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to the Lincoln Hospital.

BNORMAL tension in the heart and blood vessels needs definition. By that we mean an increase or diminution of the normal continuous partial contraction of the muscular coat of the heart and blood vessels. This increase or diminution may be general and uniform or partial and irregular. There may be and often is increase in one part of the cardio-vascular system and diminution in another part. These alterations of tone may or may not be accompanied by symptoms.

The tone of the muscular coat of the blood vessels is measured by the habitual degree of contraction of the vessels. This is in turn inferred by the facts observed by the direct evidence of an examination of the vessels themselves, by symptoms, and from so-called blood pressure measurements.

The tone of the heart muscle is likewise determined by direct examination, by symptoms and by an analysis of the findings of instruments to determine the condition of the activities of the circulatory organs in general.

The process of feeling the pulse is too important a procedure to be discussed in a brief paper, nor can we enter into the subject of auscultation and percussion. The measurement of the quantity known in recent clinical medicine as blood pressure is of much importance. In the laboratory we mean the pressure of blood as measured by connecting the blood current to a pressure gauge. In clinical work we mean the force required to obstruct the pulse wave in the arteries, when applied in the form of elastic pressure.

In recent practice the band compressing the brachial artery has come into general use. The elastic pressure is applied and measured in various ways. For my own use I have devised an instrument consisting of the usual arm band, but I make pressure by fluid falling from a height through a tube from a flexible rubber bag. I measure and apply the pressure at the same time by regulating the height of the bag, and I read the pressure at the level of the brachial artery and the middle of the arm band from numbers placed on the tube. About four inches from the cuff there is inserted in the tube a sphygmoscope of my own design consisting of a floating body and a magnifying lense. By its use diastolic pressure can be measured better than with any other instrument. In the cut it is seen resting on the shoulder of the patient.

Last year I showed the society an instrument

Read before the Medical Society of the State of New York at Albany, N. Y., January 27, 1909.

on this principle in which water was used, but now I am substituting a solution of cadmium. borotungstate. By using this solution that is much heavier than water I can obtain sufficient elevation without the use of a string and pully. I carry this instrument in my pocket, and make a practice of measuring the blood pressure as often as I feel the pulse.

Hypertonicity of the blood vessels and loss of tone of the heart muscle is found in a large number of cases of broken compensation in valvular disease. The same thing is found when toxic substances circulate in the blood, and while damaging the heart muscle at the same time cause a demand for high blood pressure to bring about elimination through the kidneys. Loss of tone in the heart muscle also follows as a terminal result of degeneration of the blood vessels and hypertrophy of the heart.

Let us trace a few typical cases of disordered vascular tone. A patient suffers from vascular disease causing a demand for a large amount of work on the part of the heart. This in turn leads to hypertrophy of the heart, and if everything goes well, the patient has no symptoms. However, if anything interferes with nutrition, or if the heart is strained by any great exertion, there results a loss of tone in the heart muscle leading to dilatation. This leads to a tendency to loss of pessure in the blood vessels, and that in turn to a contraction of the vessels in an attempt on the part of nature to make up a sufficient pressure. So there comes about a condition of loss of tone in the heart and an overtone in the blood vessels.

Next let us consider what happens in a toxic There may exist for a long time a condition of fermentation in the intestines causing absorption into the blood of those substances that are typified by indican. After a time the

heart muscle becomes involved, and perhaps the muscles of the blood vessels also. Then there results a loss of tone in both heart and blood vessels, and we find the patient suffering from dilatation of the heart with a soft systolic murmur, with a low blood pressure reading, and many disagreeable symptoms that go with poor circulation, but later in such a case there may develop degeneration of the blood vessels with a tendency to spasm, and the kidneys are apt to suffer. Indeed, one of the earliest symptoms of such a case is albumen in the urine.

Now, let us trace a case of nervous origin. This occurs in persons carrying a great strain from anxiety and mental overwork. The mental tension results in an exaggeration of the natural tone of the blood vessels. This in turn leads to hypertrophy of the heart, and degeneration of the blood vessels. If any of the causes of loss of tone in the heart muscle exist there may be cardiac dilatation. The ultimate termination of such a case, if the heart escapes, is apoplexy or fatal kidney disease.

It is in correction of these conditions of abnormal tone that the Nauheim-Schott treatment is worthy of study. This treatment consists of a system of baths and resistance exercises. The baths are ordinarily strong solutions of brine with calcium chloride, and other minor ingredients. Less often they contain noticeable quantities of carbolic acid gas, and occasionally they are used as they come directly from the spring, with a large quantity of gas in them. The patient is immersed in this form of bath from 5 to 15 minutes, and is then rubbed dry with hot towels, and is instructed to rest quietly for a time. The whole procedure is very simple, though the effects are striking.

The Schott movements constitute a form of gymnastics in which a series of motions on the part of the patient designed to bring into play all the muscles of the body are gently restored by an operator, so that the tonus of the muscles is voluntarily increased without the existence of anything corresponding to ordinary exercise. The Nauheim-Schott treatment involves a good many other things beside the baths and exercise. It involves diet, rest, out-of-door life, change, travel, and divertion. My own impression is that the exercises are more specific than the baths, though no one element is the essential

one.

The treatment is carried on in Germany with a beautiful elaboration of detail. The baths are built and controlled by the state, and the town of Nauheim is carefully governed in the interests of those who come for treatment. The baths and exercise act, as I believe, through their influence upon the tonicity of the blood vessels. The result is a lowering of a general overtone of the heart and blood vessels, the elevation of the harmful undertone of the heart and blood vessels, or the restoration of the tone to the heart, and the relaxation of the overtone of the

JOURNAL OF MEDICINE

blood vessels when there is a lack of balance between these two parts of the circulatory sys

tem.

In America the principles are successfully applied by many heart specialists, who have grasped the essential principles of the treatment.

During a month spent at Nauheim, through the courtesy of the local profession, I was enabled to study numerous cases, but the time will not permit a description of them in detail. I took my blood-pressure apparatus with me into the baths, and I am ready to affirm that I have seen low tension elevated, high tension relieved, balance restored, as an apparent direct result of the treatment. I have seen the same thing accomplished in America when the essentials of the treatment were carried out.

SCARLATINA.*

By HENRY A. FAIRBAIRN, A.M., M.D. BROOKLYN, N. Y.

W

HEN one is called upon to define scarlatina he encounters great difficulty. This is due to the fact, of course, that, as yet, we have failed to discover the etiological factor and are compelled to rely entirely on the clinical picture. We are well aware now of the errors reliance on clinical pictures led to in the case of typhoid fever and diphtheria before the main characteristics of these diseases had been discovered. The typical clinical pictures of these diseases were diagnostic. We may say the same of scarlatina; but, unfortunately, the variations from this type are numerous and multiform. There is no symptom upon which we can rest a positive diagnosis. This fact has acted as a deterrent to the prosecution of one failing to report the disease, for the very reason that it was impossible positively to define the condition. Neither the abruptness of access, nor the temperature range, nor the rash, nor the desquamation, nor any other manifestation could be produced as differentiating it from certain others of far less serious nature. The phenomena taken as a whole from onset to termination can alone make up the evidence necessary to establish the diagnosis. For surely no one would rest a positive diagnosis upon the eruption alone if he had had opportunity to observe its occurrence with other toxins as its base. This occurrence is not infrequent. Chronic nephritis at times presents a rose rash that for a period cannot be distinguished from scarlatina. Similar manifestations are the accompaniment of septic surgical and puerperal cases and when these hyperemic conditions of the skin persist for a length of time desquamation will occur, or, in other words, it offers no criterion for the pre-existence of scarlatina.

*Read before the Medical Society of the State of New York at Albany, N. Y., January 26, 1909.

June, 1909

Some years since this phenomena of erythema scarlatinaformo, followed by a marked desquamation, appeared in several ward surgical cases in a large hospital during my term of service and caused much annoyance to staff and officers on account of hasty observations by a medical official. The diagnosis of toxic erythema was finally agreed upon and confirmed by subsequent history.

An obstetrician of some distinction, practising in New York city, was threatened with a suit for a large sum on the ground that he had brought scarlatina to his patient during her confinement. The case never came to trial, the plaintiff, no doubt, realizing the difficulty, if not impossibility, of proof. No secondary case occurred. As there were septic symptoms the case was in all probability erythema. I was very much interested, at that time, in aiding the doctor in the preparation of his defense. We were very confident of a victory, as the burden of proof rested upon the plaintiff and we saw that it was a well nigh impossible task. The abandonment of the case was a great relief, however.

We are

We have all read of the benefit certain practitioners have obtained from the use of antidiphtheric serum in cases of scarlatina. disposed to doubt the diagnosis, bearing in mind the not infrequent occurrence in diphtheria of a rash very similar to that of scarlatina. It is all very well to discourse on the uniform erythematous redness of this rash as contrasted with the peculiar punctuated form of that of scarlatina. But the uniform redness of skin, and tonsillar exudate, combined with rapid pulse and high temperature mark the onset of both diseases occasionally. The use of the antidiphtheritic serum in such cases I have seen of marked benefit and although in a number I have been unable to find the Kleb-Loffler bacillus I am confident they were caused by such infection. The effect of the serum was more positively diagnostic than any other phenomenon presented.

That scarlatina, in its irregular forms, is difficult and at times impossible to diagnose, the clinician will acknowledge. It may begin with entire absence of symptoms of invasion such as temperature and gastric disturbance. We may find but slight redness of pharynx and fauces and tongue. The typical rash is a pin point eruption with a scarlet flush appearing within twenty-four hours; but it may resemble ordinary erythema or blush due to fever, or may be macular and of most any or no color at all. It may be delayed until the eighth or eleventh day and instead of generally and rapidly diffusing over the whole body it may occur in patches and require two or three days to cover the surface. Again, there are cases where there is no rash discoverable. view of these facts one must admit that there is no disease of wider variation in every symptom and must recognize the necessity for long-continued and careful observation in cases of illness

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of the mildest form, especially when occurring in the young. In this way alone is it possible to successfully care for the painful and dangerous sequela which follow in the train of this and other diseases.

Etiological Factors-The search thus far for the specific cause of scarlatina has been as futile and unproductive as the investigation, along similar lines, in other well marked diseases. But the demonstration that the streptococcus pyogenes and the staphyococcus aureus or other pus producers are active agents in the train of this unknown scarlatinal virus has been of much service.

Complications-These cocci are the agents which produce many of the complications by infecting the tonsil, fauces, nasopharynx and structures of the eye and ear, and their treatment is on the same principle applied to similar affections under other conditions. The discharges are all carriers of contagion and call for strict antiseptic precautions. There is nothing peculiarly characteristic to be found in scarlatinal nephritis according to Councilman. It is due to the toxins of the virus. The same condition is found where Its treatment deother toxins are operative. pends upon rest and excretion of the toxins. It is remarkable that severe suppurative conditions can arise during the convalescence from this disease without any rise in temperature. In such cases the differential leucocyte count is of inestimable value. It should be employed as a routine measure.

If

Important Factors in Treatment-The care of the skin presents itself as the first and most manifest indication. Various antiseptic ointments have been recommended. But the amount of the antiseptic one is compelled to use when the whole surface of the body is covered becomes an important consideration. I have seen serious trouble result from absorption and therefore have long since confined myself to the use of plain vaselin properly sterilized by heat. This relieves the dermatitis, confines the scales and secondarily alleviates the general condition. washed off by fomaldic soap the process of disinfection can be applied without fear of absorption. This treatment certainly limits the contagion, as I saw well illustrated in a country town on the Hudson. There prevailed there an epidemic of scarlet fever which refused to be blotted out. The health officer applied to me for suggestions as I was visiting in the district. Upon examination I found that the treatment of the skin had been neglected and the measure was adpoted by my advice. The disease was promptly eradicated. Milk diet with cereals has commended itself to the practitioner in this disease for two reasons. It is diuretic, easy to digest and from its fatty nature and sugar is well adapted to keep up the strength and at the same. time it contains little sodium chloride. It is not rich in extractives and in potassium salts. By its