dissociated moments have become again sub-
merged. There is a constant struggle going on in
the hunting out of the stray dissociated systems.
The state brought about by hypnoidization is
essentially a transient, evanescent, mental disag-
gregation of the personal consciousness from the
reflex subconsciousness. The hypnoidal state
borders closely on light hypnosis; and still it is not
exactly a hypnotic state and may be regarded as
an intermediate state. In a series of experiments
on the nature of sleep of lower animals as well as
of infants and adults, now being carried on by
me at the physiological laboratory of Harvard
Medical School and in my own laboratory, the
facts tend to indicate that the hypnoidal state is
intermediary betAveen hypnosis and sleep on the
one hand and the waking state on the other. The
relation may be represented by the following
diagram:
hypnoidal state may cither lead to sleep or
The
to hypnosis.
The close relationship of the hypnoidal si a le
and of hypnosis is sometimes forcibly brought to
the attention of the experimenter. Some patients
while in the hypnoidal state are observed to
become unusually quiet, less talkative, become
relaxed, and after a time a distinctly cataleptic
condition of the extremities may be observed.
The patient, has apparently passed into hypnosis.
In most of the rases the hypnosis is of very brief
duration, while in a few cases the hypnosis may
become lasting and deep. On the other hand,
in many cases the subject falls into a sleeping
state without as much as touching on hypnosis.
The hypnoidal state is an intermediary state, in-
termediate between the waking state, and sleep
hypnosis. Subwaking may possibly be an appro-
priate descriptive term of the character of the
hypnoidal state. The subwaking hypnoidal state,
like sleep and hypnosis, may be of various depth
and duration; it may range from the fully waking
consciousness and again may closely approach and
even merge into sleep or hypnosis. The same
patient may at \rarious times reach different
levels, and hence subconscious experiences which
are inaccessible at one time may become revealed
at some subsequent time, Avhen the patient hap-
pens to go into a deeper level of the hypnoidal
state.
On account of the instability of the hypnoidal
state and because of the continuous fluctuation
and variation of the depth of its level, the sub-
conscious dissociated experiences come up in bits
and scraps and often may lack the sense of
familiarity and recognition. The patient often
loses the train of subconscious associations; there
is a constant struggle to maintain this highly
unstable hypnoidal state, and one has again and
again to return to the same subconscious train
started into activity for a brief interval of time.
One must pick his Avay among streams of disturb-
ing associations before the dissociated subcon-
scious experiences can be synthetized into a
Avhole, reproducing representatively the original
experience that has given rise to the Avhole train
of symptoms. The hypnoidal state may some-
times reproduce the original experience which, at
first struggling up in a broken, distorted form and
finally becoming synthetized, gives rise to a full
attack. The symptoms of the malady turn out
to be portions, bits and chips of past experiences
Avhich have become dissociated, subconscious, giv-
ing rise to a disaggregated subconsciousness. The
method of hypnoidization and the hypnoidal
states induced by it enable us to trace the history
and etiology of the symptoms and also to effect a
synthesis and a cure by means of methods which
will be described further on.
From the cursory discussion of the insistent
psychomotor states, of the method of hypnoidiza-
tion and hypnoidal states Ave can turn noAV to the
cases.
(To be continued.)
THE RELATIVE VALUE OF MASSAGE, EXER-
CISES AND BATHS IN THE TREATMENT
OF HEART AFFECTIONS.
BY DOUGLAS GRAHAM, M.D., BOSTON.
Harvey, in 1650, narrated the case of
"
a man
Avho in consequence of an injury or an affront
which he could not revenge Avas so overcome
Avith hatred, spite and passion that he fell into
a strange disorder, suffering from extreme com-
pressions and pain in the heart and breast from
which he only received some little relief at last
when the whole of his chest was pummelled by
a strong man as the baker kneads dough."
Physical or external therapeutics, in contradis-
tinction to medical or internal remedies, have
come much into faAror in the treatment of disease
of the heart in the past feAV years. These are
massage, resistive movements, saline baths, and
mountain-climbing. Of these, massage is the
most generally applicable. It can be used in
cases so weak as to preclude the possibility of
applying any of the others. In almost every
conceivable form of Aveak and diseased heart
I have been called upon to do massage, and
usually Avith marked relief and comfort, before
Oertel Avere ever heard of. While it
Schott or
was being done and lor some time after, the
patients have generally been able to lie on either
side or flat on the back, and often go to sleep in
this position,—what they could not have done
before. In other cases, Avhere it Avas impossible
for them to lie doAvn at all, I have niasséed with
relief until Avithin a short time of their death.
Massage of the chest over the region of the
heart has a poAverfully tonic and sedative effect
on this organ, as either physicians or patients can
prove by observing its effects in their own persons notice by the Drs. Schott, avIio up to 1891 had
by means of Bowie's excellent stethoscope. Even treated in this way 2,700 cases of cardiac
a well but lazy heart Avili be found to beat much disease, mostly with great benefit or recovery.
better and with clearer accentuation after a feAV Each resisted movement of extremity or trunk
minutes of massage, reminding one A'ery much of is slowly and completely executed, folloAved by
the effect of using the bellows on a fire that burns a pause, after which the opposing movement
slowly. This is most marked in the flabby alternates in the same way, while the physician
neurasthenics. person avIio makes the resistance is ever watch-
or
The enthusiasm of Professor Oertel over mas- ful to avoid anything like fatigue, difficulty of
sage of the heart may have gone a little too far, respiration, or increased disturbance of heart,
but perhaps this may have been necessary in and should such arise a longer pause is giA'eii.
order to wake up the profession to its great value. Some of the advocates of this method state that
In a recent Avork on this subject, he considers no movement is to be repeated twice in succession
that massage acts upon the heart in the same to the same limb or group of muscles, but 1 have
Avay that it does upon the muscles of the ex- yet to learn that Schott himself is so absolute
tremities. In order to do this, the chest Avail in his directions.
Avould have to be removed, so that the heart The immediate effect of the bath is not quite
so marked as after the exercises, but it lasts
might be grasped and directly massfed a pro-
—

cedure that Avould hardly be justificable in the
human being, except in extreme cases. While
the patient stands he advises that gliding pres-
sure should be made upon the chest walls down-
ward and inward, the benefits of which, he states,
"
are not only referable to its influence in per-
fecting expiration, but also to the direct pressure
upon the heart, influencing its nutrition precisely
as massage benefits the muscles of the extremi-
ties." The patient Avould have to be pretty well
to stand Avhile this was being done. The in-
fluence of massage over the heart is indisputable,
but evidently it must be more indirect and
sympathetic than direct. Oertel very properly
considers this treatment indicated :
"
1. When the heart muscle is Aveak from de-
ficient nutrition, anemia, or corpulence.
"
2. When the arterial system is imperfectly
filled and there is passive congestion as a result
of insufficiency of the myocardium.
"
3. When there are valvular lesions or ob-
structions to the circulation, the pressure of
tumors, or constriction of the pulmonary orifice,
emphysema, or curvature of the spine.
"
4. As an accompaniment of treatment of
the heart by mountain climbing.
"
It is contra-indicated in acute or recurring
endocarditis or pericarditis, in acute and sub-
longer
Avhilc the exercises can be used repeatedly on
the same day and without regard to place. In
illustration of this the resistive movements Avere
given to a boy who was weak and anemic. Per-
cussion showed dilatation of the heart. Two
skiagraphs Avere taken, one before, the other
fifteen minutes after, a quarter of an hour of
exercises of moderate resistance. It Avas evident
that the heart had contracted strongly on both
sides and that it had changed from the shape of
an orange to that of a lemon and was one-half
inch smaller by measurement. For the sake of
comparison and in order to ascertain the effect
of the Nauheim effervescent bath alone, Dr.
Schott had a somewhat similar case, a girl four-
teen years of age, carried to the bath and after
this back to the table. It was found as a result
of the bath that the heart had contracted about
one centimeter (less than half an inch) in its hori-
zontal diameter. This is getting matters doAvn
pretty fine.
It has also been shoAvn by Dr. Schott to the
satisfaction of impartial observers that wrestling
until the breathing became "short or excessive,
bicycling produced dilatation of the heart and
weakened it, from which he has deduced the
axiom,
Systematic exercises strengthen the heart,
" —

acute myocarditis, the result of sclerosis of the
coronary arteries, and in general arteriosclerosis."
I have never seen a case of arteriosclerosis that
Avas harmed in any way by massage, nor have 1
met any one Avho has. Such a statement is
made on purely theoretical grounds.
General massage, carefully administered, is
of great aid to the peripheral circulation, lessens
the work of the heart, tranquilizes the nervous
system, and induces sleep in the Avorst kind of
heart disease, and massage of the abdomen often
works well as a diuretic and to relieve the stasis
of the mesenteric veins and all the other abdomi-
nal veins.
Next to massage in its universality of applica-
tion and under circumstances in which patients
have been too Aveak to undergo saline baths or
mountain-climbing, come resisted movements.
These, combined Avith the saline, sparkling Avaters
of Nauheim, Avere first brought prominently to
unsystematic exercises Aveaken it." l
Dr. W. Bezly Thorne, of London, who has
witnessed the effects of systematic resisted move-
ments in many cases, says of them: " The results
are such as would scarcely be believed by any
but an eye-Avitness. It is by no means uncommon
in cases of dilatation to see within one hour the
oblique long diameter of the heart's area of
dulness diminished by from three quarters of an
inch to an inch and a quarter; and, perhaps more
surprising still, to observe a diminution by as
many as two inches in vertical measurement of
of a liver Avhich at first extended to the umbilical
level, and to hear the patient, at the conclusion
of what cannot be considered an ordeal, volunteer
the statement that a load has been removed
from the precordium, that he breathes easier and
more deeply, and experiences a sense of general
relief."
' New York Moil, lice., March 20, 1808.
 When such good results can be obtained from
massage or resistive movements alone, it would
seem almost superfluous to burden patients with
baths besides other than what may be necessary
for cleanliness. Indeed, the advocates of the
mineralized baths are not very clear in their
ideas as to when the one or the other should be
used or when they should be alternated or com-
bined, so that these problems must be left to the
discretion of the attending physician, who will
be guided by the effects upon the patients.
Dilatation of the arterioles and reduction of high
arterial pressure may be obtained by slow, deep
kneading of the muscles of the system at large;
while on the other hand, increase of the strength
of the systole may be brought about by gentle
resistive movements of the limbs and by friction
or stroking of' the limbs and body towards the
heart.
The waters of Nauheim consist largely of a
solution of chloride of sodium and chloride of
calcium with an abundance of carbonic acid gas,
and are of varying degrees of strength. Similar
combinations are for sale at the drug-stores which
can be dissolved in one's own bath-tub; but era-
ployed in this way the effects are not so favorable
as they are at Nauheim, where pleasant scenery,
bracing atmosphere, and absence from the cares
of home all contribute beneficial influences. The
duration of the bath at first should not exceed ten
minutes, and the temperature of the water should
be about 92° or 93° F. At the commencement,
the bath should be omitted every other day, then
every third day, next every fourth day. Later,
the baths are given offener and longer, their
mineral ingredients are stronger, and the tem-
perature is cooler, down to 88° or 85° F. Though
the immediate effect of these sparkling waters
conveys the impression of a bath of champagne
and induces a sense of exhilaration, yet the first
few baths are apt to be associated with a sense of
oppression at the precordium and the patients
breathe more slowly and deeply for a few minutes.
Respiration then becomes easy and continues
slower. When infiltration or deposit has occurred
in accessible places careful massage succeeds the
bath. Sometimes the resisted movements are
used to prepare patients for the baths, and they
should be continued sufficiently long after until
the patients can climb mountains. After the
completion of the bath and exercise treatment
Dr. Schott says he has seen patients make
extensive tours through the Alps and even climb
Mont Blanc and Monte Rosa without any diffi-
culty. Nothing is said about the duration of
the treatment. It must vary greatly to suit
different cases and be limited or extended by the
convenience of the patient.
It is certain that but few American patients
who are well enough to go to Nauheim would be
willing to submit to this treatment at home for a
sufficient length of time to do any good at all.
Respiratory exercises are often of great value,
even when not enforced by the exhilarating
exercise of mountain cljmbing. John Hunter, in
his graphic sketch of his own case, stated his
belief that he had often prevented himself from
dying by deep breathing. Deep respiration alle-
viates the suffering of many cases characterized
by extreme arterial pressure as well as those
attended by cyanosis. It probably acts by un-
loading the right cavities of the heart and by
relieving pressure from the aorta. (Gibson.)
It is emphatically declared that gymnastics
or physical exercises by means of mechanical
appliances should form no part of the system
of resisted movements, and that they are even
opposed to it as harmful. They ought to be
helpful when improvement has sufficiently pro-
gressed, especially exercises with elastic cords,
as their use gives alternate resisted movements
each way.
Possibly the advocates of the saline bath in
disease of the heart have not taken sufficient
account of the fact that when a body floats in
water it is buoyed up by an elastic resistance
equal to its own weight, and this presses the
venous blood and lymph back to the heart from
the parts that are submerged. This is massage
by hydraulic pressure of the immersed portions
of the body.
According to Fleischt, the shock of the blood
sent into the capillaries at each cardiac systole
has a mechanical action in aiding the chemical
processes of tissue change in somewhat the same
way, though to a less extent, as a blow upon a
percussion cap. If a heart is too feeble or the
resistance in the vessels too great to allow the
blood entering the aorta at each systole to give
a distinct forcible impulse to the blood present
in the arteries, the chemical changes in the tissues
will be sluggish and imperfect. It is therefore
of the utmost importance in the treatment of
disease to maintain the action of the heart and
to stimulate it when flagging. (T. Lauder
Brunton.)
Dr. Douglas PoAvell, in the British Medical
Journal of April 9, 1898, helps to define more
clearly the use of massage and exercise. He tells
us that massage is a means of helping on the
convalescent stage of acute heart disease and of
combating the tendency, to stagnant circulation
in those who are disabled by chronic heart
disease. The treatment, he thinks, is still more
useful in maintaining the circulation and mildly
stimulating the coronary circulation in those
who are bedridden and, on that account, suffer
from impairment of heart nutrition and chilly
extremities, feeble pulse, torpid digestion, and
passive congestion of the lungs. The treatment
is not advisable in acute affections of the heart.
The effects of the Schott or Nauheim exercises
are a stimulation of the heart's action, with a
steadying effect or increased completion of the
systole, improved circulation through the coro-
nary vessels, and an increased motility of the
blood by its readier passage in greater bulk
through the muscles, thus relieving stagnation
in the great internal organs, especially of their
veins. The graduated exercises may be regarded
as a counsel of perfection, as a preliminary to the
return to this increase of active life of which the
 condition of their heart admits, and also as a
guide to what that measure of exercise will be.
Resistive exercises are especially adapted for
the initial treatment of those flabby, irritable,
"
stuffy " hearts, applying this term to cases of
fatty infiltration and impaired metabolism Avhich
are met with in people of venous plethora. Irri-produce
the only unfavorable one of the kind he had ever
had; the patient was unduly fatigued. Ifhecould
have ridden to the patient's door, the result would
most likely have been different.)
3
Dr. Albert Abrams finds that any cutaneous
stimulant mechanic, chemic, or electric Avili
diminution of the size of the heart with
— —

tation of a sensory nerve causes general contrac- temporary dilatation of the lungs. Vigorous
tion of blood vessels. cutaneous friction by means of a wire brush
In cases of chlorosis with dilated heart, after seemed to afford him results in heart disease
a preliminary week or two of rest, the Schott nearly as good as those obtained by the more
treatment is valuable if combined with a dry, elaborate treatment by means of baths, massage,
bracing air and milk chalybeate. It is useful and exercises. He quotes Moccucci, vvho sprayed
in commencing failure of the heart, in chronic the left half of the abdomen with ether in twelve
valvular lesions, combined with less of other cases of enlarged spleen with the result of decrease
exercises, and also after such cases have been in volume of the spleen in all the cases. In re-
restored to a certain extent by digitalis. It is peating these experiments Dr. Abrams noticed
unsuited in all cases of acute endocarditis while a decided diminution of the size of the spleen in
there is any trace of activity of lesion left, and in all the people he tried it on, irrespective of the
cases of advanced cardiovascular changes of the fact whether the spleen was enlarged or not.
nature of sclerosis, or in introspective people Ether spray over the heart and over the liver
with neurotic hearts. caused decrease in size of both these organs. The
An excellent summary of this treatment of results were confirmed not only by percussion,
heart affections was given by Sir Grainger but also by sight, by means of the fluoroscope.
Stewart before the British Medical Association Mass 4 has reported two cases in Avhich patients
at Carlisle. He has fully satisfied himself on the apparently dead from chloroform syncope were
following points: resuscitated by compression in the region of the
1. That in the great majority of cases of cardiac heart. In both cases, respiration and radial
dilatation the area of cardiac dulness diminishes pulse had entirely stopped and the pupils were
perceptibly during each administration of mas- dilated. The manipulation of the heart in both
sage. cases was carried out for over an hour. Com-
2. That the character of the cardiac sounds and pression over the heart was used one hundred
the rhythm and strength of the pulse correspond- and twenty times a minute, and soon after it was
ingly improve. begun the pupils became smaller and the pale-
.
3. That the patients usually experience a ness of the face disappeared. Aftenvards both
sensation of comfort and feel the better for the patients suffered from mental derangement,
treatment. difficulty of swallowing and speaking, all of which
4. That although the immediate favorable passed off shortly.
effects pass off in a few hours, yet they frequently Physiologists have not been idle in their efforts
do not pass off completely, for he has often found to shoAV how weak and failed hearts may be
the line of cardiac dulness within that with which revived; indeed some good men give them credit
they had started at the previous seances. for leading the way.
5. That repeated applications of massage bring If any more confirmatory testimony of the
about a permanent diminution of the area of efficacy of massage for weak hearts Avere needed
dulness, with improvement of pulse and of the we certainly have it in the experiments of
patient's sensations. Professor Prus,6 in which dogs were suffocated
6. He has seen a case in which the so-called and brought back to life by massage of the heart.
Schott treatments produced a deleterious effect, The supply of air was shut off by clamping an
rendering the heart more irregular and intermit- India-rubber tube which connected the tracheo-
tent. It was afterwards treated by massage alone tomy cannula with an artificial respiration ap-
on the following day with most striking benefit. paratus. Immediately after the death of the
It turned out that the patient was not sufficiently animals some of the rib cartilages in front of the
Avell to bear the active movements, but was heart were removed, the pericardial sac was in-
greatly benefited by tho passive ones. cised, and the heart exposed. After it had been
7. That on one or two occasions he has seen ascertained that there Avas no trace of any contrac-
the manipulations produce unfavorable effects, tion of either auricle or ventricle, Professor Prus
apparently because the heart was too feeble and waited from fifteen to sixty minutes before he
the patient was fatigued at the time of applica- began his efforts at artificial resuscitation. Then
tion.2 (In this last case it is possible that the the clamp was removed and artificial resuscita-
massage was too vigorous, or that the manipu- tion started. The heart was grasped in the right
lator himself Avas not in good condition. The hand so that the thumb rested on the right ventri-
writer one day had to walk three quarters of a cle, and the four fingers surrounded the left
mile in the teeth of a cold wind to give massage ventricle. Both ventricles Avere then compressed
to a patient with a weak heart. The result Avas
Jan.3Meel. News,
1809. 7,
> Mcoliano-Thorapy in the Treatment of Heart Disease, Dr. T. «Borl. klin. Wochenschr., 1802, No, 12.
Streich Dowse, 1S9S. »Treatment,, Oot., 1000, anil New York Meil. Her., Nov., 1000.
with moderate force, the compressions being
made to imitate the systolic and diastolic action
of the heart. In 31 cases, or 70%, life was re-
stored. In chloroformed dogs under the same
conditions, 76%, and in dogs shocked by the
electric current, 14% were brought back to life.
An attempt to try massage of the heart was made
on the body of an alcoholic who had committed
suicide by hanging, but without success, as might
have been expected.
Statistics gleaned from various sources at home
and abroad by Prof. Wm. W. Keen, show that
of 28 cases of apparent death in the human being,
during chloroform narcosis, 42 recovered by mas-
sage of the heart. But this treatment should not
be relied upon alone. Artificial respiration should
also be carried on and the patient should receive
sufficient oxygen. For the purpose of restoring
vasomotor tone adrenalin should be employed."
In the great zeal to collect statistics on this
interesting subject, doubtless many of them come
from the same sources. Thus Lanermant has
collected 25 cases of Avhom 4 were restored to
life.7
Mauclair and Zezas report 28 cases with 6
successful results.8
Three methods are employed to do massage
of the heart:
1. Incising the anterior wall of the chest so
that the hand can grasp the heart.
2. Incising the diaphragm and then passing
the hand up from the abdominal cavity.
3. Seizing the heart through the diaphragm
without cutting it. In syncope the diaphragm
is relaxed enough to render the last method easy.
It has given the greatest percentage of recoveries
(5 out of 9). It is the least mutilating and the
only one that should be employed. Although
the number of deaths seems large it should be
ceptible of being made, through practice, of much
value.
The physician, placing himself opposite to his
patient, should lay the pulp of his extended
(right) forefinger over the patient's (right) radial
artery, at the same time interlocking his fore-
finger and thumb with the forefinger and thumb
of the patient's hand. With his disengaged (left)
hand, the physician should then grasp the patient's
relaxed arm, just above the elbow and just below
the swell of the biceps, in such a way that with
his thumb he may compress the patient's brachial
artery against the underlying humérus, while with
his fingers he may make counter-pressure on the
outer portion of the arm. It becomes, then, very
easy to estimate just the amount of muscular
effort that is required to close the brachial artery
so that the pulse is no longer to be felt by the
finger at the wrist, and this effort measures the
maximal pressure of the pulse. Even the mini-
mal pressure, that is, the point- at which the
impulse in the two arteries becomes the same as
the compressing thumb is raised, can be estimated
better with the aid of the brachial artery, in
this fashion, than with the radial alone, and
fairly well, provided the physician has been
accustomed to take sych pressures accurately
with an instrument suited for the purpose.
It is astonishing to find what a difference there
is between the tension which the compressing
thumb and fingers must overcome in the case of
a compressible brachial artery and that in the
case of an artery altered through hypertrophy.
In well-marked arteriosclerosis the amount of
pressure required for complete closure may be
so great that the effort exerted in overcoming it
must be considerable.
-

remembered that all the cases saved Avould

doubtless have died without the use of this New Instrument
method.
When babies arc born, if their respiration and A NEW DEVICE FOR ADJUSTING THE
circulation are at fault, they are promptly rubbed FOREHEAD MIRROR.
and slapped without- waiting for a diagnosis and
usually with the result of bringing them around BY WILLIAM E. CHENERY, M.D., BOSTON.
all right. So the poet of the future may have a
chance to express himself with regard to massage In operating on the nose and throat I have
somewhat as follows: often desired some form of appliance by which
the forehead mirror could be easily and asepti-
When this world you outer if you're gasping for breath, cally adjusted. It has been customary to use
"Pis this first thing they do to saves you from death;
If toe) soon you woulel lesnve this terrestrial sphere pieces of aseptic gauze, but this has not been
'Tis the last, thing they do to keep you long here. wholly satisfactory.
It occurred to me that a steel spring clamp
might be made which could be boiled Avith the
PULSE-PRESSURE ESTIMATION. other instruments, and when needed slipped on
to the side of the mirror and left there during
BY JAMES J. PUTNAM, M.D., OF BOSTON.
the operation, thereby giving the operator an
Having been interested for some time past aseptic handle which he could use at Avili to move
in the measurement of pulse-pressure, and having the mirror in or out of position.
striven to find the best method of estimating its I have had several made and perfected and
degree by the finger, in the absence of instru- now present this one which I have called the
ments, I have decided upon the following plan universal head mirror adjuster.
as decidedly preferable to any other and as sus- All users of the forehead mirror will appreciate
"Ther. Gai., Philadelphia, Apiil 16, 1004. it. It may be easily applied, fits large and small
'Rev. ile Cbir., No. 8, 1000. mirrors and will cling tightly so that the mirror
»Ibid., Ill, i, 1000.