Pellagra.-Pellagra has been carefully investigated by various commissions and although some students of this disease believe that there may be an infection present, it is probably incidental, as it seems proved that this disease is due to privation of proteins, and apparently of the vitamines contained in meat. Goldberger and Wheeler1 have clinically demonstrated that pellagra can be caused by restrictions in diet.

Xerophthalmia.-This peculiar eye disease of infants is apparently due to vitamine deficiency, and probably rarely occurs except in real food privation. The inflammation of the eyes may be due to a dry condition of the conjunctivæ, and hence a lack of resistance to germs. The disease is due to a deficiency in fat-soluble vitamines, and therefore especially occurs in long abstinence from these vitamines and from fats.

1 Archives of Internal Medicine, May, 1920, p. 451.

PART VIII

GENERAL PHYSICAL MEASURES

HYPEREMIC TREATMENT

Local hyperemia, mostly discussed under the name of Bier's hyperemic treatment of disease, is produced by three methods: (1) by any means that obstructs the flow of the venous circulation by constriction above the affected part; (2) by dry cupping; and (3) by hot air.

The object of hyperemia is to increase the quantity of blood, hence leucocytes and any antibodies, in the part affected. When constriction is applied above the affected part (not touching the inflamed area) it should not stop the circulation of the blood, it should only slow the venous return; the arterial pulse must always be readily felt below the point of constriction. The venous congestion should not cause pain, but should rather abolish pain, and the part below the constriction should not be pale, and yet not darker than a deep crimson; also the part must be warm and not cold. If the venous congestion lasts for some hours, edema below the point of constriction may

occur.

Though it is a frequent and apparently sometimes successful treatment to apply an ice bag directly to a beginning inflammation, if the part may be readily reached, theoretically this is not what an infected area biologically requires. Protective leucocytes quickly surround an infected region to seal and isolate the infection from the rest of the body. Therefore, in such a condition, theoretically, the hyperemic method is the better, and an abortion of the inflammation caused by the infection means a successful fight of the blood corpuscles and blood serum against the germs or virus. On the other hand, applications of ice or cold are of value when there is an injury or bruise of a part without a lesion of the skin, and hence without bacterial contamination, as such treatment tends to

prevent hemorrhage and excessive exudate and swelling, and therefore the later repair will be more rapid.

There are various kinds of elastic bandages, etc., that may be used to produce constriction hyperemia in different parts of the body. The length of time the constricting band should remain applied, and its intermittency, must be decided by the physician or surgeon, as it depends entirely upon the condition for which the constriction is used and the results caused. If the part below the constriction is not painful at first but becomes painful later, the constriction should be removed, and the bandage re-applied less firmly.

Dry Cupping. The second method of producing local hyperemia is by cupping. The cup is applied firmly to the skin and the air is exhausted from it by means of a suction syringe or pump, which causes a negative pressure and consequently hyperemia of the part encircled by the cup. Not only the skin, but the parts beneath the skin are sucked up into the cup, if the negative pressure is sufficient, but the suction should not be strong enough to cause pain, or sufficient for the rim of the cup to shut off the circulation; the color of the part within the cup should be crimson and not white.

The length of time a cup should remain on the part depends upon the pressure exerted. If the pressure is not great, the cup may be allowed to gradually fill with air, as it will, and fall off of itself; but if the hyperemia caused is intense, it should be relieved by removing the cup within a few minutes. Bleeding or much bruising of the tissues should not be caused. Various shapes of cups for all parts of the body may be obtained.

Hyperemia by Means of Hot Air.-Hyperemia produced by hot air differs from the venous congestion caused by other methods. By hot air, or dry heat, the arterial circulation is increased by dilatation of the arterioles. It will be readily understood that increased arterial circulation tends to remove exudates and extravasations due to chronic inflammations, therefore this method of treatment is more applicable to chronic than to acute conditions.

There are various methods of applying heat to the body: moist heat by hot baths, or locally by hot fomentations or poul

tices; dry heat by electric light baths, body baking or sun baths; and localized dry heat by electric lamps, by diathermy, by local baking, by bran bags, sand bags, etc. Another method of applying heat to a part is by a hot air douche, as it is termed, in which a long tube or pipe directs hot air (best from an electric heater) to the part affected. Frequently beneficial is the application of a hot iron over a part protected by one layer of a dampened bath towel. The whole back may be thus treated. Whatever the heat apparatus used, it is often of advantage to have gentle massage follow it. These hot air treatments vary in duration depending entirely upon the part of the body treated and the method used. Sweating and blistering should be prevented by Turkish towels, if the heat is intense enough to cause the possibility of blistering. If the feet and hands are subjected to heat that may cause blistering the fingers and toes should be bound separately with flannel.

Various hot air apparatus for the treatment of local diseases of the skin and diseases of the ear, eye, throat and genitourinary organs can be obtained.

HELIOTHERAPY

All of the ancients recognized the value of the sun in curing and preventing disease, and many of them worshiped the sun. Though Finsen urged the value of sun baths in 1902, it is only recently that the medical profession has taken real scientific interest in the beneficial effect of sun rays in diseased condi- . tions. Even at the present time only a very few surgeons and physicians throughout the world have made a study of what the different rays of the sun can do physiologically and therapeutically to the human body.

This is not the place to more than briefly refer to the physics of the various parts of the solar spectrum. It may be stated that the distance of the sun from the earth is 90 million eight hundred thousand miles, and that the light and heat rays travel at the rate of 186,500 miles per second, which means that it takes a little more than eight minutes for the sun rays to reach the earth. The rays from the sun which the eye distinguishes is the solar spectrum, consisting, it will be remembered.

of red, orange, yellow, green, blue, indigo, and violet; but there are rays both above and below this spectrum which the eye cannot recognize. At the red end are the infra red or heat rays, and at the violet end are the ultra violet rays. Below the infra red are the so-called Hertz waves and N-rays, and beyond the ultra violet are waves which correspond to the roentgen rays. The Hertz waves are short waves of high frequency and identical with the electric waves used in wireless telegraphy. The ultra violet rays have been termed chemical rays, and it is these rays that form ozone and kill bacteria. The Finsen lamp has iron electrodes which increase the ultra violet rays, and this lamp has been used in the treatment of some skin diseases. The ultra violet rays may cause quite intense skin reactions. For advantageous action of the sun's rays on the body there should, ordinarily, be no intercepting clothing, and the air through which the rays come must be clean, not dust-laden. The rays that cause pigmentation, bronzing, or tanning of the skin are more active in the higher altitudes than in the lower altitudes, and the more pigment the skin contains, the more the rays are absorbed and the more beneficial is their action. As the reaction of the body is both physical and chemical, the action of the rays on the whole body is greater than when a certain part only is exposed. When any clothing is interposed between the body and the rays, it is the ultra violet, perhaps the most beneficial rays, that have their action inhibited.

In beginning the sun bath exposures, the patient should first have part of the body exposed for a few minutes, perhaps the legs; the next day a larger part of the body, and so on until at the end of four or five days the whole body may be exposed. The head should always be protected.

Undoubtedly the direct rays have their greatest therapeutic effect in solariums especially built for these treatments. However, such exposures are sometimes impossible, and patients may then be concealed and receive reflected sunlight from mirrors. When the sun's rays are reflected from mirrors, the heat rays must be cut off. This may be done by covering the mirrors with blue glass. These reflected treatments are for the exposure