CHAPTER XII – MISCELLANEOUS
W. Duffield Robinson attended to a large number of patients suffering from purpura (red or purple discolored spots on the skin caused by bleeding underneath the skin). The majority were prisoners who had been subjected to abstinence from meat for a long time.
He noticed in the case in which he had Bergeon’s enemata administered a prompt disappearance of the affection of the skin, and thereupon he applied these inflations in a number of purpura cases. Some of these patients recovered within four weeks, while those treated with tonics alone often required many months of treatment.
Carbon dioxide is the refrigerating fluid preferred for this purpose at Neisser’s clinic at Breslau. The surface is sprayed with the carbon dioxide as when making frozen sections. The broad perforated nozzle of the vial is held about one centimeter from the skin, and the fluid is forced out by a bulb. In half a minute the skin is frozen hard. There is anemia at first; this is followed by intense hyperemia, and half an hour later by profuse serous transudation. In twelve hours an inflammatory redness develops, with blisters. When the freezing has been very intense, actual ulceration may follow. When it is necessary to repeat the application, an interval of five to ten days is interposed. Three sittings in less than a month are generally sufficient. This method of treatment proved particularly effective in nine cases of systemic lupus erythematosus (SLE, an autoimmune disease in which the body’s immune system mistakenly attacks healthy tissue in many parts of the body) thus treated. From three to nine applications were made and the patches healed remarkably promptly, but traces of recurrence became visible after a few months, showing that the refrigeration needs to be combined with some other measure to ensure permanency. According to Neisser the ideal combination is with crude hydrochloric acid, according to Dreuw’s technic, substituting carbon dioxide for the ethyl chloride. Tuberculous skin affections are evidently the chosen field for this mode of treatment when phototherapy is impracticable for any reason. A lupous patch about six months old, on the forearm, healed with a keloid cicatrix after two applications of carbon dioxide and hydrochloric acid. In another case, two lupous patches on hand and arm ulcerated at first under three weeks of the combined treatment, but then healed over smoothly. All were favorably influenced and apparently cured to date. The experiences at the clinic were with psoriasis, primary sores, leg ulcers, and sycosis, besides the tuberculous affections. The primary sores all healed rapidly after a single application of the refrigeration and hydrochloric acid before mercurial treatment had been instituted.
The results of the Nauheim treatment in diseases of the heart and circulatory system have stimulated investigations into methods of obtaining artificial carbonated thermal baths. R. Hatschek describes such a method in the Wiener klinische Rundschau (January 28, 1900). He quickly applies a paste of bicarbonate of soda to the body of the patient and follows this with wrapping him in a cloth saturated with weak hydrochloric or acetic acid. By occasionally wetting this cloth with the acidified water, a very lively effervescence is produced and the evolution of carbon dioxide is well developed. It is claimed as worthy of notice that the production of the gas goes on even within the skin, for the paste finds its way through the pores and meeting the acid secretions of the sweat and sebaceous glands is converted into carbon dioxide gas. The gas evinces its efficacy directly upon its production by its action on the capillaries and nerve- endings in the skin. Beyond this, its too great activity is somewhat hindered by the cloth wrapped about the patient. The action of the gas is shown by the originally constricted blood vessels and cold, cyanotic extremities returning to their normal state and assuming a ruddy, healthy glow. The rubbing and other forms of friction take much longer to accomplish this same result than does the gas when formed in this way. For one application for an adult, about two ounces of sodium bicarbonate were found necessary, producing at the ordinary temperature of the room nearly 16,000 cubic centimeters of carbon dioxide. In preparing the paste several teaspoonfuls of warm water should be mixed with it in order not to chill the body before the cloth is applied. The application must be made hurriedly and the parts of the body may remain covered alternately, while the others are being treated with the paste. The acidified solutions are to be markedly thinned and diluted in order that no inflammatory reaction on the part of the skin should follow.
Ewart, of London, maintains that carbon dioxide inhalation treatment brings within the scope of Nauheim therapeutics a considerable number of cases that would otherwise be set down as unfit; indeed, he attributes much of the efficacy of the Nauheim bath treatment to the incidental inhalation of carbon dioxide gas. Whereas balnear treatment exercises its greatest influence over the period of recuperation, the inhalation treatment is indicated in the stage of failing cardiac energy. Ewart claims that those cases will derive the most benefit in which the elements of respiratory distress and cardiac pain predominate. Other drugs that in large doses possess a toxic and baneful effect, carbon dioxide gas has in lesser doses an active physiological effect. It would seem that none of the carbon dioxide inhaled passes directly into the bloodstream, but by raising the partial pressure of that gas in the lung prevents the liberation of some portion of the same gas already in the blood. Short of the asphyxial state induced by large doses of an irrespirable gas, Ewart enumerates the following as the chief physiological effects of smaller doses of carbon dioxide gas, inhaled experimentally in moderate concentration: (1) A feeling of internal warmth, and after a time some flushing; (2) a strong desire to breathe, and particularly to breathe out; (3) an excited state of the circulation, which may amount to throbbing or palpitation; (4) a slight giddiness and headache supervening after a while in some susceptible subjects; (5) general anesthesia is not brought about by moderate inhalations; (6) cutaneous anesthesia has been obtained not as a result of the inhalation, but only by the local action of the gas upon the skin. Side by side with these effects of inhalation of carbon dioxide gas on the healthy subject, Ewart sets the observations of its effects on patients with cardiac symptoms. The subjective effects are: (1) Rapid diminution or cessation of cardiac distress or pain; (2) a feeling of increased freedom of respiration. The objective effects are: (3) A visible increase in the depth of respiration; (4) a marked improvement of the pulse; (5) an obvious improvement both in the complexion and expression of more than the transitory duration; (6) by systematic repetition progressive improvement in the patient’s general condition, as well as in the cardiac and respiratory functions. Thus it will be seen that the direct effect upon the cardiovascular system is reinforced by the greater range of respiratory movements, which, so to say, open up wider channels by which the blood may find its way through the lungs.
CHAPTER XIII – THE CONTINUOUS WARM BATH
We have seen how the effect of the warm water bath has many similarities with the effect of carbon dioxide baths—either dry or watery—and it appears opportune to devote a special chapter to the comparatively modern therapeutic measure, the continuous warm bath.
Considering this bath as a therapeutic means, we find that fixed laws to govern its employment are yet to be determined, and much which is known is to be complemented in several directions. However, some facts, founded on experience, have been demonstrated already on a scientific, physiological basis. Of hydro therapeutics in general it may be said that many rational facts, found by scientific research, would be retained if numerous as yet isolated truths of experience would have been appreciated according to their value, instead of being lost to memory and to practice.
To demonstrate the effect of the continuous warm bath on innervation and circulation I may be permitted to describe a case which I presented before the New York German Medical Society, May 2, 1892.
Delia G, 24 years of age, always well before, and of remarkably strong muscular development, was taken ill toward the end of September 1891, with inflammation of the left elbow joint; there were unusually severe symptoms of inflammation, especially violent pains. Several antirheumatics given brought little or no relief; even antipyrin, which at that time was the favored remedy, did not ease the pain or procure sleep for the night. Of all the remedies employed it was only the plaster-of-Paris bandage which gave some satisfaction. I left this bandage on for a fortnight, and a second time for ten days on the arm, and removed it when I had reason to suppose that the symptoms of inflammation, viz., swelling, pain, and increased temperature, had subsided. This proved to be the case when I removed the plaster-of-Paris.
Soon after the removal of the first bandage symptoms of inflammation reappeared; after removal of the second, stiffness of the joint remained. It was only while the patient was under the influence of chloroform that I was able to bend and stretch the arm. While I made these forced flexions and extensions, frictions, the symptom of synovitis fibrinous (inflammatory arthritis), could plainly be felt. The forced flexion and extension under the influence of chloroform gave no permanent result. On the contrary, the exudation in the synovial cavity increased, and mobility was reduced to a minimum. The perisynovial soft parts became infiltrated and still more restricted the slight mobility.
At this time patient could not and would not remain with the family that had hired her to do general housework, and on November 30, 1891, she became an inmate of a hospital in this city.
One of the physicians of this institution told me that according to his opinion the prognosis in regard to the usefulness of the arm of my patient appeared doubtful. The treatment, he informed me, consisted in forcing the joint, which could be brought to a right angle with difficulty, by means of graduated bandages into an acute angle. The patient said that during her stay in the hospital she took no medicine of any kind.
On December 12, 1891, she left the hospital. I now found the arm in the same condition as before she entered the hospital. To bring the joint from an obtuse to a right angle gave the patient considerable pain, and to go further in the way of flexion I regarded as too risky.
On December 15, 1891, I had the arm submerged in a warm bath, the bathing tub consisting of an oval-shaped wash-boilered some water taken out hourly and hot water added to keep the temperature as high as would be consistent with the patient’s comfort. For the night moist compresses covered with flannel bandages were substituted. No medicine was given while the arm was treated by permanent submersion.
The patient had followed my orders only too conscientiously. She had taken the water so hot that it scalded hand and arm, and the epidermis become raised in the shape of numerous blisters. I did not place much stress on this accident, because, according to my experience, the warm bath simply continued would be the remedy for the effects of the too-hot bath. Such proved to be the case. No pain or ill consequence of any kind followed.
The effect of the permanent bath was highly gratifying All pain the patient had been complaining of ceased at once. From day to day I could make more extensive flexions and extensions of the arm without causing violent pain to the patient. The comparatively slight pain which I caused now while making passive motions disappeared very soon when the arm was submerged again.
On the third day the patient herself could bring the elbow joint to a right angle, the following day she could do this without causing any pain. On the fifth day, she brought the joint to an acute angle, and on the tenth-day flexion and extension were normal.
Since that date (December 26, 1891) patient has been attending to her housework, and she is able to do washing and ironing for the household. Unfortunately, she is still exposed to the danger of rheumatic invasion, and from time to time new rheumatic attacks in the elbow joint supervened.
Since then, whenever new rheumatic inflammation has set in, the case has been benefited by salipyrin. However, when pain and other symptoms of new inflammation appeared, I ordered the arm to be placed in the warm bath for one or two hours at night, and the result was invariable that this relieved the pain.
I have to confess that when I presented the case the arm could not be flexed quite as far as the sound one, also that there existed a minimal swelling at the elbow joint; but I am convinced that if the patient would have desisted from work and for days employ the warm bath, and, above all, be removed from all causes of new rheumatic infection, these comparatively slight remnants of rheumatic inflammation would have disappeared completely.
The continuous warm bath is employed in Leuk, in the canton of Wallis, 1,415 meters above the sea, situated in a ravine with grand Alpine scenery. The water of the springs is of 41.5° and 51° C (170° and 123° F) temperature, and contains sulfate of lime, sulfate of magnesia, and other salts, besides a small trace of carbon dioxide. As a bath it is to be classified as an indifferent therme—the sulfate of lime is neither absorbed nor can it irritate the skin—on account of its being contained in the water in too small a quantity.
The average course of treatment is calculated to last twenty-five days, during which time either every second day or every day the patients bathe once or twice during the day. The duration of the bath is in the beginning one-half hour, and is increased gradually to five and eight hours, divided between forenoon and afternoon; after eight to twelve days of gradual increase, there is gradual reduction of the duration of the bath until the initial bathing time has been reached. Ladies and gentlemen bathe at the same time in one common basin, the size of which is calculated for twenty per The bathers pass the time in conversation, reading, and playing dominoes on floating little boards. At noon the basins are partly, and at night they are completely, emptied and replenished. During the night the temperature of the water sinks to about 35° C (95° F). The diseases treated thus are gouty and rheumatic exudations, chronic exanthemata, psoriasis, eczema, prurigo.
Hueter recommends in polyarthritis synovialis acuta (rheumatismus articulorum acutus), after the acute stage has passed, and also in polypanarthritis (arthritis deformans), therapeutics which aid absorption and excite circulation, and praised, as the best means to this end, permanent warm baths, for either arm or leg, in tubs of proper size and shape, or general baths, as the case may require. He states that this therapeutic measure in polyarthritis synovialis chronica, as well as in polypanarthritis, had not been surpassed by any other method of treatment. He says: “In regard to poly panarthritis it is well known that no remedy is perfect, not even the permanent bath, but the permanent bath gives more satisfaction than all the other remedies.”
Riess recommends permanent warm baths in articular and muscular rheumatism; he spreads a bathing sheet, like a hammock, above the bathtub in such a manner that the patient may rest on this sheet in the water. The read rests on a rubber ring.
It is a well-known fact that a warm bath of a long duration is mostly well tolerated. To emphasize this fact I shall give an extract of a communication from Dr. Baelz, Berlin Klin. Wochenschr 1884, 48, on the permanent thermal baths of the Japanese: “The Japanese bathe in indifferent or slightly salty, thermes of 42° to 48° C temperature, ten to fifteen times daily. Of special interest is a rudimentary bathing establishment situated in the mountainous region of Dzooshin, named Kawanaka. It is an Indian therme of 36.2° C. The patients remain in the water not only for whole days but for weeks at a stretch. They leave the water only to attend to calls of nature, or occasionally to take a little exercise. The body is placed in a half-recumbent or otherwise comfortable position, the occiput and neck rest on the margin of the wooden basin, in which a number of patients at the same time are gathered together. To prevent the rising to the surface during sleep the bathers place a more or less heavy stone across their groins, The proprietor of the bathing establishment, a man seventy years of age, remains during nearly the whole winter in the water—without garments and without stove he feels comfortable and warm, while outside snow covers the ground for four or five months in succession. His functions and his general condition are normal.”
To comprehend the therapeutical value of the permanent warm bath we shall have to study the elementary effect of the warm bath.
While by the cold bath the muscles and the capillaries of the skin, and of those tissues to which the effect of the cold extends, are made to contract—a contraction which, after the irritation produced by cold has ceased, is followed by dilatation, the local anemia is changed into hyperemia—the mechanical proceeding under the topical effect of warmth runs in the opposite direction; the capillaries and arteries become dilated, as has been described in a foregoing chapter.
If a limb is left in warm water for some length of time the soft parts become swollen, quite considerable increase of volume takes place, and after removal from the bath the skin of the submerged limb is warmer, often quite red, which discoloration disappears only after a few days.
Winternitz made experiments in the institution for experimental pathology of Professor Stricker, of Vienna, in measuring the increase of volume of the limbs subjected to baths of different temperatures. Employing for this purpose an ingenious contrivance, he was enabled to measure, on the arm suspended in water in the apparatus, increase of volume, which occurred simultaneously with the pulsebeat, and was caused by the large amount of blood driven into the arm with each systole of the heart, also changes of volume which corresponded with the larger amount of blood passing out during each interval between two systoles. He could establish the fact that the change of volume of the arm suspended in water of 8° C could well be distinguished from the one obtained when the arm was suspended at 38° or 40° C. In the former experiment, each heart systole presses only a relatively small amount of blood into the arm. The reason of this can only be—the strength of the heart’s action not having materially changed during the experiment—that there is a greater power of resistance of the blood vessels (which have been contracted by the effect of cold); this power of resistance opposes the entering of the blood wave to a certain extent.
Winternitz thus demonstrated ad oculos by his experiments that when some part of the body is submerged in warm water a considerably increased amount of blood passes into it with each systole, and a correspondingly large amount flows back through the veins during the intervals.
Indifferent baths, however, according to Jacob, likewise affect, to a certain degree, the circulation. As a rule, the skin is from 5° to 10° C cooler than the axilla. The normal in different temperatures of the bath, which is 35° to 36° C, increases the temperature of the skin to almost the same degree of temperature of the internal organs, the latter sinking generally to 0.5° to 1° C, the outside temperature rising to such extent that there is often found a difference of only 0.5º C in favor of internal temperature. This sinking of the internal and rising of external temperature means acceleration of blood circulation, mostly accompanied by a slight reduction of frequency of the pulse, and is followed necessarily by relaxation of muscles, stimulation of sensory nerves, and calming of nerves of warmth and pain.
The warm bath, while it surrounds the surface of the body, or part of the body, with an equally tempered medium, does away with fluctuation as to space and time of the loss of heat, and thus acts soothing. This is of especial advantage for therapeutical purposes. It is probable that a law exists according to which soaking of the peripheral ends of the nerves reduces, and drying increases, their excitability: At least Heyman thinks it possible that the calming effect of the warm baths is superinduced by suppression of perspiration, and thus retention of moisture, which proceeding takes place during the bath, and which causes, in the first instance, soaking of Krause’s endbulbs and Meissner’s tactile corpuscles; in the second instance, cessation of molecular movements in the extremities of the nerves, and thereby general calming of the nervous system.
In some papers, I cited the example of Napoleon, who, while at St. Helena, and while the monotony of his life was interrupted only by the pains he suffered from his cancerous disease, found relief when he remained for hours, or even whole days, in the warm bath.
In the paper on the effects of the continuous warm bath in arthritis, which I read before the German Medical Society, I said it is to be supposed that the permanent warm bath will prove serviceable in sciatica (pain going down the leg from the lower back.)
Indeed, a few months ago I had the satisfaction to learn from Dr. Fr. Grosse that he, accepting my suggestion, had had excellent results in a case of sciatica which had resisted all sorts of treatment, by placing the patient in the continuous warm bath.
Numerous physiological facts are known which support the theory that withdrawal of water excites the nerves, while gradual taking up of water (assimilation) reduces the irritability of nerves. This theory is based on the hypodermic injection of water to produce local anesthesia.
The thermic irritation of nerves, while it lessens the sensation of pain, excites at the same time, by way of reflex action, especially in the muscle, an increased metabolism. To relieve pain in the muscles caused by fatigue, there are no better means than a warm bath. Even comparatively high degrees of temperature have a refreshing effect. The fatigue or exhaustion of muscles is caused by more than normal accumulation of the products of their function. To oxidize and eliminate these products a certain amount of metabolism is required, which the fatigued muscular fiber is unable to perform. The specific effect of the warm bath is to afford immediate facility for oxidation. Without the warm bath, this relief would be obtainable only after bodily rest for hours or days. In the evening after a battle, instead of seeking rest and sleep in bed, Napoleon would take a warm bath, to enable him to resume the march during the night and fight a second battle the following day. On the morning of June 21, 1815, when he arrived, coming directly from the battlefield of Waterloo, in the Elysée, and dismounted from his carriage, he had to lean heavily on the arm of Caulaincourt, and he asked for a warm bath. Six days he had been on horseback nearly all the time. While he was in the bath Davout came twice to urge him to come to the assembled ministers. There was no time given for long rest; the warm bath alone stimulated him to renewed activity.
We have seen how the changes of the chemical and physical condition of tissues, the augmentation of the organic functions, the acceleration of the blood circulation, the dilatation of the vessels, the increased blood pressure depend on the specific action of the warm bath, as well as the carbon dioxide gas bath, on innervation.
Conclusive evidence exists of the power of the continuous warm bath to remove products of inflammation and infection in the case of erysipelas of the extremities. As long as fourteen years ago I published my observations in this regard. I treated a child affected with erysipelas (bacterial infection of the superficial layer of the ski) of the leg from the knee up to the groin. The Riedel-Kraske method, which at that time was the latest treatment in use, could not be employed, since it was difficult to establish the antiseptic fence in the region of the groin. The temperature was 107° F when I immersed the child’s body partly in warm water; after six hours it had become almost normal. This experience of mine was invariably confirmed in every case of erysipelas of the extremities treated with the continuous bath. The method is rational, is simple, and it is difficult to see why it is not generally known.
Dr. E. C. Dent, medical superintendent of Manhattan State Hospital, Wards Island (a hospital with five thousand patients), had the kindness to give me the following information on the experience with the continuous bath in his hospital:
In acute maniacal conditions, or acute delirium states, characterized by great motor activity, the prolonged warm bath has proven very efficacious. It not only decreases the motor activity but after some time in the bath (that is some hours) it produces sleep. In some cases of insomnia, we have found great benefit in this way without the use of sedatives.
In acute delirious conditions characterized by great restiveness, restlessness, and increased temperature, the following results have been noted: The restlessness has been reduced, sleep promoted, and the temperature has also been reduced. This is undoubtedly due to the stimulation of metabolism, as the bowels are more active and become regular. The movements are usually loose. The urine is increased in amount. We often find that tactile hallucinations are relieved. Occasionally after treatment for several days, an erythema (redness) of the skin develops. This does not occur in all cases, however. If removed from the bath for a few days this condition of the skin improves. We have also noted an increase in the appetite, the patient taking food better and receiving more benefit from the food. We have also noted occasionally after prolonged treatment by this method a tendency to the formation of furuncles (skin abscesses.)
Some benefit has been derived in certain cases of melancholia with frenzy. The temperature of the prolonged bath used here varies from 98° to 100° F. In some cases, hot baths are given, 102° to 105° F. These baths, however, are of short duration.
The length of time required in these baths varies. Some cases become quiet after a few hours, other cases require a longer treatment. In manic depressive cases, manic form, it is not unusual to leave the patient in the prolonged bath for four or five days or even weeks. There is no doubt that the prolonged bath is a great benefit, and the cases from a mental standpoint are much improved.
This form of treatment is not distasteful to patients, as a rule, very few object to it after once becoming familiar with it. In fact, some patients after removal from the tubs have requested to go back.
The continuous or prolonged immersion bath, as used in the Manhattan State Hospital, has been constructed by the Kny-Scheerer Company in accordance with Dr. Dent’s directions.
A fire-enameled metal bathtub of the best quality, with a broad rim, each tub being six feet long and thirty inches wide, has a broad, fan-shaped inlet at the head, allowing a stream of water to flow over the neck and shoulders of the patient, who rests in a canvas cradle or hammock, suspended sufficiently deep to immerse the body of the patient as far as the neck.
As the water becomes cooler and therefore denser, it gradually sinks to the foot of the tub, where a specially regulated outlet removes the surplus water. At the level of the water at the foot of the tub is a broad outlet that allows feces and other débris to escape.
In the tubbing-room of the hospital, where a series of tubs is in constant operation, there is a controlling table so arranged that the temperature of the water in each individual tub can be noted by the nurse in charge, and both the temperature and the rapidity of the flow can be controlled from the thermohydrostat.
The cradle is so arranged on a series of hooks that it can be changed without removing the patient from the water. The temperature of the water is usually kept at 98.5° F. Of course this is varied according to the clinical indications. It is customary when the bath is continued longer than three days to anoint the body with lard, or some oleaginous substance of this character, to prevent water-soaking.
I myself had some experience with the continuous bath in cerebrospinal men. In the year 1872 hydrostat. 1873 we had an epidemic of cerebrospinal meningitis in New York.
While in charge of a large hospital then I attended twelve cases at one time. The mortality during that epidemic was not great, certainly much less than during the present epidemic. Our experience was that medicines like iodids, bromids, and morphine, which we prescribed for a while, seemed to have no perceptible influence on the course of the disease nor even on the symptoms. We were well satisfied, however, with the effect of the continuous warm bath. Our method was to place the patient, as soon as he became delirious, into the bathtub, the temperature of the water was kept at about blood heat or one or two degrees less, and we left the patient in the water, with an ice bag on the head, until he became calm, or until he fell asleep. This took sometimes two hours, sometimes as long as six hours, and the bath had in some cases to be repeated several times a day. The diet was regulated according to circumstances; in all cases, we gave stimulants generously when the temperature was high, and it was on average very high, 107° F being nothing unusual. The principle in using the warm bath in cerebrospinal meningitis is to eliminate the products of inflammation and infection.