Imagens das páginas

am increased amount of urea is decidedly excreted by the kidneys, such increase cannot now be held to be per se evidence of increased tissue change, as it has by some been considered to be; for it may result, 1st, merely from increased elimination, with or without previous retention; 2nd, from immediate formation of urea from food (for the vital question of the "luxus consumption" of Bidder and Schmidt is by no means settled,* and the possibility of this origin of urea cannot be disregarded); 3rd, from vicarious action when the skin is inactive, for if the late observations of Picard and Funke be correct, and if some quantity of urea is daily excreted by the healthy skin, we cannot reject the possibility of the skin and kidneys acting vicariously as regards urea, as they undoubtedly do as regards water and chloride of sodium; 4th, from increased tissue metamorphosis; 5th, from perverted metamorphosis, for it appears probable that a portion of the albuminous food and tissues normally runs through a series of metamorphoses which end in eliminating its nitrogen as ammonia, and this portion may conceivably vary in amount. It is obvious, therefore, that in many cases the cause of an increased excretion of urea will be determined with great difficulty, and conclusions must be drawn with the utmost caution, f

The difficulties with other excreta are scarcely less formidable, and in fact it may be said that absolutely certain results will not be arrived at until all the products passing off from all channels (skin, kidneys, lungs, and bowels) can be quantitatively determined during the same period. At present this perfection of analyst has not been attained, though we appear certainly to be approaching it.

We have made these few remarks before proceeding to bring before our readers some of the late inquiries conducted on the plan now referred to. Did we not believe that these inquiries are really of great value, in spite of the egroi& and inconsistencies which are obvious in them, we should not think of wMflesting the serious attention of our readers. But-we do believe that as jasitroscopic research has been the character of the last, fifteen years, and as molecular chemistry arid moleoular physics (if we may .use" the term) will be the great object of the next generation of physicians, so an era of chemical inquiries is commencing for \is, which, like the microscope, must contribute its share towards the formation of the exacter science which it is not too much to hope is dawning upon us.

On the present occasion we have selected for our subject the influence of BATHS, and we proceed to analyse the chief papers which during the last three or four years have been published on this head.

The writer who has contributed most largely to this subject is Dr. Julius Lehmann (a namesake of the great physiological chemist), an observer wfiose name we have had to quote several times in this journal in connexion with inquiries of a like kind. Dr. J. Lehmann is evidently not only an industrious but an accurate man, and we believe we may safely accept the record of his experiments as conscientious and true.

1. Hip Baths.—Lehmann's earliest experiments were with Cold Hip (site) Baths,] and were conducted as follows. During six fasting hours on eight days, the exact loss of weight of the body (caused by the constant elimination without fresh supply of food), and the exact amount of urine and faeces, were determined. The weight of the urine and fa>ces deducted from the total loss of weight of the body at the end of the period of experiment, gave of course the loss by "insensible perspiration."J During eight other days, one or two cold sitz baths (fifteen minutes) were taken during the six hours; the loss of body-weight, the amount of urine, , feces, and insensible perspiration, were again determined. The two series were then compared. We give the mean results:

• Tbe arguments of F. Fiihrer and H. I.ndwlg rDJc Quellen de» Harnstoffs, Archiv fur pbys. Hellk., 18SB, p. 491,) iof m to us very strong against the view of Blschoff and Liebig, even If they do not prove the writer's own view of tbe part played by the red corpuscles.

t Archiv des Verieus fur wiseenschaftl. Hellk., Band L p. 521. The water in the siti-hath covers the upper parts of the thighs and the body to just above the pelvis.

% The "insensible perspiration " Is a term usually employed to de note tho quantity of all the products pas-ng off by the skin and lungs.

The mean loss of weight in each six hours was,

Without baths 463-5 grammes (16i ozs. av.)

With 748 „ (26* „ )

The loss produced by the fasting alone was thus made up—

By urine 271-91 grammes.

By insensible perspiration .... 175-96 „
By faeces 15-63 „

Total 463-50 „

The loss produced by combined fasting and baths was—

By urine 463-1 grammes

By insensible perspiration 245-4 „

By feces 40 3 ,,

Total 748-8 „

The increase in the urine was owing partly to increased flow of water (£), partly to augmented discharge of solids. The increase in the solids was owing to urea in great measure (j), and then to chloride of sodium; the sulphuric acid was unaltered; the phosphoric acid rather lessened; the uric acid way only altered in so narrow a limit as to be within the range of error of observation.

Such, then, are the mean results; now, what are they worth? s-W(5 admit at once that the experiments were exact, and that really this increase did occur. But was it owing to the batlts, or to some one or more of the other influences External temperature, movement, nervous action, ,fcc.), which are constantly acting on the metamorphosis of tissue? f-^ .

The first objection, and, to our minds, a fatal one, is the circumstance that the experiments were not made on successive days, but were scattered over an interval of nearly four months, some experiments being conducted in J uly, others in August, September, October, and November. Nothing can be more fallacious than such a method, as the amount of urine is subject to great and even periodical changes,* and by selecting a day here and there, we may chance to hit on one of the greatest deviations from the mean. Secondly, the number of days (eight) is not sufficient to allow a true mean to be drawn. On this point opinions have lately undergone some development, and it is now generally considered that observations must be carried on for many days (twenty or thirty at the least) before a sufficiently correct mean is arrived at, unless in cases in which, as in disease, deviations so enormous as to preclude the idea of error, occur from the mean. Thirdly, on subjecting some of Lehmann's daily observations (from which the mean is drawn)s to an analysis similar to that recommended by Radiche, we find the possible errors to be so great, as to render any decided deductions hazardous.! The utmost that

• A certain periodical or wave-like increase and decrease in the urinary exoretion was affirmed by tho writer of this Review, in the Gulstonian lectures for 1855. Radiche from bis calculations, and Vierordt from independent observation, have lately stated the same feet. If an experimenter on the urine happens to take a day at the ebb, or at the full flow of the wave, how different would be the result from the real avornge amount .

t We have, in fact, only calculated the possible errors in one in-redient, viz., the water of the urine, as we thought it unnecessary to take further trouble. We may briefly sketch the result:

The measured quantity of urine on each of the non-bathing days amounted during the six hours in cubic centimetres to 201-85, 474-8, 226-8, 864,194, 282 6, 290-85. 841 5. The successive means (obtained by taking the means first of the two first days, then of the three first, of the four first, and so on) aro 288t)75, 284 816. 266, 787, 25219, 257-26, 262-06. 271-98. The probable mean (mean .,f six last successive means), may be taken as 262 (10 o. c. under the mean given by Lehmann). -Tho mean variations from this quantity may be taken as 60 c . c .

The measured quantity of urine on each of the bath days was. during the six honrs, 884 4, 674, 280.200, 601, 864, 5S842, 66S-2; the successive means are, 504 2, 4271, 8721, 417 7, 408-9,488 8,4681. The probable mean may be taken •s 481; the mean variation as 180. *

The difference between 262 and 431\ the received, means of the two series, is very considerable, viz., 169 c. c . in favour of the bath days, and does at first . sight appear to justify Lehmannss conclusion, but . owing to the great Inequality of the quantities on different days, the range of error is so enormous (the variation being 60 +180 =240) as to render a certain ooncluslon quite impossible. *

can be said is, that there is a probability (the extent of which is scarcely worth numerical expression) of the effect of the cold sitz bath being really that assigned to it. If, indeed, other observations conducted on a larger scale should accord with these, it would give them more weight.

We will, then, pass on to further observations. Dr. J. Lehmann's second inquiry was into the effect of warm sitz-baths.* The experiments were made in a somewhat different manner. The amount of urine was determined every hour. As long as no food and no great exercise were taken, when nothing, in fact, disturbed the normal metamorphosis, the flow of urine was so stable, that Lehmann found the amount of any two hours multiplied by three, gave always very closely the amount for six hours. If now during such a stable excretion a fresh agent" is employed, and if any great change, either in the urine or other excretions, occurs, it is; but right to refer it to the action of the agent; and if in experiment after expesriment the same result is found to occur, the cogency of proof becomes at last very great.

Conducted in this manner, Lehmann's experiments led him to the following conclusions: The waste of the body was increased by 15 minutes' sitz-bath of temperatures of 15° R. (65°-75 Fahr.), and of 25°—31° Reaumur (88° to 99°s5 Fahr.) and this waste was produced by an increased excretion of urinary water and of solids (urea, uric acid, fire-proof salts, and chlorine) .f But the surprising fact was discovered that baths of a medium, temperature (17°—25° R., 70°—88° Fahr.) did not have this effect. Excretion, therefore, according to Lehmann, is increased by sitz-baths below 70° Fahr., by sitz-baths above 88° Fahr., but not by baths between 70* and 88.°

We have already seen reason to call in question the experiments supposed to prove the first opinion, and the singular difference of effect attributed to lukewarm and hot baths, makes us very suspicious of this inquiry also. On going over the items of the experiments, however, we do not observe any obvious fallacy: six hours on five days were occupied with the hot-bath experiments; the excretion of the two first hours being taken as the standard : in all the cases the urinary flow was greatly and immediately augmented, rising from 30 or 50 c. c. per hour to 90, 100, or even 150 c. c. Nor for this great increase does there appear to have been any other cause than the baths. Yet it must be said that the experiments are not sufficiently numerous, and on this ground it is advisable to defer our judgment, and to consider the supposed eliminative effect of the hot baths as very probable, but as not proved.J

Leaving, then, the question of cold and hot hip-baths, we will inquire what observations have lately been made on the effects of

2. General Warm Baths of simple water.—The indefatigable Dr. L. Lehmann s again the person who has most carefully investigated this point.§ A great num

* Uebcr die Wirksamkelt 16—90 5 Beaumur warmer Sitz BMer. Archly dcs Verelna far wtsa. Heilk. Band II. p. 1.

t Lehmann states (p. 19) that the Insensible perspiration (skin and lunps) is also Increased, bat this does not appear from the table given at p. 10; the mean amount of insensible perspiration Is even a little less with baths of f5--80° fill, than withont baths.

X In this paper Lebmann records some careful experiments on the much debated question whether water Is absorbed by the skln; and to show the discrepancies of experiment and opinion even on this comparatively simple point, we may be permitted to quote his and other late experiments. In order,.to avoid all the nsual fallacies, Lebmann prepared two baths containing an equal quantity of weighed water; one of these only was used; the body was wiped with a weighed cloth, which was a-ain weighed immediately; then the two baths were weighed, the loss of weight of the unused bath -iving the amount of water lost by evaporation. Lehmann found that the absorption of water was extremely small; there was a mean loss of water from the bath of only 7-5 grammes (116 -rains) out of 50! bs. of water, a quantity equivalent only to one three thousand three hundred and thirty-third of the entire bulk.

The late experiments of Poulet (L'Unlon Med, 1866, No. 83, and Schmidtss Jahrb. IsM), Sept, p. S78) accord with those of Lehmann. No water seemed to be absorbed through the skin, although both cuticle and hair arc hydroscopic, and tako up some water. On the other hand, Durian (Archives Gen. de Med.s Fev. 1858, p. 156), wh" distin-uishes carefully between tho hygroscopic swelling of the Inte-uments and the actual absorption of water, bellc-ves that water may be absorbed by the skin under certain circumstances. There Is a point, he thinks (different in different men), when elimination from, and absorption by, the skin exactly balance each other; In all warm baths, elimination by the skin surpasses absorption; In cold, the reverse Is the case. Vlerordt, again (Phys. fllitthlelungen, Arohlv fur phys. Heilk.. 1856, p. 575), believes that some experiments undertaken under his direction by Etchberg prove the absorption. To avoid fallacies, an arm-bath of distilled water only was used; the water and the towel used for drying the arm were weighed before and after the experiment, and every precaution was taken to prevent evaporation. Absorption from hot baths was held to be decidedly proved, and the amount for the whole body was c^oas lated at 200 grammes (6>i fld. oxs.) per hour. At low temperatures the absorption was much less, Indeed trifling. These experiments will show what extraordinary diversities of opinion still exist on this point.

I Die Soolthorme in Bad Oeynhausen (Eehme) und das gewohnllche Waseer. Von Dr. L. Lehmann. Guttingon,

ber of experiments have been made, and the results of the last series have been calculated according to mathematical rules. We will quote only the last series of experiments,* which consisted of observations on ten days without, and on ten with, baths; all precautions were taken, as in the former experiments; fasting hours were chosen for the bath; the whole ingesta and egesta of twenty-four hours were measured, and the conditions of the external temperature and barometric pressure were noted.

The general results of the experiments were—the water of the urine was increased by the general warm bath to a very great extent (89° Fahr.; time of bath, half an hour) for the, time—but the amount for twenty-four hours was not increased, so that the diuresis caused by the bath must have been compensated by lessened excretion afterwards. The figures proving this conclusion, seem to be satisfactory, if experiments for twenty days are to be considered sufficient, and after carefully considering them, we believe that Lehmann may be considered to have made out this point. The amount of temporary increase was very great, so that if the normal hourly excretion be taken as 1, after the bath it became as 3-9.

Some experiments by Nassef entirely agree with the above, though they are not so free from possible error. The augmentation of the urine was for a time increased even fourfold. Poulet also found the water increased.J

The effect on the solids of the urine cannot be held to be yet determined; for although many experiments were made by Lehmann, the results of which are tolerably accordant, yet in so difficult a point much more evidence is required. Lehmann, indeed, at one time believed he had proved a decided increase in the elimination of nitrogen (as urea); but in his last paper, in speaking of urea, he qualifies this, and says that " these experiments are not yet sufficiently numerous to affirm with certainty that the urea is increased after customary baths, but such an increase is probable."§ The change in the other constituents is not more certain, and in fact it is not safe at present to come to any conclusion as to the urinary solids more definite than that given above by Lehmann.

The acid reaction of the urine is said by Homolle|| to be diminished after all bnt very hot baths, and other observers have noted the same thing. It is very desirable that a repetition of experiments should decide this point, as it is not possible to determine the effect on the acidity of the urine of medicinal baths until that of simple water is known.

The condition of the insensible perspiration must of course be considered undecided, but it is probably increased.

Whatever may be the immediate effect of the bath in increasing the loss of bodyweight during fasting, from increased discharge of urinary water, and perhaps of solids, and from increased cutaneous transpiration, it does not cause the body to lose weight in a cycle of twenty-four hours. When on a regulated weighed diet, Lehmann lost during ten days 1235 grammes (43£ ozs. av.); with warm baths he lost during an equal time, and with the equal diet, only 805 grammes (28£ ozs. &v.)%

General Cold Bat/is, as far as is at present known, have the same effect as warm baths—i. e., they temporarily increase the flow of urinary water, and perhaps the excretion of solids ;** they are said, however, to differ from cold sitz-baths in lessening instead of increasing the " insensible perspiration" (skin and lung excretions). The evidence on this point is, however, decidedly incomplete.**

• Archlv des Vereins far Wibs. Hellk. 1858, Band iv. p. 18. For some obiecUons to Lehmann, and his reply sea Deutsche Klinik, 1857, Nos. 10,11, 22, 24, 25.

t Elnlsre Beobachtungen uber die Wirkung warmer Bader auf die Harnabsonderung von II. Nasso; Archlv dea Vereins fur wiss. Heilk., Band 1i. p. 265.

t Falck did not, however, find the same effect, bnt as his experiments are unknown to us, and as, Indeed, we believe the details have not been published, we shall not place them In opposition to Lehmann*s strong testimony.

I Archiv des Vereins, Band lv. p. 80.

I I/Union Med., 1858, p. I77.

^ Archlv des Vereins, Band iv. p. 85.

** Lehmann In his earlier work (Bad Oeynhausen, p. 29), fonnd the urea, uric acid, sulphuric acid, phosphoric acid, chlorine, and the alkalies all Increased by the general cold bath; the extractives and pigment were lessened. There was increased loss nf body-weight from the ut,e of the bath. Further experiments, however, are wanted before these statements can be accepted as basis for reasoning.

t In this stage of the Inquiry we do not think It worth while to discuss the modus operandi of baths; Lehmann,

3. Natural Saline BatJis.—The effect of natural saline baths has been investigated by Neubauer* and by Lehmann. Neubauer's experiments were made with the warm saline baths of Wiesbaden,f and were conducted on himself and on Dr. Genth. The results of the experiments on the two persons differed greatly. In Neubauer's own case the bath tor half an hour increased the water, the urea, the uric acid, and the free acidity; and in a much less degree the sulphuric and phosphoric acids, the lime, magnesia, and ammoniacal compounds in twenty-four hours.f When in addition to the bath the saline water was drunk (500 c. c., equal to 17 fl. ozs. nearly), the excretion of the solids wassstill more increased.§ The effect, therefore, of the Wiesbaden baths was, in Neubauer's case, apparently a highly eliminative one, if the experiments can be trusted. We shall not enter into a critical examination of them, but content ourselves with the statement, that they appear to us to be too few in number to warrant us in at once receiving them. We are the more confirmed in this, because the experiments on Dr- Genth were not accordant, with those on Neubauer himself. The bathing, in Genth's case, lessened, instead of increasing the urea and the sulphuric acid, and augmented only very slightly and inconsiderably the water, the uric acid, the phosphoric acid, and the ammonia. Drinking the water with the baths increased of course the water of the urine; but the urea and the sulphuric acid remained still below their healthy amount, though their amount was greater than with the baths alone ; the uric acid, which was slightly increased by the baths alone, was actually lessened when the water was also drunk.

It is therefore evident that the apparently disintegrating or simply eliminative effect of the baths, as shown by the experiments on Neubauer himself, were either attributable to other causes, or that an individual peculiarity of constitution in Genth prevented these effects from being manifested in him. It may certainly be admitted that the resistance (so to speak) offered by the system to the action of remedies is very different in different persons, and that in some, chemical stability is greater than in others, so that remedies produce less chemical action and of course a less marked effect. We should be sorry to admit, however, without cogent evidence, that this has any very great influence; were it so, it would be almost hopeless to attempt the elucidation of the chemical action of agents on the body.

The action of the Sooltherme (chloride of sodium chiefly) of Oeynhausen has been examined by Julius Lehmann ;|| the result accords rather with the experiments on Genth than Avith those of Neubauer. When a single bath was taken, the urinary water and solids were increased, but in a much less degree than by simple water; and when the baths were continued for nine days regularly, the elimination was found to be actually lessened by the bath. During the non-bathing period the daily amount of ingesta was 2038 grammes (70£ ozs. av.), of egesta 2147 grammes (76 ozs. av.); during the bathing period the mean daily ingesta were 2079 grammes (73 ozs. av.), of egesta 2072 grammes (73 ozs. av.) Thus, from some unexplained cause, there was during the non-bathing period a daily loss of weight arising from an excess of excretion over ingesta, which excess was arrested by the bath, and this arrest was found to be owing to very considerable lessening in the

In hie first paper, attributed the (presumed) eliminative effects of cold sltx-baths to the abstraction of heat, which caused an increased activity of the chemical processes as compensation. But when he found a similar effect produced by hot sitz-baths, he was obliged to give np this hypothesis, and fell back on a oommonly received opinion, that the effect is produced by ** irritation" of the cutaneous nerves. Nor do we think It necessary to discuss at present whether the increaso of urea is owing to augmented metamorphosis,or merely to au-mented diminution. Further proof must first he given of the fact. * Archiv des Verelns fur wiss. Hellk., Band iii. p. 39.

t These are chiefly chloride of sodium baths (6-S3565 parts in 1000 parts), but the water also contains a little chloride of potassium, chloride of lithium, of ammonium, of calcium, of magnesium ; a little bromide of magnesium, and traces of iodide; they contain also carbonates of lime, magnesia, baryta, strontia, Iron, and man-anese, dissolved by carbonic acid; there Is also some free carbonlo aoid, and a little nitrogen. t The exact mean Increase in twenty-four hours was—

Water tt* c. c .

Solids 10-99S -rammes.

Urea •s670

{ The Internal use of the water, with coincident exercise, Increased in Neubauer the excretion of tho skin and lun-s considerably.

I Die Sooltherme zu Bad Oeynhausen (Rehine) nnd das gewobnllcbo Wasser. Oott. 1858.

« AnteriorContinuar »