Electrotherapy Kovacs

From
the collection of the
z
j
n
TTr"^
Prelinger a
v
JLJibrary
San Francisco, California 2006
By
the
same author
A MANUAL OF PHYSICAL THERAPY

12mo, 309 pages, with 118 engravings
LEA
&
FEBIGER
PHILADELPHIA
E o
ELECTROTHERAPY
AND
LIGHT THERAPY
WITH THE ESSENTIALS OF HYDROTHERAPY AND MECHANOTHERAPY
BY
RICHARD KOVACS,
M.D.
PROFESSOR OF PHYSICAL THERAPY, NEW YORK POLYCLINIC MEDICAL SCHOOL AND HOSPITAL ATTENDING PHYSICAL THERAPIST, MANHATTAN STATE, HARLEM VALLEY STATE, COLUMBUS, AND WEST SIDE HOSPITALS; VISITING PHYSICAL THERAPIST, NEW YORK CITY DEPARTMENT OF CORRECTION HOSPITALS; CONSULTING PHYSICAL THERAPIST, NEW YORK INFIRMARY FOR WOMEN AND CHILDREN, MARY IMMACULATE HOSPITAL, JAMAICA, N. Y., HACKEN8ACK HOSPITAL, HACKEN8ACK, N. J., ST. CHARLES HOSPITAL, PORT JEFFERSON, L. I. ALEXIAN BROTHERS HOSPITAL,
ELIZABETH, N.
J.
Fifth Edition, Thoroughly Revised

Illustrated with
352 Engravings and a Color Plate
LEA & FEBIGER

PHILADELPHIA
COPYRIGHT
LEA & FEBIGER

1945
Reprinted
OCTOBER, 1946
PRINTED IN
U. S. A.
PREFACE TO THE FIFTH EDITION

THE
five successive editions of this
work
reflect
the steady expansion
of the use of physical energies for treatment during the past fifteen years. Its contents are based on the subject matter of the author's instruction
courses, given first under the auspices of the

of
Columbia University School Medicine at the Reconstruction Hospital in New York and since 1927 at the New York Polyclinic Medical School and Hospital. Electrotherapy
and
light
of physical
therapy have been always the main forms for office employment treatment agents by physicians because of their fairly simple
efficiency.
control
and
ELECTROTHERAPY AND LIGHT THERAPY was written

on the theory and practice of these The intervening years have brought
primarily to offer reliable information
two important therapeutic agents. about the development not only of new phases of the original subject but also a steady increase in the use of treatment procedures by water, exercise
and manipulation. Some of these methods require very simple equipment or none at all except the knowledge of how to use them, which makes it
possible to give patients their benefit at the bedside as well as in the
In order to furnish information about these methods, with the fourth edition of this work, the essentials of hydrobeginning therapy and mechanotherapy were included in the presentation.
physician's office.
The
story of the progress of ''physical medicine" as part of the practice
of medicine, in the period of the past twenty-five years during
which the
author has been actively engaged in it, is an impressive one. In the United States up to the time of the World War I, the few medical men practicing
as "electro therapists'
5
were looked upon by
many of then* medical
brethren
with suspicion, mingled with pity. Hydrotherapy, manipulation and were mostly exploited by poorly educated technicians. Generally massage
speaking, there were no physical therapy departments in hospitals where the different physical methods could be correlated as part of a general
be carried on.
after
therapeutic scheme and where clinical and laboratory research could This situation first changed for the better during and
World War I, by the creation of broadly conceived physical treatment departments in order to benefit those injured and disabled in that war. In these departments all the time-honored and many of the new
methods
of physical therapy
were practiced under the watchful eyes of
competent medical men.
After the
War
there
became available a
large
body
their
of
competent technicians and a

in civilian practice
number
of physicians
who
continued
work
and under
this impetus,
development of
many new and efficient physical therapy methods took place. Groups of medical men and technicians organized for mutual cooperation and study
(5)
and the medical profession at large showed much interest in physical therapy. The American Medical Association created in 1927 a Council of Physical Therapy which became a potent factor in disseminating proper information, in advocating basic training in physical therapy, and in
curbing unwarranted claims and commercialization. As a result of all these factors, in the years up to World War II there was constant progress in
education, research, and in the development of
expansion of clinical application of physical therapy.
new methods and the The lines of demarcaby general
tion between physical therapy that can be effectively carried on

practitioners,
by
specialists in various
departments of medicine and by
medicine" became gradually established. World War II thus found physical therapy ready for further expansion and for its fullest utilization for the benefit of war casualties. No wonder that the number of physical therapy departments and training centers in Army and Navy hospitals and other service and rehabilitation centers
specialists in "physical
time high. The need for caring for the injured, convalescent and those to be rehabilitated has made physical therapy methods the cornerstone of this work and also by practical necessity
has reached an
all
brought occupational therapy in close correlation to it. All this is likely to continue for many years to come. At the same time, the term Physical Medicine became officially adopted in connection with the greatly increased
Medical Association, in renaming in 1944
scope of physical methods for treatment and diagnosis. The American its Council on Physical Therapy
the Council on Physical Medicine, stated: "Physical medicine includes the employment of the physical and other effective properties of light,
heat, cold, water, electricity, massage, manipulation, exercise
ical devices for physical
treatment of disease."
and mechanand occupational therapy in the diagnosis and In the same year a great American citizen and
humanitarian appointed the Baruch Committee on Physical Medicine, and after its extensive survey of the needs of this branch of medicine
he donated a fund of over a million dollars to carry out the most Simultaneously, the urgent educational and research requirements.
National Research Council and the National Foundation for Infantile
Paralysis also
of all these
made grants for research in physical medicine. As a result new developments, prospects for large scale increase in instrucand
clinical application of physical
tion, research
medicine in the near
future are indeed bright. In the fifth edition of this
work a concise presentation

is
of all present
day
phases of physical medicine
offered, while special
emphasis on electro-
therapy and light therapy is being retained. In this volume the newer uses and methods of electronics, of electrodiagnosis, of ion transfer, and of ultraviolet radiation have been incorporated; the chapter on exercise has been considerably enlarged; a
new
chapter on hypothermy has been added, and a revised glossary inserted,

pertaining to definitions of electrotherapy and light therapy as well as to muscle and nerve action, and mechanotherapy. All chapters in the general as well as in the special part
seven
new illustrations The author is deeply
have been brought up to date. were added and 49 obsolete ones omitted.
grateful to
Eighty-
many
laboration. Drs. R. V.
Gorsch (now serving as Colonel
medical friends for their colin the U. S. Army),
serving as Commander in the U. S. Navy), and have revised their special chapters. Dr. F. W. EwerDr. Hans Behrend hardt contributed to the Glossary, Dr. Arthur L. Watkins to the chapter on
W. W. Morrison (now
Electrodiagnosis, Dr.
Jerome Weiss reviewed the chapters on physics and Dr. Robert Schlesinger again skillfully furnished a number of schematic drawings. A number of authors permitted reproductions of their illustrations and the educational and technical departments of the electromedical
industry again assisted in furnishing technical data and illustrations. credit for all these contributions appears in the text.
Due
most liberal and cooperative in producing a volume profusely illustrated and typographically excellent. R. K. NEW YORK CITY
The
publishers were again
CONTENTS
CHAPTER
Physical Therapy in the Practice of Medicine Basis of Physical Therapy Scope of Physical Therapy Place of Physical Therapy Classification of Physical Therapy Methods Apparatus for Physical Therapy Electrotherapy and Light Therapy
I
INTRODUCTION
23 23 26 27 27 28 29
PART
ELECTROPHYSICS
CHAPTER
The The
Structure of Matter and the Atomic Theory Electron Theory of Matter
II
FUNDAMENTAL ELECTROPHYSICS
'.....
30
31
Charge The Elementary Law of Electrophysics Conductors and Insulators Transfer of Electrical Charges Charging by Contact and by Induction Condensers
Static Electricity Current Electricity Electric Current Effects of Current Electricity Thermal Effects Electromagnetic Effects Chemical Effects Electrical Units Unit of Current. The Ampere Unit of Resistance. The Unit of Electromotive Force. The Volt
Electric
Ohm
Difference Between Amperes and Volts Ohm's Law Unit of Power. The Watt Unit of Capacity. The Farad Measuring and Regulating Devices Ampere Meters and Voltmeters Measuring Power in Alternating Current
.
Circuits
Rheostats'
32 32 33 34 34 34 36 38 38 39 39 40 42 44 44 44 45 45 45 46 46 47 47 49 49
CHAPTER
Chemical Generation of Electricity
Cells
III
GENERATION, CONVERSION AND DISTRIBUTION OF ELECTRICITY
and Batteries
51 51
Mechanical Generation and Conversion of Electricity
The Dynamo The Electric Motor The Faradic Coil The Transformer The Rotary Converter (8)
53 53 53 54 55 55
CONTENTS
Electric Oscillations
9
56 57 57 59
61
,
and Waves
....'..
.
Electronics
.
Thermionic Emission Vacuum-electronic Devices Gas-filled Electronic Devices . , The Electron Microscope Electrical Current Supply in Homes and Office Measuring and Protecting the House Supply The Role of Fuses Locating Trouble Current Outlets
.
....../...
PART
II
...-.-.
'.
62 62 63 63 64 65
GENERAL ELECTROTHERAPY AND ELECTRODIAGNOS1S

CHAPTER
General Considerations Classification of Currents Direction and Frequency of Flow Voltage or Tension
.
IV
ELECTROMEDICAL CURRENTS, APPARATUS AND ACCESSORIES

.
....
Amperage or Volume Electromedical Apparatus Typical Features of Apparatus Conducting Cords and Cables Electrodes Miscellaneous Accessories
Treatment Timers
Patient's Release
Foot Switches ;...''.' Treatment Tables and Couches
...:..... ............. ...

CHAPTER V
.... .... .... .... .... ....
66 67 67 68 68 68 69 69
71
76 76 76 77 77
EFFECTS OF ELECTROMEDICAL CURRENTS. PASSAGE THROUGH THE BODY. GENERAL RULES OF TREATMENT
Primary Physical Effects
Ionic Effect Thermal Effect Specific Electrical Effects Secondary Physiological Effects Psychological Effects
.
78 78 79
.
.
.
82 82 82
Electric
Conduction Through the Body Resistance of the Skin Skin Resistance to Different Currents Practical Importance of Skin Resistance Changes in Skin Resistance Resistance of Other Tissues
. .
......
,
.
....
,
Dielectric Conductivity Passage of Currents Through the
87
Body
.
Current Density
Influence of the Size and Position of Electrodes . General Rules of Electrical Treatment Method of Procedure Position of Patient Inspection of Parts Placing of Electrodes and Cords Starting the Treatment Regulation of Current Strength Termination of Treatment
.
.....
.
.....
95
10
CONTENTS CHAPTER
VI
97 97 97 98 100
101 101 101 101
ELECTROPHYSIOLOGY
Bioelectric
Phenomena
Action Currents Action Currents of Skeletal Muscles Action Currents in Nerves Injury Current Action Currents of the Heart and the Brain
of Bioelectric Phenomena Electrical Stimulation of Nerves and Muscles Nature of Nerve Impulses
....
Theory
Stimulation by Direct Current Electrotonus
.102
.
Nerve Block
Electrical Excitability
Strength-Duration Curves Chronaxie Progressive Currents Intensity-Frequency Relation
...
.
103 104 104 104 104 105 105
CHAPTER
General Considerations Motor Points
VII
107 108 109 110 Ill 112 113 114
ELECTRODIAGNOSIS
Apparatus and Accessories General Technique
Difficulties in Testing Testing Charts Faradic and Galvanic Test Reaction of Degeneration Course of the Reaction of Degeneration Diagnostic Significance of the Prognostic Significance of the Testing for the Reaction of Degeneration The Polar Formula Diagnostic Limitations Other Changes in Electrical Reactions Increased Excitability
RD RD
.116 .116
119 120 120 121 121 121 121 123 123 125 126 127 128
Diminished Excitability
Newer Methods of Electrodiagnosis Testing by Strength-Duration Measurements Testing by Chronaxie Measurement

Technique
Testing by Progressive Currents Electromyographic Diagnosis
CHAPTER
Historical
VIII
134 134 138 139 139 141 143 143 143 144 146 149 149 149 150 150 150
THE GALVANIC CURRENT AND ION TRANSFER

Physics and Apparatus
Polarity Effects of the Galvanic Current Physical Effect Physiological Effect
Upon
the
Body
Therapeutic Forms Medical Galvanism General Technique

.
'
Dosage and Length of Application The Galvanic Bath Electrolysis or Surgical Galvanism
Removal of Superfluous Hair Skin Blemishes

Hemorrhoids
Strictures
.
Galvanic Acupuncture
CONTENTS
Ion Transfer or Iontophoresis Physicochemical Considerations Leduc's Experiments Penetration of Ions Clinical Uses of Ion Transfer General Technique A. Applications From the Positive Pole Heavy Metals
11
151 151 151
....
...
Vasodilating Drugs
Histamine Mecholyl Cocain Epinephrine

Aconitine
Calcium
B. Applications Chlorine Iodine
.
...... From
. .
152 153 153 154 154 155 155 156 159 159 159 159 159 160 160 160
161
tHe Negative Pole
.159
Salicylic Acid Dangers in Galvanism fety Rules in Galvanism
CHAPTER IX
CURRENTS OF Low FREQUENCY
Historical
General Considerations Physics and Physiological Effects The Interrupted Galvanic Current The Faradic Current The Surging Faradic Current The Slow (Galvanic) Sinusoidal Current The Modulated Alternating or Interrupted Sinusoidal Current Low-frequency Apparatus Motor Generators Generators of Thermionic Tube Types Single Types of Low-frequency Apparatus Therapeutic Aspects of Electric Muscle Exercise Clinical Application of Low-frequency Currents Simple Muscle Weakness Paralysis Following Nerve Injuries or Anterior Poliomyelitis Miscellaneous Indications Choice of Current for Muscle Stimulation Special Forms of Low-frequency Currents The Leduc Current Galvano-faradization Condenser Discharges by Progressive Currents General Technique of Low-frequency Stimulation Individual Motor Point Stimulation Group Stimulation of Muscles Dangers of Application
.
...
163 163 164
,164
....
.
165 167 168 169 169 170

171
176
.
177 177 179
.179
179 180
...
Static Electricity
History Physics Physicophysiological Effects
...
183 184 184 184 185
CHAPTER X
HIGH-FREQUENCY CURRENTS AND APPARATUS
General Considerations
Historical
187
.
High-frequency Oscillations and Radiowaves Physics of High-frequency Apparatus

.
Basic Principles
Vacuum-tube Apparatus Power Supply Circuit
The The
Oscillator Circuit Patient's Circuit
Two-tube Short-wave Circuits Controls of Vacuum Tube Apparatus
19o
12
CONTENTS
197
.
Spark-gap Apparatus Operating the Spark-gap Apparatus
The Oudin
Coil
. .
Combination Apparatus Requirements for Acceptance of Diathermy Apparatus Protection Against Radio Interference by Electrical Apparatus High Frequency Treatment Methods
199 200 203 200

201
232
CHAPTER XI
MEDICAL DIATHERMY
General Considerations Experimental Demonstrations
.
Thermal Effect of Diathermy Heating by Direct Contact

Heating in the Electric Field Heating in the Electromagnetic Field Heating in Relation to Wave Length
Physiological Effects of Diathermy Effects on Circulation Effects on the Nervous System Effect on Bacteria
...
.
205 205 206 207 208 208

21
1
.....210 213
.
Diathermy vs. Long- wave Diathermy Contraindications and Dangers of Diathermy General Technique of Diathermy
Short-wave
General Considerations Regulation of Dosage Duration and Frequency of Treatment Technique of Short-wave Diathermy
Electrodes Electric or Condenser Field Heating Electromagnetic or Coil Field Heating Direct Contact Heating
Clinical Uses of
....
...
.
...
.
....
.
....
Technique of Long-wave Diathermy

Their Position and Size The Reading of the Milliampere Meter Regional Technique of Diathermy Brain
Electrodes
.....
Eyes
Head Neck
Sinuses
Dorsal and
Lumbar Spine
Coccyx Organs of the Chest and Abdomen Abdominal Organs Male and Female Organs Rectal Diathermy Shoulder and Upper Extremity
. .
..
Elbow , Wrist and Hand . Hip and Thigh Knee Ankle and Foot Sciatic Nerve \ Safety Rules in All Diathermy Treatments Special Precautions With Short-wave Diathermy Special Technique With Long-wave Diathermy General Diathermy
.
...
. . .
.
.
v
.
.
.
.
'
..
.......
'
Autocondensation Monoterminal High-frequency (Oudin) Treatment Combination of Low-frequency Currents With Diathermy
213 214 215 216 217 218 218 218 219 220 220 220 222 223 225 225 226 227 227 228 229 230 231 231 231 232 233 233 233 235 235 236 236 238 238 239 240 240 240 240 242 243
CHAPTER
General Considerations Methods of Inducing Hyperthermy Hydriatic Methods
Electrical
XII HYPERTHERMY
.
Methods
Requirements for Fever Apparatus
245 246 247 247 250
CONTENTS
Physiological Effects Bactericidal Effects Clinical Use of Hyperthermy
13
251 253 253 253 254 255 255 255 255 255 255 255 256 256 257 257
Gonorrhea and
Syphilis
.
Its
Complications
Neurosyphilis and Wassermann-fast Syphilis Chorea
Bronchial Asthma Chronic Arthritis Multiple Sclerosis Other Conditions Contraindications to Hyperthermy General Technique of Hyperthermy Preparation Initial Steps The Induction Period Period of Maintenance
.
Treatment Height, Duration and Frequency Complications of Hyperthermy

of
.
End
...........
.
....
of
Fever Sessions
Restlessness Heat Prostration
Burns / Herpes Labialis Heat Cramps and Tetany Abdominal Cramps, Nausea and Vomiting
.
259 259 259 260 260 260 260

261 261 261 261
.......
.
Circulatory Collapse Pathogenesis of Fatal Cases
...
CHAPTER
.
i
*
. .
. .
,
262
XIII
*
ELECTROSURGERY
General Considerations History
Electrosurgical Methods Electrodesiccation
and Their Effects
N
. .
Electrocoagulation Electrosection
Healing of Electrosurgical
Wounds
.
Specific Effects on Blood-vessels Advantages of Electrosurgery Apparatus for Electrosurgery Technique of Electrodesiccation
.
...
.
Experimental Practice Operative Technique Technique of Electrocoagulation

.
'
.
.
.
Electrodes
Experimental Practice The Role of the Milliammeter Operative Technique The Use of Biterminal Electrodes Technique of Electrosurgical Cutting
Electrodes
Experimental Practice Operative Technique Hemostasis Underwater Cutting Cpnization Bipolar Cutting
.
........ ......' ...........

.*
.
264 264 265 265 265 268 268 268 269 269 272 273 273 275 275 276 277 279 279 279 280 280
.277
...
.
.
281
Anesthesia in Electrosurgery Clinical Uses of Electrosurgery
Uses of Electrodesiccation Uses of Electrocoagulation and Electrosection

Critique
283 283 285
CHAPTER XIV
ELECTRICAL INJURIES
Accidents During Electrotherapy The Equation of the Operator Equation of the Patient Equation of the Apparatus
287
289
14
CONTENTS
290 290 290 290 291 291 292 292 292 292 293 293 294 295 295 297 297
Burns Pathology Burns From Heat Lamps Burns From Diathermy Burns From Galvanism Burns From Ultraviolet Electric Shock Low-frequency Current Passing Through Cardiac Area Accidental Contact With a Grounded Object Transformer Breakdown Mechanical Injuries
Medicolegal Aspects
Electrical Accidents in
Homes and
in Industry
External Injuries
Electrical Shock Injuries to Eyes
Injuries
from Lightning
PART
III
LIGHT THERAPY
CHAPTER XV
PHYSICS OF RADIANT ENERGY
General Considerations Theory of Radiant Energy Classification of Radiant Energy
'
299 300
.
.
.
.301
302 303 304 305 306 306 308 309
Measuring
Wave Length
Spectroscopic Comparison
Physical Phenomena The Inverse Square Law The Angulation of Rays (Cosine Law)
Common
Measuring Radiant Energy

.
Penetration
Comparative Physical Effects Comparative Physiological Effects
CHAPTER XVI
INFRARED AND LUMINOUS RADIATION
Physical Considerations Long-wave Infrared Short-wave Infrared Sources of Infrared Radiation Sunlight
311 311
312 312
Heat Lamps
Infrared Radiators
Electric Light Baths Physiological Effects of Infrared and Luminous Radiation Physiological Effects of Infrared Radiation Effect on Circulation Effect on Nerve Endings of the Skin General Effects Physiological Effects of Visible Radiation Clinical Use of Local Heat Radiation
.
313 315
316 317
.317
Choice Between Luminous and Non-luminous Radiators Technique of Local Radiant Heat Application
Clinical
....
320
321
Precautions Use of General Heat Radiation Indications

.
.321
321 322
Technique
CONTENTS
CHAPTER XVII
ULTRAVIOLET RADIATION
Generation
Classification
15
PHYSICS AND EFFECTS

325 325 325 326 326 327 327 327 328 328 329 329 330 330 332 332 333 333 333 334 334 335
Physical Properties Physiological Effects of Ultraviolet Radiation

.
Erythema Production Degrees of Erythema

Histological Changes Difference in Erythema Effect of Certain Wave-lengths Biological Explanation of Erythema Erythema Reaction as a Measure of Effectiveness of Ultraviolet Radiation
Pigmentation
Antirachitic Effect Bactericidal Effect Effects on Blood Effects on Metabolism Clinical Uses of Ultraviolet Radiation
Metabolic Disorders Tuberculosis Skin Conditions Miscellaneous Conditions Contraindications to Ultraviolet Radiation Photosensitization
CHAPTER
Historical Physics of Solar Radiation Clinical Considerations of Heliotherapy Technique of Heliotherapy
XVIII
HELIOTHERAPY
337 337
.
Well People and Children Ultraviolet Transmitting Window Glass
Sun Bathing
in
....
340 343
CHAPTER XIX
ARTIFICIAL ULTRAVIOLET THERAPY
Historical
Carbon Arc Lamps

Construction Radiation Characteristics Relative Advantages and Disadvantages Quartz Mercury Vapor Arcs Hot Quartz Lamps Cold Quartz Lamps Low-pressure Mercury Arcs Electrpdeless High-frequency Induction Lamps Combination of Hot Quartz and Infrared Units Choice of Ultraviolet Generators and Standards of Emission Standards of Emission
.
346 346 347
350 350 350

354 356 358 358 359
36(
36. 36(
Technique
of Ultraviolet Irradiation
Administration
Dosage
Special Techniques of Ultraviolet Irradiation Local Irradiation
The Finsen Treatment

Ultraviolet Blood Irradiation Air Sterilization
357
<*>'
Physics of Germicidal
Practical Uses
Lamps
372
16
CONTENTS
PART
IV
ESSENTIALS OF HYDROTHERAPY
AND MECHANOTHERAPY
CHAPTER XX
HYDROTHERAPY
General Considerations Physical Principles
Physiological Principles Cold Applications Hot Applications Applications of Slowly Increasing Temperature
;.
....*..
.
Hydrothermal Measures Wet Compresses Wet Packs

Ablutions
Special
Hot and Cold Baths Forms of Baths
374 374 375 375 376 376 377 377 377 379 379 384 384 384 385 387
Hydrokinetic Measures
....
. .
Douches and Showers The Whirlpool Bath Therapeutic Pools and Tanks
Colonic Irrigation
... ... ...

.
,
....
CHAPTER XXI
HYPOTHERMY
*
Methods
of
Hypothermy
Physical and Physiological Effects
Therapeutic Considerations Cold Injuries .

. .
... ... ..... ...

. .
388 389 393 394
...
CHAPTER XXII
. .
...
.
MASSAGE
Massage Movements
........
.
.
. . .
Physiological Effects of Massage Effects of Massage on Pathological Conditions
.
.
General Technique of Massage . Uses of Massage Traumatic Conditions .'' Arthritis and Rheumatic Conditions Disorders of the Digestive Tract Disorders of the Nervous System Cardiovascular Conditions .' Other Systemic Conditions
.
.
...
.
.
.'.';
.
.
.....
.
.
..'....
.
.
. .
...
.
.
......
.
. .
.
.
.
.
; ,
......
.
.
.
...
400 405 407 407 408 409 410 410 410 410
411.
Contraindications to Massage
...
.
.411
CHAPTER XXIII
EXERCISE
Physiological Effects
.
..
General Technique of Exercises Exercise in Various Conditions Circulatory System

.
.... .... .............. ....

.
.
. .
.
.
,.
Respiratory System
Gastro-intestinal
.
...
.
_.
..
.
.
.
.
. .
System
.
...
. .
.
.
.
.
Nervous System : Injuries of Bones and Joints

.
.
.
Peripheral Vascular Disease Arthritis and Rheumatic Conditions Contraindications Posture Underwater Exercises
.
..,...*.
.
412 412 414 418 418 418 420 420 420 420 420 425 425 429
CONTENTS
17
PART V
APPLIED PHYSICAL THERAPY
CHAPTER XXIV
CARDIOVASCULAR CONDITIONS
Review
General Considerations of Physical Measures in Cardiac Conditions Rest and Relaxation
Exercise
.
Massage and Passive Exercise Hydrotherapy

Electrotherapy
.
Angina Pectoris Hypertension

Exercise in Cardiac Patients
.
...
.
\
.
.
Hypotension Cardiac Neuroses
. r
.
Peripheral Vascular Disease Diagnostic Considerations Review of Physical Measures in Peripheral Vascular Disease
Thermal Measures Electrochemical Measures Mechanical Measures

. .
.-.-...'
.
"V
...
. .
Neurovascular Disorders Raynaud's Disease Organic Vascular Disorders

Arteriosclerosis Obliterans
Thrombo-angiitis Obliterans (Buerger's Disease) Thrombophlebitis Acute Thrombosis and Embolism Care of Feet in Peripheral Vascular Disease
. .
..
-. '--..
.
.
432 432 432 433 433 433 433 433 434 436 437 437 438 438 439 439 441 441 444 444 444 444 445
.445
.
446 446
CHAPTER XXV
RESPIRATORY, GASTRO-INTESTINAL AND METABOLIC CONDITIONS
Bronchitis
.
,'
: .,
.........
'
Pneumonia
Erripyema
Pleurisy
>
V%
;
".
"
*. .
Pulmonary Tuberculosis
.
....
.
:'.
".
Gastro-intestinal Conditions Gastric Neuroses

.
.....
.
.,
Constipation
Visceroptosis
...".,....,
448 448 449 450 450 450 452 452 452

455
Postoperative
.
and
Postpartum. \Yeakness
.
. .
.
of
Abdominal
.
Muscles Abdominal Adhesions
.*
...
:
45.6
Intestinal Tuberculosis
.../..
Peritoneal Tuberculosis Diseases of the Liver

Cholecystitis
Metabolic Conditions Rickets

Infantile
456 456 456 457 457
.457
458 458
Tetany
Obesity
CHAPTER XXVI
CHRONIC ARTHRITIS AND FIBROSITIS
General Considerations Role of Physical Therapy 2
461
462
18
Classification of
CONTENTS
Rheumatic Diseases Rheumatic Fever Chronic Joint Changes
. .
.
.
...
.
.,.
.."
. . .
".
.
,
Non-articular Manifestations Grading of Cases Physical Treatment Measures in Arthritis

.
' .
"
._
.
.
. .
...
'
Thermal Measures Mechanical Measures Thermal and Mechanical Measures Counterirritant Measures Thermal and Counterirritant Measures Spa Treatment Scheme of Physical Treatment
.
.
...
.
. ...-.:.
...
.
..... .....
....
.
.....
'
.
.
.
.,
....
Osteo-arthritis Rheumatoid Arthritis Gonorrheal Arthritis

.
...
.
.
.
.
....
.
Spondylitis Deformans (Marie-Striimpell Disease)
Gouty
Arthritis
.
Acute Arthritides Tuberculous Arthritis Traumatic Arthritis

Fibrositis
.
...
'.
..'.:.
Pathology
Diagnosis and Treatment
Panniculitis
Classification
.
.
Treatment
........ ....
.
>.
. .
462 462 462 463 463 464 465 467 469 469 470 470 471 472 472 472 473 474 474 474 474 474 474 476 476 477 478
CHAPTER XXVII
AFFECTIONS OF THE CENTRAL NERVOUS SYSTEM
General Considerations Hemiplegia General Paresis Locomotor Ataxia Multiple Sclerosis
. . .
.-*
.>....
.. . .
Myelitis
Chorea Minor
Cerebral Palsy (Spastic Paralysis) Obstetrical Paralysis Infantile Paralysis
The Neuroses
Vegetative Neurosis
Traumatic Neurosis Mental Conditions Electric Shock Therapy
'.....-.:..
CHAPTER XXVIII
480 482 484 484 485 486 486 486 487 487 493 494 494 495 496
AFFECTIONS OF PERIPHERAL NERVES

Peripheral Nerve Injuries Pathology and Diagnosis
.
. .
....
'
.
.
',
Treatment
Neuritis
Pathology
...
'
...'...........508
.
501 501 501 503 508
Classification Relief of Pain in

.
Acute Neuritis
"
Chronic Neuritis Special Forms of Neuritis Facial Paralysis (Bell's Palsy) Brachial Neuritis Sciatic Neuritis Meralgia Paresthetica
. Trifacial Neuralgia Intercostal Neuralgia
.
.
: -
'.
............
..... ...
.
.j*
.
...'...
.
-.
;
.j
508 509 510 510 510 514 515 516 516 517
CONTENTS
CHAPTER XXIX
AFFECTIONS OF BONES, JOINTS, MUSCLES AND TENDONS
Traumatic Conditions
General Considerations General Pathology of Injuries Objects and Methods of Physical Treatment Injuries of Joints and Muscles Contusions
.
19
"...
'.'.'.
',
519 519 519 520

521 521 522 522 524 524 525 525 525 528 528 529 529 529 530 531 531 531 532 532 532 533 533 534 534 540
Strains
Sprains Dislocations
Traumatic Arthritis
Stiff Joints Injuries of Bones
.
.
...
.
.'
.....
...*,
.
.
.
Fractures
Amputations
....
.
"..'
Back
Injuries
...
Coccygodynia Affections of Bones and Joints

Osteomyelitis Tuberculosis of Bones and Joints Affections of Muscles Acute Myositis Chronic Myositis Volkmann's Ischemic Contracture Affections of Tendons and Bursae Tenosynovitis
.
Bursitis Superficial Bursae
.:....
.
Deep Bursse Shoulder Affections Miscellaneous Surgical Conditions Adenitis

.
Burns
.... .................
.
.
Scars Foot Conditions (By Jerome Weiss, M.D.)
'.
540 540 541 541
CHAPTER XXX
GYNECOLOGICAL CONDITIONS
General Considerations General Rules of Technique
Electrodes Pelvic Heating by Diathermy Pelvic Heating by Non-electrical Methods Pelvic Iontophoresis Inflammatory Conditions
;.
.
...
Gonorrheal Cervicitis and Urethritis Pelvic Inflammations Chronic Endocervicitis . Cervical Erosion
.'
..."........
.
Miscellaneous Conditions Non-inflammatory Conditions Infantile Uterus With Stenosis of Cervix
..........."....
.
. .
Amenorrhea
Sterility
Dysmenorrhea Menopausal Syndromes Minor Surface Growths
545 545 546 547 549 551 551 551 552 553 556 556 557 557 557 558 558 558 558
CHAPTER XXXI
GENITO-URINARY CONDITIONS
Electrodes and Technique Nephritis Tuberculosis of the Kidney
.
....
.
.
...
560 560 561 562
20
Renal Colic
Cystitis. Incontinence of Urine
.
CONTENTS
.562
.
.
.-
.;
Prostatitis
and Seminal
Vesiculitis
.
...
.
.
Prostratism
.
..
....
.
Gonorrheal Epididymitis * .... .... Gonorrheal Urethritis ...'. Tuberculous Epididymitis Calcified Deposits in Corpora Cavernosa Stricture of the Urethra Electrosurgery in Urology (By Daniel A. Sinclair, M.D.)
.
....
...
..
.....
563 563 563 564 564 564 565 565 566 566
CHAPTER XXXII
PROCTOLOGICAL CONDITIONS
BY
Hemorrhoids Medical Diathermy
Electrosurgery Surgical Galvanism
R. V. GORSCH, M.D.
"'-
....
. .
.
.
.
.'
.
.....'..
.
-.
>
.
.
Fistula in Ano Fissure in Ano Stricture of the Rectum and Anal Canal Polypi of the Rectum and Colon Proctitis Pruritus Ani
*\
.
.
Coccygodynia
Neuralgia, Hysteria of the Rectum, etc Tuberculous Peritonitis, Enteritis and Anorectal Tuberculosis Cancer of the Rectum
569 570 570 572 573 573 573 574 575 576 576 576 577 577
CHAPTER XXXIII
DERMATOLOGICAL CONDITIONS
Acne Vulgaris
Alopecia
Callositas
Benign Neoplasms
Corns Dermatophytosis Eczema Seborrhoicum
'
.
579 581 581 581 581

581 581
Erysipelas
Furuncles Impetigo Keloids and Hypertrophied Scars Keratoses
Neurodermatitis
Malignant Neoplasms Molluscum Cpntagiosum
...
. .
Nevi Pigmented Nevi Pityriasis Rosea

Psoriasis
...
;
Rhinophyma
Sycosis Vulgaris Telangiectases
. .
. .
Tuberculodermas Verruca Vulgaris Ulcers and Wounds

Hypertrichosis Epilation by Electrolysis
. .
"
583 583 584 585 585 585 586 586 586 586 587 588 588 588 589 589 589
.589
.
...
Equipment
Preparation of Electrolysis Setting of Current Flow The Operation
590 591 592 592 593 594 594
CONTENTS
Hypertrichosis Epilation bv Electrolysis Technique With Insulated Needles Test Treatment Complications and Dangers Postoperative Treatment
.
21
.'.....;
Treatments
'.
Number and Frequency

Epilation
of
by High-frequency Current
The Operation
596 597 597 597 597 598 598
CHAPTER XXXIV
DISEASES OF THE EAR, NOSE AND THROAT BY WALLACE MORRISON, M.D.
p General Considerations . . ; Diseases of the Ear The Pinna and External Auditory Canal Acute Dermatitis of the Pinna and External Canal Subacute and Chronic Dermatitis of the Pinna and External Canal Furunculosis of the External Canal
.
*.
.'
600 600 600 600 600

601 601 601
The Middle Ear and Mastoid
Process
Acute Non-suppurative Otitis Acute Suppurative Otitis Media and Mastoiditis Chronic Suppurative Otitis Media Chronic Catarrhal Otitis Media, Otosclerosis and Auditory Nerve Deafness Diseases of the Nose and Nasal Accessory Sinuses The External Nose and Nasal Vestibule Acute and Chronic Dermatitis Furunculosis
.
.
....', Media
602 602 603 604 604 604 604 604 604 605 605 605 607 607 607 607 607 607 608 608
608 609 609
............
.....
Chronic
Atrophic
Rhinitis
The Nasal Chambers
Acute Rhinitis Chronic Generalized Hypertrophic

Rhinitis Chronic Localized Hypertrophies Vasomotor Rhinitis and Hay Fever
..-.- and
.
.
Nasal Synechiae
Epistaxis
.
.
...
.
Lupus and True Tuberculosis of the Nose Benign and Malignant Growths of the Nose and Sinuses
The Nasal Accessory

Acute Sinusitis Nasal Polyps
Sinuses
.
Granulation Tissue Diseases of the Pharynx
Acute Pharyngitis Chronic Pharyngitis Hypertrophied and Infected Lymphoid Tissue Hypertrophy of the Adenoid Hypertrophied Remnants of the Adenoid Acute Tonsillitis Chronic Tonsillitis and Hypertrophy of the Tonsils
.
'
.......
.
609 609
610 612 612
Electrosurgical
Peritonsillar Elongation of the Uvula Hypertrophy of the Lingual Tonsil

.
Removal of the Tonsils and Retropharyngeal Abscesses

. .
....
.
Varicose Lingual Veins Diseases of the Larynx
...
Acute Laryngitis Chronic Laryngitis
"
....
...
.
Laryngeal Tuberculosis Benign and Malignant New Growths of the Mouth, Pharynx and Larynx
614
CHAPTER XXXV
DISEASES OF THE EYE
General Considerations . Eyelids and Conjunctiva Cornea, Uveal Tract and Retina
.
.
............
.
. . .
615
'.
Electrosurgery of the
Eye
619
22
CONTENTS
CHAPTER XXXVI
PHYSICAL THERAPY IN OFFICE PRACTICE
General Considerations Planning Physical Treatment

.
...
...
..-.'
.
Frequency of Treatment Judging Results The Treatment Habit Selection of Apparatus Office Space
Office Assistants
621 622 622 623 623
624 624 626
CHAPTER XXXVII
PHYSICAL THERAPY IN INSTITUTIONAL PRACTICE
General Considerations Relation to Other Departments The Director of Physical Therapy Location and Floor Space
...
. . .
.
Equipment
Records
Physical Therapy Library
...
.
Appendix.
Glossary
Electrodiagnostic Charts
.>
.
and Tables
.
.
....
....
627 627 628 633 634 635 637
640
654
669
Author's Index
Subject Index
672
ELECTROTHERAPY AND LIGHT THERAPY

CHAPTER
I
INTRODUCTION
PHYSICAL THERAPY IN THE PRACTICE OF MEDICINE
all life on earth. The warming of the sun, the flow of water, the electrical charge in some of the rays bodies around us, all form parts of Nature's inexhaustible and all-powerful
PHYSICAL forces furnish the basis of
properly mastered are of help to increase circulation, enhance local and general body metabolism, relieve nerve irritation or stimulate nerve function, inhibit growth of germs or destroy them altogether. As a result of all these effects, physical agents may speed up repair of injured or diseased tissues, restore disturbed function, relieve pain and improve the condition of the entire body. Basis of Physical Therapy. The human body is a complex transformer of energy. Chemical energy stored up in food or in drugs is split into component molecules and serves to keep up or modify physiological functions in the body. Some of these chemical processes create physical energy such as heat, electrical action currents either as a by-product or as an essential object. Physical energy can also be conveyed to the body from the outside by various methods and thus serves to stimulate physiological processes. Any form of physical energy applied to the human tissues exerts a primary physical or physico-chemical action and this in turn affects cellular activity. These "secondary" physiological effects serve to influence a pathological condition either locally or system ically and thus
if
array of forces. The same physical forces inestimable value in the art of healing. They
may
create therapeutic effects.
Most of the procedures and effects of physical measures are applied through the skin. The skin is not merely a protective covering of the body but also a complex structure of perception, absorption and excretion. It is capable of a variety of reactions to stimuli from the outside and from within. Most of the reactions brought about by physical forces are nonspecific in character. It has been shown that stimuli of different nature, such as heat, manipulation, chemical or electrical agents may cause similar
vascular response in the skin, consisting of dilatation of blood-vessels, increased permeability of the vessel walls and increased circulation. The nervous reflex effect of "counter-irritation" through the skin upon deeper parts may be alike and this explains the seeming paradox of similar
therapeutic effects on painful conditions by physical agents of apparently There are definite reflex reactions between certain cutaneous areas and the gastro-intestinal tract. In general, internal organs are reflexly related to the skin directly overlying them, and the effect
different nature.
(23)
24
INTRODUCTION
produced by reflex is the same as that seen in the cutaneous area treated. Cold applications to the cutaneous area produce a related effect on the organ beneath, i. e., a tonic or stimulating procedure. Applications of heat cause relaxation, increased blood supply and increased activity. (Fig. 1.)
Many
canal,
may
visceral disorders, particularly disorders of the gastro-intestinal be beneficially influenced by appropriate stimulation of the
corresponding cutaneous areas. There are, on jthe other hand, specific reactions in the skin, such as those caused by ultraviolet radiation, which cannot be produced by any other agency. With physical agents capable of penetrating the protective covering of the skin and other tissues, specific effects on inner organs can be expected. This part of physical medicine offers at present a large field for clinical research.
TABLE
1.
PRINCIPAL PHYSICAL AGENTS AND SOME OF THEIR EFFECTS

Primary physical
Secondary physiological
effects
effect
Physical agent
Hot water Hot air

Radiant heaters Incandescent lamps
C
Hyperemia
Sedation of sensory or motor irritation Attenuation of germs
Thermal
Diathermy Sun Sun Heated metals Carbon arc Mercury vapor

Roentgen-ray
Erythema
Pigmentation
Activation of ergosterol Effects on blood
Photochemical
arc
Radium
Galvanic current
Physicochemical
T-, Electrochemical
,
Contraction of tissues Molecular disintegration

Polar; vasomotor stimulation
metabolic
Low frequency, interrupted

and alternating currents
Vibration
Electrokinetic
Massage
Kinetic
Muscle stimulation Increase of venous and lymph flow, stretching of tissue, reflex stimulation
The strength, duration and extent of application determine the local or general sedative, stimulative or destructive effects of any physical agent.
It is evident that a definite diagnosis arrived at by all known methods, or at least an acceptable working diagnosis, is essential before any form
of therapeutics is instituted. If physical treatment is being considered, either as a primary line of attack, or as an adjunct to other appropriate treatment, the question should not be "What kind of apparatus shall be
The query should be rather: "What type of physical agent, or combination of agents, will be best suited to overcome the anatomical or functional disorders in this individual patient?" must strenuously resist the conception fostered by commercial interests that, for treating a given condition, a certain make of apparatus is necessary. The object of physical therapy is the bringing about of certain physiological responses and the student of this branch of therapeutics must learn
applied?"
We
to choose from the available methods, according to the circumstances. He should have no difficulty to make his choice once he had sufficient
theoretical grounding
and acquired
clinical experience
under competent
guidance. For the efficient and safe application of any physical measure, the following basic knowledge is essential 1. What is the physical nature of the form of energy employed?
:

2.
25
What
are
effects
3.
its primary on the body?
physical,
and
its
secondary physiological,
it
In what pathological or functional changes does

useful?
prove
clinically
4.
5.
What What
is
are
the correct technique of its employment? its possible dangers and contraindications?
Schematic diagram to illustrate the interrelation of vasomotor, secretory and caused by sensory stimulation through the reflex arc. Afferent pathIt can thus be seen how radiant heat on left, efferent pathways on the right. the skin surface can cause reflex vasodilatation of deeper structures and change in muscle tone. Also it is apparent how visceral stimuli can elicit muscle spasm and referred pain.
1.
FIG.
myo tonic phenomena

ways on the
(After Wiggers.)
It is evident that any physical measure capable of doing good is also capable of doing harm if it is incorrectly applied. Likewise there is a threshold of intensity and duration where therapeutic efficiency begins; and there is a danger zone when that threshold is exceeded. The quantita-
26
tive or
INTRODUCTION
measured conception of physico-physiological effects is established clinical and laboratory research work and is the main factor in gradually elevating physical therapy procedures from an empirical
by painstaking
stage to that of a well-defined scientific procedure.
Scope of Physical Therapy. A frequent Abjection voiced by the uninformed is that physical therapists concern themselves with all too many pathological conditions, instead of remaining within a well-circumscribed domain. No such objection is voiced against the similar wide use of drug
1 therapy in all departments of medicine. Sollrnan states, "Although drug therapy and drugless therapy may seem direct antipodes to the superficial thinker, they involve the same principles, evoke the same phenomena, accomplish the same results. They differ only in the means which they employ, of which sometimes the one, sometimes the other is better adapted to secure the desired end. Indeed, the differences between physical therapy and pharmaco-chemical therapy are no greater than those between radiant
and
direct heat, or
Physical therapy
of conditions.
local and general anesthetics." neither a causal nor a specific therapy in the majority It serves in acute disease conditions to relieve symptoms
between
is
and speed up recovery. Simple thermal and hydriatic measures have been part of standard nursing procedures for a long time. In local and general infections, ultraviolet radiation and heat measures are of considerable importance. In certain acute systemic infections such as gonorrhea and its complications and a few others, artificial fever therapy has an almost
specific effect.
In acute traumatism, the
efficient application of physical
measures
The
and
essential for early recovery. most important field for physical therapy lies in the treatment of
is
chronic disease conditions.

safe for relieving pain
In these, physical agents are quite dependable and offer often a definite chance for recovery
by bringing about gradual
resolution of chronic inflammatory processes. General thermal or hydriatic agents acting through the skin as an organ will stimulate general circulation and elimination. Local thermal agents can stimulate the function of any organ or body region and speed up absorption of products of inflammation or trauma. Mechanical, electrical and photochemical stimuli can promote local chemical interchange which in turn affects the whole system; they also may act by active exercise or nerve reflex upon deeper situated parts or organs. Ultraviolet irradiation is a specific treatment for rickets. High-frequency electricity and surgical
galvanism are valuable methods for the destruction of minor new-growths tissue; major electrosurgery has made possible important advances in surgical technique. Among the many conditions in which physical measures prove of definite value are traumatism, both acute and chronic; the various forms of arthritis and the rheumatic states, many kinds of paralysis and other organic and functional affections of the nervous
and diseased
system, chronic digestive disturbances, chronic diseases of the heart and blood-vessels, acute and chronic inflammatory conditions of the genital organs, nose and throat and many skin lesions. There are some obvious advantages in employing physical remedies. Usually they can be directly applied to the affected parts and in acute conditions, as a rule, they give immediate relief. In chronic conditions, patient and systematic application is essential, but there is no danger of habit-forming as is the case in
27
the use of certain drugs. In some instances physical measures will enable the clearing up of lesions apparently requiring an operation. Place of Physical Therapy. Physical therapy is not a new system for
recognizing and treating disease.
of medicine
It rightfully
forms part of the practice
and will be of most value in the treatment of disease and injury when employed by or under the immediate supervision of the
physician
who has
learned
why
there
is
scientific basis for the
use of
some physical energy or its combination with others and who knows when and how to apply it. Physical therapy cannot be practiced apart from general medicine and surgery, for it must be applied with a broad knowledge of clinical diagnosis. As a matter of fact its methods serve as a diagnostic aid in a number of conditions; hence its newer designation as physical medicine. Conversely medicine and surgery should not be practiced without physical therapy, a valuable adjunct, when coordinated with other indicated therapeutic measures, and, at times, a primary method of treatment. There is ample need and opportunity for the systematic use of physical measures by all medical men. However, the best interests of patients will be most satisfactorily secured if the possibilities and limitations of each group of physicians employing physical therapy are clearly understood. The general practitioner should be able to utilize simple thermal and hydriatic measures both at his office and at the bedside, and should be able to prescribe and demonstrate exercise for traumatic, arthritic, and other every-day conditions. He should employ elaborate pieces of equipment only after he has had competent clinical instruction in their use. Specialists in various fields of medicine, such as surgery, orthopedics, gynecology, and nose and throat diseases will all derive great satisfaction from such physical measures as are applicable to their respective fields, once they have had proper theoretical grounding, and at least the rudiments of clinical training in their employment. There is need in every large center of population, and certainly in all large hospitals, for medical men with special training in general physical therapy to be able to render service with all modern resources, such as fever therapy, under-water exercise, and the various electric and light treatments. It requires training
and aptitude, as well as
official
support, to carry on clinical and experi-
mental research work, and to check on the claims for the ever-increasing number of new devices. Properly trained technicians are indispensable for administering physical therapy in institutions, and in most physicians' offices. But it is not fair to expect technical aides who have been trained to employ physical measures only according to instruction, to be responsible for the ordering of treatments, and the judging of their efficiency. This will be the case if a department is only nominally in charge of a physician or a group of physicians who have neither special interest nor training in the subject. No fountain can rise above its source and no physical therapy department can render the best possible service unless it is headed by a physician thoroughly familiar with the methods and scope of modern
physical treatment.
Classification of Physical
Therapy Methods.
The
classification of the
for no matter various physical measures is on what basis it is done, there will be overlapping, For didactic purposes and for institutional classification, heading under each physical agent
a somewhat involved problem
28
INTRODUCTION
such as electrotherapy, hydrotherapy, etc., as shown in Table 2 has proven practical. In such a classification the same agent, according to its form of application, may exert a variety of physical and physiological
effects. For an intelligent conception of basic effects and prescribing, a grouping of physical measures according to the primary thermal, mechanical or chemical effect is more desirable, as has been shown in Table 1. This brings together physical agents of a different nature electricity, water, but shows that their physiological effect is based on a similar primary light
physical effect.
TABLE
1.
2.
METHODS OF PHYSICAL MEDICINE

Electrophoresis
Electrotherapy Galvanic or direct current
Low-frequency currents Electrodiagnosis High-frequency currents Electrosurgery

Static electricity
2.
Light therapy Photo thermal radiations Visible and infrared rays Photochemical radiations Ultraviolet rays
Heliotherapy
3.
4.
5.
Hydrotherapy Hydrothermal measures Hydrokinetic measures Hyperthermy and Hypothermy Mechanotherapy Massage and manipulation Medical gymnastics
Occupational therapy
Roentgen-ray or roentgen therapy although employing an agent of

physical nature does not appear in the above classification because by well-established custom it forms part of another large special field of medicine. Apparatus for Physical Therapy. It is by no means necessary to possess
a large array of machinery to produce the few basic physical and physiological effects Simple hot and cold applications, active and passive exercise can do a world of good by themselves. There is danger in too much and too complicated apparatus for therapy, just as there is danger of too much
:
apparatus for diagnostic purposes when one's five senses and clinical experience, unaided should be adequate to solve many problems. On the other hand, modern mechanical and electrical progress offers many types of efficient apparatus, with the saving of expenditure of one's own energy, of time in accomplishing results, and with the possibility of accurate dosage and location of the physical energy to be applied. The advantages of modern electrical apparatus over some of the older crude methods are just as evident as those of the modern methods of transportation over the time-honored mode of walking and pushcarts. Those who grudgingly admit that they believe in massage and exercise, but do not care three figs for all this apparatus, the glittering machinery of practice, simply handicap themselves very sadly. They limit their speed and confine their radius of action to a narrow segment of what it might be.
For the ever-increasing scope of physical therapy, apparatus is quite indispensable, and will tend to become more so in the future. The finer and more varied the control, the larger the range of power, the more
29
accurate the measurement of energy input, the more varied and the more dependable will be the subsequent physiological and clinical results. Electrotherapy and Light Therapy. From the standpoint of the general
practitioner, electrotherapy and light therapy open up many new vistas in medicine and surgery and although not entirely replacing some of the simple methods of application of heat, massage and exercise, enable a
and more extended application of physical energies. With simple and inexpensive equipment, the general practitioner comparatively can produce results in many conditions in which treatment by medication and surgery alone is not quite satisfactory. The rational use of such measures should be part of the office work of most progressive physicians because it increases the efficiency of the medical service rendered. A striking illustration of the changed conception of the place and future of electrotherapy is contained in an editorial of the New York Times, 2 written apropos the First International Conference of Fever Therapy: "Twenty-five years ago the physician who clamped a pair of electrodes on a patient and passed an electrical current through the body either to heat tissues according to the principles of diathermy or twitch muscles or stimulate the flagging system was regarded either as a self-deluded enthusiast or as a quack who could not be restrained because he had a Now the First International Conference on Fever Therapy is license. held under the high patronage of such medical eminences as Nobel being Prize winner Wagner-Jauregg, Volhard and Bessemans. No longer is there any doubt about the cures of the electrotherapist. Venereal diseases, general paralysis of the insane, arthritis and a score of other diseases are now treated electrically and successfully without causing the professors in the medical colleges to lift their eyebrows. "In French a physicist is still called a physicien. The justification for doing so is more apparent than ever in these days of waves and highfrequency currents applied in medicine. Many of the men who practice the new electrotherapeutics are so well grounded in physics and electrical engineering that they have made striking technical improvements. This new science needs their combination of electrical and medical knowledge. It still lacks measurements, still lacks standards. But empirical as it still is it supplies evidence that the old pill box is obsolescent. Medicine today belongs to the chemist, the electrotherapist, the bacteriologist, the radiation expert. Gradually it is acquiring the precision that we associate with real science. And the electro therapists who were once regarded as little better than charlatans helped to bring about the change."
well-controlled
REFERENCES
1.
SOLLMAN,
2.
Address of Welcome to the 19th Annual Convention of the American Congress of Physical Therapy, Arch. Phys. Ther., 21, 561, 1940. New York Times, March 31, 1937.
J.:
PART
Electrophysics
CHAPTER
II
The Structure
Matter and the Atomic Theory. The Electron Theory of Matter. The Elementary Law of Electrophysics. Conductors and InsuTransfer of Electrical Charges. Charging by Induction. Condensers. lators. Electric Potential. Static Electricity. Electric Current. Thermal, Electro-magElectrical Units: the Ampere, the Ohm, the Volt. netic, and Chemical Effects. Difference Between Amperes and Volts. Ohm's Law. The Watt and the Farad. Measuring and Regulating Devices.
of
Electric Charge.
No
fairly well
one can apply electrotherapy efficiently and safely unless he is grounded in the physics of electricity and has acquired practical
experience in the therapeutic employment of the various electromedical currents. The physician must be familiar with the e very-day use of electricity and the construction and control of every piece of apparatus he employs. It would seem a poor exhibit of efficiency should a busy physician's officework come to a stop while someone scurries around to get an electrician to remedy such common troubles as a blown fuse, or a broken
connection in a conducting cord or socket plug. The Structure of Matter and the Atomic Theory. The modern theory of the structure of the atom holds that electricity forms an integral part in the structure of all matter. Anything which has weight and occupies space is called matter. Matter is composed of some ninety-two primary substances, known as elements, which cannot be split up into bodies of a different kind without changing their characteristics. Some of these are solids, like zinc, iron, sulphur, others are liquids, like bromine, mercury;
some are gases, like hydrogen, oxygen and nitrogen. All complex forms of matter, all minerals, all tissues in animal or vegetable life are formed by the combination of these elementary substances. It is obvious that, while masses can be split up into smaller and smaller particles, there must be an ultimate particle of any element that cannot be divided, and which forms the basis of the element as a stable unit. According to Dalton's classical theory, proposed in 1802, such a particle is called an atom (from the Greek a-tomos: indivisible). The atom, the most minute unit of matter, takes part in chemical changes by uniting either with the other atoms of the same kind to form appreciable quantities (molecules) of the same element or with atoms of other elements to form
finally,
compounds. A molecule may consist of two or more atoms, the atoms being for instance, all hydrogen or all oxygen, or the all of the same element
molecule may consist of different elements for instance, a molecule of water is composed of 2 atoms of hydrogen and 1 of oxygen (HÔ). The unit of atomic weight is the lightest of atoms, the hydrogen atom.
(30)
THE ELECTRON THEORY OF MATTER
31
The Electron Theory of Matter. Experimenting with electrical discharges from glass tubes having a high degree of exhaustion, J. J. Thomson, later Lord Kelvin, of Cambridge, England, discovered, in 1897, a stream of extremely minute particles projected from the negative electrode or cathode. He proved that the particles forming these "cathode rays" have each a mass amounting to about 1/1800 that of a hydrogen atom and that each carries a negative charge. He named these particles electrons (from the Greek elektron: amber, the substance which can be electrified by friction) and Millikan, the American physicist, succeeded in measuring
and
isolating
them.
electron theory supposes that every atom of matter in the neutral state is made up of a certain number of elementary positive units and an equal number of electrons. The charge on the electron is negative but this
is
The
only an accident; the choice of what was to be positive electricity and
originally quite arbitrary and it happens to have made the electron negative. Electrons have become universally accepted as the smallest known particles of matter and have now almost become an article of commerce. In radio tubes electrons are given off as readily as hot water gives off steam. The electron is the unit of electricity and represents a universal element of structure of all matter, whether flowing along slowly in an electric current or hastening through space at an extremely high rate as a cathode ray, whether it is emitted in radioactive disruption or in a photoelectric process, whether it is "jumping" in our lamps, etc. It is always the same physical unit, proving its identity by exhibiting the same charge and the same mass, in particular by keeping the ratio of charge to mass constant. Rutherford's experiments with radioactive elements established the second universal constituent of the atom called the proton. The proton has an electrical charge of the same value as the electron, though of opposite charge but its mass is quite different, being 1800 times as heavy as that of the electron. Every atom is believed to consist of an extremely small nucleus in which is packed all the positive electricity and around which the negative electrons are arranged in some definite order but with wide spaces
what negative was
between them. The atoms of all elements are thus believed to contain as constituents both positive and negative electricity. In the hydrogen atom there is only one proton and one electron present, but in all other atoms there are more protons than electrons in the nucleus, which thus possesses a positive charge. This is balanced by the addition of electrons surrounding the nucleus. The atom of oxygen contains sixteen protons and sixteen electrons.
(Fig. 2.)
Modern physical research has made numerous new discoveries about the structure of matter. Anderson in 1932 found the positron a positively charged, rather unstable elementary particle of the same weight as the electron. Chadwick in the same year discovered the neutron, an electrically neutral particle of the same weight as the proton. Research in radiation energy has added another primary constituent of matter, that of the
photon or light quantum, about which more will be said in Part III. Recent work with atoms through the use of the cyclotron and similar atom smashing devices causes atoms to give up other than electron particles; in fact, actually transforming or transmuting the atom to one of a different ele-
32
etc.,
are
mental character. Electrons, protons, neutrons, positrons, dueterons, all fragments of atomic destruction.
H
1
16
+
16 +
8
2
6
Schematic illustration of electron theory. Each atom contains an equal number of protons and electrons. Protons are represented by + sign and electrons by dots. In the hydrogen atom there is only one proton and one electron present, while the oxygen atom
FIG.
2.
contains 16 protons and 16 electrons.
(After Gibson.)
Electric Charge.
electrical
The
electron theory
is
the basis of explanation of
all
phenomena. The binding together of electrons and protons into atoms represents large amounts of energy. An object containing a normal balance of electrons and protons shows no electrical properties. If the atomic structure is disturbed by an external force of sufficient strength, such as friction, heat or chemical action some of the electrons of the atoms
be driven away. Charging a body consists of taking away or adding A negatively charged body is one which contains more electrons than its normal number; a positively charged body is one which contains less electrons than its normal number. The Elementary Law of Electrophysics. The basic law which underlies all considerations in electrophysics is: bodies charged with the same kind of electricity repel each other while those charged with a different kind of electricity attract each other. In other words, like charges repel and
may
electrons.
body one may use an electhread from a glass support or the wellknown gold leaf electroscope, two strips of thin gold leaf attached to an insulated brass rod and hung in a glass jar. (Fig. 3.)
troscope, a pith ball
unlike charges attract. For detecting the condition of an electrified
hung by a
silk
CONDUCTORS AND INSULATORS

Conductors and Insulators.
33
currents) any enough atomic change to permit a flow of electrons, and hence under sufficient electrical stress there is no sharp demarcation between conductors and non-conductors.
insulator
Substances which lead off the electric charge quickly are called conductors; those which prevent the escape of an electric charge are called non-conductors or insulators. Most substances conduct a little and under powerful influence (high voltage
may
suffer
it
Detecting an electric charge. A goldleaf electroscope is charged by approaching with an electrified vulcanite rod. The negative charges are driven toward the two leaves which show an electric charge by repelling each other.
FIG. 3.
Metals are the best conductors. In all metallic substances there are always a number of electrons free from their atoms and as soon as these free electrons are pushed along in the conductor, a flow of electricity will
larger the number of free electrons in any substance, the greater conductivity. The substances which are good conductors of electricity are also good conductors of heat. Watery solutions of acids, bases and salts are known as electrolytes (from elektron and lutos: soluble)
begin.
will
The
its
be
and
also conduct well.

is
The
difference
between metallic and
electrolytic
conductors
that in the latter a flow of electricity brings about chemical
changes. A substance in which there are no free electrons and the resistance of which to the flow of electricity is high is called an insulator. There are solid insulators such as hard rubber, mica, glass, amber, porcelain and silk and fluid insulators, such as oils, paraffme and pure distilled water. Lubricating oil placed over parts of electrical apparatus through which the current has to flow will prevent its passage instead of facilitating it. To prevent leakage of electricity electric light wires and terminals of electromedical apparatus are mounted on glass, porcelain or hard rubber,
3
34
Partial conductors are substances which ordinarily resist the flow of but under certain conditions will become conductors.
electricity
TABLE
Insulators
3.
INSULATORS AND CONDUCTORS

Good conductors
Metals
Partial conductors
Amber
Glass
Dry wood
Paper
Alcohol Tap water
Carbon
Graphite
Hard rubber
Paraffine
Watery
solution of salts
and acids
Dry
air
Porcelain
Distilled water
Moist air Kerosene
Wet wood
Important examples of partial conductors are: (1) Distilled water is an insulator, if sufficiently pure, containing no dissociated molecules; as soon as it contains a slight trace of salts, however, electrolytic dissociation takes place and the water becomes a good conductor. Ordinary tap water, always holding an admixture of salts, is therefore considered a partial conductor. (2) The tissues of the human body; they are good conductors on account of their saline ingredients, but the horny substance in the superficial layers of the skin serves as a fairly good insulator. By moistening the surface of the skin w e overcome its insulating property. In applying some forms of electricity to the body, part of our technique is directed toward overcoming skin resistance, so as to secure a free passage of current to the well-conducting tissues beneath. In conduction of so-called hightension or high-voltage forms of electricity skin resistance plays only a minor role. (3) Dry air is an insulator, while moist or ionized air is a partial conductor. The high-tension charge of static machines leaks off when the atmosphere is humid, while on dry days the charge is easily retained. Perfect vacuum is an insulator; in the so-called glass vacuum electrodes
r
used in treatment the air is only rarefied, so that they are fairly good conductors of high-tension current. Transfer of Electrical Charges. For transferring electrical charges conductors such as wires or metal plates are used; at the same time, these must be insulated from other conductors by non-conducting material, hence the covering of copper conducting wires by an insulating layer of silk or rubber, and the mounting of electrodes on insulating handles. Electricity of high tension, such as the static current or the monoterminal discharge of a high-frequency machine, is difficult to insulate, and its tendency to leak off to a neutral body or the ground in the form of sparks must be guarded against by long insulating handles and by holding it at a safe distance from all grounded objects. Charging by Contact and by Induction. This is easily explained by the When a positively charged body is brought near an electron theory. insulated conductor, the free electrons in the conductor are attracted from all parts of the conductor to the end nearest the positively charged body and this end thus becomes negatively charged. As these electrons were drawn away from the far end of the conductor, it has less than its normal
number
of electrons
and
is
therefore positively charged.
condenser consists of two opposing surfaces of metal by some insulating substance (glass, mica or air) on which separated electric charges can be collected (or condensed) because the reciprocal attraction across the separating insulation annuls the repulsion. Capacity is the relative power of holding the ratio of the electricity held captive to
Condensers.
CONDENSERS
35
the tension that arises; it depends on the size of the plates, their distance and the kind of insulating substance between them. A dielectric (unelectric) substance is one which offers great resistance to the passage of electricity
by conduction, but through which
electrical force
may
act
by induction.
Charging by contact. A Leyden jar is held by the hand, and thus grounded; brought in contact with a source of frictional charge, such as the positive terminal of the static machine; the positive charge on the outer layer will be repelled to the ground and the earth will supply the outer layer with an amount of charge sufficient to counterbalance the charge on the inner layer.
FIG. 4.
its
knob
is
Condensers may be likened to water tanks and are necessary for the holding of a definite amount of electrical energy ready for immediate flow in certain types of apparatus, such as high-frequency machines and electronic devices. If the plates of the condensers are connected, the positive and negative charges are united and the condenser is "discharged." Such
FIG. 5. Charging by influence or induction. Bringing a charged body near but not in actual contact with an insulated conductor will cause a separation of the electrical charges; the opposite charges are repelled to the far end of the conductors, and if they are led off by another conductor a definite charge is left on the first conductor.
is usually "oscillatory" in the form of electric waves and is accompanied by a sound. (See next chapter.) The Leyden jar is the earliest and best known form of a condenser and consists of a wide-mouth glass jar coated by a metal, such as tinfoil, to about two-thirds of its height, both on the inside and the outside. A brass
discharge
36
rod extends through an insulated stopper; the lower end of the rod is connected with the inside coating by means of a brass chain and terminates in a knob on its upper end. Modern electrical apparatus is usually equipped
Copper or
foil
tin.
mica or paper/
Copper or
foil
tin,
/mica or paper/
Jar
FIG. 6 FIG. 7
of
FIG. FIG.
6.
Diagram
Leyden
jar, its
discharge through a "spark gap."
7.
Plate condenser.
with plate condensers, consisting of a number of flat metal (copper) sheets separated by insulating material (mica). The alternate layers of the conducting material are connected to the terminals of an electrical source. A large capacity can be built up in these plate condensers.
FIG.
8.
Electric repulsion.
from a static machine; the charge spreading and as a result each hair repels its neighbor.
person seated on an insulated platform receives a charge all over the body electrifies each hair similarly
Static or frictional electricity is the first known form Static Electricity. the Greek name of which of electricity. The Greeks observed that amber
STATIC ELECTRICITY
is
37
attract light objects, such as feathers, Gilbert, physician to Queen Elizabeth, discovered that glass, sulphur, resin and some other substances possessed the same property as amber and he coined the name electricity (electricitas) from the Greek
elektron
when rubbed, would
or bits of paper.
word.
dissimilar substances, preferably non-conductors of electricity, some substances take on an excess of electrons, while others are left with a deficit of electrons. Those with an excess of electrons are
When
are rubbed
considered to possess a negative charge, while the ones deprived of their electrons are considered to be charged positively.
Electricity produced by friction is held on an insulated conductor in a state of tension, ready to flow away, and is called "static" electricity, in contrast to "current" electricity which flows all the time.
FIG. 9. Primitive static machine (Tcepler-Holtz type). R-R', contact brushes; N, diagonal bar for neutralizing charges; J-J', small Leyden jars to increase capacity of apparatus.
Lightning may be explained by the separation of electric charges on the heavy raindrops from the thunderclouds by the violent air currents. The negative charges remain on the finest particles blown high into the air while the heavy positively charged raindrops are left behind. Thus an electric field of enormous tension is created and, due to the overpowering pull of the lines of force, the charges rush forward, ionize the air (making it a conductor) and there is a lightning flash. The static machine is a miniature generator of lightning. In its primitive form it consists of two circular glass discs mounted on a spindle, with only a small space between them. When rotated by a handle, or by motor power, at high speed, a separation of electric charges takes place and metallic brushes draw off the positive and negative charges from the revolving disc, leading them to two metallic "prime" conductors or ter-
38
minals. When the difference of potential between these two terminal conductors becomes sufficiently high an electric discharge occurs in the form of a spark.
CURRENT ELECTRICITY
Electric Current.
is
A stream of loose electrons passing along a

To
establish or maintain
conductor
called a current of electricity.

it
is
an
electric
current
necessary that there be a source of energy generating an
FIG. 10 FIG. 10. Electric circuit. FIG. 11. Short circuit. low-resistance by-pass.
FIG. 11
An
accidental overflow of current due to an establishment of a
electric charge and there be a- complete electrical circuit maintained between the higher and lower level of electrons. The path of the current from the generating source through the various conductors back to the generating source is called an electric circuit. As the electric current flows, the circuit is said to be "closed;" if an interruption or a break occurs the circuit is said to be "open' and the current ceases to flow. This terminology
'
O
<
h_J
TIME
FIG. 12.
Diagram
of direct current derived
from an
electric cell.
originates from the employment of switches, which are closed in order to start the current and opened so as to discontinue it; although expressing
just this action, it nevertheless in electrotherapy.
is
a source of confusion for the beginner
Two
direct
and the
forms of current are employed in every-day commercial life, the alternating. In the case of direct current (D.C.) the flow
of electrons continues
unchanged in the same direction, while in the case of alternating current (A.C.) the direction of flow changes periodically, as
shown diagrammatically.
The voltage of the alternating current is represented by a double curve, one-half above and one-half below the neutral level. Each part of the curve is called an impulse or alternation; two successive alternations con-
EFFECTS OF CURRENT ELECTRICITY
39
The time consumed in the completion of a cycle is stituting a cycle. called a period. The number of cycles occurring in a second is called the frequency of the current. The ordinary alternating current usually alteris therefore a current of 60 cycles and In e very-day usage we designate as low-frequency 120 alternations. currents those of a frequency of less than 10,000 a second, while the tenii high-frequency current designates a current with 100,000 or more cycles
nates at a rate of 60 per second and
per second.
VOLTAGE
I
ZES.O LINE E
VOL;:ACE T
FIG. 13.
Diagram
of alternating current.

The
effects:
existence of
(1)
an
electric current
is
made
evident by the following
developed in all parts of the circuit. (2) Every part of the circuit deflects a magnetic needle brought near it. (3) Chemical action takes place under certain conditions. All forms of currents produce thermal and electromagnetic effects. Chemical action is mainly produced
is
Heat
by the direct current; the changes in direction of flow in the alternating current interfere with the regular movement of ions upon which chemical action is based. Currents of very rapid alternation (high-frequency currents) exert no chemical action at all. 1. Thermal Effects. All electrical currents cause a rise of temperature in a conductor, due to conversion of electricity into heat. The facts regarding this effect were established by Joule in 1877 and are known as Joule s
laws:
1. The heat produced current strength.
is
directly proportional to the square of the
2.
The heat produced
in different
conductors
is
directly proportional
to the resistance of each conductor.

3. The resulting quantity of heat is in direct proportion to the duration of the passage of the current. Both direct or alternating currents produce heating effects in solid con-
ductors.
electrolytic solution,
Heating occurs also when a direct current passes through an but this is due to chemical changes, and is, therefore,
only a secondary effect. Joule's laws are of great importance in considering the heating action of alternating currents of rapid oscillations (high-frequency currents) on the body. The tissues of the body possess a varying resistance and those of higher resistance should heat up more when traversed by the electrical current. The electrical current, however, will not pass along a high resistance if there is a parallel path of lower resistance available. The heating effects of electric currents find extended use in every-day
40
industrial
is
life
electric energy into heat or light light .of incandescent lamps is produced by the passage of a current through a filament of high resistance, such as carbon or tung-
wherever the changing of
desirable.
The
sten.
Arc
lights consist of
other; a powerful current

brilliant light.
two carbons placed at a short distance from each jumps an arc between the two and produces a In electric radiators and heaters the resistance of the wire
produces the desired heat. In the electric cautery a loop of platinum wire
becomes heated.
FIG. 14.
Electromagnetic
field.
The heating effect of electricity on a conductor is directly proportionate to the intensity of current and inversely proportionate to the cross-section of the conductor; hence the necessity of proper size wiring in every circuit
The
to prevent overheating of the wires with the consequent danger of fire. protecting action of an electric fuse is based upon the fact that a
current of excess strength develops enough heat in a calibrated length of lead alloy to bring it to immediate melting, thus the flow of the current is interrupted and overheating of other parts of the circuit is prevented. 2. Electromagnetic Effects. A magnet is a substance which has the power to attract, according to its size, small or large particles of iron or steel. It also has the property of setting itself in definite relation to the earth, when freely suspended. These effects are produced by what is called a magnetic field surrounding a magnet. An electric current also sets up a magnetic field. An electromagnet consists of a length of insulated wire
wound around a soft iron core. When an electric current is the wire, the core temporarily acquires the properties of a passed along
(electric coil)
magnet.
The
If
magnetism
parallel to
electron theory explains electromagnetic phenomena by picturing itself as due to the movement of electrons within the atom.
a wire carrying a direct current is brought over a magnetic needle and it, it will deflect the needle at right angles. The magnetic needle
41
can be taken as representing a molecule of an iron core in an electromagnet, and each molecule of iron has an electromagnetic effect. The flow of electrons in the neighborhood of the wire
makes these
infinitesimally small
Sc
FIG. 15.
Deflection of magnetic needle by an electric current. B, battery; So, switch open (no current) Sc, switch closed (current flowing)
.
;
FIG. 16.
Production of current by movement of magnet surrounded by a coil. M, magnet; G, galvanometer. Arrow indicates motion of magnet.
L, coil;
42
magnets take up definite position, just as the magnetic needle does, and produce the phenomena of magnetism. As long as the electrons are kept moving along the wire the magnetic effect continues. On the principle of
electromagnetic influence
is
based the galvanometer, the sensitive instru(Fig. 15.)
ment for the measurement of the direct current, the amount of the deflection
of the needle varying with the strength of the current.
FIG. 17.
Production of current in a coil by a current flow in a nearby B, battery; S, secondary coil; G, galvanometer.
coil.
P, primary
coil;
Corresponding to the force effected by a current upon a magnet, there a reciprocal action of a magnetic field upon a current. If a coil carrying a current is hung in a magnetic field so as to be free to move it will tend to turn so that its plane will be at right angles to the line of force of the field. This principle finds an important application in the electric motor.
is
Electromagnetic induction
observed that
it is
insulated wire, if is moved to or from the magnet.

are:
(1)
was discovered by Faraday in 1831, who possible to "induce" a flow of electricity in a coil of a magnet is moved toward or from this coil or if the coil
The two most important laws
of
Faraday
alternating electric current is electric circuit, whenever in a nearby circuit
An
generated ("induced") in an an electric current of varying
strength (an interrupted direct current or an alternating current) flows. (2) An alternating electric current can also be induced in an electric circuit if a inagnet is moved near to it or if the circuit is moved in relation to the
magnet. (Fig. 16.) Electromagnetic induction also enables us to turn mechanical power directly into electrical power and, through the means of the dynamo, serves as the basis for the large-scale production of electricity. In the most important devices in the modern uses of electricity, such as the faradic coil, the induction coil, the electric motor, the electric bell, the telegraph,
the telephone and the radio, as well as in most electrotherapeutic apparatus, the principle of current production is inevitably linked up with electroSolutions of acids, bases or salts, known as electrolytes, dissociate into free atoms or groups of atoms. These free atoms all bear an electrical charge; bases, rnetals and alkaloids are electropositive,
acids and acid radicals being electronegative. These electrified particles have been named ions, or wanderers. When a direct electrical current is applied to an electrolytic solution the ions begin to wander; those with a positive charge are attracted toward the negative pole, or cathode, and
magnetic induction. 3. Chemical Effects.

those with a negative charge toward the anode, or positive pole. process of dissociation is known as ionization.
43
The
The electrical decomposition of an electrolyte is a complicated process. It consists essentially of two phases and is shown in the example of the decomposition of a solution of common salt. (1) Primary reaction; redistribution of ions.
(2)
Secondary reaction; forming of new chemical bodies
at the electrodes.
(Figs. 18
and
19.)
*-NA
CL-*
NA
OH*
OH-*.
--NA
HzO
FIG. 18 FIG. 19
ar
FIG. 18. Primary chemical reaction in salt solution under the influence of an electrical current. Redistribution of ions in the solution. Sodium ions migrate to cathode, chlorine ions to anode, undivided sodium chloride molecules move in no definite direction. FIG. 19. Secondary chemical reaction in salt solution. Formation of new chemical bodies at the electrodes. Sodium ions become neutralized at the cathode, caustic soda and free 2H 2 O = 2NaOH Chlorine ions become neutralised 2 ). hydrogen are formed (2Na at the anode hydrochloric acid and free oxygen are formed (2C1 At H2O = 2HC1 O) the negative pole, as a rule, bodies of alkaline reaction are formed (litmus turns blue) and at the positive pole bodies of acid reaction are formed (litmus turns red)
+ H
CimRENT-
jL\.
ELECTROLYTE
ff u
) /
FIG. 20.
Diagram
of silverplating.
The chemical effects of the direct or galvanic current are extensively used in industry for electroplating, electro typing and, also, for production of chemicals on a large scale. In silver plating, for instance, the article to be plated is immersed in a- solution of some silver salt and attached to the negative pole while a rod of silver is used at the positive pole. When the current flows a thin coating of silver is evenly deposited all over the surface of the object connected to the cathode. (Fig. 20.)
44
ELECTRICAL UNITS
The analogy of water flow has been employed for a long time to visualize the conditions of the flow of electrons through a conductor. Water would remain stationary in a pipe unless pressure is present to cause it to move. Such pressure is furnished either by a pump or by a difference in level between a high tank and the ground. Similarly, a difference of potential sets up the flow of electrons, and is brought about by a generator of electricity. The pressure or tension of the electrical current is in direct proportion to the difference of potential and is known as the electromotive force (E.M.F.) or voltage.
TABLE
4.
COMPARISON OF WATER SYSTEM AND ELECTRICITY

Electricity
Water system Pressure or head
Voltage or potential
Rate
Pipes
of flow or
volume per unit second
Amperage
Pump
Water
circuit
Dynamo
or generator
Wires or conductors
Electric circuit
Valves Valve open (water flows) Valve closed (no flow) Pipes leaking Pipes stopped up Pressure gauge Water meter
Switches Switch closed (current on) Switch open (no current) Short circuit
Open
circuit (no current)
Volt meter
Ammeter
Wattage
Water power
1.
through a pipe
The rate of a current of water flowing expressed as a certain number of gallons per second. Similarly the rate of a current of electricity may be expressed as a certain quantity of electricity flowing per second past a certain point. By international agreement, the quantity of electricity which deposits 0.001118 gram of silver is one coulomb and the current which deposits silver at a rate of 0.001118 gram per second is one ampere. The ampere is the unit quantity of electricity flowing per second and serves as the unit of measuring the flow of electricity. For commercial purposes (lighting, starting motors, etc.) a current flow of several hundred amperes may be used. For electromedical work much 1 less rate of flow is required therefore, as a measuring unit, only 10 00 ampere called the milliampere is employed. 1 MA. = 0.001 ampere. Of the various therapeutic currents, the static current employs the smallest rate of flow of electricity, 0.1 to 1 milliampere; the faradic current amounts to little over 1 milliampere; the galvanic current varies from 1 to 20 milliamperes the largest rate of flow is used in high-frequency treatments, from 500 to 1500 or, frequently, even more milliamperes. 2. Unit of Resistance. The Ohm. A stream of water flowing through a
Unit of Current.
The Ampere.
may be
retarded by the friction of the pipe. longer and smaller pipe offers resistance than a large and short one. The opposition offered by* the electrical conductors to the flow of current is known as the electrical resistance and its factors are the material, the length and the diameter of
pipe
is
more
the conductors. The unit of electrical resistance is the ohm and by international agreement 1 ohm represents the resistance of a column of pure mercury, 106 cm.
ELECTRICAL UNITS
high and 1 sq. melting ice.
45
C., that of
mm.
in cross-section, at a
temperature of
The Volt. In order to get water to flow 3. Unit of Electromotive Force. along a pipe it is necessary to have some driving force due to a pump or to a difference in water level. In order to get electricity to flow along a wire we must have an electromotive force. This may be furnished by the
difference of potential of
an
electric cell or battery or
by some other
electric
generator. The unit of electromotive force or pressure is known as the volt. It represents the electromotive force or "push" needed to drive a current of 1 ampere through a resistance of 1 ohm.
The voltage in the commercial current for lighting and power is either 110 or 220. High power transmission lines carry a voltage from 2000 to 20,000. The voltage in storm clouds amounts to several millions, bringing about the tremendous electrical discharges of lightning. For a spark discharge across the very high resistance of separated electrical terminals ("spark gaps") the necessary amount of electromotive force varies with the distance of the terminals. It is estimated that a 1-inch spark requires about 10,000 volts; a 4-inch spark, about 52,000 "effective" volts. For electron! edical currents the voltage of the supply circuit is considerably modified; it may be decreased by an interposed resistance or increased by "step-up" transformers. Galvanic, faradic, and sinusoidal currents employ up to about 75 volts and are consequently grouped as low volt or low-tension currents. High-frequency and static currents
employ from several hundred to several thousand
as high volt or high-tension currents. Difference Between Amperes and Volts.
volts
and are grouped
The beginner in electricity is usually confused as to the distinction between volts and amperes; comparison with water, as shown in Table 4 will help to clear up some of the difficulty. With both water and electricity there must be a motive force (head of water or difference of potential) in order to get a flow of current,
may have the motive force and yet have no current. A closing of a valve in the water pipe acts like an open switch in electricity. There is a motive force or pressure (volts) but no current (amperes). The greater the electromotive force in a given circuit, the greater is the flow of current per unit time; the greater the pumping force or head in case of water, the larger the number of gallons flowing through a given pipe. In other words: electrical current denotes the rate of flow, electrical resistance the opposition which regulates the flow and voltage the moving force which causes the flow. Ohm's Law. All calculations of electrical measurements are done with
but we
the aid of Ohm's law which states: In an electrical circuit the flow of current (amperage) is in direct proportion to the electromotive force (voltage) of the
generator
is
and
Ohm's law can be
inversely proportional to the resistance of the circuit. easily explained with the simile of water. When water
forced through a pipe by a pump, the stream which results is in direct proportion to the pressure exerted by the pump and in inverse proportion to the resistance of the pipe. Similarly in an electrical circuit the current is in direct proportion to the electromotive force or voltage of the generator or electrical cell and inversely proportional to the resistance of the circuit. On account of the definite relation of these three factors, any two given
46
FUNDAMENTAL ELECTROPHYS1CS
is
furnish a description of the circuit, for the third can easily be calculated.
1.5, and if applied produce, according to Ohm's law, 1.5 -f- 1000 = 0.0015 ampere, or 1.5 milliamperes, of current. So, too, if we know that the voltage of a given current is 50 and the milliampere reading when applying it to the body is 10 milliamperes, we learn that the resistance of that part of the body is 5000 ohms.
For instance, the voltage of a simple galvanic cell against a body resistance of about 1000 ohms it
about
will
Ohm's law is of prime importance in every application of electrical current in medicine. Its consideration teaches that there are two ways of increasing the current in a given circuit, either by increasing the voltage or by decreasing the resistance of the circuit through which the current
Increasing the size of electrodes, decreasing their distance from each other and decreasing the resistance of the skin by moistening, all tend to decrease the ohmic resistance and thus increases the flow of current through the body. The work or energy of a flow of water is 4. Unit of Power. The Watt. measured by the number of gallons flowing, multiplied by the pressure in the pipe in a unit of time; similarly electrical power is equal to the product of the current flowing and the electromotive force (voltage) impressed for a given period of time. A statement that 10 amperes are passing in a circuit or that 100 volts are applied is no complete description of the electrical energy employed. It is necessary to state how many amperes at a certain voltage are passing in a given circuit. The total amount of electrical energy is the product of volt X ampere, which is expressed in watts. The watt is the unit of electrical power and 1 watt represents the power delivered when the current flows at the rate of 1 ampere with a pressure of 1 volt. The watt is thus nothing more than the measurement of the rate
passes.
at which
power
is
consumed.
unit of quantity used in figuring the cost of power either produced or consumed is the kilowatt. Ten amperes flowing in a circuit where the pressure is 100 volts means by power is being delivered at the rate of 1000 watts (10 100). One thousand watts are equal to 1 kilowatt, or
The
kw.
When power
is
delivered at the rate of
kilowatt for one hour the
quantity of
companies
called 1 kilowatt hour, or 1 kw.h. Electric power power charge a varying amount per kw.h., ranging, for instance, from
is
7 cents in residential districts to 4| cents to large commercial consumers.
Those
installing
and employing electrotherapeutic equipment
may
easily figure out its running cost, as each lamp and each piece of apparatus usually bears a label giving the wattage consumed. For instance, if one operates an electric motor that consumes 250 watts it will consume 1 kilowatt hour in four hours, or J kilowatt hour in one hour. If the rate is 7 cents per kilowatt hour it will cost J of 7 cents or less than 2 cents to run the motor for one hour. What is the cost of burning a 150-watt lamp for two hours continuously 150 watts multiplied by 2 if current costs 7 cents per kilowatt hour? amounts to 300 watt hours or less than ^ kilowatt hour. Thus the cost would be a little over 2 cents for two hours, or about 1 cent per hour. These calculations show that, after all, the cost of electric power is almost the smallest of the expense items involved in electrotherapy. The Farad. One farad represents the capacity of 5. Unit of Capacity. a condenser which charged with 1 coulomb gives a difference of potential
MEASURING AND REGULATING DEVICES

of 1 volt. This unit
tical unit,
47
and
is
is so large that one-millionth of it is taken as the praccalled the microfarad. The capacity of condensers is
usualty expressed in microfarads.

of the amperage and voltage of the direct and current are based on the electromagnetic effects of the current. alternating A meter consists of a box having a magnetic device that actuates a pointer in proportion to the current passing through the meter. Ampere Meters and Voltmeters. An ammeter (contracted form of ampere meter) measures the rate of flow of the electric current. Most of the electromedical meters read in milliamperes, expressing 1 1000 part of an ampere. Such a meter is called a milliampere meter or, in abbreviated form, a
Measuring instruments
milliammeter.
FIG. 21.
Ampere meter
current.
for direct
FIG. 22.
Hot-wire meter for highfrequency current.
Meters for direct current are constructed on the principle of the galvanometer; the electromagnetic deflection of a pointer connected to an electric coil. A permanent magnet maintains a uniform magnetic field through which the current to be measured flows. A rotating force is
of the
imparted upon the coil in proportion to the current strength. The pointer meter connected to this coil is deflected accordingly. (Fig. 21.) Meters for alternating current utilize the principle of magnetic repulsion between two soft iron vanes situated in the same magnetic field. A newer form of alternating current meter employs a small rectifier to change the alternating current to direct, the meter itself being of the direct current
type.
Meters
ciples:
for high-frequency current are designed on two different prinin which the heating effect of a current causes (a) Hot-wire type
an expansion of the wire
in proportion to the current strength. The wire being attached to a rotating drum, the movement of the wire causes a deflection of the pointer. (Fig. 22.) (6) Thermocouple type, based on the principle of the thermocouple.
thermocouple consists of the junction or joint of two dissimilar metals.
48
such a joint is heated, a difference of potential (voltage) is developed is proportional to the temperature of the junction. The current that flows in a circuit due to the voltage so developed is always a direct current regardless of the nature of the heating agent. Hence, a highfrequency current forced through a thermocouple will generate heat in the junction, which in turn develops a direct current in proportion to the heat generated by the high-frequency current. Connecting the wires from each side of the thermocouple to the moving coil of a very sensitive direct current meter, which has been properly calibrated, readings are obtained in high-frequency milliamperes. Such a meter referred to either as a highfrequency or a radio-frequency meter of the thermocouple type is now used in most of the high-frequency apparatus.
When
which
METER
SERIES-
IN
AMMETER
BATTERY
METER
IN
PARALLEL-
VOLTMETERVXy
any
Schematic diagram showing method of connecting ammeter and voltmeter The ammeter, A, is connected "in series" so that the current passes through while the voltmeter, V, is connected across the line in shunt so that the full voltage impressed upon it, yet by-passing the current.
FIG. 23.
circuit.
in
it,
is
current.
measuring of the voltage of the electric important for more accurate work, as for instance in electrodiagnostic procedures (condenser testing). A voltmeter is a sensitive ammeter which has a high resistance of some thousands of ohms placed in series with it so that the current that flows through the meter is extremely small and is a function of the voltage. Thus, with a
voltmeter serves for the exact
Such measurement
is
scale calibrated in volts
it gives a reading directly in volts. All meters require accurate calibration from the start
(Fig. 23.)
and must be
49
treated with the greatest of care. The pointer in the better quality of meter revolves in a carefully constructed socket, consisting of some hard semiprecious jewel, usually a ruby, and which is very sensitive to jolts and vibrations. A meter must likewise be very carefully guarded against sudden strains by too strong a current. Most meters are provided with a
set-screw for accurate adjustment. With no current flowing through the circuit, the pointer should be checked and carefully adjusted to zero. For measuring small and large currents applied from the same Ibwvoltage apparatus two-scale meters are used, which are so constructed
'
that on proper setting of a control small currents pass directly through the coil of the meter, while heavier currents pass only partly through. In long-wave diathermy apparatus often two meters are provided, one for low and the other for high reading. Measuring Power in Alternating Current Circuits. In alternating current circuits, due to the continual variations in intensity and periodic changes in direction of flow of an alternating current, as illustrated in Figure 13, a reactance is encountered in the circuit which causes a "phase displacement" between the current and the voltage. This means that the current and the voltage are actually out of step with each other, with the current either leading or lagging behind the voltage. The reactance and ordinary ohmic resistance of the circuit combine geometrically to produce a new kind of resistance to the flow of current, known as impedance. In order to measure power in an alternating current circuit, a wattmeter must be used, therefore, for measuring the voltage and amperage. A voltmeter and ammeter would give an apparent wattage which is higher than the
power being consumed. In average electromedical equipment, such as diathermy and shortwave apparatus, the actual power being consumed and paid for will vary from 50 to 80 per cent of the apparent power. Where electric sterilizers, ordinary incandescent lamps for lighting purposes, radiant light and heat lamps, and bakers are used, the apparent watts will be equal to the true watts as would be the case if direct current was being used. The reason for this is that these last-named devices do not have an appreciable property of inductance and hence do not introduce reactance in the circuit which would cause the current to be displaced.
true
A C OR D C SUPPLY
TO MACHINE
FIG. 24.
Diagram
of a rheostat with sliding contact.
Rheostats. rheostat or resistance unit makes use of the resistance of certain conductors or combinations of alloys, placed in the path of the incoming current to the apparatus to regulate the amperage. There is
usually a very negligible flow of current

4
when
the
full resistance is in
the
50
circuit,
FUNDAMENTAL ELEC TROPHYSI CS
and as the control is gradually advanced, the resistance is decreased and the current flow is correspondingly increased. A rheostat of the type most generally used in electromedical apparatus consists of a single layer of resistance wire wound on a straight or a circular form and so arranged that a sliding contact cuts in or out as much of the
coil as is
necessary to give the required current. (Fig. 24.)
For the regulation of alternating currents supplying electromedical

apparatus, a current controlling device
known
as a choke coil
is
used.
copper wire wound on an open or closed iron core. Taps brought out from given points of the coil to contact buttons, with each of which a moving contact arm makes connections and permits of the control of current. If a coil of wire forms part of an electrical circuit through which an alternating current is flowing each alternation induces within the coil a momentary counter electromotive force caused by self-induction. This self-induction is thus used to control the flow of alternating current in a circuit. (Fig. 25.)
choke
coil consists of several layers of insulated
A.C.
SUPPLY
TO MACHINE
FIG. 25.
Diagram
of choke coil.
A fheostat will regulate the current in both direct and alternating current circuits in the same manner and practically to the same degree since with both types of circuit ohmic resistance functions in the same manner. A choke coil will function as such only with alternating current. If used
on direct current it would impede the flow of current only to the extent of its ohmic resistance. The impeding property due to self-induction or inductance would be nil in a direct current circuit.
CHAPTER
III
GENERATION, CONVERSION AND DISTRIBUTION OF ELECTRICITY

Chemical Generation. Cells and Batteries. Mechanical Generation. The Dynamo, the Electric Motor, the Faradic Coil, the Transformer, the Rotary Converter. Electric Oscillations and Waves. Electronics. Thermionic Emission. Vacuum Electronic Devices. Gas-filled Electronic Devices. Electrical Current Supply in Homes and Offices. Measuring and Protecting the House Supply. The R61e of Fuses. Locating Trouble. Current Outlets.
of energy, electricity can neither be created nor can be made manifest by the transformation from another kind of energy. Thermal, chemical or mechanical energy can be converted into electrical energy, and this new form of energy can again be readily transformed into heat, light, and other useful forms of energy. The thermoelectric method of producing electricity is based on the
LIKE any other form

it
destroyed, but
series of thermocouples principle of the thermocouple (Chapter II). known as a thermopile or thermoelectric battery, but such a device
is is
only employed for laboratory work. For the production of electricity on an extended scale, only the chemical and mechanical means of generation are suitable and will be here considered.
CHEMICAL GENERATION OF ELECTRICITY

Cells
and Batteries.
by the
liberation of electrons
The chemical production of electricity is caused when metals go into chemical solution. In
a solid metal the atoms are in neutral condition. When plates of two dissimilar metals, such as copper and zinc, are placed in a vessel containing an electrolyte, as, for instance, dilute sulphuric acid, chemical action takes place, particles of zinc enter the solution as positive ions, repelling the positively charged hydrogen ions toward the
copper plate on which they appear as free hydrogen. The copper plate thus becomes positively charged and the zinc plate, negatively due to the negative charge remaining after removal of the positive zinc ions. Connecting the two metals by a wire or conductor a stream of electrons of a galvanic (direct) current will flow from the copper to the zinc plate. Each of the known metals, when employed in a galvanic cell produces an electric potential which is characteristic of that metal. In the electromotive series of metals any metal is electropositive to any other following it.
The
mercury, copper, lead, tin, nickel, iron, further apart the metals in the series, the greater potential difference can be obtained. galvanic cell consists of two metals and an electrolyte. The positive terminal or anode is the binding post at which the current leaves the anode; the negative terminal is the binding post at which the current returns to the cathode. In the copper-zinc cell the copper plate is the
silver,
series is as follows:
zinc,
aluminum, carbon.
The
positive and zinc plate is the negative electrode; in the zinc-carbon cell the zinc plate is the negative and the carbon the positive electrode. Within
(51)
52
GENERATION, CONVERSION AND DISTRIBUTION
the cell the electrons will flow in the opposite direction to the current flow in the outside circuit, but the current flow within the cell is in the same direction. (Fig. 26.) The signs positive or anode (+) and negative
( ), on instrument boards, plugs and sockets have no other than that of designating the direction of the flow of electrons. meaning Electrons always flow from the higher level to the lower level, i. e., from the anode to the cathode; the current itself flows from the cathode to the
or cathode
anode.
Wet cells are no longer used because of the secondary changes in the substance of the electrolytes and in the electrodes, with a resulting electromotive force opposite to the direcCARBON tion of the original current, known
as polarization.
cells (Fig. 27) consist essenof a zinc container lined with tially
Dry
thin blotting-paper, which serves as the negative electrode, and a carbon rod in the center as the
positive
electrode;
a hygroscopic
BLOTTING
PAPER
CARBON COKE
MN
SO
flM.CL.
FIG. 26.
Direction of current flow in an electric or galvanic cell.
FIG. 27.
Dry
cell.
mass, consisting of ammonium chloride, zinc chloride, manganese dioxide and granulated carbon, combined with water in the form of paste, fills the The top of space between the electrodes and so prevents polarization. the cells is made water-tight by a layer of pitch. cells are clean, are Dry
easily portable,
and have proved useful for modern commercial purposes, where an even flow of a small amount of current is needed, as for the ringing of door bells, for pocket flashlights, etc. The voltage of an ordinary dry cell is about 1.5 volts, and the average resistance encountered in the body is about 1000 ohms; hence one cell will produce in the body about 0.0015 amperes, or 1.5 milliamperes of current.
An
of
electric battery consists of a
number
of cells joined together in series.
The development
dry employed
of the radio industry has brought about the construction batteries of large capacity, 45 or more volts, which are now widely
in portable galvanic apparatus.
MECHANICAL GENERATION AND CONVERSION

electrical
53
Storage batteries are "reversible" batteries which can be loaded with
energy from the
line current
into
them can be taken out again;
this process
or so without renewing the battery. is lead and the electrolyte is sulphuric acid.
all of this energy put can be repeated for a year The metal used in storage batteries
and almost
MECHANICAL GENERATION AND CONVERSION OF ELECTRICITY

for producing Faraday's epoch-making discovery of electromagnetic induction laid the groundwork for the modern age of electricity by making possible the convenient, cheap and wholesale transformation of mechanical energy into electrical energy. Electricity is generated at central stations and from there is distributed through suitably insulated electric wires to homes, offices and factories.
Dry
cells
and
batteries are
somewhat expensive sources
large
quantities of electricity.
CURRENT
FIG. 28. Diagram of dynamo. In any closed circuit which is penetrated by lines of force of varying intensity, an electric current is induced. This diagram represents a wire With every half revolution the amount of lines of force by loop, rotating in a magnetic field. which it is penetrated changes from zero to maximum and back to zero; the intensity of the current generated within the loop and the light from the electric bulb connected to it vary
correspondingly
The Dynamo. The dynamo (Fig. 28) is an apparatus for the conversion of mechanical energy into electrical power. Its chief parts are: (1) The
magnetic
field,
produced by electromagnets or powerful permanent mag-
nets; (2) the armature, a coil of insulated wire mounted around a specially designed iron core; (3) the collecting mechanism which consists of metallic
brushes (to make a sliding contact), slip rings (copper rings which rotate with the armature) in alternating current dynamos or a commutator (a split-ring device to collect a direct current) in direct current dynamos; and (4) an activating mechanical power, steam, gasoline or water power which keeps either the armature or the electromagnet moving in relation to each other. The mechanical power expended in rotating the armature is transformed into electrical energy, because the rotation sets up a magnetic force which opposes this rotation and the energy spent to overcome
this force
becomes the
The
Electric Motor.
electrical energy. The electric motor is the reverse of the
dynamo,
for it is
an apparatus
for the conversion of electric energy into mechanical
54
one.

It consists of
an armature rotating in a magnetic field. The electroforce will tend to rotate the armature, and the shaft of the armamagnetic ture transfers the mechanical power created by this rotation by gearing
or belt to other apparatus. Motors are built for operation on either alternating or direct current, and certain small motors may be used on both alternating and direct current.
This is a device for the production of an induced from a direct current source. Its essential parts are: (1) A primary coil, consisting of a few turns of insulated thick wire wound around a soft iron core, the latter strengthening the magnetic field around
The Faradic
Coil.
(faradic) current
Schematic diagram of faradic coil. P, primary composed of turns of heavy wire; secondary composed of many turns of fine wire; C, soft iron core; CL, soft iron clapper; SP, spring; CS, contact screw; DC, dry cell; BP, binding posts; PT, leads to patient.
FIG. 29.
S,
fine wire; (3)
a secondary coil, consisting of many turns of insulated an interrupting device (vibrating armature), which makes and breaks the current in the primary coil. The current from a battery or from the direct current mains magnetizes the iron core, which attracts the soft iron piece vibrating armature. This motion breaks the current in the primary coil. With the current flow stopped the iron core is demagnetized, and the spring of the interrupting device restores contact of the soft iron piece and thus closes the circuit again ("makes" the current). This process goes on as long as the activating current from the direct current source flows. The tension or voltage of the induced current is considerably higher than that of the inducing direct one; it increases
the primary
coil; (2)
MECHANICAL GENERATION AND CONVERSION
55
according to the ratio or the number of turns in the two coils. Large faradic coils are known as induction coils. The Transformer. The transformer is a device changing the voltage in alternating currents. It consists of two coils side by side, having a common "core" of soft iron (Fig. 30); one coil has many turns of fine wire and the other a few turns of coarse wire. When an alternating current is set up in one coil it magnetizes the iron core; it also sets up lines of force which pass through the second coil and an alternating induced current is produced in the secondary coil. The same lines of force cut across one coil as the other. The electromotive force or voltage induced in one coil is directly proportional to the ratio of the number of turns or wire in the coils to each
other.
110
VOLTS
FIG. 30.
Diagram
of transformer with iron core.
Alternating currents are easily changed from low voltage to high, or by means of transformers. In the diagram for instance, it is required to transform 2200 volts down to 110 volts. The fine wire which is connected to the 2200-volt circuit must have 20 times as many turns as the coarse wire coil which is connected to the low-volt circuit. The current in the secondary will be then one-twentieth that in the primary. The energy spent in the secondary circuit is equal to that which the transvice versa,
former takes from the main line except for a small amount which is lost as heat in the transformer, about 2 or 3 per cent. There are two kinds of transformers: (1) Step-up transformers, which raise the voltage of the house lighting circuit for use in electrical apparatus, such as high-frequency and roentgen-ray apparatus; in these transformers the secondary coil consists of a correspondingly greater number of turns than the primary coil. (2) Step-down transformers, for the reduction of the high tension alternating current when it reaches the consumer's home, his office or the factory. In these the secondary coil has the lesser number
of turns.
The Rotary Converter. A rotary converter or motor generator is an apparatus for changing alternating current to direct current. A device sometimes used in electrotherapy for changing direct to alternating current
56
is known as an inverted rotary converter. It consists essentially of a dynamo, working either on direct or alternating current, which by a varying of the arrangement of its collecting mechanism the brushes and commutator allows the collection of either a direct or an alternating
current at the other end.
ELECTRIC OSCILLATIONS
AND WAVES
back and
forth,
When
a spring
is
bent and released

is
it
oscillates
coming
condenser, such as electricity, is discharged through a circuit of small resistance (an air gap or spark gap), the electron discharge takes place in a back-and-forth rush of current from one charged coating to the other until all the energy is spent in sound, heat, light and electric waves. (Fig. 31.) Such a discharge has been shown to consist of a group of sparks rapidly dying out and is known as an oscillatory discharge. With the general employment of thermionic devices (see next section) oscillator tubes have argely replaced the use of the spark gap for producing oscillations of
to rest only
energy a Leyden jar charged with
when
its
spent.
Similarly
when a
various wave-lengths.
TIME.
FIG. 31.
Oscillatoiy discharge of condenser.
FIG. 32.
Typical oscillating circuit, consisting of condenser (Leyden tance (coil) and spark gap.
jar),
induc-
The
oscillations
produced by the spark gap or by the
oscillating tubes
are sustained by the inductance, the most essential part of any oscillating circuit. The inductance consists of a solenoid, a coil of copper wire. Such a solenoid offers very little ohmic or "conductive" resistance to the passage of a direct current, but offers an enormous "inductive" resistance to the
ELECTRONICS
57
oscillating current which the electrical energy of the condenser discharges. Each turn of the solenoid acts as an impedance to the flow of current; as
a result instead of a sudden dying out of the electrical charge, the current oscillates back and forth in the form of wave trains. In the vacuum-tube circuit these wave trains are "undamped" or all of the same amplitude because of lack of internal resistance; in spark-gap circuit they are "damped," i. e., of decreasing amplitude. If there is too much resistance in the discharge circuit there are no oscillations, just as a pendulum hung in molasses will sink to its lowest position without swinging.
set
of an oscillatory discharge traveling through the air will similar oscillations in neighboring circuits, provided they are in "resonance," just as a tuning-fork will excite strong vibrations in a vibrator which is in tune with it. It was shown that these electric waves travel
The energy
up
through the air with the same speed as light, 186,000 miles per second, and form part of the huge field of electromagnetic oscillations, which will be extensively discussed in Chapter XV. These oscillations differ in their wave lengths, varying from a mile to a few millimeters, depending on the
physical constants of the oscillatory circuit.
Wireless telegraphy depends
on electromagnetic waves
induction coil or aerial or antenna.
up through a spark discharge of a powerful transformer and sent into the air from an high-tension
set
Electrical waves produced in a spark gap or oscillator tube circuit of an electromedical apparatus are conducted through cords or cables to the body as a high-frequency current and employed under the name of long-wave and short-wave diathermy for medical and surgical
treatments.
ELECTRONICS
In recent years the use of electron discharge phenomena in vacuum tubes has become quite commonplace, and has played an important part in the development of many technical devices. Some of these, such as the radio, television, and similar commercial devices are well known. Others are of great scientific interest. The cathode ray tube is a vacuum tube electron discharge device
which has greatly added to scientific knowledge through visualization of electrical currents. The photoelectric cell has not only been of use to the scientist but is finding increasing commercial application.
onic
More important to us, however, vacuum tube which has found
is
the thermi-
increasing use
in electromedical apparatus.
Thermionic Emission. Physicists have known for over a hundred years that when a metal is brought FIG. 33. Electron disto incandescence the air immediately surrounding charge from heated tungsten filament. it became a conductor of electricity. (Fig. 33.) This conductivity is due to the emission or "boiling off" This process is very much like of free electrons from the heated metal. that of the evaporation of water or emission of steam which is caused by the agitation of the molecules of water overcoming the surface tension.
In the ordinary electric incandescent bulb the "boiled off" free electrons are
58

to the filament because
is left
when an electron escapes from the with a positive charge which attracts the negatively charged electrons. Therefore there are almost as many electrons falling back into the filament as are "boiled off." While working on the development of the incandescent lamp in 1882, Edison noticed that when he placed a small metal plate in the lamp as shown in Figure 34 and connected this plate to the positive terminal of
drawn back
metal, the latter
FIG. 34. Edison Effect I. When plate is connected to positive potential current flows from filament to plate as indicated by the swinging out of the needle of the milliammeter.
FIG. 35.
Edison Effect
II.
When
negative charge
is
given to plate no current will flow
in
plate to filament circuit.
battery, a sensitive galvanometer the plate was connected to the negative side of the battery, as shown in Figure 35, no current would flow. This phenomenon became known to physicists as the "Edison Effect." It remained a physical curiosity but not until the development of the electron theory was it possible to understand the action that took place, and which is now known as thermionic emission.
as a
a separate battery
known
"B"
would indicate a current
flow.
When
ELECTRONICS
The explanation
of the Edison effect
59
is as follows: If a metal plate is Figure 34 and is connected to a positive terminal of a direct current source called a positive potential the fre"e negatively charged electrons swarming about the heated filament source are attracted to this positively charged plate; since a moving stream of electrons constitutes an electric current, there will be a flow of current from the plate to the filament. This also can be shown by a galvanometer. If the plate is given a negative charge, as shown in Figure 35, no current will flow because the negatively charged plate will repel the electrons emitted from the filament. Vacuum-electronic Devices. The discovery of the principle of thermionic emission led to the construction of a large number of. thermionic or vacuumelectronic devices. The main feature of each of these is an evacuated glass bulb known as a vacuum tube and the number and type of metal electrodes contained in it determine its physical characteristics and function.
inserted into the bulb as
shown
in
FIG. 36. Diagram of functioning of amplifier tube. The third element or grid introduced between the filament and plate of the thermionic tube previously shown in Figure 34 serves
to influence the current intensity in the plate-filament circuit. positive potential applied to the grid will increase the plate-filament current as shown by the excursion of the meter.
The two-electrode tube or diode was developed by Fleming in 1915. It contains a metal filament and a plate. The filament is heated by being connected to a source of current and a second source of current is connected to the plate and the filament. When an alternating current is applied to the plate, a current will flow from the fil? ir.ent to plate only while the plate is charged positively, and no current can flow during the negative phase of the A.C. A tube of this kind will conduct current in one direction only and this action enables the employment of this tube for 'rectify ing" an alternating current flow, by shutting off every other alternation and changing it into a direct current flow. The vacuum tube acts as a "valve" allowing current flow in one direction only from the plate to the filament and the result is an interrupted, undirectional, pulsating current flow. Such a tube is known as a rectifier or valve tube. It serves to change the
'
alternating current into a direct current by vacuum-tube rectification. The rectified current can be further "filtered" by suitable inductance and capacitance until it is made into a smooth galvanic current as produced
by an
electric cell or battery.
60
A vacuum tube rectifier is a device which employs a valve tube for the changing of alternating into direct current and is widely employed in
radio and in various electromedical apparatus. The three-electrode tube or triode contains as a third element a fine wire mesh, known as the grid. The purpose of this is to control the flow of electrons from the filament to the plate. The electrons passing from the
filament to the plate must pass through the spaces in the mesh, and their passage to the plate is controlled to any desired extent by varying the voltage applied to this grid. If a positive charge is applied to the grid, as shown in Figure 36, it is evident that this positively charged grid will aid
the plate in drawing electrons to it. A negative charge on the grid will cause a decrease in the plate current, and if the grid is given sufficiently high negative charge the plate current can be stopped entirely. (Fig. 37.)
FIG. 37. Diagram of functioning of amplifier tube. If the positive potential shown in the previous figure is decreased to zero and then increased on the negative side, the current in the plate-filament circuit will gradually decrease and at a sufficient high negative potential will be stopped entirely, as evidenced by the lack of excursion of the meter.
The triode can be used as an amplifier tube. From the foregoing it is seen that any variation in the grid potential will be reproduced on a larger scale in the plate circuit. Only a small voltage is needed to obtain changes in the current flowing through the tube. Fluctuations or oscillations of a weak potential cause corresponding fluctuations of a much higher amplitude in the anode current through the tube; in other words, the potential impressed upon the grid is amplified in the anode circuit. The control of the current through the tube, and thus through the circuit of which it is a part, is obtained by applying the potential whose characteristics are to be reproduced on an amplified scale, to the grid and filament. When used in the manner described above, the three-element tube is functioning as an amplifier. If the voltage applied to the grid becomes more and more positive the anode current increases up to a maximum value known as the saturation current. All electrons emitted are attracted to the anode and a further increase of the grid potential makes no change in the voltage or the current. The triode may also be used as a generator of a very high-frequency current and is then known as an oscillator tube. The operation of this device will be discussed in Chapter X.
ELECTRONICS
Gas-filled Electronic Devices.
61
An
electrical current of high voltage pass-
tube filled with gas at low pressure causes a glow discharge to take place. This is due to ionization, or breaking up of atoms of the gas and the freeing of a stream of conducting electrons. This differs from thermionic emission of electrons from a heated wire in a vacuum tube. Various colors are produced in the vacuum between the electrodes, depending on the gases ionized. In a neon filled tube the glow discharge is reddish, mercury vapor gives a bluish color, etc. When direct current is used to energize the tube the ionization is brightest near the
ing between
two electrodes
in a glass
ANODE CONNECTION
GLASS ENVELOPE
FILAMENT
GRID CONNECTION
PIN
FILAMENT PRONGS
UNUSED PRONGS
FIG. 38.
Diagram
of high-frequency oscillator tube.
(Courtesy of Westinghouse
X-ray Corporation.)
cathode (negative electrode), when alternating current is used both electrons are equally bright. Mercury vapor tubes used in therapeutic machines for rectification show a glow discharge. Two-electrode vacuum tubes (diodes) consisting of a heated filament and a metal plate and also containing mercury vapor at low pressure are extensively used as mercury-vapor rectifiers, just like thermionic vacuum tube rectifiers: when the plate is negative no electrons are drawn from the cathode and no current flows, only when the plate is positive does the
current flow.
In electromedical apparatus mercury vapor
rectifiers are
62
used in short-wave diathermy machines to convert alternating current from the mains to direct current. Three-electrode vacuum tubes (triodes) filled with gas are known as
They are employed because of their ability to carry high voltages and to accurately control not only the voltage flowing through the device but also the frequency of the wave discharge. The larger thyratron tubes contain mercury vapor gas, the smaller ones argon. The tube is usually connected across a condenser with a charging current. While the condenser is absorbing the charging current, the thyratron remains nonconducting, but as the condenser becomes charged, the gas in the thyratron becomes ionized by the rising voltage. When this happens, the tube becomes conducting and short circuits the condenser. The condenser having lost its charge, the voltage drops and becomes too low to maintain the thyratron in an ionized state, so that the tube becomes non-conducting again and the condenser starts to charge once more. (Fig. 39.) This cycle continues, with production of the wave shape shown in Figure 39. The relatively slow rise represents the charging condenser; the sudden sharp drop, the discharge of the condenser by the ionized thyratron tube. When the charging current is held at constant voltage, the rate of oscillation is
thyratrons.
FIG. 39.
Wave
shape of current produced in thyratron tube.
determined by the size of the condenser. By construction of a unit so that any one of a number of condensers may be introduced into the system as desired, low voltage currents of any desired frequency may be obtained. Extremely simple to control, such currents have perfectly regular wave
form.
The Electron Microscope. This is an electronic device in which a highly specialized vacuum tube is used to reach magnification of tiny objects to a degree formerly considered impossible. In the finest microscope using light and a lens system for its operation, a limit of utility is reached when the object is too small to cover one wave-length of light. This limit can be extended slightly by the use of ultraviolet ray with its shorter wavelength. The electron microscope uses a stream of electrons in place of
the beam of light. The usual lenses of the microscope are replaced by a series of magnetic coils which focus the electron stream on the object and then spread it correctly to cover the fluorescent screen or the photoAt present magnification of 25,000 diameters has been graphic plate. accomplished and the limit of the instrument has not yet been reached.
ELECTRICAL CURRENT SUPPLY IN
HOMES AND OFFICE
Two forms of current are supplied by central lighting and power stations, the direct and the alternating. The direct current has been more generally employed in cities, while the alternating current at first found more
ELECTRICAL CURRENT SUPPLY IN HOMES AND OFFICE

extended use in rural
63
districts. For heating and lighting purposes, both currents are equally satisfactory; for driving of motors, a special A.C. or D.C. motor is necessary, according to the type of supply current; for electroplating and refining, alternating current cannot be used. For reasons of economy of transmission, the tendency has been in recent years to employ alternating current supply everywhere and in most large cities direct current supply is gradually replaced by alternating
current.
electric
By generating alternating currents at high voltages
(up to 200,000),
power can be sent over long distances without much loss in transmission, and at any part of the line, the high-tension current can be reduced
by a step-down transformer
ready for general use. In installing electrical
supply in one's locality
to a low-tension current (110 to 220 volts)
equipment, one should know the kind of current
direct or alternating and in the latter case, the of cycles or periodicity of the current. Both direct and alternating current are equally useful for the ordinary heating and lighting appliances, but when installing motors, ultraviolet lamps, and other forms of electro-
number
medical equipment, the kind of current must be known so that suitable types of apparatus can be chosen. Measuring and Protecting the House Supply. When the current from the mains enters a building, it first passes through a service switch which permits the entire house to be disconnected from the mains. This switch is fused to protect the house circuits from excessive current flow. From the service switch the current flows through a watt-hour meter where the electrical energy consumption is recorded. The current now passes through the individual circuit fuses to the various outlets and receptacles. The Role of Fuses. A fuse is a current-limiting device, consisting of a piece of alloy of low melting-point and of such thickness and length which If more than the is calibrated to stand just a certain amount of current. contemplated amount of current is drawn the wire rapidly heats up and melts, the fuse blows and the flow of current is interrupted, thus preventing overheating of electric wires or sparking and the consequent danger of a fire. Fuses will blow most frequently through overloading or through a short circuit. Overloading occurs when more current is drawn than is allowed a given circuit. For instance, if a branch circuit is wired and fused for 15 amperes at 100 volts and one turns on a 1000-watt bulb drawing 10 amperes and then tries to light an ultraviolet generator drawing about 9 amperes on the same circuit one is usually reminded, to the tune of a blown fuse, that the limit allowed has been exceeded. Needless to say, replacing the 15-ampere fuse by a 25-ampere fuse does not solve the problem, as the capacity of the fuse and the wiring in a given circuit are related, and by attempting to draw more current one overheats the entire wiring and courts trouble and danger possibly in some inaccessible part of the circuit. To prevent overloading the number of outlets and the wiring in a given circuit, therefore, one must never use a fuse larger in capacity than
the
maximum amount
of current to
if
be drawn.
somewhere in a circuit two insulated wires come into unexpected contact, as will happen when the insulation in a conducting cord is worn away or one wire in an attachment plug becomes loose and touches the opposite one. This causes an arcing of the current across the
Short circuits occur
64
short path, and on account of the lessened resistance more current is drawn and, consequently, the fuse blows. A short circuit is by far the most frequent cause of blowing of fuses in the physician's office. Its prevention
inspecting all contact parts subject to friction and strain, either at stated periods or whenever they show wear. If a fuse has blown, before replacing it one should disconnect the piece of equipment in which the
lies in
noise, sparks
short circuit has occurred; otherwise the fuse will blow again. The hissing and heat accompanying a short circuit usually makes its location easy. Finally, fuses may blow at times without apparent reason, due perhaps
to wear of equipment or to defective construction. In such instances they have simply to be replaced. Fuses are sometimes made part of electrical apparatus, in order to protect delicate lamps and measuring devices against any excess of current.
ARC
BATTERY
GALVANOMETER
KEY
RESISTO'R
CONDENSER
CONNECTION OF WIRES
VAR. RES.
No CONNECTION
COUPLED COILS
SPARK GAP
GROUND
TRANSFORMER
VARIABLE COUPLING
VACUUM TUBE
I
FIG. 40.
Electrical symbols
most frequently employed.
Locating Trouble. In order to be able to act at once in case of fuse or other trouble, anyone employing electricity for therapeutic purposes should know the location of the fuses for each circuit and also on the apparatus itself so as to be able to replace them after the cause of the trouble has been found and eliminated. It is advisable that a panel box with all fuses pertaining to the equipment should be located in or near the office at a place easily accessible and well lighted. A complete diagram affixed to the inner door of the fuse box should show the outlets covered by each of the fuses and thus make quick repair possible. It is also advisable to have the lighting circuit of the office separate from the therapeutic circuit, so that in case of trouble the lights would not be disturbed, the light sockets even serving as an emergency supply socket for the apparatus. A sufficient supply of fuses of appropriate size should always be kept on hand in the fuse supply box, along with an electric flashlight in working order, or a piece of candle and matches. A simple trouble-testing outfit consists of an insulating electric socket
ELECTRICAL CURRENT SUPPLY IN HOMES AND OFFICE
65
with an incandescent bulb in it. The two wires leading into the socket should be well insulated and are cut off at about 1 foot distance; but their ends for about i inch should be bare so that, by simply placing these two ends over another bare metallic surface, good electric contact can be established. By doing this with fuse blocks, the feed bars of the fuse box, lamp sockets and conducting cords, the presence or absence of current can be instantly detected by the lighting-up of the test lamp or by its absence. In fuse boxes equipped with the modern type of fuses, made of glass, a simple glance at the discolored central portion of a fuse shows that it has blown. If more than one circuit has failed in the house as, for instance, a number of pieces of apparatus and the lights on several floors, this usually indicates that one of the main fuses in the meter box has blown or that the trouble may be in the meter or in the supply line outside of the house. In such case the help of the electric power company should be summoned. In recent years the use of the thermal operated circuit breakers (cutouts) to replace fuses has become popular. The advantage of this device is that it need only be reset after it has operated and after the cause of the overload has been corrected. Magnetic circuit breakers are also favored
in
some
installations.
For the efficient working of electrotherapeutic equipment, the proper number and placing of current outlets is both a convenience and a necessity. Starting from the fuse box, each electrical circuit in the home or office includes several outlets, either as base plugs or wall receptacles. A temporary connection to any electric light socket may be permissible for small apparatus provided that the outlet is wired and fused for the amperage of the particular apparatus. For permanent connections,
Current Outlets.
special outlets, preferably independent of the lighting circuit, are advisable.
These should be placed about 3 to 4 feet above the floor so as to be readily accessible for attachment of the connecting line to the apparatus. The number of outlets should correspond to the pieces of equipment; frequent plugging in and out causes unnecessary wear and tear on the connections. If both alternating and direct current supply is available it is advisable well marked to have an outlet for each kind alongside of each other; where there is only direct current available all outlets should be marked for proper polarity ( + and ), or else the connecting cable of any piece of equipment should be marked so that it is inserted in the same way each
time; this will insure that the polarity of current supply remains unchanged.
PART
II
General Electrotherapy and

Electrodiagnosis
CHAPTER
IV
ELECTROMEDICAL CURRENTS, APPARATUS AND

ACCESSORIES
General Considerations. Classification of Currents. Currents of Low Tension and Low Frequency. Currents of High Frequency. Static Electricity. Electromedical Apparatus. Typical Features. Conducting Cords and Cables. Electrodes. Miscellaneous Accessories.
General Considerations. Electromedical currents are practically all derived from the commercial lighting circuit. The galvanic current may be drawn directly from dry cells or radio batteries and also with an interposed resistance from the direct lighting current. All other currents are obtained indirectly from the direct (D.C.) and much more frequently from the alternating (A.C.) street current by suitable modification, through motor generators, transformers, and other electromagnetic or thermionic
devices.
The
source and
means
of production of
any current has but
little rela-
tion to the response of the tissues of the body. The final form of the electrical energy, the technique of application and the individual equation of
the subject will determine the effect that
it will
exert.
TABLE
5.
COMPARISON OF WATER SYSTEM AMD ELECTRIC CURRENTS

Electric current
Water system
Low
pressure High pressure
Fine spray Large volume Continuous flow

Squirts or waves
tension galvanic, sinusoidal High tension: static, high frequency Low amperage: static, faradic
Low
Large amperage: diathermy Galvanic current Interrupted and surging currents
The transformation of the basic electrical energy into the different therapeutic currents is best visualized by the simile of a water system. Water can be applied either at high pressure or at low pressure, at a large rate of flow or in a fine spray, running continuously or in abrupt squirts or waves. Similarly the flow of electrons may be even, or be interrupted,
or reversed, frequently or infrequently, symmetrically or asymmetrically; the rate at which the current is increased from zero to maximum may be slow or rapid and it may remain at low tension or rise to very high tension.
(66)
CLASSIFICATION OF CURRENTS
CLASSIFICATION OF CURRENTS
67
In classifying electromedical currents, their primary characteristics as well as their biophysical effects are taken into consideration.
TABLE
6.
ELECTROMEDICAL CURRENTS
Physical Characteristics
PHYSICS
Current
68
ELECTROMEDICAL CURRENTS, APPARATUS, ACCESSORIES
current, the interrupted galvanic, and the static modalities are unidirectional currents. Alternating currents are those which reverse their direction of flow; this group includes: (a) loiv-frequency currents with an alternation
not exceeding several hundred per second the f aradic, the slow sinusoidal and the modulated alternating current belong to this group; (b) high;
frequency currents with alternations or oscillations over 1,000,000 per second; long- and short-wave diathermy belong to this group. 2. Voltage or Tension. Low-tension currents are those with a voltage of 100 and less; the galvanic and the low-frequency currents belong to this group; high-tension currents are those with a voltage of several hundred or higher; high-frequency currents and static electricity are among these. 3. Amperage or Volume. Since no high amperage or current volume is possible without a corresponding high voltage to produce it, generally
speaking high-voltage currents are currents of high amperage, employing from 500 to 2000 or more milliamperes while currents of low tension are currents of low amperage, employing from 1 to 30 milliamperes. The static current occupies a unique position inasmuch as it represents a current flow of very high voltage to several thousand or more, but its volume of
flow
is
minimal,
7.
less
than a milliampere.
II
TABLE
ELECTROMEDICAL CURRENTS
galvanic current
PRINCIPAL FORMS OF APPLICATION
The
Medical galvanism Ion transfer Surgical galvanism (electrolysis) Currents of low tension and low frequency
The interrupted galvanic current The faradic current The slow (galvanic) sinusoidal current The modulated alternating current
High-frequency currents Long-wave diathermy Short-wave diathermy Monoterminal high-frequency sparking (Oudin current)
Electrosurgery: desiccation, coagulation and cutting Static electricity Static wave and sparks, static induced current Static brush discharge, static bath
According to biophysical
in
effects,
electromedical currents can be divided
large groups: (1) currents causing ionic changes in the tissues and a minimum of thermal effects, (2) currents causing only thermal changes.
two
The
galvanic and low-frequency currents belong in the first group, highfrequency current in the second. Static electricity again occupies a separate group. Table 7 shows the generally accepted grouping of electromedical currents and their principal forms of application. All these will be fully
presented in their respective chapters.
ELECTROMEDICAL APPARATUS
The average physician, no better than the average layman, looks upon apparatus either as something mysterious, ready to perform curative feats by the turn of a knob, or else thinks it is all make-believe. As a matter of fact, all that apparatus can do is to deliver a definite form and amount of physical energy to a given part of the body. It is up to the physician to
CONDUCTING CORDS AND CABLES

know what physiological effects to expect from such an application and when to make use of it in treating disease and injury. The physician should
be able to visualize at all time: (1) the physical events inside of the apparatus when the current is turned on from the source of electric power and (2) the physical and physiological changes in the body when the current is applied through the electrodes.
MAIN
5W1TCH
PILOT LIGHT
TIME
M1LLJAMETCR
CLOCK
GALVANIC
MACHINE:
PANEL
RHEOSTAT
FIG. 42.
Diagram
of control
board of simple galvanic apparatus.
Electrical apparatus for treatment purTypical Features of Apparatus. poses usually consist of a box or cabinet, which contains the electrical unit (motor transformer, vacuum tubes, etc.) changing the supply of alternating lighting current into one of the electron! edical currents. Some pieces of apparatus contain dry cells or batteries and are independent of any out-
knobs and terminals are mounted on insulating material, such as hard rubber or porcelain. The typical features of the average apparatus are: (1) A current inlet where the cable bringing the supply current from a wall receptacle or light socket is inserted. (2) A main switch by which the flow of supply current is turned on or off. (3) A rheostat or regulator which regulates the strength of the incoming current and enables the drawing of as much current as is needed for the individual treatment. (4) A milliammeteror simply meter showing the amount of current passing. (5) Terminals or current outlets for the insertion of cables or conducting cords which lead
side current supply source. All switches,
the current to the patient. According to the type of apparatus, there may also be other controls such as illustrated in Figure 42. (6) a pilot light, which lights up as soon as the main switch is turned on and the supply current enters the apparatus, and (7) a timing device (time clock) by which the current flow can be set from a few minutes to an hour; at the end of this period the current is automatically cut off.
CONDUCTING CORDS AND CABLES

The
electrical
patient by means
energy from electromedical apparatus is conveyed to the of conducting cords, or cables, consisting of flexible
70
copper wire surrounded by a suitable rubber insulation. The thickness of insulation depends upon whether a current of low or high voltage is carried by the conductor.
FIG. 43.
Conducting cord.
FIG. 44. Connectors and cord tips. 1, single flat connector for cord tip; 2, bent connector for binding post on apparatus; 3, cord tips; 4. double connector for binding post; 5, hook connector for vacuum or condenser electrode; 6, spring connector; 7, double connector to
lengthen cords.
color
Conducting cords used in present-day equipment are, as a rule, of uniform and serve for the conduction of both low-tension (galvanic-faradic-
Special sinusoidal) and high-tension (long-wave diathermy) currents. cables serve for short-wave diathermy. For galvanic treatment sometimes cords with different coloring of their insulating cover are employed so as to remind the operator of the different polarities. Conducting cords must be fastened securely at one end to the binding post of the apparatus, usually through a binding screw on the other end to the electrode, usually through some clip arrangement. Supporting the cord along its way from the binding post will minimize the danger of its pulling out of the clip.
;
ELECTRODES
71
For fastening conducting cords to the back of the metal electrodes clips or flexible connectors serve. In low-tension moist pad electrodes a connection for the conducting cord is usually soldered onto the metal back, and the cord tip is held there by a spring. All such connections are subject
to electrolytic deterioration
time to time.
and breaking and should be inspected from Loose-fitting clips may pull out easily, causing an excess density of current on the skin and an instantaneous burn if they should
touch the bare skin. Cords may get out of order by a break of the copper wire inside of the cord's insulation; or by loosening or slipping of the contact between the wire and metal tip. To prove that the current goes through a cord one may connect the terminals of an apparatus by the cord and turn on a very small amount of current. If the wire is intact and conduction is present, the meter will register current at once (be careful not to strain meter by sudden heavy current) Cords when not in use should be hung up and not rolled up; this will prevent the breaking of the fine copper wire. Loose contact between the wire and the cord tip is remedied by scraping off the insulation at the end of the cord and reapplying the copper wire by tightening it with the binding screw. To prevent loosening at the cord tips, cords should never be jerked out of the sockets but gently pulled out by
.
holding on to their tips. Conducting cables for short-wave diathermy consist of heavy insulated cables containing the conducting wires. Short-wave condenser pads carry a cable attached to one corner, and the other end of this cable plugs into the treatment outlets of the apparatus. These cables are shorter than conducting cords for long-wave diathermy; they form part of the treatment circuit. When they are in contact or close to a good conductor (metal frame of bed or chair) or when crossing each other they may concentrate some of the electrical energy; such energy leakage heats up the rubber insulation of the cable and may cause it to burst into flame. The most vulnerable part of the cable-pad electrode assembly is the corner where the cable joins: due to careless handling the rubber insulation may crack
there and lead to leakage of current and subsequent overheating. Regular inspection of such accessories is, therefore, essential.
ELECTRODES
An electrode is a medium intervening between an electric cord or cable and the body. It should consist of a good conducting material, the shape and form of which can be well adapted to the skin or the cavity. Water containing some salt is the simplest electrode material and makes perfect contact with an extremity immersed in it. The water bath as an electrode is used for some galvanic treatments and also may be used For the (Fig. 175) for long-wave diathermy treatments to hands and feet. great variety of electric treatments, however, most of the electrodes consist of flexible metal plates, either directly applied to the body or separated by moist padding or rubber insulation. Glass vacuum electrodes are used
for certain high-frequency treatments. Contact metal electrodes are cut to suitable size
foil
an alloy of
three grades of
and shape from electrode and zinc. Metal electrode material comes in thickness and is sold in rolls by the pound. It is cut by
lead, tin
72
about
this
shears into suitable sizes, and it is advisable to leave a small tongue, 1 by J inch to one side; folded back against the rest of the plate
tongue serves for attaching the conducting cord. Before use the smoothed out by a light roller like used for photographic prints. They should be cleansed from time to time with soap and water. Plain metal electrodes are chiefly used for long-wave diathermy
electrodes should be
treatments.
FIG. 45.
Outtins electrode
foil.
FIG.
4<i.
Plate electrode ready for use.
FIG. 47.
Condenser pads and inductance cable
for
short-wave diathermy.
Spaced metal electrodes (condenser pads and cuffs) consist of flexible metal enclosed in insulating rubber sheath. They are applied to the skin with an interposition of toweling or felt, and additional moisture-absorbing blotting or tissue paper. Spaced plates consist of metal discs enclosed in
ELECTRODES
hard circular rubber treatment drums or cylindrical glass "shoes."
are held at a suitable distance
All
for
73
They
and position by adjustable wooden arms. these electrodes carry a fixed cable connection in one corner and serve short-wave diathermy treatments.
Fiu. 48.
Short-wave diathermy apparatus with treatment drum. (Courtesy of Burdick Corp.)
Inductance cables are single electrodes used for short-wave diathermy with the electromagnetic field technique. They contain a flexible wire surrounded by heavy insulation. They are applied in the form of circular loops around the body or an extremity and also in the form of a "pancake" coil or a treatment drum. Their two ends carry plugs to fit into the current outlets of the apparatus. Moist-pad electrodes consist of flexible metal plates covered on one side with a layer of soft rubber and bearing a suitable opening for the attachment of the conducting cord. On the side to be applied to the skin there is a pad of absorbent material of suitable thickness and strength, such as asbestos, and this is covered with linen, fastened to the metal plate in back. Moist-pad electrodes serve for galvanic and low-frequency treatments in which it is necessary to soften the horny layer of the skin for the passage
74
ELECTROMED1CAL CURRENTS, APPARATUS, ACCESSORIES
The covering of the pad electrodes is soaked with tap water or a 2 per cent saline solution. The moist pad also absorbs the acid or alkaline products of the electrical decomposition of the metal and thus prevents chemical burns. The ordinary one-piece pad electrodes can be easily cleansed by soap and water, and laid out to dry until the next use. A simple method to provide a clean surface at each treatment is to cover the pad with a fresh layer of loose sterile gauze.
of the current.
FIG. 49.
Pad
The removable asbestos electrodes for low-tension currents. cleansing. (Courtesy of Burdick Corp.)
pad allows better
Instead of ready-made moist pad electrodes electrode pads of any desired size for galvanic treatments can also be improvised by folded hand towels, Turkish towels or cellucotton. In such case care must be
taken that the material used be of adequate thickness and is thoroughly soaked in saline solution, that it is well folded and that the metal foil laid on top of it should nowhere come in contact with the skin, also, that the conducting cord is well fastened to it by a clip and is safely held there.
FIG.
'50.
Small pad electrode for muscle stimulation.
Glass electrodes serve for the application of some forms of high-voltage (high-frequency) treatments to the body. They are made in two types:
Vacuum
been exhausted to a varying degree.
electrodes consist of a hollow glass tube from which the air has Condenser electrodes are made of
especially heavy glass, the inner surface of which is lined with silver; they contain air at ordinary atmospheric pressure. Glass electrodes are mounted
ELECTRODES
on an insulating handle
75
operator's fingers. No current ever passes directly through the glass wall; the rapid charging and discharging of the inner surface of the tube to which the current is led, induces charges of opposite character on the outer surface through the glass.
to prevent the leakage of current through the
Bipolar electrode, especially useful for galvanic treatment of one eye. Cup with moist cotton forms one pole, when held against the closed lid; the handle forms the other pole. (Courtesy of Teca Corporation.)
FIG. 51.
filled
Orificial electrodes of various copper, zinc, etc.
shapes and sizes are
made
of metal
Electrodes have to be applied and held snugly. chest, etc., the weight of the patient's body will hold the electrodes, while over the thigh, abdomen and front part of the chest, a small sandbag and pillow can be utilized to hold the electrodes
Securing Electrodes.
Under the back and the
FIG. 52. Metal orificial electrodes. A, cervical copper electrode; B, carbon-tipped vaginal electrode; C, metal vaginal electrode; D, metal prostatic electrode; E, metal rectal electrode; F, cylindrical rectal electrode; G, electrode for female urethra.
with the patient recumbent on his back. In applying electrodes over an extremity, the face, or other rounded portion a few turns of a woven elastic bandage, 2 inches wide, will insure an even contact. In bandaging moist pad electrodes it may be advisable to interpose oiled silk between the electrode and the bandage in order to prevent diffusion of the current due to the wet bandage, or else to use a rubber bandage. For the safe retention of the electrodes, when not held by the operator,
70
devices consisting of a stand, arms and clamps are available. In rectal and vaginal applications sandbags are usually sufficient, holding the electrode in a secure position. Some electrodes are mounted on insulated handles, made of wood or vulcanite, and the handle is fitted with attachments to make, break, or otherwise regulate the current. Electrodes with handles permanently attached or removable are used mainly for short applications to small areas, such as in testing for electrical responses of
muscles and nerves and also for treating weak or paralyzed muscles (motor
point treatment).
FIG. 53.
Metal
cuff electrodes
above and below knee.
Secured by bandaging.
will
Further details of different electrodes, their handling and securing be found in the chapters on the various currents.
MISCELLANEOUS ACCESSORIES
Treatment Timers.
as
For the accurate measuring of treatment time, and
for safety of application, special alarm clocks or automatic clock turn-offs are well nigh indispensable. These clocks can be set
an added feature
usually for any number of minutes, from one to sixty. Anyone practicing physical therapy should at the very start acquire the habit of setting a clock for the treatment period for each patient. This will avoid occasional
situations
when, on account of an absorbing telephone conversation or some other distraction, a patient may be left connected too long to a machine or under a lamp.
For a visual timer signal a 120 volt lamp of very low wattage (3 to 7) be connected across the timer as suggested by Dr. Jerome Weiss. While the machine is operating, the closed timer switch will act as a shunt across the small lamp. When the treatment time is up, and the timer switch opens, the small lamp will be in series with the machine. The lamp will light almost to full brilliancy, but the current flowing through it is not sufficient to operate the machine. If several machines are in use at
may
the same time, this visual signal will call the attention of the operator to the particular one which has completed its treatment time. In installations
where
many treatment booths are used, the signal lamp may be placed at the entrance of the booth where it will be visible to the operator in any part of the room. Patient's Release. patient's release consists of a cut-off switch which can be operated by a gentle pull of a cord placed within reach of the
MISCELLANEOUS ACCESSORIES
patient.
It will
77
an
immediately reassure a patient who is apprehensive of treatment if he knows that he can turn off the current at any time without even calling for the doctor. As a matter of fact, with skilfully
electrical
any occasion
applied electrodes and proper dosage of current there^will hardly ever be to utilize such release except in a real emergency, like the slipping of a cord tip or dislodging of an electrode
due to an untoward movement of the patient. Foot Switches. For the application of treatment where both hands of the operator are needed, as
in the surgical application of high-frequency currents, it is important to be able to start or cut off
by a foot switch. For the application monoterminal high-frequency current the foot switch is serviceable because by its use one
the current
of the
eliminate the unpleasant leakage of the highvoltage current from the conducting cord each time the electrode is lifted off the patient while the current is on. The development in the technique of the various electrical modalities brings forth constantly minor and major innovations in accessories of treatment. A study of the latest catalogue of manufacturers furnishes always a good deal of up-to-date information about these developments. Treatment Tables and Couches. Well-built tables FIG. 54. Automatic or couches are essential for the efficient administratreatment timer and A wooden patient's release. (Courtion of electrical and light treatments. tesy of the General Electable, 26 inches high, 24 inches wide and 60 inches tric X-ray Corporation.) with upholstered top and with a head-rest, long, is the most desirable when it has to serve for all treatment. It is suggested that either the head or the foot end should be adjustable. Patients with stiff backs or extensive arthritic changes prefer a low couch, and this is also more convenient for light treatments, as it allows a greater range in adjusting the distance of the lamp from the
may
patient.
rest, like
For knee and foot cases an armchair with an adjustable foota steamer chair, is quite convenient. Metal tables, as a rule, are not desirable on account of the possibility of grounding the current. For further details of office equipment see Chapter XXXVII.
CHAPTER V
EFFECTS OF ELECTROMEDICAL CURRENTS. PASSAGE THROUGH THE BODY. GENERAL RULES OF TREATMENT
Primary Physical Effects. Ionic Effect. Thermal Effect. Specific Electric Effect. Secondary Physiological Effects. Psychological Effects. Electrical Conduction Through the Body. Resistance of the Skin. Resistance to Different Currents. Practical Importance of Skin Resistance. Changes in Skin Resistance. Path and Strength of Currents Through the Body. Current Density. Influence of Size and Position of Electrodes. General Rules of Electrical Treatment.
IN medical
tion
is
electricity electrical energy of sufficient strength and duraapplied to the body, in order to exert certain physical effects, known
as "primary" physical effects.
These
produce "secondary" physiological changes. is based on these effects.
in turn affect cellular activity and The rationale of clinical use
Primary Physical Effects. The human body consists of a composite mass of tissues which have electrical constants like any other substance or matter, i. e., all of them act as conductors of electricity to a varying extent. In human tissues all cells are bathed in lymph or other intercellular fluid and an electric current, in order to reach the cells, has to pass through
this fluid.
The
and
salts.
Hence the problem
tissue fluids consist of a solution of water, albumin, fibrin of electrical conduction in the tissues can
be regarded as a problem of conduction in an electrolytic solution of a somewhat complex character. An electrolytic solution contains dissociated
component particles of acids, bases or salts. These free atoms contain an electrical charge; bases, metals and alkaloids are electropositive and acids and acid radicals electronegative. The two principal primary effects of electricity on living tissues are the ionic or chemical effect and the heating or thermal effect. Generally speaking, ionic effects are exerted by the galvanic and low-frequency currents, while a primary heating effect is exerted by high-frequency currents. Both of these effects are based on electrolytic conductivity of tissues; a current passes through an electrolyte because the electrically charged particles are the sole carriers of the electric charge. The method of short-wave diathermy has added a new form of thermal effect on the basis of dielectric "conductivity." Static electricity occupies a special position
atoms
of the
all
or ions
by
exerting so-called partly ionic and partly purely electrokinetic effects, the physical explanation of which is not as clear cut as that of ionic and
thermal
effects.
When a direct (galvanic) current passes between two immersed in an electrolytic solution, positive ions will be attracted toward the negative pole and negative ions toward the positive pole. The same "common ion transfer" or electrophoresis will take place in human tissues and since the ionic concentration is quite different inside of cells and the surrounding tissues and fluids, there must come about some changes in the ionic balance.
1. Ionic Effect.
electrodes
(78)
PRIMARY PHYSICAL EFFECTS

movements take place
79
In addition to simple transportation of ions, two further forms of ionic in the composite medium of tissues: (1) Cataphoresis is the transportation of non-dissociated molecules and colloids, due to the adsorption of these particles by the electrical ions; it has been shown to proceed always from the positive to the negative pole. (2) Electroosmosis is the shifting of the water content through an electrical or membrane structure with an electrical charge. These effects in their totality may be described as electrokinetic phenomena. (See Chapter VIII.) It is evident that these somewhat complex ionic and electrokinetic phenomena must lead to a variety of secondary chemical and colloidal processes, the extent of which may be often difficult to ascertain. There may be possible changes in the local metabolic processes, or changes of permeability and a consequent alteration in metabolic exchange. If there is a concentration of ions of sufficient, intensity at a de5mt^ point (motor point) there arises a stimulation of muscleVand nerves with Such stimulation is effected by the a resulting muscular contraction. various low-frequency currents and is the basis of one of the most important
electrotherapeutic procedures. It enables well controlled stimulation of one muscle or a group of muscles whether normal or paralyzed.
I
There
is
no ionic concentration and subsequent muscle and nerve sfimula;
tion with high-frequency currents, because of their extremely rapid oscillation through the tissues the duration of each single impulse is much below
the effective time for ionic concentration. 2. Thermal Effect. All electrical currents develop heat in their path according to Joule's laws. (Chapter II.) The strength of the direct or alternating current used in ordinary treatment, though sufficient to produce ionic effects, is not sufficient to produce a physiologically active amount of heat. An alternating current of high voltage as used in electrocution does produce enough heat to coagulate the tissues under the electrodes
body temperature appreciably. high-frequency current brings about a rise of temperature of the tissues in accordance with its frequency, strength and duration. Subsequent biological changes in the tissues are secondary to this primary physical
and
raise the
effect.
flow of high frequency electric energy through the body tissues High frequency currents of longwave length and relatively low frequency encounter a "load" in the tissues which is predominantly "resistive." Therefore, the major part of the heat
varies with the frequency of the current.
The
production in long-wave diathermy occurs by virtue of the conductivity of the tissues. (Fig. 55.) High-frequency currents of short-wave length and relatively high frequency encounter a load which is mostly "capacitative." (See later
under Electric Conductivity.) With both forms of high-frequency heating rise of local and general body temperatures within the limits of physiological toleration can be produced. According to the temperature law of Van't Hoff, for every rise of 10 C. the rate of oxidation is increased 2.5 times, and thus even
temperature changes of tenths of degrees will influence cellular oxidation and exert marked effects on physiological processes. Conductive and convective forms of heating (hot water, heated solids, hot air) heat the tissues from without inward by conduction from the skin
80
EFFECTS OF ELECTRO MEDICAL CURRENTS
surface in contrast to the through and through heating of diathermy. Heat effects of high-frequency electrical currents are one of the major procedures of modern electrotherapy because of the penetrating and wellcontrollable heat production.
C2
C2
Ca
pwH'KvH'HwH Rrl R R R
FIG. 55. Schematic illustration of passage of short-wave diathermy current from condenser pads Ci through section of human body partly as a current of conduction (through ohmic These resistances R) and partly as a current of capacity (through dielectric substances d) resistances and capacities are both in series and in parallel.
.
There are a number of reports on record Specific Electrical Effects. that the electrical current exerts certain physical effects on the cellular contents of the human fluids, which cannot be classified as either ionic or thermic. Galvanotaxis of leukocytes, described in 1891 by Dineer, consists of an attraction of normal leukocytes by the anode of a galvanic current, while leukocytes of inflamed tissues are attracted to the cathode. 8 According to Monguio the reversal from cathodal to anodal galvanotaxis on the internal condition of the cell. With the alternating curdepends rents, effects of oscillotaxis and oscillotropism have been described by 10 With higher frequencies Muth observed Scheminzky and Scheminzky. in 1927 that in the alternating current field of 2.10 4 to 2.10 6 pearl chains are formed in fat emulsions, i. e., the fat globules arrange themselves in 3 a way that their central points are in parallel with the field. Krasny-Ergen confirmed that these pearl chains are also formed with ultrashort waves
excluding thermal effects which would make fat globules Liebesny actually demonstrated these effects. (Fig. 56.) The role of these specific electric effects in our therapeutic procedures is doubtful but their existence is interesting enough to be placed on record.
of very
weak energy
boil.
Any form of physical energy is capable of prodestructive effects when applied beyond the limits of physiological ducing toleration. The well-controlled employment of such destructive effects is the basis of the various procedures of electrosurgery. (Chapter XIII.)
Destructive Effects.
PRIMARY PHYSICAL EFFECTS

TABLE
8.
81
SCHEME OF PHYSICAL AND PHYSIOLOGICAL EFFECTS BY ELECTRICAL CURRENTS

Primary
physicochemical
Secondary
physiological
effects
Therapeutic
uses
Current
effects
Galvanic
\Mild thermal; pos. pole: acid reaction; neg. pole:

i
Vasomotor stimulation
alkaline reaction; iontophoresis; cataphoresis
Relief of inflammatory changes; mild caustic effects; introduction of drugs
Low-frequency
currents
Mild thermal; alternating

acid or alkaline reaction
Sensory and motor nerve stimulation

Increased circulation sensory and motor nerve sedation;
bactericidal
Exercise of
weak and
paralyzed muscles
Relief
of pain and spasm promotion of nutrition and ab;
High-frequency
Profound thermal
sorption
Relief of local stasis; exercise of muscles
Static
wave and
Mechanical
Sensory and motor

stimulation,
lecular tissue
spark
momas-
fat FIG. 56. Electric effect of ultrahigh-frequency field on fat emulsion. A, irregular chain formation after energy li globules before energy is turned on; B, typical pearl (Courtesy of Dr. P. Liebesny.)
82
EFFECTS OF ELECTROMEDICAL CURRENTS
Secondary Physiological Effects. The physiological action of the various eloctromedical currents depends on the primary physical effects just outlined. They include: (1) action on the vasomotor system, vasomotor stimulation lasting from a few minutes to several hours, with subsequent
on circulation and nervous reflex effects, (2) action on the neuromuscular system, stimulation or sedation of muscles and nerves, (3) effects on local and general metabolism. These manifold effects are discussed in the special chapters for each current. Psychological Effects. It is well known that a certain psychological effect may occur with any form of electrical application, just as it may occur with any other form of treatment, whether by drugs, diet or surgery. The fact that electricity has become a much more commonplace object in daily, commercial and home life has taken away much of the awe formerly existing toward its seemingly mysterious nature and consequently, the more intelligent public of today is less likely to be influenced by an electrical application for merely psychic reasons. In all pathological or functional conditions patients must receive physical treatment on the basis of a definite diagnosis as well based on sound physiological principles. The
effects
additional therapeutic help supplied by the unpredictable psychic effect of electricity on any individual is not unwelcome, yet no thoughtful physician will nowadays misinterpret these effects as the main result of electrical
treatment. Hysterical paralysis and paresthesias are perhaps the only functional disturbances in which some form of electricity may be indicated for a purely suggestive effect.
ELECTRIC CONDUCTION
THROUGH THE BODY
The human body consists of a composite mass of tissues and fluids with varying electric conductivity. According to Hemingway and Sten2 strom, the problem of electrical conduction in the tissues is a problem of conduction in an electrolytic solution and a tissue may be regarded as a non-homogeneous solution. In applying an electrical current to the body conduction and subsequent effects will depend (1) on the form, strength and duration of the current, (2) on the structure and area of the application. Resistance of the Skin. The factor of skin resistance is of primary importance in electrotherapy. The resistance of the skin being comparatively much greater than that of all other parts may be considered as a measure of resistance of the entire body. Generally speaking, the skin can be considered as a partial conductor, the conductivity of which is increased by mechanical, thermal or chemical stimuli. It is an important
organ of protection, perception, absorption and excretion. It varies in thickness in the different regions of the body, from about J to 4 millimeters. The topmost of its two principal divisions is the epidermis, consisting of a superficial horny layer, the protecting and insulating coat and a heavy
subcutaneous layer; neither of these contain any blood-vessels, but they admit the flow of nutritional fluids from below through little channels. These nutritional channels, and mainly the opening of the ducts of the sweat glands, serve as paths for the entrance of low-tension currents. The lower division of the skin, the corium or true skin, is formed of connective tissue united with elastic, smooth muscle fibers, and it contains an abundance of capillary blood-vessels. (Figs. 211 and 218.)
ELECTRIC CONDUCTION THROUGH THE BODY

The
relative resistance of the various parts of the skin
is
83
determined
by their histological difference. The horny layer of the skin offers most of the resistance. Parts habitually exposed offer less resistance on account
of the thinness of the skin.
The
relative porosity or the distribution of the
sweat glands influences skin resistance considerably, hence the much better conductivity of the palms of the hands as compared to the backs of hands, in spite of the thicker horny layer. The soles of feet are the most resistant on account of their thick horny layer and the absence of sweat glands. Heat decreases skin resistance by bringing on perspiration due to an increased activity of the sweat glands. In experimental studies subcutaneous injections of pilocarpine well away from the hand increased the conductivity of the palms of the hands. Skin Resistance to Different Currents. It is evident that the form and strength of current will have a different influence on the resistance of the
skin.
*~-
been shown that the flow of a direct (galvanic) current creates an opposite electromotive force in the skin under the electrodes, known as polarization. This phenomenon can be easily demonstrated any time after the flow of the galvanic current, if one leaves the parts and electrodes in the same position after the rheostat is turned back to zero. It will be seen that the needle of the milliammeter will swing out immediately in the opposite direction for a fraction of time. This indicates an opposite Richter3 demonstrated that the current flow in the patient's circuit.
It has
resistance offered to a direct current of small strength is localized practically in the skin a minute puncture made through the skin decreased the resist;
ance from any level to zero.

current of greater strength will have a greater power to overcome Currents of high frequency such as diathermy cause no polarization on account of the very short duration of each impulse. This and their high voltage explains the minimal amount of skin resistance
skin resistance.
'
towards them.
tions
Experimental Demonstrations. The following experimental demonstrashow the difference between the skin resistance to the galvanic
current (low voltage) and diathermy (high voltage). 1. A human subject holds in his dry hands two (a) Galvanic Current. metal cylinders connected to the terminals of a galvanic generator. Advancing the rheostat far up will result in only a slight excursion of the needle
now wets
of the meter, his
about 2 to 3 milliamperes. Turn off current. The subject hands with salt water and grasps the cylinders again, being careful not to contact them. Turning on the rheostat to the same extent,
the needle will swing out

2.
much
farther.
electrodes are placed in dry condition on two opposite surfaces of the body. Connected to a galvanic source, no matter how strong a current is turned on, there is no sensation underneath the electrodes and the needle of the meter does not indicate the flow of any current.
Two pad
These experiments demonstrate that the dry skin even with good metallic contact will conduct only a fraction of the galvanic current compared to j its moist state, also that dryness of the interposed asbestos pad prevents^ the passage of any current. 3. The subject holds one cylindrical electrode in each hand. A moderate amount of galvanic current is turned on, then the subject closely approxi-
84
EFFECTS OF ELECTROMED1CAL CURRENTS

balls of the
without touching the electrodes. In spite from hand-to-hand instead of via the arms and across the shoulders, no increased current flow is shown by the
of the shorter
mates the
hands
path
offered, directly
meter.
This experiment demonstrates that the skin offers so much resistance to the galvanic current that it will take the longer course along the less resistant blood-vessels and muscles, instead of the shorter path necessitating
another passage across the skin. I. The subject holds in his dry hands two metal (6) Diathermy. cylinders, each connected to the terminals of a long-wave diathermy machine or a short-wave machine with a circuit for direct conduction heating. Increase current in the patient's circuit to about 300 to 400 milliamperes, then turn off the main switch without setting back the other controls. Let the subject moisten his hands with salt solution and grasp the cylinders again, then turn on the main switch. The meter will not register more
flow of current than before.
This experiment demonstrates that the skin
offers
comparatively
little
resistance to the high-frequency current. The current passes with equal ease through dry and wet skin. Moistening of electrodes is with diathermy, therefore, as a rule, unnecessary. 2. The subject holds two metal electrodes and about 500 milliamperes
of current are turned on.
balls of the
He now suddenly and closely approximates the hands being careful not to allow the electrodes to touch each
show
at least double
other; the milliammeter will

passing.
amount
of current
This experiment shows that the high-frequency current in contrast to low-voltage currents prefers to pass along the shortest path between the electrodes if the resistance is not unduly high. The resistance of a healthy normal individual to the direct and the alternating current was found to be from arm to arm 1050 ohms with the direct and only 250 with the alternating current; from arm to leg it was 1600 ohms with the direct and 360 ohms with the alternating current. 4 (Laqueur, et al.) Recent investigations with a 60 cycle alternating current for "electroshock" 6 showed that when voltages between 50 and 120 applied are applied and there is good contact and good conduction (electrode jelly is used), the initial ohmic resistance of 2000 drops to a value between 300 and 120 ohms almost immediately after the current is made. The living skin thus behaves like an electrolytic condenser which breaks down when voltages above 50 are applied. This study also shows that the sometimes elaborate measures to measure the resistance of the skin before an electric shock treatment are not necessary. Table 9 sums up the skin resistance to various currents.
TABLE
Current
9.
SKIN RESISTANCE TO ELECTRICAL CURRENTS

Voltage
.
Polarization
Skin resistance
Galvanic (direct) Low-frequency High-frequency

Static
. .
v
.
Low Low
High High
Yes
.,.".
...
.
.,-,
..-.
Some None None
High Moderate
Little Little
Practical Importance of
Skin Resistance.
The
difference in the skin
resistance toward the various currents explains the difference in technique

in their application.
85
When applying currents of low tension moist pads are interposed between the plain metal electrodes and the skin to overcome the high skin resistance and to prevent electrolytic changes. Warming up and moistening the skin or the use of electrode jelly helps to decrease
resistance
when dry metal

matter
and improves conductivity. Practically no conduction occurs or dry pad electrodes are placed upon the dry skin, no
strong a galvanic current is turned on. The moist gauze or also serves to prevent corrosive effects liable to occur under bare metal when a direct or galvanic current is applied. After the current has flowed for a while conduction improves and the milliammeter indicates a larger amount of current flow.
asbestos
how
pad
FIGURES
IN
0: MA.
FIGURES WITHOUT CIRCLE: VOLT
17
82
FIG. 57.
Distribution of skin resistance and pain sensitivity to electric current. of the Merck Report.)
(Courtesy
In applying currents of high voltage, such as long-wave diathermy or the static- wave current, plain metal electrodes are used. The smooth pasluminous heat or infrasage of current is aided by directing the rays of a red generator for a few minutes to the area to be treated, and by slight
of the plates by the same source of heat. The size of the electrodes and the distance between them playsân the larger size of important role in skin conductivity. It is evident that the electrodes offers larger surface for the entry of the current. This result is a decrease of skin resistance proportional to the area of application.
warming
When electrical
of current
currents are applied in a
full
water bath very large amounts
can be introduced.
86

upon moist electrodes decreases skin resistance by by producing greater saturation with moisture. Too
Gentle pressure better contact and
much or uneven pressure may lead to burns through relative ischemia of the skin or through excessive current density.
The distribution of skin resistance and pain sensitivity to the galvanic current over various points of the skin was recently investigated by Molitor7 by applying galvanic currents of increasing strength and recording the milliamperes and volts when the subject felt that the tolerable limit has been reached. While sensitivity to pain and skin resistance varied considerably in various individuals, the general trend was unmistakable. It showed that (1) at the point of maximum tolerable current the voltage readings vary greatly at various points of the body surface, depending upon skin resistance at the site of electrode application. (Fig. 57.) (2) The maximum tolerable current density depends to a large extent upon the size of the electrode, being relatively greater with a small electrode and smaller with the large one. (3) The total current which can be applied
without producing pain is far greater with a large electrode. Changes in Skin Resistance. Observations in a large number of subjects, both normal and psychopathic, by Richter 9 have shown that: (1) All agents that stimulate the skin produce a decrease of resistance; (2) the palmar resistance is dependent on the sweat glands and is controlled by nerve impulses arriving through the sympathetic nervous system; (3) the palmar resistance shows a large increase during sleep, following nerve section and severe shock, and just preceding and following death (in all of these conditions the impulses reaching the skin are diminished or there is actual interruption of the nerve pathways); (4) high palmar resistance over a prolonged period of time is liable to be associated with a depressed mental condition. An increase of skin resistance is usually found according to Richter in
hysteria, myxedema, in old age and cachectic conditions, as well as in cerebral infantile paralysis, while a decrease is found in hyperthyroid
and in traumatic neurosis. Resistance of Other Tissues. Electrical conductivity of all tissues of the 'body depends (1) on their content of water and (2) on their relative density. The relative conductivity of the various tissues is about equal to their content of water, this being approximately as follows: Muscle, 72 to 75 per cent; brain, 68 per cent; fat, 14 per cent; peripheral nerves, skin and bone, 5 to 16 per cent. In general, tissues that contain the most water, and are, therefore, richest in ions, are the best conductors. Muscle and brain show the best conductivity of all the tissues; muscle conducts about four times better in the longitudinal direction of its fibers than transversely. Tendons and fasciae are poor conductors on account of their lesser content of water and their density. The location of the brain and spinal cord in poor-conducting bony tissue does not modify their electrical conductivity to a great extent. It has been proved that effective amounts of current pass through the cranium as well as through the spinal column. Peripheral nerves conduct six times as readily as muscular substance; it is difficult to utilize this advantage, however, because a nerve is usually surrounded by fat and by a fibrous sheath, both being poor conductors. The subcutaneous tissue is a relatively good conductor. Bones are the poorest conductors, especially those of dense structure.
subjects
87
Internal organs, such as the liver, lungs, stomach and intestines, offer a varying degree of resistance, dependent on their relative content of blood, air, connective tissue and, in the case of the hollow viscera, their contents. A study of Bachem 1 on the resistance of the dead organs of the human body corroborates the above findings and demonstrates as well that the resistance depends on the variety of current. It is smallest for high-
frequency,
medium
10.
for low-frequency
and greatest toward HUMAN ORGANS

Current
direct current.
TABLE
SPECIFIC RESISTANCE OF
(BACHEM)
Liver
88
be effective in regions which would otherwise be more or less inaccessible to a purely conductive current. Hence inner organs, the spinal cord and the brain, all of which are closed off by poor conductors (fat, bones, etc.) may be heated without overheating the tissues around them. It is the general!^ accepted view that short-wave diathermy passes through the tissues of the human body partly as a current of conduction and partly as a "current of capacity" as indicated in Figure 55. However, in actual clinical practice there is little if any difference in the effectiveness between long-wave and short-wave diathermy.
O
A
B
FIG. 58. Schematic illustration of effect of a condenser field on molecular dipoles. A shows the molecules arranged in no particular order with no electric field applied; B shows their alignment under the influence of an electric field with the negative poles toward the positive The rapid change of the charger plate pole and the positive pole towards the negative pole. of the condensers will in the next instant tend to reverse the direction of these dipoles. This molecular friction exercises a heating effect on the molecules in the electric field irrespective
of their electric conductivity.
'
THE PASSAGE OF CURRENTS THROUGH THE BODY

After having overcome the resistance of the skin and entered the body, an electrical current usually flows in a direct having line from one electrode to another, as shown by the recent experimental studies of Weeks, Alexander and Dennis. 11 Only those tissues show response which lie in its direct path. It is evident that the area immediately underneath the electrodes will show most of this response. The most important factor in the action of a current on a given area is the density of the current. A given amount of current passing through a large area may exert no appreciable effect, but when concentrated in a conductor of small diameter, as, for instance, in the skin under a small electrode, it may produce a very marked effect, amounting even to destruction of tissue. The density, and hence the physiological effect, of a current is directly proportional to the square of its strength and inversely proportional to the cross-section of the area through which it flows. There is no known measure of density; the amount of milliamperes flowing through an electrode does not furnish a measure of density, but if the size of this electrode is known then the number of milliamperes per square inch will give an accurate measure of the density underneath. The density of a current may be increased (1) by decreasing the size of the electrode or (2) by increasing the amount of current. There exists a marked limit of physiological tolerance of tissues, especially of the skin, to the density of
Current Density.
current.
physiological conditions the comfortable toleration of the patient the principal guide of safe current density. It is estimated that each square inch of normal skin can comfortably tolerate about 1 to 2 milliis
Under
89
amperes of the direct current, a slightly larger volume of a low-frequency current, and about 75 to 100 milliamperes of the high-frequency current. This considerable difference in the volume of current tolerated explains
Corona
of-
heart- 4.1%
Spinal cord,
Tit'=1.38%
Long paravertebral
muscle -1. 5%
60
shock
current
FIG. 59.
Observation of distribution of 60 cycle alternating current in various parts of the
body of the cat. Passage of current from forefoot to hindfoot, amounts carried by the aorta, vena cava, spinal cord and long muscles of the back were similar. (Weeks, Alexander and Dennis, courtesy of Jour. Indust. Hyg. and Toxicol.)
the profound thermal effects of the high-frequency current. The mucous membranes, on account of the absence of an insulating horny layer and their great vascularity, tolerate more density and allow the passage of a
relatively greater
volume
of current.
90
EFFECTS OF ELECTRO MEDICAL CURRENTS
It is evident that by increasing the size of electrodes, larger amounts of current can be passed without the danger of burn, but even if the relative density of the current is thus made much smaller, there is a limit of com-
shock
current
Cet?ebellum=O%
o%
FIG. 60. Passage of current from forefoot to forefoot. Note current in spinal cord most dense at C7, diminishing cranial and caudad. Absence of measurable current in brain. (Weeks, Alexander and Dennis, courtesy of Jour. Indust. Hyg. and Toxicol.)
FIG. 61
FIG. 61.
FIG. 62
size.
Current density equal under each electrode. (Erb.) FIG. 62. Current distribution with electrodes of unequal size. Current density twice as great under the electrode which is one-half the size of the opposite one. (Erb.) Current distribution with electrodes of equal
fortable toleration, determined by the reaction of the sensory nerve endsmaller electrode does ings of the skin to the total area of application.
91
not insure the passage of a greater relative amount of current as each skin unit will tolerate only a certain density. Influence of the Size and Position of Electrodes. Employing two electrodes of equal size, the density beneath each of them is equal; while using one twice as large as the other, the density of the current under the smaller will be four times as great as under the larger. As the current spreads across the body its density must gradually, to the inverse
according
square
FIG 63. Various modes of current distribution in homogeneous medium. A, Electrodes of equal size, equidistant and relatively close to each other; current density equal all the way through. B, Electrodes of equal size, equidistant and relatively far apart; current density less in center. C, Electrodes of unequal size equidistant. D, Electrodes (See also Fig. 62.) of equal size, slightly tilted toward each other; beginning edge effects. E, Path of current
narrowing between electrodes; greatest current density in center. G, Electrodes on same surface of body; typical edge effect between proximal edges. F, Needle point active electrode and large dispersive electrode; excessive current density causing coagulation under the needle
point.
law of energy, decrease so that midway between the electrodes the density is usually less. The nearer the electrodes are applied to each other, the greater will be the density of the current between them. If both electrodes
are placed on the same side of the body or of an extremity, the density of the current will be the greatest in the skin and in the superficial parts. The closer they are placed, the greater is the density on the surface, with
a resulting "edge" effect; this
is first
manifested by an unpleasant burning
92
sensation and, when unheeded, may result in a superficial blister or deep burn. Edge effects are noted only between the near edges of electrodes and
none on their
far side.
influence of the position and relative size of electrodes upon the passage of a current of adequate strength through homogeneous tissue is
illustrated in Figure 63. Placing electrodes of equal size exactly opposite and parallel is designated as transverse application; it results in equal current density all the way
The
through, provided that the electrodes are not too far apart. Increasing the distance between the electrodes decreases the current density between them, due to the inevitable dispersion of current in the central area between the electrodes (Figs. 61, 62 and 63 B), accordingly one must use proportionately larger electrodes in order to obtain a fairly equal density all the way through. When treating inner organs, Kowarschik demonstrated by a series of experiments with diathermy that as long as the distance between the electrodes is not more than one and a half times their longest crosssection, the density, and thus the heat effect, will be equal all the way
through. Placing electrodes of unequal size exactly opposite to each other results in proportionately greater density under the small area. (Fig. 63 C.) The decrease of the size of one electrode simply limits the principal effect of the current to the area under this "active" electrode. This may be desirable when the action of the current is to be restricted, mainly under the area of one electrode (diathermy to frontal sinus, spinal column, prostate, etc., or in muscle and nerve testing). In surgical applications the current density under the active electrode, a needle point or knife, is increased far beyond physiological toleration, and thus leads to tissue destruction. (Fig. 63 F.) When electrodes are tilted toward each other as in Figure 63 the greater part of the current will take the shorter path and thus the density will be greater when the edges approximate each other. Diathermy, for instance, can be concentrated into the subdeltoid bursa by applying two electrodes on each side of the arm and tilting them toward the middle of the deltoid muscle. In the routine transverse application, however, the placing of electrodes in any other than in parallel planes is to be avoided. If the cross-section of the area between the electrodes is narrower, as in Figure 63 E there results a greater density of current in the area of the smaller cross-section than in that under each electrode. This occurs in treating the wrist or the ankle with cuff or plate electrodes applied above and below. When electrodes are placed on the same plane (Fig. 63 G) whether with low-frequency or long-wave diathermy currents the passage of current will be almost entirely limited to the surface area between the proximal edges. When two electrodes are placed on the same plane but some distance apart, the technique of application is designated as longitudinal or co-plane application. It is estimated that in order to get deeper effects the distance between these electrodes must be not less than 10 inches. If these electrodes are placed circularly around a limb, this is known as the cuff method. If these cuffs are quite close the current density will be greatest along the surface, and the bulk of the current completes its circuit by travel-
GENERAL RULES OF ELECTRICAL TREATMENT

ing along the skin from electrode to electrode
If the cuffs are placed far
93
degree of
all the way around the limb. enough apart, however, there will be a certain deeper penetration. Treatment by the longitudinal method (cuffs
is the method of choice in the treatment of pathological changes located in the superficial soft tissues, skin, muscles and nerves.
and semi-cuffs)
FIG. 64.
Schematic representation of edge effect. Electrodes are applied on the same Zone of greatest density is shaded. (Erb.) surface, close by.
In the inductance cable technique by short-wave diathermy, a cable loop or pancake coil placed on one plane of the body causes so-called "eddy current" effects in the underlying tissues and brings about heating by the circulation of a current in the conductive soft parts.
FIG. 65.
Diagram of eddy current (electromagnetic field) effect of short-wave diathermy applied with inductance cable wound around an extremity or the trunk.
GENERAL RULES OF ELECTRICAL TREATMENT

In order to employ electrotherapy safely and efficiently the rigid observation of certain general rules of technique is essential. These rules are herewith given, while additional special rules for each of the currents are presented in the respective chapter for each. Calm and business-like method of procedure 1. Method of Procedure.
is
essential.
Many
patients are apprehensive
when
receiving electrical
94
first time and a nervous, fidgety operator adds to their Patients should be told that electrical treatments do not hurt and do not burn and that there is never more current administered than can be comfortably tolerated. Before patients are brought near an apparatus, the operator must know that it is properly connected up, in good working order and all controls are off or in zero position. Patients should be placed in a position in which 2. Position of Patient. For will remain comfortable during the entire treatment period. they treatment of the head, abdomen, pelvis and thigh or entire lower extremity, patients are best put in a recumbent position. The shoulder and upper
treatment for the
uneasiness.
usually be treated with the arm propped up (as much abducted as possible) by pillows on a small table; the elbow and forearm should be treated resting on a table. In neck or chest treatments patients may sit propped up in an armchair. For knee, leg or foot treatments an armchair
arm should
with a foot-part which can be raised is convenient. Before applying electrodes inspect carefully 3. Inspection of Parts. to be treated to make sure that the skin over these looks and feels parts normal. Special precautions in treatment are necessary in case of recent scar tissue, in peripheral nerve injuries and other cases of disturbed sensation. Preliminary exposure for ten minutes to luminous heat is a good routine measure to warm and relax the parts and decrease skin resistance. Choose electrodes of proper type 4. Placing of Electrodes and Cords. and size, warm diathermy plates under a heat lamp or moisten galvanic pad electrodes with warm salt solution. Place electrodes in correct position and see that they are in good contact all the way through. Secure electrodes by elastic bandages (avoid too much and too tight bandaging) or small sandbags; whenever possible hold one electrode by part of the body resting on it. Fasten conducting cords to the electrodes and binding posts (terminals) of the apparatus, hold condenser pads by bandaging and insert their cable connection into the terminals of the apparatus. See that electrodes and conducting cords stay secure during entire treatment. Avoid crossing of short-wave diathermy cables and the touching of any metal surface by them.
Starting the Treatment. Everything is now ready to start the flow Set the time clock or automatic switch for the prescribed time. Turn on the main switch to admit the supply current. Proceed to turn on
5.
of current.
a comfortable current strength by gradually opening the controls. Warn the patient to report any unpleasant sensation pricking, excess heat at once. Never leave the patient out of sight or sound once the treatment has been started, unless there is an arrangement whereby if necessary the patient can instantly shut off the current and knows how to use it. It should take three to five minutes 6. Regulation of Current Strength. to reach the maximum current strength and to allow for gradual overof skin resistance, avoiding stimulation of sensory reflexes. The strength of current to be employed depends on the size of the active electrode, the condition to be treated and the individual sensitivity of the
coming
patient.
If the patient complains any time during treatment about pain, burning or any other unpleasant sensation and decreasing the current strength does not give immediate relief, turn off current entirely. After patient is comfortable again advance controls carefully; if patient still
REFERENCES
complains, take
all
off.
95
controls are
off.
and inspect electrodes and their site, making sure that There may be poor contact or too much pressure
under the electrodes, or the patient may be simply oversensitive. After reapplying electrodes proceed as on first starting current; never push up current strength if the patient is not entirely comfortable. It is generally more beneficial to use a moderate amount of current for a longer period than to push up the current to the full limit of toleration for a short intensive treatment.
In judging sensitivity of patients, their temperaments as well as the location of electrodes must be taken into consideration. Patients of the
nervous type usually stand less current at the beginning. On the other hand there are patients who are not satisfied unless they get the maximum current they can stand. There are ignorant types like the patient who does not believe that the medicine can be active unless it has a nasty taste, who think that an electrical current must burn and consequently fail to report burning sensations at their inception; as a result some of these patients may develop burns. In nervous children, in order to get them used to the situation, it may be advisable at the first sitting to apply the electrodes without turning on the current. Different areas of the skin are of different sensitivity, it is well known that the skin of the forehead, the hands and feet tolerates heat better than other parts. In nerve injuries and other disturbances of peripheral sensitivity special precautions have to be taken as will be pointed out later. Turn off controls slowly in the reverse 7. Termination of Treatment. order to that in which they were turned on. Take off electrodes only after the current has been turned off entirely. See that all controls are turned back to zero. Inspect the site of electrodes; nurses must report any unusual changes at once to the physician in charge and make a record of them. Let patients rest for a few moments after every treatment. In inclement weather make sure that patients are allowed ten to fifteen minutes to cool
sensitive,
before they go outside. Observing these simple precautions will greatly help to avoid embarrassing moments at the beginning of one's electro therapeutic practice. Accidents resulting in burns or other mishaps may occur unavoidably from time to time, but as long as the physician has used a method and technique accepted as standard, and the accident is not the result of any neglect or improper act, he will be relieved from all unreasonable responsibility. Accidental
off
injuries are discussed in detail in
Chapter XIV.
REFERENCES
1.
BACHEM,
A.:
The
Resistance of Various Tissues for Various Electric Currents,
2.
HEMINGWAY,
3.
Arch. Phys. Ther., X-ray and Rad., August, 1930. Physical Characteristics of High FreA., and STENSTROM, W. K: quency Current, Jour. Am. Med. Assn., 98, 1446-1455, 1932. Point Heating and Mechanical Effect of Short Waves, Arch. KRASNY-ERGEN, W.
:
Phys. Ther., 21, 362-366, 1940.

4.
LAQUEUR,
A.,
MUELLER,
O.,
and NIXDORF, W.:
Leitfaden der Elektromedizin,
Halle, Carl Marhold, 1922. 5. LIEBESNY, P. : Film Shown at International Congress Short Waves, Vienna, July, 1937. The Human Skin as a Conductor of 60 Cycle 6. LOWENBACH, H., and MORGAN, J. E. : " " Electroshock Patients, Alternating Current of High Intensity, Studied on
Jour. Lab.
and
Clin.
Med., 28, 1995, 1943.
96
7.

MOLITOR, HANS:
fer,
:
8.
Pharmacological Aspects of Drug Administration by Ion TransThe Merck Report, 52, 22-29, 1943. Ueber die polare Wirkung des galvanischen Stromes auf Leukocyten, MONGUIO, J.
Ztschr.
f.
Biol., 93, 6, 1933.
9.
RICHTER, C.
10.
and Daily Variations in Psyand Psychiat., 19, 488, 1928. SCHEMINZKY, FERDINAND, and ScHEMiNZKY, FRiEDERiKE: Ueber die WechselP.:
Electrical Skin Resistance; Diurnal
chopathic and in
Normal
Persons, Arch. Neurol.
stromeinstellung bei einigen Ciliaten, Oscillo taxis, Pfliiger's Arch. f. Physiol., 213, 1-2, 1926. Distribution of Electric 11. WEEKS, A. W., ALEXANDER, L., and DENNIS, R. M.:
Current in Animal Body: Experimental Investigation of 60 Cycle Alternating Current, Jour. Indust. Hyg. and ToxicoL, 21, 517-525, 1939.
CHAPTER
VI
ELECTROPHYSIOLOGY
Bioelectric
Action Currents in Skeletal Muscles. Action Currents in Injury Current. Action Currents of the Heart and Brain. Theory of Bioelectric Phenomena. Electrical Stimulation of Muscles and Nerves. Nature of Nerve Impulses. Stimulation by Direct Current. Electrotonus. Nerve Block. Electrical Curves. Chronaxie. Progressive Excitability. Strength Duration Currents. Intensity Frequency Relation.
Nerves.
Phenomena.
made about
Phenomena. In recent years far reaching discoveries were the production of electrical potentials in the living tissues. It seems evident that changes of ionic concentration are constant byBioelectric
products or factors in all living processes. This newer knowledge allows not only a better understanding of the principles of electrodiagnosis, but also enables some interpretation of the possible effects of electromedical currents on the structures of the body especially in low-frequency stimulation of muscles. Hence it seems appropriate that as an introduction to
the physiological basis of electrodiagnosis presentation be made of some of the bioelectric phenomena connected with vital processes.
ACTION CURRENTS
Electrical currents arising within the body in connection with cellular activity have been demonstrated in all living tissues, such as nerves, the central nervous system, glands, retina, etc. Starling 5 states: "Every beat
of the heart, every twitch of a muscle, every stage of secretion of a gland 1 is associated in some way with electrical changes." Burr and Lance state:
"Electrical differences are constant but vary from moment to moment therefore, must be intimately related to such things as cell division rates, metabolic rates, the internal economy of each cell, etc."
and presumably,
The momentary
ing parts of a nerve fiber or muscle
difference in electric potential between active and restis known as the action current. It can
be demonstrated by connecting the two parts with a sensitive galvanometer.

necessary to employ non-polarized electrodes, is dipped into a solution containing its own ions such as zinc, copper or silver; this solution is separated from the sodium chloride solution of the tissues by a porous material such as kaolin. Such an arrangement prevents a "polarization" current from the liberated
it is
To record
in
these potentials
which the metallic electrode
in ordinary electrodes, which complicates the depolarization phenomena associated with excitation (page 83). In the human body it is possible to Action Currents of Skeletal Muscles. record the action potentials resulting from voluntary muscular contraction. If coaxial needle electrodes are inserted into the muscle the activity of a single motor unit is recorded. Surface electrodes are used to record from the whole muscle. The single action potential is a diphasic wave of short duration in the range of one millisecond with the characteristics of a spike. At rest under conditions of complete relaxation there are no currents recorded with standard techniques. During gentle muscular contractions
hydrogen and dissolved metal
(97)
98
ELECTROPHYSIOLOGY
the motor units discharge in a range between 6 and 60 per cent, the amplitude and frequency increasing with the strength of contraction. (Fig. 66.) The individual motor units discharge independently and asynchronously. The entire muscle discharges at a higher frequency about 300 per second
during a muscle tetanus.
ÂÂ*vuW^ftW^^
FIG. 66. contraction.
Normal muscle. Electromyogram of gentle (A), moderate (B) and strong (C) Time interval one second on bottom signal. (Electro my ographic Laboratory,
Massachusetts General Hospital.)
In recent years apparatus has been developed which can be used in the study of a number of diseases affecting the lower motor neuron. The electromy ographic findings in poliomyelitis, progressive muscular atrophy, Parkinson's disease and peripheral nerve injuries will be discussed
clinical
in a later section.
Action Currents in Nerves.
With the use
of the
gation, notably the cathode ray oscillograph action currents of nerves have been studied
newer methods of investiand vacuum tube amplifier, and conduction along indi-
vidual nerve fibers, rather than whole nerves investigated, for it has been found that different types of nerve fibers have different rates of conduction. It has been known for some time to physiologists that the excitement of a
nerve is followed by certain definite periods of excitability. On stimulation, a physicochemical change takes place in the nerve for a very short interval of time, during which no further excitement is possible. This period is known as the absolute refractory period and lasts about 1 a (1 sigma is 1/1000 of a second). Following this is a variable period up to 15 <r in length during which the nerve recovers its conductivity, first rather rapidly and then more gradually. This is the relative refractory period. This period is often followed by the supernormal period during which the nerve is most excitable. The highest frequency of stimulation to which a nerve is able to
respond depends upon the length of
its refractory period. Thus, an absolute of 1 <r limits the rate stimulation to 1000 impulses per refractory period second. Some of the larger myelinated axons respond to a current of 2000
ACTION CURRENTS
about 0.5
99
impulses per second, hence must have an absolute refractory period of <r. The maximum frequencies noted in nerves carrying natural impulses was about 400 per second. This gives a rather large factor of tolerance for the rate of the stimulating current.
FIG. 67.
Cathode-ray recorded by action potentials
in a
phrenic nerve.
A, upper curve,
Temsingle shock; B, brief tetanus at 180 per second; C, brief tetanus at 350 per second. perature 37 C. Note development of positive after-potential. (Gasser, Harvey Lectures, Wilkins Company.) courtesy of Williams
&
FIG. 68. Diagram illustrating method of determining components in branches of a mixed nerve. DR, dorsal root; VR, ventral root; S, sympathetic component; X, Y, Z, leads to amplifying oscillograph; M, point of stimulation of whole nerve. (Wiggers.)
The
All somatic nerves are large bundles of mixed fibers of varying kinds. sciatic nerve of a frog, for example, contains about 4000 myelinated
and about 8000 unmyelinated fibers. Each type of fiber has a specific conduction rate. Cathode ray studies have shown three types of waves, A, B, and C. A waves travel along a nerve bundle at the rate of 30 to 90 meters per second, B waves at the rate of 15 to 25 meters per second and C waves at the rate of 1 to 2 meters per second. Motor fibers are known to have predominantly the A type of conduction. Sensory fibers at the dorsal root show a mixture of all three types of conduction while the sympathetic gray rami show types B and C.
100
ELECTROPHYSIOLOGY
phenomenon
is
is
known
Another bioelectrical Injury Current. as the injury current. If there

is
in muscles
and nerves
tissues
local injury to the
human
and one non-polarized electrode
applied to the damaged region while the other remains in contact with the uninjured part, a current Avill flow towards the damaged region, as shown in Figure 69.
FIG. 69.
Scheme
of injury
current.
(Winton and Bayliss'
Human
Current flow from uninjured to damaged region. Physiology, courtesy of J. and A. Churchill.)
of the injury current according to Winton and Bayliss8 is*that the injury ruptures a structure in the tissues, presumably a membrane of varying permeability which ordinarily prevents the passsage of a
The explanation
polarization current.
pass in
As a result ions, normally kept apart, are allowed to and out through the membrane. The direction of the current shows
Rest
Local Bioelectric Current
Di poles
+-+
4-
+
h
R
local bioelectric currents and spread of impulse according to theory of transverse depolarization, and (below) spread of excitation according to the theory of longitudinal polarization. E, excitation; R, recovery. (Wiggers.)
FIG. 70.
Scheme showing (above)
that negative ions pass out and positive ions pass in. It is evident that since tissues are not electrically charged, they cannot contain a store of negative ions without also containing a, store of a corresponding number of positive ions. If these positive ions were also inside the membrane, they would neutralize the negative ions and there would be no such thing as an injury current. This leads to the conclusion that the positive ions must be outside the membrane, and the negative ions inside, as shown in Figure 69, there must be, therefore, a state of permanent polarization in resting nerve and muscle.
ELECTRICAL STIMULATION OF NERVES AND MUSCLES
101
Action Currents of the Heart and the Brain. It was known since 1856 that the contraction of the heart was associated with a change of electric potential and in 1903 Einthoven invented the delicate string electrocardiograph with a camera to photograph its deflections. Electrocardiography has since that time assumed a major role in the diagnosis of heart conditions.
In recent years it was recognized that all functional activities of the cortex of the brain are associated with electric changes and gradually electroencephalography has begun to play an increasingly important role
in the
understanding of the function of the brain and in the diagnosis of the
disorders of the central nervous system.
Theory of Bioelectric Phenomena. The electrical potential differences may be explained either by movement of ions across polarized membranes or by a sudden fall of potential across the memfollowing excitation
brane.
The
local bioelectric current so
developed
is
believed to affect adjacent
regions of the membrane causing a serial depolarization or potential drop and a spread of the impulse, as shown in Figure 70.

Nature of Nerve Impulses. A stimulus or excitant according to Wiggers7 represents biologically a change in environment either naturally or artificially induced. In the body these generally consist of chemical or physical influences which produce polarity changes at membrane interfaces with
a cell to action. Electrical stimuli when properly used and controlled most nearly approximate natural physiological impulses. The effectiveness of an electrical stimulus depends on its intensity, its form and on the duration of its effective period. When a nerve is excited naturally or artificially by a stimulus, i. e., by a sudden change in its environment, a local disturbance is set up which is propagated in both directions from the point of stimulation. This is variously designated as the nerve impulse, the excitation wave or the propasufficient rapidity to stimulate
gated disturbance. It differs fundamentally from physical waves or mechanical oscillations, (a) in that the energy for progression is not derived from the energy of the stimulus but from successive physical and chemical changes in the fiber over which it travels and (6) in that it is conducted
without loss of intensity, i. e., without decrement. The velocity of impulse conduction in motor nerves in general has been found to be 70 to 100 meters per second in mammals. The independent irritability of muscles was first demonstrated by the classical experiment of Claude Bernard, who injected an infusion of curare into the dorsal lymph sac of a frog. The animal became paralyzed and the stimulation of motor nerves by single electrical impulses caused no connormal response. traction, while direct stimulation of the muscle evoked a The prevalent opinion is that in normal muscles an electrical current stimulates muscle cells directly as well as excites twigs of nerve fibers in
the muscular mass.
All forms of voluntary muscular contraction are of tetanic nature. Wiggers states that stimuli originate in the pyramidal cells of the cerebral cortex, are propagated by a long axon down the spinal cord and pass over synaptic
102
ELEC TROPH YSIOLOG Y
junctions with the dendrites of spinal cord cells. In this way the excitation process, initiated in the central neuron, excites the cell bodies of the peripheral neurons. From the spinal motor neurons impulses are transmitted to
the muscle fibers by axons leaving the spinal cord. It is well known that such voluntary contractions are not twitches nor jerks such as have been discussed; on the contrary, they are smooth, graded, sustained and larger
contractions which result in graceful movements of the bony levers to which they are attached. Such contractions are due to the fact that the pyramidal cells send out not a single stimulus, but successive volleys of impulses which
are graded as to frequency and duration. According to Piper they enter the muscle at a rate of 42 to 100 per second.
Time
A
'
-A
FIG. 71. Response of normal muscle to stimulation by direct or galvanic current. M, make; 5, break. Response occurs only at peaks between to 3 and 20 to 23 and is less strong on break than on make. (After Cowan.)
If a galvanic (direct) current is suddenly Stimulation by Direct Current. started or interrupted ("made" or "broken") over muscular parts or motor nerves, there occurs a muscular contraction or phenomenon of a sensory character (slight shock), at first under the electrode connected to
the negative pole and with a suitable increase of current strength also under the electrode connected to the positive pole. The law of electrical muscle and nerve stimulation as first formulated 2 by DuBois-Reymond states that the intensity of a stimulus and the subsequent muscular contraction are directly proportional to the magnitude and change in current strength (voltage and amperage) or, in the presence of same current strength, the intensity is proportional to the rate of fluctuation (the rapidity with which it occurs). Nernst3 first promulgated the
theory that stimulation of muscles and nerves was due to changes in ionic
103
concentration at the cell membrane: ions migrate at different velocity through the two media of the body in which they are soluble: the interstitial tissue fluid and the protoplasma of the cells themselves. At the border zone of these fluids, changes in ionic concentration occur in accordance with the strength of the current and its duration. These differences in concentration act as stimuli until they are equalized by a process of diffusion. The steadily flowing galvanic current causes no muscular contraction because there is not enough change in its strength or its rate of fluctuation to act as a stimulus. Turrell* and others state that the relatively high velocity of the hydrogen ion is primarily responsible for the stimulation of muscle and nerve tissues at the make-and-break of the galvanic current. The velocity of the hydrogen ion is so high compared with other ions that when we abruptly make or increase in strength a direct current flowing through the body, the hydrogen ions of the tissues traversed by the current momentarily concentrate in excess of the normal equilibrium at the negative pole and cause a muscular contraction or phenomena of a sensory character in the neighborhood of the negative pole. When we break or abruptly decrease in strength an electric current passing through the body, the hydrogen ions have been traveling with such relatively high velocity from the positive pole that a temporary deficiency of them exists in that region, leading to a hydroxyl ion or alkaline concentration. This, in turn, excites a contraction in the neighborhood of the positive pole. The closing ("make") of a direct current on a nerve proElectrotonus. duces an increase of irritability at the negative pole or cathode (catelectrotonus) and a decrease of irritability at the positive pole or anode (anelectro4 tonus) This is Pfl tiger's well known law and can now be explained by our of bioelectric currents. The closing contractions, elicited with knowledge weak and moderate stimuli are due to a depolarization at the anode.
.
FIG. 72. Diagram illustrating effects of the anode and cathode on human nerves. A, C, physical poles of electrodes applied to skin; a, c, physiological poles in underlying nerve a and c beneath C correspond to a', c', in text description. (Wiggers.)
important to know that the changes of irritability which develop immediately on closing a current do not persist in a static state while the Furthermore if the anode and cathode are current continues to flow. of applied over human nerves the effects are complicated by the spread
It
is
current through the tissues as shown in Figure 72. As is easily visualized under each physical anode and cathode (A-C) there exist what may be termed a pair of physiological anodes and cathodes (etc and a'c'). When the current is closed the excitation could develop at either physiological
04
ELEC TROPH YSJOLOG Y
cathode (c or c'), but as the density of the current is greater at c', the As the current strength is closing contraction originates at this point. increased it also develops at c. In accordance with Pfliiger's law, still stronger currents are required, however, to produce excitation at the physiological anodes a and a', but as the density of current is greater at a than at a' it will arise at a' last and only When currents are exceedingly
strong.
may therefore align the sequence of responses as follows, with regard 1 to the physiological poles: c' and c on closing, a and a on opening. In practice, however, these are referred to the physical electrodes applied
(A and
C),
We
hence the sequence.
Cathode
closing contraction
(CCC),
Anode closing contraction (ACC), Anode opening contraction (AOC),

Cathode opening contraction (COC).
Nerve Block.
Passage of an impulse through a nerve can be impeded
or prevented entirely by mechanical or chemical agencies as well as by the anodal effects of the direct current. This means that functional block can
be produced without cutting or injuring the fibers permanently. The "electrotonic" interruption of the conduction of stimulation only occurs with stronger currents and is considered to be due to deep secondary chemical and colloidal processes on the nerve membrane causing a reversal of the normal process of irritability. Electrical Excitability. The power of a muscle to respond to an electrical stimulus is a complex function dependent on a number of variable factors which make quantitative measurements difficult. The muscle contraction will vary according to the intensity of the electric current applied, the duration of the stimulus
is
also altered
Insofar as
and the rate of development of the current. Irritability by changes in the length of a muscle or the degree of stretch. possible these variables must be controlled or measured when
In clinical practice a minimal or threshold chosen as the index of response, as it can be more accurately repeated than a sub-maximal response and maximal stimuli are usually too painful to be tolerated. The rate of propagation of the stimulating current or its wave form may be held constant in character depending on
contraction
is
testing muscle excitability. Strength-Duration Curves.
the choice of stimulator. The two variables remaining are the intensity of the stimulus and its duration. The excitability of muscle can be determined then, by taking a constant index of response, a constant wave form of stimulating current and measuring the intensity of current required to produce the response when it is applied for a measured duration. The results of such measurements at varying intensity and duration of stimulus may be plotted in the form of a strength-duration curve which gives a graphic index of excitability. (Fig. 73.) Several different types of stimulators may be used for this purpose including rheotomes, condenser discharges, or more recently electronic stimulators which produce currents of rectilinear wave form. Chronaxie. If a long duration or constant current is used to stimulate a muscle or nerve, the intensity which is just sufficient to cause a threshold contraction has been called by Lapique the RHEOBASE. He also introduced
REFERENCES
105
the idea of doubling the rheobasic current arbitrarily and of determining the shortest time interval that it must act in order to produce a minimal reaction. This time is called CHRONAXIE. By referring to the graph of the strength-duration curve (Fig. 73) it can be seen that the chronaxie of a tissue is determined by measuring an arbitrary point on the curve. It is obvious that chronaxie is a reciprocal of excitability; decreased chronaxie signifying increased excitability and vice versa. Chronaxie determination has become of practical importance in electrodtagnosis as a fairly exact
index of excitability although it does not give as complete information as the whole strength-duration curve.
5-0-
^ma.
FIG. 73.
jt
Diagram
illustrating excitation time, rheobase
and chronaxie.
As previously mentioned the response of a muscle Progressive Currents. to stimulation by an electric current is influenced by the rate of propagation
by the intensity and duration. Experimental normal muscles, as the current gradient decreases, the current strength required for excitation increases. Currents which increase linearly or exponentially are called progressive currents and have been used both for electrodiagnosis and for treatment of denervated muscles.
of the current as well as
work has shown that
in
(See next Chapter.) Another measure of excitability has been Intensity-Frequency Relation. the response of nerve and muscle to sinusoidal alternating currents of different frequencies. With this type of current both the duration of the
stimulus and the rate of rise vary according to the frequency. At high frequencies the gradient is steep and the duration brief, while at low frequencies the rise is slow and the duration long. As stimulators supplying a wide range of frequencies are not generally available there is little experience to indicate their value in clinical use. An increasing amount of clinical and laboratory studies indicate that low-frequency sinusoidal currents are
of value in treatment of denervated muscles.
(See Chapter
XXVIII.)
REFERENCES
1.
BURR, H.
and LANCE, C. T.: Electrical Characteristics Jour. Biol. and Med., 8, 31, 33, 1935.
S.,
of Living Systems,
Yale
106
2.
ELECTROPH YSIOLOGY
E.:
DuBois-REYMOND,
Untersuchungen
iiber
thierische
Elektrizitat,
Virchow's
Arch., 2, 258, 1845.

3.
NERNST, W.: Zur Theories des elektrischen Reizes, Arch.

1908.
f.
d. ges. Physiol., 122, 275,
4.
5.
6.
Ueber die tetanisierende Wirkung des constanten Stromes und das Allgemeingesetz der Reizung, Virchow's Arch., 3, 13, 1858. STARLING, E. H.: Principles of Human Physiology, 5th ed., p. 112, 1930. TURRELL, W. J.: Principles of Electrotherapy and Their Practical Application, Oxford University Press, 1929.
PFLUGER, E. F. W.:
7.
WIGGERS, CARL
J.:
Physiology in Health and Disease, 3d
ed., Philadelphia,
Lea
&
Febiger, 1939. 8. WINTON, F. R., and BAYLISS, L. E.: Blakiston's Son & Co., Inc., 1935.
Human
Physiology, 2d ed., Philadelphia, P.
CHAPTER
VII
ELECTRODIAGNOSIS
General Considerations. Principles of Electrodiagnosis. Motor Points. General Technique. Difficulties in Testing. Testing Charts. The Faradic and Galvanic Course of the Reaction of Degeneration. Test. The Reaction of Degeneration. Diagnostic Significance. Testing for the Reaction of Degeneration. Diagnostic Other Changes in Electrical Reactions. Increased Excitability. Limitations. Diminished Excitability. Limitations of the Faradic and Galvanic Tests. Newer Methods of Electrodiagnosis. Testing by Strength Duration Measurements. TestElectromyoing by Chronaxie Measurement. Testing by Progressive Currents.
graphic Diagnosis.
General Considerations. Electrodiagnosis deals with the reaction of muscles and motor nerves to electrical stimuli. It furnishes a valuable aid from the standpoint of diagnosis, prognosis and therapy in pathological conditions of the motor tract, including the brain, the spinal cord and the peripheral nerves as, also, of the muscles. Every practitioner of medicine who has occasion to examine and treat nerve injuries and lesions of the central and peripheral nervous system should be able to carry out an electrodiagnostic examination. A physician skilled in electrical testing of muscles and nerves can testify as an expert and, if necessary, demonstrate his findings in court in the cases of paralysis, real and simulated, now so numerous following industrial and other accidents. Turrell states: "The special value of the electrical tests is that they afford objective evidence in place of the subjective signs afforded by the other methods of observation. We may suspect, from the appearance of th skin and from the tone of the muscles, that the loss of voluntary power inea limb is only functional; but a very brief examination of the muscles of this limb by the faradic current will definitely prove to us, if the muscles co ntract, that the case is a functional one, and if no contraction is elicited that there is an organic nerve lesion." Electrical stimulation of muscles and nerves has for over a century
formed part of the large

nosis
field of
physiology.
The
principle of electrodiag-
was discovered by a Frenchman, Duchenne and were further developed by French and German physiologists, among them Erb, Remak, Pfluger, DuBois-Reymond and Babinski, until the classical method of testing by the faradic and galvanic currents was fully established. Newer English and French investigators, Lewis Jones and, later, Lapicque, Bourguignon and Adrian, developed modern methods of greater precision.
One of these
is the testing by condenser discharges, using electrical impulses of definite strength; the other is the determination of the chronaxie. have seen in the foregoing electrophysiological considerations that each skeletal muscle possesses the property of independent irritability and
We
contractility
if artificial stimuli are directly applied to it. Likewise, any nerve fiber may be stimulated by artificial means at any point of its course. Electrical stimulation is the most effective and convenient artificial stimulant of both muscle and nerve. A suitable electrical stimulus applied to a motor nerve elicits a contraction in all of the muscles supplied by the
(107)
108
ELECTRODIAGNOSIS
nerve below the point of stimulation.
A suitable electrical stimulus applied
and may also spread to the neighboring muscles. The character of the response varies with the nature and strength of the stimulus employed and the normal or pathological state or the nerve or muscle. Many of the pathological conditions in the central and peripheral nervous system are accompanied by typical changes in the electrical reaction. It
to a muscle elicits a contraction of the muscle itself
may
be normal,
it
in character,
and
it
may be exaggerated, it may be diminished, or changed may be entirely absent. Under normal conditions all
muscle stimulation occurs through the more excitable nerve fibers. After damage of the nerv.e supply the muscle degenerates, a quick stimulus does not elicit response in either nerve or muscle. A longer and more powerful stimulus however, will still bring about a response in the muscle. Lack of any response to either muscle or nerve stimulation proves that there is neither conductive nerve tissue nor contractive muscle tissue present. This occurs only in the later stages of peripheral nerve injuries or in poliomyelitis or in progressive muscular atrophy.
TABLE
12.
CHANGES
(a)
(6)
IN ELECTRICAL REACTIONS
Quantitative changes
Qualitative
Qualitativequantitative
Hyperexcitability Hypoexcitability (a) Contraction sluggish (6) Contraction persists (c) Contraction quickly ceases (a) No response to faradism (brief stimulus) (6) Sluggish response to galvanism (long stimulus) (reaction of degeneration)
Using the electrical reactions of nerves and muscles as aids in diagnosis, one must always bear in mind that these tests are only part of the evidence, the other part being supplied by the clinical examination of the muscular
power, the reflexes and of the sensory condition of the region affected. A knowledge of the clinical pathology of the central and peripheral nervous system is, therefore, equally essential for the proper interpretation of the
findings.
Motor Points. Strong electric stimuli applied to any muscular part of the body will cause disagreeable shocks and muscular jerks in a widespread area. In contrast to this, electrodiagnosis is a delicate and relatively painless procedure which elicits a well-localized muscular response with a
minimum amount of current. Every nerve and every muscle,
unless deeply covered by other muscles, possesses a small area where it is most easily excited and where a visible contraction can be elicited with a minimal amount of stimulation. This area is called the motor point. The motor point of a normal muscle is located usually about the middle of the muscle In a nerve trunk the belly, where the motor nerve enters the muscle. motor point can be found where the position of the nerve is nearest to the skin and consequently its shape is somewhat linear. There may be several points of maximal irritability in the course of a long nerve. The topography of motor points was first studied by Erb, and a set of diagrams based upon his studies is shown at the end of this volume. A set of motor point charts is an indispensable part of the equipment of the beginner; those doing electrical testing should frequently practice the finding of motor points. Even within normal limits there are individual
GENERAL CONSIDERATIONS
differences in their location
109
and sensitiveness to electric stimulation. In pathological conditions leading to a reaction of degeneration the motor point of a muscle is displaced distally, and the motor points of a nerve
disappear entirely.
FIG. 74.
Applying
electrical stimulus over
motor point.
Apparatus and Accessories. The apparatus for the classical method of by the faradic and galvanic current consists of a faradic coil and galvanic generator as described in Chapters VIII and IX. In the more recent thermionic low frequency generators there is usually a current labeled "faradic" available, produced either by a suitable vacuum tube*or by a small faradic coil within the generator.
testing
FIG. 75.
Electrode for nerve and muscle testing.
(1) an active or testing electrode, of a small metal disc, covered with asbestos or chamois or several consisting layers of gauze, and mounted on a handle with an interrupting device
The accessories for electrodiagnosis are:
(make and break key). This electrode serves to concentrate the current over motor points and allows for its make and break. For nerves and small muscles, a disc of about f inch in diameter is suitable for larger ones, one of 1J inches in diameter. Applying the large disc edgewise also limits the contact surface; too much current crowded into a small electrode causes pain, however. For bipolar testing two active electrodes are employed. (2) A dispersive (indifferent) electrode, large enough to avoid a current density which may give rise to a painful sensation or contraction under that electrode. A 2 by 4 inch or 3 by 5 inch, or even larger plate, covered with gauze or asbestos is usually satisfactory.
;
110
ELECTRODIAGNOSIS
has constructed a simplified device for testing with the interrupted galvanic current only, as illustrated in Figure 76. It combines in one single holder the active electrode and an adjustable dispersive one
De Yong
and offers the advantage that it is light in weight, portable and also enables muscle stimulation for therapeutic purpose.
FIG. 76.
Bipolar testing electrode,
(de Yong.)
FIG. 77.
Position of patient and Operator for electrical testing, courtesy J ! J. B. Lippincott Company.)
(International Clinics,
General Technique.
Practical working knowledge in electrodiagnosis
must be acquired by
testing normal muscles and nerves and thus learning to appreciate the range of normal variations, It is well to start on a muscle
DIFFICULTIES IN TESTING
or nerve that
111
is easily located and the response of which can readily be observed, such as the biceps of the arm. A routine for making an electrical
examination
may
be as follows:
well lighted so that the slightest response of muscles warm so as to avoid chilling of the patient.
The room must be

can be observed, and
patient and the operator should be placed in a comfortable position undue fatigue. The operator should be able to reach all parts of the apparatus without changing his position. For testing the upper extremity, neck, shoulder and face the patient may be seated at a small table, resting his arm on it; the examiner sits at the opposite side of the
so as to avoid
table.
The
patient should
is
For the examination of the lower extremity and the back region the lie on a table. A supported position of the parts to be tested
essential for relaxing the muscles.
area to be examined should be warmed up by a heat lamp, by hot by immersion in a hot whirlpool bath. The hyperemia produced decreases skin resistance and will also minimize the painfulness of the testing. Electrodes should be well moistened by soaking in hot water, a
towels, or
The
pinch of table salt added to the water is sufficient to improve its conductivity. A small basin of salt water should be on hand and the testing electrode should be frequently soaked in it during the course of a longer test. The routine procedure for testing and treatment is unipolar testing. The dispersing electrode is placed over any part of the body with little muscular tissue, such as the chest, the small of the back or the sacrum. Firm contact is secured by the weight of the patient by a small sandbag or by bandaging. The testing or active electrode is placed directly over each motor point to be tested. With any form of electrical testing a certain inertia of muscles has to be overcome at first. For this reason at the beginning more current is needed; after a contraction or two have been elicited usually less current will be necessary for a response. It is best to first turn on a current of moderate strength and, on decreasing it gradually, ascertain the minimum strength, which is just enough to cause response. In paralyzed muscles often the only response that can be elicited is a slight contraction palpable over the muscle tendon. After the first response, one may slightly shift the testing electrode in order to find a better location of the motor point and thus elicit response with less current. The response of adjoining muscles caused by spreading of electrical impulses is often disturbing. It occurs especially with very weak muscles, and under such circumstances experience is required to recognize slight contractions.
Electrical testing done by experienced operators is rarely painful. Young children with infantile paralysis may be tested without much crying, once
they are coaxed over the preliminaries of their unusual experience.
As to technical difficulties, it is seldom that the Difficulties in Testing. apparatus gets out of order. It may happen that after the electrodes have been applied, the galvanic current turned on and the controls advanced, the patient feels no sensation at all and no muscular response occurs. One may note also that the needle of the milliampere meter does not move. If one persists in turning on more and more current, under such circumstances, the patient may experience a painful shock quite suddenly and the meter needle swings way over. All of this is usually due either to a
break in one of the conducting cords or to insufficient moistening of the
112
electrodes.
resistance,
ELECTRODIAGNOSIS
The greater strength of current suddenly overcomes the added but rudely shakes the confidence of the patient by the sudden shock. New pad electrodes need more moistening than old ones. The addition of a few pinches of salt to the water helps conductivity. The metal plate underneath the pad is subject to gradual wear by electrolytic corrosion and the connection for the cord tip soldered on the plate also corrodes in time. For these reasons as soon as ready made pad electrodes show sign of trouble they are best discarded. Before stating that any muscle shows total lack of response to any electrical stimulation, one should bear in mind that skin resistance, much
edema
of the tissues or spreading of current to neighboring muscles, at times may temporarily prevent a response to the galvanic test. In any doubtful case repeated and carefurexamination is required.
FIG. 78.
Bipolar muscular stimulation. This concentrates the current over a weak muscle and tends to avoid "splashing" of current to adjacent normal muscles.
Bipolar testing consists of placing two small disc electrodes directly over the belly of each muscle to be tested. This furnishes more current density over the testing area, and does away with the spreading of excess current
The bipolar procedure to surrounding muscle groups. cases only, when the muscles are very weak exceptional
is employed in and the testing
current tends to spread, causing contractions in neighboring muscles. A combination of the two methods can be used. For instance, in testing the intrinsic muscles of the hand the palm of the hand is laid over the dispersing electrode and the testing electrode is placed over the interossei on
the back of the hand.

Testing Charts.
trical testing
An
accurate record should be kept of the result of elec-
and all further tests should be likewise recorded. Tables 15, 16 and 17 show part of the charts used by the author for clinical recording of muscle and nerve tests; in the originals there is room for one or two more subsequent examinations. In each examination there is a column for recording the faradic and galvanic testing and the third column serves for entering the result of either condenser or chronaxie testing. In the motor point charts in the Appendix the relative excitability of muscles and nerves hasjbeen indicated by numbers from 1 to 4.
THE FARADIC AND GALVANIC TEST
113
The Faradic and Galvanic Test. The faradic current applied to a normal muscle or motor nerve elicits a continuous (tetanic) contraction during its entire flow. The galvanic current applied to a normal muscle or motor nerve does not elicit any contraction while flowing steadily, but it causes a brisk single (clonic) contraction whenever it is suddenly started or interrupted (made or broken) in a flow of sufficient strength. These contractions are always the result of the indirect stimulation of the muscle through the nerve fibers of the motor nerve. Under normal conditions the nerve fibers are more excitable than the muscle. Only when the motor nerve is in a pathological state and cannot be stimulated does the independent property of contraction of the muscle become evident. Such response, however, is of different character; it is sluggish and worm-like instead of the normally brisk contraction.
FIG. 79. Graph of electric response of muscles. G, single brisk contraction on stimulation with interrupted galvanic current; F, tetanic contraction on stimulation with faradic current.
The dispersing electrode is connected to one (a) The Faradic Test. binding post of the faradic coil (it makes no difference to which one), and the testing electrode is connected to the other. The active electrode, well moistened, is placed in good contact, over the motor point of the muscle or nerve to be tested. Turn on the current, slightly advance either the secondary coil or the intensity control in the generator, then press the key of the interrupting handle. The patient will feel a slight stinging sensation under the testing electrode; if the current strength is sufficient, and the electrode is in the correct position, a tetanic contraction of the muscle or group of muscles occurs. This contraction will persist while the current flows. After the first response cut down the current strength to just enough to cause a visible contraction. Also try, by shifting of the
motor point more accurately. In routine normal faradic response usually obviates the necessity of a galvanic testing test. If, by comparison with the normal side, there is more current needed to get a response note the position of the secondary coil on the scale. The dispersing electrode is connected to the (b) The Galvanic Test. and the testing electrode to the negative terminal of the galvanic positive
testing electrode, to locate the
supply. Place the testing electrode over the motor point. Advance the rheostat slowly, increasing the strength of the current from zero upward. Then, pressing the key down from time to time, watch for the first visible contraction. By a little practice one should learn to find the threshold of
excitation,
i. e.,
the
minimum amount
of current necessary for a response.
testing is being repeated, the needle of the milliampere meter will out further and further with the same rheostat setting. This is due swing to the fact that the repeated passage of the current decreases skin resistance.
As the
Why are two currents necessary for testing f The fact that two kinds of current are used for testing is somewhat bewildering for the beginner,
8
114
ELECTRODIAGNOSIS
or
fibers are stimulated by the make and break of any current sudden change in its intensity, but do not respond to a current which any flows steadily without a change in strength. The faradic current consists of rapid and short impulses, each rising to a maximum in about TW^ second and recurring about 100 times in a second.
Motor nerve
One stimulus
occurring in rapid succession keeps a normal muscle in tetanic contraction during the entire time
after the other
of
flow.
This makes observation of the
response very easy.
The galvanic current, while flowing steadily, furnishes no stimulus for muscular response; only when its flow is suddenly started at sufficient strength, or while flowing at sufficient is interrupted
strength, does muscular response occur. The response to galvanic stimulation occurs in It has been estimated single contractions. that the impulse of the make and break of the galvanic current through the testing electrode lasts about one-half second. For ordinary testing we have thus a stimulus of very brief duration the faradic current, and one of relatively long duration the make of the galvanic current.
THE REACTION OF DEGENERATION

FIG. 80.
tract.
motor A, Central or upper motor
Diagram
of the
segment; begins with the psychocells in the cortex (1) and continues through the pyramidal tract, the lateral columns of the spinal cord to the terminal arborization in the horns (2) of the cord. B, Peripheral or lower motor segment; it begins with the ganglion celfs in the anterior (ventral) horns of the spinal cord (or the motor nuclei in the cerebral nerves) and continues through the peripheral motor nerve (3) to the end-plate The trophic (4) over a muscle. center of muscles is located in the
motor
The most important use of the faradic and galvanic test occurs in testing for the reaction of degeneration. In the diagnosis and prognosis of lesions of the lower motor neuron of the motor tract this reaction as expressed in the terms of the galvanic and faradic test, is still the standard test and has not been superseded by any of the newer methods of
trauma conduction of a peripheral nerve has impulses through ceased, either by gross anatomical or finer molecular disarrangement of the nerve trunk or the anterior roots, or by a lesion in the spinal cord, within ten days certain well known changes in the electrical reaction occur. These changes are known as the reaction of degeneration or abbreviated,RD. The anatomical changes consist of the breaking
electrodiagnosis. If due to disease or
horn cells; any lesion above the trophic center results in

anterior
slight atrophy, increased reflexes and absence of RD; a lesion below the trophic center results in flaccid paralysis,
spastic paralysis,
marked atrophy,
development
of
lost reflexes
and
up of the affected nerve trunk and of atrophy and later fatty degeneration of the muscles supplied by it. Consequently the nerve loses its electric conductivity and the character of the muscular contraction changes. There is no response to the quick stimulus of the faradic current and only a sluggish response to galvanism; the latter change is due to the fact that only the muscle
an
RD.
"

fibers
115
to the adjoining fibers, in contrast to the fibers when their nerve supply is intact.
in the fact
immediately under the electrode respond and the stimulus then passes immediate response of all muscle
The importance of the lies that when present ten days after an injury or disease, it indicates changes in nerve and muscle substance that will take considerable time to recover, and that in a minority of cases may lead to irreparable damage. The reaction of degeneration may be full, partial, or absolute. Total or Full Reaction of Degeneration. (a) The nerve does not respond to either faradic or galvanic stimulation.
(6)
1
.
RD
The muscle
after a period of hyperexcitability does not respond
to faradic stimulation.
2.
The muscle responds
to galvanic stimulation but demands a greater current strength and the response is sluggish and slow.
FIG. 81.
Curves showing response to both galvanic and faradic stimulation

muscles; absence of faradic response in
in
normal
RD.
3.
The motor
4.
point is displaced toward the periphery, where the muscle fibers join the tendon (longitudinal reaction). The formula of polar response often changes, i. e., stimulation from the positive pole elicits an equally prompt or often better response than from the negative pole. This change, however, is not constant enough, and for this reason it is
the opinion of modern investigators that the polar inversion should be disregarded (page 120). Partial Reaction of Degeneration. (a) The nerve shows a decrease of both faradic and galvanic responses. (b) The muscle shows:
1.
2.
3.
Decrease of faradic excitability. Increase of galvanic excitability (this is irregular, most frequently observed in facial muscles). The response is slow, but this is not as pronounced as in full
RD.
4.
There
may
be longitudinal reaction and inversion of polar
formula.
Many
forms of transition
of degeneration; partial may develop into full exist not only in the same extremity simultaneously group of muscles, especially in infantile paralysis.
RD
may
occur between
full
and
partial reaction
RD, and
but also
both
may
same
in the
116
ELECTRODIAGNOSIS
This term is applicable to cases in absolutely no response to any current in either nerve or muscle. It represents the final stage of a previous full with an unfavorable outcome. It must be made certain always that testing conditions are correct; also it may be better to repeat a test at least once before a definite verdict of hopelessness for the return of function is rendered.
Absolute Reaction of Degeneration.
is
which there
RD
j,
r^/c
FIG. 82.
Contrast of galvanic response. A, brisk response in normal muscle; B, slow, sluggish response in degeneration.
TABLE
Normal
Partial
13.
ELECTRICAL REACTIONS OF MUSCLES AND NERVES

Faradic
Galvanic
reaction
<* Muscle
\
\
I
Tetanic contraction
Brisk single contraction
RD
(
Full
RD
RD
Nerve Muscle
N
-K
res P nse
No No
response
{ Sluggish response
Absolute
No
response
response
Course of the Reaction of Degeneration. Whether it is partial or full, the course of the can be divided into three stages: always There may be a 1. The initial stage lasts from ten days to two weeks. brief period of hyperexcitability of both muscle and nerve during the first
RD
After the first week the nerve loses all response to faradic and stimulation; the muscles respond but feebly or not at all to the galvanic faradic current; galvanic testing, instead of the usual brisk, lightning contraction, elicits only slow and torpid response of the muscles. The average case presents by the middle of the second week all signs of the classical,
few days.
full
2.
RD.
The stage of full RD: it lasts from a few weeks to a year or more, according to the severity of the lesion. 3. The final stage: in this there is either a gradual return of the voluntary function and electrical response or absolute develops and the outcome is definitely unfavorable. Figures 83 to 86 show the course of the reaction of degeneration in four
RD
typical cases. Diagnostic Significance of the
RD.
The occurrence
of the reaction of
degeneration signifies a separation anatomical or physiological between a muscle and its trophic center and, therefore, may mean any of the following:

1
.
117
2. 3.
Complete section of the nerve. Compression due to callus.

Degeneration of nerve after
IJegeneration of the nerve
interstitial sclerosis
(neuroma, hyper-
trophic interstitial neuritis).

At
if Mi.;
IUUS.-U ar
111.
res
Cirrhosis.
'e
10
11
12
Week.
FIG. 83. Paralysis with relatively early return of motion. A, voluntary motion; (Erb.) B, galvanic excitability of muscle; C, faradic excitability of muscle; D, excitability of nerve to either current; *, return of voluntary motion.
Degeneration
of the nerve.
Atrophy of the
muscles.
Cirrhosis.
Kegene ration.
a*
4f>
Week.
FIG. 84. (Erb.) Paralysis with late return of motion. excitability of muscle; C, faradic excitability of muscle; current; *, return of voluntary motion.
Degeneration
of the nerve.
A, voluntary motion; fi, galvanic D, excitability of nerve to either
Atrophy, nuclear proliferation, cirrhosis.
FIG. 85. Incurable paralysis. Motion lost permanently. A, voluntary motion; (Erb.) B, galvanic excitability of muscle; C, faradic excitability of muscle; D, excitability of nerve to either current.
4.
Abolition of function of trophic center in the spinal cord due to anatomical lesion in the anterior horns (poliomyelitis, syringomyelia, etc.).
118
5.
ELECTRODIAGNOSIS
Alteration of the peripheral nerve endings due to toxic lesions (polyneuritis following alcoholism, diphtheria, lead poisoning and all forms of peripheral toxic neuritis). In the last type of lesion the does not represent all of the changes as in injury of a nerve or in degenerative changes of the spinal cord. is found in the following conditions
RD
RD
Nerve
Degenerative atrophy of the
Regeneration.
muscular
fibres.
Week.
FIG. 86. Schematic representation of partial degenerative reaction. A, volun(Erb.) tary motion; B, galvanic excitability of muscle; C, faradic excitability of muscle; D, excitability of nerve to either current; *, return of voluntary motion. The faradic and galvanic irritability of the nerve and the faradic irritability of the muscle are diminished to a slight extent. Motor power returns at an early period; complete and rapid recovery. Degeneration of the nerve probably absent.
(a) Affections of the anterior horn cells of the spinal cord and of the nuclei of the cranial nerves; acute, subacute and chronic anterior poliomyelitis, spinal forms of progressive muscular atrophy (in contrast to the myopathic muscular atrophy), local affections of the spinal cord if involving
the anterior horns (transverse myelitis, disseminated sclerosis, hematooccurs myelia, new growths, syringomyelia, new growths in the cord) in cerebral conditions when the nuclei of the cranial nerves are affected, because these are trophic centers of equal significance as the anterior horn cells. Bulbar paralysis of various kinds result in full in the respective cranial nerves and the muscles supplied by them. (6) "Affections of the anterior spinal roots, which may be either primary due to traumatism, or secondary, due to affections of the spinal meninges (syphilitic) or of the vertebrae (tumors, cancer, tuberculosis). (c) Diseases or injuries of the peripheral nerves. ^Mechanical or chemical
.
RD
RD
injuries alike
to peripheral nerves
tion), of
may cause degenerative changes in peripheral nerves. Injuries may result in complete division, partial division (laceracallus),
but it cannot determine whether the nerve has been divided or not. Primary inflammation of the nerve, infections and toxic irritations, as well as inflammations of adjoining tissues, cause various forms of neuritis, classified as toxic (alcohol, lead), infectious (diphtheria, typhoid, influenza), and rheumatic
or idiopathic (exposure, polyneuritis). (See Chapter XXVIII.) Functional, hysterical paralyses and paralyses of cerebral origin, are never accompanied by important disturbances of the electrical reactions. At most there is slight electrical hyperexcitability, while in the later stages there
is
RD serves as an important guide in diagnosis and prognosis,
compression (scar tissue or
and simple
bruising.
The presence
usually hypoexcitability from muscular atrophy.
Therefore, the absence
119
may serve as important evidence in determining malingering or funcof tional paralysis and differentiating them from other conditions. Table 14 gives the summary of the diagnostic significance of the changes
in the electrical reaction in pathological conditions.
RD
TABLE
14.
DIAGNOSTIC SIGNIFICANCE OF CHANGES IN ELECTRICAL REACTIONS

Recent hemiplegia,
first
Increased response
days of nerve
injuries, tetany, spasmophilia,
chorea, initial stages of spinal cord diseases
Advanced hemiplegia,
Decreased response
tabes, paralysis agitans, later stages of spinal
cord diseases, muscle atrophy due to disuse in arthritis, myositis, mechanical conditions, young children
120
ELECTRODIAGNOSIS
always permits a more favorable prognosis as to the expected recovery than a full reaction of degeneration. It also indicates the necessity of continued observation and the repetition of the electrical tests. The absence of reaction of degeneration allows the conclusion that no gross anatomical changes are present in the nerve anywhere, and that one may expect an early recovery, possibly in three or four weeks. The prognosis based on electrical testing is of especial value in such
rather frequent types of paralysis, as facial paralysis following exposure, paralysis of extremities due to pressure or exposure (wrist-drop after sleeping with arm under head), and in infantile paralysis. Testing in these conditions, about ten days after onset, enables one to differentiate between mild, moderately severe and severe cases. When there is no there is usually recovery in two to four weeks; if there is partial present is found recovery recovery may take six to twelve weeks if complete
RD
RD
RD
In organic spinal affections, as well as in peripheral toxic neuritis, no definite prognosis can be made on the basis of partial or full alone because it may represent only a transiwill
take at least six to twelve months.
RD
tional stage in an otherwise progressive and incurable condition. The preparations of the patient Testing for the Reaction of Degeneration. are made as described previously. motor point chart is an indispensable
aid for beginners (see charts in Appendix of this volume) The usual plan of testing is as follows:
1.
Testing with the faradic current (a) nerve and (6) muscles. Testing with the galvanic current (a) nerve and (b) muscles. Beginners should remember in testing one-sided lesions to begin on the normal side for comparison and for easier finding of the motor points. motor points of muscles are They should also bear in mind that in toward the periphery and motor points of affected nerves are displaced lost altogether. It is the rule to begin with the faradic test because if it is normal there is usually no need to proceed further. In real paralysis, it may be less painful to begin however, and in the presence of full with the galvanic test, as it permits the location of motor points with less current. Once the motor points have been found, the testing electrode may be left in position and the faradic test can be done with less pain. Before commencing electrical testing one should always endeavor to Muscles get an idea of the active voluntary muscular power present. of active contraction almost always respond to farad ism. Testing capable for skin sensation gives a lead in case of mixed nerve involvement. For instance, anesthesia over part of the deltoid area points to paralysis of the circumflex nerve (see Figs. 301 and 302). The Polar Formula. We have seen under electrotonus that the order in which muscular contraction appears in normal muscles is presented as C.C.C. >A.C.C. >A.O.C. >C.O.C., signifying that cathodal closing (the make of the current with the negative pole) excites contraction with the least amount of current; more current is needed for anodal closing and still more for the anodal opening, and most for the cathodal opening contraction. It has been proven by modern investigators that at the make of the current stimulation occurs chiefly at the negative pole, and at the break of the current, at the positive pole. The generally accepted view is that at the make (closing) of the current the negative pole alone is active and at the break (opening) only the positive pole.
2.
RD
RD
OTHER CHANGES IN ELECTRICAL REACTIONS
121
In ordinary clinical testing practice one may disregard the polar formula; galvanic testing should always be done with the negative pole as the active pole and with the "make" of the current. Diagnostic Limitations. The presence of an may be a deciding factor in diagnosis, but it is not infallible. It must always be considered in conjunction with other clinical evidence. For instance, in both anterior polio-
RD
myelitis
and peripheral nerve lesion flaccid paralysis and rapid muscle occur and the typical reaction of degeneration develops. In poliowasting myelitis there is no sensory change, because only the motor cells of the anterior horn are out of function, while in peripheral nerve lesions, the sensory fibers being included in the common nerve cord, there are always
definite sensory changes. The distribution of paralysis in poliomyelitis is irregularly located in the various muscles (with some well-known sites of
predilection)
and does not correspond with any particular peripheral nerve. Another example of the difficulty of making a diagnosis on the basis of
nerve tests alone are multiple injuries of the extremities, especially of the forearm. Extensive scar formations and adhesions, due to longitudinal incisions or multiple infectious processes, result in a loss of response of several muscles, thus imitating a nerve lesion. A nerve lesion might also be aggravated or appear more extensive from the coexistence of tendons bound down by adhesions. Electrical testing without a thorough clinical examination in paralysis of traumatic origin cannot determine whether the paralysis is caused by the original trauma or secondarily by contracting scars or pressure of callus. The possibility of a coincident systemic infection must also be borne in mind.
OTHER CHANGES
IN ELECTRICAL REACTIONS
stimulation there exists
Increased excitability to electrical Increased Excitability. occurs in pathological conditions of the nervous system where a state of irritation of the brain centers or where the brain inhibitory influence upon the peripheral nerve tracts. Recent
has lost
its
hemiplegia,
early stages of brain tumor, first stages of peripheral nerve injuries, acute neuritis and the early stages of progressive muscular atrophy, of sclerosis In multiplex and myelitis are characterized by increased excitability. tetany, spasmophilia, chorea minor, in various occupational diseases or
due to the hypertonicity of the muscles, the same condition preIncreased irritability, however, is of little diagnostic value; it might aid in a differential diagnosis between tetanus and hysterical spasms; in the latter a decreased excitability is the rule. (See also Table 55.) Diminished Excitability. Diminished excitability is much more frequent and occurs in three groups of conditions: 1. In muscular lesions following continued inactivity; in such event, clinically, there appear atrophy, decrease of muscular power and decrease
injuries
vails.
Prolonged immobilization after fractures or joint affections a frequent cause for electrical hypoexcitability, as shown in the atrophy of the deltoid after shoulder lesions and that of the quadriceps following injuries to the knee. Electrical testing helps to differentiate this condition from the atrophy following true neuritis because in the latter affection
of the reflexes.
is
reaction of degeneration is present. The practical importance of these differences lies in the determination of the appropriate method of treat-
122
ELECTRODIAGNOSIS
ment. In simple muscular atrophy, as signified by simple hypoexcitability, rhythmic electrical stimulation by the surging faradic or sinusoidal current usually results in prompt improvement. Marked hypoexcitability without qualitative changes is usually characteristic of primary (myopathic) muscular atrophies, such as progressive muscular atrophy, pseudohypertrophic paralysis, myotonia and myasthenia, while muscular atrophies of spinal origin invariably show the reaction of degeneration, due to the involvement of the peripheral neuron and after a sufficiently large number of bundles
have degenerated.
FIG. 87.
Muscle curve
of
myotonic reaction.
Sustained response
X point of
single stimulus.
2. In certain lesions of the peripheral neuron, that are not sufficiently advanced, or are not affecting all fibers of a certain muscle. Early stages of peripheral nerve injuries, chronic poliomyelitis, tract diseases of the spinal cord, certain forms of toxic neuritis may manifest themselves elec-
trically
by hypoexcitability instead
of a reaction of degeneration.
P'lo. 88.
Muscle curve
of
myasthenic reaction
X-Y time of tetanizing current.
A, Time
of
single galvanic stimulus.
peripheral neuron.
when there is no change in the Late stages of hemiplegia, tabetic paralysis, myelitis, etc., result in simple hypoexcitability, due to muscular inactivity. Myotonic and Myasthenic Reaction. These reactions consist in qualitative changes in the electrical response and both are of specific significance in the diagnosis of two typical but rather rare pathological conditions. The myotonic reaction is characterized by the fact that on faradic
3.
Lesions of the central motor neuron
NEWER METHODS OF ELECTRODIAGNOSIS
123
stimulation the muscles remain in tetanic contraction for some time, as long as twenty seconds, after the stimulus has ceased. This is characteristic
of
Thomsen's
disease.
reaction consists of an abnormal exhaustion of muscles; normal response to the faradic current subsequent stimulation elicits less and less response, until contractions cease altogether. After a period of rest response returns and the same process can be repeated. This
after initial
The myasthenic
typical reaction serves to corroborate the diagnosis of
my asthenia.
Limitations of the Faradic and Galvanic Test. The classical galvanicfaradic method of testing is easily comprehensible and the apparatus is
simple and inexpensive. The technique, however, requires time, patience and exactness and well-grounded knowledge of the anatomy and physiology of the nervous and muscular systems. It is the most important test for the recognition of gross changes in the electrical response of peripheral nerves and muscles. It is evident, however, that the simple faradic and galvanic test is insufficient for exact measurements of the degree of change and for definite measuring of progress or further degeneration. The strength of the ordinary faradic current is not measurable at all, and the length of each impulse varies not only in different coils, but even in the same coil. Faradic response moreover has no prognostic value because in a paralyzed muscle voluntary power returns, as a rule, before the response to faradism. The strength of the galvanic current can be measured, but its duration of flow is not measurable. Both the faradic and galvanic tests are often painful because, as a rule, the currents used for testing are much too strong and last much too long. Newer methods overcome the limitations of the simple faradic and galvanic test through testing by condenser discharges and chronaxie
measuring. These methods allow accurate charting of results, but require more elaborate and more expensive equipment and much more time for
testing.

Testing by Strength-Duration Measurements. To determine the strength-duration relationship of a current producing a threshold contraction, condenser discharges are usually used for stimulation. A condenser, as described in Chapter II, when electrically charged, stores up an amount of electricity in accordance with its capacity. When discharged through the body it will set up a momentary flow of unidirectional current and its stimulating effects will depend on the capacity of the condenser. Testiiig by condenser discharges is based on the fact that the discharge of a condenser through a constant resistance varies in duration according to the capacity of the condenser. The discharge starts at its maximum value and falls off gradually, so that with a set of condensers of various capacity it is possible to obtain currents whose total duration varies from $4000 to ?fa second. The working of a condenser set can be compared to a set of springs of gradually increasing size kept at even tension. As each spring
released it will oscillate according to its length and furnish an impulse, the duration of which will depend on the length of the spring. Thus the largest spring, representing the largest condenser capacity, will furnish
is
the longest duration of stimulation (Jones) 6 Stimulators for these tests may consist of progressive decades of con.
124
ELECTRODIAGNOSIS
densers varying in capacity between 10 and 0.0001 microfarads. A voltmeter and voltage controlling rheostat are provided so that the threshold voltage may be adjusted and read on the meter for each condenser capacity used. Resistances in shunt and series are coupled in the patient's circuit to
FIG. 89.
Diagram
of control of condenser discharges.
FIG. 90.
Graph
of discharge of
a condenser.
FIG. 91.
Testing with condenser
set.
minimize differences in skin resistance. It
is
convenient to plot the voltage
and capacity readings on logarithmic graph paper. If desired the duration of the stimulus may be computed by use of the following equation: Duration (seconds) = resistance (megohms) X capacity (microfarads).
NEWER METHODS OF ELECTRO DIAGNOSIS

For example and a capacity
:
125
of 1 microfarad
:
taking an average resistance of 1000 ohms (0.001 megohms) and substituting these values in the above
10 = 0.01 seconds (10 milliseconds). If an electronic stimulator is used which provides square waves the duration of each impulse in milliseconds is indicated on a dial of the instrument. The duration of such waves may vary from 20 to 0.02 milliseconds. The technique of testing is similar to that of the ordinary galvanic test. A large dispersing electrode connected to the positive terminal is placed over a remote part of the body and a small \ inch wet disc electrode connected to the negative terminal is placed exactly over the motor point to be tested. The largest condenser or longest duration stimulus is used first and the voltage adjusted until a minimal contraction is obtained. A smaller capacity condenser is next tried and the threshold voltage determined. To get even distribution of points on the curve when recording logarithmically it is convenient to use values such as 10, 5, 2, 1,0.5, 0.2, 0.1, 0.05, etc., microfarads or milliseconds. It is important to be sure that the highest voltages (400 v.) are used only with the smallest condensers or stimuli of shortest duration to avoid painful shocks. Some observers have found that a small bore needle may be inserted into the muscle as the stimulating electrode. This is not painful after the initial prick and lower current voltages may be used as a just perceptible movement of the needle is taken as the index of response. The reliability of the readings is somewhat enhanced by this technique. Determination of strength-duration curves is the most accurate clinical method of measuring excitability. Slight changes in both voltage and time factors may be observed which are helpful in detecting evidence of nerve regeneration at an early date. Progressive improvement in the strength-duration curves toward the normal suggests a good prognosis for recovery of function and gives an objective record of progress. It is at times possible to observe a "break" in the strength-duration curve during nerve regeneration. This is taken to indicate beginning reinnervation of the muscle and may appear before other signs of recovery are
0.001
equation we find Duration time
detectable. 7
The drawbacks of the strength-duration method of testing are that it takes considerably more time than ordinary testing and some experience before reliable results are obtained. Commercial apparatus is not readily available and this method is chiefly used in institutions in connection with
physiological laboratories.
Bauwens 1 has recently devised an apparatus yielding single impulses of rectangular wave form whose duration was restricted to 1 second, TW? second and ô second; by using pentode valves in the output circuit, current could be measured and remained unaffected, within reasonable limits, by
fluctuations of resistance.
It
is
desirable that this fairly simple type of

is
testing apparatus should receive large scale clinical testing. Testing by Chronaxie Measurement. Testing for [chronaxie
based
on the electrophysiological considerations outlined in the preceding chapter. It can be seen by referring to Figure 73 that chronaxie is a single point on the strength-duration curve of excitability. As a method of testing its 7 2 originators were Lapicque and Bourguignon.
In chronaxie testing a current intensity of a
known
contractile effect
126
ELEC TRODIA GNOSIS
upon an individual muscle or nerve is applied; the difference in time necessary to get a contraction is the only variable factor; this can be accurately observed and recorded. The unit of measurement is the Sigma a representing TTroT7 of a second and is recorded like condenser testing in decimal figures from 0.1 to 10 or more.
FIG. 92.
Chroiiaxie meter.
(Courtesy of R.
J.
Lindquist.)
For chronaxie testing chronaxie meters serve; and a control board of such an instrument is shown just above. The instrument produces a galvanic current which serves to determine the rheobase the minimum amount of current necessary for response in an individual muscle and nerve. A milliammeter and voltmeter on the panelboard give a reading of this current intensity. The instrument also contains a series of condensers which can be progressively charged and discharged until the condenser giving the value of the chronaxie is found.
FIG. 93. Circuit of chronaxie meter (Lindquist). C, C, C, C, C, values selected for discharge intervals as indicated on panel. Direct-reading range is from 0.01 to 111.10 sigma.
The first step in chronaxie testing is to ascertain the weakwithout regard to its duration, which applied to a nerve or muscle produces the faintest perceptible contraction. This is done by unipolar testing with the galvanic current of the chronaxie meter, using the negative pole as the active pole. The testing electrode is placed over the motor point and the current is allowed to flow at a gradually increasing strength; from time to time one "makes" the current over the motor point with the rheobase switch until with a certain current strength a minimum contraction occurs. The voltmeter records the amount flowing and this
Technique.
est current
127
voltage required for a minimal response with the make of the current is called the single rheobase or the threshold of excitation. Next, with the
current increased to read exactly double the rheobase value as observed on the voltmeter and with the testing electrode on the same point, one charges and then discharges a series of condensers. By successive discharges one arrives at the condenser capacity just sufficient to produce a contraction equal to that obtained with the single rheobase and this is the value of the chronaxie. This is a time dimension because it refers to the rate of discharge of a condenser. It is recorded in decimal system as stated. The advantage of chronaxie meters is that as long as the position of the testing electrode is unchanged, the chronaxie is not influenced by the skin resistance and the position of the muscle and allows, therefore, more accurate testing
and recording.
the motor nerve of a muscle has undergone degeneration, the muscle also degenerates and we find certain alterations in its chronaxie. YOT some time after section of the motor nerve the chronaxie of nerve and muscle remains unaltered; this period may last a week or ten days. After this the chronaxie becomes very high; 20 to 100 times the normal amount. Chronaxie testing furnishes constant values for the purposes of accurate charting and has enabled important conclusions to be drawn as to func-
When
and embryological similitudes. 2 Bourguignon made the important observation that different muscles their nerves) have different chronaxies, and further, that in the same (with segment of a limb, muscles of similar function have the same chronaxie. Thus, when the chronaxie of flexor and extensor muscles is compared, it is found that the flexors have a chronaxie only half as great as the extensors. The chronaxie increases toward the periphery and thus is greater in
tional
muscles in the same functional group, when these are situated more distally. It is the same whether the muscle is stimulated directly or through the
nerve.
Chronaxie has been criticized by physiologists as a measure of excitability, because of its arbitrary and empirical character and because the 4 type, shape and position of electrodes alter the results (Davis ). Testing by Progressive Currents. Testing by progressive currents has been recently described by Pollock et a/. 8 The principle of this procedure is to use, instead of the sudden make and break of a galvanic current or the discharges of a condenser, a current with slow rate of rise and long duration. A modified form of condenser discharge as introduced by Lapicque may be used (Fig. 131) or waves in the form of isosceles triangles as described
by Pollock
et al.
One
characteristic of denervated muscle
is its
response to a slowly rising

to
current, whereas
normal muscle because of
its ability
accommodate
to
slow changes in potential does not contract when stimulated by such a current. A sudden increase in the amperage of current necessary to produce a contraction when stimulating a denervated muscle with a progressive current can be taken as an indication that a successful junction between the regenerating nerve and the muscle has been effected. It is claimed that with this method selective stimulation of sluggish muscle groups is possible, which is especially valuable in partial reaction of degeneration, when there are degenerated muscle bundles mixed with
128
ELECTRODIAGNOSIS
This development
is
normal bundles.
of considerable interest,
but
its
practical utilization for
measurement
is still
to be perfected.
Electromyographic Diagnosis. The recording of electrical discharges from peripheral skeletal muscles often gives information of value in dif-
PARKINSON'S DISEASE
HfPROGRESSIVE MUSCULAR ATROPHY

tremor in Parkinson's disease and of fasciculation in prointerval, one second on upper signal. (Electromyographic Laboratory, Massachusetts General Hospital.)
FIG. 94.
Electromyogram
of
gressive muscular atrophy.
Time
MEDIAN
NERVE INJURY
FLEXOR CARPI
ABDUCTOR POLLICIS
FLEXOR CARPI
__^___^_^___
(,_/_
ABDUCTOR POLLICIS
=
FIG. 95.
ioou v
(Watkins and Brazier.)
Spontaneous discharges during period of recovery.
ferential diagnosis. This is particularly true in the case of tremors and muscular fasciculations and fibrillations. Experience has shown that the tremor associated with Parkinson's disease has a characteristic frequency of about 6 per second which is easily distinguished on the electromyogram from all other tremors such as may occur with hyperthyroidism or hysteria.
NEWER METHODS OF ELECTRODI AGNOSIS

(Fig. 94.) Electromyograms have and spastic conditions. 11
129
also
been useful
in the
study of athetosis
POLIOMYELITIS
TRICEPS
=100
UV
iî
BICEPS
FIG. 96.
Synchronous activation
poliomyelitis.
of opposing muscles during voluntary (Watkins and Brazier.)
elbow
flexion in
RESTING
MUSCLES
POLYNEURIT1S
POLIOMYELITIS
PERIPHERAL NERVE INJURY
FIG. 97.
Spontaneous discharges during period of recovery. and Schwab.)
(Watkins, Brazier
Visible fasciculation and fibrillation of muscles is a recognized essential point in the diagnosis of progressive muscular atrophy and amyotrophic lateral sclerosis. The electromyographic recording of these has a characteristic appearance and at times these discharges may be picked up by this
of study when not observed clinically. (Fig. 95.) The degree of spontaneous electrical activity is also thought to be of prognostic sig-
method
nificance.
130
ELECTRODIAGNOSIS
reliable test
which indicates beginning reinnervation of a muscle is of considerable clinical value. Spontaneous be found electromyographically before other signs of discharges may 9 Thus this type of examination is useful in folregeneration are present. lowing progress after nerve suture or in compression and stretch injuries.
Any
after a peripheral nerve injury
(Fig. 96.)
In poliomyelitis studies have been made of the nature of the dysfunction means of electromyograms. 10 Hyperirritability or "spasm" has been demonstrated; also disordered reciprocal innervation with simultaneous activation of antagonistic muscles. (Fig. 97.) During recovery spontaneous discharges are obtained similar to those seen in cases of nerve injury and polyneuritis. 3 This method of investigation may be used for judging the effects of therapeutic agents and for following
present in the lower motoneuron by
the progress of recovery.
An electromyographic test has also been described for the diagnosis of tetanus in obscure cases. 11 In muscular dystrophy no abnormalities are found and the test is not valuable in diagnosis of this condition. At the
present time, electromyography, although of clinical value, is done chiefly in hospitals or medical schools in connection with research projects.
REFERENCES
1.
2.
3.
BAUWENS, PHILIPPE: Electrodiagnostic Interpretations of Nerve Lesions, Arch. Phys. Ther., 25, 88, 1944. BOURGUIGNON, GEORGES: Rev. neurol., April 30, 1914. BRAZIER, M. A. B., WATKINS, A. L., and SCHWAB, R. S.: Electromyographic Studies of Muscle Dysfunction in Infectious Polyneuritis and Poliomyelitis,
4.
5.
6.
New England Jour. Med., 230, 185, 1944. DAVIS, H., and FORBES, A.: Chronaxie, Physiol. Rev., 16, 407-441, 1936. DE YONG, H. Simplification of the Method of Electrical Examination and Therapy of Nerves and Muscles, North Carolina Med. Jour., 5, 3, 1944. The Use of Condenser Discharges in Electrical Testing, Proc. Roy. JONES, H. L.
:
:
Soc. Med., London, 13, VI, Electrother. Sec., pp. 49-61, 1912. Jour, de physiol., 10, 601, 1908; 11, 1009, 1909, etc. 7. LAPICQUE, L.: 8. POLLOCK, L. J., GOLSETH, J. G., ARIEFF, A. J., SHERMAN, I. C., SCHILLER,
t
M.
A.,
9.
10.
11.
Currents of Long Duration: Studies on Cats With Experimentally Produced Section of the Sciatic Nerve, Arch. Neurol. and Psychiat., 51, 147-154, 1944. WATKINS, A. L.: Electrical Aids in Diagnosis and Prognosis of Nerve Injuries, Arch. Phys. Ther., 23, 76-83, 1942. WATKINS, A. L., BRAZIER, M. A. B., and SCHWAB, R. S.: Concepts of Muscle Dysfunction in Poliomyelitis Based on Electromyographic Studies, Jour. Am. Med. Assn., 123, 188-192, 1943. WEDDELL, G., FEINSTEIN, B., and POTTLE, R. E.: Clinical Application of Electromyography, Lancet, 1, 236-239, 1943.
:
and TIGAY, E. L.
Electrodiagnosis
by Means
of Progressive
TESTING CHARTS
TABLE
I.
131
15.
MUSCLE AND NERVE TEST CHART OF UPPER EXTREMITY
SHOULDER AND MUSCULO-SPIRAL (RADIAL) DISTRIBUTION

..Number
Date
Diagnosis....
Name.
132
TABLE
16.
ELECTRODIAGNOSIS
MUSCLE AND NERVE TEST CHART OF UPPER EXTREMITY II. MEDIAN AND ULNAR DISTRIBUTION
Name
Number
Date
Diagnosis.....
TESTING CHARTS
TABLE
17.
133
MUSCLE AND NERVE TEST CHART OF LOWER EXTREMITY Number

Diagnosis
Name
Date
CHAPTER
VIII

Historical.
Effect.
Physics and Apparatus. Polarity. Effects Upon the Body. Physical Medical Galvanism. Clinical Physiological Effect. Therapeutic Forms. Indications. General Technique. Regional Technique. The Galvanic Effects. Bath. Electrolysis or Surgical Galvanism. Ion Transfer. Physicochemical ConPenetration of Ions. Clinical Uses. General Technique. Applicasiderations. tions From the Positive Pole. Heavy Metals, Copper and Zinc. Vasodilating Drugs, Histamine and Mecholyl. Cocain. Epinephrine. Aconitine. Calcium. Applicacations From the Negative Pole. Chlorine. Iodine. Salicylic Acid. Dangers in Galvanism. Safety Rules.
galvanic current, also described as the direct or conthe basic and also the first known form of electrical current flow. Gal van i, professor of anatomy at the University of Bologna in Italy, noticed in 1789 that whenever a spark leapt between the electrodes of an electrical friction machine, a freshly dissected frog's leg which was lying on a metal plate suddenly twitched. But if the leg was hung on an iron grille by a copper hook it also twitched every time it touched the grille. Galvani interpreted this as an evidence that the animal body was a source of electricity and the metals served to discharge it. Soon thereafter another Italian, Volta, proved that electricity arose at the contact of two different rnetals and caused the muscles of the leg to contract. He constructed the " voltaic pile" from alternate discs of copper and zinc, separated from each other by porous discs made of paper soaked in vinegar. This was the first electric cell ever produced. Volta's discovery was the first means of generating a constant flow of current, but the name galvanism was retained to honor the original discoverer of the phenomenon itself. The galvanic current came into general therapeutic use at the end of the last century with the construction of wet batteries of fairly large capacity; together with the faradic current it served for many basic observations in the physiology of nerves and muscles. Apostoli's method of treating uterine fibroids by surgical galvanism and Leduc's discovery that it is possible to introduce medicinal substances into the skin through the ionic effects of the galvanic current caused great interest for a few years, but this soon subsided and after 1910 high-frequency currents occupied the center of the electrotherapeutic stage. In recent years improved simplified and inexpensive apparatus for galvanic and low-frequency treatments and the increasing scope of electrophoretic applications restored interest in the therapeutic employment of galvanism. There is unquestionably more \room for the extended use of all forms of galvanic treatments. * Physics and Apparatus. The galvanic or direct (also known as constant)
Historical.
The
stant current,
is
current is an uninterrupted, unidirectional flow of electrons. It may be derived from a variety of sources. Dry cells or batteries are the source of the smoothest flow of current; they have also the advantage that they are easily portable and can be used
everywhere.
(134)
Their essential physics have been presented in Chapter
III.
A single dry cell furnishes only a very small amount of current. A
1 J-volt
HISTORICAL
135
dry cell has an output, when working at fullest efficiency, at about 15 amperes. Usually the load is not that heavy and the current depends upon
LU
\
U
FIG. 98. flow which
cell in
TIME
due
Graph
is
Note slight wave in current of galvanic current from direct current line. Contrast with even flow from electric to "commutator ripple" of dynamo.
Figure 12.
HMHln
DC.
FIG. 99. Schematic diagram of simple galvanic generator. Upper figure: schematic diagram of a simple galvanic circuit. Lower figure: Equivalent electrical diagram of the above figure. DCi, DCz, DCs, dry cells in series; P, potentiometer; M, milliammeter T, treatment terminals; S, switch.
;
the resistance of the circuit.
It
is
more convenient to use the
batteries originally designed for radio purposes formerly
known
large dry as B bat-
130
teries. They serve as an efficient source of galvanic current. In cases of emergency, several IJ-volt dry cells may be combined into a large battery. The large dry batteries are available in 22f-volt and 45-volt or larger strength. Any electrician should be able to build a homemade galvanic outfit with one of these, placing it in a suitable box and connecting it in series with a rheostat and a plain milliammeter. A rheostat is necessary to control the current strength in the circuit and a meter allows the reading of this amount; the meter also serves to register the eventual decline of the battery. There should be also an indication of the polarity of the apparatus by marking the terminals plainly with -f and signs. Manu-
facturers furnish, however, also quite reasonably
some battery
outfits.
FIG. 100.
Galvanic generator with vacuum tube rectification.

Electric
(Courtesy of the General
X-Ray Corp^
or valve-tube rectifiers consist of thermionic tubes (Chapter III) to change an alternating current supply into a fairly smooth direct or galvanic current. These rectifiers consist of a small box or cabinet
Vacuum
and serve
containing the rectifying tube, a current regulator or rheostat, meter, terminals marked for polarity and pole changing switch. They are portable and relatively inexpensive and are most frequently employed nowadays as a source of galvanism, and of the basic low-frequency currents. (Figs.
100 and 103.)

Metallic rectifiers are so-called bi-metallic junctions of copper and copper oxide arranged at such minimal distance which is comparable with the spacing of the molecules of the two materials. They allow an easy passage of electrons in one direction and stop it in the other and serve as an additional means to change the alternating current into a direct current where
the amperage to be passed
is
of small quantity.
HISTORICAL
137
Motor generators consist of a combination of a motor and a dynamo. is either an alternating or direct current motor, according to the supply current, and it rotates the dynamo which furnishes the galvanic current and also usually a number of low-frequency currents. For the
The motor
A A VAv A AAAA
FIG. 101.
The
stages
Scheme of changing alternating into direct current by vacuum-tube rectification. shown are half-wave rectification, full-wave rectification, partial filtration and
finally total filtration.
production of a smooth galvanic current additional condensers and choke coils are incorporated, while rheostats and a motor starting resistance or mechanism, serve to produce some of the low-frequency modifications. These devices make the construction of motor generators both complicated
and expensive.
fn
Q(j\_
I
(t
Q\
4-
TO PATIENT
FIG. 102. Schematic diagram of transforming commercial alternating current into direct T is a transformer (galvanic) current by means of a vacuum (thermionic) tube (rectifier. connected to the alternating current supply; VT, a vacuum tube rectifier; C, condensers;
/,
choke
coils;
R, a variable resistance; S, reversing switch and
MA,
milliammeter.
Wall plates or cabinets are devices using either the direct lighting current, with the interposition of a suitable resistance or the alternating current, with the use of a rectifier tube for the furnishing of a galvanic current. On
138
their panel are mounted the necessary controls, a rheostat to regulate it. the volume of flow (amperage) and a milliamperemeter to measure
Some Most
of these outfits also furnish a faradic or other alternating current.

of
them are portable and
relatively inexpensive.
FIG. 103.
Portable galvanic and low-frequency generator, furnishing basic four low voltage currents. (Courtesy of Wappler, Inc.)
Polarity.
The
galvanic current
is
the only current applied according
All generators of a galvanic current have two terminals or poles, a positive and a negative one. In all forms of galvanic treatments in which an "active" or therapeutically effective electrode is employed,
to "polarity."
it
must be connected to the pole required by the condition treated. Hence the operator must be at times sure which is the positive and which is the negative pole or terminal. Dry cells, rectifier tubes and motor
generators are of "fixed" polarity, that is the terminals of the apparatus are marked positive (+) or negative ( ); if it is desirable to change their polarity, a suitable switch arrangement always clearly indicates the posiIn apparatus using the direct lighting current tive and negative poles. (D.C.) the polarity of the terminals will change each time the supply plug delivering the current to the apparatus is inserted into the current outlet in a different direction at times there may be also a change in the direction of the current flow in the main line. In such apparatus it is safer to test each time for correct polarity of the terminals and in case of doubt this should be done with any galvanic apparatus.
;
Fasten two conducting cords to the two terminals Testing for Polarity. of a galvanic source and drop the distal tips about 2 inches apart in a flat
EFFECTS OF THE GALVANIC CURRENT UPON THE BODY

vessel containing tap water with a pinch of salt added.
139
current
As soon as a little turned on white bubbles appear rapidly and in great numbers around one cord tip. The pole which causes the rapid bubbling is the negative pole (cathode); the bubbles consist of hydrogen gas. After a while a few large bubbles appear slowly at the other cord tip, the positive pole (anode) these bubbles consist of oxygen. This polarity action of the galvanic current is invariably characteristic for each of its poles; if by a "pole-changer" or by different insertion of the line plug the direction of current flow is reversed and the experiment is repeated the rapid bubble formation will take place at the opposite cord tip. Thus the negative pole of a galvanic source can always readily be determined by the quick appearance of many small bubbles (Fig. 104).
is
;
FIG. 104. Testing for polarity of galvanic generator. With two cord tips placed in a container of salt water many small bubbles (hydrogen gas) appear rapidly around the negative pole and only a few heavier bubbles (oxygen gas) develop slowly around the positive pole.
Another simple test for polarity is the phenolphthalein test: a piece of blotting paper is moistened with a dilute phenolphthalein solution. Touching it with the two cord tips with a slight amount of current flowing, a red
dot appears at the negative pole.

While the description of physics of the galvanic current is comparatively simple, the exposition of its physical and physiological effects on the body is a somewhat complicated problem, because of the necessity for explaining
not only the action of the current itself, but also that of the two poles. It can be best approached by considering the physical and physiological
The human body may be considered from the viewpoint of electrotherapy as a bag of skin holding a solution of common salt (NaCl). Figures 18 and 19 in Chapter II show that when the molecules of NaCl dissolve in water they dissociate into sodium ions (Na) bearing a positive charge and chlorine ions (Cl) bearing a negative charge. The flow of a direct current through the salt solution causes these ions to move in a definite direction, the sodium ions migrating toward the negative pole (cathode) and the chlorine ions toward the positive pole (anode), the process known as ion transfer or iontophoresis. When the positively charged sodium ions arrive at the negative pole, and the negatively charged chlorine ions at the positive pole, they lose their charge and become free unelectrified atoms; these in turn, cause a secondary chemical reaction in
effects separately. Physical Effect.
140
at the water and form caustic sodium hydroxide and liberate hydrogen acid and liberate oxygen the negative pole and form caustic hydrochloric the at thepositive pole. The principal physical effect of the ion transfer by the current is an acid reaction at the positive and an alkaline one at
galvanic
reaction varies with the strength and negative pole; the intensity of each effect relative density of the current at each pole. This acid and alkaline because it occurs only under the electrodes. a be described as
may
of the poles of the galvanic current when increased to sufficient intensity will lead to destruction of tissue by coagulation of protein at the positive pole and by liquefaction of protein at the two bare copper negative pole. This can be demonstrated by bringing wires from the terminals of a galvanic generator to a piece of raw steak, the loose ends into the steak about 2 inches distant from each
polar
effect
The
alkaline
and acid reaction
inserting other. Turning
on the current, after awhile a green discoloration appears around the positive pole. This is due to the liberation of the positive and the subsequent copper ions by the repelling effect of the positive pole formation of copper oxychloride in the tissues. The positive wire becomes adherent to the meat due to coagulation of the protein. Around the negative pole a white foam appears (hydrogen gas) and the wire becomes loose, due to the liquefying action of sodium hydroxide on the protein around the wire. This experiment demonstrates that the positive pole of the galvanic current hardens tissue while the negative pole softens it, provided that a current of sufficient intensity is applied and bare metal electrodes are employed. Such intensity is only used in the technique of "surgical"
galvanism. In addition to the polar effect caused by ionic movement, non-dissociated molecules of albumin known as colloids, such as droplets of fat, particles of starch, blood cells, bacteria and other single cells which all have an electrical charge due to the absorption of ions, also move under the influence of a direct current. This movement always occurs towards the negative pole and is therefore known as cataphoresis. Finally there occurs also a shifting of the water content of the tissues through a membrane structure with an electrical charge, known as electroosmosis. The totality of these phenomena is designated as electrophoresis. All this makes it evident that the passage of the galvanic current across or around cell membranes of
and along fluids of different conductivity and ionic The classical composition presents a complicated biophysical process. in Figure 105 is an effective demonstration of the fact potato experiment that the galvanic current causes ionic movement throughout its path. A hole is scooped ir? a potato and filled with a dilute solution of potassium iodide two platinum needles are inserted at opposite parts of the potato, connected to a galvanic source and about 3 milliamperes of current is passed through for one-half hour. Bisecting the potato in the level of the needles, a sharply defined dark-blue coloring is found around the positive electrode. This is due to the attraction to the positive pole of the iodine ion which becomes free iodine there and forms starch iodide. No trace of blue is found in the intervening path. Much speculation has been made as to the possible effects of the change of the electrochemical concentration in the deeper tissues, but there are nowhere definite data or proofs available as to what actually constitutes the interpolar effect of the galvanic current. The vague statement as to a
variable permeability
141
general ionic rearrangement conveys little exact meaning. Faraday demonstrated many years ago that electrolytic action takes place solely at the
electrodes.
Turrell 19 endeavored to prove that the prolonged passage of the galvanic current along an extremity causes a considerable rise in its temperature. Others, however, are of the opinion that the increase of temperature was due to an increase of the blood supply of the limb consequent to vasodilatation and assert that no heating effect of any therapeutic value can be generated by a current of less than 300 to 500 milliamperes; this amount would greatly exceed physiological toleration.
Pofass-
FIG. 105.
Potato experiment. While direct current flows it attracts the iodine anion toward the positive pole and the free iodine there forms blue starch iodine.
may
Physiological Effect. The effect of the galvanic current on the skin be visualized by the following experimental demonstration: Place
two pad electrodes well soaked with saline solution upon opposite sides of the knee joint; connecting them to a galvanic current source start a current flow and keep it up at comfortable toleration for twenty minutes. (With
electrodes of a size 3x3 inches in correct equidistant position, the average patient should tolerate from 6 to 9 milliamperes of current.) When the current begins to flow there will be gentle tingling and pricking under the electrodes; as the resistance of the skin gradually decreases, more current
can be tolerated and the pricking sensation changes to a feeling of gentle warmth. As the electrodes are taken off at the end of the treatment, the skin will show a marked redness sharply restricted to the area covered by the electrodes; this color will keep up from ten minutes to one-half hour. The galvanic skin reaction hyperemia just demonstrated has been
analyzed by Freund and Simo as consisting of three phases: A primary period with an active reddening of the skin, which may last several hours a latent period in which reddening disappears entirely or is only indicated and then a period of renewed hyperemia, designated as a "late reaction" which appears several hours after the primary reaction and may last for several hours. The late reaction can be made to reappear a day later by another stimulus, such as a hot bath; this brings on again an intensive hyperemia on the part previously treated with galvanism. As a rule the redness lasts longer in the area under the influence of the negative pole. These observations are important not only from the standpoint of immediate physiological response of the skin, but also point to the fact that an electrical application of a relatively short duration may be followed by vasomotor stimulation lasting several hours or days. Proper spacing
7
;
142
may keep up the stimulative effect and promote a better nutrition not only in the skin, but possibly in the deeper tissues. Much has been written about an alleged specific pain relieving effect of the positive pole of the galvanic current. The physiological phenomenon
of the treatments of
electrotonwthe change of
irritability
produced in motor nerves by the
passage of the galvanic current described in Chapter VI had been used by the older electro therapists as a basis for the statement that the action of
the positive pole of the galvanic current is sedative and the action of the negative pole is stimulative on tissues in general. Modern clinicians pointed out that laboratory experiments conducted on the isolated motor nerve with a current of definite intensity are quite different from the action in the human body, where an extremely minute current of unascertainable strength passes along a nerve situated deeply in tissues of low electrical Kowarschik 13 states that in the treatment of neuralgias, so resistance. far as the relief of pain is concerned it makes in most cases no difference whether the anode or cathode was applied over the painful part as long as treatments of sufficient intensity and duration are given. However, in muscle and nerve testing the more irritant effect of the negative pole is unquestionable and it is therefore routinely used as the "stimulating" pole. In clinical use most patients seem to report more discomfort under the negative electrode and nerve irritation seems to be more frequently relieved by connecting the electrode over the affected area to the positive pole. As a newer explanation for the less irritative effect of the positive pole it has been advanced that irritable tissues such as muscles and nerves do not conduct impulses readily in an acid medium, such as produced by the positive pole. Table 18 sums up the physicochemical and physiological effects of the galvanic poles. Those who wish to carry on some more extensive
experimental studies on these effects are referred to the elaborate series

of experiments presented in the recent
work
of
Osborne and Holmquest. 17
TABLE
Positive pole
18.
EFFECTS OF THE GALVANIC POLES

Physiological
;
Physicochemical
Acid reaction repels metals and alkaloids hardens tissue

;
Decrease of nerve
irritability
Negative pole
Alkaline reaction; repels acids and acid

radicals; softens tissue
Increase of nerve irritability
Both poles
Mild heating, electrophoresis
Vasomotor stimulation
TABLE
19.
EFFECTS AND USES OF THE GALVANIC CURRENT

Interpolar
effect
Polar effect
Medical galvanism
Both
poles:
vasomotor
Mild
stimulation; positive pole: acid reaction, coagulation of albumen; negative pole alkaline reaction; liquefaction
:
heat; increase of circulation
Technique Moist pad electrodes preferably even size
Principal uses Selected cases of acute and chronic inflam-
matory conditions,
especially
thickening,
fibrotic circula-
of
albumen
Negligible
tory
Active electrode: pointed metal,
dispersive electrode: large pad
disturbances
of
Electrolysis (surgical
galvanism)
Positive pole: acid caustic, tissue constriction; negative pole: alkaline caustic, tissue liquefaction Positive pole for copper, zinc, quinine ions and alkaloids negative pole
;
Removal
superflu-
ous hair, warts and moles; treatment of

dilated blood-vessels
Ion transfer
(iontophoresis)
Mild
heat;
increase of circulation
chlorine, iodine, salic. acid ions
for
Solution or metal containing ions serves as active electrode
Chlorine ions to soften

scars;
ptitis
zinc
ions
in
media; copper
ions in cervicitis and vasodilating drugs in

arthritis
MEDICAL GALVANISM
Therapeutic Forms.
of the
143
For therapeutic purposes, there are three forms
(1) medical galvanism, the administration of the "straight" galvanic current within physiological toleration; (2) electrolysis or surgical galvanism, the electrochemical destruction of tissues by the galvanic current; (3) ion transfer, electrophoresis or medical ionization, the application of the galvanic current within physiological toleration to effect the passage of medicinal ions through the skin or mucous membrane.
employment
of the galvanic current:
MEDICAL GALVANISM
Clinical Effects. The galvanic current applied within physiological toleration to a part of the body surface causes vasomotor stimulation of the skin and increased circulation and nutrition of the parts in the path of the current. The generally accepted explanation of the clinical effect
is that the improvement of circulation speeds up the resolution of inflammatory products, reflex stimulation or relief of pressure relieves pain;
galvanic treatments of sufficient extent or intensity (galvanic baths) may also influence general circulation and metabolism. Indications. Medical galvanism has proven clinically useful in a number of acute and chronic inflammatory conditions such as: (1) selected cases of traumatism, contusions, sprains, myositis, both in the acute and chronic stage; (2) selected cases of arthritis and rheumatic conditions,
neuritis and neuralgia, mostly in the chronic stage. In the management some circulatory disturbances of the brain, such as in after-treatment
of
of selected cases of cerebral hemorrhage, medical galvanism often serves as a useful adjunct.
time-proven effectiveness, the "straight" galvanic current employed in the United States at present, compared to the increasing popularity of its uses for electrophoresis. It should be remembered as a useful alternate for diathermy treatments, especially in heat
its
is
In spite of
still
too
little
sensitive patients.
General Technique. In medical galvanism the area to be treated is covered by moist-pad electrodes corresponding with its size. Transverse application of electrodes of equal size is preferable. The interposition of a moist pad between the plate and the skin is necessary for overcoming skin resistance, for protection of the skin by absorbing the caustic metallic compounds formed on the surface of the metal plate and for maintaining perfect contact. The smooth flow of current depends on the thorough moistening and good apposition of the pads and on their safe retention. Moistening of electrodes is best done by holding them first under running warm water; after they are thoroughly soaked they should be placed in a flat vessel containing a warm saline solution. This brings the pads to the required temperature, and after gently squeezing out the excess water, they are placed over the parts to be treated. They are held by an elastic bandage, preferably a rubber one. Patients sensitive to cold and to moisture will complain if the electrodes are not applied at a comfortable temperature or are too wet, causing oozing all over the body and clothing. It is helpful to cover the pads with a bath towel or oiled silk during treatment. Insufficient moistening of the pads will cause their drying out during treatment and may give rise to imperfect conduction. If the patient complains of unpleasant burning at any time
144
during treatment, and the amount of current does not seem excessive, the first thought is insufficient moistening of the pads causing undue current density in one spot. The remedy is to shut off the current, take off the pads, remoisten them and reapply them carefully. No special attention to polarity has to be paid when "straight" galvanism is applied with electrodes of equal size, therefore it makes little difference to which pole each electrode is being attached. In case however there is a more sensitive area on one side of a joint, it may be more comfortable to connect it to the positive pole because it is less irritating. On the same principle it is also advantageous to reverse the polarity of the current during the second half of each treatment. This must be done by carefully returning the control to zero, turning the reversing switch or changing the position of the cord tips in the terminals and then gradually advance the control again to the same comfortable point of toleration.
RECOMMENDED CURRENTS FOR ELECTRODES OF VARIOUS SIZES

30
25
100
200 300 400 Square Centimeters Electrode Area
500
FIG. 106.
Recommended
iontophoresis.
current values with electrodes of various sizes for therapeutic (Molitor and Fernandez.)
Dosage and Length

about i to
surface.
1
of Application.
within comfortable toleration.
Current strength must be always As an average, the normal skin tolerates
milliampere of galvanic current per square inch of electrode size of electrodes furnishes, therefore, a guide as to the expected current toleration. The smaller the electrodes, the greater the current density and the less current can be applied. If the electrodes are placed on the same body surface the question of edge effect must be taken
The
into consideration.
As the treatment goes

shows a
slight increase.
on, skin resistance decreases
and the meter reading
At the same time the
sensitiveness of superficial
MEDICAL GALVANISM
nerve also decreases and the rheostat can
of better toleration of the current.
to
145
now be
further advanced because
With
10 to 20 milliamperes of current may 30 milliamperes in sciatic neuritis and about the
electrodes of suitable size, from be used in facial neuralgia; from 15
same amount
in
abdom-
current values for electrodes of various sizes have been studied by Molitor and Fernandez 16 and their findings are shown in
inal conditions.
The
Figure 106. As a general rule, galvanic treatments should start with fifteen- or twentyminute periods and extend up to thirty or forty minutes. Newer investigators emphasize that the alleged ineffectiveness of galvanic treatments which led to their gradual abandonment was mainly caused by too little current being applied for too short a period. The seeming superiority of ionic medication in joint conditions has been attributed more to treatments
than to action of the specific drug employed. Treatbe repeated daily or every other day. Patients should never be allowed to get off the table and go outdoors with their underwear or other clothing w et from a galvanic treatment. Galvanic treatment of the brain has been in use Regional Technique. under the designation of cerebral galvanism for many years. In its technique two pad electrodes, about 4 inches long and 2J inches wide, are moulded and retained in firm apposition to the forehead and the nape of the neck. A few turns of an elastic bandage will secure the frontal electrode; the occipital electrode may be held by the head resting on a suitable pillow or should be also secured by bandaging, especially if the patient is restless and likely to attempt moving during treatment. One should never apply cerebral treatment to a sitting patient. The frontal electrode is connected to the negative pole and the occipital one to the positive pole. Bitemporal (from side to side) application of galvanism causes dizziness, the head falling over toward the side of the positive pole. The current should be turned on very gradually, 1 milliampere at the start, and be increased
of sufficient length
ments
may
very slowly up to 2 to 5 milliamperes. A smooth galvanic current supply is important and with careful avoidance of sudden current interruption or fluctuation the technique is perfectly safe and easily tolerated. At the end of treatment the current must be turned off very gradually. Cerebral galvanism may be employed in treatment of some of the after effects of hemiplegia (Chapter XXVII) and also in nervous headaches and mild neuroses. For treatment of the face (in facial paralysis or trifacial neuralgia) a crescent-shaped electrode is applied over the affected side and connected to the positive pole. The large dispersive electrode is placed under ;the chest or back. From 5 to 15 milliamperes of current may he applied. JFor treating the thyroid gland a suitably shaped and sized pad electrode is placed across the gland and a larger dispersive one is applied under-vthe upper back. For treating the upper extremity (in brachial neuritis) a% electrode about 3x4 inches is applied across the neck corresponding with the brachial inches over the flexor Surface of the plexus and another electrode forearm (longitudinal technique). Immersing the hand and part of the forearm in a water-bath appears to be more effective. Another method of treatment is to wrap up the entire area with asbestos fabric paper or .a
2x5
10
146
thin towel moistened with saline solution (placing a metal electrode on back. top) and use a large dispersive pad under the For treating the lower extremity (in sciatica) the same methods as for the upper extremity may be employed. In addition the transverse techelectrodes from well nique may be also applied, by making up two long moistened Turkish toweling for the anterior and posterior surface of the
and thigh, and applying metal plates over these (the towel connected to the positive pole will show metal stains). For treatment of the knee
leg
(in chronic arthritis) electrodes
3x3
inches in size are applied over either
paper may be wrapped around the joint and a dispersive electrode placed under the gluteal region. The Galvanic Bath. The galvanic current may be conveniently and or more extremities by efficiently applied to the whole body or to one means of hydroelectric baths. Such baths have been used abroad as part of the established physical therapeutic armamentarium for over half a century, but until very recently have been comparatively neglected in the
side of the joint or moistened asbestos fabric
United States. They differ from the usual method of applying the galvanic current by the very much enlarged contact surface through the medium of the water and by the possibility of employing much larger amounts of current flow. As a source of current supply for the full galvanic bath, motor generators are generally preferable to wall-plates or other not ground-free sources. A distinct danger in full galvanic baths, which has led to a number of fatal
is the possibility of the patient touching .grounded object in the bathtub or outside of it and receiving an electrical shock through the
accidents,
free
ground current. (See Chapter XV.) To prevent this risk, bathtubs insulated, metal fittings and taps within the reach of patients avoided and patients emphatically warned against touching metallic
must be
objects inside or outside the bath.

hydroelectric apparatus treatments
With
may
especially constructed modern be administered in perfect safety
ment the author 12 has
and the patient may even touch any grounded object. For general treatin recent years employed a two circuit apparatus which is ground free and enables a variety of combination in technique, and which also allows additional stimulation by the use of a rippled or
pulsating direct current. The electrodes for galvanic baths consist of carbon plates held in perforated wood which enables the current to pass but prevents the plate from touching the patient's skin. As a rule five electrodes are used for the full bath, one on each side of the bathtub, one on the foot end, one in the center and one large back electrode equipped with a head rest. The tub is filled with tap water at a temperature comfortable to the patient (any-
where between 92 and 100
F.). It is well known that a small amount of salt decreases the resistance of the water and allows more milliamperage
to pass at a lower voltage. In recent years adding of a tannin bark solution became a standard procedure in hydroelectric baths on the ground that it reduces the resistance of the water to a certain suitable degree and decreases skin tingling; by its dark color it also helps to avoid exposure of the uncovered body and saves the use of linen sheets or a rubber sheet
covering on the patient. The usual technique is to establish one longitudinal one side of the apparatus and a transverse circuit to the other side. The polarity of the electrodes and the direction of current flow can be
circuit to
MEDICAL GALVANISM
regulated according to a
147
Since
all
number
of schemes.
electrodes are
movable, it is possible to concentrate the current flow to any desired part and vary the amount of local or general stimulation. From 60 to 100 or even more milliamperes may be used on each of the two circuits. The duration of general bath treatment should be from fifteen to thirty minutes. Itching occurs in a number of instances after either local or general treatment. Application of fine talcum powder or of a calamine lotion or oint-
ment usually promptly
relieves this.
FIG. 107.
Electrogalvanic bath.
(Courtesy of Teca Corp.)
The factors governing the mode of action of hydroelectric baths are the form of current and the technique of its application, the temperature and hydrostatic action of the water and additional stimulation when chemical ingredients are added. It seems established that only about one-third of the current employed flows through the body, but even this amount is larger than in any other form of galvanic or low-frequency treatment, and
evenly and relatively painlessly distributed. electrochemical effects of the galvanic current employed in the bath bring about chiefly a stimulation of the skin and of the nervous system. The additional use of the pulsating or rippled current adds to the stimula20 tion. According to Wedekind and others the filling of the peripheral blood-vessels is normally decreased and the blood-pressure generally falls,
it is
The
especially in cases of hypertension. Electrocardiographic tests as well as studies of the blood picture did not show consistent results; neither did
metabolic tests prove a conclusive effect. Clinically there appears to be a definite influence in the general well being and appetite of patients. The
148

of the water
is
buoyancy
a factor in the general comfort and increased As the water in the hydroelectric bath. mobility of painful or weak parts In local treatis generally negligible. is usually tepid, the thermal effect stimulant of local metabolism ments, the action of the galvanic current as a of the clinical as a counterirritant is well known and explains most and
results.
Local galvanic baths can also be administered with the same apparatu which is used for the full bath treatment. It is important that the apparatus since it is not used for local treatments produces a very smooth current of current which should be use the large amount possible otherwise to effective. It is also of advantage to have applied to make the treatment or current available. The apparatus is connected to one, two a pulsating Not only more water filled tanks into which the extremities are immersed.
FIG. 108.
Galvanic generator not shown. Four-cell galvanic bath (Schnee type) of the Medical Supply Association, Ltd., London.)
.
(Courtesy
the galvanic current but also all other forms- of low-frequency currents may be administered through the medium of a hydroelectric bath. Abroad the hydroelectric Schnee-bath is a well known apparatus. An improved American tank unit has the advantages over the Schnee-bath that the two circuits of this power unit allow a separate regulation of current flow between two extremities, as well as the treatment of two patients at the
same time. In local galvanic bath treatments the simplest procedure is to place two extremities in one tank each, thus having the area to be treated between one positive and one negative electrode. The amount of current comfortably tolerable to the patient between 20 and 50 milliamperes This is several times the amount which can be is gradually turned on. safely applied with ordinary moist pad electrodes. In the routine treatment, after ten to fifteen minutes the direction of the current flow is reversed by reducing the current to zero, turning the pole-changing switch and then
ELECTROLYSIS OR SURGICAL GALVANISM
149
advancing the current again and allowing it to flow for another ten to fifteen minutes. Stimulative effect may be exerted by advancing the pulsating current control switch and admitting a tolerable amount of rippled current. A combination of tank treatments with ordinary moist pad electrodes is also possible, as for instance application of a moist pad over the shoulder and holding one or both forearms in one or respectively two tanks with the polarity suitably chosen (Fig. 247). If an extremity is placed in one tank between two electrodes (positive and negative) between 100 and 150 milliamperes can be used. In this arrangement only the part of the extremity between the two electrodes can be treated. Clinical Uses. Galvanic baths have been recommended abroad as aids to general medical treatment in mild general arteriosclerosis and in many rheumatic and nervous ailments. In the author's recent experience best results were seen from full baths in selected early cases of multiple joint involvement, both rheumatoid and osteo-arthritic. The relief from pain
and the improvement
of function was striking in some of the cases, and the general roborative effect was marked in most cases. Satisfactory 3 responses were also seen in several cases of polyneuritis. Behrend reports results in a series of cases with a pain syndrome of true neuralgia striking which resisted the ordinary conservative methods of treatment. Nervous exhaustion in the war disabled alsohas been reportedresponding satisfactorily. Local galvanic baths may be employed in all cases where galvanic treatment along the extremities is indicated such as vasomotor disturbances, paresthesias, neuralgias, and also selected cases of peripheral nerve injuries and other traumatism.
ELECTROLYSIS OR SURGICAL GALVANISM

The term electrolysis denotes in the technical world the decomposition of a chemical compound by the ionizing effect of a direct current. In medicine it has become identified with well controlled tissue destruction by the
caustic effects of the galvanic current, applied through a fine needle as the "active" electrode while a fairly large moist pad serves as a "dispersive" electrode to complete the circuit. The needle electrode is usually made of
platinum
iridium, fixed in a suitable holder;
it is
connected to the nega-
tive pole for tissue liquefaction (alkaline caustic effect) and to the positive pole for tissue coagulation (acid caustic effect). The chief advantage of
is that the amount of destruction, depending on the strength and duration of the current flow, is always under control and well localized, and the cosmetic effects are very satisfactory because of the minimum of scarring.
surgical galvanism
Removal
of Superfluous Hair.
The
is
hair (hypertrichosis)
by
electrolysis
principle in treating superfluous to apply current of sufficient strength
from the negative pole to destroy the follicular lining, the papilla and If properly carried out the treatment is followed by a smooth and almost invisible scar and the total disappearance of the unwanted
hair root.
(For details see Chapter on dermatological conditions.) Skin Blemishes. The mild and well regulable caustic effect of the galvanic current has been employed for many years successfully for the destruction of minor blemishes and benign tumors of the skin. Among these
hair.
150
of small size, filiform
are telangiectasis, moles containing hair, rosacea, spider nevus, angioma and flat warts, xanthelasma, adenoma sebaceum
16 (Lewis ). Every dermatologist warns against applying the method when dealing with any potentially dangerous lesions of the skin, such as black pigmented moles and melanoma. In such cases, death of a patient may result from subsequent metastases. A moist pad electrode placed suitably or a moist sponge Technique. held by the patient serves as a dispersive electrode and is connected to the positive pole. The active electrode is a needle held in a needle holder it is connected to the negative pole and inserted across the base of the growth transfixing it parallel with the skin surface. For the usual small growth a current of 1 to 2 milliamperes is turned on and then slightly increased until in a minute or so a whitish-gray discoloration along the
;
to the
is then withdrawn and employed at right angles and this process is repeated until the entire growth appears discolored and swollen.
needle appears.
first
The needle
insertion
Experience is necessary to judge accurately the amount of current to be employed. The needle should never dip down into the mole; for a perfect
result parallel insertions of the needle are essential. At the end of the treatment the growth is either covered with a small
aseptic dressing or
off
may
be
left
uncovered.
The
devitalized parts sub-
and separate spontaneously within a few days; a small sequently dry dry scab covers the surface underneath, and in the course of a few more days this area becomes epithelialized. The cosmetic result is usually
satisfactory.
In moles containing hairs the latter must be always removed first, before anything is done to treat the mole. These hairs are more difficult to remove than other hairs, because their length is very variable and the course of their follicle is usually tortuous. A fairly strong current may be employed because it will help to shrink the mole. Small hairy moles containing many hairs often entirely disappear after the hairs have been removed. In larger moles, after the hairs have been treated, either electrolysis or electrodesiccation should be employed to finish the work. Hairy moles are never
malignant.
Filiform and flat warts are treated by a technique similar to non-hairy moles; they should be held by a small forceps and their base transfixed when tense. Only a minimum of current should be employed. Hemorrhoids. Obliteration of hemorrhoids by surgical galvanism has
been variously recommended. (See Chapter on proctologic conditions.) Strictures. Galvanism from the negative pole in gradually increasing strength has been successfully employed in strictures of the male urethra
(Chapter XXXI), stenosis of the cervix (Chapter bronchial strictures (Kernan and Baker 10 ).
XXX)
and
also in
Galvanic Acupuncture. Galvanic acupuncture is a method for relief of pain in stubborn cases of chronic neuritis by mild surgical galvanism. It is not at all practiced in the United States, but favorably spoken of in
England, where
it
by ^Cumberbatch, 5
was originated by Davies. The procedure, as described consists of first locating the hyperalgesic areas by an
active disc electrode, J inch in diameter, connected to a source of faradic or sinusoidal current. Just enough current is turned on to elicit a painless sensation of pins and needles in the normal skin. The spots in which the
ION TRANSFER OR IONTOPHORESIS

same amount
151
of current causes severe pain are treated in succession on days as follows: A few drops of a 1 per cent novocaine solution are injected under the skin in the center of each spot. A needle electrode of special design, connected to the negative pole of a source of galvanic
different
current, is passed through the opening made by the syringe needle. A current of 1 to 2 milliamperes is passed and the needle is made to explore the skin and fascia until a location is found where the neuritic pain com-
most intense. The electrode is kept for at least five minutes and the current may be increased at 5 milliamperes. The rationale of this treatment is explained by a counterirritation of a nerve twig along which the pain is referred to the surface, and it is claimed that patients can be made free from pain after all painful spots have been
plained of
is
in this situation,
treated.

Physicochemical Considerations. lonization in a wider sense refers to the breaking up of any substance, gaseous, solid or fluid, into its component ions by an outside force, usually an electrical current. Molecules of acids, bases or salts dissolved in liquid divide into positively and negatively charged ions even without the flow of any current. As a constant or galvanic current passes through such a solution, it causes a migration of the ions in a definite direction; those with a positive charge are attracted to
the negative pole and those with a negative charge to the positive pole. is known as ion transfer or iontophoresis. The galvanic current not only affects the transfer of ions contained in the tissues, but also may be employed to break up medicinal substances at its poles by opposite electrochemical affinities and to drive them into the human body through the skin and the mucous membranes. Ions with a positive charge metals (zinc, copper, etc.) and alkaloids may be introduced into the tissues from the positive pole, while ions with a negative charge iodine, chlorine, acid radicals are introduced into the tissues from the negative pole. Leduc, 14 the chief originator of ionic "medication" proved by classical animal experiments that the introduction of drugs in solution into the body was directly due to the flow of current and not to simple absorption by the skin from the wet pad soaked in the drug. Leduc's Experiments. A pad of gauze moistened with a solution of strychnine sulphate was applied to the internal surface of a rabbit's ear and held down by a small metal plate. Even if the pad was thus left in contact for a long time nothing happened. If, however, the pad was made part of a galvanic circuit and connected to the positive pole, while an indifferent pad electrode moistened with water or salt solution placed against any other part of the rabbit's body was connected to the negative pole, upon starting the current flow, in a few minutes the rabbit was seized with convulsions and died with the symptoms of strychnine poisoning. Leduc 14 repeated the same experiment with two rabbits and two drugs as illustrated and described in Figure 109. Newer investigations particularly those of Rein have demonstrated that besides iontophoresis, movement of electrical ions, electroosmosis or of shifting of the water content through the pores of the skin under the influence of a galvanic current plays an equally important role in the introduction of electrically charged colloidal substances.
This process
152

It has
Penetration of Ions.
been shown that as rule medicinal ions
cannot be made to migrate far below the surface of the skin and mucous membranes; consequently ionic medication is essentially a local or intradermic form of treatment and systemic effects are an exception. conclusion is based on the following established facts:
This
Leduc's classic experiment. Two rabbits are placed in series in the same FIG. 109. The current enters into the galvanic circuit, so that the current has to pass through both. first rabbit by a positive electrode soaked in strychnine sulphate, leaves by a negative electrode soaked with plain water, enters the second rabbit by an anode soaked with water and When a current of 40 to 50 milliamperes is turned leaves by a cathode of potassium cyanide. on, the first rabbit is seized by tetanic convulsions, due to introduction of the strychnine ion, while the second rabbit dies rapidly with symptoms of cyanide poisoning. If the two animals are replaced by new ones and the flow is reversed, the animals are not harmed, because now the strychnine ion is not repelled by the positive pole and the cyanide not repelled by the
negative pole.
1. Different ions move at fixed rates of speed which increase with the voltage and diminish with the distance in the electrolyte through which they travel. The displacement of the ions being the electric current itself, the traveling speed of the fastest positive ions, the hydrogen ions, must be considered identical with that of the current. The fastest negative ion
is
the hydroxyl radical, and as this and the hydrogen ion are present in in the body fluids, the greater part of any electrical current is carried by them. The other ions being much less speedy and less numerous, they do not transport the electric current at all. This reason alone explains why medicinal ions are introduced into the tissues only in a very small quantity (Turrell 19 ). 2. When a medicinal ion enters the body it is almost immediately deprived of its charge by the electrolyte salts of the body fluid, the blood stream and lymph. In addition ions of the heavy metals rapidly unite with the tissue proteins, forming insoluble compounds. Data are now available on the actual depth of migration of ions under the influence of the current. Rein introduced methylene blue in animal experiments with dogs and rabbits and found deep blue staining of the stratum corneum, dark blue of the stratum Malpighii, with the stained hair follicles reaching into the subcutaneous fat tissue. Harpuder8 confirmed this on animals but with biopsy material of the human skin there resulted only a staining of the epithelial skin, most intensive on hair follicles and oil glands, with no demonstrable stain at the muscle fascia. It is the consensus of investigators that the introduction of certain drugs
immense number
by
in
electrophoresis increases their
their therapeutic result.
pharmacodynamic With some drugs ionization
effects
and thereby
results in a deposit
the layers of the skin with slow absorption and sustained clinical effect.
153
Generally speaking, more intense penetration occurs from the positive Ions introduced by the positive pole are the heavy metals copper, zinc, magnesium alkaloids, morphine, cocain, histamine, and cholin derivThe negative pole will introduce salicylates, iodides and bromides. atives. Clinical Uses of Ion Transfer. The introduction of electrically charged particles of certain drugs or of the salts of heavy metals by the polarity effects of the galvanic current finds a steadily increasing employment in all departments of medicine. The object of these electrophoretic applications is either local stimulation of the function of tissues a form of counterirritation or a mild local caustic effect, the precipitation of tissue proteins and the resulting elimination of diseased tissue. The mode of action and clinical uses of the various substances employed for electrophoretic applications and also some of the special techniques will be described in this chapter. The critique of the methods and the detailed technique relative to the most frequently treated conditions will be presented in the chapters dealing with special conditions. In skin conditions, fungus infections and other forms of chronic dermatitis
pole.
of
hand and
feet
silver nitrate ion transfer;
have been successfully treated by copper as well as by scleroderma and keloids by mecholyl or potas-
sium iodide ion transfer;
light superficial scars in varicose ulcers spectacular results have been transfer.
by
chlorine ion transfer;
achieved by mecholyl ion
In gynecology, chronic endocervicitis and cervical erosions have been many years treated with copper ion transfer; recently, mecholyl ion transfer has been used in pelvic inflammation (Chapter on gynecologic
for
and throat conditions, zinc ion transfer has been used for years in the treatment of chronic otorrhea, and in recent years, in chronic and vasomotor rhinitis, and also in trachoma. (Chapter on nose and throat conditions.) In arthritis and rheumatoid conditions, as well as in traumatic conditions
conditions). In ear, nose
many
of soft tissues, both mecholyl and histamine ion transfer spread application in recent years. (Chapter XXVII.)
have found wide-
In medical conditions, histamine ion transfer has been employed for relief of migraine and headache, epinephrine for severe asthma, aconitine and of nupercaine for muscular spasm. Calcium ion transfer by cerebral galvanism has been recommended for the chronic stage of hemiplegia. In peripheral vascular disease, mecholyl ion transfer has been found useful in producing prolonged local vasodilatation. General Technique. A galvanic current generator in good working order is essential; its two terminals must be marked for their proper polarity. For application through the skin the active electrode conveying the medicinal solution should be made of absorbent material of sufficient thickness or consist of a medicated water bath. The strength of all solutions should be 1 per cent or less as no advantage is gained by making it stronger. Gauze of a thickness of J inch (about 16 layers) is best, but cellucotton, felt or folded hand towels of the same thickness may serve for pads. For the
the
introduction of vasodilating drugs special asbestos fabric paper is availThe active electrode is soaked with the solution at a temperature of comfortable warmth and is laid on with firm contact over the area to be treated. A metal plate of somewhat smaller size or a metal foil is placed
able.
154

careful that
upon the pad, being very
no metal edge anywhere touches the
skin; even a minute, direct contact between the metal and the skin may lead to a chemical burn. (Fig. 113.) For a dispersive electrode, a pad electrode of larger size than the active electrode is soaked in tap water or saline solution and is placed in firm
contact with a convenient part of the body surface. Suitable metal clips or other fastenings serve to secure the conducting cords to the metal plates of the active and dispersive electrodes; one must strictly avoid possible contact to the skin of this clip; if necessary use a small piece of rubber sheeting. The conducting cords must be securely attached to the proper
foot or arm bath may also be used terminals of the galvanic apparatus. as a dispersive electrode in all forms of treatment. For treatment of mucous surfaces the cervix, nasal cavity or the inner ear a metallic electrode, solution or packing containing the ions is placed
in direct contact
with the walls of the cavity and serves as the active
electrode.
The strength of the current used in iontophoresis should be generally the maximum that can be tolerated with comfort. Figure 106 shows the current strength in relation to the size of the active electrode as in the
varies with the condition
curve worked out by Molitor and Fernandez. The length of treatment and the potency of the drug; from five minutes in histamine ion transfer for counterirritation to one hour in chlorine ion
transfer for softening scars.
The danger
of burns
is
always present
in electrophoretic applications
and can be avoided only by the rigid observance of the general rules of treatment described at the end of this chapter. If treatment pads are to be used again they must be thoroughly cleaned and rinsed after each treatment in order to get rid of the secondary chemical
products near the metal plate. The asbestos fabric paper can be employed two or three tunes and is simply remoistened each time with the same stock
solution.
A. Applications
From
the Positive Pole
Heavy Metals. Copper and Zinc. The action of the ions of the heavy metals differs from the action of the medicinal ions; instead of a soluble molecule which is absorbed by the tissues, the free ions of copper and zinc produce an insoluble protein precipitate. The result is a local germicidal effect, due to the antiseptic properties of nascent ions and also a coagulation of tissue protein in proportion to the strength and the flow of the current from the positive pole. Following the application a slow separation of detritus takes place from the thin or heavy slough and later healthy new granulation tissue is formed. In contrast to superficial action of the usual caustics, copper and zinc ion transfer extend deeper into the recesses of the mucous membrane. Accordingly, these caustic ions have been found
clinically effective for
treatment of infected granulation
tissue, for
mild
cauterization of
mucous membranes,
for stimulation of indolent ulcers
and
for sterilization of infected sinuses.
Copper is employed in the treatment of endocervicitis through a plain copper electrode (Chapter XXX), and also as a solution of copper sulphate for the treatment of sluggish wounds or ulcers, and also in fungus infections of the skin (Chapter XXXIII).
155
Zinc is the most antiseptic of the caustic ions and is being employed in the form of zinc sulphate or zinc chloride solution for treatment of infected sinuses, indolent ulcers, selected forms of chronic otitis media, and some
For details of treatment of otorrhea and hay fever and other allergic conditions, see Chapter XXXIV. Before treating any cavity or sinus with zinc ion transfer it must be first thoroughly syringed out by a solution of 1 per cent zinc sulphate in order to remove all foreign material, pus, debris, which prevent the thorough contact of the ionizing substance with the infected surface. A fresh supply of zinc solution is then injected, a zinc rod or wire inserted and kept in situ by suitable insulation. (Fig. 337.) This electrode is connected to the positive pole. A dispersive moist pad electrode is placed in a suitable location and connected to the negative pole. Current of comfortable toleration is employed and kept up for ten minutes to one-half hour,
inflammatory eye conditions.
of
according to the pathological changes present. grayish-white discoloration of the tissues appears, the extent of which enables the operator to gauge the effectiveness of the treatment. Treatment may be repeated in
a week or two.
Vasodilating Drugs. Interest in the use of vasodilating drugs for improving the peripheral circulation in rheumatic and other conditions led to the discovery that when administered by ionization these drugs are readily
absorbed and exert well controlled local as well as general effects. The vasomotor stimulation by the galvanic current itself also adds to the effect. Histamine. Histamine is a substance which is regularly formed in the skin as a result of thermal, mechanical or chemical irritation as shown by Lewis and Grant. It causes dilatation of the capillary blood-vessels
and
so
if
the injury or irritation
is
severe enough, capillary permeability
is
much increased that formation of wheals occurs. Histamine is introduced
into the skin by the positive pole of the galvanic current from a solution or ointment applied to the skin. A few minutes application of a weak solution will result in intense hyperemia, formation of wheals and large patches of urticaria. This local reaction probably extends to some depth. Skin temperature measurements show a rise of 3 to 5 F. The effects of local vasodilatation persist from one to four hours and the skin returns to normal appearance. The vasodilating and counterirritant effect of histamine ion transfer has been found effective in treatment of traumatic and rheumatic affections of superficial soft tissues, such as myositis, fibrositis, sprains, neuritis. Deutsch 6 who introduced histamine treatment attributed the favorable results to a nervous reflex effect on muscle pain and spasm without an
anesthetic effect in the ordinary sense. He emphasizes that histamine will only relieve pain which is connected with local tenderness or limitation of motion. Favorable reports have been given of cerebral histamine ion transfer for treatment of migraine and headache and for post traumatic conditions. Older patients often report a feeling of well-being after local histamine treatment; this may be attributable to a slight systemic effect, causing a fall of blood-pressure. With the usual technique of local treatment there are no general effects of histamine administration; prolonged or excessive administration however may result in increase of pulse and metabolic rate, a fall of blood pressure, a sensation of flushing and heat around the head and neck and
156
Patients with a history of bronchial asthma should not treatment by any vasodilating to avoid any possible untoward receive systemic effects. In the technique of histamine ion transfer, one may employ a 1 to 1000 solution of histamine dihydrochloride or histamine acid phosphate or a For applying the solution several thick1 per cent histamine ointment. nesses of gauze or flannel are saturated with it; one may also use asbestos fabric paper or several layers of filter paper; the resulting "active" pad electrode is lightly wrung out and placed over the area to be treated over this pad is laid a malleable metal electrode of slightly smaller size (to prevent skin contact of the metal) or a ready made moist pad electrode of suitable size. For treatment with an ointment one may employ the ready made "imadyl" unction, rubbing a small amount of it gently into the area, after it has been warmed for ten minutes by a heat lamp or warm towels. Wiping off the excess ointment the area is then covered with a pad electrode as already described. The histamine bearing electrode must always be connected to the positive pole, while the standard type of dispersive electrode is connected to the negative pole. For the first treatment it is advisable to use only a current strength of 5 milliamperes for five minutes; this can be increased subsequently up to 10 milliamperes and ten minutes, according to the extent of reaction obtained. Treatments can be given daily or every other day (Hummon 9 )
severe headache.
;
.
FIG. 110.
Curves showing systemic
effects of iontophoresis 11 chloride. (J. Kovacs. )
by acetyl-beta-methylcholine
Mecholyl. Acetylcholine is a substance of great physiologic potency; as a parasympathetic stimulant it causes dilatation of peripheral bloodvessels, slowing of the heart, falling of blood-pressure, constriction of the
pupils, increase of intestinal tone and peristalsis, stimulation of the detrusor muscle of the bladder and increase in intestinal tone and It peristalsis. is a pharmacologic antagonist to epinephrine. Mecholyl (acetyl-betamethylcholine chloride) is a derivative of acetylcholine, which can be administered by ion transfer through the unbroken skin and exerts a well
controllable local action in peripheral vascular conditions of arthritis.
and some types
157
The
local effects of
mecholyl ion transfer observable immediately after
application are as follows: Marked redness of the skin, sharply localized to the area of application, and remaining for one and a half to two hours; "goose flesh," due to contraction of the erector muscles of the hair follicles,
remaining for ten to thirty minutes; perspiration of the treated skin area, continuing for eight to ten hours, probably due to direct action on the skin glands; increase of the skin temperature in cases where a spasm of the peripheral blood supply was present; increased salivation when treatment was applied in the region of the salivary glands; and finally a warm feeling of the treated part for twenty-four to seventy-two hours. General effects when large areas are treated, or there is a special sensitivity of the
patient; they consist of flushing, general sweating, salivation, reduction of blood-pressure, increase of pulse-rate and peristalsis, and in some cases
vomiting.
These can be immediately checked by subcutaneous injection
of T^Q- grain of atropine.
FIG. 111. Equipment for mecholyl ion transfer; mecholyl solution, asbestos fabric paper, tray for moistening asbestos paper, electrode foil to place over moistened asbestos paper bandage to hold latter in place.
The effects of mecholyl ion transfer and of body heating on the cutaneous blood flow of the forearm and leg were measured by photoelectric plethys18 Heat to the trunk resulted in profuse sweating and increased mographs. the flow 2.5 times in forearm skin and 3.5 times in leg skin. Cooling of the skin by evaporation probably prevented a maximal dilatation. Mecholyl ion transfer increased the flow 5 times in forearm skin and 6.5 times in leg skin. The greater dilatation with mecholyl probably represents the maximal blood flow which can be provided in the skin at normal levels of bloodpressure and therefore the maximum expansion of the cutaneous vascular bed. There is a question whether the so-called reflex thermal dilatation is entirely due to decreased vasomotor tone or to the direct effects of temperature on the vessels. These observations make it evident that mecholyl administered by ion transfer penetrates the skin, is absorbed by the blood stream and exerts marked local as welLas some general effect. In administering treatment it is desirable to keep the general effects at a minimum and exclude from treatment any patient with a history of asthma or hay fever.
158

clinical effects
from mecholyl ion transfer have been reported vascular disease in chronic arthritis of the rheumatoid type, in peripheral in Raynaud's disease, in thrombophlebitis in which spasm is a major factor, and in varicose ulcers. For details see respective chapters. Pelvic ion for massive celltransfer with mecholyl has been recently recommended
Favorable
ulitic infections
(Chapter
XXX).
FIG. 112.
Mecholyl ion transfer treatment of elbow by asbestos fabric paper technique.
FIG. 113. Mecholyl ion transfer treatment of shoulder by towel technique; placing of electrode foil over moistened towel; to be followed by wrapping a bandage or placing a small sandbag over shoulder.
The technique of mecholyl iontophoresis consists of saturating reinforced asbestos paper with a 0.2 to 0.5 per cent solution and wrapping it around the affected parts. The author keeps a 10 per cent stock solution on hand and dilutes a sufficient amount for each treatment. Instead of asbestos paper, thin hand toweling can also be used, it is saturated with the solution and snugly wrapped around the part to be treated. A fairly large malleable
is placed on this wrapping and is connected to the positive pole of a galvanic generator; a very large dispersive, moist pad is applied to the back and connected to the negative pole. The current is slowly
metal plate
159
increased from 5 to 20 or 30 milliamperes and kept up for twenty minutes. After treatment the part is dried and kept covered.
Comparison has been made as to the relative value and practicability and mecholyl iontophoresis. Histamine applied by the generally used technique produces an intense local "counter irritant" effect and is applied in a very dilute solution for a few minutes only. Systemic effects are an exception. It is reported to give best clinical results in
of histamine
muscular affections. Mecholyl ionization produces a less intense local reaction, its effect amounting to a deposition of the drug in the deeper layers of the skin and its gradual absorption. It is applied in a more concentrated solution and for a longer period of time. Systemic effects occur as a rule. It appears to give best results in joint affections and also in varicose ulcers.
Other electropositive drugs: Cocain. Cocain iontophoresis with a 1 per cent solution applied for ten minutes at 1 m illiampere strength per square inch is effective in anes8 thetizing a definite area of the skin or mucous membrane. Harpuder considers electrophoresis of anesthetics of definite value for relief of referred pain or neuralgic or neuritic pain with localized hyperesthesia and hyperalgesia of the skin. The entire involved skin area is treated with a 1 per
cent solution of nupercaine in 80 per cent alcohol containing 1:20,000 epinephrine for twenty to thirty minutes from the positive pole at 0.25 to 0.5 milliamperes per sq. cm. The skin becomes pale and remains hypesthetic for several hours. The use of this drug has been recommended by Abramson 1 Epinephrine. to reduce the severity of symptoms in the asthmatic state. The local reaction of vasoconstriction (blanching) acts to retard the absorption of the drug present in the deposits formed in the skin. Abramson soaked cotton with a solution of 1 per cent epinephrine dihydrogen phosphate, buffeted with phosphoric acid and applied it from an active electrode of about 30 sq. cm. area, for ten to fifteen minutes with a current of 5 to 7 milliamperes; he repeated this two to three times at each sitting. Aconitine. Aconitine is in addition to its effect on motor, cardiac and 2 respiratory functions an antalgic. Barakin has revived its electrophoretic use for relief in various neuralgias and plexus neuralgia. The active electrode is a gauze pad of sufficient size soaked with a 1 per cent solution connected to the positive pole and is applied towards the periphery of the affected nerve; current of 2 to 5 milliamperes is employed for thirty minutes or longer. Calcium. Calcium iontophoresis with a 1 per cent solution of calcium chloride has been recommended for old cases of hemiplegia by Bourguignon. 4 An active electrode consisting of a pad with a 1 per cent solution of calcium chloride is applied over one closed eyelid and connected to the positive pole a dispersive pad connected to the negative pole is applied to the nape of the neck.
;
B. Applications
From
the Negative Pole
Chlorine. In the standard technique of galvanism, in which moist pads are soaked with salt solution, under the negative pad chlorine ions are always liberated and at the same time sodium hydroxide is formed. The
latter being mildly caustic, following a
prolonged application, often
will
160
soften superficial scars; it may also affect more dense scars and make them more amenable to subsequent stretching and massage. For further details
see
Chapter XXXIII.
Iodine.
Good
results
have been reported by French and German
clinicians, especially in Dupuytren's contracture, muscular infiltrations and in skin scars and scleroderma. It has been claimed that free iodine
is liberated in the tissues during the passage of the current as shown by Iodine typical blue discoloration (iodine reaction) in the deep tissues. ionization has been recommended also for simple hypertrophic goiter and
pad electrode corresponding in size with the area to be treated is soaked in a 1 to 2 per cent solution of sodium or potassium iodide and connected to the negative pole of the galvanic generator, while the larger dispersive electrode is connected to the positive pole. Treatments should take from twenty to forty minutes at comfortable
toleration.
Salicylic Acid.
also for peripheral facial paralysis. In the technique of application a
salicylate solution has been
Salicylic acid iontophoresis recommended in
with a 2 per cent sodium rheumatic affections. It is
introduced from the negative pole.

TABLE
Conditions treated
20.
Uses of Ion Transfer

Solution or
Active ion
drug employed
and polarity
Skin conditions
Fungus
infections
Scleroderma
Varicose ulcers Indolent ulcers Keloids
Copper sulphate Mecholyl Mecholyl

Zinc sulphate
Copper
Potassium iodide
Recent scars
Medical-surgical conditions
Sodium
chloride
Choline + Choline + Zinc + Iodide Chloride Choline -fCholine + Histamine
Chronic arthritis
Peripheral vascular disease
Rheumatic and traumatic

conditions
Hemiplegia
Gynecological
conditions
Mecholyl Mecholyl Histamine dihydrochloride or ointment Calcium chloride
Chronic endocervicitis
Cervical erosion Pelvic inflammation Chronic otorrhea
Copper sulphate Copper sulphate Mecholyl

Zinc sulphate Zinc sulphate Zinc sulphate
Nose, throat and eye conditions
+ + + Choline +
Calcium
Copper Copper
Zinc -f Zinc -f Zinc
Vasomotor
rhinitis
Trachoma
The chief danger in all galvanic treatments the occurrence of skin burns or excessive destruction of the mucous membrane; these are always due to excessive density of current. Molitor and Fernandez 16 found that a definite relation ratio of 3 to 4 exists between current density producing pain and that of burns. Therefore
Dangers in Galvanism.
is
producing
inadvisable to depend on pain sensation as a criterion for prevention of burns, but keep current strength always in relation to the size of electrodes. Another potent cause for burns is the touching of the skin by the electrode metal, insufficient padding or denuded areas in the skin. If the metal touches the skin as shown in Figure 114, burns are produced by a much lower current, evidently because of excessive currrent density at the point of contact.
it is
In copper iontophoresis excessive amount of current applied to the cervix can cause undue amount of late sloughing and subsequent stenosis

of the cervix.
161
In zinc iontophoresis of the nasal mucosa excessive current cause permanent damage to the nasal mucosa and impairment of the sense of smell. In mecholyl iontophoresis excessive dosage or individual sensitivity may cause unwanted systemic reaction. In addition to the general rules of treatSafety Rules in Galvanism. ment described in Chapter V, the observation of the following special rules will safeguard the patient in all galvanic treatments and electrophoretic treatments. 1. Be sure that the patient's skin sensation is normal; otherwise calculate and control the current strength carefully in accordance with the size of electrodes and the milliammeter reading.
strength
may
FIG. 114.
Effect of uneven distribution of current.
Ten milliamperes flowing
for fifteen
minutes through a well-padded electrode with a thin, cross-shaped metal sheet placed between the padded electrode and the skin. (Molitor and Fernandez.)
2.
Do
not apply the current over denuded areas and be most careful
scar tissue.
when over recent

3.
See that the metal plate of the electrode is evenly covered by the padding and that there are no bare edges in contact with the skin. 4. See that the covering pad is evenly soaked with tap water or saline
solution.
5. Apply electrodes in good contact, and with even pressure. Uneven pressure from tight bandaging or from folds or creases in the pad and insufficiently moistened areas lead to uneven distribution of current, the
first
subjective manifestation of which
is
a burning sensation in one or
more spots. If the patient complains of burning at any time during treatment and the amount of current does not seem excessive, the first thought
is uneven current distribution or insufficient moistening of the pads. The remedy is to shut off the current, take off the pads, remoisten them and reapply them carefully.
6.
Fasten the conducting cords securely to the electrodes, making sure

11
162

come
in
that the metal of the cord tip does not

at
contact with the bare skin
any point. 7. Always advance current gently when
starting; never close the current
sharply while the milliammeter registers current flow. 8. Be sure that the patient understands that he is to report undue burning or pain at once. The individual judgment of patients as to what they feel as burning or pain varies considerably, so that it is a safe rule never to apply more current than the patient states is comfortable, no matter what the milliampere reading shows; but, on the other hand, never exceed the safe milliammeter reading, in relation to electrode size; even One should bear in if the patient claims that he can stand more current. mind that in the course of galvanic treatments the meter reading has a tendency to mount as skin resistance decreases. If the opposite occurs, this is usually a sign that the pads are becoming dry and need remoistening. 9. If at any time the patient complains of annoying symptoms, decrease the strength of current; then, should this not afford relief turn off the current entirely, take off the electrodes and investigate. 10. After conclusion of treatment, do not allow patient to go outdoors with underwear or other clothing wet from the galvanic treatment.
REFERENCES
1.
ABRAMSON, H.:
of
2.
Comparison of Treatment of Severe Asthma by Electrophoresis Epinephrin With Other Methods, Arch. Phys. Ther., 21, 261-266, 1940. BARAKIN, M.: Value of Aconitin Electrophoresis, Ann. de mecl. phys., 32, 125-130,
1939.
3. 4.
BEHREND, H. J.: Modern Hydrotherapy, Arch. Phys. Ther., 25, 5, 1944. BOURGUIGNON, G.: Nouvelle technique d'introduction electrolytique d'ions, Rev.
d'actinol. et
de physiother.,
P.:
5, 180,
1929.
5.
CUMBERBATCH, E.
p. 55, 1934.
Lectures on Medical Electricity, London,
Henry Kimpton,
6.
DEUTSCH, D.:
Histamin in der Therapie rheumatischer Erkrankungen, Med. Klin.,
27, 1491, 1931.

7.
FREUND and SIMO:
Zur Analyse der galvanischen Hautreaktion, Ztschr.

in Physical
f.
phys.
diat. Ther., 25, 308, 1921.

8.
HARPUDER, K.: Electrophoresis and Rad., 18, 221, 1937.
Therapy, Arch. Phys. Ther., X-ray
9.
HUMMON,
KERNAN,
J. F., JR.:
10.
D.,
Histamine Ion Transfer, Arch. Phys. Ther., 25, 212, 1944. and BAKER, D. C., JR.: Galvanism in Treatment of Bronchial StricPhys. Ther., 20, 739-744, 1939.
of
tures, Arch.
11.
12.
KOVACS, J.: Am. Jour. Med. Sci., 188, 1, 1934. KOVACS, RICHARD: Hydrogalvanic Apparatus
Ther., 24, 598, 1943.
Improved Type, Arch. Phys.
13.
14. 15. 16.
KOWARSCHIK,
J.:
Elektrotherapie, Berlin, Julius Springer, p. 220, 1929.
LEDUC, S.: Electric Ions and Their Use in Medicine, London, Rebman, Ltd., 1908. LEWIS, G. M.: Electrolysis in Skin Disorders, Med. Jour, and Rec., Sept. 16, 1931. MOLITOR, H., and FERNANDEZ, L.: Experimental Studies on Causes and Prevention of lontophoretic Burns, Am. Jour. Med. Sci., 198, 778-785, 1939. Technic of Electrotherapy and Its Physical OSBORNE, S. L., and HOLMQUEST, H. J. and Physiological Basis, Springfield and Baltimore, Charles C Thomas, pp. 7-37,
:
17.
1944.
18.
RANDALL, W. C., and HERTZMAN, A. B.: Effects of Mecholyl Iontophoresis and Reflex Thermal Dilatation of the Cutaneous Blood Flow, Am. Soc. Exp. Biol.,
3, 38, 1944.
J.: Principles of Electrotherapy and Their Practical Application, Oxford University Press, p. 45, 1929. 20. WEDEKIND, W. H.: Untersuchungen ueber elektrische Vollstrom und Teilstrom-
19.
TURRELL, W.
baeder, Ztschr.
f.
d. ges. phys. Ther., 43, 4, 1933.
CHAPTER IX
CURRENTS OF LOW FREQUENCY
Historical: General Considerations.
Physics and Physiological Effects: (1) Interrupted (3) Current, The Surging Faradic Current. The Slow (Galvanic) Sinusoidal Current. (4) The Modulated Alternating or Interrupted Sinusoidal Current. Low-frequency Apparatus. Therapeutic Aspects of Clinical Use of Low-frequency Currents. Choice of Electrical Muscle Exercise. Current. General Technique. Individual Motor Point Stimulation and Group Stimulation. Dangers of Application. Static Electricity.
Galvanic Current.
(2)
The Faradic
Historical. Galvani observed first in 1780, the twitching of the muscles of a frog's leg under the influence of electricity; Volta proved twenty years later that this was due to the sudden "make" of the current flow in an
The induction or faradic coil was discovered by Faraday in 1831; Duchenne in 1855 described its application for electric stimulation Remak first demonstrated the motor points for accurate of muscles. electrical testing of muscles. Du Bois Reymond in 1849 formulated the law of electrical muscle and nerve stimulation and first employed the induction coil for muscle stimulation. He also made the first make and
electric cell.
break key for interrupting an electric current. Bergonie of Bordeaux constructed the first device for general electric muscle stimulation by faradism; Kellogg, of Battle Creek, described the first sinusoidal muscle stimulating apparatus. The newer methods of electrodiagnosis by condenser discharges and chronaxia testing as presented in Chapter VII, also led to the employment of these newer forms of low frequency devices
muscle stimulation. General Considerations. Under the term of currents of low frequency a variety of currents are included. Their common physical characteristics are that their voltage or tension is constantly changing and is quite low as a rule, there is only a few milliamperes of current flow between the electrodes applied to the body. Their primary physical effect is a sudden
for therapeutic
in the tissues affected; their physiological a stimulation of motor and sensory nerves. The term low frequency relates to a rate of change or frequency below 10,000 per second; in contrast, high-frequency currents with a rate of frequency over 100,000 per second do not cause any stimulation of excitable tissues. The therapeutic importance of low-frequency currents is twofold: (1) They furnish a characteristic procedure known as electrodiagnosis for the recognition of pathological conditions of the motor tract; (2) they furnish means for the stimulation of weak or paralyzed muscles, a form of electrical muscle exercise valuable in the treatment of injuries and diseases. We have seen in Chapter VI that an electrical stimulus exerting ionic changes with sufficient suddenness over muscular parts or motor nerves,
change of ionic concentration

effect is
an impulse for muscular contraction. The steadily flowing galvanic current causes no muscular contraction because there is not enough change in its strength or its rate of fluctuation to act as a stimulus. Only when the flow of the current is suddenly started or broken at sufficient strength, over a muscle or motor nerve, does a contraction occur. The extent and
acts as
(163)
164
type of these contractions varies with the intensity, form, and duration of the electrical stimulation and the condition or type of muscle affected. In normal skeletal muscles (with an intact nerve supply), if the number of alterations or interruptions of the current is below twenty per second such as in case of an interrupted galvanic current, single (clonic) contractions occur; if they are above twenty, such as in case of stimulation with a faradic type of current, prolonged (tonic or tetanic) contractions In muscles of normal physiological state, contraction is of a tetanic type and always the result of indirect stimulation through the nerve which is more excitable than the muscle. When the motor nerve has degenerated as a result of trauma or disease it cannot be stimulated, and then the independent property of contraction of the muscle becomes evident. Such response, however, is of different character; because of the secondary degenerative changes in the muscle, it is sluggish and worm-like instead of the normally brisk contraction. It also requires an electric stimulus of longer duration and greater volume for its production. This qualitativequantitative change in the type of electrical reaction known as the reaction of degeneration, has been fully described in the chapter on electrodiagnosis. Hence it is evident at the outset, that for effective stimulation of muscles,
result.
just like in electrodiagnosis, at least two types of stimuli are required; one relatively quick and rapid to stimulate muscles with intact nerve supply
and one
relatively slow to affect denervated muscles. All forms of low-frequency currents act as a stimuli to
both motor and
sensory nerves, hence they will cause not only muscular contraction, but also a variety of sensations, ranging from simple tingling to actual pain, according to the mode of application. Physics and Physiological Effects. For a number of years manufacturers of apparatus have turned out apparatus furnishing a bewildering variety of low-frequency currents and there was no universally accepted terminology. To a large extent this situation still prevails. We will describe the four principal forms of low-frequency currents and present some
experimental demonstration of their action. l.'The Interrupted Galvanic Current. The interrupted galvanic current is usually produced by a mechanical device placed in a galvanic circuit that interrupts the current flow at regular intervals, such as 30, 60, 120 times per second, as shown by an indicator. A make and break key in the
operator's hand, usually mounted on the handle of the testing electrode, is the simplest means for muscle and nerve testing or stimulation with the galvanic current when single contractions are wanted. The strength of
the current
is
regulated
by a
rheostat.
Experimental Demonstration. The subject places the palm of one hand over a wet pad electrode, about inches in diameter, connected to the positive pole of a galvanic generator. A wet-padded disc electrode, about 1 inch in diameter, mounted on an interrupting handle and connected to the negative pole, is placed over the middle of the belly of the biceps muscle. The forearm is well supported and the biceps thus relaxed. A current of about 5 milliamperes is turned on. The subject feels a slight stinging under both electrodes, especially under the smaller one. The current is now suddenly "broken" by the interrupting handle and brisk contraction of the biceps occurs. Contraction can be produced with less
3x4
THE FARADIC CURRENT
165
current by starting ("making") the current with the electrodes in the same position, as the make of current is more effective than the break. This experiment proves that while the galvanic current flows steadily it exerts only mild sensory effects, due to skin stimulation; if the current applied over muscles at sufficient density is interrupted, a brisk single contraction occurs at the make and the break. Besides the muscular effect as described, the sudden ionic change of the interrupted galvanic current causes painful stimulation of the sensory skin endings. This stimulation is distinct from the sensation which accompanies the muscular contraction produced by the same current. It has been shown that "electromuscular sensibility" is caused by the irritation of intramuscular sensory nerves and is a dull, tensile sensation which increases with the strength of the current until it may become actual pain. Single contractions as brought about by the make and break of the galvanic current are not physiological types of contractions, because we have seen in Chapter VI that all forms of voluntary muscular contractions are of tetanic nature and the cells of the brain send out not a single stimulus, but successive volleys of impulses.
-
The make and break
of the galvanic current serves in electrodiagnosis
for testing of the response of the muscles and nerves; it also serves in treatment for the stimulation of extremely weak muscles before they begin
to respond to the
stimulation
2.
more physiological form of rythmically increasing muscle by a surging current. The Faradic Current. The faradic current is produced by a faradic
coil,
or induction
described in Chapter III.
The "primary"
current pro-
duced
rapidly
its
in a faradic coil is essentially a direct
made and broken. make a short flow of current
(unidirectional) current This current induces in the secondary coil at

in the opposite direction, while at the
break the induced current flows in the same direction as the original primary current. The "secondary" current of a faradic coil is the current employed in electrotherapy, and the one commonly known as the faradic
current.
Due
retards
to "self-induction" in the primary current, which at the make and at the break increases the currents formed in the secondary,
the "break" current in the secondary is much stronger than the "make." It lasts usually only about one-thousandth second, and its frequency is the same as that of the primary current. The make part of this current in the secondary can be disregarded from the standpoint of muscle stimulation and the effective part of any faradic current is essentially a very abruptly
interrupted unidirectional current. from 80 to 100 per second.
The number
of interruptions
is
usually
The sensory effect of the faradic current is even more marked than that of the interrupted galvanic current. It causes sharp stinging and jarring sensations which increase in intensity as the current strength increases. If a sensory nerve is directly stimulated the sensation is felt in its entire area of distribution. Like the effects of the interrupted galvanic current, the painful sensations caused by the faradic current contain two elements, cutaneous and muscular. The faradic test on page 113 shows that if the testing electrode is applied to a normal motor nerve, all muscles supplied by the nerve below the point of stimulation will go into continuous contraction. If a faradic
166

is
or motor nerve it excites a applied to a normal muscle succession of stimuli occurring at a rate tetanic contraction. The rapid each of 50 to 100 within a second keeps up the contraction produced by and thus a continuous contraction of the muscle takes preceding stimulus, The tetanic conis known as a muscle tetanus. place. Such a condition on indefinitely and after a varying number not will
type of current
traction, however,
go
-from 40
relax.
the muscle becomes exhausted and will muscle exhausted by repeated stimulation will recover after a
to 50 contractions
period of rest.
FIG. 115.
Diagram showing
direction of current in primary the make and break.
and secondary induction
coil at
The
ways:
faradic current differs from the interrupted galvanic in the following is (1) The voltage of the faradic current is higher and its amperage
correspondingly lower, because the difference in the ratio of wiring between the primary and secondary coils of the faradic apparatus amounts to that
FIG. 116.
Myograph
of muscle tetanus under continued faradic stimulation. cease when muscle becomes exhausted.
Contractions
of a step-up transformer.
(2)
There
is
no
electrolytic effect because,
although the current flow at the make can be disregarded for practical purposes it represents an amount of current flow equal to that at the break and thus they neutralize each other's effect. When applying this current for electrical muscle and nerve testing, therefore, it is irrelevant
THE FARADIC CURRENT
167
to which terminal of the coil the testing electrode is connected. (3) The faradic surges are often irregular, because of the mechanical features of
make and break arrangement in the primary circuit. Standard dimensions for a faradic coil were decided upon at the International Electrical Congress of 1881, and unless each faradic coil is constructed in accordance with these specifications which is not each coil In actual practice the only way to gauge the dosage is a law unto itself.
the electromagnetic
of the faradic current
is
according to the sensation of the patient and the
strength of the muscular contractions produced.
FIG. 117.
Graph
of faradic current.
The intensity of a faradic current is regulated through varying the relative distance of the primary and secondary coil thus changing their
inductive capacity. The secondary coil is usually movable on a track. This track is provided with a centimeter scale; each number thereon is simply a relative indication of the strength of the current produced in the
secondary. In small dry cell faradic batteries the primary and secondary coils are usually wound one upon the other in a fixed position and a movable hollow metal cylinder serves as a regulator. As it is drawn out or pushed in between the iron core and the primary coil, it interferes with the magnetic field: the current is weaker when the shield is entirely over the core and becomes proportionately stronger as the shield is drawn out. (Fig. 126.)
FIG. 118.
Graph
of surging faradic current.
continuously flowing faradic current is chiefly employed in electrodiagnosis for muscle testing; it is not suitable without gradual surging for electric muscle exercise because of its painful tetanizing effect. The Surging Faradic Current. In the older type of galvanic-faradic cabinets, motor-driven devices "surge" the faradic current by interposing a varying resistance. (Fig. 118.) This arrangement allows the use of the
The
108
current with a gradual rise and fall in its voltage, causing graduated muscular stimulation without a tetanus. In the Smart-Morton coil a sliding coil moved by the operator causes suitable surging of the current. These surging forms of current which allow alternate contraction and relaxation of muscles are the most desirable form of exercising current for non-paralyzed muscles. (Fig. 126.) In newer type of low-frequency apparatus with thermionic tubes, it is possible to produce a current with the approximate characteristics of the induced current of the faradic coil. Variations in the thermionic circuit
surge the current. If a galvanic current is 3. The Slow (Galvanic) Sinusoidal Current. passed through a rhythmically varying resistance which at the same time periodically reverses the direction of flow of the current, a reversing galvanic wave or slow sinusoidal current is produced. Thus defined, a sinusoidal current consists of rhythmical waves, each of which gradually increases in intensity and volume from zero to maximum and without a pause decreases to zero and then repeats the same process in the opposite direction. Five to thirty periods in a minute is the usual rate at which the galvanic sinusoidal current is employed. The commercial alternating current as well as the alternating current produced by the various motor generators are also sinusoidal currents according to the above definition. The principal difference between these reversing currents is the frequency of their reversal or alternation, varying from a few per minute in the slow sinusoidal to a hundred or more per second in the other forms. It has
ones; there
been attempted to classify sinusoidal currents as slow, medium and rapid is, however, as yet, no generally accepted figure according to which this distinction may be made. According to Krusen it has been suggested that when the duration of flow in one direction is not greater than of a second, such a sinusoidal current be called rapid.
ZKRO LINE
FIG. 119.
Graph
of sinusoidal galvanic current.
It has been established by both clinical and experimental evidence that the slow sinusoidal current furnishes a stimulus of long duration and slowly surging quality. Smooth muscles and skeletal muscles in the stage of flaccid paralysis respond to such a stimulus, while they cannot be stimulated by the normal quick forms of electrical stimulation. The slow sinusoidal current is the main in the treatment of
paralysis with the involvement of the lower
nerve injuries and infantile paralysis, power of contraction and no response to the faradic type of stimulation. For exercising weak muscles without motor nerve involvement this current is not so pleasantly tolerated and not so effective as the surging currents of more rapid frequency.
standby motor neuron, such as peripheral in the stage when there is no voluntary
LOW-FREQUENCY APPARATUS
169
The 4. The Modulated Alternating or Interrupted Sinusoidal Current. ordinary alternating current from the lighting circuit in its usual form of 60 cycles or 120 alternations per second when applied to muscles and nerves has an effect similar to the faradic current; it brings about a tetanic In some apparatus a surging device contraction and is quite painful. enables the application of this current labeled as rapid sinusoidal current for treatment purposes. Most of the present type generators provide a current of somewhat more rapid alternation, with a surging or gradual rise and fall of voltage and they usually label it as the rapid sinusoidal As the voltage of successive stimuli gradually decreases and current. increases, there is no tetanus and, due to the rapid alternation within each surge, the polar or electrolytic effect is minimal. As a result, a current of medium strength causes little skin sensation and is usually well tolerated. Among these modifications is the Morse wave current with 360 alternations per second. The variations of this modulated alternating current as to frequency and as to shape and duration of each surge are numerous. These currents exert the same effects for muscle stimulation as those of the surging faradic type, i. e., graduated contractions in muscles with intact nerve supply.
FIG. 120.
Graph
21.
of
one variety of surging or modulated alternating current.
TABLE
Current
CLASSIFICATION OF LOW-FREQUENCY CURRENTS

Physics
Principal use
Interrupted galvanic
Unidirectional low tension current rising and falling at a frequency of 30 to 120 p. second
Electrodiagnosis
cles
stimula-
tion of denervated
mus-
Faradic
Asymmetric, interrupted, alternating

current
of
Electrodiagnosis
higher
tension;
fre-
quency about 100 a second; single impulse lasts about T oVo second
Surging faradic
Gradual
pulses
rise
and
fall of
faradic im-
muscles Stimulation of with intact nerve supply

Stimulation of muscles with intact nerve supply
Modulated alternating
(rapid sinusoidal)
Rapid alternations
per second;
60 to 90 cycles be surged (modulated); single impulses last about second r

of
may
Galvanic sinusoidal or
wave
Alternating current of 5 to 30 cycles per minute; single impulse lasts 5 second or longer
'
Stimulation of denervated muscles
The
and paralysis explains the need
variety of pathological conditions underlying muscular weakness for a certain variety of low-tension and
170
low-frequency currents. Unfortunately, so far, there is as yet no universally accepted standard for the construction of low-frequency apparatus and for the measurement and comparison of the different currents produced. The requirements for an apparatus furnishing low-tension and lowfrequency currents would appear to be as follows: It should run on either the commercial direct or alternating current; it should allow modification of both amperage and voltage; it should produce surges of any desired frequency and duration so as to allow gradual contraction and relaxation in all types of muscular weakness and paralysis; it should furnish a slow smooth galvanic wave and preferably serve also as a source of smooth
galvanic current.
VARIABLE RESISTOR
C
PATIENT
TERMINALS
o
CURRENT
GENERATOR
FIG. 121.
Diagram
of variable resistor for producing surging low-frequency currents.
In present-day practice there are two main types of apparatus for generation of a variety of low-frequency currents, motor generators and thermionic tube types of generators.
Motor Generators. The main features of motor generators have already been described in the previous chapter. Motor generators can furnish a large variety of low-frequency currents, and manufacturers have been entirely too eager to outbid each other by offering a multiplicity of such varieties, for which no real need exists.
motor generators are: (1) The currents furnished are no connection between the patient's circuit and the supply current; hence there is no danger of shock to the patient if an accidental contact with a grounded line is made. (See Chapter XIV.) (2) In case of sudden break in the outside circuit or blowing of a fuse, the
of
^
The advantages
"earth-free," there
is
motor
of its of the apparatus will keep
171
on turning for a short time on account there will be no shock of a sudden interruption an important consideration when applying, for instance, galvanism to the brain. (3) A reasonable variety of currents is obtainable. The disadvantages of motor generators are their more complicated structure with many
momentum and
moving
parts, their bulkiness
and
their
much
higher price.
FIG. 122.
wave mechanism and
Interior view of low-frequency apparatus showing combination of motor-driven rectifying tube. (Courtesy of the Mclntosh Electric Corp.)
Among the well known types of motor generators are the Morse wave generator and the Polysine generator. In the first one an armature revolving in a magnetic field provides an alternating current of 360 alternations a second. A set of cams which can be slipped in and out of the machine serve to vary the distance between the armature and the pole pieces and
produce from 11 to 36 rhythmic surges per minute. These also make it possible to alter the shape and peak duration of each wave. Thus a varying form of stimulation with intervening periods of rest can be produced. The Polysine generator is a combination of a motor and alternating current generator in a single housing, furnishes a 350 cycle "rapid sinusoidal" current which can be suitably modified as to shape and duration of its waves. In both generators a rectifier and additional filtering also provide a smooth galvanic current and its variations. Generators of Thermionic Tube Types. Vacuum types of generators have come into general use in recent years. They utilize a variety of
devices:
vacuum tubes
for rectifying the alternating current; grid
glow
and thyratron tubes to rhythmically change its strength and frequency without any sort of rotating mechanism. The advantage of these generators is their lower cost, lesser weight and the absence of moving parts, with silent operation and no need of lubrication. A simple type of apparatus is that developed by Weiss 16 in which the 60 cycle alternating current is interrupted or surged at will by the combination of a thermal operated current interrupter "flasher") and vacuum tubes.
(commercial sign
172
FIG.
Push-bottom type modality selector of low-frequency currents, also showing 123. (Courtesy of the Mclntosh Electric Corp.) oscillographic outline of wave forms.
Input 120 VA.C.
FIG. 124. Basic circuit diagram of flasher sinusoidal generator (Weiss). The sign flasher (S.F.) can be switched in or out of the circuit. The first transformer (T) operates the filament of the surge vacuum tubes. The second and third transformers (Tz and 7M serve to render the control (.Ri) electrically free of the remainder of the circuit, and also reduce the voltage
at Ri to
accommodate an ordinary 30 supply for a cautery loop.
ohm
potentiometer. Rz and T* form an optional current
FIG. 125. Portable galvanic and faradic battery. The galvanic current is supplied by two 45-volt batteries contained in the cabinet. Useful at the bedside and where no lighting current is available. Current output is even while dry cells last.
cells
173
Single Types of Low-frequency Apparatus utilize the current of dry or large radio batteries and are thus independent of the lighting current supply and easily portable; others are run on the ordinary alternating
circuit.
Two portable types of faradic coils suitable for electrical muscle testing as well as for graduated electric muscle exercise are the Bristow coil and the Morton-Smart coil. Figure 126 shows the diagram of their construction.
A laminated soft iron core when pushed into the induction coil increases mutual inductance and can be employed to surge the current. The output terminals furnish damped unsustained oscillations, the frequency of which depends on the capacity of the condenser and the inductance of the coils.
J
FIG. 126.
Diagram
of faradic coil with
hand surging and graph
of oscillations produced.
T, interrupter; E, electromagnet; <S, switch; C, condenser; B, battery; P, primary; Sy, secondary; M, movable iron core; T, tap switch; P.T. patient terminals.
Therapeutic Aspects of Electric Muscle Exercise. While there is no little controversy about the indications for electrical muscle exercise in simple muscle weakness, there is still considerable difference of opinion about the advisability of such exercise in real paralysis. Hence, it seems desirable to review the whole matter before presenting the indications for the clinical use of low-frequency currents.
or only
174
In treatment of weak muscles there can be no argument on the point that voluntary exercise is the most desirable form of activity and that no other form of exercise can have the same physiological value. Yet there are a great many conditions in which natural muscle function is lost or diminished and encouragement of the restoration of function by artificial stimulation not only offers the usual beneficial changes resulting from muscle action but also directly encourages volitional effort on the part of
the patient.
When muscles are atonic and 1. In Muscles With Intact Nerve Supply. wasted from any cause and voluntary exercise is not feasible, so long as the nerve path is intact, the production of painless graduated muscular exercise by electric stimulation reproduces the physical and chemical phenomena connected with normal muscular work. As a result the restoration of muscles to their normal physiological activity takes place more
rapidly and all tissues in the neighborhood are benefited by the increased activity produced by the muscle movements in the circulation of blood and lymph. Acting as an external stimulus to physiological circulatory changes, muscle action not only mechanically assists in prevention of blood and lymph stasis but also lessens the formation of adhesions perhaps
the most frequent cause of long-standing disability after even minor 13 injuries. (Smart. ) The main function of every striated muscle 2. In Denervated Muscles. is to contract in response to voluntary impulses. A muscle with an injured nerve does not contract voluntarily or reflexly and, being unable to perform its natural function of contraction, tends to revert to non-contractile connective tissue type. Since paralyzed muscles are unable to do any active work, it seems self-evident to many clinicians that a method which enables muscles to maintain part of their contractility and their nutrition is a desirable one. Electrical stimulation is the only known means for this purpose and its value is being attested by both clinical and experimental evidence. The earliest experimental work to prove the importance of electric stimulation in maintaining the nutrition of a muscle deprived of its nervous influence was performed over a hundred years ago, in 1841, by Reid, lecturer on physiology at the University of Edinburgh. The original object of his investigation was to settle the controversy over whether the property of muscle contractility is inherent in the muscle itself or is derived from the nervous system. In these experiments, the spinal nerves were cut across on four frogs, and the muscles of one of the paralyzed limbs were daily exercised by a weak galvanic battery, while the muscles of the other limb were allowed to remain quiescent. This was continued for two months, and at the end of that time the muscles of the exercised limb retained their original size and firmness and contracted vigorously, but those of the quiescent limb had shrunk to at least one-half of their former bulk and presented a marked contrast with those of the
exercised limb. Subsequent animal experiments have proved that paralysis caused by cutting symmetrical nerve trunks will disappear quicker on 1 the extremity treated by electricity than on the non-treated one (Bordier ).
Clinical experience in the treatment of large
:
number
of cases of periph-
eral paralysis has amply established the value of electric tion. Pollock 11 states serves to conserve
muscle stimula-
"Electrotherapy vitality, prevent complete atonia, and increase the contractility of paralyzed muscles."
175
Souttar and Twining 14 state: "Were we limited in the treatment of peripheral nerve injuries to one method of treatment and had nothing but the muscle to consider we should ourselves prefer electrical stimulation to all other methods." On the other hand, some orthopedic men doubt any value of electrical muscle stimulation in paralysis and strongly voice their conviction that voluntary muscle exercise is the most desirable form of activity and no other form of exercise can have the same physiological value. Experimental evidence is being cited that electrical stimulation cannot retard atrophy and degeneration of denervated muscle and that the degree of regeneration of the peripheral nerve is not influenced by 2 Tower 15 maintains that because the physical measures (Chor et a/. ). of denervated muscles is due to a continuous fibrillation, leading atrophy to exhaustion of the muscle, electric stimulation does not appear rational.
10 20 30 PERCENT OF CONTROL
FIG. 127. A graph showing average values for the effects of electrical stimulation on the rate of muscle atrophy. The stimuli were of different intensities (expressed in milliamperes) and applied for three minutes daily for fourteen days. The black bars represent the control expressed as 100 per cent. The control values were from non-stimulated denervated contralateral muscles. (Hines, Thomson and Lazard, courtesy of Arch. Phys.
Ther.)
tions of
Very recent experimental work has corroborated the classical observaReid and added new evidence as to the value of electrical muscle
4 Fischer, experimenting with electrical treatment starting at various times after denervation, demonstrated that the best results are obtained with a treatment starting immediately after denervation, and that the strength and the duration of the electrical currents must be adapted to
exercise.
the changing excitability of the atrophying muscle. It is postulated that the electrical treatment causes mainly a training effect in the denervated muscle, similar to that in normal muscle, which only increases the size of the fibers and their metabolic capacity. In surveying the work done so far the same author states: "Preference of weak and ineffective stimulation
for therapeutic use is astonishing." Gutmann and Guttmann 6 have demonstrated that electric stimulation accelerates the return of the muscle to
initial volume after reinnervation and possibly prevents atrophy; the muscles treated with interrupted galvanism showed better excitability
its
176
than those untreated. contractility as well as stronger reflex action, 9 Liebesny proved that such stimulation can produce response even in a 8 Finally, Hines concluded that electrical completely fatigued muscle. stimulation to the point of overstretching and even local fatigue does not appear to be detrimental to any phase of neuromuscular regeneration; but on the contrary, it delays atrophy and enhances recovery, if the stimulation is of sufficient intensity to induce strong contractions (Fig. 127). On the basis of extended clinical use and of the enumerated experimental evidence it would appear that the case still stands for the judicious employment of electric stimulation in paralysis, alongside with other indicated measures such as heat, suitable support, and the earliest possible
and
use of voluntary exercise.

in paralysis see
For further discussion of
electrical stimulation
Chapters
XVII and XVIII.
CLINICAL APPLICATION OF
1.
LOW-FREQUENCY CURRENTS
Simple Muscle Weakness. In the treatment of the various injuries trauma graduated muscular contraction is said to be the greatest advance in physical therapy since the introduction of massage and can be used to the exclusion of massage. (Sherman. 12 ) Its use is indicated in injuries to the soft parts, i. e., muscle and ligament strains, sprains and bruises, both acute and chronic hematoma; adhesions of muscles which frequently follow the operative treatment of fractures, myositis, lumbago, torticollis, disuse atrophy, atony of the abdominal muscles after childbirth, low back trauma, acute and chronic synovitis, periarticular adhesions,
incident to
synovial adhesions, wasting following dislocations and fractures, fibrous ankylosis, and for restoration of muscle strength following prolonged or chronic illness. The object of the treatment is to restore the tone to injured muscles, to prevent inter- and intramuscular adhesions, to keep the ten-
dons and other parts moving so that they do not become adherent to contiguous structures, and above all generally to increase the blood supply
to the injured tissues and to stimulate the rate of repair moting absorption of waste products.
by rapidly pro-
The author's experience in the treatment of muscular weakness in traumatic conditions and of atrophy following disuse largely corroborates the claims of Smart and Sherman. In atrophy of the quadriceps following prolonged immobilization after fractures of the thigh or patella, in weakness of the deltoid and of other muscles following injuries, the systematic stimulation of muscles speeds up the restoration of muscle power and gives patients a feeling of increasing strength and comfort. For details
Chapter XXIX. In atonic conditions of the abdominal wall, following operations, childbirth or associated with constipation, painless, rhythmic contractions
see
applied systematically have proven useful in restoring the tone and contractility of muscles and the capacity for regular bowel action. For further
details see
Chapter XXV. In functional paralysis resulting from traumatic neurosis, hysteria or neurasthenia electric stimulation is valuable as a stimulative treatment. (Chapter XVII.) 2. Paralysis Following Nerve For Injuries or Anterior Poliomyelitis. the reasons already stated electrical muscle exercise is of the greatest
CLINICAL APPLICATION OF LOW-FREQUENCY CURRENTS
177
value in maintaining the functional properties of muscles in these conditions until normal nerve response returns. For further details see Chapters
XXVII and XXVIII.

Miscellaneous Indications. In the treatment of causalgia, the pain amputation stumps of nerves, the Leduc current has been successfully employed. Reports on this treatment during the First World War state that it relieved painful sensations for hours with such certainty that it was even used as a diagnostic evidence of the real character of the lesion. For the improvement of the muscle tone in cardiovascular disorders and in peripheral vasomotor disturbances low-frequency stimulation by the sinusoidal current may be employed through the medium of full or
3.
in
partial hydroelectric baths. (See Chapter VIII.) Electrical muscle exercise is being employed
for weight reduction Faradic stimulation has been recommended for resuscita(Chapter XXV). tion in asphyxia of the newborn. The most recent application of low-frequency currents is "electric shock therapy;" the employment of an alternating current to the brain once or repeatedly for inducing convulsions in the treatment of mental disorders. It has been shown in ChapVI that in order to produce a contraction, a current must have a certain minimal strength and there must be a certain minimal duration below
ter
For details see Chapter XXVII. Choice of Current for Muscle Stimulation.
which a current of minimal strength will not produce a contraction. If the minimal duration is reduced, no contraction will result unless the strength of the current is increased. The chronaxie is the minimal effective duration time over which a strength of current previously determined as the threshold of intensity must be applied to secure a maximal response.
Besides the factors of the exciting agent, the electric current, the quickness of the excitability of the particular nerve or muscle treated must also be taken into consideration. This implies that in order to get an
effective response the form and strength of stimulus employed adapted to the type and condition of muscle to be influenced.
must be
The chronaxie of a healthy nerve has been found to be about y^W second, that of a degenerated muscle about -$ second and involuntary muscle fiber may require a stimulus lasting for one second or more. As the quickness of excitability varies so much, it is evident that the duration of the
stimuli
employed must similarly be varied.
It
would be
useless to apply
a f aradic stimulus with its time duration of KÔO second to excite a paralyzed muscle with a chronaxie of -$ second, for no contraction could result. On the other hand, the quick chronaxie of a healthy, neuromuscular mechanism requires a very rapid make and break to secure the maximum effect. Grodins et al. b recently pointed out that it is unfortunate that the terms "galvanic" and "faradic" have become so deeply ingrained in the clinical and physiological literature. Actually, from a physiological viewthere is no sharp line of demarcation between them. They state that point the ideal stimulating current for normal muscle would consist of a series of pulses of instantaneous rise which gradually increase in intensity from threshold to maximal and in frequency from zero to 100 per second. For denervated muscle, the ideal current would be of similar form, but the individual pulses would have to be of longer duration and of lower fre-
quency and perhaps of more gradual

12
rise.
From
this viewpoint "galvanic"
178
current simply represents a "faradic" current of very low frequency. 10 Osborne and Holmquest state that the theoretical current best suited is the surging for stimulation of skeletal muscles with intact nerve supply with alternate polarity. The interruptions are interrupted direct current from 40 to 120 per second and the frequency of surge ranges from 5 to 100 is followed by a period during which no per minute. Each current surge
C YCL
OF C O/V TR. fiCTlQH
CYCLE OF CONTRACTION
CRTHODftL
CYCLE
(From Osborne and 'Theoretical current for muscle with intact nerve supply. Holmquest's Technic of Electrotherapy; courtesy of Charles C Thomas.)
FIG. 128.
TIME
CYCLEOF- CONTRACTION
YCL
OF CONTRRC TION Cf)THODf=)L
OWE
FIG. 129.
EL.E.CTR/C
CYCLE
Holm-
Theoretical current for muscle without nerve supply. (From Osborne and quest's Technic of Electrotherapy; courtesy of Charles C Thomas.)
current flows (rest period). The ratio of the time of the surge of current to the time no current is flowing is about 2 to 1. For the stimulation best suited for a muscle without nerve supply, the same authors suggest the surging uninterrupted direct current with alternate polarity. Surge frequency, 10 to 20 per minute and each surge of current is followed by a rest period.. The ratio of the time of the surge of current to the time no current is flowing is about 2 to 1. (Figs. 128 and 129.) There is no such
CLINICAL APPLICATION OF LOW-FREQUENCY CURRENTS
179
ideally constructed apparatus available in actual practice as yet, hence for the present one must use the clinically established methods of electrical
muscle exercise.
Weak muscles with no organic nerve involvement respond best to a succession of very short stimuli, at a rate of 50 to 100 per second, sufficiently surged and spaced so as to allow gradual contraction and an intervening
rest (relaxation). This is known as graduated muscular stimulation. For this purpose surged forms of the faradic type of current and the interrupted
and modulated forms of alternating current serve best. In muscle with spastic atrophy, such as following hemiplegia, the same type of stimulation as in simple atrophy of disuse can be applied, and a quick normal stimulus brings on the best response. There is a difference of opinion in the literature as to whether it is better to treat the spastic muscles themselves, teaching them how to relax following a contractile impulse or whether it is better to treat the opponents of the spastic muscles to minimize contracture and the effects of overstretching of the normal muscles. Further details as to technique will be found under Hemiplegia. The treatment of spastic muscles by electrical stimulation is much less
satisfactory than that of flaccid types of paralysis. It should be considered at best only as an adjunct to muscle training and re-education.
respond only to a very slow rate 10 to 20 per minute and their contraction is sluggish and wormlike compared to the brisk contraction of normal muscles. A slow, smooth stimulus such as the slow (galvanic) sinusoidal is the current of choice. It produces a stimulus of long duration and slowly surging quality to which the paralyzed muscles respond gently and painlessly. The use of the interrupted galvanic current for the eliciting of contractions gave rise to considerable controversy in the past. As long as we believe that it is beneficial to cause contractions in degenerated muscles, interrupted galvanism will supply a need in cases that do not respond to the slow sinusoidal current. It causes a response on account of its greater
the stage of flaccid paralysis
Muscles in
of stimulation
strength and longer flow. The Leduc Current is a galSpecial Forms of Low-frequency Currents. vanic current of 1 to 2 milliamperes strength and of a potential of 10 to 25 volts interrupted at a rate of 100 times a second, so that one-tenth of a period of current flow (make) is followed by nine-tenths of rest (break). Leduc claims that in animals he has produced experimentally single contractions, tetanus, local anesthesias, general anesthesia, coma, paralysis of the heart and respiration and, finally, death. Experimenting on himself
he produced general anesthesia and electric sleep. The Leduc current may be explained by the exhaustion of the sensory receptors by over stimulation. The local anesthesia seems to be identical with that obtained by percussing the skin rapidly and repeatedly. Galvano-Faradization. The combined use of the galvanic and faradic current is made possible by the use of a special switch incorporated in most of the older galvanic wall plates and known as the DeWatteville switch. At the same time, both currents can be surged by an evenly
and
his assistants,
action of the
alternating resistance. Condenser Discharges by Progressive Currents, the modified form of condenser discharges described under Electrodiagnosis, have been utilized by several clinicians, especially Turrell, 16 for selective stimulation of fully or
180
that the condenser method partly degenerated muscles. Turrell claimed of the opposing normal muscles and effectively suppresses the excitation stimulates the less excitable paralyzed ones. The technique is based on the
difference in the quickness of excitability
between normal and abnormal
PAUSE
INTERRUPTED CURRENT (LEDUC)
PAUSE
INTERRUPTED INCREASING PROGRESSIVE CURRENT

FIG. 130.
Graphs
of interrupted
and progressive current.
A smooth galvanic current is used, which is a metronome and regulated by a water resistance, with interrupted by condensers in parallel, varying from a capacity of 2 microfarads to 30 microfarads. Owing to its gradual onset, the stimulation is almost painless.
neuromuscular mechanism.
FIG. 131. Comparative diagram of results of muscle stimulation of paralyzed muscle (A) by interrupted galvanic current; (JB) by progressive Leduc current. After five minutes' stimulation with 6 milliamperes of interrupted galvanic muscle was completely fatigued, but with 4.6 milliamperes of progressive Leduc current vigorous contractions started again. (Dr. P. Liebesny.)
The apparatus
is
simple and inexpensive and Turrell reports equally good
results in flaccid stages of Bell's palsy and infantile paralysis. Liebesny 9 reported on the successful use of this method. He describes it as an inter-
rupted and progressive current (Leduc) and the results claimed call for further clinical corroboration when suitable apparatus will be more generally available.
GENERAL TECHNIQUE OF LOW-FREQUENCY STIMULATION

Electrical stimulation of muscles may be carried out technique: individual stimulation or group stimulation. bination of these two procedures is advisable.
'
by two forms of At times a com-
181
Individual Motor Point Stimulation. This technique consists of applying to each muscle a low-frequency current of just enough strength to bring about its stimulation.
The patient is placed in a comfortable position, where the parts to be treated are well supported and relaxed. These parts should be warmed up fairly large by the preliminary application of a heat lamp or hot towels. inches) moist pad dispersive electrode is placed upon a part (at least the sternum, the spine or of the body where there are no muscle bellies a remote part of the extremity under treatment. An active small moist
3x4
1 inch in diameter and preferably with an interrupting placed in good contact with the skin over the middle of the muscle belly. This part also known as the motor point is the area where the muscle normally responds to the minimum amount of current. It takes practice until the operator becomes an expert in locating quickly the best point of stimulation in each muscle.
pad electrode
key,
is
Fi<;.
1X2.
Stimulation of facial nerve
active electrode over motor pointelectrode under palm of hand.
dispersive
As muscle stimulation is, as a rule, done by a surging current, sudden Nevertheless the painful stimulation by the current is usually absent. amount of current flow should be kept down at first to the lowest possible
degree compatible with comfort. It must be remembered that with lowtension currents considerable amount of skin resistance has to be overcome and therefore an impulse which at first will not penetrate well enough to cause muscular response on being repeated at the same strength may after a few seconds act as a stimulus of sufficient strength. For this reason too rapid shifting of the active electrode must be avoided. Once a muscular contraction is produced, the operator must see to it that it is followed by sufficient relaxation, before the next impulse is started. With the double control of current strength and frequency there should be no difficulty in administering stimulation at the proper strength and spacing. The number of contractions to be elicited will depend entirely on the degree of weakness and type of response and may vary from one or two in a fully paralyzed muscle to ten in a case of simple weakness. The second contraction should be a little stronger than the first, the third still a little
182
more strong; subsequent contractions should be about the same strength, their spacing depending on the time it takes the muscle to relax fully
before the next stimulus is applied. No mechanically controlled rate of stimulation can be ever so efficient and pleasant as stimulation done with individual setting for each and every stimulus, such as is made possible
for instance
by the
its
core, hence
faradic types of apparatus controlled by an adjustable appropriate designation as "graduated muscle exercise."
states that a skilled operator can cause a group of muscles to contract at a rate of 90 contractions per minute and if carried out for thirty minutes, this will result in the group contracting 2700 times. Large groups of muscles such as the quadriceps are more able to withstand prolonged treatment without showing signs of fatigue than the interossei of the hands or feet or an isolated muscle such as the adductor longus or
Smart 13
sartorius.
In the average case of paralysis the method of unipolar stimulation preferable, with a large dispersive electrode over the cervical or lumbar spine or at any place central to the lesion and a small active electrode over the individual muscles. In all these cases the normal motor point is displaced distally (toward the tendon) and to save time in subsequent treatments it is advisable to mark with indelible pencil the most effective point of stimulation for each muscle. In the early stage of fully paralyzed muscles one must be well aware of the danger of overexercising muscle by electricity. Not more than a flicker of the tendon is necessary to prove a successful contraction in a paralyzed muscle. This flicker may not even be visible; it is enough when it is palpable to the trained finger at the insertion of the tendon. It is interesting to note, that at first it may be necessary to use a larger amount of current to cause contractions but that after the first one or two contractions we can elicit response with markedly less current. One can aptly express it by stating that the muscle needs at first and then responds more briskly. From 3 to 10 con"waking up" tractions of each muscle are ample at the start, with an increase to the maximum of 30 to 40 effected gradually. A careful operator will very quickly notice that a larger amount of current is needed in case of a muscle that has been overtired previously. Preceding and during electrical treatment the affected extremity should be placed so that the paralyzed muscles are relaxed and not kept on a stretch by their healthy antagonists and the maximum treatment time to an individual muscle should be from two to three minutes and about fifteen minutes to an entire extremity. The signs of overstimulation in strength or frequency in any muscle are: a slower rate of contraction and relaxation, a well-marked tremor during contraction; several hours after treatment there may be a feeling of stiffness and pain instead of the usual prolonged feeling of comfort. At the first sign of fatigue stimulation should be shifted to an adjacent muscle or group of muscles. A special form of individual muscle stimulation in extremely weak muscle consists of bipolar stimulation by two equal-sized active electrodes placed at the two ends of a muscle belly. (Fig. 77.) This method is only applied when the muscle is so extremely weak that the current strength necessary for a palpable response causes very strong contraction in the neighboring muscles and this often makes it impossible to observe the
is
response in the affected muscle.
With the
bipolar technique the density
183
of current is located just where it is most needed and within a certain limit this current strength will not exert stimulation of neighboring groups. Individual muscle stimulation is the method of choice when only a
few muscles of an extremity are affected; if an entire extremity or a large group of muscles need treatment, it is permissible to use the group treatment. Group Stimulation of Muscles. This technique consists of applying two electrodes, as a rule of equal size to the opposite ends of an extremity; for instance, for the lower extremity one electrode may be applied to the sole of the foot, the other under the buttocks or under the sole of the other foot; for the upper extremity, the palm of the hand may be placed on one electrode, the other is applied in the interscapular space. A convenient
way of group stimulation is by the galvanic-bath method (Chapter VIII). One may place the two hands separately, or one hand and one foot or
each foot separately, in a basin of water connected to the source of a suitable low-frequency current. The placing of the patient, gradual starting of the current and the necessity for watching of alternate contraction and relaxation is the same as in individual muscle stimulation. In the majority of cases, when the condition of muscles along an extremity is about the same, such as in weakness due to disuse, the surging current passing along the extremity results in a fairly even response of all muscle groups. It is almost uncanny to observe, how the different groups contract and relax alternately, once on the flexor and next on the extensor surface. This is due to the fact that the stronger stimulus always originates first from the negative pole and as in alternating-current stimulation first one end and then the other end of the extremity becomes negative, the most effective stimulus travels alternately from the two electrodes on the opposite ends of the extremity. With muscles in fairly good condition, group stimulation of an extremity may be kept up from five to ten minutes, and repeated every day or every other day according to the prevailing condition. Stimulation by low-frequency currents may be preceded by or combined with longitudinal diathermy. In a limb which has been fully warmed up every muscle responds better and all local resorptive processes are accelerated. In aftertreatment of fractures, in adhesions in the extremities following operations for infection or abdominal adhesions following laparotomy, combined
diathermy and low-frequency stimulation is quite effective. (Page 243.) Dangers of Application. It was shown in animal experiments that cardiac fibrillation can be brought about by alternating low-frequency currents. In electrical shock cardiac fibrillation is often thought to be the main cause of death. Patients with myocardial weakness seem to be especially sensitive to low-frequency currents, while they can stand a high-frequency current (diathermy) through the heart with apparent benefit. Some unfortunate experiences on record should make it an invariable rule, never to apply low-frequency currents through the heart or with a technique which brings a considerable amount of current through the
cardiac area.
The
out.
possibility of overexercising very weak muscles has been pointed Electrical muscle stimulation should never be employed to the
neglect of such well indicated methods as rest and proper splinting in early stages of paralysis and muscle re-education and voluntary exercise
184
in the stage of
all
its
considered at muscle and nerve regeneration. It should be measures and times an adjunct to the other well established therapeutic entrusted only to technicians administration in institutional work be
familiar with muscle physiology
and pathology and
fully instructed in
proper technique.
STATIC ELECTRICITY
the oldest form of electricity used in History.-Static electricity is electrical machine by treatment After the discovery of the first frictional in in 1670, and the Leyden jar by von Kleist, Guericke, of Magdeburg, and muscular used for the treatment of disorders of the nervous 1745 it was and Abbe Nollet. Charcot used static sparks system by Jallabert, Priest nervous conditions. In America at his clinic in Paris for the treatment of the subject by introducing, in addition to this J Morton advanced The Morton method, the use of the sustained pulsatory discharge. the late William wave and other modalities were further developed by
Benham Snow,
of
New York.
FIG. 133.
Static apparatus of the Holtz type.
separate "charger"
is
contained in the
compartment on the
right side.
use of static electricity reached a peak at the beginning of the present century when the high voltage energy of static machines served also for activating the first roentgen-ray tubes and for the first d'Arsonval high-frequency circuits. The general design of static machines has not changed during the past thirty years. Because of the bulkiness of its apparatus and of the many newer forms of efficient electromedical currents, static electricity has fallen generally into disuse; therefore it will be presented in this volume very briefly as compared to previous editions. Physics. From a medicophysical viewpoint, static electricity represents a unique current. It is a unidirectional flow of electrons at the highest
The
STATIC ELECTRICITY
voltage:
185
several thousand volts, but the lowest amperage: less than a milliampere. Static electricity is primarily produced by friction and the
small charge of electrons is increased to a very high voltage self induction (influence) in a well insulated circuit.
by repeated
FIG. 134.
Graph
of pulsatory discharge of static
wave
current.
The
static
machine consists of 6 to 12 pairs of large circular-glass plates

shaft
and held in a large glass case. The outside current In the Holtz-Wimshurst type of machine first an initial electric charge is furnished by two smaller glass plates rotating against small tinsel brushes; the rotation of the large plates then "builds up" this charge so high that it sparks across two metal balls in front of the glass case. This unidirectional charge is then led off from either the positive or the negative terminal of the machine to the patient placed on an insulating platform, while the other terminal is "grounded."
mounted on a
rotates the shaft.
FIG. 135.
Diagram
of
"hook-up"
for administering indirect static sparks.
of
Physicophysiological Effects. The spark discharge across the terminals the static machine represents a high-tension condenser discharge.
(Fig. 134.) Such a pulsatory discharge at low frequency furnishes a repeated make-and-break of a unidirectional surging current; when applied to contractile tissues, it results in a response of nerves and muscles as caused by low-frequency currents; hence the presentation of static electricity as an appendix to this chapter. In the static wave current the gradual opening of the spark gap brings about a series of rapid pulsatory discharges, which are conducted by a
186
cord to a soft metal plate placed over the skin of the area to be treated. As a result of the comfortably regulated impulses, visible muscle contractions occur which help to improve circulation, reduce swelling and aid to overcome muscle spasm in acute traumatic and congestive conditions, such as myositis, sprains and selected forms of chronic arthritis. Static sparks consist of a sudden release of the static charge by approaching the patient with a grounded ball electrode; they also serve for decongestion and also for counterirritation in chronic inflammatory conditions. Other forms of static treatments are the "static charge" or bath and the "static head breeze" in which the static charge is applied to the patient from the widely separated gap without any spark discharge; they may serve by "electrification" for treatment of nervous headache, and insomnia and other nervous states. In the "static brush discharge" a fan-like discharge is applied to acutely painful areas for gentle counterirritation and sedation. In competent hands the static apparatus is still a very useful
and
versatile piece of electrical
equipment.
REFERENCES
1.
2.
BORDIER, H.: Bull, de 1'Acad. de med., February, 1917. CHOR, H., CLEVELAND, D., DAVENPORT, H. A., DOLKART, R. E., and BEARD, GERTRUDE: Atrophy and Regeneration of the Gastrocnemius-Soleus Muscles,
Physiother. Rev., 19, 340, 1939. P. Essentials of Medical Electricity, London, Henry Kimpton, p. 29, 1933. Effect of Faradic and Galvanic Stimulation on Course of Atrophy in FISCHER, E. Denervated Skeletal Muscles, Am. Jour. Physiol., 127, 605, 1939. GRODINS, F. S.: Present Status of Electrical Stimulation of Denervated Muscle, Arch. Phys. Ther., 23, 12, 1942. GUTMANN, ERNEST, and GUTTMANN, LUDWIG: Effect of Electrotherapy on Denervated Muscles in Rabbits, Lancet, 1, 169, 1942. HARTMAN, F. A., and BLATZ, E. W.: Studies in the Regeneration of Denervated Mammalian Muscles: III. Effects of Massage and Electrical Treatment, Jour. Physiol., 53, 290, 1920.
3
4.
CUMBERBATCH, ELKIN
:
5.
6.
7.
8.
9.
HINES, H. M., THOMSON, J. D., and LAZARE, B.: Physiological Basis for Treatment of Paralyzed Muscle, Arch. Phys. Ther., 24, 69, 1943. LIEBESNY, PAUL: Electrotherapy in Flaccid Paralysis, Arch. Phys. Ther., 23, 1,
1942.
10.
11.
12.
Technic of Electrotherapy and Its Physical OSBORNE, S. L., and HOLMQUEST, J. J. and Physiological Basis, Springfield and Baltimore, Charles C Thomas, 1944. POLLOCK, LEWIS: Principle and Practice of Physical Therapeutics, Hagerstown, Md., W. E. Prior & Co., vol. 2, Chap. 7, 1933. SHERMAN, W. O'NEIL: Nelson's Loose Leaf Surgery, New York, Thomas Nelson
:
&
Sons.
13.
14.
SMART, MORTON: The Rationale and Technique of Treatment by Graduated Muscular Contractions, The British Jour. Phys. Med., 8, 88, 1933. SOUTTAR and TWINING: Injuries of the Peripheral Nerves, New York, William
Wood &
Study
Co., p. 25, 1920.
15.
TOWER,
S. S.:
of
.Trophic Control of Non-nervous Tissues by Nervous Systems: Muscle and Bone Innervation From Isolated and Quiescent Region of
Spinal Cord, J.
16.
TURRELL, W. T.:
WEISS,
J.:
tion to Theh- Therapeutic Effect, Proc.

17.
of Interrupted Currents in RelaRoy. Soc. Med.,^0, 13, 1926. The Flasher Sinusoidal Machine, Arch. Phys. Ther., 16, 2, 1935.
Comp. Neurol., 67, 241,. 1937. The Physico-chemical Action
CHAPTER X
General
Considerations. Experimental Demonstrations. Historical. Terminology. High-frequency Oscillations and Radio Waves. Physics of High-frequency AppaBasic Principles. Vacuum Tube Apparatus. Controls of Vacuum Tube ratus. Combination Apparatus. Apparatus. Spark-gap Apparatus. The Oudin Coil. Requirements for Acceptance of Diathermy Apparatus. Protection Against Radio Interference. High-frequency Treatment Methods.
General Considerations. A high-frequency current may be defined as an alternating current consisting of oscillations of a million or more per
second.
When
applied to the
human
tissues, the
extremely short impulse
of each oscillation can barely cause any ionic movement and if it should this would be nullified by an impulse coming from the opposite direction.
When an
electric current flows through a conductor, the free electrons in the conductor are accelerated and acquire a "drift velocity" which is superimposed upon their irregular thermal motions. Through collision with the atoms in the conductor these electrons lose their kinetic energy and create thermal energy. Because of the absence of electrochemical reactions, there is no stimulation of sensory and motor nerves, in contrast to other
forms of
electricity.
There are two methods of high-frequency

present time.
tissue heating in use at the
as conventional or long-wave diathermy employs oscillations of a frequency of about a million per second and is routinely applied through electrodes placed in direct contact with
The
older
method known
the skin. The newer method of short-wave diathermy employs oscillations from ten to a hundred million per second and is routinely applied through a spacing of air, glass or rubber, but may also be applied by direct contact. It is the spacing property of electrodes with its attendant advantages which is the outstanding feature of short-wave diathermy. Historical. The fundamental observation that the discharges from Leyden jar condensers were of oscillating character was made by the American physicist, Joseph Henry in 1842 and further elaborated in 1853 by William Thomson of England. Thomson concluded that the frequency of alternations might be thousands or even millions per second. In 1885 Hertz devised the means of producing and detecting electrical oscillations at a distance, thus proving the correctness of Maxwell's theory concerning
the equal speed of propagation of all electromagnetic forces. Hertz' apparatus enabled Marconi to construct his first wireless sending set in 1896. Arsene d' Arson val of Paris in 1892 was first to study the effect of high-frequency oscillations on the human body. In the United States Nicola Tesla in 1891 had observed the heating action of high-frequency
currents.
D'Arsonval reported the initial decrease and later the total absence of neuromuscular response when the frequency reached above 10,000 per second. He also observed the heat production in the body, but declared that it was an unpleasant accompanying sensation. Zeynek, of Germany, collaborating with the Austrians, Preyss and Bernd, started in 1904, experiments on animals and first used the high(187)
188
frequency current to treat gonorrheal arthritis in a man. They worked with an apparatus producing undamped oscillations through an electric arc, constructed by Poulsen, a Danish engineer, and called the method in 1907, "Thermopenetration." Nagelschmidt, in Berlin, also made experiments independently, named his method "transthermy," later changing it to "diathermy." American physicians took an early interest in diathermy, With the especially the late Frederic deKraft, and Edward C. Titus. increased interest in physical therapy after the first World War, the use of high-frequency spark-gap apparatus came to a high peak in the United
States.
Apparatus producing higher frequencies by oscillating tubes was conby the French Gosset in 1924 and by the German Stiebock in 1925. The first animal experiments with very high-frequency oscillations were begun in 1924 by Schereschewsky of the United States Public Health Service. Schliephake of Germany in collaboration with the physicists Esau and Patzold, in 1926 began biological work with short-wave oscillations up to 100 millions. Almost simultaneously Whitney, research director of the General Electric Company discovered that powerful tubes used for broadcasting caused general body heating and with the cooperation of Carpenter and Page inaugurated the use of short-wave diathermy for
structed
electropyrexia. After a large amount of experimental and clinical work, it appears well established that short-wave diathermy does not essentially
differ in its clinical effects
Hence the
from conventional or long-wave diathermy. joint presentation of both forms of diathermy.
WAVELENGTH -ANGSTROMS
WAVELENGTH in METERS FREQUENCY in

THERAPEUTIC
*o 3000
*5Ji
1500 515
300
I
[5,000.0001
1000
150 Cycles]
V
Pendrrfr^l Non-Pen.tr.rtm.
'
UNUSED
V
LonjWve
t
SKortWave
(5-25M.)
LOW
VOLTAtC
INFRA RED
(COOO
- 110.
OOO A"
DIATHERMY
)
CURRENTS
range of the
(^00-300
M.)
FIG. 136.
Wave
lengths and
wave frequencies
in the infrared-high-frequency
electromagnetic spectrum.
High-frequency Oscillations and Radiowaves. Electromagnetic waves (Chapter XV) all travel at the speed of light, at 186,000 miles or 300,000 kilometers per second in vacuum. The frequency of electromagnetic oscillations sent out by a spark-gap or oscillator tube generator is determined
characteristics of the generating circuit. The generally accepted view of the propagation of electromagnetic oscillations is that they proceed in the form of waves and since all these waves travel at the same speed it is evident that the wave lengths of those of higher frequency
by the physical
HIGH-FREQUENCY OSCILLATIONS AND RADIOWAVES
189
In other words the oscillations are shorter, as indicated in Figure 137. higher the frequency of a certain form of electromagnetic energy, the shorter its wave-length. The unqualified use of the term "short-wave" to designate oscillations of higher frequency in therapy is confusing. There are relatively long and relatively short waves in every part of the electromagnetic spectrum, either in descending or ascending range in the infrared, in the ultraviolet, in the roentgen-ray part hence it would be incorrect to describe a form of electromagnetic energy as simply short wanes.
300,000,000 METERS
FIG. 137. Graphic comparison of wave length and wave frequency. The base line, A, is a time unit during which electromagnetic waves, and C, travel with the same speed (300 million meters per second), in order to cover the same distance in the same unit of time; the oscillation frequency of the longer waves, B, is less than that of the shorter waves, C. In other words, the shorter the wave length the greater is the frequency of oscillations.
The term "short-wave diathermy" has been accepted as the most comprehensive term for the newer form of high-frequency energy, while the logical term for the older method of contact plate treatment with 300 meter waves is "long-wave diathermy." Some of the authors still describe it as "conventional" diathermy, disregarding the fact that the newer generation of students is learning chiefly to use short-wave diathermy and hence will regard it as the "conventional" method of the present day. For the differentiation of various electromagnetic waves the naming of their frequency serves to a large extent in radio broadcasting. In physical therapy the established custom is to describe these forms of energy by their wave length; this avoids the use of long figures. The relation of wave length and frequency in the most frequently
employed therapeutic electromagnetic
TABLE
I
oscillations
is
as follows:
(CYCLES PER SECOND)
22.
WAVE LENGTH (METERS) AND WAVE FREQUENCY

Frequency
Wave
length
Term
Long-wave diathermy
Short-wave diathermy Short-wave diathermy Microwaves
1 megacycle) million ( 10 millions ( 10 megacycles) 100 millions (100 megacycles) 300 millions (300 megacycles)
300 meters 30 meters 3 meters 1 meter
190
The wave length is obtained through a simple equation by dividing the distance covered in one second by the number of oscillations occurring in one second.
Wave
length
Speed of light
p.
s.
Num ber^fîllations pT7.
The
is the metric system generally accepted standard of measurement and hence all wave lengths are calculated in meters. Wave length can be measured by especially constructed wave meters. If by such a wave
meter the length of a wave is determined at 10 meters, the number of oscillations per second can be calculated according to the formula by
dividing the speed of light
by the number
-
of meters.
30,000,000 oscillations
The electromagnetic waves of short-wave diathermy are generated by the same physical means as those of the short-wave broadcast band and are as a matter of fact identical with them. However, for therapeutic purposes the oscillations produced are not transferred to an "open circuit" through the aerial and ground connections, but to a "closed" or treatment circuit which can be considered as two aerials, between which the part to be treated is placed. Actually the treatment plates are these two aerials; when paired in this manner they form a condenser. The part to be treated
introduced into the electric or condenser field between the plates; this conveys regular impulses to the particles of the substance. When these impulses enter the body tissues, they become a high-frequency current just as the oscillations of conventional or long-wave diathermy.
is
field
PHYSICS OF HIGH-FREQUENCY APPARATUS

In order to produce oscillations of sufficiently high and power to heat the human tissues, two essential changes frequency have to be effected in the commercial alternating current which serves as the source of all high-frequency electricity: (1) the voltage must be increased; this is done by a step-up transformer; (2) the frequency must be increased; this is done by an "oscillating circuit" as described in Chapter III. Such a circuit consists of condenser, inductance and a spark gap in the spark gap apparatus and of condenser, inductance and oscillating tube
Basic Principles.
in the
circuit, in a tube as well as in that any desired wave length may be obtained by suitable variation of the physical characteristics of the circuit. The frequency is determined by the capacity of the circuit, depending on the surface area and number of the plates of the condenser and the inductance, depending on the diameter and number of turns in the coil. Decrease of capacity or self-induction or both together result in increasing the frequency or decreasing the wave length. A given combination of capacity and inductance produces a definite wave length, for instance, 12 meters; if an alternative
vacuum tube type apparatus. The important property of an oscillator

is
a spark-gap apparatus,
wave length of 24 meters is desired, than a separate circuit of different capacity and inductance must be incorporated in the apparatus, and this circuit must be switched on, in place of the other.
VACUUM-TUBE APPARATUS
There are
at shorter
tically efficient oscillations of
191
definite physical limitations to the production of therapeuvery short-wave length, due to the fact that
wave lengths the connections between the parts of the oscillating such as the cables also take up some part of the oscillating energy. circuit, The lower limit for the generation of short waves of an output of more than a few watts is at present between 3 and 4 meters.
FIG. 138. Showing a typical oscillator circuit consisting of an inductance (coil, L) and This circuit will produce an oscillating current of a given frequency capacity (condenser, C) depending on the electrical values of L and C. When the condenser is charged by a source of current and allowed to discharge, such a circuit will be resonant to a given frequency. In order to produce different frequencies the value of L or C, or both, must be changed.
.
three principal divisions of the vacuum-tube apparatus are: (1) the (2) the oscillator, (3) the output or patient's circuit. The details of these circuits and the frequencies produced vary in different
The
power supply,
present one of the simplest and most typical construction and the operation of the rectifier and oscillator tubes employed in these circuits have been already described in
types of apparatus.
We will
constructions.
III.
The
Chapter
Grid
Plate
^/Variable
condenser
Electrodes
High voltage on plate
Inductance
FIG. 139.
Schematic diagram of typical oscillator circuit with vacuum tube. (Hemingway, courtesy of Archives of Physical Therapy.)
Power Supply Circuit. The function of this circuit is to provide a source of low voltage alternating current to light the filaments of the oscillator tubes, and a source of high-voltage direct current for the plates of these tubes. The power supply circuit consists of several power transformers
(with step-up and step-down secondary coil windings to provide the required voltages), a pair of rectifier tubes, and, sometimes, a filtering
circuit.
primary windings of the transformers. The high-voltage transformer usually has a choke coil in its primary circuit
line voltage is fed to the
The
192
which controls the output of this device and thereby controls the output lowof the machine. Separate step-down secondary windings provide
of the rectifier and oscilvoltage alternating current to light the filaments lator tubes. The usual type of mercury vapor rectifiers require 2| volts to light their filaments. The average oscillator tubes require 10 volts of filament voltage. A regulating device and meter may be provided to keep the oscillator filament voltage constant, thereby prolonging the life of the
tubes.
Regulator circuit
Short wave circuit of 6 to 8 meters
prevents overheating of applicators
Short wave circuit of approx. 20 meters
Tuning condenser
Wave change
selects
relae
proper wavs length when applicatory are plugged in
Surgical circuit for
minor electrosurgery
Voltage compensator
Automatic relay os
prevent overloading
of tubeg
Oscillator tubes
Power
circuit:
two*
rectifier tubes,
transformers and] connections [
Supply current
connection
FIG. 140. Interior view of short-wave apparatus, furnishing a 6 to 8 meter circuit for condenser field treatment (pads) and a 20 meter circuit for electromagnetic field (inductance coil) treatments. (Courtesy of the Liebel-Flarsheim Company.)
The high-voltage alternating current from the power transformer is fed to the plates of the 2 mercury- vapor rectifier tubes. Each tube passes current during that half of the alternating current cycle when its plate is
positively charged. With two tubes operating a pulsating unidirectional current of high voltage is allowed to pass. This current is rough but has definite polarity. Some machines provide an additional filtering circuit
filters
consisting of a smoothing choke coil and a large capacity condenser. This the rough unidirectional current to provide a smooth high-voltage direct current. Such a smooth current applied to the oscillator tubes
improves the frequency stability of the apparatus. The Oscillator Circuit. This produces the high-frequency oscillations. It consists of a grid circuit, a pair of oscillator tubes and a plate circuit* The grid circuit is a coil and condenser whose values of capacity and inductance have been fixed to determine the frequency desired from the machine. When this circuit is charged with electrical energy it provides a source of voltage at the grids of the oscillator tubes. One grid will be
charged positive when the other grid is negative and the charge is reversed during the next high-frequency cycle. Thus many million times a second the electrical charge at grids of the tubes changes (Fig. 141).
The
oscillator tubes
193
under the influence of the charge of the high-voltage
direct current supplied at their plates produce a high voltage very rapidly alternating (or high-frequency) current. The filaments provide an electron
path to the plates, over which the current can flow. The positively charged plates of both tubes tend to draw current over this path. But the grid of one of the tubes is negatively charged at any given moment and current
can flow through the plate circuit only from the other tube.
SWITCH
1
At the next
TRANSFORMERS POWER STEP STEP CONTROL
UP
CHOKE
Hx
MERCURY VAPOR RECTIFIER TUBES

5
6
FILTER
CHOKE 7
FILTER
CONDENSER 6 MILLIAMETER 9
RESISTOR
10
COIL
11
GRID COMDENSER
12
TRIODE VACUUM
TUBES
13
1*
PLATE CONDENSER
15
PLATE COIL
16
CHOKE 1T
OUTPUT
COIL 16
OUTPUT
VARIABLE TUNING
CONDENSER
BLOCKING-
19 BLOCKING
CONOCNSCR11
CONOCMSCRtO
PATIENT TERMINALS
21
FIG. 141.
Diagram
of 4-tube oscillator circuit.
half cycle this grid becomes positive, allowing current to flow through this tube. Thus a changing direction of current, first from the plate of one tube and then from the other, is set up in the plate circuit.
plate circuit, or tank circuit, is made up of capacity and inductance. frequency of operation is fixed at the same point as that of the grid circuit by the use of equivalent condenser and coil values. These two circuits being resonant to the same frequency, mutually energize each other
Its
The
13
194
of curto maintain oscillation at this frequency. The changing direction rent in the plate circuit sets up an electromagnetic field which cuts across to the grid circuit and sets up a small current in it. This current serves of the oscillator tubes and thereby maintain high-frequency charge the grids alternations in the plate circuit. This same electromagnetic field excites an auxiliary circuit by induction. This circuit, the output or patient's
circuit also
is
resonant.
FIG. 142. Two typical condensers used for tuning short-wave output. The right condenser varies capacity by rotary motion of the moving plates. by transverse linear motion of moving plates. The advantage of the latter the capacity diminishes spacing increases and this prevents spark-over from (Courtesy of the Peerless Laboratories, Inc.) increasing voltage.
Left condenser
varies capacity type is that as
the consequent
or both
The Patient's Circuit. This consists of inductance and capacity. Either may be variable in order to "tune" this circuit, but usually the The tuning device of most coil is fixed and the condenser is variable. short-wave diathermy machines is this variable condenser. It serves to bring the patient's circuit into resonance with the oscillator frequency, just as one resonates a radio set when he tunes in a station. When the condenser is finally tuned it allows the maximum transfer of inductive energy from the oscillator to the patient. As one slightly detunes the condenser less energy is extracted from the oscillator circuit. In transferring the energy from the generator or tank circuit to the
patient or secondary circuit, the frequency of the secondary circuit must be the same as that of the primary circuit; that is, the product of the capacity and the inductance must be equal in both circuits. If this requirement is fulfilled, the secondary circuit will be in resonance with the generator circuit, and the machine will deliver its maximum output. This
condition of resonance
fork,
is
analogous to the musical resonance of the tuning
which responds only if its own pitch is reached. The thickness of the objects to be treated in the patient's circuit, their dielectric constants, the distance of the electrodes (condensers) from the surface, and the size of the electrodes determine the capacity of the secondary circuit and necessitate careful "tuning" of this circuit with the generating circuit. A milliammeter is placed in short-wave apparatus usually in the plate circuit of the oscillator. It serves primarily as an indicator that electrical energy is passing. The removal of energy from the oscillator to the patient
195
causes a greater current drain which is noted by the rise in the meter. The meter will also indicate that at a certain position of the controls when the patient's circuit is 'tuned" to the main oscillator circuit there is a maximal flow of energy in the treatment field. But in contrast to the meter in long-wave apparatus it does not register the amount of energy passing through the patient.
'
Vacuum-tube apparatus produces oscillations of frequency from 10 to 100 millions per second. These oscillations are "undamped" and have a uniform amplitude in contrast to the damped oscillations of a spark-gap apparatus. When applied to the human tissues, both damped and un-
damped
silently
oscillations produce heat. Vacuum-tube apparatus operates and needs no adjustment, except the replacement of worn-out
tubes.
FIG. 143.
Graph
of
undamped, sustained high-frequency
current.
The tubes are the heart of the short-wave apparatus and on their proper function depends the efficient output of the apparatus. Tubes are not made by manufacturers of apparatus, but are received by them under a guarantee that they are free from electrical and mechanical defects. Well
made and
properly operated tubes have a normal life cycle from five hundred to one thousand hours and at the end of this period do not burn out as a rule, but gradually decrease in output. A defective tube will result
it will also cause overheating crack in the glass of a tube will result in the admission of air and destruction of the tube. Most American built short-wave diathermy equipment employs tubes whose filaments are "thoriated" or treated with thorium for improved electron emission. This improves the emission efficiency enormously and also adds to the useful life of tubes. It is, however, of paramount importance that filaments be maintained at a constant temperature (i. e., voltage) or they will quickly become paralyzed and lose all output. Most well constructed apparatus contain a device to determine at any time whether the filament voltage is proper and also may provide a danger reading on the voltage indicator. Other safety features are automatic overload relays or audible warning signals when the safe tube current limit is exceeded. Modern tubes are of the air or self-cooled variety and do not require forced cooling. However, in the interior of some apparatus ventilation is poor, so frequently a fan is provided to keep the air circulating and prevent overheating of the various parts. Two-tube Short-wave Circuits. In contrast to the typical four-tube arrangement described, some of the short-wave diathermy machines in use today contain only two tubes. These tubes are connected directly to the secondary of the main power transformer and are supplied with high-
in the
dropping
off in
power of the apparatus;
of another tube in the circuit.
196
voltage alternating current. In order to operate as oscillators, these tubes require high-voltage direct current to flow through their grid and plate circuits. Therefore self-rectification takes place in these tubes just as in regular rectifier tubes and a source of intermittent direct current is produced. This direct current source is then utilized by the tubes for oscillation. Self-rectification dissipates considerable power in the tubes, hence
these tubes are usually larger in size than those used for oscillation alone.
The high-frequency energy which self-rectified tubes deliver is modulated by the rise and fall in the rectified current at a rate of about 120 times a
second.
Therefore the power output for a given voltage
is
less
than that
The controls and steps in operatthe average short-wave diathermy apparatus are as follows: ing
for straight oscillator tubes. Controls of Vacuum Tube Apparatus.
SHORT WAVE DIATHERMY PANEL
TUNING-
CONTROL
MAIN
OFF
SWITCH
POWER CONTROL
r
<i>
FIG. 144.
<>
<
CABLE
cum
SURGERY
Controls on panel of short-wave diathermy apparatus.
The Main Switch of Power Inlet provides the supply current flow. It serves first for the warming up of the filament (cathode) in the vacuum tubes. It takes a few seconds for this heating. The filament should always
be allowed to heat up a few seconds before the plate voltage control is turned on. The Current Output Control is a controlling device with numbered steps or an indicator arrow; it enables the turning on of an increasing amount of supply current to the oscillator tubes according to the conditions of
the patient's circuit. The Coupling or Tuning Device controls the energy transfer from the oscillating or tank circuit to the patient's circuit. The maximum excursion of the meter needle shows that in a given set up there is a maximum energy flow and full resonance.
SPARK-GAP APPARATUS
197
SPARK-GAP APPARATUS
Figure 145 shows a diagram of the typical parts of a spark-gap apparatus and the graph of the current produced in each. The incoming alternating current supply passes through a choke coil which regulates the amount of current drawn on to the transformer which consists of insulated strands of wire wound on a core made up of thin plates of electromagnetic steel; it steps up the 110- volt current to 2000 volts or more. No change in
the
number
of alternations or frequency takes place in the transformer.

CYCLES
INLCT IIOMptra
HOUSE CURRENT GO CYCLES PER Sec.
/\
\
PRIMARY V^XTA&E CONTROL
\7
MAI N TRAMSfORMER
PRIMARY
SECONDARY
SPARK
PISCHJ
SPARK GAPS
CONDENSERS
MAIM RESOMATOR
DIATHERMY CURRENT
FREQUENCY ENORMOUSLY
'fp^
.CWBU*T
VOLTAQE FURTHER
INCREASED
FIG. 145.
Diagram
of circuits
and
oscillations
produced
in
diathermy apparatus of
spark-gap type.
high-voltage current from the secondary side of the transformer circuit, consisting of a spark gap, a condenser and the resonator. The condenser in most machines consists of plates comacts
The
on the high-frequency
198
mica (Fig. 8) except in very highposed of alternate sheets of metal and The condenser works voltage apparatus where Leyden jars are employed. that the electricity is not stored by a chemical like a storage battery except but by an electrostatic process. If the condenser is filled to capacity and the contact points of the spark gap are brought within a suitable distance,
the condenser empties itself by an oscillatory discharge. The discharge second and as soon as the charge period of the condenser takes about TFOTF is dissipated the condenser is charged again.
Typical multiple spark gap as used in large cabinet type diathermy apparatus. short-circuiting rod, shown lying in front of the gap, may be inserted from the left to short circuit as many gap sections as desired when very fine desiccation, for example, is to be done. Each gap section is individually adjustable initially, and the entire gap is ordinarily manipulated by the master control. It is mounted on blocks of high insulating material such as
FIG. 146.
lava,
and covered by a protective shock-proof guard.
The spark gap consists of two or more tungsten metal discs insulated from each other. As the spark discharge heats up the discs, cooling is provided by mounting them on metal blocks with radiating fins. It is important that spark gaps and their cooling arrangement should be mounted so that they cannot be touched accidentally, because this may lead to a burn or electric shock. The hissing noise heard in the operation of a spark-gap apparatus is normal to the function of the spark gap. The inductance
in
spark-gap apparatus
is
furnished
by the
resonator
which consists of two coils: the d'Arsonval coil or the primary is formed by a few turns of heavy wire and is wound over the Tesla coil or secondary, which contains many turns of small magnet wire. The Tesla coil is essentially another step-up transformer which serves to increase the voltage
of the high-frequency oscillations. The oscillations from the resonator are conducted to the patient from the outlets or terminals on the control panel of the machine. The oscilla-
tions of the long-wave spark-gap
machine are not continuous but occur
in separate oscillation periods, each consisting of a series of rapidly decreasing oscillation trains. Such oscillations are known as "damped" oscillations
and
The milliammeter
their frequency varies from 500,000 to 2,000,000 per second. in spark-gap machines is either of the hot wire 01 of
It
is
the thermocouple type.
placed in series with one of the leads to the
SPARK-GAP APPARATUS
199
patient. It indicates the quantity of current passing in the circuit of the patient, but not the heat developed in the tissues. It is possible, if the meter is out of order, to have current passing through the patient without defective meter usually manifests the meter indicating any current flow.
itself
by sparking within the meter case and
this causes the patient to
experience a faradic sensation.
FIG. 147.
Graph
of
damped
intermittent high-frequency current.
meter usually reads from 100 to 2500 milliamperes or In order to provide accurate reading, ordinarily a double scale is provided, one for currents from 100 to 1000 (low reading), the other for currents from 2500 or 4000 (high reading). In some apparatus, in order to protect the meter in case of short circuit caused by unexpected contact of cord tips or other accidents, a fuse is inserted in the patient's circuit. One should learn where this fuse is located and how it can be replaced.
scale of the
The
more.
FIG. 148.
Diagram
of control
of the
board of cabinet type diathermy apparatus. Burdick Corporation.)
(Courtesy
zero position of the needle of the hot wire type of milliammeter is subject to slight change with the room temperature, due to expansion or contraction of the wire. regulating device enables the
setting
The
resetting of the needle at zero point. Operating the Spark-gap Apparatus.
The supply current is turned on through the main switch and the amount drawn is regulated by the choke coil. The high-frequency oscillations are regulated by the spark-gap control. At its lowest point no oscillations occur and there is no current
flow in the patient's circuit.
200

Oudin
first
Most spark gap machines contain a third coil or Coil. constructed by Oudin and hence known as the Oudin coil solenoid, or Oudin resonator. It consists of a coil of fine wire connected to a lead off from the resonator. The Oudin coil constitutes an additional step-up transformer. It produces a high- voltage modification of the high-frequency current known as the Oudin current. This current is led off from a single terminal of the diathermy apparatus known as the Oudin (monoterminal) outlet. The voltage of the Oudin current is so high that when a glass vacuum or condenser electrode is attached to the Oudin terminal, it will become powerfully charged and on approaching the patient's skin it discharges in the form of a fine "effleuve" or coarse sparks. The output of the Oudin circuit is also regulated through the double control of the choke coil and
The
the spark gap.
Combination Apparatus. Either the spark gap or the tube type of diathermy machine can be used for medical or surgical purposes. There is also available specially constructed apparatus, which combines the features of one type of apparatus with those of the other one, exclusively for surgical purposes. Combinations are arranged: (1) By placing a spark gap and a tube machine in the same cabinet; the former serves for coagulation and desiccation, the second for cutting; (2) by arranging a spark-gap machine with various spark frequencies; high-spark frequency for cutting
and low-spark frequency

It
is
for desiccation
and coagulation. (Chapter XIII.)
also possible to construct spark-gap apparatus to produce oscillations of much higher frequency, and these can then be employed for
treatment techniques just as those of the tube apparatus for short-wave diathermy. Because of the higher expense of construction this type of spark-gap apparatus is at present not manufactured in the United States. Requirements for Acceptance of Diathermy Apparatus. In order to insure mechanical efficiency of a diathermy apparatus and its ability to produce deep heat within the body tissues certain requirements have to be fulfilled. Before placing any apparatus on its list of accepted apparatus the Council on Physical Medicine of the American Medical Association requires the submission of satisfactory physical and therapeutic evidence of the performance of the apparatus. Physical data required by the Council 1 before acceptance of any short-wave diathermy apparatus are:
" 1. Power output and input. The power output may be determined by a lamp load or by a calorimeter. "2. Transformer final temperature and temperature at various levels inside the cabinet taken after a two-hour run at full load. "3. Patent number or copy of license agreement. "4. Evidence indicating that radio interference has been reduced to a minimum by inclusion of filters or other devices for this purpose. "5. report from the Underwriter's Laboratories or assurances that the parts used in construction meet the Underwriter's requirements. "6. Evidence to substantiate the heating ability of the unit. This consists of six tests made for each treatment technique for which claims are made in the advertising matter or descriptive literature of the firm. Deep muscle temperatures are taken by thermocouples. A final temperature of 103 to 104 F. in the deep muscle of the thigh is considered ample by the Council." Two physical tests are performed on each short-wave unit submitted for the Council's consideration. The one test determines the maximum power output of the unit, and the other the temperature rise of the transformer.
SPARK-GAP APPARATUS
201
5 According to Mittelmann and Holmquest misleading use of the term output power, i. e., the total available output of a generator is responsible for false conclusions regarding the heating effectiveness of short-wave diathermy generators. The voltage used in clinical practice is relatively small in comparison to output power, because the total power delivered by the apparatus is divided into two components: the energy absorbed by the patient and the radiation losses. Both are subject to wide variation
according to technique of application, electrodes, air space, etc., besides current flow and its frequency of oscillation. Measurement of the actual power absorbed by the patient is possible by means of a direct reading wattmeter. A properly designed generator having a maximal output of 200 watts will provide sufficient power even for fever therapy. Holmquest and Mittelmann 4 have described a phantom which can be used to determine the useful output of short-wave diathermy apparatus. Protection Against Radio Interference by Electrical Apparatus. Installation of radio apparatus in homes has become universal, and every physician operating a high-frequency, roentgen-ray or static machine may be re-
minded by
his neighbors of its disturbing influence on radio reception. to Williams 7 the most prominent offenders in our armamentarium According are the various medical and surgical diathermy machines, particularly the new short-wave diathermy and artificial fever devices. Important activities
of the
Naval Research Laboratory at Washington, D. C., were subjected to interference so serious as to stop the work completely. Eventually, after great trouble and expense, the disturbance was traced to therapeutic
equipment. The first disturbing instrument located was a diathermy unit in a hospital at Cambridge, Mass. 3 Since interference by electrical apparatus can be reduced to a minimum,
physicians should have knowledge of the means of doing so. Low-voltage and low-frequency electrical apparatus cause little trouble. Occasionally the make and break of the circuit may cause some disturbance to get back into the power line and produce clicks or thumps. The motors driving such low-frequency generators may cause interference due to sparking at the brushes, just as any other motor, such as a fan, would. High-voltage and high-frequency currents can surge back through the power supply into the power line, or they may actually radiate into space
as radio waves.
its
Any
high-frequency apparatus
is
capable of radiation
if
fed into an open electrical circuit. Long-wave energy requires wires for efficient radiation, therefore the usual length of cords used long on conventional diathermy machines radiate little. Such energy as is
power
is
soon dissipated as a ground wave transmission at these freHigher frequencies used in short-wave machines require shorter wire from which to radiate efficiently, and therefore a considerable amount of energy may leave the conducting leads. Such energy as leaves the wire
radiated
is
quencies.
is
more Ukely
to travel far,
by
virtue of refraction
and
reflection
by the
stratospheric Kennelly-Heaviside layer of ionized particles high over the earth's surface. A glance at the chart by Schlesinger 6 will reveal how much
radiated energy can interfere with many forms of radio services. Poorly designed and unstable apparatus are a further cause of radio disturbances. Two remedies have been proposed to eliminate radio interference by one is screening of short-wave diathermy high-frequency apparatus:
202
for therapeutic machines, the other allocation of a special wave band Elimination of radio interference by protection against leakage purposes. waves consists of full metallic shielding of the rooms in which apparatus manner. It is housed and of grounding the metal sheath in an approved is an expensive procedure and has not proven successful.
WAVELENGTH
HIGH-FREQUENCY TREATMENT METHODS

The two forms
203
of medical high-frequency application are short-wave
diathermy and long-wave diathermy. They are principally used for tissue heating within physiological toleration. For this purpose three forms of
technique are available: 1. Direct contact heating. The metal electrodes charged by the current are placed in direct contact to the skin or mucous membrane. This is the classical method for long-wave diathermy, but with certain provision can also be used for short-wave diathermy. 2. Electric or condenser field heating: the electrodes are separated from the skin or mucous membrane by an insulating layer of air, glass or rubber. 3. Electromagnetic field heating: an insulated cable in the form of a coil or loop is wound around the part or is held against it in a treatment
drum.
The electric and electromagnetic field methods are employed with shortwave diathermy. The energy output of a long-wave spark gap diathermy apparatus may be used medically also for two special forms of applications: (1) Autocondensation, where one electrode is applied directly to the skin, another held separated from it by a dielectric of hard rubber or a thick mattress. (2) Oudin treatment or monopolar high frequency where the current, being further stepped up by a transformer, is led from a single high voltage terminal to a glass electrode and thence to the body. Table 23 gives a condensed presentation of present day high-frequency
methods.
TABLE
23.
HIGH-FREQUENCY TREATMENT METHODS

Medical Methods
Technique
Effect
Short-wave diathermy
Electric field heating
Depth heating
of all tissues
Electromagnetic field heating Direct metal contact
Heating chiefly vascular tissues Heating more localized
Long-wave diathermy
Direct metal contact
Autocondensation
Oudin treatment
Heating of all tissues Mild general heating, local heating under contact electrode Mild counterirri tation; .surface
heating
Electrodesiccation
Surgical Methods Single electrode from Oudin terminal of spark gap
Drying of small growths; epilation
Electrocoagulation
One
active and one dispersive electrode Two active (biterminal electrodes)
Extensive coagulation; sealing of

small blood-vessels
Coagulation sharply localized be-
tween electrode points

Cutting of tissues with minimal
coagulation:
sealing of capillar-
Electrosurgical cutting
One
active, one dispersive electrode from terminals of
tube machine
REFERENCES
1.
2.
Apparatus Accepted by the Council on Physical Therapy of the American Medical Association Chicago, American Medical Association, p. 21, 1940. Editorial: Interference With Radio Communications, Jour. Am. Med. Assn., 117,
1787, 1941.
3.
Federal Communications Commission:
News
Release No. 80302,
May
17, 1945.
204
4.
5.
HOLMQUEST, H. J., and MITTELMANN, E.: Physical Method of Determining Useful Output of Short Wave Diathermy Apparatus, Quart. Bull. Northwest. Univ. Med. School, 15, 255-262, 1941. MITTELMANN, E., and HOLMQUEST, H. J.: Useful Power Output of Short Wave Diathermy Apparatus, Quart. Bull. Northwest. Univ. Med. School, 14, 172-182,
1940.
6.
SCHLESINGER, R. A.:
Diathermy Apparatus in Relation to Radio Interference,
Rec., 149, 309-312, 1939. 7. WILLIAMS, H. B.: Interference With Radio Communication ment, Jour. Am. Med. Assn., 107, 1810, 1936.
Med.
by Therapeutic Equip-
CHAPTER
XI
MEDICAL DIATHERMY
General Considerations.
logical Effects.
Experimental Demonstrations. Thermal Effect. PhysioDiathermy. Short-wave vs. Long-wave Diathermy. Contraindication and Dangers. General Technique. Technique of Short-wave Diathermy. Technique of Long-wave Diathermy. Regional Technique of Diathermy. Safety Rules in All Diathermy Treatments. Special Precautions With Short-wave Diathermy. Special Techniques of Long-wave Diathermy. General Diathermy. Autocondensation. Monoterminal High-frequency (Oudin) Treatment Combination of Low-frequency Currents With Diathermy.
Clinical Uses of
General Considerations. The principal physical effect of high-frequency treatment is the heating of the human tissues. The production of heat is not a specific property of the high-frequency current, for any electrical current, in accordance with Joule's laws, will heat tissues. Low-frequency currents are not suitable for tissue heating because their electrolytic or polarity effects will bring about tissue destruction at a strength which would cause appreciable heating. Radiant sources of heating (heat lamps and infrared generators) as well as conductive sources of heating (hotwater bottles and electric pads) produce chiefly superficial heating, as
shown by the skin redness due to dilatation of the capillaries. It is also evident that in any "external" heating through the skin, increased circulation and perspiration will tend to disperse some of the heat and preclude
deeper penetration. It is furthermore difficult, if not impossible, to cause intensive heating of deeper parts by conductive heating without overheating the skin. The experimental proofs of the penetrating heating by diathermy and the clinical result produced by it have established highfrequency tissue heating as one of the most important methods in physical medicine. Experimental Demonstrations. Three classical experiments have been employed with long-wave diathermy apparatus for many years to demonstrate the basic physical effect of a high-frequency current upon conductors and its difference from that of a low-frequency current. The high-frequency current exerts no electrolytic (a) Water Experiment. or electrochemical effect. The tips of two conducting cords leading from the terminals are placed about 2 inches apart in the flat vessel containing tap water. Turning on a fair amount of current, the excursion of the meter needle will show passage of the current, but no bubbles appear around either cord tip, no matter how long the current flows. If a few pinches of salt are added to the water the meter will rise further, showing the passage of more current due to increased conductivity, but there still will be no formation of gas bubbles. The high-frequency current exerts heating (6) Light Bulb Experiment. A person effects on the body without causing neuromuscular stimulation. holds a cylindrical electrode in each hand; the base of one cylinder is connected to one terminal of the high-frequency machine, the base of the other to an electric light bulb (socket-testing device). The latter is then connected to the second terminal. As soon as the current is turned on
(205)
206
MEDICAL DIATHERMY
the lamp lights up, yet the individual through whom the current passes is no muscular twitch. perceives practically no sensation and there
The maximum heat effect of a high-frequency (c) Wrist Experiment. current occurs along the shortest path of the current, where the density is person grips one cylindrical electrode in each hand holding the greatest. wrists straight. With 500 milliamperes of current turned on the heat is
felt
about equally around the wrist. If the subject ately more heat is felt at the volar surface, while heat is felt on the dorsal surface.
flexes his wrists,

if
immedihe extends them more
THERMAL EFFECT OF DIATHERMY

The penetrative effect of high-frequency electrical energy extends from electrode to electrode through the human tissues and has become the standard method for deeper tissue heating in the body. The basic laws
for heating of conductors are those
known
as Joule's
Laws
(a)
The heat
produced
(6)
The
directly proportional to the square of the current strength. heat produced is directly proportional to the resistance of the
is
(c) The heat produced is directly proportional to the time during which the current flows. The actual heating of tissues depends on the number of calories supplied to the tissues per second by the highfrequency current. This can be expressed as a power unit; 1 watt equals 0.239 calories per second (Mittelmann, Osborne and Coulter). 19 A quantitative measure of treatment is obtained by measuring the actual power absorbed by the patient. Measurement by these authors showed that in local treatments absorption of 80 watts can produce temperature elevations of 8 to 10 F., which corresponds to final temperatures of approximately 106 and 107 F. In fever treatments by electromagnetic induction the average rise of temperature is about 1 F. each fifteen minutes with the absorbed power not exceeding 160 watts in a subject of average weight.
conductor,
1 Binger and Christie, with long-wave diathermy at the Rockefeller Institute for Medical Research, showed that: (1) The heat gradient of the body is reversed during diathermy so that heating occurs from without inward the maximum heating occurring at
The
classical investigations of
the point of greatest concentration of the lines of current flow; (2) deep heating during diathermy is greater than that which results from the application of local heat to the skin (3) the lung can be heated by diathermy in spite of simultaneous cooling of the chest. In considering heat distribution in the various parts of the body, the question of heat loss by conduction, radiation and convection must always be taken into account. In highly vascular organs, such as the lungs, the blood stream always carries away a considerable amount of heat. This occurs especially when the general direction of the blood stream is across the path of the Current, such as in transverse application of diathermy to the organs of the chest or abdomen. When the lines of the current flow are the same as the general direction of the blood stream, such as in the case when the current is directed along an extremity, the distribution of the heat effect is more even and a smaller proportion of the heat is carried away by the blood. For this reason, conditions for the control and uniformity of heat distribution along a limb are more satisfactory than in
;
internal organs.

with
207
These general principles of heat production and distribution prevail all methods of diathermy, whereas the passage of current and the
distribution of heating vary somewhat with the different techniques. Heating by Direct Contact. When metal electrodes connected to the
terminals of a long-wave diathermy apparatus are placed in direct contact on opposite surfaces of the body or on the same plane, current conduction and distribution in the heterogenous tissues of the body will vary according
path of the current. Under average treatment conditions the current has to pass through a cross-section of the body consisting of tissues of varying electrical resistance. Table 24 shows the specific resistance of the tissues to a high-frequency current of about one million cycles.
to the resistance of the tissues in the
TABLE
24.
HIGH-FREQUENCY RESISTANCE OF HUMAN TISSUES (HEMINGWAY AND
McCLENDON
Tissvie
11
Ohms
289 2180 1800
Tissue
Ohms
.
Skin
Fat
Bone
Muscle (voluntary) 110 (Tissues from surgical operations)
126 298 Heart 132 256 Spleen (Tissues from fresh postmortems)
Kidney
.
Liver
Generally speaking, the current will follow the soft tissues and heat them chiefly; highly resistant parts such as bones and joints will heat up chiefly when they are in the direct and shortest path of the current and even then it is likely that most of the heating effect arises by conduction from the surrounding soft parts and from the superheated blood stream.
up
FIG. 150. Electrodes in position for long-wave diathermy to chest in bed patient. Posterior electrode is slipped in position by depressing mattress; anterior electrode is held in place
by
light sandbag.
most
Fatty tissue is the most resistant and this explains why, even under the careful technique with long-wave diathermy, there may occur at times a coagulation of fat in the subcutaneous tissues when it becomes overheated in the direct path of the current. Temperature distribution with different types of long-wave diathermy
208
electrodes
MEDICAL DIATHERMY
was investigated by Hemingway and
Collins who found that cutaneous than muscular heating, while a metallic electrode caused greater occurs in the with a saline pad electrode a higher increase of temperature muscles than in the superficial layers of tissues. of a frequency of ten million Heating in the Electric Field. -Currents as employed in short-wave diathermy, or more oscillations per second, than can pass more readily through substances which are non-conductive, These higher-frequency currents can thereof lower
a current
frequency.
fore,
or be conveyed to the body through a layer of air, insulating pad, This allows a more flexible and often more convenient an insulated cable. with and safer technique. There is no need to insure good contact as the problems metal contact plates, uneven surfaces can be treated, and
of edge effect
(Chapter V) are greatly reduced.
FIG. 151.
Electric field heating by air-spaced plates held on adjustable arms. (Courtesy of the Lepel High Frequency Corporation.)
It is the physical characteristic of electric oscillations of very high with frequency, as stated in Chapter V, that in a condenser arrangement between two electrodes (Fig. 55) part of the conductive tissue placed electric charge will pass as a conduction current, and part of it as a so-called "current of capacity." It has been found experimentally, that the higher " " the frequency of the current applied, the greater is the capacitative component and the less is the conductive current component. It is there-
fore claimed that because of the dielectric property of
poor conductive
some the ordinarily a very high frequency current may cause effective heating in regions which would otherwise be more or less inaccessible to a purely conductive current. It is claimed that inner organs, spinal cord, brain, which are closed off with poor conductors (fat, bones, etc.) may be heated without overheating the tissues around them. 23 Because of the two different forms of heating it is also contended that the heating effect on the tissues is more uniform. Heating in the Electromagnetic Field. A flexible heat insulated cable in the form of a coil or loop is wound around an extremity or is placed in the form of a pancake over part of the body. A high-frequency current
tissues,
209
traversing such a coil creates a magnetic field and in conductive substances placed inside this field induced currents known as eddy currents will arise which flow in a direction opposite to that of the changing current in the coil. If of sufficient strength, the eddy current generates heat in the conductive substance such as the soft tissues of the human body.
FIG. 152. Electromagnetic field heating. Thermocouple inserted to a depth of 2 inches from the surface of the thigh registers up to 106 F. after a twenty minute application through a cable wrapped around the thigh. (Courtesy of the Burdick Corporation.)
The eddy currents induced in the more conductive materials will be more intense and, therefore, the generation of heat per unit of time will
be greater
in these
than in the
less
conductive materials.
Obviously
if
body composed
of materials of different electrical conductivities, such as
the tissues of the human body, is placed within the field, the intensity of the eddy currents, and consequently the rate of heat generation, will be greatest in those materials of the greatest conductivity. The relative conductivity of the various tissues of the body is about equal to their fluid content, this being about as follows:
TABLE
25.
RELATIVE FLUID CONTENT OF BODY TISSUES

Per cent
Muscle
Brain
.
72-75 68
.
Fat
15
Skin and bone
5-16
Heating in an electromagnetic field is especially effective in the vascular " type of tissue. It is generally designated in the United States as inductothermy."
factors relating to coil field heating, according to Patzold 23 are: the magnitude of the coil inductance (length and shape of the coil); (1) (2) the coil capacity (depending upon the distance between coil windings, on the magnitude of the dielectric constants of the insulating material and on the distance from the coil to the surface of the body) and (3) the length of the wave used. If the frequency of the electrical energy is small compared with the natural frequency of the coil, then the coil functions inductively, by eddy current heating; if the fixed frequencies are large
The
14
210
MEDICAL DIATHERMY
coil functions capacitatively compared with frequency of the coil then the Efficient heating by a coil field requires proper by condenser field heating. Generally speaking with wave lengths under design of the apparatus. 13 10 meters coil field heating is not satisfactory. Holmquest and Osborne
have shown experimentally that wave lengths

present
in the
of
25 to 20 meters cause the

is
best ratio of heat generation in physiological saline solution, such as
human
tissues.
102
5'
PHYSIOLOGICAL EFFECTS OF DIATHERMY

of
211
wave
bone marrow.
lengths, muscle temperature was always higher than that of the This in accordance with the generally accepted fact that
is
with any technique of diathermy the thermal gradient periphery to the interior.
105.9
always from the
Temp.
105104.5 104.3 104.2
104103.6
103-
5 o
c o
'
102-
101-
II
99.6Complete Data
Electromagnetic
Field
SE
Electric Field
Electric Field
FIG. 154.
Relation of heating to technique regardless of wave length used. and Osborne.)
(Coulter
relative effects of long-wave versus short-wave heating have been studied, especially regarding the claim that short waves offer better penetration and consequently deeper heating of the tissues than long
The
waves. Investigating deep heating in the female pelvis with both methods, the same increases of temperature could be produced by both methods with proper technique, using large enough electrodes for long-wave dia-
thermy. A comparison of deep tissue heating by metal contact electrodes from a 12. meter apparatus and by air spaced discs from a tube apparatus was 14 reported by the author, based on measurements made by William Bierman. These tests proved that cutaneous, subcutaneous, and deep muscle temperatures were substantially the same in both methods of application. Summing up the present views as to the thermal effects of various methods and techniques of diathermy, it appears to be a consensus of opinion that in actual practice the uniform biological factors: the flow of blood and heat conduction to adjacent colder parts will level off differences very considerably. As a matter of fact clinical results with the different methods are fairly uniform as long as the current is applied within
the limit of physiological toleration.

physiological and clinical effects of diathermy are due to the raising temperature of the parts under the influence of the heating current. The heat regulating mechanism of the body endeavors to maintain a constant temperature. When heat is applied to a part from any external source, the vasomotor mechanism responds with an effort to dissipate the
of the
The
212
excess heat.
MEDICAL DIATHERMY
There follows an active vasodilatation of the capillaries and increase of arterial and venous circulation. There appears to subsequent be an inherent tone in the capillaries which causes vasoconstriction. Lewis has shown that irritation of the tissues by the application of heat produces a release of vasodilator substance histamine which in turn results in the dilatation of the capillaries. Upon the absorption of the vasodilator substance a greater proportion of the capillaries dilates instead of the few which carry blood under normal conditions; as a result a greater blood supply to the part occurs. This local hyperemia in turn brings about an increase of the rate of removal of local tissue products and stimulation of the local resistive forces. An increase of the histamine content of the blood following diathermy was shown by Hildebrandt. 12 According to the temperature law of Van't Hoff, for every rise of 10 C. the rate of oxidation
is increased 2.5 times. Cellular oxidations are easily influenced by changes of temperature of only tenths of degrees, and in the physiological processes of inner organs slight changes in temperature may give results entirely
out of proportion to the change; therefore, it does not appear to be necessary that for clinical effects the local temperature be raised to the extent of 4 to 5 F.
When
heating
is
applied in sufficient intensity to a large part of the
body surface, general physiological effects arise. A comprehensive summary by Bazett of the combined local and general effects of heating is shown in Table 26.
TABLE
26.
EFFECTS OF HEATING (MODIFIED FROM BAZETT)

Local
.
On
circulation:
General
Superficial arterioles Superficial capillaries Superficial veins Circulation rate
Pulse-rate
....
.
Dilated Dilated Dilated Increased
Blood-pressure arterial Blood-pressure capillary Blood-pressure venous
Unchanged Unchanged
Increased Increased
Dilated Dilated Dilated Increased Increased
Decreased Decreased or increased Decreased or unchanged

Increased
On
the blood:
Alkalinity Alkaline reserve CO2 tension Oz tension

.
...
. ,
Decreased
Unchanged
Increased Increased
....
.
;
Decreased Decreased Decreased
Oz content (arterial) Oz content (venous) Phagocytosis
Unchanged
Decreased
Increased
. .
Unchanged or decreased
Usually increased Increased or unchanged
On
On
the
lymph:
.
Formation
Alkalinity
tissues:
Increased
Decreased
Increased
Decreased
Increased Increased
Metabolism COz and Oz tension

.
Unchanged or increased
On
respiration:
Rate
..'....
.
Depth Volume per minute
Unchanged Unchanged Unchanged
Increased Increased Increased

Increased Increased Increased Increased
On
urine and sweat:

.
Volume
Alkalinity
NaHCOs in urine Alkalinity of sweat

Infections:
...
. .
Unchanged Unchanged Unchanged Unchanged

Increased
(if
Local immunity
heat
continued)
Increased (if heat continued
is

While diathermy undoubtedly produces many of
its effects
213
by
raising
the temperature of deeper tissues, one must not lose sight of the fact that local thermal stimulation of any skin area exerts reflex reactions on deeper structures (Fig. 1). According to physiologists localized hyperemia of the skin is accompanied by localized hyperemia in the corresponding inner
organ.
generally recognized local and general physiological effects of diathermy can be grouped as follows:
1. Effects
The
on Circulation.
in
(a)
Local Effects.
The
local
application of
an active arterial hyperemia which appears to be more penetrating than the hyperemia following external forms of heat applications. In a loop of intestine exposed to the electromagnetic field, a tripling of the blood flow was found by Schmidt, Beazell and Ivy, 28 after the temperature had been raised to 102 F. There is also an increased flow of lymph and as a result of both hyperemia and hyperlymphia there is an increase in the volume of the part thus affected. In glandular organs
diathermy results
there
(6)
is
a marked increase of secretion. General Effects. Diathermy applied
by a method
of general
admin-
istration results in a dilatation of peripheral blood-vessels, which appears very rapidly; this is accompanied by a rise in body temperature, which in
turn results in an increase of the pulse-rate and respirations and an increase of the general body metabolism. Regarding blood-pressure there are in the literature, some authors reporting very marked contradictory reports decrease, which lasts for some time, others found an increase. Early basal metabolic studies conducted at the Massachusetts Homeo8 pathic Hospital (Granger ) showed that under autocondensation (general low basal metabolic rates became progressively higher and diathermy), that in the great majority of cases they tended to remain at an appreciably higher rate after cessation of treatment. Urinary solids hitherto deficient doubled and even trebled in quantity. This corroborated d'Arsonval's pioneer findings on the effects of general high-frequency treatment on 29 who reported an general body metabolism, as well as those of Steel, increased quantity of urine, increase of urea and increase of elimination of Modern laboratory nitrogen products after high-frequency treatment. work with hyperthermy has shown that each degree of rise in body temperature increases the basal metabolic rate about 7 per cent. 2. Effects on the Nervous System. Diathermy exerts a marked sedative effect on irritative conditions of sensory nerves (pain) and motor nerves (spasms and cramps). There is no generally accepted explanation for the pain relieving effect. It may be that heat in some way lessens nerve sensibility, perhaps as a result of inhibition through the temperature nerves of the skin. Short-wave diathermy definitely reduces nerve con21 ductivity in a physiological frog nerve-muscle preparation (Mogendovich ). Other investigators called attention to the fact that thermal measures exert reflex action in internal organs by stimulation of the vegetative nervous system through the nerve endings in the skin. The sedative action on hypertonic conditions of motor nerves is generally explained by the mild heating effects. The relief of muscle cramps by heat is well known and the effect of diathermic heat on hypertonic conditions of the unstriped muscles of the stomach and intestines is the more efficient sequel to the old-fashioned use of a hot brick to relieve colic. It is inter-
214
MEDICAL DIATHERMY
in normal animals there was esting to note that in experimental studies no other effect than a slight increase in the rate of contraction per minute.
(McLoughlin
17
et a/.)
It is a well known fact that heat sensitive organ3. Effect on Bacteria. isms can be attenuated or killed by heat. Favorable effects of long-wave 5 diathermy on gonococcal infections were reported by the late Cumberbatch work with fever therapy and the establishand others, but not until the ment of the variable thermal death time of gonococci was the reason for the somewhat divergent result clarified. (See Chapter XII.) At the same time it has been acknowledged that the disappearance of gonococci and the relief of symptoms may not be due wholly to the direct heat action on the gonococcus, but rather to the secondary effect in the ability of the tissues to exterminate the invading organism by increased phagocytosis
results of the increased local immunity. The possibility of Specific Effects Claimed for Short-wave Diathermy. other effects than heating by high-frequency currents has been a subject for speculation ever since d'Arsonval claimed specific high-frequency effects
and other
apart from those of heat. In Chapter V specific electric effects of alternating currents, especially of an ultra high-frequency field were discussed. 6 16 Liebesny, and Dognon hold that certain phenomena in the short-wave field like stimulation or inhibition of cellular activity cannot be explained on the basis of the thermal factor only. Non-thermic changes induced in colloidal particles by an electric field are proven, according to Krasny15 Ergen by the fact that their manifestations are depending on the direction 16 of the electric field. (Fig. 56.) Liebesny was actually able to photograph these effects in films. The existence of a specific non-thermal effect of alternating currents which takes a particular course in the short-wave field
must
therefore be considered possible, although so far
it
has no practical
clinical
meaning.
Among the specific biological effects claimed for short-wave diathermy were effects on capillaries (Pflomm), on tumors (Schereschewsky, 26 Reiter24 ), and specific bactericidal action (Haase and Schliephake 10 ). Some observers described "athermic" effects which come about by employing only a low output of a short-wave apparatus, and claimed specific influence on the autonomic and sensory nervous system. All these claims were disproved one by one in the literature of the past decade, and summing up all the available evidence at present it would appear that besides the possibility of specific electric changes, thermal effects The are the only proven biophysical effects of short-wave diathermy.
diversity of opinions
clinical findings
and
of
some
of the conflict in the experimental
and
can be attributed to two factors.
One
is
the undoubted
lack of training in biophysical research in some of the investigators. The other factor is the lack of a generally accepted method of dosimetry. In order to be able to compare results in intricate biophysical research one
must recognize the elementary biophysical law of a minimum energy threshold as well as an optimum dosage for certain effects, and one must also be able to employ comparable amounts of energies. It is the consensus of present day medical opinion that short-wave diathermy is a specific form of heat therapy which differs from long-wave diathermy chiefly in the mode and extent of passage through tissues.
CLINICAL USES OF DIATHERMY

CLINICAL USES OF
215
DIATHERMY
upon
its
The
therapeutic indications of diathermy are based
enumerated
physical and physiological effects. The heat of diathermy is generated in the tissues by the direct action of electrical energy, and in its gradual introduction does not appear to bring about such a marked reflex action
of the heat-regulating mechanism as "external" forms of heating. placing of electrodes directly over the heated parts also prevents
The
any
^considerable cooling
by evaporation.
Deep hyperemia causes an increased arterial flow with more oxygen and improved nutrition, while the greater venous flow carries away in These effects promote larger degree the products of local metabolism. disintegration of inflammatory exudates and assist in their resorption, as shown clinically by the decrease of swelling, relief of pain and restoration of function. Hence the therapeutic effectiveness of diathermy in subacute and chronic inflammatory and congestive conditions and circulatory disorders. The pain and spasm relieving effect of diathermy makes its use indicated in irritations of sensory and motor nerves, while the effect on thermolabile organisms such as the gonococcus makes it of specific value
in the
treatment of gonococcal infections.
is often indicated alone; in some conditions it will work to best advantage if properly combined with other physical measures, notably with those producing mechanical effects. brief enumeration of the
Diathermy
principal conditions in which the use of both long- and short-wave diathermy has become a standard aid in treatment is as follows:
In traumatic and inflammatory conditions of bursse, bones and joints after the acute stage, also in delayed union of bones when there is a fair degree of fixation, and in painful and exuberant callus formation and
fibrous ankylosis following joint injuries. In chronic inflammations of abdominal organs, such as the gall-bladder and ducts, where surgery is contraindicated. In peritoneal adhesions following gastric or intestinal conditions, and in postoperative adhesions
diathermy is advantageously combined with muscle exercising currents. Spastic conditions of the stomach, gall-bladder, intestines and pelvis of the kidney, as well as gastric neuroses, are frequently relieved by diathermy. Subacute and chronic inflammations of the female organs, such as metritis, parametritis, diseased adnexa, respond well because of the efficient localization of deep heating; the same relates to gonorrheal infections and to prostatitis, epididymitis and seminal vesiculitis in the male. In congestive chest conditions, such as acute, subacute and chronic forms of bronchitis, as well as in pleurisy, diathermy helps to relieve pain,
loosens cough and speeds recovery, while in essential forms of bronchial asthma relaxation of muscular spasm follows its application. In the pneu-
monias diathermy offers a valuable adjunct to standard forms of therapy. In the treatment of neuritis, and in certain varieties of neuralgia or myalgia, diathermy helps to relieve pain and also promotes resorption of inflammatory changes. In angina pectoris, in essential forms of hypertension and in selected cases of peripheral vascular disease, diathermy
may
serve as a useful adjunct to other medical treatment. In organic nervous disorders, such as general paralysis, and locomotor
216
MEDICAL DIATHERMY
ataxia and other syphilitic affections of the central nervous system, artificial fever therapy by diathermy is being successfully employed. Details of indications and technique of the application of diathermy in most of the enumerated conditions will be found in the special chapters
of Part V.
Claims have been made for specific action of short-wave diathermy in acute skin infections such a,s furuncles and carbuncles and lung abscesses, but seasoned medical opinion attributes the undoubted clinical relief rather to the fact that only mild heating was applied, which is always beneficial
such cases. Short-wave "provocation" as a diagnostic aid in suspected foci of 9 infection has been proposed because of a fairly consistent increase in the rate when short-wave diathermy was applied to the blood sedimentation Similar changes in the sedimentation site of an active dental infection. rate following abdominal diathermy in pelvic infections were also reported. The indications of the two special forms of long-wave diathermy, the Oudin current and autocondensation will be presented later on. Short-wave vs. Long-wave Diathermy. The advantages of the simplified technique and increased adaptability of short-wave diathermy and the enthusiastic reports on its clinical results in a very large number of conditions seemed to have doomed long-wave diathermy in general and the contact plate technique in particular to oblivion. American manufacturers have actually discontinued the making of long-wave apparatus for medical purposes, although for electrosurgery spark-gap apparatus is
in
still
it is essential for administration of the Oudin current. the opinion of most seasoned observers that long-wave However, diathermy still holds its own very definitely. Because of convenience of application short-wave technique may be preferable for certain locations or conditions. For instance, inductance coil heating is very convenient in peripheral vascular conditions for gentle heating effect on account of easy controllability and the avoidance of skin contact; also for treating two knees simultaneously. In conditions of the head sinuses and for facial involvements, the spaced air plate or treatment drum method of short-wave diathermy is quite convenient and fairly safe. In gynecologic conditions clinicians generally state as an advantage of short waves their applicability and efficiency in acute cases, whereas longwave diathermy is only indicated in chronic cases (Chapter XXX). The contention that short-wave diathermy is preferable in acute cases and long-wave diathermy in chronic cases can be explained by the fact that, with the original air-spaced technique, as a rule mild heating is applied which is well tolerated and beneficial in acute cases. Long-wave diathermy with the contact-plate method results usually in more intense heating, better suited to chronic cases. In the light of present knowledge, acute inflammatory conditions are the only ones in which short-wave diathermy may be considered to be definitely preferable over long-wave diathermy because of different clinical In all other conditions either method can be employed. Longeffects. wave diathermy or the contact plate method of short-wave diathermy
being
made and
it
is
seem preferable in all techniques where the spreading of lines of force and unnecessary heating of adjacent structures is to be avoided. Shortwave diathermy as usually applied with large size electrodes and an indue-
CONTRAINDICATIONS AND DANGERS OF DIATHERMY
217
tance coil results in a great deal of wasted energy and makes heat sensitive patients f eel quite uncomfortable. In all such cases and also in such locations as the neck and head, where unnecessary heating of non-affected
<
parts is to be avoided, clinical experience of the author and a number of others has shown that the contact plate technique by either long- or short-
wave diathermy is more efficient. In treating superficially located muscles and bursse, many of the joints and the cervical spine it allows better localized heating. In the author's opinion, it is still the method of choice for orificial treatment of the pelvic contents. Long-wave diathermy as well
and thus a better control
of the patient.
as the contact plate short-wave technique always allows the use of a meter of the dosage instead of the subjective sensation
CONTRAINDICATIONS AND DANGERS OF DIATHERMY

Diathermy is relatively contraindicated in disease processes in which the usual safer methods of superficial heat give satisfactory results. Ordinary contusions, simple myositis, will readily respond to luminous heat, the same form of heat causing acceptable results in bronchitis of children and in non-purulent forms of sinusitis or otitis media. So, too, complicated
methods recommended by some for applying diathermy to fingers and seem superfluous in view of the fact that such areas can be more effectively and more safely heated by radiation, hot water or paraffin baths. Superficial neuralgias and neuritis can be frequently relieved by radiant heat followed by a mild application of the Oudin current or in resistant cases by galvanism. Diathermy should not be used as a panacea for all sorts of undiagnosed
toes
painful conditions.
A complete diagnosis, a definite conception of the underlying pathology to be influenced and consideration of the individual equation in each patient are essentials for its successful application. Diathermy is absolutely contraindicated in three conditions: (1) In acute
The inflammatory processes accompanied by fever and suppuration. pain and swelling of acutely inflamed joints in infectious arthritis are usually aggravated by diathermy, and it is almost a diagnostic evidence that the process has entered the subacute stage when diathermy can be well tolerated. In acute, non-draining suppuration, such as otitis media, appendicular abscess, acute pelvic infections, unwisely applied diathermy may lead to real danger by spreading the process. (2) In tendency to hemorrhage. Diathermy must not be employed in recent hemoptysis, in
bleeding gastric ulcer, in large varicose veins, and in pregnancy. It inadvisable to apply diathermy to pelvic organs during the menstru period. (3) In malignant tumors or in case of the suspicion of such. Coulter3 considers peripheral nerve injuries absolute contraindications, for the reason that the disturbed or absent skin sensitivity greatly increases the risk of burns. The author is of the opinion that in experienced hands in many instances the benefit of diathermy may outweigh its danger, especially as burns are just as liable to occur under any other form of
heating.
fever,
In acute inflammatory conditions accompanied by suppuration and long-wave diathermy has always been considered contraindicated, while competent observers have reported unquestionably good results by
218
MEDICAL DIATHERMY
the application of mild doses of short-wave diathermy. Some reason for its applicability is the fact that air-spaced plates can be employed where contact electrodes would cause painful pressure and possibly excess heating. Great care must always be exercised, a minimal dosage applied and the
principle of the necessity for surgical drainage in purulent infections always be kept in mind. The danger of burns is present in any form of thermal therapy and is of especially prevalent with metal contact plate conveying large amounts
diathermy
electrical energy, as shown by the not infrequent burns with long-wave in inexperienced hands. With short-wave diathermy this danger
is relatively less but burns by this method will also happen, for a variety of reasons. Proper technique and the observation of all precautions enumerare essential at all times for their prevention. ated in Chapter
GENERAL TECHNIQUE OF DIATHERMY

The object of both long- and short-wave to produce penetrating heating of the entire body, or of a diathermy part of it. Effective heating will depend on the correct selection of treatGeneral Considerations.
is
ment technique,
ment.
as well as on the proper dosage
and duration
of the treat-
The
selection of the
method
of treatment, long
wave
or short wave, and
particular technique, electric or electromagnetic field or direct conduction heating, will depend on the available apparatus and on the condition to
be treated in the individual patient. Generally speaking, all forms of diathermy when applied intelligently will result in satisfactory deep tissue heating. Certain techniques are, however, preferable because of convenience or safety for certain locations and certain pathological conditions, as has been already pointed out and will be further stressed in this chapter as well as in Part V. Regulation of Dosage. Medical diathermy must be a pleasant procedure at all times, and must never cause pain during treatment, or damage to the tissues. As a general rule, the strength of current should be no more, at any time, than that which feels comfortable to the individual patient. We have not enough experimental data to tell us at what degree of heat best therapeutic results are achieved, neither have we any practicable device for the exact measurement of the heat attained in the interior of the body, except in electropyrexia where the temperature of the body as a whole can be measured by thermometry. In long-wave diathermy the reading of the milliampere meter is a definite help in regulating the amount of current passing on to the patient. The meter in short-wave apparatus only serves as an indicator that electrical energy is passing; but it does not register the amount of energy passing through the patient. "Dosimeters" have been constructed for short-wave apparatus measuring the power absorption by the patient (Mittelmann and Kobak 19 ), but have not stood the test of general clinical use. The heat sensation of the patient is the supreme guide of dosage in all diathermy treatments. Hence the physician must be certain at all times that the patient perceives heat normally and in doubtful cases, testing by test tubes filled with hot and cold water should be done. Long-wave diathermy is more apt to cause unpleasant skin sensations when applied
GENERAL TECHNIQUE OF DIATHERMY
219
even in small excess or with incorrect technique; particularly with the spark gap opened too wide there occurs an unpleasant "faradic" sensation even with a minimal amount of current. A definite excess amount of current will manifest itself by an unpleasant burning sensation in the skin or a feeling of pressure in the subcutaneous tissues. Patients complain
of the latter, especially when in longitudinal (cuff) application too much current is crowded into a narrow area, such as the wrist or ankle. Short-wave diathermy produces more of a smooth, "velvety" sensation
Four grades of heat sensation in of heat, which many patients prefer. short-wave treatments have been established by several clinicians: (1) threshold value (glow-like sensation); (2) distinct feeling of agreeable warmth; (3) intensive heat; (4) unbearable heat. An effort has been made to correlate these heat sensations to the power absorption (Mittelmann and Kobak). For very mild dosage, as in acute inflammatory conditions one should stay within the glow-like sensation, while in chronic cases the sensation should be just this side of intensive heat. A rapid rise of heating by fairly strong amounts of energy is not desirable in deep heating with either long-wave or short-wave diathermy. In treating internal organs, especially the thoracic, abdominal and pelvic organs, a moderate amount of current and comparatively long treatment produces better effects. This is partly explained by some experiments by Fiirstenberg and Schemel 7 conducted on the dog's stomach, using thermocouples for measuring its temperature. By directing a current through the abdomen they found that stronger currents produced a slighter rise of temperature than weaker currents. When the dog was killed the temperature in the stomach rose with the increase of current and dropped with its decrease. The apparent contrast is explained thus: Strong currents caused in the living animal a reflex vasodilatation of the heat-regulating blood-vessels and thus the excess heat was led away. Weaker currents, on the other hand, applied over long periods, cause considerable deep heat effects without stimulating the reflexes. The same findings were obtained recently with currents of low and high wattage in short-wave diathermy (Mittelmann, 20 et al). As long as the absorbed power does not exceed 100 watts, the temperature in the deep tissue raises in a straight line until near termination of the twenty-minute treatment period. If the power absorption exceeds values much over 100 watts, the final temperature is actually much lower. This may be also explained by the rapid dissipation by the increased blood circulation. Weaker currents to the extremities are indicated, as a general rule, in acute painful conditions, such as in acute neuritis, recent cases of traumatism, and also in chronic arthritis with marked trophic changes. In treatment of acute inflammatory conditions by short-wave diathermy best results have been achieved with ten minute applications of low intensity. Mucous membranes can stand larger amounts of current than the skin. This is partly explained by their much better vascularization, which enables excess heat to be carried away much faster than in the skin, furthermore the lessened electrical resistance of the membranes decreases the amount of heat produced. Duration and Frequency of Treatment. It is evident that it takes a certain amount of time for the temperature of the part treated to reach the desired height and then, through automatic heat regulation (the blood
220
MEDICAL DIATHERMY
stream and conduction by the surrounding tissues), a condition of equilibrium will ensue so that a fairly constant temperature is maintained. It in less time than deepis also evident that superficial parts can be heated therefore longer treatments are indicated for inner seated structures,
Clinical experience has established that twenty minutes is the minimum time required for an efficient diathermy treatment in extremities or superof the body. In treatment of internal organs about one-half ficial
organs.
parts
hour or even longer treatment
is
advisable.
effect
Excessively long treatments
may
cause too intensive a heat if he is aged. Acute and very painful conditions or recent injuries in which the early return of function is essential, as a rule, require daily treatment. With For the of such conditions this repetition can be reduced.
especially
and thereby exhaust the patient,
improvement
on alternate average patient suffering from some chronic ailment, treatment suffices and may be administered even less often, dependent days usually upon the progress noted.
TECHNIQUE OF SHORT-WAVE DIATHERMY

Electrodes. Each of the three forms of short-wave diathermy application involves the use of different types of electrodes.
TABLE
1.
27.
ELECTRODES IN SHORT-WAVE DIATHERMY APPLICATION

Flexible condenser pads, air-spaced plates, single
Electric or condenser field heating
and double
2.
cuffs
Electromagnetic field heating (inductothermy)

Direct contact heating
Inductance cable wound round part or placed upon body in form of a loop, pancake coil, treatment
drum
3.
Metal contact electrodes for vaginal or rectal application with condenser pads for dispersive electrode, metal contact electrodes all around
with apparatus with extra condenser in patient's
circuit.
Condenser Field Heating. Electric field heating consists two spaced metal electrodes condenser pads and cuffs, or air-spaced electrodes either on opposite surfaces or the same body surface to heat the interposed part. These electrodes have been already briefly described in Chapter IV. Condenser pads are held in place by elastic bandaging or perforated rubber bands or by some other suitable means, such as sandbags or by the patient resting on them. The advantage of pads is their pliability which enables their bending or shaping to conform with the surface to be treated. The rubber insulation of imperfectly jointed or pressed pads may puncture with subsequent danger of arcing and burns through the exposed part of the metal. For this reason, and for the avoidance of overheating of the
1.
Electric or
of applying
skin the pads should never be placed directly over the skin; a dry towel or some other dry insulating material such as perforated felt, of at least J-inch thickness should be interposed. In applying the pads care must
be taken that their cable connection should nowhere directly touch the
patient's skin.
Accumulation of moisture due to perspiration under the electrodes leads to a concentration of electrical energy near the skin and the pos-

sibility of superficial burns.
221
Hence,
it is
a general rule to place in addition
to suitable spacing, moisture absorbing material between the electrodes and the skin. If turkish towels are used for spacing this is not necessary; in all other cases, linen or paper towels, thin blotting paper or tissue paper
should be employed. Felt pads used for spacing should always be free from
moisture.
FIG. 155.
Flexible condenser pads applied to shoulder.
Double cuffs consist of a pair of long and narrow condenser pads which are applied along an extremity at suitable distance from each other. They should be so placed that they include only the part to be heated and the skin-electrode distance under both cuffs should be equal. It makes no
difference
if
part of the cuff overlaps.
FIG. 156.
Double
cuffs applied to knee.
Air-spaced condenser plates consist of circular metal plates or discs covered with insulating material. The plates are mounted on adjustable arms in the form of treatment arms and are self retaining in any desired position and distance. (Fig. 151.) This is especially convenient over the knees, shoulders and cavities of the head. Spaced glass electrodes consist of a hollow cylindrical glass "shoe" containing a metal plate which can be moved back and forth parallel to the bottom of the glass cylinder and held at the desired distance, usually between \ and 3 inches from the body. The advantage of glass as an electrode cover is that it does not become heated as rubber does and does not deteriorate through use. These glass condenser electrodes have found little employment in the United States.
222
MEDICAL DIATHERMY
a probcorrect spacing of these various forms of electrodes is quite the part of the body to be treated lem. Generally speaking the thicker the greater should the greater should be the skin-electrode distance and instructions given size of the electrodes. It is important to follow the
The
be the
by the manufacturers
may of spacing on the underlying tissues. Under certain conditions effect desirable to produce more surface heating on one side and more depth this can be done by using less spacing on one side and more the
it
output of their apparatus. Figure
for the correct spacing in relation to the power 157 diagrammatically shows the influence
be
on other; on the other.
FIG. 157.
spacing,
Schematic diagram of influence of spacing on extent of depth effect, more superficial heating; B, wider spacing, more depth heating.
A, close
Electromagnetic or Coil Field Heating. Coil field heating or inductofor heating an entire extremity or part of it; it also serves for fever treatment. To treat an entire extremity or a joint two to four thicknesses of turkish toweling should be placed between the cable and the skin. There should be two to four turns of the cable wound round the part to be treated depending on its size these turns should be spaced 1 inch or more apart; convenient wooden "spacers" serve for this purpose. In all inductance cable treatments the ends of the cable leading to the appa2.
thermy serves
223
ratus should be of equal length and should be separated at least the distance of the outlets on the apparatus. (Fig. 158.)
Instead of winding an inductance cable around an extremity, it can be applied in the form of a pancake or held in a so-called treatment drum in a similar circular form. In this form, it can be applied on any part of the body, held at a proper distance by interposition of spacing by felt or by air. The turns of the pancake coil should be about 1 inch apart from each other. The advantage of this type of electrode is its convenience of application to anatomic location, its disadvantage is the unnecessarily extensive heating of adjacent parts when treating such small locations, as the ear, eye or sinuses. (Fig. 48.)
FIG. 158.
Heating of elbow by electromagnetic induction (inductothermy) in (Courtesy of the Burdick Corporation.)
coil field.
3. Direct Contact Heating. Direct contact heating by metal electrodes applied to the skin without any spacing involves a technique similar to long-wave diathermy. It is only possible with apparatus so constructed that an extra condenser in the patient's circuit makes up for the lack of spacing. (Fig. 159.) In applying this method, the principle of spacing is given up, but the advantage gained is the possibility of using a milliammeter for correct reading in the patient's circuit. Experimental evidence has shown that the heat effect in the depth is the same as with air-spaced electrodes; in addition there is less electrical energy needed because there is no wasted radiation into space.
224
MEDICAL DIATHERMY
For cavity work in the vagina and rectum, contact heating avoids cumbersome glass sheathed electrodes. If in electric field heating one electrode is applied by direct contact to a cavity, such as the rectum or vagina, the output of the apparatus must be balanced by adequate spacing of the other electrode by placing it sometimes far below the wooden treatment table. With apparatus equipped with the extra condenser the dispersive electrode can be applied in direct skin contact over the abdomen
or back.
UJ
TECHNIQUE OF LONG-WAVE DIATHERMY

of the patient
225
is at present our only guide. For this reason it is imperative to ascertain beforehand that the sensory perception of the patient is
normal or near normal. In proceeding with the treatment therefore, the initial strength of the current must be adjusted in accordance with previous experience and be
guided by the patient's sensation, as stated in the previous section.
TECHNIQUE OF LONG-WAVE DIATHERMY

Long-wave diathermy
consists of the application of bare metal electrodes
to opposite surfaces of the body. This technique is more exacting than that of short-wave diathermy and therefore gives a better foundation for the general use of diathermy.
Electrodes Their Position and Size. Metal electrodes cut of soft sheet metal, described in Chapter IV serve for the entrance of the high-frequency current through the skin; suitable shaped metal electrodes serve also for vaginal and rectal treatment. These electrodes must be held and applied in perfect contact throughout the treatment. This is usually done by an elastic bandage, but it must not be applied too tightly because the parts expand as they warm up. On a flat surface the electrodes can be held by sandbags and there are also available ready-made electrodes in holders. Preliminary warming of the part to be treated, as well as of the electrodes by radiation from a heat lamp is advisable this will also moisten the skin and make for better contact, and also take away the chill of a cold metal. Sharp edges and wrinkles in electrodes must be smoothed out beforehand. Usually no interposition of soaping or electrode jelly is needed for perfect contact except in patients with abnormally dry or tough skin.
;
FIG. 161.
Diathermy
to elbow.
Cuff method.
The
relative position of the electrodes
may
be transverse or longitudinal
(Chapter V). The transverse method serves for treating joint and ligamentous-bony structures and internal organs. With electrodes of equal size and fairly parallel there should be an even distribution of current in areas of the same electrical resistance. To concentrate diathermy over a circumscribed area as in painful tendon insertions, circumscribed periosteal inflammations or in the subdeltoid bursa a small plate of thin tinfoil is moulded over the spot and a large dispersive electrode placed over the
15,
226
MEDICAL DIATHERMY
chest on the opposite side. This also avoids heating up large masses of tissue unnecessarily as it is constantly done in short-wave diathermy. The longitudinal (cuff and semi-cuff) method when two suitably curved an extremity, will principally warm plates are placed fully or partly around the muscles, the periarticular structures and nerves, which are the skin, not too deeply situated. Circular cuffs should be placed around an extremity the current will cononly if the limb can be fully extended, otherwise where the electrodes are closer to each other. centrate more on the surface
Cuffs must be kept from 12 to 15 inches apart, for if too close the current will have the tendency to pass along the skin only. Exposing of the area between cuff electrodes to a heat lamp during treatment will diminish heat loss by radiation from the skin and increase the deep heat effect. With electrodes in tilted position toward each other, the current always takes the shortest path between the electrodes and thus there will be
more heat where the surfaces converge. If the two electrodes are placed will be limited to the area practically on the same plane the heating effect between the near edges. This "edge" effect must always be anticipated
when
electrodes are placed in other than exact opposition to each other.
Wherever there is increased density of the current in a shorter path or in a path of lower resistance, there is likelihood of a burn, if the limit of
physiological toleration is exceeded. The Reading of the Milliampere Meter. While the patient's heat sensation is our supreme indicator at all times, the milliammeter is nevertheless
in applying diathermy with contact plates. The meter amount of current flowing in the circuit of the patient, and not the absolute amount of heat developed in the tissues. Its reading must always be considered in relation to the size and position of electrodes. The larger the size of the electrode, the more current can be administered. The relation of milliamperage to the size of the active electrode is known as current density. A fairly generally accepted method of calculation is
an important guide
only indicates the
from 75 to 100 milliamperes per square inch of the active electrode applied to the normal skin. Table 28 gives an estimate of maximum milliamperage with standard sizes of electrodes in individuals with normal skin sensation, and with electrodes equidistant and opposite each other. With electrodes of unequal size maximum milliamperage has to be estito figure
when
mated according
TABLE
28.
to the size of the smaller active electrode.
MAXIMUM MILLIAMPERAGE FOB DIATHERMY BY DIRECT CONTACT

Average Estimate 100 Milliamperes per Square Inch
2X2= 3X3= = X 2X4=

4
Electrode surface
Milliamperage
4sq. 9 sq.
in. in.
16 sq. in. 8 sq. in.
X X X X
100 100 100 100
= = = =
400 900 1200-1400 800
MA MA MA MA
The
increase of milliamperage does not increase the heat effect in the
same proportion, but, according to Joule's third law, in relation to its square. A double amount of milliamperage, therefore, results in four times the amount of heat under the electrode. This explains why patients are
often so sensitive to a slight increase in milliamperage after the limit of comfortable toleration is reached.
There is very marked sensitiveness of the skin to the application of diathermy on large areas of the abdomen and with electrodes of large size
REGIONAL TECHNIQUE OF DIATHERMY
227
the milliamperage cannot be increased in the same proportion as over other parts.
The calculations of Table 28 cannot be applied when using cuff electrodes or active electrodes of larger surface than 4 by 4 inches. In the cuff method the tendency of the current to take the shortest and least resistant path
from electrode to electrode
will lead to increased density in the
near edges
of the cuffs and, therefore, the safe amount of current is determined by comfortable toleration of the individual and by the experience of the
operator.

The general principles of application of long- and short-wave diathermy to various regions and organs are in many respects similar. The three forms of technique by short-wave diathermy allow quite a variety of application and flexibility of technique in certain locations.
FIG. 162.
Diathermy
to brain.
Brain.
The brain
is
an excellent conductor of
however,
it is
electricity,
due to
its
encased in bone which is a poor conductor, as is the fibrous scalp. A metal electrode placed on the skull creates a physical arrangement equivalent to a condenser, and represents one plate of the condenser, the brain the other; between these two lies The the poorly-conducting bone-skin-layer representing the dielectric. transmission of the current from one plate to the other of the condenser is effected by virtue of its capacity; the bony skull-cap itself possesses a small conductive capacity on account of the blood-vessels contained in it. In the experiments of Schliephake 27 a thermocouple inserted in the brain showed an increase of temperature of 0.9 C., a thermocouple within the temporal muscle showed an increase of 3.3 C. and one in the skin of the top of the skull showed a rise of 1.8 C. Short-wave diathermy may be applied to the brain by condenser pads or spaced plates, held antero-posteriorly or bitemporally with suitable spacing. Treatment must be always applied with the patient in recumbent The current should be turned position, to minimize possible dizziness.
of water;
abundant content
228
MEDICAL DIATHERMY
on very gradually and should only be strong enough to produce a pleasant A strong current may cause dizziness or headache. feeling of warmth. Treatment should last from fifteen to twenty minutes and the patient must be left in the recumbent position for at least ten to fifteen minutes
afterward.
transLong-wave diathermy to the brain may be applied by the lateral 2 by 2 inches are placed on both temples verse method; two small electrodes and held by an elastic bandage; interposition of wet gauze or electrode undue pricking at the beginning of the treatjelly is advisable to avoid ment. This method will heat the mid-brain, the temporal lobes, part of the frontal lobes and may reach the hypophysis. (2) In the antero-posterior method (Fig. 162) larger electrodes about 2\ by 4 inches can be applied. One is placed across the forehead, the other on the back of the head at the should hairy border, or even on the hair; in the latter case electrode jelly
be interposed to moisten the
hair.
FIG. 163.
Condenser pads
for
head sinuses.
(Courtesy of Burdick Corp.)
Eyes. Short-wave diathermy can be applied by the pancake coil technique: a pillow is placed over the coil and the patient's face rests on it with the eye in the center. Long-wave diathermy allows a more exacting technique. An active electrode is cut from sheet metal into a shape conforming with the contour of the eye and placed over the lid, a larger dispersive electrode is placed under the nape of the neck. It is better to use wet gauze or electrode jelly under both electrodes to avoid air spaces and
undue pricking. Care must be taken in insulating the cord tip well when attaching it to the eye electrode. For treating of both eyes two similar

active electrodes can be cut
available ready
229
and connected by a
split cord.
There are also
electrodes, consisting of glass cups on a suitably wired handle; the depression of the cup is filled with well moistened cotton and placed over the eye. Only about 200 to 250 milliamperes can be
made eye
tolerated over one eye
and proportionally more over two.
FIG. 164.
Air-spaced treatment for antrums and facial structures.
(Courtesy of
Mclntosh
Electrical Corporation-.)
FIG. 165.
Throat treatment by inductance
coil.
Head Sinuses. The sinuses of the head may be treated by short-wave diathermy by a pancake coil or a condenser pad (Fig. 163) placed over the face. For individual sinuses a small condenser pad or spaced plate is
employed and a larger dispersive pad or plate held opposite the active
230
electrode.
MEDICAL DIATHERMY
For further
details, including
treatment of ears see chapter on
ear conditions.
is risky in the hands of the inexbecause direct metal contact over a bony surface may lead to perienced a burn.
Long-wave diathermy to the sinuses
FIG. 166.
Treatment
of spine
by spaced
plates.
Neck. The cervical spine may be treated with condenser pads either antero-posteriorly (a narrower pad over the cervical spine, a dispersive pad over the upper anterior chest) or laterally (two equal-sized pads on
each side of the neck). Spaced plates may also be applied. All structures of the neck may be treated by several turns of an inductance cable, wrapped
FIG. 167.
Treatment
of lower
back by disc electrode.
around several thicknesses of turkish toweling. Finally, a few turns of the pancake coil may be placed over the cervical spine with toweling
interposed.
For long-wave diathermy, two equal-sized electrodes about 2 inches long are placed on the lateral aspects of the neck and held by bandaging. While a certain tilting of the electrodes toward the spine cannot be avoided,
231
they can be kept far enough apart to allow about 600 to 800 milliamperes of current to pass, and this will cause a heating of the intervening parts. Dorsal and Lumbar Spine. The dorsal spine may be treated with the patient lying on his back or abdomen having one narrow condenser pad placed over the dorsal spine and a large dispersive one over the abdomen. The pancake coil may be also applied to the spine with the patient lying
face
downwards.
spine and the sacro-iliac joints may be treated similarly by transverse condenser pads or by the pancake coil. In the sitting patient
The lumbar
spaced condenser plates may be employed, a smaller active one over the region to be treated and a larger one held opposite. Suitably interposed toweling or felt pads are always essential. With long-wave treatment, the patient is placed in either the dorsal or the ventral recumbent position and the electrodes then placed anteroposteriorly. The posterior electrode is the active one and should correspond in size with the area of the spinal column or cord to be treated, the anterior one should be the larger and be placed on the opposite surface of the chest or abdomen. This technique concentrates the path of the current chiefly over the relatively narrow area of the spine. Coccyx. Treatment by the contact plate technique is the most suitable and efficient for treatment of the coccyx. The patient is placed in the ventral recumbent position and a cylindrical electrode (round prostatic electrode) is inserted about 1| inches into the rectum and held in position by sandbags; a piece of tinfoil of suitable shape and size, about 1| inches square, is placed directly over the coccyx and held by adhesive straps or a small sandbag. The patient may also lie in a dorsal position on the coccygeal electrode placed on a pillow. Current is applied at comfortable toleration, about 250 to 300 milliamperes. Organs of the Chest and Abdomen. The possibility of directing diathermy through every cavity and organ of the body makes it a therapeutic measure of unique potency. Diathermy can be applied to the lungs, the heart, the mediastinum, the liver and gall-bladder, stomach and gastrointestinal tract, to the kidneys and, finally, to the pelvis and to every one
of the genito-urinary organs. follows
:
The
general principles of application are as
Electrodes must be of sufficiently large size to allow for the inevitable dissipation of the current in the center; this is just the contrary to the former incorrect teaching, which maintained that the diathermic heat
1
.
could be focused between the electrodes. The heat of diathermy always begins at the surface and travels inward. It is preferable to have electrodes of an equal size, unless one wishes to restrict the heat action to the area of the smaller electrode. 2. Efficient treatment of internal organs demands a treatment time of from half an hour to one hour, because more allowance must be made for warming up the intervening parts. The increase of current strength should always be made gradually so as to avoid unnecessary deep reflexes and increased heat dissipation. Lungs. Ambulatory cases of bronchitis, bronchial asthma and pleurisy can be treated with the patient sitting up in an arm-chair. With shortwave diathermy, treatment may be given by condenser pads or contact
232
MEDICAL DIATHERMY
round the
an inductance coil wound plates placed anteroposteriorly, by surface (Fig. 168). chest, or by a pancake coil placed over the anterior With long-wave diathermy, a plate electrode 5 by 6, is placed over the middle of the back, one of similar size is placed across the front of the held in position by a few chest, moulded to the contours of the chest and turns of bandage. As the patient leans back he secures the posterior eleccurone. (Fig. 150.) trode, he may also hold a pillow against the front rent of 1000 to 1500 milliamperes is applied for twenty to thirty minutes. and in other conditions where the patient is in bed the In
pneumonia
the back by simply depressing posterior electrode may be slipped under the mattress; the anterior one is covered by a thick towel and may be held in firm contact by the hand of the nurse or by a fairly light sandbag. The to place the affected lobes position of the electrodes can be varied so as in the shortest path of the current. It may be advisable to alternate anteroposterior application with bilateral ones (cross-fire diathermy),
by placing
the plates in the axillary regions.
FIG. 168.
Treatment
of chest
by pancake
coil.
Abdominal Organs. Treatment to the stomach, gall-bladder, liver or to the intestines is applied with the patient in dorsal recumbency. The relative size and position of electrodes must be varied according to the
and depth of the organs to be treated. The gall-bladder may be treated by a smaller condenser electrode placed in front and a larger plate under the back. In body treatments administered to the patient in the reclining position, cognizance must be taken of the fact that the weight of the body slightly diminishes the dielectric spacing of the posterior electrode. For increased depth effect considerable spacing or large electrodes must be used. In using long-wave diathermy a 4 by 5 inch or smaller plate, accordsize
A folded towel or small pillow may be placed under the back so as to insure even contact. The anterior plate may be held by a bandage, or by a small sandbag, or by the patient's hand resting on a thick folded
plate.
ing to the size of the individual, is placed over the organ to be treated and a plate of similar size is placed under the back opposite to the anterior
towel placed over the plate. Current toleration ranges from 1000 to 1500 milliamperes duration of treatment should be half an hour or more. In treating kidneys electrodes of equal size and shape are placed over one or both kidneys, and connected to one terminal, while a dispersive electrode, 5 by 6 inches or of a size corresponding to the size of the two
;
233
kidney electrodes is placed upon the abdomen. Patients are best treated while lying on the stomach. A current from 1000 to 1500 milliamperes is
employed. Male and Female Organs.

Rectal Diathermy.
For techniques and genito-urinary conditions.

efficient for treating
see Chapters
on gynecological
The metal contact plate technique is the most the rectum and prostate. For long-wave diathermy, an active electrode is inserted into the rectum and the dispersive electrode is placed above the symphysis. The size and shape of the active electrode depends on the condition to be treated. In ordinary cases the regular cylindrical prostatic electrode will serve; in cases of spasm of the anal opening cone-shaped electrodes of suitable size are employed; in relaxed cases a flat rectal electrode tapered at its base may be used. For treatment of strictures special sized and slightly curved electrodes have been conThe active electrode is held by sandbags or elastic bandage structed. suitably fixed to the electrode. From 1000 to 1200 milliamperes of current should be employed patients as a rule report only a mild sensation of heat in the anus with such a current strength.
;
FIG. 169.
Electrodes for rectal diathermy.
(Frankfeldt.)
The irregular contour of the shoulder presents quite a task for efficient and comfortable application of diathermy. As a general rule, in order to relax all structures, the patient should be reclining on a treatment couch with the arm abducted and propped up
Shoulder and Upper Extremity.
pillows. Short-wave treatment may be given by a pancake or loop placed over several layers of toweling or by spaced plates held antero-posteriorly by treatment arms. Condenser pads may also be applied antero-posteriorly or laterally. For treatment of both shoulders a circular
by supporting
coil
cuff electrode
may
be placed round the middle of each arm.
For concen-
pad or spaced plate may be placed over the region of the bursa and a large dispersive pad or plate held over the lateral chest wall of the opposite side. For long-wave diathermy application can be made antero-posteriorly with electrodes of equal size, from 2 to 3 inches square or 2^ inches wide and 4 inches long, placed opposite each other and equidistant; for longitudinal application, acutely painful shoulder conditions, such as brachial neuritis and subdeltoid bursitis, one-half cuff malleable plate electrode is held across the upper edge of the trapezius; another electrode of the same size and shape is placed across the middle of the upper arm.
Simultaneous treatment of both shoulders
arthritis or bursitis
elastic
tration over the subdeltoid bursa a smaller condenser
may
be employed in bilateral
and held by bands; this technique has practically no effect on chest structures.
suitable shaped plate electrodes,
by two
234
MEDICAL DIATHERMY
FIG. 170.
Curved
disc applied to shoulder.
(Courtesy of Liebel-Flarsheim Co.)
FIG. 171.
Treatment
of shoulders
and lower back by pancake
coil.
FIG. 172.
Longitudinal heating of upper extremity by condenser pads.
235
Elbow. Treatment may be rendered by an inductance cable wrapped round (Fig. 158) or by cuffs applied above and below the elbow or, finally, by semiflexible condenser pads applied laterally. When the elbow cannot be fully extended the cuff method of heating should not be applied, as it will lead to undue current concentration on the flexor surface of the joint. For long-wave treatment the transverse position of electrodes is most
suitable.
FIG. 173.
Wrist treatment by
cuff
and pad.
Wrist and Hand. The inductance cable method is quite effective, either form of a loop wound round the parts or with the hand placed over a pancake coil. The hand also can be treated by being placed between two large flexible condenser pads. Fingers can be heated jointly or singly by being placed in contact with one condenser pad, while the other pad is placed behind the arm, the elbow being held in flexion.
in the
FIG. 174.
Wrist treatment by two condenser pads.
For the treatment of the entire upper or lower extremity either an inductance cable or the circular cuffs can be employed. Cuffs should be as far apart as possible, with a minimum of skin-electrode distance. Two condenser parts may also serve as shown in Figure 174.
230
MEDICAL DIATHERMY
of the wrist, electrodes
For long-wave treatment
may
be placed on
its
around the middle of the opposing surface or a cuff electrode is placed forearm while a cylindrical electrode is held in the patient's grip or the bath. In treatment of the hand and patient's fingers are placed in a water or paraffin bath is much simpler to apply and causes fingers the whirlpool
a more even distribution of heat.
FIG. 175.
Diathermy to hand and wrist by water bath and
cuff
method.
FIG. 176.
Transverse heating of both knees by condenser pads.
Hip and Thigh. Flexible condenser pads or spaced plates may be applied antero-posteriorly with the patient lying down. The pancake coil technique can be also employed, by placing a few turns of the inductance cable directly over the region to be treated. For long-wave treatment,
two
large size (4 by 6) electrodes are placed antero-posteriorly, one above Poupart's ligament, held by a sandbag and the other under the gluteal A current from 1200 to 1500 milliamperes region, held by the body. should easily be tolerated. For the thigh, either antero-posterior or laterotransverse application can be made. Knee. The knee should always be treated with the patient on a table or couch or in a steamer chair with the foot rest raised. The inductance cable is quite convenient using several turns wound around the knee. The same technique can also be employed for treating two (Fig. 152.)
237
knees simultaneously. One may use a cuff above and below the knee. Finally condenser pads or spaced plates may be placed laterally. For long-wave treatment, two broad cuffs, 3 inches wide, are applied one around the middle of the thigh, the other around the middle of the leg and held by a few turns of elastic bandage.
FIG. 177.
Treatment
of ankle
by
coil
method.
(Courtesy of General Electric X-ray Corp.)
FIG. 178
FIG. 178. FIG. 179.
FIG. 179
Diathermy to ankle and heel*(cuff and plate). Diathermy to forefoot (cuff and plate).
238
MEDICAL DIATHERMY
The ankle can be
treated by condenser pads or spaced cable wound around it. It may plates placed laterally or an inductance a condenser pad under the heel and foot and a circular be also treated by similar cuff placed around the middle of the leg. The foot can be treated by electrodes placed warmed up by pad technique. Both feet and legs can be under the sole of each foot. It is important that both electrodes be kept at suitable distance from the floor to avoid loss of energy due to semi-
Ankle and Foot.
conductors.
FIG. 180.
Air-spaced treatment along course of sciatic nerve. Mclntosh Electrical Corporation.)
(Courtesy of
For long-wave treatment, if the ankle is much enlarged the lateral transverse method may be used, placing two oval electrodes about 2 by 3 inches on either side of the joint. On account of the irregular bony prominence of the malleoli, it is more convenient to use the combination plate and
cuff
method.
Safe and efficient heating of all structures of the foot can be accomplished by hot foot baths, especially the whirlpool bath, or by an inductance coil. In another method, a plate is placed under the forefoot and a cuff around the leg as illustrated; a current strength from 300 to 500 milliamperes
may be employed.
FIG. 181.
Diathermy
to sciatic nerve (longitudinal).
Short-wave diathermy may be applied by an inductance the lower extremity, by two condenser pads or airspaced plates: one placed over the lumbar or gluteal region, the other on the posterior aspect of the thigh just above the knee. After twenty minutes treatment this electrode is moved to the middle of the calf, and twenty
Sciatic Nerve.
cable
wound around
239
minutes more treatment applied. A cuff electrode placed around the calf may be also used as the lower electrode. For long-wave diathermy a similar procedure can be used by contact Transverse heating may be accomplished plates, as shown in Figure 181. by a narrow plate about 2 inches wide and 4 to 6 inches long, placed directly over the course of the nerve, with a dispersive electrode of slightly larger size placed on the opposite surface of the groin or thigh. This is the only
really penetrating treatment. The longitudinal method only acts indirectly by warming up the surrounding muscles and other soft parts. Clinically, either method appears effective in most instances. Safety Rules in All Diathermy Treatments. In addition to the general rules for electric treatment in Chapter VI, the following special rules are
to be observed in applying all diathermy treatments: 1. Before applying electrodes inspect carefully the parts to be treated to make sure that the continuity of the skin is nowhere broken and that
the heat sensation of the patient is normal. In case of scar tissue, peripheral nerve injuries, of hysterical anesthesia, be extremely careful in the application of diathermy.
2. Before turning on the current from the main inlet inform the patient that the sensation to be expected is that of mild heat. Instruct the patient to report any uncomfortable faradic sensation, pricking or burning at once. 3. After starting the current through the main switch, open up gradually first the current regulator (rheostat) and then the spark gap in long-wave apparatus. Only practical experience will teach how to manipulate this double control properly. In some short-wave apparatus one control serves to regulate the current in others, first a separate tuning control must be set. 4. Do not try to push the current up to the maximum amount of toleration during the first few treatments. Patients often are burned in their endeavor to show how much current they can stand. Remember the principle that a moderate amount of heat applied for a longer period is more effective than pushing up to the limit of tolerance for a shorter period. 5. If at any time during the treatment the patient complains of an uncomfortable sensation anywhere turn off the controls, shutting off the main current inlet in case of emergency and, if necessary, take off, inspect and reapply the electrodes. When inspecting or adjusting electrodes be sure that the current is turned off and increased gradually again after such a procedure. 6. Do not leave the patient alone during treatment unless you have arranged that by the simple pulling of a cord or the turning of a switch the patient himself can turn off the current at any time. Watch the milliampere meter during the entire treatment for an even flow of the current. 7. At the end of the treatment turn off the controls in the reverse order to which they have been turned on. This will leave all the switches and controls in safe position to start the next treatment. Take off the electrodes carefully and inspect the site of application each time. 8. Let the patient rest after treatment long enough to make sure that the skin has fully cooled off, especially in inclement weather. Correct application of diathermy in the various conditions to be enumerated can only be acquired through ample clinical instruction. It is not
;
fair to
in technique.
reputable manufacturers to expect their salesmen to be instructors The safe and efficient use of diathermy does not consist
240
MEDICAL DIATHERMY
simply in applying a pair of electrodes and then snapping on a few switches. Poor results and at times law-suits for malpractice on account of burns have been the outcome of attempted short cuts from manufacturer to physician, leaving out the intermediary of required instruction in the clinic. Special Precautions With Short-wave Diathermy. In applying shortwave treatment, metallic objects, such as hair pins, safety pins, buttons, keys, knives, watches, buckles should be removed from the field of treatment because they lead to a concentration of electrical energy and the posMetallic chairs or tables, radiators, water sibility of arcing and burns. pipes, electric fixtures or other grounded metal should not be within possible contact with the patient, neither should conducting cables make contact with such objects. Hence it is preferable to use treatment tables and chairs without metallic parts, and use mattresses without inner metal
springs.
Special care must be taken that no cables leading to the apparatus cut across each other or get too close to each other, because this may lead to overheating of their insulation and possible conflagration. This danger
does not exist when using contact metal electrodes with apparatus with extra condensers. Like all other electrical treatments short-wave diathermy should be applied to the unclothed body only, contrary to some ill-advised early assertions that this method enables treatment through clothing. Application of electrodes over the clothed parts breeds carelessness in neglecting the elementary rule of close inspection of the parts before and after every treatment; also the varying thickness of clothing may interfere with correct spacing of the electrodes. Hidden metal objects as well as unsuspected moisture in the clothing are also potential causes for burns.
SPECIAL TECHNIQUES WITH LONG-WAVE DIATHERMY

General Diathermy. The object of general diathermy is to administer a current of sufficient intensity to bring about a mild rise of body temperature. A current from 1500 to 3000 milliamperes is necessary for such
purpose and it requires apparatus of sufficient capacity to produce such current for an hour or more without overheating. General diathermy may be applied by the three plate method: the patient reclines over a large electrode under his bare buttocks; another plate 6 by 6 inches is placed under his shoulders and a third one under the calf of the legs; the two outside electrodes are jointly connected to one terminal, the middle electrode to the other terminal. Another arrangement is the one used for the original hyperpyrexia treatment by diathermy: one electrode is applied to the chest, another to the abdomen and these two are connected to one terminal, while one large plate corresponding in size to the two former ones is placed under the back and connected to the second terminal. General diathermy may be useful in selected cases of chronic arthritis, and in mild degrees pf arteriosclerosis. Auto condensation. Autocondensation is a modified form of general
diathermy. One or two electrodes (metal cylinders or plates) are applied by direct contact to the palms, soles, forearms, or chest, and connected to one terminal of the apparatus, while another very large electrode known as an autocondensation pad and consisting of a large plate separated from

the
241
insulating material (fiber), is connected to the other terminal. the current is turned on the body becomes one part of a condenser, and the metal plate under the pad is the other. If a glass vacuum electrode, grounded through the operator's hand, is held at some distance from the patient under treatment, it will light up and prove the presence of an electric charge all over the body. In the early days of high-frequency treatment the specially constructed autocondensation chair of DeKraft was quite popular. Current from 500 to 1200 milliamperes may be employed for ten to thirty minutes depending on the condition and the type of apparatus and technique used.
body by
When
FIG. 182.
Autocondensation pad.
(Courtesy of Westinghouse X-ray Corporation.)
directly applied
Autocondensation produces local heating where the electrodes are and also slight general heating if the treatment is con-
tinued long enough and the apparatus is sufficiently powerful. The physiological effects of autocondensation correspond to those of general diathermy. In patients with high blood-pressure without marked cardio-vascular changes or in the early stages of arteriosclerosis, there often occurs a drop in blood-pressure of from 5 to 10 millimeters, hence the long-standing popularity of this method in treatment of hyperpiesis
(see Chapter XXIV). and nervous insomnia.
It is also useful in
treatment of functional neuroses
The autocondensation
as described
by
Turrell: 30
chair
is
approached by
also aid in diathermic massage patient placed in the autocondensation the operator's fingers, the operator being grounded,
chair or
pad may
when a
16
242
attracts the current
MEDICAL DIATHERMY
from the patient's capacity. Gentle stroking of the area imparts a pleasant sensation of warmth, which is painful superficial very soothing, especially in acute facial neuralgia. (Oudin) Treatment. Because of the
Monoterminal High-frequency
of the recent interest in short-wave diathermy, the medical employment Oudin current has been almost forgotten, in contrast to its continued Yet the Oudin treatment has some very surgical use for electrodesiccation. and therefore deserves to be retained in our definite clinical usefulness
physical therapeutic armamentarium. In administering Oudin treatment the glass vacuum or condenser electrode is attached to the high voltage (Oudin) terminal and is held close comto the part to be treated. The current strength is regulated by the bined use of the voltage control and spark-gap control; while the length of sparks is regulated by varying the distance of the electrode from the skin thus a variety of effects can be produced.
;
FIG. 183.
Treatment with Oudin current through
glass condenser electrode.
Mild surface heating occurs, when the electrode is held in close contact over an area of the skin for some time. Counterirritation over a larger area may be produced by moving the electrode back and forth in only slight contact with the skin so as to cause definite sparking. Longer sparks and a stronger current cause a marked erythema which often lasts for hours. Gentle stroking massage is exerted when the electrode is kept moving. A very weak current may bring about a mild antipruritic effect. The high-voltage current has a tendency to penetrate the insulation of the conducting cord when the electrode is lifted off the skin, operators should therefore hold the cord iri a folded towel or wooden handle. Dusting talcum powder over the area insures a smooth moving about of the electrode.
Mild sparking with the electrode held fairly close exerts sedative effects on neuralgias of the skin nerves and on other superficial nerve irritations. A heavier spark discharge causes a marked stimulation of the vasomotor nerves and may serve as a counterirritant for relieving deeper seated muscular pain or neuralgia. To tender areas of the skin the Oudin current may be applied through
243
the operator's finger tips; by making the patient hold a metal cylinder connected to the Oudin terminal, he is being charged by the high-frequency current and the finger-tips of the operator will draw a shower of mild sparks along tender spots. This is similar to diathermic massage.
Sparks may be drawn from a patient in contact with a condenser electrode during Oudin treatment if approached by a grounded metal tip and "indirect desiccation" may thus be performed.
is very effective for the relief of such as of the intercostal, supraorbital, occipital and ulnar nerves and in meralgia paresthetica, a painful affection of the nervus femoris cutaneus lateralis. It is also useful in other forms of neuralgia and neuritis such as brachial neuritis and postoperative scar neuralgias. One should commence with a sedative technique, i. e., a mild current strength, a minimum of sparking effect and treatment time of from five to ten minutes and gradually increase these according to the relief produced. Preliminary heating by an infrared or luminous heat radiator is helpful. Treatments are repeated daily in acute pain. (b) In the treatment of recent traumatism such as contusions, traumatic myositis, sprains and in the deep-seated chronic pain of sciatica, lumbago,
Clinical Uses.
(a)
The Oudin
current
pain in neuralgias of the skin nerves,
fairly vigorous sparking by the Oudin current for ten to fifteen minutes often renders instantaneous relief through counterirritation. It is also advisable to precede these applications by luminous heat or local diathermy.
(c) In sluggish ulcers and selected forms of low-grade skin infections high-frequency sparking exerts mild bactericidal, antipruritic and stimulating action. Anal fissures and pruritis, sluggish wounds about the anus and vulva may also be benefited. (d) In hay fever a few minutes daily application of the Oudin current to the nasal mucosa may give symptomatic relief. This has been explained
and tenosynovitis,
of the mucous membrane. It has been recommended treatment with vigorous sparking up and down the spine for the "revulsive" effect. (e) In functional neuroses or in minor degrees of chronic inflammatory changes of inner organs, vigorous sparking of the corresponding skin areas (Head's zones) may bring symptomatic relief. This has been attributed to reflex stimulation through the vegetative nervous system. Such action explains the occasional relief lay people find from "violet ray" treatments self-applied through glass electrodes activated from a cheap imitation
"
by
desensitization
this
"
to
combine
high-frequency
coil.
Combination of Low-frequency Currents With Diathermy. The simultaneous application of low-frequency currents for muscle stimulation and long-wave diathermy for heating as reported by the author26 is based on
A heating current when applied to a congested body area, which may contain unresolved inflammatory exudates, may cause a relief of symptoms, but the material of congestion may not be eliminated and carried away. In such cases a supplemental mechanical agent may further promote repair. The routine method of treatment in traumatic and arthritic conditions in following thermal measures by mechanical ones, is based upon this principle. Muscle exercise is best carried out after preliminary heating. Since a rise of temperature in the tissues brought about by any form of heating will begin to subside
definite physiological considerations.
244
MEDICAL DIATHERMY
as soon as the heating agent ceases to act, it appears advantageous from the standpoint of efficiency as well as of saving time to apply thermal and dynamic measures in certain conditions simultaneously.
The physical principle enabling combined administration of high- and low-frequency currents is a double filtering device which (1) prevents the flow of the diathermy current into the low-frequency generator by a suitable impedance (choke-coil) and (2) prevents the flow of the lowfrequency current into the diathermy circuit by condensers. A coil of thick wire consisting of closely adjacent turns interposed on the lowfrequency side offers an effective impedance to the high-frequency current but offers only a minute resistance to the low-frequency current. A set of condensers on the high-frequency side between the resonator and the binding posts prevents an overflow of the low-frequency current but does not impede the diathermy current. Such a device can be incorporated into an apparatus containing the two types of generators or can be employed as an independent unit in conjunction with any make of long-wave diathermy and low-frequency apparatus. With the described arrangement both currents can simultaneously be delivered to the patient from the same binding posts. In the technique of applying the combined current moist pad electrodes
are employed in order to obviate the possibility of a burning sensation due to the slight polarity effect of the low-frequency current. Diathermy metal can be converted into a suitable electrode by interposing 12 to 16 thicknesses of moist gauze between the plate and the skin. For treating the extremities, the hand or foot may be placed in a water-bath and a circular cuff or semicuff employed around the arm or thigh. The longi-
tudinal technique of application is the rule in order to carry out group stimulation of muscles. For vaginal or rectal administration, the ordinary metal electrode is satisfactory and the author has found that in a number of cases even plain metal electrodes on the skin such as metal footpads
are well tolerated. For trans-abdominal treatment large moist-pad electrodes are employed. Applying diathermy through moist pads increases the resistance in the circuit considerably and also introduces a relative danger of a burn, due to the drying out of the gauze pad in spots.
It is advisable to start with the diathermy current and after it has flowed for five to ten minutes and the parts have begun to become warm, turn on the low-frequency current. In cases of peripheral nerve injury, special precaution is necessary to avoid burns by diathermy. Clinical Uses. The author has employed the combination of diathermy with the surging faradic or modulated alternating current with satisfactory results in the following conditions: (1) in subacute and chronic forms of arthritis, in which there is joint pain and muscular stiffness (longitudinal
technique), (2) in peripheral nerve injuries (slow sinusoidal if there is present), (3) in abdominal adhesions (transverse technique), (4) in chronic prostatitis (metal electrode in rectum, large moist or metal pad over abdomen), (5) in adhesions and stiffness following infections or vasomotor
RD
disturbances of the extremities.
REFERENCES
1.
BINGER, C.
An Experimental Study of Diathermy, A., and CHRISTIE, R. V.: 1-IV, Jour. Exp. Med., vol. 56, Nos. 4 and 5, 1927.
REFERENCES
2.
245
3.
4.
5. 6.
BRUGSCH, H., and PRATT, J. H.: Short Wave and Ultra Short Wave Diathermy, Am. J. Med. Sci., 197, 653, 1939. COULTER JOHN S., and OSBORNE, S. L.: Medical Diathermy: Principles and Practice of Physical Therapy, Hagerstown, Prior & Co., vol. 3, Chap. 22, 1937. COULTER, JOHN S., and OSBORNE, S. L.: Wavelengths in the Heating of Human Tissues by Short Wave Diathermy, Jour. Am. Med. Assn., 110, 639, 1938. CUMBERBATCH, E. P.: Diathermy, 3d ed., London, Wm. Heinemann, 1937. DOGNON, A.: Elementary Biologic Phenomena of Short Wave Action, Rev. de.
phys. ther., 14, 345, 1938.
7.
8.
9.
FURSTENBERG, A., and SCHEMEL, K.: Das Verhalten der Korper- und Gewebetemperatur d. Menschen, Deutsch. med. Wchnschr., p. 1780, 1912. GRANGER, F. B.: Physical Therapeutic Technique, Philadelphia, W. B. Saunders Company, 1929. GUTZEIT, K., and KUECHLIN, W.: Beitrag zur dentalen Infektion und neuer Weg zu ihrer Diagnosestellung durch Kurzwellenprovocation, Munchen. med.
Wchnschr., 84, 961, 1937.
10.
11.
Versuche ueber den Einfluss kurzer elektrischer HAASE, W., and SCHLIEPHAKE, E. Wellen auf das Wachstum von Bakterien, Strahlentherapie, 40, 133, 1931. HEMINGWAY, A., and MCCLENDON, J. F.: The High-frequency Resistance of
:
Human
12. 13.
Tissue,
:
Am.
Jour. Physiol., 102, 56, 1932.

of Short
HILDEBRANDT, F.
1274, 1929.
Pharmacology
Waves, Jour. Am. Med. Assn.,
112,
HOLMQUEST, H.
:
14.
J., and OSBORNE, J. G.: Heating of Electrolytes by High Frequency Currents, Am. Cong. Phys. Ther., September, 1933. Present Status of Short Wave Diathermy, Arch. Phys. Ther., 20, 559, KOVACS, R.
1939.
Point Heating and Mechanical Effects of Short Waves, Arch. Phys. Ther., 21, 362, 1940. 16. LIEBESNY, P.: Film shown by Liebesny, and discussed by W. KRASNY-ERGEN, Internat. Congress Short Wave, Vienna, July, 1937; Athermic Short Wave Therapy, Arch. Phys. Ther., 19, 736, 1938. 17 MCLENNAN, J. C., and BURTON, H. C.: Selective Heating by Short Waves and
15.
KRASNY-ERGEN, W.:
18.
McLouGHLiN, C.
MITTELMANN,
Its Application to Electrotherapy, Canad. J. Res., 19, 736, 1938. Effect of Short Wave Diathermy on Intestinal Activity, J., et aL:
Arch. Phys. Ther., 22, 325, 1941. E., and KOBAK, D.: Dosage Measurement in Short Wave Diathermy, Arch. Phys. Ther., 20, 725, 1938. 20. MITTELMANN, E., OSBORNE, S. C., and COULTER, J. S.: Short Wave Diathermy Power Absorption and Deep Tissue Temperature, Arch. Phys. Ther., 22, 133,
19.
1941.
R.: Action of an Electric Field of Ultra High Frequency on the Function of Nerves, Bull, de biol. et de meU exper. de 1'URSS, 4, 237, 1937. 22. MORTIMER, B. Experimental Hyperthermia Induced by High Frequency Current, Radiology, 16, 705, 1931. 23. PATZOLD, J.: Short Wave Therapy as a Superior Form of Deep Heat Therapy, Brit. J. Phys. Med., 11, 27, 1936. 24. REITER, T.: Some Investigations of Properties of Short Waves, Brit. Jour. Phys.
21.
:
MOGENDOVICH, M.
Med., 8, 119, 1933. Report of the Committee on Standardization of Physical Therapeutic Apparatus of the American Electrotherapeutic Association: An Apparatus for the Combined Application of Diathermy and the Rhythmically Interrupted Slow Sinusoidal Current, Richard Kovdcs, Chairman, Phys. Ther., 48, 5, 1930. 26. SCHERESCHEWSKY, J. W.: The Physiological Effects of Currents of Very High Frequency, Pub. Health Rep., 41, 1939-1963, 1926. 27. SCHLIEPHAKE, J. Short Wave Therapy, London, Actinic Press, 1936. 28. SCHMIDT, C. R., BEAZELL, J. M., and IVY, A. C. Effect of Heat Applied by Elliot's Treatment and Short Wave Diathermy on Blood and Lymph Flow of Intestine and Colon, Arch. Phys. Ther., 18, 677, 1937. 29. STEEL, M. A Study on the Influence of Electricity on Metabolism, Am. Jour. Elec.
25.
:
30.
and Rad., April, May, 1918. The Principles of Electrotherapy and Their Practical Application, TURRELL, W. J. 2d ed., Oxford Med. Publ., p. 113, 1929.
:
CHAPTER
XII
HYPERTHERMY
ological Effects.
Methods.
Hydriatic Methods.
Electrical
Methods.
Physi-
Gonorrhea and Its ComClinical Uses. Bactericidal Effects. Other Conditions. Contraindications. General Technique. Syphilis. plications. Complications. Preparation. The Inductance Period. The Maintenance Period.
General Considerations. The production of fever for the increase of the protective and defensive mechanism of the body has taken a definite place in modern therapeutics. Following the original method of malarial inoculation for fever production a number of methods have been developed for raising body temperature such as by inoculation with typhoid vaccine
as well as by various physical methods. It has been that in the clinical results achieved, the sustained temperature recognized elevation in the body is the important factor. Electrical methods of raising body temperature were the first to be applied generally, and for these the term electropyrexia has found general However, equally good results can be obtained by other acceptance. methods and the term of artificial hyperpyrexia or hyperthermy physical
and other substances
The advantage of is therefore more suitable because it is all inclusive. hyperthermy over other therapeutic fever methods is that it is sterile, always available and the intensity of the febrile reaction is under accurate
control.
cases.
hyperthermy: there
Different pathological conditions require different degrees of is no uniform scale of hyperthermy applicable to all The physiological consideration, indication and contraindications
and various phases of hyperthermy are principally alike in all methods. For practical reasons the entire subject matter will be presented in this
chapter.
METHODS OF INDUCING HYPERTHERMY

Hyperthermy by physical means is brought about partly by supplying the body with a suitable amount of extra thermal energy from without and partly by preventing heat loss from the body. The temperature of the human body can be raised by external forms of heating which primarily heat the skin and in turn affect the inner organs via the blood stream and deeper circulation. Among these belong the various hydriatic procedures, heat radiation from luminous and infrared sources and circulating superheated air. Penetrating forms of heating effect
more
of a general heating of all body tissues. These consist of long-wave diathermy and short-wave diathermy. The body temperature can be raised equally efficiently by both forms of heating. In the heated body the heat regulating mechanism attempts to bring about heat loss, partly by radiation and partly by vaporization of water from the skin and lungs. Regardless of the method of heating used, careful attention must be given to prevent heat loss from the patient if a fever temperature is to be maintained for a number of hours. During the stage of evolution tight wrapping of the body with blankets or placing it in an insulating "zipper" treatment bag was employed but both methods were
(246)
247
largely discarded because of the discomfort of close confinement, the irritation of excessive perspiration and the inability to satisfactorily observe the patient's skin during the entire treatment time.
Cabinets are considered the most satisfactory method for the prevention in these the surrounding temperature is maintained at a level above fever temperature, usually by hot humidified air; as a matter of fact one of the most efficient types of fever apparatus consists of nothing else but an "air-conditioned" cabinet. The chief advantage of cabinets is that the patient is free to move and thus more comfortable. There is less likelihood of a burn and all parts of the unclothed body can be observed during treatment through either a transparent window or side openingst Hydriatic Methods. A hot water bath is undoubtedly the simples, means for quick elevation of body temperature, but is neither comfortable nor safe. The patients may be immersed in a full bath at 105 F., the
of heat loss
;
FIG. 184.
Luminous heat
cabinet.
(Courtesy of Dr. Stafford L. Warren and Journal of the
American Medical Association.)
water temperature is gradually raised to 110 F., and the patient kept in the tub until his temperature is within 1.5 of the desired height. This method has only been found practical for short and low fevers. Hot water bottles placed around the patient wrapped in heavy blankets may serve as another simple but most uncomfortable hydriatic method. Hot vapor or steam or hot-water spray cabinets are more efficient; for the last procedure a somewhat elaborate apparatus is available, in which the temperature is raised by a spray of nebulized hot water. A thermostatic control serves to maintain the water temperature, and also enables a quick shift to a spray of cool water to refresh the patient momentarily without
impairing the temperature
Electrical
rise.
a large number of properly insulated wires incorporated with rubber, the temperature of the blankets being controlled by a rheostat. These blankets are less expensive
Methods.
Electric blankets consist of
than other fever apparatus; however, not alone is their close confinement uncomfortable to the patient, but in poorly constructed and non-moisture
proof blankets, there the blanket.
is
also a definite
danger of short circuits and
fire
to
248
HYPERTHERMY
Luminous heat cabinets consist usually of a box of celotex or wood, fitting over a table or hospital bed, or it may be a single unit. A number of carbon filament lamps (5 to 6) of a wattage of 100 to 200 are wired in the top of the box and controlled by a rheostat. The patient is placed in this box
with his head protruding from one end through an opening around which serves to prevent heat loss. suitably shaped cloth or soft rubber insulation cabinets sliding doors at the side allow access to the patient at In most 5 all times. Bishop, Lehman and Warren state that heating by radiant energy is the most convenient and economical method. (Fig. 184.)
FIG. 185.
Air-conditioned fever cabinet.
(Courtesy of
The Liebel-Flarsheim
Corp.)
light cabinets but are bottom of the cabinets
Non-luminous heat cabinets are similar in construction to the electric heated by resistance coils, usually placed at the from which the heated air ascends. There is avail-
able a simple hot-air cabinet containing a shallow copper trough filled with water at the bottom of the cabinet, which is kept simmering by a
flat coil
heater in addition to three large 600-watt heating elements. This cabinet supplies humidified air at a temperature varying from 120 to 130 F. (Atsatt 1 ).
The air-conditioned cabinet developed by Simpson, Kettering and Sittler an apparatus in which air temperature, relative humidity and air velocity may be fully controlled. (Fig. 185.) The walls of the cabinet are heavily insulated and rust-proof. There are two chambers in the cabinet. A large
is
one, for the patient, has a semicircular portion cut out for the patient's head and neck ; a small chamber at the foot end contains the air conditioning
of the heater, humidifier, blower, thermostat and a humidostat, all operated by electrical current. The heating element is a resistance unit of 1550 watts, controlled by the thermostat. The humidity is secured by a pan of water heated by a 2000-watt electrical immersion heater. The water level is maintained by a reservoir placed outside the cabinet and regulated by a self-feeding water system. Humidity is regulated by the humidostat and is checked by dry- and wet-bulb thermometer
mechanism, consisting

readings.
249
The air thus heated and humidified is circulated through the upper portion of the chamber by the blower. The air is forced through the holes at the head end of the cabinet and returns by the grill at the foot end. The circulation is adjusted to a change of about 10 times a minute or an air velocity of 200 cubic feet per minute.
General diathermy
Xeymann and Osborne 21 and was
by the long-wave method was first reported on by applied by special apparatus with about
double the output of the ordinary long-wave machine. Large flexible metal electrodes were applied antero-posteriorly on the body and held by a tight fitting canvas jacket. The modern, safer and infinitely more comfortable short-wave diathermy methods using cabinets have made this
method
obsolete.
In this method as first developed by Whitney 32 patients were placed between two large condenser plates activated by a short-wave apparatus producing 30 meter waves. The patient was surrounded by blankets or placed in an insulating zipper bag. Due to accumulation of perspiration, which acts as a condenser of the energy over some areas, burns occurred frequently.
Condenser Field Heating.
FIG.
186.
electropyrexia.
Combination of luminous heating and spark-gap condenser field heating (Courtesy of the Lepel High Frequency Laboratories.)
for
Recent types of condenser field fever apparatus employ large electrodes held by suitable treatment arms above the patient's body. The author for a number of years has used most satisfactorily a home-built cabinet
which contains on top a double row of 150-watt bulbs controlled by a rheostat. Two large condenser plates connected to a short-wave apparatus are held in a grating above the patient (Fig. 186). The placing of air-spaced electrodes above the patient aims to prevent condenser effects on accumulated moisture and subsequent burns. After the induction period the short-wave energy is turned off and cabinet temperature is maintained at
110
F. by burning of the light bulbs. Coil Field Heating or Inductothermy.
efficiently or held in
cable
is is
ment
General body heating is being accomplished by inductance cable wound around the patient a form of a single loop either above or below the body; this connected to the short-wave diathermy machine. Such arrangenormally provided in connection with a metal fever cabinet in
250
HYPERTHERMY
which the patient lies on a special type of mattress. Suitable humidity is also maintained by a water container, fill able from the outside, a water heater and a fan. There are also available combination fever cabinets which provide air and temperature conditioning within the cabinet itself, both humidity the same time the cabinet is wired for coil field heatbeing controlled; at in the initial stage of the ing, which enables a lower cabinet temperature treatment, only one or two degrees above the required patient's temperature.
FIG. 187.
Inductance cable heating in fever cabinet.
(Courtesy of the General Electric
X-ray Corporation.)
In spite of the great variety of efficient and elaborate fever therapy 27 apparatus available one must emphasize again with Simpson that the skill of personnel far transcends the perfection of apparatus and that the worst possible apparatus managed with skill and the best possible technique is much more likely to give good results than an excellent apparatus placed in unskilled hands. One factor of equal importance is the careful selection
of cases.
Requirements
for
Fever Apparatus.
by the Council on Physical Therapy
In discussing the evidence required for consideration of apparatus used
in fever therapy, it is stated: 8 "The most acceptable device would seem to be of the cabinet type, so arranged- that the patient during the treat-
ment and
accurate
is
way
his physical needs can be attended to conveniently. The only of keeping close check on the temperature of the patient
by using the rectal thermometer. Hence, means should be provided to read the temperature conveniently. The unit must be so constructed that the patient may be withdrawn with facility, in case of emergency, and restorative treatment administered. The Council emphasizes the
PHYSIOLOGICAL EFFECTS
251
convenience and safeguards attached to apparatus as fully as it does the physical claims made for such apparatus. The paramount question is not so much one of the most suitable methods of raising the body temperature as of the safety to the patient with any particular method."
Artificially produced fever causes marked changes in the physiologic functions of the body. To a certain extent these changes are an intensification of those following mild general heating of the body and shown in the comprehensive table by Bazett (see Table 26). The close observation of these changes during the entire treatment period is the best safeguard
against untoward physio-pathologic complications leading to collapse and possibly death. The pulse-rate increases with the rise of temperature but there is no generally accepted fixed rule regarding this increase. With the temperature maintained at a given level for a considerable period, the pulse-rate may rise or fall. Any sudden rise of this rate as the temperature is being prolonged or a marked rise of the pulse as the body temperature is rising, must be regarded as a definite sign of danger. rate of 160 or more should indicate that the danger zone is being reached. The blood-pressure shows usually first a slight elevation of the systolic level and a decrease of the diastolic pressure to 60 to 50 mm. With the rise of temperature the circulatory rate is greatly increased, with a maxiincrease between 103 and 100 F., and there is a marked increase in the pulse volume in the fingers of the patient. The venous pressure may
mum
show marked fluctuations in either direction. The number of red and white cells is increased.
Leukocytosis occurs
at the height of the fever with usually a high polymorphonuclear count and a relative decrease in the lymphocytes and monocytes. There is only
a slight change in the blood chemistry. The blood plasma volume is decreased during artificial fever due to concentration of blood from loss
of fluid
The
by sweating. basal metabolic-rate increases at a rate of about 7 per cent for
each degree rise in temperature. Every patient who has undergone five hours or more of fever treatment will lose from 4 to 5 pounds of weight, due to the fluid excreted by perspiration. The urine may be suppressed at the beginning due to sweating but the total output is usually normal. The loss of chlorides through the Specific gravity may be increased. perspiration may amount to 20 to 26 grams in one febrile session. All these changes return to normal after a few hours. The loss of fluids through the skin, the lungs and the urine brings about a disturbance in the acid-base balance of the blood. This as well as the decrease of its carbon dioxide content brings about a pronounced alkalosis. The degree of alkalosis which approaches critical levels is dependent,
upon the severity of dehydration and, secondarily, upon the extent of the hyperventilation. Hence the maintenance of a proper fluid intake during the treatment is vital, especially if long treatments are administered. In severe cases intravenous administration of fluid is indicated for the restoration of the diminished blood volume. Another important consideration is the maintenance of the chloride balance, requiring the administration of salt solution from the very beginning of treatment.
primarily,
252
HYPERTHERMY
Placing the body in an environment of extremely high humidity (over 80 per cent) also minimizes the loss of fluids through insensible perspiration.
The relative physiological effects of external heating and penetrating 2 21 23 Neyheating have been studied by Neymann, Phillips, and Benson. mann has shown that external heating reverses the natural temperature gradient of the body; during the rise of temperature the skin temperature mounts above the internal temperature and continues at this pathological level for some time after the fever temperature has been reached. Because
^^
FIG. 188.
Typical fever chart in short-wave fever treatment.
(New York
Polyclinic Hospital.)
the heart-rate depends on the temperature of the skin it is decidedly higher when external heat is used to induce fever. The capillary pulse volume is also relatively increased by external heating while the amount of perspiration is relatively decreased. Because he considers external heating more exhausting Neymann favors electromagnetic fever induction. Phillips, corroborating the irritating effect of high external temperatures on the pulse-rate, recommends that if air-conditioned cabinets are used in combination with penetrating heat the cabinet temperature should be relatively low 105 to 110 F. and the saturation high, 85 to 90 per cent. Krusen 18
CLINICAL USE OF HYPERTHERMY
253
corroborated these findings with the newer technique of hot humid air cabinet technique, in which 130 F. is only maintained during the induction period and the cabinet temperature is then allowed to drop to 110 to 115 F. during the maintenance period. Krusen therefore concludes that the lowering of the pulse is not the result of the employment of internal heat, but of the relatively low environmental temperature and for this reason prefers to use the air-conditioned cabinet alone. Bactericidal Effects. Artificial fever treatment became recognized as a specific therapy when it was shown that it could destroy in the human body at least one very prevalent pathogenic organism, the gonococcus, without injury to the human host. The basic principle of this effect was clarified by the research of Warren et al They established that 99 per cent of all strains of gonococci were destroyed at a temperature of 105.8 F. (41 C.) in five hours whereas the remaining 1 per cent of gonococci required as much as twenty-three hours to be destroyed completely. The thermal death time of Treponema pallidum was established by the same investigators at 106.8 F. (41.5 C.) in the laboratory at one hour. In humans with early syphilis these results are not so clear cut
as in cases of gonorrhea.
Regarding meningococci, Moench found some significant changes in reduction of growth after temperatures from 104 to 107.6 F. Doan 11 calls specific attention to the tremendous increase of phagocytic
20
cludes that
nodes, spleen and liver following hyperthermy and connot only provides the thermal factor of importance for eradication of the gonococcus and the spirocheta pallida, but also exerts a powerful effect in the cellular equilibriums of the body. It acts as an "assistant extraordinary" to the humoral defense mechanisms of the body. The presumable clinical benefits of fever therapy have been summed
cells in
lymph
it
15 up by Hench, Slocumb and Popp as follows: (1) A direct bacteriolytic or bacteriostatic effect due to the influence of heat itself on bacteria (without necessarily implying formation of immune bodies); (2) an indirect bacteriolytic or bacteriostatic effect resulting from increasing formation or mobilization of immune bodies; (3) a local effect from vasodilatation, providing an augmented blood supply to inflamed tissues, and (4) a general effect from the heightened metabolism incident to fever.
CLINICAL USE OF
HYPERTHERMY
Fever therapy has undergone a period of enthusiastic experimental in a large number of conditions, often without much rhyme or reason as to its clinical rationale. There can be no doubt that in gonorrheal infections it is of specific value, but even here, subsequently modern discoveries of chemotherapy have brought about a much more simple alternate. By this time the rationale and effectiveness of fever treatment has been definitely established in a limited number of conditions and has become part of standard therapeutic practice.
work
The list of the established uses of fever therapy in various conditions, with some comments will be given here; particulars, technique and detailed discussions of results will take place in the part on applied physical therapy.
Gonorrhea and Its Complications. Warren 29 and his associates determined the "thermal death time" of an infective strain of gonococci at
254
106.7
HYPERTHERMY
F. and subjected the patient to the temperature sustained at this Practically 100 per cent cures have resulted from this procedure. 30 average length of fever treatments of Warren, Scott and Carpenter 14.8 hours. Other clinicians hold that in the great majority of cases
time.
The
was
Krusen, Randall and such prolonged treatments are not necessary. Stuhler17 of the Mayo Clinic reported that with single ten-hour sessions at 106.7 F. negative cultures were produced in a high percentage of cases 10 with gonorrhea. Desjardins, Stuhler and Popp of the same clinic reported that in 90 per cent of cases three to six sessions at six to ten hours are 3 sufficient to effect a permanent and complete cure. Bierman doubts that is an exact parallelism between the thermal death time of a particular there strain of gonococcus in vitro with a fever of the same height and duration in its living human host. He states that the percentage of favorable results reported by those giving shorter treatments is about as good and that
when the gonococci survive an
initial heating they disappear following 30 treatments at no greater duration and temperature. Warren subsequent himself admits that a fever with a duration of only 20 per cent of the thermal death time will often cure a patient who is in good physical condition, especially patients with acute infections. Combined systemic and additional local heating for the treatment of 4 They gonorrhea in the female was devised by Bierman and Horowitz. and then apply additional first elevate the temperature by physical means heating to the pelvic organs by diathermy. The average number of treatments for the eradication of all gonococci in a series of 121 cases was 1.4
per patient. (See Chapter on gynecological conditions.) Gonorrheal complications such as epididymitis, prostatitis,
vesiculitis, pelvic cellulitis, cervicitis, salpingitis
seminal
and gonococcic ophthalmia
showed similar satisfactory response.

Gonorrheal arthritis according to unanimous reports receives almost dramatic relief from fever treatment. Eighty-eight per cent of the patients with acute gonococcic arthritis were promptly cured according to
Hench
et a/.;
15
these results are striking and apparently superior to those

of sulfanilamide
obtained by other methods.
The advent
and
its
derivatives for the treatment of
infections brought about a considerable decrease in the demand for fever therapy as the first line of attack on gonorrhea. However, it soon developed
that there were cases which failed to respond to chemical treatment, whereas they promptly yielded to combined fever and chemical therapy. A combination treatment has been worked out with the following routine: sulfathiazole 2 gm. is given at 12 noon the day before fever, repeated at 2 P.M., 6 P.M. and 10 P.M. the same day and at 2 A.M. and 6 A.M. on the next day. The fever treatment of eight hours at 106 F. is started at 8 A.M. that day. No other medication is given. Favorable results of such combination treatment were reported by Phillips and Mundorff, 24 King et a/., 16
Bundesen
et a/.
Syphilis.
Carpenter,
Boak and Warren 7
established the death time of
treponemas in the laboratory at 41 C. (105.8 F.) as one hour and cured rabbit syphilis in several sessions of temperatures between 41 and 42 C.
lasting six hours.
Clinical studies in
humans with
early syphilis
by Simp-
son 27 and others, with fever between 105 and 106 F., for fifty hours led to the prompt healing of the clinical lesions in some cases, but not to a
CONTRAINDICATIONS TO HYPERTHERMY
255
reversal of the positive serological findings; furthermore, there was a relapse in a few cases. It was therefore concluded that while sustained fever will
quickly kill the vast majority of spirochetes and quickly heal all skin lesions, it will not affect the more resistant germs in the lymph glands, and these serve as foci of reinfection. Evidence presented by Simpson points to the fact that fever treatment
combined with chemotherapy (arsphenamine and bismuth) will considerably reduce the average length of treatment and that in patients resistant to chemotherapy its combination with fever therapy is distinctly advan6 tageous. Bundesen et a/ report favorable results in early syphilis by the
following fever chemotherapy routine: eight hours of fever at 106 (rectal) in the air-conditioned cabinet, first dose of mapharsen when the tem-
perature reaches 100, a second and third dose at the beginning of the
third
and
fifth
hour of maintained
fever.
Neurosyphilis and Wassermann-Fast Syphilis. In symptomatic neurosyphilis, asymptomatic neurosyphilis, ocular syphilis and resistant seropositive syphilis the results with fever therapy are at least comparable, if not superior to the results obtained with the more hazardous, time22 consuming and inconstant malaria therapy (Simpson). O'Leary states: has a high thermal death point (114 F.) so it would "Spirochseta pallida appear that the favorable results obtained in neurosyphilis by fever therapy whatever the type may be, are the result of some biological phenomena, the nature of which at present is not known." For further details see Chapter on affections of central nervous system. Chorea. In the majority of cases reported on there were excellent immediate results in the choreic movements of patients, with recovery in the majority of cases. Complicating rheumatic carditis showed striking
Chapter XXVII. Encouraging reports by Philipps and others, justify fever therapy in cases of intractable bronchial asthma which fail to respond to other treatment. Mild degrees of fever should be employed. Chronic Arthritis. Reports in this condition vary chiefly on account of the variety of types treated and the difference in the method and scale of fever. There seems to be enough evidence to point to the value of mild fever therapy in infectious cases of arthritis. Good results were also reported in painful neuritic and radicular affections. For details see Chapter on
response.
For
details see also
Bronchial Asthma.
chronic arthritis.
Multiple Sclerosis. Fever therapy may result in temporary remission, but in advanced cases has no value. Other Conditions. Reports are on record on the favorable effect of fever therapy in rheumatic fever, undulant fever, lymphogranuloma venereum, meningococcus meningitis, corneal ulcers and iritis and a variety
of chronic skin conditions.
CONTRAINDICATIONS TO HYPERTHERMY
To subject a patient to an artificial fever of from 105 to 106 F., sustained for five hours or more, is to subject him to a fairly strenuous cardiovascular functional test, according to the Council on Physical Therapy. 8 Patients with normal heart, kidneys and blood-vessels tolerate it well, but patients with myocardial degeneration or with valvular, coronary or
256
HYPERTHERMY
other cardiac abnormalities, with impaired renal function from organic or with disease, with excessively high blood-pressure or arteriosclerosis, tuberculosis, diabetes or far advanced syphilis of the central nervous system (late, rapidly progressing neglected cases, or patients who are well and should not be totally demented) do not tolerate such treatment
subjected to it. 31 Additional contraindications listed by Warren are chronic alcoholism, acute respiratory infections and those rendered susceptible to heat prostration by a low salt intake during summer months. Mild valvular damage with full compensation is not necessarily a contraindication in patients
under thirty years of age.
The age limit for administering fever treatments is about sixty years. Children of an age of two years have been successfully treated.
GENERAL TECHNIQUE OF HYPERTHERMY

Preparation. A patient for fever treatment must undergo a thorough physical examination which should include a complete blood count and a twenty-four-hour specimen of urine. Any serious cardiorenal condition
must be excluded and in doubtful cases an electrocardiogram, a roentgenogram of the chest and a chemical examination of the blood and that of the total sodium chloride in the urine should be made. If the fasting sugar
level is low, a glucose tolerance test is advisable to determine the posThe patient should have an sibility of a pending hypoglycemic shock.
ample bowel movement the day before the treatment; if not, the large bowel should be evacuated the night before by an enema or colonic irrigation. If a laxative or cathartic is to be given, this must be done early so that its results subside before treatment begins. Patients are encouraged
to drink large
amounts
of fluids the
day before treatment.

19
for all preliminary conditioning session is advocated by Krusen cases which are to receive a fever treatment of six hours or longer. It is given the afternoon before and consists of an erythemal dose of ultraviolet radiation, followed by immersion in a tub of hot water at 105 to 108 F. for iialf an hour, and wrapping the patient loosely in blankets for another hour and a half; all this in an effort to make the patient more tolerant to the long fever treatment. Krusen also states that on the morning of the treatment, 500 cc. of 5 per cent dextrose in physiologic saline solution may
be injected intravenously. Treatment is started about 8 or 9 A.M. and patients may arrive at the hospital just before that time or be admitted the night previously. Only a fluid breakfast should be taken. Patients are weighed and their temperature, pulse and respiration recorded as they are placed in the apparatus. A quiet, slightly darkened room is preferable and friends and relatives should not be allowed to visit. The specially trained nurse should give her full attention to the patient and the physician in charge should frequently visit and encourage the patient especially during the period of
fever induction.
Knowledge of the medical supervision and nursing care of fever therapy can be acquired only under competent instruction with actual} cases. The details of manipulation of controls of various types of fever apparatus can be explained by their manufacturers, but this is only the preliminary

to
257
an adequate clinical experience. Only the essential steps for the principal types of apparatus will be discussed here. Initial Steps. 1. Inductothermy or coil field method. The single loop of the cable is permanently fixed to the framework, which supports the latex mattress which is covered with terry cloth to absorb perspiration. Before placing the patient in the cabinet it should be preheated to 110 F. by the resistance heater; during this time the head opening should be closed with a pillow. After the preheating the completely undressed patient is placed in the cabinet and the short-wave apparatus is turned on, with its full output properly tuned, while the cabinet temperature is maintained
at
110.
2.
Condenser
field
method.
If
short-wave diathermy
is
applied in a
must be preheated as before. The nude patient is placed in the cabinet and the two condenser plates are suitably adjusted over his chest and abdomen. The full output is turned on and the patient is instructed to report any "hot spots" or any other unpleasant skin sensation
fever cabinet this
at once.
3.
f
F. Air-conditioned cabinets. The fever cabinet is preheated to^BO After the patient enters his body is covered with a thin linen terry sjieet cloth. After the desired temperature has been reached, the cabift|l; temperature is lowered to 110 to 115 F. There are two steps in the production of artificial fever by physical means. One is the elevation of temperature to the desired level, also known as the induction period of fever, and the other is the maintenance of the fever level. The induction period is the most trying part for both
patient and nurse. The Induction Period. After the patient has been placed in the apparatus and the controls for the administration of heat energy set, his temperature, pulse and respiration are recorded every fifteen to twenty minutes and any sudden changes are immediately reported to the physician in charge.
The
rise of temperature does not take place evenly in patients. Some have a tendency to a rapid rise, in others or in the same patients at different
times the rise may take place more slowly. It is safer to cause a rise of not more than 1 F. every twenty minutes. In all events the rise of temperature to an average of 106 F. should take at least ninety minutes in
methods. In all apparatus it is advisable to discontinue the electric energy when one degree below the desired height of temperature has been reached, because in most well-insulated patients the temperature keeps on rising after the heat-regulating mechanism of the body has been overcome. The temperature should never go above 107 F. and at the first session stay well below that height. In cases where there is doubt as to how the patient will stand the treatment a trial treatment of shorter duration and less fever may be planned. Temperature measuring is done in the rectum and in the majority of cases an ordinary clinical rectal thermometer suffices. With all forma of high-frequency heating, the apparatus must be turned off when the rectal
all
temperature
is
false readings.
taken, otherwise the heating of the mercury will lead to In purely air-conditioned and luminous heat cabinets it is
possible to use indicating electric thermometers, with their thermocouple ending left constantly in the rectum. These devices are expensive, but are
17
258
HYPERTHERMY
labor savers and give immediate warning if the temperature should have a continuous recording tendency to "overshoot." An instrument for the
of rectal temperature
is
available.
counted over the temporal artery. A rise of pulse-rate over 160 is a danger signal and if it remains at this level for one hour, treatment must be discontinued. If there is any question of cardio-circumust be taken at intervals. Dropping latory disturbance the blood-pressure below 80 mm. of mercury and a pulse-pressure of the systolic-pressure below 30 mm. of mercury calls also for immediate discontinuance of
(Fig. 189.)
The
pulse
is
treatment.
FIG. 189.
Continuous recording rectal thermometer.
As the temperature perspire and a number
of the patient keeps of
on
rising, patients
begin to
them show a period
while the fever rises from 102 to 104 mental make-up of the patient how troublesome this period is. Most of those of a determined type used to self discipline will go through this period under encouragement by the nurse and physician, with only a frequently changed cold moist compress over the forehead and a few cold drinks. Many patients will require a sedative. Finally there are very occasional patients who want to get out of the cabinet or their wrappings or women
of mild excitement, especially F. It depends entirely on the
who become hysterical and in whom treatment cannot be kept up. The administration of sedatives during fever treatment has received
ful study.
care-
It has
hyperpyrexia is the heat center as well as a depression of the respiratory center. Hence only small and single doses of sedatives may be given safely. In the average patient a small dose of amytal (3 grains) or 1J grains of pentobarbital sodium given just before treatment or at the beginning of the restless
been established that the effect of sedative drugs during greatly enhanced and there is also a probable effect on

period
259
is helpful and well tolerated. In others the hypodermic administration of J grain of morphine or J grain of pantopon is more effective. It is not advisable to repeat this dose in case of continued restlessness.
administration of fluids during the entire treatment is of vital Patients not only get great comfort from repeated drinks from an iced solution of physiological salt solution, lemonade, orange juice, carbonated beverages, or sweetened tea, but proper fluid intake is also
The
importance.
essential for the prevention of heat prostration and the more rapid restoration of the acid-base balance of the blood. During an average six to ten
hours treatment, the patient should take 3 to 6 liters of a 0.3 or 0.6 per cent solution. Drinking of large quantities at one time should be discouraged because it may lead to nausea. The average temperature of fluids should be from 50 to 60 F. so as not to interfere with the maintenance of the fever. Period of Maintenance. During this period the technician must exert continued watchfulness to prevent unnecessary heat loss from the body. Such loss may be caused by frequent opening of the side doors of the
sodium chloride
cabinet, by passing into it cold urinals or bedpans, by prolonged cold packs on the neck, by large amounts of cold fluids ingested. During fever treatment some patients may not have normal bladder sensibility and the urge to urinate may not be manifest. A vague aching distress in the lower abdomen is usually due to a distended bladder. At the height of fever temperature many well managed patients doze off and keep on sleeping during the entire maintenance period. This period may be extended from three to seven hours, according to the condition treated and the patient's tolerance. More than six hours of continued fever, especially around 106 F. entails a serious strain on the vasomotor system and requires great care. The fever maintenance is accomplished according to the method administered; with patients in well insulated fever cabinets the temperature usually stays up with the proper setting; if the temperature shows a tendency to drop, the heat-producing energy must be turned on again for an appropriate period. End of Treatment. After completion of the treatment time, the patient is taken out of the insulation or the cabinet, comfortably placed in bed, and his temperature will gradually drop to normal. According to the
some hospitals, patients are kept resting in the physical therapy department until their temperature has become normal, in others they are sent to their hospital beds. One must be careful not to expose the patient or allow him to become chilled at this period. When the temperature nears normal an alcohol rub may be administered. After a long fever session, patients must be restrained from food for a few hours, and
available facilities in
their temperature should be observed for the next twelve hours. Patients upon reaching their bed usually fall asleep and wake up next morning some-
what fatigued. After shorter three- to four-hour fever sessions most patients feel quite normal and can be kept in bed often only with difficulty. With efficient physical Height, Duration and Frequency of Fever Sessions. methods it is possible to produce temperature elevations of a height only limited by considerations of safety and maintain them at this level for
many hours. The rate and limit of rise depend on the amount of heating energy introduced, on the mass of the patient and on the efficiency of
insulation.
260
HYPERTHERMY
Clinical experience during the past few years has developed two ranges F. of therapeutic fever, mild and severe. Mild fevers from 103 to 105 are maintained for three to six hours and may be employed in syphilis
various sequelae, in chorea, multiple sclerosis and other diseases, as well as in selected forms of arthritis and rheumatoid conditions. Severe F. are maintained from five to seven hours or fevers from 105 to 107 and are chiefly employed in gonorrhea and its complications. The longer was twenty-seven hours. longest fever maintenance reported by Warren at the New York Polyclinic HosThe following table is being employed interested in the routine of fever pital for the information of physicians
and
its
therapy.
TABLE
29.
REFERENCE TABLE FOR HYPERTHERMY TREATMENTS

Treatments
Duration, hours
Disease
Number
.
Frequency
2 x 1 x 2 x 1 x
Height
Gonorrheal complications (including

arthritis)
Neurosyphilis Ocular syphilis Arthritis (rheumatoid)
......
.
4 to
.
.
6 6 to 10
.
6 to 10
week week week week
105 to 107 105 103
5 to 6
5
3 to 5
COMPLICATIONS OF HYPERTHERMY
Restlessness. Restlessness is the most frequent reaction in fever patients and can usually be quite well controlled by the means described previously.
In psychiatric patients with an anxious, unstable personality, delirious episodes are frequently apt to occur; according to Ebaugh, Barnacle and Ewalt 12 such patients should be accepted only if they respond to psychotherapeutic measures, for it is well known that paretics do not tolerate the administration of sedatives. Gonorrhoeic patients seem to require sedatives more often than any other group. Alcoholics are most difficult to manage. Heat Prostration. Heat prostration may be evidenced by an uncontrollable restlessness, or increasing exhaustion or the symptoms of tetany. Keeping of a sufficient intake of fluid and sodium chloride are best preventatives. In addition cold compresses or the playing of a fan over the
Warren advises excluding fac& help to keep the patient comfortable. patients rendered susceptible to heat prostration by a low salt intake during the summer months or by acute respiratory infections. Burns. Burns occur not infrequently in fever treatments even with the most careful technique. However, in the great majority of cases they consist only of small blisters over especially heat sensitive parts of the skin. These minor burns heal without scarring and do not necessitate discontinuance of further treatment. With diathermy plates and short-wave pads, burns may be caused by undue density of current in areas too close to the electrodes or those rendered anemic by pressure. They may become severe if the patient is not warned to report any localized feeling of excess heat at once. In fever cabinets contact with a heating element or light bulb can occur only in extremely restless and uncontrolled patients. However, the superheated air can and does sometimes cause very extensive For this reason, in all fever blistering and subsequent scar formation. treatments with high temperatures and, especially, in light haired thin skinned patients, the skin must be watched most carefully for signs of undue reddening as a precursor of a burn. Such areas may be cooled by
COMPLICATIONS OF HYPERTHERMY
261
rubbing with ice and also protected with extra padding. Bony prominences, pendulous breasts and the skin of the toes are especially vulnerable. Herpes Labialis. Herpes labialis occurs in a fair percentage of cases, three or four days after the first treatment. Occurrence of herpes of the cornea in one case was reported and was also seen in one case of the author's after the second treatment. Both of these lesions cleared up without and there is no way at present to prevent this rare occurrence. complications Warren 31 et al. found that out of 411 fever therapy patients, 190 almost every other one developed herpes, but only 7 of 131 in subsequent treatments, suggesting that some immunity develops after the first attack. Neither the method of fever production or the height or duration of fever bear direct relation to the occurrence of herpes, which usually clears up
scars,
spontaneously.
Heat Cramps and Tetany.
Tetany
is
a rather rare occurrence, mani-
festing itself by twitching of the arms and legs and at times the abdominal wall. It is attributed to alkalosis caused by hyperventilation and it may
occur whenever the temperature rise occurs very rapidly, as for instance in hot-water baths; but it may occur also in cabinets for the same reason. The symptoms may be promptly relieved by the intramuscular or intravenous injection of 10 per cent calcium gluconate. Abdominal cramps, nausea and vomiting are other rare occurrences chiefly reported with the use of fever cabinets. Minor instances may occur in patients who have eaten too much breakfast contrary to advice. Excessive nausea may necessitate the termination of treatment because it not only weakens the patient but also prevents his drinking of salt solution. Des10 jardins states that an intravenous injection of 500 to 1000 cc. of a solution containing 10 per cent of dextrose and 1 per cent of sodium chloride rapidly 25 relieves this condition. Rosenberg and Epstein advocate the routine administration of hypertonic (5 per cent) saline solution immediately preceding fever therapy to reduce the incidence, frequency and severity of nausea and vomiting and also to reduce the incidence and severity of reactions to intolerance to heat and postoperative debility. Vasomo tor collapse is a rare complication and is Circulatory Collapse. characterized by a gradual or sudden increase of pulse-rate with cyanosis. To avoid this serious complication, whenever the pulse exceeds 160 for any length of time and is of poor quality, treatment must be stopped. Inhalation of oxygen with 7 per cent concentration of CC>2 is at once employed as well as intravenous infusion of normal saline and 5 per cent glucose, 800 to 1500 cc., to give the heart fluid to pump. In addition, caffein, sodium benzoate and adrenalin may be injected. Sedatives should not be used unless to control convulsions. Cullen et al. 9 have found that oxygen therapy prevents reduction in arterial oxygen tension and thus should be used during fever therapy. Sudden, uncontrolled hyperpyrexia, associated with circulatory collapse and followed by deep coma is the rarest accident in the experience of Stecher and Solomon. 28 Sudden rise of temperature may occur in both mild and severe treatments. Its management consists of removing the patient immediately from the cabinet or his wrappings, directing an electric fan against his body and administering adrenalin intramuscularly if indicated. Gentle rubbing of the extremities with cooled water (50 to 60 F. is 26 recommended) (Schmitt ) to increase the rate of evaporation from the
262
HYPERTHERMY
skin; if the temperature keeps on rising or is only slightly dropped, the trunk should be cooled with the exception of the abdomen. The rate of temperature reduction however should not be too rapid, after a drop of 3 or 4 the body should be lightly covered and the temperature further observed; a second treatment may be administered within an hour if no
The mortality in well administered fever pathological changes as seen by Hartman and 14 Major in patients and experimental animals following artificial fever therapy consisted of marked engorgement of the blood-vessels, especially of the capillaries, associated with hemorrhage of varying extent and necrosis
treatments
is
further decline occurs. Pathogenesis of Fatal Cases.

small.
The
of the tissues, including the muscles, liver, kidney, lungs, adrenals and brain. The hemorrhages and patchy necrosis in the central nervous system
are a striking
is
and consistent finding, especially where the sedative used a respiratory depressant, as morphine, pantopon or one of the barbitur13
ates.
According to Hartman untoward results of fever therapy are always preceded by cyanosis and vascular collapse. He considers anoxia as the underlying cause of the lesions described and the sedatives administered as its initiating or predisposing cause. Anoxia may be prevented by the administration of oxygen throughout fever therapy, provided respiration and blood-pressure are maintained at reasonable levels.
REFERENCES
1.
ATSATT, R.
F.,
and PATTERSON, L. E.:
Fever Therapy Apparatus, Arch. Phys.
Ther., 18, 108, 1936. Relative Influence of External 2. BENSON, S.:
and Body Temperatures Upon the
Heart, Arch. Phys. Ther., 15, 303, 1934.

3. 4.
BIERMAN, W.: Jour. Am. Med. Assn., 109, 1434, 1937. (Discussion.) BIERMAN, W., and HOROWITZ, E. A.: Treatment of Gonorrhea in the Female by Means of Systemic and Additional Pelvic Heating, Jour. Am. Med. Assn., 104,
1797, 1935.
5.
BISHOP, F. W., LEHMAN, E., and WARREN, S. E.: A Comparison of Three Electrical Methods of Producing Artificial Hyperthermia, Jour. Am. Med. Assn.,
104, 910, 1935.
6.
7.
BUNDESEN, H. N., BAUER, T. J., and KENDELL, H. W.: Intensive Treatment of Gonorrhea and Syphilis; Organization, Activities and Accomplishments of the Chicago Intensive Treatment Center, Jour. Am. Med. Assn., 123, 816-820, 1943. CARPENTER, C. M., BOAK, RUTH A., and WARREN, S. L.: The Thermal Death Time of Treponema Pallidum in Vitro, With Special Reference to Fever Tem-
peratures, Jour. Exp. Med., 56, 741, 1932. Council on Physical Therapy, American Medical Association: Hyperpyrexia Produced by Physical Agents, Jour. Am. Med. Assn., 103, 17, 1308, 1934. 9. CULLEN, S. C., WEIR, E. F., and COOK, E.: Rationale of Oxygen Therapy During Fever Therapy, Arch. Phys. Ther., 23, 529, 1942. 10. DESJARDINS, A. U., STUHLER, L. G., and POPP, W. C.: Fever Therapy for Gono8.
11. 12.
coccic Infections, Jour. Am. Med. Assn., 104, 873, 1935. DOAN, CHARLES A.: Peripheral Blood Phenomena and Differential Response Bone, Marrow and Lymph Nodes to Hyperpyrexia. EBAUGH, F. G., BARNACLE, C. H., and EWALT, J. R.: Psychiatric Aspects
Artificial
of of
Fever Therapy, First
Int'l.
Conf on Fever Therapy,

.
New York,
March,
1937.
13.
HARTMAN,
F. W.:
Lesions of the Brain Following Fever Therapy, Jour.
Am. Med.
Assn., 109, 2116, 1937. 14. HARTMAN, F. W., and MAJOR, R. C.: rately Controlled Artificial Fever,
Am.
Pathologic Changes Resulting From AccuJour. Clin. Path., 5, 392, 1935.
REFERENCES
15.
263
HENCH,
Fever Therapy, Results for P. S., SLOCUMB, C. H., and POPP, W. C.: Gonorrhea! Arthritis, Chronic Infectious (Atrophic) Arthritis and Other Forms,
Jour.
16.
Am. Med.
J.,
Assn., 104, 1779, 1935.
KING, A.
1943.
WILLIAMS, D. L, and NICOL, C. S.: Hyperthermia in Treatment of Resistant Gonococcic and Non-specific Urethritis, Brit. J. Ven. Dis., 19, 141,
17.
KRUSEN,
F. H., RANDALL, L. M., and STUHLER, L. G.: Fever Therapy Plus Additional Local Heating in the Treatment of Gonorrhea, First Int'l. Conf on
.
18.
York, March, 1937. KRUSEN, F. H., and ELKINS, EARL C.: Fever Therapy by Physical Means, Jour.
Fever Therapy,
New
19.
Am. Med. Assn., 112, 1689, 1939. KRUSEN, F.: Physical Medicine, Philadelphia and London, W. B. Saunders Company,
p. 67, 1941.
20.
MOENCH,
and
Vitro Within the
of the Heat Sensitivity of the Meningococcus in of Therapeutic Temperatures: Fever Therapy Abstracts Discussions of the First International Conference on Fever Therapy,
L.
MARY:
Study
Range
New
York, Paul B. Hoeber,

21. 22. 23.
C. A.: by Physical Means, Its Development and Application, Springfield, 111., Charles C Thomas, 1937. O'LEARY, PAUL: Present Day Status of the Treatment of Neurosyphilis, Jour. Am. Med. Assn., 109, 1163, 1937. A Comparison of Physical Methods in Fever Production From a PHILLIPS, K.
NEYMANN,
Inc., p. 100, 1937. Artificial Fever Produced
Physiological Viewpoint, Arch. Phys. Ther., 19, 473, 1938. Reduction of Manpower Loss From Gonor24. PHILLIPS, K., and MUNDORFF, A. B.: rheal Urethritis by Early Application of Fever-chemotherapy, Arch. Phys. Ther., 25, 150, 1943. Use of Intravenous Sodium Chloride in 25. ROSENBERG, E. E., and EPSTEIN, N. N.: Pyretotherapy, Am. Jour. Med. Sci., 199, 650, 1940. 26. SCHMITT, M. G.: Fever Therapy by Short Wave Diathermy, in Medical Physics,
Chicago,
27. 28.
SIMPSON,
The Year Book Publishers, Inc., W. M.: Artificial Fever Therapy
1944.
of Syphilis, Jour.
Am. Med.
Assn.,
105, 2132, 1935.
29.
30.
STECHER, R. M., and SOLOMON, W. M.: The Complications and Hazards of Fever Therapy: Analysis of 1000 Consecutive Fever Treatments With the Kettering Hypertherm., Ann. Int. Med., 10, 7, 1937. WARREN, S. L., CARPENTER, C. M., and BOAK, R. A.: The Basic Principles for the Cure of Gonococcal Infections by a Single Fever Treatment, Rep. 5th Ann. Fever Conf., p. 5, May, 1935. WARREN, S. L., SCOTT, W. W., and CARPENTER, C. M.: Artificially Induced Fever for the Treatment of Gonococcic Infections in the Male, Jour. Am. Med. Assn.,
109, 18, 1937.
S. L., CARPENTER, C. M., and BOAK, RUTH A.: Symptomatic Herpes, a Sequelae of Artificially Induced Fever, Jour. Exp. Med., 71, 155, 1940. 32. WHITNEY, W. R.: Radiothermy, Gen. Elec. Rev., 35, 410, 1932.
31.
WARREN,
CHAPTER
XIII
ELECTROSURGERY
of
Electrodesiccation.
surgical Cutting.
Technique Electrosurgical Methods. Apparatus. of Electrocoagulation. Technique of ElectroAnesthesia in Electrosurgery. Clinical Uses. Critique.
History.
Technique
General Considerations. Electrosurgery or surgical diathermy denotes the application of electricity for the destruction of new growths and diseased tissue and for cutting through normal tissues with minimal bleeding. In the strict sense of the term the electrocautery (the employment of metal tips or wires heated by the lighting current) and electrolysis for the removal of superfluous hair and for destruction of tissue would also
come under the heading

restricted the
of electrosurgery.
Modern usage
has, however,
of electrosurgery to the surgical application of highelectrical currents. frequency The principle of action of all electrosurgical methods is an intense concentration of current under a small active electrode; this results in a destructive heat effect which leads to instantaneous coagulation of the
term
albumin of the tissues. The extent and form of tissue destruction varies with the type of current and the technique of application. Heated metals in the form of the electrocautery have been used for a long time for the destruction of superficial tissues and malignancies but their action is superficial and the heat cannot be maintained at an even temperature; With if they are too hot, normal as well as malignant tissue is destroyed. high-frequency electrosurgical apparatus the scalpel or needle remains cold all through the operation, the heat generated is in the tissues themselves and is always under perfect control of the operator. Oudin was the first to describe, in 1899, the tissue-destroying History. effects of sparks derived from a resonator attached to the d'Arsonval solenoid. Riviere, in 1900, advocated them in the form of an "effleuve" for malignant tumors and tuberculous skin lesions. Subsequently, deKeating Hart and Doyen published results on cancer treated with powerful sparks drawn from a high-tension transformer. They used a biterminal technique, producing heavy carbonization of tissues and named the method "fulguration." In the United States, F. R. Cook first described, in 1907,
the use of high-frequency sparks for the destruction of abnormal tissue, and Beer employed it for tumors of the bladder. In 1909, Clark, of Philadelphia, developed the technique of electrodesiccation, or the drying of tissue without actual coagulation. He made studies subsequently of the biterminal, more. penetrating method of electrocoagulation and rendered a classical description of the histopathological effect of these two procedures. In the past decades Wyeth, 21 Gushing, 3 Kelly and Ward, 12 and others developed these methods further.
Electrosurgical methods have come to fill a very definite role in both major and minor surgery. When first introduced in the form of desiccation and coagulation they were welcomed for their effectiveness in local tissue destruction. From the original field of tumor surgery the newer method of
(264)
ELECTROSURGICAL METHODS AND THEIR EFFECTS
265
electrical cutting and its modifications have brought electrosurgery into the field of general surgery, enabling the successful attack on vascular
organs anywhere in the body and leading to a
new
surgical technique.

The
three major varieties of electrosurgical effects are
shown
in
Table
30.
TABLE
Form
30.
ELECTROSURGICAL,
METHODS
Characteristic effects
Technique
Electrodesiccation
"3
S
Electrocoagulation
Needle-point single electrode con- Dehydration and shrinknected to high voltage (Oudin) age of superficial parts terminal and held in contact or at slight distance
Operating (active) needle or ball point electrode connected to one

terminal, large dispersive electrode to the other
Coagulation of cell proof toplasm sealing

;
small blood-vessels by active electrode
Biterminal needle electrode or clamp connected to two terminals
Coagulation limited to area between biactive

points
Electrosection or
electric
cut-,
tt
ting
Operating electrode a needle point or blade connected to one terminal; dispersive electrode to
other terminal
Dissection of tissues with a minimum of coagulation;

laries
sealing of capil-
only
A needle-point electrode is connected to the single terminal of the long-wave diathermy apparatus and high-voltage (Oudin) held in contact with or at a slight sparking distance to the area to be treated. The current employed is one of comparatively high voltage and low amperage and its oscillations are damped. When this current is applied to the tissues at appropriate strength and duration, drying and shrinkage of the parts occur, due to the evaporation of the water content of the cells. A dry mass remains which can be curetted away or left in place to slough
Electrodesiccation.
off in
due time.
cells
Following electrodesiccation, Clark showed tissue shrunken and shriveled, their nuclei condensed and elongated, with a suggestion of cell outline, the whole assuming a mummified appearance (mummification necrosis). The blood-vessels were thrombosed and there were no evidences of hemorrhage. Since this mode of cell death is associated with very little degenerative change and scant disintegrated material, there is but a small amount of fibrous tissue as an end-result. This explains the good cosmetic results and the fact that the neighboring healthy tissues are spared the devitalization resulting from the formation of abundant
Histological Changes.
contractile fibrous tissue.

of higher amperage and of damped oscillations. in electrocoagulation: (1) The usual method
current employed in electrocoagulation is one There exist two techniques is to connect an "active" needle or other pointed electrode to one terminal of a high-frequency apparatus and a large dispersing one to the other terminal. Wherever the active electrode is brought in contact with the tissues, a grayish white
Electrocoagulation.
The
266
ELEC TROS URGER Y
FIG. 190.
Tumor
cells are
Journal of
Photomicrograph showing desiccation with Oudin current. (Dr. G. E. Ward.) (Courtesy of dehydrated, elongated and shriveled with shrunken nuclei. the American Medical Association and W. B. Saunders Company.)
FIG. 191. Photomicrograph showing coagulation with biterminal damped current. (Dr. G. E. Ward.) Tumor cells have been changed into masses of homogeneous debris by the high temperature which literally boils them in their own tissue juice. Blood-vessels are clotted and the stroma is converted into a hyaline mass with sparsely scattered nuclei. (Courtesy of Journal of the American Medical Association and W. B. Saunders Company.)
267
discoloration of varying depth appears, corresponding with widespread modified method of electrocoagulation coagulation of these tissues. (2)
electrodes, two needle-points or a specially constructed clamp electrode. This is called biterminal coagulation. As a result of this technique, coagulation only occurs in the small area between the two active electrodes.
consists of the
employment
of
two active
FIG. 192.
Photomicrograph
(Courtesy of
showing
is
fine line destruction 10
of incision made with cutting current from tube apparatus, in thickness or l?ss. /j, (Dr. G. E. Ward.) Primary union
the rule here.
W.
B. Saunders Company.)
Histological Change. Following electrocoagulation Clark showed histologically that the cell outline is entirely lost; the affected tissue elements become fused into a structureless homogeneous mass presenting an appear-
ance not unlike that of hyalinization. This greater degree of destruction results finally in a proportionally greater amount of fibrous tissue (scar)
formation. Investigations by Keysser 13 and Nieden 19 show two definite zones in the coagulated area. The inner zone is blanched and on histological examination shows typical coagulation necrosis in which the tissues are shrunken; the nuclei have lost their definition, stain poorly or disappear altogether. This inner zone shows a primary heat effect identical with the necrosis of ordinary skin burns. It passes over into an ill-defined zone of shriveled cells and a region of dilated blood-vessels. Examinations made several days later show that the outer zone becomes invaded by roundcell infiltration, fibroblasts and foreign-body giant-cell formation. Nieden pointed out that deep coagulation even in the inner zone of complete necrosis is always uneven according to the variation of resistance in different tissues and the resulting tissue injury is, therefore, unpredictable. Unexpected coagulation necrosis accounts for the dangerous secondary hemorrhages occurring after electrocoagulation in the neighborhood of For this reason there appears to be a tendency in large blood-vessels.
2G8
ELEC TROS URGER Y
as being unsurgical electrosurgery to get away from massive coagulation and dangerous and lean toward the use of cutting currents. A needle-point or thin blade is connected to one terElectrosection.
minal of an apparatus producing a current of undamped oscillations; a to the other terminal. With approlarge dispersive electrode is connected of current, the active or operating electrode applied to the priate strength tissues will glide through them with ease. Like butter under a hot knife, the tissues almost melt under the influence of the cutting current. The zones. The innermost area is a zone of histological effect also occurs in two molecular disruption due to the explosion of cells. There is no clear-cut explanation of this process as yet. One explanation is that the assumption by the molecules in the tissues of a high rate of vibration causes dissolution of the molecular structure; another explanation is that the sudden expansion of the cell, due to intensive heating, converts its liquid contents into explosive steam. In the outer zone there is evidence of elongation of tissue cells and a slight amount of coagulation. The width of these zones equals about 0.1 mm. when the average cutting strength is employed. The high frequency resistance of the various tissues, as shown in Table 26, accounts for a certain variation of resistance to electrical cutting. There is much more resistance when cutting through fat than through skin and muscle, hence more power must be used. 5 Healing of Electrosurgical Wounds. A study by Ellis on the healing
wounds in different tissues after coagulation and cutting showed that it is not possible to produce a purely cutting effect without some necrosis on a skin with a horny layer, but this slight necrosis does not always preclude healing by primary intention. In comparison with 97.5 per cent of primary union in scalpel wounds, Ellis found 60 per cent primary union in electrosurgically produced wounds. In the mid-period of healing the electric wounds are weaker, as shown in animal experiments by comparison of the tensile strength in the wounds. The healing of wounds by the cutting current in skeletal muscles and the muscular wall of the stomach and intestines have been found entirely comparable in strength to scalpel wounds and without secondary necrosis or infection. The coagulation current causes in skeletal muscles and in hollow organs the same inverted coagulation as in the skin and healing occurs after absorption of the necrotic area by extensive fibrosis. The most important argument in Specific Effects on Blood-vessels. favor of electrosurgery is the effect on the three classes of blood-vessels. 1. Very small vessels, capillaries, arterioles and venules. These are vessels of a size which do not usually bleed after a clamp is removed during
of electrosurgical
When tissues containing such vessels are severed with a cutting current without any zone of coagulation, there is momentarily some capillary hemorrhage but within a few minutes this hemorrhage ceases comoperation.
pletely.
brain, the kidney,
In organs with oozing capillary beds, such as the liver, spleen, and in muscles, this result offers a revelation to most
9
showed histologically obstruction and wrinkling of the vessel wall and in laboratory tests an abundant liberation of thrombokinase from the vascular wall. The latter phenomenon accounts for the sudden and effective hemostasis by the cutting current. A flash, a simple division of the tissue by the cutting current is sufficient to produce the sealing effect.
surgeons. Investigation by Heitz-Boyer of the lumen by endothelial lining cells
APPARATUS FOR ELECTROSURGERY

2.
269
Small or moderate-size vessels, which bleed after taking the clamp and must be ligated in ordinary surgery. These vessels are usually not obliterated by the cutting current but can be successfully sealed off by the coagulating current. The usual method of accomplishing this is to touch either the hemostat which grips them or touch the vessel directly
off
by the
necrosis follows
tip of the coagulating electrode. The less tissue coagulated the less and the less the chance of secondary hemorrhage or infec-
tion from the

3.
thrombosed blood-vessel.
Larger blood-vessels, of the size of the radial artery or larger. In these Ellis 6 found merely the occurrence of a coagulation thrombosis in the vessel the vessel wall was not destroyed. In these vessels the customary
;
ligation
is
preferable to electrical hemotasis.
In experimental work with nephrotomy Higgins and Glazier 10 found that there is less primary hemorrhage when an extensive nephrotomy is performed with the cutting current than with the scalpel. Advantages of Electrosurgery. On the basis of the changes described the advantages claimed for electrosurgery are
:
Lessening or elimination of bleeding; the immediate sealing of bloodvessels and lymph vessels gives not only a clearer and better operating field but also sterilizes it to a great extent. 2. Facilitating the rapid and gentle handling of even the most delicate tissues, enabling the use of fewer and simpler instruments and the wider use of local anesthesia and brief gas anesthesia. 3. Lessening of operative shock and after pain for reasons already stated and also through decrease of the capillary wound surface, through slowing up the resorption of toxic tissue products and by destruction of afferent
1.
nerve paths of pain.

in the average case in comparison with granulate after ordinary surgery, promoting an antiseptic after course and leading to a softer and less disfiguring scar; at the same time follow-up work in overlooked or recurrent areas is much easier.
4.
Promoting more rapid healing

left to
wounds

The two types
of high-frequency apparatus serving for electrosurgery
damped oscillations, and the tube type producing undamped oscillations. Spark-gap apparatus produces principally a current suitable for fine desiccation and heavy coagulation but not for electrosection with suitable
are the spark-gap type, producing
;
superimposing trains of damped oscillations which produce an equivalent of an undamped current it has been used for cutting purposes. The modern short-wave diathermy tube apparatus is eminently
modification
suited for cutting
two types
The
and light coagulation. The physics and control of the of apparatus have been described in Chapter X. so-called blended current is offered by a special electrosurgical unit
containing both a spark-gap and a tube circuit. This arrangement enables the combination of the tissue cutting effect of the vacuum tube apparatus with the coagulating effects of the spark-gap current (Fig. 193). An additional simplification of controls serves for rapid adjustment of currents and thus the blended current apparatus enables a more efficient electrosurgical control
and combination
of all effects.
270
ELECTROSURGERY
Additional equipment needed for electrosurgery consists of the following: a needle for desiccation, preferably mounted on a handle with a make-
VACUUM TUBE CUTTING CURRENT GENERATOR
FIG. 193.
Interior of blended current producing apparatus.
(Courtesy of the Burdick Corp.)
FIG. 194. Diagram of undamped (A) and damped (B) high-frequency oscillations and their combination (C) ("blended" current for electrosurgery). (Courtesy of the Burdick
Corporation.)
and-break arrangement; two sizes of ball electrodes for coagulation straight and curved flat blades for cutting and loops for scalloping out unresectable
;
areas; also biterminal electrodes.
Some
of these electrodes are illustrated

in Figures 195
271
rectal
and
196.
For gynecological, nose and throat and
work
special electrodes serve.

(Fig. 198.)
indispensable for quickly starting and stopping the power flow and keeping the operator's hands free.
is
foot switch
FIG. 195.
Electrodes for general electrosurgery a, fine needle; b, heavy needle with makeand-break control on handle. (Courtesy of Wappler, Inc.)
:
The
factors influencing the
amount
of tissue destruction in
any
electro-
whether desiccation, coagulation, or cutting with the tube or blended current are several: (1) The amount of power used plain
surgical procedure,
the more power, the more destruction. (2) The length of application (a) longer contact, deeper desiccation or coagulation (6) the faster the cutting electrode is moved, the less destruction on each side of the incision. (3) The size of the electrode also affects the tissue change larger surface contact gives more room for current to flow and therefore produces more
destruction.
FIG. 196.
Special electrodes for electrosurgery.
(Courtesy of the Burdick Corporation.)
The Council on Physical Therapy states: "The perfect generator should produce a smooth current without faradic effect, varying from the finest desiccation spark to heavy coagulation without much flashing or uncontrollable flame. Efficient coagulation by a blunt or ball electrode brought near to the tissues, with the minimal visible sparking, is another criterion of a perfect current. There ought not to be any fusion of coagulated tissues to the electrode but to date no material is available out
272
of
ELECTROSURGERY
which electrodes can be made which will not stick to the tissues, pulling some away when removed and risking tearing a vessel. In addition, the cutting current should be adjustable from one, severing tissue with only 0.1 mm. of destruction on each side, to one, coagulating 1 or 2 mm. in depth. All these features, characterizing the perfect machine with the
of controls, should be available at the operating table a proper foot switch or by sterile connections for the operator's through immediate control, without calling for an extra assistant."
minimum number
A safe and efficient working knowledge of electrosurgical apparatus must be acquired by experimental practice on meat and on animals and later by actual work on patients, under the guidance of an experienced colleague. The principles and technique of the three main methods are
only presented for general guidance.
TECHNIQUE OF ELECTRODESICCATION
In electrodesiccation only one electrode is employed, a steel or platinum needle of 'varying thickness, held in an insulating handle, with a makeand-break arrangement, or still better, with a foot switch. Proper control of current strength and duration of flow and the employment of a fine
FIG. 197.
Small unit for electrodesiccation.
(Courtesy of the Birtcher Corporation.)
desiccating needle should enable the operator to dry off small growths with very little pain, no hemorrhage and with very little subsequent scar
tissue.
of vision
Small growths on the cornea can be removed without impairment by subsequent scar tissue and papillomas of the vocal cord without any impairment of phonation. The physician must learn to produce a minimum sparking at first and increase current strength, if necessary, according to the size and consistency
TECHNIQUE OF ELECTRODESICCATION
of the growth.
273
Since there is no meter in circuit to measure the current the operator must begin with a minimum spark and increase its strength, intensity to adequate requirement. Experimental Practice. Insert the needle holder in the Oudin terminal. Start the current flow in the apparatus and open the rheostat slightly with the spark-gap closed. (If there is an extra control rod for the sparkgap it should be closed all the way in so that the current is short-circuited in the machine.) Approach with the needle a cylindrical metal electrode or any other metallic object held in the operator's hand. No sparking occurs until the spark-gap is slightly opened. Learn to produce a spark length of only about 3^ inch. This will cause no sensation whatsoever in the operator's hand on account of the diffusion of the current from the
comparatively large metallic surface. Next, learn to approach your own thumb nail with the desiccation needle, turning on just enough current to produce visible sparking through the nail. Such current strength is practically painless if kept up only for a fraction of time. The author invariably determines by this method the
current strength suitable to begin desiccation. Clark's classical soap experiment should be practiced by all beginners to visualize how actual drying of tissues can be accomplished without carbonization, by a minimum of current. Cover a cake of white soap with
minimum
one thickness of white paper. Bring the needle in direct contact with the paper and turn on just enough current to cause no trace on the paper, but to dry out the soap on the area immediately below, causing a minute erosion filled with dried-out soap. This is the current strength just sufficient
for fine desiccation.
The final experiment should be done on a piece of meat beef or liver, moist and warm, so as to approximate living tissue. Allow a fine stream of sparks to flow over it without actual contact and observe the drying out of the superficial layers. Note how the extent of destruction can be varied at various settings of the rheostat and spark-gap and with a varying size of the sparks from the very thinnest to large "hot" ones. Note that it takes less current and fewer sparks to dry out less vascular and less juicy
tissue.
FIG. 198.
Foot switch
for electrosurgical apparatus.
(Courtesy of the General Electric

,
X-ray Corporation.)
Operative Technique. The part to be treated should rest on a nonconducting support preferably a wooden table. The operator should be seated and have good support of the arm holding the desiccating instrument. There should be good light and the controls of the apparatus should be within easy reach if one is working alone. The use of a separate foot switch is more convenient. In tonsil and rectal work it is often preferable
18
274
to
ELECTROSURGERY
of the controls according to the
have an assistant present to take charge
cords should be heavily instruction of the operator. in order to prevent unpleasant leakage of the current to the insulated
The conducting
operator's hand. After the current flow to the apparatus has been started (the main switch being closed), the controls are opened to the desired strength. The needle is held just far enough from the lesion to produce a minute spark. As soon as the current has flown at sufficient strength, a whitish discoloration appears, showing that the tissue has been dried out; the needle is then moved to the adjoining surface. The strength of the current is regulated to the size arid density of the growth or diseased area. The rule
according is to use as
little
control; this scar (keloid) formation.

in
amperage as possible and work more on the spark-gap tends to keep down current volume and prevents excessive
This technique is just contrary to the usual where the rheostat control is advanced as far as diathermy technique as much as possible. necessary and the spark-gap control is kept down
âfcw
FIG. 199. Papilloma of the tongue before electrodesiccation. Courtesy of Dr. J. J.

Ellef.)
FIG. 200. Papilloma of the tongue after electrodesiccation. (Courtesy of Dr. J. J.

Eller.)
size must be estimated. the current is best delivered through a short superficial air space; when of medium size the needle is brought in contact with the tissue to be destroyed when the growth is large the needle is inserted into the tissue. The length of flow is the other factor in determining the extent
Current strength to destroy growths of varying

the lesion
is
When
of destruction.
The operation is ended when the whole growth turns white or when, the needle being placed in the lesion, the spark lights up like flame in the tissue, showing tnat the entire lesion has been dried out. A dry shrunken appearance of the treated area as if receding from the surrounding normal structures is also a sign of sufficient treatment. In case of doubt whether all pathological tissue has been destroyed, one should remember that it is easy to make up for insufficient dehydration at the time of the first or later follow-up examinations. Too extensive sparking may cause slowhealing ulceration. Local anesthesia
is
usually not necessary
when
treating small skin
TECHNIQUE OF ELECTROCOAGULATION
extended areas
lesions or cervical erosions; in cases of hemorrhoids or tonsils or in other locations, local anesthesia is essential.
275
more
Small
pedunculated growths may be almost painlessly treated by the following technique: Grasp the base with fine forceps and apply the desiccating current to the top of the growth; the forceps grounds the surplus current through the operator and the growth shrivels up without any painful sensation and can be removed without bleeding. At the end of the operation small growths and other pathological tissue may be left in situ to dry off and separate spontaneously. The sterile dry scab usually affords protection and insures better cosmetic result. Most of the growths, both small and large, are, however, best curetted off immediately. The raw area should be lightly sparked over to prevent oozing and infection and then may be painted over with 7 per cent iodine,
mercurochrome or Bohlman's gentian
violet solution (gentian violet, 2
grams; 95 per cent alcohol, 55 cc.; acetone, 10 cc.; distilled water 35 cc.). A small neat adhesive plaster dressing will further protect the area. Over areas of the face where a perfect cosmetic result is desired it is better to apply a bland ointment and a small gauze dressing, for this obviates injury to the sensitive epithelium when an adhesive plaster dressing is pulled off. A sterile dry dressing should be employed over any larger area of destruction.
Healing of dry scabs over small areas usually occurs within ten days. If there is any indication of it, the scab to insure undisturbed healing with good cosmetic result. Epithelialization may be further stimulated by a balsam of Peru or 5 per cent scarlet red ointment. Larger growths (up to 1 cm. in diameter) may require from one to three weeks for complete epithelializa-
Pus may form under the scab. must be removed for drainage
The resulting scar is usually smooth and pliable. Growths on mucous surfaces are best allowed to slough off spontaneously after desiccation;
tion.
this avoids the possibility of secondary hemorrhage after curetting. Patients should return for re-examination as after any other surgical
Areas previously not entirely desiccated can be thus more thoroughly treated and subsequent new growths recognized early.
procedure.
Electrocoagulation serves for the destruction of larger new growths or Conditions amenable to desiccation larger amounts of diseased tissue. may be more thoroughly eradicated by coagulation. The difference between the two methods is often only of degree. Due to the variable factors in current control and in the electrical resistance of the tissues, fine desiccation
may also
be effected by mild biterminal application.
For the active electrode in electrocoagulation, a needle or a small-sized ball attached to an insulated holder are employed. For electrohemostasis, the tip of a hemostat suffices. A dispersive electrode is used in both electrocoagulation and cutting, in order to complete the electrical circuit through the body. It consists of a fairly large plate of diathermy metal, about 8 by 10 inches in size. It is best placed under the buttocks at a safe distance from the field of operation. It must be in good contact with the skin at all times and well insulated by sheet rubber from the operating table or other metal parts.
Electrodes.
276
ELECTROSURGERY
The dispersive electrode should be rolled perfectly flat before use each time so as to avoid poor or uneven contact due to surface irregularities. Sharp points may cause burns. It is advisable to securely fix the dispersing
by an elastic bandage so as to prevent its displacement if the moves. For light work the electrode may be bandaged to the arm patient or applied to the back of the neck and for these locations a smaller, 3 by 6, plate will suffice. Special caution must be taken to securely attach the conducting cord to the dispersing plate and to protect the skin against
electrode
pressure or contact by the connecting clip. The use of the term indifferent or inactive plate instead of dispersing plate should be avoided because it misleads beginners to believe that no action takes place beneath this electrode and, therefore, no attention has to be paid to it. As a matter of fact, severe burns have occurred under improperly applied dispersive plates and the victim of such an occurrence
will
hardly
call
the means of such an unpleasant effect an "indifferent"
one.
Preliminary experimental work on moist and (1) To learn to estimate the coagulating power of the apparatus; (2) to observe the tissue changes under different settings, technique and also on a variety of tissues; and (3) to acquire the necessary dexterity in handling the electrodes and the controls of the
Experimental Practice.
tissue
is
warm dead
essential:
apparatus.
Apparatus, two conducting cords, an active electrode such an insulated holder and a fairly large dispersive plate. Place a piece of juicy meat about 2 inches thick and about 5 by 5 inches in size preferably containing some fat, cartilage and fascia, on the dispersive
Equipment.
as steel needle in
plate.
1.
fairly
Insert the active electrode to a depth of about \ inch and turn on a heavy current. In a few seconds gray blanching will appear all
around the needle and hissing noise of escaping steam is heard. The coagulated tissue becomes drier and drier and finally sparking takes place from all sides of the coagulated area. This is the sign that the part is quite dry and no longer conducts the current. It is also the sign to discontinue the current immediately. Cutting through the coagulated tissue one finds a moderate amount of coagulation extending in all directions from the needle track. There is a well-marked line of demarcation between coagulated and unaffected tissue.
2. The same active electrode is similarly inserted into another part of the meat. Approximately only one-half of the current strength employed before is turned on and kept up considerably longer. Cutting through the coagulated area it will be noted that its extent is much greater and the
line of
is
demarcation between the coagulated part and the unaffected one
and ill-defined. These experiments demonstrate that the depth of destruction under the active electrode depends on the strength as well as on the duration of current flow and that a heavy current flowing for a short time does not coagulate so deeply as a lighter current flowing for a longer period. Rapid drying of the surrounding tissue causes loss of conductivity and sparking around
irregular
the coagulated part. 3. Insert the active electrode successively into meat, fat and fascia and note the difference in the setting of the rheostat and spark-gap necessary
to
(
277
produce coagulation to the same extent and during the same time. Continue these observations on live animals and on human tissues, pref er-
ahly under the guidance of an experienced operator. The Role of the Milliammeter. There is no meter in circuit during electrodesiccation and most operators consider it unnecessary to employ a meter during electrocoagulation. It is not practicable to measure the current strength necessary for destruction by a meter, because it may vary from 300 to 3000 or more milliamperes. When a meter is used its reading is materially influenced by the resistance in the circuit. This, in turn, is determined by the size and density of the tissues, the size of the patient, the distance of the dispersive electrode and the size of the active electrode itself. Observation of the actual coagulation effected is a more practical guide in regulating the current strength. The violent fluctuations of current strength during operation frequently lead to burning out of the meter. For the reasons given, most spark-gap apparatus provide a set of binding posts, marked "electrocoagulation/' which permit drawing of the full amount of current without any meter in
circuit.
FIG. 201. Epithelioma of the lower lip; duration, four and a half months. (Courtesy of Dr. J. J. Eller.)
FIG. 202. Same patient as shown in Figure 201 after electrocoagulation of epithelioma. (Courtesy of Dr. J. J. Eller.)
Patient must be prepared as for a major surgical Operative Technique. Local or general anesthesia is necessary, according to the operation. size and location of the new growth. For light work on mucous membranes
factory.
the topical use of novocaine or a drop of benzyl alcohol is usually satisIn injecting a local anesthetic one should avoid infiltration of the operating field with a large quantity of fluid and rather inject around or under the operative area or employ nerve-blocking. During operation conducting cords should not come in contact at any time and should not lie too near any metal part or to the patient and
short-circuit, causing unpleasant shock, scorching and burning operator. out of the milliammeter, may be the result on account of the heavy current flowing. Using sheet-rubber insulation liberally all over the field of operais the best prevention of accidental short-circuiting. In performing the operation, as soon as the current is started a grayishwhite discoloration, indicating coagulation, occurs under the needle. The
tion
278
ELECTROSURGERY
needle is moved in succession over the area to be destroyed. It is preferable not to lift it off in order not to break contact. As destruction to an increasing depth occurs, if the growth is vascular, the tissue fluids begin to boil; soon sparks pass from the needle over the coagulated parts to the noncoagulated tissue beyond, indicating the complete drying of the former.
shrivel into a dry mass. When sparking appears over inside of the growth, the current should be turned off; the dead mass must be curetted or cut away, because otherwise it acts as an insulator. If at the base or edges destruction seems incomplete, the current is re-
Some growths simply

all
applied.
In treating malignancies one should aim to destroy all suspicious tissue at one sitting. New growths and other lesions located on cutaneous surfaces, once they are devitalized by either electrodesiccation or electrocoagulation, should be removed, as a rule, immediately, by cutting or
curettage. Any oozing in normal tissue which might be due to the curetting or other methods of removing the tumor should be lightly desiccated.
dry dressing is to be applied after the operation. It is one of the limitations of electrocoagulation that in destroying large masses even experienced surgeons cannot always exactly gauge the depth There is no possibility of differentiating adjacent vital of destruction.
structures (nerves, blood-vessels). Too heavy a current applied near large blood-vessels and other vital structures may result in serious secondary hemorrhage or other complications. When near bony structures, destruction of the periosteum cannot always be avoided, and this may entail necrosis of the bone and considerable delay in healing. The premature
separation of sloughs also
greater vascularity, there is a greater of a secondary hemorrhage; for this reason it is advisable to possibility let the devitalized tissue slough off by degrees. This will take a variable
time, according to the character of the destroyed tissue
tion.
may cause On mucous membranes, due to the
secondary hemorrhage.
and
its
loca-
In mucous membranes like the mouth, frequent antiseptic washes should be used.
Postoperative pain is often comparatively little, due to destruction of nerve endings and the sealing up of all possible sources of infection. Depending on the size and depth of the lesion, healing may be complete in from two to four weeks. The rapidity with which healthy granulations spring up after the slough has been removed is praised as a great advantage of electrocoagulation over roentgen-rays. Occasionally, indolent, slowhealing ulcers and inflammation of the surrounding tissues follow, usually due to overtreatment and needless irritation of the surrounding healthy tissue. Bone and cartilage take the longest time to sequestrate. The Use of Biterminal Electrodes. In recent years there has been an increasing use of the biterminal method of coagulation. Two insulated needles in a suitable holder are connected separately to the terminals of the apparatus. Each of the needle-points represents an active electrode and no dispersive electrode is used. In this method coagulation takes place only between and around the two needle-points and very little current is employed. For destruction of tonsillar tabs or parts of tonsils, small tumors of the skin and mucous membranes, notably hemorrhoids, this
technique is quite useful. For fine coagulation in neurosurgery a two-point 7 coagulation forceps has been described by Greenwood.
TECHNIQUE OF ELECTRO&URG1CAL CUTTING

the points and the "burning" out of the electrode.
279
Care must be taken to avoid excess current. This leads to arcing between
TECHNIQUE OF ELECTROSURGICAL CUTTING

Electrodes.
thin flat blade or needle serves as the active electrode
and the usual large metal plate as the dispersing electrode. The thinner the edge of the cutting electrode with the same current strength and speed
of cutting, the less coagulation occurs along the line of separation.
If
desired, a thin needle or very thin blade should be used for skin incision. Large needles are used for heavier coagulation and
primary union
is
hemostasis, such as incising vascular tumors, the lip or tongue or lung abscesses. Thin loops, oval and round, are used for taking biopsy specimens or piecemeal removal of other tissue. Conization electrodes serve
for excision of tissue
from the
cervix,
and other
special electrodes for
underwater cutting.
is the same as for experimental coagulation except that a cutting blade as well as a steel needle should be employed as the active electrode. Lay the piece of steak on the dispersive plate just as in electrocoagulation. 1. Adjust the controls to about one-third of the available current Practice strength, contact the tip of the cutting blade with the meat. turning on the current simultaneously with the moving of the active electrode. Note that it will move along the meat with practically no resistance. Turn off the current before the electrode has reached the end of the cut. There should be an even area of dehydration along the entire cut with no evidence of deeper coagulation. 2. Turn on the current before the electrode contacts with the tissue and take the electrode off before the current is turned off. In both instances there will be a flash on contact and a marked area of coagulation where the blade starts or ends its incision. An uneven line of dehydration and the
(Fig. 196.) Experimental Practice. The equipment necessary
excess
3.
amount of coagulated tissue often interferes with primary union. Touch the meat with the entire edge of the cutting electrode instead
A wide area of coagulation will occur under the area of contact and there will be a delay in straight cutting. Note the same occurrence if the cutting blade approaches the meat sidewise. Operators of cutting apparatus must learn to synchronize movement of the electrode with closing and opening the electrical circuit and must learn to use only the tip of the electrode for incision directly across the tissues. 4. Repeat these experiments with a straight needle as an active electrode instead of the cutting blade. Note that with the same current strength there will be a greater depth of dehydration, due to the greater density of current around the tip.
of the tip only.
the
first
5. Repeat these experiments on fatty, fibrous and cartilaginous tissue. Note that it requires different settings of power to proceed with equal ease. Note that when cutting through considerable thickness of fat, the electrode does not cut readily and "boiling" of fatty tissue occurs. Learn to overcome this by very rapid incision at moderate strength of current, making many shallow cuts rather than a few deep ones. Keeping up
traction on both edges of the cut further diminishes boiling of fatty tissues.
280
ELECTROSURGERY
Operative Technique. Upon proper adjusting of the strength of the current and with suitable dexterity in the speed of cutting, the active electrode sears its way through the tissues meeting with almost no resistance. The surgeon has to acquire a new sense in applying the electrode delicately and drawing it rapidly through or over the tissues. Only a tiny arc should be maintained between the electrode and the tissues. A thin film of coagulation forms along either side of the incision, sealing the small blood-vessels and the lymphatics. The edges separated by the "electric
knife" can be sutured, and healing by first intention will follow, provided that the proper technique was used and there was neither charring nor
deep coagulation of neighboring
tissues.
cardinal rule in regulating the strength of current is that one should always use the lowest strength that cuts freely to the desired depth, and one should choose the size and shape of the electrode according to the
The
electrical resistance of tissue
under the
current.
electric knife.
is
sclerotic tissue require
more
Fatty tissue
heavy current; hence rapid, shallow cuts are more It is necessary to understand current characteristics to be able to meet varying conditions. As a matter of general policy it appears more advisable to use ordinary scalpel cutting for incision of tissues of high electrical resistance, such as the skin, fasciae and tendons; chances of rapid and firm healing are better Unless one has acquired if there is less necrosis along the lines of incision.
union.
Fat, cartilage, dry likely to boil under suitable for subsequent
delicate control over the coagulating effects of the cutting current, the percentage of undisturbed primary healing after orthodox scalpel incision in the enumerated tissues is greater. Sudden muscular twitches in the field of operation occur occasionally. They have been attributed by some physicians to a f aradic effect through a supposedly badly adjusted apparatus. As a matter of fact, they are due to the stimulating effect of sudden intense heat on motor nerves in the operating field. The only way to minimize them is to use the least possible amount of current strength in such location. It has been suggested also to maintain traction on each side of the line of incision, so as to keep the affected muscles under tension while the cutting current is on. Hemostasis. The superiority of electric cutting over the non-electric scalpel is at once evident in the operation on the liver, spleen, kidney, The lung, thyroid and the brain with their extensive capillary beds. sealing of all small blood-vessels gives a clearer and better operating field, a much faster operating time. If a larger vessel is severed and is not sealed by the cutting current, it should be grasped with the usual hemostatic forceps. At any convenient time during the operation, the clamp held in the operator's left hand should be touched 1 or 2 inches from its end by the active electrode not with its tip, because the heavy sparking may damage the .edge. (Fig. 203.) Within one or two seconds a thin visible zone of coagulation appears around the tip of the hemostat; the circuit should be now broken and the hemostat removed. This electrohemostasis results in saving of time and ligature material; on account of the lesser amount of foreign material in the wound, the wound heals quicker, there is very little hemorrhage during the operation and practically none afterward; the wound is sterile and the danger of metastasis
is
much
lessened.
TECHNIQUE OF ELECT ROSURGICAL CUTTING

tissue
281
In using this technique care should be taken to avoid grasping excess about the vessel itself within the jaws of the artery clamp so that excessive necrosis in surrounding tissue does not occur. 3 Gushing developed a special technique for the sealing of smaller bloodvessels which are exposed and free from organs, such as occur in the brain. A ball electrode, about J inch in diameter, is employed as the active electrode with the coagulating current. Beginning with a clamped end of the blood-vessel, this electrode is applied in a series of short strokes along the surface of the blood-vessel, at a current strength commensurate with the size of the vessel. This results in pushing the blood back in the lumen and
in
the gradual collapse and shrinkage of the vessel wall.
FIG. 203.
Hemostasis by electrocoagulation.
Underwater Cutting. Underwater cutting is a modification of electrical cutting which enables excision of tumors in the bladder and the prostate. It is done with the usual biterminal technique, but the active electrode must be insulated as far as the cutting tip t6 insure minimum of current leakage through the conductive medium of water. There is also need of considerable current strength to make up for this inevitable leakage. The ordinary uninsulated electrosurgical knife or loop 'operating from a low power machine caftnot cut under water. Conization. Conization is a special technique developed by Hyams 11 for destruction and removal of infected cervical tissue by the cutting current. The active electrode is a fine tungstepwire stretched over a silicon tube in the form of an arc which conforms to the contour of the cervical canal. With a current of suitable strength the electrode is rotated completely around the cervix and the îre'cuts a core of cervical mucosa.
(See Chapter on gynecological conditions.)" Bipolar Cutting. Bipolar cutting, similar to bipolar coagulation is advocated by Guleke 8 in brain operations because some of the inevitable
282
ELECTROSURGERY
can be avoided by-effects of current dispersion through the sensitive tissues if the current is confined between two active electrodes.
ANESTHESIA IN ELECTRO SURGERY

For most
not necessary.
of the applications of electrodesiccation a local anesthetic is In especially sensitive patients or for larger areas, the
2 per cent solulocal injection of procaine or novocaine is satisfactory. tion is recommended in preference to 0.5 or 1 per cent so commonly used
A generous amount is injected, for the heat of the in scalpel surgery. current frequently passes out beyond the area blocked off if a weak solution or scanty amount is employed. In conditions requiring general anesthesia there is a danger of explosion when ethylene is used in connection with electrosurgery. Even the smallest 18 spark may cause a violent explosion. Mock states that one should refuse to do electrosurgery if ethylene was given in the same operating room within the previous thirty minutes. On the other hand he does not hesitate
to use either ether or nitrous oxide anesthesia in
tions except those about the
all
electrosurgical opera-
oxide and ether anesthesia they are more explosive. Breast and other operations on the trunk, abdomen, pelvis and extremities are performed under ether anesthesia, provided the anesthetist remains back of a screen and reasonable precautions are taken not to spill the ether or scatter gauze or towels saturated with ether about the operating room, or near the electrosurgical apparatus or electrodes. Since, however, there have been occasional serious accidents resulting from ignition and explosion of ether vapor it is better to avoid its use when possible. The use of local infiltration about or under small lesions and field-block or nerve-block in larger lesions, is the most desirable technique for operations that can be performed under limited anesthesia in short time. Spinal or sacral epidural block is an admirable technique for For the upper larger lesions in the lower extremities or perineal area.
trunk, head, neck and breast, colonic or intravenous anesthesia is most satisfactory when novocaine or nitrous oxide is inadequate. Colonic instillations of avertin, evipal, paraldehyde and intravenous evipal or pentothal
are becoming
thetists
The combination of nitrous should not be used because, when combined,

mouth and
face.
more generally recognized as excellent techniques as anesbecome more familiar with their administration. In the inhalation group of anesthetics it must be remembered that the mixture of nitrous oxide and oxygen is not inflammable, but when mixed with ether vapor the gases may be ignited by sparks or glowing
exposed electric cautery. This is likewise true of ethylene, cyclopropane and the vapor of ethyl chloride, either used alone or in combination with
any other
gas.
CLINICAL USES OF ELECTROSURGERY
The employment of electrosurgical methods can be considered from two viewpoints, that of the general practitioner and that of the general surgeon or specialist. For the general practitioner, the skilful use of electrodesiccation, based on accurate diagnosis, offers the possibility of treating a large number of minor surgical conditions. For the general surgeon and
CLINICAL USES OF ELECTROSURGERY
283
specialist the use of electrocoagulation combined with electric cutting has made possible decided advances in the surgical treatment of parenchymatous organs, due to decrease of bleeding, increased speed of operation and
decrease of postoperative shock and pain. It affords also a new technique in attacking malignant disease. Uses of Electrodesiccation. For the destruction of superficial lesions of small size, where good cosmetic effects are essential and also where the delicacy of the tissue makes surgical intervention difficult, electrodesiccation is the method of choice. Its principal indications and some of the special points of technique are herewith enumerated. Skin Conditions. Electrodesiccation may be employed in treatment of warts, moles, small congenital angiomas, mollusca contagiosa, tattoo marks, nsevus vasculosus and pigmentosus, xanthomas, lupus vulgaris and erythematosus, keratoses and precancerous dermatoses. Most of these conditions and the points of technique are discussed in the Chapter on skin
conditions.
Epilation or removal of superfluous hair by electrodesiccation is a wellestablished procedure but it requires an apparatus or a suitably decreased output producing a very fine current within delicate control. (Fig. 197.)
It enables destruction of hair follicles in a few seconds in rapid succession and with a minimum of after-effect. For full description of technique see Chapter on skin conditions. Other locations suitable for electrodesiccation are: Mucous Membranes: papillomata and other benign growths of the mouth, vocal cords and bladder, leukoplakia, selected cases of infected tonsils and other nose and throat conditions (Chapter on nose and throat conditions), epulis and ranula. Eye Lesions: corneal ulcer, granular conjunctivitis, trachoma, pterygium and chalazion. (Chapter on eye conditions.) Gynecological Conditions: skenitis, urethral caruncle and other benign vascular tumors in urethral orifices, condylomata of the vulva, vaginal cysts, cervical cysts, and erosions, nabothian cysts, cervical polyps and other benign growths of the cervix (Chapter on gynecological conditions).
Proctological Conditions:
papilloma, selected cases of hemorrhoids, anal
fissures, pruritus ani (Chapter on proctological conditions). Uses of Electrocoagulation and Electrosection. Electrocoagulation
may
be employed as a matter of choice for any of the conditions enumerated. It supplants desiccation in the destruction of large tumors or in securing hemostasis. Electrocoagulation combined with cutting has evolved a new technique in the treatment of accessible malignancies. In all larger size epitheliomas, as well as in all other new growths of a frankly or potentially malignant character, it not only rapidly destroys all accessible tissue " " but also can be used to circumvallate the diseased tissue by a coagulation ring in the adjoining healthy tissue, thus separating it from the rest of the organism with little risk of producing metastasis. In the treatment of any form of malignancy surgical judgment and broad experience are needed to determine whether electrocoagulation alone or the combination with the cutting current is advisable or whether the knife, roentgen-rays or radium should be employed. According to Clark, electrothermic destruction should be used alone only in localized tumors of a type which does not tend to metastasize.
284
ELECTROSURGERY
field
The
outlined
by Kelly
of electric cutting, 1* as follows:
combined with electrocoagulation was
face, lips, mouth, tongue, fauces. renders signal services in exsecting the diseased area, it undoubtleaving a clean, sound, aseptic, rapidly healing wound; in fact, edly replaces the actual cautery. "In malignancy of the skin in all parts of the body, electrosurgery is second only to radium; it supersedes radium in nevi. Often when the use either of the roentgen-ray or radium has been overdone, and there still
"Various malignancies about
"For carbuncles
it
remains a sclerosed or an extensively ulcerated mass, nothing approaches the efficiency of the exsections of electrosurgery. " Epitheliomata of the dorsum of hand or wrist, even when the growths extend into the tendons, are admirably handled by electrosurgery which
secondary only to radium well managed. certain breast cases it is supreme, especially in the presence of nodular, ulcerated, massive scirrhous breasts, when there is not a shadow In such cases of a hope of a successful removal by classical methods. of the mass often proves of inestimable value electrosurgical extirpation in stopping the pain and the discharges, as well as in freeing the poor victim of the unsightly reminder of a doom daily approaching. "Malignancies about the abdomen offer a fertile field for electrosurgery. We can destroy papillomatous ovarian implants faster than it can be stated. Small areas of carcinoma are readily destroyed and left where found, while a scirrhous nodule in the intestinal tract can be widely deis
"For
stroyed. "
Malignant vulvar disease should always be removed by electrosurgery and any inguinal glands sparked out of existence. " In experiments on the liver and kidney, Ward and Pearse have resected portions of both organs with a marked lessening of the hemorrhage. In the liver there was practically no bleeding during excision of a complete lobe. In nephrotomy and partial nephrectomy, in spite of the large arterial supply of the kidney bleeding was markedly diminished in the peripheral
areas. In the
neighborhood of the
pelvis, the larger vessels required
clamp-
ing
and coagulation.
"Electrosurgery is opening up a large field in brain work as it will in spinal cord surgery. In the brain, as shown by Gushing, electrosurgery is of the greatest value in opening up the meninges, in making safe a passage to an abscess, and above all in the effective handling of hemorrhage. It also enlarges the field of control over malignancy." Electric cutting methods have been generally adopted in the treatment
McCarthy and others developed ingenious instruments and methods for employing the underwater cutting current. Any desired amount of prostatic tissue may be removed under vision by electrosurgery, without bleeding, with a shorter period of hospitalization, with elimination of shock and with avoidance of permanent suprapubic
of prostatic obstruction.
16
drainage. (See Chapter on genito-urinary conditions.) Conization of the cervix has been found valuable in expert hands for the treatment of selected cases of chronic endocervicitis and for biopsy of cervical tissue. (See Chapter on gynecological conditions.) In lung surgery new possibilities for removal of lung tissue and severing
CLINICAL USES OF ELECT ROSURGERY
285
17 adhesions have been shown (Matson ). In goiter surgery by electrical methods the shortening of the operative period and the absence of a severe 18 reaction during convalescence have been reported by Mock. In nose and throat work, electrical cutting, coagulation and desiccation have become part of the routine work. In ophthalmology retinal detachment has been treated with multiple diathermic puncture. Complete exenteration was done by electrosurgery
in extensive radioresistant cancer of the orbit. Electrocoagulation of the 20 choroid plexus in infantile hydrocephalus was developed by Putnam and
others.
Electrosurgical excisional biopsy according to Kime choice for all skin lesions suspected of being cancerous.
15
is
the method of The method may
be used on any comparatively small neoplasm (less than 3 cm. in diameter and 1 cm. depth) which is readily accessible. Local anesthesia is always used. The growth is completely excised by the cutting current and the base sealed by hemostat coagulation. The tissue excised en block is suitable for histologic study. Kime found the method satisfactory in 98 per cent of 392 malignant epitheliomas followed through the five to ten year period. The list of conditions amenable to cure by electrosurgical biopsy has been
given by
Kime 14
as follows:
Irritated blue-black moles, papillomas, senile
keratoses, leukoplakia, senile verrucse, cutaneous horns, cicatrices following old burns, keratotic and telangiectatic radiodermatoses and areas of radio-
necrosis following radium or roentgen-ray burns and oil gland tumors and cysts. Cervical erosions, cervical polyps, urethral carbuncles, cysts of the female external genitals, inclusion and dermoid cysts, sweat gland adeno-
mas, glomus tumors, hemolymphangiomas and endotheliomas. Malignant neoplasms amenable to electrosurgical excisional biopsy include various basal cell and squamous cell carcinomas, melanomas and adenocarcinomas. Mock's 18 conclusions as to the present status of electrosurgery Critique.
are as follows:
"1. Electrosurgery offers a distinct advantage over scalpel surgery in a limited number of surgical conditions. "2. Surgeons must understand the differences between the dehydrating, coagulating and cutting currents and must learn through much experimentation how to control and use these various currents before attempting
to
do electrosurgery.
"3. Knowledge in the use of electrosurgery is of secondary importance to surgical experience and judgment. The possession of an electrosurgery apparatus and a little instruction by a manufacturer's agent does not fit
one to attempt surgical operations by this method. No physician not thoroughly trained in scalpel surgery should attempt electrosurgery.
"4. Electrosurgery
is
useful in
many
operations in the various fields of
special surgery. Here again the specialist's knowledge and surgical experience are of paramount importance before attempting to use electrosurgery. "5. Electrosurgery is the best means of attacking malignant lesions of the skin, breast, the various orifices, and even the deeper malignant lesions after they have been exposed by scalpel surgery. It has proved of great value in neurologic, thoracic, genito-urinary, skin and thyroid surgery.
It
has a limited
field of usefulness in
many
of the other specialties."
286
ELEC TROS URGER Y
REFERENCES
1.
CLARK, W.
1924.
Electrothermic Methods in the Treatment of Neoplasms and L., et al.: Other Lesions, With Clinical and Histological Observations, Radiology, April,
2.
3.
Congress of the American College of Surgeons, Philadelphia, October, 1930, Surg., Gynec. and Obst., p. 503, February, 1931. GUSHING, H.: Electrosurgery as an Aid to the Removal of Intracranial Tumors,
Surg., Gynec. and Obst., 47, 751, 1928. DAVIS, THEO. M.: Prostate Operation, Jour. Am. Med. Assn., 97, No. 23, 1931. ELLIS, J. D.: The Rate of Healing of Electrosurgical Wounds as Expressed by
4.
5.
6.
7.
8.
Tensile Strength, Jour. Am. Med. Assn., 96, 16, 1931. Electrosurgical Currents and the Histology of Electrosurgical Wounds, Principles and Practice of Physical Therapy, vol. 2, Chap. XIX, Hagerstown, Prior & Co., 1933. GREENWOOD, JAMES: Two-point Coagulation, Arch. Phys. Ther., 23, 552, 1942. GULEKE, PROF.: Das doppel-polige elektrische Schneiden, Der. Chirurg., vol. 18,
1933.
Action "disse~quante" du bistouri a haute frequence, Bull, et me"m. Soc. nat. de chir., 55, 750, 1929. Relative Merits of the Scalpel 10. HIGGINS, CHARLES C., and GLAZIER, MCCLEERY: and High Frequency Current in Nephrotomy, Surgery, 9, 220, 1941. Conization of the Uterine Cervix, Am. Jour. Obst. and Gynec., 11. HYAMS, M. N.:
9.
HEITZ-BOYER, M.:
25, 653, 1933.

12.
KELLY, H.
A.,
and WARD, G. E.:
Electrosurgery, Philadelphia,
W.
B. Saunders
Company,
13.
14.
1932.
KEYSSER, F.: Die Elektrochirurgie, Leipzig, Fischer's Med. Buchhandl., 1931. KIME, EDWIN N.: Surgical Applications of Physical Medicine, Jour. Indiana Med.
15. 16.
Assn., 34, 117, 1941.
MCCARTHY, JOSEPH
1932.
Electrosurgical Excisional Biopsy, Jour. Indiana Med. Assn., 31, 556, 1938. F.: Prevention of Prostatism, Jour. Am. Med. Assn., 99, 1926,
C.: Operative Collapse Therapy in the Treatment of Pulmonary Tuberculosis, Western Jour. Surg., November, 1930. 18. MOCK, HARRY E.: Electrosurgery, Jour. Am. Med. Assn., 104, 2341, 1935. Neue Anwendungsgebiete der Elektrokoagulation und deren tech19. NIEDEN, A.: nische Vorbedingungen, Zentralbl. f. Chir., 57, 1488, 1930. Treatment of Hydrocephalus by Endoscopic Coagulation of the 20. PUTNAM, T. J.:
17.
MATSON, RALPH
21.
WYETH, G.
Choroid Plexus, New England J. Med., 210, 1373, 1934. A.: Surgery of Neoplastic Disease by Electrothermic Methods, York, Paul B. Hoeber, Inc., 1926.
New
CHAPTER XIV
ELECTRICAL INJURIES
Causes: The Equation of the Operator, of the Accidents During Electrotherapy. MedicoPatient, and of Apparatus. Burns. Electric Shock. Mechanical Injuries. Accidents in Homes and Industry. Injuries From Lightning. legal Aspects.
ELECTRICAL energy
is
an obedient and accommodating servant and
is
indispensable as the prime mover in innumerable phases of industry, travel, home life and likewise in the art of healing. But, like any other powerful agent, it must be employed with care and a knowledge of how to
prevent ill-effects from its use. Accidental injuries most frequently occur in connection with the use of electricity in homes and industries, but they also occur from time to time during the therapeutic application of electricity. They consist of either local injuries, that is, burns of varying extent; or they may be general in electric shock or electrocution. At times a combination of their effects both local and general effects may occur. Local injuries are usually caused by a current of small voltage and small amperage, such as used in electrotherapy. General or lethal effects may occur when a voltage large enough to overcome the resistance of the tissues is combined with an excessive amperage, as is the case in high-voltage electrical contacts, or else when the resistance of the tissues is much decreased, as with a person in a bath or when standing on a wet floor.
ACCIDENTS DURING ELECTROTHERAPY*

is the first of all do not cause any harm Latin pronouncement as to the duties of the physician toward his patient. Legal authorities tell us that the average physician when taking charge of a patient must have the reasonable degree of learning and skill that is ordinarily possessed by physicians and surgeons in the locality where he practices. On the other hand, "a physician who holds himself out as being specially versed in some phase of medicine is required to possess special knowledge and skill, not merely such knowledge and skill as the average physician has but such as is possessed by the average
"Primum non nocere"
classic
specialist.
"The modern development

has
of medicine
to the extended use of apparatus for diagnostic
and surgery with the tendency and therapeutic purposes
made these demands much more complicated. The doctor is not only supposed to be a diagnostician and have a good knowledge of the action of drugs and of the principles of surgery, but is also expected to be a mechanic and somewhat of an electrotechnician. He must be able to supervise
direct his nurses and other technical personnel and is liable for improper treatment on their part; yet no matter how skilled the physician or his personnel, accidents are unavoidable from time to time. A patient sneezes and the sudden muscular action dislodges a pair of electrodes over the
and
From
and reprinted from the Journal
a paper of the author read before the Society of Medical Jurisprudence, New York, of the American Medical Association, 100, 107, 1933.
(287)
288
ELECTRICAL INJURIES
shoulder or causes one of the cord tips to slip out from its insertion; in both cases the current may be shut off almost immediately by the physician or his nurse, yet a certain amount of damage will occur. "Considering the widespread application of electricity for therapeutic purposes, there is an almost negligible amount of injury caused by it; this, of course, is due to the safe and efficient types of apparatus and to the careful technique used by physicians and technicians in the application
Nevertheless, accidents from time to time are unavoidable. The causes which lead to their occurrence can be classified in three broad groups: (1) the equation of the operator: improper technique or inattention; (2) the equation, of the patient: unusual sensitiveness or idiosyncrasy, lack of cooperation, contributory negligence; (3) the equation of apparatus and accessories: faulty construction or mechanical breakdown. Many injuries are attributable to an unfortunate combination of causes; as long as the general rules of safe technique are followed, a single cause usually does not lead to any serious injury.
of the variotis durrents.
"1. The Equation of the Operator. The operator of any piece of apparatus used for diagnosis and treatment must have a fair conception of its working mechanism and have full knowledge of the technique of its applica-
Such knowledge should be acquired on the basis of clinical instruction and experience and not from the salesman of apparatus. The operator of any apparatus must know how the energy output of that apparatus is controlled, and how it will affect the parts of the body subject to its influence. He must know how to apply and hold electrodes in good position and must know how to proceed with the treatment to the degree of maximum efficiency without discomfort to the patient. He must be familiar with the danger signals of chemical or heat burns. He must take nothing for granted, so far as the patient is concerned, and use all reasonable
tion.
precautions to avoid accidents, save for wilful acts or neglect of the patient in disregarding properly understood warnings. " No complaint of a patient during examination or treatment, no matter how trivial, should ever be lightly brushed aside. Proper technique requires that the patient is made comfortable and remains so during the entire treatment with the part under treatment well supported and relaxed also in a busy office, that a time clock or other controlling device be used to cut off the current automatically at the expiration of the treatment period.
,
"It is an important rule of the routine of any office that the parts receiving treatment be carefully inspected before and after each application, any changes being noted. One occasionally hears complaints made by patients that they noticed a blister on returning home after an electric treatment. If thorough routine .inspection of the parts after any treatment is consistently carried out and no changes are found in the office, one can safely assert that the lesion complained of did not originate from the treatment there, for any damage to the skin from a galvanic, diathermic or other electric current would produce enough change in the tissues to be visible immediately and not hours afterward. Burns due to heat treatment by lamps as a rule also show up immediately, but occasionally a blister may develop overnight, following a long heat exposure. Such lesions are due to the raising of the superficial epithelium by an exudation of lymph, but being quite superficial they dry up in a day or two and never can give rise to a serious complaint. Burns after ultraviolet exposure take twenty*
^
ACCIDENTS DURING ELECTROTHERAPY
289
four to seventy-two hours to develop fully, while roentgen-ray burns are well known to take weeks to develop. The chief protection of the operator in all cases is an indisputable record as to a generally correct technique. 'A final point of safe technique is never to leave a patient alone during
'
a treatment in which the slipping of a conducting cord or a fastening clip any of the electrodes could give rise to an immediate burn. Either the physician or his trained office assistants must be ready at all times to decrease the current strength or to shut it off altogether if the patient complains or there is any possible sign of danger. There are timing devices available which, connected to the apparatus, enable the patient to shut off the current by simply pulling a cord; simultaneously a gong summons the operator. This is a perfectly safe arrangement, provided the patient is told how to use it. "2. Equation of the Patient. The physical and mental equation of the patient is of paramount importance in administering treatments. A safe technique in many instances depends on the patient's cooperation in reporting at once an unpleasant sensation or a feeling of excessive heat, or in keeping still in a certain position; if patients fail to comprehend or follow these instructions their lack of attention or misunderstanding becomes a contributory factor in accidental injuries. In long-wave diathermy and galvanic treatments the theoretical amount of current toleration is estimated according to the size of the active electrode. The meter reading of the apparatus mainly serves as a safeguard as to the maximum amount that may be administered. The patient's comfortable toleration is always the principal guide. In the technique of longitudinal heating by diathermy, instead of burning and pain, a feeling of tension in the wrist or ankle serves as a subjective warning sign. " The individual skin sensitiveness toward ultraviolet radiation in those of fair complexion, blondes and old persons is well known and must always receive consideration. The minimal dose within safe toleration of such patients can be determined only by preliminary testing over a small area of the skin. "3. Equation of the Apparatus. Apparatus must be in good working order as an essential for the safe application of any kind of treatment. At the same time, any apparatus used day by day is apt to get out of order through continued friction or wear, such as slow disintegration of insulation due to heat, or through defective construction. When a patient is treated by an apparatus with an undetected defect, a minor mishap or a real tragedy may occur. Kowarschik 6 reported a case in which galvanic treatment for facial paralysis was administered from a new type vacuum tube galvanic generator. One electrode in the form of a half mask was placed over the face, the other over the forearm. A small, cheap circular wire rheostat, similar to the control on radio boards, was used to regulate the strength of the current. At the end of the treatment the assistant slowly turned this control back to zero, and just at that moment the patient cried aloud and fell unconscious to the floor as if struck by an electric bolt. The cause for the profound electric shock was found in the poor construction of the rheostat which swung over from the zero position to 360 degrees that of full strength, without an intervening catch. The patient thus suddenly received the full strength of the current through trie head. He recovered subsequently."
or of
19
290
ELECTRICAL INJURIES
Such extreme cases are, fortunately, rare in this country, but should serve as a warning to buy only apparatus of standard make and from a responsible manufacturer. Cheap appliances of flimsy make may readily give rise to similar accidents. Apparatus must be kept in good working order by regular frequent inspection and by immediately correcting any trouble, no matter how trivial. It is bad psychology ever to discuss any
Some patients are apprehensive receiving electrical treatment for the first time and any doubts expressed about the smooth working of the apparatus may cause them to
trouble with apparatus before a patient.
when
jump, throw
off electrodes at
the slightest provocation, and thereby lead
to a real injury.
BURNS*
Burns are always due to an undesired excess of thermal energy applied through the medium of electricity, radiation, water, paraffin, to the skin or mucous membrane. In the course of electrosurgery excessive current
density
purposely employed in order to produce tissue destruction and is not due to the absolute strength of the current, but rather to the disproportion of the area of the active and dispersive electrodes. A galvanic current of a few milliamperes strength or a diathermy current of 200 or 300 milliamperes may cause destruction if concentrated to a small area. Pathology. According to the form of energy employed, burns are caused
is
most
of the time the destructive effect
electrochemical or photochemical tissue destruction, and their and treatment varies accordingly. The common feature of all prevention of these injuries is that they are due to the devitalization or destruction of tissue; that their appearance may be immediate or take several hours or days. Their clinical appearance may vary from a passing erythema to blistering of superficial layers of the skin or deep tissue coagulation with subsequent ulcer formation they are slow of healing, may become infected and according to the depth and the location of destruction, may be followed
by thermal,
at times by extensive, unsightly scarring. Burns from Heat Lamps. Exposure to infrared or visible radiation results
normally in an erythemal response consisting of single dark red spots or a confluent network of these, and occurs according to the distance from the lamp, the wattage of the bulb, and the type of reflector, and the sensiExcess radiation, or hypersensitivity, or other tivity of the patient. causes, may produce, after the initial erythema, wheal formation, local
edema and eventually

overnight.
blistering. Sometimes these blisters only develop Excess radiation in normal patients always gives rise to a varying degree of burning sensation. Unfortunately, there are quite a few persons who, when receiving treatment for the first time, think, in spite of warning to the contrary, that a severe burning sensation is part of an effective treatment and become blistered due to their own contributory
negligence.
Burns from Diathermy. Undue current density of either long-wave or short-wave diathermy may cause drying or coagulation of tissue such as is produced intentionally by electrodesiccation or coagulation. According to the contact surface between the active electrode and the skin and the strength and duration of the current flow, the effects vary from a whitish
*
Reprinted with permission from International Clinics. 6
BURNS
291
discoloration of the epidermis at one or more points to actual formation of blisters and changes to a considerable depth in the color and consistency of the skin. The current flow is fortunately usually cut short, as most of
these burns are preceded by an intense reaction of pain, so that the patient usually cries out for help or shakes off the electrodes. At times, however, the burns may happen unnoticed in people with defective heat sensation.
In the later course of diathermy burns, should only the superficial epithelium have been seared, this peels off in a few days, leaving no trace of a lesion. In patients with a marked exudative diathesis a large wheal may appear immediately or a few hours later over an overheated area, only to disappear by next morning almost entirely, or leave only a small erythematous area or perhaps a small blister. In certain instances, however, there is subsequent sloughing and ulceration, possibly with exposure of subcutaneous tissues, of muscles, even of bone. Another form of diathermic burn is fat coagulation in the subcutaneous tissue, usually occurring in adipose women. As a result, one or more painful nodules appear under the skin, however, they usually decrease and absorb in a few weeks without any further damage or permanent sign.
The advent of short-wave diathermy with its simplified and safer technique of spaced condenser electrodes or the induction coil has done away with most of the burns due to direct metal contact. Because of the relatively less heating of the skin there is also less occasion of overheating the skin, but the possibility still exists, and burns by short-wave treatment have occurred when warning signs were disregarded. Burns from Galvanism. In galvanic treatment or ion transfer with electrophoretic drugs, if the bare metal electrode or any corner of it comes into contact with the skin, or if the pad is too thin or not sufficiently wet, or if there is a rent in the wrappings for ion transfer, or a scratch in the skin, there may be direct chemical action from either the positive or negative pole, through the metal plate or due to excess density of the current itself which if not detected in time, causes a burn. Galvanic burns develop, unfortunately, often without a sensation of excess burning or pain, owing to the small amount of current employed. After removal of the electrode or the wrappings for ion transfer only an excessive erythema over a small area or a slight wheal formation may show; both of these may last several hours and disappear next day. In the next degree of damage there may be blister formation of varying size and shape; these blisters may be single or confluent and are usually painless. In a day or two a red line of inflammation appears and the blister breaks, leaving an open ulcer. Should several blisters form, a large denuded area of varying depth may develop and this, due to the usual secondary infection, as a rule, becomes quite
painful
and heals
slowly.
Burns from Ultraviolet. These burns differ from other burns, inasmuch as, first of all, a mild degree of "sunburn" is a normal and desired reaction of the average treatment with ultraviolet; second, hypersensitivity plays a definite role in the occurence of these burns when they are not due to simple overdosage. Certain drugs or substances when circulating in the " " blood or applied to the skin cause a marked photocatalytic reaction. Among these photosensitizers are endocrines, fluorescent dyes, heavy metals, and also, as recently claimed, sulfanilamide. There are also a few individuals with inborn sensitivity to both sunlight and artificial ultra-
292
violet.
ELECTRICAL INJURIES
The results of an increased reaction in such cases vary all the way from a severe itching to a rapidly developing dermatitis, edema of the in normal skin, formation of bullse, fever and general malaise. Overdosage individuals such as occurs when a careless operator forgets to turn off the ultraviolet lamp in time, or an individual falls asleep under a self-adminThe severe general istered lamp treatment, shows the same variation. reaction in each case is due to the flooding of the blood stream with the a severe "protein shock." In extreme split protein products of the skin, cases, gastric and duodenal ulceration may also occur, with a lethal outcome. Fortunately, in the course of ordinary treatments severe reactions are extremely rare because it has been estimated that a margin of safety
as great as 50 per cent against overdosage exists.
Treatment of burns occurring during electrical treatment is similar to that of any other burn. After antiseptic cleansing the first dressing is made with a boric-acid ointment. If on the next day the burn is found to be more or less dry and the surface of the skin is not broken a dusting powder with dry gauze held by adhesive plaster is all that is needed. When the burn is a large one and ulcerated, the boric-acid ointment dressing should be continued. Daily exposure to the rays of an infrared or incandescent lamp for one-half hour or more promotes nutrition and speeds up healing. The healing of small burns can also be speeded up by daily short exposures to ultraviolet irradiation. They should be kept dressed with plain gauze pads soaked in paraffin. (See also Chapter on skin conditions.) Diffuse dermatitis and severe effects due to a severe ultraviolet reaction must be treated according to general medical principles.
ELECTRIC SHOCK
Electric shock denotes the sudden harmful influence of an electric current to the entire body. Serious shock can never occur during electrical treatments applied with a careful technique. Under rare conditions minor
degrees of electrical shock may be caused by the following contingencies: Low-frequency Current Passing Through Cardiac Area. In using lowfrequency currents, there never should be an electrode over or near the heart, because even a small amount of current passing through the cardiac area may cause fibrillation of the heart and electric shock. This danger to the heart is the reason why, generally speaking, shocks from an alternating current source are more dangerous than from direct current. Accidental Contact With a Grounded Object. Touching a water pipe, radiator, electric light socket while undergoing electrical treatment from an apparatus or while immersed in a galvanic bath may cause shock. An apparatus which utilizes the commercial lighting current directly, interposing only a variable resistance, offers this possibility of leakage of ground current to a patient. This danger is best avoided by using groundfree
apparatus (motor generators) or else by carefully avoiding any grounded object within the reach of the patient or operator. At any rate, shock caused by such occurrences becomes serious only if a large surface of the body offers good conduction as an electric bath. Transformer Breakdown. If a therapeutic current is derived from a high-tension transformer, and during treatment, a breakdown of insulation occurs between the primary and the secondary side of the transformer,
MEDICOLEGAL ASPECTS
293
there is danger of the high-tension, low-frequency current jumping over to the patient. Such a case occurred in Italy a few years ago when a physician demonstrated to a group of friends the mild heat effects of a high-frequency current, by passing the current through each person using When the current was cylindrical metal electrodes held in the hands. put on in the same manner to a girl aged nineteen years she fell dead. A
broken wire in the transformer had caused the high-voltage, low-frequency

current to jump over into the high-frequency circuit, there being contrary to the safe custom direct (galvanic) coupling between the two sides instead of the safe inductive or magnetic coupling.
MECHANICAL INJURIES
Mechanical injuries
may occur in connection with therapeutic procedures

piece of apparatus falls upon the patient of the skin. The excessive action of me-
when an improperly supported

and causes a contusion or tear
chanical exercising apparatus of such organs as the bladder.
therapy the
thin-walled excessive reactions and at times fracture of atrophied bones.
may cause injury to the skin or a rupture Among non-electrical procedures, in colonic now outmoded long stiff colon tubes may cause a rupture of diverticula. Manipulation of deformed joints may cause
MEDICOLEGAL ASPECTS
Legal authorities
of a patient
tell
us that the average physician
when taking charge
ordinarily
practices.
must have the reasonable degree of learning and skill that is possessed by physicians and surgeons in the locality where he
holds himself out as being required to possess special knowledge and skill, not merely such knowledge and skill as the average physician has but such as is possessed by the average specialist. The law does not compel the physician to be an insurer of good results and does not hold him responsible for an honest error of judgment. However, the law does create a standard of knowledge, skill and diligence and the standard is higher for a specialist than for the practitioner of general medicine and still higher for the specialist of renown than for one in a more modest
the other hand, a physician
specially versed in
On
who
is
some phase
of medicine
position. Malpractice suits are based on alleged negligence, carelessness, want of requisite skill and poor judgment. An accident, if it be merely an accident and not the result of any neglect or improper act or neglect,
does not form the basis of liability. The statement of an individual or his lawyers that when he went to the doctor he was all right and then came away with a burn, does not prove anything against the doctor. It must be shown that he has done something that is negligent and the patient must have been free from contributory negligence before liability can be
established.
The law demands that the patient follow the directions of the physician and do nothing to jeopardize the results; he must cooperate in a manner to help obtain good results and to help to avoid bad results. The patient
may
be found guilty of contributory negligence.
The employment of technicians in physicians' offices and the institutional work of physicians has also created some definite legal aspects. If an injury has been occasioned by negligent or improper treatment or
294
ELECTRICAL INJURIES
neglect in an institution, the nurse or technician whose improper act of neglect resulted in the injury is, of course, personally liable. Such liability the technician or the nurse is usually is, however, rarely enforced because
not financially responsible.

trine of respondeat superior.
The physician under whose

is
direction treat-
ments are rendered by a nurse or technician
The physician
is
responsible under the docnot, however, liable for any
injury occasioned
of their
by an act
of the nurse or technician without the scope
employment, such, for example, as a wilful attack upon a patient. The hospital, if it be an institution organized for profit, would be responsible to the same extent as would be the physician and upon the same principle
of respondeat superior. If the hospital, however, is a non-profit institution, the hospital is relieved by law from any responsibility.
If
the physician sends a nurse or technician in the physician's employ
to a patient and makes that nurse or technician his own agent or representative in the treatment of the patient, then the physician is responsible for damages occasioned by the negligent or improper acts or omissions of the
nurse or technician, other than for wilful acts of the nurse or technician clearly outside the scope of their employment. If, on the other hand, the physician suggests to the patient that he knows a technician or a nurse,
and with the patient's consent undertakes the mechanical details of having the nurse or technician come to the patient's house, thus making the nurse or technician an independent contracting party, the physician is liable only in the event that he has not exercised reasonable care in the selection of the nurse or technician. Our legal advisers point out two important matters which are often neglected by the average physician. One is the keeping of sufficient or adequate records for the treatment of office cases, even of a minor nature. In most states a malpractice suit can be instituted any time up until two years after the cause of action occurs. Two years after treatment has been administered it is very difficult for a physician to remember anything about it and back up his statements unless he can consult definite records of the case. Another point is that following an accident, should any sort of injury develop, he should freely and fairly deal with the patient and not conceal anything from him.
ELECTRICAL ACCIDENTS IN
HOMES AND
IN INDUSTRY
The extended use of electricity for lighting and for power requires conduits of large voltage and amperage practically everywhere. If through ignorance or carelessness a person either touches the two poles of the
current or touches one pole and the ground he becomes part of a circuit and an accident may happen. One line of the ordinary 110-volt house current can be safely touched by a person standing in dry shoes upon a dry non-metallic floor; an electrician often tests a lamp socket for live current by putting two fingers against the charged parts, and all he feels is a disagreeable pricking but no shock, on account of the small area of such contact and its great resistance if he were to continue to keep his fingers in contact, however, he would soon receive a burn. So far as the general use of electrical appliances in the household is concerned there are two general rules of precaution for everyone. The
;
ELECTRICAL ACCIDENTS IN HOMES AND IN INDUSTRY

first is
295
never to touch an electrical appliance while standing in water, on damp floor, or while any portion of the hand or feet is wet; second, never handle two electrical fixtures at the same time. There is always the danger of a worn-out insulation in one apparatus and, by touching its metallic part while handling another apparatus, there is the chance of a leakage ground current to cause a sudden shock. Frequent causes of electrical mishaps are: Pulling the metal chain of an electric light and touching with the other hand a pipe, radiator or other grounded metal, or while standing with wet feet upon wet ground or in a bathtub; or touching any part of an electric light fixture and at the same time screwing on a bulb and accidentally touching the metal base of the bulb or the charged part of the socket.
a
The danger of accidents, of course, is much greater when high-tension currents of thousands of volts are approached; then even the touching of
one of the terminals may discharge a fatal current, overcoming the resistance between the person and the ground. Visitors to a high-tension plant should, therefore, stand on dry and insulated platforms as far as possible,
the pocket. Lightning, of course, is the electrical of the highest potential, and it may hit and kill under almost discharge
and
also
keep one hand in
any circumstances. As a result of any

external injuries
is
of the conditions
enumerated, there
may
The
occur either
first
burns, or a shock to the entire body. External Injuries. External injuries are of two kinds.
variety
caused by the effect of heat due to passage of the current into or out of the skin through the contacting electrode. The heat may be produced within the cutaneous tissues by localized excessive current density continued for some length of time. The second variety is due to an electric arc between the surface of the body and the contacting or nearly contacting electrode, whereby the impact of the arc strikes the body surface. Both of these actions may occur simultaneously and the result may vary from a mild superficial blister to a deeply charred burn/with destruction of tissue. 2 Jellinek, of Vienna, the foremost student pf the. pathological effect of electricity, contends that true electrical wounds, due to sudden electrical sparking or contact from high-tension sources, are different from ordinary electric heat or chemical burns. He states that the most striking characteristics of true electrical wounds are their complete painlessness the retention for days and even weeks of their original appearance, their failure to react upon the tissues in their proximity and the. fact that every electric lesion possesses a remarkable tendency to heal. After a period of latency, lasting days or even weeks, large portions of soft tissue in the region of
the wound, as well as pieces of bones, may drop spontaneously away without causing any noticeable discomfort, irritation and without producing suppuration.
Based on the character

is
of the electrical
wounds
just described, Jellinek
a strictly conservative method of treatment. Electrical Shock. Electrical shock is produced by the sudden, powerful influence of an electric current upon the entire body and is characterized
in favor of
by tonic or clonic spasm and rigidity of muscles, including the respiratory muscles during the passage of the current, and may be accompanied by There may be fibrillation, paralysis or entire stoppage of heart action.
29G
;
ELECTRICAL INJURIES
burns at the places pf entry and exit. Shock may be caused by any of the forms of low- and high-tension currents used in industry or homes and by
lightning.
Of the two major types of currents, the direct is less dangerous than the alternating, all things being equal. Low- voltage current has a tendency to throw the heart into ventricular fibrillation if the heart is in the path of the electric current in the body. Higher voltage affects the central nervous system, causing an inhibition or block of the respiration center in the brain. High voltage sustained for any appreciable time will cause heart
Cardiac death as well as asphyxial death from respiratory stoppage. fibrillation from low voltages is fatal, but respiratory paralysis often associated with high voltages may be overcome by artificial respiration performed until the respiratory center is able to overcome the inhibition and carry on itself. Alternating current produces more severe muscular contractions tHari direct current; this often results in the victim "freezing" to the electric conductor and being unable to free himself from the current,
thereby increasing the duration of time that the current is flowing into his body. 3 Kennelly states that it is hard to say just where the danger from accidental electric shock commences. It usually depends more upon the conditions of the accidental contact than upon the nature of the circuit with which contact is made. The longer the exposure to the current flow, the less the possibility of resuscitation. Another factor determining the severity of electric shock is the character of the ground connection, i. e., whether wet or dry. The former offers less resistance to the current flow through the skin; the latter offers greater resistance and as a result generates greater heat in the tissues and produces greater destruction. With wet perspiring skin, resistance is low, more current enters the body, and the shock is more severe. A 1000-volt direct current touched briefly by a swiftly moving dry finger may give a much less severe shock than a 110-volt alternating current grasped with a wet hand by a person standing in the water of a well-grounded bathtub. Williams 8 states that in the last fifteen years there have been many reports about people who seem to die from touching low-voltage alternating
For a 110-volt circuit to kill it is necessary that the skin be sufficiently moist, that the contact be sufficiently large and that the current pass through the heart muscle in sufficient quantity to throw the ventricles into fibrillation. Not every case of ventricular fibrillation continues to death, but the usual outcome is death. There has been much discussion whether death is due to cardiac fibrillation or to respiratory paralysis caused by the action on the medulla. The prevailing opinion is that cardiac damage is the principal cause, and this view has been corroborated by animal experiments (Koeppen 4 ). This fact also explains why artificial respiration will often maintain sufficient circulation to keep the cellular elements of the central nervous system alive. Immediately following shock respiration may cease while the heart action continues, but this is explained by tonic spasm of the respiratory muscles, and breathing is resumed as soon as the electrical contact ceases. It has been also observed, that respiration continues after the heart has gone into fibrillation or stopped. Instances of the spontaneous resumption
current circuits.
ELECTRICAL ACCIDENTS IN HOMES AND IN INDUSTRY

of the
297
suspended heart action have been reported, but this never occurs
after intervals as long as
two minutes.
to disengage the victim from the current, the power or short-circuiting it. At times it is necessary to pull the victim away from the circuit, and for this purpose, of course, heavy rubber gloves or shoes or any other available insulation shall be used. Many secondary accidents have happened due to the careless haste of would-be rescuers. If no insulating substances are available and, especially, if the ground is wet it is better to attempt dislodging the victim by a non-conducting object, a stick of wood or rubber, or by trying to knock
Treatment.
The
first rule is
either
by turning
off
the wire out of his hand. As to the medical emergency treatment, heart massage applied within five minutes after cessation of heart action has been reported as effective.
If
there
if
and
respiratory paralysis artificial respiration is absolutely necessary, kept up long enough it may lead to returning of the heart action. If
is
the heart once begins fibrillation
it
very seldom recovers.
Strychnine,
camphor and adrenalin have been recommended intravenously, the latter even intracardially, and accompanied by heart massage. Cardiac stimulahowever, should not delay or interfere with artificial respiration, which should begin without the slightest delay. 1 Injuries to Eyes. According to Fisher electric flash or glare injury to the eyes is one of the commonest forms of electrical accident. Flashes occur when metal comes in contact with electric current. An arc is formed which produces a blinding glare of light rich in ultraviolet rays. Rarely, the flash may reach the patient's eyes and produce an actual burn. Usually there is no actual contact with the flash, but the heat and ultraviolet rays may produce reddening of the skin surfaces and the brilliant light causes the pupils to be violently contracted and the mechanism of the eyes to Visual purple in the retina of the eye receive a powerful stimulation. becomes completely blanched, and transitory dimness or fogging of vision results. Generally, within forty-eight hours all symptoms disappear and
tion,
visual acuity
is
not disturbed.
Persons struck by lightning, an extremely Injuries from Lightning. high potential discharge between clouds and the earth, are always subject to electrical shock which is often fatal and, in addition, show local lesions which form a peculiar clinical picture. The markings found upon the skin show a striking resemblance to the trunk and limbs of a tree. These are formed by erythematous skin lesions, dilated capillaries and extravasations, and are evidently due to the distribution of the high-tension electrical discharge along the path of least resistance. These surface markings have no relation to the severity of symptoms produced and if the victim survives usually disappear in a few days. The internal damage and the severity of shock depend upon the organs lying in the path between the entry and the exit of the electrical bolt. Treatment is the same as for shock.
REFERENCES
1.
FISHER, H. E.: Electrical Accidents: Arch. Phys. Ther., 22, 611, 1941.
Shock, Burns and Glare Injuries to Eyes,

1927.
2.
JELLINEK,
S.
Der
elektrische
Unf all, Wien, F. Deutike,
298
3.
ELECTRICAL INJURIES
Am.
E.: The Danger of Electric Shock From the Engineering Standpoint, Jour. Electrother. and Radiol., 45, 1, 1927.
S.:
KENNELLY, A.
KOEPPEN,
4.
Cause
of
Death
in Accidents
Caused by
Electricity, Miinchen.
med.
5.
Wchnschr., 80, 1805, 1933. KOVACS, R.: Accidental Injuries in Office Practice, Internat.
1940.
Clin., vol. 3, Series 3,

d. ges.
6.
KOWABSCHIK, JOSEF:
STRYKEK, L.
1932.
P.:
Die Gefahren elektromedizinischer Apparate, Ztschr.
f.
phys. Ther., 42, 82, 1932.

7.
Courts and Doctors,
New
York, The Macmillan Company,
p. 16,
8.
WILLIAMS, H. B.:
The Problem
of Electric Shock,
Am.
Jour. Surg., 27, 151, 1935.
PART
III
Light Therapy
CHAPTER XV
Length.
Theory
of
Radiant Energy.
Classification.
Measuring
Wave
Spectroscopic Comparison. Measuring Radiant Energy. Common Physical Phenomena. The Inverse Square Law. The Angulation of Rays. Penetration. Comparative Physical Effects. Comparative Physiological Effects.
General Considerations. It was stated that a current of electricity denotes a flow of electrons that is set up by a disturbance of the atomic structure and that takes its path through a set of conductors, called an electrical circuit. The therapeutic effects of the different electrical currents are produced by making the human body part of the path of the electrical
circuit.
We are now to present the therapeutic aspects of another broad division

Radiation is the process by which energy is propagated through space. Every substance with a temperature above absolute zero emits radiant energy in the form of heat
of physical science, that of radiant energy.
radiation.
When electrical or chemical forces of suitable intensity are applied to various forms of matter, luminous and other forms of radiations are produced. Infrared, luminous and ultraviolet rays all are forms of radiant energy. The common characteristics of all forms of radiant energy are as follows: they are produced by applying electrical and other forces to various forms of matter; they all may be transmitted without the support of a sensible medium their velocity of travel is equal in vacuum but varies with different media. Their direction of propagation is normally a straight line; they undergo reflection, deflection and absorption by the media. They are designated collectively as electromagnetic radiations. Light is a form of radiant energy which makes objects visible by stimulating the retina of the eye. Ultraviolet and infrared radiation does not render objects visible. The general term of light therapy or phototherapy by custom also includes the employment of the visible as well as invisible radiations of heat and ultraviolet or actinic rays, because they are all, as a rule, produced at the same time and the therapeutic results are due to
;
their
combined
effect.
The term
actino-therapy relates more specifically
to the
employment
of ultraviolet radiation.
The application of radiant energy for the treatment of disease or the stimulation of lagging biological processes forms one of the most interesting and most complex chapters of present-day physical therapy. A maze of clinical and experimental material has been accumulated in recent years on every phase of the subject. For the purpose of this volume only the basic physical and physiological facts and the practical uses of infrared,
visible
and ultraviolet radiation
will
be presented.
Roentgen-rays and
(299)

are not included radium, although in a physical sense part of radiant energy, form part in this consideration because, by well-established custom, they of medicine. of another large special field of the practice
TABLE
31.
THE ELECTROMAGNETIC SPECTRUM

Wave
length
Frequency
Name
of subdivision
i
in cycles per sec.
301
According to our present day knowledge a light ray consists of an enormously large number of exceedingly small entities known as photons. These photons are produced by profound atomic changes when a swiftly moving electron collides with an atom. The impact transforms the kinetic energy of the electron into a photon. The photon is ejected from a light source at a velocity of 186,000 miles per second in vacuum, which speed it maintains until slowed or stopped by a liquid or solid body. A light source loses weight when it radiates photons. Photons exert a pressure upon any
object that they strike for they possess inertia and mass. They, therefore, appear to be material particles but while in flight they exhibit many properties associated with wave forms of energy. The kind of radiation, whether roentgen-ray, ultraviolet, visible or infrared, is associated with the size
The intensity of light is a measure of the number of photons arriving at a given 'area per second. The kind of light (wave-length) and the intensity of light (energy per given area per second) are two very
of the photon.
important considerations in radiation therapy.
[THERMOCOUPLES
LJ
C ATCn
COLORS OF RAINBOW
\PHOTOGRAPHIC PLATE
COMPONENT PARTS
OF SOLAR RADIATION
FIG. 204.
Component
parts of solar radiation.
Modern physicists, among them Planck, Bohr, Compton and Einstein, evolved ingenious formulas, such as the quantum theory, endeavoring to coordinate in mathematical language the laws of electromagnetism, gravity and light. These formulas belong strictly to the realm of higher mathematics.
Radiant Energy. If a beam of white light passes through not only refracted but also dispersed, and a series of color bands called a spectrum is seen in the prism. Each color corresponds to a different kind of radiation, and their appearance is due to the fact that each is refracted differently. The radiation producing the sensation of red is refracted least, that producing the sensation of violet is refracted most. Beyond the part of the spectrum which affects the retina, the visible A thermometer or thermocouple placed rays, there are invisible rays. beyond the red side of the visible spectrum will register heat, and a sensitive photographic plate held beyond the violet will register chemical changes. The rays beyond the red end are called infrared and those beyond the violet end are known as ultraviolet rays. It has been found that the visible spectrum just described comprises only a small part of the full range of radiant energy. At the red end there exists a large region of radiations designated as infrared, and next to these another very large range of
Classification of
a glass prism
it is
302

and wireless transmission, the so-called (For greater detail see Fig. 205.) At the violet end of the visible spectrum there is the region of ultraviolet rays and beyond these are the roentgen-rays, the gamma rays of radium and some other radiations, not fully explored as yet. The graphic representation of the various energy waves in an ascending order of length is known as the electromagnetic spectrum. Lukiesh4 calculated that if the visible portions were 1 foot long the entire electromagnetic spectrum would be several
million miles in length. The basis of comparison of the different parts of the electromagnetic spec-
radiations which are used in radio
Hertzian waves.
trum, besides their physical and physiological effects, is either their wave length (the distance between the crests of two successive waves) or their frequency of vibration. Since all electromagneticenergy travels at the same velocity through vacuum and air, the thermal, luminous, ultraviolet and other rays of the sun strike the earth at approximately the same time. It is evident that the shorter waves must vibrate at a greater
frequency and
visualize this
A homely comparison to be a motley army of giants may and dwarfs, all under orders to reach the same goal simultaneously; in order to do so the giants step out leisurely, while the dwarfs run and take hundreds of steps for each one of the giants. Dividing 186,000 miles, the uniform speed of radiant energy in vacuum, with the wave length,
vice versa.
wave frequency or the rate of propulsion per second. One can classify electromagnetic radiations either by their wave length or
furnishes the
by
their
frequency, as
is
done with the radio
waves.
(See Chapter X.)
The
frequencies of the
different forms of electromagnetic radiation used in therapy are so very great that it would be im-
practicable to use such huge figures. The classification of the therapeutic parts of the electromagnetic spectrum,
is
therefore,
made by
stating their
wave
lengths.
Measuring Wave Length. The standard unit of measuring wave length is the Angstrom unit, proposed first by the Swedish physicist of that name. One Angstrom (abbreviated A or A.U.) repre-> or TTF millimicron (niju.). Many authors abroad and the United States National Bureau of Standards use the millimicron as the wave length scale. Ten Angstroms correspond to 1 millimicron and one translates millimicrons
sents fo^kooo
mm
into
Angstroms by multiplying them by
10.
SPECTROSCOPIC COMPARISON
Table 33 shows the wave range and
radiation.
303
classification of phototherapeutic
TABLE
Radiation
32.
WAVE LENGTHS
OF RADIATIONS
Wave
length
Very long electric waves Hertzian waves Radio waves Commercial broadcast
5,000,000 meters 30,000 meters to 1 cm. 30,000 to 10 meters
Amateur broadcast
International broadcast
.
High-frequency (long- wave diathermy) High-frequency (short-wave diathermy)

Infrared rays
.
...
meters to 3 meters 150,000 to 7,7000 A

7,700 to 3,900 A 3,900 to 136 A 136 to 1.4 A
1.4 to 0.01
600 175 50 300 30
to 200 meters to 20 meters to 15 meters
Visible rays Ultraviolet rays
Roentgen rays
Gamma
rays
of
The term spectrum denotes a charted band Spectroscopic Comparison. wave lengths of electromagnetic radiation obtained by refraction or
diffraction
by means of a prism or grating. For determining the wave transmission of substances in the ultraviolet and visible regions, length spectrograms are all that are necessary. Spectra can be classified into three kinds: (1) Continuous spectra are those emitted by incandescent solid substances, such as the sun, the carbon arc lamp and incandescent lamps; they are pure temperature radiations and contain a whole scale of wave lengths, the extent and energy distribution of which depends on the temperature of the hot body. (2) Line spectra are emitted by incandescent
vapors and gases, consisting of elementary substances such as mercury vapor; they consist of more or less sharply defined lines which are generally No two elements give distributed without any apparent regularity. spectral lines in exactly the same position in the field and thus an element may be detected merely by observing its spectral lines. The present view is that these lines are produced by the "falling in" of electrons which have been displaced from their normal orbits. (3) Banded spectra are given by compounds when these are dissociated; they always can be
resolved into groups of fine lines.
TABLE
33.
RANGE AND CLASSIFICATION OF PHOTOTHERAPEUTIC RADIATION

>>< 4000 to 7800
Visible light
>>
-1000 to 4000 Ultraviolet
-7800 to 120,000Infrared
Angstrom
units
Logarithmic scale
2200 to 3200 -<-3200 to 6500->-<-6500to 14000>-<

therapeutic
ultraviolet
longer
wave
and
penetrating
visible
14000 to 120000 > non-penetrating heat
ultraviolet
visible
and
infrared
The frontispiece of this volume shows the comparative spectra of the It must be strongly principal sources of phototherapeutic radiation. emphasized that ordinary spectrograms indicate only the wave lengths
304
available and tell nothing of the light energy at each Wave. Comparative spectrograms of the various sources of light, often displayed to unwary physicians by salesmen of lamps, are of little value in judging the efficiency 1 of the light source. Anderson states that on the basis of a spectrogram the ideal ultraviolet source would be the automobile spark plug operated on the automobile ignition system, for it gives a better spectrogram than can be obtained by the quartz mercury arc or any of the carbon arcs. Spectrograms must, therefore, be completed by a chart or table showing the light energy of each wave length. In comparing the graphic representation of energy distribution from various sources at different wave lengths the strength of the activating current must also be stated, for it makes a difference if one set of curves is produced by a 30-ampere source and the other by a 5-ampere source. Comparative spectrograms are of value only if taken under identical conditions as to distance, energy input, exposuretime and on plates of equal sensitivity.
FIG. 206.
Photometer
for
measuring radiant energy.
Measuring Radiant Energy. In checking up the efficiency of his sources of radiation the average physician can employ simple clinical tests, as described under ultraviolet radiation, which merely indicate the presence and the gross intensity of certain wave lengths those causing dermatitis or
sunburn.
For accurate measurements he will have to depend on the laboratory services furnished by the manufacturer of his lamp or by an independent physicist. For this purpose chemical as well as photoelectric methods have been developed by some investigators; the most effective method appears to be the radiometric one. Its principle is the use of a thermopile connected with a high-sensitivity galvanometer. These radiometers are equally sensitive to all wave lengths of the radiant energy spectrum. All energy, regardless of wave length, when absorbed by the receiving area of the instrument is transformed into heat, the intensity is expressed quantitatively as the number of calories or ergs of heat produced per unit area of absorbing material. The interposition of filters which in turn absorb
COMMON PHYSICAL PHENOMENA
305
either the infrared or luminous or ultraviolet energy makes it possible to obtain the percentages of these radiations. These readings are compared to and thus it becomes posprevious calibration against a radiation standard to specify the intensity of the energy incident at the point where sible measurement is made, in gram calories per square centimeter per second. Common Physical Phenomena. The physical phenomena which occur when electromagnetic radiations encounter other substances may be the
following:
100
700
900
FIG. 207.
Transmission curves for the various skin layers.
(Bachem and Reed.)
UUTUVUMVIi
70
Fused Quartz Cor ex (Corning)
Window
Purple Corex
306
than to heat rays. The various quartz are more transparent to light rays are variously transparent to certain layers of the skin and various glasses
wave
3.
lengths. (Figs. 207, 208.)
to
The rays are absorbed by all substances to a certain extent. Secondary this absorption, chemical and biological phenomena result, such as
effect and chemical fluorescence, phosphorescence, ionization, photoelectric The discussion of these purely photophysical effects is beyond catalysis.
the scope of this presentation. The Inverse Square Law. In administering radiant energy from any source one must be cognizant of the fact that the intensity of radiation varies inversely with the square of the distance from the source. Figure 209 visualizes this law of the inverse square demonstrating that if the surface to be radiated receives at a distance of 1 foot 1 unit of light, at twice the distance it will only receive J unit, instead of J, due to the spreading of the rays. Reversely, when the distance between the source of radiation and the surface to be radiated is decreased to one-half, the intensity of
radiation will be four times as
much
as before.
FIG. 209.
Diagram
visualizing inverse square law.
of this law must caution operators not to decrease the lamp from the body without careful calculation, in order to prevent overexposure and possible severe dermatitis. Administering treatments in the majority of cases at a fixed distance obviates the necessity of these calculations and leaves only the time as a variable factor. Because the law of inverse squares relates only to the radiation from one point, whereas therapeutic lamps produce a large amount of scattered radiation from the surface of the reflector, the calculations as to varying distance
The knowledge
distance of a
can never be made accurately. The Angulation of Rays (Cosine Law). Patients receive optimum radiation if the source of radiation is at right angles to the center of the area to be radiated. Figure 210 shows the increase of time necessary to compensate for the decrease of radiation due to angulation. For instance, at one-third of a right angle (30 degrees) double exposure is necessary to produce the same intensity as at 90 degrees. Within small deviation of the latter, less than 30 degrees, the small loss of radiation can be disregarded. Penetration. According to the law of Grotthus, formulated in 1819, only the rays which are absorbed are physiologically active. Painstaking
PENETRATION
studies in recent years
of radiant energy
307
have established the transmission of various forms through the skin.
FIG. 210.
Cosine law.
Intensity per unit area
^B
skin consists of two principal layers, the outer skin or and the derma or corium. In the outer skin there is the horny epidermis layer or corneum with flat epithelial cells, the transitional layer of granulosum with flat granular cells and the rete mucosum or Malpighian layer, with the basal layer and pigment cells. In the derma there is a papillary layer or rete vasculosum containing nerve terminals and vessels and a reticular layer. Below the two layers of the skin is the subcutaneous tissue
The human
FIG. 211.
Diagrammatic structure
of skin,
showing areas of infrared absorption.
(Courtesy of Dr. F. G. Hall.)
mainly consisting of fat. (See Fig. 211.) Radiant sources of energy penetrate through these layers differently according to their wave length and exert physiological effects in the layers where they are absorbed. The classical table of Bachem and Reed 2 (Fig. 212) shows the penetration, absorption and relative energy transmission of radiant human skin. The summary of their findings is as follows:
energy in the
Far
infrared:
Practically
no penetration.
308

in
Near infrared: Strongly increasing absorption

in lower layers.
upper layers, decreasing
Visible:
Minimum
absorption in stratum corneum.

of
Most
radiation
absorbed in corium.
Pronounced radiation
subcutaneous layers.
both visible and infrared radiation reaches
LAYER.
CORNEUH
200
(00
250
100
280
}00
400
550
100
750
100
1000
100
(1400)
100
APPLIED
AMD Rtrucrto
'9
H1ALPIGHII .05
80
87
78
71
A&6OR8CO
22.
+CORIUM
2.0
THAUVimiO
21
4SWGUTAH.
EXTREME
ULTRA VIOLET
All
VISIBLE
Vttt:
GREEN
WCO
ME AR
mraA uto
FAR rNf REt
GEMERAL REMARKS
Creates? absorption in stratum corneum
/te/dr/i/e
by cor nturn
Some
w
radialion
Ho
radatton.
comeum
reaches corium
,
absorp- Strongly increasing tion in stratum absorption in upper in layers,
Minimum
no
reachine
No
&#/:
absorbed m coriun
lover layer*.
decreasing
radiation reaches
Subcutaneous layers
Pronounced radiation reaching subcutaneous /ayerj
FIG. 212. Energy distribution in the layers of the skin. The number 100 designates the applied intensity. The encircled numbers represent percentages absorbed in each layer. The numbers in the narrow zones between layers represent the percentages of the original intensities transmitted through the layer above. (Bachem and Reed.)
Near
Far
ultraviolet:
ultraviolet:
Relatively large absorption in stratum Malpighii. Greatest absorption in stratum corneum. Some radia-
tion reaches corium (papillare). No radiation of near ultraviolet or far ultraviolet reaches subcutaneous
layers.
Extreme
ultraviolet:
All absorbed
by corneum.
No
radiation reaching
germinativum.
HE/IT
/A/ff?/7 /?
ULTRffWOiff
FIG. 213.
Relative extent of physical action of various portions of the light spectrum.
Comparative Physical Effects. Although we can sharply differentiate between infrared, visible and ultraviolet radiation from a standpoint of physical measurements, on the borderline between these different wave lengths no such sharp demarcation occurs, either from the standpoint of
COMPARATIVE PHYSIOLOGICAL EFFECTS
309
physical or physiological effects. Table 34 and Figure 213 show the gradual merging of the physical effects of infrared (thermal), luminous and ultraviolet (chemical) radiation.
TABLE
34.
COMPARATIVE PHYSICAL EFFECTS OF RADIATION

f
Infrared
Mainly thermal
Red
Yellow
Strong heating effects Fairly marked heating effects Fairly marked luminous effects
Little heating
Green
Marked luminous
Little effect
effects
on the photographic plate
Luminous
f
Very
little
heat effect
Violet
Marked luminous effects Marked effects in photography
Mainly chemical
Ultraviolet
Marked
effects in
photography
Comparative Physiological Effects. Radiant energy when absorbed by the tissue cells brings about a complex variety of physical, chemical and From the standpoint of physical therapy we may biological reactions. divide radiant energy into photothermal and photochemical radiations.
Photothermal radiations, comprising infrared and visible radiation, comparatively speaking, penetrate subcutaneous tissues, heat the blood, accelerate vital reactions and act instantaneously; they produce a burning
sensation or immediate burn
effects
when
their intensity
is
too great.
By
reflex,
on pain and circulation in deeper structures can be elicited. Photochemical radiations, comprising ultraviolet radiation, comparatively speaking, penetrate only to fractions of millimeters; they are absorbed by protoplasm, and this absorption results in physical and biological changes which manifest themselves only several hours after exposure. Thermal radiations are employed more often for immediate local action, while photochemical radiations are used more frequently for their subsequent effect on the general organism.
TABLE
35.
SUMMARY OF THE PHYSICAL AND BIOLOGICAL CHARACTERISTICS OF THE PRINCIPAL AREAS OF THE ELECTROMAGNETIC SPECTRUM (COBLENTZ)
Source
Spectral region
Far ultra violet; 180 to 200 m/x.
Metals in carbon arc and spark of metals (mercury arc)

Sun; metals in carbon arc and arc of metals Sun; carbon arc
Sun; carbon arc;

sten
gas-filled tung-
lamp
infrared
Carbon
arc; heaters)
(radiant
Wave
lengths are expressed in millimicrons;
1 rmx. is
equal to 10 Angstrom units.
The
therapeutic importance of ultraviolet part of radiant energy has
justly received considerable attention in recent years, while the tremendous value of the longer spectral wave lengths has not received the considera-
tion
it
deserves.
Visible
and infrared radiation are at

It has
essential for all organic
life.
been stated that
if
least equally as the heat rays of
310
the sun were to be screened off from the earth it would be surrounded by ice crust in short order. Likewise if the sun were to cease sending us the green portion of the spectrum, on which depends the formation of chlorophyll all important for vegetable life --all life on earth would become extinct. Just as normal organic life demands an unbroken supply of all of the rays of the solar spectrum, so in therapy in many of the results following the application of radiant energy infrared and luminous radiation
an
play an essential
role.
Coblentz' 3 table presents the sources and the physical and biological characteristics of the therapeutic range of radiant energy.
REFERENCES
1.
2.
ANDERSON, W. T., JR.: The Quartz Mercury Arc, Radiology, 15, 109, 1930. BACHEM, A., and REED, E. C.: Skin and Radiation, Arch. Phys. Ther., X-ray and
Rad., vol. 12, 1931.
3.
4.
COBLENTZ, W. W.: Sources and Properties of Thermal Radiation, Especially Ultraviolet Rays, Used in Phototherapy, Physical Therapeutics, 55, 9, 1927. LUKIESH, M.: Ultraviolet Radiation, New York, D. Van Nostrand Company, 1922.
CHAPTER XVI
Physical Considerations. Sources of Infrared Radiation. Heat Lamps. Infrared Generators. Electric Light Baths. Physiological Effects. Clinical Use of Local Heat Radiation. Choice Between Luminous and Non-luminous Generators. Technique of Local Radiant Heat Application. Precautions. Clinical Use of General Heat Radiation. Indications. Technique.
Physical Considerations. Any object heated to a higher temperature than its surroundings will send out its excess of heat by radiation to the surrounding objects. An iron rod when heated first "feels" hot without showing any change in color (so-called black body radiation), then starts glowing and becomes "red-hot", and later "white-hot." At each stage of heating a variety of radiation is emitted in the stage of low heat there occurs long-wave or far infrared radiation, invisible to the eye; at a further stage of heat the red, green and blue rays of the visible spectrum are added and at the stage of white-heat long-wave ultraviolet radiation can be demonstrated. The quality as well as the quantity of radiations emitted from any source depends not only on the physical properties of the source itself but also on the energy input, the intensity of heat generated in the
;
radiating object.
The
generally accepted classification differentiates between
two groups
of infrared radiations.
TABLE
Source
36.
SOURCES OF THERAPEUTIC HEATING

Form
of
energy
Heat transmitted
Hot-water bottle Hot compress Hot- water bath Paraffin bath Hot-air and steam bath
Electric heating pad Infrared radiator (non-
Long-wave infrared rays
By conduction and convection
Long-wave infrared rays Long- and short-wave infrared rays

Short-wave infrared rays, visible
rays.
)
By
conduction and radiation
luminous)
Heat lamp (incandescent, bulb
By
radiation
Carbon arc lamp Sun Long-wave diathermy

Short-wave diathermy
Short-wave infrared rays

rays (also ultraviolet rays)
/ Visible
High-frequency oscillations (300meter waves) Very high-frequency oscillations (30- to 6-meter waves)
By
conversion of oscillations
These rays are emitted by all heated bodies, (a) Long-wave Infrared. and exclusively by low temperature bodies such as hot-water bottles, electric heating pads, and dull red heaters. Their wave-lengths extend mostly from 15,000 to 120,000 Angstroms; they do not penetrate tissue deeper than 2 millimeters and are strongly absorbed in the upper layers of skin (upper 0.5 mm.). These rays are emitted by all incandescent (6) Short-wave Infrared. bodies such as the sun, electric arc, incandescent lamps, and especially
designed high temperature infrared radiators. They comprise radiations between 7000 and 15,000 Angstroms. The employment of a special red (311)
312
glass filter
5 (Danforth ) restricts these sources to such wave-lengths exclusively. They can penetrate through 5 to 10 mm. of skin tissue. They are therefore able to directly influence blood-vessels, lymph vessels, nerve endings and other subcutaneous tissue. Table 36 shows the various sources of heat in treatment and their transmission. Only radiant sources of heat are discussed in this chapter. Diathermy and its relation to radiant heating has been presented in Chapter XI.
SOURCES OF INFRARED RADIATION

Sunlight is the most important natural source of infrared radiation, the proportion of infrared being over 60 per cent in the average sunlight, as
compared to
ultraviolet and visible light. Artificial sources of infrared are metallic conductors which become heated by the passage of an electrical current. For low temperature heating a
bare wire or carbon held in suitable non-conducting material is employed; for high temperature the oxidation of the wire must be prevented and hence the use of tungsten or carbon filaments enclosed in an evacuated. or
inert gas filled glass bulb. High temperature generators emit a large amount of luminous radiation. Artificial sources of infrared are divided into two groups: low temperature or non-luminous sources, or infrared radiators and high temperature or luminous sources or heat lamps. As a matter of fact in both groups infrared radiation is the chief heating factor. In actual practice the so-called non-luminous sources always attain a red glow and emit a quantity of visible red radiation, hence their designation as non-luminous is not entirely
correct.
Heat lamps or incandescent filament radiators are the principal forms of luminous heat radiation. They consist of tungsten or carbon
filaments, enclosed in a glass bulb mounted on the center of a concave reflector. Tung-
FIG. 214. Large luminous heat on stand. generator (Courtesy of The Burdick Corporation.)
sten filament lamps are most generally used and come in different sizes, varying in wattage from 150 to 1500 watts. The penetration of the radiation from these
luminous heat generators through the skin is the same whether they are of small (150 to 250 watts) or large (1500) wattage. The principal difference between the use of the smaller and larger lamps is that the former serve for treatment of small areas, such as the face, the shoulders, hands or feet, while the large lamps are suitable to warm up larger areas of the body, such as the entire back or abdomen, both legs, etc. (Fig. 214.) Two or more incandescent bulbs of small candle power (25 to 50 watts)
mounted in semicircular containers are designated
as electric light
"
bakers."

The term
oven.
313
originated from the resemblance of this heating device to an In contrast to the high temperatures needed for real "baking," resulting in the coagulation of albumen, the temperature rise in the skin produced by these bakers never exceeds more than about 110 F. under safe limits. Heat lamps mounted on stands are more easily moved about than some of the older type heavy bakers. Figure 215 illustrates and gives the specification of a light and inexpensive home-made baker or electric cradle suggested by the Council on Physical Therapy. Carbon arcs are other sources of luminous heat radiation (Chapter XIX). They may produce as much as 80 per cent infrared, 15 per cent visible and a varying amount of ultraviolet, according to the type of carbons and the amperage of the lamp. The spectrum of the mercury vapor arc is weak in rays at the red end of the visible spectrum with exception of a few strong bands in short infrared, infrared rays emitted by such lamps come mostly from the heated quartz itself by reradiation or from the warmed-up metal hood of the lamp. For comparison of these radiations study the colored
;
frontispiece.
FIG. 215.
Home-made
baker.
(Council on Physical Therapy.)
(a) frame Specifications: YS by f inch strap iron; (b) reflector highly polished tin sheeting; (c) 2 double receptacles, General Electric Company, catalogue 66722; 250 volts, 050 watts; (d) 4 60- watt mazda lamps. The tin is riveted to the strap iron. Receptacles connected in multiple with heavy lamp cord 6 feet long. Hubble plug at the end of cord. The above baker is designed for applying heat to the legs or arms. If baker is to be used for the body, supports should be 2 or 3 inches
longer.
Infrared radiators consist of a heating element which is mounted in the center of a parabolic reflector and warmed up by an electrical current to a dull red heat. The reflector should concentrate the heat rays on the surface of the body, evenly and without hot spots. In the popularly known
bathroom heater, which is also an infrared generator, the wide hood reflects the rays over a wide area and the heater itself is not adjustable. The heating element consists of either a resistance wire wound or embedded on a non-conducting material (porcelain or steatite) or a rod or circular plate of resistant metal (carborundum). Similar to luminous heat generators, infrared generators are marketed in small units, drawing 50 to 300 watts of current, and large units drawing up to 1500 watts. Reflectors with
314
difference follows:
suitable sockets usually allow the interchanging use of incandescent bulbs and heating elements of the same wattage. (Fig. 216.) in emission of heat lamps and infrared radiators is as The
FIG. 216.
Interchangeable incandescent bulb and infrared unit. Electric JT-ray Corporation.)
(Courtesy of the General
FIG. 217.
Non-metallic infrared radiator (Zoalite) in reflector. Burdick Corporation.)
(Courtesy of The
Heat lamps emit a radiation of about 95 per cent infrared, 4.8 visible and 0.1 ultraviolet radiation, of which the latter is absorbed by ordinary

glass.
315
The wave length of the infrared extends from 4000 to 40,000 Angstroms, with a maximum emission from 7000 to 16,000 Angstroms. Carbon filament lamps emit more of long infrared. Infrared radiators from a non-luminous source emit radiation throughout the entire length of the infrared spectrum to 150,000 Angstroms. The quality of radiation varies according to the surface temperature of the heating element. At the usual intensity, the emission consists principally
of the shorter
wave
lengths,
from 20,000 to 30,000 Angstroms.
STRATUM CORNEUM ABSORPTION -20%

ST.
ST. ST.
LUCIOUM GRANULOSUM
MUCOSUM
ABSORPTION -16% 6.4
ST.
6ERMINATIVUM
CORIUM
2 MM
PAPILLA OF
ABSORPTION -19%
TRANSMISSION - J|%
ABSORPTION-INFRARED-SKIN
A-RADIATION "OH TUNGSTEN
AT
B- RADIATION
- IRON
2970 K
*T
1000K.
FIG. 218.
Per cent differential absorption of infrared by skin. (Courtesy of Dr. Anderson, Jr., and Archives of Physical Therapy, X-ray and Radium.)
W.
T.
The
difference in penetration according to
Anderson 1
is:
radiator
operating at relatively low temperature emits long wave-lengths absorbed primarily in the stratum corneum of the skin; a generator at high temperature such as the tungsten filament lamp, emits a predominance of near infrared and visible radiation which penetrates deeply through skin layers and even into the subcutaneous layers of fat and muscles; between these two are generators at medium temperature, such as the carbon filament lamp which gives less heating effect in the stratum corneum than an iron resistor, but more than a tungsten filament; its radiation would penetrate less than that of the tungsten filament lamp. These findings are 7 2 in harmony with the published investigations of Sonne, Bierman and 3 In actual practice however the various types of infrared Cartwright. radiators are being used almost interchangeably because much of the effect
of infrared radiation
is
is
due to
reflex effect, for
which no deep penetration
necessary. Electric Light Baths. Electric light baths of the upright type consist of a metal or wooden cabinet fitted with a number of incandescent lamps
arranged along the inner sides.
The lamps
are, as
a rule, 80-watt bulbs
31G
having a carbon or tungsten filament controlled by a number of switches, so that some or all of them may be turned on. The cabinet should be at the partially open at the top and should have an air vent, preferably center of the floor. A thermometer emerging from the top registers the
temperature
inside.
general light baths are desired for bed-ridden patients and no cabinet is available, a fairly efficient substitution can be made by a light string of carbon filament lamps draped over a bed cradle and covered by
When
a bed sheet.
Electric light cabinets of the reclining type for fever therapy have been described in Chapter XII.
PHYSIOLOGICAL EFFECTS OF INFRARED AND LUMINOUS RADIATION

Physiological Effects of Infrared Radiation. Heating the superficial infrared radiation exerts local as well as general body by effects; these effects vary according to the extent of the area exposed and
tissues of the
the intensity of radiation. general action.

of radiant heating
There
is
often an interplay between local
and
Table 26 in Chapter XI by Bazett shows the local and general effects on the circulation, the blood, the lymph, on the tissues, on respiration, on the urine and sweat and on infections. From the clinical standpoint two main local effects of heat radiation are the stimulation of local circulation and the stimulation of the nerve
endings of the skin. 1. Effect on Circulation. Within a few minutes after exposure to radiant heating the skin turns red and feels hot; there is no latent period as with ultraviolet radiation. The resulting erythema appears in the form of red spots or a network of red lines; it persists depending on the length of exposure from ten minutes up to one hour. This erythema is due to the stimulation of the vasomotor mechanism and manifests itself by active vasodilatation of the capillaries and subsequent increase of arterial and venous circulation. As already stated in Chapter XI, there exists an inherent tone in the capillaries which causes vasoconstriction and the application of heat produces a release of vasodilator substance. Upon the absorption of the vasodilator substance more capillaries become active and as a result a greater blood supply to the part occurs. The erythema caused by dilatation of the capillaries in the corium of the skin occurs after exposure to any form of infrared radiation; in addition, luminous sources containing a large amount of the more penetrating infrared cause a marked stimulation of the sweat glands located in the subcutaneous tissue; as a result, drops of perspiration soon appear in the area under exposure. This effect becomes especially evident when large areas of the skin are exposed to general heat radiation from incandescent sources,
an electric light cabinet. Repeated exposure to infrared radiation may lead to permanent pigmentation which, in contrast to the homogeneous tanning following ultra.violet radiation, is always mottled, like the surface of marble. The mottled appearance of the skin in regions habitually exposed to heat radiation is well known.
as in
317
Table 37 shows a comparison of infrared and ultraviolet radiation, with special reference to erythema production, pigmentation and tolerance. Excess amount of infrared radiation or special sensitivity thereto results Careless in wheal formation, local edema and eventually in blistering.
exposure may cause deep sloughing not only in the skin but also in adjacent subcutaneous and fibrous structures.
TABLE
Radiation
37.
COMPARISON OF INFRARED AND ULTRAVIOLET RAYS

Infrared
Ultraviolet
Short:
Wave
length
Penetration
.... ....
.
Long:
Long:
Short:
120,000 to
16,000
0.1 to 3
15,000 to
A
mm.
7000
10 to 30
A
mm.
4000 to 2900 A
0.3 to 0.5
2900 to 1800 A
0.1 to 0.3
mm.
mm.
Appearance
Duration (Development
.
Pigmentation Tolerance
....
Immediately Darker red, spots or network Less than one hour Mottled Develops occasionally
After hours
Lighter red, sharply bordered
Hours and days Homogeneous (tanning)

Increases constantly
TABLE
38.
MAXIMUM TOLERANCE SURFACE TEMPERATURES UNDER RADIANT

HEATING (SONNE)
Surface
Under surface
temperature
Radiation
temperature
. .
Short infrared and visible
110.8F.
113. 9
117.8F.
107.
Long
2. Effect
infrared
F.
F.
on Nerve Endings of the Skin.
Mild heating
results in sedation
or relief of pain while strong heat stimuli cause marked counterirritation. The mechanism of counterirritation may be explained by the desensitization of superficial sensory nerves or
by a considerable
increase of the stimuli
which pass over them: the
effect is that of relief of local painful stimuli
as well as of those originating from deeper parts and possessing the same nerve center as the area of the skin under the influence of heat. Aside from
these two groups of effects explainable by the local thermal effects on tissues, there is no evidence of any specific action of infrared rays, neither is there any evidence of antagonism between these rays and visible or ultraviolet rays in regard to biological effect. There is no scientific basis
for giving treatment with a dark infrared source for a few minutes, as were comparable to a powerful source of ultraviolet rays (Coblentz).
if it
General Effects.
Every
local application of heat brings
about a certain
of general heating. The local excess heat is taken up by the blood stream and carried into the general circulation. The temperature control
amount
mechanism
of the body will immediately throw off the additional heat by mild perspiration. Intense general heat application from large heating units ("body bakers" or high-wattage lamps or heat cabinets) stimulates the heat-regulating mechanism to full activity in its endeavor to make the output of heat equal that of the increased input. The generally recognized effects of mild general body heating are: (1) Increased heat elimination and profuse perspiration (2) increased circulation, a rise of the pulse-rate in the ratio of about 10 beats for each degree Fahrenheit, just as it does in fever; (3) a lowering of blood-pressure (in
;
contrast to the effects of cold); (4) increased respiration; (5) increased elimination through the kidneys. There is a loss of water, salt, urea and other nitrogenous substances, with a relative excess of alkali remaining in the blood and in the tissues, while there is also a temporary loss of body
weight.
General nervous sensibility
is
usually markedly lessened.
318
The effects of prolonged and intense heat application in the form of fever therapy have been discussed in Chapter XII. Physiological Effects of Visible Radiation. Visible radiation is present in all radiation from incandescent sources, carbon arc and mercury vapor lamps, but its total quantity is relatively small (5 to 15 per cent); the
thermal effects of radiation are attributable principally to the near (short) infrared rays. The generally accepted conception of the physics of luminous radiation in relation to the tissues is as follows: 11 per cent of the visible radiation from a tungsten filament lamp is absorbed by the glass bulb and 33 per cent is reflected by the skin; all of the remainder is absorbed by the superficial layers of the skin but does not penetrate as deeply as the short infrared. Tyndall demonstrated by classical experiments that it is possible to convert light into heat and vice versa. He passed a beam of electric light through water to absorb the heat rays and then by passing the resultant rays through a lens of ice, he set fire to black paper, and ignited gun cotton on the other side of the ice, showing that this result was brought about
by the
light rays exclusively.
Other physiological effects than those due to heat are attributed to luminous rays, but they are doubtful. The theory has been advanced that luminous rays mitigate the burn produced by ultraviolet rays by increasing the supply of lymph and blood, and so wash away the product
of tissue
damage produced by the
ultraviolet rays.
The
curative effects of
light on wounds, sinuses, etc., the visible rays.
has been attributed to the stimulation by
The totality of the visible spectrum may be broken up by prisms or suitable filters in different wave lengths representing different colors:
TABLE
39.
.
WAVE LENGTHS
. . . .
.
OF VISIBLE SPECTRUM
4000 4500 4900 5500 5900 6300
to 4500 to 4900 to 5500 to 5900 to 6300 to 7800
Violet
Blue Green Yellow Orange
Red.
It has
...... ... ...... ...

.
.
.
....
.
A.U. A.U. A.U. A.U. A.U. A.U.
been claimed that by separating the visible white into its cometc., these colored bands can be utilized for specific therapeutic purposes, such as blue for sedation and red for stimulation. There is little evidence so far to substantiate these claims, chiefly because the filter arrangements for the production of such pure blue, red or other light, if effective physically, usually produce an inert radiation by keeping off the bulk of the electromagnetic energy. Different colors of light undoubtedly exert a certain amount of psychological effect
ponent parts, red, yellow, blue,
irrespective of the
amount
of effective radiation.
CLINICAL USE OF LOCAL
HEAT RADIATION
Luminous and non-luminous sources of heat radiation produce marked hyperemia, tissue relaxation and relief of pain in an irradiated area. These
effects will assist in the resorption of
reaction
products of trauma and inflammatory and aid the natural forces of defense and restoration. The advantage of heat radiation over methods of conductive heating
CLINICAL USE OF LOCAL HEAT RADIATION
319
(1) that its action extends to a (hot-water bottles, poultices, etc.) is: that there is no pressure over the parts; and (3) that greater depth; (2) the parts may be kept under constant observation without difficulty. Thus signs of undue heating can be discovered immediately. Kellogg pointed out some time ago that if the surface of the skin be kept cool by fans, much
more heat can be applied
for the relief of deep-seated pain.
FIG. 219.
Application from localizing infrared radiator. The Burdick Corporation.)
(Courtesy of
Infrared radiation, on account of its comparative simplicity and safety of application, is preferable to diathermy in many conditions when efficient heating of structures not too deeply situated is desirable. Figure 212,
showing the penetration of human tissues by the various wave lengths of therapeutic radiation, demonstrates that near infrared penetrates the entire thickness of the skin, part of the subcutaneous tissue, superficial strata of muscles and accessibly located tendons and bones.
The
indications for the clinical use of infrared heating overlap those
from conductive and conversive sources. The choice of method depends partly on clinical experience and partly on the considerations as to which method is more easily available. No hard and fast rule exists which would
320
condition.
the selection of a particular form of heating imperative in a given With heat radiation applied daily to hospitalized patients with traumatic and arthritic conditions the author has produced results fully comparable to diathermy treatments applied every other day to ambulatory
make
patients with the same conditions. The principal indications for radiant heating are as follows: 1. Subacute and chronic traumatic and inflammatory conditions in
locations accessible to external heating.
Contusions and muscle strains,
traumatic synovitis and tenosynovitis, sprains, dislocations and fractures. 2. Various forms of arthritis and rheumatoid conditions, neuritis and neuralgia; in acute forms, mild infrared radiation may be the only means of relieving pain without medication. In these conditions the advantage over poulticing and hot-water bottles is especially evident because of the
avoidance of pressure. 3. Acute, subacute and chronic catarrhal conditions of the mucous
membranes in accessible location: conjunctivitis, coryza, sinusitis, otitis media (non-suppurative form), bronchitis. In incipient cases early and efficient use of radiant heat may abort an otherwise prolonged attack.
Circulatory disturbances of the extremities (thrombo-angiitis oblitRaynaud's disease and erythromelalgia). Great caution is always needed and thermostatically
4.
erans, thrombophlebitis, endarteritis obliterans,
controlled heating (kept around 97 F.) is safer. 5. Infections of the skin, folliculitis, furunculosis
and even extended
abscess formation in the skin. Efficient infrared application may in minor cases reduce surgical intervention in form of incision and drainage to a minimum or make it unnecessary. Infrared radiation is convenient to
keep up the required temperature in hot antiseptic dressings in infections and cellulitis. It offers the advantage that the heat is constant, is applied without pressure and there is no carrying of infection as may be the case with water; furthermore, the patient need not be disturbed and does not need so much attention. 6. Radiant heating may be applied as a preliminary to other physical measures. Massage, voluntary and passive exercise and passive muscular exercise by low-frequency currents should always be preceded by some form of heating; the relaxation and preliminary warming making the tissues supple for manipulation or exercise. Radiant heat is most efficient
for this purpose. Preceding the application of the galvanic current or of long-wave diathermy with a few minutes' exposure to radiant heat will improve skin conductivity by inducing hyperemia and a slight perspiration.
more
mercury vapor lamps
satisfactory general reaction to ultraviolet irradiation from may also be produced by preliminary general radiant
heat application. Choice Between Luminous and Non-luminous Radiators. While the quality and penetrating power of the radiation from these two types of generators differ considerably, there are, as yet, no reliable clinical data to indicate any preference in routine application of radiant heat therapy. It has been stated that the difference between the output of high temperature (luminous) and low-temperature (non-luminous) radiators is the predominance of the short, more penetrating infrared rays in the first group. More of the long infrared (non-penetrating) radiation from non-luminous radiators is absorbed by the top layers of the skin, and for this reason such generators
CLINICAL USE OF GENERAL HEAT RADIATION

hotter from the same distance than luminous heat generators same wattage and with the same type of reflector.
feel
321
of the
Individual preferences of patients sometimes favor one source over the other. Patients at times feel bothered by a bright light whereas the dull glow of infrared feels more comfortable. This is especially the case when the face is treated and also in feverish, restless children. There are also some indications that in acute painful conditions radiation from a nonluminous source often feels more soothing. In the author's clinical experience luminous sources of radiation furnish more penetrating heating and should therefore, be preferable for treatment of traumatic conditions
affecting deeper parts. Luminous heating has also proven in conditions where more rapid perspiration is desirable.
more
effective
Technique of Local Radiant Heat Application. The patient should be placed in a comfortable, relaxed position and the radiation from the generator is directed over the part to be treated, at a distance from which it feels comfortable. The distance will average from 2 to 3 feet, according to the sensitivity of the parts, the intensity of the radiation and the type of
reflector.
Exposure is continued for from ten to fifteen minutes when the object merely to warm up the parts preliminary to some form of treatment; for one-half to one hour, if heat radiation is the main part of the treatment. The routine employment of a time clock for exact measurement of the time of treatment serves as a protection for patient and physician. Too long exposure, if not too intense, usually does not produce harmful effects in local treatments; in some acute painful conditions, such as brachial neuritis, it may be helpful to apply infrared radiation for as long as one to two hours at a time. Physicians and technicians often err by using heat radiation for too short a period to be effective. Precautions. If at any time during treatment the patient complains of unpleasant burning over the entire area or over one spot, the heat lamp should be moved a few inches farther away; this process may have to be
is
repeated until the patient feels entirely comfortable. Patients who receive treatment for the first time often think that a severe burning sensation is part of the treatment; such indiscreet patients may become blistered and, therefore, special watchfulness is always indicated when treatment is applied for the first time. Anesthetic areas in patients with peripheral nerve injuries and over scars are especially prone to blister, so that in these cases heat generators should be kept at a distance of at least one and half or more of the usual space and even then one should always look out for signs of possible
blistering.
CLINICAL USE OF
GENERAL HEAT RADIATION
Indications. The effects of mild systemic heating on metabolism, on the circulation and as a sedative led to its clinical employment as a valuable adjunct to general therapeutic measures in the following conditions: Chronic arthritis and rheumatoid conditions, especially in the well
nourished, robust type of patient; chronic nephritis; psychoneuroses in combination with hydriatic measures and in agitated and maniacal mental
states in cooperative patients toxic multiple neuritis, obesity, early arterio;
sclerosis.
21
322
In chilling after exposure a large heat lamp is a most efficient emergency measure. It is much safer than hot-water bottles and should therefore be available in all accident wards. The indications and technique of hyperpyrexia by general heat radiation
have been presented
in
Chapter XII.
is
Technique. lamps or infrared radiators
The technique
of general heating by large wattage heat the same as in local heating save for the
Applications larger surface exposed. hour at a distance of comfortable toleration are administered.
from
fifteen
minutes or one-half
FIG. 220.
Large
electric light cabinet.
(Courtesy of The Burdick Corporation.)
In the use of electric light cabinets before the patient enters the cabinet should be turned on to raise the inside temperature. The patient comes covered by a large sheet or thin bathgown; the covering is then discarded with the patient seated on a low stool. The top of the cabinet is closed so that the head remains outside. The forehead is covered by a cold-water compress; this prevents headache and too much flushing of the face. If the purpose of the bath is to promote elimination the patient may freely drink during the treatment in order to encourage perspiration. The patient should never be left alone, and if at any time he feels faint or the pulse-rate rises above 100 or becomes irregular the treatment must be stopped. There are cabinets in w hich patients can recline, such as the newer fever cabinets and they are quite convenient for mild general heating.
its lights
r
CLINICAL USE OF GENERAL HEAT RADIATION

In the light bath thus administered, as a rule, an immediate of the skin occurs there is also a gradual onset of perspiration.
;
323
hyperemia
The
pulse,
temperature and respiration rise in a degree varying with the length of the bath and the individual reaction. As a result all metabolic and vital
bath should depend on the desired effect. If general tonic action is desired the exposure should be brief, five to eight minutes, just to the point of beginning good perspiration. For marked elimination and derivative action, eight to fifteen minutes' exposure should
be given. After the bath the patient should receive a tepid shower or a contrast, hot and cold (Scotch) douche, according to the stimulation desired; or at least a good rub-down should be given with warm towels or with alcohol. A dry garment is then put on and the patient allowed to rest for twenty to forty minutes. No patient may leave after a light bath until he has thoroughly cooled off. Baths for tonic purposes may be administered every day or every other day, those for elimination about twice a week. In bedridden patients general light baths may be administered by suitable
electric light bakers.
activities are quickened. The duration of the light
is
patient enveloped snugly in a blanket, the electric light baker placed over the body, with the exception of the head, and the various
is
"
Pemberton 6 describes the technique as
follows:
' '
The
apertures of the appliance through which heat might escape are covered with several blankets, as is indeed the whole apparatus. The number of electric lights to be used must be determined by experience, and the current should be controlled by a switch on the outside of the 'baker.' A thermometer should be placed above the body of the patient but under the covering blanket and, in order that the temperature may be easily and frequently determined, it should be fastened to a cane or yardstick. A common mistake in this connection is to place the thermometer above the blanket exposed to the full influence of the lights, at which point it does not indicate properly the temperature to which the subject is actually exposed, and the process as a whole may be, therefore, unduly curtailed. The usual practice is to begin by elevating the temperature within the apparatus to 49 C. (120 F.) and to maintain this temperature for twenty minutes, after which the lights are turned off and the patient is allowed to remain wrapped in the blanket until he has cooled down to normal. The duration and temperature of the process must vary with cirumstances and it is always well, except in emergencies, to err on the conservative side, especially at the outset. The body temperature may rise from 0.5 to 1.5 F., and it is customary to place an ice-cap on the head and to administer water. Too much water, however, may prevent the degree of hyper-
pyrexia necessary to determine sweating, and it is also obvious that, in the presence of edema, ingestion of water may partly defeat the purpose in mind. Usually one glass of cool water during the 'bake' is ample. It is sometimes advisable to include only part of the body, especially the loins, in the 'bake,' leaving the chest outside. Pulmonary edema has resulted from careless or undue application in severe nephritis. "Considerable prostration may occasionally follow the general procedure described; and, furthermore, although the effect of any one 'bake' may be inappreciable, the effect of many treatments is sometimes cumula-
324

REFERENCES
1.
2.
3.
4.
Physical Aspects of Infrared Radiant Energy in Therapy, T., JR.: Arch. Phys. Ther., X-ray and Rad., 18, 11, 1937. BIERMAN, WILLIAM: Effects of Photothermal Radiations Upon Cutaneous and Subcutaneous Temperatures, Arch. Phys. Ther., X-ray and Rad., 14, 717, 1933. CARTWRIGHT, C. HAWLEY: Infra-red Transmission of Flesh, Jour. Opt. Soc. Am., COBLENTZ, W. W.: Sources of Ultraviolet and Infrared Radiation Used in Therapy;
ANDERSON, WM.
Physical Characteristics, Jour.
Am. Med.
Assn., 103, 183, 1934.
March, 1928.
5.
DANFORTH, R.
6.
S. The Penetration of Living Tissue by Ordinary Radiant Energy, Proc. Soc. Exp. Biol. and Med., 27, 283, 1930. PEMBERTON, RALPH et al.: The Influence and Therapeutic Use of External Heat,
:
Handbook
1933.
7.
of Physical
Therapy, Chicago, American Medical Association,
p. 39,
SONNE, CARL:
Investigation on Action of Luminous Rays and Their Mocle of Action, Arch. Phys. Ther., X-ray and Rad., 10, 93, 239, 1929.
CHAPTER
XVII
ULTRAVIOLET RADIATION -PHYSICS AND EFFECTS

Generation. Classification. Physical Properties. Physiological Effects. Erythema Production. Pigmentation. Antirachitic Effect. Bactericidal Effect. Effects on Effects on Metabolism. Clinical Uses. Contraindications. PhotosensitizaBlood.
tion.
Generation. Very hot bodies and ionized gases emit ultraviolet rays. In order to obtain an appreciable amount of ultraviolet radiation it is necessary to heat the radiating substance to a temperature of 3000 C. 4 (5400 F.) or higher (Coblentz ). The chief natural source of ultraviolet radiation is the sun. The sources of artificial ultraviolet radiation are
chiefly electric arcs between electrodes of metals, of carbon and of mercury in quartz. Radiations from artificial sources represent but approximations to sunlight, and no two are alike in respect to the spectrum distribution
of the energy they emit. The range of radiant energy designated as ultraviolet Classification. " extends from 3900 to 1800 Angstroms and is divided into: (1) Near ultra-
violet" radiation, which is continuous to the luminous rays, and consists of comparatively long rays, extending to 2900 Angstroms; (2) the "far ultraviolet" radiation, consisting of comparatively short rays, extending
from 2900 to 1800 Angstroms. The sun's spectrum contains none of these
short rays.
5
1
TRANSMISSION or ULTRAVIOLET THROUGH OF LIVE HUMAN TISSUE

.
I *,
ANDERSON* FRASER
BRITISH JOUR. PHYS.MEDICINF
Ito
e
NOV. 1931.
2400
FIG. 221.
^_
2600
2800
IN
3000
3200
through
3400
tissue.
ULTRAVIOLET WAVELENGHTS
ANGSTROMS
Curve
of ultraviolet transmission
human
Physical Properties. Ultraviolet rays penetrate to a very limited extent through bodies. Quartz permits their passage up to 1800 Angstroms, hence the employment of quartz for the construction of burners and filters. Air permits passage up to 1850 Angstroms, but impurities in the air, dust and smoke will filter out even more especially at low levels. Ordinary window glass permits only the passage of rays longer than 3200 Angstroms.
skin arrests all ultraviolet radiation, and beyond the depth only the rays longer than 4500 Angstroms can penetrate. Paper and even the thinnest underwear arrest most of the radiation.
of 2
The human
mm.
Ultraviolet radiation brings about fluorescence of
The surface of a roentgen-ray screen becomes phosphorescent
many
substances.
after exposure
(325)
320
ULTRAVIOLET RADIATION-PHYSICS AND EFFECTS

They
exert photochemical effects in decomposing silver
to ultraviolet rays.
salts
in discoloring vegetable colors, and photoelectric effects causing If a negatively emission of electrons from negatively charged metals. electroscope is placed in the path of certain ultraviolet rays its
and
charged
leaves collapse, showing the loss of its electric charge. The presence of ultraviolet rays in any light can be proved by this simple test. The formation of ozone from the oxygen of the air by photosynthesis is also attributed to the action of ultraviolet rays.
PHYSIOLOGICAL EFFECTS OF ULTRAVIOLET RADIATION

the
The variety of effects of ultraviolet radiation on substances outside of human organism points to the possibility of effects of much more
13 complex nature on the intricate tissues in the living organism. Laurens the fundamental principles of the biophysics and physiology of says that radiation are still unsolved, and the real action of radiation on the living cell is unknown.

easiest to detect,
327
it has come to be considered as a sign of an effective source or as a measure of an effective dose of radiation. light Degrees of Erythema. Erythema of the skin is a true inflammatory reaction and can be described according to its intensity, as of four different Each of these degrees is associated with the conception of a degrees.
definite
dosage of ultraviolet.
(a) First degree

is
erythema or tonic dose:
reaction so slight that
it
scarcely noticed by the patient. The skin reddening is very faint, occurs after a latent period of some hours, usually subsides within one or two days and without leaving any trace whatsoever. Should be administered
on the entire body or largest possible area. A reaction just below the first degree erythema is variously called the minimum perceptible erythema or a suberythemal dose.
(6)
is
Second degree erythema: A mild sunburn reaction. The reddening plainly visible and is followed on subsidence by slight desquamation. Subsides in about three days and may leave some pigmentation. (c) Third degree erythema, also designated as a counterirritant dose:
An
intense reaction similar to severe sunburn.
The reddening
is
intense
and there is also a slight edema. It is followed by peeling of the skin and takes about a week to subside, leaving pigmentation. This intense sunburn is essentially employed as a local reaction. (d) Fourth degree erythema, also designated as a bactericidal or destructive dose:
An
intense reddening, supervening after a short latent period
(about two hours) and increasing until exudation and blistering results; persists for many days and leaves deep pigmentation in its wake. Only administered on small areas, at contact, or short distance. The histological changes associated with erythema Histological Changes.
production are as follows: The capillary vessels of the irradiated area are filled with red blood cells; there is also marked leukocytosis in the irradiated area; this reaction is not confined to the irradiated surface, but extends deeply in the tissues. Following intense irradiation there is serofibrinous and often hemorrhagic exudation and in a further stage thrombi form in the vessels of the arteries and degeneration and necrosis of the skin as well as of the deeper parts may follow. With the routine mild erythema doses, however, the usual reaction is a dilatation of the superficial vessels with some increase in blood flow; after a duration of the hyperemia for a varying period there is full restoration to normal.
No perceptible Difference in Erythema Effect of Certain Wave-lengths. erythemal effect is produced by wave lengths below 2400 Angstroms and above 3200 Angstroms. The almost immediate reddening of the skin after irradiation by a strong source of mixed radiation such as the sun or a heat lamp or carbon arc lamp is due to radiant heat rays. Such radiation is not restricted to the irradiated parts of the skin, has a mottled appearance and disappears soon after irradiation has stopped. (Table 37.) Within the range of wave lengths with erythemal action there are two
maximal areas
is
of erythemal effectiveness, as
shown
in Figure 223.
One
These
at about 3000 Angstroms, the other at about 2500 Angstroms.
two maxima have not the same value in a photobiological sense. Erythema produced by radiation at 3000 Angstroms is followed, according to its a real sunburn intensity, by strong pigmentation and painful blistering
,328
while erythema produced by radiation around 2500 Angstroms leaves scarcely any, or at most only an inconsiderable pigmentation. Explanation of Erythema. Research work on the biophysical
Biological
wave lengths has offered an response of the skin to radiation at different of the diverse erythema and pigmentation action of the two explanation maxima of the erythema curve.
E
|
i
_ji
ERYTHEMA PRODUCTION.
COBlENTZ, STAIRS HOGUE J. of (?E5. BUREAU OF STANDARDS
nn
544
(I13Z.)
329
(6) It is practically the only physiological reaction to ultraviolet rays that is established with a relatively high degree of accuracy, permitting a calculation of the approximate time of exposure from a simple physical measurement of the ultraviolet radiant flux emitted by the lamp. (c) It is a simple and practicable means of preventing severe burns when using powerful sources of ultraviolet radiation. (d) It is an efficient safeguard against the fraudulent sale of lamps that emit little or no radiation of wave lengths shorter than about 3130 Angstroms, generally accepted as having a specific therapeutic value in pre-
venting rickets.
The
on
specifications for minimum intensity of ultraviolet generators this test will be presented in Chapter XVIII.
based
2. Pigmentation. Repeated irradiation with erythema doses between 2800 and 3000 Angstroms causes pigmentation which consists of a deposit of granules of the pigment melanin in the basal cells of the epidermis. Pigmentation and erythema are associated only in the longer wave lengths, for as already stated, the erythema producing wave lengths around 2500 are not followed by late pigmentation. It is also well known that repeated stimulation by other agents such as repeated friction and other mechanical irritation may also bring about deposition of pigment. The role of pigmentation is still a matter of controversy. Rollier 21 advanced the theory that the short, lethal waves are transformed by the
fluorescent action of
pigment into long waves, thereby increasing the
depth of penetration and the intensity of reaction. According to a slightly different point of view, pigment favors the penetration of energy by
greater the pigmentation of the subjects the more marked in blood reaction. Bernhard 2 pointed out that dark skin
changing a white reflective surface into a dark absorbing one and the is the change
warms much
more quickly and thoroughly than does fair skin. Aitken 1 on the basis of an experimental study concludes that pigment is produced in greatest abundance under the influence of luminous rays and serves to protect
deeper parts against these rays.
Laurens 14 considers pigment formation and healing, or benefit from the

energy, as independent, coordinate phenomena proceeding simultaneously in the same direction. Since the horny layer is a more important protector against over-irradiation by shorter ultraviolet rays than is the skin pigment, there is left but one outstanding significant connection between radiation and pigment, namely, as an indicator of the action of the radiant energy, its intensity being, to a certain extent, proportional to the amount of action. But it is also very dependent upon individual factors such as
race, constitution and body function. Pigment formation is an indicator of the wished-for action and can be used as a measuring rod for treatment.
3. Antirachitic Effect. (Activation of vitamin D.) Ultraviolet radiation between 2800 and 3200 Angstroms causes in the skin an activation of cholesterol, accompanied by ergosterol, and in turn about 60 per cent of the latter substance is converted into vitamin D. The mechanism of this transformation is a complicated biochemical process. Vitamin D is an essential necessity of everyday life; it promotes normal anabolism of calcium and retention of phosphorus. Following ultraviolet irradiation calcium and phosphorus are absorbed to a greater extent and calcium deficiency in a growing child, resulting in rickets, is overcome.
330
ULTRAVIOLET RADIATION PHYSICS AND EFFECTS
Ultraviolet irradiation of a lactating woman increases to some extent the quantity and antirachitic potency of the milk. It also has been found possible to render cow's milk antirachitic by direct irradiation. Milk is the only common food considered for acceptance by the Council on Foods and Nutrition when fortified with vitamin D. One of the methods used to
impart antirachitic properties to vitamin
milk
is
irradiation with ultra-
violet rays shorter than 3130 Angstroms. The action of ultraviolet and cod-liver oil
on calcium and phosphorus

13
retention are interchangeable; however, according to Laurens cod-liver oil has much less general beneficial effect than ultraviolet rays and the
produce more general improvement in the activity, muscle tone and contentment of rachitic infants.
latter
VITAMIN
D ACTIVATION OF ERGOSTEROL
loo ôn

effects via the skin
331
and possibly via the sympathetic nervous system. There is some conflict in the findings reported in the extensive literature and this is explainable, as Laurens 13 points out, by the fact that observations reported by various clinicians were made under the most varied conditions, with a variety of light sources and on the healthy, the sick, on children and adults, as well as on animals.
FIG. 225.
Curves of relative effectiveness of ultraviolet spectrum and indication of bactericidal selectivity at 2650 (General Electric Co., Nela Park Division.)
A.
TABLE
Group Hemoglobin:
Controls
40.
EFFECTS OF ULTRAVIOLET IN SECONDARY ANEMIA"

Averages
No.
of
cases
Before
After
Increase
Filtered irradiation Complete irradiation Red blood cells:
14 19
21
14 19
64.0 65.0 64.5

3,023,000 3,056,000 3,132,000
64.5 76.1 78.0

3,128,000 3,675,000 3,723,000
0.5 11.1 13.5

105,000 619,000 591,000
Controls
....
.
.
Filtered irradiation Complete irradiation White blood cells:
21
14 19 21
Controls
....
. .
Filtered irradiation Complete irradiation

Effects of ultraviolet
8750 7950 7420
9100 8600 8180
350 750 760
from hot quartz mercury arc on the blood picture of three groups of hospitalized patients with secondary anemia. Fourteen controls with the same average anemia received no irradiation, 19 patients were irradiated through a Corex D filter and
21 received the complete spectrum.
increased consistently red blood cells and reticulocytes.
Radiation with massive exposures from carbon and mercury arcs has In animal experi-
332
mentation, blood regeneration in anemic conditions takes place more rapidly under irradiation than in its absence. In human anemias the fairly consistent increase of red cells and the hemoglobin content under ultra12 in a study of hosviolet radiation were demonstrated by the author As a rule acceleration appears pitalized patients and controls (Table 40). to be greater if the complete spectrum is used instead of only the longer The increase of white cells filter. ultraviolet range through a Corex was not quite so definite. Rebbeck20 showed that irradiation of the blood and its reinjection into the patient raised the blood cell count and hemoglobin. The mechanism of this effect is not quite clear. Other authors report a definite increase of white blood cells with leuko-
cytosis
and lymphocytosis and an increase
of
polymorphic
cells.
Among
other reported effects on the blood are: (1) a rise in its bactericidal power due to the erythema producing rays and there is probably associated with this factor an increase of resistance to some forms of infections. (2) An increase in the calcium and phosphorus content of the blood serum due in all probability to an increased absorption of calcium from the intestines. (3) Increased alkalinity of the blood under solar irradiation. (4) Decrease of the blood coagulation time. A reduction of blood-pressure has also been reported after radiation from carbon arc sources. In all probability this is not a specific effect, but due to luminous and infrared components in these rays.
it
In rickets, both experimental and infantile, 6. Effects on Metabolism. has been shown that the beneficial action of radiant energy is not limited
It supplies
to the rachitic process.
something which makes metabolism
more
efficient,
13
causing the organism to operate with increased
economy
(Laurens ). Blood sugar of the normal person is not influenced by ultraviolet irradiation, but that of some persons with diabetes may be temporarily diminished.
olism.
Irradiation of moderate intensity increases endogenous nitrogen metabIrradiation may double the fat content of the blood, cholesterol
increasing by 30 per cent. It makes respiration easier, deeper and less frequent, although total ventilation per minute remains constant. Basal metabolism is not influenced. Ultraviolet rays exert a glycogen-storing
prevent lowering of the respiratory quotient after muscular exercise. rays have no influence on thyroid activity. Although light is one of the most striking attributes of the environment of living organisms, the results of practically all of the experiments go to show that its effects on the normal growth processes of animals have been
effect,
The
negative (Laurens).
CONICAL USES OF ULTRAVIOLET RADIATION

In extolling the curative effects of ultraviolet therapy from non-specified sources on a large number of pathological conditions early enthusiasts failed to take cognizance of two facts; one is that while speaking of ultraviolet in treatment, an admixture of infrared, visible and ultraviolet radiation is employed; the second is that in many of these conditions similar
or perhaps even better results may have been achieved by visible and thermal radiation alone. In employing heliotherapy along with ultraviolet there is not only the large amount of visible and infrared to consider, but
also climatic conditions
and other
factors.
CLINICAL USES OF ULTRAVIOLET RADIATION
333
The ideal situation, according to some authors would be to discontinue the use of the term ultraviolet and substitute either a more exact designation which would associate the range of radiation employed with some definite physiological action such as erythema producing rays or, instead, prescribe a certain wave length of effective intensity. The following summary of the established clinical uses of radiation from ultraviolet sources is therefore presented with due qualification by the preceding statements. Further details will be found in the special
chapters in Part V. Metabolic Disorders. In rickets experimental work of Hess 10 and Huld11 schinsky has definitely established the specificity of ultraviolet radiaand this disease has become the criterion of appraising the biological tion, action of the ultraviolet rays in the region of 3000 Angstroms. It is emphasized by all clinicians that this radiation not only cures rickets but also materially benefits the child's general health. Prenatal irradiation of the mother and also irradiation of the nursing mother has a definite preventative influence on rickets. Infantile tetany or spasmophilia, the minor degrees of calcium and phosphorus deficiency, marasmus in children and osteomalacia in pregnant or nursing women also respond favorably.
Tuberculosis.
in
Both sunlight and

of tuberculosis.
many forms
artificial radiation are of definite value Sunlight (especially in the highlands) is
the treatment of choice for the treatment of tuberculosis of bones and lymph nodes and the genito-urinary tract without active pulmonary tuberculosis. Results are excellent if sunlight is employed over prolonged periods. Artificial radiation should be used, in addition, on cloudy days, especially in cutaneous tuberculosis or discharging sinuses. Artificial radiation may be preferable to sunlight for such complications as superficial,
joints,
peritoneal and intestinal tuberculosis. General exposures are always with additional local exposures over the disease area.
made
In extrapulmonary tuberculosis with active pulmonary tuberculosis accompanied by fever, sunlight of low intensity is the treatment of choice for the bones and joints and genito-urinary tract. The mercury quartz light often is preferred when pulmonary disease is exudative and febrile,
because of the relative absence of heat rays. It is advisable to alternate mercury quartz irradiation with exposure to outside air and diffuse daylight. In acute progressive tuberculous laryngitis, local ultraviolet irradiation is inadvisable until the acuteness has subsided; it may be tried as final treatment if other measures have failed. Ocular tuberculosis and aural tuberculosis respond infrequently to light. Oral tuberculosis is most resistant. Fistulas are often resistant, but postoperative sinuses are most responsive. Intestinal, peritoneal and lymph node tuberculosis often are rapidly responsive to ultraviolet therapy. In pulmonary tuberculosis there is some division of opinion among clinicians regarding the desirability of light therapy, with the majority favoring it in all except active and feverish cases. For further details see
Chapter on respiratory condition. Skin Conditions. In lupus vulgaris, carbon arc therapy applied in the Finsen method is of specific value. In erysipelas ultraviolet is safe and successful especially in the very young and the old, but since this disease
responds so well in all ages to sulfonamides, ultraviolet therapy is being used less frequently. According to the Council on Physical Therapy it is
334
reasonably well established that ultraviolet is at times useful either alone or as an adjuvant in acne vulgaris, adenoma sebaceum, pityriasis rosea, In parapsoriasis, psoriasis, telangiectasia, indolent ulcers and wounds. the last two groups the admixture of infrared and visible radiation is undoubtedly helpful and may often alone accomplish similar results. Ulcers occurring in Raynaud's disease or thrombo-angiitis obliterans and
also old chronic varicose ulcers respond poorly to ultraviolet. Miscellaneous Conditions. In selected forms of general debility and secondary anemia, in convalescence after operations and infectious diseases, in chronic bronchitis and sensitiveness to acute respiratory disorders, in bronchial asthma, light therapy has proved a valuable adjunct to general
medical treatment.
There is fairly uniform agreement as to the frequent benefits of general irradiation in improving appetite and sleep. Marked
effect
mental stimulation and analgesic
on painful areas
may
be explained
by
reflex action.
Counterirritation of a definite area of the skin by a measured erythema reaction from sunburn to blistering, has been recommended by Eidinow 7 for selected cases of acute pain in brachial and sciatic neuritis, lumbago,
fibrositis, etc.
;
asthma with
in swelling of joints due to effusion of fluid, in long-standing signs of bronchitis and emphysema. The rationale of this
treatment may be partly explained by an absorption of the destroyed " " albumin in the irradiated area, amounting to a non-specific protein shock and partly by reflex stimulation from the irradiated "zone." Selected cases of inflammatory and ulcerative conditions of the mucous membranes in eye, nose and throat as well as in genito-urinary and gynecological diseases, respond favorably to ultraviolet irradiations; for details see respective chapters. Ultraviolet irradiation of the blood has been reported as effective in
may
acute pyogenic infections and acute thrombophlebitis.
For
details see
Chapter XIX.
CONTRAINDICATIONS TO ULTRAVIOLET RADIATION

In active and progressive forms of pulmonary tuberculosis irradiation be followed by an increase of fever, loss of weight and a fall in bloodpressure. The same reaction has been reported in cases of children with tracheo-bronchial adenitis. In tuberculous patients the rapid appearance of intense pigmentation accompanied by a decline in the blood-pressure suggests the likelihood of involvement of the suprarenal glands and should cause suspension of the irradiation. Advanced cachexia or inanition from any cause, advanced heart disease with failure of compensation, advanced arteriosclerosis, gross renal or
may
hepatic insufficiency are all absolute contraindications to actinic radiation. In aged people, milder forms of acute or chronic nephritis or myocarditis also contraindicate irradiation.
In hyperthyroid subjects and patients with diabetes, severe itching and annoying general symptoms may occur after irradiation; highly nervous people are often made worse and at times show marked pruritis. Menstruation is not necessarily a contraindication to irradiation, although it may be more convenient to omit irradiation during the menstrual period. All forms of generalized dermatitis as a rule serve as a contraindication
CONTRAINDICATIONS TO ULTRAVIOLET RADIATION
335
to ultraviolet irradiation. In eczema, psoriasis, lupus erythematosus, herpes simplex, erythema solare perstans, xeroderma pigmentosum, freckles, atrophy, keratoses, prematurely senile skin, irradiation may cause an exacerbation, provoke an attack or cause other injurious effects. The possibility of producing cancer in the skin by ultraviolet has been receiving some study in recent years. According to the Council of Physical 5 Therapy, if the cells of the basal layer of the skin receive an excessive quantity of radiant energy, the two protective processes of cornification
and pigmentation become abnormally great (hyperkeratosis and hyperpigmentation) and a third degenerative process starts. Persons lacking in pigment or much exposed to ultraviolet rays show the highest percentage of skin cancer. The developing neoplasm occurs in the place of greatest proliferation, beginning in a wartlike hyperkeratosis, a precancerous change. A cancer develops from a precancerous lesion not only as a result of continuation of the initial insult but from any continued trauma. Thus ultraviolet rays do not cause cancer in themselves but produce characteristic cell changes leading to precancerous lesions in the skin. Any irritation, including continuously and excessively applied ultraviolet rays, can cause the precancerous change to become malignant. The eyes may be harmfully affected by ultraviolet as is commonly known. Sunlight is ordinarily harmless but when the ultraviolet component is
by reflection it produces "snow blindness." Glowing arcs and metals which emit energy shorter than 2950 Angstroms are injurious, and special ultraviolet-absorbing glasses should be worn. The damage usually is limited to conjunctivitis and blepharitis with pricking pain and uncomfortable foreign body sensation. Edema, contraction of lids and corneal
increased
may occur. Long exposure to intense ultraviolet rays may produce functional disturbances, such as color scotomas and constriction of the It is still a question whether intense ultraviolet rays peripheral field. produce lenticular cataract.
erosion
Further aspects of the dangers of light therapy end of the Chapter on artificial light treatment.
Photosensitization.
will
be presented at the
Photosensitization is a condition in which certain or substances when present in the system during ultraviolet irradiadrugs tion cause an increased (photocatalytic) reaction consisting of severe dermatitis. Some of these substances are (1) Drugs: quinine, trypaflavin,
:
methylene blue and other fluorescent dyes; (2) endocrines: insulin, adrenalin, pituitrin, thyroid; (3) heavy metals: such as mercury, iron, bismuth, gold, silver and calcium and their salts. When circulating in the blood, these metals not only increase the effect of radiation, but their
eosin,
own
action is also markedly increased by radiation. Photosensitization can serve to increase the effectivess of radiation this has been done by the indirect administration of fluorescent substances, notably eosin and by external use of certain substances, notably coal tar
;
(see psoriasis).
The sulfonamides have been described as photosensitizers by some and declared innocuous by others. Lately it has been even claimed that sulfonamides placed on the skin protect it against light erythema. 23 There are a few individuals who seem to have an inborn sensitivity to both sunlight and artificial radiation. They may react with severe itching or with rapidly developing dermatitis.
336
The only way

is
to detect and ward off the dangers of abnormal sensitivity to administer ultraviolet radiation in all doubtful cases in carefully
measured, subminimal doses.
REFERENCES
1.
AITKEN, R.:
2.
3.
Function of Pigment in the Skin, Brit. Jour. Phys. Med., BEBNHARD, O.: Light Treatment in Surgery, 1926. CAWADIAS, A. P.: Ultraviolet Radiation in Internal Medicine, Brit.
Med.,
10, 5, 1935.
10, 3, 1935.
Jour. Phys.
4.
COBLENTZ, W. W.:
teristics,
Sources of Ultraviolet Radiation and Their Physical CharacAssn., 92, 1834, 1929.
Jour.
Am. Med.
5.
Council of Physical Therapy, American Medical Association, The Therapeutic Value of Ultraviolet Irradiation, Jour. Am. Med. Assn., 120, 620, 1942; 121, 126,
1943; 121, 513, 1943. Regulations to Govern Advertising of Ultraviolet Generators to the Medical Profession Only, Jour. Am. Med. Assn., 102, 841, 1934. EIDINOW, A.: Counter-irritation by Ultraviolet Light, Lancet, p. 1404, June 20, 1936. Photodynamic Action of Sulfanilamide Compounds, Brit. Jour. Phys. Med., 2, 150, 1939. FRANKENBURGER: Strahlenther., 47, 233, 1933. HESS, A. F.: Rickets, Including Osteomalacia and Tetany, 1929. HULDSCHINSKY, K.: Ultraviolet Treatment in Rickets, 1926. KOVACS, R.: Ultraviolet Irradiation in Secondary Anemia, Arch. Phys. Ther., .X-ray and Rad., 18, 756, 1937. LAURENS, HENRY: The Physiological Effects of Radiant Energy, New York, The Chemical Catalog Company, Inc., 1933. Sunlight and Health, Scientific Monthly, p. 312, April, 1936. LEWIS, T.: The Blood Vessels of the Human Skin and Their Response, Shaw & Co., 1927.
6.
7.
8.
9.
10. 11.
12.
13.
14. 15.
16.
MAYER, EDGAR:
losis,
Principles
Physical Therapy in Pulmonary and Extrapulmonary Tubercuand Practice of Physical Therapy, Hagerstown, Prior & Co.,
of St.
17.
vol. 1, Chap. XIV, 1933. MEMMESHEIMER, A. M.: Eighteenth Rep.
18.
NEWMAN, B. A., and SHARLIT, H.: Sulfanilamide: A Photosensitizing Agent, Am. Med. Assn., 109, 1036, 1937.
PINCUSSEN, L.:
Johns Hosp. Derm. Soc.
Jour.
Effect on Ultraviolet and Visible Rays on Carbohydrate Metabolism, Arch. Phys. Ther., 18, 750, 1937. 20. REBBECK, E. W.: Irradiation of Autotransfused Blood in the Treatment of
19.
Puerperal Sepsis, Am. Jour. Surg., 54, 691, 1941. Heliotherapy, 2d ed., London, Oxford University Press, 1927. 22. STEENBOCK, H., HART, E. B., HOPPERS, C. A., and BLACK, A.: Jour. Biol. Chem.,
21.
ROLLIER, A.:
66, 441, 1925.

23.
ZENNER, B.
Protective Action of Sulfonamides Against Light Rays, Klin.
Wchn-
schr., 21, 227, 1942.
CHAPTER
XVIII
HELIOTHERAPY
Flistorical.
therapy.
Physics of Solar Radiation. Clinical Considerations. Technique of HelioSun Bathing in Well People and Children. Ultraviolet Transmitting
Glass.
Window
Historical. The great health temple erected to JSsculapius, God of the Sun, Medicine and Music, built at the time of Hippocrates, some four hundred years before Christ, served for the administration of light and water to cure disease and for the pursuit of physical and mental culture. Hippocrates prescribed sun baths for wasted muscles and employed a protective head covering for patients exposed to the sun's rays. Another Greek surgeon, Antylleus, recommended sun baths for the reduction of obesity and for the treatment of slow healing ulcers. Both Greeks and Romans were in the habit of taking daily sun baths. A solarium was part
of every
Roman dwelling house.
During the early days of the Christian era and all through the Middle Ages no progress was made in the curative uses of sunlight. The cause was a revolt against Paganism associated with sun worship. As the darkness of the Middle Ages began to lift, medical men in England, France and Germany started to advocate the treatment of wounds, rheumatism and
nervous conditions by sunlight.
man, Arnold
were
Ricli, a Swiss, to popularize cured, but Ricli's lack of medical
It remained, however, for a non-medical sun baths. of the patients
Many
knowledge prevented him from
scientific use of sunlight. Swiss physicians, Bernhard and Rollier, are responsible for the present-day world-wide recognition and extensive use of the "sun cure." Both practiced in the high Alps where sunlight was abundant and powerful. Bernhard was the first one to publish, in 1902, the remarkable results following the local sun treatment of sluggish wounds and cases of external
advancing the
Two
tuberculosis. Rollier began his work, in 1903, at Leysin by systematic general sun treatment of all forms of surgical tuberculosis. In addition, he developed a method for the prevention of tuberculosis in delicate children with predisposition to tuberculosis. Rollier's work has served as a model for similar work throughout the civilized world.
Physics of Solar Radiation. The term heliotherapy signifies the sysr temic exposure of the nude body to the rays of the sun for treatment purIn evaluating the therapeutic factors in heliotherapy one must poses. take into consideration: (1) the sun's energy; (2) climatic factors, such as open air, altitude, rest or exercise. No form of artificial light treatment can fully replace all these factors. The suns radiation represents a blending of infrared, luminous and ultraviolet radiation.
As shown
radiation
is
There
in this table, about 60 per cent of the energy in the sun's in the infrared region and 40 per cent is visible and ultraviolet. exists great variation in the percentile relationship between the
ultraviolet, visible
and
infrared.
There are
six principal causes of varia(
22
337
338
HELIOTHERAPY
tion in solar radiation intensities at the surface of the earth: (1) variations in the amount of energy radiated from the sun, (2) variations in the earth's solar distance (seasons), (3) amount of water vapor in the atmosphere,
dustiness or haziness in the atmosphere, (5) zenith distance of the sun (time of day), (6) altitude above sea level.
(4)
TABLE
41.
DISTRIBUTION OF SOLAR ENERGY (AFTER C. E. GREIDER AND

Watts
A. C. DOWNES) 10~ 7 per Square Millimeter
CLINICAL CONSIDERATIONS OF HELIOTHERAPY
339
the sky
at low solar altitudes, during fall and winter, the antirachitic radiation in may equal or exceed that of direct sunshine.
large variations in the amount of ultraviolet make a generally applicable accurate dosing of the sun's radiation quite impossible; on the other hand heliotherapy is being successfully administered at high as well
The
and at the seashore. In or near large cities the necessity of the unclothed body is an additional problem. exposing
as low levels
FIG. 226.
Sunlight spectral energy distribution.
CLINICAL CONSIDERATIONS OF HELIOTHERAPY
The two large groups of disease conditions specially amenable to heliotherapy are non-pulmonary or surgical tuberculosis: tuberculosis of the skin, bones, joints, of the genito-urinary tract, the intestines and larynx;
the other group is that of pulmonary tuberculosis. It is generally recognized that in both of these conditions heliotherapy is at best only a valuable accessory to general treatment. Among the most evident clinical effects of heliotherapy are a better appetite and sleep and a replacement of fatigue
and pain by greater liveliness and euphoria. Definite improvement occurs in the skin which from a flabby, thin consistence rapidly changes to a firm, tanned appearance; the subcutaneous tissue also fills out so the
skin cannot longer be grasped in loose thin folds; finally, the muscles regain tone and firmness, even despite prolonged bed rest for joint immobilization. As an indication of the clinical progress of the patient, the sedimentation rate also improves. All these changes occur especially rapidly in cases of surgical tuberculosis but can also be looked for in pulcases after a sufficiently long period of well controlled sun baths. In conjunction with the general improvement there is a gradual or rapid amelioration of some of the local symptoms. Rollier 10 emphasizes the remarkable analgesic action of heliotherapy in surgical tuberculosis. In cases of arthritis and coxalgia, after a few treatments all pain may disappear. Tuberculous lesions of bones and joints undergo progressive favorable changes, especially if the treatment is combined with suitable
monary
340
HELIOTHERAPY
immobilization and is continued for a sufficiently long period. Patients with tuberculous peritonitis, or intestinal tuberculosis show gradual improvement. There is a marked resolving action on infiltrations and edema; as also the gradual return of function in many joints with oldstanding ankylosis. Open tuberculosis, on account of the prevailing mixed
infection, responds
much
less readily to insolation.
In pulmonary tuberculosis, the main object of heliotherapy is to increase the patient's general health and resistance without interfering with the degree of rest considered necessary for the individual patient. No miraculous improvement should be expected but a slow steady improvement in the patient's general condition and, indirectly, of his tuberculous lesions, as shown by a diminished cough and sputum and diminishing of the physical
signs over the lungs.
Treatment by sunlight as a whole is desirable in the treatment of tubercu9 and other investigators, rather than by any losis, according to Phelps
one particular part of the spectrum. Others conclude that since the treatment of tuberculosis is as satisfactory in the mountains as at the seashore, it is not alone the short ultraviolet rays, obtainable only in the mountains, but also the longer ultraviolet rays, in conjunction with the visible violet and blue rays, that are effective; a great quantity of these rays is present in the sunshine in mountains and near the seashore, where refraction and reflection by the water and the white sand augments them; furthermore, result of treatment by the winter sun in the mountains is excellent when admittedly no wave lengths shorter than 3130 Angstroms are present. There is general agreement as to the desirability of heliotherapy over artificial light treatment in suitable locations because of its inexpensiveness and because of the additional advantages of climatotherapy.
Contraindications to heliotherapy in high altitudes are nephritis, ulcerous with diarrhea, decompensated cardiac lesions, amyloid degeneration. Further clinical aspects of pulmonary tuberculosis will be discussed in the Chapter on respiratory conditions. A survey4 on heliotherapy in connection with tuberculosis sanatoria in the United States showed that facilities for it are quite uniformly present. Most of the institutions have convenient arrangements on porches, on roof solariums or in sun pens. As regards artificial heliotherapy, there is a considerable variation in equipment. Many of the larger sanatoriums, especially those which also conduct a preventorium service, have large and well equipped heliotherapy departments for treatment en masse. In others portable lamps are used. It appears that in the use of heliotherapy the tuberculosis institutions adhere fairly closely to the methods and indications now generally accepted. A few, however, employ heliotherapy as a routine procedure for practically all patients regardless of the type, stage or activity of the disease. Of the 602 institutions that replied to the questionnaire, 440 reported facilities for artificial heliotherapy and a total of 1,589,720 treatments: 1,114,709 for adults, 320,704 for children and 154,307 not classified.
enteritis
TECHNIQUE OF HELIOTHERAPY
Heliotherapy can be practiced equally well at high and low altitudes. A sufficient amount of sunshine and clearness of the atmosphere are, however, prerequisites.
TECHNIQUE OF HELIOTHERAPY
The
resorts
341
generally accepted scheme of procedure especially in mountain is to begin by training the patient to grow accustomed to exposure to the air without sunshine. The patient is supplied with a hat, with protecting eye glasses and bathing slips and lies on his bed first in the shade for a few days. This aerotherapy plays an important part in the early part of the treatment because it accustoms the patient to expose his skin
which has usually a flabby, unhealthy appearance and has been heretofore covered with too many garments. There is a powerful tonic reaction from
the cool air in motion, especially in the mountains.
Sonny Days.
1.
342
protective horny layer.
HELIOTHERAPY
and objective reactions (rise in must be carefully watched. Patients pulse, erythema) best treated in the recumbent dorsal or ventral positions and may
subjective
The
temperature and
are
alternate between these if the condition permits. Following this systematic exposure the body gradually becomes tanned and finally it becomes possible to reach an average of three to four hours' total exposure time in winter and of two to three hours in summer. The best hours for exposure are those when the air is clear and the heat is moderate. In the mountains in summer these are the early morning hours between 7 and 11 A.M., and in winter from 10 A.M. to 3 P.M. In carrying on a regime of heliotherapy it is important, according to 7 Mayer that patients during and after solar exposures should feel as well as or even better than they did before taking them. Headaches, restlessness, nervousness or irritability, elevation of body temperature over 98.6 or pulse-rate over 90 are all indications of undue reactions that call for some change in the program. Overheating is the chief danger of general light treatment. One must be especially careful when the sun is very hot and there is no wind. In patients lying fully clothed in the sun overheating much more readily occurs. In patients with a stronger constitution a short cold spray or shower after sun baths often exerts an additional tonic
effect.
FIG. 228. Patient treated at Rollier's. This in ventral position; the patient rests on elbows protected against the sun.
is
and has hands
a case of spinal tuberculosis immobilized The head is free for work.
Sun Bathing in Well People and Children. Sun bathing is deservedly popular and the caged-in office dwellers of big cities can get definite benefits from careful exposures to the summer sun after having missed its stimulating rays during the dreary winter months. However, adult individuals react in different ways and so do children, adults and the aged. The differences in the reactions of blondes and brunettes are generally known and there may occur severe reactions due to abnormal sensitivity or in the presence of light sensitizing substances.
ULTRAVIOLET TRANSMITTING WINDOW GLASS
343
Overexposure to sunlight may cause varying degrees of sunstroke, heat stroke or sun burns and such symptoms as headache, lassitude, undue fatigue, irritability or gastro-intestinal upset. Properly applied on the other hand, sunshine and open air will act as a powerful tonic, increasing general powers of resistance and promoting mental and physical development. For this reason the duration and extent of exposure to sunshine
should be carefully graduated and those who do not pigment efficiently or easily should be warned to be especially careful. In robust young adults or in fairly well persons who take sun-baths for tonic purposes only, exposure of the entire body can be carried out, beginning with a total of eight minutes' exposure to four surfaces (including the two sides) of the body. Healthy persons not accustomed to the sun should never expose themselves for more than fifteen minutes at first and increase this exposure five minutes daily during two weeks. Exposure of babies and children must take place under an even more careful control of dosage on account of the more sensitive skin. A child, aged from six to eight months, may be started at one-half minute on the back and one-half minute on the front, once a day, for two weeks; this dosage may be increased with one minute each day for two weeks until a total exposure period of six minutes per day and no more is reached. The head and eyes should always be protected and on very warm days no exposure be given during the noon hours. Children aged from eight months to two years who are especially benefited by the preventive applications of sun-bathsmay be started on fractional body exposure, using a scheme as follows: first four days: expose the chest, arms and small part of the back for three minutes; next four days: increase exposure to five minutes; next week increase exposure of arms up to fifteen minutes; third week: expose in addition abdomen for three to five minutes and beginning the fourth week, the entire body for three minutes at first, increasing it to ten minutes within twelve days, continuing treatment of the arms and chest for a total of thirty minutes. After the second year children may be exposed similarly to the schedule for adults.
ULTRAVIOLET TRANSMITTING WINDOW GLASS

Ordinary window glass does not permit the passage of ultraviolet rays, on account of its content of iron oxide. Glass made of clear silica (quartz) transmits practically all of the ultraviolet rays of sunlight. Such window glass can be employed as an auxiliary in heliotherapy. It has been much advertised not only for use in hospitals and nurseries, but also for schools, office buildings and homes, on the ground that it permits the exposure to sunlight, especially in winter in situations where it would be impractical or uncomfortable to expose the nude or partly or even fully
chiefly
clothed body to the sunshine of the open air. As a result of this propaganda, expensive instalments have been made in many places with these glasses. The National Bureau of Standards reports on some of these window glass substitutes as shown in Table 42. Tests reported on by the Council of Physical Therapy 3 showed that only those glasses which have a transmission of 30 per cent or higher, at
protection
3020 Angstroms, gave an appreciable protection against rickets, but this was not 100 per cent. The ultraviolet-lamp radiation gave
344
HELIOTHERAPY
100 per cent protection. It was also shown that subsequent to a period as of exposure to the sunlight a physical and chemical change known of solarization takes place in these glasses, which decreases the amount 2 that the newer types of glasses Coblentz reports ultraviolet transmission. made especially for transmitting short-wave ultraviolet solar radiation, of after complete solarization have a transmission of 40 per cent or higher this renders the incident radiation at wave lengths of 3020 Angstroms; these glasses efficient as being within the limitations of the ultraviolet by Moisture proof cellophane may be used as an efficient other factors.
5 ultraviolet transmitting window pane, according to Krusen, transmits at 3000 Angstroms, about 60 to 70 per cent of the available radiation
and develops a yellow discoloration slowly and can be replaced easily cheaply.
TABLE
42.
TOTAL TRANSMISSION,
WHEN NEW, OF SOLAR ULTRAVIOLET RAYS TO WHICH COMMON GLASS is OPAQUE

Per cent
Fused quartz
CorexD
Helioglass Vitaglass Cel-o-glass Quartz-lite Flexoglass
92 92 50 50
.20
5
1
Common window
It
is
glass
to 5
evident that
when
there
is
no applicable ultraviolet present
in the
transmit sunlight, such as in the winter months, these windows cannot 1 states that in March in a north room equipped with ultraviolet any. Clark
transmitting windows, a child would have to sit in a place where the illumination is 10-foot candles for at least twenty hours to get as much ultraviolet radiation as he would get in two minutes outdoors in sunlight at noon. It is therefore a sheer waste of money to equip business offices and school rooms with these glasses. Solaria of special glass are useful in hospitals and sanatoria where patients
can be exposed just as for outdoor sun treatment, but with protection against drafts and chilly atmosphere. These windows must be carefully cleansed from accumulation of dust and dirt which cuts down their ultraviolet transparency considerably; the increased transparency for heat and light rays and lack of sufficient ventilation often make the atmosphere as
oppressive as that of a hothouse.
REFERENCES
Jour. Hyg., 3, 481, 1929. 2. Trans. Ilium. Engin., 23, 247, 1928. 3. Council on Physical Therapy: Report on Ultraviolet Transmitting Glasses, Handbook of Physical Therapy, Jour. Am. Med. Assn., 1933. 4. Jour. Am. Med. Assn., 105, 1873, 1935. 5. KRUSEN, F. H.: Physical Medicine, Philadelphia and London, W. B. Saunders Company, 1941.
1.
Am. CLARK, COBLENTZ, W. WJ.
H.:
6.
7.
LAURENS, HENRY: Factors Influencing the Choice of a Source of Radiant Energy, Jour. Am. Med. Assn., 103, 1447, 1934. MAYER, EDGAR: Physical Therapy in Pulmonary and Extrapulmonary Tuberculosis, Principles and Practice of Physical Therapy, Hagerstown, Prior & Co., vol. 1, Chap. XIV, 1933.
REFERENCES
8.
345
Summary of Intensity and S., GRAHAM, J. S., and LATTRENS, H.: Spectral Distribution of Solar Radiation at New Orleans, 1931-1940, Monthly Weather Rev., 70, 43, 1942. 9. PHELPS, W. M.: Jour. Bone and Joint Surg., 12, 253, 1930. 10. ROLLIER, A.: Heliotherapy, 2d ed., London, Oxford Univ. Press, 1927. Seasonal Variation in Antirachitic Effect of 11. TISDALL, F. F., and BROWN, A.: Sunshine, Am. Jour. Dis. Child., 42, 1144, 1931. Loss of Actinic Intensity in 12. TONNEY, F. O., HOEFT, G. L., and SOMERS, P. P.: Urban Sunshine Due to Air Pollution, Jour. Proc. Med., 4, 139, 1930.
MAYERSON, H.
CHAPTER XIX
ARTIFICIAL ULTRAVIOLET
tive
THERAPY
Carbon Arcs: Radiation Characteristics, RelaHistorical. Advantages and Disadvantages. Quartz Mercury Vapor Arcs. Hot Quartz Lamps, Cold Quartz Lamps. Low Pressure Mercury Arcs. Electrodeless Highfrequency Induction Lamps. Choice of Ultraviolet Generators and Standards of Ultraviolet Emission. Technique of Artificial Ultraviolet Irradiation. Special Techniques of Ultraviolet Irradiation. Local Irradiation. The Finsen Treatment. Air Sterilization. Dangers of Light Therapy. Ultraviolet Blood Irradiation.
General Considerations. The sun has been described as the greatest physician of all, the only trouble being to get an appointment with him. The difficulty of applying heliotherapy with regularity and under constant conditions, especially in lowlands and cities on one hand and the easy availability of a great variety of dependable sources of artificial radiation on the other, has made recourse to artificial sources of radiation an established necessity.
However, even
in artificial sources of radiation there
may be considerable
difference in the proportion and intensity of the various wave lengths, as indicated in Table 43. Furthermore, while we speak of ultraviolet rays,
the fact holds that in most instances radiation together with the ultraviolet.
we
are using infrared and visible
TABLE
43.
PRINCIPAL FORMS OF PHOTOTHERAPEUTIC RADIATION

Approximate
Predominant rays Infrared Infrared and visible Infrared
Source
wave lengths
120,000 to 6000 50,000 to 4000 120,000 to 2400
Heating elements Incandescent lamps

f |
Visible Long ultraviolet Low voltage mercury arc (hot quartz) / Visible \ Long and short ultraviolet High-frequency induction lamp Long and short ultraviolet High voltage mercury arc (cold quartz) Short ultraviolet
[
.
.
A A
A
30,000 to 2000
Almost
10,000 to 2000 A all at 2540
therapy had its inception in Niels Finsen's done in 1893, at Copenhagen, showing that the ultraviolet or chemical rays of sunlight have stimulating and bactericidal effects on lower organisms. Employing carbon arc light which just then came into use for lighting, he filtered out the heat rays through water and achieved excellent results in the treatment of tuberculosis of the skin (lupus) by concentrated carbon light. The mercury vapor or quartz lamp was developed from the Cooper-Hewitt lamp of 1891, in which mercury vapor was excited by an electrical current for lighting purposes. In 1903, Herseus devised tubes from fused quartz transparent to ultraviolet rays and allowing intensive radiation without the danger of exploding the tube. Bach and Nagelschmidt developed the quartz mercury vapor lamp for general radiation and Kromayer the "water-cooled" mercury vapor lamp for contact treatments. In recent years many newer, efficient forms of ultraviolet generators have been developed.
Historical.
Artificial light
classical experiments,
(346)
CARBON ARC LAMPS
347
CARBON ARC LAMPS

Construction.
follows
Two
The principle of construction of carbon arc lamps is as carbon rods or electrodes are held in the lamp so that their
FIG. 229.
Arc stream in carbon arc radiation.
FIG. 230.
Two
bed carbon arc lamp.
(Courtesy of National Carbon Company.)
ends are opposite each other. They may be vertically, horizontally, or otherwise arranged, and may be of several different sizes. The far ends of these electrodes are connected through suitable resistances or reactances with a source of direct or alternating current. As the current is turned on
free
348

free
and the two

circuit
is
ends of the carbons are brought into contact, an electric The points in contact with each other become very hot as the electric current passes through them. The carbons are then motor separated by a suitable arrangement, which may be a spring or mechanism and the current continues to flow through the circuit even
established.
though the electrodes have become separated. The electric current flowing across the gap is called an arc. Modern arc lamps are entirely automatic in operation and are started or stopped by the throw of a switch. They vary according to the amount of power they consume, the amount of radiation they emit and the kind of electrode employed, which determines the kind of radiation emitted. Carbon arc lamps large enough to be useful for general body treatment in a physician's office where individual patients are treated may use as much as 40 amperes at the arc but draw only 15 amperes or less from the electric mains and can, therefore, be used on any convenient outlet. Hospital type arcs applicable to institutional treatments are large enough to give therapeutic quantities of radiation over entire hospital wards so that large groups can be treated at once from one lamp, but they require special
wiring.
The electrodes in carbon arc lamps may be solid carbons or may be carbon tubes impregnated with various metals. In Europe pure metal electrodes, like tungsten or iron, are also employed. The lamps may be equipped with single, double or four pairs of electrodes. The multiple electrode type prevents waste of current and, when suitably arranged, permits the treatment of several people placed in a circle around or underneath the lamp. Solarium types of both mercury vapor and carbon arc lamps have been found useful in large institutions for group irradiation. A proper balance between the strength of the current and the size of the carbons is essential for efficient radiation. In using carbon arc lamps on direct current the temperature of the electrode at lower potential (called the positive electrode) is raised considerably higher than in the negative electrode. The crater forms at the end of the positive electrode, and thus it burns up quickly. With the alternating current the consumption of carbons is equal on both ends. Radiation Characteristics. The radiation of arc lamps is emitted from two sources. (1) The glowing ends of the electrodes are very hot. These tips emit radiation the same as any other incandescent body. Spectral analysis shows that this radiation has a continuous spectrum with all wave lengths present. (2) The arc stream itself or the path of the current through the gap between the ends of the electrodes is much more important. It is the source of most of the radiation from the carbon arc. Its spectral analysis shows a line or band spectrum consisting of lines or bands of definite wave lengths. This radiation comes from the vapors of the metals being melted and volatilized at the ends of the electrodes. In the case of iron and other heavy metals, this radiation from the arc stream consists of a multitude of lines so closely spaced that unless a powerful spectroscope is used the radiation appears to be continuous. Different metals give different kinds of radiation and the kind desired can be obtained by selecting the proper type of electrode. The carbon arc furnishes a radiation more nearly like sunlight, with
the following differences: there are
more shorter rays present
in the ultra-
CARBON ARC LAMPS

violet zone than in the sun, there is less luminous radiation intense infrared emission present. (See Frontispiece.)
349
and a more
VIOLET
|
BLUE
GREEN
YELLOW OSANGt
RED
EVEREADY "SUNSHINE" CARBON
EVEREADY THERAPEUTIC "C" CARBON
EVEREADY THERAPEUTIC
"E"
CARBON
2000
3000
4000
5000
6000
WAVE
Fio-231.
LENGTHS
IN
ANGSTROM
UNITS
(Courtesy of the National
Radiation characteristics of therapeutic carbons.
Carbon Company.)
intensity and quality of radiation from carbon arcs depends on the kind of carbons and their size, (2) the direction of current when direct current is employed, and (3) the amount of current employed. It is important that the various kinds of carbons be employed in suitable lamps because the efficiency of output depends on the correct proportion between voltage, amperage and the diameter of the carbons. There are three types of carbons available at present: (1) the sunshine type of carbon furnishes an artificial source of radiation more nearly like sunlight than any other artificial source. It contains cerium and other rare earth type elements in addition to carbon. Radiation from this arc when applied through a Corex glass screen furnishes a spectrum ranging
(1)
The
from 2900 to 40,000 Angstrom
units,
which
is
very similar to outdoor
350
sunlight.
(2)

Therapeutic
C" type carbons contain iron, carbons. Arcs with this type are in addition to carbon. aluminum and nickel, to produce a maximum amount of ultraviolet of the short-wave designed region from 2000 A. U. to 3100 A.U. These regions chiefly produce erythema and antirachitic effects. In the untanned skin of an individual of average susceptibility to sunburn the "C" carbons will produce a first
degree erythema with one minute exposure at 36 inches. (3) Therapeutic "E" carbons contain strontium and produce maximum amounts of radiation from 7000 to 10,000 Angstrom units, which is the radiation that
penetrates deeply into subcutaneous tissue, thereby assisting in raising subcutaneous temperatures, and useful where infrared is to be applied. The carbon arc is the hottest Relative Advantages and Disadvantages. artificial source of radiation readily obtainable and in this respect is the 6 closest approach to sunlight. (Coblentz. ) The early makes of carbon arc
"C"
"
lamps employed in the United States were unsatisfactory, because their radiant energy emission was weak. The arcs sputtered on account of the current fluctuation and unpleasant fumes and ashes were produced. In the newer types of lamps the problem of fumes and sparks is solved by a perfected system of ventilation and screening. The full power of the lamp
is developed instantly, so no warming-up period is required as in mercury vapor lamps. The lamps are rugged, portable and, since they consist chiefly of metal, reasonable mechanical shocks have no effect upon them. On the other hand, in comparison to mercury vapor lamps, carbon arcs consume more current and their carbons have to be adjusted and replaced from time to time.
QUARTZ MERCURY VAPOR ARCS

Mercury, a
fluid metal,
when vaporized
in a quartz container
by intense
heat, emits a spectrum rich in ultraviolet, characterized by a series of intense spectral lines or bands. The wave length and flux intensity of these bands vary according to the construction of the generator. (See
comparative spectra of quartz mercury arc and high voltage mercury discharge on frontispiece.) In the original quartz mercury lamp an electric arc produced between two electrodes vaporizes the mercury in the quartz burner. These arcs operate at a high vapor pressure, large current consumption and relatively high temperature and are known as hot quartz lamps. Newer mercury vapor
lamps come in three principal types: (1) Low-pressure mercury arcs in which mercury becomes vaporized through a tungsten filament heated at low voltage in a quartz container, (2) cold quartz lamps in which a high voltage current illuminates a mixture of neon gas and mercury vapor
contained in a quartz tube or other special container, (3) electrodeless induction lamps in which a high-frequency coil encircling a quartz bulb containing a trace of mercury induces a mercury vapor glow. Hot Quartz Lamps. In all quartz vapor lamps the principal part is the "burner," a fused quartz tube, air exhausted and containing mercury, with suitable attachments to conduct an electric current to it. The older type burners contain a large amount of mercury. After turning on the current the burner has to be slightly tilted: this makes the mercury run across the vacuum and for a moment complete the circuit.

The heat generated immediately vaporizes enough
351
of the mercury to fill the tube; this vapor continues to conduct the current and thus more and more of the mercury is vaporized, resulting in gradually more intense radiation. In contrast to the carbon arc lamps, the arc of which is struck at nearly full intensity as soon as the lamp begins to function the older
mercury vapor arc lamps require from

so that treatment
five to ten
earlier.
minutes to "build up"
must not be started
FIG. 232.
Older type tungsten-mercury burner.
The newer type
of
hot quartz mercury arcs consist of a straight length
of fused-quartz tubing, containing a small, measured quantity of mercury and a small amount of rare gases to provide a quickly available vapor
These burners operate on 220 volts alternating curprovided by a suitable transformer. As soon as the current is turned on the tube lights up due to the arc passing through the inert gas atmosphere. The mercury is at once vaporized and a very brilliant mercury
to start the discharge.
rent which
is
_._j
FIG 233.
Quartz burner with activated electrode. (Courtesy of^the'Hanovia Chemical and Manufacturing Company.)
vapor arc in the form of a cord is produced. The new hot mercury arc operates equally well in any position and can be started at the snap of a switch instead of the uncertain "rocking" of the older burners; it also makes possible a more efficient conversion of electrical energy into ultraviolet light and the tubes are less heavy and less likely to be broken. The
spectral energy distribution
is
similar to
all
other hot high pressure quartz
mercury
arcs.
352

of the
The emission
hot quartz mercury lamp contains very
little
short
infrared radiation, a fairly large
amount
of the violet
end of the
visible
about 6 per cent of the total spectrum and a large amount of ultraviolet; radiation is of wave lengths shorter than 2900 Angstroms, entirely absent in sunlight. There is considerable difference between this type of radiation
and that
of the sun.
series of spectral lines
Frontispiece.)
of the mercury arc consists of a on a faint continuous spectrum. (See superimposed The quartz tube and the hood emit a low temperature,
The spectrogram
long-wave radiation.
FIG. 234.
Hot quartz mercury lamp.
(Courtesy of General Electric Co.)
Quartz burners slowly deteriorate with use, due to the fact that the quartz tube decreases in transparency and does not transmit as much of the light as before. The decrease of intensity affects all portions of the spectrum in nearly equal measure. The greatest decrease occurs during the first hundred hours of operation and it is estimated that after that period the ultraviolet intensity is about 80 per cent of the original one. After one thousand hours the total intensity of radiation is from twothirds to one-half of the lamps when new, provided that the lamps operate on the same voltage and amperage. Erythema tests should be applied
.
353
periodically to check up efficiency of the burner. The ultraviolet energy output can also be physically measured from time to time.
The burners and lamps

irradiation
air
illustrated heretofore serve chiefly for general
and being kept at a considerable distance from the body, the circulating under their hood is sufficient to keep the burners from
Special overheating; hence their designation as "air-cooled" lamps. mercury vapor lamps, specially designed for local treatment have been earlier known as "water-cooled" or Kromeyer lamps. In these the burner is surrounded by a water jacket with inflow and outflow tubes for cold water and has a quartz window at one side for the transmission of radiation from which the heat rays have been absorbed. These somewhat cumber-
some and expensive lamps have been recently superseded by an air-cooled ultraviolet lamp (Aero-Kromeyer), which eliminates the watercirculation system; it enables exposure of an area approximately 1J inches
local
in diameter at close approximation. Suitably shaped quartz rods can be attached to the "windows" of both forms of lamps, enabling the conduction of the rays inside of any mucous orifice, sinus or sluggishly healing wound cavity. Ultraviolet radiation will travel along these rods even when they are bent at an angle and then pass out at the end in a direct beam. It does not radiate along the sides of the rods.
Spectrum of quartz mercury arc through Corex-D glass. Upper photograph spectrum; lower shows only radiation of longer wave lengths than 2800 A, all short waves having been filtered out.
FIG. 235.
full
shows
The simplicity of handling and upkeep has the most widely used source of artificial light.
little
made the hot quartz lamps They require comparatively
current; any other source of ultraviolet energy can produce the same intensity of radiation only by the expenditure of four or more times the
electrical energy.
With suitable "filters" various parts of their spectral emissions can be utilized. (Figs. 208 and 235.) Cold Quartz Lamps. In these lamps a narrow quartz tube containing and neon gas, resembling the old time Geissler tube, becomes mercury illuminated by an electrical current of high voltage. A transformer steps
23
354
'ARTIFICIAL ULTRAVIOLET
THERAPY
volts; the
up the alternating current supply to about 2500

pressure in the
amperage and
glow tube is very low; there is very little current vapor consumption and consequently the tube remains cold and can be readily approached to the body or inserted in orifices. The full energy emission of these lamps is present within a minute and it remains extremely constant. The spectral emission of cold quartz lamps consists of about 95 per cent in the line of 2537, in the short ultraviolet field. (See Frontispiece.) This ultraviolet band has enough penetrating power through the epidermis to
cause biological and therapeutic effects;
are
all
it
also
is
antirachitic in rats, as
It produces erythema without much pigmentation or blistering. (Bachem. 3 ) Cold quartz lamp generators come in two models: general body radiation lamps consisting of quartz tube in the form of a hexagonal grid mounted on a large aluminum reflector and supported on a stand and an orificial lamp, consisting of a holder of variously shaped rods for introduction in body orifices such as the mouth, vagina, urethra and rectum. These orificial tubes emit rays from all sides and not only at their tip.
radiations around 2500
Angstrom
units.
FIG. 236.
Low-pressure cold quartz lamp for local application. (Courtesy of the Hanovia Chemical and Manufacturing Company.)
The prevalence of bactericidal radiation from cold quartz generators points to their usefulness in superficial infections of the skin as well as of
mucous membranes; also in some skin conditions. Coblentz 6 has expressed doubt whether in spite of its erythemogenic efficiency this type of lamp is suitable for general body irradiation. Although the lamp has been on the market for a number of years, no reports in the literature have appeared about its clinical usefulness for general body treatment. Low-pressure Mercury Arcs. -In these lamps a bulb of quartz or other special glass contains a trace of mercury; an electric circuit heats up a tungsten filament and then two electrodes between them which an arc of mercury vapor forms, causing a glow which fills the entire bulb. These lamps come in two general types.

The Thin Window Mercury Glow Lamp.
355
In a glass bulb an indrawn
thin bubble forms an extremely thin window which permits the passage of ultraviolet radiation down to 1800 A.U. which are not transmitted through the glass of ordinary thickness, and which are filtered out by the
water in water-cooled lamps. A tungsten filament between two electrodes is heated by an independent circuit; in a few seconds a mercury arc forms between these two electrodes from the traces of mercury in the bulb. The lamp operates at 2 amperes at 16 volts and a special reactance (stepdown transformer) serves to reduce the voltage of the A.C. supply curOn account of the relatively low temperature, the lamp can be rent. brought in close approximation to the skin and serves for conditions
amenable to
local ultraviolet irradiation.
LINE
PLUG
SWITCH
FIG. 237.
Diagram
of
thin-window lamp.
(Courtesy of the Westinghouse
X-Ray
Corp.)
The relative energy distribution of the thin window lamp consists of 55 per cent ultraviolet, chiefly in the region of 2537 Angstroms, 10 per cent visible and 35 per cent infrared; this is therefore similar to that of the cold quartz units. The author5 has made extensive clinical tests with this lamp and found that in the average skin an application for five minutes of close contact causes an erythema lasting five to ten days, which does not result in either peeling or blistering. A ten minute exposure is followed only by slight pigmentation. Laboratory studies show that it is possible to get a sterile culture from the surface of the skin after five minutes exposure. Clinical results were reported with the thin window lamp by the author and others in: (1) pyogenic infections of the skin; (2) fungous and parasitic affections of the skin, and (3) sluggish ulcers and wounds. This type of lamp has been further developed for air sterilizing. (See end
of Chapter.)
Mercury Arcs in Corex.In these lamps an ultraviolet transmitting Corex D or quartz bulb similar in shape to the ordinary electric light bulb
356
electrodes.
contains a tungsten filament of V-shape and on top of this two tungsten There is a drop of mercury in the bulb, and after the heating of the filament the vaporized mercury forms an arc between the tungsten
electrodes.
emission from the bulb is a combination of incandescent solid the visible and (tungsten) radiation from 3650 Angstroms throughout short infrared and mercury vapor radiation with strong lines between bulb absorbs all ultraviolet 2800 and 4050 Angstroms. The Corex
The
radiations shorter than 2800 Angstroms which are not present in sunlight. These lamps serve principally for home use as a source of radiation similar to sunlight. They come in two sizes: the S-l type tulb at a distance of 30 inches produces the same ultraviolet effectiveness as midday, midsummer has the same effect at 24 inches. sunlight, .while the smaller S-2 type bulb
FIG. 238.
Contact treatment by thin- window lamp.
Ten
to fifteen minutes exposure at these distances will mildly sunburn the average person. The bulbs of these lamps do not operate directly on the house current, but must be placed in a special fixture with a transformer; for this reason they are activated only by an alternating current supply. They are useful devices for home treatment under competent medical supervision. Electrodeless Highfrequency Induction Lamps. In these lamps a mercury is formed by the inductive effect of a high voltage circuit surrounding glow
an evacuated quartz bulb containing a tiny drop A small induction coil is placed on the outside
of
mercury.
(Fig. 239.)
round bulb and is connected to the transformer of a diathermy machine, as an attachment to which this lamp serves. A potential of 5000 volts from the secondary brings the vapor of the mercury in the bulb to full luminescence within
of a
thirty seconds.

The
of the
357
special energy emission of this lamp is essentially the same as that hot mercury arc lamp, and the only difference according to Coblentz 6 In the ordinary is the intrinsic brightness (flux-density) of the lamp. quartz mercury arc all radiant energy is concentrated in a luminous column less than 10 mm. in diameter, whereas in the electrodeless discharge the radiation spreads over the entire bulb, some 6 to 8 cm. in diameter. Bulbs of different transparency of glass can be made to transmit or absorb shorter waves. During treatment the bulb remains comparatively
FIG. 239.
Electrodeless induction lamp, energized by short-wave diathermy machine. (Courtesy of the Lepel High Frequency Laboratories.)
cool
and
it is
claimed that
it
retains its transparency to ultraviolet radia-
tion in contrast to the gradual clouding of the hot quartz burners. The fact that there are no seals or electrodes protects the burner against loss
of its
vacuum.
Electrodeless quartz lamps can be furnished in the form of a general body lamp as illustrated, and in the form of a hand lamp for local application.
The mounting
of miniature quartz bulbs
on the end of wired catheter
tubes, enables the insertion of these sources of radiation into practically every orifice and cavity of the body, kidney, colon and stomach.
358

lamp with a high-frequency apparatus enables small offices. Some long-wave and short-wave diathermy
of this
circuits to energize
The combination
saving of space in
units
ultraviolet lamps.
have been equipped with
such electrodeless
FIG. 240.
Combination hot quartz and infrared burner. Flarsheim Company.)
(Courtesy of The Liebel-
Combination of Hot Quartz and Infrared Units.
combination of the
radiation of a hot quartz unit with an infrared one offers the advantage of the full range of the phototherapeutic spectrum when desired or the use of either component. The employment of one .stand is an economic
advantage especially in a small
office.
(Fig. 240.)
CHOICE OF ULTRAVIOLET GENERATORS AND STANDARDS OF EMISSION

It was pointed out repeatedly that the ideal situation would be to be able to select a radiant energy generator furnishing an efficient emission of a single wave length which has proved specific for a given pathological condition. According to present-day clinical practice, supported by the
8 ruling of the Council on Physical Therapy all generators emitting a sufficient intensity of sunburning (erythema producing) radiation are accept-
able for ultraviolet therapy. Our present ultraviolet generators generally furnish combinations of the three principal groups of radiations: (1) infra-
luminous and full range of ultraviolet radiation, as represented by the modern carbon arc lamp; (2) luminous and a full range of ultraviolet radiation as represented by the hot quartz and electrodeless induction lamp; (3) an almost monochromatic radiation of short ultraviolet as represented by the cold quartz lamp, the thin window mercury glow lamp,
red,
GENERATORS STANDARDS OF EMISSION

and the recent
'
359
air-sterilizing units. Table 43 shows the principal sources of phototherapeutic radiation and the spectral range of their emissions. In considering the available ultraviolet generators in treatment of a
specific case the first question arising is
whether heat radiation
in addition
to ultraviolet
is
desirable or not.
itself is beneficial in rheumatoid tuberculosis; in these conditions carbon arc irradiation may be more preferable, therefore, or an infrared generator may be employed in addition
Clinical experience shows that heat in conditions and in joint and glandular
On the other hand an excess of heat radiation often undesirable in pulmonary or intestinal tuberculosis and in rickets, hence the preference of a radiation mainly restricted to ultraviolet in these conditions. In superficial infections of the skin and mucous membranes
to the ultraviolet source.
is
a generator furnishing only the shorter bactericidal range of ultraviolet radiation is preferable. The present range of generators enables a fairly wide selection according to these postulates, but there still exists need for further controlled clinical work. Standards of Emission. The effectiveness of ultraviolet generators is 8 judged by the Council on Physical Therapy on the basis of the erythemal reaction. The specifications of minimum intensity are based on a comfortable and convenient operating distance (24 inches, or 61 cm.) from the front edge of the reflector, at which distance the exposure can be made without burning the skin by coming in contact with the burner or by the infrared rays. The ultraviolet intensity of the lamp shall be such that the time of exposure to produce a minimum perceptible erythema (one that disappears in less than twenty-four hours) will not be longer than fifteen minutes for a therapeutic lamp and sixty minutes for so-called sun-lamps.
TABLE
44.
ERYTHEMOGENIC EQUIVALENT OF ULTRAVIOLET RADIATION REQUIRED To PRODUCE ERYTHEMA (CoBLENrz 6)

Ultraviolet intensity in microwatts per
Source
square centimeter
Sun: Midday, midsummer, midlatitude, sea level Carbon arc: Blue flame, cored carbon, in reflector, no window Carbon arc: Glass window, opaque to 2800 Angstroms and shorter
.
91
48
90
(estimated)
Mazda, type S-l lamp; high temperature arc in parallel with V-shaped tungsten filament Mercury arc: General Electric Mazda, type S-2 lamp; similar to the
Mercury
arc: General Electric
....
83 93
108
Mercury
S-l lamp, but smaller; both in glass bulbs arc: Types G-l and G-5; low temperature, low voltage thermionic glow discharge; glass bulb Mercury arc: High temperature, high vapor pressure, low voltage; quartz tube Mercury arc: High-frequency electrodeless discharge; quartz bulb Mercury arc: Low temperature, low vapor pressure, high voltage, "cold quartz," Geissler tube discharge
.
.
58 60
36
As the emission line of the mercury arc lamp of 2967 Angstroms has the highest efficiency in generating an erythema, 100 per cent, in comparison to all other wave lengths, this line appears suited as a natural standard for evaluating sources of heterogenous ultraviolet radiation. The Council has therefore adopted 20 microwatts per square centimeter of homogenous radiation of wave lengths 2967 Angstroms as the erythemal unit (E. U.) of dosage; that is, 1 E. U. = 20 microwatts per square centimeter of radiation of wave length 2967 Angstroms. 8 For home use the Council only accepts lamps which emit practically no ultraviolet radiation shorter than
2800 Angstrom units.
360
TECHNIQUE OF ULTRAVIOLET IRRADIATION

In general irradiation the entire unclothed body is room should be warm and also well aired. exposed, hence the treatment to provide an individual dressing gown or sheet for each It is advisable The eyes of the the actual exposure. patient which covers him until as well as those of the operator should be protected by goggles. patient the dozen, and Ordinary leatherette goggles can be bought cheaply by for each patient. In case of doubt as to the individual goggles provided effectiveness of protection, goggles should be tested for ultraviolet transmission. In patients with a sensitive skin it may be well to cover the face a thin towel at first; the genitalia should generally be covered by a
Administration.
by
from heavy paper may protect should not rest on a high support, as this would result in a more intense exposure because of the shorter distance from the lamp. (Fig. 234.)
loin cloth or a folded towel.
shield cut
it
the nipples.
If
the face
is
exposed
FIG. 241.
Solarium shower.
(Courtesy of
The Burdick Corporation)
Patients are usually treated in the recumbent position. The table or couch on which the patient rests should be a low one, allowing a ready variation of the distance from the lamp. Modern mercury and carbon
arc vapor lamps now allow radiation at various angles instead of only from the horizontal or vertical position. The center part of the body should be placed in the direct line of radiation, but no old style hot quartz
directly over the patient's body. application of luminous heat from a large 1500-watt lamp is generally advisable, with the first few treatments with the mercury vapor lamp. Warming of the skin makes the patients feel more comfortable than if a very short exposure to the comparatively cold mercury vapor radiation is applied alone and will also accelerate the chemico-
lamp should ever be placed
The preliminary
361
biological process following radiation. The duration of the heat radiation should be from ten to fifteen minutes and its length decreased as the length
of the ultraviolet exposures
is
increased.
ready for use as soon as it is lit and preliminary heat radiation is not necessary. With the hot mercury vapor lamp one must wait for two minutes or more according to the type of lamp, until
arc
The carbon
lamp
is
full output of radiation is developed. Patients experience no sensation except that of the slight warmth during treatment with the mercury arc and more intense heat when the carbon arc is used. A time-clock should always be used to measure the time of exposure. As general radiation is usually equally divided between the front and back, the patient is instructed to turn over with the first signal and the clock is then set again for the second half of the treatment. At the end of the treatment with old style burners the hood is closed and the lamp is kept burning if there are other treatments to follow. This keeps the intensity of radiation on an equal level. All other lamps should be switched off to save current. At the finish of treatment, patients are ready to leave the office as soon as dressed. Dosage. In our present practice the erythemal response of the individual patient serves as a guide of dosage. For general irradiation the first dose is usually one which just about causes a first degree erythema. The principal factors in dosage are distance of the burner and length of exposure. These will vary according to the efficiency of the apparatus, the individual sensitivity of the patient and the progress of treatment. As patients are irradiated with ultraviolet they develop an increasing tolerance enabling them to stand successively larger doses. Further combined clinical and laboratory research may determine what wave length and intensity of radiation per unit of body area is necessary
the
for therapeutic effect in different pathological conditions. Gerstenberger and Hartman 10 demonstrated the possibility of such definite dosage, com-
parable with dosages in drug therapy. They found that exposure from a mercury vapor lamp in doses of erythema units, determined by a definite scale, given once a week is sufficient in the cure and prevention of rickets
and
Lamps. Various types of apparatus prodegree erythema at various distances and exposure times. The efficiency of one's apparatus chiefly depending on the condition of the burner in hot quartz lamps should be checked up from time to time by simple skin tests; the same tests serve also to test individual sensitiveduce a
first
rachitic spasmophilia. (a) Efficiency of Ultraviolet
ness of patients.
is the following: The upper arm is covered a large manila envelope, or by a sleeve made of black cloth in which five small holes are cut. Under this shield is placed a shutter strip of the same material. The forearm and the face are protected by a towel. The arm is placed at 30 inches directly under the lamp burning at full strength. The shutter strip is withdrawn from the first opening, two minutes later it is withdrawn from the second. One minute later, it is withdrawn from the third opening; thirty seconds later, from the fourth; fifteen seconds later from the fifth and, after fifteen seconds more, the light is shut off. This results in a progressive period of total exposure for the various openings, ranging from fifteen seconds for the
A simple method
shield
for testing
by a
made from
362
fifth
Within a few hours opening to four minutes for the first. (Fig. 242.) there should be an erythema visible over one or more of the areas exposed. The exposure time of the area which becomes pale next morning shows a first degree erythema dose and indicates the average dosage for it at
30 inches.
FIG. 242.
Testing for lamp efficiency or ultraviolet sensitivity. National Carbon Company.)
(Courtesy of the
(6)
The Distance From
the Burner.
It
is
at a standard skin-burner distance of 30 inches
advisable to start treatment and with the exposure
time calculated to give a first-degree erythema; on subsequent treatments, one should not change the distance, but gradually increase the exposure time. In keeping the factor of distance constant there is less chance of confusion or error. When the maximum time of exposure, say fifteen minutes with the hot quartz lamp has been reached one can begin to change the skin-burner distance. This can be lowered 2 inches at each successive treatment, until the lamp is at 18 inches. A distance of less than 15 inches is not safe for general irradiation on account of the possibility of a heat burn from the infrared emissions of the hot quartz burner. There is also more loss due to the angulation of radiation if the lamp is brought too close to the body. With carbon arcs it is not advisable to bring the burner closer to the body than 30 inches, except for local treatments, on account of the possibility of a heat burn. According to the law of inverse square, moving an object to double the distance from a source of radiation cuts the intensity of radiation to onequarter; this law does not apply quite strictly to radiation sources which are not a point, but a more extended surface. Anderson's table 1 shows the relative intensity of uniform time exposures given at different distances:
TABLE
45.
RELATIVE RADIATION INTENSITY AT DIFFERENT DISTANCES
Distance (inches) Proportionate dose
... ...11|22|
40
31
26
22
20
3
17
14
12
10 9
Contrary to previous misconception as Krusen 17 points out the shorter distance from the burner to the skin does not increase the proportion of short ultraviolet rays reaching the skin because the air absorption of other rays of the therapeutic range is negligible at the usual treatment distances.

(c)
363
Length of Exposure. The time necessary to produce a first-degree in a patient with average susceptibility at a given distance is different for each type of lamp. With the average hot quartz lamp one minute at 30 inches is usually sufficient. As in succeeding treatments a gradual tolerance to radiation develops and the t me of exposure as a rule can be safely increased by two minutes each time. For general tonic treatment by the hot quartz lamp in the average patient the second exposure may be given next day, and the time of exposure should be three minutes; further increase of two minutes is made at each successive treatment so that, at the end of two weeks with treatments two days apart, an exposure of fifteen minutes is reached. All these treatments are administered at first at the standard distance of 30 inches. A scheme of exposure for the average " tonic" treatment by a hot quartz lamp with a fairly new burner is given in Table 46.
erythema
TABLE
46.
SCHEME
Treatment
No.
1
. . .
2 3
,.'
364

irritative
dose should never be applied except to small areas, whereas a tonic dose should be applied to as much of the body surface as possible. Different body areas react differently to radiation; those with a thick Bach the most sensitive horny layer are the least sensitive. According to are the face, the chest, .the abdomen, back and sacral region, next come and least sensitive are the hands and feet. Flexor surthe arms and
An
No erythema dose should be repeated (e) Frequency of Irradiation. has completely if any until the reaction from the previous exposure subsided. With patients treated in hospitals or at home daily treatments
office may be treated every given at first; patients coming to the other day. A course of twelve treatments administered to ambulatory patients week is usually sufduring four weeks at a rate of three treatments per ficient for general tonic purposes, provided that it is accompanied by After a full course of irradiation it satisfactory clinical improvement. be advisable to continue irradiation once or twice a week, or stop
legs faces are generally
more
sensitive than extensor surfaces.
may be
may
altogether.
periods.
In cases of tuberculosis treatment
may
be continued for longer
states that overdosage through too frequent irradiation may In irradiation for prevention of colds interfere with a favorable result. 19 or biweekly dosages of only ten minutes (Maughan ) have been weekly
Mayer
20
This
down the incidence of colds as much as 40 per cent. an important argument against over-use of self-prescribed and selfadministered ultraviolet irradiations by lay people which is usually overdone in both duration and frequency. Blondes are from 40 to 170 per cent more sensiIndividual Sensitivity. tive than brunettes and men 20 per cent more sensitive than women. Persons between twenty and fifty are more sensitive than those younger or older. The minimal dose within toleration is best determined by preliminary skin testing, for if an overdose is given burns or itching may develop. As a matter of safe routine it is advisable to administer to children and aged people only one-half, to women about three-quarters, and to blondes and red-haired persons about one-third to one-quarter of the
effective in cutting
is
average dose. People with tanned skins and dark complexions can stand an initial dose larger than the average. People with inborn sensitivity do usually
their poor tolerance to sunlight. Temporarily increased sensitivity to radiation may occur after any procedures which enhance the circulation of the skin, such as an incandescent-light bath, hot bath, massage given before irradiation. Alcoholic subjects, patients with long-standing malaria or syphilis may show increased reaction, likewise persons sensitized by any of the agents enumerated in
know about
Chapter XVII. Dangers in General Ultraviolet Irradiation. When applying radiation from any source it is important to keep in mind not only a safe dosage but also the possibility of abnormal sensitivity of the patient. Burns or other injuries may occur in connection with artificial light treatment on account of two groups of cases: (1) hypersensitivity, either inborn or due to causes predisposing pathological conditions. These causes
365
have already been discussed in this chapter as well as in Chapter XVtI. (2) Overdose of radiation and other improper handling of apparatus. Overdose from any light source may result either from an excessive single exposure or from exposures repeated over too long a period. The immediate visible effect of a single over-exposure may be an erythema due to the infrared (heat) rays; exceptionally there may be immediate blister formation. Ordinarily the erythema disappears in an hour or so and in a few hours the effect of the ultraviolet rays begins to show. A dermatitis skin burn of varying intensity and extent develops. The main features and treatment of these burns have been presented in the chapter on electrical injuries. The longest wave length that can produce a burn is about 3150 Angstroms. In addition to burns, there may occur general
symptoms: headache, nausea, or high fever and irregular heart action. Such reactions occurred when patients fell asleep under an ultraviolet lamp or when they insisted to find out how much irradiation they could stand. The severe general effects are due to the flooding of the blood
stream with the destroyed protein substances, a severe "protein shock." Tt is, of course, well known that over-doses of natural sunlight can bring about similar severe reactions. Humphris 13 reports a fatal case of a woman, aged forty-eight years, who took the "sunlight treatment" on her own, and who after the second treatment became ill and showed two burns of brick-red color on the left leg, and the lower back. A few days later she developed fever, diarrhea, hematemesis, passed dark blood and died after twelve days. Postmortem examination showed gastric and duodenal ulceration and the medical men present agreed that these were the result
of the burn.
In the course of ordinary treatments such severe reactions are very rare, because fortunately a margin of safety as great as 50 per cent exists 20 (Mayer ) and nature reacts much less severely to overdosage from light than to overdosage from roentgen-rays. Improper Handling of Apparatus relates usually to the home use of ultraviolet. In a fatal accident reported from England a young man was electrocuted while touching an ultraviolet lamp which he lit in a bathroom. It was found that there were about one-half dozen ways in which electrical short-circuiting could have happened with that flimsy make of lamp. Of course the use of any electrical equipment in a bathroom is dangerous. There is some risk in placing the old style hot quartz burner directly over the patient because it might suddenly crack. The modern "hot quartz" burner which contains no fluid mercury is free from this danger. Neglecting to protect the eyes against irradiation may result in various degrees of inflammation as described in Chapter XVII. Painful conjunctivitis in both patients and careless operators has been reported. Lear 18 described a general inflammation of the conjunctiva, cornea, iris and the One of his cases occurred in a man lens, known as photoophthalmia. who had several "sun ray" treatments in a Y. M. C. A. gymnasium, with
his eyes unprotected.
Dangers of
self-prescribed
Home
Treatment.
survey of the possible
ill-effects
of
and self-administered treatments by the laity was made a committee of the Medical Society of the County of New York 14 conby sisting of clinicians, pediatrists, orthopaedic surgeons, dermatologists and physical therapists. There were reported aggravation of cases of quiescent
366
pulmonary tuberculosis; aggravation
of various skin conditions, such as eczema, psoriasis, lupus erythematosus and numerous instances of burns of varying severity, including dermatitis Solaris lasting many months; a number of cases of conjunctivitis, due to careless and unskilled exposure; in children a decrease of hemoglobin count when ultraviolet irradiations were continued for a period of months; also some cases of immediate febrile The committee expressed the practically unanimous opinion reactions. of the medical profession that, with so many injurious effects already on record, the prevailing practice of uncontrolled self-treatment by the laity
harmful. In spite of the vigorous commercial propaganda in favor of home treatment, there are comparatively few instances in which there is real indication for the use of powerful sources of ultraviolet radiation in the patient's home. The danger of over-exposure, of careless handling of apparatus and of the indefinite continuation of radiations are all valid reasons against home treatments, without the immediate and continuous supervision of a
is
competent physician. The Council on Physical Therapy 8 will not include sun lamps in its list of accepted devices if they emit radiations shorter than 2800 Angstroms without using a Corex D filter and if they are recommended for use without supervision of a physician.
SPECIAL TECHNIQUES OF ULTRAVIOLET IRRADIATION

Local Irradiation. Local irradiation to a circumscribed area of the skin from the usual types of lamps does not involve any new principle nor are any additional devices necessary. One may use any type of body lamp by simply covering the area not to be treated and radiate only the affected part. It is important that such areas be thoroughly cleansed from dead cells, scales and greasy material which interfere with penetration. The dosage in local irradiation will depend on the condition to be treated. Burns, clean granulating tissue should receive mild erythema dosage; this can be repeated daily. Suppurating areas or those with old skin lesions usually do better under intensive dosage. A four-minute irradiation at 15 inches distance from a new air-cooled mercury vapor lamp will produce a marked dermatitis (third degree erythema). Such a dose can be repeated only every four or five days. In erysipelas very intense dosage ten to twenty times the erythema dosage at fairly close range has been recommended. (See Chapter on skin conditions.) For local irradiation at close range and for cavities the various types of local irradiation units may be employed. Special applicators serve to reach locations which cannot be subjected to direct radiation. In determining dosage one must remember the normal mucous membranes tolerate about twice the dosage of the average skin; the nasal mucosa tolerates several times more. When applying an intensive dose to a mucosa, the surrounding skin must be protected by some greasy substance against
over-exposure.
The Finsen Treatment. The original Finsen apparatus consists of a metal stand, as illustrated. In its upper part an arc is struck between two carbon electrodes by a direct current of 55 volts and 50 amperes. This
powerful light
is
radiated in four directions through four telescopes con-
SPECIAI TECHNIQUES OF ULTRAVIOLET IRRADIATION
367
taining quartz lenses, running water between the lenses absorbs most of the heat rays. The remaining luminous and ultraviolet rays are applied to the skin through a compressor consisting of two rock-crystal lenses;
a flow of cold water between these layers eliminates the last portions of heat rays while pressure of the compressor renders the part anemic and permits deeper penetration of the radiation. In the Finsen treatment only an area of about the size of a dime is irradiated each time, for sixty to seventy minutes. The result of such intense local raying is a severe local inflammatory reaction, usually leading to a blister over the area exposed. It takes about three days for the full development of this reaction and about fourteen days for its retrogression. In the later stages there forms a smooth scar over this area and this cosmetic result is hailed as the chief advantage of the Finsen treatment.
FIG. 243.
The Finsen treatment.
For the treatment of one patient at a time the late Reyn has constructed a small 20-ampere lamp with the carbons in an angular position; the rays of this device radiate only in the direction of the single telescope and
cooling apparatus.
The Finsen treatment started as a purely local treatment. Later general carbon arc irradiations were added alternating with local treatment. Best results by Finsen treatment are seen in lupus vulgaris and lupus erythematosus. In various forms of eczema and acne the treatment is claimed to be superior to other methods. Laryngeal tuberculosis, tuberculous glands, Roentgen-ray and radium burns have also been considerably benefited. In the United States the Finsen treatment has found very little employment, partly because lupus vulgaris cases are not as frequent as they are in Northern Europe and partly because the treatment is tedious
Irradiation. After clinical use for over five years, 4 23 spectacular results are claimed for Miley, Barrett, Rebbeck for hemoirradiation by ultraviolet in certain conditions and it is stated that there
and expensive. Ultraviolet Blood
368

For effects on blood cells or other untoward reactions. a special apparatus has been constructed by Knott. It procedure
were no harmful
this
FIG. 244. Hemo-irradiation outfit. Hemo-irradiator. 1, glass-tipped adapter for suction or withdrawal end of rubber tubing system; 2, glass-tipped adapter for intravenous or injection end of system fitted to needle in patient's vein. Citrated blood that has just passed through irradiation chamber (4) is returned to venous circulation through this adapter. 3, watercooled, mercury-quartz burner, source of high-intensity ultraviolet energy used in irradiating blood; 4> Knott irradiation chamber with quartz window held in contact with mercury-quartz burner. Blood is passed through this chamber, its time of exposure being automatically adjusted. 5, starting switch; 6, synchronized transfusion pump; 7, dial regulating rate of flow and time of exposure; 5, voltmeter. (Courtesy of Dr. G. Miley.)
consists of a circular irradiation
chamber 2 inches in diameter and 1 inch which a water-cooled-mercury quartz burner is held. Transdeep, against fusion tubings are attached to two outlets from the chamber. The formula
AIR STERILIZATION
369
A= determines the amount of blood to be withdrawn, with A the amount in cubic centimeters, K a constant (1.5) and the weight expressed in pounds. The average blood withdrawn is 225 cc. The venous blood
KW
withdrawn is citrated (1 part 2.5 per cent sodium citrate to 5 parts of blood) and immediately returned to the patient through the hemo-irradiator to the vein from which it was withdrawn. The time of exposure is considered the time required for the passage of 1 cc. blood through the chamber while exposed to ultraviolet irradiation. An automatic transfusion pump and a mechanism for controlling the flow of blood and consequently the irradipart of the apparatus. biophysical effects attributed to this procedure are: attenuation and destruction of bacteria, inactivation of toxins and viruses, increased absorption of oxygen by the blood and increase in general resistance to
is
ation time
The
infection.
Good
results are reported
by Miley
22
in 103 cases of acute
pyogenic
infection, including staphylococcemias (septic abortion, puerperal sepsis); the treatment in successful cases resulted in reduction of high fever and
in twenty-four to thirty-six hours; in 13 cases of acute thrombophlebitis, most of which failed to respond to routine treatment by
toxic
symptoms
heat, bed rest, elevation and also sulf onamides there was rapid disappearance of pain and tenderness after a single blood irradiation; 80 patients with intractable bronchial asthma exhibited marked improvement. Rebbeck 23 also reported on successful treatment of a series of cases of puerperal
;
sepsis and postabortional sepsis. It is interesting to note that while the three clinicians here
mentioned
have for over
five years reported favorable results with hemo-irradiation, other clinicians have made no reports whatsoever on this procedure.
There seems to be need for clearing up two doubtful points in conjunction with hemo-irradiation. One is an explanation why irradiation of such a small amount of blood exerts such a profound effect on the entire blood. The other is answering the contention made that similar results can be achieved in some conditions by using autotransfusion alone without irradiation.
AIR STERILIZATION
12 26 Following the path-finding studies of Hart, Wells, and others it has been well established that ultraviolet radiation can destroy air-borne microorganisms and that such radiation can be used to prevent air-borne infection in operating rooms 16 and thus diminish the incidence of infection in clean wounds; such radiation can also be employed to prevent cross-
infection in contagious
offices
wards 11 and the spread
of respiratory infections in
and public rooms. The spectral band of 2650 appears to exert maximal bactericidal action. 7 (Coblentz. ) In the most readily obtainable sources of germicidal radiation the emission line of 2537 dominates the spectrum and is therefore taken as the standard of homogeneous radiation for evaluating the output of germicidal radiation. From experimental data it appears that the minimal radiant flux of wave length 2537 A at a distance of 1 M. from the lamp should not be less than 100 microwatts per sq. cm. Physics of Germicidal Lamps. For air sanitation and for others sterilization purposes mercury discharge lamps are universally used at present.
24
370
pressure quartz discharge lamp emits 93 to 95 per cent of its near the peak of bactericidal between 2500 and 2600 efficiency. They can be made of high transmission glass which allows the
ultraviolet energy
The low
A,
rays to be given off but absorbs the shorter ozone producing rays neighborhood of 2000 A. A lamp used for disinfecting purposes is a single unit and its usual types consume about 15 watts, sometimes as much as 45 watts.
2537
in the
3000
3400
3800
4200
4600
5000
5400
RELATIVE ENERGY DISTRIBUTION AND EFFECT CURVES
FIG. 245. Relative energy distribution for equal electric inputs to hot quartz lamps and low-pressure bactericidal lamps with superimposed effect curves. (General Electric Co.,
Nela Park Division.)
Ultraviolet radiation of 2000

of the air
and shorter wave length converts some
around the lamp into ozone. When ozone is undesirable, the quartz burners are supplied with a filter jacket to filter out these short
wave
lengths.
first installed, the radiant ultraviolet energy is considerably more intense than 20 microwatts per sq. cm. at 1 M., the minimum intensity for acceptance. As the lamps age, the intensity drops off rapidly at first
When
and slower
later.
intensity or above for the guaranteed period of 4000 hours of continuous operation. Users of the equipment are advised to test the lamps each month to determine that they are up to standard. Since the lamps burn at a characteristic color constantly, there is no way of determining whether they are emitting sufficient ultraviolet radiation
minimum
Under ordinary usage the lamps maintain the acceptable
by
testing
them with an
except
ultraviolet meter.
Discharge tubes of lamps should be kept clean, since dust would absorb
AIR STERILIZATION
371
This should be done by appreciable amounts of ultraviolet radiation. wiping them frequently with a clean cloth moistened with pure residuefree absolute alcohol, carbon tetrachloride or distilled water. 9 Acceptance of Germicidal Lamps. The Council on Physical Therapy
limits acceptance to ultraviolet disinfecting lamps designed for installation in hospital nurseries, hospital wards and operating rooms. Satisfactory evidence is not available to warrant acceptance of ultraviolet lamps for
In view of available evidence, ultraviolet radiation disinfecting solids. appears to be an uncertain means of sterilizing solid objects (drinking cups,
combs, brushes, shaving utensils, toilet seats and shoes) even if irradiation of the whole surface is possible. Ultraviolet lamps for disinfecting purposes are not accepted for disinfecting air in schools, waiting rooms, public gathering places and large halls.
unit.
Sterilamps arranged in octagon form around an offset operating room lighting This arrangement permits moving the lighting unit to any position without disturbing the ultraviolet radiation. (Courtesy of Westinghouse Electric & Manufacturing Company.)
FIG. 246.
The total amount of direct and scattered ultraviolet radiation incident on the occupants must be kept below the level that will produce conjunctivitis, erythema and any other (at present unforeseen) injurious effects from prolonged irradiation. This requirement may be met by suitable arrangements of the lamp fixtures and baffles and not by requiring the applicants to wear glasses and special covering of exposed parts normally
uncovered.
pital, care
If the radiation is penetrating, e. g., in the corridor of a hosshould be taken that attendants do not receive an exposure
372
which will cause injury to skin or eyes, and particular attention should be taken to assure that the intensity of the space at eye level through which a transient may pass or tarry momentarily will not cause eye injury.
FIG. 247. Nursery instalment of constant intensity ultraviolet unit equipped with shields to prevent the direct radiation reaching the cribs but allowing the ultraviolet rays to reach the aisles between cubicles and the entire upper portion of the room. This forms barriers
against cross-infection.
(Courtesy of Westinghouse Electric
&
Manufacturing Company.)
Practical Uses.
Practical installation of ultraviolet air sterilization
may be grouped in one of three categories: 25 (1) rooms in which direct radiation is permissible because of absence or short duration of human occupancy, with suitable precautions to safeguard the eyes and skin of any occupants; (2) rooms in which indirect irradiation must, for practical reasons, be used; (3) air-circulating systems in which ultraviolet lamps may be installed in ducts or otherwise in the circulating system with or without recourse to supplemental irradiation in the rooms involved. The first is used in operating rooms, food storage spaces, bacteriology laboratories, food preparation rooms and for sanitation of air in a hospital room recently evacuated before installation of a new patient. The second is adaptable to hospital nurseries and wards, corridors of hospitals for contagious diseases, school rooms, offices and public rooms where people
REFERENCES
373
congregate. The third type is used in air-conditioning systems, in foodprocessing rooms where exclusion of bacterial contamination is important and for purification of air or other gases used in food handling.
REFERENCES
1.
ANDERSON, W.
pany, 1933.
T., JR.:
Actinotherapy Technique, London, Sollux Publishing
Com-
2.
ANDERSON, W.
of
Low Work
3.
4.
5.
BACHEM, A.: and Rad., 13, 614, 1932. BARRETT, H. A.: Five Years Experience With Thermo-irradiation According to the Knott Technic, Am. Jour. Surg., 59, 42, 1943. BUTTOLPH, L. J. Physical Basis of Air Disinfection by Ultraviolet Energy, Arch.
:
and BIRD, L. F.: A Quartz Mercury Arc With Electrodes Function, Jour. O. S. A., 27, 95, 1937. Physiology of the Mercury Line, 254 u.u., Arch. Phys. Ther., X-ray
T., JR.,
6.
Phys. Ther., 25, 671, 1944. COBLENTZ, W. W. Sources of Ultraviolet and Infrared Radiation Used in Therapy,
:
Jour.
7.
Am. Med.
Assn., 102, 257, 1934.
Standardization of Ultraviolet
Lamps Used
as Sources of Germicidal
8.
9.
Radiation, Aerobiology, 138, 1942. Council on Physical Therapy: Acceptance of Ultraviolet Sunlamps, Jour. Med. Assn., 102, 42, 1934. Acceptance of Ultraviolet Lamps for Disinfective Purposes, Jour. Med. Assn., 122, 503, 1943.
Am. Am.
10.
11.
GERSTENBERGER, H. J., and HARTMAN, J. L.: Quartz Lamp Therapy in Human Rickets and Rachitic Spasmophilia, Jour. Am. Med. Assn., 92, 367, 1929. GREENE, D., BARENBERG, L. H., and GREENBERG, B.: Effect of Irradiation of Air
in a
Ward on
Incidence of Infections of the Respiratory Tract,
Am.
Jour. Dis.
Child, 61, 273, 1941.

12.
13.
14.
Sterilization of the Air in the Operating Room by Bactericidal Radiant Energy, Arch. Surg., 37, 956, 1938. HUMPHRIS, F. H.: Artificial Sunlight and Its Therapeutic Uses, 5th ed., Oxford Univ. Press, p. 133, 1928. Uses and Dangers of Light Therapy, Med. Jour, and Rec., December, KOVACS, R.
HART, D.:
4, 1929.
15.
16.
17. 18.
19.
20. 21. 22.

23.
Mercury Glow Lamp, Arch. Phys. Ther., 19, 661, 1938. CIMIOTTI, B. S., and MELENEY, F. L.: Considerations in the Use of Ultraviolet Radiation in Operating Rooms, Ann. Surg., Ill, 161, 185, 1940. KRUSEN, F. H.: Light Therapy, 2d ed., New York, Paul B. Hoeber, Inc., 1937. LEAR, E. G. Pathological Effects of the Ultraviolet Rays on the Eye and Treatment, New York State Jour. Med., 29, 1270, 1929. MAUGHAN, G. H.: Ultraviolet Radiation as an Aid in the Prevention of Common Colds, Arch. Phys. Ther., X-ray and Rad., 14, 6, 1933. MAYER, EDGAR: Technic of Artificial Radiation, Principles and Practice of Physical Therapy, Hagerstown, W. F. Prior & Co., vol. 3, Chap. Ill, 1933. MILEY, GEORGE: Control of Acute Thrombophlebitis With Ultraviolet Blood
KRAISSL, C.
J.,
:
- New Type of
Irradiation Therapy,
Am.
Jour. Surg., 60, 354, 1943.
Knott Technic of Ultraviolet Blood Irradiation in Acute Pyogenic Infections, New York State Jour. Med., 42, 38, 1942. REBBECK, E. W.: Ultraviolet Irradiation of Autotransfused Blood in Treatment
of Postabortional Sepsis, C.,
24.
Jour. Surg., 55, 476, 1942. Bactericidal Effect of Ultraviolet Radiation, Jour. Bact., 41, 745, 1941. 25. ROBINSON, FREDERIC W.: Practical Considerations in Design and Maintenance of Ultraviolet Air Sanitation Equipment, Aerobiology, pp. 181, 1942. 26. WELLS, W. F., and WELLS, MILDRED: Air Borne Infection, Sanitary Control Jour. Am. Med. Assn., 107, 22, 1936.
Am.
RENTSCHLER, H.
NAGY,
R.,
and MONROMSEFF, G.
PART
Essentials of
IV
Hydrotherapy and Mechanotherapy

CHAPTER XX
HYDROTHERAPY
General Considerations. Physical Principles. Physiological Principles. Hydrothermal Measures. Wet Compresses. Wet Packs. Ablutions. Baths. Special Forms of Baths. The Elliot Treatment Regulator. Hot-air Baths. The Paraffin Bath. Hydrokinetic Measures. Douches and Showers. The Whirlpool Bath. Therapeutic Pools and Tanks. Colonic Irrigation.
General Considerations. The term hydrotherapy designates collectively the therapeutic procedures related to the external application of water and other forms of baths to the body. One cannot speak of water treatment without specifying what form of physical energy it conveys, just as one
cannot speak of electrical treatment without stating what form of elecIn practically all forms of water applications used tricity is employed. for treatment thermal effects play the leading role; in many of them the mechanical effects of immersion, of the pressure and of the flow of water exert, in addition, certain specific action. Hence the classification of water treatment under the two headings of hydrothermal and hydrokinetic measures. There occur also hydrochemical effects in addition to hydrothermal effects with some special forms of baths. In the modern development of hydrotherapy an imposing array of apparatus was devised for the application of the various water treatment measures. In proportion as the complexity of the outfits increased their
in general decreased, for instead of encouraging the use of simple hydriatic measures in the patient's home or in the physician's office, hydrotherapy became almost entirely a method of institutional use. It is a fact, however, that in trained hands, with no more expensive and complicated implements than a supply of hot and cold water, a bathtub, a few towels and sheets, a multiplicity of remedial effects can be accom-
employment
plished.
Physical Principles.
The employment
its
peutic agent depends principally on conveying of certain physical forces.
of water as a physical theraproperty as a medium for the
highest of
for absorbing heat, its specific heat being ordinary substances except hydrogen. It cools relatively slowly. It is, therefore, valuable as a medium for abstracting heat, for storing heat and for applying heat. Its utility as a thermal agent is further enhanced by the ease with which its temperature can be measured, reguall
Water has a great capacity
lated
and controlled. Water can readily be applied with varying and regulated pressure. body immersed in water is buoyed up by a force equal to the weight
(374)
A
of
PHYSIOLOGICAL PRINCIPLES
375
water it displaces. Ingenious use has been made of this principle in recent years for underwater exercising of muscles, too weak to work outside of the water. TABLE 47. --TEMPERATURES OF WATER APPLICATIONS
Cold bath Cool bath Tepid bath Warm bath Hot bath
40
..... .....
65 85 95 100
to 65 to 75 to 95 to 100 to 110
F. F. F. F. F.
4.4
(18.3
(29.4 (35.0 (37.7
to to to to to
18.3 23.8 35.0 37.7 43.3
C.) C.) C.) C.) C.)
Physiological Principles. The human skin may be regarded as a great sheath of imperfectly sheltered blood-vessels and nerve endings and the effect of hydriatic measures is essentially a reaction in the skin and in the organs reflexly connected. It has been shown by physiologists that there are special nerve endings, "receptors," for heat and cold in- the skin. The more intense the stimulus, the larger surface of the skin it affects and the longer it lasts, the more intense will be the reaction caused by it. About 25 per cent of the blood of the body is contained in the capillary beds, many of which are in the superficial tissues, especially in the limbs. Heat and cold, manipulation through the skin can more profoundly influence the distribution of blood than any medicinal measure. There occurs also an exchange of ions in a bath between the water and the skin tissue, with
some change
pit
is
in the structure of the skin itself.
The normal
98.4
or average temperature of the
F.; the average temperature of the skin surface
human body under the armis much lower,
F., due to constant cooling through the evaporation of the moisture on its surface. If water at a temperature different from that of the skin is applied to the body it either will conduct heat to the body or absorb heat from it. The difference in temperature acts as a "stimulus" or irritation of the nerve endings of the skin. By such stimulation one can influence the balance of the sympathetic system and also affect the endocrine system. Tepid water, at a temperature of 92 to 94 F. causes no external stimulation of the skin nerves and is principally used to exert a marked relaxing, nerve-resting effect upon the entire body. One can lie in such a bath for hours in perfect repose. The greater the difference from the normal skin temperature, the more
about 92
marked are the physiological effects of hot and cold water applications. Short applications of intense heat or cold are equally stimulating. 1. Cold Applications. A short cold application exerts the most profound effect among all water procedures. Under its influence the skin becomes pale and usually takes on the appearance of goose-flesh, which is due to the constriction of the small blood-vessels and the contraction of the muscular and elastic tissues in and under the skin. If the application lasts only a short while, the constricted blood-vessels immediately dilate again, more blood flows through the parts than before and the skin becomes At the moment of application deep inhalation pink and feels warm. occurs with a momentary arrest of the respiratory movement the familiar "gasping," which is followed by deep exhalation and the respiratory movements continue deeper, especially if the cold application is prolonged. The sum of these stimulative effects of a cold application on the circulation and other vital functions is known as a cold " reaction." Many of the hydrotherapeutic measures have as their object to bring about such an effective reaction. In persons of low vitality poor circulation, scanty respiration,
376
HYDROTHERAPY
run-down condition cold applications do not bring about such a reaction and are, therefore, to be avoided. In normal persons a sensation of wellbeing and that of a general stimulation follows a good cold reaction. Other physiological effects of a short cold application are the slowing of the pulse, an increase of the tone and work of the heart muscle, provided that it is not too weak to overcome the increased resistance in the peripheral circulation. The blood-pressure shows an initial rise and later a fall but it usually stays higher than before the application, due to the
increased tone of the blood-vessels.
Cold applications
of long duration cause
primary contraction of blood-
vessels, followed by their paralysis due to damage of the nervous system of the vessel wall. More about these effects will be said in the chapter on
hypothermy. A short intense hot application causes the same 2. Hot Applications. immediate vascular reaction as a cold one, the skin blanches, the tissues contract and goose-flesh appears. Plunging one leg or arm for a second in This primary effect, however, very hot water will demonstrate this. subsides quicker than after a cold application. A dilatation of the peripheral blood-vessels also follows but the resulting hyperemia is more widespread and is atonic in character in contrast to the reactive hyperemia induced by cold. The local and general physiological changes following the continued application of hot water within physiological toleration correspond with those described in Chapter XI. Too intense heating leads
to tissue destruction
and permanent damage, just as too intense cold
application. 3. Applications of Slowly Increasing Temperature. Applications of slowly increasing temperature through the medium of water cause a dilatation
and a gradual rise of the skin temperature. With an arm or leg bath of increasing temperature, the peripheral arteries become dilated andmore blood is drawn into the extremity. In recent years it was found that by partial baths of increasing temperature, it is possible to influence the peripheral and general circulation more effectively than by the abrupt stimulus of intense hot or cold applications.
of blood-vessels
Mechanical force adds considerably to the stimulating effect of any hydriatic application. The force of the impact of the water and the amount of friction during and after treatment are important factors in determining the total effect of a hydro therapeutic reaction.
An interesting table by Fox and Van Breemen 1 presents a scale extending from stimulation to sedation by external heat chiefly hydro thermal. TABLE 48. A SCALE or SEDATION AND STIMULATION BY EXTERNAL HEAT (Fox AND VAN BREEMEN)
Accelerating or stimulant
Hyperthermal mud (115 to 120 F.) High-pressure douches, hot or cold (with or without strong manipulation) Vapor baths (hot) Whirlpool baths Brine baths
Diathermy
Hot-air baths Half baths Radiation baths
(light, heat, ultraviolet)
All at 93
to 98
F.
Pool baths (with or without sedative manipulations)

Retarding or sedative
HYDROTHERMAL MEASURES
Among
will
377
the large variety of hydrotherapeutic measures principally those be discussed which lend themselves for application in general practice or the use of which has become an essential part of modern physical therapy.
Wet Compresses.
In
all
compresses a folded linen cloth serves as a
vehicle for the application of either hot or cold water. Compresses are slightly wrung out and held in position by a dry flannel bandage.
this reason a valuable
cold compress causes contraction of the peripheral vessels and is for measure for immediate relief in recent injuries, as
well as in early stages of inflammation, for combating swelling, redness and pain. In order to maintain fairly even cooling, the compress should be
renewed frequently, every one-half to one minute or kept cool by a coil with circulating cold water or an ice-bag. Cold compresses to the forehead are useful in cerebral congestions of various origin. Applied to the nape of the neck they are sedative in nervous disorders, such as nervous palpitation and in nervous sexual excitement. A cold precordial compress is valuable in nervous irritation of the heart. A stimulating compress is a cold compress covered over with several layers of dry flannel so that they completely overlap the wet linen underneath. With the compress left in position there is at first a vasoconstriction but as soon as a reactive vasodilatation sets in, the compress becomes warmed from the increased supply of blood due to the insulating covering, it takes on the temperature of the blood, its water content evaporates and it becomes dry, within one to four hours. The mild vascular skin reaction of the stimulating compress is a convenient treatment measure in many acute congestive conditions. A throat compress is useful in sore throat, laryngitis and tonsillitis. A chest com;
press serves in diseases of the respiratory system, bronchitis, pneumonia and in pulmonary tuberculosis. It should be followed by a local or general
cold application or in patients with night sweats with an alcohol rub. The abdominal compress exerts a depleting and soothing effect in gall-bladder or liver congestion and in venous stasis of other abdominal organs. It is
applied so as to cover the parts from the costal arch to the symphysis and may be applied overnight in ambulatory patients and several times during the day in bed cases. Many patients with abdominal complaints regularly
sleep in this compress
and
feel greatly benefited.
Stimulating compresses should not be applied in patients with eczema and should be discontinued if there are signs of skin irritation. A compress in use should be boiled daily to prevent infection of the skin. A hot compress is applied much in the same way as the cold compress with several layers of folded linen cloth dipped in hot water (105 to 115 F.) and covered with flannel or woolen cloth to maintain the heat. Kept on for one to two hours it will bring on an intense hyperemia and
help to soften or disintegrate inflammatory congestion and also relieve pain
and spasm.
Wet Packs. Wet packs are among the most effective of hydriatic measures. According to the temperature of the water employed, we distinguish between cold wet packs for sedation and antipyretic effect and hot wet packs for elimination; according to the extent and size of the pack,
we
distinguish between full
and three-quarter packs.
378
HYDROTHERAPY
full wet
pack needs the following equipment (Council of Physical Therapy): Any ordinary bed and mattress; if packs are to be repeatedly renewed, two beds and double equipment must be provided. A stool, small table or straight chair should hold a pillow, rubber sheet or large or four piece of oilcloth, one or two sheets (72 by 99 or 80 by 90), three woolen blankets (72 by 84 or 80 by 90), two small towels, a hotheavy water bottle or hot soapstone. The room temperature should be 68 to
72
F.
is applied as follows: Prepare the bed by spreading a rubber sheet next to the mattress and spread two or three woolen blankets over the rubber sheet. Best results are obtained when the sheet is folded in such a way that it may be easily spread out under the patient while he is
The
The pack
reclining
6 or 8 inches wide;
on the bed; fold the sheet lengthwise and in plait-like folds of now fold crosswise forming a bundle 6 or 8 inches
wide and approximately 30 inches long; this leaves the sheet in a convenient form to be immersed and wrung out; the sheet is dipped in cold water 60 to 70 F. "Prepare the patient; patient should be in the nude; turn the patient on his side and over to one side of the bed; lay the sheet in the middle of the bed open crosswise but still folded lengthwise; it will look like a white strip dividing the middle of the bed; unfold half of the sheet; spread it over the vacant portion of the bed on top of the blanket; place top edge of blanket 1 inch below the patient's shoulders; roll the patient on the wet open half and spread the other half; patient will shudder at first contact with the cold wet sheet; discomfort should pass quickly; tuck the sheet snugly around the patient; have patient raise arms above head; fold onehalf of wet sheet closely over the patient, high under the arms tuck edges smoothly under body and legs; press a fold down between the legs and feet; be sure the sheet clings snugly to the body everywhere; put patient's arms dow n to sides; wrap the remaining half of the wet sheet around the patient upper edge closely surrounding neck; fold lower end under the heels sheet should be snug but not binding too tight wrapping makes the patient both uncomfortable and apprehensive; be sure to guard against
;
cofd feet and

"
any prolonged chilling; work fast. the blanket smoothly around the neck and over the chest tuck corner under the shoulder, and edge under body; patient should be getting thoroughly warm now and becoming relaxed; if feet will not warm up, use hot-water bottle; a towel might be tucked around the patient's
Now wrap
neck for comfort. The patient should not be left alone in a pack at first, as, if weak, he may suffer from shock and require a hot drink or aromatic spirits of ammonia or even have to be taken out, though this is a rare occurrence. The pack may last from fifteen minutes up to one hour. When taken out, a rub should be given with a coarse towel or alcohol or in the form of a
warm sponge
restore the tone of the relaxed peripheral vessels. oughly dry before putting the patient to rest in a
bath, according to individual circumstances, in order to Be sure the skin is thor-
warm
bed.
three-quarter pack may be applied in nervous patients who cannot tolerate being fully wrapped up. In this technique, the wet sheet and blanket are only applied up to the arm-pits, the arms being left free and
379
covered separately with a blanket. The result is almost identical with that of a full pack. The physiological effects of the full wet pack are as follows: The contact of the cold wet sheet with the skin causes reactive peripheral hyperemia. The heat released from the dilated blood-vessels accumulates between the skin and the pack, forming a layer of warm air. A sedative or even hypnotic effect is produced by the action of warm vapor on sensory nerve
endings,
eral vessels,
by depletion of cerebral vessels resulting from repletion of periphby the absolute immobility enforced by the snugly fitting pack and by the entire absence of mechanical stimulation. The pulse-rate and respiration are slowed after primary stimulation. Repeated wet packs are
antipyretic in effect. The cold wet pack is one of our
most effective sedatives as many patients asleep within a short time. In psychoses, psychoneuroses and some forms of insomnia resistant to medication it is a measure of great value,
fall
but it is contraindicated in debility, in marked degree of circulatory disturbance or in cardiac weakness. Ablutions. Pouring water over the entire body or part of it serves as a mild form of thermal stimulation for getting the patient accustomed to cold water and also for judging his vascular reaction. For a full ablution the patient may sit in an empty bathtub or lie on a rubber cot. Water at a temperature from 60 to 70 F. is poured from a pitcher over the back and the chest. This deepens respiration and stimulates and refreshes the nervous system but as it also raises blood-pressure it is contraindicated where this is too high. The degree of stimulation is in proportion to the temperature of the water employed and the height from which it is allowed to descend upon the patient. This procedure should be a very short one to attain the desired effect. The partial ablution or towel bath is a milder measure for bringing about a local vascular reaction without increasing the blood-pressure. It is administered to a patient lying in bed, covered only with a sheet and blanket. Towels are placed in a bucket containing water at 65 F. and after wringing, spread in succession over the arms, legs, chest and back. While each towel is in position, the attendant rubs it until it feels warm. As the wet towel is removed from one area, the skin is quickly dried and the part is covered with the blanket and the next area is treated with another towel from the bucket. The total duration of treatment should not be more than five minutes, following which the patient should remain
in
bed for some time, sleeping
if
possible.
The towel bath can be employed with

elderly people
benefit in febrile cases
and
in
and
it
can be safely repeated a number of times. It exerts
a mild stimulating effect. Hot and Cold Baths. Baths may be classified according to their extent as full or partial baths and according to their temperature as cold, tepid
and hot baths. The
to individual susceptibility
on the body varies to a certain extent according and gradual accustoming to certain procedures. The immediate sensation upon entering any bath will also depend on the skin temperature at that time; if the patient's skin is warm and perspiring, a tepid bath may feel cool, while with a cold skin, the same bath temperature may feel warm. Short Cold Baths. A. short cold bath or plunge is given in a tub for a
effect
380
HYDROTHERAPY
few seconds to two minutes at a temperature ranging between 80 and 65 F. If necessary the skin should be previously warmed by some other procedure and then the face and neck bathed with cold water. While the body is immersed in water it should be vigorously rubbed or the bather should exercise. As soon as the patient has rubbed himself dry with a turkish towel he should exercise moderately or receive a general massage. As a water treatment measure a full cold bath requires the strongest
reactive response from the patient. It is generally contraindicated in high blood-pressure, weak heart or tendency to hemorrhage and when employed at any time should be always combined with brisk friction in order to assist the reactive power of the patient. cold plunge bath in the morning is an excellent tonic and hardening
measure for healthy people and is followed by a definite rousing of the vital energy of the body, a glowing pink skin and alert zest for the day. In chronic conditions with diminished functional activity atonic conit should be carried on systematically. stipation, obesity, mental lassitude Continuous Tepid Baths. A. bath administered at a temperature from 94 to 98 F. for continuous periods is one of the most effective of sedative measures and is widely employed in mental hospitals for quieting disturbed patients.
Hot Baths. -Yu\\ tub baths at a temperature of 100
to 108
F. are
of the room in which a hot bath is given should be and 80 F. and warm towels and sheets should be in readiness. The temperature at the start should be minimum and be quickly raised after the patient has been immersed to the chin. The bath is continued for ten to twenty minutes, in which time there occurs a rise in the bloodpressure and body temperature, as well as in the frequency of the pulse
known as hot baths. The temperature

between 70
and, as a rule, profuse perspiration sets in. The mouth temperature usually rises to 101 F. in thirty minutes. Upon termination of the bath, the patient may receive an alcohol rub or a quick cold water application or
he may be rapidly dried and further perspiration is desired.
wrapped up
in
hot blankets, especially
if
The hot bath brings about an increase of metabolism and elimination. In chronic arthritis and rheumatoid conditions hot baths at a temperature from 96 to 102 F., employed from five minutes to one-half hour, two or three times a week are a most useful measure for home treatment.
Hip and Sitz Baths. These are local baths and may be employed in the form of hot, tepid or cold baths. Any tub not higher than 1 foot may be used, though for institutional use special tubs are built, supporting the patient's back and arm. There should be enough water to reach to the umbilicus of the patient when he is seated in the tub and he should be
protected from chilling
feet.
by
suitable covering, especially over the legs
and
by vigorous friction of the abdomen. A long cold sitz bath at 65 from ten to fifteen minutes causes a more prolonged contraction and is useful in combating inflammations and hemorrhage; it
The sitz bath acts on the abdominal and pelvic organs, its action dependshort cold sitz bath, at a teming on the temperature and its duration. perature of 65 F. given for a few minutes acts as a strong stimulus on the abdominal blood-vessels and intestinal muscles. It must be accompanied
F., lasting of muscles

is
contra-
SPECIAL FORMS OF BATHS
381
indicated in spasms and abdominal colic. A hot sitz bath, at a temperature from 110 to 115 F., lasting for fifteen minutes, causes after a short initial
contraction a relaxation of all parts and is, therefore, helpful in combating spastic conditions of the abdomen and pelvic organs but it is contraindicated when there is already a good deal of congestion. Contrast baths consist of alternate immersion of a part in a pail of hot water- 105 to 110 F.-for three minutes and cold water-60 to 70 F.-
one minute, repeating this cycle several times. Constant temperature maintained by frequent addition of hot or cold water. This performance causes an intense vascular reaction in the circulation and may cause quite a strain in peripheral vascular disease on account of the extreme vasoconstriction. Hence contrast baths should not be used in advanced circulatory disturbances, but may be usefully applied in sluggish circulafor
is
tion following wounds and scars, for the toughening of and their preparation for massage; also in chilblains.
amputation stumps
SPECIAL
FORMS OF BATHS
The carbon dioxide bath, also known as the Nauheim bath, consists of the application of either spring water saturated with natural carbon dioxide gas or is produced by various methods of artificial carbonization. The active principles are the temperature of the water and the stimulus exerted by the carbon dioxide bubbles of minute size. Such a bath affects the blood-vessels and the heart action causing a dilatation of the peripheral vessels, increasing pulse-pressure, the cardiac output and the bloodpressure. Carbon dioxide baths cannot be given or should not be given in a routine manner but by experienced medical men and highly skilled technical personnel.
Medicated baths containing aromatic, resinous and other substances have received attention from time to time but offer only a very limited scope of usefulness. Aromatic baths are prepared by the addition of pine needle extract, extracts of aromatic herbs; they add to the pleasantness of a warm bath, but not to its actual effect. Resinom baths containing
marked
irritating vegetable substances in suitable concentration may exert very irritation of the skin as shown by a burning sensation and sub-
sequent redness. Extravagant claims made as to supposed special benefits in rheumatic conditions have not been corroborated by any large scale
clinical experience.
The galvanic bath consists in the application of a galvanic or other forms of low-tension current through the medium of water to the body surface.
(Chapter VIII.) The Elliot Treatment Regulator.
heating
is
;
In the Elliot treatment conductive
applied to body cavities and nearby organs from a thermostatically controlled water bath an electrically driven pump circulates the
heated water through slightly distensible, gum rubber applicators. The applicators are interchangeable so that the size and shape can be varied according to the lumen of the part to be treated the vagina, rectum, nose and eye. The Elliot apparatus holds 2 quarts of water, which can be applied at a temperature beginning at 115 to a maximum of 130 and a pressure of 1 to 3 pounds. Treatment may start at fifteen minutes and gradually increase up to one hour.
:
382
HYDROTHERAPY
effects of this
other forms of local heating, and congestion, resorpnamely improvement tion of exudates. The special advantages claimed for the Elliot technique is the even and generally diffused heating and the regulable amount of heating and pressure. The clinical indications are chiefly acute, subacute and chronic inflammatory conditions in the pelvis, rectum and bladder. The possible dangers are the rare rupture of the rubber applicators and subsequent scalding; more frequent are various degrees of burns following
The
treatment are those of
all
of circulation, relief of pain
excessive heating. Contraindications to pelvic heating are profuse menstruation, uterine hemorrhage, tumors, much scar formation and severe
secondary anemia.
Hot-air and steam baths make use of extreme temHot-air Baths. and are usually administered in cabinets which enclose the entire peratures body with the exception of the head. The advent of electric light cabinets has made most of the older forms of hot-air and steam baths obsolete; on the other hand, the modern interest in fever therapy has led to the
development of several forms of highly efficient cabinets for artificial fever production as described in Chapter XIII. Local application of hot air for treatment of cavities, especially the pelvis, has been made possible through an arrangement similar to the Elliot treatment regulator; instead of hot water, hot air is kept circulating in the rubber applicator from a heating unit. (See Chapter on gynecological
conditions.)
The Paraffin Bath. The paraffin bath is a simple and efficient method of applying a fairly high degree of surface heating. It consists of immersion of the extremities into melted paraffin or the application of paraffin with a paint brush to the surface of the body. Ordinary commercial paraffin, with the addition of a little paraffin oil, melts at around 130 F. Due to the low heat conduction of paraffin, the average skin tolerates such temperature quite well. On immersion of an extremity the melted paraffin congeals around it, as body temperature is below its melting point. The semisolid paraffin wax forms a coating which transmits to the skin the heat of the melted part. Under this coating the skin sweats, and the vapor of this and the entangled air acts as an insulator and prevents burning of the skin. The result is great local flushing and sweating and a raised temperature, not only of the extremity but of the whole body, if a large enough surface is immersed. Careful temperature tests have shown the skin " " temperature in a paraffin bath after the formation of the protective glove is around 116 F. and patients feel comfortable. It renders the skin soft and pliable, thus in good condition also for subsequent massage and
exercise.
For applying the paraffin bath a simple home-made outfit consisting of a If gallon double boiler, an electric or gas stove and 8 pounds of paraffin may suffice. The lower part of the boiler is filled with hot water and the
upper part contains the paraffin.
paraffin
is
The
boiler
is
is
heated until almost
all
melted.
The heating
As
is
bath
is
ready for use.
discontinued, and the long as an unmelted piece of paraffin remains,

of the boiler
now
the temperature of the bath
safe for use.
more efficient form of paraffin bath is an electrically heated metal bath, in which the melting point of the paraffin can be set at a somewhat higher point (136 F.) by thermostat control and subsequently maintained
SPECIAL FORMS OF BATHS
383
FIG. 248.
Paraffin bath, with thermostatic control.
FIG. 249.
Portion of douche room showing control table and combination douche (background) where patient stands during treatment.
384
HYDROTHERAPY
at an operating temperature of about 10 lower. Slats of bakelite or wood fastened to the bottom of the metal tank, safeguard against the touching
metal by the immersed part of the patient's extremity. The use of a suitable thermometer is an additional safeguard. In applying a paraffin bath, the part to be treated is first washed and dried. The patient is instructed to dip in the hand or foot quickly and lift it out so that only a thin coat of paraffin congeals on the skin. Repeating this procedure from six to twelve times gradually a paraffin glove of sufof the heated
ficient thickness is
immersed
is
lifted
formed and the extremity then can be kept safely After ten minutes to one-half hour, the extremity out, the glove is taken off by gentle traction and the part is ready
in the bath.
for further procedure.
In treating body surfaces not suitable for immersion, a warmed paint brush is dipped in the bath and with quick strokes several coats of liquid
The congealed coating is kept on up to one-half peeled off glove or coating is in either case placed back in the bath, where it melts and is thus used over again. Bacteriological tests have shown that, after a while, the paraffin in the tank becomes sterile again and with ordinary cleansing precautions, these tanks are quite
paraffin are applied.
hour.
The
sanitary; they can be also fully sterilized with thermostat ic control. The paraffin bath is useful in the after-treatment of traumatic condifractures, sprains, contusions, lacerations effective in chronic arthritis of the hands.
tions involving the extremities, such as swelling and stiffness following and infections. It is also quite
In disturbed skin sensation following nerve injuries and in recent thin scars, the bath can be applied only with great care. It should not be used at all in case of skin infections and
open wounds.
HYDROKINETIC MEASURES
In the employment of hydrokinetic measures combined use is made of the temperature and pressure of water or its lifting power. Among these
measures belong douches and showers, the whirlpool bath, therapeutic pools and tanks and colonic irrigation. Douches and Showers. Showers consist of streams of water projected under pressure in a fixed direction, while with douches the direction of the stream can be moved over any part of the body. Alternately hot and cold douche application is also known as a Scotch douche. For the administration of all forms of douches at various pressures and temperatures a
hydrotherapeutic control table serves, which is part of the more elaborate institutional equipment. The Whirlpool Bath. The whirlpool bath is a hydrokinetic measure, in which water at a temperature between 110 and 115 F. is kept in constant agitation in a vessel which holds an arm or a leg. As a result of the combined action of heat and the gentle mechanical and softening effect of the whirling water, the immersed extremity shows a marked response. After fifteen to forty-five minutes of such "hydromassage"the skin becomes pink and feels warm, inflammatory induration is softened, pain and spasm relieved, the repair of wounds stimulated, the removal of necrosed tissue and pus is speeded up. There are several types of apparatus. A simple home outfit can be made from a washboiler with suitable hot water and air inlet and water
HYDROKINETIC MEASURES
385
Another portable type ejector working under ordinary water pressure. consists of an electric washing machine, capable of ejecting 300 cubic feet
of water a minute, attached to a tank on wheels; the tank can be raised or lowered for either arm or leg treatments. The most efficient types are
stationary baths connected with a mixing chamber, a thermostatic valve and a pressure gauge; by these means the temperature and pressure of the water can be accurately regulated and maintained during treatment. Mixing the inflowing water with air, by means of a so-called aerator, a large
number
of air bubbles
add
to the mechanical stimulation.
FIG. 250.
Portable hydromassage apparatus.
(Courtesy of
Ille
Electric Corporation.)
The whirlpool bath is a most valuable treatment measure in a large number of traumatic and chronic inflammatory conditions. It is excellent
for early treatment of stiffness, pain and sluggish skin circulation following fractures and constitutes the best treatment which can be given as soon
as a fractured limb can be taken out from its immobilization.
In painful
scars, adhesions, peripheral nerve injuries and some forms of neuritis, joint stiffness and suitable cases of arthritis, tenosynovitis, indolent and
chronic suppurating wounds, painful stumps,

also
weak and
painful feet
it is
employed with benefit.
In administering the whirlpool bath the part must be gently placed temperature should be slightly lower at first and then gradThe arm or leg should be well supported. In case of nerve with impaired sensation, care must be exercised to prevent scalding. injuries The bath also serves as an excellent preparation for subsequent massage or electrical treatment by making the extremity more supple and less
in water; the ually raised.
sensitive.
Therapeutic Pools and Tanks.
Underwater
exercises (hydrogymnastics)
for infantile paralysis have aroused country wide interest in recent years and their scope has gradually extended to include many other conditions.
Therapeutic pool treatment takes advantage of two facts: (1) the buoyancy of the water reduces the weight of the body and largely eliminates gravity; thus muscles too weak to perform outside of water can be actively exer25
386
HYDROTHERAPY
general effect;
muscles and improves cised; (2) the heat of the water relaxes spastic fresh air and sunshine add to the beneficial circulation. In outdoor pools in salt water pools, there is specific effect on wound healing
and added buoyancy.
FIG. 251.
Large Hubbard tank.
(Currence.)
FIG. 252.
Hydromassage tank with turbine

for
ejectors, also
showing overhead body stretcher

Electric Corporation.)
conveying patient into tank.
(Courtesy of
Ille
Much money has been wasted on the building of elaborate, large pools requiring an expensive upkeep. Only in large, specialized orthopedic institutions is there justification for such outlay. Large and small tanks of the "Hubbard" type enable full extension of
all
extremities in a T-shaped vessel.
in institutions
and
also in
homes.
It
is
of all sizes can be treated.
They serve for individual treatment In the original Hubbard tank children inexpensive being made of galvanized iron.
REFERENCE
For home treatment,
in
387
emergency, even a large bath-tub can be employed.

is
A larger tank
The
technician.
(Fig. 252) serves for the treatment of adults. principal factor in administering underwater exercises
is
the skilled
Special training required to become fully familiar with the action of all muscles and the means of exercising the muscles lacking
For function, according to the directions of the attending physician. further details of treatment technique see Chapter on exercise. Underwater exercises are now employed not only in the after-treatment
of infantile and spastic paralysis, but also in many traumatic and orthopedic conditions and in suitable cases of chronic arthritis, especially of the
osteo-arthritic type.
Colonic irrigation forms part of the routine work most hospital physical therapy departments and of physical therapy specialists' offices, because of the special facilities and skill needed for its administration. The principle of measured suction and pressure embodied in modern colonic treatment apparatus has made these particularly efficient and safe. The indications for colonic irrigation are: impactions and threatened obstructions of the large bowel chronic or acute toxemia, from
Colon! c Irrigation.
of
;
absorption of putrefactive products; preparation for surgery to prevent postoperative gas pains, from decomposition of retained material preparation for fever therapy, where absorption of toxins from retained feces adds to the hazard; postoperative clearing on the fourth or fifth day after
;
surgery, to
remove hardened
feces
and gas; amcebiasis, trichomonas and

all
other parasitic infections; diagnostic aid in
disturbances of the
ali-
mentary
tract.
REFERENCE
Fox, R. F., and BREEMEN, .!.: Chronic Rheumatism, Causation and Treatment, London, J. and A. Churchill Ltd., 1934, p. 253.
CHAPTER XXI
HYPOTHERMY
Injuries.
Therapeutic Considerations.
Chilblains.
Methods of Hypothermy. Physical and Physiological Effects. Local Hypothermy. General Hypothermy. Cold Immersion Foot. Frostbite.
tion
is
General Considerations. The term cold denotes subjectively the sensawhich is brought about by contact with a substance whose temperature lower than the normal; objectively a condition of material bodies which
a warm body is brought into contact cooled while the latter is warmed. Thus the exchange of heat between two bodies which are at a different temperature results in a gain of heat to the colder body and a net loss of heat from the hotter body until they finally arrive at the same temperature. During the progressive development of modern physics it was a debated question whether cold in the objective sense was to be regarded as a positive quality or merely the absence of heat. The general acceptance of the dynamical theory settled this question, for under its meaning cold is to be regarded
gives rise to that sensation. with a cold body the former
is
When
as a negative condition, depending on decrease in the ularvibration that constitutes heat.
amount
of the molec-
The elementary observations on the therapeutic effect of different degrees

of thermal application can be traced to Hippocrates, the master medical mind of ancient Greece, who in 450 B.C. recorded the first reliable observa-
tions on the effect of hot and cold water upon the body. He stated: (1) that cold water warms, (2) whilst warm water cools the body, (3) that warm shower baths induce sleep, (4) that cold water stimulates, and (5) he recommended cold water to assuage fever and pain. Cooling or chilling by cold water applications at various temperatures in order to produce general or local stimulation, or mild sedation, has for a hong time formed the mainstay of modern hydrotherapy. These procedures, as described in the preceding pages, are generally of short duration and as a rule are accompanied by changes of skin temperatures only. In recent years extensive clinical and laboratory work has been carried on with applications of cold for prolonged periods with the object of lowering temperature and metabolism in deeper parts or the entire body, also to bring about destruction of tissue or local anesthesia in certain cases. Dermatologists were first to use liquid carbon dioxide and carbon dioxide snow to destroy superficial growths by freezing. This method was named cryo therapy, or chrymotherapy (Kryos: cold). Fay and Smith 23 were the first in the United States to report on clinical research on the effects of local and general "refrigeration" upon malignancies, while Allen and Grossman 1 first demonstrated the value of the refrigeration method for amputations. Much additional clinical work was done lately with use of sustained cold applications in peripheral vascular disease and
in military
and
The term
at 32 F. (0
refrigeration
industrial surgery. is apt to cause misunderstanding. Water freezes C.), blood and tissues at a slightly lower degree. With the
(388)
METHODS OF HYPOTHERMY
original
389
methods of refrigeration, surrounding the body or a limb with icewater and cracked ice results in lowering the temperature to 0.5 to 5 above freezing, hence refrigeration brings about chilling but not freezing of the tissues. With the latest mechanical devices for cold treatment the degrees of lowering the temperature can be exactly regulated, hence the general term of hypothermy or hypothermia appears more appropriate and by general consensus is being used to denote the sustained application of cold for lowering body temperature. This is in keeping with the accepted use of the term hyperthermy for raising body temperature for therapeutic purposes. Most of the techniques of hypothermy make use of water or ice and hence the presentation of this subject as part of the section on hydrotherapy seems appropriate.
FIG. 253. Wooden refrigeration box with galvanized tin lining; outlet tubes for drainage at distal end; tourniquet around limb to be amputated is not depicted; box is to be filled with small pieces of ice and lid is fastened in place. (Dr. J. D. Gordon.)
Methods of Hypothermy. The ice-bag is a time-honored device for the application of cold to a small flat area, such as the trunk or the abdomen it is difficult to adjust and to hold over a rounded surface as the head or
;
390
HYPOTHERMY
the neck. In multiple numbers thin ice-bags can be used over larger areas for general body cooling but they must be kept constantly refilled to maintain a fairly even degree of cold. Ice-water is quite simple and effective for chilling the distal parts of an
extremity. the cold application Finely cracked ice offers the advantage of moulding to the part and is quite easy to apply. It needs to be constantly replaced as it melts and the water from the melting must be led away so as to keep the patient fairly dry. A simple ice filled refrigeration box for amputation
has been described by Gordon. 11 (Fig. 253.) Mechanical apparatus for hypothermy is more complicated and more expensive but when efficient it enables the maintenance of temperature at any desired level and enables local as well as general body treatment.
FIG. 254. General hypothermy to patient in hospital bed, using underpad and overblanket connected to refrigeration apparatus. Also note hood for head treatment. (Courtesy of Therm-O-Rite Products Co.)
An apparatus constructed by Brenner is a cabinet unit containing a brine tank, electric pump, pressure and temperature control; the refrigerating device cools a fluid (35 per cent alcohol) and pumps it through suitable
20
It can produce thermostatically controlled temperatures from tubing. to 130 F. without the use of ice. When used for general hypothermy,
the patient is entirely enclosed within an underpad and over-blanket which, when zipped up the sides and around the shoulders, resembles a sleeping bag. It can be used in the regular hospital room and does not require the 50 F. room temperature necessary when ice is applied directly to the body. (Fig. 254.) Single extremities can be cooled by envelopment in flexible applicators, made of waterproof material and containing rubber tubing channels through which the cooling fluid circulates rapidly. For treatment of local areas or cavities metal applicators serve as illustrated in Figure 256. They
made of copper and chromium or silver plated. There is also available a hood for head treatment which entirely encloses the head with the exception of the face.
are
body treatment has also been by Bigelow and Lanyon. 5 For treatment of an extremity, Eve 9 has suggested the use of cold air by a simple gravity method. His device consists of a metal cylinder containing ice and salt, enclosed in a second cylinder; heavy cold air is formed in the space between the cylinders and
described
similar type of apparatus for general
METHODS OF HYPOTHERMY
391
flows through a hose to a cradle containing the limb and well insulated by blankets. Green 12 described an apparatus for extremity treatment making use of carbon dioxide. It consists of a cabinet with an upper and lower compartment. In the upper is a metal tray in which solid carbon dioxide
FIG. 255.
Lew
lypothermy to upper arm surrounded by waterproof applicator with rubber tubing. (Courtesy of Th3rm-O-Rite Products Co.)
is
placed.
The lower compartment opens in two sections and has two padded
apertures for the hands or feet. It contains a thermometer which registers on a dial at the back of the cabinet. Air circulates through two flues between the compartments. These flues are controlled by knobs at the back, by manipulation of which the desired temperature can be maintained. The patient's feet or hands padded with cotton wool or bandages,
FIG. 256.
Metal applicators
for cavity
treatment with hypothermy.
are placed in the lower cabinet, then two blocks of solid carbon dioxide refrigerant are placed in the upper tray. The air flues are opened until the desired temperature is reached. The cabinet uses 8 to 10 pounds of
refrigerant in twenty-four hours.
392
HYPOTHERMY
13
Various arrangements have been described in recent years for strictly

Hall uses a regular refrigeration apparatus local applications of cold. for quick freezing with applicators especially designed for gynecological
it is equipped with a defrosting device which simplifies the with15 drawal of the applicators from frozen tissue. Koskoff et a/. have described a method for freezing areas of the brain with liquid nitrogen as an adjunct in brain surgery for removal of vascular tumors and for obtaining biopsy 20 specimens. Poppe reported the use of a cold air blast from a current of air blown through a coil of metal tubing packed in carbon compressed dioxide ice, for treatment of precancerous skin lesions and hemangiomas. There are many modifications available for applying solidified carbon
therapy;
dioxide for skin conditions.
Physical and Physiological Effects. The primary physical effect of prolonged cold applied locally to the tissues (local hypothermy) is a drop in temperature of the tissues exposed. This cooling effect is quite penetrating; it has been shown that with ice-bags applied to the abdominal wall a temperature drop of 7.5 to 15.6 F. is effected in thirty minutes in the intraperitoneal areas below, and that with ice-bags applied to the calf of the leg for one and a half to two hours, a drop of 15 to 26 F. is caused in the muscle 2 inches beneath the surface. Cold water circulated through the rectum for a prolonged period through a hollow metal applicator resulted in a fall of the urethral temperature as much as 23.8 F.; and with a similar arrangement in the vagina the urethral temperature dropped 8 F. in fifty minutes. Cold applied to the outer side of the cheek by a similar technique resulted in an average drop of 9.5 F. on the inner surface of the cheek in 30 minutes (Bierman and Friedlander. 4) The physiological effects of lowered tissue temperatures are predominantly vasomotor: the vessels of the skin contract, blood flow is reduced and heat loss from the skin is diminished. The vasomotor constriction 18 comprises three phases (Lewis ): a direct and persistent response of the superficial vessels by local contraction a transient general vasoconstriction due to reflex action and finally a persistent general vasoconstriction due to cooling of the circulating blood by the returning cold venous blood. The subsequent physiological effects of the local cold reaction are the reduction of the local blood volume, of cellular metabolism and oxygen needs of the tissue cells in muscles, also an anesthesia of the parts affected. After a prolonged exposure of a body area to cold the temperature may penetrate sufficiently to modify the activity of muscles causing them to be capable of slow movements only. Pathological and destructive effects by cold are governed by the factors of duration and degree, although cold does not destroy tissue chemically in such a rapid and obvious manner as heat. The injurious effects of cold cause an inhibition or suspension of vital activities and this process may or may not be reversible. Immersion of a finger in ice-cold water for ten minutes produces severe pain and subsequent tenderness which may last for hours, but finally subsides totally. Cooling of the arm with an ice cube produces local redness which is the result of the release of a vasodilator substance in the skin as result of cellular damage. The first pathological effect of prolonged cooling is a definite swelling of the cooled part. As an example of edema Lewis states that hands immersed in water at 41 F. undergo in three hours a 15 per cent increase of volume.
;
THERAPEUTIC CONSIDERATIONS
The temperature
upon the
of 43
393
F.
is critical
tissues according to Lake. 16
in relationship to the effects of cold Sustained cold below this point
produces actual damage and frostbite; above this point it causes vasomotor paralysis with its secondary effects. General hypothermy or prolonged cold application to the entire body also produces a reduction in the chemical and physical processes or metabolism: the heart rate becomes slowed, staying over 50 beats per minute; the circulation of the blood is prolonged the blood-pressure and peripheral pulse may disappear entirely for hours at a time and the peripheral veins collapse entirely; the respiratory rate drops to 12 to 14 per minute. No
;
impairment of renal function is apparent. If fluids are given, they are excreted with very little loss through respiration or the skin. Urinalysis has been regularly negative. Postmortem examination has not revealed any acute or other changes possibly attributable to refrigeration. Lowering of body temperature to 88 F. and less has been successfully maintained
for several days. Simpson and Herring 21 and Troedsson 26 have shown that in the cat, rabbit and even monkey a condition simulating hibernation
can be induced by narcosis and a body temperature of 56 to 60 F. attained and maintained for hours. In applying general hypothermy to humans, narcosis must be administered usually by the intravenous method while the body temperature is being lowered. As the temperature passes between 93 and 92 F., a period of reflex shivering occurs on the lowering of temperature, and occurs also later when it is being allowed to rise again. The patient's mind usually remains a complete blank from the onset of the induction period. Therapeutic Considerations. The practical value of hypothermy has been demonstrated in four fields according to Fay: 10 (1) as a local analgesic and anesthetic, (2) as a bacteriostatic agent in combating infection, (3)
as a sedative and alterative in certain psychopathic states, (4) as an agent of retardation of cell growth in certain malignant tumors.
Local Hypothermy. The numbing effect of cold is generally well known. use of an ice-bag and cold packs over the abdomen and the chest as an aid for painful visceral and thoracic conditions has been empirically established for a long time. The rationale of this procedure has been 10 pointed out by Fay on an anatomical and physiological basis. In localized and referred visceral pain cold produces reflex vasoconstriction and relieves congestion and stretch on vascular pain fibres, but to be effective on such pain it must be applied over the entire distribution of the involved spinal segment and root and the physician must be familiar with the normal skin pattern. Severe headache connected with real pain or tenderness about the head may be relieved by the use of cold in a head applicator constructed like a helmet. Fay states that in minor trigeminal neuralgia, consisting of painful involvement of the branches of the fifth nerve with demonstrable impairment of sensation the use of cold is beneficial, while cases of true "tic douloureux" or major trigeminal neuralgia are made worse by it. Local hypothermy has been successfully employed as a preoperative anesthetic in gangrenous extremities. With the extremity placed in ice or ice-water in a simple container, complete anesthesia can be produced in the entire extremity within a few hours; after the operation, the further application of ice-bags to the stump not only controls the after-pain but
The
394
HYPOTHERMY
edema, promotion of drainage, inhibition of
also results in the control of
The rationale and technique of this pro1 cedure has been developed by Allen and Grossman and its effectiveness has been corroborated by a number of surgeons. Allen and Grossman state that refrigeration anesthesia has reduced all complications, except pneumonia, frequent in such operations. Wound healing is improved, and the number of patients requiring reamputation is greatly reduced. They have practically banished electric cradles and other appliances for nonPresent operative treatment of diabetic or arteriosclerotic gangrene. of temperature adjustment in these cases is inadequate, howknowledge ever. There is no guide or standard except the patient's comfort; any temperature that causes severe or persistent pain is wrong.
infection
and avoidance
of shock.
Because of these effects and its ability to control hemorrhage, infection, pain and progressive shock, hypothermic anesthesia has also been recom-
mended
in
compound
fractures, severe burns,
and crushing
injuries of
soft tissues.
In peripheral vascular disease local hypothermy is being advocated on the ground that in advanced cases heat may be contraindicated, as the metabolic requirements of the tissues are not met by the diminished blood flow. On the other hand, reduction of the temperature reduces cellular metabolism, makes the blood supply adequate and prevents gangrene. It has been shown that limbs can survive prolonged local cooling without
danger in acute circulatory accidents with thrombosis and embolism and there is less danger of tissue necrosis and gangrene. For these reasons in peripheral vascular disease, as well as in "immersion feet" and frostbite, the systematic use of cold has been employed with marked relief of pain, subsidence of edema and a minimal amount of subsequent tisssue damage. Large scale clinical experience in all phases of trauma associated with
war and
industrial accidents will
undoubtedly further
clarify the indica-
tions for the
employment
of cold treatments.
General hypothermy was originally introduced for treatment of advanced cancer cases, but no specific results were obtained except a marked diminution of hitherto uncontrollable pain. At present good results are claimed
mental condition of young schizophrenic than three years. In extensive burns general treatment in air-cooled rooms has been advocated in addition to local treatment by ice-bags on the ground that general vasoconstriction and decrease of body temperature serves to conserve the body energy and also promotes local recovery.
for^ general
hypothermy
in the
less
patients
who have been
ill
indications and techniques of hypothermy are at present still in a of evolution and some of the experimental findings still await the stage test of extensive clinical corroboration.
The
COLD INJURIES
Cold injuries have received much study in recent years all over the world; their great prevalence has been due to the global warfare carried on in trenches, on the high seas, in the cold of air and in arctic regions. The mechanism of injuries due to cold is still a disputed and unsettled subject, partly because of actual differences in the causes and results. The effects of different degrees and durations of cold, of wet and dry cold,
COLD INJURIES
and
of moisture with or without cold, besides complications
395
by
circulatory stasis elucidation.

Clinically
and other
factors, will require
much study
pressure, for clear
from the
tissue necrosis does not result immediately but appears as a secondary complication. While necrosis may result from immediate action of cold, in practice this is seldom observed at ground temperature. Due to poor heat conductivity
effect of cold
and pathologically,
of
human
tissues, the effect of cold is in direct
proportion to length of
Time, therefore, plays a decisive role in chilling; brief action of cold, as employed in local anesthesia, is tolerated without ill effect. The course of necrosis is determined primarily by interference with or
exposure.
eventual complete stoppage in blood circulation. Freezing has some points in common with burns, in that each can produce both local necrosis and systemic shock; but in general the injuries from cold have more tendency to chronicity, prolonged subnormal tissue vitality, persistent nerve disturbances (pain, hyperesthesia, or partial or complete anesthesia), and subacute or chronic vasomotor or circulatory abnormalities, with white, cyanotic, mottled or red colors at different
stages.
Until a classification based on extensive modern research is adopted, best to follow the heretofore generally accepted scheme of classification: (1) lesions without destruction of tissue, circumscribed cold-induced
it is
lesions of the skin, as first-degree frostbite, erythema and chilblain; (2) lesions with destruction of tissue, consisting of (a) second-degree frostbite,
blister formation and superficial ulceration, and (6) thirdfrostbite, i. e., frost gangrene; (3) generalized conditions with degree involvement of the skin, i. e., cold-induced diseases, death from freezing
erythema with
(Bering
).
special types of cold injuries, caused by exposure to cold insufficient to cause frostbite. They occur chiefly in survivors of shipwrecks and resemble the trench foot of World
Immersion foot and immersion hand are
War I.
Physical treatment methods play an important role in all schemes of treatment but in accordance with a gradual change in the conception of the pathology of cold injuries, the opinion as to the best method of treatment, especially as to the role of temperature, has been considerably
changed
in recent years.
Chilblains, a first degree frost injury, caused by repeated exposure to mild degrees of cold, consist of an inflammatory reaction in the affected parts toes, feet or fingers, which assume a violet-red color and are swollen and numb. In early cases there may be only constant burning and itching. Diathermy followed by vigorous application of the Oudin current is useful in this condition. For the treatment of the toes and foot it is usually best to follow the air-spaced technique and employ luminous heat in addition during a treatment period of at least one-half hour. It is better to keep the amount of current at a strength causing just comfortable warmth. Short-wave diathermy by the coil method offers an A stimulating dose of Oudin application should alternate procedure. follow both for ten minutes. Daily treatment is usually followed by prompt improvement within a few days. The use of passive hyperemia for chilblains was recommended by
C hilblains.
396
14
HYPOTHERMY
A constricting rubber bandage is applied at the level of Herxheimer. the middle of the humerus or femur, just tightly enough to insure mild venous congestion in the distal part of the limb; this may be left in position for twenty-two out of twenty-four hours. The bandage usually was used only at night and proved sufficient in most cases. In 90 per cent of the cases complete success was achieved in five to seven days; swelling, pains and itching had disappeared, and small ulcers and cracks of the skin had The only remaining sign was redness of the skin, sometimes healed. associated with thickening and wrinkling of the epidermis. The good result
fact that passive hyperemia forces blood through all blood spaces in the limb, including the capillary spaces dilated potential (and paralyzed) by cold, thus reopening the circulation through them. This explanation is supported by the fact that passive congestion slightly raises the temperature of a limb, indicating good circulation. If, however, the bandage is applied too firmly and the outflow restricted too much, the limb becomes cold and congestion has no curative effect. Other measures recommended for chilblains are contrast baths (five minutes in water of 28 to 30 C. one minute in water of room temperature; then one minute in cold water). Stroking and kneading massage in connection with the baths, hot air or diathermy is also useful. Galvanic baths have also been recommended. Immersion Foot. According to Ungley 27 duration of exposure and temperature of water are the most important factors influencing occurrence and severity of immersion foot. During exposure the affected extremities swell and become numb. For some hours after rescue they remain cold; they are pale, blue or mottled and show variable areas of anesthesia. Pulsation is absent from the peripheral arteries permanently in cases that terminate in extensive gangrene. This prehyperemic stage is followed by a stage of hyperemia, in which the affected parts become hot, red, painful,
was explained by the
more swollen and perhaps
blistered; in
more severe
cases patches of gan-
grene, usually superficial, may appear; damage to nerves declares itself in anesthesia and in motor, vasomotor and sudomotor paralyses. This, in
turn, is succeeded by a posthyperemic stage, in which inflammation has subsided, vascular tone has recovered and skin temperature has fallen, but the vessels may be hypersensitive to cold. Late sequels include recur-
rence of pain, tingling, swelling or blisters; persistence of a cold-sensitive state or of hyperhidrosis, and occasionally circulatory deficiency suggestive of vascular occlusion. With minimal injury patients have no interference with nerve function, and with mild injury they display reversible nerve
damage.
tive)
With moderately severe injury there are irreversible (degeneranerve lesions, and with very severe injury, irreversible nerve lesions, usually with gangrene.
The
cool
essential principle of
treatment
is
to keep the affected extremities
and the body warm. The rescued man must be carried, not allowed to walk on damaged feet. Stripped of wet clothing, his body is wrapped in
given hot drinks, but not bottles must not be In the hyperemic stage, dry applied and massage is contraindicated. cooling of the limbs has been accomplished with dry ice-bags, with a current of air from a fan into which cold water is sprayed from a nebulizer or by exposure to room temperature in a cold ward. Webster28 has achieved good
is
blankets, with the affected limbs exposed. left near a fire or in an overheated room.
He
Hot water
COLD INJURIES
results
397
used intermittently and exposure to For patients who require long, uninterrupted cooling and who are not intolerant to restriction of leg movements, the mechanical refrigerator might prove useful. Patients with immersion foot must rest in bed until all swelling has gone and they are able to walk without pain; in severe cases this may be many
electric fan
merely with an
room temperature
at other times.
cause excoriation, blistering or increased pillows, exposed to air and kept dry. state that in the early stage of inflammation pain is due to anoxia of the injured superficial tissues and nerve endings. This can be controlled by cooling the legs, lowering cellular metabolism and making the reduced demand for oxygen commensurate with the limited
weeks.
Early walking
may
swelling.
The feet are White and Warren 29
raised
on
supply which can be supplied by thrombosed superficial blood-vessels. After inflammation has subsided, aching pain and rigidity of the toes may cause prolonged incapacity in persons with severe injury from immersion foot. Microscopic examination of skin, subcutaneous tissue and muscle (extensor digitorum brevis) show that there is increase superficial in interstitial connective tissue and collagen, involving blood-vessels, muscle fibers and nerves. The last are embedded in fibrous tissue and show endoneural fibrosis also. This pain tends to clear after six to eight months, the period at which collagen surrounding the nerves ceases to contract. Although there is no effective treatment once fibrosis has developed, much can be accomplished in prevention. Efficient cooling of the injured extremities throughout the early period of recovery and inflammation should do much to prevent fibrosis and prolonged incapacity from pain
and
is
rigidity of feet.
may be superimposed on immersion foot. In trench foot there opportunity for combination of the two lesions; a succession of rain, mud and slush would give prolonged chilling sufficient for development of immersion foot and by washing away of skin oils would, with advent of
Frostbite
predispose the tissues to frostbite. As stated previously at the outset the extent of frostbite cannot be determined and it is impossible to tell whether the lesion will be limited to second degree or go on to necrosis. In mild cases, in which the skin is pale and cold with decreased touch and pain sensation, the
frost,
Frostbite.
patients have a subjective feeling of stiffness, but objectively the tissue is of good consistency. The next stage consists of reactive hyperemia and subjective burning pain. The cases next in severity are those associated with injury to the vessel walls and more severe regression. Lesions in different individuals vary considerably in more severe degrees of frostbite.
In some there is true vascular spasm, in others a pure endarteritis, and in some these two factors are mixed. In more severe cases, with absolute anemia, there is no bleeding from a small incision. The tissues are hard and white. Early treatment must be distinguished from management of late lesions,
particularly necrosis.
The first consideration is that frostbite produces circulatory stasis, and counteraction of stagnation in peripheral vessels is the prime aim of immediate treatment. There has been extended con-
troversy as to whether rubbing the affected part with snow is right or 1 wrong. Allen states that the folk medicine of cold countries generally favors slow warming of the frozen part: i. e., rubbing it with snow, keeping
398
it
HYPOTHERMY
some time
in a cool
atmosphere and especially avoidance of strong chloride spray recommended some years ago must be ethyl heating. ranked as equivalent to the popular rubbing with snow. Many physicians recommend gentle kneading of the frostbitten extremity, massaging toward the heart after which the extremity should be carefully wrapped in a clean
for
The
towel.
Present day medical opinion agrees that a slow rate of thawing should be maintained in frostbite to minimize the metabolic demands of the tissue. This may be accomplished by local hypothermy to the extremity with heat to the remainder of the body. This would aid in counteracting 6 shock and produce a reflex vasodilatation in the affected limb. Bigelow
Canadian Army pamphlet suggests immersing the unaffected limb or limbs in hot water to accomplish this. Refrigeration may be con18 tinued for one to several days, depending on severity of the lesion. Lewis of suggests that controlled thawing may be accompanied by application cold water at 10 to 15 C., and elevation of the extremities to aid venous return. Sterile dressings should be kept on the limbs and pressure points
states that the
carefully protected.
based on extensive wartime experience recommends that except treatment should not be undertaken until the In extremely mild cases, in line of demarcation shows signs of forming. which tissue loss need not be feared, Buerger's exercises appear to yield fairly satisfactory results; for very slight cases, contrast baths also are recommended. Patients should be kept in bed and the frostbitten parts protected carefully from contact with bed clothes with cages. Warm air in the cages was found to be painful and harmful, but a free circulation of cool air was always assured. When once the line of demarcation had formed ultimate healing was facilitated by the use of a short wave diathermy. Although heat applied to the parts in other ways greatly increased pain, heating of the tissues by short-wave therapy was comforting. These observations were confirmed by Cignolini 8 and Borini and Matli 7 who report satisfactory results in second and even third-degree lesions with short-wave diathermy applied with air-spaced electrodes, daily treatment from twelve to twenty minutes with an intensity so small that the patient has no sensation of heat for the first six or eight minutes and feels only a slight warmth between the eighth and tenth minutes. Treatments must be systematically administered for weeks, with sterile vaseline dressing applied in the meanwhile. Even in patients admitted with dry gangrene only the mummified part was lost with this procedure. In the United States Theis25 and others have seen good results with passive vascular exercise with additional reflex heat. Theis also emphasizes that amputation of gangrenous parts should be delayed until definite demarcation has taken place and the circulation has been sufficiently restored in the surviving tissue.
Moser,
19
in the mildest cases, active
REFERENCES
1.
2. 3. 4.
ALLEN, FREDERICK M.: Theoretical and Experimental Aspects of Surgical Refrigeration, Canad. Med. Assn. Jour., 51, 220-226, 1944. BARBER, H. W.: Treatment of Chilblains, Lancet, December 4, 1926. BERING, FR.: Frost Injuries, Miinchen. med. Wchnschr., 88, 123-125, 1941. BIERMAN, W., and FRIEDLANDER, M.: Penetrative Effect of Cold, Arch. Phys.
Ther., 21, 585-592, 1940.
REFERENCES
5.
399
BIGELOW, W.
6.
Some Uses for Dry Cold Therapy and G., and LANYON, E. C. G.: Proposed Cooling Cabinet, Brit. Med. Jour., 1, 215-217, 1944. Modern Concept and Treatment of Frost-bite, Canad. Med. Assn. Jour.,
7.
8.
47, 529-534, 1942. BORINI, L., and MATLI, G.: Marconitherapy of Frostbite Occurring During the Italo-French Campaign of 1940, Minerva Med., 31, 586-588, 1940. CIGNOLINI, P.: Short Wave Therapy in Hypothermic Shock and in Congelation,
9.
Quaderni di radiol., 2, 67-86, 1937. EVE, FRANK C.: Treatment by Cold Air:
662, 1944.
Gravity Method, Brit. Med. Jour.,
1,
10.
FAY, TEMPLE:
Refrigeration Therapy, in Medical Physics, Chicago,
The Year
11.
Book Publishers, Inc., pp. 1224-1226, 1944. GORDON, J. D.: Refrigeration Box for Amputations, Am.
1942.
Jour. Surg., 63, 453-455,

to Cold, Lancet, 2, 695
12.
GREEN, RAYMOND:
Cold in Treatment of
Damage Due
697, 1942. 13. HALL, E. F.:
Use of Quick Freezing Methods in Gynecologic Practice, Am. Jour. Obst. and Gynec., 43, 105-111, 1942. 14. HERXHEIMER, H.: Passive Hyperemia for Chilblains, Lancet, 2, 640-641, 1942. 15. KOSKOFF, Y. D., MARKSON, V., and WALL, N. M.: A Method for Removal of Areas of Brain Following Freezing In Situ, Am. Jour. Surg., 50, 271-273, 1940. 16. LAKE, N. C.: An Investigation Into the Effect of Cold Upon the Body, Lancet,
2, 557,
1917.
17. 18.
19.
20. 21.
22.
23.
24.
25. 26.
LORTAT, JACOB L., and SOLENTE, G.: La Cryotherapy, Paris, Masson et Cie, 1930. Observations on Some Normal and Injurious Effects of Cold on the LEWIS, T. Skin and Underlying Tissues, Brit. Med. Jour., 2, 795, 837, 869, 1941. MOSER, H.: Frost-bite, Deutsch. med. Wchnschr., 68, 549-555, 1942. POPPE, J. K.: Use of Cold Air Blast in Precancerous Skin Lesions and Hemangiomas, Surgery, 11, 460-465, 1942. SIMPSON, S., and HERRING, P. T.: The Effect of Cold Narcosis on Reflex Action in Warm Blooded Animals, Jour. Phys., 32, 305-311, 1905. SMITH, L. W.: Use of Cold in Medicine, Ann. Int. Med., 17, 618, 1942. SMITH, L. W., and FAY, TEMPLE: Temperature Factors in Cancer and Embryonical Cell Growth, Jour. Am. Med. Assn., 113, 653-660, 1939. TALBOTT, J. H., and TILOTSON, K. J.: Effect of Cold on Mental Diseases: Study of 10 Patients Suffering From Schizophrenia and Treated With Hypothermia, Dis. Nerv. System, 2, 116, 1940. THEIS, F. V.: Frostbite of Extremities, Arch. Phys. Ther., 21, 663-670, 1940. TROEDSSON, B. S.: Experimental Lowering of Body Temperature of Rabbits and
:
Its Possible Application to 27.

28.
Man, Arch. Phys.
Ther., 20, 501-504, 1939.
29.
Immersion Foot and Immersion Hand (Peripheral Vasoneuropathy After Chilling), Bull. War Med., 4, 61-65, 1943. WEBSTER, D. R., WOOLHOUSE, F. M., and JOHNSTON, J.: Immersion Foot, Jour. Bone and Joint Surg., 24, 785, 1942. WHITE, J. C., and WARREN, S.: Causes of Pain in Feet After Prolonged Exposure in Cold Water, War Med., 5, 6-13, 1944.
UNGLEY, C. C.
CHAPTER XXII
MASSAGE
Effects of
of Massage.
Massage Movements. Physiological Effects of .Massage. Massage on Pathological Conditions. General Technique of Massage. Uses
Massage
is
one of the most simple and most
In its application, the mechanical useful forms of physical treatment. effect of the technician's hands is transmitted to the patient. The physical elements constituting the different movements of massage are: (1) Contact
between the skin of the technician and the skin of the patient; and (2) pressure, the application of a varying amount of mechanical energy to the touching surfaces. The quantitative measurement of the mechanical energy employed is not possible; the individual equation of the technician
the sense of touch of his hands and his alertness in adapting massage
movements to the condition treated play the principle role. "Rubbing" by a husky bath attendant has no relation to scientific massage and the effectiveness of the treatment depends by no means on the amount of
employment of massage is a fair knowledge anatomy and physiology, and understanding of the pathology of the most common conditions of disease and injury for which massage is used and thorough training in theory and practice of massage, itself. The real leaders and pathfinders in massage were physicians of broad training and experience. More and more physicians have turned to applying massage
themselves, especially abroad. In the United States massage is mainly administered by nurses or by specially trained massage technicians. Physicians prescribing massage are expected to give a definite prescription for the type and amount of massage to be given; they should also keep a check-up on the patient's condition and modify their order if indicated.
physical effort expended. The basis of the intelligent
of
Massage Movements. Massage is an art which cannot be taught except by manual demonstration. Students of massage should gain experience by taking massage treatment themselves and by practicing massage under competent guidance. Three main varieties of movements are employed, singly or in combination: stroking, compression and percussion. Stroking or effleurage is the fundamental form of massage, which is almost instinctive. The mother gently strokes a child's bruised forehead with the palm of her hand in order to relieve pain and to diminish swelling;
patients stroke aching parts seeking to ease their painful sensations. Every massage treatment, as a rule, starts with stroking. In stroking even and uniform pressure is exerted along a certain path,
by means which are indicated by the topographical characteristics of the region to be treated or by the effect to be produced. Stroking is always exerted from the periphery toward the center, in the direction of venous and lymphatic circulation. On large surfaces it is done with the palm of the hand or with the radial side of the hand, on smaller surfaces with the thumb over the parts hemmed in by bones, while the tips of the fingers may be employed around the knee-, ankle-, elbow- or wrist-joints.
(400)
MASSAGE MOVEMENTS
401
Superficial stroking is used chiefly for the sedative reflex effect and should be performed as if stroking a cat with a slow, gentle, even movement. Simple as it sounds, it is one of the most difficult movements to master and requires much practice. The hands of the operator must be
FIG. 257.
Stroking massage to back
(first
movement).
fully relaxed so that the whole hand and fingers adapt themselves to the contours of the treated area. They should be kept always in contact with the parts, returning lightly to the starting point of the stroke before changing the direction of the stroke. Common mistakes by beginners are: the tendency to scratch the patient at the beginning and the end of the stroke,
FIG. 258.
Stroking massage to back (second movement).
changing the direction of stroking, improper return movement of hands and holding the hands and fingers stiff. Deep stroking is used principally for unloading engorged veins and
lymph
26
channels, as in fractures, sprains, inflamed synovial
membranes
402
MASSAGE
in all chronic
inflammatory conditions where resorption of an exudate The pressure exerted should be deep but not heavy, muscles must be relaxed in order that the veins and lymphatics the patient's can be properly emptied.
and
is
to be promoted.
FIG. 259.
Stroking massage to back (third movement).
movements should be uniformly slow; it times in a minute over larger surfaces where it is intended to exert movements of fluids, to 15 to 30 light strokes a minute over smaller areas for sedative effect.
of
all
The rhythm
stroking
five
may
vary from four to
FIG. 260.
Stroking massage to back (fourth movement)
Compression movements are most effective for accomplishing the most frequent object of massage: that of toning up muscles and freeing adherent
parts.
The
is
ments
principal difference between stroking and compression movethat in the former the fingers of the operator glide evenly over the
MASSAGE MOVEMENTS
403
skin of the patient, while in compression the skin of the patient is carried along in order to act on the subcutaneous and deeper structures and a
is applied. There are two forms of compression movements: kneading and friction. Kneading is a mixture of grasping and pinching at varying degrees of pressure. The operator picks up the skin and subcutaneous tissue between the thumb and fingers with an amount of force not sufficient to cause pain. In this movement the skin moves with the hand of the operator and the underlying structures are thus massaged under the pressure of the fingers. It is best done by the two hands opposed to one another, by the thumb
variety of pressure
opposed by the first finger or by the fingers opposed to the palm of the hand. The thumb and fingers are used to reach individual muscles and small groups, such as muscles of the hand, foot, forearm and upper arm. The use of the fingers opposed to the thumb and hand or both hands, the muscles being rolled beneath them and pressed against the bone, is required in treating muscle masses of the thigh and calf. This has the same effect as friction on deep structures and is better for sensitive, easily irritated
.4.1
FIG. 261.
Kneading
of back.
moving with the hand like a glove. The movement should always be gradual and proceeding from the periphery inward. The hand should never be removed entirely from the surface while the pressure is being given, the skin should be moved with the hand and the part squeezed inward or toward the direction of the venous flow. The tissues acted upon by this manipulation are both superficial and deep skin, fat and muscles of the thorax and extremities, as well as the nerves, arteries,
surfaces, the skin
;
veins and lymphatics.

is on the muscles and soft tissues it serves and tendons, aids in stretching adhesions and removing waste products from muscle; it also assists the venous and lymph circulation. With a knowledge of the anatomy of muscles the operator in the proximal position of the limb and works distally; the motion begins itself must always be toward the heart or in line with the venous return.
The main
effect of
kneading
to stretch retracted muscles
patient's muscles must, of course, be absolutely relaxed. Friction is a circular form of kneading with pressure against an underlying part of such tissue which cannot be grasped. On a limited area it
The
404
is
MASSAGE
;
by the tips of the thumbs, both working in opposite direction other parts by the tips of the fingers or one hand open or clenched. Friction by the tips of fingers is used around joints; the entire hand is used over the fleshy part of the thigh, the arm and the lumbar region.
best done
in
-I
FIG. 262.
Slapping of back.
FIG. 263.
Beating
ot back.
FIG. 264.
Hacking
of back.
PHYSIOLOGICAL EFFECTS OF MASSAGE

Friction
is
405
face,
of special value in the manipulation of smaller parts
hand or foot and its chief effect is to free adherent skin, to loosen scars and adhesions of deeper parts, as tendons, etc. It should be always preceded or followed by stroking movements and be carried out in the same
the most stimulating form of movement do damage in overzealous or clumsy hands. We speak of slapping, tapping, clapping and beating according to the position of the hands and fingers delivering a succession of short rhythmic
is
general direction. Percussion or tapotement
and one which
is
most
liable to
blows to the parts.

effect
Percussion movements exert a powerful stimulating
on the vasomotor system, the skin, blood-vessels and superficial nerves, as well as on the muscles. Slapping is done with the palmar surface of the fingers, by quick light, alternating strokes, with the wrist relaxed and the fingers immediately rebounding. The mechanical effect of these short strokes is intensively stimulating not only to the superficial capillaries and the sensory nerve endings of the skin but also to the entire nervous system. Hacking is done with the ulnar side of the hand and the little finger. It consists of rapidly delivered chopping motions from the wrist-joint and the blows may be light or heavy. This movement is fairly difficult to apply skilfully and it must never be given with stiff wrists or with a full arm stroke. When properly applied it exerts a powerful effect on deeper structures and serves to relax muscle spasm, stimulate deep muscle structures and help in breaking up organized exudates.
Two
other not so frequently used percussion

;
movements
are tapping
and beating. Tapping is done with the tips of fingers like striking the keyboard of a piano beating is done with the tightly clenched fists striking the body with the back of the second phalanges of the fingers. Beating is the most vigorous form of percussion and is very popular with the bathrubbers. In scientific massage it is used occasionally for the stimulation of heavy muscles.
TABLE
49.
FORMS AND EFFECTS OF MASSAGE (AFTER REY)

/
/
Stroking (effleurage)
Superficial friction
Acts on skin and subcutaneous tissue and elements included therein
all
Deep
Stimulative
friction
Acts on
Kneading
Percussion
(petrissage)
all layers of soft tissue and on all elements included therein Acts on all soft layers; kneading of muscle par
excellence
Acts on soft parts, causes stimulation of muscle which responds with a mild contraction
exerts manifold effects
Physiological Effects of Massage. The variety of massage movements on the structures of the body and upon the general
organism. Upon the skin massage exerts a mechanical stimulation, its immediate effect being a dilatation of the capillaries, accompanied by a subjective
warmth. This hyperemia is only temporary, disappearing as soon as the reaction of the capillary vessels ceases. Massage exerts a cleansing effect on the superficial layers of the epidermis, dead cells are removed, the contents of sebaceous ducts emptied and thus sebaceous
feeling of
406
secretion
is
MASSAGE
facilitated.
The movement
of fluids in the skin
is
stimulated
and after frequent massage the skin becomes softer and more moist.
skin as the principal organ of touch usually responds gratefully to the massage movements of stroking and friction; perhaps no sensation is felt so pleasantly as skilfully applied massage. In the subcutaneous tissue massage also promotes the movement of
The
fluids
As a
result the skin
and loosens the elastic layer, thus making the skin itself more firm. moves more easily and skinfolds and wrinkles due to
tenseness of the subcutaneous structures gradually disappear. In spite of its popularity in "beauty culture/' massage does not remove the wrinkles of old age, neither can it disperse nor squeeze out lumps of fat under the skin. Only when the entire organism is affected by regular massage and
exercise does the subcutaneous fat begin to disappear. In other words, fat accumulation under the skin cannot be affected by massage except indirectly through increasing general body metabolism. The blood-vessels of the skin and subcutaneous tissue
can be effectively In persons who are not too fat the superficial veins emptied by massage. can be seen collapsing and filling up again as their contents are pushed along by hand. By assisting the venous return, the blood column in front of the arterioles is decreased and the blood can pass through the capillary circulation more readily. As a further result a larger supply of arterial blood will be forced through the part under treatment. The same pressure acts upon the lymphatic vessels, causing a more rapid absorption of nutriment and of pathological products through their walls. Thus the links
in the chain of physiological
phenomena produced by massage
are arterial
stimulation, active hyperemia, more active nutrition, secretion, excretion and absorption, in fact more rapid and more thorough metabolism and
increased functional activity in the part or parts subjected to massage. It has been shown that after massage there is an increase of red blood
the superficial vessels amounting to from 40 to 50 per cent. Muscles are among the chief objects of treatment by massage. Physiological experiments are on record proving that massage applied to a resting muscle increases its power for work and retards fatigue, it prevents the accumulation of fatigue products in a muscle and furthermore it enables the muscle to do more work than can a corresponding amount of rest. Through the active hyperemia brought about, massage stimulates the nutrition of muscle tissue and restores the tone and strength of muscles if they have weakened from lack of activity, local or general. Percussion movements may cause local muscular contraction but this does not replace active muscular exercise because no work is performed. In the nervous system gentle massage over a healthy nerve by its stimulative effect causes irritability and pain. In aching nerves mild pressure
cells in
increases the irritability, firm pressure lessens
it
and
may
eventually
suspend
it
altogether.
General massage affects the circulation of the entire body by speeding in the soft parts, the skin, subcutaneous tissue and muscles. The capillary blood-vessels become dilated and more than the usual number open up, thus there is an increased circulation of blood and better nutrition of the parts without exerting the heart. There is also a corresponding increase in general metabolism. Many persons go more There is also usually an easily to sleep after a general body massage.
up the blood flow
GENERAL TECHNIQUE OF MASSAGE
407
increase in urinary excretion but no marked alteration in the rate of excretion of the various urinary constituents. The influence of masEffects of Massage on Pathological Conditions.
sage upon pathological processes

ones.
is
no
less
decided than upon physiological
Chronic inflammatory changes in the tissues caused by trauma or and their after-effects, local edema, indurations and infiltrations, extravasations of blood, scars, adhesions in the skin, tendon sheaths, in muscles and around joints are favorably influenced by appropriate masinfections
sage movements: resorption is accelerated, adhesions are freed and indurated parts are softened. This is due to the speeding up of the movement of the venous and lymphatic circulation, to the pushing effect on the extravasated fluid and to the mechanical stretching of the strings and bands of connective and fibrous tissue. Skilful massage will prevent or minimize scars and adhesions in the skin as well as in deeper tissues within reach of
massage movements. In conditions of muscular weakness which are due to disuse, general systemic inactivity or exhausting disease, massage will help to keep up muscular tone and prevent further atrophy of the muscles. In real paralysis following peripheral nerve injuries or anterior poliomyelitis massage will not restore muscular power and if roughly done it will rather increase muscular atrophy and diminish muscular tone. Very gently superficial stroking, preceded by mild heating, may be applied after the acute stage it will stimulate the venous and lymphatic circulation of the limb and carry away some of the waste products. In this way properly applied massage will induce better nutrition and may delay muscular atrophy. Edema of the skin and subcutaneous tissue due to circulatory changes can be locally dispersed and the work of the heart relieved by combined local and general massage; the flow of blood becomes accelerated without straining the heart, edema, cyanosis and shortness of breath are improved. In chronic circulatory diseases due to a weak heart muscle, massage is a most beneficial measure at the bedside. General Technique of Massage. Rooms for massage should be light and kept at an even temperature, which is most comfortable to patients somewhere between 70 to 75 F. The patient must be comfortably relaxed in either sitting or recumbent position, lying down being generally preferable because it insures more relaxation. For institutional treatments special massage tables are essential; they should be 30 inches high, 2^ feet wide and be covered with a good mattress without springs. When patients are treated in the sitting position for treatment of the head, neck, shoulder and upper extremity suitably placed pillows should insure comfortable relaxation of the parts. Parts not under treatment should be covered. The patient's skin should be clean and careful note should be taken of wounds, small abrasions and inflamed skin follicles; massage should never be applied over such parts. Most massage technicians use some lubricant as talcum powder or a fatty substance, vaseline, albolene or olive oil. No hard and fast rule can be laid down, for the choice of lubricant depends on the skin of the patient and his condition and on the skin of the operator. Too much lubrication interferes with good friction which is essential for efficient massage. Over a hairy skin powder should be used because oily lubricants frequently cause
;
408
MASSAGE
inflammation of hair follicles. Powder is generally preferable in fractures and traumatic conditions and also for operators whose hands are moist. For a dry and scaly skin a fatty lubricant is more suitable. The remnants of an oily lubricant should be removed by alcohol after massage and powder should be rubbed off with a towel or with soap and water. Preparatory to massage the warming up of the part or the entire body by radiant heat or hot bath insures softening of the skin and relaxation
of the muscles. Excellent results are accomplished by the practice in certain spas of massaging stiff joints under a hot shower (Aix-le-Bain massage). This corresponds with the hydromassage technique now so extensively
employed
in treatment of
wartime and industrial traumatism.
duration of a local massage to one part should be from ten to fifteen minutes when massage alone is used and from five to ten minutes If several parts are to if other forms of physical therapy are employed. be treated at one sitting each part ought to be treated as if it were the only
The average
this
one affected. General massage treatment should take about one hour and time may be proportioned in the following sequence: legs, fifteen;
arms, ten; chest, five; abdomen, fifteen; back, fifteen minutes. It is generally advisable to begin with short and mild treatments and continue according to the condition and reaction of the patient. No massage treatment should be painful or bring on pain as its aftereffect. Neither should it exhaust nor irritate a patient. A rest period should follow every massage, the length of which may vary from ten minutes to one hour, according to the duration and extent of the massage or other
physical measures applied.
The frequency of massage depends on the condition treated. In acute traumatic or painful conditions, as a rule, daily treatments are administered.
of Massage. Massage with its manifold effects upon the structure body and upon the general system offers valuable aid in the treatment of many disabilities and diseased conditions. Until the present-day large variety of physical measures, many medical men considered massage and heat all there was to physical therapy. Some of the older text-books of the
Uses
on -massage contain a massage prescription for practically every disease condition known. At the other extreme were medical men who practiced all kinds of electrical and light treatments and never employed massage.
Nowadays
and
in the practice of physical
in institutional
work, massage
is
therapy by competent physicians regarded as an essential part of
routine treatment, especially where hand power is cheap. At the same time, it is realized that massage effects may be produced in many conditions by other mechanical measures, more convenient and more efficient. Sherstated that in the treatment of traumatic condiproducing graduated muscular contractions have satisfactorily replaced massage. (See page 176.) There can be no doubt that the well-controllable mechanical effect of low-frequency currents, of the static wave current, static sparks, and the gentle mechanical action of the Oudin application and the hot whirlpool bath offer effective alternates of some of the massage movements. For the protection of the nurse or technician, these measures should be substituted for massage by the prescribing physician when it is desirable to avoid physical contact with a patient. For the general rank and file of patients
tions,
electrical units
man and Smart4 have

3
USES OF MASSAGE
409
and for emergency and many home treatments, the skilled massage technician will always remain a desirable member of the medical auxiliary personnel. No clinic and no physician employing physical therapy can do very well
without massage.
The
and
The pathfinding studies of Lucas-Championnere, B. Mennell, 2 of England, have shown that massage, movements may be successfully employed for the relief of pain and spasm, even in the most acute stages of an injury. Such treatment must be given by an experienced physician. The patient is placed in a comfortable position, with the injured part fully supported and relaxed and slow regular stroking movements at a rate of 10 to 12 a minute are made over it without touching at first; gradually light contact is made, with the part of the 1 operator's hands fitting it uniformly. It is stated by Heald that after 12 to 250 movements the parts become fully 'relaxed, due to "local hypnosis." There is no mystery to these movements; if the patient's confidence is won and he relaxes the spasm with which the injured parts are protected, no pain will be caused by such massage. Storms 5 believes that massage is properly used for detection and relief of muscle spasm. If a muscle is subjected to greater strain than it can stand, some of its fibers tear. Pain, swelling and other signs of inflammation of the muscle appear, and the entire muscle or part of it goes into spasm. This is painful and may last for hours or years. If it persists for long, part of the muscle involved destroys a portion of its substance by its continuous contracture, and there is replacement by scar tissue, resulting in fibrosis of the muscle, with its subsequent effects. Spasm can at any time be felt by the examining fingers and it is the direct cause of the pain for which relief is sought. It should be detected by palpation and treated at once. Storms recommends a kneading stroke and occasionally some firm effleurage. In an acutely swollen, sprained ankle, firm, slow effleurage is required to drain fluid out of tissues and engorged veins; light stroking would only irritate. In kneading of the spasm, the cushions of the finger-tips or the balls of the thumbs do not slide over the skin; instead they hold position on the skin, the short stroke being made possible by the loose connective tissues. The direction of the kneading stroke is always parallel to the muscle fibers, never across, to keep the discomfort at a minimum; the power of the stroke is adjusted to the patient's tolerance. As soon as the spasm begins to soften, treatment should be stopped for that day. Otherwise the spasm may tighten up, not to soften again during the treatment, and may produce more pain than there was at the beginning of treatment. After the disappearance of the spasm and pain of the initial stage,
of Paris,
surgical conditions Traumatic Conditions.
generally recognized scope of massage in the variety of medical is as follows:
and
J.
regular massage treatment may be started. It is advisable, as a rule, to precede it by local heat application as already stated. The injured part must be carefully supported and stroking movements are applied with Additional increasing firmness and gradually including a wider area. massage movements such as deep kneading are applied according to the site, extent and nature of the injury. Massage is indispensable as part of the efficient treatment of fractures, dislocations, stiff joints and other traumatic conditions. In these condi-
410
tions
MASSAGE
massage is usually combined with suitable exercises and preceded by thermal measures. The details of indications and technique will be presented in chapter on traumatic conditions. In arthritis and rheumatic condiArthritis and Rheumatic Conditions. tions, massage serves to improve circulation in the neighborhood of affected joints, and soft structures (chiefly the muscles) and to compensate to a certain extent for the lack of muscular inactivity due to the disabling condition. It should be preceded by heating by hot water, lamps or diathermy.
For further
details see chapter on chronic arthritis. Atonic conditions of the gastro-intestiDisorders of the Digestive Tract. nal tract, especially chronic constipation, can be considerably benefited by appropriate massage. There are many forms of manipulations recom;
mended
as long as
as a rule, the simpler the technique the more efficient it becomes, All massage movements to it follows physiological principles.
the abdominal wall must be applied at a slow rate, about twelve movements a minute, because the peristaltic wave travels slowly and a stimulus applied before relaxation follows a contraction may cause a spasm. Too much pressure must also be avoided, because through a relaxed abdominal wall, pressure is directly transmitted to the viscera. Finally, massage movements must be carried out in the direction of the movement of the intestinal contents, starting with gentle stroking, beginning at the ascending colon, continuing along the hepatic flexure, the transverse colon and sigmoid flexure until the whole abdomen is relaxed. This should be followed by gentle kneading applied in the same direction. For further details see
chapter on abdominal conditions. Disorders of the Nervous System. In peripheral nerve injuries and anterior poliomyelitis, the only favorable effect that can be expected from
massage
is
paralysis, the lack of
by
excess
to injury.
form; one
Too long
by stimulating circulation. In flaccid muscle tone carries the danger of paralytic dilatation manipulation of the small blood-vessels, thereby adding insult Hence in paralysis, massage must be given only in a most gentle should never squeeze or press paralyzed muscles against bones. treatments must also be avoided, because they exhaust the
to improve nutrition
mtfscles and increase atrophy. For details see chapter on affections of the peripheral nervous system. In spastic paralysis there exists an increase of muscle tone and massage is employed to minimize atrophy and together with muscle re-education to prevent contractures and joint stiffness. Massage should begin by slow
and even stroking, continued with gentle re-educational exercises. details see chapter on affections of central nervous system.
For
In organic diseases of the central nervous system, general massage is often useful for its tonic and soothing action; the details of treatment
must be regulated according

Cardiovascular Conditions.
to the patient's condition.
In chronic decompensated heart conditions
systematically and cautiously applied general stroking and gentle kneading may be of considerable aid in returning the stagnant tissue fluids, relieving the edema and preserving muscle tone. General massage also aids by the
increase of kidney function. In acute cardiac decompensation advanced chronic conditions massage promises no such help. see respective chapter.
and For
in far-
details
REFERENCES
411
Other Systemic Conditions. In convalescence, secondary anemia and in chronic disease conditions which keep patients in bed for a prolonged period, massage can be effectively applied for general stimulative purposes. With treatments carefully administered, daily or every other day, patients
all
show improvement
in their general well-being, sleep, appetite, color
and
muscle tone. Hence, general massage is an important treatment measure in these conditions. In obesity regulation of diet and systematic exercise accompanied by a judicious amount of general massage will help by the For effect on the general organism but not by local mechanical action.
details see
Chapter
XXV.
Contraindications to Massage. Wounds, skin eruptions and inflammatory processes in or underneath the skin exclude the use of massage to the affected parts. Acute inflammatory conditions anywhere in the
body, but especially in the abdomen, are also contraindications, likewise tumors and tuberculous joint affections. No massage should be given to the abdomen and lumbar region during menstruation and none to the
abdomen during pregnancy.

In the acute stage of local inflammatory and irritative conditions of peripheral nerves, neuritis and neuralgia, massage is as a rule harmful, for even mild stroking may bring on a violent increase of pain.
REFERENCES
1.
HEALD, C.
2.
MENNELL,
3.
B.: Injuries and Sport, London, Oxford Univ. Press, p. 96, 1931. J. R.: Physical Treatment by Movement, Manipulation and Massage, 3d ed., Philadelphia, P. Blakiston Sons & Co., 1933. SHERMAN, W. O'NEILL: Foreword to Smart, M., Injured Muscles and Joints and
4.
5.
Their Treatment by Graduated Muscular Contractions, in Nelson's Loose-Leaf Surgery, New York, Thomas Nelson & Son, vol. 3, Chap. II-A, 1936. SMART, MORTON: The Principles of Treatment of Muscles and Joints by Graduated Muscular Contractions, London, Oxford Univ. Press, 1933. STORMS, H. D.: Diagnostic and Therapeutic Massage, Arch. Phys. Ther., 25, 550552, 1944.
CHAPTER
XXIII
EXERCISE
BY H.
J.
BEHREND,
M.D.
ASSOCIATE PHYSICAL, THERAPIST, HOSPITAL FOB JOINT DISEASES; VISITING PHYSICAL THERAPIST, WELFARE HOSPITAL, NEW YORK CITY
General
General Technique. Indications. Considerations. Physiological Effects. GasExercise in Various Conditions. Circulatory System. Respiratory System.
Nervous System. Conditions of Bones and Joints. Arthritis and Rheumatic Conditions. Peripheral Vascular Diseases. Posture. Underwater
tro-intestinal System.
Exercises.
General Considerations. The term "Corrective Exercises" is applied to certain gymnastic movements which aim to improve the function of therefore must disthe more or less weakened body or parts of it. tinguish between general corrective gymnastics and partial corrective
We
exercises as given, for instance, in the treatment of regional muscle conditions or of diseases of the bones, joints and nerves. It is the latter group
the general practitioner is most likely confronted with and the necessity of his being acquainted with the fundamentals of this form of therapy becomes apparent. He should be able to prescribe corrective exercises intelligently and to supervise their execution if performed by nurses, technicians or other assistants. Two groups of corrective exercises are generally recognized, namely passive and active exercises. In passive exercises the operator or a mechanical device performs the movements of the body or parts of it, and the
patient remains inert sitting comfortably or lying down in a relaxed position. This form of exercise is widely used for the treatment of stiff joints, contractures, scar tissue, and muscular paresis due to central or peripheral nerve lesions. Active exercises are performed by the patient himself. He
either uses his muscles freely or against an opposing resistance. This Two forms of resistance requires the full cooperation of the patient.
exercises are possible: Either the operator gives the resistance while the patient goes through the movement, or the operator moves every part of the body with the patient resisting. Active exercises will develop muscle
strength and are therefore indicated in all cases where muscle strength has been impaired. Under systematic active exercises muscles which became atrophic because of inactivity, for instance after immobilization, will improve as will those weakened because of an impaired nerve supply. As compared with massage exercise is the only method to develop muscle strength. Massage alone will never "work up" a muscle. However, it will prepare the muscles for exercises by improving the local circulation and metabolism. The efficiency of the muscle tissue is increased by massage. The combination of exercises and massage is therefore well indicated and should never be neglected.
effects
Physiological Effects. Exercises exert on the muscles, nerves and joints.
their
principal
physiological
(412)
413
muscle carried through any form of exercise will respond with an
The circulation is improved not only because the active hyperemia. and small arteries dilate, but also on account of the mechanical capillaries
effect on the small veins. Muscular contraction produces a compression on the venous system resulting in an enhanced reflux of the venous blood toward the heart. This increase of circulation will remove faster the products of fatigue, mainly lactic acid. Lactic acid is a product of the normal glycogen metabolism in the muscle. It is produced during muscle activity and is eliminated by combination with oxygen during the rest period. It is therefore essential to interpose sufficient intervals of rest and
relaxation during exercises. The sensation of fatigue normally protects the muscle; its disregard results in overstraining of the muscle. In addition to the production of lactic acid a depletion of its protein reserves will weaken the muscle tissue. Weakening of muscle tissue means decrease of
muscle tonus. Diminished muscle tone results in a slower response to stimulation. If a patient under treatment shows sign of fatigue or increased muscle flabbiness, this should call for immediate termination of the exercise and for interpolation of a rest period which should last, at least, ten minutes. In addition to the improved circulation exercise affects the muscle tissue Continued training of a muscle increases its bulk, whereby the itself. size of the individual muscle fiber is enlarged by no means their number. In atrophy due to inactivity or nerve injury or disease the bulk of the muscle diminishes until, in severe cases, the muscular tissue almost disappears. Corrective exercise may counteract some of this tendency. The physiological effect of corrective exercises on the nervous system results in an improvement of the coordination of the neuromuscular element. In disorders of the central nervous system exercises will stimulate
re-establish peripheral nerve conductivity. For instance in hemiplegia early instituted exercises will keep up the nutrition of the muscles and
and
will
prevent the development of contractures and deformities unless the an irreparable damage. Even more important are exercises in lesions of the peripheral nervous system (neuritis, Bell's palsy, etc.), which are associated with degenerative changes of the muscles,
central lesion has caused
skin and bones.
In the physiological effects on bones and joints we deal with an improved which leads to a mobilization of stiff joints, their capsule and pericapsular tissue. The re-education of the muscular activity re-establishes the normal function and position of the joint if not ankylosed or otherwise
circulation,
destroyed. Besides the effects on muscles, nerves or joints the general stimulative effect of exercise on the body is of utmost importance for it will affect
favorably the cardiovascular and respiratory system as well as metabolism. Although exercises primarily will put a strain on the heart, circulation and respiration, this should later result in a strengthening of these organs. The exercises therefore have to be given in increasing doses according to the individual constitution and disposition. This requires experience and strict observation of the reactions of the patient. The blood-pressure rises and the pulse-rate is increased. This fact is used as a tolerance test for exercises. If the blood-pressure does not rise and the pulse-rate does not return to normal after one to two minutes of rest, it may be assumed that
414
EXERCISE
the circulatory system deserves special attention before starting exercises, and that the amount of exercises given must be increased very slowly. Diseases of the heart are by no means always contraindications for care-
On the contrary, the strength of the fully applied corrective exercises. heart muscle increases parallel with the development of the voluntary musculature. Since the activities of the heart and lungs return to normal rapidly, and since it requires much more time for the metabolism of the muscle to be restored to its usual level, the interposition of the rest periods mentioned above is essential. The rest period is best filled out with observation of Control of the the patient's breathing technique and its improvement.
Breathing exercises Correct breathing will produce relaxation. Shallow or incorrect breathing will produce tension. It affects the circulation and the sympathetic nervous system through the respiratory center. Tension is caused in all muscle groups participating in respiration, because these muscles do not relax sufficiently during A certain residual tension remains in these muscle groups exhalation. which, reflexly, is transmitted to other muscles and if not removed will establish a vicious circle because circulatory changes will occur due to decreased negative pressure in the thorax which impairs venous return. Shallow breathing combined with impaired circulation reduces oxygenation of the blood, the most important factor in restoring the function of a fatigued muscle to normal. The importance of breathing exercises therefore becomes apparent. They will increase the mobility of the chest, further thoracic respiration and will relieve abdominal stasis. Systemic deep breathing will cause a fall of blood-pressure in cases of hypertension and has widely been used for the treatment of this condition.
respiration during exercises
is
of
utmost importance.
must be interposed frequently during the
rest period.
to be given
General Technique of Exercises. All orders for corrective exercise have by the physician in detail. It is not advisable, for instance, to
prescribe just exercises for a certain joint or extremity without specifying the movements wanted. An exact diagnosis is essential before starting treatments. During a course of treatments the condition of the patient has -to be controlled frequently and the exercises have to be adjusted
according to progress. There has been a great variety of exercises suggested for corrective treatment. Because of the large number of conditions that respond to
many systems of exercises have been developed. Their value as an unrestricted method is questionable and its indiscriminate use often dangerous. For better understanding, however, one may classify all exercises into two major groups: (a) Local exercises for the treatments of a specific part of the body. (b) General exercises. Local exercises are employed in post-traumatic, inflammatory or degenerative conditions in order to re-establish normal function. General
exercises are chiefly
corrective exercises
employed
in postural conditions
and
for recreational
purposes. (a) Local Exercises.

for
No
definite technique
can be described generally
for instance, affects the muscles, ligaments, bones or joints of the extremities.
any traumatic, inflammatory or degenerative condition which,
All
415
movements
depends on the individual case. It is, however, important that all possible with regard to the functional structure of the joint
be carried out.
FIG. 265
FIG. 265. FIG. 266.
FIG. 266
Passive exercises of fingers. Active exercises of fingers.
FIG. 267.
Passive flexion of wrist.
To obtain the greatest benefit from local corrective exercise one must have a clear conception of the basic principles involved. In a neutral
position of a joint, or in a part at rest, the muscles controlling movement are in a state of balanced tone. Due to the principle of reciprocal innervation, movement of a joint involves increase in tone which results in contraction of one muscle or group and a corresponding decreased tone or relaxation of the opponents. Increased tone amounting to spasticity without the possibility of the reciprocal relaxation noted above will nullify
efforts to administer
proper corrective exercise. In such cases it is of prime by some means. In cases of decreased tone, muscle weakness or atrophy for any reason, it is essential to avoid undesired training of any normal muscle group. The affected muscles must be singled out and training directed to them exclusively. If necessary, fixation of the parts may be required so that the affected muscles will be sure to perform as desired.
importance to secure relaxation
416
EXERCISE
must be
In treating the upper extremity, the hand, elbow or shoulder joint well supported and the exercises are given with the patient either
in the sitting or lying position. To exercise the fingers, for instance, the patient sits on a chair and supports the hand on a small table on which a firm small pillow is placed. The operator holds with one of his hands the patient's wrist in fixation and then moves the joints of all fingers in all directions which are physiologically possible. The (Figs. 265-267.) knowledge of the average amplitude of the principal active movements is necessary to appreciate the limitation in the range of motion of a joint. These measurements can be taken with a simple device consisting of jointed arms and a protractor scale; one arm is fixed at zero of the scale while the motion of the other arm shows on the scale the degree of motion. For
The average range

Shoulder:
correct reading of progress regular charting of joint motion is indispensable. of joint movements is shown in Table 50.
TABLE
50.
AVERAGE RANGE OF JOINT MOVEMENTS

to 160
Abduction zero to 160. Range 160. (From zero to 80 is the range in the shoulder-joint itself, while from 80 ment is made by elevation and rotation of the scapula.)
Flexion zero to 180. Range 180. Extension zero to 45. Range 45.
Internal rotation
move-
External rotation
zero to 80. zero to 45.
Range 80. Range 45.

135.
Elbow:
Flexion to Pronation
45.
Extension to 180.
zero to 90. Supination zero to 90.
Range Range 90. 90. Range
Wrist: Flexion to 100. Extension to 240. Range Abduction zero to 35. Range 35. Adduction zero to 50. Range 50.
140.
Metacarpophalangeal
joint
Proximal
interphalangeal
joint
Distal
interphalangeal
joint
Flexion. Fingers: 2d, 3d, 4th and 5th fingers
Thumb
Abduction Adduction
zero to zero to
85 70
110 85
75
Range 45. Range 45. Flexion to 60. Extension to 180. Range 120. Hyperextension from 180. Extension to 135. Range External rotation zero to 60. Range 60. Internal rotation zero to 30. Range 30.
Knee:
Flexion to
45. 45.
45.
45.
90
Extension to 180.
to
Range
35.
Ankle:
Dorsiflexion
135.
to
Plantar flexion
90
70.
Range 45. Range 20.
It is essential that passive and active exercises combined are given in every session. The operator begins with gentle passive exercises and then instructs the patient to move the joint actively first without and later with resistance which will be either concentric (the operator gives the
resistance)
or eccentric (the patient resists to the movement). Flexion, extension, abduction, adduction and rotation is thus performed successively. The principles discussed for the treatment of the upper extremity are also applied in treating the trunk, the head or the lower extremities.
417
Care has to be taken that the patient does not become too fatigued. The average duration of a session should be fifteen to thirty minutes after which the patient should rest quite some time.
FIG. 268.
Convalescent group exercise in ward.
In order to carry out general exercises successfully a definite program has to be planned to avoid the exercises from becoming boring and monotonous. The condition of the heart, lungs, kidneys, bones and joints must be ascertained by a complete medical examination, and the simple circulatory test described will prove very useful and can be easily performed.
FIG. 269.
Convalescent group exercise outdoors.
In the untrained or the weak the exercises have to be graded beginning with the patient lying down and later in the sittingor standing posiThe temperature of the treatment room should be about 70 F., tion.
first
27
418
EXERCISE
and the patient's clothing should be adapted to the work. Before beginning the session the patient should empty the bladder and bowels and clean The orders should be given in a determined, low his nose thoroughly. voice, and every movement must be carried out exactly as ordered and repeated slowly and precisely until properly done. Here again it is important to interpose sufficient rest periods so as not to fatigue the patient. Breathing exercises should be inserted frequently for the reasons already given. The duration of an individual session should be thirty-five to fortyfive minutes at most, including rests during the time, and a rest of fifteen
to thirty minutes at the conclusion of the treatment should follow. Overtiring has to be avoided. The patient should feel relaxed and invigorated
at the end of the treatment. For the average purpose no apparatus is necessary. The use of apparatus may even be dangerous. Nothing can take the place of active exercises. For reconditioning group exercises have a definite advantage. They are
used for the rehabilitation of the wounded of the Army and Navy. Figures 268 and 269 demonstrate some group exercises as used in the reconditioning
program
of the
Army
Air Forces.
EXERCISE IN VARIOUS CONDITIONS

Circulatory System. graduated gymnastics. compensation.
The The
circulatory system responds most readily to heart muscle can be trained to exertion and
The
resistive exercises of
Schott and Oertel are based upon the graduated
resistance given to the patient's movement, thus making the heart increase its work as it improves after each exercise; the heart-rate must be allowed
to fall to its previous count or even below before continuing. exercises are principally for mitral and aortic insufficiency.
of the heart muscle.
The Schott
Oertel has introduced graded walking exercises to increase the efficiency The patient has to take a walk first on the level
ground for a few minutes; later depending upon the progress and reaction of the heart, the time factor is increased and walking on hilly territory
is
added.
Systematic exercises have been recommended for the treatment of

arterial hypertension. They will procure relaxation and decrease of peripheral resistance. For further details see Chapter XXIV.
Respiratory System. The physiological effects of breathing exercises have been discussed. For performing correct breathing exercises the patient is placed on a cushioned table in a comfortable dorsal recumbent position.
He
exhales blowing through the pursed lips. The patient must now and wait until natural inspiration occurs. This inspiration must be smooth without conscious forcing of the chest or abdominal walls into certain positions. This exercise should be performed several times
first
rest quietly
and
is
to be supported
by movements
of the extremities, for instance,
raising, lowering and stretching in accordance with inhalation or exhalation. To establish a complete breathing act and relaxation we must examine
the patient to determine whether any muscles are embarrassed in their function because of impaired antagonist muscles or obstruction in the respiratory tract. Particular attention must be paid to the lateral muscles of the chest and those of the back. In many cases unusual tension of the
FIG. 270
FIG. 271
FIG. 270. FIG. 271.
Exercises for abdominal muscles I, single leg raising. Forceful contraction of abdominal muscles, double leg raising.
FIG. 272
<
FIG.
272.
Exercises for
FIG. 273 abdominal muscles II.

is
Abdominal muscles
flattened.
relaxed;
lumbar
lordosis present.
FIG. 273.
Abdominal muscles contracted; back
(419)
420
EXERCISE
muscles controlling the costal margin is observed. This can be remedied by suitable training to increase the lateral excursion of the ribs. In some cases of emphysematous type or barrel chest, uneven excursion of the chest wall may be noted. Movement of the lateral portions may be excessive. Equalizing the movement of the chest cage will often clear up symptoms of cardiac involvement which, thereby, prove to have been functional. The indications for breathing exercises are chronic bronchitis, emphysema and pleurisy; pleuritic adhesions especially will be influenced favorably. In the treatment of bronchial asthma they will help restore elasticity of the thorax, which has been impaired by decreased mobility and here also play an important role in relaxing the patient. Conditions such as constipation, flatulence, Gastro-intestinal System. visceroptosis, obesity, hemorrhoids, etc., may be helped by general and special exercises and, in particular, by the development of good body mechanics. Here again the breathing exercises will increase the activity of the diaphragm thus massaging the abdominal organs and promoting the flow through the portal vein and inferior vena cava. Strengthening of the abdominal wall will have a direct influence upon the liver and gallSome bladder and will increase intestinal peristalsis where required. typical exercises for the strengthening of the abdominal muscles are shown in Figures 270-273. Nervous System. There is a large field for therapeutic exercise in the organic and functional disorders of the central and peripheral nervous Acute anterior poliomyelitis, hemiplegia, Bell's palsy, tabes system. dorsalis, neuritis among the organic and chorea, neuralgia, neurasthenia and the neuroses among the functional disorders, will call for special exercises to teach alertness, steadiness and coordination in the process of muscular re-education.
Rest and relaxation must frequently interrupt these exercises, for fatigue the great foe of nerve tissue. Injuries of Bones and Joints. In the after-treatment of fractures, dislocations and sprains it is impossible to give other than general directions. Gentle heat and stroking massage of the muscles controlling the movements of the joint will first be instituted. As soon as the surgeon permits exercises will be started. They will first involve joints distal to the injury, as the fingers, in cases of injuries to the wrist or arm, the toes, in injuries to the foot, leg, thigh, etc. These exercises should be active because these alone are going to restore function and will prevent too great damage. Passive motion has usually no place in fractures, but is of value in sprains and dislocations after the inflammatory stage has subsided. Early institution of exercises will secure better results because unnecessary fixation, adhesions and contractures are being avoided. Where they are present, their mobilization will be facilitated.
is
Early, carefully considered postoperative exercises are both prophylactic and regenerative. Thrombophlebitis and embolism are less likely to occur. For further details see Chapter XXIX. Peripheral Vascular Disease. For the treatment of peripheral vascular diseases Buerger's exercises and the use of suitable apparatus have been recommended and is fully discussed in Chapter XXIV. Arthritis and Rheumatic Conditions. In arthritis and in rheumatic conditions therapeutic exercises are being applied for
many reasons. Function

of the joints
421
must be maintained and improved. Involved muscle groups must be strengthened and deformities must be corrected. General improvement of the circulation is in order and body mechanics must be restored to normal in order to guarantee a smooth and coordinated functioning of the bones, joints and muscles.
In applying corrective exercises it is necessary to differentiate between the infectious rheumatoid and the degenerative osteo-arthritic conditions. Great care should be taken not to aggravate or activate the first group by too strenuous treatments. In conjunction with rest and gentle massage, passive exercises should be given in order to keep up a normal range of motion and to avoid the formation of adhesions. These exercises should rather be given several times daily instead of exhausting the patient in one too excessive session. Repeated exercises with interposed rest periods constitute the best training and prophylaxis for an acutely diseased arthritic joint.
FIG. 274
FIG. 274. FIG. 275.
FIG. 275
Exercise for Exercise for
stiff stiff
shoulder in supine position: shoulder in sitting position.
in
In chronic degenerative or osteo-arthritis active and passive exercises combination with all tools and equipment of physical therapy are indicated. The technique depends on the individual case in accordance with all principles outlined at previous occasions. Exercises under water have a wide field of usefulness in these cases. Light work will help to keep
up the motion and general upbuilding will help considerably. There are three arthritic conditions which the general practitioner is frequently confronted with where corrective exercises are especially helpful. The treatment of the arthritic hand has been described. (Figs. 265-267.) For the painful shoulder corrective exercises are of extreme importance. The lesions most frequently found here are bursitis, arthritis and periIn the acute stage exercises are definitely contraindicated. In the subacute stage or in the more chronic phases carefully administered exercises are of the greatest value in preventing the formation of adhesions and limitation of motion. Treatment of the stiff shoulder by manipulation, under anesthesia, is only of very limited value. It is in these cases that conservative corrective
arthritis.
422
exercises are very helpful.
EXERCISE
After application of heat and massage exercises are given with the patient first in the supine position, lying flat. The arm is moved forward, upward and then carried backward until further move-
FIG. 276. Passive exercise of shoulder to increase range of lateral abduction. Seapula held firmly to prevent rotation of the shoulder girdle. (Courtesy of Drs. G. E. Haggart and C. R. Carr and New England Jour. Med.)
FIG. 277. Exercise to improve external and internal rotation of shoulder in chronic adhesive subacromial bursitis. (Courtesy of Drs. Haggart and Carr and New England Jour.
Med.)
423
ment is limited by pain. It must be carried slightly beyond this point, and so held for a few seconds (Fig. 274). The arm is then carefully and slowly restored to the neutral position at the side and left so until pain has subsided. In the second maneuver the arm is carried into abduction until further movement is here, too, limited by pain; The shoulder is then abducted a little further and again held for a few moments. It is then slowly restored to the neutral position at the side and the patient rests until the pain subsides. Mild massage applied between movements will
aid in easing the pain.
ing
These procedures are repeated upon the severity and duration of the affection.
several times depend-
FIG. 278
FIG. 279
stiff
FIG. 278. FIG. 279.
Indian club exercise (the loop) for Stretching of iliotibial band.
shoulder.
patient then is treated in the sitting position. The above manipularepeated in this position, and the shoulder is rotated slowly in all planes (Figs. 275-277). Finally the treatment is repeated with the patient standing. In this position internal rotation of the shoulder is carried to the greatest possible
The
tion
is
degree.
This
will frequently
be the most
difficult
procedure, but
it is
very
424
important.
EXERCISE
In order to strengthen the musculature of the shoulder girdle Swinging of the arm in all directions, first without and later with the help of an Indian club will help to restore normal motion for the shoulder joint. (Fig. 278.) In all these manipulative procedures we cannot stress too strongly the need for care and consideration. The patient must be carefully observed and his endurance estimated. Loss of confidence will mean loss of the patient and almost inevitable stiffening of the shoulder, which may require operative intervention. Beneficial results must not be expected immediately, particularly in a case of long duration. Apparently hopeless conditions have responded in a satisfactory manner after treatment extending over periods of six weeks to even a year. For the treatment of the lame back exercises are very important for the
active exercises are finally added.
strengthening of the usually weak leg, gluteal, abdominal and back muscles. are begun while the patient is still in bed as soon as the condition permits movement without causing too much muscle spasm. With the patient improving, more exercises are added until they can be continued with the patient in the standing position.
They
FIG. 280.
Stretching of calf muscles.
FIG. 281.
Passive stretching of hamstrings.
Postural abnormalities should then be corrected. Bad posture very Examination frequently frequently is the source of low back trouble. reveals that many muscle groups controlling posture are in spasm or even contracted.
These muscles in question are the posterior muscle groups of the leg, and hamstring muscles, the tensor fasciae latse, the abdominals and the erector spinse muscles. These muscles should first be stretched as
calf
in Figures 279-282. Later on active exercises should be added in order to strengthen the gluteals by straightleg raising in the prone position. (Fig. 283.) Contraction of the abdominal muscles in the supine position should be given as shown in Figure 285 in order to strengthen their tone. Slow and rhythmical contraction must be obtained.
shown
Physical exercises will help to re-establish proper coordination of the lower back muscles and will thereby decrease muscle spasm which very
425
frequently is the cause for the continued pain. There again breathing exercises will play an important role in addition to exercises for the strengthening of the abdominal wall.
Contraindications. Contraindications to exercises include, besides acute inflammations or active infections, any depleting disease or new growth. In prescribing corrective exercises it is well to bear in mind that just as in other forms of physical treatments the best results are often obtained by combining several forms of treatments. Therefore a combination of exercises with heat and massage is often of great advantage and enhances the effect.
FIG. 282
FIG. 283
FIG. 282. muscles. FIG. 283.
Active stretching of hamstrings.
This exercise also strengthens the abdominal

leg.
Strengthening of gluteus maximus by hyperextension of
Posture.
Ewerhardt's definition of good posture
is
the mechanical
correlation of various systems of the body with special reference to skeletal, muscular and visceral systems and their neurologic associations.
Proper posture
is
not inherent as
is
commonly supposed but
is
the result
Its
of constant thought, attention and discipline from earliest childhood. neglect makes for grave defects and consequent illness.
Improvement of faulty posture will improve many a condition caused by bad body mechanics and will result in better health. Figures 286 and 287 demonstrate faulty and corrected posture in the standing position. Of perhaps greater importance than the treatment of deformities is
426
their prevention. of
EXERCISE
Examination of the very small child even below the age two years will frequently reveal to the trained observer those slight or marked signs of muscle imbalance which might later lead to scoliosis if A prominent scapula, a drooping shoulder, inequality left uncorrected.
of the extremities, habitual strained posture or imbalance of muscle tension form some of the outstanding points to be noted. Many deformities, however, have a definite and apparent cause. Some of these are congenital
while many are hereditary. In many of these cases, for instance, in club foot or congenital hallux valgus, prophylactic therapy will naturally be
of
no
avail.
FIG. 284
FIG. 285
FIGS. 284 and 285.
Exercise of gluteal muscles.
Fig. 284
relaxed.
Fig. 285
contracted.
Many
postural and other defects develop in older children,
who
in
earlier years show no apparent abnormality. Since we cannot tell which child will grow straight and which one will develop postural defects it is
the physician's duty, as supervisor of the rising generation, to make prophylactic exercises available to all children of school age and particularly of preschool age. Muscular education can be effected best during the early years of life, as it is during this period that the body still has the degree of flexibility which it is so desirable to preserve. Carefully supervised exercises will prevent the formation of habit errors in posture and
carriage.
Habit errors and muscle imbalance resulting therefrom must be considered the cause of poor posture much rather than underdevelopment of the musculature due to chronic illness or to faulty nutrition.
427
Some of these exercises require apparatus while others do not. None is strenuous or exhausting. The exercises are given with the following principal objectives in view, namely to strengthen the muscles of the chest in order to benefit the circulation and respiration, to stretch the anterior shoulder girdle muscles which are frequently in spasm or shortened, to stimulate the abdominal muscles, and to stretch the shortened psoas group; to strengthen the muscles of the back and the weakened muscles
FIG. 286
FIG. 286.
FIG. 287
posture: Head carried forward, chest sunken, round shoulders, abdomen sticking out, feet everted. FIG. 287. Good posture: Head up, chest raised, abdomen in, gluteals contracted, toes pointed straight ahead.
Bad
and the glutei, so that all muscle secure the correct posture of the pelvis, the normal position of which is mainly responsible for good alignment of the entire skeleton. In this connection it must be mentioned that the posterior muscle groups of the legs, the calves and hamstring muscles very frequently show a tendency to shorten and to go into spasm. The cause for this spasm
of the leg, especially the anterior tibials
groups involved
may
sometimes
is obscure, sometimes it is due to diseases of the back or it is secondary to a weak foot condition. Wearing of exceptionally high heels
428
EXERCISE
cause it or it may be the penalty we pay for standing in a position to which the human body is not yet fully adapted. which could Tight posterior muscle groups may cause painful condition be explained otherwise. Obscure pain in the lower extremities, the hardly lower back, the shoulders, even the arms, can thus be explained and
may
remedied by the application of special corrective exercises which stretch the posterior muscle groups (Fig. 288).
will
FIG. 288
FIG. 288. FIG. 289.
FIG. 289
Exercise for stretching of posterior muscle groups. Wall exercise to obtain proper posture.
methods have been described for promotion of proper posture. Ewerhardt has suggested a useful posture test. By placing a proper distribution of weight on the feet and adjustment of hips, chest and head the patient raises his heels off the floor without further forward swaying of the body. The patient is instructed to repeat this test every hour for two to three weeks until he has learned "the feel" of this movement. Then repetition will establish the "habit" of the position. In standing the patient must be reminded to assume the correct position
Many
of the pelvis.
This
is
obtained by standing as
tall
as possible against the
429
wall with back flat and abdomen in, the feet, hips and shoulders touching the wall (Fig. 289). This position must be maintained when walking. To avoid fatigue insist on frequent rests, lying and sitting, with proper res-
piratory exercises at regular intervals. To secure proper poise without muscle tension the trunk should be in proper alignment with the weight forward and on the outer borders of the feet, the lower abdomen pulled in and up, the back flat, the chest
raised, the head up, the chin in. The body must be stretched tall, easily without tension and the shoulders will assume their proper place. A firm flat abdomen is the foundation of good body mechanics; therefore, the abdominal muscles must be specially trained (Figs. 270-273). Great attention must also be given to develop correct breathing as outlined above. If a patient shows too much fatigue, tension or weakness he should be kept in the recumbent position until he masters the entire muscle group. The sitting posture likewise calls for the back flat against the back of
the chair, the pelvis horizontal, the chest and head up, chin and abdomen in. Sitting as tall as possible without tension must be insisted upon. Patients suffering from chronic diseases frequently fall into slovenly attitudes which will retard recovery and eventually lead to mental and
Bedridden patients unconsciously slump, especially of pillows. This is particularly true in traumatic cases and in arthritic and tuberculous conditions, and calls for constant vigilance. Poor body mechanics will then make for tension, fatigue and increased irritability. The first consideration with a bed patient is to see that he is lying properly, that the back is flat, the chest up, the chin in and all muscles relaxed. This position must be maintained when the upper part of the bed is raised and pillows are placed for comfort. Stressing the raised chest and flat abdomen, and telling the patient to be tall will help to impress the
physical defection.
when supported by a number
lesson.
If postural exercises be instituted early and the position changed frequently, bedsores, wasting, constipation, weakness and prolonged convalescence can be avoided. When a scoliosis has developed one should not assume that any group
back muscles can be isolated and strengthened by means of exercise as to correct a structural curvature. Such a technique would render the
of
spine only more flexible and would therefore cause progression of the deformity. In functional scoliosis carefully chosen and supervised asymmetrical exercises may be of benefit to make the patient conscious of a lower shoulder or of a prominent hip. However, even there the use of symmetrical exercises is preferable. Experience has shown that children respond much better to this type of gymnastics. Underwater Exercises. In the re-education of a patient with muscle
,
in the gymnasium have proven to be of however, present themselves when a patient is treated in the dry gymnasium, namely the elimination of gravity and of friction. The problem was met to some degree by various devices. Overhead swimming belts and slings to support the trunk and the extremities, smooth powdered boards to eliminate friction of the treatment table are helpful to a certain extent. Since it is known that a body will float in
weakness corrective exercises
definite value.
Two problems,
430
water despite
its
EXERCISE
own weight a method was developed weak muscles.
to utilize this
medium
for the treatment of
In water the action of gravity and friction can be eliminated. The into water loses weight because its specific gravity is so that of water; therefore weak muscles are able to perform movements nearly with greater ease, and even can execute action that could not be done in the dry gymnasium. In addition to this mechanical effect of the water its thermal effect also must be considered. Water of neutral temperature (92 to 96 F.) has a known sedative effect and will improve the circula-
body submersed
Water of somewhat higher temperature (96 to 101 F.) will prove even more relaxing and will help in reducing muscle spasm. The sedative effect is of great importance in order to obtain a smooth rhythmic coordinated movement. Two means of underwater exercises have been developed, the large pool with its moderate temperature and the tank, the temperature of which can be adapted more readily to the individual patient's needs. Tanks of various shapes have been devised to permit as complete a The key-hole shaped range of motion of the extremities as possible. Hubbard tank is widely used, as is the butterfly shaped Currence modification (Fig. 250). These tanks are constructed of monel metal which renders them durable and non-corrosive. But even a galvanized iron tank usually used for different purposes and available through mail order houses could be adapted for underwater therapy. The patient is lowered into the tank by means of an overhead trolley. In the tank he is supported by a shoulder sling or a plinth depending on how much support is required. The temperature of the tank ranges between 96 and 101 F. The average duration of the treatment is twenty minutes.
tion.
The exercises are given by the They may consist of passive or
technician standing outside of the tank.

active exercises.
Whirlpool agitators can be placed in the tank for an added hydromechanical effect (Fig. 251.) This will stimulate the skin, improve the circulation and will have a toning
effect.
The tank
It
is
lends
itself for
treatment of a great variety of conditions.
largely used for patients suffering from rheumatic orders, also for mobilization of limbs following fractures
and arthritic disand postoperative
orthopedic procedures. As a general rule to acquaint patients with underwater therapy the tank is used before the institution of pool therapy. This will eliminate apprehension and fear of water. The therapeutic pool should be located in a light and well ventilated room. It should be sufficiently large to accommodate two to four patients and one or two technicians. It should be about 24 to 26 feet long, 12 to 15 feet wide, the depth should be graded from 2 to 4 feet. The floor should consist of non-skid tile. Underwater lights are an excellent addition. There should be an overflow gutter, strongly built so that appliances and supporting rests may be hung from it. and also to enable the patient to hold on for free exercises. The temperature of the water should be 90 to 94, the room temperature about 86 F. The water must be filtered and
sterilized
and preferably constantly circulating. Sterilization is effected by chlorination or by means of ultraviolet light. The chlorine content of the water is checked several times a day with the Hellige colorimetric
method. Bacteriological
tests for B. coli are
taken twice a week. Suction
REFERENCES
431
cleaners are used twice a week and the pool is emptied and scrubbed once a week or once in two weeks depending on its use and load. Before the patient in his bathing suit is lowered into the pool by means
on a ramp or by an overhead trolley he is asked to void and then given a cleansing shower. In the pool he is floated by the technician to his particular station either to a monel metal plinth or to a trunk or head support. The various types of supports are necessary to localize as much as possible muscle action and to prevent muscle substitution. Splints may be applied to keep an extremity supported. The technician can give exercises to one patient while supervising another in the pool. One technician should not attend to more than 2 patients at a time unless she is teaching swimming to a homogenous group. The average treatment will last up to thirty minutes, after which time
of a stretcher
the patient is removed from the pool, dried and moved to an adjoining solarium or rest room. Pool treatments were originally introduced for the redevelopment of muscles weakened by infantile paralysis. Even in the acute phase of the disease hot pool treatments have been recommended by Hipps and Crook and long previously by others. Today the scope of the therapeutic pool
Postoperative orthopedic conditions, sciatica, low back pains, osteo- and rheumatoid arthritis, spastic paralysis, muscular incoordination and various neurological conditions have been benefited by the underwater therapy. Experience has shown that the low back syndrome group has done unusually well in the pool. Since movement is much easier under water, the danger of increasing spasm in the back muscles
has been widened.
is
decreased.
The
psychological effect of comparatively easy
movement
of the patient
must not be overlooked.
Most patients prefer pool and tank treatments to dry gymnasium treatment because of the obvious relaxation and ease of movement experienced
in the pool.
REFERENCES
1.
CURRENCE,
1935.
J.
D.:
Under Water Therapy
in Arthritis, Arch. Phys. Ther., 16, 291,
2.
3.
EWERHARDT, E. W.: Posture, Medical Physics, The Year Book Publishers, 1944, HANSSON, K. G.: After Treatment of Poliomyelitis, Jour. Am. Med. Assn., 113, 32.
1939.
4.
5.
Hydrogymnastics, Medical Physics, The Year Book Publishers, 1944.
6.
HIPPS, H. E., and CROOK, B. L.: Early Treatment of Infantile Paralysis, Arch. Phys. Ther., 25, 403-407, 1944. LOWMAN, C. L. Technique of Underwater Gymnastics: A Study in Practical Appli:
7.
Los Angeles American Publications, Inc., 1937. SMITH, E. M., and CROOK, B. L.: Underwater Therapy at Spas, Jour. Am. Med.
cation,
Assn., 124, 505-509, 1944.
PART V
Applied Physical Therapy
CHAPTER XXIV
General Considerations. Review of Physical Measures. Angina Pectoris. HypertenExercise in Cardiac Patients. Hypotension. Cardiac Neuroses. Peripheral sion. Vascular Disease. Diagnostic Considerations. Review of Physical Measures. Neurovascular Disorders. Raynaud's Disease. Organic Vascular Disorders. ArterioObliterans. Thrombophlebitis. Thromboangiitis Obliterans. Thrombosis and Embolism. Care of Feet in Peripheral Vascular Disease.
sclerosis
Acute
General Considerations. Physical measures in the treatment of internal medical conditions form an important part of their routine management. The European literature has contained for many years studies by clinicians of physical therapy in medical conditions and it is a sign of definite progress that there appear now in the American literature on the same subject, an increasing number of contributions on controlled clinical and experimental studies. These measures will be of best service in the hands of a good clinician, who employs them in conjunction with other indicated therapeutic measures and not to their exclusion. Their rational employment must be based on a definite diagnosis and a clear conception of their physiological effects, and of course, also on a safe and efficient technique
of application. All competent clinicians agree that there is a large field of applicability for physical therapy in cardiovascular disorders. Rest, voluntary exercise,
massage and mechanotherapy, hydrotherapy and electrotherapy may be employed, according to the type and stage of the disorder and the circumstances of the patient. Physical measures are especially valuable in cardiovascular psychoneuroses or the nervous type of cardiac diseases; but even
in hypertension or arteriosclerotic cardiovascular disease or that caused by other general systemic degenerative diseases syphilis, bacterial infec-
tions or toxins much relief can be given by properly selected and applied physical therapeutic agents. Many of these measures can be effectively applied at physicians' offices and the patients' home; others involve institutional care or belong to well-equipped health resorts. Review of Physical Measures in Cardiac Conditions. Rest and Relaxation. Physical as well as mental rest is a primary measure of effective treatment in all cases of circulatory insufficiency and in many cases of nervous heart conditions. Reduction of activity in less severe cases requires
judgment and experience.
It has been shown that excessive neuromuscular tension tends to maintain elevated blood-pressure even in normal individuals, while cultivated relaxation of skeletal muscles (Jacobson) has enabled a satisfactory control of many cases of hypertension. Undoubtedly
(432)
ANGINA PECTORIS
433
part of the favorable effect of many physical therapeutic office procedures can be traced to their systematic introduction of a period of rest and, at least, partial relaxation amidst an active daily life. Exercise. Active exercises if performed gently, slowly, evenly and with sufficient rest between movements, aid more than stimulate the heart in its work, provided cardiac insufficiency is not too pronounced. They stimulate respiratory movements and thus facilitate pulmonary circulation. Vigorous exercises enhance the work of the heart and with enough cardiac reserve power present, a grading of exercises can be accomplished according to the individual cardiac condition. Massage and Passive Exercise. When the patient is confined to bed because there is marked dyspnea even during rest and the heart is unable to maintain a fairly normal circulation, gentle stroking massage and passive movements may be instituted. Massage tends to move the blood out of the veins of the manipulated parts, while passive movements cause an alternate lengthening and shortening of blood-vessels and expression of the blood towards the heart. Most of these patients also respond well to general body massage. Gentle electrical muscular exercises of the extremities by the Bergonie method or by other surging low frequency current applied in a water bath are also of definite clinical value. Hydrotherapy. A cold bath at 85 F. and less increases peripheral resistance and thus slows the heart's action and increases its work. Warm baths, 100 to 104 F., increase the heart frequency and lower the bloodpressure by decreasing the peripheral resistance; arterial tone falls, and despite the increased work of the heart, the needed increase of blood flow to the heart muscle may not take place. Such baths are therefore contraindicated in coronary sclerosis. In the carbon dioxide bath the tiny bubbles of the gas stimulate the nerve endings and give rise to the sensation of heat. In addition, the fine bubbles of carbon dioxide covering the body prevent heat loss; hence a bath containing carbon dioxide can be given at a decidedly lower temperature than one without it. These baths cause dilatation of the peripheral vessels, and increase pulse-pressure, the cardiac output, and the bloodpressure. At 92 F. they facilitate the work of the heart, while at lower temperatures, about 86, they stimulate its action. Electrotherapy. Electrotherapy is chiefly employed in the form of cardiac diathermy, although some clinicians have reported results with mild galvanic treatment through the cardiac area. Deep heating of the cardiac muscle and its blood-vessels should increase the blood flow to an impoverished myocardium and causes disappearance of the partial
anoxemia.
small heat
lamp applied
to the cardiac area for fifteen minutes to
half hour, will often give relief in cases of precordial distress due to neurosis or reflex irritation; in others, short applications of the Oudin current may
be helpful.
Angina Pectoris.
There are no
definite pathological
changes responsible
for this distressing symptom complex, consisting of recurrent attacks of severe pain in the region of the heart radiating to the shoulder and often
show
accompanied by great anxiety and fear of approaching death. Some cases alterations in the aorta, and changes limited to the muscles of the coronary arteries. In patients beyond middle age there may be general
28
434
In younger individuals, aortitis, primarily luetic, be the underlying cause. During the acute attack, physical measures may of treatment consist of absolute rest and mild heating to the precordial
arteriosclerotic changes.
region.
Recent studies by Freedberg et a/. 6 on the effect of external heat and cold on patients with angina pectoris support the concept that coronary artery vasomotor changes, probably reflex in origin, exert a contributory influence in precipitation of attacks of angina pectoris and that heat acts as a coronary vasodilator and cold as a vasoconstrictor, or to prevent vasodilatation. Prophylactic use of heat enables many patients to do considerably more work in a cold atmosphere and suggests that local application of heat may be valuable in preventing attacks in daily life under
certain circumstances.
7 Cardiac diathermy has been reported on favorably by Hyman and by observers abroad as an interval treatment of angina pectoris caused by coronary disease. Either form of diathermy may be employed one condenser pad or metal electrode corresponding with the size of the heart is placed over the cardiac area and a somewhat larger dispersive electrode over the back. A single coil or treatment drum may also be employed. A very moderate strength of current, 500 to 750 milliamperes with longwave diathermy, is employed for ten to twenty minutes. The patient is best treated in the sitting position and a careful check on the rate and quality of the pulse must be kept and, after treatment, he should rest in the recumbent position for one-half hour before he is allowed to leave the office. Whenever so indicated, home treatment may be administered with a portable machine at the patient's residence. In the majority of Hyman's cases with coronary thrombosis and with electrocardiograms showing deviations of the terminal ventricular complex, diathermy gave symptomatic relief in those instances when standard methods of drug therapy had failed to produce any lasting benefit. Simultaneously with the clinical improvement there was improvement in the electrocardiograms, the previous negativity of the T-waves first lessened and then a normal positive deflection was obtained. These cases were all
:
treated at least six months or later after their last attack. Hyman is of the opinion that diathermy will do more harm than good in the acute and
subacute stages of coronary disease. The dramatic results reported by Nagelschmidt 12 with diathermy in acute attacks of angina pectoris may possibly be explained by the fact that these cases were mostly attacks of pseudoangina, caused by a cardiac neurosis. In such event, diathermy may bring immediate relief. Hypertension. The level of the blood-pressure is a resultant of several factors, chiefly the cardiac contractions, the arterial recoil, the arteriolar peripheral resistance and the state of the capillary bed. Continued high blood-pressure occurs from a number of different causes: (1) nephritic conditions, such as acute glomerulonephritis; (2) essential hypertension and (3) symptomatic hypertension due to hyperthyroidism, denervation of the carotid sinus, etc. Essential hypertension is still idiopathic as to its origin. According to some, it represents the first stage of arteriosclerotic high blood-pressure, while according to others, it is brought about by toxic, nervous or other factors, causing an increased tonus or spasm of the arterial walls. There seem to be no demonstrable anatomical changes,
HYPERTENSION
435
only functional disturbances in this primary type. In the other types of hypertension there are pathological alterations in both small and large blood-vessels, arteriosclerosis, aortic insufficiency and degenerative processes in the kidneys and brain. These changes result in increased heart action and a permanent increase of blood-pressure and, as this is necessarily a compensatory measure, there is usually no justification for physical therapy directed toward a lowered pressure. We do not combat fever as a symptom unless its continued intensity endangers the organism. Physical measures are of a recognized value in the essential type of hypertension. It is a well-known fact that increase or decrease of bloodpressure can be induced by a number of physical agents. Rest, avoidance of bodily and mental exertion is the simplest and most rational of these. Others are the high-frequency current, carbon dioxide baths, general ultraviolet irradiations and hot body baths. Not every case of primary hypertension needs treatment, only those in which there appear such definite symptoms as headache, dizziness and a eense of oppression. Several methods of high frequency application, local and general, have been reported on favorably in the reduction of essential hypertension. The earliest ones were autocondensation and general diathermy, advocated by Albutt and others. The technique of these two methods is described in
Chapter
XL
The
physiological effects are chiefly attributable to the mild
general heating action, consisting of flushing and capillary dilatation; mild sweating may occur, while metabolism is quickened with an increase of These effects are coupled with a relaxation of the solids in the urine. vascular periphery, leading to a fall in blood-pressure. The fall as a whole
usually temporary but, over a series of treatments, as a rule a small net gain results. The symptomatic improvement is usually marked and may be explained by a redistribution of the vascular load, a tonic effect on the heart muscle and the metabolic stimulus following the repeated mild general heating and relaxation. It appears as if a vicious circle is being interrupted and the normal tendency to correction is allowed to exert its influence. Treatments should be administered on alternate days at first; after about a dozen treatments, depending upon the result achieved, the frequency of treatments is gradually reduced. If in patients with a primary hypertension there is no reduction after a course of treatment, the existence of marked organic changes may be suspected. Clinical work with short-wave diathermy has established several new
is
techniques of treating essential hypertension. Laubry, Walser and Meyer report that transcerebral short-wave diathermy of weak intensity but of comparatively longer application ordinarily reduces the tension by several Comparatively good results were obtained by intense heating degrees. with short-wave or long-wave diathermy of the muscular masses of the
10
Reduction of pressure was noted irrespective of the localization of short-wave or diathermic application. Intense dosage has permanently lowered the arterial tension in some patients. Types were encounextremities.
others,
in
tered in which no measure produced a reduction of pressure, while in any form of treatment resulted in reduction, but this effect was
maintain. These clinicians are of the opinion that the manner which either local or general short-wave applications affect angina pectoris and high blood-pressure is not definitely established. Undoubtedly, there is an underlying effect on the sympathetic nervous system which
difficult to
436
apparently reacts more favorably to low intensities of local short-wave irradiation; however, that the thermic effects play an important role need not be doubted. The view that the factors inducing lowering of essential hypertension are sympathetic reflexes, is supported by the results reported by Pizarro and Levisman 14 following application of diathermy to the carotid sinuses. They selected patients who did not improve on rest and applied diathermy by two electrodes of 1 by 3 inches over the carotid sinuses of the neck and a dispersive electrode of 4 square inches over the pectoral region. This treatment lasted ten minutes and its duration was increased five minutes every other day up to thirty minutes. Short-wave diathermy to the kidneys in cases of hypertension due to 15 Patients are treated nephrosclerosis has been recommended by Rausch. with condenser pad electrodes of equal size in the recumbent position over the kidneys and the abdomen and a felt spacing of 1 to 2 cm. between
the electrodes and the body. Treatments of one and one-half to two hours' duration, at heat of comfortable toleration are applied. Best results were seen in cases where the sclerosis was in its initial stage and no changes in
21 the renal parenchyma have taken place. Trolow and associates report on long-wave diathermy to the iliac plexus and the suprarenals in hypertension and attribute the favorable result to an effect on the endocrinesympathetic system and an amelioration of the vascular spasm in the abdominal organs. Two electrodes of suitable size were placed so as to cover the two kidneys and the suprarenals and a third electrode was applied in the center of the epigastrium. A current from 500 to 2000 was applied for five to ten minutes and the patient had to rest thirty minutes afterwards. Out of 25 patients blood-pressure was reduced in 15 and this lasted from eight to ten months in some of the cases. Among other physical measures for relief of arteriosclerotic cardiovascular disease is the galvanic bath, administered as a full bath or a four cell bath (Chapter VIII). It has been recommended in compensated valvular lesions for the increase of the reserve strength of the heart and also in selected cases of myocardial weakness and cardiac neuroses for general tonic effects, similar to those of the carbon dioxide (Nauheim) bath. These and some other measures are often best administered under close supervision in well-equipped health resorts or institutions. Exercise in Cardiac Patients. Exercise is one of the most important
MA
measures in patients with ambulatory cardiac conditions, arteriosclerotic and other. Nylin 13 states that no standard program for exercises can be given, but the following rules must be strictly observed: (1) There should be an interval of at least one hour between a meal and the exercises. (2) No exercises should be taken in the evening. (3) Treatment must be progressive. (4) In the beginning, exercises are taken in the supine position, later in the sitting and then the standing position. (5) The force of gravity must be considered in execution of the exercises. The operator may have to assist movement in upward raising of the leg or trunk and may have to resist it in lowering the part to the horizontal position. (6) Uni- or bilaterality of exercises of the extremities and their range must amount of cardiac reserve power. (7) individual exercise
depend on the
is
An
not repeated
in the
same part
of the body,
but the whole set
of
movements may be
CARDIAC NEUROSES
437
repeated if the patient's condition permits. (8) Inspiration must accompany exercises of the arm that expand the thorax, expiration those that compress
it.
(9)
A pause of two or three minutes should follow each individual

deep respirations should precede and follow each
of terrain exercises practiced in health resorts, ground and for a short
is
exercise.
whole
(10) Five to 10 set of exercises.
The
Stokes-Oertel
method
consists of graded walking outdoors, first on level distance; as cardiac function improves the distance
gradually lengthened
and the walking done on a gradually inclined plane. The pace should be slow and even with frequent periods of rest. If dyspnea occurs, walking is discontinued until breathing has become normal. Benches and markers are placed at intervals along the path, and a competent attendant accompanies the patient, or a conveyance
if
is
held ready to take the patient
home
he becomes
tired.
The etiology of "essential" low blood-pressure is as as that of essential high blood-pressure. Its syndrome includes idiopathic fatigue, lack of physical and psychological tone, pallor and depression. Although any cardiac abnormality may not be present, signs of circulatory
Hypotension.
skin and muscles.
lants
insufficiency abound, such as irregular pulse, acrocyanosis, limpness of Low blood-pressure can be raised by peripheral stimu-
The
which reflexly affect the endocrines or the autonomic nervous system. static modalities are foremost among these, such as the static head
The Oudin
and the static wave current applied to the spine. current through a condenser electrode played up and down the spine or over the abdomen exerts a similar effect. Short applications of diathermy directly to the heart also raise the blood-pressure by improving the tone of the heart muscle. General ultraviolet irradiations are also
breeze, static insulation
useful.
course of thermal baths

first,
tion at
is often helpful: they must be of short duraand then gradually lengthened. Additional general massage
or exercise are valuable
if carefully administered. Cardiac Neuroses. A very large group of patients with temperamental, unstable make-up complain of pain which, they believe, originates in the heart. At times patients with an organic heart disease present exaggeration
symptoms which are clearly psychogenic. Palpitation, dizziness, shortness of breath are the most common symptoms complained of in those
of
patients.
Profound emotional disturbances, a misinterpreted remark of an examining physician, or a series of dramatic exertions like in the late
war, are the precipitating factors. Physical therapeutic procedures are eminently suitable to combat these cases, for they render not only subjective comfort but also allow repeated reassurance on the physician's part, the restoration of the patient's confidence; one should choose between thermal, hydriatic and electrical measures the most suited for the patient's condition: a simple heat lamp,
cardiac diathermy or galvanic current in mild cases for combating pain and palpitation, general ultraviolet irradiation in increasing doses, hydrotherapy in the form of Scotch douche, general body massage for tonic and sedative purposes. At times the removal from home environment, and
treatment in a resort or institution equipped with modalities may be advisable.
all
physical therapy
438
PERIPHERAL VASCULAR DISEASE
The study and treatment of peripheral vascular disease has made considerable advance in recent years and physical measures play a definite role in its treatment. The common feature in all types of the disease is
bed and there are two main facvascular spasm or organic occlusion. tors in this condition, an obstruction
of the peripheral vascular
TABLE
51.
CLASSIFICATION OF PERIPHERAL VASCULAR DISEASE (DE TAKATs) 20

Organic
Functional
Acute Thrombosis
Vasospastic
Embolism
Chronic Anomalies (1) Congenital
Occlusions
(1) (2) (3)
Neurogenic Mechanical Endocrine Toxic

Vasopsralytic Erythromelalgia
Traumatic Inflammatory (thrombo-angiitis)

Degenerative (arteriosclerosis)
first
Diagnostic Considerations. In treating peripheral vascular disease the prerequisite is a definite diagnosis. Unrecognized cases of this condition are often treated under such stereotyped diagnoses as neuritis, flat foot, varicose veins, periostitis and myositis. The next prerequisite is a differentiation of the type and extent of the vascular occlusion including the determination of how much dilatation the vascular bed is capable. The simplest tests are the palpation of the arteries of the lower extremity, the femoral, popliteal, dorsalis pedis (first interosseal space) and the posterior tibial (behind internal malleolus). Occasional instances of absence of pedal pulses in case of existing adequate circulation can be discounted by the good color and warmth of the feet. In spastic occlusion, at times, the presence of pulsation may vary. Color changes with the elevation of the leg are also valuable signs but the most useful ones are those of determining the skin temperature of the extremities. Differences between two sides greater than about 1 F. are discernible by the palpating fingers or thejpalm of the hand. Electrical readings of the surface temperature of the
skin with thermocouples are Oscillometric examination
available for accurate measuring. of a delicate pressure recorddevice, the oscillometer, records the extent of the arterial blood flow ing in the extremities. Comparison of the pressure levels of two sides known as the oscillometric index, may furnish evidence of unilateral peripheral
now
by the readings
vascular disease, or comparison with normals may furnish evidence of bilateral general vascular disease, if both indices are equally decreased. In the presence of major arterial obliteration the oscillometric reading is very low; in spastic conditions of major arteries it is somewhat lowered, while in purely arteriolar obliteration or spasm it is practically normal.
19 According to de Takats patients with organic arterial disease are divided into four groups: (1) those who have an oscillometric index of over 0.5 cm. at the ankle, who complain of claudication after walking five blocks or more and who have no pain at rest; (2) those with an oscillometric index under 0.5 cm., who complain of claudication within two blocks and who have no pain at rest; (3) those who have continuous pain at rest, show no or minimal oscillations at the ankle and have signs and symptoms of ischemic neuritis; (4) those who have actual gangrene with no oscillations

at the ankle.
439
Obviously there are borderline cases, as there
may
be some
variation of these criteria from
day
to day.
Landis and Gibbon 9 use an easily applicable diagnostic test to determine how much dilatation of the vascular bed is possible. The patient is placed in a recumbent position in a room at temperature of about 70 to 72 F. The temperature of the skin surface of the big toe is determined with an ordinary fever thermometer. The arms and hands of the patient are then immersed in hot water at about 113 F. for twenty minutes; this causes a reflex vasodilatation and now a second reading on the big toe is made. F. is obtained, it shows that either there is If a normal reading of 91.4 sufficient vascular bed to overcome the organic obstruction or there is an element of spasm present. If the normal vasodilatation level of 91.4 F. is not reached, there must be a deficiency of available collateral circulation and a diminution of safety factors. This will frequently occur in arteriosclerosis, thrombo-angiitis obliterans and embolism. Review of Physical Measures in Peripheral Vascular Disease. A someof physical measures, thermal, mechanical, electrochemical has been proposed in the treatment of peripheral vascular diseases. Every method and apparatus has its merit in the proper place,
what bewildering variety
but none should be applied indiscriminately, because it may produce more benefit. The skin and underlying tissues of an extremity suffering from peripheral vascular diseases are very easily vulnerable by mechanical, chemical or thermal agents. Therapeutic measures which in usual conditions would not damage tissues are apt to produce gangrene and necrosis in ischemic extremities which in turn may necessitate major 1 amputation. Barker reported that the precipitating cause of ulceration and gangrene in approximately 39 per cent of a series of 171 cases of thrombo-angiitis obliterans and in 35 per cent of 115 cases of arterio-
harm than
sclerosis obliterans
was due to
ill-advised therapeutic procedures.
In order to avoid repetition, the pertinent physiological and clinical effects as well as the contraindications and dangers of the numerous physical therapeutic measures will be first presented in detail, while the pathological considerations and the scheme of treatment of each condition will be discussed subsequently. Thermal Measures. Heating causes an increase of circulation and metabolism which is paralleled with the increase of temperature; but while heat increases considerably the rate of blood flow in a normal extremity, in peripheral vascular diseases, where the circulation is impeded as a result of organic or spastic changes, little or no increase of blood flow may be brought about. The consequence is that the excess amount of heat which in normal conditions would be dissipated by the increased circulation, remains locally concentrated in the tissues and, therefore, easily results in severe burns and gangrene of the extremities. Therefore, in all forms of thermal applications the vulnerability of tissues with poor blood supply must be remembered and it should become axiomatic, that the more the circulation of the limb is interfered with, the nearer the neutral point must be the temperature of application. (Scupham. 16 )
Generally speaking in
all
cases of peripheral vascular disease circulation
be increased by warming the patient's trunk and thighs or opposite normal extremities (reflex action) or by a generally
of the extremities should
440
increased blood flow.

electric
Conductive heating from hot water bottles and pads should not be applied directly to the extremities. Thermostatically controlled heating, according to Starr and Bierman, is
the safest form of heating. A heating hood, as illustrated, is placed over the affected parts and the temperature control is adjusted between 93.2 and 95 F., at the degree at which it gives the greatest comfort experienced by the patient; the constant maintenance of such a temperature keeps the circulation nearest to normal. In case of gangrene and ulceration, conIn emergencies trolled heating may be kept up for twenty-four hours.
and the absence
of thermostatic control,
an ordinary heating cradle can
be standardized to maintain a given temperature by means of light bulbs of graduated wattage; the patient may be instructed to turn on or off as
many
lights as will give
him most comfort.
FIG. 290.
Diagrammatic view
of arrangement for constant temperature treatment of lower extremities. (Courtesy of Ille Electric Corp.)
be employed in the treatment of gangrene and ulcers, remove thick sloughs and crusts, but the temperature should never be more than 102 to 105 F. Strong antiseptic solutions should never be used; boric acid is the most commonly used substance. In the treatment of acute thrombophlebitis hot wet packs may be used. Hot baths if employed should be of increasing temperature, starting at 95 F. and slowly increased to a comfortable temperature, but never over 105 F. Behrend 3 advocates the use of partial baths of slowly increasing
Hot soaks
may
especially to
The temperature is slowly twenty minutes from 37 C. to 44 C. Duration of the bath is fifteen to forty-five minutes. Slowly increasing temperature dilates the capillaries, and the plethysmographic studies proved that the
temperature
in obliterative vascular diseases.
raised within fifteen to
deeper located arteries are also dilated. Contrast baths have been widely advocated as a home treatment for peripheral vascular disease, especially for the symptom of intermittent claudication and in frostbite. Their technique has been described in Chapter XX. Contrast baths act as powerful skin stimulants, but do not increase collateral skin circulation. They can be employed twice a day;

care
441
must be taken that the
feet are carefully dried afterwards to prevent
cracking or maceration.
Diathermy is capable of inducing dangerous amounts of heating when applied to extremities with vascular disease. Even with the most expert technique there may occur increasing pain, cyanosis or, at times, definite
by reflex ischemia. It is now generally recommended that diathermy never be applied to the area of involvement, but higher up, to the thigh, lumbar region, or the trunk, so as to cause increased circulation indirectly without local overheating. The method of electromagnetic field heating is especially convenient, with the inductance coil wound round the thighs or the lower abdomen. Hypothermy has been recently recommended in the prevention and treatment of gangrene resulting from arterial occlusion and will be discussed further under arteriosclerosis obliterans. Electrochemical Measures. Ion transfer with vasodilating drugs is being on an increasing scale in treatment of certain types of peripheral employed vascular disease, with the technique described in Chapter VIII. Very 8 n satisfactory results have been reported by J. Kovacs, Montgomery et al.
pallor
in Raynaud's disease and scleroderma; painful ulcerations in some of these cases also healed concurrently. Chronic ulcers associated either with varicose veins or with occlusions following phlebitis seem to respond very well to this treatment; encourag-
have been seen in both acute and chronic phlebitis. Mecholyl ion transfer is contraindicated in patients who show constant elevation of temperature, also in cases complicated by asthma. Caution must be exercised and shorter treatments given to patients with heart involvement and to old persons in a feeble condition. Histamine ion transfer may be employed for the same indications but the therapeutic results have been less satisfactory. Mechanical Measures. Rest in bed with the extremities in horizontal position is of the utmost importance in all types of obliterative vascular diseases where gangrene or ulceration is present. It is also essential in acute embolism or thrombosis. To achieve full benefits it is necessary to find the level of greatest circulatory efficiency which is usually from 10 to 15 below the horizontal level. Postural exercises, first recommended by Buerger, are most valuable in the early stage of obliterative vascular diseases. It has not been proven that such exercise promotes the development of collateral circulation, but by emptying the vessels of old blood and filling them with new it seems to increase the peripheral circulation and promote tissue nutrition. The exercises are effective only if they are carried out systematically over a long period of time. The technique of Buerger's classic exercises is very
ing results
patient should start the exercises lying horizontal in the bed. are elevated to 45 degrees for one-half to two minutes, dependlegs ing on the length of time for complete blanching of the feet to occur. (2) Immediately after the first exercises the patient sits on the edge of the bed with his legs dependent, for two to three minutes, to develop an actual redness of the feet. (3) He completes the cycle by lying in a horizontal
simple:
(1)
The
The
position for three minutes. Usually five cycles are done consecutively and the exercises are carried out two to three times daily. Intermittent claudi-
442
cation seems to be the most benefited. In gangrene or ulceration this form of treatment is contraindicated. Intermittent venous occlusion produced by an inflatable cuff, brings about an increased blood flow by an active dilatation of the arterioles of the
compressed extremity. This method
is
fairly simple
and inexpensive, and
FIG. 291.
Rhythmic
is
constrictor.
(Courtesy of
The Burdick
Corp.)
its
chief
advantage
that
it
can be carried on for months away from the
hospital: one leg can be treated in the morning, the other in the afternoon, de Takats 20 states that in acute occlusions and threatening gangrene,
which require several hours of treatment, suction and pressure therapy
FIG. 292.
Suction-pressure unit.
(Courtesy of The Burdick Corp.)
is
far
more preferable, while in ambulatory patients, especially those living from hospitals or who cannot afford a long series of treatments, the
is preferable. This is also given to patients who have undergone sympathectomy for Buerger's disease or who have had
inflatable cuff therapy

one leg amputated and the other leg
of vascular occlusion.
is
443
or second stage
showing the
first
Passive vascular exercise (pavaex) is based on the observation by Landis 9 and others that by employing environmental changes in pressure periodically to the surface of a limb, there is an increased blood flow and some
elevation of skin temperature. At least temporary relief of "rest pain" of indolent ulcers are also observed. From a review of the therapeutic results nothing has pointed to a permanent improvement following the temporary benefit of the treatment. The uniform opinion is
and healing
that thrombo-angiitis obliterans does not respond so well to this form of treatment, and other simpler methods often produce better results. This is especially true in cases with intense rest pains or if an acute migratory phlebitis is present. On the other hand in acute arterial occlusions, frostbite and arteriosclerosis obliterans with or without diabetes, passive vascular exercises have been proved of value. Especially the latter group of patients often do not tolerate other forms of treatment. It is contraindicated if any acute or subacute inflammation, cellulitis, lymphangitis or thrombophlebitis is present. It should be particularly avoided in the
purulent type of diabetic gangrene.
FIG. 293.
Combination pressure and exercising device.
(Courtesy of the Plethorator Co.
The
form
oscillating bed, introduced by Sanders, is a modified and improved of Buerger's exercises, offering a convenient and comfortable method
of producing postural exercises regularly and systematically as well as passively for a long period of time without effort on the part of the patient. The unit is, in principle, a motorized hospital bed in which the head and
is alternately elevated and lowered. It can be applied for several hours daily without any discomfort. The speed of the cycle can be adjusted. It is indicated in the obliterative form of vascular diseases.
the foot
444
of the oscillating
Combinations
recently introduced.
The
by means
of a sling inflates the cuff at regular intervals
bed and venous hyperaemia have been in Figure 293 elevates the extremity and cuff at a rate of fifteen times an hour; it also
unit
shown
up
to the level of diastolic pressure,
followed by automatic deflation. These procedures can be employed combined or separately and thus the apparatus is applicable in obi iterative as well as in traumatic vascular deficiencies.
NEUROVASCULAR DISORDERS
Raynaud's Disease. The typical signs are attacks of vasomotor spasm, extreme pallor of a sharply circumscribed area, numbness and severe pain along the symmetrically affected extremities, more frequently the upper ones. The cause of this condition is still unknown, but is probably central local cold as well as anxiety or anger, may bring about or exaggerate attacks. Vasoconstriction of this nature may be relieved by peripheral stimuli; a failure to respond by dilatation is a sign of organic lesion. The most effective palliative measure in Raynaud's syndrome is iontophoresis with vasodilating drugs, mecholyl or histamine, with the technique described in Chapter VIII. This treatment is especially valuable for the relief of pain and the healing of ulcers. A systematic course of 10 to 20 treatments two or three times a week is advisable. Mild degrees of heating and, in selected cases, ultraviolet irradiation in mild sunburning doses, may be also considered. In scleroderma similar measures as in Raynaud's syndrome are useful.
;
ORGANIC VASCULAR DISORDERS

Arteriosclerosis is the most frequent Arteriosclerosis Obliterans. organic peripheral vascular disease; it is primarily a senile degenerative process in both the intima and media and is particularly common in males after the age of fifty. Arteriosclerotic changes are also underlying in the diabetic vascular disturbance, which usually appears about ten years earlier and is characterized rather by occlusion of smaller vessels. In most cases of arteriosclerosis the typical pipe-stem radials and the prominent and tortuous temporals are visible evidence of the widespread location of the degenerative changes. The arteries of the lower extremities are much
more frequently
affected, however, than those of the upper extremities. 19 According to de Takats so long as myocardial function is sufficient,
the increased peripheral resistance is overcome by an increased stroke volume of the heart and by a gradual development of collateral circulation. The failure of cardiac reserve as manifested by falling blood-pressure becomes the frequent cause of peripheral circulatory disorders, de Takats states that in treatment of these arteriosclerotic patients, who complain of intermittent claudication and later of rest pain, numbness, tingling or burning of the feet, all the vasodilators, sedatives and physical measures and also abstinence from tobacco must be utilized. It is in these cases where there is a real field for passive vascular exercise to develop and sustain collateral circulation. Mild heating by the thermal measures discussed is also in order. The author has seen a number of cases of early claudication promptly relieved by a course of inductance coil heating to
ORGANIC VASCULAR DISORDERS
445
the thighs. Careful heating may be also applied at home several times a for periods of fifteen to forty-five minutes, alternating with Buerger's postural exercises. In advanced cases where there are secondary skin lesions, ulceration or beginning gangrene, rest in bed and thermostatically controlled heat applied continuously for several hours are indicated, as well as mild passive vascular exercise, possibly use of the oscillating bed.
day
Hypothermy
stated in Chapter
(refrigeration) has been recently recommended, for reasons XXXI, to safeguard against or minimize gangrene
resulting from arterial occlusion. The most dramatic results from application of cold may be expected in arteriosclerotic gangrene complicating diabetes mellitus. 5 Surgery is usually contraindicated in such cases and refrigeration offers an alternative. The gangrenous leg may be packed in
ice,
thereby reducing catabolism of ischemic tissue and temporarily check-
This procedure may make possible control of ing growth of bacteria. diabetic acidosis so that the patient has a reasonable chance to survive
operation. It may be supplemented by application of a tourniquet distal to the proposed site of amputation. This completely isolates the gangrenous
area from the general circulation. Once applied, such a tourniquet must never be removed. Hypothermy is also valuable in preparation of the poor risk patient with vascular disease for life-saving surgery, and when used as an anesthetic in these cases it has valuable advantages over conventional methods. Thrombo-angiitis Obliterans (Buerger's Disease). This is a progressive vascular inflammation characterized by a migrating arteritis, with secondary thrombosis. It occurs in younger individuals and it has been shown that in the large majority of cases there is hypersensitivity to tobacco
present and since vasoconstrictor effects of nicotine are definite, smoking should be prohibited in any condition of impaired peripheral circulation. In the acute stage of thrombo-angiitis obliterans, thrombosis of a segment of an artery frequently occurs, leading to complete occlusion; this segment may be quite short or may extend from the popliteals to the dorsalis pedis vessels. In the chronic stage the arteries, veins and nerves are bound together in a dense mass of fibrous tissue. After the fiftieth year the disease usually subsides or arteriosclerotic changes may take place. The physical treatment of these conditions must be based on the amount of collateral circulation and spasm present and whether or not there are any secondary skin lesions. The general scheme of the physical treatment is the same as in arteriosclerosis.
Thrombophlebitis. In acute cases of inflammation of a vein associated with formation of a thrombus, circulation will be aided by elevation, and normal involution of the thrombus and periphlebitis promoted by external Barker and Counselled advocate that the leg be elevated 30 heating. the knee kept in extension and the hip in slightly outward rotation; degrees, the patient may move occasionally. Continuous hot packs are applied until the temperature has been normal for at least three days, until tenderness has disappeared, and until swelling has gone from the lower leg. Then the leg is lowered for two days and ten to sixteen days after onset of thrombophlebitis the patient is allowed up. In order to prevent
varices, edema, ulceration due to inadequate circulation, a leg support, either a solid rubber bandage or a heavy elastic stocking is applied from toes to knee before the patient gets out of bed.
development of secondary
446
twice during the day and removed at Ordinary activity is permitted, except long standing without walking, but when sitting or sleeping the leg should be slightly elevated for one or two months. After a few months the leg support can be permanently discarded, if there is no swelling after its temporary removal. Mecholyl iontophoresis has been favorably reported in cases of deep 17 also by de Takats for the thrombophlebitis by Sokolov and Meyers, softening of thrombophlebitic indurations. It should be applied in a 0.2 per cent solution, with the technique described in Chapter VIII, daily, for forty-five minutes for six to ten days, then two to three times weekly. Acute Thrombosis and Embolism. In these conditions combined treat-
The support should be rewrapped

bedtime.
controlled heating and careful passive vascular have been reported as of striking effect. Care of Feet in Peripheral Vascular Disease. In all cases of peripheral vascular disease and especially in those with signs of trophic disorders, in "inflamed" toes which are cold and in any form of infection, surgical procedures must be instituted only with utmost circumspection; small lesions must be treated with strict surgical cleanliness; any infection is preferably treated with moist wet dressings and the patient kept off his feet, de Takats 20 quotes the following general directions for the home
ment by thermostatically
exercise
care of the feet, prescribed at the Vascular Clinic of the Cincinnati General
Hospital
1.
2. 3.
Wash feet each night with neutral (face) soap and warm water. Dry feet with a clean soft cloth without rubbing the skin.
Apply rubbing alcohol (70 per cent) and allow the feet to dry thoroughly. liberal amount of petrolatum or toilet lanolin and gently massage. 4. Always keep the feet warm. Use woolen socks or wool-lined shoes in the winter and white cotton socks in warm weather. Use a clean pair of socks each day. 5. Use loose-fitting bed socks instead of hot water bottles, electric heaters or any other form of mechanical heating devices. 6. Wear properly fitting shoes and be particularly careful that they are not too Use shoes made of soft leather, without box toes. tight. 7. Cut the toenails only in good light and only after the feet have been cleaned thoroughly. Cut the nails straight across.
Then apply a
& Do not
9.
cut corns or calluses.
10.
feet. Particularly never use tincture of iodine, lysol, cresol or carbolic acid. 12. Go to the doctor at the first sign of a blister, infection of the toes, ingrowing toenail or trouble with bunions, corns or calluses. 13. Drink at least 4 qts. water each day. 14. Eat plenty of green vegetables and fruit in an otherwise well-balanced liberal diet, unless some special diet has been ordered. 15. Do not use tobacco in any form. 16. Have some member of the family examine the feet at least once each week. 17. Carry out the exercises prescribed. Do them regularly and faithfully.
11.
Do Do Do
not wear circular garters. not sit with legs crossed. not use strong antiseptic drugs on the
REFERENCES
1.
BARKER, NELSON W.:

Assn., 104, 24, 1935.
The Danger
of
Gangrene
of the Toes, Jour.
Am. Med.
2.
BARKER, NELSON W., and COUNSELLER, VIRGIL

of Postoperative Thrombophlebitis,
S.:
Am.
Jour. Obst.
Prevention and Treatment and Gynec., 37-44, 644-651,

Ther., 18, 146-163, 1937.
1939.
3.
BEHREND, H.
J.:
Modern Hydrotherapy, Arch. Phys.
REFERENCES
4.
447
5.
6.
7.
BIBRMAN, WILLIAM: Thermostatically Controlled Heating Hood in Vascular Disease of the Lower Extremities, Arch. Phys. Ther., X-ray and Rad., 15, 530, 1934. EGAN, RICHARD L.: Refrigeration Treatment of Peripheral Vascular Diseases, Nebraska Med. Jour., 29, 217-218, 1944. FREEDBERG, A. S., SPIEGEL, E. D., and KISEMAN, J. E. F.: Effect of External Heat and Cold on Patients With Angina Pectoris: Evidence for Existence of a Reflex Factor, Am. Heart J., 27, 611-622, 1944. HYMAN, A. S.: Electrocardiographic Control of Diathermy in Angina Pectoris and Coronary Artery Disease, Arch. Phys. Ther., X-ray and Rad., 14, 270, 1933.
KOVA.CS,
J.
:
8.
ment
9.
of
The Iontophoresis of Acetyl-beta-methylcholine Chloride in the TreatChronic Arthritis and Peripheral Vascular Disease, Am. Jour. Med.
1934.
Sci., 188, 32,
LANDIS, E. M., and GIBBON,

dilatation in the
10.
A Simple Method of Producing VasoJ. H., JR.: Lower Extremities, Arch. Int. Med., 52, 785-808, 1933. LAUBRY, CHARLES, WALSER, J., and MEYER, JEAN: Pyretotherapy in Cardiovascular Diseases, Arch. Phys. Ther., 19, 144-154, 1938.
11.
MONTGOMERY, HUGH, TURNER, SARA
C.,
and SAMMIS, ELIZABETH
C.:
Use
of
Acetyl-beta-methylcholine Chloride Iontophoresis in Nonarterial Peripheral Vascular Disease, Am. Jour. Med. Sci., 201, 227-289, 1941. 12. NAGELSCHMIDT, F.: Medical Diathermy, Arch. Phys. Ther., X-ray and Rad.,
13.
November, 1928. NYLIN, JOSEF B.: Physical Exercise

376, 1939.
in Cardiac Conditions,
Med.
Rec., 149, 373-
14.
15.
16.
PIZARRO, R. CORLERO, and LEVISMAN, P.: Diathermy in Arterial Hypertension, Prensa meU argent., 24, 1625-1628, 1937. RAUSCH, Z.: Indications and Successes of Short Wave Diathermy in Circulatory and Renal Diseases, Fortschr. Ther., 10, 394, 1934. SCUPHAM, G. W.: Therapy of Arterial Thrombosis of the Extremities, Jour. Am.
Med.
17.
Assn., 104, 14, 1935.
SOKOLOV, RAYMOND A., and MEYERS, MAURICE P.: Treatment of Deep Thrombophlebitis and Chronic Leg Ulcers With Mecholyl Iontophoresis, Am. Heart Jour.,
17, 316-324, 1939.
STARR, ISAAC: A Thermo-regulated Foot Cradle for the Treatment of Peripheral Vascular Disease, Proc. Soc. Exp. Biol. and Med., 29, 166, 1931. 19. TAKATS, G. DE: Peripheral Vascular Disease, Jour. Am. Med. Assn., 104, 17, 1935. 20. TAKATS, G. DE, BECK, W. C., and ROTH, EUNICE A.: Peripheral Vascular Disease, Ann. Int. Med., 13, 957-979, 1939. 21. TROLOW, MALKOWA-RIABOWO and ALTMANN-PARGANIK: Diathermy in Hypertension, Wien. klin. Wchnschr., 47, 1121, 1934.
18.
CHAPTER XXV
RESPIRATORY, GASTROINTESTINAL CONDITIONS
Tuberculosis.
Bronchitis.
AND METABOLIC
Pleurisy.
Pneumonia.
Empyema.
Pulmonary
Gastric Neuroses. Conditions. Constipation. Intestinal and Peritoneal Tuberculosis. Abdominal Adhesions. Visceroptosis. Diseases of the Liver. Cholecystitis. Metabolic Conditions. Rickets. Infantile
Gastro-intestinal
Tetany.
Obesity.
Physical therapy measures in respiratory and conditions can be employed for combating the principal gastro-intestinal pathological changes or for alleviating one or more of the disturbing symptoms, as pain, spasm or other functional disorder. They can be directly applied to the site of the pathological changes or used for con-
stitutional effect.
Heat is the most important, most versatile and most readily available physical measure for the relief of pain and spasm when not caused by suppuration or an obstructive process and for the promotion of resolution in inflammatory conditions. The time-honored methods of poulticing
and
electrical
pads have been augmented by the more
efficient
radiant heat
generators and
by the penetrating method
of diathermy,
and short-wave
diathermy.
Low-frequency electrical currents are useful in atonic conditions of the abdominal wall and the hollow viscera. They exert a direct effect on the abdominal muscles and a reflex effect upon peristalsis. Ultraviolet irradiation in internal medicine may be employed either for
general tonic effect by small suberythematous doses, or for a marked erythema reaction in a circumscribed area with the idea of a protein shock therapy. Such irradiation, as well as incandescent light baths, may serve for constitutional effects also, in postoperative debility and some metabolic
disorders.
and systemic
combination or alternation of various physical measures for local effect forms the backbone of the treatment methods employed in health resorts. There is no reason why they cannot be similarly utilized in the treatment of many gastro-intestinal conditions in the office or at the home. Bronchitis. Acute and chronic types of bronchitis respond with symptomatic improvement to diathermy. In acute cases there is relief from the
pain and the soreness in the chest; in chronic cases there is less cough and easier expectoration. The technique of diathermy to the Behest is quite simple. With shortwave diathermy condenser pads of suitable size are placed antero-posteriorly with ample spacing (2 to 3 inches), by towels or by felt spacing with one layer of absorbent toweling next to the skin so as to absorb perspiration and prevent burns. The shorter the wave length employed and the more powerful the apparatus the more spacing may be employed. On alternate treatments the pads may be placed laterally on the chest or
(448)
PNEUMONIA
449
treatment disks on adjustable arms are employed. With the coil field method a treatment disk with a pancake coil is more convenient. (Fig. 168.) The duration of each treatment should be from one-half hour upwards. Treatment should be given at optimal intensity. With long-wave dia-
thermy, the simple antero-posterior technique as described in Chapter XI applied. The strength of the current may vary from 1000 to 2000 milliamperes. Preliminary surface heating by a 1000- or 1500-watt lamp directed to both sides of the chest adds to the effect. In chronic cases, especially those of asthmatic type, the additional use of ultraviolet irradiation is indicated. It may be employed either as general irradiation or applied to the chest only, using doses causing mild
is
dermatitis.
The marked relief given by this is explained by counter-irritation and by the mild protein shock from the irradiated area of the skin.
FIG. 294.
Short-wave diathermy to chest with condenser pad. Burdick Corp.)
(Courtesy of
The
A chest compress is a useful hydriatic measure for home treatment in both acute and chronic bronchitis. It is applied diagonally from under the axilla across the opposite shoulder on either side and the covering dry flannel strips are applied the same way and fastened with safety-pins. A compress applied for several hours or during the night relieves pain and
diminishes coughing by easing expectoration. Pneumonia. In the early literature on diathermy, much has been written about its use in pneumonia; and a number of reports attesting to the favorable effect of long-wave diathermy on the pneumonias appeared in the world literature, the only controlled study being that of Wetherbee, 23 who reported a mortality of 11.1 per cent in the diathermy group and 33f per cent in the control group. In classical animal studies of Binger and Christie 1 the rise of temperature within the pneumonic lungs following diathermy was readily demonstrable, yet in 3 pneumonia patients in which experimental lung punctures were performed no such rise was evident. They feel that the therapeutic value of diathermy might be due to effects on the pulmonary circulation and not to local heating. The technique of application is the same as in bronchitis. Treatments should be administered for one-half to one hour at a time and repeated several times a day, at intervals of six to eight hours, depending on the severity of the symptoms present. After resolution they may be continued
29
450
RESPIRATORY CONDITIONS
all
about twice a day for another week in

of being affected.
cases where the heart
is
suspected
The usual clinical effects observed in an uncomplicated case of lobar pneumonia are the relief of pain, relief of dyspnea and cyanosis, improvement of the heart action, general sedation and often an induction of sleep. All these effects are interpreted as due to an improvement in the pulmonary circulation and in the heart action. It has been reported that in the majority of cases of lobar pneumonia resolution occurred by lysis rather than by crisis, and that in those treated early with diathermy the mortality-rate was lower. Most conservative observers agree that diathermy in pneumonia may be regarded as an adjuvant measure, especially for the relief of pain and that no untoward effects have been reported in the many
thousands of cases treated. In view of the present day dramatic results with the sulfa drugs, there is much less occasion for the symptomatic treatment of pneumonias by
diathermy
in the early stages.
for the early use of this
Perhaps the major remaining indication measure would be for the possible prevention of
14 postoperative pneumonias. Portman reported at the Cleveland Clinic the immediate application of diathermy to prevent the development of postoperative pneumonia in elderly or debilitated patients and the application of diathermy to the chest of any patient who may have an unexplainable rise in temperature with increased respiratory and pulse-rate. The late use of diathermy may also be indicated in the sequelse of pneumonia, delayed resolution and extensive postpneumonic bronchitis. In pneumonias and bronchopneumonias of children favorable results 7 comparable to those in adults were reported with diathermy by Forbes. In the experience of the author, luminous or infrared radiation produces in most instances clinical results nearly as favorable as those with diathermy, with much less trouble and risk. Empyema. The postoperative stage of this occasional sequel of acute pulmonary affections, complicated with osteomyelitis of the sectioned ribs has been benefited by diathermy directly applied through the site of infection. In postoperative cases the addition of general ultraviolet irradia-
titih is
indicated.
Pleurisy. In acute inflammation of the pleura, external applications of heat are a well known means of relief; prolonged exposures (one-half
hour every two hours) from a large luminous heat generator are of marked In selected cases diathermy may be added, with the current through the affected area. In chronic non-suppurative cases the same technique is employed in order to speed up the resorption of the exudate and to prevent adhesions. Pulmonary Tuberculosis. Heliotherapy and artificial ultraviolet irradiation have been extensively employed in the past two decades in pulmonary tuberculosis. Clinicians agree that progressive and active cases with high fever are not suitable for light therapy. Opinion as to its use in chronic cases is divided. Mayer 13 considers pulmonary tuberculosis per se not an indication for light therapy; stationary pleural tuberculosis has often been
benefit.
helped by
children.
it;
also
"hilum" tuberculosis
in tuberculosis
of adults set
and pretuberculosis
of
Overdosage
may
up
focal reaction similar to
that of tuberculin. 15 Pottenger holds that patients with active tuberculosis should not be
PULMONARY TUBERCULOSIS
is
451
subjected to direct exposure to strong sunlight, especially when the weather very warm. The chief fear is that of a severe reaction following its em-
ployment. Such an effect can be easily avoided by proper technique. Other authorities agree that since from the clinical point of view it is well established that the sun does good through its general effect on the patient, there is no contraindication to its use in pulmonary disease. Krusen finds that there is no logical explanation for the exclusion of pulmonary tuberculosis from the list of those benefited by light therapy and Coulter and Carter 2 state that the generally listed dangers following ultraviolet radiation in pulmonary tuberculosis have been exaggerated, provided the
dosage of ultraviolet is carefully regulated. The scheme of graduated exposures to heliotherapy recommended by " Three minutes' exposure on the front of the body Pottenger is as follows the first day; three minutes back and three minutes front the second day; six minutes front and three minutes back the third day; six minutes front and six minutes back the fourth day; nine minutes front and six minutes back the fifth day and so on. If the patient is standing the exposure quite well and tanning has well started, then exposure may increase five minutes front and back each day. One hour's exposure a day is sufficient for many patients, although others can spend most of the day with bare skins, particularly if exercising, with good effects." For places and seasons when the exposure of patients to the direct sun's rays seems difficult, Pottenger recommends artificial radiation. Indoor ultraviolet irradiation lacks such important features of heliotherapy as the moving fresh air with its deeper effects produced through the skin and respiration and in colder weather the uniform warming of the whole cutaneous surface with its production of sense of comfort, well:
being and relaxation. (Mayer.) However, Ellman reporting on ambulatory treatments at London states that light therapy (not heat therapy) as an adjunct to the routine treatment, in selected cases will aid in improving the physical and mental condition, definitely diminish physical signs in the chest and relieve symptoms such as cough and sputum and improve
5
all
weight and sleep. He considers ultraviolet absolutely contraindicated in exudative types.
Physicians may use light therapy in suberythemal doses as an adjunct to the constitutional treatment of pulmonary tuberculosis, provided it is
applied with careful observation of the patient's reaction. It must be avoided in far advanced and toxic cases and the amount of heat rays should be restricted to a minimum at any time. There is no question about the fact that the majority of patients like light treatment and are in a much more cheerful mental state while taking it. A proper balance of rest and exercise in tuberculosis are physical measures of paramount importance. Rest will heal tuberculosis, but it must be mental as well as physical rest. Bed rest must be maintained in a patient with constitutional signs and symptoms until the disease becomes stabilized; after that he may be allowed a graduated amount of exercise if other signs are favorable. Patients with minimal disease and positive sputum should be kept in bed until the sputum becomes negative. No patient with active tuberculosis, regardless of the stage of the disease or the presence or absence of symptoms, should be allowed to indulge in any activity to the
point of fatigue.
To
strengthen weakened respiratory and circulatory
452
GASTRO-INTESTINAL CONDITIONS
organs after prolonged inactivity in the case of pulmonary tuberculosis, Voute 21 recommends early institution of work therapy by means of light individual gymnastics combined with massage. When the work therapy is begun, rest periods should be gradually reduced so that when the patient is discharged, he requires at the most two hours of rest daily.
Gastric Neuroses.
Functional disturbances of the stomach
may
be of
sensory type, gastralgia; motor type, nervous vomiting; or the secretory type, hyperacidity and hypersecretion. The diagnosis of a gastric neurosis is made if local signs associated with those of some functional nervous
disorder are present and no definite pathological changes can be proven. The treatment of the nervous condition is of paramount importance. Diathermy is a useful adjunct for local treatment. Short-wave diathermy
be administered by antero-posterior condenser pads or by a pancake placed on the abdomen. With long-wave diathermy a 4 by 6 inch plate electrode is placed posteriorly, and a somewhat smaller one 4 by 4 Treatments should last twenty-five to inches over the epigastrium. minutes and a current strength of moderate intensity, 1000 to 1300 thirty milliamperes, should be used with long-wave diathermy. The galvanic current may serve as an alternate measure in selected cases. It is employed through moist pad electrodes of the same size and position as in diathermy. The current is applied for about thirty minutes and its strength should be from 10 to 15 milliamperes. General ultraviolet irradiation as well as various hydrotherapeutic
may
coil
measures
it
may
be added for tonic
effect.
is a clinical problem in itself: be only a symptom accompanying a pathological condition of the gastro-intestinal tract, or it may be the direct outcome of incorrect habits or living conditions. From the therapeutic standpoint it has been found practicable to adopt a classification into atonic and spastic types; this also serves as a convenient guide in the consideration of rational physical
Constipation.
Each case
of constipation
may
therapy.
The
may be brought about by many factors, among them bad habits of eating, neglect of the urge of defecation, congenital weakness of abdominal muscles and weakening diseases. In its management, general hygiene, diet, judicious medication and mental treatment are effectively aided by physical agents exerting
acterized
atonic type of constipation which is by far by weakness of the large intestine; this
more frequent
is
char-
general and local stimulation.

exercise,
these agents belong massage, light therapy. Massage is the simplest and most readily available stimulative measure in the treatment of constipation. When applied to the abdomen its main effect is to increase the tone of abdominal muscles and to bring about increased peristalsis by reflex action. No amount of massage can actually move the abdominal contents; neither can the massage have much effect on the tone of the intestinal musculature and of back and pelvic muscles;
Among
low frequency
electrical currents,
hydrotherapy and
hence in cases of real ptosis and relaxation of the pelvic floor, more effective forms of stimulation must be employed. In carrying on abdominal massage it is far from necessary that it be
CONSTIPATION
453
vigorous or prolonged. Slow and gentle movements applied at a rate of about twelve a minute and with a pressure only to dent the abdominal wall are sufficient. The patient lies relaxed on a low couch and gentle rhythmical stroking is applied along the ascending, transverse and descending colon. After the patient has learned how to relax under these stroking movements, gentle kneading and rolling and finally rhythmical vibration of the various parts of the abdomen are performed. All of this should not take more than ten minutes. There is no reason why the physician himself should not apply abdominal massage with the simple technique recommended. Massage should be given daily, then every other day for several weeks; in many cases results show after the first few treatments; if no improvement is noted within two weeks, massage should be discontinued. General massage may be conveniently prescribed in such cases of the atonic type where stimulation of the general circulation and muscle tone appear desirable. Ten to fifteen minutes of general massage, following the abdominal massage, is all that is indicated, especially when active exercises also form part of the program. No massage treatment should
leave the patient all tired out; the strength and extent of the massage must be adapted to the musculature and reflexes of the patient. Electrical muscle stimulation combined with massage or applied alone serves to tone up the abdominal and pelvic muscles by active contractions it is the method of choice in atonic cases where massage is not practicable or which prove to be more resistant, or where direct stimulation of the
;
pelvic floor
peristalsis
is
desirable.
by
reflex stimulation
Electrical stimulation, like massage, also aids and increases glandular function and the
venous return from the abdomen to the heart. Reynolds 17 proved experimentally that electrical currents exert no direct stimulation of the intestinal walls and the tonic effects enumerated are due to reflex action. The author has obtained equally favorable results by a variety of currents, such as the surging faradic, the interrupted slow sinusoidal and the modulated alternating current. Hence, as long as the type of current employed and
the technique of application produce efficient stimulation within pleasant toleration of the patient, it does not matter particularly what make of apparatus and what modification of current is used. The method employed by the author is as follows: A large moist pad electrode, 5 inches wide and 7 inches long, is placed over the abdomen and another one of equal size directly opposite, under the back of the Either the surging faradic or modulated alternating current patient. (Morse wave) is used; the current strength is gradually increased until definite contractions of the abdominal wall are evident; it should be the endeavor to synchronize these contractions with the rate of respiration, producing about 18 to 20 contractions per minute. Patients seem to tolerate the modulated alternating current better; this can be explained by the fact that the shorter duration of each impulse has a minimal sensory irritating effect. At successive treatments a current of increased strength may be administered, and it can be generally noted that in patients with ptosis the abdomen becomes more firm and bowel movements more regular. Treatments should last from ten to twenty minutes and be administered every other day for several weeks. Voluntary exercise forms an indispensable part in treatment of chronic General exercise serves to improve the general physical constipation.
454
state
and to react indirectly on the gastro-intestinal function; it may be in both types of constipation. Abdominal exercise serves specifito strengthen the abdominal and respiratory muscles and is chiefly
employed
cally
is preferable, especially when taken one big sweep over the week-end. Tennis, golf, horseback riding, running or swimming, done in moderation and within individual taste and endurance, are beneficial; walking is of comparatively little direct value, as shown by the fact that many persons in occupations which require a great deal of walking, such as letter-carriers, are con-
applicable to atonic states. For general exercise the outdoors
regularly
and not
in
stipated.
Abdominal gymnastics are valuable when prescribed and carried out

systematically within individual tolerance. Exercises that necessitate holding of the breath or keeping the lower trunk muscles in strong continued contraction are not suitable. There is no end to the variety of different forms of active and passive exercise in the treatment of constipation. Two simple sets of exercises which can be easily demonstrated to every patient
are as follows:
A. Exercise
in lying posture; resting flat on the back with hands on the sides. 1. Deep breathing; inhale slowly, hold breath for five seconds; exhale slowly. 2. Raise right thigh with leg extended. 3. Raise left thigh with leg extended. 4. Raise both thighs with legs extended. 5. Raise thighs with knees bent. 6. Raise body upon thighs. B. Exercises in standing posture; legs together, with hands on hips.
1.
2. 3.
Bend trunk forward as far as possible. Bend trunk backward as far as possible.
Carry trunk to right side. Carry trunk to left side. Rotate trunk to right. Rotate trunk to left.
4.
5. 6.
Exercises are preferably carried out upon rising in the morning; if this is not practical, an hour before lunch or dinner. They can be done on a bed with firm springs and mattress, but still better on the floor, on a folded woolen blanket. They should be performed slowly, each exercise three times the first day and increased by one each day until ten to fifteen is reached. A few minutes' rest in supine position is advisable afterwards; patients must be advised to acquire the habit of full body relaxation whenever they rest. Exercises should be done daily for many months; they
(Figs. 270-275.) spastic type of constipation is characterized in its severe forms by contracted, sensitive abdominal walls, tight anal sphincter and typical pencil-shaped stools. It occurs frequently in patients with signs of neur-
may
be varied according to the individual conditions.
The
asthenia
who present an endless story of their symptoms and who
anxiously
mild laxative may cause marked colic in these patients because of the spasm of the intestines and the emptiness of the rectum. In the treatment, general nervous relaxation and sedation are indicated, while heat is the chief standby of local treatment.
their stools.
watch
VISCEROPTOSIS
455
In the general or constitutional treatment of spastic constipation general tonic forms of physical therapy are useful, selected according to the individual circumstance. general light bath in an electric cabinet or under
a large heat lamp, followed by a mild alternate hot and cold douche (Scotch douche) may be administered; likewise general irradiations from ultraviolet sources and general forms of exercise, outdoor and indoor, should also be considered. For the local treatment heat, the age-old measure for the relief of sensory or motor nerve irritation, is the sovereign remedial agent. In cases of
mild local spasm, exposure for half an hour twice a day under a small luminous heat lamp or infrared generator will be beneficial. In more severe forms the penetrating heat effect of either short- or long-wave diathermy is the method of choice. Two large electrodes are placed over the abdomen and back respectively, and from 1500 to 2500 milliamperes of current are employed for one-half hour, four times a week for four weeks. Kendall 16 saw favorable results by diathermy in a large number of obstinate cases which had resisted treatment by diet and other measures. Zeiter 24 reports encouraging results from short-wave diathermy as an adjunct in treatment of irritable colon, the term synonymously applied for spastic constipation. Hydrotherapy in either form of constipation may utilize the mechanical cleansing effects of moving water or the stimulative or sedative effects of its temperature. A glass of cold water on an empty stomach on arising acts as a stimulant of peristalsis in many people; especially when first employed it produces a soft movement within half an hour. The water should never be so cold as to cause a chilly sensation. In some persons, a glass of fairly hot water exerts the same effect. Hence, in atonic types of constipation these mild effects can be utilized. Water by rectum, in the form of an enema, may be used with advantage at the beginning of treatment in mechanically cleansing the rectum and colon. Tepid water with some bicarbonate of soda and witch hazel serves best for a cleansing enema. A cold water enema at a temperature of 60 to 70 F. is more irritating than a cold drink and is indicated only occasionally. Cold water may also be employed externally in institutional practice as a cold sitz bath or cold jet douche, alternating with a hot jet the regulation Scotch douche. In spastic conditions these forms of treatment are strictly contraindicated however, hot sitz baths at 110 for fifteen minutes and hot enema of the same temperature may be of service. Colonic irrigation has only a limited place in the treatment of constipation. When there is an accompanying colitis or a good deal of intestinal putrefaction, suitable medicated irrigations may be temporarily employed. Visceroptosis. Postoperative and Postpartum Weakness of Abdominal
;
Muscles.
These conditions present common features of dysfunction, namely lack of tone of the musculature of the stomach and intestines and often weakness of the abdominal walls. Graduated muscular exercise by low-frequency currents and reflex stimulation of peristalsis tend to improve
the tone of the musculature of the visceral tract. It should also aid the venous return from the abdomen to the heart and stimulate glandular function. The technique of treatment is the same as described for atonic
constipation. In atonic abdominal muscles after child-birth
it is
advisable to tone up
450
CASTRO-INTESTINAL CONDITIONS
the pelvic muscles also by employing a vaginal or rectal electrode and a dispersive electrode on the abdomen. Abdominal Adhesions. Peritoneal adhesions are a frequently suspected cause of pain and other distress following operations and inflammatory conditions in the abdomen. They form either as a result of a local peritonitis
or traumatism at the time of an abdominal operation. An exercising current or diathermy is equally indicated in the management of this disability and the author has had some excellent results from the combined
use of the two modalities with the apparatus and technique described in Chapter XI. It is advisable to start with diathermy for five to ten minutes and then turn on the surging low-frequency current and continue the two
for ten to fifteen minutes.
Treatment should be repeated
first
daily
and
then
of
less frequently.
Intestinal Tuberculosis.
The
prognosis of this frequent complication
6 pulmonary tuberculosis is generally pessimistic. Erickson holds that ultraviolet is one of the major therapeutic measures and should be used In a study of sanauntil better methods of treatment become known. torium cases treated with ultraviolet 85 per cent showed some symptomatic improvement and of these 27 per cent had entire relief from symptoms and 47 per cent were very much improved. Relief came generally within a month, entire loss of symptoms within three to four months. In a study of Coulter and Hardt, 3 patients who did not receive ultraviolet radiation showed a lower percentage of improvement than the same groups receiving
ultraviolet radiation.
The
radiation apparently decreases the

all
symptoms
or at least keeps them stationary in the large percentage of or without calcium therapy.
groups, with
Peritoneal Tuberculosis.
this condition.
Mayer 13
I ight therapy always deserves a first trial in states that the serous exudative type generally
responds to light irradiation, both in children and in adults.

proliferative form, usually adhesive, been ulcerations and large caseous
children, the results are
is
The dry
more refractory. When there have lymph nodes, as commonly seen in most unsatisfactory. Stubenbord and Spies 19
found light therapy most satisfactory in chronic plastic adhesive types of cases with localized peritonitis. As a source of irradiation, in both intestinal and peritoneal tuberculosis,
sources combining a preponderance of ultraviolet (mercury vapor lamps) are generally preferable to sources containing a large amount of heat radiation. Treatment must be applied over the entire body in suberythemal doses and not, as it is often erroneously ordered, to the abdomen only. A mild degree of fever is no contraindication in these cases but it is advisable to treat such cases only on alternate days, so as to enable subsidence of occasional febrile reactions after irradiation. It is necessary to continue treatment .for many weeks, although it usually quickly results in the disappearance of pain, especially in children. Rest, approved diet
and fresh
air
form other important essentials in treatment.
Diseases of the Liver.

of the beneficial effects of
The
literature contains a
number
of reports
in chronic diffuse hepatitis, hyperliver insufficiency of toxic origin. trophic cirrhosis Animal and human experiments through the means of a duodenal sound proved that diathermy increased both the quantity and quality of bile
diathermy and mild forms of
(Goldgruber
).
Before diathermy only pale-green bile flowed through the
RICKETS
457
sound; immediately after turning on the current, a strikingly dark bile in Goldgruber used diathermy in treating large quantities flowed out. ratarrhal icterus, salvarsan jaundice, subacute and chronic cholangitis and in early cases of cirrhosis. After a couple of treatments the urine became free of bilirubin and contained only urobilin and urobilinogen in great quantities. Goldgruber assumes that the diseased liver parenchyma regained during diathermy treatment its power of dealing with the urobilin poured into the intestine, thus taking from the kidneys the work of secreTreatments of two hours' duration were given. tion. Experimental 4 investigations by Couperus and Moor in dogs with biliary fistulse showed that diathermy to the liver increased the secretion of bile from 7 to 17 per cent during a twenty-four hour period, while during the twelve-hour period immediately following the application of diathermy the increase varied from 8 to 46 per cent. In subacute and chronic cholecystitis diathermy is the Cholecystitis. treatment, and to diminish the volume of painful and enlarged principal In cholecystitis livers there is nothing that equals diathermy (Weiss 22 ). repeated applications enable the liver and gall-bladder to function more satisfactorily. The treatment can have no curative action on a sclerosed gall-bladder, on those which are packed with calculi, on constriction of the gall-bladder or in cholangitis with jaundice. The author found diathermy of definite value in chronic cholecystitis, as an adjunct to medicinal and dietetic regime. In recurrent attacks of pain not due to obstruction or infection diathermy generally tends to shorten the attack and keeps the patient comfortable without recourse to morphine. A dispersive electrode, 5 by 7 inches, is placed under the center and somewhat to the right of the lumbar spine and a smaller electrode, 4 by 4 or 5 by 5 inches, is laid over the gall-bladder region in front. In securing the anterior electrode one must be careful to keep away from the edge of the costal arch or else bridge it over evenly in order to avoid uneven contact or too much pressure. With long-wave diathermy from 1000 to 1500 milliamperes of current are usually well tolerated. Treatments should be kept up for at least one-half hour each time and be administered daily or twice a day at first and then less often. Short-wave diathermy offers a simpler technique with a pancake coil over the liver
region.
Weiss advocates diathermy as an aid in cholecystography, especially where there is delayed filling or poor visibility of the gall-bladder shadow. The best results are obtained three to five hours after the intravenous, oral or combined use of the dye; it permits better visualization even
shortly before cholecystography for it will cause the gases in the intestine to diminish and a denser shadow of the gall-bladder will be obtained.
METABOLIC CONDITIONS
Ultraviolet irradiation from the sun or from artificial sources a potent and reliable specific in the treatment of rickets. Exposure must be gradual and proceed according to the child's susceptibility. Gersten8 berger and Hartman found that exposure to a mercury vapor lamp in doses of erythema units given once a week for five to eleven weeks is Luce-Clausen 12 states sufficient for the care and prevention of rickets.
Rickets.
is
458
that the average case requires irradiation every other day for a total period of four weeks, but severe cases may require eight or ten weeks. If treatment is begun after January, it will not be necessary to repeat the course of treatment during the winter, but if it is begun in the autumn, a second series of irradiation should be given before March.
This symptom-complex occurring in rickets when Infantile Tetany. the blood calcium is low, will yield to ultraviolet irradiation. The treatment of choice, according to Laurens, 11 is a combination of calcium salt (lactate or gluconate), a diet low in phosphate and optimal in vitamin D. If ultraviolet is used an initial increase of nervous irritability may be
Latent tetany may become manifest when rachitic infants are if sufficient calcium is not available, due to the suddenly increased mobilization of calcium and deposition in the growing bones. Preliminary medication is therefore necessary in these cases. The same considerations prevail in the treatment of spasmophilia.
expected.
irradiated,
FIG. ,295.
Bergonie apparatus for general faradic stimulation.
(Courtesy of the Medical
Supply Association, Ltd.)
Obesity is a general systemic disorder, in which either exogenous causes, such as overeating and lack of exercise or endogenous causes, such as endocrine imbalance, predominate; at the bottom of it all there is always the uncertain factor of constitutional predisposition one that keeps lean people as they are in spite of all they eat and keeps others stout in spite of all exercising and dieting. Many of the commercialized obesity cures carried on by self-styled experts only add to the already existing disorder. No therapeutic measure directed against obesity can be called rational unless one first makes the attempt to combat the underlying pathology and, therefore, it must not be inferred that the method described constitutes the whole treatment of obesity. This condition is of such complex and diverse origin that the treatment must be individualized in accordance with the causative factors. Massage has only very limited value in the treatment of obesity although the lay mind is made to believe that it is possible to break up "fat" and
Obesity.
stout ladies hopefully crowd into commercially advertised reducing studios
OBESITY
459
where underpaid slaves maul them in long sessions of vain efforts. Only may exert some effects on metabolism in obesity. For local conditions, like an obese, relaxed abdomen the following scheme of massage treatment may be prescribed: Begin with firm stroking movements in a longitudinal direction, from the symphysis towards the costal arch. After a few minutes alternate with deep kneading by one or two hands, then percussion with the open hand. Conclude treatment with another series of deep, stroking movements, making them end in light stroking. Electrical muscle exercise for weight reduction has been for many years employed, by means of a modified faradic apparatus, constructed by Bergonie in 1913. The output of the secondary winding of a powerful faradic coil is led to a special chair, which has six metal surfaces for the various parts of the body. Six movable electrodes fit over the other parts. The undressed patient is placed on the chair, and firm contact is made between the electrodes and the various body surfaces by moist towels.
a judicious use of general massage
adjusting the rheostats controlling the six circuits, graduated contractions are started in the various parts. routine course of treatment 20 (E. C. Titus ) consists of an initial application of one-half hour, with an
By
increase of ten minutes each day, up to one hour in duration. After three or four weeks, treatments are administered every other day and then at longer intervals, if indicated, for a total period of from six to ten weeks. It is claimed that by exercising passively a large group of muscles a
reduction of fatty tissue can be accomplished without any strain on the heart and for this reason the method has been recommended as a form of exercise in conditions of chronic arthritis. Turrell calls attention to the
appearance of patients who have undermethod has been named in contrast gone passive ergo therapy to the victims of a starvation diet with their pinched countenances, parchment skins and shrunken and lusterless eyes. In spite of its enthusiastic advocates, the Bergonie method is at present only employed in a very limited measure. While there is no doubt that weight reduction by electrical means, as described, is possible to a certain extent, it can be considered only as an adjuvant measure to a general plan of medical treatment. Heald 10 states: "Bergonie's chair is nothing more than a clever conhealthy, vigorous
and
athletic
as the
trivance for bringing easily controlled and graduated interrupted faradic contractions to the muscles of the body, particularly to those of the abdomen and buttock. It is more effective as a treatment for chronic constipation than it is for reducing fat, the original purpose of the instru-
ment."
REFERENCES
1.
BINGER, C. A.
2.
3.
4.
5.
L., and CHRISTIE, R. V.: Diathermy in Pneumonia, Jour. Am. Med. Assn., 91, 6, 1928. COULTER, J. S., and CARTER, H. A.: The Treatment of Pulmonary Tuberculosis by Ultraviolet Radiation, Jour. Am. Med. Assn., 105, 3, 1935. COULTER, JOHN S., and HARDT, LEO L.: Ultraviolet Radiation in Gastro-intestinal Tuberculosis, Arch. Phys. Then, 20, 143-148, 1939. COUPERUS, M., and MOOR, F. B.: The Effect of Diathermy Upon the Secretion of Bile, Arch. Phys. Ther., X-ray and Rad., 15, 5, 1934. ELLMAN, P.: Physical Treatment of Pulmonary Diseases, Brit. Jour. Phys. Med.,
9, 11, 1935.
4fiO
6.
7.
EBICKSON, R. J.: Intestinal Tuberculosis, Rev. Gastro-enteroL, 3, 3, 238, 1936. FORBES, R. P.: Diathermy in the Treatment of Pneumonia in Children, Arch.
Pediat., June, 1927.
8.
9.
10.
Quartz Lamp Therapy in Human GERSTENBEBGER, H. J., and HARTMAN, J. L. Rickets and Rachitic Spasmophilia, Jour. Am. Med. Assn., 92, 367, 1929. GOLDGRUBER, G.: Diathermy in Liver Conditions, Klin. Wchnschr., 2, 7, 1932. HEALD, C. B.: The Physical Treatment of Constipation, The Practitioner, 131,
:
666, 1936.
11.
12.
13.
14.
LAURENS, HENRY: The Physiologic Effects of Ultraviolet Radiation, Jour. Am. Med. Assn., Ill, 2385, 1938. LUCE-CLAUSEN, ETHEL M.: Clinical Aspects of Ultraviolet Therapy, Jour. Am. Med. Assn., Ill, 311, 1938. MAYER, E.: Light Therapy and Roentgen Therapy in Tuberculosis, Jour. Am. Med. Assn., 105, 20, 1935. PORTMAN, U. V.: Diathermy as a Means of Prevention and Treatment of Surgical Shock and of Postoperative Pneumonia, Brit. Jour. Actinotherap. and Physiotherap.,
May,
1929.
15.
POTTENGER, G. M.:
Tuberculosis in the Child and the Adult, St. Louis, C. V.
16. 17.
Mosby Company, p. 424, 1934. RENDALL, V. M. H.: Diathermy in Obstinate Constipation, Lancet, 2, 284, 1932. The Response of the Gastro-intestinal Tract to External StimuREYNOLDS, G. S.
:
lation, Radiology, 8, 1276, 1931. The Principles of 18. SMART, MORTON:

19.
Treatment
of
Muscles and Joints by Gradu-
ated Muscular Contractions, London, Oxford Univ. Press, p. 156, 1933.
20.
21.
22.
STUBENBORD, JOHN G., and SPIES, JACK: Tuberculous Peritonitis, Surg., Gynec. and Obst., 67, 269-272, 1938. TITUS, E. C.: Modern Treatment of Obesity, Med. Rec., Jan. 24, 1920. VOUTE: Exercise and Rest in Pulmonary Tuberculosis, Schweiz. med. Wchnschr.,
WEISS,
pp. 921-924, September, 1937. S.: Diathermy as an Aid to Cholecystography, Arch. Phys. Ther., X-ray and Rad., 14, 591, 1933.
JR., FOLEY, J. A., and RESNIK, J.: Diathermy in Lobar Pneumonia, New England Jour. Med., 213, 741-786, 1935. 24. ZEITER, W. J., and RENSHAW, R. F.: Diathermy in the Treatment of Irritable. Colon: Preliminary Report, Arch. Phys. Ther., 22, 8, 418, 1941.
23.
WETHERBEE, W.,
CHAPTER XXVI
Role of Physical Therapy. Classification. Grading of Cases. Physical Therapy Measures in Arthritis: Thermal Measures, Mechanical Measures, Counterirritant Measures. Spa Treatment. Scheme of Physical Treatment.
Arthritis.
Rheumatoid Arthritis. Gonorrheal Arthritis. Spondylitis. Gouty Acute Arthritides. Fibrositis. Pathology. Classification. Diagnosis. Treatment. Panniculitis. Results of Treatment.
Osteo-arthritis.
the low ebb of interest hitherto shown in chronic arthritis and rheumatoid conditions, a very definite change of attitude has taken place in recent years. Economists have shown that rheumatism presents one of the most important problems because of the long and expensive medical treatment required, the loss of earning power of those affected and the economic consequences on the patients and their dependents. With special attention focused on the rheumatic problem, there are now in some of our large centers groups of specialists actively interested in research work as well as in clinical observations. However, chronic arthritis is equally prevalent in cities and in the country. Its early recognition and treatment, as well as the comforting of those in its later stages, must always remain in the hands of the physician in the field, and therefore it is up to the general practitioner to learn to attack rheumatism efficiently and intelligently in its incipiency. This demands more than the prescription of a few pills, the administration of a stock vaccine or the perfunctory advice to "bathe" in hot water. It requires adequate teaching in medical schools and familiarity with the basic concepts of arthritis and all recognized means of its treatment. Most medical men agree on two major concepts of chronic arthritis: (1) Chronic arthritis is a constitutional disease with local changes in the joints as well as disturbances in the circulation and general metabolism. (2) Chronic arthritis is a disease of varied etiology and of varied types, and hence there is no single method of treatment which is applicable to all its forms. It is now generally recognized that the focal infection theory of rheumatism has been overemphasized in the United States for many years. Abroad there is more inclination to accept a theory of a hyperergic response There are of a constitutionally and hereditarily predisposed organism. many reasons to support the view that a lowered body resistance due to a weak constitutional make-up is one of the principal factors, if not the main factor, responsible for the development of chronic arthritis. Such hereditary weakness of the mesenchymal apparatus or the lack of sufficient defense mechanism of the mucous membranes may explain frequent colds as well as the tendency to focal infection. The favorable response to treatment measures directed to overcoming the lack of body resistance corroborates this concept. Similar considerations prevail to a large extent regarding the etiology and treatment of the large group of rheumatoid conditions, or non-articular
From
by the medical profession and the public
(461)
462
fibrositis, panniculitis, muscular rheumatism, bursitis and certain forms of neuritis. Role of Physical Therapy. Physical measures have been used since ancient times for the treatment of chronic arthritis, as evidenced by the pilgrimage of rheumatic sufferers to hot springs. Modern clinical research has taught us a better understanding of the rationale of heat measures, and the evolution of physical therapy has added many effective measures to the fight against the disease. Today physical treatment measures fill an important role in the complex therapeutic problem presented by the
manifestations of rheumatism, such as
necessity of combating allergic, climatic, dietetic and hygienic factors, of correcting dysfunctions of the skin, endocrine glands and gastro-intestinal system, of relieving nervous and functional disorders and of eliminating
demonstrable bacterial and focal infection, as well as ameliorating an arthritic constitution. General or systemic physical measures may serve as part of constitutional therapy for the increase of circulation and metabolism, the promotion of activity of the digestive tract and the correction of faulty body mechanism. Physical measures locally applied serve to
prevent and relieve local arthritic changes: pain, stiffness, exudation, muscular atrophy and weakness. There is, of course, often an interplay between general and local effects. A statement of the British Ministry of " Health 5 reads, almost every case of chronic arthritis at some stage of the disease requires physical treatment, usually consisting of the application of heat in some form, either alone or together with massage and movement. No scheme of treatment for chronic arthritis can be considered complete unless an extensive range of physical methods of treatment under skilled direction is available. There appears to be a rapidly increasing demand for such treatment." Pemberton 13 states that physical measures have as much value in the treatment of arthritis in its early stages as probably any others at our disposal, although their value is far from being appreciated.
Classification of
Rheumatic Diseases.
The
generally accepted division
of rheumatic diseases into three groups is useful as a basis for consideration of their pathology and for our therapeutic endeavors.
1.
Rheumatic Fever.
less fever, affection of several joints, at
Acute and subacute rheumatism, with more or once or in rotation and responding,
as a rule, to antipyretic medication (salicylates). Physical therapy plays little role in this condition. 2. Chronic Joint Changes. (a) Osteo-arthritis or hypertrophic arthritis is usually not accompanied by fever and has a gradual onset. It is often at first confined to one large joint; it affects fewer and larger joints, especially the
knee and hips; there
is
grating, lipping
and formation
of osteo-
phytes.
The average patient with osteo-arthritis is usually a well-nourished individual past middle age; trauma, overuse or metabolic disturbance are the most frequent causative factors, and not infection. Early cases of this type as a rule can be almost completely relieved by suitable physical measures
in conjunction
(b)
with a suitable dietetic regimen and regulation of habits. Rheumatoid arthritis (infective periarthritis or atrophic arthritis).
is
of the cartilage takes place, although the synovial generally the site of the greatest changes at first; the destruction of cartilage follows as the disease progresses; new formation of bone
Primary degeneration
membrane
CLASSIFICATION OF RHEUMATIC DISEASES
463
or cartilage by periehondrial proliferation may also take place. Usually many smaller joints are affected, especially the proximal interphalangeal joints; the lesions are often bilaterally symmetrical.
younger persons, usually in a poor state play a role in its onset, and it usually affects many of the smaller joints. In this condition the heat-regulating apparatus is often disturbed and the circulation is out of order, as manifested by its variations in the skin and extremities, especially the fingers and toes.
of nutrition.
Rheumatoid
arthritis occurs in
Infection
may
is unstable. The basal metabolic-rate is changed and the blood-pressure is low. Function of the gastro-intestinal tract is poor, and there is always secondary anemia. It seems as though the entire defense mechanism of the body is below par. In this syndrome the entire range of available physical measures must be drawn on to aid the general medical treatment. Thermal methods acting as general alterants on the constitution are of especial value. The prognosis is always doubtful so
Vasomotor control
is concerned, but patients treated early and efficiently almost always can be kept comfortable and deformities can be prevented. Other well-defined types of chronic arth(c) Special forms of arthritis. ritis are gonorrheal, gouty and traumatic; spondylitis deformans may also be considered a special type, although its pathology is that of the rheumatoid group. Physical measures of treatment are indicated in all these types and are of almost specific value in the traumatic and the gonorrheal.
far as full recovery
3.
ing fibrositis, lumbago, bursitis
Muscular rheumatism (myalgia) includand certain forms of neuritis. Physical therapy plays a most important part in the treatment of
Non-articular Manifestations.
chronic joint changes as well as of non-articular manifestations. The principal factor in the origin of rheumatic diseases and colds seems to be a choking of the arterial blood supply, as substantiated by the fact that all effective measures in rheumatism produce hypersemization. Grading of Cases. The differentiation of chronic arthritis into its various types is not sufficient for the purpose of prognosis and planning treatment. There are many mixed or uncertain types of chronic arthritis. In many of these cases, as in the well-determined types, the amount of involvement of the joints is the most important question for the planning of treatment. One clinician recently emphasized the similarity of a chronic arthritic joint to that of a rusty hinge on a farmer's gate. It is evident that so far as the possibility of relief of the local "rustiness" by physical and other
measures is concerned, the amount of involvement is more important than whether it is caused by osteo-arthritis or by rheumatoid arthritis.
Hence the
desirability of grading chronic arthritis according to the degree of involvement.
practical system of grading into mild, moderate, severe
and extreme
is
cases,
based on combined
23
clinical
and
radiological findings,
described
Patients are ambulant, usually are first degree arthritis. able to continue their normal occupations and have no demonstrable joint changes aside from soft tissue swellings. Pains or aches are felt, but there
by Taylor 1. Mild or
as follows:
and "lipping," although there is intra- and extracapsular swelling. These cases offer the best prognosis. 2. Moderate or second degree arthritis. Patients may be prevented by trouble from continuing at work, but they can usually walk about joint
are only slight decalcification
464
of themselves. The joint space is definitely altered, there being loss of cartilage or bone substance, moderate decalcification, capsular There is definite and prolonged swelling and adjacent tissue atrophy. localized limitation of movement, with definite osteophytes or spur formation, and local hypercalcification. Prognosis is fairly hopeful under adequate treatment. Patients are so incapacitated by 3. Severe or third degree arthritis. demonstrable joint lesions that they are unfit for work and are dependent on others for proper care. They may walk for short distances but are
and take care
usually limited to bed and chair existence. There are joint subluxations, deformities, local ankyloses, marked decalcification and hypertrophic changes, osteophytes and spurs. The outlook is serious. Such patients need institutional treatment and training to preserve and regain as much joint function as possible. Patients are completely incapac4. Extreme or fourth degree arthritis. itated and bedridden. There may be little or no pain when the active
disease has subsided, and general health may be satisfactory. Joint changes are extremely widespread; there is much destruction, and bony ankyloses
accompany marked hypertrophy. The outlook
is
poor.
essential for prognosis, as well as for recording cases and judging benefits of different forms of treatment. It is evident that measures directed towards improvement of circulation and reduction
The grading
of arthritis
is
of swellings can expect favorable response chiefly in the first two grades of the disease. When one encounters unexpected clinical results in advanced
may be explained by the fact, that in chronic arthritis many of the painful processes are located in the periarticular tissues, which respond well to appropriate physical treatment. No amount of late treatment will replace a destroyed joint cartilage or remove excessive bony deposits. In such advanced cases, however, orthopedic and surgical methods still hold out hope for a reasonable amount of improvement.
cases, it
Physical Treatment Measures in Arthritis

chronic arthritis.
principles:
Table 52 shows the large number of physical measures available in They are in fact variations of only three basic treatment
heat, exercise
and
counterirritation.
TABLE
Thermal
52.
Hot bath
Radiant heating
Paraffin bath
PHYSICAL MEASURES IN CHRONIC ARTHRITIS Thermal and Mechanical Underwater exercise

Whirlpool bath
Counterirritant Galvanic current lonization with vasodilators High-frequency (Oudin) current Ultraviolet rays (mercury vapor lamp) Thermal and Counterirritant
Mud
Hot
pack douche Diathermy, long and short wave

air
,
Artificial fever
Mechanical Rest
Natural sunlight
Massage
Exercise, active Exercise, passive Exercise, electric muscle stimulation Colonic irrigation
Carbon arc lamp

Galvanic bath
selection of a physical treatment
be applied either locally or systemically The measure and its combination with others must depend on the type, stage and extent of the arthritis and on the
These measures
may
PHYSICAL TREATMENT MEASURES IN ARTHRITIS

and
465
The experience of the physician subjective complaints of the patient. his location also are factors in the selection from the available measures.
The reason for the desirability of a variety or intermittency of physical measures, as well as the combination of several, is that some patients with chronic arthritis are more responsive to certain physical measures than to others and that certain stimuli lose their effect after a time. It is most desirable in some cases that simpler treatment measures be carried out systematically in the patient's home.
Thermal Measures. Heating measures are potent agents in influencing and metabolism. Rheumatic exudations have been likened to smoldering foci of disease, and heat, properly used, often effects their
circulation
resorption.
General thermal measures act as constitutional alterants.
LOCAL HEAT TREATMENT has, as its object, the increase of local blood and lymph circulation and local tissue metabolism, promotion of resorption
and restoration
stiffness, is
of function.
is
A highly desirable effect of suitably mild local
relief of pain, the symptom which, next to usually the most bothersome. Heat lamps and infrared radiators enable simple yet efficient "dry" heat applications at the office and in the home. They have largely replaced the former cumbersome dry baking apparatus and light boxes. For home treatments patients should be instructed to use these appliances for one-
thermal applications
the
two or three times a day over the affected joints. Such heating should be followed by gentle stroking massage. Well-planned home treatments help to keep patients comfortable and allow the bridging of the time between office visits. In painful acute and subacute conditions, patients can bear only mild radiant heating. In such cases thermostatically controlled heat appliances are of definite value because they can be regulated to furnish a temperature just comfortable to the patient. Diathermy is the most efficient procedure of heating the deeper structures and has been satisfactorily used for many years in treating the larger joints and the spine. In osteo-arthritis localized in such parts, diathermy is almost specific for local relief of pain, promotion of resorption and restoration of function; it also lends itself easily to combination with other measures. In the frequent bilateral knee involvement of the osteo-arthritic type in middle-aged women, diathermy combined with suitable rest usually gives complete relief. In traumatic arthritis, diathermy followed by massage or other mechanical agent is likewise the line of first attack. The methods of applying diathermy to different joints have been presented in
half hour
Chapter
tion;
XL
The usual technique of long-wave diathermy is that of transverse applicaif more of the periarticular structures are affected it may be alternated with the cuff method. The longitudinal method of treating the entire extremity may be advisable where several joints are involved in the same
extremity.
Short-wave diathermy gives the same clinical results as long-wave diathermy, but its technique is more simple and more flexible; especially the inductance cable or coil field method is valuable for warming up an entire extremity. Warren 25 states that the effectiveness of diathermy is enhanced very materially by prolonging the treatment for periods of from two to eight hours, with short rest periods of five to ten minutes every
30
466
two to three hours. Such treatments undertaken one to three times a week for a month will often be sufficient and are far more effective than twenty to forty minute treatments three to five times a week over the same period. The paraffin bath is most effective in the treatment of involvements of the hands and feet, offering an even comfortable form of heating, which
leaves the skin in a condition of velvety hyperemia. Another useful alternate for treatment of fingers or other painful small areas is the hot air
"
douche," an ordinary hot air dryer held on a stand and blowing hot
air
for ten to thirty minutes against the painful part. packs consist of application of smooth plastic material
Mud
a
temperature compress, maintaining leaving the skin in a warm velvety condition. This treatment is quite cumbersome, requiring a suitable mud to begin with and skilled technical preparation; hence it is chiefly a method to be used in institutions or spas.
like
warm wet
its
for a long time
which acts and
Claims for radioactivity of muds have not been proved. GENERAL HEAT TREATMENT has as its object the stimulation of the general circulation and the increase of body metabolism the local changes
;
are only indirectly affected, yet in many instances, following general thermal treatment, there is a decrease of pain and swelling and functional improvement in the affected parts.
The
hot bath is the simplest
and most universally available general
be started at a temperature of from 96 to 99 F. and gradually carried up to 102 F., employed from five minutes to onehalf hour, two or three times a week. It should never exhaust a patient. 25 According to Warren the short hot bath is very successful as a routine measure at home; even in advanced infectious arthritis in old persons, it usually results in the immediate subsidence of symptoms, a gain of 10 to 15 pounds of weight and a feeling of rejuvenation. He warns about raising the mouth temperature of patients above 101 F. in the bath, for it is apt to be followed by faintness, weakness and prostration. During the cold weather period a great many patients of the older group can be kept quiescent by this procedure when used regularly three times a week and, occasionally, as often as three times a day or enough to relieve symptoms of acute exacerbation. If one or several joints are particularly slow in respondthermal measure. It
may
ing, the application of additional Electric cabinet baths are being
heating to these joints is indicated. employed in the institutional treatment of chronic arthritis of the robust type. Eight- to fifteen-minute treatments may be administered, followed by a tepid shower and a gentle rub down. Patients must rest from one-half to one hour after a light bath. General heating may be conveniently administered in a physician's office by large radiant heating units incandescent lamps and infrared radiators of 1000 to 1500 watt output applied for half an hour to one hour. It may also be obtained from high-frequency sources in the form of general diathermy, short-wave diathermy, or in a fever cabinet. Such general heat treatments may be used once or twice a week, interspersed with local treatments at home or at the office. Artificial fever treatment is indicated only Artificial Fever Treatment. in cases of moderate severity which apparently resist all other forms of treatment. A series of treatments at a moderately high temperature (102 to 104 F.) seems to be preferable; some of the good results obtained
467
by a systematic cure in the hot spas are undoubtedly due to the artificial fever production by the prolonged hot baths. Krusen 10 estimates that
about 30 per cent of patients treated with
nificantly.
artificial
fever improved sig-
states that while the effect of fever treatment in younger patients with predominantly soft tissue proliferative processes is only maintained for a week or a month at the most, older patients and
Warren 25
which joint destruction is a primary factor are probably the most effectively treated by this means. To his great surprise several cases with degenerative arthritis have been markedly relieved over a long period of time following a single artificial fever treatment at 40.5 C. (105 F.) maintained for four hours. Mechanical Measures. Rest. Rest is one of the most important and most frequently overlooked measures in the effective treatment of chronic arthritis. Pain or inflammation, whether of traumatic or of infectious is Nature's way of enforcing rest, which is the first requisite for origin, repair in all joints with pain aggravated by movement. Placing the joint at rest either in bed in the most favorable position or by support in light splints or suitable bandaging is a physical therapeutic measure of prime importance that is not sufficiently often appreciated. Not until a joint at rest is without pain, i. e., without inflammation, should it be exercised. Chronic fatigue is considered one of the chief factors in arthritis; therefore general bodily and mental rest are of great importance in the nervous, Rest should be anemic, overworked patient of the rheumatoid type. prescribed systematically, with so many periods daily or one or two entire days a week. If it were economically possible in the early stages of this disease to institute a complete rest cure of several months, many more patients could make a complete recovery. Attempts to make such arrangements have been undertaken in England in connection with large rheumatic treatment centers. Bach 1 states that rest in bed helps the undernourished patient to gain weight and affords an opportunity to remodel the body
especially those in
by
correcting functional deformity, usually due to faulty posture, and
by
Relaxation must be taught by the restoring normal body mechanics. technician. Certain positions should be assumed daily for short but increasing periods. The patient lies supine, with a small hard pillow placed beneath the midthoracic spine. Voluntary exercises, starting in recumbency, are taught to increase chest capacity by increasing diaphragmatic excursion and by strengthening other muscles of respiration, to improve tone and increase power of anterior and lateral abdominal, gluteal, quadriceps and hamstring muscles and muscles of the foot. Later, exercises are done in the sitting and standing positions. Deformity must be corrected and shoulders, wrists and knees must be put in best positions. Active and passive exercise is indispensable in the treatment of almost every patient with chronic arthritis for the maintenance of mobility around the affected joints, correction of inactivity or atrophy of the muscles and prevention of deformities. (See chapter on exercise.) Massage. Massage combined with suitable exercise is the most readily available mechanical measure. Since arthritic joints are already a seat of an inflammatory process, it is a cardinal rule in arthritis that massage must be gentle and must be carried out in the neighborhood but not immediately over the affected joints. Some years ago in one of the author's hospitals an arthritic clinic was added to the existing traumatic clinic;
468
the
first
patients were admitted to the physical therapy department for "baking and massage/' and the sturdy Swedish personnel started to treat them the way they did husky laborers with some local injury. Fol-
massage treatment, practically every one of these arthritic up for several days. The only massage movement permissible at times over an arthritic joint is the lightest form of stroking. There should be no twisting movement of the joint during massage; the patient should be encouraged to move the joints actively after application of heat and massage. When the help of a skilled technician is not available,
lowing that
first
patients was
laid
the physician should give suitable instruction to family
members
for
massage of a patient confined to the home; this will enable the patient to receive at least some massage with a measure of success. General body massage is of definite value for overcoming the feeling of fatigue, strengthening the muscular system, stimulating body metabolism and soothing the nervous system. The application of any form of massage, local or general, should always be preceded by the application of heat, external or penetrating, for it opens the vascular channels, relaxes the parts and enlarges the range of motion. This is the reason for the effectiveness of the combination of heating and gentle massage or exercise enabled by the whirlpool bath and by underwater exercise. Active motion must be insisted on in arthritis of the rheumatoid type if fibrous, and later bony, ankylosis is to be prevented. The safest way of carrying this out is to begin in subacute cases with muscle setting exercises (Chapter XXIX) and then start active exercises, first without weightbearing and gradually extending them within the full possible range of motion after the parts have been limbered up by heat and massage. Manipulation of joints in conjunction with massage requires great caution. The patient must receive individualized instruction as to what exercises he can do at home and as to the range of motion he should attempt to attain. General exercise is invaluable toward effecting body General Exercise. correction in arthritis. Deep breathing and abdominal muscle control exert a beneficial effect on the circulation and functions of the body. For the restoration of function, the gradual use of these joints by corrective exercises and occupational therapy is much preferable to manipulation. In certain cases, exercise on simple apparatus may be useful. Much of the disturbed physiological function in chronic arthritis can be ascribed to incorrect use of the body in faulty posture. Systematic corrective exercises and rest in the corrected position serve to remedy many of these physiological disturbances; therefore, from the very beginning of treatment of arthritis, correction of posture can help materially.
is
invaluable for rehabilitating patients in
all stages.
For visceroptosis and sluggish bowel activity of arthritic patients, exercise of the abdominal muscles by voluntary work or by a low tension wave current (the surging faradic or interrupted sinusoidal) may be indicated. Its systematic application aims to improve the tone of the musculature, peristalsis, venous return from the abdomen to the heart and also glandular function. Abdominal massage is also useful in such cases. Electhe large muscles of the extremities may aid in maintaining the tone and in preventing atrophy, so common in the later stages of
tric exercise of
arthritis.
469
Colonic Irrigation. Colonic irrigation enables mechanical stimulation of the lower intestinal tract and combating colonic stasis by occasional
thorough flushing and evacuation. Some clinicians consider the intestinal major secondary focus of infection. Applied for definite indications and under responsible direction, colonic irrigation is a useful adjunct in treatment of arthritic patients in whom the gastro-intestinal tract appears to be the cause of some of the symptoms. Thermal and Mechanical Measures. The whirlpool bath by combination of heat and gentle friction softens inflammatory induration and relieves pain and spasm. It may be employed in chronic arthritis affecting several joints of an extremity, for weak and painful feet and in patients with additional myositic and neuritic involvement. Underwater exercises, originally introduced for the treatment of paralysis, have proved to be quite effective in chronic arthritis for restoring joint function and muscular strength by well-directed exercise and manipulation. In the underwater treatment tank, joints can be put through a range of motion much beyond that achieved outside the water. As a matter of fact, there is danger of overdoing joint exercise in fairly tender joints. Often patients with badly affected hips, knees or ankles, unable to
tract a
walk, gradually regain that function in the pool. Most patients prefer pool or tank treatments to gymnasium treatments because of the additional
cases,
mental and physical stimulation. To be truly effective in advanced underwater exercise needs expert guidance and sometimes special
equipment for hoisting patients and placing them in the pools comfortably. However, in early cases the thoughtful physician can often devise suitable arrangements for such exercises in simple home surroundings. Counterirritant Measures. The galvanic current offers a useful adjunct
treatment of chronic arthritis, especially the atrophic type. It brings about prolonged hyperemia of the skin and has some effect on the deeper circulation by reflex or direct penetration. For therapeutic efficiency it is important that as large an amount of current as can be borne be applied for a sufficiently long time, at least a forty-five minute session. The galvanic bath offers a combination of mild general heating with the stimulating or "alterative" effect of the current to the skin. It serves as an alternate measure in institutional treatment and exerts no specific effects. Fragrant pine extracts or other resinous substances added to electric baths cause
in
additional skin stimulation.
Ion transfer with vasodilating drugs is based on research work pointing to the close connection between the disturbed peripheral circulation and the arthritic conditions. These studies showed that in arthritis the capillaries of
in
them
the skin have a tendency to remain empty and the flow of blood is sluggish. There is much less blood as a whole in fewer visible
r
many cases of arthritis than in normal persons. Histamine and choline compounds, w hen introduced by iontophoresis, penetrate the deeper layers of the skin and exert systemic as well as local effects; acting as antagonists to atropine, they stimulate the parasympathetic nerves and dilate the peripheral vascular system. Histamine ionization by the usual " " effect. counterirritant Mecholyl technique produces an intense local ionization produces a less intense local reaction, its effect amounting to a deposition of the drug in the deeper layers of the skin followed by gradual
capillaries in
470
absorption.
The physiological effects and technique of both procedures have been presented in Chapter VIII. Mecholyl ionization has been found useful in rheumatoid arthritis when other methods directed to the relief of the local condition have failed. 9 (Kovacs, J. and R., Boyd et al.) Histamine ionization brings about a vigorous local reaction and is preferable in rheumatic myositis and neuritis symptomatic relief in chronic and acute arthritides was reported by Reiley and Knapp. 15 High-frequency treatment from the single high voltage or Oudin terminal of a spark-gap diathermy apparatus (Chapter XI) may give marked relief in cases of diffuse pains of neuritic character and of fairly subacute
;
arthritis involving several joints.
It should
be given following external
heating.
radiation from a mercury vapor lamp furnishes relatively cold radiation, These rays will cause various i. e., with elimination of infrared rays. degrees of the familiar sunburn (erythema). Applied over a painful joint, such a sunburn often acts as a counterirritant and alterative; hence the
Ultraviolet
Radiation.
Ultraviolet
of
lamp or cold quartz type
instinctive desire of
many
arthritics to expose their painful joints to the
may
artificial radiation from the sources mentioned serve as an adjunct or alternate to other physical treatment and should be repeated only after the previous reaction has subsided. Sun-
sun.
Cautious local use of
burning doses should only be applied to one region and not to the entire body. Thermal and Counterirritant Measures. Natural sunlight or artificial radiation from a carbon arc lamp represents a combination of infrared
and
ultraviolet radiation.
it
suberythemal doses,
When applied for general body irradiation in serves as an aid in the constitutional treatment of
asthenic arthritics, especially those of the rheumatoid type. The beneficial effects of light therapy are partly attributable to the general tonic effect
of ultraviolet irradiation, partly to the thermal effect of the infrared component and perhaps also to the increase of the defensive power of the
body by the products
of biochemical changes in the skin and their effect through the circulation. Spa Treatment. A spa is a health resort developed around a mineral spring or springs which makes curative use of the water in conjunction with other natural resources and physical treatment agencies, such as climate, rest, exercise, and diet. The hot springs of the continent of Europe were the Meccas of rheumatic sufferers for many centuries and much of the gradually developed system of spa treatment was built around the treatment of these patients. It is evident that the general systemic debility,
the vascular changes, the disturbed metabolism, the improper living habits and surroundings, as well as the painful inflammatory conditions of joints and soft tissues can be particularly well benefited by the combination of therapeutic factors, which well organized and medically well controlled
spa treatment can offer. The position of a modern health resort is midway between the home and hospital. It is not a diagnostic clinic or a research institution but a place for such patients who will be benefited by a combination of physical treatment, climate, diet and psychotherapy. Such a combination is most suitable for many cases of rheumatism and is the reason why most of the
SCHEME OF PHYSICAL TREATMENT

conditions.
471
health resorts emphasize that they are treating arthritis and rheumatic Some of these even profess to specialize in the handling of such conditions. It is, however, evident that not all types of rheumatism will respond to spa treatment and that there exists no spa treatment method which exerts a specific curative effect on rheumatism. Unless the principal factors pertaining to the success of a health resort are available, the reliance of emphasis on any single therapeutic agent does not justify the sending of a patient to a distant spa. The presence of an ideal climate and a well equipped hydro therapeutic department is not sufficient unless
the patient gets the benefit of competent medical direction and trained
technical assistance.
and appropriate
conducive to rest
financial
diet,
also receive suitable hotel accommodations and the general atmosphere of the resort must be and relaxation. All of this must be available within the
He must
means of the rheumatic sufferer. So far as the selection of types of rheumatism suitable for spa treatment
concerned,
it
is
appears to be a consensus that patients in the active stage
of the rheumatic disease, especially rheumatoid arthritis, do better at home or at an institution at prolonged rest. In these cases, the exertion
would far outweigh the possible benefit After the acute stage, rheumatoid cases may be sent to a warm, dry region, where in addition to suitable rest, heliotherapy and diet, balneo- and hydro therapeutic measures may be carefully applied. The application of too much heat must be avoided at all times. Osteo-arthritis cases are generally more suitable for spa treatment. They are usually patients past middle age, often overfed and obese who have
of taking treatments in a spa
derived therefrom.
varying degrees of arthritic changes in some of their weight-bearing joints. They cannot change their mode of living or the abuse of their joints in
their
home
surroundings.
Such patients often do exceedingly
well
by
"taking the cure" consisting of thermal measures, massage, judiciously restricted exercise, suitable diet and rest from business worrying or nagging In addition, any existing strain on the heart and the general relatives. circulation can be beneficially influenced and after a sojourn of several
weeks these patients return home
literally rejuvenated.
No wonder
that
patients of this type return faithfully to their favorite spa for a renewal of the spa regime and keep comfortable, although the roentgen-ray pictures of their joints
show the usual slow progress
of the degenerative
changes. Similar considerations prevail in the employment of spa treatment in the treatment of cases of soft tissue rheumatism, chronic myositis, fibrositis, brachial neuritis and sciatica which have proven resistant to treatment at home. Long standing cases of traumatic, metabolic and gouty arthritis
may
also be considerably benefited
by
intelligently applied spa therapy.
Scheme
of Physical
Treatment
The large number of physical measures described constitutes an invaluable aid in the treatment of chronic arthritis and allows a selection of physical agents to fit almost every type or stage of the disease. It is evident
in conjunction with a plan of general treatment measures are strictly institutional procedures, but most of them can be applied in the physician's
that
all
these measures
must be used
of the
medical treatment.
Some
472
offices

and some
may
be carried out under skilled direction in the patient's
home.
To be truly effective and safe, all forms of physical treatment must be used with the proper technique, including adequate dosage and length of The frequency of application and the duration of a each treatment. course of treatment must be regulated according to the severity of the condition and the patient's response. Because of the not too rare interplay
mental and physical distress in arthritis, spectacular results in some cases of long-standing pain or other symptoms are apt to signify primarily a relief of the superimposed nerve tension. Best success is achieved by a
of
plan of painstaking, systematic use of treatment measures which take a long range view of the condition. Most patients will cooperate in this respect if the situation is frankly and fully explained to them. A note of optimism should always prevail a cheerful outlook by both physician and patient is an important necessity in the treatment of chronic arthritis. Patients can be safely assured that in most cases there need be no fear of crippling and therefore that they should never become unduly worried when, despite treatment, attacks of pain return. Taking into consideration the principal types and grades of chronic arthritis, the physical measures best suited for the average cases are as
;
follows.
Osteo- arthritis. In mild and moderate cases affecting one or two joints, radiant heat and massage or diathermy and massage should be used. In severe cases or in cases affecting several joints, a course of general heating measures is indicated; this may be done at times in the form of a cure at a spa. Exercises should be carried on regularly in all cases. In "worn out" joints, further wear and tear must be avoided by restriction of activities for a while and by suitable support by elastic bandages, caps or belts.
On the other hand, in cases may help to restore motion.

Rheumatoid
Arthritis.
of
advanced
stiffness, suitable
manipulation
Early cases require mild thermal treatment
locally as well as systemically to aid general circulation. Acutely painful joints must have complete rest from the beginning. Early heliotherapy,
natural or artificial, is important for general tonic effect. Suitable exercises, general as well as local, are to be instituted early to correct posture and prevent deformities. For local treatment, especially at home, daily use of luminous or infrared sources is advisable, followed by gentle massage and active exercise. Paraffin baths, whirlpool baths or ionization with vasodilating drugs are usually effective in reducing swelling and relieving pain in small joints which do not respond well to simple radiant heating. Patients with advanced cases may receive cautious fever therapy if all other measures fail to cause enough response. Underwater exercises
skilfully applied, systematic exercises to correct posture and support of weak joints are more essential here than in any other form of arthritis.
.
A few weeks' stay in a spa or health resort where suitable treatment measures are available under skilled medical direction is often eminently beneficial to many sufferers from both forms of chronic arthritis as already
elaborated. Gonorrheal Arthritis.
and
local
its
The specific effect of sulfa drugs on gonorrhea have to a great extent replaced fever therapy and complications heat therapy in their former predominant role. However, there are
SCHEME OF PHYSICAL TREATMENT
473
patients who are hypersensitive to chemotherapy; there are also contraindications such as liver and renal disease and the blood dyscrasias; finally
field for
there are cases in which drug therapy fails; consequently there is still a application of thermal measures, either alone or in combination
with drug therapy. Patients with acute gonorrheal arthritis must be kept in bed if a weightbearing joint is involved; mild heating from radiant sources should be employed, preferably thermostatically controlled, at the degree most comfortable to the patient. Treatment to the focus of infection the prostate and seminal vesicles, the female urethra and cervix has been successfully employed by Cumberbatch and his co-workers (for technique see Chapters and XXXI). Cumberbatch emphasized the importance of treating the originally infected parts and at the same time of giving the diseased joint the benefit of local diathermy as well as that of other physical measures. In the chronic stage intense diathermy applied to the joints
XXX
and duration of Solomon and Stecher 20 report improvement in 30 per cent of their cases with fever between 106 and 107 F. maintained from five to seven hours and repeated when necessary after intervals of two to seven days. The author has produced a similar average of good results in a series of 20 cases with temperatures between 105 and 106 F., maintained for an average of five hours. The relief of pain and return of function in some
to the height
up many cases. Hyperthermy fulfils the indications for and the affected parts in one full swoop. There is some difference of opinion as
will clear
treating the focus of infection
fever treatment in gonorrheal arthritis. complete relief in 52 per cent and marked
even one fever treatment seems at times almost draKrusen 10 believes that one very long, very high session of fever, ten hours at 106.8, is the most effective. In the combination treatment by sulfanilamide and fever, as developed at the Mayo Clinic, the patient is given 80 grains of sulfanilamide each day for two days; this produces a concentration of 8 to 9 mg. of the drug per
of these cases after
matic.
With this high concentration of sulfanilamide in the a ten-hour fever treatment is given on the third day. With this blood, procedure Krusen has found apparent remission of all symptoms and negative cultures in 96.2 per cent patients who did not respond to sulfanilamide. In chronic cases of gonorrheal arthritis the management of residual pain, swelling, adhesions and limitation of motion often greatly taxes the endurance and skill of the physical therapist. It requires treatment along the lines already described. This is a painful stiffSpondylitis Deformans (Marie -Striimpell Disease). ness of the spine caused by either atrophic or hypertrophic arthritic changes, ossification of ligaments, atrophic changes in the intervertebral discs or productive arthritis (osteophytes) with disintegration of the cartilage. An intensive course of general thermal measures, such as artificial fever or long applications of diathermy to the spine, is indicated in all grades, combined with suitable support to the back and careful active exercises. Suitable posture in bed with stretching of the spine is essential to prevent stiffening and kyphosis. A simple procedure is to place the patient on a flat surface, with a small soft cushion under the head, allowing
100
cc. of blood.
474
sinking of the head and gentle stretching of the spinal column, beginning at five to ten minutes and increasing with a few minutes daily. Respiratory exercises are useful to increase chest expansion. Underwater treatment is
frequently helpful. Abroad, galvanic full baths with the addition of vegetable extracts (Stanger bath) have been extolled. Good results from local ion transfer with a solution containing 1 per cent nupercaine and 70 per cent alcohol and 1 to 5000 epinephrine have been reported by Harpuder. 6 Gouty Arthritis. Typical attacks of this condition appear in overweight men after the age of forty with a sudden onset, usually caused by extreme pain and purplish-red swelling of the metatarsophalangeal joint of the big toe and adjacent parts. After keeping the patient miserable for a few days there is complete recovery and only after repeated attacks do bony changes and typical uric acid deposits known as tophi occur. Physical treatment in the acute stage consists of absolute bed rest, and possibly also a posterior splint holding the joint immobile; mild heating by warm compresses or still better a thermostatically controlled heating hood. Some In the chronic stage more patients do better under cold applications.
fibrosis
intense local heating serves, to absorb exudation and prevent residual 21 (Solomon and Stecher ); also electric cabinet or other baths may
be used to secure diaphoresis and elimination of waste products. Acute Arthritides. In acute non-specific arthritis, as well as in acute rheumatic fever with active endocarditis favorable results with fever 22 17 therapy have been reported by Stecher and Solomon as well as Simmons. In the now more frequently recognized joint manifestations of brucellosis 18 (undulant fever) fever therapy has also been found effective. (Simpson, Phalen et a/. 14 ) Tuberculous Arthritis. This condition is being presented in Chapter
XXIX.
Traumatic
Arthritis.
This condition
is
also discussed in
Chapter
XXIX.
FIBROSITIS
Pathology.
It
is
now
the generally accepted view that the "rheumatic
syndrome" includes a great many acute and chronic inflammations outside of the joints, in the muscles, tendons, bursse and in the nerve sheaths.
The common
fibrositis.
pathological change in
all
these conditions
is
of the connective tissues of the body,
and
is
known under
This term has found universal acceptance in only gradually so becoming recognized in the United States. Fibrositis has been defined as the reaction of the fibrous supporting tissues of the body to extraneous poisons which may be bacterial or toxic, and occurs in persons who are constitutionally disposed to such a reaction. The reaction may be acute or chronic. Osier states that in acute cases there is a serous exudate into the affected parts, following which there may be proliferation of the fibrous tissue, which may extend between muscle fibers, causing stiffness and pain. The acute stage is characterized by extreme tenderness and severe pain, either constant or only on certain movements; the affection is entirely local and the constitutional disturbance is slight. Muscular spasm is a frequent accompanying feature of this stage; this may be so painful that the patient is quite unable to move. No wonder that acute lumbago, the most frequent form of acute muscular involve-
an inflammation the term of England, but is
FIBROSITIS
475
ment is known in German under the fitting term of " Hexenschuss " which means "shot by a witch." In the acute attack the muscular spasm may produce an extremely tender lump which resembles the nodule to be described but which disappears spontaneously when the attack passes off. If resolution is not obtained in acute cases, by insidious progress the
exudate becomes organized in the form of a "nodule" the typical pathological lesion of chronic fibrositis. The nodule is a round, oval or longitudinal mass of avascular scar tissue, differing from normal fibrous tissue in its poor blood supply, lack of elasticity and tendency to contract. These nodules can be located by the trained finger in palpating relaxed muscles
FIG. 296.
Common sites for fibrositic induration on posterior portion of body. (Courtesy of Dr. F. H. Krusen 11 and Archives of Physical Therapy, X-ray and Radium.)
and may or
or other fibrous structures
may
not be tender; they are the
characteristic evidence of the chronicity of the disease. They may become tender again if further toxins are deposited as a result of lowered local
resistance such as
may follow local
chilling.
The nodule may be considered
as a tissue reaction to the circulating toxins and not to bacteria, because the latter are never found in it; it is histologically very similar to the
bodies described in the myocardium by Aschoff. According to Thompson and Gordon 24 the fibrous tissue formed as a result of inflammatory reaction is of a lower order than the normal fibrous tissue supporting the various organs. Once formed, the fibrositic nodule tends to persist until dispersed
476

of the essentials of treatment
is
by appropriate treatment. One the nodule and "rub it out."

Diagnosis and Classification.
to find
The
diagnosis of fibrositis
is
made on
the
basis of the following points: (1) Typical pain and stiffness, following either exposure to cold or to strain or coming on insidiously in a person
with a rheumatic disposition. (2) Typical bands or nodules, often acutely The structure to be examined must be relaxed as much as possible and the fingers are passed along with a deep, firm stroke. When a nodule is situated in muscle fibers, firm pressure on it will often induce a reflex contraction of the muscle. (3) Exclusion of other conditions which may give rise to similar symptoms, such as affections of bony structures, organic nervous disease, tumors of inner organs. Fibrositis is often associated with
tender.
chronic arthritis.
Slocumb 19 states that patients with fibrositis usually appear to be in good physical condition, which is not so frequently the case in arthritis; in fibrositis there is no intra-articular hydrops and no muscular atrophy
although there may be slight thickening of the capsule subsidence of the acute stage of fibrositis the function of the joints generally returns to normal, although occasionally fibrous contractures occur. The roentgenograms of the joints remain normal and the sedimentation rate of erythrocytes is normal or only slightly elevated. Finally, in contrast to the average case of arthritis, there is usually no loss of weight and no significant anemia. The main varieties of fibrositis are, according to the Arthritis Committee of the British Medical Association: 16 (a) intramuscular, fascial and periarticular fibrositis and bursitis. The acute and chronic muscular rheumatism are types in this group; (6) perineuritis, an involvement of the nerve sheath, especially in the brachial and lumbar plexuses, with the pain referred often down the course of the nerve. The large number of so-called neuritis cases without the typical sensory changes or trophic disturbances is explained by fibrous nodules often far removed from the localization of the pain; (c) panniculitis or fibrositis of the subcutaneous tissues. Treatment. The principles for the treatment of chronic arthritis are applicable to the treatment of fibrositis; general treatment must remove the cause and counteract the constitutional factors while local treatment aims to relieve pain and stiffness and to remove the cause of local symptoms, the nodule. Indeed, the treatment of the chronic condition is generally more effective because of the possibility to employ efficient physical measures for the resorption of the inflammatory thickening. Only the general principles of treatment will be enumerated here. The severe local (a) Relief of pain and stiffness in the acute stage. in the acute stages of fibrositis overshadows all other symptoms. pain The patients instinctively seek to immobilize the affected part and physiological rest is indeed the most indispensable physical measure next to local heat application for the relief of pain. Immobilization should be provided by whatever mechanical means are best suited for a given location: firm bandaging, strapping, wearing of a sling; or complete rest in bed. Heat is administered by exposure to luminous heat or infrared radiation in efficient dosage. Diathermy is as a rule well tolerated in the acute stage of myositis, but not so well tolerated in neuritic affections. Ultraviolet radiation is
arthritis,
such as in
of the joint.
On
definitely contraindicated in this stage.
The
use of sedative medication
FIBROSITIS
for a
477
is often indispensable, especially in order to insure rest the night. during removal of underlying causes and pre(6) Constitutional treatment: venting of recurrence. Constitutional treatment should be instituted at the earliest possible moment, i. e., as soon as the acute symptoms have subsided and the probable cause of the condition has been ascertained. It should be planned on the lines of attack outlined for chronic arthritis with the difference however that especial emphasis must be laid from the outset to locate and eradicate possible foci of toxins circulating in the system, as may exist in the form of dental abscesses, dead teeth, infected tonsils, disturbances in the absorption or elimination from the gastro-
day or two
intestinal tract.
An
equally important phase of the constitutional treatment
is
the
increase of elimination through the skin and the raising of general metabolism. Nothing fulfils this object so satisfactorily as a systematic course
of general thermal measures as outlined in the first part of this chapter. Clinical experience has shown that in the vast majority of cases patients
respond with definite improvement in their general as well as in their local condition to such a course of treatment, provided it is selected and carried on in accordance with the tolerance of the individual. Systematic muscular exercise, "hardening" of the skin against chilling by suitable hydrotherapeutic procedures should also be employed if indicated. It is the instinctive desire of the rheumatic sufferer for a general regimen of elimination, relaxation and upbuilding, which fills many of the health resorts. Many of the beneficial effects of a well directed "cure" can be provided,
however, in home surroundings and in physicians' offices by comparatively simple means. As an all year round prophylaxis against the recurrence of the disabling and painful attacks in the various forms of fibrositis, a continued constitutional therapy is of paramount importance. The local treatment of fibrositis in its diverse manifestations will be discussed under the heading of neuritis in Chapter XXVIII and under
bursitis
and myositis
in
Chapter
XXIX.
specific treatment for the fibrositic nodule recommended by practically all clinicians is manipulative treatment, i. e., actual breaking up and dispersal by heavy local massage. Ordinary massage over an entire 12 extremity is useless according to Mennell, whereas concentration over the affected regions, deep thumbing movements, deep kneading and upward pressure seems actually to break up the deposits and relieve the muscular pain. Krusen 11 confirms the occasional disappearance of nodules under special heavy massage, but also reports frequent recurrences. The author believes that with well directed heavy static sparks he has accom-
The
plished similar results;
Smart
is
extols the use of the faradic current for the
same purpose.
a condition which most frequently occurs in is characterized by an atrophy of the skin in middle-aged circumscribed spots, due to a subcutaneous fibrositis. The affected areas are extremely tender and show a characteristic mottled dimpled appearance. This tenderness is best demonstrated by attempting to pick up the skin between the finger and the thumb. The normal elasticity of tissues shows great diminution and there is often a cyanotic change due to venous
Panniculitis.
This
women and
congestion.
478
Patients are usually of an obese type, complain of peculiar aches and soreness in various parts of the body, are easily fatigued and nearly always
constipated. Treatment.
Treatment along the general
lines
for fibrositis
usually
Small doses of thyroid extract are helpful; this proves that the disease is connected with some endocrine dysfunction, thus resembling Dercum's disease or adiposis dolorosa. The earlier in the Results of Physical Therapy in Rheumatic Disease. disease physical measures are instituted the more satisfactory are the
gives satisfactory results.
results as reported by Glover, Cross Clinic for Rheumatism. 8
all
it
5
Pemberton,
13
Wyatt
26
The Red Cross
Clinic treats patients
and the British Red by

;
recognized methods but places special emphasis on physical treatment reports that of 2314 patients discharged in 1935 with treatment completed, 51 per cent were cured or free from symptoms, 35 per cent definitely improved, 13 per cent unchanged or only slightly improved and less than 1 per cent worse. These reports of competent observers further corroborate the now generally accepted conception that to a great extent the rheumatic group of diseases, including chronic arthritis, is both preventable and curable. It is essential, therefore, that the pessimism resulting in the inactivity of However such yesteryears be replaced by a well-founded optimism. optimism must be based on the medical man's correct diagnostic capacity as well as his ability to select from all established methods of treatment those most likely to benefit the individual patient. Physical measures should play a large role in the treatment of all forms of chronic arthritis.
REFERENCES
1.
2.
BACH, Management BOYD, D., OSBORNE, S.
F.:
of
Early Rheumatoid Arthritis, Practitioner, 152, 20, 1944.
L.,
and MARKSON, D.
E.:
Mecholyl-ionization in the
Arthritic, Arch. Phys. Ther., 20, 406-410, 1939. 3. BREDALL, J. J.: Newer Treatment of Arthritis
4. 5.
and Similar Conditions, Jour. Missouri Med. Assn., 35, 164-168, 1938. FRITZ, J.: Spondylitis Deformans, Therap. d. Gegenw., 78, 457-462, 1937. GLOVER, J. A.: A Report on Chronic Arthritis With Special Reference to Provision
of
Treatment, Ministry of Health, London, His Majesty's Stationery
Office, 1928.
6.
7.
8.
9.
HARPUDER, K.: Electrophoresis in Physical Therapy, Arch. Phys. Ther., .X-ray and Rad., 18, 221, 1937. HUNT, L. W.: Diagnosis and Treatment of Fibrositis and Myositis, Med. Clin. North America, 21, 257, 1937. KOVACS, R.: The Rheumatic Problem in Great Britain, Arch. Phys. Ther., X-ray and Rad., 17, 10, 1936. KOVACS, R., and KOVACS, J.: Newer Aspects of Iontophoresis in the Treatment of Arthritis and Circulatory Disturbances, Arch. Phys. Ther., X-ray and Rad.,
October, 1934.
10.
11.
KRUSEN, F. H.: Physical Medicine, Philadelphia and London, W. B. Saunders Company, p. 707, 1941. -Physical Therapy of Fibrositis, Arch. Phys. Ther., X-ray and Rad., 18,
687, 1937.
J. B.: Massage, Its Principle and Practice, 2d ed., Philadelphia, P. Blakiston's Son & Co., p. 535, 1920. 13. PEMBERTON, R.: Arthritis and Rheumatoid Conditions, Philadelphia, Lea & Febiger, 1935. 14. PHALEN, G. S., PRICKMAN, L. E., and KRUSEN, F. H.: Brucellosis Spondylitis, Jour. Am. Med. Assn., 118, 859, 1942. 15. REILEY, R. E., and KNAPP, M. E.: Symptomatic Relief in Chronic and Acute Arthritides by Histamine Iontophoresis, Arch. Phys. Ther., 22, 288-294, 1941.
12.
MENNELL,
REFERENCES
16.
479
17.
Report of Arthritis Committee of British Medical Association, Brit. Med. Jour., p. 1033, June 17, 1933. SIMMONS, E. E.: Value of Fever Therapy in the Arthritides, Am. Jour. Med. Sci.,
194, 170, 1937.
18.
19.
SIMPSON, W. M.: New Development in Diagnosis and Treatment of Brucellosis (Undulant Fever), Minnesota Med., 24, 725, 1941. SLOCUMB, C. H.: Differential Diagnosis of Periarticular Fibrositis and Arthritis,
Jour. Am. Med. Assn., 107, 534, 1936. SOLOMON, W. M., and STECHER, R. M.: Treatment
Artificial Fever,
20.
of Gonorrheal Arthritis
With
.
21
- Gout
Arch. Phys. Ther., 19, 389-392, 1938. a Prevalent Arthritic Disease, Arch. Phys. Ther., 22, 462, 466, 1941
22.
23. 24.
25.
26.
STECHER, R. M., and SOLOMON, W. M.: The Treatment of Acute Infectious Arthritis of Undetermined Origin With Artificial Fever, Am. Jour. Med. Sci. No. 4, 194, 485, 1937. TAYLOR, D.: Degree of Involvement in Chronic Arthritis, Journal of Chartered Society of Massage and Medical Gymnastics, 23, 79, 1937. THOMPSON, F. G., and GORDON, R. G.: Chronic Rheumatic Diseases: Their Diagnosis and Treatment, Edinburgh, Oxford University Press, p. 202, 1926. WARREN, S. G., and LEHMAN, E.: Use of Heat in the Care of the Arthritis Patient, New York State Jour. Med., p. 36, October 15, 1936. WYATT, B. L.: Chronic Arthritis and Fibrositis, Diagnosis and Treatment, Baltimore, William Wood & Co., 1933.
CHAPTER XXVII
General Considerations. Hemiplegia. General Paresis. Poliomyelitis. Locomotor Ataxia, Multiple Sclerosis, Myelitis. Chorea Minor. Cerebral Palsy. Obstetric Paralysis. Infantile Paralysis. The Neuroses. Mental Conditions. Electric Shock
Therapy.
General Considerations. The evolution of the application of physical energies for the treatment of nervous and mental diseases represents a change from crude superstition and empirical therapy into well controlled clinical methods resting on a rational theoretical and experimental basis.
centuries, sufferers from mental disease were supposed to be "possessed" by Satan and were subjected to cruel physical restraint, being kept in chains with thieves and murderers. About one hundred and fifty years ago Pinel took off the fetters of mental patients at the Saltpetriere in Paris and espoused the use of hydrotherapy for its sedative and tonic effect on mental illness. Gradually other forms of physical treatment were introduced, especially electricity, but at first without either rhyme or reason. In Haynes' text-book on electrotherapeutics printed thirty-five years ago one can still read such statements as, "It is believed that the galvanic current penetrates the substance of the brain while the faradic current is distributed chiefly to the membranes," also "This rule has been given for the use of galvanism in insanity; recent cases and functional
For many
while old cases and structural diseases resist that well known neurologists recommended the use of electricity more or less in the form of a placebo or as a convenient means of disguising suggestive therapeutics and gave blanket recommendations for its use without specifying its form and without any reference
diseases are benefited
its
by
it
influence."
No wonder
to technique.
of the
Modern progress in physical therapy has given us a definite conception mode of action of physical energies in affections of the central
nervous system and their limitations. No form of physical therapy can be expected to restore highly differentiated elements of the central nervous system once they have been destroyed, but it is a fact that many of the pathological changes in the nervous system are subject to restitution. Table 53 indicates changes in the nervous system and the problems of
treatment.
All physical measures exert a certain amount of psychic effect partly tonic action and partly in the form of suggestive therapy. Hence they offer a valuable therapeutic aid in psychoses and psychoneuroses. It is
by
a frequent experience in mental hospitals that the mental status of patients shows improvement while they receive physical treatment for a nonmental condition such as traumatism or arthritis. Neurosurgeons and orthopedic surgeons have learned to appreciate the value of currents of low tension and low frequency in the treatment of muscular weakness and paralysis. Underwater exercises enable a new form of treatment of infantile paralysis and have been also extended to
(480)
481
the treatment of the after effects of hemiplegia and cerebral palsy. The various forms of hydrotherapy form today an indispensable part of the routine treatment in mental institutions.
TABLE
I.
53.
CHANGES IN NERVOUS SYSTEM AND PROBLEMS OF TREATMENT (AFTER VERAGUTH 36)

Treatment
(a)
Changes of possible reversibility (a) Disturbances of optimal excitability

1.
to facilitate
Return of optimal
1. (
excitability
2.
3.
In vegetative nervous system In sensomotor part In substratum of higher psyche

(c)
Physical, medicinal
and
2. \ dietetic therapy 3. Principally by psycho-
therapy
Detoxication Resorption Regeneration
to retard
(6)
(c)
Toxemia
Inflammation
Destruction of neurons capable of regeneration
II.
(d)
II.
Threatening or absolute irreversibility
Treatment
progress
Toxemia
Destruction of neurons through
Inflammation Anomalies of
culation
cir-
Mechanical force
Foci causing pressure
Physical, medicinal, diet therapy Possibly through surgery Possibly through X-ray therapy
III. Treatment in all cases
Improve function of intact part of nervous system

Care of connective organs
TABLE 54. CONNECTION BETWEEN PATHOLOGICAL STATES OF THE MOTOR TRACT AND MUSCLES AND THEIR ELECTRODIAGNOSTIC SYMPTOMS (AFTER POTTS)
Seat of lesion or disease
1.
Electrical reactions
:
Brain cortex and the pyramidal tracts cerebral apoplexy and the resultant paralysis; tumor; abscess; transverse or compression myelitis (muscles supplied by nerves arising from segments below the
seat of the lesion); lateral sclerosis; hysterical paralysis. Pyramidal tracts and the cells of the anterior horns of the cord (central and peripheral neurons).
Normal
usually; if paralysis is of long duration, sometimes slight
diminution of excitability.
In non-atrophied muscles, normal; in atrophied muscle either

quantitative decrease or
(usually partial).
Amyo trophic
2.
lateral sclerosis.
RD
Cells of the anterior horns of the cord and bulbar motor nuclei (peripheral neuron) (a) Acute poliomyelitis; transverse myelitis, tumor hemorrhage, localized meningitis, syringo-
(a)
myelia (muscles supplied by nerves from the affected segments when the gray matter of the cord is involved) and glossolabiolaryn(6)
Various degrees of RD; in acute poliomyelitis most often complete.
geal paralysis. Progressive muscular atrophy
(b)
Quantitative
in decrease early stages. Various dein the later. gree? of This may also apply to
RD
syringomyelia, localized
meningitis and glossolabiolaryngeal paralysis.
(c)
Myasthenia
gravis.
:
(c)
Myasthenic reaction.
3.
Peripheral nerves (peripheral neuron) neuritis from various causes, as rheumatic, traumatic or toxic; progressive neuritic muscular atrophy
Quantitative decrease in mild cases. Various degrees of in the more severe ones.
RD
4.
Muscles.
(a)
Myopathies or dystrophies
(a)
Normal
crease.
or quantitative dereaction,
(b)
(c)
Myotonia congenita Tetany
(6)
(c)
Myotonic
Quantitative increase.
31
482
Electrodiagnosis has been recognized for many years as invaluable in amplifying or corroborating clinical findings or in affording the means of important differential diagnosis between organic (central and peripheral) and functional or hysterical paralyses. It is an important help in prognosis and forms the basis for the selection of the effective form of electrotherapy in lesions of the central and peripheral nervous system as shown in Chapters VI and VII. Testing by condenser discharges, by determination of the chronaxie and by electromyography has added newer methods of great
accuracy. For the determination of appropriate therapy in affections of the motor tract the differentiation of paralysis according to the site of the lesion is important. The upper motor tract extends from the psychomotor cells in the brain to the terminal arborization of the pyramidal tract in the anterior horns of the spinal cord, while the lower motor tract extends from the ganglion cells in the anterior horns through the motor root and the peripheral motor nerve to the end-plate in the muscle fibers. (Fig. 80.) A lesion
any part of this long path may produce paralysis. The essential difference between the two types is that in upper motor neuron lesions the trophic center of the muscle in the spinal cord remains unimpaired and no denervation of muscle follows, whereas in those of the lower motor neuron musin
cular atrophy or a reaction of degeneration eventually occurs. In lesions of the central neuron electrical stimulation of muscles has
little clinical value, whereas in those of the lower motor tract it has become an indispensable part of routine treatment for the maintenance of muscular function, improvement of nutrition and in some cases for acceleration
of the return of function.
Hemiplegia. The term hemiplegia signifies paralysis of one side of the body. It is the result of a primary lesion in the cardiovascular system. Hemiplegia is brought about by one of two causes: (1) Arterial obstruction with resultant softening of the brain due to embolism or thrombosis.
(2) Arterial hemorrhage; this is less frequent than thrombosis, but more often fatal. Intracerebral hemorrhage is caused by the combination of the .degeneration of the arterial wall and high blood-pressure.
The manifestations of an attack of hemiplegia is the apoplectic stroke which usually comes on suddenly and is accompanied by focal signs which
reflect the loss of function of the affected parts of the brain. As a result there remains a distressing train of symptoms that may include disturbances of speech, of gait, of the movements of the arm and hand and often mental
lassitude, dizziness and loss of memory. Most of these symptoms have the tendency to recover spontaneously. The extreme limit of spontaneous restitution ends between the ninth to twelfth month. Physical therapy has a definite place in this condition for the early
rehabilitation and re-education of affected extremities, hastening convalescence and restitution and contributing to mental ease. The physical therapist as a rule does not see many cases of hemiplegia in the acute stage
except in general hospitals. Early treatment gives the patient a better chance of recovery; the final result depends on the extent of the subsequent recovery of the affected motor areas. In the first week of hemiplegia while the patient may be still in bed, the application of radiant heat to the affected arm or leg will comfort and tend to relax the paralyzed limbs. Faulty positions of the joints with subsequent contractures are prevented
HEMIPLEGIA
by simple
483
splinting and frequent changes in the position. Passive movements should be performed early and be accompanied by gentle stroking massage. As soon as some muscular power has returned the patient should be encouraged to do active exercise, thus counteracting the tendency to
contracture.
In the subacute stage physical treatment may be instituted in two direcOne is for accelerating the circulation in the brain. Cerebral galvanism, transcerebral calcium iontophoresis and diathermy have been employed for this purpose. The technique of cerebral galvanism has been described in Chapter VIII. The author has seen frequent benefit from this treatment in patients in the subacute stage complaining of headache and dizziness not due to persistence of high blood-pressure. Whether the favorable results are due to a direct influence upon the pathology or to reflex stimulation from the periphery, is undetermined. Treatment by skilled hands is perfectly safe and pleasant and can be administered at the bedside. It should be applied daily at first, later every other day and continued for several weeks, depending upon the response. Cerebral diathermy has been reported on by Martucci et a/. 22 With treatment administered three times a week for twenty minutes to one hour these authors have produced considerable relief and explain their results by reflex acceleration of the circulation. French authors have
tions.
reported a favorable influence on contractures, gait and speech by shortwave diathermy to the brain. Calcium ion transfer (Chapter VIII) has been extolled by Bourguignon and Cross 8 for old cases of hemiplegia, recommending treatment of thirty minutes' duration at a current strength from 2 to 4 milliamperes. This is
to be carried on daily for six days and subsequently on alternate days for three weeks. three week rest period should follow the month's active
treatment; and they assert that definite improvement
is
usually manifest
by
this time.
further important object of physical treatment is the improvement vasomotor and sensory disturbances and the spastic paralysis. Early gentle massage may help greatly in relaxing spasticity and restoring normal motion. Suitable manipulation and active exercise may be comof the
The application of bined with graduated electric muscle stimulation. radiant heat always should precede such treatments. Electrical stimulation of the paralyzed muscles by a suitable surging current may begin after a few weeks. The dispersive large pad electrode, well moistened, is placed under the cervical or lumbar spine, according to whether the upper or the lower extremity is treated. The active electrode, a small disc, 1J inches in diameter, covered with gauze, is placed in turn over each motor point. Current at sufficient intensity is used to cause a few gentle contractions in each muscle. Such treatment requires patience and perseverence. It may be time-saving to mark the motor points on the skin with an indelible pencil to help to locate them at subsequent treatments. A simple method of group stimulation is that through the medium of a water-bath. The hand or foot of the affected side is placed in a basin or other container with warm water, and the two terminals of the apparatus are connected to metal strips laid in the water. Just enough current is used to cause a faint visible muscular response at a rate of about thirty
484
contractions per minute. This is kept up for five to twenty minutes and repeated every other day. This technique stimulates primarily the normal muscles and only secondarily those which are out of control. The value of electrical treatment is doubted by those who feel that
spastic muscles are only too prone to respond to any stimulus; it is recommended, therefore, that electrical treatment should be applied to the opposing normal muscles in order to prevent their overstretching. Most
observers agree that this is rather far-fetched and that gentle electric exercise tends to relax and contract the spastic muscles and serves to maintain nutrition during the process of recovery. Occupational therapy is important in keeping up the patient's morale and serves, too, as a
stimulus for active exercise. Underwater exercises in a tank or pool have been successfully employed in recent years to relax spastic muscles in hemiplegia and to encourage voluntary use. Hydromassage of the affected limbs by a whirlpool bath
an efficient combination of heating and massage. For paresthesias and other painful sensations the monoterminal highfrequency (Oudin) current may be applied advantageously. The glass condenser electrode is rapidly moved over the well-powdered skin and is
is
held in close contact to the parts. (Fig. 183.) The current is regulated so as to cause just a gentle pricking and mild surface warming. General Paresis. Artificial fever therapy has opened up a new vista in the treatment of this formerly so resistant affection. Neymann 26 states that intense and prolonged treatment with electropyrexia offers a decided hope of recovery to every early case of general paresis and that the extent of psychotic manifestations has no bearing on the question of recovery. All observers found most favorable clinical and serological results in those paretics who received fever therapy followed by intense chemotherapy. Ewalt and Ebaugh 10 in a five-year study found 69 per cent remission in a group treated with fever and 58 per cent remission in that treated with malaria. They hold that an important asset of fever therapy is that the patient may be safely treated at higher levels of temperature than is
possible with therapeutic malaria. The patient also usually gains weight and is in better physical condition, whereas malaria therapy causes loss of weight and some degree of anemia. Results were good in the mild cases
of
both groups and

is
chemotherapy
less satisfactory in severe cases. Intensive follow-up essential to obtain optimal sustained results.
In applying fever treatment to cases with cerebrospinal lues it is important that sessions of sufficient intensity and frequency be given. Temperatures below 103 to 105 F. have little clinical value in any type of syphilis. In the series of Ewalt and Ebaugh treatments at 105.8 F. were administered for three hours for twelve sessions. Simultaneous chemotherapy was given, which is not possible when administering malaria treatment. In serologically fast syphilitics the use of ultraviolet irradiation, combined with autohemotherapy injections of progressive amounts of the 32 Liberman patient's own blood was proposed by Rajka and Radnai. and Spark20 claim that by using gradually increasing erythema doses of ultraviolet in addition to chemotherapy in dementia paralytica, patients
improved more rapidly. Locomotor Ataxia. It
is to be expected that in a trying condition like locomotor ataxia various forms of electricity should be employed symp-
tomatically in an effort to stimulate function and relieve pain.
MULTIPLE SCLEROSIS
485
Diathermy has proved beneficial for the relief of lancinating gastric, bladder and leg pains. It may be applied either through the spine or to the spine and the site of the lancinating pains. In employing diathermy it must be remembered that the sense of temperature is often impaired in locomotor ataxia. The current strength must be kept well within the toleration calculated according to the size and relative position of electrodes. Galvanism has been advocated in the form of galvanic baths and by direct application to the spine, at 20 to 30 milliamperes for twenty to thirty minutes. No definite reports on the results of this treatment have been made. The static wave current applied to the spine and followed by static sparks to the spine and lower extremities has been employed by the author and other clinicians for improving the paresthesias and the general strength. It should be preceded by radiant heating or diathermy along the spine. Artificial fever therapy has been employed in recent years with similar technique as in dementia paralytica. It is recommended that fever treatment should be used mainly in progressive cases which appear clinically and biologically resistant to the usual specific treatment; it appears useful in relieving tabetic pains especially in those cases which are characterized
by repeated shooting pains or

tabetic optic atrophy.
gastric crises;
it is
also
recommended
in
A series of
with a temperature a little The degree of improvement possible depends mainly on the advised. extent of pathological changes in the cord prior to treatment and is, there25 of cases treated with fore, not predictable. A tabulation by Neymann fever therapy shows improvement in 54 to 60 per cent. The author has had some encouraging results with fever therapy in early cases. Multiple Sclerosis. Artificial fever treatment of this inflammatory affection of the spinal cord of uncertain origin, so resistant to various lines of treatment has been employed in recent years. The conclusions as to results are somewhat divergent, chiefly because the number of cases in each series was too small and therefore not classified. Bennett and Lewis 3
reported 51 cases of multiple sclerosis treated by artificial fever and followed up for an average of thirty-one months. These cases were evaluated on the basis of the following comprehensive classification: (1) early cases 10 patients could walk without assistance when admitted for treatment, did not need hospitalization and their symptoms did not date back longer than one year; (2) intermediate cases 25 patients required some form of
assistance to be ambulatory, were unable to
10 treatments two or three times a week above 105 F., applied for four to six hours is
work and were almost com-
pletely disabled because of cerebellar and pyramidal tract involvement; 16 patients were either bedridden or needed wheel (3) advanced cases
symptoms were of long duration. No patient was included received at least four treatments. Most of them received 6 treatments, each of three or four hours at 104 F. These authors conclude that fever therapy should be tried in the early cases for the results seem better than might be expected without treatment. In the intermediate types, the benefits are doubtful; therefore, other
chairs
and
their
who had not
less vigorous methods are indicated. In the bedridden group, fever therapy does no good and may do harm. Before the advent of fever therapy, diathermy to the spine was favored by some neurologists in the spinal type of the disease. Improvement in the sensory fields was noted within twenty-four to forty-eight hours after
486
the first treatment. Improvement of the spastic syndromes after shortwave diathermy to the spine was reported by Walthard. 37 Treatment calls for restoration of function. Weisenburg and Myelitis. 38 Alpers state that physical treatments in myelitis must be carried out over a prolonged period, and it is surprising how persistence will be rewarded often by encouraging results.
In paraplegia gentle muscular electrical exercise is useful in stimulating the muscular function. A large dispersive electrode is placed over the spinal column well above the site of the lesion and connected to one pole; two smaller electrodes are placed under the soles of the feet and connected to the other pole. On alternate days only the two foot electrodes may be employed, each connected to one pole. Each leg may also be treated sepaThe patient is encouraged to do rately, with a longitudinal technique. active work with the affected muscle groups. The improvement depends on the extent of the lesion. Decubitus or bed-sores do well under irradiation from a luminous heat lamp followed by local ultraviolet treatment. Chorea Minor. Striking results by fever therapy have been produced in this condition regardless as to whether its etiology was infectious or psychogenic. Treatment of children in heat cabinets or by electromagnetic fever induction has proved safe and practical. Sutton and Dodge 36 used temperatures between 105 and 106 F. for four to five hours and found that it was possible to cut short an attack of chorea with 1 or 2 treatments, especially when cases are treated early, regardless of the severity of the disease. Carditis is no contraindication to treatment and, according to Sutton and Dodge, fever therapy may be a valuable measure in rheumatic carditis. Barnacle et a/., 2 in a series of 45 cases treated at temperatures ranging from 105 to 105.4 F. with short daily sessions of only two and one-half hours' duration achieved similar excellent results with an average of 12.6 treatments of a total duration of 32.9 hours. There were only four recurrences. Finally, Osborne et a/. 28 treated 25 patients with chorea minor, 7 of whom presented some degree of carditis. The electrocardiograms of some of the patients showed striking improvement. These observers concluded that artificial fever ranging up to 107.6 F. sustained for five to eight hours does not adversely affect the heart or the cardiovascular system if the doses of fever are those
normally employed for treatment of disease. Cerebral Palsy (Spastic Paralysis). In this
common
affection of infants
and children the essential pathological change is the destruction of the upper motor neurons resulting in disturbance of the voluntary motor function. The most frequent cause is intracranial hemorrhage resulting from trauma at birth; however it may be also due to arrested development before birth and to infections or traumatic lesions after birth (encephalitis,
meningitis, etc.).
of the characteristic spastic symptom complex is essena process of rehabilitation, embracing a long program of muscle training. It must be adapted to the two types of spastic paralysis spasticity and athetosis. (1) In spasticity there is injury to the cortex of the brain and if the hemorrhage affects the intelligence area, the child's mentality is impaired. The spastic muscle is thrown into maximal contraction at the least stimulus especially by the stretch brought about by any movetially
;
The treatment
INFANTILE PARALYSIS
487
ment of its antagonist. This results in difficult and inaccurate voluntary movements and in an increased muscular resistance to passive manipulation. The. spastic patient is to be treated by careful exercise, avoiding stretch reflex. The spastic muscles must be taught to relax voluntarily to the stimulus that would ordinarily cause them to contract. Still more important is exercise of the weakened antagonist. Surgery upon the brain, nerve roots, muscles and tendons may be done in some cases to diminish muscle spasm, equalize the power of opposing muscles, or correct deformity.
due to an injury to the basal ganglia or extra-pyramidal characterized by more or less constant involuntary contraction of successive muscles, which becomes superimposed upon voluntary movements and results in marked incoordination. The muscles of the athetoid
(2) Athetosis is
;
tracts
it is
are essentially normal and do not need any exercise to strengthen them; he needs to learn relaxation, so as to be able to move them with a minimum amount of tension and be able to control the force and direction of the
Occupational therapy and vocational rehabilitation is the both types of cases for "total activities." (Phelps. 30 ) "Birth palsy" is due to mechanical injury of the Obstetrical Paralysis. nerve roots of the brachial plexus during prolonged and difficult birth, resulting in paralysis of the muscles of the upper extremity. There are three types of this lesion: (1) The upper arm or Erb-Duchenne type is due to injury of the fifth and sixth cervical trunks; it results in typical internal rotation and adduction of the shoulder, while the movements of the wrists and fingers are not affected. (2) The lower arm or Klumpke
desired act.
final step in training
type, due to a lesion of the first dorsal and eighth cervical trunks; it affects the intrinsic muscles of the hand and sometimes the long flexors of the
(3) The whole arm type. In all cases there is a flail or limp extremthe infant will flinch or cry on passive motion of the injured arm and a painful neuritis is present for several weeks. The prognosis depends on the amount of injury varying from slight stretching to complete rupture and resulting in severe cases in cicatricial fibrosis. The early treatment of this condition consists in suitable splinting, maintaining rest and taking tension off the torn fibers of the brachial plexus in a position favorable to healing. After subsidence of the neuritis the arm should be taken out of the splint several times a day for gentle massage and manipulation to prevent the development of contractures; this should include passive movements of all joints of the upper extremity. Metal braces or splints are used later to maintain the best position for the arm and as function gradually returns, the brace may be left off for gradActive and passive exercises ually increasing periods during the day. should be continued for a long period and surgical help considered in cases which do not make satisfactory recovery. In postoperative care intelligent
fingers.
ity;
physical therapy again plays an important role. Infantile Paralysis. The pathology and the methods of treatment of anterior poliomyelitis or infantile paralysis received much study during
and as a
recent years chiefly due to the interest created by Sister Kenny's work result the role of physical therapy in early treatment has been
occurring in the spinal cord following an attack 14 of acute anterior poliomyelitis are described as follows (Hansson ): (1) Round cell infiltration and transitory productive inflammation can
much advanced. The variety of changes
488
produce enough pressure on the anterior horn cells to inhibit their function temporarily. (2) Interference with the horn cells' nutrition may occur by
surrounding hemorrhage or blocking of nutritional vessels. (3) The virus the nerve cell without destroying it. (4) The nerve cell may be completely destroyed. When paralysis occurs during poliomyelitis one can make no estimate of this injury, but one has to deal with muscles presenting varying degrees of weakness. The degree of recovery depends upon the extent of the damage to the cells of the cord: those destroyed will not recover, but cells only injured by the virus or by inflammatory changes of the cord may recover and allow the nerve filaments to the muscles to regenerate. Early in infantile paralysis no prognosis can be given as to which muscles will recover and which ones will be permanently paralyzed: only time can determine this. The three phases of infantile paralysis are: the acute, characterized by fever, tenderness and systemic disturbance; the convalescent, beginning with the disappearance of muscle soreness and characterized by the tendency of the paralyzed muscles to recover their tone and power; the chronic, in which spontaneous improvement can no longer be observed. Until very recently the generally established orthopedic management of acute cases consisted chiefly of strict immobilization of the affected parts, in order to lessen tenderness and prevent contractures. Although it was observed that during this period muscles undergo rapid wasting and there is extensive loss of function, physical treatment toward restoration of function was as a rule not started until all tenderness disappeared.
may injure
FIG. 297.
nal.)
Hot fomentations
for
of thighs to relax psoas spasm.
abdominal and low back "muscles in spasm"; flexion (Courtesy of Dr. Philip Lewin and Illinois Medical Jour-
The newer concept

affects the anterior
it
may
of infantile paralysis holds that the disease not only cells but also adjacent portions of the cord and involve the central nervous system including the sympathetic
horn
it
system; furthermore,
responsible for
causes extensive muscle spasm, which
much
may
be
of the functional disturbance
promulgated the three concepts of and "mental alienation" which result in shortening of the affected muscles, disorganized movement and loss of power in non-affected muscles. She advocated immediate physical treatment of spasm by hot "foments" with a painstaking technique, while keeping the patient at rest without formal splinting. (Fig. 297.) Re-education of muscles is started as soon
and pain. Sister Kenny "muscle spasm," "incoordination,"
INFANTILE PARALYSIS
spasm permits; it consists of recreating an "awareness" in the patient's mind of the existence of the muscle and its proper function and is accomplished by fixing the patient's attention on the insertion of the "alienated" muscle followed by the gentlest passive motion. (Fig. 298.) As soon as
as
the patient's condition warrants, carefully supervised active motion is undertaken. Sister Kenny claimed that patients treated by this method have complete freedom from all contractures, and there is no scoliosis or joint stiffness. Pain disappears quickly and respirators are not needed.
FIG. 298.
Muscle re-education:
Dr. Philip Lewin and
left for deltoid, right for pectoralis Illinois Medical Journal.)
major.
(Courtesy of
The extensive clinical and laboratory study stimulated by the interest awakened by the Kenny concept confirmed the existence of muscle spasm, chiefly in the antagonists of weakened muscles, but it also showed its 5 presence in the weakened muscles themselves. Neck muscles show spasin nearly all cases. It was also corroborated that the early judicious ticity
use of sedative-decongestive fomentations reduces muscular spasm, pain and tenderness so that careful assisted movement is possible without pain. 39 The early use of physical therapy prevents much of the muscle contracture and dysfunction following the method of rigid immobilization, and in the end-results the incidence of late deformity appears low and the incidence of functional ability is rather high. But there has been no acceptable proof offered anywhere that the incidence of residual paralysis has been changed to any extent; in other words the muscular units which have received permanent primary insult from the activity of the virus remain paralyzed
under any form of presently known treatment. A comprehensive plan of the present day treatment of infantile paralysis from the standpoint of the orthopedic surgeon has been presented by
Compere:
(1) strict contact isolation and quarantine; (2) stage: administration of convalescent serum immediately; (3) application of hot moist packs, changed every hour for twelve hours each day; (4) use of a respirator at the first indication of cyanosis or dyspnea, with continuation
In the acute
490
and (5) gentle passive motion of all extremities at least once a day. In the subacute stage, the following measures are employed: (1) cursory orthopedic examination with minimal manipulation; (2) careful positioning with a hard mattress and foot board; (3) hot packs to the hamstrings and spine of all patients with stiffness; (4) hot packs to the muscles of all extremities with tenderness or evidence of spasm (5) adminof hot packs,
;
istration of prostigmine bromide; (6) passive exercises with encouragement of active motion; (7) correction of incoordination and mental alienation
(8) mobilization of the spine by extension of the knees in a sitting position (9) free activity one hour each morning before application of hot packs and each afternoon after application, and (10) early attempts at standing and walking. Treatment in the chronic stage consists of: (1) use of braces and abdominal support according to individual indications; (2) surgical procedures, such as tendon transplants and arthrodeses, as indicated, and (3) frequent observation and maintenance of If scoliosis becomes apparent in a child whose mobility of the spine. growth lies mostly in the future, a prophylactic spinal fusion longitudinal may be in order. Physical therapists have for a long time advocated early thermal treatment in infantile paralysis by radiant heat or diathermy. While the Kenny method of hot fomentations is undoubtedly effective it requires a relatively large number of technicians or nurses and much special material. It may be possible to replace them with a simpler and just as effective form of thermotherapy and develop a more definite estimate as to what extent and how long thermal applications are to be continued. Underwater treatment of weakened muscles offers a desirable means to combine early heat treatment with careful muscle exercise. A recent report 15 by Hipps and Crook states that patients receiving early underwater treatment showed twice as much improvement as two sets of patients, one treated by early rest and immobilization, the other receiving no early treatment of any kind. For further details of underwater treatment see
by the Kenny method;
chapter on exercise. Fr-om the standpoint of physical therapy it is fortunate that the great Figure 299 majority of muscles are weakened rather than paralyzed. shows schematically how a muscle is innervated by nerve fibers from various levels or segments of the spinal cord. Consequently in affection of the anterior horn cells at one level one muscle may still be innervated by fibers from an adjacent unaffected spinal segment. This explains the frequent occurrence of the retention of partial muscle power and the partial on electrical examination. It also increases the chances of recovery by strengthening the unaffected part of a muscle by suitable exercise. Careful grading of muscle power should be made as early as possible to serve as a guide for suitable physical treatment and as a basis to judge
RD
progress.
At present three methods of muscle grading are available: (1) Clinical examination, tabulating muscles from zero, meaning no trace of power up to 50 per cent at which the muscle can complete the whole arc of motion of gravity, but may tire after two to three movements, while at 100 per cent the muscle is able to act against maximum resistance. This method must be carried through by one examiner because of the element of individual equation. (2) Electrodiagnosis as described in Chapter VII. Muscles
INFANTILE PARALYSIS
49 L
without RD will recover spontaneously or the recovery will be speeded up by appropriate therapy; those with RD may show varying degrees of affection and should receive treatment as early as possible. This method is applicable only in older children, (3) Electromyographic testing by recording the action currents of muscles (Chapter VI) is the latest method; it is exact, but it requires complicated equipment. For the grading of spasm functionally, a comprehensive scheme was described by McFarland and Graves. 23
FIG. 299.
Schematic diagram of anatomical location of anterior horn-muscle lesion

infantile paralysis.
in
Careful muscle training, combined with gentle massage is the most natural form of re-education of weak muscles. The joints should be moved passively through a small range of motion if there is much muscle weakness in order to prevent joint stiffness. All treatments must be given in definite dosage measured in terms of muscle response carefully and frequently charted. Exercises which do not involve weight-bearing will improve the strength of weakened muscles. If too much strain is put upon these muscles as in weight-bearing, recovery will be retarded. When underwater exercises are not readily available one may employ the simple procedure of moving a limb on a smooth, well-powdered board in such a way as to eliminate the pull of gravity during exercise of an involved muscle; the other is carrying the extremity in a sling attached to
492

freely
an overhead frame, allowing the extremity to swing arc in which the involved muscle contracts.
through the
The role of electrical stimulation in infantile paralysis is a controversial matter in the opinion of some orthopedic men. Ober 27 blandly stated: "Electricity has no place in treatment of infantile paralysis." On the
other hand Lewin 19 holds that electricity may improve the local condition in poliomyelitis and induce contractions in muscles otherwise inaccessible; in trained hands, used as a simple muscle tonic, electricity should be helpful. There is an increasing amount of clinical and experimental evidence that electrical stimulation is of definite aid in recovery of paralysis. Hansson 14 states: "I should not be surprised to see return of electrical stimulation to the weakened muscles, making the treatment of poliomyelitis similar to the care of traumatic nerve lesions."
be carefully planned and According to the electrodiagnostic findings, the slow sinusoidal current is used in cases showing the reaction of degeneration and the surging faradic or modulated alternating current in cases with absence of full RD. The most amenable cases for electrical stimulation are those with paralysis of one group of muscles or a few single muscles. The most effective method of electric treatment is unipolar muscular stimulation, with the technique outlined in Chapter IX. The group technique is advisable only if the muscles of the extremity are all nearly evenly
affected.
Electric stimulation, to be effective, must skilfully applied for a sufficiently long period.
Smart 33 advocates the early use of graduated muscular contraction in order to keep the neighboring unparalyzed muscles in activity during the acute stages of paralysis with the consequent benefits derived from muscle movements. When muscles that have been paralyzed show signs of recovery, the graduated contraction greatly hastens recovery. Modern research (Gila, 11 Liebesny21 ) has corroborated the earlier work of Lapicque, advocating the use of "progressive" currents in paralysis (Chapter IX). Such stimulation furnishes a slowly increasing stimulus which is able to excite the paralyzed muscles electively without affecting the normal ones. So far no suitable apparatus is available in the United States for this form of electrical stimulation. A long time is required for the regeneration of muscles after an attack of poliomyelitis. Therefore long, persistent treatment, involving the skilful use of all available measures, is the keynote of success. Electrical stimulation must go hand in hand with muscle re-education and be abandoned in favor of the latter as soon as there is return of active muscle power. Thermal measures luminous heat, the whirlpool bath or diathermy should be employed preliminary to electrotherapy. Supportive orthopedic measures must never be neglected. When spontaneous improvement can no longer be observed electrodiagnosis may help to differentiate muscles which, though apparently inactive due to continued spasm and shortening, electrically show fairly good response. The author 18 has reported a case of eighteen years' duration in which the active power of an atrophied leg returned to the flexors of the knee after four weeks of electrical stimulation. Electrodiagnosis shows the total lack of response in some of the muscles; in case of doubt careful observation and treatment of these may be carried on for a while; if the
THE NEUROSES
493
lack of response persists then replacement of these muscles becomes a problem for the orthopedic surgeon.
THE NEUROSES
Among
neurasthenia,
the so-called functional affections of the nervous system belong hysteria, traumatic and occupational neuroses, various
spasms, tremors, vasomotor and secretory disorders and, finally, such illdefined symptoms as headaches, sleeplessness and nervous exhaustion. In the management of these complex conditions physical measures serve for the alleviation of symptoms, for general tonic effect and as adjuncts
to psychotherapy.
Neurosis is a term frequently applied solely as a diagnosis of exclusion. has been pointed out by Comroe 7 and others that the diagnosis of neurosis by exclusion is fraught with considerable dangers. In a follow-up
It
study of 250 cases, organic pathological changes were found subsequently a large percentage of cases and the following diagnoses were confirmed by autopsy, operative results or laboratory or roentgen-ray findings: abdominal carcinomatosis, carcinoma of the liver, gastric carcinoma, disease of the coronary arteries, Addison's disease, pellagra and myocardial degeneration. Of the remaining 17 cases in which evidence of organic disease had developed, the diagnoses were diabetes mellitus, gall-bladder disease (3 cases, all proved by operation), duodenal ulcer, pulmonary tuberculosis
in
(2 cases), ureteral stone, chronic appendicitis, Buerger's disease, suppurative mesenteric adenitis, cardiovascular renal disease with hypertension, renal calculus, uterine myoma, pregnancy, mitral stenosis and toxic goiter.
pointed out that neurosis and organic pathological changes often and either may be the forerunner of the other or they may be Neurosis is in reality an emotional entirely separate from each other. instability out of proportion to active organic impairment. In neurasthenics a combination of electrotherapeutic and hydriatic measures is most valuable. For tonic effects electric cabinet baths, hot and cold douches, galvanic baths and, in milder cases, ultraviolet irradiation or the static charge or head breeze may be employed. The interrupted sinusoidal or other low-tension and low-frequency currents applied to the abdomen help to overcome the motor and secretory weakness of the digestive tract. They may also be used for general body stimulation. Sexual weakness of neurasthenics often responds very well to the lowfrequency stimulation of the prostate. Cerebral galvanism or diathermy may be applied in patients with stubborn head symptoms. In contrast to neurasthenics, hysterical patients do not seem to take kindly to electrotherapy. Electrical measures should be only used as a
It
is
coexist
and preferably for definite pathological changes. Faradism is recommended for hysterical aphonia; the shock of painful stimulation may bring back phonation. For paralysis, spasms and the variety of other disorders, static sparks, the interrupted sinusoidal or the Oudin current
last resort
may be applied.
In sleeplessness due to nervous exhaustion a full or three-quarters cold In cases of low blood-pressure is a classical treatment measure. the static modalities may be helpful. General light baths may be also effective. Turrell recommends gentle stroking of the forehead while the
wet pack
494
patient
AFFECTfONS OF THE CENTRAL NERVOUS SYSTEM

sits
chair, thus drawing off a mild amount Intense applications of light along the spine have also been General massage exerts remarkable hypnotic effect in recommended.
on the autocondensation
of current.
some
patients.
24 Vegetative Neurosis. Attention has been called by Neergard to the fact that so-called vegetative neurotic symptoms occurring in many middleaged people in spring and fall, and consisting in fatigue, vertigo, headache, neuralgic pain, as well as such mental signs as moodiness, irritability, etc. are in fact due to infection with a filtrable vaso- and neuro tropic virus; repeated encounters with small amounts of this antigen lead to sensitization and allergic reactions and these form the basis of the vegetative-neurotic syndrome. The aim of physical therapy in these cases is to increase the " " immunobiological process through desensitization by a course of either cold or hot hydrotherapeutic application according to the patient's sensi" " suggestive tivity. The good results with such a regime erroneously called are in fact due to the stimulation of the regulatory powers of the organism and the overcoming of the somatic syndrome. Traumatic Neurosis. In the treatment of traumatic neuroses a puzzling picture confronts medical men. The emotional state of the patient is a combination of fear of disability (anxiety), resentment toward the agent responsible for the injury and toward any one, such as the doctor, suggesting that the injury is physically negligible. There is almost always a characteristic reaction of the patient to therapeutic effort. There is a tendency to blame any medicine or other therapeutic agent for the continuation or exacerbation of these symptoms. However, the term post-traumatic neurosis should not be used as a waste-basket into which diagnostic failures are thrown. Traumatic neuroses are recognizable by a definite symptomatology and the salient points of
their classification are as follows (Hall and Mackay 13 ) Post-traumatic neurasthenia exhibits abnormal fatigue
:
and
irritability,
associated with extreme emotionalism and a disproportion between the actual strength of the patient and his supposed weakness.
Post-traumatic anxiety neurosis is characterized by a marked hypochondria which concerns itself chiefly with one organ or symptom until it becomes almost an obsession. A typical anxiety headache is often present which is usually not a true pain but rather a sense of weight or pressure and is very often constantly present for days in contrast to the intermittent headaches of organic origin. Finally there are symptoms of overstimulation of the sympathicus; excessive sweating, cold clammy hands, tremulousness
and dilated
pupils.
Post-traumatic hysteria:
symptoms: of motion or
patients exhibit pseudo-organic signs and blindness, deafness, paralysis, anesthesias and disturbances gait. It is characteristic that these signs do not correspond to
actual anatomical relationship but rather to the patient's idea of anatomical relationship, such as "stocking and glove" anesthesias, complete paraThese patients also plegia without sphincter disturbance and the like.
manifest an abnormal degree of suggestibility. Post-traumatic hysteria is the most frequent among the functional nervous conditions. Traumatic neuroses are among the most baffling problems of physicians dealing with traumatic conditions, and physical therapy departments are constantly confronted with these trying cases. Hall and Mackay 13
MENTAL CONDITIONS
advise that instead of arguing with the patient, one should
his friend, secure his confidence
495
make
oneself
listening patiently to his story. It is absolutely necessary that all financial controversy be settled once and for all in the form of a lump sum. The next step is the re-establishment of
by
the patient in some form in which he can transfer his attention from himself to outside interests; this may be possible only after intensive suggestion. "To expect the patient to become free from all symptoms without treatment is almost equivalent to expecting him to admit that his symptoms
were
'unreal.' Therefore, medication, various forms of physical therapy or electrotherapy are very useful in giving him reason to expect improve-
ment and a basis for relinquishing his symptoms. Such methods, however, must not be unduly prolonged, as they only fix the patient's attention
too firmly on his ailments."
MENTAL CONDITIONS
In the large field of mental disorders, physical measures especially in the form of hydro therapeutic procedures find wide application for either Overholser29 recognizes two classifications of stimulation or sedation.
physical therapy in psychiatric patients. One includes the types prescribed primarily on account of the total behavior of the patient, i. e., on account of his mental condition, such as the continuous bath and the wet sheet
for states involving tension, overactivity and restlessness, and the various forms of stimulative therapy, such as the contrast douche, the salt glow, the friction rub and ultraviolet irradiation, which may be used in states of depression and decreased motor activity. In the other group are included numerous other forms which are useful even though they are directed toward systemic conditions or conditions of particular organs. Among the conditions frequently encountered are traumatism, arthritis and rheumatic conditions, etc. There is no question but that the attention given to incidental conditions in these patients is well repaid. The systematic application of physical measures as treatment adjuncts increases the patients' well being and reacts favorably to their mental state con-
pack
approach to their psychical self. Sedative physical therapy is indicated in excited patients, those with manias, epilepsy, toxic and organic conditions and some with schizophrenia; continuous baths, warm needle sprays, Scotch douches, and hot fomentations are useful for this purpose. Cold or warm wet packs are usually contraindicated because the element of restraint produces fear. Most patients like the continuous bath best; a temperature between 94 to 96 F. is the most desirable in excited patients. One must be alert to the potential dangers of continuous baths in excited, debilitated patients such as stroke, cardiac collapse; there exists also the ever present possibility of suicide and drowning. Cold sitz baths reduce sexual tension. Stimulative therapy is indicated in apathetic, stuporous and catatonic patients with schizophrenia and also certain hysterical individuals. Accord1 ing to Barnacle, the psychiatrist is attempting to interest the patient in reality through stimulation. Alternating hot and cold sprays, Scotch 17 douches, salt rubs and general massage are indicated. In the author's clinic at Manhattan State Hospital dementia precox cases, if not too far
deteriorated showed
stituting a direct
some improvement
in their
mental state and became
496
more
easily manageable following general stimulation by ultraviolet radiation or the static bath. Postencephalitis cases became more alert and
showed increased emotional stability following the same measures, also in some instances following cerebral galvanism. Most of these patients showed improvement in their general physical condition, weight and nutrition.
Barnacle states that electric light cabinet treatments should be used cautiously for so-called elimination in chronic alcoholic and other toxic conditions, because in alcoholics, delirious and convulsive reactions may follow intense heating. In paranoid reactions physical treatment is likewise contraindicated, because the mechanical procedures and apparatus are likely to be misinterpreted as persecution.
Overholser emphasizes that it is not a criticism of physical therapy or any other branch of medicine that it produces psychologic effects. The tangible effects of the various procedures are demonstrable and well known. That there are positively suggestive effects at the same time simply re-enforces the local effect and serves as an adjuvant if one recognizes those effects; by ethical and wise utilization of them, the welfare of the patient is promoted and the desired therapeutic result is hastened. Hence any well equipped psychiatric hospital needs to have an active physical therapy department. Patients in mental hospitals exhibit little difference from patients outside. They are perhaps more susceptible to the intangibles, atmosphere, personality, attention to their needs and interest shown in them. The physical therapy department should be made as
of
attractive as possible.
Such
details of
atmosphere do much to promote
relaxation, stimulate cooperation of the patient and put him in a psychologic condition to receive maximum benefit from treatment.
A.C.
VOLTAGE REGULATOR
TRANSFORMER
IMPULSE
PATIENT
TIMER
FIG. 300.
Diagram
of electric
shock treatment.
(Fleming
el al.;
courtesy of Lancet.)
Electric Shock Therapy. Cerletti and Bini, in a quest for a safer measure to produce convulsions in schizophrenia than by chemical shock (insulin), discovered that an alternating current of 125 volts can be applied to the human head once or repeatedly without causing damage and that the therapeutic effects of such an electric shock in a number of mental conditions are highly satisfactory. These observations were quickly corroborated by other psychiatrists; suitable apparatus was developed and the scope of application of the new method and its most effective technique received much study in recent years. Apparatus and Technique. Most of the apparatus used employ the commercial alternating current, its voltage modified by a step-down transformer and the length of its flow controlled by a time switch. Berkwitz 4 has constructed a portable apparatus, in which a 6 volt dry cell energizes
MENTAL CONDITIONS
497
an induction coil of the model T Ford spark coil type. Figure 300 shows the diagram of one type of apparatus in which there are two circuits, a low tension circuit through which the efficacy of the electrode contact is tested and the resistance in ohms is computed; and then switching over to the high tension circuit is done. It takes from 80 to 120 volts, flowing for 0.2 second to produce a shock, with the electrodes applied to two sides
of the forehead.
Rahm
and Scarff 31 constructed with the aid
of a thyratron tube
and
suitable condensers a simple yet very efficient stimulator calibrated in volts, which enables excitation of the cortex with stimuli of two to four
and the use of a choice of frequency ranging from second; all this is done without any extra computation.
volts,
7.5 to 960 per
Electrodes are applied either biparietally (Fig. 300) or to the forehead of the neck. Various clinicians apply stimulation slightly varying in duration and strength but they all agree that the production of a fairly strong convulsive response is essential; if the dose is too small only a few muscular twitch ings will occur. Treatments may be administered two or three times weekly in the morning on a fasting stomach. Patients should be placed on a padded wooden table with a hard pillow under the dorsal spine to prevent vertebral fractures. Metal articles such
and the nape
as bridges
and hairpins are removed.
Electrocerebral shock causes mass cerebral and autonomic nervous system irritation, the manifestations of which are profound effects on heart-rate, blood-pressure, pupils, state of muscular tonus, mental equilibrium, etc. With electric shock administered at suitable strength and duration patients lose consciousness immediately and
Physiological Effects.
undergo a typical epileptic fit: there occurs first a generalized tonic contraction, lasting about ten seconds in which the face is flushed; this is followed by a clonic stage, in which the face may become cyanosed with frothing at the mouth, wide dilation of the pupils and at times evidence
of urine
and
feces.
The average duration

:
of the
fit is fifty
seconds.
The
recovery varies in each patient some walk away from the treatment couch others sleep for several hours; some are confused or delirious others
apologetic.
The advantages claimed

vulsive
for electric shock therapy over the other con-
are: (1) the patient does not experience pain and does not, therefore, resent treatment; (2) since no toxins are introduced into the
methods
system, pulmonary and myocardial complications are avoided (3) psychomotor excitement similar to that following cardiazol convulsions is not present; (4) difficulties involved in intravenous medication do not arise; (5) if no convulsions ensue, the treatment can be immediately repeated; (6) the method requires little time and expense. By this time the electrical
;
method
of shock treatment
by
its
marked advantages
of accuracy
and
control has almost completely replaced shock treatment by chemical means, just as fever treatment by physical means has completely super-
seded malarial treatment in central nervous system affections. Several explanations have been offered for the working mechanism and the results obtained by electric shock therapy. Gronner 12 states that much more happens to the patient under treatment than passage of a weak current through his head for 0.3 second twice a week. He receives repeatedly
498
the benefit of short amnesias which tend to converge and may constitute a powerful aid in removing conflictual material and in decreasing the compulsive quality of psychotic thinking or action. Experiments on animals
have shown that damage to the ganglion cell is present, though temporary and reversible. Apnea lasting up to one minute undoubtedly causes anoxia and some alteration of brain metabolism. Basically, it probably represents a change of milieu, in biologic terms. In attempts to correlate somatic and psychologic variations, electro-encephalographic readings have shown abnormalities with psychotic manifestations but have failed to demonstrate that an anatomic substratum exists for improvement or failure.
Cerletti originally proposed that electric shock Therapeutic Indications. treatment be given preference in depressive states, especially in those with psychomotor inhibition or retardation, and in most schizophrenics. Clinical experience during recent years has proved that this treatment is most effective in involutional melancholia and manic-depressive psychosis. Manic patients do not hold their recovery as well as those who have an agitated depression. There is no evidence to indicate that electric shock may prevent future psychotic attacks, or that it might interfere with
34 spontaneous clinical recovery. According to Smith, et a/. on the other hand, it is not effective in treatment of schizophrenia and is of doubtful value in treatment of psychoneuroses. 16 Kalinowsky stresses the efficacy of electric convulsion treatment in
acute schizophrenia if the number of convulsions is sufficient; discontinuation of treatment after the usual early clinical improvement almost invariably leads to relapse and is the most important reason for its failure. Neymann 26 believes that neurotic patients, except extremely recalcitrant ones, should never be treated by shock therapy. They are accessible to
psychotherapy without temporary dulling of their mentality. Shock therapy only serves to disturb a psychoneurotic patient and often produces permanent fear of dementia because he becomes acutely aware of his retrograde amnesia or lapse of memory. Complications and Dangers. Complications of electric shock therapy are similar to those of other types of convulsive shock treatment but are
include dislocations of the mandible, ligamental tears, of the arm or clavicle. As in cardiazol therapy, the danger of a flare-up of latent tuberculous infection is stressed by some authors. Contraindications include severe cardiovascular renal disease, especially endocarditis, thrombophlebitis and decomless frequent.
They
and dislocations and occasionally fractures
pensated heart diseases; pulmonary diseases, especially tuberculosis; acute infectious or febrile diseases and extreme debilitated states in which susceptibility to fracture might exist because of deficiency and disturbances of calcium metabolism. The review of the litrature indicates that the cause of death after electric convulsion treatment is still obscure.
REFERENCES
1.
BARNACLE, C. H.
1939.
Physical Therapy in Psychiatry, Physiother. Rev., 19, 282-285,
2.
3.
BARNACLE, C. H., EWALT, J. R., and EBAUGH, F. O.: Artificial Fever Treatment of Chorea, Jour. Am. Med. Assn., 109, 2, 1937. Artificial Fever Therapy in Multiple Sclerosis, BENNETT, A. E., and LEWIS, M. D. Jour. Nerv. and Ment. Dis., 92, 202-213, 1940.
:
REFERENCES
4.
499
5.
6.
J. Faradic Shock in Treatment of Functional Mental Disorders, Arch. Neurol. and Psychiat., 44, 760-775, 1940. BOUMAN, H. D., and SCHWARTZ, R. P.: Degree, Extent and Mechanism of Muscle Spasm in Infantile Paralysis, New York State Jour. Med., 44, 147, 1944. COMPERE, E. L. Management and Care of the Infantile Paralysis Patient, Arch
BERKWITZ,
7.
Phys. Ther., 24, 709-712, 1943. COMROE, B. J.: Follow-up of 100 Patients Diagnosed as "Neurosis," Jour. Nerv.
and Ment.
8.
CROSS, H. A.:
Dis., 83, 679, 1936. Electricity in Therapeutics,
London, C. Lockwood
&
Son, Ltd.,
p. 240, 1936.
9.
10.
and BRONN, E. B.: Making Man Power: Vocational RehabilitaThose Handicapped by Cerebral Palsy, Arch. Phys. Ther., 23, 719, 1942. EWALT, J. R., and EBAUGH, G.: Treatment of Dementia Paralytica, Jour. Am.
DEAVER,
J. G.,
tion of
Med.
11.
Assn., 116, 2474-2477, 1941.
GILA, G.:
Use
:
Paralysis, Boll, e
12.
GRONNER, R.
1944.
of Progressive Currents in Treatment of Sequelae of Infantile mem. Soc. piemontese di chir., 9, 735, 1939. Results of Electric Shock Treatment, Illinois Med. Jour., 85, 29 34,
13.
HALL, G. W., and MACKAY, R.
P.:
The Posttraumatic
Neuroses, Jour.
Am. Med.
Assn., 113,
Assn., 102, 510, 1933. 14. HANSSON, K. G.: After-treatment of Poliomyelitis, Jour. 32-35, 1939.
15.
Am. Med.
HIPPS, H. E., and CROOK, B. L.: Early Treatment of Infantile Paralysis, Arch. Phys. Ther., 25, 403, 1944. Electric Convulsion Therapy, With Emphasis on Importance 16. KALINOWSKY, L. B.: of Adequate Treatment, Arch. Neurol. and Psychiat., 51, 397, 1944. The Role of Physical Therapy in the Treatment of Nervous and 17. KOVA.CS, R.:
18.
19.
Mental Diseases, Psych. Quart., January, 1938. Electrodiagnosis and Electrotherapy in Infantile Paralysis, Jour. Am. Med. Assn., 86, 741-747, 1926. LEWIN, PHILIP: Infantile Paralysis, Philadelphia and London, W. B. Saunders
Company,
20.
1941.
LIBERMAN, D.
44, 1940.
Ultraviolet Irradiation as Adjuvant to ChemoL., and SPARK, I.: therapy of Seroresistant Dementia Paralytica, Med. Bull. Vet. Admin., 17, 33-
21.
22. 23.
LIEBESNY, P.:
1942.
Physical Therapy in Flaccid Paralysis, Arch. Phys. Ther., 23, 23,
MARTUCCI, A.
Further Studies With A., HADDEN, G. B., and McGLONE, B.: Transcerebral Diathermy, Arch. Phys. Ther., .XT-ray and Rad., 18, 7, 1937.
J.
MCFARLAND,
W., and GRAVES, D. A.:
Grading
of
Spasm
in Infantile Paralysis,
Arch. Phys. Ther., 25, 553, 1944. 24. NEERGARD, R. V.: Origin and Treatment of So-called Vegetative Neuroses, Fortschr. d. Therap., 16, 191-196, 1940. 25. NEYMANN, C. A.: Handbook of Physical Therapy, Hagerstown, Md., Prior &
Co., vol.
26.
1,
Chap.
A.:
17.
NEYMANN, C.
Some Thoughts About Shock Therapy,
Arch. Phys. Ther., 24,
660, 1943. 27. OBER, F. R.:
Physical Therapy in Infantile Paralysis, Jour. Am. Med. Assn., 110, 45-46, 1938. 28. OSBORNE, S. L., BLATT, M. A., and NEYMANN, A. A.: Electropyrexia in Rheumatic Carditis, Chorea and Other Childhood Diseases, Physiother. Rev., 18, 68, 1938. 29. OVERHOLSER, WiNFRED: Physical Therapy in Psychiatric Practice, Jour. Am.
Assn., 123, 32-35, 1943. Correlation of Physical and Occupational Therapy in Cerebral Palsy, Arch. Phys. Ther., 22, 587, 1941. Electric Excitation of the Cerebral Cortex, 31. RAHM, W. E., JR., and SCARFF, J. E.: Arch. Neurol. and Psychiat., 50, 183, 1943. 32. RAJKA, E., and RADNAI, E.: Ultraviolet Irradiation and Autochemotherapy in Late Syphilis, Arch. Dermat. and Syph., 24, 228-235, 1931. 33. SMART, MORTON: The Principles of Treatment of Muscles and Joints by Graduated Muscular Contractions, London, Oxford Univ. Press, 1933.
30.
Med.
PHELPS,
W. M.:
500
34. 35. 36.

SMITH, L. H., HASTINGS, D. W., and HUGHES, J.: Immediate and Follow-up Results of Electric Shock Therapy, Am. Jour. Psychiat., 100, 351, 1943. SUTTON, LUCY PORTER, and DODGE, KATHERINE G.: Fever Therapy in Chorea and in Rheumatic Carditis, First Int'l. Conf Fever Therapy, New York, 1937. VERAGUTH, O.: Schweiz. med. Wchnschr., 65, 6, 1935. WALTHARD, KARL M.: Short Wave Therapy in Multiple Sclerosis, First Int'l. Conf. Fever Therapy, New York, 1937. WEISENBURG, F. H., and ALPERS, B. J.: Principles and Practice of Physical
.
37.
38. 39.
WRIGHT, JESSIE:
& Co., vol. 1, Chap. 16, 1933. Basis for Transitions in Physical Treatment of Poliomyelitis Arch. Phys. Ther., 23, 662, 1942.
Therapy, Hagerstown, Md., Prior
CHAPTER XXVIII
Palsy).
Peripheral Nerve Injuries. Neuritis. Facial Paralysis (Bell's Brachial Neuritis. Sciatic Neuritis. Meralgia Paresthetica. Trifacial Intercostal Neuralgia. Xeuralgia.
General Considerations. In treatment of affections of peripheral nerves physical therapy plays an important role because due to the comparative accessibility of the affected parts, intelligently applied physical measures often give prompt relief, shorten the period of disability to a great extent
and, in painful inflammatory conditions, lessen the need of sedative medication considerably. There are two principal groups of peripheral nerve affections: traumatic
and inflammatory. Following a lesion of a peripheral nerve, loss of motor and trophic changes produce a varied clinical picture and the effective employment of physical measures for the relief
function, sensory disturbances
of these symptoms as well as for the treatment of the underlying condition demands a knowledge of the cause, location, extent and stage of the lesion. This is at times simple and at other times quite difficult. Electrodiagnosis in some instances, such as in facial paralysis, in hysteria and in malingering will be invaluable for diagnosis and prognosis.
TABLE
55.
SYMPTOMATIC DIFFERENCES BETWEEN CENTRAL AND PERIPHERAL LESIONS

Lesions of central neuron
Lesions of peripheral neuron
Type:
Hemiplegia
Spastic paralysis Slight atrophy Reflexes increased
Anterior poliomyelitis Peripheral nerve injuries Flaccid paralysis
Type:
Marked atrophy
Reflexes lost
No
RD
RD present
PERIPHERAL NERVE INJURIES
Pathology and Diagnosis. Injuries of peripheral nerves can be brought about by falls, blows, dislocations, fractures, penetrating wounds, or by continued pressure. The anatomical changes in the nerve may be a contusion, laceration or division, with a loss of motor power flaccid paralysis and loss of sensation in the part supplied by the nerve involved. There will be immediate complete or incomplete paralysis in the muscles supplied
by the injured nerve.

the coincident or subsequent syndromes vary according to the extent of the trauma and its circumstances. There are immediate or gradual loss of function in the affected parts, sensory changes, and typical posture. Histologically, in the distal part of the injured nerve, total or partial degeneration of the axis cylinder and muscle sheath occurs, while the affected muscle first shows fibrillation.
will
its fibers become pale, shrink in size, and, if unsupported, stretch indefinitely. Coincidentally, typical changes in the electric excitability of the nerves and muscles occur, and there are also characteristic chemical
The microscopic changes and
Later
changes
in the muscles.
(501)
502
supplied by the nerve become weakened or fully paralyzed from lack of nutrition, due to the separation from their trophic center and lack of exercise. They also suffer from overstretching by their strong antagonists if allowed to remain in a faulty position. The other soft parts, joints, bones and tendons suffer from lack of nutrition and may develop adhesions, faulty positions, trophic ulcers and other patho-
The muscles
suffer
and
logical conditions.
Unrecognized and unskilfully treated nerve injuries are important causes

dents.
disability of individuals injured in industrial or other acciAll medical men should, therefore, be familiar with their early recognition and their effective treatment. The principal signs of the most
of
permanent
frequent forms of nerve injuries are shown in Table 56.
Cervical plexus
Cervical plexus
Circumflex
Circumflex
- -
-Intercostal
humeral
Intercostal
humeral
esscr interna
cutaneous
Radial
HTusmlo-cutaneousr
Internal cuta-
neous
-- Musculo-cutaneouK
Ulnar
Median
Anterior aspect
Posterior aspect
FIG. 301.
Areas of cutaneous
sensibility,
upper extremity.
In many cases it is clinically impossible to ascertain at first whether the vitality of the nerve axons has been sufficiently damaged or broken to cause progressive nerve degeneration below the site of injury. Electrodiagnosis, as described in Chapter VII, will enable a differentiation to be
made
after ten
days or so between injuries leading to
RD and those which
do not.
Sensory changes manifest themselves in areas of anesthesia corresponding with the sensory area of the affected nerve or nerves (Figs. 301 and 302), in loss of deep sensation, at times hyperesthesia or paresthesia with abnormal sensations of burning and tingling. At times the patient may complain
that the part feels
lifeless.
503
Contrary to an erroneous conception persisting in some minds, there no electrical test available which will ascertain whether or not there is a separation of nerve fibers to such an extent that spontaneous regrowth is impossible. In case of penetrating injuries the surgeon must decide on purely anatomical considerations whether to make an immediate nerve suture or not. Contrary to another belief curiously persisting in some minds, even immediate nerve suture does not prevent subsequent nerve degeneration. In the majority of suspected incomplete nerve lacerations the tendency now is to wait and to make an exploratory operation only if (1) there is total loss of function for two months or more in an area
is
Genito-crura I
Inferior gluteal
Jlio-inguinal
External cutaneous
External cutaneous
Internal cutaneous
Sciatii
Anterior crural internal cutaneous branch
Anterior cn.ral internal cutaneous branch
Anterior crural long
Posterior tibial
saphenous branch
External popliteal
External popliteal
External saphenous
Musculo-cutaneous
External saphenous
Anterior tibial
!
--^_
Posterior aspect
Anterior aspect
FIG. 302.
Areas of cutaneous
sensibility, lower extremity.
exclusively supplied by a nerve or (2) if recovery is extremely slow or there is a relapse or (3) if there is a palpable neuroma at the site of the injury of a nerve, the function of which is seriously disturbed or (4) there is severe, persistent and intractable pain. Treatment. 'Physical therapy holds the first place in the treatment
'
of peripheral nerve lesions; operative procedures of suture and neurolysis will not serve to restore function. They only make it possible for the
nerves to regenerate" (Pollock 8 ). As long as in an injured nerve its ends remain in close anatomical approximation, regeneration of the nerves takes place automatically by the descent of new axis cylinders from the
504
intact central end at a rate of from 1 to 2 mm. a day, about 1 to 2 inches The per month, but restoration of nerve function occurs much later. anatomical regeneration of the nerve can only be assisted indirectly by improvement of the circulation and nutrition.
505
It is conceivable that perfect regeneration might occur in the nerve an extremity be functionless, because of interphalangeal fibrosis, retraction of capsular ligaments, marked atrophy and fibrosis of muscles, shortening of muscles, spasms of muscles and ankylosed joints. Hence, according to Pollock 8 when a primary or secondary suture is indicated immediately, physiotherapeutic treatment must assist the operative procedure. When
it
must be
it
advisable to defer the operative procedure, physical therapy promptly to the end that when the nerve regenerates will activate a mechanism capable of adequate movement.
is
felt
initiated
The
the
Army Report on Physical Reconstruction, issued at end of World War I, outlines the duties of the physical therapy departofficial
U.
S.
ment in
cases of nerve injuries as follows In the physiotherapy treatment of nerve injury cases it is essential that the director of physiotherapy make
:
"
a clinical examination, together with a brief history. The following notations should be included on a suitable clinical record form: cause and date of injury; date of healing of wound; time of appearance of paralysis in relation to injury; treatment up to present time, including surgical measures; muscle groups paralyzed; area of sensory impairment; degree of atrophy; extent of fibrosis; presence of trophic ulcers; vasomotor changes and neuromata; information on the 'D.T.P.' (distal tingling on percussion); measurement of girth of affected limb as compared with the opposite or normal limb, and measurements with suitable protractors of any limitation The electrical reactions should be of joint mobility, if such is present. taken, following which the specific treatment should be outlined, with proper instructions to the aide to whom the case is referred. A report is then sent to the surgeon of the findings of the electrical reactions, stating in terms of pathology the condition of the nerve as interpreted from the reactions, and the outline of treatment which the patient will receive. A monthly progress note and report to the surgeon is in order, with special reference to any material changes in electrical reactions, return of sensory or motor functions, progressive advancement of the D.T.P., and the like. The practice of personal consultations with the surgeon who has charge of the patient can well be emphasized."
TABLE
Splinting
57.
PHYSICAL,
TREATMENT MEASURES
Object
IN
NERVE INJURIES
Period of use
Form
Heating
Electric muscle stimulation
Prevention of deformity
Improvement of and nutrition
circulation
From beginning From beginning
Preserve functional capacity of muscles
From
beginning
Passive
movement
Prevent
tures
fibrosis
and contrac-
From beginning
From beginning
In later period
Massage
Active exercise
Aid circulation, improve nutrition
Re-education of muscle function
Hasten muscular recovery
In later period
of an experienced physician usually combined with the an expert technician is required to carry on the physical treatment of a severe nerve injury through its various stages. Splinting is a physical measure of primary importance in maintaining the condition of paralyzed muscles and assuring a position of anatomical rest and complete relaxation of all paralyzed muscles. It will also prevent
The judgment
skill of
506
shortening of their antagonists. Splinting is absolutely essential in every case of nerve injury, because even the most painstaking form of electrical exercise applied for a short period daily cannot possibly overcome the
potential harm caused by the continuous drag of the antagonists when proper splinting is neglected. On the other hand, splinting should not be kept up indefinitely as prolonged immobilization in itself will cause periarticular joint changes and muscle atrophy. Many patients have been incapacitated by the fibrosis which has resulted from the prolonged and uninterrupted use of splints. Splints must be simple, light, easily applied and removed. Table 56 also indicates the type of splints indicated in the principal forms of nerve injuries. Thermal Measures. The object of thermal measures is to improve nutrition and relax muscles and prepare the limb for further treatment. The most convenient and safest measure for this purpose is the hot whirlpool bath, at a temperature of 100 to 105 F., in which the affected extremity should be submerged for at least half an hour. When it is not available, a heat lamp or infrared generator may be applied. Because of the frequent prevalence of disturbed sensation, impaired circulation, and other trophic changes, all heat measures must be applied very cautiously in order to avoid the production of slowly healing burns. For the same reason the use of diathermy in these cases should be reserved for expert hands. It has been argued that diathermy exerts a more efficient heating effect in extensive muscle atrophy and that in early cases it may retard or arrest muscle fibrillation which, according to Langley, always follows severance of the nerve and is the cause of muscle atrophy. Short-wave diathermy is best applied with the inductance cable wound around the extremity and kept up for thirty minutes at a rate of moderate heating. Any method of heat treatment should be applied systematically, preferably daily, to accomplish the best results. 9 Electrotherapy. English and French authors, notably Tinel state that the simple passage of a galvanic current seems to be able to stimulate regeneration of a nerve. Electrical stimulation is the main therapeutic standby in improving the condition of the paralyzed muscles. The principles and technique of electrical stimulation in paralysis have been presented in Chapter IX. The slow sinusoidal current, beginning with two or three contractions of each muscle, is used at the beginning and gradually increased. In cases with partial or only slight quantitative electrical changes, more vigorous stimulation may be employed. Pollock believes that stimulation by the interrupted galvanic current although often painful is as useful as that produced by any other type of galvanic current; the suddenness of contraction can produce no harm after the second week following injury or surgical procedures, if the muscles are kept practically at rest during the
RD
two weeks in which they are fragile and are easily bruised. Overtiring, however, must always be avoided. Active exercise is instituted as soon as there is any indication of return of active power. Electrical stimulation, along with other adjuvant treatment, must be continued systematically. Corresponding with the progress of anatomical regeneration of the nerve, the atrophy of the muscles gradually disappears and their response improves. Testing by the condenser set or for chronaxie
first
(Chapter VI) every four to
six
weeks enables charting
of this progress in

figures.
507
After many weeks or months a time comes when there is the first indication of return of voluntary motion in one or more of the paralyzed muscles. This is proof that the nerve trunk and the motor end-plate have
regenerated. Response to the faradic current returns about this time or, as a rule, somewhat later. One must be careful not to replace the slow sinusoidal too quickly by the surging faradic or interrupted sinusoidal
current, exercise
Massage as an aid to circulation and for the improvement of a useful part of the routine physical treatment. So far as the prevention of muscle atrophy is concerned, massage is only of slight As a matter of fact, according to Mennell, heavy massage is benefit. transmitted to the blood-vessels and may cause paralytic dilatation. Massage should be always preceded by a thermal measure and administered to the well-supported and completely relaxed extremity. It should begin with rhythmic superficial stroking and continue with gentle kneading of the skin and of any contracted muscles, with friction over ankylosed joints. The average massage treatment should take from ten to twenty minutes. Passive ovement. Suitable manipulation of joints and stretching of muscles in peripheral nerve injuries is of even greater importance than routine massage; however, it is best carried on in conjunction with massage. Contractures and adhesion of joints, muscles, and tendons are due to shrinkage of newly formed connective tissue. Introductory heating and massage tend to soften this tissue and to promote its absorption, while
nutrition
is
Massage.
and
for recovering muscles are sensitive may be easily tired out.
toward more exhausting
gentle manipulation serves to stretch it and slowly free it. Such manipulation will also enable normal joints to keep active and increase the range of motion in those which already have become impaired. In manipulating
it is better to increase the movements which are not so much limited, in the course of their restoration to normal, gradually to limber up the most obviously limited movements. The latter are resisted by the
a joint
and
strongest adhesions. There is no reason for stretching under anesthesia in these cases because this is likely to cause considerable damage to the capsule and the periarticular tissues. Early and skilful employment of suitable passive movements and manipulation is the best preventative of
the formidable ankylosis and contractures. In order to make possible must be removable, and in case of nerve suture passive movement should be instituted as soon as the condition of the scar permits usually after two weeks. Active Exercise. Active exercise and re-education of muscle function comprise the most important part of the treatment after active power to the affected muscles has begun to return. This occurs, as a rule, not earlier than the fourth month after injury. However, a nerve injury causes loss of function of an extremity far beyond the structures that are actually involved, because the normal use of the extremity has been lost. Furthermore, the usual routine of splinting and immobilization tends to cause patients to restrict the use of the limb to a minimum. The early use of suitable exercises will reduce much of the unnecessary waste of muscles and stiffening of joints. Hence, even in the early treatment of nerve injuries, exercises are indicated for maintaining the function of muscles not directly affected and also for maintaining the full range of joint motion. When signs of active power appear in the affected muscles, the simplest possible
this early treatment, splints
508
active exercises with these muscles are begun, at first with as much assistance by the technician as required. Movements on a powdered board or under water will greatly aid in overcoming gravity and in allowing gradual redevelopment of function in the very weak muscles. Exercises must be carried on in all instances with the parts properly supported and previously warmed. It is very rarely necessary to use artificial exercise apparatus for this purpose, but use can be made of the various types of simple active exercise devices that are available. Overexercising must be avoided at all
times.
Occupational Therapy.
The
last stage of
muscle re-education consists
in active stimulation of the patient's efforts
by occupational therapy. A
well-equipped and supervised work shop, where various simple tools provide practical and attractive work, is most desirable for this purpose. The same set-up can be used in cases where there is lack of recovery, to teach the injured to make the best use of what remains to him. Gymnastic exercises are also valuable in this stage for general muscle redevelopment and increase of coordination.
NEURITIS
Neuritis is a painful, degenerative and often inflammatory any part of the peripheral neuron, causing functional disability. This functional loss according to the anatomy involved may be sensory, motor or mixed. The element of pain may be extremely mild and evanesPathology.
process in
cent, as in lead poisoning and infantile paralysis. The symptomatology often indicates the location of the primary pathological changes in one part of the nerve fiber, such as in the dorsal root ganglion (causing herpes
zoster
and
filaments of the skin).
localized pain in the course of the nerve or in the terminal The pathological changes vary greatly in the
different forms of neuritis, with a multitudinous etiology. Classification. The division of neuritis into a generalized
and
localized
form
important from the standpoint of rational physical therapy. In polyneuritis of the rheumatic type general heat measures and at times fever therapy, are indicated and as a rule helpful; increased elimination by such measures is also to be considered in some of the toxic types, due to chemical poisoning. In deficiency types, ultraviolet irradiation may be of definite value in disturbed calcium metabolism. Artificial fever therapy is justified in severe or resistant types and has been favorably reported on, 1 recently, by clinicians (Bennett and Cash ). Only mild fevers of 103 to 105 F. for two to four hours each for two to six treatments are indicated. Due care is essential to prevent burns because of anesthetic parts of limbs. Localized neuritis caused by trauma or pressure is one of the most prevalent forms and offers a most extended field of applicability for proper physical therapy, both for causal treatment and for symptomatic relief. The ultimate outcome in all forms of localized neuritis will depend on the removal of the exciting cause, and at .times is a straight surgical probis
lem.
will
essential; at times this
definite diagnosis as to the cause, extent and stage of neuritis is is quite difficult. It is evident that physical therapy
always best work in conjunction with other indicated procedures. Neuralgia denotes a pain in the distribution of a sensory nerve, due to an irritative lesion anywhere in the sensory tract but without pathological changes in the nerve itself. However, the dividing line between neuralgia
NEURITIS
and
neuritis
is
509
Treatment in these cases depends, and removal of the source of irritation. Physical measures play the same role in the management and therefore there is no reason to separate discussion of the so-called neuralgias from the large group of neuritides, to which they properly belong. Relief of Pain in Acute Neuritis. Generally speaking, one is called upon most frequently to treat one of the two principal symptoms in the acute stage of neuritis, paralysis or paresis when a motor nerve is involved, or pain and the various paresthesias when sensory nerves are affected. The methods of treating paralysis have been dealt with in Chapter IX and in the preceding chapter; therefore, only the clinical aspects for the
definite.
by no means
just as in neuritis, in the location
pain will be presented here. in neuritis is usually sharp or aching, and may be localized, or it continues along the course of a nerve. It is usually accompanied by tingling, numbness or loss of sensation; the nerve is tender to pressure and there may be tenderness all over the affected area. The knowledge of the location of the painful areas described by Valleix is important, because local measures directed for the relief of pain will be most efficient when
relief of
The pain
applied to these. Patients suffering from neuritic pain, which at times may be of torturing intensity, instinctively seek rest and relaxation for the affected area, and the first effort of the physician should be to secure as much of this as
possible. Light splinting, avoiding pressure of bandages or carrying an affected limb in a sling may help considerably and will protect the patient
from accidental touching or pushing the affected area while going about. It is indeed quite a problem whether in acute neuritis with very severe pain the relief obtained by any form of office treatment is worth the effort and risk of traveling from a distance. The portable apparatus now available helps to solve this difficulty, because it allows the institution of physical measures in the patient's home. In other cases mild sedatives help to overcome the temporary aggravation due to the exertion and enable ambulatory treatment when it is essential for combating the underlying
pathology.
Diathermy is the measure of choice in the average case not only for obtaining relief from pain but also for influencing its most frequent causes, i. e., pressure and muscle spasm. Instances of immediate relief from pain upon removal of pressure by an abscess or constricting band are well known. In administering diathermy it is advisable to precede it by five to ten minutes' application of radiant heat to the area to be treated, and this radiation may be continued during the entire treatment. With short-wave diathermy one condenser pad is placed well above the spinal center of the affected nerve, the other along its peripheral origin, so as to include the area of painful sensation. The inductance cable offers another and possibly more effective method of heating an entire extremity. The current should be pushed up slowly to comfortable toleration which will vary according to the sensitiveness of the patient. One must avoid an amount of current which causes throbbing or marked exacerbation of pain during treatment. A slight increase of pain immediately following treatment, however, is not a contraindication for repeating it within twenty-four hours or even more often, provided that there is some relief of the pain in the periods between treatments.
510
It is usually advisable to follow diathermy by the monoterminal (Oudin) current applied through a condenser or vacuum electrode over the painful area. This adds mild counterirritation of the skin to the analgesic and resorptive effects of deep heat. In instances where sensitiveness is so great
as to interfere with the application and fixation of diathermy electrodes luminous heat or infrared radiation followed by a very mild Oudin current may give relief. Treatments should be applied daily or even twice a day at first and be continued as frequently as necessary to keep the patient comfortable. The gradual relief thus given allows one to dispense with
sedatives and narcotics. In resistant cases the galvanic current may be employed. Electrodes should be applied so as to include the entire affected area. The current is
pushed up gradually to maximum toleration. It has been emphasized by Kowarschik that the current should be applied for long treatment periods, at least thirty to forty minutes at a time. Histamine and mecholyl ion transfer have been employed in recent years with some success and are offering an alternate measure worthy of trial. Reports on the usefulness of local ultraviolet radiation administered to a degree to produce a mild dermatitis have been explained by counterirritation. A mild non-specific protein reaction due to reabsorption from the area of the mild burn may also play a role in the relief produced. In particularly resistant cases of sciatic and brachial neuritis fever 1 therapy was employed by Bennett and Cash with a measure of success, but not comparable to the almost complete relief obtained in toxic infectious
In long-standing cases of neuritis, fibrositis develops, causing pressure and contraction of scar tissue around the nerve. This occurs especially in chronic sciatic neuritis. In these cases thermal applications should be followed by a mechanical measure, in order to break up perineuritic adhesions, to exercise flabby muscles and to tone up the tissues. Low-frequency stimulation by modulated alternating current or surging faradism is often helpful. Skilful massage and therapeutic exercise, acting on the principle of limbering up the parts, have also proven valuable. Good results have been reported also with roentgen-ray treatments which
poly neuritis. Chronic Neuritis.
by selective absorption of scar tissue. In particularly resistant and fairly definitely localized cases of chronic neuritis galvanic acupuncture with the technique described in Chapter VIII may be employed.
are explained
SPECIAL
motor nerve and supplies
FORMS OF NEURITIS
Facial Paralysis (Bell's Palsy). The seventh cranial nerve is a pure all the muscles of the face, except the masseter. It has three branches, the upper one supplying the closing muscles of the
eye, the other two the muscles around the nose and mouth. The nerve follows a tortuous course from the floor olthe fourth ventricle through the inner ear and emerges through the stylo-mastoid foramen in front of the external auditory canal, passing through the substance of the parotid
gland. Due to its anatomical relationships many conditions may affect the nerve; an important differential diagnostic point is that lesions due to cerebral hemorrhage, pressure of a new growth or softening of the brain
SPECIAL FORMS OF NEURITIS
511
usually do not affect the upper branch of the nerve, and in these cases the closure of the eye and wrinkling of the forehead remain unaffected. Traumatism, such as fractured skull, mastoid operation or wounds of the face, usually affects the main nerve trunk and results in immediate paralysis
of all muscles of the affected side.
facial neuritis, known as Bell's palsy, is the most affection of the facial nerve. Its etiology is usually exposure of frequent the face to severe cold, a chilling draft or such as driving a closed automobile with only one window open. pre-existing focal infection may
rheumatic type of
furnish a predisposing factor.
The well-known symptoms

after a short period of
of this distressing nerve lesion
may
appear
symptoms.
tingling or without any premonitory Since the facial nerve carries no sensory fibers, there is usually
numbness or
little pain, but the sudden onset often disturbs the nervous equilibrium of the patient seriously, especially in women. The uncertain prognosis offered by the average physician, who is unfamiliar with electrodiagnosis and of the means of relief by electrotherapy, only adds to the distress of the
patients.
Rationale of Early Treatment.
The
rheumatic
facial paralysis is explained
by the anatomical condition
effectiveness of early treatment in of the
facial nerve. It has been shown that exposure of a side of the face to the play of a current of air (draft) leads to a rapid evaporation from the skin, with an accompanying superficial vasoconstriction and a simultaneous deep-seated congestion. As a result, the neurilemma of the nerve trunk becomes swelled and impinges upon the neuroaxial fibers because of the non-yielding bony constriction of the stylomastoid foramen. Cobb and 2 Coggeshall state that exposure of the facial nerve brings on an edema
that blocks the stylomastoid foramen and presses on the facial nerve. This etiology offers the possibility of a quick absorption by suitable physical measures, as has been amply proved by clinical experience and it also explains the number of spontaneous recoveries within a few weeks, with absence of the reaction of degeneration in the so-called light cases. On the other hand, in untreated or originally severe cases, secondary involvement of the nerve fibers occurs due to continued pressure and, according to the extent of the nerve degeneration, a condition lasting from a few weeks to a year and leading possibly to permanent atrophy of some of the smaller muscles may ensue.
" " basis of these facts, the immediate application of decongestive measures in cases of Bell's palsy seems rational and the author's favorable
On the
experience with cases treated from the onset makes it evident that the former dictum, that no treatment and especially "no electricity" should be administered during the so-called painful period, is obsolete. Other clinicians report similar experiences; the variety of physical measures
recommended for early treatment of Bell's palsy include thermal, mechanical and electrochemical agents. The fact that they all have been reported on favorably can signify only that when employed in sufficient dosage and frequency they all accomplish their main object, the improvement of
local circulation
with the subsequent
relief of
Treatment should begin
in all cases
pressure from edema. with a superficial thermal measure
512
such as the radiation from a small luminous heat or infrared generator. An exposure of from twenty minutes to one-half hour results in improve-
ment
of the circulation
and nutrition and
also serves to relieve pain

:
if
held close to the affected side, another larger electrode The treatment drum method is also convenient. with contact plates is more difficult. Long-wave diathermy application " " Thermal measures bring about decongestion by influencing circulation and metabolism of the soft structures in the area treated. Electrochemical measures are recommended by clinicians here and abroad. The late Granger4 lauded galvanism from the negative pole, at a strength of 5 to 15 milliamperes for twenty minutes. For pain he recommended ionization with 2 per cent sodium salicylate. After galvanism Granger advocates electrical stimulation with the interrupted galvanic current from the very beginning. Bourguignon and his followers are quite enthusiastic over ionization with a 1 per cent potassium iodide solution, applied from the negative pole not only to the side of the face but also along the external auditory canal through a cotton pack soaked in the solution. It is claimed that this method acts more directly on the facial nerve. It is a justifiable assumption that electrochemical interchange of fluids and their ionic contents will result in an effect similar to that of thermal measures and thus help in the absorption of the local edema. Mechanical measures for early treatment comprise the static wave current, the monoterminal high frequency or Oudin current, and manual massage. The static wave current when available is applied with a crescentshaped electrode in front of the ear and offers the advantage of a two-fold effect: rhythmic mechanical action on the soft tissues underneath the electrode and electric stimulation of all muscles supplied by the facial
is
present. air-spaced electrode
The comfort given by diathermy is even more marked one smaller

side.
over the normal
nerve.
tion.
The Oudin effleuve, furnishes a combination of gentle mechanical action, mild heating and some counterirritation, without muscle stimulais generally agreed that electrical stimulation is a useful measure in cases of facial paralysis, but there appears to be a difference of opinion whether it is to be used from the beginning or only in a later stage. As
It
all
long as we accept that electrical stimulation is useful in maintaining physiological activity in weak and paralyzed muscles and that when correctly applied it cannot do harm, there is every reason why carefully graded stimulation should be employed in all cases from the beginning. Besides its physiological effect it helps to bolster the patient's morale, which is usually badly impaired by the dramatic appearance of a "crooked face." Clinicians using the static wave current from the beginning report great satisfaction from the combined use of decongestion and electrical stimulation.
The often repeated effect in clearing up the condition in a comparatively short time by early treatment can be explained by the removal of the inflammatory infiltration around the nerve trunk. In such cases testing
of the
after eight days of daily treatment will show its absence and the presence of the normal type of faradic response. As stated in Chapter VII the electrical reactions will not show any appreciable change during the first eight days of facial paralysis. If the
RD
513
patient reports for treatment only eight days or later after the onset of the disease the first step is to test for the reaction of degeneration. If there is no the prognosis for early recovery is favorable, and treatment
RD
should be instituted with the same technique and gradually changed from daily treatment to every other day until full voluntary function returns. In cases of partial or full reaction of degeneration, individual motor point stimulation should begin immediately by a low-tension and low-frequency current such as the interrupted galvanic, slow (galvanic) sinusoidal, or a modulated alternating current. It is doubtful whether return of function is ever speeded up by such treatment; on the other hand it is likely that it counteracts atrophy of the smaller muscles, just as atrophy of the small intrinsic muscles of the hand in nerve injuries may be combated by suitable
electric stimulation.
After the electrical treatment gentle stroking hand massage is applied minutes and the patient is instructed to exercise the facial muscles as much as possible, preferably in front of a mirror. It is important that the sagging of the affected side of the face be prevented as much as possible from the onset. An adhesive strap may be used overnight to pull up the face toward the zygoma or a suitable elastic strap may be worn around the affected side; a padded fish-hook inserted into the angle of the mouth and fastened around the ear may serve also. As soon as there is response to the faradic current, gentle faradic surges or the interrupted sinusoidal current may be used. It has been claimed that the occurrence of late secondary contractures in severe cases is due to the use of the faradic current. As long as the current is applied with a gentle technique and the muscles are not fatigued the treatment can cause no such effect. A sign of overstimulation would be if on subsequent treatments, using the same technique, more current should be needed to elicit the same response. Voluntary exercise is most desirable for restoring muscle tone and should
for five to ten
be used as early as possible. Many patients complain of irritation of the eye on the paralyzed side. The eye is best protected by wearing glasses on the street. Frequent washes with boric acid lotion and closing the eyelid passively at frequent
intervals
may
relieve the unpleasant tearing.
Through the management
as outlined
and with the general condition
of the patient receiving careful attention at all times, most cases of peripheral facial neuritis will recover within a period predetermined by electro-
diagnosis.
In facial paralysis due to a central or focal lesion or to traumatism the ultimate prognosis depends on the elimination of the cause; the local treatment is practically the same; perseverance and careful attention to all factors offers the best chance for recovery. In early cases of traumatic and toxic facial paralysis careful stimulation through the nerve also is indicated. It need not consist of more than a few contractions at first. In all cases in which irritability through the nerve is maintained, electric treatment may be continued only until it
can be replaced by voluntary exercise. Treatment by physical measures should be continued as long as there This may mean a period anywhere from four is room for improvement.
33
514
electrical reactions serve as an important guide for or discontinuing treatment, especially in traumatic cases. continuing 7 Regarding ear cases, Niihsman states that if facial paralysis lasted two months or longer and there is complete lack of electrical response of the nerve and of all muscles, the possibility of restitution is highly doubtful. Most otologists are inclined to continue conservative treatment even in case of known severance of the facial nerve, as long as electrical reactions
weeks to a year. The
are present. The facial nerve has a very marked power of regeneration. In cases at a standstill or hopeless, well-tried methods of plastic repair
The
The diagnosis of this lesion is often unsatisfactory. generally accepted signs are diffuse pain, disturbance of sensation, tenderness of nerve trunks and weakness or paralysis of muscles definitely limited to a certain nerve or group of nerves. The present tendency is to attribute diffuse pain not following typical nerve distribution to radiculitis
are available. Brachial Neuritis.
or to a lesion of the spinal nerve roots embracing the part of the nerve extending from the anterior horns of the cord to the emergence of the nerve through the dura mater. Inflammation or pressure within the interspinal segment, due to trauma, arthritis or focal infections, is often a causative When the nerve root is included in the area of treatment the factor.
results are often
radiculitis as
much more satisfactory, thus supporting the theory of an etiological factor. Among other etiological factors are traumatism around the shoulder leading to organization of extravasated blood between the shoulder muscles and in the axilla and through contracture about the nerves with subsequent pressure. Pressure of the head of the humerus upon the brachial plexus in stoop shoulders may also be
a factor.
FIG. 303. Galvanic treatment to right upper extremity through medium of local hydrogalvanic bath. Two tanks holding the two arms have the same polarity, while shoulder pad serves as active electrode (Courtesy of Teca Corporation.)
general principles of physical treatment are those previously deShort-wave diathermy if applied with one pad on the side of the neck opposite to the affected area, the other along the upper arm or
scribed.
The
more
distal.
pancake
The monoterminal
add to the
relief.
coil may also be applied against the shoulder. current subsequently applied along the entire area will Ultraviolet radiation to the degree of mild counter-
515
irritation may be also helpful. In chronic cases with adhesions and thickening, prolonged administration of galvanism or iontophoresis with vasodilating drugs is recommended and radiotherapy is also extolled. Galvanism
may be administered with the hand in a water-bath and one electrode over the cervical region. (Fig. 303.) Sciatic Neuritis. The sciatic nerve is the longest nerve in the body and in its long course from the lumbo-sacral vertebrae to the heel and the sole of the foot may be subject to various kinds of lesions, traumatic, mechanical, toxic and infectious. The definite diagnosis of sciatic neuritis must be based on careful investigation of every portion of the nerve, location of typical points of tenderness and on the corroborating evidence of the positive Lasegue's test: flexing the thigh on the pelvis with the leg extended which manipulation stretches the sciatic nerve and brings about
diathermy is the measure primarily recomIn very painful cases it must be administered in the patient's home or in the hospital. Diathermy should be preceded by a fifteen-minute application of luminous heat from a powerful source, a 1500- to 2000-watt lamp, in order to bring about hyperemia of the limb and lower back. Stroking massage or the Oudin current applied over the course of the nerve may be added for gentle countering tat ion. In a report from the Mayo Clinic 3 on the treatment of sciatica by various combinations of treatment the best result in ambulatory cases 85 per cent complete relief was accomplished by the combination of epidural injection (40 to 60 cc. of a 1 per cent solution of procaine hydrochloride), a belt and diathermy. In bed cases, 85.7 per cent were completely relieved by the combination double Buck's extension, diathermy, epidural injections, intravenous injeccharacteristic pain. In acute sciatic neuritis mild
mended.
tions of foreign protein and elimination of foci of infection. As in other forms of neuritis, galvanism may serve as an alternate treateither by the longitudinal or the transverse technique. In the former a moist pad electrode, large enough to cover the lumbo-sacral region and most of the buttock of the affected side, is used; the foot is enveloped in a thick layer of wet gauze up to the upper third of the leg and a metal pad is placed under the part covering the sole of the foot. It makes no difference in which direction the current travels. The principal effort is directed toward applying a current of a strength
ment and may be employed
as one electrode.
to 20 to 30 milliamperes at each session. foot bath may be used also The transverse method consists of applying two long narrow electrodes opposite and equidistant to each other on each side of
up
the entire lower extremity, with the interposition of a thick layer of gauze or bath toweling, well soaked in saline. Kowarschik administered up to 100 or more milliamperes by this method, from thirty to fifty minutes, and claims that his results were quite satisfactory. As in diathermy, treatments are given first daily and then every other day. The author has
recently employed ion transfer with mecholyl in selected cases and found method more effective than simple galvanism. In a bed-ridden patient and with a limited apparatus, prolonged applications of luminous heat or infrared rays may give marked relief. Starting from the lumbo-sacral region an area corresponding to the range of the lamp is exposed for onethis
half
hour and then the lamp

is
is
moved over the next

some
cases.
area. Counterirritation
by
ultraviolet
also applicable in
516
In chronic cases of sciatic neuritis the characteristic symptoms are dull aching and paresthesia instead of the continuous sharp pain in acute form and possibly also atrophy and weakness of the leg muscles. These symptoms are the result of a true fibrositis, degenerative processes in the nerve and adhesions and pressure in its sheath. Thermal measures followed by active mechanical measures for the breaking-up of adhesions are indicated for this condition. The surging faradic current or the interrupted sinusoidal applied with either the longitudinal method or with the individual motor point technique will exercise muscles and assist in breaking-up adhesions. The static wave current followed by vigorous sparking over the points of special tenderness is very effective. Irradiation of the spinal nerve roots by roentgen-rays has been The prognosis is extolled and may be worth trying in resistant cases. more favorable in early cases when diathermy quickly produces a subPatients with defective heat jective feeling of heat in the affected leg. sensation offer a less favorable prognosis on account of the organic changes in and around the nerve. Lack of heat response contraindicates diathermy or short-wave diathermy. In cases which do not respond well, efforts should be made to better locate the seat of inflammation and treat it directly. In some of these patients counterirritation by vigorous short sparking from the Oudin terminal or sun-burning doses of ultraviolet irradiation may help. General thermal measures in the form of electric light cabinets or regular fever treatments may bring about a favorable turn in particularly resistant cases.
Radicular pain due to pressure upon nerve roots has received added 11 study recently. In discussing the treatment of back injuries Wentworth states that one may accept that the posterior primary division of the spinal nerve winds closely over the ligamenture of the articulation, and that any inflammation of the joint may institute radiating pain; but that there is direct pressure upon the nerve roots appears improbable; there would seem to be ample space for the nerve in any spinal position. Others believe
that the occurrence of neuritic pain suggesting spinal arthritis is often duetto segmental neuritis resulting from compression of the nerve roots by narrowing of the intervertebral foramina. In a number of the cervical cases the application of head traction or at least suitable bracing is essential.
Diathermy is useful for relief of pain in many cases. Meralgia Paresthetica. Meralgia paresthetica is a localized neuritis of the external cutaneous nerve of the leg manifesting itself by a constant
burning sensation and hyperesthesia along the outer surface of the thigh. Its cause is a fibrosis, pressure on the nerve as it passes through a fibrous tunnel of the fascia lata. Radiant heating followed by mild Oudin application usually relieves this condition in a few treatments. Trifacial Neuralgia. All true cases of tic douloureux are most painful. The most resistant form of nerve irritations are due to a lesion of the Gasserian ganglion, situated at the base of the skull and practically inaccessible to any form of treatment, save surgery. There are conflicting views as to the pathology in the Gasserian ganglion; one point of view suggests arteriospasm, angioneurosis, brought about by some sympathetic
unbalance. Yet, as Turrell stated the attempt to corroborate this seemingly rational view by the results of treatment by diathermy fails. Theoretically, it should be able to relieve an arterial spasm even at considerable depth,
517
yet in the majority of cases of trifacial neuralgia diathermy and even the more penetrating short-wave diathermy do not seem to help. Typical cases of tic douloureux are characterized by excruciating attacks of pain and spasm of sudden onset and without apparent cause or following a very slight provocation, like a slight touch or blow of air. The sleep of these patients is usually not disturbed. Cases with referred trifacial pain, peripheral neuritis of some of the branches, may be due to a lesion of the teeth, infection of the jaws or jaw bones, as osteitis, or in the sinuses. The pain in such cases is less paroxysmal, more constant and often disturbs the sleep. Careful differential diagnosis based on competent dental, nose and throat and neurological examination is essential. Cases of peripheral neuritis can be more rationally attacked. The galvanic current is successful in some cases and it has enabled the author to comfort some patients in whom the painful alcohol injections
The technique of application consists of using a special crescent-shaped pad electrode covering the entire facial distribution of the nerve, with suitable indentations for the eye and mouth; a large dispersive pad electrode may be placed over the chest or back of the patient; this offers, to the greater part of the current, a path outside of the skull. The active electrode may be connected to the positive pole, and a current strength from 10 milliamperes working up to a maximum of 40 or 50 should be aimed at. The good results obtained by intensive galvanization are attributed by Turrell to a counterirritating skin effect, desensitizing the receptors in the affected area. Symptomatic relief by "rapid sinusoidal" current the 60 cycle alter10 nating current controlled by a rheostat has been reported by Ulanski. a few minutes' stimulation is applied by a small active electrode Only over the painful areas. Ion transfer with quinine or aconitin solution applied from the positive pole has also been recommended. The static brush discharge may give Ultraviolet irradiation has been relief over particularly tender areas. unsuccessful. Roentgenologists claim results from roentgen-rays and they may, therefore, be tried. Modern surgery in the form of a section of the
failed to give lasting relief.
dorsal root instead of the barbarous and extremely dangerous extirpation of the ganglion is being employed as an ultimate resort with complete success in
many
cases.
The most frequent cause of severe intercostal pain is the inflammation of the spinal ganglion in herpes zoster; traumatism, exposure or a local or general inflammatory process (pleurisy, pneumonia, arthritis or myositis) are among the other causes. Physical measures serve for relief of pain and for shortening the course of the condition. Diathermy combined with ultraviolet is clinically the most effective measure next to the static brush discharge, which, however, is not so readily available. In diathermic treatment one electrode should be placed over the entry of the affected intercostal nerves at the side of the spinal column; the other electrode should be in front at the site of the greater pain. An inductance coil may be also placed over the entire painful area. Diathermy may be followed with mild sparking from the Oudin terminal. Much more satisfactory is the application of ultraviolet radiation to the site of the pain, to the degree of a mild dermatitis. This combined treatIntercostal Neuralgia.
ment should be repeated
daily until there
is
marked improvement. How-
518

com-
ever, severe cases of true ganglionitis may take many weeks until bined use of medicinal and physical measures brings final relief.
REFERENCES
1.
2.
3.
Relief of Neuritic Pain by Artificial Fever E., and CASH, PAUL T.: Therapy, Arch. Phys. and Ther., 19, 69, 1938. COBB, S., and COGGESHALL, H. C.: Neuritis, Jour. Am. Med. Assn., 103, 21, 1934. CRAIG, W. McK., and GHORMLEY, R. K.: The Significance and Treatment of
BENNETT, A.
4.
5.
Sciatic Pain, Jour. Am. Med. Assn., 100, 1143, 1933. GRANGER, F. B.: Physical Therapeutic Technic, Philadelphia, W. B. Saunders Company, p. 233, 1929. KOVACS, RICHARD: Evaluation of Physical Therapeutic Measures in Facial Paralysis, Arch. Phys. Ther., 22, 145, 1941. Medical Department of the United States Army in the World War, Washington, U. S. Government Printing Office, 13, 138, 1927. NUHSMAN, T.: Diagnose, Prognose and Therapy der Otogenen Facialislahmung, Hals-, Nasen- u. Ohrenarztl., 8, 268, 1926. POLLOCK, L. J., and DAVIS, LLOYD: Peripheral Nerve Injuries, New York, Paul B. Hoeber, Inc., 1933. Nerve Wounds, London, Bailliere, Tindall & Cox, p. 36, 1917. TINEL, J. ULANSKI, B.: Conservative Treatment of Trigeminal Neuralgia: Preliminary Report, Arch. Phys. Ther., X-ray and Rad., 18, 1-64, 1937. WENTWORTH, E. T.: Bed Rest for Back Injuries, New York State Jour. Med., 37,
:
6.
7.
8.
9.
10.
11.
1914, 1937.
CHAPTER XXIX
Traumatic Conditions. General Considerations. General Pathology. Objects and Forms of Physical Treatment. Contusions. Injuries of Joints and Muscles. Strains. Dislocations. Traumatic Arthritis. Stiff Joints. Injuries of Bones. Sprains. Fractures. Amputations. Back Injuries. Coccygodynia. Affections of Bones and Joints. Osteomyelitis. Tuberculosis of Bones and Joints. Affections of Muscles. Acute Myositis. Chronic Myositis. Volkmann's Ischemic Contracture. Affections of Tendons and Bursae. Bursitis. Shoulder Conditions. MisTenosynovitis. cellaneous Surgical Conditions. Adenitis. Burns. Foot Conditions.
TRAUMATIC CONDITIONS
General Considerations. The value of physical measures in the treatof traumatic conditions is well established. Their correct employment however entails the observation of certain prerequisites and
ment
safeguards.
1. There must be a definite diagnosis of the local injury as well as of the general condition of the patient before physical treatment is ever
instituted.
work must be the very best. No amount of treatment can compensate for poor surgery. 3. Physical treatment must be properly indicated and must never be applied to the neglect or exclusion of important or superior medical or
2.
The
initial surgical
skilled physical
surgical procedure.
4.
The
physical treatment best suited for the condition

intelligence, skill
and applied with
and
diligence.
must be selected There must be a sufficient
variety of available measures. 5. Physical treatment should cease when the patient can do for himself what the treatment is designed to help him perform. Adequate records must be kept from beginning to the final check-up. 6. There must be complete cooperation between the surgeon and physical therapist. Physical treatment must be instituted from the time of admission, for it is just as grievous to indulge the patient in continued unneces-
sary treatment as to neglect giving him the benefit of treatment early in his disability. Periodic consultations are essential. General Pathology of Injuries. In recent injuries there is extravasation of blood and lymph from torn vessels and capillaries, edema from increased transudation of lymph and there may be tearing of ligaments, rupture of muscles and tendons or injury to cartilage or bone. The primary indications for treatment are the stopping of hemorrhage, overcoming of shock, prevention of infection, uniting of broken surfaces and provision of physiological rest for undisturbed healing. Chronic disability is maintained by the fact that the body forces are not always successful in removing unaided the products of recent traumatism, and in combating the subsequent infection. Passive hyperemia is caused by damage to vessel walls and the irritation of vasomotor nerves; its final result may be structural changes such as permanent enlargement
(519)
520
of small vessels, increase of connective tissue and later fibrotic induration. Adhesions are caused by the organization of "coagulable" lymph exuded
following the injury and formed during the process of inflammation and In the early stages this granulation tissue holding together the repair. adjoining surfaces of muscles, tendons and fasciae can be easily separated. In the later stages the newly formed blood-vessels disappear, the new
becomes fibrous and contracts; bands form which irregularly bind together adjacent surfaces, causing limitation of motion and pain by pressure or by stretching of nerve endings. Muscle atrophy may be caused by disuse, by interference with circulation, by disease of adjacent joints or by injury to the nerve supply. In most cases of injury a vicious circle is established, the injury itself causing a diminution of blood supply and inactivity and the subsequent loss of muscle action resulting in further
tissue
loss of
tone and atrophy. For many years the routine management
of recent
traumatism con-
The sisted of immobilization in order to provide undisturbed healing. three principles of Thomas for treatment were: rest, test of recovery by
tentative use in splints and finally, natural use. This procedure ignored the fact that for the repair of an injury efficient blood supply is necessary
and that rest itself promoted the organization of the extravasated fluid and induce formation of intra- and perimuscular as well as periarticular
of muscles.
adhesions. In immobilized extremities there also develops an early atrophy The present day tendency in treatment of recent injury is
to provide immobilization only as long as necessary for the proper coaptation and adherence of broken surfaces or torn ligaments for it is now
damage is often the cause of delayed recovery and subsequent discomfort. principal Objects and Methods of Physical Treatment. The object of physical treatment in injuries will vary with the type of injury and the individual in whom it occurred. Just as general surgical principles must be maintained in the varied types of injuries while the treatment in the individual may vary widely, so must physical measures be adapted to the individual and must include an armamentarium sufficiently wide to be used effectively. Generally speaking physical treatment may have as its object: in acute cases, the acceleration of the process of repair and restoration of function, the promotion of absorption, the prevention of adhesions, the relief of pain and the relaxation of muscle spasm; in chronic cases, the removal of inflammatory products, the softening of adhesions or scar tissue, the improvement of nutrition in muscles and the maintenance or increase of
mobility in joints. The general scheme of the treatment of recent injuries is as follows The first requisite is an accurate diagnosis as to the nature and extent of If the injury does not demand complete immobilization the injuries. immediate application of gentle stroking massage by the physician to the periphery of the traumatized area, will reflexly speed up the circulation, hasten the dissipation of the edema and relieve pain. A short cold application in the form of an ice-bag or an iced compress exerts a vasoconstricting and pain relieving effect and is useful in the immediate treatment of contusions and hematomata. After the checking of edema and swelling an elastic bandage or strapping may be applied; the injured part may be elevated and kept at rest.
:
generally recognized that the neglect of soft tissue
INJURIES OF JOINTS AND MUSCLES
521
for the
With the passing of the acute stage thermal measures should be employed improvement of circulation and the relief of pain and as an intro-
duction to suitable mechanical measures. In all subacute and chronic injuries, heat is one of the principal means for speeding up the process of repair and to comfort the patient. Its various forms are selected according to the location and extent of the injury. Radiant sources of heating serve conveniently for affecting the skin, subcutaneous tissue and the superficial layers of muscles, while diathermy and short-wave diathermy serve more
heating deeper structures, especially joints and bursse. whirlpool-bath offers a combination of heating with hydromasssage. It is most effective as a circulatory stimulant in fractures immediately after removal of splints or cast, in indolent ulcers, adherent scars and peripheral nerve lesions. Mechanical measures such as massage, active and passive exercise and electrical stimulation of muscles and tissues, may be employed for combating the immediate effects of trauma; edema, exudation and muscle spasm, or its sequelae: adhesions and stiffness. They may also serve to
efficiently for
The modern hot
weak or paralyzed muscles, and for relieving pain by reflex action by removing pressure. As a rule mechanical measures work best when preceded by suitable heating. Massage is the simplest and most popular mechanical agent, requiring only a pair of skilled hands, directed by a trained brain. Early application of relaxed passive movement or of exercising electrical currents will act as
exercise
or
and muscular atrophy. Later, careful is the most desirable for re-educating wasted muscles and, for increasing the range of joint movement and for promoting muscle coordination. Resistive exercises enable localization of effects to certain joints and muscles. Passive exercise is a dangerous procedure and must be reserved for special conditions and
a preventative of
stiffness, fibrosis
active
movements
are instituted.
Active exercise
expert hands. Electrical currents of low frequency, such as the surging faradic, serve for stimulating weak muscles without moving the joints upon which they act; they also serve in other forms for maintaining some of the functions in fully paralyzed muscles. Electrodiagnosis is at times indispensable for diagnosis and prognosis in nerve lesions or simulated paralysis. The static wave current when available offers a useful combination of muscle exercise
with gentle tissue massage. Electrochemical measures in the form of the galvanic current or chlorine ion transfer may serve for promoting absorption of small scars. Ultraviolet radiation may help locally in some infections, in burns and for stimulating
epithelization.
INJURIES OF JOINTS
AND MUSCLES
Contusions. The typical signs of a contusion are swelling, ecchymosis, discoloration of the skin due to hemorrhage, local tenderness and limitation of motion. diagnosis of contusion is not justified until every other pos-
has been eliminated. Immediately following the injury nothing will give so much relief from pain as cold compresses or an ice-bag; the contraction caused by cold will also tend to arrest hemorrhage. After twenty-four hours, hot moist applications or exposure to radiant heat may be started; the latter should be kept up for one-half hour every two or
sible lesion
522

Hot compresses
are less desirable because they dry rapidly. hot water keeps the part hanging down, whereas elevation If there is marked local edema, gentle is more important than heat. should be given for a few minutes after heating. stroking massage Local tenderness not fully relieved by these measures may be further comforted by a ten-minute application of the Oudin current or highfrequency stroking (Chapter XI). Careful passive motion for a few minutes by the operator and a few minutes active motion by the patient should end the treatment, which is to be repeated at first once daily; later every other day, until the condition has fully cleared up. Strains. Excessive use as a rule stretching of a muscle or a joint without a tear or displacement is known as a strain. Muscular strain is suspected when particular pain is elicited by contraction of a specific muscle against resistance and when localized tenderness is present over Smart22 states that even a slight strain may this muscle or its tendon. result in a slackness of the injured muscle and a loss of its tone and interfere early or later with the mechanics of the joint upon which the affected muscle or muscles act. Such a condition is often overlooked because there appears to be little the matter with the joint except a feeling of weakness and insecurity. Smart states that this constantly occurs as the result of the injury of the knee-joint and if a knee presenting undue mobility is carefully examined the atonic condition of muscles will be readily noticed. In severe muscle strain a subcutaneous wound of more or less severity accompanies the loss of tone and contractility; there is extravasation of lymph and blood, and considerable restriction of motion. In the later stages adhesions are formed which are highly sensitive; in addition there may be a protective spasm of the neighboring muscles opposing any attempt to drag on the adhesions. The final result may be fixation and stiffness of a muscle or group of muscles. Immediate treatment should be applied as described under contusions; this is followed by the artificial contraction and relaxation of muscle advocated by Smart. This treatment aids recovery of muscle tone, promotes absorption of the effusion, directly stimulates free circulation of blood in the injured part and its neighborhood and above all prevents the formation of adhesions around the muscles and tendons. Massage and
three hours.
Immersion
in
active exercise serve as important alternates of treatment. Sprains. sprain of a joint implies primarily a tearing of ligaments, but may also involve injury to the periosteum, muscles, tendons, blood-
and supporting soft tissues. The typical signs are swelling, pain, increased or abnormal mobility of the joint when there is damage to its ligaments and localized tenderness. The pathological signs will vary greatly according to locality. In some, as in the ankle, more of the stress is taken on by the ligaments; in others like the shoulder, damage affects the muscles more. The key to recovery, however, in each of these cases is the release of the effusion and the completeness and speed of its absorption.
vessels
Every
examination.
joint injury diagnosed as a sprain must receive a radiographic Severe sprains at times must be immobilized and in most
is
cases elastic pressure in the form of bandaging or strapping prevent or limit effusion.
applied to
Treatment.
of
Besides the use of external forms of heating the early use diathermy has proved especially effective for the reduction of swelling
INJURIES OF JOINTS AND MUSCLES

and promotion
523
of absorption; it should be followed by either graduated muscular contraction or massage. The immediate stimulation of all involved muscles by a surging faradic
current in uncomplicated sprains is considered by Laquerriere 15 more effective than any other form of physical treatment. He bases its rationale
on the similarity of reported quick recovery of sprains after an injection of a local anesthetic and early motion. Its further advantage is that with portable small apparatus it can be employed at the bedside in sessions of ten minutes several times a day. Smart 22 reported similar experiences and the author can corroborate these.
Correctly applied massage will help considerably to speed up recovery. should begin with gentle stroking above the site of the injury, with the whole limb in a position to relax all muscles. This procedure aims to restore vasomotor tone and prevent further swelling. After treatment firm bandaging or strapping is to be applied. At subsequent treatments deep stroking and kneading may be used to dissipate the effusion. Careful and limited passive movements are given to the affected joint, while those distal to the injury are freely moved. Treatment should be given daily from ten to thirty minutes and gradually increased, while the support of bandaging or strapping is gradually reduced. The joints most frequently sprained are the ankle, knee, elbow, shoulder and wrist, more rarely the hip and the sacro-iliac joint. In ankle joint injury the first concern is to reduce the swelling; cold application of half hour or so in a foot bath or by an ice-bag, followed by adhesive plaster strapping, so applied that it approximates the torn ends of the ligaments.
It
Ewerhardt 8 strongly recommends immediate walking in uncomplicated cases, for muscle contraction and joint motion accelerates the circulation and hastens resorption more than the use of heat alone. The new techniques
of short-wave of
diathermy enable early heat treatment without the necessity removing the strapping.
Knee injuries of some severity require immobilization in a cast, followed by use of heat, massage and exercise. Mild sprains of the shoulder usually
respond well to adhesive tape support extending over the joint and from there to the anterior and posterior wall of the chest, with the arm supported in a sling for a week. Sprains of the wrist may require immobilization during the acute stage with moulded volar plaster splint which may be
removed daily for use of heat and massage. Mild sprains of the elbow may be treated by early application of cold compresses to prevent effusion, followed by a compression bandage applied with the elbow in 90 degree flexion and supported by a sling. Later the
Manual massage should be avoided in whirlpool bath may be used. traumatized elbows, especially in younger people on account of the tendency to promote the occurrence of the condition known as myositis ossificans, formation of extensive calcifications. In the elbow single or recurrent muscle exertion often brings about " another typical traumatic condition, known as tennis elbow" although Its signs are tenderness it may occur in baseball pitchers and others. localized over the internal lateral ligament and the extensor muscles, usually swelling about the elbow and pain on extension of the elbow and supination of the forearm. The pathological changes underlying this condition have been variously described as an arthritis of the radiohumeral joint and as a
524

11
radiohumeral bursa. Hansson and Norwich described it as an epicondylitis due to a periosteal tear and a myof ascitis of the extensor muscles originating from the external epicondyle. The treatment recommended consists of: (1) physiological rest by a light cock-up splint to the forearm such as used for wrist-drop, and held by two straps; this enables the patient to continue all flexion activities of the hand; (2) diathermy for thirty minutes to the extensor muscles with a semicuff applied over the upper half of the extensors and the other electrode under the flexor surface; this is to be followed by ten minutes massage. In resistant cases surging faradism or the static-wave current may be applied over the extensor
bursitis of the
muscles.
Dislocations.
In a dislocation there occurs a rupture of the joint
capsule, usually at its weakest point. After the displacement is reduced, we are dealing essentially with an arthro-chondrosynovitis, and a wound The rest of the capsule and the ligaments are usually in the capsule.
and only certain motions may cause a redislocation. Perhaps the commonest joint dislocated is the shoulder with anterior dislocation as the most frequent type. After proper reduction the only motion that will result in redislocation is abduction and extension. If these be prevented there is no possibility of the joint redislocating. A simple sling should be worn for a few days and the patient advised not to make attempts at the motions which might cause redislocation; there should be no delay in starting other motions and physical therapy which
intact
will
promote the rapid absorption
of extravasated blood
and hasten the
repair in the soft tissues surrounding the joint. Dislocations of the elbow usually are posterior. After reduction, cold applications are followed by use of a compression bandage. Some surgeons
employ acute
flexion with the wrist in supination, and others favor right"Muscle angle flexion and a neutral pronation-supination position. setting" exercises may be instituted while the arm is in the sling. As soon as the sling can be removed temporarily, the arm may be placed in the whirlpool bath and active motion encouraged to the point of pain. When the arm is removed from the sling, exercises should be continued.
In uncomplicated dislocation of any joint which has been reduced physitherapy should start on the day of the accident. If this is done much time will be saved in the restoration of function. The muscles acting upon the joint are usually damaged and may immediately lose their tone and suffer further damage if rest is enforced. Heat measures, graduated muscle contractions are the standbys of treatment;
cal
early massage in the form of effleurage promotes the absorption of effusion and relaxes muscle spasm. Gentle friction prevents the formation of adhesions. During passive movements the injured joint must be well
supported by the operator's hand. Traumatic Arthritis. Traumatic arthritis may be caused by: (1) a single severe injury to the joint cartilage; (2) repeated mild injury to the joint cartilage; (3) disorganization of the mechanics of a joint; (4) abnormal function in a joint on account of bony deformity so that use brings about repeated injury to the joint surface; (5) gradual deformity in a joint as a result of abnormal pressure (Key 12 ). The pathological changes resemble those in osteo-arthritis; there is degeneration of the articular cartilage, fibrosis of the joint capsule, production of new bone and cartilage around
INJURIES OF BONES
525
the articular margins and hypertrophy of the sy no vial membrane. The chief characteristics of these changes are that they occur only in one joint, the joint which has been subjected to injury. All clinicians agree that rest is the most important initial physical therapy measure in this condition; after the acute symptoms have subsided, gradual mobilization, support by elastic or leather and protection from strain by correcting posture are advisable. Smart 22 states that it has been laid down as a general rule, that when a joint is restricted in movements in all directions, the joint should be rested and not manipulated, because such limitation usually means that the joint is or has been in the state of acute arthritis. If movements are only limited in some directions, the joint may be manipulated with due care. Diathermy is the most effective measure to improve local circulation and speed up the subsidence of inflammation, and serves as an introduction for active and passive movements. Daily treatments are indicated. Graduated muscular contractions or massage should be also systematically
employed.
The final prognosis in traumatic arthritis depends upon the cause of the condition, the amount of use to which the joint has to be subjected, and whether or not the abnormality incident to the injury can be corrected.
In younger persons, especially men, the chances for
usually
Stiff
full
recovery are
much
better.
Joints.
rest
Many
lotions
instances of joint stiffness following sprains in
which
were used are due to the immobilization and not to injury. Likewise, the flabbiness and weakness of muscles around a joint is due to reflex atrophy; these muscles usually being supplied by the same nerves as the joint. The early use of appropriate physical measures may
and
prevent most ankylosis. If ankylosis is once established before instituting treatment one must make sure that there is no real bony block present, and, furthermore, that adhesions exist only between the articular ends of the bone and the capsule or that only the capsule is adherent and contracted. When there is serious
destruction of cartilage or marked deformity of the adjoining joint surfaces physical measures do not promise the best results. The principle of treatment in suitable cases is to limber up the fibrous, contracted tissues by a thermal measure, preferably, diathermy, or luminous heat or a hot whirlpool bath as its substitute, and follow this by active exercise, massage and manipulation. Graduated muscular contractions by surging faradic or the static-wave current applied with a moulded electrode
over the joint will often help by their gentle stretching and exercising effects on muscles and periarticular tissues. Appropriate massage movements are most helpful in stretching adhesions. After preliminary warming, deep stroking is used at first, followed by deep kneading of the muscles above and below the joint. Friction movements may be applied over the joint and finally passive movements and resistive exercises are added. A fairly severe reaction may follow such heavy massage and in such cases temporary rest and immobilization has to be applied.
Fractures.
INJURIES OF BONES The modern treatment of fractures

is
pathological change present
recognizes that the a solution of continuity of a bone situated
526

which have been extensively damaged.
Consequently the
in soft tissues
early employment of efficient physical therapy to the damaged soft parts will obviate the necessity of much of so-called after-treatment of fractures
and it will be productive and anatomical recovery.

In
all
5 17
-
of
much
earlier
and more complete functional
three stages of fracture treatment physical therapy
may
be used
advantageously. When fractures are accompanied by severe (1) Prereduction Period. trauma to the surrounding soft parts with extensive hemorrhage, and reduction, open or closed, must be delayed for several days, heat and massage may improve the condition of the soft parts and permit application of definite treatment much sooner than would otherwise be possible. 17 Murray reserves such prereduction therapy primarily for fractures about the wrist and ankle seen after marked swelling has occurred and also in conjunction with use of traction suspension, whether by wire or by skin traction. Temporary skin immobilization, with the employment of elevation, constant low degree of heat by means of a blanket tent beneath which is an ordinary goose-neck lamp, light sedative massage, and one or more half-hour applications of the positive and negative pressure boot will frequently, within eight to twelve hours, result in such reduction and softening of the swollen and indurated part that manipulation can be far more easily accomplished because of the better recognition of bony land-
marks.
In this period the aim is to remove the (2) Postr eduction Period. changes caused by the fracture and manipulative procedure. Murray employs elevation of the affected part, sedative massage of the whole extremity, constant low degree of heat by means of low milliamperage and muscle stimulation through some form of sinusoidal current. Wherever possible, this procedure is used in conjunction with counterbalanced suspension and active mobilization of the part by the patient. Such treatment prevents the organization of scar tissue in muscle and soft parts about vessels and nerves, in joint capsules and in tendons. It therefore minimizes the amount of functional limitation that has to be dealt with after the bone~is healed. Under appropriate physical treatment a dislocated or fractured shoulder shows at the end of five days a soft clear skin, soft relaxed muscles, and freedom from pain and spasm. The saving in time of recovery is marked. The use of traction, or suspension or of hinged splints should enable employment of these measures from the very beginning, because they are most valuable during the first ten days. "Muscle setting" is a very important active form of voluntary muscle contraction which the patient may be taught to use even when the extremity is completely encased in plaster dressing. It consists of the patient "setting" or contracting actively the individual muscles of the injured extremity, without any actual movement of the joints; this is done several times a day and serves to increase circulation and maintain some of the muscle tone. In
all observing surgeons laud electrical stimulation for maintaining muscle function when used gently and painlessly and without causing spasm. (3) After-treatment. Unfortunately in the average case this is the period when physical therapy is most generally employed. It begins when bone healing has advanced sufficiently to allow discarding splints or apparatus.
addition,
INJURIES OF BONES
Here physical therapy
527
finds its greatest use in treating stiffness and atrophy immobilization. If physical therapy is used intelligently following prolonged during the first two stages, necessity for a prolonged third stage is eliminated to a large degree. In this stage all methods of treatment may be
employed according to indications: whirlpool bath, paraffine bath, contrast baths, heat, massage and exercise. In late stages of fractures physical therapy is only an adjuvant, full restoration of function depends chiefly on the efforts of the patient to regain the function by normal muscular activity. All physical therapy can do is to make it easier for the patient to carry out this task. There is no injury in which massage and exercise can be used to greater advantage than in fractures. In fractures with great displacement massage and mobilization has to begin much later than in fractures with little deformity and the fragments held in good position. This is, of course, a matter for the attending surgeon to decide and as he assumes the responsibility for instituting the early treatment, it is expected that he supervise the treatment at first and issue definite instructions for the removal of splints, joint movement with the splint or without it and the type and duration of massage and exercise. It is impossible to give other than general rules for each stage; the particular movements will have to vary with the type and location of fracture and the immediate response to treatment. The same considerations relate to the combination of active and passive movements with massage. Gentle surface stroking applied for a few minutes is always the first treatment in
fractures.
It should
be preceded by mild external heating and, as a
rule,
no other massage movement should be applied until the knitting of the bony ends is firm. Great care must be taken to support the fracture. If it is possible a minute amount of motion should be performed in the joint distal to the fracture if it can be done without danger of displacement of the fracture ends. Hence this is preferably done by the surgeon at first. After six or eight days add light friction and careful passive movements in all neighboring joints and after ten days add kneading of muscles above and below the injury. After three weeks, treatment may include effleurage, petrissage, frictions and active movements in neighboring joints. After four weeks more vigorous massage may be employed with active movements. The patient must be encouraged to take movements by himself. Massage and other physical measures are a means to an end and the patient must be forced to realize this and work hard himself through work and exercise to assist in the recovery. In delayed union, provided that there is no anatomical cause for it and there is a fair degree of fixation, diathermy is indicated for its effects on the local circulation and nutrition. The ordinary technique of transverse
26 application at a comfortable tolerance should be used. Voshell has seen the plaster encouraging results with short-wave diathermy applied through cast. There was no need of a supporting diet or viosterol in addition.
favorable action of ultraviolet radiation on the consolidation of the by causing greater fixation of calcium salts in the fracture and more rapid evolution of the osteogenic process was shown in a series of con19 Irradiation was limited to the trolled animal experiments by Racugno.
callus
site of
the fracture and employed in erythema doses,
528
An important function of physical therapy is the preparaan amputation stump for early and efficient function. Heat, massage and early exercise are the means. Either whirlpool or contrast baths are used to improve the circulation in many cyanotic, cold and painful stumps and in those with low grade inflammatory condition or ulceration. Such
Amputations.
tion of
baths are also beneficial when there is persistent edema or excessive periosteal connective tissue formation; they relieve the pain caused by poorly fitting prostheses at weight-bearing points. They should be used daily, and the patient may be instructed to use contrast baths at home
six or seven days after Following heat treatment, superficial and, later, deep stroking, kneading and friction are given in successive order and are followed in turn by passive exercise and stretching. Early exercise of the amputated limb results in disappearance of the edema and further shortening of the period preparatory to fitting the artificial limb. Learning the mechanics of standing and walking with an artificial limb involves re-education in coordination of movement in the muscles of the stump and of tactile, muscular and joint sensation in the remaining part of the limb. After learning the mechanics of walking, the patient puts it into practice by walking between parallel bars used for support. When this has been mastered he is taught to walk with short steps using two canes and then to walk with longer steps using only one
with 2 ordinary
if
pails.
is
Massage can be started

infection.
amputation
there
no
cane.
Back Injuries. Back injuries form one of the most complex problems in present day traumatic surgery, partly because of the difficulty in accurate diagnosis of a condition largely subjective, partly because of frequent anatomical deviations from the normal which are not and never have been connected with the injury under consideration, and finally because of the complication of the picture by factors related to compensation in one form or another for injuries received while under employment or in some other accident. When confronted with a case of back injury, because of the vagueness and unreliability of many of the signs and symptoms presented, one needs to search for every bit of definite anatomical and pathological data one can elicit. Roentgenograms will ascertain or rule out lesions of the bony parts and a thorough clinical examination is indispensable for the recognition of pathological changes in the soft parts and in the patient
Two general types of back injuries may be differentiated: with damage to the bony structure of the spine and those with injuries 20 damage limited to the muscular-ligamentous system. SchaufHer states: "For years sacro-iliac displacements or sprains have been overplayed. Then the honors were divided between lumbo-sacral and sacro-iliac sprains or they were simply said to be a low back sprain. Now the pendulum has
in general.
and many articles in recent literature claim these back pains are toxic." Shands 21 states that even with the help of roentgenograms, accurate differentiation between certain types of lumbo-sacral and sacro-iliac affections is often difficult. Physical therapy
swung
that
far to the opposite side
all
plays an important part in the management of back injuries; if its results are not as clear cut and dependable as in other types of injuries, this may be due to the often confused pathology and to the other factors enumerated.
There is general agreement that immediate and proper rest is most desirable for recovery of back injuries; it must be kept up from one to
AFFECTIONS OF BONES AND JOINTS
529
three weeks according to the seriousness of the injury. The back must be protected to avoid protective muscle spasm. According to Wentworth 28 the change due to injury is functional rather than anatomical. If muscle fibers or ligaments are torn or pulled away a new protective muscle function
is
immediately instituted, which persists until proper and adequate rest
conditions are established. If not soon replaced by proper outside support, this spasm becomes a source of pain and disability in itself. In further physical treatment heat and massage are added the author is using either long-wave or short-wave diathermy for thirty minutes or more, followed by
;
massage, the surging faradic current or, if available, the static wave current and sparks. In stubborn cases of chronic myositis iontophoresis with mecholyl may give satisfactory results; in others second degree erythema doses from an ultraviolet generator are helpful. Postural exercises, a careful regime of general hygiene, the alternation of rest and work are employed with
success in selected cases.
In the manifold other types of back pain, traumatic and non-traumatic, is a large field of applicability for physical measures, once the relative contributing influence of each factor has been recognized. A thorough review of this complex problem has been presented by Krusen. 14 Coccygodynia. Injuries of the coccyx often present a clear-cut picture, such as direct traumatism to the coccyx through a fall or blow, followed by acute pain and tenderness. At other times the symptoms are so obscure that the patients are considered neurasthenics. In these cases continued local pain and especially pain on movement or after sitting for a short time are suggestive. An examination of the coccyx through the rectum
there
will
show tenderness and slight manipulation may give instantaneous relief. Surgeons have been prone to suggest operative removal of the coccyx on account of suspicious fracture lines or a questionable dislocation. Mock reports that roentgenograms of the normal coccyx in large number of cases show all kinds of variations in the position; he advises that all cases should receive careful physical therapy before operative removal of the bone is
considered.
Thiele 24 reports that in practically all cases of coccygodynia spasm of the levator ani and coccygeus muscles can be accounted for as the cause of pain, while supragluteal pain and pain down the back of the thigh is caused by spasm of the pyriformis muscle. He found improvement in a 6 large percentage of cases by massage of the muscles involved. Duncan
reports on successful non-operative management, consisting of improving posture by having the patient sit erect and pull the buttocks in under the trunk hot sitz baths thirty minutes twice a day local massage and finally steady but firm stretching of the coccyx posteriorly, in order to
overcome spasticity and prevent adhesions. The author has had most satisfactory results
in a series of cases
by
diathermy applied with the technique described in Chapter XL In three to eight treatments the pain and discomfort disappeared and patients were enabled to sit comfortably for the first time in many months.
AFFECTIONS OF BONES AND JOINTS Osteomyelitis. The treatment of acute osteomyelitis is

gical
problem.
34
In chronic cases there
is
a strictly sura discharging sinus or more of
530
them, a sclerosing osteitis, induration of surrounding soft parts, atrophy of muscles and stiffness in neighboring joints. Penetrating heat will improve the blood and lymph supply and it also relieves pain. Short-wave diathermy by the inductance coil or air-spaced technique is especially suitable for deep heating, because it overcomes the handicap of irregular
bony surfaces or too extensive local processes preventing good electrode contact and position. On account of slow heating of bone a minimum of thirty-minute treatment periods are advisable. Luminous heat may be used simultaneously over the open sinus. Ultraviolet radiation should be used systematically in all cases for improving the blood picture and to assist in overcoming calcium deficiency. Deep and tortuous sinuses furnish one of the few indications for the use of the local ultraviolet irradiation with quartz rods, introduced gently
along the sinus tract for one to two minutes daily exposure. The results of treatment show in the lessening of the discharge and odor, the gradual improvement of the condition of soft tissues and the Dressing with a plain petrolatum pack after each filling-out of the sinus. treatment is usually satisfactory. Other physical measures for overcoming the muscular atrophy and the stiffness of joints should be instituted according to the circumstances. In tuberculous osteomyelitis ultraviolet radiation is indicated, together with general hygienic measures and rest. Physical therapy in osteomyelitis must be used only in conjunction with proper surgical and radiographic control. Long continued and recurrent inflammation and drainage are usually associated with unremoved sequestra. Tuberculosis of Bones and Joints. Joint tuberculosis must be considered as a local manifestation of a constitutional disease and in its; management heliotherapy or artificial light therapy is most valuable in conjunction with orthopaedic and general hygienic measures, as stated in Chapter XIX. Following non-surgical regime restoration of function may occur in the synovial form of joint tuberculosis even in the presence of
16 large effusions, according to Mayer. Light therapy cannot produce new to replace that which has been destroyed, but it will help orthocartilage
paedic treatment in fusing diseased surfaces especially when employed together with postural treatment. Surgical fusion and prolonged immo-
a procedure to be considered chiefly in advanced joint destrucopposed to any surgery except in unusual instances, and claims that radiation heals, while surgery destroys. In the invigorating mountain atmosphere combined treatment by immobilization and heliotherapy may indeed achieve exceptional results. While natural heliotherapy and the accompanying regime are most desirable, Mayer states that both mercury arc in quartz and carbon arc
bilization
is
tion. Rollier's school is
irradiations, employed as general and local exposures for prolonged periods of time, have proved aids in the treatment of bone and joint tuberculosis.
The technique
of irradiation is the same as that described with other forms of tuberculosis. With early exposures the joints or bones often respond with increase of the local swelling and pain and, if a sinus is present, increased secretion. These in turn subside. Small joints yield more quickly to treatment than large ones. The knee joint is refractory, and particularly obstinate are old fistulas of the spinal column, pelvis or hip.
Treatment demands two years or more
in
many
instances.
AFFECTIONS OF MUSCLES
531
AFFECTIONS OF MUSCLES
Acute Myositis. Acute myositis is characterized by an ache in the affected muscle, which is tender and is held rigid in order to prevent movement. It may follow exposure or a strain or it may come about in the course of an infectious condition, such as an attack of rheumatic fever. Pemberton attributes the condition to an alteration of the finer blood supply, as shown
by a rather immobile capillary bed, in a state resembling vasoconstriction and responding inadequately to stimulation. According to the present conception of the rheumatic syndrome both acute and chronic myositis belong in the group of fibrositis and the main points of their pathology, diagnosis and constitutional treatment have been presented in Chapter
XXVI.
Acute myositis has certain sites of predilection; among those are the shoulder, the lumbar region: lumbago, the intercostal muscles: pleurodynia, the posterior muscles of the neck: rheumatic torticollis. Local treatment in acute cases consists of the measures discussed under fibrositis, such as physiological rest and heat. This may be followed by gentle massage or the surging faradic current. If stiffness or spasm persist after such treatment surging faradism or a few static sparks usually help. This procedure, as a rule, effectively relieves both the pain and the spasm. Rest is essential during the acute stage. Chronic Myositis. In this condition the pain is duller and is particularly evident when the muscle is put into active use, while passive motion is usually free. In chronic cases this is an important differential diagnostic
sign
from
motion.
The
arthritic involvement, where as a rule there is pain on passive chief pathological characteristic of chronic myositis is the
tendency toward fibrosis. (See Chapter XXVI.) Inflammatory deposits form in the muscle, often near its tendon attachment and are demonstrable by definitely localized tender areas, with a palpable induration. Albee described this condition as myofascitis and considers it a local manifestation of a toxic condition.
The
treatment of chronic myositis
must
as a rule be planned
from the
constitutional standpoint as well as from the standpoint of specific local relief. Local treatment is directed to the removal of the inflammatory
products through the increase of circulation by luminous heat or diathermy and by mechanical measures: massage by hand, by the static-wave current and sparks or by graduated muscular contraction. These measures must be instituted in accordance with the individual reaction of patients. When the painful nodules are definitely located they must be manipulated or stretched and the patient must be informed that this may involve a great deal of discomfort and at times real pain. " " At times very prompt and impressive cures can be affected by manipulative procedures in freeing fibrous adhesions and moving joints through a range of motion, which the patient heretofore has not dared to attempt on account of the apprehension of the pain experienced in the acute stage. As a rule, however, long continued local as well as general measures are necessary until the patient is definitely relieved; even then he must be warned to watch out for the slightest evidence of a return of symptoms. In stubborn form of chronic myositis large doses of galvanism, with the negative pad as the active electrode have proven useful. In recent
532
years very good results have been reported by histamin-iontophoresis, with the technique described in Chapter VIII. Volkmann's Ischemic Contracture. Volkmann's ischemic contracture is a typical flexion contracture of the muscles of the fingers, wrist and forearm, described by Volkmann as a result of interference with the circulation in muscle cells from tight splinting with subsequent ischemia and ischemic necrosis. "Once established as an extensive degeneration and atrophy of muscle parenchyma, with fibrosis of the muscle-tendon stroma and secondary involvement of nerve trunks and joints it challenges the most expert attempts at reconstructive surgical treatment" (Ellis 7 ). Promptly recognized early stages of this condition may be benefited by gentle massage, active exercise in a warm whirlpool bath' and gentle traction by suitable devices. Even moderately intense heating is dangerous both in early and late stages on account of the existing trophic disturbance and the lack of temperature appreciation by the patient. The author has
seen fairly acceptable results in minor degrees of atrophy and fibrosis of forearm muscles in young adults by the systematic application of the whirlpool bath followed by graduated electrical muscular contractions and elastic traction splinting continued patiently over many months.
AFFECTIONS OF TENDONS AND BURStfl

Tenosynovitis. The tendon in a tendon sheath has been compared to an umbrella in an umbrella cover. Inflammation of a tendon sheath may follow a local infection, an infectious disease, but most frequently traumatism; the trauma may be one severe blow or multiple minimal strains or sprains; occupational tenosynovitis is due to habitual overuse of a tendon or group of tendons. Tenosynovitis generally affects the sheath more than the tendon itself; its presence is recognized by the patient at first not so much on account of pain which is usually slight, but because of the feeling of weakness when attempting to bring the tendon into use; a palpable and audible creaking (crepitus) may be noted when the tendon is active. The crepitus is due to a deposit of fibrin between the tendon and the walls
of the sheath; if, subsequently, effusion of any quantity takes place, a fusiform swelling becomes visible along the tendon and the crepitation ceases. In chronic cases especially when infection occurs, granulation tissue forms within the sheath, firm adhesions develop and interference with free action and marked pain results.
the ankle.
The tendons commonly affected are those of the wrist, thumb, and of The extensor muscles are more frequently involved than flexors.
Tenosynovitis of the long head of the biceps, as it passes through its sheath in the groove of the humeral head beneath the deltoid muscle, has been described as "golfer's" shoulder. "Trigger finger" is the term used to designate a chronic adhesive inflammation of one of the flexor tendons of the hand. Its usual location is where the tendon passes under the transverse ligament; due to the fibrous organization of a nodule there mechanical difficulty arises on flexion, the involved finger may become locked and on exertion to straighten it out it snaps like a trigger. Rest is the first consideration in the treatment of acute tenosynovitis. The activities which cause discomfort and pain should be avoided. Luminous heat for periods of one hour twice a day should be instituted at once
AFFECTIONS OF TENDONS AND BURSM
533
or else diathermy given by any suitable method for one-half hour daily. In cases which do not respond satisfactorily or which appear as severe cases from the beginning light splinting should be applied in the form of a removable moulded plaster-of-Paris splint or a supporting sling in case of the shoulder. Adhesive plaster strapping for fixation of ankle, fingers or
wrist-joint may be used, permitting short-wave diathermy to be applied through the dressing. Massage is usually not well tolerated at the begin-
ning.
chronic cases adhesions develop because of thoughtless habit Local heating by paraffin or whirlpool bath or by diathermy, followed by massage, will tend to soften and break up the inflammatory exudate, if not too densely contracted. Smart advises in all cases the early institution of graduated muscular contractions by electrical stimulation. Bursitis. Bursal sacs are found between a muscle or its tendon and bone, between two muscles or tendons or between the skin and some harder tissue. They enable movements with a minimum of friction where surfaces move upon another. Being of the same anatomical structure as tendon sheaths and joint cavities, bursse show the same pathological changes following trauma as infection. These changes have been classified in the
of immobilizing the parts for too long a period.
In
many
following stages: "1. Acute reactions with effusion or fibrin deposition beginning. "2. Fibrous adhesions forming and contracting, with associated fascial
and sometimes periarticular fibrosis in a contiguous joint. "3. Muscular atrophy. "4. Calcium and fat deposition in the bursa or obliterative
fibrosis."
Bursal inflammations as a rule gratefully respond to physical measures. Ellis 7 recommends for early local treatment heat, particularly diathermy and absolute rest of the part in a position relaxing pressure upon the affected bursa, also gentle massage up to the threshold of pain for the maintenance of muscle nutrition and for relaxation of spasm. Aspiration is indicated in the first stage as long as the bursa is markedly distended with fluid. In the second stage it is important to prevent fibrous adhesions in or around the bursa, hence while continuing diathermy, gentle manipulations and active stretching exercises are advisable. In the third stage when fibrosis and muscle atrophy have been established Ellis believes that forcible manipulation under gas is necessary, while graduated muscular stimulation initiates muscle retraining. In the last stage diathermy has an almost specific action in hastening resorption of calcium or amorphous fat desposits in the bursa. Wallace 27 stated that bursitis whether of infectious or traumatic origin, readily responds to physical therapy, consisting of early application of external heat and rest during the acute stage; later of diathermy. He recalls no case of bursitis during the past fourteen years that had not responded to such method of treatment.
Superficial Bursae. Superficial bursse are found in many locations under the skin where there is constant or repeated pressure, such as by shoes upon bony parts or deformities of the foot. Pain and swelling over a bunion is usually due to the inflammation of the adventitious bursa located there. Ellis states that inflamed superficial bursse can be operated upon after which large doses of diathermy, followed by compression bandaging, may result in their obliteration. In simpler forms of inflammation, immobiliza-
534

luminous heat
will often satis-
tion of the part and systematic exposure to factorily control the condition.
Deep
BUTSSB.
Deeper bursse are located under muscles
(as typified
by
the subdeltoid bursa), under tendons, fasciae or in the periarticular structures, and are often connected with a joint. When inflamed they are as a rule not palpable, but produce sharply circumscribed pain in typical locaNear the tions. Their non-recognition often leads to diagnostic errors.
shoulder are the coraco-acromial, subscapular and infraspinatus bursse; they rarely become inflamed, but if they do, the location of exquisitely tender areas differs from the characteristic local tenderness in subdeltoid bursitis. About the elbow are bursse under the insertion of the triceps and near the radio-humeral joints. The inflammation of the radio-humeral bursa has been already described as epicondylitis or "tennis elbow" in
this chapter.
The subdeltoid bursa is one of the largest in the body, about the size of a silver dollar. It is adherent to the inner surface of the deltoid and above to the undersurface of the acromion process and sometimes consists of two portions, subdeltoid and subacromial, which communicate. The bursa encircles almost one-half of the circumference of the humerus. There is still controversy as to whether subdeltoid bursitis is really the most common cause of shoulder disabilities, as claimed. In the European literature very little is said of subdeltoid bursitis, and the condition usually regarded as bursitis here is described as periarthritis of the shoulder (omarthritis). This term has now begun to be used in the American literature. Other authors attribute the entire symptom complex to subacromial The treatment of bursitis or calcification of the supraspinatus tendon. these conditions will be jointly discussed in the next section.
SHOULDER AFFECTIONS
of shoulder affections
the standpoint of physical therapy, the diagnosis and management is one of the most frequent problems. Among the reasons for the slow recovery and the painfulness of shoulder lesions many are the complex anatomical conditions, the intimate connection of many important structures and the lack of proper vascularization of the shoulder
joint. Excessive muscle spasm lesions. Systemic causes often
From
and radiating pain accompany even minor play an important role in the etiology and
contribute to delayed recovery. Table 58 shows the various types of painful shoulder affections, with the radiographic findings and points of differential diagnosis. It is evident that a correct diagnosis and the appreciation of the stage and severity of the pathological changes as well of their possible relation to systemic causes
are essential as a basis for instituting physical therapy as part of the therapeutic management. Traumatic lesions of the shoulder are comparatively frequent. The point of the shoulder projects well out from the side of the body, and for this reason it often suffers painful injury; because the head of the humerus moves in a shallow cup formed by an extension of the scapula, the shoulder
has less stability and protection than any other large joint. The tendons of the short rotators, the supraspinatus, the infraspinatus, the teres minor and the subscapularis muscles are actually fused with the capsule and
SHOULDER AFFECTIONS
The supraspinatus tendon forms the
535
play a relatively important part in maintaining the stability of the joint. floor of the subdeltoid bursa. The intimate connection of so many structures with the relatively unprotected joint leads to frequent multiple involvement in injuries, with subsequent muscle contracture and atrophy, and makes also for difficult diagnostic Codman 3 and his followers believe that rupture of the supraanalysis. tendon is the most frequent traumatic lesion of the shoulder and spinatus that the lesion in most cases of subdeltoid bursitis is in fact located in the supraspinatus tendon. Roentgenologically, however, it is possible to differentiate between calcified deposits in the supraspinatus tendon and those in the subdeltoid bursa.
TABLE
Diagnosis
58.
PAINFUL CONDITIONS OF THE SHOULDER

Clinical signs
Roentgenograms
Physical therapy
Contusion, sprain, dislocation, fracture
Vary with
injuries
Vary
Negative Negative
Indicated
Myositis, tenosynovitis
Tenderness of single muscles and spasm

Circumscribed tenderness; few degrees free abduction; spasm
Indicated
Acute
bursitis
Indicated
Bursitis with calcification
Same
Sensory disturbance tenderness of nerve trunks
;
Positive
Indicated
Brachial
neuritis
and
Negative
Indicated
radiculitis
Acute
tion)
arthritis
(infec-
Swelling; extreme tenderness; all motion restricted by pain; fever
First
negative
later
vary with degree of

destruction
Indicated at times
Chronic arthritis (traumatic,

tic,
Thickening; crepitus;
limitation of motion
Characteristic narrow-
Indicated
osteo-arthri-
ing of
Positive
rheumatoid)
Indefinite
space; lipping; deposits

joint
Neoplasm-gumma
Reflex pain
Vary
Negative
Contraindicated Indicated at times
The calcium deposits in the tendinous cuff which forms the capsule of the shoulder joint are recognized as potential sources of shoulder pain, but the origin of the deposits is still obscure. They are often found on roentgen-ray examination of shoulders in which symptoms are entirely absent. Bosworth 1 showed that among 6061 supposedly normal persons of the white collar class, calcium deposits were found about the shoulder in 2.7 per cent. This author reiterated the opinion of other surgeons that
a single trauma per se does not cause calcium deposition, although it is fluorooccasionally associated with the onset of bursitis; that, although visible calcium deposits may form within as short a period as scopically two months, most deposits require considerably longer for their formation,
and finally, that medium and tiny deposits may disappear without symptoms but large deposits result sooner or later in a painful shoulder. limitation Long-standing bursitis leading to adhesions and considerable 3 of motion has been described by Codman as tendinitis, or "frozen" conshoulder, and by other authors as obliterative bursitis. A similar tracture of the short rotators and their ligaments, however, may occur after any trauma or infection as well as after prolonged immobilization of
536
the

arm
at the side for
any cause.
Periarthritis or periarticular fibrositis
seems to be a more appropriate term for these conditions, although some clinicians apply these terms to all extra-articular disorders of the shoulder. In minor injuries or other acutely painful conditions, once the proper diagnosis has been established and appropriate surgical care is given, rest is the most important routine therapeutic measure. A sling which supports the elbow and takes the weight of the arm off the painful shoulder is of
An ice-bag or ice-cold compress applied to the swollen area immediately after an injury usually relieves pain; it also checks the flow of more blood from torn blood-vessels. After a day or two mild heat radiation should be employed to give comfort and speed up absorption of blood and lymph. In selected cases the use of an ethyl chloride spray followed by active motion may speed up return of motion. As soon as the acute pain is over and there is no complication demanding further rest for the injured shoulder, gentle massage and gradually increased exercise may be started. The intelligent use of these simple measures tends to reduce swelling, to prevent adhesions and to overcome stiffness.
great help.
is the most frequent cause of painful shoulder and it as a definite disease entity, although, for the reasons enumerated, clinically it often cannot be differentiated with certainty from lesions of other closely related shoulder structures. The cause of its inflam-
Subdeltoid bursitis
must be accepted
is usually repeated mild trauma associated with calcification; attacks of variable intensity lead to sudden and extreme disablement. How ever, there is also a primary acute bursitis without calcification which follows a single trauma or an infection. The sudden onset, localized tenderness, limitation of motion due to muscle spasm and the characteristic roentgen picture form the well known clinical picture of subdeltoid bursitis with calcification, acute or chronic. The generally employed physical treatment of acute subdeltoid bursitis
mation
r
with calcification consists of rest and support in as much abduction as can be secured. Suitably applied heating, especially diathermy, has come to be regarded as the chief stand-by for the relief of pain and muscle spasm. Diathermy is especially effective for the promotion of absorption of the calcareous deposit because of the deep hyperemia it produces. Its introduction some twenty years ago encouraged surgeons to give up the routine advocated by Brickner 2 of operating and cleaning out the bursa. In the acute stage of bursitis the application of radiant heat is often the only measure the patient can tolerate; a small lamp of 150 to 200 watts is used for one-half hour to one hour several times a day. The patient should be kept in bed; the use of sedative drugs may be necessary for a few days to insure rest and sleep. In rare instances any form of heating aggravates the symptoms. In these cases the placing of wet ice packs over the shoulder for the first twenty-four to forty-eight hours with the joint at absolute rest gives the patient much needed relief. The injection of 5 to 10 cc. of 2 per cent procaine hydrochloride solution into the bursal sac frequently aids in ameliorating acute symptoms and histamine ion transfer to the shoulder is often helpful. After the acute stage careful application of diathermy can begin; in cases in which the onset is less acute it should be started at once. The use of air-spaced plates or of a treatment drum enables one to avoid the slightest pressure on the tender tissues and to keep the amount of heat
SHOULDER AFFECTIONS
down
537
to a comfortable minimum. Half-hour treatments are administered twice daily or even oftener. As the tenderness subsides, use of diathermy may be continued by the long wave or by the "contact plate" short-wave method, because it permits exact localization of the diathermic heat and eliminates the scattering of energy and the needless heating of adjacent tissues which occur with condenser pads or an inductance coil. One semi-
FIG. 304.
Absorption of
calcified deposit in subdeltoid
bursa during course of diathermy.
is placed above the prominence of the shoulder and the other across the middle of the upper arm. Later, after the bursa has become less tender, the electrodes may be applied to each side of the deltoid muscle in a position slightly tilted forward or in any position in which they include
cuff electrode
the location of the deposit. Treatments of forty-five minutes to one hour in duration are given first daily, then every other day. The clinical results
538
in my experience and in that of a number of my colleagues appear distinctly 25 superior with this technique. Troedsson in a carefully observed series of cases found the routine anteroposterior technique more effective for the absorption of calcified deposits than the longitudinal technique. Marked neuralgic pain along the arm can often be relieved by a mild application
monoterminal high-frequency (Oudin) current. A certain amount motion should be encouraged from the start to prevent the formation of adhesions and to minimize the secondary contracture of the adductors. Massage or ,any other form of manipulation as employed by the
of the
of active
average operator usually aggravates acute conditions. In some cases, especially when the patient is a nervous irritable woman, after the subsidence of the local tenderness severe neuralgic pains persist, disturbing the patient's sleep and making her and everybody around her miserable. In these cases in my experience mecholyl ion transfer, applied with the routine technique of asbestos paper saturated with a 0.5 per cent solution and wrapped around the painful area, has frequently given excellent results. The electrode foil or metal plate placed over the saturated paper is connected to the positive pole, while a dispersive electrode placed under the lower part of the back is connected to the negative pole. It is difficult to determine whether the relief obtained is due to the effect on the local circulation or to the mild counterirritation. Suspected foci of infection should be attended to in all cases after the passing of the acute stage. According to the extent of the symptoms and the size of the calcification, it may take from two to eight weeks of treatment before all clinical symptoms subside and the calcified deposit gradually disappears, as shown by successive roentgenograms. Because of the undoubted length and expense of this course, irrigation of the bursa and "needling" the deposit itself by multiple punctures have been advocated for acute cases. It is claimed that through the puncture holes the calcareous material on the floor of the bursa is liberated into the bursa, relieving the tension, while the increased vascularization following the trauma promotes absorption. The author has had no first hand experience with this procedure, and so far no comparative statistical evaluation has been published. In chronic bursitis, in which chronic periarthritis brings about painful adhesions and stiffness, a systematic course of diathermy is logical as the first line of attack, but it must be combined with systematic exercises, such as wall climbing or circumduction. This may be followed by mild stretching. (Figs. 274 to 278.) Only if such a regimen proves ineffectual should manipulation under anesthesia or operative excision of the bursa be considered. Bosworth recommended that in all cases of calcification large deposits be excised, regardless of symptoms, to forestall the development of an acute attack of bursitis. He confessed, however, that no patient had yet been willing to have this done. Excision of a bursa is a procedure which means hospitalization, with its attendant expense, plus the time required for healing of the operative wound and the resultant scar; manipulation under anesthesia must be also followed by a period of suspension and traction plus prolonged physical therapy. Hence, the routine of systematic conservative therapy seems generally preferable. The results of roentgen therapy in the treatment of subdeltoid bursitis have been compared with those of short-wave diathermy by Solomon
and Morton. 23
Both methods appeared capable
of securing relief in a
SHOULDER AFFECTIONS
large percentage of cases in a relatively short time,
identical.
539
and the
results
were
The diathermy technique employed by
of an inductance coil applied for a maximum times a week. Perhaps with the more efficient technique described previously the results of diathermy would have been still better. So far as the
these authors consisted of twenty minutes three
saving of time is concerned, no advantage has been claimed for either procedure. Rupture of the supraspinatus tendon as a cause of an acutely painful shoulder may as a rule be recognized by the rather violent trauma preceding it and the immediate inability to abduct the arm. It is most frequent in laborers. The question of suturing must be decided by the surgeon. In the after-treatment, physical therapy is applied on the same principles as in bursitis. Many patients with undoubted partial recover rupture
fully
with conservative treatment.

Calcification of the supraspinatus tendon may cause pain, spasm and limitation of motion similar to those in acute bursitis. Suitable roentgenograms taken in several planes will locate the deposits. The same physical therapy routine is applicable as in calcified bursitis. Dick and Hunt 4 cor-
roborated the value of diathermy in this condition; in addition, they recommended large doses of ammonium chloride for producing mild acidosis, which tends to cause absorption of deposits. Arthritic involvement of the shoulder is comparatively infrequent but must always receive diagnostic consideration. Synovitis or acute arthritis occurs after trauma or an acute infection and responds to the measures recommended for acutely painful conditions. Pyogenic infection is a surgical problem. Chronic arthritis, osteo-arthritic or atrophic, is usually part of a general arthritic condition in which more than one joint is involved. Traumatic arthritis may also occur in some instances. Physical treatment, local as well as systemic, forms an essential part of the treatment. Tuberculosis of the joint is insidious in onset and can be differentiated only by the characteristic roentgen findings. Its treatment requires a general regimen of rest and heliotherapy. Gonorrheal arthritis of the shoulder is rare. In all conditions of joint involvement, studies of an infective aspect are essential to appropriate treatment. Non-articular "rheumatism" about the shoulder includes bursitis and myositis, acute or chronic, in one or more muscles, following exposure or infection. Various forms of nerve lesions also belong to this classification;
these are neuralgias, as already described, and typical neuritis and radiculitis. Root pressure from arthritic deposits in the cervical and upper dorsal part of the spine appears to be a more frequent cause of such shoulder
pain than focal infection (the role of which has been much overemphasized in years past). The author 13 showed some years ago in a series of 151 cases of involvement of the shoulder that focal infection played a minor role in the causation. More attention has been given recently to the cervicobrachial syndrome (Naffziger and Grant, 18 Hansson 11 ) as a cause of pain and other symptoms in the shoulder and upper part of the arm. Physical therapeutic measures in the form of heat, suitable exercise and mild counterirritation should serve as useful adjuncts in the management of
most of these conditions. The success or failure
of certain physical measures
offer at times valuable differential diagnostic evidence, corroborating for instance the diagnosis of simple myositis or fibrositis.
may
540
Finally, mention must be made of well known instances of shoulder pain due to a reflex from a cardiac or gall-bladder condition, and there also occur instances of more obscure pain due to a new growth or gum ma somewhere in or near the structures of the shoulder. A complete diagnosticcheck-up and continued observation are the only safe means of recognizing and appropriately managing these rarer conditions. The accompanying table shows the classification of all painful shoulder conditions and some
of the diagnostic aspects.
MISCELLANEOUS SURGICAL CONDITIONS

Adenitis. Primary adenitis in both children and adults often shows favorable response to light therapy, especially adenitis of tuberculous nature. In hard enlarged glands, a combination of local and general .ultraviolet
advisable.
irradiation, preceded by local application of luminous heat, is The latter is applied for one-half hour to the glands, followed
by general
local ultraviolet
ultraviolet in increasing dosage, three times weekly; finally is applied in third-degree erythema dosage, repeated when
Irradiation from an efficient carbon arc source the reaction subsides. may be often preferable. This course of treatment usually requires several weeks before the glands are reduced in size. At times additional roentgenray radiation may be advisable. If the glands have broken down, they must be drained and general ultraviolet irradiation, possibly combined with local radiation through a quartz applicator, be continued. Ulcerated and deep-seated glands with sinuses call for intense and protracted radiation and skilful surgical treatment. Burns. The explosive and incendiary agents of modern warfare are producing a very large proportion of burns among casualties. The primary treatment in all cases of extensive burns (10 per cent or more of the body surface) is prevention or limitation of shock by injection of morphine and the administration of fluids whole blood, blood plasma or saline solution. The previous teaching of applying external heat to severely shocked patients is now questioned on the basis that cutaneous vasodilatation causes peripheral accumulation of blood and thus contributes to circulatory
collapse.
There is no universal agreement as to the best method of immediate treatment except that the application of some form of coagulating agent appears to be the most practical type of treatment. The National Research Council recommends for immediate application to all parts of the body other than the face, hands and genitalia, a water-soluble jelly containing 10 per cent tannic acid and 5 per cent sulfadiazine, or, in the absence of such a preparation, tannic acid ointment. A sterile gauze covering should be used over the injured parts. In the later stages of treatment a heat
local
tent or, in cases of extensive burns, a thermostatically controlled saline
bath
may
all
be employed.
sloughs have disappeared and the
After
wound
is
cleanly granulating,
be employed to promote regeneration or to the field for skin grafting. One has to be careful to apply minimal prepare dosage only because the newly formed epithelium is very sensitive to the short ultraviolet rays. The burn is cleansed and covered with a film of thin paraffine; ultraviolet irradiation from a mercury vapor lamp is given
ultraviolet irradiation
may
FOOT CONDITIONS
with a
daily.
first
541
degree erythema dose (two minutes at 30 inches) and repeated film of paraffine acts as a filter to keep off the short ultraviolet rays (below 2400 Angstroms) and serves as an innocuous dressing between treatments. If the lesion is markedly infected, a 50 per cent, heavier dose is given in the first treatment and the milder dosage continued. It is important that in the stage of healing the development of contractures be minimized by active and passive motion and early massage and that this treatment be kept up for a sufficiently long period. Small burns can be treated with the water-cooled ultraviolet or thin window lamp in first degree erythema doses, preferably through a thin These lesions can be kept dressed with plain gauze paraffine covering. pads soaked in paraffine and the irradiation repeated daily. Scars. Light superficial scars may be subjected to the softening effect of the negative pole of the galvanic current, which makes them more amenable to subsequent mechanical stretching by massage. The procedure
The
is known as chlorine ion transfer and its general principles have been described in Chapter VIII. An active electrode corresponding in size to the scar is made of twelve to fifteen layers of gauze, is soaked with 2 per cent common salt solution; on it is placed a metal electrode of somewhat smaller size and connected to the negative pole. The large dispersive pad may be laid over any convenient part and is connected to the positive pole. The current strength depends on the size of the active electrode; it may amount anywhere from 2 to 20 milliamperes. Beneath the active electrode sodium hydroxide is formed, and being mildly caustic its prolonged action The current strength must be always within softens light scar tissue. comfortable toleration of the patient. On account of the frequency of
sensory disturbance over scars, it is necessary to proceed most carefully. Excessive current density over scars may cause burns leading to slow healing ulcers; if during treatment the patient cannot exactly state whether there is any burning sensation or not, one should turn off the current and inspect the site of the active electrode. Marked reddening in a circumscribed area is a sign of excessive current density and indicates the danger of a burn. The average treatment should last from one-half to one hour.
FOOT CONDITIONS*
The treatment
of physical therapy.
of foot disorders offers a vast field for the application To neglect physical measures in this work is to
overlook an excellent means of bringing relief in many conditions. The common weak foot, with its tendency to pronate, requires orthopedic care for its correction. Proper exercise designed to relax the peroneal muscles is of great assistance, and can be kept simple and easy. Gentle low-frequency sinusoidal stimulation is also helpful, and can be easily administered with the patient seated and each foot placed on a separate
pad on the
floor.
Many
foot ailments, as well as complaints of remote distress, can be
traced to the syndrome of tight posterior muscle groups of the legs. Foot examination should always include a test of these muscles. If found
* This section was kindly contributed by Jerome Weiss, M.D., Attending Physical TheraHospital for Joint Diseases, New York, and Assistant Professor of Orthopedics, Long Island Medical College Hospital, Brooklyn.
pist,
542

tight, suitable exercise
abnormally
must be taught the patient
to secure
relaxation of the muscles.
The treatment
and
is
of calcaneal
is
frequently operation
relief of
symptoms
and other spurs is of course surgical. But contraindicated or is undesirable for some reason, must be sought otherwise. Here physical therapy
of the greatest value. Diathermy carefully applied will usually afford complete relief of symptoms, although it will in no way change the appear-
ance of the spurs on roentgen-ray examination. Reduction of inflammation and relief of the bursitis is accomplished, with resultant disappearance of pain and disability. This explanation is logical when we consider the patient who complains of a painful heel of two weeks' duration, and on roentgen-ray examination shows a calcaneal spur which was certainly many months in developing. Occasionally no pain is felt until a spur is
fractured.
For treatment
of the calcaneal spur, either plantar or posterior, long-
wave diathermy may be applied by the transverse or by the longitudinal method with equal facility. For the posterior spur it is better not to
attempt application of the diathermy plate directly over the site, as it is obtain good contact. Short-wave diathermy may be used in the treatment of spurs, but if possible contact electrodes with an ammeter Ion transfer with histamine or mecholyl has also in series should be used. been used successfully in the treatment of painful spurs. Hallux valgus, or bunion, is another condition which calls for orthopedic correction, either by operation or splinting. Proper shoes must also be In this painful condition prescribed or all attempts at relief will fail.
difficult to
diathermy properly applied will frequently give complete relief of symptoms, though here again the roentgen-ray findings will remain unchanged. However, unlike the case of spurs which usually shows little or no disturbance externally, the clinical picture of the hallux valgus case is decidedly improved following successful therapy. Inflammation disappears, movement of the joint is improved, and masses which were apparently bony soften and flatten out. Diathermy may easily be applied to a bunion by means of small plates above and below the joint, firmly fastened to assure good contact. Attempts to cup a plate over the bunion should be avoided, as this method is painful and usually is less satisfactory. An excellent method of applying the diathermy current in a case of hallux valgus, though one which is a little more troublesome, is by use of a rubber glove as a shield for the foot and a dish of saline for contact. The thumb is cut off an old surgical rubber glove, which is then slipped over the foot so that the great toe protrudes through the hole left by the loss of the thumb. The glove is drawn well up on the foot so that the metatarsus is covered. A metal cuff is applied above the ankle, and the foot is placed in a dish of saline so that the toes are immersed. Care must be taken that the upper edge of the rubber glove is above the surface to avoid short circuit of the current. A strip of metal clipped to the side of the dish contacts the saline and completes the circuit. In using this method we are assured that the diathermy current is directed through the inflamed joint and bursse, with no danger of slipping plates. A small current loss will occur by displacement through the rubber, but this will remain very low because of the slight difference of potential. Short-wave diathermy may also be used in the treatment of hallux valgus,
FOOT CONDITIONS
543
but here again the use of contact electrodes and the series ammeter are preferred. Iontophoresis using histamine or mecholyl also has given very favorable results in the treatment of this distressing condition. Superficial infections of the foot are particularly amenable to treatment with ultraviolet light, more so to the shorter wave-lengths found in the cold quartz lamps. Possibly this is due to the fact that the infecting organisms had found their best environment in the darkness and diminished air supply of the leather shoe. The use of cold quartz therapy should always be an adjunct to the treatment of infections of the foot and their causative pathology, such as ingrowing toe nail. Surgical diathermy finds excellent application in the treatment of benign but disabling neoplasms of the foot. Plantar helomata and verrucse respond well to both monopolar and bipolar treatment. Care must be taken to avoid development of painful scars, though the danger of this mishap is less when using the diathermy methods than it is following surgical excision. The galvanic current has also been used in the treatment of plantar warts, but this method now has few followers. The use of copper iontophoresis in the treatment of fungus infections,
as described elsewhere, constitutes a valuable aid to the control of this obstinate condition. In the treatment of circulatory disorders of the feet passive vascular exercise has proved to be of the greatest assistance. It has materially improved the prognosis in cases of frostbite, arteriosclerosis and Buerger's
disease.
Apparatus for administering passive vascular exercise has been greatly improved to supplement the original simple exercise introduced by Buerger. The thermostatically controlled baker is an example of the modern efficient aids for restoring circulation to the feet in vascular dis(See also Chapter XXIV.) Painful bursitis may occur at many points of the foot, either in conjunction with a spur or hallux valgus, or independently of any such condition. Here we have the choice of two excellent methods of treatment,
orders.
diathermy and iontophoresis. Care must be taken that the affected bursa receives the full benefit of the application, without excessive by-pass
through the surrounding
tissues.
Arthritis involving the numerous joints of the foot is of particular interest because of its obstinacy and disabling nature. Physical therapy is a
particularly valuable adjunct to the treatment of arthritis of the foot. Treatment of the arthritis which usually complicates a hallux valgus has
already been described. At the correct stages diathermy and iontophoresis
Gonorrheal arthritis an extremely painful complication which responds in a most gratifying manner to the use of diathermy. This may be applied even in the acute stage, but great care must be observed in the application of the electrodes because of the severe pain on movement. Here the use of short-wave diathermy with condenser electrodes will eliminate much manipulation
find excellent application for arthritic involvement.
is
otherwise unavoidable. In many types of arthritis involving the foot the use of histamine or mecholyl by iontophoresis either alone or alternated with diathermy treatment should be considered. In tuberculosis of any structure of the foot, as elsewhere in the body, the use of ultraviolet light, both local and general, is indicated.
544
REFERENCES
1.
BOSWORTH, BOARDMAN MARCH:

acromial Bursitis:
2477, 1941.
Calcium Deposits
in the
Shoulder and SubAssn., 116,
Survey
of 12,122 Shoulders, Jour.
Am. Med.
2.
BRICKNER, WALTER M.:

ment, Internat.
Certain Affections of the Shoulder and Their Manage-
Clin., vol. 11, series 34, 1924.
3. 4.
CODMAN, E.
A.:
The
Shoulder, Boston,
Thomas Todd Company,
1934.
5.
DICK, G. F., HUNT, L. W., and FERRY, J. L.: Calcification of the Supraspinatus Tendon, Jour. Am. Med. Assn., 116, 1202, 1941. DICKSON, F. D.: Physical Therapy in Treatment of Fractures, Jour. Am. Med.
6.
7.
DUNCAN, G.
Assn., Ill, 1016-1019, 1938. A.: Painful Coccyx, Arch. Surg., 14, 1088-1104, 1937. Principles of Physical Treatment of the Muscle-tendon System, Bursse, in Principles and Practice of Physical Therapy, Hagerstown, W. E. Prior & Co., vol. 2, Chap. 6.
ELLIS, J. D.:
Tendon Sheaths and

8.
EWERHARDT,
F. H.
The Treatment
of Athletic Injuries, Surg. Clin.
North America,
20, 1439-1453, 1940.
The Use of Ultraviolet Light in the Preparation of Infected Granulation Tissue for Skin Grafting, Surg., Gynec. and Obst., 50, 478, 1930. The Cervico-brachial Syndrome, Arch. Phys. Ther., 22, 662, 10. HANSSON, K. G.:
9.
GATCH, W. D., and TRUSLER, H. M.:
1941.
11.
HANSSON, K.
G., and NORWICH, Assn., 94, 1557, 1930.

J.
I.
D.:
Epicondylitis Humeri, Jour.
Am. Med.
12, 9,
12.
KEY,
ALBERT:
Traumatic
Arthritis, Arch. Phys. Ther.,
X-r&y and Rad.,
1931.
13.
14.
15.
KOVACS, R.: Painful Shoulder Conditions, Phys. Ther., 44, 2, 1926. KRUSEN, F. H.: Physical Medicine, Philadelphia and London, W. B. Saunders Company, pp. 737-758, 1941. LAQUERRIERE, A.: Reflexions sur quelques observations a'entorses traitees par la
faradisation, Jour, de radiol., 21, 8, 1927.
16.
17.
MAYER, EDGAR: Light Therapy and Roentgen Therapy in Tuberculosis, Jour. Am. Med. Assn., 105, 20, 1935. MURRAY, CLAY, RAY: Immediate and Early Physical Therapy in Fracture Management, Arch. Phys. Ther., 19, 74-78, 1938. NAFFZIGER, H. C., and GRANT, W. T.: Neuritis of the Brachial Plexus, Mechanical in Origin, the Scalenus Syndrome, Surg., Gynec. and Obst., 67, 722, 1938. RACUGNO, L.: Influence of Ultraviolet Rays on Bone Callus, Minerva med., 31,
75-79, 1940.
18.
19.
20.
SCHAUFFLER, R.:
Jour.
Disabling Back Pain:
Differential Diagnosis
and Treatment,
Assn., 95, 1717, 1930. 21. SHANDS, A. R., JR.: Handbook of Orthopedic Surgery, St. Louis, C. V. Mosby Company, p. 443, 1940. 22. SMART, MORTON: The Principles of Treatment of Muscles and Joints by Graduated Muscular Contractions, London, Oxford University Press, 1930. 23. SOLOMON, W. M., and MORTON, J. L.: Periarthritis of the Shoulder: Comparison
Am. Med.
Obtained by Physical Therapy and by Roentgen Therapy, Arch. Phys. Ther., 22, 607, 1941. 24. THIELE, G. H.: Coccygodynia, Jour. Am. Med. Assn., 109, 16, 1937. 25. TROEDSSON, B. S.: Diathermy in Subacromial Bursa and Supraspinatus Tendon Calcification, Arch. Phys. Ther., 19, 166, 1938. 26. VOSHELL, ALLEN' F.: Delayed Union in Fractures, Arch. Phys. Ther., 18, 561-564,
of Results
1937.
27.
28.
WALLACE, CHARLTON:
Painful Shoulder,
New York
Injuries,
WENTWORTH,
E. T.:
Bed Rest
for
Back
New York
State Jour. Med., 33, 1, 1933. State Jour. Med.,
17, 1914-1918, 1937.
CHAPTER XXX
General Rules of Technique. Electrodes. Pelvic Heating by Non-electrical Methods. Inflammatory Conditions. Gonorrheal Cervicitis and Urethritis. Pelvic Inflammations. Chronic Endocervicitis. Infantile Uterus With Stenosis of Non-inflammatory Conditions.
by Diathermy.
Pelvic Heating
Cervix. Amenorrhea. Surface Growths.
Sterility.
Dysmenorrhea.
Menopausal Syndromes.
Minor
General Considerations. Physical measures serve as important adjuncts treatment of conditions peculiar to women in the hands of the physician who can make a correct gynecological diagnosis and who has training and experience in using these measures. Local infections of the female genital tract form the largest group of conditions amenable to treatment by physical measures. In gonorrheal and postpartum infections, endocervicitis and pelvic inflammations, electrothermal and electrochemical measures serve to relieve pain, to overcome the infection and to speed up the resorption of the products of inflammation. External heat is employed in the form of hot baths, hot irrigations, infrared radiation, "baking" by dry heat and heat lamps. Long- and short-wave diathermy serve as methods of penetrating heat in controllable Artificial fever treatment makes possible the intensity and location. efficient and rapid combating of all forms of gonorrheal infections resistant
in the
to chemotherapy.
The galvanic current in the form of copper and zinc ionization has been used for many years for its germicidal and mild coagulative effects upon the more superficial forms of chronic infections. Recently good results with pelvic iontophoresis by vasodilating drugs have been reported. Negative galvanism serves to soften and gradually dilate the cervix in congenital and acquired stenosis. Low-tension wave currents are useful in developing the musculature of an infantile uterus and in toning-up and strengthening relaxed pelvic muscles after childbirth and after plastic operations. There is a large field for electrosurgical application in gynecological conditions. The ready accessibility of the female genital tract lends itself to the comparatively easy yet thorough destruction of surface growths and to the destruction of diseased epithelial lining in the cervix by electrosurgical methods. The choice of method is the task of the expert gynecologist
and operator. patient as a whole has to be considered in gynecology even more than in other departments of medicine. Here again physical measures in the form of ultraviolet irradiation, light cabinet baths, massage and corrective exercise offer valuable help for amelioration of a temporary
The
anemia, a functional nervous disorder, an asthenic constitution or postural imbalance.
must be
General Rules of Technique. Electrical applications in gynecology carried out under the same rules of asepsis as any other gynecological examination or instrumentation. The hands of the operator must be scrubbed and preferably covered with rubber gloves. Specula and some
35
(545)
546
of the metal
and glass instruments are boiled. Electrodes which cannot be subjected to boiling can be sterilized over a flame. After use each instrument should be cleansed immediately of mucus and pus by wiping and then held under running cold water. Mucus is soluble in water but if heat or bichloride is used the mucus coagulates and will stick to the instrument. Next, the instrument is thoroughly washed with soap and hot water and then boiled if possible or put in a compound solution of cresol for ten to fifteen minutes. Before the instrument is used again it must be well dried with clean gauze. The vaginal walls, cervical canal and urethral meatus should be swabbed It is possible and preferable to free from secretions before treatment. insert the cervical electrode without using traction forceps on the cervix. As both the cervix and the vagina are relatively insensitive to heat or to chemical action, with every intra-vaginal application carried to excess, there is danger of a sloughing burn without any warning complaint on the part of the patient. It is advisable, therefore, to keep a record of the dosage administered at each treatment and to make an inspection through a speculum prior to each application.
FIG. 305.
Vaginal electrode with thermometer.
(Courtesy of the General Electric Corp.)
Electrodes. Transpelvic (abdomino-sacral) forms of treatment are applied with electrodes placed over the abdomen and under the sacrum. Other forms of treatment call for the use of an active electrode within the genitalia or in the rectum and that of a dispersive electrode on the outside.
(Figs. 306-308.)
The
of metal of a shape
active electrodes for gynecological applications are usually made and size to conform with the urethra, cervix or vagina
and are mounted on an insulated handle. Galvanic and low-frequency currents exert ionizing effects around a metal electrode no matter to which pole it is connected. While it is true that metallic ions are only
diffused
when the electrode is connected to the positive pole, nevertheless the nascent sodium ions around the negative pole attack the metallic coating of the electrode also and take away its smooth and bright appearance.
Carbon-tip intravaginal electrodes have been recommended to this. For the routine reamalgamation of copper or metal electrodes with mercury, one can use the solution of Derow, consisting of J pure nitric acid and J of water, to which a few drops of metallic mercury are added. The electrode is dipped in this solution before each treatment and becomes sterile and its surface smooth. For non-ionizing currents diathermy and the static current the same electrodes or simple nickel-plated electrodes may be employed. Any metal sound of suitable size, insulated over the portion which is in contact with parts not to be heated can be used for applying diathermy to the urethra and cervix. Specially constructed electrodes with arrangement for ther-
overcome
PELVIC HEATING BY DIATHERMY
547
mometry are also available. The principal part of these is a thin-walled metal tube mounted in an insulating hard rubber tube; the first tube contains the thermometer; if its tip is inserted into the urethra or cervix
the thermometer shows an approximately correct reading of the temperature of the parts immediately around the metal
tip.
Corbus and O'Conor5 is the best known universal diathermy electrode for thermometric purposes. It is available in three sizes, fitting the cervix of either a nullipara or a multipara and the urethra,
of
The thermophore
respectively.
The pelvic diathermy electrode of Zener consists of a hard rubber vaginal speculum of the Ferguson type, fitted with four similarly curved blades. The two outer vaginal blades may be expanded laterally so as to conform to the vaginal fornix and cul-de-sac; the two cervical contracting blades
against the cervix. It is claimed that this electrode enables the passage of a larger current directly through the body of the uterus and the adnexal regions and that a thermometer passed through it in the cervical canal showed that cervical temperatures of 110 F. may be maintained if desired.
fit
The same electrodes can be used as active electrodes for both long-wave and short-wave diathermy; glass insulated electrodes recommended abroad for short-wave diathermy have not been found satisfactory. As dispersive electrodes, for galvanic and other low-tension and lowfrequency treatments, moist pad electrodes of suitable size are used. For
diathermy, plain metal electrodes of similar size or a belt electrode encircling the pelvis may be used. For short-wave diathermy large size condenser pads with suitable spacing serve as dispersive electrodes. A belt electrode has been recommended as a dispersive electrode in all intravaginal, cervical, urethral or rectal treatments, with the reasoning that it would insure an even distribution of current all around the active electrode. An electrical current has always the tendency to complete its circuit along the shortest path; as there is bound to be a difference in the distance either anteriorly or posteriorly, from the active electrode to the belt, the main part of the current will travel, as a rule, along whichever path is the shortest one. In copper ionization of the cervix, when a single dispersive pad is applied either over the abdomen or under the back, an even ring of green discoloration will occur in either case all around the cervix, proving that in the immediate vicinity of the active electrode the current distribution is fairly equal. It is usually sufficient, therefore, to use a metal plate, 3 by 5 inches or larger, as a dispersive electrode and place it either just above the symphysis or under the sacrum; there is no objection to placing an electrode over each location and connecting both to one terminal of the apparatus. Pelvic Heating by Diathermy. One can treat all pelvic organs en masse by the abdomino-sacral or transpelvic technique; each organ can be treated individually, using special electrodes in the interior of the pelvis in close proximity to the part to be treated. The latter technique produces localized heat of a definitely known degree, and it is, therefore, more
efficient
and more generally employed. Transpelvic (Abdomino-sacral) Diathermy. This technique is indicated in inflammations of the entire pelvic contents or whenever it is imprac-
ticable to apply the more efficient vaginal or rectal method. The patient lies on her back; for long-wave diathermy or short-wave by the contact
548
plate method the sacrum rests on a plate, 4 inches wide and 5 inches long. If there is a hollow under the lumbar spine a flat sandbag or folded towel will be needed to secure firm contact under the sacral electrode. The other electrode about 3 by 4 inches in size is placed just above the symphysis and is secured in place by a small sandbag. larger electrode is used in the back because most patients are quite sensitive to heat there; the reason
is most likely the limited amount of collateral circulation over the bony sacrum to take away excess heat and the additional anemia caused by the weight of the body pressing upon the plate. Hence it is safer to produce less local heat under the posterior electrode. About 1000 to 1200 milliamperes can be comfortably applied by this method and the treatment is to be kept up for twenty-five to thirty minutes. Short-wave diathermy to the pelvic contents can be applied by the
for this
method with two suitably spaced condenser plates placed long-wave method just described; the other more used method is the electromagnetic field method, with a pancake generally coil over the lower abdomen, with the interposition of suitable spacingelectric field
similarly as in the
several thicknesses of bath toweling
according to the output of the
apparatus.
FIG. 306
FIG. 307
FIG. 306. Transpelvic (abdomiiio-sacral) diathermy, tribution do not form a straight line. FIG. 307. Abdomino-vaginal diathermy.
Actually the lines of current dis-
K vaginal elecVaginal (Abdomino-vaginal or Intravaginal) Diathermy trode of suitable size and shape, usually cylindrical, is placed directly against the cervix and cul-de-sac, and a metal belt electrode is placed around the hips, or one plate electrode is applied above the symphysis and connected to the other terminal. (Fig. 307.) The vaginal electrode being smaller, serves as the active electrode and, through its close contact with the internal genitalia enables the production of intense local heating. The electrode may be all metal or it may consist of a blunt metal cylinder, usually with suitable depression for the cervix, mounted on a hard rubber shaft. A terminal on the latter serves for the attachment of the cord. The vaginal electrode may be safely held in position by a few sandbags of suitable size, between the flexed thighs of the patient.
.
PELVIC HEATING BY NON-ELECTRICAL METHODS

The employment
tribution of heat in
549
all
of a vaginal electrode enables the fairly even disdirections around the cervix. About 1000 to 1500
milliamperes can be applied, and usually all that the patient feels is mild heat under the belt electrode. If the contact is poor there may be some
faradic sensation.
The
cervix itself
is
not sensitive to heat and the mucous
membrane
vagina offers very little resistance, hence the necessity to watch the milliammeter for any sudden rise, which would indicate some interference with the circulation and danger of local electrocoagulation. The maximum heat is developed in the parts next to the metal end. The intravaginal technique is principally used for treating diseased
tubes, ovaries and parametria, and Cumberbatch suggested the term of general pelvic diathermy for it. The vaginal electrode with a thermometer allows a fairly accurate estimate of the heat produced around the electrode.
of the
FIG. 308.
Abdomino-rectal diathermy.
insulated stem
A. cylindrical electrode on an Rectal or Abdomino-rectal Diathermy. is inserted into the rectum as the active electrode, while a
plate, 4 by 5 inches, placed above the symphysis serves as a dispersive electrode. The patient resting on her back, the rectal electrode, well lubricated, is inserted by a gentle turning motion and held in position by
a sandbag. The dispersive electrode is held by a sandbag. About 500 to 1000 milliamperes can be comfortably tolerated, depending upon the size of the rectal electrode and on the sensitivity of the patient. This technique may be used as an alternate method for applying diathermy to the body of the uterus and to the adnexa and pelvic supporting tissues. It is less effective, however, than the vaginal method. Pelvic Heating by Non-electrical Methods. The hot douche is a timehonored, inexpensive method conveying heat to the pelvic organs. In order to be effective it must be administered in the lying-down position, from a douche bag hung at a height about 2 feet above the pelvis, at a slow rate of flow, for at least thirty to forty-five minutes and a water temperature from 98 to 110, depending on the pathology and the patient's sensitiveness. It may be best taken in the bathtub, if the bathroom is not too cold or the patient is covered with blankets in the tub or on the edge of the bed the patient lying relaxed on a douche pan or on a piece
550
of oilcloth the lower
end of which is rolled into a conical spout, that leads into a slop pail. The douche is preferably taken at bedtime or when complete rest for the relaxed organs can be assured. It can be employed as
a home treatment for pelvic pain and inflammation; addition of sodium bicarbonate will help to dissolve mucus and allay itching, as well as to neutralize acidity. The chief problem in effectively using the douche is that patients learn to control the flow of water, relax properly and take the douches long enough and regularly daily or three times a week as indicated.
BAG
TEMPERATURE
PRESSURE
CONTROL
THERMOMETER
GAUGE
SWITCH
APPLICATOR
PRESSURE BULB
FIG. 309.
Device for superheated
air
treatment of pelvic contents.
(Newman.)
is
The
Elliot treatment regulator, described
in
Chapter
XX,
in fact a
dry douche, given for forty-five to sixty minutes, at a temperature gradually increased to around 128 F.; this raises the urethral temperature to 104
and the
all
rectal temperature to 106 F. in the average. It is applicable in forms of inflammations, but it requires careful supervision because of the possibility of burns and scaldings and is therefore chiefly an institu-
tional procedure. Superheated air for intravaginal treatment can be applied by the apparatus shown in Figure 309. The air is heated by a small electric unit and
circulated
by a motor-driven fan
is
bag, which
in a specially shaped thin-walled rubber inserted into the vagina in a collapsed state and then inflated
INFLAMMATORY CONDITIONS
551
with air by a rubber bulb so as to distend the vagina. A pressure gauge indicates the pressure which is about 1 to 1J pounds. Treatment is administered at a temperature up to 130 F. This arrangement allows conductive heating at a uniform pressure without the discomfort of a heavy waterfilled bag and with increased security from scalding by hot water in case
of occasional bursting of the bag. also the various pelvic
The
indications for applications are
inflammatory conditions. (Newman. 13 ) Radiant heating from a tubular light bulb housed within a sturdy glass speculum placed in the vagina was proposed by Bengston recently. He claims that this device enables him to maintain safely a tissue temperature just under 114 for ten to twenty hours; a voltage regulator indicates milliamperes of electric energy and the temperature of the vaginal mucous membrane is also shown.
1
Pelvic Iontophoresis.
The
use of mecholyl ion transfer in pelvic inflam-
matory conditions, specifically in massive cellulitic infections of recent origin which failed to yield to ordinary treatment, was recommended by Gordon and Rosen thai. 9 The technique consists of wrapping about the end of a vaginal electrode a suitable piece of gauze saturated with a 0.5 to
1 per cent solution of mecholyl chloride; this is applied through a speculum against the vaginal vault, after it has been wiped dry. The electrode is connected to the positive pole of a galvanic generator, while a 6 to 8 inch
moist dispersive pad is placed over the abdomen and connected to the negative pole. Treatment is administered for twenty minutes with a current strength gradually increased to 15 to 20 milliamperes. Some of the effects of this application may be due to the galvanic current itself
size
which in its early days was extensively used with a similar technique. 6 Craig and Kraff reported good results with pelvic mecholyl ion transfer in acute pelvic inflammations of tubal origin.
In acute gonorrheal infections the generally accepted first line of attack at present. In chemotherapy resistant acute cases as well as in subacute and chronic cases intense local heating by diathermy or general heating by hyperthermy are still the standbys of physical treatment, because of the thermal vulnerability of the gonococcus.
is
Gonorrheal Cervicitis and Urethritis.
Cumberbatch 7 in local diathermic treatment of and urethritis is based on long-wave diathermy. Cumberbatch found that the cervix uteri can be heated to 120 F. and the urethra to 105 F. without damage, and that a maintenance of this temperature for ten minutes, repeated if necessary, was sufficient to eliminate many cases of gonorrheal infection. The technique consists of applying a belt electrode as a dispersive electrode and a special urethral electrode as the active electrode. The current is turned on and gradually increased until the
classic
The
method
of
cervicitis
patient has the sensation of heat in the urethra; it is then slowly increased further until the sensation of heat changes to one of pain and then slightly decreased until all feeling of pain disappears. In working out this technique with the aid of thermometers it was found that pain was usually felt between 114 and 115 F. The strength of the current at this point is maintained the degree of heat that the patient can stand without pain
552
for ten
minutes and the reading of the milliamperemeter is noted, as it forms the guide to the strength of the current to be applied in the treatment of the cervix which is insensitive to heat. After the urethral treatment the cervix is exposed by a vaginal speculum and the cervical electrode The current is introduced into the cervical canal, to a distance of f inch. is turned on gradually and kept at one-half of the milliamperage which was used in the urethra. This amount will produce the same temperature in the tissues of the cervix because the diameter of the electrodes is the same but the contact surface of the urethral electrode is larger; therefore, less current is needed to produce the same current density around the cervical electrode. This current strength is maintained also for ten minutes. Cumberbatch and Robinson found that with the technique outlined and treatment applied from three to eight times at intervals of three to seven days or about twice a week, it is usually possible to eliminate the infection, as shown by laboratory tests. Corbus and O'Conor 5 developed a technique " " with the thermophore introduced into the cervix and with a belt electrode applied around the lower abdomen and pelvis. The current is turned on gradually and increased until the thermometer registers 116 to 117 F. and continued for thirty to seventy minutes at this strength. According to these authors, this treatment repeated every eight to ten days resulted
in the elimination of gonorrheal infection in practically all cases where the infection was confined to the cervix. The thick purulent discharge took
over.
is
on a thin watery character and the accompanying cervical erosions healed Treatment is continued until five successive smears, one of which
taken forty-eight hours after cessation of menstruation, are negative. Combined systemic heating by fever therapy and pelvic heating by 2 long-wave diathermy (Bierman and Horowitz ) is applicable in chemoresistant and chemosensitive cases. First the systemic temperature is elevated (usually by a heating cabinet) and held for twelve hours between 105.5 and 106.5 F. During this period, for seven to eight hours, pelvic temperatures of 109 to 110 F. are maintained by means of high-frequency currents. A vaginal electrode equipped with a thermometer is used as an active electrode and four cuff electrodes applied on the lower extremities serve as dispersive electrodes. Following six or seven hours of this local heating, one or two hours of pelvic heating by short-wave diathermy,
using the same vaginal electrode is administered. A more rapid destruction of gonococci by this method is claimed. This is a drastic treatment, to be administered only in hospitals and with a personnel qualified by special
training and experience, Pelvic Inflammations.
Pelvic inflammations are caused

bacteria.
by
infection
is
by the gonococcus or pyogenic
The gonorrheal
infection
practically a self-limited pelvic disease, progressing
on the surface and
causing typical pathological changes in the pelvic organs, such as inflammation of the adnexa, pelvic peritonitis, parametritis and pelvic cellulitis. Pyogenic bacteria, due to septic abortion, septic childbirth, instrumentations, etc., cause more severe inflammation, invasion of bacteria through the blood and lymph circulation into the pelvic tissues, and the pathological Thermal changes are more severe than the gonorrheal inflammation. measures are practically specific in their action on most cases of pelvic inflammation. Diathermy is a most satisfactory agent for treatment of these conditions
and seems to act best when the inflammation
4
553
as in chronic
is interstitial
parametritis. Cherry reported that diathermy relieves pain, diminishes the pelvic masses and aids in restoration. Used as a preoperative thera-
peutic measure,
it will
eliminate
many
of the technical difficulties in the
removal of large pelvic masses and thereby contributes to a smoother

convalescence.
tion
is
lessened.
difficulty
was
Incidentally the percentage of postoperative wound infec15 Sheffey and Schmidt emphasized that less technical noted in the operative cases preceded by diathermy, as
evidenced by decreased density of adhesions and their more ready separation. Either short-wave or long-wave diathermy can be employed; the latter method still seems the more preferable because its technique is simpler and it enables the use of a milliammeter. The various techniques have been discussed in the preceding pages. From 1000 to 1500 milliamperes of current should be applied, in stout women as much as 2500 to 3000 milliamperes. The length of treatments should be from one-half to one hour, repeated daily or every other day according to conditions. As to the relative value of the two forms of diathermy in inflammatory conditions clinical observers have reported that the advantage of shortwave application is the applicability and efficiency in acute cases. Longwave diathermy seemed to be preferable for intense localized heating in chronic cases. As to the claim of more intense depth effect by short waves, Scholtz 14 found with long-wave diathermy electrodes of sufficiently large size deep heating effects equal to those produced by powerful short-wave The contention that short-wave diathermy is specifically apparatus. beneficial in acute cases may be partly explained by the fact that in such cases it is usually administered in very low dosage and mild heating is usually well tolerated even in acute inflammations. A recent report by 17 Upton and Benson in 100 cases of gonorrhea, postabortal infection and postoperative complication states that best results were obtained with long-wave diathermy for which a vaginal electrode was used and when a
moderately high temperature was sustained. The contraindications to diathermy as well as other thermal application to the pelvis are acute infections, bleeding, pregnancy, localized pus and
loss of skin sensitivity. Each of the other
non-diathermic thermal applications have their advocates; their range of applicability and contraindications are similar to those of diathermy. For office use by physicians diathermy appears to be the simplest and most efficient method. Chronic Endocervicitis. Cervicitis is produced by the gonococcus or by non-specific pyogenic organisms which have gained a hold because of trauma to the cervix. Erosion of the cervix occurs when columnar epithelium replaces the squamous epithelium. Healing of the erosion takes place when the squamous epithelium grows back over the columnar
extension. This causes the racemose glands to become permanently blocked, with a resulting hypertrophy of the entire cervix producing the picture of chronic cystic cervicitis. Whatever erosion exists at this stage depends
upon the completion of regrowth of squamous epithelium. If the columnar epithelium is piled up so that the squamous epithelium cannot replace it,
a papillary erosion with ectropion formation exists. Hyams 12 states that in the treatment of endocervicitis progressive
advances in electrotherapeutic measures have practically outmoded major
554
surgery, for electrotherapy in skilled hands is relatively simple and is adequate in selected cases. However, it is dangerous unless the technique Too often, unhappy results are due not to the is thoroughly mastered.
but to lack of mechanical skill and errors in technical one procedure now used fulfills all requirements for cure; judgment. age, degree of disease, presence or absence of complicating factors and previous treatment of the cervix influence the choice. The simplest and mildest form of electrosurgery, suitable for almost any general practitioner's
method
of treatment
No
electrochemical destruction by copper ionization. Electrothermal destruction by the coagulation and cutting current or electrocautery is reserved for more severe cases and requires more skill and experience and more elaborate accessories. Copper Ion Transfer. Copper "ionization" of the endocervix has been employed for many years. The rationale of its therapeutic action is that, from a copper electrode inserted into the cervix and connected to the
office is
positive pole of a galvanic generator, ions of copper are introduced and oxychloride of copper is formed which infiltrates the tissues and enters deeply into the crypts of the cervix. Depending upon the strength and duration of current flow, chemical destruction occurs in the superficial tissues while in the depth there are changes in the circulation.
FIG. 310. Intracervical copper electrode (Tovey). The various sizes are li inches long. Nos. 16 to 28 French in diameter. The small rounded end enters, but will not pass the internal os, being prevented by the rounded shoulder.
bare copper electrode of is introduced under The electrode is connected to the aseptic precautions into the cervix. positive terminal of a galvanic generator or battery and held in position by packing in the vagina. The dispersing moist pad electrode, about 4 by 6 inches in size, is placed over the lower abdomen and connected to the negative pole. Commencing with a current within comfortable toleration (2 to 5 milliamperes), one gradually increases it to the limit of toleration (15 to 25 milliamperes) and continues this current from ten to twenty minutes. The only sensation of the patient is slight prickling under the abdominal electrode, when the current begins to flow or is too suddenly increased. From the first a blue discoloration appears around the electrode, due to copper deposition in the cervical crypts. At the end of treatment the electrode is usually firmly adherent to the cervical canal and cannot be withdrawn without force. In order to avoid trauma and bleeding one must reverse the flow of current for a few minutes. The action of the negative pole in the cervix produces hydrogen bubbles and a softening alkaline effect around the electrode which becomes loosened in the canal and can easily be withdrawn after a minute or two. One should learn to make the first treatment as thorough as possible. A second treatment is given after all reactive symptoms have subsided and the coagulum in the cervix has entirely separated. This takes usually one or two weeks. In well-selected and efficiently treated cases only a few treatments are necesof
is
The technique
treatment
as follows:
suitable size
and shape, held
in
an insulated handle,
sary.
ment
555
In reporting a series of cases of cervicitis treated at the author's departat the Poly clinic Hospital by copper ionization, the late D. W. " 16 Tovey, a gynecologist of the hospital, stated that The result is a lessening of the discharge; in a week or ten days it has disappeared, the cervix shrinks and after three or four treatments it appears normal. The infection, erosion,
Nabothian cysts and discharge have disappeared. Large infected cervices that in the past required amputation shrink to normal."
FIG. 311.
Copper-tipped electrode
in diseased cervix.
(Tovey,
Am.
Jour. Obst. and Gynec.)
Electrocoagulation accomplishes destruction of diseased tissue by application of long-wave diathermy through an active electrode placed in contact
with the cervix or cervical canal. Effects depend on intensity of current, duration of treatment and form of electrodes. Both bipolar and unipolar currents are used, and many special instruments have been devised for the purpose. Application varies; some use an inactive electrode on an external surface of the body, the active electrode in contact with the cervix. The Cherry 3 instrument incorporates both poles in one electrode. Amount of current ranges from 200 to 2200 milliamperes and duration from a few seconds to fifteen minutes. The majority maintain that the active electrode should be held in one position during treatment; a few advocate rotating the instrument. A whitish coagulation will appear all around the cervical electrode, and the slough of varying extent will separate in a few days, leaving a clean granulating surface. The end-result is a smooth pliable surface, free from scar formation. Unpleasant secondary hemorrhage, a large amount of scar formation and subsequent stenosis of the canal are
556
the dangers in the hands of the less experienced and hence the preference much safer method of copper ionization for the average case. Conization by the cutting high-frequency current has been devised by 11 Hyams. A fine cutting instrument, a metal tube with a platinum-iridium wire, is inserted into the cervix as the active electrode (Fig. 312); a dispersive electrode is connected to the other terminal. The instrument conforms to the spindle shape of the cervical canal, and the cutting element removes f inch endocervical lining with each revolution. The cut surface of tissue thus excised shows minimal coagulation and the specimen is
for the
satisfactory for microscopic study. In competent hands this instrument enables the "coring" and complete removal of the mucous lining of the cervical canal and its glands in a few minutes, with subsequent minimum scar tissue formation. The procedure can be repeated as often as deemed
advisable.
FIG. 312. Conization of cervix. 1, Insulated electrode handle. 2, Insulated silicon tube. 3, Tungsten wire cutting element. 4 Portion of cervical lining being conized. 6, Cervical canal after conization. 6, Cervical canal before Conization. (Courtesy of The
Burdick Corp.)
In cauterization, the nasal tip and heavy duty cauteries destroy diseased tissue by direct contact and dissemination of heat; the amount of destruccautery tip and duration of application. result of chronic inflammatory conditions of the cervix usually heals after successful treatment of the underlying condition and the cessation of irritating discharge from the cervical In stubborn cases one may use ultraviolet irradiation from a glands. mercury vapor lamp with a local quartz applicator, producing a secondor third-degree erythema reaction over the lesion. For direct destruction electrodesiccation or electrocoagulation of the red and eroded areas may be applied. After the usual cleansing of the vagina and cervix the eroded surface is painted over with a 5 per cent solution of novocaine. Either a light desiccating or a stronger coagulating current is applied and every part of the erosion is fully treated. For prophylaxis of cervical cancer, it is advisable that every cervical lesion be cleared up by suitable measures. Miscellaneous Conditions. Skenitis, or the chronic infection of the small glands situated in the meatus of the urethra or just outside of it, is often
tion depends
size of
on
Cervical Erosion.
The troublesome
NON-INFLAMMATORY CONDITIONS
557
coagulate Chancroidal ulcers in which no spirochetes have been found and localized areas of pruritus may be likewise effectively treated by electrodesiccation. In gonorrheal Bartholinitis the electrocautery can be used for incising the infected glands to evacuate the pus, subsequently the electrocutting loop can be applied to remove the infected glandular
responsible for the upkeep of a chronic gonorrhea. For its eradication after suitable local anesthesia the desiccating needle is introduced into the affected gland or glands and just enough current is turned on to
the entire duct.
tissue.
NON-INFLAMMATORY CONDITIONS
Infantile Uterus With Stenosis of Cervix. Negative galvanism is a time-honored means for gradually dilating a congenitally stenosed cervix. A metal cervical electrode is connected to the negative pole and a dispersing pad placed above the symphysis is connected to the positive pole. One should first employ an active electrode of smallest diameter, insert it under antiseptic precautions, turn on 1 to 3 milliamperes of current at first and increase its amount, always within comfortable toleration, to about 10 milliamperes. After a few minutes white bubbles appear all around the electrode in the cervix and it can be easily moved about. It should now be replaced by the electrode next in size, which easily slips in the softened cervical canal; a still larger electrode can be inserted perhaps once more, during a total treatment time of fifteen to twenty-five minutes. In the infantile uterus after the dilatation of the cervix, the last electrode should be left in situ and the surging faradic or sinusoidal current turned on, causing gentle contractions for from fifteen minutes to one-half hour. This treatment should be repeated twice a week for a period of several months, avoiding the proximity of menstrual periods. Good results with this technique have been corroborated by Dannreuther 8 and Hirst. 10 The latter author observed the relief of chronic constipation following electrical stimulation of the uterus. Hirst concludes that the best treatment for constipation in women resisting ordinary methods is
by the sinusoidal current. A large abdominal pad electrode is employed and the other electrode is placed either in the uterus, rectum or simply in the vagina. "In view of the demonstrated possibilities of this treatment, it seems strange that it should be ignored by most gynecolostimulation
gists."
The possibility that the absence of menses may be due always present and should, therefore, be definitely excluded before any physical measures are applied. In the functional type of amenorrhea occurring in young, undernourished (or dieting) girls and also in healthy well-nourished girls with ovarian dysfunction, general ultraviolet irradiations combined with transpelvic diathermy are advisable when the usual means of hygiene and medication are not fully satisfactory. TransAmenorrhea.
is
to pregnancy
pelvic galvanism or the static-wave current applied through the rectal electrode may also be considered as an adjunct to glandular therapy.
In secondary amenorrhea, such as may follow a sea voyage, mental excitement or a cold, the same measures will be of assistance. In married women vagino-abdominal diathermy may be employed or, still better, the interrupted sinusoidal or surging faradic current. For the latter a cylindrical vaginal electrode is employed and a large wet pad electrode is placed above
558
the symphysis, 10 to 15 milliamperes of current are used for twenty minutes and the treatment is given twice a week. The same technique may be employed for building-up the muscles of the pelvic outlet in multipart
and
after repair operations of large tears.
Sterility.
Diathermy has been recommended
in cases of sterility that
appear to be due to genital hypoplasia or to disturbances in circulation, 18 This author to a hematoma or inflammation according to Von Bodo. employed simultaneous heating of the uterus and the ovaries by the
For the increase of the ovarian circulatwo electrodes on each side of the pelvis in the trochanemployed teric region and a vaginal electrode. The author reports that out of 20 women treated by this method for a sufficiently long period (20 to 40 treatments for fifteen to thirty minutes) 14 subsequently became pregnant. Dysmenorrhea. In dysmenorrhea due to congenital non-development, gradual dilatation of the cervix by negative galvanism, as described, has given good results. Two to 10 milliamperes of current should be used for thirty minutes, twice a week. In the spasmodic type of dysmenorrhea the
abdomino-dorso-vaginal method.
tion he
A cylindrical metal static-wave current has given considerable relief. is inserted into the rectum and connected to the positive side of the static machine, the negative pole being grounded. The current is applied in increasing intensity, always to the point of tolerance. Dysmenorrhea in connection with pelvic adhesions, ovarian dysfunction or disease or uterine displacements, necessitates a combination of methods. Menopausal Syndromes. In conditions not benefited by estrogenic substances, intrapelvic or intracervical diathermy may be applied. Robinson extols the effect of diathermy on menopausal disturbances, especially menopausal arthritis, due at times to the effect of a pelvic focus of infection. Minor Surface Growths. For the treatment of superficial benign growths on the vulva, such as condylomata, urethral caruncles, cysts or of the Nabothian glands, electrodesiccation offers an ideal method. It
electrode
can be applied always without general anesthesia and generally without even a local one. For the latter purpose infiltrating the base of the new growth with a few drops of 2 per cent novocaine is sufficient.
Electrosurgical biopsy, as discussed in Chapter
XIII
is
a very useful
procedure in gynecological diagnosis.
REFERENCES
1.
2.
Sustained Internal Radiant Heating in Lesions of the Pelvis, Arch. Phys. Ther., 24, 26-33, 1943. BIEBMAN, WM., and HOROWITZ, E. A.: Treatment of Gonorrhea in Women by Means of Combined Systemic and Additional Local Heat, First Int'l. Fever
BENGSTON, B. N.:
3.
CHERRY, TH. H.
York, 1937. Further Advancement in Gynecological Diathermy, State Jour. Med., November 15, 1930.
Conf.,
:
New
New Jersey
Assn.,
4.
-The
CORBUS, B.
Results of Diathermy in Pelvic Infections, Jour.
Am. Med.
86, 1745, 1926.

5.
6.
7.
and O'CoNOR, V. J.: Diathermy in the Treatment of Gonococcal Am. Med. Assn., 87, 1816, 1926. CRAIG, R. L., and KRAFF, H.: Treatment of Acute Inflammatory Pelvic Masses of Tubal Origin by Iontophoresis With Acetyl Beta Methyl Choline Chloride, Am. J. Obst. and Gynec., 45, 96-102, 1943. CUMBERBATCH, E. P., and ROBINSON, C. A.: Treatment of Gonococcal Infection by Diathermy, St. Louis, C. V. Mosby Company, p. 6, 1925.
C.,
Endocervicitis, Jour.
REFERENCES
8.
559
of Gynecological Patients,
DANNREUTHEB, W.
GORDON, CHARLES
T.:
The
Office
Treatment
Med.
Jour., February, 1928.
Studies in Pelvic IontoA., and ROSENTHAL, ALEXANDER H.: phoresis, Am. Jour. Obst. and Gynec., 41, 237-242, 1941. 10. HIRST, B. C.: The Development of Infantile Uteri, Am. Jour. Electrother. and
9.
Radiol., vol. 38, 1920.

11.
12.
13.
14.
15.
16.
17.
18.
Methods of Treatment of Chronic Cervicitis, New York State Jour. Med., 44, 1785, 1944. NEWMAN, L. B.: An Improved Method for Applying Pelvic Heat Using Air, Am. Jour. Obst. and Gynec., 38, 725, 1939. SCHOLTZ, H. G.: Untersuchungen iiber Tiefenerwarmung im Weiblichen Becken bei Diathermic und Kurzwellenbehandlung, Fortschr. Ther., 14, 7-11, 1938. SHEFFEY, L. C., and SCHMIDT, W. H.: Diathermy as an Adjunct in Treatment of Pelvic Inflammatory Disease, Am. Jour. Obst. and Gynec., 18, 230, 1929. TOVEY, D. W.: Copper lonization in the Treatment of Cervicitis, New York State Jour. Med., 30, No. 15, 1930. UPTON, J. R., and BENSON, G.: Results With Local Heating in Pelvic Inflammatory Diseases, Jour. Am. Med. Assn., 121, 38, 1943. VON BODO, B.: The Role of Diathermy in Treating Sterility, Fortschr. Ther., 10,
605, 1934.
HYAMS, M. N.: and Rad., 11,
Surgical
Diathermy
in
Gynecology, Arch. Phys. Ther., X-ray
171, 1930. Evaluation of Various
CHAPTER XXXI
General Considerations. Technique. Nephritis. Tuberculosis of the Kidney. Renal Prostatitis and Seminal Vesiculitis. Incontinence of Urine. Colic. Cystitis. Tuberculous Epididymitis. Gonorrheal Gonorrheal Epididymitis. Prostatism. Urethritis. Calcified Deposits in Corpora Cavernosa. Stricture of Urethra. Electrosurgery in Urology.
General Considerations. Physical measures are useful adjuncts in treatment of a number of genito-urinary conditions. A complete diagnosis arrived at by tests of the urine, rectal and possibly urethroscopic examination is essential in any doubtful case before physical therapy is undertaken. Thermal measures are employed in the form of local heating by hot sitz baths, hot water and hot air applications, and short-wave and longwave diathermy; systemic heating by electric light cabinets and the various methods of hyperpyrexia. They serve for treatment of subacute and chronic inflammations, especially in gonorrheal infections. Research work in fever therapy (Chapter XI) demonstrated varying heat resistance of the many strains of gonococci. In the majority of cases the chief virtue of local heat therapy, as it is generally employed, seems to be to create an unfavorable condition for the viability of the gonococcus. There is ample clinical proof that in complications of gonorrhea local use of diathermy is quite effective in many cases and there is no need for the routine use of
fever therapy in
all cases.
Electrothermal destruction of tissues finds an increasing employment in surgical disorders of the genito-urinary tract because it facilitates the
rapid and gentle handling of tissues, lessens or eliminates bleeding and operative shock and after-pain. Ultraviolet irradiation is indicated in tuberculosis of the urogenital tract or in fistulae or slow healing wounds following operations for urogenital
tuberculosis.
Mechanical measures, in the form of massage or by currents of low frequency for muscle stimulation serve as adjuncts in the treatment of certain chronic inflammatory conditions where local stasis is a predominant symptom. Preliminary deep heating makes mechanical measures more
effective.
For prostatic diathermy electrodes with an end and with a slight depression to fit the bulk of the prostate are preferable to those with only a small metallic contact area. These electrodes can be employed for long-wave diathermy or short-wave diathermy with the direct contact method. They should be inserted with
Electrodes and Technique.
all-metal
the tip well lubricated with petrolatum^ by slow, turning motions, into the anal opening and gradually pushed about 2 to 3 inches into the rectum, while the patient lies on his side. He is then told to turn on his back, while the prostatic electrode is propped up in its position by a few sandbags; a dispersive electrode, 4 by 5 inches in size, is placed just above the symphysis. The current is turned on gradually, never causing any ache or
burning sensation; usually from 1000 to 1200 milliamperes can be well (560)
NEPHRITIS
tolerated.
561
The
current should be flowing for at least twenty-five minutes.
Cumberbatch, with an electrode containing a thermometer, found that most patients could stand temperatures of 111 to 112 F., which corresponds to 3 or 4 F. lower temperature in the interior of the prostate. Pushing the prostatic electrode somewhat higher up on either side and moving the indifferent electrode somewhat further up from the symphysis usually puts either of the seminal vesicles in the direct path of the current and the same technique is used. Short-wave diathermy to the perineum, prostate and seminal vesicles can be applied by the electromagnetic field method with a pancake coil covered by suitable spacing and a pillow; all this is placed on a wooden chair and the patient sits on the pillow. For short-wave diathermy to the epididymis and testis air-spaced electrodes serve conveniently. For long-wave diathermy the contour and consistency of the scrotum make exact adaptation of electrodes difficult. The standard method is a clamp-holder with electrodes of suitable size (Fig. 313) which are adapted against the sides of the scrotum. The current flow must be started very gently and usually kept between 300 to 400
milliamperes.
FIG. 313.
Scrotal electrode.
(Courtesy of General Electric X-ray Corporation.)
Both short- and long-wave diathermy may be applied to the penis by external electrodes, as described later in this chapter. Nephritis. It is a physiologically established fact that external heating
procedures cause a simultaneous dilatation of the blood-vessels of the skin and the kidneys and thus increase the excretory function of the latter. Local heating of the kidneys becomes effective either by direct thermal reflex via the same spinal segment or by the secondary skin effect of prolonged heating. In deficient kidney function external heating increases diuresis as well as the elimination of salt and nitrogen. While some authors consider the stimulation of kidney function by sweating procedures as most important, others stress the increased function of the skin by such procedures and the vicarious removal of nitrogenous substances through the
skin.
Pemberton 9 recommends in nephritic conditions accompanied by marked laboratory evidences of retention of nitrogen, or by clinical evidences which suggest the toxemia consequent to such retention, a sweating process; he
36
562
edema
or anasarca of renal origin, the hot
believes that in the presence of
pack or general body bake may at times result in significant consequences in the form of loss of fluid from the tissues almost from the start. The particular manner in which heat is systemically applied in nephritis is of secondary importance; the simplest form and one that can be carried out in any household, is the hot pack. General heating from large incandescent lamps or an electric light cabinet may also serve. (Chapter XVI.) Diathermy to the kidneys has been recommended by German clinicians in threatening uremia, especially anuria no matter of what origin. They also favor its application in subacute and chronic nephritis. Eppinger, Rein and Schurmeyer 3 report on the use of diathermy for two to four hours daily in acute glomerulonephritis, and attribute the favorable results in all but the most severe cases to increase capillarization of the glomeruli. Corroborative evidence of increased diuresis and decrease of albuminuria 4 is offered by Ewig and others. Short-wave diathermy is equally applicable and according to Rausch 10 on account of its more intense deep effect is additionally indicated in nephrosclerosis, where it is claimed to result in a more lasting lowering of blood-pressure than long-wave diathermy. In applying diathermy to the kidneys, a smaller, active electrode corresponding in shape and size with one or both kidneys is placed posteriorly and a large dispersive electrode about 8 by 10 inches is placed on the upper abdomen. Short-wave diathermy is applied similarly with one smaller condenser electrode over one or two kidneys and a larger one in front with suitable spacing under both. For a report on the use of short-wave diathermy in nephrosclerosis and hypertension see Chapter XXIV. Good results have also been reported in fistulas after nephrectomy and in cystopyelitis.
In the technique of short-wave diathermy to the kidney a small condenser pad electrode is applied over one or two kidneys and a larger one in front with suitable spacing under both. More generalized heating in threatening uremia can be done by a disc or coil electrode centered above the upper part of the abdomen for the first half of the treatment and over the lower part of the back for the second half. Between the skin and the disc or coil there is introduced the equivalent of six thicknesses of turkish toweling. The patient is covered with sheets or blankets, to induce sweating and to retain heat. At intervals, the perspiration is wiped off with suitable soft towels. Rectal temperature is taken every fifteen minutes and should not exceed 102 to 103 F. If possible, the treatments are gradually increased to one hour twice daily and, if advisable, a third application is
made
This is usually unilateral and offers an indication for nephrectomy. As a palliative treatment diathermy to the affected kidney has been recommended. In operative cases there is a tendency for a breakdown of the wound and formation of fistula. In these cases artificial ultraviolet irradiation or natural heliotherapy is most
effective in speeding up healing (Wang 13 ). been recommended for the same purpose.
at midnight. Tuberculosis of the Kidney.
Short-wave diathermy has

in the pelvis of the
Renal
Colic.
In renal
colic
due to stones
kidney
and hot-tub baths often give marked relief and enable cutting down or omitting morphine injections. The author has seen dramatic relief in a few cases by diathermy. In stone impaction in
local heat applications
PROSTATITIS AND SEMINAL VESICULITIS
563
the ureter which has been located by roentgen-rays it may be possible to bring about enough deep relaxation by diathermy or short-wave diathermy to relax the spasm and allow the passage of the stone. In acute cases luminous heat or infrared radiation to the Cystitis. suprapubic region serves to relieve pain and draw the blood to the surface from the congested parts. It should be applied fairly continuously at first.
Diathermy with one electrode over the symphysis and another under the sacrum may be employed in resistant cases. Incontinence of Urine. Incontinence of urine due to an atonic bladder
or sphincter after operations may be treated by the surging faradic current, with electrodes above the symphysis and under the sacrum or with the
static-wave current, a cylindrical electrode in the rectum or a plate above the symphysis. Prostatitis and Seminal Vesiculitis. Inflammations of these organs are in the large percentage of cases of gonorrhcal origin. Diathermy is the choice of management in acute cases which are not suitable for chemo5 therapy and in subacute or chronic cases. Harrison states it far surpasses the time-honored methods of applying heat by sitz baths and rectal douches. It actively directs heat to the prostate with a higher temperature which is more uniform and over a longer period of time. It usually brings quick relief of the distressing symptoms and reduces the size of the gland rapidly. Patients of course must have bed rest, possibly in a hospital. Daily diathermy treatments for thirty to forty minutes are advisable with an active electrode of suitable size and shape introduced into the rectum in close relation to the posterior surface of the prostate, previously palpated. The current must be started gently, for often the pain is increased at first, due to the added hyperemia in the already distended parts; this initial discomfort, as a rule, soon subsides and patients feel more comfortable than before the treatment. Up to 1200 milliamperes of current can be usually
comfortably tolerated.
The
whether there
success of this procedure depends altogether upon the fact as to is proper drainage from the prostate and seminal vesicles,
the only indication of which is the marked improvement of the condition. Treatments should not be continued if there is more elevation of temperature and fluctuation of the prostate, because this indicates pus formation Short-wave diathermy by the inductance coil technique in that organ. was applied by Hibbs and Osborne 6 in chronic prostatitis, who found first a moderate exacerbation of subjective symptoms in the more resistant cases, as shown by slight fever and leukocytosis which continued into the fifth week of treatment, at which time there was a complete remission of subjective complaints, reduced leukocyte count, lowered temperature, and general appearance of well-being. At the end of the series consisting of
an average of ten treatments these patients showed a definitely reduced pus content of expressed secretion and on subsequent re-examination showed a continued small amount of pus cells with increased lecithin content. For mechanical effects in chronic prostatitis, the static wave current, if available, is a most efficient and pleasantly tolerated method.
static machine, the sinusoidal or the interrupted galvanic be applied through a metal electrode in the rectum and a wet-pad electrode over the symphysis. The combination of diathermy with the sinusoidal current is useful in selected cases. (See Chapter XL)
Lacking a
current
may
564
Prostatism.
One of the most frequent troubles in men past the age prostatism, that disturbance of the function of the prostate that manifests itself by a variety of local symptoms, such as slow and frequent micturition, dribbling, frequent urination at night, possibly followed by complications in the genito-urinary tract; of general symptoms
of fifty years
is
memory, chronic cona variety of causes chronic inflammatory changes in the prostate, congestion and infiltration or actual hyperplasia, fibrosis and myomatous enlargement, calcareous or neoplastic formations. In any set of such symptoms it is obviously of first importance to ascertain by all available means the exact underlying pathology. There is histological and pathological evidence for the fact that in many cases the so-called hypertrophied prostate is only an inflammatory enlargement due to a variety of causes (old infection, stasis, sedentary habits, etc.). When such a patient is operated upon by the usual two-step prostatectomy the first step consists only of a suprapubic incision of the bladder. This operation only insures improved drainage of the urine, and yet the subsequent rapid shrinking of the large hypertrophied prostate is remarkable, leaving only a small fibrotic gland to enucleate. This corroborates the empirical experience that some cases of enlarged prostate are readily amenable to treatment by physical measures. According to Pedersen 8 the best results may be expected in cases where congestion of the prostate is the
there
may
be general debility,
.
loss of sleep, loss of
stipation
and impotency These
may be due to
predominating factor, grafted on underlying simple hypertrophy. With diathermy or the static-wave current the author has seen elderly patients suffering from painful and irritating prostatic disturbance improve
steadily.
Lack of prompt and progressive improvement after a series of treatments, especially as measured by an improvement in the residual urine may be taken as evidence that the pathological changes in the prostate are of a more permanent nature. On the other hand, even in a case diagnosed as an organic hypertrophy or adenoma, treatment by the staticwave current or diathermy may be worth trying because, by removing part of the accompanying edema and infiltration a satisfactory measure of relief may often be achieved and operation postponed until a more suitable
time.
Gonorrheal Epididymitis. Diathermy is of almost specific value in chemoresistant cases, for in most instances it relieves pain and quite promptly aborts the attack. The techniques of application have been described. It is advisable to apply half-hour treatments with the scrotum kept elevated by the usual adhesive bridge method. The result of the treatment is shown by the subsidence of pain, swelling and tenderness. Treatment should be repeated daily until the acute condition is entirely relieved. Rest and wearing a suspensory are essential; in severe cases the patient must stay in bed and the testicle be kept constantly elevated. In patients with much edema and tenderness treatment can be started with luminous heat radiation for one-half to one hour several times a day. In resistant cases fever therapy may serve as a last resort.
Gonorrheal Urethritis.
The
results of
modern chemotherapy have made
the discussion about the various techniques of local diathermy in this condition largely academic. Reports on fever therapy in acute gonorrheal cases showed a high
CALCIFIED DEPOSITS IN CORPORA CAVERNOSA
505
percentage of negative cultures in patients with single ten-hour sessions (See Chapter XII.) Tuberculous Epididymitis. The combination of general irradiation from a mercury vapor or carbon arc lamp with some local irradiation often relieves pain and swelling and may lead to gradual absorption without aspiration or more extensive surgery. In cases where surgical removal of the epididymis becomes a necessity, in the after-treatment ultraviolet irradiation will speed up the healing of sinuses.
Position of first
side
sponge -pubtaer
piece.
Both sponge r>ubber> aide pieces in place
plate
Metal plate in place vubbei" plots.

5
sponge.
FIG. 314. Diathermy to penis. Pair of penile electrodes made from sponge rubber and block tin. Large electrode lies below and supports phallus, while small one is placed directly over plaque. Electrodes held in place with rubber bands, J and K. If edge of tin comes in contact with skin, it will cause a burn, hence in the large one the ends must be bent under rubber and sides covered with "side boards" of rubber, A, D; in small one, tin can be bent to bury edges in excavation in rubber, E, H. Internal electrode, /, is made from female sound, a rubber cuff controlling depth of insertion, with electrical connection at exposed Metal disc of end, sometimes helpful in addition to, or in place of, ventral electrode, D. small electrode should be same size as plaque and placed directly over it. (Courtesy of Dr. M. B. Wesson.)
Calcified Deposits in Corpora Cavernosa. Calcified plaques in the sheath of the erectile tissues of the penis are the result of a slowly progressing chronic inflammation of uncertain origin, possibly rheumatic. This condition has also been described as Peyronie's disease or plastic induration. There are first some painless areas of induration which interfere with erection and later cause a marked curvation of the organ. Since diathermy affects the absorption of calcified deposits in other locations, notably in bursse it suggests itself for this condition so notoriously resistant
566
to
all
GENI TO-URINARY CONDITIONS

much
other forms of treatment. The author has seen in several cases improvement corroborated by roentgen-ray evidence.
of
of treatment is to apply two narrow strips (about J inch) diathermy metal opposite each other along the entire length of the penis and hold them by smaller sandbags under and above the organ; heating of comfortable toleration (from 300 to 500 M) is administered for thirty minutes to one hour two or three times a week. Either long- or short-wave apparatus may be used. (Contact plate technique with the latter.) Heating may be also administered by small condenser pads held on either side of the penis, the amount of heat energy applied controlled 14 by the feeling of comfortable warmth. Wesson has recently also reported encouraging results in several cases by diathermy (Fig. 314), combined with administration of disodium phosphate by mouth. A method very little used nowadays is the Stricture of the Urethra.
The technique
dissolution of scar tissue in the urethra
by negative galvanism, introduced
by Newman many years

is
ago.
An olive tip two sizes larger than the stricture
placed on an insulated handle and inserted so it just engages the stricture. is connected to the negative pole of a galvanic source and a wet-pad dispersive electrode placed over the abdomen or under the buttocks is connected to the positive pole. The current is increased gradually so as never to cause a decided burning sensation; the maximum amount will depend on the relative size of the olive. The current flow is kept up until the olive tip slips of its own weight past the obstruction. This takes about five to ten minutes. The treatment is repeated with olives of increasing size, until a No. 28 French sound can be easily passed. Urethroscopic examination in cases thus treated has shown the increase of the caliber of the urethra and the changed appearance of the texture of the mucosa. Uthoff 12 reported very satisfactory results with this method in organic or 1 definitely fibrotic strictures and Beck has corroborated these results.
It
ELECTROSURGERY IN UROLOGY
BY DANIEL A. SINCLAIR, M.D. PROFESSOR OF UROLOGY, POLYCLINIC MEDICAL SCHOOL AND HOSPITAL,
NEW YORK
CITY
THE surgical application of electricity in urology has, in recent years, been extended to resection of the enlarged prostate gland with gratifying results. It has been, and still is, extensively and successfully employed, in the treatment of benign papilloma of the bladder, cystitis cystica, ureterocele
of
and for the enlargement
of the ureteral orifices to facilitate the passage
impacted calculi, as well as in malignant non-infiltrating papillary carcinoma of the bladder. All of these procedures are carried out by the
transurethral route, through the cystoscope, using either the coagulating or cutting current or a combination of both.
Meatotomy, when indicated, especially in balanic hypospadias, where the enlargement should be made at the expense of the tissue of the glans penis, is happily changed from an often bloody and annoying operation to one of safety and permanency by the cutting current. Non-tuberculous obstructions, such as chronic inflammatory vesical neck contracture or bars, are most amenable to electrosurgical resection by the transurethral route.
ELECTROSVRGERY IN UROLOGY
567
Epididymectomy for tuberculosis of the epididymis is most satisfactorily accomplished by the fine and neat dissection, afforded by the cutting current, using an ordinary cambric needle attachment. Verruca acuminata on and about the glans penis may be completely
destroyed by electrodesiccation. Papillary growths of the bladder, when extensive, multiple, benign or malignant, and infiltrating carcinomata of the bladder, are indications for open operation by means of a suprapubic cystotomy. In such a procedure, the scalpel is dispensed with, the usual incision through skin and fascia being made by the cutting current of the proper strength, which cuts and coagulates at the same time. If there be an active bleeding-point, it may be controlled by coagulation. After the separation of the recti muscles by the fingers, and the stripping upward of the prevesical fat and peritoneum with the gauze-covered finger, the bladder is ready for opening,
which
of the
is
accomplished by severing freely
all
of its coats.
The
situation
growth to be resected having been determined by cystoscopy, sufficient mobilization of the viscus is carried out, so that the growth proper is not cut through when opening the bladder. The growth, including the wall of the bladder at its base, and a portion of apparently healthy
bladder tissue surrounding it, is now excised. The margin of healthy bladder wall should be about \ inch in width. Smaller scattered growths or suspicious-looking spots may be treated by the coagulating current. The types of adenomatous prostatic obstruction that are suitable for moderate middle lobe enlargement, transurethral electrosurgery are: moderate unilateral or bilateral intraurethral enlargement, or a combinathree types. anesthesia is ideal for resection, and unless otherwise contraSpinal indicated should be employed. Res'ection of the obstructing portion of the prostate gland is performed transurethrally. The McCarthy- Wappler unit is most efficient and satisfactory for this type of operation. The sheath of the endoscope is made of bakelite, which is a non-conductor of electricity. It is fitted with an obturator to facilitate its passage into the posterior
tion of
all
urethra and bladder. After obtaining a clear field by irrigation with distilled water, which solution only should be used, the telescope and cutting element are placed
in position.
The verumontanum
is
now
visualized, as
it is
a valuable landmark and
provides proper orientation for the operator. It must not be injured. Under continuous irrigation, only the obstructing prostatic lobes above it are to be resected. After each piece of tissue is removed, the resulting the groove is inspected for bleeding points, and over any bleeding spot same loop electrode is passed, now carrying the coagulating current, butinstantly obtained by the operator placing his foot on the coagulating ton of the foot switch. Control of bleeding is an all-important point in the
is cut away. technique and should be thorough after each piece of tissue In the case of carcinoma of the prostate gland, when obstructive symptoms develop, resection is indicated as a palliative procedure. Heretofore, in this type of pathology, a patient, when he could not empty his bladder, was forced to lead a catheter life, and when this became impractical or was instituted impossible a suprapubic cystotomy and permanent drainage as a last resort. The selection of suitable types of enlargement, as outlined
568
GENITO-UR1NARY CONDITIONS
above, the visual control of the operative field through the cystoscope, the efficient cutting power of the current and the hemostasis accomplished by the application of the coagulating current make this operation a safe one. However, good urological judgment, the result of experience in prostatic and bladder surgery, must decide the method of procedure, as no hard and fast rules can be laid down for the sure guidance of inexperienced instrumenteurs.
REFERENCES
1.
BECK, O. H.:
Treatment
of Urethral
J.:
and Ureteral
Strictures, Mississippi Doctor,
19, 401, 1942.

2.
CORBUS, B.
C.,
and O'CoNOR, V.
Diathermy
in the
Treatment
of Genito-
3.
4.
urinary Diseases, Bruce Publishing Company, 1925. EPPINGER, L. D., REIN, H., and SCHURMEYER, A.: Circulatory Disturbances in the Diseased Kidney, Klin. Wchjischr., 9, 633, 1930. EWIG, W.: Diathermy Treatment of Nephritis, Deutsch. med. Wchnschr., 57,
51, 1931.
Principles and Practice of Physical Therapy, Hagerstown, Md., Co., vol. 2, Chap. 21. 6. HIBBS, DONALD K., and OSBORNE, STAFFORD, L.: Short Wave Diathermy in Chronic Prostatitis, Am. Jour. Physiol., 133, 2, 404.
5.
HARRISON, F. G.:
Prior
&
7.
8.
PARSONS, E. H., BOWMAN, P. N., and PLUMMER, D. E.: Artificial Fever Therapy of Gonorrhea in the Male: A Comparative Study, First Int'l. Fever Conf., New York, April, 1937. PEDERSEN, V. C.: Electrotherapeutics in Urology, Am. Jour. Electrother. and
Radio!., August, 1925.
9.
PEMBERTON, R.:
The
Influence and Therapeutic Use of Heat, Jour.
Am. Med.
Assn., 105, 275, 1935. 10. RAUSCH, Z.: Indications

11.
and Successes of Short Wave Diathermy in Circulatory and Renal Diseases, Fortschr. Ther., 10, 304, 1934. STARK, GEORGE W.: Thermotherapy of Bright's Disease and Its Complications,
Arch. Phys. Ther., 20, 94-100, 1939. J.: Galvanism in the Treatment of Urethral Stricture, Urol. and, Cutan. Rev., 42, 240, 1938.
12.
UTHOFF, C.
S. L.: Quartz Light Therapy in Urogenital Tuberculosis, Jour. Am. Med. Assn., 104, 720, 1935. 14. WESSON, M. B.: Peyronie's Disease (Plastic Induration), Cause and Treatment, Jour. Urol., 49, 350, 1943.
13.
WANG,
Contributions in electrosurgery of the genito-urinary tract:

1.
2.
BLECH, G. W.: Evaluation of Electro-surgery in Genito-urinary Diseases, Urol. and Cutan. Rev., 42, 253-256, 1938. CULVER, H.: Electrosurgical Management of Bladder Neoplasms, Arch. Phys.
Ther., 20, 538-543, 1939.
3.
EMMETT,
4.
5.
6.
J. L.: Recent Developments in Transurethral Prostatectomy, Arch. Phys. Ther., 20, 473-481, 1939. MYERS, H. C.: Status of Transurethral Prostatic Resection, Arch. Phys. Ther., 20, 342-345, 1939. RANDALL, A., and UHLE, C. A. W.: Transvesical Diathermy in Treatment of Carcinoma of the Bladder, Surg., Gynec. and Obst., 66, 927-932, 1938. WHITE, E. W.: Evaluation of Surgical Diathermy in Treatment of Tumors of the Urinary Bladder and Vicinity, Urol. and Cutan. Rev., 42, 248-252, 1938.
.
CHAPTER XXXH
BY
Hemorrhoids.
Canal.
R. V.
GORSCH, M.D.
POLYCLINIC MEDICAL SCHOOL AND HOSPITAL
CLINICAL PROFESSOR OF PROCTOLOGY,
NEW YORK
Fistula in Ano. Fissure in Ano. Stricture of the Rectum and Anal Polypi of the Rectum and Colon. Biopsy. Proctitis. Pruritus Ani. Coccygodynia. Neuralgia, Hysteria of Rectum. Tuberculous Peritonitis, Enteritis and Anorectal Tuberculosis. Cancer of the Rectum.
IN the proctologic field a review of the literature reveals that the indicaand limitations of physical therapeutic measures have become more sharply defined and their use has become somewhat restricted to definite
tions
conditions.
Electrothermic surgical methods offer certain advantages and simplify the technique in many proctological surgical procedures, e. g.: They minimize hemorrhage and prevent the lymphatic spread of the disease. The removal of malignant or benign tumors, large papillae, infected deep crypts,
division of strictures, excision of pilonidal sinuses
may
be carried out with
the cutting current or coagulation. Hence electrosurgery in selected cases widens the scope and safety of proctological surgery. There still remains a not unconsiderable number of proctologic patients who fail to receive the benefits of physical therapy A closer liaison between
.
general practitioner, physiotherapist and proctologist seems desirable. Hemorrhoids. The electrotherapeutic treatment of hemorrhoids is either palliative or radical, depending in great measure on the type of piles, the general condition of the patient, the exciting causes and the coexistence of other pathological changes which are commonly enough overlooked. Carcinoma higher up in the bowel should be particularly ruled out. Hemorrhoids are broadly classified into external and internal. The external are further subdivided into external thrombotic and true external piles, which are comparatively rare. External thrombotic piles are actually not hemorrhoids but merely hematomas of varying size in the perianal tissues. They are preferably removed with scissors or scalpel under local infiltration anesthesia. When complicated or associated with strangulated internal hemorrhoids they should be removed with the internal hemorrhoids. When their surgical removal is considered inadvisable, the injection of an oil soluble anesthetic (anucaine), hot sitz baths and then local application of heat, diathermy are valuable palliative measures. The infrequent true external piles which consist of dilatation or varicosities of the external hemorrhoidal plexus of veins are usually the result of prolonged constipation with straining at stool. Their structure represents an exaggeration of the normal physiological venous dilatation occurring in these veins during defecation. They are, therefore, only prominent during the activity of the anal canal and do not usually require surgical intervention except in the rare advanced case in which a large coronal mass of enlarged veins surrounds the anus externally. Internal hemorrhoids are the common type and they are quite frequently
(569)
570
related etiologically to other diseases, such as cirrhosis of the liver with
portal congestion, chronic constipation, colitis, enteroptosis, uterine tumors and retroversion, enlarged prostate, spasmodic sphincters, obstructive In fact, anything which valves, strictures of the rectum and urethra.
causes an abnormal increase in the venous pressure of the hemorrhoidal plexus predisposes to hemorrhoidal disease. Many of these associated conditions may be benefited by appropriate physical measures. For example, portal congestion is relieved by diathermy to the liver with a salutary effect on the hemorrhoids, using the technique as described for cholecystitis. Chronic constipation may also be benefited by other physical methods enumerated in Chapter XXIV. Genito-urinary conditions responsible for hemorrhoidal stasis are frequently amenable to diathermy or electrosurgical or other modalities described in the previous
chapter.
Electrotherapeutic measures should only be applied to simple uncomplicated cases of internal hemorrhoids. Any one of the following modalities may be applicable to a given case of hemorrhoids and the practice of
restricting oneself to
sirable.
one form of treatment in
all
cases
is
distinctly unde-
In selected cases of early varicosities without probleeding medical diathermy may be used with good results, as reported by Kobak. 5 It is of particular value in those cases of excessive scarring or stricture of the anal canal which are sometimes quite painful and obstruct to varying degrees the evacuation of the fecal mass. The
Medical Diathermy.
little
lapse and
technique of application is described in Chapter XL The active electrode should preferably be tapered and fit the anal canal without undue pain or trauma. The author frequently uses as an active electrode a small Brinkerhoff speculum which affords some degree of dilatation as the sphincters relax from the salutary effects of the heat. A current flow from 1000 to 1500 milliamperes should be continued over a period of twenty to thirty minutes, twice a week. The ordinary metal rectal dilators make useful
active electrodes
and are self-retaining. Diathermy may also prove useful in aiding the decongestive process of hemorrhoids following pregnancy, and it may likewise afford considerable
relief in
those sometimes intractable cases of anal neuralgia, sphincteralgia and coccygodynia from obscure causes frequently associated with hemorrhoids. Insulated electrodes may be preferable when short-wave diathermy
is
used.
Electrosurgery. (a) Electrodesiccation.The usual technique consists of applying a needle-point electrode connected to the high-voltage (Oudin) terminal either close to the hemorrhoid or at a sparking distance from its surface; this is similar to the technique in removing small tumors of the
Subsequent drying, shrinkage and sloughing occurs, depending on the strength of the current and the depth of its penetration, which in large hemorrhoids must be considerable. The hemorrhoidal area must be, of The course, anesthetized sufficiently to freely expose the hemorrhoids. injection of anucaine as advocated by the writer greatly facilitates the relaxation of the sphincters and prevents much of the after-pain. All of the piles should usually be treated at one sitting to avoid the repetition of A very strong injecting the anesthetic solutions into inflamed tissues. Oudin current may actually char or coagulate the tissues, particularly
skin.
HEMORRHOIDS
epithelial or
571
mucous membrane and the procedure may be incorrectly Electrodesiccation should not be used in thought to be desiccation. advanced cases of hemorrhoids or those complicated by other ano-rectal
pathology.
single pointed electrode as
Electrocoagulation.Electroco&guldition may be performed with a an active electrode and a large dispersive electrode is used on the abdomen or back. In this procedure the same technique may be used as in desiccation: either sparking or plunging the electrode into the depth of the hemorrhoid. Obviously the depth of current
(b)
penetration is difficult to control. In the biterminal procedure of coagulation a biterminal active electrode is employed and a dispersive electrode is not necessary. With the idea of confining the depth of coagulation several biterminal electrodes have been devised, a popular example of which is the Bierman clamp. This clamp
consists essentially of two active parallel insulated electrodes buried in the insulated jaw of the clamp.
The technique of the biterminal clamp method consists in freely and firmly grasping the pile along its basis parallel to the bowel, just as in the usual clamp and cautery operation. The current is controlled through a
foot switch
and its strength and duration determined by the previous experience of the operator. The neophyte should experiment with strips of meat beforehand. Sufficient current strength is used to coagulate the entire base of the pile. Theoretically the desired degree of coagulation is determined by the tissue turning to a light gray color; actually the tissue cannot be seen between the jaws of the clamp. The portion of the pile above the clamp is removed with a cutting loop or scissors. Each of the hemorrhoids is removed in turn and a small piece of petrolatum gauze inserted into the rectum. The skin should never be included in the jaws of the clamp. If excessive skin tabs are present with the piles they should be cut away or undercut up to the mucous membrane at the beginning of the pile and removed en masse with it. It is important that the incision freeing the skin tag should be made sufficiently deep so as to include the external
hemorrhoidal plexus of veins and their supporting stroma which commonly shares in the hyperplasia of the veins and is an important part of the
pathology. The patient
1
rhoidal operations.
per cent,
or,
prepared by catharsis and sedation as in the usual hemorThe anesthesia may be local infiltration of novocaine, better, the injection of anucaine supplemented by novocaine.
is
will give decidedly better relaxation of the sphincters essential in using a cumbersome clamp and the after-pain will also
Anucaine
less.
which
is
be decid-
edly
The postoperative treatment consists in the application of hot compresses

of boric acid or saline solution, appropriate sedation tion of soothing ointments.
and the
local applica-
The cutting current has no place in the surgical (c) Cutting Current. treatment of any type of hemorrhoid. The electric snare has been used and recommended for the removal of internal hemorrhoids. However, the technique will not be described because the author considers the method uncertain and unsurgical. Its use has resulted in large ulcerated areas,
followed anus.
by
excessive scarring, secondary hemorrhage
and
stricture of the
572
Theoretically surgical diathermy and other electrical methods Critique. would appear to be ideal in the removal of hemorrhoids, but in practice these methods are distinctly less satisfactory than a clean surgical ligature 3 The vaunted advantages of these methods being operation (Gorsch ). or an office procedure and bloodless can only be offered to a ambulatory few selected cases of uncomplicated internal hemorrhoids, since the vast majority of them are complicated with other pathological changes. Hemorrhoidectomy is not and should not be an office procedure. A hemorrhoidectomy of even moderate degree demands a few days' rest in bed for the comfort and safety of the patient and for the prevention and immediate treatment of complications. It, therefore, cannot be considered an ambulatory method. The fact that electrical methods may be bloodless is erroneously thought to be a decided advantage. Actually the majority of the cases of hemorrhoids have chronic submucosal infections, with infected crypts and muscular glands and large chronically infected skin tabs. Removal of these and proper subsequent drainage at the base of the hemorrhoid is essential to a complete hemorrhoidectomy and satisfactory endresult. Moreover the blood loss in a properly performed surgical operation for hemorrhoids is quite negligible. Electrothermal surgical methods in the hands of the inexperienced have
led to excessive scarring with indolent ulcerations, burrowing infection, deep sloughing, secondary hemorrhage and an unwarranted amount of
postoperative pain. In carefully selected cases and for palliation and in experienced hands the results may be satisfactory. Surgical Galvanism. Surgical galvanism or electrolysis (Chapter VIII) depends on the deposition of caustic ions into the hemorrhoid and its supporting connective-tissue stroma. An inflammatory reaction ensues which after final resolution and absorption of the inflammatory exudate supposedly shrinks up the pile. The technique of destruction by negative galvanism as advocated by 4 Keesey is as follows: An extra long especially constructed steel needle is used as the active electrode from the negative pole; it is inserted in the longitudinal axis of the lumen of the hemorrhoidal vein, care being taken
not to transfix
it.
several minutes, until the entire
black color. It is usually is absorbed with very little pain. The negative galvanic method is recommended only for internal hemorrhoids and is not applicable for those covered with skin. Non-protruding hemorrhoids must be treated after adequate exposure through a speculum. No local anesthesia is employed, for if one succeeds in inserting the needle into the lumen of a vein, as Keesey expects, there should be no undue sensation; a burning pain should indicate the need for shifting and reinsertion of the needle-point. As a matter of fact the relative lack of pain, in our opinion, may be much better explained by the insertion above the papillary line where there is a comparative lack of sensation of pain. Large hemorrhoids should be treated by several sessions about every third day, treating separate parts of the tumor with a current flow of not over five minutes each time. Keesey estimates about six treatments required for the average large hemorrhoidal mass, and he claims that postoperative recovery is smooth, hemorrhage never occurs and recurrence is rare.
current from 10 to 15 milliamperes is applied for tumor turns a characteristic dark red or claimed that following treatment the thrombosed mass
STRICTURE OF THE RECTUM AND ANAL CANAL

definite value of this
573
Further experience in competent hands is needed to determine the method. Fistula In Ano. Physical measures play a minor role in anorectal fistula. Iontophoresis has been used but is of questionable value. The roentgen-ray has been highly recommended by French authors and in extensive fistulse with multiple openings, it may perhaps be of some value. We have had no experience with this method and it does not appear to be popular in the United States. The use of roentgen-rays around the genitalia has obvious limitations. In the surgical treatment the cutting current would theoretically appear to offer decided advantages in the excision or incision of fistulse. However, in our experience, the electric knife cuts with such rapidity that it is difficult to judge whether one is cutting through diseased or normal tissue, a most important consideration for good fistula surgery. We still find the scalpel the most sensitive effective weapon for this type of surgery. Moreover the dissection of tracts close to the rectal wall with the cutting current is done with considerable risk of immediate or remote perforation. The
actual cautery
is
preferred
by some
in the tuberculous variety of fistula
when
can be determined beforehand. Fissure In Ano. Uncomplicated cases of fissure in ano which commonly result from the passage of hard stools may be treated successfully by electrotherapeutic measures. The severe pain, spasm and soreness often accompanying fissure may be relieved by medical diathermy applied to the anal musculature. A small metallic rectal dilator may be used as the active electrode. The application should be continued for from fifteen to twenty minutes with a current strength of from 1000 to 1500 milliamperes. Complicated fissures secondary to hemorrhoids or fistulas should be treated
this
surgically.
The static-wave current or the Oudin current may also be used with the usual percutaneous application. Chronic constipation is so commonly associated with fissure that electrotherapeutic measures directed to its alleviation should be enjoined. Medical diathermy has Stricture of the Rectum and Anal Canal. proved to be of marked benefit in those cases of rectal stricture in which surgical intervention is either contraindicated, refused or unwarranted because of the nature and extent of the pathological process. Lymphogranuloma inguinale, the fourth venereal disease or, better termed, lymphopathia venerea has now assumed a particularly important etiological role
diathermy has unquestionably saved
majority of rectal strictures, particularly in women. Medical many of these patients the disagreeable stigmata of a colostomy. It has also materially lessened the rectal discharge always present in stricture, reduced the pain and tenesmus and has made these unfortunates decidedly more comfortable. Diathermy has also been recommended as a postoperative therapeutic measure in those cases in which the walls of the stricture have been freed
in the vast
by
incisions into the ischio-rectal fossa.
of diathermy application in these cases is sometimes quite difficult and exacting; the treatment entails the skilful introduction of a metallic electrode through spastic anal sphincters and through a long stricture, the lumen of which is quite irregular and variable in caliber. It is essential that the electrode employed should extend the entire length of
The technique
574
the stricture, since the entire stricture must be treated; furthermore, as the stricture becomes gradually dilated larger electrodes must be used, either during the same treatment or in subsequent treatments. For this
reason
it is
strongly advisable that treatments be carried on through a
close cooperation of the proctologist and the physical therapist; the former should preferably pass the electrodes during the first few treatments.
Patience and close application are necessary and the treatment must be extended over a long period of time at regular intervals. The gratifying results make this effort worthwhile. Each treatment should continue for at least one-half hour with a current strength of 1000 to 1500 milliamperes, according to comfortable toleration. The type of electrode to be preferred is shown in Figure 169; these electrodes are available in increasing size. In small-caliber strictures large urethral sounds may be usefully employed.
Anal strictures usually respond to surgical treatment; however if this be contraindicated, diathermy may be helpful. Increasing sized metal Pratt dilators make suitable electrodes for the anal canal; for the rectum, the simple straight graduated tubular electrodes devised by Frankfeldt
are quite satisfactory. Polypi of the Rectum and Colon. Under the generic name of polypi are included a number of usually benign tumors of various histological
structure.
They predominate
in the
potentially malignant, particularly the demand prompt eradication. are

all
rectum and sigmoid, and since they adenomata in adults, they
Surgical diathermy is decidedly the method of choice in the removal of these tumors and may be employed with excellent results. The sphincters should be relaxed either with the injection of anucaine or novocaine and
the patient placed either in the Hanes or raised later to Sims' position. large proctoscope which is preferably insulated is introduced and the tumor removed by biterminal coagulation with the Gorsch suction electrode, which removes the smoke and keeps the field clear. The base of the tumor should be completely destroyed, leaving a healthy granulating surface after the tissue has sloughed away. This procedure is particularly useful in the pedunculated polypi usually found in children. It may be further advisable when malignancy is suspected to coagulate around the periphery of the pedicle to prevent spreading through the immediate
adjacent lymph vessels as much as possible. Tumors higher in the rectum or in the sigmoid and usually found in adults are frequently already malignant and often present a difficult problem. If pedunculated they may be destroyed by fulgurating or coagulating the pedicle as previously described. Their removal may be more easily carried out with a suitable electric snare (Fig. 315). The wire loop ensnares the entire pedicle of the tumor and as the wire cuts through its base the loop is gradually drawn up. The wire snare should not cut through the tumor too rapidly, since the object of the electric snare is to destroy as much of the tumor pedicle as is feasible while the wire actually coagulates and destroys it. Additional fulguration of the base if deemed necessary may be done with a blunt tip of the Gorsch suction electrode, assuring complete destruction of the base. The technique requires practice and is not as easy as described. It is essential that the operator be familiar with his machine and the
PROCTITIS
575
depth of current penetration, under various settings and in various tissues. A slow cutting current with some coagulation in its wake is the best. Peritoneal penetration is, of course, possible and should this occur, immedi-
FIG. 315.
Electrosurgical snare particularly useful in proctological electrosurgery, with various types of electrodes. (Gorsch, courtesy of the Am. Jour. Surg.)
ate laparotomy must be done. In carrying out electrosurgical operations about the anus it is advisable to use a separate source of current for illuminating the anoscope or proctoscope because the current from the machine may blow out the illuminating lamps and may likewise shock the patient.
O
FIG. 316.
Hr-o
(Gorsch, courtesy of the
Electrosurgical snare showing biopsy cups. Am. Jour. Surg.)
Frequent re-examination of the
site of
removal
is
desirable.
may
appear.
Radium implants
to accessible malignant
tumors
New tumors may also

of obtaining
be advisable.
Biopsy.
The
cutting current loop affords the ideal
method
specimens of tumors from the rectum or sigmoid and other inaccessible locations. The chances of hemorrhages are greatly minimized and the site of excision may promptly be coagulated to prevent the spread of tumor tissue by implant or traumatic extension. The author's electrosurgical snare shown in Figure 316 is of particular value in securing biopsy specimens from the sigmoid through long and small
caliber sigmoidoscopes.
glands
Certain types of proctitis with infected anal crypts and be benefited by medical diathermy, as already described. Ultraviolet rays applied through a quartz rod into the rectum may prove
Proctitis.
may
of benefit in the chronic cases of proctitis complicated by rectal or anal tuberculosis. Physical measures directed to build up the general condition of the patient are likewise to be considered.
576
Rectal gonorrhea
is
Gonorrheal Proctitis.
much more
frequently asso-
ciated with a genital infection of gonorrhea than is usually suspected. 1 Desjardins and his co-workers state that with improved methods of fever
therapy 90 to 95 per cent of patients can be cured of this usually so resistant chronic infection. It appears that fever therapy combined with chemotherapy, the sulfonamides, and penicillin will eventually supplant the older and less specific methods of rectal irrigations or topical applications. It should be worthy of emphasis that rectal gonorrheal cryptitis may
be an important focus for protracted gonorrheal arthritis and hence fever therapy should be of particular value in these cases. Pruritus Ani. Pruritus ani is sometimes benefited by the application of ultraviolet radiation. A second- or third-degree erythema should be produced, depending on the tolerance of the patient and the condition of the pruritic skin. Experience is needed to determine the correct dosage in the In refractory cases ultraviolet radiation has often proved individual.
disappointing.
Favorable results have been reported by Rolfe 6 with ionic medication in the treatment of pruritus ani. Zinc sulphate, zinc permanganate, copper sulphate and iodine have been among the recommended chemicals. Twelve to 20 treatments are usually necessary and the cure is frequently not permanent. The necessity for special apparatus and for an exact technique together with the length of treatments have tended to discourage the average physician from the use of ionization. However, in selected cases the results would seem to warrant its use. Roentgen radiation in the treatment of pruritus ani should be used This form of treatment seems to benefit many cases but cautiously. recurrence following its application, in the author's experience, has been all too frequent. Roentgen-ray dermatitis or burns with permanent skin destruction have resulted often enough to stamp the roentgen-rays as of
at least questionable value. Furthermore, it is impossible to predict the reaction of the perianal skin and mucocutaneous junction in many cases of pruritus ani. In intractable cases Turell 8 has reported some success by
tattooing with mercuric sulphide.
Coccygodynia. In agreement with the statements in Chapter XXVIII the author wishes to go on record that in coccygodynia surgery is frequently disappointing and it should be preferably used only after a thorough trial of diathermy and other physical measures. (Rectal Phobia, Sphincteralgia, Neuralgia, Hysteria of the Rectum, etc. Sphincterismus, and Anal Cramp). This collection of terms refers to a group of ill-defined conditions, usually functional, which manifest themselves primarily through the neuromuscular apparatus of the anorectal region. They are not all well understood, in fact, the innervation of the anus and rectum is not fully understood. These functional aberrations are characterized by sensory disturbances of which attacks of pain, spasm,
burning, itching, irritability, etc., are common complaints. Several of these intractable cases follow rectal surgery in which excessive scarring persists in the anal canal. Reflex possibilities and psychogenic factors are important. It is frequently impossible to assign any causative demonstrable pathology, but organic pathology must be carefully ruled
out and psychopathic examinations are advisable. It would seem that physical measures should be of great value in these
CANCER OF THE RECTUM
577
intractable cases and this is not sufficiently appreciated. Surgery usually aggravates their conditions. Rectal diathermy, abdomino-rectal, abdominovaginal or transpelvic diathermy are most generally available. Cabinet electric baths, ultraviolet radiation, the static wave and the galvanic bath
may likewise prove useful. These electrical modalities combine psychic with general systemic effects which may prove of considerable benefit to this type of patient. Tuberculous Peritonitis, Enteritis and Anorectal Tuberculosis. The value of the ultraviolet light in the treatment of selected forms of tuberculosis seems well established. It reduces the incidence of pain, cramping, diarrhea, nausea and vomiting, stimulates appetite, and prolongs life. However, the therapeutic value of heliotherapy in this condition depends almost entirely on its general systemic effects and hence local application of light in tuberculosis is of little value. The author prefers large carbon arc lamps. The proctologist might well avail himself of the value of heliotherapy both before and after operative procedures on patients with tuberculous fistulse, coccygeal, and sacral tuberculous involvement, and particularly anorectal tuberculous ulcerations which are notoriously resistant to all forms of therapy. Tuberculous involvement of the intestines and peritoneum should be watched for. A course of general ultraviolet often has a salutary effect on sluggish perineal wounds and in selected cases roentgen-rays may be cautiously
used.
Cancer of the Rectum. Electrocoagulation in the treatment of cancer rectum was first introduced by Kolischer in 1910. It was primarily used for cases considered inoperable but with improvements in armamentarium and electrosurgical techniques its scope broadened to include cases also falling within the field of radical surgery. This has provoked some controversial opinions concerning operability and other criteria which are
of the
still
unsettled.
Earlier diagnosis, improved surgical technique, better pre- and postoperative care together with chemotherapy have increased materially the
These factors have operability rate and the scope of radical surgery. tended to circumscribe the indications and limitations of electrosurgical methods and there appears to be less enthusiasm for them than formerly. Electrocoagulation in rectal cancer has inherent limitations. The more important of these are the location of the tumor with particular reference
of the
to adjacent viscera, the extent of the metastases, if any, the configuration tumor and finally the grade of the malignancy. The size and loca-
growth bear no constant relation to the extent of the remote metastases or the local infiltration. Obviously electrothermic methods can only destroy the growth accessible through the proctoscope and the depth and ultimate destruction are sometimes difficult to
tion of the primary
local or
determine.
These limitations are less applicable to radical surgery and they should be carefully considered in the selection of the method to be used. On the other hand electrocoagulation has three undisputed advantages as enumerated by Sawyer: 7 (1) The almost complete lack of shock. (2) The low morbidity and mortality. (3) The avoidance of colostomy in most
cases.
These advantages unfortunately apply largely to the inoperable

37
578
in the rejection
group and they should not receive undue consideration

of radical surgery.
Electrosurgical
methods have
definite
and
justifiable indication in the
following cases.
question which in competent hands.

1.
of operability should be based on a careful
The question
however is always a moot and complete investigation

and
in colostomized
Inoperable cases
to relieve rectal obstruction
2.
patients to relieve hemorrhage and tenesmus. Cases in which radical surgery is contraindicated.
3.
4.
Cases refusing radical surgery. Malignant polyps or adenomata.
The commonest indication for electrocoagulation is the malignant polyp or adenoma, usually single, of low grade malignancy and usually readily accessible through the proctoscope. Routine proctoscopy would undoubtedly disclose many of these tumors in their early stages and materially increase the opportunities for their complete eradication by electrocoagulation or desiccation, particularly the pedunculated variety. The location of these tumors with respect to the peritoneal reflection is very important, particularly in the sessilated variety where the unknown factors of local infiltration or extramural metastases must receive serious consideration. The pedunculated tumors are preferably removed with the electric snare (Fig. 280), and the base coagulated as indicated. This procedure offers the maximum of tumor tissue for histological examination. In the small sessilated tumor it may also be advisable to do a biopsy. With a high grade of malignancy in a young adult patient the decision as to the best approach may be difficult. Although only a small percentage of malignant growths are amenable to electrosurgical methods a better evaluation and a sharper definition of its indications and limitations is advisable, through a larger number of accurately recorded results. The technique of electrocoagulation is exacting and requires a thorough knowledge of the electrosurgical modality used and its particular electrosurgical effects on the tissues. A suction electrode which effectively clears the field of smoke is essential. Proctoscopes should be well lighted from a separate current source than that used for the electrocoagulating unit.
REFERENCES
1.
DESJARDINS, A. U., STUHLER, L. G., and POPP, W. C.:
Jour.
Am. Med.
Assn., 106,
690, 1936. 2. GORSCH, R. V.:

3.
A New
1937.
Perineo-pelvic Anatomy, New York, Tilghman Press, 1941. Electrosurgical Snare, Am. Jour. Surg., n.s., 35, No. 3, 617-618,
4.
KEESEY, W.
5.
6.
E.: Obliteration of Hemorrhoids With Negative Galvanism, Arch. Phys. Ther., X-ray and Rad., 15, 9, 1934. KOBAK, D.: Medical Diathermy in the Treatment of Hemorrhoids, Arch. Phys. Ther., X-ray and Rad., 15, 12, 1930. ROLFE, W. A.: Treatment of Pruritus Ani by Ionic Medication, Jour. Am. Proctol.
Soc., p. 9, 1921. F.
:
7.
SAWYER, HAROLD
Trans.
The Use
of Electrocoagulation in
Carcinoma
of the
Rectum,
Am.
Proct. Soc., 1942.
8.
TURELL, R.:
Pruritus; Anatomico-Clinical Study, 1944.
Tattooing With Mercuric Sulphide for Treatment of Intractable Am. Jour. Obst. and Gynec., 42, 290-296,
CHAPTER XXXIII
Corns.
Dermatophytosis.
Acne Vulgaris. Alopecia. Benign Neoplasm. Callositas. Eczema Seborrhoicum. Erysipelas. Furunculosis. Im-
petigo. Keloid. Keratoses. Leukoplakia. Malignant Neoplasms. Neurodermatitis. Psoriasis. Rhinophyma. Sycosis Vulgaris. Telangiectases. Tuberculodermas.
Ulcers and Wounds.
Verruca.
Hypertrichosis.
(a)
Electrolysis.
(6)
High-fre-
quency Epilation.
General Considerations. Dermatological treatment has been practically revolutionized during the past the introduction and twenty-five years by widespread use of physical therapeutic measures. Foremost among these are roentgen-rays, but included are all other forms of electrotherapy and
and to a limited extent hypothermy or therapeutic refrigeraand massage. Surgical diathermy or electrosurgery is widely employed in the form of desiccation for removal of superficial lesions where good cosmetic results are essential; in recent years it also has been used as an alternate method for the removal of superfluous hair. Warts of all types, keratoses of the seborrheic, senile, radiodermatitic and chemical types are best eradicated with some form of surgical diathermy. Even so-called permanent freckles
light therapy,
tion,
may
be made to disappear when treated with superficial electrodesiccation. Small localized lesions of lupus vulgaris, tuberculosis verrucosa cutis,
and lupus erythematosus are quickly, easily and permanently destroyed with electrocoagulation or electrodesiccation. Cavernous angiomas, pigmehted and hairy moles can be destroyed with little or no scarring by the proper selection and application of electrosurgery. However, in nevi one must be careful not to traumatize a potentially malignant melasarcoid
noma.
In malignant growths of the skin seasoned surgical judgment is necessary to decide whether electrosurgery is indicated at all and, if so, whether it is to be used alone or in combination with roentgen-ray or radium.
Many
benign lesions such as fibromas, granuloma pyogenicum, xanthoma,

cystic epitheliomas are often
adenoma sebaceum, and multiple benign
very satisfactorily treated with electrosurgery. Rhinophyma, a most disfiguring condition, can be improved with electrodesiccation, electrocoagulation and electrocutting. The type of current selected depends upon the severity of the condition. Tattoo marks and powder stains may be
superficial electrodesiccation and gentle curettage. The and technique of all electrosurgical methods have been general principles fully described in Chapter XIII. According to Cipollaro, a mistake which often occurs is to remove benign and malignant new growths as well as verrucse and keratoses with moderately strong electrosurgical currents without using anesthesia. The operator has to work hurriedly and may not remove the lesion thoroughly, because of the great pain caused by electrosurgery. Anesthesia is always recommended. The galvanic current has been employed for many years in the form of electrolysis as the standard treatment for hypertrichosis, and can be also
improved by very
(579)
580
used for the destruction of telangiectases associated with radiodermatitis, rosacea and nsevus araneus. Small nevoid and seborrheic keratoses, multiple benign cystic epitheliomas and adenoma sebaceum as well as small common hairy nevi and the flat, digitate, filiform and small common warts can be destroyed without disfigurement with the galvanic current. There
is
no danger in treating by
this
method brown hairy moles that have been
present since birth, provided the diagnosis is correctly made. It is difficult sometimes to differentiate a potentially malignant mole from one which All dermatologists agree that whenever there is doubt one is benign.
should resort either to radical destructive methods or leave the mole alone and carefully observe it periodically. Iontophoresis has found in recent years an increasing employment in dermatological conditions. Mecholyl iontophoresis is valuable in the treatment of chronic varicose ulcers, lupus pernio, sclerodactylia, scleroderma and Raynaud's disease. Copper iontophoresis has been recommended in the treatment of fungous infections of the skin, especially dermatophytosis and chronic recurrent eczema of the hands. The general technique of iontophoresis as well as of electrolysis has been described in Chapter VIII. Ultraviolet irradiation, local and general, has a definite applicability in
skin conditions, as already stated in Chapter XVIII. There exists some confusion as to the therapeutic effectiveness of light therapy in skin infections; some of this is based on the recently more and more emphasized
fact that ultraviolet radiation penetrates only to a very slight depth through the skin (see Fig. 212 of Bachem and Reed); therefore the bactericidal effects of ultraviolet are necessarily limited to conditions which are situated at a depth accessible to this radiation. Scholtz 9 states that
may be divided into three groups, according to the average depth of the pathological process: Group 1, those wholly or for the most part in the epidermis Group 2, those wholly or for the most
bacterial diseases of the skin
;
part in the superficial corium; Group 3, those wholly or for the most part in the deep corium or subcutaneous tissue. Scholtz 9 concludes that only a few bacterial diseases are accessible to bactericidal ultraviolet radiation. However, clinical experience shows favorable results in a number of conditions which are situated outside of the effective range of bactericidal radiation. The additional factors accountable for these results appear to be the following: (1) Most of the ultraviolet generators emit a varying amount of infrared radiation which has a definite role as an aid in the local defense mechanism; (2) the circulatory changes associated with the erythemal effect of ultraviolet play an undoubted role in the subsequent therapeutic effect; (3) compression of the skin with quartz lenses as in the Finsen treatment allows a deeper penetration of the bactericidal radiation
itself.
It is evident, that as in all other specialties correct diagnosis is the essential prerequisite for the proper selection of indicated physical measures in dermatology but in the following alphabetical discussion of the various
,
skin conditions because of limitation of space diagnostic considerations had to be minimal or fully omitted. The treatment of hypertrichosis by
electrolysis and by high-frequency removal will be presented separately at the end of this chapter, because of the large amount of detailed technical
considerations involved.
DERMA TOPHYTOSIS
Acne Vulgaris.
581
According to Cipollaro practically all forms of acne Some cases require erythema vulgaris respond to ultraviolet radiation. doses and others do better with more intense radiation. Judgment is
required in selecting the particular technique for the particular stage of the disease. Severe cases of acne can be kept under control indefinitely with ultraviolet rays and many of them can be cured permanently. Exfoliating doses of cold quartz are particularly effective in improving post-acne
scarring.
There are two main groups of alopecia, the premature group be subdivided into the seborrheic, idiopathic and hereditary may types and the areata group which may be of the localized or universal type. All these types have been treated by dermatologists and others with ultraviolet rays. All are not in agreement that this agent is essential in the treatment of these conditions. However, it can be safely stated that it is a useful adjuvant for the treatment of alopecia areata and some cases of alopecia prematura. The doses, however, should be sufficiently large to produce hyperemia or a moderate reaction. It must be understood that in no sense is ultraviolet radiation a "hair grower." Benign Neoplasms. Adenoma sebaceum consists of small papules which can be destroyed by mild electrodesiccation with perfect cosmetic result. Lesions should be left to slough off naturally and are not to be curetted off. Fibroma. Fibroma, especially the small, pedunculated type common on the neck can easily be destroyed by a very light sparking of electrodesiccation. Xanthoma nodules also can be removed by desiccation, while in xanthelasma lesions located on the eyelids, destruction by trichloracetic acid usually works better. Callositas. Callosities are usually very sensitive and occur for the
Alopecia.
which
in regions of pressure and friction. They appear most often on the plantar surfaces of the feet. Electrodesiccation is suitable for most of the smaller and medium-sized lesions. In applying the current the author uses no anesthesia during the first treatments. This necessitates staying within the callus to prevent destruction of normal sensitive tissue and causing postoperative pain. Two or three treatments are necessary and at the last, when the tumor is reduced to a small size, a small quantity of novocaine is injected to treat the last vestige of callus. During treatments a protecting pad with an opening the size of the lesion must be worn about the area and continued for about a month to guard against recurrence from too early pressure. Larger calluses can be excised with the
most part
cutting current, but this requires full local anesthesia and usually keeps the patient off the feet for a day or two. Corns. Corns (clavus) are treated in the same manner as callosities. 4 Dermatophytosis. The author has reported a series of chronic cases with 1 to 3 treatments of the thin window lamp, and fully cleared up
undoubtedly other ultraviolet generators exert similar beneficial effects. Cipollaro warns that acute cases should not be further traumatized with intensive ultraviolet irradiation. Topical remedies are always used and ultraviolet radiation is a valuable adjuvant in some types. One should not rely solely on ultraviolet rays for the treatment of fungous infections. 3 Copper iontophoresis is praised by Haggard et al. because of the fungicidal The technique of treatment conproperties of copper and its low toxicity. sists of using rectangular enamel pans for the feet and bain marie basins
582
for the hands, as illustrated. When the infection is on the feet, the hands are immersed in saline solution and the feet in a 0.2 per cent copper sulphate
solution; for infection of the hands the relations are reversed. If hands and feet are infected, the solutions in the baths were reversed at the end of the regular twenty minutes of treatment and an additional period of
is given. Copper electrodes are used: the positive pole is attached to the electrode in the copper solution and the negative to that in the saline solution. If only one hand or foot is immersed, 4 to 6 milliamperes of
treatment
current is used, and if both are immersed, 8 to 10 milliamperes of current. In the series reported, these clinicians treated when possible each patient two or three times a week; no other treatment was used. When it was necessary to clean the hands or feet, the crusts were removed mechanically
FIG. 317.
Copper iontophoresis
in fungus infection.
(Courtesy of F.
W. Haggard
et al.
and
Jour.
Am. Med.
Assn.)
with soap and water. However, preliminary soaking of the extremities for a few minutes in a dilute solution of sodium hypochlorite i highly efficacious in preparing the skin for treatment. The treatment was given to 37 patients in whom diagnosis of dermatophytosis was made clinically. Most cases were severe and of long standing. Various types of eruption were present: erythematous, scaly, desquamating, denuded, macerated, fissured, hyperkeratotic, vesicular and pustular. Results were most striking
when the
infection
was particularly active and showed
bullse
and
vesicles.
In most instances, subjective symptoms disappeared within twenty-four hours after the first treatment and the vesicles flattened without rupturing. One of the first results was lessening of the moisture in the skin. When the entire extremity showed dry, normal-appearing skin, treatment was
ERYSIPELAS
583
discontinued. Twenty-six patients obtained a clinical cure. The number of treatments required varied from 4 given in two weeks to 18 given in eight weeks, the average being slightly more than 6.
While some dermatologists regard the

as doubtful,
it
stubborn cases. Eczema Seborrhoicum. Occasionally this condition improves when treated with ultraviolet rays, especially if the lesions are chronic and of
long standing. To localized areas fairly intensive doses may be administered with the air-cooled lamp. Generalized and recalcitrant cases sometimes respond better after the administration of general body radiation. Chronic eczema of childhood and intertrigo are also sometimes benefited
results of copper iontophoresis unquestionably represents a method worth trying in all
by
this
mode
of therapy.
Fro. 318.
Feet before copper treatment.

Jour.
(Courtesy of N.
Assn.)
W. Haggard
et al.
and
Am. Med.
Erysipelas. In recent years the successful use of sulfa drugs has obviated the necessity for much local treatment used heretofore. Mention has been made in Chapter XVIII of the specific effect claimed for ultraviolet radia-
on erysipelas. The original investigators recommended local irradiation of the affected area, including 1J inches of the healthy skin to the extent of a third-degree reaction. Either an air-cooled or a water-cooled
tion
lamp may be employed. The area should be
left
uncovered after treatment.
state that one treatment usually suffices to bring about a critical fall in temperature and a clearing up of the condition and that relapses
They
584
up with equal promptness on subsequent
irradia-
are rare and can be cleared

tion.
In an early stage of a furuncle (incipient abscess or hard an attempt may be made to abort the process by producing a thirddegree erythema in the center of the lesion by a local contact ultraviolet This will take from twenty irradiation through a suitable applicator. seconds to a minute according to the condition of the burner. This dosage may be repeated, if necessary, as soon as the skin reaction subsides. Granger
Furuncles.
boil)
recommended
boil
either indirect or direct
"
"
f ulguration
to the center of the
from the Oudin terminal.
FIG. 319.
Feet after copper treatment.

Jour.
(Courtesy of N.
Assn.)
W. Haggard
el al.
and
Am. Med.
If the abscess or boil is in the stage of suppuration, repeated exposure to a small luminous heat lamp, one-half hour once, or more often, daily will promptly relieve the unpleasant throbbing and tenderness and promote,
like
a poultice, spontaneous opening and quick resolution. When. the abscess has evacuated or is chronic, exposure to ultraviolet for a second-
degree erythema, dose, will speed up resolution. It is important that proper drainage be maintained. Short-wave diathermy has had a passing vogue by some clinicians in recent years on account of the pain-relieving and resorptive effect claimed
it on all types of furuncles. In multiple abscesses (furunculosis) of adults, a systematic course of general ultraviolet baths should be administered, in addition to local treatment of individual lesions. In infants, similarly, general ultraviolet irradia-
for
tion
is
advisable in increasing doses while the Speeding
is
suitably regulated.
KERATOSES
is
585
up by a single ten-minute exposure with the thin window lamp. The additional advantage of this treatment is the avoidance of messy ointments. Keloids and Hypertrophied Scars. A keloid denotes idiosyncrasy, and removal by any method that causes traumatism is likely to be followed
a
Impetigo. -Ultraviolet irradiation, especially of the bactericidal range indicated; the authors has reported a series of cases completely cleared
by However, some keloids may be eradicated by first removing them with electrosurgical cutting and while the wound is healing
still
larger keloid.
by applying roentgen-rays.
Hypertrophic scars may be due to tension and do not necessarily indicate idiosyncrasy. Larger scars yield only to roentgen-ray or radium, but in smaller ones chlorine-iontophoresis, as described in Chapter VIII brings often a good result if persistently applied.
FIG. 320. Keloid before treatment with cutting current and roentgen-rays. (Courtesy of Dr. J. J. Eller.)
'
FIG. 321. Keloid after treatment with cutting current and roentgen-rays. (Courtesy of Dr. J. J. Eller.)
Keratoses. Physical measures are sovereign in treating keratoses, but a correct diagnosis and a differentiation of the type in treating of keratosis is essential before the kind and extent of treatment is determined. Keratosis seborrho?ica is the most common type and it usually yields promptly to thorough desiccation, which also should include the normal skin around the periphery. According to MacKee and Cipollaro 7 if there is a definite
under the horny layer, the area may be curetted after such and the resulting wound again electrodesiccated, although such procedure usually leaves a mild permanent scar. Keratosis senilis is one of the forerunners of epidermoid cancer; it yields to the same treatment as just outlined in case the lesion is thick or elevated, more thorough destruction is indicated, which should include establishing first a circle of coagulation a few millimeters beyond the lesion and extendinfiltration
desiccation
ing down to the corium. Arsenical keratoses resemble senile keratoses and should be treated the same way. They often give rise to basal or prickle cell cancer and, therefore, if numerous must be treated expectantly and the patient kept under
586
close observation.
Roentgen-ray and radium keratoses also yield to electrois much less favorable because of the frequency of subsequent degeneration and sclerosis. Leukoplakia may likewise be the forerunner of a cancer; when treated with desiccation the entire thickness of the mucous membrane must be thoroughly destroyed, with the treatment extending beyond the periphery
desiccation but the outlook
of the lesion.
Malignant Neoplasms. The diagnosis and treatment of the various forms of cutaneous cancer require adequate skill and experience, and the average physician therefore had better consult in case of all malignancies a colleague who has such specialized knowledge. Basal and squamous cell epitheliomas, melanomas and malignant sarcomas should not be treated with mild destructive agents such as electrolysis, carbon dioxide snow or
cauterization, as these usually result in irritation, widespread metastasis.
more rapid growth and
FIG. 322 FIG. 322.

of chin.
FIG. 323
was a lemon-size stony hard mass of Lymphosarcoma twelve years' duration in a man, aged sixty years. There was a nut-size hard gland on left side ef neck. Microscopic diagnosis of lymphosarcoma. The tumor and gland were removed by the high-frequency knife while the base was electrocoagulated. Following this, three treatments of high-voltage roentgen-rays were given the neck lymphatics and site of tumor. FIG. 323. Lymphosarcoma of chin after treatment. No recurrence after two and a half years. (Eller and Fox, New York State Jour, of Medicine.)
lesion
The
These lesions may be curetted by using a novocaine or a spray of ethyl chloride; then iodine is applied to the base of each lesion. Very good results are also obtained by electrodesiccation, as in verruca vulgaris. Neurodermatitis. Patients with either the localized or the disseminated type of neurodermatitis improve when exposed to ultraviolet radiation. The rays are applied to the entire body. Excessive reaction should be avoided. During the summer, patients are invariably better than in winter. This is true especially in those cases that have the disseminate
local anesthetic of
Molluscum Contagiosum.
of neurodermatitis. The same good results may be accomplished during the cold months if generalized ultraviolet rays are applied daily in suberythema doses. Nevi. There are a variety of suitable physical agents for the various
and generalized variety
types of birthmarks.
PIGMENTED NEVI
In Nsevus Flammeus or
wine marks
587
port occasionally blistering doses of ultraviolet radiation with or without compression from a water-cooled lamp may eradicate very faint lesions or may reduce the color of the more pronounced lesions. Treatments may have to be administered for several
months or years. Small-sized lesions may be eradicated by carbon dioxide snow with less scarring than with desiccation.
FIG. 324.
Cavernous angioma
(Eller,
before- electro-
FIG. 325.
Cavernous angioma after

(Eller,
electro-
coagulation.
Phys. Therapeutics.)
coagulation.
Phys. Therapeutics.)
Spider or stellar nevi may be best treated by electrolysis. The advantage of treating dilated blood-vessels by electrochemical cauterization instead of thermal coagulation is that there is a minimal skin destruction and less
scarring. With the electrolysis needle, correctly inserted in the lumen of the dilated vein there is an immediate coagulation of its contents and the
subsequent shrinking process of the growth leaves an almost invisible scar. The technique of treatment varies according to whether there is a large central vein or several small ones. A dispersive pad electrode connected to the positive pole is placed under one palm of the patient. The electrolysis needle connected to the negative pole of the galvanic source is inserted for a short distance into the central vein and a current of i to 1 milliampere passed for not over one minute. The blood-vessels treated should change almost immediately to a whitish streak. Small capillary veins and angiomata may be treated by repeated transfixation through the entire mass as in moles. If there are several small visible blood-vessels they should be treated individually, but the insertions are best spaced as far apart as possible to avoid confluence of the secondary reaction and a visibly
depressed scar. Pigmented Nevi. The common mole, a smooth elevated lesion of normal color or of various shades of brown can be removed by electrolysis without any scarring. If brown, pigmented with hairs, these must be first destroyed by electrolysis, afterwards the lesion often disappears without further treatment or the remnants can be desiccated. Black pigmented moles without hair are almost always a dormant melanotic cancer and should be left untreated unless there is an area which is subject to irritation or where there is some sign of growth. The removal should always be
588
palliative treatment
done radically for any mild metastasis and death.
may
result in a general
The course of this disease can be considerably shortPityriasis Rosea. ened by the use of ultraviolet radiation. Not only do lesions disappear but new lesions fail to appear. According to Cipollaro "cold quartz" seems to yield better results than "hot quartz" in most cases. This is
probably due to the exfoliating properties of these shorter wave length
ultraviolet rays. Psoriasis. Carefully applied ultraviolet radiation in suberythema doses is valuable in the treatment of this disease. However, doses sufficiently
large to cause
erythema
may
also cause widespread dissemination
and
generalization of the disease.
Goeckerman and modified by

to ultraviolet radiation.
special technique has been developed by 8 O'Leary in employing coal tar as a sensitizer
A 3 per cent coal tar ointment is applied thickly overnight over all patches of psoriasis, removed next day by a light weight mineral oil, being careful to leave a thin film of the oil on the skin. At the first treatment radiation is applied for one minute at a 30-inch distance after dividing the skin surface into six areas. The time of exposure is increased and the distance decreased each day in order to maintain the skin in a state of mild erythema. After irradiation the patient spends half an hour to two hours in an oatmeal bath or in a tub of water kept at approximately 95 F. This procedure loosens the scales and allows the patient to remove them by brisk rubbing of the skin while in the tub. After the bath a thick coating of the ointment is applied again to the lesions. An inexpensive cotton suit of underwear or a gauze covering is worn to protect the bed clothing. In
addition, O'Leary uses autohemotherapy. The technique consists of drawing 10 cc. of blood from the cubital vein and injecting immediately 5 cc. into each buttock. This is administered at two-day intervals for five doses.
FIG. 326.
Rhinophyma
before treatment.
J. J. Eller.)
(Courtesy of Dr.
FIG. 327. Rhinophyma after combined electrosurgery and roentgen-ray.
According to Eller the early cases can readily be cured They are treated by penetrating each nodule or enlarged sebaceous gland with the needle. The current is then turned on
Rhinophyma.
by
electrocoagulation.
VERRUCA VULGARIS
for the
589
stage, fractional roentgen-rays, unfiltered, are given weekly for several doses in order to prevent a recurrence of the enlargement of the glands. In the more advanced cases, surgery must be resorted to, followed by roentgen-
time necessary for coagulation. After several treatments there is a slight contraction of the inflamed and enlarged sebaceous glands, with the result that the size of the nose gradually returns to normal. At this
ray therapy.
Sycosis Vulgaris. Chronic pustular folliculitis of the bearded region is often incurable. However, patients are much better in the summertime
when they are exposed to solar radiation than they are in the winter. Localized as well as generalized ultraviolet irradiation combined with topical remedies often improves this condition.
Telangiectases. Telangiectatic vessels which occur without discernible cause and those found in radiodermatitis and rosacea may be made to disappear when treated with intensive water-cooled ultraviolet rays under compression. One should avoid overirradiating tissues which have been
damaged by roentgen-rays. Congenital stellar nevi should be treated as described under that heading. Tuberculodermas. Most of the skin manifestations of tuberculosis are aided in varying degrees by exposure to ultraviolet rays. According to Cipollaro the tuberculodermas most frequently treated with light are
erythema induratum
losis cutis orificialis.
of Bazin, lupus vulgaris, scrofuloderma
and tubercu-
radiation,
A. Erythema Induratum of Bazin. General as well as local ultraviolet combined with bed rest, high-vitamin and salt-poor diet and injections of tuberculin yield satisfactory results within a few weeks. B. Lupus Vulgaris. The results of treating this disease with ultraviolet
marked the beginning of the era of artificial ultraviolet radiation. It is well to supplement local radiation with general radiation, especially if there is no evidence of acute visceral tuberculosis. Best results are obtained
with the Finsen lamp (see Chapter XVIII)
.
Perseverance in the administra-
tion of other sources of ultraviolet rays is essential for successful results. C. Scrofuloderma. Local and general ultraviolet radiation should be
used in combination with systemic treatment. Gerson-Sauerbruch diet injections are valuable adjuvants. Small and often repeated doses of ultraviolet rays (natural or artificial) are better than large doses
and tuberculin
applied infrequently. D. Tuberculosis Cutis Orificialis. This form of cutaneous tuberculosis often yields to treatment with ultraviolet radiation, but unfortunately
of
a manifestation of an extension of visceral tuberculosis, in spite in the local lesions the outcome is usually fatal. Verruca Vulgaris. The ordinary types of verruca are readily destroyed by electrodesiccation and then removed with the curette. If a small spark is used very little scarring results. A local anesthetic, such as novocaine
since
it is
improvement
solution,
is
used.
In destroying warts with desiccation one should guard against blistering the surrounding normal tissue. The keratotic areas of the wart are such poor conductors of current that the current often shunts off the wart to the adjacent normal skin where it is concentrated sufficiently to blister. This may be prevented by inserting the needle through the wart to the Here the current soft moist base which is a good electrical conductor.
590
generates heat which destroys the growing center. It is usually preferable to cut the top of the desiccated wart off with scissors and redesiccate the base to prevent recurrences. Ulcers and Wounds. Among the many varieties of ulcers, varicose, trophic and syphilitic ulcers are the most frequently seen by the physical therapist. Whether an ulcer is primarily due to a specific organism or to
trauma, secondary infection with pyogenic organisms is always present. Physical measures aid in clearing up this sepsis, in stimulating regeneration of epithelium and, in chronic ulcers, in improving defective circulation and poor nutrition.
is
Ultraviolet irradiation from either an air-cooled or water-cooled source a generally used measure. The surface of the ulcer must be carefully
cleansed from discharges and all traces of ointments. A second-degree erythema dose is applied in the average case either from an air-cooled or water-cooled lamp. Preliminary radiation for from fifteen to thirty minutes from a heat lamp is advisable. The ulcer is then covered over with a mild antiseptic ointment, preferably boric acid ointment, and the treatment is repeated two to three times at two to three-day intervals, according to the When the ulcer looks cleaner and new granulations appear, condition. only first-degree erythemal or suberythemal irradiation should be employed preceded by one-half hour of luminous heat radiation at a distance of
comfortable warmth.
FIG. 328.
Treatment
of varicose ulcer
by mecholyl
ion transfer.
In tuberculous ulcers a course of general irradiation is indicated in conjunction with the local treatment. In trophic ulcers such a course is
frequently also of benefit. In chronic leg ulcers where the circulation is poor, longitudinal diathermy may be instituted, applied with a foot plate and a cuff below the knee and a mild dosage for thirty minutes. The hot whirlpool bath is even more effective on account of its additional cleansing and stimulating action. It
HYPERTRICHOSIS
591
F. for half
may be applied at a temperature of 105 followed by ultraviolet irradiation.
to 110
an hour and
The galvanic current is a valuable alternate measure in particularly resistant cases, in the form of copper or mecholyl ionization. Copper ionization is administered with the following technique: All interstices of
soaked in a
the ulcerated surface or sinus are packed with small pledgets of cotton 1 per cent solution of copper sulphate. A suitable metal plate
is placed on top of this layer and is held in position with a rubber bandage. Treatment is applied for ten to twenty minutes at a suitable strength of current according to the condition. For an ulcer of a silver-dollar size from 3 to 5 milliamperes of current may be employed for ten to fifteen
minutes; this treatment is repeated once or twice within a few days according to the change in the appearance of the ulcer. In varicose ulcers excellent results were reported with mecholyl ionization
The technique consists in wrapping around the foot and reinforced asbestos paper saturated with 0.5 per cent solution of leg mecholyl and connecting this to the positive pole. A dispersive pad is connected to the negative pole. The ulcerated area is not covered during
(J.
Kovacs 4 ).
treatment until a firm scab has formed over it. Twenty to 30 milliamperes from twenty to thirty minutes and treatment generally given two or three times weekly. Simple varicose ulcers heal more rapidly than other indolent ulcers which have a foundation in thrombophlebitis,
of current are used
obesity,
trauma or
arteriosclerosis.
In chronic leg ulcers other supportive measures are important, especially for the prevention of recurrence. Varicose veins should be treated by elastic bandages. In many cases weekly applications of Unna's paste boot or elastic adhesive bandage are very effective. If there are no contraindications the veins may be obliterated by injections or ligation. Leg ulcers due to arterial disease may be helped by mechanical intermittent occlusion and use of radiant heat. Infected wounds respond to ultraviolet irradiation applied with the same technique as for ulcers. Preliminary exposure for one-half hour to luminous heat or infrared is even more important. As a matter of fact many of these wounds improve rapidly on heat radiation alone, applied daily for thirty minutes or longer, at a distance of gentle warmth. The classical observations of Bernhard of Switzerland on the action of sunlight on infected wounds and those of the late Ochsner of Chicago on the effects of luminous heat on operative and other wounds served as the foundation
for the present-day widespread ditions.
employment
of light therapy in these con-
HYPERTRICHOSIS
Removal of superfluous hair or epilation by physical means has become nowadays a procedure very much in demand for cosmetic or other reasons. Roentgen-ray application which was formerly advocated for a period has been totally abandoned because of its inherent dangers: the dose destructive for the hair root must be applied through the entire thickness of the skin and is, therefore, often followed by atrophy and telangiectasis, with more disfigurement than originally. The two methods of present-day efficient and safe hair removal are electrolysis or removal by electrochemical destruction, and high-frequency
592
removal, preferably by electrodesiccation. Both methods bring the required intensity of caustic application just where it is wanted and are followed by practically invisible scarring. Both methods require a definite amount of skill, knowledge of anatomy of the skin, of antisepsis and of tissue tolerance to thermal and chemical trauma, as well as of the physics and mechanics of the apparatus involved. Electrolysis is the older and more widely practiced method and has been much exploited by lay operators. Physicians should be able to acquire without much difficulty the necessary skill and
experience to do either form of procedure. The essential part of the procedure is to Epilation by Electrolysis. introduce a fine needle, connected to the negative pole of a galvanic generator, to each individual hair follicle and employ an amount of current
just sufficient for destruction. source of galvanic current, as described in Equipment. 1.
Chapter
VIII.
2.
There are two types
Active electrodes, fine needles for introduction into the hair follicle. of needles, non-insulated and insulated. (Fig. 329).
FIG. 329.
Electrolysis needles,
a, insulated; b,
non-insulated.
(Courtesy of Dr.
M.
Marton and Medical Record.)
The more commonly employed non-insulated needles are made of steel or iridoplatinum. They end in a sharp point which facilitates entry into the
hair
follicle.
is
which
usually furnished with a current interrupter. technique the interrupter is seldom used.
Non-insulated needles are held in a needle holder (Fig. 330) In the present-day
FIG. 330.
Needle holder with interrupter and needle.
Insulated needles are
made
of fine wire
with a round end; almost the
entire length of the wire with the exception of about 1 ihillimeter at the end is insulated by several layers of enamel and this arrangement provides
for the concentration of the current
on the end
of the needle.
The
needles
are held in a small base which
directly connected with the fine cord leading to the negative terrninal of the generator. These needles are especially useful for the so-called multiple method of hair removal.
is
3. Accessories: (a) Dispersive electrode, connected to the positive pole; either a moist pad, at least 2 by 3 inches in size, placed under the palm of the patient's hand or a sponge moistened with salt solution and held by
the patient, or a cylindrical metal electrode held in the palm of the patient. (b) Conducting cords as light as possible; a heavy cord drags on the needle holder .and makes manipulation clumsy, (c) A fine epilation forceps (tweezers) for the lifting out of the hair after its follicle has been destroyed.
HYPERTRICHOSIS
593
The forceps with little spring will tire the operator's fingers less. Some needle holders carry an enlarging glass; this is often awkward on account of its fixed position; eye-glasses with suitably strong lenses or a hand lens are better, (d) Good light from an artificial source with a reflector on a flexible stand is indispensable. The author uses with great satisfaction a
special light
equipped with an adjustable magnifying glass (Fig. 331).
FIG. 331.
Magnifying lamp suitable
for epilation and other operations requiring bright illumination.
Preparation of Electrolysis. The patient's skin is sponged with alcohol; removes the skin grease. The operator's hands are washed with soap and water and the needle is sterilized in alcohol or by dry heat.
this also
Electrolysis is a tedious procedure and both the patient and the operator should be as relaxed as possible during the proceedings. The light should be so placed that its glare does not disturb the operator and the patient's eyes should also be shielded. The patient should be placed on a table and the operator should be comfortably seated with the forearm supported. Some operators place the patient in a reclining chair and sit behind them; the chair is so adjusted that the head-rest and the patient's head are almost in the operator's lap.
38
594
The current control of the galvanic generator should be within easy reach of the operator so that current strength can be immediately adjusted according to the sensitivity of the parts and the condition of individual hair follicles. A watch with a plainly visible second hand should also be placed so that the operator can easily time the seconds. In the technique of operation there is a choice of two procedures. With non-insulated needles, the flow of minimum current is set before the insertion of the needle and the current is kept "on" during the entire performance. With the insulated needles, the current flow is started only after the needle or a group of needles has been inserted into the hair follicles.
The second procedure is somewhat safer so far as subsequent scarring is concerned. The method with non-insulated needles is generally employed
and
will
be described
first.
Preliminary setting of the current flow at a speeds up the operation and also helps the needle to in each follicle, as the softening action of the negative pole takes effect as soon as the needle touches the follicular opening. With this arrangement the length of the current flow is simply controlled by the insertion and withdrawal of the needle; the current strength may be
Setting of Current Flow.
minimum strength slip in much easier
changed at any time according to circumstances.

setting of the rheostat should be done by placing the on the dispersing electrode and touching the back of the patient's palm hand with the needle, without inserting it in a hair follicle; this also gets
The preliminary
the patient used to the sensation of the current. A rheostat setting allowing the flow of I milliampere under the condition described usually furnishes a satisfactory strength, about 1 milliampere of current flow for the
operation. The Operation. The patient should be assured that except for a slight stinging at the point treated, there will be no sensation of "shock" which the timid seem to expect. Patients must be instructed to keep the palm
pressed firmly against the dispersive electrode during the entire course of the operation. The operator grasps the needle holder, connected to the negative pole, with one hand and exerts slight traction with the free hand on the parts to be treated. Observing the direction of the axis of the first hair selected, he inserts the needle gently alongside the hair, without any pressure. Traction helps to dilate the follicular opening and straightens the hair
follicle.
If
the direction of the needle
is
correct
it
will slip in
without
dif-
ficulty, and an operator with some experience will have no difficulty in judging by a sense of touch when the end of the hair canal has been reached. This depth varies from T& to inch, according to the type of hair and
its
location.
With the needle correctly connected and entered, a white foam will appear in the opening of the hair follicle very soon and a fine crackling noise may be perceived both of these îre due to hydrogen bubbles produced by the negative pole. The operator should ascertain the strength of current flowing, by glancing at the milliammeter the time and current
;
;
strength necessary for the destruction of the hair papilla vary according to the coarseness of the hair. With a hair of average thickness, a current flow of 1 milliampere for thirty to forty seconds is sufficient; for coarse hajrs the strength of current should be 1J to 1J milliamperes, with finer
HYPERTR1CHOSIS
595
hairs only J milliampere and on the lips only \ milliampere for the same length of time. At the end of this period the needle is withdrawn and the hair treated
grasped by the forceps held in the free hand. It should be possible to out from the follicle with hardly any pull. The end of a correctly removed hair shaft should show the thick hair bulb at its lower end, and there are usually a few hydrogen bubbles clinging to the shaft.
is
lift it
.'
FIG. 332.
Removal
of superfluous hair:
Epilation needle along the hair shaft.
is
correctly inserted
If resistance is encountered in removing the hair, no force should be employed in pulling it out; either the needle may have been inserted in the wrong direction or not enough current was used. Hair follicles, as a rule, run at an oblique angle from the skin and, therefore, the needle must be inserted at a corresponding angle and be felt sliding in easily in the direction of the hair shaft. Any hair which does not come out easily after
the first treatment may be attacked again immediately by reinserting the needle in the correct direction and by assisting with gentle traction of the skin to straighten out a possibly tortuous hair follicle. In other cases, adding a few seconds to the flow of current or increasing its strength by 0.5 milliampere will help, according to the judgment of the operator.
FIG. 333. Epilation needle is inserted at the wrong angle, forcing a false passage. As a result the papilla of the hair will not be destroyed and the hair will grow out again.
With a current more than 1 milliampere there may be danger in the hands of beginners of using it too long and causing subsequent "pitting" of the follicle due to scar formation, hence the technique of some operators of trying every few seconds to remove the hair by gentle traction of the forceps, while the needle is still inserted and withdrawing the needle as soon as the hair comes out. In the average case of hypertrichosis the experienced operator will have little difficulty in continuing after removal of the first few hairs with the
596
current strength found effective and comfortably tolerable. One should be careful in not removing at one sitting too many closely adjacent hairs, for this may result in too much irritation afterward. One also should avoid areas that show signs of previous irritation. After a few hairs in the same location are removed, the sensation of the patient at each insertion of the needle usually becomes less, either due to a certain anesthetizing influence of the current or perhaps simply to the patient's getting used to the procedure. In a sitting lasting from one-half to one hour, 25 to 50 hairs can be removed, depending upon the individual case, the coarseness, proximity and direction of the hair follicles.
Technique With Insulated Needles. Insulated needles offer the advantage that the current flow is restricted to a small area at the end of the electrode, once it has been properly inserted into the follicle. (Fig. 334.) This advantage would be lost if the needle were inserted with the current "on," hence the necessity of starting and shutting off the current flow for each hair and the development of the "multiple" electrode method to avoid the inevitable loss of time with individual hairs.
Insulated electrodes and their holders are lighter than the non-insulated; they cannot be forced into the hair follicle and the needle will bend rather than enter a These electrodes follicle at a wrong angle. must be held about 1 inch back of their tip between the thumb and index finger of the operator and inserted with a slight rotating motion into the hair follicle, observing the direction of the hair. Once properly inserted the electrode usually easily slips along the hair and there is no danger of its piercing the bottom of the follicle. After the needle is inserted the current is gently started, turning on the rheostat to 2 milliamperes,
much
FIG.
cle
334.
Schematic diagram
kept up from fifteen to twenty with a strength of only 1 milliamseconds; pere, the flow must be kept up twice as long. After this period the current is turned off, the electrode withdrawn and the hair
which
is
of insulated electrode in hair folli-
lifted out.
B, inactive insulated (A). portion; C, active insulated portion.
With
insulated electrodes there
is
more
(Courtesy of Dr.
M. H.
Marton and Medical Record.)
difficulty in entering hair follicles; this is frequently due to the clogging of the follicle
by skin fat and may be remedied by wiping the part off repeatedly with alcohol or softening it with a little cold cream. At times it may be necessary to resort to a non-insulated electrode. In the multiple electrode method from 4 to 6 electrodes held in a suitable holder placed on the patient's head are inserted. Their cords are united and their common terminal is inserted in the negative terminal of the generator, the dispersive electrode is connected to the positive terminal. Current strength and time of flow must be calculated according to the
HYPERTRICHOSIS
number
of needles inserted.
597
doing a large amount once the needles
With
skilled operators
of electrolysis this
method
results in saving of time as,
are inserted, all hair roots are simultaneously destroyed. Test Treatment. For beginners in electrolysis and in case of delicate skins or location it may be advisable to remove at the first a
few hairs with a minimum of current strength (not more than 1 milliampere), and in inspecting the area at five-day intervals. Test treatment enables the operator to discover special sensitivity and gets the patient more easily accustomed to the full treatment; it also demonstrates the healing qualities of a particular skin. Except in unusual instances, electrolysis should not be so painful that patients hesitate in going on with it; the great majority do not complain about pain at all. It is not a good plan to use the same strength of current in every patient. Complications and Dangers. The chief danger with an unskilled operation is a false passage by forcing the needle through the side of the follicle, as shown in Figure 333. In the hands of careless operators there also exists the danger of tattooing the patient if the steel needle is connected to
the positive pole instead of the negative one; the polarity effect of the current will lead to the deposition of iron oxide around the opening of the hair follicle. Very occasionally there may be some capillary bleeding from one follicle; this signifies that the needle has gone outside or below the follicle; for the follicle itself will never bleed because it is outside of the skin. At times a sudden edema or blanching may appear around the needle without any hydrogen bubbles; this also shows that the needle penetrated through the follicle. The cautious operator will soon automatically acquire the proper sense of touch and never force the entry of a needle. Postoperative Treatment. After treatment the parts should be sponged off with alcohol and a mild antiseptic dusting powder or a soothing lotion applied. The employment of alternate hot and cold compresses at intervals of every hour or so for the first twenty-four hours is often helpful in keeping down the inevitable skin reaction to a minimum. In other cases frequent
sitting only
dabbing with a mild "lotio alba" solution is advisable. A slight swelling around each follicle treated and a certain amount of diffuse redness over the entire area is inevitable in every case as an immediate sequence of a mild chemical and mechanical irritation. Twenty-four hours later a red ring as after a bee sting may be seen around each hair follicle treated, and this may remain for several days. Over some of the follicles a soft scaly scab forms which falls off in a few days, leaving a scar which should be invisible except on very close inspection. If hairs too close together are removed, these scars may become confluent and remain
unsightly for some time.
An interval of five to seven days of Treatments. advisable before repeating treatment in the same area. If a patient is anxious to have treatment continued as rapidly as possible, one can work in a different area of the skin every few days. The number of treatments necessary to remove all hairs will depend on their total number, their closeness to each other and their degree of attachment to the papilla. A few scattered coarse hairs are usually definitely removed in one sitting. When there is considerable amount of work to be done, one should begin working for a shorter period at first and extend the time gradually, repeating the treatment as frequently as practicable.
Number and Frequency
is
598
From 10 to 20 per cent of the hairs removed may show return, but can be removed permanently at follow-up sittings. Poorest results are to be expected in patients with an abundance of fine downy hair these patients must agree from the beginning to submit to a much prolonged course of
;
treatment.
Follow-up treatment for removal of the percentage of unsuccessfully treated hair follicles should begin about three weeks after the last treatment. One reason for missing some of the hairs at first is the fact that
many women come

There
They must be instructed to come grown hair left untouched.

is
for treatment with closely shaven or clipped hairs. for follow-up treatments with the newly
no guarantee that after a series of treatments no other coarse form in a certain area. Likewise there is no evidence that removal in any way stimulates the formation of new hair. Later outcroppings can always be easily controlled. This procedure has been gainEpilation by High-frequency Current. ing increasing favor in recent years. Its use demands an apparatus furnishing a very fine desiccating current under perfect control. Like in electrolhairs will
ysis the procedure consists in the destruction of the hair follicle by the insertion of a fine steel needle and by turning on a very minimum of current
for a length of time estimated according to the size and location of the hair. Placing and preparation of the patient should be done as in electrolysis.
Besides a necessary apparatus, the required accessories are a fine needle in a suitable holder, a foot switch and a pair of spring forceps and, of course, good natural light or artificial light with an adjustable reflector and for
operators of poor eyesight some special magnifying device. While long-wave spark-gap apparatus is the most convenient,
possible to
it is
also
employ any short-wave diathermy apparatus provided that it is equipped with an extra resistance coil to cut down the output to a very small amount; because of the necessity for a biterminal technique (shortwave apparatus does not furnish a desiccating current) besides the usual active needle electrode a second dispersive electrode has to be employed; this has to be placed near the patient at a distance determined by the conditions in the particular circuit. Such a set-up is somewhat cumbersome compared to the simplicity of using the spark-gap machine. The Operation. The essential procedure is the sliding in of the needle tip without any force. Beginners should start with gross hair; if it is too long and interferes with the introduction of the needle it can be clipped. Most hairs stick out at a slight angle to the skin surface and the operator should insert the needle parallel to the hair shaft. With a little practice under adequate light this can be easily learned by persons with good eyesight and a steady hand. In some cases seizure of the hair with the forceps will help to guide the needle into the follicular opening. The depth of insertion should be to the point where the needle meets with slight resistance. Patients usually do not mind the insertion of the needle at all. As soon as the needle electrode is in proper position, the current flow should be started by light pressure on the foot switch; it should be kept up for only the count of one the space of a second. It is important that the foot of the operator should be comfortably placed, though only a slight pressure of the big toe or the ball of the foot is needed. The patient should be told that only a slight sting will be felt when the current flows. After the first second, the foot should be taken off the switch and immediately
REFERENCES
'599
depressed again, repeating again the procedure at the count of two, three, four up to eight to ten seconds, or more often, depending on the coarseness of the hair. At the close of the treatment period with skilful technique there is hardly any change except slight blanching and the hair can be lifted out easily from the follicle, with its root plainly showing. There is very little pain in the average patient, for the gentle current itself brings about anesthesia around the follicle. Definite pain and slight sparking around the needle tip will make the patient twitch, however, if an absent-minded
operator keeps his foot on the switch while inserting or withdrawing the
needle.
Small thin hairs may need only three to four seconds for complete removal; if in coarser hairs, or hairs with an irregular root, gentle pulling with the forceps does not bring out the hair easily, it is advisable to reinsert the needle and add a few seconds to the treatment time. Never use force to pull out a hair. In proceeding with the operation, just like in electrolysis, care must be taken not to take out too many closely grouped hairs in order to keep postoperative reaction at a minimum. Occurrence of capillary bleeding is a sign that the follicle has been punctured at one place. It usually stops on very slight pressure and has no after-effect. In contrast to the normal, more pronounced, inflammatory reaction and scab formation around each hair follicle treated by electrochemical destruction and occasional infection and swelling of one or more follicles, with skilled high-frequency destruction there occurs, as a rule, only slight reddening around each follicle and the formation of only a minimal scab. Patients should be warned to let scabs separate voluntarily, as the cosmetic result is better. In the author's experience high-frequency epilation is much speedier, less painful and causes much less reaction than electrolysis and may be used as a method of preference by skilled operators. From 100 to- 150 hairs can be comfortably removed during an hour's treatment, compared to an average of 50 with electrolysis. However, because of the rapidity of
the procedure, the percentage of recurrence
is
usually greater.
REFERENCES
1.
2.
ELLER, JOSEPH JORDAN: X-rays, Radium, Endothermy and Other Physical Agents in Dermatology, Med. Jour, and Rec., April 20 and May 4, 1927. GOECKERMAN, W. H. The Treatment of Psoriasis, Northwest. Med., 24, 229-231,
:
1925.
3.
HAGGARD, H. W., STRAUSS, M. J., and GREENBERG, L. A.: Fungous Infections of Hands and Feet Treated by Copper Iontophoresis, Jour. Am. Med. Assn., 112,
1229, 1939.
4.
KOVACS,
J.:
Iontophoresis of Varicose Ulcers, Arch. Phys. Ther., X-ray and Rad.,
18, 103, 1937.

5.
KOVACS, RICHARD:
661-668, 1938.
New Type
of
Mercury Glow Lamp, Arch. Phys. Ther.,
19,
6.
7.
8.
Electrolysis in Skin Disorders, Med. Jour, and Rec., September 2 and 16, 1931. MACKEE, GEORGE M., and CIPOLLARO, A.: Treatment of Skin Diseases by Physical Methods Other Than Radiation, Handbook of Physical Therapy, American Medical Association, Chicago, 1939. O'LEARY, PAUL A.: A Method of Treating Psoriasis, Canad. Med. Jour., 48, 34,
LEWIS, GEORGE M.:
1943.
9.
SCHOLTZ, B.:
Ultraviolet in Skin Infections, Arch. -Phys. Ther., 19, 419-426, 1938.
CHAPTER XXXIV
DISEASES OF THE EAR, NOSE
BY
AND THROAT
M.D.
WALLACE MORRISON,
PROFESSOR OF OTOLARYNGOLOGY, POLYCLINIC MEDICAL SCHOOL AND HOSPITAL,

Furunculosis of the External Canal.
NEW YORK
Acute Non-suppurative Otitis Media. Acute Suppurative Otitis Media and Mastoiditis. Chronic Suppurative Otitis Media. Chronic Catarrhal Otitis Media. Otosclerosis and Auditory Nerve Deafness. Acute Rhinitus. Chronic Generalized Hypertrophic Rhinitis and Chronic Atrophic Rhinitis. Vasomotor Rhinitis and Hay Fever. Acute Sinusitis. Acute Pharyngitis. Chronic Pharyngitis. Hypertrophied and Infected Lymphoid Tissue. Acute Tonsillitis. Electrosurgical Removal of Tonsils. Acute Laryngitis. Chronic Laryngitis. Laryngeal Tuberculosis.
its
Electrotherapy
is
coming more and more into
in the field of oto-rhino-laryngology. In many conditions in this region electrotherapy offers methods of treatment which are indispensable; the bloodless removal of hypertrophied or diseased tissue or of accessible
own
new growths by electrosurgery is an example. In other conditions electrotherapy offers relief of symptoms in ways which are not equalled by other methods of treatment; relief of pain by application of luminous heat or infrared radiation in very many of the acute inflammatory processes in the ear, sinuses and pharynx is an example. In still other diseases it offers methods which readily take the place of older forms of treatment; zinc ionization in chronic otitis media is an example. In other conditions it affords treatment which must be used only in conjunction with the accepted forms of medical and surgical treatment; medical diathermy for acute sinus infection must not be given without obtaining the best possible drainage of the sinus affected by the usual intranasal medication, suction, etc., and medical diathermy in tinnitus and deafness must always be accompanied by removal of causative factors, proper local and general treatment, if good results are to be achieved. The modalities used are: (a) Luminous heat; (6) infrared radiation; (c) ultraviolet radiation; (d) galvanism and ion transfer; (e) diathermy, medical and surgical; (/) short-wave diathermy.
DISEASES OF THE EAR

The Pinna and External Auditory Canal. Acute Dermatitis of the Pinna and External Canal. This condition may be treated by application of luminous heat in mild doses, once or twice daily, avoiding sufficient heat to irritate the inflamed skin the luminous heat may be followed once daily or every other day by a short irradiation of the ultraviolet light, giving only a fraction of a first-degree erythema dose. Cold, wet dressings of aluminum acetate solution or tampons of boroglyceride between treat;
ments are very
helpful.
Subacute and Chronic Dermatitis of the Pinna and External Canal. This condition may be treated much more vigorously, purposely giving stimulation. The best results are obtained by blistering doses of the water-cooled
(600)
DISEASES OF THE EAR

mercury vapor
601
ultraviolet lamp at short distances, with or without the quartz rod applicator. Not too large an area should be blistered at a time; treatments to any one area should only be repeated when the reaction of the previous dose has subsided.
earliest stages of the process
Furunculosis may be treated in the with the water-cooled ultraviolet lamp, with or without the quartz rod applicator. A dose is given sufficient to cause a contact dermatitis without blistering, over the affected part, and a small zone of normal skin about it. This often aborts suppuration.
Furunculosis of the External Canal.
Short-wave diathermy to the ear is very useful in relieving pain, and at times in preventing suppuration. It is most readily applied by seating the patient in a comfortable wooden chair, between the arm brackets of a suitable floor stand. To one arm of the stand, a 4-inch circular, spaced condenser plate is attached. It is applied to the affected ear, after being covered with sterile paper; or a layer of Turkish towel or a Hnch thick felt pad may be inserted between the ear and the electrode. The plate must be held gently but firmly against the head so that the pinna is flattened against the side of the cranium. A 6-inch circular spaced condenser plate is attached to the second arm of the stand and placed 2 inches away from the opposite side of the head, or it may be covered with a i inch of felt and placed against the opposite shoulder. The points of technique enumerated in Chapter XI must be observed and accordingly one must be sure that metal objects such as wire hair pins, earrings, metal spectacle frames, metal necklaces, etc., are removed from the area beneath the plates. If the electrode is not placed so as to compress the pinna against the head its protruding margin will become uncomfortably hot, or may be burned. The careless placing of either electrode over a prominent bony area will lead to focal heating and a burn may result. After the current is turned on the controls of the machine are adjusted until the patient feels a gentle and comfortable heat beneath the small electrode. He is allowed to control the current with a foot switch, and is instructed to release the switch instantly if he feels any uncomfortable sensation, or wishes to change his position. A trained attendant must be within instant call at all times. Felt pads and towel or paper spacers placed between electrode and skin must always be dry, and so attached to the electrode that they cannot become displaced. The treatment is for fifteen minutes and may be repeated twice daily. given The tolerance of the patient is the only guide to the amount of current to be used for there is no way of accurately measuring the amount of current flowing through the patient in the high-frequency field. The controls must always be set low at first and very gradually increased. Luminous heat is a simple and often quite effective means of relieving the pain of furunculosis. It may be applied for twenty minutes every hour or two hours, with the lamp so placed that the ear becomes comfortably warm. Wet dressings of aluminum acetate solution or tampons of boroglyceride containing 4 per cent salicylic acid between treatments are indicated. When suppuration with pointing has occurred the furuncle may be incised with the cutting current without hemorrhage. The Middle Ear and Mastoid Process. Acute Non-suppurative Otitis Media. This condition is very much benefited by luminous heat or infrared radiation applied to the entire side of the head, for twenty minutes
002
DISEASES OF THE EAR, NOSE AND THROAT
every hour or two hours. Pain is relieved, and the outpouring of serum in the middle-ear may be prevented. When inflation of the middle-ear shows the presence of serum after the early stages, and particularly in the subacute cases, daily treatment by medical diathermy is advisable. It should be applied with metal electrodes placed within the external canals of both sides. The current is passed for fifteen minutes and always kept within the limit of toleration. The use of short-wave diathermy is even more efficacious and easier of application. It is applied as has been described for furunculosis, above. The treatment is given for fifteen minutes twice daily. A very mild degree of heat will usually relieve pain and promote absorption of serum. Acute Suppurative Otitis Media and Mastoiditis. Here surgical treatment plays the most important part by far; the absolute necessity for prompt incision of the drum and of well-timed exenteration of diseased mastoid cells is no longer open to question. Luminous heat may well be used for a short period in an endeavor to abort suppuration in the tympanum; persistent pain and rising temperature call for incision of the drum without any further waiting. Once free drainage has thus been established, the use of luminous heat is very valuable in relieving pain, promoting drainage and perhaps in preventing spread of the infection to the mastoid cells. Infrared radiation may be used as an alternative, especially in children made restless by the luminous heat. The general resistance may be increased by full-body ultraviolet baths in increasing doses daily. Even when an acute mastoiditis is present, in the absence of signs of complications, the above regime may be followed for a time with the hope that the process may resolve. The length of trial must vary with the individual case, and surgery must no longer be withheld when it is evident that the process in the mastoid is not resolving. Short-wave diathermy may be tried in place of the luminous heat or infrared radiation. It is useful for the relief of pain and the promotion of healing through the hyperemia brought about by its deep heating effect. It is applied as described under furunculosis above, using a gentle heat over the affected ear and mastoid; it must not be continued if it increases pain and fever. It should not be carried on when it is obvious that the suppuration in the mastoid process is not resolving.
FIG. 335.
Aural ion transfer electrode.
(Courtesy of the General Electric X-ray Corp.)
Chronic suppurative otitis media, in Chronic Suppurative Otitis Media. the absence of bone necrosis, polyp or marked granulation tissue formation, or cholesteatoma, is sometimes markedly benefited by use of the water-cooled ultraviolet lamp, applied two or three times a week with the (a) The canal and middle-ear are very carefully following technique: cleansed by dry or alcohol cotton applicators and capillary suction, avoiding any irrigation; (6) 2 per cent mercurochrome solution is dropped into the canal, with the head well inclined to the opposite side (after ten minutes the excess solution is swabbed out) (c) ultraviolet is applied with or with;
DISEASES OF THE EAR
003
out a suitable quartz rod applicator in the canal, beginning with a dose of one minute, and increasing it slightly with each treatment, without blistering; in time doses of eight to ten minutes may be given. Another method of use in uncomplicated chronic middle-ear suppuraThe tion, especially with large drum perforation, is zinc iontophoresis. method can scarcely be expected to give permanent results when there is polyp or much granulation tissue formation, bone caries, chronic mastoiditis, cholesteatoma and recurrent infection via the Eustachian tube from the nose and pharynx. The technique is as follows: (a) The canal and middle-ear are carefully cleansed by capillary suction and cotton applicators wet with 0.2 per cent zinc sulphate solution, 1 grain to 1 ounce of distilled water; (b) with the patient lying on the opposite side, the ear and canal are filled with the same solution; (c) the positive pole of a source of galvanic current is connected to a zinc wire placed in the solution in the canal, protecting the latter by means of a hard rubber speculum (d) the negative pole of the apparatus is connected to a large electrode of the moist sponge type placed on the skin of the arm or back; (e) 2 to 4 milliamperes of current One treatment may suffice to is passed for from ten to fifteen minutes. dry up the discharge; if not, it may be repeated twice a week; but if the
;
discharge continues after three or four treatments the method will probablv not succeed.
FIG. 336.
Application of aural ion transfer electrode. (Courtesy of the General Electric <X"-ray Corporation.)
Chronic Catarrhal Otitis Media, Otosclerosis and Auditory Nerve Deafness. These are conditions which are widely separated pathologically, and yet may be considered together because they all produce at least two symp-
toms
in
common,
essential treatment in all
possible; baths. The local application of the deeply penetrating heat of medical diathermy should theoretically soften the scar tissue formed in the tym-
and diminished acuity of hearing. The most to remove the underlying cause, if that is the general health should be improved using full-body ultraviolet
tinnitus
is
panum
in the first disease, perhaps slow up the spongy new-bone formation characteristic of otosclerosis, and slow or prevent the degeneration of the and proauditory nerve in neuritis, by increasing the local blood supply Medical diathermy is applied in several ways. moting lymph drainage. be placed within the ear canals of each side; Metal electrodes
(a)
may
004
(b)
with the metal cuff electrode around each wrist, the tip of the patient's forefinger is inserted into the canal as an electrode; (c) wire electrodes may be inserted in cotton wet with 10 per cent saline solution packed
own
into the ear canals; (d) perhaps the best method is the use of two oval plate electrodes, 1J by 2 inches in size, one over the mastoid of the side to
be treated and the other on the opposite cheek. Sufficient current is passed to create a comfortable sensation of heat, without causing vertigo or nausea; the treatment should last from ten to twenty minutes, and be repeated two or three times a week for long periods. As to actual results obtained, no great promises may be made, although encouraging reports
have come from careful observers.
FIG. 337.
Schematic diagram of zinc iontophoresis of chronic middle-ear disease.
The deep heating effect of short-wave diathermy may be tried in these stubborn conditions. It is given as described for furunculosis, above. When both ears are affected, 4-inch rubber-covered electrodes, enclosed in sterile paper, may be applied against both ears at once, compressing both pinnae against the skull, and the current passed for ten to twelve minutes. Gentle heat is felt in both sides. The treatment is given two or three times weekly and must be persisted in for several months.
DISEASES OF THE NOSE AND NASAL ACCESSORY SINUSES

The External Nose and Nasal Vestibule.
Acute and Chronic Dermatitis.
Acute and chronic dermatitis occurs here, usually with infections of the interior of the nose or sinuses; the essential treatment is that of the causative lesion. They are often benefited by the use of luminous heat and ultraviolet radiation, as described for similar conditions in the pinna and
external auditory canal. Furunculosis. Furunculosis of the nasal vestibule
outlined for similar conditions in the ear canal.
may be treated as Furuncles in this area
should never be pinched or squeezed, nor opened until they point, for fear of setting up a spreading septic thrombophlebitis of the angular vein, leading to cavernous sinus thrombosis. The Nasal Chambers. Acute Rhinitis. Acute rhinitis is often much benefited by applications of luminous heat or infrared radiation to the entire face and head for twenty minutes every two hours. Intranasal ultraviolet may also be applied with the water-cooled mercury vapor lamp, with a speculum or through a suitable quartz rod applicator, beginning with doses of one-half minute or less, once daily; the length of exposure
605
may
be slowly increased with succeeding doses. This method is perhaps even more efficacious if employed following nasal tamponade with one of
the colloidal silver solutions. Full-body ultraviolet baths may be used during convalescence and to aid in prevention of further attacks. Chronic Generalized Hypertrophic Rhinitis and Chronic Atrophic Rhinitis. These conditions are both aided symptomatically by: (a) Intranasal
ultraviolet radiation after colloidal
tamponade, as described above; (b) intranasal ionization with a silver colloid solution or zinc sulphate solution (the positive electrode is of bare copper or zinc wires wrapped in cotton dipped in the solution used and inserted within the nose) and 3 or 4 milli-
amperes of galvanic current passed for five minutes in each side of the nose as an average treatment; (c) in resistant cases the interior of the nose may be treated by application of the Oudin current with a non-vacuum electrode which is gently rubbed over the mucosa for ten minutes two or three times a week. Recently chronic atrophic rhinitis has been treated by some workers by intranasal ionization with mecholyl. This vasodilating drug brings about increased secretion and tends to lessen crust formation and so to decrease
the fetor. The nasal cavities are cleansed of secretion, anesthetized by spraying twice with any suitable anesthetic solution, and then packed with cotton pledgets moistened with 1 to 500 solution of mecholyl. The cord from the positive pole of the galvanic current apparatus is clipped to the cotton left protruding from the nostrils. The negative pole is connected to a 6- by 8-inch piece of block tin, which is placed centrally upon an 8- by 10-inch piece of absorbent cotton \ inch thick, and wet with normal saline solution. The whole is firmly bandaged to the bare skin of the patient's forearm. The current is turned on and very slowly increased to 15 milliamperes. This is allowed to pass for twenty minutes, and then slowly decreased to zero. The packing and electrodes are removed. The treatment is given once or twice weekly.
Chronic localized hypertrophies in the Chronic Localized Hypertrophies. commonly seen as hypertrophy of the anterior or posterior ends or of the whole body of the middle and inferior turbinates, may very easily be removed under local anesthesia by means of an insulated nasal snare,
nose,
employing combined cutting and

size of the
body
light coagulating current. of the inferior turbinate is best accomplished
Reduction in
by submucous
coagulation with the double-needle electrode, which is inserted beneath the mucosa under local anesthesia and a delicate coagulating current passed from one needle to the other. This produces a scar which reduces the hypertrophy with a minimum of damage to the turbinate mucosa.
are best treated
Vasomotor Rhinitis and Hay Fever. Vasomotor rhinitis and hay fever by the removal of the substance or substances to which
is
the patient
to
hypersensitive from his environment, or his desensitization To aid in symptomatic relief the following is possible. methods are used: (a) Full-body baths of ultraviolet twice a week; (b) intranasal ultraviolet with the water-cooled lamp, as described above;
them
if
this
intranasal ionization with the silver colloid solution, as described previously; (d) intranasal application of the Oudin current, as explained above (this is best applied in the intervals between attacks); (e) medical
(c)
diathermy
may
be applied by means of two plate electrodes placed on the
606

path of the current,
side of the face, so that the nasal chambers lie in the being very careful to avoid "edge effects."
The treatment of nasal allergy by the zinc iontophoresis of the nasal mucosa has been widely used in the past few years. It produces a wellmarked inflammatory reaction in the mucosa, with destruction of cilia, desquamation of the epithelium, vascular congestion and cellular infiltration in the submucosa. In time much of the epithelium regenerates, although the cilia may be lost, and a submucous fibrosis results. Whether any permanent damage is done to the mucosa which might lead to atrophy in later years has not been fully decided, but it seems quite unlikely in
the light of recent proof of the great power of regeneration to normal structure and function of the nasal mucosa, even after its complete surgical removal, as from the sinuses.
Technique of Zinc Iontophoresis. Any source of a smooth galvanic current, which can be accurately measured with a milliamperemeter, and The nasal cavity is controlled by a fine rheostat, may be employed.
anesthetized
solution.
by spraying
it
The
interior of the nose
two or three times with any suitable anesthetic is filled by packing it with long, slender
pledgets of cotton wet with 1 per cent zinc sulphate solution. The olfactory area must not be so packed, or anosmia will result, and may persist for many months. A space is left between the inferior turbinate and the
septum, in which, among the pledgets, a slender zinc electrode is introduced after being lightly wrapped in cotton; the bare metal must not touch the tissues or a burn will result. A simpler method is to clip the cord firmly to the wet cotton left protruding from the nostril. The positive pole is connected to the nose. The skin of the forearm is cleansed of oil with carbon tetrachloride or ether, and an 8- by 10-inch piece of absorbent cotton, \ inch thick, thoroughly wet with normal saline solution, is placed on the arm. Centered on the cotton, a piece of block tin 6 by 8 inches, is applied to fit the shape of the arm smoothly, and the cord from the negative pole is attached to it firmly. The whole is snugly bandaged to the arm; burns will result unless there is smooth and even contact over the whole electrode. The current is turned on, and very slowly increased to 10 milliamperes. The patient will complain of a salty, metallic taste, and free salivation occurs; he is given a pus basin into which to expectorate. There should be no painful sensation in the nose or arm if this occurs, the current must be shut off at once, and search made fpr a point of contact of bare metal with skin or mucosa; this must be remedied or a burn will result. The current is passed for ten to twelve minutes and then slowly decreased to zero. The electrodes and packing are removed. The nasal mucosa is seen to be covered with a white deposit. Within a short time, the patient will have some neuralgic pain in the face; he must be given 10 to 20 grains of
;
phenacetine or 1 grain of codein, and instructed to lie down and apply cold compresses to the face. The pain passes away in eight to twelve hours. The nasal cavity becomes filled with a rubbery, white fibrin, which is adherent to the mucosa. It loosens and can be removed by blowing the nose, or with forceps, after the fourth day. Instead of nasal packing, the nasal cavity may be filled with a semifluid jelly of gum tragacanth, containing 1 per cent of zinc sulphate. It The jelly must be is supplied in collapsible tubes with long nasal tips. prevented from entering the olfactory area by inserting between the
607
middle turbinate and septum, up to the roof of nose, a 3-inch long piece gauze packing. This is removed from the nose after the treatment, and the jelly blown or sucked out. The jelly is sufficiently stiff so as not to run into the pharynx. The positive electrode is a hard rubber tip which fits into the nostril and from which protrudes a piece of zinc wire 2 millimeters long. The wire lies in the jelly and must not touch the
of petrolatum
tissues.
The
tip is held in the nostril
by the
from a head band made for
this purpose.
The arm
patient, or it is suspended electrode and the
method of applying the current is the same as with packing; the jelly is much more comfortable for the patient than packing. In seasonal hay fever, the treatment is best given just at the commencement of the season. The symptoms are usually relieved at once, and do not recur for six to eight weeks, or longer. The treatment must be repeated each year for most patients. Properly applied, more than 75 per cent of hay fever sufferers will be relieved of 90 per cent of their symptoms. Both sides of the nose may be done at one sitting, although this causes a more severe reaction than when one side is done, and the second treated after
an interval of five to seven days. In the more chronic, non-seasonal forms of nasal allergy, usually termed vasomotor rhinitis, ionization may be done at any time, and affords a very good chance for relief from the most troublesome symptoms for periods of three to six months or longer. It is most useful when symptoms persist
despite allergic control, or when the patient teins which he cannot avoid.
thesia
is
sensitized to inhalant pro-
Nasal Synechise. Nasal synechise are easily divided under local anesby coagulating the bands with a suitable nasal needle electrode and a dispersive electrode on the arm or back. If the coagulum produced is left in situ until it sloughs away there is little probability that the synechia
will reform.
Epistaxis. Epistaxis, due to rupture of small vessels on the lower and anterior portion of the septum or other accessible areas, is readily stopped and recurrence often prevented by coagulating the area under local anes-^
thesia with a light current. Lupus and True Tuberculosis of the Nose.
seen.
These conditions are rarely
usual local treatment comprises: (a) Repeated treatment with the mercury vapor lamp, with a speculum or quartz rod applicator; (b) destruction of lupus or tuberculous granulations with the coagulating
The
current and the needle nasal electrode. Benign and Malignant Growths of the Nose and Sinuses. These growths may require electrosurgery, but because of the surgical skill and judgment
required this
is
best left for the specialist.

often
face;
The Nasal Accessory Sinuses. Acute Sinusitis. Acute sinusitis if greatly helped by: (a) Luminous heat or infrared radiation of the
for the relief of pain
and promotion of drainage twenty to thirty minutes every hour is not too great a dosage; (b) medical diathermy for the antrum or frontal, a plate electrode moulded to fit closely is applied over the sinus, with a larger dispersive plate on the back of the neck, and for the ethinoids and sphenoid plates of equal size are placed on the sides of the face; the and treatheating current is made to pass through the sinus being treated
ment
is
session.
given once or twice daily, for twenty to thirty minutes at each The strength of the current must be kept within the limit that
608
gives the patient a pleasant sensation of heat only. It must be noted that before medical diathermy is applied the best possible drainage of the
affected sinuses
tion, irrigation, inflamed sinus.
must be secured by the usual

tampons,
etc.,
or the heat
intranasal medication, sucmay increase the pain of the
is
Short-wave diathermy applied over painful and suppurating sinuses welcomed by the patient. It provides very pleasant heat and pain is
often relieved.
The
short
wave
is
much
easier
and more comfortable
of
application than the long-wave diathermy, which demanded close fit of metal electrodes, and often produced faradic sensations. The patient is
placed in a wooden chair between the arms of the electrode stand. A 4-inch circular condenser pad, wrapped in sterile paper or a thickness of Turkish towel is fitted over the forehead or cheek to be heated. The air space, or felt or glass space type of electrode may be used. With any form of electrode, current concentration and undue heat over bony prominences or protruding soft parts must be avoided, or burns will result. The second electrode should be much larger, spaced with dry felt or towel, and applied firmly against the back, chest, or under the buttocks. The second electrode may be simply suspended 2 inches from the back, chest or shoulder, from the second arm of the stand. The heat applied must always be well within the level of tolerance, and maintained for fifteen to thirty minutes, once or twice daily.
Chronic sinusitis occasionally calls for electrotherapy. Chronic Sinusitis. Medical diathermy will aid in the relief of pain in acute exacerbations, and is to be applied as outlined. It will not help the reduction of mucosal hypertrophies and polyps. Zinc iontophoresis has a limited use in promotion of the healing of the antrum, frontal or sphenoid sinuses after they have been surgically drained, etc. The head is so placed that the sinus to be treated can be filled with 0.1 per cent zinc sulphate solution, into which
a zinc wire is placed so that it is not in contact with the nose; this is connected to the positive pole of the galvanic current apparatus. A dispersive electrode is placed on the back of the neck or arm, and 2 to 5 milliamperes of current passed for ten or fifteen minutes. Nasal Polyps. Nasal polyps may be removed with the cutting current applied by the insulated nasal snare, such as described for the removal of turbinate hypertrophies. Granulation Tissue. Granulation tissue following intranasal operations is readily removed by application of the desiccating or very light coagulating current, under local anesthesia, with a suitable nasal electrode.
DISEASES OF THE PHARYNX

Acute Pharyngitis.
Acute pharyngitis
is
much
helped symptomatically
by luminous heat applied to the entire head and neck twenty to thirty minutes every two or three hours; infrared radiation may be used similarly. Diathermy also may be applied by plate electrodes on each side of the
neck, with care to avoid "edge effects;" only enough current is passed to cause a comfortable heat sensation, for thirty minutes once or twice daily. Short-wave diathermy may be similarly used. The air spaced or glass or rubber-covered electrodes of the 4-inch circular size are placed on each side of the neck, centered below the angle of the jaw. Mild heat is applied

for
609
twenty minutes once or twice daily. The usual internal and local antiseptic or astringent medication must not be neglected. Chronic Pharyngitis. Chronic pharyngitis calls first for the discovery and removal of the underlying cause or causes. Symptoms are often relieved by medical diathermy applied across the pharynx and the tissues of the neck, as described above. The fullgeneral health is
improved by
In addition, chronically congested areas, such as the lateral pharyngeal folds, pharyngeal follicles ("granulations") and the vault or posterior wall of the nasopharynx, may be given mild erythema doses of ultraviolet radiation by means of the water-cooled lamp and suitably shaped quartz rod applicators; burns must be avoided, and the treatment repeated once a week.
body
ultraviolet baths.
infected
is
Hypertrophied and Infected Lymphoid Tissue. Hypertrophied and lymphoid tissue in the pharynx, such as follicles, lateral folds, etc.,
best treated by electrocoagulation. The current is applied by means of insulated electrodes of the needle type, or small button, on the surface, with a dispersive electrode of large size on the back or under the buttocks.
if the coagulation is done by means of the double-needle electrode, in which each needle carries the current, and is separated from the other for 3 or 4 millimeters. The needle-points are plunged into the tissue under the guidance of vision, and enough current
The latter may be dispensed with
passed to slowly coagulate an area of several millimeters in diameter. Small areas may be done under local anesthesia, not too much at a time, and the process repeated until the hypertrophy is destroyed. Extensive areas may be destroyed in one sitting if performed under chloroform anesthesia. Hypertrophy of the Adenoid. Hypertrophy of the adenoid calls for complete surgical removal. To date, as far as the author knows, no practicable instrument has been developed for the removal of the adenoid by means of the cutting current. Hypertrophied Remnants of the Adenoid. Hypertrophied remnants left after poor surgical removal, especially those so commonly found in Rosenmiiller's fossa and about the Eustachian tube mouth, are very readily
and bloodlessly removed by coagulation in situ. A palate retractor or nasopharyngoscope of the Yankauer type is used, and the current applied by multiple puncture with suitably shaped needle electrodes; a large dispersive electrode is placed under the buttocks or on the back. Chloroform anesthesia is used and all the infected tissue coagulated at one sitting. Acute Tonsillitis. Acute tonsillitis is helped symptomatically by luminous heat to the entire head and neck, twenty to thirty minutes three or four times a day. Direct application of the water-cooled ultraviolet lamp by a curved quartz rod to the tonsils is sometimes of striking benefit. Burns must be avoided by beginning with one-half minute dose and increasing one-half minute daily. Pain and soreness due to swelling of the
cervical
lymph glands may be relieved by medical diathermy, given by electrodes on the sides of the neck; a comfortable heat for thirty plate minutes once or twice a day is sufficient. Short-wave diathermy may be applied for the relief of pain and of dysphagia, as has been described for
acute pharyngitis, above. Since acute tonsillitis is practically always due to the hemolytic streptococcus, the essential treatment is proper medication with sulfanilamide, given at once in full dosage, and continued until the symptoms disappear.
610
by
of
Chronic Tonsillitis and Hypertrophy of the Tonsils. This is best treated surgical methods. Electrosurgical Removal of the Tonsils. This is accomplished in one
two ways
(a)
Coagulation of tonsils in situ by the method of multiple
This is the method which has been most widely used. It is performed under local anesthesia. The usual method of securing the anesthesia is to paint the tonsil several times at intervals of five minutes with an anesthetic solution applied on very small cotton swabs. The author
punctures.
prefers a solution of equal parts of aniline
oil,
absolute alcohol, and alypin
powder. Novocaine or other similar solutions may also be injected, if used in small quantities, and at least fifteen minutes allowed to elapse between
the injection and coagulation, to permit the solution to diffuse through the tissues, and to allow the edema caused by the injection to subside.
FIG. 338. Electrocoagulation of tonsil by needle electrode, using metal tongue depressor as dispersive electrode.
FIG.
339.
Electrocoagulation
of
tonsil
electrode, using insulated metal pillar retractor as dispersive electrode.
by
The active electrode most commonly used is a thick, curved needle in an insulated handle. The dispersive electrode may be the large metal plate on the bare back or under the buttocks; or a metal tongue depressor, or pillar retractor may be employed for the double purpose of exposing the tonsil, and as a dispersive electrode, with no danger of burning the patient or short-circuiting the diathermy machine if the operator avoids contacting the bare metal active electrode and the dispersive electrode
while the current is flowing. The biterminal method of tonsil coagulation consists of employing a double needle tonsil electrode; two short curved needles are insulated from
611
each other within a suitable handle; the points are separated for 4 millimeters; each needle carries the current, and coagulation takes place between and around the two points. No dispersive electrode is
In use, when anesthesia is complete, the active electrode is punctured into the tonsil under the guidance of vision, with the area illuminated with head lamp or reflected light, the tongue depressed or the anterior
pillar retracted as the case may require. the needle point is in the tonsil tissue at the desired spot, a light coagulating current is passed by closing the foot switch of the machine until an area of 4 millimeters of tissue about the needle turns white; the current is then shut off and the
necessary.
When
needle withdrawn. Another area is then treated similarly. While there has been some discussion as to the exact sequence in which the tonsil should be coagulated, it seems to the author that coagulation should begin at the center of the surface of the tonsil, and then be carried forward, upward, and backward in successive steps until the capsule is reached. These steps are shown diagrammatically in Figures 338 and 339.
stances.
The number of areas treated at any one sitting must vary with circumThe operator must remember that if too much coagulation be
result; if large areas are coaguin large portions, bleeding may
done at a session, considerable soreness will lated and the slough so created comes away
result.
feels that four to five punctures at each treatment are one tonsil is treated at a time; the process is begun on the Only second tonsil in a week, and the coagulation is not repeated on the first tonsil until soreness, reaction, and the slough have disappeared this usually takes ten days to two weeks. Thus each tonsil is treated every two weeks, and individual treatments are given once a week on alternate tonsils. Aftertreatment is simple, and calls only for soft, bland food for two days after each session, and the use of a throat lozenge containing a local anesthetic. The number of treatments required to completely remove the tonsils will naturally vary with the size and consistence of the tonsils, on the amount of coagulation that can be done per treatment, and on regularity of the sessions. In the experience of the author the rather firm tonsil found in most adults will require ten treatments for complete removal this means twenty treatments for both tonsils, and these are spread over a period of at least four months; this length of time is the one great disadvantage of the method. While some authors have not found incomplete removal of the tonsils by this method apparently harmful, the author can only be guided by analogy with the results noted after incomplete removal by the surgical, non-diathermic method, in which very many competent observers have stated that incomplete removal of infected lymphoid tissue is very objectionable. One must have for his aim the thorough removal of every visible and palpable bit of tonsil tissue. This requires patience and skill, especially in the patient with very large, or very fibrous tonsils, with the sensitive throat in which any procedure is carried on with difficulty; in these patients, one needs all the skill necessary to perform complete surgical tonsillectomy under local anesthesia.
sufficient.
;
The author
The method
of electrocoagulation
by multiple puncture
is
especially
adapted for the removal of small portions of

tonsillectomy; the technique
(b)
tonsil left after ordinary
is exactly the same as that outlined above. Enucleation of tonsils by the cutting current or combined cutting
612
Local anesthesia is used in adults, and light coagulating currents. chloroform in children. An insulated snare, the wire of which carries the current, is employed. The dispersive electrode is a very large plate on the back or under the buttocks. The tonsil is engaged in the instrument so that when the wire is tightened and the current applied the wire cuts the tonsil from its bed along the line of the capsular attachment, without damaging the pillars, tongue, etc. Enough coagulating current is used to seal small blood-vessels; if larger vessels are opened the bleeding-point is seized with an ordinary tonsil hemostat and the coagulating current applied through the clamp to seal the open vessel. The advantages of this method are that it completely removes the tonsil at one sitting, and that it is relatively or completely bloodless; the operation is quickly done and the anesthesia is thus short. Reaction and soreness following electrosurgical
and
FIG. 340.
Electrocoagulation of bleeding-point in tonsil fossa by means of insulated hemostat and needle electrode.
tonsillectomy
There
by this method is no greater than with ordinary dissection. some possibility of secondary hemorrhage with the separation of the slough which takes place within from five to ten days. Peritonsillar and Retropharyngeal Abscesses. These may be opened with the cutting current applied by means of the needle electrode and a dispersive plate on the back or buttocks. The current should be used to incise the mucosa and submucosa only; if pus is not encountered at this level the abscess should be opened by the insertion of blunt forceps or scissors, to avoid the damaging of larger blood-vessels. Elongation of the Uvula. Elongation of the uvula is readily and bloodlessly cured by amputation of the redundant portion by the insulated snare and the cutting current, under local anesthesia. Hypertrophy of the Lingual Tonsil. Hypertrophy of the lingual tonsil is readily reduced by multiple punctures and coagulation under local
is
DISEASES OF THE LARYNX

anesthesia.
613
The
single needle electrode
is
on the back; a metal tongue depressor or the laryngeal mirror may
used with the dispersive electrode

also
be used as the dispersive electrode, if care is taken not to touch the two electrodes while the current is on. The double-needle electrode may also be used without any dispersive plate. Light coagulation is used, and
repeated sittings at intervals of seven to ten days until the hypertrophy is reduced are advised. Varicose Lingual Veins. Varicose lingual veins may be coagulated by the method described for the lingual tonsil.
DISEASES OF THE LARYNX

Acute laryngitis may be treated by electrotherapy, measures of vocal rest, and local and internal medication. Application of luminous heat, or infrared radiation, over the neck and chest may be made for twenty to thirty minutes every two or
in addition to the usual
Acute Laryngitis.
FIG. 341.
Applications of ultraviolet radiation from water-cooled lamp to larynx.
Medical diathermy may also be applied by means of plate on the sides of the neck, being careful to avoid "edge effects." Because of the difficulty of maintaining an electrode directly over the larynx, it is best not to attempt it, as a burn of the skin may result. Enough current is passed to maintain a comfortable heat for twenty or thirty
three hours.
electrodes
minutes once or twice a day. Short-wave diathermy often gives prompt relief from the soreness and discomfort of acute laryngitis. It may be applied by placing 4-inch circular electrodes, of the air, glass or felt space type on opposite sides of the neck, so that the larynx lies between them. Edge effects across the narrow anterior part of the larynx must be avoided. A very comfortable method is the use of the induction cable, which is wrapped several times about the neck over J inch of dry Turkish towel or felt spacing. A comfortable heat for
fifteen or
twenty minutes
is
given.
(Fig. 165.)
614
Chronic Laryngitis. Chronic laryngitis is best treated by the discovery of the underlying cause; this usually calls for a very close and extensive study by the specialist. It may be helped symptomatically by the use of luminous heat, infrared radiation and medical diathermy, as described above for acute laryngitis. In addition, ultraviolet radiation from the water-cooled lamp may be applied by means of a suitable quartz rod and prism in the mouth and pharynx, so placed that the radiation passes down to the larynx. Very great care must be used to prevent even slight burns, because of the danger of reaction, with swelling and interference with respiration, that may result. The doses at the beginning must be very short, ten or fifteen seconds, increasing slowly, and giving the treatment twice a week is advisable. Laryngeal Tuberculosis. Laryngeal tuberculosis is best treated by the
and removal
laryngologist
and pulmonary
specialist,
is
since
it
is
always secondary to
of great aid in well-chosen cases. pulmonary phthisis. Electrotherapy Medical diathermy may be used as for acute laryngitis, to help relieve local
Ultraviolet radiation to take the place of sunlight applied to the larynx by means of mirrors has given good results in some hands. It is given, as described above, with the quartz rod and prism, with great For the destruction of tuberculous care to avoid reaction and edema. granulation tissue, the treatment of tuberculous ulcers and the reduction of edematous and infiltrated tissue in the larynx, the desiccating and coagulating currents are applied with suitable insulated needle electrodes, either by suspension laryngoscopy or peroral direct laryngoscopy. Since such procedures require special skill, they are best left to the specialist. Benign and Malignant New Growths of the Mouth, Pharynx and Larynx. These growths are being treated by electrosurgical removal by many. Like nasal new growths, this is best left for the specialist or surgeon, who. has the technical skill to attack what often prove to be formidable
symptoms.
procedures.
REFERENCES
literature,
From
the large
the following text-books
and monographs are
available for
additional reading.
HOLLENDER, A. R.: Physical Therapeutic Methods in Otolaryngology, St. Louis, C. V. Mosby Company, 1937. KURD, LEE M.: Diathermy, Surgical and Medical, in Otolaryngology, Laryngoscope,
43, 730, 1933.
KELLY, H.
A.,
and WARD, G. E.:
Electrosurgery, Philadelphia,
W.
B. Saunders
Com-
pany, 1932.
The Use of Medical and Surgical Diathermy in Otolaryngology Arch. Phys. Ther., X-ray and Rad., 14, 230, 1933. The Use of the Galvanic Current in the Treatment of Atrophic Rhinitis, STOVIN, J. S. Arch. Otolaryngol., 25, 3, 305, 1937. WYETH, G. A.: Surgery in Neoplastic Diseases by Electrothermic Methods, New York, Paul B. Hoeber, Inc.,
:
MORRISON, W. W.:
CHAPTER XXXV
DISEASES OF THE EYE
General Considerations. Dangers. Eyelids and Conjunctiva. and Retina. Ocular Syphilis. Electrosurgery of the Eye.
Cornea, Uveal Tract
Physical measures oft'er valuable aid in the ophthalmological conditions. Dramatic results have been described in corneal ulcers with ultraviolet irradiation while artificial fever therapy has opened up a new path in the effective treatment of many forms of ocular syphilis. Fever therapy, infrared radiation and diathermy
of
management
many
relief of pain and promotion of resolution in acute ocular inflammatory conditions. General ultraviolet application is indicated for tuberculous and phlyctenular conditions. Zinc ionization is of value within a limited scope. Electrodesiccation is an ideal method to remove small neoplasms from the tissues of the eye with a perfect cosmetic result, while other forms of electrosurgery have been successfully employed in a variety of conditions. Dangers. Exposure of the unprotected eye to ultraviolet radiation results in a painful inflammatory reaction already mentioned in Chapter XIX as photoophthalmia. Duke-Elder5 regards it as a form of keratitis rather than of conjunctivitis. He emphasizes the fact that while exposure of a diseased part of the cornea for therapeutic purposes and a subsequent inflammatory reaction may be desirable, exposure of the lens is to be avoided under all circumstances. Hence the necessity that the lens be
have been found useful for
excluded from the path of incident rays in any technique of phototherapy. Law 13 has cautioned against overexposure to infrared radiation; he is of the opinion that such overexposure may occur either by direct penetration of the rays or secondarily by the heat transmitted to the lens by the iris, which presents an efficient absorptive surface for heat radiation.
Eyelids and Conjunctiva. In acute conjunctivitis, after removal of all immediate causes, luminous heat or infrared radiation is advisable; it is applied to the closed eyelids of the patient from a distance where it feels and is repeated at just pleasantly warm, for twenty to thirty minutes It usually results in prompt relief of pain and least three times daily.
discomfort and in the gradual subsidence of the other signs of inflammation. In acute gonorrheal conjunctivitis for the first twenty-four to forty-eight hours ice cold compresses are most effective but they never should be local heat after the applied continuously and should be superseded by
initial period.
In refractive cases of chronic conjunctivitis, blepharitis, trachoma and vernal catarrh, local ultraviolet irradiation with a quartz applicator has 5 8 third-degree been recommended (Hollender and Cottle, Duke-Elder ).
employed which results in desquamation and rapid regeneraerythema tion of the mucous membrane. The treatment is applied by contact to
is
the everted inner corneal surface of the conjunctiva while the cornea is until a fresh and protected against the rays. The process is repeated unscarred mucous membrane is produced; this compares very favorably (615)
616
DISEASES OF THE EYE
with the usual cicatrization which results after prolonged silver or other
caustic application.
In hordeolum luminous heat may be applied in prolonged and repeated doses to bring the stye to a head. Ardent users of static electricity claim that the application of the static brush discharge is a specific in aborting a beginning stye through the powerful actinic and absorptive effects of the brush discharge. For chalazion local ultraviolet application is sometimes of value (Hoilender and Cottle 8 ) in stubborn cases electrodesiccation is indicated. This may be also utilized to destroy the remnants after the chalazion has been incised and curetted. In angiomas, trichiasis, either electrodesiccation or
;
electrolysis
may
be employed.
Stenosis of the lachrymal duct has been treated with the negative pole of
the galvanic current through special probes devised
by Jarecky (quoted
Cottle) and good results have been claimed following the simultaneous dilatation and electrolysis. Cornea, Uveal Tract and Retina. Corneal ulcer responds favorably to
by Hollender and
ultraviolet radiation according to Duke-Elder and Nugent. 18 Nugent concludes that ultraviolet irradiation is efficient because of the transparency
of the cornea to ultraviolet rays
and because corneal necrosis
is
chiefly
due to bacterial invasion.
Irradiation from a suitable ultraviolet source accomplishes sterilization of the necrotic and perinecrotic area of the ulcer; regeneration of new epithelial cells to cover the area is quite rapid;
scar formation
is
A
is
special ultraviolet
greatly reduced and the resulting scar is thinner. 2 lamp has been designed by Birch-Hirschfeld.
filter of
It
and a quartz lens system which allows the focusing of a fine bundle of light on the corneal lesion. The uviol filter absorbs all short-wave lengths below 2850 Angstroms and also some of the infrared rays and an extra quartz cell containing distilled water absorbs the rest of the heat rays. An application of from three and a half to six minutes is repeated from three times a day to three times a week, depending on the extent of infection and the amount of discharge from the necrotic surface. Law 13 has designed a lamp which is much less expensive and for which he claims equal effectiveness. Its ultraviolet source is a small mercury vapor lamp, and the optical system is composed entirely of quartz; an iris diaphragm is included in the system. By this means a concentrated beam, rich in ultraviolet light, can be directed accurately onto a lesion of the cornea or other parts of the anterior segment of the globe.
a carbon arc lamp with a
uviol glass
Zinc ionization has been recommended for corneal ulcers by Erlanger, 6 Friel 7 and others. The technique consists of anesthetizing the eye with a cocaine solution, cleansing the ulceration and applying to it a pad of cotton, saturated with a 0.25 per cent solution of zinc sulphate. A zinc rod connected to the positive pole of a galvanic source is pressed against the pad and a current of 1 milliampere is applied for five minutes. Erlanger also advocates the use of ionization (histamine 1 to 10,000 solution or acetylcholin 1 to 200) to the sclera in cases of choroido-retinitis for relieving spasm of the small arteries and to improve circulation. Cauterization by regulated heat is a standard procedure. The thermophore of Shahan consists of an electrical heating unit and metal applicators of various size and shape. The fine metal tip selected for a lesion is heated
CORNEA, UVEAL TRACT AND RETINA
617
to a set degree of temperature and is applied by direct contact to the anesthetized corneal surface for a minute or a fraction thereof. High temperature (up to 165 F.) is recommended to stop progress of an ulcer and lower temperature to stimulate absorption. It was originally advocated as a treatment for serpiginous ulcer of pneumococcus origin but it also proved efficacious in the ulcer of dendritic keratitis and ring ulcer. Artificial fever therapy has been reported on favorably by Whitney 22
treatment of corneal ulcer and acute iritis. Recurrent abrasions of the cornea are better treated by ultraviolet than by any other means
in the
according to Law. Phlyctenular keratitis, kerato-conjunctivitis and tuberculous iritis respond to general ultraviolet therapy. Cases of phlyctenular conjunctivitis as a rule clear up rapidly after a course of general irradiation. Ill-nourished children in whom the condition has recurred chronically for a number of years need local applications of ultraviolet to the conjunctiva, together with general light baths. (For technique, see Chapter XIX.) According to Duke-Elder, tuberculous iridocyclitis is notoriously one of the most
difficult
14
eye diseases to treat; yet it responds often dramatically to general ultraviolet irradiation, provided it is begun at a reasonably early stage of the disease. In tuberculous forms of choiroiditis and scleritis, the results
are similarly satisfactory. Vitreous Opacities, Cataract and Glaucoma.
results
In vitreous opacities good
have been claimed
in
some
cases
by both the galvanic current and
1 diathermy. Bauwens states that diathermy is indicated in deep opacities, keratitis punctata and adhesions between the lens capsule and the iris. French clinicians advocate the galvanic current for opacities and flocculi of the vitreous. Diathermy and the galvanic current should be administered over the closed lids. For galvanism a well-moistened electrode of suitable size and shape is applied over the affected eye and a dispersive pad electrode is held under the nape of the neck; a current strength not exceeding 5 milliamperes is applied for fifteen to twenty minutes. For diathermy, bare metal electrodes are employed with a current strength not exceeding 400 milliamperes and always within careful limits of individual sensibility. The universal headband of Hollender is offering a convenient means of treating one or both eyes and there are also available double eye electrodes (Fig. 342). The efficient heating of the contents of the orbit by diathermy was demonstrated by the experimental studies of Moncrieff, Coulter and
Holmquest. As to treatment of glaucoma by galvanism and diathermy, there is theoretical objection to the use of both because the increase of circulation may increase the tension. This was also proven experimentally. On the other hand, careful clinical observation (Hollender and Cottle) has shown that they have given symptomatic relief in early cases where emergency 15 that tension surgery is not called for. Lyle in a few cases studied found in either normal eyes, nor in those with chronic hyperwas not increased
tension, while the pain
17
was
relieved.
In acute inflammatory diseases of the eye, intensive prolonged hyperthermy relieves pain promptly and may restore vision, totally or partially, treatdepending on duration of the infection and extent and number of n to Knight et al. They recommend five-hour sessions of ments, according
618
fever at 105
DISEASES OF THE EYE
F. at three to five-day intervals, continued, if the patient's rendition permits, to the point of maximal improvement. Temperatures of 106 to 107 F. for longer periods with concurrent use of sulfathiazole are indicated for gonqcoccic iniectfons.
FIG. 342.
Two
for straight galvanism, or
cup eye electrode: Cup is filled with cotton saturated with saline solution with medicated solution for ion transfer. (Courtesy of the Teca
Corporation.)
Culler and Simpson 4 hold that the various manifestations of syphilis in the eye rank with those of involvement of the central nervous system in their reluctance to yield to antisyphilitic chemotherapy,
Ocular Syphilis.
orthodox treatment has been repeatedly demon58 patients with various manifestations of ocular syphilis have been treated with approximately fifty hours of fever with temperatures above 105 F. in ten weekly sessions of five hours each, and a course of thirty injections of bismarsen was given in conjunction with the fever treatments. Best response was seen in exudative lesions of ocular syphilis, interstitial keratitis, exudative uveitis, active optic neuritis, neuroretinitis and choroiditis. Atrophy of the optic nerve is no contraindication to fever therapy and if it is associated with foci of active infiltration along the optic tract, they probably will respond. Culler and Simpson are of the opinion that early manifestations of syphilis offer the greater field of usefulness for artificial fever therapy combined with specific therapy, with a view to prevention of the often disastrous ocular complications. In advanced optic neuritis, the galvanic current has been advocated by German clinicians and also by the late Granger who stated that approximately 50 per cent of the cases treated by his technique were benefited.
and the inadequacy

strated.
of
series of
REFERENCES
619
Glass or metal double eye cups are filled with moist cotton adjusted to the closed lids and connected to the negative pole of a galvanic source. A dispersive pad, 4 by 5 inches is placed over the back of the neck and connected to the positive pole. The current is turned on very gently and from 1 to 8 milliamperes are applied for fifteen minutes. Through the same electrodes a rapid sinusoidal current, slowed to a rate of tolerance, is applied for eight minutes. The strength of the current should be such that the patient is just aware of flashes of light before his eyes. If the current is slowed too much, the patient may become faint. In case he complains of a blurry feeling in his eyes, the seance should be ended by a five-minute treatment with a double high-frequency vacuum electrode from the Oudin terminal. Treatment should be administered two or three times a week. Electrosurgery of the Eye. Ophthalmologists the world over have pointed to the possibilities of electrosurgery. The usefulness of electrodesiccation for the removal of warts, moles and cysts about the eyelids has been pointed out in Chapter XII. Trachomatous pannus and conjunctival lesions of trachoma have been successfully treated by electrocoagulation as well as by zinc ionization.
cicatricial bands in the orbit which prevent the wearing of an artificial eye. They emphasize the advantage of destroying large tumors by coagulation through two active needlepoint electrodes, which enable complete destruction of neoplastic tissues without the danger of extensive necrosis of adjacent bone. In detachment of the retina an ingenious method of electrocoagulation
Monbrun and Casteran 16 advocate and electrocoagulation for removal of
fine electrodesiccation for trichiasis
was
first
12 proposed by Larsson.
He
performed surface coagulation of the
sclera with the object of producing an adhesive process in the choroid and retina which, in turn, should bring about reattachment of the retina.
Jess 9 has
shown in animal experiments a firm union of the retina to the choroid by Larsson's procedure. Weve 21 subsequently developed the micropuncture method, in which perforation of the sclera is done near the retinal tear, by a very fine needle-point electrode and coagulation through 10 3 the puncture performed. In the United States Knapp and Cottle corroborated the successful application of this procedure. 20 Among other ingenious electrosurgical methods is that of Safar who relieved stubborn cases of blepharospasm by first locating the branch of the facial nerve by the galvanic current and then partly destroying it through coagulation through the same needle.
REFERENCES
1.
BAUWENS, PHILLIPPE:
8, 139, 1934.
Physiotherapy in Ophthalmology, Brit. Jour. Phys. Med.,
2.
BmcH-HiRSCHFELD and HOFFMANN: Die Lichtbehandlung in der Augenheilkunde, Berlin, Urban & Schwarzenberg, 1928.
Electrosurgery in Ophthalmology, Arch. Phys. Ther., X-ray and Rad., 15, 463, 1934. CULLER, A. M., and SIMPSON, W. M.: Artificial Fever Therapy in Cases of Ocular Syphilis, Arch. Ophth., 15, 624, 1936. Actinotherapy in Diseases of the Eye, Brit. Jour. Actin. and DUKE-ELDER, W. S.
3.
COTTLE, M. H.:
4.
5.
Physiother., 4, 82, 1929. Scientific and Practical Value of Ionization in Ophthalmology, 6. ERLANGER, G.: Brit. Jour. Ophth., April, 1936.
620
7.
DISEASES OF THE EYE

FRIEL, A. R.:
Electric lonization,
New
York, William
Wood &
Co., p. 108, 1922.
8.
9.
HOLLENDER, A. R., and COTTLE, M. H.: Physical Therapy in Diseases of the Eye, Ear, Nose and Throat, New York, The Macmillan Company, 1926. JESS (GIESSEN) Elektrochirurgie des Auges und seiner Umgebung, Klin. Monatsh.
:
f.
Augenheilk., 87, 839, 1931.
10.
KNAPP, ARNOLD:
Operative Treatment of Retinal Detachment With Electro-
coagulation, Arch. Ophth., 6, 733, 1933.

11.
12.
13.
14.
KNIGHT, H. C., EMORY, M., and CALLAHAN, N.: Hyperpyrexia in Treatment of Acute Ocular Inflammations, Am. Jour. Ophth., 27, 381, 1944. LARSSON, SVEN: Surgical Diathermy in Certain Diseased Conditions of the Eye, Acta ophthalmol., 3, 319, 1926. LAW, F. W.: A New Radiation Lamp for Local Therapy, Brit. Jour. Ophth., 1935. Ultraviolet Therapy in Eye Disease, London, Middlesex Hospital Press,
1934.
15.
16.
17.
LYLE, DONALD J.: The Study of Action of Diathermy on the Eye, Cincinnati Jour. Med., November, 1924. MONBRUN, A., and CASTERAN, M.: La haute frequence en ophthalmologie: Diathermic medicales, diathermic chirurgicales, Paris, Etincelage, 1929. MONCRIEFF, W. T., COULTER, J. S., and HOLMQUEST, H. J.: Experimental
Studies in Diathermy Applied to Eye and Orbit, Am. Jour. Ophth., 15, 199, 1932. NUGENT, OSCAR B.: The Pathology and Treatment of Corneal Ulcers, Jour. Am. Med. Assn., 98, 207, 1932.
18.
PETENYI: Monatsh. f. Kinderheilk., 21, 269, 1921. SAFAR: Quoted by Cottle. 21. WEVE: Diathermy in Treatment of Retinal Detachment, Nederl. Tijdschr.
19.
20.
v.
Geneesk., 76, 3591, 1932. 22. WHITNEY, E. L.: Artificial Fever Therapy in the Treatment of and Acute Iritis, Jour. Am. Med. Assn., 104, 1794, 1935.
Corneal Ulcer
CHAPTER XXXVI
General Considerations. Planning the Treatment. Frequency of Treatments. The Treatment Habit. Judging Results. Selection of Apparatus. Office Space. Office
Assistance.
The employment
integral part of the practice of medicine has
of physical agents as an become firmly established
during the past two decades. Their intelligent use is the best answer that scientific medicine can give to the cults, the chief stock-in-trade of most
of these being the exploitation of some physical measures. Every practitioner of medicine can and should make use of physical measures in his
daily practice. In order to be able to do so intelligently and consistently he must be familiar with the theory and practice of the principal physical
methods in their application to general medicine and pathology. No physical agent should be employed by the physician unless he knows the source and nature of the physical energy and can predict the effects it will produce. good clinician will make a better physical therapist than the man who excels only in the knowledge of physics and machinery. The real
physician will always choose from all available therapeutic measures, and will not neglect all for the sake of one in which he happens to be particularly
Seasoned experience and balanced judgment are needed to counteract the therapeutic enthusiast who exploits a single measure for a multitude of conditions. The application of some form of physical treatment should be considered when in the opinion of the physician it will either serve as the primary method of treatment ultraviolet in rickets, diathermy or fever therapy in gonorrheal arthritis, heat and massage in a traumatized joint or else serve as an adjunct to other forms of medical and surgical treatment. As a basis of treatment the establishment of a definite diagnosis by all known methods is essential. Uncertain abdominal pain treated by diathermy has turned out to be cancer of the pancreas or chronic appendicitis; shooting pains down the leg treated by light therapy proved to be caused by a new growth in the spinal cord; a "bursitis" of the shoulder treated by massage and static sparks turned out to be a traumatic neuritis of the circumflex nerve with paralysis of the deltoid muscle, and so on. It may be somewhat easier to avoid pitfalls of diagnosis in one's own patients but it requires both knowledge and tact when a patient comes referred for physical therapy from a fellow physician. Stereotyped diagnosis, like neuritis, bursitis, chronic arthritis, lumbago, neurasthenia, on closer investigation may prove to be something entirely different. Another source of embarrassment is having patients referred with a statement that their condition is hopeless or functional only and that treatment is to be administered as a placebo. The multitude of available physical measures raises the problem whether or not the medical profession can be so well taught the fundamentals of physical therapy in medical school and its application in hospital that
interested.
(621)
622
future physicians can all make the most of such therapy. In other words can the general practitioner be expected to replace in large measure the
specialist in physical therapy?
1 Irving states that he cannot do so now because except here and there he has not been so trained. "At the present time the whole problem of more extended use of physical measures seems to call for team work of a kind that will recognize the elements of time consumption and convenience for doctor and patient alike, the overhead cost as distributed among the patients and finally closer concert between the practitioner and the specialist
Given every diagnostic analysis needed, there still which breadth of experience in administration alone, required judgment, can give to devise the appropriate measures and to estimate frequency of treatment and length of continuance." Planning Physical Treatment. When planning physical treatment, the
in physical therapy.
is
chief consideration should not be "Will a given apparatus fit a given diagnosis" but rather "Will in a given pathological condition in the
individual a remedial agent or a combination of agents be of benefit?" It is not electricity in itself, but the thermal, mechanical and chemical effects of the various currents, that produce the desired therapeutic results.
While in our mechanical age apparatus has become almost indispensable, physical therapy must not be necessarily identified with apparatotherapy. The relative value of the various remedial agents must be always taken into consideration, and the simpler methods not neglected for the complicated or spectacular ones. In the average patient there are usually well-defined indications or
contraindications for the application of remedial agents. If some form of electrotherapy or its combination with other physical agents is deemed best, the next step is to determine what technique is to be used and how
often and how long it is to be applied. In other words, an exact prescription for electrotherapy has to be given just as in the case of prescribing
a patient that he should get some electricity" is equivalent him to get some "medicine." The records used in physical therapy clinics such as the New York Polyclinic Medical School and Hospital (shown in Chapter XXXVII) should enable the prescribing of the strength, duration and technique of application of each measure and the recording of each treatment. On the reverse side space is provided for a short history, physical examination, progress notes and time of discharge and the recording of the final result. For office use simpler forms may be
tell
drugs. To to telling
"
employed.
Definite data put
down on
initial
examination furnish the most desirable
of comparison for later examination. In traumatic conditions, for instance, one must note: (1) State of injury or repair, measurements, circumstance of limbs and joints, conditions and measurements of wounds
scars; (2) state of function, range of motion in joints, strength of Electrical tests of the individual muscles or groups of muscles (grip). response of muscles may furnish another definite record for subsequent
means
and
comparison.
Frequency
of Treatment.
Physical therapy ought to be administered
as often as required by the exigencies of the condition. Acute and very painful conditions, as a rule, require daily treatments or even two or more per day. One designates as "bridging" those kept up just often enough,
THE TREATMENT HABIT

for instance, to relieve a painful condition.
623
administered even less often, but this, of course, depends on the diagnosis and the progress noted. Judging Results. No treatment should be continued beyond a period of reasonable length if it is not bringing about visible improvement or relief of pain. Either the diagnosis must be wrong or the treatment inappropriate as to selection or technique if results are not forthcoming. It is impossible, of course, to make a general statement as to how soon results should be obtained, because it all depends on the individual condition. Patients very often will ask, "How long will I have to take these treat-
With improvement, the freFor the average patient suffering from some chronic ailment treatment every other day is often sufficient and may be
quency can be reduced.
ments?" In many instances the experienced physician will be able to give an approximate estimate, once he is thoroughly familiar with all the facts.
If
physical therapy
is
directed for the relief of pain
it
should effect improve-
ment within a few treatments; if it is directed toward the increase of function results must be clinically measurable and demonstrable after a
few weeks.
Both in the clinic and in the physician's office a definite procedure should be established to discharge patients and record the result. Treatment should be discontinued when on repeated examination no further improvement is found in the pathology or in the function of a diseased or injured
part, or when, according to one's experience, further improvement ought to take place through the forces of natural recuperation. Often, however,
it
may
be advisable to follow a successful course of treatments, directed
relief of local pathology, by a course of general restorative measures. It is not often that the physician can claim to have "cured" a patient by remedial agents, for that would imply complete anatomical and functional restoration. In the practice of physical therapy we often learn to appreciate full functional recovery more often than a full anatomical one. A knee deformed by arthritis may never return to its normal contour, but as long as it is usable and does not pain we can state that "recovery is In chronic prostatitis there still may remain a perfectly satisfactory." palpable mass, but most of the inflammatory infiltration can be removed, the discharge and painful sensations stopped. One may state that "the condition is improved" if at least some of the principal symptoms or some of the pathological changes have been favorably influenced. "Maximum " possible improvement attained ought to be stated when the fullest amount of restoration has been achieved and no further physical therapy is indi-
toward the
cated.
The Treatment Habit. Certain chronic patients have a tendency to develop a "treatment habit," insisting on a certain line of treatment This is no doubt undesirable and should be discouraged. indefinitely. However, the other side of the picture should be considered also. If some form of physical treatment keeps a chronic sufferer comfortable and does not hold him back from other really indicated, sometimes vital, treatment it is perhaps a lesser evil to continue with such treatment, which serves both as a physical and as a moral support, than to let him drift. "The treatment habit" by physical methods is far less dangerous than by possibly habit-forming drugs.
624
Selection of Apparatus. One of the most frequent questions asked of teachers in physical therapy is "What make of apparatus do you recom" mend? The reply may be a counter question, " What make of automobile " do you recommend? and may be followed by the statement that apparatus
by manufacturers of good reputation and experience in the electrofield and tested by physicians of clinics of standing is preferable to models volubly advertised by new sales concerns and endorsed by socalled experts whose names are unknown in scientific circles. The Council on Physical Medicine of the American Medical Association stands ready to pass upon specifications and therapeutic claims of all electromedical
built
medical
apparatus intended for the use of physicians. Apparatus accepted is produced by ethical manufacturers in accordance with engineering standards, it is tested in a clinic acceptable to the Council and therapeutic claims for the apparatus must be corroborated by definite evidence furnished to the
Council.
The Council has repeatedly warned the profession as a whole against the acceptance of enthusiastic statements by manufacturers' agents salesmen absolutely untrained in medical science. It is pointed out that while for the most part, the sales agents of manufacturers of physical therapeutic equipment are no less trained and no more overenthusiastic than the representatives of many drug and surgical supply houses, physicians should beware of the high pressure type of salesman of physical therapy equipment who extols his device in terms of its earning ability. Choice of such devices should be based solely on the decision as to their
therapeutic efficiency. If the prospective purchaser of any piece of equipment can bring himself to disregard argumentation of the sales firm emphasizing some special features in the apparatus in question, he should satisfy himself (1) that it is of standard type ("Council Accepted") and (2) that he can expect prompt service from the manufacturer or his authorized representative. Under the conditions of ordinary medical practice a piece of apparatus practically lasts a lifetime, and the only replacements ever needed are new
bulbs or burners in phototherapy apparatus. The installation of a modest layout for the principal electrotherapeutic measures can be had for less than $1000, and compared to the expense of a roentgen-ray outfit which, so far as general practice is concerned is of hardly any value for therapeutic purposes, a modest electrotherapeutic installation is a very useful and relatively inexpensive investment for the average medical man and will pay liberal returns during a lifetime, pro-
vided that
its
owner
will
devote himself to
its
proper study and use.
physician's office can be utilized If the physician has to administer many forms of physical treatment. one room in which to see and to treat patients, one or two spaces, only about 8 by 5 feet, can be screened or partitioned off and will hold one treatment table or cot and the apparatus and provide privacy. If there are two such spaces available one may contain a comfortable arm-chair or
Office Space.
Even the most modest
steamer chair in which patients can be treated in sitting position, with a comfortable support for the lower extremities. Providing electrical outlets for the attachment of apparatus is simple enough. One or two treatment-timers or automatic cut-off clocks should be used from the start to insure the methodical and efficient timing of treatments. Most busy prac-
OFFICE ASSISTANTS
625
titioners, especially those caring for post-traumatic or compensation cases, find it of advantage to install physical therapy apparatus in a room adjoin-
ing their
office.
is to be used principally for physical therapy, demands not only because of numerous and often bulky pieces of special planning, apparatus, but, also, because the treatment time for the average patient amounts to about one hour. Besides the regular waiting and examination rooms, there must be at least one additional large room, subdivided into a number of treatment cubicles or a series of small individual treatment rooms. One large room housing all patients under treatment, yet allowing individual privacy, is preferable, because it allows the doctor or his technicians to be constantly within sight and sound of every patient. Also, it permits of switching or combining of apparatus with a minimum of time
An
office
which
and
effort.
FIG. 343.
Treatment
cubicle.
Individual treatment cubicles should allow room for a treatment table or couch, space for some apparatus, a stool, and a small table or dresser. Room dimensions should be approximately 8 by 10 feet. Partitions between to provide privacy and at the individual cubicles should be 6 feet
same time allow a maximum
high, of light and air in each treatment space. of each space, allowing quick accesWell-fitting curtains at the entrance 40
626

and apparatus
It
is,
sibility to patients
in case of
any emergency, are preferable
to doors.
Office Assistants.
employ one or more
skilled
of course, advantageous if a physician can workers to assist him in the technical applicaof the older physicians
tion of his treatments.
However, many
who
are
responsible for the present advanced status of physical therapy have never had any assistants. Indeed, they attribute their success to the fact that
close observation of their patients has made them much more familiar with their condition, and has also made the patients more appreciative. physician beginning the practice of physical therapy had better give
every treatment himself, for thus he learns to appreciate the importance of every technical detail. He should not hesitate to administer all physical treatment measures, including massage. When his practice warrants the employment of a technician, the physician should make it a matter of invariable routine to inaugurate the treatment on each patient himself, and to be present for as much of the treatment time as possible. On subsequent visits he should see the patient each time he comes to the office and re-examine him at frequent intervals. Treatment of internal medical, gynecological or such other nature as require the physician's knowledge and technical skill, of course, must be attended by him at all times.
physicians well-versed in physical therapy prefer to train their Naturally, a person who receives training in physical therapy after having had a grounding in anatomy, physiology, and pathology and the handling of the sick makes a better technician than the average office girl who has been merely taught how to turn on switches
Many
own
technicians.
and put on electrodes. In hospital departments of physical therapy wellFor further details on trained technicians are virtually indispensable. technical personnel see next chapter.
REFERENCE
1.
IRVING, PETER: Physical Therapy in Internal Medicine, Cincinnati, September, 1937.
Am. Cong. Phys.
Ther.,
CHAPTER XXXVII
apy.
Technicians.
Relation to Other Departments. Director of Physical TherLocation and Floor Space. Equipment, Records. Physical
Therapy Books
for Library.
General Considerations. A physical therapy department is an integral part of every modern clinic and hospital and the number of hospitals still lacking such a department is steadily decreasing. A hospital survey of the Council on Medical Education showed in 1936 that 2008 or 31.7 per cent of hospitals in the United States have physical therapeutic departments. A survey of the hospitals of New York State in 1930 showed that 57 per cent possess a physical therapy department and 34 per cent of the
remainder planned to organize one. It has been estimated that in a general hospital about one-fifth to one-quarter of the patients will be benefited by some form of physical treatment; in surgical, orthopedic and neurological hospitals about three-quarters of the patients will require physical treatment.
1 College of Surgeons urges that all Class A hospitals should possess adequately manned and equipped physical therapy departments. It advises the observance of the following requirements as to the organization and management of a modern physical therapy service: 1. Hospitals carrying on physical therapy should have a well-organized
The American
department under competent supervision. 2. The department be properly planned and equipped
in accordance with present-day standards. 3. There shall be adequate, trained personnel under competent super-
vision.
4.
and
5.
filed in
comprehensive system of records be available in the department an accessible manner. definite procedure be established for the reception, treatment and
discharge of the patient. 6. As far as possible there be periodic analysis of the work of the department to determine the results.
Relation to Other Departments. The physical therapy department should be practically a reference department, like the roentgen-ray department. Patients referred there from other departments should have had the benefit of indicated diagnostic procedures beforehand and be treated Cases may originate from in close cooperation with these departments. the department itself only when special authority is vested in the director
for this purpose.
Physicians referring patients to the physical therapy department, besides should indicate what giving the diagnosis and possibly some salient facts, is the object of physical treatment, such as "relief of pain," "restoration of function," "general tonic effect," etc. It is perfectly evident that sugThe value of such gestions as to the type of treatment should be welcome. will depend upon how much knowledge and practical experience suggestions (627)
628

9
the referring physician has in physical measures.

sultation
is is
In doubtful cases conits first
desirable.
Given a properly manned and equipped department,

not so
problem
much how
most
which
will
to treat its patients as how to receive the type of cases benefit by its work. Very often patients sent for physical
treatment are referred much too late or should not have been sent there at all, whereas patients to whom properly applied measures should be of immeasurable benefit never receive them. Tactful missionary work by
the director of the department is the only way to overcome by degrees such an undesirable state of affairs. The physical therapy department should not be made the dumping ground of chronic and incurable cases. Many conditions of fibrositis, adhesions, atrophy, ankylosis following inflammatory conditions could have been returned to useful activity by the early and intelligent use of physical measures promoting resorption and restoring function. In recent trauma the early use of physical measures for relief of pain and for the speeding-up of the process of repair is invaluable and can be applied without interfering with immobilization. Much valuable time is wasted and much needless suffering is prolonged in hospitals which do not provide adequate physical measures at the In most modern hospitals the physical therapy department bedside. works as a unit for both in- and out-patients. Not only massage and therapeutic exercise, but all forms of electrotherapy, light therapy and hydrotherapy can be administered at the bedside with the many convenient
and
efficient
types of portable apparatus
now
available.
Profiting from the experience of present-day military hospitals, there is also an increasing tendency to coordinate the work of the occupational
therapy department with that of the physical therapy department under the same medical direction (Watkins 9 ). In order to stimulate interest in the work of the department, its director may hold scheduled clinics for visiting physicians, the staff and internes from time to time; it is also recommended that internes and nurses be given a number of lectures on the subject. The physical therapy department should be open for inspection at all working hours consultation with other members of the staff, collaboration in clinical research with other departments all will tend to secure an understanding of the potential
;
offerings of this indispensable tion of the other departments.
department and secure the
fullest coopera-
The director of a department of should be a physician who has had special training physical therapeutics in this subject. The truism of a stream flowing no higher than its source applies with especial force to the physician in charge of a really efficient physical therapy service. Consulting daily with colleagues from any of the other hospital departments, and prepared to deal W ith a correspondThe Director
of Physical Therapy.
7
must be many-sided indeed. He should be preferably a Class A school graduate, and then have had best of all foundations, some years at least this followed by thorough-going postgraduate courses, of general practice
under recognized authorities, in physical therapy. Just as comprehensive training is needed for this activity as for neurology, surgery, orthopedics or any other special field of practice. Ideally he should be on a full-time paid status. The medical director, because of training, is the one to pre-
ingly large
number
of referred pathological conditions, his qualifications
THE DIRECTOR OF PHYSICAL THERAPY

scribe the patient's physical therapy tration.
629
its
and
is
responsible for
adminis-
Consistency in ordering physical measures and in the working-out of a technique best suited to the needs of certain classes of cases and to the interests of the institution is only possible when one responsible medical man or department does all the prescribing and continues or supervises treatment until the limit of improvement according to his knowledge has been achieved. This does not preclude the constant observation of patients by the other members of the staff. McEachern 6 reports that the American College of Surgeons advocates that the director of physical therapy be a member of the staff and have the same standing on the staff as any other specialist. Under no circumstances should physical therapy be prescribed by others than physicians. During the years of early evolution of physical therapy some medical men, unable or too busy to study physical therapy, established departments by leaving the ordering and treatment wholly to the supposedly well-trained technician. It is a confession of ignorance and is certainly not serving the best interests of the patients or the proper development of physical therapeutics that there appear still to be some otherwise reputable institutions following this deplorable example. It is equally objectionable to place the department nominally in charge of a member of the staff who may be a good orthopedic surgeon or radiologist but wholly without comprehensive training along the broad field of physical medicine. The duties of the director of a department are summarized by Coulter2
all new cases, to prescribe for those in the clinic, and to prescribe for those in the hospital in consultation with the physician
as follows: "1. To see
referring the case. " 2. To see all cases at least once every
maximum improvement
changing.
"
3.
two weeks and to decide whether has been reached or whether treatment needs
any time at the request of the technicians. the attention of the staff from time to time to certain treatments which might be helpful from the standpoint of physical therapy. "5. To prepare and keep up by abstracts of literature a bibliography of physical therapy which will be available for members of the department
see cases at
"4.
To To
call
and
"6.
for the staff physicians of the hospital. To check with the chief technician
and see that
all
directions are
carried out faithfully,
remembering always that these physical agents
have high potential danger if handled carelessly. "7. To do all in his power to make the department as truly scientific as possible and of real assistance to the members of the staff. "8. To stimulate research among the younger members of the staff. "9. To interest the physicians of the hospital in physical therapy, showin which they are interested. ing them the work being done in the fields To organize a teaching program for the nurses, internes, technicians "10. and physicians who might be interested in physical therapy.
"11. To prepare a schedule of places of interest in physical therapy for the visitation of technicians, each technician to have a half day every other month for this purpose.
630
"12.

To check all equipment and supplies for the department of physical An accurate tabulation of all costs relative to material, repairs,
therapy.
office of administration.
help, supplies, etc., should be obtained at regular intervals from the central This is necessary in order that the department
may
It
be put on a paying basis."
is evident that assistant physicians and internes in the department should aid the director in his duties in as much as they are assigned to. It has been recommended that the interne on laboratory service be assigned to the physicial therapy department in addition to his other duties and this practice is also followed at the New York Polyclinic Hospital. The Council on Physical Medicine stated: "Most medical graduates devote
about two years to hospital work before engaging in private practice. During this period they should receive broad practical experience in physical Internes should be encouraged to take an active interest in therapy. physical therapy during their incumbency and should be required at least to make themselves familiar with the procedures followed in every case coming under their care for which physical therapy is prescribed. Resident interneships or fellowships might well be established in physical therapy."
Technicians. Properly trained technicians are indispensable for the carrying on of physical therapy in institutional work. The 1937 hospital survey of the Council on Medical Education and Hospitals states that 2382 "physical therapists" were reported by 1302 hospitals. The greatest number of physical therapists, 1648, appears to be serving in general hospitals. Other types of hospitals reported as follows: mental, 350; orthopedic, 167; tuberculosis, 62; children's, 41;
The war time emergency has brought about training The 1945 Hospital Service Report of technicians.
other institutions, 114. of a large number of the Council reports 3220 full time and 747 part time physical therapy technicians, a total of 3967. The estimated number of new graduates for 1945 is 904. " To Coulter lists among the duties of the chief technician the following: direct the activities of the technicians; to see that all assistant aids are given proper division of responsibility and, with the doctor in charge, to
all
and
outline a teaching program by which the technique shall be reviewed and the best methods obtainable instituted where advisable to have all requisi;
tions for equipment, supplies, etc., signed by herself, but where amounts are large to obtain the approval of the doctor in charge; to have any defects in machines or equipment reported immediately; to appoint one
of the technicians in the clinic as assistant chief technician
who shall assume
the duties of the chief technician in her absence and who shall be responsible for certain activities of the clinic; to keep constantly on the alert and to call the attention of the physician in charge to anything of unusual interest to keep the doctor in charge informed at all times concerning the arrival of new cases referred to the department; to encourage the making of
;
criticisms
As
to the technician herself,
and recommendations among the assistant aides." " The nurse who studies McGuinness 7 states
:
physical therapy has a decided advantage over the ordinary technician. She has already learned the code of ethics as between the physician and herself and the patient and herself. Above all else she will be called upon to display tact, patience, forbearance, cheerfulness in greater measure than
ever in her nursing career.
TECHNICIANS
631
"Neatness, cleanliness, appropriate clothing and quietness of manner, movements are as prime essentials as in the nurse. The patient will be quick to note if the technician be neatly and suitably dressed, washes her hands before as well as after the treatment, enters and moves about the room quickly and speaks in a low, modulated voice. "A loud voice, a running comment of chatter especially on other cases,
voice,
careless
and noisy movements are more distasteful to the patient treated by a technician even than to one receiving nursing care. Especially is this so with the nervous, high-strung woman. Patients are only interested
in themselves, their worries, troubles, illness or misfortunes usually are slightest concern in those of others, espe-
paramount. They have not the

is
cially of other patients, the physician or technician.
They
feel their
pay
attention wanders from their immediate condition. "Some patients wish to talk, to discuss symptoms, treatments, physicians, their peculiar case (every case is peculiar), the outcome, the length
if
not well earned
and number of treatments. The more nervous they are, the more they seem to have a compulsion neurosis to chatter. This must be discouraged. It is unwise to discuss these subjects, one is sure to be quoted, usually wrongly or adversely and trouble is likely to ensue, besides lack
of time of benefit to the patient. "
patient should be impressed by the physician that every physical calls for quiet and complete cooperation between the patient and technician. The latter should impress this by her manner and attention to the work on hand. Good work cannot be done if the mind is not upon it and the full measure of relief and relaxation will be wanting upon the completion of the treatment. The physician will notice this or be told about it and a new technician may be asked for. "Do not tire the patient with too much, too long or too strenuous a
The
measure
treatment. Frequent rests are in order. Avoid fatigue. A quiet, relaxed patient will receive much greater benefit than a tense, irritable one. Overtreatment may have the opposite effect to relaxation and cause more Nerves and muscles may be overstimulated or greatly nervousness. fatigued to their disadvantage. In addition to the rests of one, two or three minutes required between exercises, there should be a prolonged one following the treatment as a whole, varying from fifteen to sixty minutes.
If sleep can be induced so " If the patient reports
the better. that she was so tired she could not find rest for hours after her treatment, this has been too long and too strenuous. Decrease the amount, increase the rest periods, be less vigorous. If cold or chilliness is complained of, especially of the feet, be sure these are treated
first
much
and then wrapped up to retain their warmth when possible. This will do more for the comfort of the patient than almost any other maneuver. " See that the patient is in no danger of catching cold. Every new symptom will be ascribed to the treatment, colds will be blamed upon it and adverse effects because of it, will be related at great length. Therefore see
that the patient is not in a perspiration. A weak patient should receive a light general massage with alcohol. A strong one may have a warm, then a cool shower with a vigorous massage. "No treatment should last longer than forty-five minutes with rest receive no longer than a fifteen-minute interspersed. A weak patient should treatment with rests to begin with. The patient's reaction is the criterion.
632
Gradually lengthen the treatment in time and strength and keep rest periods according to the physician's orders and your best judgment. "If the technician be in good health and properly trained, she should have no adverse effects from her work. Neuromuscular control is the prime essential of a good technician and next comes a sense of economy as to energy and time expended. No one can teach relaxation who is tense and nervous. No one can do good work whose muscles are strained after a treatis easily fatigued. for the technician to guard health and important, therefore, strength, by. getting the proper amount of sleep, food, rest, recreation, relaxation and exercise, quite as much as for the patient." is
ment. "It
No
one can continue long in the profession who
to the training of technicians, the late Granger, 4 who did such outstanding work in organizing physical therapy services in the World War I
As
period, stated: "Physical therapy technicians, still called in government service reconstruction aides in physiotherapy, basically should have had
thorough grounding in anatomy, physiology, the analysis of muscle and joint motion and scientific massage. While a knowledge of electrophysiology and electrotherapeutic and hydrotherapeutic technique is desirable, yet it is not absolutely essential, as these subjects can be readily taught in any well-organized department of physical therapeutics. Graduates of schools of physical education or college graduates who have majored in physical education have in my experience made the best technicians. Nurses, though often good, have not, as a rule, had sufficient basic training. A well-trained technician is invaluable, not only in carrying out intelligently the treatments ordered but also in observing and reporting symptoms and
the reactions of the patient to their physical therapeutic prescription. If the carrying-out of this procedure is insisted on the daily work becomes interesting and does not deteriorate into a mere mechanical routine." The training and qualifications of technicians during the development period of modern physical therapy was in a somewhat chaotic condition in the United States, varying from those with college background and training in schools of physical education and in a few high class physical
therapy schools to graduates of massage schools and of some downright commercial establishments even offering training by correspondence. It is
evident that "graduates" of the latter type of schools had very poor educational background, very meager clinical training and at times total lack of such ethical standards as nurses possess. Following a resolution passed by the House of Delegates of the American Medical Association in 1934, a program of standardization and classification of schools for physical therapy technicians has been successfully carried out by the cooperative effort of the Council on Physical Medicine and the Council on Medical Education and Hospitals. After inspection by the latter Council a list of approved schools for physical therapy technicians
was published. Essentials
of acceptable schools
and
lists
containing com-
plete data may be secured, on request to the office of the Council on Medical Education and Hospitals, 535 North Dearborn Street, Chicago. In conjunction with the standardization of schools, an American Registry of Physical Therapy Technicians, located at 30 North Michigan Avenue, Chicago 2, has been established. Only those with acceptable training are
included as
members
of the Registry.
It provides
two
classes of certifica-
tion: Technician
and Junior Technician.
LOCATION AND FLOOR SPACE
633
Location and Floor Space. A physical therapy department can be started in one modest room with a few pieces of apparatus furnishing the basic forms of measures heat, light, massage and exercise. With a capable
physician at its head and a well-trained technician to carry out most of the clinical details, it will prove its worth very quickly. Any hospital, however, planning to make full use of modern physical therapy should anticipate future growth and provide ample room for its department. The question of space is quite a problem in old hospitals, where space is at a premium, and hence one often sees this department which should typify light and exercise crowded into a dark basement. The prime consideration
FIG. 344.
Floor plan of physical therapy department in Medical School and Hospital.
New York
Polyclinic
of locating the
department should be easy
accessibility to all parts of the
hospital and
will have to be clinic, near to the elevators, for patients to it for treatment and apparatus has to be taken to the wards brought and rooms. Location on the first floor is best and even the basement is not wholly undesirable, provided that the rooms are high and there is adequate light and ventilation. In making use of the space at disposal it is generally preferable to arrange for one large general treatment room, where most electrical treatments and active exercise are administered. Such a large room allows and
massage more economy
of operation
and better supervision and better ventilation
634
than a number of small individual rooms. Separate rooms should be provided for hydrotherapy equipment, for a static machine and for gymnasium apparatus, if such is to be used. The large treatment room is conveniently subdivided into individual treatment cubicles by sheets suspended on wires or metal pipes, or else by wooden or steel partitions, 6 feet high, allowing ample space for circulation of air. The size of each of these cubicles should be 8 by 8 or 8 by 10 feet, allowing space for two treatment tables or cots and two pieces of apparatus. Two men or two women can thus be treated at the same time. If private patients are to be treated at the same hours, one or more separate smaller individual cubicles with substantial partitions can be provided for in the same or in an adjoining room. Besides treatment rooms, there must be a waiting room or space for patients, an examination room for the physician, a dressing and rest room for the technicians, and sufficient closet space for linen and other supplies; if possible, also a store and repair room. In teaching clinics a small lecture room should be provided. The total floor space for the department will depend on the average number of patients to be treated and the variety of equipment to be installed. A clinic expecting an average of from 25 to 50 patients' visits daily would require a total floor space of about 600 to 1000 square feet.
3 2 5 4 Papers of Granger, Grober, Coulter and the Council on Physical Therapy contain details of the layout and equipment for clinics of various capacity. Equipment. A complete modern physical therapy clinic would consist
of the following subdivisions:
(1)
Electrotherapy, (2) light therapy, (3)
hydrotherapy and (4) mechanotherapy. Roentgen-ray therapy should not be carried under physical therapy, neither should the physical therapy department, as a rule, be made part of the roentgen-ray department except,
possibly, in small hospitals. Planning for the necessary
should be
equipment and the mode of its intallation the director of the clinic and not be planned for him by others. War-time physical therapy departments deal with a circumscribed number of conditions and, therefore, it is possible to specify a standard
left to
list
of equipment. In general hospitals the number and types of apparatus, as well as the necessary and special accessories, will vary according to the will prevailing type of work; a clinic dealing chiefly with traumatic cases where largely pediatric or neuropsychiatric have different needs from that
cases prevail. For the sum of from $2000 to $3000 a fairly complete equipment of the principal types of apparatus needed for electrotherapy and
light therapy
can be installed in a general hospital. A complete hydrotherapy and mechanotherapy equipment the latter usually in the form of simple gymnasium type of apparatus would about double the cost of
initial installation.
The equipment of a small electrotherapy and light therapy department should consist of a few luminous heat and infrared radiators ranging from 150- to 250-watt capacity, two of 1500-watt capacity, two diathermy machines, one of these portable, a low-frequency (muscle stimulating) air-cooled mercury generator, a galvanic-f aradic electrodiagnostic outfit, an vapor lamp or carbon arc lamp. The principal types of accessories, as described in Chapter IV, must also be provided. It may be well for the
director of the department to ask for a blanket appropriation for accessories covering about double his initial needs, so that he may have no difficulty
RECORDS
635
in securing extra items sure to be needed when the department gets well under way. A model hydrotherapy room includes one control table with a shower bath, one electric light cabinet, two arm and one leg whirlpool baths, and one sitz bath. A 6-foot bathtub equipped for the administration of various treatments, may be added. In orthopaedic hospitals therapeutic pools or large treatment tanks are essential.
mechanotherapy room should include a
set of
gymnasium apparatus
for active exercise, also a set of steel bars, a rowing machine, a nautical wheel, a creeping board, a few dumb-bells and Indian clubs and one foot-
inversion treadle.
FIG. 345.
Military ward with physical therapy equipment.
(Signal Corps, U. S. Army.)
All apparatus should be of standard type and purchased from manufacturers of good repute who will agree to furnish adequate service of
periodic inspection and adjustments. Details about current supply for apparatus and about current outlets
have been presented

Records.
in
Chapter
III.
of results and Well-kept records are required for evaluation or for organized cooperation with the other departments of the hospital
clinic.
.
.
a patient is referred to the physical therapy department desirable that his entire record, including roentgen-ray and laboratory In hospitals where there is no unit him. findings, should accompany
When
636
history system the written order referring to patient should contain at least the diagnosis and the condition which is to receive special attention;
it
may
department
in the
The physical therapy also offer suggestions for the treatment. may keep its own histories if there is no unit system in vogue.
record sheet or card is the most important document department. It should contain an exact order for the forms of treatment to be given, the sequence, duration, strength and details of technique of each, with a space for the signature of the administering technician. This is important for later check-up in cases of alleged accidents.
The treatment
NEW YORK
POLYCLINIC HOSPITAL
No.
PHYSICAL THERAPY RECORD

NAME.
DIAGNOSIS
.
REFERENCES
637
The physical findings at the time of admission should be carefully entered, in order to furnish definite comparisons for the checking-up of progress. The back of the regulation treatment record sheet is best suited for this purpose, as shown in the treatment chart used at the New York
Polyclinic Hospital.
Regular progress notes must be made on the treatment record patients coming daily should have such a notation entered at least once a week or whenever there is a definite change in the condition or in the treatment; patients coming every other day should have a note at least every two weeks and chronic cases at least once a month. Careful and systemic checkup of all patients by the director of the clinic is the only means to prevent patients continuing treatment indefinitely or without any apparent result.
;
A diagnosis card for cross-indexing of pathology is important for scientific check-up work. A record book in the department should contain a list of patients treated each day, the classification of patients if there is any (clinic, ward, private, semiprivate, compensation), a marker for new patients, and possibly the name of the referring physician. This gives information at a glance of
the
amount of work going on. Physical Therapy Library. The Council on Medical Education and Hospitals enumerates the following books on physical medicine for the up-to-date hospital library in the May 19, 1945 issue of the Journal of the
American Medical Association, Council on Physical Medicine:
Medicine.
$2.
American Medical Association:

Handbook
of Physical
Am. Med.
Assn., 1945.
Medical Applications of the Short Wave Current, 2d ed. $5. Baltimore, Williams & Wilkins Company, 1942. GLASSER, OTTO, and others (eds.): Medical Physics. $18. Year Book Pubs., 1944. KOVACS, RICHARD: Electrotherapy and Light Therapy, 4th ed. $8. Philadelphia, Lea & Febiger, 1942. Manual of Physical Therapy, 3d ed. $3.25. Philadelphia, Lea & Febiger, 1944. KRUSEN, FRANK H.: Physical Medicine. $10. Philadelphia, W. B. Saunders Com-
BIERMAN, WILLIAM:
pany, 1941. Physical Therapy in Arthritis.

1937.
$2.25.
New
York, Paul B. Hoeber,
Inc.,
and Its OSBORNE, STAFFORD L., and HOLMQUEST, H. J.: Technique of Electrotherapy Charles C Thomas, 1944. Physical and Physiological Basis. $7.50. Springfield, 111., Tudor WRIGHT, REBEKAH: Hydrotherapy in Psychiatric Hospitals. $4. Boston,
Press, Inc., 1940.
Physical Treatment by Movement, Manipulation and Massage, Philadelphia, P. Blakiston, 1940. MOCK, HARRY E., PEMBERTON, RALPH, and COULTER, J. S. (eds.): Principles and Practice of Physical Therapy. In 3 volumes. $35. Hagerstown, Md., W. F. Prior Company, 1944.
MENNELL,
4th ed.
J.
B.:
$7.
In addition, there are two physical therapy periodicals available:

of Physical Archives of Physical Medicine. (Official journal of the American Congress 111. Medicine.) $5.00 yearly. 30 North Michigan Avenue, Chicago, The British Journal of Physical Medicine and Industrial Hygiene. $5.00. 4-6 Bell
Yard, Temple Bar WC.2, London, England.
REFERENCES
1.
American College
p. 269, 1937.
of Surgeons'
Manual of Hospital Standardization, October
Bulletin,
638
2.

:
3.
4.
COULTER, J. S. Physical Therapy in the Hospital, in the School for Crippled Children and in the Private Office, Principles and Practice of Physical Therapy, Hagerstown, Md., W. F. Prior & Co., Chap. XXI, vol. 3, 1932. Council on Physical Therapy. Physical Therapy Departments in Hospitals With 50 or More Beds, Jour. Am. Med. Assn., 110, 896-899, 1938. GRANGER, F. B.: A Hospital Department of Physical Therapy, Jour. Am. Med.
Assn., vol. 88, 1927.
5.
6.
7.
Die physikalisch-therapeutische Abteilung, Das deutsche KrankenJ.: haus (Handbuch), Jena, Gustav Fischer, 1932. MCEACHERN, M. T.: Standards of Physical Therapy and Occupation Therapy Departments in a General Hospital, Arch. Phys. Ther., 20, 753, 1939. McGuiNNESS, M. C. L.: In Kovacs' Manual of Physical Therapy, Philadelphia,
GROBER,
8.
Lea & Febiger, 3rd ed., 1944. A Physical Therapy Unit for an Industrial Area Hospital, SAVAGE, P. G.
:
16, 52-55,
1942.
9.
WATKINS, A.
L.:
Co-ordination of Physical Therapy and Occupational Therapy,
Occup. Therapy, 22, 115-119, 1943.
Appendix
ELECTRODIAGNOSTIC CHARTS AND TABLES

1.
Tables of Motor Nerves and Muscles.
2.
Charts of Motor Points.
MOTOR NERVES AND MUSCLES OF FACE.

Motor
nerves.
ELECTROD1 AGNOSTIC CHARTS AND TABLES
641
Frontalis
Temporal
branch
Corrugator
Orbicularis
palpebrarum
"SiJSssr (Mandibular
-
^
"
-_-_-=.-
Nasal compressor:
Buccal branch
N. Facial
Trigeminus j Temporalia "/ ^ Masseter JV. (
Erb's point, (Brachial Plexus)
-i>r
FIG. 340.
Motor points
of face.
41
(>42
APPENDIX
Moron NERVES AND MUSCLES OF ANTERIOR ASPECT OF TRUNK.

Motor
nerves.
643
Sterno-cleido-mastoid
Deltoid
(
Circumflex
(anterior)
N.
Deltoid (middle)
_ Pectoralis
r major
f (
Brachial Pl Plexus)
Brack ial Plexus
Serra'tif anterior
Intercostal
Intercostal
Ilio-inguinal Ilio-hypogastric
External Oblique
Pyramidalis
FIG. 347.
Motor points
of anterior aspect of trunk.
644
APPENDIX
MOTOR NERVES AND MUSCLES OP POSTERIOR ASPECT OP TRUNK.

Motor
nerves.
ELECTRODI AGNOSTIC CHARTS AND TABLES
645
Spinal
accessory
Stemo-cleidomastoid
Trapezius (upper)
lUi,
Supraspinatus
Brachial 1 Rhomboid plexus )
Deltoid (poster.)
Brachial plexus
Infraspinatus
Brachial \ Latissimu dorsi plexus )
Ilio-hypogastrtc
External oblique {
(
and
Intercostal
N.
Gluteus medius
Superior
(jluteai
N.
Inferior
gluteal
N.
\ r<1 (r ' ulcns
mximiis
FIG. 348.
Motor points
of posterior aspect of trunk.
MOTOR NERVES AND MUSCLES OF ANTERIOR ASPECT OF UPPER EXTREMITY.

Motor
nerves.
Motor
nerves.
648
APPENDIX
MOTOR NERVES AND MUSCLES OP POSTERIOR ASPECT OF UPPER EXTREMITY.

Motor
nerves.
649
Deltoid (middle) Deltoid

(posterior)
Circumflex N.
Triceps
(long head)
-Triceps (lateral head)
Triceps (medial head)
Radial (musculo-spiral
Ulnar Nerve
nerve)
Extensor carpi radialis longn* Extensor carpi ulnaris

Extensor carpi
radialis brevis
-
Radial
N.
Extensor indicis
Extensor communis digitorum Extensor ossis metacarpi pollicis (Extensor brevis

pollicis)
Extensor longus
pollicis
Ulnar
.:
Jnlerossei
FIG. 350.
Motor points
of posterior aspect of
upper extremity.
650
APPENDIX
MOTOR NERVES AND MUSCLES OF ANTERIOR ASPECT OF LOWER EXTREMITY.

Motor
nerves.
ELECT RODI AGNOSTIC CHARTS AND TABLES
051
Femoral Nerve
Sartoriu
'\
Pectineua
\
Anterior crural
Adductor]
longus
Rectux femoris
Gracilit
Obturator N.
Femoral N.
Vastua extemua
Vattua internua
I
Deep
peroneal
Tibialis anticua
\ [
N.
Extensor digitorum longus ' Peroneus longus
Superficial ptroneal N.
Extensor
hallucia
longus
Peroneus brevis
Deep Peroneal N.
Extensor digitorum brema
Deep peroneal N.:
Interoaaei
FIG. 351.
Motor points
of anterior aspect of lower extremity.
652
APPENDIX
MOTOR NERVES AND MUSCLES OF POSTERIOR ASPECT OF LOWER EXTREMITY.

Motor
nerves.
653
Gluteu* Medius
Glutens
Maximus
Biceps femorii.
Tibial Nerve
Gastrocnemius
Soleus
Flexor digitorum
Tibial Nerve
Flexor halluds
FIG. 352.
Motor points
of posterior aspect of lower extremity.
GLOSSARY
PART
Actinic.
I:
ELECTROPHYSICS
Pertaining to actinism. Capable of producing chemical changes as applied to radiant energy. Usually applied to radiant energy having this property. Actinism. The property of radiant energy which produces chemical changes, as in photography or heliotherapy.
Actinometer.
Actinotherapy.
light.
An
instrument to measure the intensity of an actinic effect. Treatment of disease by rays of light, especially actinic or chemical
Alternating current.
current which periodically flows in opposite directions.
Ammeter.
instrument calibrated to read in amperes the strength of a current flowing in a circuit. For medical purposes the ampere is too large a unit; hence, it A meter calibrated to read in is divided into a thousand parts or milliamperes. milliamperes is called a milliammeter.
An
Amperage. Strength of the electrical current expressed in amperes or milliamperes. Ampere. The unit of the rate of transfer of electricity. The international ampere is the unvarying electrical current which, when passed through a solution of silver
nitrate in accordance with certain specifications, deposits silver at the rate of 0.001 1 18
A device to magnify electric impulses, such as high-frequency currents. Its output is of greater amplitude than the energy which actuates it. It usually involves thermionic tubes. Amplitude. The measure of the maximum deviation from zero to normal axis. Anaphoresis. Transmission of electropositive bodies into the tissues by passage of electric current. The flow is toward the positive pole.
Amplifier.
gm. per second.
equal to 10 000 micron. 4 (or 10~ ) microns 7 .000 000 1 (or 10~ ) millimeters 8 .000 000 01 (or 10~ ) centimeters 10 .000 000 000 1 (or 1Q- ) meters Anelectrotonus. The state of diminished irritability of a nerve or muscle produced in the region near the anode during the passage of an electric current. Angle of incidence. The angle between a ray incident on a surface and a line drawn perpendicular to the surface at the point of incidence. Anion. See Ion. An ion carrying a negative charge. Since unlike forms of electricity attract each other, the anion is attracted by, and travels to, the positive anode. Examples are acid radicals and corresponding radicals of their salts. Anode. The positive pole of an electrical device. In a thermionic tube, it is sometimes called the plate. When a positive potential is impressed on it from a battery or rectifier, the anode serves as a collector for the electrons emitted from the hot filament of the tube. Anode current. The current passing between the anode and the cathode through the
Angstrom.
A unit
1
of wave length of light. Angstrom unit = .000 1
It is
vacuous or partially evacuated space. The voltage between the anode and some specified point of the cathode. voltage. Arc lamp. Source of light consisting of gaseous particles from the electrodes of an electric arc which are raised to a temperature of incandescence by an electric current. Arc light. The light from glowing electrodes or luminous particles between two electrodes of carbon, tungsten or other material, when an electric current is applied
Anode
and the electrodes separated a short distance. Armamentarium. Outfit of a practitioner or institution, including books, instruments, medicine, and surgical supplies. (Obsolete.) Atom. The smallest particle of an element that can exist alone or in combination with like atoms or other elements.
(654)
GLOSSARY
Autoconduction.
655
the patient. Autotransformer.
A method, formerly much in vogue in France, of administering highfrequency currents. The patient stood or sat inside a large solenoid, the ends of which were connected to the two terminals of a high-frequency generator. The high-frequency current flowing through the solenoid generated a rapidly alternating magnetic field. This alternating magnetic field induced high-frequency currents in
and secondary
Bases.
circuits.
transformer that has part of See Transformer.
its
turns
common
to both primary
Compounds of an alkaline character in solution, capable of reacting with acids to form salts and water; specifically the hydroxide of a positive element or radical. Bias. The voltage impressed on the grid, relative to the cathode (filament), usually negative. The use of two poles in electrotherapeutic treatments. When referring to an Bipolar. alternating current, biterminal should be used. Biterminal. See Bipolar. Booster. device, consisting essentially of a small induction coil with
adjustable
A critical value of voltage at which a discharge device such as a voltage. spark gap or a grid-glow tube begins to pass current. Brush discharge. In electrotherapeutics, the discharge from a static machine (less commonly from a high-frequency apparatus), having a disruptoconvective character.
Breakdown
Capacitance. That property of a system of conductors and dielectrics which permits the storage of electric charges. Capacitor. A device used primarily because it possesses the property of capacitance. It consists of two conducting surfaces separated by a non-conductor or dielectric. A condenser. Capacity. Capacity, or capacitance, is a measure of the amount of electrical energy a
core, for increasing the electromotive force of an alternating current circuit of a device such as a dynamo in series to increase the voltage of a direct current circuit.
condenser can store up. Cataphoresis. The transmission of electronegative ions into the body tissues or through a membrane by use of an electric current. Catelectrotonus. The state of increased excitability produced in a nerve current. Cathode. The negative pole or electrode of any electrical device. In a thermionic or roentgen-ray tube it is often called the filament, and is an emitter of electrons. Cathode current. The total current passing to or from the cathode through the
vacuous space. Characteristics. Dynamic characteristics of a tube are the values obtained with an alternating current voltage on the control grid under various conditions of direct
current potentials in the electrodes. Amplification factor, plate resistance and mutual conductance are dynamic characteristics. Another characteristic frequently referred to as dynamic characteristic is the dynamic transfer characteristic, the characteristic of a tube combined with an optimum load in the plate circuit, reactive or resistance, and the control grid excited with accelerating current. The mutual characteristic shows the relation between grid voltage and plate current of a highvoltage amplifier. Static characteristics of a tube are the values obtained with different direct current potentials applied to the tube electrodes. Choke coil. A coil having a large inductance, thereby introducing opposition to the flow of alternating current, or choking the current. The higher the frequency to the current which tries to flow, the greater the choking effect. There is no choking effect to direct current. Chronaxie. Time intensity relation of electric stimuli. The minimal time for a current having twice the intensity of the rheobasic current.
A special switch, arranged to open a circuit quickly and automatically, without injury to itself, when the circuit is overloaded. The usual circuit breaker can be closed or opened by hand, as any switch. Close coupling. The position in which two circuits or coils are placed in close magnetic proximity to each other, so that the transfer of energy from one to another is large. A substance which, when apparently dissolved in water or other liquid, diffuses Colloid. not at all or very slowly through a membrane. Colloids are often gelatinous as albumen, gelatin, or starch. They generally resemble glue.
Circuit breaker.
656
Commutator.
GLOSSARY
A device for reversing the direction of an electric current; usually a segmental ring attached to a dynamo, on which brushes slide. Also similar handoperated devices. Condenser. A device for storing up electrical energy. It usually consists of conducting surfaces separated by an insulating medium called the dielectric. A capacitor is a
condenser.
Conductance.
circuit,
The property of an electric circuit, or a body used as a part of that which determines, for a given potential difference between its terminals, the average rate at which electric energy is converted into heat. It is the reciprocal
of resistance.
Conductive heat.
An
obsolete term applied to heat transferred
by conduction from
poultices, bags, etc.
Conductivity. The specific electric conducting ability of a substance. Constant current. See Direct current. Continuous current. See Direct current. Continuous spectrum. An unbroken series of wave lengths, either visible or invisible. Such a spectrum is produced by light from incandescent solids, liquids or gases under high pressure passed through a prism. Also an unbroken range of radiations
of different wave lengths in any portion of the invisible spectrum. Convective discharges. Discharges from a high potential source in the form of visible or invisible streams of electrical energy passing through the air to the patient. Convective heat. An obsolete term used to designate heat which is transferred by convection, as by a stream of air or water. Conversive heat. An obsolete term used to designate heat generated in the tissues by a current of electricity or by radiant energy. Cored carbons. See Impregnated carbons. Coulomb. The quantity of electricity or the charge transmitted in one second by a current of 1 ampere. It is crudely analogous to the quantity of water, in gallons for instance, that flows into a container, or is stored in a tank. Coupler. A device for the transfer of the energy of radio oscillations from one circuit to another, without a direct metallic connection, usually through an insulating
medium.
Coupling. The amount of flux linkage of one circuit with another. It is a measure of the transfer of energy between two circuits. Cycle. One period of alternating current, that is the complete change from zero to positive maximum, to zero, to negative maximum and back to zero.
Damped
current.
An
cessive alternations
oscillating current of electricity in which the become less and less until it finally dies away.
amplitude of suc-
Damping.
electric
The steady diminution wave or current.

The
of the
amplitude of successive vibrations, as of an
Decrement.
Desiccation.
A measure of the degree of damping of a series of oscillations.

process of drying up.
Diathermia.
An
The
inferior
term
for diathermy.
See Diathermy.
therapeutic use of a high-frequency current to generate heat within some part of the body. An insulating substance that allows electrostatic induction to act across Dielectric. An insulating or it, as the insulating medium between the plates of a condenser. non-conducting material. Diode. A thermionic tube containing two electrodes which pass current wholly or
Diathermy.
Direct current. A current that flows in one direction only. When used medically it is called the "galvanic" current. Disruptive discharge. A passage of current through an insulating medium due to the breakdown of the medium under the electrostatic stress. Disruptoconductive discharge. The static brush discharge that simulates both the Convective effluve and the disruptive or spark-discharge. Dry heat. In contradistinction to moist heat. Sources of dry heat are the hot water bottle, the electric heating pad, and radiant heat lamps of various types.
Effluve.
predominantly in one direction.
Electric circuit.
conductive discharge of a high potential current through a dielectric. The path through conductors by which an electric current passes.
GLOSSARY
Electricity.
657
A form of energy which, when in motion, exhibits magnetic, chemical, mechanical and thermal effects and when at rest or in motion exerts a force on
other electricity. To charge a body with electricity. Electrocautery. An apparatus for cauterizing tissue, consisting of a holder containing a wire, which may be heated to a red or a white heat by a current of electricity, either direct or alternating.
Electrify.
Electrocoagulation.
rent.
The heat producing
Coagulation of tissue by means of a high-frequency electric curthe coagulation is generated within the tissue to be deof electric current.
stroyed. Electrocution. Electrode. A
electric conductor and the object to to be applied. In electrotherapy an electrode is an instrument with a point or a surface from which to discharge current to the body of a patient. Electrodesiccation. The destructive drying of cells and tissue by means of short high-
The destruction of life by means medium intervening between an

is
which the current
frequency electric sparks, in contradistinction to fulguration which is the destruction of tissue by means of long high-frequency electric sparks. Elect rodiagnosis. The determination of functional states of various organs and
tissues according to their response to electrical stimulation.
Electrodynamometer.
An
instrument to measure the strength of an electric current,
either alternating or direct, as the current.
by means
of the interaction of
two wire
coils
carrying
Electrology.
electricity.
The branch
of science that deals with the
phenomena and
properties of
Electrolysis.
The electrical decomposition of a chemical compound. Examples: the separation of an electrolyte into its constituent parts by a direct current the removal of hair by the electrolytic effect of a direct current. 1. A substance which in solution conducts an electric current and is Electrolyte. decomposed by the passage of an electric current. 2. A solution which is a con;
ductor of
Electrolyzer.
electricity.
Instrument for reducing stricture with electricity. Electromagnetic induction. Generation of an electromotive force in an insulated conductor moving in an electromagnetic field, or in a fixed conductor in a moving
magnetic field. Electromotive force (abbreviation, E.M.F.). That effect of difference of potential which, on the closing of a circuit, causes a flow of electricity from one place to another, giving rise to an electric current. The strength of an electric current is directly proportional to the resistance in the case of direct current and to the impedance in the case of alternating current. Electromotive force is measured in volts or in some convenient multiple or fraction of a volt. Microvolt, millivolt and kilovolt are, respectively, one-millionth, one-thousandth volt and 1000 volts. Electron. An extremely minute corpuscle or charge of negative electricity the smallest that is known to exist. The dimension of the electron is estimated as:
;
10 ~" or
10,000,000,000,000
centimeter.
its electrical
Electronic tube. A vacuum tube evacuated to such a degree that acteristics are due to electron emission. Electrophoresis. See Phoresis.
char-
Electrophonis. Elect ropyrexia.
instrument for obtaining static electricity by means of induction. of electricity for production of fever. Electrotherapist. A medical graduate who has had special training and has acquired The term is sometimes used incorrectly skill in the therapeutic use of electricity. to designate any one who administers electrical treatments.
An
The use
Electrotherapy.
Treatment
of disease
by means
of electricity.
Electrothermotherapy. The production of heat within the living tissues for therapeutic purposes by means of bodily resistance to the passing of an electric current. Electrotonic. Of or pertaining to electrotonus. Electrotonus. The change in the irritability of a nerve or muscle during the passage
of an electric current. Endothermy. A term used as a synonym
Epilation.
for surgical diathermy.
Removal
of hair.
Erythema. 42
Active hyperemia of the skin indicated by abnormal redness.
658
Erythema dose.
of the skin.
GLOSSARY
The amount
of radiant energy sufficient to
evoke perceptible redness
Erythemogenic. Pertaining to erythema. Ether. Hypothetic substance once regarded as permeating all space and capable of transmitting electromagnetic vibrations or waves. (Obsolete.)
Far ultraviolet radiation. Ultraviolet radiation of short-wave length; farthest away from the visible spectrum. Farad. A unit of electrical capacity. The capacity of a capacitor which, charged with one coulomb, gives a difference of potential of 1 volt. This unit is so large that one-millionth part of it has been adopted as a practical unit called a microfarad. Faradic current. An intermittent, alternating current induced in the secondary winding
of an induction coil. Faradism. The therapeutic use of an interrupted current to stimulate muscles and nerves. Such a current is derived from the secondary of an induction coil. Filament. The cathode of a thermionic tube in which heat is supplied by current passing through it; also the incandescent element in luminous sources of heat. A selective circuit network designed to pass freely currents within a continuous Filter. band or bands of frequencies, or direct current, and substantially reduce the amplitude of currents of undesired frequencies. In radiation therapy, screens or various substances which permit passage of some wave lengths while absorbing others. Finsen lamp. A carbon arc lamp operating at 50 volts and 50 amperes so constructed that radiation is concentrated on an area 1 inch square; a water-cooled quartz system to remove infrared radiation and a compression quartz piece to dehematize the skin. Fluorescence. Luminescence of a substance when acted on by short-wave ultraviolet
radiation; usually ultraviolet. Flux. The electromagnetic lines of force, or the magnetic
in a coil.
field,
produced by a current
Fraunhofer's lines.
Frequency.
Dark lines of a solar spectrum. rate of oscillation or alternation in an alternating current circuit, in contradistinction to periodicity in the interruptions or regular variations of current in a direct current circuit. The frequency is computed on the basis of a complete cycle, a complete cycle being one in which the current rises from zero to a maximum, returns to zero, and rises to an opposite maximum and returns to zero again.
The
Frictional electricity. See Static electricity. Fulguration. See Electrodesiccation.
A double element rectifier arranged so the current is allowed to rectifier. pass in the same direction to the load circuit during each half cycle of the alternating current supply; one element functioning during one-half cycle and the other during next half cycle. Fuse. A safety device comprising a strip of wire of easily fusible metal, the conductance ot which is predetermined. The metal fuses and breaks the circuit when an excess of current passes through it.
Full-wave
Galvanic current. A steady unidirectional current. Galvanism. Therapeutic use of direct current. Galvanocautery. See Electrocautery. Galvanometer. An instrument that measures current by electromagnetic action. It may consist of a magnetic needle delicately suspended in the center of a permanent When the coil of wire, or a suspended coil between the poles of a fixed magnet. current is applied to the coil, the needle is deflected over a calibrated scale. Galvanometers detect current and enable one to determine its direction, amperage and voltage. The d'Arsonval form is more common, in which a coil moves in a permanent magnetic field. The instrument is called a voltmeter when used in series with a high resistance to measure voltage; an ammeter when used across a shunt to
Gamma
measure amperage. rays. Heterogenous electromagnetic vibrations caused by electronic disturbance in atoms of radioactive elements during their disintegration appear identical with roentgen-rays except that the wave lengths range from about 1.4 to 0.01 Ang-
strom. Geissler tube.
The original discharge tube for showing the luminous effects of discharges through rarified gases. The density of the gas in the tube is roughly onethousandth that of atmospheric pressure.
GLOSSARY
Grenz
1
659
of 2 Angstroms (range from than 10 kilovolts. Synonym:
rays. Roentgen-rays with an average to 3 Angstroms); obtained with
wave length
less
peak voltage of
over-soft x-rays. Grid. An electrode having openings through which electrons or ions may pass. In a thermionic tube, it is generally placed between the cathode and the anode. Its potential controls the discharge between the cathode and anode (plate) in a predetermined manner without carrying any appreciable current itself. Grid-glow device. A tube which passes no current until the voltage equals a critical value called the breakdown voltage.
Grid voltage.
also Bias.
The voltage between a
grid
and a
specified point of the cathode.
See
Grid voltage supply. The means for supplying and applying with proper regulation, the bias or a potential to the grid of a vacuum tube, which is usually negative with
respect to the cathode.
Ground.
An
electrical connection
with the earth, or with any conductor of large
capacity.
Heliotherapy. The therapeutic application of radiation from the sun. Henry. A unit of inductance. A circuit has an inductance of 1 henry when a current changing at the rate of 1 ampere per second produces a back electromotive force of
1
volt.
Hertzian waves.
or longer.
Electromagnetic vibrations that have wave lengths of
centimeter
High frequency.
sufficiently high so that tetanic contractions are not set living contractile tissues.
current having a frequency of interruption or change of direction up when it is passed through
Hook-up.
Homogeneous. Having the same nature or qualities of uniform character in all parts. Used in speaking of the method of arranging circuits, appliances and electrodes in the giving of any particular treatment; as, for instance, the hook-up for
direct sparks.
A vacuum tube in which the cathode is electrically heated (usually to incandescence) in order to increase the emission of electrons. Hot wire meter. A type of meter used to measure the amperage of high-frequency circuits. The needle of the meter is connected to a wire having a known thermic expansion under the passage of a certain milliamperage and, as the wire expands, the needle moves across a calibrated scale until it indicates the amperage. Hydroelectric bath. A bath in which electricity is administered to the tissues through
Hot-cathode tube.
water.
Impedance.
measure of the opposition to current flow. It may be caused by resistance, inductance, capacity or combination of these. The ratio of voltage to current flow in a circuit.
Inductance. The property of an electric circuit by virtue of which a varying current induces an electromotive force in that circuit or in a neighboring circuit. Inductance coil. A device consisting of a cable containing a central conductor with heavy insulation used for electromagnetic field application in short wave diathermy. Induction coil. A transformer with open magnetic circuit, excited by an interrupted
or variable current. Influence machine. A particular type of "static machine." Probably the only type used in physical therapy. Infrared rays. Radiations just beyond the red end of the spectrum. Their wave lengths range between 7700 to 500,000 Angstroms. The therapeutic range extends from
Insulation.
about 7700 to about 14,000 Angstroms. The state in which the communication of
electricity to other bodies is
prevented by the interposition of a non-conductor; also, the material or substance which insulates. The electrical resistance of an insulator is for convenience expressed in megohms, a unit representing a million ohms. Insulation may be also expressed in terms of dielectric value. A substance or body that interrupts the transmission of electricity to surInsulator.
rounding objects by conduction. Intensity of electric field. The intensity of an electric field is measured by the force exerted on unit charge. Unit field intensity is the field which exerts the force of one dyne on unit positive charge.
660
Interrupted current.
Interrupter.
GLOSSARY
A current which is frequently opened and closed. A mechanical or electrolytic device for making and breaking
circuit.
opening alternately) an electrical
Such a device
is
ordinarily
(closing and employed in
low-voltage, direct current circuits. Inverse square law. The intensity of radiation at any distance is inversely proportional to the square of the distance between the irradiated surface and a point source. Invisible spectrum. Part of the spectrum, either below the red (infrared) or above the violet (ultraviolet), which is invisible to the eye. Ion. One of the electrified particles consisting of an atom or group of atoms into which the molecules of an electrolyte are divided; or one of the electrified particles into which the molecules of a gas are divided by ultraviolet rays, gamma rays or roentgenrays, or by other ionizing agents. Ionic medication. See Ion transfer, lonization. The process by which neutral atoms or molecules become charged, either
positively or negatively. Iontophoresis. Synonym to Ion transfer. Ion transfer. The introduction of chemical ions into the superficial tissues for medicinal purposes by means of a direct current. Iontophoresis. Irradiation. Application of roentgen-rays, radium rays, ultraviolet rays or other radiation to a patient or object.
Joule.
A unit of electrical energy equivalent to work expended when a current of 1 ampere flows for one second against a resistance of 1 ohm; a unit of work = 10,000,000
1000 cycles.
ergs.
Kilocycle.
Leyden
A glass jar coated partially, inside and out, with metal, or coated outside jar. with metal and having salt solution inside. It is a capacitor. The sensation produced by electromagnetic radiation which falls on the retina. Light. Radiant energy producing a sensation of luminosity on the retina limited to wave lengths from 4000 to 7000 Angstroms. Light therapy. The therapeutic application of radiation in the visible spectrum; some
Low
include also, ultraviolet radiation. frequency. An alternating current whose frequency in cycles per second is low. In general, low-frequency currents are attended by tetanic contraction when passed through the body.
circuit.
Magnetic
The
closed path of magnetic lines;
e.
g.,
the magnetic circuit of a

of force surrounding a
transformer.
Magnetic field. The space permeated by the magnetic lines permanent magnet or coil of wire carrying electric current.
that deliver the current as it comes in from the if one is used. Mechanical rectifier. device which, by changing contacts at the proper moment in a cycle, changes alternating current into pulsating direct current.
Mains
or
main
line.
The conductors
street supply or
from a motor-generator,
Megohm. 1,000,000 ohms. Meter. The unit of length

Mho.
Micro.
of
Corresponds to 39.37 inches. as a voltmeter.
in the metric system, largely used in European countries. An instrument or means for measuring some quantity,
The
unit of conductivity; the reciprocal of Prefix which means the millionth part.
ohm.
micro-ampere
is
the millionth part
an ampere.
j
Microfarad,
Og
of a farad.
convenient division of the large unit.
Micron. The millionth part of a meter; the thousandth part of a millimeter; 1/x. Milliammeter. See Ammeter. Milliampere. One one-thousandth of 1 ampere. Milliampere-minute. An electrical unit of quantity, equivalent to that delivered by 1 milliampere in one minute. Millimicron. One-millionth of a millimeter; 1 m. Modality. A modal character of, denoting a mode. In medicine it is a method of
application or the employment of any therapeutic agent; limited usually to physical agents. The word is avoided by scholarly writers.
GLOSSARY
Molecule.
substance.
661
A chemical combination of two or more atoms which form a specific chemical
Monochromatic rays. Rays characterized by a definite wave length, as secondary rays. Monochromator. A device designed for selective transmission of homogeneous radiant
energy.
Monopolar. See Monoterminal. Monoterminal. Use of one terminal only in the giving of treatments, the ground acting as the second terminal for the completion of the electrical circuit. Morton wave current. An interrupted current obtained from a static machine. Motor generator. A device consisting of a motor mechanically connected to a generator. Such machines are designed to generate direct current when alternating alone is
available, or vice versa.
Non-conductor.
is
A substance that will not conduct electricity. Strictly speaking, there no perfect non-conductor. On the application of a sufficiently high voltage, current may be caused to flow through materials usually spoken of as non-conductors. See
Insulator.
Ohm.
The unit of resistance. The resistance that will allow 1 ampere of current to pass under the pressure due to an electromotive force of 1 volt. Ohm's law. The law, determined experimentally by the physicist Ohm, which states that the strength of an electric current in a direct current circuit varies directly as the applied electromotive force, and inversely as the resistance of the circuit. Open circuit. A circuit having some break in it so that current is not passing or cannot pass. The break may be intentional, as an open switch, or accidental, as a blown fuse, a loose connection or a broken wire. Oscillating current. A current alternating, in direction, and of either constant or gradually decreasing amplitude. An oscillating current of constant amplitude is called an undamped current; one of gradually increasing amplitude, a damped current. Oscillatory circuit. One which offers very little opposition to the establishment of an oscillating current of the frequency to which it is tuned. Oscilloscope. An instrument for making visible the presence to the nature and form of oscillations or irregularities of an electric current. Oudin current. A high-frequency current of higher voltage than the high-frequency currents used for long wave diathermy treatments.
Parallel connection.
One
in
which the current divides and passes along more than one
path. Period. In an alternating current, the time required for one cycle to pass through a complete set of positive and negative values. The rate of rise and fall or interruption of a unidirectional electric current. Periodicity. Phoresis. The migration of ions through a membrane by the action of an electric current. Phosphorescence. The induced luminescence that persists after cessation of the irradiation that caused it. Photoluminescence. The light emission of an object which becomes luminescent when acted on by light. Photometer. A device for measuring the intensity of light. Photosynthesis. A chemical combination caused by the action of light. Phototaxis. The movement of cells and micro-organisms under the influence of light. Physiatrics. The science that relates to the medicinal and curative application of physical forces, as light, heat and electricity.
The physician who practices physiatrics. Physical therapist. A medical graduate skilled in physical therapy. Physical therapy. Physical therapy is the therapeutic use of physical agents. It comof heat, light, water, elecprises the use of physical, chemical and other properties tricity, massage and exercise. See also Physiatrics. Physical therapy technician or aide. A lay assistant trained to apply the physical measures of treatment which have been prescribed by a physician. The positively charged plate-like element which collects the electrons emitted Plate. by the filament. A term commonly used for the anode. Plate circuit. All the devices connected directly in the external circuit between the
Physiatrist.
filament
and the plate elements.
662
Polarity.
1.
GLOSSARY
The
fact or condition of having poles.
2.
The
exhibition of opposite
two extremities. Pole changing switch. A switch by which the polarity of a circuit may be reversed. Positive rays. Streams of positively charged atoms traveling at high speed from the anode of a partially evacuated tube, under the influence of an applied voltage. A condition by which current tends to flow from a place of higher to one of Potential. lower potential. The practical unit of measurement is the volt. Potentiometer. An arrangement for securing any desired voltage by utilizing the
effects at the
Power.
voltage drop across a portion of current-carrying resistance. Rate at which work is being done. The electrical unit of power
is
the watt.
See Watt. Prescription carbons. See Therapeutic carbons. Primary cell. A device consisting of a container, two solid conducting elements and an electrolyte, for the production of electric current by chemical energy. Proton. The nucleus of the hydrogen atom. It is assumed to be the unit positive charge of electricity. See Electron.
Pulsating current. A current pulsating regularly in magnitude. applies to a unidirectional current.
As
ordinarily used,
Quantum.
As much as; a certain specified quantity or amount; an elementary unit of energy; the supposed atom of light and other radiants, constant quantity or standard. Quartz. Silicon dioxide, the principal ingredient of sandstone (crystallized silica; rock crystals). When crystal is clear and colorless it permits the passage of ultraviolet
Quartz applicators.
radiations in large proportions. Quartz rods of various shapes and angles to conduct (by total internal reflection) ultraviolet radiation from a water-cooled mercury arc quartz
lamp. Quartz glass. Crystalline quartz is used for prisms and lenses, fused quartz for windows, etc., through which ultraviolet radiations are freely transmitted. Quenched spark gap. One arranged and designed to put out, or quench, the spark very quickly, it is usually multiple with numerous electrodes about 0.3 mm. apart and equipped with a copper air-cooling device.
Radiant energy. That form of energy which is transmitted through space without the support of a sensible medium. Radio waves, infrared rays, visible rays, ultraviolet rays, roentgen-rays, gamma rays, and the recently discovered cosmic rays
are energy in this form. Radiation. A general term for any form of radiant energy, emission or divergence, as of energy in all directions from luminous bodies, roentgen-ray tubes, radioactive elements, fluorescent substances, or from an antenna. Radio frequency. Currents of frequency above 10,000 cycles per second; currents of this frequency and higher are easily radiated by an antenna. Radiotherapist. A physician who employs radiant energy for therapeutic purposes. Radiotherapy. The treatment of disease by application of roentgen-rays, radium, ultraviolet and other radiations. Rationale. A rational exposition of principles; the logical basis of a procedure. Reactance. That component of impedance or opposition to flow of accelerating current, produced by capacitance or inductance. The ratio between the voltage and that component of the current which is 90 degrees out of phase with the voltage. A device which converts alternating current into unidirectional current by Rectifier. virtue of a characteristic permitting appreciable flow of current in one direction only. Refraction. The change of direction of a ray when it passes from one medium to
another of a different density.

Regenerative circuit. An electron-tube circuit in which additional amplification is produced by feeding back some of the energy in the plate circuit into the grid circuit. Relay. A device by which contacts in one circuit are operated by a change in conditions in the same circuit or in one or more associated circuits. Resistance. The opposing influence of a body (solid, liquid or gaseous) to the passage of an electric current. It is expressed in ohms; 1 ohm of a pressure of 1 volt. The
Resistivity.
effect of the expenditure of electrical energy in resistance is to generate heat. measure of resitance or opposition to the flow of electricity. It is generally expressed in ohms per centimeter cube, i. e., the resistance of a cube of 1 cm.
on each side
of the particular material.
GLOSSARY
Eesonance.
663
Two circuits are in resonance if they are in tune with each other; if the products of the inductance and capacity of each are equal. Resonator. An electrical circuit in which oscillations of a certain frequency are set up by oscillations of the same frequency in another circuit. When this occurs, the circuits are said to be in syntony. Rheobase. The voltage required for a minimal response with the make of the current
in electric stimulation.
A cord connecting a patient to an electrical outfit. (Obsolete.) Rheostat. A fixed or variable resistance for controlling the amount of current entering a circuit.
Rheophore.
Rheotome.
An
Ripple current.
component
interrupter with an adjustable speed control. A pulsating current, superimposed on a direct current. The constant is usually large relative to the sum of the amplitudes of the harmonic
components. Roentgen-rays.
Radiation associated with the sudden change in velocity of free electrons (general radiation) or the transfer from higher to lower energy levels of electrons
bound in atoms (characteristic radiation). "Roentgen-rays" is preferred by medical authorities, but "x-rays" is in more general use by physicists. The wave lengths concerned are usually between 0.005 and 1 millimicron or 0.05 to 10 Angstroms or 50 to 10,000 units.
Roentgen-ray tube.
A glass vacuum bulb containing two electrodes. Electrons are obtained either from gas in the tube or from a heated cathode. When suitable potential is applied, electrons travel at high velocity from cathode to anode, where they are suddenly arrested, giving rise to roentgen-rays. Ruhmkorff coil. An apparatus consisting of two insulated coils, the primary consisting of a few turns of coarse wire, the secondary consisting of many turns of fine wire, enclosing a core of soft iron wires. The primary coil is connected with current supply and an interrupter. See Induction coil.
Ultraviolet rays in the region bounded between 2000 and 1250 Angrays. stroms. Screens. See Filters. Secondary. In a transformer, the output winding.
cell is one which can be alternately charged and discharged. See Primary cell. Self -inductance. The property of an electric circuit which determines, for a given rate of change of current in the circuit, the electromotive force induced in the circuit
Schumann
Secondary
cell.
Secondary
Hence
it is
reversible.
itself.
Series.
A mode
series."
end to end to form a

be "in
of arranging the parts of a circuit single path for the current.
by connecting them successively
The
parts so arranged are said to
Series connection. One in which all of the current passes through each of the devices in succession, or one after the other. Short circuit. An accidental overflow of current due to the establishment of a low resistance by-pass. Shunt. When two or more electrical devices or resistance are so connected that the current is divided between them, the current through each device or resistance being inversely proportioned to the resistance, they are said to be connected "in shunt" parallel or multiple, with one another. Sinusoidal current. Also see Alternating current. An alternating current following in the sine law and of such frequency as to afford the opportunity of separate (clonic) muscular contractions. Solarium. A room designed for heliotherapy or for the application of artificial light. Solenoid. A coil or series of turns of wire spaced equally between turns. Usually designates a coil whose length is greater than its diameter. When an electric current flows through a solenoid, the solenoid acts in general like a magnet. Spark ball or Point electrode. An insulating handle having on one end a metallic ball or point. Used in giving static sparks. Spark gaps. Arrangement of opposed points or surfaces, between which an electric spark may jump. An adjustable gap between needle points or between spheres is
used to measure high potentials. For spark-over voltage see Electrical Engineers Standardization Rules.
American Institute
of
664
GLOSSARY
Spectrograph. An instrument designed to photograph spectrums on a sensitive photographic plate. Spectrometer. A spectroscope so constructed that angular deviation of a ray of light produced by a prism or by a diffraction grating, thus indicating the wave length of the light, can be accurately measured. Spectroscope. An instrument for separating radiant energy into its component frequencies or wave lengths by means of a prism or grating. Spectroscopy. The branch of physical science that treats of the phenomena observed with the spectroscope, or those principles on which its action is based; also, the art of using the spectroscope. Spectrum. Charted band of wave lengths of electromagnetic vibrations obtained by refraction and diffraction. The visible spectrum consists of the colors from red to violet. The invisible spectrum is composed of Hertzian rays, infrared rays, ultraviolet rays and roentgen-rays (x-rays), gamma rays and cosmic rays. Static breeze. The brush discharge as used in therapy. Static brush. See Static breeze.
Static electricity. Electricity produced by friction. The charging and discharging current of a pair of Static induced current. or other condensers, the current of which is passed through a patient. Static
Leyden
jars
applied to certain types of machine for producing high-tension in physical therapy are influence machines. Static wave current. The current resulting from the sudden periodic discharge from a patient who has been raised to a high potential by means of an electrostatic generator. Step-down transformer. A transformer in which the number of turns of wire in the primary and secondary windings is in such relation as to reduce voltage. (See Trans-
machine.
Term
direct current.
Those used
former.)
Step-up transformer. A transformer in which the number of turns of wire in the primary and secondary windings is in such relation as to increase voltage. (See Transformer.) Surgical diathermy. The use of high-frequency electrical oscillations in such a way that animal tissues are destroyed.
Sometimes used as a synonym for voltage; thus high tension would mean high voltage. Tesla current. A high-frequency current having a voltage which is high, but intermediate between an Oudin and a d'Arsonval current. (Obsolete.) Therapeutic carbons. Carbon electrodes cored or filled with various materials. When burning, they emit radiation containing various intensities and qualities of ultraTension.
Thermal. Pertaining to heat. Thermal unit = the amount of heat required to raise F. or C. Common thermal unit is the trie temperature to a given mass of water 1 B.T.U., the heat required to raise 1 pound of water 1 F., and the Calorie, the amount of heat required to raise 1 gram of water 1 C. Thermal capacity; the amount of to 1 C. heat required to raise temperature of a body from Thermionic rectifier. A device that converts alternating current into direct current. It is an electric valve in which the electrons are supplied by a heated electrode. Thermionic tube. A tube in which the electron emission is produced by the heating
of
violet, visual
and
infrared energy.
an
electrode.
effect.
Thermoelectric
two
dissimilar metals;
Thermophile. A degree of heat. It consists of a number of dissimilar metallic plates connected together, in which, under the influence of heat, an electric current is produced. Thermotherapy. The therapeutic application of heat. Tickler. A coil in the plate circuit used to feed some of the energy back into the grid
circuit.
voltage effect generated at the terminals of a junction of greater with some metals than with others. thermoelectric battery used in measuring small variations in the
it is
The
Transformer.
A A
device used for transferring electrical energy from one circuit to
another, usually
by magnetic
field effect.
Tuned
circuit.
circuit is said to
be tuned when
its
natural period of oscillation

coupled.
is
the same as that of some other circuit to which
it is
Tuning. The operation of adjusting any circuit to be in electrical resonance with any other circuit or circuits.
GLOSSARY
Ultraviolet radiation.
665
Badiation characterized by invisible rays in the electromagnetic spectrum between the violet rays and the roentgen-rays. In wave length it ranges from 4000 to 200 Angstroms. It possesses powerful actinic and chemical properties. Undamped current. An alternating current of electricity in which the amplitude of
successive alternations is maintained. Unidirectional. The state of transmission in one direction as electric currents in a
circuit.
Unipolar. See Monoterminal. Uniterminal. See Monoterminal. Uviol. Glass which is unusually transparent to ultraviolet rays. Uviol lamp. An electric lamp with a globe of uviol glass.
Vacuum
tube.
vessel of insulating material (usually glass) provided with metal
which has been so highly evacuated that the residual gas does not affect the current between the electrodes. Valve tube. An electric valve consisting of a vacuum tube having for one electrode a
electrodes,
hot filament. Variable condenser.

Variocoupler.
One whose
set of coils, generally so arranged as to make it possible to vary the coupling between different circuits. Variometer. Two coils which may be placed in such relative positions that the inductance effects of each winding may be made to assist or practically neutralize each
electrical capacity
may
be changed or varied.
other.
The unit of electromotive force. The electrical pressure required to send a current of 1 ampere through the resistance of 1 ohm. Voltage. Electromotive force or difference in potential expressed in volts. Voltmeter. A meter designed and calibrated to measure voltage. Voltmeters are connected in parallel with the circuit or resistance over which the potential drop is to
Volt.
be measured.
Water-cooled quartz mercury vapor arc lamp. A small quartz mercury vapor arc lamp enclosed in a double-walled metal box with a quartz window for generation and application of ultraviolet rays. Water is circulated between the walls to conduct away the intense heat. Often called a Kromayer lamp after the inventor, Dr. E.
Kromayer.
The unit of electrical power. The product of current and electromotive force. Wattage. The power output or consumption of an electrical device expressed in watts. Watt-hour. An electrical unit of work of energy. It is equal to the wattage multiplied by the time in hours. Its mechanical equivalent is 2655 foot-pounds. Watt meter. A meter for measuring electric power. Wave. A single impulse, or the disturbance included in a space of one wave length or the advance of a disturbance into a medium. Wave length. The distance between corresponding points in two adjacent waves; e. g., between two crests. In therapeutic radiations it is stated in Angstroms milliWatt.
microns. A measuring device, arranged and calibrated to read the length of a meter. radiated wave directly in meters. Wave train. A series of waves, of the same or diminishing amplitude, usually repeating
Wave
after intervals of inaction.
Wims hurst
Wood's
machine.
filter.
A type of influence machine. A screen that absorbs visible rays but allows a
portion of the ultraviolet
rays to be transmitted.
X-rays.
See Roentgen-rays.
PART
II:
MECHANOTHERAPY AND MUSCLE AND NERVE ACTION*
Abduction. A movement away from the mid-plane of the body. Adduction. A movement towards the mid-plane of the body. Afferent nerve fibres. Transmit impulses from various parts of the body to the brain
or spinal cord.
*
Courtesy of Dr. F.
W. Ewerhardt.
666
GLOSSARY
All-or-none law. This states that when an individual muscle fibre is stimulated sufficiently to produce action, it contracts to its fullest extent. This applies to the motor unit only and not the entire muscle.
The total range through which a, muscle joint functions. Insensibility to pain. Anatomical position. An erect standing position with the feet parallel the side with palms turned forward.
Amplitude.
Analgesia.
and arms at
Anesthesia. Insensibility, especially to touch. Antagonists. Those which oppose the prime mover. Athetoid movements. Continuous, rhythmical, slow, worm-like movements which are always the same in the same patient and cease only during sleep.
Bone atrophy
(or osteoporosis).
Accompanies paralyses and
disuse.
Central excitatory states.
When
afferent impulses enter the central nervous system

reflex response,
they
may
elicit
a sensation, a
a voluntary act, or any combination
of these resultant activities. If the excitability of the synapse is increased it is known as central excitatory state. If the excitability is decreased, it is a central inhibitory
state.
Circumduction.
flexion, extension, rotation, so that the
term given to the combined movements of abduction, adduction, moving bone describes a cone-like figure
with the apex at the joint, the base at its distal end. Compression movements. Kneading, friction and petrissage. Contraction. Permanent adaptation of normal muscles to a newly acquired position
without pathological changes. Contracture. Permanent shortening of a muscle due to contraction of connective tissue and pathological changes of muscle fibres which persists even after the stimulus has ceased. Volkmann's contracture.
Dendrites and axons.
Diplegia.
Extensions of processes from the main body of the nerve
cell.
paralysis of Dupuytren's contracture.
any two
extremities.
contraction of the palmar fascia.
Etiology controversial.
Efferent nerve fibres. Transmit impulses from the brain and spinal cord outward to various special structures. The use of the whole palmar surface of the hand to administer slow, longiEffleurage. tudinal strokes. Pressure distinguishes superficial from deep effleurage. End plate. The ending of a motor nerve fibre in a muscle. Enteroceptive impulses. These arise in the viscera. Fine or more exact sensations, as those Epicritic sensations, Discriminative sensations.
evoked by cotton, wool and moderate temperatures.

Extension.
The movement
of straightening parts of the
body
in a sagittal plane.
Fascia. Connective tissue covering the outside of the muscle. Fixation muscles. These maintain an extremity in a position appropriate for the performance of a particular movement by the agonists. Flexion. The movements of bending parts of the body in sagittal plane. Friction. The use of finger tips or thumb to move superficial tissue over subjacent
structures.
Hemiplegia. A spastic paralysis of one lateral half of the body and extremities limited by the median line in front and in back. Hypalgesia. Diminished sensibility to pain. Hyperalgesia. Excessive sensibility to pain. Hyperesthesia. Excessive sensibility. Hypesthesia. Diminished tactile sense.
Inhibition.
Under normal conditions muscular relaxation is brought about by an inhibition of a portion of the normal muscle tension. Contraction of a prime mover is accompanied by an inhibition of its antagonist, according to Sherrington's law of
reciprocal innervation.
GLOSSARY
667
Kneading. The use of the palmar surface of the hand to administer rotary motion to compress the superficial tissues. Kyphosis. Abnormal dorsal curvature of the spine.
Latent time. Period of delay between the application of a stimulus and the beginning of the muscular contraction. Lordosis. Exaggerated lumbar curve, with increased convexity forward; sway back. Lubricant. Cream, oil or talc applied to skin to facilitate a smooth stroke in massage.
Monoplegia.
Motor
unit.
paralysis of one extremity only.
motor neuron, a nerve
fibre
and the 100 more or
less
muscle
fibres in
which the various branches
of the axis terminate.
Movement.
effects
Various manipulations or strokes used to produce reflex or mechanical

soft tissue.
on
Muscle atrophy of disuse. This follows any prolonged immobilization. Muscle rest. A state of action where the pressure is equal in both groups of muscles, sometimes called "zero position," and is not a state of inactivity. Muscle tonus. A state of continuous contraction or tension of muscles accounted for by the fact that only a few motor units contract and do so in continual rotation. Muscular atrophies. These result from a neural lesion, involving either the cell body or axon of the lower motor neuron. Muscular dystrophies (or myopathies) These result from primary disease of the muscle
.
itself.
Myostatic contraction. A condition of permanent shortening in a resting muscle which is maintained in the entire absence of nerve impulses. Myotatic irritability. Muscle fibres freed of neural connections and inhibitions respond with increased activity to direct mechanical stimuli, such as tapping the muscle. This phenomenon is known as "myotatic irritability."
Paraplegia. Paresthesia.
A symmetrical paralysis of both lower extremities.
Perverted sensation, as pins and needles. Percussion movements. Tapotement. The use of one or both hands to pick up and wring soft tissue. Petrissage. Phasic contraction. This is of brief duration and causes some displacement of a movable part. It is usually a voluntary act but may be purely reflex.
Referring to the soles of the feet. Postural tonus. This is determined primarily by proprioceptive reflexes which are confined largely to the muscles themselves. Prime mover or agonists. Those whose contraction is essentially responsible for the movement of the part. Pronation. Turning hand downward; rotating tarsal bones inward. Prone. Lying with face downward. Proprioceptive impulses. These arise in muscles, tendons and joints. Proprioceptive reflexes. Confined largely to the muscles themselves. Protopathic sensations, Affective sensations. Coarser or deeper sensations, as those
Plantar.
responses to pain and extreme temperature.
Quadriplegia or Tetraplegia.
Reciprocal innervation.
stimuli.
paralysis of all four extremities.
The
process of maintaining relationship between two sets of
Simplest functional unit of the nervous system consisting of at least three neurons, afferent or sensory, efferent or motor and internuncial. Rotation. The name given for the revolving movements of a part around its longitudinal
Reflex arc.
axis.
Lateral curvature of the spine. Gross vibration to an extremity or the whole body. Spasm. Involuntary, continuous contraction of muscles. Hypertonicity. Stretch reflex. A sudden stretch of a muscle which causes a reflex stimulation of the muscle by producing a quick contraction. Knee jerk.
Scoliosis.
Shaking.
668
GLOSSARY
Stroking movements. Superficial and deep effleurage. Supination. The act of turning the hand upward; rotating the tarsal bones outward. Supine. Lying with face upward. Synapse. A connection by contiguity between dentrites of two neurons. Synergists. Add and stabilize movements initiated and carried out by prime movers.
Tapotement.
Use
of relaxed fingers,
palm
or
fist
to administer a rhythmical series of
blows. Tonic contraction.

reflex in
Tonus. which exists independently of voluntary innervation. Tremor. Involuntary trembling or quivering movements.
This is usually a sustained contraction; it is almost always entirely nature and as a rule does not cause any motion. Tone or tonicity. Particularly, a condition of contractile tension in muscle
Vibration. The use of the fingers or mechanical apparatus to administer light taps in rapid succession.
Vibratory movements.
Vibration and shaking. Volkmann's contracture. Contracture of fingers and sometimes wrist with due to impaired circulation of muscles of forearm.
loss of
power
AUTHORS' INDEX
British Medical Association Arthritis Committee, 476 British Ministry of Health.
DALTON, 30 Danforth, 312 British Red Cross Clinic for Dannreuther, 557 Rheumatism, 478 d'Arsonval, 187 Da vies, 150 Brown, 338 Brugsch, 245 Davis, 130 Allen, 388, 394 De Keating-Hart, 264 Bundesen, 254, 255 Alpers, 486 De Kraft, 188, 265 Burr, 97 American College of Sur- Burton, 210 Dennis, 88 geons, 629 Desjardins, 254, 261, 575 Anderson, 304, 315, 351, 362 de Takats, 438, 441, 444 Apostoli, 134 de Yong, 110 Arieff, 127 CARPENTER, 188, 253, 254 Deutsch, 155 Atsatt, 248 Carter, 449, 451 Dick, 538 Cartwright, 315 Dickson, 526 B Cash, 508 Dineer, 80 Casteran, 619 Doan, 253 BABINSKI, 107 Cerletti, 496, 498 Dodge, 486 Bach, 364, 467 Chadwick, 31 Dognon, 214 Bachem, 87, 307, 354 Cherry, 553 Downes, 338 Baker, 150 Chor, 175 Doyen, 264 Du Bois-Reymond, 102 Barakin, 159 Christie, 206, 447 Barker, 439, 445 Cignolini, 398 Duchenne, 107 Barnacle, 486, 495 Cipollaro, 579, 581, 585, Duke-Elder, 615, 617 Barrett, 367 588, 589 Duncan, 528 Bauer, 255 Clark, J. H., 344 Bauwens, 130, 617 Clark, W. L., 264, 265 Bayliss, 100 Cobb, 511 Bazett, 212 Coblentz, 310, 325, 344, Beazell, 213 354, 357, 369 EBAUGH, 484 Beck, 566 Codman, 535 Eidinow, 334 Beer, 264 Coggeshall, 511 Einstein, 301 Behrend, 149, 412, 440 Collins, 208 Eller, 588 Bengston, 551 Compere, 489 Ellis, 267 Bennett, 455, 508 Compton, 301 Ellman, 449 Benson, 553 Comroe, 493 Eppinger, 562 Bergonie, 163, 459 Cook, F. R., 264 Epstein, 261 Bering, 395 Corbus, 552 Erb, 107, 108 Berkwitz, 496 Cottle, 615, 617, 619 Erickson, 456 Bernard, 101 Coulter, 206, 210, 217, 456, Erlanger, 616 Bernd, 187 617, 629, 634 Esau, 188 Council on Foods and Nutri- Eve, 390 Bernhard, 329, 591 Bierman, 211, 254, 315, 392, tion, 330 Ewalt, 484 Council on Medical Educa- Ewerhardt, 425, 428, 523, 440, 552 398 tion and Hospitals, 630, 665 Bigelow, 390, 632, 637 Binger, 206, 449 Ewig, 562 496 Council on Physical MediBini, Birch-Hirschfeld, 616 cine, 6, 200, 250, 271, 313, Bird, 351 328, 333, 343, 358, 366, 248 371, 378, 624, 630, 634 Bishop, FARADAY, 42, 141 Blatz, 175 Counsellor, 445 Fay, 388, 393 Federal Communications Boak, 254 Couperus, 456 Bohr, 301 Commission, 202 Craig, 515 Crook, 490 Feinstein, 130 Bordier, 174 Cross, 483 Borini, 398 Fernandez, 145, 160 Finsen, 330 Bourguignon, 107, 127, 159, Grossman, 388, 394 Cullen, 261 483, 512 Fischer, 175 Culler, 618 Bosworth, 535, 538 Fisher, 297 Cumberbatch, 150, 214, 549, Forbes, 450 Boyd, 470 551 Brazier, 130 Fox, 376 Brickner, 536 Gushing, 264 Frankenburger, 328
Adrian, 107 Aitken, 329 Albee, 531 Albutt, 439 Alexander, 88
ABRAMSON, 159
462
670
Frankfeldt, 233 Freedberg, 434 Freund, 141
Friedlander, 392
Friel, Fritz,
AUTHORS' INDEX
Hibbs, 563
Higgins, 269 Hildebrandt, 210 Hines, 176
Landis, 439, 443 Langley, 506
Lanyon, 390
Lapicque, 104, 125 Laquerriere, 523 Laqueur, 84 Larsson, 619 Laubry, 435 Laurens, 326, 331, 338, 458
616 474
Fiirstenberg, 219
Hipps, 496 Hirst, 557 Hoeft, 338

Hollender, 615, 617
Holmquest, 142, 178, 201, 210 Law, 616, 617 Horowitz, 254, 552 Lear, 365 Leduc, 134 GALVANI, 134 Huldschinsky, 333 Hummon, 156 Lehman, 248 Gatch, 540 Levisman, 436 Gerstenberger, 457 Humphris, 365 Lewis, G. M., 150 Hunt, 538 Ghormley, 515 Lewis, Th., 155, 328, 392 Kurd, 664 Gibbon, 439 Lieberman, 484 Gibson, 32 Hyams, 281, 553, 556 Liebesny, 80, 176, 214, 492 Gila, 492 Hyman, 434 Lucas-Championnere, 409 Gilbert, 37 Luce-Claussen, 457 Glazier, 269 Luckiesh, 302 Glover, 477 Lyle, 617 Goldgruber, 456 IRVING, 622 Golseth, 127 Gordon, C. A., 551 Ivy, 213 MACKAY, 494 Gordon, J. D., 390 MacKee, 585 Gordon, R. G., 475 Major, 262 Gorsch, 569 Marconi, 187 JACOBSON, 432 Gosset, 188 Marton, 596 Granger, 213, 512, 584, 618, Jellinek, 295 Martucci, 483 632, 634 Jess, 619 Matli, 398 Grant, 155 Jones, 107, 123 Matson, 285 Graves, 491 Maughan, 364 Green, 391 Mayer, 342, 364, 449, 456, Greene, 420 530 Greider, 338 Mayerhoff, 338 Grober, 688 KALINOWSKY, 498 Mayo Clinic, 515 Grodins, 177 Keesey, 572 McCarty, 284 Gronner, 497 Kellogg, 163, 319 McClendon, 207 Guleke, 281 Kelly, 264, 284 McFarland, 491 Gutmann, 175 Kelvin, 31 McEachern, 629 Guttmann, 175 Kendell, 255 McGuinness, 630 Gutzeit, 216 Kennelly, 296 McLennan, 210 Kenny, 487 McLoughlin, 213 Kernon, 150 H Memmesheimer, 328 Kettering, 248 Mennell, 477, 507 Key, 524 Meyer, 435 HAASE, 214 Keysser, 267 Meyers, 446 Kime, 285 Haggard, 581 Miley, 367 Hall, 494 Knapp, A., 619 Millikan, 31 Hall, E. F., 392 Knapp, M. E., 470 Mittelmann, 201, 206, 218 Hansson, 482, 492, 539 Knight, 617 Mock, 282, 285, 528 Hardt, 456 Kobak, 218, 570 Moench, 255 Harpuder, 159, 163, 474 Koeppen, 296 Mogendorvch, 213 Harrison, 563 Koskoff, 392 Hart, 369 KovAcs, J., 156, 448, 470, Molitor, 86, 145, 160 591 Monbrun, 619 Hartman, F. A., 175 Kovrcs, R., 211, 287, 332, Moncrieff, 617 Hartman, T. L., 457 355, 470, 478, 492, 495, Monguio, 80 Hartman, F. W., 262 539 Montgomery, 441 Haynes, 480 Moor, 456 Kowarschik, 142, 289, 510 Heald, 409 Morrison, 600 Kraissl, 372 Heitz-Boyer, 268 Mortimer, 210 Krasny-Ergen, 80, 214 Hemingway, 82, 207, 208 Krusen, 253, 256, 344, 449, Morton, 538 Hench, 253, 279 Moser, 398 467, 477, 528 Henry, 187 Murray, 526 Heraeus, 346 Muth, 80 Herring, 393 Hertz, 187 N Hertzmen, 157 NAFFZIGER, 539 Herxheimer, 396 LAKE, 392 Nagelschmidt, 188, 346, 434 Lance, 97 Hess, 333
AUTHORS' INDEX
National Bureau of Standards, 343 National Research Council, 540 Neergard, 494 Nernst, 102 Newman, B. A., 335 Newman, L. B., 551 Newton, 300 Neymann, 249, 484, 485 Nieden, 267 Norwich, 524 Nugent, 616 Nylin, 436
Reynolds, 453 Richter, 83, 86
Riviere, 264 Robinson, 372, 576 Rolfe, 576 Rollier, 329, 337, 341, 530
671
Theis, 398 Thiele, 528
Thompson, 475 Thomson, 31

Tigay, 127
Tinel, 506 Tisdall, 338 Titus, E. C., 188, 459
Rosenberg, 261 Rosenthal, 551 Rutherford, 31
SAFAR, 619 Sanders, 443 Sawyer, 577 O Scarff, 497 OBER, 492 Schauffler, 528 Ochsner, 591 Schemel, 219 O'Conor, 552 Scheminzky, 80 O'Leary, 588 Schereschewsky, 214 Osborne, 142, 178, 206, 210, Schiller, 127 249, 486, 562, 617 Schlesinger, R. A., 201 Osier, 474 Schliephake, 214, 227 Oudin, 264 Schmidt, C. R., 213 Overholser, 495 Schmidt, W. H., 553 Schmitt, 261 Scholtz, B., 580 PAGE, 188 Scholtz, H. G., 553 Patzold, 188, 209 Schurmayer, 562 Pearse, 284 Schwab, 130 Pedersen, 564 Scott, 254 Pemberton, 323, 462, 477, Scupham, 439 531, 561 Shands, 528 Pflomm, 214 Sharlit, 335 Pfltiger, 107 Sheffey, 553 Phelps, 340, 487 Sherman, I. C., 127 Phillips, 252, 255 Sherman, W. O. N., 174, 408 Pincussen, 332 Simmons, 474 Pizarro, 436 Simo, 141 Planck, 301 Simpson, S., 393 Pollock, L., 174 Simpson, W. M., 248, 250, Pollock, L. J., 127, 503, 505 255, 618 Popp, 253 Sinclair, 566 Portman, 449 Sittler, 248 Pottenger, 449 Slocumb, 253, 476 Pottle, 130 Smart, 174, 408, 492, 522 Potts, 481 Smith, 388 Poulsen, 188 Snow, 184 Pratt, 245 Sokolov, 446 Preyss, 187 Solomon, 261, 473, 474, 538 Putnam, 285 Somers, 338 Sonne, 315 Souttar, 175 Spark, 484 RACUGNO, 527 Spies, 456 Radnai, 484 Starling, 97 Rahm, 497 Starr, 440 484 Rajka, Stecher, 261, 473, 474 Randall, A., 568 Steel, 213 Randall, L. M., 254 Stenstrom, 82 Randall, W. C., 157 Stiebock, 188 Rausch, 436, 562 Storms, 409 Rebbeck, 332, 367 Stovin, 614 Reed, 307 Stryker, 287 Reid, 174 Stubenbord, 456 Reiley, 470 Stuhler, 254 Rein, 562 Sutton, 486 Reiter, 214 Remak, 107 TAYLOR, 463 Rendall, 455 Tesla, 187 Reyn, 367
Tonney, 338 Tovey, 555 Tower, 175 Troedsson, 393 Trolow, 436 Trusler, 540
Turrell, 103, 107, 141, 179, 241, 516
Twining, 175 Tyndall, 318
ULANSKI, 517 Ungley, 396 Upton, 553 Uthoff, 566
VAN BREMEN, 376

Veraguth, 481 Volta, 134 Von Bodo, 558 Voshell, 527 Voute, 452
W
WALLACE, 533 Walser, 435 Walthard, 486 Wang, 562 Ward, 264, 284 Warren, S., 397 Warren, S. W., 253, 254, 256, 261, 465, 466, 628 Watkins, 129, 130, 628 Webster, 396 Weddell, 130 Wedekind, 147 Weeks, 88 Weisenburg, 486
Weiss, J., 76, 171, 541 Weiss, S., 456, 457 Wells, 369
Wentworth, 528 Wesson, 565 Weve, 619 Whetherbee, 449 White, 397 Whitney, E. L., 617 Whitney, W. R., 188, 249
Wiggers, 99, 100, 101 Williams, 201, 296 Winton, 100
Wyatt, 477 Wyeth, 264
ZEITER, 455 Zeynek, 187
SUBJECT INDEX
A
ABDOMINAL
adhesions, 456
combined diathermy and quency current in, 244 compress, 377 cramps in hyperthermy, 261 gymnastics, 454
in arthritis,
Air sterilization by ultraviolet, 369 superheated intrayaginal, 550 Air-conditioned cabinet, 248 low-fre- Air-cooled lamps, 353 Aix-le-Bain massage, 408 Alkalosis in electropyrexia, 261
All or none law, 666 Alopecia, 581 Alternating current, 38, 654 cycle of, 39
muscles, atonic, after childbirth, 455 electrical stimulation of, 453
468
postoperative weakness of, 455 organs, diathermy of, 232 Abdomino-rectal diathermy, 549 Abdomino-sacral diathermy, 547 Abdomino-vaginal diathermy, 548
Abduction, 665 Ablutions, 379 full, 379 partial, 379 Abscess, 320
peritonsillar,
frequency of, 39 meters, 47 modulated, 169 transformation by vacuum tubes, 60, 136 Amber, 36 Amenorrhea, 551 American Registry of Physical Therapy Technicians, 632
612
retropharyngeal, 612 Absolute reaction of degeneration, 116 Absorption, Grotthus' law of, 306 of infrared by skin, 361
of radiation, 353 Accessories, electromedical, 66 miscellaneous, 76 Accessory nasal sinuses, diseases of, 607 Accidents during electrotherapy, 287 electrical, in homes and in industry, 294 therapeutic, medicolegal aspects, 293 Acid-base balance, disturbance in hyper-
Ammeter, 49, 654 Amperage, 654 influence of, on path Ampere, 44, 654
of current,
88
meters, 47 for alternating current, 47 for direct current, 47 Amplifier, 654 tube, 60 Amplitude, 654, 666
thermy, 251
Acne
vulgaris, 581
Aconitine-iontransfer, 159 Actinic, 654 Actinic rays. See Ultraviolet rays.
Amputation, stumps, 528 Amputations, 527 Anal canal, stricture of, 523 cramps, 576 Analgesia, 666 Anaphoresis, 654 Anatomical position, 666 Anelectrotonus, 103, 654 Anemia, secondary, effect of ultraviolet on,
331 Anesthesia, 666
Actinism, 654 Actinometer, 654 Actinotherapy, 299, 654 Action current, 97

in nerves, 98 of heart and brain, 101 of skeletal muscles, 97 potential, 99 Active electrode, 109, 275, 546
by Leduc current, 179 Angina pectoris, 433 Angle of incidence, 654 Angstrom unit, 302, 654 Angulation of rays, 306 Anion, 654 Ankle-joint, diathermy of, 238
sprain, 523 Ankylosis of joints, 525
Acupuncture, galvanic, 150 Adduction, 665 Adenitis, 540 Adenoid, hypertrophy of, 609 remnants of, electrocoagulation of, 609 Adenoma sebaceum, 579 Adherent scars, chlorine ionization for, 160, 541 Adhesions, abdominal, 456 Adipositas dolorosa, 478 Aero-Kromayer lamp, 353 Aerotherapy, 341 Afferent nerve fibres, 665 Agonists. See Prime movers.
Anode, 43,
Anorectal
52,
654
current, 654 voltage, 654

fistula,
573
tuberculosis, 577
in fever therapy, 262 Antagonists, 666 Anterior poliomyelitis, 487 Antirachitic effect of ultraviolet rays, 329 Anxiety neurosis, post-traumatic, 494
Anoxia
Aphonia, hysterical, 493 Apparatus, Bergonie, 459 electromedical, 68
(672)
SUBJECT INDEX
Apparatus, electromedical, typical features of, 69 electrosurgical, 269 Finsen, 366, 658 for artificial light treatment, 347, 350 for faradic-galvanic testing, 109 high-frequency, 187 low-frequency, 169 galvanic, 134 radio interference by, 201 selection of, for institutions, 634 for offices, 624 spark-gap, 197 static, 184 typical features of, 69 vacuum-tube, 191 Arc lamp, 654
.
673
Autocondensation, 240 chair, 241 effects of, 241 in hypertension, 435 pad, 241 technique of, 240 Autoconduction, 655 Autohemotherapy, 588 Autotransformer, 655
BABIES, exposure of, to heliotherapy, 343 Back injuries, 528 Bactericidal effect of diathermy, 214 of hyperthermy, 253 of ultraviolet rays, 330, 369 carbon, 347 Bake in light baker, 323 light, 654 mercury vapor, 356 Baker, light, 313 stream, 347 Bartholinitis, gonorrheal, 557 Base plugs, location for, 65 Armamentarium, 654 Armature, 53 Bases, 655 54 vibrating, Bath, aromatic, 381 Aromatic bath, 381 cabinet, light, 315 Arsenical keratosis, 585 carbon dioxide, 381 Arteriosclerosis obliterans, 444 cold, 380 462 Arthritis, acute, plung, 380 artificial fever for, 466 continuous, 380, 475 462 atrophic, tepid, 380 chronic, 461 contrast, 381 classification of, 462 electric light, 315 Committee, British Medical Association, four-cell, 148 476 galvanic, 146 in arthritis, 469 gonorrheal, 472 474 in locomotor ataxia, 485 gouty, grading of cases, 463 hip, 380 hypertrophic, 462 hot, 380, 466 osteo-arthritis, 462 air, 382 scheme of treatment, 472 medicated, 381 Nauheim. See Carbon dioxide. physical treatment measures in, 464 counterirritant, 469 paraffin, 382 mechanical, 467 resinous, 381 thermal, 465 sitz, 380 rheumatoid, 462 static, 186 scheme of treatment, 472 tepid, 380 physical treatment, 472 towel, 379 spa treatment, 470 whirlpool, 384, 521 Bathroom heater, 313 spondylitis deformans, 473 traumatic, 524 Battery, 52, 134 tuberculous, 530 storage, 53 Asbestos paper for iontophoresis, 158 thermoelectric, 51 Aschoff bodies, 475 Bazin's disease, 589 Asphyxia in newborn, faradic resuscitation Beating, 405 for, 177 Bed, oscillating, 443 Asthma, bronchial, hyperthermy for, 255 sores, 486 ultraviolet rays for, 334 Bell's palsy, 510 Athermic effects of short-wave diathermy, Belt electrode, 547 214 Bergonie apparatus, 459 Athetoid movements, 666 treatment of obesity, 459 Athetosis, 487 Bias, 655 Bierman clamp, 571 Atom, 30, 654 hydrogen, 30 Biliary affections, 456 Bioelectric phenomena, 97 nucleus, 30 oxygen, 31 theory of, 101 Atomic theory, 30 Biopsy, electrosurgical excisional, 285 in gynecology, 558 Atrophy, muscular, 174, 667 of disuse, 176 in proctology, 575 Auditory nerve deafness, 603 Bipolar, 655 Aural iontransfer electrode, 602 cutting, 281
43
674
SUBJECT INDEX
Bipolar, electrical testing, 112 stimulation of muscles, 182 Birch-Hirschfeld ultraviolet lamp, 616 Birth palsy, 487
ABINET, air-conditioned, 248 electric light, 322 Birthmarks. See Nevi. luminous heat, 248 Biterminal clamp method in hemorrhoids, non-luminous heat, 248 571 ables, conducting, 71 inductance, 73 coagulation, 267 of tonsils, 610 alcaneal spurs, 542 electrodes for electrodesiccation, 278 alcified deposits in corpora cavernosa, 565 in subdeltoid bursitis, 536 Black body radiation, 311 Calcium deficiency, ultraviolet rays in, Bladder, electrosurgery of, 567 329, 458 incontinence, 563 iontransfer, 159, 483 papillary growths of, 567 Callositas, 581 Blanket, electric, for hyperthermy, 247 Blended current, 269 Capacitance, 655 Capacitative current, 87, 208 Blepharitis, 615 Capacitor, 655 Blepharospasm, 619 Blondes, sensitivity of, to light, 364 Capacity, 655 Blood, effect of ultraviolet rays on, 330 current, 79, 208 unit of, 46 Blood-pressure, high, 434 low, 437 Capillaries, specific effects on, 214 Blue pencil brush discharge, 655 Carbohydrate metabolism, influenced by ultraviolet and visible rays, 332 Body temperature, effects of hyperthermy Carbon arc lamp, 347 on, 246 Bohlman's solution, 275 construction, 347 radiation characteristics, 348 Boils, 583 Bone atrophy, 666 relative advantages and disadvandelayed union of, diathermy in, 527 tages, 350 relative conductivity of, 86 tip electrodes, intravaginal, 546 Carbon dioxide bath, 381 tuberculosis of, 530 Bones, and joints, tuberculosis of, 530 Carbons, principal types of, 349 sunshine type, 349 injuries of, 525 joints, muscles and tendons, affections therapeutic, 350 of, 519-544 Carbuncles, short-wave diathermy in, 216 Carcinoma of bladder, electrosurgery in, Booster, 655 Brachial neuritis, 514 567 of prostate, electrosurgery in, 568 plexus injury, 504 Cardiac diathermy, 434 Brain, diathermy of, 227, 483 fibrillation, 153 galvanism of, 145, 483 relative conductivity of, 86 neuroses, 437 Cardiovascular conditions, treatment of, transcerebral galvanism of, 483 Breakdown voltage, 655 432-447 Bristow coil, 173 Carotid sinus, diathermy to, 436 Bronchitis, 448 Caruncle, urethral, electrodesiccation for, 559 Bronchopneumonia in children, 450 Brucellosis, 474 Cataphoresis, 79, 140, 655 Brush discharge, 655 Cataract, 617 Catelectrotonus, 103, 655 Buerger's disease, 445 exercises, 441 Cathode, 42, 52, 655 activated, in quartz burners, 351 Bunion, 542 Burner in quartz lamps, 351 current, 655 Burns, 540 Causalgia treatment of, by Leduc current accidental electric, 290 177 difference from electric wounds, 295 Cells and batteries, 51, 134 electrical, 295 dry, 52, 134 from diathermy, 290 galvanic, 51 from galvanism, 291 polarization, 52 from heat lamps, 290 Central excitatory states, 666 from ultraviolet, 291 nervous system, affections of, 480-499 Cerebral diathermy, 227, 483 galvanic or electrolytic, 160, 291 in hyperthermy, 260 galvanism, 145, 483 pathology, 290 palsy, 486 treatment of, 292, 540 Cervical erosion, 556 See Endocervicitis. Cervicitis. by ultraviolet radiation, 540 Cervicobrachial syndrome, 539 Bursitis, 533 Cervix, diathermy of, 551 deep, 533 of radiohumeral bursa. See Epicondylitis erosion of, 556 stenosis of, 557 subdeltoid, 536 Chalazion, 616 superficial, 533
SUBJECT INDEX
Chancroidal ulcers, 558 Characteristics, 655 Charge, electric, 32 by contact, 34 by induction, 34
Cold, reaction, 375
Colds, prevention of,
tion, 364 Colic, renal,
675
by
ultraviolet radia-
562
Colloid,
655
Chemical
effects of electricity, 42 of galvanic current, 139 generation of electricity, 51
Colon, polyps, 574 Colonic irrigation, 387 in chronic arthritis, 469

in constipation,
Cherry-electrode, 555 Chest, compress, 377, 449 diathermy of, 231, 448
Chilblains, 395
455
indications for, 387
Children, exposure to artificial ultraviolet

light,
364
to heliotherapy, 343 Chloride balance in electropyrexia, 251 Chlorine iontransfer, 159, 541
Choke
coil, 50,
653
in,
Cholecystitis, chronic, 457
Cholecystography, diathermy
457
Cholesterol, activation of ultraviolet, 329
Chorea minor, 486 hyperthermy of, 486 Chronaxie, 104, 655 measurement, 125
meters, 126
testing, 125 Chronaximeter, 126 Chryometherapy, 388 Circuit breakers, 65, 655 closed, 38 electric, 38 open, 38 oscillating, 56, 190 plate, 193 short, 64 air spaced, 221 tank, 193 tuned, 664 plate, 36 Circumduction, 666 testing, 124 Circumvallation of tissues by surgical diatuning, 207 variable, 665 thermy, 283 Clark's soap experiment, 273 Conductance, 656 Clavus. See Corns. Conducting cables, 71 Close coupling, 655 cords, 70 Closed circuit, 38 fastening of, 71 trouble with, 71 Coagulable lymph, 520 Conduction of currents through body, 78 Coagulation. See Electrocoagulation. Cocaine iontransfer, 159 current, 87 Conductive heating, 318, 656 Coccygodynia, 528, 576 Conductivity, 656 Coccyx, diathermy to, 231 dielectric, 87 Cock-up splint in radial paralysis, 504 relative, of tissues, 86 Coil, Bristow, 173 Conductors, electrical, 33 choke, 50 electrolytic, 33 diagram of, 50 partial, 34 d'Arsonval, 198 Conization by cutting current, 281, 556 faradic, 54, 172 field heating, 208, 222 Conjunctivitis, 615 Constant current, 134, 656 induction, 55 Constants, dielectric, 87 Oudin, 200 Constipation, 452 primary, 54 atonic, 452 secondary, 54 electric muscle stimulation in, 453 Tesla, 198 exercise in, 453 Cold, 375, 388 hydrotherapy in, 455 applications, 375 in women, relieved by electric stimulain trauma, 520 tion of uterus, 557 bath, 379 massage, 410, 453 compress, 377 spastic, 454 injuries, 394 Constrictor, rhythmic, 442 pack, 378 Continuous baths, 534 quartz lamp, 353
Combination, diathermy apparatus, 200 fever cabinets, 250 of diathermy and low-frequency current, 243 pressure and exercising device, 443 Commutator, 53, 656 Comparison of water system and electric current, 44, 66 Compress, abdominal, 377, 449 chest, 377 cold, 377 hot, 377 stimulating, 377 throat, 377 wet, 377 Compression movements, 402, 666 Compressor in Finsen treatment, 367 Condenser, 34, 656 capacity, 34, 123 cuffs, 72 discharge, 35, 56, 123 field, 208, 223 glass electrodes, 74 in high-frequency circuit, 192, 198 Leyden jar, 35, 198 pad electrodes, 72, 220
676
Continuous spectrum, 656
Contraction, 666
phasic, 667
tonic,
SUBJECT INDEX
Current, effects of, primary physical, 78 secondary physiological, 82
specific electric,
electric,
80
668
39
Cqntracture, 666 ischemic (Volkmann's), 532 Dupuytren's, 160, 666 Contraindications for diathermy, 217 for electric shock therapy, 498
for hyperthermy, 255 for massage, 411 for ultraviolet, 334
electricity, generation of, 51
electromedical, 66
faradic, 165, 657 galvanic, 134, 658 high-frequency, 68, 187
Contrast bath, 381 Contusions, 524 Convective discharges, 656 heat, 656 Conventional diathermy. See Long- wave diathermy. Conversion of electricity, 53 Conversive heat, 656 Converter, rotary, 55 Cooper-Hewitt lamp, 346 Copper ion transfer, 154 in chronic endocervicitis, 554 in dermatophytosis, 581 in indolent ulcers, 591 Corbus and O'Conor thermophore, 547 Cord, clips, 71
tips, 71 Cords, conducting, 70 Core of transformer, 55 Cored carbons, 656
filter, 353, 404 Cornea, diseases of, 616 Corneal ulcer, 616 Corns, 581
induced, 42 injury, 100 interrupted galvanic, 164 Leduc, 179 low-frequency, 68, 163
modulated alternating, 169 of capacity, 79, 208

Oudin, 200, 242, 661 outlets for, 65 polarization, 97 progressive, 105 sinusoidal, 168 source of supply, 65 static, 184 surging faradic, 167
Currents, electromedical, classification of
67 Cutaneous
sensibility, areas of, 502 Cut-outs, electric, 65 Cutting current. See Electrosection.
bipolar, 281
Corex
underwater, 281 Cycle of alternating current, 39, 656 Cystitis, 563
Coronary disease, diathermy in, 434 Corpora cavernosa, calcified deposits 565 Corpuscular theory of Newton, 300 Corrective exercise, 412
Coryza. See Rhinitis. Cosine law, 306 Couches, treatment, 77
D ALTON'S atomic theory,

in,
30
Damped
current, 656
oscillations,
198
Damping, 656 Dangers of diathermy, 217

of of of of of of
electric
electrolysis,
shock therapy, 498 597 galvanism, 160 hyperthermy, 255 Coulomb, unit of quantity, 44, 656 Counterirritant measures in chronic arthlow-frequency currents, 183 ultraviolet therapy, 364 ritis, 469 Counterirritation by histamme ionization, Daylight, component parts of, 338 469 Deafness, 603 Decongestion in facial paralysis, 511 by Oudin current, 242, 243 Decrement, 656 by ultraviolet irradiation, 334 Decubitus, treatment of, 486 Coupler, 656 Degeneration, reaction of, 114 Coupling, 656 DeKraft blue pencil, 655 device in tube apparatus, 196 chair for autocondensation, 241 Cramps, abdominal, in hypothermy, 261 Delayed union of fractures, 527 Cryotherapy, 388 Cubicles for treatment, 625 diathermy in, 527 ultraviolet in, 528 Cuff electrodes, 76, 92, 220 Dendrites and axons, 666 method, 92 Cumberbatch's treatment of gonorrheal Denervated muscles, electric exercise of, 175 cervicitis and urethritis, 551 Density of current, 88 Current, action, 97 Department of physical therapy, 627 alternating, 38 Depth effects of short-wave diathermy, 208 kt blended, 269 Dercum's disease, 478 capacitative, 87, 208 Dermatitis of ear, 600 conductive, 87 Dermatological conditions, 579-599 cutting, 268 Dermatophytosis, copper iontophoresis for, density, 88 581 direct, 39, 134, 656 ultraviolet rays for, 581 direction in battery, 52
SUBJECT INDEX
Derow's solution, 546
Desensitization by Oudin current, 243 Desiccation, 656. See also Electrodesiccation.
677
of foot,
Diathermy
of of of of of of of of of of
238
frontal sinus, 229, 607 gall-bladder, 232
hand, 235
Detachment
of retina, electrosurgery for,
619 DeWatteville current.

dization, 179 switch, 179 Diathermic burns, 290
See Galvanofara-
head sinuses, 229 heart, 434 hip-joint, 236

kidneys, 232 knee, 235
liver,
232
massage, 241
Diathermy, 656
apparatus, 190
combination type, 200 milliammeter in, 198 requirements for, 200 vacuum tube type, 191 autocondensation, 240 burns, 290 cardiac, 434 cerebral, 227, 483 clinical uses of, 215 combination with low-frequency current, 243 contraindications to, 217 cuff method of application of, 192 current, steps in production of, 190 dangers of, 217 direct contact heating, 220 dosage of, 218 duration of treatment, 219 effects of, 206, 211 heat, 211 on bacteria, 214 on circulation, 213 on nervous system, 213 physiological, 211 electrodes, 225 experimental demonstrations, 205 frequency of treatment, 219 general, 240 general technique of, 218 long-wave diathermy, 225 short-wave diathermy, 220 direct contact heating, 222 electric field heating, 220
electromagnetic
field
lungs, 231 of male urethra, 560 of middle ear, 602 of neck, 230 of pelvis, 547 of penis, 561 of prostate, 560 of rectum, 233 of sciatic nerve, 238 of seminal vesicles, 561 of shoulder, 233 of spine, 230, 231
cervical,
230
dorsal
of of of of of of
and lumbar, 231
stomach, 232 testis, 561 thigh, 236 upper extremity, 233 vagina, 548 wrist, 235 physiological effects, 211 on bacteria, 214 on circulation, 213 on nervous system, 213 rectal, 233, 549 regional technique of diathermy, 227 regulation of dosage, long-wave diathermy, 226 short-wave diathermy, 224 safety rules in, 239 short-wave vs. long- wave diathermy, 216 special precautions with short-wave diathermy, 240
See Electrosurgery. technique of, 239, 267 thermal effect, 206 heating by direct contact, 207 in electric field, 208 in electromagnetic field, 208
surgical.
heating,
222
in chronic arthritis, 465 in delayed union of bones,
527
transpelvic, 547
indications for, 215 specific for short-wave diathermy, 216 intravaginal, 548 medical, 205 of abdominal organs, 232 of ankle, 238 of antrum, 229, 607 of brain, 227
of of of of of of of of of of of of
vagino-abdominal, 548
Dielectric, 35,
656
conductivity, 87 constants, 87 permeability, 87 substances, 87
Diode, 59, 656

Diplegia, 666 Dipoles, electric, 87 molecular, 88 Direct current, 39, 134, 656 meters, 47 stimulation by, 102 Dislocations, 523 Dispersive electrode, 109 for electrocoagulation, 275 Displacement, condenser, 83
dielectric,
bunion, 542
carotid sinus, 436
cervix, 551 chest, 231,
448
coccyx, 231 corpora cavernosa, 585
601 elbow, 235 epididymis, 561

ear,
eye, 228 female urethra, 551

fingers,
83
236
Disruptive discharge, 656 Disruptoconductive discharge, 656
678
Dosage
of of of of
of diathermy,
SUBJECT INDEX
218
Electric units, 44
galvanic current, 144 heliotherapy, 341
short-wave diathermy, 219 ultraviolet irradiation, 361 Dosimeters for short-wave diathermy, 218 Douche, 384 hot air, 466 vaginal, 549
Scotch, 384 Drift velocity of electrons, 187
cells, 52, 134 heat, 656 Dupuytren's contracture, 666 iodine iontophoresis in, 160
waves, 56 wounds, 295 conservative treatment Electricitas, 37

Electricity,
of,
295
657
conversion of, 51 destructive effects, 80

effect of,
39
Dry
chemical, 42 electromagnetic, 40 thermal, 39 generation of, 51 chemical, 51

frictional,
36
Dynamo, 53
for alternating current, 53 for direct current, 53
mechanical, 53 physical effects of, 78

physiological effects of, 82 psychological effects of, 82
specific electrical effects of,
Dysmenorrhea, 558
Dystrophies, muscular, 667
E
EAR, middle, diathermy of, 601 diseases of, 600 nose and throat, diseases of, 600-614
supply in homes and unit of, 31 Electrification, 37 negative, 37 positive, 37 Electrify, 657
offices,
80 62
Eczema seborrhoicum, 583
Eddy
Edge
current, 209
effects,
93
heating, 209
effect of electrodes, 91,
effect,
Electrocardiography, 101 Electrocautery, 657 Electrocoagulation, 265, 275, 659 biterminal electrodes in, 278 clinical uses of, 283
electrodes,
226
275
Edison
58
Efferent nerve fibres, 666

Effleurage, 400, 666
Eflfluve,
experimental practice, 276 histological changes, 267

in proctological conditions, 57
1
high-frequency, 214, 235, 656
Elbow, diathermy of, 235 dislocation of, 524 technique of, 275 Electric accidents, 287 Electrocution, 657 blanket, 247 Electrode, 71, 657 burns, 290 active, 109, 138, 153, 275 treatment of, 292 aural, for ion transfer, 602 cabinet bath, 248, 322 belt, 547 charge, 32 biterminal, 278 carbon- tip, 546 circuit, 38, 656 conduction through body, 82 cherry, 555 condenser pads, 72, 220 current, 38 and water system, 44, 66 contact metal, 71 effects of, on body, 78 co-plane application, 92 Corbus and O'Conor, 547 passage through body, 82, 86 dipoles, 87 cuff, 72, 97 effects, specific, 80 Cumberbatch, 551 excitability, 104 dispersive, 109 field, 208 foil, 71 for gynecological applications, 546 heating, 208 for electrocoagulation, 270 injuries, 287 for electrodiagnosis, 109 knife, 280 for electrosection, 279 motor, 53 muscle exercise, 173 for short-wave diathermy, 220 oscillations, 56 Frankfeldt, 233 potential, 44, 662 glass, 74 shock, 292, 295 vacuum, 74 indifferent. See Dispersive. therapy, 496 treatment of, 297 inductance cable, 73, 208, 223 stimulation of muscles and nerves, 101, influence of size and position of, 91 163 intracervical, 554 symbols, 64 intravaginal, Zener, 547 testing of muscles and nerves. See Eleclongitudinal application of, 92 moist pad, 73 trodiagnosis. treatment, general rules of, 93 multiple for electrolysis, 596
operative technique, 277 role of milliammeter, 277
SUBJECT INDEX
Electrode, orificial, 75 pelvic diathermy, 547
679
field,
Electromagnetic heating, 208

laws
of,
40
560 reamalgamation rectal, 233

prostatic,
induction, 42, 657

of,
546
42
electron theory, 40
phenomena and
88
561 securing of, 75

scrotal,
size in relation to dosage,
spaced metal, 72 Tovey, 554

transverse application
of,
92
vacuum, 74
vaginal, 548 Zener, 547 Electrodeless high-frequency lamps, 356 Electrodesiccation, 265, 272, 657
spectrum, 302 theory of Maxwell, 300 Electromedical accessories, 66 apparatus, 68 currents, 66 classification, 67, 68 effects of, 78 Electromotive force, 44, 657
unit
of,
45
series of metals, 51
anesthesia
275 clinical uses, 283 experimental practice, 273 for superfluous hair, 598 histological changes, 265
in,
Electromuscular sensibility, 165 Electromyographic diagnosis, 138 Electron, 31, 657

discovery
of,
drift velocity,
31 197
in proctological conditions,
570
operative technique, 273 practice work, experimental, 273 Electrodiagnosis, 103-133
microscope, 62 theory of, 31 Electronic devices, gas-filled, 61 tube, 657

Electronics, 57
apparatus for, 109 bipolar, 112 by condenser discharges, 123

diagnostic limitations
difficulties in testing,
of,
121
111
electromyographic diagnosis, 128 faradic test, 113 for chrpnaxie, 125 galvanic test, 113
in affections of peripheral nerves, in facial paralysis, 512 in infantile paralysis, 490
Electroosmosis, 79, 140 Electrpphoresis, 78, 140 clinical uses, 153 general technique, 153 Leduc's experiments, 151 penetration of ions, 152 physicochemical considerations, 151 Electrophorus, 657 Electrophysics, fundamental, 30
502
elementary law glossary, 654
of,
32
motor points for, 108 normal reactions in, 113

polar formula, 120
principle of, 107 reaction of degeneration, 114
Electrophysiology, 97-106 Electroplating, 45 Electropyrexia, 246-263, 657.
See also
Hyperthermy. by electric method, 247 by hydriatic method, 247

clinical use, 253 in bronchial
strength-duration measurements, 123 technique of, 110 testing charts for, 131-133, 640-654 unipolar testing, 111
asthma, 255
Electrodynamometer, 657
Electroencephalography, 101 Electrokinetic phenomena, 79
Electrology, 657
657 equipment, 592 for hemorrhoids, 572 for removal of moles and warts, 150 of superfluous hair, 592 for stricture of urethra, 566 for strictures, 150, 566 number of treatments, 597 operation, 594 postoperative treatment, 597 preparation for, 593 setting of current flow, 594 technique with insulated needles, 596 test treatment, 597 Electrolyte, 33, 657 electrical decomposition of, 43 Electrolytic conductors, 34 solution, effects of electricity on, 43 Electrolyzer, 657 Electromagnetic effects of electricity, 40
Electrolysis, 149,
gonorrhea and complications, 253 multiple sclerosis, 255 neurosyphilis, 255 syphilis, 254 Wassermann-fas syphilis, 255 complications, 260 contraindications, 255 general technique of, 256 induction period, 257 initial steps, 257 maintenance period, 259 physiological effects of, 251 preparation, 256 requirements for fever apparatus, 250 Electroscope, 32 See also ElectrosurElectrosection, 268.
gical cutting. Electrostatics. See Static electricity.
in in in in in in in
chorea, 255 chronic arthritis, 255
Electrosurgery, 264-286
269 282 apparatus for, 269 clinical uses, 282 critique of, 285
advantages
anesthesia
of, in,
680
Electrosurgery history, 264 in dermatology, 579 in gynecology, 555 in proctology, 570
SUBJECT INDEX
Erythema
degrees
as a measure of effectiveness of ultra-violet radiation, 328 biological explanation of, 328
of,
326
in urology, 566 of eye, 618 of tonsils, 610 technique of electrocoagulation, of electrodesiccation, 272 of electrosection, 279
difference in.
by
certain
wave
lengths,
327 dose, 657

275
histological changes in, 327 induratum of Bazin, 589
Electrosurgical cutting, 279

clinical uses, 283 electrodes, 279 experimental practice,
production by infrared rays, 317 by ultraviolet radiation, 326
Erythemal
279
unit, 359 tests for efficiency of apparatus, 361
Erythemogenic, 658
equivalent of ultraviolet radiation, 358 Ether, 657
Exercise, 412-431 active, 412 breathing, 418 Buerger's, 441
classification,
hemostasis, 279 histological changes, 268 in resection of prostate, 567
methods, 265
operative technique, 279
effects,
265
of electrocoagulation, 265 of electrodesiccation, 265 of electrosection, 268 specific on blood-vessels, 268 excisional biopsy, 285
412
of,
contraindications
corrective,
425
173
412
electrical, of muscles,
general,
414
wounds, healing of, 268 methods, 265 Electrotherapist, 657 Electrotherapy, 657 accidents during, 287-294 general rules for, 93 Electrothermotherapy, 657 Electrotonic, 657 Electrotonus, 103, 142, 657 Elements, 31 Elliot apparatus. See Elliot treatment
regulator,
technique; 414 group, 418 in cardiac patients, 436

in constipation,
local,
453
indications for, 418
414
Oertel, 418 passive, 412 vascular, 474
physiological effects of, 412

resistive,
412
treatment, 381
respiratory, 418 Schott, 418
and indications, 382, 550 regulator, 381 Elongation of uvula, 612

effects
Embolism, acute, 446
Empyema, 449
Endocervicitis, chronic, 553 copper ion transfer for, 554
electrosurgery
in,
555
Endothermy, 657
End
plate, 666 Enteritis, tuberculous,
Stokes-Oertel method of, 437 under water, 385, 429 walking, 418 Excitability, diminished, 121 electrical, 104 increased, 121 Excitation time, 105 Extension, 666 External forms of heating, 205 and penetrating heating,
effects of,
relative
577 Enteroceptiye impulses, 666 See Tennis elbow. Epicondylitis. Epicritic sensations, 666
Epididymectomy
by
cutting
of, 561 Epididymitis, gonorrheal, 564 tuberculous, 565 Epilation. See Removal of superfluous hair,
566 Epididymis, diathermy
252 Eye, diseases of, 615-620 electrode, two cup, 618 electrosurgery of, 619 current, Eyelids, diseases of, 615-620 Eyes, dangers to, by ultraviolet rays, 365, 615 injuries, electric, 297
protection 365, 615
of,
in ultraviolet radiation,
by electrolysis, 592 by high-frequency current, 598

forceps, 592 Epinephrin ion transfer, 159 Epistaxis, 607 Epithelioma, 283, 586 Erb-Duchenne type of paralysis, 487 Erb's diagrams of motor points, 641-653 Ergotherapy, 459 Erosion, cervical, 556 Erysipelas, ultraviolet radiation in, 583 Erythema, 657
FACE, protection tion, 360

Facial neuralgia.
of, in ultraviolet radia-
See Trifacial neuralgia,
paralysis, 510 Far ultraviolet radiation, 658 Farad, unit of capacity, 40, 657 Faraday's laws of electromagnetic induction,
42
coil,
Faradic
54
SUBJECT INDEX
Farad ic
coil,
681
Bristow, 173
dry-cell battery, 172
Full-wave rectifier, 658 Functional paralysis, electrical reactions current, 165, 657 of, 118 experimental demonstration, 113, 165 Furuncles, 583 Morton-Smart coil, 173 Furunculosis, general, 583 of ear, 601 physics, 54, 165, 658 of nose, 604 physiological effects, 165 primary, 165 Fuse, 63, 658 production of, 54 box, 64 regulation of, intensity of, 167 trouble, 63, 64 resuscitation, 177 Fuses, overloading, 63 role of, 63 secondary, 165 surging, 167 test in electrodiagnosis, 113 Faradism, 658 Fascia, 666 GALL-BLADDER, diathermy of, 232, 456 Fatal cases in hyperthermy, 262 Galvanic acupuncture, 150 Federal Communications Commission, 202 apparatus, 134 Feet, care of, in peripheral vascular disease, bath, 146 446 clinical uses, 149 Fever, artificial. See Electropyrexia. four-cell, 148 apparatus requirements for, 250 full, 146 in cardio-vascular conditions, 436 Fibrillation, cardiac, 153, 295 of muscle after severance of nerve, 506 method for group stimulation of Fibrositis, 474 muscles, 183 classification, 476 partial, 148 diagnosis, 476 battery, 134 induration, common sites of, 475 burns, 291 nodule, treatment of, 476 cell, 52 pathology, 474 current, 134, 658 treatment, 476 apparatus for, 134 difference in skin resistance to diaFilament, 658 non-thoriated, 195 thermy, 83 Filter, 658 dosage of, 144 Filters for ultraviolet, 305 effects of poles, 142 Finsen apparatus, 366, 658 upon body, 139 treatment, 367 experimental demonstrations of, 83, 141 Finsen's experiments, 346 Fissure, anal, 573 heating effects of, 141 Fistula in ano, 573 historical, 134 Fixation muscles, 666 interpolar effects of, 140 Flasher sinusoidal generator, 171 interrupted, 164 physical effects of, 139 Fleming tube, 59 physics and apparatus, 134, 160 Flexion, 666 Floor space of physical therapy departphysiological effects of, 141 polarity, 138 ment, 633 relief of pain by, 142 Fluorescence, 325, 658 safety rules in applying, 161 Flux, 658 sinusoidal, 168 Flux-density of mercury lamps, 357
for,
primary, 54 secondary, 54 standard dimensions
Frostbites, 397 Frozen shoulder, 535 Fulguration. See Electrodesiccation.
167
Foot, care
ease,
of,
in peripheral vascular disof,
446
541-543
skin reaction, 141 therapeutic forms, 143

poles, effects of, 142 test in electrodiagnosis, 113
conditions, treatment diathermy of, 238 switches, 77 weak, 541
Four-cell bath, 148 in cardiac conditions, 436
Galvanism, medical, 143, 658 cerebral, 145, 483 clinical effects, 143 dangers in, 160
safety rules in, 161 dosage and length of application, 144 general technique, 143 indications, 143 regional technique, 145 transcerebral, 145, 483 surgical, 149 for dilated blood-vessels, 587 for hemorrhoids, 572 for moles and warts, 156
Fractures, 525
delayed union of, 527 Frauenhofer's lines, 658 Frequency, 658 assignments of diathermy apparatus, 202 Friction, 403, 666 Frictional electricity, 37, 658 Frontal sinus, long-wave diathermy of, 607 short-wave diathermy of, 607 I) Frost injuries. See Cold injuries.
44
682
SUBJECT INDEX
Hairy moles, combined method
150 Hallux valgus, 542
of,
breeze, static, 186 short-wave diathermy of, 229 Heart, diathermy of, 434 massage for electric shock, 297 Heat cramps in hyperthermy, 261 effects of diathermy, 206 lamps, 312 prostration in hyperthermy, 260 radiation, general, clinical use of, 317, 321 local uses, clinical use of, 318 sources for treatment, 311 thermal, 51 Heating cabinets for hyperthermy, 248 thermionic tube types, 57, 664 luminous, 248 Generator, Morse wave, 171 non-luminous, 248 effects of, 316 polysine, 171 thermionic tube types, 171 elements, 312 Genitalia, female, diathermy of, 546 thermostatically controlled, 440 male, diathermy of, 560 Heliotherapy, 337-345, 659 clinical considerations, 339 Genito-urinary conditions, treatment of, 560-569 contraindications, 340 in pulmonary tuberculosis, 450 Gentian-violet solution of Bohlman, 275 in tuberculosis sanatoria, 340 Germicidal lamp, 371 Glare injury, 297 physics of solar radiation, 337 Glass electrodes, 74 technique of, 340 ultraviolet transmitting window glass Glaucoma, 617 343 Glomerulonephritis, 562 Glossary, 654-668 Hemiplegia, 482, 666 Goeckerman's method, 588 Hemo-irradiation, 368 Hemorrhoids, electrosurgery for, 570 Goggles in ultraviolet treatment, 360 medical diathermy for, 570 Golfer's shoulder, 532 Gonococcus, thermal death time of, 253 surgical galvanism for, 572 treatment of, 569 Gonorrhea, treatment by electropyrexia, 254 Hemostasis, 280 Gonorrheal arthritis, 472 Henry, 659 Herpes labialis in hyperthermy, 261 electropyrexia for, 254 Bartholinitis, 557 zoster, 517 intercostal neuralgia following, 517 cervicitis, 553 Hertzian waves, 302, 659 epididymitis, 564 Hexenschuss. See Lumbago. proctitis, 575 High frequency, 659 prostatitis, 560 urethritis, female, 551 High-frequency apparatus, 187-204 combination apparatus, 200 male, 564 Gorsch electrode, 574 physics, 190 requirements for acceptance, 200 Gouty arthritis, 474 Granulation tissue following intranasal spark gap, 197 vacuum tube, 191 operations, 608 basic principles, 190 Grenz rays, 659 circuit, 190 Grid, 60, 658 current, 68, 187 glow device, 659 damped intermittent, graph of, 199 voltage, 659 definition of, 187 supply, 659 Grotthus' law, 306 experimental demonstrations, 205 Ground, 659 history of, 187 current causing shock, 292 knife, 280 oscillations and radio waves, 188 Group stimulation of muscles, 183 principle of production, 190 Gynecological conditions, treatment of, 545-559 undamped, sustained, graph of, 195 meter, 47 oscillations and radio waves, 188 treatment methods, 202 HACKING, 405 Hip bath, 380 diathermy of, 236 Hah-, superfluous, removal by high-freHistamine, 328 quency current, 598 ion transfer, 155, 469 by electrolysis, 592
Galvanism, surgical, for strictures, 566, 573 skin blemishes, 149 for superfluous hair, 592 galvanic acupuncture, 150 Galvano-faradization, 179 Galvanometer, 42, 658 Galvanotaxis, 80 Gamma rays, 658 Ganglipnitis, 516 Gasserian ganglion, 516 Gastric neuroses, 452 Gastro-intestinal conditions, treatment of, 452-457 Geissler tube, 658 General paresis, 484 Generation of electricity, chemical, 51 mechanical, 53
of
removal
Hand, diathermy
of,
235
Hay
fever,
605
Head
SUBJECT INDEX
Histidine, 328
683
of tonsils,
Hypertrophy
609
Holtz-Wimshurst machine, 185 Homogenous, 659 Hood, thermostatic, 440 Hook-up, 659 Hordeolum, 616 Hot applications, effects of, 376 air bath, 382 bath, 380, 466 compress, 377 douche, 549 quartz lamps, 350 soaks, 440 vapor cabinets for hyperthermy, 247 wire meter, 47, 659 Hot-air douche, 466 Hot-cathode tube, 659 Hot-water bath for hyperthermy, 247 House supply of current, 63 Hubbard tank, 386 Hydriatic methods of hyperpyrexia, 247 Hydroelectric bath, 146, 659 Hydrogen atom, 30 Hydrogymnastics, 385, 429 Hydrokinetic measures, 384-387 colonic irrigation, 387 douches, 384 showers, 384 therapeutic pools, 385 whirlpool bath, 384 Hydromassage, 384 Hydrotherapy, 347-387 hydro-thermal measures, 377 physical principles, 374 physiological principles, 375 Hydrothermal measures, 377-384 ablutions, 379 baths, 379 special form of baths, 381 wet compresses, 377 packs, 377 Hypalgesia, 666 Hyperacidity, gastric, 452 Hyperalgesia, 666 Hyperesthesia, 666
Hyperexcitability to electrical stimulation, 121 Hyperpyrexia, 269. See also Hypothermy.
Hypesthesia. 666 Hypoexcitability to electrical stimulation, 121 Hypoplasia of uterus, 551 Hypotension, 437
Hypothermy, 388-399
cold injuries, 394
in peripheral vascular disease, general, 394
445
393 methods, 389

local,
physical and physiological effects, 392 therapeutic considerations, 303 Hysteria, 494 of rectum, 576 post-traumatic, 495 Hysterical aphonia, 493 electrical reactions, 118
ICE-BAG, 389
Immersion foot, 398 Impedance, 49, 659 Impetigo, 583

Inactive electrode.
trode.
See Dispersive elec-
Incandescent fihme it radiators. See Heat lamps. Incontinence of urine, 563 Indifferent electrode. See Dispersive. Individual sensitivity to ultraviolet radiation, 364
stimulation of muscles, 181 Indolent wounds, copper ionization
in,
591
Induced charges, 42 current, 42 Inductance, 56, 659 cable, 73, 208, 223 coil, 659 Induction, 42 coil, 58, 659 electromagnetic, 42
lamps, electrodeless, 356 period in hyperthermy, 257
Inductothermy, 225
Induration, fibrositic, 475
Infantile paralysis, 487-493 tetany, 458 uterus, 557
methods, 247 hydriatic methods, 247 Hypersecretion, gastric, 452 Hypertension, 434 Hyperthermy, 246-263 bactericidal effects, 253 clinical use, 253 complications, 260 contraindications, 255 general technique, 256 methods of inducing, 246 electrical, 247 hydriatic, 247 physiological effects, 251 requirements for full apparatus, 250 Hypertrichosis, danger of removal by roentgen-rays, 591 treatment by electrolysis, 592 by high-frequency current, 283, 598 Hypertrophic arthritis, 462 rhinitis, 605 Hypertrophy of adenoid, 609
by by
electrical
Influence machine, 659 Infrared radiation, 311, 659

artificial sources,
312
classification of, 311 clinical uses, 318 difference in penetration,
315
general effects, 317 long wave, 311 physiological effects of, 316 radiators, 312, 313 short-wave, 311
sources, 312
technique, 321
Inhibition, 666 Injuries, electrical, 287-298 equation of apparatus, 289 of operator, 288 of patient, 289
684
Injuries
SUBJECT INDEX
from lightning, 297
Joint, tuberculosis of, 530 Jones' method of condenser testing, 124 Joule, 660 Joule's laws, 39, 206
mechanical, 293 medicolegal aspects, 293 of joints and muscles, 521

to eyes, 297 Injury current, 100 Insomnia. See Sleeplessness. Institutional practice of physical therapy,
627-638
Insulated needles for electrolysis, 592
Insulation, 659 Insulator, 33, 659 Intensity of electric
KELOID, 583
Kennelly-Heaviside layer, 201 Kenny treatment in infantile paralysis, 488 Keratitis, phlyctenular, 617 Keratosis, 585 arsenical, 585 seborrhoica, 585 senile, 585 Kidney, diathermy of, 232 tuberculosis of, 562 Kilocycle, 660 Kilowatt, 46 hour, 46 Klumpke type of paralysis, 487 Kneading, 403, 667 Knee, diathermy of, 235 sprain of, 523 Knife, electric or high-frequency, 280 Kromayer lamp. See Water-cooled lamp. Kyphosis, 667
field,
659
Intensity-frequency relation, 105

Intercostal neuralgia, 517
Intermittent venous occlusion, 442 Interpolar effects of galvanism, 140 Interrupted current, 660 galvanic current, 164 for muscle stimulation, 179 in nerve injuries, 506 physics, 164 physiological effect, 164 therapeutic use, 165
Interrupter, 660 Intestinal tuberculosis, 456 Inverse square law, 306, 660 Invisible spectrum, 660 Iodine ion transfer, 160 Ionic effects of currents, 78
medication, 151, 660 lonization, 43, 151 Ions, 42, 660

penetration of, 152 Iontophoresis, 151, 660.
fer.
LACHRYMAL
See also Ion trans-
duct, stenosis
of,
616
Lamps, Aero-Kromayer, 353

air-cooled, 353 carbon arc, 347
cold quartz, 353
pelvic, 551 Ion transfer, 78, 139, 151, 160 aconitine, 159
Cooper-Hewitt, 346
efficiency skin test for, 361 electrodeless induction, 356
applications from negative pole, 159 positive pole, 154 calcium, 159, 483 chlorine, 159, 541
clinical uses,
Finsen, 366
heat, 312 hot quartz, 350
153
cocain, 159
Kromayer. See Water-cooled. magnifying, 593 mercury vapor, 350

Reyn, 366
copper, 154, 554, 581 epinephrin, 159 general technique, 153 heavy metals, 154 histamine, 155, 469
iodine, 160
window mercury glow, 355 water-cooled, 346, 353, 665

thin
Leduc's experiments, 151 mecholyl, 156, 469 nupercaine, 159 penetration of ions, 152 physico-chemical considerations, 151 salicylic acid, 160
vasodilating drugs, 155, 469
zinc, 155,
Iritis,
603
tuberculous, 617
Irradiation, 660 Irritability of muscles, 107
Laryngeal tuberculosis, 614 Laryngitis, acute, 613 chronic, 614 Larynx, diseases of, 613 Laspgue's test, 515 Latent time, 667 Law, cosine, 306 Faraday's, 42 Grotthus', 306 inverse square, 306, 660 Joule's, 39, 206 Ohm's, 45, 661 Pfltiger's, 103 Van't Hoff, 212
Ischemic contracture, Volkman's, 532
Leakage current. See Ground Leduc current, 179, 180
current.
JOINT, injuries of, treatment
of, of,
movements, average range stiff, 525
521 416
Leduc's experiments, 151 treatment of causalgia, 177 Leg ulcers, chronic, 590 varicose, 591 Legal responsibility in therapeutic accidents, 293
SUBJECT INDEX
Leukoplakia, 586
685
Leyden
jar, 35,
660
Massage movements, 400 physiological effects, 405

uses
of,
Library, physical therapy, 637 Light, 660 bath, electric, 315 general, 322 rays, penetration of skin, 307 therapy, 299-373, 660 dangers, 364 Lightning, injuries from, 297
408
in arthritic
and rheumatic
conditions,
410,467
cardiovascular conditions, 410, 433 digestive tract disorders, 410, 452 nervous system disorders, 410 obesity, 458 traumatic conditions, 409, 521 Mastoiditis, 602 Matter, structure of, 30
in in in in in
Line spectrum, 303 Lingual tonsil, hypertrophy veins, varicose, 613 Liver, diathermy of, 232 diseases of, 456
of,
612
Maxwell's electromagnetic theory, 300 McCarty-Wappler unit, 567 Measuring devices, electrical, 47 Locomotor ataxia, 484 Meatotomy by cutting current, 566 Mechanical injuries in therapy, 293 Longitudinal application of electrodes, 42 measures in chronic arthritis, 467 Long-wave diathermy, 203, 225 in traumatism, 521 electrodes, 225 general technique, 225 rectifier, 660 infrared, 311 Mechanotherapy, glossary, 665 Lordosis, 667 Mecholyl ion transfer, 156 Low blood-pressure. See Hypotension. in pelvic inflammations, 551 Low frequency, 660 in rheumatoid arthritis, 470 in varicose ulcers, 591 Low-frequency currents, 163-186 apparatus, 169 intranasal, 605 clinical uses of, 176 physiological effects, 157 combination with diathermy, 243 Medical diathermy, 205 effects and uses, 206, 211 dangers of, 192 thermal effects, 206 general considerations, 163 historical, 163 galvanism, 143 physics and physiological effects, 164 Medicolegal aspects of therapeutic accidents, 293 Low-pressure mercury arcs, 354 in corex, 355 Megohm, 660 thin window mercury glow lamp, 355 Menopausal syndrome, 558 Mental conditions, 495 Lubricant, 667 and palmar resistance, 86 Lumbago, 475 Luminous and non-luminous generators, Meralgia paresthetica, 516 choice between, 320 Mercury arcs in corex, 355 heat radiation, 311 glow lamp. See Thin window mercury glow lamp. physiological effects of, 318 Mercury-vapor arc. See Quartz mercuryLungs, long- wave diathermy of, 231 short-wave, 448 vapor arcs, rectifier, 61 Lupus, Finsen treatment of, 367 Metabolic conditions, treatment of, 457 vulgaris, 588 459 Lymphogranuloma inguinale, 573 Metabolism, effects of autocondensation, Lymphoid tissue, infected, 609 215 of ultraviolet on, 332 Metallic conductors, 33 rectifiers, 136 shielding against radio interference, MAGNET, 40 201 Magnetic action of a current, 40 Metals, electromotive series of, 51 circuit, 660 Meter, 660 field, 40, 660 chronaxie, 127 Magnifying lamp for epilation, 593 for alternating current, 47 Mains, 660 for direct current, 47 Main switch, 63 Maintenance period in hyperthermy, 259 high-frequency, 47 hot wire, 47 Malignancies, treatment by electrosurgery, See also Epithelioma. 284. milliampere, 47 thermocouple type, 47 Marie-Strumpell disease, 472 two-scale, 49 Massage, 400^11 volt, 48 Aix-le-Bain, 408 watt, 49, 665 contraindications, 411 Mho, 660 diathermic, 241 Micro, 660 effects of general, 406 Microfarad, 124, 660 on pathological conditions, 407 Micropuncture method of Weve, 619 general technique, 407 Middle ear, diathermy of, 602 in arthritis, 410
686
SUBJECT INDEX
Muscles, normal reactions, 113
Middle ear, diseases of, 601 Milliammeter. See Milliampere meter. Milliampere, 44, 660 meter, 47 defective, 199 in short-wave apparatus, 194 in spark-gap apparatus, 198 role in coagulation, 277 Millimicron, 302, 660 Modality, 660 Modulated alternating current, 169 Moist pad electrodes, 73 'Molecular dipole, 88 Molecule, 30, 661 Moles, removal of, by electrodesiccation, 587.
Muscular atrophies, 667 dystrophies, 667

Myalgia.
See Myositis.
Myasthenic reaction, 122 Myelitis, 486

Myofascitis, 531 of extensor muscles of forearm, 523. also Tennis elbow. Myositis, acute, 531 chronic, 531 Myostatic contraction, 667
irritability,
See
667
Myotonic
reaction, 122
by electrolysis, 587 Molluscum contagiosum, 586 Monochromatic radiation, 326, 661 Monochrometer, 661
Monoplegia, 667 Monoterminal, 661 high-frequency current, 200, 242.
also Oudin treatment. Morse wave current, 169
N
NABOTHIAN
glands, electrodesiccation of,
558 Naevus flammeus, 587 stellar, 587 See Nasal accessory sinuses, 607 diseases of, 604
effect of electrosurgery
on malignant
generator, 171
new growths
of,
607
Morton-Smart apparatus, 173 Morton wave current, 661

Motor,
electric,
53
polyps, 608 turbinates, hypertrophy of, 605 Nausea in hyperthermy, 261
generators, 137, 170, 661
advantages of, 170 points, 108 charts of, 640-653

individual stimulation
unit,
of,
181
667 Mouth, benign and malignant new growths Nephritis, 561 of, 614 Nephrosclerosis, 562 effect of electrosurgery on, 614 Nernst's theory, 102 Nerve block, 104 Movement, 667 Mucous membranes, tolerance to diaimpulses, nature of, 101 injuries, peripheral, 505 thermy, 219 to ultraviolet, 366 Nerves, action currents in, 98 motor points of, 108 Mud packs, 466 normal electrical reaction of, 113 Multiple electrode for electrolysis, 596 sclerosis, 485 regeneration of, 503 Muminification necrosis after electrodesrelative conductivity of, 86 iccation, 265 Neuralgia, 508 Muscle and nerve action glossary, 665 intercostal, 517 of rectum, 576 atrophy of disuse, 178, 667 trifacial, 516 denervated, 174 Neurasthenia, 494 exercise, electric, 173 fibrillation after severance of nerve, 506 post-traumatic, 495 Neuritis, 508-518 grading in infantile paralysis, 490 acute, 509 injury, current in, 100 rest, 667 brachial, 514 chronic, 508 setting, 526' classification, 508 stimulation, electric, 101, 173 choice of current for, 177 facial, 510 for weight reduction, 457 localized, 508 general technique, 180 optic, 618 pathology, 508 therapeutic aspects of, 173 strain, 562 polyneuritis, 508 relief of pain in, 509 tonus, 667 sciatic, 515 Muscles, action currents of, 97 affections of, 531 special forms of, 510 Neurodermatitis, 586 bipolar stimulation of, 182 Neurosis, 491 group stimulation of, 183 cardiac, 437 independent irritability of, 101 individual stimulation, 181 gastric, 452 traumatic, 494 injuries of, 521
Neck, diathermy of, 230 Needles for electrolysis, 592 insulated, 592 non-insulated, 592 Neoplasms, benign, of skin, 581 malignant, of skin, 586
SUBJECT INDEX
Neurosis, vegetative, 494 Neurosyphilis, hyperthermy for, 255
|
687
Outlets for current, 65
Neurovascular disorders, 444 Neutron, 31 Nevi, 586 pigmented, 587 stelkr, 587
Output power
in
short-wave diathermy
generators, 200
PAIN
Newman's method
in urethral strictures.
relief
566 Newton's corpuscular theory, 300 Nodule of fibrositis, 475

Non-conductor, 33, 661
tube. See Condenser tubes. Nose, diseases of, 604 malignant new growths of, effect of electrosurgery on, 607 tuberculosis of, 607 Nupercaine, iontophoresis, 159
in acute neuritis, 509 by positive pole, 142
Painful amputation stumps. See Causalgia. Palmar resistance and mental conditions,
86
Palsy, Bell's, 510
birth, 487 cerebral, 486 Panniculitis, 477
Non-vacuum
Pannus, 619
Papillary growths of bladder, 567 Paraffin bath, 382 Parallel connection, 661 Paralysis, electrical muscle stimulation
in,
OBESITY, 458 Bergonie treatment
for,
459
Obstetrical paralysis, 487 Occupational tenosynovitis, 532
Ocular syphilis, 618 Oertel exercises, 418

Office practice of physical therapy, 621-626 frequency of treatment, 622
174 dangers of application, 183 general technique of, 180 indications for, 176 Erb-Duchenne type, 487 facial, 510 flaccid, 179
functional, electrical reactions in, 118
infantile,
487
type, 487
Klumpke
judging results, 623 office assistants, 626 space, 624 planning physical treatment, 622 selection of apparatus, 624 treatment habit, 623 Ohm, 44, 661 OhnVs law, 45, 661 Ohmic resistance, 56 Omarthritis, 534 Open circuit, 661 Optic neuritis, 618 Oscillating bed, 443 current, 661 Oscillations, electric, 56 Oscillator tube, 60, 205 circuit, 192 Oscillatory circuit, 661 discharge, 35, 56 damped, 198 d' Arson val current, 198 of condenser, 35, 56 undamped, 195 Oscillometric examination, 438 OsciUoscope, 661 Osteo-arthritis, 462 scheme of treatment, 472 Osteomyelitis, chronic, 528 Otitis media, 601 acute non-suppurative, 601 suppurative, 602 chronic catarrhal, 603 suppurative, 602 Otosclerosis, 603 Oudin coil, 200 current, 200, 242, 661 clinical uses, 243 for chilblains, 395 technique of, 242 terminal, 200
obstetrical, 487 of lower motor tract, characteristics of,
118, 501
of
upper motor
tract, characteristics of,
118, 501 peripheral, 501 spastic, 486
Paraplegia, 486, 667

Paresis, general,
484
Paresthesia, 667
Passive exercise, 412 vascular exercise, 443 Path of currents through body, 88 Patient's release in apparatus, 76 Pearl chain formations, 80 Pelvic diathermy, 547
electrode, 547 heating, 547
inflammations, 552 iontophoresis, 551 Penetrating and external heating, relative

effects of, 252 forms of heating, 246 Penetration of ions, 152 of radiation, 306 Penis, diathermy of, 565 Percussion, 405 movements, 667 Periarthritis, infective, 462 Perineuritis, 476 Period of current, 40, 661 Periodicity, 661 Peripheral nerve affections, 501 444 neuroyascular, organic, 445 thermal measures in, 506 vascular disease, 438-446 classification, 438
diagnostic considerations, 438
hypothermy
for,
394
SUBJECT INDEX
Peripheral
vascular
in,
diseases,
physical
Pleurisy,
449
in,
measures
Peristalsis,
439
Pleurodynia, 531
stimulation
by low-frequency Pneumonia, diathermy
449
current, 453 Peritoneal adhesions, 456 tuberculosis, 456

Peritonitis, tuberculous, 577 Peritonsillar abscess, 612
Polar effects of galvanic current, 140 formula in electrodiagnosis, 120

Polarity, 138, 662 and relief of pain, 142 of galvanic current, 138 of static current, 320
Permeability, dielectric, 87
Petrissage, 405, 667 Pfluger's law, 103 Pharyngitis, 608 Pharynx, diseases of, 608
testing for, 138 Polarization current, 97

in skin, 83 of dry cell, 55
Phase displacement, 49 Phasic contraction, 667

Phoresis, 661
Pole changing switch, 662

Poles, effects of galvanic, 142 acute anterior, Poliomyelitis,
physical
Phlyctenular keratitis, 617 Phosphorescence, 306, 661 Photocatalytic reaction, 335 Photochemical radiation, 309
Photoelectric effect, 304
therapy
in,
487^93
measurement, 304
Photoluminescence, 661 Photometer, 304, 661 Photon, 31, 301 Photoophthalmia, 365 Photophysical effects, 306 Photosensitization, 335 Photosynthesis, 661 Photo taxis, 661 Phototherapy, 299
Polyneuritis, 508 Polyps, nasal, 608 of colon, 574 rectal, 574 Poly sine-generator, 171
Pool, therapeutic, 385, 430
Port-wine marks, 587

of electrodes, influence of, on density, 91 Positive pole (anode), 43, 52, 654 rays, 662 Positron, 31 Post-encephalitis, 496 Postoperative adhesions, peritoneal, 456 nasal granulation tissue, 608
Position
Photothermal radiations, 309

Physiatrics, 661 Physiatrist, 661 Physical agents, classification and effects of, 24, 27 effects of electrical currents, 78
pneumonias, diathermy in, 450 weakness of abdominal muscles, 455 Post-traumatic neurosis, 494 Postural exercises of Buerger, 441 tonus, 667 medicine, methods of, 28 Posture, 425 test, 428 therapy, 23, 661 Potato experiment for electrophoresis, 141 apparatus for, 28 basis of, 23 Potential, electric, 44, 662 department, 627 Potentiometer, 662 director, 628 Power, 662 Prenatal irradiation of mothers, 333 equipment, 634 library, 637 Primary cell, 662 location and floor space, 633 Prime mover, 667 records, 635 Proctitis, 575 relation to other departments, 627 Proctological conditions, 569-578 technicians, 630, 661 Progressive currents, 105, 179 in infantile paralysis, 180 place, 27 26 scope of, testing by, 127 Pronation, 667 Physiological effects of diathermy, 211 of electricity, 82 Prone, 667 141 of galvanic current, Proprioceptive impulses, 667 of infrared radiation, 316 reflexes, 667 of low-frequency currents, 164 Prostate, carcinoma of, 567 of luminous radiation, 318 diathermy of, 560 of ultraviolet radiation, 326 Prostatic electrode, 560 obstruction, electrosurgery for, 567 specific, of short-wave diathermy, 216 Pigmentation by infrared, 316 Prostatism, 567 ultraviolet, 329 Prostatitis, 566 Protection against radio interference, 201 Pigmented moles, 587 Protein shock by ultraviolet irradiation, naevi, 587 Pilot light in apparatus, 69 334 Pinna, diseases of, 600 Proton, 31, 662 Pityriasis rosea, 588 Protopathic sensations, 667 Provocation by short-wave diathermy, 216 Plantar, 667 Pruritus ani, 576 warts, 543 Plate, 661 Psoriasis, 588 circuit, 193, 661 Psychological effects of electricity, 82
SUBJECT INDEX
Pulmonary
tuberculosis,
689
of,
449
Pulsating current, 662
Rectum, neuralgia
polypi, 574
stricture, 573
576
Reflection of radiation, 305 Reflex arc, 667

stretch,
667
QUADRIPLEGIA or
tetraplegia,
667
Quantum
of light, 31
theory, 301
Refraction, 662 Refractory period, absolute, 98

relative,
98
Quartz, 662
applicators, 353, 662
burner, 352
662 mercury vapor

glass,
arcs,
350
cold quartz lamps, 353 electrodeless induction lamp, 356
See Hypothermy. Regeneration of nerves, 503 Regenerative circuit, 602 Regulating devices, 47 Relay, 662 Release, patients, 76 Renal colic, 562
Refrigeration.
hot quartz lamps, 350 low-pressure mercury arcs, 354

rods,
353, 354
Quenched spark gap, 662
R
RADIANT energy, 662
classification of, 301 heat application, technique
of,
321
304 penetration through physics of, 299 theory of, 300 Radiation, 662 Radiators, infrared, 312 Radio frequency, 662
measuring
of,
skin, 307,
315
Requirements for fever apparatus, 250 Resinous bath, 382 Resistance, 662 conductive, 56 inductive, 56 of human tissues, 207 of skin, 82 ohmic, 56 specific, of human organs, 87 to different currents, 84 unit of, 44 Resistivity, 662 Resonance, 57, 663 in tube apparatus, 194 in oscillatory discharges, 57 Resonator, 198, 663
Respirators, use in infantile paralysis, 489 Respiratory system, diseases of, 448-452 Rest in chronic arthritis, 467 Restlessness in hyperthermy, 260
interference
knife.
by
electrical apparatus, 201
See Electric knife.
therapist,
662
oscillations,
therapy, 662
waves and high-frequency

188
Radiohumeral bursitis, 523 Rationale, 662 Raynaud's disease, 444

Rays. See Radiation. Reactance, 49, 662 Reaction, myasthenic, 122 myotonic, 122 of degeneration, 1 14 absolute, 116 course of, 116
diagnostic significance
full,
Resuscitation, faradic, 177 Retina, detachment of, 619 Retropharyngeal abscess, 612 Reversible batteries. See Storage batteries.
Reyn lamp, 367

Rheobase, 104, 663 Rheophore, 663 Rheostat, 49, 69 Rheotome, 663
Rheumatic
diseases, classification, fever, 462 type of facial paralysis, 510
462
Rheumatoid arthritis, 462 scheme of treatment, 472

of,
116
115
Rhinitis, acute, chronic, 605
604
limitations of, 121

partial, 115
vasomotor, 605
Rhinophyma, 588
of,
prognostic significance testing for, 120

to cold, 375
119
Reamalgamation
of electrodes, 546 Receptors for heat and cold, 375 Reciprocal innervation, 667 Records of physical therapy, 635 Rectal diathermy, 233, 549 phobia, 576 Rectification, vacuum tube, 60, 136 Rectifier, 662 mercury vapor, 61 metallic, 136 transforming alternating current, 60, 136 SAFETY rules in diathermy, 239 vacuum tube, 54, 136 in electrotherapy, 93 Rectum, cancer, 577
Rickets, ultraviolet rays in, 457 Ripple current, 663 Roentgen-rays, 663 dangers of treatment in hypertrichosis, 591 in dermatology, 579 in pruritus ani, 576 in tuberculous glands, 367 Roentgen-ray tube, 663 Rotary converter, 55 Rotation, 667 Ruhmkorff coil, 663
690
SUBJECT INDEX
Short-wave diathermy, general technique, of ear, 601 of elbow, 235 of foot, 238 of gall-bladder, 232 of hand, 235 of head, 229 of hip, 236 of knee, 236 of lungs, 231 of neck, 230 of region of head, 227 of sciatic nerve, 238 of shoulder, 233 of sinuses of head, 229, 607 of spine, 231 of thigh, 236 of wrist, 235 regulation of dosage, 224 indications for, 215 physics, 190 radio waves and high-frequency
oscillations,
Safety rules in galvanism, 161 in short-wave diathermy, 240 low-frequency currents, 183 special, in short-wave diathermy, 240 Salicylic acid iontophoresis, 160 Sander's bed, 443 Scar tissue, contraction of, around nerves, 508 Scars, hypertrophied, 585 treatment by chlorine ion transfer, 541 Schnee-bath, 148 Schott exercises, 418
Schumann rays, 663 Sciatic nerve, diathermy of, 238

neuritis, 515 Sclerosis, multiple, Scoliosis, 667
485
Scotch douche, 384 Scrofuloderma, 588 Scrotal electrode, 561 Secondary, 663 cell, 663
Sedatives in electropyrexia, 258
Selection of apparatus for institutions, 634
for offices, 624 Selective heating by high-frequency cur-
188
wave length and wave frequency,
189 provocation by, 216 rents, 210 special precautions in, 240 Self-induction, 165, 663 specific effects claimed for, 214 Self-rectification in tubes, 196 indications for, 232 Self-treatment by ultraviolet rays, dangers technique of, 220 thermal effects, 206 of, 365 Seminal vesicles, diathermy of, 561 depth effect, 211 direct contact heating, 207 vesiculitis, 563 electric field heating, 208 Sensibility, electromuscular, 165 of different body areas, 364 Sensitivity electromagnetic field, 208 to ultraviolet radiation, 364 relation of heating to frequency, Sensitization. See Photosensitization. 208 selective heating, 210 Series, 663 wave length, 211 connection, 663 Sexual weakness in neurasthenia, 494 transcerebral, 435 vs. long-wave diathermy, 216 Shaking, 667 Shoulder affections, 534 Shielding from electrical apparatus, 202 Shock, electric, 292, 295 diathermy of, 233 from accidental contact with grounded exercise, 421 object, 292 frozen, 535 from low-frequency current through golfer's, 532 cardiac area, 292 Shower, 384 from transformer breakdown, 292 solarium, 360 protein from radiation, 334, 510 Shunt, 663 therapy, electric, 496 Sigma, 126 apparatus, 496 Silverplating, 43 Sinus, frontal, diathermy of, 607 complications and dangers, 498 Sinuses, short-wave diathermy of, 229, 607 physiologic effects, 497 Sinusitis, acute, 607 therapeutic indications, 498 treatment of, 297 chronic, 608 Short circuit, 38, 63, 663 Sinusoidal current, 168, 663 Short-wave diathermy, 189, 200, 214, 216 effect on paralyzed muscles, 168 apparatus for, 191 generator of Weiss, 171 control of, 196 slow galvanic, 168 radio interference by, 201 surging and interrupted, 169 Sitz bath, 380 general technique, 220 field heating, 222 Skeletal muscles, action currents of, 97 C9il direct contact heating, 223 Skene's glands, electrodesiccation of, 556 electric field heating, 220 Skenitis, 556 Skin blemishes, surgical galvanism in, 149 electrodes, 72, 220 conditions, electrosurgery in, 579 electromagnetic field heating, 222 of abdomen, 231 effect of ultraviolet rays on, 333, 580 of ankle, 238 diseases. See Dermatological conditions, of brain, 227 grafting, preparing for, by ultraviolet, of chest, 232 540
SUBJECT INDEX
Skin, pigmentation resistance of, 82
of,
691
329 85
and pain
changes
Stenosis of cervix, congenital, 557 of lachrymal duct, 616
sensitivity,
in,
86
practical importance of, 84 to different currents, 83, 84 test for lamp efficiency, 361
Skull, penetration of,
Step-down transformer, 55, 664 Step-up transformer, 55, 664 Sterility, 558
Sterilization of air
Stiff joints,
by
ultraviolet,
369
525
by current, 227
Skyshine, 338 Slapping, 405

Sleeplessness, 493 Slip rings, 53 Slow (galvanic) sinusoidal current, 168 Slowly increasing temperature, effect of,
Stimulating compress, 377

Stimulation by direct current, 102 by low-frequency current, 173 Stimulus in water treatment, 375 Stokes-Oertel method of exercise, 437
of, 232 Storage batteries, 53 Strains, 522 Strength-duration curves, 104 measurements, 123 Stretch reflex, 667 Strictures of anus, 574 of rectum, 573 of urethra, dissolution by galvanic current, 566
Stomach, diathermy
Smart-Morton
coil,
168
Snare, electrosurgical, 575 Soap experiment of Clark, 273 Solar radiation. See Heliotherapy. Solarium, 344, 663 shower, 360
Solarization, 344 Solenoid, 663
Stroking, 400 470 movements, 668 Spacers" for short-wave diathermy, 221, Subdeltoid bursitis, 536 Suction-pressure unit, 441 Sunbaths in adults, 342 Spark ball, 663 in babies, 343 discharge, 56 in children, 343 gap, 56, 198, 663 apparatus, 197 Sunlamps for home use, 356 operation of, 199 Sunlight. See Heliotherapy. Sunshine type of carbon, 349 Sparks, static, 186 Spasm, 667 Superfluous hair, removal of, by electrolSpasmophilia, ultraviolet rays in, 458 ysis, 592 Spastic paralysis, 486 by high-frequency current, 598 Specific electrical effects, 80 Superheated air, 550 resistance of human organs, 87 Supination, 668 Supine, 668 Spectrogram, 303 Surface temperature tolerance, 317 Spectrum, 302, 664 banded, 303 Surgical diathermy, 264, 664 galvanism, 149 comparative, of mercury arc and carbon arc lamps, 303 tuberculosis, ultraviolet rays in, 333 Surging faradic current, 167 continuous, 303 Sweat glands, influence on skin resistance, electromagnetic, 300 86 line, 303 of carbon arc, 348 Switches, foot, 77 of quartz mercury arc, 350 Sycosis vulgaris, 588 of visible light, 318 Symbols, electrical, 64 Synapse, 668 Sphincteralgia, 576 Synechiae, nasal, 607 Sphincterismus, 576 Synergists, 668 Spider nevus, 587 Syphilis, electropyrexia for, 254 Spine, diathermy of cervical, 230 dorsal and lumbar region, 231 ocular, 618 Spirochaeta pallida, thermal death point of, 253 Splinting in paralysis, 505 TABLES for treatment, 77 Spondylitis deformans, 473 Tank circuit, 193 Sprains, 522 therapeutic, 385 Spurs, calcaneal, 542 Static apparatus, 184 Tanning the skin by radiation. See Pig-
Spa treatment "
for chronic arthritis,
breeze, 186 brush discharge, 186 charge, 186 electricity, 36, 184, 664 head breeze, 186 induced current, 664 machine, 37, 184, 664 sparks, 186 wave current, 185, 664 Stellar nevus, 587
mentation.
Tapotement, 668 Tapping, 405 Tattoo marks, electrodesiccation for, 579 Technicians, Registry, American Physical Therapy, 632 training of, 632 Telangiectasia, 588 Temperature distribution with long wave, 207
692
SUBJECT INDEX
Trachoma, 615
Transcerebral galvanism, 145, 483 short-wave diathermy, 435 Transfer of ions, 78, 139
of electric charges, 34
Temperature, law of Van't Hoff, 79, 212 recording in electropyrexia, 257 Tendinitis, 535 Tennis elbow, 523 Tenosynovitis, 532 Tension, 664 Tepid baths, 380 Terminals, 69 Terrain exercises, 418 Tesla coil, 198 current, 664 Testing charts, 112, 131, 640 by progressive currents, 127 condenser discharges, 124 electrode, 109 faradic and galvanic, 113 for chronaxie, 125 Testis, in diathermy of, 561 Tetanic contraction on faradic stimulation, 113, 166 Tetany in hyperthermy, 261 infantile, 458 Therapeutic carbons, 349, 664 currents, conduction through body, 78 exercise in traumatic conditions, 521 pools, 385, 430 Thermal, 664 death time of gonococcus, 253 of Spirochaeta pallida, 253 effect of diathermy, 206 electricity, 39, 79 Thermionic emission, 57 rectifier, 664 tube, 57, 664 type generator, 171 Thermocouple, 51 type meter, 47 Thermoelectric battery, 51 effect, 664 Thermolability of gonococcus, 253 Thermopenetration, 188 Thermophile, 51, 664 Thermophore of Corbus and O'Conor, 547 of Shahan, 616 Thermostatically controlled heating, 440 hood, 440 Thermotherapy, 664 Thigh, diathermy of, 236 Thin window mercury glow lamp, 355 Thomsen's disease, electric reaction in, 123 Thoriated filament, 195 Three-electrode vacuum tube, 60 Threshold of excitation or rheobase, 104, 663 Throat compress, 377 Thrombo-angiitis obliterans, 445 Thrombophlebitis, 445 Thrombosis, acute, 446 Thyratrons, 62 Tic douloureux, 516 Tickler, 664 Timer signal, visual, 76 Timing device in apparatus, 69, 76 Tinnitus and deafness, 603 Tonic contraction, 668 Tonsillitis, 609 Tonsils, electrosurgical removal of, 610 hypertrophy and chronic infection of, 610 Tonus, 668 Torticollis, rheumatic, 531 Towel bath, 379
Transformer, 55, 664
breakdown, 292 diagram of, 55 step-down, 55 step-up, 55 turn ratio of, 55 Transpelvic diahermy, 547
Transurethral electrosurgery, 566 Transverse application of electrodes, 92
Traumatic
arthritis,
524
conditions, general pathology of, 519 physical treatment, objects and meth-
ods
of,
519
scheme
of treatment, 520
of,
neurosis, 494 Treatment, general rules tables, 77 timers, 76 Tremor, 668 Trench foot, 397
93
Trichiasis, electrodesiccation for, Trifacial neuralgia, 516
619
Trigger finger, 532 Triode, 60 Trouble-testing outfit, 64 Tube apparatus. See Vacuum tube apparatus.
thoriated, 195 vacuum, 59, 191
Tuberculodermas, 588
Tuberculosis, anorectal, 577
cutis orificialis,
intestinal,
588
456
bones and joints, 530 kidney, 562 larynx, 614 nose, 607 peritoneal, 456 pulmonary, 449
of of of of
sanatoria, heliotherapy in, 340 ultraviolet therapy, 333
Tuberculous arthritis, 530 enteritis, 577 epididymitis, 565 iritis, 617 of bones and joints, 530 peritonitis, 456
tumors, specific biologic effects of shortwave diathermy, 214
Tuned
664 Tungsten filament bulb 356 mercury burners, 351 Tuning, 664
ulcers, 580 circuit,
of
sunlamp type,
device in vacuum tube apparatus, 194 Turbinates, nasal, hypertrophies of, 605 Turn ratio of transformer, 55 Two-electrode vacuum tube, 59 Two-scale reading on meters, 49 Two-tube short-wave circuits, 195
ULCERS, 590
chancroidal, 557
SUBJECT INDEX
Ulcers, chronic, in vascular disease, 441 corneal, 616 of leg, 590
Urethritis, gonorrheal, in male, 564 Urine, incontinence of, 563 Urology, electrosurgery in, 566
693
tuberculous, 580
varicose, 591
Uterus, infantile, 551 Uviol, 665
Ultra short-wave diathermy. See Shortwave diathermy. Ultraviolet lamp of Birch-Hirschfeld, 616
radiation, 325, 665 amount in sunlight, 338 antirachitic effect, 329 bactericidal effects, 330
lamp, 665 Uvula, elongation
of,
612
VACUUM
blood irradiation, 267 carbon arc lamps, 347 classification, 325 clinical uses, 332
constitutional sensitivity to. 364 contraindications of, 334
electrodes, 74 electronic devices, 59 tube, 59, 665
apparatus, 191 controls of, 196

oscillator circuit,
192
dangers, 364
dosage, 361 effects on blood, 331
tubes, 193 patient's circuit, 194
power supply
circuit,
191
on metabolism, 332 in delayed union of fractures, 527 in skin conditions, 333 erythema production, 326 for air sterilization, 369 generation, 325 penetration, 325 physical properties, 325 physiological effects, 326 pigmentation by, 327 quartz mercury vapor arcs, 350 sensitivity to, 364 standards of, 358 transmission through tissues, 326 therapy, artificial, 346 carbon arc, 347 choice of ultraviolet generators, 358 combination of hot quartz and infrared units, 358 dangers of, 364 dosage, 361 Finsen treatment, 366 quartz mercury vapor arc, 350 standards of emission, 359 technique of general irradiation, 360 of local irradiation, 366 transmitting window glass, 343 Undamped current, 665 oscillations, 195 Underwater cutting, 281 exercises, 385, 429 in chronic arthritis, 469 in infantile paralysis, 490 Undulant fever, 474 Unidirectional, 665 Unipolar stimulation of muscles, 181 testing in electrodiagnosis, 114 Unit of capacity, 46 of current, 44 of electromotive force, 45 of erythema, 359 of power, 46 of quantity, 44 of resistance, 44 Urethra, female, diathermy of, 551 male, diathermy of, 566
Urethral stricture, dissolution
two-tube short-wave circuit, 195 rectification, 59 rectifiers, 136 three-electrode, 60 mercury vapor, 61 two-electrode, 59 Vaginal diathermy, 548 Valleix' areas, 508 Valve tube, 59, 665 rectifiers, 54, 136 Van't Hoff's temperature law, 79, 212 Variable condenser, 665 Variocoupler, 665 Variometer, 665 Varicose lingual veins, 613 ulcers, 591 Vascular disease. See Peripheral vascular
disease.
Vasodilating drugs, ion transfer by, 155 Vasomotor collapse in hyperthermy, 261
rhinitis,
605
Vegetative neurosis, 494
Venous
occlusion, intermittent, 442 Verruca acuminata, electrodesiccation of, 566 vulgaris, 589 Vesicles, seminal, diathermy of, 561 Vesiculitis, seminal, 563 Vibration, 668 Vibratory movements, 668 Visceroptosis, 455 Visible radiation, 318 physiological effects of, 318 Visual timer signal, 76 Vital rays, 326 Vitamin D, creation by ultraviolet, 329 Vitreous opacities, 617 Volkman's ischemic contracture, 532, 668 Volt, 45, 665 Voltage amplification ability of transformer, 55 Voltaic pile, 134 Voltmeter, 48, 665 Vomiting in hyperthermy, 261
by galvan-
ism, 566 Urethritis, gonorrheal, in female, 551
WALL
plates, 137 Warts, electrosurgical removal
of,
589
694
Warts,
electrosurgical
SUBJECT INDEX
removal
of,
by Weiss
sinusoidal generator, 171
electrolysis,
589
syphilis,
Wet
electropyrexia
plantar, 543 Wassermann-fast for, 255
compress, 377 packs, 377

full,
partial,
378 378
applications, temperatures of, 375 bath method in galvanism, 145 conductivity of, 34 system and electric current comparison of, 44, 66 Water-cooled quartz mercury vapor arc lamp, 246, 353, 665 Watt, 46, 665 Wattage, 665 Watt-hour, 665 meter, 665 Wave, 665 current generator, Morse, 171 Morton-Smart, 173 static, 185 vacuum tube, 170 length, 189 and wave frequency, 189 difference in erythemal effects, 327 measuring of, 302 train, 665 Waves, electromagnetic, 57, 188, 302 frequency of, 189 Hertzian, 302, 659 Weak foot, 541 Weakness of abdominal wall, postoperative, 455 of muscles following disuse, 176 sexual, in neurasthenia, 494 Weight reduction by electric muscle exercise, 459
Water
physiological effects, 379 Whirlpool bath, 384 Wimshurst machine, 185, 665
Window glass,
electric,
transmitting ultraviolet, 343
Wood's filter, 665 Wounds, 590

295
electrosurgical, healing of, 268 infected, 591 sluggish, copper ionization in, 591 ultraviolet rays in, 591 surfaces, preparing for skin grafting
by
540 Wrist, diathermy of, 235

ultraviolet,
XANTHOMA, 581
X-rays.
See Roentgen-rays.
ZENER'S
electrode,
547
otitis
Zinc ion transfer, 154 in treatment of chronic
media, 603
of corneal ulcers, 616 of hay fever, 606 of nasal accessory sinusitis, 608 of vasomotor rhinitis, 606

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From

the collection of the

San Francisco, California 2006

A MANUAL OF PHYSICAL THERAPY

Fifth Edition, Thoroughly Revised

352 Engravings and a Color Plate

LEA & FEBIGER

LEA & FEBIGER

PREFACE TO THE FIFTH EDITION

the steady expansion

courses, given first under the auspices of the

ELECTROTHERAPY AND LIGHT THERAPY was written

primarily to offer reliable information

story of the progress of ''physical medicine" as part of the practice

of medicine, in the period of the past twenty-five years during

were looked upon by

many of then* medical

were practiced under the watchful eyes of

competent medical men.

competent technicians and a

PREFACE TO THE FIFTH EDITION

expansion of clinical application of physical therapy.

new methods and the The lines of demarcaby general

tion between physical therapy that can be effectively carried on

departments of medicine and by

Medical Association, in renaming in 1944

medicine in the near

future are indeed bright. In the fifth edition of this

work a concise presentation

phases of physical medicine

offered, while special

PREFACE TO THE FIFTH EDITION

chapter on hypothermy has been added, and a revised glossary inserted,

new illustrations The author is deeply

Gorsch (now serving as Colonel

medical friends for their colin the U. S. Army),

publishers were again

GENERATION, CONVERSION AND DISTRIBUTION OF ELECTRICITY

Mechanical Generation and Conversion of Electricity

GENERAL ELECTROTHERAPY AND ELECTRODIAGNOS1S

ELECTROMEDICAL CURRENTS, APPARATUS AND ACCESSORIES

Foot Switches ;...''.' Treatment Tables and Couches

...:..... ............. ...

.... .... .... .... .... ....

Dielectric Conductivity Passage of Currents Through the

Stimulation by Direct Current Electrotonus

Strength-Duration Curves Chronaxie Progressive Currents Intensity-Frequency Relation

103 104 104 104 104 105 105

Newer Methods of Electrodiagnosis Testing by Strength-Duration Measurements Testing by Chronaxie Measurement

THE GALVANIC CURRENT AND ION TRANSFER

Therapeutic Forms Medical Galvanism General Technique

Removal of Superfluous Hair Skin Blemishes

Histamine Mecholyl Cocain Epinephrine

tHe Negative Pole

Salicylic Acid Dangers in Galvanism fety Rules in Galvanism

163 163 164

165 167 168 169 169 170

177 177 179

History Physics Physicophysiological Effects

183 184 184 184 185