France, 351 Montebello Spring, Vt., 321, 361 Monteeatini, 386 Montecito Hot Springs, Calif., 362, 398 Montesano Spring, Mo., 338, 343, 360, 361, 438 Montgomery White Sulphur Springs, Va., 365 Montvale Springs, Tenn., 443, 480 Moor baths, 404 ; mechanical irritation of, 374 ; baths, thermic irritation of, 374. See also Peat baths. Moorman Mineral Well, Ypsilanti, Mich., 337, 438, 449 Moritzquelle, Elster, 456 Mother-lye, 383 Mt. Clemens Mineral Springs, Mich., 319, 337, 338, 362, 386, 449, 459, 465, 470, 483, 497, 500 Mount Hartford Water, 466 Mt. Vernon Springs, N. C., 330 Mucous membranes, atony of, alkaline muriated acidulous waters for, 421; catarrh of, alkaline muriated acidulous waters for, 421 Mud baths, 404, 406 ; mechanical irritation of, 374. See under Baths, Mineral. Mud Indian Spring, Calif., 346, 347 Muenster, 386, 469 Munnekatah Spring, S. Dak., 335 Muscles, atrophy of, hydrotherapy of, 168, 171; contractures of, bathing-cures for, 501; hyster- ical, hydrotherapy of, 159 ; diseases of, hot ap- plications for, 127 ; hydrotherapy of, 170 ; ther- mic massage for, 277; effect of light on, 51 ; of thermic and mechanical stimulation on, 27 ; old exudates in, lime baths for, 412 Muscular tissue, unstriped, effect of chemical cu- taneous irritation of mineral baths on, 373; effect of thermic and mechanical stimulation on, 27 Mush-pot Spring, Yellowstone, 345 Muskau, 400, 445, 456, 479, 482, 486, 487, 495, 497, 500 Mustard baths, 4x1 Mutterlauge, 383 Myalgia, incandescent electric light bath for, 239 ; thermic massage in, 277 Mycosis fungoides, saline infusion in, 295 Myelitis, hydrotherapy of, 16S ; chronic, Turkish bath for, 266 ; due to gout, bathing-and drink- ing-cures for, 4S7 ; due to spondylarthroses, bathing- and drinking-cures for, 487 Myocardium, disease of, acid baths in, 381, 536; precordial coil for, 97,186; fatty degeneration of, bath treatment of, 466. See also Heart dis- ease,, Muscular. Myoma of uterus, bathing-cures for secondary symptoms of, 496 Myxedema, sun bath for, 221 N Nantwich, 386, 428, 458, 459 Napa Soda Springs, Calif., 321, 350, 356, 400, 419, 420, 443, 449, 466, 476, 490, 495 Nasopharyngeal space, chronic catarrh of, simple sodium chlorid waters in, 427 Nasse, 43, 45 Natronlithionquelle, Weilbach, 465 Nauheim, 313, 333, 386, 403, 428, 458, 465, 474, 483, 485, 4S6, 487, 495,497, 500, 536 Nauheim baths, artificial, 382, 474, 475, 536. See also under Baths. Naumann, 372 Nausea, Winternitz combination compress for, 101; postoperative, saline infusion in, 293 Navajo Spring, Manitou Springs, Colo., 319 Nenndorf, 313, 358, 437, 470, 500 Neoplasms, secondary symptoms of, bathing- cures for, 496 Nephritis, caution necessary in use of Turkish bath in, 267; incandescent electric light baths for, 239 ; phototherapy of, 54; acute, hydi'o- therapy of, 198 ; thermotherapy of, 527 ; chronic, bathing- and drinking-cures for, 491; hydro- therapy of, 199; parenchymatous, sand bath for, 125; scarlatinal, hot bath for, 140 Neptune girdle, 101 Neptune Spring, Glen Springs, N. Y., 338 Neris, 379 Nerve pain, diffuse, high bath for, 61 Nerves, effect of acid baths on, 381; effect of light oxi, 51; effect of lime baths on, 412; effect of medicated baths on, 410; effects of mineral steam baths on, 408 ; peripheral, disorders of, douches for, 85 Nervous disease, chronic, Turkish bath for, 266 Nei'vous disoi'ders, acid baths in, 381 ; cold sea bath in, 390 ; ii'on waters in, 442 ; steel baths in, 399 ; of heart, wet pack for, 109 Nervous reaction, excessive, in hydrotherapy, high bath for, 61; stimulation in fever, 516 Nei'vous system, action of cai'bonated watei's on, 417; diseases of, bathing- and drinking-cures for, 484; half-baths for, 64; hydrotherapy of, 152, 153; chronic, steel baths for, 399; func- tional disturbance of, cold sea baths for, 390 ;INDEX 559 influence of light on, 212; sedative action of acratothermal baths on, 377 Neu Rakoczy, 428 Neuenahr, 419, 420, 463, 464, 477, 479, 482, 489, 491, 494 Neuhaus, 378, 485, 486 Neuralgia, alternating half-baths for, 69; arsen- ical iron waters in, 446 ; bathing- and drinking- cures for, 488; brine baths in, 384; carbonic acid baths in, 402 : cold sea bath in, 390 ; douche filiforme for, 89 ; douches for, 85; elbow-bath for, 71; hydrogen sulphid gas baths in, 403; hydrotherapy of, 162 ; hot applications for, 127 ; incandescent electric light baths in, 239; local heating in, 277; mud baths in, 406; peat baths in, 405; phototherapy of 54; sand baths for, 125 ; Scotch douches for, 89 ; stimulating com- presses for, 95 ; warm compress for, 94; wet pack for, 109; brachial, hydrotherapy of, 164; in chloranemia, bathing- and drinking-cures for, 488; in diabetes, hydrotherapy of, 150; in diseases of stomach, 488; in uterine dis- ease, bathing- and drinking-cures for, 488; intercostal, hydrotherapy of, 164 ; incandescent electric light bath for, 239; of neck of bladder, bathing-cures for, 491; drinking-cures for, 490; of testicle, psychophore for, 114; post- traumatic, bathing-cures for, 501; trigeminal, bathing- and drinking-cures for, 488 ; hydro- therapy of, 164 Neuralgic affections, dry pack in, 276; pain, pelvic, aggravated by cold irrigation, 535 Neurasthenia, acid baths in, 381 ; electric light bath for, 238 ; hydrotherapy of, 152 ; incandes- cent electric light baths in, 238 ; insomnia in, hydriatric measures for, 156 ; saline infusion in, 295 ; spinal, running irrigation of the back for, 85; sun bath for, 221 ; Turkish bath for, 266 ; erethistic, high bath for, 61 ; erethistic, warm douches for, 85 Neuritis, elbow-bath for, 71 ; hot blanket com- press for, 526; hot wet pack for, 526 ; hydro- therapy of, 165 ; shock bath for, 529 ; Turkish bath for, 266; diabetic, hydrotherapy of, 150 ; optic, Simpson sweat bath for, 528 Neuroses, alternating half-baths for, 69 ; thermal brine baths in, 385 ; cardiac, drinking-cures for, 474 ; occipital bath for, 71 ; partial douche for, 85; precordial coil for, 97; depressive, steam bath for, 122; functional motor, wet pack for, 109 ; malarial, bathing-cures for, 488 ; drinking-cures for, 488; motor, sulphur baths in, 396 ; in scrofulosis, bathing- and drinking- cures for, 488; occupation, hydrotherapy of, 162 ; peripheral, bathing-cures for, 488, 489 ; drinking-cures for, 488, 489 ; rheumatic, bath- ing-cures for, 488 ; drinking-cures for, 488 ; sen- sory, sulphur baths in, 396; syphilitic, bath- ing-cures for, 488; drinking-cures for, 488; traumatic, bathing-cures for, 488 ; drinking- cures for, 488 New Putnam Spring, Saratoga, 354, 430 New Spring at Dwerkheim, 429 Newbury Springs, Vt., 480 Newport Sulphur Springs, Fla., 363 Newsom’s Arroyo Grande Springs, Calif., 327, 400, 459 Niederbronn, 428 Nitrogen, inhalation of, 413 ; waters containing, 356. See Waters, Mineral, Azotized. Nitrogenous tissues augmented by water-drink- ing, 44 Nobscott Mountain Spring, Mass., 319 No-che-mo Springs, Reed City, Mich., 320 Norderney, 460 North Sea, 392 North Spring, Cherry Valley Springs, N. Y., 449 Nose, chronic catarrh of, bathing- and drinking- cures for, 503 ; irrigation of, 535 Nutrition, effect of medicated baths upon, 380, 410; effect of sodium chlorid waters upon, 426. See also under Metabolism. Nutritonal measure, cold shower baths as, 84 Nye Chalybeate Spring, Va., 321 Nye Lithia Spring, Va., 353, 430 O Oak Grove Spring, Mich., 338 Oak Orchard Acid Spring, N. Y., 344, 346, 351, 445> 476, 479, 484, 502 Oak Ridge Spring, Ohio, 326 Oberbrunnen, Salzbrunn, 429, 465, 492 Obesity, bathing- and drinking-cures for, 462 ; cold full bath for, 70; diaphoretic measures for, 149; dry pack for, 112 ; hydrotherapy of, 147 ; incandescent electric light bath for, 238, 239 ; mineral steam baths in, 408 ; muscular ex- ercise in, 149 ; phototherapy of, 54 ; prolonged hot bath for, 258 ; steam bath for, 122 ; sun bath for, 221; thermotherapy of, 258 ; Turkish bath for, 266 ; associated with diabetes, hydro- therapy of, 150 (see also under Diabetes) ; chronic intestinal catarrh in, drinking-cures for, 479; constipation in, drinking-cures for, 479 ; fatty heart in, cold precordial coil for, 149 ; partial ablutions for, 149 Obstruction, intestinal, lavage for, 534 ; pyloric, lavage for, 533 Occupation neuroses, hydrotherapy of, 162 Ocean Springs, Miss., 339 Ochee Springs, R. I., 325 Oconee White Sulphur Springs, Ga., 363 Odessa, 407 Odynphagia, gavage in, 534 Oeynhausen, 428 Ofen, 474 Offenbach-on-the-Main, 492 Ohio Magnetic Springs, Ohio, 320 Ohlon’s Mineral Well, Baldwinsville, N. Y., 337 Oil baths, 411 (see also under Baths) ; enemata for fecal impaction, 533 Ojai Hot Sulphur Springs, Calif., 362, 500 Ojo Azufre, New Mex., 364 Ojo Caliente, New Mex., 320, 350, 400, 443, 444, 457) 474) 477 Old Black Sulphur Spring, Monegaw Springs, Mo., 338 Old Faithful Geyser, Yellowstone, 348, 352, 355 Old Sulphur Spring, Harrogate, 438 Old Sweet Spring, Va., 325 Old Sweet Springs, W. Va., 356, 451, 490 Olympian Springs, Ky.,338, 363 Ombrophore, 85 Oophoritis, chronic, bathing-cures for, 495; drinking-cures for, 494. See also under Pelvic organs, Diseases of. Operations, pelvic, bowel irrigation after, 293, 531 Ophthalmology, phototherapy of, 54 Opium suppository for intestinal hemorrhage, 532 Optic neuritis, sweat bath for, 528 Orange Spring, Mammoth Hot Springs, 348, 469 Orchitis, bathing-cures for, 498; drinking-cures for, 498. See also under Testicle. Orkney Powder Spring, Orkney Springs, Va., 36i,439 Orkney Spring Water, 352 Orkney Springs, Va., 356, 357, 439 Osceola Spring, Va., 320, 490 Osmosis in mineral baths, 371 Ostend, 460 Osteomalacia, earthy waters in, 448 Otorrhea, bathing- and drinking-cures for, 503 Otterburn Magnesia and Lithia Springs, Va., 430.490 Ovarian disease, bathing- and drinking-cures for, 494; colonic irrigation in, 531; vaginal irri- gation in, 535 ; inflammation, combined hydri- atric application for, 260; tumors, incipient, secondary symptoms of, bathing-cures for, 497 Overall Mineral Wells, Texas, 346 Owens Lake, Calif., 459560 INDEX Owosso Spring, Mich., 321, 350, 400, 443, 444, 449, 480, 495 Oxaluria, alkaline acidulous waters in, 419; hy- driatric measures for, 151 ; steam bath for, 122 ; water-drinking for, 44 Oxford Mineral Spring, Conn., 336 Oxidation, effect of water-drinking on, 44 ; defi- cient, sun bath for, 221 Oxygen, absorption of, effect of brine baths on, 384; effect of light on, 51; effect of water- drinking on, 44 Oxygenated waters, 357. See under Waters, Mineral. Ozonated waters, 357. See under Waters, Min- eral. P Pacific Congress Springs, Calif., 330, 443,444,446, 459> 466, 497 Pack, wet and dry, 104 Packs, 104; dry, in, 275; counterindications to, 112,276; action of, in; as a diaphoretic, in, 275 ; indications for, 112, 276 ; mode of em- ployment, in, 275; half, no; hot wet, 525 ; in neuritis, 526; in sciatica, 526; partial, no; three-quarter, Buxbaum’s modification of, no; wet, 104; action of, 104; antipyretic use of, 107; counterindications for, 109; indica- tions for, 108 ; in typhoid fever, 514 ; method of, 104; secondary effects of., 106; to promote sleep, 106; to produce sweating, 106. See also Dry packs ; and Wet packs. Pack Monadnock Lithia Spring, N. H., 320, 353 Pagoda Spring, Napa Soda Springs, Calif., 321, 350, 356, 4I9> 420 Pagosa Springs, Colo., 324, 331, 353, 386, 424, 435, 479, 489, 495 Pain in hysteria, Scotch douches for, 159; in tabes dorsalis, cold spinal coil for, 168 Palate, soft, inflammatory processes in, cold collar for, 96 Palermo, 392 Palmyra Springs, Wis., 320, 451 Palo Pinto Well, Texas, 335 Palpitation, cardiac, hydrotherapy of, 161; iron waters for, 474; precordial coil for, 97 Panacea Spring, Fla., 329 Panacea Springs, N. C., 320 Panaris, elbow-bath for, 71 Parad, 400, 445,456, 479, 486 Paradise Spring, South Poland, Maine, 319 Paralysis, 164 ; acratothermal baths for, 378; ap- plication of concentrated electric light rays for, 240; hydriatric management of, 165; hot- air baths in, 409; Irish-Roman baths for, 409; mud baths in, 406 ; peat baths in, 405 ; sea bath- ing in, 486; sunlight for, 240; thermal brine baths in, 385; Turkish bath for, 266; after acute ex- anthemata, bathing- and drinking-cures for, 485 ; after cerebral hemorrhage, partial ab- lutions and tepid half-baths for, 170 ; after diph- theria, affusions and half-baths for, 164; bath- ing- and drinking-cures for, 485; after puerper- al fever, bathing- and drinking-cures for, 485 ; after typhoid fever, affusions and half-baths for, 164; bathing- and drinking-cures for, 485 ; arthritic, bathing- and drinking-cures, 486; hysteric, bathing-cures for, 486 ; brief cold ap- plications for, 158; intestinal, bowel irrigation for, 531; of bladder, hydriatric management of, 202 ; irrigation for, 534; in tabes, tepid half- baths for, 167; of limbs, dry pack in, 276; of rectum, in tabes, tepid half-baths for, 167; peripheral, carbonic acid gas baths in, 402 ; peat baths for, 405 ; reflex, bathing- and drink- ing-cures for, 486; rheumatic, bathing- and drmking-cures for, 486; brine baths in, 384; syphilitic, bathing- and drinking-cures for, 486; traumatic, bathing- and drinking-cures for, 486 Paralytic state, douches for, 85 Parametritis, bathing-cures for, 495; drinking- cures for, 494 ; hydriatric management of, 205 ; irrigation for, 531 ; peat baths in, 405 Paresis, Turkish bath for, 266 Paresthesise, hysteric, hydrotherapy of, 159; neurasthenic, 155; in mineral baths, 373 Paris Springs, Williams’s Spring, Mo., 325 Park Spa, Llandrindod Wells, 438 Park Spring, Mo., 336, 351 Parker Mineral Springs, Pa., 338, 386, 450, 497 Parkersburg Mineral Well, W. Va., 341, 483 Park’s Spring, N. C., 326 Parnassus Springs, Colo., 428 Paroquet Springs, Ky., 342 Pate Sour Well, Texas, 346 Patients, classes of, needing careful watching in sun and sand bath, 219; debilitated, alcohol rub for, 218; debilitated, carbon dioxid douches for, 86 ; hysteric, light bath for, 124 ; neurasthenic, light bath for, 124 ; nervous, tepid rain baths for, 85 ; sensitive, tepid rain baths for, 85 Patterson Spring, Saratoga Springs, N. Y., 329, 342 Pavilion Spring, Mt. d’Or, France, 351 Pavilion Spring, Saratoga Springs, N. Y., 328, 342, 354, 430 Pavilion Spring, Wernersville, Pa., 319 Pearl Geyser, 352 Pearl Spring, Mo., 360 Peat, varieties of, 404; baths, 404 (see under Baths, Mineral) ; cataplasms, in catarrhal jaundice, 482 Peerless Spring, Saratoga Springs, N. Y., 329,342 Peiden,. 449 Pelvic inflammation, trunk compresses for, 100; operations, bowel irrigation after, 531; saline infusions after, 284; pain, aggravated by cold ir- rigation, 535; viscera, chronic inflammation of, combined heat and cold for, 261; heat for, 259 ; Turkish baths for, 267; diseases of, sitzbaths for, 75. See also under Congestion ; Exudates ; and Inflammation. Pence Spring, W. Va., 319 Perfusion, saline, 293 Pericarditis, hydrotherapy of, 187 Perimetritis, bathing-cures for, 495; drinking- cures for, 494 Periostitis, thermal calcium baths in, 412 Peripheral heart, 28, 246 Periproctitis, hydrotherapy of, 189 Peristalsis, effect of heat and cold on, 27, 245, 248 ; effect of hydrotherapeutic measures on, 74, 85, 101, 147, 191, 194 ; effect of water-drinking on, 45 Peritoneal flushing, 284 Peritonitis, acute general, hydrotherapy of, 196 ; vomiting in, 197; residua of, acratothermal baths for, 378; pelvic, bathing-cures for, 495; drinking-cures for, 494 Perityphlitis, residua of, acratothermal baths for, 378 ; hydrotherapy of, 197 Pernau, 407 Perry County Springs, Pennsylvania, 315 Perry Springs, 111., 320, 363 Perspiration, methods of inducing, 55, 106, 111, 118-126, 183, 212, 229, 234, 236, 247, 263, 265, 268, 27L 275, 377, 395, 405, 406, 407, 409, 412, 526, 527, 528; therapeutic uses of, 37; sensible and insensible, effect of thermic and mechanical stimulation on, 37. See also Diaphoresis; and Sweating. Petersthal, 443, 456, 472 Petroleum, crude, as a solvent for impacted feces, 531 • Pettenkofer, 51, 52, 212 Pfaefers-Ragatz, 465 Pfeiffer, 419 Pfliiger, 38 Pfriem, 382 Pharyngitis, throat compress in, 523 Pharynx, chronic catarrh of, simple sodiumINDEX 56l chlorid waters in, 427; sulphurous waters in, 537. See also under Catarrh. Phlegmon, elbow-bath for, 71 Phosphatic calculi, 492, 493. See under Calculi, Urinary. Phosphaturia, hydriatric measures in, 151 PHOTOTHERAPY, 49,53, 209, 213 ; during conva- lescence, 54 ; for enfeebled innervation, 54 ; for stimulating metabolism, 54; for tuberculous ulcers, 54 ; hygienic value of, 240 ; In Alloxuria, 238 ; autointoxication, 54 ; Cardiac disease, 222 ; Debility, congenital, 54; dyscrasic processes, 55 ; Hemogenetic disorders, chronic, 54; Neuro- ses due to autointoxication, 54; Ophthalmology, 54: Paralysis, 240; Trophic disorders, 240; Variola, 55; of Alopecia, 225; acne, chronic, 221, 225; anemia, 54, 221,239; arthritis, rheu- matoid, 222 ; asthma, bronchial, 240; autoin- toxication, 239 ; Bronchitis, chronic, 240 ; Car- diac hypertrophy, 240; chlorosis, 54, 221, 239; choroiditis, chronic, 54 ; cirrhosis of liver, 221 ; corneal exudates, 237; Diabetes, 221, 238; dys- pepsia, chronic, 221 ; dropsy, cardiac, 240; Eczema, 221 ; epithelioma, 225 ; eruptive fevers, 221; Febrile disorders, 221 ; fevers, eruptive, 221 ; Gout, 54, 221, 222, 238 ; goiter, exophthal- mic, 221; Insomnia, 222; iritis, chronic, 54; Leg ulcers, chronic, 240 ; lithiasis, 238 ; lupus, 54, 55, 225, 230, 537 ; Metallic poisoning, chronic, 239 ; myxedema, 221; Nephritis, 54, 221, 239 ; neuralgia, 54, 239 ; neurasthenia, 221; neuras- thenia due to alloxuremia, 238 ; Obesity, 54, 221, 238, 239; Psoriasis, 221; Retinitis, chronic, 54: rheumatic affections, 54; rheumatism, 221, 222, 238; rheumatoid arthritis, 222; Sciatica, 339; scleritis, chronic, 54; scrofulosis, 54; skin diseases, 54 ; syphilis, 240 ; Tuberculosis, bone, 240 ; tuberculosis of joints, 221; Uric acid diathesis, 221; Vitreous opacities, 237 Piatigorsk, 397 Pickwick Red and White Sulphur Springs, Tenn., 365 Pictet’s cold (sulpho-carbonic acid) fountain, 128 Piedmont White Sulphur Spring, Calif., 324, 339, 362 Pine Lawn Spring, N. J., 320 Pine needle baths, 410 Pistyan, 406, 465, 467, 485, 500 Plethora, abdominal, sulphurous waters in, 437 Pleura, inflammatory processes of, cooling chest compresses for, 96 Pleurisy, bitter waters in, 434 ; hydrotherapy of, 198 ; acute stage of, hydriatric management of, 180; chronic, Scotch douches for, 89; dry, 178; after-treatment of, 179; exudative, 179; absorption of exudate of, 179; residua of, al- kaline muriated acidulous waters in, 421 Pliny, 301 Plombieres, 312, 340> 379> 465, 485> 5°o Pluto’s Well, French Lick Springs, Ind., 306 Plymouth Rock Mineral Well, Mich., 330, 422, 489, 492 Pneumonia, chest compress in, 523 ; cotton poul- tice in, 278; heat in, 522 ; hydrotherapeutic ap- plications in, 177, 522 ; ice-bags in, rules for use of, 522 ; ice cradle in, 522 ; ice pack in, 516 ; ice pack, partial, in, 522 ; lamb’s wool jacket in, 278 ; saline infusion in, 294 ; sweat baths in, 528; thermotherapy of, 258; complicating measles, cold affusions in, 139; immersion in, 139 Pneumonic processes, cheesy, earthy waters in, 448 Poisoning, heat in, 258 ; lavage in, 533 ; metallic, saline infusion for, 295 ; sweat baths for, 528 ; metallic, chronic, cold full bath for, 70; dry pack for, 112; hydrotherapy of, 143; incan- descent electric light bath for, 239 ; steam bath for, 122; sulphur baths in, 396; sulphurous waters in, 436 ; wet pack for, 109 Poland Springs, Me., 304, 310, 319, 464 Poland Water, 466 IX—36 Pollutions, bathing- and drinking-cures for, 497 ; occipital bath for, 71 Polyarthritis, acute rheumatic, hydrotherapy of, 170 Polyneuritis, high bath for, 61; hydrotherapy of, 165 ; wet pack for, 109 Ponce de Leon Springs, Meadville, Pa., 319, 357 Ponemah Spring, Milford, N. H., 324 Pool baths, 396 Poretta, Italy, 357 Port Huron Mineral Bath, Mich., 337, 341 Pospischil, Otto, 34, 36, 148, 166, 181 Post-operative thirst, peritoneal infusion to pre- vent, 284 Potash Sulphur Spring, Ark., 485 Potassa waters, 303. See under Waters, Min- eral. Potassic waters, 318. See under Waters, Min- eral. Alkaline ; Alkaline-saline ; and Saline. Powder Spring, Orkney Springs, Va., 361 Powder Springs, Ga., 336, 361, 438 Pownal Spring, Maine, 320 Preblau, 419, 470, 478, 482, 490 Precautions in giving sun bath, 221 ; in giving hot-air bath, 274 ; in giving electric light baths, 230, 235; in giving Turkish bath, 263, 264, 267; in hydrotherapy, 60 Precordial coil, method of making, 521 ; technic and uses of, 96. See also under Coils; Heart disease ; Fever, Typhoid; etc. Pregnancy, baths during, 496; bitter waters in, 434; disorders resulting from, hydriatric man- agement of, 206; hydriatric measures during, 205 Prescription, hydriatric, 59 Priessnitz, 59 Prillieux, 226 Primm’s Springs (No. 2), Tenn., 360 Proctitis, cold sitzbath and rectal irrigation for, 189 Progressive muscular atrophy, hydriatric meas- ures in, 168 Proserpine Spring, French Lick Springs, Ind., 335 Prostate, hypertrophy of, bathing- and drinking- cures for, 498; induration of, bathing- and drinking-cures for, 498 Prostatitis, Atzperger’s irrigator for, 204 Prostatorrhea, psychrophore for, 115 ; rectal irri- gation for, 532 Prurigo, sulphur baths in, 396 Pruritus, Scotch douches for, 203 ; wet pack for, 109, 203; diabetic, drinking-cures for, 502; hydrotherapy for, 150 Pseudo-tabes, alcoholic, half-baths and cold spinal coil for, 144 Psoriasis, bathing- and drinking-cures for, 502; prolonged tepid baths for, 203; sulphur baths for, 396 ; sun bath for, 221 Psychoses, hydriatric procedures in, 170; saline infusion in, 295 Psychrophore, 113 PSYCHROTHERAPY, 127 ; for anorexia in tuber- culosis, 127; of dyspepsia, nervous, 128; of neuralgia, trigeminal, 127; of neurasthenia, 128; of tic, spasmodic, 127 Puellna, 434, 435 Puerperal fever, 206 Pullna, 312, 340, 474 Pulmonary disease, inhalation of nitrogen from thermal springs for, 413 ; tuberculosis, difficult expectoration in, 175; first stage, alkaline muriated acidulous waters in, 421 ; hydrother- apy of, 173. See also Tuberculosis, Pulmonary. Pulse, effect of brine baths on, 384 ; effect of car- bonated baths on, 381 ; effect of carbonic gas baths on, 401; effect of heat 011,245; effect of Irish-Roman bath on, 409; effect of light on, 220; effect of mineral steam baths on, 408; effect of peat baths on, 405; effect of Russian baths on, 408; effect of sea baths on, 389; effect of sulphurous gas baths on, 403 ; effect of562 INDEX thermic and mechanical stimulation on. 28; effect of Turkish bath on, 267 ; effect of water- drinking on, 40; tracing, value of, 29. See also Blood pressure ; Circulation ; and Heart. Purgative waters, 332, 433. See under Waters, Mineral. Puschkin, 249 Putnam Spring, Saratoga, N. Y., 329, 342 Puzzuoli, 437 Pyloric obstruction, lavage in, 533; saline in- fusion in, 292 Pyrexia in infectious fevers, dangers of, 132; function of, 132; hydriatric management of, 133 Pyrmont, 311, 349, 350, 386, 397, 400,403, 406, 428, 429, 443, 444, 455, 459, 463, 474, 476, 486, 487, 495, 497 Pyrosis in anemia, combined epigastric applica- tion for, 147 Q Queirel, 288 Quincke, 126, 211,442 Quitman Red Sulphur Springs, Miss., 364 R Rabateau, 370 Rachitis, baths in, 466; brine baths in, 384; drinking-cures in, 466; earthy waters in, 448; sodium chlorid waters in, 427; diarrhea in, chronic, drinking-cures for, 479; splenic enlargement in, bathing- and drinking-cures for, 483 Radeim, 421, 422, 429, 492 Ragatz, 378, 464, 485, 486, 487, 500 Rain bath, 81. See also under Baths. Rakoczy, Kissingen, 429, 458 Rakoczybrunnen, Kissingen, 494 Rakoczyquelle, Kissingen, 479 Raleigh Mineral Springs, Tenn., 357 Randolph Springs, Mo., 337 Ratzes, 400, 445, 456 Ravenden Springs, Ark., 356 Rawley Springs, Va., 321, 356, 456, 459 Rawlins’ Sulphur Springs, Wyo., 335, 365 Rays, actinic or chemical, 50, 209; physiologic effects of, 53, 211; calorific or heat, 50, 209; luminous or light, 50, 209; percentage of- various classes of, in light from different sources, 213, 227 ; X-, 50 Reaction, physiologic, 18, 46; effect of stimuli on, 47; factors affecting, 47; necessity of, 47; philosophy of, 48 Reactive manifestations to thermic changes, 22 Recoaro, 447, 490 Rectum, irrigators for, 115, 529; inflammatory disorders of, protracted cold sitzbath for, 75 Red Boiling Springs, Tenn., 327, 335, 398 Red Cross Lithia Spring, N. Y., 325 Red Spring, Red Boiling Springs, Tenn., 327 Red Spring, Saratoga, N. Y., 329, 354, 430 Red Spring, Tuscan Springs, Cal., 431, 432, 498 Red Spring, Va., 336, 356, 357 Red Sulphur Spring, Blue Lick Springs, Mo., 337 Red Sulphur Spring, Colo., 398 Red Sulphur Springs, W. Va., 325, 365, 398, 458, 470 Reed’s Mineral Springs, Mo., 321 Reflex areas, cutaneous, related with visceral circulation, 253 Refrigeration in phototherapy, 537 Rehme. 465, 469, 485, 486, 487, 495, 497, 5°o Rehme-Oeynhausen, 386, 428 Reich, 126 Reichenhall, 386, 457, 459, 469, 472, 495, 497, 500 Reinerz, 400, 406, 443, 459, 466, 472, 474, 479, 485, 495 Reitler, 126 Renal calculi, 491 (see also under Calculi, Renal); insufficiency, saline infusions for, 294. See also Kidney diseases. Rennes-les-Bains, 443 Resistance exercises, 537 Respiration, effect on, of alkaline acidulous waters, 418; of arsenical iron waters, 446; of brine baths, '384; of heat, 247 ; of mineral baths, 373; of light, 51, 211, 236; of thermic, mechani- cal and chemical stimulation, 21, 34. Respiratory gaseous interchange in mineral baths, 373 Respiratory organs, catarrh of, alkaline acidu- lous waters in, 419; carbonated waters in, 417 (see also Air-passages; Catarrh; etc.); dis- eases of, bathing- and drinking-cures for, 469; cold rub for, 80; hydrotherapy of, 173. See also under Asthma; Bronchitis; Bron- chopneumonia ; Lungs; Pleurisy; Pneu- monia ; Pulmonary ; Tuberculosis, etc. Retrograde hypostatic congestion, 60 Revulsion, 246 Rex Ferro Lithia Springs, Ohio, 353 Rheinfelden, 386 Rheumatic affections, peat baths in, 405 ; chronic, sulphur baths in, 396; processes, hot applica- tion for, 127 ; sand bath for, 125. See also un- der Rheumatism. Rheumatism, ankylosis in, bathing-cures prepar- atory to orthopedic treatment of, 500; brine baths in, 385 ; electric light bath for, 238 ; hot- air baths in, 409 ; in syphilis, thermal sulphur- ous baths for, 467; phototherapy and helio- therapy of, 54, 221, 222, 238 ; steam bath for, 122 ; sun baths for, 52; thermal calcium or lime baths in, 412; valvular heart disease in, bath- ing-cures for, 500 ; acute, local hot-air bath for, 275 ; thermotherapy of, 258; chronic, mineral steam baths in, 408 ; sun and sand bath for, 219 ; sun bath for, 221; thermotherapv of, 258. See also under Ankylosis; Arthritis; Exu- dates; Joints ; and Muscles. Articular, wet pack for, 109; acute, hydro- therapy of, 141; wet pack for, 141 ; endocarditis in, precordial coil for, 142 ; swelling and tender- ness in, sheet bath for, 141; residual processes in, circular compresses for, 142 ; electricity and massage for, 142; chronic, bathing-cures for, 499 ; hydriatric applications for, 170 ; local hot- air bath for, 275; subacute, local hot-air bath for, 275. Gonorrheal, sequelae of, local hot-air bath for, 275. Muscular, hydrotherapy of, 172; thermic massage for, 277; chronic, bathing-cures for, 499; wet pack for, 109 ; obstinate, bathing-cures for, 500. See also under Myalgia. Rheumatoid arthritis, hydrotherapy of, 170; local hot-air bath for, 275. See also under Arthritis, Rheumatoid. Rhigolene, spraying with, 127 Rhinopharyngitis, bathing- and drinking-cures for, 469. See also under Catarrh. Richfield Iron Spring, N, Y., 443, 444, 497 Richfield Magnesia Spring, N. Y., 479, 490 Richfield Springs, N. Y., 398, 403, 439, 443, 449, 456, 466, 483, 485, 500 Richfield White Sulphur Spring, N. Y., 325, 360 Rieder, 240 Ringer, Sidney, 287, 289 Rippoldsau, 443^ 456, 472, 474, 485 Ritter, 370, 371 Riva-Rocci, 291 Rivanazzano, 386 Rives Mineral Spring, S. C., 330 Roanoke Red Sulphur Springs, Va., 319, 321, 365, 470, 483 Robertson, 531 Robin, 384 Rockbridge Alum Springs, Va., 345, 352>356> 357 > 400, 446, 456, 458, 481, 490, 502INDEX 563 Rock Castle Springs, Ky., 326, 469 Rock Enon Springs, Va., 336, 443, 444, 456, 459, 466, 497 ROemerquelle, Medbad-Sulzbrunn, 458 Rohitsch, 424, 425, 462, 473, 477, 482, 484, 490, 494 Rohrig, 35, 36, 39, 45, 370, 371, 372, 381, 384 Roisdorf, 421, 422 Roman-Irish baths, 409 Roncegno, 446, 447, 456, 463, 479 ; Ronneby, 400, 406, 445, 456 Rosbach, 417 Rose Hill (Hart Well), Willow Island, W. Va., 328 Rosenheim, 386 Rosscommon Spring, Pa., 320 Ross Mineral Springs, 111., 363 Round Spring, Mo., 339,353 Royal Gorge Hot Springs, Colo., 324, 331, 424, 435' 457, 479, 4§i Royal Oak Spring, Mich., 339 Royal Spring, Saratoga Spring, N. Y., 329, 342 Royat, 312, 353,421, 422, 458, 463,464 Rub, alcohol, 218, 529 Rub, cold, 76. See Cold rub. Rubber coils, 96 ; method of making, 521 Rubinat, Spain, 333 Rudolfsquelle, Marienbad, 479, 490 Runge, 158 Russian baths, 407 S Sabattus Mineral Spring, Maine, 320 Saegerstown Mineral Springs, Pa., 329 Sahli, 294, 295 Saidschitz, 434, 435, 474 St. Anne’s Well, Brighton, 445 St. Augustine, Fla., 486 St. Catherine’s Wells, Ontario, 424, 459, 500 St. Clair Springs, Mich., 338, 363, 386, 422, 449, 459, 497 St. Gervais, France, 333 St. Helena White Sulphur Springs, Calif., 337, 340, 360, 398 St. Honore, 472 St. Louis Spring, Mich., 321, 480 St. Lucas Bath, Buda-Pest, 397 St. Moritz, 311, 349, 351, 443, 444, 455, 456, 466, 474, 485, 475 Saint-Sauveur, 470 Saki, 407 Salies-de-Bearn, 386 Saline infusions, 279-296; hot, in heat exhaus- tion, 525 ; in scarlet fever, 140; irrigation, 279 ; solution, clinical, 287, 530 ; vapor, inhalation of, 385; waters, 331, 426, 433. See under Waters, Mineral. Salins, 386 Saloon Spring at Harrodsburg Springs, Ky., 435 Salt Lake City, Utah, 314 Salt Lake City Warm Springs, Utah, 338, 365 Salt Lake Hot Springs, Utah, 386, 428, 440, 457, 459, 468, 486, 495 Salt Lake Thermal Springs, Utah, 428. See also Salt Lake Hot Spring s. Salt Spring, Pa., 428 Salt Sulphur Springs, W. Va., 325, 335, 342, 365, 398, 432, 450, 498 Salutaris Spring, St. Clair Springs, Mich., 328, 355* 422, 458 Salvator Mineral Springs, Wis., 321 Salvator Spring, Eperies, 419,420. See Salvator- quelle. Salvatorquelle, Eperies, 419, 420, 429, 464, 482, 490,492 Salzbrunn, 419, 420, 429, 431, 432, 465, 469, 471, 472, 473, 489, 492 Salzbrunnen, Ems, 469 Salzhausen, 496 Salzquelle, Elster, 479, 494 Salzquelle, Franzensbad, 456, 478, 494 Salzschlirf, 429, 431, 432, 465, 492 Salzungen, 386 San Bernardino Hot Springs, Calif., 335 San Marco Sulphur Springs, Calif., 362 Sand baths, 118,124; combined with sunbath, 219; indications for, 125 Sand Beach Mineral Water, Mich., 343 Sandefjord, 406 Sander, 279 Satidrock, 445, 456 Sandwich Springs, Ontario, 424 Sanicula Spring, 111., 329 Santa Barbara Hot Springs, Calif., 335, 440, 468, 486 Santa Barbara Hot Sulphur Spring, Calif., 353, 379 Santa Rosa Hot Sulphur Springs, Calif., 362 Santa Rosa White Sulphur Springs, Calif., 335 Santa Ysabel, Calif., 328, 398 Santlus, 39 Sarat, 226 Saratoga A or Alum Spring, Saratoga Springs, N. Y., 328, 354, 430 Saratoga Springs, N. Y., 328, 341, 353, 354, 355, 403, 419, 420, 422, 428, 429, 430, 432, 458,464, 465, 470, 475, 476, 478, 480, 481, 483, 484, 489, 492, 494, 498 Saratoga Sulphur Springs, Neb., 364 Saratoga Vichy Spring, N. Y., 419, 420,470,481, 492 Saratoga Vichy Water, 466 Saturnism, chronic, steam cabinet baths for, 143 Sauerbrunnen, Bilin, 492 Sauerbrunnen at Radein,429 Sauerquelle, Radein, 492 Saxon, 458 Saxon-les-Bains, 495 Scarborough, 435 Scarlatina, hot baths and hot applications in, 525; hot drinks in, 525; hydrotherapy of, 139 ; tepid baths in, 525 ; warm baths in, 525 Scarlatinal angina, hydrotherapy of, 140 ; neph- ritis, saline infusions in, 140; thermother- apy in, 140 Scheveningen, 460 Schiff, 254 Schinznach, 397! 437 Schlamkessel, Yellowstone, 347 Schlangenbad, 312,- 340, 378, 480, 485, 486, 487, 488, 495 Schlossbrunnen, Carlsbad, 478 Schmalkalden, 428 Schmidt, 45 Schoenenberger, 51, 53 Scholz, 147, 374, 381 Schooley’s Mountain, Heath House Spring, N. J., 339 Schooley’s Mountain Spring, N. J., 326, 456, 495 Schott, 381, 382, 537; exercises, 537 ; treatment of heart disease, 381 Schroff, 442 Schuecking, 288 Schueller, Max, 171 Schultz, H., 436, 446 Schuyler County Springs, 111., 445, 476 Schwalbach, 311, 349, 350, 400, 443, 444, 455, 463, 474, 476, 487, 495,497 Schwartz, 382 Schweitzer, Paul, 358 Sciatica, acratothermal baths for, 378 ; bathing- and drinking-cures for, 488; hot applications for, 127,526; hot blanket compress for, 526; hot wet pack for, 526; hydrotherapy of, 163; incandescent electric light bath for, 239 ; min- eral steam baths in, 408; Scotch douches for, 89 Sclerosis, heat for, 258 Scotch douches, 81, 82, 396, 528; indications for, 85, 89 Scouttetten, 39, 373 Scrofulosis, arsenical iron waters in, 446; bath- ing- and drinking-cures in, 457 ; brine baths564 INDEX in, 384; charitable sanatoria for, 460; chronic diarrhea in, drinking-cures for, 479; cold full bath for, 70; cold sea bath in, 390; earthy waters in, 448; iodin waters in, 431; photo- therapy in, 54 ; simple sodium chlorid waters in, 427 ; skin diseases in, bathing- and drinking- cures for, 502 ; splenic enlargement in, bathing- and drinking-cures for, 483 ; erethistic, baths for, 459; sea baths for, 460; torpid, cold sea baths for, 390; steam bath for, 122. See also Dyscrasic processes ; and Glands, Lymphatic, Diseases of \ Scrofulous habitus, cold sea bath in, 390 Sea baths, 387, 388, 457; concentration of, 388; duration of, 391; effects and uses of, 389, 390 ; in scrofulosis, 460 ; indications for, 390 ; locali- ties of, 392; movement of water in, 388; seasons for, 391 ; temperatures, comparative, 39i Sea mud baths, 406 Sebastopol, 407 Seborrhea, invigorating applications in, 203 Secretion, disorders of, invigorating applica- tions in, 203; effect of alkaline acidulous waters on, 418 ; of carbonated waters on, 417 ; of heat on, 244,247, 249, 250; of light on, 212 ; of mineral steam baths on, 408; of sodium chlorid waters on, 426 ; of thermic and mechani- cal stimulation on, 37; of water-drinking on, 43)45- See also Diaphoresis; Diuresis; Per- spiration, etc. Secretions, effect of earthy waters on, 448; mor- bid, effect of Irish-Roman bath on, 409 Selters, 312, 331, 417, 421, 422, 463, 481, 493 Seltzer Spring, Saratoga Springs, N. Y., 329, 331, 354, 428, 429, 430 Seltzer Springs, Colo., 449 Senator, 38 Seneca Spa Springs, N. Y., 432 Seneca Spring, Glen Springs, N. Y., 319 Senile marasmus, premature, acratothermal baths in, 377 Sepsis, ice pack in, 516 saline infusions in, 294 Septicemias, saline infusions for, 280 Serebrenica, 456 Serrey, 371 Sexual desire, diminished, cold sitzbath for, 75 ; organs, diseases of, 198, 204, 494; diseases of, iron waters in, 442 ; irritability of, douche for, 85 ; female, diseases of, bathing- and drinking- cures for, 494 ; hydrotherapy of, 204 ; peat baths for, 405 ; steel baths for, 399 ; power, enfeebled, psychrophore for, 115. See under Menstrual disorders ; Pelvic organs, etc. Shallow bath, 218 Sharon Chalybeate Spring, N. Y.,. 336, 426, 445 Sharon Springs, N. Y., 336, 398, 456, 479, 480, 483, 485, 500 Sharon White Sulphur Spring, N. Y., 325, 360 Shealtiel Mineral Springs, Wis., 320 Sheboygan Mineral Spring, Wis., 358 Sheboygan Mineral Wells, Wis., 338, 428 Sheep Rock Spring, 320 Sheet bath, 78 ; in typhoid fever, 514 Shelbyville Lithia Spring, Ind., 353 Shocco Springs, N. C., 335 Shock, colonic irrigation in, 531 ; saline infusion in, 291; surgical, dry pack in, 276; with hemorrhage, peritoneal infusion in, 284; baths, local, 528. See under Baths. Shoshone Spring, Manitou, Colo., 325 Shultz, 43 Siemens, William, 226 Siliceous waters, 344, 345. See under Waters, Mineral. Siloam Springs, Colo., 428 Siloam Springs, Iowa, 320 Silurian Spring, Waukesha, Wis., 320 Silva, 181 Silver King Spring, Eastman Springs, Mich., 320, 353, 490 Simmons Hot Sulphur Springs, Calif., 362 Simpson sweat bath, 528 Sims, 2S1 Singultus, Winternitz combination compress for, 101 Sinnberger, 493 Siradan, 449 Sitka Hot Springs, Alaska, 398 Sitka Warm Sulphur Springs, Alaska, 362 Sitzbaths, 73 ; mode of action of, 73 ; cold, brief \ indications and counterindications for, 75; protracted, indications and counterindications for, 75; hot, method and uses of, 75; warm, effect of, on composition of blood, 32; indi- cations for, 75; sedative effect of, 74; tepid, uses of, 75 Sizer Mineral Spring, Pa., 330 Skagg’s Hot Springs, Calif., 319, 339, 341, 356 Skin, diseases of, bathing- and drinking-curcs for, 502; brine baths in, 385; carbonic acid baths in, 402 ; continuous bath in, 521; hydro- therapy of, 202; in scrofulous individuals, bathing- and drinking-cures for, 502; iodin waters in, 431; phototherapy of, 55; sunlight locally for, 225; chronic, steam bath for, 122; thermal calcium bath for, 412; chronic ulcer- ative, hot applications for, 127; effect of acid baths on, 380; of electric light on, 227; of drinking-water on, 42; of Irish-Roman baths on, 409 ; of light on, 212 ; of lime baths on, 412 ; of medicated baths on, 410; of mineral baths on, 373; of mineral steam baths 011,408; dry, sallow, an indication for care in sun and sand bath, 219 ; preparation of, for cold hydriatric applications, heat for, 259. See also Cutaneous. Sleeplessness, nervous, acratothermal baths in, 377; hot alcohol sponge for, 529. See also Hypnotics, Hydriatric • and Insomnia. Slushing, in thermic and in typhoid fever, 519, 524 Smith, Marion E., 507 Soda Spring, Hot Springs, Va., 319 Sodaville Sulphur Springs, Nev., 364 Soden, 428, 429, 458, 465, 469, 471, 472, 478, 480, 490 Sodic waters, 303, 318, 319. See also under Waters, Mineral; also Alkaline; Alkaline- saline; and Saline. Sodium chlorid waters, 306, 307,332, 416, 426. See also under Waters, Mineral; and Saline. Solar erythema, 53, 211 Solfatra, 437 Solutions for infusion, 287 ; for lavage, 532 Soolbader, 333, 383. See Brine \baths, under Baths, Mineral. Soolen, 333, 383, 426 Sour Lake Spring, Texas, 346 Sour Spring, Anderson Springs, Calif., 349 Source de l'Hopital, Vichy, 482 Source Pavilion, Contrexeville, 490 South Farm Mangano-Chalybeate Well, Conn., 321 Soyka, 53 Spa, 350, 400, 406, 442, 444, 455, 463, 474, 487, 495 Sparta (Wis.) Artesian Well, 443, 444 ; Magnetic Spring, 321, 350 ; Mineral Wells, 400, 443, 444, 476, 486 Spasin, colonic irrigation for, 531 ; hot and cold applications for, 172 : warm sitzbath for, 75 ; of bladder, cold sitzbaths for, 202 Spasmodic tic, cold shower-baths for, 167 Spastic state of vessels, hot compress for, 95 Spastic tabes, hydriatric measures for, 168 Special sense, organs of, diseases of, bathing- and drinking-cures for, 502 Speck, 36 Spermatorrhea, bathing- and drinking-cures for, 498; cold sitzbath for, 75; psychrophore for, 115 Spinal cord, diseases of, bathing- and drinking- cures in, 487 ; hydrotherapy of, 167 ; functional disorders of, running irrigation of the back for, 85 Spinal irritation, douche filiforme for, 89 ; thermal brine baths for, 385INDEX 565 Spleen, chronic enlargement of, drinking-cures for, 482 ; congestion of, Turkish bath for, 267 Splendid Geyser, 348, 352, 355 Spondylarthroses, myelitis in, bathing- and drinking-cures for, 487 Sponge, hot alcohol, 529 ; to induce sleep, 529 Sponging, 516. See Ablution. Spout Bath Spring, Hot Springs, Va., 320 Sprague hot-air apparatus, 126 Sprains, bathing-cures after, 501; local hot-air bath for, 275 ; local shock baths for, 528 Spray bath, mineral, 409; absorption of chem- ical constituents of, 371; effect of, 410. See also Bains a Vhydro/ere. Springboro Mineral Spring, Pa., 329 Springdale Seltzer Springs, Colo., 327, 424, 432, 435) 479' 480, 494 Spring Lake Well, Mich., 338, 340, 343, 479 Springs, Mineral, 299, 415. See Waters, Mineral. Sprinkling in thermic fever, 524; in typhoid fever, 513, 514,515. See also Fever, Typhoid. Sprudel, Carlsbad, 331, 479 Srebernik, 446, 447, 463 Staddman, 295 Stafford Mineral Springs, Miss., 310, 321 Stafford Spring, Conn., 327 Star Spring, Saratoga, N. Y., 329, 343, 354, 430 Starch baths, 411 Stark Mineral Spring, Conn., 319 Stasis, venous, in abdominal organs, abdominal binder for, 102 ; warm compress for, 94 Stassfurt salt, 387 Steam bath in tub, 122 Steam baths, 60 ; Russian, 407 Steam cabinet bath, 118; duration of, 121; effects of, 119 ; on composition of the blood, 31 ; horizontal, 118 ; indications for, 122; tempera- ture of, 121 Steam compress, 93 Steam mineral baths, 407 ; absorption of chemi- cals in solution during, 371 ; effects of, 408 ; indications, 408; localities, 408; methods, 407 Steamboat Springs, Colo., 361, 379 Steben, 400, 406, 443,444, 445, 456, 463,474,485, 495 Steel baths, 398 (see also under Baths, Mineral); waters, 306, 441. See also under Waters, Min- eral; also Chalybeate. Stellmachovich, 172 Sterility, bathing- and drinking-cures for, 495 Stiller, 381 Stimulants, effect of, on reaction, 47; with half- bath, 65 Stimulation, chemical, of mineral baths, 372; cutaneous, of acid baths, 380 ; electric, of min- eral baths, 373; general, fan douche for, 85 ; movable jet for, 85; with little heat abstrac- tion, plunge bath for, 61 ; mechanical of min- eral baths, 374; measure of, in hydrotherapy, 59 ; primary thermic, mechanical, and chemi- cal, 18 ; effect of, on heart, 28 ; effect of, on in- testines, 20; effect of, on metabolism, 21 ; effect of, on muscles, 20; effect of, on nervous system, 18; effect of, on organic functions, 20; effect of, on respiration, 21; effect of, on secretion and excretion, 21 ; vascular contraction and di- latation in, 20 ; profound general, cold shower baths for, 84; secondary effects of thermic, mechanical, and chemical, 21-26; on special tissues and organs, 27-38 ; thermic, of mineral baths, 374 Stinking Springs, N. Mex., 364 Stomach, action of carbonated waters on, 417; action of sodium chlorid waters on, 426; cancer of, lavage in, 534; catarrhal disorders of, Winternitz combination compress for, 101 ; chronic catarrh of, hydriatric applications for, 191; lavage fort 534; sodium chlorid waters in, 427; chronic inflammation of, Turkish bath for, 267 ; dilatation of, lavage for, 533 ; dis- eases of, abdominal binder for, 102; cold rub for, 80 ; drinking-cures for, 477 ; health resorts for, 478; hydrotherapy of, 190; partial ab- lution for, 80; excessive cooling of, by water-drinking, 45 ; functional insufficiency of, Winternitz combination compress for, 101 ; motor disorders of, Scotch douches for, 89; nervous disorders of, Winternitz combination compress for, 101 ; peristaltic movements of, effect of thermic stimulation on, 20, 27, 249 ; effect of water-drinking on, 45 ; secretions of, effect of thermic stimulation on, 38, 249; effect of water-drinking on, 45 ; secretory disorders of, Winternitz combination compress for, 101 ; tube, recurrent, 533 ; ulcer of, alkaline-saline waters in, 423 ; drinking-cures for, 478 ; hydro- therapy of, 192; lavage for, 534; sulphated iron waters in, 445; warm alkaline-saline waters in, 423. See also under Catarrh, Gas- tric ; Digestive organs; Dyspepsia; Gas- tric; Gastro-intestinal; Peristalsis, etc. Storm Lake Springs, Iowa, 326 Strangury, rectal dilator for, 116 Strasser, Alois, 36, 37, 136, 148 Strasser, Alois, 59-128 Strathpeffer, 386, 438, 508 Stribiing Springs, Va., 319, 321, 400, 446 Strontia Spring, Md., 356, 357 Struma, hydriatric measures for, 161. See Goiter. Stupor, half-bath for, 66 Sturm, 125 Subinvolution, intrauterine, irrigation for, 535 Suderode, 386 Sulphated iron waters, 326,.336, 350, 351, 441, 444. See under Waters, Mineral. Sulphur Bath, Va., 379 Sulphur Baths, 395. See Baths, Mineral. Sulphur Mountain Spring, Calif., 335 Sulphur Spring, Anderson Springs, Calif., 362 Sulphur Spring, Conn., 363 Sulphur Spring, El Paso de Robles, Calif., 328 Sulphur Spring, Garfield County, Wash., 365 Sulphur Spring, Washington Springs, Va., 325 Sulphur Springs, Ark., 362 Sulphur Springs, Calif., 328 Sulphur Springs, Kan., 363 Sulphur Springs, Oregon, 364 Sulphur Springs, Tex., 365 Sulphur Springs, Wyoming, 365 Sulphur Waters, 306, 308, 310, 358, 360, 416, 435. See also under Waters, Mineral. Suiza, 386, 497 Sulzbrunn, 498 Summit Soda Springs, Calif., 330, 356 SUN BATHS, 214 ; ancient method of, 219 ; cold applications after,217; combined with sand bath, 219 ; counterindications for, 221; duration of, 215 ; indications for, 221; method of preventing access of chemical rays in, 51 ; physiologic effects of, 219 ; technic of, 214 ; therapeutic ex- periences with, 54, 221; wet sheet rub after, 218. See also Heliotherapy. Sunlight, 50 ; composition of, 209 ; local applica- tion of, 222; duration of, 224; effects of, 222 ; Finsen’s method of, 223 ; indications for, 225 ; mode of action of, 225 ; technic of, 223 ; thera- peutic use of, 54, 213 Sunstroke, 213, 524 (see also Insolation; and Thermic Fever) ; electric, 227 Suppuration, stimulating compress to hasten, 94 Surgical operation, gastric lavage preliminary to, 534 ; saline infusion after, 293 Surprise Spring, Byron Hot Springs, Calif., 337, 343 Suwanee Sulphur Springs, Fla., 325, 363, 469 Swanlinbar, 438 Sweat baths, 118, 526; additional uses of, 527, 528 ; Simpson, 528 Sweat cabinets, 118 Sweating, acratothermal baths to induce, 377; dry pack to induce, 276 (see also under Diapho- resis ; and Perspiration); morbid, vitriol566 INDEX baths in, 400; of extremities, hand-baths and foot-baths for, 72 Sweating-cures in chlorosis, 147 Sweet Chalybeate Springs,Va., 336, 356, 400,444, 458, 481, 486, 490, 495 Sweet Spring, Bedford Springs, Pa., 470 Sweet Spring, Blue Lick Springs, Mo., 337 Sweet Spring, Sweet Springs, Mo., 338 Sweet Springs, Mo., 334, 338, 340 Sweet Springs, Pa., 466 Swimming bath, 218 Swimming pools, 397 Swinefad’s Arsenic Lithia Springs, Va., 337, 352, 447 Sylt, 460 Synovitis, local hot-air bath for, 275 Syphilis, bathing-cures for, 467; cold full bath for, 70 ; drinking-cures for, 467 ; drinking-cures for laryngeal, 470; dry pack for, 112; hot-air baths in, 409 ; hydrotherapy of, 204 ; incandes- cent electric light bath for, 240 ; iodin waters in, 431 ; Irish-Roman baths for, 409 ; lime baths for, 412 ; mineral steam baths in, 408 ; saline infu- sion for, 295 ; steam bath for, 122 ; sulphur baths in, 396; sulphurous waters in, 436; sweat baths in, 528 ; eruptions of, bathing- and drinking- cures for, 502; malignant, saline infusion in, 295; optic neuritis in, sweat baths for, 528; splenic enlargement in, bathing-cures for, 483; drinking-cures for, 482 ; tabes in, bathing-cures for, 487 ; drinking-cures for, 487 Szczawnica, 421, 422, 481 Szinye-Lipocz, 429 Szkleno, 413, 450, 451 Szliacs, 400, 402, 443, 444, 455 T Tabes dorsalis, brine baths in, 385; high bath for, 61; heat for, 258 ; hydriatric measures for, 167 ; pains of, warm baths for, 64 ; sulphur baths in, 396 ; thermal brine baths for, 385 ; spastic, hy- driatric measures for, 168 ; syphilitic, bathing- and drinking-cures for, 487. See also Ataxia, Locomotor. Table waters, 308, 417, 463, 464, 470 Talladega Spring, Ala., 361, 438 Tallerman, 171 Tallerman-Sheffield Apparatus, 272, 273 Tampa Spring, Glenwood, Colo., 483 Tanning, 211 Tar Spring, Ind., 443, 476 Tarasp, 470, 471, 473, 474, 476, 477, 479, 482, 484, 494 Tarasp-Schuls, 424,425,461 Tassajara Hot Springs, Calif., 362 Tate Epsom Spring, Tenn., 336, 450, 480 Tate Springs, Tenn., 488, 490 Tatra-Fuered, 485 Taunusquelle, near Frankfurt, 417 Taurus Geyser, 348 T-bandage compress, 102 Tchokrak, 407 Teissieres-les-Boulies, 417 Tempelbrunnen, Rohitsch, 494 Tempelquelle at Steben, 443 Temperature, effect of water-drinking on, 41; elevating acratothermal baths, 378; high, tolerance of, 25, 26, 123, 125; high, morbid, repetition of half-bath for, 66. See under Hy- perpyrexia. Tendons, diseases of, hot application for, 127 Tenesmus, rectal dilator for, 116 Tenosynovitis, local hot-air bath for, 275 Testicle, chronic inflammation of, bathing- and drinking-cures for, 498; inflammatory disease of, T-bandage compress for, 102 ; neuralgia of, psychrophore for, 114 Tetanus, saline infusion for, 294 Texas Sour Springs, Tex., 344, 346, 490 Therapeutic methods of water-drinking, 43 Theresienbrunnen, 478 Thermal baths, electric conducting power of, 374 Thermic fever, 516, 524 ; hydriatric management of, 524; ice bags in, 524; ice cradle in, 524; ice pack in, 525 ; ice rub in, 524 ; ice-water coils in, 524; ice-water enemas in, 525; saline infusion for, 294 ; slushing in, 524 ; sprinkling in, 524 Thermic irritation of mineral baths, 374 Thermic massage, 277 Thermophore, 277 THEEMOTHEKAPY, 242 ; anatomic basis of, 250 ; general applications of, 258, 259 ; general in- dications for, 258 ; after ligation of arteries, 276 ; In Anasarca, 528; anemia, 266; ankylosis, fibrous, 275; apoplexy, 267; arteriosclerosis, 267; arthritis, rheumatoid, 275; arthritis, trau- matic, 275; autointoxication, acute, 258; auto- intoxication due to chronic dyspepsia, 266 ; Bronchitis, acute, 528 ; bronchitis, chronic, 259 ; bronchopneumonia, 528; Cardiac dilatation, 267; catarrh, bronchial, chronic, 259; catarrh, intestinal, 259, 267; cerebral congestion, 267; cerebral congestion, chronic, 259, 260; cerebral hyperemia, 267; chlorosis, 266; cholera, 525; collapse of infectious fevers, 258; collapse of typhoid fever, 258; congestions, 267; coryza, 528 ; Diabetes, 258, 266 ; diathetic maladies, 258 ; dilatation, cardiac, 267 ; dyspepsia, chronic, 266 ; Exhaustion, 258 ; exophthalmic goiter, 267 ; Fatigue, 258; Gangrene, senile, threatened, 276; gastritis, chronic, 259, 267; gout, 275; Heart disease, organic, 267; heat exhaustion, 525; hepatic congestion, 267; hypochondria, 266; Inflammations, 259, 260; influenza, 528; Joint tuberculosis, 275; Laryngitis, acute, 528; leg ulcer, 275; locomotor ataxia, 266; Measles, 525; melancholia, 266; myelitis, chronic, 266; Nephritis, acute, 527; nervous diseases, chronic, 266; neuralgic affections, 276; neurasthenia, 266; neuritis, 266; Obesity, 258, 266; ovarian congestion, 267; ovarian in- flammation, 260; Paralysis, 266, 275; paresis, 266; pelvic congestion, 261; pelvic inflamma- tion, chronic, 259 ; pneumonia, 258 ; poisoning, 258; poisoning, metallic, 528 ; Renal congestion, 261, 267; rheumatism, acute, 258, 275; rheuma- tism, articular, chronic, 275; rheumatism, chronic, 258; rheumatism, gonorrheal, 275; rheumatoid arthritis, 275; Scarlet fever, 525 ; skin affections, irritable, 267; spinal conges- tion, chronic, 267 ; spinal sclerosis, 25S ; splenic congestion, 261; sprains, 275; synovitis, 275; syphilis, 377,385,528 ; Tabes dorsalis, 258 ; tachy- cardia, 267; tenosynovitis, 275; Uremia, 527; uric acid diathesis, 258; uterine congestion, 267 ; for diaphoresis, 258 ; methods of, 262-278 ; modes of application, general, 260; local, 260; practice of, 258; principles of, 242. See also Heat; Hot air; Sweat-cabinets; Turkish bath, etc. Thirst in diabetes, hydrotherapy for, 150 Thompson’s Bromine and Arsenic Spring, N. C., 3*9» 343, 352, 432, 447, 457 Thomson, 370 Thorn Spring, Montesano Springs, Mo., 360 Thorp’s Spring, Tex., 476 Three Springs, Pa., 356 Throat coil, 95 Throat compress in diphtheria, 140, 523; in la- ryngitis, 523, 524; in pharyngitis, 523, 524; in scarlatinal angina, 140; in tonsillitis, 524; in tracheal affections, 523 Tic, spasmodic, cold shower-baths for, 167 Tilford’s Mineral Well, Tenn., 357, 361 Tioga Mineral Wells, Texas, 338 Tissue pressure, 29 Tissues, flooding of, water-drinking for, 43 Tobelbad, 378, 486, 488 Toeplitz, 312, 487 Toeplitz-Krapina, 485, 500 Toeplitz-Schoenau, 379, 465, 485, 486, 500 Toeplitz-Trencsin, 465, 485, 500INDEX 567 Tolenas Spring, Calif., 329, 339, 341, 431, 458 Tolerance for high temperature, 25, 26, 123, 125 Tomichi Hot Springs, Colo., 363 Tone, muscular, effect of hydriatric stimulation on, 25, 27; vascular, effect of hydriatric stimu- lation on, 25, 28 Tonometer, 29 Tonsillitis, throat compress for, 523 Topeka Mineral Wells, Kan., 3257, 350, 424, 478, 484 Topusko, 379, 500 Torf’s Artesian Well, Concord, N. H., 325 Torticollis, alternating hot and cold applications for, 172 ; thermic massage for, 277 Towel bath, 514 Toxic absorption, disorders from, bowel irriga- tion for, 532. See also Autointoxication. Toxic products, elimination of, Scotch douche for, 82 ; heat for, 258 ; irrigation for, 531 ; saline infusion for, 293. See Intoxication. Tracheal disease, throat compress in, 523 Traumatic arthritis, treatment of, 275; lesions, sequels of, sulphur baths for, 396 Traumatism, sequels of, bathing-cures for, 501 Trefriw, 445, 479 Tremors, in exophthalmic goiter, hydriatric measures for, 161 Trencsin, 500 Trenzsin-Toeplitz, 397 Treves, 254, 258 Trinkquelle, Hall, Upper Austria, 458 Triton Springs, Saratoga, 430, 432 Trophic disorders, application of concentrated electric light ray for, 240; sunlight for, 240 Trouve. 537 Tubal disease, colonic irrigation, 531; vaginal ir- rigation in, 535. See also Pelvic; and Sexual organs, Female. Tubbing, 508. See Baths ; and Cold bathing. Tube, esophageal, 532 ; stomach, 533 Tuberculosis, charitable sanatoria for, 460; cold full bath for, 70; gavage in, 534; of joints, local hot-air bath for, 275; hot application for, 127; pulmonary, 175,471 ; Aberg’s hydrotherapeutic method in, 176; bathing-cures for, 472; drink- ing-cures for, 471 ; fever in, 146, 515, 522 ; hard- ening in, 174; hemorrhage in, 176; prophylaxis of, 173 ; hydrotherapy of, 175, 176 ; waters counterindicated in, 472 Tuberculous bone-disease, chronic, concentrated electric light rays for, 240; sunlight for, 240; joint-affections, hot application for, 127 Tueffer, 379, 480, 488 Tumors, 496 ; see also Neoplasms, 497 (see under Uterus) ; of lymphatic glands, arsenical iron waters in, 446 ; ovarian, incipient, bathing- cures for secondary symptoms of, 497. See also under Ovarian. Tunbridge Wells, 443, 456, 466, 474,476 Turban and Grand Geyser, Y. P., 348, 352, 355 Tuscan Springs, Calif., 431, 498 Tuscarora Lithia Spring, Pa., 430 Tuscarora Sour Spring, Canada, 344 Tympanites relieved by colonic irrigation, 531 Tympanum, catarrh of, bathing- and drinking- cures for, 503 Typhoid fever, hydrotherapy of, 134, 508. See under Fever, Typhoid. Typhus, saline infusion in, 292 U Ukiah Vichy Spring, Calif., 330, 351, 356 Ulcerative affections of skin, chronic, hot appli- cation for, 127 ; processes involving skin of ex- tremities, circular compress for, 103 Ulcers, chronic, thermal calcium baths in, 4m ; chronic, saline infusions in, 296; gastric, alka- line-saline mineral waters for, 423 ; drinking- cures for, 478 ; hydriatric measures for, 192 ; lavage for, 534; leg, chronic, application of concentrated electric light rays for, 240; circu- lar and stimulating compresses for, 203 ; sun- light for, 240; torpid, hot circular bandage for, 103; tuberculous, phototherapy of, 54 Ulmann, 127 Ungemachquelle at Baden-Baden, 429 Union Spring, Saratoga Springs, N. Y., 329, 342, 354, 430, 432 United States Spring, Saratoga Springs, N. Y., 329, 354, 430 Upper Blue Lick Spring, Ky., 337, 342, 428, 429 Urea, elimination of, diminished by carbonated baths, 381 ; effect of brine baths on, 384 ; of min- eral steam baths on, 408; of perspiration on, 37 ; increased by cold sea baths, 390 Uremia, colonic irrigation in, 531; hot-air bath in, 527 ; hot bath in, 527; hydrotherapy of, 200; saline infusion in, 294 Urethra, cooling sound for, 113; hydrophore for, 117; psychrophore for, 113; blennorrhea of, bathing-cures for, 491; drinking-cures for, 489 Uric acid concretions, alkaline acidulous waters in, 419; drinking-cures for, 491; diathesis, earthy waters in, 448; hydrotherapy of, 150; prolonged hot bath for, 258 ; sun bath for, 221; Turkish bath for, 266; elimination of, de- creased by cold sea baths, 390; effect of alkaline acidulous waters on, 418; effect of alkaline- saline waters 011, 423; effect of brine baths on, 384; effect of lithia waters on, 427; effect of mineral steam baths on, 408; effect of sodium chlorid waters 011,427 ; sulphur baths for, 396 ; lithiasis, drinking-cures for, 492 ; sediment, drinking-cures in, 491. See also under Allox- uria; Calculi; Diathesis ; Gouty; Lithemia, etc. Urinary apparatus, diseases of, bathing-cures for, 491; drinking-cures for, 489 ; hydrotherapy of, 198; organs, chronic catarrh of, alkaline muri- ated acidulous waters in, 421 ; chronic catarrh of, earthy waters in, 448 ; calculi, 491 (see under Calculi) ; secretion, effect of alkaline acid- ulous waters 011,418; effect of alkaline-saline waters on, 423; effect of brine baths on, 384; effect of mineral steam baths on, 408 ; effect of thermic influences 011,38, 250; effect of water- drinking on, 44 Uropoietic tract, chronic catarrh of, bathing-cures for, 491; drinking-cures for, 490 Urticaria, sulphur baths in, 396; chronic, bath- ing- and drinking-cures in, 502 Ussat, 413 Utah Hot Springs, Utah, 337, 386, 387, 428, 429, 451, 479 Uterine appendages, inflammation of, hot douch- ing for, 535; contractility, hot irrigations for, 535 ; excitability, hot irrigations for, 535 Uterovaginal mucous membrane, disease of, bathing-cures for, 4911 drinking-cures for, 490 Uterus, myoma of, bathing-cures for secondary symptoms of, 496 V Vade Mecum Spring, Stokes County, N. C., 354 Vagina, dilator for, 117; irrigation of, 534. See under Irrigation. Vaginal catarrh, vitriol baths in, 400; douching, irrigation of bowel as a substitute for, 531 Vaginismus, occipital bath for, 71; rectal dilator for, 116 Vallejo Sulphur Springs, Calif., 362 Vais, 318, 419, 420, 451, 464, 490 Valvular disease. See under Heart. Vapor baths, 526. See also under Baths. Vapor, saline, inhalation of, 385 Variety Springs, Va., 446 Variola, red light in, 55 Vascular areas, correlated, 253; tension, effect of, thermic influences on, 20, 24, 28; effect of568 INDEX water-drinking on, 43. See under Blood pres- sure ; and Circulation. Vasomotor system, effect of water-drinking on, 42 Venereal diseases, hydrotherapy of, 204 Venesection, with saline infusion, 295 Vermont Mineral Spring, Vt., 336 Vernet-les-Bains. 397 Verona Mineral Springs, N. Y., 353, 476 Versailles Medical Springs, 111., 351 Versailles Medical Springs (Alum Spring), Mo., 336 Vesta Mineral Spring, Waukesha, Wis., 320 Vicar’s Bridge, 445 Vichy, 311 , 318, 322, 419, 420, 462, 464, 477, 479, 481,482,489,491,494 Vichy Spring, Saratoga Springs, N. Y., 329, 343> 354, 420, 422, 430, 489, 492 Vichy Springs, Colo., 479 Victoria, Buda-Pest, 435 Victoria Mineral Springs, Nebraska, 325 Victoria Spa, 474 Victoria Spring, Saratoga Springs, N. Y., 329 Victorquelle at Koenigswart, 443 Victory Spring, Mt. Clemens, Mich., 319 Vihnye, 443, 444 Vinadio, 397 Vinay, 69 Vincenzbrunnen, Luhatschowitz, 458 Virginia Magnesian Lithia Springs, Va., 430 Virginia Waukesha Lithia Springs, Va., 430 Viscera, abdominal, muscular weakness of, fan douches for, 85; pelvic, chronic inflammation of, 25a Vitriol baths, 400,457 (see under Baths, Mineral); waters, 306, 326, 336, 350, 351, 444. See under Waters, Mineral. Vittorio, 386 Vogl, 513 Voit, 35, 51, 52, 212 Von Noorden, 442 Vomiting, lavage for, 533; Winternitz’s combi- nation compress for; 101, 193; in anemia, trunk compress and stomach coil with very hot running water for, 147 ; in peritonitis, trunk compress with cold abdominal coil for, 197 Vulvitis, rectal dilator for, 116 W Waconda Spring, Kansas, 337, 340, 341, 478 Wagner Spring, Oregon, 321 Waldquelle, Marienbad, 478 Walker, Swift, 197 Wallawhatoola Alum Springs, Va., 345, 490 Walley’s Hot Springs, Nev., 335, 379 Walton, George E., 309, 310, 332, 358 Walton’s classification of mineral waters, 309 Warasdin, 500 Warasdin-Teplitz, 397, 406, 465, 485 Warm Springs, Arlc., 356 Warm Springs, Ga., 325, 378, 488, 490, 495 Warm Springs, N. C., 364 Warm Springs, Utah, 340, 387 Warm Springs, Va., 327, 398, 480 Warm Sulphur Spring, N. Mex., 364 Warm Sulphur Springs, Calif., 362 Warm Sulphur Springs, Idaho, 363 Warm Sulphur Springs, Va., 451 Warmann, 281 Warmbrunn, 379, 465, 485, 486, 487, 500 Warnemunde, 392, 460 Warren, 531 Wasatka Mineral Springs, Utah, 338 Washington Lithia Well, N. Y., 490 Washington Spring, Saratoga, N. Y., 329, 341 Washington Springs, Va., 325, 326, 352, 443 Waste, increase of, water-drinking for, 44 Water, absorption of, effect on blood, 42 ; ad- ministration of, 43 ; chemical effects and in- ternal uses of, 39, 40; drinking of, effect on bile secretion, 45; effect on body-weight, 44; effect on metabolism, 44 ; effect on oxidation, 44 ; effect on peristalsis, 45 ; effect on pulse, 40 ; effect on renal secretion, 44 ; effect on skin, 42 ; effect on temperature, 41 ; effect on vasomotor system, 42 external application of, 17, 39 ; influence of car- bon dioxid in, 39 Water-bags, 60, 277 ; bed, Hebra’s, 520 (see un- der Baths) ; coils. See under Coils. Waters Mineral, 299, 415; classification of, 300, 301, 302, 416 ; American, 309 ; compara- tive, 305 ; comparative, of European, 311 ; Sng- , lish, 308 ; French, 307 ; German, 305 ; Walton’s, 309; Weber's, 308 Varieties of— Acid, 302, 303, 310, 343 ; distribution of, in the United States, 344; muriated, 344; siliceous, 344 ; sulphated, 344, 345 Acidulous, 303, 304, 306, 355, 380, 417 ; effects and uses of, 417 ; localities, 417 ; table waters, 4i7 Acratothermal, 306, 309, 376, 416, 452 Alkaline, 301, 302, 308, 310, 317, 416, 417 ; com- parison of American with European, 322 ; dis- tribution of, in United States, 318; table of American, with analyses, 319 ; acidulous, 418 ; analysis, table of, 420; effects of, 418; indica- tions for, 419; localities of, 419; calcic, 318, 319; calcic-magnesic, 320; calcic-sodic, 320; chalybeate, 318, 320, 350; lithic-so&Sz, 320; magnesia, 318 ; magtiesic-sodic, 319 ; muriated acidulous, 420 ; analysis, table of, 422 ; effects and uses, 420 ; indications, 421 ; localities, 421; potassic, 318; sodic, 319; sodic-borated, 319; sodic-calcic, 319 ; sodic-calcic-magnesic, 319 ; sodic-magnesic, 319 Alkaline-saline, 302, 323, 324, 422 ; analyses, table of, 424; classification, comparative of, 323 ; comparison of American with European, 331 ; constituents of, 422 ; distribution of in the United States, 323 ; dosage of, 423 ; effects and uses of, 423 ; indications for, 423 ; localities of, 424. Muriated, American, analyses, table of, 328 ; calcic-magnesic-sodic, 330 ; calcic-potas- sic, 330; calcic-sodic, 328; chalybeate, 330, 351 ; sodic, 328 ; sodic-calcic, 328 ; sodic-mag- nesic, 329. Sulphated, American, analyses, table of, 324 ; calcic, 325; calcic-magnesic, 325; calcic-potassic, 325; calcic-sodic, 325; chalybeate, 326, 350; sodic, 324 ; sodic-magne- sic, 324; sodie-magnesic-calcic, 324 Arsenic, 351 Arsenical iron, 306, 351, 446 ; analysis, table of, 447 ; dosage of, 446; indications for, 446 ; localities of, 446 Azotized, 303, 356 Bitter, 306, 416, 433 ; action and effects of, 433; analyses, table of, 435 ; constituents of, 433 > dosage of, 434 ; indications for, 434 ; local- ities of, 434 Brines, 306, 383, 416, 426 Bromin, 306, 416, 340 (see also iodo-bromic), 430 ; analyses, table 01,432 ; constituents, 430; effects and uses, 431; localities, 431 Calcareous, 306 Calcic, 303, 310, 318, 319, 412, 448. See also under Alkaline; Alkaline-saline ; and Earthy. Carbonated, 303, 304, 306, 355, 380, 417, 441 Carbureted, 303, 357 Chalybeate, 303, 306, 308, 310, 317, 318, 334, 336, 349, 441* 444 ; alkaline, 318, 320, 350 ; alka- line-saline, 326, 330, 350, 351 ; distribution of, in the United States, 349 ; saline, 351. See also under Iron and Arsenical iron. Common Salt, 306, 426. See Sodium chlorid. Earthy, 306, 416, 448 ; analysis, table, 451 ; constituents, 448 ; effects and indications, 448 ; dosage, 449 ; localities, 449 Epsom Salt, 306, 433, 435 Ferruginous, 308. See also Chalybeate ; and Iron.INDEX 569 Glauber’s Salt, 306, 332, 335, 433, 435, 461 Indifferent, 304, 306, 308, 310, 416 Iodin, 430 Iodobromic, 340, 430 ; of the United States, 341 Iron, 306, 307, 349, 416, 441; arsenical, 306, 351, 446 ; carbonated, 306, 441 (see also Chalybeate ; Iron ; and Steel) ; sulphated or vitriol 441, 444 Lithia (also titillated or tit hie), 303, 353, 427; localities of, 353, 429 ; of the United States, 353 ; uses of, 427' Magnesic, 318, 319, 433, 448. See also under Alkaline ; and Alkaline-saline. Muriated, 308, 331,337, 344, 416, 420, 426. See also under Alkaline-saline ; and Saline. Neutral, 310. See also Indifferent. Non-gaseous, 303 Non-potable, 300 Non-thermal, 302 Oxygenated, 303, 357 Ozonated, 357 Potable, 300 Potassic, 303, 318 Purgative, 301, 310 Saline, 302,310, 331, 335, 351,383, 416, 426, 433; comparison of American with European, 339; distribution of, in the United States, 334; borated, sodic, 339 ; chalybeate-sulphated, 336 ; muriated, 331, 337; calcic, 338; chalybeate, 339 ; magnesic, 338 ; magnesic-sodic, 338 ; sodic, 337) 338; sodic-calcic, 338; sodic-calcic-mag- nesic, 338; sodic-magnesic, 338; sodic-potassic, 338 ; sulphated, 331, 335, 33^ ; calcic, 335, 336 ; calcic-alumino-manganous, 336; calcic-magne- sic, 335; calcic-sodic, 335; calcic-sodic-mag- nesic, 335 ; chalybeate, 336; magnesic, 335; magnesic-aluminic, 335; sodic, 335 ; sodic-mag- nesic, 335; sulphated-muriated, 337; calcic- magnesic-sodic, 337; magnesic-sodic, 337 ; sodic, 337; sodic-calcic, 337 ; sodic-calcic- magnesic, 337 ; sodic-magnesic, 337 ; sodic-po- tassic, 337 ; table of American, with analyses, 335 Siliceous, 344 Sodic, 303, 318, 319. See also under Alkaline ; Alkaline-saline ; and Saline. Sodic muriated, 303, 333, 337, 338, 416, 426. See also under Saline. Sodic sulphated, 303, 335, 433)435, 461. See also under Saline. Sodium chlorid, 306, 307, 331, 333, 337, 338, 416, 426 ; brontin, 340, 430; analyses, table of, 432 ; effects and uses of, 431 ; localities of, 431 ; iodin, 340, 430; iodobromic, 340, 341; lit hi a, 353, 427 ; localities of, 353, 429 ; lithic, 303 ; simple, 426 ; analyses, table of, 429 ; dosage of, 427 ; effects and uses of, 426 ; indications for, 427 ; localities of, 428. See also under Brine; and Saline. Steel, 306, 349, 356, 441. See also under Cha- lybeate ; and Iron; dosage, 442; effects and uses of, 441; indications for, 442 ; location of, 442 Sulphated, 324, 331, 333, 335, 336, 416; acid, 344, 345 ; muriated, 334, 337 (see also under Alkaline-saline; Bitter; and Saline) ; iron, 306,350,351,444 Sulphocarbonated, 304, 359, 360, 361 Sulphur, 301, 306,308, 310, 358, 416, 435 ; classi- fication of, 435; counterindications for, 436; distribution of, in the United States, 360; dosage of, 437 ; effects and uses of, 436 ; indica- tions for, 436; inhalations of, 437; localities of, 437 Sulphureted, 303; list of, in the United States by States, 362 Table Waters, 308, 417 Thermal, 301, 302, 308, 310, 313, 376, 412, 416, 452 ; cause of heat of, 314; distribution of, in the United States, 315 Vitriol, 441, 444 ; analyses, table of, 445 ; dos- age of, 445; employment of, 444; localities of, 445. See also Sulphated iron ; Vitriol. Waukesha Mineral Springs, 450, 464, 477, 480, 494 Wave baths, 374, 390 ; mechanical irritation of, 374 Wayland Spring, Glenola Springs, Virginia, 319 Weakness, cold sea bath in, 390; half-bath for, 67 ; motor, Scotch douche for, 82 ; of abdominal organs, cold sitzbath for, 75; muscular, of abdominal viscera, fan douches for, 85 Weber, Sir H., and F. Parkes, 308, 309, 318, 357, 358 Webster Salt Sulphur Spring, W. Va., 338, 353 Weight, body, decrease of, from excessive water- ■ drinking, 44 ; gain in, by water-drinking, 44 Weilbach, 403, 421, 422, 429, 437, 465, 470, 472, 492 Weissenburg, 413, 450, 451, 470 Welcome Island Lithia Spring, Michigan, 320 Wenzelquelle, Rippoldsau, 456 Wernatzerbrunnen, 493 Wessington Springs, S. D., 365 Wesson’s Iron Spring, Fla., 444 West Baden Springs, Ind., 327, 356, 357 West Nashville Sulphur Springs, Tenn., 360 West Newfield Spring, Me., 363 West Springs, S. C., 325 Wet pack, 60, 104, 514; counterindications for, 109 ; duration of, 106; mode of action of, 105 ; mode of employment of, 104 ; Buxbaum’s modi- fication of, no ; hot, 525. See also under Pack. Wet sheet rub, after sun bath, 218 Wet stockings, 103 Weyrich, 37 Whann Alkaline Lithia Mineral Springs, Pa., 329 Wheeling, West Virginia, 315 Whelan’s White Sulphur and Mineral Springs, Nev., 364 White Mineral Springs, Minn., 320 White Rock Mineral Spring, Waukesha, Wis., 320, 357 White Springs, Fla., 469 White Sulphur Mineral Springs, Ky., 363 White Sulphur Spring at El Paso de Robles, Calif., 438 White Sulphur Spring at Richfield Springs, N. Y., 439, 449 White Sulphur Spring, Blue Lick Springs, Mo., 337 White Sulphur Spring, Byron Hot Springs, Calif., 330 White Sulphur Spring, Calif., 340, 360 White Sulphur Springs, Ala., 362 White Sulphur Springs, Fla., 363 White Sulphur Springs, Ga., 363 White Sulphur Springs, Iowa, 328, 363 White Sulphur Springs, La., 363 White Sulphur Springs, Miss., 364 White Sulphur Springs, Montana, 324, 364 White Sulphur Springs, Ohio, 364 White Sulphur Springs, Okla., 327 White Sulphur Springs, Oregon, 364 White Sulphur Springs, Pa., 364 White Sulphur Springs, Tenn., 365 White Sulphur Springs, Tex., 365 White Sulphur Springs, W. Va., 480 White Sulphur Well, Ky., 363 Wiesbaden, 312, 333, 428, 429, 458, 462, 464, 478, 479, 481, 483, 485, 487, 489, 490, 500 Wilbur Springs, Calif., 326 Wildbad, 379, 464, 465, 485, 487, 488, 495 Wildbad-Sulzbrunn, 458 Wilde, 211 Wildegg, 431, 432 Wildungen, 311, 449, 451, 479, 490, 492 Wilhelinsquelle at Ems, 429 Wilhelmsquelle at Kronthal, 417 Wilhoit’s Soda Spring, Oregon, 330, 351 Williams’s Springs, Mo., 325 Williamstown, Massachusetts, 315 Wilson, J. C., 509 Windsor Sulphur Springs, Mo., 363 Winternitz, Wilhelm, 59, 60, 64, 85, 95, 100, in, 122, 133, 140, 148, 176, 181, 183, 192, 193, 221, 236, 244,370.$7° INDEX Winternitz, Professor Wilhelm, 17-55 Wipfeld, 470 Witch’s Caldron (California Geysers), Calif., 335 Witlekind, 386 Witter’s Mineral Spring, Calif., 327, 331 Wolf Trap Lithia Springs, Va., 356 Women, diseases of, 204, 494; acid baths in, 381 ; brine baths in, 384; peat baths in, 405; steel baths in, 399. See also under Sexual organs, Female. Woodhall Spa, 386, 431, 432, 458, 459, 473, 478, 498 Wootan Wells, Texas, 400, 464 Wounds, gunshot, bathing-cures after, 501 Wright’s Epsom Lithia Well, Tenn., 335 Wringer for hot wet pack, 526 Wurtzel Mineral Well, Mich., 329 Wyandot Magnetic Well, Ohio, 364 Wyandotte White Sulphur Spring, Mich., 363 Wyk, 460 Wyk-on-the-Foehr, 460 X X-rays, 50 Y Yampa Spring, Colo., 337, 383, 44°, 457 Yates Sulphur Springs, N. Y., 364 Yellow Springs, Ohio, 321 Yellow Sulphur Springs, Tenn., 365 Yellow Sulphur Springs, Va., 326, 365, 450 Yellowstone National Park, 315, 341, 344, 345, 346, 347, 352, 353, 355 ; springs of, 315 York Sulphur Springs, Pa., 364 Young’s Medicinal Well, Mo., 337 Young’s Mineral Springs, Calif., 357 Young’s Natural Gas Well, Calif., 327, 341 Ypsilanti Mineral Well, Mich., 339, 341, 438, 458 Ypsilanti Moorman Mineral Well, Mich., 337 360, 386 Ypsilanti Springs, Mich., 483 Z Zaizon, 43T, 432, 458 Ziemssen, 66, 68 Ziemssen’s graduated bath, 68 Zimmermann, 389 Zollhaus, 417 Zonian Springs, 111., 320 Zoppot, 460 Zuntz, 35, 36, 384