GENERAL RULES, PRINCIPLES, AND SUGGESTIONS RELATING TO THE PRACTICAL EMPLOYMENT OF HYDROTHERAPY

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John Harvey Kellogg, M.D., LL.D., F.A.C.S.
Fellow of the Royal Society of Medicine; the Societe d'
Hygiene of France; the British and American Association
for the Advancement of Science; Medical Director of the
Battle Creek (Michigan) Sanitarium

In the employment of water as a therapeutic means, it is first of all important to keep in mind the principle that it is the patient, not his disease, who is to be treated. The fundamental idea in hydrotherapy, as with all rational measures of treatment, is that the curative force resides in the body, and that the office of the physician, aided by intelligent and trained assistants and nurses, and by the cooperation of the patient, is to supply such conditions as will aid the natural forces of the body in combating the disease. It is hence of the utmost importance that the general plan of treatment adopted for the relief of any particular case shall first of all take into account the causes by which the patient's maladies may have been induced. These will usually be found to exist in some wrong habits of life, of which the patient himself may have been wholly ignorant, at least as regards their deleterious character.

All cases of chronic disease may be roughly divided into two general classes:

1. Those in which the seat of the disease is a local irritation of mechanical or other origin, such as eye-strain, catarrh of the nose, stomach, liver, or bladder; or in which there is a local mechanical or tissue injury, as in dilatation or prolapse of the stomach, floating kidney, displacement of the pelvic organs, ulceration of the stomach, etc.

2. Those due to a diathesis, or a constitutional condition, as in diabetes, obesity, migraine, neurasthenia, chronic uric acid poisoning, Bright's disease, and the various degenerations.

In order, then, to form an intelligent idea of the proper course to be pursued in the treatment of any given case, there must be a careful scrutiny of the causes which have led up to it, and of the exact pathological conditions existing. For example, in indigestion we must ascertain with accuracy, in order to employ the proper measures, whether or not a patient is suffering from apepsia, hypopepsia, hyperpepsia, or simple dyspepsia, and whether or not there exists so-called diminished sensory or motor irritability. Insomnia may be due to local irritation of some sort, to chronic toxemia, or to cerebral anemia or congestion. An anemia found present may be the result of a recent hemorrhage from a wound, of profuse menorrhagia, hemorrhoids, gastric ulcer, a surgical operation, a fever, tuberculosis, malaria.

GENERAL DIRECTIONS FOR THE USE OF THE BATH: Before beginning a course of general applications of cold water, careful investigation should be made respecting the condition of the heart, the nervous system, the liver, the kidneys, and other viscera, so that all contraindications may be at once apprehended and the proper allowance made therefor. It is also important to ascertain in each case a patient's reaction power by means of a partial cold bath of some sort, and by the dermographic test.

In very feeble patients, there may be sufficient nervous energy to react well when an application of cold is very limited in extent, but not enough to secure prompt and vigorous reaction when the application extends to the entire surface of the body; in such cases, the effects produced by the first bath should be carefully noted, and the prescription should be arranged in accordance with the indications thus obtained.
If any of the symptoms of imperfect reaction occur, those measures necessary to encourage reaction should be adopted, as elsewhere indicated. If the reaction is excessive, less strongly stimulating measures should be employed; that is, (a) raise the temperature a few degrees; (b) substitute a non-percutient form of bath for the douche, as a cold friction bath, a wet-sheet or a towel rub, a sitz, immersion, or affusion; (c) have the patient exercise less long or vigorously before or after the bath; or (d) follow the cold application by a short cool or tepid non-percutient application, as a wet-sheet rub or affusion at 75 or 80 F, cover less warmly in bed, or otherwise modify the vital processes which promote reaction.

2. After short, very cold applications, watch carefully for the appearance of the bright-red color which indicates normal reaction. If this does not, under vigorous friction, appear within one minure or less, it will usually be found wise to precede the cold application by the hot rain or jet douche, hot bath, steam bath, or some other general hot application. The hot application should be continued from three to five minutes, followed by a cold application, when a good reaction will be assured, even in patients whose power in this direction is quite limited. The application of heat in this manner greatly diminishes the unpleasant impression of cold applications, while at the same time promoting to a high degree the circulatory reaction. After a very hot bath it is sometimes well to diminish the shock resulting from the contact of very cold water by an intermediate tepid or cool application.

3. The Duration of Application: The lower the temperature of the water, the shorter should be the application. For very cold applications, the duration should be 1 to 5 seconds. The duration of the cool douche may be 10 to 30 seconds. Tepid, warm, and hot douches may be much more prolonged, especially when moderate pressure is employed. The duration may be from 1 or 2 minutes to 10 to 15 minutes. Very hot applications should be of moderate length, rarely more than one minute. When employed to reduce the temperature in fever, and for antiphlogistic effects, non-percutient, cool applications may be prolonged to 15 to 20 minutes.
The neutral bath may be continued as long as circumstances require. It may be made practically continuous for several months, if care is taken to regulate the temperature so carefully that thermic reaction is wholly suppressed. For sedative effects, from 30 minutes to 1 or 2 hours is the usual time required.

4. The Temperature of Applications: In general, it should be the constant aim to train the patient progressively to react to water at as low a temperature as possible, the temperature of the water being steadily lowered day by day.

5. The best and most durable effects are produced by short cold applications, frequently repeated.

6. Long cold applications may be too exciting by producing a too strong reaction, or the effect may prove to be sedative or exhausting instead of tonic. This is especially true of emaciated and anemic persons, and those suffering from sclerosis. In emaciated persons the amount of fuel for heat production is diminished, and the amount of oxygen taken into the blood is also below the normal standard; hence the calorific, or heat-making, powers are deficient and easily exhausted, so that a too prolonged cold application may result in an excessive loss of heat, as indicated by delayed reaction, prolonged chill, or the frequent recurrence of chill or chilliness after the application.

7. In persons suffering from nervous exhaustion, especially, the reaction ability of the nerve centers is speedily exhausted; hence the importance of making cold applications very short in duration.

THE THERAPEUTIC SIGNIFICANCE OF REACTION: The phenomena of reaction under physiological and pathological states is a subject which must be thoroughly understood by the hydriatist. Elsewhere, the rationale of reaction under physiological conditions has been fully explained; here the subject will be considered briefly from the standpoint of practical therapeutics.

First of all, it may be remarked that a large share of the therapeutic applications of water require either the production or the suppression of reaction, or the production of atonic reaction effects. Hence it is of the utmost importance not only that every patient should be carefully studied in relation to his ability to react at the beginning of a course of hydriatic treatment, but that the reaction of the system to each different procedures employed, and to each daily application,should be carefully noted, and any necessary readjustment of the prescription made at once. Hydriatic treatment must be under the immediate supervision of a competent medically educated person, and must never be left to the inaccuracies of a bath attendant, no matter how well trained.

CONDITIONS THAT CONTROL REACTION: The intensity of the reaction effects following a given application depend upon:
1. The method of application, especially whether percutient or non-percutient.
2. The temperature of the water.
3. The length of the application
4. The condition of the patient, whether (a) febrile or non-febrile, (b) weak or strong, (c) fat or thin, (d) rested or fatigued, (e) warm or chilly.
5. The ability to develop animal heat. 7. The condition of the nervous system at the time of the application.
8. Whether accustomed to cold bathing.
9. The mental state of the patient, whether apprehensive and fearful, or resigned, cheerful, and in a condition of mind to cooperate with the treatment.

It is well to recall that in cases in which a patient does not react well to low temperatures, the reaction effect desired may be encouraged by strong friction or by increased pressure if the douche is employed.

OSCILLATORY REACTION: Several oscillations of reaction are sometimes observed following a cold bath, each recurrent reaction being weaker than the preceding. These oscillations are doubtless due to the swift rush of blood to the skin during the first reaction, whereby it is rapidly cooled by evaporation from the moist surface which has perhaps been insufficiently dried, and also through the consumption of heat energy by its conversion into mechanical work by friction and exercise.

SUPPRESSION OF REACTION: While it is usually the aim to promote reaction, there are cases in which the suppression of reaction is of the highest importance. Sometimes reaction must be suppressed altogether- when sedative effects are desired, as in cases of fever, inflammation, nervous irritability or insomnia, burns, wounds of various sorts, and hemorrhages. The means by which reaction may be diminished or increased have been fully described elsewhere.

EXERCISE IN CONNECTION WITH HYDRIATIC APPLICATIONS.

From the days of the earliest cold-water cures, the importance of exercise in connection with water treatment, especially applications of cold water, has been fully recognized. Priessnitz kept his patients sawing and chopping wood a considerable part of the time when they were not occupied with the multitudinous drinkings, packings, douchings, cold plunges etc., to which they were subjected under the heroic regimen in vogue at Graefenberg. It is more than likely that a large share of the benefit obtained from treatment under the cold water-cure system was the result of the muscular activity required in connection with the routine of baths to which each patient was required to submit himself. Extended trips along the steep paths of the neighboring mountains and hard work at the wood-pile were required of all patients able to endure any considerable degree of physical exertion, those who were not able to exercise being considered too weak to be subjected to cold-water applications. No doubt many persons were damaged by the excessive amount of muscular work required of them; but as a large share of the patients who visited Priessnitz were persons of robust constitution who were suffering chiefly from the effects of high living, sedentary habits, and wine drinking, the measures employed were for the most part successful.

Exercise not only encourages circulatory reaction, but especially encourages heat elimination. It has been clearly demonstrated by experience that the temperature lowering which begins from five to fifteen minutes after a cold bath is continued and increased by exercise, so that the maximum diminution is fully half a degree greater with moderate exercise than without it.

EXERCISE BEFORE THE BATH: In persons able to take exercise, a sufficient amount of physical activity to produce slight perspiration before a bath favors the tonic effect of the application, and reenforces it to a very considerable extent. Care should be taken, however, to avoid profuse perspiration in feeble persons, for the result would be so great an expenditure of energy that both circulatory and thermic reaction might fail, producing a secondary chill and most unfavorable effects. The bath should be taken immediately after the termination of the exercise, and before there has been opportunity for cooling of the skin by evaporation, which takes place with great rapidity when the skin is exposed. If there must be even the slightest interval between the removal of the clothing and the administration of the douche, the body should be protected by wrapping in a blanket or Turkish sheet.

Exercise should not be sufficiently vigorous to induce excessive action of either the heart or the lungs, as a cold bath should never be administered when these organs are excited. The best forms of exercise are walking, Swedish gymnastics, bicycle riding, dumb-bell exercise, club swinging, self-resistive exercises, and moderate exercise with chest-weights.

Persons who are unable to take exercise may be prepared for a cold bath by massage, by vigorous friction, by manual Swedish movements, or by an application of heat.

A preparation by exercise, either active or passive, is to be preferred to a preparatory hot bath; but when necessary, the hot douche, hot immersion, vapor douche, Turkish bath, or best of all, the electric-light bath, may be employed. The electric-light bath is preferable to all other means of heating the skin, aside from exercise, for the reason that it quickly warms the skin, and does not produce a depressing effect. The douche should be applied before profuse perspiration has been induced.

Violent exercise should always be avoided, for the reason that the skin and the body become thereby so strongly overheated that the absorption of the surplus heat requires so prolonged an application of the cold douche or other cold application that the nerve centers are apt to be quite exhausted by the too strong reflex activities set up, especially in feeble persons, resulting in incomplete reaction and depression.

EXERCISE AFTER THE BATH: Imperfect reaction after the cold bath is in the highest degree injurious, and lack of knowledge as to how to avoid this exceedingly disagreeable and inconvenient accident is responsible for much of the prejudice existing against the employment of the cold bath as a hygienic or therapeutic measure.

Incomplete reaction not only frequently results in a secondary chill, but in successive chills or an almost continuous chill, not only for an hour or two, but often for several hours, after the bath. The hands and feet are cold, there is headache, not infrequently diarrhea, and other evidences of internal congestion, such as abdominal and ovarian pains, rheumatic pains in the joints, neuralgic pains in various parts of the body, vertigo, lassitude, and an increase of catarrhal discharge from the nose, throat, lungs, or other mucous surfaces,when there is actively present a catarrhal affection of these parts.

As a rule, exercise should always be taken after a cold bath when the patient is sufficiently strong to walk.

Reaction may be favored by covering the patient with blankets or surrounding him with hot-water bags or other means of artificial heating, or by his remaining in a warm room; but the reaction effects obtained are far less beneficial than those which result from exercise. The reason of this will appear when it is remembered that exercise favors thermic reaction, and that thermic reaction means activity, not only in the nerve-muscular thermogenetic apparatus, but in every cell and tissue of the body, and an exaltation of function.

The application of artificial heat, on the other hand, lessens thermic reaction by the atonic reaction effect which is connected with hot applications of all sorts. Thus exercise promotes the most efficient element of the reaction following cold applications when tonic and reconstructive effects are desired, viz., the thermic reaction, whereas artificial heat diminishes this most important factor.

Exercise immediately following the bath favors regular and complete circulatory and thermic reaction, thus increasing the fall of temperature, and making the bath more thoroughgoing and efficient in its effects upon the system. The fall of temperature produced by exercise following a cold bath may amount to nearly one degree Fahrenheit.

An interesting fact has been pointed out by Delmas, to which attention should be called in this connection. Increase of blood pressure, whether induced by exercise or other agents, ordinarily causes a slowing of the pulse-rate; but under the influence of cold, the increased blood pressure induced by stimulation of the heart and contraction of the peripheral vessels is accompanied by a quickened pulse.

The reason for this is obvious. When the blood pressure is raised by cold applications to the surface, nature increases the rate of the heart's action through the specific influence of cold upon the heart-regulating mechanism, so that an increased amount of blood may be carried to the surface, thus compensating, to some degree, for the diminished caliber of the surface vessels, and protecting the parts, so far as possible, from the evil effects of refrigeration. When reaction begins, and the blood pressure falls (though not below normal) with the dilatation of the surface vessels, the heart's action is slowed- the reverse of what ordinarily happens under diminished blood pressure.

The result of this slowing of the circulation is to delay reaction, which under ordinary conditions is desirable, for otherwise slight changes in the atmospheric temperature might result in excessive and exhausting perturbations of the nervous and vascular systems; as it is the purpose of therapeutic applications which promote reaction to produce systemic perturbations and metabolic and catabolic changes, it is desirable that the tendency to slowing of the heart's action , which sets in with the beginning of reaction, should be antagonized by means of exercise whereby the heart's action will be quickened and the blood promptly forced to the surface of the body.

The increased vascularity of the skin thus induced, encourages heat dissipation, and both thermic and circulatory reaction. If the exercise is moderate in degree, the heat elimination developed by it exceeds the heat production resulting from the muscular activity; but if it is too violent in character, heat production may be in excess of heat elimination, in which case there will be a rise in temperature, and the effect of the bath will be antagonized. It is thus apparent that exercise after a bath, in order to be effective and helpful, must be moderate in character.

Walking at a moderate rate for twenty to sixty minutes after a vigorous cold douche is the most generally useful form of exercise. Very vigorous exercise for a short time cannot, however, be substituted for moderate exercise for a longer time, for the reason that time must be allowed for heat elimination; besides, vigorous exercise for even a short time might, by overexciting heat production, place the balance between heat production and heat elimination on the wrong side, and thus occasion a rise of temperature, and to a considerable degree destroy the good effects of the bath. It is for this reason, in the author's opinion, that better results are obtained from reaction when the process takes place regularly and slowly, as has long been known to be the case from clinical observation.

There are, of course, cases in which cold applications are indicated, but in which the patient is too feeble to take the necessary amount of exercise by walking or by other means. In such cases, vigorous massage, especially friction and percussion movements, or manual Swedish movements and deep breathing, may be employed until the return of warmth to the surface, indicating that active reaction has begun.

Occasionally cases are met in which the patient is so feeble that he cannot react spontaneously, even by the aid of massage, and it is necessary to employ artificial means to assist the reaction. The patient should be wrapped in a Turkish sheet as quickly as possible after the bath, covered with blankets, and dried by vigorous rubbing underneath the blankets. The moist sheet should be removed, the woolen blanket placed next the body should be tucked carefully around each limb and close about the neck, and hot bags placed to the feet and the sides, extra blankets being thrown over all. The patient must be carefully watched by observing the condition of the skin of the face, and noting the pulse, and the hot bags and blankets carefully withdrawn as reaction sets in, so that excessive reaction with sweating may be prevented, as this will destroy the tonic effect of the cold application.

AVOID EXCESSIVE HEAT: A rule which was insisted upon by Priessnitz and which is quite universally followed by hydrotherapeutists, is that the sun, excessive clothing, heated rooms, and especially stove heat or other artificial heat, should be sedulously avoided after a bath. By this artificial heating of the skin the heat elimination and thermic reaction necessary for a general systemic vital perturbation, upon which the tonic and restorative effect of cold applications depends, are arrested before being fully developed by atonic thermic reaction.

Great care should be taken after a cold bath to avoid any circumstance or condition which will cause perspiration, which, when produced in any manner after a cold bath, is followed by an undesirable sedative effect, whereby vital resistance is lessened, the tonic effect desired is antagonized and the patient is exposed to the risk of taking cold.

Many times patients imagine that they have taken cold in a bath from the application of cold water, when the untoward effects are really the result of either incomplete reaction after the bath or a reaction accompanied by perspiration.

A THOROUGH SCIENTIFIC EXAMINATION NECESSARY AS A FOUNDATION FOR A HYDRIATIC PRESCRIPTION
1. A careful investigation of the urine is necessary in ever case, not merely for the determination of the presence or absence of albumin, sugar, blood, urinary casts, or other morbid elements, but for the determination of the coefficient of elimination of nitrogenous wastes. Careful note must be taken of the relation of the total solids to the urea, as an indicator of the relative activity of destructive tissue processes.
2. An examination of the blood is essential for a determination of the color coefficient, the blood-count, and the relative proportion of white and red cells. It is also important , in cases of anemia, to note the relative proportion of the different varieties of white cells. There is no means by which the blood-count and the quality of the blood can be so profoundly and so quickly modified as by the resources of hydrotherapy.
3. Headache may mean cerebral congestion, cerebral anemia, or simple sympathetic nerve irritation. Fever may be the result of toxins of bacterial origin, as in typhoid fever, pneumonia, septic infection; or it may indicate the presence of an excess of ordinary tissue poisons, or leucomaines, either from diminished excretion, as from cold, or from overproduction, as in exhaustion or fatigue fever from muscular exertion. Neurasthenic symptoms of various sorts may be due either to the presence in excess of nitrogenous wastes, the so-called uric acid diathesis, or sympathetic irritation arising from enteroptosis.
4. Every case must be carefully investigated with reference to the existence of pathological changes, either functional or structural.
5. The general physical state of the patient must be considered: Is he fat or lean? Is he weak or strong? Has he a thin or a thick skin? Is he a person of resolution and strong will, or a weak-willed, irresolute individual? Is he of a persevering, reliable disposition? or is he unstable, vacillating, easily discouraged? The treatment must be carefully planned with reference to all these considerations.

PHYSICAL COEFFICIENTS: It is of immense advantage to make a careful study of the patient's physical coefficients. By means of a graphic representation of the principal physical coefficients, more may be learned at a glance respecting the general vital capabilities and the physical peculiarities of a patient than by weeks of "cut-and-try" experience. The chief practical deductions to be drawn from physical coefficients are the following:
1. A high height-weight coefficient indicates an excess of reserve tissue or fat, and hence ability to endure reducing or spoliative measures, if otherwise indicated.
2. A low height-weight coefficient gives contrary indications as regards the prolonged use of tissue-wasting measures, though not forbidding their temporary or careful use.
3. A high strength-weight coeficient may indicate either a deficiency of fat or an unusual muscular development. This coefficient must accordingly be considered in connection with the height-weight and strength-weight coefficients.
4. A high strength-weight coefficient with normal height-weight coefficient, indicates a good foundation for thermic reaction to cold applications, a constitution not greatly impaired, nutrition well sustained.
5. A high strength-weight coefficient with high height-weight coefficient indicates the ability to bear vigorous reducing measures and a probable constitutional predisposition to obesity that ought to be combated by frequent sweating baths, followed by cold baths.
6. A high strength-weight coefficient, with low height-weight coefficient, indicates that with a deficiency of reserve tissue and hence lack of ability for sustained resistance to cold applications, there is at least fairly good vitality and power to effect a good reaction; but the cold applications must be short and not too frequent.
7. A low strength-weight coefficient with a normal height-weight coefficient indicates diminished muscular and nervous energy and the need of great care in the use of hydrotherapeutic measures. Very short cold applications will be best borne, especially douches with high pressure. Hot baths and all spoliative measures must be avoided, except in cases of toxemia in which short sweating baths accompanied by copious water-drinking may be employed, especially the electric-light bath; but care must be taken to follow the hot application with a short cold douche at high pressure.
8. A low strength-weight coefficient with a high height-weight coefficient indicates in general the need of spoliative measures, but small ability to bear general hot applications or sweating baths. There being good ability for sustained heat production, the patient should have frequent cold baths, with abundance of exercise. Sweating baths may be employed later, as the strength increases, and may be used at the beginning if very short, and not too frequently administered, provided the actual total strength of the patient is not much below the normal average for a person of his height, and provided also that the strength-weight coefficient is nearly normal.
9. A low strength-weight coefficient with a low hight-weight coefficient indicates a state of great debility and impairment of nutrition, little power to support either the sedative effect of hot baths or the calorification required by cold baths. Strongly tonic measures are needed, with careful avoidance of spoliative procedures; but the patient will tolerate cold badly and will be easily overstimulated. The very short hot douche will be invaluable as a preparation for the short cold douche. Neutral baths may be needed to encourage elimination without depression, also the cold hepatic and renal douches and the epigastric douche (cold in hypopepsia and hot in hyperpepsia).
10. The strength-height coefficient is a good indication of the general neuro-muscular condition of the patient. A normal or high strength-height coefficient indicates a good store of nerve energy and good power of circulatory and thermic reaction, the muscles being the seat of the most active heat-making processes. The nerve tone and muscular development are good, and, unless otherwise contraindicated, all kinds of rational hydriatic means will be well tolerated.
11. A low strength-height coefficient indicates a low state of nerve and muscular energy, little reaction power, and necessity for the use of all precautions in the arrangement of a hydriatic prescription. Tonic applications are specially needed, but any form of cold application must be preceded by a short hot application, preferably the hot douche or the electric-light bath. Strongly percutient measures must be used, or in the absence of a douche apparatus, cold friction or the wet-sheet rub may be employed. The patient should have vigorous rubbing after the bath to promote reaction, but should not be required to exercise very freely until the muscular power is considerably increased.

ADAPTATION TO INDIVIDUAL CASES: The patient's physical aptitudes or temperament must also be carefully considered. Is he phlegmatic, nervous, or sanguine? Is he afraid of cold water, or has he any idiosyncrasy against it? Has he good powers of calorification; that is, has he good ability to endure cold, or does he become easily chilled by exposure to cold air or water? Has he good reaction powers? Determine this by a simple test. Before prescribing treatment for a new patient, Priessnitz invariably made a careful examination of the skin, and was always present at the application of the first bath, noting carefully the intensity of the reaction produced and the rapidity with which it occurred. Although an empiric, he was a remarkably sagacious one, and his success was largely due to his acute powers of observation. For example, he reasoned that if chilling the feet will cause congestion and inflammation of the internal organs, there must be some important relation existing between these parts capable of use in the treatment of diseased parts. This he accomplished by studying and utilizing the principle of reaction.

It is impossible to make a routine prescription of hydriatic measures. These powerful agencies must be regulated with even greater nicety than medicinal agents, as the difference of a few degrees of temperature or a few seconds in the length of an application may not only negative the results expected, but produce results the very opposite in character, which, under some circumstances, might inflict irreparable injury upon the patient.

The patient's habits of life, - whether he has been accustomed to cold bathing and regular active exercise; what have been his habits as regards clothing, especially whether or not excessive clothing has been habitually worn; the length of time he intends to remain under treatment,- these and other kindred matters must be carefully considered.

SYMPTOMATIC TREATMENT TO BE AVOIDED: Before making a prescription in any case, it is also necessary to determine which most requires immediate attention- some urgent symptom, or the fundamental morbid condition which furnished the background for the pathological picture presented. In general, the treatment must be both palliative and curative. Patients generally need to be encouraged by the relief from distressing and annoying symptoms, even though the measures employed therefore may not be radically curative in their character; at the same time, which, if perseveringly used, may ultimately result in abolishing the symptoms altogether. It is above all things important to avoid falling into the error of making the course of treatment merely a running flight with the ever-changing symptoms presented in most cases of chronic disease.

Of all the so-called systems of treatment which have appeared and disappeared within the last century and which have been so prolific with novel medical ideas, " organopathy" has perhaps the least to commend it to rational consideration. Dyspeptics never get well by the treatment of their stomachs only; neurasthenics never get well by the treatment of their nerves alone. Equally futile is the exclusive treatment of the skin in most forms of cutaneous disease. It is the patient himself who is sick, not some circumscribed portion of his anatomy. The organ which seems to be the chief seat of the disorder is simply that portion of the body which, being the point of least resistance, suffers greatest disturbance of structure or function, or both, and thus becomes the medium through which the morbid condition is most distinctly expressed.

Patients usually clamor for the relief of those symptoms which most urgently obtrude themselves upon their attention, and judge of their progress toward recovery by the extent to which a chronic pain, a palpitation, a gastric acidity, a chronic discharge, or some othe definitely recognizable symptom, is relieved by the measures of treatment employed.

The fact that certain symptoms, and, in particular, painful symptoms, such as neuralgia, migraine, and nervous attacks, which have been aptly termed "nerve storms," sometimes become more frequent during the first few weeks of treatment, often presents a perplexing problem to the inexperienced hydriatist, and occasions him much inconvenience because of the necessity of maintaining the patient's courage, so that he may be induced to persevere in his efforts. But that some patients under a course of treatment by physiological measures which are addressed to the removal of causes, the reconstruction of disordered tissues, and the reorganization of disordered functions, must thus pass through a period in which many symptoms and various functional disturbances appear to undergo a temporary exacerbation, is a matter of common observation.

EXAGGERATION OF SYMPTOMS UNDER TREATMENT: In French and German hydropathic establishments the more experienced patients often encourage novices with the remark, "You must expect to feel worse before you feel better." After carefully studying this question in thousands of cases during a quarter of a century of experience in the use of hydriatic measures, the author feels confirmed in the view which he formulated many years ago; namely, that this exaggeration of symptoms and the occasional appearance of symptoms quite new must be attributed to the intensity of the visceral activity set up by the strong stimulation of the sympathetic nervous system produced by hydriatic applications. This being true, it is evident that the increased intensity of symptoms occurring within the first few weeks after the patient begins a course of treatment need not necessarily be regarded as an indication that he is getting worse, or that his treatment does not agree with him. It is only an indication that the treatment is producing a powerful effect upon the system, and that a reorganization of functions and forces is taking place.

Haig has observed that when a highly nitrogenous diet is exchanged for a strictly non-flesh diet in a case of chronic migraine, for example, there is likely to be, within the first few weeks, an increased frequency in the occurrence of the paroxysms. This he explains by the supposition that a change in the character of the blood results in the dissolving out of the tissues of a larger amount of uric acid, which, being brought into the circulation, irritates the nerve ends with which it comes in contact particularly those of the sympathetic, thus giving rise to recurrence of the paroxysms.

This explanation seems rational, and the principle may aid us in explaining the exaggeration of other unpleasant symptoms which not infrequently occurs during the first few weeks of a systematic course of hydriatic treatment. Whatever the explanation may be, experience shows that if the patient can be induced to persevere, and the treatment is properly managed, the unpleasant symptoms soon disappear, and usually do not reappear, although it sometimes happens that they disappear in an oscillatory manner, being less pronounced at each reappearance until they finally pass away entirely. This is likely to be the case with such disorders as epilepsy, hysteria, periodical migraine, chronic malarial affections with intermittent paroxysms, and other maladies in which periodicity is more or less marked.

It is well to encourage patients to dwell less upon symptoms and to consider more the fundamental morbid conditions out of which they grow. Symptoms are noting more than the leaves and fruit of the pathological tree, the roots of which are deeply seated in the intimate recesses of the tissues, and consist in disturbed nutritive processes.

It too much attention is given to the treatment of symptoms, the result may be so great exhaustion of the vital resources of the patient that he will not be able to respond to the more thoroughgoing measures which look toward the actual eradication of his real malady.

WHY REAL PROGRESS MUST BE SLOW: In the organization of a plan of treatment in a given case, it is necessary to determine not only the course of treatment to be employed, but the length of each treatment and the number of daily applications, and the time of day when the applications should be made. The settlement of each of these questions depends upon the object to be accomplished by treatment, upon the mode of treatment employed, upon the strength and susceptibility of the patient, etc.

A general plan should be made also respecting the length of time during which the course of treatment is to be continued. If the patient can devote but few days or a few weeks to treatment, the plan employed may be quite different from that which would be pursued if he were willing or ble to devote a sufficient amount of time to render possible a more thoroughgoing renovation of his system and reorganization of his vital processes.

Patients should be made to appreciate the fact that in the employment of rational and physiological measures of treatment, the cooperation of the system is required; that whatever real progress is made is the result of a growth which takes place within the body, just as growth takes place in a tree or a flower. Recovery from a chronic disease is simply the growing out of a condition of disease into a state of health. Time is required for the development of health just as for the growth of a crop of grain. The physician tills the soil and plants the seed, to use an agricultural illustration, but nature grows the crop; and the patient must be content to wait for the harvest.

It may be said, however, for the encouragement of patients, that in not a small proportion of cases, immediate relief is experienced from those symptoms which have occasioned the greatest distress and inconvenience. There is certainly no therapeutic agent, or class of agents, which so promptly affords such real and permanent relief as may be obtained from the diversity of the resources of hydrotherapy.

If there is at first an increase in intensity of symptoms, it is usually due to the leaving off of opiates, hypnotics, medicinal tonics, and other remedies which have simply obscured the patient's condition by hiding his symptoms; in other words, by silencing the voice of nature, of which pain and a vast number of other symptoms recognized as evidence of disease, constitute the vocabulary. An opiate may cure a pain, but it does not remove the cause of it; and when it is withdrawn, the patient will of course be made to appreciate his real condition. The brief interval which elapses between the withdrawal of symptom-obscuring remedies and the amelioration of symptoms which come from the accumulation of hydriatic applications is sometimes a pretty severe ordeal for the patient to pass through; but with proper moral support and encouragement, he may be carried along until he begins to appreciate for himself that he is making real, not fancied, progress toward health, that the fetters of his morbid condition are being loosened, and that he himself is being reconstructed upon a sounder foundation- that he is growing out of disease into health.

If the patient can remain under treatment but a few days, or two or three weeks, perhaps the best that can be done for him is to teach him how to correct his wrong habits of life, how to adjust diet, exercise, work, etc., to the morbid conditions which exist in his system, how to employ such palliative means as will give him some relief, and encourage him to continue in a direction which may ultimately result in his cure. Moderately tonic measures may be added, but measures of treatment calculated to produce a high degree of perturbation, such as frequently repeated very cold applications, strongly eliminative treatment, and other powerful measures, should be used only with the very greatest care.

With patients who are undertaking a systematic course of treatment for tonic effects, applications should be made daily, in some cases twice daily, very rarely three times a day. In acute disorders, applications may be repeated hourly, or many times a day, as when antipyretic effects are sought, and in many instances continuous treatment is required, especially when local antiphlogistic effects are desired.

Patients should be taught that they cannot usually expect to realize the best results of treatment during the first few weeks. If there is no unpleasant exacerbation of symptoms, there may be no diminution in the intensity of the chronic symptoms for some time, a fact which is often a source of great discouragement to the patient.

It is astonishing, however, how obstinate and distressing symptoms will in some cases seem to disappear all of a sudden, after many weeks in which there has been no perceptible change for the better. In many instances, a patient who has been under treatment for several months without apparent relief, will arise on a certain morning entirely free from annoying symptoms which have been incessantly present for months or even years. Sometimes this result will take place after only a few weeks of treatment. In one case, a patient who had suffered for several years with pain in the back, after a few weeks' treatment, while bending forward one day, felt, as he expressed it, a sudden "letting up" in the back, and from that moment he was entirely free from the pain which had obstinately resisted the efforts of the most eminent physicians of the United States and Europe. And this relief was permanent.

It is not easy to explain what happens in a case like this; nevertheless, in this instance something did happen which brought deliverance to the patient; and the thing which happened was without doubt the sudden culmination of the beneficial effects which had been developed during the preceding weeks of treament. Chronic symptoms often yield to therapeutic blows persistently administered by the physician, just as does the rock to the sledge-hammer of the stone-mason. Even after long and persistent hammering upon the same spot, there may be no evidence of progress; but at the very next blow the rock may be shattered. It is true, however, that in a majority of cases gradually progressive relief from symptoms is experienced from the first.

It is very important for the permanency of the effects obtained that the patient under treatment for chronic disease should continue treatment until there has been a disappearance of all the symptoms of his malady, and not only this, but until the body has been so fortified by an increase of its vital resistance that the symptoms will not again return, provided, of course, that the patient pursue such a course of life regarding diet, exercise, and other matter of regimen, as his particular malady may require.

It is important for the physician, as well as for the patient, to remember that chronic disease is rarely entirely cured; in fact, we may almost say that a complete cure of a chronic malady never occurs. The symptoms may disappear, but the patient's constitution has been permanently weakened in certain directions, so that his condition is analogous to that of a steam-boiler which has been strained by overpressure. There is a weak spot somewhere,which is likely to give way, and it cannot be safely used except at low pressure. A person who once succumbs to the causes of chronic disease will ever afterward be liable to another breakdown of the same sort. Hence, he should sedulously guard himself against those causes which his system has lost the power to resist.

The chief benefits to be derived from a course of hydrotherapeutic or other rational treatment are the result of constitutional changes which require a considerable length of time for development, and consequently the best results of treatment are not experienced for some time, often many months, after it is begun.

Not infrequently, in fact, the patient does not really appreciated the full benefit which he has received until some months after the course of treatment has been discontinued. This however, should not lead the patient to abbreviate his course of treatment, which is almost certain to be quite too limited, but should rather encourage him to lay a broad foundation in a prolonged and thoroughgoing course, which may be expected to develop large and excellent results subsequently, when the processes of regeneration of tissue and reorganization of function have been completed by those natural curative forces within the body which it is the purpose of rational hydriatic treatment to organize and set in operation.

It sometimes happens that the prolonged use of tonic measures results in a condition of nervous weakness following a period of apparent marked improvement. In such a case, the treatment should be at once suspended or modified; but the same measures should be again employed as soon as the evidences of therapeutic overwork have passed away. Often patients feel so much improved, when such a suspension of treatment takes place, that they imagine that the treatment has been doing them harm, and that they are better off without it than with it. They should be made to understand that is but the ligitimate result of the therapeutic applications made, and that it is simply a foretaste of the greater improvement and permanet benefit which they wille xperience later as the result of the internal vital work which it is the purpose of the treatment to organize and maintain.

It is, most of all, important to keep always before the patient the great fact that disease is only normal vital energy manifested under abnormal conditions. When a sick person recovers, it is by the operation of forces within him, the same forces by which the ordinary processes of growth and repair are carried on. Nature, not the doctor, heals. The healing agency is within the man, not outside of him. No new force or principle comes into operation in the struggle of the body under the abnormal conditions which we call disease. The diseases itself is not the thing to make war upon; it is rather the causes of diseases which we should combat. The chief concern of the physician, then, should be to discover and remove the causes which have made his patient ill, and to aid, by supplying favorable conditions, the remedial effort which constitutes the pathological picture we call disease.

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