PR I N C I PLES A ND P R A C T I C E

OF

HY D R O T HER APY -

STUD E NT S A ND PR A C T I T I O N ER S

OF

ME D I C I N E

mbod y ing a Con s ideration of the

E
Sc i e nt ifi c B as is T ec hniqu e an d Therapeutic s
,

of H y drotherap y and s ome A llied B ranch es of

P h y s iolog ic Thera p y

7
8

GE O R GE K NA PP A BBO TT A B M D , .
'

.
, . .

D ea n ofF a cu l ty an d
P r o fe ss o r of P h y si o l o g i c T h e ra p y a n d P r a c ti c e of M e d i c i n e
v
i n T h e C o l l e g e of M e d i c a l E a n g e l i s t s
S u p e ri n t e n d e nt of T h e L
o rn a Li nd a H o s p i t a l

SEC O ND ED I T I O N , R EV ISE D A N D E N L A R G ED
W ITH 1 28 I LLU STR A T IO NS

THE CO L L E G E P R E SS
L O MA L IN D A C A L , .
C op yri gh t
L orna
 P R E F A CE T O SE CO N D E D I T I O N

HE ki ndl y rece ption given the fi rst edition of H Y D R O T H E R

A F Y in Spite of i t s many faults and the reque sts for a
, ,

text thoroughly i ll u strated have indu ced the author and pub ,

l i she r s to p re pare th is revised an d enlarged edition The .

w rite r more than ever real ize s the i mposs ibil ity of making any
text book a complete treat i se and e speciall y so i n the rapeutics
-

, ,

the s cie nce and art of wh ich are advancing so ra pidl y .

Much ne w matte r has been added among wh ich are : A ch ap

.
,

ter on l nsa n z ly a nd D r ug A ddi cti ons for which the author de

'

s i r e s t o thank Dr J e ss ie H S impson of the S outhe rn Cal iforni a

. .

S tate H osp ital for the In sane ; a section on P r escr ip ti on I I

a n d T rea l m en l C om o z n a i i on s; and one on H y d r oI /z e r ape u /z c A pp a
' '

For condu cting an original r e

'

T rea tm e ui R oom s
’
r a l u s a na .

se arch i nto the eff e cts of tonic h ydrothe rapy u pon the meta b o l
i sm of i ndiv idu al s on a l ow p roteid diet the author i s indebted ,

to hi s col lea g ue Dr E H Ri sle y ,

. . . .

Many of the new illu strations have been p repared in th e

Laboratory of P hys iologic The rap y of The Col lege of Me d i c a l
E van gel is ts a nd i n The Loma Linda H os pital For aid i n th i s .

work the author de sire s to acknowledge the hel pful a s si stan ce

of medical stu de nts nurse s and others and e speciall y me d i cal
, ,

students Wm R i c hl i and L D Trott i n t he pre paration of

,
. . .
,

drawings and charts For diagram s and il lu strations copied

.

from medical l ite ratu re we have e ndeavored to gi ve full c red it .

For cuts fu rni shed thanks a re du e to Dr H P Coil e the . . .

,

H o ffmann B ill ings Manufactu ring Com pan y J ame s B Cl ow ,

.

S ons the B oston S u rgi cal S u p pl y Com pa n y a nd Mr A

, , . .

Ca mpbell .

Last bu t not least thank s a re du e to The College P res s for

, ,

it s endeavor to fu lfil l the wi she s of the author i n the pre pa ra

tion of a pre se ntabl e text .

Lo ma Linda Cal ifornia ,

G K A . . .
 P R E FA C E

O apol og y nee d be gi ve n for the pre sentation of a work on

hydrotherapy In sp ite of the advance s made i n mode rn
.

ph ysiologic the rapy in general h ydrotherap y i s still a bran ch

,

of therapeut i cs bu t l ittle u sed by the general practitioner Th e .

reason i s not di ffi cul t to find A s a scie nce i t rece ive s but
.
,

s cant atte ntion from teachers of the rapeuti cs and i n the medi cal ,

cu rricul um i s u su all y allotted a fe w hours from the combin ed

course on mate ria m edica and the rapeutics whi ch i s al read y ,

overcrowde d by the p re sentation of a needle s sl y large nu mbe r

of preparat ion s of dou btful or very l imited u seful ne s s A s an .

art eve n l es s ti me i s de vote d to it

,
I t m ust howe ve r be
.
, ,

a cknowledged that thi s brie f consideration is a di stinct advance

ove r twenty years ago when the medical curriculu m w a s qu ite
,

i nnoce nt of e ve n a mention of ph ysiol ogi c the rapy .

I t i s the author s firm bel i e f stre ngth ene d by years of e x p e r i

’

ence in the teaching of both medi cal students a nd nurses that ,

the student or p ractitioner should first acqu i re a k nowl edge of

the technique of hydrotherapy in the sa m e way that nu rse s a re
tau ght z e b y actual drill u nder an expe rience d in s t ru ctor
'

. . .
, ,

I ns istan ce u pon accurate personal obse rvation of patient s du r

,

i ng the ir tre atment will hel p to stren g th en i n the mi nd of th e i

stude nt the ne ce ssity for cl ose cl i ni cal obser vation I n the

‘

management of disea se su ch obse rvati on can not be replaced

,

by i nstrume nts of pre ci sion In thi s conne cti on we can not

.

refrai n fro m expres sing ou r opinion that instruction i n practi cal

therapeu tics and the care of patie nts sh ould not be left to th e
l ater years of the m edi cal cu rri cul um .

With th i s p ract ical knowledge of the vi si bl e re sul ts to be

obta ined the stu dent shou ld devote car eful stud y to the physi o
,

logic and therapeu ti c e ff ect s of each repre se ntati ve cl ass of

treatments Thi s study shou ld i nclu de personal laborator y
.

i nve s tigation into the eff e cts of thermic and mechani cal stimul i
u pon blood pres su re the heart rate and force general change s
, ,

in bl ood di s tribu tion and its cell ular c omposition m uscu lar ,

(3)
ca pacit y and m e ta b ol i c change s as revealed by
,

i nat io n of the excretions parti cularl y the u rine

,
.

In the presentation of the subje ct the author ha s ,

serve the closest connection between experi mental

and therapeutic dedu ctions and reco m mendation s .

a ll times endeavored to seek out a reason for the

in practice It is onl y in this w a y that va rying

.

be successfull y met .

The modern search for specifi cs

d evelopment of scientific medicine .

ever must not without modificati o

, ,
n ,

therap y. Specific r ow /ls are to be sou g h

of the treatment to the individual case i n
ri g id adherence to thi s or that type of
reason ph y siologic eff ects have been dwe
and have been considered apart
The subject of therapeutics h
to the elucidation of bas 1 c pr i nciple s I t i .

logic or structu ral state present in a given disease that

” ”
treatment rather than the disease as an entity .

most ame nable to hydrotherapy have therefore been , ,

in classes according to the general p rinciples involved

treatment after an explanati on of which each di sea se
, ,

particular attention .

While hydrotherapy i s the most important branch of

i

” H
logic therapy i t is not by any means a cure al l
, .

line between physiologi c and radi cal thera peuti cs

drawn b y disease lists but mu st be settled by rational ,

tious consideration of the ends to be sought and the trend of

t he morbid condition in hand .

In presentation of thi s work the author lays no clai m s to

,

originality In add ition to personal experience all availab l e ,

sources of information have be en drawn upon The text matte r .

and diagrams are those used by the author in hi

medi cal students The part on t e c hm q ue 1 8 an
.

”
of a brief treatise on the Technique of H yd r ot
hs he d by the author i n 1 9 0 8 .

Loma Linda Ca l , .
 CO N T E N T S

P A RT I
SC I ENT I F I C BA S I S AND P H Y S I O LO G I C E FF E C T S

C H APT ER I
TH E P H Y S IC A L PR O P E R T I ES OF W A T ER
Commu ni cation an d A bsorption of H eat P hysics of H eat . .

C alorie s S peci fi c H eat

. Latent H eat
. Thermi c S timul i . .

Me chanical S ti mu li S olve nt and Chemi cal P roperties

. U se
—
.

of Water in all Three S tate s 1 7 25 .

C HA PT ER II
PR I N CI PL ES O F E FF E C T S AN D T HE RA P Y
m
Thera py fro Withi n Warm and Col d bloode d A ni mal s
.
-

I ntrinsic E ff e cts Reaction Type s and Degree s of Reacti on

. .
.

C onditi ons I nfluencing Re a ction Comm on N am es of Te m .

p e ra t ur e s 26 —
. 38
C H APT ER I I I
ANAT O M Y AN D P H Y S I O L O GY O F T H E S K I N
Muscu l a r and E l a stic T is sue Bl ood V es sel s Lymph ati cs
—
. . .

39 44
C H A PT E R I v
THE P E R I P HE RA L HEA R T
Traube H e ri n g W a v e s
-
. P rinci ple s of V a scular E ff ects .

—
.

Q uantit y of C irculating Fl ui d . 45 53

C H A PT E R V

A NA T O M Y AN D P H Y S I O L O GY O F T H E S K I N ( C ON T I N U E D )
S udoriparou s G l ands S u mmary of P e rspi ratory Influe nce s
. .

S e bace ou s G lands A bsorption by the S kin

. Cutaneou s Re s .

p i ra t i o n The S ki n a H eat Regul ator N erve s of the S kin

—
. . .

54 61
C H A PT E R V I
THE CI R C U L A T I O N —R E F L EX E FF E C T S
Reflex A reas Re flex A r e S pe cial Re flex A rea s . . Cl asse s
—
.

O f Re flex E ff ects S peci al Reflex E f ects

.
f 62 77 .
 C H AP T E R V I I
T HE CI RC U L A T I ON HYDRO S T A T IC — E FFECT S
rinciples of H d t i Law of A ntagoni sm
—
P y r o s a s s .
.

derivation 7 8 85 .

C H AP T E R V I I I
T H E CI R C U L A T I O N — B A L AN C E B E T W EEN R E F L EX AND
HYDRO S T A T IC E FF E C T S
Laws of Balance E xample s Double E ff ects .
8 . .

C H AP T E R I X
TH E CI RC U L A T I O N —BL OO D PR E S S U R E
Force of H eart Beat . A mount of Circulating Fl u i d
lar Calibre and A ction . Mii l l e r
’
s Laws 89 — 99 .

C H AP T E R X

THE CI RC U LAT I ON —HAN

ES I N C O M P O S I T I ON O F T H E B
C G

Cor pu scular E lements Mechani sm of Di stribu tion .

—
.

c o si t y Reaction P ractical A ppl i cation

. . 1 00 1 1 0 .

C H AP T E R XI
N I TROGEN O U S ME T A B O L I SM AN D EX C R E T I ON
E ffects of Cold N itrogen E conomy
. U rea and A m .

U ric A cid and P urin B ases E xtractives P hosphor i c . .

S ulphates and Chlorides E ff ects of H eat E ff ects on

. .

P roteid Diet 1 1 1 —
. 1 24
C H A PT E R X I I
RES P I RA T I ON RES P I RAT O RY C HAN GES AN D C A RB ONA C E O U S ME T AfB
,

Respiratory E ff ects G aseous I nterchange Carbon

—
. .

ide O xygen 1 2 5 1 29
. .

C H A PT E R X I I I
M U S C U L AR C A PA CI T Y
E ff ects of Cold E ff ects of H eat
. E rgograph and D y no m o .

meter E xperiments F at i g ue P oi son s Therapeutic A ppli ca

—
'

.
.

tio ns 1 30 1 3 8
.
‘

C H AP T E R X I V
T H E HEA T ME C HAN I SM

Regu l ation of H ea t P roduction Re g u l ation of H eat L oss .

.

—
E x pe riments in H eat P roduction and E l im i nation S u mmary ‘

. .

1 39 1 54
 CKHVTEUVTS

P A RE
‘
H

T H E RA P E U T I C S
C H AP T E R X V
THE R EA L M AN D L I M I T A T I ON S O F P H Y S I O L O GIC HE R A PYT

Fu nctional and O rgani c Di sease s . N atural Means Radical .

Means B asic P ri nciple s of Therap y

. . 1 55 — 1 59

C H A PT E R X V I
F EVE R S AN D AN T I P Y RE T IC E FF E C T S
Causes and S ymptom s of Feve r P rin ciple s of Tre atment . .

Ra t ionale of H ydrotherap y i n I nfe ctiou s Fevers Tox ic V aso .

Medi cinal A nti pyreti cs

'

m o to r P a r al y s i s . A ntip yreti c E ff ects .

of The rmic A ppli cations The H eat Me cha ni sm in Fe ver . .

V ariations that P roduce Fe ve r and The ir Rel ation to Treat

m ent 1 60 —
. 1 78
C H A PT E R XV I I
T H E T R EA T MEN T O F F EVE R S

T y phoid Feve r Malaria Measle s .S carlet Fe ver I nflu . . .

en z a 1 7 9 2 1 1
.
—
C H A PT E R X V I I I
I N F L AM M A T I O NS AN D AN T I P H L O G I S T IC E F F E C T S
De pletion Fluxi on Re vul sion
. P athogene s is of I n fl a m
. .

—
.

mation P rinciple s of Treatment 2 1 2 2 2 4

. .

C H A PT E R XIX
TH E T R EA T MEN T OF I N F A MM AT I O N S

I n fl a m m a t i on s O f the E ye E rysipelas O ti ti s Media Mas . . .

t oi d i t i s A lveolar A bsces s
. P haryngitis Tonsill iti s B oil s . . . .

S epti ce mia P oison I vy. P ne umonia B ronchop neumonia . . .

P leuri s y P e r i cardi tis

. Myocarditi s Rheumati c Fever I n . . .

fe c t i ou s A rthritide s Meningiti s B i l i a r y I n fl a m m at i on s
. . .

A ppendi citi s P el vi c I n fl am m a ti on s
. P hlebiti s Mu cou s C O . .

liti s . Cystiti s S pecifi c U rethriti s . 225 — 2 59 .

C HA PT ER X X
S T I M U LAN T S AN D T O N IC S
Tonics A n e m i a
H ydr i a t i e N eurasthenia S planchnic . . .

N e ura sthenia H yste ri a Dyspe ps ia P ul monary T ub e r c u

. . .
l os i s Insomnia
.
C h r o n i c I nebriety .
. Ghro mi
Diabetes S unstroke V alv u lar
‘

Rheumatism . .
.

ease O be sity with Fatty H eart E xcitant and

.
.

E ffects U terine V esical and I ntestinal S timulants

.
,
.

C H A PT E R XX I
SE D A T IVE E F F E C T S
General S edatives . P ure S edatives . Tonic S edati
cal S edatives Insomnia Chorea . . . P aralysi s
tic S pinal P aralyses Locomotor A t .

G oitre The Relief of P ain

. U lcer . .

ra l g i a Tenesmu s Dysmenorrhoea Renal

. . .

Bu rn s S prains and B r uises Fractu res H eadache

. . . .

C H AP T E R X X II
EXP E C T ORAN T E FF E C T S
Colds A cute Cory z a A cute Bronch iti s Croup
—
. . . .

Chronic Bronchiti s 33 1 3 3 6 .

C H A PT ER X X I I I
D I AP HO RE T IC AN D D I U R E T IC E F F E C T S
Diaphoretic E ff ects . Diuretic E ffects . 33 7 — 3 40

C H A PT E R XXIV
S Y S T EM IC A N D MET A B O L IC D I SEASES
O besity Icterus S ystemic P oi soning
. Internal
.
.

tions Gout and Gouty R h e u m a t i s m B right s

.
.
’

U remia and E c lampsia 34 1 — 362 .

C HA PT E R X X V
PE PT OGEN IC E FF E C T S
A tonicDyspepsia Gastrectasia H ypochl orhydri a
chlorhyd ria 3 6 3 —3 6 9
.
. .

C H AP T E R X X V I
HEM O S T A T IC E FF E C TS
E pistaxis P ulmona ry H emorrhage .
G astri c H emorrhage .

U terine H emorrhage A poplex y 370 — 37 2 .

.

C H A P T E R XX V I I
HYDRO T HERAPY I N S U R GER Y
P reparatory Treatment .
Immedi ate Care . S urgic al S ho ek -
 C ON TE N TS
V asomotor and Ca rdiac Change s ; Treatment of
H yd r i a t i e
S hock . D ru g T reatment of S hock . A fter Treatme nt 373 .

3 93
C H AP T E R X X V I I I
INSAN I T Y AN D DR U G A DD IC T I ONS
Mania . De pre s sed Case s . Morphi ni s m . A l cohol ism 3 94
—3 9 6
.

P A RT I II
T E C H N I QU E OF H YD R O T H E R A P Y
C L ASS I F IC A T I O N OF PR O C E D U R ES AN D G L O SSA R Y OF T E RM S
B as i s Of Cla s sifi cation
Defi nitions 3 9 7 . .
—4 0 0
L O C AL APPL IC A T I ONS O F HEA T
Fomentations H ot Compre s s . Stupes Alte rnate and .

S imultaneous H ot and Cold Treatments H ot Water Bottle s .

-

—
.

H ot Wate r Coil Radiant H eat 4 0 1 4 09

. .

L O C A L A PPL IC A T I ONS O F C O LD
Cold Compre ss I ce P a c k I ce Cravat I ce B ag Col d
—
. . . .

Water Coil 4 0 9 4 1 2 .

HEA T IN G C O M PR ES SES
Moi st Ches t Pa c k Dry Che st P a c k Moi st A bdominal Ban
. .

dage H eating Throat Compre s s H eating J oi nt Compre ss

—
. . .

Medicated Compre s se s 41 2 41 7 .

P O U L T IC ES
Wh ite Cla y and G l yceri ne Cha rcoal 4 1 7 4 1 8— . .

T O N I C F R IC T I O NS

Cold Mi tten Fri ction Wet H and Rub Cold Towel Rub . . .

Wet S heet Ru b Dripping S heet Rub . Ice Ru b S alt G low . . .

—
4 1 8 423
S P O N GI N G
H ot Cold and Tepi d S ponge
,
S al ine S ponge A lkal ine . .

S ponge V inegar and S alt Rub

.
“

A lcohol Rub Wi t chhaz e l . .

Rub Menthol Rub S oap I Va s h 4 2 3 4 2 5

.
— . .

R U B S AN D F R IC T I ONS
Centri petal Fri ction O i l Rub Talcum Rub . Dry Frie . .

—
tion 4 2 5 4 3 0
.
10
( H9DWTEHVTT3

B AT HS
Immersion H and and A rm Bath
P artial
.
.

Bath S.
itz Bath H o t H alf Bath Ful l I.
.

H o t Cold and N eutra l Tub Baths

,
B rand .

Bath Cold
.
S hallow Bath H ydro E lectric B .
-

Baths N auheim Bath

.
O xygen Bath Ru ss i .
.

Bath Turkish Bath S uperheated A i r B ath

—
.
.
.

Bath 4 30 45 2
SHAM P O O S
.

S wedi sh S hampoo Tub S hampoo Turk ish S ham . .

PA C K S
Full H ot Blanket P ack Dry Bl anket P ack .
.

Pelvic P ack H i p and Leg P ack.

H o t P ack s wi th .

E lectro thermal P ack-

E vaporating N eu tral He .
, ,

S weating Wet S heet P acks

H eating Trunk P ack
H eating Trunk P ack
H eating P elvic P ack 4 54 46
.
.

.
—
.

S PRAY S AN D D O U C H E S
S hower Bath S pray Bath Revul siv e A lter n ate
. .
, ,

sion and S pray Dou ches S pray and Douche P r e scri .

A ff usions P ail P our . 46 7 — 47 6 .

ENEMA T A
H o t Cold and G raduated E nemata
, Cold and .

Rectal Irrigation Coloclyster S al ine E nema P roc

. . .

S oapsuds O il A safoetida G lyceri ne and E psom S a l ts

—
, , , ,

A stringent Q uassia Q uinin E n emata

, 47 6 4 86, .

VA GINA L I RRI GA T I ON
I l ot and Alternate H ot and Col d V aginal I rrigation
, .

infec tant and S typti c Vaginal I rrigation 4 86—4 89

—
.

PRES C RI PT I ON WR IT IN G AN D T R EA T MEN T C O M B INA T I Ns

General Rules Illustrat ions

, a nd P rescriptions . 490 494

HY DR OT HE R A P EU T IC A PPARAT U S A N D T REA T MEN T R O O M S

General Treatment Rooms Fomen t ati on Tank .

Boxes , Leg Tubs Foot Tubs B a t h Tubs

.
S i tz .
.

E lectr i c L i ght Cabinets Russian a nd .

Dryer
troller Douch es 4 9 5 —5 1 0
.

.
.
 I LL U ST R AT I O N S

P L ATE S
P LAT E OPP P AGE

Re flex a r e from sk i n to heart

F r on t i s p l a t e ,

D iagram matic se cti on of Ski n

V i sceral sympatheti c nerve s
The innervation of t he heart
The e ff ect of baths on bl ood p res su re
P ortabl e tub on wheel s
P ortabl e tub wi th rai sing device
The Coil e bed bath
Continuou s cooling i n typh oi d fever
Su do r i fi c treatment i n in fl uen z a
De pletion by Simul taneou s heat a nd col d
H ot and cold immersion for i nfecte d hand
Fome ntation s to che st for pl euris y
Ice pack to knee i n acu te arth riti s
Fomentation s to knee i n ch roni c arthriti s
Local superheate d ai r bath pre pari ng ,

Local s upe rheated ai r bath u sing ,

H ot a ir bath in bed
The Wi nte rnitz p ac k with h ot w at e r e oi l
'

The VVi nt e r n i t z p ack wit h hot water bottle

-

The conti nu ou s flowing bath

The sedat ive w e t Sh eet pack
Wri nging a fom e ntati on by hand
A fomentation tank with wri nge rs
S team boxe s for heating fomentations cl osed ,

S team boxes for heating fomentations in u se ,

H ot water bottle s
-

I ce bags
S quare che st pack roller C he st pack and moi st
, ,

abdomi nal bandage

The roll er che st pack appl ying ,

The roller C he st pack fini she d ,

12
IL L US TR A TION S

The square che st pack applying ,

The square chest pack fin ished ,

The moist abdominal bandage

The cold towel rub
The cold mitten friction
The we t sh eet rub appl ying the sheet
,

The wet sheet rub rubbing the patient

,

The sit z bath

The hot half bath
The Russian bath room in u se ,

The Ru ssian bath room open showing Sh

, ,

The Tu rki sh bath cabinet s

S uperheated ai r bath ready for u se
,

S uperheated air bath patient in Turki sh towel

,

ing suit
S uperheated air bath in u se
,

E lectric l ight bath cabinet upright for m

,

E lectric light bath cabinet hori zontal form

,

The hot blanket pa ck

The evaporati ng wet Sheet pack
The author s h y drotherap y control table
’

A seepage apparatu s
Continuous p r oc toc l ys 1 s
Adju stable standard for enema and dou che cans
E nema cans arranged for alte rnate hot and col d
rectal I rr i gation
Rectal and vaginal t u be s

T E X T FI G U R E S
P I GU R E

l E xpansion Of water at di ff erent temperatu re s

9
Comparati ve the rm omete r scale s
3 Chart of wave energie s
4 D i agram I llustrating time factor in i ntri nsi c and r e ac
t i o n a r y e ffect s
‘

5 O rigin of l ymphatic vessel s i n a papi lla O f the hand

( S appey )
6 S u p erfi cial l ymphatics of the arm ( S appey )
7 Valves of mese nteric chyl iferous ve ss l s ( Delame re
e )
 I L L US TR A TIO N S

B l o o d pressure traci ng showing Traube H ering

,
-

curve s take n from a dog u nder artificial respi ration

B l O 0 d p re ssure traci ng s how ing Traube H e ri ng
,
-

cu rve s taken from a dog after ce ssation of respiration

Rhy thmical vasomotor w aves of blood p re ssu re in a
dog
Tone wave s i n h eart m us cle
P e ri odi c flu ctuations i n bl ood pre ssure traci ng take n
from man at re st
D iagram O f gl omerulu s and urinife rou s tubule
Diagram of coil gland of sk i n and vas cular network
Diagram to Show vasomotor re flex a r e ( H o w ell )
A nterior re flex area s ( Kel l ogg )
S ph ygmograph tracing showi ng e ff ect of p roximal a p
pl i c a ti on o n pul se wave ( Kell ogg
P leth ysmographi c t raci ng showi n g e ff e ct O f proxima l
appl ication on volume cu rve ( Kell ogg
D a g r a m showing con ge sti on of lu ngs
Diagra m showing re flex action of i ce bag on conge sted
lu ng
V ol ume cu rve of right arm du ri ng a hot S it z bath ,

showing derivative effe ct ( Winternitz )

V ol ume cu rve O f right ar m du ring cold Sitz bath show,

i ng re t r o s ta t i c e ff ect ( I Vi n te r n i t z )
Curve showi ng e ff ect of a su dden rise in the arte ria l
re si stance on the ou tpu t and vol ume of the ventri cle s
( S tarling )
Ca rdiomete r tracing showi ng e ff ect of in creasing the
volume O f circu lating fluid on the total ou tpu t and
vol ume of the heart ( Roy )
F a u g ht s sphygmomanometer
’

Riva Rocci sphygmomanomete r

-

G artner s tonometer
’

Chart showi ng e ff ect of cold on blood cou nt and h emo

globin
P leth ysmograph i c tracing of S pleen showing the Spon
,

t an e ou s rhy thmical contrac tions of th is 0 r g a n

( H owell )
Cha rt Showing e ff ect of thermic procedu re s on alka
-

l i n i t y O f bl ood
14 I L L US TR A TION S

Chart showing eff e ct of the rm ic procedu res ,

O f u rine

Curve showing e ff ect of cold treatment on

urinar y nitrogen ( S trasser )
Curve showing e ff ect of cold treatment on u rea ,

p h a te s and ammonia ( S trasse r )

Curve showing eff ect of cold treatment on the
tion of puri ns ( S trasser )
Curve showing e ff ect of cold treatment on the
line and earthy phosphate s ( S trasser )
Mosso s ergograph
’

E rgograms showing effect of c old bath on m

capacity
E rgograms showing e ff ect of graduated
c ul ar capacity

E rgograms Showing e ff ect of graduated bath on

tigue
E rgograms showing e ff e ct O f col d wet sheet rub
fatigue
E rgograms showing e ff ect of warm bath and warm
douche on fatigue
Tracings showing e ff ect of caffeine on v o l u n t a r y
muscle ( I VO O d )
Rubner s chart showi ng manner of heat loss at di ff e r
’

ent temperatu res

Diagram illustrating he at r e g u l a t i n g mechanis m
( Wood )
Reiche rt s water calorimeter
’

Chart showing effe ct O f physi cal measu res on heat

el i mination ( Winternit z )
Diagra m showing quantitative relation betwee n te m
pe r a t u re raising and temperature lowe ring capaci ty
-
-

of d i fferent treatments
Bu rr portable bat h
Marag l i ano s chart of temperature and peripheral
’

va soc o ns t r 1 c t 1 o n in malari a

Capillaries as a ff ected by i rritant and inflammat ion

( B runton )
A pparatus for treating i n fl a mm at i ons of eye
The window tent for the fresh ai r treatment of fevers
The pe rineal douche
 PA R T I
SC I E N T I FI C BASI S A N D PH Y S IO LO GI C E FF E CT S

CH APT E R I

TH E P H Y SIC AL P R O P E R T I E S O F W AT E R

N the appl ication of an y therapeuti c agent it i s essential to ,

obtain an unde rstanding of those p roperties of the agent

itself of wh ich particular u se i s made i n the treatm ent of d i s
,

ease In the e ase of water these e ssential p rope rt ie s may be

.
,

discu s sed under the following heads

1 . " ts a bi l i t
y to com m un i ca te a n d a os or o l a rg e qu a n ti ti es f
o lz ea t
by eon ta et .

( a ) Specifi c tz ea t ( o) L a ten t b ea t
—
—
. .

2 . 1 ts g r ea t te mper a h i r e con d u cti ng cap aci ty

-
ther m i c s ti m u l a ti on .

T/z e per/ectfl u i a i ty of w a ter i ts use i n m ee/z a n i ea / s ti m u l a ti on

’
3 .

" ts sol ven t p r ope r ti es m e ta bol i c e/z a ng es

’
4 . a n d u se in n u tr i ti v e a n a .

— f m a tte r w i t/z i n a
5 . E x i s te nce f
o w a te r i n til e t/z r ee s ta tes o s/
z or t

r a ng e o f te mpe r a tu r e
-
p r a cti ea oi ti ty f app tyi ng i t to t/z e ooafy
o in a ll

t/z ese t/z r ee s ta tes .

l . The C om m u ni c a t i o n an d Ab so rp tion of H e at . H y d r o t he r
ap y consi sts ch iefly in the application of heat and cold to the
body by means of water I t s most helpful results are O btaine d .

from the heat applied In i t s most scientific and practi cal

.

phases it i s a stu dy of thermotherap y Th is being tru e in the .

,

power of water to communicate and absorb large qu antities of

heat w ithout itself undergoing a corresponding change in tem
,

p e r at u r e l ies i t s most u seful p ro perty

, To rightly appl y so .

powe rful an a gent one should understand the physi cs of heat

,

as it applies to water A brief summary of th is subj ect will .

not therefore be out O f place

, , .

2
18 P R O PE R TIE S OF WA TE R

P H YS IC S O F H E AT

cold S olids are thus ma

.

With some sol ids thi s is SO

into various Shapes even
The bod y tissues are l ikewi se made soft and pl
influence of heat The skin i s expanded . ,

the blood vessel s dilated -

.

E
2

m ag num

F ig 1 .
E xp a nsi o n o f w ate r at tem p e r a t u re s f
ro m 0° C . t o 1 00 ° C .

In ge ne ra l hea t expands some howeve r , ,

greater degree than others .

definite degree of increase

p mds occu pying more sp a
i
4 C ( 39 2
.
,

°
N early
I nd e fin i t e l
y unde r
 IN TE N SI T Y OF H E A T

heat B ut wate r after cool ing to 4 C expands u ntil fro z en

.
,
0
.
, .

Fou r degrees C or F.
, i s therefore said to be the point
.
, , ,

O f maximum dens ity of water ( F ig I ) A t this temperatu re

. . .

a given weight of water occupies ( is crowde d into ) the least

pos s ible Space I t i s becau se of th i s .

F h nh it
a re C ntigr d
e e a e

change ( expans ion ) in free z ing that

ice floats I f water continued to con .

t ract ou freezing it then being denser , ,

would Sink to the bottom and S O r e ,

main fro z en for a mu ch longer ti me ,

as solar heat lose s i t s e ff ect in pene

t r a t i ng s o far D id this occu r onl y .

,

very Shallow bodies of water would

ever entirel y thaw out at tempera
tures common to tempe rate and frigi d
z ones .

D e g re e s or the Intensity o f H e a t .

The i n tens i ty or degree O f heat i s

measu red by a the r mometer ( the r
mo—heat mete r—measure )
,

O nl y ,
.

the Fahrenhe it and Centigrade scales

need be de scribe d The Fahrenhe it .

thermometer more commonl y used ,

for domestic and cl inical purpose s

will be described fi rst T he f r eez i ng .

°
p o i n t O f water i s marked as 3 2 F
that i s 3 2 above th e z ero or start ing
0
,

point O f thi s scale Water boil s at .

0
1 80 F above freezing
0
21 2 F i e .
, . .
,
. .

The Centigrade thermometer i s a

more simple instru ment as the fr e e z ,

ing point of water i s marked while

the boiling point i s marked
0
From this we se e that 3 2 Fahrenhe it
a i i fifi ifg
fgz
F g z th O 0
‘ a ‘
corresponds t O 0 C and 2 1 2 F
er '
' '

o s .
, .

0
corresponds to 1 00 C and there .
, ,

fore 1 80 Fahrenheit degrees ( 2 1 2 minu s 3 2 ) are the e qu i v a

,

0
lent O f 1 00 Centigrade degree s or F e qual 1 C ( F ig
,
. . .
 E qui val ent R ea di ng s To .

t ig ra de sc a l e to Fahrenheit ,

9 5 ( 1 80
- This gi ves the numbe r
above the free z ing point S ince th is p .

scale is 3 2 above z ero 3 2 should be

°
,

O btain the correct Fahrenheit reading .

Fahrenheit reading which corresponds

3 5 by 9 5 g ives 6 3 above freezing ; ad
° °
-

To O btain the correct Centi

heit t e m pe rat ur e i t i s only necessary t ,
.

Take for example

,
F the normal body ,
.
,

mouth Thi s i s
. minus 3 2 ) above
°
multiplied by 5 9 equ al s 3 7 C S ince 0 C i s the
°
-
. .

point this is the correct Centi g rade reading

,
.

Con de nsed R ul es :
TO change Centigrade to Fahrenheit , multipl y by
add 3 2 .

To change Fahrenheit to Centigrade subtract , 32

pl y b y 5 9
-
.

H e at U ni ts Q uanti ty of H e at ( a ) S P E C I F I C H
or .

a m ou n t of heat required to raise a gram of w

a heat unit or ca l or ie The large Calorie

, .

initial capital ) i s the amount of heat necessary to ra is e

grams ( 1 liter ) of water 1 C and is therefore equ al to 0
.
, , ,

small calori es .

The amount of heat that would raise the temperatu re

given weight of water 1 C would °
.

same weight of mercury 30 C T °

.

cu ry in be ing heated through 1 °

a calorie i e 1 3 0 of the amount O f heat absorbed by the sa me

, . .
,
-

weight of water in being heated t h

it will be seen that water absorbs a
o ut man ifesting a corresponding change in temper

a small amount O f heat produces a cons iderable ch

tempe rature of mercury .

The heat necessary to raise a given weight of

greater than that of any other sub
sa id to have a high specific heat .
 L A TE N T H E A T

a s u bs ta n ce f or a bs or b i ng b ea t as com p a r e d w i th the ca pa ci ty o f a

s ta n da r d su bsta n ce More accu ratel y it i s t he amou nt of heat a

.
,

given weight of a su bstance a bsorbs in be ing raised in tempera

°
tu re 1 C as compared with the amount of heat nece ssary to
.
_

accompl ish the same ri se in temperatu re in the same weigh t O f

a st an d ar d sub st an ce S ince water absorbs more heat than a n y
'

othe r substance it i s taken as the standard A gram of mer

, .

cu ry absorbing onl y 1 —
, 3 0 the amount O f heat absorbe d by 1
gram of water i s said to have a specifi c heat of 1 —
, 3 0 that of
water Copper has a specifi c heat O f 1 1 2 that of water
.
-
.

I t will be seen from the preceding di scu ss ion that a large ,

amount of heat i s stored in hot water I t i s thi s high specifi c .

heat of water that makes it especiall y valuable in appl ying heat

to the body A pound of hot water will commu nicate thi rt y
.

time s as mu ch heat to the body as a pound of mercu ry A n d .

conversel y a pound of col d water will abstract from the body

,

th i rt y times a s much heat as a pound of me rcu ry I n each .

case the temperatu re O f the water or the mercu ry will be

changed onl y The hot water not onl y stores u p a great
a mount of heat but it communicate s this very readily to th ings
,

with which it comes in C ontact Conversel y col d water ver y .

,

readily absorbs heat by contact with other bodie s H ence if .

,

applied to the human body it qu ickly cool s the skin adjacent , ,

ti ssues and their blood cu rrent

,
.

( b ) L AT E N T H E A T therm ometer placed on ice as it is

. A
melting and another pl aced in the water ju st after regi ster ex ,

°
a c t l y th e same degree or intensity of heat via 0 C S ince it , ,
.

re qu ires heat to mel t ice a mere change in ph ys ical state w e , ,

may ve ry naturall y ask What be comes of thi s heat when the ,

sol id changes to a li qu id ? I t i s not apparent nor man i fe st by a

change in the thermometer We ma y call it b i dden or l a te n t .

heat B y careful expe rimentation it is found that an astoni sh

.
,

i ng l y large quantity of heat i s absorbe d in this p roces s ; in the

melting of one gram O f ice su fficient in fact to raise the tem , , ,

p e r a tu re of one gram of water C This gram O f ice in .

melting therefore absorbs

,
calories with no consequent
, ,

rise in th e temperature as measu re d in degrees Thi s amou n t , .

of heat i s made latent The latent heat of fu sion or melting of

.
,
ice i s thus fixed at
,

the body so much more

ice that melts ab st rac t i n °
the same weight of water warmed through 1 C .

the ice rub i s thus ampl y demonstrated For the .

an ice bag produces a greater intensity of e ff e ct

compress .

The same
de ns ing of
units i s re s
boi l ing
after it i s formed ; and yet this change from liqu id
5 3 7 calo r ies to each gram of water The latent
.

z at i on of water i s therefore,
5 3 7 calories
,
.

When steam condenses it gives off this heat

nom e n on l ies the explanation of the fact that a

gives a great intensity of eff ect since ,

denses the water particles remaining

,

the room as a thick fog For every gram of

.

condenses 5 3 7 calories of heat are l iberated

,
.

burns produced by the condensing of steam di

surface i s readily understood when this fact
The marked co
or hot and cold
abstracted from the body by the process
With al l these facts before one it i s ap ,

value of w ater a s a thermic agent l ies in i t s

specific and latent heat c oe fli c ie nt s .

Specifi c lz ea t refers to the amount of heat conce rned

te mper a tu r e cha ng e s O f matter w i t/t i n a si ng l e s ta te .

L a te n t lz e a t refers to the amount of heat conce rned

change O f matter f r om one s ta te to a not/z e r w i t/t out a ny on
te mper a tu r e .

2 Te m p e rature C ondu cti ng C ap a c ity

.
-
of
Sti m uli It might on first thought seem
.
, ,

ulus
24 P R OP E R TIE S OF WA TE R

mitten friction In this case it i s the .

ten that is the chief sou rce of friction .

bing bath i s another example of th i s c

and thermic stimuli each enh ,

posed however that the marked eff ect of th i s

, ,

due mere l y to a com bi na ti on O f the t/z er m i c

stimuli I t i s necessa r y that water be used
.
.

question we quote the followi ng fro m B a r uch

,

again insist upon the fact that ne ither in t y phoid

inadequacy can these eff ects or anything like
, ,

duc e d by cold alone ( for that has been thorough ]

cases ) by the temporary appl ication of wate
,

ever temperature or by either dry saline or ,

a ni ca l irritants It i s absolutel y necessary

.

col d but col d wa te r Should be u sed that the

, ,

literall y r ubbed with this for a considerable

The same may be said of the
i sh i ng results of this procedure can
application of cold alone nor by friction with the
is onl y by Vigorou s rubbing with the mitt dipped in ,

that the maximum e ff ects are produced .

4 Solve nt and C he mi ca l Prop e rti es

. That these .

are of less importa nce than the precedi

those familiar with hydr iat i c measures The solvent p .

of water are utili z ed in the shampoo enema etc I t s , , .

a solvent in the proce sses of osmosis and dialysi s are

made use of in hypodermoclysis and sal ine enemata .

means of combining thermic and chemical s timul i it i s ,

a solvent in the N auheim or effervescent bath saline b a ,

I nte r na l H y dr other apy G oing a little further from t h

.

cal into the chemical activities and almost outside ,

range of hydrotherapy unless it be in water drinking ,

-

consider water in its rel

cesses of the human body I t is the medium .

and exchange in the carrying of nutri tion to

wastes from them to the excretory organs I t consti t utes 7 5 .

pe r cent of the body weight Without i t life woul d be i m p os

—
.

2 Baruc h P r i nci pl es a nd P ract i ce o f Hyd rot h e ra py p , . 12 .

 WA TE R IN TH R E E S TA TE S
Sible N ot only i s it concerne d in the mere physical inter
.

change O f nutrient and waste substance s but it i s actuall y ,

nece ssary in by far the greater nu mber of all chemical change s

which the se substances u ndergo Many body waste s are bu t .

spari ngl y soluble and for this reason require l arge amou nts of
,

water to hold them in solu tion The flu shing of the syste m .

conse quent on free water drink ing i s therefore one of the -

, ,

greate st of all aids to el i mination 3

.

The popular bel ief that particular virtu e res ide s in the m in
eral constituents O f water u se d for h ydrotherapeutic purpose s i s
al most wholl y erroneou s This i s rarel y the case and i s con .

fined to a very few proce du re s su ch as the N auhe im bath above

mentioned The treatment of rheumatism and obes ity at vari
.

ou s hot springs derives but l ittle advantage from m inerals pre s

ent in the water ( unles s it be that faith in these indu ce s the
patient to drink more water than u sual ) The re sults are due .

to the therm ic e ff ects of the hot water combined w ith regulation

—
,

of diet and cop iou s water drink ing B alneology the u se of -

.

m ineral waters in the treatment of disease therefore adds little , ,

or nothing to the science O f h ydrotherap y .

5 Use o f W a te r in So l i d Liq ui d an d G a s eo us St ate s N o

.
, , .

other substance capable of su ch divers ifie d utility as water

, ,

exists in al l the three state s of matter in such a short range

O f temperature The change from the sol id through the l iqui d
.

°
to the gaseou s state i s accompl ished in a range of 1 80 F .

°
( 1 00 N ot on l y is this t rue but it also change s readil y ,

from one form to another I t i s poss ible to appl y water to the .

body in any of these forms ; even the appl ication of the two ex
— —
treme form s ice and steam is of practical u tility The i ce .

bag i s an indispensable adj unct to a great variet y of treatments .

The ice rub has al so been mentione d The u se of Ru ssian and .

s im ilar Vapor baths is well known The steam dou che has al so .

acqu ire d some degree of reputation as a therapeutic agent in

certain conditions Thi s practicability O f employing water in al l
.

three states of matter and its ready change from one to another
,

withi n a comparativel y short range of temperature greatl y ,

enhance s i t s util ity as a therapeutic agent .

3 Se e C h pt
a er XI H
, aw k ‘

s O b se r v a t i o ns .
 CH APTER II

P R I N CI P L E S O F E FF E CT S A N D T H ER AP Y

basi c principle s of hydrotherap y are fou nd chie fly in an

E
explanation of the e ff ects of heat and cold V iewed in .

thi s light the science i s that O f the rmotherap y E ff ects similar

,
.

to those produ ce d by thermi c impres sions can be obta ined by

sunlight friction percussion and in fac t all physiologic agents
, , , ,
.

This is most notabl y true of l ight many of the p hysiologic ,

e ff ects of which ru n parallel w ith those of h ydrotherapy In .

fact thermic and actinic energie s are so closel y relate d that the y
,

overlap each other in the vis ible spe ct r um ( F ig From the .

lowest l imit of the scale of ener gi e s up throu gh elect ri c ener g y

, ,

heat l ight and acti ni c rays to radium emanations and the

, ,

X ray there i s laid out before the physician a greater suppl y

-

O f e ffi cie nt curative means than can be found anywhere el se i n

the whole real m of therapeutics .

T H E RA P Y F R O M W IT H I N
Those agents which by thei r toxi c action arou se the body to
, ,

resi st their intru sion can not be classed a s physiologic means

,
.

They excite abnormal and u nu sual act ivities which are largel y
directed against the toxi c age nt itself rather than he ightening ,

the normal activitie s whi ch keep the body i n health and repe l ‘

t he onset O f morbid proces ses Merely to rel ieve te mporari ly a

.

di stres sing condition without enabl ing the body itself to over
,

come that condition i s doing no permanent good The sick can

,
.

not always be applying Special means A fter re covery the y .

,

mu st depend upon the natural su rroundi ngs and ordinary agen

cies which keep the body i n health For example to relieve .
,

pai n by cocaine an i ce bag pressure or a fomentation i s p ro

, , ,
a

( 27 )
28 P R IN CIP L E S OF E FFE C TS A N D TH E R AP Y

d uc t i v e of no l asting good unless that coca i ne 1c

, ,

ure or fomentation causes t/z e body to overcome

,

producing the pain ; and i t s repeated appl ication

such a change that the pain ( or
reappear after the curative age
must be made to cure itself The re .

nature The natural God g iven forces mu

.
-

The power from witho ut must produce or arou se power

w ithin .

W A R M A N D CO L D B L OO D E D A N I M A L S -

The reason that thermic applications and impressions

po w erful in arousing body functions lie s i
activities are carried on onl y within a
temperature With regard to body temperature
. ,

general classes of animal s v i a the warm and the

The temperature of SO —
, ,

” “
called cold blooded -

mi c ) animal s rises and fall s with their su rrou

organism is not inj ured by comparativel y wide var
0
frog for example i s lively i n water at 7 0 F
, ,
.
,

°
in water at 4 5 F but it nevertheless live s and .
,

mal in either These va r iations do not seri ou sl y

.
‘

activities The organism i s able to withstand

.

changes in the temperature of it s blood and b o

w ithout this change being i nimical to i t s

pe r at u re of the se animal s remains slightly above that

cold water they may be i n and Slightly below that of
water .Cold blooded animals are principally aquatic and
-

amphibian .

Certain other ani mals maintain a constant t emperature unde r

varying conditions The surrounding air whether hot or cold
.
, ,

does not mate rially alter their body

mechanism i s so nicely adj usted that
when the surrou nding medium i s cold and le ss when the air or
’

other medium is hot This class of a .

blooded ( homeothe rmic ) because of t

"

at which their blood is kept A rterial blood i s slightly warmer .

t ha t venous The o rdi nar y l i m i t s for man are about 1 0 1 °

;
.

1 03 F .
 IN TR IN SIC E FFE C TS
O rgans constant act ivit y such as the heart liver and
Of

brai n have a temperature 2 —4 higher than the average of the

, , ,
° °

blood stream A t ordi na r y room temperature the uncovered

skin has a temperature of from 9 2 —9 5 F Thi s fact i s O f
.
,

° °
.

importance i n the administration of ne utral baths The wat er .

° °
should be 1 or 2 higher than that of the general sk in temper a
ture Thi s secu re s a full sedation by addi ng a Sl i g htl y r e l ax i ng
.

e ffect A s noted above the inte rnal tempe rature of warm

.
,

blooded ani mal s i s comparativel y a fixed point or varies with in ,

only very narrow li mit s not more than one de gree in heal th , .

A n y radical or prolonged depart ure from this fixed point

F by mouth ) i nte rfere s with vital fu nctions
. .

I N TRI N S IC E F F E CT S
Whe n the body becomes thoroughl y chilled as by a long ride .
,

i n the cold the pulse and respiration are slowed the ci rculati on
, ,

i s le ss rapid the ne r ve s benu mbed the mu scle s respond slu g

, ,

g i shl y and clu msil y the finer skilled movements are i m p os,

sible dige stion i s retarded the body temperature i s lowered

, ,
.

Cold i s therefore i n i tself a vital depres sant i e i t retards

, , , , . .
,

vital processe s This i s i t s i ntri nsic e ff ect

. Kellogg records .

an expe ri ment i n which i mmersion of the bo dy i n water at

5 5 F for te n minutes reduced the pulse rate from sevent y —
°
. si x

to fift y per minute A nother i n whi ch twenty mi nute s i n.

,

°
water at 4 5 F the patient be i ng rubbed continuou sl y r e
.
, ,

d u ce d the pul se rate from eighty to fi ft y e ight Both e x p e ri -

.

ments were upon healthy persons I n another expe ri ment ex .

p osu r e to cold showed tactile sens ibi lity decreased B efore the .

exposure the poi nts of an esthe sio m eter were detected as two
separate point s at a mini m u m separation of 2 mm A fter five .

°
minutes immersion i n water at 4 0 F the mini m u m distance
w a s i ncreased to 6 mm A nother in whi ch five minutes in .
,

°
water at 6 8 4 F reduced the body te mperature .
, F The se .

data serve to make definite facts with whi ch we are acqu ai nted ,

i n a general way onl y .

I t will be seen from thi s that an overactive process ma y be

retarded and brought back tow a r d the normal by an applicati on
of cold continued until i t s i ntri nsic e ff ects are man i fest The
,
.
30 PR

longer the duration O f the cold application ,

e ff ect The same i s true of the degree of co l d

.
.

temperature the more pronounced the e ffects

,
.

Wh ile cold
what it i s to e
a fire or sunlight after being
The circulation is quickened ;
is more rapid ; nerve sens ibili
i s q uicker more certain and
, ,

more rapidl y In watchi ng

.

under the mi croscope the ,

movements wil l cease The am oeba . ,

one celled animal s exhibit their peculi

-

presence of a certain amount of heat .

ments cease entirel y Cold pe r se decreases

.
, ,

metabolic activities ; heat increases the oxi dizing

tissues and metabolic activities are haste ned .

When the body i s overheated i t s functions

increased and if long continued permanent inj
, ,

When heated onl y to a sl ight degree however , ,

ties are whipped up and if the appli cations of hea ,

at intervals the retarded functions tend to return

,

R E A CTI O N
The most intere sting and phenomenal results O f
are due to that complex proce ss r eaction i e t — , . .
,

the body itself takes in its own recuperation and

interesting phenomenon in i t s entirety i s O b , ,

homeothermic animal s Cold bl ooded animal s .

-

acting to their external medium are subject to

of their environment O n the contrary warm —
,

. blooded ,

main tain more or less uniformity of function becau s e of

feet control exercised over Vital processes by the ne rvou s
This control i s more highl y developed and compl icated
poikilothermic animal s .

We have seen that the influence of cold i s to depre

activities ; that is if continued l ong enough its i nt r i n si
, ,

i s manifest in depression Bu t let u s notice .

32 P R IN CIP L E S OF E FFE C TS A N D TH E R A P Y
tions O f cold so that what i s seen as a resu lt of the se long
,

applications i s reall y a mixture O f the i ntrinsic and react i onary

e ff ects. A s to which shall predominate depends upon the
intensity and duration of the appli cation With the more pro .

longed applications the reaction i s suppres sed or obscu red

,

w hile i n those of intermediate duration we O ften s e e as mu ch ,

of one as of the other .

With heat as used in actual practice we O bserve i t s i ntr i ns i c

,
,

eff ects when the hot application i s short i e of brief du ration ,

. .
,
.

The first eff ect of heat i s that of a stimulant and toni c ; but if ,

long continued depression results This depre ssion i s by

,
. ,

some termed a reaction

,
Baruch objects to this term as .

applied to heat If we define reaction as the vital re sponse to

.

an external force or the attempt on the part of the organi sm to

,

co unteract an external agent w e can se e no great objection to ,

the term or to saying that the r ea cti on to heat i s of an at omi c

,

nature .

F ig 4 Di g a ra m g f
ill us t ra t i n t h e t i m e a c t o r i n t h e O bt a ini n g of
f
.

i nt ri ns i c a nd re a c t i o n a r y e f e c t s .

The accompanying diagram ( F ig illu strate s the relation .

existing between the duration of the appl ication and the O btain
ing of intrinsic and reactionary e ff ects The th ick ends of the .

we dg e s i nd i c a te prolonged appl ications ; the thi n ends brief

'

appl ications Intrinsic eff ects are shown at the left and r e a c
.

tions at the right .

Tonic e ff ects are O btained from the : Intrinsic e ff ects of heat

( short ) ; reaction to cold ( short ) .

Retarding and depressant e ff ects are O btained from the : Re

action to heat ( long ) ; intrinsic e ff ects of col d ( long ) .
 P H A SE S OF R E A C TION

I t mu st not be conclu de d from the above group ing that the

depre ssant e ff ects of a long col d appl ication ( intrinsic ) and
those O f a long hot appl ication ( reaction ) are i dentical in nature .

The depression i s manife st in di ff erent wa ys With col d the .

depression i s i n the nature O f a simple retardation of vi tal func

tions whereas w ith the heat the depre ssion i s manifest ch ie fly
,

4
i n the nervou s and mu scular system s and i s perhaps be st de ,

scribe d a s atonic That thi s i s largely a nervou s phenomenon

.

i s apparent from the fact that a vigorou s col d treatment follow

i ng p rolonged heat O ften qu ickl y re store s the patient to a nor
mal conditi on .

2
A brams make s the following stateme nt : Respect ing the
ph ysiolo gi c e ff e cts of heat it su ffi ce s to say that a p rolonge d , ,

application of a high tem peratu re i s prima ril y an excitant and ,

secondaril y a depres sant ; a brief application however i s , ,

strongl y excitant and the depre ssing e ff ects if any are i mper , ,

ceptible ”
I n di scu ssing the eff ects of thermic stimul i ( on
.

3
secretion ) P ope says I n general te rm s it may be state d that
,

brief appl ications of therm ic stimul i whether hot or cold st i m u , ,

late secretion di ff e ring i n de gree rather than i n toto; long con

,
-

”
t i nu e d a p p l i ca t i on s depres s
'

Phas es of R e a c ti o n
There are two i mportant phase s O f .

reaction v i a the circulatory and the nervou s T he ci r cu l a tor i/

’

.
, ,

i s most apparent and i s that by wh ich we j u dge of the com

p l e t e n e ss of reaction The Skin shoul d become ru ddy and .

warm . The patient feel s a warm g l ow over the entire skin

surface There shoul d be nothing of stasi s no cyanosi s or
.
, ,

goose fle sh The Skin shoul d be smooth soft and pl iable

.
, ,
.

The ner vous reaction i s appreciated not only by the patient but
by the O bserver The dull listle ss appearance of the eye a n d
.
,

countenance generall y give s way to a decide d brightening I f , .

there i s del iriu m or stupor as in typhoi d pneumonia etc it , , , .

,

may be replaced by qu iet sleep I n fact the salutary e ff ects .

,

are vi sible i n all the nervou s functions of the body With a .

neurasthenie patient the feel ing O f languor restle ssne ss and ,

2 S p nd y l t h p y p
o o e ra . . 1 75 .

3 H y d t h p y p 35
ro e ra , . .

4 M t b li h g
e a o c c an e s a re h a st e n e d by p ro l o n g dhe eat

3
34

weight in the abdomen

aration An other pbas
.

It i s the response of the heat mechan i sm

of less practical importance sin ce it can
utili zed in jud gi ng of the completene ss of reaction .

TY P E S AN D D E G RE E S OF R E A CTI O N

Sup p resse d R ea ction I t i s O ften de sirable

.

limit the reaction a ri sing from some application .

i al l y true with long cold appl ications which a

delay vital acti vities
attempts to react to al l
The reaction m a y be limi ted ,

as an ice bag to a part The .

bv the continuous and severe

reaction do not appear in the i

a slower heart beat slower and deepe r re sp irati on

, ,

reaso n of the continuance of the cold I n general the .

,

sion of the reaction depends u p on the i n tens i ty of t he

its dur a ti on being greater w ith the lower temperat u re s
,

the prolongi ng of the application .

R e p ea ted R ea cti on
I n the gi vi ng of alte r nate hot
.

treatments the body i s called upon to react several t i me

,

two or three applications the ,

oscillatory changes occu rring

and less in amplitude after
order to produce complete re
repe ated it i s neces sa ry to
,

lus This ma y b e done in the ca se O f

.

using a higher tempe rature for the hot

for the cold or by adding mechani ca l st i mul i
, .

Incom p lete R ea c tio n . A ppl ications

the rea ctive ability O f a patient wi ll
re action S hould this
.

fee l ing of fulness in the head and even fai ntness and naus ea
, .
 C ON D I TION S IN FL UE N CI N G R E A C TION

These are due mostl y to the i nternal cong estion which ha s not
been rel ieved or ha s been made more intense .

C O N D IT I O N S I N F L U E N CI N G R E A CT I O N
Ag e an d V itality of the Pati e nt
I n either extreme of l ife the .

abil ity to react i s quite l imite d N either infants nor age d per .

sons be ar col d treatment well We have treate d pe rsons in .

advance d l ife who were utterl y unable to react to even cool

water a s applie d by the wet hand rub and wh o i nva r iabl y ,

ch illed after a col d m itten friction .

I n certai n di seases or state s the vital ity i s so reduce d as to

render reaction extremel y di ffi cul t This i s tru e of nearl y all .

those di sease s wh ich produce a profound asthenia I n ane mia .

and extreme emaciation the same conditions prevail I n all .

su ch case s it i s nece ssary to thoroughly warm the bo dy previ ou s

to the col d application and gi ve vigorou s friction du ri ng and
followi ng the treatment E ven these means will not always
.

insure a reaction .

Exe rc ise su ffi cient to warm the body promote s reac tion
, ,
.

Th is i s true whether taken before or after the treatment I t .

quickens the circulation and brings the bl ood to the surface .

B ody heat i s i n cr e ase d so that the su rface bl oo d ve ssel s be come

~
.
-

dilate d in order to increase heat elimination : F ati gu e i s not

condu cive to completeness O f reacti on I n case it i s nece ssary .

to treat persons who are fatigue d a Short hot appl ication Shoul d ,

be given first quickl y followe d by some Short but very vi gor

,

ou s col d treatment accompanie d by fri ction or percu s sion

,
.

The Warm th of the B o dy When the bo dy i s warm reaction

.
,

appears promptl y The internal heat of the body may be ever

.

so much and yet reaction be impossible if the skin i s col d and ,

clammy pale cyanotic or goo se flesh in appearan c e

, , ,
The .

sk in shoul d be warm and if poss ible ru ddy before col d a p pl i

, ,

cations are u sed I n case it i s not some sort of hot treatment

.
,

Shoul d be u se d first i n order to draw the blood to the Skin

,
.

The air of the room in wh ich the patient i s treate d shou l d be

warm and he shoul d remain in a warm room after treatment
u ntil reaction is complete It m ay be ne ces sary to give a
.
‘

drink O f hot water in order to warm the body More e s sential .

36

than all of these is the warmth of the feet I t is .

secure fu ll reaction or the best possible results

'

cold .
It should therefore be a general rule
, ,

should be warm ed by a hot foot bath or alternate

foo t bath or hot foot pack previou s to any and ,

In the g iving of even an ene

meri t it may be necessary to
cove ring either in the form
,

secure full reaction .

Psychi c Atti tude It is difficult to .

in a patient that disl ike s the measure s

exercise an inhibitory influence over b od
doubted b y those whose pract i ce brings
profound neurasth enia Those under .

worry or anxiety react poorl y

, ,
.

C haracte r of Treatm e n t and Mode of

cases where reaction i s likely to be tard
should be preceded by a hot treatment .

hot appli cation shoul

It should thoroughly warm
come change The reaction .

if extreme cold i s used and

sion The cold er the water
.

cold treatment shoul d be gi

part at a time favors the
The larger an appli ca tion
the less promptly wi ll the
d r y hand or a rough towel ,

the reaction P ercussion has the same

.

from sprays and general appli cations of

as quickly and as thoroughly as possible If .

the su rface the re sulting evaporation cool s

,

acti on is delayed The patient Should be

.
,

room near the place where the

made To properly shape ciren
.

action requi res much care and

,

attendant nurse A 1 .
 N A ME S OF TE MP E R A T UR E S

T es t of R e a c tive Ab i l ity
to react to cold appli ca A bility
'

tions varie s with the cli mate O f u sual re side nce state of health , ,

occupation and habits of the patient A s to the reactive capacity

,
.

little can be dete rmined by questioning the pat ient O fte n .

those w ho sa y they are unable to take cold baths react a s well

or better than those who a ffi rm their ability to react What one .

calls very cold anothe r regards a s onl y cool S ome persons .

consider that they have been taking col d baths when bathing
i n water at 9 0 — 95 F
° °
The r esponse of a p atient with anem ia
.

i s u suall y in direct propo r tion to the de gre e of anemia The .

state of the v a som ot or s and the readines s with which the y react
to mechanical sti muli serve a s a rough test of the abilit y to r e
s p on d to cold treatme nt Thi s te st i s mentioned by nearly al l
.

5
writers on hydrotherapy Baru ch make s the following state .

ment
I have found that the re sponse of the cutaneou s circulation
to mechani cal excitation furnishe s an index to the probable r e
acti ve capacity O f the patient P as sing the b a Ck of the nail O f .

the i ndex finger rapi dl y but gentl y across the abdomen and ,

i ncreasing the pre ssure of the nail with a second stroke paral le l
to the first induce s a m ore or less deep reddening of the i rri
,

t a t e d sk in The rapidity with which the re d l ine de v e l op s aft e r '

the nai l i s removed and the pressure requ ired to produ ce it

, ,

a ff ord the traine d eye a cru de but fairl y correct te st of the , ,

patient s reactive capacity B y appl y i ng thi s test frequentl y

’
.

before each procedure one may readily tra in the appreciation ,

of thi s te st and thu s avoid the nece ssity of slow de velopment

of the reaction by gradual increase of the intensit y of the treat
”
ment which the author adopts in most case s .

C O MM O N N A ME S OF T E MP E R A T URE S
H eat and col d are relative not absolute terms and mu st , ,

needs be define d Thi s can not be done w ith accuracy since

.
,

patients differ in their toleration of heat and col d What one .

de signate s as very cold may be only cool to another The ex .

tent O f Skin surface expose d to the rm ic stimulation al so make s

a di ff ere nce in the de gr ee of the temperatu re impre ssion r e
5 H yd th
ro p y p 1 02
e ra , . .
88 P R IN CIP L E S OF E FFE C TS AN D

ce i v e dFor example immersion of the hand in

.
,

will g ive an impre ssion of cold ; but i f t he ,

immersed the water will seem very col d

,
.

°
bath at 1 0 5 F will seem very hot ; while if on ]
.
,

immersed the impre ssion received i s that of onl y

,

The most satisfactory w a y of desi gnating tem

define the limits in te rms O f de gree s .

b een found practical The designations

.

those that would be u sed for full tub baths ; those

are such as would be u sed for partial i mmersion
V ery hot
°
1 04 and
H ot 1 oo — °
1 04
°
F
—
.

Warm ( neutral , 94
°
92
°
1 00
°
F .

Tepid 80
°
92
°
F
Cool 70
°
80
°
F .

Cold 55
0
70 F .

V er y cold 32
°
55
°
F .
40 A N A TO M Y A N D P H Y SI OL O G

deeper layers nearer the subcutaneou s fat are coarser

, ,

loosel y arranged .

M U SC U L A R A N D E L A STIC T I S SU E
S mooth mu scle fibers are intimatel y associ ated with
ti e fibers The two together constitute
.

tant anatomic arrangements in the skin

entl y In many part s of t he skin the mu scle fi bers
.

2
the form of a network contracting diagonall y ,
.

tissue exists mostly as the erectore s pilorum di spo

in connection with the hair folli cle s and l yi n g
direction through the thickness of the skin .

bundles are sur

they are enclose
of w hi c h serve as tendons to connect the
,

fasciculi to the connective ti ssue bundles

varied degrees of tension O f the skin are
this m uScul O elastic mechani sm B aru ch
-

these changes as being the C hief cau s

ne ou s circulation which are brought ,

sions U nder medium temperatures

.

medium tension and the skin i s ordinaril y pliable .

contraction of these muscular bundle s and they ,

their action the smaller vessels of the corium ,

term i nal capillar y loops ( both

papill ae produ ce blanching of the
,

muscles ; the tension being rel ieved the elastic ,

their usual condition and the skin i s again

pliable H igher degrees cause increased rel
.

certain point where heightened tension i s

,

These facts explain the m e cha n ism a nd the

'

the contractility of the skin in the prop

both blood and
t he muscular coat of the blood vess -

situation The elastic fibe rs formin

.
,

brane around the blood vessels and o p p osi n -

muscular fibe rs may be su pposed to support

—
,

2 B h P i n i p l nd P t i f H y d t h p y p 5
g m w—
ar uc r c es a ra c ce o ro
3 Hyd
e ra
nd M
Di f t h S k i n p 35
, . .

e a o nt o e se ase s o e . . .
PL A T E I D i g
. a ra m m a tic se c t i o n o f t h e s k in .
 TH E BL O OD VE SSE L S 41

The disappearance of elasti c fibers from the skin in arterio

sclerosi s ( Mei ssner ) where rigidity and high tension are essen
tial accompaniments may lend color to thi s view and poss ibl y ,

reveal something of the pathogenes i s of high tension and sub

s equent vas cular scl erosis .

THE B L OO D V E -
SS E L S
The bl ood vascular system of the sk in on the arterial side i s
arrange d in two quite di stinct horizontal networks an u pper —
and a lower beside s being e speciall y abundant about the hair
,

follicles and coil glands The latter stru ctures are surrounded
by a basket like network of blood —
.

-
ve ssel s The lower or inferi or .

plexu s l ie s i n the deepest part of the de r ma It consists of com .

p a r at i v e l y large ve ssel s From this plexu s ve ssel s extend more

.
,

or les s verti call y upward to form the u pper or subpapillary

plexu s From thi s plexu s vascular l oops extend dire ctl y into
.
,

the pap ill ae above I n the papillary vascular system the

.

” 4
arterie s are narrow and the veins wide .

B aruch state s that the papillary loop may be so fille d with

blood ; that it may double and fol d over i n spiral wi ndings until
it occupie s al most the e n ti re space of the p apilla Thi s capacity .

for i ncreasing or di mini shing the si ze of the papillary loop

furni she s an i mportant agency by whi ch h ydrother apy may a ffect
5
the circulation .

B oth papillary veins and arterie s consi st of an endothelial tube

only N ear the middle of the subcutaneou s ti s sue the media
.
,

and adventitia appear I n the veins the mu scular coat i s found .

earlier i e in the plexu s at the base of the derm a where they

, . .
, ,
'

6
al so seem to posses s valve s I n the case of the capillary ves sel s .

the se c oats are supplie d by the m a sculo elasti c ti ssues of the -

skin itself as mentione d above

,
V asomotor ne rves are twined .

7
around these vessel s in all their r am i fi c at i on s .

TH E L Y M P H A TIC S
The lymph vessel s of the t rue skin are al so di stributed in
—
two layers a dee p and wide me she d plexu s ( colle cting trunks ) -

4 Hyd nd M nt g m
—Di f th Ski p 29 se as e s o n,
—P i n i pl nd P t i f H y d t h p y p 6
e a y o o er e

—
. .

5 B u h
ar c r c es a ra c ce o ro e ra , . .

6 B h m D vi d ff an d H b H i t l g y p 386
H y d d M n t g m y —I bi d p 29
o , a o ,
u er s o o , . .

7 e an o o er .
, . .
42 A N A T OM Y

in the subcutis and a su pe rficial

l a ri e s ) immediately beneath the pap
( F ig begin in the papill ae as an
.

of endothelial lined and absolutel y -

the connective tissue These cul s de sac divide .

- -

mose in a very free manner The capillaries of .

lary plexus also possess endothel ial walls of t he i r ‘

are devoid of valve s .

While the l ymphatic capillaries comm un i ca

connective ti ssue space s nor with
nevertheless i n very intimate

take place
capillarie s ful fi
as drains and ,

naut selective ,

ing to U nna ,

Spaces delicat ,

the cement s
the epithel ial
m u n i c a t i on w
spaces of the
of the corium B ut .
,

above thi s i s not an ,

communication but ,

P g 5 O i gi
l . f l ym p h ti v
. r l n o logical relation and a c e ss e s
in a p p il l f t h h d ( S pp y )
a a o e
less the path an . a e .

stance s which ar
the skin surface S ome a ffi rm that .

through the coil glands The epithelium of .

ha s however but slight absorptive powers

, ,
A t the ir com .

m e nce m e nt i n the capillarie s the lymphatics have a capacity

,

equal to and greate r than that of the ve ins Thi s diminishe s .

,

t he nearer we approach to the thoracic duct the cal ibre of

.
,

wh ch i s mu ch smaller than that of the vena cava

i 10

—
.

—
8 B hm D id fl d H b H i t l g p 387 '
o av o an
, u er s o o y.

—
,

C n D L y m ph pp
. .

9 F o ur
i e r. u e o , a nd e l a m e re T he a t ics , 74 76
P C un D p 62
.

10
. .

o nn e r . e o , a nd e la m e re l bi d .
. . .
 '
TH E L YMP H A TICS
The deep wide — me she d plexu s locate d in the subcut is forms
, ,

part of the superfi cial l ymphati cs ( collecting t r u nk s ) of gross

anatom y ( F ig The y are l arger .
,

though ve ry irre gu lar and sacciform chan

nel s dividing and anastomosing freel y ,
.

The wall consists of e ndothel iu m together ,

with an ela stic and mu scul ar coat They .

are provided with valve s at variable dis

tance s From the fingers to the axillary .

F ig 7 V lv
a es of
'

h f
t h e m e se n t e ri c c y li e r o u s v e sse l s
b
. .

of t he new orn ca t .( D e l a rn e re )
.

glands S appe y counte d sixty to e ighty ,

.

The se are cre scentic folds of endothel ium ,

re sembling the aort ic semilunar valve s and

arrange d in pairs ( F zg 7 The alternate .

constrict ions and swellings which give the

lymphatic ve ssel s their be ade d appearance
are due to the se valve s A ccording to .

Delamere the supravalvu lar enlargement s ,

are t rue contractile sacs similar to the ,

F ig 6 S u p fi i l l y m l ymphati c hearts of batrachians

. . er c a From .

p h ti a f th
cs o m nt e ar a er
u f L y m ph t i the standpoint of hydrothe rap y the fol
,

ior s r ace a c
k f fi ng
,
.

n twe or o d e rs an
p l m C ll ct i g t u k lowing statement by the same writer i s
a o e n r n s
d f
.

o f th em ar m an o re a r
( S pp y ) a significant H e says that becau se of the
e .
44 A N A T OM Y A N D

elasti c fibe rs connective ,

walls are in spite of the ,

retracti l e They withstand w ithout rupture

. , ,

column of mercury of from thi rty to fort y

We have noted above the vari ous str u ct u
blood and the l ymph vesse l s are rendered
ought now to consider briefly t he contractility of
lium .
This i s of no l ittle i mportance in tho se
blood and lymph capillaries which posse ss no ,

These endothelial cells contract and expand cau ,

in the calibre of the capillary channel .

these contractions
which
phenomena are to be obse rved espec 1 a
living animal Sc hm e t k i n found nerve .

large blood vessel s not only in the adventitia and

-

also in the intima .

1“

It seems then a well e stablished fact that all

, ,

vascular system, whether large or small arte rioles ,

or venules whether blood or lymph ve ss

,

all possess the power of contractility P .

Sels of the body are under the control of

through those filaments

played upon by su c h contractile mechani sm
i s itself influenced by stimul i similar to t h
nature These vasomotor fi bers are sai d to
'

first t h
,

second ,

to the

While
and seem to be more abundant in ce rt
tain ne rve t runks they are neve rtheless dist ri bute d wi th, , ,

nerv e fibe rs and are found in al l parts of the body

,

nd D l m r —
.

11 P u oC un
ri e r , T h L y m ph t i
eo, a e a e e e a cs , p 70
Ph y i l g y 1 898 p 289
. .

12 s o o , . . .

13 H um n Ph y i l g y 1 905 p 1 32
a s o o . . . .

14 B oh m D i d fl nd H ub H i t l g y p 223
, av o
'

, a efi
-
s o o , . .
46 THE P E R I P H E R A L H E A R T

p
ressure being due to a widening or dilatation of the vessel s
ll l d an increase of pressure to t he oppos ite condition a narrow ,

ing or contraction of the vessels The vascular condition e n .

tering into t he normal rapidity of the circul ation i s neither the

.

o ne nor the other extreme A pe rmanent widening of the .

vessels leads to stasis of blood while a pe rmanent narrowing ,

re sults in heightened blood pre ssure a rte ri osclerosis and its \

, ,

re su l tant chain of disaste rs .

F ig s B l d p u t i ng h w i n g T u b H i n g
8 a nd 9 oo r ess re ra c s s o ra e -
er
u v t k n f ( M t i n ) T h u pp i ng t k n
. .

c r es ma d ge ro a t o ar e er ra c a e
w h il p b i ng i d n h w t h th
u v s —
. ,

e tifi lar i ti n w
cra re s ra o as e c a rr e o s o s e re e
p ul w v p nt d b y h d u bl t k t h
,

c r e th e se a e re re se e eac o e s ro e; e
p t yw v v i n g b u t fi p ul w v ; nd t h v
.

r es i ra o r a e . co er a o ve se a es a e as o
m t o or or T b H i n g w v t h l w u nd u l t i n v i n g
ra u e er a e e s o er a o s co er
p t y w v i n g t k n ju t ft t h
-
.
.

fi ve re s i ra o r Th l w t a es e o er ra c a e s a er e
t ifi i l p i t i n h w nl y t h p u l w v n d
.
,

ti n f
c e ss a o o ar c a re s ra o s o s o e se a es a
ub H i ng w v
,

th T e ra e -
er a es .

Traub e H e ri n g W aves
-
health there are continuou s and . In
more or less rhythmic alterations in the cal ibre of the blood
vesse l s S peaking al ong this line Landoi s says the diameter
.
1
,

of t he vessel s i s subject to pe riodic variati ons not onl y i n the ,

vessels provided with muscular tissue but al so in the c a p il

—
lari s i h the latter in consequence of the spontaneou s con
o ,
,

traction of the protoplasmic cells that form their walls ”

More .

1 H m Ph y i l g y 1 905 p 1 80
u an s o o , , .
 TR A UBE H E R IN G -
WA VE S

over S ir Michael Foster state s that these change s which vary

,

considerabl y both in the ir rh yth m and e xtent occu r without

, ,

any obvi ou s changes i n e ither the heart beat or the ge neral c ir

culation and when the ani mal ( unde r observation ) i s appar
,

entl y subj ected to no distu rbing cau se s H e regards the m a s .

spontaneou s although subject to va somotor control

,
.

In determi ni ng changes in the amount of blood in the arm b y

the plethys mograph the flu ctuations i n volume a s re g istered , ,

by the kymograph permit reco g nition of the fol lowi ng phe ,

2
momena ( F ig s 8 a n d
. 1 P ul satory fluctuations due to
. .

each individual heart beat 2 Respi ratory fluctuations 3 Ce r . . . .

tain periodic flu ctuations dependent upon pe riodic re g ulatory -

movements of the blood vessel s pa rticularl y the smaller ve ssel s -

,
.

F ig 1 0 R h y t hm i l v m t w v ca aso o or a es of bl d p
oo r e ss u re in a d og
b H i n g w v ) T h u pp t g bl d p
. .

( T ra u e -
er a es e er r a ci n ( 1 ) is t he oo re ss u r e
d t k n w ith t h m u y m n g
.

re c o r as a e e e rc r a om e t e r ; t he l ow e r t r a c i n ( 2)
is ta k n w it h H u t hl m n m t
e a r e a o e er .

Wave s are ofte n obse rve d on the blood pre s sure cu rve ,

which must a ri se i n a slow rh yt hmic va riation of the constrictor

i mpulse s sent out from the va somotor ce nte r The se wave s are .

” 3
known as the Traube H e ri ng cu rve s Relative to the blood-
.

pre ssure tracing as take n w ith a mercury manomete r ( F ig 1 0 ) .

4
H owell says The latte r wave s ( Traube H e ring ) are
,
-

due to a rh ythmi c action of the vasomotor ce nte r Duri ng .

sleep ce rtain much longer wave like va riations i n the blood

, ,
-

pre ssure al so occur that are agai n due doubtle s s to a rh yth mi c

d i—
, ,

2 L H um Ph y i l g y p 1 90
l i g—
an o s an s o o

E l m t f H um n Ph y i l g y p 27 6
. .
,

3 St ar n e en s o a s o o
Ph y gy pp
, . .

4 si o l o , 1 908 , . 564 5 65
, .
48 TH E P E R IP H E R A L H E A R T

change of tone in the vasoconstrictor center Change s similar .

to those producing the Traube H e ring wave ma y also b e -

observed in the spleen ( See O l a/bi er X ) and in heart mu scle .

( F ig . T he manife station of pe ri odic variations in tone

is therefore common to the involuntary muscle of several
, ,

diff e rent organs and structu res S ome obse rvers regard the se .

tone waves as spontaneous though subj ect to ne rve control , .

In discussing periodic variations in blood pre ssure J aneway

i v c s the following : These are evident in the human being a s
in the animal The respiratory and the Traube H e ri ng wave s
.
-

F ig 11 v h
T o ne w a e s i n e ar t m u scl e T he re c or s ow s c o n t ra e d h
p v p h p d d
. .
.

t i o n s o f a s t ri o f t he s i n us e n o s us ( t e rr a i n s e a rt ) s u s e n e in
‘

a b h
at of b
l oo s e r u m d
In a -

i t i on t o t h e s a r dd c o n t ra c t i o n s h p
k d h g v k h g
.

m a r e b y t h e l i n es t e re a r e l o n e r w a e l i e s o rt e n i n s a n d
x g h h h v
-
.

re l a a t i o n s i rre u l a r i n c a r a c t e r w i c a re d u e t o a ri a t i o n s i n
H
.
.

t o ne . ( ow e ll ) .

in d t he other l e ss rhythmical but apparently spontaneou s fl uc

t ua t i o n s in mean blood pre ssure mu st be in mind du ring every
,

clinical experiment E xact figures for the poss ible pres s

.

u re variations due to these causes are hard to give but thei r ,

extent in animals combined with my observations on the ,

change s noted in patients from moment to moment lead me to ,

place 3 0 mm H g as the probable maximum rise which may be

. .

attributed to them O ne sees these larger fluctuations mai nl y

—
.

in patients with hype rt ension O rdinaril y 5 1 0 mm would b e .

, .

a libe ral estimate In thi s connection J aneway gives a trac

.

i ng ( F ig .
by Mosso taken from a man at re st in which the ,
,

Traube H ering w ave covers on an average of fifteen pul se

-

5 C l i ni cal St dy f Bl
u dP o
DD 1 1 2 1 1 3oo
l pp 1 6—
21 re ss u re . .
. : s ee a s o . .
 VA SC UL A R E FFE C TS
waves thus showi ng a fluctuation recurri ng about fou r or fiv e
,

ti me s a min ute .

E vents occurring i n other part s of the body ma y g ive rise t o

large changes so that the a rte riole s may become constricte d
,

almost to obl iteration or dilated to more than double thei r ,

u sual diameter The se obse rvations appl y to a rte rie s ca p i l

.
,

l a ri e s and veins I n the ve ssels of the web of a fr og s foot ’

, .
,

direct treatment of the web may bri ng about the same changes .

S ince the se rh ythmic vascular change s normall y oc cur quite

independentl y of the hea rt be at we have he re a factor i n the ,

circulation which u nde r proper ph ys iolo g ic stimulation may

, ,

be utili zed to rel ieve that organ of much of its work so that ,

F ig P 12 e ri o di fl u c ct u a ti o n s i n t h e t r a ci n g of bl d p u
oo r e ss re
k nf m D C ol bo M ph y g m g ph
. .

ta e ro oc or t om (a t re st ) . ( o ss o s S o ra . )

when overburdened it may obtain neede d rest through the ,

slowi ng of the rate and the i ncreasi ng of the force consequent

6
u pon this help Landois i n di scuss ing blood pressu re a s
.
,

altere d by change s in the si ze of the vessels me ntions the ,

application of heat and cold to ci rcum scribed areas as i n fl ue nc

i ng blood pre ssure through the vasomotor ne rves It i s to the .

applications which bring about su ch change s as the se that we

now tu rn ou r attention .

THE P RI N CI P L E S O F V A SC U L A R E F F E CT S
The u nderl ying p rinciple of appl ications cal cul ated to awake n
an activit y of the ci rculation i s found in the ol d dictum a bz i r
’

r i l a ti o
,
ibi afi ux us Where there i s an irritation there is an
.
,

6 H um an Ph y si o l o gy p . . 1 66 .

4
 TH E P E R IP H E R A L H E A R T

of bl ood Rub vigorou sl y

a fli u x .

skin becomes reddened with an

or a dash of cold water produ ce

i . the pri mary

e .
,

traction The oscill atory chan .

are different with the diff erent

this reaction with which we are
cases the first eff ect i s of no
others i t i s u ,

const riction Th .

and become less

cation so that a p ,

mum dilatation .

fomentation heating ,

to heat i s therefore , ,

With a co ld application to the skin th ,

ing ( vasoconstriction ) but this i s soon ,

( active h ype remia ) Which as we know , ,

side r ab l e len g th of time

H ere the oscil lations in v

,

a way that they are

passive dilatation T .

c han i c a l irritation ,

results H owever the two comb .

,

tion cold percu ssion douche etc gi ve qu ieke

, , .

lasting e ff ects .

7
Kellogg records the following expe riment as showing
vantage of mechanical i rritati on combined wi th cold .

compress and a percu ssion douch

t ane ousl y admini stered

five seconds After the cold compress the reaction .

forty seconds whereas aft e r the cold percu ssion , ,

ci rculatory reaction appears in five seconds .

7 R ti n l H yd t h ap y 1 90 1 p 1 1 26
o a ro e ra . . . .
 VA SC UL A R E FFE C TS
As the cold appl ication is prolonged the ampl itude of the va s ,

c ul ar oscillat ions become s le s s and le ss until t he condition i s

more nearl y that of a constant va soconstri ct ion Fol lowing .

the p rocess to an extreme point we find that by int ensel y low , ,

te mperatu re s the ci rcu lat ion i n the capill ari es i s at first accel
,

e r a t e d and the nu mber of blood corpuscl e s di mini shed when ,

the p a rt becomes pale Q ui ckl y followi ng this acceleration .

there i s a stas i s i n t he capillaries whil e in the smalle r veins an d ,

arteries the slowing of the circulat ion i s followe d by bri ef and

,

rapid oscill ations wh ich become slower and more infre quent
, .

S lowl y the vessel s become more pale less transparent and , ,

” 8
finall y the move ment s cease Thi s i s of course providing .
, ,

reacti on occu rs at all a s i t u suall y doe s if the cold i s appli e d to

,

a li mited area If the reaction does not occu r as where there

.
,

i s a general appl icat ion of col d withou t frict ion the ski n b e ,

comes blanched and goose fle s h appears due to the contraction ,

of the e rectores p iloru m I n case an i ce col d ap pl ication r e

.
-

mai ns long enough on one part paral ysi s of the vessel s re sults ,

and a consequent dilatation .

S al ine sub stance s and ce rtain gas eou s irritants ch ief among ,

which i s C 0 2 when appl i ed to the ski n al so p rodu ce an act ive

, ,

dilatation and contract ion of the blood vessel s wh ich re sults i n -

qu i ckene d circulation and increase of blood in the skin S al ine .

bath s are often more e ff ective than plain water Carbon dioxide .

and sal ine s are most e ff ectivel y u sed i n the combinat ion const i
tuti ng the N au heim or e ff ervescent bath H ere the cool wate r .

itself plays some pa r t since temperature s somewhat below neu

,

tral are u sed S o m arked i s the e ff ect of th is sk in t en i c that

.

i n severe case s of dilatation ( of the hea rt ) the al most incredible

re sult i s attained of cau sing the apex actuall y to retract three
,

qu arters of an inch toward i t s norm al position i n a single treat

9
ment The heart beat i s decreased i n frequency and i n
creased in force ; i t s previou sl y labore d be at give s wa y to a
steady eas y movement and in some cases w e have actuall y
, , ,

been unable to detect murmurs wh ich were previou sly distinctl y

heard These re sults are by all conceded to be due chiefly if
.
,

8 B a r uc h—P i n ipl
r c e s and P r a c t i ce o f Hyd r ot h e ra py p , . 39 .

9 B a ru c h I b id p 1 0
-
.
, . .
52 TH E P E R IP H E R A L H E A R T

not almost wholly to the ,

of the skin the so call ed ,

-

When we consider the ma

longer be comes a wonde r
V i e rord t estimate s the com
s y stemic ci rculation at 800
t i on
.

magnit
acting
tube s .

nine .

t a t i on is sho w n by the fact t h

cyanotic an evidence of already
,

dilatation while on emerging from the b a

,

brighter and more normal color N either .

vasoconstriction are condu cive to a slower ,

The result i s therefore not a pas sive change

, , ,

E lectric currents appli ed to the skin also

motors N ear the positive pole
.

w hile i n the region of the cathode

alternating or inte rrupted curren
more powerfully stimulated .

the sinusoidal cu rrent the u se of which in the ,

c u l a r e ffects will be mentione d more in deta il

therapeutics .

THE Q U A N TIT Y O F CIRC U L A TI N G F L U ID S

When we consider the total quantity of blood and l ymph
b ody and the fact that the skin and adj acent
,

tain a large share of this or influence its di st ,

w e see how powe rful an agent the skin i s in

culation of these fluids in the variou s organs .

A bo ut one th irteenth of the body weight

-

nearl y 30 per cent may be e

influence of c e rta in conditions
the re is one fou rth of the blood -

blood ve ssels ; one fou rth in the

- -
 C H APT E R V

A N AT O M Y A N D P H Y SI O LO G Y O F T H E SK I N
( C on t i nu d ) e

THE SU DO R I P A R O U S OR CO IL G LA N DS

HE sweat glands are distributed throughou t the entire sk in .

They are most numerou s i n the axilla palm s and soles , , ,

where they are al so of unu sual size A nd according to Krau se .

, ,

there are between 2 000 and 3 000 per square inch The total .

number in the body i s estimated at from to

and their aggregate length uncoiled and placed end to end as ,

about eight miles ; while the total surface of the du c t s i s e sti m

ated at square feet These figu res serve to show the .

great importance of hygiene directed toward the maintaining of

their normal functions and the tremendou s e ff ect of bad hygiene
i n causing disease .

The sweat gland consists of a long tubu le coiled at the ,

deeper end The globular coil ( glomerulu s ) l ies in the sub

.

cutaneous fat or i n the fat columns of the deeper part of the

.

corium N ext to the epithelium in the coiled part of the tubule

.

are found smooth mu scle fibers disposed longitudinally or , ,

spi rally These mu scle fibers are doubtless concerned al ong

.

w ith the erectores pilorum in the checking of perspiration ,

which resul ts from cold applications : E ach tube i s abou t fou r

or five millimeters long Three fourths of thi s make s up the
—
-
.

—
1
coil
.
The sweat pore that part of the duct l ying in the ep i
dermis i s a wall le ss channel spiral or straight i n cou rse
-

, .

The outer end i s funnel shaped The pore i s in free communi -

cation with the juice space s of the epithel ium as was mentioned ,

1 11 cons i der i ng the l y mphatics of the skin I t will be seen from

B h m D v id ff nd H b —
.

1 o , H i t l g y p 3 97
a o . a u er s o o , . .

( 54 )
 TH E C OIL GL A N D S

this fact that the drying of the skin i s not alone a drying of the
surface but also a drying of the flu id found between the deeper
,

cells of the ep iderm is A cap illary network of blood ve ssel s .

-

surrounds the coiled part of the gland N erve s from the sym .

pathetic neurons e nd i n the secreting cells .

F ig s 13 a nd 14 Di g
h w i n g i m il i t y i n t u t u f t h
a ra m s s o s ar s r c re o e
t bul nd gl m f t h ki dn y t t h il g l n d kin
. .

u es a ul i o er o f th e e o e co a s o e s
nd th i v ul n tw k A t h u i ni f u t u b u l m ny
or s e r e ro s e s a re a

F ig 1 3 U T —
a e r a sc ar e
t h l n gt h f t h i l gl nd mp i n f th iz i in
.

t im

—
es e e n o e co a s, o co a r so o e s e s
t d b y th d w ing ;u i n i f t u bu l C B
f B wm n G —
di e ra u s r e ro s e
p ul —
ca e
gl m ul u— F i g 1 4 S u d i p u
. . . . . . . .

ca s e o o a o er s or a ro s
gl n d E p i t h l i u m f k — P D p pi t y d u t C G
. . . .
.
‘

a : e n e o s i e rs r a or e

il d p t i n f gl nd V N v ul n t w k
. . . .
. , ,

co e or o o a , . . a sc ar e or .

The se cret ion of the sweat g l an d s v ar i e s with the character '

and amount of food and drink the s tate of health temperature , ,

2
and hum idity of the air etc A bout 9 8 per cent i s water t he ,
. .
,

remainder be ing chie fly sal ine s p igment and a small amou nt , ,

of fat .
In twenty fou r hours one and one half or two p ints of
-

,
-

water are excreted Thi s is approximatel y double the amount .

2 Hyd e an d M on t g om e r y
—
D i s e a se s of t h e S ki n p , . 46 .
56 A N A TOM Y A N D P H YSIOL OG Y OF TH E SK IN

exhaled by the lungs Contrary to the general notion the skin . ,

doe s not excrete large quantities of deleteriou s substance s I n .

hea /{1 2 the poisons exc reted by the skin are ve ry small in amou nt .

Vi c ari ous Fun c ti ons of the Sk in There i s a great simil arity .

i n the stru cture of the tubules and glomerul i of the k idney to

the coil glands of the skin and their vascular tufts ( F ig s 1 3 a n d .

T his very similarity in stru cture suggests a s imilarity in .

function The perspiration and u rine are both excretions and

. ,

to a great extent may replace each other I n disease th is fact

,
.

becomes very evident When the kidney s become incompet ent .

to excrete certain waste s these are often found in the sweat ,

and v i ce ver sa when persp iration i s inte rfered with more

, , ,

work i s thrown on the kidneys I n warm weather e xcess ive .

perspiration occurs while the u rine is scanty In col d weather ,

.

the perspiration decreases and the urine increases in amount .

U rea normal in the urine to the extent of about 2 per cent

,
.
,

i s found in normal perspiration to the extent of to pe r

cent Schotte i n in certain cases of the u rem ia of cholera saw
.
, ,

the whole body covered with a thin white crystalline layer of

In cases of pyemia where the staphylococcu s albu s was ,

present in the blood the sweat indu ced by packs has shown ,

abundance of the staphylococcu s The sam e i s tru e of many .

_

other diseases i n which there are germs in the blood ( bacteri

emia ) the kidneys also excreting the germ s
, B ouchard h as
4
.

called particular attention to the cuta n eou s eruptions which

accompany auto intoxication especiall y with a dilated stomach
-

, ,

or after eating mu ssels shell fi sh etc as be ing due to pto ,

-

, .
,

maine s eliminated through the skin In s ome for m s of auto .

'

intoxication various poisons excrete d by the skin may be a pp r e

c i a t e d by their odors The pe cul iar odors about pri sons and .

asylums are doubtless more or less due to the volatile poisons

of faulty nutrition which the skin exhale s In case s of j aundice .

bile pigments are found i n the sweat so that sheets and bedding
are stained by it S ugar may be found in the sweat of dia.

be t i c s and in the sweat of cases of forced gl ycosuria .

Dr H erbert U Williams of B u ff alo has shown that i n

.
5

—
.

3 B h P i ipl d P f H yd
ar uc ti r nc th
es an p y p 26 rac ce o ro e ra
4 A t I nt x i ti n in Di pp 20 1 62
, . .

u o -
o ca o se a s e ,
5 J u n l f Am i n M di i t i n A p i l 1 7 1 909 p 1 2 7 6
.

l A
, .

o r a o e r ca e ca s s oc a o , r , , . .
 P E R SP I R A TOR Y I N F UE N CE S

chronic nephriti s the sweat glands are extens ivel y altered i n

structure H e examined skin from va r ious part s in seventy
.

cases of chroni c ne ph r itis and fou nd a variety of conditions

including de squamation of the epithel ium cysti c dil atation of ,

the tubule s atrophy of the tubule s and cast like materi al in

, ,
-

the tubules I n fou rteen cases arteriosclerosis of the arte ries

.

of the skin was present I n some ca se s hypertroph y of the .

epithel ium was observe d even to the formation of tw o or three

,

l ayers of ce ll s Dr Williams states that these studie s were

. .

u nde rtaken because from the earliest age s faith ha s been

, ,

place d in the e ffi cacy of active skin excretion i n cases of .

nephritis .

SU MMA R Y OF P E R S P I RA T O R Y I N F U E N CE S

F a ctor s z o/
z i c/
z g ove r n per spi r a ti on
1 De g ree of in ternal or exte rnal heat
. .

2 A mou nt of water i n the bod y

. .

3 A mou nt of blood i n the skin

. .

4 S pecific stimula tion of secretory ( sweat ) ne rve s

. as ,
bv
ele ctri city shock ( as cold sweat of fright
,
and drugs , .

f per spi r a ti on
’
Con a i i i ons tha t g i ve r i se to i n cr ea se o .

1 . A ppl ications of heat as hot ai r hot water steam light

, , , ,
.

2 . Water drink ing e spe ciall y of hot water

, .

3 . E xercise .

4 . Me chani cal i rritation as fr iction or pe rcu s sion , .

5 . Diaphoretic dru gs .

Con di ti ons i li a t decr ea se per sp i r a l i on :

1 Chilling or cold appl ications
. .

2 E xcretion of large amounts of wate r by the ki dne ys or

‘

bowel s .

3 Ce rtain drugs as atrop ine

.
,
.

4 Local appli cations of astri ngents or cool ing preparations

.
, ,

as al cohol vinegar talcu m powder etc

, , , .

The facts liste d in the above outline are perhap s too e vi dent
as matters of eve ry day experi ence to nee d comment
-
I n prae .

tice we u suall y combine two or more of the se measu re s i n order

to secure qui cker and better results For example the drink .
,

ing of cold wate r be fore and duri ng the electri c light bath
58

greatl y enhances its

conjunction with hot
gi ves quicker results
creases the blood about
di rectly the secreting e e l
,

a decrease in the amount

the available fluid which
It has been shown that
the sweat glands ca use alterations in ,

ing cells thus provi ng detrimental to

,

THEDS S E BA C E O U S GLAN
The sebaceou s glands are sacciform in shape ,

n e c t i on with the hairs of the skin and pou ri ng

i nto the folli cle s of the hair an d lanugo The .

prod uced
more cells being produced
their place It i s de si gn ed to oil the
.

are situated next the hair follicle ,

muscle H ea t softens the oi l in the

.

about its extru sion O il i s a .

the skin with oil hinders both

su rrounding atmosphere i s cold and t he absorpt ion ,

where the atmosphere i s heated .

A B SO R P TI O N B Y TH E S KI N
We are not g reatl y concerned in hydroth erap y with
sorptive powers of the skin O il y substance s are .

absorbed watery solutions not at

,

stances alcoholic or ether eal solu

,

bath and cleansing of the skin 5 ,

O pen and the increased circulation fa

e
G u y H i n sd al e gi v e s an excellent
c utaneous absorption from which we

J ame s Cu rrie who wrote one of ,

hydrotherapy states that there i ,

b a th an d while the skin remains

,

tion of solid liquid or aeriform , ,

6 H yd th
ro py p 21 er a , . .
 C U TA N E G US R E SP IR A TI ON

surface I n the i nstances that are su ppose d to favor t he con

.

t rar y O pinion it will be found that the a rticle i s force d throu gh

,

the epide rmi s by mechani cal pre ssure or that the epide rmis has ,

been previou sly de stroyed by inju ry or disease .

R oh rig in experimenting with a bath to whi ch pota ssiu m

’

iodide had bee n added found that full immersion i n this for ,

three quarters of an hour gave ri se to no iod i ne i n the u rine

-
.

N egative re sults have also been obtai ne d by a n umbe r of other

observers u sing various soluble substance s S ubst ance s cau s .

ing inju ry to the skin may b e absorbed al so ethereal solut ions

~

of certain alkaloids but R Winte rn it z found no evidence of the

,
.

entrance of the se substance s from watery solutions .

—
O n e mu st therefore conclu de that the mineral constituent s
,

of wate r other than strong sal ines and gaseou s constituents

,

have no e ffect whatever upon the human system when appl ie d

to the unbroken sk in H insdale make s a very apt state ment of
.

the case We are thu s forced to the conclu sion previou sl y

—
,

enunciate d that the mineral waters the anal y si s of which are

, ,

quoted w ith su ch parti cular exactitu de unto the third or fou rth
de cimal pla ce of grains per gallon are ne ither more or less e ffi ,

c a c i ou s on that accou nt .

C U TA N E O U S R E S P IRA T I O N
To a l imite d extent the skin acts as a re spiratory organ whe n
,

°
the temperature i s above 85 F A bo ut 0 5 per cent of the total
'

. .

gaseou s exchange of the body occurs i n thi s manner The .

°
amount of C 0 2 e xhale d at F may be double d at 9 3 F . .
,

i ncreasing in about the same ratio as the watery excretion .

H ot moi st appl ications to the ski n increase the el imination of

C O Z since diffu sion of gase s i s hastene d by the moi ste ni ng of
,

the su rface and t he larger amount of bl ood brought to the ski n .

It i s sai d that in di sease s of the heart and lungs where there

, ,

i s dimini shed ex c retion of C 0 2 i n the expired air cutaneou s ex ,

halation i s i ncreased In asthmatic dyspnoea when the skin

.

become s flu shed and persp iration free the dyspnoea i s somewhat ,

relieve d Ge neral perspirat ion p roduce d by hot appli cations

.

al so rel ieves dy spnoea I n e ither case however the re sult i s

.
, ,

probabl y due more to the i ncreased rate of the ci rculation of

 A N A TOM Y A N D P H YSIOL O G Y OF TH E SK IN

blood through the lungs r e fl e xl y p roduced by the appl ication ,

thus increasing the amount of oxyge n there absorbed than to

'

increase of cutaneou s re spiration .

THE S KI N A H E AT RE G U L A TO R
This will be considered agai n under the subj ect of heat reg u
lation The skin i tself take s pa rt in heat loss onl y although
.
,

through nerve connection it i s one of the most import ant mea ns

,

i n controlling heat production The loss of heat by the skin

.

” 7
amounts to about 7 7 per cent of the total heat loss I t i s there .
,

fore the most important factor in the el imination of heat The

,
.

regulation of heat loss by the skin i s acco m pl i shed by variations

in the amount of heat radiation and evaporation of sweat .

It will be seen that heat appl ied to the skin increase s heat
loss in two ways : first by dilati ng the su rface ve s sel s and qu ick
,

e n i ng cutaneou s circulation thu s increasing heat radiation and

,

convection ; second by inducing free perspiration and the con

,

sequent loss of heat by evaporation Conversel y col d appl ied .

,

to the skin decrease s heat loss by driving the blood i nward and
checking perspiration .

It i s chiefly through the temperature ne rve s of the ski n that

.

thi s organ i nfluence s heat production S o profound i s thi s .

influence that extensive burns cove ri ng more than two third s ,

-

of the body are fata l through dest ru ct ion of the sensory nerve
,

terminals . N o t onl y i s heat elimi nation i nterfered with b ut ,

metaboli sm becomes excessive and heat product ion i s immensel y

increased .
Internal conge stion and i n fl am m at i on s re sult with ,

a fatal termination .

A fter a drunken debauch the unfortunate vi ctim i s i n great

danger from exposure to cold becau se the sensibil ity of the ,

ne rve s i s temporaril y destroyed so that the heat regulati ng ,

-

centers are not apprised of the danger The bo y who died from .

gilding of the skin to represent a n angel i s an e xample of the

disturbance of the heat mechani sm due to interference with the
re g ulator y functions of the skin A fter va rnishing of the ski n .

the temperatu re at first ri ses and the n fall s accompanied by

symptoms of p oi soning due to defective oxidation .

7 S t l i ng—H um n Ph y i l g y p 505
ar a s o o , . .
 C H A PT E R V I

TH E —
CI R C U LAT I O N R E FL E X

U RI N G health there are vasomotor ,

playing upon the arteries in all pa rt

influence s hold the vessel s in tone i e ,
. .
,

oscillations in calibre so that blood pre ,

These influence s seem to emanate from a

w hich i s located in the me d ulla oblongata
. '

fourth ventricle I rritation of thi s center

.

of all the arteries and in c on se que nc ,

”
blood pres sure P aralysis of the c c
.

and dilatation of all the arterie s with e ,

blood pressure U nder normal conditions the

.

i s in a state of moderate tonic excitation ”

Wh .
l

exercises a controlling influence over all it is ,

Centers for t he vascular

“
vasomotor center .

vasomotor and vasodilator are distributed ,

”
entire spinal axi s ( P l a ie They
.

although they are subordinated to the dominating

”
the medulla oblongata I t i s obviou s that su c h .
2

ism as that de scribed i s su scepti ble of reflex 5

through sensory nerves and accordi ng to our ,

edge we should suppose that a tonic center of

have i t s tonicity increased ( excitation ) or deere
It i s to the reflex sti mulat ion of these
we now wi sh to tu rn our attention for through ,

hydrotherapy produce s some of its most i mportant

1 L nd oi s —
—
Ph gy 1 905 p
—Ph
a y si ol o , . . 7 62 .

2 L nd
a i Ph y i l gy p 7 35
o s s o o se e al so H o w e ll y s io l o gy p 564 a nd F o st e i Ph y si
l g y 1 898 p 285
3 H w ll —
, . . ‘
.
, .

o o .

Ph y i l g y p 560
. . .

o e s o o . . .

(62 )
 PL A T E I I V i l ym p th ti
sc e ran v
s a e c er es D i g m h w ing t h
a ra s o f exita re a s o e
f m t h p n f t h ym p t h ti n v lli g t h v g n f th b dy
. .

ro e s i e o e s a e c er e s c o n t ro n e i ar o us or a s o e o
i n t h t b l i n di at v S t im u l t i n f t h n t f m
.

Th d lin
e re es e a m t
e c e a so o or a re a s a o o e ce e rs ro
w hi h th ym p t h ti v ig n t g n pp li d b y t h m ( P i l
. .

c e se s a e c ner es or i a e a ff e c t th e or a s su e e
g m)
.

ri .
 E X P E R IME N TS I N R E FL E X E FFE C TS
Maxim il ian S chuller in experimenting on trephine d rabbits
,
‘
,

obse rved that seve ring single nerve t runk s on one side of the
animal p rodu ce d a distinct ( though transient ) dilatation of the
p ial ve ssel s on the corre sponding side thu s p roving that th e ,

blood ve ssels of the p i a m at e r are held in ste ady tone by con

-

t i n uou s excitation from the cutaneou s sensory nerve s Thi s .

r e sul t w a s obse r ve d onl y on the side of the severe d nerv e s o

that it coul d not have bee n due to shock or pain .

N aumann has demonstrate d clearl y that the e ff ects of ex

ternal irritants upon the circu lati on within the body are really
re flex H e separate d the hea d of a frog from the body
.
,

leavi ng them connected by the me dulla oblongata onl y H e .

next severed one leg after preventing los s of blood by tyi ng,

the vessel s so as to leave it connecte d with the body by the

,

sciatic nerve N ow he applied thermal chemi cal and electric

.
, ,

stimuli to the foot of the partially severed leg while he ,

obs erve d under the mi cros cope t he me sentery of the frog

, ,
.

S hortl y after gentle irritat ion of the pe ripheral endings of the

sciati c nerve in the foot the circulation in the vascular net ,

work of the lungs and me sentery was accelerated and re su med ,

the former condition slowl y after the withdrawal of the i rritant .

A more severe irri tation produce d retardation of the flow and ,

eve n stas is occurre d a s if the he art had be come tempora ri l y

,

paral yzed A strong i rri tant produ ce d dilatation ; a feeble one

.
,

constri ction of the vessel s The e ff ect of the se peripheral i rri .

t a t i on s on the hea rt w a s al so noted A strong irritation of the .

skin weakened i t s circulation ; a feeble irritant strengthened it .

A s there w a s no possible vasc u lar or ne rve channel from the

part i rritated to the part thu s vis ibl y a ff ecte d the conclu sion i s ,

inevitable that the eff ect is entirel y reflex H ot water acted .

” 5
precisel y as other i rritants These experiments al so prove .

that the re are two re flex means by whi ch the circulation may
be i nflu enced v i a re fle x stimulation of the v a som ot or s pro
, , ,

d u c i n g change s in vascular calibre and re flex stimulation of the ,

heart mu s cle itself A nother point brought out by the e x p e r i

.
,

ments of R ohrig i s that when intense cutaneou s i rritants pro

'

A h i v fu k l i h Me di c i n N o 4 1 87 4
h—
4 D e utc he s rc r n i sc e , .
, .

5 B a ruc P i nci p l
r e s a nd P ra c t i ce o f Hyd r ot h e ra py p
. . 37 .
64 R E F L E X E FFE C TS
duce considerable slowing of the heart beat the y al so increase ,

it s force Thi s i s the e ffect of a prolonged col d appl ication

. ,

whether general as with the B rand bath or local as with the , , ,

ice bag to the precordia .

RE F L E X ARE A S

The fact of reflex stimulation being e stabl i shed we may next ,

consider the location ( topography ) of the vari ou s re flex areas .

While the brain heart and other vi scera may be r e fl e xl y , ,

influenced by stimuli appl ied to many di ff erent cuta neou s areas ,

some even very remote from the se organs the m aximum e ff e cts ,

are produ ced by stimulation of cert ai n very definite and well

re cogni ze d areas I n general it may be said that the skin ove r .
,

an organ i s r e fl e xl y related with that organ I n most cases it .

,

i s not d ifficult to trace the nerve c onne ction .

In general the ski n overl ying an organ i s re fl e xl y as soci

,
-

ated w ith it which i s the reason wh y appl i cations of electri city

,

over an organ u sually influence it and not altogether be cau se ,

the current is passe d through the organ When the se areas .

are studied comparativel y it i s note d that the y are pract icall y ,

the same as those re gi ons poin ted out a s showi ng re flex pain ,

which would suggest a ne rvous path from the organ to the skin
and from the skin to the organ the terminations of which are in ,

” 6
the same vi sceral and cutaneou s fields S o definite and cir .

c um sc ri b e d are some of these areas that B G A Moynihan has . . .

frequentl y obse rved i n cases of duodenal ulcer a small hyper , ,

sensitive spot i n the skin cove ri ng the abdomen directl y ove r ,

the ulcerated area It i s no larger tha n a six pe nce and he .

-

attache s much value to thi s phenomenon in di ff erentiating ulce r 7

.

I t must not however be supposed that the re flex path from

, ,

the vi scera to the skin over which pain i s referre d i s the same
path as that utili zed in therapeutics for re flex e ffects u pon the
inte rnal organs N or are the ski n areas to which pain i s .

refe rred a l w ay s the same areas that shoul d be util i z ed to

S D L dl um —T h R l ti h i p b tw S pi n l C d S ym p th Sy
6
— u e e a o ns ee n t he t he e t ic st e m

—
. .
e a or a

M J f Am M di l A pp
,

$0? 1 h
1 T ti ra euu n l e ri c a n Ma y
gs
p c e a s u re s o r a o e ca ss o ci a t i o n , 2 , 1 908 , .

7W D H . . a i ne s
-
T he D iff e re n t i al D i gn a os is of D u od e n al Ul cer a nd Ga l l St o ne s
S u g y Gy n
,
r er . ec o l o gy . a nd O b s t e t ri cs , M h a rc , 1 908 ,
p . 279 .
 TH E R E FL E X A R C

influence r e fl e xl y the organ in which the cau se of pain i s

located For example i n the case of l iver and gall —
.
,
bladder
disease there i s frequentl y a pain i n the re g ion of the ri ght
,

shoulder or shoulder blade but it i s not to thi s re gi on that ,

appl ications are made to rel ieve di stre ss due to hepatic or biliary
a ffe ctions .

The variou s cutaneous areas to whi ch the pain or tende rne ss ,

due to vi sceral di sea se i s referred are spoken of as the ae r m a

, ,
’

tom es of H e a a The y are i n some case s of considerable se rvi ce

’
.

in diagnosi s and are sometime s se rv iceable as a gui de i n the

placing of therapeuti c appl ications T he v can not howev er .
, ,

b e impli citl y relied upon for e ither pu rpose Relative to this .

8
unrel iability A brams says The el ici tation of the de rmatomes
,

of H ead i s a tediou s method of exam ination and not always

accompanied by sati sfactory resu lts for the reason that a
great amount of expe rience i s nece ssa ry A l sbe rg in the .

examination of two hundre d wome n ( w ith gynecological a ff e c

tions ) found cutaneous areas of h yperalge sia in onl y seventeen ,

ten of w hom were h v ste r i c al Therefore he coul d attribute no .

,

dia g nostic import to the z one s in question be yond commenting

on the fact that hy steri cal st igmata mu st be exclude d be fore
‘

”
the zones of h yperal gesia could be regarded a s tru stwort h y .

Dia gnosi s and therapeu ti cs based on para spinal tende rne ss -

mu st therefore be of a highly imagi native character and e spe c

, ,

i a ll y so when approache d from the standpoint of a prejudgm ent

as to the cau ses of di sease and consequentl y i t s treatment .

The law that the skin over an organ i s r e fl e xl y related w ith

that organ may be regarded as an a mpl ifi ca ti on of H ilton s law : ’

The p r i n cip a l ne r ve to a joi n t not on ly s upp l i es t/z e a r ti cu l a r s u r

f a ces ou t a l so som e of t/z e m a i n m uscl es t/z a t m ove tha t joi n t a nd Me
9
sk i n ove r I n the case of the vi scera however the
t/z ese m us cl es .
, ,

deeper part of the re flex arc consi sts of a sympatheti c neuron .

RE F LE X AR C
TH E

The re flex arc consists of several pa rts ( F r on ti sp l a te a n d F ig .

I n general the following i s the path taken by a stimulu s

,

ari sing i n the ski n from a the rmi c appl ication and t raced as a
8 Sp dy l t h py p 7 1
v —A pp l i d A t my 1 90 1 p 2 09
on o e ra ,
. .

9 T re es e na o , , . .

5
66 R E FL E X E FFE C TS
re flex stimulu s to the organ u nderlying the ski n su rface treated .

From the skin it i s conveyed by a sensory ( te mperature ) ne rve

along a ne rve t ru nk to the posterior root of the sp inal ne rve ;
ente ring th e posterior root ganglion where the fiber i s seen to ,

be the distal axon of a T cell -

it passes on throu gh the cen

tral axon of the T cell into the -

posterior si de of the spinal cord .

O n ente ring the cord the fiber ,

imme diatel y divides i nto an as

c e n di n g and descending branch ,

both located in the poster i or

white col umns and wh ich give
off collaterals to the gray mat
0 1
ter The ones w e are con .

cerned with end i n tufts about

the cel l s of the column of Cl ark .

A ccording to S tarl ing the ,

vasomotor center in the me

dul la corresponds in position to
the colu mn of Clark which i s
doubtles s that which re pre sents
the vasomotor center through
F ig 15 D i g m t h w p t h f out the rest of the cord
a ra o s o
From a o
v fib f m
. .

t i t
a s oc o n s r c o r n t i
.
e rs ro v as o c o s r c
tor t
ce n e r t th bl d v l nd—t h
o e
these
oo
cell s axons
e ss e s a
pas s eithe r e
p th f fl x t i m l t i n— v
-

a or re e s th u a o c e ,

v
. . .

ne uro n o
t i t
a so c o n s r c o r
f th v
t
e
l
t i t
th
p th 2
nt
ce n e r , l
a so c o n s r c
into G ower s tract and end i n
.

or
e
a
ce ra ’

pin l n (p g gl
.
,

th ) 3 12
e s
p h
a ne u r o
g g the re
cerebellum
an
or pass out with
i on i c

4 —
, .

the s y m t t
a i e n( li
c n e u roi ) an on c a ,

y fib
.

th i l th f
e
th p
e
t
ar e r o e ,
t i
os e r o r r oo t nn t ng b y
.

ll t
co
e
the ante ri or root and through
s e n so r
ec i co
e rs
a er
o
,

l w it h t h v— n t i t d
a s
su b t c e n e rs , 5 fib
e
f m
a so c o
ti
t
l
er ll
the white
s r c
ro
ramu s to the
or c e n e r
gangl
c or
ion ca
an
ce
t ng p n th v
.

n t i t
ac i u o
( H w ll )
e
o
t
a soc o
of the l a t e r a l s y m p a t h e t i c
e .
s r c or ce n e r .

8 1
chain P as sing di rectly through .

this or up or down through an adj acent gangl ion they end ,

in a peripheral ganglion from which the viscu s i s supplied .

The fibe rs of the white ramus which pas s through the gang
l ion and go to the periphery are known as the spl a n c/z n i c ejjf er en t
10 Wh i t k A n t m y f t h B i n nd S p i n l C d p 38
a e r- a o o e ra a a or
Ph y i l g y p 25 9
—
, . .

1 1 s o o , . .

12 L udl um J u n l f A m i n M di l A i t i n M y 2
o r a o e r ca e ca ss oc a o a 1 908 p 1 403
Wh i t k I bi d p 39
, , , . .

13 a e r- , . .
68 R E FL E X E FFE C TS

tion is carried to the spinal cord

,

thoracic ne rv es whi ch end in the s

accelerator fi bers of the heart arise .

stimulus produced by the a ff erent

upon the cells in the column of Clark i s
the axons of these cells through the a nte
of the white rami reaches the sympath
which they pass to the i nferior ce rvi cal g a
the inferior ( sympatheti c ) cardiac nerve
plexu s and the heart mu scle The .

depressed the heart beat s slower,

the proportionatel y greater action

A n ice bag o v er the heart
the accelerator ( sympathetic ) ner
vagu s as has been claimed by
,

seen would be impossible since

, ,

bag exerts a depressing and not a

mu st be the case w
The Stom a c h The skin over the pi .

plied by the seventh and eighth i nte rc o s

splanchnic nerve i s formed by branches
lia bet w een the fifth or sixth and the ni nth or tenth .

m i na t e s i n the semilunar ganglion of the solar plexu s 18

.

the solar plexu s ( coeliac pa rt ) fibers accompany the,

ve ssel s to the stomach .

The ne rve s su ppl ying the abdominal mu s

are deri ved from the lower ntercostal nerve s and are i

connected with the sympathetic ne rves suppl ying the

viscera through the lower thoracic ganglia from w hi
”
splanchnic nerves are de rived .
’9

These reflex arcs may be traced out in the case of other

and areas While an appli cation to the skin over an
.

gi ve s a maximum e ffect applications to eve ,

may be quite e ff ective For e xample hot .

,

circulation of the brain . But under c

17 G y A t m y 1 905 p 997
ra
'

s na o
p
, , . .

18 l b id 1 079
bd p
. . .

19 l i . . 99 7 .
A ug mm t o r '
or
A cce l er at o r

s ta r e

PL A T E I II T he i nne r v at i o n o f t he h e a rt . ( P ow e l l . )
 SP E CIA L R E FL E X A R E A S

instability such as that followi ng a sunstroke a hot foot bath

, ,

may cause conge stion of the brain ( pe rsonal observation ) .

S P E CI A L R E F L E X ARE A S

The following are t he principal reflex areas e mployed in

h ydrotherapy ( F ig .

1 .The skin area s of the face scalp and back of the ne ck are , ,

r e fl e x l y relate d with the brain .

2 The sk in of the ne ck i s r e fl e x l y related with the pharynx

.

and larynx .

3 The back of the neck i s r e fl e x l y related with the mu cou s

.

membrane of the nose .

4 The skin of the che st ( front back

. and si de s ) dorsa l , , ,

region and shoulders ha s reflex relations with the l ungs

, .

5 The precordia i s i n very perfect re flex relation with the

.

heart through it s a ccelerator nerve s .

6 The hands are related wit h the brain and na sal mucous
. .

me mbrane .

7 The skin over the l ower right chest with the li ver
.
, .

8 The skin over the lower left chest with the spleen
.
, .

9 The skin over the lower third of the sternum with the
.
,

kidneys ( Kellogg .

1 0 The mid dorsal spine ( from fifth to seventh ve rtebr ae ) is

.
-

related with the stomach .

1 1 .Lower dorsal and lumbar spine w ith the kidneys and ,

intestine s .

1 2 The lower lumbar and sacral spine w ith the pel vi c organs
—uteru s ovarie s bladder and rectum
.
,

.
, , ,

1 3 The epigastriu m w ith the stomach

.
,
.

1 4 .The skin of the entire abdome n especiall y that of the ,

umbilical region i s r e fl e x l y related with the inte stine s The

, .

fact that the pain of col ic appendi citi s etc i s referre d to the , ,
.
,

region of the u mbilicu s i s an evi de nce of a si milar nervous con

n e c t i on .

1 5 The lower abdomen including the groin and also the

.
,

upper i nner surface s of the thighs are re fl e xl y related with the

pelvi c organs .

1 6 The ski n of the feet and legs i s r e fl e xl y relate d with the

.
 I nt e s ti n e s

F ig . 16 . A nt e ri o r re fl x
e a re a s . ( K e l lo gg )
 S P E CIA L R E FL E X E FFE C TS
brain lungs and pelvic organs This i s not as powerful a
, ,
.

re flex area as some others .

More practical l y state d the circulation secretory and m u s , , ,

c u l a r activitie s of the vis ce ra may be influenced r efl ex /y by

appl icat ions as follows :
.1 The brain by appl i cations to the b ea d f a ce ba ck of neck
, , , ,

hands and feet

,
.

.2 The nasal mu cous membrane by appl icat ions to the f a ce , ,

hands and ce r v i ca l and upp er dor sa l sp i ne

,
.

.3 The lungs by appl ication s to the c/z est s/z on l de r s and

, , ,

dorsal spi ne .

.4 The heart by appl ications to the precor d i a and u pper dor

,

s a l spine .

.5 The stomach by applications to the ep ig a s tr i u m and mi d

,

dorsal sp ine .

.6 The l iver by appl i cations to the lower right che st and the
,

abdomen .

.7 The spleen by applications to the lower left che st and the

,

abdomen .

.8 The kidneys by appli cations to the lower third of the,

sternum lowe r dorsal and l umbar spine

,
.

.9 The intestine by applications to the a bdom e n and lower

, ,

dorsal and l u mbar spine .

1 0 The bl adder by appli cations to the l ow er a bdom e n i n ner

.
, ,

f t/z ig /z s and the feet

s u rf a ces o ,
.

1 1
. The uteru s by appl ications to the l umbar and sa cr a l
,

regions l ow e r a bdom e n i n ne r sz u f a ces of t/z ig /z s br eas ts feet and

, ,
'

, , ,

cervix .

In the large maj ority of cases the ventral areas give strong e r ,

re flex e ff ec t s than the dorsal areas Thi s i s doubtless for the .

reas on that with a ventral area the e ff ect is concentrate d upon

, ,

a s ingle organ while in the case of a dorsal area l imited to the

, ,

region of the spine itself the e ffe ct would be spread out over ,

several organs or poss ibl y the vis cera of both the che st and
, ,

abdomen If an i ce bag i s placed in conta ct with the whole

.

l ength of the spine the same e ff ect on the hea rt and lungs is,

p rodu ced a s that which i s des ire d on the inte stine s and the ,

whole process is negat ived whereas if limited ant e r i ora l l y to , ,

72 R E FL E X E FFE C TS

the sixth se gm ent ,

the e ff ect i s l ocal ized on
” ° 2
viscera .

re flex e ff ect i s then an

D efi n i ti on of R efl ex . A
prod uced through ne rve conne
part of the body which i
another
?
A brams
involunta ry
conduction
the motor cell s
vert ed into an impulse by the motor
then conducted to a part by means of an

CL A SSE S OF RE F L E X
H aving establ ished the fact of r e fl e
some of the reflex arcs let ,

variou s r e fl e x e ff ects NVe -

.

three kinds of fibe rs which

via the secr etory v iscer a m
, ,
-

the ch ief functions of the

b ol i sm itself and all other functions
applying heat or col d or other stimul i
skin w hose endings are in a segment
motor vasomotor or other activitie s w
, , ,

organ supplied by these tracts That .

been shown by the re

chiefly through
obse rved by heat and cold impa ,

( steady or alternated ) electricity , ,

other means yet the underl ying ,

The application of these physical forms

made more and more accu ratel y to get the
There are two general classe s of effects produced
applications The y may be des ignated as p ressor a n d
.

as sti m ul a nt a n d ca l m a ti ve or ex ci ta n t a nd seda ti ve , .

20 S D L d
. . u n l Am
u l um —
J o r a e ri ca n M di
e an A ss oc i a t i o n , Ma y 2 1 908
S p o nd y l t h p y p 26
. .

21

S D L udl um —
o e ra . .

22 . . i bi d pp 1 403 . .
, 1 405 .
74 R E FL E X E FFE C TS
the blood going to the brain and head gene rall y S uch an .

appli cation is calle d a pr ox i m a l appl i ca ti on s ince it i s loca ted ,

between the heart and the part suppl ied .

9 P rolonged immers ion of the h ands in cold water cau ses

contraction of the vessel s of the brain and na sal mu cou s mem
brane .

F ig 17 S ph y g m g ph i o ra c t ra c i ng o f ra di l p ul
a se s h ow i n g c on t ra ct i on of t he
v f ul t i n g f pp l t b nd b
. .

of t he o re a rm r om i ca i o n o f i ce to e of e l ow
e ss e ls res a .

( K e llo gg )

F ig 18 Pl t h y m g ph t
e s o ra ra ci n g h s o wi n g d i m i nu t i n i n t h v o e ol u m e o f t he
f ult ing f m pp l i lb w ( K ll gg )
. .

o re a r m re s ro a ca t io n o f i ce t o e o . e o

3 . cold to the cerv i cal and upper dorsal region

P rolonged
causes contraction of the ve ssel s of the nasal mu cou s membrane
and lungs .

4 A n ice bag appl ied to the precordia slows the heart rate
.
,

increases its force and rai ses a rterial blood pre ssure , .

5 A n ice bag applied over the th yroi d gland ( in p a r e nc hy

.

matous goitre ) decreases i t s vascularity and lessens its gl an du

lar acti vi ty .

6 Long cold appl ications to the chest at the back front or

.
, , ,

side s contract the blood ves sel s of the lungs ( F ig s 1 9 a nd

,
-

, .

slow r e spi ration and increase i t s depth , .

 SP E CIA L R E FL E X E FFE C TS

7 ice bag to the epigastrium or m id dorsal region cau se s

. An -

contract ion of the vessel s of the stomach and les sens gastric
”
secretion whil e the appl ication cont inue s
, .

8 A long col d appl i cation to the pelvi s groin or inner sur

.
, ,

face of the thighs contracts the blood ve ssels of the pelvi c -

organs .

9 A long col d s itz bath cau ses firm contract ion of the ute ri ne
.

mu scl e the reby redu cing subinvol ution

,
.

1 0 A much p rolonged very cold application to the sacrum

.
, ,

such a s a large ice bag dilates the bl ood vessel s of the u teru s
,
-

thu s i ncreasing me nst rual flow and inhibiting pain Th is .

F ig 19 D g h
i a ra m s ow i n g F ig Di g 20 a ra m s h ow i n g
g g fl x ti n f
. .
.

con e st i o n of t h e l u n s re e ac o o an i ce b a g i n
d ing ng
.

e c re as co e st i o n of t h e
l un g s .

paral y z e s the reflex T he posterior re flex area being i n les s

.

perfect relation w ith the ute ru s than the anterior area make s ,

thi s pos sible .

1 1 Long col d appl ications to the face forehead scalp and

.
, , ,

back of the neck cau se contraction of the bl ood ve ssel s of the -

brain .

1 2 A n ice bag to the lower third of the ste rnu m or over the
.

lower dorsal and uppe r lu mbar regions cau ses contraction of

the blood ves sel s of the ki dne y
-
.

1 3 I ce bags appl ied to the side s of the neck j u st below the

.

j aw contr act the blood ve ssel s of the pharynx -

.

23 Se e e xp e ri m e n t s b y K a sa ns k i i n c h pt
a e r on p pt g
e o e n ic e f e c t s f .
76 I l EYELl i XTI ZFYW
EROTYg

Sp e c ial R e flex Effe c ts of Short C o ld . S nor t cold a pp l i ca ti ons

to a r e ex fl a r ea p r odu ce ton i c a n d s ti m u l a ti ng j
e ects i n tb e deep

tb c r ea cti on z i c/
z o/ f oll ow s Tb e sa m e is
par t by v i r tue f
o z soon .

a n d col d
tr ue of a l te r n a ti ng a ppl i ca ti ons of b ea t .

1 . S hort cold appl ications to the face and head stimulate

mental act ivity .

2 A short cold appli cation to the chest as a col d rub fric

. , ,

tion or cold douche at first increases the respi ration rate

, ,
.

S oon it results in deeper respiration with a somewhat slowed

rate .

3 A cold douche to the precordia or slap pi ng the che st wi th

.

a cold t owel increases both the heart rate and force A fter the .

cessation of the appl ication the rate decreases wh ile the forc e ,

remains increased .

4 A short very col d percuss ion douche to a reflex area cau se s

active dilatation of the bl ood ve ssel s i n the related Viscera —
.

as -

a short cold do uche to the sacr um or feet c a use s dil atation of

the vessel s of the uter us .

5 S hort or moderatel y prolonged col d appl ications to the

—
.

breasts cause vigorous contractions of th e ute r us o f u se in

ine rtia uteri .

6 S hort very cold appl ications to abdomen hands or feet

.
, ,

cause contraction of the muscles of the bladder bowel s and , ,

u teru s .

7 A short cold douche or i ce bag inte rmittently to the l owe r

.

third of the sternum cause s i ncreased renal secretion .

8 A very sho r t cold douche to the l iver cau ses active dilata
.
,

tion of its vessels and increases its glandul ar acti vity .

9 The reaction from a moderatel y prolonged cold appl ication

.

to the epigast r i um cau ses i ncrease d gastri c secret i on 3

.
2

R e flex Effe c ts of H ot Ap p li c ati o ns .

A
very mu ch prolonged hot application to a re flex area
produces passive dilatation of the blood vessels of the related -

organ .

2 Long hot appl ications to the p recordia and to many othe r

.

part s increase the hea rt rate decrease i t s force and lower , ,

blood pressure .
 SP E CIA L R E FL E X E FFE C TS

3 . H ot moist appl ications to the chest facil itate respiration

and expectoration .

4 Long moderately hot appl ications ove r the stomach afte r

.
,

meal s increase gastric secretion and hasten digest ion The .

same if given before a meal decrease gastric secret ion because

, ,

of the atonic reaction wh ich ensue s .

5 P rolonged hot appl ications to the abdomen lessen peri

.

s t al s i s and in case of intestinal col ic

,
rel ieve pain due to m u s,

c u l a r s pasm .

6 P rolonge d hot appl ications to the pelvis as a fomentation

.
, ,

hot pack or s it z bath relax the mu scle s of the bladde r rectu m

, , , ,

and uteru s and dilate their blood ve ssel s thu s relieving tenes
-

mu s i n these organs and increasing the menstrual flow .

7 A l arge hot application to the tru nk as a hot pack in

.
, , ,

bil iary or renal col ic relaxes the muscle s of the bile du cts gall
, ,

bl adde r or urete rs and aid s in relie ving the pain due to spasm
'

of the se mu scles .
 C H A PT E R V I I

TH E
—
CI R CU LAT I O N H Y DR O ST AT IC E FF E CT S

OT all of the circul atory e ff ect s occurri ng in organs and

pa rts di stant from an appli cation can be explai ne d by
reflex action I n fact many of the e ff ects produ ce d by h ydri
.
,

atic applicat ions are qu ite contrary to what w e m ight expect ,

were the results due alone to re flex stimulation When Sc hii l l e r .

,

i n the course of hi s expe riments upon trephined rabbits placed ,

°
a sponge dipped in cold water ( 5 2 F ) u pon the tru nk of a peri .

p he r a l nerve he observed narrowing of the pi al ve ssel s

,
Thi s .

was the same result as that obtaine d by pie ce s of ice applied to

the dura In both there wa s vasoconstriction of the ves sel s
.
,

of the pia ; and we have seen that by reflex stimulation the , ,

same e ff ects are observed i nternall y as occur externall y in the

skin area treated But when he applied to the bell y or back of
.

the rabbit a wet compre s s of the same temperature it always ,

pro duced a prolonged and decided dilatation of the p ial ve ssels ,

just opposite to the e ff ect obtained in the first experi ment

quoted and which w e know w as due to re flex stimulation
, .

A gain he found that the application of w a rm water to the

‘

nerve trunk produced dilatation of the ve ssel s wh ile warm ,

water applied to the general skin su rface by immersion pro ,

d uc e d a narrowing of the pial vessel s S ince these e ff e cts are

.

directly opposite both can not be explained by reflex action

, .

Moreover Schii ll e r observed that i m m e r si on i n warm water pro

,

d uc e d a more de cided narrowing of the vessel s than a warm

comp r ess; and i m m e r s i on in col d water a more decided dilatation
,

of the ve ssels than a cold comp r ess Tli ese eff ects w e re i n ex a ct
.

pr opor ti on to t/z e ex ten t of su rf a ce i m m e r se d When the ears of .

the animal were kept out of cold water they likewise filled with ,

( 7 8)
 H Y D R OS TA SI S A N D BL OOD P R E SS UR E
blood i n common with th e pial ves sel s but when the y were also ,

dippe d into the w ater the ve s sel s of the pia fille d still more
, .

The expl anati on of t he se contrary effect s i s qu ite obviou s and

wil l occur to anyone acquainted with the principle s of hydro
stati cs When the warm compress was appl ie d to the animal
.
,

the cu taneou s vessel s dil ated thu s increas ing the flow of bl ood ,

to and amount of blood in the sk in area treated Thi s left .

le ss blood to flow to the brain and in consequence the bl ood , ,

ves sels of the p ia wer e l e ss c om p l e t e l v filled When a greater .

surface wa s treated as by im mers i on i n warm water a greater

, ,

number of blood ves sel s were dilate d and m uch les s blood left
'

to flow to the head resulting in an increased narrowing of the

,

p ial vessel s .

Cons ide ri ng the experiment with the col d compre ss and bath ,

w e have the same u nderlying princ iple s The cold compress .

produ ce d blanch ing of the skin and a de crease d amou nt of blood

i n the periphery with a resulting increase in th e fill ing of the
,

blood vessel s of the brain be cau se of r e t r o st asi s

-
.

Sc h ii l l e r observed that rectal i nj ections of cold water always

produ ced some dilatation of th e ve ssel s of the pia These .

e ff ects have been confirme d by the experiment s of V inaj ,

N aumann Winternit z and others

,
‘
,
.

That these re sults are hydrostati c or mechani cal and not ,

reflex i s al so confirme d by the cha nge s in blood pre ssure

,

observe d at the Same ti me I n dilatation of the bl ood ve ssel s.

-

due to va som otor action there i s a f a l l of blood pre s sure Q u ite

,
.

the opposite occurre d when the pial vessel s dilate d becau se of a

col d comp ress or col d i m m ers i on i e a dec ide d r i se in arterial
,
. .
,

pre ssure Th is we know i s associated with vasoconstriction

.

and can not there for e be due to paralysis of the v a som otor s
, , .

B ut when we conside r that the col d appli cation produced blanch

i ng of the skin and va soconstrict ion over qu ite a large area and
conse quentl y an i ncre ase in blood pressure the whole p roces s ,

is qu ite apparent The r e t r ost a si s and increase of blood pre ss

.

ure cause s the cerebral vessel s wh ich are not u nder the i n fl u ,

ence of the col d to fill in order to a ccommodate the blood

,
.

The oppo site group of conditions pr evailed with the hot

application v i a na r ro wing of the p ial ve ssel s w i th a fall i n
, ,
80 H Y D R OS TA TI C E FFE C TS

blood pre ssure The same principle s appl y here as above

.
,

opposite conditions resulting from opposite cau se s The hot .

bath produ ced afflux of bl ood to the skin through vasodilatati on ,

with a consequent decrease in blood pre s su re the cerebral v e s ,

sel s narrowed be cau se of a relative anemia I f the narrowing .

of t he pial ve ssel s had been due to reflex action there shoul d ,

have been a rise instead of a fall i n bl oo d pres sure .

Sc hii ll e r obse rved that prolonging the warm appl ication pro
duc e d an increasing con stri ction of the c erebral ve ssel s This .

may be explained by the fact that a pas sive and e xtreme dilata ~

tion of the cutan eou s ve ssel s occurs whe re the heat i s main
rained for a long time This i s the eff ect of a long hot pack .

w hich in pract ice we utili ze where decided de rivat ion i s

, ,

desired .

F ig 21 V ol u m e c u r v f i gh t m d u
e o r ar ri n g a si t z b tha at 1 1 0° F s h ow
d v v ff ( W i n t ni t z )
.
. . ,

i ng e ri a ti e e e ct . er .

The h y drostat ic e ff ec t s of both de r i va ti on and r etr ostasi s have

been demo nstrated by W i nt e r ni t z by clini cal expe ri ments B y l
.

means of the plethysmograph he determined the volume cu r ve .

of the forearm du ring a hot sit z bath and al so during a col d

sit z bath T he hydrostat ic results are g ra phicall y shown in
.

F ig s 2 1 a n d 2 2
. The cold sitz bath cause d an increase i n the
.

volume of the forearm d ue to re tr os ta sis consequent on contrae , ,

tion of the vessel s under the influen ce of the c old wate r In .

the ca se of the hot sitz bath the bloo d ve ssels u nder the i nfluence -

1 Wi nt e rn i t z—Ph y s io l o gi h sc e d g
G ru n l a en der H yd ro u nd T h e rm o t h e ra p i pp e . . 4 3 44
, .
82 H Y D R OS TA TI C E FFE C TS

The accompanyi ng cha rt summari z e s t he h ydrostati c eff ect s

of heat and cold
—
.

H eat draws blood to the surface

derivation

The H ydrostati c
—
E ffect of
P rimary drives
te r i o r —
blood to the
r e tr o st as i s
in

—
Secondary draws blood to the sur
—
face derivation

Law of An ta g o n is m The se hydrostatic e ff e cts are well re cog

.

n i z e d by physiologists There i s an antagoni sm betwee n the .

vessel s of the ski n and vi scera be tween the inte rnal and ex ,

te rnal vessels so that when the periphery i s wel l filled there

, , ,

i s a relati ve anemia of the vi scera and v i ce ver sa The so ,

.

called D astr e Morat Law of A ntagonism i s thu s s tated by S ir

-

M Foster Moreover the vascul ar change s i n the skin are

“
2
.
, ,

accompanied by correspondi ng vascular change s i n the vi s

cera ( chiefl y abdominal ) of the re verse kind When the ves sel s .

of the skin are dilated those of the viscera are constricted and , ,

v i ce ver sa ; so that the blood ebbs and flows so to speak accord , ,

ing to ci rcumstance s from skin to vi scera and from vi scera to

'

”
skin .

These mechanical e ffects are ne cessaril y produ ced solel y by

vascular connection and not by nerve connection A re flex .

e ff ect i s an indirect or distant e ffect produ ced through nerve con

n e c t i on A hydrostati c e ff ect i s a di stant e ff ect produ ce d
.

through vascular connection The extent of thi s e ff e ct de .

pends upon nothing so mu ch as u pon the extent of the su r

face involved a s w as shown by the experiments with the
,
-

compresses and baths Thi s action i s not confined to the blood .

vascular system bu t applie s to the l ymphati c system a s well

, .

A warm appli cation which cau se s va sodilatation will of n e ce s ,

Si t y , draw blood from all other part s of the body ; and con
v e r sl y a cold application
, cau sing vasoconstriction will i n the , , ,

nature of the case drive t he blood el sewhere principally to the

, ,

2 h
P y si ol o y g p , . 287 .
 A R E A S F OR D E R I VA TI ON

i nte rior I n e ither ca se the blood i s driven into or drawn from

.

the deeper parts I n the normal body these hydrostatic e ff ects

.

are more or less evenl y distributed over the e ntire vascular

system so that the e ff ect in an y one part i s not so marked
, .

For exampl e a hot bath or pack i n heal th draws th e blood m ore

,

or le ss equall y from al l the viscera ; but in case of congesti on of

some part i cul ar organ that organ wil l be a ff ected m ore than
,

others by either derivation or r e t r ost asi s A common example .

i s found in the i ncrease of pul monary congestion produced b v ,

cold drafts on the shoul de rs I n a healthy pe rson thi s might .

not re sult seriou sl y b ut in one s us cept ible to col ds or with an

,

already existing congestion it may cau se an extreme conge stion ,

i n a ve ry short time I n the same condition a hot pack will

.

draw proport ionatel y more bl ood from the lungs than from other
pa r ts A gain a large fo m entation to the loins or a hot pack
.
,

woul d u nde r no rmal conditions w ithdraw from the kidneys

, ,

onl y a small amou nt of blood ; but when these organs are con
ge sted there i s a ma r ked deplet ing e ff ect manifest Tb c pa ti e nt .

i s bl e d i n to hi s ow n l i m bs a n d sk i n .

N ot onl y may areas qu ite distant from a part be utili z ed

for depleti ng that part but in many cases skin areas nearby ,

may be u se d to advantage That this i s not a new p rinciple in

.

the rapeutics wil l be seen by referring to leech bleeding .

It i s directe d that the leech b e appl ied to the skin over the i n
flame d part I t su cks bl ood from the superficial branches of
.

the same ve ssels that suppl y the deeper inflamed part If by .

,

hot applications the a rterie s of the supe r ficial se t of branches

,

be wide ned ou t there will be le ss blood to flow i nto the deeper

,

branches Thus will a fomentation draw blood from a part

.

nearby th at receives its bl ood from the same large artery .

Where there are large thi ck mu scle s u nder the skin a rea treated
the total vascular capacity of bo th when filled to the li mit may , ,

produ ce a very de cided derivat ion .

A RE A S F O R
D E RI V A T I O N
The variou s viscera are mechani cally relate d to su perficial
and other areas as follows In most cases these areas are .

utilized for depleting ( de ri vati ve ) e ff ect bu t the O pposite con ,

di tion ( r e t rostasi s ) may obtain where these area s are chilled .

84 H Y D R OS TA TI C E FFE CTS

1 The B rain B lood may

. .

hot applications to the feet 1 ,

the spine or entire su rface of '

uti l ize
pose ,

would be gr eater than the depi

sunstroke the v a som otor s are so unbalanced
foot bath m a y r e fle xl y produce cerebral conge
depletion and mu st therefore be avoided
, , ,
.

2 S pinal Cord
. Congestion here if .
,

be relieved by large fomentations

the back ) T
his diverts the blood
.

the posterior divisions of the intercostal

al so by hot applications to the feet legs , ,

the trunk I n case s of acute cerebro s

.
-

be st to ut ili z e the more di stant areas .

3 E ye. A ppl i cations may be made to t

.

O f the face thus dilating some O f the

,

branches O f the carotids and depleting the deeper ,

4 Middle E ar and Mastoid

. B y appl i cations to .

side of the head also by very hot applications to ,

abdomen and spine , .

5 P harynx and Larynx

. B y appli cations to the .

depleting the deeper organs and conge sti ng the surfa

6 Lungs
. The fe et and low.

trunk and hips al so the hands arms a nd , , ,

the congestion i s limited to a sm all area ,

pleuris y a fomentation may be u sed di r ce

,

Thi s dil ates the post e rior lateral and a nteri or cu ta , ,

branches of the intercostal arterie s thereby wi thdrawing ,

from the inflamed pleu ra .

7 Kidneys
.
The circulation in the se org
.

hot applications to the back thus dilating ,

of the lumbar and lower inte rcostal arterie s and ,

blood to pass from the aorta to the renal arterie s .

conge stion O f the kidneys it i s necess ary to util i z e

areas as the enti re su rface of the tru nk hips and
,
, ,

O f the se areas alone .

 A R E A S F OR D E R I VA TION

8 . S tomach B y large applications cente r ing at the e p i g a s

.

tr ium but extending ove r the lowe r chest and sides of the
,

abdome n and well down over the u mbilical region also to the ,

e ntire tru nk .

9 Liver
. B y applica t ions over the li ver also to the lower
.

dorsal Spine of the ri ght ride extending forward and covering,

the epigastric and u mbili cal regions The skin area of the .

lower l imbs and hips i s as important if not more so than the , ,

nearer areas .

1 0 S pleen
. S i milar to the live r on the opposite side also
.
, ,

lower l imbs
—
.

1 1
. P elvic O rgans bladde r ute ru s ova r ies tube s rectum , , , ,

and prostate To deplete the se organs two p r incipal are as are

—
.

util ized fir st the entire skin su rface of the h ips pelvi s etc
, , , ,
.
,

as in a hot sitz bath or hot hip pack ; second t he l ower l imbs

.

as in a hot leg bath or hot le g pa ck B oth areas may be .

uti li z ed by the u se of the hot hip and leg pack or hot half bath .

The student who is famil iar with the anatomy of the ci rcula
tory syste m will be able to figure out the vascular conne ctions
between the organs mentioned abo ve and areas named with
each . In nearly eve ry case it i s quite O bvi o us These areas .

are of i mportance not alone in ordi nary congestion bu t of

, ,

al most inestimable service in actual inflammation of the se parts ,

as shown later ( S ee treatment Of i n fl am m a ti on s )

. .
 C H APTE R VI I I

THE —
CI R C U LAT I O N BALA N CE BE T W EE N

R E FL E X A N D H Y D R O ST A T IC E FF E CT S

Y reference to the observations recorde d u nder reflex and

hydrostati c e ff ects it will be seen that the rmic applications
—
,

to the surface exert two classes of e ffe cts a re fle x and a h ydro

static eff ect—which are dire ctl y opposite and therefore con , ,

fli c ti ng . P rob ably an application produce s more or less of both ,

though one or the other u suall y predominates S ince the y are .

l
O pposite one will neu trali z e or overshadow the othe r Kellogg
,
.

make s t he following statement Doubtles s both of the se

e ffects are always produced Whe n t he appl icat ion is general .

the mechanical eff ect i s dominant ; when the area i nvolve d i s

l imited the reflex effe ct is prominent
, I n general appl ications .
,

the primary reflex e ff ect i s qui ckly e ff aced by the su cceeding

mechanical e ff ect due ( in case of cold ) to the inru sh of blood
,

from the periphery Thi s dive rs ion of blood from the surface
.

vessel s to the interior of the body i s te rmed r e t r o sta si s . .

Marked re t ro st a si s i s produ ce d only when the cold appli cation

is made si m ultaneou sl y to a very large cu taneous area The se .

a re esse ntiall y the views of Sc h ii l l e r who considered that at , ,

the be g inning of the application the pial vessel s were a ff ected ,

r e fl e xl y which e ff ect i s soon overbal anced by the thermi c e ff e ct

,

upon the vessel s of the skin .

”
If the surface area to wh ich the application i s made i s small ,

the reflex e ff ect may be confined to the inte rnal area i n s ympa
thetic relation therewith and w ill be greater and more prolonged
,

for the reason that the reflex influence is concentrate d u pon a

circumscribed area ; while the mechanical e ff ect i s di stributed
over the re st of the body so that i t does not overshado w and,

1 H y d t h p y p 1 03
ro e ra . . .

( 86 )
 L A WS OF BA L A N CE

applie d to large portions of the body doubtle ss have a hydro ,

static effect ; wh ile dou c/z es whi ch imp inge on l i mited portions
, ,

and are combined with mechanical e ff e cts ( i r r i ta ti on ) act ,

”
chiefly by reflex influence .

I s i t possible to determine Which re sult will be greater in a

given case or which will be practicall y the onl y e ff ect from a
,

certai n appl ication ? I n repl y to th is very natu ral que st ion we ,

may state that there are definite laws governing these oppos
i ng actions B y the m one ma y so time and regulate appl ica
.

tions as to secu re a des ired and definite re sult .

L AW S O F BA L A N C E
The follow ing are the laws ; other things be ing e qual the ,

results stated obtain :

1 Si z e O f Are a
.
( a ) When an appl i cation covers a small
.

area the e ff ect i s chiefl y re flex and i s concentrated upon th e

,

internal part i n re flex relation with the su rface treate d .

( b ) When appl ications are made to a large area the hydro

static e ff ect pre dominates and the larger the area treate d the
,

greater the hydrostati c e ff e c t .

2 Lo c ati on o f Are a
.
( a ) T he chief e ff ect of an appl icatio n
.

to ce rtain areas ( example the head or the p re cordia ) i s a re flex

,

e ff ect .

( b ) The p rincipal result of an appl icat ion to certain othe r

‘

areas ( example the feet and legs ) is hydrostat i c

,
.

D u r a ti on a n d I n te ns i ty of A pp l i ca ti on The duration and i n

.

ten sity of the e ff ect e ither re fl ex of hydrostatic depend upon

, ,

the du ration and intensity of the appl icat ion The intensity .

of an appl ication i s gauged by the degree of heat or cold and

by the form and pre s su re of douches or the degree and a mount ,

O f frict ion .

E x a mp l e s: The prolonged appl ication of an i ce bag ( small

application of i ntense col d ) to the pr ecordia ( spe cial area ) p ro
duce s a ( re flex e ffect ) prolonge d slow ing of the rate of the heart
beat and a de cided i ncrease i n its force for the same lengt h of
,

2 P i i pl
r nc d P
e s an ti
ra c f Hyd th
ce o p p 48
ro e ra y , . .
88 BA L A N CE IN CIR C UL A T OR Y E FFE C TS
time The re i s no tendency to produce re t ro st a si s of blood or
.

engorgement of the heart ( h ydrostatic e ff ect ) .

A hot t runk pack ( large area ) wi th draws blood from the v i s

cera ( hydrostatic e ff ect ) rathe r than producing dilatation and
engorgement O f their vessel s ( re flex e ff ect ) .

A hot and cold douch e to the chest ( small i ntense appl ica
tion ) stimulates the heart and re spi ration ( re flex e ff ect ) rather
than having any decided h ydrostatic eff e ct upon the blood cur
rent of these organs A ppl ications to the head ( special area )
.
,

whether hot or cold have a reflex e ff ect almost enti rely

,
.

Many other example s might be given but the princi ple s i n ,

volved i n the above are the same a s those which gove rn other
applications It will be seen that although re flex and h ydro
.
,

static eff ects directl y O ppose each other the r efl ex ove r s/z a dows ,

and obliterates the hydrostatic when cer ta i n a r eas a re i nvolved ,

and especially when t/z ese a r eas a re sm a ll The hy dr os ta ti c eff ect .

w ipes ou t the reflex e ff ect when the appl ication i s to certai n

other areas and especially when those areas are very l a rg e
, .

We have so far di scusse d these t w o cl asses of e ff e cts a s to

their O pposing results Re flex and mechani cal e ffects may be
.

made to assist each other in securing depletion when di verse

appl ications are made to di ff erent area s si multaneou sl y Thi s .

3
will be discu ssed u nder th e head O f derivation .

D oubl e Efl ects In the case of hot app l i cations appl ied over
.

congested organs certain phase s of both the reflex and t he hy

,

d ro s t a t i c e ffect may prevail Thi s i s expeciall y noti ceable .

w ith l a rge fomentat ions or hot packs over the l iver or ki dneys .

These r e fle xl y relax ( and dil ate ) the bl ood ves sel s O f the i n -

te rnal organ while hydrostat ical ly they draw bl ood from the
organ thus leaving the ve ssel s of that organ rel axed but onl y
partially fille d with blood i e partly collap se d Thi s double , . .
, .

e ff ect from a single appl ication i s of gr eat importance i n acute

congestions of the kidneys and l iver a s in ecla mpsia whe re v as
cul ar tension i s high bu t the organ functionall y i nactive The .

tension bei ng relieved by rel axation of the mu scular coat

( re fle x l y ) and the congestion de pleted ( hydrostatically ) the ,

blood again circulates more rap idl y and funct ional activit y
be gins almost at once .

3 Se e c h pt
a e r on in fl a mm a t i o n a nd a nt i ph l gi o s t ic e ff ec t s .
 CIR C UL A TIN G F L UI D

so rai se blood pressure A fte r a brief ri se hot appl ications to .

,

the pre cordia decrea se blood pres sure S hort cold applications .

to the precordia i ncrea se the heart rate while long col d a p p l i ,

cation s d e c r e a s e
the heart rate I n .

the normal person

both r e s u l t s are
associated with a
ri se in blood press
ure Rapid l y alter .

nat ing hot and

cold appl ications to
the pre cordia have
much the same e f
feet as s ho r t col d
appl icat ions ex ,

cept th at the st im u
lation be ing g reat ,

er cau se s a great ,

e r rise in blood
pre s su re This .

rise i s le ss perma
nent t han t hat ac ~

companying p r o
F i g 24 C d i m t t i ng f m d g h t
ar o e er longed cold ap pl i
ra c ro a o
‘

s ear
i g t h v l um
.

h w m g ff
s o t f i e ec o f i l t
nc re a s n e o e o c rc u a
i g fl d
n uith t t l
on tp ut d v l m
e f th
o a ou cations to the p re
an o u e o e
h t B tw
ear th p e t A d B 30
een fw
e m
ar s an c c o ar
ph y i l g i i j t d i t
. . .

ous ly
s o o
nd b t w
lt
n B
l ti n w
c sa
d C 20 m
so u
B t h th
o c o r d i a
e re T h e s en ec e n r av e n .

a e ee an c c o re o e
d di t l i v l um d i
, . . .

y t l
s
h t i m
s o i c an
e ar s
in
as o
di t n d d d i g d i t l n d d
or e s e
c tho
e
point s
ur n
have
e a re
been c r e a se
as o e , a
, . e . ,

oe s
e

n t nt t t it n m l iz i y t l Th
o
lt i
su
co
v y l g ly i
s a
rac
er
o
d tp t (R )
ar
s
e
or
t h orou ghl y d i s
a
n c r e a se
s e
ou
n s
u
s o e
.
.

oy .
e re

cus se d el sewhere .

2 The Am oun t O f the C irc ulat in g Fluid

. A n increase in the .

quantity of blood i n the vascular system othe r thi ngs be ing ,

equal i ncreases blood pre ssure I n order to i ntell igently appl y

, .

those therapeut ic measure s whi ch are designed to maintai n

blood pre s sure throu gh change s i n the amou nt of the ci r cu l at
92 BL O OD P R E SS UR E

ing fluids it i s nece ssary , .

laws gove rning the intake

the absorption of extra v as -

edge of the fluids of t he

S tarling From thi s source w e
.
l

lowing information .

The absorptive membrane s of the body

i ng or i rreciprocal permeability to flu i ds ,

certain sal ine substance s are readil y

w hile fluids containing other salts are
onl y after long contact .

If the solutions contain sul phate

whose anions the gut wall i s relative
of events i s ve ry mu ch t he same as
these
w all of par
i n amount by the attraction of w a
until their molecular concentrati
” 2
plasma B y long contact the y
.

di ff erent i s the fate of solut ions

chloride The se are .

slightl y hypertonic I f the .

three per cent N a Cl the y at ,

fu sion of water into them .

duction however salt i s passing from

, ,

circulating th rough the inte stinal wall an ,

osmotic pressu re i s redu ced to a point a

blood plasma both water and salt begi n ,
.

Thi s selective action i s fou nd to depen

the cell s com posing the
cells have been damage
fluid introduced into the
i ts con c entration The epithel ial cell .

membrane O f the inte stine posses s the power of pump

and salts from one side O f the cell to the other .

2
He rt e r

St
L tu N w Y
li ng T h F l ui d
ar — k 1 908
ec

f t h B od y p
e
re s . e

s o
or

e
, .

, . 53 .

3 1 b id p 53
. . .
94 BL OOD P R E SS UR E

introduced by h y podermocl ysis S tarl ing concl ude s that thi s ,

occurs mostl y by the blood rather than the l ymphati cs as has ,

long been supposed Indigo carmi ne or methylene blue i n

.
, ,

je c te d i nto the pleural or peritoneal cavitie s ma y appear i n the ,

urine within si x minutes after the moment of inject ion at a

time when the l ymph in the thoracic duct i s free from color .

St r vc hn i n e or other dr ug injected under the ski n of a limb

exerts i t s poisonous eff ects on the ne rvou s s yste m long before
the drug i tself appears in the l ymph flowing from the l imb .

It has be en shown that blood returning from an edematou s

limb is more dilute than blood retu rning from a normal l imb .

6
The experiment conducted by S tarl i ng i s as follows : B y me an s
of cannulas inserted into the femoral artery and vei n de fib r i n ,

ated blood of the same osmotic pressure as normal blood se r um ,

w as ca u sed to pass through the arte rie s cap illari es and veins , ,

O f the normal leg O f a dog The same w as done with the .

opposite leg made edematous by the injection of a one per cent

solution of N a Cl Blood which had been le d through the nor
.

mal leg twelve to twenty fiv e ti mes was u naltered or su ff ered -

trifling change while that le d the same numbe r of t ime s

,

through the edematous leg had in al l case s absorbed flu id .

From these experiments we may a ffirm wi th ce rt ai n i t y that

isotonic salt solutions can be taken u p dire ctl y by the blood
” 7
circulating in the blood vessels H ypodermocl ysi s i s the -
.

most rapid method ( aside from direct vein inj ection ) of intro
d uc i ng fluid into the circulation I ncrease i n the amou nt of .

fluid in the vascular system results in heightened venou s press

ure which in tu rn produces an increase in di astolic filling
, , ,
‘

systol ic output and arterial p re s s u re and greatl y hastens the ,

velocity of the circulation ( F ig B lood with its lower . .

vi scosity passes readily through the dilated arterioles and cap

il l a r i e s s o that the velocity O f the bl ood fl ow may be easil y
,
-

” 8
increased from s i x to ten time s I nj ect ing salt solution .

equivalent to 5 0 per cent of the total blood has been fou nd to

augment the velocity O f the blood s i x to e ight ti mes the normal
rate 9

—
.

6 S t l i
arn g T h F l i d f t h B d y p 95
e u s O e o
I b id p
, . .

7 97
I bi d p
, . .

g—
8 , . 1 38
Ph y gy p
.

9 St a r li n si o l o , . 284 .
 VA SC UL A R CA L IBR E AN D A C TI ON

The ri se i n blood pre ssure oc c asioned by the absorption of

fl u id i ntroduced by either h ypodermocl ysi s or p roctocl ysi s is of
special advantage in variou s conditions where the blood press
ure has fallen very l ow su ch as i n collapse ( after hemorrhage )
, ,

i n peritoniti s etc The Mu rp hy method of proctocl ysis is e spec

,
.

i al l y recommended in the treatment of peritonitis after the i n

s t i tu t i o n of su rgical drai nage I t i s des igned to flush the
.

dra ined su rface s and so ai d i n getting rid of septic material

,

and infection We bel ieve its beneficial action is however

.
, ,

du e as mu ch to the m aintenance of bl ood pre ssu re a s to the ,

flu shing of the absorbents and drai ne d surface s .

G iven i n the order in whi ch the y most rap idl y increase the
volume of the blood the methods of i ntrodu cing flu id into the
,

circulatory system may be l i sted as follows :

( a ) H ypodermocl ysi s .

( b ) P roctocl ysi s .

( e ) Wate r drink ing

-
.

3 va
. s c ul ar C a lib re a n d Ac tio n We have see n that a hot
.

appl icat i on dilates the blood — ve ssel s produ cing an a ffl ux of ,

blood to the ski n and superficial parts i ncreas ing with the ,

prolongation of the appl ication It ha s also been shown that

.

th e reaction to a cold application produces an affl ux of blood

to the skin . I n both cases there i s a hypere mia establi shed ,

but the two are of an entirel y di ff erent nature With the .

hot application there i s a fall of bl ood pres sure becau se of a

loss of tone i n the vessel s ( passive dilatation ) and a p re p on
derance of venou s blood in the part ; W h ile the dilatation which
comes with the reaction to a col d appl ication is accompanie d
by an i ncrease in blood pres sure the tone of the ve ssel s i s pre ,

served an d there i s a preponderance of arterial bl ood i n the

,

part These conditions are respectivel y known as venous or

.

p a ss i ve hyper e m z a and a r z er z a / or a d z ve bypere m z a I t is i mport

' ' ’ '
‘
.

ant to distingu i sh the physiologi c di ff erence between the hyper

em i a of cold and that of hot applications A t first both pro .

duce an arterial hyperemia I n the case of the hot application.

the end result i s a slowing of the circulation a stasi s of blood , ,

which nece ssarily results i n an i ncrease of the v e n ous ov er the

arterial blood in the p art With the col d appl icati on afte r the
.
,
96 BL O OD P RESS URE

initial vasoconstriction and ane mia have given way the retu rn ,

to a normal condition ( reacti on ) i s accompani ed by an i n c rease

of from three to five time s i n the rapidity of the c i r cu l a t i on fi "

The blood flows rapidly through the part and conse quentl y ,

arterial blood p redom inates The remote result i s the same ; .

there is no after tendency to stas is This i s no small factor in

-
.

nutrition and heal i ng I n fact it is u pon the blood that they

.
,

depend ; the y are ca rried on and hastene d i n proportion to the

amount of arterial blood e nutriti on and oxygen suppl ied
, .
, ,

to the tissue s .

F ig . 25 . F gh t
au s sp hy g m om a n o rrfe t e r .

B ie r in hi s work on the treatment of di sease by hypere mia

,

claim s for the tissues a selecti ve action i e th at the y have the , . .

,

appear i rrational to suppose anyth ing else The e ssential fea .

tu re i s not i n t he sel ecti ve action but in the suppl ying of su ffi ,

cient arte rial blood so that the tis sues ma y m a mf es z their

,
’
‘

selective action The cold has al so a direct action on the hemo

.

globin in producing a higher degree of ox ygenation i e a

u h—
,
.
,
.

10 B P i n ipl d P
ar c r c ti f H yd
es an th py p 55 rac ce o ro e ra , . .
93 BL O O D P RESS URE
12
ing the e ff ects of the rmi c appl i cations upon blood pres sure .

The pressu re was te sted by means of the Riva Rocci sph ygm o -

manometer ( F ig Brie fly stated his conclu sions are as

.

follows ( P l a te I V ) .

Efl eets of Col d B aths and thermic ap p l i .

cations not accompanied by mechani cal i rrita

,

tion if g iven be l ow the temper a tur e of t/z e sk i n

,
,

produce increased blood pre ssu re wi th slowed

pulse rate .

2 Efl eets of H ea t
.
Therm ic a p p l i c a t i o n s .

ao ooe t/z e sk i n te mper a tu r e after a brief rise , ,

produce a fall in blood pres sure which later

0
rises H ot baths above 1 04 F persi stentl y i n
.
.

crease blood pressure and the pulse rate .

3 . Efl eets o f N e u tr a l Te m
eu tral bat h s
per a tu r es . N
equalize or regulate blood
pres sure .

4 . Efi eets
‘
of M e e /z a i z i ea l
S ti m u l i With douches and
.

other procedures where the ,

mechanical irritation i s the

p r ed o m i nant
factor there i s ,

a ri se of blood
pressure less e n
du r i n g t h a n
with cold ap pl i
cations E very . F i g 27 G tn T n m t . . ar er s
’
o o e er .

hot or c ol d
douche call s forth an increase of blood pressu re paradoxical ,
” 3
as i t may seem .
'

The experiments of S chulle r al ready quoted su stain the se , ,

observations Many other experiments along this l ine might

.

be quoted Kellogg records an expe riment in which the

.

drinking of a large quantity of col d flu id ( 5 0 F ) ra ise d the °

—
.

1 2 Al fi ll D t h A h fu k l i M d 1 902 V l 7 4
eh e u sc rc r n e o
H i d l H y d t h p y p 48
. . .
, . .

13 ns a e ro e ra
1 4 R ti l H yd th py p 1 1 1 5
, . .

a ona ro e ra , . .
 PL A T E I V C h t h w i n g i n fl u n ar s o e ce of b tha d i f nt t m
s of e re e
n bl d p —u nd p u l h — lth y m n
.

pe ra tu re s o oo re ss re a se t
ra e in a ea f a o
t w nt y i x
e d l n
s : bl d p u
re i es oo r e ss re b l k l i n p ul
ac es tse ra e

( R iv R ph g m ) ( M ul l )
-
.
,

a -
oc c 1 s s y . er
 C H A PT E R X

TH E CI R C U LAT I O N —
CH A N GE S IN TH E

CO M P O SI T I O N O F T H E B L OO D

CO R P U S C U L A R E L E ME N T S

U CH a large volume of experimental work has bee n r e

ported along thi s l ine that we can not do more than tabu
late the principal results obse rved The inve stigations of .

P rofes sor Winte rnitz and those of Strasser u ndertaken at his

, ,

request and re ported in 1 89 3 are consi dered the basis of ou r

,

knowledge of these changes T

he re sults obtai ned by all
.

obse rve rs are so uniform as to leave no dou bt of their rel iability .

A fter all sorts of col d procedures involving the general skin ,

surface and as sociated with mechani cal p rocedu re s after hot ,

baths or dou che s whe n followe d by cold appl ications the blood ,

counts reveal an increase in both the re d cel ls and W hite cell s ,

and a marked change in their ratio In Winternitz e x p e r i .

’

ment s the greatest increase i n red cell s amounted to i

per cubic millimeter ; in white c e l l s from 2 00 to 3 00 pe r cent ;

,

and i n hemoglobin 1 4 per cent, .

O n the first and third bath days of St ra s se r s experiment s

’

refe rred to in Chapter X 1 blood counts were taken after the

,

cold douche and afte r the graduated hal f bath The counts .

were as follows :
E ffe c ts of C o l d D ou c h e
Red cell s
White cell s
H emoglobin ( F l ei sc/z l )
 BL OOD C O UN T
E ffe c t s of G ra du a te d H a lf B a th B e fo re A ft e r
Re d cells
Wh ite cell s
H emoglobin 85 % 95

The results in detail of some of the experiments pe r forme d

by Winternitz are gi ven i n the accompanying chart
1
and table .

R ed s .

5 00 0 0 0 0

I 00 0 0 0 0

5 0 0 00 0

F ig C h t h w i n g t h ff t f h y d i t i p
28 ar s o du n th e e ec s o r a c ro c e re s o e
bl d ou n t nd h m g l b i n U p i gh t b l o k—w i t h d i g on l l i n
. .

oo c a e o o r c s a a es

k—
b k w it h h z w h it ou n t b l k
.

re d un t
co l nt l oc l n s o riin o a c r o ss i es e c oc s
bl h m og l b i n p
, ,

ac e nt ( W i nt n t )
o e r ce . er 1 z .

C ol d F ul l B ath R ed C e ll s W hi t e C e l l s
B e fore
I mmed i atel y after
A fte r plu s 1 2 hr re st in bed - -
.

C ol d R ain B ath

Before
A fter plu s 1 —
2 h -
r . exerci se
Sc o tc h D ou c h e

B efore
A fter plus exer c ise 1 hr-
.

1 B B xb um —
. u L h bu h d H y d
a e r c er r ot h e ra pi I I A ufl
e, ag e ,
p . 35 .
1 02 BL O OD C OMP OSITION
The se changes were maintained for from one ha l f hou r or one -

hour up to two hou rs or longer after appli ca tions graduall y ,

retu rning to normal The increase i n the white cell s w as.

-

maintained longer than the increase in reds The se obse rva .

tions have been confi rmed by Thayer B a ruch and Kell ogg i n , , ,

thi s country .

Where do these cells come from ? Re peate d cold applicat ions

stimulate hematogenesi s as the y stimulate all other fun cti ons , ,

as i s shown by the fact that i n case s of anemi a this increase in

cells continues longer and longer after each su cceeding a p p l i

cation until finall y a normal count i s reached and maintained .

But of course so great an i ncrease as 3 0 or 3 5 pe r ce nt in the

, ,

total number of reds and 2 00 per cent i n the total numbe r of

whites could not result from a single application This incr ea se .

in the corpuscular ele ments i n the pe ripheral ci rculation mu st

be at the expense of the numbe r elsewhere Winte rnitz clai ms .

that this increase of cell s in the periphe ral circulation i s du e to

the dr ivi ng of large numbe rs of cell s from the vi scera where ,

2
sta sis has taken place B reitenstein has confi rmed this vi ew by
.

expe ri ments upon rabbits These animal s were overhea ted in .

a hot box be fore and after which the red cell s in the pe ri phe ral
,

circulation ( ear ) and viscera ( l iver ) we re estimated B efore .

the heating process the cells i n the ear and l iver were e qual
,

in number Af ter it there wa s an e no r mou s i ncrea se i n the

.
,

red blood cell s i n the liver T schl e no ff obse rve d a decrease of .

5 0 per cent in the white cel ls in rabbits subj ected to a tempe r

°
ature of 4 2 C for five or six hours These expe ri ments al so
. .

confi rm the observation of Winternit z and o thers that general ,

hot appli cations much prolonged decrease the blood count and
, ,

the hemoglobin per cent the white cell s suff ering a greater ,

diminution than the reds .

N ot the least interesting of the obse rvations made by Winter

nitz i s that relating to the local increase i n the bl ood count
taken from ci rcumsc ri bed areas treated by col d or hot and col d
douches partial baths etc while count s taken from a di stant
, , .
,

part showed a decrease i n both the red and white cell s P ro .

lon g ed loca l applications of heat not followe d by cold whil e ,

2 A h i v fii E p P t h u nd Ph m Bd 32 1 896
rc . r x er . a . ar .
. .
1 04 BL OOD C OMP O SI TION
rhythmical contraction and rel axation of the organ occu rring ,

in cats and dogs at interval s of about one minute .

Roy supposes th at the se contractions are eff ecte d throu gh

—
the i nt ri nsic mu sculature of the organ that i s the plain
muscle ti ssue prese nt i n the capsule and t rab e c ul m a nd he
, ,

,
—
believes that the contractions se rve to keep up a circu lati on
through the spleen and to make its vascular supply more or le ss
inde pe ndent of variations in general arteri al pre ssu re The .

fact that there i s a spe cial local a rrangement for maintaining i t s

circulation makes the spleen u nique a mong the organs of the
,

body but no light i s thrown upon the nature of the functio n

,

fulfilled The spleen i s supplie d richl y wi th motor nerve fibers

.

F i g : 29 P l t h y m g ph i
e s o ra c t rac i n g of s pl e en (u pp e r cur v e) f ro m d og
h g t h p nt n u h y t hm i hi g
.

s ow i n e s o a eo s r ca l c on t r a c t i o n s of t s or an
ft S t l i n g )
.

( Se hii fe r a er ar .

which when stimulated either directl y or r efl ex ly cau se the

, .

organ to diminish in volume A ccording to S ch afer the se

’

fibe rs are contai ned in the spl anchnic ne rves whi ch ca rry al so ,

inhibitory fibers whose stimu l ati on causes a dilata t ion of the

” 5
spleen .

The bl ood of the spleni c veins contai ns a much g reater nu m

b er of white cell s than the arterial bl ood suppl ied to the organ .

Mie scher expe rimenting with Rhine salmon found fou r time s
“

as man y leucocytes in the splenic bl ood as in the c ard i ac blood .

This increa se in the cellular ele ment s increa se s the vi scosit y ,

5 H w ll —
o Ph y i l g y
e 800 s o o , .

6 B g Ph y i l g i nd P t h l gi C h m i t y S n d E n g l i h E d i t i n p 229
un e- s o o c a a o o c e s r . e co s o ,
. .
 VISC OSIT Y

and consequentl y tends to diminish the rate of blood flow The .

gathe ri ng u p of these cells together w ith the closenes s of the

,

spleni c mes hwork in which the blood circulate s makes meces ,

sary some mechani s m for additional propul sive force .

It i s evi dent that the bl ood must meet with considerable

re si stance i n passi ng throu gh the close me shwork of the Splenic
pul p To ensure a constant circulation throu gh the gland we
.
,

find that the mu scular tissu e of the capsule and trabecul a:

ha s the property of rhythm ic contract ion If the spleen be .

inclosed i n a plethys mograph or sp l e ni e oncometer and its , ,

volu me be re corded by conne cting thi s wi th the oncograph i t ,

will be seen that it i s subj ect to a se rie s of large slow varia ,

tions each contraction and expansion lasting about a minute

, ,

and recu rring with great regul arit y ( F ig S upe rpose d on .

t hese large wave s are see n the smaller undulations du e to the

re spiratory variations of the blood pre s sure and on the se again ,

the l ittl e excu rsions corresponding to each heart beat The .

contract i l e power of the s pleen i s under the control of the

nervou s s ystem and a rap id contraction ma y be indu ce d by
,

”
stimulation of the splanchnic nerves .

The u se of col d appli cations es peciall y whe n acco mpanied by ,

mechanical sti mulat ion such as the cold mitten friction to the
,

abdomen and the col d sple nic douche have a de c i de l y sti m u ,

lant e ff ect u pon the movements of the spleen The same is .

true of the revu l sive compre ss and the alte rnate hot and cold
dou che to the s pleni c region and abdomen S uch st imulation .

i ncrease s the extent and for c e and greatl y enhances the effi
‘

c i e n c y of the splen ic contract ions thereby proving a powerfu l ,

means of a ccompl ishing the even di stribu ti on of the blood cell s ,

e specially the leu coc ytes .

V I SCO S I T Y
8
G rawit z and al so B urton O pitz have shown that cold a p p l i
-

cation s increase the vi scosity and spe cific gravity of the bl ood ,

while warm appl ications decrease both Thi s th inning of the .

bl ood conti nued eve n after prolonge d heating with free p e r sp i

7 S t l i g—E l m nt f H m n Ph y i l g y 1 907 p 5 1 4
ar n e e s o u a s o o . , . .

8 Jou rn l f E xp i m n t l M di i n
a o er e J n u y 1 906
a e c e, a ar , .
 A L K A LI N IT Y OF T H E B L OO D

F ig 30 Ch a rt s h ow i n g h ng c a es in t he al k a l i ni t y of t he b l ood un d er
h p ed u re s F ig f f k al i n i t y
. .

t m ic
er r oc t
u re s a le t re e r t o al of 1 00 c e o f
bl St
. . .

ood se r u m i n t e rm s o f c c o f d e c i n o rm a l
. . N a oH .
( ra s s e r a nd K ut h y ) .
1 08 BL O OD C OMP OSI TION
ration Thi s result Burton O pi tz attributed to the blood b e
.
-

coming relatively richer in se ru m at the expense of the

tissues These facts h ave been confi rmed by L tiw y and agree
.

with the deductions of Winternitz and K nop fe l m ache r

’

In general it may be sai d that conditions that produce vaso

,

constriction increase the nu mber of corpu scles in the ve ssel s

,

constricted togethe r with an increase in the specifi c gravity

,

and viscosity of the blood Conversel y conditions that rel ax .

,

the blood vessels decrease the corpu scular ele me nts in the
-

dilated vessels together with a thinning of the bl ood ,

.

R E A CTI O N
S trasser and K ut hy performed experiments to dete rmine the
9

eff ect of hy dr i at i c procedures upon the chem ical reaction of the

blood and urine The y found that procedu re s rai si ng the body .

temperature i e much prolonge d heating measure s re sul t in

, . .
, ,

lessening the degree of alkale scence of the blood : al so that col d

stimulating procedures increase the alkales cence ( F ig .

S trasser conclude s that the re sult in the case of cold b ath s i s

due to an increase of oxidation over di sinte gration i e to , . .
,

completer burning of acid organi c substance s and hence to thei r ,

disappearance This i s preci sel y what happens to the organic

.

acids and acid organic salts of fru its and green vegetables .

The organi c radicle undergoing oxidation largel y in to C 0 2 and ,

H 2 0 leave s in the blood and body flui ds the alkaline base of the
,

salt and therefore raises the alkal i nity of the se flui ds While
, , .

heating procedures increase oxi dation they bring about a ,

greater di sintegration of tissue i e partial combustion and so , . .

,

result in an acidification which acid products remai n to be ,

excreted as su ch in the u rine .

That St r a sse r s deductions are correct i s shown by the ’

changes i n the acidity of the u rine accompanying these change s

i n the alkal inity of the blood ( F ig I n the ca se of col d . .

procedures there occurs a decrease i n the acidit y of the u ri ne

parallel with the de crease in the acid of the bl ood ( i ncrease of
alkalescence ) thu s proving that the acidifyi ng substance s have
, ,

—
to that extent wholl y disappeared Conversel y i n the heating
, .
,

9 D ut h M di zi n l Z i t n g J n 1 5 1 896 q u t d f m B B uxb um L h b u h d
e sc e e a e u u e o e ro e r c er
-
, , a

H y d t h p i I I A fl g pp 38 39
. .

ro e ra e, u a e, .
, .
 P R A C TI CA L A P P L I CA TI ON 1 09

procedures an increase of acid in the blood ( decrease of al k al

e sc e n c e ) i s accompanie d by a like increase i n the acidity of the

u ri ne showi ng an actual incre ase in acidifyi ng substa n ces u noxi

,

di z ed and hence comi ng to ex cretion as such

, .

P R A CT ICA L A P P L IC A TI O N

S ome of the most be ne ficial re sults of measures a re hy d r i a t i c

due to the facts recorde d above I n the maj orit y of disease s .
,

there i s a re duction i n the alkalinity of the blood This is par .

t ic u l a r l y t rue of fevers and infectiou s di seases A n agent whi ch .

will tend to re s tore the blood to i t s normal alkali nity w il l hasten

all the proce sses of repai r and raise vital re si stance by suppl y
i ng a more n orm al mediu m for the phagocyte s .

The role of the leu cocyt e ( phagocytosis ) in combating i nfe c

tion i s now an e stablishe d fact The adm irable rese arche s of .

Metchniko ff along thi s l ine leave no dou bt that the white cell
itself i s the p rime factor ( and that not excepting opsoni n ) i n
phagocytosi s the p rodu ction and mainte nan ce of i mmunity and
,

the body s general re sistance to bacte r ial i nvas ion H e ha s

’
.

shown what si gnal di saster to th e production and eve n the

1°
,

continuance of immu nity results from the administration of ,

alcohol qu inine o piu m and other medi cinal substances ; thi s

, , ,

di s a ster being manife st by a dimi nution i n the numbe r and

especiall y i n the activity of the white blo od cell s H e fu rthe r .

recommends the di scarding of me dicinal substan c e s and the u se

of hygieni c measure s i n the prophylaxi s and treatment of i nfe c
tiou s disease s We have every reason to believe that cold
.

hyd r i at i c applications not onl y increase the number of l e u e o

cyte s i n the peripheral ci rculation but also ener g i z e thei r ,

—
action am oeboid moveme nts phagocytosis and the p roduction , ,

of antibodies Thi s we might safel y i nfer from the re sults

.

ob t a i n e d b y col d applications in increasing muscular capacity ,

O

glandul ar activit y etc A l l protoplasm whethe r of mu scle

,
.
,

cell s gl andular epithel ium or leucocyte responds al ike to the

, , ,

tonic influence of short vigorou s cold appl ications The write r .

has repeatedl y seen infe ctions of the hand and arm clear u p i n
fou r to s ix days or e ve n les s time when treate d by alte rnating
, ,

1 0 T h N w H y gi n
e e e e .
1 1 0 BL OOD C OMP OSI TION
extreme hot and cold immersion wh ile other case s not so ,

treated have required a month to accompli sh the same results .

S ince the blood and tissue cells are the source of O psonin ,

agglutinins lysins and other antibodie s conce rned i n i mmunity

, , ,

it is but reasonable to expect an increase i n the se a s a re sul t of

the cellular stimulation produced by cold or alternate hot and
cold applications This has been partiall y demonstrated by
.

G raz i an i who found that of rabbits i njected with the filtrates of

,
ll

typhoid cultures and kept at di ff erent temperature s ( plu s 3 8

, ,

°
3 7 2 and minus 4
, ,
those kept at low temperature s devel
oped more agglutinin than those kept at higher temperatu res .

°
H e also experimented w ith rabbits kept at 3 2 C bathing hal f .
,

0
of the number morning and evening i n wate r at 2 0 C for , .

thirty minutes The animals treated by bathing produced more

.

agglutinin than the othe rs .

These facts demonstrate the truth of the S cripture stateme nt

that t/z e bl ood i s Me lif e The state ment ha s not onl y it s spirit .

ual application but i s al so founded u pon demonstrate d ph ys ical

,

facts .

I Votw i t/z s ta n di ng
'

the m a ny a n ti se p ti cs , g er m i ci des , e tc .
,
t/z a t
lz a ve been va un te d f or Me tr ea tm en t f
o i nf ecti ous d i sea ses , t/z e w /z i te
bl ood cell i tself i s the m ost ef fici en t g e r m i ci de k n ow n , an d will
a l w ay s re ta i n i ts b ig li p l a ce i n tb e def en ce of thebody ag a i n st ba c
ter i a l i n v as i on ; f u r t/z er m or e the ag e n t w /z i c/z ass i s ts t/z e bod
y by ,

a ug men ti ng i ts n a tu r a l pow er s of def ence w i l l never occupy a p l a ce

secon da ry to pu r e ly a r ti fici a l a n d c/
ze m i ca l m ea ns f
o des tr oy i ng tlz e
” 12
i n va de r s .

1 1 C e n t ra l b l a t t fii r B kt e ri o l o gi 1 90 7 I X LII
— 633
a e , . , , .

12 A bb El ot t e m e nt s of H yd r ot h e ra py fo r N u r se s . p . 54 .
1 12 N I TR OGE N O US ME TA BOL ISM

perceptible contraction in orde r to eff ect metaboli c changes .

Through the i nnervation of the mu scl es oxidation is controlle d ,

and may be greatl y i ncreased b v hot or col d appli cations with ,

out vi sible contractions Thi s conclus ion was arrived at by .

R oh ri g and Z un t z w ho further confirme d thei r O pinion by ex

’

p e r i m e n t s upon animal s i n which the i nnervation of the

muscles w as hel d in obeyance by arrow poi son I n such ani .

mal s tissue change was not onl y not increased by cold b u t w as ,

”
O ther stimul i than cold al so a ffect
2
even reduced one half -
.

tissue changes The r el a ti ve value of variou s cutaneous stimul i

.
,

varying degrees of heat and the quantitative re sponse of meta ,

holi sm i s best studied with carbonaceou s metabol ism ( o .

E F F E CT S OF CO L D
S trasser conducted two serie s of experiment s at different
times I n the fi r st series two y ou ng m e n were selected a s su b
.

je c t s The dail y ration u rine and feces were carefull y meas

.
, ,

ure d and from chemical analyse s and estimations from the se

, .

the results were obtained The p rocedure s were such as woul d .

ordinaril y be administered to p ati ents In the second serie s a .

single indivi dual was chosen I n th is series the intake con .

t a i n e d 1 2 2 gm of proteid . gm nitroge n ) bes ide s c arb oh y .

drate and fat The output in fece s and urine w a s measu re d for
.

five days in order to establ ish the normal quantiti e s of the

variou s constituents for the i ndividual under experiment .

The bath peri od lasted three days O n e ach day the man .

°
received i n the morning at 8 o clock a fri ction at 1 4 R ’
'

F . Forenoons at a general col d ra i n bath with movi ng

° °
fan douche and afternoons a half bath at 2 2 cooled to 1 8 R
, .

to F ) of fou r minute s du ration Moderate e xe r

. .

ci se followed each procedure as much a s seemed nece ssa ry for ,

”
warm ing i e the attainment of a good reaction
, . .
, .

The results of the fi r s t work as tabulated by S tras ser are a s

follows
1 Increase of nitrogen metabolism i e increase of the
.

, . .
,

n i trogen excretion in the u ri ne ; a simultaneou s de crease in

fecal nitrogen
—
.

2 B aru c h Hyd ro t h e ra py p
, . 80 .
 N I TR OGE N E C ON OM Y

2 . A bsolute
and relative increase i n the excretion of urea .

3 H igh absolute increase i n the excret ion of u ri c acid wi th

.
,

relat ive p roportion almost unchanged .

4 H igh absolute and rel ative increase in phosphoru s e x c r e

.

t i on .

5 S mall rel ative fl u ctuations in ammonia exc retion

. .

6 Decrease i n the sum of the extractive s to a minimu m

. .

The re sults i n the se cond se rie s of experi ments entirel y con

firmed the fi ndings i n the first and are of the same general ,

character 3
.

F ig
n i t ro g
. 32
en
—
.S h
re v
ow i n
e al s a
g t h ff
h i gh t
e
e e ect
e ne
o f c ol
d
d
a ssi m il a t i on ofp
f
t re a t m e n t o n e ca l an d u r i n a r y
d
rot e i . S
( t r a ss e r )
.

Nitrog e n E c ono m yThe excretion of nitrogen ( F ig on . .

the first bath d a y was increase d per cent over the average
of the p re p e ri od ; a maximum increase of pe r cent wa s
re ached on the second day and on the last per ce nt thu s , ,

averaging pe r cent The i ncrease continued throughout the .

after pe riod I n the two fi rst case s the average increase was
-
.

re spectivel y 1 0 and per cent The fecal nitrogen shows .

a corresponding decrease The subj ect of the experiment r e .

mained practicall y in nitrogen balance th roughout the e x p e r i

3 . U nl e ss o th e rw i se st a t e d th e c h f
a rt s a n d e st i m a t i o ns re e r t o t h e s e c on d se ri e s o f e x

p e ri m e n t s .
 F i g 33 Sh owi n g re l a t i v
i nc re as e
e o f u re a a n d t he ph o ph at e s
v d
.

St
.

s
a n d re l a t i o f a m m onia
e ec re ase .
( rasse r . )
1 1 6 N I TR O GE N O US ME TA BOL ISM

le ss alkali ( ammonia ) for thei r neutrali z ation and so l e ssen the

“
relative amount of the latter formed .

U ri c Aci d and P uri n B ases T he accepted theorie s of nucl ei n .

metabolism are pe rhaps too w ell known to need explanation here .

A n increase i n pu ri n excretion ma y ari se from e ither endogen

ou s or exogenous pu rins That the i ncrease d excreti on of uri c .

acid is d ue to heighte ned act ivity and breaki ng u p of the l e ue o

cyte s and therefor e bea rs a de finite relation to the l eu coc yt osi s
, ,

wh ich alway s accompanie s the re action to col d p rocedure s can ,

be corre ct i n pa r t onl y The ex c reted pu r ins mu st of n e ce s .

si t y come from all the nu clear nitrogen of the body as well as

from the leu cocytes The m ore complete oxidation of e xogen

.

ou s purins and the hastening of their excretion m a y al so ac

count for the i ncrea se i n uri c acid .

The results obtained by di fferent expe ri menters all agree as to

the absol u te increase in uric acid excretion u nde r the in fluence
of the rmic procedu re s I t ru ns parallel w ith the e xcretion of
.

u rea I n St r asse r s expe r iments there wa s an immed i ate i n

.
’

crease of u r ic acid on the fi rst bath day which rea ched a maxi ,

mum of 2 5 per cent on the thi rd bath da y a nd an average of

2 2 pe r cent during the e nti re bath peri od The i ncrea se .
,

though somewhat l ess i n per ce nt c on tin ue d t hrou ghout the ,

entire aft er pe riod at an average hei ght of

-
per cent above
the level of the p r e p e ri od The re sults i n the two cases of h i s .

first se rie s e ntirel y coi n cided w ith th is I n the se ca se s the .

increase i n the total pu ri n averaged per cent du ring the

bath pe ri od and even a hi gh er sta ge w a s reac hed and mai n
t a i n e d d u ring the e ntire three day after peri od - -
.

Relative to the total nitrogen there was al so a sl ight i ncrease , .

O f 1 0 0 pa rt s of total nitrogen the nitrogen of the u r i c acid con

stituted per cent in the p r e p e ri od pe r cent i n the ,

bath pe ri od and per cent in the after period -

.

4 I t w o ul se e m d h v h
o w e e r t a t t he s m a ll re l a ti e i n c r e a se o f a m m o n i a i s d u e t o t h ev
v p v b p d
, .

re la t i e l y m o re c o m l e t e c o n e r si o n o f a m m o n i u m c a r o n a t e i n t o u rea i t s e n d ro u c t
d p d b b d xd h
.
,

A S a P ro u c t o f r o t e i m e t a o li s m i t i s s u jec t t o i n c r e as e o i a t i o n i n c om m o n w i t
h
o t e r n i t ro e n g
e ri d v v g
a t i e s a l a r e r re l a t i e i nc r e a s e i s re e n t e v
b y t h e i n c re as e i or p v d dvg
h p v g p h h g b d b
,

of e a t i c a c t i i t y t e ndi n to us t he c an e e y on a m m oni um c a r o na t e t o t h e
fo rm a t i o n o f u re a .

In g or a ni c ac i d s req ui l k l i f t h i n ut l i z t i n
re a a or e r e ra a o as g d
w e ll a s o r a n i c a c i s a n d t h e
form e n a r e no t o nl y n t do d i n m u n t b ut
e cre ase o d
a re a c t ua ll y i n c r e a s e f
F o r u rt e r h
—
a

eq u g id f fix d k h
m n Di b t —
, .

di s uss m n o f t h e r
c

m nt f
i re e ni o mm
or a c ac s or a o n i a a nd e a l a l i se e G ra a m
L us k M
e ta o l i s b i a J u n l A m i n M di
e es o r a e r ca e ca l A D
ss oc i a t i o n ,
b
ec e m e r 1 7 1 9 1 0. .
 P UR IN
Of particular intere st in connection with nu c le in metaboli sm
i s the behavior of the pu r in base s A s the u ri c acid excretion i n .

crease s i n amount the pu ri n bases progres sivel y decrease until ,

on the third bath day the e ntire purin excretion consi sts of uri c
acid the bases having wholl y di sappeared A t the close of the
, .

treatment the pu rin bases again rise to reach on t he third day ,

F i g 34 Sh ow i n g ff e e c t o f c ol dt r e a t m e nt o n t he o i xd a t i on o f
p St
. .

ur i ns (
. rasse r . )

of the after pe ri od the height of the p re p e ri od Thi s change in

-

,
.

the proportion of the two const ituents of purin ex cretion i s

graphi call y shown i n F ig 3 4 Letting 1 0 0 per cent represent
. .

the total p uri n nitrogen per ce nt appears as u ri c aci d and

,

per c ent as pu ri n bases O n the bath days the per cent of

.

u ri c acid rises to 9 6 the n to 9 8 and finally to 1 0 0 pe r cent

,
.

The nitroge n content of the base s sinks to 4 then to 2 and ,

finall y to 0 pe r cent .
1 18 N ITR OGE N O US ME TA B OL ISM

With the compo sition of u r ic acid and the base s i n mi nd the ,

explanation of the above change s i s not diffi cul t U ri c aci d i s .

t r i ox yp ur i n while the bases all contain l e s s oxygen being

, ,

mostly mono or d iox yp ur i n with ami ne or h ydrocarbon side

,

g roups . U r ic acid is therefore the most

,
hi ghl y oxidi,
z e d of t he

pu ri n bodies I t i s pl ain to be seen that the sti mul u s of the

.

hy dr i at i c procedure s ha s resulte d in oxi dation of the base s t o

ur i c acid ,
a distinct cumul a tive e ffe ct be i ng mani fe st by th e
progr e ss ive compl etene ss of thi s oxid a t ion u ntil on the third ,

bath day no base s are l eft all purin ni t rogen appea ri ng a s

,

uric acid .

Thi s r esult is of no l ittle impo r tance in the treatment of t he

gouty dia these s With a ki dney pe rmeable to u ri c aci d a s it i s
.

in uncompl icated gout the pu ri ns may be m ade to come to both

,

complete oxidation and complete excreti on The i ncrease i n .

the alkalescence of the bl ood and bod y ti ssue s al s o re sulti ng

from cold appl i cations gr eatl y favors thes e change s .

The condition in u rati c diathe si s in real ity consists of a n

accumulation of all the pu ri n b odies ( u ric acid plu s bases )
“
Beca u se of this K ol i sch p ro posed the te rm p uri n diathe s is
instead of u ric acid di athe si s The excret ion of the ba se s
.

exercise s a delete riou s e ff ect upon the k idney s and the altered ,

kidney i s i n tu rn le ss capable of excreti ng basi c pur i n Thi s .

vi ci ous ci r cl e would b e done away wit h w e re the ba se s ex cr e te d ,

in a mor e completel y oxidize d st ate i e as uri c a ci d A s , . .

,
.

re m a rked by S trasser toni c h ydroth e rap y breaks throu gh thi s

,

vicious circle and completel y change s the aspect of puri n auto

intoxication The excretion of a waste not a s su ch but i n an
.
, ,

altered and less toxic state may b e c on side r e d t he re moval of

poison par excellence .

Extra cti v es summa r y of the rel a tion of the nitroge nou s

. A
extractives to the total nitroge n shows that the y co nstitute
re s pectively per cent i n the p r e pe r iod per cent i n the ,

bath pe r iod and per cent in the afte r pe r iod As al ready -

.

mentioned on the thi rd bath day they di sa p pear e nti rel y and
,

urea ur i c acid and ammonia cl aim the whole nitrogen for

, ,

themselve s .
1 20 N ITR OGE N O US ME TA BOL ISM

p horu s comes from le cithin as well as certai n proteids I n the .

first experiments the rel ative i ncrease laste d throughout the

whole of the after pe r iod-
I t i s sign ificant th at onl y the more
.

labile ph osphates take part in the increase This increase i n .

urinary phosphoru s i s wholly i n the alkal ine phosph ates the ,

earthy phosphate s remai n u nchanged ( F ig .

Sulp hat es and C hlori des The sulphu r of the urine al so come s
.

from protei d substances and the u ri nary sul phates ar e therefore , ,

another end product of proteid metabol i sm and sh oul d increa se

with the nitrogen The average i n c rea se w a s
. per cent
du ring the bath period which height w a s mai ntained du ring
,

nearl y the whol e of the after pe riod The i n crease in the sul
-
.

p ha t e s w as alm ost entirely i n the mine ral sul phates the ethe ,

real sulphate s su ff ering but a tri fling change Th is m i ght be .

expected since more compl ete di gestion and as similation of pro

t e i d together with completer oxi dation would tend to decrea se
, ,

putrefactive changes and so lessen the relati ve amou nt of eth e

real sulphate H awk obse r ved decrease d i nte sti nal put r efaction
.

a s a resu l t of copiou s water drink ing Thi s result w as measured

-
.

by the indican output It seemed to be due to more complete

.

intestinal absorption .

The increase in the excretion of sod iu m chl ori de w as chiefl y

on the first bath day ( 1 5 per cent ) and di d not outla st the bath
pe ri od The excretion of sodium chloride in oedema i s a matte r
.

of no l ittle importance I n th i s condition hy dr i a t i c appl i cati ons

.

produce an increase i n chlori de excretion i n two ways ; fi rst ,

by increasing the absorption of interstitial flui d and second by , ,

stimulating kidney activity .

E F F E CT S O F H E AT

The reported researches regarding the e ff ects of heat upon

metabolism are somewhat confli cting in thei r results This i s .

doubtless due to di ff erence s in the mode of appl icat ion the i n ,

tensity duration and frequency of repetition of the tre atment

, ,

as well as i n the reactive response of the organi sm Formanek .

observed that a single hot bath scarcely changed the nitrogen ,

but after two or more su ch baths on su cce ssive days there

occu rred a decided increase of nitrogen el imination I t woul d .
 E FFE C TS OF H E A T

seem that a s ingl e hot bath if not too prolonged shoul d de , ,

crease the el im ination of nitroge n for the time being as a -

re sult of the atoni c reaction and the les sened amou nt of water
excreted by the k idney .

I n general thi s agree s w ith the results obtained by two di ff er

5
ent observers one working with the Turkish bath and one
,

with the Ru ssian bath .

E ffe c t s of T u r i shk B ath a t 1 22F fo r 5 0 M i nu t e s

.

D a y b e fo r e a th DB ay of B ath

A mount of u rine 24 hours c c . . 950 . c c . .

S pecific gravity
U rea gm . gm
U ri c aci d gm . gm .

E ffe c t s of R u s si a n B at h a t F fo r 2 5 M i nu t e s
1 1 3
°
.

D a y b e fo r e ath B
D ay of B at h

A mou nt of u ri ne 24 hou rs e . c . 9 00 . c c . .

S pe cific gravity
U rea gm . gm .

U ri c acid gm .
gm .

Ba st el s , N aun yn , and S chle ich fou nd an increase of u rea

and total nitrogen excretion which late r s howed diminution .

I t i s altogether pos sible that these oppos ite results may also be
accounted for by the di ff erences in the am ou nt of water i n
ge sted by the subj ects du ri ng the re spective experi ments Loss .

of wate r through sweating decrease s the tissue flu ids and there

fore the uri na ry solvent if thi s los s is not replaced by water
,

drinking It has bee n shown by H awk that cop iou s water

.
6

drinking increases the excretion of nitrogen i n the form of u rea ,

due to the washing out from the tissue s of preforme d u rea H e ‘

al so observed a greater phosphoru s excretion The max imu m .

increase occurred regularl y on the second day of the e x p e r i

ment .

The se condary diminution i n the nitroge n excretion obse rved

by S chleich woul d te nd to show that the metabolize d n itroge n
i n the case of hot baths c ome s more from the ti ss ue a l bu m e n
than from any increase in the intestinal absorption of prote ids .

5 Hin d l —
s a eH y d t h p y pp 22 23
ro e ra , .
, .

6 U ni v i t y f P nn y l v n i M di l B ull t i
e rs o e s a a1 905 e ca e n, .
1 22 N ITR OGE N O US ME TA BOL ISM

I n case prolonged hot appl ications increase th e e ffi ciency of

absorption there should be a gradual return of the cu rve of i n
,

creased excretion to the normal Instead of this le ssened ex .

,

cretion occu rs i n an e ffort to re store the nitrogen balance Th is .

also a gree s with cli nical e xperience A course of hot baths .

u naccompanied by the tonic of c old appl i cations re sul ts in los s

of weight I t is true thi s i s largel y a los s of fat but the ti ssue
.
,

proteids are al so concerned in the incre ased oxi dation .

A l l obse rvers seem to agree that the excretion of u r i c acid i s

increased by hot baths This be ing tru e both hot and col d .
,

baths should be useful in gout .

E F F E CT S O N L OW P RO T E ID DI E T

—
St ra sse r experiments were all conducted upon individual s
’
s

s ubsisting upon a high prote id diet 1 2 2 grams of prote id In .

Ma y of 1 9 1 2 P rof E H Ri sle y condu cted at the reque st of

7
. . .
,

the writer a se ries of experiments to deter m ine the e ff ects of

,

stimulating hy dr i a t ic procedu res u pon the nitrogen metabol i sm

of healthy individuals subsisting upon a l ow prote i d die t
( Chittenden standard ) .

S ix medi c al students were chosen The diet contai ned dail y .

6 1 grams of proteid and inclu ding carboh ydrate and fat pos , ,

sessed a total calori fic value of calorie s A s all were .

accu stomed to a non fl e sh diet ary this was no great change -

from their u sual fare The excretion s for the first day of the .

standard diet were discarde d For the nine days following .

,

e stimations were made of the quantity specific gra v ity acidity , ,

urea ammonia ,creatinin uri c acid total pu rin and total nitro
, , , ,

gen of the urine ; al so the total nitr oge n of the fece s .

The p r e p e r iod the tre atment period and the after period
, ,
-

each lasted three days During th e treatment period three .

,

treatments d ail y were admini stered to ea c h man The se were .

as follows : A t A M was given a cold shower or sp ray or . .

,

a hot and cold shower with te mperatures ac c ordi ng to th e ,

ability of the individual to re act The forenoon treatment at .

1 0 A M consisted of an alte rnate hot and c ol d leg bath with

. .

7 E H Ri l y M D f m
. .
ly p
s e f f h m i t y i n th C ll g
or f M di
erl Ev ro e ss or o c e s r e o e e o e ca an
Do t Ri g xp di di b
, .

ge li s ts . c or sl e y 8 lon e e ri e n c e in st u es in e t a nd m e ta ol i s m a ss u re s t he
a cc ur ac y o f t he re s u l t s .
1 24 N I TR OGE N 0 US ME TA BOL ISM
change s without encroaching at all u pon the more stabile or
necessary nitrogen require d by normal body funct ions I t is.
,

the refore to be confidently expecte d that h ydrotherapeutic

,

measures shoul d have the ir greate st e ff ects both qualitativel y

,

and quantitatively i n disorders of prote id met abol i sm and i n

,

individuals who have for years been accu stomed to a high

proteid diet i e an excessive inge stion of nitrogen
, . .
, .

Thi s view of the matter i s entirel y consi stent with the fa ct

that the nitrogen of the food doe s not se rve pri maril y as fuel
for the supply of energy but i s util i z e d in tis su e building and i n
,

tissue repair N either changes in season nor in the amou nt of

.

muscular work p roduce appre ciable changes i n the metabol ism

of ti ss ue nitrogen O n the other hand c hange s in season and
.

the amount of mu scular work pe rforme d produce large change s

i n the amount of non nitroge nou s food requ ired
-
Likewise
.

thermic and mechanical sti mulation produce most conspicuous

changes in carbonaceou s metabol ism I t i s t o these change s
.

we shall now tu rn ou r attention .

 CH APTER XII

R E SP I R A T I O N ,
R E SP I R A T O R Y CH A N GE S

AN D C AR BO N A C E O U S ME T A BO L I SM
N THE previou s chapter we have considered ti ssu e change
,

solel y from the standpoint of protei d metabol ism and chie fl y

as regards the nitrogenou s moiety There remains of cou rse
.
.

a certain a m ount of carbo hydrate when urea i s spilt off from the
,

prot ei d molecul e al so the carboh ydrate taken a s such and the

,

fat al l of which contain no nitrogen The ir metabol i sm is so

, .

intimatel y as sociated with re spiratory interchanges that we shall

consider them togethe r ; the r esp iratory excret ion bei ng qu ite
as much a gu i de to these changes as is renal excretion t o
nitroge nou s changes .

R E S P IRA T O R Y E F F E CT S
We have note d that all sort s of stimul i appl ie d to the ski n
produ ce more or l es s pronounced vasomotor and cardi ac
change s through re flex action
,
The re spirati on i s more
.

readi l y affecte d by cu ta neous stimul i than i s any other fu nction .

O n e of the most e ffi cient means of resu scitating the new born
infant is the u se of heat and col d The same method i e the
.
, . .
,

alte rnate appl ication of heat and col d to the chest is scarc el y ,

le ss e ff e ctive in the adult The su dde n appli cation of either

.

extreme heat or cold especiall y if accompanie d by p ercu ssi on

, ,

produ ces an initi al deep re spiration whi ch i s almost a s su ddenl y

,

i nte rrupte d this bei ng followe d by other spasmodi c e ff orts so

, ,

that the respiration assume s a sta ccato type With prolonge d .

appl i cations of e ither heat or cold the respirat ion soon become s
,

regular the rate and depth depe ndi ng upon the temperature of
,

the appl ication .

1 26 CA R BON A CE O US ME TA BOL ISM
Kellogg records the following expe ri ments as illustrative of 1

the eff ect of thermic stimuli upon the volu me of tidal air .

To a subject whose tidal a ir measured 2 8 cubic i nche s a wet ,

°
sheet rub at 4 0 F was administered I mmedi atel y afte r the
. .

treatment the ti dal ai r measu red 3 5 cub i c inche s an i ncrease

, ,

of nearly 2 6 pe r cent .

To another subject with an initial tidal ai r vol u me of 3 3 ,

°
cubic inches a cold mitten fri ction was admi ni stere d at 4 5 F
,
.

Immediatel y after the tidal air measu red 5 1 cubic inche s an

, ,

increase of 5 5 per cent .

In a third subj ect the amount of tidal a ir be fore the treat

ment w a s 2 7 cubi c inches A wet sheet pack wrung from .

°
water at 4 5 F w a s appl ied and continue d for one hour A fter
-
. .

the ini t ial wa rming the pack was ke pt at the neutral stage ,
.

Two m inutes afte r the sheet was appl ie d the volume of the ,

tidal ai r w a s 3 6 cubic i nches an increase of 3 3 1 3 per cent ,

-
.

In 1 5 minute s it w a s 3 3 cubic i nche s The volume graduall y .

’

decreased until at the end of the hour it was 2 8 cub i c inche s .

During the enti re period there was an average increase of ,

1 8 1 2 per cent
-
.

In a fourth subj ect a heating compre s s wrung from ice

wate r w as applied to the chest onl y The tidal air i m m e d i .

atel y rose from 5 0 7 c c to 7 5 1 c c an i ncrease of 4 8 per . . . .

,

cent A t the end of 20 minute s the tidal a ir m easure d 604 c e

. . .
,

20 per cent more than at the beginning The ave rage increase .

w as 1 7 0 c e or 3 3 per cent
. .
, .

A nother subj e ct whose tidal ai r w as 4 3 cubic i nche s , was ,

i mmersed in a hot bath at 1 0 8 F A fter 1 2 minu te s the t idal ° ‘

air had decrease d to 2 7 cubi c inches or a decrea se of per ,

cent Ten minute s afte r the bath it had risen to 3 3 cubi c

.
,

inche s ; 3 0 minute s after to 3 7 cubic i nche s The loss in the , .

volume of re spired air amounted to 3 7 1 2 per cent -

.

B rief sudden appli cations of col d produce spasmodic respira

,

tion The reaction to cold appl ications i s accompanied by a

.

slowed rate and greater depth of respiration as shown by th e ,

above experiments The rate i s slowe d and the amplitude of .

movement i ncreased in p roportion to the completeness of r e ac

tion .

1 R i n l H y d t h p y pp 1 1 22 1 1 33
at o a ro e ra , .
, .
1 28 CA R BON A C E O US ME TA B OL ISM
Rubner ( 1 9 0 3 ) has given u s some observations which are of
2

a ve ry practical nature since the re sults obtaine d we re after ,

hot and cold appli cations given as the y are ordinaril y applie d
in practice The following table shows the e ff e ct of short baths
.

u pon the consumption of oxygen and the eli mination of carbon

dioxide
B a th at
°
61 F .

°
86 F .

°
91 F .

°
1 04 F .

°
1 1 1 F .

Winternitz ( 1 89 9 ) in seven expe riments upon the same

H .

individual observe d that hot baths continu ed 3 0 minu te s p ro

,

duce duri ng that time an ave rage i ncrease in the consumption

of oxygen amounting to 7 8 per cent and in C 0 2 elimination of :

9 1 per cent O bservations made on an ave rage nearl y an hou r

.

afte r the bath still revealed an i ncrease of 2 2 per cent in the

,

oxygen consumed and 1 6 per cent i n C 0 2 exhaled Rubner .

ha s sho wn that metabol ism i s at a mi nimu m u nder tempe rature s

° ° ° °
from to 9 5 F ( 3 3 to 3 5 A fall of every 1 .C in .

the su r rounding temperature increase s metaboli sm by 2 or 3

per cent .

From the above obse rvations we may dedu ce the l aw thaf

appli cations below the ski n temperature i ncrease resp iratory
changes in p roportion to the degree of cold N eutral tempera .

ture s exe rt but li ttle influence Temperatu res above that of .

the ski n surface again increase the re spi ratory functi on i n p ro

portion to the degree of heat .

4
Rubner found in h is experime nts that a dou che p roduced
more than double the change produced by a bath at the same
t emperatu re each c ontinue d for the same length of time v i z
, ,
.
,

3 1 2 to 5 minute s
-

The accompanying table shows the increase

.

i n per cent .

2 A h i v ffi H y gi
rc r e ne , 1 903 , Bd 46
. .

3 p
T h e n o n u a l re s i ra t o r y u oti e nt is q
a nd is ou n f d by d i v i d i ng t h e a m o u n t o f ox y
d h
g e n i n a l e b y t h e a m o u nt o f c a r o n i o i e e ale b d xd xh d
A hv H g p
.

4 rc i ffl r y i e n e 1 903 Bd 46 , 390 , .
, . .
 ME CH A N ICA L S TIM UL I
D ou c h e at 61
°
F . B a th a t 61
°
F .

V olu me of air plu s plu s

C 0 2 exhale d
0 consumed
These obse rvations prove the immense advantage of m e chan i
cal stimul i combined with the rmi c and al so of exercise follow
i ng h ydr i at i c treatment espe cially when take n in the open air
, .

A swimming bath or col d rubbing bath produce s more decided

t i ssue change than qu ie t immers ion for the same reason The .

s ame i s tr ue of massage following bath s of whateve r te mpera

tu re A t A i x le s B ains a spec ialt y i s made of what i s calle d
.
- -

the massage dou che Thi s consi sts of de ep kneading of the

.
-

m uscle s give n while one or more streams of water are pou ri ng

ove r the pa rt s treate d The Turki sh shampoo following a
.

Turkish or Russian bath also combi ne s many of the procedures

of massage and i s very popular with the obe se
,
A l l su ch .

combinat ions of extreme the rm i c w ith vigorou s mechanical

stimulation are of great advantage in the treatment of obe sity
s ince the resultant oxidation of carbon compou nds i s more than
double that produced by the rm ic stimulation alone The lu ng .

gymnasti cs p rodu ce d by hyd r i at i c appl ications are by no means

t he least important factor i n the result s produce d by hydro
therap y .
 C H APT ER XIII

M U SC U LAR C AP A CI T Y

HE re storative e ff e ct of warm baths in rel ieving the sense

of fatigue and the tonic e ffect of the cold douche or spray
,

in ove rcomi ng the e ff ects of fati g ue are famil i ar to all w ho are ,

acquainted with the practical appl i cation of hy d r iat i c proced

ures These e ff ects are extensi vely u sed by athlete s i n over
.

coming the exhau stion of severe or prolonge d exertion A nd .

medi cally considered the y are by no means the least i mpor

,

tant of the re sults obtaine d by hy d r i ati c appli cations .

I n 1 89 2 and 1 89 3 V inaj and Maggiori reporte d a se rie s of

1

experiments undertaken to show the e ff e c t of h ydr i at i c meas

ures upon the capacity of the mu scles for work and the ir res ist
ance to fati g ue These inve stigations were made w ith Mos so s
.
’

ergograph ( F ig This instrument i s so constructed as to

.

hold the hand and forearm stationary i n the body of the appa
ratu s while one finger i s left free for fl e x i on and extens ion
, .

The forefinger or middle finger i s u suall y employed so that

, , ,

b y means of a cord over a pulle y it raises and lowers a wei ght , .

Thi s i s kept u p until the mu scles are fatigu e d and u nable to i

contract longer A writing point m ak e s a graphic record on

.

the drum of an u pright or ho ri z ontal kymograph Thei r ex .

p e r i m e n t s were done with a weight of three or four k ilogram s ,

rai sed every two se conds .

In one experiment ( F ig 3 7 A ) the middle finger of the right

. .

hand was under normal conditions able to execute fifty con

, ,

tractions representing a work of

, k i l og r a mm e t er s A fter .

a col d bath at 5 0 F for fifteen se conds the same grou p of

°
.

muscles executed be fore fatigued seventy fou r contractions

, ,
-

representing a work of k i l og r am m e t e r s ( F ig .

1 B l at t fti k li ni h H y d t h p i
er r sc e ro e ra e .

( 1 30 )
1 32 M USC UL A R CA P A CI T Y

Wi th hot baths the opposite e ff ect s prevail There i s a de .

cided les sening of the mu scular capacity amounting i n one of ,

Kellogg s expe ri ments to a decrease of 44 p er cent H i s ex

’
.

p e r i m e n t s cover a wi de range and are very instru ctive He .

u sed both Mos so s ergograph and the d yn om om e t e r ; the latte r

’

a machi ne of his own des i gn The following table i s compiled .

from hi s expe riments with Mosso s ergograph ’

S u b je c t H o t T r e a t m e nt C ol d T r ea t m e n t
AG E WE I G H T I N I T CA L D EG R EE T I ME R ES U LT D EG R EE T I ME R T
TR T
ES U L
S ENG H
S p r 1 1 3° Sp t 60° 1 0 Mi n
D
. . .

60° 1 Mi n
D D
. .

1 1 5° 0 9 27 55 ° 1 5 Se c
D
. . .

8 282 60° 3 Mi n
D G n D
. .

Ge n 1 1 2° e 56 ° 1 5 Se c
B
. . . . .

1 04°
G n D
.

e 55 ° 1 5 Se c
N b th
. . .

e u t ra l a
Sh l B
a 65 ° 2 Mi n
W S P
. . .

. . . 60° 20 Mi n .

b th
F ig 37 F tfi g
a ue c u r v e o f ri gh t h nd A —n or m a l , —
B a ft 8 r
F fif nd
a
. .
.

a at 50’ . or t e e n se c o s

Considering both the d v n om om e t e r and ergograph e x p e r i

ments there w a s a fter cold procedure s an average gain in
,
,
,

muscular capacity of about thi rty pe r cent and after hot app i i ,

cati ons an average loss of thirty per cent i n the work aecom
,

p l i s he d .
Cold therefore i ncrea se s the muscular working
, ,

capacity ; while warmth not combined with mechani cal effe cts ,
,

diminishes mu scular power Af te r f a ti ue a si mple warm bath

g .

may slightl y increase mu scular power although thi s e ff ect i s ,

2 R d d n R t i l H y d th py
e co r e i a o na ro e ra .
 ME CH AN ICA L S TIM UL I 1 33

not decided ( F ig 4 1 A ) Warm p rocedure s when combined

. .

with friction or pe rcus sion a s i a dou che s produ ce an i ncre a se

'

'

, ,

in mu scular power ( F ig 4 1 C ) but to a le s s e xte nt than cold

.
,
.

In p ract ice alte rnate hot and cold dou che s when so gi ven that ,

F ig . 38 . F at i gu e cu r v e . A —
b f e or e , B —f
a te r g dura a te d

B C
C —ft r w o k
E k nd g d u t d b t h u p o n f ti gu
c ur
F ig
v e
. 39 .

—
A no rm
ff e c t of
al
w or
B -
ft a
a
ti v e r ac
ra a e
e wo kr
a
a e
a
r
e

f d b h
.
, .

oll ow e b y at .

the hot i s short and u sed onl y to prepar e the body for cold ,

produce the g reatest increa se i n the worki ng po wer Mec ha n i .

cal e ff e cts alone such as m a ssage al so ra i s e the worki ng

, ,

capacity of the mu scle s bu t to a le ss ext ent than cold proced

ure s.
1 34 M USC UL A R CA P A CI T Y

To what a re these tonic and re storative due This e ff ects ?

question may be somewhat di ffi c ul t to answer ; bu t it wou ld

A B C
ff b— ld w h pon f t i g u
C —ft
F ig 40 E
— e ct o f lao nd r a co et s t ee r ub u a e
v ft l bo b f ll we d
. .

cu r e A n o rm a l , B a er a r, a er la or o o
h
.

b y wet s e e t ru b .

A B C
F ig 41 E ff p
—
m l e w a rm b t h nd f w m d u h
—
e c t o f si a a o ar o c e on
f t gu d m u f f ll w d b y w
C —ft
. .

a i e sc l es A m usc ul a r t ig u
a e o o e a rm
b t h B ft f ti g u f t i g u f ll w d
.

a a er a e o nl y . o o e by
m d u h
. a er a e
w ar o c e .

seem that the restoration of the muscle to its normal working

po wer i s due to more than one change A mong these changes .

may be mentioned the restoration of tone to the nerve and i ts

 M USC UL A R CA P A CI T Y

pa rt icularly of the meta bol ism of nuclear protei d seem to e x e r

ci se the same e ff ect S ince the amou nt of these from the
.

organism itself i s sma ll and fairl y constant the e ff ect s are most
apparent i n t he ca se of i ngestion of much pu rin wi th the food
( exogenous purin ) The premature appearance of fatigue in
.

meat ea te rs and u sers of coff ee and tea i s s carcel y to be

recounted for on any other basi s .

I t is a well known fact that the fatigue curve s of vegetarians

revea l a high degree of abil ity to sustai n continu ou s and pro
l onged e ff ort ; while ou the contra r y the fat igue curve s of mea t
e a t e r s show a great su sce ptibility to fatigu e and hence i ts ea rl y ,

onset in endurance tes ts But tn e r s recent compilation of .

’

FI R S T A FT E R 10 0 A FT ER as o AFT E R 4 0 0
C O N T R A C N OH S '
C om mons
F ig 42 T he f
e f ec ts o f ca ff e i ne o n v ol un t a ry m u sc l e T he t w o
g f m th g f g
. .
.

t ra i n s
c a re ro e t wo as t roc n e m i i of a ro T he m u sc l e
h h d d th pp k p t i n ph g
.

w ic r e co r e e u e r o ne w as e a y s i ol o i c s a l t
s ol ut1 0 n . t h e l ow e r on e in a d il u t e so l ut i n f
o f
o ca f ei ne . W
( o od )

experimental work in thi s l ine in hi s treati se on A Fleshless

”
Diet leave s no question as to the final ity of these conclu s ions .

The data there given are most intere sting and im porta nt and
should claim the attention of all who undertake to advi se or
prescribe in matters d iete t ic .

That the early onset of fatigue in meat eaters and coff ee

u se rs i s due largely or wholly to purin subs ta nce s i s very well
sho wn by t he experiments of H C Wood J r 4
H e e xp eri . .
, .

m e n te d with the voluntary mu scle of a frog u sing a solution of

,

4 P h arm ac o l o gy a nd T h e ra p
e u ti cs , p . 36 .
 TH E R AP E U TIC A P P L I CA TI ON

ca ff eine ( t ri methyl xanth in ) wh ich i s one of the basic pu rins .

T he re sul t wa s at first an increase d height of the muscul ar con

t raction and hence an increase of the work performed Later .
,

fatigue se t in earl ier and the contract ions showe d a mu ch di m

i n i she d ampl itu de and greate r irregul arity than in the normal
( F ig T he se observations agree with the e ff ects observed
—
.

”
i n meat eating athletes w ho excel vegetarians in a spu rt ,

i. a short conte st bu t w ho inva ri abl y fal l ou t before th e

,

fi ni sh or c om e i n be hind i n cases of prolonged e ff ort .

THE R A P E U TIC A P P LIC A TI O N

The therape uti c points of practical i mportan ce which one

may gain from the facts brought out by the above experi me nts
are these : H ot appl ications are u seful i n de creasi ng the toni ci ty
o f hypertonic mu scles l e ssening the ir i rri ta bility and r e l ie v
,

i n g e ither clonic or te tan ic s pas m These e ff e cts bring .

a bout relaxat ion and re st The ne rvou s system i s qu iete d and

.

t he nervou s man ifestations of extre me fatigu e disappear s o that

i deal conditions for sle ep are p roduced These sedative e ff e cts .

are dis cu ss ed further in t he part on the rape utics The heat .

leave s no ba d afte r e ff ects

-
There i s no feeling of drowsines s
.

o r l angu or the following forenoon as i s so common afte r sleep

i nduced by tr i on ol ve ronal et c U nl ike morphia or the bro

, ,
.

mides heat d oe s not cover u p or mask important symptom s

,
.

I t does not poison or anesthe ti ze the nerve centers or e ndings .

I n cold appl i cations p roperl y gradu ate d to su it the needs of

.

variou s conditions we pos ses s the most u seful mu scular sti m u

l ant and tonic known to medical science The stimulating .

e ff ects of st rychnine are not comparable with it The stimula .

tion produ ce d by st rychnine i s not constant or u niform I ts .

toxic action be com es manifest i n eve n small doses I t s fre .

_

quent repet ition soon wears out the response and depression ,

results W hen fre quentl y re peate d the sti mulating stage i s of

.

very transient duration and later is absent altogethe r It pro .

duces a feel ing of exhau st ion and i rritability rather than e x ,

hil arat i on O n the whol e stry c/z n i ne m us t be l ooked up on on ly as

.
,

a te mpor a ry r e m e dy It mu st be re membered that it doe s not i n

.

any w a y permanentl y i mprove the condition of the central

1 38

ne rvous system nor does it i ncrease any of t he

,

except re flex i rri tabil ity It i s doubtful whether the

.

maintenan c e of this arti ficiall y rai sed i rritabili t y i s

”5
b e n e fit .

In the case of caffeine the stimulating e ff ects are

di ff erent from those of col d and are in no
them Ca ff eine deadens the sense of fati gue and b y an
.

action heightens the tonicity of voluntary mu scle so

re spo nse to stimul ation i s for a time , ,

it res p onds to a feebler stimul u s Thu .

formed on the mere sti mulation of a cu p

the body i s already fatigued and should rest .

gives a false sense of energy and as a re sul t the .

neglects to take the proper amount of food whi c h

ulti mate source of mu scular energy H ence the .

hau st i ng its supply draws on it s futu re re sou r ce s and

,

the constitution is undermined .

5 S oll m a n n —Ph m a c ol o
ar gy p
, . 1 75 .
1 40 TH E H E A T ME CH A N ISM

R E G U L AT IO N O F H E A T P RO D U CT I O N

It has al ready been mentioned that i f a frog or other cold ,

blooded animal be exposed to a hi gher te mpe ratu re it s i nte rna l ,

temperature wi ll also ri se If at t he same time we mea s ure .

, ,

the respiratory inte rchanges of the frog we find that at the ,

higher te m p eratu re more carbon di oxide i s e v ol ved and m ore

oxygen taken u p showing that i n thi s ca se a ri se of te mpera
,

ture i n the surrounding medium cau ses a ri se i n the tempera

tu re of the frog and at the sa m e ti me i ncrea se s the activi ty of
, ,

its metaboli c changes C ool i ng has the reve rse e ff ect . If a .

°
frog be cooled to 0 C the chemical chan g es i n i t s ti ssu e s ar e
so reduced that in may be kept alive for some day s in an atmos

p he re devoid of oxyge n The ca se i s qu ite othe rw i se wi t h .

wa r m blood ed an i mals
-
E xposure of one of them to a col d .

m edium rai se s the amount of carbon di oxide gi ve n o ff and

oxygen t aken in while the temperature of the ani mal re ma ins
,

unaltered This power of the animal to rea ct to change s in th e

.

temperature of the su r rounding mediu m i s dependent on th e

integrity of the ne rvou s system and it s conne ction w ith the
mu scles If a dog or rabbit be p oi soned with cu rare ( whi ch
.

paralyzes the m uscle e nd pl ates ) or if i t s spinal cord be divi ded -

ju st below the medulla its temperatu r e sink s continuou sl y I t, .

is then found that the ani m al reacts to change s i n the tem p e r

—
ature of the surroundi ng medium preci sel y l ike a col d bl ooded -

ani mal r i se of the external tempe ratu re cau sing ri s e of the

inte rnal temperatu re and increa sed el imi nation of C 0 2 while a ,

fall of the exte nal temperature has the rev e rse e ff ect
r ”
.

It ha s be en shown that m etabol ism and heat production are

proportional to the skin area of the animal u nder obse rvation .

The temperature ne r ve s of the skin c onstitute the m e chani sm

by which thermi c impres sions are rece ived Q u antitat ive r e .
‘

weight produce s heat not according to i t s wei ght but according

,

to the extent of the skin surfac e e xposed to the surrou nding

medium
— —
.

1 St
a r l in g Ph y sio l o gy , 1 907 . DD . 5 00 503 .
 H E A T L O SS

R E G U L A TI O N OF H E AT L O SS
From the standpoint of h ydroth erapy however of more i m , ,

portance than the regulation of tem perature by the production ,

i s regulation by heat loss H ea t i s lost from the body in three

.

ways O nly the last two of the se are of any practi cal i mpor
.

tance and the third i s of the greatest u tility for it i s largel y ,

through thi s avenue that febrile te mperatures are controlle d .

The three way s are as follows

1 By tk e U r i n e a n d F eces
. A bou t 3 per cent of the total
.

heat lost from the body l eave s i t with the excretions .

2 . The i ns pired ai r i s taken in at the

By the E xp i r e d A i r .

te mperature of the su rrounding atmosphere and contains onl y ,

a small amount of aqueou s vapor The expired air has a

’

°
temperatu re of about 1 lower than the body temperature and ,

i s saturated with water vapor H eat i s therefore lost i n resp i

.
, ,

ration i n two ways : first in warming the i nspired air ; second

, ,

i n the evaporation of large quantities of water These two .

sou rce s of loss constitute abou t 2 0 per cent of the total heat
”
loss .

3 By t/z e Sk i n
. H ere again the loss of heat i s a ffecte d in
.

two ways : fi rst by radiation and conve ction

,
B y these means .
,

an interchange of heat take s place betwee n the surface of the

body and surrou nding obje cts tending to cool the body unde r ,

ordinary circum stances whe n the external temperature i s below

° °
98 4 F or 3 7 C or to warm the bod y when the exte rn al
.
,
.
,

temperature i s higher than thi s a s during the hot season in the ,

trop ics or i n a Tu rk ish bath The amount of i nterchange of

.

heat betwee n two bodie s i s di re ctl y proportionate to the di ff e r

ence of temperature between them Thu s the warmer the su r .
,

face of the body in compa ri son with that of su rrounding obje cts ,

the greater w ill be the amount of heat i nterchange whi ch i n

this case impl ie s a loss of heat to the body S ince very l ittle .

heat is generated in the skin itself its temperature i s intim ,

atel y dependent on the amou nt of blood flowing through it ,

and thi s i n i t s tu rn on the condition of the bl ood ves sel s of the -

skin When the se are d ilated there i s a constant su ppl y of

.
,

warm blood from the deepe r parts of the body to the skin which ,
1 42 TH E H E A T ME CH A N ISM

therefore i s kept warm and feel s warm bo th subj ectivel y and

,
,

objectively H ence dilatation of the bl ood vessels of the ski n

.
-

under normal circu mstances brings about increased loss of heat .

If on the other hand the vessels are constricted the smal l

, , ,

amount of blood supplied to the skin rapidl y be comes cooled

and the skin i s also cool and the loss of heat s mal l ,
.

S econd by the evaporation of the sweat

,
I n the conver .

sion of water into wate ry vapor a large amount of heat become s ,

latent Thi s principle is made u se of i n mak ing i ce or i n cool

. ,

ing a bottle of water by su rrounding it w ith damp cloths whi ch

are exposed to a draught of air to facilitate evaporation If the .

secretion of sweat i s small it evaporate s as it i s secrete d and ,

the skin remains dry Thi s i s spoken of as insensible p e r sp ir a

.

tion If the secretion be very cop ious it may be forme d

.
,

faster than it can evaporate and appears on the skin a s drop s ,

—
of sensible perspiration The formation of sensible p e r sp i r a .

tion depends then on two factors the amount of sweat secreted

and the rapidity of evaporation whi ch latter agai n i s dependent ,

on the amount of saturation of the su rroundi ng atmosphere

with watery vapor .

The loss of heat by the sk in amounts to about 7 7 pe r cent

of the total heat loss and i s therefore the most import ant of , , ,

a l l the channels for the discharge of heat The regulation of .

the total heat loss i s al so eff ected chiefl y by changes in the loss
through the skin The nervou s channel s by which thi s i s car
.

ried out are the vasomotor and the sweat nerves If the ex .

te rnal temperature be bel ow that of the body the los s by radia ,

tion and convection may be su ffi cient to get ri d of the exce s s of

heat produced If however the exte rnal temperatu re be
.
, ,

higher than that of the body radiation and convection will ,

serve only to warm the body still fu rther and the sole los s of ,

heat that can be a ff ected i s by the evaporation of sweat which ,

is accordingly under such circumstance s secreted i n large

,
,

quant ities ( F ig .

O ften especially after severe mu scular exercise radiation

,
,

and convection are not su ffi cient to c arry off the exce ss of h eat
produced and hence there i s a copi ous secretion of sweat as
,

well even though the external temperature may be cool ” 2

li n g —
,

Ph y i l g y pp 504—
.

2 St ar s o o
506 . .
.
1 43 TH E H E A T ME CH A N ISM

We may at pre sent adopt the conservative view that he at

produ ction and heat di ssipation i n the body are control led not
by a special heat regulating apparat us com pose d of heat centers
-

and heat ne rves but by the coordinated acti vi ty of a number of

,

diff erent centers i n addition to the voluntary means al ready

specified The unconsciou s re gulat ion of the body te mper
.

4
ature i s e ff ected chiefly through the foll owing :
H ea t D i ssipa ti on .

1 . The sweat centers and sweat nerves

2 .
The vasoconstrictor centers and the ir nerve fibe rs to the
skin .

3 . The re spiratory center .

H ea t P r oducti on .

The motor ne rve centers and the motor ne rve fibers to the
1 .

skeletal muscles .

2 The quantity and character of the food

. .

3 S e cretory and other glandular nerve s

. .

The principal parts of this heat re g ul ating mechani sm and -

their relation to each other are well shown in the accom panying
diagram ( F ig .

E X P E RI M E N TS IN H E A T P R O D U CT I O N
AN D E LI M I N A T I O N
In the cl inical study of the heat me chani sm it is nece ssa ry to
understand something of the means employe d in such study .

To ascertain the heat output of any organi sm some form of

calorimeter i s used The most accurate calori meters are those .

that util i z e wate r for the absorption of the heat communicated

from the body From the total volume of the water and the
.

change i n i t s temperature it i s an eas y matter to fi gure the

number of calorie s absorbed by it and consequentl y the amount ,

of heat given o ff from the body under expe ri ment in a given

len g th of time This of cou rse i s the quantity of heat e l i m i n
.

ated If the temperature of the organism remains constant

.

du ring the experiment then its heat produ ction i s equ al to it s ,

heat elimi nation If the temperature rises or falls the increase

.

or decrease of heat production above or be low the heat elimina

tion can be e stimate d from the we ight of the body and change
in the temperature
4 M odi fi d f m H w ll —
.

Ph y i l g y 1 908 p 866
e ro o e s o o , , . .
 CA L OR IME TE R S 1 45

The construction of the calori meter for animal expe rime nts
can be readil y gra sped from a study of F ig 45 For rough . .

cl inical w ork a bath tu b of water may be util ized The te m .

p e ra t u r e of the wate r serves to make th e thermic appl icat ion

with which it i s de sired to ex pe ri ment and it s volu me together ,

with the change s in its tem perature se rve as the bas is for fig u r
i ng the heat el imination in cal ori e s It has the di sadvantage .

of be ing unsu itable for estimating the after re sults of the rm ic

F ——
D i g m s h ow i n g h g ul t i ng m h
H—
ni m

—
a ra t ea re a ec a s
h t gul ti n g n t h t f m ti n
-
.

— —
ea re a ntce er, ce er or ea or a o
h t di i p t i on V v as om ot o c nt
-
,

D ce nt f
er or ea ss a T r e er,
th m og n i t i ss u s g l nd C
,

er e c S nb
e f w t
ee er or s ea a s.
p i l l y b l oo d v l s of sk i n G w t gl n d ( W ood )
,

ca ar -
e ss e , s ea a .

applications For aft er re sults relati ve value s may be obtained

.

by the d A r son v a l calorimeter Thi s inst rument i s a l arge

’
.

upright cyl inder of heavy pasteboard or other good non con -

ductor The upper end i s closed except for an O pening in wh ich

.

i s fitted an anemometer and the lower end al so except for s mall

openings to a dm i t ai r The subj ect of the expe riment stands
'

in t hi cyl inder the heat of the body cau sing a moveme nt of

1 s ,
1 46 TH E H E A T M E CH A N ISM

ai r which i s registered by the anemomete r The re sults are of .

course only relative but are of value in determining an increa se

or decrease of heat el imin ation .

For our purpose no time need be spent on experimental

proof of the e ff ects of muscular gl andular and other vital , ,

activities on heat production and eli mination We wi sh how .

,

ever to quote more or le ss at length the experi me ntal ba si s of

,

F ig . 45 . R e ic h e rt s
‘

w ate r ca l o r i m e t e r .

the ph y siolo gi c e ff ects of hydr i at i c appl ications upon heat pro

duction and heat loss Kellogg s experiments along thi s line
.
’

are very practical since the te sts were made after application s
of the intensit y and duration actually employe d i n practi ce .

W w a s given a cold percussion douche for thirt y seconds

.

The change in rectal temperatu re i mmediatel y after re vealed

1 43

It has already
the surroundi ng tem
i sm amounting to 2
with a bath of one
resul ts in the ca se of
whom there w as a no
hour .

E ff e ct s of Bathing
T e m p e ra tu re I nc r ea s e d
of Ba th H ea t P rod u c ti o n M e ta b o l i sm i n
G ra m s of F at

95
°
F . 7 calorie s gra m s
°
86 F . 77
°
77 F . 1 67
°
68 F . 29 7
59
°
F . 40 7

In regard to the heat loss it i s e sti mated

86 F the heat loss i s doubled ; in a
°
.

°
and at 6 8 F it reaches five tim .

to note that
thirds of the
the first thi rd of the t re atme nt .

fifteen minutes du ration and wi t

or i e s 4 3 calories of thi s heat loss
,

minutes In another case with .

and one half -

or i e s nearl y 44
,

minute Because of the se fact s short

.

t iona te l y to their du ration more e ff ec ,

than long cold baths .

The reason for the greater heat loss e

cold bath is doubt l e ss due to the fact
pared to resi st the abstraction of heat ,

elimination .
 CL IN ICAL E X P E R IME N TS

The activity of the su rface circu lat ion being the es se ntial
factor i n the loss of heat during a col d bath it follow s there , ,

fore that whatever i ncrease s the amount of blood i n the skin

,

and the rapi dity of t he circulation in the ski n will ma rkedl y

i ncrease heat loss du ring a col d bath T his i s one of the ch ief .

reasons for the u s e of short hot appl ications preparatory to th e

u se of the cold bath .

F i g 46 Ch a rt s h ow i n gh e at e l i m in a t i on b y t h e s kin as a ff e c t e d by
v ph y h pp l i
. .

a ri ous si c a l m e as u re s , t e rm i c a ca t i o n s , e t c .

The following are some of the results cla imed by O tto P os

p i sc hl as a re sult of hi s work a s assi stant to P rofe ssor Winter
nit z .
( F ig 4é ) . .
s

1
. D isplaci ng the blood and arre sting the ci rculation in a
part of the body les sens heat los s as much as per cent .

5 B u xb aum
—L h b e r uc hd er Hyd r ot h e ra p i II A u fl
e. ag e , p . 48 .
1 50 TH E H E A T

2 . H inderi ng
the circulation
sive hyperemia lessens heat 1 0 5
3 Mechanical irritation may
.

up to 9 5 per cent .

4 Weak chemical i rri tation produce

.

to 40 per cent strong i rritation on the other hand

,

to 8 per cent .

5 Thermic influences which cau se goose fle sh

.

loss as much as per cent .

6 A hot rain bath m a y t hr o ug h the produ ction

'

cause a lessening of heat loss up to per cent .

7 P artial cold w e t friction may raise the heat

.

a s 80 pe r cent .

8 Cold rain baths and rest followi ng

.

tory decrease of heat loss an increase up to

9 Cold rain baths with exerci se fo l l ow i n
.

much as per cent .

1 0 Warm rain baths with cold fan douche a n d

.

rai se the heat loss up to 1 6 per cent .

1 1 In two illnesses with increasing fever the

.

decreased as much as per cent .

SU MM A R Y
H eat Pro du c ti on ( The rm og e n esis )

The followi ng are some of the conditions and meas

increase heat production .

Vi ta l a cti v i ti es s u ck as

1 . G landular activi ty .

2 . Mu scu l ar activity .

3 . Digestive activity .

4 . Mental activity .

E x te r na l condi ti on s ,

5 .
Reaction to cold appl ications ( either l ong or short )
6 . Fri ction .

7 . Low atmospheric tem p e ratu res .

8 . H igh atmosphe r ic tempe ratu res .

1 52
'

3 .
Decrease in vol ume of t idal air slow ,
"

or

tion .

4 . V ery
high atmospheri c temperature s .

5 O iling of the ski n

.
.

There are two local appli cations of cold whose

upon the body temperature is not by the
These are the ice cap applied to the
appl ied over the hea rt Their action .

influence s heat product i on through i t s

thermogenic centers of the brain The .

heart beat and thereby the general circu i

decreases heat production O f cou rse a .
,

the se eff ects are very sl ight in health but of i ne sti ‘

in febrile di seases .

H e at R e g ulati o n ( The rm otaxis )

The normal temperatu re of the body i s mai

nicety of the balance between heat production an
ation Increased heat producti on doe s not nece
.

rise of body tempe ratu re since under normal ,

heat i s dissi pated as rapidl y as produce d The .

tions that tend to increase heat produ ct i on 1 1

eli mination of heat as well and so a bal ,

For example the body i s exposed to a draft of col d air

,

skin assumes a goose fle sh appearance by contract ion

involuntary mu scle s ; it i s p al e and contai n s le ss bl ood
.
.

the cold ai r abstracts or conducts heat from the body ,

ened circulation in the skin decrea ses the amount of

from the surface The perspi ratory glands are les s active
.
,

the consequent lessened evaporation of water from the skin

decreases the amount of heat eliminated A t the same .

the sens ation of cold influence s the thermogeni c centers ,

they cau se the ti ssues to produce more

Thus the temperatu re of the body i s maintained at

stant point rather than lowered by the cold atmos pher e .

conve rs e i s true of a short mode ratel y warm bath Thi s .

 TH E R M O TAX IS

communi cate heat to the body and so tend to ra ise the tem ,

p e r a t u r e ; but the body react s i n such a way as to pre se rve the

balance The skin i s relaxed the blood ve s sel s dilated and the
.
,
-

persp iration i ncreased so that more heat i s lost by di ssipation

,

from the su rface A t the same time th is relaxing effect cau se s

.

loss of tone i n the tissues generall y and so le ss heat i s produced

,
.

T hese re sults are due to th e control exercise d by the heat regu -

lating centers before mentione d .

It mu st not be su pposed however that heat always decrease s

, ,

heat production V ery high temperature s markedly i ncrease

.

heat production so mu ch so that fatal poi soning ma y occu r in

,

su ch condit ions as heatstroke S eriou s case s never wholly

.

re cover from the e ffect s of the h igh exte rnal temperature and
the inte rnal heat pr oduced by i t They are ever after extremel y
.

su sceptible to even the moderate heat of trop ical cl imate s or

di rect su nl ight .

Wh ile an agent may increase both heat p roduction and eli m

i n at i on at the same time one i s u suall y i ncreased to a greate r
,

extent than the othe r For e xample a col d mitte n friction at

.
,

first abstracts heat from the body bu t t he reaction cau se s ,

”
increase d heat produ ct ion as shown by the warm ing e ff ect
,
.

The increased circulation of the skin which i s part of the ,

reaction cau ses more heat to be lost The total eff ect how
,
.
,

ever i s an i ncrease of heat i n the body becau se heat produ c

, ,

t ion i s stimulated more than heat el i mination .

A s we have seen thermic appl ications produ ce decide d

,

changes i n heat production and el im ination H owever the s e .

,

change s do not i n health p roduce wide alterations in the body

, ,

temperature O n the contrary the same i nfluence s applied i n

.
,

febril e conditions p rodu ce decided alterations .

From the pre ceding experiments it will be seen that water at

the varying temperature s and in the di ff ere nt ways in whi ch it
may be applie d to the body is capable of any and all poss ibl e
,

variation s and de g ree s of eff ect u pon the heat mechani sm No .

poss ible alte ration of heat production or el im ination can be con

c e i v e d of that water i s not capable of p roducing It is this .

versatil it y of appli cation and e ff e ct that make s hot and cold

water of so much service in feve r and distu rbance s of the he at
mechani sm .
1 54 TH E H E A T ME CH A N ISM

On the contrary drug action i s pa rti cularl y

,

ideal combinations impos sible to make If .

a rational manner upon one part of the

found that they have an adverse action
A nd usually thi s adverse action more than
which may be accompl ished There are no
.

crease heat production by stimulating oxidation

all safe to use Those d rugs such as acetanil id
.

which decrease heat produ ction do so by a toxic

,

the thermogenic centers and ti ssue s so that the r e i

,

of the toxic products of metaboli sm rather than a

the other hand the drugs su ch as al cohol and
,

bring about greater heat el i minatio n by dilating the

vessel s accomplish this by paral yzing the v asom ot or s
, ,

which i s not only u nde sirable in fevers but often

gerons as will be shown under the su bj ect of fever
,

pyretic eff ects

.
1 56 R E A L M OF P H YSIOL OGIC TH E R A P Y
as the removal of a mali gnant
may ( l e done to overbalance or p
case as in t he case of Talma s
’

or E do b o hl s operation for renal

’

t i onal diseases are however nearl y always , ,

physiologic means .

In the course of many di seases a point i s

which a retu rn to the normal is i mpossible w
v e nt i o n of some radical procedure Thi s i s e s .

in i n fla m m at io n s I n .

inflammation it is ent
a ffect the return to normal
of radical measu re s Thi s is true of su .

d r y or serou s pleuris y pneu monia or , ,

tion but where these i n fl a m m at ion s

,

formation of a suppurative focu s or

means alone are unable to
normal condition T r ue in time t h .
, ,

w a y to the surface and so evacuate , ,

long tedious process and the patient

v i t a ht y by such delay which delay ,

absorption of toxic products It i s ne ce ssary .

,

means to accompli sh the speedy evacuation of

,

drainage of the abscess cavity The old dic .

m a m a i s ju st as true now as when it was

,

Translated into terms of activity

provide an outl et .

for This nature

.
,

attempts are accompanied by great destru ction of

much delay B y vigorou s treatment systematically applied
.
, ,

it i s often possible to obviate the necessity for radi cal i nte fe r

ence B ut when the stage of suppuration has been reache d or
.

i s imminent surgical i nte rvention i s j ust a s much an ass istan t

,

to nature as physiologic means and the refore j u st as rational .

The same principles appl y to the u se of vaccine s and an ti

to xm e s I f the body has su ffi cient rese rve
.

fe c t io n doe s not pro g ress too rapidl y the system may provi de
,

adequate means of cure Yet the cou rse of ce rtain infec tions .
 R A D ICA L TH E R A P Y
teache s u s that su ch circu mstance s can not always be relied
u pon Whe re availabl e and of demonstrate d value no one
.
,

wou l d thi nk of om i t i n g the use of seru m therap y When it i s .

u sed ph ysical means shoul d not be left out s impl y be cau se other
,

p rocedures are more e ssential in a g i ven ca se A l l measu re s of .

v alue shoul d be u sed in orde r to still fu rt her ass i st the body i n

combat ing the infe ction .

We may then in gene ral sa y that where physiologic means

, ,

are unabl e to ai d the organi sm in reestabli shi ng the normal

stru ctu re and function radical interference is nece ssary Thi s
, .

divi sion l ine can be st be dete rm ined by careful cons ide ration of
the u sual tre nd of th e pa rt icular disease i n q ue st ion E xp e r i .

ence has sho w n that a ce rtain t ype of in fl ammation i n one organ

or location may early tend to a se riou s i ssue such as abscess ,

or gangre ne while i n another org an or locat ion the re i s less

, ,

i mmediate danger the i nflammat ion tendi ng to become chronic

,
.

For example we ma y cite the ca se of appendi citi s on the one

,

hand and of salpingiti s on the other I n both case s p hy si ol og i c .

,

means m ay accompl i sh a return to the norm al but i n the case ,

of appendi citi s thi s return is not to be rel ie d upon for per

,

manent cu re . The tendenc y i s to recu rrence and even in a ,

s ingl e attack , to pe rforation an d peritonit is ; w hile with the

pelv ic inflammat ion physiologic means produ ce a safe i ssue
,

whi ch can better be relied upon for permanency ; i e if taken . .

,

e arly there i s littl e or at l east le ss te ndency to ru ptu re and

, , ,

absce ss formation E ven in the case of fo rmation of p us i n the

.

tu be it i s be st to delay surg i cal interference u ntil the acute

,

inflammation has subs ide d and if p ossi b l e t h e temperature ha s

‘

, ,

retu rned to normal A t best i t i s dangerou s and conducive

.
,

to spread of infection if sal pingectomy be done during the

continu ance of t he acute i nflammation .

It is qu ite otherwi se with appendicitis N ot onl y does opera .

t i on i n the acute stage give goo d resu lts but be cau se of the ,

i nability to determine the i mmediate i ssue it i s i mperati ve to ,

inte rfere as soon as poss ible True a patie nt may go through .

,

a nu mbe r of acute attacks all of which subsi de withou t seriou s

,

complicat ions but thi s can not be relie d u pon to continue

,
In .

ea ch succeeding attack there i s greater liability to perforation .

1 58 R EAL

Conside ring all we ma y , ,

rational the rapy i s based upo

pe r i e nc e and j udgment the -

ing to the individual

relative to that conditi
pe rfect balance
border line case should be treated by
the rapy Thi s faculty has been termed
.

But i ts application require s more than a

technique The surgeon who i s p re em
.
-

whose ar m e m e n tar i um is well stocked

will meet wi th the best succe ss Let .

enthu siastic about operative

confi dent of natural means
surgical interference o ffers
manent recovery .

In some organic diseases t h

therapy i s that of calli n g into re qu i siti on
functions of stimulating structure s whi ch
,

di seased tissue or organ of p art of its work .

the case in valvular heart le sions and in the

B right s disease In val vular heart di sease
’
.

may be made to assume much of the circ

so relieve the central hea rt to that extent .

the sweat glands may in B right s disea se be made ’

ment the work of the kidne ys .

We have already learned that the basic principl e

logic therapy l ies i n b ringing into requisitio n

To do this most e ff ectively the p

oughly conversant with norm al an
s pend hi s best eff orts in studying
sued by the organism in defending itsel f agai nst a
or pathogenic agent These natural methods of
.

shall endeavor to point out i n c onnection with the .

the
 C H A PT E R XV I

F E V E R AN D AN T I P YR E T I C

C A US E S AN D SY M P T O M S OF

E VE R is a distu rbance of the heat

there i s a more or less prolonged ris
the normal The principal cau se i s the
.

toxic substance s in the bl ood I t i s .

e ffort an attempt on the part of the

,

poi sons ; but the organism may be ove r whelme d

be unable to oxidi z e them with sufli c ie n t rapidit
body O r becau se of the nature of these poi
.
,

regulating centers and the vasomotor center

the balance unsettled If heat el imination were .

with the heat production even though the l atter ,

increased there could be no ri s e of tempe rature

, .

cause a sensation of chillines s and thu s decrease

and fever re sults Whil e the .

its e ff ort s are not always well

The poisons producing pyrexia are of
may be formed in the bod y or introduce
former case the toxemia may be due
body poisons i e those wh ich , . .
,

by ordinary metaboli sm but ,

formed These poi sons are

.

produce the higher types of fever ,

T he p oi so n s due to anger worry and oth , ,

a nc e s are cla ssed under this head although ,

to the body .

P rominent among the l e u co m a i ne s ja s a

the puri n base s A prop os of thi s subj ect we
.

ing from Lu sk :
1 S i n f N ut it i 1 906 p 267
c e ce o r on . . . .

( 1 60)
 CA USE S OF P YR E X IA
H owever , t here is a very note w orthy record made by A R . .

Mandel that the rise of temperature in asepti c or su rgical fevers

i s accompanied by a large increase i n the purin bases in the
u rine of patients fe d with milk The te mperature rises and .

fall s with the qu antit y of puri n base s eliminated The u ri c .

aci d el imination is re duce d .

That the puri n base s can be the cau se of the rise of tem
p e r a t u r e i s i ndi cate d by the experiment s of B urian and S chu r
who fo und that when nu cl e op r ot e i d was admini stered i nt rav e n
o u sl y to a dog a rise of temperature followe d Mandel showe d .

that a subcu taneou s injection of 4 0 m illi grams of xanthi n cau sed

a marke d rise i n the temperatu re of a monke y and that the ,

admi nistration of a strong decoction of 6 0 gram s of co ffee ( con

taining trimet hyl xanthin ) to a man u nused to co ff ee drinking
- -

”
w a s fol lowed by a febrile te mperatu re .

Tox ines m ay be produced by saprophyti c bacte ria ( those of

decompos ition ) growing in the body or i n the alimenta ry tract
,
.

The se conditions are known as sap r e m i a and a u to i n tox i ca ti on -

.

Foods decomposed by bacterial act ion ma y se r ve as the source

of poison as i n the eating of decomposed meat cheese etc
, , , .

S uch products of bacterial decomposition are known as p to

m a i n es B a cte r i a l tox i nes produce d by pathogeni c bacte ri a
.
,

growing within the body itself are the most u su al causes of ,

fever and those with wh ich we are most concern e d in the treat
ment of this co n dit ion .

U lt i m a t e C a u se s o f Pyre xia The fol lowing outline i s modi .

fi e d and abridged from Sol l m an n

2
.

Fever may be due to ,

1 .E xposure to exce ssive external heat as i n su nstroke A l so .

i nternal heat ( over ox idation ) a s i n excess ive mu scula r exerci se

-
.

2 .Certain drugs such as the convul sants cocaine and strych

, ,

nine by the p roduction of convul sions or spasm of the mu scle s

,
“

3 . Toxic prote ins .

( a ) B acterial toxine s of infectiou s disease s .

P tomaine s .

( c ) A uto intoxication ( inte stinal biliary urinary

-

, , ,

2 Te t x B k oo of Ph a r m a c ol o gy . 1 90 1 , p . 394 .

1 1
1 62 FE VE R A N D A N TIP YR E TIC E FFE C TS

A bsorption of unconverted dige stive products as albu ,

moses and peptones in a d i e t too ri ch in proteid ; or due to

digestive disorders .

Manifestations of Fe v e r I n addit ion to the cau se s of fever

. ,

it i s necessary to consi der the symptom s si nce the se are an ,

indication of the real condition of the patient and may be of

such a magnitude as in tu rn to become a cause of additional
, ,

trouble ; in which case special treatment mu st be di recte d

,

toward their rel ief or pall iation .

The toxine s or the high temperatu re cau se the following

, ,

symptoms recognized as characteristi c of feve rs :

,

1 N ervous disturbances su ch a s mal ai se headache back

. , , ,

ache insomnia delirium etc

, , ,
.

2 H ot dry skin or cold cl ammy skin

.
,
.

3 Increased pul se rate and blood tens ion

.
.

4 Increased rate of respiration

. .

E xcessive thirst .

Loss of appetite foul breath coated tongue

, ,
.

Constipation .

8 U rine scanty highl y colored

. high specifi c g r a v i t y i n
, , , ,

crease of u rea .

P R IN CI P L E S OF TR E A T M E N T
S ince oxidation one of the means of getting rid of toxine s
is ,

this burning i s to be encouraged rather than hinde red The .

fever should be controll ed not combated The system i s to be , .

aided in its attempt to oxidi ze and eli mi na te the poi sons Thi s .

i s where failure in the protective mechanism i s e speciall y mani

fest i n febrile di sease s While the decompos ition and d e st r u c
.

tion of body tissue is much increased i n fever true oxidative ,

changes are nearly always decreased For this reason the .

system i s compelled to cope not onl y with the toxine s of direct

bacterial origin but al so with those of de compos ition and i ncom
pl ote metabolism .

The i dea that the reduction of tempe rature i s the sole obje ct
in the treatment of fevers has be come so fi rml y fixe d in the
minds of physicians and laymen that i t i s hard to eradi cate .

It was this idea that led to the u se of the medicinal anti pyretics ,
1 64 FE VE R A N D A N TIP YR E TIC E FFE C TS
in dealing with bacteria A few like he x am e thyl e n am i n are .

valuable aids but of l im ite d range The chem ical de st ru ction

,
.

of bacteria within the human organi sm i s a di sappointment and

as remarked by one we aim at the germs and hit the patient
,
.

The organism i s h indered more than it is helped Concerning .

methods of treating infections W J Mayo ha s the fol lowing

3
. .

to say : E xpe r ience soon taught u s however that in combat , ,

ing infectiou s disease it is even more important that we famil ,

i ari z e ourselves wi th those conditions of the body by which

”
nature combats disease U pon the physicians knowledge of
.

these natural methods depends to a large extent hi s abil it y to

employ physiologic therapy in a rational way .

The body itself must be arou sed to combat the infection .

This i s most eff ectually accompl i shed by those means which

increase the vital re sistance of the body conse rving its power , ,

and especially by those means which increase the nu mber and

e ffi ciency of the phagocytes It has already be en shown how .

thi s may be accompl ished It will al so be noted that cold .

applications as suited to the varying needs of di ff e re nt di seases ,

compass al l of these results We have see n that col d produce s .

a leucocytosis restores the dimini shed alkal inity of the blood

, ,

produces an active arterial hyperemia i ncreases and su stains ,

blood pressure so that life gi vi ng energi zing blood circulate s

, ,

more rapidly where previou sl y there was stas is venou s hyper ,

emia leucopenia lowered alkal inity and a blood laden with

, , ,

leucomaines toxine s and acid poisons The eli mination of

, , .

toxi c products of bacterial l ife i s hastened and their oxidation

i

increased by cold The phagocyte s and b od y t issue s are so

.

energized that the histogenou s production of antitoxines bac ,

t e ri ol y s i n s opsonin etc
, i s i ncreased, While all the se change s
.
, .

are being brought about the lessened toxicity of the body fl uids ,

relieves the nervou s system and it i s qu ieted and invigorated

by the tonic influence of the col d Re stlessne ss insomnia .
, ,

or delirium gives way to clear coordinated action or undis

t ur be d sleep .
The hot dry skin or the cold clam my skin i s , ,

replaced by the warm moi st surface This remarkable grou p .

of change s a l l of which are beneficial and de rive d from a s ingle

,

3 M y o C l in i
a c .1 91 0 p 1 1 8 . . .
 T OX I C VA SOM O TOR P A R A L YSIS
—
agent col d wate — i s im possible to br ng about by any other
r it i
known therapeuti c agent or combination of agents I t i s si mpl y .

u ni que i n the realm of therapy .

T oxi c V as om otor P a ralysis F urther i n regard to the con .

n e c t i on of the circul atory s y ste m w ith the general manifesta

ti ons of feve r and e special l y with regard to the circulatory

compl i cations w h ich contribute so largel y to the mortal ity ,

experimental pathology ha s laid a very fi rm fou ndat ion for the

u se of hydrotherap y i n fevers of infectiou s origin The .

re searches of Romberg and P assl e r are cons idered the basis of

ou r knowl edge of th e state of the hea rt and blood vessel s in -

the se diseases The report s of their w ork have shown con

.
“

elu s i vel y that circulatory fai lure i s not p rima ril y due to the
heart itself bu t to p aral ys is of the blood ves sel s brought abo ut
,
-

by damage to the va somotor centers I n thi s connecti on w e .

can not do bette r than quote from the brief resu me of the se
researc he s given by J aneway and from remarks made by
For c hhe imer .
5

The y studie d the fatal collapse which occurred i n rabbits

after infection with th e pneu mococcu s the bacillu s p yoc y an e u s , ,

and the di p htheria bacillus ; the fi rst p roducing a tr ue septi

c ze m i a
-
the latter a local le s ion with general t ox mm i a A l l of
, .

the 2 5 0 ani mal s u se d w ere au top sied an d the heart and othe r ,

i mportant organs exami ned m i cr o sc0 p i c a ll y The ir method .

consi ste d i n obse rv ing the mean carot id p ressure at di ff erent

st a ges of the disea se and the e ff ect up on it of ( 1 ) abdom inal
,

mas sage which increased the work of the heart by suppl ying
,

it with more blood ; ( 2 ) compres sion of the aorta above the

diaphrag m which makes the work of the heart maximal ;
,

( 3 ) i rritation of the nasal mucou s membrane wit h a Faradi c

current whi ch cau se s extrem e re fl ex vasoconst ri ction ; and
,

( 4 ) short asph yxi a ( th irty se conds ) which acts similarl y onl y on ,

bo th me dulla ry and spi nal va somotor cente rs ; while sensory

‘

stimulation a ff ects onl y the cente r in the medulla The y .

reasoned that shoul d there be no rise in pre s su re from sensory

,

4 Rom b g er and P ass l e t e ut sc h A h iv

rc fti r klin Me d 1 89 5 L X I V pp 65 2 — 7 63 ; a l s o
Mu h W h n h i ft 1 90 1 X L V II I N 8
. . .
, . .

P as sl e r nc e n Me d oc e sc r o
-
. .

T h C l i ni 1 55 1 56 ; n d C
. . , . ,

l St udy f Bl d P pp d V C om
t i n i n Pn u m ni —
5 e ca u o oo i r e ss re a ar ac an d asc u l a r
J u n l f A m i n M di l A p
.
, ,

p hc a o s e o a o r i t
a o er ca e ca ss oc a i o n , O c t 30 1 909
.
, , . 1 45 0 .
1 66 FE VE R A N D A N TIP YR E TIC E FFE C TS
i rri tation or su ff ocation while abdominal massage and ligatu re
,

of the aorta still called forth a well marked one the n the heart ,

must be functionall y capable and the vasomotor mechani sm

paraly z ed To determi ne whether the central or pe riphe ral
.

vasomotor mechani sm w a s at fault the y u sed inj ections of ,

barium chloride which cause constriction of the arte rie s by

,

purely local action upon them .

Their experiments showed that the blood pre ssu re and the
response to al l the procedure s remained perfectl y normal
throughout the early stage of the di sease be ing u na ff ected by ,

the feve r The greatest ele vation of pre ssure was obtaine d on
.

stimulating the mucous membrane of the nose When the .

animals showed si gns of i mpending collapse i n thei r behavior ,

the blood pressure thou gh still normal began to si nk while

, , ,

the heart beat more forcibl y H and in hand with thi s went a .

great red uction in the ri se of pre ssure from sensory irritation ,

a moderate decrease in the asphyxial elevation but as high a ,

pressure as before after abdominal massage I n many case s .

the pressure did not fall until the reflex ri se had bee n almost
abolished evidentl y being maintaine d by i ncreased cardiac
,

energy in spite of the vascular dilatation Finall y in complete

, .

collapse which developed very rapidly the aorti c pres sure fel l
, ,

to the lowest level a s after destru ction of the spinal cord ; no

,

reflex rise Could be obtained but abdominal massage gave an ,

immediate elevat ion I t was evi dent the refore t/z a t t/z e ci r ca
.
, ,

l a tory di s tnr oa nce at t/z e lz e ig /z t o f the i nf ecti on depe nde d a bsol u tely
upon a pa r a ly s i s of t/z e vessel s , not upon a ny da m ag e to the f or ce

of the lz ea r t .

Asregards thei r reaction to compre ss ion of the thora cic

aorta the diphtheria animals showed a dive rgence from the
,

pneumococcu s ones ; the latter evi ncing practi call y normal

cardiac reserve force while the former showed a distinct fall
,

ing o ff A natomically al so the dip htheria hearts had suffere d

.
, ,

damage parenchymatou s degene rati on being well marke d a s

,
,

in clinical diphtheria The pneumococcu s ani mals had scarcel y

.

any change in thei r cardiac mu scle Thus evidence of weak .

1 68 FE VE R A N D A N TIP YR E TIC E FFE C TS

1 . D r u
gs lz a v
Vi r i de These lessen the
.

blood vessels so lowe ring

-

i s decreased be cause of thi s latter action

,
.

the loss of heat from the skin This is not .

dilatation and so in no way restore s the l ,

l at o r y system Both these dru gs decrease.

of the heart s action and so prove dangerou s i

’

or where there i s cardiac weakness dilatation ,

al ready existing .

2 A l co/z ol
. The onl y beneficial. action
lied upon in fever and as gi ven i n so calle d t -

is upon the smaller blood vessel s in whi ch it -

or paretic dilatation and consequent loss of he

“

A t the same time it dilates the viscera ,

already congested in febrile conditions .

tion renders the vi scera much more l iable to

stasi s when the body i s exposed to col d .

6
metaboli c proce sse s and oxidation The tis s .

so that toxines instead of be ing more rap ,

eliminated tend to accumulate i n the system

,

the phagocytic a c tivity the natu ral defence ,

— '

and discharges i mmunity D e l e ar d e h a s show n that .

sorption of alcohol i s a grave obstacle to immunization

h y drophobia A bbot in experimenting on animal s
.
, ,

that those subjected to the influence of al cohol were m

c e p t i b l e to the harmful eff ects of streptococci
,

other bacteria Both D e l e ar de and Laitinen .

sible to vaccinate against anthrax animals that ,

alcohol on several succe ssive days .

3 . The Coa l Ta r P r odu cts ,

as A ce ta n i l i d ,

These decrease heat production

/{ vr i n .

action of their aromatic radicles on the

6 Al h co ol in e x ce ss i v d
e o se s a n
 ME D ICIN A L A N TIP YR E TICS

brain and on the proce sse s of oxidation and prote id metaboli sm .

7

This i s shown by the decrease i n ti ssue de st ruction le sse ning ,

of urea etc Thi s e ff ect i s most marke d in fever where the

,
.
,

rational procedu re i s to increase the bu rning u p of poi sons .

,

( pu rins t oxa l b u m e n s bacte rial toxines etc ) in orde r to get

, , , .

rid of them N either do these dr ugs increase the elimination

.

of poisons They are very powerful car d iac dep re ssants and
.

posses s a decided collapse action Thi s i s most m arke d with .

a cetanil id They cau se breaki ng u p of the re d cells with the

.

formation of methemoglobin thu s in a second way preventi ng , ,

oxidation by lim iting the oxygen carrying capacity of the blood -

.

The move ments of the white s are arrested P hagocytosi s i s .

prevented Thi s i s another example of dru gs that render the

.

body les s able to re sist infecti on .

4 Qu i n i n e
. This drug lowers temperature by decreas ing
.

heat production I ts acti on i s said to be chie fly peripheral

.

u pon the thermogenic tissue s i n decrea sing nitrogenou s met ,

a b ol i sm Th is de crease may reach as high a s 3 9 per cent

.

8
with l arge dose s The dru g probabl y owes its toxicity to its
.

aromatic nucleus the same as the coal tar p rodu cts ,

I t not .

onl y hinders the de struction of ni trogenou s toxine s but i s a ,

powerful poison to the phagocytes arresting their movements ,

immediatel y on contact with the m This result obtains when .

onl y to 1 part in 1 0 00 of solution i s u sed A somewhat .

large r dose cau se s their de stru ction ( B in z ; Sol l m ann ) A ccord .

ing to re ce nt experi ments by Manwaring and Ru h larger ,

amou nts t han per cent of qu ini ne cau se complete su p

p re ssi on of phagocytosi s S ince 1 1 3 of the body weight i s .
-

blood an individual we igh ing 1 30 pou nds posse s ses 1 0 pounds

,

of blood totalling ,
grai ns If at any one time there .
, ,

shoul d be in the blood of a person of thi s weight te n gra i ns of ,

qui nine there woul d then be acting u pon the phagocytes an

,

amount nearl y double the minimum toxic dose Q u inine fr e .

quentl y cau se s hemoglobinu ria Metchniko ff make s the fol 9

.

”
lowing state ment : I t i s not onl y op ium and alcohol which

7 Wh i t n d W i l x —M t i M d i
e a nd T h p ut i 1 900 p 300 l S l l m n n
co a er a
‘

e ca a e ra e c s, a so o a
T xt B k f Ph m l g y 1 901 p 3 55
.
_ , ,

A d m i —I fl m m t i 1 907 p 1 5 2
e oo o ar ac o o , . .

J I b i d p 346
,

8 S ll mo an n S-
l
-
. . . e e a so a n a a on , , . .

9 N w H y gi n
e p 28 e e , . .
1 70 FE VE R A N D A N TIP YR E TIC E FFE C TS
hinder the phagocytic action A nu mber of othe r substan ce s .

regularly employed in medicine cau se the same resul ts E ven ,

.

quinine the eff ect of whi ch in mal arial fevers i s i nd i s p ut

,

able is a poison for the white bl ood cell s O ne should there

,
.
,

fore as a general r ule avoid a s far as pos s ibl e the u se of all

, ,

sort s of medicaments and l i mit one s self to the hygienic ,

’

measures which may check the outbreak of infect iou s di sease .

This postulate fu rther strengt hens the thesi s that t he fu ture of

medicine rests far more in hygie ne than therapeutics .

5 D i aphor e ti cs a s P i l oca rp i n a n d D ove r s P ow der

.
,
The se ,
’
.

lower febrile te mperature by producing sweating Thi s in .

itself i s not irrational I n the case of t he former it has

,
. ,

recently been shown that thi s i s at the expense of the heart s ’

action The latter dru g contains opium which has the same
.

action on the phagoc y tes as alcohol qu inine and coal tar pro , ,
.

du cts .

6 . R ef r ig e r a n ts , s uch as the A l ha l i ne Ci tr a tes , Org a n i c A ci ds ,

a nd A ci d The alkale scence of the blood i s
Org a n i c Sa l t s .

diminished in auto intoxi cation and infe ctiou s di se ase s B ou

-
.

chard failed to neutral i z e the excess of acid in the blood by the

administration of inorganic alkal ies The citrate s tartrate s .
, ,

etc do however favor kidney activity ( diure sis ) and sweat

.
, , ,

ing ( d i ap hor e si s ) and so aid in the el imi nati on of toxines

,
.

E xperi ence demonstrate s th at the natu ral fru i t j u ice s c on tain ,

ing these acids and their salts give better re s ults in these ’

respects than art ificial preparations and do posse ss a true r e

fri g e r a n t action .

N o g reat disce rnment i s nece ssary to dec 1 de that antip yreti c

drugs are harmful in fever The majority of feve rs are due to .

infections i e are bacte rial toxemias , . .The se drugs i n no

, .

w a v remove the cau se nor do the y assi st the body to over ,

come t he infection O n the contrary the y de stroy or cripple

the agents of natu ral defens e the leu coc y te s rende ring them
.

— ,

an easy prey to bacte ri a .

A N TI P Y R E TIC EF F E CT S O F T H E R M IC A P P L ICA T I O N S
Let u s now turn our attention to the di ff erences in the effect s
of the vari ous thermic appl ications used in the treatment of
fevers The fol l o w m g classification will be found he l p ful z L
. —
1 72

friction itsel f se rve to give a sens

and so prevent chill ing and the
I n di ca ti ons
. These e ff ects are
astheni c fevers such as typhoid typhu s and in
, ,

The treatment mu st be frequentl y repeate d ove r

len gt h of time since i t can not be hoped that the
,

emia will be eradicated by a few appl i cat i ons .

Short C old appli cations are almost always

mechanical sti muli The cold mitten friction
.

ample of this class .

1 . H eat production i s i ncrease d by reason

the thermi c and mechanical sti mul i on the
2 The contact with the col d water i s of too bri e
.

ab stract much heat from the body The c ooling .

fe st except on the skin Later heat elimination .

,

be cause of the vascular reaction i n t he ski n .

I n di ca ti ons
. S hort sthenic feve rs a ,

where the skin i s cold and clammy

the skin and raising the blood
occurs in typhoid .

Lo ng H ot A ny of the sweating
.

serve to illustrate the e ff ects of thi s

1 . H eat production i s i ncreased
least to some extent The atonic reaction wh ich
.

result in de crea se of heat produ ction .

2 H eat i s communicated to the body

. Thi s .

cause of the initial rise of temperature befor e

becomes well established and general Later heat .
,

i s enormou sly increased becau se of the i nc r e a

the skin and especiall y by the evaporation of
This latter is the essential effect of sweating t
I n di ca ti ons
.
S weating tre atments are indi cated in
stage of nearly all fevers i e at the onset I t i s at
, . .
, .

that the initial chill occurs They are u seful at this .

such fevers as measles influenza scarlet fever etc

, , , .

Short Ho t Fomentations short hot

.
,

and the hot evaporating w e t sheet pack

 H Y D R I A TI C A N TI P Y R E TI CS

cl ass of anti pyretics Their special advantage i s the preparing

.

of the skin to properl y react to succeeding col d treatment .

The ski n i s warm ed and heat el im i nation i s increased through

the warm ing eff ect S ome heat i s communicate d to the body
. .

H eat production i s little if at all in fluence d Wherever there ,

.

i s chilli ness cyanos i s or goose flesh in febrile disease some

, , ,

form of hot appli cation mu st be u se d be fore re sort ing to cold ,

since i n the abse nce of the former the col d may have a de ,

c id e d l y adverse e ff ect .

I n addition to the e ff e cts noted i n the gene ral cl asse s of treat

ments di scu ssed above it s hould be u nderstood that by prope r
,

variations i n the manner of giving hy dr i at i c treatme nt it i s ,

p os sible to p rodu ce any desired e ff ect upon the heat mechani sm

T em p e ra t u r e r a i si n
-
gv a l ue .

cT
. . R . wsR . . . Brand Cold
Bath Bath

T e m p e ra t u re l ow e ri n-
gv al ue .

F i g 47 Di g a ra m s h ow i n g qu a n t it a t i v e re l a t i o n b tw e ee n t he
p g p ing p
. .

tem e ra t u re r ai si n
-
a nd the te m e ra t u re -
l ow e r ca a c i t y of
di ff e re n t t re a t m e n t s .

and upon febrile temperature In the case of col d treatments .

the se variations are produced by changes i n the degree of

fri ction u sed and i n t he qu antity of col d water brought i n con
tact with the ski n surface The more the friction and the les s .

the contact with cold water the greater the tempe ratu re raising ,
-

capacity T he larger the amount of col d water brought in

.

contact with the body provide d reaction be mai ntained the , ,

greate r the temperature lowering capacity Thi s relation i s -

.

graphicall y shown in F ig 4 7 The proportion of each block . .

below the cross l ine indicates the relat ive value of the treatment
in lowering temperature as compared with i t s temperature
rai si ng valu e indic ated by the p roportion of the block above
the l ine.
1 74 FE VE R A N D AN TIP YR E TIC E FFE C TS

THE H E AT

The mechani sm of the

and one somewhat outside of
are however a few points that
, ,

an understanding of the p ri me
of fever i e in order to treat
,
. .
,

G raham Lu sk gives t
A high fever may be
i sm of onl y 1 5 per cent .

be due to diminution i n
d u ce d In .

of heat within the body

discharge of a normal rabbit w as
twelve hours of infection in which
the di scharge of hea
the heat production to have been the same
( as w a s actually the case in the rabbit s of
retained would account for the pat holo gi cal increase
ture A t a later sta ge the discharge of heat rose
.

its production at the higher tempe rature .

In the state of le ssened heat el im ination

begi nning of most fevers l ie s the rea son for
hot applications so frequently advi se d in the s
of thi s w ork .

N e b e l t ha u ha s shown a fall in te
duction in a rabbit whose cord w a s
and seventh cervical vertebra and ,

under the se c ircumstances infection

had no influence on tempe rature or
ference i s that the febrile toxines
motor centers whose regul atory control i ,

experiment .

A kindred interp retation ma y be placed

of Me n de l se n who w a s unable to produce,

i n jections when the dog

w as unde r
mo rphine although such treatment
,

10 S i n f N ut i t i n p 255
c e ce o r o . . .
1 76

C lini ca l Anti p yresis

These variations are .

of theoretical interest H owever there i s a .

,

tion to be made of the si gns and symptoms

a ti on .

such a s the c
heat abstract
water The .

dition which absolutel y contra indicates -

applications and in many cases even the short

,

less preceded by hot application s I n case s of .

following signs indicate a great increase in heat p

l Full pul se and flushed face
. .

2 A hot dry skin

. .

A consideration of the se will at once reveal the

cold mitten fri ction would be i nappropriate s i nce ,

tendency to lower blood pre ssu re al so becau se the ,

stimulates heat production ; but the contact with col d

too brief duration to abstract much heat from the body .

would a hot application or a sweating tre atment b est

condition It i s necessary to abstract he at from the
.

some more or less prol onged cold appli cation .

O n the other hand the followi ng symptoms show a

,

decrease in heat el imi nation :

1 Cold skin whether dry or moist and clammy
.
, , .

2 Cyanosi s
. .

3 G oose flesh appearance

.
.

4 Chilly sensations
.
.

5 S hivering
.
.

Again consideration of these conditions reveals the f act

,

cold appl ications unle ss accompanied by vigorous friction

,
,

not even then in some cases will greatl y i nc re as ,

of the skin and the internal

the chilling In these case s hot appl ication
.
 TH E R A P E U TIC CL A SSI F I CA TION

shiveri ng Thi s is al so indi cated i n the fi rst stage of many

.

fevers where the chill has actuall y begun or where chill y se n

sa t i on s i ndicate i t s app roach In th is case the hot s w eati ng
.

treatment shoul d not be re peated at least not frequentl y as i t , ,

i s too weakening I t s fre quent repetiti on doe s not increase the

.

vital re sistance but rath er decreases it

,
It de crease s p hag oc y .

t osi s and the produ ction of antibodies Malaria i s an exception .

to the general rule of the use of hot treatment at the onset .

H e re it i s a detriment rather than a be nefit O n the othe r .

hand in acute nephriti s much sweating treatment should be

,

u sed al l throu gh the cou rse of the di seas e .

I n general then it may be said that l ong cold appl i cations

,

shou l d be u sed whe re great increase of heat produ ction i s the

ch ief cau se of feve r ; and hot appl i cations where the dec ide d
de crease of heat elimination i s a prime factor in the fever .

T ab l e of T h e ra p e u t i c C l a ss i fi c a ti on
G rou p A G r ou p B

Ful l pul se flushed face

, ,
Col d ski n wet or dry
, ,

hot dry ski n cyanos is goose flesh

, ,

shiveri ng
Chi ef con di G reat increase in heat A decided decrease i n
ti on p r ese n t produ cti on heat el i mination
I n di ca ti ons A bstract heat by long Warm the skin combat ,

contact w ith cold internal conge stion

T r ea tm e nt Long cold appl i cations H ot ap pl icat ions u nti l
blood i s brought ba ck
to skin
The fol lowing li sts of hot and of cold treatments are those that
are most u sefu l in fevers When prope rl y sele cte d and su ited
.

to the i ndividual case the col d treatments meet the fi rst i ndi
,

cation and the hot treatments the second indi cation .

Cold appli cations useful in febri le conditions :

1 B rand bath
. .

2 G radu ate d bath w ith friction

. .

3 Tepid or cool bath

. .

4 E vaporating wet sheet pack

. .

5 Cold towel ru b
. .

1 2
1 78 FE VE R A N D A N TIP YR E TI C
6 I ce rub
. .

7 Cold sponging
. .

8 Cold aff usions

. .

9 Cold to head and neck

. .

1 0 I ce bag or cold compre ss to heart

. .

1 1 Cold compress to abdomen

. .

1 2 Cold water coils to head and abdomen

.

1 3 Cold rectal i rrigation e r enema

. .

1 4 Cold wate r dri nking

. .

1 5 Fre sh cold air in the sick room

. .

H o t applications which may be u se d to

the cold appl ications :
1 H ot blanket pack
. .

2 H ot bath ( ve ry short )
. .

3 H ot evaporating sheet
. .

F~ H ot s p onging .

Fomenta tions to spine

I
I
C .

\
O Fomenta tions to abdomen .

H ot water drinking
I

\ .

8 Cold mitten friction ( re ac tion simulate s

.

hot appl ication ) .

1 80 TR E A TME N T O F F E VE R S

act directl y upon the bacteria ; sec

emia by increasing the oxidation
hastening the ir el imination in an
The body poisons the leu comaine
,

same way and by the same means .

obj ects to be attained i n the t re a t m

p e r at ure is only incidental
guide to the completeness 0
u se of m edicinal an
runs parallel with the accompli shment of the se e
With both qu inine and the coal tar produ cts ,

interfered with if not wholl y abol ished and

,

increased be cau se of a decrease i n the oxidation

of the poisons U nder the u se of h ydrothe rap y
.

ployed typhoid fever presents an

,

ture from that which w e have bee

t e r i st i c of this di sease The cold
.

the conditions and symptoms w h

The hea rt and ci rculat ion
nervou s system i s arou sed and the n ervou s sym p t
,

regarded as an invari abl e accompanime nt either ( 1 ,

or are mitigated in severity The emunctories are .

that elimination i s greatly increased .

Tre atm e n t
S ince the cold friction bath is the be st means
t y phoid ou r consideration of thi s di se a se w il l largel y
,
s

c ussi o n of the methods rationale and re sults 0

, ,

The original cold frict ion bath as devi sed by ,

i n the full immersion of the body i n water at a

not less than 6 5 F nor more th a n 7 0 F
°
.
0
.

Brand
skin surface
abdomen i s ,

of the fr ict i o
of chilliness
t a i ne d thu s
,
 T YP H OID FE VE R
by cont inue d shive ring and chatte r i ng of the teeth he
ca t e d ,

must at once be remove d from the bath The B rand bath i s to .

be repeated whenever the te mperatu re of the patient exceeds

0
or 1 0 3 F I n p ractice it has been fou nd that thi s means
.

every three or fou r hours .

A s to the appl iances ne ces sary it h a s been fou nd that some ,

form of portabl e bath i s most convenient O f these there are

—
.
,

two forms worthy of desc ription the bath tub on wheel s and ,

the bed tub The former ( P l a te V1 ) i s of ordinary bath tub

.

F ig . 48 . B u po
rr rt a bl b t h
e a . A —f
ra m e , —p
B c om lete .

constru cti on and su ffi ci ent in len g th to allow the full extens ion
of the pat ient while i mmersed i n the water and of such depth ,

that the patient i s cove red with water u p to the chin Thi s tub .

can be wh eele d to the si de of the bed being pl ace d a sufli c i e n t ,

di stance from the side of the bed to allow of two attendant s

re versing the patient in carrying hi m from the be d to the bath ,

or it may be place d close to the be d and the patient lowered

directl y into the tub by hand or by means of a special rai sing
and lowering device ( P l a te
’

The Bur r p ort ab l e b at h ( F ig i s p robabl y the best t ype

—
'

of the bed bath It cons ists of two pa rt s a l arge rubbe r she et

.
1 82

with rings near

and a light wooden crib capable of be ing folde d
bundle The rubbe r sheet i s fi rst slipped un der
'

brought up over the pillow be ing tucked alo ng ,

bod y . The frame is the n u nfol ded placed ,

patient so as to re st on the mattress su ,

pillow and rubbe r sheet The edges of

,
.

drawn up over the top rail and fastened to

rings When complete it i s c apable of h
.

gallons of water I t may be filled by ei ther

.

attached to a fauce t and emptied by a siphon

'

ment demands le ss moving of the patient than

of bath
There has recentl y been devised another type
the Coile bed bath ( P l a te VI I ) Thi s i s a col .

rubber sheeting the wall s of which cons ist of

,

posed pneumatic rings When deflated thi s .

the patient in the same manner as the rubber s

B urr bed tub It is then inflated by means of
.

pump and i s ready to receive the wate r It i s

, .

sleeve outlet a s shown in the illustration .

Before being i mmersed in the cold water ,

of the patient are bathed in ice water If the .

necessar y to provide an i nvalid ring for th e h

cu shion or water pillow should support the
patient s skin i s warm on ente ri ng the bath and
’

vigorou s and kept up du ring the entire period

there i s l ittle danger of ch illi ng or coll apse .

this should occur the patient mu st be immediate ]

,

placed in a dry blanket the surface ,

until the skin i s warm and reaction fu

p l aint of chilliness on the part of the
i ndication for removal from the bath .

flesh however nece ss itates re moval

, , .

be allowed to remain in the bath until

osis or any other decided symptom of
th e first week ye t th is method i s not appl ica ble t o those ca s es
,

w hich appl y for trea tment du ri ng the s econd or th i rd week ,

s i nce the y h ave al r ead y b e come so weakene d tha t the re i s not

suffi cient v ital ity to full y react t o so vi gorou s a m eans The .

B ran d ba t h i s al so c ontr ain di ca ted in case s o f much red u ced

vi tal ity from an y other cau se and in the ve ry young and i n the
,

a ged . I n regard to the u se of meas u res ot he r tha n the strict

B rand ba t h B uxba um i ncli nes to the view that the es senti al
featu re i s the o bta in i ng of the rea ctio n by sui ti ng th e t rea tment
to t he need s of the i ndi v idual ca se H e sa ys . I Vi th refe ren ce ,

t o the s pe c ial mea su re s to be empl o y ed the desi red r e sul t ca n ,

no dou bt be attai ned w i th t he most vari e d h ydr i a t i c proce du re s ,

provi ded the the rmic a nd m echani c al stimul ati o ns are graduat ed
i n a cc orda nce wi th the i n di ca ti o ns o f the in di vidual ca se .

H en ce the re c an be no i nvariable a nd exclu sive ro uti ne .

Wi th many pati en t s it i s bette r t o em pl o y a ba th at a hi gher

tempe rat ur e the g r adua te d ba th of Z ie mssen or t he w e t sh e et
,

pa ck cold spongi ng compre s ses etc A grad uate d ba th b e

—
.
, , ,
° °
gi ns at a te mpe ratu re of i e 3 . 5 l o we r t h an the bod y
.
,

tempe ratu re or even 90 or 9 5 F and conti nue s for half an

° °
.

hour or l o nge r du ring whi ch ti me the te m pe r atu re i s gra du

,

all y lowe red by t he addi ti o n of co ld wate r fri ction be ing e m ,

p l o y e d as soon as the pati ent compl a i ns of an y chill ine ss The .

° °
tempe ra ture ma y be dec reas ed to be twee n 7 0 an d 80 F
a cc ording t o the cond iti on of the pa tient This ba th i s j ust a s
.

e ff ect ive as the B rand ba th in the redu cti o n of the fever ; i n

.

fa ct it is a mistake t o su p pose that the colde r the bath the

, ,

grea ter i s the re du cti o n i n te m peratu re Thi s i s not the cas e . .

A h i ghe r te m pera tu re for a l o nger t im e may redu c e the fever

j u st as e ff ecti vely a s a l ower te m pe ratu re for a sho rt e r tim e .

The re is h oweve r this ve ry e ssenti al di ff e ren ce th at the stim

, , ,

ul a t i ng of the body fun c tio ns is gr eater in pro po rti o n to the

degree of cold With the gr aduated ba th as e ffi c ient and

.
,

thorough stimulati o n i s not obta i ne d as w ith the B rand ba th .

B ut on t he o ther hand be cau se of th is extr eme stimula ti o n

, ,

therm ogen esi s i s markedl y in c rea s ed and foll o wi ng the B rand ,

ba t h th e t em pe ratu re rap i dl y rega i ns i ts forme r height so tha t

. ,
1 84 TR E A TME N T OF F E VE R S

it i s necessary to repeat t
graduated bath in which the tempe ratu re of the
lowered below 85 F and especial ly when it i s
0

thirty minutes to an hour the temperature of t h ,

not so quickly regain its former height and the

be repeated so frequently .

O f other methods the following are u seful in

or where the i deal treatment can not be
1 .The Wet S heet P ack i s perhaps 1
patient than a cold bath Lie be rmei ster .

packs of ten m inutes duration each are

bath of ten minutes ; and Baruch that si x 5 ,

lent to a B rand bath The sheet should .

water or very cold water It i s appl ied .

and after the initial warm ing maintained at ,

stage being renewed by sprinkling of more c

,

sheet The rapidity of evaporation ma y be

.

ning .

2 T he Cold Towel Rub given with a towel well

.

very cold water i s an excellent substitute for the

pack The u se of the w e t sheet p a ck ne cessi tate s m
.

moving of the patient which i s not the ,

towel rub The wet towel may be appl ied

.

same part and even ice water used , .

3 The Ice Rub

. H A H are has employed. . .

good success A flat piece of ice i s wrappe d

.

gauze and by rapid movements di ff erent pa rts

,

gone over H e recommends thi s applicati on t

.

avoiding the extremitie s O thers however u t .

, ,

e ral measure in place of the cold bath .

4 Cold S ponging and Cold A ff u sions are of

.

age in those ca ses whe re the bath or pack

Cold a ff usions to the head are
in fact whenever ne rvous ,

5 The Cold A bdominal Compress is

.

should be kept i n place between othe

results from this are obtained when
placed over one layer of the compress .
1 86 TR E A TME N T OF F E VE R S -

disturb the patient If ke pt up long at

.

not be very cold but rather te p i d or coo l .

tage of stim ulating diuresi s and

toxines through the ab or p t i on
The se means e ff ectuall y
gene ral cutaneous stimul ation
or two tub baths dail y ,

in the afternoon This may be a

.

or a graduated bath Where tubs .

towel rub the ice rub or the evap

, ,

b used for the same purpose

e
In .

of methods appears to g ive the be s

H ot Tre atm e n t In those case s
.

osi s are produced by the cold bath

or i n wh ich this condition i s more
sary to tho
surface and e ff ectually reducing t h
before any cold application can be made with
these prel iminary hot treatment s one m ay u se
the hot pack the hot evaporati ng sheet or
,

according to the ci rcumstances and i ndications

aided b v hot water —
.

drinking Duri ng the col d .

wate r bottle s and spine bags shoul d be u sed to

warm and prevent chill ing The skin shou l d .

and the patient feel warm before any col d trea

The cold mitten friction and the cold towel
adjuncts to the hot applicat ion s since they i n ,

ing of the skin more than they

tions such as ice bags and i ce caps
, ,

head and over the carotids whenever any

tions are made These help to prevent a
.

while the patient i s being prepared by

order to react to the succeeding cold .

The D i ag nos ti c Ba th .

bath a ce rtain value as

ing the first week of
method : When the re
other symptoms i ndi cat
 PL A T E V II . T he C oi le b ed b th
a .

PL A T E V I I I A u t h
.
'

or s met h d
o o f cont i n uo us c o o l i n g i n t y ph i d f v
o e er .
1 88 TR E A TME N T OF F E VE R S

2 . The Ci r cu l a tory Sy ste mfailure . H eart

have been taught to ascribe all the failu res
and it is toward the hea rt mu scle that man
designed to a ct upon the c i r cul
has re sulted in the deluging o
di gi tal is and the like and the
, ,

been compelled to do doubl e se rvi ce to

idea i s almost wholl y e rroneous has been q u ite fu ll y
in the previ ou s chapte r .

Rombe rg and F assler have shown that the chi e f

the ci rcu lation i n i nfectious di seases comes throu g h .

and derangement of the v asom oto r s and i s ,

damage to the hea r t it self F assle r fu rthe r

’

derangement i s caused by loss of the control

.

vasomotor centers in the medulla and s

vasomotor nerves and th
e ff ects are still possi ble The .

an absence of the natural phys

t a i ne d by the proper tone of
the loss of the rhythmic a ction
very aptl y co m pare s the heart
tory system respectivel y to a locomotive
o ff ered to its driving wheels H e says .
,

intended to meet and stand any re si stance ,

i s removed by sli ppe ry rail s the wheel s fly ,

racking the machinery and de stroying its .

the above some i mportant dia gn osti c and t he ra p e

,

learned : ( 1 ) that a rapid pul se may be d uein no

ordered heart but to vasom otor relaxation ; ( 2 ) that the p ro
,

per w a y to treat thi s rapid pul se i s to put sand on the track and
increase the resi stance and not to make more steam or give —
—
«
,

digitali s which only cau se the e ngine or hea rt to work aw ay , ,

o n sl ippery rail s with more wear and tear and make no pro ,
”
gress .
That thi s wear and tear may be considerable and
result i n a weaker and more rapid pul se any one may observ e ,

w ho will after 1 60 grain of strychnine has be en administered

,
-

to a typhoid patient every three hou rs for a week or more di s ,

continue the drug recording the bl ood pre ssu re before and afte r
,
 TYPH 01 D FE VE R
di scontinuance of the strychnin e by means of some accurate
blood p re ssu re instrume nt Indeed the change for the bette r .

i s so marked that i t can be very readil y appreciated by the

finger wi thou t othe r ai d I n one case th at came under the .

au thor s observation this w as so m arked and appeare d so

’

promptl y that i t w as obse r ved at once b v both the day and

,

the night nurses .

The cold fri ction bath meets the i ndicat ion p re se nte d by the
deranged v asom ot or s more full y than i s poss ible wi th any other
means It st imul ate s the blood ve ssel s to normal rhythm ic
.
-

action and rel ieve s the heart of the exces sive burden im posed
u pon i t by the ir failure I n typhoi d fever the blood i s very
.
,

much re du ce d i n qu al ity The re d cell s and hemoglobi n are .

decreased the l atter to a greater extent than the former espe

, ,

c i all y du ring conval e scence The re i s a decided l eu copenia .

,

the white cell s be i ng decreas ed in nu mbe r one third or even -

more than one hal f The bl ood i s laden with acid poi sons and
-
.

i s therefore redu ce d in alkal init y ( Bi r e g e r )

, ,
The a mou nt of .

toxic extract ive s i n the blood has bee n shown by Robin to be

doubled or treble d in case of feve rs We have alread y qu ite .

extensivel y di scu ssed the e ff ect of the cold bath on the com
posit ion of the blood S uffi ce it to sa y that observations made
.

by S tras ser B reitenste in Baru ch and others p rove conclu sivel y

, ,

that i n t yphoi d fever every constituent of the blood is favor

, ,

abl y influenced by the col d fri ct ion The re d cell s in the pe ri .

p he r a l ci rculation are greatl y i ncrease d the white cell s i n ,

crease d as h igh a s two or threefold the alkalinity i s re stored ,

and aci d produ cts decreased B ecau se of these normal nutri .

,

t r i v e change s proceed more promptl y .

3 . The K i dney s E li mi nat ion i n febril e conditions is very

.

defecti ve The quantity of urine i s decrease d and while there

.
,

may be an increase i n the soli d consti tuents i t i s s till qu ite ,

insu ffi cient to prevent the accumul ation of toxi c wastes i n the
blood and tissue s Du ring convale sce n ce the sol ids of the u rine
.
,

increase from 1 0 to 2 0 per ce n t or more over the amount , ,

excreted du r ing the febril e period The poisonous wastes are .

more insoluble than those of l ittle or no t oxicit y and so requ ire

—
a larger quantity of the solvent water for their effi cient el im —
i n a t i on .
1 90 TR E A TME N T OF FE VE R S

The
so lvent i s inc rea s ed ,

But th is alone doe s ,

toxicity of the u rine

poisons of the u ri ne
amount Roq ue ,

the cold ba th Bouchard also fou nd the tox i

.

u rine g reatl y i n crea sed by the cold bath .

found the urea in c reased to 2 0 pe r cent .

anti pyretic drugs dim i nish the excretion of

The liver in those ca se s
is said to be heavie r than the l i ve r of thos
bath treatment These dru gs pr odu ce
.

ch a nges in the liver and kidneys .

The re spi ratory el imination of C 0 2 and

decreased in feve rs the amount of t h ,

invers proporti on to the severity of

e

course to the le ssened ca pacity of

,

oxygen Both oxygen absorption a

.

tion are enhanced by the cold bath .

approximating 2 0 to 3 0
t y phoid fever That all these results are
.

a rgument The re i s no organ tissue or

.
, ,

ably influenced b y the hy dr ia t i c t r e a t m e n

Because of the maintenance of the vital
elimination of toxines d
is much shortened when

C ontrain di ca ti ons
P neu mo n i a The cold bath i s contra indi ca ted
.

of the loba r type The cas e shoul d be treate d as

.

as simple pneu m on ia alone would be trea ted .

co ld compres ses alte rnate hot and cold

,

pack to the che st and such means are ,

pneu m onia a r i s s as a compl icat ion and

e

the sa me ma nner as i s ordi na ry pneu

1 92 TR E A TME N T OF F E VE R S
di scontinued the patient be ing treated by
,

to control the shock so that ope ration ma ,

possible . I f pe ri toniti s su pe rvenes i t ,

objective point .

The reduction in mortality from typhoi d

tion of the cold bath has
tality from hemorrha g e
the mortality from the s e
tion of the Brand bath i s
from all other cause s
per cent and in spite of no c
,

conditions the re w a s a total d

,

pe r cent .

Adens tr ua ti on The mense s

.

febrile conditions , bu t case s in which

been successfully treated by cold baths ;
ment case s of pre gnancy complicat e d
, ,

carried to a succe ssful i ssue .

Ty mpa n i tes The cold bath g reatl y

.

The continuous use of the ice wate r coil ,

or two b v fomentations gi ves great re ,

turpentine enema should not be om itted

means are needed The plain col d enema or
.

i rrigation are al so ve ry u seful in t ympanite s .

Mortality an d Stat isti cs

Mode rn method s in the rational treatment
accompl ished few more st ri
ing the h ydri at i c treatment
mortality compare
small pox since the introdu ct ion of
diphtheria since the employment of
lactic use of antityphoid vac ci nation
fail ing means of preventing la rge e p
army practice and even in hospital s It i s to b e .

will al so show itself of m ate rial hel p in t reatment

the seve rity of the attack .

3 B i b
rs H o p i t l Q u n l n d 1 882—
a ne s a . 1 896
ee s a . .
 T Y P H O]D FE VE R
U nder the ordina ry expectant plan with admi ni stration of
medic inal anti pyreti cs stati sti cs from G e rman y show among
, ,

case s a mortality of
,
per cent In another collee .

tion of case s there was a mortality of

,
per cent .

In stil l another collection of case s there w as a mortal ity ,

of per cent .

In one divison of the G erman army during seventeen years ,

among 1 9 7 0 cases the morta l it y was

,
per cent I n the .

E ngli sh arm y for six years ending with 1 87 7 ,

the re w a s a ,

mortal ity from typhoid of 3 2 per ce nt I n recent years Dela .

,

field shows a mortali ty of 2 6 per cent from the N ew Y ork hos

p i ta l s. A n d throughout A merican citie s the mortal it y from ,

typ hoi d fever i s claimed to be from 2 5 to 4 0 per ce nt I n th e .

t y phoid wards of the J ohns H opki ns H ospital du r ing the first ten ,

years nine of w hich i s s ince the introduction of h ydrotherap y

, ,

O sler report s among 82 9 case s a mortal ity of per cent

, .

During the first year of thi s t ime the cases were treated by the ,

ordinary expe ctant plan and moreover thi s seri es i ncl ude s all
, ,

case s ad mitted those dying withi n one or two days and those
,

diagnose d at autopsy From the B ri sbane H ospital H are r e

.
,

ports a typhoid mortality of per cent p re viou s to the intro

du ction of hydrotherap y and per cent si nce i t s employment .

In 1 887 B rand gathered statistics of cases showing ,

under all forms of hy dr i at i c treatment a redu ction i n mortal it y ,

from per cent to pe r cent I n another series of ca se s .

colle cte d by B ra nd and enl arge d by B aru ch in whi ch the strict ,

cold bath treat ment w a s u sed B a ru ch clai ms a redu ction of

,

mortal it y to per cent .

In the divison of the G erman a r m y abo ve refe rre d to the ,

mortalit y u nder th e stri ct B rand syste m w a s reduce d from

per cent to per cent B aruch further claims that among
.

1 2 2 3 cases treate d onl y by apostles of the B rand system there ,

was a re du ction i n mortal it y to 1 per cent ( twelve cases ) and

“
that n ot one of the se twel ve dea ths occur r ed i n a ny case tha t ca m e
”
un der tr ea tm e n t bef or e the fif th day .

Contra ry to what might be expected the mortalit y i s less i n ,

p rivate p racti ce than i n hospitals This i s doubtless becau se .

the cases come u nder observation at once and ca n be treated

1 3
from the be ginning The same is true of .

p i ta l s where all indi spos itions are at once

medical o ffi ce r .

The stati stics gathered by B aru ch relat ive 4

from typhoid feve r under the varying methods

tensive on record The redu ction in mortali ty
.

upon ( 1 ) the st rict employment of

bath me thod where cases come under
day ; ( 2 ) the di scarding of all medicinal
c io u s employment of various forms of hy

can not be treated from the beginni ng ; ( 4 ) private

M A L A RI A
infectiou s nat ure
H
S ince this di sease i s of an ,

the malarial plasmodium treatment must ,

the destruction of th e parasite Thi s may

—
.

either of two ways fi rst by t h , ,

second by the ph agocytic action of t

,

qu inine doe s kill the parasite and the

one can di spute B ut that it also fail s o
.

t he larger numbe r of chronic cases

cases i s al so indisputable be ing w i t ne
, ,

a l l practitioners whose practice brings them in

disease The last word concerning malaria

.

spoken It would seem that giving qu inine i

.

which has not previou sly been taking a course

ad m i n st e r e d that the re i s a

v io u s to sporu lation which

no more being given until

p e c t e d paroxysm i s produ c ,

fails in the e stivo autumnal -

the above p rogram can

It has also been shown that
fails altogether where it has
some time as a prophylactic
4 B a ru c —
h P
ri n ci pl e s a nd P ra ct i c e o f
,

H yd ro t h e ra py p
. . 20 2 .
1 96 TR E A TME N T OF FE VE R S

was deemed necessary to get the men out of the trop ics as se v ,

eral cases of a perniciou s type and two of blackwate r feve r had

appeared A ccordingl y the shi p sailed for B oston J ul y 1 6
.
.

N otwithstanding the prophylactic u se of qu ini ne u nder ,

military observation for those who we re not cinchonized there , ,

were 2 1 5 acute malarial paroxysm s among 2 9 8 men du ring the

five days trip from S an J uan to B oston A bout 1 0 0 men of the
’
.

original 3 9 8 h ad been transferred to other sh ip s and stations

prior to the sailing of the Colu mbia for B oston The character
—
.

of the paroxysms was atyp ical there was no frank chill Th e .

men would feel fai rl y well until shortl y before an attack the y ,

would then complain of chill iness and weakne ss and ei the r li e

down or fall down in a heap on deck P assed A ssi stant S urgeon .

Butler U S N state s in a report that whe n the men arrived

, . . .
, ,

at Boston so man y were anemic and weak that they were u nfit t o
return to the tropics Doctor Butler al so noted the fact that .

these cases did not seem to respond at all satisfactoril y to q ui

nine even when given hypodermaticall y B efore the case s b e .

came so numerous bloo d examin at ions were made and the f orm ,

of malaria w a s considered to be c hi e fl v terti an The cli nical .

features however woul d i ndi cate that there was e sti vo autumnal
, ,
-

infection in many of the cases .

I n considering the experience of the se marine s who were

given prophylactic I might even say cu rative dose s of quinine , ,

du ring a period j ust exceeding a month and when thi s w a s di s ,

continued du ring the days of July 7 8 9 and 1 0 showed an , , , ,

extensive malarial morbidity the que stion natu rally present s ,

itself as to the explanation of thi s Furtherm ore we mu st not e .

,

the fact that resumption of quinine prophylaxis at th i s time i n

those not cinchonized ap parentl y had l ittle effect i n che cking
the outbreak and that when quinine w a s a dm i n st e r e d in cura
,

tive dose s at time s hypodermaticall y it did not seem to con

,
,

trol infection as i s u sual It i s common experience that mal .

aria responds readily and promptl y to qu inine prope rly admin

i st e r e d I can not but believe that malarial parasite s may de
.

ve l o p a r e i s t a n ce to qu ini ne .

( C

Br ow m ng r e po r t m g recent work i n E hr h c h s laboratory

o

’
,
,

state s that when m 1 e e infected with trypanosomes we re not given

 MA L A R IA

su ffi c e n tdoses to destroy the fl ag e l l at e s the se protozoa devel ,

oped a re sistance to the therapeu ti c age nt duri ng the t ime their

developme nt was held i n abeyance A most startling di scovery .

w a s too that these trypanosome s retained their chemo resi st

, ,
.
-

ance through nu mbe rle s s generations A fter passage during a .

pe riod of fou rteen months through 1 4 4 m ice the se last genera ,

tions of trypanosome s still retaine d thei r i mmu nit y to the 5x c i t

i ng drug B rowning experi mented with atoxyl p ar a fu chsi n
.
, ,

and trypan bl ue E xpe ri ments with parameciu m have al so

.

shown th at these ciliate s may de velop marked res istance to

agents prima ril y toxic to them .

While not commonl y m et with in subtropi cal countrie s it i s ,

poss i bl e for the bod y to acqu ire immunit y to mala ria Thi s i s .

manife st i n numerou s dark sk inned races In regard to the -

.

action of qu inine in preventing the acqui sition of immuni ty the ,

6
following from H T B rook s i s pa rti cularl y significant :
. . F or
a cqu i s i ti on o f thi s i m m un i ty however , ,
i t is necessa ry tha t the n a t
u r a l cou r se of the di sea se r em a i n u n i n te r r up te d by a dm i n i s tr a ti on

f
o q u i n i ne , i n or der tha t the n a tu r a l i m m u n i z i ng p r ocesse s m ay
com p l e te ly ta he p l a ce i n R Koch has demonstrated
the bl ood . .

that i n all localities where the adult natives are so to speak , ,

i mmune to malari a the ch ildren inva riabl y are attacked by the

,

di sease The y i nvariabl y pass through febrile attacks and

.
_

always have mal arial parasites i n th e blood often abu ndantl y , .

The natives knowneither qu i nine nor any similarl y acting drug

for controlling the malady They allow i t to take its course .
,

and nu merou s children die o f the di sease ; those who su rvi ve ,

however are i mmune for the rest of the ir l ive s that i s in spite
, , ,

of the sting of infected anophel es the y no longer o ff er a good ,

soil for the ma l arial pl asmodia and hence the latter are i n c ap ,

able of developmen t i n their blood .

7
The experiments of B as s an d Johns in the cu ltivation of
m alarial plasmodia i n v i tr o have brought ou t some very inter
e sting and i mportant facts relative to the mechanism of p rot e c
tion i n malarial infection From the report of this work w e .

quote the following

6 G n e l nd S p i l P th l g y 1 91 2 p 41 1
e ra a ec a a o o

C ltiv ti
, . . .

7 Th e f M l i ] Pl
u a m di
on o ( p l m d i m v i v x nd p l m di um f l i
a ar a as o a as o u a a as o a c
p m ) i n Vi t J
a ru l f E xp i m n t l M di i
ro , o u rn a V l XVI N
o 4 1 91 2
er e a e c ne , o .
, o .
, .
1 98 TR E A TME N T OF F E VERS

The parasites have be en grown i n the prese nce of red bl ood

cells onl y We have not seen an y evide nce that the y can be
.

grown independentl y of the se cell s A s al re ady stated they .

,

can not live for even a few minute s free i n the serum S eru m .

inactivated of i t s complement i s le ss de st ructive but the plas ,

modia can not l ive i n it for any considerable length of t ime .

Whe ii cultures are prepared according to the technique described

for the cultivation of one generat ion onl y the leucocyte s m i ,

grate more or le ss toward the surface and soon be come actu all y
concentrated in the layer in which the parasites grow Leu co .

cytes do not phagocyti z e parasite s a s long as the y are i nside of

the red blood cell s but a s soon as segmentation take s p fac e
,

and the capsule of the red cell s ruptures l iberating mero z oites , ,

the latter are promptl y engulfed I n fact it i s not u ncom mon

.
,

to se e a leucocyte that has phagocyti z ed one or more full

rosettes . This probabl y occu rs afte r the paras ite has dige sted
the capsule or othe rwi se made a small opening through it ,

whereb y it is conve rted into a foreign body which t he l e uc oc yt e s

try to remove Dead parasites i n red blood cell s are al so
.

phagocytized providing the enveloping cel l substance i s su hi

,

c i e n t l y permeable P arasites phagocyti z ed are soon kill ed and

.

finally digested A s a result of this phagocytosi s fe w if any

.
,

parasites in such a culture escape to develop a second gene ra

”
tion . I f more than one generat ion of plasmodia i s to be
cultivated it i s necessary to remove the leu cocyte s when the
,

culture i s made i n order to avoi d de struction of the parasite s

”
b v them at the ti me of se gm entation
’

It i s thu s ampl y demonstrated that t he phagocyte s and the

protective substances of the serum are highl y destru ctive to the
paras ites .
For the natu ral protection of the bod y against
malarial parasite s it i s therefore ne ce ssary to increase the
, ,

number and activity of the phagocytes and stimulate the pro

duction of chemical l ysins .

It is a well known fact that while quinine kill s the plasmo

d i um it also kill s the white bl ood cell
, I n fact the two are .

quite similar bits of protoplasm manifesting qu ite s im il ar ac t i v i

ties The white blood cell s a cquire l ittle or no resi stance to it
.
.

If they are not de stroyed the y are for the ti me being paral yzed
,
-
£200 TR E A TME N T OF F E VE R
'
S

sweating i s wel l e stabl ished li ttle attention bei ng given to the ,

frequent and systemati c u se of cold frictions a ff u sions douche s , , ,

etc The sweati ng combats nothing but the e ff ects of the chill ;
.

it i n no way removes the cause au gment s the vital re si sta nce , ,

or restores the blood to that condition in which it i s be st abl e

to combat i nfe ction O n the contrary if at al l prolonged the
.
, ,

re sistance i s le ssened Q u inine the malarial toxine and l ong

.
, ,

hot treatments all lessen the nu mber of leu cocyte s driving

, ,

9
them into the viscera where the y stagnate .

N earl y all who employ hydrotherapy in an y regular manner

have witne ssed the beneficial results that may be obtained in
the treatment of chr on i c m alaria The general plan to be fol .

lowed is that of some syste m atic regime of tonic measure s care ,

fully graduated and suited to th e n eeds of the indi vidual case .

We have seen chronic case s i n wh ich 3 0 grains of quinine

'

administered daily had failed to c heck the feve r brought t o a ,

successful issue by the regular u se of the cold m itte n friction

and al ternate hot and cold applications .

The plan followed by Fleu ry in the treatment of over 1 00

case s of malari a in the German colonie s i n A frica i s worthy of
imitation O ne or two hours previou s to the expected par
he administe red douche s at 5 5 —6 0 F From h i s
.

o x ys m
° °
, .

experience there he conclude s that i n chroni c case s of inter

,

mittent mala r i al fever with cachexi a anemia rel ap se s etc , , ,

cold douches ar e a l w ay s to be preferred to qu ini ne also that in ,

acute intermittent fever it may be u sed i ns tea d of quinine .

These conclusions were confi rmed at the mil itary hospital at

B ru sse l s by the i nvestigations of a Royal Belgian Commis sion
S trasser Fi sher Fodor and others have reporte d cases su c
, , ,

cc s sfull y treated by col d applications H F Rand formerl y . . .

,

professor of physiologic therapeutics i n the U niversity of Colo

rado has successfully treated cases by the u se of the cold
,

mitten friction cold towel r ub and the col d half bath with
, ,

friction H e begins a number of hours before the chill i s du e

.
.

H e reports a case of chroni cmalaria in which no chill appeared

9
I n t he
fi
rs t a t t a c
k b v
a s ol u t e a n d r e l a t i e l e u o k p
e ni a is o s e r e v d h h
w ic b
is d u e t o t he
L 0 1 1 e e t i on o f t he w
h v
i t e c e l l s m t h e l i e r a nd s l e e n p
t o t he d
e st r uc t i o n of t h e ph g
a nd h x
i n c ac e i a t o l e si o ns o f t h e b l o 0 d m a i
k g
.

g Ed d P
a oc y t e s
M d
.

p n war 5 ra c t i ce o f
. ,
or ans e i
c i ne 1 907
.

. , 1 13, .
 MAL A R IA

after the beginning of the treatment A t the end of a week .

the blood w a s free from plasmodia .

A s i n other fe ve rs the rationale of these measu res i s not

,

di ffi cult of explanation I t has been shown by Mar ag l i ano that

.
10

c ontraction of the surface ve ssels in mal a ri a begins two hours

before the temperat ure begins to ri se and about three hours
before the paroxysm ( F ig The skin vessel s continue to
.

F i g 49 .Ch h
a r t s o wi n
f v
g
h q
v
t h e c a u sa t i e r e l a t i o n o f e ri
d
p ph l — e ra v a soc o n

g ph T —t m p
s t ri c t i o n t o t h e e e r a n d c i l l i n u ot i i a n m a l a ri a P t t f p s a e o en
b dv h p h
.

p h e ra l l oo -
e ss e l s a s s o w n b y t h e l e t y s m o ra , e e ra
t u re . ( Ma ra g l i a n o )

contract and the fever reache s the highest point when the
,

ves sel s are i n a state of maxi mum constriction Du ri ng the .

sweating stage the ve ssel s dilate and when maximu m dilata ,

tion i s reache d the temperature retu rn s to normal During the .

two hours refe rred to the constriction of the skin ves sel s and
,

”
anemia of the skin becomes well fixed so that a severe pro
‘

l onge d chill i s provided for A t th e sa m e ti me there i s an

‘

enormou s rete ntion of heat due to the failure in heat elimina

1 0 Pl t hy m g
e ph xp i m n t—q t d f m B xb u m —L h b h d H y d t h
s o ra e er e uo e ro u a e r uc er ro e ra
p i e . 1 90 3
2 02 TR E A TME N T OF F E VE R S

tion The internal congestion i s intense U nde r the se circum

.
.

stances the cold percussi on or friction has a doubl e e ffe ct .

First by the production of circulatory reacti on the spasm of the

,

peripheral vessel s i s relieved and the internal congestion give s

way because of an equ alization of the circu lation The ch ill i s .

”
thu s aborted S econd the leu cocyte s are
.
,
mobil ize d and
phagocytosis encou raged In malaria the leu cocyte s forsa ke
.

t he peripheral circulation and accu mulate i n the viscera es pe ,

c i a l l y the spleen E xperi ments with the oncometer show that

.

cold applications cau se contraction of thi s organ This act ion .

,

together with the stimulation of the v asom ot or s of the pe ri

p he r a l ve ssels serve s to di st ri bute and energize thi s va st army
,

of phagocyte s B esides the mobilization of the phagocyte s

.
,

vi sceral globular stasis of the red cell s i s prevented It i s .

believed by Bass and J ohns that for m alari al parasite s to pass

from red cell to re d cell these mu st be in ac t ual conta ct wi th
,

each other in order that the parasite escape the de structive

action of the s erum in which they can not li ve for eve n a few
minutes Their conclu sion i s thi s :
. From our obse rvations
of malarial plasmodia growi ng i n oi tr o we believe that i n v i vo ,

they can pass from cell to cell onl y when a cell i s in direct con
tact with another cell contai ning a segmenting parasite and then ,

onl y when the opening for the exit of mero z oites occu rs oppo
”
site the cell to b e infe cted .

If this conclu sion be t ru e such re infection of re d cells would

‘

be greatl y favored by the globular stasi s which occu rs at the

time of the chill O n the other hand it would be very greatl y
.
,

hindered by an active vi sceral and pe rip heral circulation in

which condition the maj orit y of the young parasi te s would for
a long time be exposed to the de stru cti ve action of the seru m
and would be readil y phagocyti z e d by the leu cocyte s .

H otapplications be ginning j ust before the onset of the chill

,
,

would serve to d ilate the periphe ral ve ssels and so counteract

the vasoconst ri ction for the time being B ut su ch i ntense and -
.

prolonged heat has no tendency to combat the cau se i e i t doe s , . .

,

not produ ce mobilization of the leucocytes nor cause them to

destroy the parasite s O n the contrary it has the opposite
.
2 04 TR E A TM E N T OF F E VE R S
ment of a cold application combined with powerful thermi c ,

stimulation The form of the application is a matter of i nd i f

.

ference The most i mportant requirement however i s the

. , ,

production of a good reaction When th is fail s to take place .

,

success will be wanting With the powerful stimul ating pro .

ce d u re which may be chosen a c cording to personal preference

, ,

a fan douche to the region of the spleen may s erviceabl y be

conjoined The princi pal objects of the therapeuti st s attention
.
’

are the proper selection of the ti me and th e produ ction of a ,

The shorter the i nte rval between the procedur e

'

g ood r ea cti on .

and the anticipated ch ill the more certain the re sul t With ,
.

regard to the procedures to be employed the y consi st i n cold ,

vi gorous shower baths a cold rub in cou rse sheets in combina ,

tion wi th sheet bath s ; col d sitz baths of te n minute s duration ; ’

cold full baths ; plunge baths and other su itable measu re s The .

treatment should be continued u ntil the constitution of the

blood the dige stion and circulation are restored to normal
, ,

b r i e fl y until e v e r y si g n of cachexia has di sappeared

'

, .

A c c ordi n g to S trasser the ej ect of hy d r i a t i c procedure s i s

’

to be attri bu ted to the fact that shortly before the attack the
infected erythrocytes disintegrate unde r the influence of the
powerful stimulation of cold so that the plasmodia thu s set free ,

”
are destroyed by the P hagocyte s .
12

ME AS L E S
Measles is an acute contagious febrile d i sease characte rized , ,

by a blotchy exanthem and accompanie d by coryza It i s .

u suall y uneventful i n its course and not accompanied by an y

great mortality H oweve r the patient may be made much
.
,

more comfortable during the febrile period and the vital re si st ,

ance so su stained that there i s les s tendency to b r on chop ne u

monia The eruption doe s not appear until the fou rth day so
.

the treatment must be begun before a positive diagnosis can be

made .

d th t qu n n h d
“

1 iS gg
t
n su e st e
m d
5 a i i e as o e
p n m l t b ing p i bl y t nd
'

1 D1 o
’ .

a a ri a
t th
as d
o ia, i s e ec e o ss o re er e re
p
0 t t ng t h p
211 91 53 um I f t h t m
ro e c i
p m b l t e
th ll u fli i n t d
a ra s i
t u tiv
e or e
i nfl u er ea e o e a s
‘
c e es r c e
1 3 1 e se rt u q u n n w uld
.
ff t n l y t h p
is is r
it e,
in t h i uli i e o a ec o e aras es e c rc a

Sg mggg
e
n n t t
h l dg d n
o ~
p ll ose w h h w ul d n t b
o e i h d b y t u nt l t h y
ca i a ri e s , ic o o e re a c e i i e
 I n th is di sease as well as in scarlet fever the firs t thing to
, ,

be accompl ished i s the rel ieving of the internal congestion

occasioned by the infective proces s I f the case i s untreated .
,

the vi s ceral conges tion i s consi de rabl y lessened on the appear

ance of the eruption The ol d idea t hat measle s is much more
.

seriou s if th e eruptio n strikes in or doe s not appear frankl y , ,

i s not wholl y without foun dation A t the time the eru ption .

makes i ts appearance the skin become s markedl y conge sted and

this serves to at least partiall y rel ieve the vi sceral conge stion
, , .

A treatment which most e ffi cientl y rel ieve s the i nternal con

ge sti on i s al so condu cive to the speed y a ppeara nce of the ra sh .

I n our pract ice we have seen thi s be st accom pl ishe d by means

of some hot sweating treatment e ithe r the hot pack or bath , ,

accompanie d by the drinking of some hot liqu id The head .

s houl d be kept cold by com pres se s or ice bags I n some cases .

,

where there i s not m uch chill ine ss sweating i s very wel l ,

accompl i she d by the u se of the w e t shee t pack prolonge d to ,

the sweating stage This draws the blood from the viscera and
.

congests the skin A t th e ter m inat ion of such a treatme nt the

.
,

case if one of measles w ill show the characteristi c dull red

, , ,
,

blotch y e ruption .

B aru ch re commends some form of col d treatment for the same

pu rpose and a s an antipyretic throughou t the febrile period .

H e p refers the gradu ate d bath or a warm bath i n whi ch the ,

patient s its whil e cold water i s poured over the chest and
shoul ders .The full expansion of the lungs occasioned by such
treatment aids in the pre ve nt ion of b r on chO p n e u m on i a Be .

cau se of the i rritabilit y of the skin it i s not be st to employ ,

friction during th e cold bath Cold a ff us ions to the head and

.

back of th e neck are usefu l i n rel ieving stupor del irium and
,
, ,

othe r ce rebral s ym ptoms We have fou nd the wet sheet pack

.
,

frequentl y renewe d by sprinkli ng col d water over i t an e xcel ,

lent means of re du cing the temperature and at the same time , ,

it provides agai nst chilli ness since be tween each renewal of

,

the pack i t warms u p and reaction i s completed Thi s m a y be

, .

°
repeated until the temperatu re has been reduced to 1 0 1 F or .
,

even less . The evaporati ng stage of the pack sh oul d last for a
greater leng th of time than the heat ing stage so that t he total ,

e ffect will be that of heat abstraction .

 TR E A TME N T

Br onchopne u m on i a Capillary .

and fatal of the complication s

measles In thi s disease there i
.

tion of the
de nc e d by
condition of
thi s i s not an
morta lity I n the treatment
.

ing measles we employ the same methods

,

ment of thi s di sease when occu rring alone .

be placed at interval s of abou t three hou rs

, ,

When suffi ciently warm le t the child s ,

aff u sions be
water for the a ff usion may be
This vigorou s means pr
ation which i s fol lowed for a
,

pi rations of greater depth I t facilitates .

A nother treatment that has gi ven e

cold compress applied to the chest Thi s .

from ve ry cold water applied quickl y over,

chest allowed to remain for a very short ti me and

, ,

newed Thi s may be repeated from two to four ti me s

.

compress used being allowed to remain for thi rty

minutes The che st may be sl ap ped in rapid
.

cold wet towel s This of course shoul d not

.
, ,

temperatu re i s ver y high In the latter ca se .

wet sheet pack provide s for the re duct i on of

se rves to stimulate re spiration G .

g e n a t i o n of the blood are greatl y pro

increased and the hea rt strengt hened
, .

A mong other measure s that ma y be u se d

a r e cold sponging hot sponging and the col d towel rub
, , .

SCA RL E T F E VE R
Scarlat i na an a cute contagiou s feve r characteriz ed
IS
'

diff u se scarlet e ryt hema and accompanied

tonsillitis I t has a hi g he
.
208 TR E A TME N T OF FE VE R S

tendency to renal congestion and neph ritis Thi s latte r con .

dition i s t he most important compli cation of scarlet fever .

N ephr i ti s S hould this condition appear during the febrile

.

period it i s not ne cessa ry to stop all col d treatments but the

, ,

temperature should be somewhat moderated and the tim e

shortened S hort hot applications m ay be made so as to e n
.

hance the react ive ability and these immediatel y followe d by ,

such measu re s as cold affu sions col d sponging wet sheet pack , , ,

or the graduated bath In the case of the graduated bath the

.
,

initial heating may be ac compl i sh ed by be ginni ng the bath at

°
95 raisi ng the temperatu re a few degree s u nt il the
patient i s well warmed and then gradually cool ing t he bath t o
,

0
80 or Chill ine ss should not result from any tre atment ,

as this tends to increase the renal conge stion .

If the wet sheet pack i s u sed the sheet may be w r ung from ,

hot water and then mai ntained at the evaporati ng stage and
renewed by spri nkling col d water ove r the sheet Du ring all .
'

this time the drinking of large quantities of water should be

,

encouraged If the nephriti s shoul d make its first appearance

.

afte r or at the close of the febril e period it i s pe rhaps best to

, , ,

employ the means com monl y u sed i n treating nephriti s th at is , ,

diaphoreti c measu res The hot bath with ice to the head and
.

hea r t the hot blanket pack or partial hot appl ications such a s
, , ,

the hot foot bath accompanied by fomentations to the spine ,

chest or abdomen are al l u seful in produ ci ng sweati ng The

, , .

hot air bath m a y be admi ni stered i n b e d according to the plan

mentioned u nder acute neph riti s If the hot blanket pack i s .

u sed it may be very conveni entl y follow ed by the wet sheet

,

pack w ru ng from wate r at 7 5 and continued to the sweating

,
°

stage Reaction should ensue promptl y The ch il d may be

.
.

left in thi s pack an hour or two or until the sheet i s nearl y dry , .

The cold towel ru b and cold mitten frict ion may be u sed to
promote circulatory rea ction providing desquamati on has well ,

be gun It i s best not to employ the cold m itten friction should

.

the nephriti s occu r be fore the eruption subside s U nde r the se .

treatments the albumen gradually le ssens and casts disappear

,
'

from the urine S hould the re be edema about the fe e t and

.

ankles the alternate hot and cold foot or leg bath shoul d be
,
 IN F L UE N Z A

u se d and followed by centripetal massage To ai d de squ ama .

t ion and p revent spreading of the contagion the col d mitten ,

friction or salt gl ow may be u sed to hasten the removal of the

scal es
. E ither treatment should be fol lowe d by an oil rub to
pre vent fu rthe r rubbing off of the conta gi on ca rr ying ep i -

thel iu m .

E ndoca r a i ti s’
S h oul d thi s compli cation ari se all cold tu b
.
,

bath s should be di s continu ed al so col d a ff u sions

,
The patient .

mu st be kept at absolute re st w ith the i ce bag t o the heart

,

intermittentl y A fter the eruption has di sappeared there i s no

.
,

mea su re e qual to the cold mitte n friction i n a s si sting the ci re n

lat ion and rel ie vi ng the hea rt For fu rther treatment se e .
,

endocardit i s i n rheum atic feve r .

LA G RI P P E —IN F L UE N Z A
The cli nical conditi on i n i nfluen z a i s quite diff erent from that
of typhoid feve r I n thi s di sease the feve r i s of the short
.
, ,

h igh type with rapi d p ul se and high bl ood p res sure These
, .

are the manifestati ons that are found in you ng adults With .

older persons the di sease is qu ite l ikely to be accompanied by

,

considerab l e a sthenia the dige stive system and the ne rvou s

,

system beari ng the bru nt of the infecti ve proces s Wit h .

y ou nger persons the respiratory tract i s more l ikel y to be

aff ected .

S ince th i s i s a short sth eni c fever the treatment empl oyed ,

wil l di ffer cons iderabl y from that u sed in typhoid feve r A side .

from col d appl ications to the h ead it i s unnece ssa ry to employ ,

long cold treatment s for t he p u rpose of redu cing the feve r and
all generalized col d appl ications are contrai ndi cated With a n .

i ndividual that ha s been previ ou sl y strong and well and i s in

good fle sh it may be po ssibl e to treat the ca se from th e s ta rt
,

by vi gorou s cold appl i cati ons wi th friction Thi s enhance s the .

vi tal re sistanc e i ncre as es leucocyt osi s and so combats the in

,

fe ct i on in a very di rect manner .

With case s as the y u sually pre sent t hemselve s w e have ob ,

t ai n e d the be s t re sults by the u se of an i nitial sweating treat

ment su ch for example a s the hot l eg bath accompanied by
, ,

fomentations to the spine or to the chest and throat wi th cold ,

1 4
21 0 TR E A TME N T OF F E VE R S

compresses to the head and neck ( P l a te I X ) A t the same

. .

time the patient should dri nk several glas ses of hot l emonade
,
.

Chill iness i s soon overcome and the patient be gins to pe rspire

profu sely A s soon as profu se persp iration is wel l e stabl i shed
. ,

the patient may be given a graduate d shower be g inn ing at

about graduall y increas ing the te mpe rature to the l imit of
tole ration .Wh ile in the hot Spray the patient shoul d wear a
,

cold compress to the head A s soon a s he i s agai n well wa rmed

.
,

the tempe rature should very g radu all y be redu ced to Thi s
abstracts m uch of the heat that ha s been communi cated to the
body by the sweating treatment The patient shoul d now be
.

put to bed w ith hot water bo ttles to the fe et and allowed to

-

perspire gentl y for a number of hours .

G reat care must be take nthat the patient i s not overheated

by the sweat ing treatment si nce fainting i s quite l ikel y to
,

result unless the cold compre sse s to the head and neck are fr e
quentl y renewed I n some cases it i s necessary that the patient
.

be in a recumbent position whi le taking the treatment and for ,

thi s reason the horizontal ele ctri c l ight cabinet i s very service
,

abl e in securing free di aphoresis The u se of the upright

.

cabinet at the onset of l a grippe i s al most ce rtain to result in

fainting .

I n case thi s sweating treatment has been carrie d out i n the

evening on the following morning the patient should be treated
,

by preliminary hot appl ications for the pu rpose of relievi ng th e

aching of the back and limbs Thi s i s be st accompli she d by
.

the leg pack and large fomentations to the spine The y shoul d .

not be continued l ong and should be fol l owed im me diatel y by

a vigorous cold mitten friction From thi s poi nt on i t i s be st
.
,

to treat the case as far as possible with tonic measu re s such a s ,

the cold mitten fri ction cold towel rub or the hot and col d
, ,

douche to the spine a nd legs finishing with the alte rnating

,

douche to t he feet The sweati ng treatment should not be

.

repeated unle ss it seems qu ite necessary .

A n y plan of treatment may fail of i ts be st re sult s i n case the

bowel i s not thoroughly unloaded at the beginning Thi s may .

be be st accomp l ished by thorou gh e nemata S pecial complica .

tions requ ire attention outside of t he general plan of treating

influen z a . B ronchiti s and cou gh with pain in the che st
, ,

shoul d be tre ate d by large fomentations followed by the heat ,

ing che st pack .P har y ngiti s or tonsill iti s should be treated in

the same manner that is with fomentations and a col d heati ng
, ,

compre ss appl ied between treatme nts The ne rvou s s ymptoms

.

a re best met by the i ce cap or cold compre ss to the head The

, .

pai n ma y be very materi all y reli eved by the u se of very hot

fomentations . In all ca ses however the treatment sho u ld be
, ,

conclude d with a vigorous cold m itten fri ction It is not .

de si g ned that the cold fri ct ions shall m ate ri ally lower the tem
p e r a t u r e i n and of themselves that i s the fall i n tem p erature
, ,

d oe s not re sult immediatel y afte r the appli cat ion but rather ,

s u cceeds i n a few hou rs . If the temp erat ure i s very hi gh it ,

m ay be e ff e ctu all y combated by the u se of the ice bag to the

heart with i ce appl ications to the head B oth shoul d be con
.

tinne d with bu t l ittle interruption .

The asthenic t y pe of influ enza e xcept in ol d peopl e or c h ronic

,

invalids i s not now a s common a s during the pandemic of 1 889

,

and the years immediatel y following I n the event of severe .

a sthenia the treatment i s to be carri ed on along general l ine s

with speci al reference to those measure s which w ill su stai n the
heart and circulation . The treatment of respiratory or diges
tive compl ications dem ands special care and i s to be carried on
along l ines laid down el sewhere
'
.
 C H A PT E R X VII I

I N F L A M M AT I O N A N D

E FF E CT S

BE O R E consider i ng the conditions pre sent in

and their tr eatment it will
,

c i p l e s involved i n the

which are much u sed

shall therefore first tu rn
, ,

principles concerned in the producti on of de

D epl eti on i s the redu ct ion of congestion
organ .

D e r i va ti on i s depletion secu re d by
from an organ or part of the body by
blood in some other part . P r ac
cong es ti o n ( and i nflamma tion ) by drawing the

pa rt congested into some othe r pa rt The re i s

.

l a te r a l hy pe r e m i a with l oca l a ne m ia.

F l ux i on consists in increasing the rapidity of

rent in a particular part and conse quentl y t h
, ,

of blood pas sing through that pa r t in a gi ven time .

production of a r te r i a l hype r e m ia .

D E P L E TI O N —D E RIV A T I O N

There are three pra ct i cal methods of secu ri ng

fi rst by the appli cation of heat alone ; se cond by
,
,

tion of cold alone ; and thi rd by ,

cold appl ied simultaneou sl y T .

in a
 DEUULE TYOAJ
.

M ethod s of S ecu ring Depletion

W h e re P l ac ed M od e of A c ti o n
—
Collate ral ove r Derivation
part or at a ‘

di s
tance
P roximal or di
r e c t l y over part

H eat and Cold over pa rt Refle x

col d si m or p roximal
ultane H eat col late ral De rivation
o u sl y

Sim ulta n e o us H e at d C old

Depletion i s most e ff e ctuall y
an .

secu red by the s i m ultaneou s appli cation of both heat and cold
i n the fol low ing manner ( P l a te X A large ve ry hot applica
tion i s made to a di stant part ; i n many ca ses it extends u p to ,

and i nclude s the conge ste d part A t the same ti me a n ice bag .
,

i ce pack or ice compress i s place d directl y over the inflamed

,

organ . I n thi s way collateral h yperemi a is secure d and the

l ocal anemia reenforce d by the d irect or reflex v asoc on st ri c t
ing in fluence of the ice The local anemia i s m a d e e x t r e m e
.

”
by both a pu sh and a pull e ff ect on the circul ation the ,

pul l be ing secured by the vi s a f r on te of the hot appli cation ,

and the pu sh by the v i s a te rg o of the reflex contract ion of

the bl ood ve ssel s due to the col d appl ication over the part
-

,
.

The most e ff ect ive de ri vation i s se cu re d by di r ect contact of the

body w ith hot water A hot leg bath i s more e ff ective than a
.

hot leg pack and a hot leg pack w it h the wet blanket applied
,

directl y to the skin i s more e ffective than where a dry blanket

i ntervene s N either the local hot ai r bath or the local ele ct ri c
.

l ight bath ( or e ither as a general appl ication ) are a s e ff ective

as a hot pack or a local hot bath The reason for thi s di ff erence
i s found in the fact that the blood —
.

ve ssel s dilate to a mu ch
greater exte nt under the action of hot water appl ied directl y
to the skin s urface The hot ai r bath and the ele ctric l ight
.

bath may produce more profu se perspirati on but the bloo d ,

21 4 A N TIP H L O GIS TIC

vessel s do not dilate to the same

action of hot water H owever in .
,

tub bath and a hot blanket pack the ,

extreme in the former case a s to cau s

entered with congestion of the brain
,

general rise in blood p ressure For .

bath for ex tr e me derivation i s not a

in practice we u se the hot blanket
application of ice to the head and
if necessary .

The following are the principal derivative

.

i n the acute stage of the diseases mentioned

1 A p p E N D I CI T I s
. H ot h ip and leg pack .
,

the appendix .

2 P ER IT O N IT I S
. H ot hip and leg pack or
.
,

w ith ice compress or i ce bags to the abdomen .

3 P U E R P E RA L I N F E C T I O N A N D
.

hot blanket pack or hip and leg pack with , ,

4 A CU T E C O N G E S T I O N O F T H E LU N G S
. .

and leg pack or full blanket pack with or without

, ,

compress over the lobe a ff ected .

5 MEN I N G I T I S
. H ot leg pack with ice cravat ice
.
, ,

bag to the base of the brai n and the upper spine .

6 MA S T O ID I T I S
.
H ot leg bath with ice cravat
.

over carotid art ery i ce cap and fomentations to the , ,

7 A LV E O LA R A B S C ES S
. S ame as .

to the jaw .

8 A CU T E O S I E O M Y E L I T I S ( of t ibia )
.
’ ‘

F om e n tat i o .

leg pack w ith i ce ove r the fem oral artery

, .

9 C E R E B R A L CO NG E ST I O N H ot leg bath with

'

.
.

ice cap or cold compress to the entire face and cran

,

1 0 REN A L C O N G ES T I O N
.
Fomentations to back ; .

pack or full blanket pack with i ce bag ,

P r eca u ti ons :
In order to maintain
treatment mu st be conclu ded with su
ure a s a cold mit
21 6 A N TI P H L O GI S TI C E FFE C TS

ence almost specifi c In some c a se s of

,
.

ove r the carotids and cold appl ications to

all that i s needed In the earl y stage a.

by appl yi ng an i c e bag directly over the s

F L UX IO N
When hot and cold appl ications are u sed to
they are u sed s i m ul ta neousl y and
and cold are u sed a l te r na te ly and
fl ux i on Thi s may be e ither by
.

treated or by re flex act ion in a relate d part

,
.

intensified by friction or percussion .

A l l alternate hot and col d applications are toni

and generall y We ma y here for the sake of
.
,

brevity confine ou rselve s to the consideration

,

desired to produce chiefly violent circulatory

part or organ .

The following are the princi pal means u sed

fl ux i on

1 . A lternate
hot and cold u sing fomentations ,

fomentations and cold compre sse s ( revul si ve com

2 A lte rnate hot and cold douche s or spray s a s
.
,

legs l iver etc, , .

3 A lternate hot and col d pa cks

. .

4 A lternate hot and cold as to head or kidneys and

.
,

5 Revul sive or alternate hot and col d sitz bath

.
.

6 A lternate hot and cold foot or l eg bath

.
.

7 A lternate hot and cold immersi on a s of

.
,

8 A lternate hot and cold vaginal douche re

.
,

In all the above measure s

active ( a rteri al ) hyperemia The al te rnate d .

traction of the blood vessels i s stimulated -

.

known a s a cti ve di l a ta ti on The se alte rnating .

constricti on and vasodilatation are more rapi d

the normal They very markedl y increase the
.

bl ood cells i n a given part and cons ,

phagocytosis It i s thi s which makes

.

and almost
 F L UX I ON

mations su ch as an acute i nfection of a hand or a foot where

, ,

l ymphangit is and l ymphade nitis are likel y to follow so quickl y .

P erh aps the larges t fiel d for the u se of fl ux i on ( arterial hyper

emia ) i s in chroni c conge stions whether a seque l to ch ronic ,

i nfe cti ons or non i n fl am m at or y

-

I n these case s the congestion .

i s of a p ass ive type i e venou s stas is The treatment i s al so

, . .
, .

i ndicate d i n local ane mias .

B elow are given some of the more i m portant indicat ions for
the use of fl ux io n z
. 1 A cu te i nfections as of hand arm or foot
, , , .

. 2 Convalescence from al l local infections ( stage of pass ive or

venou s conge stion ) .

. 3 Chronic conge stion of l iver

. 4 Chronic pelv ic conge stion as of ute r us or adnexa whether , ,

s im ple or followin g infections .

. 5 U te ri ne su binvolution .

. 6 A menorrhea .

. 7 Myel it i s ( chroni c stage ) .

. 8 Locomotor ataxia and other paralyse s of spinal origin ( in

c hronic s tage ) .

. 9 A l coholi c neu ritis ( afte r acute stage ) .

1 0 Mu scular atrophie s
. .

1 1
. Tubercu lar arthriti s and synoviti s .

1 2
. Chronic osteomyel iti s .

1 3 V aricose ul cer
. .

P r eca u ti ons : I n acute infections massage e ff ects su ch as , ,

friction or percu ssion shou l d be avoided D ire e ff ects in the

, .

q u ick sp rea d of the bacte ri a to other parts wil l result if the se ,

a re u sed .

R ev ulsi o n . A ccording
to Dorl and thi s term i s synonomous ,

with deri vation and depletion Kellogg evidentl y u se s it to .

d e signate the mode of giving a hot and cold appl i cation the ,

chief e ff ect of which is fl u x i on for example a re vuls ive com

—
, ,

p res s a treatment consi sting of a s ingle prolonged hot a p p l i

cation foll owed by a s ingle very brief appl icat ion of cold
,
.

A gain it is u sed to de signate derivation secure d by collateral

fl u xi on as in the use of the hot and col d foot or leg bath or a
, ,
21 8 A N TIP H L OGIS TIC E FFE C TS
hot and col d percu ssion douche to the
cerebral conge stion Wh en hot and cold .

to one part of the body thu s p roducing ,

pa rts This diverse application of the te

.

confusion While the te rm can not be full y

.

the st ud e nt should bear in mind that the e ff e ct

de ri vation or fl uxi on
P ATH O GE N E SIS O F I N F L A MMA

Inflammation consi sts of the series of

the local manifestation of the attem pt a
refe rred inj ury to a part or brie fly it i s , , the

F ig 50 3 A — arte
A
ri ol e s a n d ca p ill i
a r e s , n or m al B —
t h e sa m e a ft er

od u c t i o n f i g n b od y b g i nni n g
.
,

i nt r o f a n i rri ta nt o re a nd t he e of i n fl am
m a ti on .

at repair of actual or referred inju ry I nfla mmatio n .

reaction of irritated and damaged ti ssues which st il l

”
v ital ity .

The pathologic conditions in an inflamm atory p rocess

—
partially unde rstood by the five card i nal symptoms vi z

—
.
, ,

Rubor redness

—
1 .
.

2 Tumor
. swelling .

3 Cal m
. heat .

4 D ol or p ai n
—
b
. .

5 .Functio l aes a loss of functi on .

The primary cause of the i n flammation what eve r i t ,

is res ponsible for these conditions which are largel y ,

-

tory disturbances The condition i n the a c ute

.

( 1 ) arte rial hyperemia ( F ig wi th ( 2 ) a

A d m i—
.

l a I n fl m m t i n pp 5 227
a a o , .
. .
220 A N TI P H L O GI S TI C E FFE C TS

I n ( 1 ) S timulate and qu icken the ciren

the Chr on i c S tag e .

lation by the prod uction of arteri al h yperem ia and ( 2 ) st i m u ,

late the process of phagocytosi s th us ( 3 ) promoting re solution ,

and absorption of t he exudate and thereby preventi ng it s

organi z ation .

In t he acute stage of an inflammation i e du ring the fi rs t , . .

,

few hours or first day or two extreme col d shoul d be u se d over ,

.

the part continuou sl y or with onl y short i ntermis sions i n , ,

order to le ssen the conge stion relieve the pain and i f possible , , , ,

thereby abort the inflammation I n many case s i t i s neces sary .

to reenforce the continuou s cold by hot appl i cations to collateral

areas ( de ri vation ) in order to e ff e ctuall y redu ce the congestion .

The cold energize s the white blood cells i ncreas ing thei r nu m ,

be r and e ffi ciency i n the de struction of ba c teria and ha stens ,

thei r return to the blood stream .

A fter t he acute stage has passed i e at the end of a few , . .

,

hours or on the second day the col d appl i cation s shoul d be

, ,

replaced by a heating compre ss ; or if col d compre sse s were ,

u sed i n the first stage it i s only necessary to leave them on , , ,

thus making a heating compres s The se col d and heating .

compresses shoul d be repl aced at interval s of one t o three

hours u sing sho rt fo m entations when the change i s made
, .

A s the inflammation progresse s tow a r d the chronic stage ,

more heat and less cold shoul d be u sed A fter the acutenes s .

of the inflammation ha s entirel y subsided the mos t vigorou s ,

hot and cold appl ications shoul d be u sed i n order to lesse n

venou s stasis and bring to the organ a greater su pply of fresh
blood ( fl ux i on ) for the ti me producing an arterial h yperemia
‘

, .

It i s possible to use fl ux ion even immediatel y following the

first few hours of some i nfl am m at i on s provide d the y are not i n ,

a dangerou s area i e where ru ptu re would prove fatal or

, . .
,

produce seriou s compl ications .

It has be en shown that i n some case s the mai ntenance of a

high external temperature i s conducive to a more rapid and
benign course of the i n flammation than where cold is u sed .

4 I nfl a m m a t io n , pp . 1 99 2 1 8
. .
 P R IN CIP L E S OF TR E A TME N T

blood brought to the pa rt In the m aj ority of case s still greater

.

benefit results from the u se of alternate hot and col d appl ica
tions s ince the se produ ce an arte ri al hyperem ia whi ch has no
,

after tendency to sta si s

-

The stage of the inflammation may best be ju dge d by the

color A bright red col or i s e vidence of an acute p roce ss and
.
,

a dull red du sky or blu ish color of a chron i c proces s I nfl am

, , , .

mations in certain localities sh ould be treated by hot al one ,

u nti l after the fi rst stage is passed Thi s i s true of ple u ris y . .

For antiphlogi sti c pu rposes i t m ay be safel y held that i n,

the earl y stage of conge stion col d application s are u seful so ,

long as the circul ation in the aff e cted part i s still open which ,

i s i ndicated by the tu rgor But when the pa rt s as su me a

.

cyanoti c hue whe n leu cocyte s h ave be gu n to adhere in large

,

numbe rs to the ve ssel wall and e m igration has be come active ,

appl ications of warmt h further the latter and hasten suppu ra

ti on when i t i s unavoidabl e The col d compres s di minishe s .

c ongestion retards leucocytosi s and emigration of white cells

, ,
“

whil e th e warm appl ications have the contrary e ff ect each ,

being most u seful in the re specti v e stage of inflam mation .

“
The anti phlogistic e ff e cts of cold comp re sses are readily
explained by the results of Ge n z m e r s experiments u pon l ocal ’

blood letting H e came to the conclu s ion that the favorable

.

eff ect of bleeding u pon the i nflamed parts beneath was a sc r i b

able n ot to the ir becom i ng more ane mic but to the fact that
, ,

the blood Stream be came m ore rapid and thu s the corpu scle s ,

w hich had adhered to the vessel wall s were loosened and driven
into the general circulation The fl u x ion t he r e fofe which the
.
, ,

appl ication of col d or warm compre sse s produ ce s i n the pa rts ,

below them i s the true cau se of the changes in the latte r when
,

inflame d Thu s may the ol d theory of derivati on be sa t i sfac

.

t or i l y explained .

Th is e ff ect of cold appl i cati ons may be calle d i nto action in

some local i nfl am m a t i on s in which the parts appear cyanotic
and i t i s important to prevent impending sup pu ration H ere .

hot compresse s or catapl asms are also u seful to arouse the

su rface circulation ; as the y cool o ff they widen the deeper ,

ves sel s and th us ree stablish the c i rculation which has become
Q2?

stagnant Thi s be ing accom pli s

.

ce e d the hot i n orde r to limit

,

remove stagnant corpuscle s It .

of sound j udgment the p roper tem pe rature ,

” 5
m a y be ni cel y adj u sted to each case .

It must not be supposed that circul atory

only eff ects produced by the treatment outline
regulation of the circulation by means
stimulates the cells conce rn
From the above we may ,

in gene ral appl icable to ,

stage the treatment should be di re cted toward the

,

the congestion whether by collateral heat alone

, ,

assisted by cold over the part or by cold al b ne , .

o p h y of the treatment i s summed up in the word

understood in its broade st

ing of conge stion I n the c hr on i .

i ndications are met by the produ cti on of fl ux i on .

panying outline will serve to make clear these

A c ute S t ag e
C o ndi ti o ns I ndi ca ti o ns fo r
T r ea t m e n t

1 . A rt erialhyperemi a Lim it congestion

2 . Increasing serou s Cau se absorption of
exudate e xudate
3 . O ve rplus of leuco E nergi ze leu cocyte s
cytes
4 . B right red color
5 . P ain severe and Rel ieve pain
throbbing
C hroni c St ag e
P ass ive
hyperemia S timulate circu lation
O rganization of ex P romote resolution
ud a t e

Dea rth of leucocyt e s S timulate leu cocyt osi s

Dark red du sky or blui sh color
,

P ain le ss seve re and dul l

5 Ba ruc —
h P r i nci pl es a nd Pr
ac t i ce o f Hyd r ot h e ra p y pp
, . 1 54 1 55
, .
22 4 A N TI P H L OGI S TI C E FFE C TS
most e ff ectually the ice bag mu st be placed over the t ru t
,

the large artery suppl yi ng the inflamed part and not ove i
part itself while heat i s appl ied di re ctl y to the inflam ed
,

Ice appl ied ove r an i nflammation confined i n bony wall s

ally increases the pai n while heat de crease s it N e i the r w i
‘

.
,

ice bag or cold compre ss rel ieve the pain of an abscess e m

soft ti ssue or onl y to a sl ight de g ree last ing onl y whil e
, ,

treatment conti nues Thi s very fact i s of dia gn ostic i m

.

ance It i s presu mptive evidence that the inflammatio n

.

gone on to suppu ration and mu st be opened It shoul d .

be treated by hot appl ications to ha sten the proce ss and l oc

the absce ss pre paratory to drainage .

N ot i nfrequentl y in the u se of ph ys iol ogic therapy the s;

to m a t i c res ponse to a gi ven measu re is of mate rial he l

diagnosi s Thi s may be e ithe r i n di ff erential dia gn os is

.
,

the case of the diagnostic bath in typhoid fever or in sug

ing the location or stage of a pathologi c proce ss as in the
ju st cited.
 CH APT E R XIX

T H E T R E A T ME N T O F I N F L A MM A T I O N S

I N F L A M MA T I O N S OF T H E EY E

i ri tis , K e ra titis , C o nju n c tivitis , D a c hry o c ystitis, O p hthal mi a

E CA U SE of the s itu ation it i s necessa ry to u se more col d

,

than heat i n tre a ting these i n fl am m at i on s since l ong hot

,

applications to the he ad produce cerebral conge stion The cold .

application may b e made by means of compresses of fou r to six

thickne sse s of gau z e wru ng ou t of ice wate r or kept on a block
of ice .The compre sse s should be appl ied al most continu ousl y ,

be ing renewe d a s frequentl y a s w armed whi ch means eve r y

,

two or three minu te s A more convenient and satisfactory

.

method of appl ying continuou s cold and one whi ch saves much
,

time i s the i ce water coil

, Thi s i s a coil about three i nche s in
.

diameter ( F ig . I t i s made of very small rubber tubing

wit h a l umen of about 2 mm I ce wate r shoul d be kept i n the
.

i rrigat ing can an d p ie ce s of ice i n the re ceptacl e for the outflow

s o th at the irrigating can may be fille d from the outflow as

soon as empt y I t may be nece ssary to u se a hot gau z e com

.

pre ss occ a s ionall y often enough to renew the reacti ve abil ity
,

and make the cold comfortable and acceptable to the patient .

B rief applications of the fomentation may be u sed over the side

of the face to secure de rivation or with a small p iece of ice
, ,

wrapped in gau z e applie d ove r the e ye itself a larger fomenta

,

tion may be appl ied so as to cove r the e ye forehead and cheek

, ,
.

I n al l cases the hot appl ications shoul d be of short duration

,
.

A fte r the acutene ss of the inflammation subside s sm all gauze ,

fomentations m ay be used alternatel y w ith the cold compress ,

the heat be ing u sed for a shorte r time than the cold I t i s .

u suall y necessary to renew the compresses about every two

1 5 ( 225 )
22 6

minutes The re sults are app

'

tion i nflammation and pai n

, ,
.

the re vul sive compress should be u sed .

I n the in fl a m m a t i on s men
septi c t reatment the u se of
,

G lauc om a Toxi c Am blyop i a

,

Loc a l i z e d
di stu rbance s in the eye depe ndent u p 6 n
o i

d i seases may be gr eatl y be

228 TR E A TME N T OF I N F L A MMA TION S

the closu re of the E usta chian tube The .

and aural neuralgi as i s best rel ieved by

hot treatment the patient shoul d be unu s
,

i s rendered more susceptible to col ds If .

ru pture of the d ru m may be prevented or while waiting ,

paracentesi s tympani the following treatment may be u sed :

,

Direct the patient to take a hot foot bath or better a leg b ath , , ,

with fomentations over the ear and side of the face col d c om ,

presses being u sed to the neck and opposite side of the hea d :
In adults the ice cravat or i ce bag to the carotid of the s am e
,

side m ay be used This derivat ion w ill reduce the conge st ion
.

and partially or ent irel y rel ieve the pain

,
I t may al so le s se n
,
.

the liabil ity to rupture of the drum .

O the rwi se the condition should be treated ac c ording to plan s

,

outl ined i n any standard text on di seases of the ear The u se of .

hot air deserves mention as a most effi cient means i n both ac ute
and chronic su ppurat ive otitis media .

AC U T E M A S T O ID IT I S
Those case s w hich tend toward recovery that i s where t he , ,

inflammation doe s not go be y ond turge scence and congestion of

the l ining membrane of the mastoid cell s may be aided to an ,

uneventful recove r by the u se of fomentations to the mastoid

y
,

d ry heat and derivation

, In infants an d you nger children t he
.
,

Leiter coil w ith ice water or the ice bag may be u sed ov er t he
mastoid . A t this age mastoid pe riostitis i s very commo n ,

which condition i s always be nefite d by the cold coil I n older ‘

.

children and adults we have not be en able to u se cold ove r the

,

mastoid becau se of the pain occasioned by it .

I n m a n v cases the pain may be reli eve d by strong derivati ve

means a s a very hot leg bath and fomentations to the mastoid
, ,

with the ice cravat or an i ce bag to the caroti d of the same side .

This should be continued from twenty or thirt y minute s to an

hour and fini shed with a vigorou s col d mitten friction to the
l imbs and trunk We have found thi s pl an very successfu l in
.

obviating the nece ssity for large doses of hy pnoti c drugs in

those case s which refuse operation or w hile preparations are ,

be i ng made for surgical interfe rence .

 A C UTE TON SI L L I TIS
‘

A L V E O L A R A B SC E SS
Thi s condi ti o n s hould b e treate d on precisel y the sam e prin
c i p l e s as ma stoid it i s alway s beari ng i n m i nd that the cu re l ies
,

in securing dra i nage as pro mptl y a s po ss i ble .

SIMP L E P H A R Y N G ITI S

The sorene ss of the throat i s m ost e ff ectual l y re l ieve d b y

large fomentati ons to the th roat comi ng well up u nder the j aw
,

a nd back to the ears If there i s mu ch fever a m il d sweating

.
,

treatment will be beneficial at the beginning Thi s may b e .

accompl ished by a hot foot bath w i th the fomentation to the

throat or an electric l ight bath The treatment should be con
, .

cluded w it h a cold m itte n friction and a heating comp re ss ,

applie d to the throat to be left over night The next day u se .

,

the hot foot bath and revul s ive Compre ss to t he throat E ach .

hot treatment shoul d be concluded with some toni c measu re ,

su ch as the col d mitten frict i on col d to w el rub graduated or

, ,

h ot and cold sp ra y . It may be ne ce s sary to re peat t he hot foot

bath and revuls ive compre ss two or three time s a da y always ,

leaving the heating compres s in pl ace between treatments a nd

over night Thi s latter measure i s more i mport ant than an y
.

othe r i n the treatment of sore throat The i nhalation of stea m .

a nd gargli ng of hot water will ai d in rel ieving the pain Or .

di n a ry antiseptic throat gargles in hot water shoul d also be u sed .

ACUTE T O N SI L L I T I S
The temperature i s usuall y very high but of a transient type ,
.

It is u nnece ssar y to e mplo y antip yreti c measures I n fact .

,

general ap pl ications of col d are qu ite l ikel y to produce chilling .

A t the be ginning of treatme nt the patient shoul d be given ,

some sweating measure such a s a hot l eg pack full blanke t

, ,

pack or hot leg bath with fome ntations to the thr oat and i ce
,

compress or ice cap to the top and sides of the head B e cau se
_
.

of the rapi d pul se and extreme p rostration an ice bag shou ld ,

be appl ied to the heart The patient may be take n out with a
.

cold mitten friction or if able to stand a graduated shower

, , ,
.

A well covere d heating compre ss shoul d be applie d to the ne ck .

A fter the initial treatment fomentation s or the revu l s ive com

,
23 0 TR E A TME N T OF I N F L A MMA TION S
press should be applied to the ne ck at frequent interval s al w ay s ,

follo w ing th em by the heating compre s s I n perhaps the .

majority of cases and always i n severe tons illiti s with hig h

fever it i s better to appl y i ce bags over the tonsillar area at
,

the sides of the neck These will al so c ove r the caroti d arterie s
.

and may be kept on almost continuou sl y Throughout t he .

disease very vigorou s toni c treatment may be e mployed The

,
.

cold mitten fri ction or cold towel rub wet sheet pack etc
, , , .
,

have been found u seful i n maintaining the vitalit y of the patient .

In case of quinsy the p a rat on s il l ar absces s shoul d be lance d

,

at the proper time P revious to this fomentations freq uentl y

.
,

repeated will aid in h asten ing su ppu rati on l ocali z ing t h e ,

abs c ess and m aking more appare nt the p ointing O ccasionall y .

in those subject to attacks of qu ins y the earl y and cont inuou s ,

u se of the ice bag may p revent absces s formation .

BO I L S A N D C A R B U N CL E S
I n the beginning wh ile the boil i s onl y a pimple it may be
, ,

aborted by the prolonged use of i ce over it wi th a fomentation ,

covering it and a l arger a rea appl ied at th e same t ime Th e , .

u se of extreme hot and col d appl i cati ons alternatel y appl ie d ,

( fl uxi on ) i s al so an advantage
, When it i s no longer possibl e .

to stop the progres s of the boil fomentations pou lti ces heati ng , , ,

compresses etc may be u se d to relieve the pai n and hasten

, .
,

the local i z ation of the pu s It should then be lanced The . .

absorption of the indurated re sidue about the boi l may be ha st

ened by hot and cold appl ications such as fomentation s and ice ,

or the alte rnate hot and cold pou r P res s u re about the boil or .
,

fricti on to the sk in shoul d be avoided a s these measure s tend ,

to spreading of the bacteria and the i nfe ction of other area s .

ACUT E B L O O D P O I SO N I N G

Se p ti c e m ia of H an d, Fo ot, E tc
These i nfe ctions are u suall y .

occasioned by scratches cuts brui ses t horns etc While the

, , , ,
.

initi al lesion may seem to be tri vi al serious resul ts follow very ,

qu ickly For thi s reason blood p oisoning shoul d be treate d

.
,

most vigorou sly The obj ect to be accom plishe d i s the i nc r e as

.

ing of phagocytosis and so increasing the circulation a s to rapidl y

 2 32

and soft part s ,

succe ssfull y treated along the same l ines .

Mo se t ig s bone wax followed by the alte rnate

’
-

appl ied dail y give s good re sul t s

,
.

P O I SO N I VY AND OAK

These i n fla m m at ion s requ ire some a ct ive

ment I n the earlier st age s
. ,

the ice bag may be u se d wi th benefit

-
.

and col d compresses pou rs or sp rays , ,

This latter means has p roven of ine stimable

standi ng refractory cases
,
.

PN E U M O N IA
P neumoni a i s an acute self l im ited i nfe c t i ,
-

ac te r i z e d by a gene ral toxemia and pat ,

serie s of changes in the lu ngs The .

intense pulmonary conge stion In the .

exudation into the alveol i so that the ,

consol idated the condi tion bei ng know

—
,

The th ird stage gray hepati z ation i s —

accompanyi ng resolution .

marks the transition from the

beginning of re solution Cl inic .

are prominent : pain in the che st ,

tion m ore or less cyanosis an

, ,
H
”
expectoration of p r un e j u ice or -

monia runs a short course and if the ,

is su fficient antitoxi nes are p roduced

,

progress of the infection is arrested .

that pneumonia i s a general i nfection ,

the refore demands systemic treatment .

The greate st danger i n pneumonia a

p rincipally ( 1 ) deficient aeration of t h
,

of the circulation The ai r hunge r i s.

respi ration dyspnoea a, ,

there i s on the part of

,

absorption of oxygen .
P LAT E X I Al t
. e r nat e hot a nd c o l d im m e rs io n fo r i n f ect ion o f t he h nd
a .
23 4

more than a congesti on ,

or sweating t reatment i n
the pu l monary conge stion .

a very hot leg bath a hot

-
.

pack The latte r will be

.

T he sc measu re s should be reenforced by the

hot liquid to produce perspi ration an d thu s a
internal conge stion In appl y ing the col d to
.

be born e in mind that the l obe s a ff ecte d are

l obes and present the greater su rface at th e
t he chest O ver thi s area m a y be u sed a v e
.

ice pack This shoul d not be pl ace

.

warmed si nce otherwi s e i t may

,

collate ral heat and local cold should

derivati on is secured If thi s requ ire s a very
.

pack must be reenforced by hot water bottle s ,

the cold over the aff ected lobe replaced for a

ver y hot fomentation to renew the nerve
promote the vigor of the re flex e ff ect from the
to u se the ice bag ove r the hea rt if the
Treatment may be conclude d with a col
ver y short fomentati on may be applied to t h
by a heati ng compress or a moi st che st pack
left in place until the next treatment .

The suppl ying of pl enty of f r esh cold a i r i s

ance It has be en stated that du ri ng
.
,

pneumonia treated i n tents i n the most ri

better than those t reated in hospital bu ildings The .
'

treatment as carried out in some hospital s ha s great l y

the m i r tal i t y The laity fear t h e eff e cts of col d a ir
.

di sease bel ieving that the patient i s l ikel y to take col

,

the pneumoni a be made worse P e rsons with fever .

likel y to su ff er from an overdose of cold ai r .

reason stated above it i s ve ry nece ssa ry that the

,

supplied with the greate st pos sible amount of pure

N either sh ould the air b e wa rmed The depth of re s .

stimulate
hyd r i a t ic
resp ration a nd so enable the body to make u se of the oxyge n
i

suppl ie d by the fresh ai r Thi s i s tru e of the cold compress

.
,

the heating compre ss the i ce pack and col d rubs and fricti ons
, .

If it i s not possible be cau se of the season to obtain very col d

, ,

air much might be saved i n the mortal it y by provi ding means

,

of refri gerating the air su pplied to the pat ient The air may .

be suppl ied through a ho od fitte d into the opening made by

raising the lower sa sh of any ordinary window ( F ig The .

other end of the hood shou ld fit down over t he head of the

, F ig
’

52 . T he w in d ow t e n t fo r t h e f re s h ai r t re a t m e n t o f f v
e e rs .

patient an d can be tucked i n about the pillow coming no lower ,

than j ust under the chin Th is may be arranged with glas s .

w indows so as to obviate the nece s sit y of removing the h ood

for observation of the patient ,etc Those who have l i ved in .

t he A rcti c regions Labrador and other ve ry cold cl imates tell

, ,

u s that p neu monia and tuberculosis are rare di sease s there and

i n some places al most u nknown .

Relat ive to the beneficial e ff e cts of fresh ai r in febrile

diseases the follow ing i s rel ated of Dr A lon z o Clarke
,
.

I t i s interesting to read how he managed typhu s fever i n

B ellevue H osp ital There were two hu ndre d fift y case s con
.
236 TR E A TME N T O F

st an tl y u nder h i s care and as ,

hi s collea g ue s The mortality.

the draughts of air for fear ,

adopted Doctor C .

there
ness A l t h
.

sto ve s were placed before the ope n

ture of the incoming air cl othing w a ,

were given in moderate quant itie s and ,

di spensed with O f the two hundred .

occu rred in the period of a fortnight .

convale scent In other wards of the

.

a g e m e nt wa s u nchanged the mortali ty ,

S i r William O sl er says
“
death i s ,
l

g re ss i v e l owering of the blo o d pressu re .

’

indication i s to suppor t the ci r cu l a ti on H .

ing the patient out of doors are of great

The sustaining of the heart
p l i shc d by j udicious hyd r ot he r a p
shown that the toxi c albu minoid
paral y z es the vasomotor center in t
regards this as the most common can
a s far as the cir culation is conce rned .

essential in pneumonia as in other

eff ect of hydrotherap y as a v asom
i mportant asset in thi s disease H a .

goe s stimulati on of respiration and of

cold compress to the chest i s appl icable
na r v linen towel or hand towel may be

two or three thi

should be wrung from ice water and applied to the
sides of the che st and covered with a flannel cloth .

to greatly stimulate re spiration and the hea rt acti on

be frequentl y renewed In ordi nary case s it m ay .
,

fifteen twenty or th irty minute s at a time

, , .

i s sleep i ng or when it i s desired to give

,

1 P i i pl
r nc d P ti
es an f M di i n
ra cE i gh t h E d it i n
ce o e c e. o .
2 88 TR E A TME N T OF I N F L A MMA TION S

skin i s red and reaction complete The part shoul d then be

.

very rapidl y dried with a rough to w el Dry fri ction and .

percu s sion should follow i n order to secure thorou gh reaction .

There are two principle s invol ved i n thi s method fi rst , ,

the stimulat ion of the pe ripheral ci rcul ation so a s to relieve

the heart of its adde d burden ; and second be caus e of th e ,

tonic dilatat ion of the surface ve ssels there i s produced a very ,

decided and lasting derivation so that the extreme engorge

,

ment of the heart and lungs i s rel ie ved .

°
A warm bath at 9 8 or 1 00 graduall y coole d t o 90 i s highl y
° 0

re commended by some The e ffect of thi s tre atme nt may be

.

very much increased by all ow ing the pati ent to remai n j u st

long e nou gh to secu re a thorou gh warming col d appl i cation s ,

to the head and hear t being kept i n place du ring thi s time .

The patient then sits u p while he re cei ve s to the che st .

shoulders and back two to fou r a ff u sions of water at

,
This
stimulate s resp iration and increases the e ffi cien c y of e x p e c
t ora ti on . If such tub baths are to be u sed in pneu monia i t ,

must be onl y in well sel ecte d cases and certainl y onl y i n mil d
cases without high fever or dyspn oea .

S ome have very highl y reco m mended the B rand bath i n

l obar pneumonia We can se e no advantage i n thi s measu re
.

over the others menti oned and can readil y understand that i n
many case s it m ight prove dangerou s a s the heart and lungs ,

are u nable to withstand the re tr o st a si s occasioned by the i ni tial

anemia of the ski n which follows contact with the col d water
, .

In general it may be sai d th at full tub b aths are not appl icable
,

in pneumonia .

P ain. The pain in pneumonia i s due chi e fl v to the aecom

panying pleurisy The inflammation i s largely on the si de of
.

the vi sceral layer and so does not contraindicate the u se of col d

appl ications P ain i s pe rhaps best rel ieved by the u se of fom e n
.

tat ions.
The se should be large enou gh to cover an entire
side of the chest and are more e fficient when appl ied from spine
to st ern um with the patient ly ing on the opposite side The .

chest pack or heating compre ss should follow the hot treatment .

Coug h a n d E x pector a ti on A ll of the treatments recommende d

.

above are bene ficial in aidi ng the expulsion of mucu s A severe .

 2 39

c ough may be relieved by the u se of fomentations and the

h eating compres s Inhalations of s team are al so beneficial
.
.

T he re vulsive compre ss is perhaps the most e ffi cient means i n

st imulating expectorat ion A la rge fomentati on is fi rst appl ied ;
.

a s soon a s the heat begins to subsi de it should be replaced by ,

a towel wrung from i ce wate r Thi s shoul d be left on u nti l it .

h as become slightl y he ated perhaps one to three mi nute s , .

T he part should be dried and the se cond fomen tation appli ed .

T hree or fou r change s a re us ua l l y suffi cient to acc ompli sh the

desired res ult A revuls ive com p res s al so sti mulates the hea rt
.

a n d i n cr e a se s
. the de pth of re sp iration and th e consequent
a erat ion of the blood .

The patie nt sh oul d drink large quantitie s of wate r by taking

i t frequentl y in smal l amount s Th is increases diuresis and .

the el imi nation of toxines E ither hot or cold water ma y be .

u sed according to indica tions The bowel s shoul d b e kept ope n .

by sal ines and enemata as nee ded A very light diet l ow i n .

p rote i d also a ids in l im it i ng the tox e mia .

Me di c in al T re a tm e n t
Qu i n i ne . S o much
re ce ntl y been w ritten concerning the
has
u se of large dose s of qu inine in the treatment of pneu monia that
no discu ss ion of thi s di sease woul d be complete without refer
‘

e nce to i t s e ff e cts .

”
It has been suggested that i t s e ffi cie ncy in fever is due to
a n antisept ic action on the bloo d Thi s i s not the case s ince .
,

bacteria are ve ry re sistant to it and would not be aff ected by it

i n the con centrati o n in which it coul d e xist in the bl ood It .

doe s ce rt ai nl y reduce the tempe ratu re as we ha v e p r e vi ousl y

noted but thi s i s not of p rime importance in pneumonia A nt i
,
.

p y re s i s i s of secondary importance nor do patients bear great ,

abstraction of heat as i s the case in typhoid fever The tem

,
.

p e rat ur e i s lowe re d at the expense of the he art s action and

’

oxygen carrying capacity of the red blood cell s B oth of these

-
.
,

i t i s ne ces sary to sus ta in and enhance in pne umonia Q uinine .

l im its leu cocytosis and che ck s phagocytosi s If 2 0 to 3 0 grains .

are gi ven dail y the disease i s likel y to run an atypical course

, ,

2 S ol l m a nn —x Te t B k oo of Ph ar m a c ol o gy p , . 35 0 .
2 40 TR E A TME N T

there being no frank crisi s which i s replaced ,

delayed resol ution the feve r declining by l ysi s ,

.

Moi st rale s may be heard in the che st long

should be complete O n e are a will .

before anothe r area i s i nvolved so ,

and re involvement of another area ,

sort of migratory t
t he a p p e a ra n c e of the c ri si s i s
condition has been reduce d to
s ufli c i e n t vital ity to p roduce a

take the trouble to read up on the eff ects of

soon be convinced of its harmfulne ss in p neu moni a .

sounded b y Dr W C A lvarez i n a re cent letter

’

. . .

the J ournal of the

3
timel y In a pe r
.

A lvarez he state s ,

afte r the p u
came from
the quinine treatment
serie s seven bad cases of empyema O n the
, .

plan it shoul d take two hundred to fou r

,

pneumonia to furni sh seven of em pyema .

cell s were paralyzed by the quinine and so

to the infection Too much can not be sa id .

of the quinine treatment of pneu monia .

S try chn i ne Thi s d r u g has been very much

.

specific in meeting
to the di scredit of the
followed i s that of giving 1 6 0 grain
hours thi s being kept up during the
,

A s some one has said continual ,

the heart i s l ike kicking a

we have already shown ,

are be st attained by proper hyd ri at i c means .

Frank B ill ings says S trych nine and’

,

commonl y used in failing left hea rt are

3 J n l
ou r f Am i aM di l A o i ti n J un 1 3 1 908
o e r ca n e ca ss c a o e

I bi d p
. . .

4 , O c t o b e r 30 1 909
, , . 1 45 3 .
2 42

the blood ves sel s of the i sol ated hea rt in the

-
,

that if the amount we re su fficientl y large

noticeable eff ect there was manifest temporary
,

diminution of the strength of the

a rryth mia and a consi derable reduction
,

numbe r of the pul sations A lcohol al so li mi ts .

phagocyti c action
J ohn H Mu sser give s the followi ng summ ar y
.

trea tment of pneumonia : In the m ajori ty of t h

to rel y on fres h ai r on j udiciou ,

therapeutics on re gulation of the

,

a nd parti cularly on care that t h

watch carefull y for the phenomena so we
Forchheimer guarding against the p ossi b il
,

s y ndrome by proper renal el iminati on .

el imination i s of the greate st importance

of the cases of pneumoni a looking towa ,

cardiac failure ; i n other

seriou s toxic symptom s that
parti cularl y i n the phenomena j ust pointe d out .

the amou nt of food i s of the greate st i mportance

ment of pneumonia patients Watch carefull y .

inte stinal tract Tympany i s a seriou s toxi

.

pneumonia and its i ncrease with

,

point that I depend on as suggestive of the

motor failure This can be preve nte d v e
.

occu rs with the pneumococcu s i nfection ,

undoubtedly the cau se of the devel op ment

colitis plu s the toxemia invite s an intestin
to preven t thi s col itis which give s rise to the
well to obse rve carefull y the diet regulating j udi ,

amount and kind of food taken and washing ou t the ,

with normal salt solution .

BR O N C H O P N E U M O N IA
 BR ON CH OP N E UM ON IA

that age lobar p neumonia i s the prevailing form

, I n man y .

ways the treatment of b r on c h O p ne u m on i a i s conducted on the

,

same p ri nci ples as that for the lobar type The first two .

i ndi cations i e increase aeration of the blood and sustain the

, . .
,

heart and circulation are th e m ost important Br on c hop n e u

, .

mon i a i s noth ing more nor less than an extension downward of

the inflam mation of a bronchiti s It i s a capillary bronchitis or
In order to accompli sh the first result—the
.

l obul ar pneu monia

—
.

proper aeration of the blood i t i s very necessary to i ncrease

the facil ity and the amou nt of expectoration so that the l ungs ,

m ay be free for proper re sp iration The child may be place d .

°
i n a bath at 1 00 and while sitting rece ive to the chest a nd , ,

°
shoulders cold affu sions at 7 5 depending upon the age
and vital ity : With infants t he wet sheet pack i s perhap s the ,

most effi ci ent mean s The pack may be w ru ng from tep id cool
.
,

or col d water and spread out on a blanket The chil d i s then .

placed on th e we t sheet which i s wrap ped snugl y abou t the

body the blanket being folded over all
,
The child should .

remai n in the pack to th e s w eating st a ge A t first there i s .

,

gasp ing respiration and the child crie s Thi s aids in the .

expul sion of mu cu s A s the pack he ats u p the respi ration

. .

become s deeper easier and the expectoration much le ss di th

,

cult Fever may drop one or two degree s and the ch ild pas s
.

i nto a qu iet sleep I f thi s occu rs the chil d should be kept

.
,

warm being left in the pack u ntil it awake s

,
I t may then be .

taken o ut with a wet hand rub or thi s ma y be done soone r if ,

the child doe s not sleep The moi st che st pack and h eating .

comp res s to the che st are also e ffi ci ent means of su sta ining the
heart and increasing the depth of re sp i ration If there i s much .

cyanosis e speciall y if acco mpanied b y ch illiness it i s best

, ,

to place the ch il d i n a full warm bath ; or if the pack i s ,

used it may be wru n g from warm water or hot w ater

,
In .

case of the bath after the sk in ha s become well warmed the

, ,

chil d may rece ive an a ff u s ion to the che st or to the entire bod y
j u st as it i s take n from the bath I n case of the pack after the . ,

chi ld i s well warmed it may be taken out with a w e t ha n d rub

,
c
.

I nfants do not react well to e ither extreme heat or cold For .

tun a t e l y h owever they respond to mil der temperatures in a s

, ,

decided a manne r as adult s do to greater e xtremes .

2 44 TR E A TME N T OF I N F L A MMA TION S

P LE U RI SY
The re are several forms of pleuris y O nl y the t reatment of
.

the dry and serou s forms will be conside red s ince emp y ema of ,

the pleu ra is a surgical di sease In the pleu ri sy u su all y aecom

.

panying pneumonia the inflammation i s l argel y on the si de of the

,

visceral l ayer In ordi na r y pleuris y however the inflammation

.
, ,

involves chiefly the parietal layer of the pl eura The blood .

suppl y of the two laye rs i s q uite diff erent That of the visceral .

layer i s of course from the same blood ves sel s as the lung itsel f -

w hile the parietal layer i s su ppl ied by the blood ve ssel s from -

the intercostal a rterie s and w ith nerves from the anterior divis
i ons of the intercostal s It has been shown that the severe
.
,

acute pain in both pe ritoniti s and pleu ri sy o ri ginate i n th e

parietal layer of these membrane s Wi th these facts i n m ind.
,

it will be seen that the circulation and con se quently the conge s
ti on of the vi sceral laye r will be most readil y influ ence d
re fl e x l y ; while with the parietal layer the circulation and ,

congestion are influen ced to a greater extent by hydrostati c

means since the blood vessel s are conne cte d dire ctl y with those
,
-

of the superficial stru ctures .

For the se reasons wh ile col d decrease s r e fl e x l y the conge s

,

tion i n the lungs by local r e t r o st asi s it increases the congestion

,

of pleurisy . I n acute pleu risy col d appl ications greatl y

,

increase the pain and if u sed persi stentl y may so prol ong the
, ,

inflammation that weeks or month s are requ ired for its enti re
relief .

O n the first indications of pl euris y the pat ie nt should be ,

given a hot foot bath for the purpose of warming the feet and
providing for thorough reacti on to any othe r treatment that
may be gi ven This al so ai ds s w
. eati ng whi ch help s to rel ieve
internal congestion That which i s of the most importance i s
.

the u se of v e r y hot fomentations applied ove r the a ffe cte d area .

These shoul d be made of t hick heavy flannel w rung from boil

, ,

ing water and wrapped i n one thickne s s of dry fl annel N o .

cold should be appl ied between fomentations From three to .

five may be necessary in order to completel y relieve the pain .

If one side only i s a ff ected these fomentations shoul d

,

b e applied f r om sp i ne {0 s ter n u m and not simpl y to the

2 46

the alternate hot and cold

bath while the patient i s convale scing Th is .

the circulation and re nder exposure to col d m u ch

ou s .

P E RICA RD ITI S

The conditions i n pe ri carditis whi le ve ry s imila r ,

pleu ri sy mu st be treate d u pon somewhat di ff e rent

,

becau se of diff ering anatom i cal relation s I Vhi l e the .

to a ce rtain extent be immobil ized or re stri cted in

,

of movement th is i s ,

that can be hoped i n t h

beat Thi s i s adm ira
.

bag over the heart an

cold mitten friction .

measure since by it s stimulat ion

relieves the heart of i t s excessive
the parietal layer of the pericardi
with the surface blood ve ssel s so that i n fl a
-

d uc e d in the same manner a s with pleurisy .

over the heart increase i t s rate and de crease its

reflex action it i s not possibl e to appl y them
,

pleuris y The be st re sults may be ob ta i na d by

.

ice bag appl ied dire ctl y over the hea r t wh ile ,

fomentat ion i s so a rranged as to cover it

area arou nd the heart The heat .

the ice bag slows the heart rate Three .

m a y be g iven in succes sion and the trea

heating compress ; or the ice bag may be
ments be ing removed frequentl y enough
,

excitability of the nerves Du ri .

the cold mitten friction should be

depending upon the degree of
In the later stages the revu ,

of the che st should be u sed to

treatments that are of advantage
after the first fe w days al so h ot ,

towel rub It i s not ne cessary

.

a c cumulation of fluid the heart i ,

2 48 TR E A TME N T OF I N F A MMA TI ON S

oil of wintergreen in 2 0 minim doses eve ry two to fou r hours

al so ad d s to the comfort of the patient and seem s to shorten the
course of the inflammation We have never seen any harmful
.

results from i ts u se
.

H o t appl i cations frequentl y fail to produ ce the best re sults .

Where continuous cold to the j oi nts has been tried it ha s be en ,

found to give better re sults than hot appl i cat ion s The joint .

should be well covered with a th ick flannel cloth outside of ,

which should be packed cracked i ce or snow ( P l a te XI I I ) or .

the joint may be surrou nded with i ce bags Thi s pack shoul d
.

be left i n place until the part becomes al most numb care being ,

taken that actual free z ing does not occur A t the same time .
,

the warmth of the body shoul d be sustained by hot wate r

bottles the foot bath or fomentation s to othe r part s When
, ,
.

the pack has been in pl ace a sufficient length of time to do

away with tenderne ss it may be removed and the skin ru bbed
,

thorou ghl y with the dry hand or snow u ntil it i s red I f the .

inflammation i s severe the ice pack should then be r e placed

,
.

The rubbi ng must be repeated at i nterval s to promote reaction

and prevent free z ing If thought nece ssary thi s opportun ity
.
,

may be taken to mobili z e the joint I n the ordinary case the

.

heating compress may be u sed between the ice packs the ,

latter being repeated from two to fou r times a day each lasting ,

for thirty minute s to one hour Two or th ree j oints may be

.

treated in this manner at the same time When the se extrem e

.

cold appl ications are u sed the i nflammation seems to ru n a

,

much shorter cou rse .Where moderate movement of the

patient i s not objectionable the u se of al t ernate extre me hot
,

and cold immersion of t he hands and wri sts or feet and ankl e s
is one of the best measu res for controll ing the pain and i n fl am
mation in these joints Thi s i s e spe ciall y appli cable when the
.

inflammation has subs ided somewhat .

The patient s general vitality should be su stained by c ol d

mitten fri ctions hot and cold to the sp ine and th e he a rt
, ,

steadied b v the u se of the ice bag and cold m itten fri cti on .

Fomentations to the chest may be used every fou r or five hou rs ,

or oftener if necessary in order to renew the re flex a ctivity

,

whe re the ice bag i s u sed for a considerable length of time .

 RHE UMA TI C FE VE R
Free water drinki ng should be encouraged A n actual sweat
-

ing treatment i s benefi cial and m ay be em ploye d daily or two

or three t imes a week B oth of the se measures favor e l i m i n .

ation of toxines If thi s plan of treatment i s thoroughl y carried

.

out e ndocarditis i s less like l y to occur

, .

S houl d the valvular endocardiu m become

i nvolved it i s neces sary to keep the patient at perfe c t rest
, ,

both during the cou rse of the fever a nd for a considerable time
after The ice bag to the heart shoul d be u sed intermittentl y ;
.

that i s being p ut on for twenty fiv e or thirty mi nutes and left

,
-

off for the same l ength of ti me or even allowing it to remain ,

i n place for a longer ti me de pending upon the results produ ced , .

8
B uxbau m and Laqueur re commend the u se of the cold coil
7

to the precordia two or three time s dail y for a half hou r to an

h our or even longer at a ti me
, .

Cold mitte n frict ions shoul d be given from one to three ti me s

dail y hot foot baths being u se d as frequentl y as neces sary
,
It .

i s nee dl e ss to sa y that the heart shou l d be examined daily the ,

fi ndings being compare d with the cli ni cal manifestations .

A fte r the fever has subsided the p atient mu st be carefull y ,

g uarded from all exposu re to cold and damp H e sh oul d .

retu rn to an active condition very gradu all y rest in bed being ,

kept up unti l the pul se rate i s nearl y normal The wheel chair .

may be used from this point but before fu rther advancement ,

may be made the pul se rate mu st again retu rn to normal

, .

The patient may the n be allowed to lounge abou t being

”

dre ssed and around the roo m part of the ti me W a lking shoul d .

not be allowed if the pulse rise s above ninety Du ring all th is . .

time s u ch ton ic measu re s as hot and cold to the spine the cold
, ,

mitten fricti on and cold towel rub shoul d be u sed A fter the .

subsi dence of the fever gentle massage may be perm itte d ,

.

The re sistant movements of the S chott method and the e if er ,

v e sc e n t bath should not be given u ntil well i nto convalescence ;

that i s aft er the fever has bee n normal for a month or two
,
.

F rom this on the treatment i s e ssentiall y that of chronic

,

endocardit is ( 9 .

7 L h b h d e H y d t h p i 1 903 p 234
-

e r uc r ro e ra e, , . .

8 Di P e x i d H y d t h p i 1 9 1 0 p 1 43
ra s er ro e ra e. , . .
25 0 TR E A TME N T O F IN FL A MMA TION S
IN F E CTI O U S AR T H R ITID E S
N ot only in rheumatic fe ver bu t also in a number of other
infections arthriti s i s a prominent and ofte nvery trouble some
,

o c currence S ome of these especiall y i n the chronic stage

. ,

respond well to the use of vaccine s but we have obta ine d more ,

uniform and satisfa ctor y results from the u se of sci enti fic

hydrotherapy I n these arthritides w e i ncl ude gonorrhea ]
.

rheumati sm syphil itic arthriti s and the se condary non —

,
su ppu ,

r a t i v e a rthriti s of scarlet fever tonsill itis and other infectiou s ,

fevers The principles and methods of treatment a re very

.

definite For cl ini cal purpose s the ca ses may be div ided i nto
.

acu te and chroni c .

T/z e A cu te S tag e . E ach

i nflame d j oint shoul d be packe d i n
ice for thirt y minutes to one hour two or three time s a day .

The more acute the inflammat ion the greater shoul d be the
total duration of the cold A t the cl ose of each of the se a p p l i
.

cations some treatment should be given to promote reaction .

Thi s may be by rubbing with snow or by two or th ree change s

of an alternate hot and col d i mmersion pour or s pray douche , ,
.

A s the inflammation progresses toward the chroni c stage more ,

heat and less cold shoul d be use d .

The C/z r on z c S tag eWhen an infectious arthriti s has existed

'

some weeks or month s the treat ment should di ff er radi call y

from that which i s given during the first fe w days or week or
two of the i nflammation For chroni c arth rit is apply to the
.

j oint some form of hot appl ication Th is may be the fom e n .

t a t i o n ( P l a te X I V the local electri c light or superheate d ai r ,

.

A fter ten to thirty m inute s of such appl ications treat the part
by a vigorou s a l ternate hot and cold immersion or alte rnate
spra y douche using from three to six or more changes
, The .

spray douche i s better than the immersion The hot wate r .

should be as hot as can be borne and the col d as col d as it can

be obtained which for the be st results should not be above
, ,
,
°
60 F .
If there i s pain i n the j oint or if it shoul d seem desi r
able for other reasons the heating j oint compress may be ,

applied after each treatment and kept on until the next treat
ment .
 The se m ethods have gi ve n such u niforml y satisfactory results
that i nfectiou s arthriti s has w ith u s ceased to be a perplexing
, ,

proble m .

M E N I N G IT I S
I n acute cerebro sp inal meni ngitis there i s a purulent
-

exu date covering the convex dorsa l surfa ces of the brai n
between the dura mater and th e leptomeninge s fill ing the
me shes of the arachnoi d and extending downward al ong the
cord The meninges of the brain are i ntensel y congested
.
.

The intracranial pressu re i s increased Q u incke s l umbar .

’

p uncture should be u sed for diagnosi s and treatme nt The .

most i mportant treatment i s the u se of F lex ner s se r u m which ’

ha s given 7 5 per ce nt of recoverie s in four hundred case s

‘

The most commonl y employed hydrotherapeuti c applications

are the ice cap and spinal ice bag appl ie d continuou sl y or with ,

but l ittle inter p tion

r u T
he sp inal i ce bag should be fille d with
.

fi nel y p ounded i ce and placed along the cervica l and uppe r

dorsal spine A nother smalle r i ce bag should be place d cross
.

wise of the neck at the base of the brai n The i ce cap or .

hel met should cover as large an area a s possible of the convex

surfa ce and s ide s of the cranium These applications though
.
,

extensive and extreme do not u suall y cau se ch illing It will

,
.

be found helpful to appl y heat to the extremities at i nte rval s .

The hot foot bath hot leg pack or l arge fomentations to the
, ,

l imbs and abdomen may be used The y ass ist the action of
,
.
_

the ice bags in re ducing ce rebral congestion The ice bags .

and i ce cap m a y convenientl y be replaced by rubber coils through

which ice water i s flowing .

Rohre r report s a nu mbe r of cases i n whi ch cold a ff us ion s to

the head and neck were of great service in rel ieving or m i t i g a t
i ng th e severity of cerebral symptom s and bringing about a
s u ccessf ul termination H e al so advi ses th e cold a ff us ion for
.

the rel ief of cerebral s ymptoms whether deliriu m or coma, ,

accomp any ing i nfectiou s disease s s uch as pneumonia acute ,

meningitis and in su nstroke neoplasms and tubercular menin

,

gitis When made very col d and mu ch prolonged the y are

.
,

decidedly a ntipyretic .

I n chroni c and tubercular meni ngiti s t he O pi sthotonos and

“

,
 TR E A TME N T OF I N F A MMA TI ON S

muscular r i d ig i t y are best met by the u se of the full warm hat h

—
given at a temperatu re of 9 8 1 OZ F The se may be con
° O
.

ti nned from ten or fifteen m inute s to an hour according to the ,

need s of t he case The re stlessne s s del iriu m and headache

.
,

are often entirel y rel ieved The rigidit y of the sp ine an d

.

abdomi nal muscle s i s favorabl y i nfl ue nced We have seen .

coma give way to a fai rly clear sensoriu m followi ng th e :

bath Where the temperature of the patient i s above

. the
ice bag shoul d be kept at the base of the brain and a col d
compre ss to the head du ring the bath This i s e speciall y .

necessary in the epidemic form of ce rebro Spi nal meningiti s -

.

I n tuberculou s meningiti s it may not be needed A u fre cht .

,

Wa r os c hil sk y Wol l i sc h N etter and othe rs report favorable

, ,

results from the full war m bath R og a n sk y report s among .

fift y one cases ( not tubercu lar ) in women where the warm bath
-

wa s u sed a mortality of 3 3 pe r cent ; and among fift y c a se s where

,

the bath w a s not u sed a mortality of 80 per cent Th e warm

, .

bath acts as a relaxing and sedative agent It al s o aids in .

depleting the cerebral and spinal circulation and serves as a

tonic to the c irculatory syste m E xcitant and stimulating.

measures should be avoi ded .

B I L IA RY I N F L A MMA T I O N S
C hole cystitis C a tarrhal J uandice Sub a c ute Pa n cre atiti s
, ,

Inflammatory state s i n these du cts and organs are qu ite likel y

to be followed by conditions th at requ ire operat i v e interference ;
but if take n earl y the mil der i n fl am m at i on s su bside under
,

proper treatment In case s of subacute pancreatiti s and

.

cata r rhal inflamma tion of the gall bladder and ducts we have ,

found the following method su cce ssful : O nce or twi ce dail y

the re should be given a treatment consisting of a hot foot bath
with fomentations to the abdomen and conclu ded by the cold
mitten fri ction The hot foot bath and fomentations produce
.

eff ectual de rivation whil e the latter application relieve s the

,

pain and relaxe s the musculature of the d u cts and the gal l
bladde r The cold mitten friction i s given for toni c purposes
.

to increase leu cocytosis and combat infection Fomentations .

and hot and cold to the spine are u sed for sedative and ton i c
£ 54 TR E A TME N T OF I N F L A MMA TI ON S

appendix B y means of the combi ne d e ff ect of t he hot i n

. ,

drawing the blood from the inflamed part and the i ce bag i n , ,

causing contracti on of the ve ssels re fl e xl y the most e ffectual ,

de rivation i s se cured The pai n i s almost in sta ntl y relieved

.

i n those case s i n whi ch the i nflammati on has not prod uced

rupture of the append ix A fter twenty or th irty m inut e s in
.

the pack i t sho ul d be removed and a vi gorou s cold m itten

,

friction be give n to all parts i nclu ded by it exce pt the abdo ,

men . Th i s se r ves to fix the blood in the sk in and so make

derivation more permanent Following thi s treatment the
.
,

heating compress may be appl ied to the lower abdomen or the

i ce bag may be appli ed over the appendix almost conti n u ou sl y .

The hip and leg pack with ice bag shou ld be repeate d a s often
as necessary to rel ieve the pain and make the patient comfort
able I t i s perhaps needl ess to say that the treatment shoul d
.

be pre ceded by a thorough e nema Catha rti cs sh oul d be

.

avoided A very large fomentation with an i ce bag under the

.

center over the appendix may be substitu ted for the pack .

A fte r the temperat ure has become normal and the acute tender
ness has subsided the patient should be given general ton ic
,

treatments always avoiding extreme m easures to the abdomen

,

or about the appendix si nce exc itat ion of pe r i stal sis m a y cau se
,

return of the inflammati o n or rupture of the appe ndix In .

chroni c appendi citi s the fomentation to the abdomen i s be st

calculated to rel ieve the pain and tendernes s Where possible .
,

these case s should be operate d in the i nterval .

PE L V IC I N F L A M MA T I O N S
Ac ute En dom e tri ti s from Pue rp e ral Se p sis , Salp ing itis,
Ov ari ti s, Pe lvi c C e lluliti s an d Pe ri t onitis
I t i s nec essary to di ff erentiate be tween the se conditions ,

although h y d r i at i c treatment i s carried out along much the

same line in all In the case of retained secu ndines following
.

l abor or abortion it i s i mperative to pe rform cu rrettage a s

,

e arl y a s possible In the case of simple sal pingitis ope rati o n

.
,

shoul d not be done at all S hould the i nflammation go on to

.

the formation of a pyosal pinx ope ration should be delayed ,

 P E L VI C IN FL A MMA TION S
u ntil the temperatu re i s normal and the acute inflammation has
subside d . I n pelvic cellul iti s operation i s u nne ce ssary and
dange rous S houl d absce ss formation occur either in the
.
,

cellular ti ssue or in the peritoneal cavi ty drainage shoul d be ,

p rovide d .

With these di ff erent cond iti ons i n mind and the poss ible out
come of each the inflamm ation should be treated in the same
,

manner a s that outline d for appendiciti s The patient may be .

give n the hot leg pa ck or h ip and leg pack with the ice bag ,

applie d to the groin suprapubic region or other part nearest

,

the inflamed organ Thi s should be cont inu e d twe nt y to thirty

.

m inutes and concl uded with the col d m itte n friction The .

heating compre s s may be appl ie d or if it seem s wi se i n some , ,

cases the ice bag may be left in place I n othe r cases fo m e n .

,

t at i on s to the lower abdomen may be given every two hours .

The h ip and leg pack with the i ce bag followe d by the cold ,

m itte n friction shoul d be repeate d two or th ree time s dail y

,

according to the necessitie s of the case I t i s well i n nearl y

'

.
,

all of the se i n fl am m at i ons to precede the pack by very hot ,

vaginal i rrigati on A s the acuteness of the inflammation

.

subs ide s the revul s ive comp re ss and other alte rnate hot and
,

col d appl ication s may be u sed P e rhaps the most eff ectual .

means of tre a ting chroni c pelvic i n fl a m m at i ons i s found in the

s itz bath Whe n it i s cons idere d safe to allo w the patient to
.

begin to walk the hot sitz or revul sive s itz may be u sed Th e
,
.

temperature of the bath shou ld be graduall y lowered until the

p atient i s ta king a hot s itz followed by a brief appl ication of
col d or very cold wate r The hot half bath i s an e ff ectual means
.

of appl ying the princi ples of the s itz bath In some case s it i s .
,

to be prefe rred The bod y i s less cramped and both the li mbs
.

and hips are entirely i mmersed in the wate r A t the conclu .

s ion the p atient shoul d recei ve a col d p ail pou r to the hi ps It

,
.

i s not neces sary to u se the extre me or prolonged col d sitz in

the conditions mentioned above In pl ace of thi s the patient .
,

should be given alte rnate hot and col d percussion douches to

the sac ru m feet an d legs
,
O the r tonic measures should form
,
.

part of the cou rse of treatment The col d rubbing s it z i s bene .

fi c i al i n del ayed re solution H ot vaginal i rrigation or alternate

.
25 6 TR E A TME N T OF I N F L A MMA TION S

hot and col d irrigation shoul d be u sed until resolution i s com

p l e te .

PH L E B ITI S
Du ring the early stages of phlebitis the cold com pres s or i ce ,

bag should be u sed over the a ff ected vein A t the same ti me .

,

the limb mu st be elevated and kept warm A l l massage move .

ments are stri ctly contra i ndi cate d in th i s condition A fter the
-
.

first day or so fomentations shoul d be used freque ntl y the ice

, ,

bag or cold compress being left in place between fomentations .

While the patient i s recovering that i s after the temperature , ,

becomes normal and all signs of acu te inflam m ation have sub
sided the revul sive compre ss may be u sed The edema shoul d
,
.

be treated by el evation and su ch alternate hot and cold me as

ure s as the revul sive compre ss hot and cold foot or l eg bath ,

and the alternate pou r When there i s no longer danger from.

emboli sm massage may be u sed avoi ding however the ve in

, , , ,

i tself Later on whe n there remains onl y the stas is and

.
,

edema the most vigorou s hot and cold m easures su ch a s the

,

alternate dou che are bene ficial ,

.

M U CO U S CO L IT I S
The first object to be accom pl i shed in the treatment of
mu cou s col iti s i s the re moval of the mucou s cast cove ring the
mu cou s membrane The thorough removal of thi s coati ng will
.

be accompanied by more or les s pain s ince it leave s a raw , ,

u nprotected surface That wh ich most eff e ctually remove s the

.

coating i s some form of treatment wh ic h will produ ce a vigor

ous exosmosi s This may be accompl ished by the h ype rtoni c
.

saline enema or the hone y ene ma ,

I n pre paring the sal ine .

enema about double the amount of salt shoul d be added as i n

,

preparing a physiologi c sal t sol ution or to each pint of sal ine ,

solution there may be added a quarter of a teaspoonful of

E psom salts Th is tends to draw water from the tis sue s
.

be cau se of the concentration of the solu tion Before u si ng the .

sal t solution the bowel shou ld be thoroughl y cleansed if nec

, ,

essa ry by both low and high enemata ; after which the salt
'

solution i s introduced b v means of t he h i g h bowel cathete r or ,

by the ordinary enema given in the knee che st positi on A -

.
25 8 TR E A TME N T OF I N F L A MMA TI ON S
brane The hot application s tend to relax the mu s cul ature and
.

dra w blood from the Organ to the su rface The patient shou l d .

drink freel y of water i n order to dil ut e the uri ne th u s l esse n ,

ing its i rritating qu alitie s Regulation of the diet i s ful l y as

.

important a s these m easu res .

In the chronic stage more cold treatment may be used su c h ,

.

as the revul si ve sit z gradu ated sit z h ot and cold pe rin eal
, ,

spray hot and cold re ctal irrigation and the al ternate spr a y
, ,

douche to the pelvis The se alte rnate appl i cations may at

.
,

first occasion some vesical spasm but if persisted i n hel p to

, , ,

relieve the stagnant ci rculation .

The hot sal ine enema and continu

ou s hot rectal irrigation also pro
duce good results B ladder i rriga
.

tion with hot ph ysiologic salt sol u

tion or some mild anti septic as
boric acid or potassium perman
g a n a te should be done once dail y ,

rarel y oftener In long standing

.

chronic case s alternate hot and

co l d rectal irrigation g ive s excel
lent results Thi s plan of treat
.

ment i s espe ciall y be nefi cial in

those cases in which the capa city F i g 53 T h p i n l d w h - ° e er ea c e :

of the organ i s very much reduced and the wall s h ave be come
greatly th ickened and indu rated .

SP E C I F I C U R E T H RITI S , V AG IN IT I S ,ox P R O S T A T IT I S
In the acute stage in addition to the local medication the ice
, ,

bag shoul d be u sed almost continuou sly The Le iter coil i s an .

excellent means of continuous cool ing S ome form of i nternal .

coole r may be u sed The holl ow prostati c cooler wh ich i s

.
 SP E CIFIC UR E TH R I TIS
ward the ch ronic stage short hot appl ications should be u sed al
, ,

t e r n a t i n g with the cold and after the acute i nflammation has

,

subsided the most vigorou s hot and cold measure s are n e ce ssa r v
, .

That whi ch i s the most serviceable i s the alternate hot and

c ol d perineal spra y . ( F ig . Chro nic case s whi ch have
re s isted all sorts of medication very readil y respond to th i s
measure . I t greatl y increases the circul ation and sti mulates
l ocal le ucocytos is both of whi ch are ne ce ssary in order to com
,

bat the infection whi ch frequently be come s crypti c in th is stage

and so i s be yond the reach of topi cal medi cation The grad .

u at e d sitz or even the cold s itz may al so be u sed . Thi s shoul d

°
be b e gu n at a temperature of 9 8 and after one or two
mi nute s the tempe ratu re graduall y lowere d to
,
or after
several appli cati ons to a s low as
,
The bath should last
from four to si x or eight minute s and be followed by the alter
,

nate hot and col d perineal spray I n ch ronic prosta titi s alter
.

nate hot and col d rectal i rrigation produ ce s astonishingl y good

results .
 CH APT E R XX

ST I M U LA N T S A N D '

H E R E is a deci ded di ff erence i n the

stimulant and a toni c The idea t h .

sary for tonic purpose s has lead to

proper understanding of the se terms .

wide range of applicability the n e c e s ,

much more l imited We qu ote the

.

Willia m B roadbent as giving the be st i

“
du ce d by stimulants : A fal sehood w hi c
that stimulants of whatever ki nd
are nece ssary for the m ai ntenance
i s not the case and the well worn compar i son -

whip and spur and not the corn and grass i s

, , ,

A nyth ing accompli shed under the i nfluence

done at the expense of blood and tis sue and if ,

”
p e a t e d at the expense of the constitution
, .

O n the other hand a tonic tends to restore t h

,

a condition that it i s bette r able to perform its

“
It not only stimulates and hastens the nor
of energy but it al so i ncreases the vi tal capacity of
,

for work Thi s i t doe s by i t s action i n augmenting

.

cesses of anabol ism It will be seen from thi s that

.

can not be a tonic since it i n no way tends to restore

,

to its normal condition nor does it so shape ,

that the ti ssues of the organ are bu ilt u p .

strychnine should be consi dered a stimulant ,

only . A l l tonic measu re s are ph ys iologi c

while stimulants may or ma y not
stimulants produce an u nnatural
( 260 )
2 62 S TYW
. I UQLAI VTE; 1 1 AUD TYLAUZX?

creasing thei r number in the pe ri pheral circ ulation and thereby

preventi ng globul ar stasis .

1 3 In crease alkal inity of the bl ood

.
.

1 4 A ugment the production of agglutini n and other a nti

.

bodies .

1 5 S timulate phagocytosi s
. .

1 6 Increase m uscular capacity

. .

1 7 De crease fati gu e
. .

Tonic measu re s to a g reater or les s extent are indicated i n

, ,

all form s of disease I n some conditions the tonic resu lt s

.

derived from measures whose princi pal e ff e cts are other than,

toni c are su ffi cient to se cure recovery ; but in nearl y all di sease s

,

some special toni c treatment i s needed and i n not a few thi s , ,

al one i s su ffi cient I n the majority of cases it i s nece ssary to

.
,

be g in with the milde st of toni c mea sure s i ncreasing the vi gor ,

ou sne ss of the treatment as the patient develop s the abil ity to

react .

The fol low ing are the p rincipal toni c measu re s i n the orde r
of thei r seve rity Taken one after another the y may be sai d
.
,

to con stitute a ther ape u ti c l a dder .

1 WE T H AN D R U B
. A few very anem ic patient s do not
.

posses s su ffi cient vital ity to rea ct at fi rst to the col d mitte n
friction These patie nts shoul d be give n a w e t hand rub
.

beginning with one or two parts only and i ncrea sing the ex ,

tent of the area treate d as the patient s reactive powe rs ’

increase A t first tepid or cold water may tax the reactive

.
,

powers If so the patient mu st be rubbed vigorou sl y du rin g

.
,

and following t he appl ication The temperature of the wate r .

should be decreased daily 2 or 3 F u nti l cold water or i ce ° °

.
,

wate r i s used U sually before thi s poi nt i s reached the col d

.
, ,

m itten friction may be employe d .

2 .
C O L D MI I T E N F R I C T I O N
’ ‘
Begin with col d water di p .
,

ping the mitte n once for each part and rubbing it vigorou sly ,

u ntil it i s well warmed I t shoul d the n be dried and rubbe d .

w ith the dry hand With each succeeding treatment the tem
.

p e r a t ur e may be lowered and in a day or two the number of , ,

times the mitten is dipped for each pa rt may be i ncre ased to

 H YD R IA TI C T ON ICS
two and l ate r to three or fou r W hen th e patient i s able to .

react to i ce water u se d in th is manne r othe r more vigorous ,

means ma y be tried .

3 CO L D TOW E L R U B
. This i s graduate d in the same man .

n e r as the col d m itten friction S ince the cold water i s applied .

t o a greate r su rface at one time it requ ires somewh a t greater ,

v ital it y to react to th is measu re .

4 P AI L POUR
. Af ter the warm bath or some other hot
.

t reatm ent the patient m ay rece ive to the s houlde rs che st and
, ,

back two or three pails of water differing in temperatu re from 5 °

—1 5 F The first u se d shoul d contain water from 1 00

,

° °
.

°
t he se con d from 80 and the third from 6 5 °

A s the patient shows ability to react to these measu res the ,

t emperatu re of the water may be decreased or additional pail s ,

5 . S ALT GLOW
This m ay be made a mild or extre me
. ,
.

m easure according as fi ne or coarse salt i s u sed and mu ch or ,

l ittle fri ction gi ven S ince it i s not accompanied b y cold

.

w ater it doe s not severel y tax the reactive powers

,
A pail pou r .

o r shower may be u se d to remove the s alt an d so combine it

w ith other tonic measures .

6 C O L D DO U C H E
. Th is s hou ld be p receded b y a warm or
.

hot shower or it m a y be given as a hot and cold dou che con

,

s isti ng of three or fou r changes The reaction is enhanced by .

-

t he u se of pe rcu ss ion A t first onl y a l imite d por tion of the

.

body shoul d be treate d i n thi s manner su ch as the feet and ,

l egs later the spine and chest al so

,
.

7 W E T S H EE T R U B
. The patient s hould stand i n a tub of
.

h ot water A t fi rst the sheet shoul d be w r ung nearl y d r y from

.

c old wate r T his i s wrappe d about the patient in the manner

.

d ire cte d under technique The rubbing shoul d be over the .

sheet u nt il the sk in i s warm and the n the patient qu ickl y dried

by mean s of sheets and towel s Late r colder wate r s hou l d be .
,
‘

u se d a nd the sheet w rung l e ss t hor oug hl y .

8 D R I P P I N G S H EE T R U B
. When the patient has a cquired .

the ability to react to the wet she e t r ub the treatment may ‘

be increased i n vigor by pou ri ng ove r the shoulde rs while

2 64 S TIM UL AN TS A N D T ON ICS

the patient i s still wrapped in the sheet a nd after he h as

been warmed by rubbing from one to three pai ls of cold water , ,

at first u sing one containing cool water and late r two or three ,

pail s of colde r water A fter each pou r the rubbing should be .

,

renewed and c ontinued u ntil the patient i s warm .

9 S H A L LO W B AT H
. A full length tub should be partl y .

filled with col d wate r The patient then enters the tub sitting .
,

upright while both patient and attendant rub the l imbs and
hips The patient now recl ines in the tub while he i s aga i n
.

rubbed with cold water it be ing da shed u p over the body ,

du ring the course of the rubbing The water shoul d hardl y .

more than half cover the body The temperature of the .

shallow bath may be gradu all y decreased .

1 0 C O L D P LU N G E
. This mea sure may be considered th e .

last round of the ladder B y active swi mmi ng move ments the .
,

0
patient shoul d promptl y react to a pl unge i n cold wate r at 80
—85 F and later to much lower temperature s The plunge
°
.
, .

bath should not be continu ed l ong A t first one or two .

minutes onl y are su fficient Later fi v e ten or eve n fifteen .

, , ,

m inutes may profitabl y be spent in swi mmi ng .

1

We have already mentioned that there are a large nu mber of

conditions in whi ch toni c measures are i ndicated I n some .
,

however it i s nece ssary to provide a spe cial c ou rse of toni c

,

treatment The followi ng i s a partial l i st of such conditions

. .

A few of these will be considered somewhat at le ngth .

Indication s for Sp e c i al To n i c Tre atm e n t .

1 . A nemia .

2 . N eurasthenia .

3 . Melancholia and hypochondria .

4 . H ysteria .

5 . Dyspepsia .

6. I nsomni a .

7 . Chronic inebriety .

8 . Chroni c articular rheumatism .

9 . P ulmonary tube rculos is .

1 0 . V al vular heart disease and obe s ity with fatty heart .

1 F o r m o re co p
m l e te d e t a i ls o f t h e se t re a t m e n t s se e t e c h n iq u e .
2 66 S TIM UL A N TS A N D T ON ICS

organic c om p ou n
i s doubtles s an immediate
cient i s this in the for m ation
”
( hematoge n )
“
call it the blood former The .

vegetables fruits grains and nuts contai n

, , ,

amounts of organic iron A sparagus a nd Sp in ach .

2 0 to nearly 40 milligram s of organic i ron to 1 0 0

substance 8
Ten mill igram s or 1 6 grai n
.
-

amount requ ired by an adult woul d be contai n e d ,

of the yol k of egg Moreove r thi s i ron i s i n a .

,

most easil y digested and most full y absorbe d .

I t i s thu s amply demonstrated that i norgani c

preparations of iron are not
in many case s pos iti vel y inj uriou s , ,

digestion O n the other hand the be

.
,

cient organi c i ron w ill n ot su ffi ce to c ,

pu trefaction continue s ; and through ,

circulati on the body i s u nable to

,

rece ive s I n addition then to the

.
, ,

natural diet and special attention di

the dige stion there are two other obje ,

the blood m aking organs must be

-

ci rculation mu st be improved That al .

accompl ished by toni c hydroth e rap y has bee n

shown in the chapters on the ci rcul ation .

That tonic hydrotherapy combined with a ,

diet and outdoor l ife fre sh air and su nsh ine

, ,

cient than i ron strychnine arseni c the

‘

, , ,

quinine and the l ike ,

s v s te m a t i cal l y e mpl oy physiologic m e ans I t has .

proven that arsenic h as any e ffect on the bl ood bu t

e r i s h it That it lessens both the per cent of red c
.

hemoglobin whe n regularl y administered ha

, ,

proven I n searching for e x p e

.

positive benefit that may be deri

arseni c one i s stru ck with the
,

l ine We are asked to rel y u

.

,
3 B ung e
—Ph y s i ol o gi c a l a nd P a t ho l o
mostly emp iri cal i n nature We have freq uently tre ated case s
.

of p rofound anemia i n wh ich the whole p icture was that of

chroni c arse ni c poi soning rather than simple anem ia the ,

arse nic h aving been administered to cure the ane mia .

In the h y d r i at i c management of anemia it i s nece ssary to ,

provide a carefull y graded syste m of tonic treatment I n the .

extreme forms of anemia the be gi n n ing mu st be at the bottom

,

round of the ladder of tonic measures E ach application of .

cold shoul d be preceded by a short hot appl ication such as ,

fomentations to the spi ne or abdomen the hot foot bath or , ,

local ele ctri c l ight bath N o long hot tre atments should be
.

u sed since the v ita l ity i s so much reduced as to i ll y bear the

dep res sion occasioned by sweati ng H owever all forms of .
,

local appl ications of heat are indi cated in anemi a Following .

one or more short moderatel y hot appli cations the patient ,

shoul d be give n a w e t h an d ru b cold mitte n friction or col d

,

towel ru b according to hi s abil ity to react Thi s shoul d be

, .

repeated abou t twice daily or a l ight m assage may be given

,

once a day . Later on a s the circu lation i mprove s the patient

, ,

may be treate d by the col d towel ru b hot and cold to the sp ine , ,

and stil l l ate r alte rnate hot and cold douches and sprays
,
.

A dvance ment i n the tonics shoul d be made sl owl y I t may .

take se veral weeks for the patient to acqu ire su fficient vital ity
to react to a gene ral shower bath The salt gl ow may be u se d .

before the more vigorou s cold appl ications can be borne .

Following this ma y be used the general a ff u sion or pail pou r

, ,

at first of warm or tep id water late r of coo l and cold water ,

.

A fter some week s a short full ele ctric light bath may be gi ve n ,

followed by a v igorous hot and cold spra y When th is point .

has b e e n reache d advance may be made more rap idl y u s ing

, ,

the w e t sheet ru b dri pping shee t rub cold shallow bath and
, , ,

the col d plu nge .

Mas sage i s especiall y i ndi cated in anemia before the patient

i s abl e to take mu ch exerci se T he man ipul ation shoul d be
.

wh at i s te r m e d general m as sage ; z e it should c om bine al l

'

. .
,

of the proce du re s u suall y given in S wedish mas sage O f spec .

i al importance are the movements of deep kneading A fte r a .

single m as sage lasting forty fi v e to s ixty minu te s the re d cells

-

,
2 68 S TIM UL A N TS A N D T ON ICS

frequentl y show a gain of 2 5 to 5 0 per ce nt and may eve n b e

doubled in number The se gai ns are of cou rse not permane nt.

but they last longer and longer a s the treatment s are re peate d .

The hemogl obin per cent ri se s m ore sl owl y than the red cell s .

Full sun bath s are e speciall y beneficial The scientific basi s .

for the u se of the su n bath in anemia and chlorosi s has bee n

4
well demonstrated experimentall y E xposu re to sunlight i n .

creases the oxygen carrying capacity of the red blood cell s -

It .

sti mulates he matogenesi s increasing both the nu mber of re d ,

cells and the he moglobin pe r cent I t i s a fundamental proto .

plasmi c stimulant I t hastens cel l divi sion and cel l growth

. .

It i s a most e ff e cti ve sti mulant to the periphe ral circulat ion .

P ure fre sh ai r su pplie s the needed oxygen that makes pos sibl e
,

the best results from the sunlight Z u n t z and hi s school have .

shown that the e ff ects of mountai n air are apparent not ,

onl y in thei r i nfluence on red corpu scl es but al so on the nitro ,

genous metaboli sm of the body a s a whole so that the re i s i n ,

most individual s a positive nitrogen balance an actual re pro ,

” 5
duction of the conditions fou nd i n the growing organism .

A n A nglo A me rican expedition to P ike s P eak i n the su m

’
-

mer of 1 9 1 1 confi rm ed the claim s of E uropean observers in the

A lp s relative to the e ff ect of hi gh al titudes u pon the blood .

The y found a l arge increase in red cell s hemoglobin and white , ,

cell s 6
. The red cell s i ncreased 3 0 to 4 0 per cent and the hemo
globin kept pace with it O n descent i t requi re d about fou r .

week s for the excess of hemoglobi n to di sappear The se oh .

servers clai m that the lungs develop a capaci t y to se crete oxy

gen from the alveolar ai r into the bl ood .

The eff ects of sunlight and out door l ife among natural su r -

roundings are apparent not alone i n the physi cal change s the y
induce but al so i n the p sychi c improvement of the p atie nt
, .

When proper attention i s g i ven to all of the item s menti oned .

,

al so to digesti on ( se e dyspepsi a ) the max imu m good m ay be

obtained
—
.

Cl v L gh E n g y pp
g—
4 ea es i t er . . 27 1 . 322
F l ui d B od y p 1 4 2
.

5 St a rl i n s of t he . . .

6 D
m ph i P
ugl o as s . H e n d a ne H n d on n d S h n i d
e e rs a c e e r: T he Ph y si o l o gi E ff
c e c t s of L ow A t
Ob v d n Pi k P k C d P L nd B)
,

os er c re s s u re s . as se r e o o l o ra R S oc (
LX X X V 65 , .
e s ea . o, roc oy o on ,
2 70 S TIM UL A N TS AN D T ON ICS

function The treatme nt of dyspepsia i s cons ide red i n another

.

place .

The overworking of any organ or function l ead s to e x ha us

tion The chief cau se of ne rve exhau stion l ie s i n overactivit y
.

of the brai n and nerves accompanying deficient ph ysical a ct i v

,

ity N eu rasthenia may h owever occur i n an individual w ho

. , ,

i s engaged in an occu pation requ iring constant bodil y activity

— —
.

Worry grief disappointme nt fi n an ci al or social these all have

, ,

their place i n the causation of nerve exhau stion A c ompre .

he ns i v e View of the disease and i t s cau ses reveal s the nece ssity
for two cl asse s of physiologic e ff ects v i z toni c and sedative : , .
,

sedative to assist i n secu ring rest the most e ssential element

, ,

i n bu il ding up lost nerve force ; tonic to re store normal ne r e ,

v

activity and hasten the bu ilding u p proce ss N o hard and fast .

line s may however be drawn between p rocedure s dire cte d to

, ,

these ends T on i c measure s are of cou rse in the long run

.
, ,

conducive to normal re st but the y may al so be i mmediatel y

,

sedative in their eff e cts Thi s pecu li ar paradox that toni c

.
,

measu re s produ ce sedation and sedati ve measure s are toni c ,

exi sts only i n the realm of phys iol ogic therap y O ne woul d .

not pick u pon the bromides to restore the normal ne rve tone or
u pon strychnine to produce re st or sleep The special tre at .

ment of insomnia and the irritative neura sthenie state will be

considered more at length unde r sedative effects ( q .

I n be gi nni ng the treatment of a neu rasthen ie patient it i s ,

well at first to test the rea ctive powers by mild measure s

, ,

whi ch will produce no shock S ince first i mpre ssions are often
.

ve ry lasting the initial treatment may c onsi st of such forms of

,

the bath a s are not greatly d i ff erent from those u sed at home .

This serve s to make the patie n t ac quainte d with the attendant

and the attendant with some of the p e c ul ar i t i e s of the patient .

The ful l warm tub bath and tub shampoo fini shed with a warm ,

and then a cool pail pou r serves thi s pu rpose for a large num
ber of patients S ince nearl y al l neurastheni cs complai n of
.

cold feet and more or less abdom inal di stre ss we frequentl y ,

u se the hot foot bath with fomentations to the abdomen Thi s .

may be made the second treatment and conclu de d with a wet

hand rub or cold mitten friction With thi s or following .
,
 NE UR A S TH E N IA
closel y we ut il ize hot and cold to the sp ine the revul sive com
, ,

pre ss the pail pour salt glow and graduated spray Later
, , , .
,

after considerable reactive capaci ty has been developed the ,

cold towel ru b and wet sheet rub may be u sed T he alternate .

spray al ternate dou che and shallow bath are qu ite vigorous
, ,

mea ns and should not be ventured u pon in the agitative form

of neu rasthenia or not until milde r tonics have been u sed for
,

some time .

The wet shee t pack althou gh an ex ce llent toni c as well as

, ,

se dative mean s i s often obje cted to b y the neurasthenie H e

, .

complains that it make s hi m n ervou s he feel s restrained etc , , .

The sit z bath at the variou s te mperatu res at which it may be

u sed i s capable of m ost e xcelle nt re sults For this purpose the
, .

tub must b e deep e nough so that the wate r will cover the
gr eater pa rt of the abdomen P rovided there ar e no local
.

condit ions re qu iri ng treatment the sit z tub mav fi rst be fil l ed,

°
with water at 9 8 whi ch i s gradu all y ra ised to 1 0 2 or 1 03 and 0 0

°
then lowered to 9 0 or 85 ju st before the close or it ma y be
°
,

concluded with a col d pail pou r to th e hip s ( revuls ive sit z ) .

0
The se cond bath may be begu n at 9 8 or 95 and w ithout ra is °
,

ing the temperature of the wate r graduall y lowered to 85 or ,

°

O n each su cceedin g day it i s begun at a slight l y lower

,

temperature and finishe d with col der wate r until it i s essen ,

t i al l y a prol onged cold s it z The bath acts by redu ci ng the

.

bl ood su ppl y to the abdome n and pelv is de conge sting the ,

abdominal and pelvi c s ympatheti cs and restoring thei r tone It

.
.

aids i n the relief of gene ral splanch noptosi s .

A bout once a week the patient shoul d be gi ven a short

electric l ight bath followed by a spray or shampoo and spra y ,
.

The electri c light bath should be three or four minutes in

length suffi cient to thoroughl y warm the sk in and p rodu ce
,

beginning pe rspiration .

The old idea that the mel anchol ic state is d ue to l iver

.

derange ment ( black bile ) i s not wholl y without foundation .

Wrong habits of diet together with constipation are large

, ,

factors i n the production of the depre ssed type of neu rasthenia .

B oth of the se crowd the l iver with toxins and products of

impe rfe ct dige st ion A n overworked l ive r in ti me become s
.
2 72

a sluggish torpid l i ver

, ,

as a toxin de stroye r and

treatment and treatment
d o n and
app l i cations to the hepat ic area of special
re vulsive compre ss alte rnate hot and cold
, ,

alte rnate hot and cold percu ssion dou che to t

u sed fr e que n tl v .

For cerebral congestion nothing

hot and cold foot bath or
feet The latter may be
.

hot leg bath with cold co

The work cure for
hands of a few physi
for su ch treatment .

in the line of i ndoor

of gardeni ng fl o ,

and occupy the

occupations take
to the extent he can b e intere sted in
ju st to that extent the succe s s of th e p
I t has al so been shown by P a nsi ni 7

sunl ight or arti ficial l ight increase

red l ight has the O p pos ite e ff ect .

la rgel y
that of heat B lue l ight ( actinic ray ) i n c r e a
.

p l i t u d e and number of contractions as shown b

I n a control test the mu scle s were abl e to l ift
b efore recoveri ng from the fati g ue of t hi s te st ,

kilograms ; and after the exposure to the l ight of a

the total of the cu rve showed ki logra ms i n d ,
'

onl y the recove ry from fati gue but a gai n of 1 1 2 .

over the capacity of the u nfati gu ed mu scles .

The general progra m a n d the distributi on of the

during the day are of importa nce .

It will be found that the be st results are obtained by

t reatment a day A short sedative treatment may be
.

7 Cl v —
ea esLi gh t E gy pp 30 1 —
ne r 303 . .
.
2 74 S TIM UL A N TS A N D TON ICS

thi s pu rpose A pplied by means of a stationary spinal ele ctrode

.

and a labil e abdominal sponge the treatment i s ce rtainl y most ,

e ff ective The abdominal muscl es are powerfull y sti mulate d

.

b y the slow sinusoidal current thu s i ncrea si ng intra abdomi nal

,
-

pre ssu re but the greatest e ffect i s u pon the splanchnic va so

,

motors re fle xl y .

The se patients experien ce mu ch rel ief by assuming the hori

z on t a l position The movement of inspi rator y lifting
. as ,

ca rried out in abdominal mas sage al so a ff ords instant relief , .

The u se of abdominal s upporters and the application of broad ,

bands of adhe sive plaste r to the abdomen i n spl anchnoptos i s ,

and spl anchnic neu rasthenia give relief a s long a s the y are i n
place Both these means however ultimatel y re su lt in weak
.
, ,

e n i n g the abdominal mu scle s and so unless accompanied by

, ,

other treatment defeat the ir own p u rpose Whe re it i s at all

,
.

possible to strengthe n th e abdom inal mu scl es it i s better to .

adopt some system of exerci ses espe ciall y cal cul ated to devel op
them .

O f h vd r i ati c means the following combi nation i s e speci all y

,

e ffi c aC I o u s in splanchnic neu ra stheni a for the pu rpose of d e c r e a s

i ng the splanchnic congesti on A h ot foot bath with the col d

'

Winternitz coil to the abdomen and cold compresse s to the head

and neck continu ed for from twelve to twenty minute s i s the
, ,

first part A col d sit z of fou r to si x minutes du ration follows

.
,

and the treatment i s concluded by a wet sheet rub Thi s i s .

especially adapted to warm weather Du ring the winter month s .

it may be necessary to appl y more heat With le ss vi gorou s .

patients the first combi nation of hot foot bath wi th cold coil to
“

the abdomen and cold compre sse s to the head may be conti nue d
thirt y minutes or l onger and concl uded with a cold mitten
,

friction These cold appli cations to the abdome n and pelvi s

.

produce decided and prolonged contraction of the vis ceral bl ood

vessels The fan douche to the hepati c region and abdomen
.

al so ac c ompl ishe s much the same re sults .

H Y ST E RI A
While some case s requ ire a greater p roportion of sedative
treatment nearl y all requ i re more or les s of toni c treatment
, . .
 T UBE R C UL OSIS
The ch ief re sult to be obtai ned by tonic treatment i s the r e st or a
tion of tone to the neurons so that by training self —,
control , ,

be comes pos sible The methods outlined for neurasthenia are

.

a l l appli cable i n h ysteri a .

DY SP E P S IA
The special treatme nt nece ssary in thi s condition will be con
s i d e r e d late r but l ocal measure s u naccompanied by general
,

toni c treatment are often insu ffi cie nt to accompl i sh full retu rn

to health The measure s recommende d for anemia and those
.

nece ssary in neu rastheni a are all appli cable in altered state s of
the di ge stion .

P U L MO N A R Y T U B E R C U L O S I S
The recovery fro m pulmonary tuberculosi s i s esse ntiall y a
matter of vi tal re sistance H ence e ffi cient treatment re solves
.
,

itself i nto means for the promotion of thi s vi tal re si stance and
the improvement of nutri tion These mean s are fre s h a ir su n
.
,

shi ne and d iet together with othe r mea su res which have toni c
, ,

e ff ects A lthou gh earl y tu be rculosis has proven one of the

.

most cu rabl e di sea ses by these h ygienic methods yet no hard ,

an d fast l ines can be laid down for the ir employment in indi

vidual cases The exerci se of enlightened and scientific com
.

m on sense is e sp e c ia l l v neces sary i n deal ing with thi s di sease .

N ot all patients c a n eat the same th ing While m ilk and eggs .

may form a sort of dietetic center for the improvement of nutri

tion yet these mu st be intell igentl y u sed ; nor should other
,

arti cl es such a s cereal s a n d fr u i t s be negl ected The latter

'

.
, ,

are especially u seful i n maintaini ng the alkal inity of the blood

and imp roving uri nary elim ination The nutriti on ma y be .

pu shed by a m ilk diet i n some case s with most excellent re sults ,

while othe r patients do not be ar thi s method well Like all .

excl u sive methods if u sed it shoul d be for a l imited ti me onl y

, ,

and for the accompl ishment of certain re sults retu rn then be ing ,

made to a more general diet by which onl y a l l the needs of ,

nu triti on c an be permanentl y met The tuberculou s patient .

requ ires as careful dieteti c treatment a s that given to the patient

with a gastric or intestinal disorder only .
2 76 S TIM UL A N TS A N D T ON ICS

I n regard to fresh air it mu st ,

than t w ent y four hours of outdoor a i r

-

results Thi s means that proper sleepi ng

.

be provided so that fog and dampne ss

,

climate s whe re the se are prevalent O f .

change shoul d be made to a dry cli mate .

be a warm or a cold dry cl imate ,

altitude w ill depend upon the stage of the

,

needs of the i ndi vidual ca se A n alt itude of .

i s beneficial to those who are not nervou s ,

i ng in the lung has progre ssed su fficie ntl y to

lung gy mnasti cs of deep breathing .

The patient with a ri se of

obse rve complete rest With t h .

complete rest i s not nece ssary ; t he

about but rest i s still the r ule The full
,
.

p o su re of the enti re skin su rface to the

be neficial form of l ight therapy The K
'

for the concentration of actini c rays upon

u seful means of promoting heali ng The .

the nutrition increase s cell division and

,

hematogene si s and increase s oxidation

, It .

circulation so as to do away with the

— ,

lati on cold hands and feet I t .

of the patient a re sul t whi ch i s not to be

,

In regard to hydr i a t i c toni cs we mu st ,

against anything but those of a ve r y mi

tions to the va rious porti ons of the body ,

mitten friction i s all that we have found ,

tonic baths sprays and douche s had be s t

, ,

O f course the se mav be u sed in building

one w ho ha s re c ove red but the y are no ,

tr ea tm e n t of the disease .

i n the treatment of pleu ri sy and t h

other abnormal sensations The .

one of the be st means of checking

directl y upon the vasomotor and
of thi s by i ts tonic eff ect i t he
,
-

,
2 78

such as the neutral bath the wet sheet ,

the cold m itten friction .

C H RO N IC A RTIC U L A R R H

It i s the u sual cu stom in gouty rheu

treme s udor i fi c m easure s
tonic measure s ,

those cases only

treatment may temporaril y increase the .

it i s quite esse ntial that the se patients shoul d .

treatment The col d mitten fri ction i s p robabl y

.

u re si nce it quickl y produces a reaction and can

,

pa rts of the body avoi ding the j oints

, T on i c .

necessary not onl y to as sist the

,

and elimination of toxines and the s ur p l u

t e r ia l whi ch by long crowding wi th protei
, ,

content has become well fixed ; but al so to increase

,

up process and the general body weight .

D IA BE T E S
Diabetes i s a condition in which the s ystem
warehou se and consu me the carbohydrate of a n
The di sease may be classified u n de r two heads :
mentary form in w hich withdrawal of
diet for a time produces a cure z e t h , . .
,

to utili z e a moderate amou nt of su gar .

a functional di sease although a s , ,

due to partial destru ction of the

S econd a pe rmanent or organic
,

sugar continue s
has be en pretty
Langerhans i s the cau sative le sion i n
The se ductless bodies are beli eved to
oxidi zing fe rm ent ( oxidase ) which ha s ,

and oxidi ze
system but ,

the p a nc r e a
re sults onl y
 D IA BE TE S

and Delame re Langerhan s insu ffi ciency i s fou nd in abou t 80

,

per cent of case s Defect in t he gl ycogenic function of the

.

l iver may als o cau se permanent diabete s .

The u su al treatment of diabetes i s di recte d toward securing

b u t one end ; v i z decreasing the excretion of grape s ugar by
.
,

le ssening the ingestion of carboh ydrates substituting prote i d ,

( chie fly meat ) a s recomme nde d by von N oor den

.

, Chi t te n .

den has rece ntly shown that the i ngesti on of proteid above a
9
,

certain mi nimal re qu irement which he sets at about 3 5 to 60 ,

grams re su lts i n a very few hours in the excretion of p r a ct i

,

cally all the s urplu s n itrogen i n the form of u rea the residue ,

being simple carboh ydrate not distin g uishable from the carbo
hydrate take n as such S u ch a p rocess can hardl y be said i n
.

any way to conse rve the body powe rs The great amount of .

u seless labor de mande d of the liver by such a diet must result

i n ove rworking that organ A l l thi s occurs to sa y nothing of
.
,

the detrim ental e ff ects of flooding the syste m w ith puri ns from .

the large quantities of meat which the v on N oorden diet n e c e s

si t a t e s
. While temporary exclu sion of carboh ydrate from the
diet w ith a gradual return to a moderate inge stion of starches
'

and su gars i s qu ite e ssential and an e ff ective plan for the

dietetic management of diabetes th is alone does not meet the ,

nee ds of the condition The real cau se of the di sease lie s i n

.

alte re d carbohydrate metaboli sm The sugar pas sing through .

u noxidized cau se s a loss of energy that should accrue from thi s

source . In other words the carbohydrate fuel fall s through
,

the grate before being bu rned becau se of lack of proper regu ,

lation of the fire Le sseni ng the amou nt of fuel whi le a most

.
,

important factor in treatment onl y partially remedies the defect ,

.

The rat i onal manage ment mu st therefore ai m at increasing , ,

the oxidation of grape sugar and thereby preventing its elim ,

i n at i o n in an unoxidi ze d state with the consequent energy loss .

There are no know n medi cinal agents or e ven any mode of

die tetic ma nage ment which will accomplish th is re sult E x p e ri .

ment has revealed the fact that nothing so g reatl y promotes

oxidative change s as exerci se in the fre sh air and tonic hydro
therap y The e ff ects of these agents on carbonaceou s metabol
.

9 N u t i ti n f M
r o o p 1 31
an , . .
2 80 S TIM UL A N TS A N D T ON ICS

is m we have al ready considere d Becau se of the langu or .

,

lessened vital ity and great su sceptibil ity to fati gu ewhich i s an

,

al most constant accompani ment of diabete s it is often diffi cult ,

not to say unwise i n many case s to p ur s ua d e the patient to

,

exe rcise When the re i s much loss of vitality the exe rcise mu st
.

be of a passive nature z e secu red by massage Massage

'

. .
, .
,

stimulates the gl ycol ytic powers of the muscles improve s the ,

ci rculation and aids nutri ti ve changes More important than

,
.

this howeve r are the e ff e cts derived from appl ications of col d
, ,

water accompanied by friction or pe rcu ssion Cold friction s .

-
,

cold douche s and mild alte rnating hot and col d applications
,

effectually sti mulate metabolis m Those hy dr i at i c meas ur e s .

which are accompanied by strong mechani cal sti muli have

double the effect of cold appli cations without fri ction or p e r cu s
sion Cold douches have been shown to increa se oxi da tion
.

more than 1 0 0 per cent These means also improve the nutri .

tion of the skin and so aid in preve nting many of the annoyi ng
,

cutaneou s compli cations .

G raham Lu sk reports a se ries of expe ri ments on the i nfluence

of col d baths on the gl ycogen con tent of man in which he shows
that extre me cold treatment so greatl y enhance s oxidation as to
quickl y change the aspe ct of combu stion from su pport by car
b ohy d r a te s to support by fat These experiments were done .

10
with normal i ndividuals From this report we qu ote the fol .

lowing :
During the shivering which followe d the second col d bath
the metaboli sm a s measure d by the he at production was 63
, ,

per cent higher than du ring the subseque nt re sting pe riod but ,

the respiratory quotient of re mained unchanged du ring

both periods It is evident from thi s expe riment that the i nfl u
.

en ce f
o t wo s u ccess i ve col d ba ths ,
w hi ch ca use shi ver i ng d u r i ng a

pe r i od whe n the i n tes ti ne i s f r ee f r om ca r bohy dr a te , i s fici ent

s uf to
cha ng e the me ta bol i s m f r om m a i n ta i ned the
one at ex p ense of ca r bo

hy dr a te (R . to one m a i n ta i ne d essen ti a l ly by the com ba s

ti on of f a t ( R H en ce the org a n i s m of ma n m ay be
.

qu i ck ly r i d of g lycog e n by shi ve r i ng .

10 I fl
T h e n ue nc e C ol d B t h
of a s on t he G ly c o g en C o nt e n t o f Ma n Am e ri c a n J o u r na l o f
Ph g X X V II N V p
.

y si o l o y V o l
. .
. o .
. . 4 27 .
282

of langu or and debilit y

exerci se and so hyd r ot h
,

of the other great aid in

With thin diabe t
can take onl y the
bear well any great
unfavorable condit
'

massage Much time shoul d be spe nt in the open

.

shine careful attention being paid to general

,

e speciall y to good skin activity .

C E R E B RA L CO N G E S T I O N
D ue to the Effe c ts of Sunstro k e
P atients who have once su ff ered from
cold climate in whi ch to live E ven .

length of ti me produce s harmfu l r e su

in thi s condition the vasomotor ce nters
with that there i s a los s of vascul ar control .

some case s be so extreme that eve n a short

,

l imited to a small area may indu ce general vaso

a special tendency toward cerebral conge stion .

i s be st treated by cold appl ic

I vo hot appl i ca ti ons a t a l l shou l d

the head should be kept cool by

bag or the i ce cravat to the ne ck
, .

cold towel rub w e t sheet rub cool

, ,

may all be u sed according as the

brain seems u ndul y conge sted a gre
tion is be st secured by the cold p e
Mu ch the same line of treatment i s to be pursue d
nitroglycerine poi soning whi ch occasionally occu rs
,

This may be ve ry troublesome It i s accompanied .

headaches in some ca se s assuming a migrai ne type

, .

ing the se patients the cerebral circulation should

,
 VA L V UL A R H E A R T D ISE A SE

s ion dou che s and the cold plu nge ,If milde r measures mu st .

be u sed the cold mitten friction with i ce water gi ve s excellent

,

resu lts H owever these patients bear m uch more extreme

.
,
'

col d treatme nt than any other cl ass and seem to have no d i ffi ,

culty in reacting .

V A L V UL A R H E A RT DI S E A S E
Eti olo gy an d Pa t ho l o gy
O rgani c heart di sease refe rs to su ch di seases of the heart a s
are du e to gross structu ral change s The te rm i s applied .

almost exclu s ively to chronic valvul ar disease I n the large r .

nu mbe r of cases th i s is the resul t of some acute inflammatory

condition on or abou t the valve s Th es e valve i n fl a m m a ti ons .

may ari se as compli cations of rheumatic fever tonsillitis , ,

scarle t fever se psi s gonorrhoea pneumonia pleu risy or

, , , , ,

pulmonary tubercul osi s P re di spositions a re found i n pro

.

l onged and heavy mu s cula r exercise auto intoxication gout ,

-

, ,

alcohol i sm syphili s B right s dise ase and a rterio scleros is The

, ,
’

,
-
.

re sult i s a val ve orifice e ithe r too large or too small S car

'

tissue fol low ing the inflammati on m a y cau se the valve segment s
to adhere to each other and so by p artially obstru cting the ,

orifice cau se ste nosis ; the valve l eaflets may be parti ally de
,

stroyed or thei r attachments weakene d so that the ori fice i s

too large or the hea r t dilated so that the segments are i n com
,

petent to close the opening .

In the first case that i s stenosi s too l ittl e blood passe s

, , ,

throu gh the ori fice and extra force i s requi red to overcome the
obst r uction I n the latter c a se pa rt of the blood retu rn s
.
,

through the enlarge d opening or past the incompetent valves ,

so that re gu rgi tation take s place at every hea r t beat Becau se .

of the forme r condit ion the first change in the heart mu scle i s ,

t hat of hypertroph y I n the second condition the first change

.
,

i s that of dilatation of one or more cardiac chambers I f com

‘

p e n sa t e d both conditions re sult i n great hypertroph y and

,

thickening of the mu scular wall The maxi mum force of the .

heart will be greater than normal but the work requi red of it ,

i s al so greater so that i n thi s condition i t s reserve force above

, ,

what it ordinaril y u ses i s les s than the normal re se rve H ere .

2 8h S TIM UL A N TS A N D T ON ICS

the heart i s sai d to be i n a state of compe nsa ti on Since the ,

muscle i s so much h ypertrophied as to still be able to perform

i t s work under ordinary ci rcu mstance s S ometime s there i s .

l ittle or no such rese rve z e th e heart ma y have barel y

'

.
, .
,

enough force for its w ork when the body i s at re st I n thi s .

F ig 54 D— i g m
a ra Sh w i n g d y n m i nd i t i n i n v l v u l h t
o a c co o s a ar ear
d i— f q ui d t t u nd n d it i n i ndi t d
. .

se as e : A o rc e re re a re s er co o s ca e
dd i t i n l f d m n d d b y m d t m u ul w k C
,
”
B a o a o rc e e a e o e ra e sc ar or
v d i fo b v th t n d d f m d t w k
,

r e se r e ca r ac rc e a o e a ee e or o e ra e or .

condition the heart i s sai d to be in a state of br oken compensa

,

ti on .Thi s state that i s where the maxi m um force i s i n con

, ,

stant u se is revealed by such symptoms a s edema cyanosi s

, , ,

dyspnoea heart pang or di stre ss rapi d pulse palp itat ion slee p
, , , ,

start enlarged l iver etc

, , .

Mod erate muscular work demands fou r times the energy u sed
at re st and the total rese rve power of the heart m uscle is from
,
2 86 S TIM UL A N TS A N D T ON ICS

( diastole ) It al so shortens the systole and increa ses i t s force

.
.

The i ce bag should be well wrapped to modif y the intens ity so ,

that the ap pli cation may be prolonged I n some case s the cold .
,

compress i s to be prefe rred While the ice bag tends to i ncrea se .

the force of the systole it can hardl y be sai d to come under the ,

head of pure stimulants since by its repeated u se the e ff e ct s , ,

of over st imulation are never see n

-
It always exerci ses a be ne .

fi c i a l e ffect i n aiding h ype rtroph y of the h eart mu scle since by ,

i t s shortening the systol e and increasing the l en gth of the dias

tole the actual period of rest i s increased
,
It may therefore .
, ,

be said to be a true physiologic measure .

3 Me asures whi c h Stim ulate the Pe ri p he ral H e art,

. pe rform
ing part of the work of the circu lation i ncreasing its activity , ,

and so aiding the central heart I n the chapter on the pe r i .

phe r a l he a r t w e have di scu sse d at length the physiology of th e

,

blood vessel s thei r normal action and the rationale of th e

-

, ,

measu re s u sed to increase thi s activity .

We need here only briefly summari z e the fact s already pointed

out . Independentl y of the heart the blood ve ssels exert a ,
-

pumping or propul sive action u pon the blood stream .

Lauder B runton makes the following obse rvation rel ative to

1 “

this activity : When worki n g u nder P rofe s sor Lu dwig i n 1 86 9 ,

he directe d m y attention t o the contractil e po w e r of the small

arteries apart from an y nerve center and while watching the ir ,

movements I h ave sometimes see n a re gu lar pe ri stalti c a ction

take pl ace by which the blood was driven forward i n the
,

a rteriole j u st a s f aecal matte r woul d be driven forward i n the

”
i nte stine .

Franke di s cu sses the va ri ou s theories p revail ing i n regard

to the fu nctional i mportance of the peri pheral bl ood ve ssel s -
.

H i s conclusions reaffi rm he asse rt s : that the pe ripheral ve ssel s ,

have an i ndependent pressure and suction action simila r to that

of the heart Thi s assumption i s su stai ned by the ir anatomi c
.

stru ctu re ph ysiologic experiment s d irect observation of the

.
,

blood ve ssel s i n l i ving animals and i n certain pathologic con

-

d i t i on s in man A t th e points where there i s the greate st

.

re si stance to the c i rculation N ature ha s place d a s y stem of ,

14 T h e ra p e u ti cs o f t he Ci rc ul a t i o n . p . 5 .
 VA L V UL A R H E A R T D ISE A SE

especial l y powerful blood vessels l ike a second peripheral heart -

as in the portal and inte stinal ves se l s Compensation m a y .

fai l from distu rbances in the peripheral ve ssel s as well a s i n the

heart itsel f and the peri pheral system m a y compensate the
,

heart at need ; the ve ssel s i n the abdomen e speciall y are the

last resort of all m eans to mai ntai n the balance of the circula
t ion These views he considers e xplai n the beneficial e ffects
.
, ,

”
of gymnastics mas sage and bath s , , .
15

In disease as long a s there remains any vasomotor control

,

at all the activity of the blood ve ssel s m ay be stimulated by

,
-

applications to th e ski n su rface The condition of the blood .

vessels to b e sou ght i n th e treatm ent of valvul ar heart disease

i s that known as active dilatation not onl y of the a rteriole s , ,

but al so of th e other bl ood vessel s I t consi sts of an alternate

,
-
.

contraction and relaxation occu rring at regular i nterval s It .

i s i n short a pump ing action

, , It i s often astonishing to note .

the amount of assistance rendered the circulation i n this way ,

as s hown by p rompt decrease i n the pul se rate following or ,

eve n during, S Om e of the procedure s l isted below These may .

be gi ve n separatel y combined i n one treatment or at differe n t ,

time s du ring a cou rse of treatment as indi cated by conditions ,

i n the i ndi vi d u al case .

( a ) M a ssag e Friction is perhaps the milde st of measure s by

.

wh i ch th e peri pheral circulation may be st imul ate d It st i m u .

late s the arte riol es and by proper movements the venou s cir , ,

culation i s hastened A l l the other procedures of massage are .

al so vasomotor excitants .

The procedu re of deep kneadi ng accompli she s more than the

othe r movements of massage It acts upon the circul ation in .

al most t h e same manner as exercise T

he alte rnate compre s .

sion and releas e of the mu scle s forces on their contained blood ,

so that the rate of flow i s greatly accelerated Lau der B runton

I

records graph icall y the re sults of some interesting expe riments

6
.
1

Showing the i ncrease i n the rate of venou s outflow from muscles

during and after massage I n some instances the rap idity was .

increase d two or three time s th e normal rate .

1 5 A b t t i n J n l f A m i M di l A i t i
s ra c ou r f ti l b y M F n k i
a o e r can e ca sso c a on o ar c e ra e n
W i n k l i ni h W h n h ft M h 1 0 1 91 0 X X II I N 1 0 p 6 4
.

'

e er sc e oc e sc n a rc o 1

Ci
. . .
, ,

h p p
, , ,

16 T e ra e u t i cs Of t h e rc u l a t i o n , . 1 35 .
2 88 S TIM UL A N TS A N D TON ICS

Mechani cal vibration i s quite s im ilar i n i ts e ffe ct to manual

massage V ibration when properl y given i s an excellent
.
, ,

means of assi sti ng the pe ri pheral circulation e speciall y that of ,

the feet and l imbs V ibration may also be given to the back
.

and other parts a s i ndicated ,

.

( b ) H ydr i a tl c Vasom otor Ton z cs The cold mitte n fri ction

'

has the greate st range of adaptabil ity i n organi c heart di sease .

It can be used i n all stages from the inception of th e acute

endocarditis through all the varying conditi ons of e stabl i she d
or broken compensation Th is i s largely due to the readines s
.

with which it ma y be made a mil d medium or powerful vaso , ,

motor tonic and stimulant Thi s can be accompl i shed by vary .

ing the temperatu re of the wate r u sed and alte ri ng the amount
and vigorou sness of the fri ction given We have neve r .

observed even after the most vigorou s col d m itten frict ion or
, ,

i t s long u se over a period of months any oversti mulatio n su ch ,

a s doe s sometime s occur w ith the e ff ervesce nt bath The cold .

m itten friction and i ce bag can be u sed i n the acute stage of

endocardial inflammation wh ile it m ight be dange rou s to u se ,

the N auhe im bath i n thi s stage The re are man y other h ydri .

atic measure s si milar i n e ffect to the col d m itten fri ction .

E ach has its advantages and spe cial indications a s wel l as ,

limitations The follow ing i s a l i st of the more im portant and

.

com monl y u sed hyd r i at i c measure s i n the treatment of organi c

heart disease : The salt gl ow ; hot and col d to the spi ne ; hot and
cold douch e to th e spine legs and feet ; the alte rnate hot and
, ,

co l d foot or leg bath B rief fomentations followed by a brisk

.

but brief cold mitten friction may be give n to any part of the
body as a means of stimulating the peripheral circulati on .

( c ) N a uhe i m or Efl e r vescen t Ba th The e ssential feature .

here i s the che m ical i rritation of the sk in produced by the

carbon dioxide and salines with whi ch the water i s charged .

N atural carbonated waters can b e secu red in onl y a few l ocal i

ties but the carbonic aci d g a s may be produ ced artificiall y i n
,

any one of several ways It powe rfully stimulate s the vaso

.

motors having however a cumulative action on the vaso

, , ,

dilators so that the heart i s left without a re si stance governor

—
.

17 Ha re P t i l T h p ut i
ra c ca e ra e cs .
2 90

example while the atten d ant

,

tracts the bicep s flexin g the

,

be en flexed the patie nt co

,

attendant re sists the moveme nt .

number of time s for each group of mu s cle s .

c e c d i ng treatment the nu mbe r of moveme nt s and

F ig 55 A —b—dor d i d ul l n i n
e r of ca r ac f di
e ss a c as e o

D —m
dh ft i ng l N u h i m b t h C
. .

la te e a rt B m sa e a er a s e a e a
g d i ) li v ft
,
.

l ow e r ed e of co ng t d (
es e ca r ac e r. sa e a er
a c o u rs e o f t o ni c h y d t h py
ro e ra .

of the re sistance i s i nc r e a se d .
l8

relaxation of fi rst one and the

has tens the peri pheral circulation
of ac t i v
not be
chronic
 VA L V UL A R H E A R T D ISE A SE

( e ) Oe r tel M e thod . G ene ral

exe rcises such as walking u se , ,

of the arms etc follow a s a natu ral consequ ence of the m ethod
, .
,

ju st de scribed A s a s yste m the O er tel me thod consists i n

.
,

gradu ate d cli mbing exerci ses u p h ill s of v ariou s grade s and ,

finall y e ven mountain cl i mbing A t first the patient walks for .

,

short distanc e s each day ; and later longer distances and up ,

ste eper grades Thi s i s of course appl icabl e only where a

.
, ,

fai r degree of compensation has already been e stabli shed ; never

when the compensation i s broken or in the sl ightest impaired .

Where systematicall y followe d for months or years i t has ,

resulte d i n m u ch good and will secure for the patient the maxi
mum cardiac reserve .

These measure s combine d wi th carefu l die t re gu lation fre sh ,

air and su nshine w il l give results which often appear like a

,

co mplete cure but of course do not re move the defect in the

, ,

hear t A t the beginning of the i ncom petency the progress

.
,

may he staye d for ye ars The promptness with which the se .

measures act and the ir e ffi ciency has to be seen to obtain a real

appreciation of their value For example the ice bag to the .
,

heart accompanied by a cold mitten friction may reduce the

, ,

p ul se from 1 1 5 or 1 2 0 per minu te to 1 00 or less withi n fifteen

or twenty minutes I n case of a dilated heart the cardiac dull
.
,

ness may de crease more than an inch in diameter and the ape x
retract half an inch or more toward i t s normal position follow
ing a single trea tment I n case the valve i s relati vely i n su ffi
.

cient the murmur occa sione d by this insu fficiency may entirel y
,

disappear w hereas before tre atment i t m ay have been con

, ,

s i d e r e d to consti tute a real organi c lesion The mi nor mu r .

murs of the valve s se condaril y a ff ected often disappear foll owing

a treatm ent of fifteen minute s with the ice bag to the heart and
the col d mitten friction or ten minute s i n a N auhei m bath ,
.

E x tre me s t i m u l a n t s and excitants are

contraindicate d i n organic he art di sease unl e ss i t may be i n ,

emergency .For this reas on the percuss ion dou che to the ,

ch est w e t sheet rub the cold plunge and su ch measure s Should

, , ,

not be u se d The use of elec t ricity i n any form may p roduce

.

shock . Th e electri c l igh t bath i s u su all y contraindicated or ,

if u sed at all i t mu st be in thos e patie nts whi ch ha v e acqu i red

,
.
2 92

a goo d degree of compe nsation and then ,

A l l other extre me su d or ifi c measure s are

G en e ral Pro gra m

We have al ready outlined u nder the he ad of
treatment for the stage of acute inflammati on .

endocardial inflammation
dail y or three times a week a l ight
ing the chest The ice bag shoul d be
.

or five diff erent time s during the day ,

twenty to th irty minute s each time .

Shoul d have a tre atment consi sting of

the following measure s : H ot
abdomen hot and cold to the
,

cold towel rub Thi s ton ic tre

.

forenoon The massage m ay

.

evening .

be st to gi v
ing

for sho rt distance s onl y .

fore any re gular walk ing exerci se s

now be given a salt glow alternate ,

graduated Shower etc The N a u h , .

the temperatu re ha s been normal

should be followed by
should last onl y a few
Later this
In case the
chronic stage with compensation
,

be gu n at thi s point or perhaps

res istant movements should not ,

stage of broken compensation .

patient i s not
necessary but ,

cient time
an d o nl y
2 94 S TIM UL A N TS A N D T ON ICS

The ice having a greate r reflex e ff ect

, ,

blood ve ssel s of the l ive r wh ile the hot

-

effect chiefl y in derivation Al te rnating .

the revul s ive com pre

u sed The alt
.

be st measures
r e c t l y by a derivative process the hot and cold leg ,

found to be a s e ff i cient a s the l ocal treat ment .

A m i e E de m a of Me L u ng s Thi s condition may .

cau se of chill ing and ne rvou s shock The heart . .

gorged and the chambers dilated at the same time ;

should be immediatel y wrapped i n a large blank et ,

legs be ing placed in hot water and an ice bag held

precordia I t i s u su all y neces sar
.

The ice bag may

ski n be ing

brief but very cold and brisk c

A nothe r fomentation should
pa rt may be drie d well and
arm and leg shoul d be treate d i n a
skin well warmed and reddened by
atel y followed by a cold m i tten fric
th oroughly dried with a rough
by fricti on with the b a
red The object to be obtai ned in this treatment
.

of the blood from the hea rt and lu ngs to the s ki

muscle s H oweve r this can not be eff ectuall y
.
,

alone but must b e accompl ished by what may be

,

lateral fl ux io n that is the blood vesse

, ,
-

be stimulated to unusual acti vity so that ,

i n the periphery .

bad afte r e ff ects

 OBE SI T Y WI TH FA T T Y H E AR T

will have entirely di sappeared The fi ne r crepitant rale s which .

‘

remai n in the base s of the lower lobe s sh oul d clear up in from

one to three days .

The se condit ions are large l y

a nd A r r /zy tfi m z a
’

due to dige stive di sturbance s e speciall y that form of indige s ,

tion ac compani ed by ga s formation Th e tre at ment should .

,

therefore be di re cte d toward the relievi ng of con stipation and

,

de creasi ng of amyl aceou s dyspep si a It may be nece ssary to .

avoid even mode rate quantitie s of sta rch y foods unle ss most
thoroughl y de x t r i ni z e d T achyc ardia i s best control led b y the
.

i ce bag col d m itten fri ction re st etc N e rvou s disturbances

, , , .
,

nerve fati gue etc are al so responsi ble for te m pora ry a rr hy

,
.
,

thm i a .

OBE S I T Y W IT H F A TT Y H E A RT

It i s not safe to empl oy extreme swe ati ng measure s in obe sit y

accompan ied b y fatty degenerati on of the hea rt mu scle
.
Con .

sequ entl y th e treatme nt of the se ca se s at the hot springs i s a

,

dange rou s proce dure The y mu st be treated i n m u ch the same

.

manne r as valvular heart di sease The patient shou ld be kept .

at re st w ith an i ce bag over the h eart for a con siderabl e portion

of the ti me Bes ide t his the patient should be given col d
.
,

mitte n fri ction s col d towel rubs hot and cold to the spine
, ,

, ,

general ma ssage ; and l ate r th e altern ate dou che to the spine ,

and l egs hot a nd col d foot bath wet sheet ru b et c Treat

, , , .

ment shoul d be ve ry carefull y graduated so that the heart i s

not subje cted to ove r st imulation be fore i t ha s su ff i cientl y i n
-

creased i t s stren gt h .

E X CI T A N T A N D S TI M U L A T I N G E F F E CT S
I n many e me rgencie s it i s necessary to e mploy ext reme
st i mulating measu re s These a im at the su stai ning of vi tal
.

a ctivit y i n order to tide the system over a c ri si s or until su ch .

ti me a s the natural vitality of the pati ent comes to h i s a ssi st

ance . S u ch measu re s are espe ciall y d irected toward the hea rt ,

bl ood ve s sel s a n d re spiration

-

,
I n col lap se surgical shock .
, ,

dro w ning an d asphyxia these measu re s are indi cated A s w e

, ,
.

have note d man y time s t he greatest a m ount of assi st a nce to ,

2 96 S TIM UL A N TS A N D T ON ICS

the heart can be gi ven by vigorou s stimul ation of the peri

p h e r a l blood vessel s I n additi
-
on to such measu
. res ce rtain ,

app l i cations may be u se d which have a d ire ct re flex e ff ect u pon

the heart itself The most e ffi cient reflex stimul ati on come s
.

through the a cc e l e ra tor n e r v e s S hort very hot fome ntations .

mav be applied to t he front of the che st covering wel l the ,

heart area Thi s s hould be cont inue d from thi rty seconds to a
.

minute and i mmediatel y fol lowe d by the rubbing of a cake of

,

ice over the heart The extreme change i n temperature pro

.

duces powerful stimul ation The part shoul d be immediatel y .

dried afte r whi ch a second fomentatio n very hot and con

, ,

tinned for hal f a minute or more may be u sed again follo wed ,

by the ice rub A fter three or fou r su ch appl ications it i s

.
,

well to rub vigorousl y with the bare hand the ski n of the p re
cordia These p rocedu res may be give n at the same ti me as
.

artifi cial respi ration .

A very effi cient stimul ati ng m easu re i s the slapping of the

chest with a col d wet towel If thi s i s done during the move
.

ments of artifi cial respirati on it shoul d be given wh ile the ,

inspiratory movement i s m ade I n the asphyxia of the new .

born infant thermic appl i cations are i ndispensabl e

,
I f slap .

ping of the che st and buttocks doe s not produce res piration it ,

i s well to empl oy the a l ternate hot and col d i mmersion Two .

large dish pans will be fou nd handy contai ners for the hot water
and the cold water The hot water mu st not be hot enough to
.

produ ce a bu rn or even e rythema It mu st be of such a te m .

p e r at ur e as may be well borne on th e back of the h and or the

c he c k . The col d wate r s hould produce deci ded excitation but ,

ice water should not be u sed The child shoul d be hel d i n the .

hot water for ten or fifteen seconds and the n merel y dippe d in ,

the cold water I t should then be returne d to the hot for about
.

the same length of time and aga in dipped i n the cold A nother .

plan which h as proven equall y e ff ective i s rubbing the che st

with a s mooth cake of ice while the i nfant l ies i n the hot water .

The se procedu res are u suall y the most e ff e ctive sti mulants that
can be u sed A l l other means of re su scitating the new born
.
-

have their place and applicability The physician should not .

too readil y become di scou raged in work ing with an asphyxiated

2 98 S TI M UL A N TS A N D T ON ICS

alter nate hot

m a y be ac compli s
press to the lowe r abdomen or u pper i nner
thighs .

Intestinal exci tation i s indi ca ted chiefly i n

There are a large n umbe r of measu re s whi ch are
l a xe d conditions of the inte sti nal mu s c ul ature .

shou ld b e put u pon som

v e ni e nt l y embody several

stimu lating peristal sis .

e nema ,

The gr
patient to the
patient s w ho h ave
appl ications the re m
men the re vul sive c
,

abdomen The se sa .

from the middle of the

alternate hot and col d
also tends to sti mu l ate peri sta l si s .

cold rubbing s itz i s an excelle nt measu re .

two to four mi nutes and be followed by the

the spi ne and a bdomen The se mea su res
.

sele cted and utili z ed accordi ng to the se

s pecial attenti on being give n to

ments except the h ot enema and

,

are not appl icable in spa stic cons

pan y ing lead poisoning In th is .

t ions to the abdomen the h ot sit

,

e nemata for thorough cleansing o

pain O i l enemata may be given
.

ni ght or for several hours .

A numbe r of other measu res not

conveniently c o m b i n e d w i t h h
A mong the se are the follow i ng
ne rve stimulation special exerci se s
,

mu scles vi bration
,
 C ON TR A I N D I CA TI ON S

abdomen and s pi ne also sinu soidal ele ctricity and the Morton
,

wave from the static machine S ome of the se forms of e l e c t r i .

cal stimul ation may be applie d by means of a rectal electrode

and an abdominal sponge A l l exe rci ses which strengthen the.

abdom inal mu scle s should be utili zed such as walking ro w ing , , ,

horseback riding bicycl ing e tc , , .

to E x ez i a n t and S i i m u /a l i ng Weas ur es
'

z .

1 . Old age .

2 . I nfancy .

3 . A rte rio —
sclerosi s .

P- A cute mania .

U
I

Tuberculos is ( pulmonary ) .

E ma ci ation
N
O .

Q Thi n diabeti c patients .

O
O B right s di sease
’
.

O
x E xhau stion from any cau se .

1 0 . H emorrhage .

1 1 . S evere coughing .

1 2 . A sthma .

1 3 . E mph ysema .

1 4 . O rgani c heart trouble .

1 5 . Chorea .

1 6 . E xtreme ne urasthe nia .

 C H APT E R XX I

SE D A T I V E E FF E CT S

which reduce or check the ove r activity of an

E A SU R E S -

organ or function are said to have a sedative eff e ct .

S ince there are many organs and functions one might so elab ,

o r a t e l v classify sedative e ff ects as to prove confu s ing and so ,

lose the di stinctive p ri nciple s governing h y dri at i c sedatives .

A n y appl ication mu st of nece ssity a ff ect more than on e stru e

tu re a s w e have learned concerning toni c measu re s ; but we
,

have also l earned that eve ry appl i cation has its predominati ng
eff ect For the sake of clearne ss we shall the refore he re dis
—
.
, ,

cu s s o nl v ne rve sedatives those mea su re s wh ich rel ie ve i rri ta

tion nervou sne ss spasm and convul sions and are condu cive to
, , ,

rest relaxation or sleep The pr i n cipa l sedati ve mea su re s

“

, , .

may be classi fied as follows

I . G EN E R A L S E DAT I V E S .

1 . P uresedative s .

2 . Tonic sedative s .

I I L O C A L S E D AT IV E S
. .

1 For the rel ief of pain ( analge sics )

.
.

2 For the rel ief of par ae sthesia

.
.

The first ( I ) employs mild h ypnotic calmative and anti , ,

spasmodi c means and mild toni cs almost entirel y The se cond

, .

( I I ) mu st of necessity employ extreme means si nce pai n and

, , ,

abnormal sensations can not be rel ieved by mild applications .

G E N E R A L SE DA T IV E S
1 . Pure Se dativ es : Temperature s at or not far removed from
neutral .

( 300)
302 S E D A TI VE E FFE C TS
bral h y pe remia The p ronou nced sinking of the brai n sub
.

stance the positi ve diminution o f the re spiration and heart beat

, ,

the weakening of the re flex e xcitabil ity and of activity of the

cerebral gangl ia obse rve d i n tre phined rabbits during the we t
pack combined with the pos itive dim inution of the ves sel s of
,

the pia mate r represe nt the fundamental conditions for physi

,

cal cal m and sleep The se are probabl y al so present i n man .

du ring th e wet pack S lee p i s accompanied by a decided di m .

i nu t i on of blood in the ce rebral vessel s ; indeed the l atter ha s ,

been accepte d a s an es sential condition for the produ ction of

sleep Thi s may expl ai n wh y the w e t p ack properl y appl ied
.
, ,

”
i s a u seful procedu re in the i nsomnia of neura sthe nics .

The col d sitz col d coil to the abdomen etc p rodu ce sedat ion
, ,
.
,

by redu ci ng conge stion of the sympathetic ganglia of the abdo

men and pelvi s Fomentations to the spine withdraw blood
.

from the spinal c ord and the he at i s i n itself relaxi ng and de ,

pre ssant H eating compresses are mild derivative s and com

.

bine with thi s derivation a neutral temperatu re A l l an ti p y .

retie mea sures are in the nature of the case anti spasmodic and
h ypnotic since the y l esse n toxem ia and so rel ieve the nervou s
,

system Col d sponging i s sedative in both act ual feve r and

'

feve ri shne ss H ot sponging i s u suall y m ost effe ctive i n condi

.

tions purel y ne rvou s In acute mania the wet sheet pack i s a .

most excellent means and serves a doubl e pu rpose i n re strai n ,

ing the patient while appl yi n g the neutral temperatu re .

I n di ca ti ons f or the U se f P ur e Seda ti ves

o .

1 . Insomnia .

2 . A gitative neurasthenia .

3 . H ysteria .

4 . Mania .

5 . Chorea and chore iform disease s .

P aralysi s agitans
\
O .

S pastic spinal paral yse s

I

\ .

O
O E pileps y .

D
\ Locomotor ataxia ( fi rst stage ) .

1 0 . N e r v ou sne ss due to congesti ve headache .

1 1 .
Clonic and tetanic spasms from va riou s c au ses .
 T ON IC SE D A TI VE S

P r e ca u ti on sThe pe rsonal factor or idiosyncrasy has much

.

to do with the sel e ction of a sedative treatme nt If a patient .

has take n a di slike to a certai n measu re i t i s l ikel y to produce ,

agitation rather than sedation S edat ive e ffects are likel y to .

be transient and so the treatment mu st be freque ntl y repeated

, .

With neurasthenie patients a treatment which may have gi ve n

good results i n a certain case ma y be robbe d of its e ff e ct by
some unu su al occu rrence whi ch may see m trivial i n itsel f su ch ,

as sl ight alterat ion in the manne r i n which it i s given or the ,

changing of an atte ndant .

2 . T o ni c Se dat iv e s
Insomnia and nervou snes s may be due
.

to a lack of normal fati gue su ch a s follows active work espe ,

c i al l y out of doors Thi s i s particul arl y true of those i n seden

.

tary occupations such as p rofess ional busines s and o ffi ce men

, , , .

The se persons may be of fai rl y good phys ique and health other
w ise I t also occ u rs in enforced idlenes s as after fractu re s
.
, ,

operations etc ,
an d in the case of ch ronic inval ids The
.
,
.

rational treatment consi sts i n the produ ction of fati g ue Where .

poss ible of course exe rcise i n the open air i s the most e ffi cient
, ,

means of producing fatigue M il d tonics are u suall y all that .

can be well borne A fe w cases may be given even the most .

vigorou s treatment The following are the means most used .

a s toni c sedative s :
( a ) H ot and cold to the sp ine .

( b ) We t han d rub .

( c ) Cold mitten friction .

( d ) H ot and cold spray shower or dou che , ,

.

( e ) N eutral fa rad ic tub .

( f ) Massage .

( g ) Rapi d faradic current .

The i n di ca ti ons have bee n outl ined above S o me of the p r i n .

ei/ m/ condition s requi ring tonic me asure s i n order to produce

se dation are ,

1. I nsomnia .

2. N eu rasthenia .

3 S planchnic neurast hen ia

. .

4 Chronic rheu mati sm

. .

5 P aralyse s ( flacci d )
. .
3 04 S E D A TI VE E FFE C TS
L O CA L SE DA T IV E S
1 . An alg e si cs ( rel ief of pain )
For the pu rpose of relieving .

pain extreme hot or col d appl ications are absolutel y es senti al

,
.

J u st wh ich shall be u sed depends upon the parti cular cau se and
conditi on i n each case S ome ai m at the cau se and others at .

the i mmediate rel ief of the pa in whe re the cau se can not be ,

removed in a short time .

For th e relief of pain hot appl ications are usually em ployed , .

We sa y that heat ha s a spe ci fic pain rel ieving eff e ct Thi s i s -

tru e ; but it mu st be remembered that the rel ief of the pain i s

due to the produ ction of de fi nite circulatory chang es which r e
move the cau se of pain I n inflammat ory state s the cau se of .

F ig 56 Di ga ra m h
t o s ow t h e e ff ec t s o f h e a t a n d c ol d in l e sse n
p fl B
. .

i ng t h e ai n o f in am m a t i on . ( r u nt o n )

pain i s to be found i n pre ssu re u pon nerve filament s occasioned

by the conge stion and hei ghtene d vascular tension B y deriva .

tion heat redu ce s the conge stion or it r elaxe s th e tension and

, ,

thu s the cau se of pai n i s removed When properl y applied .

,

cold m a y accompl ish the same results The s e p ri nci ple s are .

well illu strated in a diagram devi se d b y Lau der B ru nton .

2

The diagram ( F ig i s supposed to repre sent the end of.

the finge r The small star indicates the point of irritation

.
,

e g
. a p ri ck by a thorn The li ne in the center of each finge r
.
, .

i s i ntended to repre sent the ne rve going to the inj ured part ;
and at the side of each figure i s an a rte r y and ve in connecte d
by a capillary network I n a the capi l lary network around the .

2 T h e ra pe u t ics o f t he Ci rc u l a t i o n , p . 1 74 .
806 SE D A TI VE E FFE C TS

( a) Ice bag .

( b ) I mmersion in col d water or i ce water .

( c ) V ery hot sponging .

( d ) S tupes .

( e ) Weak chemical i rritants as neu tral sali ne bath bicar , ,

bonate of soda bath saline sponging alcohol rub wi tch hazel

, , ,
-

rub menthol compres s

,
.

( f ) S hort sweating bath followed by tub shampoo and cool

bath .

1 . from variou s cau ses

P ru r i t i s .

2 . H i ves and heat rashe s .

3 . Formication .

4 . N umbne ss and tingli ng .

5 . B urning and smarting .

I N SO M N I A
Baru ch not i naptl y style s the i nsomn ia of neurasthenia an
opp r obr i u m m edi cor w n If one were to form an op inion from
.

the bad eff ects of medicinal treatment and the fre quency wi th
wh ich su ch treatment i s u sed the condition i s indee d a di s ,

credit to scientific medical practi ce The insom ni a accompany .

~

i ng neurasthenia i s due to a peculi ar association of ne rve

exha u stion with h ype rirritabil ity Dou btless nerve poi sons .

from auto intoxi cation pl ay a large part in the cau sation

-
It .

would seem that congesti on of the cerebral and spinal centers

is al so a cause of ne rve i rri tabil ity and sleepl es snes s It i s .

present i n the maj ority of ca se s .

Becau se of the lack of nerve tone general tonic treatment a s , ,

outlined for neu rasthenia i s qu ite as es senti al as sedative ,

measures which aim pri ncipall y at the insomnia I n many .

patients lack of norm al fati gue i s the ch ief if not the sole
, ,

cau se In su ch cases a mil d or even a vi gorou s t on i c treat

.

ment given about an hou r before bedtime w ill produ ce th e be st

results With some pe rsons brisk exe rci se to the point of
.

moderate fati g ue taken ju st before retiring wil l accompl ish

, .

the same res ults .

We have princi pall y to consi der the insomnia du e to increase d

 re flex excitability and unu sual irritabil ity of the nerve centers .

The condition may be pe rpetuated long after removal of the

first cause ha s been e ff ected Thi s i s especiall y tru e of those
.

patients who can t go to sleep because of constant worrying

’

about the ir inabil ity to sleep The se persons are the bane of .

the neu rologist s l ife The y are exceedingl y i ntrospective and

’
.

ofte n almost hysterical I n order to de crease re flex excitabil ity

.

it i s ne ce ssary to remove as far a s poss ible all external stimul i

and at the same ti me decongest the spinal and cerebral centers .

For these pu rposes the i deal means is fou nd i n the neutral

bath or pack . The body i s enveloped i n a non irritating -

medium the skin i s sligh tl y war m ed and both the ski n and
,

the skeletal mu s cles relaxe d The temperatu re of the neutral

.

0
bath shoul d be not le ss than 9 4 F and it i s often bette r to u se .

water a l ittle warmer say 9 6 or 9 7 F since the warmth

,
0 0
.
,

se cures a fu l l rel axation The bath should be given i n a qu i et

.
,

fairl y warm room and last for fifteen or twenty m inutes to a

half hou r or longe r The di sturbing e ff ect of drafts may be
.

avoi ded by stret ching a sheet across the top of the tub It i s .

well to lowe r the temperature of t he water two or three degree s

j u st at th e close of the bath A patie nt s houl d never be put .

i nto a neu tral bath with cold feet A ll parts of the body shoul d .

b e warm befo reha n d The neutral bath or warm bath ha s an

.

e ff e ct s im il ar to the neutral pack i n cau s ing the s inking of the

brain substance The rationale of the wet sheet pack has
.
“

already be en explained \Vith many patients it i s the most

.

effi cie nt means th at can be used B y means of woolen blankets .

the cove r i ng of the pack can by an observant nu rse be so , ,

regulate d a s to be kept constantl y at the neutral s ta ge The .

feet should be more warml y cove red than the u pper par t of the
b od y A n exceedingly re stle s s patient who has had but l ittle
.

sleep for week s may sleep for hours or all n ight i n a neutral
p ack.

F or c a se s of agitative neurasthenia with insomni a w e have

'

r ecentl y fou nd the oxygen bath more e ff icient th an a n y other

0 0
means The temperature of the water should be 9 7 or 9 8 F
. .

since the oxygen gas produces a sligh t anemia of the skin For .

the same reason it i s well to precede the bath by a hot foot

3 08 S E D A TI VE E FFE C TS
bath or fomentations to t he Spi ne The bath itself lasts twenty .

minutes N o pou r or showe r or any other stimul ating measu re

.

should be used afte r it The bath shoul d be take n i n the late

.

afternoon or earl y evening neve r l ater than ,

P M I t may . .

be u sed daily but it seems to give as good or better re sult s

,

admini stered three time s a week onl y The method and othe r .

e ff ects are descri be d unde r te chni que ( g .

T he salutary e ffects of a drugle ss sleep are fel t a l l the nex t

day .
There i s not the u su al afte r —tende nc y to drows i ness .

The patient feels l ike h imself Q uite the c ontrary c ond iti on
.

follows the rest obtained by trional the brom ides and othe r ,

hypnotics The patient i s l ikel y to be d rows y du ri ng the su c

.

c e e di n g forenoon For thi s reason medi cinal sop or ifi c s ofte n

'

defeat their own end The patie nt mu st be kep t awake during

.

the daytime so that natural fatigue may res ult and thu s the
system demand rest and sleep .

There are many other measures whi ch will be fou nd u seful _

.

The milder t ype s of insomn ia respond very qui ckl y to a set of

three fomentations to the spine given j ust at bedti me If .

thought be st this may be followed by a l ight rub e ither to the

,

spine alone or to the body gene rall y The tep id spi nal a ff u sion .

has an e ffect similar to the spinal fomentation I t shoul d be .

applied to the lower dorsal and lumb ar spine S ome case s of .

insomnia seem to be due solel y to cerebral h yperem ia Thi s i s .

common in brain workers I n these case s the feet are almost

.

i nvariabl y cold If the u nbalance i s extreme a very hot foot

.
,

or leg bath with col d to the head shoul d be gi ve n for about ten
or fiftee n m inute s Th i s shoul d be foll owed by an alternate
.

hot and col d percu ssion dou che to the feet S ometime s the .

latter will accompli sh the results as wel l when given alone a s

following the hot foot bath The vigorou s fl ux i on p rodu ce d i n
.

the feet by the combination of percu ssion with the rmic stimul i
re sults i n more permanent ce rebral derivation than a hot foot
bath alone .

The moist abdominal girdle i s an excelle nt adju nct to a

sedative treatment A s shown by the experiments of Sc hii l l e r
.
,

it lessens the filling of the cerebral ve ssel s I t m a v be u sed .

after any of the treatments recommended above It shoul d b e .

81 0 SE D A TI VE E FFE C TS

once or twi ce a day a nd

hour The bath shoul
.

° 0
96 or 9 7 F O n the .

substitu ted with goo

be u sed being kept at the
,

the sam e length of time a

:

allowed to slee p in it and be

A fter some i mprovement h
davs other ,

tonic e ff ects
such
aff u sion or
abdominal bandage
the spine followed ,

twenty minutes i s an
course of treatment t h ,

tinned I Vhe n c onv al e s

.

fri ction col d towel ru b

, ,

u sed al so l ight massage

, A ll .

remed y the anemia ; even the n

di re ction The beneficial e ff ects
.

su nshine and fresh air can not be

I n case chorea i s com
system of treatment shoul
doc ar di t i s of rheumati sm .

substituti on of sedative treatment once or

of the tonic treatment su ch as the col d mitten friction ,

rheumatic endocarditi s .

P A RA L Y S I S A G IT A N S
While this is considered an in cu rabl e a ff ection t he ,

may be much be nefited and the p rogre ss of the di

for qu ite l ong periods of time by g e
combine d with sedative and mild
measu res recommended above for
shaking pal sy Dana e s pe ciall y
3
.

( neutral ) bath and m

3 T xt B e k f N v u DW oo o er o s
f th N v u Sy t m
.

4 Di sea ses o e er o s s e .
 SP A S TI C P A R A L Y SE S

improvement following the u se of the faradic bath V ibrating .

chairs or vibrati ng machine s adj usted to give a fine rapid move

ment ma y show good re sults O utdoor l ife i n the woods and .

cou ntry are e speciall y beneficial .

S P A S TIC S P I N A L P A RA L Y S E S
There are a nu mber of le sions of the cord wh ich ultimatel y
resul t in degeneration of the u pper motor neuron chiefly in the ,

l ate ral col um n The inhibitory control from the cerebral cortex
.

be ing cut off a condition of Spastic p aral ysi s results i e a

, ,
. .
,

loss of control as sociated with rigidity and spasticity of the

mu scle s S u ch a condition occurs afte r various forms of
.

m yeliti s especiall y a transverse myel iti s al so i n amyotrophi c

, ,

l ateral s cl eros is If there i s an acute onset as by trauma or i n

.

fl am m a t i on as frequentl y occurs i n mye li tis the patie nt mu st

, ,

be pu t to re st either absolute or partial a ccording to th e

, ,

natu re and nee ds of the case I n some case s gentl e spinal ex

.

ten sion should be u se d for some weeks and pe rfect qu iet ob

s erved I n other ca ses the patient may be allowe d to mo ve
.
,

about the bed During th is time s pinal fomentati ons may be

.

appl ie d twice dail y fol lowed by the he ating spinal comp re s s

, .

The warmth of the l imbs s houl d be m ainta ined by the hot foot
bath or hot water bottle s I t i s ne cessary t hat the patient be
.

given toni c treatment to keep u p the nu trition and invigorate

the circulation These must however be quite mild su ch as
.
, , ,

th e wet hand rub and moderatel y cold mitten frictions Late r .

,

l ight mas sage to the l imbs may be u sed .

A s soon as the necess ity for absolute rest i s past in the ,

chroni c s tage whe n s pasticity become s marked nothi ng has ,

proven so h el pful a s the prolonged neutral or warm bath In .

those cases i n wh ich c u r e i s pos sible th is measu re i s a l most a

specific The patient shoul d be made very comfortable i n the
.

tub by u sing a sheet hammock rubber p illows etc The

—
.
, ,
° O
tem pe ratu re of the water should be from 9 5 97 F It must .

feel sl ightl y warm to the patie nt A t first the bath may be .

twenty minute s to an hou r in l engt h graduall y increasing the ,

time u p to th ree or fou r hours of conti nuou s i mmersion dail y .

E ven si x hours in the neutral bath may prove beneficial .

31 2 SE D A TI VE E FFE C TS
Whe re the ne c e ssary facil itie s can be ha d the continuou s fl ow ,

ing bath i s a most grateful substitute The gentle motion of .

the wate r appears to add mu ch to the eff ect The sal utary .

eff ects are m anife st i n a l essene d degree of rigi dity the l imbs ,

become more supple and can be separated to a greater extent .

In order to obtai n any pe rma ne nt benefit the patient mu st ,

submit to treatment for man y m onths .

I n the subacute stage positive gal vanism to the spine ma y

,

be useful During thi s time mil d alternating hot and col d

.

applications may be u sed to the part of the spi ne a ff e cted .

Later i n th e disease prol onge d neutral baths give be tter

,

re sults .

L O CO M O T O R A T A X I A
I n the treatment of tabes dorsal is we are concerned chiefl y ,

with the first two stage s the i nitial or pre ataxi c and the ataxic
,
-
.

I n the paralytic or third stage there i s l ittle that can be done

,

except to make the patient comfortable and treat symptoms as

the y ari se .

I n the pre ataxic stage the patie nt m u st be pu t to rest Thi s

-
.

may be accompl ished by restricting or prohibiting exe rci se I t .

i s u suall y best to p re sc r i b e exe rci se altogethe r for a time The .

wheel chair may be u se d or if thou ght be st the p atient may be

, ,

pu t to bed for two or three month s S i mple re gul ar habit s are

.
,

imperative Du ring the pe ri od of re st th e patient may be

.
,

tre ated by fomentations to the spine col d m itten frictions and ,

the warm bath Dana re commends that th i s latter be given

.

for ten to twenty mi nute s dail y and fol lowed b v a single col d
pou r to the spine and rubbing The obj ect of treatme nt during.

this stage i s to keep u p the patie nt s ge neral nutrition and a ff ord

’

re st both mental and ph ysical so a s to rel ieve the tax on the

, ,

spinal nerve s .

I f the progre ss of t he di sease can be stayed the treatment

'

outl ined for the ataxi c stage may be ventured u pon beginning ,

mildl y . The Fraenkel exe rcises may now be be g un These .

s hould at first consi st of the more simple movements and the ~

eff ort re stricted to a few mi nu tes Late r on as coordination.

,

improves the y may be more prolonged and made u p of more

,

compl icated exerci ses .

31 4 SE D A TI VE E F F E C TS

and hyperactivity
descri be d as h ype
le ss glands producing an i nternal
cal nature of th is secretion i s no
closely associated with some i od
'

that class of subs tance s know

mone s It exercise s a spe cial
.

known as cretini sm i n which ,

main in an undeveloped state .

of the gland produce s the con

cachexia st ru mipriva I n thes .

bel ow par ce rebration i s,

ments are del ibe rate and physi cal ac t i v

The opposite condition known as hyp ,

either by h yper troph y of the glandul ar t is

doses of th y roid extract produce s a train ,

oppos ite of the above The patient .

able and may be subject to insom nia

,
.

of the fingers when the hand i s hel d away from

w ith the digits S pread During the earl y part of
.

mental activity i s exce ssive ideation i s rap id and , ,

functions are increased in acu ity If intoxi cati on .

tense the pul se m ay be very rapid

, ,

1 60 or more per mi nute ; the Ski n

being covered with perspiration t h
blood vessel s are dilated
-
.

hastened as Shown by the fever and

nitroge n There i s a feel ing of lang uor
.
,

come ve ry marked I n the gland itself .

,

de ficient i n amount there i s an i nc r e a

,

secreting cells even to the filling of the

,

blood ve ssel s of the gland are dilate d

-

numbe r Later the paren c hymatous cell s

.
,

l ysi s ) l iberating a l arge amount of th yroid

aggravated symptoms may be present while
The stethoscope applied over the gland fre qu
tol ic
 H Y P E R TH Y R OI D I SM

troph y of the parench ymatous ti ssue the thyroi d i s enlarged , .

Later i n the disease the e ye s beco m e promi nent the l i ds are ,

closed w ith di ffi culty and t he e yes feel dry I t i s su pposed that , .

the exophthal mia i s du e to dilatation of the bl ood ve ssel s in the -

orbit .

I t will be seen th at these conditions se t forth the nece ssity

for treatment directed toward decreasing and depre ssing the
activity of the th yroi d gland I n the spontaneou s cure of .

thi s condition the colloid material increase s i n amount pro

, ,

d u c i n g p re ssure u pon the pare nchymatou s cell s thu s cau sing ,

their atroph y The increase of the fibrou s stroma of the gland

.

ha s the sam e e ff ect I n these facts l ies the rationale of the

.

beneficial action of the X ray It has a Speci fic e ff e ct in d e s -

.

t r oyi n g or cau sing atroph y of highl y diff erentiated tissue while ,

it favors the produ ction of conne ctive tissue X ra y exposu re s .

-

S hould not be given so frequentl y as to cau se u ndul y rapid dis

i ntegration of th e secreti ng cells i n whic h case thy roid i n t oxi ,

cation may ensue The va scula rity of the gland must also be
.

decreased .

6
A l be rt Ko oker makes the fol lowing statements : B y redue
i ng the hype r trophi c thyroid ti s sue or reducing i t s blood suppl y ,

w e redu ce the p os s ibility of too extensi ve reaction to the p ri

mary cause and al so e nable the gland to adapt itsel f to cou n
t e r a c t new ou tbreaks of primary cau ses whi ch a ne rvou s subject
can easil y Sh ow .

The fact that i ncre ased vascularization i s indi spensable for

the development of the di sease also proves that what reduces
”
vascul arizati on prevents its development .

A t the same time it i s ne ces sary to Slow the heart rate and
.
i

re store the blood ves sel s to the i r normal tone Whil e all cases
-
.

will not respon d to the same treatment or even to di ff erent ,

measures a rranged i n di ff erent wa y s yet i n general the treat , ,

ment Should con si st of the mean s making up the following pro

gram : A n ice cap Should be place d over the goiter almost con
t i nu o u sl y or for th i rt y minute s to an hou r from two to five times
a day The se cold applications re fl e x l y contract the blood
—
.

6 S gi
ur ca l
—
T re a t m e n t o f E x O p h t h a l m i c G oi t e r J
o u rn a l o f Am e ric an M di
e c al A ss oci a

t i on , O cto b e r 1 2 1 90 7
, , pp
1 2 4 2 1 243
. .
31 6 SE D A TI VE E FFE C TS
ve ssels of the gland thu s decreasing its vascu larity and the
,

amount of blood i n th e gland The y al so tend to inh ibi t or

.

depress the glandular activity decr easing the formation of the ,

i nte rnal secretion A t the same time an i ce bag should be

.
,

appl ied to the precord ia in much the same manner and for th e
same length of time as the i ce bag to the goiter I t may be .

fou n d convenient to al ternate the se applications keep ing the ,

i ce bag ove r the goi te r for thirty mi nu tes then appl ying it to ,

the heart for the same length of time the n reappl yi ng i t to the ,

goiter ; the se alte rnations be ing continu ed m ore or le ss du ring

the entire day The vaso dilatation and warm m oi st Skin r e
.
-

qu ire some treatment which will restore the ve ssel s to the i r

normal tone and check the over activit y of the sweat glands -
.

Thi s i s be st accompl ished by the cold m itten fri ct ion It shoul d .

be give n from one to three time s dail y Many of the princi .

ples governing the tre atment of organic hea rt di sease are i n

volved i n the tre atment of paren chymatou s goiter The cold .

fri ction by re stori ng the pe riphe ral vessel s to the i r normal tone
, ,

assi sts the heart action and so reduce s the rate .

The vascular conditi ons pre sent i n exophthalm ic goiter and

“

the therapeutic indications to be de ri ve d therefrom are very

ably discu ssed by J ames Mackenzie from whom we quote the
7

following :
The es sential featu res arising from the circul ation i n many
cases of exophthalmi c goiter it see ms to me are the ab n ,
ormal ,

and persistent dilatation of the arterioles and a heart acting ,

with a force rel ativel y great to the re si stance opposed These .

are indicated by the rapid and forcible p u l se wave felt by the -

finger and the vi sible pul sation of the su perficial a rteries and
,

the carotid The co r responding sphygmograph i c feature s a re

.

a high upstroke and a rapid fall so that the d i e r ot i c notch i s ,

near the base l ine The rate of the pul se may be greatl y i n
The same factors —the
.

creased up to 1 4 0 to 1 60 per minute

, .

u nu su all y forcible injection of the blood into the arterie s of low

—
blood pres sure are present i n aorti c regurgi tation Though .

the beating of the caroti d i s due to Similar cau ses i n the two
cases the low arterial pre ssu re at the end of the diastole i s
,

7 Di f th H
se ase s o t S e nd E d i t
e ar p 1 33
. eco ion, . .
31 8 SE D A TI VE E FFE C TS

t rue there i s a natural tenden cy to recovery among you ng

adults nineteen out of twenty recove ri ng without mu ch
,

treatment but rest H yperth yroidi sm beginning i n persons

.

from eightee n to twenty years of age i s l ikel y to ru n a course

of three or fou r years and e nd i n a spontaneou s cure O pera .

—
tive interference will be mu ch le ss frequentl y nece ssa ry when
the se measu res rest h ydrotherap y etc — are given a thorou gh
, ,
.

trial by those experien ced i n thei r u se .

ME T H O D S F OR T H E RE L IE F OF P AIN
D e e p Se ate d l nflam m ations
-

Those treatments which have al ready bee n outli ned for th e

relief of conge stion and inflammation in i nte rnal organs are al so
most e ffective i n rel ieving the pai n occa s ione d by th e i nfl am
mation I n the maj ority of case s derivation by collateral heat
.
, ,

together with col d directl y over the part i s u sed to rel ieve the ,

congestion and pain I n others hot appl ications alone are

.
,

u sed This i s true of pleu ri sy i n wh ich col d appl icati ons i n

.
,

crease the pain I n many cases the pain i s relieve d be st by

.

very hot appl ications appl ie d dire ctl y over the s eat of pai n It .

h as already been mentioned that c o l d may be u sed over an i n

fl a m m a t o r y proces s i n soft ti ssue whi le in bony parts i t i s ne c
,

essary to u se hot appl ications dire ctl y over the seat of the pai n .

In the ease of osteomyel itis and u sually i n mastoiditi s cold ,

applicati ons or the i ce bag appl ied over the in flamed p art i n
creases the pain When an i nflammation has gone on to the
.

formation of an abscess cold appl ications especiall y the ice bag

, , ,

have very little i nfluence on the pai n a s far a s rel ieving it i s

concerned and may make it worse
, Fomentations ove r an a b .

sce ss may rel ieve the pai n for a time bu t thi s doe s not last as ,

l ong a s the rel ief a ff orded previou s to th e form ation of the

abscess .

I n order to decrease the throbbing pai n of an inflammatory

process or collection of p us in the bone it is best to apply the i ce ,

bag over the large artery suppl ying the i nflame d pa rt T he .

relief of the pain i n thi s case i s brought about chie fly by redue

ing the conge stion If at the same time a very hot fomenta
.
, ,

tion i s appl ie d ove r the part the e ff e ct is i ntens ifie d by the

,

Specifi c pain relieving act ion of the heat

-

.
 R E L IE F OF P A IN

Sup e rfi c i al Inflam m ati on

I n the early stage of a su perficial in flammation a prolonged ,

col d appl i cation is u su al ly very e ff ective i n reli eving the pai n .

Thi s Shoul d be accompl ishe d by immersion in cold water or ice

water or by the u se of the ice bag Late r on it will be found
.
,

that very hot appl ications more eff e ctivel y rel ieve the pain .

E ither very hot fomentations or hot immersion may be used .

S ometi mes the neutral or wa rm pour i s very grateful there ,

seem ing to be an added e ff e ct from the aff us ion that i s not ob

ta i ne d by qu iet immers ion The production of fl ux i on by alter
.

nate extreme hot and col d i mmersion i s productive of good

results where the re i s not m uch throbbi ng pain .

G astri c or D u o de n al U lc e r
It i s of te n the cas e th at the pa in i s worse du ri ng th e t ime
that there i s l ittle if any he mo rrhage from the ulcerated su r
, ,

face . I n case he morrhage of any moment occu rs it i s mece s ,

sary to u se some col d appl ications su ch a s cracked i ce by

,

mouth or the i ce bag over the stomach O the r wise the pa in .

,

i s be st rel ieved by very hot fomentations appl ied to the e p i g a s

t ri u m or the full hot tru nk pack
,
The se appl ications m y be
.

followed by e ithe r the moi st abdominal girdle or by the heating

wet Sheet trunk pack The e ff ect of these applications i s to r e
.

lax the mu scul ature of the stomach and so by de creas ing peri ,

sta l s i s relieve the pa in incident t o m u s e u l a r contractions

'

.
,

R e c tal U l c e r
The same principle s appl y he re as above The pain is most .

e ff ectivel y relieved by appli cations wh ich relax the bowel thu s ,

d e c r e a s m g the movement and consequent irritation of the ulce r

ate d surface Th is may be accompl i shed by the hot enema or
.

fom entations .U su all y the hot s itz bath i s much more e ff ective .

H e m orrho ids
Two diff erent plans may be followe d i n rel ieving the pai n
dcc a si on e d by rectal varicose vei ns V ery hot applicati ons are
.

e ff ective in relie v i ng the pai n but the se have no tendency to

,

decrease the Size of the he mo rrhoids O n the contrary they

. ,
32 0

m ay increase the
sequent pain O f the h ot .

very hot S itz bath i s most eff ective .

a re not at hand fomen tation s may be

,

For permanent re sults we prefer ,

the prol onged col d sitz bath i ce bag ,

hot and cold pe rineal spray To be effect .

should be re peated once or t w ice dail y for

temperature of the cold Sit z bath may be
as the patient i s able to bear it .

N e uralg ia

The clas sifi cation of neu ralgias int o t wo types

the treatment of this condition S im ple me .

pre ssure from tu mors exos tose s etc we , ,

.
,

e ither tox ic or i nflamm atory B y the ter m .

such neu ralgias as are due to r he u m at i

or s ome for m of au to intoxication The -
.

the cau sation of th is form of neu ralgia i s t

i n s i n the body or the accumulation of tox
,

centers or nerve tru nk s .

B y the term inflammatory neu ral gia we ,

conditions as are due to actual inflammation ,

fl a m m at i on s as pass through the regu lar stage

8
tory process from acute to chronic
,
It ma y .

i mpossible and i n some case s u nnece ssary to

.
,

t i nc t i o n s .It wil l be readil y u nderstoo d that

changes occu rring in an ordinary inflam mation ar
the accumul ati on of toxi n s about nerve trunks .

of ti ssue s occu rs in both case s .

1 Toxi c N e uralgi a
. Whe re there i s alocal
.

toxins about a nerve trunk i t appears that ,

most eff ectuall y rel ieve the pain while col d i n

N itrogenou s extractives and othe r nitroge nou s
uble with di ffi culty The y are more readil y d
.

wate r S ince prolonged hot appl ications raise

.

fl g
8 T he t e rm i n am m a t o r y n e u r a l i a i s n o t i n t e n e d d
h
a l c o o li c ne u ri t i s w ic
, h h
l a t t e r re s u l t s i n n e r e d e g v
e l e c t ri c t e s t
.
32 2 S E D A TI VE E FFE C TS

douche applie d u p and down the thigh

I n all ca ses of neuralgia i t i s be st to
,

for the cause Wh ile the maj ori ty of ca

.

neuralgias are not

operation yet thi s
,

mi ght be mention
majority of case s ,

the pat ie nt The rel ief

.

because of shock ne rve exh au stion etc re pe a ted

, ,
.
,

render the patient much more su sce ptible to pain .

Myalg i a —L u m b ag o
Lumbago i s the most common myalgia and ,

here . It follows colds and exposu re to cold ‘

The actual cau se and the morbid condition are

stood The treatment
.

measure s in that the

,

vigorous stimulation .

failing results from the u se of l arge very

the lumbar s pine followed by the alte rnate
s ion douche to same region and heavy mas
the large lumbar mu scl es A bout once .

static spray or Shor t stati c S

so i d al or static su r g ing

tions . In acute ca se s these tre atment s bring

and in chronic cases in a few days or a week or two
, .

Te n es m us ,
—R e c t al or Ves i cal
P ain hollow mu scular organs i s chiefly due to
in
tractions of the muscular ti ssu e Thi s activity of the
.

wall increase s the irritation arising in the mucou s m

To relieve tenesmus of the bladder or rectu m ,

the hot sit z bath the most eff ectual The heat .

l onged a su ffi cient length of ti me

O nly a brief dash of cold water Sho
In some cases i t Should b e omitte d
 D Y SME N OR R H E A

shoul d be give n before fomentations or the hot Sitz i s appl ied .

Col d appl i cations sti mul ate mu scular contraction an d hence ,

increase the pain .

D y sm e n orrhe a
The condition here i s somewhat sim ilar to a tene smu s It i s
'

most freq uent i n Sharp a n t e fl e x i on s of the uteru s or may be ,

occas ione d by chill ing I n order to a ff ord i mmediate rel ief it

.
,

i s ne ce ssary to relax the mu sculatu re of the organ Col d cau ses .

contractions of the uteri ne mu scle and so prevent s the out

flow of blood whil e hot appl ication s relax the mu scl e O ften
, .

S imple fo m entations are suffi cient to a ff ord relief I t may .

,

howe ve r be nece s sary to u se the short hot Sitz bath N o cold

, .

treatment S houl d follow it The application of the u nwrappe d

.

ice bag to the s acru m may be u sed accompanyi ng som e hot ,

appl ication to the feet and legs I t may be necessary to con .

t i nu e this twe nty or thirt y m inutes H ot applications in front .

m a y be u se d at the same ti me The i ce bag when appl ied an .

t e r i ora ll y has the opposite eff e ct that i s i t cau se s contraction , ,

rath er than rel axation P robabl y the explanation of the action

.

of the i ce bag to the sacru m i n relaxing the ute r us a s has ,

been poi nted ou t l ie s i n the fact that the poste ri or area i s in

,

le s s perfect re flex relati on with the u te ru s ; and for th is reason ,

the re flex i s easily paraly z e d the e ff ect then bei ng opposite to ,

that wh ich we u sually expect from the ice bag The u se of the .

ice bag howeve r is not as sati sfactory a s hot applications alone

, ,
.

I n addition to these measures the hot ene ma a nd very hot ,

vagi nal irrigatio n may be administered prior to the use of the

fomentati on or hot Sitz I n the ca se of suppre ssed me nse s
.

with pain when due to colds or exposure to d am p n e s s ni t i s wel l

,

to u se a hot foot bath ; or be tter hot leg bath together w ith , ,

s ome local hot appl ications Thi s reduce s the e xtreme pelvi c
.

conge stion renders the outflow eas ier and so relieves pai n
, ,
.

C oli c —R
, e n al B iliary Intesti nal
, ,

The pai n of renal bil ia ry a nd intestinal coli c i s largel y du e

, ,

to spasmodic contraction of the non stri ped mu scle of these -

pa rts T he irritati on of the mu cou s membrane by the calcu lus

.

stimulates the mus c le to contract To reli eve pain from cal .

3 24 SE D A TI VE E FFE C TS

c u l us or the pain of i nte stinal col ic

hot applications in order to secu re
1 R e nal an d B i li a ry C oli c
. It .

morph ine is absol utel y e ss

u se of the full hot blanket
may often be enti rel y
fully
would otherwise be require d ,

Should be wrung from boil ing wate r ,

bed over a dry blanket and as qui ckl y

the patient A thi n dry blanket may be us e d
.

if it seems advisable It i s not nece ssary to

.

i n the pack A hot water bottle ove r the ab

.
-

bags along each s ide of the trunk will hel p to

of the pack I n cases where the pai n is
.

fomentations may be su fli c i e n t '

.

good resul ts in some cases .

prolonged col d compresse s Should be a

,

neck N o cold appl ications whateve r

.

pac k E ven a very brief appl ication of

.

pain .

2 Intest i n al C o li c
. In regard to the c a usat io
.

in hollow viscera and parti cularl y the intestine

to which it i s referred Macken z ie relate s an ,

p e r i e n ce with a patient on whom he pe rformed

secti on without anesthesia H e says I .
,

had expected and I w a s able to break down

,

recent peritoneal adhe sions to detach the m from the ,

bowel to resect a piece of bowel and me sentery and

,
,

these str uctures without the p atie nt experie nci ng the

sensation B ut I found that he occas ionally groaned
.

when I was not tou chi ng him and ,

found that the uppe r part of the re

on one Side in a warm asepti c
peristal s is ,

when thi s
him where
over the
32 6 SE D A TI VE E FFE C TS
wa rm pou r to the burned part i s ve ry e ff ecti ve i n rel ievi ng the
pain I n e xtens ive burns it i s often ne ces sary to u se a full
. ,

immersion bath of ei ther neutral or cool water I n the absence .

of facilit ies for thi s a p rolonged wet Sheet pack re newe d by

, ,

frequent sprinkl ing with col d wate r may be u sed With the ,
.

exception of extensive burns or where the pain i s unbearable ,

we do not greatl y favor the u se of hydrotherap y for th e rel ief

of the pai n The u se of p icric acid i n saturated aqueou s sol u
.

tion followe d by drying and du sting the part with stearate of

,

zinc has give n su ch good re sults i n the rel ief of pain rapid
, ,

d e r m a t i z a t i on and heal ing that we u se it as a routine treatment

,
.

Sp ra i n s an d B ruises
H ot appl ications i ncluding fomentations and h ot im mersion
, ,

are common hou sehold remedie s for th e rel ief of pai n occa
S i on e d by Sprains and brui se s The se appl ications do e ff ectu ally
.

relieve the pai n and rel ax the mu scles I n many cases mu ch .

,

better results may be obtai ne d by the prol onged col d immers ion .

Thi s reduces the congestion and hel ps to prevent exce s sive ex

u d a t ion of serum i nto the soft ti ssu es abou t the sprai ned part .

A long thi s l ine we ma y draw a practical le sson from the method

,

instinctivel y pu rsue d by wild ani mal s The y u suall y seek a .

stream or body of cold wate r and stand i n it for hours at a time .

W hatever method i s u sed at first after a day or two it will be , ,

fou nd advantageou s to ut il i z e alte rnate hot and col d appl ica

tions such as the hot and col d spray pour or immersion
, , , .

These stimulate the circulation thu s ha stening the absorption ,

of the edema .

Fra c tures
There are two obje cts to be attaine d by h y dr i a ti c appl i cations
in fractu res The se are the rel ief of the pai n and the relax
.

ation of the mu scles The l i m b shoul d be enveloped i n a large

.

fomentation or immersed in very hot water Care Should be .

taken that a b u rn or bl i ste r doe s not re sul t The se methods .

are i n too common u se to need extensive di s cu ssion I t wil l .

alway s b e fou nd easier to set a bone if the mu s cles have been

thoroughl y relaxed by the prel iminary u se of hot appl i cations .

The same princi ple s appl y to the re duction of hernia by taxis .

 H E A D A CH E

H e a da c he

The subject of headach e i s su ch a large one tha t we can not

ente r into it here with any de gree of complete ness A few .

principle s of therapeutics will however be hel pful in obtaining , ,

an u nderstanding of the scientific appl ication of phys iologi c

therap y i n the relief of thi s condition I n or de r to gi ve these .

principle s with the least possible repetition we have adopted

the classification of J W S hiel s : . .
— 10
,

. I Fu nctional headaches .

1
. Toxem i c heada che s ( acute chronic ) , .

2
. N eu ropath ic .

3 Re flex
. .

I I O rgani c headache s
. .

I I I C irculatory h eadaches
. .

1
. A nem i c .

2
. H yperemi c ( active )
3 H ypere mic ( passi ve )
. .

The above i s very mu ch a b r e v i ate d A S given by S hiel s .

eac h division embrace s from five to twelve or more individu al

—
items the de signations of morbid conditions diseases or , ,

pathol ogi c state s .

Fun c tional H ea da ches T he a cu te tox em i c nea da cnes of acute

.

i nfections acute nephritis u re m i a diabetic acidemia and acute

, , , ,

dru g poi sonings ar e be st rel ieved by dire ct and vigorou s treat

,

ment of the cau sative di seases Ice bags to the carotids and to . .

the base and vertex of the brai n will help in relievi ng the
accompanying conge stion .

The c/z r on i c tox em i c lz ea da c/z es of gout rhe umat ism constipa , ,

tion torpid l i ver and other di sease s a ff e cting m etabol ism are
, , ,

al so to be treated by treati ng the cau sative disease B ut in .

these condi ti ons it re qu ires patient persi stent e ff ort over week s ,

or months of ti me i n order to produce sati sfactory results .

O u t of door l ife
- -
sunshine and tonic and eli minative hydro
, ,

therap y will do mu ch to remove the toxins by stimul ating thei r

oxidati on . I n addition to thi s the mea su re s re commended for ,

neuropathi c headaches will p rove hel pful in relieving or miti

1 0 S hi l
e s —
C l if m ia S t t J u n l f M d i i N v m b 1 909 p 40 1
o a a e o r a o e c ne , o e e r. . . .
328 SE D A TI VE E FFE C TS
gating the distress u ntil m ore permane nt re su lts can be se cur ed
by the removal of the cause I n some of the se disease s th e .

headache i s made worse by an accompanying anemia or h yper

emia i n which case the measures recommende d below for these
,

circulatory conditions Shoul d als obe u sed .

A e nr opa t/z i c lz ea da c/z es are rel ie ved w it h ease or diffi culty

’

according as they are of Short or long standi ng i e as to , . .

,

whether or not the y have become habits appearing periodi ,

cally The ne urasthenie headache u su all y re sponds to toni c

hydrotherap y and ou t of—
.

door life I t i s the form of headache

-
.

whi ch i s most benefited by nerve pressu re and nerve st imul a

ti on Spinal and head mas sage
,
I t i s i n these ne u rO p at hi c
.

headaches that the osteopath acquire s a ju stl y obtained reputa

tio n for Skill H owever any thorou ghl y trai ne d m as seur who
.
,

has acqu ired a fair knowle d ge of anatom y can accompl i sh the

same re sults without the re cital of osteopathic dogmas wi th
which the osteopath accompani es h i s treatment and by wh ich
he ties hi s patient to hi mself and hi s creed greatl y to the ,

patient s det riment i n case of other or more se riou s maladie s

’
.

P ositive gal vanism to the bas e of th e brai n or forehead the ,

posi tive static head bree z e or m ild faradism to the head are , ,

u seful in ce rtain case s of neu ropathi c headache .

Migraine in our expe rience i s both toxemic ( metabol i c )

, , ,

hyperemic and in many cases re flex ( from the l iver stomach

, , ,

or pelvis ) I t is most di scouraging and u nsati sfactory to treat

.

as far as i m mediate r el ief i s concerne d We have atta ined su c .

ce ss onl y by a painstak ing dil igent and often prol onged search, ,

for the cau se If i t i s the expres sion of vi sceral gou t a rigidly

.
,

purin free diet with eliminative and tonic hydrotherapy fre sh

-

ai r and sunshine continued for months or ye ars will ulti

, , ,

matel y result i n a sati sfactory cure If re flex the disease d .

,

organ or function mu st be sought out and treated I n all case s .

out o f door work i s one of the most bene ficial means of treat
- -

m ent .

O rg an i c H ea da ches The headache of a cu te or chron ic

.

meningitis i s to be treate d i n the same way as any he adache

due to acute congestion The results are l es s sati sfactory .

be cau se of the high i ntracranial p ressu re Thi s factor may be .

330 SE D A TI VE E FFE C TS
susceptible to hyperemia the treatment Should
,

by the hot foot bath or hot le g pack and

ten fri ction or the alte rnate hot and
the feet in order to prevent active congestion
‘

pe rmanent de ri vation .

In conne ction with the subj ect of headach e ,

frain from utte ri ng a c aution against the u se of

i s true that patients desire and often de m a nd
immediate relief The rel ief rece ived
.
,

reform or i n many case s no attempt

,

cause s are not searche d out The he adac h .

on the next occu rrence of the headache ,

time the habit i s formed I t i s t he n a mu

.
'

matter to a ff ord temporary rel ief withou t the

more di ffi cult matte r to eff ect a permanent cu re .

The patient had better have suff ere d a little

comfort and pain and have yielde d to the
,

starting a search for the cau se and instituting a

treatment for i t s removal and the correction of
habit P racticall y all headache s othe r than
.

some of these may be entirel y reme died by

,

pai nstaking e ndeavor .

 CH APT ER XXII

E XP E CT O R A N T E FF E CT S
'

HE R E i s a definite serie s of chang e s ac com p an yi n g the course

of su ch conditions as colds acute bronchitis and simple , ,

crou p I n all congestions and i n fl a m ma t ion s of the mu cou s mem

.

brane of the re spiratory tract the fi rst change i s that of intense

,

congestion accompanied by swell ing and turge scence of the mem

brane which is dry and much i rritated I n this condition the .

”
cold i s said to be tight be cau se of the extreme i rritation and
the fa ct that the dry mu cou s membrane renders gaseou s inter
change d ifli c ul t Very soon the re begins to appear a secretion
.

of a th ick tenaciou s m u cu s accom panied by leucocytes Later

‘

, .
,

the character of th e se cret ion become s altere d It i s more .

flu id contains frothy mu cu s and i s more pu rulent i n nature

, .

”
When th i s change occurs t he cold i s sai d to have loosened
, .

From thi s time on expe ctoration be comes easier D uring the

, .

first stage of the t u rgesce nce of the mu cous membrane there i s ,

no expectoration Late r there is a ver y smal l amount of thick

.
,

mu cu s whi ch i s expe ctorated with di ffi culty ; and afte r the cold
has thoroughly loosened the qu antity i s ver y mu ch i ncreased
, ,

while the sputu m i s qu ite fluid .

I n the appli catio n of measure s de signed to rel ieve the se

conditions that whi ch appears most rational i s the hastening of
,

thi s serie s of change s and rel ie ving su ch s ymptoms as pai n and

cough Du ring the fi r st stage that is the stage of congestion
.
-

, , ,

and the se cond stage when there begins to be a secretion of

thi ck mu cus it i s neces sary to decrease the congestion and
,

increa se the flui dity of the se cretion This is be st accompl ished .

by moi st heat such a s the inhalation of steam fomentations

, ,

to the che st and throat hot water dri nking the heating chest
, ,

( 33 1 )
3 32 E XP E C T OR AN T E FFE C TS

pack or some general sud or ific measu re The moist heat .

dilates the blood ve ssel s and stim ulate s the activity of the
-

mucou s glands so that the y produce a more flu id se cre tion

,
.

These measu re s Shoul d be continued with but l ittle ch ange

until the symptom s are conside rabl y a meliorated Then after .

the first day it i s be st to employ alternate hot and cold appl ica
tions the revul sive com press cold mitten friction etc i n order
, . ,
.
,

to promote resolution absorb the exudate and prevent further

, ,

excessive secretion Thi s i s best a ccompli s hed by stim ulating

.

the circulation so e quali z i ng it that congestion of the pul mon

,

ary mucous membrane and the mucou s me mbrane of the nose

and th roat i s de creased The se measu res also stim ulate th e .

de pth of respi ration and i ncrease gaseou s interchange Al l .

s u d o r i fic measures ease di ffi cult resp iration and increase the

'

flu idity of expectoration The following are the most u seful . .

measu re s in the treatment of i n fl a mm a t i ons of the re spiratory

tract :
1 . Ru ssi an or vapor bath .

2 . Inhalation of steam plain or medicated , .

3 Fomentations to che st and throat or the hot trunk pa ck

.
, .

4 H eating chest pack and heating throat comp re s s

. .

5 H ot wate r dri nking

. .

S everal of the se m ay be combined : for example fomentations ,

to the che st and throat may be accom panied by hot wate r

drinking inhalation of steam and the hot foot bath E x p e c
, , .

toraut e ff ects are i ndicate d in the followi ng conditions :

1 Colds .

2 A cute bronch iti s

. .

3 Chronic bronchitis
.
.

4 A sthma
. .

5 C roup
. .

6 B ronch iectasi s
.
.

7 P ulmonary tube rculosi s

.
.

P r eca uti ons A ll

of the applications recommende d for e xp e c
.

toraut e ff ects are of a more or le ss diaphoretic nature and con ,

sequentl y the patient i s pre disposed to col ds and there i s greater

l iabil ity to a return of the symptom s For the se reasons i t i s .
,

be st to employ such mea sures as the al cohol or witch hazel ru b -

33 4 E XP E C TOR A N T E FFE C TS
to the che st and n e c k Thi s should be conti nued u ntil t he
.

harsh brassy cough give s wa y to free and eas ier expe ctoration
,
.

Whe n this occu rs the dyspnoea and cyanos is wil l be relieved .

The inhalation of medicated steam i s a great ai d in the treat

ment S pecial i nhal ers may be provided ( F ig s 5 7 a nd
. or .

an ordinary tea — kettle or basi n may be util ized for the produ ction
of steam which may be conve ye d to the patie nt by means of an
i nhal ing funnel or mask The drinking of some h ot l iqu id will
.

increase the sweating and hasten the loosening of the se creti ons .

F ig . 57 . I nh ale r d
for m e i c a t e d st e a m . ( K e ll o gg )

The heating compres s or the moi st che st pack Shoul d be applie d

after the fome n tations and left in place from thi rty mi nute s to
two or three hours The child u suall y fal ls into an eas y sleep
.

following such treatment I n some case s it may be necessary

.

to dispense with the moi st ins ide part of the chest pack u sing ,

only the dry pack .

A S T H MA

The treatment of the asthmati c paroxysm by means of h ydro

the rapy i s a disappointment and thi s i n Spite of the fact that by
,

a more or le s s prolonged course of hy dr ia t i c dietetic and cl i , ,

matic treatment ve ry severe cases of asth ma of long standing

,

are almost completel y cu red P ermanent and ve ry de cided r e

.
 CH R ON IC BR ON CH I TIS
su l t s
are obtained i n case s that submit to treatment for a su ffi
cie nt length of ti me H y d r i at i e appl ications however ma y be
.

, ,

made to assist i n rel ieving the patie nt du ring the paroxysm

Two obje cts are to be attained the lessening of the dyspnoea
,
— .

and facil itating expectoration The se may be accompl ished by

.

some mil d s weating treatment fomentations to the che st or the

,
,

i nhaling of medi cated steam A s soon as the patient break s

.

out into a gentle pe rspirat ion the dyspn oea begins to lessen
, .

F ig . 58
. A n im p v d
ro e c rou pk e t tl e . ( D ief en b h
ac

C H R O N IC B R O N C H I T I S
Thi s condition i s treate d in mu ch the same manner an y

chronic inflammation The resu lts to be obtained are : First

.
,

relief of the cou gh ; and second les sening of the amount of ex

,

p e c t or a t i on and fa cil itating i t s expulsi on The patient Shou ld .

be give n a definite program of treatment such for exampl e as

-

, , ,

the following : H ot foot b ath together with fomentations to the

,

che st an d the col d mitten fricti on ; also fomentations or r e v ul

sive compre s s to the abdomen revu lsive com pre ss to the che st
, ,

hot and cold to the Spine cold towel rub salt glow
,
It i s , .

u suall y be st to have the patient wear some form of a dry chest

pack A l l of the se measure s stimulate the circulation reducing
.
,
83 6

the venous stasi s in the lungs a nd promote

,

fact that the circulation i n the l ungs i s

crease th e amount of the secretion The .

re si stance i s rai sed by such a course of tre atme nt .

The dige stion requ ires Spe cial attention .

i s not a bad name for many case s of chroni c

the indigestion auto intoxication and sl ug g i s
,
-

li ver are ve ry l argel y accou ntable for the

If the patient may be i ndu ced to gi ve u p al l com
de sserts meats rich and hi ghl y seasoned foods and
, , ,

self to a very si mple diet the condition will yield to

, .

much more readil y . The sam e i s true of br onch i al

a stoni shing are the re sults obta ined i n both these
rigid dietetic regul at ion accomp anied by gene ral
,

ment that although re qui ring a long time to

, ,

seem almost mi raculou s .

338 D IA P H OR E TIC A N D D I UR E TI C E FFE C TS

8 .Dry pack .

9 E lectro thermal pack

.
-
.

1 0 H eating wet Sheet pack

.
.

1 1 .H ot Spra y or dou che .

1 2 .H ot leg or foot bath .

1 3 H ot Sitz bath
. .

1 4 Fome ntations to the spi ne

. .

1 5 H ot water dri nking

. .

1 6 H ot enema
. .

E ach measu re ha s i t s own range of appl icabil ity

adaptability to the needs of the indivi du al case .

local and milder measu res have a wide ra nge of

The more extreme and ge neral b e
contraindications which mu st not
applications Shou ld u sually follow sweatin g
main e ff ects of diaphoretic appli cations are a s
1 .I ncrease perspiration ( water chie fly ) .

2 Increase catab ol ic change s ( spol iative or

.

3 I ncrease el imination of
.

through the kidneys indi rectl y

ove rworked or conge sted ,

whi ch i s done In health

.
,

the amount of u ri ne and may

all conditions where there i s l e S
kidneys diaphoretic me as ure s te nd to
,

hasten the elimination of toxins through that channel .

4 Increase the acti vity of the sebaceou s glands and

.

general thu s improvi ng its nutrition

, .

5 Reli eve internal conge stion

. .

6 Decrease dropsical e ff u sions

. .

7 P repare the patient for cold treatment by

.

ability to react .

There are a l arge number of conditi ons in wh ich

measures are i ndicated I n a few disea se.

sweating treatments may be

given a l i st of dis
spe cial diaphoretic
u sed in all but the first three .
 D I UR E TI C E FFE C TS
I n di ca ti on s for diaphoresis :
1 . I c terus .

2 . S ystem ic poison ing ( toxemia ) .

3 . I nte rnal congestions .

S econdary syphili s .

5 . O besity .

A cute rheu mati c feve r

\
O .

G outy rheu matis m

I

\ .

O
O G ou t ( poda g ra ) .

O
\ B right s disease acu te and ch roni c
’

, .

1 0 . U remia .

1 1 . E clampsi a .

Con tr a i n d i ca ti on s to ex tr e m e s u dor i fi c measu re s .

1 . A sthma .

2 . O rgani c heart disease .

3 . E maciate d rheumatics and di abetics .

4 . S unstroke and heatstroke .

P ulmonary tu berculosi s .

6 . A st he ni c fevers .

7 . I cte ru s .

8 . E maciation and exhau stion .

9 . O l d age .

D I U R E TIC E F F E CT S
We have prev i ou sl y shown the close connection exi sti ng
between the functions of the kidne ys and skin in disease s of
e ither of the se organs A bove i s given a l ist of the vari ou s.

s u d o r i fi c measure s A l l of these treatments are beneficial i n

.

conditions of defective kidne y acti v ity It has long be en .

k nown that nephritis and disease s of metaboli sm clos el y ,

a ssociated with the functions of the kidney are benefite d by ,

free diaphores is I n these diseases al l brisk sudori fi c measures

.

i ndire ctl y i ncrease urinary secretion This i s p r ob ab l v due to .

the fact that renal conge stion is le ssene d the stagnation ,

rel ieved so that while there i s l ess blood i n the k idne ys at any
.

one ti me the rapi dity of the renal circu lation i s increased The
,
.

secretion of u rine i s therefore more effi cient and the q uantity of

the water y and soli d constituents is increased The increase in .
 D IA P H OR E TIC A N D D I UR E TIC E FFE C TS
u rinary sol ids i s due not alone to sti mulation of the renal
epithelium by a qu ickened ci rculation but al so to heightene d ,

metabolic changes occu rring in the ti ssue s themsel ves The .

sti mulation of the ge neral ci rculation and e spe ciall y of th e

hepati c circulation and of the l iver cell s p rodu ced by sweating ,

treatment or accompanying the reacti on to col d treatme nt ha s ,

been Shown to i ncrea se the t oxi c ol y t ic powers of the li ve r .

Toxemia i s thu s lessened i n a very direct manner Th e bl ood .

being less toxic i rritation of the renal cells is decrease d and

,

the work done by the kidne y i s m ore eff icient .

The followi ng are the principal diureti c mea su res which are
u seful i n k idne y insuffi ciency and allied conditions :
1 .Full blanket pack .

2 E lectric l ight bath

. .

3 Russ ian and other vapor bath s

. .

4 H ot ai r baths
. .

5 Ful l warm tub bath

. .

6 Water drinking ( espe ciall y with above )

. .

7 Col d ( or hot and cold ) dou che to lowe r ste r nu m and

.

lumbar spine ( entire width of back ) .

8 Cold heating trunk pack or the rubbing wet sheet pack

. .

9 Fomentations to l u m b ar sp i ne
'

. .

1 0 Inter m ittent or continuou s p roctocl ysi s with warm ph ys io

.

logic salt solu tion .

I n di ca ti ons :

1 . B right s disease acute or chronic

’
, .

2 . U remia ecl ampsia and othe r toxemias

, , .

3 . A cute suppression of the u rine .

4 . E ther and post ope rative neph riti s

-
.

5 . P tomaine poisoning .

6 . P oi soning by lead tu rpe ntine alcohol etc

, , ,
.
3 42 S YS TE MIC AN D ME TA BO L IC D ISE A SE S
pack The full hot bath and the m ud baths commonly u sed at
.

hot Springs may be u sed These do not howeve r have any .

, ,

advantage ove r the first three measu re s mentione d .

The patient Shou ld have one prol onged swe ating treatment
dail y I t i s ofte n ne cessary to finish wi th a ve ry Short cold
.

Spray This Should not be greatl y prol onged for the rea sons
.

above mentioned The patie nt Shou ld take as much vigorou s

.

exe rcise as possible H eavy massage ma y al so be used

.
. I t is .

needless to say that the following of su ch a program will re sult

in weakening the patient as well a s in re du cing the weight , .

These measu re s will all fail unless the diet i s redu ce d e speciall y ,

as regards the total number of cal ories A S soon as the patient .

returns to hi s u sual habits of i nactivity and over feeding there -

will be a prompt gain in weight whi ch wi l l re pl ace all that ha s

bee n l ost E xtreme sweating treatme nts do howeve r materi
.
, ,

all y reduce the weight and by guarding the diet and e n c ou ra g ,

i ng exercise the loss i n weight may be qu ite permanent

, .

ICT E R U S
It i s u suall y imposs ible to e m p loy p rolonged or extreme dia
phoretic treatment i n thi s conditi on but free perspiration ,

Should be encouraged s ince by increa sing the eli mi nati on of ,

bil e through the sweat it rel ieve s the nervou s irritabil ity and ,

ai ds in relieving p ruritu s Local hot appl ications are ill y borne .

becau se of the extreme sensitivene s s of the Ski n The ele ctric .

light bath i s a very e ffi cient mean s sin ce i t s heat i s evenl y di s ,

tributed The drinking of much water i s an es sential for both

.

free diaphore si s and d iure si s .

SY S T E M IC P O I SO N I N G

I n man y conditions i n which toxi c substance s circulate i n the

blood and l ymph free diaphore si s materiall y hastens thei r
,

el imi nation S uch substance s may be produ ced by au to in tox i

.
-

cation from i nte stinal source s or faulty metabol ism G eneral , .

poisoning may re sult from the inge stion of ptomaines lead , ,

mercu ry alcohol etc , In some case s vigorou s diaphore si s i s

, .
,

nece ssary ; i n others onl y mild diaphoresis with cop iou s wate r
,

drinking shoul d be u sed Becau se of the weakne ss and debil ity .

 GO U I
’

3 43

re sul ting from the p oison extreme sweating measures can not ,

be u sed A short ele ctri c light bath i s often al l that i s meces

.

sary Re nal el im ination shoul d be hastene d by free water

.

drink ing .

I N T E R N A L CO N G E S TI O N S
The u se of su dor ifi c measu re s in rel ieving conge stion of the
vi sce ra ha s be en cons idere d el sewhere e spe cially i n connection ,

with i n fl am m a t i on s and di sea ses of the k idne ys It i s not pos .

s ibl e for an extreme congestion to exi st i n the internal organs

while the Ski n i s red and congested as occu rs in a sweating ,

treatme nt B ut in orde r to more permanently rel ieve the

.

i nte rnal congestion i t i s nece ssary that the blood be retai ned
,
-

i n the Sk in This i s not accompl i she d by the hot alone bu t

.
,

can be by the reaction h yperemia re sulting from a cold fri ction .

The princi ple of t he se e ff e cts has been considered i n connection

with the subj ects of de rivation and fl ux ion The relief of .

visce ral congestions by gene ral sudor i fi c measu re s i s i ndicate d

i n acute nephriti s e clampsia u remi a pulmonary conge stion
, , , ,

acute ple urisy and the earl y stage s of many infectiou s di seases
,

such as i nflue nza me asl es scarlet fever etc, , ,

.

GO U T A N D GO U TY R H E U MA TI S M
G e n e ral C o n side ra tio n
The l iterature on the p uri n diathe si s i s most vol uminou s and
mu ch of i t u nrel iable ; the re are however some importa n t facts , ,

regarding purin metabol i s m that have been suffi cientl y wel l

p roven to all ow of the ir being u sed as a fou ndation for the
basi c p rinciples i nvolve d in the treatment of the se conditions .

We can n ot he re attempt an yth ing l ike a compl ete cons ideration

of th is quest ion but merel y point out those fact s wh ich see m to
,

u s to be of i mportance i n dete rm ining the treatment There .

see m to be three caus es for the accumulation of basic purins

and u ric acid i n the syste m The se are : F irst exce ss ive .
,

i ngestion of purin contai ni ng foods over long periods of time ;

-

se cond defective and deficie n t xanthi n oxidation and uricol ysi s

,

and th i rd de creased el iminati on of purins be cause of kidney

,

i nsu ffi ciency .
3 44 S YS TE MIC AN D ME TA B OL IC D ISE A SE S

To provide a diet free from pu ri n i s not d i fli c ul t and so th e ,

removal of this first cau se i s a comparativel y eas y matter To .

remedy the second i s however a more di ffi cul t matte r I t ha s , ,

.

b e en Shown how appl ications of bo th heat and cold accompl i sh

a quite thorough xanthi n oxidation i e a change of the bas ic ,
. .
,

purins to u ric aci d Thi s cha n ge of bas ic puri ns to u ri c aci d i s

.

a distinct advantage as uri c acid i s l ess i rrit ating to the renal ,

epithel ium than the bases Mammal s form u ri c acid onl y .

from the purins and have the powe r of de stroy ing some of the
'

uric acid formed Thi s uricol ytic power i s relati vel y weak i n
.

1
man .
“

N u cl e o p r o t e id s are converted into free puri ns and th e se in ,

tu rn are changed into uric aci d by the los s of ni troge n and th e

,

addition of oxygen Wi e chowsk i has parti c ul arl y studied the

.

enzyme conce rned i n the de stru ction of uric aci d by the ti ssue s ,

and the fate of free uri c aci d i n the body Thi s u ri col yti c .

enzyme which has be e n appropriatel y calle d u rica se by Batte l i

,

and S tern i s an oxidi z ing enzyme acting best i n experimental

, ,

dige stions when a l ivel y curre nt of ai r i s ru nning through th e ‘

digestion mixture and whi ch seems not to be present i n th e ,

blood plasma and ti ssue flu ids but onl y in the cel ls I t a ct s , .

rapidly and with stri king eff ect for act ive organ extracts are ,

someti mes able to destroy qu ite considerabl e quantitie s of u ri c

acid i n a few hours ; for example one g ram of powdered ti ssue , ,

dry wei ght can often de stroy totall y , gram of u ri c acid i n

four hours U nl ike the en z y me s of autol yti c di sintegration of
.

tissues uri case i s not inhibite d by the p re sence of a nexce ss of

,

se ru m A nother interesting feature i s that th is enzyme acts

.

reversibl y or at least tiss u e extracts wh ich destroy u ric aci d

,

with a curre nt of air ru nning throu gh soon bu i l d up the u r i c ,

2
a ci d ag a i n z o/
z en t/z e air is shu t

The above facts Show the benefit to be derive d from hydro

t he ra py in sti mulating the circu lation i ncreas ing the oxygen ,

carrying capacity of the red cell s and i ncreasing oxidati on i n

the body ti ssues O ut of —
,

door life in the fresh ai r and sleeping

.
-

I H G .
W l l —T.n C h i g P t h l g i l S i t y M y 1 1 909
e s ra s . ca o a o o ca oc e , a , .

2 E d it i l in J
or a n l f Am i n M di
ou r l A i ti n O t b
a o9 1 909 p 1 1 9 1 e r ca e ca s s oc a o c o er :
T h O xid B ul l t n N 59 p 1 03 f H y g i n i L b t y P b li H l t h
, . , .

l
se e a s o e ase s . e i o o e c a o ra or u c ea
d M H pt l S v f t h U ni t d S t t
. .
, , ,
an a ri n e os i a er i ce o e e a es .
3 46 S YS TE MIC AN D ME TA B OL IC D IS E A SE S

Onthe resul t of an anal ysis of about two score of t he se

called mineral waters the Bu reau of Chem i stry of the Depart
,

ment of A griculture has re centl y i ssued a ci rcul ar of i nqui r y ,

the essential featu re s of wh ich I give herewith I t ha s be e n .

‘
found that nearl y all lithia waters e ither contain onl y s pe ctro
scopic traces of l ithium ( unwe ighable quant itie s i n from 2 to 4
liters ) or contain le ss than one part per million ( approxi matel y
,

”
grain per gallon ) of l ithium .

6
A long the same line we quote the followi ng from B u nge
If it be des ired to p revent the formation of u ric aci d sedi
ments or to di ssolve concretions that are al ready formed by the
, ,

admini stration of alkal ies it i s m ore se nsible to advi se the u se,

of fruits and potatoe s than to order alkal i ne mi ne ral waters the ,

continue d u se of which may p rodu ce dis turbance s which we are

unable to estimate Be cau se the combi nation of u ri c acid and
.

l ith ia i s more solubl e in water than its c ombinati on w ith soda

or potash it has been thought nece ssary to treat the u ri c a cid
,

di athesi s with a few decigramme s of carbonate of l i thia or even ,

with m ine ral waters containin g one centi gra m of lithi a to the
l iter This naive idea simpl y implie s ignorance of B e rthollet s
.
’

law We kno w that in solu tions of b as e s and aci ds e ve ry aci d

.
,

i s di stribute d to all the base s i n p ropor ti on to the i r quantity .

I t follows that onl y the ve ry s malle st porti on of u ri c acid wil l

combine with the l ithia the large st propor tion combi ning with
,

the preponder ating qu antity of soda which we introduce a s ,

chloride of s odiu m T he l argest proportion of l ithi a will

.

reappear in the urine united with the chl ori ne of the chl oride
, ,

with sulphuric and phosphoric acid T here will be no increas e .

”
i n the sol ubility of u ri c acid .

Tre atm e n t
P u rin diathe sis true gout and allied conditions su ch as the
, , ,

m yalgias l umbago the visceral forms of gout etc are u suall y

, , ,
.
,

treated by extreme diaphoretic measures I t mu st be confe ssed . ,

however that the maj ority of rheu matics are not abl e to stand
,

such treatment O nl y those who are obese or of more tha n

.

average we ight can stand extreme sweating measure s It is .

6 Ph y i l gi l nd P t h l g
s o o l Ch mi t y S
ca a ad E n gl i h E di t i n p 3 22
o o i ca e s r , ec o n s o , . .
 R HE UMA TI SM
for the se reasons that many a rheu matic patient leaves a course
of baths at the hot Springs i n worse condition than when he
began Many and m an y are the patients that year after year
.

vi sit the variou s spas of this country and E urope deriving ,

each time onl y a te mporar y benefit For this there are two .
,

reasons : A l l are gi ven the same routine of hot baths regard ,

less of the i ndividual cond itions and needs O bese or ema .

c i at e d
, the y a re all trea te d alike S e cond there i s a failu re to
.
,

el iminate fro m the d ie t all pu rin containing foods and reduce to -

a mini mum the p rote i d intake Chittenden has shown that a

.

dail y ration co ntaining 3 5 to 6 0 grams of p roteid i s not only

compatible with pe rfe ct health but also conducive to gain i n ,

mu scular capacity increas ing the e ndu rance to prolonged m u s

,

c ul ar e ff ort and le ssening fatigue I n gout and gouty rheuma .

t i sm the prote id Shou ld be reduced to the least amount com

p atibl e with the actual need of the bod y for nitrogen AS .

pointe d out by G arrod eve ry particle of food not absolutel y

,

neede d for the nou ri shment of the body merel y nourishe s the
disease . O n e can not hope to cu re di sease unle ss the cause i s
remove d I n the p urin diathes is the two chie f cause s are over
.
,

feeding and under e xe rcise The over —feeding i s in the l ine of

.

heavily prote id foods and foods contai ning purin The se mu st .

be el im inate d from the diet if great benefit i s to be derived from

,

treatment .

For practical pu rposes w e mu st divide gouty rheumati sm into

,

two cl asse s v iz obe se rheumati cs and emaci ated anemic

,
.
, ,

rheu mati cs I n the fi rst clas s sweating treatment may be u sed

.
,

with benefit when properl y combi ned with tonic measures In .

the se cond clas s extre me s weat ing treatme nt i s not permi ssible
,
.

R he u m a tism with Ob es ity Those patients w ho are well

.

nourished ma y be gi ven a thorough sweating treatment dail y .

A n y of the su d or i fi c measure s recommended in obes ity are

se rvi ceable The Turki sh bath Ru ssian bath electric l ight
.
, ,

bath full su perheate d dry a ir bath hot bl anket pack sweating

wet Sheet pack or electro —
, , ,

,
thermal pack are al l appl icable ,
.

The ir e ff e cts ma y be greatly enhan ce d by free water drinking .

The mine ral waters possess no advantage over any pure wate r .

The beneficial re sults are derived from the free perspiration

3 48 S YS TE MIC AN D ME TA BOL IC D ISE A SE S

and diuresis it induces I t thu s a ff ords ample solvent for the .

increased nitrogen excretion F U mbe r claims that alkal i ne

7
. .

wate r has the opposite e ff ect ; al so that the bl ood of gouty

patients i s able to dissol ve large r proportions of free u ric acid
than it e ver contains H e de clare s that none of the alkalies or .

mine ral waters have any specifi c i nfluence on the pu rin met
a b o l i s m i n gout and that the propaganda for the l ithium con
”
tent ,
etc of springs Shoul d be abandoned
.
,
.

Toni c measures sh ould not be neglected The strength .

shoul d be maintaine d and the ci rculation stimulated A l l h ot .

baths shoul d be followe d by some form of c ol d treatment .

These may at first have to be mi ld but obe se patient s stand

“

cold treatment well The al te rnate hot and cold pe rcu ssi on
.

douche i s an excellent means I t serves as a mas sage s t im u .

,

late s the v a som otor s a nd re stores the tone lost becau se of the ,

hot bath I t Should be appl ie d e spe ciall y to the Spi ne and legs
.

and shoul d cons ist of from three to fi ve compl ete change s from
hot to cold The patient Shoul d be dri ed from the cold and
.

may either rest or take exerci se after it a ccording to the con ,

di t i on s of the particula r case u nde r obse rvation Individu al iza .

tion i s the li fe of therapy no l es s with rheumatism than with

othe r disease s Light or heavy mas sage may be given The
. .

massage douche i s highl y recommended by some I t possibl y .

posse sses some advantage over the pe rcu ss ion douche The .

Turkish shampoo i s an excellent means of combining massage

with vigorou s sudo rific measu re s O ther toni c applications .

m a y be u sed such as cold a ff us ions and general Sprays and

,

showers Later in the disease the wet S heet rub may be u sed
.
,

to advantage .

R he um atism wi th Em a c iat ion Thi s condition is doubtle ss .

”
i n som e case s the direct resul t of
'

hot Springs treatment .

H o t treatment mu st be u sed w ith m u c h c a u t i on T he vigorou s .

sweating treatments are never to be e mployed if the pati e nt i s

u nde r we ight Local hot appli cations are pe rmi ssible and a
.

mild sweating treatment once a week may i n some case s be

ve ntured u pon H ot appl ications to the swollen j oi nts as fe men
.
,

t at i o n s local hot ai r bath s su perheated ai r ( P l a tes X V a n d

, ,

7 Th p i d G g nw t F b
e ra e y L N
er pp 7 3—1 20
e e ar , e r ua r , , o . . .
 R HE UMA TI SM
X VI or local electric l igh t bath Should be followe d by a tonic
friction A t fi rst this may be a we t hand ru b with tepi d water
.

then w ith col d wate r and later the col d mitten friction These , .

frictions Should be appl ied to the muscular portions of the body ,

the swollen j oints be ing avoided The joi nts should be envel .

oped i n heati ng compres ses or pa cks wru ng from cold wate r .

These S houl d be thoroughl y covered with several layers of

fla nnel or absorbent cotton if necessary i n orde r to exclude , ,

the ai r The e ff ect may be increased by counter irritants or

.

anodyne s A fter a ti me the alternate soft Sp i a y douche m ay

.

be appl ied to th e j oints and the bod y ge nerall y When couva .

l e sc e n ce i s well e stabl ished the patient S hould be given dail y

,

some general tonic treatment with onl y Short prelimi nary hot
appli cations .

I n true gout i e whe re th e di sease i s local i z e d i n the

, . .
,

metatarso phalangeal j oint of the great toe the toni c measures

-

outl ined for gouty rheumati s m mu st be use d i n the i nterval .

O nl y hot appl ications can be made to the foot during the par
ox y sm .

At first the patient su ff ering from rheumatis m will complain

some of i ncreased sti ff ne ss and possibl y pain i n the j oints afte r
e ven a m il d col d friction Thi s shoul d not deter the ph ys ician
.

from following the plan outli ned nor cau se di scouragement on

the part of the patie nt I f mu ch complaint i s made the alcohol
.
,

rub may for a time be substitu ted .

Faradi z ation of the j oints by the rap id fa radic current hel ps

to rel ieve the p ain and the annoy ing pare sthesias that keep the
p atient awake G entle massage of the mu scles and ru bbing to
.

the S p ine are hel ps i n treating th e i nsomnia The myalgias .

such as l umbago ma y be treate d a s re commended elsewhere .

I n lumbago however the most vigorou s hot and cold p e r cu s

, ,

sion douche to the back s hould be u sed followe d by heavy ,

massage or firm deep vibration to the large mu scles of the

back These rel ie ve th e pai n as milde r measure s will not
. .

I n some cases of rheumatis m notabl y whe re the patient i s ,

be d ridden or mu st be closel y confine d to the wheel chair i t i s

-
,

best to foll ow a somewhat di ff erent plan than that outlined

above I n the se case s ; only mildl y hot loc al applications such
.
,
 S YS TE MIC AN D ME TA B OL IC D ISE A SE S

as the fomentation radiant heat and the hot foot bath Should
, ,

be u sed . The u sual regi m e of cold treatment shoul d be

omitted and its pl ace taken by carefull y appl ie d but thorough
massage . Thi s massage Shou ld i nclude special attention to
nerve stimulation ; Spi nal and abdominal movements The u se .

of faradic and sinu soidal electri city for the same purpose i s an
addition of di stinct advantage .

I n all cases of chronic rheumati sm special attention mu st be ,

given to the alime ntary tract and to the dige stion Mode rn .

i n ve St ig a t i on s into the contributing causes of chronic articular

rheumatis m are tu rning more and more to ali mentary stasi s ,

inte stinal infections and auto intoxications for an explanation of

,
-

the pathogenesis of me taboli c forms of chronic articular rheu

m at i sm . I n some of the se cases the puri n di athe si s doubtle s s
h as noth ing to do with the di sease or at most play s onl y a
minor part The routine u se of gastric lavage and copio us
.

enemata for a l imite d time may be produ ctive of excellent

results . The se treatments mu st be thorough to be e ff ective .

P u rin accu mulation through defe ctive xanthi n oxidation and

very limited u ri col ysis are a part of thi s a u to intoxi cati on and -

are surel y to be traced to an ove rworke d and functionall y

derange d l iver as one sou rce of thei r occurre nce .

B RI G H T
’
S D I SE A SE
Diaphoretic measure s are valuable i n both acute neph riti s
and i n the vari ou s clinical and pathological va ri etie s of chronic
nephriti s It i s hardl y nece s sa ry for our purpose to discuss the
.

stru ctural alterations occurring in the k idne ys in B right s ’

disease O nl y in acu te nephriti s i s there h e pe of any marked

.

restoration of the normal stru ctu re H owever the functional .

,

pe rversions may to a great extent be corre cted The alteration .

of function which i s the chief if not the sol e cau se of the ,

variou s cl inical manifestatio n s of nephriti s i s the renal impe r ,

m e ab i l i t y and i nsuffi ciency in the el imination of nitrogenou s

wastes and saline s There i s also an abnormal pe rmeabil it y to
.

albumen and i n some cases to water notabl y so in the inte r

, , ,

s t i t i a l vari ety of ch ronic neph riti s .

In i nterstitial ne phriti s and the kidne y of arterio scle rosi s -

,
352 S YS TE MIC AN D ME TA B OL IC D ISE A SE S

chlorides or nitroge n i n the diet The full warm bath fre .

quentl y increase d the el imination of sodi um chlorid e two or

three time s the u sual amount I n one case increase i n the .
,

nitrogen and sodiu m chloride of the urine oc cu rred without

increase i n the total a mou nt of u rine and continued for three

—
da y s after the treatment .

Relative to the relation of the two crystall oids glucose and

—
sodium chloride to dropsy and diure s is some i ntere sting ,

facts have been pointe d out by S tarl ing While the presence .

of unu sual amount s of gl ucose in the circu lating flu i d i ndu ce s

diu re sis at the expense of ti ssu e fluids the i ngestion of much ,

salt doe s u nder certain ci rcum stance s tend to increase ti ssue

, ,

fluids and l im it diuresi s p rodu cing a water logge d condition

,
-
.

If a solution of 3 0 grains of glucose in about 3 0 cubic ce nti

meters of water be inj ected i nto the jugular vein the first eff ect ,

i s a great increase in the volu me of the ci rcul ating bl ood ,

brought about by the osmotic attraction of water into the ve ssel s

at the expense first of the ti ssue spaces but ultimatel y of the
, , .

ti ssue cells The conseque nce of the hydremic plethora t he fe

.

by induced i s increased circulation through the kidne y s and

i ncreased output of u ri ne containing large quantities of sugar .

U nder ordinary ci rcu mstance s the concentration of the ,

tis sue s thus induced woul d prod u ce i ntense thirst and an i n

creased i nta ke of water so that the u r i na r v flow would be main
,

ta i n e d at a hi gh level u ntil the whole exce ss of the gl ucose had

been excreted .

H
T he i nge stion of an exce ssive quantity of salt provoke s
thi rst rather than diuresi s I f thi s ex ce ssive inge stion were.

continued or became chronic the re would be a tendency for ,

the amount of thi s sal t i n the body to continuall y i ncrease ,

the salt be ing associated with suffi cient water to maintain the
molecular concentration of the body flu ids at their normal
height It i s not surp ri s ing therefore that excess ive qu anti
.
, ,

ties of salt have been found to exert a deleteriou s i nfluence in

cases of dropsy or that marked be nefits a s regards the redue
,

tion of drop sy have bee n a tt ai de d by the limitation of salt in the

” 1 °
d iet
li g —
.

9 St ar F l uid f t h BM W D 1 5 3
n s o e
bid p
. . .

10 I . . . 1 54 .
 N E P H R I TI S

E de ma i s le sse ned by warm or sweating baths and sometime s

very promptl y The drops y res ponds even more promptl y to
.

alte rn ate hot and col d appl ications to the edematou s parts .

The rationale of the se h ydri a t i c e ff ects in lessening edema i s a

ve ry intere sting stu d y We have already dwel t qu ite at length
.

u po n the vascular ch ange s p roduced by alte rnating the rm ic

appl ications S ta rling ha s recentl y correlate d present knowledge
.

regardi ng the cau sation of dropsy I n the su mmary he bri ngs .

out a nu mbe r of pra ctical points Ranvi er ha s Shown that i f .

,

after ligatu re of the i nferi or vena cava the sciatic nerve be ,

divi ded on one side s o as to produce dilatat ion of the arte rioles
on that s ide the l i mb in which the ne rve has been divided will
,

” 1 1
be com e ede matou s There m u st be other factors be side
.

ve nou s obstru ction if e dema is to result S tarl ing conclude s .

that the determining cau se othe r than stas is l ies i n an i n , ,

creased pe rmeability of the ve ssel wall Thi s i s due in di s .

e ase to lack of the proper nutrition and oxygen suppl y to the

“
cell s of the ve s sel wall Coh nhei m showed that after long
.
,

continued anemia of the rabbit s ear the ve ssel s became so per ’

meable that re storation of the normal circulation was followed

” 12
by pronounce d e de ma of al l the ti ssue s .

The same re sults we re obtai ned by B arlow This anemia .

result ed in asph yxia and starvation of the cell s A long con .

tinned venou s stasi s mu st a ff e ct the ves se l walls i n much the

same wa y since it al so de crease s the oxygen and nutritive sup
,

pl y . In chroni c nephri ti s the re i s u sually a marked anemia

with h ydremi c blood and this appears before the edema From .

experi ments by B olton one may conclude that edema re sults

,

solel y be cau se of thi s se rie s of change s occasioned by the s tag

nation of blood in dilate d ve i ns and that plethora or increased
cap ill ary tension are neithe r of them necessa ry for the produc
tion of edema The s e facts have le d S tarl ing to the bel ief that
.

alterations i n the endothelium of t he capillary wall mu st be re

garded as the e ssential factor i n the production of edema The .

retent ion of ni t rogenou s wastes i n nephriti s mu st be an added

cau se of i nj ury to the ve ssel s With these facts i n mind the .
,

1 1 St l i ng—
ar F l u i d f t h B d y p 1 59
s o e o , . .

12 I bi d p . 1 62 .

23
35 4 S YS TE MIC AN D ME TA BO L IC D ISE A S E S

rationale o f h ydri at i c treatme nt i s qu ite evident The re st e ra .

tion of tone to the ve ssels both blood and lymph hastens the , ,

circul ation thus relieving the stasis and consequentl y im provi ng

,

the nu trition of the ves sel walls The nutritive proce sse s an d .

activity of the endothelial cel l s are di re ctl y sti mulated b y h ydri

atic appl ications I n Short the enti re ser i e s of morbid change s
.
,

from the de creased permeability of the ki dneys to the ve nou s

stasi s and increased pe rmeabil ity of the ve ssel wa l l s i s me t by
—
the one age nt warm water There i s no evidence that fre e .
,

wate r drinking i s harmfu l i n ede ma where the amount of

u rine i s l ess th an normal O n the contrary it ha s been Shown
.
,

that plethora i s not a cont ri buting factor i n edema The diu .

r e si s it induce s greatl y le s sens nitrogenou s rete ntion and thu s ,

by decre asing the toxem ia aids re covery ,

.

Ac ut e N e p hritis Beginning as it doe s as an acute i m fl a m

.

mation and pass ing throu g h the va ri ou s stage s of the i nfl am

m a t or y process acute B right s di sease Shoul d be treated along
’

the l ines laid down for i n fl a m m at i on s The pe cul iar cou rse of .

the di sea se is gove rned by the anatomic and ph ysiol ogic re

l at i on s of the ki dneys organs of nece ssa ril y constant activi ty
, ,

and activity of such a character that i t must m ilitate against

thei r recovery The kidne y is congested swollen edematou s
.
, , ,

and tense at the onset of the first symptoms ; l ater venou s stasi s ,

i s the predominating ph ysical change To rel ieve these condi .

tions sweating measures have abundantl y p roven thei r superior

,

i ty These conge st the skin and rel ie ve the k idne y conge stion
. .

The patient shoul d perspi re freel y for an hour or more at le ast

’

once a day The skin Should be warm and moi st all of the
‘

time Free diaphores is may be accom pl i shed i n S eve ral ways

.
.

I t i s often best to resort to some of t he m il de r measu re s su ch ,

as the hot foot bath with fome ntations to the abdomen or Spine ,

or the hot trunk pack I f the symptom s a re urgent the full

.
,

hot pack may be u sed The head should be kept cool and if
.
,

the pul se i s over 1 00 an ice ba g placed ove r the heart Du ring

, .

the sweat copiou s wate r drinking Shoul d be encou raged Thi s

, .

favors diaphore sis and as soon as the renal congestion l es se ns

, .
,

it aids in diure si s The patient ma y be Sponged o ff with te pid

.

water and then placed be tween wa rm blankets to continue per

356 S YS TE MIC AN D M E TA B OL IC D ISE A SE S
u suall y nece ssary and if a large ice cap i s u sed i t will cover
, ,

the sternal kidne y area as well O the r form s of hot bath such .
,

a s the Ru ssian and ele ctric l ight may be be st left for subacute ,

or ch ronic nephriti s after th e acute symptom s h ave largel y

subsided .

C hro n i c Ne p hriti s I n chronic neph ritis whether a sequel

.
,

of th e acute or com ing on i nsidiou sl y and compl icated by

cardiac and vascular change s i t i s possible to u til i z e a g reate r
,

va riety of m easu re s and more vi gorou s toni cs can be borne A .

southern cl imate i s of advantage largel y be cau se free p e r sp i r a

tion i s secu red without effort and the re i s les s tendency to chill
ing We have utilized with su cce ss all hot baths su ch a s the
.
,

Rus sian Turki sh electric l ight and su perheated air

, ,
These , .

may be given two or th ree ti mes a week A bout once a week .

or once i n two weeks it i s de s irable to follow a vi g orou s sweat

,

ing treatment by the Turkish Shampoo A l l the se e xtreme .

s ud or i fi c treatments sho ul d be concl ude d by some form of th e

hot and cold Shower dou che or Spra y The douche i s the be st
, ,
.

means Since it combine s pe rcu ssion eff e cts with the thermic
sti mulu s and so les sens the tendency to chill ing The alternate .

applicati on of fomentation s and an i ce bag to the lower sternu m

and kidney region p rodu ce s mil d fl ux ion i n the kidne y The .

alternate hot and col d percu ss ion douche to the l ower ste rnum
and the lower dorsal and lumbar regions i s more vigorous and
a very effi cient means of sti mul ating renal activity .

N earl y all hy dri a t i st s recommend very hi ghl y the full warm

bath as the most se rviceable measure i n su bacute neph riti s
'

Whil e we do not doubt its great utility yet we have se en better ,

r e sul t s b y employing in about two ou t of every three treat

,

ments more vigorou s means and means em ploy ing more toni c
,

e ff ects These are obtained to onl y a Sl ight extent by the warm

.

bath Whe re the re are m arke d changes i n the heart and v e s

.

sel s we have found toni c hydrothe rapy a nece ssity O f toni c

, .

measure s one may u se hot and cold to the Spine the revul sive
, ,

com press to the kidne y region or abdomen th e cold m itte n ,

friction the ice bag to the hea rt and the alternating dou che
, ,
.
.

The N auhei m bath i s h ighl y recommende d bo th for the relief

of dropsy and the treatment of cardio vas cul ar di sturbances -
.
35 8 S YS TE MIC AN D M E TA BOL IC D ISE A SE S

I t has recentl y been shown that the endogenou s uric aci d i n

the bl ood i n i nterstitial neph ri ti s varie s accordi ng to the
“
functional activity of the kidneys The se obse rvations were .

made on a p u ri n free d iet This retention of u ric acid i s very-

.

favorably influenced by exerci se and hydrotherapy U mber .

noticed that on a puri n free diet the el imination of uric aci d -

decreased after exe rcise owing to its partici pation i n the i n ,

creased oxidation incident to mu scular exertion That like r e .

s ul t s may be o
btai ned by hydrothe rap y ha s bee n Shown by the
researches of S trasser .

U RE MIA AN D E CL A M P S I A
These pathologic states whil e not identical have many poi nts , ,

i n common I n uremia there i s in the majorit y of case s a

.
, , ,

retention of toxic u rinary p roducts becau se of the kidney iusuf

fi e i e nc y Wh ile al l obse rvers are not a gree d as to the constant
.

occu rrence of kidne y insu ffi ciency in eclamps ia yet nearl y al l ,

agree that its manifestations are accom pani ed by a severe poi son
ing from some autotoxi c sou rce C r oft a n says the re i s mu ch .
"

che mical and clinical evidence to Show that in u re m ia the gen

eral metabolism and in particular th e m anifold functions of the , ,

liver are pe rverted The k idney may not be pri maril y involved
,
.

and possibly in some few case s not at all I n the maj ority of .

cases however there are demonstrable le sions i n the kidne y

, ,

as well as functional i nadequacy during l ife A great variety .

of conditions have been re ported among wh ich are infarcts , ,

acute and chronic congesti on ede ma greatly increased ten sion , , ,

and actual nephriti s I n a case of e cl am p s1 a reported by .

15
Wiemer the tension was so marke d that the kidney substance
bulged out on inci sion i n the course of E debohl s operation ’
.

B raak and Mi jn l i e ff report a ca se i n which the right k idne y ‘6

was much enlarged and so painfu l that the patient in coma , ,

reacted when it w a s palpated The y report thi rteen othe r case s .

14 I n g o ut t he en d g
d i n t h bl d i mo nd n v
e n o us u ri c a ci
n t nt x d e oo s o re c o s a a e er e ce e s a
n m x m um m u nt ( b ut A d m n t bl m u n t f u i
'

t
ce r a i a i p nt )
a o a o e r ce e o s ra e a o o r c
p nt n t h bl d i n g u t v n w h n t h f od h b n f f m
.

a c1d lw y
lS a a s re s e i e oo o e e e o as ee re e ro

d —
e
pu n f w k m nt h w h il b l d f m n m l i nd i v id u l p u in f d
.

ri s or ee s or o s. i t e oo
n ro or a a s o a r re e e
J u l f A m i n M di l A i t i n A p i l 3 1 909 p 1 1 1 0
-

t n
co n a i n u s o ri c a c 1 . o rn a o e r ca e ca ss oc a o r . .
, .

h 1 908
,

15 M n t h i ft fii G b u t h nd G y n k l g i M
o a sc r r e r s ti a o o e a rc

O t b
, . .

1 6 C nt l b l t t fii G y n k l g i
e ra a r
1 9 1 908 a o o e , c o er .
,
of e cl amp sia a ccompanied by increased tens ion in the kidney .

A l l we re treate d by de capsul ation and with one exception , ,

recove red Franck reports ten case s with no bul ging or

.

increased i ntracapsula r tens ion .

H epatic change s are almost u niversall y p re sent I n fact .

,

functional and stru ctural alterations of the kidneys and liver

are very freque ntl y associated Thei r functions are con se c u .

t ive i e the l ive r i s the ch ief agent in the preparation of

, . .
,

waste s for excretion and the kidne ys re ce ive these for p u rpose s
of excretion This naturally leads to the view whi ch is al so
.
,

s upported by cl ini cal anal yses that in many cases the de crease ,

of urea i n the u ri ne i s du e not to failu re i n its elimination but .

to failure i n i t s format ion from the variou s precursors inclu d ,

ing the ammonia compounds ; u rem ia then being due to these ,

toxic antecedents rathe r than to poi sons retained with the urea
. ,

and of the amou nt of whi ch the decreased u rea excretion i s a

”
ga uge S omewhe re i n the organi s m there i s a deficient
.

changing of ammonia and amino acids into urea Thi s has -

.

‘
been calle d de ficient de sam ida t i on by E wing who as serts ’

that the process i s no more than an oxi dation Thi s work i s in .

a great measu re pe rformed by the l iver and therefore w e are ,

”
not s urp ri se d to find the live r most severely involved .
17

In th i s connection it i s i ntere sti ng to note the relation of one

of the chief cau se s of uremia and eclampsia v i z a diet ri ch ,
.
,

8
i n meat to th e Si z e of the liver Dr Chal mers Watson calls
,
. .
1

attention to the di ff erence i n the S i z e of the liver in meat fed -

rats and in bread and m ilk fe d rats F rom an examination of - - -

.

the l i v e r s i n the two cases i t wa s Shown that the average l iver ,

weight of the meat fe d rats w a s 6 grams while the average -

liver weight of the bread and milk fed rats w as 4 grams The - - -
.

meat diet ha d cau sed an i ncrease of 5 0 per cent in the mm of

the l iver .

Moreove r it has been Shown that a severe acide mia may cau se
the convulsions an d coma characteri stic of uremia and e c l a m p
si a Were thi s the case sweating treatment if mu ch pro
.
, ,

1 7 D via s a nd F o u l k r od T he — E ti ol o gy of E cla m p si a
—
J o u rn a l of Am e ri c a n M e di ca l
A ss oci a t i on , J anu ar y 7 1 91 1
, , pp . 1 1 , 1 2 .

18 L on d on L a n ce t . Octo b er 1 2 . 1 907 .
3 60 S YS TE MIC AN D M E TA B OL IC D ISE A SE S

longe d would onl y deepen the di ffi culty Since if unaccompanied

, ,

by cold it increases the acidosi s

,
.

For practical purposes we may divide the treatme nt into two ,

parts : First the treatme nt of ch roni c u remia the conditions

, ,

that predi spose to the acute attack and the pre ecl ampti c state ; ,
-

second the treatment of the a cute attack of ure mia or e cl a m p

,

si a ,
the convul sive se izu re s and coma I t Shou ld be borne i n .

mind th at i n e cl ampsia a neuroti c te m p e r m e n t predi sposes to

the attack and that there i s the adde d factor of pre gnancy
which may in spite of vi gorou s treatment demand hasty
, ,

emptying of the uteru s .

”
C hroni c U re m ia and the Pre e c lam p ti c State The prin -
.

c i p l e s involved i n the treatment of faulty nitrogenou s m e t a b o

l i s m have bee n di scu ssed i n the consideration of gout a nd

B righ t s di sease T he se pe rsons l iving upon a hi ghl y n i tr og
’
.

e nou s diet containing pu rins are predi sposed to the uremi c

, ,

state Women w ho pa rtake heavil y of tea and co ff e e are pre

.

di spose d to eclampsia The reason for thi s i s that the ca ff e i n

.

greatl y increase s the amou nt of basic purins which must there

fore be raked ove r by the l i ver and thrown out by th e kidneys .

9 1
A lfred Sc hi tt e nhe l m has shown by experime nts u pon dogs
the extent to which caff ei n increases bas ic purins and u ric acid .

We give below a table of averages wh ich shows the se item s .

The dog was kept on a p uri n free diet previou s to the te sts -
.

The pre pe ri od laste d three days

-
For three days following .

this three dail y dose s each of

, grams of ca ffe in we re admin
i st e r e d N ext i ntervene d a pe riod of two days with purin free
.
-

diet and following thi s the same dail y amou nt of t heobromi n

,

( as previou sl y of caff ein ) was give n for two days .

T H EOB R O MI N
P R E PE
-
R IOD PE R IO D

U ri c aci d i n gm . N .

P u ri n bases in gm . N .

The vicious cycle and di sorde re d l iver accompanying periodic

e
19
B d
Z ur
e ut un
F gd
g
ra
i n
e d e r h a m sa u r e y e rm e h re n d e n
'

e r G 1 c h t t h e ra p i e T e ra e u t i sc —h p
W i k un g n K f
e
r
h M n t h ft M
o a
vo
s e e,
a e e un d
a rc h ,
T e e und i
1 91 0 .
p
1 15 . .
h re r
3 62 S YS TE MIC AN D ME TA B OL IC D ISE A SE S

p rolong the hot pack Whe neve r it is u sed the ce rebral ci rcul a
.
,

tion Shoul d be guarded by the cold compre ss ice bag or cold , ,

affusions to the head A n i ce bag Should al so be u sed ove r the

.

heart The patie nt may be remove d from the pack by a w e t

.

hand rub or othe r cold friction and put be tween blankets to

conti nue pe rspiring gentl y Cr oft an E dwards and others favor .
, ,

the use of the full hot bath a s recommended by Lieberme ister .

0
The bath begins at 9 8 or the reabouts and i s generall y run u p
5 or the head being kept cool by cold a ff u sions
°
.

The rationale of these sweati ng treatments l ie s not al one i n

the elimination of toxins by the sk in In fact w e bel ieve thi s .
,

i s onl y a pa rt and perhaps ofte n a small pa rt of the real effe ct

,
.

S oon after free diaphore si s ha s bee n e stabl i shed u rinary secre ,

tion be gi ns to increase and may in acute suppre s sion appear , ,

ve ry promptl y Thi s i s doubtle ss due to the relief of the kid

.

ney conge stion and the reduction of renal edema and increased
tension in those case s i n whi ch these occur Relievi ng renal .

stasis always re su lts in freer excretion of urine The case of .

eclampsia with great enlargement of the ki dne y mentioned

above a s reported by B raak and Mijn l i e ff ha ving refuse d O p e ra ,

tion recovered under the u se of wet packs with hot wate r

,
-

bottle s and medici nal measure s The coma subsided and the .

kidne y graduall y retu rned to normal Si z e O M H ayward . . .

20
reports a case of e c l am p si a i n which two hot packs faile d to
'

relieve the coma With the patient deepl y comatose pul se 1 6 0

.
,

and v e r v weak axillary tem p erature

, F and res piration .
,

i rregular and gaspi ng She w a s wrapped in a sheet placed on a

, ,

table and a cold rubbing pour adm ini stered

, I n five mi nute s .

there w as some improvement and the cold pour and rubbing were
continued I n thirty mi nute s the patient was returned to be d
.

with a temperatu re of 1 00 F pul se 1 00 and respiration nearl y 0

.
, ,

normal The failure in the hot pack wa s doubtle ss due to the

.
-

fact that it was u naccompanied by a cold fri ction This might .

have been admini stered by the cold mitten or as was done ,

late r by the cold pour and rubbing wet Sheet p ack

, .

The u se of a l arge ice ca p to the heart and ove r the lowe r

third of the ste rnum i s de sirabl e and u suall y ne ce ssa ry .

20 M d on M di in
er M h 1 908 p 60
e c e . a rc . . . .
 CH APT E R XXV

P E P T O GE N IC E FF E CT S

HIS te rm peptogenic eff e cts is —here u sed to designate

a va riety of e ff ects upon the digestive organs and dige s
t ive activity i n the sense of increasing the e fli ci e nc y of these
organs and fu nctions The measu re s dire cted toward improv
.

i ng the digestion al so i ncrease the activity of the l iver A l l .

tonic treatments increase the mu scul ar and glandular activity

of the stomach and i nte stine s al so the glandular activity of the
,

l iver and pancreas T he y a i d dige stion and Sharpe n the ap p e

'

tite
. I n addition to general ton ic treatments it i s necessary to ,

di rect special attention to t he digestive organs themselve s .

The following are some of these special treatments w hi ch are

u seful i n promoting digestion and absorption
.1 Winternitz pack ( hot and heating t ru nk pack ) .

2 H o t tru nk pack
. .

3 Fomentations to the abdomen

. .

4 Revul sive compre ss to the abdomen

. .

5 H ot and cold to the Spine

. .

6 H ot and col d douche to the abdomen l iver and spine

. , ,
.

7 The u mschlag ( moist abdominal girdle )

.
.

8 H ot wate r bottle or Wintern itz coil over the stomach after

.
-

a meal .

9 I ce bag over the stomach or col d water dri nking before a

.
, ,

meal .

These treatme nts properl y sele ct ed to meet the nee ds of the

individual case are indi cated in ,

1 .A ll forms of atoni c indige stion .

( a ) H ypochlorhydria
‘

( b ) A n a c i di a .
3 64 P E P T OGE N IC E FFE C TS

(c) G astre ctasia .

(d) G astroptosi s .

(e) Lowe red g a str i c motility .

( f)
General splanchnoptosi s .

( g)
B iliou sness .

(h)P e riodic s ick headache s ( i n i nterval ) .

(i) A m ylaceou s dyspepsia .

2 . Chronic congestion of l i ver .

3 . A nemia of l iver .

A TO N IC D Y SP E P SI A
Th is te rm i s not u sed in i ts ordi nary re stri c ted sense as apply
ing alone to painful digestion We use it here to de signate a .

great variety of dige stive di sorders as sociated with defi cient

gastric secretion an d les sened motil ity with more or l e ss d i s
,

tress or discomfort afte r meal s The se va riou s conditions may

.

be groupe d i n th is manner for convenience i n considering the i r

hy d ri a t i c management for thi s mu st be ca rrie d on along m uch
,

the same l ines i n all The ai m i s to produce a gene ral i ncrea se

.

of tone in both the gl ands and mu sculatu re of the dige stive

organs We hardl y need menti on that s pe cial attention mu st
.

be paid to the matter of diet exerci se rest favorable environ , , ,

ment etc Th e se are all of p ri me i mportance

,
. .

I n the m ore severe grade s of defective digestion something .

l ike the followi ng program should be carrie d out

H alf an hour before the meal the patient Shoul d be i nstructed ,

to take half a gl ass of cold water or even ice wate r B its of ice .

or a small amou nt of fru it i ce may be t aken twenty minute s to

i

hal f an hou r be fore the meal Instead of col d i nte rnall y an ice
.
,

bag may be placed over the stomach beginning half or three

quarters of an hou r before the meal and conti nue d for ten or
fifteen minutes The skin over the stoma ch Shoul d warm u p
.

before the meal i s take n This will re qu i re abou t fifteen mi n

.

utes after the i ce bag has been removed The ph il osoph y of .

these meas u res l ie s i n the fact that the cold appli cation produ ce s
a reacti on which comes on at the time the meal i s taken so th at ,

the glandul ar acti vity i s increase d du ri ng the period of digestion .

The experimental basi s of th i s ol d and very su cces sfu l means

3 66 P E P TO GE N IC E FFE C TS

ru b . O the r appl icati ons which m ay be u sed are the hot and
col d douche to the abdome n and l iver al so to the Spi ne A t , .

night it i s well to appl y the moi st abdomi nal girdle I t Shoul d .

be d r y by morning The protected gi rdle i s not u se d in thi s

.

condition .

I n addition to these hy d r iat i c mea sures the patient shoul d be ,

give n ge neral massage w ith Spe cial abdominal mas sage vibra ,

tion to the abdomen faradic or sinu soidal electricit y to abdo

,

men and spine or the Morton wave to the abdomen and spine
,
.

S ince the se variou s measu re s are not appl i cable to all case s of
atonic dys pep sia they Should be sele cted according to the needs
,

of the individual case A l l of them with the exception of

.
,

fomentations to the abdom en and the hot tru nk pack are con ,

t r a i n di c a te d i n h yperchlorhydria and g a st r i c or duode nal ul ce r

w ith much hemorrhage .

P atients with dyspepsia soon become accus tomed to col d

appl ications and may be given most vi gorou s toni cs A fter a .

week or so of treatment a general cold a ff u s ion or pail pou r

ma y be u sed dail y The col d w e t Sheet rub may al so be u sed
.

after tolerance for do uches and pail pou rs ha s bee n acqu ire d .

The cold morni ng pl u nge i s not excelled a s a general toni c

and e xe rts a bene ficial action on dige stion It sha rpens the
.

”
appetite thu s aiding i n the produ cti on of
,
psychi c j u ice
which P avlov assures u s i s five ti mes a s e ffi c ient i n gastri c
digestion as the chem ically excite d secret ion .

P avlov has further shown that anothe r of the ci rcumstance s

favorable to the activity of the gastric glands i s an abundant
2
su ppl y of water in the organi sm H e says . O n e of these ,

favoring circum stances we dis covered i n the introduction of

large quantitie s of water i nto the s y stem We based thi s u pon .

earl ier facts Showing that the quantity of j u ice was strikingl y
,

”
de pendent upon the amou nt of water i n the organi sm Th i s .

make s clear the neces s ity for free water dri nk ing between meal s
i n orde r to provide flu id for the formation of the requis ite amount
of gastric ju ice .

I n cases of motor insuffi ciency associate d wi th marked dila

tati e n cold drinks can not be used before the meal Since there
, ,

2 W ork f t h D i g t i v G l nd S
o e es e d E n gl i h E d i t i n p 2 45
a s, ec o n s o , . .
PL A T E X V I I I W i nt . e r ni t zp k ac ( hot an d h e at i n gt run k p ac k ) .

v \ ' A m “ v v v v v i t ? “ I
'
A l L a l k fl “ 1 ° \
 P E P TO GE N IC E FFE C TS

one half i nche s from the right il iac spine I t would ea sil y hold
- .

one and one half or t wo gallons The pyloru s for a distance of

-
.
,

two inche s admitted with great d i ffi cul ty a small size lead

,

pencil The condition of course Should have be en treated

.
, ,

su rgicall y by some form of p ylorectomy .

The cau tion here i s not against systemati c washing of the

stomach to free it from decomposing remnants of food but ,

against the u se of li ot water for th is purpose If it seems a dv i s .

able to resort to gastric l avage frequentl y and warm water i s

used first it should be followed by a dash of c old
, ,
.

I n those case s of gastric dilatation and le ssene d motility not

associated with pyloric obstruction hyd r i a ti c means produce ,

excellent results I n addition to the mea sure s recommended

.

above the alternate hot and cold do uche to the epi gastriu m
,

may be u sed ; at first with l ittle or no force later with mode r , , ,

ate percu ss i on The percus sion dou ch e to the m id dorsal spine

.
-

also to the legs and feet serve s a s a vigorou s toni c Ga st re c , .

tasia associated w ith a general s pl anch noptosis i rritable ten

, , ,

der sympathetics and a feeling of wei ght and dragging in th e

,

abdomen may be benefite d by the col d S itz bath begu n a s a -

g raduated measure The continu ou s col d coil to the abdome n

.

acts i n the same way The cold S itz may be prol onge d to five
'

or Six m inute s and the cold coil left i n pl ace twenty to thi rt y
3
mi nutes
H YP E RC H L O R H Y DR I A
N earl y
all cases of i ndige stion pas s through the stage of
hyperacidity at the be ginning of the de partu re from normal .

In onl y a few however i s this condition so marked as to

, ,

requi re Special treatment The pati ent i s of a nervou s temper .

ment and eats rapi dly swallowing hi s food with very imper
, ,

feet mastication The free h ydrochloric acid may be double or

.

even treble the normal amount The course to be fol lowe d i s .

j ust the opposite to that outl ined for h ypochlorh ydria The .

patient may drink hot water or use a hot appli cation ove r th e
stomach preceding the me al after which an i ce bag Shou ld be ,

u sed for twenty to thirty minute s or eve n longe r The hot , .

3 Se e a l so t h e t r e a t m e n t re c o m m e n e d d fo r s pl a nc h ni c n e ura st h e ni a .
 H YP E R CH L OR H Y D R I A
water drinki ng or the hot appl ication to the epigastrium p r o
duce s an atonic reaction In thi s connection it Shoul d be noted
.

that among the experiments p e rformed by P rofessor P avlov on ,

one occas ion the work of the large stomach w as arre sted for
se veral days by the appl ication of very hot water Thu s it will .

be seen that by applications of heat of a su itable tempe ratu re

an ove racti ve sta te of the gastric gl ands may be depre ssed and
the ir activity be brought back toward normal .

It i s needle s s to say that dieteti c re g ul ation i s the most i m

portant factor i n the treatment of thi s co ndition O il s whether
.
.

free or e mulsified have a Spe ci fic inhibitory action u pon the

,

secretion of h ydrochlo ric acid The patient Should di scard the

.

u se of meats entirel y . O ther heavil y proteid foods shoul d be

i nterdicted. S alt and condiments shoul d be proscribed The .

hyperaci dity m ay be les sened by the u se of the p rote cted or

sweati ng moist abdominal girdle Tonic treatments Shoul d be
.

replace d b y se dative measu res such as the neutral bath neutral

‘

pack or b e a ti ng pack The se may be given one or two hou rs

,
.

a meal or at night .
 CH APT E R XXVI

H E M O ST A T IC E FF E CT S

AP I L L AR Y hemorrhage and hemorrhage

blood —
vessel s doe s not u suall y requ ire su rgi cal
H emorrhage into the hollow organs tends to check
v i d e d the circumstance s are at all favorable so that i n ,

absolute rest accompanie d by the u se of the i ce

,

duce all that i s desi red Therm i c appl ication s

.

di rectl y to the part or so as to in flu en ce the bl

fl e xl y . Cold may al so be u sed ove r the tru nk of
plying a part If heat i s u se d to check the
.

appl ication mu st be very hot and

ing pa rt The r efl ex e ff ect of eve n
.

only a transient n arr ow m g of the v e s

the ve ssel s become dilated and the hemorrhage i n
applications may be u sed eithe r to the part itself
area In fact it is quite a gene ral rul e that col d i s
.
,

through re flex action while hot is e fficient onl y

,

d i rectly to the bleeding ve ssel s I n nearl y e ve ry

.

i s u sed it i s well to employ some hot ap p l icati on

,

purposes The hot shoul d not however p r od u

.
, ,

Si nce thi s tends to dilate the blood ve ssel s and -

hemorrhage .

Ep istaxis
The rm ic appl ications are often very effectual in treatin g
i ll ar y hemorrhage from the nose V ery cold wate
.

water may be drawn into the nose .

be made over the nose itself O f the more remote re fl ex

.

use may b e made of that at the back of the ne ck a n d the

by having the patient hold a chunk of i ce at the back

( 3 7 0)
3 72

case s the shallow cold foot bath ( w a

,

d e e p ) w i t hout othe r means serve s to

, ,

Thi s i s through reflex action In cas e .

the patient i n bed an ice bag shoul d be ,

and anothe r ice bag betwee n the

A t the same time the patie nt Shoul d be give
leg pack The se mean s will often prove so
.

ing or ast ringent douche s are unne c es sary .

P ost partum hemorrhage i

-

del ivery of the chil d and of 5

i ng should be i mmediatel y treated by m anu al
,

uterus through the abdom inal wall or fail ing ,

hot intra ute rine douche -

If the hemorrhage .

alarming a s to require the i

be gi ven a ve ry hot vaginal douch e wi th or
ice bag ma y be u sed over th e pube s and
douche or i t m a y be kept i n place without
,

of these mean s wh ich may be at h and S

ergot h y podermatical l y being given a s soon a s ,

ing the placenta ha s been passed .

Ap op le xy
The earl y treatme nt of cerebral hemorrhage
an ice bag i ce cap or l arge ice hel met appl ied
, ,

ice bags or compre sse s placed

the carotids The l imbs Shoul d be k e .

bottle s et c The se appl i cat ions may be

, .

i s reason to bel ieve the hemorrhage ha s

the hemorrhage does not continu e for any gre
but in some case s al most the enti re cerebru m
fil t r at e d with bl ood and the ventri cl e s fille d .

if u sed promptl y m a y ,

the se P e r fe.

any form of treatment .

 C H A PT ER XXVI I

H Y D R O T H E R AP Y I N SUR GE R Y

N DE R variou s head s we have al ready cons ide re d the hydro

therapeutic treatment of many surgical disease s The
.

treatment of i nflammatory disease s many of which requi re sur

,

g i ca l i ntervention has been dis cu sse d under it s proper head

, .

I n cons idering the e ff ects of pure stimulants and u nder treat

ment de signe d to relieve pain still other surgical conditions
,

have been di scu s sed There remains then to be considered

.

onl y the gene ral relation of hydrotherap y to O perative treatment

and the care of the pati ent For convenience the subj ect of
.

h ydrotherapy i n surgery may be divide d into three sections v i z . .

,

pre paratory treatment i mmediate care and afte r treatment

, ,
-
.

P R E P A R A T O RY TR E ATME N T
The ph ysical condition of the patient at the time of operation
has a great deal to do wi th hi s behavior u pon the ope rating
table and with the comfort and rapidity of hi s subsequent con
v al e s ce n c e.O f cou rse i n conditions de m anding immediate
atte ntion there i s no ti me for preliminary treatment but in a ,

very l arge nu mbe r of su rgi cal di se ase s it i s ne ither necessary

nor advisable to hu rry the patient to the operating tabl e This .

i s true alike of many inflammatory and many non i n fl a m m at or y

-

conditions .

I n considering the real m of physiologic therapy we ha ve

al read y mentioned the advi sabil ity of delay in t he operative
treatme nt of ce rtai n i n fl a m m a t ion s especial l y of pelvi c i n fl a m
,

mations E ven defi nite inflammatory state s l a r g e l v limited to

.

the Fal lop ian tube or the ova ry are u su all y accompanied by
more or le s s cell ul itis S ometimes an inflammation whose most
.

( 37 3 )
3 74 H YD R OTH E R A P Y IN S UR GE R Y
marked e ff ects are in the cellular ti ssue i nvolve s
as to neces si tate removal of such parts or mechan
the ir release from plasti c exu dates or adhe sions . .

the induration and residual thickening may

qu ite a degree of the normal m ob i l i t v re stor
cussed u nder the treatment of
mations .The se results m a y be :

that the remaining conditions wil

operative work and work which can be
formed with a minimu m of trau ma and con se qu e
re sulting shortening of the period of ane sthes ia
tinct advantage .

The stability of the circulatory system 1 8 still

of great importance i n su rgery I n those
.

inflammatory or suppu rative l esion s and

other chronic i nvalids the ci rculation
motors fai l to properl y control the .

changes The ane sthetic

.

to further unbal ance the c ir c ul

v a so m ot o r s the l iability to und

consequent internal conge stion are mu ch in

chilling during or foll ow ing O peration m a y
re t r o st a s i s of blood to the inte rior and thu s r e su
,

an already exi sting inflammation .

The preparati on of the patient by a prel i mi nar

weeks cou rse of va scular h ydr i a t i c toni cs will
’

the se dangers I n thi s length of ti me the vitality of t h

.

may be materiall y ra ised S uch a course of treatment

.

result in ridding the system of the accu m ulation of half

leucomaines which have p iled u p du ring the pre ceding
i sm .
S weating treatments at i nterval s of two or
may al so be nece ssary to still fu rthe r enhance el im
i ncidentall y to promote the nutrition and health
skin .

The stimul ation of kidne y activity and the

crease i n urinary leucomaine s i s another factor
clearing out process -
B ecau se
.
3 76 H YD R O TH E R AP Y IN S UR GE R Y
I n th is conne ction W J Mayo
1
i n preventing surgical shock . . .

has said l Ve hear a great deal about Shock but w e don t se e

’
'
,

”
it We sometimes se e collapse from loss of bl ood
.
.

The patient shoul d not be weakened by repeated catharsi s .

Lim it the p re paratory use of cathartics to what i s reall y i ndi

c a te d and on the morning of the operation fi ni sh the cleani ng
,

out by means of a thorou gh e nema of te pi d or warm water .

The patient Shoul d rea ch the operati n g tabl e with warm feet
and hands and during the O peratio n the extremitie s Shoul d be
,

kept warm by the u se of blanket coverings and if nece ssary , ,

hot wate r bottle s appl ied outside the bl ank et The use O f a hot
-
.

foot bath concluded b y a dash O f col d wate r given ju st before

, ,

entering the operating room may do mu ch to preve nt or l imi t ,

Spl anch nic engorgement .

Surg i c al Sho ck
U ntil the researche s W Crile placed the subj ect O f the Of Ge o . .

cau sation O f su rgical Shock u pon a de finite experimental basi s ,

the ideas held by practici ng su rgeon s were m ost variou s and

confli cting and the se ideas u nderwent frequent change
, If one .

might j udge of the se ideas by the therap y employed at that

ti me ( and it i s to be regretted the therap y still u se d b y a very
l arge nu mber O f su rgeons ) one would unquestionabl y sa y that ,

some derangement O f the heart i tself or its nerve suppl y ha s

been looked upon a s the cau se of su rgi cal Shock That the .

heart i s not primaril y at fault in Shock has bee n proven be yond

question .

Crile makes a sharp di stinction be tween shock and col lapse .

A l though the re are many contribu ting cau se s he considers that ,

the primary and princi pal alteration of function in su rgical shock

i s a d e ra ng e m e n t of the vasomot or mechanis m
_
Collapse i s du e .

to los s O f bod y flu id i e to hemorrhage It may al so be due

, . .
, .

to direct damage to the heart mu scle the re spi ratory organs , ,

or the nerves of e i the r While both conditions may be present .

in a gi ven ca se at the same time yet they are e s sentiall y di s ,

tinct entitie s The se are the views general ly accepte d by sur

.

geons today .

1 R m k m d t l i m i St M y H p i t l A g u t 4 1 9 1 0
e ar s a e a c e n . ar
‘

s os a . u s , .
 S UR GICA L SH O CK
The prevention of Shock i s full y as important as i t s treatment ,

and to accompl ish e ither result it i s ne cessary to unde rstand the ,

cau ses of the disorde re d function We may therefore with .

, ,

profit discu s s brie fly the cau se s contributing to the production

of surgical shock C ri le e nu merate s these u nder approximatel y
.
2

Six heads The y are :

.

1
. Duration O f ope ration .

2 Trau ma
. .

3 Temperature
. .

4 P hysi cal conditi on O f subj ect

.
.

5 A nesthe s ia
. .

6 H em orrhage
. .

To thi s l i st Y andell H e n d e r son ha s recentl y added another 3

factor v i z acapnia The term i s u sed to designate a state in

, .
,
.

whi ch there i s a deficiency O f carbon dioxide in the blood In .

connection with these seven contribut ing causes we Should also

discu s s the vasomotor and the cardiac change s prese nt in shock .

1. D u r a ti on of Oper a ti on The duration O f an operation al .

ways bears a direct relation to the occu rrence of Shock

1 .

In .

all the expe ri ments in whi ch pure shock was produced it w a s ,

found that a cons iderable time wa s requ ired u su ally half an ,

” 4
hou r or more With ether a s the ane sthetic it was found ,

that dogs would survive its continuou s administration for a

period O f time averagi ng ten hou rs .

2 . Tr a u m a A S has been mentioned trauma i s one of the

.
,
”
chief external causes O f shock ; i n fact the term traumatic , ,

S hock i s frequentl y u sed interchangeably with sur gi cal Shock .

Trauma O f nerve ce nters nerve trunks or areas richl y supplied , ,

with ne r es i s espec ially liable to produce Shock Sho c k i s al so

v
,
.

e specially l ikely to occu r on exposure O f the brain pleura and , ,

peri tone um E xposure O f the capaciou s splanchnic area i s

.

attende d by a rapi d d ilatation O f the Splanchnic ve ssel s le ading ,

to i ntense congestion detracting thereby a dangerou s amount ,

O f blood from the somatic circulati on an d inducing a rapidl y ,

”
decli ning bloo d pressure .

2 A Enxp im n l
ert R h i
e t S g i
a l S h k 1 899 pp 1
e se a rc3 5 —1 44n o ur ca oc , . .

V l X VI I
,

3 Am i n J l f Ph y i l g
o u rn a o s o o o

4 C il —
e r ca y . . .

r Bl d P
e oo in S g y 1 903 p 298
re ss u r e ur er , , . .
378 H YD R O TH E R A P Y IN S UR GE R Y

3 . Contact with air i s a ve ry great i rri tant

Te mpe r a tu re . _

to local ti ssues owing to the lowe ri ng of l ocal temperatu re and

to the dryi ng A nimal s O perated i n a cold roo m seem to sue
.

c u m b more readil y than u nder ordi nary warmth The d e p r e s .

sing e ff ects O f cold were plainl y seen when col d wate r w as

brought in contact w ith the i ntestine s or w hen an intra ve nou s -

inj ection of col d sal ine solution was given The e ff ect s O f warm .

towel s appl ied to the exposed inte stine s or of warm sali ne sol u
tion i n the abdomen i mmediately improved the respiration and
checked de cli ning blood p ressu re The same e ff e ct O f col d and .

warm sal ines w a s notice d on the brain and expose d nerve fibers .

4 . I ndividual s i n impai red heal th poorl y

P /zy s i ca l Con di ti on .
,

nou ri shed with sluggi sh ci rcul ati on too youn g or too O l d are
, , ,

always bad subj ects for O peration We have el sewhere men .

t i on e d various phys ical conditions which contribute to the occur

rence of Shock .

5 A nesthes i a
. O ve r anesthe sia rap id ane sthe sia at the start
.
-

, ,

or awkward or irregular giving of an anesthetic contribute to ,

the production of Shock Chl oroform requi res mu c h greate r

.

care i n it s administration than eth er Chl oroform i s more toxi c .

than ether Chloroform may cau se su dde n cardiac arre st ; and

.

if thi s occu rs it i s usuall y before su rgical ane sthesia i s attained

, .

I n this respect clini cal experience coincide s with experiment .

.

For the se reasons i n A me rica the majority O f su rgeons prefe r

, ,

ether u sing it al most exclu sivel y

, .

6 . L O S S of blood al w a y s p r e d i sp o se s to the
H e m or r hag e .

occurrence O f Shock H e morrhage from ve ins i s produ ctive O f

.

more i m mediate harm than hemorrhage from arterie s H em .

o rr ha g e from large venou s trunk s cause d the m ost p rofou nd

e ff ect u pon the blood pre ssure becau se the quantity O f blood ,

su pplied to the heart was i mmediatel y dim inished whil e if the , ,

hemorrhage was arte ri al the i ncom e O f blood w a s not so sud ,

d e n l y di mini shed The output O f the h eart doe s not de pend at

'

all u pon the height O f the arte ri al pressure but i s i n direct p ro ,

portion to the ve nous pres su re ”

.

7 . A cap n i a . H e nde rson

hol ds that carbon dioxide i s a har
mone or chemi cal regulator O f re sp iration and that the phe nom
380 H YD R O TH E R A P Y I N S UR GE R Y
I n a nu mbe r of va somotor
apparent that the re are regional vasomotor ac t ions
pendent of each other .

There i s no port ion O f the circulatory apparatu s

whose equil ibrium i s so easil y distu rbed and whose ,

with all parts of the body i s S

p r i or i it woul d be the most
,

most readily exhau sted and to

tions lead u s The .

was a give n area the more rapidl y

,

i sm exhau sted when su ch area was su b je c t e

princi ple was abu ndantl y illu strated in the
”
the splanchnic area .

The experiments O f Mall Show that the

are vein nerve s and control th is large and spac
-

E ve ry experiment i n thi s area gave evi dence

the ve ssel s controlled by the se nerve s and the ,

pressure occu rred p a r i p ass u with thi s dilatation .

C ardia c C han g es It i s pe rfectl y evident as

.
,

Crile that The heart i s the base O f su

,

su re and au v i nte rference w ith its actio

,

”
change s in the pres su re The hea rt .

i nfluence d by venou s pre ssure in t h

p l ace s special emphasi s upon th i s l
i
what he has called the veno pressor -

n i t i on O f thi s factor in cardi ac action

was earl y pointed out by Crile i n h is

of altered heart action ( and lowere d
H e says The output of the hea rt i
,

sure of the vena cava and not at all ,

blood p re ssu re The venou s pre ssu re

.
,

heart s output and the venou s pres sure i s

’

de pendent u pon the force and fre quency O f the heart beats -

gether with the necessar y vascular tone whi ch i s u nder ,

control of the vasomotor ne rve s ”

.

Through vasomotor exhau stion the bl ood accu mulates l n .

dilated vei ns e spe ciall y those of the s planchni c a rea whi ch

,

S O ca pacious .There has therefore , ,

 S UR GICA L SH O CK
i nto the ve ins Thi s i s due both to exhaustion O f the va so
.

motors O f the vei ns with consequent vaso dil atation and to the -

failure of the arte ri ol e s to conti nue th ei r pumpi n g a ction Thi s .

l atter i s l ikewi se a re sult of vasomotor failu re Th e resul ts of .

vei n engorgement may be temporarily overcome by pre ssure

u pon the abdomen or by the u se of the pneu matic su it devi sed
by Crile .

I n regard to the relation of in f ra abdominal tension to the -

veno pre sso r mechani sm the O bse r vations re corded by Leonard

-

s
W he n a l arge hutch rabbit i s h el d for
H
H i l l ar e inst ructive .

a few mi nute s i n the vertical posi tion w ith i t s l i mbs stretche d

out and head uppe rmost it may become u n con sciou s and die .

from cerebral anem ia The bl ood collects in th e l arge flacci d .

abdomen the animal not bei ng abl e to retu rn i t to the heart by

,

changing its pos tu re I t stru ggle s to maintain a circulation

.

ce rebral ane mi a excite s convul si on s wh i ch squ ee z e the bl ood

from the limbs etc into the heart—but the difli cu l t y in fa ce O f
,
.
,

the ci rculati on i s too g reat and the ani m al die s A wil d rabbit .

with taut abdome n i s n ot a ff e cted in thi s w a y ne ithe r i s a cat ,

or dog bu t a goat i s with i ts capaciou s bell y The wild rabbit

,
.

can however be bro ught i nto l ike state by a dose of chl oral
, , ,

a nd SO can a dog by chloroform poi soni ng or by bleeding The .

emoti onal fai nti ng O f a man i s due to the i nhibition O f the ne r v

ou s system
— a neutral i z ation O f all other afferent sti mul i by one
—
al l p owerful one th e con sequent sudden rel axation of mu scular
-

tone coll ap se O f the body and non r eturn of venou s blood to the
,
-

heart The ho ri z ontal postu re or compres si on of t he abdomen

.

”
i mmedi atel y restore s from syncope the rabbit or the man .

Pu m p in g Acti on of the
The control or main B lood vesse ls -
.

t e n a n c e O f a defini te va scular ca l i or e i s not the onl y work O f the

v a som o t o rs ; vascul ar a cti vi ty i s also controll ed by the vasomotor

centers A rteri al vascula r activi t y help s to fill the veins and

.

venou s va scul ar activity hel ps to mai ntain blood pressure in the

vena cava Wh ile laying great stre ss upon vascul ar ca l i ore i n
.

its eff ects u pon the work O f the hea rt nearl y all observers ,

entire l y i gnore vascular acti vi ty To illu strate the three factors .

5 F ur t h er A dv a n ce s in Ph y si o l o gy p , . 1 73 .
3 82 H Y D R O TH E R A P Y I N S UR GER Y
6
i n the circulation H enderson employs a diagram i n which the
,

arte ries are represented by rigid tu be s and change s i n the ir

calibre as equ ivalent to the widening or narrowing of nozzl e
outlets Wh ile this mav il lu strate one factor in the work of the
.

v a so m o t o r s i t enti rely overlooks arterial activi ty the resul t of

, ,

whi ch it i s i mpossibl e to conce ive of a s illu strate d by mere

changes in re si stance brought about by the w idening or nar
,

rowing of the no z zle s .

I n conclu sion i t mu st therefore be adm itted that fail ure of

, ,

the va somotor me chani sm i s the ch ief immedi ate cau se of sur

g i ca l shock N eithe r the views of P orte r and Q u
. inby S eel ig ,

and Lyon or Y andel l H enderson have greatly altered thi s con

,

c e p t i on of the pathologic physiology of shock .

The Tre a tm e nt of Sho ck

There i s no better place than the O perati ng room i n wh i c h to
demonstrate the prompt tangible re sults obtaine d by the u se of
hydrotherapeuti c sti mulation I n ope rati ons u pon the head
.
,

in prolonged or extensive abdom inal ope rations breast am pu ,

t a t i on s etc
, and i n other case s where shock i s likel y to appear
.
,

and prove dangerous the su cces s attained by the u se of hydro

,

therapy has in ou r hands been uniforml y gratifying Thi s

, , .

has also been the experience of many others worki ng i n the

association of me dical institutions w ith whi ch the writer i s
conne cted .

The plan whi ch we have followed i s very si milar to that out

l ined i n Chapte r X X for the rel ief of acute edema of the lu ngs
and circul atory cri si s i n valvular hea rt di sease There are .

certain additional featu res to be taken into account so that it ,

will be repeated here in ful l The p rinciple s i nvolved i n the .

h y drothe rapeutic treatment of su rgical shock are ne ithe r com

pl icated nor diffi cult to understand Thei r intell igent effective .

application however requi re s a knowledge of the cau sation

, ,

and morbid physiology of shock a thorou gh a cquaintance with ,

the methods u sed and an experience i n their use in orde r to ,

know how to adapt the mean s to the case i n hand and bring re
s u l t s where the se re sults are di ffi cult to obta in .

6 Am i
e r ca n J n l f Ph y i l g y V l X X V II N
o ur a o I p 1 59
s o o , o . , o . . . .
3 84 H YD R O TH E R AP Y IN S UR GER Y
the water with a Tu rki sh towel A fter th is anothe r fomentation .

i s appl ied again foll owed by the ice

,
The se alternations should .

be repeated three or four time s after whi ch the wel l covered ,

ice bag shou ld agai n be placed over the heart .

Wherever there i s any hope at al l of va somotor response ,

the se measure s resul t in prompt ri s e of blood pres sure and as

p rom pt cardiac response to the increase d v e nop r e ssur e Where .

an abdominal operation i s be ing done it i s pe rhaps nee dle ss , , ,

to s a y that warm gau ze napk ins shoul d be appl ie d and if feas ,

i ble some pressu re exerted u pon the spl anchni c area in order
,

to more qu ickl y send the blood on to the heart Rathe r than .

leave fluid i n the abdomen we prefer to give warm saline solu

,

tion per rectum e ven while the patie n t i s stil l on the operati ng
table .

U nles s the shock i s very severe it w ill not be n ecessary to re

peat the vasomotor stimu l ation short of thi r ty or forty m inutes .

I f the condit i on of the patient permits and repetition of the vi g

o r o us measu re s outl ine d above i s not reall y needed it will be ,

better from now on to e mpl oy milder toni cs after giving some

e ffi cient derivative treatment .

The p rinci ple of th is plan of treating sh ock l ie s i n the e ff e ct

of brief appl ications of heat to the sk in surface and e s peciall y
to t he l imbs in order to warm the ski n and ai d i n redu cing i n
,

ternal conge stion The quickl y following col d friction produces

.

vi gorou s stimul ation of t he v as om otor s s o that the b l ood pre s ,

sure rises imm ediatel y The vas cul ar condition i s not at al l

.

comparable with that produ ce d by the inj ection of adrenal in .

I t i s not a sta tionary vaso constriction that re su lt s from a col d

—
-

friction but a vas cular activity a rapidly alte rnating dilatat ion
,

and contraction of the blood ve ssel s Thi s i s a tru e pum ping

-
.

action which is i n real ity onl y a heighte ning of the no rmal ac t iv

i ty of the bl ood ve ssel s -

The e ff e ct of di ff erent temperatu res u p on the bl ood pre ssure

has already been d is cu ssed i n Chapter I X whe re the l aws de ,

d uc e d by Mii ll c r a r e recorde d Mii l l e r s s tud ie s i nto the e ff ects

.
’

of baths on bl ood p ressu re we re ca rri ed ou t by m eans of a

,

Riva Rocci i nstrument and were ve ry c areful l y done wi th appar

-

ently e ve ry precaution ta ke n Those who de sire to stud y fur.

 D R UG TR E A TME N T

ther these experi ments w il l find a complete consi deration of the

question given in h i s paper 7
.

I n meeting H enderson s acapnia what could be more ideal ’

than rais ing the carbon dioxide c ontent of the blood and tissue s
by stimul ati ng i t s produ ction from the ti ssue s themselves
through i ncreas ed oxidation ? That this can be e fficien tl y done
by thermic and mechanical stimul i and results very promptl y
from the a p p l ic at i on o f such means has al ready been shown i n ,

Chapte r X I I The circulatory stimulation and the stimulation

.

of re sp iration by the same means serve to mai ntain the proper

pe r cent and proportion of oxygen and carbon dioxide in the
bl ood .

I n concluding the conside ration of the treatment of surgical

s hock other than a practi cal experience in the sat isfactory r e
,

su l t s attained we could o ff er no better apology for the pre

,

s e n t a t i o n of so simple a plan for its treatment than to sum m ar

i ze the experime ntal work and conclu sions therefrom reached ,

by recognize d authorities showing the fa ilure of older and m ore ,

pretentiou s methods Those who wish the fact s at first hand

.

will fi nd the re sults of the most exh au stive and conclu sive
studie s along th is l i ne given by Doctor C rile in h i s monumental
” 8
work ,
B l ood P re ssure i n S urger y which appeared in 1 90 3 ,
.

A l t o/ wt The i mmediate e ff ect of intravenou s administra

.

tion onl y was obse rved The first e ff e ct u sually notice d wa s a .

de cline i n th e blood pressu re I n the maj ority of such insta nce s .

a compensatory rise fol lowe d ; in a number of instance s no

change in the blood pre s su re w a s noted ; in but few was there a
ri se . The average length of the stroke of the m anometer
( height of p u l se w a v e ) w as i ncreased There was no evidence .

that the heart he a t more forci bl y I n animals reduced to vary .

i ng de g rees of surgical shock the u sual e ff ect of an average ,

dose of al cohol w a s the production of a further depre ss ion ; in

s malle r dose s but l ittle e ff ect was note d whil e i n larger dose s ,

a m ore marke d decline often occu rred I n few instance s the .

admini stration of a consi derable dose in deep shock was followed

7 fi b d Ei fl
er B d
n d D
n h f d n B l td u k b im M
u ss v o n a h
e rn un ouc en au e u r c e e n sc en

D t A h fu k l i M d 1 902 V l m LX X I V p 3 1 6
e

eu rc r n e o u n .
. .

d f g h dt d f hi k
. . . . .

— r om
o ll o w i n u n l e ss o t e rwi s e t s w or
8 Q u ot a t io n s i m m e i at e l y c re i e , a re ,

pp
,

. 26 1 300 .

25
3 86 H YD R O TH E R A P Y IN S UR GER Y

by al most i mmediate death I n a nu mber of experiments the

.

decline in the bl ood pre ssu re was as p rompt and as marke d as

i n the adm ini stration of the amyl n i trite and nitrogl ycerine .

I n no i nstance in the norm al animal d id death immediatel y

, ,

follow the largest dose of alcohol ; the more profou nd the shock ,

the more marke d w a s the depre ssing e ff e ct of al cohol In a .

numbe r of expe r iments al cohol w a s given prior to proce du re s

intended to produ ce shock I t i s not certai n that it rende red
.

the ani mal more su sceptible I t i s qu ite certain that the sus
.

c e p t i b i l i t y w as not dimini shed .

A i tr og tyt er i ne a n d A my " N i tr i te
f
The immediate e ff ect of
nitroglyce rine and amyl nitrite upon the pul se w a s an increas e
i n i t s volume and a decrease i n fre que ncy The immediate .

e ff ect u pon the respiration varied A t times there was a sl ight .

i ncrease more frequentl y a slowing of respi ration

,
The .

immediate e ff ect u pon the blood pre ssu re in al most eve ry i n

stance was a fall The decl ine wa s u suall y rapid Th ere were
. .

but few exceptions and in the se there was u suall y no e ff e ct

, .

A rise w a s rarel y observed I n the latter it w a s but temporary

.

and w a s usuall y followed by a fall The des ce nt in the blood .

pre ssure w a s gradu al and rather rapid ; the ascent more ,

gradual .

I n the experime nts i n which the animal w as i n dee p shock ,

and the blood pre ssu re w a s graduall y fal li ng there was no ,

e vidence to show any decrease i n the rapidi ty of the de cl ine .

O n the contrary a s nearl y as coul d be estimated nitroglycerine

, ,

distinctl y increased the rap idi ty of the de c li ne The e ff e ct of .

nitrite of amyl was i n every re s pect sim ilar to that of ni tro

glycerine . I n many instances the heart beat i rregularly afte r
t he inje ction .O n the whole nitroglyce rine and amyl ni trite
,
”
increased shock .

D ig i ta l i s . The administration of digital i s in the normal

animal produce s a ri se of blood pre ssu re wh ich i s wel l su stained .

The drug i s ve ry likel y to cau se ove r stimulation re sulting -

in sudden card iac failure I n varying degree s of shock digi

.
,

tali s produ ces a less marked ri se of bl ood pre ssure than i n the
”
normal animal .
The re spi rati on when at al l a ff ected w a s
ei the r impai red or a rre sted Death i n the di gi tal is e x p e r i
.
3 88 H YD R O TH E R A P Y IN S UR GER Y
when but little shock was pre sent a marked effect from strych ,

ni ne w as obtained ; and when most profound there was no ,

eff ect I n the inte rve ning degree s the e ff ects were propor
.

t i o n a l ; but after giving the strychnine the animal s not yet i n ,

comple te shock always pas se d into a deepe r degree of shock ,

.

I n any degree of shock afte r the admi nistration of a t he r a p e u ,

tic dose of strychni ne the an imal s passe d into dee pe r shock ,

.

Later in the re search i t was found that the most conve nient
and certai n method of producing shock for e xperimental pur
pose s i s by the admini stration of physi ologic doses of strych
,

nine The treatme nt of shock then by therapeu tic doses of

.

strychnine i s inert and physiologic dose s dange rou s .

I t then follows that treatme nt of shock by vasomotor st i m u

lants in the form of drugs i s on p re ci sel y the same basi s as
treatment by bu rning the animal or crushing hi s paw s or by ,

subj ecting i t to inj ury or operation i t woul d see m to be a s ,

reasonable to treat strychni ne shock by administering trauma

” n 1"
t i sm as traumati sm by s trychnine .

The more recent researche s of Wallace and P amment on 2 ’

the eff ects of strychnine upon blood pre ssu re fully agree w ith
those of Crile The y i nduced low blood pressure by chloral .
,

the nitrite s hemorrhage diphtheria toxin chloroform and by

, , , ,

shock I n no ca se exce pt chloral poi soni ng did the u se of

.
, ,

therapeutic dose s of strychnine produ ce a rise i n blood p re ssu re .

S urgical shock is an exhau stion of the vasomotor cente r .

N e ither the heart mu scle nor th e cardio inhibitory center nor ,

-

the cardio accel erator cente r nor the re spi ratory center are
-

, ,

othe r than secondarily involved Collap se i s due to a su sp e n .

sion of the function of the cardiac or of the vasomotor mechan

i sm .
In shat /e therapeutic dose s of strychnine are i ne rt physio ,

lo g i c dose s dangerou s or fatal I f not fatal increased e xha u s .

,

tion follows There i s no practical distinction to be made

.

between exte rnal stimulation of thi s center as i n inj urie s and

operation and internal sti mulation by vasomotor stimul ants
, ,

as by strychnine E ach i n su ffi c ient amou nt produce s shock ;

.

10 D t it M di l J n l M y 1 903 pp 38 39
e ro e ca ou r a , a ,

Do to C il h w
. .
, .

1 1 c t i on o f b
r in ti u
r v li n g d g n t i n o f t h P u k
e s o s se c s ra ss e re ea e e e ra o e r
m i ce l l f om f t y h ni n
0

e nt n uo u
s ur co i s se o s r c e

dv n m nt f C l i n i l I n v t i g t i n
.

12 R p t b fe A m i n S ci t y f
or th A
e o re e r ca o e or e a ce e o ca es a o
M y 1 3 1 91 2 Ab t t n J ou n l f A m n M di l A oc i t i o n J u l y 20 1 9 1 2 p 2 1 9
.

a . .
i s ra c i r a o e r ca e ca ss a . .
. . ,
 A F TER TR E A TME N T

and each with equal l ogi c might be u sed to treat the shock
‘

, ,

p rodu ce d b y the othe r S timu l ants of the vasomotor cente r .

are contraindi cated Cardia c sti mulants have but a sl igh t

.

ra n ge of possibl e u sefulne ss and may be injuriou s ,

A drenal in act s u pon the h ea rt and bloo d vessels It rai se s the -

.

bl ood pre ssu re i n the normal animal i n every degree of shoc k ,

,

whe n the m edul la i s cocaini zed and i n the decapitate d a n i mal , .

I t i s rapidl y oxidi z ed by the soli d ti ssu es and the blood I t s .

e fe ct s a re fle eti ng ; it shou ld be gi ven continuou sl y

f ” 3
The .
1

e ff e ct of a s ingle dose of adre na l in lasts from two to four min

ute s
‘
.
The longe st ti me that the action of the extract on the
bl oo d p re ssu re wa s prolonged wa s fou nd to be fou r m inute s .

With the conti nuou s flow of the e xtra ct into the vein ,

howeve r the p res su re wa s kept u p a s l ong a s the flow wa s con

,

t i n u e d and for t he u su al ti me after it had be en di scontinued

, .

AF TE R TR E A T M E N T
-

Post anesthe ti c
-
Infe ct ions
The qu estion of h ow be st to pre .

vent and treat post anestheti c pneu monia wou nd infections

-

, ,

and other i nfecti on s following operation s i s an ever p resent one -

and to th e su rgeon the cau se of no l ittle anx iety duri ng the first
thre e or fou r days of th e afte r care of the patient -
.

Mode rn asepti c te chnic togethe r wi th caution in regard to

u nne ce s sary trau matis m i n operati ng and in regard to inj u ry of
th e ti ssu e s by strong antisepti cs or the prolonged appl i cation of
anti septi cs al so the prope r u se of se rum dra i nage has red u ced
, ,

wou nd infe ction ve ry largel y to a matter of the res istance of the

pat ient s tis sue s
’
.

We have al ready shown how the tis su e resi stance may be i n

c re ased by p reparatory treatment There i s however one .
, ,

cause of l owering o f the vi tal res is ta n ce whi ch i n the nature of ,

-

the ca se ca n not be el i minated Thi s fa ctor i n lowering r e

,
.

s i st a n c e i s nothi ng el se t h an the ane sthetic itsel f It results in .

l im i ting or che cki ng for the time being both phagoc yt osi s and -

leu coc yti c activity .

A fte r ane sthe sia the powe r of the bl ood to destroy pat hoge n i c
,

bacteria i s mark e dl y red u ced In fact the membe rs of the .

,

13 e D t i t M di l J u n l M y 1 903 p 45
ro e ca o r a , a , . .
 3 90 H YD R O TH E R A P Y IN S UR GER Y
entire gr oup of al cohol ether and chloroform redu ce the power , ,

of the blood to combat bacteria ; the state of a man after a l ong

ane sthesia i s com parabl e to that of an al coholi c with bronchiti s
who h as been sleeping o ff an overdose of al cohol i n a door way -

or a fre ight car .

”
S o i mportant a subject i s thi s post operative pneumoni a -

that much i nterest attache s to the re cent stu die s of G raham on

ane sthe sia and the bacteri cidal powers of the blood A ccord .

ing to the se expe riments i t i s not the powe r whi ch seru m itsel f ,

has of destroying bacteria through bacte riolysi s whi ch i s

redu ced by anestheti cs but the destru ction of bacte ri a by ,

p hagocytosi s i s greatl y redu ced N ow i t so happens that the .

organisms whi ch we have to fear i n surgery the pneumococcu s ,

and the pu s cocci ar e destroyed chie fl y throu gh phagocytosi s ,

and not by bacteriol ys is wh ich give s added i mportance to th i s ,

depressing e ff ect on the bactericidal powe rs of the blood .

A pparentl y ethe r the anestheti c which G raham ha s stu died , ,

reduces both the efficiency of the opsonin s and the power of th e

leucocyte s to take up the sens iti ze d bacteria ; th ese e ff ects ca n
be seen both i n the blood of the patient s or animal s afte r anes
t he s i a and i n drawn normal blood treated with e the r i n the tes t
,

tube The action of the ethe r i s not pe rmanent the opsoni c

.
,

”
power being re stored promptl y on removal of the eth e r .

Dr C A chard has recentl y cal le d attenti on to the se facts and

. .

their i mportance in the cau sation of ce rtain post ope rative -

accidents i n a paper 1 read before the A cademie de Me d e c i n e 5

.

The u se of morphine as a n ane stheti c ai d eve n where d e fi .

n i t e l y indi cated mu st of necessity be an added sou rce of dange r

,

from infections L Re ynol ds has em p has ized th is fa ct and

6
. .
1

called attention to th e disadvantage in u s ing morphine .

From experiments pe rformed by him Reynol ds concl ude s ,

that morphine exerts a m arked in fluence on th e leu cocytes .

N o t onl y doe s i t check diapede si s but phagocytosi s i s di mi n ,

i she d in a marked degree The growth of bacteria on the .

,

other hand i s not appreciabl y a ff ected What bearing has thi s

, .

14 E dit i l i n J —or a l f Am o u r na o i ca n
er M di c al A ss o c ia t i on . F b 18 1 91 1 a l so
M a rc h 26 1 9 1 0 pp 1 043 1 045
, , . .
e e ru a r y , ,

15 Ap il 1 91 0
r . .

16 L nd o on L a nc e t . F b e r ua r y 26 , 1 91 0.
 H YD R O TH E R A P Y IN S UR GER Y

tine u se of gastric lavage before the patient recovers from the

anesthetic is one of the be st means for getting rid of the ethe r ,

pre venting vomiting and the occasional occu rrence of acute

,

gastri c dilatation The u se of the s al ine enema i s speciall y

.

hel pful I n giving continuou s p r octocl vs i s after the volu m e of

.
,

the circulating flu id ha s reached normal the added fluid i s ,

el iminated by the kidneys a s fast as it i s absorbed .

Th i s same measu re al so hel ps i n decreasing the danger from

post O perative ne phritis
-
A s s oon as the patient i s out from
.

under the anestheti c c opiou s water drinking should be ins isted

,

u pon It will not be l ikel y to cau se vomiti ng and if i t should

.
,

see m to have this e ff ect gastric lavage m ay be re sorted to and

,

continued u ntil the stomach h as be e n washed cl ean S ips of .

ve ry hot water or swallowi ng bits of ice will the n rel ieve the
trou ble and in a l ittle while the free u se of water may be
,

continued .

A n active ci rcul ation w ill al so ai d i n the el imi nati on of the

ether ; and this together with the stim ulation of leu cocytic
,

activity ma y be accompl ished by the u se of the cold m itten

,

friction with the ice bag to the heart B oth the se measu re s .

i ncre ase the de pth of respiration and the vol ume of tidal air so
that more thorough ventilation occurs .

Considerable i mportance attache s to the prevention of internal

congestions and vis ceral stasi s of bl ood e speciall y i n the lu ngs ,

and about the s ite of operation A s a means to thi s end we .

,

h ave adopte d a s almost a matte r of rou ti ne the use of the hot

foot bath the hot leg pa ck or electro thermal pack to the l egs
, ,
-

as soon as conve nient i mmediatel y following the operation If

, .

the hot leg pack i s u sed a dry blanket s houl d be placed next to
,

the skin A wel l co vere d ice bag i s place d ove r the hea rt at
.

the s ame time The treatment i s continue d u ntil the l imbs are
.

well re ddened and should be conclude d by a cold mitten friction

to the same skin surface This procedure will u su all y last
.

abou t thirty m inutes It will probably not be ne ce ssary i n

.

ordi nary cases to re peat i t for seve ral hou rs or u ntil the next
day .

Transient al bum inu ria doe s not u sual ly require an y spe c ial
treatment If al bu men and casts appear in the u ri ne de rivative
.

,
 A F TER TR E A TME N T

treatment i s indicated and free persp iration should be e nc ou r

aged S we ati n g should neve r conti nue long a t a time
. .

If pneu monia occurs u se derivative measures and appl y the

,

cold coil or col d compres s to the chest The se shoul d be .

oc cas ionall y interrupted by the application of a fomentation or

the revul sive compre ss u se d The i ce bag to the heart and the
.

col d m itten fri ction are al so of great service in treating post

ope rative pneu monia For fu rther de ta ils see article on pneu
.

monia i n Chapter X I X .

A fte r gall bl adde r appendix tubal and some other a b d om i

-

, , ,

n a l operations ,
a right si de d diaphragmatic and consequently
,

m uch h idde n ple uris y may appear It i s usuall y not severe

.

a nd wil l respond to the u sual treatment .

 C H A PT E R XXVI I I

I N SA N I T Y A N D D R U G A DDICT I O N S
J ESS I E H . S I M P SO N ,
M D
. .

THE I N SA N E
HE treatment of the i nsane i s still i n the i nvolutional
period to a more marked degree than any other l ine of
therap y and the introdu ction of hydrothe rapeu ti c measure s ha s
,

done mu ch to alleviate thi s unfortu nate clas s te nding as i t doe s ,

to eliminate the u se of hypnoti c drugs and mechani cal restraint .

In dealing w i th the insane two ve ry diff erent l ine s of sym p

tom s are encountered s o that for the purpose of thi s chapter
,

we will divide them i nto excited and depressed case s regardles s

of mental diagnosi s .

Many of the se case s when first c oming under treatme nt Show

marked s ymptom s of autotoxemia wh i ch sugge st col oni c fl u sh ,

ings and measure s calculated to stimul ate Sk in el imination

,

with free drinking of wate r and indeed all h ydrothe rapeutic ,

measures Should be prece ded by thorough cleans ing of the i n

t e s ti na l tract .

The ex ci ted cases whethe r mani c depre ssi ve paretics se nile s

,
-

, , ,

dementia p r mc ox or other pre senting the s ymptom s of Sleep

, ,

lessne ss hyperactivity logorrhea perhap s de st ru ctive profane

, , , ,

violent and res istive requ ire sedative treatment which m ust
, , ,

be adapted to the condition of the individual pati ent H ere

—
.

two methods have prove n ve ry hel pful the conti nuous flowi ng ,

bath and the wet pack .

The continuou s flowing bath ( P l a te XX ) requ ires a special .

tub S i x feet long which i s supplied with a l arge overflow vent

,

ne a r t he top and a large ou tflow so that the tub can be emptied ,

and cleaned qu ickl y The inflow may consist of one large

.

( 394 )
 DR UG H A BI T UE S
night or he ma y be remo v ed at any time when the re st raint
,

be come s ti re some If h owe ver he doe s not be come quiet i n

.
, ,

an hour he should be removed from the pack and S ponged and

,

dried a s unde r these condition s the pack ma y be come heatin g

,

and se nd hi s tempe ratu re u p to an ala r mi ng de g ree De hil i .

t a t e d patient s or those su ff e ri ng from arte ri o sclerosi s shoul d

.
-

not recei ve thi s treatment the continu ou s bath being pre fe rable ,
.

D ep r essed cases re qui re tonic treatme nts O f the se the sal t .

glow holds a leading pl ace ; hot and cold to the spine foll owe d
by the needle Spray and fan dou ch e; fomentation s to the l ive r ,

i f that organ i s i na ctive foll owed by the spra y and dou c h e ; the
,

electric l ight or hot ai r bath foll owed b y th e spra y and dou ch e

are all u seful together w ith liberal feeding a nd good hy gi en e
,
.

DR U G H A B IT U E S
Morp/z i ne Coca i ne E tc, Whether immediate or gradual
, .

withdrawal of the d ru g i s practiced or whatever method of c ure

i s u sed h y drothe rapy i s a u seful adju nct
, Du ring the earl y .

ab ste n a n c e s ymptoms whe n the patient i s su ff e ri ng from nau sea

, ,

dia rrhea shifting p ains and great re stle ssne ss and Sleepl ess
, ,

ne ss the continu ou s bath admi ni ste red for one hal f hou r to t w o
,
-

or three hou rs at a time rel ieve s th e symptom s and frequ entl y

induce s sleep S ometime s a wet pack will bri n g sleep fom e n
.
,

t a t i on s will rel ieve the pains when the y are more local ized ,

and an i ce cap at the pit of the stomach w il l frequ entl y r e

l ieve the na u sea .

A fte r the se earl y s ymptom s have been relieved eli mination ,

can be stimulated and the patie nt toned up generall y by the u s e

of electric l ight or hot air bath s followed by the spray and
douche .

A l co/z ol In deli rium t re i n e n s the continu ou s bath i s indi

.

ca te d togethe r with other mea sure s If thi s i s not availabl e .

,

hot packs may be u sed For the l ater eff e c ts of al c ohol el im

.
,

i n at i on and tonic treatments are needed the ele ctric li ght and
, ,

hot ai r bath s holding a leadi ng place each to be foll owed by the

spray and douche .
 PL A T E X X fl
T h e c o n t i nu o u s ow i n g b th
a as i n st a l l e d at t he
S ut h n C l i f S H p
.

o er a o r ni a t ate os i t a l .

PL A T E X X I . T he w e t s h eet p k ac and p kac ta bl e s at t he

898 TE CH N I Q UE

7 . R ubs a n d These are procedu re s in which the

F r i cti ons .

chief e ff ect i s de rived from fri ction with the bare hands .

E xamples : Cent ri petal fri ction oil rub ,

.

8 Ba t/i s
. U nder this heading are inclu de d va riou s local
.

and general procedure s in which the bod y i s i mmerse d in water ,

l ight heated ai r or vapor E xamp l es : Tub bath foot bath

, ,
.
, ,

electric light or Ru ssian baths .

9 Sha mpoos
. The te rm shampoo ap pl ie s to l ocal or general
.

cleansing meas u res by means of soap and wate r ( I t is some .

times appl ied to massage ) E xample s : S we di sh shampoo .

,

Turki sh shampoo .

1 0 P a c/es
. A pack i s a procedure in wh ich a considerabl e
.

portion of the bod y i s enveloped in wet sheets or blankets for

therapeutic pu rposes E xample s : H ot blanket pack h ot hi p
.
,

and leg pack w e t sheet pack , .

1 1. Sp r ay s a n d D on c/z es A spray or douche consists i n the .

proj ection of one or more stream s of water against the body .

E xample s : S hower bath needle Spray pail pou r hot and col d , , ,

dou che .

1 2. E ne m a ta A n enema i s an injecti on of flu id i nto the

.

lower bowel E xamples : . Warm ene ma re ctal irri gation , ,

col ocl yster O il enema starch enema

, , .

1 3. Vag i n a l D ou c/z es The vaginal dou che consi sts i n th e .

flushing or irrigating of the vaginal cavity with a flui d .

E xamples : H ot vaginal irrigation d isinfectant douche s st y p , ,

t i e douche .

G L O SS A R Y O F T E RMS
The te rm s l isted below are u se d to de signate the variou s
physiologic or therapeutic e ff ects of water and i n the de sc r i p
tion of methods S ome of these have applied meanings sl ightl y
.

di fferent from that ordinaril y given .

1 .Ton i c A tonic e ff e ct i s one i n wh ich vital activitie s are

.

i ncreased so a s to restore the body to a normal tone or condition .

The nutrit i on C i rculation and othe r body fu nctions are pro

, ,

moted .

2 .P u re S ti m u l a n t A stimulant arou se s the bod y to u nu su al

.

activities I t may be compa red to a whip and i s u sed chie fly

.
 GL OSSA R Y OF TE R MS

in e mergencie s Like a tonic i t i ncreases vital activitie s but

.
,

to a mu ch greate r degree B etween a p u re stimulant and a .

tonic there are variou s gradations which might be des ignated

as mild stimulant extre me tonic etc , , .

3 . Se da ti ve sedative or calmative agent i s one which

. A
lessens Vital activity and i s conducive to relaxation and rest .

4 A n ti spa s m oa i c
. The relaxing of spasm or relieving of ’
.

convulsions .

5 D epr essa n t
. A depressant e ff ect i s one in whi ch heightened
.

or normal body activitie s are decreased to a marked degree .

S uch an e ff ect i s des irable onl y where a function i s greatl y

overactive .

c A n oay ne
.
’
A n anodyne e ff ect refers to the rel ief of pain
. .

7 Spol i a ti ve
. A Spoliative treatment i s one wh ich increases
.

the oxidation an d b reaking down ( catabol ism ) of ti ssue ; tend

i ng to reduce weight .

8 D i ap/z or e ti c
. The p rodu ction of sweati n g A n agent that
. .

p roduces sweating i s said to have a diaphoretic or sudor ific

eff ect .

9 D i u r esi s
. I ncreased excretion of urine
. .

1 0 E l i m i n a ti v e
. A n el iminative e ff e ct cons i sts in promoting
.

an d hastening excret ion from the kidneys ( diu resis ) skin ,

( diaphore si s ) and lu ngs , .

1 1 D ep le ti on Depletion i s the lessening of the amount O f

—
-

. .

blood i n a give n p art practically it i s the redu ction of con ,

e

ge stion .

I 2 D e r i va ti ve
. De ri vation i s the dr aw m g of blood or l ymph
.

from one part of the body by increas ing the amount i n another
part The term depletion i s al so appl ie d to th is process but
.
,

refe rs particularl y to the re sult produced .

1 3 . F l ux i on Fluxion consists in greatl y increasing the

.

rapi dity of the blood cu rrent in a pa r ticular part It i s the .

produ ction of active or arterial h yperemia .

1 4 R evu l si ve
. A term u se d to designate a treatment con
.

s isti ng of a S ingle p rolonged appl ication of heat followed by a

single very brief appl ication O f cold Thi s meaning i s not .
400 TE CH N IQ UE
strictl y adhered to as the te rm i s al so u sed whe re three applica
tions of such p roportionate d ur ati on a r e made .

H
1 5 .A l te r n a te .The expression alternate hot and c ol d is
u sed i n thi s text to describe treatme nts i n which the du rati on
O f the cold application i s from one fou rth to one half that of the - -

heat ( in a few cases equal with it ) and i n wh ich three or more

change s fro m heat to cold are made .

1 6 A n tipy re ti c
. The lowering O f the body tem perature in
.

fever .

1 7 .R efr ig er a n t Relieving O f th irst and re stori ng the alka

.

li mity of the blood by such means a s free wate r drinking and

the u se of fru it j uices .

L O CA L A P P LIC A T I O N S OF H E A T

Fo m e n tations —F 0 .

A fomentation i s a l ocal ap pl i cation of moist heat by me an s

of cloths wrung from h ot wate r .

( a ) A r ti cl es N ecessa ry I n well e qu i pped treatment room s

.

the fomentat i on tank shoul d be so arranged that the wate r from

which the foment ations are to be wrung can be heated by live
steam passed i nto th e wate r throu gh a coil When properl y .

arranged the e scape of steam from thi s coil i nto the water wil l
be noi seless and cau se the water to boi l more vigorou sl y than
over a fire The ou tlet of the tank Sh ould be controll ed by a
.

valve never by a plu g A wringer w ith extra long ro l lers

, .

should be clamped to the Si de or e nd O f the tank and a tabl e

placed immediatel y be y ond the wr inger on which the fomenta
tions may be wrapped ( P l a te X X I /L ) The fomentation s .

will be hotter if heated di rectl y by l ive steam S pecial steam .

boxe s ( P l a tes XXI V a n a X X V ) may be provided for thi s pu r

’
.

pose or l ive steam passe d i nto fome ntation cl oth s packed i n a

"
pail I f treatment i s give n at the patient s residence a boile r
.

or pail of hot wate r may be u sed I n an institution i t i s rarel y

.

nece ssary to carry a pa il of hot water to the patie nt s room a s ’

the fomentation s will be hotter i f prepared in the treatment

rooms and packed i n a pail in the manner de scribed below .

The nu rse should al so be provided wi th a set of Six fome ntation

402 TE CH N IQ UE
shape and size for the part to be treated fold it qui ckl y in side ,

the d ry fomentation cl oth I t i s now ready for u se

. B y again .

doubl ing togethe r the su rface of the fomentation to be appl ied

to the patie nt it can be carried with le s s l os s of heat
,
The .

fomentation should be l arge enou gh to cover a much larger a rea

than the part a ff ected .

Where it i s nece ssary to w ri ng the fomentation by hand par ,

t i a l l y twist the l ong fol ded pi ece wh ile it i s h eld doubled to

gether with one hand holding each e nd B oth ends are now .

grasped in one hand and the fomentati on di pped into the boil ing
water When it i s ready to wri ng twi st ti ghtl y handl ing the
.
, ,

fomentation cl oth by the dry ends N ext pull the e nds apart
. .

The water i s thus squeezed out ( P l a te XXI I ) The twi sting

. .

and pull i n g may be repeated as nece ssary for thorough w r i ngi ng

of the cloth B y releas ing one e nd wh il e hol ding u p the cl oth
.

by the other it may be qu i ckl y u ntwi sted and at once wrapped

,

i n the dry covering .

Where i t i S nece ssary to give the tre atment i n the patient s ’

room a set of three fomentations may be packed i n a pap i er

,

m a c/z e pail in su ch a way as to pre serve their heat for a hal f

hou r or even longe r F irst li ne the pail with large dry fomenta
.
, ,

tion cloth s P repare each fomentation as u su al and pack in

.

tightl y or better still w ri ng by hand the i nside cl oth s leaving

, ,

the m twisted as tightl y as possibl e and pack closel y i n the l ine d

bu cket A hot water bottl e may be pl aced in the bottom of the
.
-

pail if thought neces sary an d anothe r over the w e t cl oths The .

neces sar y number of dry fomentation cloths may be packe d i nto

the top of the pail and the fomentations made u p i n the room a s
needed .

P r oce du r e The fomentation should l ie closel y i n contact

.

with the Skin and be renewe d in three or fou r mi nute s ; or in

,

ca se of pain a s soon as i t be come s comfortable

, If u nbearabl y .

hot rub the part with the hand u nder the fomentati on or r e
,

move the moi stu re by fi rm rubbi ng once or twi ce with a Tu rk

i s h towel wrapped abou t the hand The fomentations may be .

appl ied ove r a towel i n order to temper the heat A l ways be .

carefu l to p rotect from chilling the area be ing treated by keep ,

ing it covere d with the fomentation cl oth or a towel .

 TE CH N IQ UE

as hot as can be borne and renewed a s s oon a s i t be c ome s

,

comfortable . In some cases of pain the cold appli cation at the

close shoul d be omitted the part bei ng drie d and i mmediatel y
,

covered with flannel or othe r dry cove ri ng .

For san itary reasons it i s de si rable that each patient fu rni s h

.

hi s own fomentation cloths H oweve r persons with commu ni

.
,

cable di sea ses Shoul d not be admitted to a ge ne ral treatment

room .

( f ) E f ects .The fomentation i s u sed to rel ieve pain produ ce ,

de rivation as a pre paration for cold treatment an d for st i m u

, ,

lating or sedative e ff ects according to the temperature and

,

mode of appli cation I t s first e ff ect i s that of a v ital sti mulant ;

.
‘

unl ess followed by a col d appl ication th e rea cti on i s atoni c A , .

brief application i s stimulating ; p rolonged appl i cati on s se dative

or depre ssing For sedative effects the heat Should be moder
.

ate and the application more prolonged before renewal The se .

points should be observe d in appl yi ng fomentations to the sp in e

for insomni a
—H
.

H ot G auz e C om p ress . C om p .

Thi s i s used wh en it i s de sired to appl y moi st heat to such

sensitive parts as the e ye a wou nd or i nfected part where th e
,

cloth must be di s infe cted or di scarde d afte r be i ng u se d .

S everal thick ne sse s of gau ze chee secloth or ordi nary cotton

,

cloth of appropriate si z e and Shape are wrung from boili ng ,

wate r and appl ied i n the same w ay as a fomentation B ecau se .

t he compre ss i s usually small and u nprotected i t cool s qui ckl y , ,

and for thi s reason mu st be more freque ntl y renewe d nor doe s ,

cotton hold heat as long as wool From ten to fiftee n minu te s .

will u suall y su ffice to obtai n the desi red re su lt The treatme nt .

should be concl uded in a manne r sim ilar to the fome ntati on .

Stup es
A stupe consi sts i n the appl ication of a medi cament by means
of a fomentation When gau ze compre sses are u sed the di si n
.
,

fe c ta n t or medicament may be put i nto the hot water from wh ich

the compre ss i s w rung I n case of a large fomentation with
.

fl annel cl oths the medicame nt may be applied by compre sse s

,
 PLAT E X X I V . St e am b x o es fo r h e at i n gf om e n t a t i o n s a nd p k
ac s- c l ose d .

PLAT E X X V .
St ea m b x
o es fo r h e atin gf o m e n t a t i on s a nd p k —p
ac s O e n a nd in us e .
 TE CH N IQ UE
Alte rnate H ot an d C old to H e a —
d H . C Hd
. .

( a ) A r ti cl es N ecessa ry Two compre s se s of th ree to fi ve

.

thicknesse s O f gauze or cheese c loth about twelve i nche s squ are ,

two ice bags fill ed with finel y chopped i ce and covere d with
cheesecloth a Spine bag partl y fille d with hot wate r and c ov
,

ere d with a fomentation cloth or towel a bowl of i ce water and ,

a pail of boiling water .

( o) P r ocedu r e P lace the sp ine bag cros swi se of the ce rvical

.

spine bringi ng it Well u p u nde r back of head and ne ck

,
Lightl y .

wring cheese cloth from ice wate r and appl y to face cove ri ng ,

top of head and ears P ress down firml y over forehead an d

.

temporal arterie s ; renew every minute .

A fter three minute s repla ce sp ine bag by two cloth cove re d -

i ce bags and the cold compre ss to face by anothe r w ru ng qu ite

,

dry from hot water ; the l atter should be re newed e very mi nute .

I n another three mi nute s repl ace the fi rst appl i cations of spine
bag to the back of the neck and col d compres s to the face .

Continu e these alternations for three complete sets of hot and

cold. Cool al l the parts by wi ping O ff wi th a cold com pre ss
and dry thoroughl y espe ciall y the hair
, .

( c) Efi lf cf These alternating hot and col d appl ication s

.

stimul ate the cerebral circulation and the treatme nt i s there ,

fore i ndicated i n headach e due to anem ia O f the brain al s o i n

, ,

passive congestion and i n a col d in the he ad A n y a l te r na ti ng .

hot and cold appli cation produce s fl zcx i on .

Sim ultane ous H ot an d CO

ld to H e a d —Sim ul . H . C Hd. .

P lace an ice bag to the base of the brai n and anothe r ice bag ,

or better i ce cap to the ve rtex after moi stening the hai r so that
, ,

the cold will penetrate A l so pl ace ice bags or i ce compre sse s

.

over the carotids N ow ap pl y a fomentation to the face cove r

.
,

i ng the ears and forehead G au ze or ch ee secloth Should be .

u sed u nde r the fomentation when applied to the face The .

nose Should not be covered by the fomentation a s it i s u ncom

fo rta b l e when s o done and it i s better for the patient to breathe
,

cool er air .

Thi s treatment i s ve ry e ff ective i n reducing c erebral conge s

ti on and rel ieving conge stive h eadache I t i s well to concl ude .
 L O CA L A P P L ICA TION S OF H E A T 40 7

the treatment by an alternate hot and col d percu ssion douche

to the feet cold cervical and cephal ic compresse s being kept on
,

wh ile giving the dou che .

S i m u l ta n eous appl i cations of heat and cold so given that the

cold applicat ion i s place d ove r a re flex are a of or the large ,

artery su pplying the deep part produ ce dep l etion

, , .

H o t W ater B o ttles
-

These shoul d be p artly filled with hot wate r ( never bo il ing

water ) and wrapped i n cloth preferabl y flannel or a Turkis h ,

towel . G re at care shoul d be taken i n appl ying them to patients

w ith paral ysis and d uri ng an d after operations that burns do
not re sul t The safety of th e hot water bottle may be te sted by
.
-

'

hol ding it agai nst the cheek When not in u se the bottl e .
,

Shoul d be hu ng bottom end u p with the stopper out It shoul d .

never be left double d sharpl y upon itself as it i s likel y to crack

at the fol d The hot —
.water bottle i s made in two and three
quart s ize s The S pinal hot water bottle i s u seful in giving hot
.
-

packs al so for the local appli cation of h eat to the Spine or legs
,
.

T he metal hot water bottle is very du rable

-
It i s serviceable a s .

a be d warmer and for the feet It mu st be well covered and .

great care exe rcised i n its u se that burn s are not produ ced by
l eaving som e part of the metal exposed These bottles are .

shown i n P l a te XX VI .

Fomentations and hot pack s may be reenforced or prolonged

.

by the u se of hot water bottle s or the bag may be wrapped i n

-

a moi st cloth covere d ove r by a d r v one to give the e ff ects of ,

a mild fomentation .

W i n te rn itz C o i l
Thi s consists of a coil of ru bber tubing about ten or eleven
i nche s i n diameter through which a stream of h ot water i s
cau se d to flow ( F ig A dry blanket i s placed on the
. .

treatment table and over thi s i s placed a doubled Sheet wrung

, ,

from col d wate r or ice wate r so that it may be wrapped about ,

the trunk The pat ient l ie s down on the wet sheet and one end
.

i s wrapped tightly about the chest and abdomen The coil i s .

now placed on the abdomen ove r the wet Sheet and the other ,

end of the sheet wrapped a round the trunk ove r the coil The .
 TE CH N IQ UE
dry blanket i s folded ove r and about the patient A small .

0
stream of hot wate r at 1 3 5 flows slowl y through the coi l fr Om _

the center outwards The treatment i s conti nu ed from thi rt y

.

to forty minutes or even three hours i n ca se s of very sl ow and

,

defective digestion I t i s conclu ded by a col d m itte n fri ction

. .

A hot water bottle may be u sed in pl ace of the coil

-

( S ee h ot .

and heat ing trunk pack ) .

The coi l may be u sed for cold water i n the same m anner a s
the Lei ter coil In fa ct the cold coil i s much m ore frequ entl y
.

used an d for a greater numbe r of purposes than the hot coil .

F ig . 59 . T h re e si z e s o f ra di a nt h e at .

R adia n t H e a —
t R a d H e at
. .

The radiant heat is a local appl i cation of heat by means of

elec tric l ight s arranged i n a re flecting metal case ( F ig . .

From one to twel ve or more such light s may be arrange d in a

Si n gle case and the case so constru cted as to fit to any part of
,

the body A n i nstrument w ith one light i s p erhap s the most

.

u seful A n O blong case containi ng three lights i s a conve nient

.

means of appl ying heat to the spine A case i n the shape of a .

half cyl inder and containing s ix or more l i ghts may be made

for the feet and l egs .

In ap pl ying the radiant heat the body shoul d be prote cted ,

from the edge of the case by towel s or fome ntati on cl oth s The .
 L O CA L A P P L ICA TI ON S OF ’ C OL D 40 9

a mou nt of heat may be regul ated b ythe numbe r of lights or the

d i sta nce from the skin Le ave i n place for ten to t w e n t v .

m i nute s or u ntil the de s i re d results are obtained Cove r the

, .

part wel l after dry ing pers piration or use a cold wet towel , .

The local electric l ight i s a conve nient means of appl ying heat
to the feet knee s and othe r j oints
, I t ma y be u sed over band
, .

age s and su rgical dre ssings where i t i s not desi rable to remove
them .

L O CA L A P P L IC A T I O N S O F C O LD
C o ld C o m p ress —C . C om p .

A col d compress is a local application of col d by means of a

cloth w r ung from col d wate r H and towel s ordinary cotton .
,

cloths or better still cheesecloth may be u sed These Sh ould

, , .

be folded to the de sired S i z e and wrung from cold water or i ce ,

wate r The wri nging Shoul d be j u st suffi cient to preve nt drip

.

p ing The y will be colder if taken immediatel y from a bl ock of

.

i ce A s a cont inuo us cold appl icat ion the compres s mu st be

.
,

very frequently renewed always before it i s warmed to any ,

great extent The th icker the compre ss the less frequently

.
,

will i t re qu ire rene w al A set of two compress es Should be.

u se d and renewed at interval s of from one to fi ve m inute s

depend ing on the thickne s s of the compres s and the re sult to be
obta ined Cold compre sse s m a y be applie d to the head neck
.
, ,

over the heart or lungs to t he abdomen spine etc When , , , .

ap plie d to the head they shoul d be pressed firml y down on the

su rface be ing treated e spe cial ly over the forehead and the tem
,

poral arteries The pillow shoul d be protected by rubbe r cloth

.

covere d by a towel Whe n appl ied to the abdomen in t y phoid

.

fever the be dding and patient s garments should be protected

,
’

by Tu rkish towel s U nle ss very thick and always when left

.

longer than three to fi ve minu te s the natu re O f the appl ication ,

change s and it be co m es a heating compress .

When appl ie d over a large arte ry it decreases the amount of

bl ood i n the part b e v on d the appl ication S uch an application
i s calle d a p r ox i m a l comp r ess E xa m
.

ple s of this are found i n .

such ap pl ications a s a col d compres s to the neck ove r the .

,

femoral a rtery at the bend of the el bo w etc

,
I ce bags are ,
.

al so u sed for the same purpose .

 TE CH N IQ UE
'

l e e Pa —
ck I ce Pk .

An ice pack i s u se d where a l arge continu ou s and very cold

appl ication i s de si red S pread cra cked i ce ove r a thi ck Tu rki sh
.

towel foldin g one e nd and the edge s over thi s so as to retai n

,

the i ce A p pl y next to the sk i n or over a Single layer of

.

flannel This may be u sed over the heart al so ove r a consol i

.
,

d ated lung area i n pne umoni a I n the l atte r case it should

.
.

neve r be a ppl ied until afte r th e hot packs u sed i n thi s di sease
have warme d the bod y su ffi cientl y to preve nt chil ling I t .

Shoul d o c c a si onl y be i nterrupted by appl yi ng a fomentation .

Thi s help s to preserve the desi red re flex eff ect .

S now m ay be u sed i n pl ace of the pou n ded ice I n appl yi ng .

an i ce pack to a j oint first wrap the part i n flannel so as to

,

prevent actual free zing then pack the s now or pou nded ice
,

cl osel y aga inst the flannel form ing a layer abou t one inch thick ,

retaining it i n place by a l arger flannel cl oth wrap ped about al l

and p inne d together ( P l a te S everal gu m ru bber i ce
b ags filled with snow or pou nde d i ce are better for pack pu r
pose s as there i s no dange r O f wetting the bed l inen
, .

I ce pack s shoul d be i nterru pted O ften enough to preve nt

freezing and the part either ru bbed w ith snow or a fomenta
,

tion appl ied to renew the local reaction .

l ce C rav a t

The ice cravat or colla r i s made i n the same way as the ice
pack the towel being fille d with i ce and folded so as to be
,

about three i nche s wi de and enci rcl e the ne ck I f the towel is .

wrung from ice water i t mu st be more frequ entl y renewed

,

than when cracked ice i s u se d .

A n ice cravat may al so be made b Y usin two narrow spi nal .

i ce bags ( P l a te XX VI I fi g These Shoul d be filled wi th

, .

pou nded ice and w rapped i n li nen or cotton cloth .

The e ff ect i s that of a proxi m al appl icat ion The carotid .

arterie s and the i r di stal branche s are contracted al so the ve rte ,

bral arte ries Thu s the bl ood su ppl y to the brai n and he ad
.

generall y i s very much le ssened The i ce collar i s frequentl y

.

u sed in fever in conge stive h eada che in a cute e pi demi c men

, ,
41 2

the coil The rate .

by t ying a knot i n t
the rece i vi ng pail .

for
The reservoir Shou ld be abou t two
coil and m ay be a large can with an
ordinary pail may be u sed and the
age .

The coil should always be a p p l i e

covered with a dry flannel cl oth
appl y ing it to the head the coil ,

cap ( P l a te VI I I ) and held i .

folded towel s A lway s w e t the .

The Leiter coil i s not u sed a s

a small flat coil of flexible metal
of cold water or i ce water passes I t may be .

any pa r t and i s often u sed over the mastoid

,
.

H E ATIN G CO M P R E SS E S
A heati ng compre ss i s a col d compres s so covere d
ing up soon occu rs The e ff ect .

appli ca tion of moist heat .

A heating pack or compre ss consi sts

to the body b y means of three or fou r
one of li nen or cotton cl oth wru ng fro
fe c t l v covered with dry flannel or m
prevent the circulation of ai r and
b ody heat I n case warm ing doe s not occu r
.

be aided by hot water bottles or the radiant

-

left i n place for several hou rs between othe r

night If left on over night it Should be dry
.

an i mpe rviou s covering such as a

use d O n removal of the compre ss the
.

with cold water .

A ccording to the extent and l ocation

the nature and thickne ss of the cove ri ngs the ,

amou nt O f water left in the wet cloth and th ,

appli ca tion i t may have the following eff ects

, ,

tive derivative or sweating

, , .
 PL A T E X X V I I ] 1 T he s q u a re c h e st p k
ac 2 T he ro l l e r c h est p k
ac .

T h m i t bd m i b d g
. .
. .

3 . e o s a o nal an a e .
41 4

The oute r flannel part shoul d be about two i nche s wider and of
the same length and Sl it i n the same fashi on The flannel p art .

should be sp read out on the treatment tabl e and the l i nen over
it afte r being w r ung from col d wate r The patient now l ie s .

back on this The narrow strips are brought u p ove r the

.

shoulde r and across the che st ( P l a tes XXX] a n d XXX/I )

. .

The top of the wider stri ps shoul d fit under the axill a and be
brought acros s the chest The flannel shoul d now be applied
.

in the same manne r and at all loose place s be drawn tight or

folded in and the whole fastened with safety pins .

3 Fitt e d C he st Pa ck
. From flannel cut a front and a back
.

piece in much the same shape as for a vest making the n e ce s

sary curve d cuts about the arm s and neck The front p iece .

sh ould be the larger so as to come back u nde r the arms and lap
over the back piece ; al so on each Si de of the n eck a stri p fou r ,

inche s wide should be made l ong eno u gh to overl ap the back

piece .

A n inside piece of the same Shape shoul d be cut from ga u ze

or th in linen This i nside piece shoul d be about one and one
.

hal f inche s narrowe r at all edge s so that when covered by the

flannel it wil l not be exposed at any place but be covered at ,

least one inch be yond its edge .

A fte r appl ying se e that i t fi t s snu gl y and i s wel l p inned with

safety pins so as to prevent the entrance of air at any pl ace
along the edge s .

V ariou s other forms may be improvi sed to meet the needs of

the home not provided with th e more perfe ct requ i s ite s To .

retain the moi sture and s o give greater sweati ng eff ects the
cloth may be covered with mack intosh gos samer cloth or O ile d , ,

silk O f the same si ze and shape Whe n so covere d it i s spoke n.

of as a p rotected che st pack .

4 . Parti al C hest Pac k

I t i s often desirable to apply th e
.

moi st cl oth to onl y a p ortion of the chest The gau ze or li ne n .

may be cut to any desi red shape and si z e and appl ied to the
p r O p e r area under the square or rolle r flannel p ack The chest .

be ing cove red principall y b y d r y flannel this form ap proaches ,

i n eff ect the dry pack .

41 6

The m oi s t u
mackintosh of the same width a s
it and the flannel Thi s i s spoke .

The sweating u nde rneath will

the i mpe rviou s cove ring S ince .

not be dry by morning The p rote cted .

h yperaci dity and whe re i t i s de sirabl e to

relaxation .

The ordinary moi st abdominal bandage

forms of atonic i ndi ge stion i n neu rastheni a , ,

l ive r insomnia catarrhal j aund ice consti pation

, , , ,

conditions it i s u suall y wa rn onl y at n ight .

H e a tin g Thro at C om p ress

Fou r to si x thi cknesse s of chee secloth or two

ordinary cotton cloth about three i nche s wide a nd
to e ncircle the ne ck t w i ce are u sed i nside .

of two thickne sse s of flannel not les s

Th is compres s be ing small considerabl e ,

it and still be found dry by morning .

ru bbed with cold water i mmediatel y afte

“
pre ss i n the m orni ng The col d cl oth a.

very common hou seh ol d remedy f

tonsill iti s etc , It i s i ndeed a very
.

ne ss can hardly be overestimated The heating .

press i s i ndicated in pharyngi ti s acute l a r y ng i t i ,

quinsy and i n inflammati on of the E usta chian tub

,

u seful i n cl ergyman s sore th roat In tons ill iti s quin

’
.
,

i nflammation O f the E ustach ian tube the compre ss ,

extend u pward a b out the l ow e r part of the ea r and may be

1 1 1 pl ace b y a bandage over the top of the head .

H ea tin g J oi n t C o m p ress
H eating compresse s ma y be applied to the foot ankle , ,

hand w ri st etc Rarel y more than two t hi c k n e s

, , .

are u sed I t i s O ften ne ce ssary to u se cotton for

.
 T he poulti ce i s especiall y
cha r coa l

ulce rs or wou nds In may be prepa .

adding equal parts of fl a x s e e d meal

boil ing wate r u ntil the re sulting m
mush This i s evenl y spread on a c l Oth and
.

part or dire ctl y on the part and cove re d w ith a

,

a nd some i mperviou s cl oth a s oil ed s ilk .

T O N IC FRICT I O N S
A tonic fri ction i s an application of co l d water
with friction as to produ ce decided the rm i
rea ction The e ff ects are brie fly described as
.

toni c These have been di scu ssed i n detail in

.

stimulants and tonics a v , . .

G iven in the orde r of thei r se ve ri ty th e toni c ,

follows : Wet hand rub col d m itte n ,

wet sheet rub and dripping sheet ,

adde d the ice rub and salt gl ow While the .

t i c ul ar l y an appli cation of col d the friction ,

Similar to the others and the proce du re i s not fa r

,

The ice rub may be u sed for sti mul ant or toni c p ur p o
i s more frequentl y u se d as an antipyreti c .

C o ld Mi tte n Fri c tion —C . M F . . or Cm i .

( a ) A rti cl es R equ i re d bowl or pail O f col d water

. A
°
or 60 F or i ce wate r a sheet three Tu rki sh towel s
.
, , ,

ti on mitts made of such coarse m at e r ial a s Woolen .

( see cor ne r fig u r e i n P l a te XXX V and compres se

head and ne ck .

( 0 ) P r oce d u r e The pati ent shoul d be

.

the feet warm ; if not give hot foot bath , .

body at a time Do not expose any part longer than

.

dry qui ckl y and thoroughl y and re cover at once with

cove ri ng Before begi nning the regular part of the
.

bathe the patient s face and neck wi th cold wate r or

’

compre s ses to the head and neck Thi s i s .

in treating patients with valvula r heart ( 1

di tion an ice bag should be pl aced ove r the
 PLAT E X XX II I . T h e m o i st a bd o m i nal b nd g
a a e .

PL A T E X X X I V . T he c ol dt ow e l ru b
— t re a t i n g th b k
e ac .
 To vary the severi ty and toni c
the wate r ma y be changed ; more may be left i n .

the mitts dippe d tw o or three times i n treating

the friction give n more vigorou sl y .

We t H a nd R ub —W . H R
. . or Whr .

The sa me orde r and general procedu re i s

cold mitten fri ction O ne part .

the hand dipped in col d wate r fo ,

d ried fini shi ng with bri sk rubbing with the

,

hands .Dipping from tw o to fou r or more time s

toni c e ff e ct .

C ol d T o w e l R u —
b C . T R . . or Ctr .

I n giving the col d towel rub a plain hand,

stead of the mitts employed for

same orde r is followed as i n the tw o
ginning w ith the arm s then the che s
,

last the back ( P l a te

,

The arm i s held ve rticall y wi th the pal

towel i s dipped in cold wate r and w r u n
folded and wrapped lengthwise around
u pper corners i nto t
pat ient or the a rm may
,

attendant wrap s the towe

ci rcular movement The part .

movements outside of the towel P e rcu s sion may

.

to insure a greater reaction The towel i s now

.
‘

the arm dried as after the col d mitten fri ct ion .

When the che st and abdomen are treated the ,

spread out over the entire surface and

u pper corners next the shoulders and holds
nu rse ru bs with downward stroke s outside
othe r parts are treated in a similar manner .

It should be reme mbe red that the col d tow

heat from the
fore
 l c e R ub

The orde r of parts treated and the

are substantially the same a s in the
mi tten friction I n giving the ice rub
.
,

to more thorou ghl y p rotect the bed or

ing with oil cloth and towel s Tu .

closel y abou t each part so as to

the skin The cake of i ce to be
.

or better yet wrappe d i n one or

,

The ice rub i s not mu ch u se d

more frequentl y a s an an t i p yr e
pose each part Shoul d be
,

without fricti on or p e r c u s
application to the Spine i s
same length of appl ication el sewhe re .

fever the abdomen Should be avoided

,
.

be applied to the head and neck and al s o to -

essary .

—
Salt G low Sg l .

P repare abou t two pounds of coarse salt wet

water The treatment sh ould be g 1 v e n i n a
.

in a bath tub The patient stands in a tu

.

standing at the Side of the pat ient ,

th e enti re Skin surface of the Shoulder arm ,

water from the foot t ub Th i s i s done by .

with the hands N e xt appl y th e wet salt

.
,

over the skin N ow with one hand on each

.
,

rub vigorou sl y with to and fro movements u nti - -

glow S tepping behind the patient to the O p

.

c e e d i n the same manne r with the other arm .

Retain the last position to

trunk With one h and i n
.

surface with hot water from

a s before and rub the enti re

shoulde rs back and butto, ,

and with one hand unde r ea

 ZYZCTI AUTQUU?

part at a time and treat i n the following order : The arm s ,

chest abdomen legs thi ghs and back The cloth or sponge
, , ,
.

should be dipped seve ral ti mes for each part Dry thorou ghly
—
. .

2 Te p i d Sp o ng e Te p i d Sp g
. The tepid S ponge has an e ff ect
.

Similar to that of the neu tral bath i e it i s sedative ,

I t m ay . .
,
.

also be u sed to redu ce fever bu t is not a s e ff ective a s e i t he r the

hot or the cold Sponge
—
.

3. C oo l or C o ld Sp on g e C Sp g Cold sponging i s u se d i n
. .

the treatment of fever where the Skin i s hot and there i s no

tend e nc y to chilline ss E ach part should be gone over several
.

times The temperature of th e water and the du ration of the

.

treatment should be gove rned by the i ntensity of e ff ect de sired .

Sa line Sp o n ge
—S l a . Sp g .

A bout fou r ou nce s of common sal t are di ssolved in a ba sin or

bowl O f tepid water The bare hand i s di pped i n the sal t wate r
.

and each p art rubbed lightl y .

The sal ine sponge has a mil d tonic e ffe ct B ecau se O f the .

sal t it stimul ate s the vaso motors to a greater extent than plai n
,
-

water
—
.

Alk alin e Sp on g e Alk Sp g . .

U se about two ounce s of bicarbonate O f soda to a sm all basi n

of hot or cool wate r accordi ng to the case A pply with the bare .
“

hand a soft cloth or sponge

,
The alkal ine sponge i s u seful i n
.

itch ing smart ing and other abnorm al sensations

, I t i s u suall y .

appl ied onl y to the part a ff ected .

V ine g a r an d Sa lt R ub
The vinega r and salt rub i s very u seful i n check ing the e x c e s
s ive perspirati on or night sweat s of phthi s is .

P repare a half pint of e qu al parts of vinegar and wate r to

which add one or two table spoonfuls of salt A ppl y with the .

b are hand drying lightl y afterward The appl i cation Should be

, .

thorough to the parts that pe rspire the most ; othe r parts m ay

b e gone over le s s thoroughl y .

Alc oho l R ub —Al e . R .

The al cohol rub is frequentl y use d following a sweating treat

ment i nstead of the cold friction or spray I ts pu rpose i s O f .
,
 R UBS AN D FR IC TI ON S 42 5

cou rse t he prevention of ta king cold U se one pa rt of alcohol

, .

to one part of water ( proof Spirit 5 0 per cent ) Di p the hands , .

i n the alcohol and rub each pa rt dippi ng the second time if ,

needed N o drying w ith the towel i s necessary

.
.

Witc hhaz e l R ub —W z r .

The w i tc hha z e l rub ha s about the same e ff e ct as the alcohol

ru b It i s sedative and a mild astringent The same procedu re
. .

i s u se d as for the al cohol ru b .

Me ntho l R u —
b M e nth . R .

The applicat ion of menthol to the ski n give s a sensation of

col d The e ff ect i s Similar to that of the alcohol rub or cold
.
,

s ponging U se one ounce of menthol l ini ment ( menthol c r v st

. .

1 oz al cohol 1 p int ) to th ree or fou r ounce s of water

.
, .

So ap Wash
The soap w ash i s u se d for cleans ing the sk in in the case O f
be d p atients U sing a b owl of water at 1 0 2 F w ith soap a nd
.
°
.
,

wash cloth go over each part separately With anothe r bowl of .

water at 7 5 — 85
° °
F and another cloth remove the soap y .
,

wate r and dry thorou ghl y with a Tu rki sh towel E ach part i s .

gone over with the soapy wate r followed by ri nsing with plai n
cool water and the n drie d before the next part i s treated .

RUBS AN D FRICT I O N S
The se terms are appl ied to procedu res i n which the ch ief e ff ect
is de rive d from friction with the bare hands .

C en tr i p e tal Fri c ti on —C . F . or c f .

The ce ntri petal friction cons ists princi pally of friction stroke s
from the p e riphery toward the center I t i s designe d to hasten .

the ci rculatio n especiall y i n the superfic ial ve ins

,
.

Gene r a l O r de r f
o rld ov e m en ts

Light to and —
.

1 . fro friction once

-
,
.

2 . A ppl y l ubricant twice ,

.

3 . Centripe tal friction three ti me s ,

.

4 . P e rc us sion twice ,
.

5 . S troking ( centri fugal ) three times ,

.
 A R MS

1 Beginning at fingertips give l ight qu i ck

.
, ,

tion to the sh ou lder being su re to cover ,

su rface Let the hands glide back

.

2 A ppl y lubricant with long stroke s

.

de r returning w ith four rotar y sweeps

,
G ive .

3 F riction
. .

H a nd .

( a ) H eavy centripetal stroking to back o f

times .

( b ) P al m of hand same back of hand as ,

fingertips . Fini sh with double rotary movement i .

th ree time s .

A rm and F or ea r m .

( a ) E mpty blood ve ssel s by heavy even strokin g -

to elbow The patient s elbow rests on the tabl e

.
’
.

hand on each side and u sing hands

ments with each .

( b ) E mpty blood ves sel s from elbow to s -

well over shoulder With hands in the s ame .

nati ng as for forearm give three move ments with ,

4 P ercussion
. With one hand on each Side .

which i s hel d u p by the pat ie nt and with hands ,

gethe r give percu ssion from Shoulder to fingers

,

G ive twice P lace the patient s arm on the table at

’
.

give percussion down and up to external surface as far

5 S troki ng three ti me s
.
, .

LE G S
1 Leg flexed and foot flexed P la cing one han d
. .

sole the other on the dorsu m of the foot give light

to —
, , ,

and fro friction transverse of foot

-
Then .

flat continu e with rapid stroke s t o the Side s of

,

and front of the thigh G lide hands to knee ; q u .

back of th igh ; gli de to toes .

2 A ppl y l ubricant with long strokes to back of

.

of thi gh coming down to knee with three rota ry

,

long strokes to back of thigh down w ith ,

from knee to ank le G ive twice .

.
i ng outward from median
ti me s advancing toward
,

( d ) S troki ng fr om
ward middle of P oupart s ligament ’
,

4 P ercu ssi on u p and do w n left side

. ,

G ive twi ce .

5 S troking th ree time s

.
,
.

1 .Light friction w ith t he full h and down

nating three time s each ; to and fro
,
- -

up on neck cove ring Shoulders back and

, ,

time s .

2 A ppl y l ubri cant with long stroke s up

.

sweeps down Sides twi ce ,

.

3 F ricti on
. .

( a ) H eavy fri ction with full hand down

nat ing each thre e times
, .

( b ) H e a v v rotary full swee p to sh oulders

, ,

( c ) From shoulde rs down following the ,

arm s stroking toward the Spine si x time s , .

—
Lower back heavy friction u pward over
ward Sp ine three ti mes ; upward on hi p s three
, ,

ward u sing thu mb and thenar su rface ove r crest of

,

time s .

4 P e rcu ssi on u p and down on l eft S ide sam e on

.
,

G ive twice .

5 S troking
. .

( a ) F ul l sw e e p s coveri ng back three time s

'

.
,

( b ) S low stroke s w i th full hand down sp i ne six ,

O il R ub —O . R .

The rub softe ns the ski n and i s fre qu e ntl y

oi l

t e c t i v e after sweating tre atments It ma y b e .

Same manne r as the

numbe r one
 R UBS AN D FR IC TION S
Ge ner a l Or de r :
1 . A ppl y lubri cant .

2 . Rotary friction .

3 . P ercu s sion .

4 . S troki ng ( centrifugal ) .

ARMS
1 .l ubricant ; beginning at han ds with a long stroke
A pply ,

go ove r the a rm up to the Shoul de r three times , .

2 Beginning at hand appl y long stroke up to shoulder re

.
, ,

t u rning wit h alternate rotary movements three each to s houlder , ,

arm elbow forearm wrist and hand three time s

, , , , .

3 P ercuss ion u p and down twi ce on external su rface

. G ive .

s ame on i n n er s urface ; si x percu ssion stroke s to the hand .

4 Fi nish with l ong strokes from shoulder to fingertips three

.
,

ti mes
LE G S
1 B egi nning at foot appl y lubricant with l ong strokes up to
.
,

h i p with both hands covering the e nti re surface three t ime s

, , .

2 A ppl y long stroke s from the foot to knee retu rning with
.
,

alte r nate rotary moveme nts three each to knee cal f ankle , , ,

and foo t twice Retu rn to h i p with long stroke With hands

, . .

on anterior su rface O f thigh from hip to knee give e ight or , ,

ten rapid alternate rotary friction movements G ive the same .

on the poste rior surface O f the thigh thre e ti me s Continue , .

with rotary friction from knee down as at first once ,

.

3 P ercu s sion same a s arm

. .

4 .Long stroking move ment from h ip to toes three times ,

.

C H E ST AN D A B D O M E N
1 .Lubricate ; with hands working together begin at median ,

l i ne below going l ightl y up the median l ine and down the

,

s i de s three time s ,
.

2 H ands work ing together stroke the neck downward three

.
,

ti me s ; the n give rotary movements three each above clavicle ,

to Shoulder below clavicle ni ne down each s ide nine u p over

'

,
,

m edian pa rt of abdomen and chest three ti mes ,

.

3 H ave patient take and hol d a deep breath

.
B eginning .

well ove r at lower left side give pe rcu ssion up that side to top ,
43 0

of shoulder down on same Si de ,

s i de of m e dian l ine to top of Sh oul de r ,

twice .

4 S troking ( moveme nt sam e as in 1

.

B ACK
P ro c edure the same a s for the che st .

gentle downward stroke s to Sp ine .

The talcu m ru b i s u seful where oi l i s

warm we ather
spiration after treatment I t drie s rather .

skin I t i s al so u seful i n h ives and shoul d

.
,

prolonged cool bath The procedu re i s the .

o i l ru b

D ry Fri c ti o n —D . F .

The procedure for dry fri ction or the

i s the same a s for the O i l rub
If gi ven bri skl y w ith vigorous
by percu ssion the eff e ct i s t ,

skin and warm the surface The treatment .

heat p roduction .

S low heavy fri ction wi thou t pe rcu s sion as

, ,

head etc i s sedative

,
.
, .

BA T H S
V ariou s
procedu re s m ore or le ss Si milar and co
baths are included u nde r th i s head .

1 . P AR T I A L I M M E R S IO N B AT H S
H an d an d Ann B ath
The hand and arm may be im merse d in neutral
wate r or the two latte r alte rnatel y
,

a foot tu b ( be tter one O f ell iptical

to imme rse the hand and for e ar m t
el b ow V e ry deep pail s ma y be
.

u sed it should b e aS ho
,
'
patient S itting up and i n al l case s whe re there i s a tendency to
,

faintness .

Efl ects .
The foot bath i s an e ffi cient means O f se curing a
derivative e ff ect I t draws blood from all othe r parts e spe
.
,

c ia l l y those that are conge sted The col d pou r or dou che
.

given at the close hel ps to mai ntain the bl ood in the feet It .

is sometimes de si rable to u se a m us ta r d foot oa t/z in wh ich ca se ,

add three or four tabl e spoonful s of mu stard to the water

—
.

2 C o ld Foo t B ath C it B The wa ter Shoul d be from tw o

—
. . . .

° °
to f our inche s deep at a te mpe ratu re of 4 5 60 F The feet .

Should be p reviou sl y warmed and du ring the bath rubbed with ,

the hands or one foot by the other ; durati on one to fi ve ,

mi nute s .

Efl ects .The Shallow cold foot bath cau ses re flex contraction
of the blood vessel s of th e brai n pelvic organs and l iver ; al so
-

contraction of the mu scle s of th e uterus bladde r stomach and , ,

i ntesti nes The col d foot bath Should not be given du ring the
.

me nstrual period or i n case of acute pul monary abdomi nal or , ,

pel vic inflammation

—
.

3 Alte rnate H o t a n d C old Fo o t B ath H

. C ft B U se . . . .

two tubs of wate r deep enou gh to well cover the ankles one a s ,

hot a s can be borne ( temperature gradu all y rai sed ) and the
°
other at 4 5 F Im merse the fee t i n the hot w ate r for two
.

minute s and i n the cold fiftee n to thi rty seconds Continue .

al ternation s for ten to fiftee n m inute s wiping from th e col d , .

’
E fl ects . The alte rnate hot and cold foot bath p rodu ce s
powerful fl ux i on e ff ects in the feet For thi s reason the deri .

vation se cu red by i t s u se i s very deci ded and end u ring It i s .

espe ciall y u seful i n conge stive headache in whi ch case i t is well ,

to appl y a cold com pre ss to the head or he ad and neck at the

same time It i s al so u seful i n treating infection s of the foot
.
,

Cha rcot s j oint at the ankle tube rcul osi s of the ankle or bone s of
’

,
’

the foot and in gangrene to ha sten the produ ction O f the l i ne

of demarkation
—Lg
.

Le g B ath . B .

For the leg bath a tub shoul d he provided deep enou gh to

i mme rse the legs to the knee s ( P l a te I X ) I f u sed i n th e. .
 BA TH S

treatme nt room the tub shoul d be fitted with an outlet at the

base so a s to obviate the necessity of ti pping the tub over to
empty it I t should be placed near or ag ainst the wall so that
.
,

it m ay be filled from a hot and a cold water wa l l fau cet by t w o

short rubber hose A lso provide a stool an i nch or two higher
.

than the tub The patient Shoul d be covered w ith a Sheet or

.

blanke t and i f the room i s not warm enough a large fomenta

, ,

tion cloth or Turki sh towel place d over the knees If n e ce s .

sary pl ace a doubled fome ntation cl oth under the knee s over
,

t he ri m of the tub
th—H
.

H o t Le g B a lg B
°
I . Begin with the water at 1 0 3 F
. . . .

a n d increase the tem perat u re a s rapidl y as can be borne U se .

cold cephal i c and cervi cal compre sse s ( or ice bags ) an d renew
before they become warm In case the l eg bath i s combined
.

with other hot treatment a s fomentations to the Spine it may

,. ,

be ne ce s sary to u se an i ce bag over the heart especiall y if the ,

treatment i s continued to profuse perspiration The treatme nt .

s houl d be continu ed i n a give n case u ntil the de sired eff ect i s

p roduced Thi s ma y requ ire from five to thirty minutes accord
.

i ng to con dition s and the part icular e ffe ct de si re d Fini sh with .

a cold dash to the legs .

Efl ects The hot leg bath i s a much more powerful deriva

.

t ive measu re than the hot foot bath and i s one of the be st tre at
me nt s that can be u sed for thi s purpose When combined with .

fomen tations to the spi ne or chest and especiall y when the ,

p atient drinks some hot l iqu id at the same t ime very profu se ,

perspiration i s produ ce d If used in the home su ch a sweating

.
,

t reatment shou ld be conclu de d by a col d mitten fri ction or if ,

give n in the treatment room by a graduated or alternate hot ,

a nd col d shower and spray The p ail pou r i s al so sometimes.

u se d for the same purpose

—
.

2 Al tern a t e H o t a nd C o ld Le g B a th H
.
C lg B The . . . .

procedure i s the same a s w ith the alternate foot bath It i s .

ne cessary to appl y a cold compre ss to the head and often an ice

bag to the heart .

Efl ects The alternate hot and cold leg bath produ ce s most
.

powerful fl uxi on i n the legs and feet It i s espe ciall y u seful .

28
in t reating edema of these p arts whether du e to heart or kidne y
di sease A fte r two or three treatments have b een given piece s
.
,

of i ce should be added to the cold wate r The t reatment ma y .

be followed by heavy centri petal friction to the feet and legs .

Sitz B at —
h Z .

For the s itz bath a porcel ai n Sitz tub with spe cial i nlet and
outlet i s the most sati sfactory ; one of metal or an ordinary
wash tub may be u sed I n addi tion there Should be a foot tub
.

for imme rsi on of the feet i n hot water A l so a pail of col d .

w ater with a ha n d towel for kee pi ng the head cool ( P l a te

P rote ct
the pati ent from contact with the tub by towel s or
fomentation cloth s place d beh i nd the back and u nder the knees
Cover the pat ient with a blanket or sh eet The temperature of .

the foot bath Shou l d be at l east t w o or three degrees above th at

of the S it z bath .

1 . C old Sitz —
B a th C . Z . S uffi cient water shoul d be
sed to u

cove r the hi ps and come u p on the abdomen ; tempe ratu re

55 —
° °
7 5 F ; foot bath 1 0 5 . 1 1 0 F ; time ,
°
one to e ight min — O
.
,
,

utes Rub the hi ps to promote reaction

. Friction m itt s m ay .

be u sed I f de sired the water may be flowing It adds some

.
,
.

what to the e ff ect .

Eff ects If of brief duration ( two to fou r m inute s ) it greatl y

.
,

stimul ates the pelvi c ci rcul ation and the mu scul atu re of t he
bowel s bl adder and uteru s When give n with ve ry col d wate r
, .

°
( 55 and vigorou s fri ction ( col d r ubbi ng s i t oa t/z ) the se ~
e

e ff e cts are i ntensified The cold rubbing S itz bath i s very u se

.

ful in constipation i n subinvolution and in haste ning the

,

absorption of res idual thickening after pelvic i n fl a m m a t i on s .

With the temperatu re somewhat modifie d i t may be u sed i n ,

children in treating noctu rnal enu resi s

—C —
.

Prolo n g e d C old Si tz B ath

° °
2 Temperatu re 7 0 85 Z
—
. . .
,

o °
F ; time fifteen to forty mi n ute s ; foot bath
.
, 1 05 1 1 0 F ,
.

Thi s may be begun at a higher te mperature and ve ry gradu all y

lowered to the desi red poi nt ( g r a dua ted si tz oa t/z ) It Sh oul d .

not at any time cause ch illine ss and rubbing i s not desi rable ,
.
43 6 TE CH N IQ UE

at 5 5 ° —85
F ; foot bath s
°
1 05 1 1 5
. F A ppl y col d com ,
° — °
.

pre sse s to the head and neck The patient Sits i n the hot .

wate r for two or three mi nute s then i n the cold for fifteen to ,

twenty seconds and agai n in th e hot water Three comple te

,
.

change s from hot to col d are m ade as i s u sual i n a l ter na te

treatments .

Efl ects The alte rnate sitz bath produ ce s powe rful fl uxi on
.

e ff ects i n the pelvic visce ra I t i s u seful in chroni c pelvi c i n .

fl a m m a t i on s after the patient ha s become accu stomed to the

revul si ve Sitz It may al so be used to great advantage i n atoni c
.

constipation
—
.

H ot H al f B a th H .
it B .

The hot hal f bath i s give n in a full length bath tub Fil l th e
—
.

° O
tub with water at 1 00 1 02 F and deep e nou gh to reach the .

patient s navel when the patie nt i s sitting : The p atient n o w

'

s its down in the tub with the shoulde rs cove red by a sheet and
the head kept cool by a cold we t towel ( P l a te It is
u suall y best to appl y thi s j u st before the patie nt enters the
°
bath The te mpe ratu re of the bath i s graduall y rai se d to 1 08
.

°
or 1 1 0 F and continued for th re e to e ight minute s
.
‘

If ne c .

e ssary an ice bag Shoul d be u sed over the heart Conclu de th e

,
.
.

treatment by a col d pail pou r to the hi ps .

The e ff ects and u se s are the same as those of the revul si ve

sit z Thi s treat ment mu st not be confu sed with the Shall ow
.

bath which i s given with cold water and i s a toni c measure ,

.

I I F U L L I M M E R S I O N B AT H S
.

The tub u sed for general or ful l immersi on bath s Shoul d be

long enough so that the body may be com pletel y im me rsed ,

a 6 foot tub for men i n man y case s a Silt foot tub i s long enou gh
-

,
-

for women The head Shou ld rest on an ai r pillow or small

.

i nval i d ring and for emaci ated pati ents a folded s hee t pl aced
, ,

u nde r the nate s I n a hot bath the head mu st be ke pt cool by

.
,

a cold com pre ss In the case of full tub bath s it i s especiall y

.

nece ssary that the te mperature O f the wate r he te sted b y mean s

of a the rmome ter In ordering tub bath s the de si red tem
.
,

p e ra t u re should be spe cified on the pre scription .

 PL A T E X X X V III . T he si t z b th
a .

PL A T E X XX I X . T he h ot h lf b th
a a .
 3 . C o ntinuous Flo wi ng B a th
Thi s .

feet l ong whi ch i s pro v ided w ith a

,

ove rflow vent near the top ( P l a te XX

si st O f one large open ing at the head
small openings along the s ides .

from a m ixing chambe r whi ch i s

conti nuou s suppl y of hot wate r at a con
pre ssu re mu st be a ssu red al so of cold water
,
.

regul ated to the de si red temperatu re i n th e m

before it i s tu rned i nto the tub The u su al .

°
98 F I Vhe n the tub i s ful l and overflowing
’
.

reduced to a gentle stream The pat

.

hammock wh ich swings from the ri m of ‘

b y a canvas cover and provide d with a

i c e turban Shoul d be placed u pon h i s

given cold water pl entiful ly t o drink .

thermomete r in the tub and con sul

wholl y upon the the rm ome ter i n the
A s thi s bath i s u se
mu st be watched const
shoul d be wrapped i n
securel y pinned about
duration of the bath de pends u pon
e ff ect obtai ne d I t may last for hou rs
.

case the patient mu st be removed once

fou r hou rs the bowel s gi ven proper att
,

noi nted with oil to pre vent t oo great ma

o us flowing bath i s perhaps the most u seful t

cited cases of i nsanity It together with the wet

.
,

ha s revolutionized the treatment of mania

—
.

4 C o ld B ath C B o r C Tub
. . . .Temperatu re 5
.
,

ti me a plunge onl y to twenty or more minute s de

, ,

t he temperatu re and e ff ect de sired It i s n .

ru bbing constantl y or at freq uent interval

face Shoul d be bat hed in cold wate r before
and it i s i mperative that the ski n be warm
give n .
 BA TH S 43 9

and lasting for a few seconds or m inute s onl y the e ff ect is that ,

of a stimul ant and toni c The col d r uooz ng ba t/z i s the most
'

commonl y employed method O f treating typhoi d fe ver i n i n s t i tu

tions where tu bs are availabl e and convenient to u se The .

strict B ra nd bath i s too severe a measu re for many patients .

The methods indications for and the pre cautions in t he u se of

,

the cold bath have been very full y di scu ssed u nde r t he treat
me nt of t y phoid fever (1 v , . .

5 B ra n d B a t h
. A s advised b y B rand for the treatment of
.

typhoid fe ver the procedure i s as follows :

Te mperature 6 5 —
, 70 F
° °
Bathe the face and head i n col d.

water or i ce w ater Lift the pati ent into the bath H e Should
. .

be rubbed constantl y to keep the blood i n the skin If chill in g .

c a n not be preve nted by vigorou s rubbing the patient mu st be ,

re moved from the bath Time fifteen minutes . Repeat when , .

the te mperature reaches or 1 0 3 F E ff ect anti pyreti c 0

—
.
, .

6 Gra duate d B a t h G ra d B
. T he graduated bath i s as . .

e fficie nt i n lowering febrile tem pe ratu re whe n much prolonged

and i s le ss O bj ectionable to the patie nt than the B rand bath .

A s the bath i s frequentl y used in typhoid the patient Should be ,

made comfortab l e by an air pillow and hammock made by

tying a shee t across the tub fastening the corners and Si de s
°
unde rn eath Temperatu re begi n at 9 8 or above depending
—
.
, ,
° °
on the h eight of the fever i e from 3 5 lower than the ,
. .
,

mouth te m p erature The ski n mu st be warm to begin with

. .

A ppl y cold compresse s to the head G radual l y reduce the tem .

°
p e r a t u r e of the bath to about 85 F ; when below 9 0 F or if
°
. .

the patient feels ch illy or sh ows goose flesh he Should be ,

rubbe d constantl y to keep the blood i n the Skin and so p revent ,

or overcome chill i ng A spine bag filled w ith hot water may

.

be laid along the Spine for the same pu rpose B oth pul se and .

temperatu re should be closel y watche d du ri ng the bath The .

te mpe ratu re of the patient Should be taken e very twelve or

fi fteen mi nu tes . O n removal i mmediatel y wrap the patient in ,

a sheet drying qu ickl y and if there i s g oose fle sh or chilliness

, , ,

rub bri skl y with the hand s u ntil the blood retu rns to the skin .

If very cyanotic p ut the pati ent into a hot blanket pack for a
,

few minute s and take h im out with a col d mitten friction .

.
440 TE CH N IQ UE

E ff ect ,
tonic chie fly or antipyretic according to the condition i n
whi ch it i s gi ven
—
.

7 C old Shallo w B a t h C S B Fill the tub fou r to si x

—
. . . .

° °
i nche s deep with water at 6 5 75 F The patient s feet .
’

Should be warm before entering and the head kept cool by col d ,

wet towel s The patient sits down in the col d water and ru bs
.

the arm s l egs and che st vigorou sl y wh ile the attendant rub s
,

the hi ps and back Col d wate r di ppe d from the tub i s dashe d
.

over the Shoulde rs and back and the se parts a re agai n rubbed , .

The patient now l ie s down in the bath and rubs the che st and
abdomen wh ile the attendant rubs the legs
,
Thi s procedu re .

may be re peate d once or twice if de si re d .

The entire treatment Shoul d last from two to four minu te s ,

and on eme rging from the bath the skin su rface shoul d be in a ,

decide d gl ow otherwise the p roper e ff ect h a s not been O btained

, .

The col d Shal low bath i s one of the most vigorou s toni c mea s
u re s employed in h ydrotherap y .

Hydro Ele c tri c B aths

-

I n giving the hydro electri c or ele ctrothermal bath a neutral

-

temperature i s u suall y employed The patient i s completel y .

i mmersed in the water with the head on an air pillow and kept
cool by a cold wet towel The ele ctrode s Should hang from the
.

s ide of the tub so they may be place d in any desi re d posit ion
,

along the side s or at the fee t of the patient The tre atment i s .

begu n with one el ectrode at the feet and the othe r near the arm
on the opposite side The ele ctri city i s tu rned on to comfort
.

able tole rance Time five to twenty m inutes A fter hal f the
.
,
.

ti me has expired the electrode shoul d be reversed the one at ,

the foot of the tub being brought u p along the arm O f same
side and the other near the O ppos ite arm being pl ace d at the
, ,

foot on the same s ide The se d ire ctions do not appl y to the
.

galvanic bath I n u sing galvani sm the positi ve pole shoul d be

.

pl ace d at the head preferabl y dippi ng into th e water under

,

neath the pill ow and the ne gative pole at the feet

, .

P r eca u ti ons T O avoid shock there Shoul d be no current pass

.

i ng when the patient steps i n or out B e sure all appl iance s .

are i n good order before the patient e nters the bath Keep al l .
ing system gal vani c e l e c tr i c i t
,

may resu l t if carelessl y u sed .

entru ste d to a nu rse unl es s

and pos se ssing the requ i site
galvanic curre nt Moreover th e e ffe cts
.

galvani c tub bath may b e obtained in

risk to the patient .

P r eca u ti on s I n the use of the galvani c

.

cautions me nti oned above S houl d be care

curre nt mu st never be tu rned on befo
always be turned O ff before he step s
not done a se ve re Shock may be occas
one foot in the bath with the other on
a gr ou nding contact through a cement
.

some metal p ipe nea r by .

A lways a scertai nthe pol arity before

To do thi s place the ele ctrode
,

and turn the current on The .

pole are larger and more

and th e negative at t he foot B e s u .

contact w ith the ski n at an y point .

arv faradic are alte rnating cu rrents

no d istinction as to polarity .

E fiects.The positive pole i s a v a

pole a vasodilator For thi s reason .

congestion the negative pole i nc re

,

has a sedative eff ect ; the negati ve

e ffect The se are the reasons for placi ng the
.

the head and the ne gative pole at the feet of t

a neutral tem pe ratu re i s u sed the total effect i s
t i ve A l l form s O f the electri c tub bath are
.

some pe rsons The se idios yncras ie s Should

.

The temperatu re and duration

 BA TH S

sal ine subst ances dissolved in the bath , the amperage will r un
mu ch higher before the same e ff ects are produ ce d as with
ord inary water With th in subj ects a comparativel y l ow
.

amperage mu st be used ; with subj ects i n good flesh or over

wei gh t a stronge r current ma y be employed .

Me dic a te d B a ths
A tub bath may be altered by the addition of various medica
ments S uch baths are not of great practi cal importance
.

e xcept i n a very lim ited number of skin di seases

—
.

1 Sa lin e Bath Sa l B A dd from three to fi v e pou nds of

—
. . .

common salt to the tub of water at 9 0 94 F ; time ten to

° °
.
,

twe nty m inutes The addition O f salt adds to the tonic e ff ect
.

through sti mulation of the pe ripheral circulation SO that the

water ma y be a few degree s coole r than an ordinary neutral
bath The e ff ect i s Similar to a bath in se a water
—
. .

2 Alk al i ne B a t h Alk B
. A dd one half to one pound O f
. .
-

b icarbonate of soda to the tub of wate r at a neutral tempe ratu re .

O n e fourth pou nd of carbonate of soda m ay be u sed

-
Time .
,

te n to t w e n t v m inute s ; eff ects ; rel ieve s cutaneous i rritation ,

i tching et c U seful in certain skin dise ase s as ec z ema also

,
.
, ,

i n rel ieving the itch ing of hives and j aundice .

Na uhe im B a th
The e fferve s cent or artifici al N au he im bath i s one in w hich
the wate r i s charged with sali ne substance s and carbon dioxide
g as. Many di ffe re nt formulae are u sed to prepare such a bath .

To p roduce the carbon dioxide ga s i n the bath i t i s ne cessar y ,

that an acid come i n contact with an alkaline carbonate setting ,

free the carbon d ioxide ; or sal ine s may be dis solved in the
water a nd the carbon dioxide added from a generator .

V ariou s p r op r i e t ar v mixtu res prepared in cake s are o ff ere d

for u se I n u sing these dissol ve the sodium chloride and
.
,

s odiu m bi carbonate in forty or fifty gall on s of water The .

bottom of the tub i s then covered With rubber Sheeting O n .

thi s rubbe r Sheeti ng place the acid cakes In about three .

minute s when eff erves cence i s well u nder way the patient
,
,

shoul d l ie down i n the bath .

 TE CH N IQ UE

A very complete and sati sfactory formul a i s the foll o win g

S od ium carbonate ( sal soda ) I f lb .

S od iu m bicarbonate ( baking soda ) 5 lb .

Calciu m chloride 3 lb .

S odium chlori d e ( common sal t ) 2 lb .

S odium bisulphate 1 lb .

A fter m ixing the first fou r dis sol ve i n a fe w i nche s of warm

,

water in the bottom O f the bath tub Whe n thoroughl y di s .

solv ed fill the tub with water at the de si red temperature The
,
.

sodium bi sul phate which i s the a cid part of the formul a shou ld ,

be granul ar or finel y pou nded and dissolve d separatel y in a

wooden or p ape r pail contai ning hot wate r A s it m a y re qu i re .

some time for thi s to dissolve i t should be prepare d before the

,

bath i s to be gi ven When thorou ghl y dissol ved pour i nto the
.
,

tub a nd qu ickl y mi x with the re s t of th e water The bath i s .

now ready for u se The amounts of the sal i ne i ngre dients ma y

.

be graduall y increase d for the succeedi ng bath s of a cou rse .

Three fou rth s O f a pou nd of commercial hydroc hlori c aci d

-

may be u se d i n place of the sodiu m bi su l phate This shou ld be .

mixed with two or three time s i ts volume of water and afte r ,

the salts are al l di ssolved and the tub fille d w ith water at the
de sired te mperatu re the bottle containing t he aci d shoul d be
,

opened under the water I t m ay be move d abou t to hasten

.

the di ff usion of the aci d into the water of the bath .

The following i s a simpler and l e ss expensive formula ; it i s

the formul a we u sual ly e mploy .

S odium chloride 3 to 8 l b .

S odiu m bicarbonate 2 to I f lb .

Mu riatic aci d 2 lb
—
.

° °
The temperatu re of the bath shoul d range from 85 94 F .

The l ower temperature s shoul d be u sed for the late r baths of a

series The duration of the bath shou ld at first be from five to
.

eight minutes The time may then be gradu ally exte nded to
.

fifteen or even twenty m inu te s A col d compress should be.

appl ied to the head and an ice bag to the heart The pat ient .

Should not be rubbed du ring the bath A bout three baths a .

week ma y be taken for three or fou r week s N ot ove r twenty .

bath s shoul d constitute a cou rse .

acute stage of endocarditi s . S ome h ighl y
in locomotor ataxia .

This bath i s si milar i n eff ect a nd te chni que

bath . It w as i ntrodu ced
s tead of carbo n dioxide t h ,

g as. T
an oxygen con -

u sed for the s a

becau se of t he l arge r si ze o f
i s di s sol ved in the water w h i
that whi ch col l ects a s bubbl e
The standard meth od of
follows : Fill the tu b w
cover the patient to h i s ne ck .

sodium pe rborate ( N a B0 3 ) by :

su rface of the wate r N ext ad .

manganese borate
patient gets into the water in one or two
c a t al i z e r ha s been p ut i n The l i be ration of
.

for fiftee n to twenty minute s The patient .

qui et a s pos sible moving th e limbs onl y occa

,

sation i s that of an a greeabl e t i ckl ing and

spine Shoulders and l imbs A t t he end
, .

remove the p atient and dry wi th as l ittle

sible . If a browni sh sediment remains i n
easil y rin se d o ff i f th i s i s done im mediatel y
,

The baths may be admini ster

or five days a week a cou rse ,

bath s The eff ects are similar to those of

.

bat h i n the p roduction of a powe rful st i m u

phe ra l bl ood ve ssel s
-
The oxyge n bath
.
,

e ssentiall y i n the following points : I nste ad

the ski n p roduced by
no change or the Ski
bl ood occu rring into t
A lowe ring of blood
 BA TH S

i nstead of a rise as after the carbon dioxide bath F or thi s

, .

reason it i s i ndi cated i n case s of high blood pres sure and i n car
diac a nd renal disease s a ssoci ate d with increased va scul ar te n
s ion.

I t i s al so a powerful sedative to the nervou s s ystem and i s ,

therefore a most e ffi cie nt measure i n the treatment of i nsomnia ,

al so in asthma ne urasthenia and variou s paresthesi as

,
Be .

cau se of the tende ncy to pal enes s of the Ski n i t i s an advantage ,

to pre cede the bath by some heati ng p rocedu re such as a hot ,

foot bath fomentations to the spine or a Short electric l ight

,

bath For the same reasons the bath i s admini stere d at h ighe r
.

temperature s tha n the carbo n dioxi de bath For sedative pur .

p ose s the bath shou l d be admini stered in the afternoon or earl y

e vening or at least an hou r before retiri ng I n case s of hyper
,
.

ten sion redu ction s i n bl oo d pre ssure of from 1 5 to 3 5 mm H g . .

have bee n rep orted .

III . MI S C E L L A N E O U S
R uss i a n B ath
The Ru s sian bath cons ists in the immersi on of the body in
hot vapor The ste am as it is turne d into the Ru s sian room
.
, ,

partiall y conde nse s and hangs su spended a s a th ick fog For .

e very gram of stea m th at thu s condense s 5 3 7 calorie s of heat ,

a re l iberated Thi s fact accou nts for the inte nse heating e ff e ct
.

obtai ne d b y the u se O f thi s form of hot treatme nt .

For the Ru ssian bath provide a steam tight room with a

marble slab A Sl iding window Should be so arranged at the
.

end of the slab that the patient s head may be outside of the ’

s te am room ( P l a te X L ) T he steam Should e nte r below the

. .

slab so as not to strike the patient directl y and be controlled by '

,

a valve near the sl iding w i n dow so that the attendant may

regulate the amou nt of ste am and keep the head cool at the
the same time by frequentl y changed cold com pre sse s to the
head and neck .

P r oce d u r e Move the bowel s by an enema and give a pre

.

l iminary hot foot bath H ave the patient drink water before
.

and freque ntl y du ring the bath Thi s i s ne ce ssary in order to

.

p rovide for the p rofu se persp iration which the treatment Should
induce S ee that the slab i s warm ; i f not pou r over it seve ral
.
,
0
pail s O f hot water Warm the room to about 1 00 F and
. .
,

cover the Sl ab with a fol ded sheet .

T he patient i s now assisted onto the tabl e and l ies on the

back w ith th e head on an ai r p illow j u st wi thou t the ope ni ng .

The wi ndow i s l owered and a towel wrung from i ce water i s

placed about the neck or h ung across the l owe r end of the
,

window and tu cked arou nd the neck A nother cold com pres s .

i s appl ied to the he ad and covers the tempora l arte rie s A .

thi rd col d compre s s Sh ould be appl ied to the precordia In .

some case s it wil l be ne ce ssary to u se an i ce bag over th e heart .

N ext tu rn on the steam graduall y rai s ing the temperatu re of

,

° 0
the room to 1 1 5 or 1 2 0 F A small amount of steam sh ou l d .

be constantly escap ing to mai ntai n the tem pe ratu re Change .

the compre sses to the head and ne ck fre q ue ntl y The patient .

Should be closel y watche d du ring the enti re time of the treat

ment The bath shoul d l ast from ten to th irty m inute s Ju st
. .

before the patie nt rise s from the slab rene w the i ce compre s s ,

to the head Fini sh th e treatment w ith a gra d u ated or alte r

.

nate spray or showe r or bette r sti ll a sha m poo and gradu ate d
, ,

shower The s pra y or sh ower shou ld be i n the Ru ssian room

.

or onl y a few ste ps from it ( P l a te X L I ) . .

Efi ects The e ffe cts O f vigorou s sweating me asu re s h ave

.

”
bee n considered el sewhe re The wash ing out e ff e ct i s per
.
,

haps the greate st ; and the thoroughne s s of thi s de p ends very

,

largel y upon the water taken before and duri ng the treatment .

S weating measu res greatl y in crease cataboli sm e spe ciall y of , ,

carbohydrate s and fats The products of nitrogenou s m e t ab o

.

l i s m Show more com plete O xidation .

The Ru s s ian bath i s of great se rvi ce in obes ity chroni c ,

rheumatism with obesity gout B right s di sease a u to i n t ox i c a

, ,
’
,

t ions chroni c al cohol is m and i n a rterio sclerosi s u nle ss

, ,
-

extreme It i s contra indicated i n diabete s valvu la r heart

.
-

di sease all disease s associated with emaciation and in extreme

,

a rte rio scl erosi s

-
.

C a b ine t V a p o r B a t h
The princi ple involved i n the cabinet vapor bath i s the same
as that of the Ru ssian bath V ariou s wate r proof cabinets are .
-
 BA TH S

Of fered for sale T he v are u seful in a home where more elabor

.

a t e facil itie s can not be provi ded A n alcohol stove heats .

water in a basin unde r or near the stool provided for the

p atien t. Thi s i s continu ed until the cabinet i s ful l of vapor ,

when it i s ready to e nter The patient sits on the stool with .

the h ea d outside of the cabi net The du ration O f the treatment .

s hould dep end u pon th e rapidity of vapori z ation and u pon the
e ff ect des ired The p rel im inarie s p rocedu re and precautions
.
,

t o be taken are the same as i n the Ru ss ian bath Conclude the .

t reatment w ith a shampoo col d towe l rub graduated Sho w er , ,

o r othe r col d a ppl ication .

T ur ki sh B a th

The Tu rki sh bath consi sts in the immersio n of the body in

h ot ai r . The Ru ss ian room m ay be u sed for thi s pu rpose and
Convenientl y he ate d by steam coil s H o t ai r boxes simil ar i n .

shape and Si ze to the u pright electric l ight cabinet may be u sed

( P l a te The patie nt i s treated i n the same manner as
i n the Ru ssian bath The head and neck Should be kept cool
.

by cold com pre sse s and if ne cessary an i ce b ag appl ied over

, ,

the hea rt T he temperat ure of the room shoul d be graduall y

.

rai sed from 1 2 0 to about 1 7 0 F The bath ma y last from

0 °
.

fifteen to fort y fi v e m inu te s -

P ersp irati on i s O ften somewhat.

delayed i n wh ich case bri sk friction to the ski n may hasten its
,

appeara nce I f persp iration i s mu ch dela y ed the patient i s

. ,

l ikel y to behave b a dl v in the hot air bath and for thi s reason ,

shou l d b e cl osel y watched until free pe rspiration i s e sta bl ished .

O wing to the di fficult y w ith whi ch some patients react to dry

hot ai r , the appli cabili ty of the Tu rkish bath i s somewhat more
l im ited t han th at of the Ru s sian bath .

The T urki sh or h ot ai r bath i s of ve r y great se rvice in

, ,

chronic B right s disease I t may be u se d dail y

’
. I t le ssens .

nephr i ti c dropsy both directl y th rough increased perspirat ion

and i ndire ctly by ai ding kidney eli mination .

Su p e rhe ate d Air B a th

°
I n the su perheated air bath th e te mperature reaches 2 5 0
350
°
F S pecial
.
metal cabinets for t h e entire bod y ( P l a te

29
45 0

XL I I I ) or variou s part s ( P l a tes X V a n

.

cha sed The bo d y or part to be treated

.

wrapped in Tu rki sh
re st on any part of
burn B y means of
.

ture of the air i n the

F The se burners
.

them are fitted i n v e

'

ing directl y into the cabinet .

spread by means of an asbestos shield so

strike the ski n surface The patient s .
’

dition mu st be watched very closel y i

bath A n i ce bag Should be ke pt on
.

pre sses on the head and neck These .

necessary where onl y a single p art su ,

and ankle are be i ng treated The tre atment .

by an al cohol or w i t c hha z e l ru b G reat care .

that the patient doe s not take col d a ft e r w a

toweling with which the body or l imb i s
absorbs t he perspiration thu s preve n ting i t s ,

ski n in drops S hould i t colle ct i n drop s

.
,

l ikel y to re sult .

Efi ects The superheate d ai r bath i s a m u

.

measure than the Tu rki sh bath I t i s of .

articular rheu mati sm whethe r occurring ,

fever chr onic gouty rheu mati sm or i n spec

,

one or two j oints are bei ng treated ,

t i n ue from twent y m inute s to an hour afte

has reached 3 0 0 — 3 50 F
0
Whe n the part °
.

mentary da sh O f cold water may be give n or th e part

from perspi ration and a heat ing compre ss applie d .

r r he a l rheumati sm thi s treatment may be fol lowed by ,

nate with the prolonge d i ce pack i e prolonge d to a

, ,
. .
,

hou r s du ration
’

—E
.

Ele c tri c Lig ht B ath . L B

. .

I n gi ving the electri c l ight bath special u pri ght or ,

cabinets fitted with m irrors and i ncande scent l ights

( P l a tes X L VI a nd X L VI I ) .
 PL A T E X L I V S u p h t d d
er ea e ry hot ai r b th P
a a t i e nt k h t ow
i n T ur is el i n g
d y t b l d i n t bi n t
. .

s uitre a o e s i o ca e .

PL A T E XL V .
S p h
u er e at e dd ry h ot air ca bi n et i n us e .
 TE CH N IQ UE

c a te d to the b od v by direct conducti on or by conve ction but by ,

absorption of the ra y s of radiant e nergy a s they are retarde d

and stopped by the sk in and subcutaneou s ti s sue s .

O n the othe r hand for s trong de ri vative e ff ect s the el ectr i c

, ,

light bath i s u nsatisfactory For derivative purpose s th e he at

.

must be brought in actual contact with the skin by ap pl ying

the heate d substance d i r e c t l v to the skin For th i s re ason .
,

stronger derivati ve e ff e cts are secure d by pa rt ial or ful l h ot

bath s and hot pack s .

The u se s of the electric l igh t bath are nume rou s and con
s i d e r a b l e Space would be re quired merel y to e nu merate them .

H owever i t i s of special advantage i n B right s di sease arte rio

’

, ,

sclerosi s lead poi soning and other toxemia s obe s ity gout
, , ,

acute and chronic rheu matism neu ra sth enia diabetes Ski n , , ,

d isease s and al so for ge ne ral toni c and su d or i fi c e ffect s It .

see ms to be almost a specifi c i n treating m orphine habi t u e s .

T hey obtai n from it more rel ief than from any oth er mea su re .

SH A M P O O S

Swe dish Sham p oo —S h s .

For giving the S wedi sh or Slab Shampoo provide a pail O f

—
,

° °
wate r at 1 0 3 1 0 5 F on a stool O f conve nie nt h e ight near the
.

head of the slab al so a Shampoo bru sh and a h al f bar O f Soap

,
.

If the slab i s not ke pt warm by being in a warm room pour ,

over it t w o or three pail s of hot wate r Cover the Slab with a .

double d Sheet and assist the patient onto the slab placing the ,

head on an ai r p ill ow Q u i ckl y lathe r an a r m by dipping the

.

bru sh and soap i n the pail of hot w ater and rubbing togethe r
ove r the part With bri sk short move ments go over the part
.

thoroughl y u sing as much friction as i s comfortabl y born e

,
.

D O the same with the che st abdomen and l egs ,

.

N e xt assi st the pati ent to tu rn over on the Slab by putting

one arm u nder the ne ck and grasping the O pposite shoulde r ,

i nd the othe r arm under t he near leg and graspi ng the oppo

site knee .Treat the back hips and back s of the legs i n the
,

same manne r as the front of the body P ou r the re maini ng .

water in the pail ove r the patient to rin se off the soap su ds .

Follow the sham poo by a warm and col d shower or spra y .

PL A T E X L V I E l
. e c t ri c li gh t b t h
a ca bi n et (u p i gh t f
r o r m ) re a dy f
o r u se .
45 4

the che st also the thigh s and l egs Was h

,
.
‘

face with water .

F r i cti on M i tt Dip the m itt i n the se c on

.
,

°
90 F and be ginning with the back
.
,

legs go ove r each part twice

,

tu rn the patient and treat the che st

the same manne r Wash O ff with the re s t .

°
at 90 F .

S/z a mpoo Treat each part a s in the S we

.

hands a l oofah or bath bru sh and the

, ,

Fini sh with prol onge d tepid or cool S howe r

the close a short cold spray Dry thorou ghl y .

towel s The patie nt Shoul d be careful not t o take

.

ward
P A CK S

P a ck s are procedu res in wh ich a con

body i s e nveloped in wet Sheets or blanke t s -

pu rposes .

B LA N K ET
'

I . H OT P Acx s

The hot bl anket pack i s a procedu re in wh i ch hot

a re u se d to commu nicate heat to the body .

Full H ot B lank e t Pa —
ck H . B P . .

( a ) A r ti cles N e cessa ry Two double blanket s

A

and one double blanket ; one hot water

°
bags half fill ed with hot water at 1 6 0 F
water with compre s se s for the head ne ,

Turki sh towel s ; a tu mbler a drinking tube ,

wate r for d rinki ng .

( 5 ) P r e l i m i n a r i es Move the bowel s by enem a .

,

foot bath and have the patie nt dri nk hot wat er

, .

( c ) P r oced ur e S pre ad a doubl e bla nk et on the

.

table or bed A dju st .

whi le his feet are still in the hot

blanket or anothe r double bl anke
longer ) len gt hwi se i n conve nie nt
wri nger or w ri ng i ng by hand .
covered ) th ere i s danger of bu rn
made they shoul d at once be covered m
,

In some case s it i s necessary to u se a

bag to the hea rt .

G eneral free perspiration should be

Long continu ed he at w ithou t
In giving packs i n case of
ne s s u nder or soon afte r an
,

the i nsane it i s safe r if a t h

,

between the patie nt and the wet blanket .

should be more thoroughl y cove red and the

shoul d be at a l ower temperat u re than ordi n
( e ) Efi ects The hot blanket pack i s a
.

mea su re .I t al so p
treatment decreases internal c ong e s t i o
more marked when the w e t bl anket i s placed
Where the conge stion i s not local i z ed i n some
but consi sts of a gene ral internal conge stion a ,

ing treatment i s u su all y suffi c ient for i t s rel ie

case in the first stage of m any feve rs e speci all y ,

ata i n colds l a grippe etc

, , ,
.

In uremia eclamps ia and acute B ri ght s

,
’

i hc and strong de rivative effe cts shoul d

form s of renal congestion thi s i s al so ne ce ssary In .

insuffi ciency the skin excrete s much large r qu antitie s of

than i n health Free or profu se perspi ration greatl y
.

this vicarious function Thi s e ffect i s not h owever the

.
, ,

one nor the most importa nt e ff ect of swe ating measure s .

conge stion of the skin se cure d by a hot pack re du ce s the

gestion and hi gh blood pressu re i n th e kidney so tha t i t
begins to fu nctionate when the se cau ses are r emoved .

hot blanket pack i s al so u seful in pneumonia and someti mes in

ty phoid feve r It i s a l most indi spensible i n the treat me nt of
.

renal col ic and gall stone col ic In the se con

-

i s decreased i mmediatel y the pack i s appl ied ;

entirel y obviates the necess ity for morphi ne wh ile i n others ,

the dose may be cut to one thi rd or one fou rt h the amou n t that
- -

woul d othe rwi se be requ ired .

 P A CK S

D ry B la n k e t Pa ck —D . B P . .

S weating ma y be p roduced by enveloping the body in a dry

woolen blanke t and u sing hot water bottle s i n the same way as
-

with a wet p ack The same preliminarie s shoul d be obse rved

.
,

e speciall y the giving of the hot foot bath before It i s qu ite .

e ssential that the patient t ake a considerable quantity of a hot

drink du ring the treatment H ot l emonade i s ideal as it favors
.

both diaphore si s and diure si s The sweating may be a s profuse

.

as with the wet pack but the de r ivati on i s less e ffi cient S ince .

no we t bl ank et i s u sed the patient may be fi rst wrapped in a

,

dry sheet and then in the dry blanket The perspiration will .

be absorbe d by the sheet and so i n a short time the e ffe c t will

, ,

s omewhat approa ch that of the sweating wet sheet pack .

H o t T run k Pa —
ck H . Tr Pk . .

The m ethod of appl yi ng the hot trunk pack i s the same as

with the full bl anket pack The wet blanket should include the
.

pelvi s but exclude the a rms rea ch ing u p to the axilla The, .

outsi de dry blanket shoul d i nclude the whole body but be u sed
onl y for prote ction ; it should not be wrapped tightl y about the
patie nt . It i s u suall y be st to appl y a large dry fomentation
cloth betwe en the pat i ent and the wet blanket P lace a hot .

wate r bottle over the abdomen between the folds of the dry
bl anket and spine bags on e ither s ide of the trunk A hot foot
, .

bath should begin b efore and continue during the pack Time .
,

twe nty to thirty m inu te s If give n for the rel ief of the pain of
.

any form of col i c omit the cold friction at the cl ose

,
.

The hot trunk pack has the same general e ffect a s the hot
blanket pack S ince i t covers les s su rface the derivative eff e cts
.

a re le s s I t i s e spe ciall y u sefu l in digestive di stu rbances and

.

i n relievi ng the pai n of re nal and bil iary col ic al so in i ntestinal ,

col ic
—
.

v l
R e u s ve
i T ru n k Pa ck R e v Tr Pk . . .

The rev ul si ve trunk pack consi sts of a hot trunk pack given
a s directed above and followed by a wet sheet t ru nk pack .

O nl y thi s one change from heat to cold i s made The wet .

sheet i s wr ung from water at about 6 0 F and applied to the °

.
45 8

t runk afte r re mo v i ng the wet fla nnel b l an ket .

de scri b ed u nde r the headi ng of w e t sheet pa cks .

The hot blanket shoul d b e remove d while i t

‘

the wet sheet appl ied at once

the revul si ve compress T h .

remain i n place u ntil the

be remove d and a cold mitten fri ction
spray douche given to the p art s c ov e r e
w ith the same to the feet If de s i red.
,

may be m ade a hot and heati ng tru nk

water coil or a hot wate r bottle over the
-

The re v ul sive trunk pack i s u se d for

chron i c conge stions of the li ver and the

H o t Pe lvi c Pa —
ck H . Pe ly . Pk .

The hot pelvic pack i s appl ied i n the same manne r

trunk pack I t should come wel l above the cre sts
.

and include nearly half of the thi gh s It i s .

of pelvi c pain from dys me norrhea cysti t i s , ,

eff ects do not greatl y di ff e r from those of the

large ver y hot fomentatio n s to the pelvi s both of w h i
, ,
'

ments are mu ch easi er to apply .

R e v ulsiv e Pe lv i c Pa .
—
ck R ev . Pe lv . Pk .

Thi s treatment i s appli e d i n th e sa me wa y a s the re

trunk pack The col d pack should be prol onge
.

stage The e ff e cts are somewhat simila r t

.

sive sit z and hot ha l f bath It .

and chroni c i n fl a m m a t i on s of the pel vic organs such as ,

metritis and endometriti s with much thi cke ning al so i n ,

i nvolution .

H o t H ip an d Le g Pa —
ck H . Hp . Lg . Pk .

The hi p and leg pack should incl u de the feet l egs t h , .

pel vi s reachin g slightl y above the cre st s of the il ia

, .

water bottle shoul d be placed at the feet with in the

dry blanket and a spine b a g be tween the legs T .

to forty minu te s Takin .

packs ,

sive pack i n wh ich a

hot blanket pack .

I ce bags may be u sed with the ful l p ack

partial pack s The following comb i nations
.

acute stage s of the di sea se s indicated :

—
A P P E N D I C I r l s H o t h i p and le g pa ck with ,

appe ndiceal r i g i o n .

PE R I I ON I T I S
’ ‘ — H o t hip and leg p ack or l eg ,

an ice com pre ss or i ce cap to abdome n .

P U E R P E R A L I N F E C T I O N S A N D A C UT E
l eg pack with ice to pel vi s ( suprapubi c
—
,

P N EU M O N I A H ip
cracke d i ce compress
—
ME N I N G I T I s H ot
bag to base of brain and u ppe r
—
MA ST O I D I I I S H ot hi p and l e
’ ‘

i ce cravat or i ce bag over the carotid artery ,

and fomentations to mastoi d .

—
A LV E O LA R A BS C E ss S ame as mastoiditis e x ce ,

t a t i o n s to the j aw .

—
RE N A L C O N G E S T I O N H ot tru nk pack or full
with i ce bag to lower thi rd of sternu m :
O ther combinations will sugge st the mselve s to the
ful m ind .

Ele c trothe rrnal Pac —

k El em Pk .

The electrothermal pa ck i s given by means of

prepare d blanket containi ng flexible re si stance W i r e .

be u sed d ry the bod y or p a r t t

,

in a dry sheet or thi n fl a n n e

blanket and the ele ctri city
,

and consequent eff ect may

current I f to be u sed wet
.
,

nearl y dry from col d or te

blanket The treatment i s
.

spray or dou che .

 PL A T E XL V III . T he ho t bl n k t p k
a e ac .

PL A T E X L I X . T he e v p
a o ra t i n gw et s h eet p k ac ,
 TE CH N I Q UE
sheet with the shoulde rs th ree or fou r inche s bel ow the u ppe r
edge B oth arms should be rai sed while one side of the sheet
.

i s qu ic kl y wra pped arou nd the body drawing it ti ghtl y i n con

tact a t all place s and tucking the edge u nder the opposi te si de .

B elow the hips the sheet i s wrappe d a rou nd the leg of the same
side The arm s are now lowe red and the opposite s ide of the
.

sheet drawn tightly over the bo dy and tucke d i n The sheet is .

now folded over the shoulde rs and a cros s the neck The nar .

rowe r edge of the bl anket i s drawn tightl y arou nd the bod y an d

tucked in along the si de The wide r edge i s d ispos ed of in a
.

similar manne r pul li ng it ti ghtl y to bri ng all parts i n cl ose

,

contact and the extra amount wrappe d enti rel y around the
patient The foot end i s double d under the feet A Tu rki s h
. .

towel i s pl aced abo u t the neck to prote ct the face and ne ck from
c ontact w i th the blanke t and more pe rfe ctl y exclu de the ai r .

A n additi onal bl anket may be lai d ove r the patie nt and tu cke d
i n al ong the si de s and abo u t th e fe et or two blanket s ma y be ,

placed on the table at first .

( d ) P r eca u ti ons The wet sheet mu st come i n close contact

.

w ith the body at all points The dry blanke t must e ff ectu al ly
.

prevent the entrance of air oth erwi se chilling will result , .

War m i ng u p shoul d occu r promptl y The feet must be kept

”
H

warm during the entire tre at ment I t i s pe rm i ssible to pl ace a

.

hot water bottle to the feet to hasten reaction i n ca se th i s i s

-

delayed .

( e ) S tag es A ccordi ng to the degree of warming the pack

.

undergoe s i t passe s through fou r stage s v i z

, cool i ng or ev ap , .
,

or a ti ng n e utr a l b ea ti ng a n d sw ea ti ng
, , It is often de s irable to.

prolong the eff ect of one stage so that thi s e ff ect may predom
inat e A ccordingl y the treatment i s varie d as follows
—
.

1 . Cr i We t She e t Pa
oo ling o r Ev W S P
ap o at n g
ap ck Ev . . . .

Thi s i s the fi rst stage of the pack before the sheet has bee n
warme d to the tempe rature of the body It requi re s from five .

to twelve m inute s to accompli sh th i s I f at the e nd of thi s time .

the sheet i s removed and another appl ied the eff ec t i s i mten ,

s ifi e d or the blanket m a y be folded back and col d wate r

,

sprinkled on the patient ove r the wet sheet I n case of vigorou s .

patients the dry cove ri ngs ma y be omitted entire l y conside rabl e ,

 water l eft in the sheet and the patient fanne d to hasten evap
,

oration more water be ing sprinkled on the sheet as soon a s it

,

i s warmed sl ightl y The electric fan may be u sed where very

.

rapid evaporation is des ired ( P l a te XL I X )

.
.

E f ects .
The evaporating wet sheet pack i s a powerfu l anti
pyretic mea su re .
It i s u seful i n typhoid fever and in other
continue d feve rs where repeated antipyresis i s necessary I t .

i s u suall y be st not to remove the pack for renewal but sprinkle

on more cold wate r A s in the use of the cold tu b bath in
.

typhoi d fever rubbing i s necessary i f the wate r i s very cold or

,

the sheet sprinkled frequ ently Th is i s known as the r nooi ng

.

w et s/z ee t pa ck. P ercussion should not be u sed The greater .

the amou nt of water appl ied to the body the stronger are the ,

a ntipyreti c e ff ects and consequentl y the qui cker i s the tem

,

p e ra t u r e of the patient redu ced .

I f des i rable the sheet may be w ru ng from hot water the

, ,

coverings be ing omitted This i s spoken of a s a 1 1 0 1 e vapor a ti ng

.

s lz eet
. I t i s u seful where slight chilline ss exists This treat .

ment i s not onl y antip yretic but also lessens heat production
be cau se of the initial heat and the conse quent atonic reaction
—
.

. 2 N e utral We t She e t Pa ck N e ut W S P . .The neutral. .

stage begin s whe n the temperature of the pack reaches or

sl ightl y exceeds the temperatu re of the skin v i z about 9 4 F , .
,
°
.

I t may be prolonge d by removing all but one or two dry cover

ings afte r the wa rmi ng u p has well b e gu n Thi s allows of .

s u ffi cient evaporation to prevent the accu mulation of heat above

the te mperature of the body The protection mu st be uniform
.

and the e ntrance and circulation of air prevented .

Eff ects
. The e ff ects of the neutral wet sheet pack have been
cons idere d u nde r the treatment of insomnia A neutral tem .

p e ra t u r e i s secu red the same as i n the neutral bath The .

marked sedative e ff ects of the neutral pack are due more to the
de rivation secured than to the neutral te mperature I n normal .

sleep the re I S a le ssening of the amount of blood in the brain

and a l ocal decrease of blood pressure The neutral pack brings
.

about the se change s and so aids i n indu cing relaxa tion and
sleep .

If the pack i s re moved before sleep i s p roduced uncover one ,

464

pa r t at a time drying thoroughl y and ,

d r y sheet or e nti rely remove t he pa ck

,

the patient in a warmed shee t finishi ng ,

as possible .

If the pack is removed afte r

the treatment by a wet hand r u
ing to the degr ee of ton i c e ff ect d esi re d .

'

The neutral we t she e t p a ck i s al so of

fevers i n m an ia epil ep sy chorea i nfa
, , , ,
‘

various othe r agitat ive neurose s ( P l a te .

3 H e atin g We t
.

stage begins when

p e r at ur e sl ightl y
n ing of general pe rspiration Wh ich m ark s the
a full reaction For toni c e ff ects th e p ack
.

abou t twenty mi nutes When the stage of a .

scribed thi s treatment i s intended

,
.

Efi ects Tonic and heating effe cts are

.

may be p rolonged by appl yi ng

continuou sl y so a s to check
effect of the heati ng wet sheet
tion The reaction and he a t i n
.

accumulation of body heat congest the ,

amount of blood in the internal organs .

twee n the neutral and the heating wet .

great importance Like t he neutral a .

e ff e cts di ff er more in degree than i n k ind

vation A s u sed i n i ns omnia and
.

l onged and i s conse q uentl y at the

greater part of the treatment .

The heating pa ck posse sse s

secu ri ng mild ton ic and deri vati
anem i a chl orosi s infectiou s
, ,

neu rasthe nia diabete s etc , ,

.

4 Elimin a ti v e o r Swe ati ng

.

The production of general

the sweati ng stage The .

l onged by additiona l cove r

 Thi s treatment i s the same as that pre viou sl y
de r the heading Winte rnit z coil .

crosswi se of the treatment tabl e or be d

ma y reach well up u nder the a rm s A .

of feeble patients a single thicknes s )

reach from the axilla to below the h
water and pl aced ove r the bla nket Th .

thi s and wh il e both arms are rai sed

pulle d tightl y a cros s and around
gastric and u mbil ical
quart hot water b ot t l
-

( P l a te X I X Wrap the other end of

.

ove r the hot water bottle and cover s

-

folding ove r one end at a time .

X VI /1 ) or a n el ect ri c pad may be

.

water bottle Conti nue the t

.

two hou rs G eneral sweating

.

be begun half an hour be fore

with a cold mitten friction or
abdomen and spine .

Efl ects . The hot and heating trunk pa c k i s

hydrotherapeu tic measu re for the treatment of
o n ces
. It promote s gastric secretion and
Liver activity and i nte stinal dige stion p r oc e
E xce ss ive or reve rse pe ri
decreased gastric motil ity stomach
Becau se of more perfect dige sti on an
gas form ation i s markedly de crea sed
The hot and heat ing trunk pack
vom iting dyspepsia flatulence
, , ,

ch ronic conge stion of the liv er and

I n case s of a l
pe rsi stent
minute s b
A col d m i
should be
 P A CK S 46 7

ke pt warm during the treatment The hot foot bath may be .

conti nued while the treatment lasts if thi s is not over thirt y ,

m inute s othe rwise i t i s well to dry the feet and wrap t he m i n

,

dry flannel so that the patie nt may re st more perfectl y For .

furt her details of the u ses and e ff ects se e treatment of atonic ,

dyspeps ia .

H e atin g P e lvi c Pa —
c k H e at . Pe lv Pk .

On the tre atment table spre ad a blanket a s for a fu l l pack .

N ext fold a single blanket to form a square and then diagonally

to form a triangl e A rrange thi s on the large blanket so that
.

the base i s upward and the apex downward where it may be

folde d abou t the pelvi s when the patient recl ine s O ver this .

place a sheet s i m i l ar l v folded and wrung nearl y dry from water

0
at 60 F The pati ent now recl i ne s and with legs flexed and
.
,

kne es se parate d the apex of the wet sheet i s brought i nto close
,

contact with the pe ri n e um and spread over the abdome n With .

legs extended each lateral angl e of the wet sheet i s drawn

,

down tightl y across the h i ps lower abdomen and uppe r thigh

,
.

T he triangul ar p ie ce of dry flannel is n ow appl ie d in the same

manne r and the patient covered with the large blanket Con
,
. .

t i n u e the pack twenty or th irty m inutes .

Efi ect .
The heating pelvi c pack i s a m ild tonic and deriva tive
means the same a s the heat ing trunk pack It helps to equal i z e .

the pelvic circulati on and reduce congestions of the pe l vi c v i s

ce ra.
I t relaxes hypertoni c mu scles and stimulates atonic
mu scles : The heating pelvic pack i s not used as much as the
sit z bath i n the treatment of pelvi c disorders It i s indicated .

i n ch roni c congestions of the pel vi c organs amenorrhea ,

'
,

chroni c metriti s backache chronic coliti s etc When u sed i n

, , ,
.

case s of much pelvic pain or other pel vic distre ss a hot water ,
-

bottle or coi l should be pl aced next to the wet sheet over the
lowe r abdomen and supr apubic region in the same manner as
i n the hot and heating trunk pack .

S P R AY S A N D D O UCH E S
A s pray o r dou che consists in the proj ection of one or more
-

stream s of water against t he body M ff

an di erent
y appl i ances .
are u sed i n givi ng the se treatments .

wide range of adaptabil ity that almost

be p r od uc e d by them For thi s reason .

the nu rse should

spray and douche controlle r For a .

tro l le r se e the section on h y drothe rapeuti c

’

P l a te L and F ig s 6 7 7 2 .
, .

Sho we r B a —
th Sh .

A showe r or ra in bath cons i sts i n the p r oje c t 1 ofi

many fine stream s fal l ing u pon the pat ient In .
.

bath gravitation i s the p rincipal force ut il i z ed ;

ever i s ofte n enhance d by adde d pres su re
,
.

di sc from which the wate r de scends should

i nche s i n diamete r and
patient s head The re shoul ’
.

wate r to flow rapidl y The room sh .

protected from drafts S ee that the .

before e ntering the sho w er If the .

obj ectionable a s w ith women protect , ,

to sh cap or with a showe r head attache d by

,

i t forward at an angl e of forty fi v e degree -

shower and adj u st to the p rope r tem pe rature

enters
—
.

1 H ot Sho we r H Sh
. Begi n th . .

F. and graduall y rai se th e t e m p e r a t

,

or sl ightl y above T ime one to .

,

chie fly as a pre paration for the cold

be nece ssary to u se a cold com pre ss to the
shower If onl y a hot shower i s p rescribe
.

°
or 85 F and dry qu ickl y with sheet and .
,

fanni ng the patie nt w ith a dry sheet

—
.

2 C o d o C oo l Sho we r C Sh
l .r Th . .

preceded by a hot showe r Whe n .

warmed l owe r the te mpe ratu re rapi dl y

,

tole rance or reactive abi lity of

point long enou gh for a vi gorou
be come accu stomed to co l d trea
 S PR A Y S A N D D O U CH E S 46 9

W ithout the prel imi nary hot sh owe r Cool 7 O — 90 F ; col d .

,
° o
.
,

55 —
°
4 0 F
°
A t fi rst before the patient become s accu stome d to
.
,

the sh ower the u pper l imits shou ld be ut il i z ed and i n each

,

0 °
su cceeding treatment the te mperatu re l owere d by 1 or 2
dai ly and the t ime prol onge d to from one half to three or more -

m inute s E ff ects toni c .

, .

.
—
3 N e utral Sho w er Ne ut Sh In giving a neu tral showe r . .
,

begin w ith the water at 1 0 0 F and very graduall y lower it to 0

.
,

97 —
0
94 F
O
The treatme nt s hould last from th ree to five m i n
.

u tes The patient shoul d be drie d qu ickl y withou t percu ssion

.

or u nnece ssary fri ct ion E ff ect s se dative

—
. .
,

4 Gra duate d Sho w er Gra d Sh

. A fte r a prolonge d or . .

vigorou s sweati ng bath whe re mu ch heat has bee n communi

c a t e d to the body it i s desi rable to lower the temperatu re of the
‘

s howe r slowl y for gradu al cool ing and to abstr act a s mu ch he at

from the body as pos si ble w ithout produci ng a decided therm i c
reaction A ppl y a cold compre ss to the hea d before the patient
—
.

° °
leave s th e hot bath Begin at 1 0 8 1 1 0 F qu ickly ra i sing
. .
,

Mainta in thi s u ntil the

0 0
the temperatu re to 1 1 5 or 1 1 8 F .

patient feel s well warmed and i s ready to wel come the cold .

° °
G raduall y lowe r the tem pe rature to between 80 and 9 0 F .
,

mai ntaining i t at th is point for from two to fou r mi nute s .

Dry as qu ickl y a s possible with sheets and towel s and s e e that

-

the patient i s not expose d to cold ai r or drafts for at least an

hour after
—
.

°
5 R e v ulsiv e Sho we r R e v Sh
. Begi n the showe r at 1 0 5 . .

o
l 0 8 F and graduall y ra ise the temperatu re to from 1 1 0
.
— l 1 5
° o

F or sl ightl y above ; continu e at th i s point for one to two mi n

.

u tes When the patie nt ha s bee n thorou ghly warmed turn the ,

—
.

9 0
mixer q u ickl y to col d at a temperatu re of 6 0 85 A fter fi v e .

to ten seconds turn the m ixe r valve back to the former tem
p e r a t u r e for one to two minutes Three com plete change s .

from hot to co l d are m ade A fter the last cold dry qui ckl y .
,

with sheets and towel s as u sual .

The revuls ive shower has a mild toni c and stimulant

'

E fiects .

e ff e ct The patie nt shoul d become accu stomed to it before

.

taking the al te rnate hot and col d shower The change from .
one to the othe r m a y be made graduall y
duration of the cold with each s u ccee d ing
6 Alte rn a t e H o t a n d C o ld Sho we r H
.
— .

the be st re sults the

A s the wate r mu st
reaches the pati ent ,

pos sibl e B egi n w .

F .
,
rai s ing the
and continue it about one mi nute
qui ckl y to col d and continue fiftee n
again to hot for abo ut one minute and follow
col d and so on for th ree compl ete change s
fini shi ng with the col d and drying a s u sual .

E fiects
’
Th e alte rnate hot and cold sh ower i s
.

and stimulant It should not be v e

.

s i d e r a b l e p rel i minary training by m ilder measure s .

it more agreeabl e than th e spray and easier to react

Sp ra y —Sp
s t .

Aspray bath consi sts i n the s imul taneou s

agai nst all parts O f the body by hori zontal je
patient For th i s .

square and havi ng

center are u sed , .

sary to have a short patient stand on a

may not strike the face A tall pat ient .

orde r to have th e spray cover the entir

thi s inconvenience and to spread the
m or e fo u r rosette s may be a rran
, ,

val s of sixteen inche s the u ppe r row ,

e ff ects and u se s of the spra y are the

shower with th e poss ible di ff e rence th at
,

what more general and the re i s more or

lation due to percu ss i on or prick i ng of the j ets Thi s .

a s the p re ssure i s incre ased by the full O pe ning of the

valve H o w ever thi s depends entirely on the size of t he
.

ings i n the pi pe s or rosette s If many and v e ry fine the .

ment i s most agreeable H o t cold ne utral graduated

.
, , , ,
making change s when nece ssary for
condi tion i n hand I n O rder to gu ard
.

sible kee p the index finge r of the ha

,

i n contact w ith the stream

n oz z le Thi s should be don
.

a n c e s and e ven when no tro

steady hand ap pl y the douche

,

t reated and have the t he r m om e te

The following are the general
fe r e n t te mpe rature s I n giving .

be used and any portion of t h

the poss ible variati ons and t h
together with the reflex or
would requ ire a small volu
peutie procedure s p racti c ,

than any amount of text de s cription and t e x t i

de signations as the S cotch dou che Charcot ,

non de scriptive and a s far as pos s ible should

-

hydrotherapeutic nomencl atu re .

I n giving dou che s it i s e sse ntial that the

from hot to col d This i s be st se
.

each with its own m ixe r so that

during the entire trea
the two alternatel y .

i nstantaneous The followi ng type s se rve onl y

.

guide The succes sful physi ci an will find u se for

.

tions between the revul sive a nd alternate hot and

—
The treatment mu st be adapted to each i ndi vi dual
1 H o t D ou c he H D
. Where th e hot dou che
. .

it i s given for a relativel y long time two to five ,

temperatu re of 1 0 5 — 1 25 F
°
and followed by °
.
,

appl i cation O f cold five to fifteen seconds ;

,

°
90 F Thi s i s su pposed to be ju st long
.

from the skin the heat communicated by the

principle i s identi cal with that of
that i n the latter three or more
-

he re onl y
 SP R A Y S A N D D O U CH E S

ves sel s and so where ap pl ied to a considerable area e ffective ,

de rivation i s secured Whe re appl ied to a small area the dila

.

t a t i o n O f the ve ssel s i n the deep part through a re flex channel

may equal or exceed the hydrostatic e ff ect P ercu ssion intensi .

fie s th e re flex e ffect The hot dou che i s used for the relief O f
.

pain i rritation ne ural gia sciatica etc

, , ,In these cases per , .

c u ss i o n i s u ndesirable

2 N e u tra l D o u c he —N e ut D
.

. Temperature 9 4 —9 7 F ;. .
,
0 o
.

time th ree to s i x minu te s The broken jet or spray dou che i s

, .

u sed since sedative e ff ects are sought The neutral spray .

dou che i s e speci all y beneficial when given to the spine N o ‘

.

force should be u sed and the patient should si t on a stool with

the back to the operator If given properly th i s treatment i s
.

e ssentiall y a neutral pour

—
.

3 C o ld D o u c he C D
. Tem perature 5 5
. .
— 70
o
F The ,
°
.

cold douche i s seldom given al one but when not pre ceded by ,

hot the pe rcu ssion jet should be u sed G iven in thi s way
,
.
,

vigorou s fl u x i on i s produ ce d i n the part treated with a corre s

pondi ng derivation from other parts For thi s reason it i s very .

e ff ective i n reli eving cold feet

—
.

4 R e v ulsi e v D ou c he R ev D Three abrupt changes from . .

—
.

° o
hot to cold are u sed Temperature O f the hot 1 1 2 1 1 5 F ,
.
’

—
.

°
ti me a half to two mi nutes ; temperature of the cold 5 5
,
70 ,

F ; time five to te n seconds

.
,
U nles s given with high pressure
.
,

( pe rcu s sion ) the reaction i s chiefly circulatory P ercu ssion is .

not u su all y desi rable with the re vulsive douche .

E f e cts .
I t will b e noted that the duration of the cold is
'

exceedingl y brief a s compared with the du ration of the hot In .

thi s item l ie s the di ff erence between the revuls ive and the alter
nate hot an d cold dou che The e ff ect of the re vul sive douche
.

i s ch iefl y circul atory and greate r i n the surface blood vessels

than i n the deep part i e the reflex e ff ect i s not prominent
,
. .
,
.

The surface e ff ect i s that O f fl u x ion and if a su fficient surface is

covered by the treatment a hydrostatic ( de rivative ) e ffect 1 1 13 0 1 1
,

othe r parts is produced .

The revul sive spray douche i s e specially appl i cable to the

chest abdomen and over the l iver and spleen also to the spine
,
, ,

pelvi s and peri neum .

47 4

5 . Alte rna te H ot an d C o ld
method of gi vi ng the alte rnate
re v ulsi ve douche except th at t h
du ration be ing ,

with i t so th at whe re the hot i s give n for

,

should la st twenty se conds to one m inute ,

reactive powe rs of the patient P ercu ssio n .

adds much to the vi gor and pe rmane n cy of

ou s in
fl ux i on
the re flex e ff ects be come prominent e
applied to onl y one or two parts of
treatme nt for example the alte rnate, ,

douche to the sp ine

e ff ects are produced The alte r nate .

feet and legs i s a m ost e ffi cient de ri v

when preceded by the hot leg bath .

indu ce s in the feet and legs produce s

de rivation .

The fol lowing li st of treatments ,

means of the spray an d dou che app

techni que and s o meth ing of the p rinciple s
e ff ects de sired .

A s A G E N E R A L T ox i c H — C P e rc D to . . . .

feet .

T o P R O DU C E RE A C T I O N I N O N E U N A C CU S T O M E D
H Sp r w ith H
. . C P erc D to s pine and l egs at
. . . .

T o RE L I E V E C O N G E S T I V E H E A D A C H E — H C . .

feet with C Com p to head . . .

P A S S I V E C O N G ES T I O N O F T H E L I V E R — Rev or A l t . .

D ( P erc or Sp r ) ove r hepati c area

. . . .

—
S C I A T I C A P rolonge d H Fan D ove r sciati c ne rve
—
. . .

V AR I C O S E U L C E R s H C S pr D to legs Si x . . . .

change s .

H Y P O C H LO R H Y D R I A — Rev Sp r D to e piga st rium . . .

C P erc D to m id dorsal spi ne -

—
. . . .

L U M BA G O H C P erc D t olowe r ba ck . . . . .
 patie nt has j ust come from a warm bath of
temperatu re may be u sed for the fi rst pai l
r e s p on d i ng l y l owe r or onl y two pail s u se ,

treatments l ow e r the degree

°
50 — °
6 0 i s u se d for the th ird pail .

after the last pail and dry a s from

pou r i s conveni ently u sed afte r t h
glow etc A col d pail pour to the
,
.

hal f bath and the hot s itz bath for revu

-

2 Lo c al Affusi o n s
. These ma y be .

the part treated and the tem peratu re of

a ff u s ion rel ieves pai n The ci rculator .

w a y to an atonic reaction A neu tral a .

s p i ne i s sedative
,
A cold a ff u s ion .
,

and toni c ; if prolonged it ,

stimulating phagocytosis A long continued .

head i s strongl y antipyreti c The alternate .

i s a powerful stimulant and toni c p roduci ng ,

treated wi th derivation from other parts

,
.

decided local leucocytosi s

of the se e ff e cts it i s a ve ry u seful
infected p art w he r e it i s imposs ible or un d e si r ab l
‘

immerse the part in water .

I n giving an a ffus ion to the spine the patient ,

edge of a bath tub or on a s tool i n the tub In .

to the arm hand foot etc the part may be hel

, , , .
,

tub while the water i s poure d from a p

treat the head by a po ur the patient
head re sting over the end and a tub u nde rn
local a ff u sions the water shoul d fall a di sta n c
i nche s to one or two feet according to the part tre ated
e ff e cts de sired .

ENE MA T A
An e nema is an i njection Of flu id into the rectu m .

Gene r a l D i r ecti ons :

a ) A r ti cl es N ecessa ry
enema can with a ca p acit y . An
one hal f to two gallons or a fountain S yringe or
-

bag .
 E N E MA TA

F ive or six feet of rubbe r tubing with cut off -

.

A glas s or ha rd rubbe r enema tube .

A di sinfe ctant soluti on for the enema tube O n e to three .

pe r cent l ysol a cts both a s a di sinfe ctant and a soap for cl eans
-

i ng A wate r the rmometer Toile t paper

. . .

If give n i n th e room the re Shoul d be i n addition a standard

,

or hook for su spendi ng the e ne ma can a bed pan slop j ar and , ,

several newspape rs .

I n the tre atment room shelve s or hooks are most convenient

for holding the can the y shoul d be SO arranged that the el eva
,

t ion of the ene ma can ma y be varied from one to four feet

above the patient ( P l a tes L I I ] L I V L V )
.
, , .

( 5 ) P r oced u r e F ill the can w i t h fr om t w o to si x qua rts of

.

wate r at the p rope r te mpe rature ( test with a thermometer ) .

The patient s houl d be warm espe ciall y the feet A l l cloth,

.

i ng not removed should be l oose .

P os ition of the patient — dorsal s itting right S im s or knee

, ,

che st .

Rel ease the cut o ff and allow the water to ru n u nti l the
-

stream i s at the same tempe ratu re a s t he wate r i n the can .

Close cut off and lubri cate the ene ma tube being careful to
-

w a sh i t beforehand removi ng the d is infectant sol ution

, .

The patient Shoul d i nse rt the tube u nle s s ve ry il l or u nabl e

to do so I nstr uct the patient to take a s much wate r as p os
.

s ible T O make it easie r to do this stop the flow by p inch ing

.
,

the tube two or three tim es du ring the taking of the enema .

C l ose cut off and remove the tube

-
I f poss ible the p atient
.

should re tai n the water a few minu te s before di scharging .

Re peat until a thorough bowe l movement i s se cu red or other

de si re d re sult i s obta ine d .

I . PLA I N \VA T E R E N E M AT A
R e c t al In je c tion or Ene m a —E . or En .

I n the ordi nary e nema the de sired amou nt of flui d i s inj e cted ,

allowe d to remai n a short time and the n pas se d The pro .

c e d u r e i s diff e re nt from re ctal i rrigation i n wh ich there i s a ,

cont inuou s inflow and outflow of flu id .

 TE CH N I Q UE

1 . H o t En e m a The tem peratu re O f the hot enem a —H . En .

should va ry from 1 0 3 — 1 1 0 F accordi n g to the condition of

° °
.

the pati ent and the resul t de si re d I t i s u seful i n re l ieving .

i rritati on the pain O f inflammat ion i n the rectu m or prostate

,

and pain of hemorrhoid s I t al so aid s i n expel l ing g a s an d .

,

helps to che ck diarrhoea by dec rea sing re ctal tene smu s It ma y .

be u sed a s a p rel iminary mea sure in th e treatment O f d ys m e no

rrhoea The hot enema i s al so u se d to warm an d stimul ate th e
.

body in shock It markedly rel ieve s the pai n in acu te pel vi c

.

and lower abdominal i n fl a m m a t i on s su ch as sal pingiti s and

appendi citi s
—
.

2 W .a rm E n e m a Eu The ordi nary enema for cl eansin g .

pu rpose s should be given at a temperature of 9 5 — 1 00 F ° °

.

Whe re i t ha s to be repeated fre q ue ntl y it i s be tter to u se tepid

water i e 80 ,
— 92 F
. to avoid a s far a s possible the relaxing
.
,
° °
.
,

e ffect of warm wate r

—
.

3 C o.ld E e a C E n I n gi ving the cool or cold ene ma

n m . .
,

the tem peratu re of the water ma y vary from 5 5 — 80 F Up

° O

—
.

0 ° O
to about 7 0 F it m ay be regarded a s col d and from 7O. SO ,
~

F as cool
. The cold enema i s a powerful stimulant to bowe l
.

movements and sh oul d be more gene rall y u se d for thi s pu rpose

in place of the warm enema For thi s reason it i s useful i n .

overcomi ng the enema and catharti c habit s If retaine d ten or .

fiftee n m inutes or frequentl y repeated i s u sefu l in shrinking ,

hemorrhoids I t m ay al so be u se d i n fever but for thi s pu r

.
,

pose prolonged rectal i rrigation i s mu ch more convenie nt and

eff ective
—G
.

Graduate d En e m a ra d E
. .

The gradu ated enema i s not a single treatment but a serie s ,

of treatments I t i s u se d to overcome the e nema or catharti c

.

habits A s u suall y given it extends ove r a pe riod of ten to

.
,

twelve days I t shoul d be p re ceded on two or three succe ssive

—
.

° °
da ys by thorough c o l o cl yst e r s of water at 9 0 1 00 F to r e .

move accumulated fece s The se ri es of enemata i s begun wi th .

a large amount of te pid wate r a nd fi ni she d with a small amou nt

O f cold water one enema be ing give n dail y I n some case s the
, .

first two or three of the serie s may be omitted .

or i f given to a bed patient i nt o a j ar pla ced a t t he
, ,

be d
—
.

1 H o t R e c tal Irri g a ti o n H R e c Irrig

—
. . . .

0
used i s at a tem pe ratu re O f 1 0 2 1 05
pro duces decided e ff ects i n th e relie
mu s It may al so be u sed with great benefit
.

c y sti ti s wi th frequ ent and pai nful u rination

—
.

2 C o ld R e c t a l Irr i g ati o n C R e c Irri g

. . . .

tion i s a very u seful antipyreti c measu re .

the wate r should not be ve ry cold but from ,

and the t reatment conti nu e d abo ut forty fi ve -

Cold i rrigati on i s al so u seful i n s

but for thi s purpose it pos se sse s no
enema .

3 Al te rn at e H o t and C o ld R e c t al
.

R e c Irri g . In givi ng al ternate hot

.

nece ssary to u se two e nema can s w i

Y tu be S O th at the
-

should be a l l owed to run from

col d from fifteen to thi rty se
more compl ete change s may be
The greater the extremes of te
the e ffect It i s possible to u se a plai n enema tu
.

but a small amount and a l lowing the water to pa ss

the enema tube afte r each inj e ction .

Thi s treatment i s a most effi cient mea su re i n

chronic i n fl a m m a t i on s of the pelvi c organs e ,

bladder prostate posterior u re thra and r ectum

, ,

pose s it should be given dail y or three or fou r time s

It i s al so one of the most e ffe ctive means of combati ng
atoni c constipation .

C o lo s
—
c ly ter C cl .

I n a coloclyste r the flu id i s i ntrodu ce d into the col on .

When the colocly ste r i s u sed to produ ce thorough cl

of the large bowel fou r to ,

at a temperatu re of 1 00 °

A n ordinary enema and ,

 E N E MA TA 4 81

fi rst u sed to cle anse the lowe r bowel H ave the patie nt take
.

the knee che st or right S im s pos ition U se an ordinary e nema

-

tube but i f results are not obtained it may be nece s sary to u se

, ,

the high bowel catheter ( colon tube ) A s the water enters .

,

ru b along th e co l on up the left s ide acros s the abdomen and ,

down on the right S ide SO as to fil l well the large bo w el A S .

mu ch wate r as possible shoul d be i nj ected but th i s Shoul d be ,

done sl owl y Re move the enema or colon tube and a s the

.
,

wate r i s expel led reverse the movement s along the colon to

,

favor complete e mptying It may be ne ce s sary to re peat the

.

procedu re .

Efl ects . The col oclyste r i s u se d to produce a full and com

p l e t e evacuation of the bowel s and for cl eansing the l arge
,

bowel in ca ses wh ere an ordi nary enema doe s not produce the
de s ired re su l ts I t i s also u sed to re move fe cal i mpact ion
, .

When som e me dicament or antisepti c i s i ntroduce d i t m ay be

u sed to dis infe ct the large i nte sti ne or de stro y para site s a s the ,

amoeba col i ( S ee qu inine al so quas si a enema )

. .

I I ME D I C A T E D
. E N E M AT A

Sali ne E ne m a —S l a . En .

For whate ve r pu rpose the sal i ne e nema i s used i t shou l d be ,

p receded by a thorou gh cle ansi ng enema u nl es s the bowel ha s

al ready be e n cleared of fe ce s .

1 Sa lin e Ene m a to b e R et a in e d a nd Absorb e d

. The ab so r p .
~

tion of sali ne flu id from the rectu m i s u seful i n hemorrhage ,

s urgi cal shock and pel vi c and abdominal absce sse s afte r drai n
age ha s been i nstituted To be absorbe d most rapidl y the
.
,

sodi um chloride solution should be i sotonic w i th bl ood serum

or sl ightl y h ypotoni c A phy siol ogi c salt solution i s so cal led
.

be cau se it i s i soton i c with bl ood serum .

I n te r m i tte n t P r octocly s is O n e half pint of phy siologic sal t

—
.

0
1 05 F i s
0
solu tion pe r cent ) at a tempe rature of 1 0 0 .

give n slowl y or by high bowel c at he t e i To make this u se one

.
,

l evel teaspoonful gram s ) O f salt to the p int of wate r For .

a hypotoni c solu tion ( more rap id absorption ) u se a l ittle le s s

salt A fter thi s has been absorbed another one hal f pi nt ma y
.
,
-
be given I f thi s amount i s not rea d il y retai ned
.

five ounces onl y .

Con ti nuous P r octocly s i s Murph y Method The . .

1

be admini stered th rough a

a three ei ghts i nch r u b b e
-

va

be flexe d al most t
strai ght tu be mu st not be u sed as the tip pro ,

the poste rior wall of the rectu m when the .

Fowle r positi on The tube i s i nsert ed into .

fl e x i on angle and secu red i n pl ace b y adh

it to the side of the thigh so that it can not c
tubing is passe d u nder th e be ddin g to the
bed to whi ch the fou ntai n i s attached
,
.

Two or three i nche s from the fou ntain

Y tube and to the upper l imb attach a piece 0
-

sam e si z e a s the outlet tube Fas ten the .

top of the fountain s yringe so that

fal l i nto the containe r When fl a .

more readily throu gh the upper

fountai n syringe Thi s .

s o aids

The fou ntain syringe Should be su spende d

teen i nche s above the le vel of the bu ttock s and
to j u st overbalance h y drostaticall y the intra
su re i e i t mu st be j u st h igh e no u gh to
, . .
,

sixty minute s for one and one half p ints -

quantity given every two h ours Tli e .

g ra v i ty a l one , a n d neve r by a f or ceps or

that when the patient endeavors to
flu id can rapi dl y flow back into the
di scharged i n the bed I t i s thi s eas .

bowe l t/z a t i n su r es ag a i ns t ove r -

di s
l i ne n The fountai n had better be a gl as s or
.

that the flow can be estimated The t e m p e r atu .

in the fou ntai n can be m aintaine d at 1 00 by °

hot wate r bags

-
The fountain i s refil led eve ry
.

1 S l i gh t l y m d i fi d f m th i g i n l d i p t i n b y J B M ph y
o e ro e or a e sc r o . . ur .
 0
wate r at about 1 0 0 F Follow by a plai n .

the soap suds .

'
Ej ects .The soap s uds enema facil itates"
bowels and should be u sed where the pl ain
du ce re su lts .

In admi ni stering the O il e nema u se the ,

small enema can giving one

of warme d cotton see d or
retai ned from two to ten 0
it the next morning
The oil enem a i s
‘

Efl ects .

i mpacted fece s I t has a soothi .

fore u sed to ove rcom e spast ic consti pation ,

poisoning Whe n given two or three days

.

for he morrhoids it softens and l oose ns the cl ot so

without cau s ing pai n or starting fre sh bleedi ng

H on e y or Molasse s En e m a
G ive one hal f to one p int of a warmed solution
-

two part s soap su ds and one of mola sse s by high

Follow by plain ene ma For les s of the cath .

fou r ou nce s O f hone y or mol asse s to the pi nt

water .

Efl ects
’
The honey or molasse s e nema
.

similar to that of the hype rtoni c saline enema

removing the mu cou s casts and mucou s a c c u ,
-

chroni c col iti s .

Asafo e tida Ene m a

To one p int of warm water add fou r ounce s of an
of asafoetida prepared by agi tating one h alf dram of
,
-

p owder in fou r ounce s O f wate r ; or add one

asafoetida to a pint of warm water G ive a s a n ordi nary .

It i s u sed to expel fl at u s .

Turp e nti ne Ene m a

To a p int of soap suds solution add ten to twe nt y
P LAT E L I A
. se e p g
a e a pp a ra t u s w it h d vi
e ce fo r w a rm i n g fl ui d .

PL AT E L I I C nt i nu u —
o p t l y i w it h h
o s r oc oc s s ot -
w at e r b ot t l e fo r
m i n g fl ui d d pp i n g d v i
.

war n
; c or fig u
er re ro e ce .
 ( a) A n ou nce of gl yce rite of tannin to on e pi nt
°
1 00 F .

Q uassia Ene m a
The quassia ene ma i s u sed to de stroy and re move
pinworms ( oxyu ri s vermiculari s ) P .

quassia by pouring over one a nd one h -

quassia wood twenty ou nce s O f warm

,

to thi rt y mi nutes and strain U se .

first ; then cleanse the colon tho

taining a te a spoonful of b orax to
colon ( coloclyste r ) a half to a pint O f the infu s io n of
reta in as l ong as pos sibl e A 1 bichlor i d e
.

may be u sed instead of the quassia I t shoul d not be .

v ery long .

Quinin e Enem a
The qu inine enema i s u s ed for amoebic dyse nte ry .

thorough cleansing of the bowel by l o w ene ma

flushing inje ct b y h igh bowel catheter from two
, ,

m ore p i nt s of a warme d sol ution of q u

’

Large and frequentl y repeated c ol oc l y

be u se d Q ui nine kill s the amoeb ae
. Col d .

them for a ti me P os iti on of patient

.
— h ips e l
In very obst inate and long standi ng ea se s
t e r y c o l o n i c fl u s hi n g s wi th cold water or the qu i n i n e s o]
,

are so m e t i n e s carried out by means of appendicostomy .

V AG I N A L DO U C H E S OR IR R I G A T I O N
A vaginal douche con si sts i n t he flu shing or irri gating
the vaginal cavity by a flu i d .

Ge n er a l D i r ecti on s : ~

( a ) A r ti cl es N ecessa ry i n the T r ea tm e n t R oom

Douche .

fountai n syringe or dou che c a n with a capacity of one

gallons five or si x feet of rubber tubing dou che tube of gla ss
, ,

or hard rubbe r lubri cant di si nfectant sheets and napkins

, , ,
.

A dditional need i n private room : S tandard or hook s for dou che

can a dou che pan slop j ar and rubbe r shee ting or p apers
, , ,
.
 VA GI N A L IR R IGA TION 487

( 5 ) P r ocedu r e P reparation
of the douche Fill the can with
. .

from two to fou r quarts of water at the prescribed temperatu re

and place it from three to four fee t above the patient A lwa y s .

u se a thermomete r i n pre paring vaginal douche s .

P reparation of patient If the clothi ng i s not removed p ro

.
,

teet thoroughl y A lways cove r the patie nt with a sheet Lub

. .

r i c a te the tube with vasel i ne or soap Release the cut o ff and .

-

all ow the wate r to ru n a few se conds I nstru ct the patient to .

i nsert the tube u nle ss hel ples s .

P osition of patient Dorsal pos ition with h i ps rai sed and

.

thighs and legs flexed .

I . P LA I N V A G I N A L I R R IG AT I O N

V ag inal Irrig a tion fo r O rdin ary Use

1 . H ot Va ginal Irrig atio n —V I
Thi s i s u se d for cle ansi ng
. .

p urpose s Two to four qu art s of wate r are e mploye d at a tem

.

p e r a t ur e O f 1 05
— o
1 1 5 F
°
Fi ni sh with a pi nt of water at 7 0 F
.
0
.

I n the treatment of pelvi c i n fl am m a t i on s the hot vaginal ,

dou che i s u suall y given a s a preli m ina ry to the u se of the Sitz

bath hot h alf bath or the h i p and l e g pack
,
-
.

2 V e ry H o t V ag in al Irrig ati o n H V I
. The very hot vag - “

. . .

i nal i rrigation i s de signe d for the rel ief of p ain or to check

h emorrhage Two to four quarts of water are u se d at a tem
—
.

o °
p e r at u r e of 1 1 0 1 25 F
—
.

3 Alt e rnate H ot a n d C o ld V a g inal Irr ig ati on H

. C V I . . . .

A lte rnate hot and col d vaginal i rri g ation i s give n for tonic and
st imulating eff e cts It i s al so u se d i n chroni c pel vic i n fl a m m a
tions U se two cans with a Y —
.

. tube connection P u t fou r quarts .

of wate r i n one c a n at a temperatu re of 1 1 0 ‘

— o
1 20 F and two °
.
,

0
quarts of wate r in the other at a te mpe rature O f 7 0 F .

G ive the hot fifteen to th irt y seconds and the col d five to ten
seconds Conti nue the alternations for five to te n mi nutes
. .

beginni ng wit h hot and fini sh ing w ith col d .

V ag i nal Irri g a ti on D uri n g Pre g n an cy

Du ring pregnancy certai n p recautions mu st be O bse r ved .

The pre s su re of the water mu st not be too great , i . e . the

,
488

douche can mu st not be place d too high .

extremely hot wate r s hould not be u sed .

es sary that the openings i n the bu lb of the

eral and not d ire ctl y on the end
irrigation i s given chie fly for cl
leu corrhoea and for the rel ief of
qu a rts of water at a tem peratu re of
douche c an twel ve to e ighteen i nche s above t

II . D I S I N F E C T A N T A N D ME D I C A T E D D O U C
So ap Suds V agi nal Irrig ation —S . S
. V .

U se two quarts of soap suds s

soap or gree n soap sol ution at a te mperatu re
Wrap the tube i n chee secl oth and swab the
but thoroughl y while the wate r i s flowing
, .

vaginal i rrigation the n gi ve a p erm ang a na

,

douche .

The soap su ds vaginal i rrigation is use d to

for su rgical operations or for spe cial c l e an sm g
pu rpose s .

P e rm a n g a n a te of P o tassium Vaginal
To one qu art of water add two drams
a satu rated 5
Tem pe ratu re
tion O xali c acid ( sa t sol
.
.

T he permanganate dou c
fe c t a n t i n the treatment of vaginal i n fl am m a t i o n s leu ,

e tc al so as a di sinfe ctant preparatory to operation .

B i c hlori de of Me rc ury Vag inal Irri g ation —Bi hl c or .

U se one dram ( a teaspoonful ) of a satu rated s ol

bichl oride of me rcury to

or Temperature
pla in vaginal i rrigat ion so a s ,

secretions If thi s i s not done t

.

bi chloride are less e ne d by its

substance s .
 P R E SC R IP T ION W R I TI

T R E A T ME

E ITH E R the a rt of p rescri ption

knowledge O f the rape uti c eff ects
prel iminar y training and experience in
the ra py Tre atment combinati ons
.

p l easi ng to the patient are pe rfect ]

a rrangement ; i n fact combinat ions ,

r a r e l v e ffi cient a

become so O n .

patients in the treatment room s Should requ ire about

or fift v mi nute s E xcept with ce rtai n appl i cations
.
,

time i s usuall y detrim ental rathe r than be neficial .

patients i n case s of ne ph ri ti s pleu ris y pneu moni a

, , ,

i nflammatory disease s organic ne rvou s ,

case should be a law unto it self a s to the

and the fre q ue ne
A mistake ver y c
i s the giving of a
w e re to be taken ,

dav For the same rea son hydroth erapeuti c trea

.

va rv o nl v as th e patient s condi tion varie s as ‘

occu rs or some s pe cial re sult i s to be obtained

, .

I n the prope r combining of procedu re s l ie s the

securing a predete rmined ph y siologi c eff ect ,

s i red therapeutic re sul t in

intimate knowledge of normal and abnormal p hysi ol og
to prescribe hydrothera py than i t doe s to prescribe
substa nce s for internal medication The secu ri ng of .

rule com bi n e f or s i m u l ta neous ppl z ca tz bn

' ’

to a as

v i dua l pr oce du r es to be g i ve n as poss i b le a nd

For exam ple i n giving a hot foot

r es u l t .
,
-

to the spi ne and a cold mi tten fri ction the

, ,

the hot foot bath and the hot and cold

 P R E SCR IP TION WR ITIN G 491

if the y are abl e to sit u p The cold friction should be

ou sl y , .

be gu n with the arm s whe n the last fomentation has bee n

appl ied to the spine A fter treating the a rms the fome ntation
.
,

i s re moved from the spi ne and th e cold fri ction give n to the
back The feet are removed from the hot water onl y when th e
.

attenda nt reache s the legs an d fee t w ith the cold fr i ct i on Th i s .

combi nation i s more pleasing to the patie nt i t secu res better ,

resul ts and re qu ire s l e s s t ime than whe re each procedu re i s

,

g iven separatel y one followi ng the other ,

S u ch a combi nation .

i s mu ch eas ier to give i n ca se of a pre scription for a hot foot

bath fomentat ions to the abd omen and a cold mitten fri ction
, .

The pati ent may re cl i ne for al l O f the treatment T h e hot foot .

bath i s sta rted the n th e fome ntati ons to the abdomen and
, ,

when the th ird one ha s bee n pl aced begin the col d friction ,

with the a rm s removing the fomentation to the abdomen when

,

re ady to treat the anterior part of the t ru nk The fee t are .

next removed from the hot water and th e friction given to th e

legs and the feet Last l y the patient turns and the back i s
.

treated G ive n in th is w a y the reaction from the col d fricti on

.
,

i s more p rompt i n appea r ing and more comple te because the ,

hot appl i cati on s give a sensati on O f heat The u se of th e h ot .

foot bath the i ce bag to the heart the col d compre ss to the
, ,

head and neck S imul taneousl y with other appli cation s a ct p r e

ly l i ke a dj uz ra n t a n d cor r ig e n s ag e n ts i n m e di ci n a l tlz e r ap y
'

ci se .

A lso as a general rul e ,

tr ea tm e n ts to be g i ve n on a tr ea tm e n t

ta bl e For
s/z ou /d p r ece de tr e a tm e n ts to be g i c e n i n tlz e a 'e t r oom s .

—
example fomentati ons ove r the l ive r a salt glow and a hot
, , ,

and col d percus s ion dou che to the spine and legs Coming i n .

any oth er order tha n that given w ould entail re peate d drying
O f t he skin su rface and s o l es se n the ple asing e ff ect of the
,

treatment .

T hi s same pre scription se rve s to ill ustrate the principle that

the m il de r p r oce du r es z ou l d
s/ be g i ve n fi r s t ,
tb ose z e lz i c/z p r oduce {be
g The fomentati on i s a m ild appl ication
r e a tes t r ea cti on l as t . ,

the salt glow i s more vigorou s and th e hot and cold douche to ,

the spine and legs the most stimu l ating of the three The fi rst .

two prep are the patient for the last appl ication G ive n in an v .

other orde r the treatm ent would resemble an anticlimax

,
.
 S omewhat the same p ri n c i p l
a si ng l e tr ea tm e n t t/z e r e slz ou l d

For example ,

not be given
hot and col d
draw too heavil y
S u ch sweating
or Turkish bath s shoul d be i mm
spray or pai l pour SO as to wa sh
body quickly and produce su ch a
not take col d .

In the appl ication of therapeuti c

i ncl ine more and more to specific therap y .

be studie d with a view to i ndivi dual izing

tre at the patient not me rely h is di sease ,
-
.

The follow ing pre scriptions will se rve

given above and in a general w a y be sugges tive of

t reatment in the conditions named .

O N SE T OF GRIP P E

H Lg B F o Sp C C H d
. . .
, . .
,
. . . Nk . drink hot
free perspi ration ) G rad S h 1 1 , . . 5
0 — 90 5 Mi n .

C H RO N I C CO L D I N H EAD
H . Ft B or
. . H .Lg P k A l t H C Hd. .
, . . .
, 30 Mm .

Hd . 8 :
Nk .
,
H . C P erc D Ft ( 6 change s )
. . . . .

D I LAT E D C O LO N A N D AT O N IC C O NST I P A T I O N
Fo C rub Z
. Ab d 5 Mi n ; A l t H.
, C Fan . . . . . . .

Al t H
. C P erc D to lower D and L Sp S S inu
. . . . . . .
,
.

ele ctrode to lowe r D : and L Sp l abile hand Sp g to . .

,
.

over colon .

A C UT E SA L P I N G I T I S ( LE F T )

H . Hp Lg P k ice ba g above l eft groi n

. . .
, ,
20 —30
Gm t . Le ave ice b ag over tu be or appl y heating
A C U T E P L E U R I sv ( RI G H T )
H . Ft . B .
,
FO
 O L D G L E ET
-

Al t . H . C Re c I rri g
. . .
, Re v . Z .
, Alt . H .

S P L AN C H N I C N E UR A ST H E N I A

H . Ft . B .
,
C coil . Ab d C C. . Hd .
, 30 Min ;

P E R S I ST EN T V O M I T I N G

H ot H eat . Tr . Pk . ( app ly 1 0 Mi n be fore .

to 2 H rs .
,
Cm f .

H Y P E R C H LO R H Y D R I A

Two gl asse s h ot wate r 1 5 Mi n before meal ; ice .

after meal 2 0 Mi n .

C H R O N I C MI T RA L I N S U F FI C I E N C Y
( with cardiac l ive r and edema of legs )
Ice Bg . Ht .
,
Rev C l i ver . .
, Al t . H . C Lg B . .

Cm f .
,
Cf Lgs . .

A C UT E E N DO C A R D I T I S W I T H D I L AT E D H

Ice Bg over . Ht . 30 Mi n every H r H Lg

. .
, . .

knee s onl y ) ice , Bg . Ht .

, Cm f ( give twice daily )
. .

I N SO M N I A
Fo . Sp .
,
Oz B (5 . P .

V A R I C OSE U LCE R
Al t C Lg B 3 0 Mi n dail y ( incre ase usual
. H . . . .
,
.

of col d to e qu al with then greater than the hot ) A l t , , ,

.

Sp r D L g s
. . .

L U M BA G O
lower Bk H
FO . .
, . C . P erc . D to same short stati c
.
,

to painful mu scle s .

T RO P H I C U L C E R OR D I AB E T I C G AN G R EN E OF FO O T
ALT . H . C Ft . . B .
, 30 Mi n tw ice daily . .

H EMORR HOID S
C S hal Mi n AM
°
P rolonged . . Z .
,
90 1 0 to 1 5 . .

C pe rineal D
. .
 A P P A R A T US

H Y D R O T H E R AP E UT I C A P P AR A T U S

A N D T R E AT ME N T R O O M S

HE plan and e qu ipme nt for hydrotherapeuti c treatment

room s mu st of nece ssi ty vary w ith the insti tution i n which
the y a re to be u sed and the class of case s to be treated We .

s hall have most to say of treatment room s for gene ral u se in

i nstitutions that accep t all classes O f me dical and su rgi cal cases
and the ward e qui pme nt in gene ral hospi tal s .

In hospi tal s for the i nsa n e the e qu i pment need not be exten
s ive in variety but many pieces of the same kind are ne ce ssar y
, .

E spe cially Shoul d the receiving ward appl iance s for th e treat
me nt of mania be nume rou s enough to treat many case s s imul
t a n e o u sl y
. The tubs for the conti nu ou s flowing bath together
with the ir mixers and controllers and the pack tabl es with the ir
ou tfit make up the chief e qu ipment re quire d The se should be .

se parate from other appl iances a s pe rfect quiet i s e s sential .

For general u se anothe r room or room s shoul d be fitte d with a

,

spra y and dou che controll er and i ts spray showe r douches , , ,

bidet or other attachments S itz tubs and flowing bath tu bs

.

a re be st not conne cted wi th the sp ray and douche controlle r ,

but Should be se paratel y controlle d I n the same room or an

.

adj oi ning room sh ould be the electri c l ight bath cabinet and
the hot a i r and ste am cabinets for the Turki sh and Ru ssian
baths . H ere and the re convenient to the ge ne ral wards of the
,

i nsti tution shoul d be a rrange d pack table s and tubs for the
,

flowing bath al so a fomentation tank and an e nem a and vagi nal

,

d ouche bench .

Gene ral Tre atm e n t R o om s

I n sanata ri a and O fli c e treatment rooms the plan and e quip
ment s houl d be ample for admini ste ri ng al l forms of hydro
therap y Convenience O f u se and e conomy of ope ration are
.

most es sent ial In any but ver y s mall institut ions separate
.

rooms shoul d be provided for m en and wome n so that the y may

be use d at any hour of the day or night Co n s iderabl y more .

than fifty per cent of all ca se s are be st treated i n the forenoo n

 49 6

he nce the di sadvantage of com mon rooms I n

hour mu st be arranged .

A s far as pos sible treatme nt rooms sh ou ld be

floor becau se of the great ex pe nse not to sa y
b i l i t y of re nde ring floors wholl y non l eaki ng -
.

may be accompl ished by the u se O f sheet lea d -

cement or the u se of the more expensive fl oo r i ng s

p l a st on e etc
,
G lazed tile wall s and unglazed til
.

ve ry se rviceable bu t are not

excellent for t he wal l s of spra y
crete wall s are equ all y durable .

E ve ry treatme nt room Shoul d be di vided i

sets of apartments by partitions from fl oor to .

di ff ere nt temperature may be mai ntaine d i n

essential w h ich should not
otherw ise great annoyance i n c o n v e n i e ,

may result to pati ents from overheating

first room Sh oul d contain the matron s ’

head nu rse s O ffice the linen suppl ie s

’

, ,

patie nt s dre s sing m

’

0
be abou t 6 8 F and wel l ve nt ilated The next room
. .
'

contain the individual treatment room s each provide d ,

treatment table a stool and hooks or bars for towel s

, ,

etc . The tem pe rature of th i s room should be about

s o that it i s comfortabl e for patients while taki ng pack

t a t i on s cold frictions massage etc

, , ,
.

The third room whi ch we may a p pr O p

wet room i s to be maintaine d at a higher
tain s at one e nd Sitz tubs l e g tubs the full , ,

salt glow room etc I f the temperatu re of t h

, .

hi gh the se appl iances should be separate d

othe r end of the wet room Shoul d be installed
douche controller and its attachments and all the
hot baths such as the electric l ight Tu rkish and ,

nets or rooms I f thou ght best these latt er ma y be p

.

room immediatel y adj oining the sp ray and dou ch e

but i n any case the patient Shou ld have to go onl y a
from an y hot bath to the Spray so that there will be ,
 TE CH N IQ UE

Tre atm e nt App li an c es

The Fom e ntati on Tank T hi s shoul d be an e na m eled i ron
.

tank of oblong deep form preferabl y with an e nd ou tlet If i t .

i s to set against the wall it may be fill ed by an ordinary wal l

faucet Where man y nu rse s are worki ng at the same time i t
.

i s best to have the fomentation tank se t away from the wall SO

that two wringers may be attached ( P l a te XXI I I ) I n thi s .

ca se th e i nlet shoul d be from below j u st ab ove the trap for the

waste ( F ig The waste Shoul d be controll ed by a valve
.
,

never by the ordin a ry pl u g in the bottom of the tank Th e .

f
F ig . 62
om e n t a t i on
St eam 0 0
w ate r —bv
“ fo r
o
h
e rse
e atin
.
g
f
F ig 63. . S
o m e nt a t i o n w a t e r
-
v
h
t e a m c o il fo r e a t i n
re e rs e .
g

water shou ld be heated by a l ong copper coil ( twelve or fi fteen

feet O f e ighth i nch pi pe ) th rough whi ch l ive steam passe s
-

The su ppl y pipe to thi s coil al so enters from bel ow and i s con
troll ed by a val ve The entering steam shou ld go to the ce nter
.

of the coil and the steam exit be by a pe rforated di sk al so at

the ce nte r of the coi l ( F ig s 6 2 a n d Thi s arrangeme nt pre

.

”
ve nts bu mping and the O peration of the coil i s absolutel y
noi seless eve n i n col d water The wri nge rs shoul d be extra .

long and may be made by replaci ng t he rubbe r covered rol lers -

of an ordi nary steel spring wringe r by rollers made of two

 A P P A R A T US 49 9

heavy unbleached mu sli n by roll ing the cloth on SO a s to make

the cove ring about three layers th ick .

Ste a m B ox es When heated directl y by li ve stea m fomenta

.
,

tions and pack s are hotte r and the heat i s retained longer than
when wrung from boi li ng wate r For thi s purpose steam .

boxes be provided several cl oth s steamed in papi er

c ur I ro n ( no or B I AN KZ T

S YZ AH 'l'f

P I R VD R AT E D
f g L g
> M

F ig . 64 . Pl a n of st e a m b ox .

mache pail . I n the form er case the boxes may be arranged as

shown i n P l a tes XXI V a nd X X V The steam inlet should be .

by a perforated pipe bel ow a perforate d fal se bottom ( F ig .

The box shoul d have an ou tle t for the condensed steam O ne .

e nd of the box sh ould have a l ong Shallow notch in it through

wh ich the e nd of the folde d fomentati on cl oth or pack blanket
may proj e ct The cove r shoul d h ave tu rned down edges one
.

an d one half or two i nche s wide whi ch should fit over th e wall s

-

of the steam box The steam should be tu rned O ff when the

.

box i s opened .
5 00 TE CH N I Q UE

Le g Tu bs These shoul d be made of heavy gal vani zed i ron

. .

The y shoul d b e si xteen i nche s i n diame ter and twenty — fou r

inches high The bottom shoul d be set u p about two in che s
.

from the base I t sh ould have an extra ring O f gal vani ze d i ron
.

soldere d underneath to hel p su pport the weight O f the wate r .

The outlet may be by a large si ze mola sse s faucet ( F ig or .

a fl u m c gate of gal vani z ed i ron ( F ig 6 6 a nd P l a te Two . .

such tubs are ne ce s sary .

Fo o t Tubs F oot tu bs shoul d be made O f medium wei ght

.

galvani z ed i ron A n elli pti cal shape i s be st with rigi d handle s

.

at the ends The base should be abou t el even i nche s i n cros s

.

diameter and fiftee n inches l ong The side s shoul d flare to a .

cross d iameter of about fiftee n i nche s and a long diamete r O f

F i g 65. . M
o l a ss e s f
a u ce t F ig 66
. . C am pb ell fl um g
e ate
o u t l e t fo r l e g t u b . o u t l e t fo r l e g t ub .

ninetee n or twe nty i nche s The tub shoul d be nine i nche s

.

deep Two e xtra sets of hot and col d water fau cets sh ould be
.

provided at some conve ni ent place for the fill ing of foot tubs ,

pail s basins etc so th at i t wil l not be neces sar y to go to bath

, , .
,

tubs or the douche controll er for thi s pu r pose .

B a th Tub s Bath tubs Shoul d be six feet l ong for me n an d

.

fi ve and a half or si x feet for women The y should be se t u p .

from the floor fou r to s ix i nche s I f th i s extra base i s of wel l

.

painted wood i t will se rve al so for the i nsul ation nece ssary i n
gi vi ng el e ctro the rmal bath s-

For t he latte r pu rpose the mix.

ing faucet su ppl y should be attached to the wall at the foot of

the tu b and have no connection with the tub itself ( P l a te
XXX/X) .
The outlet sh ould al so b e di sconnected from the
pl umbing the waste wate r runni ng into a cement gu tter The
, .

ove rflow shoul d be carried u p unde r the roll O f the tub and
5 02 TE CH N I Q UE

be of ri gid mate rial as it i s too sugge stive of confinement i n

nervou s patients and i s u nde si rabl e i n any ca se ;
R uss ian an d Turk ish B a th R oo m s The con stru ction of
.

the se ha s bee n qu ite full y considered u nde r tech nique We .

prefe r a cabinet i n the form of a room 80 th at the p ati ent may

re cline on a ma rbl e Slab with the head outside a s l i ding w i n
do w . There i s le ss danger O f fai nti ng w ith the pati ent i n th i s
position and the same may be said of the horizontal elect ri c
light cabinet Be s ide s thi s the marbl e sl ab may al so be u se d
.

for shampoo pu rpose s and a sh ower for cool i ng O ff the pati en t

be i nstall ed in the same room ( P l a tes X L a nd X L I ) Whe re .

steam coil s are arranged under the marble sl ab a thi ck layer of

some non condu ctor of he at Shoul d be pla ced ove r the se coil s so
-

that the marbl e will not be come ove rhe ated .

D rye r
. A dryer for fomentation cloth s sheets and towel s i s
,

a ne ce ss ity in every treatment room Th i s may be made after

.

the pl an of a laundry drye r bei ng hea t ed by steam coil s I t is .

well to have seve ral tra ys or carts that pull out se pa ratel y .

These may convenientl y ru n on sl id ing d oor h ange rs or a simi

lar devi ce E ach one shoul d be seve n or eight i nche s wide by
.

five or Six feet high and consi st O f five or si x half inch g as pi p e -

bars six feet long The number of su c h pull s requ ired will
.

de pend upon the nu mber of patients to be tre ate d A drye r of .

S i x takes u p but l ittle s pace and i s a mpl e for twe n t y fi v e to -

forty patients a day I t i s well for sake O f convenie nce to

.

instal l thi s near the fomentatio n tank and i n the part of the w e t
rooms where the greate st amou nt O f heat i s neede d Thi s .

econom ize s both time i n labor and expen se i n h eating a s some

heat wil l inevi tabl y escape from the dryer e ve n though tightl y
,

built and separate ventilation p rovided for .

Ene m a a nd D ouc he O utfit Th es e room s shoul d be so

.

arranged that they are ventilated enti rel y se parate from th e

general treatment room s be st di re ctl y to the outside A bench
, .

O f drai n board material six feet l ong and about twenty fou r -

i nche s wide shoul d be fitte d ove r the toilet fixture in pl ace O f

the ring and l id A t the right ha nd end of thi s shoul d be
.

pl aced the standards for hanging the enema and dou ch e ca n s .

P l a te L I I I shows a standard for hol ding two i rrigating ca n s

5 04 TE CH N IQ UE
There are ce rtai n esse ntial s w ithout whi ch sati sfactory
re sul ts are i mposs ible O f first im portance i s th e water su ppl y
.
.

The controller must be su ppl ie d with h ot and col d water by

pipe s directl y from rese rv oirs or tanks The se pipes shoul d
‘

suppl y no othe r fixture s The y Should be e ntirel y i ndependent

.

of all othe r attachme nts I f thi s i s not done the temperature

.

of a dou che stream or of the spray w il l vary when ever water i s

drawn from attached fau cets For example if th e hot and .
,

cold wate r su pply to a nearby bath tub come s from the pi pe s

F ig . 67 . Pl a n of t op of t a bl e c o n t r ol s h ow n in Pl at e L .

suppl yi ng the controlle r and while a dou che i s bei ng given at ,

0
1 1 5 F the attendant at thi s bath tu b Op e n s the cold wate r
.
,

faucet the pres su re on the col d wate r su ppl y to the dou ch e

be ing lowe red the proportion of cold wate r in the m 1 x e r will be
,

instantl y lessene d and ju st as i nstantl y the temperatu re of the

dou che will sh oot u p ten twenty or more degree s and the , ,
.

patie nt will be bu rn ed E ve n with wholl y i ndependent su ppl y

.

pipe s the pre ssure O f the incomi ng water should be controll ed

by pre ssure regulators so that the pressu re O f the hot water
and of the cold water may be adj u sted to the same number of
pounds The tempe rature of th e hot water shoul d be re gulated
.

at the tank by a thermostat wh ich should be arr anged for about

 A P P A R A T US

°
1 85 FThe col d wate r Should be su ppl ied at a temperatu re
.

of 40 — °
55 F
o
and except i n s umme r doe s not u suall y re qu ire
.
,

cool ing .

—
The re are two t ypes of controller the table control and t he
wall control The table control i s u suall y more compl ete and
. .

more satisfactory I t i s a more elegant pie ce of furnit u re but

.

i s l ikewi se more expen s ive The wall controllers on the market .

are most of the m incomplete and les s sati sfactory than t he table
control H oweve r the handling of the douche hose i s more
.
,

convenie nt and w ith attention to the es sential s of constru ction

the wal l control may be m ade nearl y as compl ete and sa t i sfa c
tory a s the tabl e control .

P l a te L il lu strate s a hydro
the rap y control table devi sed
by the au thor F ig 6 7 Shows . .

the arrange ment O f the top of

th is tabl e A s will be seen it i s .

a three uni t controlle r i e i t , . .

,

will del iver three i ndependent

stream s of water at di ff erent
tem peratures Thi s r e q u i r e s .

three m ixers two O f whi ch s u p ,

—
pl y dou che hose one for the
hot dou che and one for the col d
dou che Th e third m ixer su p .

M ti m ix
pl ie s the spray the shower and , ,
F i g 68 _ . ar n so n e r,
h w i ng i t
s o t m ti n the bidet no two of wh ich at
s c on s
‘
o '

t a c h m e n t s i s it de si rabl e to u se at the same time .

The i ntern al const ru ction i s as follow s : The pre ssure regu

l ator s are attatched to the su ppl y pipe s j u st before the y d ivide
'

for the three mixe rs The se pipe s one for the hot and one for .
,

the col d wate r are one and one half or two i nche s in diameter
,
- .

From each are taken O ff three one i nch p ipe s each of which -
.

l atter are fitte d with valve s and check val ve s the latte r being ,

pl ace d as close to the mixers as possible These check valve s .

are an absolute neces s ity as otherwi se the cold water pipe s may
fill w ith hot wate r th rou gh the mixer or vice versa even with
-
, ,

a very sl ight di ff erence i n pre s su re F ig s 68 a n d 6 9 Show . .

5 06 TE CH N IQ UE
two style s of m ixe r val ve s The fi rst i s le ss expe ns ive and
.

quite satisfactory The second costs a l i ttl e more but re sponds

.

a l ittle more evenl y and hence i s more satis factory Where .

u sed withou t other va l ve s it mu st open with the cold water ,

fi rst and i s the refore said to be non sca l ding

,
-
.

F rom the mixe r the wate r passe s O ver the bul b O f t he ther
m omete r wh ich sho ul d be pl aced a s cl ose a s pos sible to t he
,

mixe r so th at any change s in the te mperatu re will be regi stered

w ithout del ay Be yond the thermometer i s the valve which
.

opens the douche and regul ate s the volu me and p ressu re O f the
stream J u st be y ond thi s valve the pre s su re gau ge i s attached
. .

F ig . 69 . Ni d k
e ec en mi x e r, s h o wi n g w k i ng p
or a rt s .

I t i s pl aced here so as to regi ste r the u sing pre ss u re i e , . .

,

t he pres su re admini ste red to the patient S till b eyond th i s .

,

bu t bel ow the marbl e top of the tabl e the i nch pi pe divides i h ,

to two th ree fourth inch pi pe s one for t he douche hose and

-

one to se rve as a vent whi ch latte r i s control led by a val ve .

The ve nt val ve should be O pened whe neve r the dou che i s being
u sed i n order to kee p goi ng throu gh the m ixe r th e large vol
u me of water wh i ch i s al wa y s requ ire d to m aintai n a constant
,

u n fl u c t u a t i n g tempe rature We re there no ve nt the tempe r

. ,

a tu re would ri se undul y whe n a l ow pre s su re i s be ing a d m i n i s

t e re d . I n operating a controll er wi th onl y one douche uni t i t ,

im pos sibl e to secure absolu tel y instantaneou s change s from

hot to cold For the meth od of ope rating the dou che u nits
.

the reade r i s referred to the section on spay s and dou che s .

5 08 TE CH N I Q UE

e ight inche s i n dia mete r I t i s be st to have i t attached by a bal l

.

j oint union SO i t m a y face di rectl y downward or be incl i ne d

forward at an angle of forty fiv e degree s so that the patient s -

,
’

head need not be w e t I n P l a te L the Showe r head i s sh own

.

faci ng strai ght down The spra y i s constru cted of four up

.

ri ght pipes to each of whi ch are attached fou r rosettes

,
Th e .

u pper row of rosette s are atta che d by bal l j oi nt u nions so tha t

the y may be adj u sted upward or downward for individual s of
di ffe rent he ights .

The arrangement of the bidet i s shown i n F ig 7 1 A bal l . .

u nion make s it possibl e to tu rn the arm carrying the rosette

out of the and back agai nst the wal l when it not in use .

F ig . 71 . Pl a n o f se a t s p ra y fo r p e ri n e a l d o uc h e .

The stream should not be a jet but a Spray dou che O btained by , ,

a rosette a s i t i s de si red to cover a mediu m si z e surface with

,

ou t pe rcu ssion . S i nce th e vol um e O f water i s not large the ,

shower valve should be opene d to act as a vent I n th e ca se O f .

the two u nit wall control ( F ig the bi det i s attache d to the

.

same mixe r that su ppl ie s one of the douches so that a regula r ,

vent i s provided .

F ig 7 2 shows a spra y and douche controlle r of the wal l typ e

.

de vi sed by the author I t consi sts of two i nstead of three u nits

. .

O ne treatme nt combi nation v i z a hot Sp ray simul taneou s with

,
.
,

an alte rn ate hot and cold douche to the spine and legs i t i s
i mposs ible to give with thi s m achi ne I f the changes i n the .

douch e temperatu re w ere made by the mixe r it would alte r ,

 A P P A R A T US

the te mperatu re of the Sp ray hence th is treatment i s i m ,

p racti cable withou t th re e units N eve rthele s s for al l othe r .

,

treat m e nts i t i s e quall y as e ffi cie nt as the table control O n .

the other hand it ha s the advantage that the operator s itting

,

on a hi gh stool facing the controll er can kee p h i s finge r i n the

Sl at:
"
EL E VAT I O N F R ON T E L E VAT l ON

V
\ a l l c o n t ro l , S h o w mg f r o n t a nd s i d e e le v a t ion pl a ns .

stream of wate r fro m the dou che hose and so add thi s element ,

of p rotection to the patient i n ca se the te mperature of the

wate r Should su ddenl y run u p wh ile hi s eyes are on th e patie n t
i nstead Of the the rmometer H o we ve r with the table control
.
,

the thermomete r and the patient are both in front of the opera
tor a nd but a sl ight tu rn of the head or e yes i s ne ces sary to
glance from one to the othe r .
51 0 TE CH N I Q UE

The wal l control shoul d be su p pl ie d by i ndependent pipe s i n

the same way as the table control It mu st al so have pressu re
.

regul ators check val ve s ve nts etc

, , The the rmometers
, .
,

val ve s for douche s spray sh ower and bidet and the pres su re
, , ,

gauge s are i n the same rel ati ve p osi tion as i n the other type .

The wall control may be fitte d on an upright m arbl e sl ab so

that the pi pe s are conceal ed and onl y the valve wheel s ther ,

m o m e t e r s pre ssu re gau ge s face s O f the mixers and the douche

, ,

hose are vi sabl e Thi s make s a very pre se ntable appearance

. .

H owever ,
for p ractical pu rpose s th e vis abl e form made O f
,

nickel ed pipe i s j u st as good and l es s expens ive H aving al l

.

the pa rts open to inspection the me chani sm i s readil y graspe d

,

by the l earner The thermometers Should be turne d so a s to b e

.

read from a s ingl e O bservation poi nt .

I f ordinary pres su re redu cers instead O f automatic pre ssu re

,

regulators are u sed to equal i z e the pre ssu re on the hot and
,

col d water su pply the y shoul d be SO place d as to be readil y

,

accessibl e as the y will need rea dj u stment from ti me to ti me in

case of large change s of pre ssure i n the m ai n su ppl y Le t i t
.

be remembered that cons ta ncy a nd equa l i ty of p r essu r e in the

hot and col d water suppl y i s the most important requ i site to
the sati sfactory O pe rati on of any form O f h ydrothe rapy con
troller.
51 2 IN D E X
s a li n e ,44 3
S ha l l o w 264 , , 440
s ho w e r , se e Sp ray s
Sitz 434 ,

s un i n a n e m i a 268
, ,

i n n e ura st he n i a 2 7 2 ,

t ub 43 7,

T ur i s h 449 k .

v a p o r 448 ,

Bat h t ub s 500 ,

Be d b at h 1 81 1 82 , ,

Bi e r s hy p e r e m i a , 2 2 3
’

Bi li a ry c o l i c 324 ,

i n fia m m a t i o n s 2 5 2
‘
'

Bi l i o u s n e ss 3 64
'

Bl a n e t p a c k s 45 4
k
Bl o o d e ff e c t s o n c o m p o si t i o n o f
,

1 00
re a c t i o n o f 1 08 ,

v i s c o s ity o f 1 05 ,

Bl o o d p o i s o n i n g 2 30 ,

Bl o o d p r e s sur e 47 , 7 9 89 , ,

e ff e c t s o f he ar t b e a t o n , 89

c fi e c t s o f v o l um e o f fl ui d o n ,

89 9 1 ,

e ff e c t s o f v a s c ul a r c a l i b r e a n d
“

ti o n o n 95
ac ,

Br i g ht s d i se a se 35 1
’
. n ,

l a w s o f e fi e c t s on, 97
Bl o o d v e s se l s 4 1 ,

a c t i o n o f 46 95 2 86 381 , , , ,

c al i b r e o f 95 , 381 ,

c a p il l ar y l oo p s i n sk i n 41 ,

eF fe c t s o f he a t a n d c o l d o n 49 ,

p u m p in g a ct io n o f 381 ,

i n m a l ar i a 20 1 , re fl ex e ff e c s o n , t
r e a ct io n i n , 49 k
C l ar s c o l um n 66
’
, ,

R o i l s 230 , C l ay a n d g l y c er i n e
Br ig ht s di s ea se 3 5 0
’

, C oal t ar p r o du c t s x
.

a c ut e 35 4 . C o ff e e a c a u s e o f f e v e r
, ,

c hr o n i c 3 56 , ef f e c t s o n p ur i n s 360 .

l r n n c hi t i s a c ut e 3 33 , , C o i l c o l d w at e r 4 1 1
, ,

c hr o n i c , 33 5 i n t y p h o i d 1 85 ,

r o n c h o p ne um o n i a ho t w a t er 40 7
1
. 2 42 493 , , ,

i n m e as l e s 20 6 , L eiter 4 1 2 ,

Br ui s e s 3 26 , C o l d ai r i n p n e u m o ni a
, ,

Bur n s 3 2 5 , o n b l o o d p r e s sur e 99 ,

C o l d e ff e c t s o n
,

a n t ib o d i e s
'

C a fi e i n s e e c o ff e e , 1 10 ,

C a l o ri e 20 , a m m o nia 115 ,

C a l o r i m e t e r s 1 45 b l o o d p r e s su r e 5 0 , ,

C a rb o li c aci d v a g i na l irr i g a b l oo d v e s s e l s 50 , ,

t i o n 489 , c a r b on di o x i d e
C arb o n d i o x i d e e ff e c t s o n b l oo d , 1 28
v e sse l s 5 1 ,
 INDEX

c hl o ri d e s 1 20 , C o n s ti p at i o n 298 4 7 5 492 , , ,

c o m p o si t i o n o f b l o o d 1 00 , C o n t i nu o u s fl o w i n g b ath 30 1 , ,

e x t r ac t i v e s 1 18 , 3 94 438 ,

fe v e r 1 7 1 , C o nt r ol l e r fo r s p r ay s a nd

g l y c o g e n c o n t e n t o f m a n 280 , d o u c h e s 50 3 ,

he at e l i m i n a t i o n 1 4 7 1 5 1 , , C o n v e c t i o n he a t l o s s b y 1 4 1
, ,

h e at p r o duc t i o n 1 47 1 50 , , C o r y z a a c ut e 333
, ,

m u sc u l ar c a p a c i t y 1 30 ,
c hr o n i c , 4 92

n e r v o u s sy st e m i n t y p ho i d 1 87 , C o ug h, 333
n i tro g e n o u s m e t a b o l i s m 1 1 1 ,
i n p n e u m o n i a , 2 38
o x y g e n a b s or p t i o n 1 2 8 , C ra v at i c e , 4 1 0
,

p e r s p i ra t i o n 57 , C r e ol i n v ag i na l i rr i g a ti on 489
, ,

p ho s p hori c a c i d 1 1 9 , C ri l e , i n v e st i g at i o n s o f,
p ur i n , 1 1 6 C r o u p 33 3
,

re d c e l l s, 1 01 C y st it i s 2 5 7 493
, ,

re sp irat ory q uo i e n t t , 1 28, 2 80

sk in m u sc l e s 40 ,
D a c hr y o c y s t i t i s , 22 5
sul p hat e s 1 20 ,
D ep l et i on 2 1 2 ,

-
s w e a t g l an d s 5 7 , by si m ul t a n e o u s he at a n d
t o x i n e li m i n a t i o n i n t y p ho i d ,
c o ld 2 1 3 ,

1 90 b y he a t a l on e 2 1 5 ,

ur e a 1 1 5 , b y c o l d al on e , 2 1 5
ur i c a c i d 1 1 6 ,
D e p r e ssa n t e ff e c t s 32 7 2 , ,

w hi t e c e ll s 1 0 1 ,
D e ri v at i o n , 80 2 1 2 ,

Co l d hy dr o st a t i c e ff e c t s o f, 7 8 81
, , a r e a s fo r , 83
i n tri n si c e ff e c t s o f 29 , d e fi n i t i o n o f, 2 1 2
l o c a l a p p l i c a t i o n s o f 39 7 409 , ,
D e r m a t o m e s o f H e a d 65 ,

r e a c t i o n t o 30 ,
D e r m o g r a p hi sm , 3 7
r e fl e x e ff e c t s o f 7 3 ,
D i ab e t e s 2 78 ,

C o l d b l o od e d a n i m a l s 2 8
-

,
D i a l y s i s 24 ,

C o l d fr i c t i o n e ff e c t s on v a s o ,
D i a p ho r e t i c e ff e c t s 33 7 ,

m o t o r s 50 ,
D i a p hor e t i c s m e di c i n a l , 35 7 ,

i n f e v e r 1 89 D i e t i n Bri g ht s di s e a s e 35 1
’

, , ,

i n he a r t d i s e a s e 2 88 ,
i n d i ab e t e s, 2 7 9
i n s ho c 383 k , i n ur e mi a a nd e c l a m p si a 36 1 ,

C o l d p l un g e 2 64 ,
l ow p r o t e i d , m e t ab o l i s m i n
C o l d t r e a t m e n t s se e d i st i n c t i v e ,
1 22
w o rd i n e ac h m eat
C o l d s 3 33 , e ff e c t o n e r d u r a n c e 1 37 ,

C o li c 32 3 . e ff e c t o n l i v e r 35 9 ,

b i l i a r y 32 4 p u r i n fr e e i n g o u t 344
-

, ,

i n t e st i n a l 324 ,
v e g e t a b l e i n g ou t 3 4 5 ,

r e n a L 3 24 D i g i t al i s i n f e v e r s 1 1 8
, ,

C o lit i s m uc o u s 2 5 6 493
, , ,
i n surg i c a l s ho c k 3 86 ,

C o ll a p s e 37 6 ,
D i ur e si s e ff e c t s o f
,

C o l o c y s t e r 480 ,
c o l d b at h o n , 1 90

C o m p r e s se s 404 405 409 4 1 2 , , ,

r e fr i g e r a n t s o n 1 70 ,

c o l d i n t y p ho i d 1 84 ,
sw e at i n g o n 3 38 ,

he at i n g 3 9 7 4 1 2 , ,
D i ur e t i c e ff e c t s 33 9 .

ho t g a uz e 4 04 ,
D o u c he s 46 7 4 7 1 , 507
, ,

jo i n t 4 1 6 ,
c o l d a s a t onic 263 ,

m e di c at e d 4 1 7 ,
v a g i n a l se e v ag i n al irri g at i o n
,

r e v ul s i v e D o v e r s p o w d e r i n fe v e r 1 70
’
405 , , ,

th r o at 4 1 6 ,
D ri p p i n g s he e t r ub 2 63 42 1 , ,

Co njun c t i v i t i s 225 ,
D r u g ha b i t s 394 ,

33
51 4 INDEX

D r y e r fo r t r e a t m e nt ro o m s ,
502 f t i d a 484
a sa o e ,

D uo d e n a l u l c e r , 3 1 9 a s tri n g e n t 485 ,
-

D y s m e n o rrh o e a 3 2 3 ,
c o l d i n t y p h o id
, ,
1 85
D y s p e p s i a 27 5 , 3 64, g l y c e r i ne E p s o n sa l t s 485
and ,

g r a d ua t e d 47 8 ,

E c l a m p s i a 3 58 ,
m e d i c a t e d 481 ,

E d e m a a b s o r p t i o n o f 94
. , m o l a s s e s 484 ,

c o m p li c a t i n g h e art d i s e a s e 29 3 , oil ,484

i n Bri g ht s d i s e a s e 3 5 3 o ut fi t fo r 5 02
’

, ,

o f l un g s i n he a rt d i s e a se 2 94 , p l a i n w a t er 4 7 7 ,

E f e c t s a n al g e s i c 304
, , q u a s s i a 486 ,

a nt i p hl o g i s t i c 2 1 2 . q u i n i n , 486
a n t i p y r e t i c , 1 60 s al i n e 481 ,

d e p r e s sa n t 32 7 2 , , s o a p su d s -
483 ,

d e ri v at i v e 80 2 1 2 , , st ar c h 485 ,

d i a p ho r e t i c 33 7 ,
E p i st ax i s, 3 7 0
d i ur e t i c , 3 39 E r e c t or e s p il o r u m , 40
d o ub l e , 88 E rg o g r a p h e x p e r i m e n t s ,
e m m e n a g o g i c , 2 97 E r y si p e l a s 2 2 7 ,

e x c it a n t 2 95 ,
E t he r m e t ho d o f g i v i n g , 3 75
,

ex p e c t o r a n t 33 1 ,
o n i m m u n i ty 39 1 ,

he m o st a t i c , 3 7 0 E x e r c i se , e ffe c t o n l y m p h m ov e
hy dr o st at i c 7 8 ,
m e nt 5 3 ,

i ntr i n s i c 29 , e ff e c t o n r e a c t i o n 35 ,

m e t ab o l i c 1 1 1 , 1 2 5 2 7 8 3 3 7
, , , , i n di ab e t e s 2 80 ,

34 1 E x p e c t ora n t eff e c t s, 3 3 1
o x y t o c i c , 29 7 E v a p o ra t i o n , e ff e c t o n r e a c ti o n ,
p e p t o g e n i c 363 , 36
p r i m a ry , 3 1 he at l o ss b y 1 42 ,

p r i n c i p l e s o f, 2 7
re a c t i o nary, 30 F a r a di c t ub b a th , 44 1
re fl e x 62 , F a tig ue po i so n s , 1 35
of c ol d 7 3 ,
F e v er 1 , 60
o f h e at 7 6 , c a u se s o f, 1 61
r e t r o st a t i c 80 , c i r c ul a o t ry fa i l ur e
i n 1 65 ,

s e c o n d ary 31 , he at m e c ha n i s m i n 1 7 4 ,

s e da t i v e 7 2 300
, , hy d r o th e ra p y i n 1 6 3 1 7 0 , ,

st i m u l a n t 7 2 260 2 95 , , . m a n ife s t a t i o n s o f 1 62 ,

t o n i c 32 260
, , m e d i c i n al a n t i p y r e t i c s i n 1 68 ,

v a s c u l a r 49 , p r i n c i p a l s o f tr e a t m e nt 1 62 ,

E ff e r v e s c e n t b at h s e e N a uh e i m , r he um at i c 247 ,

b at h s c a r l e t , 206
E g g s i n a n e m i a 2 65 , t re at m e nt o f 1 7 9 ,

E l a st i c t i s su e o f s i n 40
'

. t y p ho i d 1 7 9 ,

E l e c t r i c l i g ht b a t h 45 0 . v a r ia t i o n s t hat p ro du c e 1 7 5 ,

E l e c tr i c l i g ht c a b i n e t s 50 1 , F l e x n e r s s e ru m 2 5 1
’
.

E l e c t r i c t u b b a t hs 440 F l ux i o n 2 1 6 222
—
E l e c tr o t he r m al b a th s 440
.

,
,

d e fi n it i o n o f 2 1 2
,

k
,

p a c s 4 60 . F o m e n t a t i o n s 400 ,

E m m e na g o g i c e ff e c t s 29 7 . F o m e nt a t i o n t a n 4 98 k ,

l i n d o c a r d i t i s i n s c ar l e t f e v e r, . F o o t b ath s 4 3 1 .

209 F o o t t ub s 5 00 ,

i n r he u m at i c f e v e r 2 49 494 . . F r a c t ur e s 32 6 .

E nd o m e t r t i s 2 5 4 . F r ic t i o n 425 .

l n e m a ta 3 98 4 7 6 c o l d m i tt e n
i

. . 262 4 1 8 ,
51 6 INDEX

t ra l 2 1 3
c o l la e ,

p as si v e 50 95 2 1 9 22 3 , , , , K eratit i s, 2 2 5
H y p e r th y r o i d i sm s e e g oi tr e , K id n e y s i n t y p h o i d , 1 89, 1 9 1
H y p e rt o n i c s ol ut i o n s 92 483 , ,

I l y p o c hl o r hy d r i a , 3 63 , 47 4 , 494 L a c t i c a c i d a s fa t i g u e p o i s o n , 1 3 5
H y p o d e r m o c l y s i s 95 , L a t e nt he a t , 2 1
H y st e r i a 2 7 4 , L a w , Be rt ho l l e t s 346
’

D a s t r e M orat, 82-

I c e b ag 4 1 1 H i l t o n s, 6 5
’
,

e ff e c t o f o v e r h e art 67 Mul l e r s 9 7 ’
,

i n h e a r t d i s e a se , 2 85 o f a n t a g o n i s m 82 ,

i n g o itr e 3 1 5 , o f b a l an c e b e t w e e n r e fl ex a n d
w i t h ho t p a c s 459 k , hy dr o st at i c e ff e c t s, 87
I c e c ap s e e i c e b ag
, L e g b ath 432
I c e c r a v at 4 1 0
,

,
p a c k , 45 9
I c e p ac , 41 0 k L e g t ub s, 500
i n p n e u m o n ia , 237 L e u c o c yt e s e ff e c t s o f a l co h o l
,

I c e r u b 422 , on 1 68, 39 1 ,

i n t y p h o i d , 1 84 a n e st he ti c s o n , 3 9 1
I c e w at e r c o il , 22 6 c o a l t a r p r o d u c t s o n , 1 68
I c t e ru s 432
,

, cold on 1 00 1 89 , ,

I m m uni ty 1 09 , 1 64 , 1 68, 1 97 , 389 , , h e at o n 1 02 200 , ,

39 1 q ui ni n o n , 1 69 200 ,

l n e b ri e ty , 2 7 7 , 396 i n fe v e r s 1 63 , 1 64 ,

I n f e c t i o n s , p o st an e sth e ti c, 389 in i n fl am m a t i ons, 2 1 9

s e e a l s o fe v e r s , i n fl a m m a t i o n s , i n m a l ari a 1 98 ,

p ue p e r ra l , L e u c o c yt o si s, fro m c ol d, 1 00
I n fl a m m a t i o n s, 21 2 i n m a l a r i a, 1 98
b i li a r y , 2 52 L e u c o m a i n e s, a c au se o f f ev e r,
d e e p s e at e d 3 1 8
-

, 1 60
de fi n e d 2 1 8 , L e u c o p e n i a, i n m a l ari a, 200
o f e y e 22 5 , i n t y p h oi d, 1 89
p e l v i c 2 54 , L i g ht 26
,

p r i n c i p l e s o f tr e at m e n t, 2 1 9 L i t hi um i n g o ut , 345 , 348
p ath o g e n es i s o f, 2 1 8 L i v e r , c o n g e sti o n o f 29 3
s up e r fi c i al , 3 1 9
,

e ff e c t s o f m e a t d i e t o n 3 59 ,

tr eat m e nt o f, 225 L o c o m o t or a t axi a 3 1 2 , 4 7 5

I n fl u e n z a 209, 492
,

, L u m b a g o , 32 2 , 47 4, 494, s e e a l so
I n sa n i ty 394 r heum ati sm
“

I n t e s t i n a l c o li c 32 4 , L y m p ha ti c s 4 1
s t i m u l a n t s 2 98
,

.
a b so r p t i o n b y , 4 1 53
I n s om n i a 2 7 7 , 3 06, 494
,

,
e ff e c t s o f st i m ul at i o n o n , 5 3
I n t e r n a l hy dro t he r a p y , 24 l y m p hat i c he art s, 43
I n tr i n si c e ff e c t s o f c ol d , 29 m o v e m e n t s o f, 44
o f h e at 3 0 ,
q uan t i t v o f fl ui d , 5 3
t i m e fa c t or i n, 32 v al v e s o f, 43
I r it i s 2 2 5
.
L y sol v a g i nal irri g ati on, 489
I ro n i n a n e m i a , 265
o r g an i c , 266 Ma ni a 394
l s o t o n i c so l uti on s, 93
,

Ma l ari a 1 94 47 5 ,
I v y p oi s o ni n g b y , 2 32
,

, Mar ag l i ano exp eri m e nt s o f 20 1 , ,

Ma s sa g e e ff e c t s on b l o od c e ll s ,

i c t e r us
,

J a un d i c e , se e 1 03
t rr hal 252
ca a , e ff e c s t on l y m p hat i c s 5 3 ,

J o i nt c o m p r e s s 4 1 6 , in an e m a, i 26 7
 i n d i ab e t e s, 280 v i sc e ra l 7 2 ,

i n he art d i s e a s e , 2 87 N e r v o u s sy s t e m a ft e r col d b at h,

i n r he um at i s m 348 , 1 87
Ma st o i di t i s 2 1 4 22 8, 460 493
, , , N e ur a l g i a, 2 1 5 32 0 ,

Me as l e s 2 04
, i n fl a m m at ory , 32 1 ’

M e at di e t , e ff e c t o n l i v e r, 359 t ox i c 320 ,

M e c ha ni c al st i m u l i, 23 N e ur ast he n i a , 2 69
e ff e c t s , sp l a n c hn i c , 2 7 3 494 ,

o n b l o o d p r e s sur e , 98 N e u t ra l b at h 437 ,

o n c a rb o n d i o x i d e a n d o x y d o u c he , 47 3
g e n , 1 29 e l e c tr i c t ub b a t h 440 ,

o n m u sc ul a r c ap a c i ty , 1 33 p a c k , 46 3
v ib r at i o n, i n he art d i se a s e , 288 s ho w er , 46 9
M e di c in al an t i p y re t i c s , s i t z b ath 4 3 5 ,

Me n i ng i t i s, 2 1 4 2 5 1 460 , ,
t e m p e r at ur e 38 ,

M e n stru at i o n i n ty p ho i d, 1 92 N i tr o g e n e c o n o m y 1 1 3 ,

M e n t ho l r ub , 425 N i tr o g e n o u s m e t ab ol i s m 1 1 1 ,

M er c ury , s p e c i fi c heat o f, 20 N i tr o g l y c e ri n i n surg i c a l sho c k , .

b i c hl or id e v a g i n al i r ri g at i on , 386
488
M e t ab o li c d i s ea s e s 34 1 , O b e s i ty 3 4 1 ,

M e t ab o li sm c arb o n a c e o us, 1 25
,
wi ht fatty he a rt 29 5 ,

n itr o g e n o u s 1 1 1 ,
rhe u m at i s m w i t h 347 ,

Mi g r ai n e 328 , O e r t e l m e t ho d 2 9 1 ,

M i n e ra l w a t e r s 2 5 ,
O il en em a, 484
a b sor p ti o n o f 5 9 ,
r ub , 42 8
i n r h e um a ti s m , 348 O p ht hal m i a 22 5 .

Mitt e n fri c t i o n se e fri c t i on ,

O s m o s i s 2 4 92 , ,

M orp hi n e ff e c t o n p hag o c yt e s
, ,
O st e o m y e l i t i s 2 1 4 2 1 7 , 3 1 8 , ,

390 O t i t i s m e di a 22 7 ,

Mo r p hi n ha b it 396 ,
O v ar i t i s 2 54 ,

Mort a l i ty i n ty p hoi d 1 92
, ,
O x y g e n e ff e c t s o f he a t a n d
, c old
M u c o u s c o l i t i s 2 56 ,
on 1 2 8 1 90 , ,

Mu s cu l ar t i s su e o f s k i n , 40 O xy g e n b at h 30 1 30 7 446 , . ,

c a p a c i ty 13 ,
O x yt o c i c e ff e c t s 2 9 7 ,

My a l g i a 322
,
O z o n e o n g l y c o sur i a, 281
,

My e l i t i s 3 1 1
,

M y o c a r di t i s 247 ,
k
P a c s 398 454 , ,

di p hth e ri ti c 1 66 ,
b l a n k e t 45 4 ,

c he s t 4 1 3

N a u he i m b at h 5 1 44 3 , ,
e l e c tr o t he r m a l 46 0 -

e ff e c t o n b l o o d p r e ssur e , 99 e v a p o ra t i n g 462 ,

i n h e a r t di s e a s e 288 ,
ha l f p a c k 46 5
-

N a um a n n e x p e r i m e nt s o f, 63
,
he a t i n g 464 s e e a l so , , com

N e p hr i t i s 3 5 0, p r e ss e s
ac u t e, 35 4 p e l i c , 46 5 v
c hr o n i c 3 5 6 ,
t r un k , 46 5
i n s c a r l e t fe v e r 208 ,
hi p l e g 4 58
and ,

i n ty p ho i d 1 9 1 ,
ho t a n d he a t i n g trun 466 k ,

sw e a t g l a n d s i n 5 7 ,
ho t p e l v i c 4 58 ,

N e r v e s o f sk i n 6 1 ,
ho t tru n 45 7 k ,

s e c r e t o ry 72 ,
ho t w i t h i c e b a g s 45 9
, ,

t e m p e r at ur e 6 1 ,
i ce 41 0
.

v a so m o t or di stri b uti on o f, 4 1
, ,
l eg 45 9
,

44 n e u t r a l 46 3 .
51 8 IN D E X
re v u l si v e p e l v i c ,
45 8 t i 342
sy s e m c ,
r e v u l si v e trunk , 457 P o ul t i c e s 39 7 4 1 7
, ,

s w ea ti ng464 ,
P r e sc i p t i o n w r i t i n g 490
r ,

w e t s he e t 46 1 ,
Pr o p e rt i e s o f w at er 1 7 ,

i n ty p hoi d 1 84 ,
P ro c t o c l y si s M urp h y m e t ho d
, ,

P a i l p our 2 63 , 4 7 5 , 482
P ai n r e li e f o f 304 3 1 8
, , , ab s or p t i o n o f fl ui d, 93
i n p n e um o ni a 2 38 , i n su r g i c a l c o l l a p s e 383 ,

P a l p i t at i o n , i n h eart di s e a s e 29 5 ,
P r o st a t i c hy p e rt ro p hy , 493
P a n c r e a tit i s sub a c ut e 2 5 3 , ,
P r o st at i t i s 25 8 4 7 5 , ,

P a r a e st he si a s r e l i e f o f 305 , , P r o x i m a l ap p l i c at i o n 7 4 , 4 1 0 ,

P a r al y si s ag it a n s 3 1 0 . P sy chi c att i t u d e e ff e c t o n r e a c ,

s p a st i c s p i n a l 3 1 1 47 5 , , t i o n 36 ,

P as si v e hy p e r e m i a , 50 95 2 1 9 , , , P u e r p er al i nfe c t i o n 2 1 4 , ,

22 3 P ul m o n ary c o n g e s t i o n 2 1 4 333
'

, ,

P at ho g e n e si s o f fe v e r 1 60 , , he m orr ha g e 3 7 1 ,

o f i n fl amm at i o n 1 74 2 1 8 , , P uri n d i a th e si s 343

, ,

P e l v i c c e l l ul i t i s 2 54
, , a c au s e o f f e v e r 1 6 1 ,

i n fla m m a t i o n s 2 54 , a s fa t i g u e p o i s o n , 1 3 6, 1 38

p a c k he ati ng , 4 65
, e ff e c t s o f c o ff e e o n 3 60 ,

ho t 458 , e ff e c t o f c o l d o n 1 1 6 ,

r e v u l si v e 458 ,
i n g o ut 343 ,

p e r it o n it i s 2 5 4 , P y r e x i a, s e e f e v e r
P e p t o g e ni c e ff e c t s 363 ,

P e rfo r ati o n i n t y p hoi d 1 9 1 , Q ua s s i a , e n e m a, 486

P e ri c arditi s 246 , Q ui ni n , e n e m a, 486
P e r i p h e ral h e ar t 45 5 2 286 , , , i n f e v e r s , 1 69
m e a sur e s w hi c h st i m ul at e 286 , i n m a l ari a 1 94, 1 99 ,

P e rit o niti s 2 1 4, 460 . i n p n e um o n i a 239 ,

p e l v i c 2 54 , p r o p hy l a c t i c u s e o f 1 95 , 1 97 ,

P ha g o c yt o si s i n f e v er s 1 63 1 68 , , , p r ot o z o an i m m unity t o, 1 97
i n m al ar i a 1 98 ,

e ff e c t s o f a n e st he si a o n 389 , , R ad i an t he at 408 ,

39 1 R a di at i on he at l o ss b y 1 4 1
, ,

c old o n 1 09 , R e a c t i o n 30 ,

d rug s o n 1 68 , ab i l i ty , t e s t o f 3 7 ,

m o r p hi n o n 390 . c ir c u l at o r y 33 49 , ,

P ha ry n g it i s 229 493 , , c o n di t i o n s i n fl u e n c i n g 3 5 ,

P ha s e s o f r e a ct i o n 3 3 , de e p re fl ex 7 3 7 6 , ,

P he n a c e t i n i n f e v er s 1 68 .
, i n c om p l et e 34 ,

P hl e b i t i s 2 56 , i n b l o o d v e s s e l s 49 ,

P ho s p hori c a c i d , e ff e c t o f c ol d i n m al ari a 2 04 ,

on 1 19 , n e r v ous 33 ,

t s i o l o g i c a g e n t s, 2 7 o f s h ort c ol d 31 ,

e ffe c t s p ri n c i p l e s o f 2 7
. , p ha s e s o f 33 ,

st i m u l a n t s 2 60 . rat i o n al e o f 3 1 ,

t h e r a p y r e al m o f 1 5 5 , , re p e at ed 34
P il o c a r p i n i n f e v e r s 1 7 0 , . sup p r e s se d 34 ,

P l e uri sy 2 1 5 244 47 5 492, , , , t he r m i c 33 ,

o m p li c at i n g ty p ho i d
c
1 91 , t i m e fa c t or in 32 ,

P l u n g e h c o l d 2 64 , t o he a t 32 ,

P n e u m o n i a 2 32 460 47 5 . , , t y p e s a n d d e g r e e s o f 34 ,

c o m p l i c a ti n g t y p ho id 1 90 . R e c t al i nje c ti o n s e e e n e m ata , .

k
P o i i l o t he r m i c a ni m a l s 28 . i r r i g ati on 4 7 9
P o i s o n i n g i v y 2 32 , , t e n e sm us 322 ,
5 20
Su n b a ths , i n a n e m i a, 2 68
i n ne ur a st he n i a, 2 7 2
S un str o k e , 2 82
Sur g e r y , aft e r tr e a t m e n t , 389
IN D E X
T y m p a n i t e s, i n t y p hoi d, 1 92
T y p ho id f e v e r, 1 7 9
ho t tr e a t m e n t i n, 1 86
-
c o l d t r e a t m e n t o f, 1 80

hy dr ot he r a p y i n, 3 7 3
i m m e d i a t e c ar e , 3 7 5 U l c e r d u o d e n al , 3 1 9
,

p r e p ar at ory tr e a t m e n t , 37 3 g a stri c , 3 1 9
r e l at i o n t o p hy si o l og i c th e r r e ct al 31 9 ,

ap y , 1 56 trop hi c 494 ,

Sur g i c al s ho c k , 3 7 6 vari c o se 47 4 494 , ,

c o ntr ib ut i n g c au se s 37 7 , U r e a e ff e c t o f c ol d o n 1 1 5
, ,

drug s i n 385 , i n u r e m i a 3 59 ,

hy dr ot he rap y i n , 383 U r e m i a, 358, 493

tr e at m e n t o f 382 , a c ut e 36 1
,

Sw e at g l an ds 54 , U r e t hr i t i s s p e c i fi c 2 5 8 4 7 5
, , ,

i n n e p h r i t i s, 5 7 U ri c a c i d e ff e c t o f c aff e i n
, o n,

p e r s p i r a t ory i n fl u e n c e s, 57 360
v i c a r i o u s fu n c t i o n s , 5 6 e ff e c t o f c o l d o n ,

Sw e di sh s ham p o o 4 52 , e ff e c t o f h e at o n 1 2 1 ,

e n dog e n o u s i n g out 3 58 , ,

T a l c u m r ub 430 , form a t i on and d e struc t i o n o f,

T e c hn i q u e o f h y dr o t he rap y 397 , 344
c l a s si fi c a t i o n , 397

g l o s sa r y o f t e r m s , 398 V a g i n al irr i g a ti o n 398 486 , ,

T e m p e ra t ur e , c om m on nam e s V ag i n it i s 2 58 ,

o f, 38 V al v ul ar he art di se as e 2 83 ,

n erv e s of 6 1 , V ap o r b a t h 448 ,

T e n e s m u s 322 . V ari c o se ul c er , 47 4
T he ra p e ut i c s 1 55 , V a s o m o t o r c e nt er 62 66 , ,

T he r a p y , b a si c p ri n c i p l e s o f, 1 5 9 p ar a l y si s o f i n f e v e r s 1 65 , ,

p hy si ol o g i c , r e al m o f 1 5 5 , i n sh o c k 37 9 ,

V a so m o t o r n er v e s 4 1 44 62
'

p r in c i p l e s o f 2 7 . , , ,

T he r m i c st i m ul i , 22 V a s om o t o r s e ff e c t on b l o od
,

T he r m o m e t e r s, 1 9 v e sse l s 44 62 , ,

T he r m oth erap y , 1 7 , 27 fai l u r e i n fe v e r s 1 65 ,

T hr oa t c o m p r e s s h e ati n g , 4 1 6 , i n S ho c k 37 9 ,

T ob ac c o b l i n dn e s s 22 7 , i n ty p h o i d 1 88 ,

T o n i c e ffe c t s 32 , 2 60 , V a s o m o t o r t o n i c s i n f e v e r s 1 67 , ,

f r i c t i o n s 39 7 4 1 8 , , i n he a r t d i s e a se 2 86 ,

s e d ati v e s 303 , i n sur g ica l sh o c k 383 ,

T o n i c s hy d r i a t i c v aso m ot or, 2 88
, V e n o p r e ss or m e ch an i sm 380
-

, ,

T o n si l l i t i s 2 29 , 381
i n s c arl e t fe v e r 20 , V e s i c al st i m ul a n t s 297 ,

T o n u s w a v e s 48 , t e n e sm u s 322
T o w e l r ub se e rub s . V i b rat i o n i n h eart d i s ea se , 288
,

T ra c o m a 22 6 . V i n aj an d Ma g g i o ri exp e r im e n t s ,

T r aub e H er i ng wa v e s 46 , 37 9
-

, o f 1 30 ,

T r aum a r e l at i o n t o sho c k 37 7 ,
, , V i n e g a r a n d s a l t r ub 424 ,

388 V i n e g ar v a g i nal irri g at io n 489 .

T r un k p a c k , he ati n g , 464 V i r a t r um v ir i d e , i n fe v e r s 1 68 ,

ho t 4 57
, V o m i t i n g 494 ,

T u b e r c u l o si s p ul m on ary 2 7 5
W a rm —
, ,

T urk i s h b a t h 449 , b l o o d e d a n i m a l s 28 .

s ha m p o o W a t e r e x p a n si o n o f 1 8
—
45 3 , , .

T u r p e n t i n e e n e m a 484 , mi n e r al , 25 . 345 , 348

 IN D E X
l
p e r t i e s o f, 1 7 ty p hoi d 1 84
in ,
~
b o tt l e s, ho t , 407
r W e t sh e e t rub s 263 42 1 , , ,

r d ri n k i n g , c o l d , e f
f e c t on rub s
>

b l o o d p r e ssur e , 98 W hit e c e ll s se e l euco cy t e s

,

>
c t o n u r e a e x c r et i o n , 1 2 1 W in . e rni t z 40 7 coil ,
dy sp e p si a 366 , i n dy s p e p si a 365 ,

pn e u m o n i a 239 , i n ty p hoi d 1 85 ,

sur g e ry , 3 7 5 , 39 1 W i n t e rnit z p ac k 407 , , 466

ha nd r ub , 262 , 420, s e e r ub s i n dy sp e p si a 365 ,

s he e t p a c 46 1 , s e e p a c k s
k ,
W i t c hha z e l r ub 42 5 ,