HX00021407 Digitized by the Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/hydrotherapyworOOhins HYDROTHERAPY A WORK ON HYDROTHERAPY IN GENERAL ITS APPLICATION TO SPECIAL AFFECTIONS THE TECHNIC OR PROCESSES EMPLOYED AND THE USE OF WATERS INTERNALLY BY GUY HINSDALE, A. M., M. D. Secretary of The American Climatological Association ; Lecturer on Climatology in the !Medico-Chirurgical College of Philadelphia ; Fellow of the College of Physicians, Philadelphia ; Corresponding Fellow of the Royal Society of Medicine of Great Britain, Balneological and Climatological Section, and of the International Antituber- culosis Association ; Ex-President of the Pennsylvania Society for the Preventon of Tu- berculosis ; Member of the American Neurological Association and of the American Academy of Medicine ILLUSTRATED W PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1910 Copyright, 1910, by W. B. Saunders Company PRINTED IN AMERICA PRESS OF W. B. SAUNDERS COMPANY PHILADELPHIA TO 2)r. Milliam ©sler, REGIUS PROFESSOR OF MEDICINE AND STUDENT OF CHRIST CHURCH, OXFORD, AS A TOKEN OF THE AUTHOR'S REGARD PREFACE No modern text-book on a medical subject can appear as the complete product of a single mind. In the evolution of a medical work, especialty one on hydrotherapy, we have an art and a science whose beginnings stretch back for two thousand years. The genealogy of such a work reaches through ages of empiricism to the great minds which gave medicine its earlier start — ^to Hippocrates, Galen, Celsus, Aretseus, Musa, Paulus iEgineta, and Oribasius. The Roman baths were one of the great features of that great empire, and were established in its most distant possessions. Only last year, a. d. 1909, in the ancient town of Bath, in England, there was a restoration of the Roman bath as it existed in the time of the Caesars. The baths of Rome became so sumptuous, and entailed such extrav- agance, that they eventually lost their h^'gienic features, and contributed to the decay of the Roman character and bodily vigor, so that in the dark ages that followed the nobler uses of water were neglected. Only within the last two hundred years has light begim to reappear, and only within the last fifty years has a scientific system of hydrotherapy been evolved. As the science exists to-day, supplemented by the use of modern apparatus, it is a powerful aid in therapeutics, rapidly growing in popularity as the knowledge of its technic becomes more widely diffused. It would be an almost hopeless task to give each writer credit for the introduction or description of particular hydrotherapeutic methods. References have been made in places throughout this work so that further studies may be made. For a bibliography one is referred to the first and second series of the Index Catalogue of the Surgeon-General's Library at Washington. A glance at this remarkable list shows 8 PREFACE at once the great hokl that hydrotherapy has in medical practice in Germany, Austria, and France. It is to be hoped that in America the growing practice of hydrotherapy and balneology may be guided along rational lines, and we believe that the ])ro- fession and the public will eventually award it first place in physiologic therapeutics. The medical profession in the United States owes a debt to Dr. Simon Baruch, of Columbia University, for advancing greatly the practice and teaching of hydrotherapy, and the author is under personal obligations to him for many sug- gestions. While the author is a firm believer in using physiologic therapeutics wherever possible, he by no means wishes to exclude the use of drugs. Rational therapeutics calls for their use, but reference to them is necessarily omitted here. It is also true that many diseases are amenable to hydrotherapeutic treat- ment whose names are not mentioned, but the underlying principles are stated, and it remains for the practitioner to apply them, along with other remedies, for the improvement of the circulation, for enhancing the tone of the skin, for an effect upon the nervous system, or in any other way that moisture or heat or cold may be deemed useful. In treating patients at spas, and especially those who have been sent away in the hope of completing a cure begun at home, great caution should be exercised in order to preserve harmony between the previous medical attendant and the one who assumes temporary charge of the case. Patients generally are willing and expect to relinquish much of their previous internal medica- tion. This, however, is by no means always necessary. In- deed, the hydrotherapeutic measures adopted are often aided by medication, and it requires a nice estimate of their value in order that their aid should not be lost. This is most true in all specific cases, and here medication can be pushed to the point of greatest efficacy. Many of the ordinary drugs, however, which patients bring with them can be dispensed with. A favorable mental attitude is a great help in all treatment; PREFACE 9 patients who have traveled far for their cure are thereby relieved of most of the harassing features of their previous surroundings; they are impressionable and readily give themselves up to a well-chosen regime. As Dr. Luke says, the visitor in search of health cannot do better than lay to heart the old Roman inscription on the baths of Caracalla: " Curae vacuus hunc adeas locum, Ut morborum vacuus abire queas; Hie enim non curatur qui curat." " Light of heart approach the shrine of health, So shalt thou leave with body freed from pain; For here's no cure for him who's full of care." Guy Hinsdale. Hot Springs, Virginia, July, 1910. Bath. The Roman baths, CONTENTS GENERAL HYDROTHERAPY PAGE The Rationale of Hydrotherapy 17 The Physiologic Action of Saline Baths Compared with Fresh- water Baths 30 The Influence op Baths on Metabolism 33 The Effect of Cold Baths on Metabolism 34 Quantitative Estimation of the Amount of the Heat Loss. Heat Regulation 41 The Effect of Hot Baths on Metabolism ; •. . . . 45 Tepid or Indifferent Baths 48 The Effects op Baths on Blood-pressure 48 The Sphygmomanometer 49 Counterindications to Baths 53 Effects of the Hot-air Bath 54 The Effect of Baths on the Rate of the Heart 54 The Effect of Baths on the Blood 56 The Effect of Cold and Heat upon Respiration 57 SPECIAL HYDROTHERAPY Typhoid Fever 59 The Brand Treatment 60 Substitutes for the Brand Treatment 71 Measles 79 Scarlet Fever 80 Cholera 87 Cerebrospinal Meningitis 87 Tetanus 89 Insolation; Sunstroke; Heatstroke; Thermic Fever 90 Tuberculosis 93 Pneumonia 100 Asphyxia Neonatorum 108 Acute Bronchitis 108 Acute Congestion of the Lung , 109 Edema of the Lung 110 Influenza; Epidemic Catarrhal Fever 110 11 12 CONTENTS PAGB Asthma 110 Renal Diseases Ill Sweating Ill Chronic Interstitial Nephritir; 114 Toxemia of Pregnancy 117 Urcniia 117 Scarlatinal Xephriti': 118 Diabetes Mellitus 118 Diabetes Insipidus 120 Phosphaturia 120 Rheumatism 120 Chronic Rheumatism 120 Acute Rheumatism 123 Cerebral Form of Rheumati. ra 124 Prophylaxis of Rheumatism 126 Rheumatic Phidocarditis 126 Acute Arthritic Outbreaks 126 GotT (Arthritis Urica) , 127 Gonorrheal Arthritis 130 Arthritis Deforjians 131 Diseases of the Heart 132 Nauheim Baths and Schott Treatment 134 Pericarditis, Endocarditis, and Myocarditis 146 Arteriosclerosis 147 Toxemic Myocarditis 148 Chronic Rheumatic Myositis; Lumbago 148 Alcoholism; Morphinism; Chronic Lead-, Mercury-, and Arsenic- Poisoning, AND Tobacco Habit 149 Digestive Disorders 150 Constipation 151 Gastroptosis 153 Chronic Gastritis and Enteritis 154 Round I'Icer of the Stomach; Hemorrhage 154 Atony and Enteroptosis 156 Ner\'ous Dyspepsia 156 Peristahic Unrest 157 Cholera Infantum 157 Peritonitis and Appendicitis 158 Seasickness • 158 Anemia; Chlorosis; Convalescence from Acute Illness 158 Anemia 158 Chlorosis 160 Vasomotor Spasm and Visceral Anemias 161 Splenic Enlargement 161 Neurasthenia. 162 Sexual Neurasthenia 165 CONTENTS 13 PAGE Spermatorrhea 165 Neuroses of the Bladder 166 Insomnia 166 Insanity 168 Melancholia 172 Excited States 173 Epilepsy 178 Headache 183 The Neuralgias 184 Trifacial and Occipital Neuralgia 184 Sciatica 184 Neuritis 186 Paralysis 187 Local Palsies 187 Paralysis of Adults 187 Locomotor Ataxia 188 Paralysis of Central Origrn 189 Obesity 190 Exophthalmic Goiter 197 Syphilis 197 Skest Diseases 203 Psoriasis 204 Leprosy 206 Eczema 208 Parasitic Skin Diseases . 208 furunculosis and pemphigus 209 Hydrotherapy in Surgical Affections 209 Diseases of the Bones and Joints 211 Sprains 211 Felons, Funmcles, and Phlegmons 214 Surgical Shock 214 Football Injuries 215 Bums and Scalds 215 Erysipelas and Ivy-poisoning 218 Bed-sores 218 Genito-urinary Diseases 219 Cystitis 219 Orchitis, Epididymitis, and Bubo 220 Gynecologic Affections 221 Diseases Amenable to Nauheim Baths 221 Sitz-baths 226 Eye Diseases .227 External Affections 227 Internal Ocular Affections 227 Induced Phenomena During a Course of Hydrotherapy 230 14 CONTENTS TECHNIC OF HYDROTHERAPY PAGE The Effects of External Applications of Heat and Cold 233 Baths 237 The Cooling Wet Sheet Pack 237 The Evaporation Bath 237 The Cold Bath 238 The So-called " Half-bath" of Priessnitz 243 The Spray Bath 244 The Ablution or Wet Mit Friction 246 The Drip Sheet or Sheet Bath 246 Sponging 248 Rubs 249 The Oil Rub 249 The Scotch Rub 250 The Alcoliol Rub . 251 Douches 251 The Needle Douche; the Needle Spray; the Circular Douche 251 The Cold Douche 253 Alternating Hot and Cold Douches 256 The Rain Douche 258 The Fan Douclie 261 Tlie Filiform Douche 262 The Perineal or Ascending Douche 262 The Aix Douche; the Massage Douche 263 The Viciiy Douche 276 The Combined Bath, Douche, and Massage 276 Tlie Percussion Douche 278 The Pail Douche or Pail-pour 278 The Hot Lumbar Douche 280 The Fleury Douche 280 The Control Table 281 Affusions 287 Continuous Baths 287 The Warm Full Bath 287 Hot-water Bathing 291 The Turkish Bath (Diaphoretic) 295 The Russian Bath (Diaphoretic) 301 Vapor or Sweating Bath 301 The Roman Bath 304 The Hot-air Bath and the Electric-light Bath 305 The Foot-bath 308 Medicated or Modified Baths 308 Nauheim Baths; Carbonated Baths; Acid Baths (Kisch); Effer- vescing liATHS 310 Artificial Nauheim Baths 311 The Oxygen Bath 323 Mud Baths and Fango Packs 332 CONTENTS 15 PAGE Mud and Peat Baths 334 Sand Baths 335 The Sitz- or Hip-bath 336 Packs — Cold Wet Packs (Fbuchte Einpackung); Hot Wet Packs; Dry Packs (Trockene Einpackung) 338 The Cold Wet Pack 340 The Hot Wet Pack 341 The Dry Hot Pack 344 Compresses 344 The Cold Compress , 346 Ice Compresses 347 Fomentations or Hot Compresses 347 Hot and Cold to the Spine 354 Salt Rub or Salt Glow 354' The Ice Rub or Ice Ironing 355 Cold Applications Under the Heart 355 Neptune's Girdle 356 Swedish Shampoo 359 Rectal and Colonic Rectal Irrigation 359 Proctoclysis 361 The Vaginal Douche 370 Public Baths 372 Shower-baths 375 Sea-baths 377 Courses of Instruction in Hydrotherapy 383 Accidents in Hydrotherapy 386 CROUNOTHERAPY, CRENOLOGY, OR THE USE OF MINERAL WATERS INTERNALLY Classification of Mineral Waters . . . : 390 Radio-activity of Mineral Waters 390 Internal Use of Water in Health 395 Hot-water Draughts 395 Cold-water Draughts 396 Distilled Water 397 Water Drinking in Disease ; 400 Specific Value of Mineral Water 403 AlkaHne Waters 403 AlkaHne-cakareous or Earthy Mineral Waters 405 Sahne Waters; Muriated Sahne Waters 406 Sea Water 411 Use of Radio-active Waters Internally 412 Bitter or Purgative Waters 413 Sulphur Waters 413 Chalybeate Waters; "Steel Waters" of Europe 415 16 CONTENTS PAGE Specific Value of Mineral Water — Sodic-bromo-iodin Waters 416 Lithia Waters 417 Water as an Emetic 419 PRESCRIPTIONS OF HYDROTHERAPY Abbreviations 421 Prescriptions .^ 421 Requisite Equipment for an Institution 431 APPENDIX Some Truths About Hydrotherapy _ 432 Electric Pad, or Thermophore 448 Electric Thermophore Blanket 449 INDEX 451 HYDROTHERAPY GENERAL HYDROTHERAPY THE RATIONALE OF HYDROTHERAPY The physical and chemic qualities of the water used in hydro- therapy must be understood. So, also, must we understand the anatomy and physiology of the skin, the nervous system, the heart, and circulation; in short, the remarkable impress which water in the various ways in which it is apphed makes upon every function of the body. This agent derives its varied powers from its remarkable flexibility of administration. It is applied as a solid, a liquid, and as a vapor; it is used in its natural state either hot or cold, pure or highly mineralized; free from gas or more or less charged with carbon dioxid or sulphur dioxid; it may be applied in pools, tubs, jets, or sprays, and with or without pres- sure ; in the quiet of the sick room or in the boisterous surf of the ocean. This capacity for infinite gradation, and its almost un- bounded applicability to various pathologic states, justifies the claim, made with growing insistence, that the use of water com- mands the first place in modern therapeutics. A glance at the list of hydrotherapy references in the cata- logue of the Surgeon-General's Library, Washington, reveals a most voluminous literature. There are 32 columns and 640 references to the subject of hydrotherapy. No other single remedial measure can compare with it in its antiquity; no other method of treatment is so extensively employed in the modern world. The time is coming when this, as well as other physical 2 17 18 HYDROTHERAPY measures, will be utilized not alone in hospitals and sanitaria, but will become the common proi)erty of general practitioners. Physicians now realize that by physiologic therapeutics much more can be done than by drugs; patients, also, demand from their medical advisere definite information as to climates, resorts, and the use of mineral springs, so that the broader the knowledge of these subjects by personal experience, the more valuable and more highly appreciated is the advice given. Resorts having a good climate with the additional advantage of hydrotherapy or of mineral baths are numerous in Europe and America. One advantage that hydrotherapy has over balneology, or the use of mineral baths, is that it is possible to install complete hydrotherapeutic apparatus anywhere, i)rovided we have a good water supply and means for heating and cooling the water. On the other hand, mineral springs, as employed in balneology, occur where nature has located them. Fortunately, the location of most of these resorts is very attractive. The most remark- able group of mineral springs in the United States is found in the Yellowstone National Park, a wonderland of beauty and sub- limity. Undoubtedly the time is near when the mineral springs of the National Park will be utilized for balneologic purposes. While many writers draw nice distinctions between hydro- therapy and balneolog}^, the author fails to see any great differ- ence, at least from the clinical standpoint. The two subjects are indissolubly connected; their effects on the human system are governed by the same laws; the results obtained are due much more to the physics of the process than to the chemistry of the medium employed. In hydrotherapeutic applications the chemic analysis of the water, as regards mineral constituents, is a negligible quantity. The water is used as a means for conveying heat to the body or abstracting heat from it; it is the medium by which force or pressure is applied to the various parts of the body ; by which an impress is made upon the circulation or other physiologic pro- cesses concerned in secretion and nutrition. THE RATIONALE OF HYDROTHERAPY 19 So with balneology. From time immemorial the mineral springs have been employed. The fame of Thermopylae (Bspfial TCvXaC), a sulphur spring that has been in use in Greece for two thousand years, of Hieropolis and Philadelphia in Asia Minor, of Helouan in Egypt, Carlsbad, Baden-Baden, Aix-les-bains, Bath, the Aguee Calientes of the Spanish American possessions, the Springs of Mt. Clemens, and the Hot Springs of Virginia, North Carolina, and Arkansas, rests upon something more than the chemic nature of the waters. Two thousand years of implicit faith in laboratory analyses has been challenged in these latter days by the "higher criticism" of the German and Austrian leaders in the field of modern hydrotherapy. Consider for a moment the well-founded reputation of the three great American resorts for the successful treatment of rheumatism, and the similarity of results in this particular affection, and then compare the chemic analyses of the waters, and see the enormous difference between these springs from the standpoint of chemic contents. Boiler Spring. ^^^1|^°^gf.'''''' (Original Spring). Hot Springs, Hot Springs, Mt. Clemens, Virginia. Arkansas. Michigan. SiUca 4.50 2.58 27.60 Potassium chlorid 53 Potassium sulphate 68 Sodium chlorid 58 .27 11,900.00 Sodium sulphate 19 .41 Sodium sulphid 21 Magnesium chlorid , . • • • 648.5 Magnesiumi bromid - • • • 6.37 Magnesium carbonate 2.70 1.13 .70 Magnesium sulphate 6.04 Calcium chlorid • • • • 934.5 Calcium carbonate 18.63 8.32 -98 Calcium sulphate 1.82 .... 100.50 Cu. in. carbon dioxid 24.60 4.71 5.80 Cu. m. hydrogen sulphid .10 11.92 40. Total soUds 43.00 13,653.32 The table shows that there is twenty thousand times as much sodium chlorid in the Mt. Clemens water as there is in the waters of Virginia Hot Springs; the former are heavily charged with hydrogen sulphid, while in the latter the gas is imperceptible, being present in only .1 cu. in. per gallon. The Hot Springs of Arkansas have comparatively little mineral content. 20 HYDROTHERAPY Here, then, we iiavc three mineral springs, widely separated geographicalh', and varying greatly in the conii)osition of the mineral contents, yet all three yielding satisfactory results in a given disease, e. g., rheumatism. No one denies that there is a difference in the sensations pro- duced by bathing in fresh water and in salt water; or between bathing in a calcareous water and in a brine containing from 1 to 2 pounds of salt to the gallon; or that, in bathing in water highly mineralized and carbonated, considerably lower tempera- tures should be employed than in the use of fresh water or that which is very lightly mineralized. This principle is recognized in the administration of the Nauheim bath, the temperature of which is usually fixed at about 95° F. (35° C), but any other effect than that on the peripheral nerve terminals, and thus modi- fying the response of the nervous system, is a -matter which has not been established. The question resolves itself into a single proposition: Are any of the mineral constituents absorbed through the skin of the bather while in the bath? Popular opinion and belief are strongly in the affirmative. The vested interests and their adherents at the various spas in Europe and America stoutly maintain that this is the case, and immediately ask how else we would explain the remarkable cures that have been observed during centuries of successful experience. The question is a vital one, and deserves a candid and un- biased consideration. The fact that cures have been observed under any given method of treatment has not always been in- terpreted properly respecting the means employed. Credit has been given frequently to remedies, and particularly to drugs, that have in nowise aided in recovery. This has been the case for ages, and will always be the case with the present constitu- tion of the human understanding. It is interesting to see the explanation of the action of the waters of Bath, England, given by Dr. Robert Pierce, who prac- tised for sixty years in that resort. In his work "History and THE RATIONALE OF HYDROTHERAPY 21 Memoirs of the Bath/' published in 1713, he records a case of intermittent Hmp which he cured. He says : 'Tor it brought warmth and heat into the part, which it was altogether destitute of before; it took off the convulsive motions which were before frequent and violent (especially at night and when he was first falling asleep.)" James Currie, who wrote one of the first and best books on hydrotherapy,^ states that there is no increase of weight in the bath, and while the skin remains "sound and entire no absorption of solid, liquid, or aeriform elastic fluid takes place on the surface. In the instances that are supposed to favor the contrary opinion, it will be found that the article is forced through the epidermis by mechanical pressure, or that the epidermis has been pre- viously destroyed by injury or disease." Currie refers to the experiments of M. Seguin,^ which were made for the purpose of determining the question of cutaneous absorption. "He dis- solved in the water of the bath, in which he made his experi- ments, substances which produce a specific effect when received into the system, by which their inhalation might be ascertained. He employed the oxygenated muriate ot mercury^ in solution on a number of venereal patients, and, while the epidermis was entire, he never perceived a single instance of salivation or even of amendment of their complaints. But in cases where a con- siderable portion of epidermis was injured or destroyed, as in the itch, the specific effects of mercury on the system were produced. The experiments of M. Seguin are very numerous, and appear to be devised so as to meet every objection.* He concludes from the whole that, while the epidermis is entire, the absorbents of the surface take up neither water nor air, nor any substance diffused or dissolved in either." 1 Medical Reports on the Effects of Water, Cold and Warm, as a Remedy in Fever and Other Diseases, second ed., Liverpool, 1798, p. 264. 2 Fourcroy, La Medecine eclairer par les Sciences physiques, p. 232; see also Appendix, No. Ill, Currie's treatise. 3 Bichlorid of mercury. * He also used solutions of antimony and potassium tartrate, muriate of ammonia and mercury, etc. 22 HYDROTHERAPY The explanation afforded by Dr. Pierce two hundred years ago, and by Currie, in the same century, of the modu.^ operandi of the mineral bath met with vigorous local ojii^osition, \yas not generally received, but it is fully substantiated by the modern school. Professor Heinrich Kisch, of the University of Prague and of j\Iarienbad, has formulated his views in a recent treatise on Mineral Waters and Their Uses,* as follows : "That circumstances upon which, formerly, a particular emphasis was placed in estimating the value of mineral baths — namely, that the constituents of the mineral water employed for the bath were capable of exerting a direct influence by absorption into the blood — has been forced into the background by recent investigation. The question as to whether the uninjured human skin is capable of absorbing the substances dissolved in the water of the bath has been decided in the negative by recent thorough research. The results of earlier studies, apparently showing that increase in weight occurs after the bath, and that this is due to absorption of water, that the increase in the quantity of urine secreted after the bath is a result of the absorption of water, and, further, that after simple muriated baths there is an increase in the urinary chloritls, indicating a diffusion of the salt of the bath, have not been confirmed. ... It is true that substances capable of injuring the horny layer of the skin — as, for instance, mercuric chlorid, arsenic, salicylic acid, salol — will, when added to the bath, be absorbed through the skin, and this appears not unimportant in connection with certain varieties of baths, such as peat-baths and mud-baths. Ethereal solutions, also, as those of atropin, cocain, lithium chlorid, veratrin and aconitin, are, according to the experiments of R. A\'internitz, absorbed by the skin. On the other hand, Winternitz found it impossible to demonstrate the direct entrance of these substances into the skin from watery solutions : "It may, therefore, be considered as established that the un- injured human skin is not permeable to water and to indifferent 1 A System of Physiologic Therapeutics, vol. be, edited by S. Solis Cohen, Philadelphia, 1902. THE RATIONALE OF HYDROTHERAPY 23 substances dissolved in it, even after long-continued exposure, and that absorption of fixed constituents through the skin does not take place in mineral baths. The skin of the bather is prob- ably, however, permeable by the gases and volatile constituents of the mineral water, as the author has demonstrated for carbon dioxid, and Rohrig, for hydrogen sulphid and illuminating gas." Rohi'ig made some experiments as to whether iodin can be absorbed from the bath. He took special precautions to protect with fat the mucous membranes exposed in the bath, and respira- tion was carried on through a tube terminating outside the room. Although he remained for three-ciuarters of an hour in full baths, to which potassium iodicl had been added, and that were maintained at a temperature of 95° F. (35° C), no iodin ap- peared in the urine. Kletzinsky, Lehman, Thomson, Rabateau, Ritter, and others, according to Kisch, obtained similar negative results in experiments with baths to which soluble substances, such as potassium ferrocyanid, potassium nitrate, ferrous sul- phate, and ferrous carbonate were added. Stas^ made similar observations on himself. On three suc- cessive days he subjected himself to baths of 86° to 90° F. (30° to 32.2° C), containing 50 mg. of sodium arsenate to the Hter. Though immersed for prolonged periods, not the slightest absorp- tion was noted. The same results were obtained from baths of potassium iodid and other salts, which would have been easily recognized in the urine had they been absorbed. Dr. Simon Baruch, who has given this subject close study for forty years, and has pubhshed an elaborate resume of the litera- ture bearing on the physiology of the bath, is in accord with these views, and in his comments makes it clear that these nega- tive results do not militate against the general impression that such mineral baths are exceedingly useful and effective thera- peutically, due in some measure to climatic and hygienic ele- ments beside the local and general temperature effects. He clearly states that the heat or cold conveyed by the peripheral cutaneous nerves to the central nervous system, and thence re- 1 La Presse Medicale Beige, 1886, No. 13. 24 HYDROTHERAPY fleeted through the motor tracts, is the really effective element in the mineral baths. The latter are aided by only such ingredients as stimulate the cutaneous nerves, e. g., strong saline or carbonic acid gas constituents. Other mineral ingredients are indifferent in their effect upon the skin, and utterly incapable of entering the system by cutaneous imbibition. These are facts substan- tiated by exact experimentation — facts which must unsettle long-cherished ideas, and arouse a healthy skepticism in the minds of medical men, and induce them to trust more frequently to the thermic and mechanical effect of pure water, i. e., hydro- therapy. We are thus forced to the conclusion previously enunciated, that hydrotherapy and balneolog}'^ go hand in hand, and that the mineral waters, the analyses of which are quoted with such particular exactitude unto the third or fourth decimal place of grains per gallon, are neither more nor less efficacious on that account. On what, then, does the value of the mineral bath depend? First of all, it is cleansing, the more so as it approaches an al- kaline reaction and an elevated temperature. The secretion of the sweat glands and the epidermal scales are removed, and this allows a more intimate contact of the water with the body. Second, there is a stimulating effect on the skin produced by the chemicals dissolved in the water. These saline or gaseous constituents affect the peripheral nerves by tactile irritation, and thus produce effects on the circulatory and nervous system in a reflex manner. This is probably more definite when the irritation is produced by such gaseous contents as carbon dioxid. Next in order would be the action of the denser saline waters, and least of all, that of the mild, calcareous alkaline waters. Third, the irritation, which, it must be borne in mind, means the effect of cold as well as of heat. This is by far the most im- portant. It is obvious that the greater the departure from the normal temperature of the body, so much greater will be the thermic irritation of the medium used. The effects of heat and cold, as applied in baths, are very different. On applying heat THE RATIONALE OF HYDROTHERAPY 25 or cold to the skin there is a direct influence on the part, but in- directly and reflexly through the central nervous system there are far-reaching effects upon the circulation in distant parts. These reflex actions are of great importance therapeutically, and will be discussed in subsequent pages in connection with par- ticular diseases and special forms of treatment. In applying heat or cold proximally, — i. e., between affected part and the heart — we attempt to control the circulation in the part, but to avoid the use of direct applications. We may in- fluence the circulation in an injured hand by applying an ice-bag in the axilla or at the bend of the elbow, or we may apply cold compresses to the neck to contract the carotids and relieve a congestion of the brain. So, also, we may use heat derivatively by drawing blood away from the affected part. The hot foot- bath and leg-bath are familiar examples. Fourth, the mechanical irritation occasioned by mud-baths, moor-baths, and any motion or pressure imparted to the mineral water in its application. If the water under pressure is dis- tributed over the body of the patient in fine spray, it is quite possible that some of the contained minerals or gases may reach the interior of the body by inhalation. While the chemicals so absorbed would certainly be infinitesimal, the gaseous emana- tions from the mineral water may have a more appreciable in- fluence. Heat and cold are two conditions of the same force, caloric, and, with reference to the human body, mean, respectively, the intensity of caloric above and below 98.4° F. (37° C.) O^ood). Dry heat, when locally applied to the absolutely dry surface, may be borne as high as 340° F. (171.1° C); in local applications it may be borne higher in the form of radiant heat, but the pres- ence of the slightest moisture or oily application quickly results in a blister or burn at this or lower temperatures. It is weU recognized that a certain tolerance is established during successive applications, and this holds true for heat as well as cold. The healthy body may absorb heat to the extent of 3 or 4 degrees or more if confined to special localities. 26 HYDROTHERAPY In order to preserve a constant body temperature, whether exposed to heat or cold, all warm-blooded animals have two inherent faculties: One, a physical regulation, causing increased or diminished heat loss; the other, a change in metabolism which can increase the heat production or chemic regulation. These are independent of the protection afforded by clothing.* Physical regulation is controlled by processes in the skin, where cold produces contraction and a bloodless state. This contraction checks loss of heat by radiation, conduction, and water evaporation. The primary hyperemia, due to long-con- tinued cold, is scarcely ever seen in actual practice. The second- ary hyperemia, however, which follows the withdrawal of ice or cold, is well known, and when artificially obtained is termed in hydrotherapy the "reaction." Its appearance means in- creased heat loss and marks the end of the control by physical regulation. In order to enhance the reaction in hydrotherapy the physical regulation may be prematurely interrupted by the application of cold after heat, by employing friction in the bath, and by using stimulating chemic substances, such as carbonic acid gas, various chlorids, etc., in the water. Great stress is always to be laid on a "reaction," and when baths differ much from the normal body temperature, it is highly necessary to secure it. The appear- ance of the reaction is not usually as well marked at the begin- ning of a course of bathing as in the subsequent baths, for the reaction can be cultivated or brought out as the skin is trained to react. The reaction of the body occurs in consequence of both cold and heat, and it is this physiologic feature which determines the effect of hydrotherapeutic treatment. Both air and water may be used in this connection, but w^ater is generally preferred because it has a greater specific heat and a greater coefficient of heat conducti\'ity. Man is particularly susceptible to hydro- therapeutic effects. There is no natural protection, and the ^ See Von Noorden, Metabolism and Practical Medicine, vol. iii, for a full discussion of this subject. THE RATIONALE OF HYDROTHERAPY 27 clothing which he wears makes him sensitive to temperature changes. In order to estimate in advance one's reactive capacity we must form a judgment of the sensitiveness of the body sur- face. Clothing forms a kind of habitual thermal zone about the body, the temperatiu-e of which has been shown by Winter- nitz to remain fairly constant at about 89.6° F. (30° C.).^ It therefore follows that an ordinary bath must have a temperature of some degi'ees above or below 89.6° F. (30° C.) in order that a decided reaction may be obtained. A tepid bath, however, as low as 85° F. (29.5° C.) or as high as 95° F. (35° C.) may be followed by a reaction, provided we employ at the same time some mechanical stimulation, as, for ex- ample, by means of a douche or jet having some force of impact. A healthy man plunging into cold water shivers and, after an involuntary pause in breathing, inspires very deeply. The skin becomes pallid, owing to the contraction of the unstriped muscle-fibers, and he may or may not show the phenomenon of ''gooseflesh'^ or cutis anserina. The reaction, as we nearly all of us know by personal experience, may set in while one remains in the bath or as one comes out of it. This reaction is the common experience of sea-bathing, and is a sine qua non if it may be indulged in with safety. The rapidity and degree of reaction for cold varies very much in different individuals. It is delayed in the weak and feeble, but develops early and rapidly in the robust, especially if they have been in the habit of taking cold baths (Weber). That great generalizer in hydrotherapy, Prof. Winternitz, has formulated some of the principles regarding the reaction, which we may summarize as follows : The secondary warming of the body is the surest sign and most marked sjrmptom of reaction. This is recognized especially in alterations of innervation, circulation, and metabolism, de- pending on various factors. 1 See Sir Hermann Weber and F. Parkes Weber, Climatotherapy and Balneo- therapy, London, 1907, p. 305. ■ 28 HYDROTHERAPY 1. The absolute amount of heat loss. The reaction is greater, within moderate bounds, the lower the temperature; the greater the fall, so much greater will be the temperature of the re- action. 2. The more quickly the loss of heat occurs, so much the more quickly will the secondary increase of temperature take place. 3. The duration of the cooHng procedure influences the secondary heat production. Long-continued and gradual heat abstraction is followed by a slow reactive temperature increase of moderate intensity; but short and colder water applications, while not abstracting so much heat, are yet followed by a good reactive increase of temperature. The best reactions with the least loss of heat are generally obtained by cold applications of short duration, administered when the patient is hot (Weber). 4. The degree of body heat before the application of cold influences the reactive temperature increase. If the body is very warm, at first it reacts more strongly to cold. / 5. A warm application previous to the cooling procedure in- creases the intensity of the reaction according to the individual's susceptibility to a stimulus. 6. A combination of cold with mechanical stimuli increases the reaction. 7. Whether the reaction is prompt or not depends more or less on what the subject does after the abstraction of heat. Rest retards, work and exercise heighten, the reaction. 8. The internal use of stimulants, especially alcohol, after the abstraction of heat promotes the reaction. 9. In general, the reaction, and the heat production as well, bear a direct relation to the thermic stimulus to the nerves. The stronger it is, the more intense is the result. Excessively cokl procedures can lead to a delayed and ex- treme or imperfect reaction. Febrile cases sometimes show this in the form of clamminess of the skin and in collapse. Such cases call for powerful mechanical stimuli. The organism usually THE RATIONALE OF HYDROTHERAPY 29 reacts to thermic and mechanical stimuli, when applied in proper dosage, toward either excitation or depression/ Dr. Simon Baruch, to whom we are greatly indebted for presenting hydrotherapy to the profession in an ardent and rational manner, has reconstructed the entire theory of reaction, and proved that the contention between Matthes and Winter- nitz regarding tonic reaction after cold was baseless, because their premise that the arteries of the skin contract under cold is false. If this were true, Matthes would be right that there can be no tonic dilatation of the arterial muscular coat — dilata- tion of arteries always is atonic, of course. Dr. Baruch has shown that the hyperemia after cold is due to filling, not of the arteries, which are too deep, but of the capillaries (arterial), after having been emptied by the constriction of the unstriped muscular fibers which abound in the skin — that the sudden narrowing of the peripheral capillaries by this muscular con- traction, together with the vasomotor stimulus, produces an enhancement of the ventricular contraction which drives ar- terial blood in abundance to the arterial capillaries which had been previously more or less emptied by the muscular constric- tion to which the cold has subjected them. This warm afflux, slowly or rapidly, according to previous duration and intensity, removes the constriction, and thus the capillaries are permitted to fill as the barrier is removed ; the ventricular activity continu- ing, forces more and more blood into these capillaries, which, having no muscular coats, dilate as far as the normal contractility of the cutaneous muscular structures admit. The latter con- tinues to offer a barrier to further distention, and in this wise is the tone at the periphery maintained — tonic reaction. Dr. Baruch has explained the atonic dilatation after warm procedures by the same anatomic and physiologic facts. Here there is little if any primary vasomotor action. The warm bath relaxes the cutaneous muscular structure ; the skin looks sodden and cyanotic as an evidence of this relaxation. The capillaries 1 This subject is thoroughly treated by Prof. W. Winternitz in his Physio- logische Grundlagen der Hydro- und Thermotherapie, Stuttgart, 1906. 30 HYDROTHERAPY dilate because there is diminished resistance ; the latter weakens the cardiac action; the heart compensates by increase of the number of contractions for the imperfection of its systole ; the local as well as the general circulation becomes enfeebled; there ensues diminished arterial tension, compressible pulse, etc. — we have atonic congestion. Hence the judicious cold bath is tonic or stimulating, while the judicious warm bath is atonic and sedative, demonstrating the flexibility of water as a remedial agent.' Cheniic regulation has an equally valuable influence in phys- iology. It depends largely on the state of nutrition, the type of diet, and the size of the individual. It is interesting to note that chemic regulation is always accompanied or called forth by muscular activity. If one exercise the will sufficiently to avoid shivering or any other movement, then physical regulation alone is manifested. This subject expands rapidly, and the reader is referred to von Noorden's monograph and the work of Speck and others.^ (See also pp. 37, 38 for a further discussion.) PHYSIOLOGIC ACTION OF SALINE BATHS COM- PARED WITH FRESH-WATER BATHS Starting with the assumption that possibly saline baths exert a different action on the organism. Dr. Theodore Groedel II made a great number of experiments bearing on this matter under the direction of Professor Rieder in the Centralbad of the Munich Clinical Institute.^ Experiments were made on the respiration, pulse, blood- pressure, and body temperature in fresh water as well as with baths containing sodium chlorid, potassium chlorid, and calcium chlorid of known concentration. The subjects were yoimg men of twenty to twenty-four years, who were placed for half an hour in the same attitude, in an empty tub, as in the subsequent bath. They were covered with a sheet and the necessary instruments 1 Personal communication to the author. 2 Speck, Die Physiologie der Atmung, 1892, p. 173. ' Berliner klinischer Wochenschrift, March 13, 1905. • ACTION OF SALINE COMPARED WITH FRESH-WATER BATHS 31 were in place. Just before the beginning of the bath careful observations were made. The temperature was taken in the mouth; the blood-pressure was taken with the Riva-Rocci sphygmomanometer; two competent observers were assigned to note the disappearance and reappearance of the pulse, so as to eliminate any personal factor. The rate of the pulse was recorded through a minute, and the respiration noted by a water mano- meter, provided with a thin rubber tambour attached to the breast by a bandage. The tubs were then filled without any dis- turbance of the subjects, and measurements were taken for five minutes and repeated in five minutes. The apparatus remained unchanged in position during the entire period of the experi- ments, so that the readings were made under similar conditions. The baths were previously arranged so that they consisted of pure fresh water, salt water in strength of 3, 4, 5, 6, 7, 8, 9, and 10 per cent., potassium chlorid 4 and 8 per cent., and calcium chlorid 4 and 8 per cent. The atmospheric temperature of the bath-rooms was maintained at 20° C. (68° F.), that of the baths at 35° C. (95° F.), which is an accepted standard for the in- different bath. A slight loss of temperature of the water of the bath was noted ; without the subject in the bath it amounted in fifteen minutes to about .4° C. (.7° F.) ; with the subject, it varied between .3° C. (.5° F.) and .5° C. (.9° F.). The body temperature fell in the fresh water between .1 ° C. (.18° F.) and .2° C. (.4° F.), and in the salt baths to .3° C. (.5° F.). The respiration record gave a variation of — 1 and +1 in the fresh water and — 4 and +4 in the salt baths. The rate of the pulse was not, on the whole, affected when the salt baths were compared with the fresh- water baths; the extreme changes noted in the salt baths were + 4 and — 8. The hlood-pressure was altered from to -t-3 mm. Hg. in the fresh- water baths and from — 10 to + 19 in the salt baths, the higher readings being obtained with the 10 per cent, sodium chlorid and the calcium chlorid baths. It was evident from these careful observations that the body temperature, the frequency of the pulse, and respiration were practically the 32 HYDROTHERAPY same in the fresh-water as in the saline baths; while in the latter the blood-pressure was both increased and diminished. Robin found that nitrogen elimination was increased by salt baths, while Keller found it to be diminished. In the case of the Turkish bath exposure of the same man to a temperature of 122° F. (50° C.) for fifty minutes in the drier air raised the axillary temperature only 1.2° F., the pulse 32 A / \ llfi \ p. iz JOif 7Z R. 15 18 15 a. b c Temperature Effect of Turkish Bath The continuous line represents temperature in the axilla. The dotted line, temperature in the rectum. Day before batli. Day of bath. Quantity of urine 15G7 cc. 950 cc. Specific gravity of urine. 1018.8 1027 Urea 45.47 gm. 39.90 gm. Uric acid .683 gm. .860 gm. Fig. 1. — Turkish bath, temperature 122° F. (50° C): a, Body temperature before entering the bath; b, temperature fifty minutes after entering the batli; c, temperature twenty minutes after leaving the batla when in the cooling chamber; P, pulse; R, respiration. beats, and the respiration only from 15 to 18 per minute. The rectal temperature was not altered. There were less marked changes in the quantity and density of the urine; the increase of uric acid excretion was about the same. Frey and Heiligenthals made careful experiments on a healthy man exposed for twenty-five minutes to the saturated air in a Russian bath. The temperature was maintained at 113° F. INFLUENCE OF BATHS ON METABOLISM 33 (45° C.) and the following changes were noted: The body- temperature was raised from 98.4° F. (36.9° C.) to 103.4° F. (39.6° C); the pulse rose from 72 to 136; the respirations, from 17 to 23. The urine, which for three days before the bath had averaged daily 1683 cc. of specific gravity 1021, was reduced Temperature Effect of Russian Bath TJie continuous line represents temperature in the axilla. The dotted line, temperature in the rectum. Day before bath. Day of bath. Quantity of urine 1683 cc. 900 cc. Specific gravity of urine 1021 1027 Urea 52.68 gm. 38.7 gm. Uric acid .858 gm. .980 gm. 103 102. »0I 100 *?8 , A 1 1 J / V \ r. 7Z 136 70 -R lY 23 17 a b c Fig. 2. — Russian bath, temperature 113° F. (45° C): a, Body temperature before entering the bath; h, temperature twenty-five minutes after entering the bath; c, temperature ten minutes after leaving the bath; P, pulse; R, respiration. in quantity to 900 cc. on the day of the bath and had a specific gravity of 1027. The urea was diminished by one-quarter and the excretion of uric acid rose 14 per cent.^ INFLUENCE OF BATHS ON METABOLISM This is a most complex and little-understood subject, but it is generally appealed to in explaining the good results obtained by hjdrotherapy. Physiologic chemistry has now reached a stage of development far beyond the comprehension of all except 1 See Stevenson and Murphy, Hygiene, Article by Hale White, vol. i, p. 641. 3 34 HYDROTHERAPY special students and laboratory experts. It remained for von Noorden to undertake the heroic task of coordinating the im- mense mass of literature on this subject accumulated during the last ten or twelve years. In his third volume, written in con- junction with Dr. Carl Dapper and Dr. Max Matthes, he has presented some of the more recent scientific work, referring, meanwhile, to the "enormous output of worthless pscudoscien- tific writings which mislead the inexpert. A clamorous jargon has been invented, which includes apparently learned expres- sions about delayed or increased metabolism, oxidation, assimila- tion, protein balance, molecular disintegration, ions, osmosis, radio-activity, and the like."' EFFECT OF COLD BATHS ON METABOLISM Tissue changes brought about by cold baths are caused by an effect on the innervation of the muscles; in fact, all combus- tion processes in the body are referable to the muscles. A simple hot-air bath may have little effect, but a series of hot-air or hot- water baths increases nitrogen elimination, urea elimina- tion keeping pace with the excretion of nitrogen, and uric acid is also excreted in greater quantity. , Elaborate studies of these metabolic changes have been made by many observers and in connection with ordinary hydriatric procedures, the half-bath, the Scotch douche, etc. It is interesting to note that Hippocrates- states that the tem- perature elevation which occurs in connection with most acute infectious diseases is, within limits, remedial in purjDOse and effect. It apparently follows that temperature-elevating baths may be beneficial in aiding resistance to infection, especially when followed by a short cold bath, by favoring the production of alexins and antitoxins. It seems to us, however, that cold baths are better, practically, in the infectious fevers — witness 1 Max Matthes, of Cologne, has contributed an excellent review of this subject with 114 modem references to European literature in von Noorden's Metabolism and Practical Medicine, vol. iii, chaps, viii, ix, London, 1907. - System of Physiologic Therapeutics, edited by S. Solis Cohen, vol. ix, p. 250. EFFECT OF COLD BATHS ON METABOLISM 35 the brilliant results obtained by the Brand treatment of typhoid fever. That baths of such obviously different character may lead to very nearly the same physiologic result is one of the seeming paradoxes of hydrotherapy. This is recognized in practice, for, if patients do not react well to the cold bath in typhoid, it is Dr. Wilson's practice at the Jefferson Hospital in Philadelphia to give them a bath at 110° or 112° F. (43.3° or 44.4° C). A patient convalescent from long illness complained to Dr. Sidney Ringer that he feared he could not resume his usual cold morning bath. "Never mind," said he, "take a hot one." He did so, having the water very hot and remaining in the bath only a short time. This procedure he carried out every morning for several years after the illness. The stimulating effect was produced, whether the baths were hot or cold. Dr. Simon Baruch explains this seeming paradox by the physiologic fact that both heat and cold are thermic irritants which, briefly applied, excite the peripheral sensory terminals and thus stimulate. The secondary effects differ decidedly if the- application be prolonged. The effect of the Naicheim hath on metabolism would naturally be expected to be most pronounced, consisting, as it does, of solid and gaseous elements in large quantities. Improved assimilation and tissue metabolism is evidenced by formation of fresh muscular substance. The area of the dilated heart is diminished, but its power and true volume are enhanced. Super- fluous fatty tissue and inflammatory residual products disappear; effete products are eliminated, and a loss of weight is commonly noted at the outset ; but more substantial evidences of construc- tive metabolism begin to be noted, and continue long after the patient ceases to take the course of treatment provided in ac- cordance with this system of hydrotherapy. Dr. Paul Franze, of Bad Nauheim,^ corroborates many other ^ The Physiologic Action of the Nauheim Springs and the Indications for their Use in Circulatory Disorders, Jour, of Balneology and Climatology, July, 1904 36 HYDROTHERAPY observers in this particular. He says: "Tissue metabolism is accelerated as in cold fresh-water baths, only more pronounced, and it is relevant to mention that researches as to the physiologic action of chalybeate baths, rich in carbonic acid, show that this gas chiefly promotes the metabolism of non-nitrogenous matter, while excreted urea is diminished relatively to its intake. Prac- tically, this means that while our baths reduce superfluous fatty tissue, they facilitate the formation of healthy muscular sub- stance. This, of course, is especially applicable to the efferves- cing Sprudel baths. The acceleration in tissue metabolism, aided as it probably is by osmosis, promotes the absorption of exudations in the joints and pelvic and serous cavities. Nau- heim baths are among the most efficient means of abolishing the residues of rheumatism and gout, of serous inflammations, such as pleurisy and pericarditis, and of inflammatory conditions of the adnexa of the female genital organs." Turkish baths tend toward a gain in weight, but if the heating process is shortened, and cold water is applied liberally in con- nection with the plunge, the subject loses, because the loss of heat has to be made good by increased catabolism in the tissues. The latest American studies of the effects of such measures on metabolism, as shown by an analysis of the urine, are those by Dr. Otto Folin and Dr. George T. Tuttle, of Waverly, ]\Iassa- chusetts.* Nine subjects, including mental patients of good physique and nurses in the McLean Asylum, at "Waverly, were given a uniform diet adapted to the capacity of the individual, contain- ing a known amount of nitrogen. After this diet had been con- tinued for two days the urine was collected for each twenty-four hours and subjected to an exceedingly careful analysis. After thi-ee or four days baths were given about as follows ■? Hot-air cabinet. 174° to 190° F. (78.9° to 87.8° C), to perspiration; circular douche, 95° F. CSS" C), twenty seconds; pressure, 26 pounds; fan douche, 85° to 75° F. (29.5° to 23.9° C), twenty-five 1 Amer. Jour, of Insanity, October, 1904. 2 For technic see p. 252. EFFECT OF COLD BATHS ON METABOLISM 37 seconds, 26 pounds; jet, 65° F. (16.3° C), five seconds, 20 pounds. The treatment was varied for individual cases. These studies, contrary to expectation, failed to show any metabolic changes, although most carefully worked out on the basis of urinary ex- cretion. The thought arises that there may have been other evidences of altered metabolism beside those shown by urinary analysis. These treatments were too brief to produce " evi- dences of altered metabolism," and there was not sufficient alternation of temperature. Beginning with 95° F. (35° C.) it was gradually reduced in the course of fifty seconds to 65° F. (18.5° C). Baruch's hyclrotherapeutic law, that the intensity of effect is in proportion to the temperature difference between water and skin, came into action here. The skin being grad- ually cooled down does not present the temperature contrast demanded for effects upon the metabolism. The general records showed a gain because the treatment was gently stim- ulating or tonic, increasing appetite and enhancing hema- tosis. The flexibility of water is demonstrated in the different results from different procedures. Dr. Baruch has pointed out this flexibility with emphasis not given to it by any previous authority, and he has offered a rational physiologic basis for every procedure, removing all apparent paradoxes. Patients free to eat and exercise at will during hydrotherapeutic treat- ment will, no doubt, gain. The general records of the McLean Hospital show that of 216 consecutive insane cases treated with similar baths, and on the usual diet, 168 gained in weight and 48 lost. The gain was from f to 33f pounds, and the loss from ^ to 22| pounds. The experiments of Otto Pospischil, an assistant of Winter- nitz, show that the rate of heat production is increased in the cold bath by vigorous rubbing by as much as 44 per cent., and this may to a great extent diminish the temperature. Short cold shower-baths increase heat elimination from 25 to 66 per cent., even more if mechanical friction be carried out. He also found the flow of respiratory air to be increased nearly three times in the half-bath. Increased vigor is undoubt- 38 HYDROTHERAPY edly the result of the procedure, but it should be remembered that if the water be at the higher temperatures, as from 80° to 90° F. (26.7° to 32.2° C), a corresponding increase in the friction is reciuired to produce good circulator}- reaction. By raising the temperature of the water and communicating heat to the body, distinct effects on metabolism are produced. Carbon dioxid is exhaled at a much more rapid rate, and this is also true of the application of cold water.' Great differences in the reaction to cold baths are noted at different times in the same individual. Jurgensen relates the case of a man in good health who showed no fall of temperature in or after a bath at 9° C. (48.2° F.), lasting twenty-five min- utes, but four days later, in a similar bath under the same condi- tions, his temperature fell to 33.9° C. (93° F.). The lower the temperature of the bath the more vigorously heat production and heat loss proceed; also, during the first minute in the bath the organism gives off more heat than in the next, and, finally, in cold baths, after a certain variable period of heat loss, the rate becomes constant. In a bath at 17.1° C. (62.8° F.), lasting two and one-half minutes, the heat production was fourteen times the normal. The subject had expended 64.63 calories and was himself .03° C. (.08° F.) warmer. It is an interesting point that of these 65 calories 43.76 were given off in the first minute and the remainder in the following one and one-half minutes. In another experiment, lasting fifteen minutes in a bath at 26.75° C. (80.25° F.), the heat loss in the first five minutes was 43 calories; in the second five minutes, 15 calories; in the third five minutes, 17 calories. Ignatowski^ found that if no reaction occurred, the heat loss, by radiation, conduction and evaporation, continued to decrease even after the bath, while heat production was lessened. This ^ Confirmed by experiments of Liebermeister, Goldscheider, Roehrjg, Zuntz, and Strasser. ~ Ignatowski, Der Warmehaushalt des Menschen nach Badem und Duschen, Archiv fiir Hygiene, 51, 320, 1904. EFFECT OF COLD BATHS ON METABOLISM 39 latter was directly proportional to the degree of cooling reached, and his subjects were really cooled down by the cold baths. If, on the contrary, a prompt reaction set in, the diminished loss by radiation and conduction could scarcely be observed and that due to evaporation rose abnormally Rubner made some studies of short cold douches and baths under ordinary conditions of life : Time, three to five minutes. Increase of respired air Increase of CO, output Increase of O intake . . . Douche. Bath. 16°C.(60.8°F.). 16°C.(60.8°F.). Per cent. 54.5 149.4 110.1 Per cent. 22.9 64.8 46.8 Baths of this kind affect favorably energy and fitness for work. Short cold baths, in wliich actual heat loss is small, cause a fairly marked increase in chemic metabolism just like the longer ones, only there is a less heat deprival, due directly to the movements which the baths set up. The heat production due to muscular activity exceeds and obscures the catabolism due to cooling, or in practice renders it quite negligible, except under very unnatural conditions. It is impossible to determine the extent of this increased catabolism accurately, because no method can be devised which will deal with muscular activity alone. Shivering and active movements in connection with cold baths are thus natural aids in the regulation against cold; they produce heat, favoring and calling forth chemic regulation, and usually fully compensate, or may overcompensate, the heat loss. If the heat loss in a healthy and moderately fat man is estimated during a period of fifteen to twenty-five minutes, it will be found that in a bath at 40° C. (104° F.) the heat loss is normal, in a bath at 30° C. (86° F.) it is almost doubled, and in a bath at 25° C. (77° F.) is tripled, and reaches five times the 40 HYDROTHERAPY normal at 20° C. (68° F.) (Liebermeistcr). Riibner made the following experimental study: Effect of bathing on heat production. Duration of bath, one hour. Heat production in calories Heat + 18 calories for heat loss in respiration Heat — 91 calories, which a man of 60 kg. normally produces Absolute value of coolino; of the bath Metabolism in the l)ath reduced to grams of fat Metabolism in bath. Total effect and after-effect Temperature of bath. 15° C. 20° C. (59°F.). (68°F.). 480 498 407 81 43 370 388 297 57 31 37 25° C. 30° C. 35° C. (77° F.). (86° F.).!(95° F.). 240 258 167 34 18 •^2 150 168 77 12 80 98 7 0.7 0.7 For a bath lasting fifteen to thirty minutes the values for heat production must be halved. The "cooling" figure remains the same if the time is not shorter than fifteen minutes. "The effect of cold water on the body surface of a healthy man under normal conditions during a long-continued application does not lessen the body temperature at all ; in many cases it even raises it" (Liebermeistcr), so that within limits the heat loss may be at first overcompensated. Cold, per se, reduces the oxidizing capacity of animal tissues. Warmed tissues have a much higher oxidizing capacity. In order to maintain a constant normal temperature, we are com- pelled in the presence of cold to call more vigorously than usual on our heat-regulation powers so as to increase our oxidative activity. Hence in eclampsia we should resort to the use of heat. Rubner* has found that in an experimental guinea-pig the metabolism at 0° C. is two and one-half times that at 30° C. Rubner also showed that a bath at 16° C. increased the oxygen absorption 46.8 per cent., and a douche at 16° C. increased the oxygen absorption 110 per cent. 1 Energiegesetze, 1902, Ditman and Walker, N. Y. IMed. Jour., I\Iay 15- June 5. 1909; see also Matthes, Lelu-buch der klinischen Hydrotherapie, Part i, Chapter iii. QUANTITATIVE ESTIMATION OF AMOUNT OF HEAT LOSS 41 QUANTITATIVE ESTIMATION OF THE AMOUNT OF THE HEAT LOSS. HEAT REGULATION. This has been estimated under various conditions in number- less experiments by Prof. Winternitz according to methods fully- explained in his various works, particularly in his last publica- tion, Physiologische Grundlagen der Hydro- und Thermo- therapie.^ Briefly stated, it is as follows: 1. Displacement of the blood and arresting of the circula- tion in a limb with an Esmarch bandage lowers the heat produc- tion 70.6 per cent. 2. Restriction of the circulation by passive hyperemia, Bier method, lowers the heat production 46.2 per cent. 3. Mechanical stimuli increase the heat production 95 per cent. 4. Weak chemical stimuH are able to raise the heat produc- tion as much as 40 per cent., while strong chemical stimuli may lower it 8 per cent. 5. Thermic influences, such as cause cutis anserina (goose- flesh), lower the heat production as much as 44.5 per cent. 6. A warm rain-bath, by production of gooseflesh, can cause lowering of heat production by 38.7 per cent. 7. Partial cold wet rubbing, or a partial application of the drip sheet, can increase the heat production by 80 per cent. 8. A cold rain-bath followed by rest on a couch produces, after a slight lowering of the heat production, an increase to 23 per cent. 9. A cold rain-bath followed by exercise can raise the heat production 66.6 per cent. 10. A warm rain-bath with a cold fan douche, followed by rest on a couch, can raise the heat production by 16 per cent. 11. In febrile diseases in the presence of rising body tempera- ture the heat production may be lowered 25.4 per cent. This is better shown in Fig. 3. Cold applications have a good moral effect in cultivating will power. While the effect of such stimulations may be for a 1 Stuttgart, Verlag von Ferd. Enke, 1906. 42 HYDROTHERAPY time unpleasant, particularly at the outset, the patient soon feels their benefit and is encouraged to continue them. Encour- agement, suggestion, firmness, and kindness from the attendant and the personal interest and presence of the physician will do much at this stage to secure the cooperation and confidence of the patient and his continuance in the prescribed method of treatment. Physicians do not always realize the mental anguish which some poor creatures undergo when they begin a new and what appears to them a formidable course of hydrotherapy. ^ /CO 9o 70. JO . /o -Zo 3o So 60 7o. A/orma/ / 2 j Ma- <> h S 6 A 4 ? ± Fig. 3. — 1, Esmarch bandage; 2, passive hyperemia; 3, mechanical stimuli; A, a, weak, and b, strong, chemical stimuli; 5, cutis anserina; 6, warm rain-bath and cutis anserina; 7, partial rubbing (cold water); 8, cold bath and rest; 9, cold bath and exercise; 10; warm rain-bath; cold fan douche and rest; 11, active fever. Some patients are hopeful and confident, others are apprehensive and distrustful. Dr. Baldwin, of Boston, relates that one of his patients, who had long felt unable to do anything by reason of fancied weak- ness, went to the baths taking with her a sheet so that she might be properly wrapped up when they brought her dead body home. But kindly management gave her confidence and the baths which she took so improved her condition that health and activity were restored. As Baldwin says, "Cases of mental depression derive QUANTITATIVE ESTIMATION OF AMOUNT OF HEAT LOSS 43 much benefit from the baths; neurasthenic and psychasthenic patients are very likely to derive benefit from hydrotherapy, but they usually expect miracles, and that, too, without efi'ort or anything disagreeable on their part. So it is that the doctor must insist on having his directions carried out. It is simply a question of whether the doctor will run the case and cure the patient, or whether the patient will continue to do as he pleases and run the doctor until such time as he dismisses him as an in- competent person. Dr. Baldwin^ wisely remarks that these patients must be made to do something else than to sit around bemoaning their condition, and bathing is useful in occupying their time; they derive at the same time the benefit of the baths in the way of improved circulation and improved processes of metabolism. The baths take the patient completely out of him- self for the time being, and though the patient does not usually like the bath, he feels that something active is being done for him. In different cases a good deal of personal persuasion is required until a reasonable attitude is assumed by the patient toward the prescribed treatment. Of course, in institutions a better control of the patient obtains than in attempting treatment in private practice. At the McLean Hospital at Waverly, Massachusetts, Dr. Tuttle had a patient who was possessed with the delusion of demoniacal possession, and after reahzing that he was being improved wrote this: "Your baths are excellent to reduce cere- bral excitement. You can't fight the devil with fire, he is in his element there, but he is mortally afraid of cold water." Undoubtedly, cases will present themselves in which it is im- possible even for those of experience to foretell what the effect of hydrotherapeutic measures will be. Especially is this true in dis- orders of psychic origin or when patients are sent by physicians who have been familiar with their history to other physicians who may not know the idiosyncrasies and peculiarities of the patient thus despatched to a sanitarium or health resort. Patients must be studied individually in the light of a full letter of advice, and time must be taken, with moderate procedures, to ^ Boston Medical and Surgical Journal, April 15, 1909. 44 HYDROTHERAPY arrive at a proj^cr estimate of the best course to follow. Dr. George Beard, in condemning routine methods, wisely said: " If two cases are given the same treatment from beginning to end it is probable that one of them has been improperly treated." Dr. Pratt, in cases of doubt, has sometimes followed Binswang- er's method in giving three different treatments on three suc- cessive days. After these have been repeated once or twice the treatment which seems to the patient to be most beneficial is selected. Usually one of the procedures will be condemned and one favored. In this way the support and confidence of the patient is gained. The following sample outline of treatment is given as a sug- gestion : First day: Electric-light bath, five to ten minutes, followed by wet mit friction. Second day : Carbon dioxid bath (one-half full strength), ten minutes. Third day : "Wet pack, duration forty-five minutes to one hour. Repeat treatments in the same order on the fourth, fifth, and sixth days. Dr. Pratt advises that half an hour to an hour of physical and mental rest should follow each treatment, unless the patient is robust and with good reactive powers, when a brisk walk may be substituted. Often it is a good idea to combine rest and ex- ercise by having the j^atient dress quickly, walk a certain dis- tance, and on reaching home rest in bed for thirty minutes to an hour. A good proportion of the neurasthenic patients wish to discontinue treatment after the first or second bath has been taken. In many neurasthenic women a feeling of exhaustion comes on a short time after the treatment and persists the remainder of the day. This is usually regarded both by phys- ician and patient as evidence that the hydrotherapeutic pro- cedure has been too strong, but, as this temporary exhaustion develops after the mildest treatments and as it almost invariably disappears after the second or third treatment, the sensation of weakness is undoubtedly due in the great majority of cases to the THE EFFECT OF HOT BATHS ON METABOLISM 45 nervous strain of the visit to the institution. The surroundings are new and the appHances are strange and somewhat formidable in appearance. Dr. Pratt relates that he recently saw a patient in whom weakness and depression persisted until the sixth treat- ment. Since then she has felt refreshed and invigorated after the bath for the rest of the day. It was possible to prove beyond question in this instance that the weakness was of purely psychic origin because the patient felt as tired after a mild treatment (wet mit friction) as after a strong one (circular and horizontal douche) . Effect of Cold Baths (Brand Baths) on the Urine.— James Tyson measured the total daily amount of urine and the actual amount and percentage of urea excreted during an entire month by a patient who had typhoid fever and was treated by Brand baths, numbering 53 during the first two weeks. There was an increase in the urinary secretion, and on one day, early in the case after 5 baths had been given, 66 ounces (1980 cc.) were voided. An albuminuria with casts {cloudy swelling) disappeared during the treatment. During hydrotherapy according to Brand's method the toxic 'property of the urine secreted is undoubtedly increased as con- trasted with the urine in cases not tubbed. Ausset attributes the entire efficiency of the Brand baths to this active elimina- tion of toxic agencies.^ It is said that excessively cold procedures may produce hemoglobinuria and albuminuria. (For further discussion of this subject see pp. 238, 240.) Albumin may be met with in predisposed persons after a cold bath, especially in the cyclic albuminuria of adolescence. THE EFFECT OF HOT BATHS ON METABOLISM In the case of hot baths there is no mechanism corre- sponding to the increased oxidation by which lack of heat is compensated for whereby the organism can reduce its heat 1 James Tyson, Trans. Association Amer. Physicians, 1897; E. Ausset, Bull, et Memoires de la Societe Med. des Hopitaux de Paris, Tome 11, 3 serie, 1894, p. 825. 46 HYDROTHERAPY production or decrease its metabolism. When exposed to heat or when heat loss is prevented, the body temperature is governed only by physical regulation; that is, it is a (lues- tion of evaporation; if this is checked, the body temperature necessarily rises. Winternitz showed that the increase in the consumption of oxygen caused by a moderately hot bath far exceeds that due to fever, and that there was a marked in- crease in metabolism, the carbon dioxid out{)ut and the oxygen intake going hand in hand; the heat balance being impaired, oxidation increases. It has also been shown that the body tem- perature can still go on rising for a short time after the end of a hot or vapor bath because the thoroughly heated skin must for a time continue to act as though it were still in the hot bath.^ This, however, is adjusted in the course of an hour or two, and afterward a slightly subnormal temperature and a slight second- ary rise has been noted. This fall after hot baths might be expected to be greater than it is, considering the fact that the skin is left in such a highly vascular state. Winternitz, for example, found that the oxygen consumption in 1 case was increased by 28 per cent, even seventy- five minutes after the bath. Comparing the effect of a hot bath at 44° C. (111.2° F.) and a cold bath at 16° C. (60.8° F.), Rubner found the increase of inspired air 18 per cent, in the former against 22.9 per cent, in the latter; the increase of carbon dioxid output was 32.1 per cent, in the hot bath and 64.8 per cent, in the cold; the increase of oxygen intake was 17.3 per cent, against 46.8 per cent. Re- peated hot baths accentuate this metabolic change as compared with the results obtained from a single bath. Hot baths, without the usual water-drinking, diminish the urine, since they promote sweating. Cold baths increase the amount of the urine temporarily. This, however, is usually quickly compensated for. The increased secretion depends on the raised blood-pressure due to cold. * Speck, Ueber den Einfluss warmer Bader auf den Atmungsprocess, Deutsches Archiv fiir Klin. Med., 37, 1885. THE EFFECT OF HOT BATHS ON METABOLISM 47 Experiments show that as much as 1 quart of sweat may be lost in a prolonged hot-air bath. Dr. J. H. Pratt has noted a loss of 1500 gm. during an energetic hot-air bath, and it can be readily understood that this abstraction of fluid must affect the entire circulation of blood and lymph and undoubtedly aid in the eUmination of morbid products. The abnormally high concentration of blood present in renal insufficiency can be reduced by sweating, and in these cases the low nitrogen con- tent and the molecular concentration of sweat is thereby con- siderably increased. Reference will be made later on to the increased secretion of sweat in the elimination of various poisons, including lead, mercury, and bacterial toxins.^ Uric Acid. — Both Formanek" and B. Laquer^ found that the excretion of uric acid was increased after hot baths. Formanek found also that a single cold bath is without effect, but that two long cold baths daily increase the uric acid output. Ebstein,* however, claims that the uric acid excretion is not changed by the use of baths. In estimating uric acid excretion it may be con- sidered as 10 per cent, of the total nitrogen eliminated, urea amounting to 85 per cent Sugar. — As for sugar, it has been found that when glycosuria has been produced artificially by administering large amounts of grape-sugar simultaneously with diuretics, free sweating sup- presses the glycosuria and the sugar appears in the sweat. This is an experimental demonstration of the vicarious action of the skin which is occasionally noted in disease. 1 J. H. Pratt, The Development of Scientific Hydrotherapy, Boston Med. and Surg. Jour., Jan. 25, 1906. 2 Ueber den Einfluss Kalter Bader auf die Stickstoff und Hamsaureaus- scheidung beim Menschen, Zeitschr. fur Physiol. Chem., Bd. 19, 271, 1894. 3 Ueber die Ausscheidungs erhaltnisse der AUoxurkorper im Hame von Gesunden und Kranken, Verhandl. des 14th Kongr. fiir innere Medizin, 333, 1896. * Flechsig also states that the excretion of urea is diminished by carbonated baths. 48 HYDROTHKRAPY TEPID, OR INDIFFERENT BATHS have no effect on the metabolism. Salt baths at indifferent temperatures likewise have no effect, but when hot or cold they are more lasting in their metabolic effect than in the case of plain water at the same temperatures. EFFECT OF BATHS ON BLOOD-PRESSURE Ever}' hot or cold douche calls forth an increase of blood- pressure, paradoxic as it may seem. Cold l)aths contract the capillaries of the skin; there is a slower but more vigorous con- traction of the heart and consequent rise of pressure. Baths between 95° and 104° F. (35° and 40° C.) produce a primary rise, a secondary fall below normal, then a rise. Baths above 104° F. (40° C.) increase the pressure and also the pulse rate, the pressure remaining high. In baths accompanied by meclianical excitation the pressure is augmented, but returns easily to nor- mal.' Carbonic acid or Nauheim baths between the temperatures of 84° F. (29° C.) and 89.6° F. (32° C.) do not lower a path- ologic hypertension. Above the latter figures there is a marked fall, which, however, tends to rise even above the original ten- sion after the bath; but this increase is not permanent.' It follows that in the application of an agent which affects the blood-pressure so noticeably care should be taken not to aggravate any state of the system that cannot bear such an influence. We should carefully note any weakness of the heart or blood-vessels, so as to avoid any accident, for undoubtedly accidents have occurred through neglect of this precaution. Dr. Osier has said that longevity is a cardiovascular f{uestion. To a majorit)'' of men death comes primarily or secondarily through this portal. For that reason the greatest care should ' A full discussion of this subject is found iu Dr. Barucli's Hydrotherapy, third ed., New York; also Therapeutics of the Circulation, by Sir Lauder Brunton, Phila., 1908. - See Hvirter, Zeitschrift fiir phys. und dietct. Therapie, Bd 12, 1908; see also Jour. Amer. Med. Assoc, April 23, 1910, pp. 1376, 1377. THE SPHYGMOMANOMETER 49 be exercised at all times, but especially after middle life, to see that the circulatory organs are preserved and not weakened by sudden and unusual strain. THE SPHYGMOMANOMETER One of the aids in the recognition of hypertension is the spygmomanometer as devised by Mosso, von Basch, Potain and Riva Rocci, and modified by Sir Lauder Brunton, C. J. Martin, Cook, Stanton, and Theodore Janeway. It is perfectly practical. Fig. 4. — Dr. C. J. Martin's modification of the Riva-Rocci sphygmomanometer. quickly used, and has been found of great value, supplementing the stethoscope in estimating the state of the vascular system. In making a sphygmographic tracing of the pulse we can read- ily see the effect on the blood-vessels by the cold spray or bath. The pulse rate is slowed, the upward stroke is lessened, and the dicrotic wave is less pronounced. The tracings made by Marey, Sir Lauder Brunton, Bezley and Leslie Thome, and W. H. Riley show this plainly. The upstroke is nearly vertical. It occurs dur- ing the dilatation of the artery and is produced by the systole of the left ventricle. The line of descent is gradual and corresponds 4 50 HYDROTHERAPY to the diminution in diameter of the arteries, and as it falls the dicrotism appears. The height of the up stroke indicates the force Fig. 5. — Faught's blood-pressure apparatus. of the systole, but at the same time its height is restricted if the arteries are tense and rigid. A relaxed and dilated condition Fig. 6. — Stanton's sphygmomanometer. of the blood-vessels favors an increase in the length of the up stroke; and conversely, arterial hypertension shows itself in a THE SPHYGMOMANOMETER 51 lower stroke and a less marked, tiicrotie- wave.- -A pew^M heart may be matched against a weakened artery. Of course, no harm ' Fig. 7. — Dr. Rogers' "Tycos" sphygmomanometer: a, Gauge, actual size. results when the vessels are resilient and free from atheroma; the accelerated circulation under favorable circumstances restores the nervous system and promotes health. Fig. 8. — ^Tracing of a normal pulse (Sir Lauder Brunton). HYDROTHERAPY Fig. 9. — ^Tracings of healthy pulse with varying degrees of tension: 1, Ten- sion is high, owing to the contraction of the arterioles from cold; 2 and 3, di- minished tension from warm clothing, showing relaxation of the arterioles (Sir Lauder Brunton, after Marey). GF 28-10-98. before I- bath 3ior. Fig. 10. — ^Tracing from the pulse of a patient aged sixty-two with gouty kidney, of a failing heart. This tracing and the three following show the effect of Nauheim baths in increasing the cardiac force and dilating the vessels (Sir Lauder Brunton). 1 F 2^-^0-98 3*^9- I'-- b3^h 3i Fig. 11. — Effect of one bath (Sir Lauder Brunton). I\ ^ after 14^^ bath 3:2"-^ effervescing bath 3toi. Fig. 12. — From the same patient (Sir Lauder Brunton). COUNTERINDICATIONS TO BATHS 53 Fig. 13. — From the same patient after nineteen baths (Sir Lauder Brunton). COUNTERINDICATIONS TO BATHS A positive counterindication to such measures as the Nauheim bath, for instance, is any acute or subacute condition of the heart, and, on the other hand, the loss of compensation, as in chronic heart disease. In aneurysm great care should be exercised/ It is highly necessary to satisfy one's self that these conditions do not exist before prescribing the more stimulating measures. Palpa- tion and percussion of the heart and the use of the sphygmo- manometer are good routine methods before prescribing hydro- therapy; just as on a dangerous coast a navigator takes frequent soundings, the more often as the channel is obscured, avoiding the shoals and inevitable shipwreck. We know that the blood- vessels can bear a strain of 250 to 300 mm. of mercury as shown by the sphygmomanometer. H. W. Cook^ has called attention to this subject: ''Overexertion, either physical or mental, anxiety, over- eating — especially of meats and certain toxins (auto, bacterial, metallic, or alkaloidal) — produce a rise in blood-pressure, and, therefore, added strain on the cardiovascular system, upon the integrity of which life and health so directly depend. This rise in blood-pressure, in part physiologic, becomes, when protracted over extended periods, a most pernicious and potent factor in inducing the train of cardiovascular diseases which develop in clinical manifestation, as cerebral apoplexy, aneurysm, arterio- sclerosis, vertigo, angina pectoris, and nephritis. After the terminal affections have fully developed into clinical entities, it is too late to establish corrective treatment." ^ The author has given these baths in a case of aneurysm of the arch of the aorta with benefit. 2 Trans. Medical Society of Virginia, 1904. 54 HYDROTHERAPY EFFECTS OF THE HOT-AIR BATH The effect of the hot-air bath, circular aud cool fan douche, have been recorded by Dr. George T. Tuttle* in the case of 10 women, nurses and patients in the McLean Asylum. The in- strument used, was that of liiva-llocci. The averages noted represent at least ten observations. He shows that there is a sudden fall of blood-pressure from 5 to 34 nmi. of mercury, but this rises quickly to normal or above when the cool douche is applied. EFFECT OF BATHS ON THE RATE OF THE HEART The most striking results are noted under the influence of the hot-air bath followed by cool douches. In the hot-air cabinet IMmvuZu / 1 3 y 7 9 r// /3 !$■ n "i XI futAt loS / /oo /\ 7 \ Qo. ^ — / S. 4o \ \ \ \ \ Hot A-.V 't^ -ner J.U 5X) Cow ZMj i">s: UH It* Fig. 14. — Effect of thermic stiiimlus on the pul.se-rate. Showing a primary rise and a secondary fall of the pulse. Hot-air cabinet, 165° F. (73.8° C), eight min- utes; jet douche, two minutes. 105° F. (40..5° C), reduced to 90° F. (32.2° C); Scotch douche, 105° and 80° F. (40.5° and 26.6° C), one minute; and douche, thirty seconds, at 78° F. (25.5° C.) ; rest on couch. Figures 14, 15, and 16 are from cases observed by the author at Hot Springs, Virginia. 1 American Journal of Insanity, October, 1904. EFFECT OF BATHS ON THE RATE OF THE HEART 55 Fig. 15. — Showing the effect of thermic stimulus on the pulse. Patient A.- — -Hot-air cabinet bath at 165° F. (73.8° C), six minutes; circular douche, seventy seconds, 80° to 70° F. (26.6°-21.1° C), two minutes. Drying and rest on the couch. Primary rise of the pulse to 130; secondary fall to 70. Patient B showed a lower primary rise and in two minutes a fall from 118 to 76. -tl dUSJ ~^^ y -^ ^ ^^ k / /■ / 7^ / \ N^ ^ -^ ?<< l_ / \ \ 1,^ / \, \ «■(? / \ s, \ ir / \ \ -r« / \ \ A.r \ \ Lo ' - ' 1 > / L / / 1 '" S / f / ■- 1 7 a ; z < 1 yniiK.. Fig. 16. — Chart showing the effect of thermic stimulation on the pulse. Ob- servations made on Mr. P., aged forty-seven, on different daj's. Heart and circu- lation normal. The upper line represents a hot-air cabinet bath, temperature 173° F. for eleven minutes; circular douche 103° > 85°, 20 pounds; two minutes; jet douche, 100° > 70° F., for one minute, 20 pounds; Scotch douche, 120° and 70°, twenty seconds, 20 pounds; Fan douche, 75°, ten seconds, 25 pounds. Initial pulse 72; maximum pulse, 112; minimum pulse (20 in minute), 66. In the second bath the temperature of the hot-air cabinet was 1 65° F. Dura- tion ten minutes. Circular douche, 106° > 85°, two minutes, 21 pounds; jet douche, 105° > 70°, one minute, 22 pounds; Scotch douche, 105° and 70°, fifteen seconds, 21 pounds; fan douche, 68°, ten seconds. 56 HYDROTHERAPY at a temperature of 170° F. (76.66° C.) the author has noted a rise in rate from about 70 to 120 per minute, antl as the douche was cooled to 65° F. (18.33° C.) the pulse rapidly fell. A drop of 60 beats inside of five minutes or less has been noticed, and, as the patient was rubbed, the rate rose to a little above normal. Such changes in the rate and slight changes in the rhythm should be expected. They illustrate the (juick res})onse which the circulatory system makes to the stimulus of water applied in this manner. (See Figs. 14, 15, 16.) THE EFFECT OF BATHS ON THE BLOOD The effect of baths on the blood-count has been carefully studied by Dr. Fernald, who found that there is sometimes an increase and again a diminution in both the red and white cells, and sometimes an increase in one and a decrease in the other. If the cold bath be prolonged, the surface vessels allow an irreg- ular distribution of cells and plasma, owing to the contraction of the surface capillaries by cold. Under strong contraction it is believed that the plasma may run on and leave the cells stranded. In all general measures producing a decided hy})er- emia of the skin, it must follow that a corresponding amount of blood is withdrawn from the internal organs; and, again, as the skin is rendered temporarily anemic, the blood returns to the deeper recesses of the body. In this manner both derive benefit, and the abdominal viscera particularly become less lethargic and by increased activity favor well-being. Hydrotherapy thus starts a conflict between the center and the periphery for the possession of the blood, and its influence in promoting a rapid interchange is doubtless more significant than any particular change in the ratio of its various elements. In all general procedures in which thermic and mechanical stimuli of not too intense a type are applied to the entire sur- face of the body, with very few exceptions, there is r^ot merely a diminution of the leukoc3^tes, but an increase of the red blood-cells when a test is made from the finger-tip or the ear. EFFECT OF COLD AND HEAT UPON RESPIRATION 57 The hemoglobin may also be increased by about 14 per cent, according to Wintemitz. Moderate procedures are thus favor- able for anemic patients (see p. 159). Warm packs and com- presses tend to increase the leukocytes and diminish the red cells. Paroxysmal hemoglobinuria has been known to occur after very cold baths. This has been ascribed to some hemolytic prop- erty imparted to the plasma. EFFECT OF COLD AND HEAT UPON RESPIRATION The cold douche produces at first short, gasping respiratory movements, a sudden cold stream under high pressure producing the most marked effect. A full cold bath produces, after the first few moments, slow, full, and deep respiratory movement. The cold douche or spray accelerates the respiratory rate. Dry heat retards the respiratory gaseous interchange, in- creases the rate of respiration, but at the same time renders it less efficient and deep. During a hot bath, although the rate is increased, the respira- tions gradually become deeper. 'The skin's action is increased, but there is a corresponding elimination through the lungs of much moisture and toxic material. The sudden stimulus of hot water, as in the case of sudden stimulus by cold, tends to check the breathing in the act of inspiration. In very hot baths or those that are long con- tinued, especially w^hen the patient is not accustomed to them, there is liable to be dyspnea and weakness of the heart. In electric-light baths there is an increase in the respiration rate corresponding to the elevation of temperature. We see, then, that the rate is increased by both heat and cold. SPECIAL HYDROTHERAPY Ix ancient times water was highly regarded as a restorative, and there arc many classic allusions to the value of warm baths. These were especially advised for the aged and commonly adopted among the Greeks. Ulysses, on his return from Ithaca, found his father, Laertes, greatly debilitated, and immediately adviserl warm bathing. Ulysses, in his famous visit to Circe, was treated to a most luxurious bath, which Homer describes in the Odyssey: "And four handmaidens, who are her servants in the house, were busy in the place. But they, indeed, were sprung from the fountains and from the groves, and from the sacred rivers which flow forth into the sea. One of them threw beautiful blankets upon the thrones, purple above; but under she put beautiful linen; another extended silver tables before the thrones, and set upon them golden dishes; a third mixed sweet honeyed wine in a silver bowl and distributed golden cups; but the fourth carried water and lighted a great fire under a large tripod and water was warmed. But when the water boiled in the shining brass, having put me in a bath, she washed me and anointed me with rich oil. She threw a beautiful cloak and garment about me and, leading me in, seated me on a silver-studded throne, beautiful, varie- gated; and a foot-stool was under my feet." Sir J. Floyer, of Litchfield, published a book on hydrotherapy in London, in 1697, that went through six editions and was translated forty years later into German and published in Bres- lau and Leipsic. The sixth edition was entitled ''^i^v^po?.ovGia. The history of cold bathing, both ancient and modern; showing that the present hydrotherapeutic treatment was successfully followed in the seventeenth and eighteenth centuries, proving 58 TYPHOID FEVEE 59 its efficiency, and containing a variety of cases and cures in gout, rheumatism, consumption, asthma, insanity, fever, smaU-pox, hypochondriasis, etc., together with a few truisms for ah doctors to think upon. Abridged from the fifth edition, pubhshed in the year 1772, Manchester, 1844." Floyer, on the title page of the first edition, added: "Also proving that the best cures done by the cold baths are lately observed to arise from the temperate use of hot baths first." TYPHOID FEVER The systematic use of water in cases of ship fever or typhus apparently dates from the time of Dr. Robert Jackson,^ who used warm baths followed by cold affusions about 1774. Dr. Wright, who practised in the West Indies, applied the same treatment to himself and a companion suffering on sliipboard about 1777. In 1797 James Currie, an EngHsh ship surgeon, advocated strongly the use of cold baths in all cases of fever, and practised it successfully on shipboard. He used affusions of salt water. His writings influenced Nathan Smith, of New Haven, who practised it in 1798, very shortly after its intro- duction by Currie, whose book was translated into several languages. In 1802 Dimsdale published in London "An account of cases of typhus fever in which the affusion of cold water has been apphed in the London House of Recovery." Since that time typhus and typhoid have been differentiated. The next prominent character in hydrotherapy was Vincenz Priessnitz (1801-51), a farmer of Grafenberg, in Silesia, who practised a crude method of hydrotherapy with astonishing suc- cess. His method was to induce perspiration and then to apply cold water so as to induce a reaction. He also made use of the cold compress known as "Priessnitz' Umschlag" — a most valu- able application.^ 1 Robert Jackson, Exposition of Cold Affusion in Fevers, 1808 . 2 See Zur Wirkung des Priessnitzchen Umschlags bei der Entziindung, by Dr. H. Schade, in Kiel Munchener Medizinischen Wochenschrift, No. 18, 1907. 60 HYDROTHERAPY Credit also is due to Dr. Hiram Corson, of Montgomery County, Pennsylvania, who for more than fifty years treated typhoid fever, as well as other infectious diseases with high temperature, by means of cold baths. This remarkable man, \\ho was graduated from the University of Pennsylvania in 1828, j)ractised cold-water bathing, notwithstanding the lack of any general sympathy with the method wliich has since become popular, and he obtained success even with all the disadvantages attending country practice. THE BRAND TREATMENT It, however, remained for Brand, of Stettin, under the title "Die IIydrotherai)ie des Typhus," published in 1861, to jiopu- larize this invaluable method of treatment. There are various modifications of Brand's method which will be referred to later. It is a mistake in treating fevers by hydrotherapy to ajiply very low temperatures, very slight mechanical stimuli, and only for a short period. Such applications, according to Winternitz, raise the temperature instead of reducing it. Long cool, not cold, baths, rather intensive mechanical stimuli, trantjuil rest under adequate covering after such a bath, and its repetition at the proper time are the necessary factors. By paying attention to the body temperature alone the physician is apt to err by too frequent and too cold baths in the severe infectious diseases. In this manner nervous disturbances may be engendered, but by longer intervals, slightly warmer water, and longer baths these complications are avoided. In typhoid a very dicrotic and rapid pulse is more important as an indication for repeating the baths than a high temperature. Very rapid pulse with a still vigorous heart calls for wet packs, repeatedly changed, which in case of a slow pulse and signs of weakness on the part of the heart would be a serious blunder. The behavior of the blood-vessels is the guide for the choice of the temperature and for the length and degree of the mechanical stimulation. When the vessels display a paralytic tendency, the most energetic thermic stimulation is demanded with avoid- THE BRAND TREATMENT 61 ance of much mechanical stimulation of the skin. This may be accomplished by brief dips and douches of quite cold water.^ Alcohol. — Although Brand himself advocated it, there is some difference of opinion as to the value of alcohol given before and after the Brand bath in typhoid fever. J. C. Wilson, Tyson, Musser, Stengel, W. Oilman Thompson, and others generalty employ it. The best time is twenty minutes before the bath, so as to allow for absorption. Winternitz gives a single mouthful of wine. It has been urged, however, that nervous sensibility is lessened by its use, and the effect of the bath on the nervous Fig. 17. — Wheeled tub (An American Text-book of Applied Therapeutics). system is to that extent reduced. In other words, their effects are antagonistic. It is probable that the theoretic objections to the use of alcohol under these circumstances are not of practi- cal importance, for clinical experience does not seem to justify the objection. Dr. James Tyson's rules for use in the Hospital of the University of Pennsylvania in typhoid cases are as follows : x4bsolute rest in bed. Milk diet as prescribed by the physi- cian in charge. Patient must be encouraged to void urine before the bath. ^ W. Winternitz, Missgriffe bei Wasserkuren, in Berliner klin. Woch., April 3, 1905. 62 HYDROTHERAPY Cover loosely with a sheet ami gently lift the patient into the tub, which is placed alongside the bed. Temperature of the water usually 70° F. (21° C). Always have an air-cushion upon which to rest the head; during the bath rub the i)atient briskly in order to keep up good circulation. A compress of iced water or an ice-cap is kept on the head. At the end of fifteen minutes lift the patient into bed. Dry and lay between blankets for fifteen minutes. As soon as the [)atient ceases to shiver — usually within fifteen or twenty minutes — take the temperature. The temperature is not taken again until three hours after the bath. If it is then 102.2° F. (39° C.) or above, the bath is repeated. If the temperature is 102° F. (38.9° C.) or below, but above 101° F. (38.3° C), it is taken again in one hour; if below 101° F. (38.3° C.) and above 100° F. (37.8° C), taken in two hours; and if below 100° F. (37.8° C), it is taken in three hours. But whenever the temperature reaches 102.2° F. (39° C.) the bath is given, provided three hours have elapsed since the last bath. Eight baths may be given in twenty-four hours. The normal effect of a cold bath is a reduction of 2° F. (1.1° C). The nurse must watch the patient's face and take the pulse frequently while in the bath. In addition to the lowered temperature, the immediate effect of the bath is to add strength to the heart and to increase the volume and slow the rate of the pulse. In sponging, a thin film of water should be kept on the surface sponged, for it is the evaporation of this which is effectual in cooling the body. If the patient be constipated, a simple enema should be given every other day. Hemorrhage demands absolute quiet, cold by means of ice to the abdomen, a minimum amount of food, and elevation of the foot of the bed. Dr. J. M. Anders, at the Medico-Chirurgical Hospital, Phila- delphia, when using baths in typhoid fever, usually keeps the patient in the bath at first for only five or ten minutes; later, ten or fifteen minutes, according to the severity of the case. The head and face are bathed from a basin and a cold compress THE BRAND TREATMENT 63 is applied to the forehead at the start. If prominent nervous symptoms are present, often associated with high temperatm-e, water at 70° F. (21.1° C.) or lower should be poured from an elevation of about 6 inches upon the head and nape of the neck several times during the bath. The ears must be stopped with cotton while douching is practised. In obstinate and severe cases in which the fall of temperature may be less than 1 degree, Dr. Anders sometimes prolongs the bath to twenty minutes, or still further reduces the temperature of the water. In light cases the cold bath should be repeated every six or eight hours; in severe ones, every three or four hours, but oftener than this is not advisable, even in the worst cases. The patient should be allowed to sleep at night if possible.^ Dr. Alfred Stengel's rules for use in the Hospital of the University of Pennsylvania for typhoid cases are : Temperature, pulse, and respiration every three hours. Sponge at temperature of 101.2° F. (38.5° C). Bath at 102.4° F. (39.1° C). Have the temperature of the water 70° F. (21.-1° C). Ice-caps to head continually. Simple enema every other day if necessary. The tub is used only in cases of typhoid which begin with some definiteness of symptoms. Those that begin in a very mild way are not usually tubbed, but only in case of some manifestation. If the patient is very nervous or the bath is not well borne, they are discontinued. No children are bathed according to the Brand method, and baths are not given during menstruation. Dr. Musser's rules are: Temperature, pulse, and respiration every two hours. Sponge at a temperature of 102° F. (38.9° C). Tub at 103° F. (39.5° C). Have temperature of the water 80° F. (26.7° C). Reduce to 70° F. (21.1° C). . Milk (oiv) with lime-water (oss) every two hours. Ice-cap to head continually. Take temperature during the bath or imme- diately after, and again in fifteen minutes. As a rule, the patient should be lifted into the tub, but very 1 J. M. Anders, Practice of Medicine, ninth ed., 1909. 64 HYDROTHERAPY heavy patients, if their conditions warrant it, may step from the bed into the tub close at hand. Some permit the patient to walk a little way to the tub, but this is a needless risk. The Tub. — A good portable tub has been made according to Dr. Baruch's design. It has the advantages of allowing the patient's legs to be flexed as he lies in the tub, the feet resting against a double bottom which is filled with warm water intro- ducetl through a tube with a funnel-shaped opening near the upper margin. The water is drained off through the lower faucet. Fig. 18. — Hospital bath-tub with elevator stretcher. The tub itself is filled with colder water. This style of tub is com- fortable to the patient and, being higher, enables the nurses to handle him more easily and work to better advantage. It is also shorter and lighter than the ordinary tub. (See also p. 66.) There are cases of typhoid fever with evidence of profound toxemia, but in which the temperature is below 102.5° F. (39.2° C). Tepid and warm or even hot (104° F.— 40° C.) full baths are then indicated and friction should be applied. In this way there is a better chance to restore circulatory equilib- rium, reduce the toxemia, and favor a restoration to the normal THE BRAND TREATMENT 65 temperature of the body. H. A. Hare has always favored substitutes for the Brand method since his personal experience with typhoid fever in 1900, and there is an evident trend of opinion away from tubbing and in favor of sponging and other substitutes, unless the temperature rises above 102.5° or 103° F. (39.2° or 39.5° C). Important Guides Besides the Thermometer. — ^^Vhile it seems necessary to formulate certain rules as to tubbing, espe- cially in hospital practice, it must not be forgotten that there are important guides besides the thermometer; for, as Oilman Thompson says, this instrument only records the average or temporary balance of heat gain and loss. Excessive heat pro- duction, if accompanied by proportionally rapid heat loss, may give a low thermometric record, and j^et the obscure abnormal metabolism producing the increase in heat may be working great havoc within the body. This fact may in some degree account for the exceptionally rapid emaciation in a certain class of cases in which the thermometric record remains low throughout ; for heat production in the body is mainly due to chemic processes, its loss, to physical processes.* During the Franco-Prussian War a large number of fatalities from typhoid fever were reported in a series of cases in which the temperature did not reach 102° F. (38.8° C). Rubbing, — The intense involvement of the nervous system in severe cases is shown by the early headache and disturbance of special senses; by restlessness and insomnia and the delirium; subsultus, tremor, and the whole train of familiar symptoms. It is here that sudden cold and vigorous rubbing are demanded. Indeed, rubbing may be the keynote to the whole system of tub- bing. For the full use of rubbing Thompson prefers a full bath- tub, so that the patient may float and all surfaces of the body be easily accessible. The Cold Bath. — Liebermeister, of Basel, over forty years ago advocated the lukewarm hath at 90° F. (32.2° C), gradually cooled, but this missed the valuable stimulating effect on the 1 W. Gilman Thompson, Trans. New York State Med. Assoc, 1902. 5 66 HYDROTHERAPY nervous system and the vigorous reaction which is tho real aim of the Brand bath properly administered. "It is the energetic friction which prevents shivering, keeps the skin in good condi- tion, determines more blood to the peripheral vessels, and helps to divert the patient's mind from discomfort. A feature of no Fig. 19. — Portable bath-tub: A, Open, ready for use: B, folded, for transporta- tion (An American Text-book of Applied Therapeutics).' little importance is the increased depth of respiration obtained throughout the cold plunge bath, which antagonizes the tend- 1 A good folding bath-tub is made by Russell M. Irwin, 103 Chambers Street, New York, at a moderate price. A good portable and folding bath-tub has been invented by Dr. C. L. Furbush. THE BRAND TREATMENT 67 ency to pulmonary congestion and bronchial catarrh. As a more remote, but no less important, effect the digestion improves and nutrition is maintained, so that extreme emaciation is rare; bed-sores and general furunculosis are practically unknown, the DATE /;ir Ar /f /r /< f, V^ ?fi &./ i*^, 93 ^/ f'.A 9, ? / ^rl 10l» 1(B» 1K= 101= 100= »= «= •7= Cyrf DUOK s < X w c M E M E M E ^ E M E l/ E M E M E M E M E M E U E M E M' E M E g s< s ^ _^ : _ _ _ s — — 1 — — . fc Date 0/ admissioit....^..r.U.~.0.9 Diet Treatment .* i ,' "^. .' 1 '1 , 1 's. f \ r 1 s V, ' "^ 1 s • u ^ _ .^-i-M ft 1 ' ▼, T^ 1 \ / A s 1 ' I ^ _X. . f \ T ■ ■" ~T " ~1 r. ^ 1 101 ° - < 1 •> 1] '/ f L i J < ^v«-va * ^ ' 1 ; X 4 ^ ^ 99° 3 3 3 ^ ^ ( «> ~- ■cS 0^ 'jj £ 98*' ~ a u ■- > ^ H V _ > ^^a " J ~~ « 97° i ■— .ct •^ — > ^■' <5 ( f Vuyo/Dis - r,^ t^ ?^ P^ ?-.^: s^- ;S^; 1^ ^i4,q- 1^ t^, ^ ko.-cs- ■ivrc « ;?i^, ^S ^^ ;^ 3^ /)a(«.^ . = 5? sr> Copj/rtghi, JH^, by Jnma C H dtan, U.D. Fig. 21. — Ice rubbing in typhoid fever. Dr. Hobart A. Hare, who has used this method exclusively for ten years, has kindly furnished the author with a chart showing the effect of ice rubbing in a case of typhoid fever. Eighty-one ice rubs were used in the course of four weeks. The SUBSTITUTES FOR THE BRAND METHOD 73 chart shows a fall of temperature of from 2° to 4° F. (1.1°- 2.2° C.) after the ice rubs; and usually, also, a slight reduction in the pulse-rate and a general subsidence of the disease. The results of ice rubbing are identical with those of the Brand bath because the same principles are applied. There is the same impression upon the nervous system and circulation. Ice rubbing is used sometimes in connection with sprink- ling. Fig. 22. — Ice rubbing and sprinkling. Cot should be elevated at the head (Cohen). When hemorrhage is a complication of typhoid fever, an ice- bag or an ice-poultice should be applied to the abdomen. (See pp. 349 and 355.) Sponging with cool water is widely preferred instead of the Brand bath, and commonly adopted when the temperature reaches 101° or 102° F. (38.3° or 38.9° C). As mentioned previously, sponging is relied upon at these more moderate temperatures and the Brand treatment is reserved until the fever rises to 102.4° or 103° F. (38° or 39.5° C). In Eng- 74 HYDROTHERAPY lish hospitals sponging is generally relied upon exclusively. The author recently visited Guy's, St. Thomas', and St. George's hospitals, and found that sponging was the only hydriatric method employed. Typhoid fever is, however, fortunatel)% more rare in England than in the United States. (For the Technic of Sponging, see p. 248.) Investigation shows a marked change in the practice of bath- ing in typhoid among Continental physicians. This was sum- marized recently in "Excerpta Medica" (Leipsig, edited by E. Graetzer), in a symposium on the Treatment of Typhoid Fever, to which Eichhorst, von Striimpell, F. Schultze, Romberg, Erb, and others contributed.' They all agree as to the useful- ness of Brand's method with certain modifications, especially when there is marked disturbance of the sensorium or of the respiratory or circulatory systems. The following general statements may be made: 1. None bathe at night, between the hours of 8 p. m. and 6 A. M. 2. With but one exception, no one tubs unless the tempera- ture is over 103° F. (39.4° C). 3. Nearly every one uses the graduated bath, beginning about 90° to 95° F. (32.2°-35° C.), and very gradually cooHng to rarely lower than 80° F. (26.6° C). 4. But one or two ever exceed three baths daily, and nearly all speak of one or two baths as all that are necessary in the great majority of cases. 5. Short baths, without apparently any special regard to the reduction of temperature, appear to be most in favor. Many speak of ten to fifteen minutes' duration, some of five to ten minutes, and a few say simply "short." In view of the interest and importance of the subject, a few quotations may perhaps be made : Weintraub says "that unless the patient feels and appre- ciates the benefit of the cold bath, it is a 'torture' which is ac- tually injurious." Korach says, "Forced bathing is horrible, 1 Editorial, Colorado Medicine, May, 1909. SUBSTITUTES FOR THE BRAND METHOD 75 and injurious in severe cases." Grunert, a pupil of Liebermeis- ter, says that "Systematic cold bathing is horrible." "Luke- warm baths of 90° to 94° F. (32.2°-34.4° C.) are desirable and sufficient for most cases," is the conclusion of Eichhorst. Len- hartz recommends "92° F. (33.3° C.) of five to ten minutes' duration, for the most part, twice daily." According to Schulze, "Their unremitting apphcation is barbarous." Prof. Umber says, " We bathe most cases only once a day." Erb, one of the few who are still ardent apostles of the Brand method, says, "It is not an antifebrile meassure"; he bathes, therefore, in all cases, but in the lightest only once daily, and in the moderate, twice, for ten to fifteen minutes in a bath gradually reduced from 95 ° to 75° F. (35°-23.8° C). According to von Striimpell, "One or two baths daily mostly suffice ; it is most earnestly warned against excesses." And, finally, Romberg writes as follows: "In the use of tubbing we cannot be guided by the temperature," having before emphasized the supreme importance of the condition of the sensorium and of the respiratory organs as an indication. "For the most part, one or two a day are enough," and "we prefer not to go below a temperature of 85° F. (29.4° C). Sprinkling is a good substitute for the Brand bath and is often better borne; it certainly is more easily carried out and has many advocates. The head of the bed is first raised 10 or 12 inches from the floor. Three boards as long as the bed is wide are placed cross- wise under the mattress to keep it from sagging. A rubber sheet covered with a linen one is placed under the patient, whose head, wrapped in a cool wet turban, rests on a pillow. The night-dress is removed, and the water, at a temperature 10 or 12 degrees cooler than would ordinarity be used in the bath, is applied from a sprinkling pot or from an irrigating apparatus provided with a large rose nozzle. Active friction is kept up as in the Brand bath. Some practitioners use a dry linen sheet over the patient and sprinkle this with ice-water, using friction. The water should come from a height of 2 or 3 feet and should be directed chiefly to the abdomen and lower extremities. The 76 HYDROTHERAPY surplus water should be allowed to drain into a pail or tub. The patient is then wrapped in a dry sheet, covered with a blanket, and rubbed. The process is repeated as in the directions for the Brand bath. (See p. 60.) The wet cold pack is another substitute, but its application is more exhausting to the patient than sprinkling, for it has to be renewed more frequently. Dr. Anders finds this method of great use in children. (For Teclinic, see p. 340.) The sheet bath (Lakenbad, of Strasser) is preferable as a substitute for the Brand bath. The linen sheet is soaked in water at from 50° to 80° F. (10°-26.7° C), as may be desired. The head and face of the patient are bathed in iced water and a cool wet turban is wrapped around the head. The bed is pro- tected by a rubber sheet on which is placed the wet sheet partly wrung out. The patient is now placed upon the wet sheet, and, while his hands are held above his head, one side of the sheet is laid over the chest close under the axilla and bej'^ond the axillary line of the opposite side, and folded in between his legs. The arms are now brought down and the opposite side of the sheet is then passed across the body and snugly fitted in place, covering the arms and shoulders and tucked under; the lower end is tucked under the heels. The nurse should rub the body thus enveloped and should pour cups of water at 50° or 60° F. (10° or 15.6° C.) as the sheet warms, and commence rubbing again. This is continued until the patient feels cold or shivers cjuite perceptibly. More friction, how^ever, will obviate this. He may lie in pack, if comfortable, for half an hour, the rubber sheet being withdrawn and a blanket substituted. The wet cold pack should be employed where tubs are not to be had or when tub-baths are opposed. (See p. 340.) Ice -water enemata may be tried in desperate cases. Hot Sponging. — Thif* substitute for bathing sometimes yields excellent results when the patient is very nervous, or when, for any other reason, Brand baths cannot be given. The water should be at about 110° or 112° F. (43.3° or 44.4° C); in SUBSTITUTES FOR THE BRAND METHOD 77 another receptacle containing water at about 100° F. (37.8° C.) place a 2-ounce bottle of grain alcohol. Sponge the limbs separately and then the body for ten min- utes, and finish with a quick general rubbing with the warm al- cohol. This is an excellent method, especially for children. The temperature of the water and alcohol may be lowered and its strength varied as judgment and experience with the patient may indicate. The alcohol sponge may be tempered to suit the feelings of the patient and the strength may vary from 25 to 95 per cent. Oil Inunctions. — Among other substitutes for bathing, used with great success when cold applications cannot be given, are inunctions of oil. Although they are not hydrotherapeutic measures, they are mentioned here because cases have arisen and will be met with in which the external use of cold must be discontinued owing to the extreme depression and shock it produces. After inunctions of oil the patient is more comfortable, the temperature is slightly reduced, and sleep is favored. There seems to be less waste and prostration.^ Conclusions. — ^As far as substitutes for the Brand bath are concerned, we need more extensive statistics of the results of treatment by sponges, ice rubbing, etc. Elaborate reports are accessible in reference to baths, and we acknowledge the good results obtained. Dr. McCrae ^ says of the substitutes for Brand baths: "They have no marked influence on the general condi- tion, and while they give comfort and are undoubtedly helpful, their effect is in no way to be compared to that which follows hydropathy in the form of baths." Much of the benefit of hydrotherapy is attributed to the greatly increased excretion of toxins. One of the errors which most of us are still laboring under is our attitude with reference to the presence of fever and a failure to recognize its remedial 1 See John H. Musser, A Protracted Case of Typhoid Fever: Some Features of Treatment, Trans. Phila. Coimty Med. Soc, 1895. 2 Osier and McCrae's System, vol. i, p. 213. 78 HYDROTHERAPY character. Patients are not to be treated in a routine manner, and fever patients, above all, are not to be given antipyretics, either internally or externally, simply because the body tem- perature rises above a certain mark. Attention has been called of late by our best clinicians to the fact that either a local or general fever develops in practically all infectious processes, failing to develop only in those cases in which the infection is so overwhelming that the organism does not have an opportunity to protect itself. If an animal be given a moderate infection it speedily recovers if fever is permitted to occur, whereas, if fever is prevented, it dies.^ Dr. Hare has pointed out that if fever is prevented by the use of antipyretic measures, infections otherwise innocent prove fatal, and from this we learn the important fact that in the vast majority of instances the physician should not attempt to modify fever, but rather to regard it as a helpful ally, and as a manifestation which will help him materially in guaging the severity of the ill- ness and the ability of his patient to combat it, although when the fever becomes a hyperpyrexia, exceeding 103° or 104° F. (39.5° or 40° C), for a considerable period of time, it may become a symptom which requires attention. This view, at first sight, may seem to be in opposition to the well-recognized value of the employment of the cold bath in typhoid fever, but in reality no such antagonism exists, because it has been proved that the use of the cold bath in typhoid fever actually increases the production of heat in the body, and probably at times actually raises the temperature of the internal organs, at least for a few moments. In other words, the use of the cold bath in typhoid fever, to use a simile, opens the draughts and increases oxidation processes — that is, it increases the production of heat, although at the same time a large amount of heat is abstracted from the body by its exposure to cold. To express it differently, the metabolic changes which are produced by the increased oxidation processes associated with the cold bath aid the system materially in combating the infection, not only the heightened * H. A. Hare, Therapeutic Gazette, March 15, 1910. MEASLES 79 temperature, but the metabolic changes, as just pointed out, being protective in their nature. MacCallum ^ goes so far as to express his conviction not only that the febrile process is an action beneficial to the organism, but believes that it is intimately associated with the development of protective substances to combat the injurious agencies which have invaded the body. MEASLES In measles the common practice is to use lukewarm baths, 96° to 98° F. (35.6°-36.7° C), to bring out the eruption and, possibly, cool sponging if the fever be high. European authori- ties, especially Winternitz, hold that the indications are for powerful mechanical with only slight thermic stimulation. Rub- bing down with a fine linen cloth wrung out of quite cold water responds to the indications in measles. The delayed eruption frequently appears at once after this procedure, and threatening symptoms vanish. If the child be irritable, the nurse may sponge with a mixture of one-fourth alcohol and three-fourths water at 80° F. (26.7° C.) under the bed-clothes, and thus prepare the way for full baths. There is no objection to giving cool water to drink during the febrile stage. Hot full baths at 103° F. (39.5° C.) have been warmly advo- cated by Dr. Friedrich Grosse, of New York, for very young children.^ The duration is only three minutes for a child one year old, but may be lengthened to four or six minutes later on. Some hotter water is added during the bath, so as to bring the temperature up to 106° or 107° F. (41.1° or 41.6° C), and this proves a wonderful stimulant in cases of impending collapse. The baths are repeated several times a day. Children do not react to cold water, and in poorly developed and poorly nourished children the higher temperatures of the bath are much better borne. They require baths considerably higher than adults. The late Dr. Hiram Corson, of Pennsylvania, treated thousands 1 W. G. MacCallum in his Harvey Lectvire, 1909. 2 Archives of Pediatrics, May, 1908. 80 HYDROTHERAPY of children with measles, and claimed that he never lost a case. He gave a laxative and sponged the whole body with cold water.' In severe cases baths may be given ever}' two hours night and day at 60° to G8° F. (15.6°-20° C). In general, the hydro- therapy of measles is similar to that of scarlet fever. Currie's method of cold bathing in these diseases applies to the more severe types.^ SCARLET FEVER Ordinarily in scarlet fever the patient should be sponged over the entire body twice a clay, using three-fourths water and one- fourth alcohol, cold, cool, or lukewarm, depending upon the fever. Petrolatum or cold cream should then be used. In mild cases a lukewarm or hot bath is commonly used to favor the action of the skin; but in severe cases, where the vessels display a paralytic tendency, the most energetic thermal stimula- tion is demanded, with avoidance of much mechanical stimula- tion of the skin. Brief dips and douches of quite cold water are often surprisingly effectual. The most prominent signs of collapse and heart weakness, in this as in other affections, are the high temperature in the mouth and rectum, with clammy extremities. This condition calls at once for the application of heat to the periphery and the ab- straction of heat from the trunk. Cold packs to the trunk and heat to the extremities will save many a desperate case. Even in desperate cases it will be a mistake to apply water too suddenly to the patient, and thus frighten him and arouse antagonism. The requisite degree of cold may be obtained by gradual stages, thus avoiding nervous excitement of the child and retaining the confidence of the parents. There is a prevalent and time-honored belief that cold water should not be used in scarlet fever and measles lest the rash be repressed or "go in," and it takes courage, tact, and good judgment on the part of the attending physician to adopt and carry out successfully measures 1 See University Medical Magazine, Philadelphia, 1891. 2 James Currie, Medical Reports on the Effects of Water, Cold and Warm, as a Remedy in Fever and Other Diseases, London, 1797. SCARLET FEVER 81 SO much opposed to widespread belief. However, the public is gaining confidence in the use of cold water, especially since the Brand method of cold-water bathing has been so widely practised with such evident success. The more prevalent use of cold com- presses and ice in pneumonia has also aided in this change of sentiment. The best of modern specialists in children's diseases hold that there is no disease of childhood with high temperature in which the application of water to the skin does harm. The indications for the use of cold are high temperature, restlessness, loss of sleep, rapidity of the heart, and an evident lowering of the vitality. The degree of temperature cannot be stated arbitrarily; at least, the thermometer must not be too implicitly relied upon. In some cases unfavorable symptoms may coexist with a temperature of only 103° F. (39.5° C); in others at 104° or 105° F. (40 or 40.5° C). The physician must be the judge, and it is probably better to begin the use of cold at the lower temperature of 103° F. (39.5° C.) than to wait for the development of the higher record. Cases must be decided on their individual needs. The Cool Pack in Scarlet Fever. — This is a safe and effective method of meeting pyrexia and its associate bad symptoms. The use of this cooling wet pack in the graduated method advocated by Kerley^ is practical because it avoids unnecessary shocks, is easily applied, and accomplishes good results. It is given as follows : Preparation of the Cool Pack. — First the bed is protected with a rubber sheet. A large bath-towel or some thick, soft absorb- ent material should be used for the pack; muslin, Hnen, or any thin material does not answer so well. Slits are cut in the towel large enough for the arms to pass through, and the towel is folded around the body, enveloping only the trunk and but- tocks. The pack should not extend below the middle of the thighs. This leaves the arms and the greater part of the lower extremities free. A hot-water bag, carefully guarded, should be placed at the feet and the patient covered with a blanket 1 C. G. Kerley, Jour. Amer. Med. Assoc, Oct. 24, 1908. 6 82 HYDROTHERAPY of medium weight. The towel is moistened with water at 95° F. (35° C). This higher temperature is necessary at first in order not to frighten the patient, as sudden cold is likely to do, and also to avoid shock. In two or three minutes the towel, without being removed, is again moistened with water at 90° F. (32.2° C), later with water at 85° F. (29.5° C), and still later at 80° F. (26.7° C). When the temperature of the water reaches 80° F. (26.7° C.) it is better to hold it at this point for half an hour; then the patient's temperature should again be taken. If at the beginning his temperature was 105° F. (40.5° C.) and now shows but slight or no reduction, the temperature of the water with which the towel is moistened should be reduced to 70° F. (21.1° C.) or, if necessary, even to 60° F. (15.0° C). The child throughout need not be disturbed, except to turn him from side to side to wet the towel with water of the desired tempera- ture, this being one of the advantages of the pack over a tub- bath or sponging. Duration of Pack. — For the first hour or two in a pack the temperature of the patient should be taken every half-hour. When it is reduced to 102° F. (38.9° C), the pack should be removed, for, if it be continued longer, too great a reduction may take place. If it rise again rapidly to 105° F. (40.5° C.) or higher, it is well to keep the patient in the pack continuously. The degree of cold necessary, in the individual case, to keep the temperature within safe limits will soon be learned. In a case of lobar pneumonia, the patient, a boy four years of age, was kept in a pack for seventy-two hours. A continuous pack of 70° F. (21.1° C.) was required to keep the temperature at 104° F. (40° C.) or slightly lower. The towel or other material employed should not be used for more than six hours, when it should be changed for a fresh one. Another reason for frequently taking the temperature is that early in the attack we do not know how it will be affected by the con- tinued cool applications. In some children it is very readily influenced, and in such a case collapse might follow a very sudden reduction of the temperature. In cases readily controlled, the SCARLET FEVER 83 pack may be necessary for only one-half hour or an hour, at intervals of three or four hours. An ice-bag may, with ad- vantage, be kept at the head when the child is in the pack. In ordinary cases a daily warm bath at 90° to 98° F. (32.2°- 36.7° C.) may be given, but little friction should be used in drying the body. Such a bath tends to reduce the body heat and to quiet restlessness. If the temperature of the bath be above 98° F. (36.7° C.) or below 90° F. (32.2° C), there is a liability to depression or collapse. Such a bath obviously cannot be continued very long, and, besides, is likely to frighten the child and render any bathing difficult. Baths between 90° and 95° F. (32.2° and 35° C.) are most agreeable and may be repeated every three or four hours, if need be, without any unpleasant effects. Water at 92° to 94° F. (33.3°-34.5° C.) has a sedative effect, and affords a protection to the central nervous system from reflex irritation. Hence, bathing should be instituted early, so as to forestall convulsions and delirium. The presence of somnolence, nervous depression, or unconsciousness is not to be construed as counter- indicating this manner of bathing. Dr. D. S. Hanson, of Cleveland, has strongly advocated bath- ing in scarlet fever^ and cites some remarkably good results : "If a bath-tub be at hand, the patient may be lowered into it lying on a sheet, and a rubber air-pillow placed under the head is a convenience, but neither are a necessity, and my patients have invariably been bathed in an ordinary wash-tub, such a luxury as a bath-tub not being at hand. "I wish especially to emphasize the early use of the bath, for in these severe nervous cases changes go on very rapidly in the central nervous system. For example : I recently treated a case of cerebrospinal meningitis in which fibrin and pus were present in the cerebrospinal fluid within twenty-one hours from the beginning of the attack, and changes in the foudroyant tj^pe of scarlatina are often equally severe and rapid. " In the toxic type, with high fever, intense rash, great rest- 1 Jour. Amer. Med. Assoc, Oct. 17, 1908. 84 HYDROTHERAPY lessness, often with double rash, rapid respiration and pulse, often beginning with convulsions and great mental depression, later often with cold extremities and cyanosis, even cases occur in which toxemia is intense, with little or no elevation of tem- perature, but with marked depression of the nervous system, manif(>sted by delirium, somnolence, apathy, or unconsciousness. "It is in the early stages of these severe toxic cases where the happy effects of this line of treatment can most frequently be seen, although in cases with high temperature, where these severe nervous symptoms are not present, the benefits to be ob- tained are nearly as striking and will do more good than any other single measure. "The method I have used with the most satisfaction is with the water at a temperature of 90° F. (32.2° C), each bath lasting from five to ten minutes, with very gentle friction to the body surface while in the bath, the bath to be repeated sufficiently often to control temperature and symptoms. Sometimes it has been necessary to do this as often as every two or four hours for three or four days." "Case 1. — E. W., aged five years. The case was ushered in by a convulsion, vomiting, and diarrhea; the convulsion was im- mediately followed by somnolence and muttering delirium, temperature very high, and rash beginning to show on neck and chest. The bath was inmiediatoly given, and the child conversed intelligently with her father before being removed from the tub. The tubbing was continued as indicated by rest- lessness and elevation of temperature for three or four days, resulting in a good recovery and no sequelie." "Case 2. — E. H., aged three and one-half years, seen the second day of an attack that was of apparently no great severity Crectal temperature not above 102° F. (38.9° C.) at any time) and rash well out, with a phanrngitis of moderate severity, kidneys normal. Her father telephoned that the child seemed disturbed mentally, that she did not seem to understand what was said to her, antl was delirious. On mj'- arriA'al, a half-hour later, she was apathetic, muscles of face twitching, she could not be SCARLET FEVER 85 aroused from stupor, and was constantly muttering. The bath had as happy an effect as in the last case, the nervous symptoms disappearing like magic. This case illustrates the benefit to be derived in nervous depression when not dependent on high tem- perature, and must have produced such marked results in some way independent of its effects on the temperature." " Case 3. — This was in a child, aged six, rapidly passing into a very dangerous state. Bathing was recommended as the only treatment. The recommendation was accepted and the treat- ment immediately begim. A bath at the temperature of 90° F. (32.2° C.) was used, with plenty of cold water poured on the head while in the bath. The duration of the bath was fifteen minutes, and was continued every two hours day and night. There was no change the first day, except that the temperature was reduced to and held at 103° F. (39.5 C). After twenty-four hours' bathing the condition of stupor was much improved. She was now conscious of her surroundings and resisted when put into the bath. She also drank water and a little milk. "A little medicine was given from now on, but the baths were yet continued day and night. By the fourth day the rash began to appear and was very profuse two or three days later. The throat symptoms were also very severe. The stupor and rest- lessness soon disappeared and the progress of the case was in every way satisfactory. There were no sequelae of any kind except five or six abscesses which developed during the period of convalescence." K. Oppenheimer ^ discusses the treatment of scarlet fever with particular reference to baths and diet. He disagrees with the majority of the German authors, agreeing rather with French and American observers in regard to baths and cold sponging; he does not employ them unless the nervous system is affected. He considers their influence dangerous for the heart, and, more particularly through the possibility of taking cold, for the kidneys. He thinks that cold water, even if applied in the form of packs, is liable to chill the kidneys and lead to nephritis. In the first 1 Miinch. med. Woch., 1908, iv, 1691. 86 HYDROTHERAPY stage of the illness his treatment is purely expectant; rest with plenty of water is probably all the child requires during this time ; if the child does not wish to eat or drink, he does not force food, but considers the rest more important. As soon as the child evinces some appetite, milk is given, also diluted tea; later in the disease any food usually given a child is allowed, with the excep- tion of meat, eggs, and their products. He emphasizes that none of the foods must be salted too much. He keeps his patients in bed for from five to six weeks; in the sixth week he permits warm bathing, using a 1 per cent, corrosive sublimate solution for the body. He has never seen a single kidney complication during the last eighteen years, although he has treated in that time more than 150 cases. If adenitis threatens, cold compresses nmst be j)romptly ap- plied to the throat and neck, and repeated hourly. Early bathing favors early desquamation, and in older subjects this is a great advantage in shortening the period of communica- bility. Unusual efforts to detach the skin from the body are not advised. A good method is to soak the soles of the feet once daily in a solution of sodium carbonate (washing-soda) for ten minutes and then in hot soapsuds for the same length of time, after which they are to be rubbed with a coarse towel. The strength of the soda solution should be about 1 ounce of soda to 2 gallons of water. Bathing in this manner favors desquama- tion and shortens the time of quarantine.* Oil Inunctions. — As a substitute for hydrotherapy in scarlet fever inunctions of oil are useful. They are almost always grateful to the i)atient. Diphtheria. — In this disease cold gives relief. Powdered ice, enclosed in thin rubber bags, may also be bound over the throat and under the ears. Similar measuses may be used in parotitis, although hot applications will generally be found more grateful. 1 See Pfaundler and Schlossman, English translation; also article on Hot Baths in Scarlet Fever, by H. W. Rorer, Colorado Medicine, July, 1908. CEREBROSPINAL MENINGITIS 87 CHOREA After washing the child's face in cool water, he is placed gently in a tub of water of 90° to 98° F. (32.2°-36.7° C). This temperature will prove agreeable at the start. The water can be cooled not more than 10 or 15 degrees during the bath. Children can usually be amused for an hour with playthings or floating toys, so that the time will pass rapidly. The bath may last an horn- and be repeated once in the day. Toward the end of the bath there should be superficial massage of the arms, legs, and trunk, and after removal from the bath the child will prob- ably take a nap. Success by this method without medication has been reported. Coincident heart disease offers no counter- indication. Wet packs of from one to one and a half hours' duration are useful in chorea when baths for any reason are not convenient, but wet packs should not be given when there is great weakness, especially of the heart. They should be used in connection with a cold precordial coil after the manner of Buxbaum. The coil should not be appHed directly to the skin, nor allowed to remain in place more than thirty or forty minutes at a time, and in some cases less, as the ice-water in the coil may chill the surface, render- ing it cyanotic. After fifteen minutes' interval the coil may be reapplied. (See p. 386.) In a case observed by Kraus an intense and slightly febrile chorea was developed while the patient was under hydrothera- peutic treatment for the relics of subacute articular rheumatism. CEREBROSPINAL MENINGITIS Warm baths are indicated in this formidable disease. The water temperature should be 104° F. (40° C), and the bath may be continued for thirty to forty-five minutes and given three or four times daily. Although the writer has not had any ex- perience in treating this disease, reports of others show that there is a marked amelioration of the symptoms and a decrease in mortality in cases treated by hydrotherapeutic measures.^ 1 Albany Medical Annals, March, 1905. Article by C. G. Stockton. 88 ■,, HYDROTHERAPY To obtain the best results the treatment should be given early. Aufrechtjin 1894, initiated this form of treatment, and Rogansky,^ in 1904, published the records of 51 patients treated with baths at 104^ F. (40° C.) for fifteen or twenty minutes, once or twice a day. Ice-bags were always placed on the head of the patient during the bath. The baths had' a marked effect in relieving delirium as early as the first or second bath, and always relieved pain. Of the 51 patients, 34 were cured and 17 died — a mortalit}'- of 33 per cent. In the men's ward of the hospital during the same epidemic 50 cases were treated by other means, and the mortality was 80 per cent. Dr. Alfred Wolisch reports 7 cases, of which 5 completely recovered. Of the deaths, 1 was a foudroyant case, which died within forty-eight hours; the other 4 died in the late stage of the disease, the baths being employed only during the first two weeks. No statement can be definitely made as to the precise action of the baths, although it is probable that the resulting hyperemia of the skin lessens the amount of blood contained in the brain and spinal cord. It is also likely that in the markedly increased perspiration the toxin which has accumulated in the blood may be eliminated. These baths in the reported cases seem to lower the temperature, to have a toning and regulating influence upon the heart, and to relieve pain and restlessness. They may be used in connection with Flexner's antimeningitis serum with good effect. The method is as follows : The patient is placed in the bath at the temperature of 90.5° to 92.75° F. (32.5°-33.8° C), and hot water gradually added until 104° F. (40° C.) is reached. While in the bath an ice-bag or a Lciter cold-water coil is placed on the head. The placing in and removal from the bath are done with great care and rapidity ; this means close proximity of bath and bed, and both should be at the same level. If there be great tenderness of the back, the sheet may be used to move the patient. The bath must be previously cushioned and thorough after-drying omitted. The patient is placed upon a 1 Meditsinskoye Obozreniye, October, 1904. TETANUS 89 dry sheet, laid upon a woolen quilt, with which he is covered. A light cover is then placed over him, and he is allowed to remain in this position for one hour. The time of the bath is immaterial — early morning or late evening. Nourishing food, even meat, should be given. Even diarrhea, should it occur, • does not contraindicate the bath. Wine, brandy (in milk), also beer are given, for the author regards alcohol as a tonic and hypnotic of the first rank in this disease.^ The hot bath may be given in the convulsions of children, but priority should be given to such medicinal measures as the chloral enema, chloroform, or nitrite of amyl inhalations. For the technic see p. 88. TETANUS In tetanus the hot pack (see p. 341) is a valuable accessory to other forms of treatment. Warm baths, also, are indicated. Cold baths were strongly advocated by James Currie as early as 1781, and cold affusions by Wright, of Jamaica, who was accustomed to treat tetanus in the West Indies. Currie treated a soldier in February with salt-water baths at 36° F. (2.2° C), into which the patient was plunged headlong and afterward en- veloped in warm blankets and rubbed briskly. The result was most satisfactory after all other measures had failed. Currie relates other cases successfully treated in this way, and quotes Hippocrates and Avicenna as having used cold baths in the treatment of tetanus.^ The modern treatment of tetanus with antitetanic serum and warm baths and packs is more successful than the ancient method of cold bathing. Yellow Fever. — In the early stage the patient should be given a hot mustard bath or foot-bath. Blankets should be used until free perspiration occurs. iTherapeutische Monatshefte, 1896, Heft 5, S. 254. " Hippocrates Aphor., 21, liber 5; Avicenna Liber, 3, cap. 7. 90 HYDROTHERAPY Cholera. — In case of collapse the patient should be placed m a hot bath (104° to 105° F.— 40°-40.6° C.) for ten minutes, and this may be repeated every two or three hours. Hot wet packs may be used in place of baths. INSOLATION; SUNSTROKE; HEAT STROKE; THERMIC FEVER Hydrotherapy is the sheet-anchor of treatment in sunstroke or thermic fever. The rapid onset and the very high degree of fever demand prompt action, death occurring sometimes within an hour. The patient should be stripped of clothing and placbd on a stretcher covered with a mbber sheet. The head should be slightly raised, an ice-cap applied, and iced cloths, frequently changed, placed about the forehead and neck. For the excessive temperature, sometimes reaching 106° tp 108° to 110° F. (41.1°-42.2°-43.3° C), the patient should be sprayed with ice-water, using a watering-can or syringe with a fine nozzle. A sprinkler provided with a temperature-indicating handle will prove very useful (see p. 245). A cold sheet bath is also excellent. Vigorous friction should be used all over the body and the limbs during the entire time in the sheet or under the spray. Dipperfuls of cold water may be dashed on the patient. The duration of the bath is, to some extent, regulated by the fall in temperature. ^Yhen this falls from 106° or 107° F. (41.1° or 41.7° C.) to 102° F. (38.9° C), or from 108° or 110° F. (42.2° or 43.3° C.) to 103° F. (39.5° C), the patient may be placed in bed with an ice-cap applied and covered with a thin sheet. Friction of the skin to bring the deeper blood to the surface; the use of ice-water enemata; and, in cases where the pulse is tense and full and the mental state bad, the use of free venesection can be carried out. Later the bath should be re- peated. A little cold water should be given by the mouth when possible. An ice-water enema is given as follows: By means of a insolation; sunstroke; heat stroke; thermic fever 91 rectal tube 4 or 5 pints of water, gradually lowered from 90° to 45° F. (32.2°-7.2°C.), are introduced high up into the rectum and allowed to be retained for about ten minutes. Using the warm water first favors retention, so that a second injection at 40° to 45° F. (4.5°-7.2 ° C.) wiU not be expeUed. One can give an ice-water enema with a minimum of ice. In India this is a favorite army method and very successful since its introduction by Captain W. A. Heppolette and Captain Foulds. The latter relates his experience with 9 cases of sun- stroke occurring when the thermometer ranged from 105° to 115° F. (40°-46° C.) in the shade. These men were taken into the hospital unconscious and with deep stertorous breathing, dry burning skin, and a temperature of 107° to 110° F. (41.4°- 43.2° C). They were stripped and put to bed in the shade. One attendant poured water over them as cold as could be ob- tained, and two others rubbed the body with ice. An enema of about 1 quart of ice-water was given every ten minutes until the axillary temperature fell to 102° F. (39° C). All the patients recovered.^ Six other men were taken into the hospital, drowsy and complaining of pains in the head and dizziness, and with temperatures varying from 103° to 105° F. (39.4°-40.5° C.)— i. e., with all the prodromata of sunstroke. They were treated with ice-water enemata and left the hospital quite well on the following morning. The time element is very important and there should be no delay. It is better to apply the best measures at hand than to wait to transport the patient any distance. One can certainly loosen the clothing and dash water as cold as can be had against the temples and the throat.^ During hot weather ambulances should be provided with ice and water, so that affusions and ice rubbing can be immediately practised. Cases of sunstroke have been lost for lack of any such provision. ^ Indian Medical Gazette, December, 1906. 2 See articles on Treatment of Sunstroke, by Drs. Dryce, G. W. Longen- ecker, R. A. Bachmann, U. S. N., T. H. Ross, G. B. Foster, New York Medical Jour., July 4, 1908; see also p. 245 for technic, and p. 436 of Appendix. 92 HYDROTHERAPY Nitroglycerin hypodermically, by dilating the peripheral vessels, aids hydrotherapy in all such cases. More blood is thereby exposed to cold and a reaction is favored. After spray- ing it is often a good practice to wrap the patient in a blanket and put a hot-water bottle to the feet. A great deal has been written about the use of ice-cold full baths and some even advise packing the body in ice. Others use ice rubbing. The latter is somewhat more rational, but ice packing should be condemned. It does not permit of the most important element in the treatment — the vigorous rubbing. The patient will not respond to a too general application of cold : the nerve-centers are too much impressed in severe ceases to react, and, in the absence of friction, the natural recuperative powers are held in abeyance. Baruch's advice is undoubtedly sound and he has made for years a strong plea for the spray bath and afTusions with con- stant rubbing, recognizing the fact that nerve depreciation is the chief lethal factor; that the nerve-centers are so overwhelmed by the high atmospheric temperature acting on predisposed individuals that the patient is incapable of response to the simultaneous impact of very cold water against the entire body. Moderation in the use of cold will be the keynote of success in these cases. It is probably the failures resulting from the excessive use of cold in these cases that has led so many hospitals to establish tents outside of the permanent buildings. In many cases of sunstroke treated in these tents very little is done except to cover the patient with a sheet, apply an ice-cap to the head, and sponge with cool water. In 1896 there was great mortality in New York from heat. Dr. Baruch gives the statistics of 520 cases of sunstroke which were treated in the New York hospitals. Of those who were treated with ice-baths ranging in temperature from 50° to 75° F. (10°-24° C), one-third were reported to have died; while in 197 cases treated with affusions of cold water, discontinued when the temperature reached 103° F. (39.5° C), the mortality TUBERCULOSIS 93 was only 6 per cent.^ The good results of cold-water sponges, affusions, or baths are probably attributable more to a reflex action on the nerve-centers than to the incidental withdrawal of heat. Hence we should not fix our attention on heat reduction , especially from the higher stages of 108° or 109° F. (42.2° or 42.7° C.) to near the normal mark in a single bath, but rather on the moderate use of cold, a better action of the heart and respiration, and on the state of the nervous system. TUBERCULOSIS Prophylaxis. — Hydrotherapy ma}^ serve a useful purpose in the prevention of tuberculosis. No uniform method is ap- plicable, but the age and general constitution will afford a guide in all measures for the invigoration of the external circulation. A child of two or three years may be gi'adually accustomed to the use of cool water after the warm bath. This cool wash may be ap- plied while the child stands in the tub with the warm water covering the feet, or while lying on the nurse's lap or on a mat- tress, or a wet sponge may be squeezed over the body. These procedures should be followed by friction. A brisk rubbing for one or two minutes with a wet towel and afterward with a dry towel until the surface is dry and warm is sufficient. Older children may plunge into cool water for from half a minute to several minutes, according to the season, the bath, whether warm or cool, being accompanied by thorough friction. Cool water bathing must be approached cautiously and with tact, as most children dread it and any sudden or unlooked-for shock will frighten the child. No amount of persuasion will in- duce him to take a second bath, not to speak of the unfavorable effect on a sensitive nervous system. The child that needs the treatment most will probably rebel the loudest. Cold water and friction presuppose a healthy heart and some strength. It is, therefore, necessary to cultivate a reaction by imperceptible gradations of temperature taken by the aid of a bath ther- mometer with favorable atmospheric conditions. Dr. Abraham 1 Medical News, July 24, 1897, Sunstroke in New York in 1896. 94 HYDROTHERAPY Jacobi, who strongly urges this plan of fortifying the system in the young, also points out that the healthy child undergoing this plan of treatment should be given a respite when taken sick or when convalescent from any acute disease oy whenever he lacks the necessary vigor. A child under size and under weight and all children under two years of age should be spared a temperature much below the body heat. Children also should not be allowed to go about with knees anii legs entirely exposed to the cold of our northern winters. AVhenever the feet after a bath or washing do not warm as quickly as the rest of the body, they should be rubbed with warm water or with a mixture of alcohol and warm water until there is evidence that the constitution is improved and fortified. Sea bathing and sunning on the sand are excellent prophylactic measures when gradually employed and not carried to extremes. The exposure of the limbs and the partial exposure of the body through thin bathing suits to the action of sun and air, develop- ing tan and increasing the tone and natural resistance of the skin, constitute the best safeguard known against tuberculous dis- ease, whether in the bones, the glands, or the lungs. Sea bathing may thus be employed as a preventive measure. In a suitable marine climate we may have a prevention sanatorium or a 'preventorium, as it has been called, in which hot and cold sea- water baths are afforded. Surf bathing would probably be dangerous for cases of pulmonary tuberculosis, but tub-baths with sea-water rubbing would doubtless be attended with benefit. Rait rubs, in which cloths or the bare hand, after being wet in warm water, are dipped in finely ground salt and then rubbed over the body, are also appropriate. Cornet's method of hydrotherapy in tuberculous cases in- volves the use of a 5 per cent, solution of salt (twice the strength of sea- water) at 90° F. (32.2° C). A sensitive patient, in the winter, begins with ordinar}' rubbing by an attendant morning and evening. No water is used at first. The patient is put into a large coarse sheet on a firm bed and rubbed with long quick strokes from head to foot, so that a strong glow may be brought TUBERCULOSIS 95 to the skin. In a week or so this is modified by rubbing the trunk and members with a wash-cloth wrung out of water, which in successive appHcation is lowered from 92° to 66° F. (33.3°- 18.9° C.) until there is a ruddy reaction. The patient is then covered and permitted to rest for half an hour. This treatment may be given daily and preferably before breakfast on an empty stomach; but weaker patients may have a glass of warm milk, or coffee or tea half an hour before ; or the patient may take a short walk or have a dry rub previously, so as to favor a good reaction. If the preliminary treatment has been found satisfactory, the following program may then be adopted regularly: The patient, entirely nude, is wrapped in a linen sheet wrung out in 5 per cent, brine at 90° F. (32.2° C), so appUed that it comes in contact with the entire body. As the course of treatment progresses the sheet may be applied dripping from the brine. The patient is then rubbed by a trained rubber, with long power- ful strokes, until there is an agreeable feehng of warmth over the entire body. A cloth wet in cold water may be laid on the head to prevent headache. The rubbing lasts but one or two minutes, after which the patient is laid on a dry sheet and again rubbed. He dresses without delay and goes out into the open air for at least half an hour. After this walk he takes breakfast. Weaker patients get into bed for at least half an hour. The temperature of the brine is lowered 1° F. (.54° C.) with each appHcation, until 70°, 65°, or even 60° F. (21.1°, 18.3°, or 15.6° C.) are reached. The full rub should be done quickly, expertly, and energetic- ally, and preferably by a trained attendant. Experience will show how headache, discomfort, and chilliness may be avoided. Douches may be used, but Cornet limits them to those who are fairly strong and then only in the physician's presence. The temperature should be from 90° to 95° F. (32.2°-35° C.) or warmer. The patient must rub himself during the douche. After he is dried, he dresses himself and walks in the open air. Irritable cases and those with much sputum are not suitable for the douche, as forced breathing and aspiration of sputum may result. These rubs harden the body and render it less susceptible 96 HYDROTHERAPY to changes of toiiiperaturc. With the douches they are a neuro- vascular stimulant, improving the "peripheral heart," enhancing the appetite, nutrition, and general mental condition. Baruch permits the initial use of colder water and reduces its temperature more quickly. The first step is a thorough cleansing with soap and warm water. On the second day the patient is wrapped snugly in a thin blanket and allowed to lie half an hour or longer unless he perspires. If the rectal tem- perature be above 100° F. (37.7° C), the treatment is omitted, and in afebrile cases additional blankets may be used, so as to dilate the cutaneous arterioles preparatory to being treated with water. The face is bathed with water at 50° F. (10° C). The blanket is then opened over the chest and abdomen and these parts rapidly and well rubbed with water at 75° F. (23.8° C). After drying, the patient is turned on his abdomen and the back is- similarly treated. The limbs are not treated. The patient is dried gently, dressed, and, if afebrile, he is sent into the open air for a short walk. Febrile cases are returned to bed. The treatment is repeated daily and the water lowered 2° F. (1.08° C.) at each ablution until 60° F. (15.6° C.) is reached. When this stage is reached the ablution is performed as follows, just as the patient emerges warm from the bed : Standing in a foot-tub containing sufficient water at 100° F. (37.7° C.) to cover the feet to the malleoli, the patient receives a rapid friction bath with water at 90° F. (32.2° C), omitting the upper extremities. He is then dried and sent into the open air if his rectal temperature be below 100° F. (37.7° C). The water temperature is reduced daily 2° to 5° F. (1.08°-2.7° C) until 60° F. (15.6° C.) is reached, when the ablution is replaced by affusion. This consists of pouring four basinfuls of water at 90° F. (32.2° C), previously held in readiness, over the body. Water is dipped from a vessel and poured with force over each shoulder, the back, and front of the chest. Rapid drying while standing on a warm towel completes the procedure. Beginning with a water treatment at 90° F. r32.2° C.) it is reduced daily • by a few degrees until 60° or 50° F. (15.6° or 10° C.) is TUBERCULOSIS 97 reached. This refreshing process may be repeated daily. In febrile cases Dr. Baruch states that the temperature should not fall below 65° F. (18.3° C). At the Adirondack Cottage Sanitarium, Dr. Lawrason Brown states in a private communication to the author that some of the patients throughout the winter take cold sponges and some cold plunges, but he does not advocate very strongly a plunge into such cold water as flows from the faucets in winter, in the neigh- borhood of 40° F. (4.5° C). His patients are treated usually Fig. 23.— Morning douche of cold water. The tuberculous patients at the Pine Ridge, R. I., sanatorium or camp were accustomed to take this douche. Photograph taken in March, 1905, for the author, by Dr. W. H. Peters. along the Hues laid down in Dr. Bro\vn's chapter on the treat- ment of pulmonary tuberculosis in Osier's "Modern Medicine," vol. iii, but such measures are not advised, except in a very moderate form, if there be heart disease, aneury^sm, or marked arteriosclerosis. The bath should be taken in a room never below 55° F. (12.8° C), and the lower half of the body should be kept clothed while the upper half is being cleansed with water at 100° F. (37.8° C). Cold water, 40° to 60° F. (4.5°-15.6° C), should be applied with a sponge to the neck, to the front and back of the 7 98 HYDROTHERAPY chest, and to the arms for from one to two minutes. The body is then dried with a coarse towel. In cases unaccustomed to a morning bath, it will be best to use tepid water at 80° to 100° F. (26.7°-37.S° C.) instead of sponging at 40° to 60° F. (4.5°- 15.0° C), gradually reducing the temperature each day until the latter temperatures are reached. In other cases it is best to begin with sponging one arm, then on the following day both arms, and so on until the body to the waist has been sponged. Alcohol rubs or salt rubs may be substituted in special cases. For more vigorous patients the cold i)lungc at 50° to 70° F. (10°-21.1° C.) may be permitted, or the cold shower, or the full cold sponge while standing in warm water. In winter these meaures are to be modified if they increase nervousness. These morning baths and sponges, however, are in no sense a substitute for a bath twice a week in water at 100° to 105° F. (37.8°^0.6° C.) with a free use of soap. In febrile cases great care should be taken to avoid any exhausting hydrotherapeutic measure. Dr. Brown advises a salt sponge in the evening, followed by an alcohol rub. This refreshes the patient and induces sleep. If the patient be weak, alcohol may be added to the salt water. If the sponges fail to reduce the temperature sufficiently, an ice rub may be given or a cold pack to the trunk. An ice-bag over the heart frequently quiets the nervous system. If patients fail to react or feel chilly, it will be well to try dry rubbing and on subsequent days sponging with warm water, gradually reducing the temperature. A little food or hot drink should be given before the morning bath. In sponging with salt water, ^ ounce of salt to the quart of water will be sufficient. Advanced febrile cachectic patients, or those with a tend- ency to hemoptysis, should never be sent to a spa; but saline waters, such as Congress or Hathorn, are sometimes valuable in relieving the catarrh of quiescent, torpid, or anemic patients. When cough is distressing, a local cold compress to the chest is useful. The cross-binder of Priessnitz and Winteniitz may be applied during the night to relieve pleuritic pains, bronchial TUBERCULOSIS 99 catarrh with tenacious sputum, and persistent cough. Sleep is thus favored. The cross-binder is applied as follows : Take several strips of linen or cotton cloth 3 or 4 inches wide and 20 to 24 inches long. Dip in cold water, pass over each apex, and hold in place by a strip 6 to 9 inches wide encircling the chest. These strips should be covered with a 3-inch flannel bandage closely applied. Oiled paper, musHn, or silk may be used under the flannel bandage, but it is not necessary. "When removed in the morning the chest should be sponged with cold water. If patients do not react to the cross-binder, they should be rubbed with or without alcohol until warm before reapplying the cross-binder. Tuberculous patients are liable to neurasthenia, and hence great tact is necessary in instituting new measures. Pulmonary Hemorrhage. — It has long been know"n that cold applied to a distant part will control a pulmonary hemorrhage. Currie (1797) refers to this, stating that he found that hemor- rhage from the lungs may be stopped by immersing the feet in cold water, or, better still, by applying it permanently to the scrotum and genitals, "which part with their heat more easily than any other portion of the body." He also obtained a more powerful effect by immersing the body up to the pubes in cold water. Cold apphcations by means of ice-bags may also be made to the chest or to the thighs, this causing a contraction of the pul- monary vessels by reflex action. It is the experience of Kraus, Brehmer, and others who have used hydrotherapy in tuberculosis that hemoptysis is never produced by these measures. A case was recently reported by Downes, in which a man lost by hemoptysis as much as 153|- ounces of blood in nine days, the greatest amount in one day being 31 ounces. The "usual methods employed for checking hemoptysis proved futile, but immediately on applying an ice-bag over the suspected lung all bleeding stopped, and not a single drop of blood was expectorated from then on. All drugs were stoppetl and the ice-bag kept in place for six days. 100 HYDROTHERAPY PNEUMONIA This disease has gradually taken first place in the mortality lists of our largest cities. In New York City it has been the leading cause of death for seventeen years, and for seventeen years had been second only to tuberculosis. The methods of treating pneumonia have changed considerably in recent years, and a larger consideration is gradually being given hydrothera- peutic methods. No matter what the i)lan adopted may be, the mortality rate in hospitals remains very high, from 30 to 40 per cent., alcoholic cases included. In private practice, how- ever, the rate is much lower. Those who have used hydro- therapy, and especially cold applications, have met with better success, and, considering the extraordinary reports, it is a matter for wonder that the methods adopted have not been more gener- ally employed. Cold. — Without reviewing the use of drugs, venesection, and the expectant treatment that have had more or less popularity, we would refer more particularly to the use of cold. In pneu- monia this is applied by means of ice-bags, snow, cold compresses to the affected chest and to the head, or by means of the Brand bath, as used in typhoid fever. The fact is that pneumonia and typhoid fever respond in very much the same manner to hydro- therapy. Both these infections are met by the same reparative processes, the full power of which is brought out and reinforced by thermic stimulation. The fact that one infection selects the lung and the other the intestine has nothing to do with the pro- priety of similar methods of treatment. The main object of treatment in pneumonia is the preserva- tion of the full and efficient action of the; heart and the peripheral circulation. Heart failure is the principal cause of death. In all infectious diseases it should be our aim to improve the cir- culation in the cutaneous arterioles, and our best agent is un- doubtedly thermic stimulation by methods which will be de- scribed further on. The danger of hyperpyrexia is not so much degeneration of the heart muscle, as interference with the pe- ripheral circulation. PNEUMONIA 101 Clinicians are constantly warning against the use of drugs to counteract hyperpyrexia. Undoubtedly much harm was done during the earlier years after their introduction and later by acetanilid mixtures masquerading under trade names. Alco- hol, also, excepting in cases where the heart is failing, is not em- ployed nearly as freely as formerly, excepting in pronounced alcoholic cases. Strychnin has also been abused in this con- nection, and all these measures when used to excess are more or less embarrassing to the struggling heart. Remedial agents directed to the skin and the vasomotor system are more rational, and not only prepare the way for cardiac stimulants when needed, but also enhance their action. The application of cold to the thorax and to the head profoundly affects the heat regulating centers of the body. These are located in the cortex and at the base of the brain. The derangement of their functions by the products of infection produces fever. The respiratory centers share in this derangement, resulting in the C|uick breathing so characteristic of pneumonia and other infections, partly central and partly reflex in its origin. When the infection is intense or when from any cause the heat-regulating centers are unduly stimulated, the neighboring convulsive cen- ters are aroused, giving rise to the convulsions of febrile diseases. The early use of cold applications to the head and chest in pneumonia is, therefore, demanded to mitigate the effects of the toxins on the central nervous system. It is conservative: while sparing the nerve-centers it favors the better distribution of the blood in which are generated those antitoxins, and the so- called antibodies, which swallow up the invader. Cold applications, therefore, to the brain and to the base of the brain are rational in connection with similar applications to the thorax. They reduce restlessness and irritability or pre- vent them altogether, and reinforce the effect of cold applied to the chest. Dr. Thomas J. Mays,^ of Philadelphia, seventeen and eigh- 1 Medical and Surgical Reporter, Dec. 19, 1906. See also Med. News, Philadelphia, Sept. 24, 1892; June 24, 1893; Oct. 13, 1894. 102 HYDROTHERAPY teen years ago published reports on the local application of cold in acute pneumonia with an analysis of 299 cases treated in this manner by physicians residing in nearlj'^ all parts of the United States. This was a remarkable collection, as the cases were dis- tributed from the Atlantic to the Pacific coast, and only 10 deaths were reported, the death rate being 3.35 per cent. Of course, in a collective investigation of this kind, where reports are requested, the tendency is to bring forward successes and withhold failures, so that some allowance must be made for the natural tendency of the human mind to respond with favor- Fig. 24 -Application of the cold-water coil to the cljist in crouixnis pneumonia or pleurisy. Leiter coil (Hare.) able data on a given subject. But with all due allowance for the natural tendency to bias in such a collective investigation, a most favorable conclusion is reached as to the value of the local applica- tion of cold in acute pneumonia. As an evidence of the character of the cases in which cold was used, ice being the medium employed, and in testimony to the favorable impression both on the part of the patients and their physicians, Dr. Mays published an additional report of 195 cases with 7 deaths.* 1 The Local Application of Cold in Acute Pneumonia, by Thomas J. Mays, Trans. Phila. County Med. Soc, vol. xvi, 1895. PNEUMONIA 103 In the pneumonia of infants and young children a moder- ately cool wet pack is useful (see p. 340). Coof spongings are sometimes employed, but thej'- require manipulation and are more likely to disturb the patient than is the pack. They are in- effective if there be a high temperature. It should be distinctly understood both in reference to children and adults that natural sleep is not to be disturbed by any hydrotherapeutic measures. Ice-bags have the advantage of causing less interference with the bodily comfort and quiet of both children and adults, and are used successfully with children as young as two or three years, taking care that the bag is not applied directly to the skin. The ice- bags must also be removed at intervals to avoid local cyanosis, for on rare occasions devitalization of the parts to which they have been applied has occurred. One such case is recorded in France, and recently a suit for damages has been brought in which it is alleged that proper precautions were not taken to prevent this accident. (See page 386.) Dr. B. Buxbaum,^ of Vienna, is a strong advocate of cool half -baths at 65° to 72° F. (18.3° to 22.2° C.) for not over five minutes, with active frictions and affusions. He also uses the chest compress or cross-binder (Stammumschlage) and warm packs to the lower extremities. The chest compress is put on cold and changed every two or three hours. He rightly insists that it is not the high temperature that must be combated, but the weakness of the heart, the nerve changes, the congestion, and hyperemia of the lung. The best treatment of very young children is by cold com- presses or sponging. The compresses should be wrung out of water at 75° to 80° F. (23.3°-26.7° C). If sponging is adopted and the child does not react from a cold sponge, a luke- warm sponge should be given. In some cases it will be impos- sible to sponge at all, and then compresses are usually better borne. They should be applied from the neck to the umbilicus. 1 B. Biixbaum, Die Hydrotherapie der Pneumonien im Kindesalter, Deutsche Medizinal Zeitung, Feb. 4, 1897; and Blatter f. klin. Hydrotherapie, 8, 1896. 104 HYDROTHERAPY A full wet pack is also sometimes used with success. It adds to the child's comfort, improves sleep, diminishes the respiration, and strengthens the heart. The Brand bath is not to be recom- mended in children. In adults the compresses should be colder and the following procedure is advised : A large towel maybe folded lengthwise in the middle, then crosswise in the middle. One-half of the length of this four-ply towel is wrung tightly from ice- water or the coldest water obtainable, and again folded crosswise, so as to give four thicknesses of wet towel inside and the same of dry towel outside when applied to the chest. The damp folds should be freshened as often as they become the least hot, whether this be in ten, twenty, oi- thirty minutes. Probably at first in severe cases changes will be as often as eight or ten minutes, the intervals lengthening more and more as the inflammation subsides, and breathing consequently becomes deeper and easier.* As the breathing becomes more natural and the compress fails to become hot, the applications may cease. The ice-bag should be applied if pain is persistent. Abundance of water should be given inter- nally; if not borne by the mouth, enemas may be substituted. When the secretions are checked and the skin hard and dry, with the tongue dry and brown, the pulse weak and rapid, and the respiration shallow and quick, and subsultus indicates depres- sion, great benefit may sometimes be obtained from the adminis- tration by hypodermocylsis or high rectal enemas of ^ to 1 pint of decinormal salt solution, or, better, the normal salt solution to which has been added a small cjuantity of a calcium salt. Ringer's solution may be employed for the purpose. It con- sists of a 1 per cent, solution of calcium chlorid, 3 parts; a 1 per cent, solution of potassium chlorid, 4 parts; a 1 per cent, solu- tion of sodium clilorid, 70 parts; and distilled water, 23 parts." In dealing with an infection like pneumonia every effort should be made to get rid of the toxins and prevent any exten- 1 C. E. Page, Medical Record, December 23, 1905. * See Prognosis and Treatment of Croupous Pneumonia, Jour. Amer. Med. Assoc, Nov. 22, 1902. PNEUMONIA 105 sion of the bacterial invasion. Fortunately, relapse is rare in pneumonia, and this is an evidence that natural protective anti- toxins are usually sufficient to limit the disease at least to one lung. In promoting elimination we should pay more attention to the skin and bowels than to the kidneys, as there is always danger that the circulation may fail. In acting on the skin we may supplement the action of a faihng heart, and hence measures that promote sweating are not only safe, but impera- tively demanded. They may be used in connection with the cold applications to the chest which we have referred to. To promote sweating is to facilitate nature's method of combating infectious diseases. In connection with a free action of the bowels it is an aid to recoveiy. A most rational method of treatment has been practised by Dr. De Lancey Rochester with great success.^ We give his method, which he has earnestly advocated for many years and wliich is well worth attention. The first indication is to relieve toxemia; the second, to prevent failure of the heart; the third, to prevent complications as they arise. As already stated, we should not attempt to stimulate the kidneys to excessive action, especially if in a state of acute inflammation. This is worse than useless, so the use of stimu- lating dim'etics is positively contraindicated. The bowel and the skin remain, and nature has shown by the profuse sweat at crisis and the occasional critical diarrhea that these are the avenues that are prefer;red. So our first indication in treatment, the rehef of toxemia, may be met by induced sweats and mild catharsis. The mild catharsis is best produced by the administration of calomel at the onset of the disease, to be followed by the use of a saturated solution of Epsom salts in moderate dose daily. The calomel dose may be repeated occasionally as the indications arise. The sweating is best and most easily induced — ^not by the administra- tion of drugs — but by the hot mustard foot-bath scientifically 1 Medical News, February 13, 1904; Jour. Amer. Med. Assoc, November 9, 1901. 106 HYDROTHERAPY given in bed with no disturbance of the patient. Much depends upon the i)rop(>r niethotl of giving this bath. The patient, in a nuele condition, lies between blankets with his knees flexed, his feet in the tub which has been introduced under the upper blanket, the long axis in the line of the patient's body and legs; another blanket passes from under the tub up over the end and over the knees of the patient; two to five blankets or a smaller number of blankets and a rubber sheet are then placed over the patient, extending from the neck of the patient over the foot of the bed and tucked in around the foot- tub and side of the patient. The tub at first is filled half full of hot water in which a heaping tablespoonful of mustard has been dissolved. From time to time during the bath more hot water is added, care being taken that the water is poured against the side of the tub and stirred in by the hand of the nurse, in order to avoid burning the patient's feet. The bath is k(>pt up from thirty to forty-five minutes, according to the amount of sweating produced. During the administration of the bath cloths wrung out of ice-water are kept constantly on the head of the patient. This sweating in connection with the stimulation, to be referred to later, is, in Dr. Rochester's opinion and that of the writer, the most important of the general therapeutic measures. In treating pneumonia, just as in the case of typhoid fever, we must recognize again the remedial power of fever, and not be in too much haste to check it by intense hydrotherapeutic measures. The toxemia of pneumonia is rarely so intense as in typhoid; moderate fever is not fraught with danger, and unless the temperature exceeds 103° F. (39.5° C) it probably aids the destruction of the specific virus. Indeed, it has been claimed that cases of loljar pneumonia, in which the temperature pursues a comparatively low range, do badly as compared with more febrile symptoms. This, however, we do not fully believe. Dr. Jacobi says of high temperatures : It is understood that a high temperature is not a uniform danger. In persons suffer- ing from an old heart disease, in the prematurely born, in the anemic of all ages, it is so, or may be. Whether a warm bath, PNEUMONIA 107 or a warm bath gradually cooled down, or a cold bath, or cold washing and sponging and friction, or a warm or a cold pack over chest and abdomen are indicated, or the local application of an ice-bag, depends on the individual case and the individual doctor. Forty years ago ^ I could speak of a fair experience with cold water in typhoid fever, pneumonia, scarlatina, variola, ophthalmia, diphtheria of the conjunctiva, heart diseases, local inflammation, phlegmon, synovitis, and peritonitis. It has served me well since. No uniform rules fitting every case of pneumonia can be given. It takes brains to treat lungs. Delearde gives revulsion as the primary indication in the treatment of bronchopneumonia and capillary bronchitis in children. It should be applied energetically four times every twenty-four hours throughout the diseases until the faU of temperature and the disappearance of the principal signs. The methods recommended are sinapisms and hydrotherapeutics. The mustard leaf may be made use of, but a much more effective application is made by wringing out a napkin in a thin mustard paste and enveloping the chest in it. The child is then wrapped in flannels and left for fifteen minutes. After this he is un- wrapped and bathed in warm water to remove the loose mustard, and dressed and put to bed, when he usually goes to sleep com- fortably. This should be repeated two or three times in twenty- four hours. The rubefacient effect lasts several hours. The mustard bath also produces a good revulsive effect. This form of application is appropriate when the extension of the lesion gives us a bad prognosis, rather than degree of the infection. Two sinapisms and four hot baths at 38° C. (100.4° F.) may be given daily. When the involvement is small in area and the infection severe the prostration would be increased by hot baths, while cold baths wiU lessen it and stimulate the child, lessen pulse tension, and increase diuresis. Cold packs have the same effect. When natural sleep occurs, no hydrotherapeutic measures ought to be used. 1 Med. Record, 1870. 108 HYDROTHERAPY ASPHYXIA NEONATORUM Asphyxia neonatorum calls for hydriatric measures. The child should be given rather vigorous vibrations, swinging or shaking movements, rubbing the chest with cloths wet in warm water, claj^ping the soles of the feet. Efforts should also be made to get the nmcus from the throat, and the child should be placed in a warm bath at 90° F. (32.2° C). The bath should be of short duration, varied with cool douches or clashes of cool water. After repeated efforts, slight and irregular breathing may be established in cases which will not yield to other measures. As the efforts are continued, the breathing is gradually estab- lished. ACUTE BRONCHITIS In acute bronchitis the hot mustard foot-bath or full bath, described on pp. 106 and 291, should be tried. A time-honored measure is the Priessnitz pack or cross-pack about the whole chest. It relieves pain and especially dyspnea and cough. The pack should be made from water at 45° to 55° F. (7.2°- 12.8° C.) and renewed every two hours by day, but may be left unchanged at night in order not to disturb rest, renewing as opportunity offers. For adults, cold douches to the chest may be used. Steam Douche to Promote Ex-pedoration. — Lissauer * has been using for a year a method of stimulating the secretions, which has proved very effectual and harmless in his hands. A spray of steam at a temperature of from 110° to 125° F. (43°-52°C.) is sprayed rapidly over the upper part of the body for fifteen seconds, followTd by a cold fan douche for three or five seconds, after w^hich the patient is rapidly rubbed down and dressed. He cites 16 cases in detail to show the prompt effect on the expectoration induced by this procedure. It does not produce much of an appreciable reaction on the skin, but the patients feel the relief very soon. Mustard Packs i7i Bronchitis. — Mustard may be used as a ^ Deut. Med. Wochenscrift, xxxii, No, 7. ACTIVE CONGESTION OF THE LUNG 109 counterirritant in the treatment of capillary bronchitis and bron- chopneumonia in infants and children. Dr. A. Herzfeld, of New York, has been using a method devised by him for the past thirteen years with great advantage. It is as follows : 250 ccm. of water and 250 ccm. of alcohol are mixed in a large bowl; to this are added from 25 to 50 ccm., according to the severity of the case, of freshly prepared spirit of mustard. The spirit of mustard is prepared, according to the German Pharmacopoeia, as follows: Oil of mustard, 1 part; pure alcohol, 49 parts. A large piece of flannel is moistened with the mixture and wrapped around the child from the neck to the knees. The child is then enveloped in a dry sheet, and the pack is left on until the skin is a bright red, usually in from fifteen to thirty minutes. The child is then taken out and wrapped, and left for another half- hour in a pack wet with 1 part alcohol and 2 parts water. At the end of this time the child is wrapped in a dry sheet. Usually one pack causes marked improvement, but relapses are frequent, and it may need renewal. Once in twenty-four hours is enough unless the indications are unavoidable. The physician should apply the first pack himself, to determine the strength needed, and to instruct the parent or nurse. Dr. Herzfeld sums up the advantages of the method as follows : It is surprisingly rapid in effect. Its light weight does not materially embarrass respira- tion. It can be appUed without removing the enfeebled patient from the bed. It is inexpensive. It is clean.^ ACTIVE CONGESTION OF THE LUNG In active congestion of the lung, without evidence of an on- coming pneumonia or other serious disease, the overfilling of the blood-vessels may often be corrected by hot applications and counterirritants. Many clinicians use a hot bath at 106°, 108° or 110° F. (41.1°, 42.2°, or 43.3° C.) for ten minutes. The warm pack may be used, and, if necessary, this may be preceded by a hot bath. If the two measures are used, the bath may be short- 1 Jour. Amer. Med. Assoc, January 9, 1909. 110 HYDROTHERAPY ened to hxc or six minutes. It is best to bring the bath gradually up to the maximum after the patient is in the tub. Sweating processes are indicated as described in the treatment of pneumonia (see pp. 105 and 10(3). EDEMA OF THE LUNG In edema of the lung the mustard pack is highly recommended by Lenhartz, applied after the following plan:' 1 to 3 pounds of mustard' are taken antl a i^ap is made by the addition of a sufficient quantity of lukewarm water. This is spread upon a sheet, laid upon a blanket, and the patient is then wrapped up in both, so that the extremities, trunk, and neck are thorouglily covered, the eyes being protected from the fumes by tucking the blanket in at the chin. The patient remains in the pack from twenty to thirty minutes and is then washed off with lukewarm water. Carbonic acid baths ought not to be given w^hen there is any tendency to pulmonary edema. INFLUENZA, EPIDEMIC CATARRHAL FEVER In this disease hot applications give more relief than cold ones. They should take the form of hot or warm baths; and the use of cold cloths to the head, whether in or out of the bath, should be repeated in accordance w4th the comfort afforded. ASTHMA Bronchiala stliina due to nasal reflex is amenable to treat- ment by cold ai)i)lic'ations. Cokl water may be poured over the back of the neck or applied in the form of a cold douche under a pressure of 10 or 12 pounds and for only a few seconds. This is an application of the principle enunciated by Winternitz; namely, that the use of cold or heat by reflex action modifies the lumen of the blood-vessels through the vasomotor and respira- ^ The Prophylaxis and Treatment of Internal Diseases, Forchheimer, p. 340. SWEATING 111 tory centers. The same effect is not realized by the application of cold elsewhere on the body nor by mere cloths wrung out of hot water. The mechanical stimulus of the poured water seems to be an important element in the relief experienced. Before dressing in the morning the simple application of the cold douche to the back of the neck gives great relief in chronic simple rhinitis, and may relieve the suffocation in asthma. RENAL DISEASES The use of hydrotherapy in renal diseases, especially in con- junction with the administration of water internally, has held a well-deserved place in therapeutics for ages. Nearly every spa and every mineral water has been advocated for this class of affections. But the forms of renal disease are so various and the different stages of the same affection exhibit such different pathologic conditions that the subject seems to become more complicated and more confused as more light is thrown upon it. Physiologists and clinicians are by no means agreed on some of the main points involved in the hydrotherapy of renal disease, points on which great stress is usually laid in explaining the action of the baths. SWEATING Aside from the subject of the use of waters internally, allied so closely to hydrotherapy and about which there is a radical difference of opinion, the action of water on the skin involves questions on which well-known authorities differ. It is commonly believed that the sweating process which precedes, accompanies, or succeeds the bath, while relieving the kidneys of some of their functions, carries off in the sweat certain toxic substances, thereby causing the skin to eliminate what the dis- eased kidney is unable fully to accomplish. In other words, the skin acts vicariously for the kidneys as an excretory organ. But this view is not accepted by some of those most competent to judge, and such men as Senator and von Noorden, in Europe, and Croftan and Ransom, in America, are on record as opposed 112 HYDROTHERAPY to this theory.* Senator says: "Warm baths are useful in removing excess of water, but the specific urinary constituents, which are the mischief maimers, are not removed in any appre- ciable ( quantity even by the most profuse sweating," von Noorclen holds that the only benefit of sweating lies in the with- drawal of water from the blood and tissues. He and his puj^ils have demonstrated that the perspiration of ncphritics contains only a trace of urea — the maxinmm is about 1 to 1.3 gm. in the total quantity of profuse sweat, while the remaining constituents are but harmless substances. He further states that poisonous substances in the sweat have never been found. Both von Noorden and Croftan express themselves decidedly against the practice of giving large amounts of fluid during the sweating process, considering it both irrational and harmful. "It is im- possible to eliminate any toxic substances in this manner; the existing edema is not relieved and may be increased, thereby adding to the burden of the enfeebled cardioAascular system; and, finally, the kidneys are in danger of being further irritated in the endeavor to excrete the excess of ingested water" (Ran- som). On the other hand, Winternitz says in this connection : "The secretion of sweat certainly undergoes considerable augmenta- tion. The small amount of organic matter eliminated at the same time, the trace of urea, the various fatty acids, and the numerous aromatic substances, as well as gases, particularly carbon dioxid, should certainly be given consideration in this connection. That toxic substances, probably various kinds of infectious matter, and even micro-organisms, may leave the body with the sweat, has already been demonstrated by numerous investigators. The depurative action of the sweat is in this way revived in the modern sense. "^ The experiments of Frey and Heiligenthal at the sodium »A.C. Croftan, Jour. Amer. Med. Assoc, June 24, 1905; C. C. Ransom, ibid.; Senator, ibid., 1906; von Noorden, Nephritis, English translation, E. B. Treat & Co., 1905, pp. 48 and 56. 2 A System of Physiologic Therapeutics, vol. ix, p. 37, by Wilhelm Win- temitz, P. Blakiston's Son & Co., Philadelphia. SWEATING 113 chlorid springs at Baden-Baden, where steam baths are given at a temperature of 122° F. (50° C.) for half an hour, are here of in- terest. These experimenters noticed a primary brief transitory contraction of the capillaries of the skin, and, as a result, increased pressure in the arterial system and moderate acceleration of the pulse; then a secondary dilatation of the capillaries, reduction in blood-pressure and cardiac vigor, and further acceleration of the pulse. Perspiration occurred in the bath. On the days of the bath there was a reduction in the amount of urine, an increase in the elimination of urea and uric acid on the first day, and an increase in this ehmination on the next succeeding days. Beneke has shown that cold sea-baths increase the elimination of urea. Although in a case of extreme sweating as much as 1.3 gm. of urea have been recovered from the sweat, as a rule the skin does not excrete toxic substances, but the essential waste prod- ucts are passed off through the urine and the bowels. The credit of secretion belongs almost entirely to the liver and the kidneys. The beneficial effect of sweating lies in the removal of an ex- cess of water, thereby relieving the circulation of an added burden during the time the kidneys are congested. When these organs resume their function, it is probably unwise to continue diaphore- sis with the hope of reducing the albuminuria. Ransom says that sweating has no effect whatsoever in lessening the albu- minuria, as the debilitating effect of the profuse sweating will not be compensated for by any good that may come from it. Besides, when the kidneys become active, it is best to have the urine as little concentrated as possible, in order to reduce the possibility of irritation from the increase of solid matters. Ransom further holds that patients suffering from acute nephritis and chronic nephritis of the parenchymatous form should not be sent to the springs. The various hydrotherapeutic procedures which are useful in the treatment of acute cases are easily carried out at home, and none of the advantages obtained from the spa treatment for chronic nephritis results to patients in the acute forms of the disease.* ^ See von Noorden on Nephritis, op. cit. 114 HYDROTHERAPY CHRONIC INTERSTITIAL NEPHRITIS We thus see that by the exclusion of the above-mentioned classes we have left the cases of chronic interstitial nephritis regarding the hydrotherapeutic treatment of which all authori- ties agree. It is pre-eminently in the case of the gouty type in which cardiovascular changes have preceded the actual changes in the kidney that baths will do most good. These patients complain of circulatory disturbances, gastric disorders, gradual loss of strength, and anemia. The urine has a low specific grav- ity, is abundant in quantity, and deficient in urea. Albumin and hyaline casts are present. Patients of this type may have a high arterial tension, but this fact need not debar them from the use of baths under proper precautions. Carbon dioxid, or so-called artificial Nauheim baths, may be employed in cases of this type. At the outset it is best to use salt baths containing only a small amount of carbon dioxid. Permanent lowering of arterial pressure has been noted after this method of treatment. (See p. 319.) The associated drinking cures at Spas are highly beneficial in these cases, particularly when alkaline, alkaline calcic, or magnesium sulphate waters are available with little or no sodium chlorid in their composition. Sulphur springs are useful in many cases, the water being applied both externally and in- ternally. Physicians practising at sulphur spas claim that great benefit is derived from the baths through their stimulating effect upon the glandular system and upon cellular activity; nutrition is improved and perverted metabolism is corrected. The stim- ulating effect of this class of waters upon the skin also tends, to a certain degree, to improve the tone of the circulation. In cases of marked arteriosclerosis, baths should not be given except with the utmost care, but in cases of high tension without arterial change, baths always do good. There is often a high-tension pulse where there is no arteriosclerosis, and it is rather common to observe patients in whom there is a high nervous tension. It is in these cases that the full warm bath for eight or ten minutes, followed by a rain bath for five or six sec- CHRONIC INTERSTITIAL NEPHRITIS 115 onds, or a fan douche, will prove eminently useful by allaying nervous irritability. These are the neurasthenic cases, for which treatment is outlined on pp. 162 and 163. Hot Applications. — In treating chronic nephritis, hot ap- pHcations are preferable to cold, the latter producing a peripheral contraction of the blood-vessels before the ensuing dilatation. A. C Croftan^ has recently called attention to this subject, and claims that, in predisposed subjects, the primary contraction may rupture weakened vessels, and, by increasing the heart's action, thus temporarily increases vascular pressure. In clironic nephritis the reaction may fail altogether, owing to a lack of vascular tone or changes in the heart muscles or those of the peripheral arteries. For reducing vascular pressure hot applications are more lasting in their effect, as deeper vessels become dilated. Moist heat is best unless there be need to avoid edema. The claim is made that dry heat abstracts so much water from the blood that the toxins become concentrated. This is a theoretic objection that is not sustained by experience. Electric -light Baths. — Pratt treated a woman with chronic nephritis who had been ill a year. She had marked general anasarca and the day urine contained over 1 per cent, of albumin. The essential features of the treatment instituted were electric- light baths and a salt-free diet. She objected strongly to the diet, but did not abandon the plan of treatment because she felt that the light baths were beneficial. After three months the edema had disappeared except for a slight swelling of the legs. When last seen, three years later, the edema had not recurred and the urine contained only a slight trace of albumin. It is probable that her recovery was due more to the salt-free diet than to the light baths, yet without them she never would have continued with the diet. Dr. Pratt adds that in nephritis with edema, the electric-light bath furnishes the best form of sweating procedures. The duration should not be more than thirty minutes. It should 1 Medical Fortnightly, March 23, 1906. 116 HYDROTHERAPY be followed by a dry blanket pack if the edema is marked and the patient not enfeebled. A hot douche may end the treat- ment. It is well to use short Ught baths followed by mild douches in svbacute and chronic nephritis to keep the sweat glands active and to aid in maintaining the normal condition of the heart and circulation. As most authorities hold that cold applications are to be avoided in parenchymatous nephritis, one may su- stitute for them a salt rub followed by a short, hot douche, which has a stimulating effect. Prescription. — Light bath, seven to twelve minutes. Salt rub. Circular douche at 105° F. (40.4° (".), thirty seconds, 15 pounds. Jet and fan douche at 105° V. (40.4° ('.), thirty seconds, 15 pounds. Drj' rub. Rest thirty minutes. Repeat three times weekly. Cold Applications. — It is no doubt possible to apply alto- gether too energetic procedures in nephritis and hence produce harm. For this reason, cold baths and douches have not been used by the author, although strongly advocated by some hydro- therapeutists, von Noorden opposes the prejudice against cold water and strongly advocates the cold rub (kalte abreibung), followed by strong friction to produce reaction. In this he is supported by Dr. Baruch. The late Dr. G. W. Foster, of the Eastern Maine Insane Hospital, used cold applications with success in the renal com- plications of acute delirious mania. The patients had a marked reduction in the amount of urine and of urea with albumin and casts. He applied cold wet packs over the loins and abdomen, and also general cold packs and full baths at 70° F. (21.1° C). These packs were applied continuously and were renewed three or four times daily. Foster held that renal engorgement of the active or passive type does not contraindicate the use of tub-baths at 70° F. (21.1 ° C.) if they are not unduly prolonged. His general packs were given with water at 70° F. (21.1 ° C.) for one and one- half hours' duration. It was the excellent reaction occurring in the pack that accomplished the result, and he claimed that no UREMIA 117 diuretic, within the limits of his eKperience, was at once so effec- tual, safe, and generally applicable as the local packs. Amount of Urine. — It is a common experience to note an increased amount of urine after various hydrotherapeutic meas- ures. This is more evident after cold apphcations than after warm ones. Cold wet packs applied over the loins and abdomen .or tub-baths at 70° F. (21.1° C.) or below wiU almost always increase the flow of urine. This may amount to double or more than triple the previous amount voided. In using the Brand bath in typhoid fever the increase of urine is commonly noted, and much of the benefit derived therefrom is due to the increased elimination of toxic matter in this way. (See p. 45.) TOXEMIA OF PREGNANCY This condition is liable to result in eclampsia if unrecognized and untreated. It is most frequent between the thirtieth and thirty-fourth weeks of pregnancy. In mild cases the skin should be stimulated by simple warm baths, given in connection with enemata and lavage by normal salt solution. In severer cases hot packs are required until free perspiration results. As the urea is diminished, batliing and the internal use of abundant pure water are demanded. UREMIA In uremic cases and in eclampsia hot packs and vapor baths are demanded. One should not postpone venesection in order to give the hot pack. The hot wet pack and vapor bath are always useful; but if the patient be unconscious, great care must be taken to see that the skin is not scalded. Packs may be given for thirty minutes everj^ four hours. In the excitement attending these cases accidents have happened in the lying-in room. Hot bricks wrapped in flannel soaked in hot water or hot bottles are commonly used to convey moist heat. A country practitioner told the author that he had used successfully hot ears of corn. Hot corn gives off a great deal of moisture and 118 HYDROTHERAPY retains its heat for a long time, especially when some of the enveloping husks are allowed to remain. (See p. 341.) Under ordinary circumstances the labor may be let alone while these measures are being instituted. Baruch has observed in the nephritis of severe eclampsia a decidedly favorable change after a wet pack at 70° F. (21.1° C.) for one hour. (See Teclmic, p. 341.) He has demonstrated to his clinical students that after such a cold wet pack the sheet is taken away warmer; wliile after a hot pack the blanket is found cool. The reason is simple: the reaction during a cold pack fills the cutaneous vessels with warm blood and thus warms the skin, which in turn warms the sheet; while the hot blanket or sheet gives ofT its heat to the skin, thus cooling it. The symptom tension is relieved by the latter, and excretion is favored or rendered more normal by the former. SCARLATINAL NEPHRITIS Water is the best safeguard in this disease. Lime-water or Vichy should be added to the milk of young children, and aerated distilled water, Poland Healing Springs, Celestin Vichy, Ballard- vale, or other alkaline water should be administered very freely to older children and adults. Freely used, it dilutes the toxins and diminishes the acidity, thereby lessening kidney irritation. By stimulating catharsis and diaphoresis the elimination of toxins is faciUtated. For treating this condition, full tub-baths at 5 or 10 degrees below the body temperature, with the child enveloped in a blanket, give the best results, as such baths provide an equal distribution of the water. For infants and young children the bath snould be warm— 100° to 101° F. (37.8°-43.3° C.).^ DIABETES MELLITUS The well-known tendency of this disease toward infections of the skin and even to such serious complications as gangrene 1 See article by Lowenburg, Jour. Amer. Med. Assoc, Feb. 17, 1906; see also p. 80. DIABETES MELLITUS 119 renders it highly important to preserve the cleanliness and in- tegrity of the skin. Aside from the usual daily cleansing bath of warm water with soap, it is desirable to educate the patient to the use of cold-water sponges, plunge baths, and douches, so as to increase the tone of the skin and of the nervous system, and, at the same time, to improve the general and, especially, the peripheral circulation. In advanced cases the best plan is to institute these measures at home and not to advise distant spas. The continuous or hammock bath at 95° F. (35° C.) for half an hour or longer, repeated twice a day, is advised in case the skin shows any serious feature. Hydrotherapy is an aid to dietetic management. The following prescription may be given in moderate cases: Electric-light bath, five to ten minutes. Circular douche, 105° F. (40.5° C), thirty seconds. Circular douche, 90° F. (32.2° C), thirty seconds. Jet and fan douche to entire body at 70° F. (21.1° C), twenty seconds. Repeat daily, gradually increasing pressure of jet douche and lowering terminal temperature until 20 pounds and 60° F. (15.5° C.) are reached. In the case of patients in which the disease is not far advanced, the beneficial effects of mountain spas at moderate altitude and conveniently reached are well recognized. Drinking Cure. — While baths are not curative in diabetes, some features of the disease are modified by hydrotherapy, especially when waters are also used internally. At most spas this is the case, and the accessories of agreeable surroundings, different air, food, and occupation improve wonderfully the morale of diabetics and work a corresponding improvement in their physical states. At Carlsbad, Marienbad, Ems, Royat, Vichy, Neuenahr, and Mont-Dore diabetic patients are treated with more or less success by the combined method. These thermal waters favorably affect the skin, which is frequently very dry, and for the obese cases warm baths are a distinct ad- vantage. Baths in the iron waters of Schwalbach, Spa, Pyrmont, and Franzensbad, and ferruginous peat-baths are commonly used abroad, but, as it has elsewhere been shown, these waters have 120 HYDROTHERAPY no special virtues by reason of their iron content. Their use in- ternally, as is also the case with alkaline carbonated waters, is of considerable value. Conscc|uently, the drinking cure is the more important. Sea-bathing is permissible when the patient is robust and reacts well and when anemia is not marked. It is not strongly indicated in obese cases. The Turkish bath is contraindicated. DIABETES INSIPIDUS In diabetes insipidus, douches, warm or cold baths, packs, and half-baths are advised. Forchheimer recommends the half-bath in all nervous children having diabetes insipidus. Baruch advises neurovascular training, as in neurasthenia. As in diabetes mellitus, Turkish baths are contraindicated. PHOSPHATURIA This is commonly met with in eases of neurasthenia and is usually relieved or cured by the hydrotherapeutic methods em- ployed in that affection. Among these are the half-bath with friction and affusions, rain baths or the descending douche, cold wet packs, and steam or electric-light baths, followed by circular and jet douches. Sea-bathing and the attendant exercises avail- able at seaside resorts are very beneficial in phosphaturia. Ex- ercise favors the return of the natural acid to the stomach and secretions. Mountain spas are well suited for such cases. (See p. 162.) RHEUMATISM CHRONIC RHEUMATISM Chronic rheumatism is essentially a fibrositis or an inflam- matory hyperplasia of the fibrous tissue of the muscles, joints, and ligaments. It is brought about by exposure to cold, damp and wet weather, sudden changes of temperature from hot to cold; or an attack may date from predisposing causes, such as injuries to limbs. An acute traumatic arthritis may eventually CHRONIC RHEUMATISM 121 become a "rheumatic" joint. Irritating toxins from the in- testinal tract or from an acute gonorrhea may result in a. so-called general acute articular rheumatism due to their specific poisons. The value of thermal springs in the treatment of chronic articular rheumatism and the arthrites is recognized the world over. The chief factors are the systematic application of heat, the manipulation practised in the baths, and the consequent improvement of the circulation in the parts affected. The patient for whom such treatment is deemed suitable is placed in a fuU bath at 102° to 104° F. (38.9°-40° C), with his head wrapped in a turban wet in cold water. An attendant rubs the limbs and the body while the patient is in the bath, applying movements graded in force to the affected joints. In patients accustomed to hot bathing, it is possible to begin with a temperature of 104° F. (40° C), which, in most cases, is quite agreeable. After eight or ten minutes of the full bath the patient is dried and laid on a couch, where he is closely packed in a hot dry sheet and enclosed in three or four blankets. Here he re- mains for eight, ten, or twelve minutes, after which he is rubbed vigorously for five minutes with alcohol. On the fourth day the bath may be omitted and afterward the baths may include a pre- liminary hot douche at 103° or 104° F. (39.3° or 40° C), applied all over the body excepting the head, the anterior chest, and the abdomen. The elements of this bath are naturally adjusted in time and in force to the needs of the patient as may be de- termined by his medical adviser. Cool sponging or a cold douche is frequently employed after the pack. General mas- sage is also employed in suitable cases, sometimes during the day, but not usually directly after the bath, as after the bath the patient should rest quietly for an hour. The rationale of this method lies in the better circulation estab- lished around the joints and in the increased mobility of all the tissues involved. Exudates in the fibrous investments of joints, in the sheaths of tendons, and in the muscular tissue create more or less disability, and, if untreated by external agencies, tend to increase pain and stiffness if not toward fixation of the limb. In 122 HYDROTHERAPY the case of spinal arthritis, even more serious fixation and deform- ity are likely to ensue, and hence the usefulness of general physi- ologic measures like hydrotherapy and massage. In a systematic course of bathing the secret of success lies in a judicious education of the patient to bear heat and manipulation in an increasing gradation. Mild measures at the outset induce confidence and make possible later a degree of manipulation, depending upon the special characteristics of the case in hand, that would not otherwise be secured. After a full bath in warm or moderately hot water, e. g., at 104° F. (40° C), followed by a hot dry pack, there is relaxation with sweating. A subsequent alcohol rub is then refreshing and produces a tonic effect. This is the main feature of the treat- ment at the Virginia Hot Springs. It is well-known that when limbs are immersed in water less pain is elicited on active or passive movements than when the same movements are practised in the usual atmospheric medium. This fact is taken advantage of in these cases to the fullest extent, constituting one of the advantages of the full bath. In the bath the action of the skin is made better by the friction, which should always be insisted on, it becoming more pliable and free from all excretory matter. Both the super- ficial and the deep blood-vessels of the part, too, are enabled to take up and carry off any exudates or infiltrates, and thus relieve the restrictive influences on the motion of the struc- tures involved, and the impairment of a proper interchange of circulation. Therefore, we adopt every means calculated to improve nutrition. Secondary muscular atrophy, which is commonly observed in chronic joint disease, may be forestalled if treatment be started early and massage judiciously used in connection with hydro- therapy. Painful Reaction. — After three or four baths there is usually a febrile painful reaction in the affected parts. This return of tenderness and swelling is discouraging to the patient. He should be warned in advance of it, and should be comforted ACUTE RHEUMATISM 123 by the thought that it is a favorable indication of the ultimate relief to be derived from the methods employed. Tlie Uric -acid Fetich. — ^This still lingers with us and will probably remain for many years a valuable asset of many a mineral spring and patent medicine factory. As Dr. Arthur P. Luff of England says : "It has become of late years a fashionable craze to attribute many of these forms of ' chronic rheumatism ' to uric acid. Most emphatically do I declare that it has neither part nor parcel in the production of any of these forms of fibrositis. I believe that uric acid possesses no toxic properties whatever, and I take this opportunity of most earnestly raising my voice against the absurd modern fetichism of this nitrogenous by- product, and of protesting against the shameful exploitation of it as a dangerous poison which too frequently disgraces the advertisement columns of our daily, weekly, and monthly papers." ACUTE RHEUMATISM In acute rheumatism, douches, affusions, and local and full baths may be employed if the patient be not wholly disabled. Most cases of acute rheumatism, however, are made worse by motion, so that it is usually a case of noli me tangere. If cold water in any form be used, however, it should be accompanied by vigorous friction. The body may first be sponged with water at 104° to 108° F. (40°-42.2° C.) for three minutes, followed with a vigorous rubbing with cold water at 70° to 60° F. (21.1°- 15.6° C.) (Cohen). The intense pain on motion, the fever, and the high pulse- rate generally observed constitute counterindications for tub- baths. If the pulse-rate in the recumbent position be above 90, the patient should not leave his bed. When the pulse is lowered to 80, tub-baths may be instituted. It is best in cases in which the heart is affected to begin with a half-bath at a tem- perature of 98° F. (36.7° C.) two or three times a week, and then increase their frequency as may be indicated. Cardiac com- plications render the use of greater heat than 98° F. (36.7° C.) unsafe. 124 HYDROTHERAPY CEREBRAL FORM OF RHEUMATISM Cold Baths. — In the hyperpyrexia of acute rheumatism, in cases of the cerebral type, where the temperature suddenly rises from 102° or 103° F. (38.9° or 39.4° C.) to 105° F. (40.6° C), cold baths should be employed at once. The water having an initial temperature of 85° to 90° F. (29.4°-32.2° C.) is gradually lowered to 65° or 60° F. (18.3° or 15.6° C). If the patient be unconscious, he should be placed in water at 65° F. (18.3° C.) without delay, the duration of the bath being governed by the fall of temperature to 101° or 100° F. (38.3° or 37.8° C). It will probably fall from 1 to 3 degrees more after removal from the bath. In the first bath a longer time is usually required to effect the same amount of temperature reduction than in sub- sequent baths — perhaps a half-hour or more. When removed from the bath the patient is dried and some stimulant given. If necessary, the baths may be repeated, but sometimes one will suffice. The cerebral form of rheumatism is so serious in itself that there are practically no counterindications. The Clinical Society of London, through a Committee, has reported that only 1 case re- covered among those observed having a temperature higher than 106° F. (41.1° C.) in which the bath was not employed; while of the batherl cases with a temperature of over 106° F. (41.1° C.) nearly 60 per cent, recovered. Several cases are on record in which the temperature reached 110° F. (43.4° C.) and in which recovery has followed the use of the bath; in some cases twenty-six baths have been employed.^ These baths not only reduce the temperature, but they quiet the delirium; if comatose, the mind becomes clear, the pulse is reduced in frequency, and normal sleep returns to relieve the nervous system. When baths for any reason cannot be used, the patient should be sponged with ice-cold water or the cold wet sheet pack should be employed; or he should be 1 See James Stewart, American Text-book of Applied Tlierapeutics, p. 535, W. B. Saunders Company. CEREBRAL FORM OF RHEUMATISM 125 placed on a cot protected with rubber and douched with water from a large sponge. Cabinet Baths and Douches. — Although the method pre- viously described ^ is the one usually adopted by the author, another method may be chosen and will give excellent results. Patients who have had the baths and packs for a time may be given a short series of cabinet baths and douches. The pre- scription would read as follows : Hot-air bath or electric-light bath at 150° to 160° F. (65.6°- 71.1° C), ten to twenty minutes. Circular douche at 90° F. (32.2° C), one minute, 20 pounds. Scotch douche at 110° F. (43.4° C.) and 60° F. (15.6° C), twenty seconds, 20 pounds. Massage for the affected joints and muscles, fifteen minutes. It may be desirable to start treatment with less contrast between the maximum and minimum of the Scotch douche, and in the course of four or five baths reach the temperature in- dicated in the prescription. If a greater contrast be desired, live steam may be employed in the Scotch douche. A rapid alternation of steam and cold water produces a profound local effect, and when the variation in temperature is so great, as in this case, the Scotch douche can be shortened to ten or fifteen seconds. The douche apparatus ordinarily in use is not pro- vided with means for employing steam, but this forms a valu- able accessory. The Scotch douche exerts a strong mechanical and thermal stimulus, and promotes the absorption of exudates in and about the joints and muscles. A combination of douches of two different pressures with simultaneous massage, as prac- tised at Aixles-Bains, is very useful. So also the fixed douche, delivering water at 102° to 104° F. (39.9°-40° C.) for eight or ten minutes at 15 to 18 pounds' pressure, may be made use of preliminary to the full bath and pack. Fomentations are useful in muscular rheumatism. The affected parts are well lubricated with petroleum so as to re- duce the danger of scalding the patient, and compresses, well 1 See p. 121. 126 HYDROTHERAPY wrung out of hot water at about 140° to 150° F. (60°-65.6°C.), should be applied. Compresses lose heat so quickly that the actual temperature of application is much less, and by making cautious attempts to place them, a fairly high degree of heat can be borne. After the fomentations have been applied and reapplied for ten, fifteen, or twenty minutes, the patient is washed off with water at 70° F. (21.1° C), with friction, and dried. The addition of magnesium sulphate will enhance the value of the compresses (see p. 220). After this treatment the patient should rest for an hour on a bed or lounge. PROPHYLAXIS OF RHEUMATISM Hydrotherapy has a place in the prevention of rheumatism. In the case of children believed to be rheumatically predisposed it would be proper to adopt a careful and systematic method of accustoming the child to cool water. Cool salt-water baths followed by vigorous friction are of value in this respect, in that they improve the resistance and reaction of the vasomotor sys- tem. These baths can be cultivated as any other physical power. Vasomotor paralysis, with its tendency to the forma- tion of toxins, should be met with appropriate exercises, cool baths, and frictions; electric-light baths and general thermic stimulation. Sea-bathing is usually attended with too much exposure and risk for children predisposed to rheumatism. RHEUMATIC ENDOCARDITIS In cases complicated with endocarditis, with a weak heart and a feeble, irregular pulse, hot fomentations should be employed locally over the heart. They will be found more stimulating than ice-bags or cold compresses. (See chapter on Diseases of the Heart, p. 132.) ACUTE ARTHRITIC OUTBREAKS The acute arthritic outbreaks which so often follow spa treat- ment depend upon the thermal action of the mineral baths. Similar attacks follow the use of plain hot-water baths devoid GOUT (arthritis urica) 127 of mineral properties. Garrod has seen a severe attack of gout brought on by taking a hot bath soon after dinner. Hot-air baths in cases of suppressed gout may determine an acute attack. These acute phenomena are usually interpreted as preparing the way for the elimination of uratic deposits. Though painful, the ultimate result is beneficial ; the absence of any reaction in a case of gout after the adoption of thermal baths does not augur well for the benefits to be derived from the treatment.^ Warnings should be given the patient of the likehhood of acute symptoms supervening. Dr. H. C. Wood says that he has frequently seen an acute attack of gout precipitated by the application of heat to a long diseased joint about which there was much exudation. This acute attack has often been accompanied by a very percep- tible lessening of the exudate, and Dr. Wood states his belief that such attacks are due to the absorption into the blood of gouty acids or salts which had been liberated from tissues of the joint. Undoubtedly the chemic movements of diseased joints or exudates in other localities are increased by the appli- cation of heat. The use of heat is of great value in the treat- ment of local inflammatory conditions with exudation, whether rheumatic or not. In these cases fomentations may afford relief. GOUT (ARTHRITIS URICA) In all probability gout consists in a defect of metabolism whereby products derived from cell nuclei are not properly used up or excreted. These products may arise either from nuclear matter contained in the food or from the natural wear and tear of tissue-nuclei; they are retained in the system, and a deposit of one of them — sodium biurate — in the joints sets up irritation there and causes an acute attack of arthritis. We must not be blind to the fact that in using "that blessed word" metabolism, we mean no more than the chemical side of life itself. All diseases are disorders of metabolism — in other 1 Francis Hare, M. D., Medical Record, June 17, 1905. 128 HYDROTHERAPY words, perverted vital activity. Hence we practically come back to our original starting point — that gout is a disease which we do not understand.' The hydrotherapy of gout follows very much the same lines as that of rheumatism. It is a protean disease capable of mani- festations from the head to the toe, and, in its acute stages, a formidable afTection. Gouty affections respond favorably to hydrotherapeutic and dietetic treatment; indeed, patients of this class constitute a very large proportion of the clientele of spas. Such patients, perhaps more than any other, recognize the importance of re- peated preventive measures and frequently make a practice of taking the cure afTortled at famous resorts in Europe and America. Choice of Spas. — An attempt has been made to differentiate the various European spas in the treatment of gout, largely on the basis of the associated use of waters internally^ (see pp. 404 and 410). The methods employed vary considerably at these spas and the waters themselves vary widely in their constituents, embrac- ing those of indifferent character, such as Teplitz, Warmbrunn, and Plombieres; the sulphur waters of Aix-la-Chapelle, Baden in Austria, Baden in Switzerland, Bareges, and Cauterets; or the brines of Nauheim, Kissingen, and Soden. In general, the distinction is made that when local effusions remain after re- peated attacks of gout, thermal baths of high temperature are indicated. These are employed for all local gouty affections as as well for their paralytic and neuralgic sequelae. In cases of great debility the baths given at Gastein, Pfaefers- Ragatz, Wildbad, and Lobche-les-bains are suitable. When there are large gouty nodules, contractures, anchyloses, and dis- orders due to effusions, local and general peat and mud-baths are used. The sulphur waters are chosen when skin affections or syph- 1 Editorial, Medical News, July 23, 1903. 2 See Prof. E. Heinrich Kisch, of Prague and Marienbad, in A System of Physiologic Therapeutics, vol. ix, p. 464. GOUT (arthritis urica) 129 ilitic diseases coexist. When the heart is impaired and general enfeeblement marks the case, the sahne baths and carbonated baths of Nauheim, Rehne, Kissingen, and Soden are prescribed. In England the baths of Buxton are largely used for gout. The Buxton undercurrent or indirect douche described on p. 277 affords an excellent combination of a partial immersion warm bath with a douche of somewhat higher temperature, 98° to 104° F. (36.7-40° C), and a moderate pressure of 15 pounds to the square inch from a small-caliber nozzle. The famous Aix douche, comprising two calibers and two pressures administered by two attendants, is used without the immersion bath, but ac- companied by general and local massage (see p. 263). At the Virginia Hot Springs use is made of a fixed descend- ing jet douche delivering water at 104° F. (40° C.) at a pressure of 14 to 18 pounds. This is commonly followed by a full bath at 100° to 104° F. (37.8°-40° C), with or without massage in the tub, and a subsequent dry blanket pack for ten to twenty minutes, terminating with a cool douche and a quick alcohol rub. At Mt. Clemens, Michigan, and at Richfield Springs, Sharon and Clifton Springs, New York, sulphur baths and douches are employed. These sulphureted saline waters are usually em- ployed at somewhat lower temperatures than at the Virginia Hot Springs, and, the waters being of a naturally lower tempera- ture, are necessarily artificially heated to the required degree. There is scarcely a spring or inland spa in Europe or America where the treatment of gout and rheumatism by hydrothera- peutic measures may not be carried out. If the pubHcations emanating from these resorts, usually accompanied by a wealth of testimony as to cures in this class of diseases, are to be believed, it must be admitted that gout and rheumatism are cured by baths in waters of most diverse chemic analysis; by baths of every type; by douches, packs, mud, peat, and fango, not to speak of drinking-waters of every description. This leads us to deny any essential difference in hydrotherapy as distinguished from balneology; they are but parts of one great system of physical therapy. The attempt to differentiate the 130 HYDROTHERAPY relative value of various mineral waters or even of various hydro- therapeutic methods in relation to the protean forms of gout and rheumatism is a relic of the time-honored search for specific remedies in given forms of disease. The modern medical world is gradually giving up this jmrsuit of the golden fleece in thera- peutics and is turning to the more rational effort to make use of general measures based on physiologic processes, relegating to the background the non-essential features once so highly prized. The prime factors in all modern hydrotherapy are moisture, heat, pressure, and manipulation. These are the four corners of the temple of hydrotherapy. GONORRHEAL ARTHRITIS Gonorrheal rheumatism, so called, or gonorrheal arthritis may be treated in the same manner as other forms of rheumatism or arthritis; namely, by warm or hot baths, douches of warm or hot water, not over 104° F. (40° C), and the subsequent use of hot dry packs. At Buxton the practice is to use the undercurrent douche to the affected joints. If synovitis be present, the joints are kept at rest. Plenty of good nourishing food and iron are used. Under this method of treatment the periosteal thickenings quickly disappear.^ (See p. 277.) The object of treatment is to promote absorption of inflam- matory products. These are found in the synovial sheaths, bursse, and tendons. They need the stimulation of heat and moisture, but do not require much, if any, manipulation, unless in the more advanced or chronic stage. Fomentations may greatly relieve the pains of the more acute cases. In dealing with advanced cases we may use more stimulus in the form of jets of higher pressure, the Scotch douche with its variations of temperature and the Aix douche, or other revulsive measures. In any case care must be exercised to avoid bringing on active inflammation by vigorous attempts at passive motion or by too severe massage. ^ Personal communication from Dr. John Braithwaite, Buxton. ARTHRITIS DEFORMANS 131 In the later stages of gonorrheal arthritis, benefit may be derived from very hot mud-baths. The general plan of treat- ing gonorrheal arthritis is similar to that of ordinary articular rheumatism, at least as far as hydrotherapy is concerned; but the writer has found the endocarditis of gonorrheal cases a serious complication and one that demands watching and very judicious management. ARTHRITIS DEFORMANS This is probably an infectious trophoneurosis. In order to bring about absorption of the exudates and restore motion to the affected joints, it is a common practice in Europe to employ hot-air baths, compresses of fango, moor baths or packs, hot wet packs, hot-sand baths, or electric-light baths. After these applications there is an increased sweat pro- duction followed by a moderation of the symptoms, together with reduction of the swelling and increased mobility of the joints. When the disease has progressed so far as to have produced hyper- plasia with deformity, the prognosis is unfavorable, no matter what means are employed. Amelioration may follow hydrother- apy, though cure may be impossible. Hot sulphur saline baths have given some good results. Most observers agree that ordinary hot baths in arthritis deformans are not to be recommended or, at least, are to be em- ployed only in the early stages. When ordinary baths are not employed it is better to use the Bier passive congestion treat- ment (compression by rubber bandage above the joint) or baking with hot dry sand or hot air. The writer uses the hot-air cabinet followed by circular, jet, Scotch, and fan douche. The type of bath employed must be determined after study of the individual case. After the bath the patient should walk in the open air. Dr. Wood states that the effects of heat are much more prompt and marked in cases of small than of large joints. The latter are not raised to that degree of heat possible with smaller joints, and for this reason better results are obtained in treating an ankle than a knee. 132 HYDROTHERAPY The use of heat in rheumatic cases should not be relied upon exclusively, but rather as an aid to general treatment. When so used, the action of the skin mut^t be increased by warm douches and tub-baths (see p. 121) and the patient well wrapped in blankets. DISEASES OF THE HEART No hydrotherapeutic measure of a general character for medical purposes should be used without competent advice. This presupposes some knowledge of the heart and circulation and ought to include some estimation of the blood-pressure. It is remarkable how man}' persons are perfectly willing, and some- times quite insistent, in their desire to take hot baths, douches, and packs without any competent medical advice, relying entirely on the bathing attendant or previous experience. Anyone who has practised at a spa is familiar with this type. Men who would not for a moment think of managing their owti legal affairs, will not hesitate to subject their bodies to all sorts of circulatory gymnastics. Whether the results are good, bad, or indifferent is probably their own affair, but it is the duty of those in charge of spas to insist on preliminary medical advice. There is prob- ably no public resort in the United States where this is strictly required. Those under private management endeavor to give treatment only on a physician's prescription, and this undoubtedly furnishes some safeguard against much disappointment or serious accident. Sudden death in the bath or within a few hours after- ward is occasionally reported in the daily press and may happen at the best regulated spas. Deaths from heart disease and apo- plexy are most to be feared and cannot always be foreseen. The class of patients coming to mineral spas includes those who have persistently overworked their brains, overfilled their stomachs, overstimulated their hearts, and indulged in all sorts of excesses, so that the problem of restoring them to normal condition is one of the greatest in medicine. Many recognize the value of hydrotherapy and return to their favorite spas once or twice a DISEASES OF THE HEART 133 year ''to take the cure," and thus Uve on, more or less restored for future work or indulgences as the case may be. The most famous, spa in the world for cardiac affections is, undoubtedly, Nauheim. Its popularity is evidenced by the fact that over 30,000 people visit this resort annually.^ How many of these thousands of people are carefully studied and frequently observed carmot be said, but in the rush of ''the season" many undoubtedly receive the most superficial medical treatment. At Carlsbad and Homburg in the fashionable season the condi- tions are probably no better, and this notwithstanding that ex- perience has taught that the best results follow strict medical supervision by a physician who can follow his patient thi'ough- out his course and occasionally see him in or just out of his bath. In no other way can the patient be properly guided. Effects of Baths in Cardiovascular Disease. — There is a notable discrepancy of opinion as to the effects of baths in cardio- vascular disease. The effect of hot and cold douches on the blood-pressure has already been described (see p. 48), and reference has alreadj^ been made to the use of the sphygmoman- ometer and the sphygmograph and to the effect of hot and cold applications on the rate of the heart. In the chapter on the Nauheim Baths reference is made to their use in cardiac disease (see p. 310), and the effects of baths in cases of arteriosclerosis are referred to on p. 147. Danger may be less apprehended in cases of aortic and mitral insufficiency than in endocarditis, myocarditis, and arterial degen- eration; less, also, from cool baths and douches than from hot baths and packs. It is noteworthy that the Nauheim bath, so beneficial in cases of cardiac dilatation, ranges considerably below the body heat. Starting at 95° F. (35° C), it is lowered in successive baths to 90° or 85° F. (32.2° or 29.5° C). Simply because a patient has a double murmur it does not follow that hot-air cabinet baths reaching 150° to 160° F. (65.6°-71.1°.C.), and followed by needle, jet, and Scotch douches should not be used. The author has used such baths in cases of this type with 1 The baths given in 1907 numbered 419,277. 134 HYDROTHERAPY benefit and is most cautious in the presence of arterial degenera- tion with high blood-pressure. Hot as well as cold baths raise the arterial pressure, and hence these measures shoukl be used only for short periods, if at all, with both elements of heat and cold properly arranged and apportioned. In this way the general circulation is improved and the nervous system refreshed without allowing either heat or cokl to make too positive or too prolonged an impression. For cases of this type it is much safer and better to use the cold pack at night preceded and fol- lowed by friction. Electric-light baths are also beneficial. The Turkish bath is especially liable to be abused, inasmuch as it is generally taken on the bather's own initiative. Its re- storative powers after excessive drinking or prolonged debauch are well known; but there comes a time, especially in these cases, when the arteries fail to withstand the strain and serious acci- dents are liable to ensue. Cases of arteriosclerosis, in which the cardiac valves may be sound but the heart muscle degenerated, are dangerous subjects for the Turkish bath. For all such cases the bath should not be more than tepid, 90° to 95° or 98° (32.2°- 35° or 36.7° C), and preferabl}' prepared more or less after the manner of the Nauheim bath, with sodium and calcium chlorid and possibly with carbonic acid gas. Here, again, caution is necessary, for the effervescent Nauheim bath raises the blood- pressure slightly for a few hours. (See p. 429.) NAUHEIM BATHS AND SCHOTT TREATMENT Any discussion of the treatment given at Nauheim for cardiac disease naturally includes the graduated exercises known as the Schott resistance exercises. Herein lies much of the advantage to be derived from a visit to Nauheim, where these exercises are skilfully practised. The tendency outside of Nauheim is to attribute the chief influence to the baths, and this belief is shared by a good many physicians at Nauheim.^ Trained assistants competent to give these exercises are now 1 See Jour. Amer. Med. Assoc, March 10, 1906, p. 714. NAUHEIM BATHS AND SCHOTT TREATMENT 135 found in the larger cities of Europe and America, and from the combined methods a great deal can be accomplished outside of Nauheim. A full description of these exercises has been pub- lished by Satterthwaite/ Kinnicutt,- Schott,^ Martin Siegfried, A. Abrams, Victor Neesen, ^Y. C. Rives, J. M. Anders,* J. Howe Adams, David Bovaird, Jr.,^ Douglas Graham, G. W. Norris, and others. The accompanying illustrations are Satterthwaite's ; they speak for themselves as to the variety and character of the ex- ercises, to the greatest importance of which there is a growing tendency toward appreciation. (Sec Figs. 25-39.) These exercises consist of slowly conducted flexion, exten- sion, adduction, abduction, and rotation, in orderly succession, of the trunk, arms, and lower extremities. Each succeeding move- ment is resisted by the attendant with such force as to oppose without arresting it. Each movement is slowly and evenly made with a. definite and uniform effort on the part of the patient. The attendant not merely resists the movement, but in addition he imposes a short interval of rest after each movement, enjoins slow and regular breathing, and prevents any undue strain, such as would be shown by hurried respiration. He also bears upon but does not grasp or constrict the limbs. Kinnicutt points out these requirements quite fully, showing that the degree of resistance and number of movements should be modified or discontinued according as they affect the pulse and respiration. The duration of a single treatment is, as a rule, fifteen to thirty minutes. In Satterthwaite's scheme they range from twenty-eight to thirty-seven minutes, including the intervals of rest. In gentle exercise the pulse is lessened three or four beats and there is a rise of blood-pressure. Later the pressure falls to normal and the pulse is frequently unaltered. 1 Thomas E. Satterthwaite, International Clinics, vol. i, 13th series. 2 F. P. Kinnicutt, Boston Med. and Surg. Jour., May 17, 1906. sTheodor Schott, Boston Med. and Surg. Jour., May 16, 1907; Medical Record, March 26, 1898; N. Y. Med. Jour., May 11, 1907. * Jour. Amer. Med. Assoc, Jan. 14, 1905, p. 116. 5 Medical Times, March, 1909. 136 HYDKOTHEIIAPY 1 i^. 2't. — Choi rai.-^ing. Fig. 26. — Shoulder raising. Fig. 27. — 1 1 ex- Fip;. 28. — Leg and thigh flexion and exten- ten.sion sion — exten.sion. Operator indicated by an X. (Figs. 25-39 are from Satterthwaite's article in International Clinics.) SCHOTT RESISTANCE EXERCISES 137 Fig. 30.^ — Thigh flexion and extension. Fig. 29 — Leg and thigh flexion and extension — flexion. Fig. 31. — Trunk flexion. Fig. 32. — Trunk extension. Operator indicated by an X. 138 HYDROTHERAPY Fig. 33. — Leg abduction. Fig. 34. — Leg adduction. Fig. 35. — Trunk rotation. Fig. 36. — .\rra separation. Operator indicated by an X. SCHOTT RESISTANCE EXERCISES 139 Fig. 37. — Arm opposition. Fig 38 — Quarter circling. Fig. 39. — Trunk flexion laterally. Operator indicated by an X. 140 HYDROTHERAPY "The effects of the baths and the Schott exercises are a shrinkage in the area of cardiac dulncss and a slight upward movement of the apex. An exact radiographic study shows that this means a lessening of the volume of the heart. The duration of this diminution in size is very short, but the continued employ- ment of the method produces j^ermancnt results. The best results are obtained in cases of enfeebled, relaxed, dilated hearts, with or without a murmur, following prolonged and exhausting diseases. It is also useful in cardiac inadequacy which follows severe muscular effort. In incurable organic disease the best results are obtained in mitral insufficiency with dilatation. Where the compensation is maintained with difficulty and in the early stages of failure very striking results are secured. "The Nauheim treatment is sometimes useful in cases of angina pectoris. In those in which the disease is due to organic coronary disease, the prospects are not so good. Cases with a high vascular pressure, those above 170, should not be subjected to this treatment. In administering the treatment little exer- tion and no fatigue should be the watchword. Much depends upon a careful selection and instruction of the operator. There is a tendency on the part of the patient to hold the breath and keep the body rigid, which involves greater conscious effort. This must be avoided. The operator should be trained in the observation of ordinary symptoms. The use of too great resist- ance is the most common fault of the operator and the most difficult to correct. The resistance exercises alone are often use- ful in cardiac inadequacy " (Kinnicutt). In all cases particular care must be exercised to adapt the baths to the individual needs. The process must be mild at the outset ; weak hearts are never suitable for strong baths and the congestion-dilatation of the heart has been observed b}' Pratt and others, as well as the author, to be distinctly increased by the bath. If there is a fall in the blood-pressure after the bath given at a temperature of 87° to 92° F. (,30.5°-33.3° C.) it indi- cates that the heart is weak and the bath too strong. Dr. Pratt usually begins the treatment with a bath one-fifth or three- NAUHEIM BATHS AND SCHOTT TREATMENT 141 3 a O 'S P_ cr CD a fO n> 1 ^ 0^ < CD M P rr w o o c ri- •-i CD X5 CD g a> rn o r1- ^ o p ►1 O (D m p p P CL CD .->> 3 a. cr p --I EI &- m o- «> cr £. 35 S- a- 2 nr '-' o "^ O p 3 CD CD 00 <) CD CD O" cr o 3 Sr o" 2^3^ CD ct- „. CL O 3 ^ 2 -[- g ^ g^ f ^^ CD „ ^ 3 cr z.. a ci ci 00 to (30 C» to 1*^ to to W Oi en 01 O O = o ^ o (» C» 00 M » 00 en Oi CD ^ GO CO ffl o s c 00 t» 02 W W Ol OT > > tr' f 3 3 to to to OJ 1— I-' to I— o o c o o o (^ q q q q ^ c d c c d c cr cr cr cr cr D* ^ ^ ^ 3 3 3 CSO oP o '" p X o o H- 3 00 OP §50 • O 333 5 <5 q pn ai B2 35 en ►1: iR S) (^ ?o a *=j > t> 02 SI "►5 > •^ H C=l GC z tr" H h-t § w H » Cl > pi a a 1— 1 ►fl t> .1 1— 1 !z! W 02 c| >i •Tj 2 *^ 1— ( 1— 1 t?3 :^ ^<: ,_^ § s w M W 142 HYDROTHERAPY tenths the full strength. At the Medical Baths in Boston the attendants take the blood-pressure before and after every carbon dioxid bath, and this furnishes a most useful guide. It is well to remember that the ''Nauheim treatment" and treatment at Nauheim are not convertible terms, and the reader is referred to a later chapter in which these various measures are more fully described.' Delimiting the Cardiac Area. — The most striking feature of the good influence of systematic resistant exercises and Nau- heim baths on the heart is the contraction of the cardiac area. In a dilated or hypertrophied heart or in one that combines both dilatation and hypertrophy this recession may be recognized after the use of the exercises which are generall}^ instituted for a time before the baths begin. During the period of bathing this rise of the apex-beat and contraction of area continues until the physical signs plainly show the improved tone of the cardiac muscle. It requires, however, a good deal of skill and experience to be able to map out accurately the area of cardiac dulness and make a proper record with which to compare future obser- vations. Even the location of the apex-beat is often beset with difficulty; and as for the borders of the heart, their limitations are so masked by the pericardium, the thorax, the superficial fat, varying conditions of the stomach and of the lungs, not to mention the possibility of a mammary gland, that reports of the alteration by | inch in successive observations have always seemed to the author beyond the power of human recognition, notwithstanding the orthodiagraph and other means for de- limiting the cardiac area. Nevertheless, in male subjects with thin chest-walls changes may be observed after a time by using a fixed method of observation. Sntterthioaite's Method of Delimiting the Cardiac Area. — The best and simplest plan is that used by Satterthwaite. He draws on the skin with the dermatographic pencil a horizontal line through the nipple and then a vertical line from the episternal notch to the umbilicus. He then traces out by percussion the 1 See pages 310 and 428. NAUHEIM BATHS AXD SCHOTT TREATMENT 143 outline of the heart and indicates the position of the apex with an X. He then applies tracing-paper to the chest and marks on it the horizontal and vertical lines, the outHne of the heart, and the positions of the apex and nipples. At each examination a similar tracing is made, and in this way, by successive records, the changes are noted. Much will naturally depend on whether light or heavy percussion is adopted, and, therefore, an effort should be made to use the same amount of force in corresponding portions of the cardiac border.^ To illustrate the method employed, the following is a record by Dr. Satterthwaite of a young woman who had cardiac hyper- trophy, mitral regurgitation, and an irritable heart. She was slight in build and a neurotic subject, addicted to hysteric sur- prises, had morbid fears, pseudo-angina, insonmia, and gastric disturbance with constipation. On February 1 her apex was found in the fifth space, in the Hne of the nipple, 3| inches from the median line. At the apex a harsh and distinct systolic murmur was heard, carried to the left. At the base a soft sys- tolic murmur was heard, confined to the aortic area. The heart sounds were feeble and the pulse intermittent. The urine was normal. After the preliminary rest and attention to her general condition, she was given a limited number of general movements, lasting fifteen minutes. These were given daily and gradually increased in number and force for five consecutive weeks. On February 8 the basic murmiu" was inaudible. The movements given on that date were twelve in number. February 11, nineteen movements, occupying half an hour. February 13, apex 3| inches from the median line; heart soimds somewhat stronger. February 16, 20 movements; pulse 96 to 84; respiration, 14. February 17, apex 3j inches from the median hne. February 23, corbonated brine bath, with resist- ant exercises; apex 3| inches from the median line. March 1, apex 3 inches from the median line. Pulse before the baths, 92; immediately after, 80; later, 73. The patient is gaining ^ See Thomas A. Claytor, Immediate Palpatory Percussion, Trans. Ameri- can Climatological Assoc, vol. xxiv, 1908; also Moritz. 144 HYDIiOTHEKAPY flesh. Menstrual flow is greater than for five or six months; there is no insomnia. She now had occasional attacks of pseu- do-angina, but these were milder than previously and yielded to monobromate of camphor. Apex now 2| inches from the median line and 2\ inches below the intermammary lino. On April 1 the apex was 1^ inches from the median line and If inches below the intermammillary line. On May 21 the pa- tient has had only one nervous attack during the past six weeks; she has slept well, and on June 4 was noted as still improving. It will be noted that in this case there was a recession of If inches in the apex-beat, and had it not been for the careful and systematic records it would scarcely have been believed. Dr. Bezley Thornc and Dr. Leslie Thorne Thorne use practi- cally the same method, except that they use auscultatory per- cussion, employing a light stroke from a rubber-topped pencil, in which thoy arc especially skilful. Enlarged hearts with valvular lesions certainly yield to this treatment, and when dilated and associated with a neu- rosis the results arc often surprising. It is only fair to say that both in Nauhcim and in America there is some doubt as to the possibility of reducing the size of a dilated or hypertrophied heart. It is only fair, perhaps, to hear the other side. Dr. David Bovaird, Jr., of New York, in a review of the Nauheim treatment, has expressed great skepticism on these points, as given in a paper before the Academy of Medicine, New York, Nov. 17, 1908: "Those who have read certain publications bearing upon the immediate change in size of the heart affected by these Nauheim baths, have been greatly impressed with the tracings shown in- dicating an immediate reduction in the size of the heart affected by a single bath. It can safely be said that there is doubt of the accurac}' of such statements and that even after a long series of these baths in most cases little or no reduction in the size of the heart can be demonstrated by accurate scientific methods. Apart from these specific effects of the bath, patients regularly NAUHEIM BATHS AND SCHOTT TREATMENT 145 find them physically very agreeable, a judgment which the writer can corroborate from personal experience. The effect of the treatment, as a whole, is to produce the first week or two a feel- ing of very marked lassitude, and weakness of which most of the patients keenly complain; but gi'aduaily the weakness and lassitude disappear and the patient becomes conscious of a steady improvement, which is usualty ver}^ satisfactory." Cases with edema or with renal or pulmonary complications are not deemed suitable for the Nauheim treatment. "The baths given in the course of treatment are prescribed for each individual patient as the judgment of his physician determines. They vary in their composition as derived from one spring or another, or by the combination of the waters of two springs; in their temperature for like reasons, and in the time de- voted to each bath. They are further modified by being given in what are known as half- and full-baths. In the half-bath the water rises only to the nipple line as the patient sits in the tub. In the full bath, to the level of the chin, the body being com- pletely covered. " The average cure consists in taking a series of from twenty- five to thirty baths, given in groups of two or three at a time, with a rest day between each group, and running in succession through the several grades of thermal, thermal-sprudel, and sprudel baths, the thermal being regarded as the mildest of the baths, the sprudel as the most effective. All of these baths have been used for many years and their effects noted, as they have been modified in the processes of a cure. We have really very little satisfactory information as to the nature of their action, and the manner of combining them appears to be determined by the experience of the individual physician" (Bovaird). The author made a special effort to settle in his own mind the uncertainty which naturally arose in view of such conflicting statements. Dr. Bezley Thorne very clearly demonstrated to him, in his office in London in 1910, that by accurate auscultatory percussion and the preservation of tracings of the cardiac area so defined, a noteworthy reduction in the size of the dilated heart 10 146 HYDROTHERAPY actually occurs in the course of artificial Nauheim baths with their associated resistant movements. The most carefully made tracings in numerous cases convinced the author that Drs. Thome, Dr. Satterthwaite, Dr. Kinnicutt, and others, who have reported such changes, are perfectly correct. Probably a great help in recording the variations in the cardiac area will be found in the use of the orthodiagraph. This instrument has been used but very little as yet in the United States. One is in use in Washington, where Dr. T. A. Claytor has employed it, and several are used in the large hospitals in Continental Europe. The author saw one in the Policlinic at Rome. It consists of a combination of fluoroscope and Rontgen tube. The fluoroscopic screen is provided with a pencil which moves synchronously with the Rontgen tube, so that the rays are always projected in parallel lines to the pencil point. A double arm holding the tube back of the patient and the pencil in front of a tablet on the chest enables one to make a perfect outline of the heart. Such an apparatus, when checked by a skilful auscultatory percussion, tends to eliminate somewhat of the personal equation in the rather difficult art of tracing the cardiac area. The instrument will no doubt be fully tested and its possibilities and limitations fully determined.^ PERICARDITIS, ENDOCARDITIS, AND MYOCARDITIS Heat uniformly accelerates the heart. Hot applications, therefore, may be expected to stimulate the faiUng heart, es- pecially if its slow action be due to intoxication, exposure to cold, partial drowning, or other depressing cause. Cold, on the other hand, slows the rate of the heart, increases the arterial pressure, represses inflammation, improves the tone of the car- diac muscle, and relieves pain. In pericarditis and endocarditis the local use of cold is of the * See article by Schiffer and Weber on Percussion of Absolute Dulness and its Value in the Determination of the Size of the Heart, Deutsch. Archiv. fiir Klin. Med., vol. xciv, No. 5. ARTERIOSCLEROSIS 147 highest importance. The ice-bags or Leiter coil should be kept on day and night, watching the skin to see that no ill effects re- sult. In delicate subjects these may be avoided by interposing a little gauze between the ice-bag and the skin. In myocarditis the ice-bag should not be used unless there are distinct signs of inflammation. Neither should the resistant exercises practised in connection with the Nauheim treatment be adopted, as a rule, unless the myocardial element is of a minor character subsidiary to other cardiac conditions. ARTERIOSCLEROSIS In general, it may be said that the blood-pressure is lowered by warm applications in cases of arteriosclerosis, whereas cold applications in these cases raise the pressure. In cases of nephritis, with arteriosclerosis and high blood- pressure, any extreme of heat or cold should be avoided. Baths of an indifferent temperature, e. g., between 95° and 100° F. (35° and 37.8° C), may be allowed; or Nauheim baths, ranging from 86° to 95° F. (30°-35° C). (See pp. 48 and 310.) An estimate of the degree of arteriosclerosis and of the blood-pres- sure should be made by means of the sphygmograph and sphygmomanometer. (See pp. 49 and 52.) Hot Baths for Arteriosclerosis.— Hirschield, noting that ar- teriosclerosis is the inherent penalty of strenuous life, meaning, of course, the overstrenuous life with excesses, advocates the systematic employment of hot baths, which have given him ' favorable results during the past two and a half years. The beneficial effect of the hot bath upon the patient suffering from arteriosclerosis is fourfold, as follows: 1. The distribution of blood-pressure is changed by the un- loading of the internal organs and the increase of vasculariza- tion of the skin. Hence these changes afford relief in many of the various cases of pain associated with internal gout, which is so frequent a cause of arteriosclerosis. The sleeplessness which is so often troublesome in arteriosclerosis becomes in a short time manageable without drugs. 148 HYDROTHERAPY 2. The hot bath increases combustion, which means in- creased metabohsm, increased oxidation of waste products, and an increased respiratory exchange. 3. EUmination of waste products is increased. 4. Blood-pressure is reduced in the same manner in which the pressure of water running from one tap is lowered as soon as another tap is turned on. The patient is bled into the skin, and the pulse at once becomes faster and more frequent. The systematic emjiloymc^it of the hot l)ath at last (establishes an increased vascular habit of the skin, thus permanently lowering blood-pressure. The oxygen hath, lately introduced, is said to have a good effect by reducing the blood-pressure in arteriosclerosis. (See p. 323.) TOXEMIC MYOCARDITIS In toxemic myocarditis, whether from (lii)htheria, scarlet fever, typhoid fever, pneumonia, or other infection, it is highly necessary to supply artificial heat to the body by means of hot- water bags in connection with gentle massage. Hot normal saline colonic flushings at about 115° F. (46.1 ° C.) will often rouse a poor circulation; especially is this the case in the intestinal paresis that may accompany a pneumonia. Another measure not to be neglected is the mustard foot-bath. A little mustard is placed in cheese-cloth and added to a foot- bath at 100° F. (37.8° C.) and the feet loathed for one minute. This may be repeated in an hour. Murphy's method of proctoclysis, in which large quantities of water are slowly absorbed, is not at all suitable for cases complicated by pneumonia, and is positively dangerous in any advanced stage of that disease. CHRONIC RHEUMATIC MYOSITIS; LUMBAGO This condition is characterized by indurations due to some autotoxic metabolic disturbance anrl is amenable to treatment, not too violent, which favors restoration of good circulation. alcoholism; morphinism 149 Tepid baths and hot dry packs are indicated. Moderate rubbing during the bath may be employed, but any systematic or vigorous massage is hable to bring on acute painful conditions simulating rheumatism. When situated in the neck or shoulder, this form of myositis is very troublesome, especially before the usual hour of waking. It wears off as the day advances and as voluntary motion favors a more vigorous circulation than during the period of rest.^ ALCOHOLISM; MORPHINISM; CHRONIC LEAD-, MER- CURY-, AND ARSENIC-POISONING, AND TOBACCO HABIT This is one of the most favorable fields for hydrotherapy. In acute cases the Turkish bath yields, as a rule, immediate re- sults. If this be not convenient, a prolonged soaking in the warm full bath at a temperature of 100° to 102° F. (37.8-39.9° C), followed by friction and rest in bed may be emplpyed. Chronic alcoholism is best treated by the use of tub-baths at 102° to 104° F. (39.9°-40° C.) for ten, fifteen, or twenty minutes, followed by packs in hot blankets for similar periods. Cases demand treatment in accordance with the general phys- ical condition. The corpulent, robust man may or may not have a good cardiac and circulatory system and the immediate effect of these procedures must be observed. If they are well-borne, these measures may be pushed to the higher limit and followed by cold sponging or cold douches. (For the neuritis resulting from abuse of alcohol see under "Neuritis.") Measures similar to those employed in alcoholism may be adopted in chronic lead- and mercury-poisoning and morphin and tobacco habitues. Tonic measures and the use of the hot-air cabinet, followed by the circular douche, jet, Scotch, and fan douche, and an alcohol rub will be required where there is debility, and especially after a course of tubs and packs. The internal use of waters, particularly those containing 1 N. S. Yawger, The Lancet, July 31, 1909. See also Sir W. R. Gowers on Lumbago, Brit. Med. Jour., Jan. 16, 1904^ p. 117. 150 htdrothp:rapy magnesium sulphate, aids in the treatment of these patients. Among the most successful resorts in America for cases of this class are French Lick and West Baden, Indiana. It is the custom there for patients to rise early, about 5 o'clock during the milder season, and drink several glasses of the Pluto Spring water. It is laxative and diuretic and has the great advantage of annulling, for a time at least, the craving for alcoholic liquors. The author has had repeated testimony on this point and has been impressed with the results which have been obtained in a comparatively short period. Several quarts or even gallons of this water are taken daily by the thousands of visitors who visit these resorts from Chicago, St. Louis, Cincinnati, and other cities in the United States. In delirium tremens the hot wet blanket pack is very useful in calming the patient and promoting sleep. DIGESTIVE DISORDERS These affections are most obstinate, being usually constitu- tional or of slow onset, and controlled by long-standing habits of the body which require months or years of well-directed treatment to correct. Medicinal treatment without dietetic, hygienic, and hydrotherapeutic measures is as "sounding brass or as a tink- ling cymbal," to use the historic phrase. Patients with chronic gastro-intestinal disease are frequently depressed in spirit, do not sleep well, and arc loath to acknowledge improvement if it occur. By the employment of hydrotherapy sleep may be im- proved and the abdominal circulation stimulated in such a way as to favor the elimination of toxic materials, especially when suitable mineral waters are administered. These latter, how- ever, are often used without any judgment. Stomachs can easily be ruined by pouring in large quantities of water containing sulphate or carbonate of lime or using strong solutions of lithium carbonate as prepared by dissolving the tablets at the table. CONSTIPATION 151 CONSTIPATION In fairly robust persons whose circulation is good the applica- tion of a cold pack or compress to the abdomen every morning may be given a preliminary trial. The cold compress should be changed once or twice during the ten or fifteen minutes of the application. Where there are suitable appliances, a cold douche at 65° or 60° F. (18.3° or 15.6° C.) may be applied for one or two minutes at 15 to 20 pounds' pressure. This will probably give better results in obstinate cases than the compress or pack. The reaction which ensues is accompanied by an increase of blood in the abdominal vessels, thus favoring functional activity. In patients not so robust, and with sluggish circulation, a hot douche or warm application may be made at first, and later the temperature may be lowered on successive days. Compresses are more suitable for old and feeble patients than the more formidable treatment by douches. As many cannot incur the expense or inconvenience of institution treatment, simpler measures are more likely to be adopted. The cold com- press, or Neptune's girdle, placed over the abdomen and renewed every four hours, may afford the desired stimulus. (See p. 356.) In spastic constipation, all forms of colic and muscular rigidity accompanying inflammatory conditions, fomentations must be used. They should be of generous dimensions, extending well beyond the borders of the irritable and painful area, should be wrung dry to avoid blistering, and should be changed every five or ten minutes and covered with rubber or any permeable material which will retain the heat. One, two, or more layers of thick cloth, flannel, or felt make a satisfactory medium to carry the water. When, in addition to heat, a counterirritant is desired, a small amount of mustard or turpentine may be added to the water for the fomentations (Gant). A hot- water coil may be used, but is not so efficacious; the covered electric com- press or cushion will be found very useful. Chronic Constipation. — The atonic variety and the spastic variety should be carefully distinguished. In the former, every 152 HYDROTHERAPY measure tending to improve the tone of the muscular system is called for. If possible, the hot-air or electric cabinet should be used to produce perspiration, followed by circular jet, Scotch, and fan douches. These measures should then be followed by skilful abdominal and general massage: Hot-air bath to gentle perspiration. Circular douche, 105° to 95° F. (40.G°-35.° C), one minute; 20 pounds. Scotch douche, ^-inch nozzle to the course of the colon, G0° •and 112° F. (15.6° and 44.5° C), fifteen seconds each, alter- nating for one or two minutes; 20 pounds. Fan douche to chest and back, 75° F. (23.9° C), ton seconds; 20 pounds. Repeat dail}^ increasing pressure 1 pound daily until 30 poimds are used. Walk in the open air afterward. Or the following : Wet pack; temperature of w^ater 60° to 70° F. (15.6°^ 21.1° C), one hour. Circular douche, 85° F. (29.4° C), fifteen seconds; 20 pounds. Repeat daily. Once or twice a week a circular douche at 90° to 75° F. (32.2°-23.9°C.). Fan douche, 85° to 65° F. (29.4°-18.3° C), five seconds; 20 pounds. The differential diagnosis between atonic and spastic con- stipation is often very difficult and sometimes impossible.' Spastic constij)ation is stated to be found more frequently the more carefully it is sought for. In the female at least 25 per cent, of the cases are of this form; and many of the most persistent cases of chronic constipation, refractory to all n:ieth- ods of treatment, are of this type. As the treatment of this form of constipation is diametrically opposite to the atonic form, it is not diflficult to see why so many patients with con- stipation arc treated for years without success. Spastic constipation, according to Dr. Albu, is most fre- quently found in neurasthenic and hysteric individuals, most often females. They are weak, poorly nourished, somewhat pale and anemic, and in the third or fourth decade of life. A perfect knowledge of the syndrome of the malady, there- lA. Albu, of Berlin, in Med. Record, July 1, 1905. GASTKOPTOSIS 153 fore, must be obtained in order to outline an intelligent course of treatment. As these spasms sometimes develop on the basis of atony, every occasion for exciting them must be avoided. Every irri- tation of the intestines, and especially massage, which is very effective in the atonic form of constipation, must be avoided. Albu recommends the use of : Warm or hot sitz-baths for from fifteen to twenty minutes at a time. The application of hot compresses to the abdomen, which not only lessen the spasm but also relieve the colic. Chronic constipation has sometimes been cured by inject- ing into the bowel | pint of cold water on rising, and retain- ing this until after breakfast. If too cold, retention may be impossible, but the bowel can be accustomed to hold this quantity by properly grading the temperature. Cold-water enemata can be more readily dispensed with than large warm enemata. Warm enemas of linseed oil or olive oil, j liter every evening, given in bed, with the hips elevated or in the knee-elbow po- sition, and retained over night if possible. The object of this treatment is not to produce bowel movements, but to act as a sedative on the spasm of the intestinal muscle, and should, therefore, remain in contact with it as long as possible. Large warm enemata are liable to engender the enema habit. This may be broken by lowering the temperature of the water each day 5 degrees, and lessening the amount | pint. GASTROPTOSIS Gastroptosis may be treated by the following procedure, advocated by Dr. George Roe Lockwood : About 11 o'clock in the morning a warm or hot bath at 105° F. (40.5° C.) is given for five minutes. This is followed by a spinal douche at 100° to 102° F. (37.8°-39.9° C.) for ten seconds at 15 to 20 pounds' pressure. The patient is then placed in bed and a hot wet flannel compress or one of spongiopiline 154 HYDROTHERAPY suflficiently large to cover a good portion of the abdomen is placed on the epigastrium. This is kept hot by a covered electric pad and is changed every two hours by day and once at night. The whole application is to be tightly applied by an elastic binder.' CHRONIC GASTRITIS AND ENTERITIS In these conditions the half-bath, which combines moisture, temperature, friction, and force, is a favorite measure abroad. (For technic see p. 243.) It may be followed by the pail-pour, which consists of pouring water from a pail held about 4 feet above the patient. This pail-pour is repeated three to six times. It seems to enhance the good effect of the bath. Winternitz has termed this thermic massage. The hot-air bath may be used previous to the half-bath, producing a stimulating and refreshing sensation and a tonic improvement. ROUND ULCER OF THE STOMACH; HEMORRHAGE In this affection apply a cold compress to the stomach, •covering this with a coil through which ice-water flows continu- ously for several days if necessary. A sheet may be wrung out of cold water, laid over the trunk, tucked in at the sides, and the ■cold coil placed on top of this. In the hyperesthesias of gastric disorders the electric heating pad to the stomach and warm hip-bath freciuontly afford relief. Sadgcr has given his experience with hydrotherapy in the •case of hemorrhage from gastric ulcer. ^ He states that he has often found that small pieces of ice introduced into the rectum act like magic in arresting acute hcmatemesis. Cold fluids introduced into the rectum, he found, reduce the temperature •of the stomach in some way. Swallowing scraps of ice has the opposite effect, and actually favors hemorrhage as the water accumulates and becomes warm. A cold coil over the stomach, over a cold compress, is an effectual adjuvant, the flow of ice- cold water through the coil being kept up continuously possibly 1 Medical Record, July 20, 1007. 2 Abstract in Jour. Amer. Med. Assoc, April 14, 1906. ROUND ULCER OF THE STOMACH; HEMORRHAGE 155 for a week. A sheet is wrung out of cold water and laid over the trunk, tucked in around the sides, and over this the cold coil is applied over the stomach. The patient is fed with tepid sweet or sour milk in small portions for four or five weeks. Sadger commences with a teaspoonf ul every fifteen minutes and increases the amount to a tablespoonful, then to half an after- dinner cofTeecupful, and finally to a teacupful, increasing the intervals to thirty or sixty minutes. He insists on this diet after acute hemorrhage and also in the treatment of chronic ulcer. Even on the day of the hemorrhage it is possible to commence with minimal amounts of the milk (ice cold). Sadger quotes from Winternitz that the factors inducing round ulcer of the stornach are a chlorotic tendency, reduction in hemoglobin, reduced alkalinity of the blood and hyperacidity of the gastric juice, with spasmodic contraction of the blood-vessels in the stomach mucosa. These factors, he says, induce a predisposition to gastric ulcer. Hydrotherapy, which has such a powerful action on all these factors, forms thus a truly causal treatment for the resulting predisposition to gastric ulcer. It seems to be the general experience that the main contingent of gastric ulcers is presented by chlorotic girls. The chief reliance is on general stimulating measures, with procedures to influence the circulation in the stomach fining and walls. These include cold sitz-baths for about four minutes, stimulating packs, generally in combination with the hot coil, which, however, is never left in place for more than ten or fifteen minutes. Sometimes the cold coil is applied to the heart to improve the general and local circulation. These measures are supplemented by a strict milk diet. Sadger applies an abdominal pack, changed every three hours. Once or twice a day a coil of hot water (104° F. — 40° C.) is inserted in the pack for ten or fifteen minutes. Once a day a sitz-bath is taken with water at 46° or 57° F. (7.7° or 13.8° C.) for from three to five minutes. Early in the morning the body is rubbed off with a cloth wrung out of very cold water, avoiding the chest and abdomen. Later, alternating hot and cold pro- cedures are used. A good arrangement for home use is a cold 156 HYDROTHERAPY pack until the sheet gets warm (twenty to thirty minutes), with a half-bath afterward at 68° or 70° F. (20° or 21.1° C.) for two or three minutes. Milk is the only food allowed for four or five weeks, commencing with a teaspoonful every fifteen minutes. The milk must always be very slowly sipped. ATONY AND ENTEROPTOSIS Atony and enteroptosis may also be helped, when spastic constipation is absent, by cold abdominal douches, such as mild jet and fan douches, and by abdominal massage. The prelimi- nary warm bath, hot-air bath, or electric-light bath until per- spiration is free is followed by a short cold application admin- istered by rubbing the patient with a mitten or coarse towel wet with water at about 60° F. (15.6° C), or by giving the patient a cold douche at 70° to 60° F. (21.1 °-15.()° C.) for five to twenty seconds. The temperature should be lowered 1 degree daily and the pressure increased by 1 pound fi-om 15 to a maximum of 30 pounds. This stimulates the circulation, prevents auto- intoxication, and improves the muscular tone: Intestinal lavage and irrigation are also useful. This may relieve the "morning diarrhea" of atonic dilatation of the stomach. NERVOUS DYSPEPSIA The measures described for aton}^ and enteroptosis are some- times useful in nervous dyspepsia. If a choice can be made that is practicable and that can be adopted for two months or more, an impress can usually be made on this obstinate affection. Thesitz-bath at 50° to 60° F. (10°-15.6° C.) for three, five, or eight minutes is also beneficial. General tonic measures, such as electric-light baths followed by douches, are indicated, but these cases are proverbially obstinate. It should be stated in this connection that the general effect of cold bathing is to diminish intestinal putrefac- tion. CHOLERA INFANTUM 157 PERISTALTIC UNREST In the condition known as peristaltic unrest of Kussmaul the hydrotherapeutic measures used for neurasthenia should be tried. These, with lavage of the lower bowel, give very satisfac- tory results. CHOLERA INFANTUM When the temperature is high, bathing should be employed at a temperature of only a few degrees below that of the body. The warm mustard bath, made with one or two tablespoonfuls of mustard enclosed in cheese-cloth and placed in a small tub of water at 98° to 100° F. (35°-37.8° C), may be used. The child, whose ears are protected with a little cotton plug, is put in the bath at the same time that the mustard is added at the foot of the bath-tub. The duration of the bath may be from four to five or eight minutes or until the person holding the child finds some reddening of her own skin. The child is then dried and dressed in night clothes and returned to bed. Marked im- provement of the general circulation and the breathing, and a quieting effect on the general nervous system will be noted as the results. Cold baths and ice- water injections into the bowels are not to be recommended, although they have been advocated by some. When no reaction follows the mustard bath the prognosis is not good. Dr. Forchheimer acids a word of caution regarding the eyes in giving mustard baths to children. The eyes should be kept clean and protected not only in the mustard bath, but throughout the course of cholera infantum in order to prevent infection. Normal salt solution, with boric acid, if necessary, should be dropped into the conjunctival sac, and when, as is usually the case, the lids are open the eyes should be kept constantly covered with moistened lint to prevent ulcer of the cornea. (See also p. 227.) 158 HYDROTHERAPY PERITONITIS AND APPENDICITIS Cold applications are to be preferred to hot ones in these comlitions. In general peritonitis cold is applied by means of ice, using the ice-poultice or ice-bags. These measures are also indicated in appendicitis previous to operation. The bag should be suspended so as not to rest too heavily on the patient. Too persistent application of cold acts as a marked depressant, and unless gauze is interposed, ice-bags and ice directly applied to the abdominal wall may produce gangrene. Such accidents have happened and have given rise to law suits. Cloths wet in ice-water may be used instead of the ice-bag, changed frequently. Murphy's method of proctoclysis has yielded good results in these cases. (See p. 361.) SEASICKNESS The full hot, dry pack to the entire body, including the head, is a simple effective remedy for seasickness. This should be kept up until the superficial vessels are fully dilated. Hot towels to the head are also useful at times. The electric pad applied to the stomach is nowadays a practical measure on the ocean steamers. ANEMIA; CHLOROSIS; CONVALESCENCE FROM ACUTE ILLNESS In treating these affections the aim is to stimulate all the sources of the body heat to a powerfully increased function. The first step is to warm the body, applying afterward vigorous brief thermic and mechanical stimulation of the nerves. Nothing accomplishes this so well as the hot-air cabinet succeeded by the circular douche, jet, and Scotch douches, followed then by an alcohol rub. ANEMIA Great improvement follows judicious hydrotherapy in this disease. To improve the circulation, the digestion, and the ANEMIA 159 excretion are the main aims. These may be attained by warm baths or cold baths; by hot-air baths followed by appropriate douches, the so-called tonic baths; by drip sheets, cold packs, and the judicious use of nearly every hydrotherapeutic measure. Cases of pernicious anemia are sometimes arrested and started toward recovery by these methods in connection with internal treatment. At times internal treatment is not well borne, and physiologic therapeutics become the mainstay. In mild grades of anemia with fair resistance, the author usually employs the hot-air cabinet or the electric-light cabinet, followed by the circular douche, jet douche, Scotch douche, fan douches, and a drying rub and friction with alcohol. The pre- scription may read as follows : Hot-air bath, eight to ten minutes or to beginning perspiration. Circular douche, two minutes, 105° to 90° F. (40.6°-32.2° C), 20 pounds. Jet douche, one minute, 100° to 80° F. (37.8°-26.7° C), 20 pounds. Scotch douche, twenty seconds, 105° and 80° F. (40.6° and 26.7° C), 20 pounds. Fan douche, ten seconds at 78° F. (25.6° C). Alcohol rub. Reduce minima 1 degree daily to 60° F. (15.6° C). When cabinets and douches are not available, simpler meas- ures, such as the systemic use of the drip sheet at bedtime, the half-bath, warm or cold l)aths, followed by friction, may be em- ployed. Warm salt-water baths are useful. In summer sea- baths at moderate temperatures and sun baths on the beach before and after the bath may be helpful, but have to be taken with judgment. In this way a good reaction is obtained and the tone of the skin is greatly improved. In extreme anemia the patient is usually too weak to stand while douches are administered, and hence graduated brine baths with effervescing carbon dioxid are recommended and can easily be carried out at home. The natural carbon dioxid baths at Nauheim, Carlsbad, and elsewhere may be taken where the means and convenience of the patient permit. Baths containing iron sulphate are useful for their astringent and bactericidal 160 HYDROTHERAPY effect on the mucous membranes, especially where vaginal ca- tarrh is associated with the anemia. In employing hot baths it is best to give them on alternate days at first, so that the patient can have massage and uninter- rupted outdoor rest, with perhaps moderate exercise, on the intervening days. The best time for these baths is in the fore- noon and about two hours after breakfast. The temperature should be from 102° to 104° F. (38.9°-40° C). At fir.st of ten minutes' duration, the bath may be lengthened to twenty minutes. A cool or cold cloth is kept on the entire scalp and frequently wrung out in cold water during the progress of the bath. Rubbing in the tub is advised. When the patient is taken out he is sponged up and down the spine or all over with water at 70° F. (21 °C.), and in this way is educated to the use of a cold douche by the time for the third or fourth bath. The cold water from a hose may be gradually lowered in tem- perature as the treatment progresses and the patient gains strength. If the patient is not too weak, the Turkish bath is useful in promoting good circulation and improving the condition of the blood, particularly is it beneficial if associated with a redundance of fat. In this latter connection massage is a most valuable adjunct. (For the effect of hot and cold applications on the blood and the blood-vessels, see pp. 50 and 210.) CHLOROSIS Cold sitz-baths for about four minutes or stimulating hot packs, generally in combination with the hot coil, favor circula- tion in the stomach-lining and walls, and are suitable in chlorosis. The hot coil should be left in place not over ten or fifteen minutes. The cold coil may be applied to the heart to improve the general and local circulation (see pp. 102 and 357). Nearly all cases can be benefited by some system of neuro- vascular training by hydrotherapy. The following prescription is suitable for moderate cases of chlorosis and anemia: SPLENIC ENLARGEMENT 161 Electric-light bath, fifteen to twenty minutes. Fan douche, 105° F. (104.5° C), thirty seconds, 20 pounds. Fan douche, 70° F. (21° C), fifteen seconds, 20 pounds. Dry rub. Rest one hour. Repeat every other day. If the patient is rather weak, the time in the electric-light cabinet may be shortened, and instead of the douche give a cold wet mit friction with water at 70° F. (21° C), reducing it daily 1 degree. VASOMOTOR SPASM AND VISCERAL ANEMIAS Hot mud baths are sometimes of great benefit. Mountain spas are of great value in anemia and chlorosis. For vasomotor spasm and visceral anemias such measures as the general Scotch douche, warm visceral or abdominal douches, short percussion douches, alternate hot and cold com- presses, etc. , are very effective. Cold sponging over the spine and outside and inside of thighs increases elimination and stimulates circulation. Constipation may be relieved and peristaltic activ- ity increased by drinking a glass of cold water, preferably car- bonated water, before breakfast; small cold enema; fomenta- tion with water at 120° F. (48.8° C.) over hver twice daily, followed by heating compress during interval; wet girdle at night; cold fan douche to abdomen; cold percussion douche to spine; abdominal massage. Douches generally act better when preceded by some warming process. SPLENIC ENLARGEMENT Mosler^ states that the application of cold water to the ab- domen produces contraction of the spleen, and that the cold douche appHed for two or three minutes, and repeated at longer or shorter intervals, very sensibly affects the enlarged spleen of intermittent or typhoid fever and even of such chronic diseases as leukemia, in which class of cases the application should be twice a day (H. C. Wood). 1 Virchow's Archiv fiir Path. Anat. und Phys., Ivii. 11 102 HYDROTHERAPY NEURASTHENIA Most neurasthenics are benefited by hydrotherapy and nearly all of the various baths that promote healthy reaction may be employed. The best of these are the drip sheet, alter- nate hot and cold sponging of the spine, the tonic treatment by means of the hot-air cabinet, the circular douche, jet, Scotclj and fan douches, and subsequent rub. The salt rub, preceded and followed by a spray or fan douche, is an excellent measure and easily applied (see p. 354). The temperature of the spray should be between 92° and 99° F. (33.3° and 37.2° C.) and should occupy from four to eight minutes. Beni Barde, of Paris, applies the sj^ray along the spine, then the anterior surface, and then the limbs, making the application twice a day. If all sudden shocks are avoided, sleep is favored, nervous agitation ceases, and the patient is generally soothed. The temperature of the bath toward the end may be reduced a trifle. Cool or cold water bathing is not always beneficial to the neurasthenic, at least at first. Patients will be met with who, for some mysterious reason, do not bear any of these measures very well. They seem to be greatly fatigued by them. In such cases one may have to be content with a general sponge three times a week. Cases of chronic fatigue are poor subjects, just as it would be improper to give a cold bath to a healthy person greatly fatigued by exercise. If such be given, there may be a secondary feeling of drowsiness or lassitude. If any hydrotherapeutic measure at moderately low temperature ap- plied for neurasthenia produces an unpleasant effect, it would probably be corrected by raising the temperature, lowering the pressure, and shortening the bath. The types of neurasthenia are so various and individual peculiarities so diverse that every patient must be judged separately. Much can be done by way of cultivating the resistive powers of these patients. A routine bath is always to be deplored, but especially here. Individualization, education, and persistence NEURASTHENIA 163 should mark the treatment of these cases. Just as in applying electricity to a neurasthenic man or woman, it is safer at first to apply the electrodes without current, so unusual care should be exercised that no shock be given from the use of either very hot or very cold water. Dr. Baruch told the writer that he con- sidered his principal contribution to the technic of hydrotherapy to be the educational bath. To render this feasible by definite gradations of pressure, temperature, and duration he had the douche table constructed which is identified with his name (see p. 282). In other words, the successful treatment of these cases depends on intelligent dosage. The most successful method of treating neurasthenia is that which was first formulated by Dr. Weir Mitchell forty years ago. This celebrated plan of the "rest cure" embraces, among other physical methods, hydrotherapy. During the earlier stages of treatment the drip sheet is usually suitable and advised by Dr. Mitchell, the technic of which is described on p. 246. It has the advantage, in common with the cold pack, of being appHed while the patient remains in bed, and does not require apparatus. During the later period of treatment, if the patient is in a hospital or sanitarium, it is easy to employ cabinet baths either by hot air or electric hght, followed by the needle (circular) douche, jet, and Scotch douches. Salt rubs are easily given and may prove useful in any stage of the treatment. Fric- tion with a dry towel after cold packs, sprays, and douches is highly important to secure reaction. Neurasthenic patients need the neurovascular training in- stituted and described by Dr. Baruch, and it is necessary to be extremely cautious in the use of cold. By tact and perseverance and the use of mild measures at the outset these highly sensitive subjects may be trained to react, and wiU become interested in the measures adopted and eventually recognize the good effect to the circulation. Not the least of all the benefits derived will be the cultivation of a healthy state of will power and the return of hope, which is always a very small asset in the neurasthenic patient. There are various trying symptoms of neurasthenia 164 HYDROTHERAPY which demand special forms of treatment. The insomnia is sometimes relieved b}^ the application of dry cold to the spine for an hour in the evening. Douche or Control Table.— In carrying out treatment with the aid of this a[)paratus the author directs the use of the hot- air cabinet short of perspiration; this takes six, eight, or ten minutes at a temperature of 170° or 180° F. (76.7° or 82.2° C). The electric-Ught cabinet may be employed, as a rule, in place of the hot-air cabinet. Then one or two minutes in the circular douche, the temperature being reduced in the time allowed from 105° to 90° F. (40.G°-32.2° C), and the pressure being 15 pounds. Then the jet douche for fifteen or thirty seconds, reduced from 90° to 75° F. (32.2°-23.9° C), at the same pressure;; followed by the fan douche at the same pressure and at 75° F. (23.9° C). From day to day the temperature of the terminal douche is reduced 1 or 2 degrees until G5° or 60° F. (18.3° or 15.6° C.) is reached; the pressure is raised to 20 pounds. The jet and cir- cular douches are correspondingly raised in pressure. The tem- perature can be lowered and the pressuse raised more rapidly in some cases, especially in those in which good reaction takes place in the first or second bath. As in all other educational processes, some subjects progress rapidly, while others are more sluggish. Hence, the physician nuist be in touch with the oper- ator, receive immediate reports, or, better still, if possible, watch the procedure. In Paris the author found that the doctors in charge of the hydrotherapeutic establishments gave all the douches personally to men and women alike. In hospitals, sana- toria, and health resorts this oversight is better systematized than elsewhere and often accounts for the better results ol> tained. Some institutions and resorts in the United States provided with douche tables are mentioned on pp. 284-286. Prolonged hot baths, the hot spout, and hot packs are not suitable measures in neurasthenia; the ultimate effect of these, even when followed by a cool shower or douche, is bad. SPERMATORRHEA 165 SEXUAL NEURASTHENIA Good results follow cold bathing in the morning. The patient is made to stand in a bath-tub containing warm water, while cold water, preferably at a temperature of 55° to 70° F. (12.8 °-21. 1 ° C), according to the temperature of the available supply, is made to flow from the occiput to the spine. Two or three minutes at first and later five minutes will suffice. The patient should rub himself briskly. Good food with moderate doses of strychnin or phosphorus aid the treatment. Local treat- ment of all kinds should be avoided. SPERMATORRHEA Cold water ablutions are often advised, but, on account of the strong reaction produced, are not so beneficial as those with lukewarm water without active rubbing of the body surface. The skin may be dried by merely applying the towel, or it may be allowed to dry spontaneously. Impotence, with general muscular weakness, loss of tone, lack of general strength and vitality, accompanied by imperfect and rapidly subsiding erections, should be treated with cold peri- neal douches having a moderate force and for considerable lengths of time. (See Ascending Douche, p. 262.) In applying cold water it should be dashed or sopped against the perineum or the scrotum. The scrotum may be submerged in a tumblerful of cold water for one or two minutes each night, at the same time applying cold to the lumbar region. Some years ago Dr. J. William White advocated strongly the use of the bidet.^ This attachment to the bowl of the or- dinary water-closet allows a current of cold water to be directed gently upward against the parts. While the principal is a good one, the arrangement has many objections and has fallen into disuse. ^ See Hare's Therapeutics, 13th edition, article on Cold. 166 HYDROTHERAPY NEUROSES OF THE BLADDER In enuresis nocturna it is best to try the half-bath, and later, in older children, a cold rain douche. Affusions with water at 00° F. (15.6° C.) may be used. In all neuroses suggestion of cure by the means employed should not be forgotten. INSOMNIA "Whatever the cause of insomnia, whether due to pain, the irritation of cough, to gastro-intestinal affections, to high arterial tension, or to low arterial tension, there is one condition which is generally considered necessary to sleep, and that is a state of cortical anemia. Hydrotherapeutic measures must be chosen with this end in view, and, fortunately, most of them are applicable. The late Sir William Broadbent, in a critical analy- sis of the various cause of insomnia,' discusses the influence of high and low arterial tension. High blood-pressure is not by any means invariably attended with sleeplessness, but it is a contributory cause of the sleeplessness of old age, of arterial de- generation, and of renal disease. The blood-pressure overcomes the resistance in the cerebral arterioles and maintains an active blood supply to the cortex which is inconsistent with sleep. When no other cause of habitual difficulty and delay in going to sleep can be found and the pulse tension is high, the possibility that this is a cause must be entertained. Sir William Broadbent remarks that "When cold feet in- terfere with sleep, it is not merely through the feeling of cold as such, but by an influence on the general and cerebral circulation. Coldness of the feet, indeed, is often a concomitant of sleepless- ness, rather than its cause, and an incident of general vasomotor disturbance, which may be a gastro-intestinal reflex. When the feet are cold after hard brain work, the blood seems to be positively shut off from the feet. A hot bottle is then often of no use, and the best way of warming the feet and procuring ^ The Practitioner, London, July, 1906. INSOMNIA 167 sleep is to stand in cold water (preferably running water) and then rub the feet dry with a rough towel." In the majority of cases the warm bath, 90° to 98° F. (32.2°- 36.7° C), or the full hot bath, 98° to 104° F. (36.7°-50° C), at bedtime may be found successful. The author has found it necessary to prolong the duration of these baths from ten to thirty minutes in obstinate cases and to have them repeated several times during the night. The attendant should not fail to keep the turban wet with cool water, changing it frequently, so as to keep the head cool. The patient should be rubbed dry quickly and put in bed. On a succeeding night the wet pack should be tried should the treatment just detailed prove in- effectual. Friction of the entire body should be given after the pack. The drip sheet has also proved useful in many cases (see p. 246). The prolonged tepid bath, 96° to 100° F. (35.6°-37.8° C), just before bedtime may also give relief. After about fifteen minutes the patient is quickly dried without much rubbing and given a cool foot bath, with brisk rubbing of the feet. The head should also be wet with cool or cold water. In cases attended with overactivity of the cerebral circula- tion, the spinal douche, with brisk rubbing of the body and cold applications to the head, often aids other forms of treatment. The object is to secure cutaneous hyperemia without per- spiration. Rationale. — ^Primary effect: Contraction of the capillaries of the surface and hyperemia of the brain and internal organs. Secondary effect: Hyperemia of the skin; depletion of the brain. The use of a towel wet in cold water placed around the neck while the patient is in bed may also be successful; or the feet and ankles may be placed for fifteen minutes in hot water. Local packs to the legs and to the abdomen may also be tried where tubs are not at hand. The abdominal pack, called Neptune's girdle, is described on p. 356. In any case it is desir- able to make cold applications to the head with free use of water 168 HYDROTHERAPY on the face and forehead. The sitz-bath, in water at 70° to 75° F. (21.1°-23.9° C), for ton to twenty minutes, with the feet and legs well covered, is useful in the insonniia accompanying sexual neurasthenia, or hypersensitive conditions. Whether cold baths, half-baths, or sitz-baths are used, it is better not to dry the l)aticnt completely, but let him quickly put on night clothing and get into bed. Forchheimer gives th(^ preference to the gen- eral moist pack carefully applied and continued for one to two hours. Sea-bathing. — In suitable localities sea-bathing may be found very useful, but the drowsiness 'whicli follows prolonged sea-bathing is undesirable and may be an index of physical weak- ness. Used with judgment, moderate sea-bathing will favor natural sleep. INSANITY Currie used cold batlis in insanity in 1796, and records several cures of maniacal patients by throwing them " headlong into the cold bath."i The following is from the record: "The direction had been followed, and on the morning of the 23d he was again tin-own into the cold bath in the height of his fury, as before. As he came out, he was thrown in again, and this was repeated five different times, till he could not leave the bath without assistance. He became perfectly calm and rational in the bath, and has remained so ever since. He never relapsed and was discharged some time afterward, in perfect health of body and mind." Systematic treatment of the insane by means of hydrotherapy has been carried out with considerable success in this country at the United States Government Hospital for the Insane, Washing- ton, D. C; at the Sheppard and Enoch Pratt Hospital, Towson, Md.; at the Eastern Maine Hospital for the Insane, at Bangor; The Craig Colony for Epileptics, at Sonyea, N. Y.; the McLean Asylum, Waverly Mass.; at the Danver's Asylum, Mass.; at the Butler Hospital Providence, R. I. ; at the Columbus State Hos- 1 Op. cit., pp. 21 and 59. INSANITY 169 pital, Columbus, Ohio; at the Ohio State Hospital for the Insane, Massilon, Ohio; at the University Hospital, Ann Arbor; at the Philadelphia General Hospital (Blockley); at the Pennsylvania Hospital for the Insane; at the Morris Plains State Hospital for the Insane; at the Manhattan State Hospital for the Insane, Wards Island, N. Y. ; at the J. Hood Wright Hospital, N. Y. ; and also at various private institutions, such as Dr. Parson's, at Ossining, N. Y., and Dr. Bond's House at Yonkers, N. Y. Fig. 40. — Continuous baths, showing an insane patient in the tub. is assigned to two patients. One attendant They are all equipped with modern douche tables and many with continuous baths. One of the first to report on the results of treatment was the late Dr. G. W. Foster. His report, pub- lished in 1899,^ gives the results of treatment in 12 epileptics and 21 cases of paresis. The average duration of treatment of the epileptics was over seven months. In every case but one a marked improvement, both mental and physical, followed. The average loss in number of fits was 40 per cent. The cases of ^ American Journal of Insanity, vol. Iv, No. 4. 170 HYDROTHERAPY general paralysis of the insane were naturally not so satisfac- tory, although. 3 were reported as arrested and G improved. Of course, in the absence of precise objective data by which a comparison may be made of the patients' mental condition be- fore and after treatment, the judgment of the medical attendant must alone be relied upon. Dr. Foster reported 3 cases of acute mania recovered; 2 of acute dementia; 1 of acute melancholia, and 1 of morphinism. The late Dr. Dent also reported great success in the treat- ment of insanity. The same methofls have been continued by Dr. William Mabon in the Manhattan State Hospital, New York. Dr. B. R. Logic has continued this method of treatment at the United States Government Hospital for the Insane during the last six years, applying it to all forms of insanity. In mania with depression he believes the disease has been shortened and the symptoms modified from the beginning. Nearly all of these cases have made rather rapid and good recoveries, pro- longed periods of excitation having been rare. In a personal communication, dated February 21, 1905, Dr. Logic writes: "In all cases of excitement and depression I would ofttimes be able to relieve the symptoms. In epilepsy I believe that during the period of a(^tivc treatment in a number of in- stances the attacks were greatly reduced in number, and j)erhaps not so severe at the time of occurrence. In the paretic and the large class of chronic insane, including, of course, the dementias, I have been able, by keeping in first-class order the physical con- dition, and by especially directed efforts toward such symptoms as excitement and depression, to render the jiatients comfortable, and perhaps to prolong their existence. Personally, I approve of the treatment, and believe that it stands to-day without a rival. "My methods of applying the treatment are few, owing to the fact that experience has apparently demonstrated that there are only a few procedures which it is really worth while to use. As a matter of routine, then, I have adopted these, and, altering INSANITY 171 them to suit any case, have confined myself almost exclusively to their use. The most prominent of these procedures is as fol- lows : First, the cold wet pack ; second, the hot-air box. After each I am in the habit of dressing the patient either by cold towels or, preferably, the Scotch douche. In cases that are very much excited I use, as a rule, a warm bath, temperature about 112° F. (44.4° C), followed by a prolonged submersion in the neutral bath." The author does not advise so hot a bath. The author would advise in all cases of moderate excitement a hot wet pack as a sedative. A blanket is laid on the bed and a linen sheet wrung out of hob water is quickh^ spread over the blanket. The patient, whose clothes have been removed, is then laid upon the sheet, which is folded about him and then enveloped in the blanket. A cold compress should be applied to the head. The result is a relaxing neutral pack when the temperature of the skin and sheet are equalized. The hammock has been utilized to hold very violent patients in the continuous bath, using water at 100° F. (37.8° C), with a remarkable sedative effect. This is the best tranquillizing pro- cedure when prolonged. The tubs used for the continuous baths in the Manhattan State Hospital are large and deep, with rolling edges, and under the edges are hooks for the attachment of a canvas hammock upon which the patient lies. There is an inlet at the head of the tub into which the water runs continuously while the tub is in use, and three outlets at the foot, one near the top which prevents overflow, one at the bottom, and one near the middle with a large stopper, by which the tub can be emptied of all excreta. The flow of the water and its temperature are controlled entirely from the table, and in addition to this, in order that all possible danger of mistake may be avoided, a bath thermometer is kept in the tub tied to its edge. The thermometer in the tub registers a slightly lower temperature than that shown on the control table, the difference varying from 1 to 3 degrees, accord- ing to the apparatus. 172 HYDROTHERAPY The patients treated by these baths are restless, delirious, and violently disturbed cases. They are kept in the tub usually for the entire twenty-four hours without removal except for cleaning the tubs, and for a sufficiently long period to allay their excite- ment, varying from a day to two or three months. The following is the routine procedure of preparing the tubs for and placing the ])atient therein: In the first place the tubs are drawn half-full of water, the hammock placed in position, and the patient, wearing a chemise, placed on the hannnock ; across the whole length of the tub are stretched sheets tied at each side, thus entirely covering the patient except her head, which rests upon a rubber air-cushion. If the patient is very disturbed and assaultive, it may be necessary to wrap her in sheets secured with safety-pins until she become quiet. The water is kept at a temperature of from 98° to 100° F. (36.6°-37.7° C.) except in very hot weather, when it is some- times allowed to drop to 95° F. (35° C). Every morning the patient is removed for an hour while the tub and the hammock are cleaned and the patient's entire body anointed with some bland ointment to prevent irritation from the continuous appli- cation of the water. A nurse in charge of the bath-room is on duty eight hours; her duties are to watch the temperature of the water, attend to the ventilation and keep the patients as quiet as possible, take their temperature twice a day or oftener if ordered, and feed them unless they are able to feed themselves. Each nurse, as a rule, has two patients. There are ten such tubs in all through- out the hospital. (See also pp. 287-291.) MELANCHOLIA In the incipient stage prolonged warm baths are useful, but should not be continued to the point of marked muscular de- bility. A change should be soon made to the more tonic form of treatment by the hot-air cabinet, circular, jet, Scotch and fan douches, follow^ed by alcohol rubbing. A good prescrii)tion for fairly robust cases would be as follows : EXCITED STATES 173 Electric-light or hot-air cabinet, eight to ten minutes, or to perspiration. Circular douche, two minutes, 105° to 90° F. (40.6°-32.2° C), 20 pounds. Jet douche, one minute, 100° to 80° F. (37.8°-26.7° C), 15 to 20 pomids. Scotch douche, twenty seconds, 105° to 80° F. (,40.6°-26.7° C), 15 to 20 pounds. Fan douche, ten seconds, 78° F. (16.7° C), 20 poimds. Dry with friction and follow with an alcohol rub. Reduce minima 1 de- gree daily until 60° F. (15.6° C.) is reached. The Scotch douche may be omitted at the commencement of treatment in most cases. Artificial Nauheim Baths. — The author would call attention to the excellent effect of the artificial Nauheim baths in all men- tal cases. He has had excellent results in their use. They are easily given in the home or hospital where the more elaborate apparatus is lacking, and it is usually agreeable and interesting to the patient (see p. 311). Oxygen baths are Hkewise suitable for these cases. EXCITED STATES The continuous bath has been inti'oduccd comparatively recently into American hospitals for the insane, although for over twenty years it has been used in England and on the continent. The experience at Bethlehem (Bedlam) and Prof. Kraepelin's clinic has been uniformly satisfactory in excited states. In April, 1907, eight continuous baths were instilled in the Phila- delphia Hospital for the Insane (Blockley). Since that time the patients treated in this manner included cases of acute, chronic, and recurrent mania; excited types of dementia pri3ecox; maniacal episodes of epilepsy; dementia paralytica and senile dementia; alcohoUc insanity, and insanity of chorea. The chief resident physician, Dr. W. W. Hawke, and the assistant phys- ician. Dr. Walter G. Bowers, report great improvement, especially in the cases of mania, excited cases of dementia prsecox, senile dementia, and toxic cases, including insanity of chorea. Dr. Bowers furnishes the following notes : '' Case 1. — Daniel D., aged thirty, white (acute mania). On admission, this patient was garrulous, vituperative, restless, 174 HYDROTHERAPY noisy, and hostile in manner. He was placed in the contin- uous bath Oct. IG, 1907. The temperature of the water was 100° F. (37.8° C). Little or no improvement was noted at the end of the first day. On the second day the temperature of the water was raised to 105° F. (40.6° C). The patient began to show improvement, which gradually continued, and at the end of the fifth day motor restlessness ceased and the patient was no longer garrulous and noisy. In this case a permanent benefit was observed and the patient was discharged a few weeks later, restored. " Case 2. — P'rank D., aged fifty-five, white (toxic insanity, al- coholic confusional), noisy and restless, fearing that he was about to be killed. The patient was placed in the bath June 19, 1907, at 5 p. M. The temperature of the water was 100° F. (37.8° C). The patient gradually became quiet, and at the end of the third day was no longer fearful or agitated. "Case 3. — John P. R., aged eighteen, white (insanity of chorea) . The patient was restless, with general choreiform move- ments. He was placed in the bath June 20, 1907, at 11a. m. The temperature of the water was 95° F. (35° C). At the end of three days movements became decidedly less in number and extent. " No restraint is used while patients are in the bath. They are allowed house diet, with milk and eggs between meals, and careful attention is paid to the emunctories. Sedatives and all forms of internal medication are removed while the patient is in the bath, save on occasional indication for diffusible stimulants. Despite careful padding of tubs, a few patients developed superficial excoriations over the regions of the scapulae, shoulders, buttocks, and elbows. Others complained of tender palms and soles, only, however, after being in the tub several days. One case of acute eczema, involving thighs, legs, and feet, which was somewhat refractory to treatment, developed in a colored patient after he had remained in the bath five days. " In two other cases a skin rash, resembling impetigo, devel- oped, which was transient in character. We have also treated EXCITED STATES 175 patients with ichthyosis and psoriasis with at least temporary benefit. " The same care used in selecting patients for the continuous flowing bath was used in selecting patients for treatment in the douche room and hot-air cabinets, as little save the detergent and slightly stimulating effect of the baths can be expected from hydrotherapy in the treatment of chronic insane. Excellent results were obtained by the use of hot-air cabinets in toxic cases, especially the acute alcoholic insanities, also cases of mania and uremia; patients in such cases were kept in the cabinet until a profuse sweat was produced. While in the cabinet the patients drank freely of water. They were then given a spray and rain bath for three minutes at 95° F. (35° C), the temperature being gradually reduced to 80 ° F. (26.7 ° C.) , save in the cases of uremia, in which the patients were given a sponge bath after sweating profusely. " A number of dementia praecox patients in a dull, stupid, and apathetic state, also a few patients with melancholia and neurasthenia, showed considerable improvement both physically and mentally after use of the spray and rain bath at 90° F. (32.2° C.) for three minutes, followed by the Scotch douche, moderate to full force at 90° F. (32.2° C), gradually reduced to 75° F. (23.9° C), for two minutes, the douche being played rapidly up and down the entire length of the spinal column. " Patients with saturnism, with the associated paralysis, also the polyneuritis of alcohol, with and without Korsakow's psy- chosis, showed marked improvement and recovery by the use of the hot-air treatment and immersion bath, the patient remain- ing in the tub thirty minutes and being urged to exercise while in the water. " Painful and inflammatory hemorrhoids were treated daily with the perineal douche ; as a result, the hemorrhoids shriveled up and ceased to be painful and inflammatory. It is recognized that constipation is habitual in the insane. Favorable results were obtained by the use of the sitz-bath and liver spray daily at a temperature of 100° or 105° F. (37.8° or 40.6° C). 176 HYDHOTHEHAPY '' For the (lotoro;ont offcct, from 10 to 20 pationts were sent from the ward daily to receive a rain and spray bath. Four thousand such baths have been given during the past year."' Baker- reports the emijloyment of hyth'Otherapv in 26 cases of melancliolia, with or without agitation, dementia pru'cox, hysteria, puerperal insanity characterized by slowness of thought, painful delusions, etc., cases showing lack of nervous and mus- cular tone, sluggish circulation, loss of weight, greasy and acne- covered skin, intestinal fermentation, and other complications. The baths in these cases are used for various pericxls, depending, of course, on the case. He rei)orts decidedly good results, such as quieting of agitation, gradual disappearance of delusions, and physical improvement. Warm baths or the modified continuous baths m^y be more conveniently used by day. They should last for from twelve to fourteen hours. Dr. Stockton, in speaking of his experience, says that the patients not only improved, gained in weight, slept better, and became quieter, but that they were also able to dis- pense with the use of drugs. Water at the proper temperature and adapted to the intli vid- ua), adds to the nervous energy, stimulates the functions of the body, and improves the resisting power against disease. The kidneys act more vigorously, the fact that the urine is found to be more toxic after a bath being abundant proof that baths assist in the elimination of poisonous material. It stimulates respira- tion and so eliminates poisonous matter. The use of baths in no way interferes with the medical treatment of patients, and, in- deed, properly administered, they largely increase the efficiency of many drugs and do not interfere with any. The warm bath renders the surface of the body less sensitive, numbs the terminal nerve-fibers, and produces a sedative action. Whenever there is delirium, restlessness, or insomnia, the neutral bath is in- dicated. 1 Jour. Amer. Med. Assoc, Oct. 24, 19C8. ^ Medical Record, Oct. 10, 1908, article by Dr. George Stockton, Columbus State Hospital for the Insane, Ohio. EXCITED STATES 177 Removing Patient from Bath to Bed. — ^Whenever the patient is to be removed from the continuous bath to Ms bed, as, for instance, toward night, when the treatment is not deemed necessary in milder cases, it is highly desirable to avoid all chilling from the ordinary atmospheric temperature of the room. A hot dry sheet should be at hand to envelop the patient. He is then put in a warmed bed and night clothes adjusted. This will avoid any check to the surface blood and in a measure main- tain a good superficial circulation. A steam-heated hot closet should be provided in planning tlie hydrotherapeutic department of any institution, so that these hot sheets may always be at hand when patients leave the bath, whether of the continuous type or after the routine application of douches. If this be not properly installed, the only recourse is to keep the sheets piled over some convenient steam radiator, although this detracts from the gen- eral appearance of the room. Daily Routine Bath. — Those who have much to do with the insane usually speak highly of the continuous bath, the cold wet sheet pack, the electric-light and steam-heated hot-air bath, the circular (needle) douche, jet, Scotch, and fan douches. In some of the more modern institutions the patients are formed in line and stand under large overhead showers (descend- ing or rain douche). The douche room should be provided with tubular brass raihngs to keep the line in order and to give support for the hands of patients who feel the need of it. This daily routine bath with suitable appliances has a wholesome effect on a large class of mental cases, and it can be given to large numbers daily with very few attendants. Excited cases should be treated by other methods, but in time these patients may improve to such an extent as to take the daily bath. The temperature is usually reduced from 100° to 90° or 80° F. (37.8°-32.2° or 26.7° C), according to the judgment of the attending physician. General Instructions. — On admission to hospitals for the insane the condition of the patient's skin is usually bad. This is almost invariably the case am.ong the poor, and hence much can be expected from hydrotherapy. Vitality is generally low, how- 12 178 HYDROTHERAPY ever strong the patient may appear. All demented and melan- cholic paticnits are more or less under the influence of an auto-in- toxication, and hence hydrotherapeutic measures and intestinal irrigation arc called for. Care, however, should always be taken that in using the cabinets, etc., no hot pipes or unguarded elec- tric lights can by any possibility be touched. The least chance of drowning should also be guarded against. It must be remem- bered that an insane patient may drink the water in the tub, tamper with the fixtures, or break the glass of apparatus in the most unexpected manner. EPILEPSY The position of hydrotherapy in the treatment of epilepsy may be considered as a means of cure; an auxiliary method of treatment; a method of making it possible to administer con- siderably larger doses of bromids than usual; a method render- ing it possible to reduce the dose of bromid to a minimum; and, finally, as an excellent hygienic measure favoring the action of the skin, improving the general tone, and favoring the oxida- tion and elimination of all toxic products. As a cure per se hydrotherapy is probably like all other medicines — it has been tried and found wanting. Notwith- standing the fact that the means employed consist of water, cold, warm, or hot, in tubs, douches, sprays, vapor baths, hot-air baths, and compresses, a method permitting the widest varia- tions in the form of treatment, it probably has rarely, if ever, cured, in and of itself, a case of genuine epilepsy. Cases have been reported cured, as is so frequently done after surgical meth- ods such as trephining, but further investigation shows that there has been some error in diagnosis, the case being one of hys- teria, or that relapses have occurred. A few French authors have advocated hydrotherapy since Fleury, in 1875, published his treatise ^ on the subject. Winter- nitz and his school have declared that hydrotherapy in epilepsy ^ Traite therapeutique et critique d'hydroth^rapie, Paris, 1875; also P. Bricon, Thesis, 1881, from Bournonville's service at Bicetre. EPILEPSY 179 employed exclusively produces no effect. On the other hand, some of the more recent German pubHcations look on the sub- ject more favorably. Schweinburg, in his work/ cites a patient, a college student, who took, under his direction, half-baths for a year, and later entered official life and has remained well for sixteen years. Schweinburg says that this is not the only sim- ilar case in his experience, but, of course, he pays very strict attention to the diet, and he notes that when the epileptic is ordered a combination of hydrotherapy with a rigid dietary the epileptic attacks diminish with very little bromid, so that there is a reduction from 6 to 8 gm. daily to 1 or 2 gm. Long inter- vals free from attacks are obtained and a general improvement in the mental and physical condition is noted. The procedure adopted at first was the half-bath at 81.5° to 86° F. (27.5°-30° C), with affusions and strong rubbing for five or six minutes once or twice daily. Before applying water of lower temperature or more energetic measures, such as douches, slapping, or in using the high temperatures, there should be caution, for attacks have occurred during the application of extreme temperatures.^ Wet packs, foot-baths, and cold com- presses to the head are useful after severe attacks. No un- pleasant results have been noted, no increase in the number of attacks, even in the most unfavorable cases. Schweinburg con- siders the combined hydrotherapeutic and dietetic method more as a school for patients, who thus learn the principles and prac- tice of hygienic treatment to be followed during the coming j^ears. Pick maintains much the same position in holding that with hydrotherapy we can employ considerably smaller doses of the bromid than when the latter is given alone. He employs dur- ing the interval between the attacks the so-called half-baths at 80.5° to 86° F. (26.9°-30° C), and of eight to fifteen min- utes' duration, as well as sitz-baths and trunk compresses or the so-called Neptune's girdle. Without necessarily expecting ^ Handbuch der allgemeinen iind Speziellen Hydrotherapie, Wiesbaden, 1904. 2 Binswanger, Nothnagel's Speziellen Pathologie, Breitung, Deutsch. Med. Woch., 1898, No. 39. 180 HYDROTHERAPY a cure, he uses systematic h3'(lrotherapy so as to promote the action of the skin or as a mode of treatment auxiliary to other measures. Binswanger advises in this connection a mild hydrotherapy as usually adopted in the general treatment of neurasthenia; also a daily bath, using water gradually cooled to r>9° F. (15° C.) ; indifferent baths two or three timers a week with or without the addition of salt or affusions at ()8° F. (20° C). For young and vigorous subjects he advises cool or cold baths of only a few min- utes' duration. The temperature should be about 7o° F. (23.9° C), and gradually cooled, according to the state of health of the patient, to 08° F. (20° C). He employs these cool baths especially during the first weeks of the use of Flechsig's treatment. Eulenberg recognizes in such measures a wide applicability to raising nutrition and improving the skin, almost never dis- appointing, especially in bad cases of bromism. He uses the spinal ice-bag when the mc^thods referred to are not permissible. Matthes,^ of Jena, takes a very conservative position, making use of hydrotherapy only for a good effect on the skin and an increase of the bodily vigor. This is especially necessary during treatment with bromids and should be adopted so as to obviate as much as possible bromid acne. He uses indifferent baths, that is, at about the body temperature, three times a week, and also the more refreshing procedures, such as the wet sheet tub (ab- reibung) and half-baths. During the attack treatment with ice-caps, stimulating compresses, or diverting methods, such as slapping the feet with cold cloths, are useless. He holds that the action of hydrotherapy in epilepsy, whether for preventing attacks or rendering them less frequent, rests on a very slender foundation. As we all know, bromids often do harm in the treatment of epilepsy. In any large institution, such as Sonyea, where 2000 cases have been treated and carefully studied, this diffi- culty is well recognized, and the average dose employed is about ^ Max Matthes, Lehrbuch der klin. Hydrotherapie, Jena, second ed., 1904. EPILEPSY 181 1 gm. daily. At Bielefeld the dose is about 3 gm. daily. In France rather larger doses are given; Fere and Jarnot have used from 12 to 16 gm. daily in special cases. Among the earlier symptoms are acne and physical depres- sion; later, a decidedly weakened action of the heart, amounting to chronic cardiac asthenia ; ptosis of the lids and even inability to walk. In extreme cases, in which the dose is very large or the patient unusually impressed by the drug, there may be dis- turbances of memory and suicidal or homicidal tendencies. I have seen an epileptic patient in an outburst of passion at a fancied wrong attack a resident physician with great violence. Such cases have been recorded by Echeverria/ Weir Mitchell, and others. We would, therefore, welcome any method that will enable us to use these larger doses with safety to the skin and to the mental equilibrium. Just as warm baths" and other hydro- therapeutic procedures undoubtedly enable us to administer potassium iodid in large doses with safety and increased efficacy, so I believe that with the help of baths the bromids will be better borne. Wet packs moderate or prevent bromid acne and help eliminate the bromin and toxins. If followed by affusions of water at 60° F. (15.5° C.) the patient is invigorated. As to any ill effects from the use of baths, I have knowledge of only two instances in which an attack occurred while bath- ing. One was in the case of a young man who for nearly a fortnight had been swimming and diving in a large enclosed swimming pool. Although in water beyond his depth, he had his convulsion at the surface and was soon brought by friends to a place of safety. The temperature of the water was about 78° F. (25.6° C), and there is no reason to believe that the water had any special influence in causing the attack. The second case was that of the unfortunate daughter of the late Mr. Samuel L. Clemens, whose death by drowning in her bath during an epileptic attack was recently reported. In America attention was first called to the value of hydro- ^ Manuel Gonzales Echeverria, Amer. Jour. Insanity, 1873-74, vol. xxx. 182 HYDROTHERAPY therapy in epilepsy by Dr. Simon Baruch, and later by the late Dr. G. W. Foster, one of the physicians at the Government Hos- pital for the Insane at ^^'ashington.^ The measures employed were the drip sheet, wet packs, and douches. By these means bromid acne was either prevented or relieved and the general tone of the patients was improved. The number of attacks in 12 patients was reduced by about 40 per cent. Since this report was issued no further records have been kept, and I am informed that few patients, if any, received any permanent bene- fit, and this treatment is not now used to any extent in this class of cases. At the Pennsylvania Epileptic Hosi^ital and Colony Farm the patients receive daily showers and a tepid tub-bath once or twice a week. These are more for hygienic than for therapeutic purposes. At the Glenmary Sanitarium at Owego, New York, baths are given only for personal cleanliness. At the Craig Colony for Epileptics at Sonyea, New York, where complete hydrotherapeutic apparatus is installed, sys- tematic treatment is given under the most favorable circum- stances, as these patients receive a minimum dose of bromid, about 1 gm. daily, and are under an excellent hygienic regime. At the Glcnwood Sanitarium at Dansville, New York, Dr. J. W. Wherry writes me that some years ago he gave considerable attention to hydrotherapeutic methods in the treatment of epilepsy, but he is not able to say that he noticed any direct effect on the epileptic condition. Since then he has discarded the measure excepting when indicated on general principles without reference to the epileptic condition itself. In a letter to me Dr. Wherry remarks very truly: "Whatever benefits the individual is an aid in the treatment of epilepsy. Some epileptics, like some other people, would be benefited by the employment of hydrotherapy; others would not." In private practice difficulties are encountered in carrying 1 Report of the U. S. Government Hospital for the Insane, 1898; also Amer. Jour. Insanity, No. 4, 1899. HEADACHE 183 on systematic treatment of this description. Daily treatment for several months would be required, and, of course, unbounded patience and hope are demanded of both physician and patient. The usual experience of outdoor clinics is that as patients im- prove, their visits are more infrequent, but not rarely we find faithful ones who report regularly for years. We would naturally expect that in focal or traumatic epilepsy less advantage would be derived than in cases of so-called idio- pathic epilepsy, alcoholic epilepsy, psychic epilepsy, or in cases arising from intestinal intoxication or obscure metabolic changes. In such cases the free use of water inside and out ought certainly to be given a prominent place in any plan of treatment that may be adopted.^ HEADACHE In those cases for which no assignable cause is discovered, hydrotherapy is valuable in its power to divert blood from the central nervous system to the periphery. Various means are employed, the more common being the hot foot-bath or the cold foot-bath, followed by vigorous rubbing. The hot foot-bath may be given with water at 95° to 110° F. (35°-43.3° C.) for from eight to ten minutes. The cold foot-bath, 45° to 55° F. (7.2°- 12.8° C), should be shorter; one to two minutes at first will be sufficient. If flowing water be used the results will be more satisfactory. If foot-baths are not available, cold compresses to the head ma}^ be employed. Vinegar should be added to the band across the forehead, and the compresses changed frec^uently. Short douches of hot or cold water to the upper spine for a fraction of a minute are also valuable. Colonic irrigations two or three times a week with normal salt solution after an evacuation of the bowels is advised. The Plombieres douche or the douches employed at Chatel-Guyon help these cases. In some severe cases of headache due to brain tumor relief may be afforded by hot mustard foot-baths or other derivative 1 Schirbach, Jour. Nerv. and Ment. Dis., May, 1907. 184 HYDROTHERAPY hot applications, such as hot spinal compresses or fomentations. The marked relief which follows in some cases of cerebral growth is of some diagnostic value. It is observed that a glioma is more amenable to relief than a sarcoma or gumma. THE NEURALGIAS TRIFACIAL AND OCCIPITAL NEURALGIA Neuralgia of the fifth nerve and ()('('ij)ital iieui-al2, _ _^ __ J . _ — 1 ■ — ~\' — "^ it ! IT '' \ f6/ __i_ — _____ r ^-- . V ■ 4— t :: E ^ ^ 5. - +- ^ *=v^ -^ ^ -— 1 =\: 1 6n ±_ :: ::_^: :£_:^ _ '— -1 : is . x ± Vi"<7 __ ZL- 7 _|_ 1 V- 16-^ ^ -Ai -— -g- = :— "=- = -- H'7 1 1 Fig. 42. — On November 1 and 8 bath was omitted, being Sunday, and patient went to luncheon at F. Farm. periods, a cool spray, and an alcohol rub. The patient is then partly dressed and allowed to rest for twenty minutes. If this treatment be in the morning, he devotes the afternoon to walk- ing, golf, or mountain climbing, as the ph3'Sical condition of the patient warrants. In the evening he has massage for an hour, or massage may be given before rising. Walks of a 5 and 10 per cent, grade are provided, so that systematic exercise may be prescribed, and it is remarkable what may be done by men and women who are gradually led to take up this form of physical training. The accompanying charts illustrate results obtained OBESITY 195 by the author in cases under the combined treatment.. (See Figs. 41-44.) A vigorous and at the same time a rational treatment of obesity in patients presenting no comphcation of the kidney, stomach, or hver is that employed by Dr. William S. Sadler, of Chicago, and is described in a personal communication to the author : UD.,. ^' (Qp/: Sffi - J(, 1 Afr- ? 5tf .1 ^ 3 « I* 5" ^ 7 s /90s /L Q < o 5 o; ^ n Al'f fA / , iA.C , / f. 3 1 *» "■ 1 J ■Llii / / / / '11 3 ' . ZJ ZJ zt 'J 1 "> AL ii _ XT iT lit i-- tr t-- 1,1/ t-- tir ^. . J u ] 1 %\<[ Fig. 43. — The descending line shows the loss of weight during the bath. Case 1. 1, Begin the procedure by short electric-light bath or some other form of sweating. Carry it to just the point of free per- spiration. 2. The patient is immediately placed under the cold shower and needle douche. Water is given at the lowest possible tem- perature and at a maximum pressure (35 to 50 pounds). This treatment is kept up until the patient is thoroughly cold. On coming from this the patient is immediately dried with a sheet and then the next step in the regime begins. 196 HYDROTHERAPY 3. Active physical exercise, such as walking up and down in the treatment room, swinging of the arms, taking breathing exercises, bending, etc. A good temperature to have the room in which the obese are to work is from 70° to 75° F. (21.1°- 23.9° C). This exercise is continued until there is a thorough- going reaction and the point of perspiration is again reached, whereupon the patient is again placed under the cold shower-bath and the same performance rejx'atcnl. This regime is repeatedly Fig. 44. — The descending line shows the loss of weight during the bath. Case 2. administered as long as the patient can stand it without any sensations of fatigue or nervous weakness. It is, therefore, best to inaugurate this regime by th(> graded method until the patient can endure it, but after the first few days the powers of endurance are strengthened and repetitions of the above proc- esses are quite possible. In robust cases, not in any way debilitated. Dr. Sadler carries out these measures at 10 o'clock in the morning and again at 4 in the afternoon. In his experience it acts much SYPHILIS 197 better than the sweating process, which he thinks weakening. Patients will follow the regime when properly administered and carefully observed, losing in flesh each day, but gaining in muscular strength. It gives the maximum carbohydrate oxy- dation with minimum proteid metabolism. When fatty degen- eration of the heart is present, emphysema, or other compli- cations, modifications of the regime will suggest themselves. Some cases of obesity, where there is no heart lesion, but where there is a tendency to palpitation on much exertion, are greatly relieved by the application of an ice-bag to the heart at the time the initial heating procedure is taken. It has been estimated that in a regime such as outlined about a fifth of the units of energy would be represented in work and about four-fifths in heat production, so that any plan combining increased muscular exercise as well as the development of excess- ive heat production will be followed by a reduction of weight. Water drinking should be restricted between meals and at night, but may be allowed at the table.^ EXOPHTHALMIC GOITER Not a great deal may be expected from hydrotherapy, ex- cepting in the form of local applications. These include cold ap- plications to the thyroid gland by means of ice-bags or the Leiter coil; and ice-bags to the heart or nape of the neck for tachy- cardia. For the nervousness, warm baths in either fresh or salt water, half-baths, and douches to the spine are advised. Turk- ish baths, Nauheim baths, and sea-baths are counterindicated. SYPHILIS Owing to the success attending the treatment of syphilis at sulphur spas, of which Aix-la-Chapelle is a type, much stress has been laid on the action of the sulphur water externally; but at all spas the waters are used internally as well, and, what is ^ For. a discussion of this subject see Obesity, Carl von Noorden; see also p. 400. 198 HYDROTHERAPY more important, tlic patients are almost invariably treated energetically with mercurials internally or by inunction or by large doses of iodids. In connection with systematic bathing and massage the medicinal treatment is greatly increased in efficacy. Undoubtedly, at the spas which have been mentioned the experience of the physicians under whose direction baths are given leads them to judge with unusual certainty of the ap- propriate amounts of medicines in particular cases. They are enabled to push these to the maximum of tolerance, and in this lies their success. This is recognized by practitioners at Hot Springs, Arkansas, Mount Clemens, and Aix-la-ChapcUe, who acknowledge that their results are due to the physical qualities of the baths and not to the chemical ingredients of the water. W. R. Huggard * says : "Formerly sulphur waters were sup- posed to render mercurial treatment more efficacious or more easily borne — a claim that cannot be substantiated and is now rarely heard." Dr. L. Duncan Bulkley^ states that much harm often results from the false security which patients have who have undergone what is called a "cure" at one of these resorts. It has been clearly demonstrated that syphilis cannot be cured by any brief course of treatment, however severe. It is true that the "cures" are distinctly beneficial. This is almost un- questionably due to the active and heroic mercuric treatment to which patients have been subjected, combined with change of air and scene, together with the natural hope and expectation of benefit. Dr. Bulkley does not recall a single instance in which he has regarded it as either beneficial or wise for the patient to undertake this cure (by mineral baths) at any great personal sacrifice. His conclusions are drawn from 20,000 personal dermatologic cases in public and private practice, of which 12 per cent, were syphilis. ^ Handbook of Climatic Treatment, Including Balneology, London, 1906. * Medical Record, New York, vol. Lxxii, No. 6, 1907. SYPHILIS 199 Regime at Aix-la-Chapelle. — It may not be out of place to refer to the regime which patients follow at Aix-la-Chapelle and Hot Springs, Arkansas, from which it will be seen that the med- ical treatment is accorded its proper place, the physicians recog- nizing that the thermal springs are no more able than any other medicinal waters to cure syphilis. Their value depends on the fact that they facilitate the use of mercury — the only real specific competent to eradicate the virus and to exercise a favorable in- fluence at all stages of the disease. It is particularly desirable to concentrate as much treatment as possible into the first few years, or even months, for only in this way can the development of the tertiary stage be avoided. Mercurial inunction is to be preferred to administration per os as producing a more energetic result and being free from the risk of intestinal complications. It is this method which is almost exclusively employed at Aix, and it is claimed to have more permanent effects than those obtained through other chan- nels of administration. To secure a satisfactory absorption of the remedy it is necessary that the skin be properly prepared. This is accomplished by means of the thermal baths, which soften the epidermis and dilate the orifices of the glands. The inunction is performed by a certificated ''frotteur," who mas- sages the prescribed quantity of the ointment into the skin. It is believed that the mercury is distributed through the body as an albuminate. As douche-massages, thermal, vapor, and electric baths increase the amount excreted in the urine, these are employed with a view to quicken the metabolic processes, in which, of course, mercury plays its appropriate part. To avoid any risk of stomatitis, disinfection of the mouth with dentifrices and mouth-washes is practised. Every morning the patient drinks two or three glasses of spring water, to which, if there is sluggishness of the bowels, a teaspoonful of Aix- la-Chapelle salts is added. This is followed by a thermal bath. The portion of the surface that is to be the site of the next rubbing is then thoroughly cleansed with soap and water, 200 HYDROTHERAPY and care is taken to avoid tlic use of soap or of friction by the towel over parts which have previoiit«ly been subjected to inunction. Occasionally a vapor l)ath or douche-massage precedes the ordinary thermal bath. Next, the patient is in- structed to rest in bed, and about an hour after breakfast the inunction is performed. The ointment used is a 33 per cent. ung. hydrarg. It is applied on different parts according to a regular daily sequence — legs, thighs, back, abdomen, iliac regions, and arms. Before the midday meal another glass of spring water is taken with a view to jjromote appetite. After every meal the patient uses a salol and chlorate of potassium tooth paste, and, in addition, he emplo3's every half-hour a solu- tion of aluminium acetico-tartaricum as a mouth-wash. The diet during the whole of the treatment should be as sup- porting as possible. Milk should be taken freely. Red wine with seltzer- water may be permitted with meals. Smoking, especially during the secondary period, is apt to provoke mu- cous plaques in the mouth and throat. Frequent observation is made of the urine, and the devel- opment of albuminuria demands a pause in the treatment. The above are the details of an ordinary course of inunction. In particular circumstances supplementary measures may be necessary. Thus, any signs of gvmmatoas development call for potassium iodid, which is given in doses of 75 to 100 gr., dissolved in milk or soda-w^ater. ^^'hen the gumma subsides, iodid is no longer necessary, but, to be on the safe side, injec- tions of 25 per cent, iodipin (iodized sesame oil, Merck) may be given. This insures a protracted action, as it is found that even six months after the injection of 200 gr. of iodipin the urine still gives a definite iodin reaction. Iodii)in further appears to in- crease the tolerance for the mercurial inunction, and this is con- tinued simultaneously. Another supplementar}^ remedy is sarsaparilla. This is indicated where former excessive mercurial treatment has so influenced the tissues that a prompt response to the inunction is not obtained. SYPHILIS 201 Sulphur Waters. — Iii a recent paper by Dr. Jean Dardel/ of Paris, great stress is laid on the use of sulphur waters in S3'philis, These are used under his direction at Aix-les-Bains. The sulphurous calcic waters, having a temperature of 113° F. (45° C), are used externally in the "Aix douche" (see p. 263); in the form of vapor baths ; and internally, for which the Marhoz water is specially employed. The waters of MarUoz are brought from a neighboring spring. It is the most sulphurous of the three springs which occur in that locality, and has a tempera- ture of 57.2° F. (14° C). It is easily borne by the stomach and is considered eminently suitable for the internal sulphur cure. It is claimed that used internally sulphur waters have a general tonic and exciting action. Dardel states, however, that in his opinion this stimulant action depends more on the mode of treatment than on the waters themselves, and that the thermal fever w^hich has been described by certain authors is due to a too energetic and rapidly applied treatment. The cure has a favor- able action on all the organs. The appetite is stimulated, the red corpuscles are increased in number, the urine is more abun- dant, and the quantity of urea eliminated is more considerable. Nutrition which is retarded by the direct action of syphilis is stimulated and activated by the use of sulphur waters. Dardel takes a very sensible view of the matter when he says that the treatment of syphilis by the use of sulphur does not cure alone, but forms a very valuable auxiliary treatment, which may be combined with a course of mercurial treatment ; also that the water will help greatly in the absorption, action, and ehm- ination of the drug. The cure is indicated at any period of the disease, since nutrition suffers at all stages. Counterindications and Indications. — Patients suffering from arteriosclerosis or liver trouble, and those who are highly nervous, should not undergo an active sulphur cure. It is especially indicated in those who take mercury badly, or who can tolerate but a small dose of it, and in those in whom the therapeutic action of mercury is not easilj" obtained. It is also indicated in 1 Medical Record, New York, July 20, 1907. 202 HYDROTHERAPY cases of groat destruction of tissue, or severe infections in feeble or worn-out patients, and in lesions of the nervous system, ulcerative lesions that threaten great destruction to the organs affected, and such other lesions in which prompt treatment is demanded. The treatment strengtliens the patient and increases his tolerance for mercury. The sulphur of the water is converted into alkaline sulphids, some of which are oxidized into hypo- sulphites and sulphites; but the most of the sulphur forms hydro- gen sulphid, which is eliminated by the lungs and skin. The water has a general tonic and exciting action, and liberates mer- curial compounds stored up in the system. The Hot Springs of Arkansas, all the bathing establish- ments of which arc on United States Government property (see p. 19), are largely used for the treatment of syphilitic affections. It is usual at first to order a Ijath of six minutes' duration at a temperature of 93 ° to 95 ° P\ r33.9°-35° C), to be gradually increased in successive baths to 100° F. (37.8° C), for ten minutes. After the tub-bath, ])acks in hot blankets, employing two, three, four, or five blankets. Alcohol rubbing is not used, as it is believed to prevent elimination through the skin. Cold douches are not usually given either, although cold cloths may be applied to the head if there be a tendency to headache. Vapor baths may be medicated with (>ither calomel or sulphur. In treating early syphilis, especially when there are extensive eruptions, 15 to 30 gr. of calomel may be volatilized by means of special apparatus, with just sufficient water to excite the skin to moderate action. Preliminary steaming is not necessary, as the heat required to volatilize the calomel is enough to excite sufficient perspiration. For sulphur vapor baths, 1 or 2 ounces of sublimed sulphur may be used. Patients with syphilis, rheu- matism, and acne may be benefited by such treatment. In iridocyclitis, with synechia^ and vitreous opacities due to syphilis, hot baths and sweating processes, such as hot packs, should be used in connection with specific and local treatment to the eyes. SKIN DISEASES 203 Cutaneous Manifestations. — It has been noted that baths are liable to induce cutaneous manifestations in syphilis, espe- cially when given before the secondary stage. They some- times reveal a latent syphilis and in this way favor a positive diagnosis. As a general measure a weekly Turkish bath is com- monly advised in the routine treatment of syphilis. The author thinks this a reprehensible practice unless the management of the public Turkish bath establishment be informed as to the nature of the disease and suitable provision be made to avoid the danger of transmission of the disease to attendants and the patrons of the baths. At certain resorts which cater to this class of patients such provision is made, and the attendants who give inunctions and baths for syphilis are both cautious and efficient, and hence carry out these measures far better than these when left to the patient himself. SKIN DISEASES Mineral waters have always had a reputation for the cure of skin diseases. Few advertisements of mineral springs fail to mention their efficacy in such cases. There must be some foun- dation for this belief, which has existed from time immemorial. To relieve fecal accumulation is the first step in the treatment of inflammatory diseases such as eczema and acne. It is necessary in many cases, therefore, to eliminate the true causes of these affections by administering the purgative waters such as Sara- toga Congress Water, Crab Orchard, Abilena, Hunjadi, Fried- richshall, Pullna, or Pluto Skin diseases may reciuire variously modified baths. The following may be used in 30 gallons of water at a temperature of 100° to 104° F. (37.8°-40° C.) : Emollient Baths. — Bran, 2 to 6 pounds, to 30 gallons of water; potato starch, 1 pound; gelatin, 1 to 3 pounds; linseed, 1 pound. These are useful in erythematous, itchy, and scaly dis- eases, as for example, psoriasis. Alkaline Baths. — Bicarbonate of soda, oij to x; carbonate of potash, §ij to vj; borax, §iij. The bicarbonate may be used 204 HYDROTHERAPY with bran liquor, made by infusing a gallon of bran. Useful in eczema, psoriasis, urticaria, lichen, and prurigo, where there is much local irritation. Potassium sulphid, oij to iv to each bath. Another formula useful in itch, chronic eczema, lichen, and psoriasis is: Precipitated sulphur, 5ij; sodium hypophosphite, 5J; dilute sulphuric acid, oss, mixed in a pint of water and added to the 30 gallons of the bath. Ichthyol baths, in the strength of oviij to x (250-300 gm.) to 40 gallons, have been used by Dubois in cases of pruritus, pityriasis, psoriasis, eczema, and scabies. Simple vapor and hot-air Turkish baths are not specially valuable in skin diseases. They are, as a rule, injurious in eczema, which forms the largest class of diseases of the skin. Precautions. — Naturally, in treating contagious skin dis- eases, precautions must be taken that the tubs and other utensils used in the bath, as well as the hands of the operator, be absolutely disinfected afterward. It would be nothing less than criminal to neglect these precautions. Patients suffering from syphilis, leprosy, scabies, tinea, and the less communicable skin diseases should never be bathed in tubs to be used by others. In resorts like Mount Clemens, Michigan, and Hot Springs, Arkansas, special porcelain tubs are assigned to sy[)hilitic cases. When cases are treated in hotels, boarding-houses, sanitaria, and hos- pitals the physician should hold himself in honor bound to see that no contagion can possibly be left when it becomes necessary to bathe any case of this type. PSORIASIS Arsenical Waters. — In the more refractory skin diseases, such as psoriasis, the internal use of arsenical waters, such as those of Royat, La Bourboule, Roncegno, and Lexdco, are useful. The latter is the strongest arsenical water known, containing about yV gr. per pint, as well as persulphate of iron. Not more than a tablespoonful is usually prescribed, or about 3^ gr. of arsenous acid. La Bourboule contains about 2 gr. of sodium PSORIASIS 205 arsenate in the gallon (0.028 to 1000 cc). The Royat Spring is richer in iron than La Bourboule, but contains only one-sixth the amount of sodium arsenate, or about + gr. per gallon. Sulphur waters have been successfully used in treating psoriasis. They are usually applied externally. Those best adapted for this purpose in America are Richfield Springs, Sharon Springs, in Nev/ York, White Sulphur Springs, in West Virginia. In England those of Harrogate and Strathpeffer, in Great Britain; Aix-la-Chapelle, Germany; Schinzerach, Switzerland; and Bareges, in the Pyrenees in France. Thermal baths in weak alkaline water are also used. Those of the Warm, Hot, and Healing Springs in Virginia and of Hot Springs in Arkansas belong to this class. Corresponding baths are found at Bath and Buxton, England; at Leuk, Switzerland, altitude 4500 feet. Canton of Valois; at Aix-les-Bains, France. The latter springs have a temperature of 112° to 116° F. (44.4°- 46.7° C). The waters of Plombieres, in the Vosges Mountains in France, are used in cases of psoriasis as well as pemphigus. They are applied in a continuous bath, the natural temperature of 117° F. (47.2° C.) being moderated. The altitude of Plom- bieres is 1310 feet and the climate is bracing. At Baden, near Vienna, and at the Sulphur Springs of Leuk, Switzerland, excel- lent results are obtained. The wet pack is useful in extensive psoriasis to remove scales and diminish hyperemia. Notwithstanding a great many testimonials regarding the efficiency of mineral springs in the treatment of psoriasis and a rather widespread faith among members of the medical profession in the use of baths in this disease, some of the most distinguished dermatologists are not so sanguine. Dr. L. D. Bulkley,^ of New York, in a recent article on the treatment of psoriasis, does not mention baths at all, and does not believe that they are of any special use in this affection. This was somewhat surprising to the writer, but correspondence showed that this position was the result of large experience. However, the author would suggest that while 1 Journal of the American Medical Association, Nov. 17, 1906. 206 HYDROTHERAPY cures may not be expected from hydrotherapy or mineral baths at resorts, owing to the chronic nature of the disease, neverthe- less some benefit may accrue, just as in cases of syphilis, and that subsequent measures, such as prolonged and rigid vegetable diet and the use of ointments, may accomplish the actual cure. LEPROSY Fortunately, this disease is so rare in America and in Europe that its treatment is practically unknown except in the- leper colonies. The discovery of a case in the United States throws the community into a panic, and the health authorities are more concerned with getting rid of him than in treating him. The author has had no personal experience with this disease, but the following plan of treatment has been found to relieve the neuritic ))ains from which many lepers suffer: Medicated Baths.* — Patients suffering from ulcerated tuber- cles or thickened skin or in whom there is neuritis or lymphade- nitis derive benefit from these baths. The medicated baths used are the alkaline, sodium bicarbonate or borax, 1 pound to the bath; astringent, alum, \ pound to the bath; potassium sulphate, J pound to the bath. The one which has proved most beneficial is a warm or hot medicated bath, made by adding to the water (30 to 40 gallons) an infusion of eucalyptus leaves (4 gallons). The bath should be given twice daily, the water of the morning bath being at a temperatui'e of from 95° to 104° F. (35°-40° C). Enough water should be used to immerse the body (30 to 40 gallons). The patient should remain in the bath at least fifteen minutes, and during the immersion active friction should be kept up on all parts of the body. Immediately after bathing the patient should be thoroughly rubbed with a towel coarse enough to cause exercise to the skin. This should be followed with an ointment composed of: ^ Hollman, Journal American Medical Association, 1906, p. 1815. LEPROSY 207 Olei eucalypti, Ung. sulphuris aa 3iv (15) Lanolini o ij (60) . — M. Ft. ungt. This ointment should be thoroughly rubbed into the skin, removing all excess. The evening hath should be at a temperature of 105° F. (40.6° C), and should be gradually raised as high as can be safely borne, about 110° F. (43.3° C). After tliis hot bath the patient should be wrapped in a warm blanket and allowed to remain thus covered for ten minutes. This causes the sweat glands to act freely, thus removing waste material from an already dis- eased body. The rubbing with a coarse towel and the use of the ointment should then follow. This hot eucalyptus bath assures the patient a good night's sleep, a thing most highly valued by a leper suffering from neuritic pains. Combination Treatment. — Dr. Matias Duque,^ of Havana, has recently reported cures in leprosy from a combination of various measures in which baths have a distinct place. In the first period of the disease cases are cured in eight, ten, or twelve months; in the second period 60 per cent, of the patients are cured in two to five years. But in the third period, when all the organs are affected, there is no cure. Internally he gives an extract of the red mangrove or mangle. The bark is extracted with alcohol and preserved in glycerin; this is also added to the baths. As to baths, he says: "The immersion bath should cover the entire body, and should be taken on going to bed, at a tempera- ture from 102.2° to 104° F. (39°-40° C), or as the patient may be able to endure it. The duration of the bath should be from fifteen to twenty minutes, and care should be taken that the temperature be always the same, that the body be immediately wiped or thoroughly dried without rubbing or friction whatso- ever, and the patient be at once put to bed well wrapped. The bath is more efficacious if a decoction of the mangle (mangrove) ^ American Journal of Dermatology, December, 1907. 208 HYDROTHERAPY be made in sufficient quantity to redden the water used in said bath." The baths undoubtedly improve the circulation, stimulate the sweat glands, and soften the skin. ECZEMA Continuous Bath. — In 1877 Ferdinand von II('l)ra intro- duced the continuous bath as a cure for chronic eczema and other chronic squamous diseases. In general it has not been considered wise to apply water in eczema, but when the affection is generally distributed over the botly and of a chronic type, the continuous bath softens the skin, hastens desquamation, and moderates or entirely relieves the excessive itching. In subacute cases a cool bath in which some borax or sodium bicarbonate has been dissolved affords comfort. The addition of flaxseed, c% I must again mention the valuable action of the Nauheim bath in many cases of rheumatism and gout. Many gynecologic patients suffer from such states, and have gouty or rheumatic nodules in various parts of the body, causing severe pain in various nerves, and causing attacks of marked occipital headache and pain along the vertebra, often associated with mild or severe attacks of migraine or pseudomigraine. Here, Nauheim baths plus massage of the nodules are often productive of marked reUef from the annoyance of this diathesis." The Method of Procedure. — " Baths when begun contain 3 to 5 pounds of sea-salt, 2 to 4 ounces of calcium chlorid, and one-half box of Triton salts. In sensitive cases the Triton salts, which furnish the carbonic acid gas, are omitted from the first few baths. The water is of a temperature of 95° F. (35° C); the duration of the bath is eight minutes. The patient lies quietly in the bath. At the expiration of the stated time the body is dried gently, preferably with warm towels, and the pa- tient then lies down in bed for one hour, first taking a cup of hot milk or weak tea. At the expiration of this hour the patient can resume her daily vocation, being careful to avoid great exertion of any sort. Baths are best taken in the morning, at least two hours after the meal. The baths are taken three days in succes- sion, then comes an interval day on which no bath is taken, then three baths more are taken, then comes another interval day, and so on, until about twenty baths have been administered. No baths, of course, are given during menstruation. Each set of three baths is made a little stronger by the addition of a little more salt, a Httle more calcium chlorid, and more of the Triton salts, but only if patients stand the baths well. The last three to six baths contain 8 to 10 pounds of sea-salt, 8 to 10 ounces of calcium chlorid, one and a half boxes of Triton salts. The tem- perature by this time has been reduced to 85° F.(29.4° C), and in some instances to 80° F. (26.7° C). The lowering of the tem- 15 226 HYDROTHERAPY perature depends upon the manner in which the patient bears the abstraction of heat. No patient should leave the bath feel- ing cold or chilly. The last baths should have a duration of eighteen to twenty minutes. The beneficial effects of these baths are very much enhanced by a subsequent change of air for from two to four weeks at an altitude of 1000 to 2000 feet. In almost all cases, and especially in cardiac cases, the administration of digitalis after a course of baths produces an extremely beneficial tonic effect." The author finds that the Dr. Zucker carbonic acid bath is very satisfactory (see p. 313). Modification of Nauheim Baths. — Bandler recommends a modification of the general Nauheim baths for cases in which it is desired to secure a purely pelvic effect, such as mild subacute pelvic inflammations. This consists of sitz-baths containing enough water to cover the pelvis up to the umbilicus when the patient is in the sitting position. This bath should contain from 3 to 5 pounds of sea-salt and from 3 to 6 ounces of calcium chlorid and should be applied at a temperature of from 95° suc- cessively reduced to 85° F. (3o°-29.4° C), lasting for from ten to twenty minutes. This procedure is usually followed bj^ an improvement in the pelvic circulation and relief of congestion and the slighter degrees of pain. SITZ-BATHS IN GYNECOLOGIC AFFECTIONS These may be given cold, from 50° to 75° F. (10°-23.9° C), or hot, 104° to 114° F. (40°-45.6° C). They require a special form of tub (see p. 336), so that the patient may sit in water reaching to the umbilicus. A blanket should be placed about the patient and the feet should be kept in a foot-tub filled with warm water. The duration of the bath is from ten to thirty min- utes. Cold sitz-baths at 85° to 80° F. (29.5-26-8 C.) are best given in the morning or afternoon and are stimulating to the pelvic and abdominal organs. Hot sitz-baths are best taken at bedtime. Internal ocular affections 227 EYE DISEASES EXTERNAL AFFECTIONS In ophthalmia neonatorvim cold compresses should be used in connection with silver salts. In the early stages, when the lids are tense and there is little secretion, small square com- presses of patent lint (perfect absorbent lint) are kept on a block of ice until needed, applying them every half-minute, day and night, for the first thirty-six or forty-eight hours (see p. 344). Fomentations are also used in conjunctivitis neonatorum, especially when corneal complications exist or the conjunctiva is covered with a gray film. These are applied with squares of antiseptic gauze wrung out of carbolized water at 120° F. (48.9° C), and should be frequently changed. They are used in con- nection with irrigation of the eyelids (see p. 347). In diphtheritic conjunctivitis, trachoma, and granular conjunctivitis cold applications should be made early in the attack. In phlyctenular conjunctivitis hot compresses applied to the eye for five or ten minutes every three hours are recom- mended. Early in iritis, compresses, as hot as can be borne, are useful to relieve pain (see p. 349). INTERNAL OCULAR AFFECTIONS Sweating Processes. — Various internal ocular affections are successfully treated by hydrotherapy, especially those which produce marked diaphoresis. Drugs like jaborandi and its alkaloid, pilocarpin,^ have been used in the treatment of vitreous opacities, chronic iridochoroiditis, hemorrhage into the vitreous and retina, toxic neuritis, and detachment of the retina, with great benefit. But it is in this class of cases that sweating processes, produced by mechanical means, are especially ap- 1 Weber, Centralblatt fiir Klin. Med., 1876; Burham, Proceedings of Section on Ophthalmology, Brit. Med. Assoc, August, 1897. 228 HYDROTHERAPY plicablc. Some ophthalmologists, such as Hansel! and Risley/ place much reliance in hot packs and electric-light baths. It is not necessary to resort to hot baths as a preliminary measure. There is danger of temporarily greatly weakening the patient, and instances are cited in which patients bathed at a temperature of 10(3° or 110° F. (41.1° or 43.3° C.) have lost con- sciousness for a few moments at the conclusion of the bath. The method which Hansell strongly advocates is as follows : Hansen's Method. — A rubber sheet covers the mattress on which the patient lies enveloped in three thick blankets. On each side, extending from the feet to the shoulders and as close to the skin as the heat will permit, are placed hot-water bags or bottles. A cup of hot fluid, preferably tea, is drunk. The sweat- ing commences almost at once, and, by renewing the hot-water bags or bottles, may be continued for the desired time. A glass of ice-water, one-half hour after the process has commenced, will serve to stimulate the sweat glands and increase perspira- tion. During the entire period an ice-cap or a towel frequently wrung out of cold water should be placed about the head and forehead. The duration of the pack should not exceed an hour and a half; longer than this is liable to enervate the patient and detract from the value of the treatment. At its conclusion the body should be well dried and rubbed with alcohol; the patient dressed with warm dry night clothing, and placed in bed with warm dry sheets and blankets, where he experiences a feeling of rest and relaxation. The most convenient hour for the treatment is in the early afternoon, the patient remaining in bed until the next morning, when he may dress, and, if the weather be suitable and other cir- cumstances permit, he may take exercise out of doors. Risley's Method. — This involves the use of an electric-hght bulb of 24- or 32-candlepower, which is hung underneath the top of a cage enclosing the patient. Air is prevented from entering the cage by blankets and other covering, only the head of the * See article by Howard F. Hansell, Pennsylvania Medical Journal, 1907, pp. 886-890. INTERNAL OCULAR AFFECTIONS 229 patient being exposed. Electric pads enclosed in a flannel covering and provided with a thermostat may be used instead of the electric bulb, and, being automatically regulated, there is no danger of exceeding a given degree of heat. The numher of sweats and their frequency depend upon the severity and chronicity of the disease and upon the physical qual- ities of the patient. In acute inflammation a week or ten days may be sufficient; in chronic inflammations they may be contin- ued for three weeks, particularly in corpulent subjects. The duration cannot be accurately stated beforehand. By noting the general and local effect and especiall}- the body tem- perature the physician is guided as to his course. It will prob- ably be found that at the conclusion of the bath the body tem- perature has risen to 102° or 103° F. (38.9° or 39.5° C), with a corresponding acceleration of the pulse. Two or three hours later both should have retmiied to normal. Delayed or a sub- normal temperature indicates physical weakness, and before the next bath strychnin should be given hypodermically. If, in spite of the stryclinin or other stimulant, the temperature remain high, the baths should be interrupted or altogether discontinued. Suitable Cases. — The class of cases suitable for the hydrothera- peutic methods above described includes inflammation of the sclerocornea, of the uveal coat, of the chorioretina, and of the optic nerve. The treatment is most valuable, according to Han- sell, in chronic inflammation associated with exudation in large amount of the uveal coat, with secondary involvement of the tissues immediately adjacent. After the stage of atrophy and connective-tissue change, notliing may be hoped for. Even after the ophthalmoscope indicates that exudation has given place entirely to connective tissue, improvement may yet take place. In alcohol and tobacco amblyopia the method of baths and packs associated with the use of strychnin are of the greatest value, especially if treatment be instituted before the stage of atrophy of the fibers of the optic nerve. In glaucoma the high vascular pressure calls for a- tranquil environment. Hot foot-baths of ten minutes' duration, with 230 HYDROTHERAPY the addition of salt or mustard, may prove useful. Full hot baths or sitz-baths are likely to aggravate the condition, but if tepid water be used at 85° to 90° F. (29.4°-32.2° C.) there will be no injurious efTect. The following cases cited by Hansell are typic of the value of hydrotherapy in ocular affections : Case 1. — Mrs. X. One year previous to treatment she became innocently infected with syphiUs. Tlie usual seconilarj' symptoms followed and she was treated witli mercury and potassium iodid. Four weeks before consulting Dr. Hansell iritlocyclitis had developed in the right, and two weeks before the eame condition tieveloped in the left eye. Vision at the time of examination was: R., counting fingers at one foot. L., -^^ff. Total posterior synechisB and vitreous opacities in both. No view of the fundus of either eye could be obtained. One week after commencing the sweats and mercurial inunctions the synecliiae were almost all broken off, the vitreous had regained, to a large extent, its transparency, and vision had improved to f J in each eye. After several weeks tlie jiaticnt was able to read and could see practically as well as ever. This patient Iiad seven sweats, each one and a iialf hours in duration, and mercurial invinctions carried to the point of saturation. Case 2. — A clerk, aged twenty-six. Four montiis before he came under obser\'ation he had fever with pain in the abdomen and back and some bladder trouble, the nature of which was not ascertained. He recovered in a few days, and during convalescence vision became affected to such a degree that he made his way with difficulty. He complained of headache and diplopia before and during his illness. Vision 5^^; the fields were concentrically contracted for form and almost entirely lost for colors, recognizing blue only at the fixation- point with the right eye. The diagnosis was acute double optic neuritis. The patient was given mercurial inunctions and sweats for nine consecutive days. Ten days after beginning treatment vision had improved to ^g, the fields had widened nearly to the normal limits^ all colors were recognized, and the optic nerve and adjacent retina were free from edema. INDUCED PHENOMENA DURING A COURSE OF HYDROTHERAPY It should not be forgotten that latent foci of infection may be aroused to renewed or primary activity during a course of hydrotherapy. This is probably more liable to occur when the patient is under treatment for some surgical condition. An auto- inoculation or reinoculation may be brought about by douches and packs and a more or less severe reaction ensue.* Kraus has ^ See p. 120, article on Rheumatism. INDUCED PHENOMENA DURING COURSE OF HYDROTHERAPY 231 applied the term " Provokationserscheinungen " to phenomena of this type. For example, in a patient who was being treated with local douches and packs to relieve chronic recurring pain in the peri- neal region, with other measures for an old chronic urethritis, signs of small abscess in the prostate became apparent on the fourth day of treatment. Kraus has noticed that patients sometimes complain of tooth- ache after hydrotherapeutic measures. This is not neuralgia, but merely the flaring up of some latent carious process. It is obviously desirable to have the teeth put in order before under- taking the various ''cures," especially when these involve long journeys. In all cases of pyosalpinx or gonorrheal genital processes there is the possibility that these may take on an acute activity. In such cases, as well as in gonorrheal joints and other forms of arthritis, one should endeavor to obtain that degree of hyperemia which promotes the absorption of morbid products. A happy mean between too little and too much is desirable. In mediis tutissimus ibis. Those who have had a large experience in the treatment of gout and rheumatism are familiar with these un- pleasant events. To the patient it is always a disheartening and trying period, to which he is rarely submissive. A few days of rest, however, usually restores his equilibrium. As Kraus remarks: "The tissues must be coaxed into proper assimilation." Experience brings skill in the appHcation of the measures, and this is the main point, and not so much the special technic. The disturbance of the vasomotor reaction to the nerve stim- ulus is liable to persist longer in nervous persons with a tendency to arteriosclerosis. There may be nervous crises, vertigo, or buzzing in the ears, but these are usually transient and, although the arteriosclerosis may not be cured, the symptoms may be abated. The aim should be to adapt the work of the tissues to the given disturbances. TECHNIC OF HYDROTHERAPY " If to do were as easy as to know wliat were good to do, chapels had been churches, and the poor men's cottages princes' palaces." — Merchant of Venice, i, 2. Centigrade. Fahrenheit. 260° 500°.. 204.4° 400° 148.7' .300° 115.6° 240° 100° .212° 93.3° 200°. 82.2° 180°. 54.4° 130°. 48.9° 120°. 46.1° 11.-)°. 40.6° 105°. 37.8° 100°. 32.2° 90°. 23.9° 75°. 22.2° 72° 15.6° 60°. 10° 50°. 4.4° 40°. . Radiant heat. .Radiant Heat Bath, maximum bear- able for full body bath. . Radiant Heat Bath, comfortable. .Very Hot Turkish Bath. . "Water boils. . " Calidarium"— Turkish Bath. . " Tepidarium"— Turkish Bath. . Fango Mud Bath, bearable. .Vapor Bath, unbearable. . Fango Mud Bath, comfortable. .Hot . Warm .Tepid .Cool . Sea Baths a it .Cold .Very Cold J Water Baths. Fig. 48. — Chart showing thermometric equivalents (Luke). 232 EFFECTS OF EXTERNAL APPLICATIONS OF HEAT AND COLD 233 STANDARDS OF TEMPERATURE, IN DEGREES FAHRENHEIT, USUALLY ACCEPTED IN HYDROTHERAPY Bath. Water. Vapor. Air. Cold.... .40° to 65° F, (4.4°-18.3° C). Cool .... .65° to 75° F. (18.3°-23.8 C). Tepid. . . .85° to 95° F. (29.4°-35° C). Warm . . . .95° to 100° F. 100° to 115° F. 110° to 120° F. (35°-37.7C.). (37.7°-46. 1° C.) . (43.3°-48.8° C.) Hot .100° to 110° F. 115° to 140° F. 120° to 180° F. (37.7°-43.3°C.). (46.1°-60° C). (48.8°-82.2 C). Very hot .110°-120° F. (43.3°-48.8° C), or more. Bath Thermometer. — The most nnportant piece of apparatus in hydrotherapy is the bath thermometer. The trouble with most bathing at- tendants is that they do not rely sufficiently on a good instrument, easily read. It takes young eyes and a good light to read the scale on the cheap bathing thermometers in common use. EFFECTS OF EXTERNAL APPLICATIONS OF HEAT AND COLD It is generally believed and stated that heat can be conveyed to or abstracted from the deeper structures of the human body by external applica- tions. This is probably true onh^ to a very limited and comparatively superficial extent. Schultze has claimed that an ice-compress can reduce the temperature 3.5° F. (1.9° C.) nearly 1 inch below the surface, and 7° F. (3.8° C.) on the inner surface of the thorax. Esmarch undertook to measure the influence of cotd on the body. He inserted a thermometer into a carious sinus in the leg and applied an ice- bag for nine hours and noted a fall of 50° F. (10° C). Similar results were obtained by immersion and also by irrigation with Fig. 49.— Bath thermometer. 234 HYDROTHERAPY cold water. Schweinburg and Schlikoff claim a lowering of tem- perature when ice is placed on the surface and measurements are taken in the mouth, the vagina, the bowel, and the pleural cavity. When ice was placed on one side of the thorax a lower- ing of the temperature in the opposite side of the thorax, amount- ing to 6.7 ° F. (3.7 ° C.) , was noted. Winternitz, Silva, Heitel, and Kowalski have recorded similar experiments, which show an undeniable temperature effect on the deeper structures when superficially applied.' Dr. W. Oilman Thompson, of New York, in some un- published experiments privately communicated to the author, arrived at very different results. He passed some long-stemmed thermometers into thoracic sinuses of patients who had been operated upon for empyema and also into the female bladder. Very hot poultices were then applied to the external surface, followed by ice-bags. The thermometers were never affected more than .125° F. (.0075° C). Similar tests were made within the cheek, with the same negative result. Dr. Thompson excised ribs of dogs and fitted in glass windows with a double flange, so that the pink lung played against the window. Poultices applied to the external surface produced no temperature effect, although in all similar experiments on the cadaver the tempera- ture was decidedly altered at once. In the latter case there is no layer of constantly moving blood beneath the poultices or the ice to quickly convey away the thermal units. The obvious reason of the failure to influence the deeper structures of the human body is that the small amount of heat units contained in any ice-bag or poultice is ridiculously small in comparison with the total units in the body. For this reason Dr. Baruch is opposed to the common practice of applying an ice-bag to the abdomen in case of hemorrhage occurring in typhoid fever. Dr. Thompson points out that the bronchial and pulmonary vessels spring from such different sources from those supplying 1 Schweinburg, Hanflbuch der AUgemeinen und Speciellen Hydrotherapie, Wiesbaden, 1904, pp. 16, 17. EFFECTS OF EXTERNAL APPLICATIONS OF HEAT AND COLD 235 the external thoracic wall that there is no reason why they should be affected. The fact that these applications relieve pain depends on an entirely different modus operandi. Neither should it be in- ferred that in pneumonia, for instance, there is no beneficial effect, notwithstanding that the external applications cannot reach the deep inflammation (see p. 101). Of course, the less vascular the parts the more appreciable will be the effects. In applying water therapeutically to the body, mention will be made of some of the principal measures shown by ex- Fig. 50. — Clow metal pack table and requisites. perience to be rehable. Acknowledgment is made to Professors Winternitz, Strasser, Baruch, Schweinburg, Jurgensen, of Kiel, Buxbaum, Brand, J. C. Wilson, Luke, Pope, Wright, and others, who have done so much to systematize the science and practice of hydrotherapy. The cooling or heat-abstracting measures will be considered first, and afterward the local and general applications of heat will be described. Many of these procedures are carried out while the patient is reclining in bed, and it is very convenient and much more sanitary to have a narrow metallic 236 HYDROTHERAPY bed for this purpose. A special bed, rendered perfectly safe by a strong spring, has been designed by Dr. Rebekah B. \\'right.' rig. ol. — l lif jiack j)rii)arf'd. . ' ^ ■ • Vj ' -y r /ri:^i Fig. 52. — Application of the cold pack (pressing the sheet between the patient's arm and body) (Stoney). It is made of steel tubing white enamel, 30 inches high, 6 feet long, and 22^ inches wide. In hospital or sanitarium practice * This bed is made by the Clow Company, Chicago THE EVAPORATION BATH 237 it is sometimes necessary to restrain a patient, and for this reason the width of the bed is an important consideration. BATHS THE COOLING WET SHEET PACK A Hnen sheet, saturated in water at 70° F. (21.1° C), should be wrung out slightly and wrapped about the patient, taking care to apply it closely to the body and around each limb and snugly about the neck. The patient may be lightly covered. In a few minutes, as the sheet warms, a second sheet, similarly prepared, is applied in place of the first one, and so on until five or six applications have been made at intervals of about five minutes. Friction with the hand outside the sheet pro- motes cutaneous circulation, and the temperature of the febrile patient may fall 1° F. (.54° C.) or more. Friction increases the heat loss about 95 per cent., and should be used after all cold applications. This pack is modified by opening up the sheet and sprinkling the body and the sheet with a sprinkling-can holding water at 40° to 45° F. (4.4°-7.2° C), allowing the patient to turn slightly to receive it on both sides. Provision should be made to protect the bed and drain the surplus water. THE EVAPORATION BATH Place a mackintosh and blanket under the patient. Cover the patient, both extremities and trunk, with one thickness of gauze moistened in water at 115° F. (46.1 ° C). Have the gauze fit the skin snugly. Fan the patient with a palm-leaf fan and moisten the gauze, as evaporation takes place, with the water still maintained at 115° F. (46.1° C). One pint of water should be evaporated in fifteen minutes. A hot-water bag is placed at the feet and a compress on the forehead. To keep the water at 115° F. (46.1° C.) the basin should be placed in a larger one containing water of a higher tem- perature. 238 HYDROTHEFiAPY Cold applications in the absence of ice or cold water may be obtained by the use of nitrate of ammonium. To 1 quart of water add ^ pound of the nitrate. If the water used has a temperature of 70° F. (21.1° C.) it will soon lose nearly 30° F. (16.2° C.) as the salt passes from the solid to the liquid state. This principle is utilized in the manufacture of artificial ice. THE COLD BATH For fairly vigorous persons the best time for the cold bath is before breakfast. Weak or delicate persons may take it in the forenoon. Chill, languor, or drowsiness coming on after cold baths are countcrindications to their continuance; tepid baths are then to be substituted. As stated above, vigorous friction should always follow the use of cold. The water of the cold bath is usually drawn in a tub from the pubUc supply, and varies, according to the season, from 40° to 70° F. (4.4°-21° C). The cold bath is the favorite one of the Anglo-Saxon race. AH are familiar with the determination with which the Englishman, wherever he is, ensures his morning cold bath, and undoubtedly it has an influence in promoting his vigor and his well-knowTi appearance of health. It is a rather curious fact, however, that the English, while devoted to bathing as a hygienic measure, have not shown a corresponding devotion to hydrotherapy as a science and a valuable department of therapeutics. Cold plunge baths and cold full baths belong to the same category, and acco plish very much the same purpose, differ- ing very little unless in the amount of water used and the extent of immersion. The plunge bath, as usually understood, is nothing more than the morning dip in the tub about half-filled with cold water, which may range from 4.^° to 70° F. (72°-21.1° C). The body is vigorously rubbed while in the bath, and water is carried over the head and shoulders by a large bathing sponge. The whole body is quickly rubbed with the hands, the bather sitting up. They both may occui)y fi'om half a minute to three THE COLD BATH 239 or four minutes, according to circumstances and the relish which the bather has for cold water. If a pool be at hand, the plunge may be had in its full significance. After a few seconds in the plunge the bather emerges for a quick rub with coarse Turkish towels and quickly dresses. A feeling of in- vigoration is generally experienced. This is the sort of bath the writer has taken for many years, and he would not exchange it for any other bath mentioned in this book. Nevertheless, he by no means approves of it for everybody. Dr. Norman Bridge is equally enthusiastic about the hot morning bath, and thinks it absurd that the average man, sick or well, should enjoy getting out of a warm bed and plunging into a tub of cold water. According to Dr. Bridge, "it is in the popular mind, among many of the more fastidious of us, that a daily bath, or one nearly every day, is necessary for health. That venerable error which reads, ' cleanliness is next to godliness ' has become part of the religion of a great number of people. Some kind of a bath must, they think, be taken, and the only one that is really pleasant, the warm and hot bath, is forbidden by lay opinion, and to a large extent by professional opinion also, as being dangerous when taken in the morning, and so the cold seems inevitable. The hot bath is more agreeable to nearly everybody than the cold, but we have been taught for genera- tions by putative hygienists, by books, professional and other- wise, by many thoughtful physicians, and a little, it may be, by an ethical fetish inherited from some severe religious past, that whatever is pleasant must be in some measure a sin — ^that a hot bath invites cold catching, and is, therefore, positively dangerous, unless taken just before going to bed, or unless it is ended by a douche of cold water or by a cold plunge. The theory that has gained currency is that the heat of the bath 'opens the pores' and leads to cold catching or some other peril, unless the 'pores' are shut up by the cold dash taken at the end of the bath. So it has come to be a part of the very positive directions generally given for a warm or hot bath, especially 240 HYDROTHERAPY if taken in the morning or before going out into the weather, that the end event of it shall be this same cold dash." ^ Of course, the propriety of cold morning plunges varies wholly with the individual, his powers of reaction, his position in life, and the climate in which he lives. What is best for a man in Boston or Montreal may be wholly different for a man in New Orleans or Southern California. A man who leaves his house at 9 or 10 o'clock in the morning can do many things unsuited for the man whose ''morning's at seven." .It is beheved that better powers of endurance are developed by the cold morning bath, and that, used with judgment, a process of hardening en- sues which fortifies the system against surrounding dangers. The morning dip in cold water has a tonic influence on flabby abdominal muscles, and is advised for the relief of sluggishness of the gastro-intestinal tract, defective nutrition, obesity, and autointoxication. It corrects mental torpor, lassitude, head- ache, and listlessnoss.- Cold full baths, oO^to 60°F. (10°-15.6=' C), should last for only a minute or less; if from 60° to 70° F. (15.6°-21.1° C), they may last for a little longer. A large tub is required, so that the entire body can be submerged up to the neck. These baths produce a tonic effect, deepen respiration, and favor a better ventilation of the lungs, just as in the case of plunge baths. The appetite is sharpened, digestion improved, peris- talsis is increased, and constipation prevented or relieved. Short stimulating baths of this type tend to correct enteroptosis, dilatation of the bowel, and intestinal intoxication. One reason why women suffer from habitual constipation much more com- monly than men is possibly due to the greater popularity of the cold morning bath among men, whereas women favor the more relaxing tepid bath. Counter indications. — Cold and cool full })aths are counter- indicated in spastic and mechanical constipation, acute inflam- ^ Trans. American Climatological Association, 1906. - For a discussion of baths for the relief of constipation see Constipation and Intestinal Obstruction, chap, xxii., by Samuel G. Gant, M. D., 1909. THE COLD BATH 241 matory affections, like appendicitis, peritonitis, and gastritis, in pronounced anemia, and during gestation (Gant). It is also counterindicated in advanced life and at any age when arterio- sclerosis exists. Cardiac weakness, emphysema, and bronchitis are better treated by hot sponge baths. Sir J. Floyer, who wrote a notable treatise on hydrotherap}'' two hundred years ago, was a strong advocate of the cold bath, but it is noteworthy that on the title page of his first edition he added, the words, "proving that the best cures done by cold ? ^^iy^^yM.^d4fe^^ :A Fig. 55. — Janeway's bed lift. baths are lately observed to arise from the temperate use of hot baths first." He wisely recognized that warming procedures render the subsequent use of the cold bath safer and more effective. An exception to this general principle is, of course, the Brand bath in typhoid fever. Bed Lift. — A helpless patient, or one whose great weight or mental condition presents difficulties, may be removed from the bed to the tub and back again by means of a bed lift. The best device is that of Dr. H. H. Janeway.^ It has the advantage 1 Journal Amer. Med. Assoc, Oct. 6, 1906, pp. 1093, 1094. 16 242 HYDROTHERAPY of lifting tlie patient directly from the bed into the tub with Fig. 54. — .Jancwa3''s bed lift. Fig. .5.3. — Janevvay's bed lift. perfect safety and with little exertion on the part of the nurse. It can be operated by one person. THE SO-CALLED " HALF-BATH " OF PRIESSNITZ 243 Four stout, broad bands of webbing, with triangular steel attachments at both ends, are placed under the head, the thorax, the pelvis, and the legs. The steel bar (Fig. 53) is then lowered by means of stout rope and pulleys connected with a substantial steel frame, set in cross-shaped wooden base and operated by a windlass. The patient is then Hfted bodily from the bed (Fig. 54). It is then a matter of only a few minutes to remove the bed for renovation and to place the movable tub in position. By using extra bands and varying their position any part of the back can be exposed to the bath or given special dressings. By depressing the bar above the feet the head need not be allowed to come in contact with the water. In cases where one nurse only is on duty, bathing becomes perfectly practicable if this apparatus be at hand.^ THE SO-CALLED "HALF-BATH" OF PRIESSNITZ This is really a shallow bath, the water reaching to the um- bihcus, but its application involves the whole surface of the body. It is a powerful tonic when applied with water at 65° to 75° F. (18.3°-23.9° C), and should occupy from three to five minutes. The tub is filled to a depth of 5 or 6 inches. The patient should enter from a warm bed, or his circulation should be stimulated by exercise. As soon as he enters the water he rubs his limbs, while the attendant rubs the chest thoroughly for a few moments with both hands and then takes tlie limbs in turn. The attendant repeats the rubbing of the various parts quickly once or twice more. The shallow water enables the attendant to get at the various parts more readily than in the full bath. The half-bath or shallow bath is useful in cases of anemia and in many chronic diseases of the spinal cord; in cardiac affections and usually in cases of asthma oppressed by the Turkish or Russian bath. It is also valuable in chronic affec- tions of the stomach and in constipation. At the higher tem- 1 This bed lift may be obtained from Charles E. Dressier, 143 East 23d Street, New York City. 244 HYDROTHERAPY peratures it is suitable for cases of sciatica and all painful affec- tions of the lower extremities and pelvis. Fig. 56. — Half-bath with affusion (Cohen). The popularity of this bath has increased among Conti- nental physicians anrl is having a great vogue throughout Europe. SPRAY BATH Technically, the spray bath, liesignated by French clini- cians bains a I'hydrofere, consists in applying to the skin of the patient a continuously fresh layer of water in a finely divided state. A specially devised spraying apparatus is used, which affords a mechanical impact to the skin, exerting a marked sed- ative effect on the nerves and removing secretion. Mineral waters with gaseous and solid contents are used in this way at European resorts. This bath is practically a douche of very fine streams issuing SPRAY BATH 245 from a large perforated rose nozzle attached to rubber tubing. It may be applied horizontally or in any other position. Fig. 57. — Sprinkler with temperature-indicating handle; designed by Dr. A. F. Shepherd of the Ohio State Hospital for the Insane, Dayton, Ohio. It is made of metal, which instantly takes the temperature of the water passing through it, thus indicating to the attendant any slight variation in the temperature of the water. See also the thermometer illustrated on p. 368. Fig. 58. — Spray bath and ice rub (Cohen). ■ The spray bath is eminently suitable for treating sunstroke. . The patient should be stripped and put on a cot covered with a 246 HYDROTHERAPY rubber sheet and an ico-cap applied to his head. The water is supi)licd from the nozzles in a fine spray at the lowest tempera- ture afforded by the ixiblic suj)])!}', or from a supply cooled to a temperature of 55° or 00° F. (12.8° or 15.0° C). \\hen the rectal temperature reaches 103° F. (39.4° C.) he may be wrapped in blankets and made comfoitable in bed ; the process being repeated if the tem{)erature rises. In subseciuent baths it may be pos- sible to reduce the temperature to 101° F. (38.3° C). For the use of the spray bath and ice rubbing in the treat- ment of typhoid fever see pi). 71 and 75. THE ABLUTION OR WET MIT FRICTION Teihvaschung of the Germans. It is the mildest general treatment, and can be employed to advantage even in the treat- met of feeble, bedridden patients. The water is b(\st aiJi)lied with a wet bath mitten. One part of the body after another should be rubbed, first with cold water, 50° to 75° F. (10°-23.8°C.), ami then with a rough towel. If the circulation is j)oor, alcohol may be added to the water. The skin of the part treated should become red and warm. The intensity of the local reaction fur- nishes a guide to the selection of the proper tonic measure. If a good reaction is obtained with the ablution, stronger measures may be used, of which the douches have the greatest range of usefulness. THE DRIP SHEET OR SHEET BATH This important measure requires very little apparatus. The best time for its application is late in the afternoon or toward night. The requisites are a pail or large basin of water at 05° F. (18.3° C); a foot-tub with water at 100° F. (37.8° C); ice-water; two face towels; a bath towel; a bed with an extra blanket at hand, and protection for the floor. Put the sheet into the water, letting the corners hang out. The patient, dressed only in one garment, stands in the foot-tub containing the warm water. One facetowel is then dipped in ice- water, wrung out, and wrapped about the head like a turban. The nurse then places the pail THE DRIP SHEET OR SHEET BATH 247 of cold water with the sheet behind the patient, and, while standing in front, seizes the wet sheet by two corners and throws it around the patient, without any attempt to wring out the sheet. A rough, smart rapid rub apphes it everywhere. This process should occupy about two minutes. Then drop the sheet and wrap in the dry blanket, and put the patient to bed. Lower the temperature of the water 1 degree each day until 55° F. (12.8° C.) be reached. Fig. 59. — Drip sheet or sheet bath (Ash ton). This is the quickest and simplest method of applying the drip sheet, and may be modified or extended by slapping the surface occasionally with the hand or a wet towel, thus increasing the mechanical irritation of the skin. In addition, a basin of water 10° F. (5.4° C.) colder than the water used for the sheet should be provided, from which water is poured over the head and shoulders two or three times at short intervals, being alternated with slapping and friction for from iive to ten minutes. In any 248 HYDROTHEIIAFY given case the physician may judge whether to commence mod- erately or with the full technic. The general effect is moderately sedative, with the abstraction of considerable heat. SPONGING Before sponging a patient, note first the exact temperature. Have water ready at between 80° to 90° F. (26.7°-32.2° C.) and also at 60° F. (15.6° C). Remove all clothing from the patient and have blankets over and under him. Put the basins, sponges, and six soft towels, etc., on a table near by, so that it will not be necessary to leave the patient for any reason what- ever. Commence the sponging at the face and neck, applying a cold compress at 60° F. (15.6° C.) to the head and forehead after sponging. Si)ongo downward, exposing only one limb at a time. When the whole body has been sponged, the patient should be flried, dressed in a night gown, wrapped in a warm blanket, and left undisturbed in bed for an hour or longer. The temperature should be taken at the end of each sponging and at the end of the hour's rest. Cold sponging is better borne by sensiti\'e patients if there be a preliminary sponging with tepid water, 80° to 90° F. (26.7°- 32.2° C), before applying the water at 60° to 70° F. (15.6°- 21.1° C). A hot bottle at the feet during 'sponging is com- fortable to the patient and may ward off a chill or tendency to collapse. Patients who are not particularly weak do not need to be so carefully dried; the arms, back, and chest may be left to dry by evajDoration. After the sponge the temperature usually falls from 1° to 3° or 4° F. (.54°-16.2° or 2.2° C), the rapidity and extent of the fall corresponding to the coldness of the water employed. Ammonia, alcohol, cologne, water, or vinegar added to the water favors cooling by rapid evaporatian. In the absence of a suitable sponge, towels may be wrung out of cold water dry enough not to drip, and placed about the body, from the neck downward, ^^'hen the feet are reached, THE OIL RUB 249 begin again at the head and renew each in succession, con- tinuing as long as necessary. Abdominal Cold Compress. — To enhance the value of the sponge bath, an abdominal cold compress is sometimes appUed after sponging. This is made by dipping two towels into water at 60° F. (15.0° C), and, after partly wringing them out, they are unfolded and placed across the abdomen and covered with a thick Turkish towel, passed around the body. RUBS THE OIL RUB In temperate climates it is probable that the main ad- vantages from such anointing is due to the massage; in other words, the circulation of the skin is improved, the muscles are cleansed of excrementitious products by such debris being forced into the lymph circulation, and the flow of blood through the muscles is improved. The oil rub has also a good therapeutic use when the skin of the patient is always dry and scaly. Such people probably do not have a normal secretion from the thyroid gland, but whatever internal medication is deemed advisable, the oil rub will add to the improvement of the skin condition. In tropical countries the oiled skin radiates heat more rapidly than the dry skin when little or no clothing is worn, On the other hand, in cold countries, where much clothing is needed, the oiled surface of the body keeps the body warmer. It also seems to be a fact that after hot bathing a patient who catches cold readily has less hability to chilhng if an oil rub is given. Locally, oil rubbing may be used, after hot bathing, for cold feet or cold legs, and the feet of such patients will remain warm longer than without it. Although it hac been stated that oil may be rubbed into the body so as to increase nutrition, and that weakly patients, especially infants, will improve, it is still a question if it is not the general toning up of the circulation, the equalization of the 250 HYDROTHERAPY circulation, and the prevention of flabbiness of muscles — in other words, the effects of the massage — that are the real cause of the improvement in the general conditon. The body should be first bathed with warm or tepid water, dried, and the oil then applied; it should not be applied to the dry, unwashed skin. The oil should, of course, be pure and clean, should be well rubbed into the skin, and any surplus should be removed with a soft towel. Some knowledge of massage is necessary to a successful oil rub, and tlie rubbing should not be suffici(>ntly vigorous to cause persj^iration. The best oil for this purpose is pure olive oil, cocoanut oil, or palm oil; cottonseed oil ma}^ be used. Animal fats do not make an ideal oil rub. THE SCOTCH RUB This is applicable to patients to whom a cold-water rub is unpleasant, and consists in washing a ])art of the body with hot water and then rubbing with a towel wet in cold water. "If under such applications the skin slowly redden or stay pale and the skin muscles are contracted, it means an abnormally high excitability of vessel innervation." This condition is found in aneniia and in some feverish conditions. "A livid red- ness of the rubbed area means circulatory insufficiency," while a slow rewarming or continued coolness of the treated area in high fevers "is suggestive of a pending circulatory collapse." The advantages are that the friction is a mild stimulant and causes the rubb(Yl area to radiate heat normally, while it also increases evaporation. The advantage is that this method is pleasanter to most patients than cold sponging, and while not tending to lower tem- perature immediately as effectively as does the tj'pical old sponging, it does tend to keep the surface of the body in a health)'' condition and causes the skin to give off heat rather than to retain it.' For Salt Rub or Salt Glow, see p. 354, ^See Dietetic and Hygienic Gazette, September, 1908; British Journal of Nursing, 1908; Jour. Amer. Med. Assoc, November 14, 1908. NEEDLE douche; NEEDLE SPRAY; CIRCULAR DOUCHE 251 ALCOHOL RUB This is an adjunct to hydrotherapy of great value, usually employed as a terminal measure. It improves the circulation and adds tone to the skin, and after packs or douches prepares the skin for contact with the outside air. Only grain alcohol should be used, and it may be used slightly diluted or pure. About 2 ounces are sufficient for each rubbing of the entire body. DOUCHES Douches may be applied to individual portions of the body, depending upon the particular organs or structures affected. The jet, the spray, the fan, or the filiform douche may be chosen as the parts require, and they may be short, prolonged, hot or cold, or alternately hot and cold, and under greater or less pres- sure — from 10 to 35 pounds to the square inch. Cold applications, lasting one or two minutes, are strongly stimulant, producing a vigorous reaction in most cases. The entire vascular and lymphatic systems immediately underlying the exposed part are affected in proportion to the pressure under which the douche is applied. If no pressure accompany the cold, the action is superficial, but may in certain localities produce reflex stimulation. Hot applications allay pain or benumb the superficial cutane- ous nerves. At a temperature of 90° to 100° F. (32.2°-37.8° C.) they produce local and reflex sedative effects. NEEDLE DOUCHE; NEEDLE SPRAY; CIRCULAR DOUCHE In its most effective form this douche is delivered from a series of "roses" having minute perforations, and arranged at different heights on an upright system of tubes connected with the control table. In modern appliances there are usually six- teen roses, the upper row being adjustable to discharge the spray at an inclination downward, so as to avoid the head and face. These roses can be adjusted to suit patients of different heights. The small volume of water emerging in the needle 252 HYDROTHERAPY douche allows a somewhat higher pressure than in douches of larger volume. There is, however, a sharp stinmlus to the skin from these innumerable jets of small caliber, wliich gives a sensation of needles, suggesting the name. The douche should be started by the operator before the patient takes his position, so as to avoitl any unexpected high temperature. Water contained in the pipes is thereby allowed to run off, and when the thermometer stands at the required initial tempera- ture the patient may be called from the adjoining cabinet bath, in case this be used as the preliminary warming measure. He enters the douche and turns around slowly to permit the spray to strike all parts of tlu^ l)ody below the head. The illustration shows that the two lower seric^s of roses expend their force chiefly in zones, but this is not 'an objection to the arrange ment. Hydrotherapeutic prescriptions frecjuently call for the hot- air bath or electric-light bath as a preliminary measure. This is usually to insure more or less perspiration and capillary dilata- tion. The electric-Hght bath for five or six minutes, or the hot- air bath for eight, ten, or twelve minutes or possibly longer, is then followed innnediately by the circular douche of the prescription. From one to two minutes is usually sufficient, and during that time the operator has the opportunity of lowering the temperature of the water as may be prescribed. As a rule, there is no need or advantage of a change in the initial pressure. The author does not ai:)prove of prescriptions calling for a rising temperature. The advantage is not commensurate wath the danger of overstepping the mark. He rarely orders an initial temperature of over 105° F. (40.6° C), believing this sufficient after the use of the cabinet, in which the temperature is usually at 150° to 100° or 105° F. (05.6°-71.1° or 73.9° C). To raise the temperature of the needle douche, and then lower it to the required point in a given time, is impossible for the average attendant, and, even with those of considerable experience, it is a delicate matter. Better results will be obtained by simple prescriptions, e. g.: COLD DOUCHE 253 Hot-air bath, eight to ten minutes or to perspiration. Circular douche, two minutes, 105° > 90° F. (40.6° > 32.2° C), 20 pounds. Jet douche, one minute, 90° > 80° F. (32.2° > 26.7° C), 15 to 20 pounds. Scotch douche, one-half minute, 105° and 80° F. (40.6° and 26.7° C), 15 to 20 pounds. Fan douche, ten seconds, 80° to 78° F. (26.7°-25.6° C), 15 to 20 pounds. , COLD DOUCHE This is a single stream of water under pressure coming from a nozzle of j or J inch in diameter at a distance of 6 to 10 feet Fig. 60. — Douche room. McLean Hospital, Waverly, Mass. Marble wall of Ver- mont marble. from the patient. The temperature may be regulated by valves which govern the mixing chamber in the control table, and may be graduated from a warm stream down to the coldest water supplied. It is a powerful stimulant and useful for its tonic effect after the hot-air bath and circular douche. It is counterindicated in asthma, as paroxysms of asthmatic breathing may be induced. The sudden contraction of the pulmonary vessels restrict the area of blood subjected to oxida- 254 HYDROTHERAPY tion in the lungs, the carbonic acid is not properly eliminated, and a sense of suffocation ensues. This is corrected as reaction occurs, and the secondary efi'ects are powerful, tissue change being highly stimulated. Fatigue gives place to renewed energy, especially if the cold applications be jn-eceded by heat and followed by vigorous rubbing. As a general thing, cold douches should follow hot applica- tions, never the revers(>, although alternate heat and cold are occasionally employed; in this case the terminal douche is cold. Kneipp Water Cure. — Cokl douches were the mainstay of the famous Father Sebastian Kneipp, a Bavarian priest. He and his assistants applied this usually to the lower limbs, and he also ordered his j^atients to walk barefoot in the morning dew on soft grass and adojit a spare diet. Many thousands of people from all over the world were treated in this manner twenty years ago with surprising results. Accompanied by suggestion and good circulation induced by this form of treat- ment, which included early morning exercise, a great amount of good was undoubtedly accomplished.' Substitute for Jet Douche. — In the absence of apparatus for the jet douche, a sul)stitute may be adopted. The patient on rising stands in a bath-tub, and turns the two faucets so that the water will be delivered at about 100° F. (37.8 C). A large bathing sponge is held under the faucet and then pressed against the back of the neck. This is done several times, and, the hot water having been turned off, the sponge is filled witli cold water and applied to the back of the neck and spine in the same way. After a brisk rubbing, the patient partly dresses and lies down for half an hour. This may act favorably in some cases in which the ordinary plunge bath or shower is not desirable. Uses. — Cold tlouches, whether locally or generally applied, preceded by some wanning measure and followed by friction, are used for anemia, insomnia, and headaches. Acne of the face and thorax and a generally bad complexion are also im- 1 Father Kneipp published a volume entitled Mon Te.stament, embodying the principles of his treatment, Ma Cure d'Eau, 1891. COLD DOUCHE 255 proved by these measures, as are also chronic constipation with muddy complexion, general auto-intoxication, and general mal- nutrition. Spinal Douche. — Charcot used the spinal douche at a low temperature, 45° to 60° F. (72°-15.6° C), in cases of hys- Fig. 61- — Spinal douche — Charcot douche (Gant). teria with marked benefit. It was never applied except to a limited portion of the spine, and hence no general depression occurred and the reaction was easy. The limited spinal douche at 20 or 30 pounds' pressure and at low temperature is some- times referred to under Charcot's name. 256 HYDROTHERAPY ALTERNATING HOT AND COLD DOUCHES This form of (louche, for some unknoun reason called the Scotch douche, i)roduces distinctly (>xciting effects. It is not appHcable to the head or the anterior chest, but may be applied to the spine and posterior thorax and sides; to the Fig. 62. — Abdominal Scotch or alternating liot and cold douche, the water under considerable pressure (Gant). abdomen and to the lower extremities. With temperatures alternating between 105° and 70° F. (65.6° and 21.1 C), or pos- sibly a few degrees higher and lower, good results are obtained; in robust patients the extremes may reach 110° and 55° F. (43.3° and 12.8° C.) or lower. Douches to the Head. — In applying a douche to the head it ALTERNATING HOT AND COLD DOUCHES 257 should be, as a rule, cold or cool, without pressure, as given from a dipper or pitcher, and the duration should be onty a few seconds. The immediate effect is a dilatation of the blood- vessels of the brain; if too long continued, a secondary contrac- tion and chilling occur. It may be designated as an affusion, Fig. 63. — Hepatic douche (Gant). and is used in connection with the Brand bath or drip sheet, and' always at a slightly lower temperature, and repeated once or twice. It may be applied in mental disease, as in melancholia and hypochondria. In cases of insomnia, mania, and paresis the water should not be less than 80° F. (26.7° C.) or more than 95° 17 258 HYDROTHERAPY F. (35° C). Douches to the bare head are generally inapplic- able to women on account of the difficulty of drying the hair. Fig. 64. — Gant's perineal (ascending) douohe. For women the full hath or the spinal douche is to be preferred. Great caution should be exercised in any case. THE RAIN DOUCHE This valuable form of douche may be used for general pur- poses of ablution and, for many reasons besides those of economy, is used as a substitute for the general cleansing tub-bath. It is a common adjunct of public baths under the name of shower- bath (see p. .375). It is easily attached to the household bath- tub for domestic purposes and is always included in the fixtures' THE RAIN DOUCHE 259 used for giving the circular or needle bath. In this apparatus American manufacturers set the rose for the rain douche slightly behind the head of the standing bather and at a moderate angle, so that, instead of descending vertically on the head, the water may strike the back of the neck and shoulders after the head has been sufficiently wet. This allows the use of soap and a general ablution if this be required. Fig. 65. — Rain douche. The pressure and temperature of the descending or rain douche may be regulated by the bathing attendant, who stands at the control table, but in the public baths and in private use the temperature is usually adjusted by the patient or attendant by means of a valve convenient to the bather, who is thus enabled to employ colder water toward the end of the bath. The pressure does not need to be very great. Usually the city pressure is sufficient. The high pressures used in the needle 260 HYDHOTIIERAPY or circular douche' arc not rc(iuired far the head, and if over 30 pounds to the square inch may tlo harm. The rain douche or shower is always used after the shampoo in the Turkish bath and before the i)lunge. It is highly desir- able before entering a swinuning i)ool. in which case it should be warmer than the pool. It is also excellent as an after-shower Fig. 66. — Mott combination "Securo" shampoo mixing valve. Tilting basin with brackets and stops (J. L. Mott Iron W'orks). at a lower temperature than the pool when that is kept at from 70° to 78° F. (21.1°-25.6° C). Many also like the rain bath of soft fresh water after sea- bathing; but, as has been noted further on, the transition from the cold water of the ocean to the fresh water of higher tempera- ture is thermometrically irrational, and, therefore, the au.thor does not approve of it. Much of the benefit of sea-bathing may be lost in this way, and the subsequent warm fresh shower FAN DOUCHE 261 should not be used unless the bather is chilled with too long an exposure and fails to react. No harm, as a rule, can result from the little sea salt that clings to the skin after the use of a rough towel. Every douche should be preceded by wetting the head with cold water and applying to it a towel wet in cold water. Effects. — The rain douche, in brief appHcations and moder- ately .low temperatures, causes a vigorous nerve stimulation and strong reaction. It accelerates metabolism and promotes the circulation. It is especially apphcable in nervous affections, functional disorders, such as neurasthenia and hysteria, neural- gias, paresis, disorders of nutrition, weak circulation when no organic changes in the heart and blood-vessels are present. It has a marked influence on heat production and sweat formation, for which applications of longer duration are required. Tepid and warm rain baths have a sedative action and are applicable, therefore, in very sensitive neurasthenic and hysteric subjects. By changing the temperature, now to warmer and now to colder, then quite warm, rain douches accomplish much in torpid conditions and enforce a good reaction, especially in anemia and chlorosis, because they bring about a good nervous stimulation without heat abstraction. They also favor the action of the skin and reheve many of its diseases. In hysteric cases, and especially where there is an hysteric back to deal with, rain douches of indifferent temperatures, fol- lowed by a Scotch douche, 105° and 80° F. (40.6° and 26.7° C), may be used. The pressure of the Scotch douche should not be more than 10 or 12 pounds at first, or with just sufficient force for the jet to reach the patient. On successive applications the force of the douche may be increased. Duration, fifteen to twenty seconds. FAN DOUCHE This is a modification of the jet douche. The thumb is placed over the nozzle delivering the jet, breaking it into a fan-shaped stream. This douche is usually cool or cold and is a terminal measure. 262 HYDROTHERAPY FILIFORM DOUCHE This is an extremely small douche driven at high pressure, as much as GO pounds to the square inch or even higher (4 to o atmospheres). When applied to tlie skin it acts as a powerful countcrirritant and stimulant, and in this respect its mechanical properties supersede its temperature. The filiform douche bears the same relation to other douches of larger volume that electric currents of high tc^nsion bear to the ordinary galvanic current. It is useful in sciatica and other neuralgias. The dui-ation is short, from one-half to two minutes. The steam douche is applied by means of a similar apparatus, but carrying live steam. THE PERINEAL OR ASCENDING DOUCHE All completely equipped douche-rooms are provided with a fixture in the floor or between the slats of the flooring for this Pig. 67. — White celluloid enameled perineal stool with opening in center for use in connection with perineal douche (J. L. Mott Iron W^orks). (See also p. 258.) douche. It is generally regulated from the control table by a special valve, and the temperature and the pressure are con- Aix douche; massage douche 263 trailed just as in the case of other douches. The patient sits upon a stool with a hollow or circular seat and receives the douche upon the jDerineum. The usual form is that of a single jet, about ^ inch in diameter, but it maj^ take the form of a spra5^ The temperatures employed are usually compara- tively low, 60° to 80° F. (15.6°-26.7° C), in order to overcome- weakness of the bladder, chronic ]:)roctitis, sexual depression, and psychic impotence. It is well suited for hemorrhoids. The duration of this douche may vary from three to ten minutes, according to individual requirements. It has some advantage over the sitz-bath, in that a certain amount of me- chanical force is applied ; this force should be sufficient to raise the column of water about 30 to 40 inches from the floor. AIX DOUCHE; MASSAGE DOUCHE This is a combination of the douche with vigorous massage. As practised for over one hundred years at Aix-les-Bains, it requires the services of two attendants, both being provided with a flexible tube or hose, bringing water at two different pressures. The two springs at Aix-les-Bains, the alum spring and the sulphur spring, are about 100 yards apart, and have almost the same chemical composition. They are waters of small mineralization, about 35 grains per gallon, alum not being a con- stituent, and the amount of sulphur being very small; the com- bined flow is about 6,000,000 liters, or 1,200,000 gallons in twenty-four hours. The temperature is 113° F. (45° C). Water from another spring, at 52° F. (11.1° C), serves to graduate the temperature of the douche and the baths. The author visited Aix-les-Bains in 1910, and was favor- ably impressed by the methods of treatment used in that resort. The Aix douche is described by Dr. Jean Dardel,^ of Aix- les-Bains, as follows: "The douche of Aix is a combination of the douche and * International Clinics, vol. ii, 17th series, 1907. See also The Spas of Aix- les-Bains and Marlioz, by Francis Bertier, J. and A. Churchill, London, 1877. 264 HYDROTHERAPY massage, sometimes called doucJic-massage. This douche- massage constitutes the real specialty of Aix-les-l^ains. This is not a douche, according to the usual signification of the word douche, for the term implies a colder and a more rapid operation. Nor is it simply a massage. It is a sjoecial operation per- formed by a petrissarje, or kneading of the muscles, the patient receiving at the same time a general and abundant douche of the thermal sulphurous water. " The douche is given in rectangular chambers, each cham- ber having a dressing-room. Some of these chambers are com- pletely closed, while others are open toward the ceiling. This Aix douche; massage douche 265 disposition allows the escape of the vapor, and at the same time avoids the overheating of the atmosphere in the room where the douche is taken. " In each cabin where the douche is administered, the temper- ature of the water varies from 57.2° to 109.4° F. (14°-43°C.), and one can have a cold, a warm, or a tepid douche, according to his need or pleasure. But the division called the central division does not admit of any but the thermal water douche. " The conduits which bring the waters, either mineral or cold, run into vessels fixed in the wall, in wliich the waters are mixed. Fig. 69. — " Etablissement Thermal," Aix-les-Bains. One of these vessels is a reservoir placed at 1.65 meters above ground. The mixing of the waters takes place in the open air, so that the pressure does not vary. This mixed water is destined to flow over the back and the upper parts of the bod3^ " The second vessel for mixing the waters is a closed box or copper cistern, into which the hot and cold waters flow. This mixed water serves to flow over the different limbs of the invalid. In this second reservoir for mixing the waters the water pre- serves its full pressure, which varies according to the different stories of the building (14, 9, or 6 meters). 266 HYDROTHERAPY " The invalid is seated upon a wooden chair, about 1 foot high, furnished with one arm about two-thirds of a foot liigh, upon which lie leans; he rests his feet upon a wooden stool. One of the doucheurs places himself before the patient, iiolding under his arm one of the tubes — the one which contains both the hot and the cold water. He directs the water over the different parts of the limbs of his patient, at the same time frictioning and petrissing the muscles; and, acconling to the case, moving \hc joints about. The second douchcur keeps behind the invalid, 111.- ball,^, Aix-lc-Hai holding the tube which contains the water from the free-air vessel. By imperceptible movements he waters the shoulders and the back of the invalid, massaging at the same time the nuiscles of the neck, back, or trunk. During the whole time of this massaging of the different parts of the body the invalid is inundated, so to speak, with thermal waters. " After a time, which varies according to medical advice, the patient leaves his chair and stretches at full length on an inclined table for massaging. The doucheur. still holding his tube of mineral water, places himself bchintl the invalid, and proceeds Aix douche; massage douche 267 to the massaging of the muscular masses of the back, and of the back parts of the thighs and legs. Massage of the back can also be performed by placing the invalid upon his chair in an inclined position, his hands leaning on the arm of the chair. Certain invaUds, who cannot move without great discomfort, are brought Fig. 71. — Bathing pool (piscine), Aix-les-Bains. to the douche upon a camp-bed, which they are not obliged to leave during the douche, and thus avoid every painful movement. " The massage being terminated, the patient places himself in a corner of the cabin, and there receives the douche in full, in a shower, or in a sprinkle, which is the most important of all. The last part is extremely important, and the doctors know how to obtain different results, from the use of a broken jet or from a 268 HYDROTHEIJAPY full jot, i\\c jet falling on the patient like a spout, throwing out in full force the water u[)on him, or coming gently upon him like a shower of rain, either in cold or in warm showers or in Scotch shower-baths or douches. " The douche-massage being completed, the patient is dried, wraj)p('(l up in a flannel dressing-gown, and then covered with a woolen rug, put into a sedan-chair, and carried to his hotel. He is put into bed thus wrapped uj), and after twenty minutes or so of heavy persjjiration, he is uncovered and again dried, and wiped by the man whose duty it is to helji him to get out of the maillot, or wraps. This done, the douche-massage is finished. " Occasionally the patient dresses himself at the end of his douche and goes out on foot, to induce perspiration either by exercise or by returning to his bed. But it is prefcu'able to return in the maillot, well wrapped up, in the sedan-chair. Formerly this method was used exclusively. Such is the most usual form of the douche of Aix-lcs-Bains, but its administration may be subjected to certain variations. " When the douche is given by a single doucheur the prepara- tion is the same as when there are two doucheurs. The patient is seated as before on a low chair. The doucheur, holding the tube which brings the water from the reservoir, pours it over the (lifTerent limbs and the muscular parts of the body. The tube, which comes from a box containing the mixtures of water kept in the open air, is fixed to a particular instrument which ends with a watering apparatus, the water from which flows over the patient during the whole operation. " The local douche is given in a chamber or cabin divided into two compartments by a wooden partition, which has two holes bored through it so as to admit either the arm or the leg. The patient is seated on a low chair and passes his arm or his leg, as the case may be, through the orifice in the partition. The doucheur is in the other compartment, and he proceeds to mas- sage the arm or the leg, or the affected part of the arm or leg, the thermal water flowing all the time, from a flexible tube con- nected with the reservoir, over the member under treatment. Aix douche; massage douche 269 " Corbin Douche. — In certain cases the chair used for the mas- sage can be replaced by a particular stool, and under this stool is fixed a crooked tube which is joined to one of the reservoirs of the mineral waters and which ends in a watering spout. The jet of thermal water strikes the region of the perineum, and is of great use in the treatment of many cases of hemorrhoids and of enlarged prostate. The name of Corbin has been given to this particular douche. " The vapor or steam baths, both local and general, are given in bouillons, or in the division of the BerthoUet apparatus. " The name of bouillons has been given to the cabinets which are connected with a certain number of douches. The mineral water rushes out bubbling from the apparatus which is used to produce this bubbling or boihng, and is converted into a pulverous, vaporous steam of 104° to 109.4° F. (40°-43° C.) of heat. This vapor produces a rapid and abundant perspiration. The patient remains in this cabinet from three to ten minutes, the vapor bath being at once followed by a douche. '* BerthoUet Apparatus. — The apparatus called BerthoUet con- stitutes another peculiarity of Aix. The daily use of this bath requires a consumption of 1,680,000 liters of water. A special arrangement of the BerthoUet bath produces a mixture of air and vapor from the mineral water at a temperature of 111.2° F. (44° C). This mixture is driven back into a receptacle of cast- iron, situated in the cabinet where the treatment is taken. The apparatus, which varies according to the part of the body to be treated, is fixed to the receptacle containing the vaporous steam, and is then directed to the affected parts, whether leg, arm, back, or shoulder. These different members of the body are first wrapped up in an impermeable cloth, so that the currents of damp hot air fall directly on the parts to be treated. The treatment lasts about twenty minutes. " The BerthoUet bath can also be taken in what is called a box-bath. The vapor comes under the box, so that the whole body, except the head, is submitted to the action of the heat. " To the BerthoUet is joined the humage. In the cabinet of 270 HYDROTHERAPY this name are placed four tamhours or cures, low down, furnished with flexible tubes. The patient himself directs the current of air saturated with vapor to his throat, his nostrils, his ears, his face, or his hands. '' The baths situated on the first floor are fed with cold and thermal water. Here the bathing is ])erfectly good and salutary. A certain number of the batlis arc^ connected with the douche cabinets, so that the bathing can be effected before or after the douche, ^\ithout dressing. '' The baths called refrigerating have eight cabinets in which baths may be taken in pure mineral water. The thermal water flows here as in all the other baths, but it is refrigerated gradually, and the cool temperature is due to a cool serpentine vessel through which the water passes before reaching the bath. This mineral- ization is employed in certain diathesique manifestations (morbid diathesis) and in dermatoses (skin diseases). " A small tube inserted in the tube of the thermal water serves to give the pressure 113° F. (45° C.) to the bath called irriga- tion. It is a mediate douche resembling the sous-niarine douche of Plombieres. The patient, after he has gotten into the bath, directs the water-jet upon his body or on the affected part, either in full jet or in part ; and, according to the layer of water between, the jet is more or less strong. The result of this simple process is wonderful. This last arrangement permits one to direct with great ease the mediate-jet on to the abdomen, and unites the effects of heat and gentle massage. " The piscines are fed by the same waters as the baths. The temperature is 95° F, (35° C). In two piscines the temperature is lowered to 86° F. (30° C.) from 10 to 11 o'clock in the morning. From a medical point of view, the piscine is very use- ful, as it permits the patients in certain cases (such as trauma- tism and arthritis) to move about in the water, movements which are otherwise difficult to make. The patient whose articulation has been immobilized is able to move about in the water because the water bears him up. He is thus able to re- educate the movement of his limbs, and he learns again to walk. Aix douche; massage douche 271 " The physiologic action of the thermal treatment at Aix re- sults from, or is caused by, many and divers agents. First, the physical and chemical factors are : the temperature of the water; its unctuousness; the abundance of the waters; a special electric action; its chemical composition, viz., its sulphurous contents. Second, factors resulting from the manner of applying the waters; massage; the mechanical action of the water; the action of the vapor or steam. Each of these various elements has its own peculiar action. The combination of these various pro- cedures produces different results. '' The greater number of those who come to Aix have pre- viously undergone various treatments, such as douches, baths, massage, and vapors. They come to ask and to look for a new treatment in the cure of Aix, which, happily, they find. This action is naturally complex. '' The treatment of Aix-les-Bains, as has been proved by ex- periment, lowers the arterial tension. The action of the treatment on the nervous syste?n is stimulating as well as sedative. The effect produced depends on the manner of applying the treat- ment; such as temperature, duration, and frequency of the operations. We can obtain very different results according to the method employed. The thermal fever which ancient authors were so pleased to describe was only the consequence of the thermal operations too warmly and too frequently applied. That thermal fever was but a result of excessive zeal. " Nourishment is influenced by the treatment, as urologic re- search has proved. The urine is rarefied and its toxic or poison- ous power is increased. Phosphoric acid and the mineral ele- ments generally are eliminated in smaller quantities; and at the same time we see the waste products of organic combustion, such as urea and uric acid, increase. In a word, the treatment has a mechanical action, both direct and indirect. The functions of the skin are stimulated by the flow to the periphery of blood, which is attracted by the warm water in contact with it; an abundant perspiration is produced, and an elimination is effected by this means. On the other hand, there is an acceleration of '>7) HYDUOTHKUAPY the lymphatic circulation which favors the resolution and re- sorption of the exudates, effusions, and periarticular dei)0sits. In a word, the diseased tissues tend to return to their normal eon( lition. *' Indications. — The detailed manner in which we have de- scribed the treatment at Aix, and its effects, will allow us to make a statement, rather than a long description, of the patho- logic conditions which may suitably be treated by the waters of Aix-les-Bains. " The indication of the treatment at Aix must be considered every time we wish to accelerate nutrition. We must distinguish the principal indications from the secondary ones. "The princii)al indications are: " Chronic rheumatism in all its forms. " Rheumatism which deforms or disfigures, to which we may add the rheumatic nodes of Ileberdon and the rheumatoid arthritis of the English. " Muscular pains, lumbago, torticollis, and the various pains often called muscular rheumatism. " The scffuehe of articular rheumatism, both acute and sub- acute, in all its forms. The seciuelic of the various conditions called infective rheumatism, " Gonorrheal rheumatism. " Asthenic gout. " Syphihs. " Every kind of neuralgia, and particularly sciatica. " Peripheral neuritis. " Chronic arthrites, joint stiffness, hydrarthroses, posttrau- matic, postarthrites. "Muscular atrophy consecutive to an inflammatory con- dition, a nervous affection, or trauma. " The consequences of phlebitis. " In addition to those affections the treatment of Aix can ameliorate other states of illness (secondary indications) con- nected with nutrition, but the indication is then less absolute. Massage in conjunction with the douche suits certain cases of Aix douche; massage douche 273 obesity, diabetic arthritis, and eczemas connected with the arthritic state. Hydrotherapy may be applied with benefit in most nervous affections. Many uterine maladies are re- lieved by copious irrigations, and the lavage is attended with great success in cases of mucomembranous enteritis. " Coimterindications. — No invalid ought to undergo the ther- mal treatment during or while just recovering from an acute at- tack of illness. This is one of the main counterindications for the use of the treatment. Tuberculosis and serious liver and kidney complaints are obstacles to the thermal treatment. Compensated valvular lesions of the heart (rheumatic endocarditis) can derive benefit from the treatment if well looked after. But all the other cardiac complaints must abstain completely. As to cases of arteriosclerosis, the cure of Aix is not denied them; only they must be well looked after by the doctore, who should exer- cise judgment and tact wliile having full control over the treat- ment. " Treatment of Syphilis. — The thermal treatment of Aix-les- Bains is perfectly suitable for the cure of syphihs. The sulphura- tion of the water in itself constitutes a specific medication. It is certain that the douche combined with massage is a valuable auxiliary to the iodid and mercurial medication. The thermal treatment acts, in the first place, by its tonic effect; second, by aiding the absorptive and ehminating functions of the skin; third, by stimulating metaboKsm. It also favors the passage of medicaments through the organism by the successive forma- tion of different albuminomercurials (by the absorption of the iodomercurial preparations and the elimination of the waste products). Thus the patient, a prey to an enfeebling and de- pressing malady, sees an amelioration of his general condition. He can also, without fear of accident, absorb a larger dose of the specific medicament, which, passing tlirough the organism, acts potently. " At Aix-les-Bains a specific cure for patients can be adminis- tered at different periods of the illness : old and new lesions, and most often tertiary lesions, are continually treated here. Inunc- .18 274 HVDROTHEUAPY tion of large doses is often prescribed; we prefer, however, in- jections of soluble mercurial salts. For all these patients the douche of Aix-les-Bains, with the bouillon, the vapor baths, and the profuse sweats which icsuit thcrcfroin, help the action of this si)ecific medication, and allow of the continuous administra- tion of a sufficient dose. This medication, more than any other, requires an attentive medical attendance. ** Zander Method. — The department of Mechanical Therapeu- tics is installed in a special pavilion, named the Vjiinder Institute. l,c:i\iii<; till- r)aliis, Aix-lcs-Haiiis. The Zander method consists in the use of the medical gymnastics devised by Ling, for which purpose mechanical apimratus is employed. Its principle is to graduate and localize the move- ments, to move each joint singly, to exercise each group of muscles one after the other, while measuring exactly the extent of each movement, and the energy of each and every effort. " In the Zander method the resistance to be overcome by the patient's effort (which resistance is represented by the gymnast's hand) consists in a graduated lever upon which a weight can be Aix douche; massage douche 275 moved. Compared with ordinary bodily exercise, such as sports or gymnastics, the mechanotherapeutic method offers many advantages, as it divides the work and diminishes the efforts. In the first, place, during the movement the resistance accom- modates itself to the natural variations of the result of muscular contraction; second, the energy of the movement is measured exactly; third, the resistance to be overcome remains fixed. It is possible to modify with exactness the energy of the move- .4a *-tS i 3^P 1 Fig. 73.— The Aix douche (Luke) ment, increasing or diminishing it, as the case may be. Different kinds of apparatus have been constructed, some for active movements, some for passive movements. Some of the appli- ances are made for mechanical procedures, such as vibrations, percussion, and kneading; others are orthopedic instruments. In the case of all these different appliances the doctor is sure to exercise the right muscles and not to touch the others; that is, he is sure not to touch those unaffected. He knows how to apply that amount of exercise which his experience has shown 27G HYDROTHERAPY him to be the most useful; not to give more than is needed, and yet not to fall short of what is required.'" ' A modified Aix douche is sometimes giv(>n with only one attendant (see page 275). VICHY DOUCHE The \'ichy dout-lie resembles the Aix douche. The patient lies in a recumbent iwsition on an india-rubber air mattress, while ma.ssage is administered under a spray douche descending Fig. 74. — Pj)t-cial douche-massage chair, allowing complete relaxation (bath) (Luke). vertically from three " roses " about 2 feet above the patient. This douche is often preceded by a steam or hot-air bath to induce free perspiration. After the Vichy douche is applied for twenty minutes the circular douche or needle douche is given as a terminal measure. COMBINED BATH, DOUCHE, AND MASSAGE At Buxton, England, a combined bath, douche, and massage are given. The illustration shows a patient recHning in a shallow 1 A complete equipment of the Zander apparatus is installed at the Massa- chusetts General Hospital, Boston, and has been purchased for use at the Virginia Hot Springs. COMBINED BATH, DOUCHE, AND MASSAGE 277 tub, at a convenient height for the attendant, who applies the douche with massage. The partial immersion bath has a temperature of 94° to 100° F. (34.4°-37.8° C). The indirect or undercurrent douche has a sli htly higher temperature than the bath tself. Its temperature ranges from 98° to 104° F. (36.7°-40° C), and the pressure about 15 pounds to the square inch. The caliber of this douche is from ^ to -^q- inch. It is applied during the last three to five minutes of the bath to tender joints, or any affected part by holding the nozzle Fig. 75. — Buxton massage and douche bath. This bath is filled with water at 94° to 100° F. (34.4°-37.8° C). The patient is getting a partial immersion bath as well as douche massage. at a variable distance, allowing the intervening water of the bath to break the force of the douche and distribute it over a greater or less area. As the affected portion improves, the direct douche may be substituted for the undercurrent method. The douche massage, as applied at Aix, Vichy, or Buxton, is very valuable in the treatment of chronic rheumatism, gout with arthritis, also chronic muscular rheumatism. In cases of obstinate atonic constipation special attention should be given to the liver, abdominal muscles, and colon. 278 hydrothp:rapy PERCUSSION DOUCHE In this douche, air ami water, under liigh pressure, are de- livered from an apparatus with a special nozzle. The stream of water is broken by the contained air, and the effect is to intensify the mechanical element of the douche. It has a highly stinmlating effect, and is useful in \isceral anemias and constipation. THE PAIL DOUCHE OR PAIL-POUR This has been referred to as a final douche in the half-bath. The water is applied in considerable quantity a few feet above Fig. 76. — Rain and circular (needle) douche (Gant). THE PAIL DOUCHE OR PAIL-POUR 279 the bather and permitted to fall on the shoulders and back (Fig. 77). It may be at any temperature desired. It unites with the thermic action of the water a mechanical effec in ac- Fig. 77. — Pail douche (Gant). cordance with the height or force with which it is applied; it is a stimulating measure. One or two pails of water are usually sufficient. 280 HYDROTHERAPY HOT LUMBAR DOUCHE A wonderful differentiation of douches has been attempted, designated as Plombifere, Charcot, Fleury, spinal, lumbar, tho- racic, shoulder, abdominal, sternal, epigastric, hepatic, renal, splenic, plantar douches, and so on. The hot lumbar douche may be used in treating lumbago. Claims are made that the douche over the hepatic region, at a pressure of 15 to 20 pounds and at a temperature of G5° to 75° F. (18.3°-23.9 C.) for five or ten minutes, may relieve congestion. One of the patterns of sitz bath-tubs is provided with perforations, giving a needle spray directly over the liver when the patient is seated. In this way the temperatures and pressures may be nicely adjusted. In cases of chronic enlargement of the liver the temperature should alternate between 105° and 70° F. (40.6° and 21.1° C); in acute congestion only the higher temperature should be used. In hepatic colic alternating temperatures may be given; but in severe cases probably better results will be obtained by the use of hot compresses, frequently repeated. FLEURY DOUCHE In using this douche, first a rapid general high-pressure appli- cation of cold water, 65° or 70° F. (18.3° or 21.1° C), is made; then a strong jet at the same temperature is directed over the liver area for from ten seconds to one minute. This is followed by a shower on the epigastrium and warm water on the feet. Professors Raymond and Duchennc, of Paris, finding that this douche is not well tolerated and frequently harmful, have modified it, beginning with warm or hot water, 100° to 113° F. (37.8°-45°C.). They advise the following technic: Begin with 100° to 102° F. f37.8°-38.9° C); raise progres- sively to 113° F. (45° C), at the same time increasing the strength of the jot. Keep at 113° F. (45° C.) until the skin becomes dark red — one-half to one minute — and then give a general cold or lukewarm douche. This is essentially an hepatic douche. It yields excellent results in hepatic congestion, hyper- THE CONTROL TABLE 281 trophy, and biliary stasis; also in alcoholism, dyspepsia, chronic jaundice, etc.^ Chronic malarial disease affecting the spleen and acute and chronic nephritis call for similar treatment. Renal calculus may be treated by very hot douches or compresses over the lumbar region. Every practitioner has seen good results from these measures. The author has never used a cold douche over the kidney, although it is claimed that it stimulates the flow of urine and relieves congestion. That the kidney can be reflexly stimu- lated by prolonged cold applications to the lower sternum is claimed by Beni-Barde (Kellogg). The small renal vessels are contracted, the pressure rises in the glomerules, and the urinary flow is stimulated. The author is not aware that clinical evi- dence supports this view, although it appears to be a rational procedure! Good results from these douches are obtained in the treatment of chronic rheumatism, gout, and in arthritis deformans. Exu- dates or articular swellings respond to this form of hydrotherapy in connection with tub-baths, warm packs, and massage. The douche should be above the body temperature, and may be continued for five to ten minutes at a pressure of 12 to 18 pounds to the square inch As usually given by the author the temperature used is 104° F. 40° C.) at the pressures stated. It is an excellent preliminary to a tub-bath of eight, ten, or twelve minutes at the same temperature and undoubtedly facilitates the action of the hot dry pack This is one of the features of the treatment of rheumatism and gout at the Virginia Hot Springs, wher^ the thermal waters have the required tempera- ture and where a constant pressure is supplied by gravity. THE CONTROL TABLE The control table, which has been perfected by various makers, is a most convenient apparatus for administering all forms of douches at various pressures and at easily adjustable ^ Journal de Physiotherapie, July 15, 1906. 282 HYDROTHERAPY temperatures (Figs. 78-80). Tlic fittings are enclosed in a marble case. On the side where the operator stands are valves for controlling the pressure and for admitting and emptying the pipes which are enclosed. On top are the valves which control the various outlets, the jet douches, the circular douche emerging from the uprights as seen in the background, FifT. 78. — Hydriatio control tabic with polished Italian marble f-^^" ■ Fig. 96. — Hot-air cabinet bath: steam radiation. plates or in dishes to prevent wetting the bed, and care be taken not to burn the bather. The bather may also be seated on a cane-bottom chair, the clothing being removed, and sur- rounded with blankets or comfortables, which must be fastened from the neck down (Fig. 96). A kettle of boiling water over a spirit-lamp or an oil-stove, or a pan or pail of boiling water, is placed under the chair. The feet may be put into a pail of hot water to increase the effect, because the blood-vessels of the surface of the body are dilated, and remain so while the heat or 304 HYDHOTHEUAPY vapor is continued; in this way the activity of the skin is in- creased, the pores of the skin are opened, and perspiration is produced. The attendant shoukl be sure that the bkankets or coverings are fastened closely around the neck and about Fig. 97. — Hot-air or .steam cabinet (.T. L. Mott Iron Works). the chair to prevent the steam escaping. The bather may gen- erally be allowed to have plenty of water to drink. THE ROMAN BATH This bath is simply an appUcation of massage with the use of unguents, either with or without the Turkish bath. An Irish -Roman bath depends entirely on dry hot air and the consequent induction of free perspiration. There is usually a series of rooms heated to various degrees of temperature. The anteroom is at the ordinary temperature, e. g'., 66° to 68° F. (18.9°-20° C), and the communicating rooms are at 95° to 104° F. (35°-40° C). The next room is at 113° to 122° F. (45°-50° C.) and the fourth room at 149° to 194° F. (65°-90° C). The bather is covered only with a bath-robe and wears sandals to THE HOT-AIR BATH AND THE ELECTRIC-LIGHT BATH 305 protect his feet from the hot floor. Sweating usually takes place freely before reaching the last room. This form of bath is decidedly inferior to the use of the hot-air or electric-hght cabinet. Give plenty of water to drink. THE HOT-AIR BATH AND THE ELECTRIC-LIGHT BATH These are used as a preliminary treatment before applying douches. The entire body, with the exception of the head, is enclosed in a cabinet provided with steam coils or electric lights. Fig. 98. — Electric-light bath cabinet, open; seventy-two 16-candIepower lamps (Max J. Walter). The head should have a cold turban and the body may be sur- rounded with a sheet or not, as desired. The heat in these cabinets rises to 140° to 180° F. ('60°-82.2° C.) and, as a rule, free perspiration is produced in seven to twelve minutes. If electric bulbs are used perspiration usually results in less time than with steam radiation, provided the heat is the same. 20 300 HYDROTHERAPY "The superiority of the hot-air cabinet over tlic ordinary Turkish bath is evident. The patient is surrounded by liot air in the cabinet and, the head being free, he breathes cooler air. Not only is he thus enabled to bear higher temperatures, but he is free from dyspnea, which is so distressing to many in the hot-air chamber of the Turkisli l)ath, and which is doubtless due to a defective supply of oxygen; the latter, being expanded by heat, is not breathed in sufficient fjuantity to fulfil its physi- Fig. 99.— Electric-light cabinet (J. L. Mott Iron Works). ologic function. If oxidation be the chief object of the hot- air bath, the cabinet bath must be far superior to the Turkish bath, because it permits a more abundant supply of oxygen as regards the temperature, and thus facilitates oxidation. Besides, the patient is not subjected to the admixture of emana- tions from the large number of persons who often occupy the hot-air chamber simultaneously in the Turkish bath establish- ments."^ Advantages of the Electric-light Cabinet Over that Heated ^Baxuch, Hydrotherapy. THE HOT-AIR BATH AND THE ELECTEIC-LIGHT BATH 307 by Steam Coils. — The electric-light cabinet is safer, quicker in action, and probably has a greater and more beneficial effect on the underlying tissues. The author has known an instance in which the steam coil burst, and if anyone had been in the cabinet at the time serious injury would have resulted. We would never have believed such an accident possible unless from per- sonal observation. The steam was turned on under high pres- sure into a coil which was not known to be defective, but was supplied by a well-known manufacturer. It is common observation, but not always true, that perspira- tion ensues in an electric-Ught cabinet more quickly than in the hot-air cabinet. The well-known penetrating quality of the electric-light rays probably aids metabolic processes in the deeper structures. Dr. Peck states this proposition as follows: ''These conclusions seem to be well founded when one stops to consider the physical properties of the tw^o agents. In one case the body is heated by a process of convection, successive layers of tissue being heated until the body temperature is raised 1 or 2 degrees; while, on the other hand, the light and heat rays, which are closely related in physical properties to sunlight rays, penetrate directly the tissues and produce their effects upon the metabolic processes by directly stimulating the normal body activities. We are coming more and more to believe that these metabolic processes are carried on through the intervention of certain enzymes or ferments, and exposing the body to the electric-light rays apparently stimulates these fermentative processes to more normal activity." ^ The same conclusions would be true of cabinets fitted with incandescent or electric arc lights. It is interesting, historically, to note that Aretseus was the first to recommend that the head should be excluded in giving vapor baths; and it was he who advised sulphur baths for the cure of melancholy and leprosy. ^ Yale Medical Journal, May, 1909. 308 HYDROTHERAPY FOOT-BATH The hot foot-batli is the best and most important of the local baths. It is a popular method of treating a cold in its earliest stnee and is a valuable preventive measure.' Hot water and a small tub or pail and an additional supply of very hot water to reinforce the heat of the bath are the only means retiuired; although it may be desirable in some cases to add a little mustard so as to invite the flow of blood to the feet and ankles. The temperature of the water may be grad- ually raised to 110°, 115°, or 120° F. (43.3°, 46.1°, or 48.9° C.) and the duration may be from ten to fifteen minutes. The depth of the water may be 8 or 10 inches. It is a proper pro- cedure after the initial chill of pneu- monia. In this case mustard should be added to the bath, which should be given in bed (see p. 106). Sprains of the ankle or foot, bruises, cramps in the legs, etc., are not only rendered much less painful by a hot local bath, but the way is prepared for massage and permanent dressings. Fig. 100.— The leg-bath (Luke). MEDICATED OR MODIFIED BATHS Sulphur baths may be prepared at home according to the following formula, which is sufficient for a bath of 30 gallons : Precipitated sulphur 2 ounces. Sodium hyposulpliitc 1 ounce. Dilute sulphuric acid J " Water 1 pint. The above ingredients should be mixed together and then added to the bath. Warm Mustard Bath. — A modification of this bath has re- MEDICATED OR MODIFIED BATHS 309 cently been recommended by 0. Heubner/ who has used it with great success in the capillary bronchitis of young children and in the suffocative attacks which are marked in weak rachitic children. About 3 pints of warm water are placed in an open vessel and 1 pound of mustard meal is added and stirred until the thin mixture emits the irritating fumes which cause smarting of the eyes. Then a Unen cloth, of sufficient length to cover the child, is saturated with the mixture and wrapped about the child, who is then covered with a woolen blanket reaching to the neck. After ten or fifteen minutes the child will complain of discomfort, and as the wrappings are removed the skin shows marked reddening. The child is then washed in warm water and placed in an ordinary warm wet pack and allowed to remain for one or two hours. This produces diapho- resis. After the pack the child is put in a warm bath which is gradually cooled. He is dried and allowed to remain quiet the remainder of the day. One advantage of this method is that the irritating fumes of the mustard are not inhaled and that the reaction is more perfect. A simple form of mustard bath is composed of potassium sulphid 1 ounce to 7 gallons of hot water. An alkaline bath may be made by adding 1 ounce of sodium bicarbonate to every 5 gallons pf water. Pine-needle Bath. — This may be used with the vapor cabinet. An ounce of pine-needle oil (oleum pini sylvestris) is placed in the vapor pan with 3 ounces of water. The patient is then steamed for twenty or thirty minutes in the cabinet; during this time perspiration is profuse. Afterward massage may be given. Baths may be medicated with pine-needle extract, 2 ounces to 40 gallons.^ * Therapie der Gegenwart, January, 1905. ^ Langbein's coniferol tablets may be obtained of the Hygienic Resorts Bureau, Chancery Lane, W. London. See also under Dr. Zucker's Carbon- ated Bath, p. 313. 310 HYDROTHERAPY "NAUHEIM^ BATHS; CARBONATED BATHS; ACID BATHS (KISCH); EFFERVESCING BATHS The Nauheim bath depends on the presence of carbon dioxid with other chemicals, principally sodium chlorid and calcium chlorid, in various degrees of solution. The natural baths are given par excellence at Bad Nauheim in tlic Grand Duchy of Hesse, near Frankfort, in Germany, near the southern foot of the Taunus Mountains. (See pages 134 and 221.) The growing popularity of Nauheim is shown by the presence of 30,000 visitors in 1907,' but the greatest tribute to their efficacy is a widespread effort to prepare these baths artificialh'' and a^•oid the long journey to Nauheim. The class of cases for which the treatment is sought renders it all the more desirable that the forms of treatment practised at Nauheim be provided, if pos- sible, at home. The season at Nauheim is from May 15 to October 1. During hot weather patients can, as a rule, take a bath at a lower tem- perature than when it is cold ; they can also take an effervescing bath at a lower temperature than a bath in still water, the presence of carbonic acid gas counteracting the feeling of cold, yet not interfering with the circulatory reaction as in the case of still water at a corresponding temperature. Dr. Thorne usually lets the patient have a hot-water bottle in bed after the bath unless the weather should be very warm. If, how- ever, the patient still does not remain comfortably warm, he regards it as an indication for raising the temperature of the bath. It is noted that a bath which would produce coldness and cj'^anosis of the extremities at the commencement of the course is usually productive of a sense of warmth and comfort, and a marked improvement of color toward the end of the treat- ment ; this is evidence of improved reaction and circulation. If patients have rigors, the baths are too long or too strong or perhaps they should be suspended. These rigors may occur even when the extremities are warm and of good color. 1 In 1907 419,277 baths were given. In 1909 about 35,000 visitors were recorded. ARTIFICIAL NAUHEIM BATHS 311 If they occur at the outset, they will probably decrease as suc- cessive baths are given, and are not always a serious indication. Aside from the associated forms of treatment, such as re- sisted (Schott) movements, graded walks, diet regulations, and the benefits of climate, the baths are given at Nauheim accord- ing to a gradual increase in strength as regards solid and gaseous contents; this is a distinguishing feature. The temperature of the three springs used at Nauheim are 85° F. (29.4° C), 90° F. (32.2° C), and 95° F. (35° C). The duration of the baths is short, four to ten minutes as a rule. The three types of baths are as follows : ^ The first and mildest type, the so-called thermal baths, are obtained by admitting the water to large reservoirs, where in contact with the atmosphere the CO, escapes and the calcium and iron salts precipitate. These salts color the water yellowish brown. The second type, containing a little moreCOa, is the thermal sprudel hath, and is obtained by conducting water to subterranean air-tight tanks, from which it is conveyed to bathing tubs. This water is clear or slightly yellow, having lost but a proportion of its CO^. The third grade, or effervescing type, is known as the sprudel haths, and contain the full amount of COj. In their natural state the waters contain from 550 to 1300 cc. of CO2 to the liter, but, of course, much of this instantly escapes as soon as the water reaches the tub. These baths are strongly effervescing, bright, sparkling, and clear as crystal. Clear brine baths, containing 3 per cent, of chlorids and no gas, are also used. ARTIFICIAL NAUHEIM BATHS These are quite extensively used and some advantages are claimed by those who have taken the trouble to apply them in selected cases according to a definite scheme of graduation. In ^ See description by Paul C. Franze, M. D., in an address before the Hun- terian Society of London, March 23, 1904. Also article on Bad Nauheim, by J. H. Honan, M. D., Illinois Medical Jour., April, 1910. 312 HYDROTHERAPY America, Dr. Thomas E. Satterthwaite and Dr. C. N. B. Camac, of New York,' and Dr. J. M. Anders, Dr. S. Solis Colien, and Dr. James- Tyson, of Philadelphia,^ and Dr. Philip K. Brown, of San Francisco,^ have endeavoretl to place tliis form of treat- ment on a tlefinite and effective basis. The necessary salts can be obtained in the most convenient form from several manu- facturers and the use of cakes of acid sodium sulphate as furnished by them is far j^referable to the hydrochloric acid wliich was previously used for the acid element in the bath. The latter is liable to destroy the tubs and injure the patient. It further- more yields a very uneven effervescence and is hard to regulate.* The box of the Cassebeer Co. contains 8 disks of acid sodium sul- phate each of 1] lbs., wrapped in heavy lead foil, and four 2-lb. packages of sodium bicarbonate. The method of preparing the bath is as follows : Fill a porcelain or enameled tub with 50 gallons of water at 105° F. (40.6° C). The required amount of bathing salt is then added. This, in an ordinary Nauheim bath, should consist of from 2 to 3| per cent, of a mixture of sodium chlorid and calcium chlorid. In the stronger baths the imported concen- trated salts, the Mutterlauge of Nauheim, is added to this mixture. It contains about 75 per cent, of calcium chlorid and may be added to the bath at about the middle of the course. This Mut- terlauge is not a natural ingredient of any of the springs except- ^ International Clinics, vol. i, Thirteenth Series, 1903. "Trans. Philadelphia County Medical Society, January 31, 1905. 3 California State Journal of Medicine, April 1, 1907. * Standard packages containing cakes of acid sodium sulphate and pack- ages of sodium bicarbonate are supplied by the Shepard Pharmacal Co., 275 Water Street, New York, and Schieffelin & Co., New York. If the prepared salts are not accessible, the elements may be prepared as follows: Take sodium carbonate, l\ lbs.; sodium bicarbonate, J lb.; calcium chlorid, 3 lbs.; sodium chlorid, 2 lbs. Mix and dis.'^ohe in the bath and add slowly the sodium bisulphate, 1 lb., which should be kept by itself. This gives a bath of moderate strength. In order to avoid the objectionable features of acid sodic sulphate vise is made of a solution of formic acid. " Dr. Zucker's carbonated bath" and the "ZeO, bath" depend on the action of formic acid on sodium bicarbonate (see p. 314). Tlie author prefers "Dr. Zucker's bath " to any of the others. Tiiis batli cannot corrode tubs or fixtures. ARTIFICIAL NAUHEIM BATHS 313 ing to a very small extent, but is a by-product of neighboring chemical works and is used at Nauheim to stimulate the skin and increase and prolong the effect of the carbonic acid gas effervescence. Th attendants and the patients themselves duly value this addition to the bath. It is quite extensively exported from Nauheim for use where artificial Nauheim baths are given. The artificial package is generally faulty in wholly omitting both calcium chlorid and sodium chlorid, although the latter can easily be obtained. The reason they are omitted is on account of the additional weight of the common salt and the additional cost of calcium chlorid and magnesium chlorid. The calcium chlorid is difficult to handle in a solid form on account of its irritating qualities and its strong affinity for water. The acid sodium sulphate likewise must be kept in a very dry place, otherwise it is sure to crumble, the free sulphuric acid eating its way through the container, ruining the soda or other neighboring objects. Naturally the efficiency of the bath cannot be insured with deteriorated contents. Precautions. — ^The Triton Co. offers the following precau- tions as to the hath-tuh: In order to prevent any injury to the bath-tub by contact with the acid cakes there are three methods of procedure : First, allow each cake to rest on the lead foil pro- vided in the boxes; second, use three or four ordinary saucers and place the cakes on them; third, use a piece of rubber sheeting sufficient to cover the bottom of the bath-tub and put the cakes on the sheeting. The use of the rubber sheeting is advised as the most efficient and reliable method of protection. Always allow the cakes to dissolve entirely before drawing off the water from the tub. The water is alkaline and will not injure the drain-pipes. Dr. Zucker's Carbonated Bath. — Under this name packages have been prepared by Max Elb, of Dresden, Germany, and introduced into the United States and England. This process of preparing artificial carbonic acid baths depends on the use of formic acid in solution and bicarbonate of soda enclosed in 314 HYDROTHERAPY gauze bags. A sufficient quantity of SO per cent, commercial formic acid in a i)int bottle is poured into a bath of 40 gallons of water at 95° F. (35° C), The patient enters the bath and during the first half of the allotted time gently applies the bags or cushions containing the sodium bicarbonate to the trunk and limbs. Carbonic acid gas is immediately generated in the neighborhood of the alkali and soon permeates the entire bath. During the latter half of the bath, which is intended to occupy in its entire duration from fifteen to thirty minutes, the subject should rest quietly and allow the entire body below the neck to be subject to the action of the contained gas. To render this package complete, 3 or 4 pounds of common salt and 3 or 4 ounces of calcium chlorid should be added. The formic acid supplied was analyzed by the author and found to be of specific gravity 1.18 and free from hydrochloric acid. These baths are furnished in five forms : The single carbonic acid bath; the carbonic acid chalybeate bath; carbonic acid bath with pine-needle extract; chalybeate with pine-needle extract; with various aromatic herbs, essences, and extracts, such as lavender, chamomile, thyme, sage, etc.; 15 minims of an ethereal oil or from 2 to 4 ounces of an alcoholic extract are sufficient for a bath.^ The author tested this bath, and found no unpleasant effects * Descriptions of these baths and their physiologic action may be found in the following references: Deutsche medicinische Wochenschrift, No. 3, 1905, p. 107; Miinchner medicinische Wochenschrift, No. 5, 1905, p. 236; Medicinische Klinik, Heft 9, 1905, p. 273; Pharmaceuti.sche Centralhalle, vol. V, January, 1905, p. 5; Pharmaceutische Zeitung, vol xi, January, 1905, p. 30; Neueste Erfindungen und Erfahrungen, part 3, Heft, 1905, p. 127; Siid- deutsche Apotheker-Zeitung, vol xvii, February, 1905, p. 112; Pharmaceu- tische Zeitung, vol. xxv, February, 1905, p. 167; Die medicinische Woche, No. 11, vol. xiii, March, 1905, p. 87; Medico, No. 4, 1905, p. 62; Zeitschrift fur Krankenpflege, February, 1905, p. 72; Zeitschrift fur Krankenpflege, October, 1906, p. 397; Deutsche Aerzte-Zeitung, No. 23, vol. 1, December, 1907; Russische Medicinische Rund.schau, No. 5, 1907; Therapeuti.sche Rundschau, No. 3, January, 1908; Herman C. Riggs, Medical Times, April, 1910. In the United States the packages may be obtained of George B. Evans, Philadelphia, and The Smith, Kline and French Co., 429 Arch Street, Phila- delphia. ARTIFICIAL NAUHEIM BATHS 315 on the skin and no injury to a porcelain tub. An agreeable stimulation and slight reddening of the skin was noted. In Great Britain packages known as Sandow's and the Croyden are used. The former contain 4 packets of sodium bicarbonate and 8 tablets of acid sodium sulphate. They are prepared so that 8 parts of the sodium bicarbonate exactly Fig. 101. — The Fischer-Kiefer COj generator for Nauheim bath (Luke). neutralize 12 parts of the acid sodium sulphate. The alkali should be a little in excess. Apparatus for generating carbonic acid gas and mixing it with the water have been devised; one of the best is probably that known as the Fischer-Kiefer Company's generator and is made in Zurich (Fig. 101). Similar apparatus is made by the Electritats gesellschaft Sanitas, Friedrich Strasse, 131 d.; Berlin, 316 HYDROTHERAPY N. (Fig. 102). Another is made by the Kny-Scheerer Co., of New York (Fig. 103). If sea-water be accessible, it may be used for the artificial Nauheim bath Besides the chlorids, sea-water contains bromids, both of which add to the efficacy of the bath. At the Hotel Chamberlin, at Fortress Monroe, N'irginia, sea-water is thus ! '■ ^ — Fig. 102. — Carbonic acid apparatus. Fig. 103. — Carbonic acid gas mixing device for Nauheim baths. utilized and the carbonic acid gas under pressure is thoroughly mixed with the water by means of an electrically driven ap- paratus. Satterthwaite Method of Giving Nauheim Baths. — Dr. Sat- terthwaite has formulated an excellent scheme for the six weeks' course of 35 graduated baths which will prove useful in practice : ARTIFICIAL NAUHEIM BATHS 317 First week (No. 1 hath), J per cent, plain warm salt bath (2 pounds of bathing salt to 50 gallons of warm water). Tem- perature 98° F. (36.7° C). Duration four minutes. Intermis- sion on the third and sixth days of this week. Second week (No. ^ bath), f per cent, warm salt bath (3 pounds of bathing salt to 50 gallons). Carbonic acid gas | per cent. (2 disks acid sodium sulphate to 1 package, 2 pounds sodium bicarbonate). Temperature 97° F. (36.1° C). Duration six minutes. Intermission on the fourth day of this week. Third week (No. 3 bath), 1 per cent, warm salt bath (4 pounds of bathing salt to 50 gallons). Temperature 96° F. (35.6° C). Carbonic acid gas J per cent. (4 disks in 2 packages). Duration eight minutes. Intermission on the fourth day. Fourth week (No. 4- bath), 1\ per cent, warm salt bath (5 pounds bathing salt to 50 gallons). Nauheim concentrated brine salt (Miitterlauge salts), 8 ounces, or h pint of the liquid salts, CO2 f per cent. (6 discs to 3 packages). Temperature 95° F. (35° C). Duration ten minutes. Intermission on the fourth clay. Fifth week (No. 5 bath), Ih per cent, warm salt bath (7 pounds bathing salt to 50 gallons). Miitterlauge salts, f pint; CO2, I per cent. (6 disks to 3 packages). Temperature 94° F. (34.4° C). Duration twelve minutes. Intermission on the fifth day. Sixth iveek (No. 6 bath), 2 per cent, warm salt bath (10 pounds of bathing salt to 50 gallons). Miitterlauge, 1 pint; CO2 1 per cent. (8 disks to 4 packages). Temperature 93° F. (33.9° C). Duration fourteen minutes. Intermission on the fifth day. In the case of robust people we may commence with No. 2 bath, or in the case of a dehcate person it may be best not to exceed the strength of No. 4 bath. In preparing the bath the best way is to draw about 20 gallons of hot water in the tub. A tub 5 feet long will then be filled to a depth of 6 inches. The sodium chlorid is then dis- 318 HYDROTHERAPY solved and well distributed, and if the Miitterlauge is to be used it is thoroughly diffused through the bath. If cakes of acid sul- phate are to be used they are now broken with a hammer and laid on the accompanying lead foil, and the bicarbonate is laid on top, 2 disks to 1 package. The water is now drawn in the bath so that the 50 gallons shall have a temperature as designated, 98° F. (36.7° C.) for No. 1 bath, or 93° F. (33.9° C.) for No. 6 bath. The alkaline and acid salts are then lowered on their leaden foils at places along the bottom of the tub. Effervescence begins at once and may take eight or ten minutes for completion. It is best to start with water a little above the requisite tem- perature to allow for cooling, and the lead and any undissolved sulphate should be removed before the patient enters. If for- mic acid is used, as described on pages 313 and 314, the prep- aration of the bath is simpler. Massage may be employed in the bath, after which the patient is carefully dried with warm towels and put to bed, or the patient should rest at least for an hour. The effect of the baths at Naulieim and of the artificial baths is principally on the heart and blood-vessels. The resistance movements which have been systematized by Professor Theo- dore Schott and his brother, the late Dr. August Schott, are con- sidered by many an essential feature of the treatment and are most thoroughly carried out at Nauheim, supplemented by the terrain km, or graduated walks on the hillside (Oertel System). The immediate effect of the first bath is a diminished pulse- rate, intensified heart sounds, and in a case of extreme cardiac dilatation, probably a reduction of the size of the heart and its cavities. This has been noted by competent observers after a single bath. While this is not always maintained, each suc- ceeding bath leaves the organ a little smaller than in the pre- vious one, and thus compensation is finally restored, in most cases at least. The effect of carbonated baths on an intermittent heart, with palpitation following severe diphtheria and augmented by tobacco, constitutes the subject of an interesting personal ob- ARTIFICIAL NAUHEIM BATHS 319 servation by Dr. Philip King Brown. At the time the baths were begun the patient was thirty-six years of age and tobacco had not been used for a month. The heart, nevertheless, was omitting every third or fourth beat and the rate was between 90 and 100. The blood-pressure was 120 with Stanton's sphyg- momanometer. Two courses of Nauheim baths were given, with 20 in each series, and a ten days' intermission between them. In the first series resisted movements followed the baths for twenty minutes. In the second series they preceded the baths. After the first five baths the heart would frequently beat fifty or sixty times without any intermission. The rate for some hours after treatment fell 15 to 20 beats, reaching normal at the end of the fifth bath. From that time on the pulse varied from 72 to 80, being brought down sometimes to 68 after treat- ment. The second series of baths was carried out to study the effect of movements given before the baths. In this particular instance it was shown that resisted move- ments had the same effect as the bath, but on evenings when they were not followed by the bath the effect was not as lasting by several hours. It was noted that exhaustion after work which preceded the first baths and which began to show itself after the first series, was definitely relieved after the second series. Dr. Brown has also studied in his own person the effect of the various elements of the Nauheim bath and has furnished the mean of the observations made during two years. A fifteen- minute warm bath, 94° to 98° F. (34.4-36.7° C), lowered the pressure on an average of 15 mm.; pulse-rate varies little or nothing. A fifteen-minute strong NaCl bath, 7 pounds to 40 gallons, 94° to 98° F. (34.4°-36.7° C), lowered the pressure 10 to 15 mm.; the pulse may be slightly slowed. A fifteen-minute calcium-chlorid bath, IJ pounds to 40 gallons, 94° F. (34.4° C.) temperature, raised the pressure 15 mm. This is true even if the pressure has been raised already by food taken a short interval before. . A fifteen-minute mustard bath, IJ pounds to 40 gallons, 320 HYDROTHERAPY 94° F. (34.4° C), had the same effect as a warm bath, lowering the pressure 15 mm., without altering the i)ulse. The skin was scarcely reddenetl. Three pounds of mustard in a bath of 94° F. (34.4° C.) tem- perature, given for ten minutes, or the weaker mustard bath, with vigorous friction applied to the skin, has the effect of raising the pressure, and reddening the skin markedly for an hour or more. A fifteen-minute full strength, alkaline effer- vescent Nauheim bath at 86° to 94° F. (30°-34.4° C), raised the pressure rapidly during the first half of the bath, and more slowly during the last half, making it altogether about 20 mm. This effect lasts during the daytime about four hours. When the bath is taken at night, 11 p. m., the pressure on the following morning at 7 a. m. is not as low as normal by 5 to 10 mm., show- ing that the usual drop through the sleeping hours is not as marked as is normal. Dr. Brown records several cases of fatty infiltration of the heart with obesity successfully treated by Nauheim baths and the von Noorden anti-obesity tliet. Regime at Nauheim. — At Nauheim the patient is usually up at 6.30 or 7 a. m. and as soon as dressed starts for the springs to drink the water. After al)out an hour he returns for breakfast, rests an hour or more, and then goes out again for his bath. He returns to his hotel and rests for another hour in bed or until nearly lunch time. In the afternoon he drives or takes other outdoor exercise, according to the advice of his physician, but the rest in bod forms a large part of the usual routine of treatment.' (See p. 133.) The Effect of Hot and Cold Baths on the Size of the Heart.— Since Moritz- introduced the method of measuring the dimen- sions of the heart by means of the orthodiagraph comparative measurements arc for the first time possible, and, in competent ' In London artificial Nauheim baths are provided at The St. George's Nauheim Institute, 6 George Street, Hanover Square, W.; in Boston and Philadelphia, at the Medical Baths; and at various Medical Baths or Hydri- atric Institutes in Boston, New York. Pliiladelphia, Chicago, and other ciiies. 2 Miinchener Med. Woch., 1900, No. 29. ARTIFICIAL NAUHEIM BATHS 321 hands, it would seem to be a fairly precise instrument.^ The original model has been greatly improved by Hoffmann, Lev}^- Dorn, and Groedel.^ There are very few of these instruments in the United States. The x-Tay tube and the sheet of paper for marking the cardiac boundaries are attached to movable arms acting at exactly the same relative distance on opposite sides of the patient and moving harmoniously. By an ingenious Fig. 104. — Orthodiagraph. contrivance the heart's area can be traced by means of an attached fluoroscope and the record made automatically on the paper for future comparison. This is infinitely superior to the previous method of percussion or auscultator}'- percussion and is the basis of conclusion which Moritz, August Hoffman, Rudolf ^ Manufactured by Reiniger, Gebbert and Schall, at Erlangen, Germany, and also by Electricitatsgesellschaft "Sanitas," Berlin, No. 24, Friedrich- strasse, 131 d. Price about $156.00 to $125.00. 'Franz M. Groedel, Orthorontgenographie, Munich, 1908. Also "Die Orthodiagraphie," Dr. Karl Francke, Munich, 1910. 21 322 HYDROTHERAPY and Beck,* and the Groedels of Nauheira have drawn as to the effect of baths on the heart. In ordinary ratliographs the shadow of the heart or of any internal organ is necessarily larger than its natural size as the rays from the anticathode of the Crookes tube are projected from a point in the shape of a cone; but with the orthodiagraph the source of the Rontgen rays, the center of the fluorescent screen, and the pneumatic pen are kept always in line. The arms supporting these parts of the instrument are attached to a carriage which, while allowing all motions in one fixed plane, will keep this straight line perpendicular to the plane. Thus the pencil of rays coming from the tube, through a small aperture in a lead diaphragm to the center of the screen, while it may be moved over a considerable surface, will always occupy parallel positions.^ Rudolf and Beck reported that in all the patients they studied, the size of the heart was measured immediately before the baths, and the operation was repeated as soon after the bath as circumstances permitted, the time between the end of the bath and the estimation of the changes in the heart not exceed- ing two or three minutes. The results obtained were quite uniform. The effect of the hot bath was to diminish the size of the heart, the amount of the change being quite considerable in most cases. In one case the heart remained unchanged in size. The effect of the cold bath was to increase the size of the heart, no change being noticed in one case only. The diminution in the size of the heart after hot baths was accompanied by an in- crease in the rapidity of the pulse and in the supply of blood to the skin, phenomena which are, of course, commonly observed after hot bathing. Cold baths, on the other hand, were followed by increased pallor of the skin and diminution in the frequency of the pulse. The limited number of cases examined does not 1 Munchener Med. Woch., January 26, 1909. ^ See Orthodiagraphy in the Study of tlie Heart and Great Vessels, by Thomas A. Claytor and Walter H. Merrill, Trans. Association of American Physicians, 1909. Studies made at the Garfield Memorial Hospital, Washing- ton, D. C. THE OXYGEN BATH 323 allow final conclusions to be drawn, but the uniformity of the results obtained speaks for the correctness of the findings. Whether the therapeutic indications for the use of cold and warm baths will be modified by the discovery of these changes in the dimensions of the heart with the different temperatures of the water remains to be seen. Rudolf and Beck measured the heart immediately before entering the bath and again directly afterward. It was uni- formly found that after a hot bath the size of the heart was considerably diminished, and, with this, a marked increase in the pulse rate; after a cold bath the size of the heart increased, the skin became pale, and there was a diminished pulse rate. Rudolf and Beck found that, in the case of Nauheim baths, natural or artificial, even in water with a temperature of 87° to 95° F. (30.6°-35° C), orthodiagrams show a marked diminu- tion in the size of the heart, \yithin this temperature range, then, it would appear that the heart responds as in the case of hot baths. This would confirm the statement of Leslie Thome, that in many cases a good reaction cannot be obtained if the temperature of the bath be below 96° F. (35.6° C). If this be found to be the case in any given instance, it would be unwise to give the baths at any lower temperature. (See pp. 140-146.) THE OXYGEN BATH This bath depends on the chemical generation and diffusion of oxygen gas in water. It is one of the newest features of hydrotherapy, having been introduced only as late as 1904 by Sarason. He used hydrogen peroxid at first and then devised the method of first dissolving about 300 gm. of sodium perborate in the tub, adding then 15 gm. of manganese borate. This latter acts the part of a catalyzer and causes the sodium perborate to part with oxygen. Various modifications of the oxygen bath have been placed on the market in Germany. Sarason adopted the name " Ozet bath "; Wolfstein called his " Brozon "; Kopp and Joseph gave theirs the name '^ Zeozon." Sarason's bath has been introduced to the American market as the " Perogen bath," the exact nature of its constituents are not yet made public, as 324 HYDROTHERAPY patents arc pending. The proprietors, Morgenstern ami Co., of New York, state that they will i)ublish the nature of the catalyzer when a patent is issued. The '' Ozet " bath is patented in all I'^uropcan countries. These baths are, in a measure, analogous to carbonic acid baths, in that minute bubbles of gas are generated and attach themselves to the bather's skin, pro- ducing a sense of exhilaration which is succeeded by a sedative action rendering it of considerable therapcnitic value. The only description of the bath that we have met with in English is by Dr. Fredrich Grosse,' but several papers have been i)ublished recently in Germany. Among these are j)apers by Frankl, Tornai, and Sommer. Dr. Grosse's description of th(> oxygen bath is as follows: " The two salts arc sold in the market in separate bags, packed in tins, and keep well for any length of time. The label gives the necessary tk'tails as to the technic of the procedure, which yields about 35 pints of nascent oxygen. The oxygen bath is usually given as a full bath (reaching uj) to the jugular fossa), but other forms, such as hip-baths, are also recom- mended. The patient lies therein without any unnecessary movement, and friction or soaping is to be avoided. As a rule, plain water is used, but there is no objection to the addition of other ingredients. The temperature of the water is usually, according to the writers, 93° to 89.5° F. (33.8°-31.9° C.) ; some of them administer it as warm as 98° F. (36.6° C); Laqueur' considers lower degrees objectionable, as he thinks patients would feel chilly, the oxygen not being so powerful in warranting the sensation of warmth as the carbonic acid. I find, however, at least in some cases, tliat the baths also of 88° to 86° F. (31.1°-30° C), tem- peratures which are mentioned also by Winternitz, are tolerated with the same good effects. " The duration of the bath is, as the first observers state, fifteen to twenty mintues ; however, I see no contraindication to prolong it, in appropriate cases, up to thirty minutes. Even iThe Post-Graduate, September, 1909. THE OXYGEN BATH 325 then enough oxygen is left to cover the bather's skin, especially if, by stirring up the lower strata of the water, the last traces of the chemicals are pushed into action. " The number of baths given as regular treatment of chronic cases should be, according to Tornai,^ from fifteen to twenty, and according to Sommer,^ from twenty to thirty. The litera- ture on the subject is yet, of course, scanty, but all writers advise taking one bath either on each of five consecutive days, with four or five free days, or every second day. In hydrotherapeutic practice waterless days are frequently introduced during the course of a 'cure.' In short, I hold it advisable not to give routine prescriptions, but rather to be guided by the needs of the case. Again, as to the hour of bathing, it is best to take into consideration all the numerous trifles of the sufferer and his surroundings, with the only exception that, to bring on sleep, the bath should be taken from thirty minutes to one hour before retiring, and even here we have to consider that sometimes we meet a case who experiences, even after the most sedative appli- cation, a transient period of excitation before sleep occurs. " As the oxygen bath is, altogether, a rather calmative, rest- producing, and yet indirectly stimulating — the German ex- pression 'schonend' includes not only these adjectives but also our epithet protective — application, it is self-evident that before the bath the patient should not have gone through any exciting movements of any nature, such as walking, for instance ; and after it also he should rest one or two hours. It may also be useful to mention that he ought to be uniformly warm; under no circumstances should he enter the tub with cold feet, because the procedure is by no means one accumulative of heat. " As the temperature of the oxygen bath is usually a few de- grees lower than that of the skin, the bather may, at the first impact of the water, or even as long as one minute, reahze a chi ly feeling; but after a minute or so this is changed into an agreeable sensation of warmth, ' as if the water had, all of a sudden, become warmer.' This feeling stays as long as the bath lasts, so that the patients often remark Hhey wished they 326 HYDROTHERAPY coukl remain in it for hours' (Tournai). Ay soon as the bather lies quiet, his skin is (juickly covered by a glistening layer of finest oxygen bubbles, which become closer every minute. Forming, driving up, bumping against the skin and its lanugo, they cause a queer tickling and prickling sensation that is very agreeable. A discoloration is caused by the formation of man- ganese oxid from the catalyser and consists of a very fine, soft, slimy mud that covers bather and tub; though it is very easily rinsed away by water without leaving any lasting stain what- ever, it is by no means recommendatory of the ozet bath. In contradistinction, the perogen bath leaves merely a very fine yellowish hue scarcely visible on a wet towel. " According to modern osniology, the skin is always covered with a layer of air, the molecules of which adhere relatively closel)^ to the body surface, so that one might roughly speak of an involucrum or tegument of condensed air. This resists decidedly even mechanical removal, so that Zickel,* a pioneer osmologist, advocates, in order to facilitate and increase the eff"ect of tub baths, rubbing of the skin with alcohol and applica- tion of thorough wet and dry friction before such a hydro- therapeutic procedure is undertaken. As to the oxygen bath, the procedure may be thus : after the perborate has been added, the patient, having previously been rubbed with alcohol, enters the tub and undergoes gentle but thorough friction all over, under water. Then the catalyser is added. "In the oxygen b^th the layer of oxygen is substituted for the air involucrum and so increased that it becomes, as it were, visible. The point of indifference of water is 93° to 99° F. (33.8°-37.2° C). This is much higher than that of air, i. e., 68° to 77° F. (20°-25° C), and the indifference point of 0, is decidedly lower yet. Furthermore, as gas is a bad conductor of warmth, the terminals of the thermic nerves are surrounded by a medium perceptibly warmer than the water. All this combines to bring about a sensation of warmth that is conveyed to the central stations, and the bather feels the water warmer than it really is. Besides this action on the thermic nerves. THE OXYGEN BATH 327 other stimuli act upon the nervous elements within the skin, regulating the peripheral circulation. Whether these are of physical or of chemical nature, or both, is difficult to decide, but there is no doubt that a pronounced contraction of the cutaneous vessels takes place, causing a distinct paleness. Entirely otherwise than in the carbon-dioxid bath and other water applications, this vessel contraction and consequent peripheral anemia is not accompanied by chills or goose-skin. Perhaps the central nervous stations, because of the aforesaid impression, fail to institute the contraction of the cutaneous muscular elements; perhaps, also, we have there a specific stimulus for the skin heart of Hutchinson. '' As to the pulse, the rate is, as all observers report, reduced in proportion to what it was before the bath, and at the same time irregularity and weakness are markedly corrected; indeed, in this line the oxygen bath has the very same favorable influence as the carbon-dioxid tubs. The respiration is acted upon in a similarly sedative way; the inner temperature remains un- changed. The experimenters do not fully agree as to blood- pressure. We know that baths below the indifference point are liable to increase it ; those of an indifferent temperature to leave it unchanged, and baths warmer than this lower the pressure. Temperature seems to have more effect upon it than any other factor. According to this the figures of Ekgren,^ Winternitz,® Laqueur, Schnuetgen,^ Tornai, Mueller,^ and Scholz^ point mostly to a reduction; only Ekgren observed an increase after 91° F. (32.7° C). Altogether, the tabulated figures are mostly relatively small, in normal cases hardly over or under naught. Immediately after the beginning of the bath a transient increase may be noticed, and, again, well observed cases show lowered figures even for hours afterward. Experiments concerning me- tabolism are yet entirely lacking. However all this may turn out, I hold, with Frankl,^'' that all these trials are of relatively little importance, as the changes caused by and following the bath are altogether minimal. Only this can be taken as sure, that the oxygen bath reduces abnormal augmentation of hlood- 328 HYDROTHERAPY pressure, rate of pulse, aiid respiration, while the healthy are not more affected than by a corresponding plain water bath of like temperature and duration. As the skin certainly . does not contain more blood, this must be directed more toward other areas. And as there are no phenomena whatever that might point to congestions of inner organs, ^^'internitz's suggestion that the blood is chiefly turned toward the skeleton muscles seems to be acceptable. Howe\'er this may be, the oxygen bath acts just contrary to the carbon-dioxid tub, which drives the blood toward the skin, powerfully depleting the inner organs. " Winternitz holds that the prickling sensation in the water is attributable to clonic contractions, and is identical with the pulsation of the skin heart. " In his first publication Sarason suggested that oxygen might be present as ozone, but according to Schnuctgen all ozone tests were negative. " It may be plausible to assume that the oxygen is of im- portance, the more so as it seems to be present in its nascent form. As to this we see, indeed, favorable effects wherever an increased respiratory intake, independent of a bath, is known as being of benefit; here asthma and cyanosis and difficult breathing, incidental to pulmonary congestion, may be men- tioned (Naumann "). Now and then we find a patient who, after entering a full bath, feels oppressed ; such cases stand the tub better in its oxygen form. " An appreciable absorption of oxygen through the skin is inadmissable (A^internitz). Zuelzer, Salomon, and Schierbeck found that the perspiring and hyperemic skin may absorb up to 4 or 5 per cent, of the pulmonary intake, but in the O^ bath the skin is not hyperemic, and even if the amount were larger, we know, from the experiments of Speck, Lowy, and Durig, that increased ingestion of oxygen does not favor metabolism.'^ Still, according to v. Koranyi (Michaelis, Handbuch dcr Sauer- stofftherapie, 1906), it may decrease the viscosity of the blood and thus facilitate metabolism and catabolism. THE OXYGEN BATH 329 " Oxygen being one of the most powerful disinfectants, it is obvious that we may expect results due to this effect. " Independently of the chemic part of the oxygen, we have to consider the physical effects of the gas bubbles. " The minute oxygen bubbles, forming and bumping against the nerve terminals, running into one another, driving up and striking along the lanugo, acting like a gas brush, as Sarason aptly pictured the process, exert uniform, mild, and constant stimulation upon the nervous endings, resembling in action a sublime massage. All stimuli of the outer world being ex- cluded, the effect of this ideal overexertion, conveyed toward the nervous centers, institutes a sedative action, almost ike the continuous bath,^ the sovereign calmative effect of which is gen- erally recognized. In conformity with this, we see that all writers on the subject lay stress upon its sedative character in the manifold paresthesias of neurasthenic, hysteric, and tabetic origin and its decided and reliable soporific action. At the same time it has a soothing and indirectly stimulating influence, as is evident in asthma and other respiratory difficulties, and in its distinct corrective action upon pulse irregularities of all kinds, and thus it, doubtlessh^, resembles the carbonic acid bath, the outbalanced pulse becoming stronger, slower, and regular. " In conclusion, we may outline the physiologic action of the oxygen bath thus: (1) It is a neutral bath that (2) acts oxidiz- ingly and disinfectingly upon the skin; (3) it has a powerfully suggestive influence, and (4) alters innervation by discontinuation of paresthesias, by its sleep-promoting peculiarity, and by its generally sedative and indirectly stimulating action; (5) it is a circulatory revulsive, most probably turning the blood from the skin toward the inner body, especially into the muscular areas, and (6) it reduces an abnormally increased blood-pressure, at the same time probably rendering the blood less viscid. '' Though the literature on oxygen gas baths is not voluminous and many points may be still disputable, further experimenta- 1 ContinuQus Bath, by Grosse, Med. Brief, 1905, viii. 330 HYDROTHERAPY tion will liardly bring forward new facts of greater importance. ►Setting aside the cutaneous anemia, with its pecuHar lack of goose skin and chilliness, the oxygen hath i)resents no feature essentially different from other well-studied hydrotlun-apeutic phenomena, so that, according to the physiologic arguments by which we have tried to analyze the difTerent components, we may state the clinical indication as follows : "The perogen bath may be given whenever a nc^utral or in- different one is indicated, which means a full l)ath of such tem- perature and duration as do not change materially the body's inner warmth, that is, of 93° to 98.0° F. (33.8°-37° C), and of fifteen to thirty minutes; and when we shorten the duration down to ten minutes we may call a temperature neutral, even as far as 90° F. (32.2°C.) and even 88° F. (31.1° C). " The gas bath is preferable also when we want to impress a case with potent suggestions. The perogen bath, with its different ingredients, which are to be carefully distributed and dissolved; with its sequent milky turbidity; with its mystic sizzling; with the queer formation of the gaseous tegument, fascinating both eyes and sensibility; with the gradual darken- ing of the water and its muddy sediment upon the skin; with the puzzling sensation, as if the water suddenly had turned warmer, and last, but not least, with blissfully free respiration, has a valuable multitude of suggestive features. Not only will the horde of hysterics fall in, but also many of the blase com- plainants of the wealthy classes, and many half-read persons, who believe they know and understand everything, will thus be induced to bathe regularly and in accordance with our pro- gi'am — details apparently of little importance and yet sometimes extraordinarily valuable. " It would further be of interest and importance, if the disin- fectant power upon germs within the epidermis and its gland ducts were examined in the wards for contagious diseases, as in scarlatina, measles, small-pox; or for microbic skin diseases, as psoriasis, favus, impetigo, certain forms of eczema, and others. THE OXYGEN BATH 331 This may be of the utmost value for the prevention of many epidemics. " Paresthesias located in the body surface are the next indica- tion. So far, the reports seem to deal chiefly with nervous forms, though those chemically caused, such as the most trouble- some itching occurring sometimes in liver diseases, are, most probably, not out of question. As another group of parasthesias is apparently characterized by superficial hyperemia, as, for instance, 'burning hands and feet' and local hyperhidroses, I tried local 0^ baths in one case of burning feet of apparently vasomotor origin, with strikingly good effect. Though one case allows of no inference, it is certainly suggestive to think of it in similar cases, the more so as the treatment of this form of a,nomalies is a crux alike for the physician and the patient. In regard to these and antisepsis, again the suggestions of our osmologists may be noteworthy, as when their advice is followed the oxidizing effect must be multiplied. " As we have seen, the perogen bath is, furthermore, of a de- cidedly sedative character, combining with this quaUty, in contradistinction to drugs, positively a welcome stimulation. It seems to me that this is of an importance that can hardly be overestimated in conditions of excitation, such as is so often met with in persons of rather too liable a nervous system, who are thrown out of balance by every little happening of every- day character. For here, again, the bodily effect is enhanced by suggestion. " Finally, here may be added the fact that Franks" advocates the oxygen bath in a special article on cUmacteric molimina; 'for the ambulant treatment of which the O2 baths, as they have been studied by other experimenters, seem to have been predestined.' Of course, anatomic alterations of the pelvic organs, some sufficiently well-known hemorrhages, and climacteric obesity are out of the question here. It is the very same line of vasomotor and nervous disturbances, mostly presenting an increased blood-pressure, from which likewise Diihrssen, Engel- mann, and others recommend a general hydro- or balneothera- 332 HYDROTHERAPY poutic procedure in. <];en('ral, and Gottschalk, Baelz, Grosse," and others, above other applications, the hot (107° F. — 41.G°C.) full bath for six to eight minutes. In all these means the reduc- tion of blood-j^ressure is the effect wanted, but even here the suggestive influence should never be excluded. " This gives me occasion to mention the only contraindica- tion concerning oxygen baths; namely, conditions of low blood- pressure, no matter of what origin. It may also be of value to direct attention to the fact that in rare cases an idiosyncrasy for oxygen has been found. Thus in one patient vomiting occurred, and in a woman, forty-six years of age, suffering from endo- carditis and mitral insufficiency, violent heart palpitation has been reported. " To sum up: Winternitz, the father of hydrotherapy, is right in stating that the oxygen bath forms a new link in the chain of procedures adapted to domesticate hydrotherapy. It is welcome as a substitute for other hydriatric applications, valua- ble as to innervation and Oj ingestion, and, above all, entirely new and without parallel as a peculiar circulatory revulsive." References. 1. Deutsch. Med. Wochenschr., 1904, No. 45. 2. Zeitschr. f. phys. u. diiit. Ther., xii, p. 424. 3. Zeitschr. f. neuere phys. Med., 1908, No. 18. 4. Neuere Fortschritte d. Klin, osmologischen Heilkunde, Berlin, 1905. 5. Zeitschr. f. Klin. Med., Bed. 57. 6. Blaett. f. Klin. Hydrother., 1907, p. 1. 7. Ther. d. Gegenwart, April, 1907. 8. Munch, med. Wochcn.sclir., 1908, No. .30. 9. Deutsch. med. Wochenschr, 29 July, 1909. 10. Zeitschr. f. phys. u. diiit. Ther., Bd. xii, p. 291. 11. Ther. d. Gegenwart, 1908, .3. 12. Low-y und Zulz, Die physiolog. Grundlagen der Sauerstoffther. 13. The Hot FuU Bath, Med. Rec, 1904, p. 326. MUD BATHS AND FANGO PACKS These are applied for rheumatism, gout, arthritis deformans, and the neuralgias. They act principally through the heat applied, and are, of course, not dependent on absorption of the MUD BATHS AND FANGO PACKS 333 minerals contained in the bath, although no doubt the skin is favorably affected by the sahne and alkahne substances employed. Mud Baths. — For these baths the patient lies in a tub contain- taining the prepared mud mixed with a sahne or carbonated water. The most famous mud baths are those of Carlsbad, Kissingen, Baden Baden, Leipsic, Vienna, Weisbaden, and Sal- somaggiore and Battaglia, Italy. (See also p. 128 et seq.) Fango is an Itahan volcanic mud. In color it is a soft grayish brown, plastic, and of about the consistency of butter and equally soft to the touch. It has no odor and after application is quickly and completely removed by a warm douche, lea\'ing the skin absolutely clean. The analysis shows that it is com- posed of 11 per cent, of combustible and volatile matter with carbonates and sulphates and sulphids of iron and hme, and sulphates of potassium and sodium. It is said to be radio- active. The fango is appUed warm hke a great sterilized poultice. It conveys heat and retains it. The pack may be appUed first at 110° F. (43.3° C.) for ten minutes, and the temperature and duration increased in successive appHcations up to 125° F. (51.7° C.) for twenty, tliirty, and forty minutes. Gentle massage may be given after the pack. Apphed in this manner to a joint or hmb the effects are of the fango bath: stimulation of cutaneous reflexes, with dilatation of superficial capillaries; increased activity in the normal pro- cesses of absorption of morbid deposits, and repair of damaged tissues. Perspiration is promoted and there is a slight increase of body temperature, 2° F. (1.1° C), subsiding rapidly after the removal of the pack, and due to direct conveyance of heat to the blood. Dr. Cecil Sharpe,^ of London, has recently re- ported 13 cases of stiff and painful joints treated in this manner. In subacute rheumatism, lumbago, rheumatoid arthritis, neuritis, sciatica, sprains, and old injuries of the ankle, fango gives good results. Among its advantages are the application only to the part involved, and the fact that these packs are ^ W. Cecil Sharpe, M. D., Jour. Balneology and Climatology, January, 1905. 334 HYDROTHERAPY given in various cities with the mud inijjortcd from Battaglia where the fango is found in connection with hot springs. This treatment can be obtained in BattagUa and Acqui, in Italy; at the Anstalt for Physiologic Therapeutics, University Clinic, Munich; at London, at Smedley's, Matlock, England; at Baden Baden, at Kissingen, Germany; at 69 West 90th Street, New York City, and at Mudlavia, near Attica, Indiana. MUD AND PEAT BATHS These are employed in Europe, especially at Franzensbad, Elster, Marienbad, Driburg, Carlsbad, and Buxton, England. The mud baths (Schlammbiider) consist of a soft mass of in- Fig. 105. — -Moor baths, Rnxton. l^ipgiiiK tho jioat in winter. organic mud rich in silicious matter. The peat baths (Moor- bader) contain both organic and inorganic matter, and, like the mud baths, are applied as immense poultices, either locally or generally at temperatures ranging from 118° to 122° F. (47.7°-50° C). These mud and moor baths can be given at higher tem- peratures because the medium is a comparatively poor conductor of heat. In local applications sand baths may be raised in spe- cial cases as high as 133° F. (56.1° C). These local baths may SAND BATHS 335 also be continued much longer than full baths and are frequently as much as an hour or an hour and a half long; while forty to forty-five minutes suffices for the full bath and forty-five to sixty minutes for the half-bath. Friction is sometimes used in mud and peat baths and the innumerable fine hard substances or spicules, the remains of shells or plants, act as a stimulant to the skin. Peat baths are used in chronic pelvic affections. Their action is Hke that of a widespread poultice. They are useful in gout^ 3!^ Fig. 106. — Moor baths, Buxton. Bringing in the peat in winter. rheumatism, lumbago, and sciatica. In all neuralgias low temperatures, 113° F. (45° C), are best. The peat baths at Marienbad are ferruginous, and those at Driburg sulphurous. SAND BATHS These are naturally not hydrotherapeutic measures, but are found at some resorts where other baths are given. It is one means of raising the body temperature and powerfully exciting the skin. 336 HYDROTHERAPY SITZ- OR HIP-BATH A special tub is retjuired for hip-baths, so that the patient may sit in water with liis thighs resting against the front of the Fig. 107.— Sitz-l. tub, and his knees, legs, and feet i)rotectcd by a blanket, while the latter are in warm water. The top of the patient's head is Fig. 108. — Sitz-bath tub made of tin (Ashton). covered with a cold wet cloth and the tub is partially filled with water. The temperature of the water can be raised or lowered as required. If necessary to raise the temperature above 104 ° F. SITZ- OR HIP-BATH 337 (40° C.) pitchers of hotter water can be added cautiously; if, on the other hand, it is necessary to lower the temperature, cold water can be added. In the latter case quick friction of the submerged portions is required. The hot bath raises the pulse and lowers the pressure, the reverse being the case when cold water is used. The results are largely due to reflex excita- tion of the sympathetic nervous system. The hot bath diverts Fig. 109. — Sitz-bath with abdominal friction (Gant). blood from the abdominal organs, while cold baths produce congestion. Hence, in all atonic states of the bowels, urinary and generative organs cold acts a a stimulant if the baths be short and friction be apphed. If such baths be prolonged, the stimulant effect is not obtained. It should .be "remembered in giving the sitz-bath carefully to cover the unimmersed parts of the body, otherwise the effect may be entirely annulled, especially in intestinal affections. In menstrual disorders warm and hot sitz-baths are often 22 338 HYDROTHERAPY corrective.' Brief cold liip- baths are useful in vesical and intestinal paralysis, in debilitated states of the male sexual organs, in prolapsus ani, and in intestinal atony. Prolonged cold hijvbaths are advocated by Misiewitz in hemorrhagic states of the urethra, bladder, intestines, and uterus; in hemorrhoids and in perimetritis. Fig. 110. — "Lisbon" seat bath (J. L. Mott Iron Works). Counterindications. — These baths are counterindicated in hyperemic states or congestions of the pelvic organs; in sexual or vesical irritability, in seminal emissions, in tenesmus, in menorrhagia, in uterine coUc, in acute cystitis, and in intense tenesmus. PACKS-COLD WET PACKS (FEUCHTE EINPACKUNG). HOT WET PACKS. DRY PACKS (TROCKENE EIN- PACKUNG) Packs were first used, as far as kno\\Ti, by Lucas, an English physician, who lived about the middle of the eighteenth century. * See page 226. For a full discussion of hydrotherapy in diseases of women, see Ashton's Practice of Gynecology, 4th ed., 1909; also Bandler's Medical Gynecology, 2d ed., 1909. COLD WET, HOT WET, AND DRY PACKS 339 Later, about 1835, they were rediscovered and used by Vinzenz Priessnitz, of Grafenberg. These procedures, apparently so dissimilar, are very closely related, not only in their visible form but also in their physiologic effect. An aphorism of Hippocrates was that cold produces heat, and this simple statement comprises one of the greatest and most fundamental truths in physiologic therapeutics. It was a remarkable mind that was able to grasp and to express over two thousand years ago what even now seems so paradoxic. One of these curious paradoxes in the practice of hydrotherapy is the fact that after the removal of the cold wet pack the damp sheet is found warm ; while after the removal of the hot blanket pack, as, for example, in cases of chronic nephritis or the nephritis of pregnancy, the damp blankets are sometimes found to be cool. (See p. 118.) Bed or Table for Applying Packs. — In applying a pack it is convenient to have a narrow bed or table of substantial con- struction, such as that shown on pages 235 and 236. This bed or table may be of iron tubing with a strong spring to support the mattress; or it may be of wood with stout legs and a plain top and not intended for a mattress, but for blankets and sheets. This is the type of table used for massage and commonly for packs and alcohol rubbing. For packs of long duration the narrow iron bed with springs and mattress is the more comfort- able for the patient. A high table is convenient for the operator, but a low bed is safer for the patient should he belong to that class of mental or refractory patients for which such measures are much employed. The bed and mattress are protected with a rubber sheet, and on this a large blanket is spread long enough to reach from the nape of the neck to beyond the foot of the bed, and wide enough to hang over the side. A hair pillow, covered with white rubber cloth, and a pillow sKp is placed at the head. 340 HYDROTHERAPY COLD WET PACK Requisites. — The bctl or table prepared as above. One or two acklitional blankets; a linen or cotton sheet; 4 small towels, and a hot-water bag. The bag is half-filled with hot water, not over 120° F. (48.9° C). A foot-bath is required with water at 102° to 105° F. (3S.9°-40.6° C). A pitcher of ice-water, a bucket of water for the sheet at 65° or 70° F. (18.3° or 21.1 ° C), or at the required temperature. Technic. — The jmtient in wrapper sits in a convenient chair with feet in the bath of warm water and with a cold compress on the head. The attendant then wrings out the sheet from the water in the bucket and spreads it smoothly over the bed, so as to reach near the foot. The patient then quickly drops all clothing and lies on the wet sheet with the arms extended. The attendant, standing on the right sitle, promptly draws the overhanging left side of the sheet across the body, smoothing it between the lower limbs and along the right side. The arms are then lowered to the sides and the remaining free portion of the sheet is drawn over the body and smoothly adjusted over the lower limbs, covering in both arms. The feet are left un- covered by the sheet, but the hot-water bag, covered with a towel, is placed at the soles. The underlying blanket is adjusted in a manner similar to the sheet, except that it is not tucked between the lower limbs, and the surplus at the feet is folded under them. The blanket should be closely adjusted at the neck so as to exclude all air. Another blanket, folded in several thicknesses, is then placed over the entire body from the neck down and tucked snugly in at the sides. A fresh turban of ice- water is adjusted, to be changed every five minutes as it warms. It is found in many cases that if the wet sheet is allowed to extend beyond the feet and is then placed over the feet with- out the use of the hot-water bag, the reaction in the feet is slow and correspondingly unsatisfactory. There is no advantage in covering in the feet with the cold wet sheet, and the use of the hot-water bag favors the action of the pack. THE HOT WET PACK THE HOT WET PACK 341 This is applied in tliree principal ways: viz., by means of a sheet wrung out of hot water; by means of a blanket wrung out of hot water; and by means of both. In many cases, espe- cially in treating children, the first method suffices, and it avoids the necessity of deahng with wet blankets. Fig. 111. — Adjusting the first half of sheet. Requisites. — These are the same as for the cold wet pack, excepting that a bucket of hot water should be provided. The bed is protected as previously described and on it two blankets are spread. Technic. — The sheet, having been wrung out of the hot water, is then unfolded and laid on the upper blanket. The patient is 342 HYDROTHERAPY then placed in bed quickly, the sheet quickly losing sufficient heat to make this possible. The sheet should not extend beyond the junction of the head and neck. AVhile the patient's arms are raised, one side of the sheet is quickly drawn across and tucked under the opposite side and folded between the lower hmbs; then the arms are lowered in l"i'_' II'-! — Patii-iit ciivcIoixmI ill tlif slieet. the cold pack, and the remaining side of the sheet is carried across and smoothly applied, enclosing both arms and lower limbs. The hot- water bottle, suitably guarded, is placed at the feet, and the upper blanket is then adjusted as in the case of the cold wet pack. After that the under blanket and the free ends of the coverings are folded under the heels. In from twenty to forty minutes perspiration forms on the forehead and THE HOT WET PACK 343 the body temperature will be found from 1 to 2 degrees higher than at the start. After a tepid or cool sponging the patient is dried and re- moved to bed, which has been previously warmed. The bed- clothing should be fairly light. Fig. 113.— Adjusting the first half of first blanket. Indications. — This pack has innumerable uses, especially where defective metabolism is met with. It is well suited for the young, the weak, and the aged. Dr. Leonard Williams, of London, has advocated it strongly in anemia, in the sequelae of scarlet fever, and in the slight catarrhs of the air-passages in children. For the convulsions of children it is far neater, more agreeable, and quite as effective as the hot bath. The child is kept quiet and his head is more easily kept cool 344 HYDROTHERAPY In uremia the hot wet pack is also useful. (See p. 117.) Fig. 114. — Patient enveloped in first blanket. Many a case of puerperal convulsions has been saved by this procedure. DRY HOT PACK The dry hot blanket pack is commonly used after the warm douche and warm or hot baths in the treatment of gout, rheuma- tism, syphilis, and obesity. COMPRESSES Action of the Compress. — When inflammation with arterial Venous congestion occurs in a given part there is a corresponding compression of the nerve trunks by the overfilled blood-vessels. COMPRESSES . 345 Fig. 115. — Hot dry pack, Hot Springs, Virginia. Fig. 116. — Reapplying the wet cold turban in the hot dry pact 346 HYDROTHERAl'Y Spasin of the nutrient vessels, by which the nerve filaments are coniprcssetl, has also been supposed to account for the pain. If the blood may be diverted to the surface or to some other part by the use of compresses, relief will be afforded. (See pp. 210 and 213.) Materials. — For the cold compress the material used is linen, which is then covered closely by several thicknesses of flannel to pnn'ent outward radiation. For the moist hot com- presses well-soaked flannel is used, covered, as in the former case, with a sufficient layer of dry flannel. COLD COMPRESS The good effects of a cold compress are well seen in the treatment of pneumonia. (See p. 100 et seq.) The water should be at 50° or 60° F. (12.8° or 15.6° C). The linen compress, 18 inches wide, partly wrung out, is laid smoothly over the affected side, extending slightly beyond the median line, front and back, and is then covered with a flannel binder, applied somewhat loosely. The compress should be changed night and day every hour, and it is i)Ossible to do this without much dis- turbance to the patient. Indications. — ^The danger in cases of pneumonia lies in the possibility of intoxication, but as a general thing this is not so great as in typhoid; full baths are, therefore, not desirable. The failure in peripheral circulation causes hypertension of the heart, the blood being driven to the inner ])arts, and it is just here that the compress gives timely assistance. The cold stimulates the heart, and with the systole blood is driven into the peripheral vessels. The central nervous system is also invigorated by the effect of cold on the capillaries through the muscle-fibers of the skin. As the skin reacts and the periph- eral circulation improves, the heart beats slower and stronger and the increased force and tension of the pulse are shown in the kidney; the urine excretion is also increased. The crisis is hastened and is marked by a drop in the temperature and a not- able improvement in the rate and character of the pulse. FOMENTATIONS OR HOT COMPRESSES 347 The use of ice in pneumonia rests upon the same basis. The end sought is not the reduction of temperature, but a check to the intoxication by improved circulation and consequent nutrition. It is possible that by these means antitoxins are developed to counteract the infection. The crisis in pneumonia is sudden and not fully to be explained. The remarkable effects cannot be accounted for by immediate changes in the physical condition of the lung. If so, hydrotherapy would be powerless; it is, therefore, a mistake to expect the compress to cure the condition of the lung itself. If the patient recovers, he does so in spite of the pulmonary consohdation; if he dies, it is not altogether from the encroachment on his breathing ca- pacity, but from the intoxication. Put two intoxications together, as that of alcohol and pneu- monia, and the result is usually fatal. As a rule, it is not best to give alcohol in cases of pneumonia treated with compresses, but in alcoholic cases some alcohol may properly be given, but it requires wise judgment to decide when to give and when to withhold. As in any other form of treatment, little can be expected from these measures in alcoholic cases, especially if treatment be started late, as, for instance, on the third day. (See chapter on Pneumonia, p. 100.) ICE COMPRESSES The apphcation of ice to the body is best made by means of water-tight rubber ice-bags, as it is obviously best to prevent wetting the bed and the patient's clothing. As stated above, the aim is not to reduce the inflammation, for the lungs of a living man would not be appreciably affected by cold applied outside the chest wall. FOMENTATIONS! OR HOT COMPRESSES Moist heat may be easily apphed to the body b}^ means of hot flannel compresses. Unless very hot compresses are used ! It is tautologic to speak of hot fomentations. They axe simply the ap- plication of moist heat by means of cloths. 348 HYDROTHERAPY Fig. 117, a and b. — Wringing hot compresses (Cohen). FOMENTATIONS OR HOT COMPRESSES 349 it is better not to interpose linen or cotton, but to have the flannel in direct contact with the skin. The compress must be very thoroughly wrung out of boiUng water. This tem- perature may be less at first. This induces hyperemia of the skin and reUeves internal congestion. The compress should be. covered with several folds of flannel to prevent external radiation. Indications. — Fomentations or steam compresses have a wide range of usefulness. They give relief in almost any condition in which pain is a symptom, especially in those conditions in- dependent of inflammation. When inflammation is present in the abdominal cavity, however, surgeons usually prefer to employ ice or very cold applications. (See p. 158.) Hot com- presses favor suppuration, promote the absorption of exudates, relieve pain, and increase the mobility of stiffened joints. In all cases of rheumatoid arthritis, in arthritis deformans with pain and swelling, in sprains, bruises, cramps of the extremities; in biliary, renal, and hepatic colic ; in affections of the bowels and pelvic viscera and in intercostal neuralgia, lumbago, and sciatica moist hot compresses are exceedingly useful. Counterindications. — Fomentations are not to be used when appendicitis threatens, or in cases of peritonitis, whether idio- pathic, due to perforation of the bowel, or to injury. Pending operation, suppuration in such cases should be fought with cold. So also at the onset of pneumonia. In such cases ice-bags, cold compresses, and such measures, elsewhere noted, are much more stimulant to the vasomotor centers and are superior to the general application of heat. Technic. — The illustration shows a convenient method of preparing a steam compress. Several layers of white flannel, of a suitable size and fastened together, are dipped into boiling hot water. The area to be treated is then covered with a thin layer of dry flannel, the so-called haby flannel answers the purpose best. The wet compress is now dropped into a towel, and twisted lightly, so as to leave it comparatively dry. It is then 350 HYDROTHERAPY unfolded, placed over the dry flannel referred to, and the whole enveloped in a dry flannel bintler. The following is Dr. Curran Pope's' graphic tlescription of the application of a hot compress: "I will now simplify my ajiparatus b}- limiting it to a basin, two towels, and a tea-kettle filled with boiling water. The majority of hot applications fail for two reasons. In the first place the application is too ivet, and in the second the hot applica- tion is too cold. Hot applications should range anywhere be- tween 125° and 165° F. (51.7° and 73.9° C). You cannot handle them with your hands, in fact, they are too hot for you to pick up and hold at all. If you put these applications on the patient's skin too wet they blister. If you put them on only warm you lose two-thirds of the benefit of the treatment. "Suppose that we are going to make a hot moist application or fomentation to the pelvis, where we want all the heat we can get. It is best to use a Turkish towel or a small piece of blanket. If you can't get that, get a piece of an old flannel petticoat. Take this and place it right in the center of your towel. Now you have everything ready, and the mistress of the house brings in the tea-kettle full of boiling water. If you were to place it on the patient without previous preparation, you would burn her. Place around the hips, pelvis, and lower abdomen a folded blanket, so applied that the ends overlap in front. Now rub the surface to be covered by the fomentation with vaselin.- This prevents maceration or softening of the superficial epithelial layers. Having poured the boiling water over the flannel that lies in the towel, so hot that you have to keep back, two persons com- mence twisting the opposite ends of the towel and keep twisting until all or nearly all the water has been removed. We have in this towel, we will say, a piece of flannel at a temperature of 165° F. (73.9° C), and what does the nurse now do? She picks up the towel containing the flannel, goes to the bedside, * Kentucky Medical Jour., December, 1908. 2 The use of vaselin in this case does not warrant its use when dry heat at much higher temperatures are used, as in "baking." FOMENTATIOXS OR HOT COMPRESSES 351 rapidly unrolls the towel, and places the hot flannel in place upon the bare skin. If the patient howls, lift it up for a second, and then put it back again. Just as soon as the patient can tolerate the high temperature, the fomentation is covered by the blanket, which is pulled as tight as possible to prevent the entrance of the air. There is very little risk of burning if plenty of vaselin has been used. Fig. 118. — The Clow fomentation sink. "Usually in less than sixty seconds you will get a relief that can be gotten from no other application that I know of. "These two procedures any doctor can use. It does not make any difference where he is or how he is situated." A little ground mustard added to the hot water intensifies the action of the fomentation. Dry and moist compresses require frequent change to be effective, and if applied directly to the skin should be tested by the physician or nurse before applying to the patient. 352 HYDROTHERAPY For pain, renewal may be made every minute or two; in less severe cases every three minutes, having a fresh fomentation ready to ai)ply before removing the one in place. Apparatus. — In hospital practice it will be convenient to have a fomentation sink with wringer and drain-board, as seen in Fig. 118. A simple invention for preparing compresses is described in the Lancet,* under the name of Haden's Patent Compress Heater. Fig. 119 — Appljing a f -ni 1 _ L.. . _ Fig. 143. — Temperature of the water at San Diego, California, 12 noon. Sea-bathing is useful in anemia when not too prolonged; in torpor of the liver; in neurasthenia and hypochondria when not associated with too much debility; in nervous dyspepsia, chronic constipation, and obesit}'. Reaction. — The principal safeguard in bathing is a good and prompt reaction. There should be a good glow, and it should be maintained by active exercise in the water. The body should be completely immersed ; wading in shallow water and failure to wet the head and chest produce irregular circula- tion. Reaction is delayed in the weak and in elderly people, whose skin circulation is languid and whose heart action is poor; in those who are fatigued or overheated before bathing, and who are not accustomed to the low temperature of the ordinary sea- bath. SEA-BATHS 381 Precautions. — Those who are bathing for the first time in the season should be cautious and moderate until they are better accustomed to it, and inexperienced bathers had better avoid emulating the feats of the more venturesome. Muscular cramps are among the more formidable dangers to swimmers. They usually attack the leg muscles and sometimes the trunk, and quickly render the swimmer helpless. They are generally due to overstrain, and come on without warning during a long swim; they may occur in good swimmers. If the bather can be brought to shore he should be rubbed vigorously, dried, and warmed. Colicky pains and abdominal spasms may follow a sea-bath taken too soon after eating. Two hours after a meal is a safe rule, but three hours is better if digestion be likely to be delayed. The effects of a sudden shock of cold water before digestion is accomplished are best met with heat externally, dry rubbing, and a small amount of tincture of ginger and water or a little whisky. Aside from the danger of being carried beyond one's depth by unknown currents, or the common danger on some parts of the New Jerse}^ coast of getting into channels of deep water on returning shoreward, a rather frequent source of trouble, there is the danger of remaining in the bath too long and of failing to react properly afterward. On entering the water there is a profound impression on the circulation. The tem- perature may be 30 or 40 degrees below that of the body, and the stimulus to the nerve-centers is great. The superficial vessels are immediately contracted, and the abstraction of heat from the extensive surface calls immediately for greater heat- production. The momentary shiver on entering the water should promptly give place to warmth and a sense of reaction. Counterindications. — When the skin circulation is poor, as it commonly is in those inherently feeble or weak from illness, or in those of advanced years, sea-bathing should be avoided — at least, until better conditions obtain. In any case of heart disease, great care should be exercised; but, as is well 382 HYDROTHERAPY known, cold bathing, when properly used, tends to strengthen the dilated and weakened heart. Persons with cardiac lesions should have friends or attendants near and take no risks. No one should bathe in the ocean who has pulmonary disease or has recentl}^ had pneumonia, pleurisy, endocarditis, peritonitis, appendicitis, or acute Bright's disease. It is stated, on good authority, that sea-baths increase the elimination of urea. On that account we might suppose, a priori, that sea-bathing at moderate water temperatures would be beneficial in cases of moderate chronic nephritis. Care should be exercised, how- ever, that the body should not be exposed to cutting winds. Women should not bathe during the menstrual period. Strange as it may seem, this rule is occasionally disregarded. Complete innnersion is a sine qua non of safety; it tends to equahze the circulation and hasten reaction. Women especiallj'', dislike to wet their heads, as it takes so long to dry their hair; but with closely fitting, rubber bathing-caps, the hair may be kept dry and the head and neck arc sufficiently cooled. Sea- bathing should not be indulged in when the body is greatly overheated; but a good warmth is to be desired, and no time lost, so as to get chilled by strong winds before going into the water. The chief safeguard in the water is to keep moving. A tennis-ball in the surf promotes activity and adds to the pleasure of the bath. Of course, no one should bathe shortly after a meal. Two hours should be allowed for digestion. One should not bathe when greatly fatigued. The bath in the quiet of one's house will be safer and more refreshing. The writer takes about 75 ocean baths each summer, and has rarely seen ill effects in those who bathe regularly. Children who go in and out, sun themselves on the sands, and return again to the water, sometimes show bad effects; but most young people acquire a well-tanned skin in summer, and become so accustomed to sun and water that they seem to bear these transi- tions with wonderful ease. The author saw a case of appendici- tis in a boy of ten, fever and pain developing on the evening of the day on which he had bathed in the surf. Forty hours COURSES OF INSTRUCTION IN HYDROTHERAPY 383 after the bath the operation disclosed free pus in the abdominal cavity. In this case, which fortunately terminated in recovery, no other exciting causes could be assigned, and it was believed that imprudent batliing had brought on the attack. Duration. — No fixed rule can be made as to the proper dura- tion of an ocean bath. This will vary from four to twenty minutes, according to the bather's age, physical condition, and the temperature of the water. COURSES OF INSTRUCTION IN HYDROTHERAPY Course at Colunibia University. — This college has the honor of having established the first chair of hydrotherapy in an American medical college. This chair is ably filled by Dr. Simon Baruch, who has done more than any other American to bring this subject to the serious attention of the medical profes- sion. Since 1907 the classes at Columbia have had the benefit of his teaching, although for several years Dr. Baruch has given instruction, with demonstrations, at the New York Postgraduate Medical School and Hospital.^ The senior class is divided into sections of ten or more, who receive chnical instruction in the hydrotherapeutic department of the Vanderbilt Clinic on Mondays and Fridays. The first half of the clinic is devoted to demonstration of cases, the diagnosis is briefly dwelt upon, and the pathology and etiology are referred to with a view to point out the therapeutic indica- tions. The aid of hydriatric measures and the reason for their employment, with or without drugs, in the concrete case are clearly gone into, and the patient is treated in the presence of the students, who are encouraged to ask explanations of any obscure point. The latter half of the clinic is devoted to de- monstration of the technic of hydriatric procedures, and stu- dents are requested to practice them, just as they are taught bandaging or other manual procedures in other clinics. The clinic is under the charge of a chief and two assistants and an 1 See introductory lecture to the course on Hydrotherapy in the College of Physicians and Surgeons, Columbia Univ. Med. Rec, Feb, 27, 1909. 384 HYDROTHERAPY attendant, who treat cases under their direction on Mondays, Wednesdays, and Fridays from 1 to 4 p. m. Only males arc treated for obvious reasons. Female patients and cases not required forteacliing are referred to the Riverside Associa- tion Hydriatric Department, which is under my tlirection, and treats about 50 cases daily. Wednesday afternoon is devoted to experiments in hydrotherapy. A course of lectures during the latter half of the semester is also provided upon the principles of hydrotherapy and their practical application in disease. The final examination contains not less than two questions on hydro- therapy. The members of the class also have access to Dr. Wittson's wards in the J. Hood Wright Memorial Hospital, where hydro- therapy is practised in suitable cases. Course at the Chicago Institute of Physiologic Therapeutics. — Dr. William S. Sadler's ^ plan of instruction in hydrotherapy provides for the following course : Nerve training, or a graded system of thermic, electric, and hydriatric applications. Muscle training, or graduated exercises, from the Schott system to the heavy manual Swedish movements. Cardiovascular training, beginning with the Nauheim regime and embracing graded hydriatric and massage measures, con- stituting a systematic course of vasomotor gjaimastics. Visceral training, consisting of special douches, massage, and phototherapy, for congested or anemic viscera. Skin training, or a graduated system of hydrotherapy, for the debilitated and inactive skin. Tonic regime for neurasthenia and other nervous disorders. Courses in Europe. — In Wiirzburg, Prof. Geigel gives a course in balneotherapy. In Jena, Prof. Kionka teaches balneotherapy during the summer session, and Prof. Matthes teaches hydrotherapy in ^ Dr. Sadler also has a clinic for hydrotherapy, electricity, massage, photo- therapy, etc., at the Post-Graduate Medical School, 2400 Dearborn Street, Chicago. COURSES OF INSTRUCTION IN HYDROTHERAPY 385 connection with clinical medicine. In Leipzig, Prof. Wind- scheid; in Halle, Profs. A. Schmidt and W. Winternitz. In Berlin, Prof. Brieger is in charge of the new Institute for Hydrotherapy, which subject he teaches practically and ably, assisted by Drs. Krebs, Lacquer, and Machant. At present chnical lectures are delivered with demonstrations on four days each week, 11 to 12 a. m. Prof. Frankenhauser gives instruction in balneotherapy. Prof. Curschman, in Leipzig, has an institute for physical therapeutics; there is also an excellent hydrothera- peutic institute, in Rome, on the via Plinio. Prof. Lechtheim teaches hydrotherapy at Konigsberg; Prof. Schulz, at Greifs- wald; Prof. Ercklentz, at Breslau. A remarkable improvement in hydrotherapeutic facilities has been recently noted throughout Europe, and crude apparatus is being rapidly supplanted by the best to be found anywhere. Dr. J. H. Pratt, of Boston, was m^uch impressed with this fact, and states that it is less than ten years ago that Munich had the only well-equipped department of physical therapeutics in Germany, and before it was opened Dr. Baruch did not find a single clinic in that country with a good hydrotherapeutic douche table. Now all this is changed. In the small city of Heidelberg, for example, there is an institute for physical therapy connected with the university polyclinic, which, in the character and excellence of its equipment, is unequalled by any in the United States. What is of equal importance is the careful medical supervision of treatment. This is under the direction of Prof. Hammer, who is assisted by 8 trained operators and masseurs. This institute for physical therapy occupies over half of the new building of the medical polycHnic, which was erected in 1906 at a cost of $40,000. The growth of scientific hydrotherapy has created a demand for better apparatus. As a result, the best hydrotherapeutic apphances, including the best douche tables obtainable to-day, are made in Germany, although, as stated above, it is only a few years ago that Dr. Baruch called attention to the lack of proper hydrotherapeutic facilities throughout that country. 25 386 HYDROTHERAPY In the medical clinic of Prof. Krehl in Heidelberg there is another complete hydrotherapeutic ecjuipment for the treatment of in-patients, A department for moehanothcrapy is maintained by Prof. Vulpius in connection with the orthopedic clinic. In addition there is a large and attractive "Halle-Bad," which is owned by the City of Heidelberg. The new and expensive buildings contain not only shower and swimming baths, but are equipped also with apparatus for electric-light and carbon- dioxid baths. In Tubingen a douche apparatus has been recently installed.' ACCIDENTS IN HYDROTHERAPY The chief dangers are from falls upon shppery places in the bath-room or douche-room; from vertigo or faintness in getting in or out of the tub, and from epileptic or other convulsions. The author has a remarkable collection of such accounts, taken from the pubHc press. Baths given for medical purposes need much more supervision than baths for ordinary purposes, as the person bathing may be weaker or have some cardiac or cerebral trouble which the heated air of the bath-room or the confine- ment and heat of the pack accentuate. Recently the public press reported the death by drowning in his own bath-tub of a man whose head had slipped below the water in a faint. Hence, an attendant should be at hand, and the patient should never be left unguarded. Drowning accidents due to epilepsy have happened in tubs and swimming pools. Patients have been burned or scalded by hot applications made while unconscious (see p. 181). Claims for damages are occasionally demanded by patients, so that a recent case in Paris has excited a good deal of atten- tion. A medical man. Dr. Cormon, had been called in to at- tend a young woman, Mile. Peyronnette, suffering from appen- dicitis, and as the result of his treatment by ice-bags an eschar had formed, and 50,000 francs damages were claimed. Dr. Balthazard, the medical expert, who had been chosen by the ^ International Clinics, eighteenth series, vol. iv, 1908. ACCIDENTS IN HYDROTHERAPY 387 court to give his opinion, had been rather severe in his first report, but when the trial came on he was much less so, and he found arrayed against him the whole faculty, who one and all considered the eschar an accident which in nowise could be foreseen. Dr. Cormon had been accused of not using a piece of flannel cloth as a protection, but he argued it was the practice of many surgeons to apply the ice-bag directly on the skin. The prosecution found that it could not attack Dr. Cormon on this count, so it accused him of having failed to see the symp- toms indicating the advent of an eschar. Dr. Cormon answered that he had foreseen them, and had then had the ice removed. Dr. Jalagnia and Prof. Dieulafoy declared that there was no exact limit as to the amount of time during which ice should be used on the abdomen, and as for the eschar, it sometimes ap- pears with the greatest rapidity. The testimony showed that Dr. Cormon had not taken the temperature of the patient, which was another fault of which he was accused. Dr. Triboulet, who succeeded to Dr. Cormon in the treatment of the patient, said he had very few changes to make in what was done. Judgment was given as usual a week after the calling of the witnesses, and Dr. Cormon was acquitted.^ Paralytics have been scalded to death by careless attendants. In a recent case the nurse turned on the hot and cold water together while a paralytic was bathing. While the nurse was absent the hot water caused fatal injuries. ^ Therapeutic Gazette, 1907, p. 747. CROUNOTHERAPY'; CRENOLOGY^; OR THE USE OF MINERAL WATERS INTERNALLY The vast extent to which mineral waters are used internally is remarkable. In the United States over 56,000,000 gallons of natural American mineral waters, from 600 springs, are sold annually at a valuation of about §7,300,000. The importations of natural mineral waters reach about 3,000,000 gallons, and are valued at SI, 033,000.^ To what extent waters are sold and con- sumed in Great Britain and the continent of Europe is unknown, but it is known that 30,000 visitors visited Carlsbad in 1906, of whom 2000 were Americans. The number of annual visitors at Nauhcim is also about 30,000. At Baden-Baden they number over 100,000 annually. Of com'se they drank the waters as well as bathed in them.* In the United States there are about 2800 spring localities and nearly 9000 individual springs. In the Yellowstone Park there are 2000 springs and 100 geysers. With this wealth of mineral water in the United States, we naturally wish to make an approximate comparison of our own springs with those of Europe. From an analytic standpoint this may be attempted, but in point of equipment, regime, and scientific appUcation of the waters, America is far behind the European system, although fair attempts are made in a few American resorts to 1 Term suggested by David Riesman, Cohen's System of Physiologic Thera- peutics, vol. ix. 2 Term suggested by Leonard Williams, The Clinical Journal, London, Feb- ruary 3, 1904. ^See The Production of Mineral Waters in 190S, by Samuel Sanford, Wasliington, D. C, Government Printing Office, 1909. Dept. of tlie Interior, U. S. Geological Survey. * It has been calculated that upward of 200,000,000 gallons of aerated waters are consumed in Great Britain and Ireland per annum (Hutchins^on). These waters were invented by the distinguished chemist, Joseph Priestley, in the latter half of the eighteenth century. 388 CEOUNOTHERAPY ; CRENOLOGY 389 carry on the principles of hydrotherapy successfully. In Europe the springs are generally owned and controlled by the local or national governments, which have spent large sums in permanent improvements, including imposing buildings, adequate apparatus, and all the accessories that make the visitor's stay agreeable as well as beneficial. There are strict regulations and usually a small tax is imposed, according to the length of stay, the pro- ceeds being apphed toward permanent improvements. In America there is no State regulation, excepting at the 900-acre reservation at Hot Springs, Arkansas, and in the Yel- lowstone National Park, where the United States Government owns the ground and exercises strict control over the use of the water and fixes the schedule of charges. Private corporations control the best resorts in this coimtry, and, as a rule, they are ahve to their own interests and jealous of the reputation of their particular springs. But the chief criticism under this arrangement will always be that ''to him that hath shall be given," but to him that hath not little attention is paid. The expense of hydrotherapy is very great, although more is being done for the poor of our cities than formerly. It is to be hoped that, as the wisdom and the feasibility of giving the fresh open- air treatment to the poor consumptives is being learned, the state or national government will eventually take up the cor- responding charity of giving to the poor rheumatic, or otherwise disabled citizen, the benefits of our hot springs or other waters so liberally provided by nature. The United States Government has equipped hospitals at Hot Springs, Arkansas, for the officers and enlisted men in both branches of its military and naval service, and also a free govern- ment bath-house for indigent sufferers. The Yellowstone Na- tional Park awaits development in this respect, and for a por- tion of the year could no doubt be utilized. The State of New York has recently appropriated one million dollars toward ac- quiring the famous springs of Saratoga, so that the famous resort, with its valuable springs, may be developed and main- tained as a State property, free from objectionable features, and available for the people of every class. 390 HYDROTHERAPY CLASSIFICATION OF MINERAL WATERS The following classification by Dr. A. C. Peale, of Washington, is the most practical.' It gives at once a definite idea of the general chemical composition and other characteristics: Group. A. Thermal. B. Non-thermal . Class. f I. Alkaline. r Sulphated, II. Alkaline-saline. < Muriatcd, [^ Borated. {Sulphated, Muriated, Borated. IV. Acid. [ Sulphated, ' Muriated, Silicious / Sulphated, I Muriated. 1. Sodic 2. Lithic 3. Potassic 4. Calcic 5. Magnesic 6. Chalybeate 7. Aluminous } Non-gaseous. Carbonated COj. Sulphurated H.,S. Azotized N. Carburated. Oxygenated O. RADIO-ACTIVITY OF MINERAL WATERS Waters containing a comparatively small amount of mineral constituents have been claimed to have a therapeutic value which the ordinary chemic analysis fails, as a rule, to explain in any adequate manner. It is barely possible that the recent discovery of radio-active properties in some of these waters may afford some explanation of these qualities. Some of the thermal springs of Europe, such as Baden near Vienna, Bad Gastein, Joachimstal near Prague, Luchon, Plombieres, Dax, La Bourboule, Aix-les-Bains, and Buxton, England, have been * See Transactions of the American Climatological Association, 1887, p. 156. RADIO-ACTIVrrY OF MINERAL WATERS 391 tested in this respect, and have been found to contain slightly varying quantities of argon and helium with distinct radio- active properties, these elements showing a constant association with waters of this class. The suggestion has been offered that this fact throws some light on one of the problems of the chemistry of mineral waters, namely, why a natural mineral water should have distinctly greater therapeutic power than a water to which is given artificially precisely similar chemic constituents accord- ing to a standard analysis. Mineral-water baths afford a great opportunity for charla- tanry. Claims are made regarding an electric action in the bath, and the mysterious quality of radio-activity has lately been brought forward, reaching England and America, in ex- plaining the efficacy of various mineral springs. W. R. Huggard says, ''There is not a particle of scientific evidence to warrant the belief in any greater electric action in the mineral baths at spas than in baths taken quietly in one's own room. The radio- activity of mineral waters now occupies much attention, but, up to the present, we have only speculations as to its therapeutic influence." ^ 1 The following letter, from Prof. Wolcott, was received by the author in response to an inquiry as to' the radio-activity of waters in Colorado : Colorado School of Mines, Golden, Colo., Jan. 3, 1906. Dear Sir: In regard to the mineral waters of Colorado, I have examined the waters at Glenwood Springs and at Manitou and found them radio-active. I have examined also several samples sent in, but found none of them radio-active. The water from Clear Creek, which flows through this city and which drains the region near Central City where the Pitchblende mine is located, is radio- active and the time of decay corresponds to that of the radium emanation. We are at present working along this line and the results have not as yet been published. Very truly yours, E. R. Wolcott. Prof. Boltwood, of Yale, was commissioned by the U. S. Government to examine the waters of Hot Springs, Arkansas, and reported them all radio- active. This is due to a dissolved radium emanation, a gas, and not the presence of salts of radium or other radio-active substances. 392 ' HYDROTHERAPY " Another antiquated notion is that the solid constituents of the baths are absorbed through the skin. The evidence is now overwhehning that through the unbroken skin there is no absorp- tion except for gases, volatile substances, and substances in- corporated with some fatty agent which can be rubbed in. Iron, even if present in tenfold the amount found in mineral waters, would, when applied externally, be quite incapable of acting on the blood." '■ The following is a partial statement of the radio-activity of various European springs, according to the authors quoted : Radio-activity in milligram minutes (10 liters of gas). Bad Ga.stein, Austria, Gratenbacker 79.20 Bagncres-dc-Luchon, France, Borden 18.36 Source, Borden, No. 2 14.43 Pre, No. 1 10.23 " Saule, No. 2 9.42 " " " " Fcrras enceinte 4.19 Plombi^res, Source, Vauquelin 14.90 Galerie de Thalweg 13.60 " Les Capucins 4.62 Aix-les-Bains, France 3.52 Dax, France, Source, Trou-des-Pauvres 2.92 Bagn6res-de-Bigorre, France, Source, Salies 2.32 La Bourboules, France ("\Vater.«) 3.56 Bagneres-de-Luchon " 2.20 Aix-les-Bains " 54 Mm. Curie and Laborde, Mm. Ch. Moureu, and A. Lepape and A. Brochet have made a systematic study of the radio- activity of some French springs. The observations are reduced to a standard of "milligram-minutes " for 10 liters of gas emanat- ing from the spring tested, and also for 10 liters of the water. The standards of measurement were first prepared by Mm. Cheneveau and Laborde,- and are detailed by ]\Im. Ch. Mouren and Adolphe Lepape in Bulletin de I'Acad^mie de Medecine, 1909, No. 13. Mouren and Lepape spent six months at Bagneres-de-Luchon * Handbook of Climatic Treatment, London, 1906. 2 Journal de Physique, 1908, 3d fascicule, p. 262. For the radio-activity of the waters of Baden-Baden, .see The Brit. Med. Jour., April 23, 1910, p. 1004. RADIO-ACTIVITY OF MINERAL WATERS 393 with Mm. les Drs. Ferras and Estradere in the study of twenty separate springs. They noted that the emanation of radium from the gas' which they tested diminished gradually and spon- taneously after collection, so that after about four days only about one-half of the radio-activity remained, corresponding in this respect with M. and Mme. Curie's statement. The Joachimsthal Baths. — Ever since the examinations, con- ducted by competent scientists, of the nature of the therapeutic action exercised by the Gastein waters have shown that the main source of the beneficent quality is the presence of radium emanation, experiments have been going on in the place where the greatest quantities of pitchblend and radium salts are found, in Joachimsthal near Prague, to ascertain whether the waters found in these mines could not be used for medical purposes. At the clinic of Prof Neusser of Vienna, a large number of patients have been subjected to a treatment with these waters. Patients with gout, rheumatism, neuritis, and diabetes have been benefited by the internal and external use of Joachimsthal mine water. It has been found that there are two distinct groups of waters to be obtained therefrom. The weaker water, containing from 8000 to 10,000 volts of emanation, was derived from the underground springs and brooks, which are constantly flowing in the deeper shafts, and have to be pumped away to keep the mine workable. The stronger water was obtained from the refuse of the mining process, wliich combines various chemic processes, and in its last step requires the washing of the material by sulphuric acid. The ultimate results are uranium (used for coloring purposes) and a water charged with radium emanation in a high degree, so that it excels the Gastein waters three or four times in its voltage. These latter waters have been used also for prostatic enlargement with remarkable success. The baths have shown themselves so active that general symptoms (due to destruction of leukocytes) may appear after incautious use. In Joachimsthal itself, a bathing house with at present only twelve cabins has been established for radium baths. In a similar way the hot sulphur baths of Baden, near Vienna, have been tested 394 HYDROTHERAPY and the presence of radium emanation, though in a lower degree, was detected. The experiments tend to show that the i)resence of the active principle is in an inverse ratio to the temperature of the water. The sulphur nmd deposited at the hot springs in this place contains radium bromid, so that it affects the photographic plate. This explains why, for instance, inveterate cases of skin disease respond so readily to the mud baths at Baden, although they are refractory to water baths and oint- ment even in Aachen or other hot suli)hur baths. It is planned now to institute special radio-active sulphur baths in this place, and it will be the first health resort of its kind which can boast both of the vicinity of the capital and of the radio-activity. Artificial Radio-active Waters.— Attempts have been made to produce radio-active water by artificial methods for thera- peutic purposes. Dr. William J. Morton uses a water rendered radio-active by immersing from 50 to 100 pounds of a high-grade pitchblend in a vessel of water, and has found that the measure of radio-activity of the water is about one-tenth to one-half that of metallic uranium. The rate of decay of the radio-activity, however, was very rapid, falling to one-half in a few hours, and no trace remaining after a few days. Dr. John B. Shober, of Philadelphia, following a suggestion of Prof. E. Rutherford, of London, has used purified cocoanut charcoal, and succeeded in raising the water so treated to one hundred and sixty times the radio-activity of uranium oxid. His conclusions are that the beneficial effects of radio-active spring waters, and the results obtained abroad by the administra- tion of weak emanation preparations, warrant the belief that in the highly radio-active charcoal we have an agent that will be followed by the same, if not better, results.^ The waters of Kreuznach have been used extensively for a long time for bathing, and of late a good deal of stress has been laid on the radio-activity of these waters as a factor in the cure. Englemann attributes great value to the well-known 1 Jour. Amer. Med. Assoc, Aug. 21, 1909, pp. 624-628; see also Nagel- schmidt, Berliner Klin. Woch., March 16, 1908. HOT-WATER DRAUGHTS 395 rich radium emanations of the water and the sediment. He has recently^ reported on the results obtained in 234 patients, who took 2595 baths, the principal indications being rheuma- tism, sciatica and other neuralgias, gout, and for the resorption of pelvic exudates. The results were considered favorable. Other springs, as those of Postyen (Pistyan), in Austria, are also coming into favor in the same manner, having a fair degree of radio-activity. INTERNAL USE OF WATER IN HEALTH The healthy adult requires, according to his weight, from 1 to 2 quarts of water daily, independent of the water contained in food. The labor of transferring this amount to the excre- tory organs — the kidneys, lungs, bowels, and skin — falls on the heart. The circulation, glandular secretions, peristalsis, and metabolism are distinctly influenced. Water is not absorbed to any very great extent by the stomach, but by the bowels, and hence as much good or more can be accomplished by en- teroclysis as by administration of water by the mouth. Regarding metabolic changes produced by water drinking, it must be recognized that for a short time, at least, nitrogenous products are washed out, but it has been shown that pure water has no effect on the sphtting up of albumins and on the general metaboHsm (Rubner). Schoendorff and other authorities believe that water drinking has very little practical effect on the excretion of uric acid. HOT-WATER DRAUGHTS Hot-water drinking is not so much in vogue as it was ten or fifteen years ago, probably on account of the tendency to undue relaxation of the gastro-intestinal tract when continued for long periods. In small quantities hot water raises the pulse- rate and lowers the blood-pressure. After twenty minutes the usual rate and pressure are restored. 1 Medizinische Klinik, May 30, 1909, No. 22. 396 HYDROTHERAPY Natural Thermal Waters. — The principles applying to the use of hot- or warm-water draughts are equally applicable to the weaker natural thermal waters. These are indicated in hyper- chlorhydria, gastrorrhea, and gastralgia; acute, suppurative, and interstitial nephritis. In the latter affection there are favor- able reports from the judicious use of water, in connection with hot applications to the back and abdomen. The author is more inclined to the moderate use of water in nephritis than in his earlier practice. Hot-water draughts are counterindicated in disease of the heart with failure of compensation. In this class of cases it is best to restrict the total quantity of water consumed to about 1200 cc, independent of the water contained in the food. In administering water to promote diuresis, it must always be borne in mind that we have to look to the heart for the vis a tergo: while there is low pressure in the kidneys there can never be satisfactory diuresis. The weaker natural waters are usually more acceptable to the stomach by reason of large gaseous contents at their source. Artificial heat applied to ordinary tap-water drives off the carbonic acid gas and oxygen, which are largely present in most thermal springs. Hot springs are found in Virginia, Arkansas, California, Colorado, New Mexico, and South Dakota. In Europe, those of Aix-la-Chapelle, Baden-Baden, Ems, Carlsbad, Wiesbaden, Gastein, Bath, and AJK-les-Bains are the most famous. COLD-WATER DRAUGHTS These are indicated in febrile states and in hypochlorhydria. The most favorable time for use is thirty to forty minutes before meals. Cool water should be used freely before and during the hot bath, and given abundantly in typhoid fever. In some hospitals a special nurse is assigned to give water to the patients. Cold water is counterindicated in gastric dilatation, gas- troptosis, colic, in cases with a weak myocardium, and in all states of fatigue and when perspiration is free. Ice-water is DISTILLED WATER 397 particularly dangerous at these times, although the temptation is very great to quench thirst. In most cases the free use of water during meals is not advisable. It is believed to delay the digestion of starchy and other foods. Individuals, however, vary greatly in this respect, and many are accustomed to drink 3 or 4 glasses of water during meals with entire impunity. The author believes that a moderate amount of cool water — 1 glassful — is not, as a rule, injurious. Patients who must avoid starchy foods, and who eat freely of meat, are no doubt benefited by the free use of pure water before and after meals. Most people drink too little, and this is particularly the case with women, and very often leads to constipation, acid, dense urine, and occasionally to irritability of the bladder accompany- ing urine of high specific gravity. Many stomachs are ruined by an attempt to flush the system with large quantities of water, and hence it is a rule to avoid large quantities of water or liquid food in cases of gastroptosis, etc. (see p. 150 et seq.). DISTILLED WATER This is a chemically pure water, made palatable by the addi- tion of oxygen, with or without carbonic acid gas. Much discus- sion has arisen as to the propriety of using a water without any solid constituents, the claim having been made that its use tends to abstract valuable salts from the system. These objec- tions are more theoretic than practical, the rather extensive use of distilled water on shipboard and elsewhere not having been attended by any bad results. Oxygenated and carbonated distilled water is ^ddely sold under various trade names in syphons. It is much more palatable than the distilled water of the chemic laboratory and more economical. Distilled water can be easily and cheaply produced for household use by means of a still heated by gas or oil. A satis- factory apparatus, shown in Fig. 144, is known as the Par- melee Automatic Aerating Water Still and Sterilizer. If oil be used to heat it, a blue-flame Primus or Khotal oil-stove should be employed. 398 HYDROTHERAPY Distilled water is no doubt an ideal drinking-water, far pref- erable to the mineralized waters for constant use. In regions where limestone formations and alkaline deposits characterize the soil, the use of distilled water would prevent the disturbance of the stomach and bowels commonly observed.* Dr. G. Bullot, of the Universit}' of California, has recently carried on some experiments with fresh-water crustaceans, finding that they die promptly when placed in distilled water. External view. Sectional view. Fig. 144. — The Parmclee still (Ashton). It is the author's belief, however, that oxygenated distilled water for drinking purposes is not injurious. Marcuse noted the total amount of urine voided by a patient aged thirty-five who, for five years, had had chronic parenchy- matous nephritis. This patient for ten days previous to the experiment passed an average of 724.5 cc. of urine, the specific * See article by Marcuse on Advantagers of Distilled Water as a Beverage in Nephritis, Berliner Klinische Wochenschrift, xliv, No. 14, 1907. See p. 405; Winckler, Zeitschr. f. diet. u. physik. Therap., Bd. viii, H. 10, p. 567. DISTILLED WATER 399 gravity varying from 1.019 to 1.025; the albumin ranging from 1.35 to 2.25 per cent, by Esbach's scale. During the sub- sequent ten days, in which from 1 to 1| liters of distilled water were given daily, the average amount of urine was 1326 cc. — an increase of 83 per cent. The specific gravity was gradually lowered to 1.007, and the amount of albumin excreted remained about the same. The increased diuresis was not accompanied by an increase in the amount of solid constituents in the urine, but rather the reverse. Under the use of Pyrmont water, however, during the next twenty days the total amount of urine slightly increased to 1610 cc, and the amount of albumin passed was slightly greater. Marcuse's conclusions are that distilled water has not the slightest injurious effect on the organism. This conclusion was borne out by further studies by Axel Winckler, Marcuse, and others. The purer the water the greater is the capacity for the solu- tion and the eUmination of the unnecessary salts produced in the process of digestion and assimilation. The food should provide all the necessary salts in abundance, and hence distilled water, or the chemically indifferent waters, are best for constant use. The author does not wish to be construed as depreciating the value of the more highly mineralized waters. They are undoubtedly valuable for purgative and other purposes and favor elimination through the bowels. They have their place for occasional use. Other individuals seem to require the constant use of an alkaline water, but the average man is better off on the purest water he can find. American waters containing a minimum of salts are the following: Maine — Poland Springs, Highland Springs, Mount Hartford Spring; Vermont — Equinox Spring; Massachusetts — ■ Commonwealth Mineral Spring, Massasoit Spring, Nobscot Moun- tain Spring; Connecticut — Stark Mineral Spring; New York — ■ Colonial Springs, L. I., Great Bear Water, Sun Ray Water, Ellen ville, N. Y.; Pennsylvania — Glen Summit Water, Ros- common Spring; Maryland — Bentley Spring. 400 HYDROTHERAPY WATER DRINKING IN DISEASE Obesity. — Authorities differ greatly regarding the use of water in this condition. Mr. Banting, who reduced himself in a year from 202 to 156 pounds, limited the total daily amount of fluid to 35 ounces. Oertel allows 8 to 16 ounces of water, 12 ounces of wine, and 2 cups of coffee, tea, or milk daily. In hot weather the amount of fluid may be slightly increased, and should be taken in small portions through the day. Schweninger suppresses all beverages at meals, and allows no fluid until two hours have elapsed since food. Germain See, on the other hand, allows large quantities of warm aromatic drinks. No doubt this is the best course in fat and gouty people, and such patients may be allowed i pint of water after each meal and at bed- time. Where physical exercise is required, and especially when depleting baths are used, water should be allowed. Even dur- ing meals some water should be taken to aid in the solution and digestion of food, (See p. 197.) In treating poorly nourished persons, water may be added to milk in the proportion of 2 tablespoonfuls of hot water to a glass of milk, to which is added 5 gr. each of common salt and sodium bicarbonate. In this way the digestibility of the milk is favored. Bronchitis. — In all cases of bronchitis with- hard and ineffect- ive cough, water generally gives relief. Warm drinks before retiring will frequently allay cough, and, as every mother knows, a drink of water will often stop a persistent cough in children after settling for the night. Measles and Bronchopneumonia. — Cold water in quantities from 4 to 6 ounces should be given to children with measles and bronchopneumonia, and repeated every two or three hours. In nephritis it is generally held that the free use of water internally is beneficial. Certainly a glassful, taken night and morning on an empty stomach, will act as an eliminant. It does not follow, however, that where much is good more is better. It is quite possible to flood the heart and arteries with water and WATER DRINKING IN DISEASE 401 seriously overtax them. Ascites is a very evident counterin- dication. The underlying motive in giving water and milk ex- tensively is to flush the kidneys and aid the elimination of toxins or other irritants. Prof, von Noorden, however, in his monograph on Nepliritis, takes the ground that, as water is always very badly excreted by the kidneys when they are acutely diseased, and frequently also in subacute and subchronic forms of nephritis, the extensive use of milk and water is not logical: "A condition of hydremia must be regarded as a constant source of irritation of the kidneys, and the problem that confronts us is to prevent excessive stimu- lation of these organs as much as possible." ^ Concentration of Blood-serum after Talcing Much Water. — Engel and Scharl were unable to discover that the blood-serum became less concentrated after ingestion of large amounts of water followed by copious voiding of urine. No hydremia to speak of is observed under such conditions, either in the healthy or in those with kidney affections. On the contrary, an actual increase in the concentration of the blood-serum may be noticed, sometimes at the time of the greatest diuresis. It has been frequently noted that water from glacier ice has an injurious effect on the gastric mucous membrane, independent of its low temperature. Some difference might be expected according to whether hypoisotonic water or hyperisotonic water were used. Grube used the former and found a very slight increase, but Grossmann,^ with waters of both these classes, found no essential alteration in his own person. In cases of disease, however, the result might be different. Unless the heart be seriously at fault, the author believes in giving water moderately in nephritis, especially pure or the slightly mineralized waters, skimmed milk, ginger ale, etc. People vary, but water drinking is certainly in most cases a piiysiologic, hygienic, and remedial measure of value. ^ Berliner Klinische Wochenschrift, xliv, No. 14. 2 Grossmann, Deutsche Med. Woch., 1903, 276. 26 402 HYDROTHERAPY A draught of cold water may reduce the frequency of the pulse and cause a slight fall in the body temperature, especially in the internal temperature as measuretl in the rectum (Weber). In typhoid fever cool water should be administered in small quantities at frecjuent and definite intervals. It may be pos- sible in tliis way to give as much as 2 or 3 quarts in twenty-four hours. The amount of urine is increased, the nervous symptoms are lessened, and the patients are made more comfortable. The internal use of cold water is a good adjuvant to the cold bath and it is believed to lessen the mortality. The method adopted by E. F. Gushing and T. W. Clarke in 100 cases treated by tliis method was to give not less than 3 pints daily. It was fountl that the amount of water that patients would take could be greatly increased. The quantity often reached 1 or IV gallons. This was accomplished by giving 4 ounces of water every fifteen minutes during the waking hours. In addition, the patient received alternately, 6 ounces of milk and 6 ounces of albumen-water every two hours during the day and once or twice at night, representing some 3 pints of fluid. Besides all tliis, a bowl of ice- water was kept by the bedside, so that the patient could help himself. An occasional patient rebelled at first, but the majority took the water readily and some greedily. The natural result was first a great increase in urine, which rose as high as 8 to 12 pints, and was maintained at tliis standard during the febrile part of the disease. Fewer baths were required and headaches were not so troublesome, the mouth w^as noticeably clean and moist, and the nervous and toxemic symptoms less. There were few complications, and the mortality as well as the severity of typhoid fever seems to be lessened by this free use of water internally. We have not noted, however, any great tendency to adopt these suggestions. It is possible that the method is open to objections. Heart Disease. — In general, it may be said that mineral waters containing lime salts should be avoided by patients with heart disease. Lime is believed to raise the blood-pressure, and an excess of fluid has ob\ious disadvantages. Those with mitral ALKALINE WATERS 403 lesions should reduce the intake of fluid to about 2 pints a day. In valvular heart disease, especially in imperfectly com- pensated mitral disease, in obese people with weakly acting hearts, and in patients suffering from atony of the stomach with dilatation, water should be restricted. People who work hard in a hot atmosphere are liable to habitually drink a large quantity of water or beer, and suffer from digestive disturbances due to a weakening of the gastric juice. Bakers and men in breweries may have what is known as a chronic hydremic plethora, which favors dropsy and degenerative changes in the heart and blood- vessels.^ SPECIFIC VALUE OF MINERAL WATER ALKALINE WATERS These are sodic or sodic-magnesic or alkaline chalybeate or calcic. The best waters of the first group are Saratoga Vichy, Ukiah Vichy, Cal.; St. Louis Spring, Mich.; Manitou, Colo.; and California Seltzer. They are rather more potent than the corresponding foreign waters. The principal European waters of this class are those of Vals, in the Ardeche, France; at Karlsbad, Austria; Vichy, in France; in the Auvergne Mountains, Bi|in and Marienbad, in Bohemia; Fachingen, Wildungen, Ems, and Apollinaris in Germany. Apollinaris is found the world over, and as a table water is par excellence. The Vichy Celestin, or Grand Grille, is also widely sold in America. This water is of great value to dyspeptics with strongly acid urine, to gouty and rheumatic subjects, to patients with biliary calculi, and to patients having eczema or psoriasis associated with markedly acid tendencies. A tumblerful may be taken two or three times a day, but not con- tinued, as a rule, more than two or three months at a time. The author has never seen any bad results from taking ^ See Climatotherapy and Balneotherapy, by Sir Hermann Weber and F. Parkes Weber, London, 1907, p. 301. 404 HYDROTHERAPY Cclcstin Vichy for long periods, notwithstanding very extensive use of this water. He is personally acquainted with a gentle- man who has had attacks of gall-stones, and has used the water almost daily with benefit during a period of over two years. Waters of the Carlsbad type, hot sodic-magnesic alkaline waters, are especially valuable in hyperchlorhydria and ulcer of the stomach. Exceptional cases arise, but in general it may be said that Carlsbad is especially useful in completing the cure of gastric ulcer. Chronic catarrhal conditions of the gastro- intestinal tract do best at Carlsbad. Patients with constipation and hemorrhoids are more successfully treated with the colder waters of Kissingen. Fachingen water has a great reputation in Germany, owing partly to the fact that the emperor is reported to take it daily. It has been subjected to elaborate tests by Klemperer,^ who demonstrated that the weak alkaline urine produced by Fach- ingen water can actually dissolve concretions of uric acid; 100 cc. of a twenty-four-hour specimen of a patient's urine were taken in three days, and a uric-acid stone was immersed for twenty-four hours in each specimen. In the faintly alkaline urine there was a slight loss; in acid urine, on the other hand, there was an infinitesimal gain. By drinking a bottle of Fach- ingen water daily the free uric aid fell practically to nil (von Noorden). Observations such as those on calculi already excreted are no doubt encouraging, but the important matter to determine is the value of these alkaline waters in controlling the excretion of uric acid in true uric-acid gout. There is a great deal of misconception as to the value of mineral waters in this respect. Patients are invariably disappointed if larger quantities of uric acid are excreted after the ingestion of such waters; and how- ever encouraging to the physician such a temporary circumstance may be, the patient always wants to know that the output is reduced. In gout, according to von Noorden, w^th or without uratic 1 Behandlung der Neirensteinkrankheit, Therapie der Gegenwart, 1904, 337. ALKALINE-CALCAREOUS OR EARTHY MINERAL WATERS 405 deposits, the normal average excretion of uric acid and purin bases is, as a rule, not quite attained, and, in spite of our ignor- ance of the pathology of gout, increased uric-acid excretion must be regarded as a good sign, provided it be not due to increased uric-acid formation. This latter process may be set up by an increased intake of purin bodies, perhaps by alcohol or even certain drugs; but inorganic substances, as far as ascer- tained, produce no such result.^ THE ALKALINE-CALCAREOUS OR EARTHY MINERAL WATERS These waters contain calcium carbonate or sulphate and are valuable for their antacid and diuretic properties. As a rule, they are well borne by the stomach, counteracting hyperacidity of the stomach and urinary tract. For this reason they are largely used for the treatment of gout and rheumatism, but too large a quantity of calcium sulphate is a disadvantage to the stomach, and renders the water somewhat difficult ' of digestion. It is noteworthy that even after the drinking of large quanti- ties of mineral water containing calcium carbonate or sulphate only traces of calcium are found in the urine. Most of this is un- absorbed or is excreted by the large intestine, von Noorden shows that an important and beneficial reaction follows; that calcium in the intestinal canal before its absorption, and perhaps also during its re-excretion into the bowel, combines with phos- phoric acid, and so prevents the latter's transference to the kidneys and urine. Thus the total amount of phosphates in the urine is diminished, and, as the reaction of the urine approaches alkalinity, the proportion of disodium to monosodium phosphates is modified in favor of the former. Most of these waters in the natural state contain considerable quantities of carbonic acid gas, and, therefore, are best used at their source. Calcium salts are eagerly sought by the acids of imperfect digestion. The latter readily combine with the ^ See Von Noorden, Metabolism and Practical Medicine, vol. iii, p. 949, English edition. 406 HYDROTHERAPY bases thus furnished, and probably in this manner obviate union with similar bases found in bone, cartilage of joints, and in other natural tissues of the body. A proper selection of food, such as vegetables rich in salts, accomplishes a similar purpose, and this diet goes hand in hand with the use of mineral waters in the treatment of these affections. Calcareous mineral waters favorably influence rheumatism of a subacute or chronic type, gout, gravel, pyelitis from kidney connection, chronic gonorrhea, broncliial catarrh ^ith profuse secretion, and allied affections. They are credited with favor- able results in scrofulosis, rachitis, and osteomalacia. The cold calcareous waters most used in the United States are those of the Healing Springs, Virginia (25 gr. per gallon); Bedford Springs, Pennsylvania (107 gr. CaSO^ per gallon); Greenbrier White Sulphur Spring, W. Va. (78 gr. CaS04 per gallon) ; CUfton and Richfield Springs, New York (69 gr. CaSO^ and 112 gr. CaSO^ per gallon); Napa. Soda Spring, California (10 gr. CaCO,), and Manitou Springs, Colorado (65 gr. CaCOj per gallon). The most extensively used thermal calcareous waters are at Hot Springs, Arkansas (7 gr. CaCO.,). Equally efficacious springs of this class are found in the Virginias, Kentucky, Michigan, New York, and Pennsylvania, some of them having rather more than local reputation. In Europe cold earthy waters of wide reputation and popu- larity are found at Marienbad in Bohemia, Contrexe\ille in France, Wildungcn in Germany, Leukerbad in Switzerland, and Bath in England. Of this class the waters of Contrexe\'ille are best known and most used in the United States. The waters of Kreuznach, Germany, are of this class, containing chlorin, iodin, and bromin in combination with the earthy bases. They are used internally for tertiary syphilides and strumous diseases. SALINE WATERS; MURIATED SALINE WATERS Springs of salt water have been used for ages in Europe, the most famous being those of Homburg, Kissingen (Rakocsy), SALINE waters; muriated saline waters 407 Karlsbad (Sprudel), Soden, Friedrichshall, Nauheim in Germany; Hall and Salzburg in Austria; Cheltenham and Leamington in England. In the United States the best springs of this class are those of Saratoga, Ballston Spa, Syracuse, and Glen Springs, New York; Mount Clemens, Michigan; Upper Blue Lick, Kentucky; Eureka Springs, California; and Waukesha, Wisconsin. There are numerous salt wells in Texas and Kansas. In Canada, Caledonia Springs, Sandwich Springs, and St. Catherine's Well, all in Ontario, have rather more than local reputation. They are purgative, and exert secondarily a good effect on the liver and gastro-intestinal functions. Their reputation having rested for years on a purely empiric foundation, it is highly gratifying to note the recent attempts to determine the true physiologic action of these waters. Effects on Metabolism. — We are indebted to von Noorden, of Frankfort, and Carl Dapper, of Kissingen, for the best exposi- tion of the effects of saline waters on metabolism.^ Their observations were made on persons undergoing a drinking cure for various affections, comprising anacidity, subacidity, and hyperacidity of the gastric juice, chronic intestinal catarrh, gastric ulcer, obesity, diabetes mellitus, and the effects of alcohol. One observation made, and a curious one, was that in numerous cases of gastric disorder, particularly in gastric catarrh, the use of saline mineral waters leads to an active and permanent in- crease in the production of hydrochloric acid. On the other hand, in cases accompanied by hyperacidity, particularly in nervous dyspepsia, the moderate use of saline mineral waters leads to a decrease of the hydrochloric acid production and a decrease of the subjective symptoms. That a given remedy should work a cure in cases of a diametrically opposite nature is one of the paradoxes of medicine. But the high standing of these clinicians, and the great care shown in minute exam- inations made of the gastric secretion while the patients were ^ Diseases of Metabolism and Nutrition, Part V, by Carl von Noorden and Carl Dapper; American edition by Boardman Reed, 1904. 408 HYDROTHERAPY undcr observation, IcAvc no doubt that the conclusions are correct. In so refractory a condition as hyperacidity no one mineral water has been found a panacea.' Another important point, brouglit out by the observations referred to above, is that the administration of saline mineral waters docs not call for any particular diet. Arbiti'ary and routine dietetic regulations are in vogue at many health resorts. There is a popular prejudice among many physicians, and it is shared by the general public, that each particular saline water calls for the exclusion of certain definite atricles of food from the diet regardless of the disease. In other words, that each water calls for a definite dietary. The governing principle should be that the diet should be adapted to the particular needs of the patient, and not be given in a routine way, according to the water prescribed. Although this antiquated method is not confined to European resorts, it is probably more commonly employed in Europe than in America. That the use of fats should be forbidden while taking saline waters is one of the fallacies that the authors quoted above have pointed out. They make the valuable practical point that many patients need the fats of a normal diet to maintain their nutrition and strength. Undoubtedly, there are patients with gastric and intestinal trouble, with diabetes or gout, many neurasthenics and convalescents from various diseases who need fats, and who are perfectly able to digest and assimilate them. That they are assimilated the records plainly show. The use of saline waters does not affect the proteid metab- olism, and hence they are suitable in cases of overfatness in which it is never desirable to diminish the proteid contents of the body. Several investigators have published the results of experiments on animals and in healthy persons, showing a ^ "To argue, as is done, that because simple saline waters are beneficial in subacidity, therefore they are contraindicated in hj'peracidity, is a form of cleverness which rejects facts and opposes the free growth of knowledge." — von Noorden. SALINE waters; muriated saline waters 409 slight increase in the excretion of urea after the ingestion of sodium chlorid, but von Noorden's conclusion that proteid metabolism is not appreciably affected is generally believed to be correct. In adopting a milk diet the small quantity of salt present is not usually considered a disadvantage;- water in this case is eliminated freely. Saline waters should never be administered to patients with nephritis^ especially when edema is present. This is now con- sidered bad practice, and much light has been thrown on the danger of chlorid retention by the works of Widal and others. A salt-free dietary is enjoined, and hence chalybeate waters, cal- careous waters, and other waters devoid of salt are to be chosen. An edema which has disappeared in the course of nephritis, may be caused to reappear when salt is ingested. It is best to avoid salt in any case of albuminuria. We believe its use is positively • counterindicated . As a laxative and cathartic good saline waters like Congress and Hathorn have for years had a great reputation in the United States. All the Saratoga waters and those of Mt. Clemens have a large saline content. It is impossible and, perhaps, unnecessary in this work to discuss fully the large question of the role of chlorid retention in nephritis. An excellent presentation of this subject was made to the American Medical Association in June, 1909, by Drs. Victor C. Vaughan, John H. Musser, Henry A. Christian, Edward F. Wells, D. L. Edsall, Rochester, Tyson, and others.^ Widal and Javal's discovery has evidently influenced medical practice throughout the world. It is pretty well agi^eed that a reduction in the amount of sodium chlorid ingested, aside from any influence on edema, helps largely to reduce the work that the kidneys do; that an amount of sodium chlorid no more than that equal to what is taken in an ordinary daily diet may cause ^ See full report in Jour. Amer. Med. Assoc, November 27, 1909. See also La Cure de Dechloruration dans le Mai de Bright et daus quelques Maladies Hydropigenes; Par le Dr. Fernand Widal et le Dr. Adolphe Javal, Paris, Bal- liere, 1906; ibid., Bull, et Mem. de la Soc. Med. des Hop. de Paris, 1903, p. 733; Delearde, L'Echo Med. du Nord, January 20, 1907. 410 HYDROTHERAPY decided failure of function on the part of the kidney, even in cases in which the kidney appears to be tloing fairly good work (Edsall). We, therefore, shoukl be on our guard not to allow patients with scarlet fever or in any stage of nephritis to di'ink waters containing sodium chlorid in any appreciable quantity.' Regarding the excretion of the uric acid the conclusion is that in cases of gout the use of saline waters (e. g., Kissingen, Rakocsy) causes an increase, amounting occasionally to as nmch as .2 grams a tlay, although in exceptional cases no change can be noted. In another case of gout, recently examined in von Noorden's laboratory, it was found that the use of saline and sulphate waters did not produce any increase of the fecal purins. As an example of what may be expected, the following case of Dr. F. K. may be quoted: Age fifty-five; frequent attacks of gout for fifteen years. Chronic gouty changes in the joints with tophi in the ears and hands. There has been \rdm and swelling. The subject was obese, and showed great muscular weakness. He had a diet of meat, mashed potato, salad at dinner and supper, bread and butter, two oranges, a bottle of mild Bordeaux wine, and a bottle of Apollinaris water. For four days his average excretion of uric acid was .566 grams. For the next five days he was given 800 cc. Homburg Elizabeth water (686 gr. salt per gallon) in place of an equal amount of Apollinaris water. The average excretion of uric acid was then .765 grams. In the after-period, in which he returned to the original solid and Uquid diet, the excretion was .695 grams. This shows that saline waters have a useful place in the treat- ment of gout. Similar cases arc cited by von Noorden.- There need be no interdiction of raw fruit while using saline mineral waters, unless the individual case demand it. The drinking of saline waters, or of any other water per se, does not call for the restriction of any particular article of food. 1 The Hindu, Charaka, advised a salt-free diet in Ascites, 1000 b. c. • Dr. Leonard Williams, of London, takes strong ground against the use of sodium chlorid waters in the treatment of gout. Jour, of Balneology and Climatology, Jan., 1907. The author heartily endorses this position. SEA WATER 411 SEA WATER In a recent number of the Repertoire de Pharmacie M. P. Carles gives an interesting account of the use of sea water in medicine. In addition to common salt, sea water contains many- important mineral substances, the total solid matter amounting to 3.2 to 3.8 per cent. Some of these substances are present only to an infinitesimal extent, but in biology the value of a substance is not necessarily dependent upon its actual size or quantity. It has been shown that various marine plants have the power of extracting from sea water minute quantities of compounds of iodin, bromin, arsenic, boron, manganese, lithium, fiuorin, rubidium, cesium, and other elements. Hence it is not unreason- able to suppose that the higher animals might derive benefit from the assimilation of even minute traces of these physiologically active substances. The employment of sea water as a remedial agent dates back to the time of Hippocrates, and modern physio- logic investigations have led to its reintroduction into medicine. Thus it has been shown that if a portion of the blood-serum of a dog be replaced by an artificial serum, the most suitable serum for the purpose is sea water, isotonic with the natural serum. Sea water has been given by the mouth and by injec- tion with good results in cases of dyspepsia, loss of appetite, and tuberculosis. In general, the appetite was improved and strength was rapidly regained. In order to obtain the best and most immediate results it is necessary to observe certain precautions. The sea water must be natural, as it is impossible to imitate so complex a liquid. Indeed, it has been proved that sea salt, when redissolved in distilled water, lacks some of the properties of natural sea water, exerting a toxic action upon a dog when injected subcutaneously. It must be freshly collected, as it loses carbon dioxid on standing, with precipitation of some of its salts. It should be taken, from the open sea, remote from rivers and other sources of pol- lution. It should be sterilized by filtration, as heat dissociates the bicarbonates and destroys the natural equilibrium of the liquid. 412 HYDROTHERAPY When required for subcutaneous injection sea water should be tUluted with water to the same concentration as normal blood-serum. Distilled water is not suitable as a diluent, as it sometimes causes pain. It is better to dilute the sea water with natural potable water in the proportion of 2 parts to 5. In conclusion, M. Carles points out that this method of treatment is not invariably suitable, and that it rests with clinical experi- ence to indicate the cases in which it may advantageously be employed.* USE OF RADIO-ACTIVE WATERS INTERNALLY Little is known of this use of mineral waters. They have been studied by Bickcll and Bergell - in their laboratory, and a definite biologic action in relation to digestion is claimed, but we are far from any exact or satisfactory knowledge of the subject. It has been shown by M. Curie that any radio-activity present in mineral waters is dissipated shortly after bottling, the radio-active gas and water losing about 50 per cent, of its activity in four days. Consequently, efforts to bottle waters charged with radium gas will prove useless regarding their radio- active properties. Taken at their source they may, however, be valuable. Bergell and Bickell say that the retarding effect of the peptonizing process which certain saUne waters exert is found only when the water has lost its radio-activity. The presence of radium emanation, although by itself inactive as regards the process of secretion, either abolishes the retarding power of saline water or overcompensates it. Incomplete as these researches are, a good deal of truth lies in the statement that there is a real difference between the physiologic workings of a water, taken fresh from the spring at its maximum of radio- * Lancet, January 4, 1908. See also R. Simon and R. Quinton, Soci^te de Th^rapeutique, Paris, January 24, 1906; also Quinton's L'Eau de Mer, Milieu Organique, Masson and Cie, Paris. 2 Bickell and Bergell, Physiol. Bedent. der Radioaktivitat der Mineral- wasser, xxii, Kongress f. innere Med., 1905, p. 157. SULPHUR WATERS 413 activity, and those of the same water altered by transportation and storage.^ BITTER OR PURGATIVE "WATERS These belong to the class of sodic-potassic-magnesic sulphated muriated saline waters. The best examples are those of Puellna, Hunjadi, Apenta, Franz Josef, Victoria of Austria; Seidlitz, Bohemia; Carabana and Riibinat, Spain. The waters of Crab Orchard and Harrodsburg, Kentucky; Abilena Spring, Kansas; Castalia Springs, California; and Clark's Riverside Spring, Michigan, are examples of the same class. They are purgative by stimulating intestinal peristalsis, stimulant to the stomach and to the flow of bile. The foreign waters of this class are used to an enormous extent in America for the relief of constipation, especially by plethoric persons. The advantage of the Hunjadi waters is that the sulphates of magnesium and sodium are in nearly equal proportions, and the taste is not so objectionable as when one or the other pre- ponderates. The strongest purgative water known is the Vic- toria Ofener. It contains a large proportion of magnesium sulphate and is a particularly disagreeable water. The Franz Josef Spring is a strong aperient, containing nearly equal parts of the sulphates of sodium and magnesium. The dose of these waters is a small wineglassful diluted with warm water; they should be taken in the morning on rising. Free purgation is obviously a great help in promoting a proper function of the stomach and the skin, and aids the action of drugs. SULPHUR WATERS These waters are characterized by the presence of hydrogen sulphid or the sulphids of sodium, potassium, calcium, or mag- nesium in connection with other salts, such as the -chlorids of sodium and potassium and the earthy salts. Unless they con- tain at least 5 cubic inches of hydrogen sulphid per gallon or 1 Confer von Noorden, Metabolism and Practical Medicine, vol. iii, p. 910, London, 1907. 414 HYDROTHERAPY 5 gr. of sulpliids, much stress cannot be laid on the sulphur as a potent factor. Waters of weaker composition are very numerous, and, though bearing the title of sulphur springs, are useful rather by reason of their thermal qualities or through other constituents, usually alkaline — saline. The advantages of these salts have been discussed. (See p. 403 et seq.) When well charged with sulphur, these waters are useful in diseases of the liver and spleen, and probably also in gout, rheumatism, and such skin diseases as acne and scrofulous eruption. The list of sulphur waters is very long; they abound in New York, Virginia, West Virginia, Alabama, Michigan, Cali- fornia, and Ontario, Canada. In England the Harrogate waters have marked sulphurous properties; so also those of Strath- pefTer, in Scotland, Aachen, or Aix-la-Chapelle of Rhenish Prussia, Baden and Nenndorf in Prussia; Luchon, Bareges, and Cautorets, in France; Baden near Vienna, and many others. The opinion has been expressed that sulphurcted hydrogen has been greatly overrated as a therapeutic agent in mineral waters, notwithstanding the general opinion of its virtues. Its value must be taken in connection with the mineral salts with which it is associated. In a case of nervous hyperacidity von Noorden has made some tests with the water of the Weilbach sulphur spring (5.2 cc. HjS per liter) ; 400 cc. of this water were taken half an hour before the test-breakfast, and the stomach contents were removed by siphonage forty minutes after the meal. Four consecutive washings gave a total acidity of 91 (decinormal soda solution per 100 cc. of gastric juice) and an average for HCl of 62; after four washings the total acidity was reduced to 42. The general conclusion is that the water im- proves the appetite and stimulates the gastric functions. Where there is a moderate content of sodium chlorid this no doubt is the case; but where calcium sulphate is present in large quanti- ties symptoms of indigestion are liable to occur. CHALYBEATE WATERS; " STEEL WATERS" OF EUROPE 415 CHALYBEATE WATERS; "STEEL WATERS" OF EUROPE These waters contain from 1 to 150 gr. of ferrous sulphate or carbonate per gallon, and are usually combined with other more active ingredients. They are usually carbonated, and are agreeable to the stomach unless associated with much alum, when their astringent properties predominate. They are useful in the anemias and in general debility; when astringent, they are valuable in chronic diarrhea, ulcer of the stomach, malarial cachexia, gout, rheumatism, eczema, and psoriasis; when as- sociated with arsenic, they are useful in chlorosis, scrofula, and other lymphatic diseases. The principal simple iron waters in the United States are those of Iron Ute Springs, Manitou, Colorado; Rock Enon Springs, Va.; Napa Soda Springs and Pacific Congress Springs, California. In Europe the principal chalybeate springs are those of Bocklet, Franzensbad, Marienbad, Pyrmont, and Schwal- bach, Germany; Tunbridge Wells, Flitwick, containing 170 gr. of persulphate of iron per gallon, Cheltenham, and Brighton, England; Spa, Belgium; and St. Moritz, Switzerland. Among the astringent iron waters (FeSOJ may be mentioned Church Hill Alum Spring, Rockbridge Alum, and Bedford Alum Springs, Virginia; Oak Orchard Spring, Genesee County, New York; St. Anne's Well at Brighton, England, belongs to this class. Weak arsenic iron waters are found at Crockett Arsenic Li- thia Spring, Virginia; at Ashley's Bromin and Arsenic Spring and Thompson's Bromin- Arsenic Spring in North Carolina. The best and strongest waters of this class are in Europe. Those most used are from Roncegno and Levico, in the Austrian Tyrol; Lansigk, in Saxony; and Royat, in the Puy de-Dome, France. These waters are administered in doses of one or two table- spoonfuls daily and the dose is gradually increased. The Roncegno water contains .1 gram of arsenic per liter and the other waters from 4 to 9 milligrams. They should be well 410 HYDROTHERAPY diluted, and taken about half an hour att(>r meals. The ferrous sulphate is present in quantities varying from 2.56 to 4.18 grams per liter (179 to 292 gr. per gallon). The Saint Victor Spring at Ro3'at is used particularly for psoriasis. Chalybeate waters always give the best results when taken directly from the spring, because, if much lime be present, as is frequently the case, the iron precipitates after bottling, and hence they do not bear transportation well. The waters of Schwalbach, on that account, keep better than those of Pyrmont, which contain lime in abundance. Those from the Prince de Conde Spa keep best of all, and may be given in quantities of from 1 to 4 or 5 tumblerfuls a day. They aid digestion and improve the blood. Experience seems to show that the natural iron waters are more beneficial in chlorosis and anemia than the various pharma- ceutic preparations of iron. This is probably due to its better solution. They are counterindicated when fever is present, in severe disturbances of the digestive organs, and in pulmonary tuberculosis with hemoptysis. SODIC-BROMO-IODIN WATERS Sodium bromid and iodid arc found associated with sodium chlorid, and are quite subordinate to the excess of the latter salt. The chief European waters of this class are those of Kreuznach, Purton Spa, and Woodhall. The last is the strongest known, containing nearly 5 gr. of bromin and | gr. of iodin to the gal- lon. The Saratoga Springs, such as Congress and Hat horn. Eureka, Excelsior, Champion, and Geyser, belong to this class, the Ypsilanti Mineral Well, the Port Huron Mineral Bath of Michigan, and about sixty others in the United States. The bromo-iodin waters are of value in the treatment of scrofula, syphilis, goiter, and diseases of the skin, but are counter- indicated in chronic inflammatory states of the digestive organs, unless the sodium iodid and bromid be insignificant in com- parison with other valuable constituents. LITHIA WATERS 417 LITHIA WATERS These have a great vogue in the United States, and are widely advertised as such, whether they contain j-^^q-q gr. per gallon or upward. All the Saratoga Springs are, comparatively sp'eaking, rich in lithia. The Londonderry and Buffalo lithia waters are widely used. The White Rock Lithia, a water from Waukesha, Wisconsin, is an artificial Hthia water, to which 20 gr. of lithium carbonate was formerly added before bottling. It is no doubt fully as efficacious even now as any of the strictly natural lithia waters, and is very widely used as a table water. It is generally suppUecl carbonated. "Buffalo Lithia is a water coming from an American spring or springs, advertised as containing a definite C|uantity of lithia, namely, 2.25 gT. per U. S. gallon, while the government analyses find much smaller amounts; and, according to the analysis made by Prof. F. Waller, the water contains but 0.018 gr. of lithium bicarbonate per gallon. "Rhens water, the product of a German spring, is freed of its iron, recarbonated, and then bottled. ''Londonderry Lithia, an American water, advertised to con- tain 7.29 gi'. per gallon, contains but a spectroscopic trace of lithia, an amount too small to be expressed in weight. "Geneva Lithia Water, again an American product, said to contain 23.8 parts per million of lithia, is found to contain but 0.1 part; in other words, one would have to consume something like 80 gallons to get a single medicinal dose of the advertised drug. "Bear Lithia, an American product, contains only a trace of lithia." 1 The late Dr. James K. Crook, who spent years in the study and classification of the American mineral waters, recognized that the medical profession are in a state of inexcusable ignorance regarding the chemic constitutents of many of our mineral waters and the worthlessness of many advertised analyses. " The fact must not be overlooked that the government anal- ^ See article by Julius Greyer, Jour. Amer. Med. Assoc, Aug. 3, 1907. 27 418 HYDROTHERAPY yses were made in each case from samples purchased in the open market. It is, therefore, possible that some of the waters ex- amined by the bureau chemists were spurious or adulterated. "The chemic ingredients set forth in the table of contents of mineral springs represent hypothetic combinations only. No chemist maintains that the salts he sets down in his analysis exist in exactly that form in the water. He ascertains by his tests the various acid and basic ions existing in the water, and, as nearly as possible, in what amounts. He then reasons that they unite to form the salts which go to make up his hypothetic table of contents, which is ppesented as the analysis. It is hardly conceivable that any two chemists separately examining a speci- men of spring water taken from its source, even at the same moment, would reach exactly the same result in stating the theoretic combination. How much greater discrepancy might reasonably be expected in the case of analyses separated by periods of thirty or forty years. All of our medicinal springs should be submitted to analysis at least once in ten years, until we are able to arrive at a correct estimate of their potency, and whether they are gaining or losing in strength. No enterprising mineral spring proprietor, ani- mated by a desire to put forth a reliable product, can object to the expense, repeated at intervals so widely separated. The decennial revisions of our works on materia medica and phar- macy should present a brief account of the mineral waters con- forming to ethical rules, so that the medical practitioner may be in possession of as authentic and authoritative a source of in- formation regarding these as he has in case of other therapeutic agents." ' Among European waters containing lithia are those of BiUn, in Bohemia; Elizabeth-brunnen, at Homburg; Konigsquelle, at Elster in Saxony; Rakocsy Spring, at Kissingen in Bavaria, and Wilhemsquelle, at Ems, in Prussia. Value of Lithia Waters. — These waters are credited with a solvent action on the uric acid, and hence they appeal strongly 1 Therapeutic Gazette, May, 1908. WATER AS AN EMETIC 419 to those who believe that an excess of uric acid is the fundamental cause of rheumatism, gout, arthritis, and other allied conditions. This doctrine is usually given a prominent place in circulars re- garding mineral springs, and is impressed on patients at various water-cure resorts so generally that it is a part of the confession of faith at most health resorts supplied with lithia waters. There should be a revision of the accepted teaching on this point : it is necessary to distinguish between the truth and poetry of uric acid. The trend of all recent investigations leads to the conclusion that uric acid is only' one of the numerous excrementitious products in the diseases in which it has been accorded such a prominent role. Nevertheless, its importance for trade purposes is such that no very radical change can be expected in this time- honored terminology. Undoubtedly, lithia waters do good. If free from common salt and used with judgment and in moderation they are applic- able in cases of nephritis of all grades, rheumatism, gout, espe- cially of the chronic forms, and are unquestionably better than the glass of water in which the 5-gr. effervescent tablet has been dissolved. When lithia is given in the latter form it is too strong for prolonged use and is liable to derange the stomach. The natural waters, or those to which a quantity (not over 20 gr. per gallon) has been added, are free from these objections. Under the provisions of the "pure food law" the United States Government has taken steps to insure proper labels on mineral waters, so that the public may not be misled. On May 3, 1910, in the United States Court at Harrisburg, Pennsylva- nia, a mineral spring water companj^ was fined $25 and costs for advertising its water to contain lithia in quantity to make it of medicinal value when analysis showed barely a trace. WATER AS AN EMETIC Finally, water may be used as an emetic. The time-honored use of lukewarm water, or slightly saline warm water, needs little comment. In cases of poisoning, especially in ptomain-poison- . ing, this simple remedy should be instantly applied. 420 HYDROTHERAPY COMPARISON OF THERMOMETERS Fahr. Cent. Fahr. Cent. Fahr. Cent. 212 100 150 65.6 90 32.2 210 98.9 148 64.4 88 31.1 208 97.8 146 63.3 86 30 206 96.7 144 62.2 84 28.9 204 95.6 142 61.1 82 27.8 202 94.4 140 60 1 80 26.7 200 93.3 138 58.9 1 78 25.6 198 92.2 136 57.8 76 24.4 196 91.1 134 56.7 1 74 23.3 194 90 132 OO.O 72 22.2 192 88.9 130 54.4 i 70 21.1 190 87.8 128 53.3 68 20 188 86.7 126 52.2 66 18.9 186 85.6 124 51.1 1 64 17.8 184 84.4 122 50 i 62 16.7 182 83.3 120 48.9 1 60 15.6 180 82.2 118 47.8 58 14.4 178 81.1 116 46.7 56 13.3 176 80 114 45.6 54 12.2 174 78.9 112 44.4 52 11.1 172 77.8 110 43.3 50 10 170 76.7 108 42.2 , 48 8.9 168 75.6 106 41.1 ! 46 7.8 166 74.4 104 40 44 6.7 164 73.3 102 38.9 42 5.6 162 72.2 1 100 37.8 40 4.4 160 71.1 98 36.7 38 3.3 158 70 96 35.6 36 2.2 156 68.9 94 34.4 34 1.1 154 67.8 92 33.3 32 0. 152 66.7 PRESCRIPTIONS FOR HYDROTHERAPY It is necessary to specify the temperatures of the water to be used, the duration of each feature of the treatment, and, if douches are called for, the pressure required. These ought to be intelligently and concisely stated by the physician, as in a prescription for any other remedy. Abbreviations are naturally used and are understood by bathing attendants. In institutions where large numbers are bathing these prescriptions are kept in a convenient place, well lighted, for frequent reference during the progress of the bath. PEESCEIPTIONS 421 The abbreviations most frequently used are as follows : L. B., Electric-light baths. Pn., Perspiration. H. A. B., Hot-air bath or electric-light bath. Either may be used. C. D., Circular or needle douche. R. D., Rain douche or descending douche. S. D., Scotch douche or alternate jet douche. F. D., Fan douche or spray douche. J. D., Jet douche. <^, Increasing temperature to. >, Decreasing temperature to. Comp., Compress. Fo., Fomentation. Rev. Comp., Revulsive compress. H. and C. Sp., Alternate hot and cold to the spine. H. and C. Hd., Alternate hot and cold to the head. Simul. H. and C. Hd., Simultaneous hot and cold to the head. C. Comp., Cold compresses. Pk., Pack. Ch. Pk., Chest pack. Dry Ch. Pk., Dry chest pack. C. M. F., Cold mitten friction. W. H. R., Wet hand rub. C. T. R., Cold towel rub. W. Sh. R., AVet sheet rub. Dr. Sh. R., Drip sheet rub. S. GL, Salt glow. Spg., sponge. Ale. R., Alcohol rub. O. R., Oil rub. ^ H. Ft. B., Hot foot-bath. C. Ft. B., Cold foot-bath. H. and C. Ft. B., Hot and cold foot-bath. Lg. B., Leg bath. H. i B., Hot half-bath. C. S. B., Cold shaUow bath. Alk. B., Alkaline bath. E. L. B., Electric-light bath. H. B. Pk., Hot blanket pack. D. B. Pk., Dry blanket pack. Elect. Pk., Electrothermal pack. PRESCRIPTIONS In the Medical Baths of Boston, which have been estab- lished under the guidance of Dr. J. H. Pratt, Dr. J. J. Put- 422 HYDROTHERAPY nam, and others, there is an excellent system of prescriptions and medical observation and reports. See Hydrotherapeutic Prescriptions, by Joseph H. Pratt, Boston Med. and Surg. Journal, March 17, 1904; also, An Introduction to the Use of Hydrotherapy in Chronic Diseases, by J. H. Pratt. Among the prescriptions used by Dr. Pratt, Dr. Baruch, and the author are the following : (1) Hot pack until skin is warm and cutaneous vessels dilated. Wet-mit friction with water at 60° F. (15.6° C). Repeat daily, reducing water temperature 2 degrees daily until 50° F. (10° C.) is reached. (2) Electric-light bath imtil skin is moist, or for five or ten minutes, followed by wet-mit friction, using cold water at 50° or 60° F. (10° or 15.6° C). (3) Hot-air cabinet bath until the skin is warm. Wet-mit friction with water at 60° F. (15.6° C), reducing the tempera- ture of water daily until water at 50° F. (10° C.) is used. Nos. 1 to 3 are useful in anemia, neurasthenia, nervous dyspepsia, debility, malnutrition, etc, (4) Hot-air bath or electric-light bath to perspiration. C. D., 105° > 80° F. (40.6° > 26.7° C), two minutes; 20 pouhds. F. D., 75° F. (23.9° C), fifteen seconds. Alcohol rub. (5) H. A. B. to Pn. (temperature 160° to 170° F.— 71.1°- 76.7° C). C. D.,105°>90°F. (40.6° > 32.2° C), two minutes; 20 pounds. J. D., 90° > 80° F. (32.2° > 26.7° C), one minute; 15 pounds. F. D., 80° F. (32.2° C), ten seconds; 15 pounds. Lower minimum temperature 2 degrees and increase pres- sure 2 pounds each treatment, until a temperature of 60° F. (15.6° C.) and a pressure of 30 pounds are used. General tonic. (6) H. A. B. to Pn., temperature 160° to 170° F. (71.1°- 76.7° C). C. D., 95° > 80° (35° > 26.7° C), thirty seconds. F. D., 70° F. (21.1° C), five seconds: 30 pounds. General massage, ten minutes. Reduce temperature of F. D. 1 degree daily. (7) H. A. B. or electric-light bath, fifteen to twenty-five PEESCRIPTIONS 423 minutes. Dry pack, thirty minutes. Rest in bed, one hour. This is useful in chronic parenchymatous nephritis and in anemia. (8) H. A. B. or electric-light bath to Pn. C. D., 105° > 90° F. (40.6° > 32.2° C), two minutes: 20 pounds. Scotch douche (S. D.) to affected part or painful areas, thirty seconds. Repeat daily. Pressure to be regulated from 10 to 20 pounds, according to sensibility and general resistance. Useful in cases of arthritis. (9) Vapor bath, 120° F. (48.9° C), ten minutes. S. D. to painful parts, twenty to thirty seconds. Hot dry pack, thirty minutes. Rest in bed, one hour. Repeat on alternate days. Useful in neuralgia and in muscular and articular rheumatism. (10) H. A. B. almost to Pn. C. D., 105° > 95° F. (40.6° > 35° C), one minute. S. D., small caliber, to course of colon, 115° and 60° F. (46.1° and 15.6° C), fifteen seconds for each temperature; 15 pounds, one to two minutes. F. D. to chest and back, 75° F. (23.9° C), ten seconds. Repeat daily, increasing pressure 2 pounds daily until 30 pounds are used. Useful in constipation. (11) Hot-air bath until cutaneous vessels are dilated. Wet sheet rub. Sitz-bath, temperature 70° F. (21.1 ° C.) , ten minutes. Simultaneous hot foot-bath, temperature 110° F. (43.3° C). Repeat daily, increasing duration gradually to twenty minutes and lowering temperature to 50° F. (10° C). Diarrhea. (12) Hot-air bath to perspiration. Circular douche, 105° to 95° F. (40.6°-35° C), one minute. Ascending douche, 60° to 70° F. (15.5°-21.1° C), two to three minutes, 5 to 10 pounds' pressure. Rain douche, 105° F. (40.6° C), thirty seconds. Fan douche to entire body, ten seconds, 15 pounds, 70° F. (21.1° C). Hemorrhoids; hypertrophy of the prostate. (13) Hot-air bath to point of perspiration. Circular douche, 105° to 90° F. (40.6°-32.2° C), two minutes. Jet and fan douche, 90° to 80° F. (32.2°-26.7° C), 15 pounds, one minute. Jet douche to spine, 75° F. (23.9° C), fifteen seconds. Lower minimum temperature 2 degrees and increase pressure 1 pound 424 HYDROTHERAPY each application until pressure of 35 pounds and temperature of 50° F. (10° C.) are reached. General tonic. (14) Hot-air bath until cutaneous vessels arc dilated. Re- move before perspiration begins. Circular douche, 95° to 85° F. (35°-29.4° C), one-half to one minute. General fan douche, 80° F. (26.6° C), 20 pounds, t(Mi to twenty seconds. Dry rapidly. AValk in open air until somewhat fatigued. Repeat daily, reducing minimum temperature 1 tlegree each treatment. Once during week allow patient to perspire five minutes in cabinet. — Baruch. General tonic. (15) Hot-air bath almost to point of perspiration. Circular douche, 95° to 85° F. (35°-29.4° C), one-half to one minute. Fan douche to back, 75° F. (23.9° C), 20 pounds, five seconds. General fan douche, 78° F. (25.6° C.\ 30 pounds, fifteen seconds. After several days substitute jet douche for fan douche to back, lower temperature of general fan douche 1 degree daily. — Baruch. For neurasthenia. (16) Hot-air bath to beginning perspiration. Circular douche, 25 pounds, 95° to 80° F. (35°-26.7 ° C), one minute. Jet douche to back, 30 pounds, 75° F. (23.9° C), five seconds, daily reduced 1 degree. Friction. Walk in open air. — Baruch. For neuras- thenia of moderate grade. (17) Hot-air bath to beginning perspiration. Circular douche, 10 pounds, 105° to 92° F. (40.6°-33.3° C), three minutes. General fan douche, 10 pounds, 85° F. (29.4° C), fifteen seconds. Walk slowly in the open air. Repeat daily, increasing pressure and lowering temperature until 15 pounds and 80° F. (26.7° C.) are reached. (18) Hot-air bath to point of perspiration. Change cold compresses to head frequently. Circular douche, 100° to 90° F. (37.8°-32.2° C), two minutes. Scotch or alternate jet douche to legs and feet, 15 pounds. Repeat daily, increasing pressure 1 pound each application until 30 pounds are borne. Arthritis of the feet. (19) Wet pack; temperature of water 60° to 70° F. (15.6°- 21.1° C), one hour. Circular douche, 85° F. (29.4° C), 20 PRESCRIPTIONS 425 pounds' pressure, fifteen seconds. Repeat daily; once or twice weekly initial temperature of circular douche, 90° F. (32.2° C), reduce quickly to 75° F. (23.9° C), followed by fan douche, 85° to 65° F. (29.4°-18.3° C), 20 pounds' pressure, five seconds. — M. F. Jacohi and Baruch. (20) Hot-air bath to perspiration. Circular douche bath, 25 pounds' pressure at 80° F. (29.4° C), thirty seconds. Spray douche, 65° F. (18.3° C), five seconds. After a few applications, use jet douche to spine at end of treatment for thre'e seconds, temperature 65° F. (18.3° C). Lower temperature of jet 2 de- grees daily until 50° F. (10° C.) is reached. If this is well borne, pressure may be increased 2 pounds daily until 30 pounds are reached. — Baruch. (21) Vapor bath, 120° F. (48.9° C), 15 minutes. Ice-bag to precordia. Salt glow. Jet douche to entire body, 10 pounds, 110° F. (43.3° C), thirty seconds. Rub dry. Rest in bed one to two hours. Repeat two to four times weekly, increasing pressure until 30 pounds are employed, and gradually increasing length of vapor bath to thirty minutes. For chronic paren- chymatous nephritis. (22) Hot full bath, 100° F. (37.8° C), raised to 106° F. (41.1° C), five to ten minutes. Salt glow. Fan or jet douche to entire body, 110° F. (43.3° C), thirty seconds. Massage to edema- tous portions. Rest one to two hours before dressing. Repeat two to four times weekly, increasing pressure until 30 pounds are used. For chronic parenchymatous nephritis. (23) Hot-air bath, forty to sixty minutes. Soap shampoo. Half-bath, temperature 70° F. (21.1° C), three to five minutes. General jet douche, pressure 25 pounds, temperature 70° F. (2L1° C), twenty seconds. Dress quickly and walk until fatigued. Repeat daily, increasing duration of hot-air bath and lowering temperature of douche as condition of patient indicates. 426 HYDROTHERAPY Prescriptions in use at the Medical Baths, Boston: Prescriplion A. — Light cabinet, five to seven minutes Cold wet mit friction to entire body. Temperature of water, 70° F. (21.1° C). Repeat daily, gradually reducing temperature of water to 60° F. (15.5° C.) or lower. Prescription B. — Light bath, five to ten minutes. Circular douche, 105° F. (40.5° C.), thirty seconds. Circular douche, 90° F. (32.2° ('.), thirty seconds. Jet and'fan douche to entire body at 70° F. (21.1° C.), twenty seconds, pressure, 10 pounds. Repeat daily, gradually increasing pressure of j(>t douche and lowering terminal temperature until pressure of 20 pounds and temperature of 60° F. (15.5° C.) are used. It is written in an abbreviated form as follows : L. B., five to ten riiinutes. C. D., 105° F. (40.5° C), tlurty seconds. C. D., 90° F. (32.2° C), thirty seconds. J. and F. D., 70° F. (21.1° C), twenty seconds. P., 10 lb. Repeat daily, increasing P. to 20 lb. and reducing T. to 60° F. (15.5° C). Prescription C^Light bath, fifteen to twenty minutes. Fan douche, 105° F. (40.5° C), thirty seconds. Fan douche, 70° F. (21.1° C.), fifteen seconds. Dry rub. Rest one hour. Repeat every other day. If the individual is weak, a milder procedure should be used (Prescription A). Prescription D. — Light bath, seven to twelve minutes. Salt rub. Circular douche, 105° F. (40.5° C), thirty seconds. Jet and fan douche, 105° F. (40.5° C), thirty seconds, pressure, 15 pounds. Dry rub. Rest thirty minutes. Repeat three times weekly. Useful in chronic interstitial nephritis. In cases of chronic uremia, headache, loss of appetite, and vomiting it is well to use a wet pack (one hour or longer) pre- ceded by a light bath of three to five minutes' duration. PRESCRIPTIONS 427 Prescription E. — Local hot-air or electric-light bath to affected joint, thirty minutes to one hour. Electric-light bath, general, three to five minutes. Jet douche to affected joint, 105° F. (40.5° C), twenty seconds. Jet douche to affected joint, 105° F. (40.5° C), twenty seconds; 70° F. (21.1° C), five seconds. Repeat four times. Circular douche to entire body, 105° F. (40.5° C), thirty seconds. Jet and fan douche to entire body, 70° F. (21.1° C), ten seconds. All douches at from 10 to 20 pounds' pressure. Repeat three to six times weekly, increasing pressure gradually. Prescription F. — Arc light, seven to ten minutes. Light bath, five to ten minutes. Alternate douche to affected part. Circular douche, 105° F. (40.5° C), tliirty seconds. Jet and fan douche, 70° F. (21.1° C), ten seconds, pressure, 10 pounds. Repeat daily, increasing pressure gradually. Used in lumbago and sciatica. Prescription G. — Hot-air douche to painful area, fifteen to twenty minutes. Light bath, five to ten minutes. Circular douche, 105° F. (40.5° C), thirty seconds, pressure, 10 pounds. Jet and fan douche to entire body, 70° F. (21.1° C), twenty seconds, pres- sure, 10 pounds. Repeat daily. Increase pressure of jet and fan douche and lower terminal temperature until pressure of 25 pounds and 60° F. (15.5° C.) are reached. Nauheim Baths. — At the beginning of treatments the fol- lowing general prescription may be given : Prescription H. — Carbon dioxid bath, -j% strength. Temperature, 93° F. (33.8° C). Duration, seven minutes. Increase strength one-tenth each treatment, lower temperature 1 degree, and increase duration one minute. Prescription I. — Carbon dioxid bath, -^-^ strength. Temperature, 93° F. (33.8° C). Duration, ten minutes. Increase strength of bath gradually, lower temperature and increase dura- tion until a bath of eight-tenths full strength 87° F. (30.5° C.) and twenty nainutes is given. Dr. Pratt finds that a powerful arc light is of service in the treatment of neuritis, myalgia, "rheumatic" joints, and neural- 428 HYDROTHERAPY gia, paiiicularly sciatica. The arc light in use at the Medical Baths in Boston has a concave parabolic mirror, so that the rays of light can be focused on a small area of the skin. In obesity, Dr. Pratt usually uses light baths followed by cold douches (Prescription D). Later in the treatment dry blanket packs or hot full baths (105° F.— 40.5° C. for ten or fifteen minutes) are used after the light bath if prolonged sweat- ing is desired. Hydrotherapy without careful attention to diet and exercise is valueless in the treatment of obesity. In chronic irderstitial nephritis, short stimulating douch treatments (Prescription D) and carbon dioxid baths hold the first place. In diabetes, Naunyn and von Noorden recognize the impo"rt- ance of hydrothcrapeutic aids to the dietetic treatment. Tonic measures increase metabolism, invigorate the patient, and im- prove the condition of the skin (Prescriptions A and B). Local Hot-air and Light Baths. — In chronic arthritis of all forms we chiefly use local light and hot-air baths followed by a cabinet bath of short duration, and then give an alternating (Scotch) douche to the affected or painful areas. (See Pre- scription E.) Nauheim Baths. — Dr. Pratt informs the author that he usually begins a course of treatments with baths two-tenths or i/hree-tenths full strength. The duration of the first bath is seven minutes and the temperature of the water 93° F. (33.8° C). Gradually the strength of the bath is increased, the tem- perature lowered, and the duration extended to fifteen or even twenty minutes. He rarely gives a bath at a lower temperature than 86° F. (30° C). A full strength bath is only used if the heart has considerable reserve power, and then only toward the end of treatment. Use in Heart Disease. — The carbon dioxid baths are indicated in the milder degrees of circulatory disturbance, when there is sUght dyspnea on exertion or moderate edema. They may also be of value in cardiac asthma (paroxj'smal dyspnea, usually nocturnal) and in milder forms of angina 'pectoris. They are of equal service in the cardiac weakness of valvular disease and in PRESCRIPTIONS 429 that due to myocardial degeneration alone. They are contra- indicated when there is oppressed breathing with the patient at rest or when edema is marked. The circulatory organs can be acted on reflexly by stimulating the sensory nerves of the skin, and the most powerful stimulus of the cutaneous sensory nerves is the carbon dioxid bath. The peripheral vessels are narrowed, but as there is an increased flow of blood through them, the skin becomes reddened and there is a pleasant sensation of warmth produced. The blood-pressure is elevated. The altered distribution of the blood in the body is an aid to the proper functioning of the heart. The breathing becomes deeper and this also accelerates the flow of blood. If the bath is not too strong, it produces a slight rise in blood-pressure when given at a temperature between 85° F. (29.4° C.) and 92° F. (33.3° C). In treating heart cases the physician should carefully note the immediate effect of the treatments. He should be present occasionally when the strength of the bath is increased. It is important to percuss out the cardiac outline before and after the bath. Dr. Pratt is a firm believer in the superiority of the local incandescent light baths over local hot-air baths. The radiant heat of the light bath penetrates the tissues to a greater depth than the conducted heat of the hot-air bath. The following is a list of general stimulating treatments most commonly used at the Medical Baths in Boston: (1) The ablution (wet-mit friction, German "Teilwaschung," see p. 246). A mild general treatment. (2) The wet sheet pack and rub (see p. 237). (3) The half-bath. Temperature 70° to 85° F. (21.1°-29.4° C). Duration one to five minutes (see p. 243). (4) The douches : (a) Circular douche, 60° to 70° F. (15.5°-21.1° C). .Pressure, 8 to 15 pounds; duration, fifty to sixty minutes. (6) Jet and fan douche, 60° to 75° F. (15.5°-23.9° C). Pressure, 10 to 25 pounds. 430 HYDROTHERAPY (5) The faradic electric baths. Temperature, 90° to 93° F. (32.2°-33.8° C). (6) The carbon-dioxid baths. Various strengths; tempera- ture, 85° to 92° F. (29.4°-33.3° C). Duration, seven to fifteen minutes. The chief sedative treatments are as follows: (1) The wet pack (see p. 340). (2) The dry blanket pack (see p. 345). (3) The hot-air bath. Temperature, 115° to 140° F. (46.1- 60° C); duration, fifteen to twenty-five minutes. (4) The electric-light bath. Temperature, 110° to 140° F. (43.3°-60° C); duration, fifteen to thirty minutes. (5) The neutral full bath. Temperature 90° to 93° F. (32.2°- 33.8° C); duration, ten to forty-five minutes. (6) The hot full bath. Temperature, 104° to 108° F. (40°- 42.2° C); duration, five to ten minutes. (7) The galvanic bath. Temperature, 90° to 93° F. (32.2°- 33.8° C); duration, five to fifteen minutes. (8) The sinusoidal bath. Temperature, 90° to 93° F. (32.2°- 33.8° C); duration, five to fifteen minutes. (9) Electric-light bath, five to ten minutes. Circular douche at 105° F. (40.5° C), thirty seconds. Circular douche at 90° F. (32.2° C), thirty seconds. Jet and fan douche to entire body at 70 ° F. (21.1° C), twenty seconds; pressure 10 pounds. Repeat daily, gradually increasing pressure of jet douche and lowering terminal temperature until pressure of 20 pounds and temperature of 60° F. (15.5° C.) are used. Local treatments with heat produce hyperemia and are used chiefly to relieve pain, to lessen inflammation, and to improve the nutrition of the affected part. They are most use- ful in the treatment of the various joint troubles, neuralgia, neuritis, and muscular affections. (1) Electric-light (incandescent) bath. (2) Arc-light with reflector. (3) Hot-air bath. REQUISITE EQUIPMENT FOR AN INSTITUTION 431 (4) Hot-air douche. (5) Hot- water douches: (a) Simple hot douche. (6) Scotch douche. (c) Alternating douche. (6) Fomentations. REQUISITE EQUIPMENT FOR AN INSTITUTION The chief apparatus is as follows: (1) Electric-light cabinet. This is a cabinet or box lined with plate-glass mirrors and lighted with eight rows of six in- candescent lights. (2) Two cabinets for hot-air and vapor baths. (3) Incandescent electric-light bath for treating single parts of the body. (4) Arc-light with reflector for local treatments. (5) Local hot-air bath. (6) Douche-table with which a large tank for hot water and a pressure pump is connected. The temperature and pressure are controlled by valves and the readings are easily made on the thermometers and gauges. (See pp. 282 and 283 for illustra- tions.) (7) Circular douche or needle bath. (8) Rain douche, descending, or shower-bath. (9) Horizontal douche, or spout : (a) Jet douche, single or double, for Scotch douche. (6) Fan douche. (10) Ascending or perineal douche. (11) Sitz-bath. (12) Porcelain tub used for carbon-dioxid baths, half-baths, full baths. When desired, electric baths may be given in the tub. APPENDIX SOME TRUTHS ABOUT HYDROTHERAPY *- By Simon Baruch, M. D., New York The material antl professional interests of the physician have been seriously injured and menaced by his neglect of physiologic remedies. The fact is demonstrated by the revolu- tion in medical education which the advent of the Naturarzt produced i!i Germany, and which I witnessed in 1890, when the priest Kneipp was in the zenith of his meretricious fame. In this paper I shall advert only to the remedial application of water, which is acknowledged to be the chief physiologic remedy by Marcuse and Strasser in their new "Monatschrift fuer die Physikalisch-diirtetischen Hcilmethoden." For half a century Winternitz, of \'ienna, had been striving to make hydrotherapy ''the common property of the medical profession." To this end he had urged his colleagues to learn, teach, and practice it, but his warnings and appeals remained without effect until the Naturarzt began to menace the material interests of the German doctor. When this unexpected danger was realized, systematic efforts were inaugiu'ated to meet the invasion of these empirics, who sprang up everywhere, prompted by the prospective harvests. A commission for the revision of medical studies, with Professor Kussmaul as chairman, was appointed, which, after due investigation, reported as follows: "There is no doubt that trust in the ]:)rescription is waning among educated people and that the confidence in dietetic 1 Delivered by invitation before the Boston Society for Medical Improve- ment, on Feb. 8, 1909. Included by permis.'sion of his friend, Dr. Baruch, the most distinguished advocate of hydrotherapy in America (Boston Med. and •Surg. Jour., April 15, 1909). 432 SOME TRUTHS ABOUT HYDROTHERAPY 433 remedies and in the remedial value of water is in the ascendant. Water has especially won for itself steadily growing confidence as a remedy. Hydrotherapy combined with diet may, un- doubtedly, bring about or aid in the cure of numberless acute and chronic diseases. Of hydrotherapy the young physician knows nothing when he leaves the university. Unhappily, he sooner or later may encounter discomjiture luhen an uneducated water- doctor steps in and cures the patient after he has failed. Herein lies a great gap in the education of our physicians. A revision of our course of study must be made above all things; distinct chairs and clinics are demanded, in which appropriate cases may be treated by hydrotherapeutic procedures." This brief extract from the report of the commission furnished clear proof of the incursion of the quack upon the status of the medical profession in Germany, and pointed out the remedy in emphatic terms. The result was remarkable, for in a very short time the principal German universities established clinics for hydrotherapy and other physical remedies, in which the development of physical therapeutics began.^ Thus it has come about that a menace to material interests speedily accomplished that which Winternitz had failed to do by earnest and persistent effort during a half century. This historic fact, which may be corroborated by other proofs, is cited here as a warning and lesson to the medical profession of our own country. Our material interests have already been 1 During a visit to Germany last spring I discovered that the Naturarzt is still active despite the numerous well-equipped clinics on hydrotherapy and other physical methods. The reason hes, probably, in the fact, which was ascertained by personal visits to or correspondence with all the larger universities, that attendance upon these clinics being optional, very few students attended them. In three -universities there were no applicants at aU for in- struction in physical therapy; in one I saw five students; and only in Leipzig did I find a respectable number obtaining excellent instruction from Dr. Steinert, the chief of Curschmann's clinic. This obsen/ation justifies my insistence upon obligatory attendance of the lectures, of instruction of sec- tions, and of a final examination as the sine qua non of the chair of hydro- therapy in Columbia University. These conditions have been satisfactorily executed, and only in this manner may the study become practically useful to student and teacher. 28 434 HYDROTHERAPY seriously damaged by empirics of high and low degree — Christian Scientists, osteopaths, water-cure doctors, vibrationists, and their ilk. Is it not our imperative duty to ascertain the cause of the defection of our patient to the empirics? It behooves us to study and apply drugs less insistently and to devote more effort to a better comprehension of the remedial action of water and other physical remedies and of those psychic agencies which the lay doctor and empiric manage so success- fully. All these may certainly be applied with more skill and judgment^ and, therefore, with better results, by the educated physician, who thus may advance not only his material interests, but also the more humane and more lofty interests involved in the amelioration and cure of disease. (1) That a better understanding of the rationale of the action of water in disease may lead to the saving of life is a proposition not difficult of proof. Example 1. — For twenty years I have endeavored to im- press upon my colleagues in this country that in the application of the bath in infectious fevers the antipyretic is secondary to the nerve-stimulating and sustaining effect. Prompted by the fact that many lives were being sacrificed by disregard of this vital principle of hydrotherapy, I spared neither sacrifice of time nor effort to establish it by addresses delivered by invitation from medical schools or societies in New York, Philadelpliia, Boston, Albany, Baltimore, Chicago, St. Louis, Buffalo, Charleston, S. C, Richmond, Va., San Francisco, and Los Angeles, besides other smaller cities. Fear of shock had long operated against the adoption of effective cold procedures, because of the erroneous antithermic idea of the cold bath, a fallacy which Hippocrates combated. Physicians had been taught to increase the dose of castor oil, morphin, or other medicine if they desired an intensified effect; hence they naturally ordered the cold bath made colder when the temperature did not yield. As a result they obtained depression from injudicious dosage, and they rejected a remedy which judiciously used would have produced quite different effects. SOME TRUTHS ABOUT HYDROTHERAPY 435 The cold bath, indeed, every cold procedure, has for its chief object the enhancement of the resisting capacity of the patient to the disease. In an acute disease like typhoid fever this is ac- complished, first, by the well-known primary effect of cold in contracting the cutaneous vessels. This is followed by reaction, which is manifested by a tonic dilatation of the vessels, whose walls had previously been in a semiparetic state by reason of the prevailing toxemia. The heart is thus materially aided in its labor to overcome the unresponsive condition of the peripheral vessels. Heart failure, which stands as a specter at the bedside of every case of infectious fever, is not due so much to enfeeble- ment of the cardiac muscle by hyperpyrexia as to the imperfect action of the peripheral vessels, which allows the blood to glide through them without resistance. Cold water applied with friction stimulates the cutaneous arterioles to a more nearly normal action; it increases peripheral elasticity and resistance and enables the heart to renew its energy. Arterial tension is increased, the danger of failure of the laboring heart is overcome. (2) The excitation of the terminal filaments in the skin which follows the repeated impact of cold water is rapidly con- veyed to the central nervous system and thence reflected upon the life-maintaining organs whose functions have been more or less impaired by the existing toxemia. Each bath or other cold procedure gives a fillip , to the depreciated nerve-centers and sends new life to the organs depending upon them. The whole machinery of the organism receives a refreshing impetus, the impression being more or less enduring according to the temperature, duration, and procedure to which the patient is subjected. All this is now recognized by the well-informed physician, and yet nearly every text-book refers to the cold bath under the caption of heat-reducing agents, and few emphasize the truth that the correct cold bath is an antifebrile remedy which meets in fevers all therapeutic indications, of which temperature reduction is only one. A far more important truth than this even still appears to lack appreciation, viz., that the cold bath is not a symptomatic remedy, but that its value is due to the 436 HYDROTHERAPY prophylactic action in infectious fevers. It has been clearly demonstrated by large bedside observations that the early and correct application of hydrotherapeutic procedures in fever prevents complications and saves liv(^s by r(>moving from the causes of death heart failure, perforation, hemorrhages, and hypostases. Upon the recognition of the prophylactic effect of judicious bathing begun in the first week of typhoid fever the Brand method is based, and only to the neglect of this principle is due the failure of the latter. That thousands of lives have been saved by the correct application is evident from Vogl's statistics, the reports of the German Army, and their corroboration in our country by Peabody, Wilson, Loomis, Osier, Thompson, myself, and others. Dr. Oilman Thompson states in his Text-book on Practice that the mortality of ty- phoid fever was reduced from 16 to 6 per cent, in the Presby- terian and in the New York hospitals, since the introduction of the Brand bath, and the late Dr. H. P. Loomis reported to the Practitioners' Society of New York, in 1903, that the mortality from typhoid fever in the principal New York hospitals had been reduced 50 per cent, since the introduction of the systematic use of the Brand bath. Bear in mind that the evidence is furnished by professors of medicine in two large medical schools. Comparing the number of deaths from this disease in previous years, it may be safely computed that 1000 lives have been saved in New York City alone by the correct application of water in one disease. If it be borne in mind that private practice, in which bathing may be begun earlier than in hospitals, where patients are brought in late in the disease, offers a far more favorable field for this treatment, it becomes quite apparent how many lives are sacrificed by the neglect of this procedure. Example 2. — ^The management of cases of isolation (heat- stroke, sunstroke) has been for several decades by cold baths, ice-packs, and similar heroic procedures, based on the fallacious idea that temperature reduction may best be accomplished by them. The loss of life which was positively attributable to this irrational practice will be clearly shown in another part of this SOME TRUTHS ABOUT HYDROTHERAPY 437 paper. Several hundred lives were sacrificed in one summer by the neglect of the well-established principle of hydrotherapy that the coldest bath is not the most antithermic procedure, and that the most successful therapy of sunstroke must be the more rational method, based upon stimulation of the nervous system, as the chief therapeutic indication, just as it is in in- fectious fevers. Example 3- — In 1892 I reported to the New York State Medical Society the striking results of judicious hydrotherapy in phthisis pulmonalis, produced by its favorable effect upon nutrition and hematosis. In my work on hydrotherapy there appears a record of similar results observed by others in large numbers, which may be regarded as a control therapeutic experi- ment. Dr. Kuthy, of the great sanatorium of Budapest, com- pares his results with those of another large institution at Belzing, near Berlin. The records show 14 per cent, more restorations under the mild systematic hydrotherapy of Budapest than under the strong douches of Belzing. Although these statistics were published several years ago, their lesson has not yet been utilized in American sanatoria. I have sought in vain for any allusion to hydrotherapy in the Tuberculosis Congress. Indeed, I am credibly informed that one of our noted sanatoria, where a complete hydriatric equipment was installed, and which by request I visited at much sacrifice of time and trouble to instruct the staff and nurses, no longer uses the apparatus. Shall we continue to be laggards in this valuable method and withhold from these desperate cases so valuable a means of enhancing their resisting powers? The Remedy. — How is the prevailing neglect of hydrotherapy to be removed? To the unbiased inquirer the answer is simple. The cause is ignorance of the physiologic and therapeutic action of water, and the remedy is its removal by instruction in our schools (as indicated in Kussmaul's report), the study, however, being made obligatory, and reading by the general practitioner of works on hydrotherapy. Until the report of the Kussmaul commission appeared, the 438 HYDROTHERAPY Vienna University was the only medical school in which hydro- therapy was taught. Very few physicians, consequently, ap- plied it in practice outside of institutions. True, as in all periods of medical history, a few wise men advocated the remedial uses of water in recent times with earnestness born of conviction. Erb, Charcot, and Semmola, in their respective countries, pre- scribed it constantly, but unfortunately their prescriptions lacked precision, and were, therefore, empirical. In Ziemssen's Cyclopedia, for instance, Erb wrote: "Among the most powerful and effective agents in our branch arc cold and cool baths and the water treatment. Its results in all possible chronic nerve troubles arc extraordinarily favorable." Aside from these laudatory statements, Erb offers no directions to guide those who would fain obtain the same "extraordinary" and "powerful" results of the "cold-water treatment." The reason may be found in the fact that I^rb entrusted his patients to institution doctors who have not transmitted their special methods to us. The result was a blind groping in the dark and consequent failure, which may be tlemonstrated by numerous examples. Let me cite one illustration published in the Inter- national Clinics. A well-known neurologist tells his class : " The best remedy for neurasthenia is cold water in the morning. Let the patient stand in warm water and with a sponge pour cold water, or very cold water, over his head, shoulders, and nape of the neck, etc." The temperature of the cold and very cold water, the duration of the procedure, the friction needed for feeble individuals, the frequency of repetition, are not mentioned, and yet when this professor comes to speak of strychnin and the phosphates he becomes jirecise in stating dose, form, and mode of administration, etc. If specialists teach hydrotherapy so vaguely, the practitioner naturally ignores this "powerful," "extraordinary" agent and plies the patient with drugs, with the appUcation of which he is more familiar. Failure and dis- appointment to physician and patient alike are inevitable. The Charcot douche has come down to us sanctioned by the great name of the man who applied it chiefly in hysteria. SOME TRUTHS ABOUT HYDROTHERAPY 439 Does any one know to-day the temperature, duration, or pressure Charcot prescribed for this douche? All we know is that it is a strong jet or stream driven upon the spinal column. So far as I am informed, specialists order it generally without regard to these essential elements because the latter have not been transmitted to posterity. A few days ago I discovered type- written instructions in a large hospital erroneously describing the Charcot douche as one of alternating temperatures. Failure is more frequent than success, as a long connection with institu- tions has demonstrated to me. Were it not pathetic, it would seem absurd to find an eminent neurologist order "hot box and Charcot douche" for most of his cases of neurasthenia. He leaves the duration of the ''hot box" (which is the cabinet) and the temperature and preparation of the douche to the attend- ant, who certainly knows less of the physiologic action of water than the druggist knows of medicines, and yet this gentleman is so careful with the latter that he directs patients where to obtain parathyroid tablets or other important drugs which he prescribes. How can the students master the technic of his hydrotherapy if he himself is so indefinite in its prescription? That the most frequent result of indefinite prescriptions of water is failure, and not rarely a change of doctors and resort to quacks, has been often demonstrated. Clearly, if the leaders in medicine had themselves received the same instruction in the rationale and therapeutics of water which was given them in drugs, they would have taught hydrotherapy as they teach drug-therapy; the young practitioner would not find himself in the sad plight depicted by Kussmaul; he would be armed with a powerful weapon against disease and quackery. In the present status of this subject, the judicious practitioner would act wisely to altogether dispense with water in thera- peutics unless he be at least as familiar with its action as he is with the effect of medicinal agents, or is able to obtain counsel on its application. The former is not as difficult as it would appear from the vague mention of baths, packs, drip sheets, in books of reference. The average text-book must he avoided by 440 HYDROTHERAPY the seeker oj knowledge in hydrotherapy. It \vcre an act of inex- cusable temerity on my part to make this statement did not the facts warrant it and the occasion demand it. Text-books on therapeutics and practice in every language may be cited as j)roof of the utter unreliability as guides in the application of water in disease. Let me offer a few examples: (a) In a recent vade mecum of therapeutics, translated from the German, and popular among Italian physicians, the trans- lator mentions in his otherwise valuable annotations — impacchio umido — the wet pack around the trunk as valuable in pneumonia. ^Mlether this wet pack is to be cold, warm or hot, its frequency, duration, and mode of application — these are left to the fancy of the doctor who consults this otherwise valuable book for guidance. (/>) In a paper on pneumonia of children read before a medical society and published in the Archives of Pediatrics, an eminent pediatrist states: "When the temperature is 103°, 104°, 105°, or 106° F. (39.4°, 40°, 40.5°, or 41.1° C.) I apply cold baths and cold packs. Cold water is the best antipyretic." The fact that cold water means water from the cold faucet, and the more important truth, that tejnd water is a better antipyretic than cold water, are entirely disregarded. Cold water ranges from 35° to 75° F. (1.6°-23.9° C.) as it comes from the "cold" faucet at different seasons and in different countries. The wise prac- titioner would do well to avoid even baths of 75° F. (23.9° C.) in the pneumonia of children. Although the temperature and technic of the cold baths and packs which the eminent pedi- atrist recommends are not regarded by him as worthy of men- tion, his diregtions for the preparation and dosage of his favorite drugs are emphasized minutely. He ingenuously admits, too, that he was asked to resign from a hospital on account of his predilection for cold baths. (c) In an excellent English work on the "Action of Medicines," which has been a text-book in many American schools, the "cold bath" is referred to among "the best antipyretics," and its technic described as a bath of 65° F. (18.3° C), reduced by ice SOME TRUTHS ABOUT HYDROTHERAPY 441 to 40° F. (4.4° C); the patient lying in this bath until his tem- perature is reduced ! The lecturer, fortunately, insists on guard- ing against collapse, which would be equivalent to a recom- mendation of dangerous doses of strychnin with a warning to watch for opisthotonos. Not a word is said of friction, the most important element of all cold baths, and the physiologic fact that such a bath would increase the body temperature instead of reducing it, as has been demonstrated by Liebermeister and others, is lost sight of by an author whose greatest merit is the rational basis of his therapeutic teaching. (d) Another very popular American text-book on therapeutics displays ignorance of what any one in hydrotherapy would know by stating that "& douche falhng more than 10 feet is neither proper nor safe." I have seen thousands of douches administered with water that fell 60 feet, and in our own institu- tion here you may observe that so feeble a douche is never used. The absurdity of this author's warning is obvious, and serves to illustrate my proposition that even the best text-books are false guides on hydrotherapy. (e) A work on the treatment of nervous diseases describes the drip sheet as a sheet wrung out of cold water. The tautology is self-evident and proves a lack of practical acquaintance with hydrotherapy, and that the author has simply copied from other faulty works. Most text-books on practice of medicine are equally unre- liable as guides in the use of water in disease. There exists a want of unanimity and absence of definite instruction in the description and effect of hydrotherapeutic procedures, if these are mentioned at all, among authors which is in striking and painful contrast to their universal agreement upon the application and dosage of drugs and other remedial agents. This absence of precision naturally intimidates the physicia.n who consults these works, and imbues him with the idea that water is inferior to drugs. Moreover, while the other- wise able and conscientious authors keep abreast of the progress of their subject in all other respects, they appear to ignore 442 HYDROTHERAPY the most reliable conti'ibutions to the literature of the water treatment. One example, briefly referred to already, may suffice to prove this statement. In 1897 Dr. Alexander Lambert, of Belle^ale Hospital, New York, read before a medical society and published in the Medical News a paper containing the largest modern statistics on sunstroke. These were gathered from hospital records, read before a medical society and published in a prominent medical journal; the number of cases treated by each method and the results were clearly stated, and their simi- larity of type is established by their simultaneous occurrence in one week. The mortality under the graduated bath of 110° to 72° F. (43.3°-22.2° C.) in the Brooklyn Homeopathic Hospital was 41.17 per cent.; the mortality under ice-baths (Bellevue Hospital) was 33.33 per cent. ; under affusions and douches with water at prevailing temperature, 70° F. (21.1° C), in theFlower Homeopathic Hospital, was 11 per cent. The remarkable fact is also mentioned that when the bath treatment in the Brooklyn Homeopathic Hospital was changed to the more rational afTusion practised in the Flower Hospital, the mortality was at once reduced to 11.5 per cent. In the St. Vincent Hospital the late Dr. O'Dwyer obtained still more favorable results by simple affusions with cold water from the cold faucet, and in severe cases with ice- water, a procedure recommended thirteen hundred years ago by Paulus ^Egineta as the only rational practice. The mortality in 197 hyperpyrexia! cases was 6 per cent. This valuable report really affords a control experiment unsur- passed in therapeutics. Nor have I noticed any reference to the latter in the numerous works of practice which I have searched for this purpose in the library of the New York Academy of Medi- cine; they all reiterate the dreary platitudes about the import- ance of reducing the temperature by the cold bath, by ice-packs, ice-baths, and similar irrational procedures. If such a report had brought forward the fact that a medicinal agent had so greatly reduced the mortality of a fatal disease, these text-books would not have omitted to mention it, with the most earnest approval. No more convincing proof can be adduced to demonstrate the SOME TRUTHS ABOUT HYDROTHERAPY 443 utter unreliability of the text-books on practice as guides in the application of water in disease, nor of the importance of its correct and rational use. How the false teaching of the text- books is perpetuated is demonstrated in the New York Medical Journal, which last spring (1908) offered a prize for the best article of the treatment of sunstroke. Not a single one of the writers of this essay referred to the report of the epidemic of 1896, in which numerous lives were lost by sunstroke, most of which would no doubt have been saved by correct management. How, then, it may be asked, is the active practitioner to obtain rehable information on hydrotherapy if the standard works of reference do not furnish it? Here he meets a difficulty which I propose to aid in surmounting. All of the special works on hydrotherapy have, until recently, been written by water- cure doctors, whose observations are chiefly on chronic diseases and who rarely see fevers and other acute maladies in which water is a very important and accessible therapeutic agent. Nor does the institution doctor have sufficient opportunity to observe the incipient stages of chronic cases, which are the bane of the family physician, who, when he consults these special works, seeks in vain for precise directions for his guidance, and only after failure to restore the sufferer to health sends him or her to a sanatorium, if a quack or Christian Scientist be not resorted to by the family before he determines to do so. As a general practitioner I long ago realized this difficulty in my early efforts to follow the French and German special works. They led me to many failures because their methods were too heroic, not clearly individualized, and not adapted to private practice. There is but one recourse that insures the practitioner against such disillusion and failure, i. e., to depend only on works written by physicians who, like himself, have experience in general or hospital practice. They alone are capable of appreciating his utter helplessness when confronted with cases in which water has been successfully applied. Happily there are now several works of this type published in German and English. In these 444 HYDROTHERAPY treatises hydrotherapy is not vaunted as a specific, but as a methotl of treatment which aids in sustaining the failing functions and thus prevents fatal complications in acute disease, and which furthers nutrition and tissue change, the chief therapeutic aims in chronic disease. Such works contain simple directions for home treatment, which in many cases suffice, and in obstinate cases prepare them for institution treatment, and thus shorten the latter. The study of hydrotherapy would be simplified were it re- garded as a method of utilizing the physiologic action of thermic excitation through the medium of water. The rationale of this thermic excitation, conveyed by water to the ner.ves and vessels of the skin, explains all hydrotherapeutic procedures, and its comprehension and application is not more difficult than are similar facts in the study of drugs. The varying effects of vary- ing temperature, duration and pressure, and technic afford greater latitude in "dosage" than do the effects of drugs, and require more detailed study. That the latter is not difficult, however, must be evident to every general practitioner who utilizes it empirically in the management of the stillborn infant. Sprinkling with cold water is the first and mildest procedure; if this does not act efficienth^ he dips the infant alternately into hot and cold water; this is a larger "dose." He docs not apply a cold bath to the stillborn infant because it would be too large a dose, nor a cold dip to the typhoid patient because it would be too small a dose of thermic excitation to arouse flagging vitality. There is no time in the obstetric case to ascertain exact temperature; the emergency must be met and the case is immediately terminated. In the typhoid patient, on the con- trary, many weary days must be spent in adapting the thermic excitation to the individual case, and exact temperature, dura- tion, and technic are of vital importance. The latter applies to other infectious diseases and to chronic and subacute cases of prolonged duration. It is only necessary to abolish the words "cold water" and "hot water" and substitute thermometric designations and the watch to convert haphazard and disappoint- SOME TRUTHS ABOUT HYDROTHERAPY 445 ing into a scientific and successful hydrotherapy. Nothing is more simple in medicine, and yet our otherwise more competent writers indulge in vague and discouraging generalities, if not absurdities, when referring to water in therapeutics, as I have endeavored to show. A change is urgently demanded if we would fulfil the measure of our duty to our patients and to ourselves. The capacity of water to produce numerous therapeutic effects — stimulant, tonic, sedative, antipyretic, diaphoretic, diu- retic, depurative, and evacuant — has led narrow men to erect a medical system — hydropathy. Being based on the fallacy that water is a specific curative agent, it failed, and is now the recourse of empirics who vaunt their successes, but are silent on their failures. I would fain arouse more attention to the vital fact that physicians are not only suffering material loss by neglecting hydrotherapy, but that in their efforts to ameliorate and cure disease they are sadly handicapped by not applying it frequently. My colleagues, you are favored in this city by having at your disposal an institution which is ideal in that it is controlled by your own colleague and not owned and conducted by one whose commercial instincts would subordinate the best interests of your patients to his own personal advantage. Another in- estimable advantage, as I have learned, lies in the fact that physicians are permitted and invited to observe the treatment, just as they are wont to do in acute cases, under trained attend- ants. Such observations would convey to you a large fund of knowledge which must inure to you and your patient's benefit. The time demanded for thus watching a case is trivial, because in chronic cases the effect of hydriatric measures is slow, and if personal observation is inconvenient, reports from the trained attendant would place you in possession of the reactive capacity of the patient, his gain or loss in weight, etc. You thus would obtain a guide for the renewal of prescriptions, and add valuable material to the history of each case so treated. It may interest you to obtain an outline of my mode of 446 HYDROTHERAPY prescribing institution treatment. For cases of defective nutri- tion or hematosis, idopathic or as a complication, the following has served me well : I?. Hot-air bath until warm, followed by circular douche, one minute, 95° to 90° F. (35°-32.2° C); pressure, 20 pounds; followed by fan douche for one-half minute at 85° F. (29.4° C), reduced daily 1 degree; fol- lowed by drj'injj and friction, same pressure. Report after three treat- ments reaction and weight. This prescription may be abbreviated as follows: l^. H. A. B. w. C. D., one m., 95° to 90° F. (35°-32.2° C), 20 lb. F. D., one-half m., 85° F (29.4° C), 20 lb. Fr. No. 3. For a case of obesity, chronic rheumatism, gout, or other malady demanding enhancement of tissue change, the prescrip- tion may read : I^. Hot-air bath, p. ten min. fto perspire ten minutes). Circular douche, one m., 100° to 95° F. (37.7°-35° C). Fan douche, one m., 95° to 85° F. (35°-29.4° C). By these cautious procedures the patient may be gi'adually restored to health, and the physician, observing the effect of each series of treatment, may increase their number and intensity according to indications in each case. In conclu.«ion. I desire to emphasize the fact that my observa- tions on the effect of water in disease have been made at the bed- side of private patients and in the wards of hospitals for a period extending over a quarter of a century. In a few months I shall pass the half-century mark of my professional career. During the first half of the period I was ignorant of the therapeutic value of water; during the latter half I have endeavored to study and utilize it. Looking back upon this large field of clinical observa- tion I am impelled to ofTer its results for the furtherance of the interests of the profession I love and honor. Imbued solely by this thought, and without hope or expectation of material benefit, SOME TRUTHS ABOUT HYDROTHERAPY 447 I come to-night, my colleagues of Boston, to bring to you the message that no agent in the entire materia mcclica has so often demonstrated to me at the bedside such life-saving prop- erties and afforded me such comfort and satisfaction as has the correct application of water since I abandoned the false teachings imbibed from faulty works on hydrotherapy. In acute diseases this was not difficult, because the patient was under the observation of trained nurses, change of technic could be readily made, and the effect observed and recorded. In this manner I was led to abandon Liebermeister's heroic cold bathing and Ziemssen's prolonged cold baths in favor of Brand's brief, sustaining baths; the management of pneumonia by compresses, which have afforded me the best results, also was an evolution from more heroic cold full baths. From close study and observation of the effect of the heroic procedures recommended by Duval, Keller, Beni-Barde, and others in chronic diseases in the Montefiore Home was evolved my method of neurovascular training (The Principles and Practice of Hydrotherapy, published by William Wood and Co., 1908, p. 436), which improves nutrition and hematosis and pre- pares the patient without shock for more intense procedures adapted to the furthering of tissue changes. Gentlemen, if I have succeeded in impressing upon you the crying need of the obligatory study of hydrotherapy in our medical schools, and the enormous import of the study and more frequent utiHzation of hydrotherapy and other physical measures, and if I have succeeded in removing from your minds some of the misconceptions which have crept into this subject, and, above all, if I have convinced you that the grasp of this subject presents no difficulty, but, on the contrary, that the action of water in disease is based on rational principles, I shall congratulate myself on adding to the sum total of knowledge for the alleviation of human suffering. 44S HVDHOTHERArY ELECTRIC PAD, OR THERMOPHORE This electric device is an aid in many hydrotherapeutic pro- cedures.* The pad consists of a special fabric into which German silver resistance wire is interwoven, the whole being; covered with mackintosh or cidonlown. The pad is provided with a coil, plug, and rheostat switch. In use it is only necessary to screw the plug into a lamji socket. A turn of the switch makes the connection, and by adjustment of the switch the current may be varied in intensity in the ratio of 1, 2, and 4. Fig. 145. — The thermophore. The No. 1 heat is designed for simple, moderate heating effects, as for bed warming, for maintaining the heat of a poultice, or to secure the effects of Bier's method. At this heat the current can be run continuously for hours without overheat- ing the pad. When a higher form is employed, however, a much higher degree of heat is generated, such as is required to produce the intense effects of a fomentation or cause general perspiration. When these heavier- currents are employed the pad must be exposed occasionally so as to prevent the excessive accumula- tion of heat. When effects itlentical with those of a fomentation are required, a moist cloth is laid over the skin, over this a dry cloth, and upon this the thermophore. The thermophore has the advantage over the fomentation, the hot-water bag, and similar forms of heating in that the temperature gradually ^ Designed and manufactured by the Modern Medicine Co., Battle Creek, Michigan. ELECTRIC PAD, OR THERMOPHORE 449 rises instead of lowering. The fomentation cools off so rapidly that it must be renewed every few minutes, whereas the electric thermophore requires but a single application and may be con- tinued as long as desired. ^Vhen the heat becomes too gi'eat to be borne, it is only necessary to adjust the switch so as to employ less current, and thus the application may be continued without interruption. Less than one minute is required to bring the pad to the full heat. The expense is only that of a 16-candlepower lamp light, while the convenience is much greater than with the hot-water bottle, clay poultices, hot-air apparatus, or other of the dirty, in- convenient, and cumbersome apparatus so commonly employed. For ordinary use the pad is made either with or without the regulating switch. The single heat pad answers very well for ordinary purposes, as the heat can be turned off and on as desired. ELECTRIC THERMOPHORE BLANKET These blankets are made upon the same principle as the electric thermophore described above. They constitute a most convenient means for making a general application of heat. They are made with regulating switch, so that any degree of heat required may be employed. 29 INDEX Abbreviations used in prescriptions, 421 Abdominal compress, 249 douche, 256 Abilena water, 203, 413 Ablution, 246 Accidents in hydrotherapy, 386 in Turkish bath, 296 Acne, cold douches for, 2o4 Adenitis, cold compresses for, 86 iEdepsos, springs of, 375 Aerated waters, 388 Affusions, 244, 287 Aix douche, 129, 263 Aix-la-Chapelle, 128, 198, 199, 414 Aix-les-Bains, 125, 205, 264 Albu on spastic constipation, 152 Albuminuria caused by cold baths, 45 diaphoresis for, 113 Alcohol in Brand baths, 61 in cerebrospinal meningitis, 89 in pneumonia, 101 rub, 251 Alcoholism, 149 Fleury douche in, 281 AlkaUne baths, 204, 309 in leprosy, 206 calcareous waters, 405 waters, 403 Alternate douche, 256 Alum in iron waters, 415 Amenorrhea, warm bath for, 291 Anders, 135, 312 on Brand baths in typhoid fever, 62 Anemia, 158 and chlorosis, Turkish bath for, 298 Anemia, cold douches for, 254 prescription for, 446 Nos. 1, 2, 3, and 7, 422 sea-bathing, 380 Angina pectoris, 53, 291, 428 Nauheim treatment, 140 Apenta, 184, 413 Apollinaris water, 410 Appendicitis, 158 Arkansas Hot Springs, analysis, 19 radio-active, 391 syphiHs, 202, 204 Arsenic iron waters, 415 not absorbed by the unbroken skin in baths, 22 Arsenical poisoning, 149 waters, 204 Arterial degeneration, 189 tension in Nauheim baths, 48 lowered by Aix douche, 271 Arterioles, 435 Arteriosclerosis, 53, 114, 147 Arthritis deformans, 131 treated by douches, 281 gonorrheal, 130 prescriptions, Nos. 8, 18, 423 treatment at Aix, 272 ' urica, 127 Ascending douche, 258, 262 Ascites a coiuiterindication to water drinking, 401 Ashley's Bromin-arsenic Spring, N. C, 415 Ashton, W. E., 221 Asphyxia neonatorum, 108 Asthma, 110 cardiac, 428 451 452 INDEX Asthma, half-bath, 243 Atheroma, 291 Atlantic City, sea-bathing, 378, 379 Atonic congestion, 30 Atrophy, secondary muscular, 122 Aufrecht on cerebro.spinal meningitis, 88 Avicenna on cold baths for tetanus, 89 Bacterial toxins elimination, 47 Bad Gastein, 390 Baden, 128, 414 Baden, 113 mud baths, 333 Baker on insanity, 176 Baldwin on mental effects, 42 Ballston Spa, N. Y., 407 Balneology alhed to hydrotherapy, 18 Baltimore houses with bath-tubs, 377 Bandler's Medical Gynccologj', 221 Banting on obesity, 400 Bareges, 128, 205, 414 Barron continuous bath, 290 Baruch, 234 hydrotherapeutic law, 37 instruction in hydrotherapy, 383 on baths for tuberculous patients, 96 on cold rubs in nephritis, 116 on eclampsia, 118 on educational bath, 163 on epilepsy, 182 on heat and cold as irritants, 35 on some truths about hydrotherapy, 432 on sunstroke, 92 preface, 23, 29 public rain baths, 375 tub for Brand baths, 64 Basch, von, 49 Bath, England, 205, 406 action of waters, 20 Baths, 237 public, 372 Roman and Greek, 372 Battaglia, Italy, mud baths, 333 Baudelocque, 289 Bear Lithia Water, 417 Beard on routine methods, 44 Bedford Alum Spring, 415 Springs, Pa., 406 Bed-sores, 218 continuous bath for, 288 Bellevue Hosjiital sunstroke statistics, 442 Belzing on tuberculosis statistics, 437 Beneke on sea-baths, 113 lieni liarde, 102, 281, 447 Bergell and Bickell on radio-activity, 412 Berlin course in hydrotherapy, 385 Berthollet apparatus, Aix, 269 Bibliography, Surgeon-general's Li- brary', 17 Bidet, 165 Bielefeld, 181 Bier method lowers heat production, 41 Bilin water, 418 Binswanger on epilepsy, 180 Bitter waters, 413 Bladder, neuroses of, 166 Blood, effect of baths on, 56 Blood-pressure, effects of baths on, 31, 48 of Nauheim baths on, 48, 429 of salt baths on, 31 increase of, 53 Blood-serum concentrated by excess- ive use of water, 401 Blue Lick, Kentucky, 407 Bocklet Iron Spring, 415 Boils, 209 Bones and joints, diseases of, 211 Boston Medical Baths, 421, 445 Bouillons, 269 Bovaird, 135, 144 Bowers on insanity, 173 Brain tumor, 183 Bran bath, 208 Brand, 235 bath, 60, 436, 447 effects on urine, 45 INDEX 453 Brehmer on ice-bags for hemoptysis, 99 Bridge on hot bath, 239 Brieger course in hydrotherapy, 385 on sciatica, 185 Broadbent on insomnia, 166 Bromin waters, 416 Bronchitis, 108, 400 Bronchopneimaonia, 107, 400 Brown, Lawrason, on bathing in tuberculosis, 97 Brown, Phihp K., 312 on Nauheim baths, 318 Brown-Sequard paralysis, 189 Brozon oxygen bath, 323 Brunton on effect of heat and cold, 211 on sphygmographic tracings, 51, 52 Bubo, 220 Buffalo Water, 417 Bulkley on psoriasis, 205 on treatment of syphihs, 198 BuUot on experiments with distilled water, 398 Burns and scalds, 215 continuous bath for, 288 Buxbaum, 235 half-baths in pneumonia, 103 Buxton, 276 England, 205 for arthritis, 130 for gout, 129 moor baths, 334 radio-activity, 391 Cabinet baths, 125 Calcareous waters, 406 baths in, 24 Calcium salts, 405 Caledonia Springs, Canada, 407 CaUfomia Coronado, 378 sea-bathing, 378 Camac, 312 Capillaries, role in reaction, 29 Carabana water, 413 CaracaUa, baths of, 372 Carbon dioxid, exhalation of, in cold baths, 38 Carbonated baths, 310 drinking waters, 397 Carles on sea- water injections, 411 Carlsbad, 19, 407 conditions at, 133 mud baths, 333 visitors to, 388 water, 404 Castahan Springs, California, 413 CataboHsm due to cooling, 39 Catarrhal fever, 110 Cauterets, 128, 414 Cerebrospinal meningitis, 87 warm baths for, 291 Chalybeate baths, 159 metabolism of, 36 (steel) waters, 415 Chamberlen on public baths, 375 Charcot, 438, 439 douche, 255 Chatel-Guyon, double current irriga- tion apparatus, 369 douche, 183 Cheltenham, England, 407, 415 Chemic analysis of waters, 18, 19, 24 stimuH raise heat production, 41 Chicago course in hydrotherapy, 384 Children, baths for, 93 Chlorid retention, 409 Chlorosis, 158 Cholera, hot baths, 90 infantum, 157 Chorea, 87 Christian on chlorid retention, 409 Circular douche, 251 Clark's Riverside Spring, Mich., 413 Claytor, T. A., 322 on orthodiagraph, 146 Cleansing effect of baths, 24* Clifton Springs, N. Y., 406 for gout, 129 Clothing, 27 Clow, J. B., and Sons, 284, 285 Cohen, S. S., 123, 312 Cold and heat, effects of, 24 454 INDEX Cold applications for nephritis, 116 bath, 238 and heart, 322 and metabolism, 34 danger of, in sunstroke, 436 fear of, 434 in typhoid fever, 67 in rheumatism, 124 douche, 253 in pneumonia, 100 in tetanus, 89 pack in scarlet fever, 81 in typhoid fever, 76 water coil illustrated, 102 meaning of, 440 Colonic irrigation, 359 Colorado waters, radio-active, 391 Columbia I'niversity, instruction in hydrotherapy, 383, 433 Compresses, 344 cold, 346 ice, 347 Conde Spa iron water, 416 Congestion of lung, 109 Congress water, 98 Constipation, 151 chronic, sea-bathing for, 380 douche-massage for, 277 prescription for, No. 10, 423 Continuous baths, 169, 287 for burns, 215 Contrexeville, 406 Control table, 164, 281 Convalescence, 158 Convulsions of children, 89 Cook, Henry W., on hypertension, 53 Corbin douche, 269 Cornet's method of bathing in tuber- culosis, 94 Corson, on treatment of measles, 79 of typhoid, 00 Cough, compress to chest for, 98 Counterindications to baths, 53 to Brand baths, 70 to cold full baths, 240 Crab Orchard "Water, 184, 203, 413 Craig Colony at Sonyea for epileptics, 168, 180, 182 Cramps, muscular, 381 Crenology, 388 Crockett's Arsenic Spring, 415 Crofton on sweating in renal disease, 112 treatment of chronic nephritis, 115 Crook on constituents of waters, 417 Cross-binder, 99 Crounotherapy, 388 Croyden bath, 315 Curie, M., 412 on radio-activity, 392 Currie, James, 301 on action of baths, 21, 22 on pulmonary hemorrhage, 99 on treatment of ship-fever, 59 of tetanus, 89 Curschmann, 385, 433 Cystitis, 219 Damage suits in connection with hydrotherapy, 386 Dapper, Carl, on baths, 34 on metabolism and saline waters, 407 Dardel, Dr. Jean, on Aix-Ies-Bains, 263 on syphilis, 201 Dax, 391, 392 Debility, prescription for, 422 Delearde, 355 on bronchopneumonia, 107 Dent, E. C, 291 on insanity, 170 Derecq, 372 Diabetes insipidus, 120 mellitus, 118 Turkish bath for, 298 prescriptions A and B, 426 Diarrhea, iron waters for, 415 morning, 156 prescription No. 11, 423 Diet and mineral waters, 408 in syphihs, 200 INDEX 455 Digestion influenced by water drink- ing, 397 Digestive disorders, 150 Dimsdale on typhus fever, 59 Diocletian, baths of, 372 Diphtheria, ice applications, 86 Distilled water, 397 Diuresis, 396 Dosage of water, 444 Douche massage (Aix), 263 room, 253 table, 164, 281 Douches, 251 for tuberculous patients, 95, 97 Downes on ice-bag for hemoptysis, 99 Driburg sulphurous peat baths, 335 Drip sheet, 246 Drowning in epileptic attack, 181 Dryce on sunstroke, 91 Duque on leprosy, 207 Duval, 447 Dysmenori'hea, warm bath for, 291 Dyspepsia, chronic, Turkish bath for, 298 Fleury douche for, 281 nervous, 156 EcHEVERRiA on epilepsy, 181 Eclampsia, 117 Eczema, continuous bath for, 208 iron waters for, 415 Turkish baths unfavorable in, 204 Edema of lung, 110 Edsall on chlorid retention, 409 Eichhorst on Brand baths, 74, 75 Ekgren, 327 Elbrecht apparatus for proctolysis, 363 Electric pad, 448 Electric-light baths, 305 for nephritis, 115 Emetic, water as an, 419 Emmet, T. A., 371 Emollient baths in skin disease, 203 Endocarditis, rheumatic, 126 Enemata of ice-water, 76 Enemata of ice-water for sunstroke, 90 of oil for constipation, 153 salt solution, in pneumonia, 104 Enteritis, 154 Enteroptosis, 156 Enuresis nocturna, 166 Epididymitis, 220 Epilepsy, 178 drowning iu, 386 Epileptics, 169 Equipment for institutions, 431 Erb, 438 on Brand baths, 74 Erysipelas, 218 Esmarch bandage lowers heat produc- tion, 41 Ethereal solutions absorbed by skin, 22 Eulenberg on epilepsy, 180 Eureka Springs, Cal., 407 Evaporation baths, 237 Exercises, Schott treatment, 135 Exophthalmic goiter, 197 Exudates resolved, 272 Eye diseases, 227 Fachingen water, 404 Fan douche, 261 Fango packs, 332 treatment at Wiesbaden, 210 Fats and saline waters, 408 Faught's sphygmomanometer, 50 Felons, 214 Fernald on blood-count, 56 Ferras, 393 Ferrous sulphate, 416 and carbonate not absorbed in baths, 23 Ferruginous waters, 415 Fever, procedures in, 436 remedial nature of, 34, 77, 106 Filiform douche, 262 Finns, sweat baths, 301 Fleury douche, 280 on epilepsy, 178 . Flexner's serum, 88 456 INDEX Flitwick, England, 415 Floating baths, New York City, 376 Florida, sea- bat lis, 378 Flower Hospital, N. Y., sunstroke statistics, 442 Floyer, 58, 241 Folin, 192 studies in metabolism, 36 Fomentations, 12.5, 347, 358 Football accidents, 213, 215 Foot-bath, 308 Forchheimer half-baths for diabetes insipidus, 120 on mustard baths, 157 Formanek on uric acid elimination, 47 Formic acid, 312, 318 Fort Monroe, Virginia, 316 Foster, 169 on cold packs for nephritis, 116 on epilepsy, 182 Foulds on ice- water encmata for sun- stroke, 91 Frankenhauser instruction in hydro- therapy, 385 Frankl on oxygen bath, 324, 331 Franz Josef water, 413 Franzcnsbad, 334, 415 Franze on metabolism in Xauheim baths, 35 on Xaulioim baths, 311 French Lick, for alcoholism, 150 Fresh- and salt-water baths compared, 20 Frey and Heiligenthal, experiments on Russian baths, 32 on sweating in baths, 1 12 Friedrichshall water, 203, 407 Furunculosis, 209, 214 Gall-stones, 404 Gant, 241 Gastein, 128 Gastralgia, 396 Gastric acidity, 414 ulcer, 154 Carlsbad water for, 404 Gastritis, 154 Gastroptosis, 153 and water drinking, 396 Geigel, course in hydrotherapy, 384 Gell on Pompeian baths, 373 Geneva Lithia Water, 417 Genito-urinary diseases, 219 German Army, typhoid statistics, 436 clinics for hydrotherapy, 433 Gibney on sprains, 212 Glacier ice-water, 401 Glaucoma, 229 Glen Springs, N. Y., 407 Summit water, 399 Gonorrheal arthritis, 130 Gooseflesh, 27, 41 Gout, 127 acute symptoms arising after baths, 298 affected by Kissingen water, 410 and Uthia waters, 419 astlienic, treated at Aix, 272 by douches, 281 Nauheim baths in, 36 Gouty kidney, sphygmographic trac- ing, 52 nephritis, 114 Greece, baths of, 374 Greenbrier White Sulphur Springs, 406 Greyer, 417 Groedel on orthodiagraph, 321 on salt- and fresh-water baths, 30 Grosse on oxygen bath, 324 on treatment of measles, 79 Grossmann, isotonic waters, 401 Grube on isotonic waters, 401 Gynecologic affections, 221 and douches, 371 Half-bath, 243 Hall, 407 Halle, course in hydrotherapy, 385 Hammock bath, 291 Hansell on sweating process in eye diseases, 228 Hanson on bathing in scarlet fever, 83 INDEX 457 Hare on fever, 78 on ice rubbing in typhoid fever, 72 on substitutes for Brand baths, 65 on Turkish baths, 300 Harrodsburg, Ky., 413 Harrogate, 205 waters, 414 Hathorn Avater, 98 Hawke on insanity, 173 Head, douches to, 256 Headache, 183 Healing Springs, Virginia, 205 water of, 406 Heart diseases, 132, 428 effect of drinking water, 402 effect of baths on its rate, 54 failure, 435, 436 reduction ia size, after baths, 318, 320 sphygmographic tracings, 51, 52 weakness in scarlet fever, 80 Heat after operations, 214 and cold to body, 233 degree of dry heat bearable, 25 loss, 27 estimated by Liebermeister, 40 physical and chemic regulation of, 26 regulation estimated by Wintemitz, 41 stroke, 90 ' Heater for compresses, 352, 448 Hebra on continuous bath, 216, 288 Heidelberg, 385 Helouan, 19 Hematemesis, 154 Hemiplegia, 189 Hemoglobin, 57 Hemoglobinuria caused by cold baths, 45 Hemorrhage in typhoid fever, 62, 73, 234 pulmonary, 99 Hemorrhoids, hip-baths for, 338 prescription for, No. 12, 423 Hepatic douche, 257 Heppolette on ice-water enemata for sunstroke, 91 Hertel, 234 Herzfeld, Dr. A., mustard packs, 109 Heubner on mustard bath, 309 Hieropohs, springs of, 19 Hippocrates, 434 on cold baths for tetanus, 89 on cold produces heat, 339 on remedial nature of fever, 34 on use of sea- water, 411 Hirschfeld on arteriosclerosis, 147 Hoffman's orthodiagraph, 321 Hollman on medicated baths, 206 Homburg, 406 conditions at, 133 Elizabeth-bnmner, 418 water, 410 Homer's description of Ulysses' bath, 58 Hot apphcations in nephritis, 115 baths and metaboHsm, 45 in cerebrospinal meningitis, 89 in tetanus, 89 dry pack, 344 full baths for measles, 79 pack, electric pad, 448 sponging in typhoid fever, 76 Springs, Arkansas, 202, 204, 396, 406 state regulation, 389 Virginia, 19, 122, 129, 186, 281 water bathing, 291 draughts, 395 wet pack, 341 Hot-air bath, 305 blood pressure in, 54 Huggard on radio-activity of waters, 391 Hinnage, 269 Hunjadi, 413 water, 203 for neuralgia, 184 Hunner on cystitis, 219 Hydremia from water drinking, 401, 403 458 INDEX Hydrogen sulphid absorbed in baths, 23 Hydrotherapy, instruction in, 383 some truths about, 432 Hyperacidity, nervous, 414 Hyperchlorhydria, 396 Hyperemia, 430 Hyperpyrexia, 435 in rheumatism, 124 Hypochlorhydria, 396 Hypochondria, douche to head for, 257 sea-bathing in, 3S0 Hysteria, rain douclie for, 261 Ice-bags, 103 for liemoptysis, 99 Ice-coil, 357 Ice-packs dangerous in sunstroke, 436 Ice-poultice, 355 Ice-rub, 245, 355 in typhoid fever, 71 Ice-water dangerous at times, 396 Ichthyol baths in skin tliseases, 204 Ignatowski on heat loss in baths, 38 Impotence, 165 Incantlescent light baths, 429 India, bathing habits in, 294 Indians, American, 301 Infants, pneumonia of, 103 Inflammation, local, 210 Influenza, 110 Insanity, 168 Turkish bath for, 298 Insolation, 90, 436 Insomnia, 166 cold tlouches for, 254 of insanity, 176 Institutions, equipment for, 431 Inunctions of oil in typhoid fever, 77 lodin waters, 416 Iridocyclitis, 202 Iritis, 227 Iron waters, 415 Irrigation for cystitis, 220 of rectum, 359 Iverson's apparatus for proctolysis, 361 Ivy poisoning, 218 Jackson on treatment of typhus, 59 Jacobi on bathing in tuberculosis, 94 on high temperature in pneumonia, 106 Jane way's bed-lift, 241, 242 Japanese and hot baths, 292 Jaundice, Fleury douche for, 281 Jet douche, substitute for, 254 Joachimstlial, 390, 392 Jolmson on sprains, 212 Jurgensen, 235 on reaction to cold baths, 38 Kaposi on continuous bath, 290 KeUor, 447 Kidney-reflex, stimulus of, 281 Ivinnicutt on Brand baths, 69 on resistant exercises, 135, 140 Kionka on balneotherapy, 384 Kisch on non-absorption of mineral constituents in baths, 22 Kissingen, 128, 406 mud baths, 333 water, effect of, in gout, 410 Klemperer on solvents, 404 Kletzinsky on absorption in baths, 23 Kneipp, 432 water cure, 254 Kothe on proctoclysis, 370 Kowalski, 234 Koracli on forced bathing, 74 KraepeUn, 173 Krause on bone tul)erculosis, 211 on chorea and rheumatism, 87 on hemoptysis, 99 on toothache after baths, 231 Kreuznach, waters of, 394, 416 Kussmaul, 432 commission on instruction in hydro- therapy, 437 INDEX 459 Kussmaul on peristaltic unrest, 157 Kuthy on tuberculosis, 437 La bourboule, 204 Lambert on sunstroke, 442 Langenbeck on continuous bath, 217, 290 Lansigk, 415 Laqueur, 327 on uric acid elimination, 47 Lead poisoning, 149 Leamington, England, 407 Leg-bath, 308 Lehman's experiments on cutaneous absorption, 23 Leipsig, course in hydrotherapy, 385 Leiter coil, 88 illustrated, 102 Lenhartz on edema of the lung, 110 Leprosy, 206 Leuk, 205 Levico arsenic spring, 415 water in psoriasis, 204 Levy-Dorn, orthodiagraph, 321 Lewandowiski on furunculosis, 209 Liebermeister, 447 on lukewarm baths in typhoid fever, 65 Lissauer, 108 Lithia waters, 416 Liver, engorgement of, 280 Lockwood on gastroptosis, 153 Locomotor ataxia, 187, 188, 291 LoSche-les-Bains, 128 Logic on insanity, 170 Londonderry Lithia Water, 417 Longettenverbanden, 185 Loofah, 296, 359 Loomis, 436 Lucas, packs, 338 Luchon, 390, 392, 414 on radio-activity of waters, 392 Luff on uric acid fetich, 123 Luke, 235 Lumbago, 148, 280 prescription F, 427 Lumbar douche, 280 Mabon, 170 MacCullum on fever as protective process, 79 Maecenas, 372 Magnesium sulphate applied in com- presses, 218, 220 solution for compresses, 126 Malarial cachexia, iron waters in, 415 disease, Fleury douche for, 281 Manhattan State Hospital, 291 Mania, douche to head for, 257 warm baths for, 291 Manitou Springs, Colo., 406 water, Colorado, 403, 415 Marcuse and Strasser, 432 on excretion of urine influenced by distilled water, 399 Marienbad, 406, 415 in gynecologic affections, 221 Martin's sphygmomanometer, 49 Matthes on epilepsy, 180 on hydrotherapy, 384 on metabohsm in baths, 34 on tonic reaction, 29 Mays on cold in pnevunonia, 102 McCrae on Brand baths, 77 McGuire on proctoclysis, 370 McLean Asylum, studies on metabo- lism in, 36 Measles, 79, 400 Mechanical irritation in baths, 25 stimuU, 41 Medical baths of Boston, 142 of Philadelphia, 283 Medicated baths, 308 in leprosy, 206 Melancholia, 172 douche to head for, 257 Menstrual disorders, sitz-baths, 337 Menstruation and Brand baths, 71 suppressed, Turkish bath for, 298 Mercurial inimctions, 199 poisoning, 149 Mercury, chlorid of, 22 cutaneous absorption impossible in baths, 21 Metabolism and hot baths, 45 460 INDEX Metabolism and saline waters, 407 and water drinking, 395 effect of baths on, 33 influenced by cold baths, 34 meaning of, 127 Metallic poisoning, 187 Metritis, 222 Mineral constituents of baths not absorbed by the unbroken skin, 22, 23, 24 waters, 3SS classification, 390 radio-active, 394 Misiewitz on hip-baths, 338 MitcheU, S. Weir, 163, 181 on heat and cold to spine, 354 on sciatica, 186 Montefiore Home, 447 Moor baths for arthritis, 131 Moritz's orthodiagraph, 321 Morphinism, 149 Morton on artificially radio-active waters, 394 Mosler on contraction of spleen, 161 Mosso, 49 Mouren and Lepape on estimate of radio-activity, 392 Mt. Clemens, Mich., 407, 409 analysis, 19 for sj-philis, 198 sulpliur baths for gout, 129 Mud batlis, 332 for arthritis, 131 Murphy's method of proctolysis, 148, 158, 361 Musser on Brand baths ip tj'phoid fever, 63 on chlorid retention, 409 on use of alcoliol in Brand baths, 61 Mustard bath, 309 foot-bath, 105, 106 packs in bronchitis, 108 Miitterlauge, 312 Myalgia, arc-light bath for, 427 Myelitis, 291 Myocarditis, 148 Myositis, 148 Napa Soda Springs, Cal., 406, 415 Xaturarzt, 432, 433 Nauheim bath, 20, 310 baths and arterial tension, 48 and Schott exercises, 134 artificial 173, 428 for anemia, 159 for gout 36, 129 for nephritis, 114 in gjTiecologic affections, 221 in rheumatism, 36 metaboUsm in, 36 prescription H, 427 visitors to, 133 Needle douche, 251 Nenndorf, Prussia, 414 Nephritis, 113, 114 after acute, sea baths dangerous, 382 aggravated by saline waters, 409 chronic, 281 interstitial, prescription D, 426, 428 parenchymatous, prescriptions for, Nos. 7, 21, 422 of scarlet fever, 118 use of water internally, 396 water drinking, 400 Neptune's girdle, 151, 167, 179, 356 Ner\'ous dj^spepsia, 156 prescription for, 422 sea-bathing, 380 Neuralgia, 184 and neuritis, 430 prescription for. No. 9, 423 rain douche for, 261 Neurasthenia, 162 in tuberculosis, 99 prescriptions for, Nos. 1, 2, 3, 15, 16, 422 rain douche in, 261 sea-bathing, 380 sexual, 165 Neuritis, 186 and neuralgia treated at Aix, 272 arc light, 427 Neuroses of bladder, 166 INDEX 461 Neurovascular training, 163 Neusser on radio-active treatment, 393 New York City public baths, 376 Hydrotherapeutic Apparatus Co., 284 Nitrogen elimination in baths, 32 Nitroglycerin an aid in hydrotherapy, 92 Noeggerath, 289 ^^ Noorden, von, 30 on cold appUcations in nephritis, 116 on Fachingen water, 404 on metabolism and sahne waters, 407 in baths, 34 on sulphur water in hyperacidity, 414 on sweating in renal disease, 1 12 on water restriction in nephritis, 401 Nutrition, defective, prescription for, 446 Oak Orchard Springs, N. Y., 415 Obesity, 190, 224, 428 prescription for, 446 sea-bathing in, 380 Turkish bath in, 298 use of water in, 400 O'Dwyer on sunstroke, 442 Oertel on obesity, 400 system, 318 Oil enemata, 153 immctions in scarlet fever, 86 in typhoid fever, 77 rub, 249 Old age and sea-bathing, 381 Ophthalmia neonatorum, 227 Oppenheimer on packs and baths in scarlet fever, 85 OrcMtis, 220 Orthodiagraph, 142, 146, 321 Osier, 48, 436 Osmotic pressure, 213 Osteomyehtis, 211 Overexertion, 53 Oxygen bath, 148, 323 in insanity, 173 intake in hot baths, 46 Ozet bath, oxygen bath, 324 Pacitic Congress Springs, Cal., 415 Pack, coohng wet sheet, 237 table, 35 Packs, 338 cool, in scarlet fever, 81 Fango, 332 mustard, in bronchitis, 108 Pail douche- or pail-pour, 278 Palm Beach, temperature of sea- water, 378 Paradoxes, 339, 407 Paralysis, 187 Paraplegia, 187, 291 Parasite skin diseases, 208 Parmelee still and sterihzer, 398 Passavant on continuous bath, 216 Paulus of iEgina, 289, 442 Peabody, 436 Peck on electric-Hght baths, 307 Pemphigus, 209 continuous bath for, 288, 290 Pennsylvania Epileptic Hospital, 182 Percussion douche, 278 Perineal douche, 258, 262 Peripheral neuritis, 187 Peristaltic unrest, 157 Peritonitis, 158 continuous bath for, 289 Peters on douche in tuberculosis, 97 Pfaefers-Ragatz, 128 Pharyngitis, Turkish bath for, 298 Philadelphia Hospital for the Insane, 169, 173 houses with bath-tubs, 377 medical baths, 283 pool baths, 376 Phlebitis treated at Aix-les-Bains, 272 Phlegmons, 214 Phosphaturia, 120 Physical regulation of heat, 26 Pick on epilepsy, 179 Pierce on action of waters of Bath, 20 402 INDEX Pine-needle bath, 309, 314 Pine Ridge, R. I., Sanatorium, 97 Piscines at Aix, 270 Pistyan Springs, Austria, radio-active, 395 Plombieres, 128, 391 douche, 183, 270, 370 in gynecologic affections, 221 Plunge bath, 238 Pluto Spring AVater, P>ench Lick, 150, 184 Pneumonia, 100 ice in, 235 Poland Springs, Maine, 399 Pompeii, baths of, 372 Pope, 235 on compresses, 350 Pospischil, 185 on rate of heat production, 37 Potain, 49 Potassium chlorid baths, 30 ferrocyanid not absorbed in baths, 23 nitrate not absorbed in baths, 23 Pozzi on vaginal douches, 371 Pratt, 385 on cardiac insufficiency, 141 on choice of procedures, 44 on hot-air baths, 47 on prescriptions, 421 Precautions, sea baths, 381 Prescriptions for hydrotherapy, 420 Priessnitz, 59 cross-binder for cough, 98 half-bath, 243 pack, 108, 339 Proctolysis, 361 Prolapsus ani, 338 Prostatic hypertrophy, prescription for, No. 12, 423 Psoriasis, 204 Royat water, 416 Piillna water, 413 pulmonary congestion, 109 Pulse in typhoid, 60 Purgative waters, 413 Purton Spa, 416 Putnam, 421 Pyosalpinx, 223 Pyrmont water, 399, 415 bottled, 416 Rabateau on cutaneous absorption in baths, 23 Radio-active waters internally, 412 Radio-activity of waters, 390 Rain bath lowers heat production if warm, 41 douche, 258, 259, 278 Rakoczy Spring, 418 Ransom on sweating and albuminuria, 113 Rationale of hydrotherapy, 17 Reaction, 26 after cold, 435 after sea-bathing, 380 painful after baths, 122 Rectal irrigation, 359 Reduction cure, 191 Reflex action of thermic stimuli, 25 Reiche, furunculosis, 209 Renal calculus, Fleury douche for, 281 comphcations and Brand baths, 71 diseases. 111 Respiration affected by baths, 31 Respiratory changes, 57 Rheumatic myositis, 148 Rheumatism, 120 and gout, 225 chronic, treated at Aix-les-Bains, 272 Nauheim baths in, 36 or gout, prescription for, 446 prescription for. No. 9, 423 treated at various springs, 20 Richelot on vaginal douches, 371 Richfield Springs, N. Y., 205, 409 for gout, 129 Rieder, 30 Riesman on crounotherapy, 388 Riess on continuous bath, 290 on warm full bath in typhoid fever, 71 Riley, 49 INDEX 46^ Ringer's solution, 104 Risley on sweating process in eye dis- eases, 229 Ritter on cutaneous absorption in baths, 23 Riva-Rocci's sphygmomanometer, 49 Rives, 135 Robin on nitrogen elimination in baths, 32 Rochester on chlorid retention, 409 on treatment of pneumonia, 105 Rock Enon Spring, Va., 415 Rockbridge Almn Spring, Va., 415 Rogansky on cerebrospinal meningi- tis, 88 Rohrig's experiments on absorption in baths, 23 Roller bandage applied wet, 218 Roman bath, 304 Romberg on Brand baths, 74 Roncegno Arsenic Spring, 415 water in psoriasis, 204 Rontgenography, 322 Rose on continuous bath, 216 on history of continuous bath, 289 Royat, 204, 415, 416 Rubbing in Brand baths, 65 Rubinat water, 413 for neuralgia, 184 Rubner on metabolism, 40 and water drinking, 395 on respiratory changes in cold baths, 39 Rubs, 249 Rudolf and Beck, 322 Russian bath, 301 effect on urine and bodily tem- perature, 33 Rutherford on radio-activity, 394 Sadger on hemorrhage from gastric ulcer, 154 Sadler on instruction in hydrotherapy, 384 on treatment of obesity, 195 SaHcylic acid not absorbed by un- broken skin in baths, 22 | Saline baths and fresh water baths compared, 30 waters, 406 and metabolism, 407 Salpingitis, 224 Salt rub, 94, 354 for nephritis, 116 in neurasthenia, 162 Sand-baths, 335 Sandow's bath, 315 Sandwich Springs, Canada, 407 Sarason, oxygen bath, 323 Saratoga, 407 Springs, 417 vichy, 403 waters, 184, 203 Satterthwaite, 312, 316 on resistant exercises, 135 Saxon on apparatus for proctolysis, 366 Scarlatinal nephritis, 118 Scarlet fever, 80 Schnuetgen on oxygen bath, 327 Schondorff on water drinking and uric acid, 395 Schott, 318 resistant exercises, 135, 311 Schultze on Brand baths, 74 on temperature of body after heat and cold, 233 Schwalbach, 415, 416 Schweinburg, 179, 234, 235 Sciatica, 184, 291 prescription F, 427 Scleroses, 187, 188 Scotch douche, 125, 256 for sciatica, 185 rub, 250 Scrofula, iron waters in, 415 Sea-baths, 27, 168, 186, 189, 260, 377 as preventive measure, 94 increase urea, 113 Seasickness, 158 Sea-water for Nauheim baths, 316 injections, 411 Sedative treatment, 430 See, Germain, on obesity, 400 464 IXDEX Seguin on cutaneous absorption in mineral baths, 21 Semmola, 438 Senator on sweating in renal disease, 111 Shampoo, 297 Swedish, 359 Sharon Springs, N. Y., for gout, 129 Sharpe on Fango packs, 333 Sheet bath, 246 in typhoid fever, 76 Shepherd's sprinkler, 245 Sheppard and Enoch Pratt Hospital, 168 Shivering, 27, 39, 381 in Brand baths, 68 Shober on radio-activity, 394 Shock, 214 Shower baths, 375 heat elimination in, 37 Silva, 234 Sinapisms, 107 Sitz-baths, 226, 336 for constipation, 153 for nervous dyspepsia, 156 Skin, cutaneous absorption in mineral baths, 21 diseases, 203 permeable to gases and volatile constituents of baths, 23 vicarious action of, 47 Sleeplessness, 147 Smedley's England, 334 Smith, Nathan, 59 Soden, 128, 407 Sodic bromo-iodin waters, 416 Sodium chlorid retention, 409 Sommer on oxygen bath, 325 Spa, Belgium, 415 Spas, clioicc of, for gout, 128 drinking cuces at, 114 Spermatorrhea, 165 Sphygmographic tracings, 49 Sphygmomanometer, 49 Spinal douche, 255 Splenic enlargement, 161 Sponging, 73, 76, 248 Sponging in typhoid, 62, 73 Sprains, 211 Spray bath, 244 Sprinkler, 245 Sprinkhng, 73, 75 Sprudel baths, 311 St. Anne's Well, England, 415 Stanton's sphygmomanometer, 50 St. Catherine's Wells, Canada, 407 Steam douche, 108, 262 Stengel on Brand baths in typhoid fever, 63 on use of alcohol in Brand baths, 61 SteriUty in women, 222 Stimulants, alcoholic, 28 Stimulating effect of baths, 24 treatments, 429 St. Moritz, Switzerland, 415 Stockton on cerebrospinal meningitis, 87 on insanity, 176 Stomatitis, 199 Strasser, 235 Strathpeffer waters, Scotland, 414 Stromeyer, continuous bath, 290 Striimpell, von, on Brand baths, 74, 75 St. Vincent Hospital, N. Y., sunstroke statistics, 442 Sugar excretion influenced by sweat- ing, 47 Sulphur waters, 413 for gout, 128 in nephritis, 114 in psoriasis, 205 in syphilis, 201 Sunstroke, 90, 436, 442 Surf-bathing. See Sea-baths. Surgical affections, 209 Sweating, 111 in steam baths, 113 processes for eye diseases, 227 Sweedish shampoo, 359 Swimming accidents, 381 Synovitis of knee, 215 Syphilis, 197 treated at Aix-les-Bains, 272, 273 Turkish bath for, 298 INDEX 465 Tar ASP, 221 Technic of hydrotherapy, 232 Teilwaschung, 246 Temperature of body affected by baths, 31 reduction, 435 standards, 233 Tepid baths, metabolism not influ- enced by, 48 Teplitz, 128 Tetanus, 89 Thermal waters, 396 Thermic fever, 90 stimulation, effect on heart rate, 55 Thermometer, 233 Thermometric scales compared, 420 Thermophore, 448 Thermopylae, 19 Thompson, 436 on experiments on heat and cold to body, 234 on rules for use of Brand baths, 65, 68 on use of alcohol in Brand baths, 61 Thomson on cutaneous absorption in baths, 23 Thome, Bezley, 144 LesUe, 144,. 323 Tinea, 208 Tobacco habit, 149 Tonic, general, prescription Nos. 13, 14, 423 Toothache after baths, 231 Tornai on oxygen bath, 324, 326 Toxemia in typhoid fever, 435 of pneumonia, 106 of pregnancy, 117 Toxemic myocarditis, 148 Toxins and blood-pressure, 53 excretion of, 77 in nephritis, 115 Triton salts for Nauheim baths, 225, 313 Tub for Brand baths, 61, 64, 66 Tuberculosis, 93 Baruch, 437 surgical, 211 30 Tubingen, 386 Tucker on use of magnesium sul- phate solution, 220 Tunbridge Wells, England, 415 Turkish bath, 295 abuse of, 134 coimterindications, 120, 299 effect on respiration, 32 eHmination of urea and uric acid in, 32 for anemia, 160 gain of weight in, 36 in sypliihs, 203 not for asthma, 243 temperature effect of, 32 Tuttle on studies in metaboKsm, 36 on mental effects of baths, 43 Tycos sphygmomanometer, 51 Tympany, rectal irrigation in, 361 Typhoid fever, 59 Baruch, 435 colonic irrigation in, 361 continuous bath, 290 water drinking in, 396, 402 Tyson, 312 on Brand baths, 45, 61 on chlorid retention, 409 Ukaiah Vichy, CaL, 403 Ulysses bath, described by Homer, 58 Umber, Brand baths, 75 Uremia, 117 Uriage, 221 Uric acid, 123 and Fachingen water, 404 and litliia waters, 418 and saUne waters, 410 excretion, 47 not influenced by water drinking, 395 Urine, effect of Brand baths, Tyson, 45 effected by cold packs, 117 Vaginal douche, 370 Vals, 403 Vapor bath, 301 for syphiHs, 202 466 INDEX Vasomotor spasm, Ifil Vaughan on chlorid retention, 409 Vichy ("elostin, 403 douche, 276 water in scarlatinal nephritis, 118 Victoria water, Austria, 413 Virginia Beach, sea-bathing, 378 Hot Springs, 122, 129, 18(3, 281 analysis, 19 Visceral anemia, 161 Volksbad, Vienna, 376 von Basch, 49 von Xoorden, 30 von Striimpell on Brand baths, 74, 75 von Walther, 289 AVarm full bath in typlioid fever, 71 Springs, Virginia, 205 Warmbrunn, 128 Water as emetic, 419 used internally, 395 "Waukesha, AVisconsin, 407 AVeber on reaction, 27 AA'eilbach Sulphur Spring, 414 AA'eintraub on Brand baths, 74 Wells on chlorid retention, 409 Wet pack, 440 mit friction, 246 Wherry on epilepsy, 182 AA'hite on bidet, 165 Rock water, 417 Sulphur Springs, 205 Widal and Javal on chlorid retention, 409 Wiesbaden, 209 Wildbad, 221 for gout, 128 Wildungen, 406 AA'ilhelmsquelle, Ems, 418 AA'ill power increased by cold, 41 AVilliams, 388 on hot wet pack, 343 on saline waters and gout, 410 Wilson, 235, 436 AA^ilson on hot baths in typhoid fever, 35 on use of alcohol in Brand baths, 61 AA'inckler on use of distilled water safe, 399 AVintemitz, 432, 433 on epilepsy, 178 on experiments on absorption in baths, 22 on heat regulation, 41 on gastric ulcer, 155 on hot baths and oxygen intake, 46 on measles, 79 on oxygen bath, 327 on reaction, 27, 29 on roller bandage apphed wet, 218 on sweating, 112 on typhoid fever, 60 Wolbarst on rectal irrigator, 359 AA'olcott on radio-active waters of Col- orado, 391 AA'ohsch on cerebrospinal meningitis, 88 AA'ood on attacks of gout, 127 on splenic enlargement, 161 on surgical shock, 214 on thermic stimuli, 25 AVoodhall, 416 Wright on treatment of tetanus in the AA'est Indies, 89 Rebekah B., 235 AA'urzburg course in baUieotlierapy, 384 Yellow fever, 89 Yellowstone National Park, 18, 388 Zander method and apparatus, 274, 210 Zeozon, oxygen batli, 323 Zickel, 326 Ziemssen's cold baths, 447 Zucker's carbonated baths, 226, 313 Zuschlag on continuous bath, 288 SAUNDERS' BOOKS ON Barnhill and Wales* Modern Otology A Text-Book of Modern Otology. By John F. Barnhill, M. D., Professor of Otology, Laryngology, and Rhinology, and Earnest DE W. Wales, M. D., Associate Professor of Otology, Laiyngology, and Rhinology, Indiana University School of Medicine, Indianapolis. Octavo of 575 pages, with 305 original illustrations. Cloth, $5.50 net; Half Morocco, $7.00 net. THE PRACTITIONER'S OTOLOGY The authors, in writing this work, kept ever in mind the needs of the physician engaged in general practice. It represents the results of personal experience as practitioners and teachers, influenced by the instruction given by such authorities as Sheppard, Dundas Grant, Percy Jakins, Jansen, and Alt. Much space is devoted to prophylaxis, diagnosis, and treatment, both medical and surgical. There is a special chapter on the bacteriology of ear affections — a feature not to be found in any other work on -otology. Great pains have been taken with the illustrations, in order to have them as practical and as helpful as possible, and at the same time highly artistic. A large number represent the best work of Mr. H. F, Aitken. PERSONAL AND PRESS OPINIONS Frank Allport, M. D. Professor of Otology, Northwestern University, Chicago. " I regard it as one of the best books in the English language on this subject. The pictures are especially good, particularly as they are practically all original and not the old reproduced pictures so frequently seen." C. C. Stephenson. M. D. Professor of Ophthalmology aud Otology, College of Physicians and Surgeons, Little Rock, Arkansas. " To my mind there is no work on modem otology that can for a moment compare with ' Barnhill and Wales.' " Journal American Medical Association "Its teaching is sound throughout and up to date. The strongest chapters are those on suppuration of the middle aar and the mastoid cells, and the intracranial complications of ear disMise." DISEASES OF THE EYE, DeSchweinitz's Diseases of the Eye The New (5th) Edition Diseases of the Eye : A Handbook of Ophthalmic Practice, By G. E. DeSchweinitz, M.D., Professor of Ophthalmology in the Uni- versity of Pennsylvania, Philadelphia, etc. Handsome octavo of 894 pages, 313 text-illustrations, and 6 chromo-lithographic plates. Cloth, ^5.00 net; Sheep or Half Morocco, ,^6.50 net. WITH 313 TEXT-ILLUSTRATIONS AND 6 COLORED PLATES For this new edition the text has been very thoroughly revised, and the work enlarged by the addition of new matter to the extent of some one hundred pages. There have been added, amongst other subjects, chapters on the following : X-Ray Treatment of Epithelioma, Xeroderma Pigmentosum ; Purulent Conjunctivitis of Young Girls ; Jequiritol and Jequiritol Serum ; X-ray Treatment of Trachoma Infected Marginal Ulcer ; Keratitis Punctata Syphilitica ; Uveitis and Its Varieties Eye- ground Lesions of Hereditary Syphilis ; Macular Atrophy of the Retina Worth's Amblyoscope ; Stovain, Alypin ; Motais' Operation for Ptosis ; Kuhnt- Miiller's Operation for Ectropion ; Haab's Method for Foreign Bodies ; and Sweet's X-Ray Method of Localizing Foreign Bodies. Other chapters have been rewritten. The excellence of the illustrative feature has been maintained. PERSONAL AND PRESS OPINIONS Samuel Theobald, M.D., Clinical Professor of Ophthalmology , Johns Hopkins University, Baltimore. " It is a work that I have held in high esteem, and is one of the two or three books upon the eye which I have been in the habit of recommending to my students in the Johns Hopkins Medical School." W. Franklin Coleman, M. D., Professor of Diseases of the Eye, Postgraduate Medical School, Chicago. "I am very much pleased with deSchweinitz's work and will recommend it to the members of my class as a most reliable, complete, and up to date text-book." British Medical Journal "A clearly written, comprehensive manual. One which we can commend to students iaH a reliable text-book, written with an evident knowledge of the wants of those entering upon the Stady of this special branch of medical science." SAUNDERS' BOOKS ON Brtihl, Politzer, and Smith's Otology Atlas and Epitome of Otology. By Gustav Bruhl, M. D., of Berlin, with the collaboration of Professor Dr. A. Politzer, of Vienna. PMited, with additions, by S. MacCuen Smith, M.D., Pro- fessor of Otology in the Jefferson Medical College, Philadelphia. With 244 colored figures on 39 lithographic plates, 99 text illustra- tions, and 292 pages of text. Cloth, ;$3.oo net. /;/ Saumiirs' Hand- Atlas Series. INCLUDING ANATOMY AND PHYSIOLOGY The work is both didactic and clinical in its teaching. A special feature is the very complete exposition of the minute anatomy of the ear, a working knowl- edge of which is so essential to an intelligent conception of the science of otology. The association of Professor Politzer and the use of so many valuable specimens from his notably rich collection especially enhance the value of the treatise. The work contains everything of importance in the elementary study of otology. Clarence J. Blake, M. D.. Professor of Otology in Harvard University Medical School, Boston. " The most complete work of its kind as yet published, and one commending itself to both the student and the teacher in the character and scope of its illustrations. " Haab and deSchweinitz*s Operative Ophthalmology Atlas and Epitome of Operative Ophthalmology. B}- Dr. O. Haab, of Zurich. Pxlited, with additions, by G. E. deSchweinitz, M. D., Professor of Ophthalmology in the University of Pennsylvania. With 30 colored lithographic plates, 154 text-cuts, and 375 pages of text. /« Saunders' Hand-Atlas Series. Cloth, $3.50 net. Dr. Haab's Atlas of Operative Ophthalmology will be found as beautiful and as practical as his two former atlases. The work represents the author' s thirty years' experience in eye work. The various operative interventions are described with all the precision and clearness that such an experience brings. Recognizing the ftict that mere verbal descriptions are frequently insufficient to give a clear idea of operative procedures. Dr. Haab has taken particular care to illustrate plainly the different parts of the operations. Johns Hopluns Hospital Bulletin " The descriptions of the various operations are so clear and full that the volume can well hold place with more pretentious text-books." DISEASES OF THE EYE. Haab and DeSchweinitz*s External Diseases qf the Eye Atlas and Epitome of External Diseases of the Eye. By Dr. O. Haab, of Zurich. Edited, with additions, by G. E. deSchweinitz, M. D., Professor of Ophthalmology, University of Pennsylvania. With 1 01 colored illustrations on 46 lithographic plates and 244 pages of text. Cloth, $3.00 net. In Saunders' Hand-Atlas Series. THE NEW (3d) EDITION Conditions attending diseases of the external eye, which are often socompHcated, have probably never been more clearly and comprehensively expounded than in the forelying work, in which the pictorial most happily supplements the verbal description. The price of the book is remarkably low. 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Pennsylvzoiia Medical Journal 'This is the most practical volume on the nose, pharynx, and ear that has appeared recently. ... It is exactly what the less experienced observer needs, as it avoids the confusion incident to a categorical statement of everybody's opinion." Kyle's Diseases of Nose and Throat Diseases of the No^e and Throat. By D. Braden Kyle, M. D., Professor of Laryngology in the Jefferson Medical College, Phila- delphia. Octavo, 797 pages; with 219 illustrations, 26 in colors. Cloth, $4.00 net; Half Morocco, |!5.50 net. THE NEW (4th) EDITION Four large editions of this excellent work fully testify to its practical value. In this edition the author has revised the text thoroughly, bringing it absolutely down to date. With the practical purpose of the book in mind, extended con- sideration has been given to treatment, each disease being considered in full, and definite courses being laid down to meet special conditions and symptoms. Pennsylvemia Medical Journal " Dr. Kyle's crisp, terse diction has enabled the inclusion of all needful nose and throat knowledge in this book. The practical man, be he special or general, will not search in vain for anything he needs." EYE, EAR, NOSE, AND THROAT. GET i^ • THE NEW THE BEST t\ ill 6 A 1 C Si 11 STANDARD Illustrated Dictionary Just Ready— The New (5th) Edition The American Illustrated Medical Dictionary. A new and com- plete dictionary of the terms used in Medicine, Surgery, Dentistry, Pharmacy, Chemistry, and kindred branches ; with over lOO new and elaborate tables and many handsome illustrations. By W. A. Newman Borland, M. D., Editor of " The American Pocket Medical Diction- ary." Large octavo, nearly 876 pages, bound in full flexible leather. Price, ^4.50 net; with thumb index, ^5.00 net. A KEY TO MEDICAL LITERATURE— WITH 2000 NEW TERMS In this edition the book has been subjected to a thorough revision. The author has also added upward of two thousand important new terms that have appeared in medical literature during the past few months. Howard A. Kelly, M. D., Professor of Gynecologic Surgery, Johns Hopkins University, Baltimore "Dr. Dorland's Dictionary is admirable. It is so well gotten up and of such convenient size. No errors have been found in my use of it." Theobald's Prevalent Eye Diseases Prevalent Diseases of the Eye. By Samuel Theobald, M. D., Clinical Professor of Ophthalmology and Otology, Johns Hopkins University. Octavo of 550pages, with 219 text-cuts and several colored plates. Cloth, ;S4.50 net ; Half Morocco, ^6.00 net. THE PRACTITIONER'S OPHTHALMOLOGY With few exceptions all the works on diseases of the eye, although written ostensibly for the general practitioner, are in reality adapted only to the specialist ; but Dr. Theobald in his book has described very clearly and in detail those condi- tions, the diagnosis and treatment of which come withm the province of the general practitioner. The therapeutic suggestions are concise, unequivocal, and specific. It is the one work on the Eye written particularly for the general practitioner. Charles A. Oliver, M.D., Clinical Professor of Ophthalmology, Woman's Medical College of Pennsylvania. " I feel I can conscientiously recommend it, not only to the general physician and medical student, for whom it is primarily written, but also to the experienced ophthalmologist. Moat surely Dr. Theobald bas accomplished his purpose." F.YE, EAR, XOSE, AND THROAT. de Schweinitz and Holloway on Pulsatin^^ Exoph- thalmos Pulsating Exophthalmos. An analysis of sixty-nine cases not pre- viously analyzed. By George E. deSchweinitz, M. D., and Thomas B. Holloway, M. D. Octavo of 125 pages. Cloth, $2.00 net. This monograph consists of an analysis of sixty-nine cases of this affection not previously analyzed. The therapeutic measures, surgical and otherwise, which have been employed are compared, and an endeavor has been made to determine from these analyses which procedures seem likely to prove of the greatest value. It is the most valuable contribution to ophthalmic liter- ature within recent years. British Medical JoumaJ " The book deals ver>' thoroughly with the whole subject and in it the most complete account of the disease will be loiind." Jackson on the Eye The New (2d) Edition A Manual of the Diagnosis and Treatment of Diseases of the Eve. By Edward Jackson, A. IM., M. D., Professor of Ophthalmology, University of Colorado. i2mo volume of 615 pages, with 184 beautiful illustrations. Cloth, I2.50 net. The Medical Record, New York " It is truly an admirable work. . . . Written in a clear, concise manner, it bears evidence of the author's comprehensive grasp of the subject. The term ' multum in parvo' is an appropriate one to apply to this work." Grant on Face, Mouth, and Jaws A Text-Book of the Surgical Principles and Surgical Diseases OF the Face, Mouth, and Jaws. For Dental Students. By H. Horace Grant, A. M., M. D., Professor of Surgery and of Clinical Surgery, Hospital College of Medicine, Louisville. Octavo of 231 pages, with 68 illustrations. Cloth, $2.50 net. Friedrich and Curtis on Nose, Larynx, and Ear RhINOLOGY, LARVNGOLOGy, AND OtOLOGV, AND ThEIR SIGNIFICANCE IN General Medicine. By Dr. E. P. Friedrich, of Leipzig. Edited by H. Holbrook Curtis, M. D., Consulting Surgeon to the New York Nose and Throat Hospital. Octavo volume of 350 pages. Cloth, $2.50 net. GENITO- URINARY AND NOSE, THROAT, ETC. 9 Greene aiui Brooks* Genito-Urinary Diseases Diseases of the Genito=Urinary Organs and the Kidney. By Robert H. Greene, M. D., Professor of Genito-Urinary Surgery at Fordham University ; and Harlow Brooks, M. D., Assistant Pro- fessor of Clinical Medicine, University and Bellevue Hospital Medical School. Octavo of 605 pages, illustrated. Cloth, $5.00 net; Half Morocco, ^6.50 net. THE NEW (2d) EDITION This new work presents both the medical and surgical sides. Designed as a work of quick reference, it has been written in a clear, condensed style, so that the information can be readily grasped and retained. Kidney diseases are very elaborately detailed. New York Medical Journal " As a whole the book is one of the most satisfactory and useful works on genito-urinary diseases now extant, and will undoubtedly be popular among practitioners and students." Gleason on Nose, Throat, and Ear A Manual of Diseases of the Nose, Throat, and Ear. By E. Baldwin Gleason, M. D., LL. D., Clinical Professor of Otology, Medico-Chirurgical College, Pliiladelphia. i2mo of 556 pages, pro- fusely illustrated. Flexible leather, $2.50 net. FOR PRACTITIONERS Methods of treatment have been simplified as much as possible, so that in most instances only those methods, drugs, and operations have been advised which have proved beneficial. A valuable feature consists of the collection of formulas. American Journal of the Medical Sciences " For the practitioner who wishes a reliable guide in laryngology and otology there are few books which can be more heartily commended." American Text=Boolc of Qenito=Urinary Diseases, Syphilis, and Diseases of the Slcin. Edited by L. Bolton Bangs, M. D., and W. A. Hardaway, M. D. Octavo, 1229 pages, 300 engravings, 20 colored plates. Cloth, ;^7.oo net. SAUNDERS' j300k^S OX StelwagonV Diseases of the Skin A Treatise on Diseases of the 5kin. By Henry W, Stelwagon, M. D., Ph. D., Professor of Dermatology in the Jefferson Medical College, Philadelphia. Octavo of 1135 pages, with 258 text-cuts and 32 plates. Cloth, $6.00 net ; Half Morocco, $7.50 net. THE NEW (5th) EDITION The demand for five editions of this work in a period of five years indicates the practical character of the book. In this edition the articles on Frambesia, Oriental Sore, and other tropical diseases have been entirely rewritten. The new subjects include Verruga Peruana, Leukemia Cutis, Meralgia Paraesthetica, Dhobie Itch, and Uncinarial Dermatitis. George T. Elliot, M. D., Professor of Dermatology, Cornell Universily. " It is a liook that I recommend to my class at Cornell, because for conservative judgment, for accurate observation, and for a thorough appreciation of the essential position of derma- tology, I think it holds first place." Schamber^'s Diseases of the Skin arid Eruptive Fevers Diseases of the Skin and the Eruptive Fevers. By Jay F. Schamberg, M. D., I'rofessor of Dermatology and the Infectious Eruptive Diseases, Philadel- phia Polyclinic. Octavo of 534 pages, illustrated. Cloth, $3.00 net. THE CUTANEOUS MANIFESTATIONS OF ALL DISEASES " The acute eruptive fevers constitute a valuable contribution, the statements made emanating from one who has studied these diseases in a practical and thorough manner from the standpoint of cutaneous medicine. . . . The views expressed on all topics are con- servative, safe to follow, and practical, and are well abreast of the knowledge of the present time, both as to general and special pathology, etiology, and treatment." — Americiin Journal of Medical Sciences. DISEASES OF THE SKIN. Mracek and Stelwa^on's Diseases of the Skin Atlas and Epitome of Diseases of the Skin. By Prof. Dr. Franz Mracek, of Vienna. Edited, with additions, by Henry W. Stelwagon, M. D., Professor of Dermatology in the Jefferson Medical College, Philadelphia. With yj colored plates, 50 half-tone illustrations, and 280 pages of text. In Saunders" Hand- Atlas Series. Clo., ^4. 00 net THE NEW (2d) EDITION This volume, the outcome of years of scientific and artistic work, contains, together with colored plates of unusual beauty, numerous illustrations in black, and a text comprehending the entire field of dermatology. The illustrations are all original and prepared from actual cases in Mracek' s clinic, and the execution of the plates is superior to that of any, even the most expensive, dermatologic atlas hitherto published. American Journal of the Medical Sciences " The advantages which we see in this book and which recommend it to our minds are : First, its handiness ; secondly, the plates, which are excellent as regards drawing, color, and the diagnostic points which they bring out." Mracek anb Bangs* Syphilis and Venereal Atlas and Epitome of Syphilis and the Venereal Diseases. By Prof. Dr. Franz Mracek, of Vienna. Edited, with additions, by L. Bolton Bangs, M. D., late Prof, of Genito-Urinary Surgery, Univer- sity and Bellevue Hospital Medical College, New York. With 71 colored plates and 122 pages of text. Cloth, S3. 50 net. /;/ Saunders^ Hand- Atlas Series. CONTAINING 71 COLORED PLATES According to the unanimous opinion of numerous authorities, to whom the original illustrations of this book were presented, they surpass in beauty anything of the kind that has been produced in this field, not only in Germany, but throughout the literature of the world. Robert L. Dickinson, M. D., Art Editor of " The Atnerican. Text-Book of Obstetrics." " The book that appeals instantly to me for the strikingly successful, valuable, and graphic character of its illustrations is the ' Atlas of Syphilis and the Venereal Diseases.' I know of nothing in this country that can compare v.ith it." 12 S.4 L^XDE/fS' BOOK'S ON Holland's Medical Chemistr y and To xicology A Text-Book of Medical Chemistry and Toxicology. ]^y James W. Holland, M.D., Professor of Medical Chemistry and Toxicology, and Dean, Jefferson Medical College, Philadelphia. Octavo of 655 pages, fully illustrated. Cloth, ^3.00 net. THE NEW (2d) EDITION Dr. Holland's work is an entirely new one, and is based on his forty years* practical experience in teaching chemistry and medicine. It has been subjected to a thorouj^h revision, and enlarged to the extent of some sixty pages. The additions to be specially noted are those relating to the electronic theor)-, chemical equilib- rium, Kjeldahl's method for determining nitrogen, chemistn,- of foods and their changes in the body, synthesis of proteins, and the latest improvements in urinary tests. More space is given to toxicology than in any other text-book on chemistry. American Medicine " Its statements are clear and terse ; its illustrations well chosen; its development logical, systematic, and comparatively easy to follow. . . . We heartily commend the work." Grtinwald and Newcomb's Mouth, Pharynx, and Nose Atlas and Epitome of Diseases of the Mouth, Pharynx, and No»e. By Dr. L. Grunwald, of Munich. From the Second Revised and Enlarged German Edition. Edited, with additions, by James PI Newcomb, M. D., Instructor in Laryngology, Cornell University Medical School. With 102 illustrations on 42 colored lithographic plates, 41 text-cuts, and 219 pages of text. Cloth, ;$3.oo net. In Saunders' Hand-Atlas Series. INCLUDING ANATOMY AND PHYSIOLOGY In designing this atlas the needs of both student and practitioner were kept constantly in mind, and as far as possible typical cases of the various diseases w«re selected. The illustrations are described in the text in exacdy the same way as a practised examiner would demonstrate the objective findings to his clg-ss. The illustrations themselves are numerous and exceedingly well executed. The editor has incorporated his own valuable experience, and has also included exten- sive notes on the use of the active principle of the suprarenal bodies. American Medioae " Its conciseness without sacrifice of clearness and thoroughness, as well as the exceUence of t«xt and illustrations, are commendable." URINE AND IMPOTENCE. 13 Ogden on the Urine Clinical Examination of Urine and Urinary Diagnosis. A Clinical Guide for the Use of Practitioners and Students of Medicine and Sur- gery. By J. Bergen Ogden, M. D., Medical Chemist to the Metro- politan Life Insurance Company, New York. Octavo, 418 pages, 54 text illustrations, and a number of colored plates. Cloth, ;$3.00 net. JUST READY— THE NEW (3d) EDITION In this edition the work has been brought absolutely down to the present day. Urinary examinations for purposes of life insurance have been incorporated, because a large number of practitioners are often called upon to make such analyses. Special attention has been paid to diagnosis by the character of the urine, the diagnosis of diseases of the kidneys and urinary passages ; an enumeration of the prominent clinical symptoms of each disease ; and the peculiarities of the urine in certain general diseases. The Lancet, London " We consider this manual to have been well compiled ; and the author's own exp)erience, so clearly stated, renders the volume a useful one both for study and reference." Vecki's Sexual Impotence The Pathology and Treatment of Sexual Impotence. By Victor G. Vecki, M. D. From the Second Revised and Enlarged German Edition. i2mo volume of 329 pages. Cloth, ^2.00 net. THIRD EDITION. REVISED AND ENLARGED The subject of impotence has but seldom been treated in this country in the truly scientific spirit that its pre-eminent importance deserves, and this volume \vill come to many as a revelation of the possibilities of therapeutics in this important 'field. The reading part of the English-speaking medical profession has passed judgment on this monograph. The whole subject of sexual impotence and its treatment is discussed by the author in an exhaustive and thoroughly scientific manner. In this edition the book has been thoroughly revised, and new matter has been added, especially to the portion dealing with treatment. Johns Hopkins Hospital Bulletin " A scientific treatise upon an important and much neglected subject. . . . The treatment of impotence in general and of sexual neurasthenia is discriminating and judicious." 14 .sVKaV'AVvW JiOOA'S ON Wells* Chemical Pathology Chemical Pathology. Being a discussion of General Path- ology from the Standpoint of the Chemical Processes Invoked. By H. Gideon Wells. Ph.D., M. D., Assi.stant Professor of Pathology in the University of Chicago. Octavo of 549 pages. Cloth, $3.25 net ; Half Morocco, $4.75 net. Dr. Wells here concisely presents the latest work systematically con- sidering the subject of general pathology from the standpoint of the chemical processes involved. Special chapters are devoted to Diabetes and to Uric- acid Metabolism and Gout. Wm. H. Welch, M. D., Professor of Pathology, Johns Hopkins University. " The work fills a real need in the English literature of a very important subject, and I shall be glad to recommend it to my students." Just Ready The New (2d 1 Edition Saxe*s Urinalysis Examination of the Urine. By G. A. De S.vntos Saxe, M. D.. Instructor in Gcnito-Urinary Surgerx', York Post-graduate Medical School and Hospital. I2m() of 448 pages, fully illustrated. Cloth, $175 net. This work is intended as an aid in diagnosis, by interpreting the clinical significance of the chemic and microscopic urinary findings. Francu Carter Wood, M. D., Adjunct Professor of Clinical Pathology, Columbia Uni- versitv. "It seems to mc to be one of the best of the smaller works on this subject ; it is, indeed, better than a good many of the larger ones." deSchweinitz and Randall on the Eye, Ear, Nose, and Throat American Text-Book of Diseases of the Eye, Ear, Nose, and Throat. P^dited by G. E. de Schweinitz, M. D., Professor of Ophthalmology in the University of Penn.sylvania ; and B. Ale.x- ANDER R.\NDALL, M. D., Clinical Professor of Diseases of the Ear in the University of Pennsylvania. Imperial octavo, 1251 pages, with 766 illustrations, 59 of them in colors. Cloth, ;^7.oo net ; Half Morocco, $8.50 net. Griinwald and Grayson on the Larynx Atlas and Epitome of Diseases of the Larynx. By Dr. L. Grunwald, of Munich. Edited, with additions, by Charles P. Grayson, M. D., Clinical Professor of Laryngology and Rhinology, University of Pennsylvania. With 107 colored figures on 44 plates, 25 text-cuts, and 103 pages of text. Cloth, ^2.50 net. In Saunders' Hand-Atlas Series, CHEMISTRY, SKIN, AND VENEREAL DISEASES. 15 American Pocket Dictionary sixth Edition— Recently issued The American Pocket Medical Dictionary. Edited by W. A. Newman Borland, M. D., Assistant Obstetrician to the Hospital of the University of Pennsylvania. Containing the pronunciation and definition of the principal words used in medicine and kindred sciences. 598 pages. Flexible leather, with gold edges, ;^i.oo net; with thumb index, ^1.25 net. James W. Holl&nd. M. D., Professor of Medical Chemistry and Toxicology, and Dean, Jefferson Medical College, Philadelphia, " I am struck at once with admiration at the compact size and attractive exterior. I can recommend it to our students without reserve." Stelwagon's Essentials of Skin just Ready— 7th Edition Essentials of Diseases of the Skin. By Henry W. Stel- WAGON, M. D., Ph.D., Professor of Dermatology in the Jeffer- son Medical College, Philadelphia. Post-octavo of 291 pages, with 72 text-illustrations and 8 plates. Cloth, ^^i.oo net. A' Saunders' Question- Comp end Series. The Medical News " In line with our present knowledge of diseases of the skin. . . . Continues to main- tain the high standard of excellence for which these question compends have been noted." Wolffs Medical Chemistry New (7th) Edition Essentials of Medical Chemistry, Organic and Inorganic. Containing also Questions on Medical Physics, Chemical Physiol- ogy, Analytical Processes, Urinalysis, and Toxicology. By Law- rence Wolff, M. D., Late Demonstrator of Chemistry, Jefferson Medical College. Revised by A. Ferree Wither, Ph. G., M. D., Formerly Assistant Demonstrator of Physiology, University of Pennsylvania. Post-octavo of 222 pages. Cloth, ^i.oo net. In Saimders' Question- Compend Series. Martin's Minor Surgery, Bandaging, and the Venereal Diseases second Edition. Revised Essentials of Minor Surgery, Bandaging, and Venereal Diseases. By Edward Martin, A. M., M. D., Professor of Clin- ical Surgery, University of Pennsylvania, etc. Post-octavo, 166 pages, with 78 illustrations. Cloth, ;^i.oo net. In Saunders' Question- Compend Series. 1 6 URINE, EVE, EAR, NOSE, AND 77/ROAT. Wolfs Examination of Urine A Laijukatoky Handbook, of Physiologic Chemistry and Urine-examination. By Charles G. L. Wolf, M. D., In.structor in Physioloi^ic Chcmi.stry, Cornell University Medical College, New York. 1 2mo volume of 204 pages, fully illustrated. Cloth, $1.25 net. British Medical Journal ■ riu- methods uf examining the urine are very fully described, and there are at the end of the book some extensive tables drawn up to assist in urinary diftgncsis." Jackson's Essentials of Eye Third Revised Edwon Kssentials of Refkactio.v and of Diseases of the Eve. By Edward Jackson, A. M., M. D., Emeritus Professor of Diseases of the P^yc, Philadelphia Polyclinic. Post-octavo of 261 pages, 82 illus- trations. Cloth, $1.00 net. In Saunders' Qucstion-Coinpend Series. Johns Hopkins Hospital Bulletin " The entire ground is covered, and the points that most need careful elucidation are made clear and easy." Gleason's Nose and Throat Fourth Edition. Revised EssENTiAi„s OF Diseases of the Nose and Throat. V>y IC. 1^. Gleason, S. B., M. D., Clinical Professor of Otology, Mcdico- Chirurgical College, Philadelphia, etc. Post-octavo, 241 pages, 1 12 illustrations. Cloth, $1.00 net. I)i Sannders" Question Compends, The Lancet, London " The careful description which is given of the various procedures would be sufficient to enable most people of average intelligence and of slight anatomical knowladge to make a very good attempt at laryngoscopy." Gleason's Diseases of the Ear Third Edition. Revised Essentials of Diseases of the P>ar. By Y.. Vi. Gleason, S. B., M. D., Clinical Professor of (3tology, Mcdico-Chirurgical College, Phila., etc. Post-octavo volume of 214 pages, with 114 illu.stra- tions. Cloth, 3 1. 00 net. /;/ Saunders' Question- Compend Series. Bristol Medico-Chirurgical Journal " We know of no other small work on ear diseases to compare with this, either in freshness of style or completeness of information." >fVilcox on Genito-Urinary and Venereal Diseases Just Ready— The New (2d) Edition Essentials of Genito-Urinary and Venereal Diseases. By Starling S. Wilcox, I\I. D., Lecturer on Genito-Urinary Diseases and Syphilology, Starling-Ohio Medical College, Columbus. 1 2mo of 321 pages, illustrated. Cloth, $1.00 net. Saunders' Compends. Stevenson*s Photoscopy Photoscofy (Skiascopy or Retinoscopy). By Mark D. Stev- enson, M. D., Ophthalmic Surgeon to the Akron City Hospital. i2mo of 126 pages, illustrated. Cloth, $1.25 net. Edward Jackson. M. D., University of Colorado. " It is well written and will prove a valuable help. Your treatment of the emergent j>encil of rays, and the part failing on the examiner's eye, is decidedly better than any previous account," COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a deHnite period after the date of borrowing as provided by the rules of the Library or by special arrange- ment with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE .L^i..^ -fit^ii— yW. .'\^.. 'i^lfi ' ^^ !S4S JUL 1 2 )9AE 1 ' C2a(t14l)MIOO