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.
INFLAMMATION AND ANTIPHLOGISTIC EFFECTS
AND PRACTICE OF HYDROTHERAPY FOR STUDENTS AND PRACTITIONERS OF MEDICINE
Prof. George Knapp Abbott
Before considering the conditions present in inflammations and their treatment, it will be well to understand the principles involved in the production of certain circulatory effects which are much used in the treatment of inflammations. We shall, therefore, first turn our attention to the methods and principles concerned in the production of depletion and fluxion.
Depletion is the reduction of congestion in a given part or organ.
Derivation is depletion secured by the withdrawing of blood from an organ or part of the body by increasing the amount of blood in some other part. Practically, it is the reduction of congestion (and inflammation) by drawing the blood from the part congested into some other part. There is produced a collateral hyperemia with local anemia.
Fluxion consists in increasing the rapidity of the blood current in a particular part, and consequently, the total amount of blood passing through that part in a given time. It is the production of arterial hyperemia.
There are three practical methods of securing depletion: first, by the application of heat alone; second, by the application of cold alone; and third, by the application of both heat and cold applied simultaneously.
Simultaneous Heat and Cold: Depletion is most effectually secured by the simultaneous application of both heat and cold in the following manner. A large very hot application is made to a distant part; in many cases, it extends up to and includes the congested part. At the same time an ice bag, ice pack, or ice compress is placed directly over the inflamed organ. In this way collateral hyperemia is secured and the local anemia reinforced by the direct or reflex vasoconstricting influence of the ice. The local anemia is made extreme by both a "push and a "pull" effect on the circulation, the "pull" being secured by the vis a fronte of the hot application, and the "push" by the vis a tergo of the reflex contraction of the blood vessels, due to the cold application over the part. The most effective derivation is secured by direct contact of the body with hot water. A hot leg bath is more effective than a hot leg pack, and a hot leg pack with the wet blanket applied directly to the skin is more effective than where a dry blanket intervenes. Neither the local hot air bath or the local electric light bath (or either as a general application) are as effective as a hot pack or a local hot bath. The reason for this difference is found in the fact that the blood vessels dilate to a much greater extent under the action of hot water applied directly to the skin surface. The hot air bath and the electric light bath may produce more profuse perspiration, but the blood vessels do not dilate to the same degree possible under the action of hot water. However, in the case of a very hot full tub bath and a hot blanket pack, the surface derivation is so extreme in the former case as to cause fainting when it is first entered, with congestion of the brain later on because of the general rise in blood pressure. For this reason, the full tub bath for extreme derivation is not a practical application, and in practice we use the hot blanket pack with the continuous application of ice to the head and neck and also to the heart if necessary.
Precautions: In order to maintain collateral hyperemia, the treatment must be concluded with such a vigorous tonic measure as a cold mitten friction applied to the part previously covered by the hot application. The hot application alone produces passive dilatation of the blood vessels. If the treatment is stopped here, the circulation will soon equalize itself, or even a worse internal congestion may occur. The cold mitten friction, however, prduces an active dilatation (alternate dilatation and contraction) of the blood vessels, thus maintaining for a longer time the derivation secured by the hot.
Depletion by Heat Alone: In some cases sufficient blood can be withdrawn from a part by applying heat over the cutaneous branches coming from the artery supplying the deeper congested part or organ. In this case the larger flow of blood is diverted into the cutaneous (and superficial) branches, leaving less to pass to the deeper branches. Examples of this are found in the treatment of:
1. Pleurisy. Large fomentations to the chest divert the blood flowing in the intercostals and internal mammary arteries from the pleural branches to the posterior, lateral, and anteriour cutaneous branches.
2. Renal Congestion. Large fomentation over the lower dorsal and lumbar spine the entire width of the back. This diverts the blood from the renal arteries to the lower intercostals and lateral lumbar branches of the aorta.
3. Simple Spinal Congestion. Large fomentation over the spine divert the blood from the spinal arteries to the posterior cutaneous arteries supplying the skin and muscles of the back.
4. Congestive Sciatica. Large fomentations to back and side of thigh divert the blood from the nerve to the skin
5. Trigeminal Neuralgia. Fomentations to side of face divert the blood to the skin. This may be reinforced by the use of an ice bag over the carotid, thus mechanically lessening the total volume of blood going to the head.
Precautions: In pleurisy and neuralgia, cold increases the pain, hence cannot be used over the seat of the pain.
Depletion by Cold Alone: In a few conditions, a congestion or inflammation may be sufficiently reduced by the use of ice or other cold applications applied directly over the part or over the artery supplying the part, without the addition of collateral heat. In acute articular rheumatism and other acute infectious arthritides this method is most effective, in fact in our experience, almost specific.
When hot and cold applications are used to secure depletion, they are used simultaneously and to different areas. If the hot and cold are used alternately and to the same area, the result is fluxion. This may be either by direct effect in the part treated, or by reflex action in a related part. This effect is intensified by friction or percussion.
All alternate hot and cold applications are tonic, both locally and generally. We may here, for the sake of clearness and brevity, confine ourselves to the consideration of measures desired to produce chiefly violent circulatory reaction in a given part or organ.
The following are the principal means used to produce fluxion:
hot and cold, using fomentations and ice, or fomentations and cold compresses
In all the above measures, the condition produced is that of active (arterial) hyperemia. The alternate dilatation and contraction of the blood vessels is stimulated. This condition is known as active dilatation. These alternating changes of vasoconstriction and vasodilatation are more rapid and extreme than the normal. They very markedly increase the number of white blood cells in a given part, and consequently the resulting phagocytosis. It is this which makes it especially valuable, and almost indispensable in some acute congestions and inflammations, such as an acute infection of a hand or a foot, where lymphangitis and lymphadenitis are likely to follow so quickly.
Revulsion: According to Dorland, this term is synonomous with derivation and depletion. Kellogg evidently uses it to designate the mode of giving a hot and cold application, the chief effect of which is fluxion, for example, a revulsive compress- a treatment consisting of a single prolonged hot application, followed by a single very brief application of cold.
Again, it is used to designate derivation secured by collateral fluxion, as in the use of the hot and cold foot or leg bath, or a hot and cold percussion douche to the feet and legs to relieve cerebral congestion. When hot and cold are alternately applied to one part of the body, thus producing fluxion in that part, it will withdraw more or less blood from other related or distant parts. This diverse application of the term has led to no little confusion. While the term cannot be fully dispensed with, the student should bear in mind that the effect is that of either derivation or fluxion.
Pathogenesis of Inflammation
"Inflammation consists of the series of changes constituting the local manifestation of the attempt at repair of actual or referred injury to a part, or briefly, it is the local attempt at repair of actual or referred injury. Inflammation is the reaction of irritated and damaged tissues which still retain vitality."
The pathologic conditions in an inflammatory process may be partially understood by the five cardinal symptoms, viz
The primary cause of the inflammation, whatever it may be, is responsible for these conditions, which are largely circulatory disturbances. The condition in the acute stage is one of (1) arterial hyperemia with (2) serous exudates, and (3) an increasing number of leucocytes in the blood stream and tissues; from the latter, they return to the blood stream less rapidly than normal. (4) The inflamed part is bright red. (5) The pain is severe and often throbbing in character because of the increasing tension on the nerves caused by the swelling.
In the chronic stage, the condition is one of (1) venous congestion (passive hyperemia). (2) There is a beginning organization of the exudates, and (3) a dearth of leukocytes. (4) The part is of a dark red or bluish color. (5) The pain is less severe, and described as dull and heavy in character. In the intermediate stages, the inflammatory process passes gradually from the first to the last condition. The circulation begins to be slowed, and more and more blood accumulates in the capillaries and veins, less arterial blood being present, so that the total amount of blood in the organ is increased above normal. The severe or throbbing pain gives way to the more constant, but less severe, dull pain.
PRINCIPLES OF TREATMENT
In the acute stage, (1) limit the congestion, (2) hasten the absorption of the exudates and prevent further exudation, (3) energize and assist the phagocytes in combating the infection or noxious agent, (4) relieve the pain. While inflammation is a protective process, it must not be supposed that it is always well regulated, or able, unassisted, to cope with the disturbing cause.
The serous exudates of this stage consists of a more concentrate lymph than normal, i.e. a lymph containing more proteins, which doubtless serve for the nutrition of the cells necessary in the regeneration of tissue which follows. It is necessary only to limit this to a proper amount and hasten its return to the blood and lymph vessels when its work is done. This means the restoration of the proper rate of exudation and absorption and is applicable to the leucocytes as well as the fluids.
In the chronic stage, (1) stimulate and quicken the circulation by the production of arterial hyperemia, and (2) stimulate the process of phagocytosis, thus (3) promoting resolution and absorption of the exudates and thereby preventing its organization.
In the acute stage of an inflammation, i.e. during the first few hours or first day or two, extreme cold should be used over the part continuously, or with only short intermissions, in order to lessen the congestion, relieve the pain, and, if possible, thereby abort the inflammation. In many cases it is necessary to reinforce the continuous cold by hot applications to collateral areas (derivation) in order to effectually reduce the congestion. The cold energizes the white blood cells, increasing their number and efficiency in the destruction of bacteria, and hastens their return to the blood stream.
After the acute stage has passed, i.e. at the end of a few hours, or on the second day, the cold applications should be replaced by a heating compress; or, if cold compresses were used in the first stage, it is only necessary to leave them on, thus making a heating compress. These cold and heating compresses should be replaced at intervals of one to three hours, using short fomentations when the change is made.
As the inflammation progresses toward the chronic stage, more heat and less cold should be used. After the acuteness of the inflammation has entirely subsided, the most vigorous hot and cold applications should be used in order to lessen venous stasis and bring to the organ a greater supply of fresh blood (fluxion), for the time producing an arterial hyperemia. It is possible to use fluxion even immediately following the first few hours of some inflammations, provided they are not in a dangerous area, i.e. where rupture would prove fatal or produce serious complications.
It has been shown that in some cases the maintenance of a high external temperature is conducive to a more rapid and benign course of the inflammation than where cold is used. These are doubtless cases of inadequate reaction as suggested by Adami, better results being due to the increased amount of blood brought to the part. In the majority of cases still greater benefit results from the use of alternate hot and cold applications, since these produce an arterial hyperemia which has no after-tendency to stasis.
The stage of inflammation may best be judged by the color. A bright red color is evidence of an acute process, and a dull red, dusky, or bluish color, of a chronic process. Inflammations in certain localities should be treated by hot alone, until after the first stage is passed. This is true of pleurisy.
"For antiphlogistic purposes, it may be safely held that in the early stage of congestion, cold applications are useful so long as the circulation in the affected part is still open, which is indicated by the turgor. But when the parts assume a cyanotic hue, when leucocytes have begun to adhere in large numbers to the vessel wall and emigration has become active, applications of warmth futher the later and hasten suppuration when it is unavoidable. The cold compress diminishes congestion, retards leucocytosis and emigration of white cells, while the warm applications have the contrary effect, each being most useful in the respective stage of inflammation.
"The antiphlogistic effects of cold compresses are readily explained by the results of Genzmer's experiments upon local blood letting. He came to the conclusion that the favorable effect of bleeding upon the inflamed parts beneath was ascribable, not to their becoming more anemic, but to the fact that the blood stream became more rapid, and thus the corpuscles which had adhered to the vessel walls were loosened and driven into the general application. The fluxion, therefore, which the application of cold or warm compresses produces, in the parts below them, is the true cause of the changes in the latter when inflamed. Thus may the old theory of derivation be satisfactorily explained.
"This effect of cold applications may be called into action in some local inflammations in which the parts appear cyanotic and it is important to prevent impending suppuration. Here hot compresses or cataplasms are also useful to arouse the surface circulation; as they cool off, they widen the deeper vessels and thus reestablish the circulation which has become stagnant. This being accomplished, cold compresses may succeed the hot, in order to limit leucocytosis and, by fluxion, remove stagnant corpuscles. It is evident that by the exercise of sound judgement, the proper temperature of the compress may be nicely adjusted to each case."
It must not be supposed that circulatory changes are the only effects produced by the treatment outlined above. Proper regulation of the circulation by means of heat and cold also stimulates the cells concerned in the healing process.
From the above, we may draw the following conclusions, as in general, applicable to inflammations. During the acute stage, the treatment should be directed toward the reducing of the congestion, whether by collateral heat alone, or by heat assisted by cold over the part, or by cold alone. The philosophy of the treatment is summed up in the word depletion, as understood in its broadest and practical sense, i.e. the reduction of congestion. In the chronic stage, all the pathologic indications are met by the producion of fluxion.