CHAPTER VIII – ON THE EFFECTS OF CARBON DIOXIDE BATHS ON THE CIRCULATION
On taking a bath, the temperature of which is below that of the skin, there will be a sensation of cold, regardless of whether such bath is taken in the river, the sea, the ordinary bathtub, or in the shape of a water- bath charged with carbon dioxide. This cold sensation, however, will soon disappear, as the human body adapts itself to all environments. In the case of flowing water, the motion is converted into heat, so that water in motion appears to be warmer to the body.
If a test- tube is filled with water in which bicarbonate of soda is dissolved together with an acid, the thermometer will rise, heat being liberated, as is always the case in a chemical reaction. If the person, while taking the bath, observes a quiet attitude, an infinite amount of heat stimulations will continuously affect the same spot, to which stimulations that spot will answer—as it will to any other continuous stimulations—by dilatation of the vessels.
In regarding the process from this standpoint, there is no fundamental difference between massage and carbon dioxide baths. The latter, however, has the advantage that by means of a very simple method the entire body may be subjected to massage at one and the same time, an effect which can not be attained either by hand massage or even by apparatus. Besides, this massage of the entire body has the advantage of extreme uniformity. The effect of the bath in flowing water is increased because here motion is converted into heat.
According to Homberger, of whose paper “Ueber die Wirkung der kohlensauren Bäder”; Vortrag gehalten auf dem Balneologen Congress, 1905, Berlin Klin. Wochenschr., 1905, No. 22—I avail myself to almost its full extent, the effect of gaseous baths is not produced by the gas, whether this is carbon dioxide gas, oxygen gas, or air, but, to use a general term, by the transmutation of phases, heat in statu nascendi. This opinion is not in accordance with the results of recent investigations concerning the effect of carbon dioxide baths. Leopold Fellner, who, like Homberger, read a paper (“Zur physiologischen Wirkung der Kohlensäure’‘) at the twenty-sixth public meeting of the Balneo logical Society in Berlin, March 9-13, 1905, and of whose paper I avail myself as I did avail myself of Homberger’s, says: The resorption theory which was at first generally recognized was denied by some, but now is supported again by the investigations of Hugo Winternitz, who adduced proof of the resorption of carbon dioxide gas by the increase of the same in the atmosphere without increasing the consumption of oxygen. There has also been some controversy as to the nature of the irritation which carbon dioxide exercises upon the skin. The opinion was entertained that carbon dioxide exercised a chemical irritation upon the cutaneous sensory nerves; later on, some investigators concluded from their researches that the irritation exercised by carbon dioxide was of a thermic nature.
They were led to this conclusion by the following facts. An average thermic point of indifference is lowered or raised in proportion to the heat-conducting and heat-producing capacity. For atmospheric air, the point of indifference at medium moisture lies between 20° and 25° C. The heat-producing capacity of carbon dioxide is less than that of the atmosphere, the proportion, according to Regnault, being 0.20246 to 0.2374; and the heat-conducting capacity is still much smaller than that of the air, namely, 59 to 100, according to Warburg. Therefore, the point of indifference of carbon dioxide must be considerably lower than that of the atmospheric air. For water, the point of indifference is at 34.5° C and reaches up to 36.4° C. A water- bath at 28° C. is cool for the majority of normal people, while moist air at 26° C. is so warm that it can not be borne for a long period. Therefore in a carbon dioxide bath, the first effect of the water is a sensation of cold. Then the carbon dioxide bubbles, which become separated from the water and also become heated beyond the point of indifference, produce a thermic irritation, and the consequence is that not only a frequent change between cold and warm sensations takes place, but there are numerous changes of cold and warm sensations simultaneously. There are pronounced effects of contrast such as are not possessed by any balneotherapeutic or hydrotherapeutic agent singly.
This would clearly explain the thermic effect of carbon dioxide baths, and it is intelligible that, in spite of the colder temperature of a carbon dioxide current, the skin experiences a sensation of heat, because the circumambient air has a higher point of indifference. On the other hand, there are a number of manifestations in connection with the use of carbon dioxide which is not explained by the thermic effect alone.
Carbon dioxide has both a stimulating and weakening effect upon the sensory and motor nerves. It stimulates the circulation and respiration centers (Ludwig, Hoffa, Brown-Séquard), and reduces the cardiac function in the diastole (vagus irritation, Cyon). It increases susceptibility to touch, as has been proved by Kisch, but reduces it after prolonged action (more than three-quarters of an hour). It creates a finer sensation of space, as was proved by Basch and Dietl. It has an anesthetizing effect (Brown-Séquard). It acts upon the sexual organs.
On the other hand, by irritating the sensory fibers of the skin, it produces reflex changes of respiration and circulation. This was explained by Hugo Winternitz, when he observed that a carbon dioxide bath had the effect of increasing the volume of respiration to such an extent that the direct irritation of the resorbed quantity of carbon dioxide upon the respiration center could not be considered a sufficient explanation, and that the presence of an additional reflex irritation had to be assumed in order to explain the increase in volume. As regards the change in circulation, we observe in the process of vasodilatation a reflex action produced by the nerve-centers of the vessels. All these manifestations point to the fact that carbon dioxide produces not only a thermic, but also a chemical, effect.
Thomas E. Satterthwaite, in his book “Diseases of the Heart and Aorta,” gives the following concise and clear description of the effects of carbon dioxide baths: Carbon dioxide is absorbed by the skin and has a reflex action on the vasomotor centers, followed by dilatation of the arteries and capillaries, and this dilatation is manifested by a sensation of warmth and redness of the skin. The pneumogastric is affected, for the frequency of the pulse is lessened. The inspirations become deeper. Dilatation of the vessels permits them to be better filled, and this means acceleration of the blood current, as we shall see presently. Diminution in cardiac frequency favors diastole, so that the ventricles are better filled, and, while they discharge more blood, they take up more blood and relieve venous congestion. In this way, there is a tendency to restore the balance of circulation between the arterial and venous systems.
Homberger rightly opposes the largely prevailing opinion that functional work is taken off the internal organs when there is an abundant flow of blood to the skin. It has been proved by Bier and Klapp that hyperemia produced by heated skin spreads to the lower strata, and from this, it follows that dilatation of the skin vessels is not necessarily followed by a contraction of the visceral vessels.
The temperature of all organs is dependent upon the quantity of blood passing a given place during a unit of time. As vessels contract, there is a decrease in the generation of heat. It has been assumed that an increased blood supply in any sphere of the body would be followed by a diminution in another sphere. In reality, however, the quantity of blood is constantly changing, and the regulation of the same takes place in the capillaries.
The effect of carbon dioxide baths had been supposed to assert itself upon patients with heart diseases somewhat in this way, that, after dilatation of the skin vessels, those of the internal organs would contract and thereby lessen the demands upon the cardiac function. This is, as we have seen, not the case. The visceral vessels are dilated in exactly the same way as the skin vessels, and physiological observations have shown that, as vessels become dilated, the blood flows more rapidly.
When a part of the body is placed in hot water or in a hot-air apparatus, the venous blood turns light red and even pulsates. The volume of the part increases, illustrating the effects of a permanent bath, as can be proved plethysmographically. Therefore, the blood circulates more rapidly when the vessels are dilated. On irritation of the nervi erigentes, the vessels become dilated, and consequently, the blood circulation is accelerated. An irritation acting upon the human body causes congestion, and under the microscope, the dilatation of the vessels can be observed, as well as the acceleration of the circulation. Physiology does not furnish a single instance in which the speed of the circulation decreases with simultaneous dilatation of the vessels. In our vascular system, there are two forces, the pressure, and the suction force, supporting each other. The heart is not a mere pressure pump, as was taught by Harvey and as has been the teaching for centuries; it is also a suction pump. The interdependence of the pressure and suction forces is subject to changes; under certain conditions, they may balance each other, so that the motion of the arterial blood is affected by pressure, that of the venous blood by suction, and that of the capillaries by both pressure and suction.
The suction or siphon action not only plays an important role in the cardiac function but everywhere else in the body where vascular dilatation creates a vacuum, the power of the siphon action causes an acceleration in the flow of blood as the vessels become dilated.
Carbon dioxide baths and blood pressure have been two inseparable conceptions during the last few years, and are of great importance in the treatment of cardiac and vascular affections.
In arteriosclerosis, the blood pressure is often increased, a manifestation which in this affection is not considered a favorable symptom. carbon dioxide baths increase the blood pressure, in spite of which, however, they exercise an improving influence. The explanation is as follows :
Increased blood pressure may be caused in two different ways, pathologically and physiologically. The former occurs by increased resistance in the vascular system, the latter by accelerated circulation. The former adds to, and the latter detracts from, the amount of work to be performed by cardiac function. The favorable effect of carbon dioxide baths in the case of patients suffering from heart diseases is explained on the ground of accelerated circulation, which reduces the demands made upon the cardiac function. In contradistinction to this phenomenon, augmented blood pressure by increased resistance always means additional work for the heart. Therefore the increased blood pressure in arteriosclerosis is pathologic, but by the action of carbon dioxide baths, the pathologic process may be changed into a physiological process.
This physiological explanation of the effect of the gas in arteriosclerosis given by Homberger I found practically confirmed in a case of far-advanced sclerotic degeneration, especially of the valves of the heart. Here the beneficial influence of the gas baths was especially manifested by preventing and relieving the attacks of angina pectoris from which the patient had been suffering frequently, especially during the night. Indeed, while this patient was under my care during many months of his stay in this city, his life was made very comfortable compared with the state in which he had been, relying on nitroglycerin and amyl nitrite. Many a peaceful night was secured by means of the carbon dioxide gas bath.
In the year 1890, Dr. J. Jacob reported at the Congress for Internal Medicine, in Vienna, the results of his experiments to determine the specific effect of carbon dioxide, externally applied, on blood pressure; and again in the Zeit schrift für klinische Medizin, Bd. XLIX., he published the result of his publication. His experiments were conducted in a most exact and scientific manner, but it is difficult to understand why he went to work with unnecessary complications. The simplest way would have been to give the person experimented on a dry carbon dioxide gas bath, Instead of that, he gave, first, plain-water baths at an indifferent temperature of 36° or 35° C., and afterward carbon dioxide-water baths of the same temperature, in order, as he says, to study the effect of carbon dioxide, when externally applied, on blood pressure.
He took great precautions to avoid errors, gave the water and the carbonated water baths alternately, and changed the order at different times on different days. He found that the after-effects of both forms of bathing consisted in enlargement of the volume of the heart pulse and acceleration of blood circulation of the aorta, but that these effects were produced in a higher degree-greater acceleration of blood circulation in general, stronger diastole, as well as stronger systole of the heart—after the carbonated bath than after the simple water bath.
It was to me a matter of interest to investigate how by the mere effect of carbon dioxide gas all these physiological processes take place which are always referred to in examining the effect of carbon dioxide mineral baths—the frequency of pulsation, respiration, and blood pressure.
We have learned in the historical chapter that while the carbon dioxide water bath as it is given in Nauheim and artificially prepared everywhere is very popular with the medical profession, very little is known, or rather a great deal has been forgotten, about the external application of carbon dioxide gas in dry form.
As far as known, Franzensbad is the only place now where natural carbon dioxide gas baths are administered. Fellner, Leopold in a paper, “Zur physiologischen Wirkung der Kohlensaurebader” read at a meeting of the Balneological Society in Berlin, March 9 to 13, 1905 (published in Berlin, klin. Wochenscbr., June 12, 1905) gives the following description of bathing in Franzensbad:
“An adult of medium stature, standing in the basin, is reached by the gas up to the hips. Persons taking a bath stand upright in the basin, so that the gas may not cause inconvenience in respiration. They are fully dressed. When using the bathing tub, which is made of sheet iron, the persons taking a bath may remove their clothing except for undergarments and stockings. The bathing tub is provided with a frame and a lid, both of which have an opening to receive the neck of the patient. A towel serves to close the opening around the neck and to prevent the escape of gas and its interference with respiration. Persons taking a bath sit in the basin on a perforated, wooden chair. The feet rest on a wooden hassock, as the basin feels very cold. In order to prevent any injurious effect of gas escaping from the pipe, several excellent ventilators are provided at the windows as well as at the floor of the room.”I can not understand the necessity of some of the precautions, which must be very inconvenient to the bather in Franzensbad. I never was in Franzensbad. This description, given by Fellner, and which I saw only a short time ago in the Berliner Klinische Wochenschrift, is the first which came to my notice.
In an old book, which is perhaps rarely consulted any more, Sobernheim’s “Arzneimittel lehre” —the last edition appeared in 1863—I found that Kuester and Perkin had treated ulcers of the rectum, especially in cases of dysentery, by inflation of the rectum with carbon dioxide gas. In no other books or papers on materia medica published since 1863—and I have consulted all I could find in the New York Academy of Medicine and the Surgeon General’s Library of Washington—have I seen this method mentioned. Theoretic reasoning and a reading of this recommendation of Kuester and Perkin made me apply the gas in dysentery. The first case thus treated by me was published in The Annals of Anatomy and Surgery, December, 1883, and, as it appears to me a specially instructive one, I may be permitted to give it in full as it was published in the said journal.
After years of experimenting, I had the bathing cabinet constructed which is represented by the figure, a very simple contrivance made of metal. The gas is taken from an ordinary cylinder containing liquefied carbon dioxide. The bather takes his seat in the tub; the gas is turned on and conducted through a rubber tube into the tub. A lighted candle is placed in the tub alongside the bather, the flame being on a level with the ensiform process or even a little higher; at any rate, below the level of the axilla of the bather sitting in the tub. The light becomes extinguished when the gas coming from the cylinder has reached it. Then the gas is shut off. Carbon dioxide gas is heavier than the air, and the bathtub is filled with the gas as it would be with water. The water, as well as the carbon dioxide gas, remains at the level given to them; but even if the gas should become agitated, or if the tub should be overfilled, it will run over the brim of the tub and sink alongside it to the floor.
The lid and the towel, as mentioned, I found superfluous. No lid with an aperture for the neck can be made gas-tight; no towel will prevent penetration of the gas, but the gas will not rise and lid and towels are worse than useless. Further, it is perfectly immaterial, as to the effect of the gas, whether the bather is dressed or undressed or partly undressed. The gas will penetrate through all clothing except rubbers. Rubber boots or shoes have to be removed.
Carbon dioxide being a colorless gas, the tubs and basins to the eye appear empty. By the experiment with a lighted candle—the flame becomes at once extinguished in the gas—we can learn the difference between gas and atmospheric air. Carbon dioxide gas, about one-half heavier than atmospheric air, sinks to the bottom, and as long as the bather keeps the head above the level of the gas there exists no possibility of any harm.
The first sensation of the bather in the bath is that of warmth, beginning at the feet and extending gradually, by means of the penetrating power of the gas over the whole surface of the body exposed to it. This changes by degrees into a piercing or prickly sensation. As the gas by itself is cool, this sensation of warmth is not due to the temperature of the gas but is a consequence of the intense irritation which it produces, especially on the peripheral nerves, followed by increased circulation in the capillaries and manifested by reddening of the skin. The capillaries and arteries become dilated, the amount of blood in both, as well as the blood pressure in the arteries, is increased, and the diastole of the heart becomes more effective. These are moments of significance for the heart and its work, in so far as the intensity of the arterial circulation, in general, is augmented, the drawing of blood from the veins facilitated, the diastolic filling improved, and the heart muscle given more time for relief and for preparation for renewed energy.
In July 1904, I published my experience with the carbon dioxide gas bath. I may be permitted to quote verbatim from this paper in order to compare my observations with those given by Fellner. My paper, “Effects of the Dry Carbon Dioxide Gas Bath on the Circulation and on the Diseased Heart.” New York Medical Journal and Philadelphia Medical Journal, July 9, 1904, reads:
“That the rapidity of the whole blood circulation increases during the bath is shown by the increased strength and volume of the radial pulse. The pulse of the bather, within a few minutes after having entered the bath, resembles a pulse stimulated by alcoholic drinks.”
“Since I have not found in the literature a record of the effect of the dry carbon dioxide gas bath on the number of the pulsations, I shall present one from my case- book.”
“The bather remains in the bath for about twenty minutes, or a little while longer. The pulse is counted every five or ten minutes, as long as the bath is continued.”
“The following case was that of I.M., 20 years of age, suffering from neurasthenia, and the treatment was confined to the carbon dioxide gas bath:
“First bath—Pulse 92, 80, 72. Second bath—88, 76, 72, 80, 88. Third bath—88, 72, 76, 68. Fourth bath—80, 72, 60, 68. Fifth bath—80, 80, T2, 60. Sixth bath—80, 76, 68, 72.
“First bath—96, 104, 100, 116. Second bath—92, 108. 104, 88. Third bath—92, 88, 112. Fourth bath—104, 104, 84, 96, 92. Fifth bath—120, 100, 96, 100. Sixth bath—96, 92, 92, 96. Seventh bath—108, 100, 96. Eighth bath—88, 88, 92. Ninth bath—88, 88, 88. Tenth bath—104, 84, 92. Eleventh bath—96, 96, 92. Twelfth bath—88, 80, 80. Thirteenth bath— 100, 88, 88. Fourteenth bath—104, 100, 92. Fifteenth bath—96, 96, 92. Sixteenth bath—88, 88, 84. Seventeenth bath—92, 88, 80. Eighteenth bath 88, 88, 92. Nineteenth bath—92, 84, 88. Twentieth bath—92, 88, 88.
“I wish to express my thanks to Dr. E. C. Dent, medical superintendent of Manhattan State Hospital, on Wards Island, for having allowed me to introduce the carbon dioxide gas bath in his hospital. I wish also to thank the members of the staff of this hospital who took interest in the method, especially Dr. C. H. Holmes, who permits me to report the following case under his care as he has recorded it in the books of the hospital, and to have the sphygmographic tracing taken by him reproduced:
“N. C, married, 24 years of age. September 15, 1903—Pulse 82, sufficient force. One intermission to the quarter ( 74 ). Impulse at apex marked; also a thrill. Apex beneath the left nipple, fifth intercostal space, three and a half inches from the median line. Very loud murmur at the apex, carried to left axillary line. Mitral regurgitation. No direct mitral, no direct aortic, no direct pulmonary. Long heart with a dilated left ventricle.
“The sphygmographic tracings on the following page furnish evidence of the effect of the carbon dioxide gas bath on the heart.
“More such tracings were taken in different cases of heart disease. I give only this one, however, because it furnishes conclusive evidence enough to establish the effect of carbon dioxide.
“The Dudgeon sphygmograph was used in these tracings, the clockwork being regulated so that five inches in length equaled ten seconds in time. The amount of pressure applied to the vessel was always the same both before and after the bath, three ounces being the average amount.
“Unless great care is used in both the manipulation and adjustment of the sphygmograph, the results derived from a series of experiments like these are likely to be fallacious and misleading With the proper amount of care, however, directed to the general running order of the instrument, and its careful and accurate adjustment to the vessel, in the series of observations on any given case, the sphygmograph furnishes a safe guide as to the changes in rhythm, force, and frequency of the pulse. The comparison of the tracings taken both before and after the baths in this line of experiments shows the following changes in the pulse after the bath:
“Heightened arterial tension, shown by the broadening of the top of the percussion wave. Improvement in the rhythm of the pulse, shown by the obliteration of intermissions—the change as a rule from an irregular, poor-volume pulse to a regular pulse of good volume. Other changes have been noticed, but in the series, taken as a whole, none have been so constantly present as those above mentioned.
“To examine in a scientific way the effect of carbon dioxide gas, externally applied, on the pulse beat and blood pressure, to secure reliable sphygmographic tracings and measurements of blood pressure is difficult. Comparisons have constantly to be made to determine whether the effect is really due to the gas or, in some degree, to manipulation. However, one thing is certain there is a decided effect manifested by carbon dioxide gas on the circulation and I hope to be able to arrive at positive and exact results. Meanwhile, I shall be well rewarded if I have succeeded in attracting the attention of those who have the facilities to follow the matter up.
“The description Fellner gives of the effects of the gas bath is as follows:
“What are the manifestations taking place in the carbon dioxide gas baths? Having entered the bath, a prickling sensation and a peculiar feeling of warmth are noticed. It rises upward to the height of the gas, gradually becoming more intense, imparting a sensation of heat which is especially noticeable at the perineum and the genitals. Finally, there is increased perspiration at these places. This sensation of heat continues for at least half an hour after leaving the bath. There is also a visible effect, the skin becoming hyperemic and turgescent where the gas has come in contact with it. Hemorrhoids undergo swelling and possibly there may be some bleeding. The sensation of prickly heat produces such an effect upon the sexual organs that there occurs sexual desire.
In giving an account of his investigations, Fellner states in detail the sensations experienced in the gas tub bath. He says: “So far as I know, Kisch’s observations are the only ones that have been made with regard to changes in pulsation and respiration. (The author has apparently not seen my article from which I have quoted above.) On the question of investigating changes in blood pressure, I have no information. Kisch found the following: Measuring the pulse every five minutes, it decreased by four to six beats a minute after a lapse of ten minutes. This diminution of frequency lasted from fifteen to twenty-five minutes, after which there was an increase. When the bath has lasted for forty to fifty minutes, the frequency increases to more than normal, so that after a forty-five to sixty minutes’ stay in the bath the increase over normal frequency amounts to four to eight beats a minute. The frequency of respiration remained unchanged when the bathing time did not exceed half an hour. After a prolonged stay, however, there was an increase by four to eight respirations a minute, accompanied by increased pulsation. This was followed by manifestations of congestion toward the head, a feeling of heaviness and pressure in the head, a feeling of anxiousness, perspiration at the forehead and temples.
“I will now proceed to state the result of my investigations, which referred to frequency of pulsation and respiration and to blood pressure. So far, I have only conducted two investigations in the bathroom where persons remain standing. Preceding the first bath, I instruct the patient to sit down for fifteen minutes, after which I determine the frequency of pulse and respiration, and the blood pressure. I then let him rise and again determine the same particulars. As is well known, the pulse is accelerated when the person is standing, while the blood pressure is diminished. This is shown by the accompanying table, which records one of these experiments. Upon rising, there was an increase of eight pulse beats a minute; respiration had decreased by one breath a minute, and the blood pressure by 30 mm. When the upright position is maintained for a prolonged period, frequency of pulsation is still further increased, respiration remains almost unchanged, and the blood pressure sinks still lower.
“We will now return to our experiments. Frequency of pulse, when standing, was 99, respiration 17, blood pressure 115 mm. Then the person went to have the gas bath. After six minutes the pulse was 102, after twelve minutes 102; respiration after seven minutes 15, after thirteen minutes 17. Blood pressure after nine minutes was 130 mm, after sixteen minutes 125 mm, after twenty minutes 130 mm. We therefore see that the frequency of pulse had increased by three a minute, respiration was unchanged, and the blood pressure had increased by 15 mm. In the second experiment the pulse after ten minutes’ standing in an upright position was 99 a minute, respiration 16 after eleven minutes, and the blood pressure 120 mm after fourteen minutes. In fifteen minutes the latter was still 120 mm. In the gas bath, pulse 102 after ten minutes, respiration 17 after twelve minutes, blood pressure 125 mm after both seventeen and nineteen minutes. Therefore, the frequency of pulsation had increased by three beats a minute, the number of respirations by one, and the blood pressure by 5 mm.
“But as these experiments did not take place under the same conditions as obtained in the case of carbon dioxide, mineral baths, and as it was important to produce the identical conditions, I proceeded to conduct my investigations with gas tub baths. The table shows the results of eleven such examinations. Before going into these details, I will describe the method according to which I made my observations and the sensations I experienced while taking these baths myself in the bathtub. The experiments were made in the beginning of October and at the end of November. In October the temperature of the open air was between 12.5° and 15° C; the room temperature between 13.5° and 14.5°, so that no fire was needed. During the second half of November the outside temperature was between 4° and – 8° C, the room was heated by a gas stove at temperatures ranging from 12.5° and 16° R. I took a seat on a wooden chair in the bathtub, with extended legs, as if I were taking an ordinary water bath. Before taking the bath I rested for fifteen minutes on a couch, occupying the same position which I afterward observed in the bath. Then pulse, respiration, and blood pressure were determined. I now entered the bath. The lid was closed and the aperture was closed with a towel. The gas was turned on, making much noise as it poured into the bath. The air escaped through an opening at the opposite wall of the room. I will now describe my sensations on the occasion of one of these experiments on October 3.
After two minutes there was a sensation of warmth both in the lap and on the abdomen. After three minutes the sensation of warmth extended to the chest, and breathing was slightly obstructed. After four minutes there was a sensation of warmth in the back and left leg, which was the side where the gas was admitted. After five and one-half minutes the sensation of warmth extended to the inner surface of the right leg, followed by an intense feeling of warmth over the upper part of the body, also in the arms. The hands were still cold, and also the feet after six minutes. After seven minutes there was perspiration on the chest and back, sensation of warmth in the feet; and after eight minutes the hands slowly commenced to feel warm. Intense feeling of heat over the entire body. Sensation of obstructed breathing disappeared.
“I have taken notes of the sensations on several occasions. They were not always alike; but I will not take up time by describing the differences, but continue the description of the method of experimentation.
“After ten to twelve minutes’ stay in the bath I counted pulse and respiration. Then the entire bath was covered with a large linen sheet, which was pulled over a frame under the lid. Now the lid was removed and I placed my left hand—the same with which the blood pressure had been determined before the bath carefully from under the linen sheet upon a small table, the height of which was on a level with my heart. After fifteen minutes ‘ stay in the bath the blood pressure was taken by my son, who is very expert in these experiments; then again after eighteen, twenty, and twenty five minutes.
“The results are chronicled in the table, showing that the blood pressure was raised in all experiments; the minimum was 5 mm, and the maximum 25 mm. In 2 experiments out of 13 respiration had decreased twice by one or two breaths a minute, 8 times it had increased by 1 to 3, and in 2 experiments the frequency remained unchanged. Pulsation decreased in 3 cases; once by 3, once by 5, and once by 8 beats per minute. In the second case possibly insufficient gas supply was at fault. Nor did I feel properly warm on that occasion. The attendant first forgot to turn on the gas, and later did so incompletely. In the experiment on October 3, the opening of the lid was not properly closed by the towel. I breathed some of the gas and experienced slight dyspnea. In the experiment on November 17 there was possibly an escape of gas from the apparatus. There was bad ventilation, causing again some dyspnea and a feeling of weakness. I believe there is so much more reason for holding these causes responsible, as in later experiments, where ventilation was perfect, there never was any reduced frequency of pulsation.
“In ten experiments pulsation was increased. The smallest increase was two and the largest twelve beats a minute.
“The results, then, are as follows:
“In the carbon dioxide gas bath the blood pressure is always increased; also frequency of pulse and respiration in a large number of experiments. This is not the case in the carbon dioxide mineral baths, in which I, and also others, have generally observed a decrease in frequency of both pulse and respiration. I have also observed that the blood pressure sinks during the bath, and reported this condition in an address I delivered at the Congress of Balneologists of Austria, in Abbazia, on October 5, 1904. A. Schott, Ewald, Graupner, Broadbent, Graigner, Leslie Thorne, Leith, Baltusewicz, have made the same observation. The temperature of the carbon dioxide gas was taken by leaving the thermometer in the bathtub for fifteen minutes. The lowest was + 11° R, the highest 14.25°, while the maximum outside temperature was 12° to 25° C; the minimum – 4º to – 8° C. Kisch found that the temperature of the gas in Marienbad at an outside temperature of over zero was lower by 0.5° to 1° R, and that in winter between – 4º and – 12° R, the temperature of the gas did not exceed – 1° R, and therefore, has a temperature of its own, which is independent of the outside temperature.
“Seeing that the temperature of carbon dioxide in my experiments varied between 11° and 14.25° R, which is equal to an average temperature of 13.5° R, the relation of heat conductivity of carbon dioxide to that of atmospheric air is in proportion of 59 to 100. The slight difference in the heat capacity between carbon dioxide and air may be neglected—the result would give approximately the figure 23 as indicating the point of indifference of air. Therefore carbon dioxide appeared as warm as atmospheric air at a temperature of 23° R, a figure which exceeds by far the average point of indifference of the same.
“If then, the frequency of pulse and respiration and the behavior of the blood pressure are different in a carbon dioxide gas bath and in a carbon dioxide water bath, the probable explanation is the difference in the effect of the two-component parts of the carbon dioxide mineral bath, namely, carbon dioxide and the water, in consequence of their different thermic point of indifference. This result may well be looked upon as supporting the theory of thermic effects of contrast as established by Senator and Frankenhäuser.
“If we wish to draw therapeutic conclusions from these results, we are justified in maintaining the following indications which had already been found out empirically: (1) On the part of the nervous system: anesthesia, hyperesthesia, neuralgia, and peripheral paralysis based upon rheumatic, traumatic, or toxic causes; (2) functional disturbances of the sexual organs: amenorrhea, dysmenorrhea, impotence, and absence of sexual desire. On the other hand, the following would be contraindications: (1) Tendency to hemorrhage, menorrhagia, bleeding from hemorrhoids, hemoptysis; (2) chronic cardiac disorders, chronic affections of the lung, and irritability of the respiratory organs.
“I would like to derive two therapeutic points of advice from the investigations I have conducted. On the assumption that the carbon dioxide gas bath does not interfere with the effect of other baths, mud baths, or steel baths, that on the contrary, it supplements the same, we have prescribed the same without scruples, to be taken shortly before or after the other bath. This position is also justified in attaining the desired effect, as, for instance, procuring menstruation, increasing sexual desire, etc. But as we have seen that the carbon dioxide gas bath increases cardiac function and frequency of respiration, it would be advisable to prescribe a certain interval between the two baths so as not to create any injurious effects by causing too great excitation of the heart; or in another case, not to interfere with the action of the other bath upon circulation and respiration.”
Dr. Satterthwaite had the courtesy to compare with me at the Manhattan State Hospital, during the summer of 1904, in some cases the effect of the carbon dioxide water bath on blood pressure with that of dry carbon dioxide gas bath, and we found that they indeed correspond.
Carbon dioxide gas baths, as means of general invigoration and recuperation, may serve as substitutes for sojourning at watering places in cases in which circumstances do not permit the business or professional man to quit his daily occupation.
In a case of progressive muscular atrophy, altho I did neither expect nor promise a curative effect, the patient-derived much benefit from the carbon dioxide gas baths, finding them more serviceable than electricity and massage. It is to be hoped they will become popular; they deserve to be.
As it is unnecessary to go to Nauheim for taking Nauheim baths, so neither is it necessary to go to Franzensbad for dry gas baths. We can imitate the one as well as the other to perfection.
The action of the gas on the circulation is beneficial, not only in heart disease but in many other conditions, even in health, as well.
After we have been in the dry carbon dioxide gas bath for from twenty to thirty minutes, we feel remarkably refreshed and exhilarated; this sensation lasts for hours and can be compared with the effects of a sojourn at the seashore or in the forest.
Twenty-five thousand patients visit Nauheim, Germany, every season to take the saline carbonated baths. Most of these are cases of cardiac affections, but a great number are sufferers from gout, rheumatism, neurasthenia, and locomotor ataxia.
These natural springs at Nauheim contain from 2 to 3 percent of sodium chloride and from 0.002 to 0.003 percent of calcium chloride, besides small quantities of various salts of iron. By fər, however, the most important ingredient is the large amount of carbon dioxide in these waters. The waters from the springs in Nauheim rise from a depth of over 500 feet to a height of 56 feet above the earth. The springs are so richly charged with carbon dioxide gas that the area where they fall is a great white seething mass.
The artificial Nauheim bath is given by the American Nauheim Bath Company, 135 West Forty-fifth Street, New York, an institution under the control of New York physicians.
Schott, of Nauheim, advances the theory that the chlorides of sodium and calcium of the Nauheim waters, together with the carbon dioxide gas passing through the epidermis, stimulate the sensory nerve- endings, and by a reflex action on the cardiac nerves cause the heart to beat more forcibly and less rapidly. It is, I believe, generally admitted that the skin has little power to absorb salts, even in solution; nevertheless, it is quite possible that the carbon dioxide gas produces some chemical change in the salts in the solution by some method as yet unknown to us, and in this way, the salts may be absorbed; and there may be produced a physiological effect, not only cutaneous stimulation directly by the carbon dioxide gas, but in addition to this by the chemically changed salts by their absorption into the circulation.
On entering the bath for the first time the patient experiences a slight depressive feeling in the chest, but this is usually succeeded in a few minutes by a general sense of warmth and well-being.
Schott found that a plain brine bath alone increased the blood pressure from 5 to 10 mm of mercury, and the saline carbonated bath increased it from 10 to 30 mm. He also found the Nauheim bath to be of diagnostic value. If in a given case the blood pressure was diminished after the bath, it indicated myocardial degeneration or pronounced arteriosclerosis.
Schott states that if the blood pressure is as low as 65 mm of Hg in the sphygmomanometer the Nauheim baths are contraindicated. That the area of cardiac dulness is diminished by the Nauheim treatment there can be no doubt. It can be proved by auscultation and percussion, but it is made more patent by the x-ray picture.
Eichhorst speaks of one case of pronounced mitral insufficiency in which the x-ray showed the increased area of cardiac dulness. After two series of baths of forty minutes each, extending over a period of eighteen months, the patient was cured and accepted by a very strict life insurance company.
Persons who are likely to derive the greatest benefit from the Nauheim baths are those having cardiac dilatation, due to overwork or worry Other cases amenable to this treatment are the dilated, enfeebled, or irritable heart, coming on often after influenza, or the result of rheumatism or gout. Dr. Samuel G. Tracy, of New York, saw decided improvement in mitral disease where lack of compensation was threatened. Patients who have cardiac disturbance from excessive smoking, dissipation, etc., are markedly improved by the Nauheim treatment. In nearly all cardiac cases, unless they are relieved by rest, diet, and Nauheim treatment, the heart becomes overloaded and overworked; an impure blood supply, congestion of the internal organs, and a progressive wrecking of the heart itself follow. On the other hand, under intelligent treatment, including a series of Nauheim baths, the patients may have their lives prolonged for a number of years in comparative comfort.
The method of taking the Nauheim bath, as practiced in the American Nauheim Bath Company of New York, is the following:
First, the patient is divested of his clothing; then the pulse is taken, after which he is put in the bath at a temperature ranging from 96° to 86° F, depending upon the case. As soon as the patient is submerged in the effervescent saline bath, millions of gas bubbles attack the nerve filaments in the skin, and the patient feels as if a very mild electric current were passing through him. This bath lasts from eight to twenty minutes, during which time his pulse is taken twice, and each time the number of beats is less per minute, and the quality of the pulse stronger. Now the patient is enveloped in a large Turkish towel and dried, and he returns to his couch, where he rests from one-half to three-quarters of an hour or longer. This is followed in heart cases by the Schott resistance movements, a sort of physical-culture exercise. These movements are given from five to fifteen minutes and have nothing to do with gymnastics in the ordinary sense of the word. They, doubtless, in the end, improve the muscles generally, but this is not their principal object. It should be distinctly understood that each exercise is designed to produce regular movements, with but little exertion and absolutely no fatigue. There are sixteen of these exercises, arranged either for the upper or lower extremities or the trunk; and while they are made, the operator offers a slight resistance to each one.
During the exercises, the patient should breathe regularly, and no limb or portion of the body should be so placed as to compress the blood vessels and thus check the circulation.
The Nauheim methods with American adaptations are fully described and illustrated in Satterthwaite’s book “Diseases of the Heart and Aorta.”
While drugs, cardiac tonics, and stimulants may relieve urgent symptoms, the carbon dioxide baths, combined with the resistance exercises, will give greater and more lasting relief than any other form of treatment.
It is only a few persons with cardiac trouble who can go to Europe; and for those who find it necessary to stay at home, good results can be obtained in New York City by means of the artificial Nauheim baths. There are different ways of preparing the artificial Nauheim baths.
The best method is to charge the water with carbon dioxide gas by means of Kny-Scheerer’s Zestoo apparatus. It charges the water thoroughly and efficiently with a high percentage of carbon dioxide, is very economical in its operation, takes up very little space, is simple in its manipulation, is reliable and durable, and recommends itself on account of the relatively small cost. With the Zestoo apparatus (Fig. 5) a carbon dioxide bath can be prepared in a manner fully equal in effect to natural waters, as the exact dosage of carbonization can be varied at will.
The apparatus itself consists of two mixing cylinders, to which a cylinder of liquefied carbon dioxide has to be coupled. The latter is provided with a pressure-regulating valve; the hydrant water is connected with the mixing cylinder and liquefied carbon dioxide is simultaneously injected, so that an intimate mixture takes place in the interior of the cylinders, whence it flows into the bath-tub and the bath is ready for use.