This article is taken from book by prof. George Abbott, published in 1914 in USA. We would like to present it to the bigger group of readers, especially when it is very difficult to be found anywhere. Therefore we took this opportunity to present an interesting matter as seen back in 1914. Still some parts of this article are valid, and hydrotherapy as presented here is being used in spa treatment.

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THE CIRCULATION-HYDROSTATIC EFFECTS

PRINCIPLES AND PRACTICE OF HYDROTHERAPY FOR STUDENTS AND PRACTITIONERS OF MEDICINE

Prof. George Knapp Abbott

Published 1914

 

Not all of the circulatory effects occurring in organs and parts distant from an application can be explained by reflex action. In fact, many of the effects produced by hydriatic applications are quite contrary to what we might expect, were the results due alone to reflex stimulation. When Schuller, in the course of his experiments upon trephined rabbits, placed a sponge dipped in cold water (52 F) upon the trunk of a peripheral nerve, he observed narrowing of the pial vessels. This was the same result as that obtained by pieces of ice applied to the dura. In both, there was vasoconstriction of the vessels of the pia; and we have seen that, by reflex stimulation, the same effects are observed internally as occur externally in the skin area treated. But when he applied to the belly or back of the rabbit, a wet compress of the same temperature, it always produced a prolonged and decided dilatation of the pial vessels, just opposite to the effect obtained in the first experiment quoted, and which we know was due to reflex stimulation. Again, he found that the application of warm water to the nerve trunk produced dilatation of the vessels, while warm water applied to the general skin surface by immersion, produced a narrowing of the pial vessels. Since these effects are directly opposite, both cannot be explained by reflex action. Moreover, Schuller observed that immersion in warm water produced a more decided narrowing of the vessels than a warm compress; and immersion in cold water, a more decided dilatation of the vessels than a cold compress. These effects were in exact proportion to the extent of surface immersed. When the ears of the animal were kept out of cold water, they likewise filled with blood in common with the pial vessels,but when they were also dipped into the water, the vessels of the pia filled still more.

The explanation of these contrary effects is quite obvious and will occur to anyone acquainted with the principle of hydrostatics. When the warm compress was applied to the animal, the cutaneous vessels filled, thus increasing the flow of blood to and amount of blood in the skin area treated. This left less blood to flow to the brain and, in consequence, the blood vessels of the pia were less completely filled. When a greater surface was treated, as by immersion in warm water, a greater number of blood vessels were dilated and much less blood left to flow to the head, resulting in an increased narrowing of the pial vessels.

Considering the experiment with the cold compress and bath, we have the same underlying principles. The cold compress produced blanching of the skin and a decreased amount of blood in the periphery, with a resulting incease in the filling of the blood vessels of the brain because of retrostasis.

Schuller observed that rectal injections of cold water always produced some dilatation of the vessels of the pia. These effects have been confirmed by the experiments of Vinaj, Naumann, Winternitz, and others.

That these results are hydrostatic or mechanical, and not reflex, is also confirmed by the changes in blood pressure observed at the same time. In dilatation of the blood vessels due to vasomotor action, there is a fall of blood pressure. Quite the opposite occurred when the pial vessels dilated because of a cold compress or cold immersion, i.e., a decided rise in arterial pressure. This we know is associated with vasoconstriction and cannot, therefore, be due to paralysis of the vasomotors. But when we consider that the cold application produced blanching of the skin and vasoconstriction over quite a large area and consequently an increase in blood pressure, the whole process is quite apparent. The retrostasis and increase of blood pressure causes the cerebral vessels, which are not under the influence of the cold, to fill in order to accommodate the blood.

The opposite group of conditions prevailed with the hot application, viz., narrowing of the pial vessels with a fall in blood pressure. The same principles apply here as above, opposite conditions resulting from opposite causes. The hot bath produced afflux of blood to the skin through vasodilatation, with a consequent decrease in blood pressure, the cerebral vessels narrowed because of a relative anemia. If the narrowing of the pial vessels had been due to reflex action, there should have been a rise instead of a fall in blood pressure.

Schuller observed that prolonging the warm application produced an increasing
constriction of the cerebral vessels. This may be explained by the fact that a passive and extreme dilatation of the cutaneous vessels occurs where the heat is maintained for a long time. This is the effect of a long hot pack which, in practice, we utilize where decided derivation is desired.

The hydrostatic effects of both derivation and retrostasis have been demonstrated by Winternitz by clinical experiments. By means of plethysmograph, he determined the volume curve of the forearm during a hot sitz bath and also during a cold sitz bath. The cold sitz bath caused an increase in the volume of the forearm, due to retrostasis, consequent on contraction of the vessels under the influence of the cold water. In the case of the hot sitz bath, the blood vessels under the influence of heat dilated, and being more completely filled, caused a fall in the volume of the forearm because of the derivative effect.

Secondary Hydrostasis: When the cold applications were prolonged, Schuller observed the widening of the pial vessles give way after a time to narrowing. In the case of compresses, this change occurred after two or three minutes, with immersion after five to ten minutes. It is apparent to all that a cold compress, after two or three minutes, becomes a heating compress, because of the cutaneous reaction and hence, a warm compress, which brings about the narrowing of the cerebral vessels. The same is true of the cold bath. When reaction sets in the skin becomes reddened, its vessels are filled with blood, and the cerebral vessels contract. This secondary hydrostatic effect is of great importance in the practical application of derivative means.

A hot and cold percussion douche to the feet reduces cerebral congestion because of blood being drawn to the extremities by the reaction in the feet.

When congestion in an organ has been reduced by a hot pack, the derivative may be secured (made more lasting) by completing the treatment with a cold mitten friction, thus retaining the blood in the skin.

The Hydrostatic Effect of:

· heat- draws blood to the surface by derivation

· cold- primary- drives blood to the interior (retrostasis); secondary- draws blood to the surface (derivation)

Law of Antagonism: These hydrostatic effects are well recognized by physiologists. There is an antagonism between the vessels of the skin and viscera, between the internal and external vessels, so that, when the periphery is well filled, there is a relative anemia of the viscera, and vice versa. The so-called Dastre-Morat Law of Antagonism is thus stated by Sir M. Foster, “Moreover, the vascular changes in the skin are accompanied by corresponding vascular changes in the viscera (chiefly abdominal) of the reverse kind. When the vessels of the skin are dilated, those of the viscera are constricted, and vice versa; so that the blood ebbs and flows, so to speak, according to circumstances, from skin to viscera and from viscera to skin.”

These mechanical effects are necessarily produced solely by vascular connection and not by nerve connection. A reflex effect is an indirect or distant effect produced through nerve connection. A hydrostatic effect is a distant effect produced through vascular connection. The extent of this effect depends upon nothing so much as upon the extent of the surface involved, as was shown by the experiments with the compresses and baths. This action is not confined to the blood vascular system, but applies to the lymphatic system as well. A warm application which causes vasodilatation will, of necessity, draw blood from all other parts of the body; and conversely, a cold application, causing vasoconstriction, will, in the nature of the case, drive the blood elsewhere, principally to the interior. In either case, the blood is driven into or drawn from the deeper parts. In the normal body, these hydrostatic effects are more or less evenly distributed over the entire vascular system, so that the effect in any one part is not so marked. For example, a hot bath or pack in health draws the blood more or less equally from all the viscera; but in the case of congestion of some particular organ, that organ will be affected more than others by either derivation or retrostasis. A common example is found in the increase of pulmonary congestion, produced by cold drafts on the shoulders. In a healthy person, this might not result seriously, but in one susceptible to colds or with an already existing congestion, it may cause an extreme congestion in a very short time. In the same condition, a hot pack will draw proportionately more blood from the lungs than from other parts. Again, a large fomentation to the loins or a hot pack would, under normal conditions, withdraw from the kidneys only a small amount of blood; but when these organs are congested, there is a marked depleting effect manifest. The patient is bled into his own limbs and skin.

Not only may areas quite distant from a part be utilized for depleting that part, but in many cases skin areas nearby may be used to advantage. That this is not a new principle in therapeutics will be seen by referring to “leech” bleeding. It is directed that the leech be applied to the skin over the inflamed part. It sucks blood from the superficial branches of the same vessels that supply the deeper inflamed part. If, by hot applications, the arteries of the superficial set of branches be widened out, there will be less blood to flow into the deeper branches. Thus will a fomentation draw blood from a part nearby that receives its blood from the same large artery. Where there are large thick muscles under the skin area treated, the total vascular capacity of both, when filled to the limit, may produce a very decided derivation.

Areas for Derivation: The various viscera are mechanically related to superficial and other areas as follows. In most cases, these areas are utilized for depleting (derivative) effect, but the opposite condition (retrostasis) may obtain where these areas are chilled.

· The brain- blood may be withdrawn from the brain by hot application to the feet, legs, or entire lower limbs, also to the spine or entire surface of the trunk. It is not practical to utilize the emissary veins of the cranial circulation for this purpose, since the reflex effect in dilating the cerebral vessels would be greater than the depleting effect. In cases of severe sunstroke, the vasomotors are so unbalanced that even a hot foot bath may reflexly produce cerebral congestion rather than depletion, and must, therefore, be avoided.

· Spinal cord- congestion here, if not too extreme, may be relieved by large fomentation to the spine (entire width of the back). This diverts the blood from the spinal arteries into the posterior divisions of the intercostals and lumbar arteries, also by hot applications to the feet, legs, or the skin surface of the trunk. In cases of acute cerebro-spinal meningitis, it is best to utilize the more distant areas

· Eye- applications may be made to the forehead and side of the face, thus dilating some of the terminal superficial branches of the carotids, and depleting the deeper branches

· Middle ear and mastoid- by applications to the entire side of the head, also by very hot applications to the legs, addomen, and spine

· Pharynx and Larynx- by applications to the neck, thus depleting the deeper organs and congesting the surface vessels

· Lungs- the feet and lower limbs, skin surface of the trunk and hips, also the hands, arms and shoulders. Where the congestion is limited to a small area, as in circumscribed pleurisy, a fomentation may be used directly over that area. This dilates the posterior, lateral, and anterior cutaneous branches of the intercostals arteries, thereby withdrawing blood from the inflamed pleura

· Kidneys- the circulation in these organs is decreased by hot applications to the back, thus dilating the posterior branches of the lumbar and lower intercostals arteries, and leaving less blood to pass from the aorta to the renal arteries. In extreme congestion of the kidneys, it is necessary to utilize much larger areas, as the entire surface of the trunk, hips, and legs, or one of these areas alone

· Stomach- by large applications centering at the epigastrium, but extending over the lower chest and sides of the abdomen and well down over the umbilical region, also to the entire trunk

· Liver- by applications over the liver also to the lower dorsal spine of the right side, extending forward and covering the epigastric and umbilical regions. The skin area of the lower limbs and hips is as important, if not more so, than the nearer areas

· Spleen- similar to the liver, on the opposite side, also lower limbs

· Pelvic organs- bladder, uterus, ovaries, tubes, rectum, and prostate. To deplete these organs, two principal areas are utilized- first, the entire skin surface of the hips, pelvis, etc., as in a hot sitz bath or hot hip pack; second, the lower limbs, as in a hot leg bath or hot leg pack. Both areas may be utilized by the use of the hot hip and leg pack or hot half bath

The student who is familiar with the anatomy of the circulatory system will be able to figure out the vascular connections between the organs mentioned above and areas named with each. In nearly every case, it is quite obvious. These areas are of importance, not alone in ordinary congestion, but of almost inestimable service in actual inflammation of these parts, as shown later.