Physical remedies for disabled soldiers

Front matter

fiotoer UBMT

PHYSICAL REMEDIES FOR DISABLED SOLDIERS

Discharged Soldiers at Work at Holmes Chapel Agricultural College.

Preface

Within the last year physical methods of treatment in military cases have attracted considerable attention, and in one form or another have been adopted in many places throughout the country. Much progress has been made in introducing them, or improving their administration, in the Army Medical Service, in the Auxiliary Military Hospitals, and also at the British Health Resorts.

Any writer may well hesitate in face of so large a subject, for, indeed, its adequate treatment would require the combined knowledge of many specialists, — in Hydrology, Electro-therapeutics, Radiology, Mechano-therapeutics, Remedial Exercises and Training, and Medical Climatology. All these sciences are now growing so rapidly that it is evident there must be for many years to come a corresponding ^ development in medical practice.

Physical treatment is the convenient term which denotes the remedial use of these closely related physical forces. It may now claim to be a special department of Medicine, not in respect to the organs or diseases treated, but in respect to the remedies employed. The practitioner who at the present time chooses to devote himself to it will have a double reward, not only by making a sensible contribution to the vast problem of the restoration of the wounded soldier, but also by adding something of permanent value to medical science and art. I shall be satisfied if the present work may serve as a guide over rather unfamiliar ground, showing how certain valuable and closely allied methods of treatment may be utilized to the best advantage upon a basis of accurate observation and records.

I have to thank Major R. Tait McKenzie, of the University

X TREFACE

of Pennsylvania, for kindly contributing a chapter on Mechanical Treatment and Remedial Exercises; also Dr. Hernaman-Johnson for one upon the Electrical Treatment of Military Cases, and Dr. J. B. Mennell for another on the Clinical Uses of Massage.

For permission to reproduce portions of papers, drawings, maps or illustrations, besides those specifically acknowledged in the text, I gladly express my obligation to the editors and publishers of the Transactions of the Royal Society of Medicine, the Lancet, British Medical Journal, Practitioner, Clinical Journal, Journal of the Royal Army Medical Corps, and Paris Medical ; also to Sir Napier Shaw and H.M. Stationery Office, and to M. Leon de Paeuw, of the Belgian Government. An acknowledgment is also due to the well-known experts, Messrs. Shanks, for their skilful technical assistance.

For valued assistance and advice during the past two years, my grateful thanks are due to Drs. William Gordon, Septimus Sunderland and Campbell McClure, and the other members of the War Disablement Committee of the Section of Balneology and Climatology of the Royal Society of Medicine; and to Mr. Louis Allen and my other colleagues at the Red Cross Clinic for the Physical Treatment of Disabled Officers; also to my distinguished friends in the French and Belgian Army Medical Services, Drs. Camus, Quiserne, and de Marneffe; and, not least, to my daughter and constant helper in the preparation of this work.

R. F. F.

London,

CONTENTS introduction: physical remedies in general - - I

Part I. Hydrological Remedies And The Indications For Their Use

CHAPTER

I. REMEDIAL BATHS ------ ^

II. INDICATIONS IN SURGICAL CASES - - - "31

III. INDICATIONS IN SPECIFIC FEVERS - - - "39

IV. INDICATIONS IN NERVOUS DISORDERS - - - - 46 V. INDICATIONS IN CARDIOVASCULAR DISORDERS - - "52

VI. INDICATIONS IN RHEUMATIC AFFECTIONS AND ARTHRITIS - 59

VII. INDICATIONS IN DIGESTIVE DISORDERS, CATARRH AND TUBER- CULOSIS - - - - - - -63

Part II. Mechanical And Electrical Remedies

VIII. FORMS OF MECHANICAL TREATMENT - - - - 69 IX. MASSAGE, PASSIVE MOVEMENT, MECHANICAL TREATMENT AND

EXERCISE, BY. MAJOR TAIT MCKENZIE - - - 89

X. THE ADMINISTRATION OF MASSAGE, BY DR. JAMES B. MENNELL 12 2 Xi. ELECTRICITY AND RADIATION, BY DR. FRANCIS HERNAMAN-

Part III. The Provision For Physical Remedies

XII. PHYSICAL REMEDIES IN THE HOSPITAL - - _ . 167

XIII. THE PHYSICAL CLINIC ------ lyy

XIV. PHYSICAL REMEDIES, RE-EDUCATION AND WORK - - I94 XV. PHYSICAL REMEDIES AT THE BRITISH SPAS - _ - 237

XVI. BRITISH MARINE RESORTS AND CLIMATES. - - - 249

LIST OF ILLUSTRATIONS

DISCHARGED SOLDIERS AT WORK AT HOLMES CHAPEL AGRI- CULTURAL COLLEGE (l) GATHERING POTATOES. (2) THE

POTATO HARVEST ... - Ftofitispiece

Flli.

1. THE author's MEDICAL BATH THERMOMETER

2. THE SEDATIVE POOL BATH -----

3. DOUCHE ROOM AT THE MEDICAL BATHS AT TORQUAY

4. LOW PRESSURE DOUCHE APPARATUS - - - -

5. THERMAL AIR CHAMBER - - - - -

6. FRENCH EAU COURANTE BATH FOR THE LEG

7. FRENCH EAU COURANTE BATH FOR THE ARM

8. HEAT LIMITS FOR GROWTH OF PATHOGENIC ORGANISMS 9-20. APPARATUS FOR ACTIVE AND PASSIVE MOVEMENTS OF THE

JOINTS, DESIGNED FOR MILITARY CASES 72, 73, 76,

21-32. ACTIVE AND PASSIVE EXERCISES BY MEANS OF DR. E. J.

HIRTZ'S MOVEABLE PLATFORM - - - .

33. PULLEY-WEIGHT APPARATUS AT THE MILITARY ORTHOP-^DIC

HOSPITAL AT SHEPHERD'S BUSH - _ - -

34. BLIND MASSEUR ___..-

35. THE VIBRATOR __-_._

36. IRRITABLE SCAR, BEST TREATED BY DRY HEAT

37. ANCHYLOSIS DUE TO CONFINEMENT IN SPLINTS

38. MANIPULATION OF ANKLE-JOINT _ . . -

39. MACHINE FOR WRIST CIRCUMDUCTION - > -

40. FLEXION OF ANKLE (pASSIVE) _ - - _

41. TRIPLEX PULLEY- WEIGHT MACHINE - - - -

42. EXERCISES BY PULLEY-WEIGHT MACHINES AT HEATON PARK 43-45. MACHINES FOR EXERCISING THE FINGERS - - - 46, 47. WRIST MACHINES - -----

48. BICYCLE TRAINER FOR THIGH AND CALF MUSCLES -

49- HEELS RAISING BY THE AID OF STICKS - - .

50. SLOW DEEP BREATHING, WITH ARMS RAISING

51. KNEE-RAISING BY A SQUAD ON LIGHT PHYSICAL TRAINING -

52. • BALANCE EXERCISES - - - -

53. HIGH KNEES RAISING THROUGH WIRE ENTANGLEMENTS

54. GROUND -PLAN OF HYDRO - THERAPEUTIC DEPARTMENT AT

HEATON PARK COMMAND DEPOT - - - -

55. VAPOUR BATH - - - - - - -

xiii

77. 78 . 82.85

87 90

93 95 96

97 100

lOI

102-3 104

105 107 108

"5 119 120

168 169 xiv LIST OF ILLUSTRATIONS

FIG. pac;k

56. RECUMBENT VAPOUR BATH - - - - - 169

59. HYDRO-THERAPEUTIC HUT AND BOILER HOUSE AT HEATON

60. GROUND-PLAN OF DEPARTMENT FOR PHYSICAL TREATMENT,

MILITARY ORTHOPEDIC HOSPITAL, BANGOUR, MIDLOTHIAN 1 75

61. WHIRLPOOL BATHS AT THE RED CROSS CLINIC, LONDON - 1 79

62. SEDATIVE POOL BATH AT THE RED CROSS CLINIC, LONDON - I81

63. DOUBLE ARM BATH AT RED CROSS CLINIC, LONDON I WHIRLPOOL

OF AIR AND WATER - - - - - 1 82

64. THE author's GONIOMETER ----- 185

65. THE author's TORSIMETER FOR MEASURING SUPINATION AND

66. FLEXIMETER FOR ELBOW->OINT - - - - 1 86

67. THE author's FLEXIMETER FOR ANKLE AND WRIST - 1 87

68. fleximeter for fingers - - - - - 1 87

69. arthrodynamometer of AMAR - - - - 188

70. THE " DYNAMOGRAPHIC PEAR" - - - - 1 89

71. chart for recording movement of joints i dr. cololian i90

72. apparatus for measuring elevation of the shoulder

73. CARPENTERS AT QUEEN MARY's WORKSHOP AT THE PAVILION

military HOSPITAL, BRIGHTON - - - - 20I

74. ONE-ARMED LABORATORY ASSISTANT AT ETON COLLEGE - 203

76. WOUNDED MEN AT WORK IN THE REMEDIAL WORKSHOPS,

MILITARY ORTHOPEDIC HOSPITAL, SHEPHERD'S BUSH - 2o8

77. SPLINT-MAKER WITH STIFF ELBOW AT SHEPHERD'S BUSH - 209

78. PHYSICAL TREATMEAT AT JUVISY - - - - 212

79. 80. WOUNDED SOLDIERS WORKING THE LAND AT JUVISY - 213-4

81. HUTMENTS AT JUVISY - - - - - 215

82. VIEW OF THE INSTITUTE FOR RE-EDUCATION AT PORT VILLEZ 2X6

83. THE SCULPTURE ROOM, PORT VILLEZ - - - " ^33

84. GARDEN SPACES FOR THE MEN, PORT VILLEZ - - 235

85. MAP OF ISOTHERMAL LINES FOR DAY TEMPERATURES IN

JANUARY ------ facing 250

86. MAP OF ISOTHERMAL LINES FOR NIGHT TEMPERATURES IN

JANUARY ---__- facing 252

87. EFFECT OF SEDATIVE POOL BATH ON THE PULSE - - 272

88. HEALTH RESORTS CASE-RECORD CARD - - . - - 273

Introduction

Physical Remedies in General.

The object of these pages is a practical one. It is to collate and present in a convenient form the information which may be useful to those who are engaged in the treatment of soldiers and civilians — by heat and cold in baths, by electricity and radiation, by massage, mechanical apparatus, exercises and medical gymnastics, as well as by medicinal . waters and climate in the British health-resorts.

The physiological action of the various agencies employed will therefore be only incidentally referred to. No time will be spent in the discussion of theories, however interesting; and where, here and there, principles are briefly stated, it is only with the object of raaking the actual practice intelligible and consistent. Only such conclusions are advanced in this work as have been attested by the experience of good observers. For a more complete account of these agencies the reader is referred to the standard works on hydrology and balneo-therapeutics, medical electricity, and physical exercise. -

The care of vast numbers of wounded and invalid soldiers obliges the medical practitioner to explore and utilize many methods of treatment, some of which are unfamiliar, to find new remedies for new conditions, and often to apply old remedies in a new manner.

In particular, it has made it necessary to explore the group of remedies that are justly called " physical." The experience of soldiers in camp or in the field has shown how swiftly both mind and body respond to physical conditions. Hard exercise and exposure to the weather in the course of military training have in a few months transformed delicate and languid youths into vigorous men, ca:pable of withstanding the severest bodily or mental strain. Again, later on, in the field, these same men, reduced to an extremity of fatigue and exhaustion, have regained their elasticity and vigour in a few hours by the use of hot baths.

These are illuminating facts. They bring to mind some realization of the truth that the living organism exists in virtue of its continual contact with the energies supplied to it from without ; that it is possible to live poverty-stricken in a minimum contact with this energy, and that there is an optimum contact in which the powers of life reach their fulness. The appeal to physical agencies is a primitive quality of life. And since life depends upon them for its well-being and proper development, so it is that to insure an ample and sufficient access to these sources of energy, by which they may be brought into vivifying contact with each individual, becomes the duty of those who are charged with the health of the community.

This dependence and this appeal seem to be at a maximum in the early years of life, in the period of development. They are well seen in what is called the " physical education " of children. But they are also the cardinal facts which underlie the laws of hygiene,- and inspire the efforts of sanitation and preventive medicine. In adult age, and especially, perhaps, in the period of decline, it is necessary that civilized man should retain touch with the energies of the outside world; and the imperative need for daily " light and water and air " is now recognized in the case of populations crowded into cities, which too often bar their access to natural surroundings.

Passing across the hazy line that divides preventive from curative medicine, it must be admitted by all thoughtful persons that these same great and fundamental remedies are more employed and valued as their powerful action on the:

INTRODUCTION 3

body is understood. It is not too much to say that they now form a chief part in the recognized treatment of fevers and of tuberculosis, and of many chronic illnesses which respond to physical surroundings — to the influence of the fresh air and the rays of the sun, of heat, of cold, and of movement in wind and water. A little consideration will serve to make it plain that these physical agencies, so potent in their influence upon the human body in the period of development and in health, must have also an equally powerful operation and efficacy in the treatment of disease.

The physical forces are known to be closely correlated. It is questionable whether they ever act singly upon the human body. In the solar r^s Ught is combined with heat and with other invisible radiation extending beyond the violet and the red. So it is in a lesser degree with all kinds of artificial radiation baths. The different kinds of rays are in process of being disentangled, and their medical value and uses determined. In the case of baths, also, the effects of heat and of cold upon the skin are combined with those of moisture and pressure, and sometimes of movement, and of the gases and salts contained in the water, besides those belonging to its physical qualities, such as electrical potential and radio-activity. Again, it is well known that frictions and movements are accompanied by heat and electric currents*

These examples show how closely physical forces are related to one another, and also how intimate and complex are the relations existing between them and the recipient human being. To bring those energies into effective operation upon the disordered tissues and organs of the body is the task of physical treatment. And it has for its foundation nothing less than a true and philosophical correspondence — ■ dynamic remedies for a dynamic organism.

All this is more or less common ground, and it may seem unnecessary to emphasize admitted truths. The facts are obvious, but here as elsewhere it may be doubted whether the full significanu of familiar facts is equally plain. The more familiar the facts, the deeper and the more concealed is apt to be their meaning. The effect of cool fresh air in tuberculosis is one of a multitude of similar observations. Do these not unmistakably signify that there are laws governing the reaction of the human body to heat and cold, and that by virtue of these laws reactions may be produced in infective disease which increase the resistance of the tissues to invasion, and so check the extension of disease and favour the natural processes of cure ? Do not such observations prove that there is in truth a complete body of doctrine, much of it still undefined, that will hereafter determine the actions and uses of physical remedies ?

This is not the place to attempt to state or summarize, even in the briefest manner, the ascertained principles or laws which have been found to govern the action of physical remedies on the body. They relate to a department of medicine which is full of interest and but little explored, and presenting much opportunity for fruitful research. Although many facts are familiar, the science of physical treatment remains still in great part a terra incognita and a doctrina indpcta.

Their proved effect upon the human body in health and disease marks out physical remedies as worthy of searching examination. No superficial study of this or that isolated method of treatment is of any permanent value. It avails nothing to proclaim cold as a remedy in the nineteenth century, or heat in the twentieth. What is needed is a critical study of physical remedies as a whole, and this goes best of all pari passu with their practical application. Here as elsewhere clinical study is the most accessible and the most fruitful field for research. Observation by the trained observer, aided by instruments of precision, will not only guide the course of treatment, but gradually build up the science upon which the art of treatmemt depends.

The treatment of soldiers is in one respect a new experience, because many of these patients are fit and healthy, were it not, perhaps, for the crippling of a limb or a disabling stiffness in one or more joints. Their trouble, therefore, is

INTRODUCTION 5

entirely a local one, and it is obvious that only local remedies can be of service.

On the other hand, many men coming back from the field are seriously ill. Besides surgical and medical infections, they have wounds or disorders of the nerve centres. And the nervous injury is shown not only by many forms of paralysis and functional nervous disorder, but by disturbances of the circulation and nutrition. Among these invalids the trouble, whether infective or nervous, is partly general and partly local and both local and general treatment is applicable.

For both local injury and for infective or nervous disorders physical remedies may be brought to bear by the surgeon and by the physician, and often, as will be shown in subsequent chapters, from an early stage in the case.

Physical treatment has acquired a new value in two departments of practice which stand rather at the poles of medicine. Surgery is finding aid from many remedies of this kind, and these, instead of being reserved as a dernier ressort for convalescent homes and camps, are now employed from an early stage in surgical cases. And at the other medical pole the same class of remedies are powerfully assisting psychological treatment. It is a perfectly sound principle that one impression should be made to assist another. Persuasion, suggestion, the influence of one personaHty over another, which are everyday facts, sometimes depend for their efficacy upon associated physical treatment, which has a whole series of powerful impressions at its command, and can often act through the body upon the mind. How much of the way one walks by sight, and how far by faith, is after all a secondary [^matter, if the journey is accomplished.

Chapter I

Remedial baths are of two kinds, according to their degree of heat in relation to the human body. The division between them is the crucial point 93° F., which is the average temperature of the skin. Baths that are above this point of temperature increase the bodily heat, and those below 93° diminish it. It is important to recognize that baths of all descriptions are subject to this grand division into cooling baths and heating baths, and that to each of these two kinds belongs a separate group of actions and effects in disease. It must, however, be remembered that, while temperature is the chief property of a bath, its effect, cooling or heating, will sometimes depend upon the condition of the body or of portions of the body.

Classification by Temperature. 1. Cooling Baths. — Cooling baths have a range of temperature from 93° to 65° F, Immersion baths at a lower point of temperature are unsuitable to persons out of health. Baths of this kind are especially applicable to acute forms of disease, such as specific and other fevers. They may be applied in a great variety of ways, according to temperature and duration, and to the entire body or to portions of it. The application of water within a certain range of tempera-

I30t

I20t iiofl E

Ml z < i <

a uj ture below that of the skin (" cooHng hydrotherapy ") is a valuable form of surface treatment. It should generally be accompanied by frictions, particularly in conditions of weakness and where low temperatures are employed (see Chapter III.).

2. Subthermal Baths. — A particular group of effects belongs to baths having a temperature from 90° to 98° F. The skin heat in many parts of the body is often considerably below 93°, and therefore these baths very nearly correspond to the range of temperature between that of the skin and that of the blood. In all febrile states they are necessarily cooling in their character, but for persons of subnormal temperature they may be heating baths. It should be noticed that their degree of warmth corresponds closely to that of portions of the body, and that they tend especially to equalize the surface temperatures. Their effects (especially upon the nerve centres and circulation) are clearly marked off from those of baths at more extreme degrees of negative and positive heat.

The epithet " subthermal " serves to distinguish this important kind of medical bath. It is very necessary that this especial class of baths, with its limited range of heat in close relationship with the body, and with its definite group of physiological effects, should not be confused either by the medical man or by bath attendants with baths of any other kind; and therefore this name, although barbarous to Fig. I. ^ the purist, has obvious advantages over its Medical Bath natural rival. " Hypothermal " might easily Thermometer, in practice be mistaken for Hyperthermal baths, which are totally different in their character and effects.

Cardiovascular Baths. — Two important forms of subthermal baths must be here mentioned: (a) Cardiovascular

70-:

50-:

hJ

Z

: — Q o cc

Baths — that is, baths of a subthermal range, especially^ adapted for cardiac and vascular affections. There is a considerable variety of such baths, in all of which the temperature should be carefully adjusted to the individual reactions of the patient. The temperature is often lowered, and the reactive impression increased, by slow degrees during a course of such baths. Subthermal temperature in a watery medium may of itself serve to control a disordered cardiovascular action, both slowing and strengthening the action of the heart, and relieving spasm of the peripheral arterioles. But over and above this chief action of heat in the bath, a further action is produced by the addition of salines and gases. By such additions the effects of temperature may be considerably augmented and modified. The effervescent salt or muriated subthermal bath may be given in natural waters, or in water artificially prepared, with results that are similar, although not identical. There are no natural medicinal waters of this description in the British Islands, but cardiovascular baths are given at most of the British health-resorts. The salt waters of Droitwich' and Woodhall Spa are well adapted for them, whilst sea-water is used for the same purpose at Sidmouth and Torquay. Such baths form a valuable arm in the treatment, not only of disorders of the heart and circulation (such as the familiar " D.A.H." of soldiers), but in neurasthenia and in the convalescent state.

{h) Long-continued and "Pool" Baths. — When baths are given at the temperature of the skin, no impression of heat or cold is produced, and the bath may be continued for long periods. In such a case the human body, like that of an amphibious animal, exchanges a gaseous for a watery atmosphere. An equable, uniform, and unchanging sensation of temperature is substituted for the multitude of changing impressions which ordinarily fall upon the body; and to this the influence of moisture and the gentle pressure of the water must be added. The total effect is sedative,, which is shown in the action on the nerve centres and circulation.

In surgical practice such baths, local or general, are used for painful or unhealed and discharging wounds, and for septic poisoning. In medical practice they have a wide application, and at many spas having subthermal waters, like Loeche-les-Bains, long-continued baths have been in tise for many years.

Fig. 2.— The Pool Bath.

Sedative Pool Bath. — A sedative pool bath has been recently devised * and introduced for the treatment of wounded and invalid soldiers. Fig. 2 represents the pool bath erected at the Heaton Park Command Pepot. It can accommodate ten to twelve soldiers at once, who are seated in the water, which covers their shoulders. Water is constantly flowing through the pool, of which the temperature is fixed at 92° to 94° F. by a thermostatic valve. It is stated that the

* See "A Model Hydrotherapeutic Installation for Soldiers, with a Ground-Plan," and " Indications and Directions " for the use of the several treatments in military cases, prepared for the use of the Command Depot at Heaton Park in November, 1915, and pubhshed in the Journal of the Royal Army Medical Corps for May, 191 6.

REMEDIAL BATHS ii

pool has been used with marked benefit in many cases of disordered action of the heart. After a month to six weeks' treatment, hght physical training and light route marches have been undertaken without much discomfort. A pulse of 120 on admission, after a daily immersion of an hours' duration, soon slows down to 95 or 80* (see chart on p. 27).

A similar bath was installed in April, 191 6, at the Command Depot at Tipperary. Referring to the installation at Tipperary, Professor Sims Woodhead writes:

" We have had as many as 155 bathers in a day, with an average of 130; and more than half of these are treated in the pool bath, though we also use the shower, douche, and needle baths pretty freely. We use the pool bath principally for shell-shock cases, many of them doing exceedingly well under this treatment; though a few, who seem to have got into a lethargic condition, do better under a hot douche, followed by an almost cold douche or spray. A few of the shell-shock cases do not appear to get any benefit from the pool bath, but I must say that they are the exception. Most of them contend that they feel tired and sleepy afterwards; but this is just the effect that I now wish to obtain, for every man is sent back to his bunk for an hour's rest. They gradually form a habit of sleeping, which becomes more and more marked as time goes on, and with this the dream becomes a less marked feature. I think that the blood is drawn away from the nerve centres, and that it gives the vessels a rest, and allows them gradually to ' tone up.' "

The following notes on the use of long-continued baths have been kindly furnished to the author by Captain Edward Ryan, C.A.M.C., of the Rockwood Hospital for the Insane at Kingston, Ontario :

" I have had upwards of ten years' experience with the long-continued baths at the Rockwood Hospital. Our installation was the first of its character in Canada. This form of treatment has been especially serviceable in soothing and calming excited patients. In all cases where there is

* See " Hydrotherapy as an Agent in the Treatment of Convalescents," by F. Radcliffe, M.B., Brit. Med. Journ., October, 1916.

any manifestation of toxaemia, and in depressed cases, we have used the baths. In fact, we have found them very serviceable in the great majority of toxic cases. The temperature of the bath ranges from 92° to 96°, and the patients have been kept therein for five hours at a time, or even for ten hours a day for three or four days, after which the time would be somewhat reduced. The clinical effects noticed were slowing of the pulse, lowering of the temperature, equalizing of the circulation, lowering of the blood-pressure. It had a marked effect in calming excited patients. In maniacal depression with constipation, foul breath, loss of appetite, etc., the continued baths helped materially in clearing up the symptoms.

" At the Ontario Hospital at Orpington we have used these baths in cases of shell-shock. Two instances that I may mention will illustrate our work. One case admitted to the hospital deaf and mute was quite depressed. We gave him treatment in the continued bath covering a period of nearly two weeks. The patient recovered hearing and voice, gained in weight, and has left the hospital. Another case was admitted with marked excitement ; this patient was also deaf and mute, was very irritable, and would jump at the lightest touch. He was placed in the continued bath daily, and made a very satisfactory recovery. The patients at Orpington now realize the value of the bath, and take very kindly to the treatment.

" It has also been used in surgical cases for septic wounds. To illustrate : One case, a gunshot wound in the knee, became very septic, abscesses forming freely, dissecting the muscles both above and below the knee. He was placed in the bath when his condition was at the worst, and when there were marked symptoms of constitutional toxaemia. The wounds cleared very satisfactorily, the temperature fell, the patient's appetite markedly improved, although, unfortunately, we found it necessary, on account of severe haemorrhage, to amputate the limb."

Further references to the action of pool baths, and the indications for their use, will be found in subsequent chapters.

3. Thermal Baths. — These baths range in temperature from 98° to 105° F. Their action is to dilate the peripheral vessels and increase the frequency of the pulse, in proportion to their degree of thermality. They also stimulate tissue change (catabolism), and so in two ways increase the amount of heat in the body — that is to say, both by adding to heat production and by diminishing heat loss, since the body is immersed in a medium hotter than itself. It will be obvious that such baths — and this observation applies to all sorts of hot baths — open a wide door to possibly injurious effects. They have a clear and definite application and value in treatment ; but their effects must always be watched with care, especially as in a " course of baths " these effects are cumulative and rather insidious, and are very apt to be manifested at a later stage, some time after the treatment is concluded. The nature and symptoms of " thermal debility " cannot be further dealt with in this place; but the subject is of great importance, and should always be kept in mind by those who prescribe and administer bath treatment.

Thermal baths are employed when it is proposed to stimulate the circulation and increase the bodily heat, especially in many chronic disorders (rheumatic and gouty) — where the tissue exchanges are sluggish, the circulation languid, and there is a tendency to morbid deposits and effusions, as in most forms of arthritis and fibrositis — and in uratic disorders. There are grounds for thinking that under thermal treatment the catabolism of morbid tissues is stimulated more than that of healthy tissues. In the chronic disorders just mentioned, there are often foci of congested and subinflammatory tissue, and thermal treatment frequently causes in these an increase of reaction, with pain, swelling, and tenderness, an example of a morbid process being temporarily intensified (intensive treatment) and made more acute, and amenable to the natural process of cure. By increasing the circulation in the muscles, thermal baths, which may be accompanied by movement and massage {vide infra), are often helpful in paralysis.