d\6o t880 cV^4\\X- " i;^is«s^ ■■■■ "old Pack axd Massag ■IN THE Treatment of Anaemia. NLM Q01MD71fl 7 SURGEON GENERAL'S. OFFICE LIBRARY. P o Section, ...................... NLM001407187 V I * » ON THE USE OF THE COLD PACK FOL LOWED BY MASSAGE IN THE TREATMENT OF ANEMIA. MARY PUTNAM JACOBI, M.D. VICTORIA A. WHITE, M.D. NEW YORK G. P. PUTNAM'S SONS 182 Fifth Avenue 1880 W H |??0 With the Compliments of the Author ON THE USE OF THE COLD PACK FOLLOWED BY MASSAGE IN THE TREATMENT OF ANEMIA. TWAS led to use the cold pack in the treatment of spanaemia from the belief that it would tend to in- crease the rapidity of tissue metamorphosis; this would be expected to indirectly increase assimilation, and therefore promote absorption of nutritive material from the digestive canal. To test the correctness of this hypothesis, I analyzed the urine elaborated during the pack and passed immediately after, and compared its composition with that of urine ex- creted during other portions of the same day. The first conspicuous result of these analyses, was the demonstra- tion of a marked increase in the elimination of urea dur- ing the hours of the pack. From this fact I at first in- ferred that my hypothesis was justified, and that the characteristic effect of the pack was to accelerate tissue metamorphosis—to increase waste and the products of oxi- dation — thus indirectly promoting assimilation. But closer examination of the facts showed that this conclusion was too general, and that the real influence of the pack both permitted and demanded a more minute analysis. I regret very much that circumstances prevented me from combining these analyses of urine with the analysis of the blood by means of the hematimetre. This will be done in another series of cases. In these, the modifications of 2 ON THE USE OF THE COLD PACK. the anaemic condition were estimated by the ordinary clini- cal tests. When the urine was analyzed, the urea was estimated by Liebig's volumetric tests. In two clinical and two experi- mental cases, the analysis of the urine was carried farther, and a quantitative estimate obtained of the inorganic salts and of the organic material other than urea, including uric acid, and the substances sometimes classed together as " ex- tractive." The method for obtaining the quantitative esti- mate of the latter, was adapted from Neubauer and Vogel, pp. 149, 150.* In the three final cases no examination of urine was made, but the cases are recorded for the sake of the clini- cal results. Case i.—Miss A. B., set. 21, first seen May 8, 1878, Then in a profoundly anaemic condition ; weighed only 78 lbs., and was so feeble that she could with great difficulty mount the stairs, or even walk on level ground. The anaemia seemed to have initiated in repeated attacks of malarial fever. At first, menstruation had been very profuse, and recurred every three weeks ; this, doubt- less, contributing to the anaemia in which the menorrhagia origin- * The entire weight of the solid constituents of the urine was first calculated from the specific gravity carried out to four decimal points. The above calcu- lation is for 1,000 c.c. ; from it a calculation is easily made for 10 c.c. The amount of urea in 10 c.c. of urine was then ascertained by Liebig's test. Another specimen of 10 c.c. was evaporated to dryness over a water-bath, in a small, accurately-weighed, fine porcelain capsule with a close cover. This capsule was then placed on a triangle and heated until all the organic matter of its contents had been completely carbonized. Boiling water was then poured upon the contents of the capsule ; allowed to stand a little while and then filtered off through a weighed filter ; and this process repeated (the same filter always being used) until the carbonaceous mass was entirely freed from the soluble salts. The filter was then returned to the capsule, the latter cov- ered, and with its contents cautiously raised to red heat, when the entire car- bonaceous mass was consumed and disappeared. To the same capsule was now returned the solution of salts ; this evaporated to dryness ; the residue heated to red heat for a moment ; the capsule cooled over sulphuric acid and weighed. After deducting the weight of the capsule and of the ashes of the fil ter previously estimated, we thus obtained the weight of inorganic salts in 10 c.c. of urea. This weight was deducted from the total amount of solids calculated from the specific gravity ; the residue was the organic matter in 10 c c From this was again deducted the amount of urea estimated volumetrically '• the residue was the extractive. ' These amounts thus ascertained for 10 c.c. were calculated for the whole amount of urine analyzed. JACOB I AND WHITE. 3 ated. For eleven months there had been complete amenorrhoea. The patient had suffered for years from constipation, but during the last year this had become excessive ; on account of it the pa- tient had been several times treated by drastic purgatives, with the effect of making her condition worse. For about nine months the constipation had been complicated with a " membranous colitis." There were frequent discharges of the characteristic mucous membrane from the bowels ; on one occasion, after a colocynth pill, this membrane was tubular, and measured three- fourths of a yard. Associated with this was marked tenderness on pressure over the left end of the transverse colon and over the entire descending colon. The anorexia was extreme. There was much sleeplessness and nervous irritability ; a good deal of spinal tenderness to pressure existed. There was absence of respiratory murmur ; prolonged expiration and'dulness at the apex of the left lung. The treatment was at first directed toward the relief of the ob- stinate constipation and (probably) passive hyperaemia of the colon. The patient was directed to take cold water enemata, from 2 quarts to a gallon in quantity daily. A grain of tartate of iron and potassa was given every hour, together with minute doses of powdered ipecac. To avoid irritation of the intestine, and to secure nour- ishment by stomach absorption, the patient was placed upon milk diet and soups, containing a fixed quantity of Leube's extract. Of this, during the first fortnight, she took only a tablespoonful a day, together with one quart of milk. On June nth there was already considerable improvement. The enemata procured regular evacuations, in which were only shreds of mucus. The tenderness over the colon, also that on the spine, was quite gone ; the sleep was much better. On this day, while insisting on an increase in the food, the cold pack was first ordered, together with entire rest in bed. The pack was to be taken every other day, to last an hour, and to be followed by massage. The patient was to be enveloped first in the wet sheet, this surrounded by a dry one, and that by six blankets, the whole drawn tightly around her body. As the patient lived at some distance, the massage was performed by a woman procured from a bathing establishment, and, as I had reason subsequently to believe, the rubbing was quite inef- fectually administered. The benefit derived from the combined treatment was therefore much more attributable to the pack. On June 22d the patient reported that she was always very much 4 ON THE USE OF THE COLD PACK. tired on the day of the pack, but " felt splendidly " the next^ day. At this date was taking two quarts of milk besides the Leube's ex- tract, and felt a desire for ordinary food, as she had not done for 18 months. Weighed 84 lbs.,—gain of 6 lbs. since beginning of treatment, and of 2^ lbs. in the week following the pack and rest in bed. The patient stayed in bed for three months from June nth, re- ceiving the packs every other day, and continuing the rest of the treatment, upon whose details it is not necessary to dwell. Mixed diet was resumed on July 4th, but after an attack of diarrhoea a temporary return was made to the milk. The cold water enemata were replaced by enemata of lime water. On September 9th, patient still required enemata, and there was occasionally some mucus in the stools, but she announced herself as feeling " perfectly well." Had a good appetite, slept well, had no pains. Weighed 93 pounds, face full and colored. At this time perspired freely in packs. From this date packs and rests in bed were given up ; enemata replaced by small doses of tamar indien ; the iron and ipecac continued. The improvement in strength was so rapid that in a short time the patient could walk several miles. Menstruation recurred a year later. The patient has continued not only well but, to her own view, robust—certainly active, rosy, and stout enough for her age. The induration or collapse at the apex of the right lung entirely disappeared. In this severe case the complexity of the treatment adopted makes it a little difficult to estimate the precise share attributable to the pack. The prolonged rest in bed might by some persons be credited with the largest share in the recovery, since the essay of Weir Mitchell has so widely popularized the idea of rest in the treatment of anaemia. I think myself, however, that this rest was of the least consequence in the case. The girl never had been overworked in any way, hence the etiology of her anaemia was entirely different from those in which rest is so beneficial ; more- over, owing to her great debility, this patient had been in a state of nearly complete repose for two or three months before I saw her, from incapacity to choose otherwise. Yet her condition steadily deteriorated ; she was wasting away from slow starvation. In regard to the massage, I have reason to believe that it was not energetic enough to affect the muscles ; its influence was prob- ably confined to the skin. The iron was unquestionably of im- portance ; but, before the course of treatment above indicated the patient had frequently taken iron without benefit. Finally JACOB J AND WHITE. 5 the enemata may be supposed to have powerfully affected the cir- culation of the intestine, and to have acted synergistically with the cold pack in promoting absorption. Case 2.—Miss C. D., young lady of 25, profound anaemia with amenorrhoea, obstinate constipation, resisting purgatives, as podo- phyllin and castor oil, which were often employed. Two years before the first consultation, patient had had an attack of scarla- tina. After this, failed to menstruate for six months, then men- struated throughout the winter for another period of six months, then the menstruation ceased again and had been absent for a year. Associated with the obstinate constipation, was atonic dyspepsia ; and as a result of both the anaemia and the digestive disturb- ances it caused, the patient suffered from abundant acne simplex, which covered the face with comedones. She was ordered to take a grain of tartate of iron and potassa every hour : daily enemata of two quarts of cold water each : diet of milk and Leube's extract, and the cold pack followed by mas- sage every day. As a further corrective of the intestinal anaemia, belladonna tincture was given, gtt. v every three hours. The patient soon found that the combination of iron and bella- donna, when taken with the large enemeta, sufficed to obviate the constipation ; but that either of the three remedies alone was quite insufficient. The treatment was begun about October 1, 1878. On December 20th, reported considerable improvement. The amount of food had not exceeded one quart of milk and nine tablespoonfuls of Leube's extract a day ; but this seemed to be sufficient, at least for the conscious wants of the patient. There was no more distress after eating, nor pain in the stomach or bowels. The acne had improved, the face was less swollen, less blackened with comedones, of which there were, however, still an undesirable abundance. The patient at the beginning of the treatment had been thin ; but now, although feeling stronger, had become still thinner. The treatment was continued, but the enemata were reduced to a pint, which was now found to be suf- ficient, while the belladonna and iron were taken regularly. Meat was allowed once a day. On June 12, 1879, reported again. While above regime was followed strictly, remained quite free from dyspepsia ; with the least variation from it, however, food lay heavy and undigested in the stomach. The acne had nearly dis- appeared. The patient went to Europe in this month, and stayed until 6 ON THE USE OF THE COLD PACK. November. During this time all treatment was interrupted. Far from benefiting from the journey, she suffered throughout in- tensely from dyspepsia, and had several severe hysterical attacks. In January of the present year came to New York again for sys- tematic treatment. Cod liver oil was now added to the iron and belladonna. The cold packs were resumed, with massage much more energetic than she had previously been able to obtain in her own home. On being removed from the pack, each part of the body was rubbed with cold salt water previous to massage. After the pack and massage would always feel " furiously hungry." An effort was now made for the first time to reestablish menstruation by means of local irritation of the endometrium. For this purpose, at first, the anode of a galvanic battery was carried to the fundus of the uterus, and held there for a few minutes while a current was passed, just perceptible to the hand of the patient grasping the cathode. This application was repeated every day for a week, causing each time a slight oozing of blood, such as was never caused by the simple introduction of a steel dilator. A month later, the general treatment having been continued with marked benefit to both dyspeptic and hysterical symptoms, an application of iodine to the endometrium was substituted for the positive cur- rent of electricity. On the day following this application a men- strual flow set in, for the first time in three years, and lasted abun- dantly for four or five days. The patient was feeling extremely well and able to eat an ordinary mixed diet. She then returned to her home, with directions to continue the general treatment, and to return to New York for the local application in case the menstruation failed to return spontaneously. In due time she wrote to say that it had done so. As in the first case the treatment adopted was complex. The hydro-therapic treatment was reenforced by the administration of cod liver oil during the last and most successful months, and by the local irritation of the endometrium, which seemed to be the immediate antecedent of menstruation. In regard to the iron, however, the patient had made abundant trial of it before coming to me, but had never seemed to derive any benefit from it; dreaded it as tending to increase the constipation. The hourly administration of small doses of iron, with a view to saturating the hematoblasts,* was suggested to me * Term given by Hayem to young, imperfectly developed corpuscles, not yet supplied with a normal amount of haemoglobin. J A COBI AND WHITE. 7 by the well-known success of an analogous method in diph- theria, where the iron seems to act, in part at least, by averting a fatal impoverishment of the blood in its cor- puscles. In Case 3, the treatment was simpler, but followed by rapid and even surprising success. Case 3.—Miss E. F., aet. 16. Intense anaemia, with loud venous humming ; pallor of skin and mucous membranes ; various points of myalgia and of spinal .tenderness ; anorexia, great debility, constant headache, sleeplessness. First menstruation had appeared a year previous to date, then once again, four months later ; since then there had been complete amenorrhcea. The patient was ordered a grain of tartrate of iron and potassa every hour, a cold pack and vigorous massage every day. She reacted very well in the packs from the beginning ; per- spiring in an hour and a-half, an unusual circumstance with these profoundly anaemic patients. At the end of a week, there was already marked improvement, much less headache, some return of appetite and of strength ; sleep sound and refreshing, pains gone. At the end of a month patient menstruated spontaneously. The double treatment was continued for a month longer, then the packs were interrupted, the iron continued. The patient has since remained perfectly well, during a period of six months. In Case 3 the urine was analyzed for urea, partially be- fore and after the pack. Case 4.—Miss G. H., aet. 35, anaemia of long standing, general, and also markedly cerebral, resulting in violent headaches. Much spinal tenderness existed. This patient had been much over- worked, and in accordance with the indication furnished by this etiology, she was kept in bed during the duration of treatment, which lasted about six weeks and consisted exclusively in packs and massage. The patient's capacity for bearing the packs was very irregular, so that their mode of administration was obliged to be varied. Sometimes, instead of receiving a cold pack, she was, previous to the massage, enveloped in blankets for an hour, and then sponged off with cold water. During the first week the patient received the cold pack for an hour daily ; at the end of this time there was some increase of ap- petite, and the aspinal tenderness was much diminished. The 8 ON THE USE OF THE COLD PACK. estimations of urea were, through some misunderstanding, only be- gun on the seventh day of the treatment (December 28th), then, as seen by reference to Table I, the amount of urine was increased, the amount of urea lessened. From this date, however, the daily elimination of urea rose for a week, up to the day of menstruation when the packs were interrupted. This rise was associated with an increase in the amount of urine, but not exactly proportionate. (See Table I, January 3d to 9th.) The urea scarcely fell until the occurrence of a violent headache, on the third day of menstruation, interfering with ingestion of food. Cold pack was resumed on January 15th, and then, for the first time, the urine was collected just after the pack (the bladder hav- ing been emptied immediately before it), and its composition com- pared with that of urine excreted at other hours of the same day. Reference to Table I (January 15th) will show : 1 st. That the amount of urea eliminated both after the cold and after the blanket packs exceeded the hourly amount of an average day without treatment. (Compare December 21st.) CASE IV.—TABLE I. Date. Form of Pack Amt. urine in oz. Amt. urea in grms. Per hour, urine. Per hour, urea. Dec. 21st Before treatment. 35 19.404 .808 " 28th Jan. 3d Day including pack. 56 36 15-719 19.678 " 4th " 5° 24-375 " 5th " 46 24.144 7th " 8th " 9th Menstruation, inter- 49 58 23.887 24-559 rupting pack. 60 22.160 " 10th 41 23.622 " nth " 12th Headache for 24 hours 48 48 24-514 15.046 " 14th Headache continues. 5° " 15th Cold pack 1 hour,then ' " 24th Blankets 2 hours. For entire day incl. pack. Blanket pack, then 4-5132 1.4995 [cold pack] 1.506 [blankets] 18.730 0.677 [rest of day] cold sponging 3 hours 4.284 24.528 " 25th For entire day, Blanket pack and cold 1.714— 0.964 [rest of day] " 26th sponging 3 hours. For entire day, Blanket pack and cold 3.058 32-563 1.019 1.405 [rest of day] " 29th sponging 3 hours. For entire day, Blanket pack and cold 3-i87 25-153 1.062 1.046 [rest of day] 30th sponging 3 hours. For entire day, Blanket pack and cold 3-058 r9-795 1.019 0.707 [rest of day] Feb. 7th sponging 3 hours. For entire day, Partial [abd.] cold 1.512 17.850 0.504 0.778 [rest of day] " 9th pack 3 hours. For entire day. Partial pack 2 hours. 4.136 18.479 2.068 1-375 0.683 [rest of day] For entire day. 16.324 1.034 0.648 [rest of day! J A COB I AND WHITE. 9 2d. That the hourly amount for the rest of the day fell below this average amount, but only about one-fifth as much as the ex- cess was above it. 3d. That the hourly amounts of urea eliminated during the cold and the blanket packs, were sensibly the same. The patient continued to improve until the 24th, when she felt unusually well. A blanket pack, followed by sponging, was then substituted for the cold pack, in which she did not react sufficiently. The 24th, day of maximum Men etrc. was also the day of maxi- mum elimination of urea. On the 25th the amount of urea di- minished after the pack was diminished ; that for the rest of the day was increased, so that the amount during the two periods ap- proximated. This approximation continued during the following days until the 29th, and coincidently, the patient ceased to feel so well; had more headache, less appetite. On the 30th (see table) the urea eliminated during the pack fell even below that for the rest of the day ; in other words, the pa- tient ceased to respond, by the characteristic phenomenon, to the pack. On the following day intense headache and nausea developed in the pack, which was therefore interrupted. On the same day menstruation recurred. This was the first case in which it was made evident that the diminution of urea during the hours following the packs is as important an element of reaction as is thie increased elimina- tion during the pack. Any alteration of this sequence is followed by symptoms of malaise, of which the deviation from rule may be the cause of the consequence. After menstruation, treatment was resumed by means of the partial pack, i.e., the wet sheet was wound around the trunk of the patient only. The table (Feb. 7th and 9th) shows that increased excretion of urea still occurs; but the increase is not as marked as with the full pack when reac- tion is well established. At this point the treatment was obliged to be interrupt- ed, as the patient left the city. At the time of leaving she did not feel as well,as in the middle of January, and about a fortnight later she wrote that she "began to feel the bene- IO ON THE USE OF THE COLD PACK. fit of the treatment." That is to say, returning to precisely the same set of conditions as she had been among pre- viously, she found herself decidedly stronger, with less headache and backache and more appetite. As regards the immediate effects of the packs, may be noticed : 1st. The highest elimination of urea took place, not dur- ing a cold pack, as we had expected, but during a blanket pack, followed by simple cold sponging (1.703 grms. per hour, Jan. 24th). 2d. The next highest elimination was on the first day of the general cold pack (1.499 grms-> Jan> lS)- The patient being then placed in blankets for two hours, the amount of urea per hour was almost the same (1.506 grms.). 3d. The third highest elimination is on Feb. 8th, first day of partial cold pack (1.300 grms.). 4th. After a few days of either method in this patient, the amount of urea eliminated during the pack falls, and at the same time various symptoms of malaise occur, often beginning- in the pack, and continuing to increase, some- times to violence, after it. 5th. The influence of headache in reducing the elimina- tion of urea seemed to depend on the anorexia, sometimes absolute, which accompanied the headache, and prevented the patient from eating for many hours. The examinations for urea in this case, and the more complete analysis of the urine made later, were first done by myself, afterward by my friend, Dr. V. A. White, who submitted to a special preparation for the work. Case 5.—Mrs. J. K., an anaemic woman, aet. 41, with moderate sub-involution of the uterus (canal measures 8}^ cm.). But pos- sibly from some areolar hyperplasia, still more from the general anaemia, there had been absence of menstrual flow for two or three years, this being replaced by slightly sanguinolent leucorrhoeal discharge at the menstrual epoch. This was preceded for a week JACOB I AND WHITE. 11 by feeling of general nervous distress, and said to be attended by sufficient prostration to keep patient in bed for three days. The anaemia seemed to have originated in profuse lactation. Multiple vaso-motor disturbances, chills, flushes, ringing in ears, etc. Fre- quent diarrhoea, attended from time to time with discharges of membrane (membranous colitis, as in Case 1) ; appetite fair. The packs and massage were recommended for the anaemia, and to equalize the abdominal circulation. Large cold enemata were ordered for the colitis ; dialyzed iron every three hours ; koumyss ; general faradization at menstrual period as a stimu- lant. This patient was never able to bear the prolonged cold pack. In 15 minutes she began to be cold, and if the pack was main- tained remained cold in it, and chilly throughout the day. This peculiarity seemed to be connected with the chronic hyperaemia of the colon, causing, this time, not constipation, but diarrhoea. This morbid condition is so far analogous to the physiological states of digestion and of menstrua- tion, that with the dilatation of a large section of abdomi- nal blood-vessels, the dilatation of cutaneous blood-vessels, necessary for reaction to the cold pack, is often rendered CASE V.—TABLE II. Urea on five days without treatment of 1st month. Date. Amount in grms. per ct. Amt. per hour in grms. Amt. urine per hour in c. c. Oct. 7th " 8th " 13th " 17th " 20th 23.76 24.60 22.88 19.00 31.20 3-3 3-5 2.6 2. 2.6 0.990 1.025 o-953 0.791 1.300 30.00 30.00 37.66 39-58 56.00 average urea per hour =1.011 Total 121.44 5.059 Urea on five days without treatment of 2d month. Date. Amount in grms. per ct. Amt. per hour in grms. Amt. urine per hour in c. c. Nov. 1 st " 32 " 10th " 12th " 19th 24.876 30.819 29.614 37.208 3°-546 2.5 2-5 2.4 3-2 2.4 1.024 1.284 1.234 i-55° 1.272 42.699 51-574 5I-453 48.449 53.032 average urea per hour =1.272 Total 152.763 6.364 12 ON THE USE OF THE COLD PACK. Urea of 24 hours including pack and massage. Date. Amount in grms. per ct. Amt. per hour in grms. Amt. urine per hour in c. c. Oct. nth " 24th Nov. 5th " 8th 20.00 28.157 31.180 26.532 2.5 2.2 0.833 1.192 1.299 O.IIO 33-33 50.41 52-577 48.42 average per hour amt.=0.856. Nov. 13th 6.648 2-5 1.899 75-97 urea after blanket pack and massage 3J hours. " 14th " 15th 5.961 6.695 1-7 2.8 1.987 2.202 116.895 78.640 5. mins. cold, then blanket and massage, Average 3 hours =2.029 " 18th 1.92 2.4 1.92 80.00 massage 1 hour with-out pack. Oct. 31st Nov. 22d " 23d " 26th j hour urine 1.68 j hour J-955 For i\ hours. 3.60 For v\ hours 3.10 2-4 2-3 3-3-* 2.24 1-564 0.144 0.154 70.00 85.00 120.00 100.00 Faradiz. \ hour dur-ing menstruation. Average per hour = 1.023 Total Urea after pack 20 minutes—massage to i/^ hours. Date. Amount in grms. per ct. Amt. per hour in grms. Amt. urine per hour in c. c. Nov. 4th (Before see N. 3d) 3.406 1. (2-5> 2.27 (1.284) 227.170 (51-574) Nov. 5th (Before pack) 3.22 2-3 2-7 1.84 (1.165) 80.00 (43.148) Nov. 7th 2.40 1.2 1.600 J33.32 Nov. 8th (Before pack) (After pack) 1.28 2-5 I.I (1.091) 1.32 (43-68) 120.00 Average urea per hour =1.928 Nov. 10th (Before pack) Nov. nth (After pack) 3-92 2.4 1.4 (1.272) 2.613 55-032 186.66 Total for hours of pack. 9-643 JACOB I AND WHITE. 13 difficult or impossible. On one occasion only was the patient in the pack three-quarters of an hour ; on all others the pack only lasted fifteen or twenty minutes; or, finally. toward the close of the term of treatment, only five min- utes ; and was then followed by a blanket pack. The cold salt water sponging or slapping, and the massage, followed during an hour as usual. The urine was only analyzed for urea, but it may be in- teresting to compare the percentage and amount of this under the several different sets of conditions indicated. The summary of Table II shows: 1st. Although the cold pack, when given, only lasted ten to twenty minutes, the increase in the amout of urine and of urea eliminated during the hour and a half which in- cluded this pack and massage, was as decided as in the cases where the pack lasted one or two hours. 2d. The same increase was observed after a warm blanket pack followed by massage. The increase was most marked when this blanket pack had been preceded by five minutes cold pack. On this day (November 14th) the amount of urea per hour was higher (2.202 grms.) than on any day but two of the hours of packs (November 4th, 2.27 grms.; No- vember 1 ith, 2.613 grms.). But it is noticeable that after the cold pack the amount of urine was very much increased (227.170 c.c, November 4th ; 186.66 c.c, November 1 ith), so that the percentage of urea was low (one per cent.); while after the blanket pack of November 15th the amount of urine was much less, yet the amount of urea almost as high. 3d. An increased elimination of urea was observed after an hour of massage alone. Thus, 1.92 grms. on November 18th, as compared with 1.272 grms. of November 19th, with- out treatment. 4th. On the first day of general faradization (October 31st) the elimination of urea during an hour was increased; but the amount was not high on the subsequent days. 14 ON THE USE OF THE COLD PACK. The average per hour for the four seances was less than for a similar period on days without treatment. This fact is interesting, as showing that cutaneous irritation alone, unless accompanied by some agency affecting the ab- dominal circulation, does not increase the elimination of urea. 5th. The estimate of averages is liable to be misleading, because the daily fluctuations in the elimination of urea are so great that it is only safe to compare the hours of the pack with the hours from the adjacent period, either just before or just after. Still it may be worth while to notice that on comparing the hourly elimination in periods of five days we find an average for: Days without treatment, Days without treatment, Hours of packs in first month. Per hour. second month. Per hour. second mouth, I.on 1.272 1.928 Thus the average confirmed the observation of individual days of treatment. The rise in the average elimination of urea in the second month, was associated with an increased consumption of food. On the other hand, the average elimination of urea for an entire period of twenty-four hours which included a pack, sank below that of the days on which no pack was given (0.858 grms.). This observation is strikingly confirmed by another case. (See Table.) It shows that a movement of compensation takes place after the exaggerated diuresis caused by the pack, in virtue of which the elimination, per- haps also the formation, of urea, is diminished. Although this case resembled Case 1 in the coexistence of membranous colitis with intense anaemia, and a diminu- tion in the menstrual flow that almost amounted to amenor- rhea, it differed from it in two important particulars. 1st. The relaxation of the blood-vessels seemed to be out of proportion to the deglobulization of the blood ; and thus JACOB I AND WHITE. I 5 this patient, though much less pallid, prostrated and starved than the other, suffered much more from headache, roaring _ in ears, and multiple vaso-motor disturbances. 2d. Perhaps in connection with this fact, the membranous discharges from the colon were accompanied by an habitual tendency to diarrhoea, while in the first existed most intense constipation. From the irritability of the colon, the case was not very well suited to the cold packs. After seven or eight of these had been given during a period of two weeks, and the patient had been eliminating about two grammes of urea during the hour of pack, she began to wake up in the morning early, with a feeling of chilliness, which was shortly followed by a large loose passage from the bowels. This made her feel quite sick and faint. Thus the pack seemed to confirm the existing morbid tendency to passive dilatation of the abdominal blood-ves- sels, and was on this account abandoned.* Could the pa- tient have been induced to persevere systematically with the cold enemata (which invariably arrested the diarrhoea, mem- branous discharges and pain accompanying them), until the hyperaemia of the colon was removed, there is reason to think that much might have been accomplished by a subse- quent hydro-therapic treatment. As it was, at the end of six weeks, the patient was some- what improved. The membranous diarrhoea had ceased, and with it the dragging pains in abdomen and hips. More par- ticularly, a menstrual flow had occurred for the first time in four or five years, and the patient, instead of remaining confined to her bed or room, went about as usual at the menstrual period. The packs were then interrupted, the other treatment continued with further results, not import- ant to record here. * In very anaemic women, with vaso-motor neuroses dependent on anaemia rather than on hysteria, I have several times observed the often daily occurrence of one or two large passages, attended by a feeling of giddiness and great pros- tration. The phenomenon evidently repeats Goltz's experiment of paralyzing the splanchnic nerve. 16 ON THE USE OF THE COLD PACK. The case is principally noted for the sake of comparing the eliminations of urea with those of other and more favor- able cases. Case 6.—Mrs. L. M., set. 24. Is too complex to be related in detail. The profound anaemia of the patient was complicated by the effects of a marked anteflexion of the uterus, with chronic hy- peraemia of the endometrium, for which local condition local treat- ment was instituted. The cold packs were given principally on account of the anorexia, which had existed for years, and which had kept the patient in a state of chronic inanition. After the cold packs and massage, she felt, for the first time, an appetite ; was able to eat, and for a week or two at a time, would be relieved of the nausea which had become almost habitual with her. Table III, gives the analysis of urine as regards urea, for four packs. The patient reacted very well in these. As in Table I, it is seen that the amount of urine is very much increased ; and the increase in the elimination of urea is in proportion to this. The great total increase of urea on February 26th, was associated with an increase in the amount of food taken, principally milk. CASE VI—TABLE III. Date. Form of pack. Amt. urine in c. c. Per cent. urea. Amt. urea. Urea per hour. Amt. urine per hour in c. c. Feb. 19th " 20th " 20th Pack and mass. 2 hours. Before pack. After pack. 177.144 590-48 295-24 1.8 2.6 1.8 3-i88 15-352 5-3*4 1-594 0.877 2.961 88.572 33-74 117.00 Feb. 24th " 26th " 26th After pack. 24 hours with-out pack. After pack. 265.716 177.144 177.144 i-3 2-3 i-7 3-454 40.743 3.011 !-973 1.697 2.011 151.20 73-8i 118.09 Case 7.—Miss N. O., a young lady aet. 21, suffering from chloro-ansemia of moderate severity, but complicated by severe trigeminal neuralgia, and also by spasmodic dysmenorrhcea. The latter condition was associated with some chronic hyperaemia of the endometrium, causing stricture of the internal os ; otherwise no uterine disease. The patient had been treated for months by iron, and also by the most approved remedies for the neuralgia. In summer, when in the country, would seem to derive great benefit from the iron ; in the winter " ran down " again com- pletely. The stomach was very irritable, and frequent attacks of JACOB I AND WHITE. 17 gastric catarrh increased the headache and debility of which the patient complained. The iron and phosphorus which the patient had been taking were continued, and on March 31st, the hydro-therapic treatment began. The urine was analyzed much more completely than in the other cases, as shown by Table IV. The packs were always enjoyed from the beginning ; the patient reacted well, growing warm, though not perspiring. At the end of the first week, she already felt decidedly stronger. On April 12th, reported herself as having been remarkably free from neuralgia, notwithstanding the occurrence of some moral excitement, such as would usually bring it on. On April 26th, the tenderness on pressure, formerly constant over the supra-orbital nerves, had quite disappeared, though some tenderness remained over the supramaxillary. On May 27th, had had no neuralgia for three weeks, and announced herself as " feeling splendidly." In the interval, a sponge tent had been introduced into the uterus to dilate the os ; and the following menstrual period had passed with scarcely any pain. On June 1st, the patient went out West for the summer. The Table IV relating to this case, has been drawn up with a great deal of care, and we think an analysis of its data will pay perusal. Calculating the averages per hour from this Table IV, we have: In hours outside of packs and massage, calculated in five days (March 31st, April 3d, 8th, 10th, 12th). Urea. Extractive. Inorganic salts. 0.971. 0.432. 0.341. For the five days adjoining, in hours of pack (March 31st, April 2d, 7th, 9th, nth). Urea. Extractive. Inorganic salts. 1.295. 0.347. 0.511. Thus a decided increase in the urea, a slighter increase in the inorganic salts, a diminution in the extractive. In the second month of treatment (see Table II), the averages per hour for the time outside of packs, were : Urea. Extractive. Inorganic salts. 1.309. 0.803. 0.653. For the hours of packs. Urea. Extractive. Inorganic salts. I.405. 0.685. 0.554. ON THE USE OF CASE VII.— THE COLD PACK. TABLE IV. First Month .5 3d §.s E < 1 a J2 "3 CO 0 '3 d CUB u 0 c u w 0 § P- d June 23d . . Before first pack. 9Z5 29.095 8.325 18.500 2.270 2 0.804 0.362 0.903 40.22 June 24th . . After pack 2 hours. 120 935 2.656 31-588 0.600 11.687 2.041 18.70 0.016 1.201 1-7 2 1.02 O.85 0.30 0.551 0.008 0.904 60.00 June 25th . . Before next pack. 42.50 June 26th . . June 27th . . After pack 2 hours. Before next pack. 95 560.656 3-984 22.219 1.520 2.28 19.072 1.50 2.464 2.4 3-4 1.14 1.03 0.76 0.092 47-5° 30:32 June 28th . . After pack. 5<- 3 o-75 25.00 July 1st . . Before pack After pack 442.86 So 15-477 2.679 I7-54I 22.130 9.742 i-55 2.2 3-1 0.463 0.620 21.08 20.00 July 5th . . Before pack 501.908 50 3-513 0.615 9536 1.200 4.492 0.398 1.9 2.4 o-433 0.600 0.159 0.307 0.204 0.199 22.859 July 6th . . After pack 25.00 July 7th . . July 8th . . Before next pack After pack 472.384 5° 29.134 2.446 5.668 o-45 "■437 1.05 12.029 0.946 2.4 2.1 0.519 0.525 0.257 0.225 1.067 0.998 21.472 25.00 July gth . . July 10th . . Before next pack After pack 575-718 45 16.097 1.886 5-i8i 0.495 11.514 1.125 0.266 2 2.5 0.548 0.562 0.247 0-133 27.415 22.50 July nth . . July nth . . Before next pack After pack. 708.576 50 38-44 2-33 8.512 0.70 17.125 i.i5 1.61 0.48 2.4 1.4 0.778 o.575 0.386 °-3S 0.851 0.24 32.208 25.00 July 14th . . Day before menst. July 15th . . Menst. Before pack No pack Massage 1 hr. 472.384 45 27.96 I-I53 3-779 0.405 8.03 0.72 4-259 0.028 i-7 1.6 0.305 0.720 0.171 0.405 0.559 0.028 21.472 45 July 17th . . Julyi8th . . Bef. rubbing Rubbing 1 hr. 339-526 55 15-03 3-395 9.846 1.32 1.789 2.9 2.4 0.447 1.32 I-I54 0.081 15-433 55 July 20th . . 1st day after menst. July 21st . . Before pack After pack 3 hours 869 162.382 12.896 4.161 2.952 1.461 7-759 2.598 2.195 0.102 2.1 1.6 0.352 0.866 0.132 •487 0.099 ■034 16.61 54.127 July 22d . . July 23d . . Before pack After pack 3 hours 649.528 "5 24.967 3-7r3 7-794 0.92 16.238 2.415 •35 0.378 2-5 2.1 .738 .805 •354 0.316 0.042 0.126 29.524 38-33 July 25th . . Visit to sea-shore July 25th . . Before pack 15 hours After pack 200 130 44.27 2.877 1.80 0.664 5.600 2.08 1-454 0.133 2.8 1.6 •373 0.693 0.12 0.221 0.090 0.044 "13-33 43-33 July 28th . . July 29th . . Before pack. After pack 305 150 i4-923 2.097 2.460 0.600 9-453 1.50 2.728 3-i 1 .429 .500 O.III .20 -"86 13-30.00 J A COB I AND WHITE. 23 \ Case 8. = Mrs. P. Q., a young married woman, aet. 22. First seen seven weeks after her first confinement. This was said to have lasted during three days. The perineum had been ruptured. On the third week, when patient first got up from bed, she was attacked with pain, chills and fever ; was obliged to return to bed, and remained there for two weeks. Two weeks later, at the time of my examination, the patient was extremely weak and pale, un- able to stand or walk, with almost absolute anorexia. The fundus of the uterus was within two fingers' breadth of the umbilicus. A slight thickening in the left cul-de-sac indicated a recent perime- tritis. The treatment was directed toward the general anaemia and toward the uterine subinvolution, principally the latter. Iron and nerve tonics were for the present postponed. The patient received f § ss of ext. ergot, fid. every four hours ; vaginal injec- tions at first of salt water, afterward of tannin, and a daily cold pack, at first of one, then of two hours' duration, followed by an hour's massage. Table VI gives the result of the examination of the urine under these conditions during a period of five weeks. This table is at once seen to differ in one particular from the tables of Case 7. The amount of urine eliminated during the hours of pack and massage is by no means always in excess of that eliminated dur- ing the same period of time in the rest of the day ; and when there is an excess this is much more variable in amount. Thus on four occasions (June 28th, July 1st, 10th and nth) the amount of urine per hour during the pack was less than the average by \, \, \ and \. On the other hand, the excess which was noticed in the majority of cases (10), varied from \ of the average to 3^ times that amount per hour ; and what is very noticeable, on two of the days on which the excess was most considerable, being twice (July 14th), or more than three times (July 17th), as much as the average, the patient received no pack, but only massage during an hour. On all the days in which the amount of urine eliminated during the pack was increased, the amount of urea at the same period was increased also (10 observations). The increase varied from a scarcely perceptible amount (¥V on June 8th, -£$ on June 10th) to 1-, £, \, i> 3 ^ie amount of the average, or even double and three times as much when the amount of the urine was increased in this proportion. Calculating the averages per hour in periods of five days, as for 24 ON THE USE OF THE COLD PACK. Case 7, we find, for five days without packs (June 23d, 25th, July 5th, 7th, nth); Urea. Extractive. Inorganic. • 676 0.785 .339 For adjoining days, hours of packs : Urea. Extractive. Inorganic. .772 0.307 .358 The diminution in the amount of extractive during the hours of the pack, as compared with the increase of urea, repeats an experience of Case 7. Comparing this fact again with another observation of Case 7, namely, the rise of extractive on the day before menstruation, coincidently with the fall of urea, we may draw the further inference that during the pack the increased elimination of urea is not alone due to the increased amount of urine, but that more organic material is converted into urea, leaving less for " other organic " or extractive. On the assump- tion that this conversion takes place in the liver, we may ascribe the increase to the increased circulation in this gland effected by means of the pack. The rapid involution of the uterus, effected during the treat- ment, and also the large doses of ergot that this patient was tak- ing, rendered the case somewhat peculiar. On July 26th, when the packs ceased, the uterus measured only 9 cm. It was to be presumed that during the treatment the fatty detritus from the diminishing uterus was circulating in the blood, perhaps acting as a diuretic. The ergot, on the other hand, tending to contract the abdominal vessels, should cause less water to pass through the kidneys ; or, in other words, the usual effect of the pack of increasing diuresis would be counteracted. I do not know precisely what was the relation of time between the adminis- tration of the ergot and the pack, but it is probable that one dose came very near to the time of the pack. During menstrua- tion the ergot was suspended, and it is noticeable that it is on two days of menstruation when massage was given, and on the first day after menstruation when the pack was resumed, that the amount of urine was so greatly in excess of the average for this individual. On August 2d the patient was sent to the sea-shore. She had regained her appetite, had lost all pelvic pains, was able to walk JACOBI AND WHITE. 25 up and down stairs, slept well, and felt, although not yet strong, in pretty good condition. On September 12th the uterine cavity measured 8 cm. It subsequently became completely normal, and the patient, though of delicate appearance, entirely well. I will now give briefly the record of three other cases, both of which would seem, at the outset, as suitable for hydro-therapic treatment as those described, but which nevertheless receive no, or only partial benefit from them. Case 9.—Miss R. S., aet. 27. Moderately anaemic, with con- tinuous venous hum in jugular, but endowed with considerable muscular strength, and excellent digestion. A retroversion of the uterus existed, producing, however, no local symptoms be- yond an occasional moderate dysmenorrhcea. The patient was extremely small of stature, with a head very well shaped, but large, out of proportion to the height. There were some traces of infantile rachitis. Whether as a result of this, or of the anae- mia, or of the long standing retroversion, the young lady had suf- fered for years from nervous headaches, which, during the last two years, since a great moral strain, had assumed exceptional severity. Cold packs and massage, iron and cod liver oil were recom- mended for the anaemia, while the efficacy of various direct pal- liatives was tried to relieve the headaches. The uterus was re- placed with a pessary. The hydro-therapic treatment extended over 22 days, with an interval caused by menstruation of six days. The analyses of the urine are recorded in Table VII. Only urea, and occasionally phosphoric acid, was estimated. As in the other cases, the amount of urine during the packs was greatly increased, the percentage of urea lowered, but its abso- lute amount increased. That it was possible, in this patient, to greatly increase the amount of urine, yet even lower the elimina- tion of urea, is shown by the observation of June 17th, fourth day of menstruation, when the amount of urine rose to 1040 c.c, yet the amount of urea was only 17.68 grms., or an hourly amount of 0.735 grms. Again, on the day of the first pack, June 8th, the amount of urine was nearly one-third the amount which had been passed in 20 hours, the amount of urea per hour was about 1% times as much. On the 10th the increase was more than double (2.44) ; also on the 12th. On the 13th the average amount rose, on the pre- 26 ON THE USE OF THE* COLD PA CK. CASE IX.—TABLE VII. Date. Amt. Urine in c. c. Amt. Urea in grms. Per cent. urea. Per hour urea. Per hour p 0 5. Per hour urine. June 7th. June 8th. 2J hours after pack . . 600.00 290. iS-3-T9 2.5 1.1 o-75 1.16 0.066 30.00 105.00 June 9th. June 10th. 676.00 480.00 14.16 4-32 2.7 0.9 o-59 2-44 0.039 28.16 160.00 June nth. Entire day, including pack 880.00 860.00 1732 3.00 1. 1.20 32.50 120.00 June 12th. 20 hours before .... 600.00 400.00 13.20 5-39 2.2 1.1 0.66 1.79 0.48 30.00 163.33 June 13th. 915.00 21.045 3-555 2.3 1.052 1-185 45.70 June 14th. June 17th. June 18th. 560.00 1040.00 920.00 885.00 14.56 17.68 19.32 20.355 2.6 i-7 2.1 0.728 o.735 0.805 1.017 0.0448 0.0732 June 19th. June 2cth. 3 hours pack..... 610.00 15-25 330 0.762 I.IO June 21st. 580.00 430.00 18.56 4-73 3-2 1.1 1-773 1.882 June 26th. June 29th. 3 hours pack, shower bath. 540.00 125.00 16.00 3-96 12.45 1.875 0.9 0.80 1.98 0.622 0.625 0.07 0.18 41.66 J A COB I AND WHITE. 27 menstrual day, thus approximating the amounts of the two periods. After the two first packs following menstruation, the increase of urea was in much smaller proportion ; on the last day the amount was identical with that of the 20 hours preceding, while on an intermediate day (June 26th) the amount was, as before, doubled, as also the amount of phosphoric acid. Clinically speaking, the patient reacted very well in the packs, and during the first week, i.e., that preceding menstruation, had less headache ; felt better. But during the last week of the treat- ment, had constant headache, loss of appetite, and rapid pulse (96). At this time, as noticed, the proportionate increase of urea diminished. These circumstances all corresponded with those already noticed in Case 1, also a patient suffering from se- vere neurasthenic headaches. Case 10.—Miss T. U., aet. 30, anaemic, but hysterical quite out of proportion to the anaemia. Principal complaint was of constant pain in the track of the right ilio-hypogastric nerves, without the least tenderness on pressure, either external or internal, in the ovarian region. The patient had no uterine or other local dis- ease, but was profoundly preoccupied ahout herself, was indeed a typical case of hysterical egotism. Whether on this account or not it is difficult to say, as the hydro-therapic treatment was com- plicated with others that might probably better have been omitted ; but the patient, who, during the first month of treatment, im- proved, during the second became excessively fatigued after each pack, and at the close considered herself rather worse than better. The urine analyses of this patient were, unfortunately, lost. Case ii.—Miss V. W., aet. 20, pure chloro-anaemia, uncompli- cated by dyspepsia or muscular atony, or uterine disturbance. Patient formerly suffered from severe headaches, which had ceased for a year or two before the time of consultation. The muscular development of the patient was remarkably fine ; her appetite was good, and digestion excellent. She was, however, extremely pale, and suffered from a constant sense of fatigue and somnolence. Her blood corpuscles, counted by Hayem's hematimetre, num- bered 3,689,000, but it is probable that the haemoglobin was diminished out of proportion to the aglobulie. The patient was ordered tartrate of iron and potassa, 3 grms. every three hours, koumyss, rectal injections of blood, and the cold packs with massage. After a month of this treatment felt a i^reat deal better, with much less fatigue and sleepiness. The pa- 28 ON THE USE OF THE COLD PACK. tient went into the country, and passed an excellent summer. In October the debility began to return. Former treatment resumed, minus the rectal injections of blood, to which the patient had a great objection. But though persevered in for two months, no sensible improvement in the condition of the patient was observed. On the contrary, she had several severe attacks of headache. From this crucial experiment we must infer that the apparent benefit derived from the hydro-therapic treatment on the first occa- sion, was really due to the blood injections. No analyses of the urine were made. The general inferences to be drawn from these clinical experiments will be discussed in a later number of the Archives. II. In the clinical cases whose history has been related in the preceding number of the Archives, we studied the effect upon the urine of the cold pack followed by mas- sage. We showed : I. That the urine formed during this double procedure, and collected immediately afterward (the bladder having been emptied immediately before), was considerably in- creased in quantity, i. e., the amount of water was greatly increased. 2. The amount of urea per hour was also absolutely in- creased, often doubled, but owing to the large excess of water, the percentage of urea in the urine was diminished. 3. The amount of extractive and of inorganic salts was generally increased, but in much smaller proportion than was the case with the urea. In not a few instances the amount of extractive was lessened. 4. In what seemed to be the typical cases of the action of the cold pack, the amount of water and of urea eliminated per hour during the rest of the day on which the pack was taken, fell below not only the amount eliminated during the pack, but below the average per hour of days preceding treatment, or days on which the pack was JACOBI AND WHITE. 29 not taken. Thus the total amount for the day was not changed by the treatment. In some cases the urine was not examined comparative- ly for the hours of the treatment and for the rest of the day, and in these a total increase of urea for twenty-four hours was often observed. But if this persisted two or three days, symptoms of malaise or exhaustion occurred ; sometimes the patient was chilly, sometimes suffered from severe headache, in all cases from a sense of great fatigue. From the foregoing it would appear that whatever modi- fications of nutrition were effected during the pack and mas- sage, were followed by a sort of movement of compensation in the opposite direction ; and this movement of compen- sation seemed to be an essential part of the therapeutical effect produced. 5. On a few occasions, massage was given for an hour without being preceded by any pack. The urine eliminated during this hour showed an increase of water and of urea—less marked than was usually the case when the pack had also been given. In no case, however, did an opportu- nity occur to test the effect of the pack entirely separate from that of the massage. As it was important to ascertain this, if only to confirm or control the experiments that have been made by others in regard to the same question, the pack was given to three healthy women, with the observance of the same precautions as in the other cases. The results are recorded in Table VIII. From this table, it is evident that the pack alone, apart from any form of muscular exercise, is capable of producing all the modifications of the urine already described; in- crease of water, of urea, and other solids. Moreover, as in the cases earlier described, during the hours following the pack, a movement of compensation occurs, in virtue of which, the elimination of both the fluids and the solids of 30 ON THE USE OF THE COLD PACK. the urine falls as much below the average, as it had risen above it during the hours of the pack. On two of the persons upon whom this experiment was made, no conscious effect was produced. The third, a TABLE VIII. a 'u 2 6 A 0 ed , S be S OJ 3 3 0 •So 0 3 O No. I. a 0 a a 0 3 3 ri 3 3 3 3 o.S E T3 a be u 0 C3 u 0 oM J3 M u J3 < 0 GO